Dean M Donahue

Massachusetts General Hospital, Boston, MA, United States

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Publications (48)156.66 Total impact

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    ABSTRACT: Pulmonary aspergilloma is resected to control life-threatening complications such as massive hemoptysis. The role of prophylactic resection in asymptomatic patients is unclear. A retrospective review was conducted of 60 patients treated at a tertiary center from 1980 to 2010. The mean age in 34 (56.7%) men and 26 (43.3%) women was 51 years. Immunosuppression, most commonly from chronic steroid use, was present in 17 (28.3%) patients, and preexisting lung disease was present in 47 (78.3%) patients. Hemoptysis occurred in 33 (55%) patients, whereas 9 (15.0%) patients were asymptomatic. Aspergilloma was simple in 13 (21.7%) patients and complex in 47 (78.3%) patients. Surgical approach was by thoracotomy (n = 51 [85.0%]), video-assisted thoracoscopic surgery (n = 7 [11.7%]), or a cavernostomy (n = 2 [3.3%]). Sublobar resections (n = 28 [46.7%]) were most common, followed by lobectomy (n = 27 [45%]) and pneumonectomy (n = 3 [5%]). Postoperative morbidity occurred in 18 (30%) patients, with prolonged air leak the most frequent complication (n = 9 [15%]). Two (3.3%) patients experienced empyema, and 4 (6.7%) patients had bronchopleural fistulas (BPFs). Two patients died within 30 days (3.3%). During a mean follow-up of 54.1 ± 62.2 months, 3 patients had recurrent aspergillomas (5.0%). Actuarial 10-year survival was 62.5% for simple and 68.5% for complex aspergillomas (p = 0.858). Comorbid conditions (human immunodeficiency virus [HIV] positivity, malignancy) and male sex were associated with lower survival. Selective surgical treatment favoring lesser pulmonary resection results in fungal eradication and control in most patients. Overall survival is similar after surgical management of simple and complex aspergillomas.
    The Annals of thoracic surgery 12/2013; · 3.45 Impact Factor
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    ABSTRACT: PURPOSE Imaging studies play a significant role in assessment of thoracic outlet syndrome (TOS). In this study, we reviewed the spectrum of CT and MR imaging findings in patients with TOS in our institution, over a period of four years. METHOD AND MATERIALS Our study included a total of 349 consecutive TOS patients, referred to our hospital between December 2008 and December 2012. Patients with non-specific symptoms were excluded. All patients underwent a biphasic contrast-enhanced CT angiography of the thoracic outlet using a TOS-optimized protocol and an MR scan with a postural maneuver. A single radiologist (RG) assessed all the scans. The findings associated with TOS were classified under the categories of vascular (venous or arterial), neurologic (due to soft tissue, bone or anatomical space abnormalities causing mass effect on the brachial plexus) and a combination of the two, i.e, neurovascular (typically secondary to post-operative or traumatic insult). RESULTS Positive CT or MR findings were seen in 78.5% of patients. Overall, 6% of patients had vascular TOS (2% venous and 4% arterial), 7.4% had neurovascular, and 86% had neurogenic TOS. Bone abnormalities were the most common cause of neurogenic TOS. Narrowing of anatomic compartments (inter-scalene triangle and costoclavicular space) was seen in 43.7% of patients with neural TOS. C7 transverse process variations were the most common bone abnormality (67.9%). Fibrous bands were the most common soft tissue abnormalities associated with neurogenic TOS. CONCLUSION This study describes the range of CT and MR findings associated with TOS. Based on our experience, a combination of CT angiography and MR imaging (with a postural maneuver) effectively demonstrate TOS abnormalities. CLINICAL RELEVANCE/APPLICATION A combination of biphasic contrast-enhanced CT angiography and MR imaging (with a postural maneuver) effectively demonstrate TOS abnormalities.
    Radiological Society of North America 2013 Scientific Assembly and Annual Meeting; 12/2013
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    ABSTRACT: Background Acquired nonmalignant tracheoesophageal fistula in the adult patient develops in a variety of conditions. We have applied surgical closure with success for 35 years. Methods From 1975 to 1991, 38 patients underwent surgical repair of a tracheoesophageal fistula. A retrospective study of 36 additional patients undergoing surgical repair from 1992 to 2010 was conducted. Results The most common causes were postintubation injury (n = 17, 47%), trauma (n = 6, 17%), prior laryngectomy (n = 6, 17%), and prior esophagectomy (n = 4, 11%). Four patients presented after failing fistula control with an endoluminal stent. The tracheal defect was closed with resection and reconstruction (n = 17, 41%), laryngotracheal resection (n = 5, 12%), membranous tracheal repair (n = 17, 41%), or repair over a tracheal T tube (n = 2, 5%), while esophageal repair consisted of 2-layer closure (n = 31, 78%), 1-layer closure (n = 6, 15%), esophagostomy (n = 1, 3%), end-to-end esophageal anastomosis (n = 1, 3%), or full thickness skin graft reconstruction (n = 1, 3%). The esophageal and tracheal repairs were buttressed by interposing pedicled muscle or omental flaps in all patients. There was 1 postoperative death (3%). Recurrence after repair developed only in fistulas arising after esophagectomy or laryngectomy (n = 4, 11%). Fistula closure was ultimately successful in 34 patients (94%). Twenty-nine patients (83%) resumed oral intake and 25 patients (71%) were breathing without a tracheal appliance. Conclusions Successful closure of benign tracheoesophageal fistula is achieved with several surgical techniques based on buttressed repair and restoration of normal breathing and swallowing. Closure of complex postsurgical fistula may fail. Endoluminal stenting was not found useful.
    The Annals of thoracic surgery 04/2013; 95(4):1141–1146. · 3.45 Impact Factor
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    ABSTRACT: BACKGROUND: As worldwide life expectancy rises, the number of candidates for surgical treatment of esophageal cancer over 70 years will increase. This study aims to examine outcomes after esophagectomy in elderly patients. METHODS: Retrospective review of 474 patients undergoing esophagectomy for cancer during 2002-2011. 334 (70.5%) patients were <70 years old (group A), 124 (26.2%) 70-79 years (group B) and 16 (3.4%) ≥80 years (group C). We analyzed the effect of age on outcome variables including overall and disease specific survival. RESULTS: Major morbidity was observed to occur in 115 (35.6%) patients of group A, 58 (47.9%) of group B and 10 (62.5%) of group C (p=0.010). Mortality, both 30- and 90-day was observed in 2(0.6%) and 7(2.2%) of group A, 4(3.2%) and 7 (6.1%) of group B, and 1(6.3%) and 2(14.3%) of group C, respectively (p=0.032 and p=0.013). Anastomotic leak was observed in 16(4.8%) patients of group A, 6(4.8%) of group B and 0(0%) of group C (p=0.685). Anastomotic stricture (defined by the need for ≥2 dilations) was observed in 76(22.8%) of group A, 13(10.5%) of group B and 1(6.3%) of group C (p=0.005). Five-year overall and disease specific survival was 64.8% and 72.4% for group A, 41.7% and 53.4% for group B, 49.2% and 49.2% for group C patients (p=0.0006), respectively. CONCLUSIONS: Esophagectomy should be carefully considered in patients 70-79 years old and can be justified with low mortality. Outcomes in octogenarians are worse suggesting esophagectomy be considered on a case by case basis. Stricture rate is inversely associated to age.
    The Annals of thoracic surgery 03/2013; · 3.45 Impact Factor
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    ABSTRACT: Purpose. To determine the efficacy and toxicity of weekly neoadjuvant cetuximab combined with irinotecan, cisplatin, and radiation therapy in patients with locally advanced esophageal or gastroesophageal junction cancer.Methods and Materials. Patients with stage IIA-IVA esophageal or gastroesophageal junction cancer were enrolled in a Simon's two-stage phase II study. Patients received weekly cetuximab on weeks 0-8 and irinotecan and cisplatin on weeks 1, 2, 4, and 5, with concurrent radiotherapy (50.4 Gy on weeks 1-6), followed by surgical resection.Results. In the first stage, 17 patients were enrolled, 16 of whom had adenocarcinoma. Because of a low pathologic complete response (pCR) rate in this cohort, the trial was discontinued for patients with adenocarcinoma but squamous cell carcinoma patients continued to be enrolled; two additional patients were enrolled before the study was closed as a result of poor accrual. Of the 19 patients enrolled, 18 patients proceeded to surgery and 16 patients underwent an R0 resection. Three patients (16%) had a pCR. The median progression-free survival interval was 10 months and the median overall survival duration was 31 months. Severe neutropenia occurred in 47% of patients, and severe diarrhea occurred in 47% of patients. One patient died preoperatively from sepsis, and one patient died prior to hospital discharge following surgical resection.Conclusions. This schedule of cetuximab in combination with irinotecan, cisplatin, and radiation therapy was toxic and did not achieve a sufficient pCR rate in patients with localized esophageal adenocarcinoma to undergo further evaluation.
    The Oncologist 02/2013; · 4.10 Impact Factor
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    ABSTRACT: Personalizing non-small-cell lung cancer (NSCLC) therapy toward oncogene addicted pathway inhibition is effective. Hence, the ability to determine a more comprehensive genotype for each case is becoming essential to optimal cancer care. We developed a multiplexed PCR-based assay (SNaPshot) to simultaneously identify >50 mutations in several key NSCLC genes. SNaPshot and FISH for ALK translocations were integrated into routine practice as Clinical Laboratory Improvement Amendments-certified tests. Here, we present analyses of the first 589 patients referred for genotyping. Pathologic prescreening identified 552 (95%) tumors with sufficient tissue for SNaPshot; 51% had ≥1 mutation identified, most commonly in KRAS (24%), EGFR (13%), PIK3CA (4%) and translocations involving ALK (5%). Unanticipated mutations were observed at lower frequencies in IDH and β-catenin. We observed several associations between genotypes and clinical characteristics, including increased PIK3CA mutations in squamous cell cancers. Genotyping distinguished multiple primary cancers from metastatic disease and steered 78 (22%) of the 353 patients with advanced disease toward a genotype-directed targeted therapy. Broad genotyping can be efficiently incorporated into an NSCLC clinic and has great utility in influencing treatment decisions and directing patients toward relevant clinical trials. As more targeted therapies are developed, such multiplexed molecular testing will become a standard part of practice.
    Annals of Oncology 11/2011; 22(12):2616-24. · 7.38 Impact Factor
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    ABSTRACT: There are few data to predict the benefit of pulmonary metastasectomy in patients with extrathoracic sarcoma. This study analyzes prognostic factors associated with improved outcomes. Between June 2002 and December 2008, 97 patients underwent pulmonary resection for metastatic sarcoma at Massachusetts General Hospital. Eight patients were excluded because of lack of follow-up data. Analysis was performed using Kaplan-Meier estimates of survival, log-rank test, and multivariate Cox model. Overall 5-year survival for the cohort was 50.1%. Patients who had multiple operations for recurrent pulmonary metastases had better 5-year survival compared with patients who had a single operation (69 versus 41%; p = 0.017). Median disease- free survival (DFS) for the reoperation group was 12.9 months compared with 9.1 months for the single-operation group (p < 0.028). Patients with a disease-free interval (DFI) greater than 12 months from detection of primary sarcoma to pulmonary metastasectomy had improved survival compared with those whose DFI was less than 12 months (p < 0.0001). Patients with bilateral metastasectomy had lower 5-year survival compared with metastasectomy for unilateral disease (22% versus 68% ;p < 0.0001). Two or more metastases were associated with poorer outcome compared with a single metastasis (p = 0.0007). A positive resection margin portended worse survival compared with a negative resection margin (p = 0.004). Patients with lesions larger than 3 cm had decreased survival compared with patients with lesions smaller than 3 cm (p = 0.017) with no difference in median DFS. Histologic type, grade of tumor, and use of chemotherapy had no effect on survival. Multivariate analysis showed that patients with a DFI greater than 12 months (p = 0.001), single-sided metastasis (p = 0.001), negative margins (p = 0.002), and multiple operations (p = 0.018) had better survival. Pulmonary metastasectomy for sarcoma can be associated with prolonged survival. Tumor resectability, DFI, number of metastases, and laterality are important factors in determining patient selection for curative surgical intervention. Repeated pulmonary metastasectomy in select patients may improve survival despite recurrent disease.
    The Annals of thoracic surgery 11/2011; 92(5):1780-6; discussion 1786-7. · 3.45 Impact Factor
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    ABSTRACT: A fall in the postpneumonectomy fluid level is considered a sign of bronchopleural fistula (BPF) requiring surgical intervention. We have discovered however that in rare asymptomatic patients, this event may not require aggressive surgical treatment. After seeing a case of benign emptying of the postpneumonectomy space (BEPS), we surveyed 28 surgeons to determine its incidence and characteristics. Forty-four cases of BEPS were reported by 23 survey respondents. Among 7 fully documented cases from 4 institutions, we defined the following criteria: the patient must be asymptomatic (no fever, white cell count elevation, or fluid expectoration), negative culture results if fluid sampled (patient not receiving antibiotics), no BPF at bronchoscopy or ventilation scintigraphy scan (or both), and recovery without drainage, or retrospective assessment that the intervention was unnecessary. BEPS occurred between 5 days and 152 days after pneumonectomy (6 cases right pneumonectomy and 1 case left pneumonectomy). Four patients underwent no treatment, 1 patient underwent thoracoscopic exploration (sterile) and closure after antibiotic irrigation, 1 patient underwent thoracoscopic exploration alone, and 1 patient underwent open window thoracostomy (sterile) with eventual closure. In all 7 patients (except the patient who underwent the open window procedure) the space refilled within 8 weeks; no patient experienced a subsequent empyema/BPF. Four patients who met the initial criteria for BEPS went on to experience empyema. The incidence of BEPS appears related to pneumonectomy volume, particularly extrapleural pneumonectomy. Using surgeon volume assumptions, the incidence of BEPS is 0.65%. To our knowledge, BEPS is a previously unreported occurrence. We hypothesize that it results from postoperative intrapleural pressure shifts, with or without a microscopic BPF, that drive fluid out of the pleural space while failing to cause contamination. Awareness of BEPS' existence may allow surgeons to safely avoid open drainage procedures occasionally in patients who experience an asymptomatic fall in fluid level.
    The Annals of thoracic surgery 09/2011; 92(3):1076-81; discussion 1081-2. · 3.45 Impact Factor
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    ABSTRACT: This study seeks to evaluate the use of postoperative pyloric balloon dilatation for delayed gastric emptying after esophageal substitution with gastric conduit. A total of 436 patients underwent esophagectomy with gastric conduit from 2002 to 2009. All approaches to esophagectomy were included except patients with alternative reconstruction or emergent esophagectomy. Gastric conduit diameter, anastomotic location, and mediastinal route were variable. Gastric outlet obstruction (GOO) was strictly defined to include patients with clinical and radiographic delayed gastric emptying requiring intervention. Gastric outlet obstruction was found in 22% (98 of 436) of patients who underwent esophagectomy. Pyloromytomy was performed on 52% (51 of 98) of these patients and employed in 41% (179 of 436) of patients in the entire cohort. GOO was present in 28% (51 of 179) of patients who underwent a pyloric drainage procedure compared with 18% (47 of 257) of patients with no pyloric intervention (p = 0.01). Endoscopic balloon dilatation of the pylorus was used to treat 39% (38 of 98) of patients with delayed gastric emptying yielding a 95% (36 of 98) success rate. Pyloric dilatations were performed with controlled radial expansion esophageal balloon dilators (range,10 to 20 mm). The remaining patients were treated conservatively with prokinetics, nasogastric drainage, or observation. Nasogastric drainage was employed for 7.4 ± 4.4 days in patients with GOO and 6.8 ± 4.0 days in asymptomatic patients (p = 0.15). Neoadjuvant chemoradiotherapy did not contribute to increased incidence of GOO. There was a significant difference in postoperative pneumonia (18.4% vs 10.6%, p = 0.05) and median length of hospital stay (12 ± 16 vs 10 ± 9 days, p < 0.0001) in patients with GOO versus normal emptying. Delayed gastric emptying after esophageal substitution with gastric conduit can be adequately treated with balloon dilatation of the pylorus despite an operative drainage procedure.
    The Annals of thoracic surgery 02/2011; 91(4):1019-24. · 3.45 Impact Factor
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    ABSTRACT: Persistent air leak (PAL; defined as air leak > 5 days) after major pulmonary resection is prevalent and associated with significant morbidity. This study examines an incompletely characterized treatment for the management of PAL, chemical pleurodesis. A retrospective case-control study examining all isolated lobectomies and bilobectomies by thoracotomy was performed. The PALs (1997 to 2006) and controls (2002 to 2006) were identified from a prospective database. Incidence, risk factors, management, and outcome were defined. Over 9 years, 78 PALs were identified in 1,393 patients (5.6%). Controls consisted of 700 consecutive patients. Propensity score analysis matching case and controls showed no predictive risk factors for air leak using a logistic regression model. Univariate analysis demonstrated that female gender, smoking history, and forced vital capacity were predictive risk factors. Treatment of PAL consisted of observation (n = 33, 42.3%), pleurodesis (n = 41, 52.6%), Heimlich valve (n = 3, 3.8%), and reoperation (n = 1, 1.3%). Seventy-three patients (93.6%) required no further intervention. One patient required a muscle flap, one readmission for pneumothorax, and one empyema resulting in death. Sclerosis was successful in 40 of 41 patients (97.6%). Mean time to treatment was 8.4 +/- 3.6 days, mean duration of air leak was 10.7 +/- 4.5, and mean duration of air leak postsclerotherapy was 2.8 +/- 2.2 days. Postoperative pneumonia occurred with increased frequency in PAL patients (6 of 45 [13.3%] vs 34 of 700 [4.9%], p = 0.014). PAL was associated with increased length of stay (14.2 vs 7.1 days, p < 0.001) and time with chest tube (11.5 vs 3.4 days, p < 0.001). Air leaks remain an important cause of morbidity. Pleurodesis is an effective option in management of PAL after major pulmonary resection.
    The Annals of thoracic surgery 03/2010; 89(3):891-7; discussion 897-8. · 3.45 Impact Factor
  • Martin Torriani, Rajiv Gupta, Dean M Donahue
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    ABSTRACT: The purpose of this study was to describe the technique, complications, and rate of symptom relief after ultrasound-guided botulinum toxin injection in subjects with suspected neurogenic thoracic outlet syndrome (NTOS). This study was IRB-approved and followed HIPPA guidelines. Subjects investigated for NTOS were identified via retrospective review of medical records. Procedures included botulinum toxin injections of the anterior scalene, pectoralis minor, and subclavius muscles performed under real-time ultrasound guidance. Technical success was defined as satisfactory muscle identification, intramuscular needle placement, and intramuscular delivery of medication. Follow-up was performed to determine procedure-related complications and therapy response using a binary assessment and modified visual analogue scale (VAS). Forty-one subjects with suspected NTOS underwent a total of 92 injections (58 anterior scalene, 33 pectoralis minor, and 1 subclavius muscle). Technical success was achieved in all procedures. No complications occurred. Symptom improvement occurred after 69% of procedures. The VAS before and after the procedure changed from 7.1 to 2.8 (P < 0.0001) respectively. The mean time to symptom improvement and duration of symptom improvement were 12 and 31 days respectively. Botulinum toxin injection under ultrasound guidance is a safe and well-tolerated procedure with a satisfactory rate of temporary symptom relief in subjects with suspected NTOS.
    Skeletal Radiology 02/2010; 39(10):973-80. · 1.74 Impact Factor
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    ABSTRACT: The objective of this study was to evaluate the operative mortality, morbidity, and long-term survival of sleeve lobectomy for non-small cell lung cancer and low-grade neoplasms. We evaluated the effects of neoadjuvant therapy on the bronchial anastomotic complication rate and determined whether sleeve lobectomy performed in patients with N1 disease resulted in decreased overall survival. This study is a retrospective review of 196 patients who underwent sleeve lobectomy. One hundred twenty-five patients had non-small cell lung cancer. There were 117 men (59.7%) and 79 women (40.3%) with a mean age of 54 years. Sixteen patients (13%) received neoadjuvant therapy. Fifty-six patients with N1 disease underwent sleeve lobectomy. There were 4 (2.0%) postoperative deaths. The postoperative morbidity rate was 36.7%. Four patients (2.0%) experienced bronchopleural fistulas. Multivariate analysis demonstrated that age older than 70 years (p = 0.02) and the diagnosis of non-small cell lung cancer (p = 0.0002) were risk factors for postoperative complications. Multivariate analysis also demonstrated that neoadjuvant therapy predicted anastomotic complications (p = 0.01). For non-small cell lung cancer patients, the 5-year survival rate was 44%. The 5-year survival rates for patients with pathologic N0 disease and N1 disease were 52.6% versus 39.3%, respectively (p = 0.205). Sleeve lobectomy can be performed with minimal bronchial anastomotic complications and low postoperative mortality. In our study, neoadjuvant therapy for non-small cell lung cancer adversely influenced the rate of anastomotic complications. Performing sleeve lobectomy for patients with N1 disease was not associated with decreased overall survival rates.
    The Annals of thoracic surgery 11/2009; 88(5):1574-81; discussion 1581-2. · 3.45 Impact Factor
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    ABSTRACT: Prior data indicate increased perioperative morbidity and mortality in patients receiving induction chemoradiotherapy before pneumonectomy for lung cancer. We reviewed a consecutive series of pneumonectomies to determine the impact of induction therapy on operative mortality. Over a 15-year period, 183 patients underwent pneumonectomy for lung cancer. Forty-six received combined preoperative radiochemotherapy (25.2%), and 137 patients underwent resection only. Indications for induction therapy were stage IIB disease in 1, IIIA in 35, IIIB in 8, and IV in 2 patients. Patients receiving induction therapy were younger (mean age 58.4 vs 61.9 years; P = .033), had less heart disease (6.5 vs 26.3%; P = .0035), higher preoperative forced expiratory volume in 1 second (2.48 vs 2.13 L; P = .0018), a lower rate of endobronchial tumor (34.8 vs 67.2%; P = .0002), and underwent intrapericardial procedures more often (71.7 vs 43.1%; P = .0011). Hospital mortality was 4.3 % (2/46) after preoperative therapy and 6.6% (9/137) after resection only (P = .73); the difference in cardiopulmonary morbidity was not significant (51.1% vs 40.4%; P = .22). Induction did not predict hospital mortality after adjustment for a propensity score derived from nonoperative and operative variables correlated with neoadjuvant therapy. A regimen of induction radiation and chemotherapy does not increase the operative mortality of pneumonectomy in carefully selected patients.
    The Journal of thoracic and cardiovascular surgery 09/2009; 138(2):289-94. · 3.41 Impact Factor
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    ABSTRACT: Obstruction of the superior vena cava (SVC) by tumor or benign disease implies unreconstructable disease and poor outcome. We analyzed the operative results, graft patency, and survival in patients undergoing SVC resection and reconstruction for benign disease and pulmonary or mediastinal malignancy. Patients undergoing SVC resection from 1997 to 2007 for surgical management of benign and invasive neoplasms were retrospectively reviewed. We identified 19 patients requiring SVC resection. Malignant disease was resected in 17: lung cancer in 9 and mediastinal malignancy in 8. Two patients (10%) with benign processes required reconstruction for chronic SVC syndrome. Ringed Gore-Tex conduit (W. L. Gore and Associates, Flagstaff, AZ) was used for 12 reconstructions (63%) of the SVC, and 7 patients underwent primary closure or autologous pericardial patch repair. Preoperative chemoradiotherapy was administered to 9 patients (53%). There was one perioperative death (5%). Major postoperative morbidities included atrial fibrillation in 5, stroke in 2, respiratory failure in 3, myocardial infarction in 1, and Horner syndrome in 1. Median survival for the entire cohort was 45.5 months (range, 0.2 to 147 months), with a mean follow-up of 45.8 months. Five-year survival probability was 30% for patients with resected lung cancer and 56% for patients with resected anterior mediastinal malignancies. Resection and reconstruction may be safely performed in selected patients for benign and malignant obstruction or infiltration of the SVC. Survival and intermediate-term patency after tubular grafting of the SVC are acceptable.
    The Annals of thoracic surgery 09/2009; 88(2):392-7. · 3.45 Impact Factor
  • Martin Torriani, Rajiv Gupta, Dean M Donahue
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    ABSTRACT: To describe the technique and complications of sonographically guided anesthetic injection of the anterior scalene muscle in patients being investigated for neurogenic thoracic outlet syndrome. Subjects were identified via a retrospective review of medical records. For the procedure a 25-gauge needle was introduced into the anterior scalene muscle under real-time ultrasound guidance followed by injection of local anesthetic. The procedures were evaluated for technical success, which was defined as satisfactory identification of anterior scalene muscle, intramuscular needle placement, and intramuscular delivery of medication. There was a short-term follow-up to determine procedure-related complications and rate of unintended brachial plexus (BP) block, manifested by upper extremity paresthesias and/or weakness. Twenty-six subjects with suspected neurogenic thoracic outlet syndrome underwent 29 injections (three subjects received bilateral injections). Technical success was achieved in all procedures. The mean duration of the procedure was 30 min, and there were no cases of intravascular needle placement or neurogenic pain during the injection. No major complications occurred. Temporary symptoms of partial BP block occurred after nine injections (9/29, 31%), and a temporary complete BP block occurred after one injection (1/29, 3%). Sonographically guided anesthetic injection of the anterior scalene muscle is a safe and well-tolerated diagnostic test for patients being investigated for neurogenic thoracic outlet syndrome.
    Skeletal Radiology 06/2009; 38(11):1083-7. · 1.74 Impact Factor
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    James S Allan, Julie M Garrity, Dean M Donahue
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    ABSTRACT: Postoperative pneumonia continues to be a leading cause of mortality and morbidity after thoracic surgery. High-frequency chest-wall compression (HFCWC) is an established therapeutic adjunct for patients with chronic pulmonary disorders that impair bronchopulmonary secretion clearance. We studied the feasibility of applying HFCWC following thoracic surgery. Twenty-five consecutive adult patients who underwent a variety of thoracic operations received at least one HFCWC treatment in the first 2 postoperative days, along with routine postoperative care. HFCWC was applied at 12 Hz, for 10 min. Routine hemodynamic and pulse oximetry data were collected before, during, and after HFCWC. We also collected qualitative data on patient tolerance and preference for HFCWC versus percussive chest physiotherapy. No major adverse events were encountered. Hemodynamic and pulse oximetry values remained stable before, during, and after HFCWC. Eighty-four percent of the subjects reported little or no discomfort during therapy, and the subjects who expressed a preference preferred HFCWC to conventional chest physiotherapy by more than two to one. HFCWC is a safe, well-tolerated adjunct after thoracic surgery. The observation of hemodynamic stability is especially important, considering that the patients were studied in the early postoperative period, during epidural analgesia.
    Respiratory care 04/2009; 54(3):340-3. · 2.03 Impact Factor
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    ABSTRACT: This study evaluated long-term results of radiofrequency ablation for medically inoperable early-stage lung cancer. Thirty-one consecutive patients with biopsy-proven non-small cell lung cancer underwent 38 treatments of computed tomographically guided radiofrequency ablation in a 4.5-year period. All patients were carefully selected and deemed medically ineligible for resection by a multidisciplinary team. Radiofrequency ablation was performed with curative intent with a single or cluster cool-tip electrode. Patients were hospitalized for 23-hour observation. Treatment was complete in all cases, with no 30-day mortality. Local recurrence was confirmed radiographically by computed tomography, positron emission tomography, or both after 31.5% of treatments (12/38). Two patients were successfully retreated for technical failures related to pneumothorax; 3 underwent radiotherapy with stable disease. Mean maximal diameter of 38 tumors treated was 2.0 +/- 1.0 cm (range 0.8-4.4 cm). After median follow-up of 17 +/- 11 months, 74% of patients (23/31) were alive. Three patients died of metastatic disease; 5 died of pneumonia remote from treatment. The 2- and 4-year survivals were 78% and 47%, respectively. Median overall survival was 30 months. Pneumothorax (13%), pneumonia (16%), and pleural effusion (21%), were the most common complications. Radiofrequency ablation of medically inoperable early-stage lung cancer in carefully selected patients yields encouraging midterm results without significant loss of pulmonary function. Local tumor progression appears related to lung tumors larger than 3 cm. Computed tomography and positron emission tomography need further validation for the early identification of local tumor progression following radiofrequency ablation.
    The Journal of thoracic and cardiovascular surgery 02/2009; 137(1):160-6. · 3.41 Impact Factor
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    ABSTRACT: Laryngotracheal invasion worsens prognosis in patients with thyroid carcinoma. The extent of resection is controversial. We performed a retrospective study of patients with thyroid carcinoma and invasion of the larynx or trachea between 1964 and 2005. Eighty-two patients, mean age 64 years and 50% female, underwent segmental airway resection. Differentiated carcinoma was present in 76% (62 of 82 patients), prior tracheal "shave" procedures in 40% (33 of 82 patients), transmural invasion in 58% (48 of 82 patients), and preoperative vocal cord paralysis in 35% (29 of 82 patients). There were 29 tracheal and 40 laryngotracheal resections (reconstruction group: 69 patients); 5 underwent laryngectomy, 7 cervical exenteration, and 1 tracheal resection after exenteration (salvage group: 13 patients). Operative mortality was 1.2% (1 of 82 patients) and anastomotic dehiscence 4.3% (3 of 69 patients). Tracheostomy was permanent in 4.3% (3 of 69 patients). Mean follow-up was 6.1 years. After reconstruction, mean survival was 9.4 years and 10-year survival was 40%; after salvage, these were 5.6 years and 15%, respectively. In differentiated carcinoma, thyroidectomy, immediate shave procedure, and delayed (mean, 67 months) resection of airway recurrence in 15 patients resulted in overall and disease-free survival of 13.1 and 5.1 years, respectively, compared with 17.9 and 14.6 years, respectively, after thyroidectomy and early airway resection in 11 patients. Airway symptoms, metastases at presentation, recurrent disease, and salvage operation were associated with decreased survival; airway resection early after thyroidectomy, complete resection, and well-differentiated tumors were associated with improved prognosis. Segmental airway resection for invasive thyroid cancer is safe, preserves the voice, and relieves airway obstruction. Complete resection of laryngeal and tracheal invasion during or early after thyroidectomy is associated with improved survival.
    The Annals of thoracic surgery 07/2007; 83(6):1952-9. · 3.45 Impact Factor
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    ABSTRACT: Gastric outlet obstruction is common after esophagectomy. Our goal was to determine the incidence of gastric outlet obstruction after esophagectomy with or without pyloromyotomy and analyze its management by endoscopic pyloric dilatation. Two hundred forty-two patients underwent esophagectomy with gastric conduit from January 2002 to June 2006. Subjects were divided into two groups: Group A had no pyloromyotomy (n=83) and Group B had a pyloromyotomy (n=159). Gastric outlet obstruction was strictly defined to include patients with clinical delayed gastric emptying supported by symptoms, barium swallow studies, persistent air-fluid level and dilated conduit on radiography, or endoscopic or surgical intervention to improve gastric drainage. The groups were similar except for a higher percentage of cervical anastomosis and older age (64- vs 61-year-old) in Group A. The overall incidence of gastric outlet obstruction was 15.3% (37/242). Pyloromyotomy did not reduce the incidence of gastric outlet obstruction (Group A 9.6% vs Group B 18.2%, p=0.078). One patient required a late pyloroplasty. Successful management of gastric outlet obstruction with pyloric dilatation (96.7%, 28/29) was unaffected by pyloromyotomy. There was no difference in length of stay, pneumonia (Group A 27.7% vs Group B 19.5%, p=0.15), respiratory failure or anastomotic stricture. There was no difference in anastomotic leaks when controlling for the anatomic location of the anastomosis (p=0.36). Mortality was equivalent between groups (2.4 vs 2.5%, p=0.96). Pyloromyotomy does not reduce the incidence of symptomatic delayed gastric emptying after esophagectomy. Post-operative gastric outlet obstruction can be effectively managed with endoscopic pyloric dilatation. Routine pyloromyotomy for the prevention of post-esophagectomy gastric outlet obstruction may be unwarranted.
    European Journal of Cardio-Thoracic Surgery 03/2007; 31(2):149-53. · 2.67 Impact Factor
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    ABSTRACT: Although early extubation of esophagectomy patients has been found to be feasible, safe, and associated with low morbidity, there is no uniform standard of care among high volume centers. Our objective is to examine a contemporary series of esophagectomies and identify the feasibility and outcome of an early extubation policy. This study is a retrospective review of all patients who underwent esophagectomy between January 2003 and December 2004 at the Massachusetts General Hospital. One hundred and two patients were analyzed from 129 consecutive patients who underwent esophagectomy and subsequently divided in two groups: The early extubation group was extubated in the operating room and the late extubation group was extubated in the intensive care unit (ICU). Ninety percent were extubated early. Although most patients underwent a transthoracic or thoracoabdominal esophagectomy, the operative approach did not influence failure to extubate. Neoadjuvant therapy was not predictive of extubation failure. Most patients age 70 or greater (86%) were extubated early. There were three nonelective reintubations in the early extubation group secondary to acute respiratory distress syndrome. The median length of stay was 11 days and median ICU stay was one day. The 30-day mortality was 1.9% and the median survival was 28 months. Attention to restricted intraoperative fluid balance, limited blood loss, anesthetic technique, and epidural use permit most patients undergoing esophageal resection to be safely extubated immediately postresection in the operating room.
    The Annals of thoracic surgery 01/2007; 82(6):2037-41. · 3.45 Impact Factor