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James D Luketich,
Arjun Pennathur,
Omar Awais,
Ryan M Levy,
Samuel Keeley, Manisha Shende,
Neil A Christie,
Benny Weksler,
Rodney J Landreneau,
Ghulam Abbas,
Matthew J Schuchert,
Katie S Nason
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ABSTRACT: Esophagectomy is a complex operation and is associated with significant morbidity and mortality. In an attempt to lower morbidity, we have adopted a minimally invasive approach to esophagectomy.
Our primary objective was to evaluate the outcomes of minimally invasive esophagectomy (MIE) in a large group of patients. Our secondary objective was to compare the modified McKeown minimally invasive approach (videothoracoscopic surgery, laparoscopy, neck anastomosis [MIE-neck]) with our current approach, a modified Ivor Lewis approach (laparoscopy, videothoracoscopic surgery, chest anastomosis [MIE-chest]).
We reviewed 1033 consecutive patients undergoing MIE. Elective operation was performed on 1011 patients; 22 patients with nonelective operations were excluded. Patients were stratified by surgical approach and perioperative outcomes analyzed. The primary endpoint studied was 30-day mortality.
The MIE-neck was performed in 481 (48%) and MIE-Ivor Lewis in 530 (52%). Patients undergoing MIE-Ivor Lewis were operated in the current era. The median number of lymph nodes resected was 21. The operative mortality was 1.68%. Median length of stay (8 days) and ICU stay (2 days) were similar between the 2 approaches. Mortality rate was 0.9%, and recurrent nerve injury was less frequent in the Ivor Lewis MIE group (P < 0.001).
MIE in our center resulted in acceptable lymph node resection, postoperative outcomes, and low mortality using either an MIE-neck or an MIE-chest approach. The MIE Ivor Lewis approach was associated with reduced recurrent laryngeal nerve injury and mortality of 0.9% and is now our preferred approach. Minimally invasive esophagectomy can be performed safely, with good results in an experienced center.
Annals of surgery 06/2012; 256(1):95-103. · 7.90 Impact Factor
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ABSTRACT: Because of the rarity of the disease and long survival of most patients, the role of adjuvant radiation therapy in patients with surgically resected stage III thymoma is unclear, and few prospective studies are available. The objective was to evaluate the impact of postoperative radiation therapy after resection of stage III thymoma.
The Surveillance, Epidemiology, and End Results (SEER) database was queried for all patients with stage III thymoma who underwent surgical therapy and survived more than 30 days after diagnosis. Survival was estimated with the Kaplan-Meier method. The hazard ratio for death was determined using a Cox proportional hazard model.
There were 476 patients with stage III thymoma identified who underwent surgical therapy, did not receive preoperative radiotherapy, and had complete SEER records with regard to radiation treatment. Postoperative radiation therapy was given to 322 patients (67.6%). Patients who received postoperative radiation therapy were younger and had a higher rate of debulking surgery than patients who did not. Patients receiving postoperative radiation had a median overall survival of 127 months (95% confidence interval, 100.9 to 153.1) compared with 105 months (95% confidence interval, 76.9 to 133.1) in patients treated with surgery alone (p=0.038). However, in multivariate analysis, postoperative radiation was not a significant factor affecting overall survival. Disease-specific survival was significantly improved in the adjuvant radiation group, and in multivariate analysis, improved outcomes were associated with postoperative radiation (p=0.049).
In this large population-based study, most patients with stage III thymoma were treated with adjuvant radiation. Postoperative radiation was associated with improved disease-specific survival, but not improved overall survival.
The Annals of thoracic surgery 05/2012; 93(6):1822-8; discussion 1828-9. · 3.74 Impact Factor
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ABSTRACT: Small cell lung carcinoma (SCLC) is rarely treated with resection, either alone or combined with other modalities. This study evaluated the role of surgical resection in the treatment of stage I and II SCLC.
We queried the Surveillance, Epidemiology, and End Results (SEER) database for patients from 1988 to 2007 with SCLC. Survival was determined by Kaplan-Meier analysis and compared using the log-rank test. A Cox proportional hazard model identified relevant survival variables.
We identified 3,566 patients with stage I or II SCLC. Lung resection was performed in 895 (25.1%), wedge resection in 251 (28.0%), lobectomy or pneumonectomy in 637 (71.2%), and lung resection not otherwise specified in 7 (0.78%). Median survival was 34.0 months (95% confidence interval [CI], 29.0 to 39.0 months) vs 16.0 months (95% CI, 15.3 to 16.7; p<0.001) in nonsurgical patients. Median survival after lobectomy or pneumonectomy was 39.0 months (95% CI, 30.7 to 40.3) and significantly longer than after wedge resection (28.0 months; 95% CI, 23.2 to 32.8; p=0.001). However, survival after wedge resection was still significantly longer than survival in nonsurgical patients (p<0.001). Sex (p=0.013), age, stage at diagnosis, radiotherapy, and operation (all p<0.001) significantly affected survival. In the surgical patients, sex (p=0.001), age (p<0.001), final stage (p<0.001), and type of resection (p=0.01) were important determinants of survival.
Surgical resection as a component of treatment for stage I or II SCLC is associated with significantly improved survival and should be considered in the management of early-stage SCLC.
The Annals of thoracic surgery 03/2012; 94(3):889-93. · 3.74 Impact Factor
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Arjun Pennathur,
Irfan Qureshi,
Matthew J Schuchert,
Rajeev Dhupar,
Peter F Ferson,
William E Gooding,
Neil A Christie,
Sebastien Gilbert, Manisha Shende,
Omar Awais,
Joel S Greenberger,
Rodney J Landreneau,
James D Luketich
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ABSTRACT: The minimally invasive, video-assisted thoracoscopic surgical (VATS) approach to resection of the thymus is frequently practiced for benign disease; however, a VATS approach for thymoma remains controversial. The objective of the present study was to evaluate the feasibility of VATS thymectomy for the treatment of early-stage thymoma and to compare the outcomes with those after open resection.
A retrospective review of 40 patients who underwent surgical resection of early-stage thymoma during a 12-year period was conducted. Data on patient characteristics, morbidity, recurrence, and survival were collected. The primary endpoint studied was overall survival.
Of the 40 patients, 14 underwent thymectomy for stage I and 26 for stage II thymoma; 19 were men and 21 were women (median age, 64 years; range, 35-86 years). Open thymectomy was performed in 22 patients, and VATS was performed in 18. The operative mortality rate was 0%. The tumor stage and number of patients undergoing adjuvant radiotherapy were comparable in both surgical groups. The median length of hospital stay was shorter in the VATS group (3 days) than in the open group (5 days) (P = .0001). The median follow-up was 36 months. No significant differences were found in the estimated recurrence-free and overall 5-year survival rates (83%-100%) between the 2 groups.
VATS of early-stage thymoma appears safe and feasible and was associated with a shorter hospital stay. The oncologic outcomes were comparable in the open and VATS groups during intermediate-term follow-up. Additional follow-up is required to evaluate the long-term results of thoracoscopic thymectomy for early-stage thymoma.
The Journal of thoracic and cardiovascular surgery 03/2011; 141(3):694-701. · 3.41 Impact Factor
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ABSTRACT: Over the past decade, our technique of MIE has evolved considerably. In the incipient phase of our experience, we used a totally laparoscopic approach similar to that described in the initial reports from DePaula and colleagues and Swanstrom and Hansen. However, it was soon apparent that there were several critical disadvantages to a purely laparoscopic approach. Laparoscopic transhiatal mobilization of the esophagus offers suboptimal visualization of important periesophageal structures, including the inferior pulmonary vein and the left mainstem bronchus. Moreover, decreased visibility hindered hemostatic division of periesophageal vessels and negatively impacted the completeness of the mediastinal lymph node dissection. These problems are further exacerbated in taller patients. In light of these considerations, we soon transitioned to a laparoscopic-thoracoscopic McKeown approach (thoracoscopic mobilization of the intrathoracic esophagus, laparoscopic gastric tube creation, cervical anastomosis). To this date, the great majority of our minimally invasive esophagectomies (>500 cases) have been performed with this 3-field technique. Indeed, the procedure has been the mainstay of our experience in the past 10 years with reduced perioperative morbidity and mortality compared with many other open series. In our experience, perhaps the most significant technical concern with this operation is the cervical dissection. Recurrent laryngeal nerve injuries, perturbations in pharyngeal transit, and swallowing dysfunction even in the absence of recurrent nerve injury are not infrequent. Moreover, as described in open series using a cervical anastomosis, anastomotic stricture and leak have been shown to occur with increased frequency [35]. In short, there is a significant learning curve with the cervical dissection. Out of these concerns emerged our more recent experience with completely thoracoscopic-laparoscopic Ivor Lewis esophagectomy. However, we did first evolve through a transition phase whereby a mini-thoracotomy (hybrid approach) was performed for creation of the intrathoracic anastomosis. We believe that the experience with totally thoracoscopic-laparoscopic Ivor Lewis esophagectomy will ultimately reproduce the low morbidity and mortality we have previously published with our established MIE technique. The omission of a cervical dissection has reduced our recurrent nerve injury rate to zero. From a theoretical standpoint, one would presume that pharyngeal transit problems and oropharyngeal swallowing dysfunction should be reduced as well with a chest anastomosis. It should be emphasized that there is a steep operator learning curve associated with this approach. Indeed, thoracoscopic port placement is critical, as poorly positioned trocars can result in difficulty maneuvering instruments through the rigid chest wall. Additionally, both blood and lung can obscure visualization of the esophagus, which lies at the dependent aspect of the operative field. Prone positioning has been described as an alternative approach that may facilitate operative exposure and address such technical concerns. Low rates of anastomotic leak (3%), low mortality (1.5%), and equivalent stage-specific survival compared with open series have been shown with this thoracoscopic prone approach [36]. In conclusion, our technique of MIE has evolved such that laparoscopic-thoracoscopic Ivor Lewis esophagectomy has become our preferred approach. Although somewhat early in our experience, we are convinced that this operative technique is feasible with reproducible results. Perioperative morbidity and mortality are comparable with our previously established MIE with cervical anastomosis while essentially eliminating recurrent nerve injury, limiting the length of the gastric conduit required, and allowing a more aggressive gastric resection margin. Recent data from other publications also suggests that lymph node yields may be improved, although insufficient data exist at this time to comment on oncologic results or outcomes with this technique.
Advances in Surgery 01/2010; 44:101-16.
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ABSTRACT: Adenocarcinoma arising in the setting of Barrett's esophagus has the fastest increasing incidence of any malignancy in the United States. Advanced esophageal cancer carries an overall poor prognosis with most patients presenting with incurable disease. Over the past several years, new options have been introduced for the purpose of providing palliative therapy to improve quality of life. Stent placement is the most widely used palliative therapy and rapidly relieves dysphagia; however, distal migration continues to be a disadvantage. Laser therapy and brachytherapy are also administered but require repeated treatment sessions. Future options for providing effective therapy for endstage disease include improved stent designs to decrease migration and multimodality methods that combine several options in one treatment session. This article focuses primarily on palliation of unresectable tumors of the esophagus and gastroesophageal junction.
Surgical Oncology Clinics of North America 08/2009; 18(3):547-60. · 1.12 Impact Factor
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ABSTRACT: Laparoscopic repair of giant paraesophageal hernia (LRGPEH) is routinely performed in many centers, but high recurrence rates have led to concerns regarding this approach. We evaluate long-term recurrence rates, symptom improvement and correlation with radiographic recurrence, and risk factors for recurrence in our cohort of patients.
A cohort of consecutive patients with a minimum of 5 years potential follow-up (1997-2003) post-LRGPEH was identified from a prospective database. Clinical outcomes, barium esophagram (BE), and quality-of-life (QoL) measures were obtained.
Laparoscopic repair was successful in 185/187 patients. Routine clinical follow-up (median 77 months) was available for all patients. Detailed questionnaires and BE were obtained in 65% and 82% of patients. Gastroesophageal Reflux Disease Health-Related QoL (GERD-HRQoL) scores were excellent to good in 86.7%. BE (median 51 months) demonstrated radiographic hernia recurrence in 15% of patients, but without consistent symptom association. There was a trend toward increased risk of radiographic recurrence in patients with a history of pulmonary disease (p = 0.08). Seven reoperations (4.4%) were performed for symptomatic recurrence (median 44 months postoperative).
LRGPEH performed in our minimally invasive center of excellence resulted in a durable repair with a high degree of satisfaction and preservation of GERD-related QoL at a median follow-up of over 6 years.
Journal of Gastrointestinal Surgery 11/2008; 12(12):2066-75; discussion 2075-7. · 2.83 Impact Factor
