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ABSTRACT: BACKGROUND: The role of surgical resection for stage IIIA non-small cell lung cancer (NSCLC) is unclear. We sought to examine outcomes after pneumonectomy for patients with stage IIIA disease. METHODS: All patients with stage IIIA NSCLC who had pneumonectomy at a single institution between 1999 and 2010 were reviewed. The Kaplan-Meier method was used to estimate long-term survival and multivariable Cox proportional hazards regression was used to identify clinical characteristics associated with survival. RESULTS: During the study period, 324 patients had surgical resection of stage IIIA NSCLC. Pneumonectomy was performed in 55 patients, 23 (42%) of whom had N2 disease. Induction treatment was used in 17 patients (31%) overall and in 11 of the patients (48%) with N2 disease. Perioperative mortality was 9% (n = 5) overall and 18% (n = 3) in patients that had received induction therapy (p = 0.17). Complications occurred in 32 patients (58%). Three-year survival was 36% and 5-year survival was 29% for all patients. Three-year survival was 40% for N0-1 patients and 29% for N2 patients (p = 0.59). In multivariable analysis, age over 60 years (hazard ratio [HR] 3.65, p = 0.001), renal insufficiency (HR 5.80, p = 0.007), and induction therapy (HR 2.17, p = 0.05) predicted worse survival, and adjuvant therapy (HR 0.35, p = 0.007) predicted improved survival. CONCLUSIONS: Long-term survival after pneumonectomy for stage IIIA NSCLC is within an acceptable range, but pneumonectomy may not be appropriate after induction therapy or in patients with renal insufficiency. Patient selection and operative technique that limit perioperative morbidity and facilitate the use of adjuvant chemotherapy are critical to optimizing outcomes.
The Annals of thoracic surgery 03/2013; · 3.74 Impact Factor
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ABSTRACT: OBJECTIVE: We sought to evaluate the effect of tumor size, location, and clinical nodal status on outcomes after thoracoscopic lobectomy for lung cancer. METHODS: All patients who underwent attempted thoracoscopic lobectomy for lung cancer between June 1999 and October 2010 at a single institution were reviewed. A model for morbidity including published risk factors as well as tumor size, location, and clinical N status was developed by multivariable logistic regression. RESULTS: During the study period, 916 thoracoscopic lobectomies met study criteria: 329 for peripheral, clinical N0 tumors ≤3 cm and 504 for tumors that were central, clinical node positive, or >3 cm. Tumor location could not be documented for 83 patients. Conversions to thoracotomy occurred in 36 patients (4%); patients with clinically node-positive disease had higher conversion rates (11 conversions in 153 clinical N1 to N3 patients [7.2%] vs 25 in 763 clinical N0 patients [3.3%, P = .03]. Overall operative mortality was 1.6% (14 patients) and morbidity was 32% (296 patients). Although patients with larger tumors (P = .006) and central tumors (P = .01) had increased complications by univariate analysis, tumor size >3 cm (P = .17) and central location (P = .5) did not predict significantly overall morbidity in multivariate analysis. Clinical node status did not predict increased complications by univariate or multivariate analysis. Significant predictors of morbidity in multivariable analysis were increasing age, decreasing forced expiratory volume in 1 second, prior chemotherapy, and congestive heart failure. CONCLUSIONS: Thoracoscopic lobectomy for lung cancers that are central, clinically node positive, or >3 cm does not confer increased morbidity compared with peripheral, clinical N0 cancers that are <3 cm.
The Journal of thoracic and cardiovascular surgery 11/2012; · 3.41 Impact Factor
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ABSTRACT: Using a national database, we asked whether video-assisted thoracoscopic surgery (VATS) lobectomy is beneficial in high-risk pulmonary patients.
Single-institution series demonstrated benefit of VATS lobectomy over lobectomy via thoracotomy in poor pulmonary function patients [FEV1 (forced expiratory volume in 1 second) or DLCO (diffusion capacity of the lung to carbon monoxide) <60% predicted].
The STS General Thoracic Database was queried for patients having undergone lobectomy by either thoracotomy or VATS between 2000 and 2010. Postoperative pulmonary complications included those defined by the STS database.
In the STS database, 12,970 patients underwent lobectomy (thoracotomy, n = 8439; VATS, n = 4531) and met inclusion criteria. The overall rate of pulmonary complications was 21.7% (1832/8439) and 17.8% (806/4531) in patients undergoing lobectomy with thoracotomy and VATS, respectively (P < 0.0001). In a multivariable model of pulmonary complications, thoracotomy approach (OR = 1.25, P < 0.001), decreasing FEV1% predicted (OR = 1.01 per unit, P < 0.001) and DLCO% predicted (OR = 1.01 per unit, P < 0.001), and increasing age (1.02 per year, P < 0.001) independently predicted pulmonary complications. When examining pulmonary complications in patients with FEV1 less than 60% predicted, thoracotomy patients have markedly increased pulmonary complications when compared with VATS patients (P = 0.023). No significant difference is noted with FEV1 more than 60% predicted.
Poor pulmonary function predicts respiratory complications regardless of approach. Respiratory complications increase at a significantly greater rate in lobectomy patients with poor pulmonary function after thoracotomy compared with VATS. Planned surgical approach should be considered while determining whether a high-risk patient is an appropriate resection candidate.
Annals of surgery 08/2012; 256(3):487-93. · 7.90 Impact Factor
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ABSTRACT: Identifying the cells of origin of lung cancer may lead to new therapeutic strategies. Previous work has focused upon the putative bronchoalveolar stem cell at the bronchioalveolar duct junction as a cancer cell of origin when a codon 12 K-Ras mutant is induced via adenoviral Cre inhalation. In the present study, we use two "knock-in" Cre-estrogen receptor alleles to inducibly express K-RasG12D in CC10(+) epithelial cells and Sftpc(+) type II alveolar cells of the adult mouse lung. Analysis of these mice identifies type II cells, Clara cells in the terminal bronchioles, and putative bronchoalveolar stem cells as cells of origin for K-Ras-induced lung hyperplasia. However, only type II cells appear to progress to adenocarcinoma.
Proceedings of the National Academy of Sciences 03/2012; 109(13):4910-5. · 9.68 Impact Factor
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ABSTRACT: Distinguishing between synchronous primary lung cancers and metastatic disease in patients with bilateral lung masses is often difficult. The objective of this study is to examine outcomes associated with a strategy of performing staged bilateral resections in patients without N2 disease based on invasive mediastinal staging and without distant metastases.
Patients undergoing resections of bilateral synchronous primary lung cancer at our institution between 1997 and 2010 were reviewed. Perioperative complications were graded according to National Cancer Institute guidelines. Survival was estimated using the Kaplan-Meier method and compared using a log-rank test. End points included overall survival, disease-free survival, operative death, cancer recurrence, and postoperative complications.
Resections of bilateral synchronous primary lung cancers were performed in 47 patients. Forty-five patients (96%) had at least a unilateral thoracoscopic approach; 28 (60%) had bilateral thoracoscopic approaches. The median postresection length of stay was 3 days. Thirteen patients (28%) had a postoperative complication; only 3 (6%) were grade 3 or higher. There was 1 perioperative death (2%). Eleven patients received adjuvant therapy; only 3 patients in whom adjuvant therapy was indicated did not receive the recommended treatment. The overall 3-year survival was 35%. Survival of patients whose bilateral tumors had identical histology did not differ from patients whose histology was different (p = 0.57). Three-year disease-free survival was 24%.
Aggressive surgical treatment of apparent synchronous bilateral primary lung cancer can be performed with low morbidity. Most patients tolerate the bilateral surgeries and adjuvant therapy. Overall survival is sufficiently high to support this aggressive approach.
The Annals of thoracic surgery 02/2012; 93(4):1055-60; discussion 1060. · 3.74 Impact Factor
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ABSTRACT: Lobectomy with an en-bloc chest wall resection is an effective but potentially morbid treatment of lung cancer invading the chest wall. Minimally invasive approaches to lobectomy have reduced morbidity compared with thoracotomy for early stage lung cancer, but there is insufficient evidence regarding the feasibility of hybrid thoracoscopic lobectomy chest wall resection. We reviewed our experience with an en-bloc chest wall resection and lobectomy to evaluate the outcomes of a hybrid approach using thoracoscopic lobectomy combined with the chest wall resection where rib spreading is avoided.
All patients who underwent lobectomy and en-bloc chest wall resection with ribs for primary non-small cell lung cancer from January 2000 to July 2010 were reviewed. Starting in April 2003, a hybrid approach was introduced where thoracoscopic techniques were utilized to accomplish the pulmonary resection and a limited counter incision was used to perform the en-bloc resection of the chest wall, avoiding scapular mobilization and rib spreading. Preoperative, perioperative and outcome variables were assessed using the standard descriptive statistics.
During the study period, 105 patients underwent en-bloc lobectomy and chest wall resection, including 93 patients with resection via thoracotomy and 12 patients with resection via the hybrid thoracoscopic approach. Complete resection was achieved in all patients in both groups. Tumour size and the extent of resection were similar in the two groups. There were no conversions and no perioperative mortality in the hybrid group. Post-operative outcomes were similar, although patients who underwent the hybrid approach had a shorter length of stay (P = 0.03).
A hybrid approach that combines thoracoscopic lobectomy and chest wall resection is feasible and effective in selected patients. The use of a limited counter incision without rib spreading does not compromise oncologic efficacy. Further experience is needed to determine if this approach provides any advantage in outcomes, including post-operative morbidity.
European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 12/2011; 41(4):888-92. · 2.40 Impact Factor
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ABSTRACT: Management of patients requiring antiplatelet therapy with clopidogrel (Plavix) and major lung resection must balance the risks of bleeding and cardiovascular events. We reviewed our experience with patients treated with clopidogrel perioperatively to examine outcomes, including results of a new strategy for high-risk patients.
Patients who underwent major lung resection and received perioperative clopidogrel between January 2005 and September 2010 were reviewed. Initially, clopidogrel management consisted of discontinuation approximately 5 days before surgery and resumption immediately after surgery. After July 2010, high-risk patients (drug-eluting coronary stent placement within prior year or previous coronary event after clopidogrel discontinuation) were admitted 2 to 3 days preoperatively and bridged with the intravenous glycoprotein IIb/IIIa receptor inhibitor eptifibatide (Integrilin) according to a multidisciplinary cardiology/anesthesiology/thoracic surgery protocol. Outcomes were compared with control patients (matched for preoperative risk factors and extent of pulmonary resection) who did not receive perioperative clopidogrel.
Fifty-four patients who had major lung resection between January 2005 and September 2010 and received clopidogrel perioperatively were matched with 108 control subjects. Both groups had similar mortality, postoperative length of stay, and no differences in the rates of perioperative transfusions, reoperations for bleeding, myocardial infarctions, and strokes. Seven of the 54 clopidogrel patients were admitted preoperatively for an eptifibatide bridge. Two of these patients received perioperative transfusions, but there were no deaths, reoperations, myocardial infarctions, or stroke.
Patients taking clopidogrel can safely undergo major lung resection. Treatment with an eptifibatide bridge may minimize the risk of cardiovascular events in higher risk patients.
The Annals of thoracic surgery 12/2011; 92(6):1971-6. · 3.74 Impact Factor
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ABSTRACT: Patients achieving a mediastinal pathologic complete response with neoadjuvant chemotherapy have improved outcomes compared with patients with persistent N2 disease. How to best manage this latter group of patients is unknown, prompting a review of our institutional experience.
All patients who initiated neoadjuvant therapy for non-small-cell lung cancer from 1995 to 2008 were evaluated. The patients were excluded if they had received preoperative radiotherapy, had had a mediastinal pathologic complete response, or had evidence of disease progression after neoadjuvant chemotherapy. The clinical endpoints were calculated using the Kaplan-Meier product-limit method and compared using a log-rank test.
A total of 28 patients were identified. The median follow-up period was 24 months. Several neoadjuvant chemotherapy regimens were used, most commonly carboplatin with vinorelbine (36%) or paclitaxel (32%). A partial response to chemotherapy was noted in 23 (82%) and stable disease was noted in 5 (18%) on postchemotherapy imaging. Resection was performed in 22 of 28 patients, consisting of lobectomy in 14, pneumonectomy in 2, and wedge/segmentectomy in 6 (21/22 R0, 1/22 R1). There were no postoperative deaths. Postoperative therapy (radiotherapy and/or additional chemotherapy) was administered to 12 patients (55%). The remaining 6 patients generally received definitive radiotherapy with or without additional chemotherapy. The overall and disease-free survival rate at 1, 3, and 5 years was 75%, 37%, and 37% and 50%, 23%, and 19%, respectively. The survival rate at 5 years was similar between patients undergoing resection (34%) and those receiving definitive radiotherapy with or without chemotherapy (40%; P = .73).
Disease-free and overall survival was sufficiently high to warrant aggressive local therapy (surgery or radiotherapy) in patients with persistent N2 disease after neoadjuvant chemotherapy.
The Journal of thoracic and cardiovascular surgery 11/2011; 142(5):1175-9. · 3.41 Impact Factor
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ABSTRACT: Post-sternotomy mediastinitis reduces survival after cardiac surgery, potentially further affected by details of mediastinal vascularized flap reconstruction. The aim of this study was to evaluate survival after different methods for sternal reconstruction in mediastinitis.
Two hundred twenty-two adult cardiac surgery patients with post-sternotomy mediastinitis were reviewed. After controlling infection, often augmented by negative pressure therapy, muscle flap, omental flap, or secondary closure was performed. Outcomes were reviewed and survival analysis was performed.
Baseline characteristics were similar. In-hospital mortality (15.7%) did not differ between groups. Secondary closure was correlated with negative pressure therapy and reduced length hospital of stay. Recurrent wound complications were more common with muscle flap repair. Survival was unaffected by sternal repair technique. By multivariate analysis, heart failure, sepsis, age, and vascular disease independently predicted mortality, while negative pressure therapy was associated with survival.
Choice of sternal repair was unrelated to survival, but mediastinal treatment with negative pressure therapy promotes favorable early and late outcomes.
American journal of surgery 09/2011; 202(5):565-7. · 2.36 Impact Factor
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ABSTRACT: The incorporation of research into a career in thoracic surgery is a complex process. Ideally, the preparation for a career in academic thoracic surgery begins with a research fellowship during training. In the academic setting, a research portfolio might include clinical research, translational research, or basic research. Using strategies for developing collaboration, thoracic surgeons in community-based programs may also be successful clinical investigators. In addition to the rigors of conducting research, strategies for reserving protected time and obtaining grant support must be considered to be successful in academic surgery.
Thoracic Surgery Clinics 08/2011; 21(3):369-77.
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ABSTRACT: Gastroesophageal reflux disease (GERD) in lung recipients is associated with decreased survival and attenuated allograft function. This study evaluates fundoplication in preventing GERD-related allograft dysfunction.
Prospectively collected data on patients who underwent transplantation between January 2001 and August 2009 were included. Lung transplant candidates underwent esophageal pH probe testing before transplantation and surveillance spirometry evaluation after transplantation. Bilateral lung transplant recipients who had pretransplant pH probe testing and posttransplant 1-year forced expiratory volume in the first second of expiration (FEV1) data were included for analysis.
Of 297 patients who met study criteria, 222 (75%) had an abnormal pH probe study before or early after transplantation and 157 (53%) had a fundoplication performed within the first year after transplantation. Patients with total proximal acid contact times greater than 1.2% or total distal acid contact times greater than 7.0% demonstrated an absolute decrease of 9.4% (±4.6) or 12.0% (±5.4) in their respective mean 1-year FEV1 values. Patients with abnormal acid contact times who did not undergo fundoplication had considerably worse predicted peak and 1-year FEV1 results compared with recipients receiving fundoplication (peak percent predicted=75% vs. 84%; p=0.004 and 1-year percent predicted=68% vs. 77%; p=0.003, respectively).
Lung transplant recipients with abnormal esophageal pH studies attain a lower peak allograft function as well as a diminished 1-year FEV1 after transplantation. However a strategy of early fundoplication in these recipients appears to preserve lung allograft function.
The Annals of thoracic surgery 08/2011; 92(2):462-8; discussion; 468-9. · 3.74 Impact Factor
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ABSTRACT: Mediastinal lymph node dissection (MLND) is an integral component of complete resection for non-small cell lung cancer (NSCLC). This study analyzed the National Comprehensive Cancer Network's (NCCN) NSCLC Database to compare the efficacy of MLND during lobectomy by video-assisted thoracoscopy surgery (VATS) and thoracotomy (open).
The NCCN NSCLC Database was queried to identify patients who underwent lobectomy to analyze the adequacy of MLND by the number of LN stations. The percentage of patients with at least three N2 stations, the number of N2 LN stations, and the total number of LN stations (N1+N2) resected was compared by approach.
Of 4215 patients with NSCLC (January 2007 to September 2010), 388 patients underwent lobectomy (199 VATS and 189 open) and met entry criteria. The groups were similar in age, sex, comorbidities, performance status, and histology. MLN assessment was similar in both groups as measured by number of N2 stations (median, 3 stations; p=0.12). At least three MLN stations were assessed in 130 patients (66%) in the VATS group vs 107 patients (58%) in the open group (p=0.12). The total number of N1+N2 stations resected for each group was also similar (median, 4 in both groups (p=0.06).
The NCCN database indicates at least three MLN stations were assessed in most patients who underwent lobectomy by either approach. As evaluated by the number of LN stations, there was no difference in the efficacy of MLN dissection by approach.
The Annals of thoracic surgery 07/2011; 92(1):226-31; discussion 231-2. · 3.74 Impact Factor
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ABSTRACT: The management of chronic empyema associated with a bronchopleural fistula can be a particularly challenging problem. Successful eradication may not occur without interposition of healthy vascularized tissue. Pedicled muscle flaps for coverage on the thorax have been well described. However, secondary to trauma or previous surgical procedures, a pedicle flap may not be sufficiently sized or available. Free tissue transfer is an attractive option to provide the appropriate vascularized tissue.
Six patients with chronic empyema-bronchopleural fistulae were reconstructed with 4 rectus abdominis myocutaneous and 2 gracilis muscle flaps. The choice of recipient vessels was dictated by existing local anatomy but included intercostal, thoracodorsal, thoracoacromial, azygous, and circumflex humeral vessels. One flap required interposition saphenous vein grafts for both artery and vein.
Patient follow-up ranged from 2 to 14 years. There were no episodes of flap loss or postoperative mortality. Empyema resolution without recurrent bronchopleural fistula was achieved in all patients.
Free tissue transfer is an excellent option for vascularized tissue interposition in patients who are not candidates for pedicled muscle transfer. Multiple potential recipient vessels provide tremendous versatility, arguing for early consideration of free tissue transfer.
The Annals of thoracic surgery 03/2011; 91(3):865-8. · 3.74 Impact Factor
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ABSTRACT: To evaluate how well the tumor, node, metastasis (TNM) 6 and TNM 7 staging systems predict rates of local/regional recurrence (LRR) after surgery alone for non-small cell lung cancer.
All patients who underwent surgery for non-small cell lung cancer at Duke between 1995 and 2005 were reviewed. Those undergoing sublobar resections, with positive margins or involvement of the chest wall, or those who received any chemotherapy or radiation therapy (RT) were excluded. Disease recurrence at the surgical margin, or within ipsilateral hilar and/or mediastinal lymph nodes, was considered as a LRR. Stage was assigned based on both TNM 6 and TNM 7. Rates of LRR were estimated using the Kaplan-Meier method. A Cox regression analysis evaluated the hazard ratio of LRR by stage within TNM 6 and TNM 7.
A total of 709 patients were eligible for the analysis. Median follow-up was 32 months. For all patients, the 5-year actuarial risk of LRR was 23%. Conversion from TNM 6 to TNM 7 resulted in 21% stage migration (upstaging in 13%; downstaging in 8%). Five-year rates of LRR for stages IA, IB, IIA, IIB, and IIIA disease using TNM 6 were 16%, 26%, 43%, 35%, and 40%, respectively. Using TNM 7, corresponding rates were 16%, 23%, 37%, 39%, and 30%, respectively. The hazard ratios for LRR were statistically different for IA and IB in both TNM 6 and 7 but were also different for IB and IIA in TNM 7.
LRR risk increases monotonically for stages IA to IIB in the new TNM 7 system. This information might be valuable when designing future studies of postoperative RT.
Journal of thoracic oncology: official publication of the International Association for the Study of Lung Cancer 02/2011; 6(4):757-61. · 4.55 Impact Factor
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ABSTRACT: Age is an important risk factor for morbidity after lung resection. This study was performed to identify specific risk factors for complications after lung resection in octogenarians.
A prospective database containing patients aged 80 years or older, who underwent lung resection at a single institution between January 2000 and June 2009, was reviewed. Preoperative, histopathologic, perioperative, and outcome variables were assessed. Morbidity was measured as a patient having any perioperative event as defined by the Society of Thoracic Surgeons General Thoracic Surgery Database. A multivariable risk model for morbidity was developed using a panel of established preoperative and operative variables. Survival was calculated using the Kaplan-Meier method.
During the study period, 193 patients aged 80 years or older (median age 82 years) underwent lung resection: wedge resection in 77, segmentectomy in 13, lobectomy in 96, bilobectomy in four, and pneumonectomy in three. Resection was accomplished via thoracoscopy in 149 patients (77%). Operative mortality was 3.6% (seven patients) and morbidity was 46% (89 patients). A total of 181 (94%) patients were discharged directly home. Postoperative events included atrial arrhythmia in 38 patients (20%), prolonged air leak in 24 patients (12%), postoperative transfusion in 22 patients (11%), delirium in 16 patients (8%), need for bronchoscopy in 14 patients (7%), and pneumonia in 10 patients (5%). Significant predictors of morbidity by multivariable analysis included resection greater than wedge (odds ratio 2.98, p=0.006), thoracotomy as operative approach (odds ratio 2.6, p=0.03), and % predicted forced expiratory volume in 1s (odds ratio 1.28 for each 10% decrement, p=0.01).
Octogenarians can undergo lung resection with low mortality. Extent of resection, use of a thoracotomy, and impaired lung function increase the risk of complications. Careful evaluation is necessary to select the most appropriate approach in octogenarians being considered for lung resection.
European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 01/2011; 39(6):989-94. · 2.40 Impact Factor
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ABSTRACT: The accurate diagnosis of idiopathic pulmonary fibrosis (IPF) is a major clinical challenge. We developed a model to diagnose IPF by applying Bayesian probit regression (BPR) modelling to gene expression profiles of whole lung tissue.
Whole lung tissue was obtained from patients with idiopathic pulmonary fibrosis (IPF) undergoing surgical lung biopsy or lung transplantation. Controls were obtained from normal organ donors. We performed cluster analyses to explore differences in our dataset. No significant difference was found between samples obtained from different lobes of the same patient. A significant difference was found between samples obtained at biopsy versus explant. Following preliminary analysis of the complete dataset, we selected three subsets for the development of diagnostic gene signatures: the first signature was developed from all IPF samples (as compared to controls); the second signature was developed from the subset of IPF samples obtained at biopsy; the third signature was developed from IPF explants. To assess the validity of each signature, we used an independent cohort of IPF and normal samples. Each signature was used to predict phenotype (IPF versus normal) in samples from the validation cohort. We compared the models' predictions to the true phenotype of each validation sample, and then calculated sensitivity, specificity and accuracy.
Surprisingly, we found that all three signatures were reasonably valid predictors of diagnosis, with small differences in test sensitivity, specificity and overall accuracy.
This study represents the first use of BPR on whole lung tissue; previously, BPR was primarily used to develop predictive models for cancer. This also represents the first report of an independently validated IPF gene expression signature. In summary, BPR is a promising tool for the development of gene expression signatures from non-neoplastic lung tissue. In the future, BPR might be used to develop definitive diagnostic gene signatures for IPF, prognostic gene signatures for IPF or gene signatures for other non-neoplastic lung disorders such as bronchiolitis obliterans.
BMC Medical Genomics 01/2011; 4:70. · 3.69 Impact Factor
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ABSTRACT: This study assesses the effect of using a comprehensive swallowing evaluation before starting oral feedings on aspiration detection and pneumonia occurrence after esophagectomy.
The records of all patients undergoing esophagectomy between January 1996 and June 2009 were reviewed. Multivariable logistic regression analysis assessed the effect of preoperative and operative variables on the incidence of aspiration and pneumonia. Separate analyses were performed on patients before (early era, 1996-2002) and after (later era, 2003-2009) a rigorous swallowing evaluation was used routinely before starting oral feedings.
During the study period, 799 patients (379 from the early era and 420 from the later era) underwent esophagectomy; 30-day mortality was 3.5% (28 patients). Cervical anastomoses were performed in 76% of patients in the later era compared with 40% of patients in the early era. Overall, 96 (12%) patients had evidence of aspiration postoperatively, and the pneumonia incidence was 14% (113 patients). Age (odds ratio, 1.05 per year; P < .0001) and later era (odds ratio, 1.90; P = .0001) predicted aspiration in all patients in a multivariable model. In the early era, cervical anastomosis and aspiration independently predicted pneumonia. With a comprehensive swallowing evaluation in the later era, the detected incidence of aspiration increased (16% vs 7%, P < .0001), whereas the incidence of pneumonia decreased (11% vs 18%, P = .004) compared with the early era, such that neither anastomotic location nor aspiration predicted pneumonia in the later era.
Esophagectomy is often associated with occult aspiration. A comprehensive swallowing evaluation for aspiration before initiating oral feedings significantly decreases the occurrence of pneumonia.
The Journal of thoracic and cardiovascular surgery 09/2010; 140(6):1266-71. · 3.41 Impact Factor
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The Annals of thoracic surgery 07/2010; 90(1):115-6. · 3.74 Impact Factor
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ABSTRACT: Pulmonary function tests predict respiratory complications and mortality after lung resection through thoracotomy. We sought to determine the impact of pulmonary function tests upon complications after thoracoscopic lobectomy.
A model for morbidity, including published preoperative risk factors and surgical approach, was developed by multivariable logistic regression. All patients who underwent lobectomy for primary lung cancer between December 1999 and October 2007 with preoperative forced expiratory volume in 1 second (FEV1) or diffusion capacity to carbon monoxide (Dlco) 60% or less predicted were reviewed. Preoperative, histopathologic, perioperative, and outcome variables were assessed using standard descriptive statistics. Pulmonary complications were defined as atelectasis requiring bronchoscopy, pneumonia, reintubation, and tracheostomy.
During the study period, 340 patients (median age 67) with Dlco or FEV1 60% or less (mean % predicted FEV1, 55+/-1; mean % predicted Dlco, 61+/-1) underwent lobectomy (173 thoracoscopy, 167 thoracotomy). Operative mortality was 5% (17 patients) and overall morbidity was 48% (164 patients). At least one pulmonary complication occurred in 57 patients (17%). Significant predictors of pulmonary complications by multivariable analysis for all patients included Dlco (odds ratio 1.03, p=0.003), FEV1 (odds ratio 1.04, p=0.003), and thoracotomy as surgical approach (odds ratio 3.46, p=0.0007). When patients were analyzed according to operative approach, Dlco and FEV1 remained significant predictors of pulmonary morbidity for patients undergoing thoracotomy but not thoracoscopy.
In patients with impaired pulmonary function, preoperative pulmonary function tests are predictors of pulmonary complications when lobectomy for lung cancer is performed through thoracotomy but not through thoracoscopy.
The Annals of thoracic surgery 04/2010; 89(4):1044-51; discussion 1051-2. · 3.74 Impact Factor
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ABSTRACT: Several single-institution series have demonstrated that compared with open thoracotomy, video-assisted thoracoscopic lobectomy may be associated with fewer postoperative complications. In the absence of randomized trials, we queried the Society of Thoracic Surgeons database to compare postoperative mortality and morbidity following open and video-assisted thoracoscopic lobectomy. A propensity-matched analysis using a large national database may enable a more comprehensive comparison of postoperative outcomes.
All patients having lobectomy as the primary procedure via thoracoscopy or thoracotomy were identified in the Society of Thoracic Surgeons database from 2002 to 2007. After exclusions, 6323 patients were identified: 5042 having thoracotomy, 1281 having thoracoscopy. A propensity analysis was performed, incorporating preoperative variables, and the incidence of postoperative complications was compared.
Matching based on propensity scores produced 1281 patients in each group for analysis of postoperative outcomes. After video-assisted thoracoscopic lobectomy, 945 patients (73.8%) had no complications, compared with 847 patients (65.3%) who had lobectomy via thoracotomy (P < .0001). Compared with open lobectomy, video-assisted thoracoscopic lobectomy was associated with a lower incidence of arrhythmias [n = 93 (7.3%) vs 147 (11.5%); P = .0004], reintubation [n = 18 (1.4%) vs 40 (3.1%); P = .0046], and blood transfusion [n = 31 (2.4%) vs n = 60 (4.7%); P = .0028], as well as a shorter length of stay (4.0 vs 6.0 days; P < .0001) and chest tube duration (3.0 vs 4.0 days; P < .0001). There was no difference in operative mortality between the 2 groups.
Video-assisted thoracoscopic lobectomy is associated with a lower incidence of complications compared with lobectomy via thoracotomy. For appropriate candidates, video-assisted thoracoscopic lobectomy may be the preferred strategy for appropriately selected patients with lung cancer.
The Journal of thoracic and cardiovascular surgery 02/2010; 139(2):366-78. · 3.41 Impact Factor
