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ABSTRACT: Oesophageal carcinoma affects more than 450,000 people worldwide and the incidence is rapidly increasing. Squamous-cell carcinoma is the predominant form of oesophageal carcinoma worldwide, but a shift in epidemiology has been seen in Australia, the UK, the USA, and some western European countries (eg, Finland, France, and the Netherlands), where the incidence of adenocarcinoma now exceeds that of squamous-cell types. The overall 5-year survival of patients with oesophageal carcinoma ranges from 15% to 25%. Diagnoses made at earlier stages are associated with better outcomes than those made at later stages. In this Seminar we discuss the epidemiology, pathophysiology, diagnosis and staging, management, prevention, and advances in the treatment of oesophageal carcinoma.
The Lancet 02/2013; 381(9864):400-12. · 38.28 Impact Factor
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ABSTRACT: The incidence of esophageal adenocarcinoma is rapidly increasing in the western population. Despite aggressive treatment, survival after esophagectomy is suboptimal. The main objective of the present study was to evaluate the gene expression profiles in esophageal adenocarcinoma and determine their association with survival after resection.
We conducted a prospective National Institutes of Health/National Cancer Institute funded study to evaluate the prognostic significance of gene expression in patients with esophageal adenocarcinoma undergoing esophagectomy. Gene expression in tumor tissue was analyzed using high-throughput oligonucleotide arrays. The association of gene expression and overall survival was analyzed using the tail-strength statistic and Cox regression analysis. Gene signatures were constructed with semisupervised methods using principal components. A cross-validated risk score was devised by conducting 10-fold cross-validation, 100 times.
We evaluated the gene expression in 64 patients with esophageal adenocarcinoma who underwent esophagectomy. The median overall survival was 27 months (95% confidence interval 22 to not reached). After filtering, 10,214 probe sets were used for survival analysis. The tail-strength statistic for these probe sets (0.318) indicated a significant association with overall survival. Patients were classified into high- and low-risk groups, according to the gene signature. High-risk patients had a predicted median survival of 19 months, but the median was not reached for the low-risk group (P < .05). On multivariate analysis, the gene signature was independently associated with survival (hazard ratio, 2.22; P = .04).
Global gene expression levels were significantly associated with overall survival after esophagectomy. Furthermore, individual genes could be successfully combined into a strongly predictive, internally cross-validated gene signature. If validated further, these results could help direct additional clinical trials of neoadjuvant and adjuvant therapies for esophageal adenocarcinoma.
The Journal of thoracic and cardiovascular surgery 02/2013; 145(2):505-13. · 3.41 Impact Factor
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ABSTRACT: OBJECTIVE: In the current era, giant paraesophageal hernia repair by experienced minimally invasive surgeons has excellent perioperative outcomes when performed electively. However, nonelective repair is associated with significantly greater morbidity and mortality, even when performed laparoscopically. We hypothesized that clinical prediction tools using pretreatment variables could be developed that would predict patient-specific risk of postoperative morbidity and mortality. METHODS: We assessed 980 patients who underwent giant paraesophageal hernia repair (1997-2010; 80% elective and 97% laparoscopic). We assessed the association between clinical predictor covariates, including demographics, comorbidity, and urgency of operation, and risk for in-hospital or 30-day mortality and major morbidity. By using forward stepwise logistic regression, clinical prediction models for mortality and major morbidity were developed. RESULTS: Urgency of operation was a significant predictor of mortality (elective 1.1% [9/778] vs nonelective 8% [16/199]; P < .001) and major morbidity (elective 18% [143/781] vs nonelective 41% [81/199]; P < .001). The most common adverse outcomes were pulmonary complications (n = 199; 20%). A 4-covariate prediction model consisting of age 80 years or more, urgency of operation, and 2 Charlson comorbidity index variables (congestive heart failure and pulmonary disease) provided discriminatory accuracy for postoperative mortality of 88%. A 5-covariate model (sex, age by decade, urgency of operation, congestive heart failure, and pulmonary disease) for major postoperative morbidity was 68% predictive. CONCLUSIONS: Predictive models using pretreatment patient characteristics can accurately predict mortality and major morbidity after giant paraesophageal hernia repair. After prospective validation, these models could provide patient-specific risk prediction, tailored for individual patient characteristics, and contribute to decision-making regarding surgical intervention.
The Journal of thoracic and cardiovascular surgery 01/2013; · 3.41 Impact Factor
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ABSTRACT: BACKGROUND: The high expression of Bmi-1, a key regulatory component of the polycomb repressive complex-1, has been associated with many solid and hematological malignancies including esophageal squamous cell carcinoma. However, little is known about the role of Bmi-1 in esophageal adenocarcinoma. The aim of this study was to investigate the amplification and high expression of Bmi-1 and the associated clinicopathological characteristics in esophageal adenocarcinoma and squamous cell carcinoma. METHODS: The protein expression level of Bmi-1 was detected by immunohistochemistry (IHC) from tissue microarrays (TMA) constructed at the University of Rochester from using tissues accrued between 1997 and 2005. Tissues included adenocarcinoma, squamous cell carcinoma and precancerous lesion. Patients' survival data, demographic, histological diagnoses and tumor staging data were collected. The intensity (0--3) and percentage of the Bmi-1 expression in TMA slides were scored by two pathologists. Genomic DNA from 116 esophageal adenocarcinoma was analyzed for copy number aberrations using Affymetrix SNP 6.0 arrays. Fisher exact tests and Kaplan-Meier methods were used to analyze data. RESULTS: By IHC, Bmi-1 is focally expressed at the basal layers of almost all esophageal squamous mucosa, which was similar to the previous reports in other organs related with stem cells. Bmi-1 high expression significantly increased from squamous epithelium (7%), columnar cell metaplasia (22%), Barrett's esophagus (22%), to low- (45%) and high-grade dysplasia (43%) and adenocarcinoma (37%). The expression level of Bmi-1 was significantly associated with esophageal adenocarcinoma differentiation. In esophageal adenocarcinoma, Bmi-1 amplification was detected by DNA microarray in low percentage (3%). However, Bmi-1 high expression did not show the association with overall survival in both esophageal adenocarcinoma and squamous cell carcinoma. CONCLUSIONS: This study demonstrates that the high expression Bmi-1 is associated with the esophageal adenocarcinoma and precancerous lesion, which implies that Bmi-1 plays an important role in early carcinogenesis in esophageal adenocarcinoma.
BMC Gastroenterology 10/2012; 12(1):146. · 2.42 Impact Factor
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ABSTRACT: Minimally invasive esophagectomy (MIE) has become an established approach for the treatment of esophageal carcinoma. In comparison with open esophagectomy MIE reduces blood loss, respiratory complications, and length of hospital stay. At the University of Pittsburgh, the authors now predominantly perform a laparoscopic-thoracoscopic Ivor Lewis esophagectomy. This article details this technique, discusses the recently published series of more than 1000 esophagectomies performed by the authors during the last 15 years, and reviews the current literature on MIE.
Surgical Clinics of North America 10/2012; 92(5):1265-85. · 2.14 Impact Factor
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ABSTRACT: Energy-based tissue fusion technology is being increasingly used for vascular division in numerous intra-abdominal applications. Very few data, however, are available regarding the application of this technology in the chest during anatomic lung resection. In the present review, we evaluated the use of energy-based fusion and lung sealants during anatomic lung resection.
We performed a review of case series and published studies to evaluate the use of energy-based coagulative fusion technology and lung sealants during anatomic lung resection. We then used energy-based coagulative fusion technology during anatomic lung resection (segmentectomy or lobectomy) in 316 cases from 2008 to 2011. Two energy applications were applied to the arterial and venous branches before vessel division.
In the first 12 cases, we used a device with a small curved jaw (range, 3.3-4.7 mm). Two partial venous dehiscences were noted and controlled intraoperatively. For the remaining cases, we used a larger jaw (6 mm × 22 mm) with no arterial or venous dehiscence occurring (vessels ranged from 0.4 to 1.2 cm). Autologous or synthetic tissue sealants applied to the parenchymal staple lines might reduce the severity and duration of perioperative air leaks. Suture line buttressing with pericardial or absorbable biosynthetic polyester strips might reduce the severity of air leaks in patients with severe emphysema undergoing anatomic lung resection or lung volume reduction surgery.
The bipolar tissue fusion system provides a safe and effective technique for the division of the pulmonary arterial and venous branches during anatomic lung resection. Surgical sealants and buttressing adjuncts might reduce perioperative air leak potential.
The Journal of thoracic and cardiovascular surgery 09/2012; 144(3):S48-51. · 3.41 Impact Factor
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ABSTRACT: INTODUCTION: In an effort to reduce the morbidity and mortality associated with open esophagectomy, a minimally invasive approach to esophagectomy was introduced at the University of Pittsburgh Medical Center (UPMC) in 1996. The objective of this article is to discuss the optimization and refinement of minimally invasive esophagectomy (MIE) techniques over the 15-year experience at UPMC. We also reviewed the literature on technical improvements in MIE.
Literature highlights for MIE and related meta-analyses comparing open esophagectomy and MIE were reviewed. The rationale and outcomes of techniques refinements were discussed in detail.
Most meta-analyses and systematic reviews confirm the feasibility and safety of MIE and suggest similar oncologic outcomes as compared with open esophagectomy. Since 1996, over 1,000 minimally invasive esophagectomies have been performed at UPMC. We have made several refinements to the MIE procedure that we believe significantly improved our surgical outcomes. It included adjustment of width of the gastric conduit, application of omental flap, and conversion from minimally invasive, three-hole esophagectomy to minimally invasive Ivor Lewis esophagectomy.
MIE became a mainstay in the surgical treatment of esophageal cancer at UPMC. The technical improvements detailed above make the UPMC approach to MIE a feasible, safe, and efficient procedure.
Journal of Gastrointestinal Surgery 07/2012; 16(9):1768-74. · 2.83 Impact Factor
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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: BackgroundRecent adjuvant chemotherapy trials after resection of stage II and III non-small cell lung cancer (NSCLC) have identified
important survival differences among patients with immunohistochemical evidence suggesting platinum resistance. No clinical
information exists regarding the impact upon survival of patients treated with platinum agents who exhibit cellular evidence
of their tumors’ resistance to platinum. We evaluated the utility of the extreme drug resistance (EDR) assay to predict mortality
among a consecutive group of stage II through IV NSCLC patients receiving adjuvant or definitive platinum-based chemotherapy
after resection or surgical biopsy.
MethodsThe Extreme Drug Resistance (EDR) Assay is a clinically validated cellular proliferation assay used to test tumors for chemotherapy
drug resistance. Based on response in the EDR assay, tumor specimens from stage II through IV NSCLC patients were segregated
into three groups: extreme drug resistant (EDR), intermediate drug resistant (IDR), and low drug resistant (LDR). Patient
survival was evaluated after platinum-based chemotherapy.
ResultsPlatinum IDR/EDR was statistically significant in predicting shorter overall survival (29.8months vs. 15.6months) among
platinum IDR/EDR-resistant patients compared with LDR patients (P = 0.047). Median survival was 16.6months for patients with IDR/EDR to platinum and any other second agent of doublet therapy
compared with patients with LDR to any platinum-based doublet where median survival was not achieved (P = 0.0268).
ConclusionsThis is the first study to demonstrate the utility of the EDR assay to predict poor clinical outcome when platinum-based therapy
is used to treat patients with biological evidence of tumor resistance to platinum. These data corroborate the finding of
recent studies evaluating possible molecular correlates to poor response to specific chemotherapeutic agents.
Annals of Surgical Oncology 04/2012; 16(10):2848-2855. · 4.17 Impact Factor
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ABSTRACT: BackgroundDistortion of esophagogastric junction anatomy in patients with gastroesophageal reflux disease produces permanent dilation
of the gastric cardia proportional to disease severity, but it remains unclear whether this mechanism underlies reflux in
patients with isolated laryngopharyngeal reflux symptoms.
MethodIn a prospective study, 113 patients were stratified into three populations based on symptom complex: laryngopharyngeal reflux
symptoms, typical reflux symptoms, and both laryngopharyngeal and typical symptoms. Subjects underwent small-caliber upper
endoscopy in the upright position. Outcome measures included gastric cardia circumference, presence and size of hiatal hernia,
and prevalence of esophagitis and Barrett’s esophagus within each group.
ResultsThere were no differences in gastric cardia circumference between patient groups. The prevalence of Barrett’s esophagus was
20.4% overall and 15.6% in pure laryngopharyngeal reflux patients. Barrett’s esophagus patients had a greater cardia circumference
compared to those without it. In the upright position, patients with isolated laryngopharyngeal reflux display the same degree
of esophagogastric junction distortion as those with typical reflux symptoms, suggesting a similar pathophysiology.
ConclusionThis indicates that, although these patients may sense reflux differently, they have similar risks as patients with typical
symptoms. Further, the identification of Barrett’s esophagus in the absence of typical reflux symptoms suggests the potential
for occult disease progression and late discovery of cancer.
Journal of Gastrointestinal Surgery 04/2012; 12(11):1880-1887. · 2.83 Impact Factor
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ABSTRACT: Anatomic segmentectomy is a versatile sublobar resection approach that can be both diagnostic and therapeutic in the setting of the indeterminate pulmonary nodule (IPN), metastasectomy, as well as small, peripheral cancers. We analyzed the clinical indications and perioperative outcomes after anatomic segmentectomy and explored its utility in the diagnosis and treatment of IPNs and small stage IA lung cancers.
This study is a retrospective review of 785 consecutive patients undergoing anatomic segmentectomy from 2002 to 2010. Primary outcome variables include perioperative course, morbidity, mortality, recurrence patterns, and survival.
Surgical indications included IPN (62.4%), known lung cancer (27.6%), suspected metastasis (4.1%), bullous disease (3.7%), or other (2.2%). Video-assisted thoracic surgery was employed in 468 (59.6%) and open thoracotomy in 317 (40.4%) patients. Median length of stay was 6 days. Overall complication rate was 34.9%. Thirty-day mortality was 1.1%. Among 490 patients with an IPN, 381 (77.7%) were found to have lung cancer, 41 (8.4%) metastatic cancer, and 68 (13.9%) benign disease. Among patients with pathologic stage IA lung cancer, there was no difference in recurrence rates (14.5% vs 13.9%) or 5-year freedom from recurrence estimates (78% in each group, p=0.738) when comparing segmentectomy and lobectomy.
Anatomic segmentectomy provides acceptable morbidity and mortality when approaching the IPN. Cancer is identified in 86% of lesions. Complete surgical resection can be achieved with generous parenchymal margins and thorough nodal staging for small, peripheral stage IA non-small cell lung cancer. The use of anatomic segmentectomy should be considered in this era of competing image-guided diagnostic and therapeutic approaches to peripheral lung pathology.
The Annals of thoracic surgery 04/2012; 93(6):1780-5; discussion 1786-7. · 3.74 Impact Factor
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ABSTRACT: Esophageal cancer consists of two major histologic types: esophageal squamous cell carcinoma (ESCC), predominant globally, and esophageal adenocarcinoma (EAC), which has a higher incidence in westernized countries. Five-year overall survival is 15%. Clinical trials frequently combine histologic types although they are different diseases with distinct origins. In the evolving era of personalized medicine and targeted therapies, we hypothesized that ESCC and EAC have genomic differences important for developing new therapeutic strategies for esophageal cancer.
We explored DNA copy number abnormalities in 70 ESCCs with publicly available array data and 189 EACs from our group. All data was from single nucleotide polymorphism arrays. Analysis was performed using a segmentation algorithm. Log ratio thresholds for copy number gain and loss were set at ±0.2 (approximately 2.3 and 1.7 copies, respectively).
The ESCC and EAC genomes showed some copy number abnormalities with similar frequencies (eg, CDKN2A, EGFR, KRAS, MYC, CDK6, MET) but also many copy number abnormalities with different frequencies between histologic types, most of which were amplification events. Some of these regions harbor genes for which targeted therapies are currently available (VEGFA, ERBB2) or for which agents are in clinical trials (PIK3CA, FGFR1). Other regions contain putative oncogenes that may be targeted in the future.
Using single nucleotide polymorphism arrays we compared genomic abnormalities in a large cohort of EACs and ESCCs. We report here the similar and different frequencies of copy number abnormalities in ESCC and EAC. These results may allow development of histology-specific therapeutic agents for esophageal cancer.
The Annals of thoracic surgery 04/2012; 93(4):1101-6. · 3.74 Impact Factor
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Matthew J Schuchert,
André P Souza,
Ghulam Abbas,
Arjun Pennathur,
Katie S Nason,
Robert Jack,
Zachary D Horne,
James R Landreneau,
Marco Santana,
David O Wilson, James D Luketich,
Rodney J Landreneau
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ABSTRACT: We present the perioperative outcomes of patients undergoing an anterior "extended Chamberlain" minithoracotomy as an alternative approach to a hemi-clamshell sternotomy or extended lateral thoracotomy for safe and reliable access to the pulmonary hilum and subsequent anatomic pulmonary resection.
This study is a retrospective review of 162 patients undergoing anatomic lung resection through a mini anterior thoracotomy from 2002 to 2010. An 8-cm anterior thoracotomy was performed with the patient in a supine position, entering the chest through the second intercostal space. The pectoralis muscle fibers were split with preservation of the mammary artery medially and the thoracoacromial neurovascular bundle laterally. Primary outcome variables included hospital course, complications, and mortality rate.
The mean age was 63.9 (range, 20 to 85 years); female to male ratio was 71:91. Neoadjuvant therapy was used in 49 (30.2%) patients. Proposed resections were successful in 161 of 162 (99%) patients. Conversion to hemi-clamshell was required in 1 patient for vascular control. Complications occurred in 48 (29.6%) patients. Three (1.9%) perioperative deaths (2 pneumonectomies [6.3%], 1 lobectomy [1.0%]) occurred. Median length of stay was 8 days.
The "extended Chamberlain" mini anterior thoracotomy provides direct and expeditious, less-invasive access to the pulmonary hilum. This approach preserves muscle function and avoids partial sternotomy or extended lateral thoracotomy, and their associated incisional-related morbidity.
The Annals of thoracic surgery 03/2012; 93(5):1641-5; discussion 1646. · 3.74 Impact Factor
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Anne F Peery,
Toshitaka Hoppo,
Katherine S Garman,
Evan S Dellon,
Norma Daugherty,
Susan Bream,
Alejandro F Sanz,
Jon Davison,
Melissa Spacek,
Diane Connors,
Ashley L Faulx,
Amitabh Chak, James D Luketich,
Nicholas J Shaheen,
Blair A Jobe
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ABSTRACT: Endoscopic screening for esophageal neoplasia can identify patients eligible for early intervention for precancerous lesions. Unsedated transnasal esophagoscopy may provide an efficient and accurate endoscopic assessment with fewer risks and less cost, compared with conventional upper endoscopy.
To assess the feasibility, safety, acceptability, and yield of unsedated transnasal esophagoscopy in a primary care population.
Multicenter, prospective, cross-sectional study.
Two outpatient tertiary-care centers.
This study involved a general medical clinic population aged between 40 and 85 years.
Unsedated, office-based transnasal esophagoscopy.
Procedure yield; completeness of examination; procedure length; adverse events and complications; choking, gagging, pain, or anxiety during the examination; and overall tolerability.
A total of 426 participants (mean [± standard deviation] age 55.8 ± 9.5 years; 43% male) enrolled in the study, and 422 (99%) completed the examination. Mean (± standard deviation) examination time was 3.7 ± 1.8 minutes. There were no serious adverse events, and 12 participants (2.8%) reported minor complications. Participants reported minimal choking, gagging, pain, or anxiety. The examination was well-tolerated by most participants. Overall, 38% of participants had an esophageal finding that changed management (34% erosive esophagitis, 4% Barrett's esophagus).
Nonrandomized study, tertiary-care centers only, self-selected population with a large proportion reporting esophageal symptoms.
Unsedated transnasal esophagoscopy is a feasible, safe, and well-tolerated method to screen for esophageal disease in a primary care population. Endoscopic findings are common in this patient population.
Gastrointestinal endoscopy 03/2012; 75(5):945-953.e2. · 6.71 Impact Factor
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ABSTRACT: Chylothorax is a rare but potentially lethal complication of esophagectomy. This study evaluated the rate of postesophagectomy chylothorax, identified associated risk factors, and compared postoperative outcomes in patients with and without chylothorax.
We reviewed 892 consecutive patients who underwent esophagectomy (1997 to 2008). Preoperative, operative, and postoperative details, including adverse outcomes and mortality, were analyzed.
Postesophagectomy chylothorax occurred in 34 patients (3.8%). Chylothorax was significantly associated with 30-day major complications (85% vs 46%; p<0.001), including an increased likelihood of sepsis (p=0.001), pneumonia (p=0.009), reintubation (p=0.002) or reoperation (p<0.001), and death (17.7% vs 3.9%, p<0.001). Median length of stay was 17 vs 8 days (p=0.005). Median time to chylothorax diagnosis was 5 days. Thoracic duct ligation was performed in 21 (62%) at a median 13 days after esophagectomy. Two patients required repeat duct ligation for persistent chylothorax. Squamous cell cancer histology (9 of 34; 26%) was an independent predictor of postoperative chylothorax (odds ratio, 4.18; 95% confidence interval, 1.39 to 12.6). Odds of chylothorax were 36 times greater with average daily chest tube output exceeding 400 mL in the first 6 postoperative days (odds ratio, 35.9; 95% confidence interval, 8.2 to 157.8).
Postoperative chylothorax is associated with significant postoperative morbidity and mortality. Patients with squamous cell cancer may be at increased risk. In addition, average daily chest tube output exceeding 400 mL in the early postoperative period should prompt fluid analysis for chylothorax to facilitate early diagnosis and consideration of thoracic duct ligation.
The Annals of thoracic surgery 03/2012; 93(3):897-903; discussion 903-4. · 3.74 Impact Factor
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Matthew J Schuchert,
Omar Awais,
Ghulam Abbas,
Zachary D Horne,
Katie S Nason,
Arjun Pennathur,
André P Souza,
Jill M Siegfried,
David O Wilson, James D Luketich,
Rodney J Landreneau
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ABSTRACT: Anatomic segmentectomy has been proposed as a reasonable alternative to lobectomy in the management of small early-stage non-small cell lung cancers. We reviewed our outcomes with anatomic segmentectomy versus lobectomy for stages IA and IB non-small cell lung cancer stratified by age and stage.
We conducted a retrospective review of prospectively-collected data analyzing outcomes after anatomic segmentectomy (n=305) for stage IA (n=187) or IB (n=118) NSCLC from 1999 to 2010. Lobectomy was performed in 594 patients for stage IA (n=290) and IB (n=304) disease during the same period. Surgical approach was stratified by stage and by the following age groups: less than 70, 70 to 79, and 80 or greater. Primary outcome variables included complications, mortality, recurrence patterns, and survival. Mean follow-up was 37 months.
Segmentectomy was associated with reduced complications (43.6% vs 58.7%) and mortality (0% vs 7.8%) in patients greater than 80 years old, without a difference in recurrence rates. There was no difference in complications or mortality in the younger age groups. Freedom from recurrence was similar between segmentectomy and lobectomy for stage IA tumors across all age groups. A reduced recurrence-free survival was seen with segmentectomy for stage IB tumors, especially with visceral pleural invasion (median 22.7 vs 29.6 months), p=0.048).
Segmentectomy appears to be a reasonable approach for early-stage NSCLC in patients 80 years of age or greater due to reduced morbidity and mortality with equivalent freedom from recurrence. Although equivalent survival was seen in all age groups for stage IA, these data further support the use of lobectomy for resection of stage IB tumors.
The Annals of thoracic surgery 03/2012; 93(3):929-35; discussion 935-6. · 3.74 Impact Factor
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ABSTRACT: The retrosternal route has been an alternative for oesophageal reconstruction after oesophagectomy. But the longer route and the higher incidence for cervical anastomotic leakage compared with the posterior mediastinal approach have always hampered its wider use. However, with the recent work reported by Chen and colleagues, the anterior route has been confirmed to provide the shortest physiological distance for oesophageal reconstruction using the stomach. Furthermore, improving the original surgical procedures seemed to improve outcomes. This research aims to evaluate whether modification of the original surgical standard of alimentary tract reconstruction after oesophagectomy can reduce the incidence of anastomotic leakage.
One hundred and two patients were divided into the research group and the control group. Subjects in the research group received the improved three-incision oesophagectomy (right chest/belly/left neck) after which the alimentary tract reconstruction was achieved by using a gastric conduit positioned through the retrosternal route. Patients in the control group received the original surgical procedures. Parameters such as the incidence of anastomotic leakage, pneumonia, length of hospital stay, ICU stay and pathological staging were compared between the two groups.
No significant statistical differences were found in parameters such as age, gender, height, weight, comorbidities, location and length of the tumour and final pathological staging of the patients between the two groups. Similarly, intraoperative and postoperative information such as operating time, hospital stay, pneumonia and volume of blood loss are comparable between the two groups. The incidence of anastomotic leakage was, respectively, 4.84% (3/62) in the research group and 20% (8/40) in the control group. The incidence of anastomotic leakage in the research group was lower than the one in the control group, and the difference was statistically significant (P = 0.037).
Modifications of the original surgical standard including expanding the retrosternal tunnel, widening the gastric tube, resection of the sternothyroid muscle and fixation of the gastric tube, contribute to decreasing the incidence of cervical anastomotic leakage.
European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 02/2012; 42(2):359-63. · 2.40 Impact Factor
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Annals of surgery 02/2012; 255(2):206-7. · 7.90 Impact Factor
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ABSTRACT: Normal bronchial tissue expression of GRPR, which encodes the gastrin-releasing peptide receptor, has been previously reported by us to be associated with lung cancer risk in 78 subjects, especially in females. We sought to define the contribution of GRPR expression in bronchial epithelia to lung cancer risk in a larger case-control study where adjustments could be made for tobacco exposure and sex.
We evaluated GRPR mRNA levels in histologically normal bronchial epithelial cells from 224 lung cancer patients and 107 surgical cancer-free controls. Associations with lung cancer were tested using logistic regression models.
Bronchial GRPR expression was significantly associated with lung cancer (OR = 4.76; 95% CI = 2.32-9.77) in a multivariable logistic regression (MLR) model adjusted for age, sex, smoking status and pulmonary function. MLR analysis stratified by smoking status indicated that ORs were higher in never and former smokers (OR = 7.74; 95% CI = 2.96-20.25) compared to active smokers (OR = 1.69; 95% CI = 0.46-6.33). GRPR expression did not differ by subject sex, and lung cancer risk associated with GRPR expression was not modified by sex.
GRPR expression in non-cancerous bronchial epithelium was significantly associated with the presence of lung cancer in never and former smokers. The association in never and former smokers was found in males and females. Association with lung cancer did not differ by sex in any smoking group.
Respiratory research 02/2012; 13:9. · 3.36 Impact Factor
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ABSTRACT: Laryngopharyngeal reflux (LPR) can cause atypical symptoms, asthma, and pulmonary fibrosis. The aim of this study was to establish the normative data for LPR using hypopharyngeal multichannel intraluminal impedance-pH (HMII).
Asymptomatic subjects underwent endoscopy followed by 24-h HMII using a specialized impedance catheter configured to detect LPR before and after a 2-week course of proton pump inhibitors (PPI). Subjects were excluded if they had esophageal pathology or a positive DeMeester score. A cohort of 24 LPR patients who had a complete response to treatment was used for comparison with the normative data.
Forty subjects were enrolled. Thirty-four subjects completed one, and 25 completed both HMII testing periods off and on PPI. There was no difference in the total number of reflux events between off and on PPI [22 (8-32) and 24 (10-28), respectively, p = 0.89]. The 95th percentiles of LPR off and on PPI were 0 and 1, respectively. All patients with treatment responsive LPR had pre-treatment HMII values of LPR greater than the 95th percentile.
LPR events are rare in an asymptomatic population. One or more LPR events should be considered abnormal in patients with LPR symptoms regardless of whether there is a positive DeMeester score.
Journal of Gastrointestinal Surgery 01/2012; 16(1):16-24; discussion 24-5. · 2.83 Impact Factor
