Dean M Donahue

Harvard Medical School, Boston, Massachusetts, United States

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Publications (57)206.65 Total impact

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    ABSTRACT: Background: Neoadjuvant therapy is integral in the treatment of locally advanced esophageal cancer. Despite increasing acceptance of minimally invasive approaches to esophagectomy, there remain concerns about the safety and oncologic soundness after neoadjuvant therapy. We examined outcomes in patients undergoing open and minimally invasive (MIE) Ivor Lewis esophagectomy after neoadjuvant therapy. Methods: This was a retrospective series of 130 consecutive patients with esophageal cancer undergoing Ivor Lewis esophagectomy with curative intention after neoadjuvant therapy at a tertiary academic center (2008 to 2012). Results: An open procedure was performed in 74 patients (56.9%), and 56 (43.1%) underwent MIE after neoadjuvant therapy. MIE patients had shorter median intensive care unit (p = 0.002) and hospital lengths of stay (p < 0.0001). The incidence of postoperative complications was similar (open: 54.8% vs MIE: 41.1%, p = 0.155). However, observed respiratory complications were significantly reduced after MIE (8.9%) compared with open (29.7%; p = 0.004). Anastomotic leak rates were similar (open: 1.4% vs. MIE: 0%, p = 1.00). Mortality at 30 and 90 days was comparable (open: 2.7% and 4.1% vs MIE: 0% and 1.8%, p = 0.506 and p = 0.634, respectively). Complete resection rates and the number of collected lymph nodes was similar. Overall survival rates at 5 years were similar (open: 61% vs MIE: 50%, p = 0.933). MIE was not a significant predictor of overall survival (hazard ratio, 1.07; 95% confidence interval, 0.61 to 1.87; p = 0.810). Conclusions: MIE proves its safety after neoadjuvant therapy because it leads to faster progression during the early postoperative period while reducing pulmonary complications. Open and MIE approaches appear equivalent with regards to perioperative oncologic outcomes after neoadjuvant therapy. Long-term outcomes need further validation.
    No preview · Article · Dec 2015 · The Annals of thoracic surgery
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    ABSTRACT: Background: Proteinaceous esophageal food impaction typically requires endoscopic intervention. An alternative approach is the use of proteolytic enzymes. Concerns regarding the use of proteolytic enzymes include the risk of perforation and aspiration pneumonitis. Objective: We retrospectively reviewed our series of 69 patients treated with papain to determine the safety and efficacy of proteolytic enzymes. Methods: Patients were retrospectively reviewed if treated for an esophageal food impaction from 1999 through 2008. Results: Median age was 56 years (range 19-91 years), with 46 male and 23 female patients. In 27 patients (39%) this was their first presentation, in 14 (20%) it was the second, and 28 (41%) had multiple previous episodes. Meat was the cause in 49 (71%), chicken in 6 (9%), fish in 3 (4%), and unspecified in 11 (16%). All patients presented with dysphagia for solids, 56 (81%) could not tolerate liquids. Papain solution, 1 tsp in 8 oz of water, was given to patients in an unlimited quantity. Papain was successful in relieving the obstruction in 60 patients (87%). The remaining 9 patients (13%) underwent endoscopy with successful retrieval. No patient suffered a perforation, either with papain ingestion or endoscopy. There were no episodes of pneumonitis or pneumonia. Conclusions: We have used proteolytic enzymes with a high success rate and with minimal complication. Further, if proteolytic enzymes fail, endoscopy can be performed safely and effectively. We recommend the use of proteolytic enzymes as the initial management in all patients with proteinaceous food impaction of the esophagus.
    Preview · Article · Sep 2015 · Journal of Emergency Medicine
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    Dean Donahue · R. Gupta · M. Torriani

    Preview · Article · Aug 2015
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    ABSTRACT: The objective of this study was to evaluate the influence of total number of resected lymph nodes, lymph node ratio, and the number of lymph node stations sampled on prognosis in patients with early stage non-small cell lung cancer (NSCLC) treated with video-assisted thoracoscopic surgery (VATS). Five hundred and fifty patients who underwent VATS lobectomy or segmentectomy for early clinical stage NSCLC were retrospectively analyzed from 2006 to 2012. Disease-free survival (DFS) and overall survival (OS) were compared for cutoff values of total number of resected lymph nodes (RNs) and lymph node stations (LNS) using Kaplan-Meier methods and Cox proportional hazard models. Lobectomy was performed in 493 (90%) patients with a median follow-up of 2.7 years. Median age was 68 (range, 29 to 92 years) and 342 (62%) were female. Pathologic stage I, II, and III was observed in 434 (79%), 80 (14.5%) and 36 (6.5%) patients, respectively. The N0, N1, and N2 pathologic nodal status was observed in 485 (88%), 38 (7%), and 27 (5%) patients, respectively. Nodal upstaging was observed in 11.3% (59 of 550) in the total cohort and 15% (49 of 332) in patients who underwent LNS greater than 3 compared with 5% (10 of 218) in patients with LNS 3 or less (p < 0.01). Multivariate analysis identified LNS greater than 3 as a negative independent predictor for DFS (hazard ratio 2.36, p = 0.003) and OS (hazard ratio 1.77, p = 0.046). Sampling greater than 3 LNS and greater than 10 RNs was associated with an increase in nodal upstaging. Only LNS greater than 3 was found to be an independent predictor of mortality in VATS lobectomy and segmentectomy in clinical early-stage NSCLC. Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
    No preview · Article · Jul 2015 · The Annals of thoracic surgery

  • No preview · Article · Jun 2014 · Interactive Cardiovascular and Thoracic Surgery
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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.
    Full-text · Article · Dec 2013 · The Annals of thoracic surgery
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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.
    No preview · Conference Paper · Dec 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.
    No preview · Article · Apr 2013 · The Annals of thoracic surgery
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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: This study is a retrospective review of 474 patients undergoing esophagectomy for cancer during 2002 to 2011. A total of 334 (70.5%) patients were less than 70 years old (group A), 124 (26.2%) 70 to 79 years (group B), and 16 (3.4%) 80 years or greater (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-day 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 to 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.
    Full-text · Article · Mar 2013 · The Annals of thoracic surgery
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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.
    Preview · Article · Feb 2013 · The Oncologist
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    Dean M. Donahue

    Preview · Article · Dec 2011 · Operative Techniques in Thoracic and Cardiovascular Surgery
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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.
    Full-text · Article · Nov 2011 · Annals of Oncology
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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.
    No preview · Article · Nov 2011 · The Annals of thoracic surgery
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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.
    No preview · Article · Sep 2011 · The Annals of thoracic surgery
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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.
    No preview · Article · Feb 2011 · The Annals of thoracic surgery
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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.
    No preview · Article · Mar 2010 · The Annals of thoracic surgery
  • 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.
    No preview · Article · Feb 2010 · Skeletal Radiology
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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.
    Full-text · Article · Nov 2009 · The Annals of thoracic surgery
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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.
    Full-text · Article · Sep 2009 · The Annals of thoracic surgery
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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.
    Full-text · Article · Sep 2009 · The Journal of thoracic and cardiovascular surgery

Publication Stats

2k Citations
206.65 Total Impact Points

Institutions

  • 2002-2015
    • Harvard Medical School
      • Department of Surgery
      Boston, Massachusetts, United States
  • 1994-2014
    • Massachusetts General Hospital
      • Division of Thoracic Surgery
      Boston, Massachusetts, United States
  • 1994-2011
    • Harvard University
      Cambridge, Massachusetts, United States