Anthony J. Ascioti

The effect of a multidisciplinary thoracic malignancy conference on the treatment of patients with lung cancer

INTRODUCTION There is a paucity of data evaluating whether a multidisciplinary conference coordinating surgery, chemotherapy and radiation therapy translates into better patient care. This article compares the experiences of patients with lung cancer before and after the formation of a prospective, multidisciplinary thoracic malignancy care conference (TMC). METHODS The records of patients with a non-small-cell lung cancer at a tertiary care hospital were reviewed for completeness of staging, multidisciplinary evaluation prior to the initiation of therapy, time from pathologic diagnosis to treatment, multimodality therapy and adherence to national treatment guidelines. The summary data of patients treated before and after the TMC were initiated, and then compared. RESULTS Between 2001 and 2007, 535 patients were treated prior to the initiation of the TMC and 687 patients within the TMC. The number of patients receiving a complete staging evaluation (79%/93%: p<0.0001), multidisciplinary evaluation prior to therapy (62%/96%: p<0.0001) and adherence to the National Comprehensive Cancer Network (NCCN) treatment guidelines (81%/97%: p<0.0001) all increased significantly while mean days from diagnosis to treatment significantly decreased (29/17: p<0.0001) following the initiation of a TMC. CONCLUSION A multidisciplinary thoracic malignancy conference increased the percentage of patients receiving complete staging, a multidisciplinary evaluation and adherence to nationally accepted care guidelines while decreasing the interval from diagnosis to treatment significantly. While the ultimate goal of treatment is to improve patient survival, the surrogate variables examined in this review indicate that patients with non-small-cell lung cancer benefit from being evaluated in a prospective, multidisciplinary care conference.

Esophageal Stent Placement for the Treatment of Spontaneous Esophageal Perforations

BACKGROUND Traditional therapy for spontaneous esophageal perforation has most often been urgent operative repair. This investigation summarizes the treatment of spontaneous perforations of the esophagus using an occlusive removable esophageal stent. METHODS During a 48-month period, patients with a spontaneous esophageal perforation were offered endoluminal esophageal stent placement as the initial therapy instead of operation. Excluded were patients with an esophageal malignancy or a chronic esophageal fistula. Silicone-coated stents were placed endoscopically using general anesthesia and fluoroscopy. Adequate drainage of infected areas was achieved. Leak occlusion was confirmed by esophagram. RESULTS Twenty-one esophageal stents were placed in 19 patients for spontaneous esophageal perforations. Associated endoscopic (n = 19) or surgical procedures (n = 9) were also simultaneously performed. Leak occlusion occurred in 17 patients (89%). Fifteen patients (79%) were able to initiate oral nutrition within 72 hours of stent placement. Two patients (10%) with a perforation extending across the gastroesophageal junction experienced a continued leak after stent placement and underwent operative repair. Stent migration in 4 patients (21%) required repositioning (n = 4) or replacement (n = 2). Stents were removed at a mean of 20 +/- 15 days after placement. Hospital length of stay was 9 +/- 12 days. CONCLUSIONS Endoluminal esophageal stent placement is an effective treatment of most spontaneous esophageal perforations. These stents result in rapid leak occlusion, provide the opportunity for early oral nutrition, may significantly reduce hospital length of stay, are removable, and avoid the potential morbidities of operative repair.

Analysis of unsuccessful esophageal stent placements for esophageal perforation, fistula, or anastomotic leak.

BACKGROUND Esophageal stent placement for the treatment of a perforation, anastomotic leak, or fistula has been adopted by some thoracic surgeons. Results have been reported for this technique, but little discussion has focused on treatment failures. This analysis reviews patients in whom esophageal stent placement was not successful in an attempt to identify factors that may increase the likelihood of failure of this technique. METHODS Patients undergoing esophageal stent placement for the treatment of an esophageal perforation, anastomotic leak, or fistula in which the stent failed to adequately seal the esophageal leak were identified from a single institutions database. The anatomic location, chronicity, and cause of the esophageal leak were recorded using a newly developed classification system. Comparison was made to patients in whom stent placement was successful. RESULTS Over a 7-year period, 187 patients had an esophageal stent placed for esophageal leaks. Fifteen (8%) of these patients required traditional operative repair when the esophageal stent failed to resolve the esophageal leak after an average of 3 days. A comparison of the 2 patient groups found that stent failure was significantly more frequent in patients who had an esophageal leak of the proximal cervical esophagus, 1 that traversed the gastroesophageal junction, an esophageal injury longer than 6 cm, or an anastomotic leak associated with a more distal conduit leak (p<0.05). Malignancy or previous radiation therapy was not associated with treatment failure. CONCLUSIONS This investigation identified 4 factors that significantly reduce the effectiveness of esophageal stent placement for the treatment of esophageal perforation, fistula, or anastomotic leak. These potential contraindications should be considered when developing a treatment plan for individual patients and may prompt traditional operative repair as initial therapy.

Esophageal stent placement for the treatment of acute intrathoracic anastomotic leak after esophagectomy.

BACKGROUND Anastomotic leak after intrathoracic esophagogastrostomy remains a dreaded complication of esophagectomy. Traditional therapy has most often consisted of reoperative repair or observation and drainage, each prolonging hospitalization and the initiation of oral nutrition. This investigation summarizes our experiences treating these patients using an occlusive, removable esophageal stent. METHODS Over a 4-year period, patients found to have an acute, significant intrathoracic anastomotic leak after esophagectomy for benign or malignant disease undergoing surgery at or transferred to a single institution were offered endoluminal esophageal stent placement as initial therapy. Stents were placed endoscopically utilizing general anesthesia and fluoroscopy. Leak occlusion was confirmed by esophagram. Patients were followed until their stent was removed and their anastomotic leak had resolved. RESULTS Seventeen patients had an esophageal stent placed for an anastomotic leak during the study period. Leak occlusion occurred in all 17 patients. One patient was found to also have a perforation of the gastric conduit and underwent operative repair. Fourteen patients (82%) were able to initiate oral nutrition within 72 hours of stent placement. Stent migration occurred in 3 patients (18%), requiring repositioning in 2 and replacement in 1. All stents were removed at a mean of 17±9 days after placement. CONCLUSIONS Endoluminal esophageal stent placement is a safe and effective method for the treatment of an intrathoracic anastomotic leak after esophagectomy. This treatment resulted in rapid leak occlusion, provided the opportunity for earlier oral nutrition, and avoided the potential morbidity of reoperative repair or esophageal diversion.

Thymic carcinoma: Outcomes after surgical resection

BACKGROUND Thymic carcinoma is a rare malignancy with little information regarding outcomes after therapy with curative intent. We undertook a retrospective analysis of all patients who underwent resection of thymic carcinoma at 2 hospitals. METHODS From 1990 to 2011, 16 patients (9 men, 7 women) underwent surgical resection of thymic carcinoma at a mean age of 52 years. Patient demographics, extent of surgical resection, and outcomes were compiled. RESULTS The distribution of Masaoka stages at presentation was I in 3 (19%), II in 4 (25%), III in 8 (50%), and IV in 1 (6%). Neoadjuvant chemotherapy was administered to 6 patients (38%) whose tumors were deemed to be more locally invasive. Surgical resection included en bloc extrapleural pneumonectomy in 1, lobectomy in 2, and superior vena cava resection and reconstruction in 4. There were no perioperative deaths. Complete resection was achieved in 14 (88%), and of these patients, only 1 experienced local recurrence. At last follow-up, 10 patients were alive and well, 1 patient was alive with disease, and 5 patients had died. Mean survival was 4.2 years. CONCLUSIONS Although considered to have greater malignant potential, long-term survival can be achieved in patients with thymic carcinoma who are amenable to surgical therapy. With increased use of computed tomography imaging, patients with early-stage disease are being identified more frequently, and complete surgical resection appears to have favorable cure rates in these patients. Select patients with locally advanced disease can experience long-term survival with a multimodality approach.

A comparison of length of stay, readmission rate, and facility reimbursement after lobectomy of the lung.

BACKGROUND Readmission to the hospital has become a focus for payers with the threat of nonpayment for preventable readmissions and a global penalty for excessive readmissions rates. This study compares readmission rates with lengths of stay (LOS) for patients undergoing lobectomy of the lung and the potential impact on reimbursement. METHODS The Premier database for a single health systems hospitals was used to identify patients undergoing lobectomy for non-small cell lung cancer by cardiothoracic surgeons over a 5-year period. Charlson comorbidity scores were also calculated. Regression analysis was used to study the relationship between length of stay and readmission rates. A comparison of the effects of LOS and readmission on reimbursement was also performed. RESULTS During the study period, 4,296 lobectomies were performed in 61 hospitals within the healthcare system that met the studys inclusion criteria. A readmission was recorded for 289 patients (7%). Factors associated with readmission were length of stay less than 5 days or more than 16 days and age more than 78 years (p = 0.001). An analysis of the effects of LOS and readmission on reimbursement found an extension of LOS was more cost effective than a readmission. CONCLUSIONS This review found that mean LOS after lobectomy is negatively associated with readmission rates, with the maximal effect being before postoperative day 5. Furthermore, facility reimbursement was optimized when LOS was extended to minimize the risk of readmission.

The Effect of a Multidisciplinary Thoracic Malignancy Conference on the Treatment of Patients With Esophageal Cancer

BACKGROUND There is a paucity of data evaluating whether a multidisciplinary conference coordinating surgery, chemotherapy and radiation therapy translates into better patient care. This review compares the experiences of patients with esophageal cancer before and after the formation of a prospective, multidisciplinary thoracic malignancy conference (TMC). METHODS The records of patients with carcinoma of the esophagus at a tertiary care hospital were reviewed for completeness of staging, multidisciplinary evaluation before the initiation of therapy, time from pathologic diagnosis to treatment, multimodality therapy, and adherence to national treatment guidelines. Summary data were compared for patients treated before and after the TMC was initiated. RESULTS Between 2001 and 2007, 117 patients were treated before the initiation of the TMC and 138 patients within the TMC. The number of patients receiving, respectively, a complete staging evaluation (67% and 97%, p < 0.0001), multidisciplinary evaluation before therapy (72% and 98%, p < 0.0001), and adherence to National Comprehensive Cancer Network treatment guidelines (83% and 98%, p < 0.0001) all increased significantly, whereas mean days from diagnosis to treatment significantly decreased (27 and 16, respectively; p < 0.0001). CONCLUSIONS A multidisciplinary TMC increased the percentage of patients receiving complete staging, a multidisciplinary evaluation, and adherence to nationally accepted care guidelines while decreasing the interval from diagnosis to treatment significantly. While the ultimate goal of treatment is to improve patient survival, the surrogate variables examined in this review indicate that patients with esophageal cancer benefit from being evaluated in a prospective, multidisciplinary manner.

Long-Term Follow-Up After Robotic Thymectomy for Nonthymomatous Myasthenia Gravis

BACKGROUND Thymectomy is recognized as a significant component in the treatment of myasthenia gravis. However, controversy exists as to the optimal surgical approach. This investigation summarizes our experience performing extended thymectomy using a robotic technique in a large group of patients with significant follow-up. METHODS Data collection for patients undergoing robotic thymectomy for nonthymomatous myasthenia gravis over a 6-year period was prospectively performed. Patients were assessed using the Myasthenia Gravis Foundation of Americas quantitative disease severity score and the post intervention status classification. RESULTS During the study period, 75 patients underwent thymectomy by this method. Mean preoperative myasthenia gravis severity score was 2.7. Mean operative time was 113±46 minutes. Extubation in the operating room occurred in 73 (98%) patients. Mean intensive care stay and total hospital length of stay were 0.9 and 2.2 days respectively. Mean interval between surgery and return to work (or prethymectomy activities of daily living) was 15±6 days. Significant improvement of myasthenia gravis symptoms occurred in 65 (87%) patients with a mean follow-up of 45±14 months. CONCLUSIONS Robotic-assisted thymectomy is a safe and effective technique for patients with symptomatic myasthenia gravis. It allowed an extended thymectomy to be performed without the associated length of stay or recovery period of a transsternal approach while producing comparable rates of symptom improvement.

Esophageal stent placement for the treatment of perforation, fistula, or anastomotic leak.

Inclusion Criteria It is currently our practice to consider esophageal stent placement for any esophageal perforation, fistula, or anastomotic leak. This is based on the results of our 4 reported patient series and subsequently treated patients1-4 (Table 1). This is regardless of the duration of the perforation or fistula before treatment or whether a previous operative repair has been performed. Included are patients who have a relatively large esophageal diameter and patients with systemic manifestations of infection related to their esophageal injury. We have also successfully treated acute perforations and fistulae of the esophagus in the setting of an esophageal malignancy. Although generally considered an indication for esophagectomy rather than operative repair, esophageal injury or fistula in the setting of malignancy will often seal with endoluminal stent placement. Systemic chemotherapy and/or radiation therapy is discontinued for a 2-week period but can then be restarted.

A propensity-matched comparison of cost and outcomes after esophageal stent placement or primary surgical repair for iatrogenic esophageal perforation

OBJECTIVES Esophageal stent placement has been shown to be a safe and effective treatment for acute esophageal perforation in selected patients. However, a comparison between surgical repair and stent placement has not been reported. This investigation compares the outcomes and costs of the 2 treatment modalities. METHODS The Premiere database for a single health systems hospitals was used to identify patients undergoing treatment for an acute intrathoracic esophageal perforation over a 4-year period. Patient cohorts for stent placement or surgical repair were formed using propensity matching. The 2 cohorts were compared for length of stay, morbidity, mortality, and costs. RESULTS Between 2009 and 2012, 60 patients undergoing esophageal stent placement or surgical repair were propensity matched. Mean patient age and Charlson comorbidity scores did not differ significantly (P = .4 and P = .4, respectively). Significant differences in morbidity (4% vs 43%; P = .02), mean length of stay (6 vs 11 days; P = .0007), time to oral intake (3 vs 8 days; P = .0004), and cost (