Bryan F. Meyers

The current role of mediastinoscopy in the evaluation of thoracic disease

OBJECTIVE Mediastinoscopy is a common procedure used for the diagnosis of thoracic disease and the staging of lung cancer. We sought to determine the current role of mediastinoscopy in the evaluation of thoracic disease. METHODS We conducted a retrospective review of all mediastinoscopies performed by members of our service between January 1988 and September 1998. RESULTS We performed mediastinoscopies on 2137 patients. A total of 1745 patients underwent mediastinoscopy for known or suspected lung cancer. In 422 of these procedures, N2 or N3 disease was identified; only 28 of these patients underwent resection. The remaining 1323 had no evidence of metastatic disease. In these patients 947 had lung cancer. Only 76 of the patients with lung cancer were found to have N2 disease at exploration. Among the 1323 patients with a negative mediastinoscopy result, 52 underwent resection of a nonbronchogenic malignancy, and 217 had resection of a benign lesion. A total of 392 patients underwent mediastinoscopy for the evaluation of mediastinal adenopathy in the absence of any identifiable pulmonary lesion. Of these, 161 had a nonbronchogenic malignancy, 209 had benign disease, and 25 had no diagnosis established; mediastinoscopy established a definitive diagnosis in 93.6% of patients. In the entire group of 2137 patients, there were 4 perioperative deaths and 12 complications. Only one death was directly attributed to mediastinoscopy. No deaths or complications occurred in patients undergoing mediastinoscopy for benign disease. CONCLUSIONS Mediastinoscopy is a highly effective and safe procedure. We believe that mediastinoscopy should currently be used routinely in the diagnosis and staging of thoracic diseases.

Traumatic diaphragmatic hernia. Occult marker of serious injury.

ObjectiveRecent experience with traumatic diaphragmatic hernias at the Massachusetts General Hospital was reviewed to identify pitfalls in the diagnosis and treatment of this injury. Summary Background DataTraumatic diaphragmatic disruption is a common injury and a marker of severe trauma. It occurs in 5% of hospitalized automobile accident victims and 10% of victims of penetrating chest trauma. Numerous reports describe splenic rupture in 25% of patients with blunt diaphragmatic rupture, liver lacerations in 25%, pelvic fracture in 40%, and thoracic aortic tears in 5%. Diaphragmatic rupture is a predictor of serious associated injuries which, unfortunately, is itself often occult. MethodsA chart review of all patients admitted to the Trauma Service with traumatic diaphragmatic hernias was undertaken for the period of January 1982 to June 1992 ResultsData on 68 patients sustaining blunt (n = 25) and penetrating (n = 43) diaphragmatic rupture or laceration were presented. The diagnosis was made preoperativery in only 21 (31%). Associated injuries were frequent in those injured by either blunt or penetrating trauma. Sixty-six patients underwent repair, 54 (82%) through a laparotomy alone and 12 (18%) with the addition of a thoracotomy. There were five (7.4%) deaths that were caused by coagulopathy, hemorrhagic shock, multisystem organ failure, and pulmonary embolism. Complications were twice as frequent in the blunt-trauma group and included abscess, pneumoria, and the sequelae of closed head injuries. ConclusionsThe recognition of diaphragmatic rupture is important because of the frequency and severity of associated injuries. The difficulties in reaching the diagnosis require an aggressive search in patients at risk.

Video-assisted thoracic surgery versus open lobectomy for lung cancer: a secondary analysis of data from the American College of Surgeons Oncology Group Z0030 randomized clinical trial.

OBJECTIVE Video-assisted thoracoscopic lobectomy remains controversial. We compared outcomes from participants in a randomized study comparing lymph node sampling versus dissection for early-stage lung cancer who underwent either video-assisted thoracoscopic or open lobectomy. METHODS Data from 964 participants in the American College of Surgeons Oncology Group Z0030 trial were used to construct propensity scores for video-assisted thoracoscopic versus open lobectomy (based on age, gender, histology, performance status, tumor location, and T1 vs T2). Propensity scores were used to estimate the adjusted risks of short-term outcomes of surgery. Patients were classified into 5 equal-sized groups and compared using conditional logistic regression or repeated measures analysis of variance. RESULTS A total of 752 patients (66 video-assisted and 686 open procedures) were analyzed on the basis of propensity score stratification. Median operative time was shorter for video-assisted thoracoscopic lobectomy (video-assisted thoracoscopy 117.5 minutes vs open 171.5 minutes; P < .001). Median total number of lymph nodes retrieved (dissection group only) was similar (video-assisted thoracoscopy 15 nodes vs open 19 nodes; P = .147), as were instances of R1/R2 resection (video-assisted thoracoscopy 0% vs open 2.3%; P = .368). Patients undergoing video-assisted thoracoscopic lobectomy had less atelectasis requiring bronchoscopy (0% vs 6.3%, P = .035), fewer chest tubes draining greater than 7 days (1.5% vs 10.8%; P = .029), and shorter median length of stay (5 days vs 7 days; P < .001). Operative mortality was similar (video-assisted thoracoscopy 0% vs open 1.6%, P = 1.0). CONCLUSION Patients undergoing video-assisted lobectomy had fewer respiratory complications and shorter length of stay. These data suggest video-assisted thoracoscopic lobectomy is safe in patients with resectable lung cancer. Longer follow-up is needed to determine the oncologic equivalency of video-assisted versus open lobectomy.

Lung Transplantation: A Decade of Experience

OBJECTIVE To review the 10-year clinical experience of a single institutions adult lung transplant program. METHODS Since July 1988, 450 lung transplants have been performed in 443 patients. Recipient diagnoses included emphysema in 229 patients, cystic fibrosis in 70 patients, pulmonary fibrosis in 48 patients, pulmonary hypertension in 49 patients, and miscellaneous end-stage lung diseases in 47 patients. Single-lung transplant was performed in 157 cases, bilateral sequential lung transplant in 283 cases, en bloc double-lung transplant in 8 cases, and heart-lung transplant in 2 cases. Graft lungs were obtained from local donors in 24% of cases and from distant donors in 76% of cases. Ideal donors were used in 74% of cases; in 26%, the donor was classified as marginal based on objective criteria. RESULTS Four hundred six (91.6%) lung transplant recipients survived to hospital discharge. There were 37 hospital deaths from cardiac events (n = 8), primary graft failure (n = 8), sepsis (n = 6), anastomotic dehiscence (n = 6), and other causes (n = 9). A diagnosis of chronic rejection (bronchiolitis obliterans syndrome [BOS]) was made in 191 patients (42.5%). BOS has not been improved by any specific therapy. Rates of freedom from BOS at 1, 3, and 5 years after the transplant are 82%, 42%, and 25%. One-, 3-, and 5-year actuarial survival rate for the entire group are 83%, 70%, and 54%. There is no statistical difference in survival according to diagnosis or type of lung transplant. Recipient waiting time was 116 days in the first 90 patients and 634 days in the most recent 90 patients. CONCLUSIONS Lung transplantation offers patients with end-stage lung disease acceptable prospects for 5-year survival. Chronic rejection and long waiting lists for donor lungs continue to be major problems facing lung transplant programs. The use of marginal and distant donors is a successful strategy in improving donor availability.

Stereotactic body radiation therapy versus surgical resection for stage I non–small cell lung cancer

OBJECTIVES Stereotactic body radiation therapy has been proposed as an alternative local treatment option for high-risk patients with early-stage lung cancer. A direct comparison of outcomes between stereotactic body radiation therapy and surgical resection has not been reported. This study compares short-term outcomes between stereotactic body radiation therapy and surgical treatment of non-small cell lung cancer. METHODS We compared all patients treated with surgery (January 2000-December 2006) or stereotactic body radiation therapy (February 2004-May 2007) with clinical stage IA/B non-small cell lung cancer staged by computed tomography and positron emission tomography. Comorbidity scores were recorded prospectively using the Adult Co-Morbidity Evaluation scoring system. Charts were reviewed to determine local tumor recurrence, disease-specific survival, and overall survival. A propensity score matching analysis was used to adjust estimated treatment hazard ratios for confounding effects of patient age, comorbidity index, and clinical stage. RESULTS A total of 462 patients underwent surgery and 76 received stereotactic body radiation therapy. Overall, surgical patients were younger (P < .001), had lower comorbidity scores (P < .001), and better pulmonary function (forced expiratory volume in 1 second and carbon monoxide diffusion in the lung) (P < .001). Among the surgical and stereotactic body radiation therapy groups, 62.6% (291/462) and 78.9% (60/76) were in clinical stage IA, respectively. Final pathology upstaged 35% (161/462) of the surgery patients. In an unmatched comparison, overall 5-year survival was 55% with surgery, and the 3-year survival was 32% with radiation therapy. Among patients with clinical stage IA disease, 3-year local tumor control was 89% with radiation therapy and 96% with surgery (P = .04). There was no difference in local tumor control in stage IB disease (P = .89). No disease-specific survival differences were found in patients with 1A (P = .33) or IB disease (P = .69). Propensity analysis matched 57 high-risk surgical patients to 57 patients undergoing stereotactic body radiation therapy. In the matched comparison of this subgroup, there was no difference in freedom from local recurrence (88% vs 90%), disease-free survival (77% vs 86%), and overall survival (54% vs 38%) at 3 years. CONCLUSIONS In an unmatched comparison of clinical stage IA disease, surgical patients were healthier and had better local tumor control compared with those receiving stereotactic body radiation therapy. Propensity analysis in clinical stage IA/B non-small cell lung cancer revealed similar rates of local recurrence and disease-specific survival in patients treated with surgery compared with stereotactic body radiation therapy.

Bronchial fenestration improves expiratory flow in emphysematous human lungs

BACKGROUND The crippling effects of emphysema are due in part to dynamic hyperinflation, resulting in altered respiratory mechanics, an increased work of breathing, and a pervasive sense of dyspnea. Because of the extensive collateral ventilation present in emphysematous lungs, we hypothesize that placement of stents between pulmonary parenchyma and large airways could effectively improve expiratory flow, thus reducing dynamic hyperinflation. METHODS Twelve human emphysematous lungs, removed at the time of lung transplantation, were placed in an airtight ventilation chamber with the bronchus attached to a tube traversing the chamber wall, and attached to a pneumotachometer. The chamber was evacuated to -10 cm H2O pressure for lung inflation. A forced expiratory maneuver was simulated by rapidly pressurizing the chamber to 20 cm H2O, while the expiratory volume was continuously recorded. A flexible bronchoscope was then inserted into the airway and a radiofrequency catheter (Broncus Technologies) was used to create a passage through the wall of three separate segmental bronchi into the adjacent lung parenchyma. An expandable stent, 1.5 cm in length and 3 mm in diameter, was then inserted through each passage. Expiratory volumes were then remeasured as above. In six experiments, two additional stents were then inserted and forced expiratory volumes again determined. RESULTS The forced expiratory volume in 1 second (FEV1) increased from 245 +/- 107 mL at baseline to 447 +/- 199 mL after placement of three bronchopulmonary stents (p < 0.001). With two additional stents, the FEV1 increased to 666 +/- 284 mL (p < 0.001). CONCLUSIONS Creation of extra-anatomic bronchopulmonary passages is a potential therapeutic option for emphysematous patients with marked hyperinflation and severe homogeneous pulmonary destruction.

Anti-human leukocyte antigen antibodies and preemptive antibody-directed therapy after lung transplantation

BACKGROUND Because the development of donor-specific anti-human leukocyte antigen (HLA) antibodies (DSA) after lung transplantation has been associated with acute and chronic rejection, we implemented a clinical protocol to screen all transplant recipients for DSA and preemptively treat those who developed DSA with rituximab and intravenous immune globulin (IVIG), or IVIG alone. METHODS We conducted a prospective observational study of this protocol and used the LABScreen Single Antigen assay to detect DSA after transplantation. We compared the incidence of acute rejection, lymphocytic bronchiolitis, and bronchiolitis obliterans syndrome (BOS) between those who developed DSA and those who did not using Cox proportional hazards models. We used the Kaplan-Meier method to compare freedom from BOS and survival between those who had persistent DSA and those who had successful depletion of DSA. RESULTS Among 116 recipients screened, DSA developed in 65 during the study period. Those who developed DSA and received antibody-directed therapy had a similar incidence of acute rejection, lymphocytic bronchiolitis, and BOS as those who did not develop DSA. Furthermore, recipients who had successful depletion of DSA had greater freedom from BOS and better survival than those who had persistent DSA. Finally, those treated for DSA had a similar incidence of infectious complications as those who did not develop DSA. CONCLUSIONS The development of DSA is surprisingly common after lung transplantation. Antibody-directed therapy may reduce the risk of rejection associated with DSA, but a randomized controlled trial is necessary to critically evaluate the efficacy of this treatment protocol.

Video-Assisted Thoracoscopic Lobectomy Is Less Costly and Morbid Than Open Lobectomy: A Retrospective Multiinstitutional Database Analysis

BACKGROUND The Premier Perspective Database (Premier Inc, Charlotte, NC) was used to compare hospital costs and perioperative outcomes for video-assisted thoracoscopic surgery (VATS) and open lobectomy procedures in the United States. METHODS Eligible patients underwent a lobectomy for cancer by a thoracic surgeon, by VATS or open thoracotomy and were captured in the database between third quarter of 2007 and through 2008. Multivariable logistic regression analyses were performed for binary outcomes. Ordinary least-squares regressions were used to estimate continuous outcomes. All models were adjusted for patient and hospital characteristics. RESULTS A total of 3,961 patients underwent a lobectomy by a thoracic surgeon by open (n = 2,907) or VATS (n = 1,054) approach. Hospital costs were higher for open versus VATS;

Thirteen-year experience in lung transplantation for emphysema.

21,016 versus

The impact of the lung allocation score on short-term transplantation outcomes: A multicenter study

20,316 (p = 0.027). Adjustment for surgeon experience with VATS over the 6 months prior to each operation showed a significant association between surgeon experience and cost. Average costs ranged from