Charles T. Bakhos

Impact of the Surgical Technique on Pulmonary Morbidity After Esophagectomy

BACKGROUND Pulmonary complications occur frequently after esophagectomy. Although multifactorial, these complications could be influenced by surgical technique. We sought to compare the respiratory complications of patients undergoing esophagectomy through different approaches, and identify technical risk factors. METHODS We conducted a retrospective analysis of consecutive esophagectomies performed at 2 institutions from January 2002 to January 2009. Primary outcome measures included postoperative ventilatory requirements, pneumonia, effusion requiring intervention, length of stay, and mortality. RESULTS A total of 220 esophagectomies were performed through 6 different approaches: 79 minimally invasive (MIE) with neck anastomosis, 20 MIE with chest anastomosis, 37 transhiatal, 33 McKeown, 36 Ivor Lewis, and 15 left thoracoabdominal. Patients who underwent MIE were more likely to be extubated in the operating room (p<0.01) and had fewer pleural effusions (p<0.01). A thoracotomy was associated with a higher incidence of tracheostomy (p=0.02) and pleural effusions (p=0.02). Neck anastomoses were negatively associated with early extubation (p=0.04) and predicted recurrent laryngeal nerve injury (p=0.04), but were not associated with pneumonia or other pulmonary complications. Multivariate analysis showed that pneumonia was independently associated with advancing age (p=0.02), lack of a pyloric drainage procedure (p=0.03), and less significantly with MIE (p=0.06, fewer events). Surgical approach was not a significant predictor of length of stay or mortality. CONCLUSIONS Patients undergoing MIE are less likely to remain intubated. Omission of a pyloric drainage procedure or performance of thoracic or neck incisions appear to be important determinants of respiratory complications. Technical aspects of the procedure in addition to the surgical approach influence important respiratory outcomes.

Technical Aspects and Outcomes of Tracheobronchoplasty for Severe Tracheobronchomalacia

BACKGROUND Tracheobronchomalacia is an underrecognized cause of dyspnea, recurrent respiratory infections, and cough. Surgical stabilization with posterior membranous tracheobronchoplasty has been shown to be effective in selected patients with severe disease. This study examines the technical details and complications of this operation. METHODS A prospectively maintained database of tracheobronchomalacia patients was queried retrospectively to review all consecutive tracheobronchoplasties performed from October 2002 to June 2009. Posterior splinting was performed with polypropylene mesh. Patient demographics, surgical outcomes, and operative data were reviewed. RESULTS Sixty-three patients underwent surgical correction of tracheal and bilateral bronchial malacia. Twenty-three patients had chronic obstructive pulmonary disease, 18 had asthma, 5 had Mounier-Kuhn syndrome, and 4 had interstitial lung disease. Seven patients had a previous tracheotomy. Operative time was 373 ± 93 minutes. Median length of stay was 8 days (range, 4 to 92 days), of which 3 days (range, 0 to 91 days) were in intensive care. Seventy-five percent of patients were discharged home (28% with visiting nurse follow-up), and 25% went to a rehabilitation facility. Two patients (3.2%) died postoperatively-1 of worsening usual interstitial pneumonia, and the other of massive pulmonary embolism. Complications included a new respiratory infection in 14 patients, pulmonary embolism in 2, and atrial fibrillation in 6. Six patients required reintubation, and 9 received a postoperative tracheotomy; 47 patients required postoperative aspiration bronchoscopy. CONCLUSIONS In experienced hands, tracheobronchoplasty can be performed with a very low mortality rate and an acceptable perioperative complications rate in patients with significant pulmonary comorbidity. Intervention for postoperative respiratory morbidity is often necessary.

Spontaneous Pneumomediastinum: An Extensive Workup Is Not Required

BACKGROUND Spontaneous pneumomediastinum is a rare entity usually caused by alveolar rupture and air tracking along the tracheobronchial tree. Despite its benign nature, an extensive workup is often undertaken to exclude hollow viscus perforation. We sought to review our experience with this condition and examine the optimal management strategy. STUDY DESIGN We conducted a retrospective review of all radiographic pneumomediastinum cases at a tertiary hospital between 2006 and 2011. The main outcomes measures included length of hospital stay, mortality, and need for investigative procedures. RESULTS Forty-nine patients with spontaneous pneumomediastinum were identified, including 26 male patients (53%). Mean age was 19 ± 9 years. Chest pain was the most common presenting symptom (65%), followed by dyspnea (51%). Forceful coughing (29%) or vomiting (16%) were the most common eliciting factors, and no precipitating event was identified in 41% of patients. Computed tomography was performed in 38 patients (78%) and showed a pneumomediastinum that was not seen on chest x-ray in 9 patients. Esophagography was performed in 17 patients (35%) and was invariably negative for a leak. Thirty-eight patients (78%) were hospitalized for a mean of 1.8 ± 2.6 days. No mortality was recorded. Compared with patients who presented with pneumomediastinum secondary to esophageal perforation, spontaneous pneumomediastinum patients were younger, had a lower white cell count, and were less likely to have a pleural effusion. CONCLUSIONS Spontaneous pneumomediastinum is a benign entity and rarely correlates with true esophageal perforation. Additional investigation with esophagography or other invasive procedures should be performed selectively with the aim of expediting the patients care. The prognosis is excellent with conservative management and the risk for recurrence is low.

Non-small cell lung cancer therapy: safety and efficacy in the elderly

Background Our objective was to evaluate and review the current literature on the treatment of non-small cell lung cancer (NSCLC) in the elderly. Methods We selected recent peer-reviewed articles addressing ageing, cancer treatment in the elderly, and lung cancer treatment in the elderly. We defined elderly as over the age of 70. Results The population is ageing dramatically throughout most of the world. Given that situation, clinicians are seeing and being asked to treat more elderly patients that have NSCLC. Elderly patients are less likely to participate or be allowed to participate in prospective or retrospective studies of treatments for NSCLC. Elderly patients are also less likely to be staged appropriately for their advanced tumors, and are less likely to be referred for surgery or adjuvant therapy after surgery. When treatment is tailored to patient comorbidities but not to age, the data support survival and outcomes comparable to those of younger patients. Conclusions Data are limited on the treatment of elderly patients with NSCLC. No data exist to support limiting recommendations for treatment based on age alone. Treatments should be determined on an individual basis.

Anti-Ri-associated paraneoplastic brainstem cerebellar syndrome with coexisting limbic encephalitis in a patient with mixed large cell neuroendocrine lung carcinoma

Paraneoplastic neurologic syndromes (PNS) can be the first manifestations of occult malignancies. If left untreated, PNS often lead to significant morbidity and mortality. Anti-Ri (anti-neuronal nuclear antibody type 2 [ANNA-2]) autoantibodies are commonly associated with breast and small cell lung cancers. Cases of anti-Ri paraneoplastic cerebellar degeneration are reported, but few describe severe nausea and coexisting limbic encephalitis as the major presenting features. We report a 75-year-old woman with medically-intractable emesis, encephalopathy, diplopia, vertigo, and gait ataxia for 3 months. Examination revealed rotary nystagmus, ocular skew deviation, limb dysmetria, and gait ataxia. After two courses of intravenous immunoglobulin, there was minimal improvement. Anti-Ri antibodies were positive in serum only. CT scan identified a 2.0 cm left lung mass, and histopathology revealed large cell neuroendocrine carcinoma with admixed adenocarcinoma non-small cell lung carcinoma (NCSLC). Though the patient achieved nearly complete clinical recovery after tumor resection, anti-Ri levels remained high at 20 months post-resection. To our knowledge this is the first report of a paraneoplastic brainstem cerebellar syndrome with coexisting limbic encephalitis involving anti-Ri positivity and associated mixed neuroendocrine/NSCLC of the lung with marked improvement after tumor resection.

Feasibility of Minimally Invasive Esophagectomy After Neoadjuvant Chemoradiation

BACKGROUND The impact of preoperative chemoradiation treatment (CRT) on outcomes after esophagectomy is still debated. The choice of surgical approach can also be influenced by this treatment modality, including the performance of minimally invasive esophagectomy (MIE), a technically demanding procedure. We sought to examine the outcomes of MIE after CRT. MATERIALS AND METHODS We conducted a retrospective analysis of consecutive MIEs performed at two institutions from June 2004 to January 2010. We analyzed the effect of CRT on perioperative results, including pulmonary complications, oncological outcomes, length of stay, and mortality. RESULTS In total, 126 patients were eligible for the study. Six patients (4.8%) were converted from MIE to an open approach and were excluded from the analysis. Of the 120 patients, 98 were male (82%), mean age was 62 ± 13 years (range, 22-88 years), and 58 underwent CRT (48%) (Group 1). Comparing both groups, the incidence of pneumonia (9 versus 11), recurrent laryngeal nerve injury (3 versus 5), anastomotic leaks (4 versus 9), number of harvested lymph nodes (16 ± 9 versus 18 ± 9), and R0 resection margins (53/58 versus 61/62) was comparable (Group 1 versus Group 2, respectively; P=not significant). There was a trend toward more pleural effusions in Group 1 (10 versus 4, P=.09). Median length of stay was comparable between both groups (10 ± 11 versus 11 ± 7 days). There were three operative deaths, exclusively in Group 1 (P=.11). CONCLUSIONS MIE can be safely performed after CRT in the management of esophageal cancer, with a low conversion rate. Outcomes seem comparable regardless of preoperative CRT.

Contemporary role of minimally invasive thoracic surgery in the management of pulmonary arteriovenous malformations: report of two cases and review of the literature.

Pulmonary arteriovenous malformations (PAVM) can have potentially serious neurological and cardiac consequences if left untreated. Embolization has supplanted surgical resection as the first line treatment modality. However, this technique is not always successful and carries risks of air embolism, migration of the coil, myocardial rupture, vascular injury, pulmonary hypertension, and pulmonary infarction. We present two patients with symptomatic PAVM despite multiple embolizations: the first one with recurrent and persistent hemoptysis who underwent a thoracoscopic lobectomy, and the second one with chronic debilitating pleuritic pain subsequent to embolization who underwent a thoracoscopic wedge resection. Video-assisted thoracoscopic surgery (VATS) with lung resection was successfully performed in both patients, with complete resolution of their symptoms. We also review the literature regarding the contemporary role of surgery in PAVM, particularly thoracoscopy.

Management of Prolonged Pulmonary Air Leaks With Endobronchial Valve Placement.

Background: Prolonged pulmonary air leaks (PALs) are associated with increased morbidity and extended hospital stay. We sought to investigate the role of bronchoscopic placement of 1-way valves in treating this condition. Methods: We queried a prospectively maintained database of patients with PAL lasting more than 7 days at a tertiary medical center. Main outcome measures included duration of chest tube placement and hospital stay before and after valve deployment. Results: Sixteen patients were eligible to be enrolled from September 2012 through December 2014. One patient refused to give consent, and in 4 patients, the source of air leak could not be identified with bronchoscopic balloon occlusion. Eleven patients (9 men; mean age, 65 ± 15 years) underwent bronchoscopic valve deployment. Eight patients had postoperative PAL and 3 had a secondary spontaneous pneumothorax. The mean duration of air leak before valve deployment was 16 ± 12 days, and the mean number of implanted valves was 1.9 (median, 2). Mean duration of hospital stay before and after valve deployment was 18 and 9 days, respectively (P = .03). Patients who had more than a 50% decrease in air leak on digital monitoring had the thoracostomy tube removed within 3–6 days. There were no procedural complications related to deployment or removal of the valves. Conclusions: Bronchoscopic placement of 1-way valves is a safe procedure that could help manage patients with prolonged PAL. A prospective randomized trial with cost-efficiency analysis is necessary to better define the role of this bronchoscopic intervention and demonstrate its effect on air leak duration.

Primary Neuroendocrine Carcinoma of the Middle Mediastinum Involving the Right Main Pulmonary Artery

Primary neuroendocrine neoplasms of the mediastinum are extremely rare. We report the case of a 54-year-old woman who presented with dyspnea and was found to have a 6.8-cm tumor completely obliterating the right main pulmonary artery. Analysis of an endobronchial ultrasound fine-needle aspiration revealed a neuroendocrine tumor. A positron emission tomography scan showed no evidence of distant disease. The patient underwent surgical resection with reconstruction of the right main pulmonary artery with a Dacron (DuPont, Wilmington, DE) graft, followed by chemoradiotherapy. We discuss the presentation and management of this patient and review the current treatment options of primary neuroendocrine carcinomas of the mediastinum.

Evaluation and management of pleural conditions

Physicians are frequently called upon to evaluate and manage patients with pleural effusions. Fifty five percent of these effusions results from a benign process, and the remaining 45% occur as the result of malignancy. The most common tumors associated with malignant pleural effusion (MPE) are lung cancer, breast cancer and lymphoma. The most common symptoms of MPE include dyspnea, cough, pleuritic chest pain and fatigue. Diagnosis, and sometimes staging, can be established via thoracentesis, which is both safe and an effective means of symptom palliation. Once the diagnosis and staging are complete, the treatment goals and approaches to reaching those goals can be developed. In the case of MPE, the focus turns to palliation of symptoms and attempts to optimize the patients, thereby allowing them greater treatment options for the underlying malignancy. In this manuscript the authors define the pathophysiology, diagnostic, and treatment options for patients suffering from MPE.