Christopher R. Morse

Pulmonary Resection of Metastatic Sarcoma: Prognostic Factors Associated With Improved Outcomes

BACKGROUND 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. METHODS 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. RESULTS 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. CONCLUSIONS 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.

Comparison of perioperative outcomes following open versus minimally invasive Ivor Lewis oesophagectomy at a single, high-volume centre

OBJECTIVES With the increasing popularity of minimally invasive oesophageal resections, equivalence, if not superiority, to open techniques must be demonstrated. Here we compare our open and minimally invasive Ivor Lewis oesophagectomy (MIE) experience. METHODS A prospective database of all oesophagectomies performed at Massachusetts General Hospital in Boston, MA between November 2007 and January 2011 was analysed. A total of 38 MIE and 76 open Ivor Lewis (OIE) oesophagectomies were performed for oesophageal carcinoma. Sixty-day surgical, oncological and postoperative outcomes were examined between the two groups. RESULTS Groups had similar demographics in terms of age, gender, tumour histology, clinical stage, preoperative comorbidities and neoadjuvant therapy. No difference was found with respect to adequacy of oncological resections. The median number of lymph nodes retrieved (OIE: 21, inter-quartile range (IQR): (16, 27) versus MIE: 19, IQR: (15, 28)), resection margins (OIE: 6.6% positive versus MIE: no positive margins) and 60-day mortality (OIE: 2.6% versus MIE: no deaths) were comparable. However, rates of pulmonary complications were significantly lower in the MIE group (OIE: 43.4 versus MIE: 2.6%, P < 0.001). Additionally, the median length of ICU and hospital stay, intraoperative blood loss and amount of intravenous fluids infused intraoperatively were also significantly decreased with MIE, while median operative times and the requirement for intraoperative blood transfusion were not significantly different between the two groups. Multivariate logistic regression analysis identified MIE as the only variable associated with a significant reduction in the rate of pulmonary complications in our study, while pre-existing pulmonary comborbidity was associated with an increased risk of pulmonary complications. CONCLUSIONS Open and MIE appear equivalent with regard to early oncological outcomes. A minimally invasive approach, however, appears to lead to a significant reduction in the rate of postoperative pulmonary complications. Length of ICU and hospital stay, as well as intraoperative blood loss and intravenous fluid requirements are also reduced in the setting of MIE. Long-term survival data will need to be followed closely. A large, multi-centred, randomized, controlled trial is warranted to confirm these results.

Reoperative Antireflux Surgery for Failed Fundoplication: An Analysis of Outcomes in 275 Patients

BACKGROUND With an increase in the performance of laparoscopic antireflux procedures, more patients with a failed primary antireflux operation are being referred to thoracic surgeons for complex redo procedures. The objective of this study was to evaluate our results of redo antireflux surgery. METHODS We conducted a retrospective review of patients who underwent redo surgery for failed fundoplication. The primary endpoint was failure of the redo operation; other endpoints included gastroesophageal reflux disease-health-related quality of life (HRQOL) after redo fundoplication. RESULTS A total of 275 patients (median age, 52 years; range, 17 to 88 years; men 82, women 193) underwent redo antireflux surgery. The most common pattern of failure of the initial operation was transmediastinal migration-recurrent hernia in 177 patients (64%). Redo surgery included Nissen fundoplication in 200 (73%), Collis gastroplasty in 119 (43%), and partial fundoplication in 41 (15%). There was no perioperative mortality. At a median follow-up of 39.6 months, 31 patients (11.2%) had a failure of the redo surgery, requiring reoperation. The two-year estimated probability of freedom from failure was 93% (95% confidence interval 89% to 96%). The HRQOL scores, available for 186 patients, were excellent to satisfactory in 85.5%, and poor in 14.5%. CONCLUSIONS Redo antireflux surgery can be performed safely in experienced centers with outcomes that are similar to published open results. Complete takedown and reestablishment of the normal anatomy, recognition of a short esophagus, and proper placement of the wrap are essential components of the procedure. Thoracic surgeons with significant laparoscopic and open esophageal surgical experience can perform minimally invasive, complex redo esophageal antireflux procedures safely with good results.

Oncologic Efficacy of Anatomic Segmentectomy in Stage IA Lung Cancer Patients With T1a Tumors

BACKGROUND Segmentectomy provides an anatomic, parenchymal-sparing strategy for patients with limited lung function. Recently, interest has been renewed in segmentectomy for the treatment of early stage lung cancer. METHODS We reviewed the medical records of all patients undergoing segmentectomy from January 1999 through December 2004. Survival curves were estimated using the Kaplan-Meier method. RESULTS There were 113 consecutive patients (58 men, 55 women); median age was 72.5 years (range, 30 to 94 years). Median forced expiratory volume in 1 second was 1.53 L (range, 0.5 L to 3.27 L). Median diffusion capacity of lung for carbon monoxide was 69% predicted (range, 23% to 129%). Significant comorbidities were present in 62 patients (55%). There was no perioperative mortality. Major morbidity occurred in 28 patients (25%). Mean tumor size was 2.1 cm. Resection margins were negative in all cases. Ninety-two patients (81%) were stage I. Overall 5-year survival was 79% for stage IA patients. Current smoking, diffusion capacity of lung for carbon monoxide less than 69%, tumor size greater than 2 cm, N2 disease, and advanced histology grade were associated with decreased survival by univariate analysis. In a multivariate model, only tumor size greater than 2 cm remained significant. Tumor recurrence was observed in 39 patients (35%): local in 17 patients (15%) and distant only in 22 (20%). For stage IA patients with T1a lesions, local recurrence was 5% and distant recurrence was 13%. Five-year recurrence-free survival of these patients was 69%. CONCLUSIONS Pulmonary segmentectomy can be performed safely in selected patients with preoperative reduced lung function and comorbidities. For stage IA disease, survival approximates that seen after lobectomy, with similar local recurrence rates for patients with T1a tumors.

Incidence and Risk Factors of Persistent Air Leak After Major Pulmonary Resection and Use of Chemical Pleurodesis

BACKGROUND 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. METHODS 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. RESULTS 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). CONCLUSIONS Air leaks remain an important cause of morbidity. Pleurodesis is an effective option in management of PAL after major pulmonary resection.

Long-term results of sleeve lobectomy in the management of non-small cell lung carcinoma and low-grade neoplasms.

BACKGROUND 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. METHODS 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. RESULTS 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). CONCLUSIONS 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.

Management of Delayed Gastric Emptying After Esophagectomy With Endoscopic Balloon Dilatation of the Pylorus

BACKGROUND This study seeks to evaluate the use of postoperative pyloric balloon dilatation for delayed gastric emptying after esophageal substitution with gastric conduit. METHODS 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. RESULTS 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. CONCLUSIONS Delayed gastric emptying after esophageal substitution with gastric conduit can be adequately treated with balloon dilatation of the pylorus despite an operative drainage procedure.

A preliminary experience with minimally invasive Ivor Lewis esophagectomy

With several small series examining minimally invasive Ivor Lewis esophagectomies, we look to contribute to a growing experience. In reporting our initial results, safety, initial oncologic completeness, and preliminary outcomes with a minimally invasive Ivor Lewis esophagectomy were demonstrated. From 2007 to 2010, 40 minimally invasive Ivor Lewis esophagectomies were carried out. The approach was a laparoscopic mobilization of the stomach and a thoracoscopic esophageal mobilization and creation of a high intrathoracic anastomosis. Indications included esophageal cancer in 39 patients and esophageal gastrointestinal stromal tumor in one patient. Median age was 62 (range 39-77) with 31 (78%) male patients. Non-emergent conversion was required in two (5%) patients. Twenty-five (63%) patients underwent neoadjuvant therapy. Mean operative time was 364 minutes (range 285-455), and mean blood loss was 205 cc (range 100-400). All patients underwent an R0 resection including the removal of all Barretts esophagus, and mean number of nodes harvested was 21 (range 11-41). Median intensive care unit stay was 1 day (range 1-3), and hospital stay was 7 days (range 6-19). There were no anastomotic leaks and no 30-day mortality. Postoperative complications included eight (21%) patients with atrial fibrillation and two (5%) chylothorax, one requiring ligation. At a mean follow-up of 16.5 months (range 1-39 months), five (13%) patients have had a distant recurrence; there have been no local recurrences. Minimally invasive Ivor Lewis esophagectomy, although technically challenging, can be carried out with reasonable operative times, a short length of stay, and minimal complication. Final oncologic validity is pending longer follow-up and a larger series.

Nonsuppressing normal thymus on chemical shift magnetic resonance imaging in a young woman.

A previously healthy 21-year-old woman presented with syncope and arrhythmia. A computed tomographic coronary angiogram was solely remarkable for an anterior mediastinal mass. Mediastinal magnetic resonance imaging of the reported mass revealed mildly prominent thymic tissue for age, with no suppression on out-of-phase chemical shift magnetic resonance imaging. Thymoma and lymphoma could not be excluded. After diagnosis and stabilization of her arrhythmia, the patient underwent median sternotomy and radical thymectomy, with pathology revealing normal thymus. This case suggests that nonsuppression of mildly prominent, homogenous thymic soft tissue in young women may not be sufficient to warrant diagnostic intervention and instead may warrant close follow-up.

Feasibility of endoscopic transesophageal thoracic sympathectomy (with video)

BACKGROUND Thoracoscopic sympathectomy is the preferred surgical treatment for patients with disabling palmar hyperhidrosis. Current methods require a transthoracic approach to permit ablation of the thoracic sympathetic chain. OBJECTIVE To develop a minimally invasive, transesophageal endoscopic technique for a sympathectomy in a swine model. DESIGN Nonsurvival animal study. SETTING Animal trial at a tertiary care academic center. SUBJECTS This study involved 8 healthy Yorkshire swine. INTERVENTIONS After insertion of a double-channel gastroscope, a Duette Band mucosectomy device was used to create a small esophageal mucosal defect. A short, 5-cm submucosal tunnel was created by using the tip of the endoscope and biopsy forceps. Within the submucosal space, a needle-knife was used to incise the muscular esophageal wall and permit entry into the mediastinum and chest. The sympathetic chain was identified at the desired thoracic level and was ablated or transected. The animals were killed at the completion of the procedure. MAIN OUTCOME MEASUREMENTS Feasibility of endoscopic transesophageal thoracic sympathectomy. RESULTS The sympathetic chain was successfully ablated in 7 of 8 swine, as confirmed by gross surgical pathology and histology. In 1 swine, muscle fibers were inadvertently transected. On average, the procedure took 61.4+/-24.5 minutes to gain access to the chest, whereas the sympathectomy was performed in less than 3 minutes in all cases. One animal was killed immediately after sympathectomy, before the completion of the observation period, because of hemodynamic instability. LIMITATIONS Nonsurvival series, animal study. CONCLUSIONS Endoscopic transesophageal thoracic sympathectomy is technically feasible, simple, and can be performed in a porcine model.