Claude Deschamps

Colorectal lung metastases: Results of surgical excision☆

Between 1960 and 1988, 139 consecutive patients underwent pulmonary resection for metastatic colorectal carcinoma. Median interval between colon resection and lung resection was 34 months. Ninety-eight patients (70.5%) had a solitary metastasis. Wedge excision was performed in 68 patients, lobectomy in 53, lobectomy plus wedge excision in 9, bilobectomy in 4, and pneumonectomy in 5. Operative mortality was 1.4%. Localized extrapulmonary colorectal cancer was also resected in 20 patients. Median follow-up was 7 years (range 1 to 20.4 years). Overall 5- and 20-year survival was 30.5% and 16.2%, respectively. Five-year survival for patients with solitary metastasis was 36.9%, as compared with 19.3% for those with two metastases (p less than 0.05) and 7.7% for those with more than two (p less than 0.01). Patients with normal carcino-embryonic antigen had a 5-year survival of 46.8% versus 16.0% for patients with increased levels (p less than 0.01). Five-year survival for patients with resected extrapulmonary disease was 30.0% versus 30.7% for those without extrapulmonary cancer (p = not significant). Repeat thoracotomy for recurrent metastases was done in 19 patients. Five-year survival after the second lung resection was 30.2%. We conclude that resection of colorectal lung metastases is safe and effective, that resectable extrapulmonary disease does not necessarily contraindicate pulmonary resection, and that repeat thoracotomy is warranted in selected patients with recurrent colorectal lung metastases.

Induction Chemoradiation and Surgical Resection for Superior Sulcus Non–Small-Cell Lung Carcinomas: Long-Term Results of Southwest Oncology Group Trial 9416 (Intergroup Trial 0160)

PURPOSE Traditional treatment for superior sulcus non-small-cell lung cancers (SS NSCLC), radiation plus surgery, yields a 50% rate of complete resection and a 30% 5-year survival. On the basis of improved outcomes in other subsets of stage III NSCLC, this trial tested the feasibility of induction chemoradiotherapy for SS NSCLC. PATIENTS AND METHODS Patients with T3-4, N0-1 SS NSCLC received two cycles of cisplatin and etoposide concurrently with radiation (45 Gy). Patients with stable or responding disease underwent thoracotomy. All patients received two more cycles of chemotherapy. Survival was calculated by the Kaplan-Meier method and prognostic factors were assessed by Cox regression analysis. RESULTS From April 1995 to November 1999, 110 eligible patients (76 men, 34 women) were entered onto the study (78 T3, 32 T4 tumors). Induction therapy was completed by 104 (95%) patients. Of 95 patients eligible for surgery, 88 (80%) underwent thoracotomy, two (1.8%) died postoperatively, and 83 (76%) had complete resection. Pathologic complete response (CR) or minimal microscopic disease was seen in 61 (56%) resection specimens. Five-year survival was 44% for all patients and 54% after complete resection, with no difference between T3 and T4 tumors. Pathologic CR led to better survival than when any residual disease was present (P = .02). Disease progression occurred mainly in distant sites. CONCLUSION This combined-modality approach is feasible and is associated with high rates of complete resection and pathologic CR in both T3 and T4 tumors. Local control and overall survival seem markedly improved relative to previous studies of radiation plus resection.

Esophageal Resection for Cancer of the Esophagus: Long-Term Function and Quality of Life

BACKGROUND Information on function and quality of life of long-term survivors after esophageal resection for carcinoma is limited. METHODS Between 1972 and 1990, 359 patients underwent esophagectomy for stage I or II esophageal carcinoma at Mayo Clinic. We evaluated long-term function and quality of life in 107 of these patients (81 men and 26 women) who survived 5 or more years. Median age at operation was 62 years (range, 30 to 81 years). The operation performed was an Ivor Lewis resection in 77 patients (72%), transhiatal esophagectomy in 14 (13%), extended esophagectomy in 4 (4%), thoracoabdominal esophagectomy in 4 (4%), and other in 8 (7%). Adenocarcinoma was present in 72 patients (67%), squamous cell carcinoma in 28 (26%), and other in 7 (7%). Thirty-four patients (32%) were in postsurgical stage I, 65 (61%) in stage IIA, and 8 (8%) in stage IIB. Median survival was 10.2 years (range, 5.0 to 23.2 years). Follow-up was complete for all patients. RESULTS Gastroesophageal reflux was present in 64 patients (60%), symptoms of dumping in 53 (50%), and dysphagia to solid food in 27 (25%). Seventeen patients (16%) were asymptomatic. Factors affecting late functional outcome were analyzed. Patients who had a cervical anastomosis had significantly fewer reflux symptoms (p < 0.05). Dumping syndrome occurred more frequently in younger patients (p < 0.05) and women (p < 0.01). Quality of life was assessed separately by the Medical Outcomes Study 36-Item Short-Form Health Survey and compared with the national norm. Scores measuring physical functioning were decreased (p < 0.01). Scores measuring ability to work, social interaction, daily activities, emotional dysfunction, perception of health, and levels of energy were similar. Mental health scores were higher (p < 0.05). CONCLUSIONS We conclude that long-term functional outcome after esophagectomy for esophageal carcinoma is affected by age, sex, and type of reconstruction. Quality of life as judged by the patients is similar to the national norm.

Inflammatory pseudotumors of the lung

BACKGROUND Inflammatory pseudotumors of the lung are rare and often present a dilemma for the surgeon at time of operation. We reviewed our experience with patients who have this unusual pathology. METHODS Between February 1946 and September 1993, 56,400 general thoracic surgical procedures were performed at the Mayo Clinic. Twenty-three patients (0.04%) had resection of an inflammatory pseudotumor of the lung. There were 12 women and 11 men. Median age was 47 years (range, 5 to 77 years). Six patients (26%) were less than 18 years old. All pathologic specimens were re-reviewed, and the diagnosis of inflammatory pseudotumor was confirmed. Eighteen patients (78%) were symptomatic which included cough in 12, weight loss in 4, fever in 4, and fatigue in 4. Four patients had prior incomplete resections performed elsewhere and underwent re-resection because of growth of residual pseudotumor. Wedge excision was performed in 7 patients, lobectomy in 6, pneumonectomy in 6, chest wall resection in 2, segmentectomy in 1, and bilobectomy in 1. Complete resection was accomplished in 18 patients (78%). Median tumor size was 4.0 cm (range, 1 to 15 cm). There were no operative deaths. Follow-up was complete in all patients and ranged from 3 to 27 years (median, 9 years). RESULTS Overall 5-year survival was 91%. Nineteen patients are currently alive. Cause of death in the remaining 4 patients was unrelated to pseudotumor. The pseudotumor recurred in 3 of the 5 patients who had incomplete resection; 2 have had subsequent complete excision with no evidence of recurrence 8 and 9 years later. CONCLUSIONS We conclude that inflammatory pseudotumors of the lung are rare. They often occur in children, can grow to a large size, and are often locally invasive, requiring significant pulmonary resection. Complete resection, when possible, is safe and leads to excellent survival. Pseudotumors, which recur, should be re-resected.

Barrett's esophagus with high-grade dysplasia: An indication for esophagectomy?

Between 1982 and 1991, 19 patients (17 men and 2 women) with Barretts esophagus, 10 of whom were in a surveillance program, were found to have high-grade dysplasia without evidence of invasive carcinoma. Median age was 66 years (range, 30 to 79 years). Heartburn was the most common presenting symptom. Esophagoscopy at the time of high-grade dysplasia diagnosis demonstrated normal Barretts mucosa in 10 patients (53%), shallow ulcers in 3, slight mucosal irregularities in 2, small mucosal nodules in 2, stricture in 1, and shallow ulcer with stricture in 1. Eighteen patients underwent esophagectomy. There were no operative deaths. Nine patients (50%) had invasive carcinoma. Postsurgical stage was stage 0 in 9 patients, stage I in 6, stage IIA in 2, and stage IIB in 1. Median follow-up was 34 months (range, 2 to 116 months). Recurrent cancer developed in 2 patients. Overall 5-year survival was 66.7%; 5-year survival for patients with stage 0 disease was 100% and for stage I and II disease, 35.7%. We conclude that high-grade dysplasia in an indication for esophageal resection because of the high rate of associated early invasive carcinoma and that resection can be done safely with the expectation of excellent long-term survival. Because of these findings, we continue to recommend endoscopic surveillance in all patients with Barretts esophagus.

Early and long-term results of prosthetic chest wall reconstruction.

OBJECTIVE The purpose of this report is to evaluate our results in patients who underwent prosthetic bony reconstruction after chest wall resection. METHODS We retrospectively reviewed all patients who underwent chest wall resection and reconstruction with prosthetic material at the Mayo Clinic. RESULTS From January 1, 1977, to December 31, 1992, 197 patients (109 male patients and 88 female patients) underwent chest wall resection and reconstruction with prosthetic material. Median age was 59 years (range, 11-86 years). The indication for resection was recurrent chest wall malignancy in 65 patients (33.0%), primary chest wall malignancy in 62 patients (31.5%), contiguous lung or breast carcinoma in 58 patients (29.4%), and other reasons in 12 patients (6.1%). Three patients (1.5%) each had an open draining wound. This review covers 2 time periods. Sixty-four patients (32.5%) underwent reconstruction with polypropylene mesh during the period from 1977 to 1986. One hundred thirty-three patients (67.5%) underwent reconstruction with polytetrafluoroethylene from 1984 to 1992. Soft tissue coverage was achieved with transposed muscle in 116 patients (58.9%), local tissue in 81 patients (41.1%), and omentum in 3 patients (1.5%). There were 8 deaths (operative mortality rate, 4.1%). Ninety-one patients (46.2%) experienced complications. Seromas occurred in 14 patients (7.1%). Wound infections occurred in 9 patients (4.6%; 5 patients with polypropylene mesh and 4 patients with polytetrafluoroethylene). The prosthesis was removed in all 5 patients with polypropylene mesh and in none of the patients with polytetrafluoroethylene. Follow-up was complete in 179 operative survivors (94.7%) and ranged from 1 to 204 months (median, 26 months). A well-healed asymptomatic wound was present in 127 patients (70.9%). CONCLUSIONS Chest wall resection and reconstruction with prosthetic material will yield satisfactory results in most patients. Little difference exists between polypropylene mesh and polytetrafluoroethylene.

Use of Lean and Six Sigma Methodology to Improve Operating Room Efficiency in a High-Volume Tertiary-Care Academic Medical Center

BACKGROUND Operating rooms (ORs) are resource-intense and costly hospital units. Maximizing OR efficiency is essential to maintaining an economically viable institution. OR efficiency projects often focus on a limited number of ORs or cases. Efforts across an entire OR suite have not been reported. Lean and Six Sigma methodologies were developed in the manufacturing industry to increase efficiency by eliminating non-value-added steps. We applied Lean and Six Sigma methodologies across an entire surgical suite to improve efficiency. STUDY DESIGN A multidisciplinary surgical process improvement team constructed a value stream map of the entire surgical process from the decision for surgery to discharge. Each process step was analyzed in 3 domains, ie, personnel, information processed, and time. Multidisciplinary teams addressed 5 work streams to increase value at each step: minimizing volume variation; streamlining the preoperative process; reducing nonoperative time; eliminating redundant information; and promoting employee engagement. Process improvements were implemented sequentially in surgical specialties. Key performance metrics were collected before and after implementation. RESULTS Across 3 surgical specialties, process redesign resulted in substantial improvements in on-time starts and reduction in number of cases past 5 pm. Substantial gains were achieved in nonoperative time, staff overtime, and ORs saved. These changes resulted in substantial increases in margin/OR/day. CONCLUSIONS Use of Lean and Six Sigma methodologies increased OR efficiency and financial performance across an entire operating suite. Process mapping, leadership support, staff engagement, and sharing performance metrics are keys to enhancing OR efficiency. The performance gains were substantial, sustainable, positive financially, and transferrable to other specialties.

Surgical treatment of non-small cell lung cancer 1 cm or less in diameter.

BACKGROUND Routine lung cancer screening does not currently exist in the United States. Computed tomography can detect small cancers and may well be the screening choice in the future. Controversy exists, however, regarding the surgical management of these small lung cancers. METHODS The records of all patients were reviewed who underwent resection of solitary non-small cell lung cancers 1 cm or less in diameter from 1980 through 1999. RESULTS The study included 100 patients (56 men and 44 women) with a median age of 67 years (range 43 to 84 years). Lobectomy was performed in 71 patients, bilobectomy in 4, segmentectomy in 12, and wedge excision in 13. Ninety-four patients had complete mediastinal lymph node dissection. The cancer was an adenocarcinoma in 48 patients, squamous cell carcinoma in 26, bronchioloalveolar carcinoma in 19, large cell carcinoma in 4, adenosquamous cell carcinoma in 2, and undifferentiated in 1. Tumor diameter ranged from 3 to 10 mm. Seven patients had lymph node metastases (N1, 5 patients; N2, 2 patients). Postsurgical stage was IA in 92 patients, IB in 1, IIA in 5, and IIIA in 2. There were four operative deaths. Follow-up was complete in all patients and ranged from 4 to 214 months (median 43 months). Eighteen patients (18.0%) developed recurrent lung cancer. Overall and lung cancer-specific 5-year survivals were 64.1% and 85.4%, respectively. Patients who underwent lobectomy had significantly better survival and fewer recurrences than patients who had wedge excision or segmentectomy (p = 0.04). CONCLUSIONS Because recurrent cancer and lymph node metastasis can occur in patients with non-small cell lung cancers 1 cm or less in size, lobectomy with lymph node dissection is warranted when medically possible.

Genetic variants and risk of lung cancer in never smokers: a genome-wide association study.

BACKGROUND Lung cancer in individuals who have never smoked tobacco products is an increasing medical and public-health issue. We aimed to unravel the genetic basis of lung cancer in never smokers. METHODS We did a four-stage investigation. First, a genome-wide association study of single nucleotide polymorphisms (SNPs) was done with 754 never smokers (377 matched case-control pairs at Mayo Clinic, Rochester, MN, USA). Second, the top candidate SNPs from the first study were validated in two independent studies among 735 (MD Anderson Cancer Center, Houston, TX, USA) and 253 (Harvard University, Boston, MA, USA) never smokers. Third, further replication of the top SNP was done in 530 never smokers (UCLA, Los Angeles, CA, USA). Fourth, expression quantitative trait loci (eQTL) and gene-expression differences were analysed to further elucidate the causal relation between the validated SNPs and the risk of lung cancer in never smokers. FINDINGS 44 top candidate SNPs were identified that might alter the risk of lung cancer in never smokers. rs2352028 at chromosome 13q31.3 was subsequently replicated with an additive genetic model in the four independent studies, with a combined odds ratio of 1.46 (95% CI 1.26-1.70, p=5.94x10(-6)). A cis eQTL analysis showed there was a strong correlation between genotypes of the replicated SNPs and the transcription level of the gene GPC5 in normal lung tissues (p=1.96x10(-4)), with the high-risk allele linked with lower expression. Additionally, the transcription level of GPC5 in normal lung tissue was twice that detected in matched lung adenocarcinoma tissue (p=6.75x10(-11)). INTERPRETATION Genetic variants at 13q31.3 alter the expression of GPC5, and are associated with susceptibility to lung cancer in never smokers. Downregulation of GPC5 might contribute to the development of lung cancer in never smokers. FUNDING US National Institutes of Health; Mayo Foundation.

High-grade esophageal dysplasia: long-term survival and quality of life after esophagectomy

BACKGROUND Esophagectomy for high-grade dysplasia in Barretts esophagus has been advocated. Although long-term survival data exist, little is known about functional outcome and quality of life in this particular subset of patients. METHODS The records of all patients who underwent esophageal resection for high-grade dysplasia from June 1991 through July 1997 were reviewed. Long-term functional outcome and quality of life were assessed using a two-part written survey. RESULTS There were 54 patients (48 men, 6 women). Median age was 64 years (range, 36 to 83 years). Ivor Lewis esophagogastrectomy was performed in 34 patients (63%), transhiatal esophagectomy in 10 (18%), extended esophagectomy in 8 (15%), and other in 2 (4%). Invasive carcinoma was found in 19 patients (35%). Five patients (9%) were stage 0, 7 (13%) stage I, 3 (6%) stage IIA, 1 (2%) stage IIB, and 3 patients (6%) stage III. There was one operative death (1.8%). Complications occurred in 31 patients (57%). Median hospitalization was 13 days (range, 11 to 44 days). Follow-up was complete in all patients and ranged from 6 months to 9 years (median, 63 months). Overall 5-year survival was 86% and did not differ significantly from a population matched for age and gender. Five-year survival for patients with only high-grade dysplasia was 96% and 68% for patients with cancer (p = 0.017). Quality of life was measured by the Medical Outcomes Study 36-Item Short-Form Health Survey. For patients with only high-grade dysplasia, the role-physical and role-emotional scores were better than for the control population (p < 0.03). For patients with cancer, the health perception score was worse than for the control population (p < 0.03). Scores measuring physical-function, social function, mental health, bodily pain, and energy/fatigue were similar. CONCLUSIONS Although perioperative morbidity is significant, surgical resection of high-grade dysplasia in Barretts esophagus provides excellent long-term survival with acceptable function and quality of life.