Daniel P. Raymond

Predictors of Major Morbidity or Mortality After Resection for Esophageal Cancer: A Society of Thoracic Surgeons General Thoracic Surgery Database Risk Adjustment Model

BACKGROUND The purpose of this analysis was to revise the model for perioperative risk for esophagectomy for cancer utilizing The Society of Thoracic Surgeons General Thoracic Surgery Database to provide enhanced risk stratification and quality improvement measures for contributing centers. METHODS The Society of Thoracic Surgeons General Thoracic Surgery Database was queried for all patients treated for esophageal cancer with esophagectomy between July 1, 2011, and June 30, 2014. Multivariable risk models for major morbidity, perioperative mortality, and combined morbidity and mortality were created with the inclusion of surgical approach as a risk factor. RESULTS In all, 4,321 esophagectomies were performed by 164 participating centers. The most common procedures included Ivor Lewis (32.5%), transhiatal (21.7%), minimally invasive esophagectomy, Ivor Lewis type (21.4%), and McKeown (10.0%). Sixty-nine percent of patients received induction therapy. Perioperative mortality (inpatient and 30-day) was 135 of 4,321 (3.4%). Major morbidity occurred in 1,429 patients (33.1%). Major morbidities include unexpected return to operating (15.6%), anastomotic leak (12.9%), reintubation (12.2%), initial ventilation beyond 48 hours (3.5%), pneumonia (12.2%), renal failure (2.0%), and recurrent laryngeal nerve paresis (2.0%). Statistically significant predictors of combined major morbidity or mortality included age more than 65 years, body mass index 35 kg/m(2) or greater, preoperative congestive heart failure, Zubrod score greater than 1, McKeown esophagectomy, current or former smoker, and squamous cell histology. CONCLUSION Thoracic surgeons participating in The Society of Thoracic Surgeons General Thoracic Surgery Database perform esophagectomy with low morbidity and mortality. McKeown esophagectomy is an independent predictor of combined postoperative morbidity or mortality. Revised predictors for perioperative outcome were identified to facilitate quality improvement processes and hospital comparisons.

Complications of Esophagectomy

Esophagectomy remains the gold standard curative therapy for the treatment of esophageal cancer. Despite 125 years of evolution, esophagectomy remains a demanding procedure associated with a 5% to 10% mortality and a 50% morbidity rate. Knowledge of the multitude of techniques possible for performing this complex procedure, as well as the host of associated complications, is vital for the practitioner aspiring to treat this challenging disease.

A genetic basis for the variation in the vulnerability of cancer to DNA damage

Radiotherapy is not currently informed by the genetic composition of an individual patients tumour. To identify genetic features regulating survival after DNA damage, here we conduct large-scale profiling of cellular survival after exposure to radiation in a diverse collection of 533 genetically annotated human tumour cell lines. We show that sensitivity to radiation is characterized by significant variation across and within lineages. We combine results from our platform with genomic features to identify parameters that predict radiation sensitivity. We identify somatic copy number alterations, gene mutations and the basal expression of individual genes and gene sets that correlate with the radiation survival, revealing new insights into the genetic basis of tumour cellular response to DNA damage. These results demonstrate the diversity of tumour cellular response to ionizing radiation and establish multiple lines of evidence that new genetic features regulating cellular response after DNA damage can be identified.

A Histologic Basis for the Efficacy of SBRT to the lung

Purpose: Stereotactic body radiation therapy (SBRT) is the standard of care for medically inoperable patients with early‐stage NSCLC. However, NSCLC is composed of several histological subtypes and the impact of this heterogeneity on SBRT treatments has yet to be established. Methods: We analyzed 740 patients with early‐stage NSCLC treated definitively with SBRT from 2003 through 2015. We calculated cumulative incidence curves using the competing risk method and identified predictors of local failure using Fine and Gray regression. Results: Overall, 72 patients had a local failure, with a cumulative incidence of local failure at 3 years of 11.8%. On univariate analysis, squamous histological subtype, younger age, fewer medical comorbidities, higher body mass index, higher positron emission tomography standardized uptake value, central tumors, and lower radiation dose were associated with an increased risk for local failure. On multivariable analysis, squamous histological subtype (hazard ratio = 2.4 p = 0.008) was the strongest predictor of local failure. Patients with squamous cancers fail SBRT at a significantly higher rate than do those with adenocarcinomas or NSCLC not otherwise specified, with 3‐year cumulative rates of local failure of 18.9% (95% confidence interval [CI]: 12.7–25.1), 8.7% (95% CI: 4.6–12.8), and 4.1% (95% CI: 0–9.6), respectively. Conclusion: Our results demonstrate an increased rate of local failure in patients with squamous cell carcinoma. Standard approaches for radiotherapy that demonstrate efficacy for a population may not achieve optimal results for individual patients. Establishing the differential dose effect of SBRT across histological groups is likely to improve efficacy and inform ongoing and future studies that aim to expand indications for SBRT.

Impact of nutritional state on lung transplant outcomes

BACKGROUND When high-risk lung transplant candidates are evaluated, nutritional state is often neglected. We evaluated the prevalence of markers reflecting pre-transplant malnutrition and their association with post-operative complications and death. METHODS From January 2005 to July 2010, 453 patients underwent primary lung transplantation at our institution. Pre-operative nutrition-related variables, including body mass index and weight/height ratio, reflecting cachexia, and albumin, total protein, immunoglobulins, and absolute lymphocyte count were considered in identifying risk factors for time-related major post-operative complications (renal failure requiring dialysis, respiratory failure requiring tracheostomy), pulmonary or bloodstream infections, and death. RESULTS Forty-eight patients had BMI <18.5 kg/m(2), 41 had a weight/height ratio ≤ 0.3, 102 had albumin <3.5 g/dl, 110 had total protein <6 g/dl, and 112 had an absolute lymphocyte count <1,000/μl, indicative of a malnourished state. At 6 months, 30% had experienced pulmonary infection, with lower total serum protein concentration an important risk (p = 0.02). One-year actuarial mortality was 15%; risk factors included lower serum albumin (p = 0.004), particularly when <3 g/dl. In contrast, variables reflecting nutritional state were not statistically significantly correlated with dialysis, respiratory failure requiring tracheostomy, or bloodstream infections. CONCLUSION Although malnutrition is uncommon in lung transplant patients, those at extremes of low serum albumin and total protein have worse survival and increased risk of post-operative infection. Strategies to improve nutrition of these high-risk candidates awaiting lung transplantation should be developed.

Endobronchial valves for treatment of bronchopleural fistula in granulomatous polyangitis: a longitudinal case report.

Bronchopleural fistula (BPF) is an abnormal communication between the bronchus and the pleural space, commonly occurring after pulmonary resection or due to a spontaneous pneumothorax secondary to an underlying lung disease. We present a case of BPF in the setting of granulomatous polyangitis treated with endobronchial valves (EBV) with a longitudinal follow-up. These 1-way valves allow air and mucus to exit the diseased segment of lung during expiration, but prevent the reentry of air upon inspiration. The targeted segment may undergo atelectasis, achieving nonsurgical lung volume reduction, and allowing the remaining lung to compensate for the loss of volume. The use of these valves has shown to decrease hospitalization, morbidity, and mortality in these patients. In this case, the patient endured a prolonged hospitalization (82 d) and was able to be discharged only 7 days after EBV placement. This facilitated engagement in a pulmonary rehabilitation program, increased physical activity, and ultimately resumption of normal activity for the patient. To our knowledge, this is the first case of EBV used to treat BPF in the setting of underlying granulomatous polyangitis. This underscores the point that in appropriate settings, EBVs can decrease morbidity and mortality, and significantly improve the quality of life.

A 33-year-old man with multiple bilateral pulmonary pseudoaneurysms

A 33-year-old man, never smoker, presented with acute-onset dyspnea secondary to bilateral pulmonary emboli. Echocardiography at the time revealed a right atrial myxoma, for which he underwent resection, followed by anticipated lifelong therapeutic anticoagulation therapy.

Surgical Intervention for Thoracic Infections

Multidisciplinary management of thoracic infection, including experts in thoracic surgery, pulmonology, infectious disease, and radiology, is ideal for optimal outcomes. Initial assessment of parapneumonic effusion and empyema requires computed tomographic evaluation and consideration for fluid sampling or drainage. Goals for the treatment of parapneumonic effusion and empyema include drainage of the pleural space and complete lung reexpansion. Pulmonary abscess is often successfully treated with antibiotics and observation. Surgical intervention for the treatment of fungal or tuberculous lung disease should be undertaken by experienced surgeons following multidisciplinary assessment. Sternoclavicular joint infection often requires joint resection.

Malignant Pleural Effusion: One Size Does Not Fit All

When surgery is indicated in the treatment of myasthenia gravis (MG), a total thymectomy is mandatory; this should be accomplished to achieve complete remission from symptoms. The embryology and anatomy of the mediastinal region and the thymus gland make the removal of all the thymic tissue—a prerequisite for symptom control given the autoimmune nature of the MG—a difficult surgical task that is usually performed in the vast majority of cases via an open-access transsternal approach. However, this approach significantly affects the postoperative morbidity, pain, and cosmesis; in recent years, many efforts have been undertaken to develop and validate less invasive techniques [1, 2]. All these approaches invariably use innovative video-assisted thoracic surgery technologies. Jurado and coworkers [3] performed a comprehensive comparative analysis of minimally invasive thymectomy performed via video-assisted thoracic surgery versus open thymectomy in a large series of patients affected mostly by MG [3]. Based on the results of this analysis, the authors conclude that, to control the effects of surgery itself on frail patients with MG (by decreasing the postoperative morbidity), the less-aggressive techniques should be preferred. We would support a cautionary attitude with this recommendation. In fact, Jaretzky and colleagues [4] clearly showed that transsternal approaches provide worse results in terms of long-term remission rate from MG if compared with less invasive approaches, given that the operation executed at the level of the mediastinum is the same. Moreover, ectopic thymic foci are found inmore thanhalf of cases [5] inwhich an extended thymectomy is performed (a type of operation virtually unfeasible through a non-trans-sternotomic or bilateral transthoracic access). One point of caution is that the feasibility and efficacy of all mini-invasive surgical techniques in the treatment ofMG should be evaluated, accounting for the postoperative surgical outcomes and long-term neurologic outcomes. Insufficient data about the neurologic outcome in the MG subgroup of patients [3] makes it difficult to interpret the results, substantially weakening the conclusion that less invasive approaches should be preferred. We would welcome a comment from the authors on this point, in light of the firm principle that the completeness of the operation as defined by the extended thymectomy approach is the goal of any approach. In addition, we would welcome additional reasoning on the relative weight of the postoperative and cosmetic outcome patterns versus the long-term neurologic and quality-of-life outcome in patients with MG and what factors a surgeon should prioritize in the clinical decision-making process at the moment of the surgical indication. Thus, any attempt at ameliorating morbidity and cosmetic patterns in the postoperative setting is, in our opinion, to be carefully matched with the fact that long-term substantial benefit in such patients can be provided only if the thymic tissue resection is complete.

Endoscopic Repair of Recurrent Tracheoesophageal Fistula With an Atrial Septal Occluder Device

A 32-year-old woman presented with recurrent trachea-esophageal fistula. Although she had undergone open repair three times in her first year of life, a residual small leak was left. In the past 2 years she had experienced several lower respiratory tract infections and she had lost 5 kilograms in the past 2 months. Recent argon plasma coagulation cauterization and clipping of the fistula had failed, so an alternative technique with placement of an atrial septal occluder device was used to obliterate the fistula. A follow-up barium swallow showed no more communication to the tracheobronchial tree, and endoscopy demonstrated epithelialization. At her 3-year follow-up visit she was asymptomatic.