Faiz Y. Bhora

Multilevel airway stenosis in patients with granulomatosis with polyangiitis (Wegener’s)

OBJECTIVES To describe the presentation and clinical course of subglottic stenosis (SGS), in particular the development of concurrent airway lesions, in patients with Granulomatosis with Polyangiitis (Wegeners) (GPA). MATERIALS AND METHODS Retrospective review of clinical data from all patients presenting to our institution from 2000 to 2012 with SGS and GPA. RESULTS Thirty-five patients were identified. The average age at diagnosis was 33 years old. Eleven patients (31%) presented with SGS as part their initial manifestation of GPA. The remaining patients developed SGS later, at a median of 2.5 years from diagnosis (range 6 months to 14 years). Twelve patients (34%) were noted to have multilevel airway involvement. Seven patients (20%) had documentation of cricoarytenoid joint fixation and vocal cord immobility. This was typically progressive in nature and occurred at an average of two years following the diagnosis of SGS. Six patients (17%) had mid/distal tracheal stenosis and four (11%) had bronchial stenosis. The majority of patients (86%) had evidence of concurrent sinonasal involvement, ten patients (29%) had evidence of otologic involvement and eight (23%) had ocular involvement. CONCLUSIONS Cricoarytenoid joint fixation and distal stenosis occur not infrequently in patients with GPA and SGS, resulting in progressive multilevel airway stenosis in about one third of patients. It is critical to identify multilevel stenosis when managing the airways of these patients.

Racial disparities in esophageal cancer survival after surgery.

Esophageal cancer (EC) black patients have higher mortality rates than Whites. The lower rate of surgery in Blacks may explain the survival difference. We explored the Surveillance Epidemiology and End Results database to determine the impact of surgery on mortality in Blacks and Whites EC.

Stents for airway strictures: selection and results

Airway stents can provide effective and timely relief in patients with central airway obstruction. Silicone based stents are the most commonly used airway stents worldwide with a long track record of safety. Metallic stents continue to evolve from the earliest uncovered versions to a variety of newly designed covered stents. Despite the availability of a variety of stent materials and designs, minimal advances have been made towards innovation in stent technology and an ideal stent has unfortunately not yet been developed. Nevertheless, the first generation of biodegradable airway stents are available, work on drug-eluted stents is in the pipeline and three-dimensional printing of a customized airway stent may be the future. In this review, we discuss selection and results for most commonly utilized airway stents.

Robotically Assisted Thoracic Surgery: Proposed Guidelines for Privileging and Credentialing

Objective Increased use of robotically assisted thoracic surgery (RATS) necessitates effective credentialing guidelines to ensure safe outcomes. We provide a stepwise algorithm for granting privileges and credentials in RATS. This algorithm reflects graduated responsibility and complexity of the surgical procedures performed. Furthermore, it takes into account volume, outcomes, surgeons competency, and appropriateness of robot usage. Methods We performed a literature review for available strategies to grant privileges and credentials for implementing robotic surgery. The following terms were queried: robot, robotic, surgery, and credentialing. We provide this algorithm on the basis of review of the literature, our institutional experience, and the experience of other medical centers around the United States. Results Currently, two pathways for robotic training exist: residency and nonresidency-trained. In the United Sates, Joint Commission: Accreditation, Health Care, Certification requires hospitals to credential and privilege physicians on their medical staff. In the proposed algorithm, a credentialing designee oversees and reviews all requests. Residency-trained surgeons must fulfill 20 cases with program directors’ attestation to obtain full privileges. Nonresidency-trained surgeons are required to fulfill simulation, didactics including online modules, wet laboratories (cadaver or animal), and observation of at least two cases before provisional privileges can be granted. A minimum number of cases (10 per year) are required to maintain privileges. All procedures are monitored via departmental QA/QI committee review. Investigational uses of the robot require institutional review board approval, and complex operations may require additional proctoring and QA/QI review. Conclusions Safety concerns with the introduction of novel and complex technologies such as RATS must be paramount. Our algorithm takes into consideration appropriate use and serves as a basic guideline for institutions that wish to implement a RATS program.

Hyperthermic Intrathoracic Chemotherapy for Metastatic Ovarian Cancer

Introduction: Ovarian serous carcinoma is an aggressive malignancy, often with metastases at presentation. Cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy has been studied as a treatment option for intraperitoneal spread of ovarian cancer. Hyperthermic intrathoracic chemotherapy, the thoracic counterpart to hyperthermic intraperitoneal chemotherapy, is emerging as a treatment option for both primary and secondary pleural cancers but has not previously been reported for treatment of ovarian metastases. The use of minimally invasive thoracoscopic techniques, including robotic assistance, for intrathoracic chemotherapy is rare. We present a case report of a patient with pleural metastasis of ovarian serous carcinoma treated with cytoreductive surgery and intrathoracic chemotherapy. Case Description: In a 55-year-old woman who underwent a total abdominal hysterectomy and bilateral salpingooophorectomy with cytoreduction in July 2011 for ovarian cancer, a right-sided pleural effusion developed on postoperative radiographs. After chemotherapy treatment, she had a 7-month remission until positron emission tomography/ computed tomography scan identified an isolated pleural metastasis. The findings of diagnostic laparoscopy were negative for occult abdominal disease. We performed robotic-assisted right-sided video-assisted thoracoscopic surgery, partial pleurectomy, and resection of pleural, diaphragmatic, mediastinal, and pericardial nodules, followed by perfusion with heated cisplatinum for 60 minutes. The surgical procedure was uncomplicated, and the patient was discharged on postoperative day 3. The serum creatinine level remained normal. The pathologic specimens showed poorly differentiated/high-grade adenocarcinoma consistent with the patient’s ovarian primary. At 10 months postoperatively, she had no evidence of early recurrence and had a normal Karnofsky performance score (100). Conclusion: We report the first case of robotic-assisted hyperthermic intrathoracic chemotherapy to treat ovarian carcinoma. Intrathoracic chemotherapy may be an important tool in the treatment of ovarian metastases in the chest.

Effect of postoperative course on midterm outcome after esophageal resection for cancer.

Esophageal resections are challenging procedures often associated with postoperative complications and a prolonged hospital stay. This study investigated the impact of postoperative course on midterm survival in 35 patients undergoing esophageal resection for malignancy between January 2002 and November 2007. The impact of preoperative and operative variables, pathology, staging, early postoperative complications, and length of hospital stay on midterm survival was determined with Cox regression analysis. During the follow-up period, 17 (48.6%) patients died. Multivariate analysis identified surgical stage and length of stay as independent predictors of midterm survival; in addition, the total number of complications reached statistical significance. In conclusion, in addition to surgical stage, postoperative course has an impact upon midterm survival after esophageal resection.

Can racial and financial disparities be overcome in the surgical treatment of NSCLC

208 Background: Considerable data exists examining disparities in the treatment of non-small cell lung cancer (NSCLC) patients. Black patients, in particular those of lower socioeconomic status (SES), are less likely to receive appropriate care, including induction therapy and resection of surgically treatable lesions. We analyzed the outcomes of resection of NSCLC among a racially and financially diverse patient population at a large urban hospital network with a comprehensive thoracic oncology program. In this system, a patient navigation support team helped overcome barriers to preoperative preparation and multidisciplinary referral. METHODS A retrospective review of 345 patients who underwent lobectomy at our institution from 2002 - 2011 was performed. Data was retrieved from the Society of Thoracic Surgeons (STS) database and patient charts. Patient demographics, payor information and preoperative characteristics were noted. Postoperative complications, 30-day survival and 3-year survival were compared. Statistical analysis was performed using SPSS 17.0 (SPSS Inc, Chicago, IL). Chi-square test was used to compare categorical variables and Students t-test was used to compare continuous variables. RESULTS Demographics of black and non-black patients were similar. There were more black patients within the Medicaid group than non-Medicaid (48.9% and 25.3%, p=0.001). Physiologic characteristics, risk factors and use of pre-operative RT and chemotherapy were similar. Post-operative complications were comparable in Medicaid vs. non-Medicaid (11.1% and 14.7%, p=0.524), however black patients had a lower rate of complications vs. non-black (6.1% and 17.4%, p=0.007). 3-year survival was similar in the black vs. non-black (82.3% and 78.6%, p=0.879) and Medicaid vs. non-Medicaid (66.7% and 78.8%, p=0.342) groups. CONCLUSIONS We demonstrated equivalent surgical outcomes for NSCLC in addition to the similar use of induction therapy. Surprisingly, complications were lower in the black cohort. Our results reveal that appropriate treatment is being provided regardless of race or SES, and postulate that our system of preoperative patient support eliminates potential barriers to care.

Endoscopic tracheoplasty: segmental tracheal ring resection in a porcine model.

Endoscopic tracheoplasty is used for the relief of airway obstruction because of several benign conditions such as postintubation stenosis, inflammatory disorders such as Wegener granulomatosis, and benign neoplastic processes. Several endoscopic treatment modalities exist for these conditions, all with good initial results. However, recurrence is common and often requires frequent reintervention. Endoscopic segmental tracheal ring resection is a novel therapeutic approach that could potentially provide a durable solution. Endoscopic segmental tracheal ring resection was performed in 3 Yorkshire pigs under general anesthesia. A combination of bipolar cautery and sharp dissection was used to resect 25% to 33% of the circumference of a single tracheal ring. Technical success was achieved in all 3 animals with no intraoperative complications. Full-thickness excision, including the anterior perichondrium, was performed in 1 animal without violation of the pretracheal fascia, with no subcutaneous emphysema or clinically apparent pneumothorax. Average operative time was 31 minutes and estimated blood loss was minimal. Heart rate, oxygen saturation, and peak airway pressures were maintained within normal ranges during the procedure and for the 60-minute postoperative period. Histologic analysis of the resected specimen confirmed complete thickness excision of the segment of tracheal cartilage. Endoscopic tracheoplasty by segmental tracheal ring resection is a safe and feasible technique in a porcine model. Long-term durability could potentially outlast other endoscopic techniques for the treatment of bening tracheal stenosis. Survival studies in a porcine model of tracheal stenosis must be performed to assess the long-term outcomes of this approach.