John M. Close

Minimally invasive esophagectomy: outcomes in 222 patients.

Objective: To assess our outcomes after minimally invasive esophagectomy (MIE). Summary Background Data: Esophagectomy has traditionally been performed by open methods. Results from most series include mortality rates in excess of 5% and hospital stays frequently greater than 10 days. MIE has the potential to improve these results, but only a few small series have been reported. This report summarizes our experience of 222 cases. Methods: From 1996 to 2002, MIE was performed in 222 patients. Indications for operation included high-grade dysplasia (n = 47) and cancer (n = 175). Neoadjuvant chemotherapy was used in 78 (35.1%) and radiation in 36 (16.2%). Initially, a laparoscopic transhiatal approach was used (n = 8), but subsequently our approach evolved to include thoracoscopic mobilization (n = 214). Results: There were 186 men and 36 women. Median age was 66.5 years (range, 39–89). Nonemergent conversion to open procedure was required in 16 patients (7.2%). MIE was successfully completed in 206 (92.8%) patients. The median intensive care unit stay was 1 day (range, 1–30); hospital stay was 7 days (range, 3–75). Operative mortality was 1.4% (n = 3). Anastomotic leak rate was 11.7% (n = 26). At a mean follow-up of 19 months (range, 1–68), quality of life scores were similar to preoperative values and population norms. Stage specific survival was similar to open series Conclusions: MIE offers results as good as or better than open operation in our center with extensive minimally invasive and open experience. In this single institution experience, we observed a lower mortality rate (1.4%) and shorter hospital stay (7 days) than most open series. Given these results, we are now developing an intergroup trial (ECOG 2202) to assess MIE in a multicenter setting.

Obliterative bronchiolitis after lung and heart-lung transplantation: An analysis of risk factors and management

With a prevalence of 34% (55/162 at-risk recipients) and a mortality of 25% (14/55 affected recipients), obliterative bronchiolitis is the most significant long-term complication after pulmonary transplantation. Because of its importance, we examined donor-recipient characteristics and antecedent clinical events to identify factors associated with development of obliterative bronchiolitis, which might be eliminated or modified to decrease its prevalence. We also compared treatment outcome between recipients whose diagnosis was made early by surveillance transbronchial lung biopsy before symptoms or decline in pulmonary function were present versus recipients whose diagnosis was made later when symptoms or declines in pulmonary function were present. Postoperative airway ischemia, an episode of moderate or severe acute rejection (grade III/IV), three or more episodes of histologic grade II (or greater) acute rejection, and cytomegalovirus disease were risk factors for development of obliterative bronchiolitis. Recipients with obliterative bronchiolitis detected in the preclinical stage were significantly more likely to be in remission than recipients who had clinical disease at the time of diagnosis: 81% (13/15) versus 33% (13/40); p < 0.05). These results indicate that acute rejection is the most significant risk factor for development of obliterative bronchiolitis and that obliterative bronchiolitis responds to treatment with augmented immunosuppression when it is detected early by surveillance transbronchial biopsy.

Margin and Local Recurrence After Sublobar Resection of Non-Small Cell Lung Cancer

BackgroundLocal recurrence is a major concern after sublobar resection (SR) of non-small cell lung cancer (NSCLC). We postulate that a large proportion of local recurrence is related to inadequate resection margins. This report analyzes local recurrence after SR of stage I NSCLC. Stratification based on distance of the tumor (<1 cm vs ≥1 cm) to the staple line was performed.MethodsWe reviewed 81 NSCLC patients (44 female) who underwent operation over an 89-month period (January 1997 to June 2004). Mean forced expiratory volume in one second percentiles (FEV1) was 57%. Mean age was 70 (46–86) years. There were 55 wedge and 26 segmental resections. There were 41 tumors with a margin <1 cm and 40 with a margin ≥1 cm. Local recurrence was defined as recurrence within the ipsilateral lung or pulmonary hilum.ResultsThere were no perioperative deaths. Mean follow-up was 20 months. Margin distance significantly impacted local recurrence; 6 of 41 patients (14.6%) developed local recurrence in the group with margin less than 1 cm versus 3 of 40 patients (7.5%) in the group with margin equal to or more than 1 cm (P = .04). Of the 41 patients with margins <1 cm, segmentectomy was used in 7 (17%), whereas in the 40 patients with the ≥1 cm margins, segmentectomy was used in 19 (47.5%).ConclusionsMargin is an important consideration after SR of NSCLC. Wedge resection is frequently associated with margins less than 1 cm and a high risk for locoregional recurrence. Segmentectomy appears to be a better choice of SR when this is chosen as therapy.

Long-term stability of rapid palatal expander treatment and edgewise mechanotherapy.

Previous studies on long-term stability of orthodontic treatment primarily have focused on the stability of the lower arch treated with edgewise appliances. The aim of this study was to evaluate the long-term stability of the upper and the lower dental arches of patients treated with a rapid palatal expander. The sample comprised of 165 dental casts randomly selected from patients who had been out of retention for 8 to 10 years at a mean age of 30 years. Measurements were made directly on dental casts obtained at the three time intervals: before treatment, after treatment, and after retention. Differences over time between the upper and the lower dental arches and between intervals were analyzed by a two-way multivariate analysis of variance (MANOVA) and post hoc Bonferroni t tests. Differences between after treatment and after retention were statistically significant (P < 0.006) for all except lower intermolar width. However, only for lower and upper arch lengths and perimeters were the differences greater than 2.0 mm. Treatment with the rapid palatal expander presented good stability for upper intercanine width, upper and lower intermolar widths and incisor irregularity. Lower intercanine, arch length, and perimeter presented poor stability.

Anatomic segmentectomy for stage I non-small-cell lung cancer: comparison of video-assisted thoracic surgery versus open approach.

OBJECTIVES Anatomic segmentectomy is increasingly being considered as a means of achieving an R0 resection for peripheral, small, stage I non-small-cell lung cancer. In the current study, we compare the results of video-assisted thoracic surgery (n = 104) versus open (n = 121) segmentectomy in the treatment of stage I non-small-cell lung cancer. METHODS A total of 225 consecutive anatomic segmentectomies were performed for stage IA (n = 138) or IB (n = 87) non-small-cell lung cancer from 2002 to 2007. Primary outcome variables included hospital course, complications, mortality, recurrence, and survival. Statistical comparisons were performed utilizing the t test and Fisher exact test. The probability of overall and recurrence-free survival was estimated with the Kaplan-Meier method, with significance being estimated by the log-rank test. RESULTS Mean age (69.9 years) and gender distribution were similar between the video-assisted thoracic surgery and open groups. Average tumor size was 2.3 cm (2.1 cm video-assisted thoracic surgery; 2.4 cm open). Mean follow-up was 16.2 (video-assisted thoracic surgery) and 28.2 (open) months. There were 2 perioperative deaths (2/225; 0.9%), both in the open group. Video-assisted thoracic surgery segmentectomy was associated with decreased length of stay (5 vs 7 days, P < .001) and pulmonary complications (15.4% vs 29.8%, P = .012) compared with open segmentectomy. Overall mortality, complications, local and systemic recurrence, and survival were similar between video-assisted thoracic surgery and open segmentectomy groups. CONCLUSIONS Video-assisted thoracic surgery segmentectomy can be performed with acceptable morbidity, mortality, recurrence, and survival. The video-assisted thoracic surgery approach affords a shorter length of stay and fewer postoperative pulmonary complications compared with open techniques. The potential benefits and limitations of segmentectomy will need to be further evaluated by prospective, randomized trials.

The effect of carbamide peroxide bleach on the tensile bond strength of ceramic brackets: An in vitro study

Recent advances in cosmetic dentistry have led to the development of a variety of new products and techniques including vital bleaching and ceramic brackets. Therefore this study was conducted to see whether the use of an at-home carbamide peroxide bleaching agent before bonding affected the tensile bond strength of a precoated ceramic orthodontic bracket. Sixty extracted human premolar teeth were randomly separated into three groups of 20. Group 1 was a control group that was etched and bonded in the usual manner. Group 2 was immersed in a carbamide peroxide home bleaching agent for 72 hours before pumicing and bonding. Group 3 was also bleached for 72 hours but was immersed in distilled water for 1 week before bonding. The results indicated that recently bleached teeth have significantly reduced bond strength values when compared with both groups 1 and 3. We suggest that if a patient is using a tooth whitening product, that they discontinue its use at least 1 week before the bonding of orthodontic attachments.

Dental health status of liver transplant candidates

A prerequisite dental evaluation is usually recommended for potential organ transplant candidates. This is based on the premise that untreated dental disease may pose a risk for infection and sepsis, although there is no evidence that this has occurred in organ transplant candidates or recipients. The purpose of this study was to assess the prevalence of dental disease and oral health behaviors in a sample of liver transplant candidates (LTCs). Oral examinations were conducted on 300 LTCs for the presence of gingivitis, dental plaque, dental caries, periodontal disease, edentulism, and xerostomia. The prevalence of these conditions was compared with oral health data from national health surveys and examined for possible associations with most recent dental visit, smoking, and type of liver disease. Significant risk factors for plaque‐related gingivitis included intervals of more than 1 yr since the last dental visit (P = 0.004), smoking (P = 0.03), and diuretic therapy (P = 0.005). Dental caries and periodontal disease were also significantly associated with intervals of more than 1 yr since the last dental visit (P = 0.004). LTCs with viral hepatitis or alcoholic cirrhosis had the highest smoking rate (78.8%). Higher rates of edentulism occurred among older LTCs who were less likely to have had a recent dental evaluation (mean 88 months). In conclusion, intervals of more than 1 yr since the last dental visit, smoking, and diuretic therapy appear to be the most significant determinants of dental disease and the need for a pretransplantation dental screening evaluation in LTCs. Edentulous patients should have periodic examinations for oral cancer. Liver Transpl 13:280–286, 2007.

The validity of the prediction of soft tissue profile changes after LeFort I osteotomy using the dentofacial planner (computer software)

The purpose of this study was to examine the validity of the prediction of soft tissue changes after LeFort I osteotomy with the DentoFacial Planner (DFP) (computer software). The preoperative and postoperative lateral cephalograms of 21 white adult orthodontic patients (10 males and 11 females) who underwent only LeFort I osteotomy as part of their overall treatment were digitized. A coordinate system of X and Y axes were used to assess the amount and direction of movement of the maxilla. The SN + 7 degrees was the X axis, and a perpendicular to this plane from nasion was the Y axis. The sample was divided into two groups depending on the amount of forward movement of the maxilla. More than 2 mm of anterior placement of the maxilla comprised the advancement group (13 patients) and less than 2 mm comprised the impaction group (8 patients). The selection criteria for the sample were (1) before and after cephalograms taken with lips in repose and in centric occlusion; (2) all preoperative records taken almost immediately before surgery; (3) postoperative records taken at least 6 months after surgery and checked by regional superimposition of the preoperative and postoperative lateral cephalograms onto the maxilla and the mandible. No tooth movement occurred between the time the records were taken. The following soft tissue landmarks were examined: pronasale, subnasale, stomion superior, middle upper lip, stomion inferior, middle lower lip, labrale inferior, labiomental fold, and pogonion. The results indicate that for some of these landmarks the amount and direction of soft tissue changes differed between the DFP prediction and the actual surgical changes by LeFort I osteotomy.(ABSTRACT TRUNCATED AT 250 WORDS)

Dentin Matrix Protein 1 (DMP1) Signals via Cell Surface Integrin

Dentin matrix phosphoprotein 1 (DMP1) is a non-collagenous, acidic extracellular matrix protein expressed chiefly in bone and dentin. We examined the DMP1 ability to engage cell-surface receptors and subsequently activate intracellular signaling pathways. Our data indeed show that the presence of extracellular DMP1 triggers focal adhesion point formation in human mesenchymal stem cells and osteoblast-like cells. We determine that DMP1 acts via interaction with αvβ3 integrin and stimulates phosphorylation of focal adhesion kinase. Further biochemical characterization confirms the activation of downstream effectors of the MAPK pathways, namely ERK and JNK, after DMP1 treatment. This activation is specifically inhibitable and can also be blocked by the addition of anti-αvβ3 integrin antibody. Furthermore, we show that extracellular treatment with DMP1 stimulates the translocation of phosphorylated JNK to the nucleus and a concomitant up-regulation of transcriptional activation by phosphorylated c-Jun. The evidence presented here indicates that DMP1 is specifically involved in signaling via extracellular matrix-cell surface interaction. Combined with the published DMP1-null data (Feng, J. Q., Ward, L. M., Liu, S., Lu, Y., Xie, Y., Yuan, B., Yu, X., Rauch, F., Davis, S. I., Zhang, S., Rios, H., Drezner, M. K., Quarles, L. D., Bonewald, L. F., and White, K. E. (2006) Nat. Genet. 38, 1310–1315) it can be hypothesized that DMP1 could be a key effector of ECM-osteocyte signaling.

Endobronchial Ultrasound as a Diagnostic Tool in Patients With Mediastinal Lymphadenopathy

BACKGROUND The diagnostic yield and accuracy of new approaches to diagnose cancer should focus on comparison with established surgical techniques. Our objective was to evaluate the diagnostic performance of endobronchial ultrasound (EBUS) to detect cancer in patients with radiographically abnormal mediastinal lymph nodes. METHODS The medical records of patients who underwent EBUS and had abnormal mediastinal lymph nodes (short-axis >1 cm and [or] positron emission topography-positive) over a 25 month period at the University of Pittsburgh were reviewed. Demographic and clinical data, cytology, and pathology results were entered in a database and analyzed. RESULTS A total of 172 patients [male to female = 1.8:1; median age, 67 years (range, 20 to 90]) were included. The diagnostic yield of EBUS cytology was 79.7% (137 of 172). Pathologic testing was available in 68% (117 of 172) and 82% (96 of 117) had a diagnostic EBUS. The diagnostic accuracy of EBUS was 91.7%. The sensitivity, specificity, positive (PPV) and negative (NPV) predictive values were 88.1% (95% confidence interval [CI], 77.3 to 94.3), 100% (95% CI, 85.9 to 100), 100% (95% CI, 92.4 to 100), and 80.6% (95% CI, 63.4 to 91.2), respectively. In 67 patients who had a suspected or biopsy-proven primary lung cancer, diagnostic yield was 86.6% and accuracy was 94.8%. In this subgroup the sensitivity, specificity, PPV, and NPV were 93% (95% CI, 76.5 to 98.9), 100% (95% CI, 69.9 to 100), 100% (95% CI, 85 to 100), and 83.3% (95% CI, 56.2 to 97.5). CONCLUSIONS Diagnostic performance data support the clinical usefulness of EBUS in the evaluation of patients with a radiographically abnormal mediastinum. It should be considered complementary to mediastinoscopy rather than substitutive.