Joshua P. Landreneau

Contemporaneous management of esophageal perforation

BACKGROUND Esophageal perforation is an important therapeutic challenge. We hypothesized that patients with minimal mediastinal contamination at the time of diagnosis could be managed successfully with nonoperative treatment modalities. METHODS We performed a retrospective review of 119 consecutive patients with esophageal perforation from 1998 to 2008. Demographics, cause of perforation, clinical presentation, diagnostic methods, and management results were evaluated. The decision to operate was based on the extent of mediastinal contamination and systemic sepsis rather than cause of perforation. RESULTS Median time to diagnosis among all patients was 12 hours (range, 1-120). Spontaneous (Boerhaaves) perforation occurred in 44 (37%) patients. Iatrogenic perforations constituted the remaining patients (n = 75). After instrumental perforation, 9 patients (13%) required esophagectomy, 48 patients were managed with repair and drainage, and the remaining 18 were managed nonoperatively. All 34 patients undergoing operative therapy for spontaneous perforations were treated with esophageal repair. Overall mortality was 14%, with intrathoracic perforations having 18% mortality, cervical 8%, and gastroesophageal junction 3%. Patients undergoing nonoperative therapy had a shorter hospitalizations (13 vs 24 days), fewer complications (36% vs 62%), and less mortality (4% vs 15%) compared with those undergoing operative intervention. CONCLUSION An approach to esophageal perforation based on injury severity and the degree of mediastinal and pleural contamination is of paramount importance. Although operative management remains the standard in the majority of patients with esophageal perforation, nonoperative management may be successfully implemented in selected patients with a low morbidity and mortality if favorable radiographic and clinical characteristics are present.

Anatomic Segmentectomy for Stage I Non-Small Cell Lung Cancer in the Elderly

BACKGROUND Anatomic segmentectomy for stage I non-small cell lung cancer (NSCLC) offers the potential of surgical cure with preservation of lung function. This may be of particular importance in elderly NSCLC patients with declining cardiopulmonary status and a limited life expectancy. METHODS The study compared outcomes of 78 elderly patients (aged > 75 years) with stage I NSCLC undergoing segmentectomy and 106 undergoing lobectomy for stage I NSCLC from 2002 to 2007. Primary outcome variables included perioperative morbidity and mortality, hospital course, recurrence patterns, and survival. RESULTS Age, gender, tumor histology, and surgical approach were similar between groups. Comorbidities were similar except for a higher incidence of chronic obstructive pulmonary disease and diabetes in segmentectomy patients. The tumors in the lobectomy group were significantly larger (3.5 vs 2.5 cm, p = 0.0001). Operative mortality was 1.3% for segmentectomy and 4.7% for lobectomy. Segmentectomy patients had fewer major complications (11.5% vs 25.5%, p = 0.02). There were no differences in median hospitalization (7 vs 6 days). The estimated overall survival at 2, 3, and 5 years was 76%, 69%, and 46% for segmentectomy patients and 68%, 59%, and 47% for lobectomy patients (p = 0.28). The 5-year disease-free survival was equivalent (segmentectomy, 49.8%; lobectomy, 45.5%; p = 0.80). CONCLUSIONS Anatomic segmentectomy can be performed safely in elderly patients with early-stage NSCLC. This approach is associated with reduced perioperative complications and comparable oncologic efficacy compared with lobectomy in older patients with a limited life expectancy.

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.

Technical Challenges and Utility of Anterior Exposure for Thoracic Spine Pathology

BACKGROUND Thoracic surgeons are frequently called upon to provide exposure to the anterior cervicothoracic, thoracic, and proximal lumbar spine. We reviewed our surgical experience and the perioperative outcomes of these spinal approaches. Relevant technical and anatomic considerations of each procedure are highlighted. METHODS A total of 213 patients (116 female, 97 male) undergoing anterior thoracic spinal exposures over an 11-year period at a single institution were analyzed. Primary endpoints include morbidity, mortality, and perioperative outcomes. RESULTS Mean age was 53.7 years. Surgical approaches were determined based on the location and length of spinal involvement, and included cervicothoracic (5), thoracotomy (117), and thoracoabdominal (91) techniques. Malignant etiologies were associated with the highest perioperative mortality (6.7%, p = 0.08). Procedures for infection were associated with a significantly higher complication rate (p = 0.041) and length of stay (p = 0.033). Correction of scoliosis required longer operative times (p < 0.001) and resulted in a trend toward higher blood loss (p = 0.16). Thoracoabdominal approaches were associated with increased operative times (386 vs 316 minutes) and length of stay (8 vs 6 days) compared with thoracotomy. CONCLUSIONS The increased use of anterior approaches to spinal pathology necessitates greater involvement by thoracic surgeons. Familiarity with the anatomic and technical features of the anterior spinal exposure is required by thoracic surgeons to optimize surgical outcomes.

Immunological Mechanisms of Low and Ultra-Low Dose Cancer Chemotherapy.

Traditionally, anticancer chemotherapy has been generally considered to be strongly immunosuppressive. However, increasing evidence suggests that certain chemotherapeutic agents rely on the induction of antitumor immune responses, in both experimental animal models and patients with cancer. Many of these chemotherapeutic agents exert immunogenic effects via the induction and release of immunostimulatory “danger” signals from dying cancerous cells when used in low doses. New data suggests that several common chemotherapeutic agents may also display direct stimulating effects on immune cells even when applied in ultra-low concentrations (chemoimmunomodulation). Importantly, it is becoming clear that both immune effector cells and immune regulatory cells can be targeted by various chemotherapeutic agents to produce favorable antitumor immune responses. Therefore, utilizing cancer drugs to enhance host antitumor immunity should be considered a feasible therapeutic approach; and recent characterization of the immunomodulatory mechanisms of anticancer chemotherapy using both new and traditional cytotoxic agents suggests that combinations of these approaches with “classical” immunomodulatory agents could lead to a viable new therapeutic paradigm for the treatment of cancer.

Use of energy-based coagulative fusion technology and lung sealants during anatomic lung resection

OBJECTIVES Energy-based tissue fusion technology is being increasingly used for vascular division in numerous intra-abdominal applications. Very few data, however, are available regarding the application of this technology in the chest during anatomic lung resection. In the present review, we evaluated the use of energy-based fusion and lung sealants during anatomic lung resection. METHODS We performed a review of case series and published studies to evaluate the use of energy-based coagulative fusion technology and lung sealants during anatomic lung resection. We then used energy-based coagulative fusion technology during anatomic lung resection (segmentectomy or lobectomy) in 316 cases from 2008 to 2011. Two energy applications were applied to the arterial and venous branches before vessel division. RESULTS In the first 12 cases, we used a device with a small curved jaw (range, 3.3-4.7 mm). Two partial venous dehiscences were noted and controlled intraoperatively. For the remaining cases, we used a larger jaw (6 mm × 22 mm) with no arterial or venous dehiscence occurring (vessels ranged from 0.4 to 1.2 cm). Autologous or synthetic tissue sealants applied to the parenchymal staple lines might reduce the severity and duration of perioperative air leaks. Suture line buttressing with pericardial or absorbable biosynthetic polyester strips might reduce the severity of air leaks in patients with severe emphysema undergoing anatomic lung resection or lung volume reduction surgery. CONCLUSIONS The bipolar tissue fusion system provides a safe and effective technique for the division of the pulmonary arterial and venous branches during anatomic lung resection. Surgical sealants and buttressing adjuncts might reduce perioperative air leak potential.

Anterior Thoracic Surgical Approaches in the Treatment of Spinal Infections and Neoplasms

BACKGROUND Thoracic surgeons are commonly consulted to provide anterior thoracic exposure for infection and malignant neoplasms involving the thoracolumbar spine. These cases can present significant technical and management challenges secondary to the underlying pathology, associated anatomic inflammation, and impaired functional status. In this study, we review the perioperative outcomes in patients undergoing anterior spinal exposure for infection and neoplasm. METHODS 130 consecutive patients (61 women, 69 men) undergoing corpectomy, debridement, or debulking for osteomyelitis (n=50) or neoplasms (n=80) with decompression/stabilization at a single institution were analyzed. Primary endpoints included morbidity, mortality, and perioperative neurologic outcomes. RESULTS The mean age was 61.1 years. A cervical/sternotomy (n=8) approach was used for levels C7 to T2, thoracotomy (n=79) for levels T3 to T10, and thoracoabdominal (n=43) for T11 to L2 involvement. Primary spinal neoplasms (n=22, 16.9 %) and metastases (n=58, 44.6%) were treated with corpectomy and prosthetic stabilization and were associated with increased operative time (310 vs 243 minutes, p=0.02) and blood loss (825 vs 500 mL, p=0.002). Osteomyelitis was associated with longer hospital stays (12 vs 7 days, p<0.001). The 30-day and 90-day mortality was 9.2% and 20.8%, respectively. The major complication rate was 27.7%. The median length of stay was 9 days. Surgical intervention resulted in significant improvement in pain, numbness, weakness, and bowel and bladder dysfunction. CONCLUSIONS Anterior spinal exposure represents an important modality in facilitating the treatment of patients with osteomyelitis, pathologic fractures, and spinal cord compression syndromes. These procedures are associated with a significant risk of morbidity and mortality, but they are effective in achieving spinal stabilization and alleviating neurologic symptoms.