Manisha Shende

Outcomes After Minimally Invasive Esophagectomy Review of Over 1000 Patients

Background: Esophagectomy is a complex operation and is associated with significant morbidity and mortality. In an attempt to lower morbidity, we have adopted a minimally invasive approach to esophagectomy. Objectives: Our primary objective was to evaluate the outcomes of minimally invasive esophagectomy (MIE) in a large group of patients. Our secondary objective was to compare the modified McKeown minimally invasive approach (videothoracoscopic surgery, laparoscopy, neck anastomosis [MIE-neck]) with our current approach, a modified Ivor Lewis approach (laparoscopy, videothoracoscopic surgery, chest anastomosis [MIE-chest]). Methods: We reviewed 1033 consecutive patients undergoing MIE. Elective operation was performed on 1011 patients; 22 patients with nonelective operations were excluded. Patients were stratified by surgical approach and perioperative outcomes analyzed. The primary endpoint studied was 30-day mortality. Results: The MIE-neck was performed in 481 (48%) and MIE-Ivor Lewis in 530 (52%). Patients undergoing MIE-Ivor Lewis were operated in the current era. The median number of lymph nodes resected was 21. The operative mortality was 1.68%. Median length of stay (8 days) and ICU stay (2 days) were similar between the 2 approaches. Mortality rate was 0.9%, and recurrent nerve injury was less frequent in the Ivor Lewis MIE group (P < 0.001). Conclusions: MIE in our center resulted in acceptable lymph node resection, postoperative outcomes, and low mortality using either an MIE-neck or an MIE-chest approach. The MIE Ivor Lewis approach was associated with reduced recurrent laryngeal nerve injury and mortality of 0.9% and is now our preferred approach. Minimally invasive esophagectomy can be performed safely, with good results in an experienced center.

Recurrence and Survival Outcomes After Anatomic Segmentectomy Versus Lobectomy for Clinical Stage I Non–Small-Cell Lung Cancer: A Propensity-Matched Analysis

PURPOSE Although anatomic segmentectomy has been considered a compromised procedure by many surgeons, recent retrospective, single-institution series have demonstrated tumor recurrence and patient survival rates that approximate those achieved by lobectomy. The primary objective of this study was to use propensity score matching to compare outcomes after these anatomic resection approaches for stage I non-small-cell lung cancer. PATIENTS AND METHODS A retrospective data set including 392 segmentectomy patients and 800 lobectomy patients was used to identify matched segmentectomy and lobectomy cohorts (n = 312 patients per group) using a propensity score matching algorithm that accounted for confounding effects of preoperative patient variables. Primary outcome variables included freedom from recurrence and overall survival. Factors affecting survival were assessed by Cox regression analysis and Kaplan-Meier estimates. RESULTS Perioperative mortality was 1.2% in the segmentectomy group and 2.5% in the lobectomy group (P = .38). At a mean follow-up of 5.4 years, comparing segmentectomy with lobectomy, no differences were noted in locoregional (5.5% v 5.1%, respectively; P = 1.00), distant (14.8% v 11.6%, respectively; P = .29), or overall recurrence rates (20.2% v 16.7%, respectively; P = .30). Furthermore, when comparing segmentectomy with lobectomy, no significant differences were noted in 5-year freedom from recurrence (70% v 71%, respectively; P = .467) or 5-year survival (54% v 60%, respectively; P = .258). Segmentectomy was not found to be an independent predictor of recurrence (hazard ratio, 1.11; 95% CI, 0.87 to 1.40) or overall survival (hazard ratio, 1.17; 95% CI, 0.89 to 1.52). CONCLUSION In this large propensity-matched comparison, lobectomy was associated with modestly increased freedom from recurrence and overall survival, but the differences were not statistically significant. These results will need further validation by prospective, randomized trials (eg, Cancer and Leukemia Group B 140503 trial).

Comparison of surgical techniques for early-stage thymoma: feasibility of minimally invasive thymectomy and comparison with open resection.

OBJECTIVE The minimally invasive, video-assisted thoracoscopic surgical (VATS) approach to resection of the thymus is frequently practiced for benign disease; however, a VATS approach for thymoma remains controversial. The objective of the present study was to evaluate the feasibility of VATS thymectomy for the treatment of early-stage thymoma and to compare the outcomes with those after open resection. METHODS A retrospective review of 40 patients who underwent surgical resection of early-stage thymoma during a 12-year period was conducted. Data on patient characteristics, morbidity, recurrence, and survival were collected. The primary endpoint studied was overall survival. RESULTS Of the 40 patients, 14 underwent thymectomy for stage I and 26 for stage II thymoma; 19 were men and 21 were women (median age, 64 years; range, 35-86 years). Open thymectomy was performed in 22 patients, and VATS was performed in 18. The operative mortality rate was 0%. The tumor stage and number of patients undergoing adjuvant radiotherapy were comparable in both surgical groups. The median length of hospital stay was shorter in the VATS group (3 days) than in the open group (5 days) (P = .0001). The median follow-up was 36 months. No significant differences were found in the estimated recurrence-free and overall 5-year survival rates (83%-100%) between the 2 groups. CONCLUSIONS VATS of early-stage thymoma appears safe and feasible and was associated with a shorter hospital stay. The oncologic outcomes were comparable in the open and VATS groups during intermediate-term follow-up. Additional follow-up is required to evaluate the long-term results of thoracoscopic thymectomy for early-stage thymoma.

Surgical Resection Should Be Considered for Stage I and II Small Cell Carcinoma of the Lung

BACKGROUND Small cell lung carcinoma (SCLC) is rarely treated with resection, either alone or combined with other modalities. This study evaluated the role of surgical resection in the treatment of stage I and II SCLC. METHODS We queried the Surveillance, Epidemiology, and End Results (SEER) database for patients from 1988 to 2007 with SCLC. Survival was determined by Kaplan-Meier analysis and compared using the log-rank test. A Cox proportional hazard model identified relevant survival variables. RESULTS We identified 3,566 patients with stage I or II SCLC. Lung resection was performed in 895 (25.1%), wedge resection in 251 (28.0%), lobectomy or pneumonectomy in 637 (71.2%), and lung resection not otherwise specified in 7 (0.78%). Median survival was 34.0 months (95% confidence interval [CI], 29.0 to 39.0 months) vs 16.0 months (95% CI, 15.3 to 16.7; p<0.001) in nonsurgical patients. Median survival after lobectomy or pneumonectomy was 39.0 months (95% CI, 30.7 to 40.3) and significantly longer than after wedge resection (28.0 months; 95% CI, 23.2 to 32.8; p=0.001). However, survival after wedge resection was still significantly longer than survival in nonsurgical patients (p<0.001). Sex (p=0.013), age, stage at diagnosis, radiotherapy, and operation (all p<0.001) significantly affected survival. In the surgical patients, sex (p=0.001), age (p<0.001), final stage (p<0.001), and type of resection (p=0.01) were important determinants of survival. CONCLUSIONS Surgical resection as a component of treatment for stage I or II SCLC is associated with significantly improved survival and should be considered in the management of early-stage SCLC.

Endoscopic Thoracic Sympathectomy: At What Level Should You Perform Surgery?

Several interventions are possible on the sympathetic chain and the nomenclature has been confusing. The authors propose a uniform nomenclature for each procedure, mainly, sympathectomy for resection or ablation of the ganglion, sympathicotomy for the transaction of the chain, ramicotomy for the procedure preserving the chain and ganglia and severing the rami, and finally, sympathetic block for clipping above and below the ganglia. They recommend intervention on the T2 ganglia for facial hyperhidrosis and rubor, on the T3 ganglia for palmar hyperhidrosis, and on the T3 and T4 ganglia for axillary hyperhidrosis.

The Role of Adjuvant Radiation Therapy for Resected Stage III Thymoma: A Population-Based Study

BACKGROUND Because of the rarity of the disease and long survival of most patients, the role of adjuvant radiation therapy in patients with surgically resected stage III thymoma is unclear, and few prospective studies are available. The objective was to evaluate the impact of postoperative radiation therapy after resection of stage III thymoma. METHODS The Surveillance, Epidemiology, and End Results (SEER) database was queried for all patients with stage III thymoma who underwent surgical therapy and survived more than 30 days after diagnosis. Survival was estimated with the Kaplan-Meier method. The hazard ratio for death was determined using a Cox proportional hazard model. RESULTS There were 476 patients with stage III thymoma identified who underwent surgical therapy, did not receive preoperative radiotherapy, and had complete SEER records with regard to radiation treatment. Postoperative radiation therapy was given to 322 patients (67.6%). Patients who received postoperative radiation therapy were younger and had a higher rate of debulking surgery than patients who did not. Patients receiving postoperative radiation had a median overall survival of 127 months (95% confidence interval, 100.9 to 153.1) compared with 105 months (95% confidence interval, 76.9 to 133.1) in patients treated with surgery alone (p=0.038). However, in multivariate analysis, postoperative radiation was not a significant factor affecting overall survival. Disease-specific survival was significantly improved in the adjuvant radiation group, and in multivariate analysis, improved outcomes were associated with postoperative radiation (p=0.049). CONCLUSIONS In this large population-based study, most patients with stage III thymoma were treated with adjuvant radiation. Postoperative radiation was associated with improved disease-specific survival, but not improved overall survival.

Surgical Palliation for Barrett's Esophagus Cancer

Adenocarcinoma arising in the setting of Barretts esophagus has the fastest increasing incidence of any malignancy in the United States. Advanced esophageal cancer carries an overall poor prognosis with most patients presenting with incurable disease. Over the past several years, new options have been introduced for the purpose of providing palliative therapy to improve quality of life. Stent placement is the most widely used palliative therapy and rapidly relieves dysphagia; however, distal migration continues to be a disadvantage. Laser therapy and brachytherapy are also administered but require repeated treatment sessions. Future options for providing effective therapy for endstage disease include improved stent designs to decrease migration and multimodality methods that combine several options in one treatment session. This article focuses primarily on palliation of unresectable tumors of the esophagus and gastroesophageal junction.

Minimally invasive esophagectomy@@@Minimal invasive Ösophagektomie

ZusammenfassungGRUNDLAGEN: Die konventionelle Ösophagektomie ist technisch aufwendig und ist mit einer entsprechenden Morbidität und Mortalität verbunden. METHODIK: Kritische Beurteilung der minimal invasiven Ösophagektomie. ERGEBNISSE: Die minimal invasive Ösophagektomie ist technisch anspruchsvoll, kann aber dazu beitragen, postoperative Komplikationen zu minimieren und die postoperative Lebensqualität zu verbessern. Die größte publizierte Serie zeigte eine Mortalität von 1,4 %, 11 % Anastomosendehiszenzrate und eine Verkürzung des Spitalsaufenthaltes nach minimal invasiver Ösophagektomie. Die Erfahrungen aus Pittsburg haben zu technischen Verbesserungen geführt, wie die Anlage eines engeren Magenpouches, Durchführung der Ivor-Lewis-Anastomose und eine radikalere Lymphknoten Resektion. SCHLUSSFOLGERUNGEN: In dieser Arbeit werden Hintergrund, Technik, Probleme und die Zukunft der minimal invasiven Ösophagektomie kritisch beleuchtet.SummaryBACKGROUND: Esophagectomy can be a formidable operation even in experienced hands. METHODS: Critical appraisal towards minimal invasive esophagectomy. RESULTS: The complications are often lethal. Patients developing postoperative pneumonia after open esophagectomy have up to a 20% mortality rate. In an effort to reduce the morbidity and mortality of open esophagectomy, minimally invasive techniques have been developed. This is a challenging procedure technically, but offers the chance to lessen complications and improve survival. The learning curve is steep. Proper port placement, patient positioning, and facile use of mechanical staplers is mandatory. However, the largest published series to date of minimally invasive esophagectomies [MIE] showed a 1.4% mortality rate, an 11% anastamotic leak rate, and lowered lengths of stay. The evolving Pittsburgh experience has resulted in technical modifications like narrower gastric pouches, Ivor Lewis type anastamoses, and more complete lymph node resection. CONCLUSIONS: This paper discusses the background, techniques, challenges, and future direction for using this technique to treat esophageal disease.

Castleman disease presenting with pseudotumour cerebri and myasthenia gravis: A case report and literature review

ABSTRACT Castleman disease (CD) is a rare lymphoproliferative disorder that may present with various autoimmune, inflammatory, or neurologic syndromes. This is a case of a 21-year-old woman who presented with signs and symptoms of pseudotumour cerebri (PTC) who subsequently developed myasthenia gravis (MG), and was incidentally found to have a large mass in the posterior mediastinum. Upon resection, the mass was classified as unicentric CD involved with follicular dendritic cell sarcoma. Following treatment with IVIG in the setting of progressive weakness and dyspnea, she has had complete symptom resolution while maintained on a low dose of pyridostigmine for the last two years. There are 13 cases of MG and five cases of optic disc edema described as PTC associated with CD in the literature, but to our knowledge, this is the sole case reported of the intersection of all three conditions in one patient. Increased serum levels of interleukin-6 and vascular endothelial growth factor may provide clues as to the association of CD with these neurologic syndromes.

806 Propensity Matched Analysis of Surgeon-Driven Treatment Allocation for Locoregionally Advanced Esophageal and Gastroesophageal Junction Adenocarcinoma

Introduction: There are few options available for treatment of fistulas, leaks, and perforations endoscopically. Here we describe our experience with a new endoscopic clipping system. Methods: A retrospective review of all cases using the Over-The-Scope-Clip system (Ovesco Endoscopy AG, Tuebingen, Germany) between August 2011 and November 2011. Resolution of leak was determined by a swallow study or CT scan. Results: The system was utilized in ten patients with clinically significant gastrointestinal surgical complications. Three patients were referred for treatment of gastric leaks following a sleeve gastrectomy, two had postoperative colonic leaks, two had gastro-gastric fistulas following roux-en-y gastric bypass, and three had esophageal perforations. All three gastric leaks occurred just distal to the GE junction and each had undergone previous attempts at treatment with other endoscopic methods. The average number of over the scope clips placed in these three patients was 2. In two patients there was complete resolution of the leak, one requiring a second clip placement. The third patient had a contained leak following clip placement that was followed clinically, follow up swallow study at six days showed improvement, and she was discharged home. Two patients had gastro-gastric fistulas following roux-en-y gastric bypass surgery. One of these patients had complete resolution of the fistula. The other had initial success but the clip displaced and fistula recurred. Two patients presented with anastomotic leak following colon resection. In one case the patient had extensive adhesions resulting in a rigid colon and the Ovesco system on a pediatric scope was too large to reach the fistula, so the procedure was aborted. In the second case, the leak was successfully treated with a single clip. Three patients were successfully treated for esophageal perforation. One had a 9 mm mid-esophageal perforation that required staged placement of two clips. One had two separate distal esophageal perforation sites, each requiring one clip. The final esophageal perforation was treated with a single clip. The average operative time for clip placement was 61 minutes. There were no complications. Conclusions: This over the scope endoscopic clip system is simple to use, safe, and successful in approximating tissue to treat traditionally difficult surgical complications. There is a potential for broad applications of this new technology. Further experience and longer follow up are needed to assess its indications as related to defect size and location.