Martin F. McKneally

Postoperative empyema improves survival in lung cancer. Documentation and analysis of a natural experiment.

Abstract A retrospective chart study revealed improved survival rates in patients in whom empyema developed after surgical resection for carcinoma of the lung. The overall five-year survival rate for the empyema group of 18 patients was 50 per cent, compared to an 18 per cent five-year survival rate in a control group consisting of a random 34-patient sample of resected cases at this institution. On further analysis, the beneficial effect of intrapleural infection was found principally in patients with tumor limited to the lung and its draining regional lymph nodes. Six of seven patients in this group survived for five years. The protection from recurrent cancer conferred on these patients by postoperative empyema may have been mediated by the activation of regional cellular immune mechanisms. The reaction between immune lymphocytes and bacterial antigens is believed to release lymphokines and activate macrophages that nonspecifically destroy residual tumor cells while containing the intrapleural infection.

Pulmonary and thymic carcinoid tumors.

Abstract. Carcinoid tumors of the lung and bronchi are usually benign lesions with no influence on life expectancy, although occasionally, they are malignant with a poor prognosis. Between these two extremes are atypical carcinoids, which can be slow-growing tumors with an average 5-year survival of 60% and an average 10-year survival of 40%. The myriad names used to describe these lesions complicates the understanding of their behavior, especially as the term carcinoid is used to describe the complete spectrum of disease or exclusively the benign well differentiated lesions with an excellent prognosis. Thymic carcinoids are uncommon lesions. Their prognosis is poor, even in cases that appear favorable in terms of resectability and histology. Pulmonary carcinoids present uncommonly with a paraneoplasic syndrome. Both carcinoid and Cushing syndromes are seen with approximately 2% of these lesions. Cushing syndrome can be present in as many as one-third of patients with thymic carcinoids but an association with the carcinoid syndrome has never been described.

Effect of perioperative blood transfusion on outcome in patients with surgically resected lung cancer

Three hundred thirty patients with non-small cell lung cancer were evaluated to assess the effect of perioperative blood transfusion on overall survival and time to recurrence. One hundred sixty-nine patients received blood products during the perioperative period, and 161 received none. The mean length of follow-up was 3.6 years. There were 90 recurrences, including second primaries, and 99 deaths in the group receiving transfusion; in the group without transfusion, recurrent cancer developed in 74 patients, and 68 died. Survival comparisons, adjusted for stage and cell type using the stratified log-rank statistic, showed significant reduction in survival (p = 0.007) for patients receiving transfusion. Time to recurrence was shorter for patients receiving transfusion (p = 0.035), but became less significant when adjusted for both cell type and stage (p = 0.11). Blood transfusion within the perioperative period appears to have an adverse effect on survival and recurrence in patients undergoing surgical resection for lung cancer.

The role of surgery in the management of selected patients with small-cell carcinoma of the lung.

This study was designed to evaluate the efficacy of surgical resection of the primary tumor and lymph nodes in patients with localized small-cell carcinoma who had responded to induction chemotherapy. The study was performed in 37 patients who received two cycles of chemotherapy consisting of cyclophosphamide, doxorubicin, and etoposide. Those patients who achieved a complete or partial (greater than 50%) response were evaluated for thoracotomy and the primary tumor and regional lymph nodes excised when feasible. Postoperatively, the patients received prophylactic cranial irradiation and were maintained on the same chemotherapy for an average of 11 months. Twelve patients were resected and found to have residual small-cell carcinoma in the operative specimen (ten) or no residual disease (two). Seven of these patients (58%) are alive without evidence of disease (median follow-up, 24 months). Seven other patients who were resected proved to have either residual foci or small-cell carcinoma mixed with adenocarcinoma or large-cell carcinoma (four) or only focal areas of adenocarcinoma, large-cell carcinoma, or squamous-cell carcinoma with no evidence of residual small-cell carcinoma. Five of these patients (71%) are alive without evidence of disease (median follow-up, 36 months). Two of the 16 patients who were not resected but treated with chemotherapy and radiation are alive at 15 and 31 months without evidence of disease, the other 14 are dead of disease.

Introducing New Technologies: Protecting Subjects of Surgical Innovation and Research

The system for protecting human research subjects is under increasing pressure. Under the currently dominant Regulatory Ethics Paradigm, clinical research protocols must be reviewed and approved by an institutional review board (IRB) or equivalent. Although the IRB was introduced into health care in part to protect patients and investigators from the inherent conflict between the best clinical interest of the individual patient and the interest of science and society in answering a clinical question, its rigorous standards and rigid framework discourage surgeons from seeking potentially valuable early IRB consultation. Most of the important advances in the history of medicine, such as anesthesia, appendectomy, antibiotics, intensive care, and immunization, were introduced through an informal, unregulated innovation process that has been enormously productive but can lead to ratification of ineffective or harmful treatment by credulous physicians and patients. We propose a surgical innovation ethics paradigm that is a more nimble, flexible source of institutional and public oversight and approval of innovations that are in the gray zone prior to their conversion to formal protocols that then require IRB approval. We also discuss the management of personal and institutional conflicts of interest.

Ethical Problems in Surgery: Innovation Leading to Unforeseen Complications

A hypothetical case that involves a surgical innovation is used to illustrate three ethical issues in surgery: the profound trust that vulnerable patients feel toward their surgeons, even when they innovate; the disequilibrating effect of new procedures on traditional safeguards of surgical competence; and the need for a systematic approach to the evaluation of new surgical procedures.

Responding to Trust: Surgeons' Perspective on Informed Consent

BackgroundEvery day thousands of surgeons and patients negotiate their way through the complex process of decision-making about operative treatments. We conducted a series of qualitative studies, asking patients and surgeons to describe their experience and beliefs about informed decision-making and consent. This study focuses on surgeons’ views.MethodsOpen-ended interviews and focus group discussions were conducted with thoracic surgeons who treated esophageal cancer patients by esophagectomy, and general surgeons who routinely performed laparoscopic cholecystectomy. Their views were analyzed using a qualitative approach, grounded in the perspectives of the participants.ResultsFive dominant themes emerged from the analysis: (1) making informed decisions; (2) communicating information and confidence; (3) managing expectations and fears; (4) consent as a decision to trust; (5) commitment inspired by trust. These themes are illustrated by verbatim quotes from the surgeon interviews.ConclusionsSurgeons carefully assess the risks and benefits of treatment before consenting to perform operative interventions. They are influenced by objective findings and by affective factors such as courage and the determination to survive expressed by their patients. They manage risks, doubts, and fears—both their patients’ and their own—relying on trust and commitment on both sides to ensure the success of the surgical mission. The trust of their patients has a strong influence on the surgeons’ decisions and actions.

Noninvasive evaluation of mediastinal metastases in bronchogenic carcinoma: A prospective comparison of chest radiography and gallium‐67 scanning

Evaluation of regional node involvement in patients with bronchogenic carcinoma is a crucial step in determining therapy and prognosis. Mediastinoscopy has been recommended for staging all potentially operable cases, but technical limitations and the need for anesthesia make this impractical. Gallium‐67 scanning and chest radiography were prospectively compared as noninvasive means of evaluating spread to regional nodes in 75 patients with bronchogenic carcinoma in whom histologic evaluation of hilar and mediastinal nodes was performed. Gallium scanning was more accurate than chest radiography in assessing regional nodes (overall accuracy 85.3% vs. 56%, P < 0.05). When positive, both procedures correctly indicate malignant involvement of regional nodes (85% vs. 87.3%). A negative gallium scan, however, was significantly more accurate in predicting the absence of such involvement (80% vs. 40%, P < 0.01). Gallium scanning appears to be a reliable, noninvasive means of assessing mediastinal spread of bronchogenic carcinoma and when used in conjunction with radiographic findings, allows selection of appropriate patients for surgical staging procedures.

Ethics of Surgical Complications

Whatever the place or period, surgical complications have been an inevitable part of surgical practice. It is not surprising, then, that studies on various aspects of surgical complications are plentiful. A PubMed search returned nearly 800 articles with the phrase ‘‘surgical complication’’ and its plural form in the title. However, despite the importance and prevalence of the matter, there is at present no agreed definition of a surgical complication [1]. Published definitions of the term range from the straightforward (‘‘any undesirable result of surgery’’) to the more elaborate [2, 3]. In this article, we propose to use the following definition, which, although unwieldy, captures more accurately the attributes of a surgical complication. A surgical complication is any undesirable, unintended, and direct result of surgery affecting the patient which would not have occurred had the surgery gone as well as could reasonably be hoped [4].

Treatment of Stage I Lung Cancer (T1N0M0, T2N0M0)

Patients with stage I lung cancer can be offered surgical treatment with an excellent prognosis for recovery and long-term cure. The recent revision of the staging definition has rearranged the prognostic categories, further improving the prognosis in Stage I disease by eliminating patients with a higher risk of recurrence. The most vexing issues remaining are the infrequency of diagnosis of lung cancer at this stage and the increasing incidence of lung cancer of all stages, even among nonsmokers. Economical screening, abolition of cigarette smoking, control of airborne environmental carcinogens, and the continued search for effective systemic treatment remain challenges for the future.