Mithran S. Sukumar

Comparison of perioperative outcomes after combined thoracoscopic-laparoscopic esophagectomy and open Ivor–Lewis esophagectomy

BACKGROUND Thoracoscopic-laparoscopic esophagectomy (TLE) has gained popularity in specialized centers. This study compares the perioperative outcomes of TLE and Ivor-Lewis esophagectomy (ILE). METHODS Forty-four consecutive TLEs were compared with 46 historical ILEs. Outcomes included surgical time and blood loss, hospital length of stay, 30-day mortality rate, and complications. RESULTS TLE took longer to perform (543 vs 437 min; P < .01) than ILE, but produced less blood loss (407 vs 780 mL; P < .01). The median length of stay and 30-day mortality did not differ between groups. Cardiovascular (41% for TLE vs 30% for ILE; P = .19) and pulmonary complications (31% TLE vs 30% ILE; P = 1.0) occurred frequently in both groups, but TLE patients had fewer wound complications (4% TLE vs 17% ILE; P = .05). CONCLUSIONS Despite longer surgical times, TLE produced decreased intraoperative blood loss and wound complications. These findings suggest that with further technical refinement TLE may ameliorate the morbidity seen with ILE.

Minimally Invasive Management of the Mediastinal Parathyroid Adenoma

Introduction/Methods: Traditional surgical management of mediastinal parathyroid adenomas has required mediastinal exploration via sternotomy or thoracotomy. By contrast minimal access approaches to the mediastinum via videoscopic transthoracic or transcervical approaches can offer equivalent visualization, patient safety and decreased patient morbidity. The availability of sternal retractor systems, the rapid parathyroid hormone (PTH) assay for intraoperative confirmation of cure, recurrent laryngeal nerve monitoring technique and video‐assisted thoracic surgery (VATS) instrumentation have made this possible. The purpose of this article is to discuss these approaches and the results with their application in five consecutive patients.

Extended transcervical video-assisted thymectomy.

This article describes surgery using a transcervical approach with thoracoscopic visualization. The video-assisted extended approach is well suited for patients undergoing thymectomy for myasthenia gravis, thymic cysts, small thymoma, or mediastinal parathyroid adenoma. It incorporates the minimally invasive nature of the transcervical method with the extensive anterior mediastinal dissection, while allowing for complete removal of the thymus and anterior mediastinal fat and avoiding the morbidity of a sternotomy.

Management Algorithms for Stage IIIA Non-Small Cell Lung Cancer with N2 Node Involvement

Stage IIIA non-small cell lung cancer (NSCLC) with N2 node involvement (IIIA[N2]) is a complex area characterized by much confusion and controversy, because data derived from a particular subgroup of IIIA(N2) often are inappropriately applied to another subgroup. The problem is not so much that stage IIIA(N2) encompasses a spectrum of disease, which is true in each stage of NSCLC. Rather, our ability to describe a patient cohort has been limited, and it is therefore often difficult to determine how and when to apply data from published studies. A simple, pragmatic approach is taken in this article to define algorithms for the management of these patients.

“Even if I Don’t Remember, I Feel Better”. A Qualitative Study of Patients with Early-Stage Non–Small Cell Lung Cancer Undergoing Stereotactic Body Radiotherapy or Surgery

RATIONALE While surgical resection is recommended for most patients with early stage lung cancer according to the National Comprehensive Cancer Network guidelines, stereotactic body radiotherapy is increasingly being used. Provider-patient communication regarding the risks and benefits of each approach may be a modifiable factor leading to improved patient-centered outcomes. OBJECTIVES To qualitatively describe the experiences of patients undergoing either surgery or stereotactic body radiotherapy for early stage non-small cell lung cancer. METHODS We qualitatively evaluated and used content analysis to describe the experiences of 13 patients with early clinical stage non-small cell lung cancer before undergoing treatment in three health care systems in the Pacific Northwest, with a focus on knowledge obtained, communication, and feelings of distress. MEASUREMENTS AND MAIN RESULTS Although most participants reported rarely having been told about other options for treatment and could not readily recall many details about specific risks of recommended treatment, they were satisfied with their care. The patients paradoxically described clinicians as displaying caring and empathy despite not explicitly addressing their concerns and worries. We found that the communication domains that underlie shared decision making occurred infrequently, but that participants were still pleased with their role in the decision-making process. We did not find substantially different themes based on where the participant received care or the treatment selected. CONCLUSIONS Patients were satisfied with all aspects of their care, despite reporting little knowledge about risks or other treatment options, no direct elicitation of worries from providers, and a lack of shared decision making. While the development of effective communication strategies to address these gaps is warranted, their effect on patient-centered outcomes, such as distress and decisional conflict, is unclear.

Presumed Second Focus of Lung Immunoglobulin G4–Related Disease Found to be Adenocarcinoma

We describe a patient presenting with bilateral radiologically similar lung lesions initially diagnosed as immunoglobulin (Ig) G4-related disease from biopsy of one lesion, but radiographic changes 6 months later prompted biopsy of the second lesion and showed adenocarcinoma. No case of lung IgG4-related disease and a distant lung malignancy has been previously reported. This is notable because lung IgG4-related disease often manifests in multiple thoracic locations but is diagnosed from a representative biopsy specimen.

Computer assisted surgical stapling

Computer assisted surgical stapling is the application of new technology to conventional staplers. The components of the system, their use in open thoracic surgery and a review of the literature to date are presented.

“It wasn’t as bad as I thought it would be”: a qualitative study of early stage non-small cell lung cancer patients after treatment

ObjectiveWhile surgical resection is recommended for most patients with early stage lung cancer, stereotactic body radiotherapy (SBRT) is being increasingly utilized. Provider-patient communication regarding risks/benefits of each approach may be a modifiable factor leading to improved patient-centered outcomes. Our objective was to determine a framework and recommended strategies on how to best communicate with patients with early stage non-small cell lung cancer (NSCLC) in the post-treatment setting. We qualitatively evaluated the experiences of 11 patients with early clinical stage NSCLC after treatment, with a focus on treatment experience, knowledge obtained, communication, and recommendations. We used conventional content analysis and a patient-centered communication theoretical model to guide our understanding.ResultsFive patients received surgery and six received SBRT. Both treatments were generally well-tolerated. Few participants reported communication deficits around receiving follow-up information, although several had remaining questions about their treatment outcome (mainly those who underwent SBRT). They described feeling anxious regarding their first surveillance CT scan and clinician visit. Overall, participants remained satisfied with care because of implicit trust in their clinicians rather than explicit communication. Communication gaps remain but may be addressed by a trusting relationship with the clinician. Patients recommend clinicians give thorough explanations and personalize when possible.

Transcervical Thymectomy and Extended Thymectomy with Bilateral Opening of the Mediastinal Pleura

Transcervical thymectomy is a now well-established procedure for thymectomy in patients with myasthenia gravis. Transcervical video-assisted extended thymectomy can be performed safely and with minimal morbidity.

Clamshell Approach for Cervical Mediastinal Esophageal Reconstruction

Objectives: The thoracic inlet is a complex anatomic structure. Many vital structures ranging from vessels to organ systems traverse through here on their way from the chest into the neck. Access to reconstruct these areas can be quite difficult. The esophagus is a structure that stretches from the cervical region through the thoracic inlet into the mediastinum. Diseases or defects in the esophagus have traditionally been repaired by end-to-end anastomosis when a distal anastomosis is possible. Lesions where the distal esophagus is not accessible through a cervical approach often necessitate a total esophagectomy with a stomach pull-up. One approach, the clamshell approach, involves a median sternotomy and right thoracotomy with rotation of the anterior and lateral bony confinements of the thoracic inlet laterally. This provides access to the anterior mediastinum. Mobilization of the upper lung provides access to the posterior mediastinum. Methods: We present an interesting case of a gentleman with Boerhaave’s syndrome who had a diverting esophagostomy at the cervical thoracic level. The distal esophagus was allowed to retract into the chest. After he survived his initial insult, reconstruction was undertaken. Results: The distal esophagus could not be connected to the proximal esophagus. Using a clamshell approach, distal and proximal esophageal segments were isolated and a free jejeunal tissue transfer was undertaken. Anastomosis to the internal mammary vessels allowed reconstruction of the esophageal conduit. Conclusion: This poster will demonstrate the interesting complexity of the thoracic inlet with a photographic demonstration of the technical approach.