Natasha M. Rueth

Esophageal stents for anastomotic leaks and perforations

OBJECTIVE Intrathoracic esophageal anastomotic leaks and perforations are very morbid and challenging problems. Esophageal stents are increasingly playing an integral role in the management of these patients. Our objective was to report our experience with esophageal stent placement for anastomotic leaks and perforations and to provide a treatment algorithm. METHODS We performed a review of patients with stent placement for esophagogastric anastomotic leaks or esophageal perforation from March 2005 to August 2009. A prospective database was used to collect data. Success was defined as endoscopic defect closure, negative esophagram, and resumption of oral intake. Failure was defined as no change in leak size or clinical signs of ongoing infection. We collected and analyzed patient demographics, diagnosis, clinical history, and poststent outcomes using descriptive statistics. RESULTS Thirty-seven patients underwent esophageal stent placement for anastomotic leaks (n = 22) and perforations (n = 15). The median time from original procedure to diagnosis of leak or perforation was 6 days (0-420 days). Nineteen patients (51%) had 21 associated procedures for source control. We placed 94 stents (mean = 2.7 stents/patient); 16 patients (43%) required more than 1 stenting procedure (mean = 1.8 procedures/patient). The median time to restoration of esophageal integrity was 33 days (7-120 days). There were 22 successes (59%); 2 failures were secondary to undrained abscess. Only 2 failures occurred in the last 15 patients (88% success). Strictures did not develop in any patients. Serious complications occurred in 3 patients (stent erosion, leak enlargement, fatal gastroaortic fistula). CONCLUSIONS Esophageal stents can potentially play an integral role in the management of anastomotic leaks and perforations. Success depends on appropriate procedures for source control and surgeon experience.

Is VATS Lobectomy Better: Perioperatively, Biologically and Oncologically?

The current review focuses on a clinical comparison of lobectomy by means of video-assisted thoracoscopic surgery (VATS) and open lobectomy. The best available evidence strongly suggests that VATS lobectomy is less morbid than open lobectomy, and that VATS lobectomy is less immunosuppressive and elicits a milder inflammatory response than open lobectomy. Midterm to long-term oncologic results of patients with early-stage non-small cell lung cancer appear to be equivalent for VATS and open lobectomy. Because a large, prospective, randomized, multiinstitutional trial of open versus VATS lobectomy will likely never take place, we are dependent on the summarized information to draw practical conclusions.

The Increasing Use of Prophylactic Mastectomy in the Prevention of Breast Cancer

Selected high-risk women without breast cancer choose to undergo bilateral prophylactic mastectomy (BPM) to reduce their risk of developing the disease. Several studies have reported that BPM significantly reduces, but does not eliminate, breast cancer risk. Few studies have reported rates or trends of BPM use. Patients with unilateral breast cancer are at increased risk for developing cancer in the normal contralateral breast. Some breast cancer patients choose contralateral prophylactic mastectomy (CPM) to prevent cancer in the contralateral breast. The risk of contralateral breast cancer is significantly reduced after CPM. Recent studies reported that CPM rates have markedly increased in recent years in the United States. Alternatives to CPM include surveillance with clinical breast examination, mammography, and, potentially, breast MRI. Endocrine therapy with tamoxifen or aromatase inhibitors significantly reduces the risk of contralateral breast cancer and may be more acceptable than CPM for some patients.

Surgical treatment of lung cancer: Predicting postoperative morbidity in the elderly population

OBJECTIVES Surgical resection is standard treatment for early-stage non-small cell lung cancer; however, perception of postoperative risk may influence the decision to proceed for elderly patients. With population data, we analyzed postoperative complications and morbidity predictors for older patients undergoing lobectomy for stage I non-small cell lung cancer. METHODS The Surveillance Epidemiology and End-Results-Medicare linked database (2000-2005) identified patients (ages 66-80 years) undergoing lobectomy for stage I non-small cell lung cancer. We comprehensively evaluated in-hospital postoperative complications (pulmonary, cardiac, infectious, noncardiopulmonary) with International Classification of Diseases, Ninth Revision, diagnosis codes. Logistic regression models were constructed to identify patient, tumor, and treatment characteristics associated with complications. RESULTS In all, 4171 patients were included, 2329 of whom had 4097 in-hospital postoperative complications (55.8%). Pulmonary complications were most common (n = 1598; 38.3%) followed by cardiac (n = 1020; 24.5%). Complications were significantly associated with age at least 75 years, male sex, higher comorbidity index, larger tumors, and treatment at nonteaching hospitals (P < .05). Patients with complications had a longer median stay (8 days) than patients without (6 days; P < .001). The 30-day mortality was 4.2%. CONCLUSIONS Population-based analysis demonstrated that perioperative complications after lobectomy for stage I non-small cell lung cancer in older patients exceeded 50% and were associated with specific patient, tumor, and treatment characteristics. Better understanding of the impact of these risk factors may facilitate surgical decision making and encourage implementation of more effective perioperative care guidelines for older surgical patients.

Hyperbaric oxygen does not improve outcome in patients with necrotizing soft tissue infection.

BACKGROUND Patients with necrotizing soft tissue infections (NSTIs) require prompt surgical debridement, appropriate intravenous antibiotics, and intensive support. Despite aggressive treatment, their mortality and morbidity rates remain high. The benefit of hyperbaric oxygen (HBO) as an adjunctive treatment is controversial. We investigated the effect of HBO in treating NSTIs. METHODS We analyzed clinical data retrospectively for 78 patients with NSTIs: 30 patients at one center were treated with surgery, antibiotics, and supportive care; 48 patients at a different center received adjunctive HBO treatment. We compared the two groups in terms of demographic characteristics, risk factors, NSTI microbiology, and patient outcomes. To identify variables associated with higher mortality rates, we used logistic regression analysis. RESULTS Demographic characteristics and risk factors were similar in the HBO and non-HBO groups. The mean patient age was 49.5 years; 37% of the patients were female, and 49% had diabetes mellitus. Patients underwent a mean of 3.0 excisional debridements. The median hospital length of stay was 16.5 days; the median duration of antibiotic use was 15.0 days. In 36% of patients, cultures were polymicrobial; group A Streptococcus was the organism most commonly isolated (28%). We identified no statistically significant differences in outcomes between the two groups. The mortality rate for the HBO group (8.3%) was lower, although not significantly different (p = 0.48), than that observed for the non-HBO group (13.3%). The number of debridements was greater in the HBO group (3.0; p = 0.03). The hospital length of stay and duration of antibiotic use were similar for the two groups. Multivariable analysis showed that hypotension on admission and immunosuppression were significant independent risk factors for death. CONCLUSIONS Adjunctive use of HBO to treat NSTIs did not reduce the mortality rate, number of debridements, hospital length of stay, or duration of antibiotic use. Immunosupression and early hypotension were important risk factors associated with higher mortality rates in patients with NSTIs.

Laparoscopic diaphragmatic plication for diaphragmatic paralysis and eventration: An objective evaluation of short-term and midterm results

OBJECTIVES We sought to objectively assess our outcomes after laparoscopic diaphragmatic plication for symptomatic hemidiaphragmatic paralysis or eventration using a respiratory quality-of-life questionnaire and pulmonary function tests. METHODS We performed a retrospective review of all symptomatic patients with hemidiaphragmatic paralysis or eventration who underwent laparoscopic diaphragmatic plication from March 1, 2005, through August 31, 2008. Patients with primary neuromuscular disorders were excluded from our analysis. We collected St Georges Respiratory Questionnaire scores (a respiratory quality-of-life questionnaire) and pulmonary function test results preoperatively and at 1 month and 1 year postoperatively. A 2-sided significance level of .05 was used for all statistical testing. RESULTS During the study period, 25 patients underwent laparoscopic diaphragmatic plication (9 right-sided and 16 left-sided plications); 1 patient required conversion to a thoracotomy. St Georges Respiratory Questionnaire total scores (59.3 +/- 26.8) improved by more than 20 points on average (a reduction of > or = 4 points after an intervention is considered a clinically significant improvement). This improvement was statistically significant at 1 month (36.6 +/- 15.9, P = .001) and maintained significance at 1 year (30.8 +/- 18.8, P = .009). Similarly, percent predicted maximum forced inspiratory flow (93.2% +/- 34.1%) was significantly improved 1 month after plication (113.9% +/- 31.8%, P = .01) and maintained significance at 1 year (111.5% +/- 30.9%, P = .02). CONCLUSIONS Our objective evaluation of laparoscopic diaphragmatic plication for hemidiaphragmatic paralysis or eventration demonstrated significant short-term and midterm improvements in respiratory quality of life and pulmonary function test results. This approach represents a potential paradigm shift in the surgical management of hemidiaphragmatic paralysis or eventration.

The long-term impact of surgical complications after resection of stage I nonsmall cell lung cancer: a population-based survival analysis.

Objective: Surgical morbidity may influence long-term cancer survival. Because resection of early stage nonsmall cell lung cancer (NSCLC) is primary therapy, we sought to determine the survival impact of surgical complications for elderly patients undergoing resection of stage I NSCLC. Methods: Using the linked Surveillance Epidemiology and End Results-Medicare database (2000–2005), we identified elderly patients who underwent lobectomy for stage I NSCLC. We then assessed the unadjusted association between in-hospital, postoperative complications, and long-term survival for patients who survived more than 30 days after resection using the Kaplan-Meier method. Finally, we used Cox proportional hazards regression to evaluate the relationship between postoperative complications and 5-year cancer-specific (CSS) and overall survival (OS) after adjusting for patient, tumor, and treatment characteristics. Results: We identified 3996 eligible patients. The overall in-hospital, postoperative complication rate was 54.2%. Pulmonary complications were the most common (n = 1464) followed by cardiac (n = 916). Unadjusted 5-year CSS was significantly worse for those who had an in-hospital, postoperative complication (70.9%) compared to those who did not (78.9%, P < 0.001). OS was also significantly worse (P < 0.001) for patients who developed a complication. Complications continued to predict worse 5-year CSS and OS after adjusting for patient, tumor, and treatment characteristics (HR: 1.38, 95% CI, 1.17–1.64). Conclusions: The occurrence of in-hospital postoperative complications was an independent predictor of worse 5-year CSS after resection of stage I NSCLC. Importantly, the impact of surgical complications extends well after the initial perioperative period. These findings may help identify important targets for best practice guidelines and quality-of-care measures.

Management of Cervical Esophageal Injury After Spinal Surgery

BACKGROUND Esophageal injury is a rare but catastrophic complication of anterior cervical spine surgery. Cases of esophageal perforation may be discovered intraoperatively, or as late as 10 years after surgery. In the current study we aim to review the principles of care and provide an algorithm that can be employed for successful management of this complex problem. METHODS We performed a retrospective, Institutional Review Board-approved review of esophageal injuries resulting from anterior cervical spine surgery that were managed at our institution between January 1, 2007 and July 31, 2009. We collected demographic information, perioperative data, and final outcomes. Data were analyzed using descriptive statistics. RESULTS We identified 6 patients who met our criteria. All patients presented with esophageal leaks, neck abscesses, and osteomyelitis. Similarly, all had been treated prior to transfer, without resolution of their leak. After debridement, removal of hardware, long-term antibiotic therapy, maximization of nutrition, and supportive care, 80% of patients resumed oral intake (median time 66.5 days). Mortality was 16.7%. CONCLUSIONS Neck exploration with removal of hardware, debridement, and open neck wound management are the basic principles of care. Management is often prolonged and requires multiple procedures; however, with persistence, closure is possible in the majority of patients. Our report serves as a guide for the treatment of this devastating problem.

Conditional cancer-specific versus cardiovascular-specific survival after lobectomy for stage i non-small cell lung cancer

BACKGROUND Conditional cancer-specific survival rates account for changes in the risk of death from cancer over time. There may be a point during follow-up when patients who undergo lobectomy for stage I non-small cell lung cancer (NSCLC) are as likely to die of cardiovascular disease as of cancer. METHODS Using the Surveillance Epidemiology and End Results Database (1988 through 2005), we identified patients 50 years old and older who underwent lobectomy for stage I NSCLC. We used competing risks methods to calculate conditional survival rates and to ascertain if there is a point in follow-up where the risk of dying of cancer is equivalent to the risk of dying of cardiovascular disease. RESULTS In all, 22,518 patients met our inclusion criteria. The difference in the 5-year conditional probability of dying of cancer and the 5-year conditional probability of dying of cardiovascular disease decreased with time; in the whole cohort, these probabilities were equivalent if patients survived to 7 years after lobectomy (p = 0.11). With increasing age, the probability of dying of cancer and the probability of dying of cardiovascular disease became equivalent at earlier time points. Furthermore, the 5-year probability of dying of cardiovascular disease was significantly greater than the 5-year probability of dying of cancer for patients aged 70 to 79 years who survived to 7 years and for patients aged 80 years and older who survived to 5 years after lobectomy. CONCLUSIONS For patients undergoing lobectomy for stage I NSCLC, cardiovascular-specific mortality becomes increasingly important over the course of follow-up, especially among elderly patients.

Pleuropulmonary Complications of Rheumatoid Arthritis: A Thoracic Surgeon's Challenge

Approximately 1% of patients with rheumatoid arthritis have chronic lung disease develop, which can lead to complications, including pneumothorax and bronchopleural fistula. Given the inflammatory changes found, along with the immunosuppressant regimen used in management, these complications are often recalcitrant to initial surgical maneuvers. Our goal in reviewing these patients is to demonstrate the escalation of therapeutic interventions that may be needed to ensure successful resolution of this challenging disease process.