Nathaniel R. Evans

Oncologic Efficacy Is Not Compromised, and May Be Improved with Minimally Invasive Esophagectomy

BACKGROUND Major morbidity and mortality rates continue to be high in large series of transthoracic esophagectomies. Minimally invasive approaches are being increasingly used. We compare our growing series of minimally invasive (combined thoracoscopic and laparoscopic) esophagectomies (MIEs) with a series of open transthoracic esophagectomies. STUDY DESIGN We identified 65 patients who underwent an MIE with thoracoscopy/laparotomy (n = 11), Ivor Lewis (n = 2), or 3-hole approach (n = 52). These patients were compared with 53 patients who underwent open Ivor-Lewis esophagectomy (n = 15) or 3-hole esophagectomy (n = 38) over the past 10 years. RESULTS The MIE and open groups were similar regarding gender and average age. The majority of patients in the open group underwent neoadjuvant chemoradiation therapy (81%); a significantly smaller (43%) number of patients in the MIE group underwent neoadjuvant therapy (p < 0.0001). Regarding oncologic efficacy, 97% and 94% of patients in both groups underwent R0 resections. Patients undergoing MIE had a significant increase in the number of harvested lymph nodes (median 20 vs 9; p < 0.0001). Length of stay was significantly decreased in patients who underwent MIE (8.5 days vs 16 days; p = 0.002). Finally, there were significantly fewer serious complications (grades 3-5) in the MIE group (19% vs 48%; p = 0.0008). CONCLUSIONS In this initial report of a single-institution series of MIE, we demonstrate that oncologic efficacy is not compromised and may actually be improved with a significantly increased number of harvested LNs. We also demonstrate that this approach is associated with fewer serious complications and a significant decrease in the length of postoperative hospital stay.

Minimally Invasive Esophagectomy Provides Significant Survival Advantage Compared with Open or Hybrid Esophagectomy for Patients with Cancers of the Esophagus and Gastroesophageal Junction

BACKGROUND Minimally invasive esophagectomy (MIE) is increasingly being used to treat patients with cancer of the esophagus and gastroesophageal junction. We previously reported that oncologic efficacy may be improved with MIE compared with open or hybrid esophagectomy (OHE). We compared survival of patients undergoing MIE and OHE. STUDY DESIGN Our contemporary series of patients who underwent MIE (2008 to 2013) was compared with a cohort undergoing OHE (3-hole [n = 39], Ivor Lewis [n = 16], hybrid [n = 13], 2000 to 2013). Summary statistics were calculated by operation type; Kaplan-Meier methods were used to compare survival. Cox regression was used to assess the impact of operation type (MIE vs OHE) on mortality, adjusting for age, sex, total lymph nodes, lymph node ratio (LNR), neoadjuvant chemoradiotherapy (CRT), and stage. RESULTS The MIE (n = 104) and OHE (n = 68) groups were similar with respect to age and sex. The MIE group tended to have higher BMI, earlier stage disease, and was less likely to receive CRT. The MIE group experienced lower operative mortality (3.9% vs 8.8%, p = 0.35) and significantly fewer major complications. Five-year survival between groups was significantly different (MIE, 64%, OHE, 35%, p < 0.001). Multivariate analysis demonstrated that patients undergoing OHE had a significantly worse survival compared with MIE independent of age, LNR, CRT, and pathologic stage (hazard ratio 2.00, p = 0.019). CONCLUSIONS This study supports MIE for EC as a superior procedure with respect to overall survival, perioperative mortality, and severity of postoperative complications. Several biases may have affected these results: earlier stage in the MIE group and disparity in timing of the procedures. These results will need to be confirmed in future prospective studies with longer follow-up.

Successful management of bleeding complications in patients supported with extracorporeal membrane oxygenation with primary respiratory failure.

Background: Extracorporeal membrane oxygenation (ECMO) is a lifesaving procedure in patients with severe respiratory insufficiency failing conventional support. Bleeding complications are common due to the necessity for anticoagulation and circuit-related factors. Methods: A retrospective review was conducted in patients requiring ECMO for respiratory failure from 7/2010 to 6/2011 to identify episodes of major bleeding, bleeding management and outcomes. Results: Twenty-one patients were supported with ECMO during the study although five experienced massive bleeding related to chest tube insertion, jejunal arterio-venous malformations, distal perfusion cannula dislodgement and ventricular rupture. Patients required aggressive resuscitation or endoscopic or operative intervention, totaling 28 procedures. There were no instances of dehiscence, infection or sepsis related to interventions. Anticoagulation was stopped six hours before and restarted 24 hours after major interventions, with no thrombotic or neurologic complications. All patients weaned off ECMO were discharged. Conclusions: ECMO bleeding complications can be managed successfully via surgical and endoscopic approaches in this high-risk population.

Complete Pulmonary Venous Occlusion After Radiofrequency Ablation for Atrial Fibrillation

Pulmonary vein stenosis is a known, yet under-recognized complication of radiofrequency ablation for atrial fibrillation. We present the case of a patient developing complete left-sided pulmonary venous occlusion following radiofrequency ablation. Recommendations are made to allow earlier diagnosis of this complication.

The impact of induction therapy on morbidity and operative mortality after resection of primary lung cancer

OBJECTIVE Use and operative results of neoadjuvant therapy before major elective resection for primary lung cancer were examined in the Society of Thoracic Surgeons General Thoracic Surgical Database. METHODS Lobectomy and pneumonectomy for primary lung cancer were identified in 12,201 patients between January 2002 and June 2008. After excluding procedures for missing clinical staging or end points; institutions with more than 10% missing data for clinical stage, discharge mortality, or length of stay; and patients treated with chemotherapy or radiation for unrelated disease, there remained 5376 resections. Study end points were discharge mortality, length of stay more than 14 days, and major morbidity. Multivariate analysis using propensity scores stratified into quintiles measured the effect of induction therapy. RESULTS In 525 of 5376 procedures (9.8%), chemotherapy (n = 153), radiotherapy (23), or chemoradiotherapy (349) preceded resection. Compared with resection only, patients receiving induction therapy were younger and had fewer comorbidities, more reoperative surgery, and higher rates of pneumonectomy. Clinical IIIA-N2 disease was treated with induction therapy in only 203 of 397 patients (51.1%). Propensity-adjusted rates detected no difference in discharge mortality, prolonged length of stay, or a composite of major morbidity for patients receiving induction therapy. Similar results were obtained in a logistic regression model (discharge mortality P = .9883; prolonged hospital stay P = .9710; major morbidity P = .9678). CONCLUSION Less than 10% of all major lung resections for primary carcinoma and just more than half of all resections for clinical stage IIIA-N2 disease are preceded by neoadjuvant chemotherapy or radiation. This study does not support concerns over excessive operative risk of induction therapy.

Minimally Invasive Esophagectomy with Extracorporeal Gastric Conduit Creation—How I Do It

Esophagectomy is associated with significant morbidity and mortality rates. In an attempt to improve these results, many groups have started applying minimally invasive techniques to esophagectomy for benign and malignant disease. A variety of minimally invasive approaches have been developed. At the Thomas Jefferson University, we have offered minimally invasive three-hole esophagectomy with extracorporeal gastric conduit creation since 2008. Herein we report our technique for the abdominal and cervical components of the procedure and briefly discuss the current literature and our short-term perioperative outcomes.

Racial disparity in in-hospital mortality after lobectomy for lung cancer

BACKGROUND Using data from the Nationwide Inpatient Sample, we investigated the impact of surgical approach and race on in-hospital mortality after lobectomy for lung cancer. METHODS Logistic regression was used to model odds ratios for in-hospital mortality related to surgical technique (thoracotomy vs video assisted thoracoscopic surgery [VATS]) and race using discharge data from the Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality (2008 to 2011). RESULTS VATS lobectomies increased each year (25.9% to 39.2%, P = .001) in the 19,353 patients identified. A racial disparity was noted, with black patients being 66% more likely to die in the hospital (odds ratio 1.66, 95% confidence interval 1.17 to 2.37, P = .005). Excluding 2010 data suggests that there is evidence of benefit associated with VATS; however, no evidence of an association between race and in-hospital mortality exists. CONCLUSIONS This study elucidates race-related mortality in lobectomy patients. Although racial disparities are present throughout health care, this finding emphasizes one of the challenges in using large databases to assess such disparities.

Surgical Apgar score (SAS) predicts perioperative morbidity, mortality, and length of stay in patients undergoing esophagectomy at a high‐volume center

Esophagectomy carries considerable morbidity. Many studies have evaluated factors to predict patients at risk. This study aimed to determine whether the surgical Apgar score (SAS) predicts complications and length of stay (LOS) for patients undergoing esophagectomy.

Surgical management of mediastinal liposarcoma extending from hypopharynx to carina: case report.

We describe the complete resection of a giant, well-differentiated mediastinal liposarcoma extending retropharynx to envelop the aortic arch, trachea and esophagus following preoperative radiotherapy.

En bloc resection of upper thoracic chordoma via a combined simultaneous anterolateral thoracoscopic and posterior approach.

BACKGROUND: En bloc resection of chordomas is associated with increased patient survival. Achievement of en bloc resection, however, may present a great surgical challenge, particularly in the mobile spine. Novel multidisciplinary techniques may enable en bloc resection of lesions presenting in anatomically challenging locations. A combined simultaneous thoracoscopic and posterior approach in a patient with an upper thoracic chordoma is presented; en bloc resection was achieved. OBJECTIVE: To show the feasibility, safety, and utility of performing a thoracoscopy-assisted en bloc resection of a chordoma involving the upper thoracic spine. METHODS: A case study is presented of a patient with biopsy-proven chordoma of T2-3 with predominantly paravertebral involvement who underwent multilevel en bloc resection via a simultaneous combined anterolateral thoracoscopic and posterior approach. Thoracoscopic assistance achieved separation of the tumor and ventral spine from the adjacent mediastinal structures. En bloc resection proceeded without complication. The spine was stabilized with posterior instrumentation. RESULTS: A multilevel en bloc resection was achieved with negative margins, preserving more than half of the remaining vertebral bodies and allowing short segment posterior fixation without extension into the cervical spine. The patient remained neurologically intact. CONCLUSION: A combined simultaneous thoracoscopic and posterior approach is safe and effective for en bloc resection of multilevel chordoma involving the upper thoracic spine. This technique allows for a plane to be established ventrally between the tumor and the mediastinum, thus assisting with safe osteotomies via the posterior approach.