Seth D. Force

Efficacy of Oral Ribavirin in Lung Transplant Patients With Respiratory Syncytial Virus Lower Respiratory Tract Infection

BACKGROUND Respiratory syncytial virus (RSV) can cause severe lower respiratory tract infection (LRI) and is a risk factor for the development of bronchiolitis obliterans syndrome (BOS) after lung transplantation (LTx). Currently, the most widely used therapy for RSV is inhaled ribavirin. However, this therapy is costly and cumbersome. We investigated the utility of using oral ribavirin for the treatment of RSV infection after LTx. METHODS RSV was identified in nasopharyngeal swabs (NPS) or bronchoalveolar lavage (BAL) using direct fluorescent antibody (DFA) in 5 symptomatic LTx patients diagnosed with LRI. Data were collected from December 2005 and August 2007 and included: age; gender; type of LTx; underlying disease; date of RSV; pulmonary function prior to, during and up to 565 days post-RSV infection; need for mechanical ventilation; concurrent infections; and radiographic features. Patients received oral ribavirin for 10 days with solumedrol (10 to 15 mg/kg/day intravenously) for 3 days, until repeat NPS were negative. RESULTS Five patients had their RSV-LRI diagnosis made at a median of 300 days post-LTx. Mean forced expiratory volume in 1 second (FEV(1)) fell 21% (p < 0.012) during infection. After treatment, FEV(1) returned to baseline and was maintained at follow-up of 565 days. There were no complications and no deaths with oral therapy. A 10-day course of oral ribavirin cost

Video-Assisted Thoracoscopic Surgery Segmentectomy: A Safe and Effective Procedure

700 compared with

Effect of sympathectomy level on the incidence of compensatory hyperhidrosis after sympathectomy for palmar hyperhidrosis

14,000 for nebulized ribavirin at 6 g/day. CONCLUSIONS Treatment of RSV after LTx with oral ribavirin and corticosteroids is well tolerated, effective and less costly than inhaled ribavirin. Further studies are needed to directly compare the long-term efficacy of oral vs nebulized therapy for RSV.

Neoadjuvant Chemoradiation Versus Chemotherapy for Patients Undergoing Esophagectomy for Esophageal Cancer

BACKGROUND Anatomic sublobar resection is currently being assessed as an alternative to lobectomy for primary lung cancers less than 2 cm in size. Open segmentectomy is a proven oncologic procedure for patients with reduced cardiopulmonary reserve and significant comorbidities. With the increased use of thoracoscopy, a video-assisted thoracoscopic surgery (VATS) segmentectomy may be as safe and effective as an open segmentectomy. METHODS We performed a retrospective review of patients who underwent a segmentectomy between May 2002 and March 2009 at Emory University Hospital. RESULTS Forty-one patients underwent pulmonary segmentectomy; 26 through thoracotomy (open) and 15 by a thoracoscopic (VATS) approach. Both groups were well matched for age, gender, and preoperative risk factors. Segmentectomy was performed for primary lung cancer in 25 (61%) patients. There was no difference in tumor size, number of lymph node stations sampled, or number of lymph nodes removed based upon approach. The remaining indications for surgery were metastatic disease in 12 patients and benign disease in 4 patients. All patients underwent R0 resections. There was no significant difference in operative time, but patients undergoing a VATS segmentectomy had significantly reduced chest tube durations and hospital stays. Major complications occurred in 19% of patients in the open group and none in the VATS group. There were two operative deaths (4.8%), both in the open group. CONCLUSIONS Video-assisted thoracoscopic surgery segmentectomy is a safe procedure which has fewer complications and a reduced hospital stay when compared with an open segmentectomy. This approach may be the ideal oncologic procedure for patients with small lung cancers (<2 cm) and (or) limited cardiopulmonary reserve and significant comorbidities.

Bilateral Lung Transplantation Offers Better Long-Term Survival, Compared With Single-Lung Transplantation, for Younger Patients With Idiopathic Pulmonary Fibrosis

OBJECTIVE Palmar hyperhidrosis can be psychosocially devastating. Sympathectomy provides effective treatment. The most common side effect after sympathectomy is compensatory hyperhidrosis, which can be debilitating. Controversy exists as to which and how many levels treated carry the lowest incidence of compensatory hyperhidrosis after sympathectomy for palmar hyperhidrosis. METHODS Retrospective review was conducted on a video-assisted thoracoscopic surgical database including all patients who underwent video-assisted thoracoscopic surgical sympathectomy for palmar hyperhidrosis. RESULTS Video-assisted sympathectomy was performed in 282 patients for palmar hyperhidrosis from May 2002 through July 2005; in all, 179 patients (64%) underwent division at T2 level only and 103 at levels T2, T3, and T4. The groups were similar in age and sex distribution. The rate of compensatory hyperhidrosis was significantly less in the T2 group (23 patients, 13%) than in the T2 through T4 group (35 patients, 34%)(P = .011). The most common site of compensatory hyperhidrosis in both groups was the lower back. Patients with compensatory hyperhidrosis were older (median 31 years vs 23 years, P = .037), had body mass index greater than 28 (P = .048), and underwent multiple level sympathectomy (P = .004). CONCLUSION Compensatory hyperhidrosis continues to occur after sympathectomy for palmar hyperhidrosis; however, a significant reduction in incidence can be achieved by dividing the sympathetic chain at a single level (T2). Patients who are older and/or have increased body mass index should be warned of their increased risk of compensatory hyperhidrosis after sympathectomy.

Receptor for Advanced Glycation End Products in Donor Lungs Is Associated with Primary Graft Dysfunction After Lung Transplantation

BACKGROUND Neoadjuvant chemoradiation followed by esophagectomy is currently the standard of care for locally advanced esophageal cancer. This intense preoperative regimen delays definitive resection and increases perioperative risks. With the improvement of chemotherapy agents, chemotherapy alone may be better suited for patients awaiting esophagectomy because of shorter preoperative treatment time and less associated perioperative complications. No recent study has compared chemoradiation to chemotherapy alone before esophageal resection with respect to operative morbidity and mortality and overall survival. METHODS A retrospective review was performed of all patients (281) who underwent an esophagectomy for cancer at our institution from July 1995 through June 2005; 122 patients (43%) had neoadjuvant treatment and form the basis of this study. RESULTS Preoperative chemoradiation (CR) was administered in 64 patients and chemotherapy only (CO) in 58 patients. Operative mortality was 6% (4 patients) in the CR group and 0% in the CO group (p = 0.12). Overall postoperative complications rate was 48% in CR patients and 33% in CO patients (p = 0.09). Complete pathologic response occurred in 11 CR patients (17%) and in 2 CO patients (4%; p = 0.02). There was no difference in recurrences between the two groups (p = 0.43). Median survival was 17 months in the CR patients and 21 months in the CO patients (p = 0.14). One-, 3-, and 5-year survivals were 76%, 46%, and 41%, respectively, in the CR patients and 70%, 40%, and 31%, respectively, in the CO patients (p = 0.31). CONCLUSIONS Although neoadjuvant chemoradiation resulted in a significantly better complete pathologic response rate when compared with chemotherapy alone, that did not translate into a long-term survival advantage. Chemotherapy alone may be the preferred neoadjuvant modality to expedite resection, decrease operative mortality and postoperative complications, and improve survival in patients with locally advanced esophageal cancer.

Low mortality after treatment for esophageal perforation: a single-center experience.

BACKGROUND Single-lung transplantation (SLT) and bilateral lung transplantation (BLT) are both good options for patients with end-stage lung disease secondary to idiopathic pulmonary fibrosis. It is, however, unclear whether BLT offers any survival advantage over SLT. The purpose of our study was to evaluate a large group of patients to determine if either SLT or BLT officered a long-term survival advantage for patients with IPF. METHODS This was an Institutional Review Board-approved retrospective analysis of the United Network of Organ Sharing database from 1987 to 2008. Survival was determined using Kaplan-Meir estimates and the effect of laterality was determined by Cox proportional hazards and propensity analyses. RESULTS Lung transplantation for idiopathic pulmonary fibrosis was performed in 3,860 patients (2,431 SLTs and 1429 BLTs). Multivariate and propensity analysis failed to show any survival advantage for BLT (hazard ratio = 0.90, 95% confidence interval = 0.78 to 1.0, p = 0.11). One-year conditional survival favored BLT (hazard ratio 0.73, 95% confidence interval 0.60 to 0.87, p = 0.00064). Risk factors for early death included recipient age over 57 and donor age over 36 years. CONCLUSIONS Bilateral lung transplantation should be considered for younger patients with idiopathic pulmonary fibrosis and results may be optimized when younger donors are used.

Chest Wall Reconstruction Using Biomaterials

Development of primary graft dysfunction (PGD) is associated with poor outcomes after transplantation. We hypothesized that Receptor for Advanced Glycation End‐products (RAGE) levels in donor lungs is associated with the development of PGD. Furthermore, we hypothesized that RAGE levels would be increased with PGD in recipients after transplantation. We measured RAGE in bronchoalveolar lavage fluid (BALf) from 25 donors and 34 recipients. RAGE was also detected in biopsies (transbronchial biopsy) from recipients with and without PGD. RAGE levels were significantly higher in donor lungs that subsequently developed sustained PGD versus transplanted lungs that did not display PGD. Donor RAGE level was a predictor of recipient PGD (odds ratio = 1.768 per 0.25 ng/mL increase in donor RAGE level). In addition, RAGE levels remained high for 14 days in those recipients that developed severe graft dysfunction. Recipients may be at higher risk for developing PGD if they receive transplanted organs that have higher levels of soluble RAGE prior to explantation. Moreover, the clinical and pathologic abnormalities associated with PGD posttransplantation are associated with increased RAGE expression. These findings also raise the possibility that targeting the RAGE signaling pathway could be a novel strategy for treatment and/or prevention of PGD.

Nodal Upstaging Is More Common with Thoracotomy than with VATS During Lobectomy for Early-Stage Lung Cancer: An Analysis from the National Cancer Data Base

BACKGROUND Historically, esophageal perforation has been associated with significant mortality. Improvements in diagnosis, critical care, and surgical and endoscopic techniques may lead to lower mortality rates in the modern era. We reviewed our experience with the management of esophageal perforation to determine whether outcomes have improved. METHODS We retrospectively reviewed all cases of esophageal perforation from 1997 through 2008 at our institution. Univariate and propensity-matching analysis were performed. RESULTS We reviewed the charts of 147 patients, and 97 met eligibility criteria. There were 45 women, (46.4%); mean age was 60.7 ± 15.6 years. Etiologies included iatrogenic in 50 (51.6%), spontaneous in 23 (23.7%), and idiopathic in 22 (22.7%). Treatment within 24 hours of presentation occurred in 55.2% of patients; 22.7% of patients were septic on presentation. Treatment included surgery in 72 patients (74.2%) and nonoperative management in 25 (25.8%). Forty-one patients (42.3%) underwent primary repair, 5 (6.9%) underwent esophageal resection, 4 (5.6%) underwent exclusion, and 22 (22.7%) underwent drainage or stent placement. Thirty-day mortality rate for the entire cohort was only 8.3% (8 patients). The mortality rate for the primary repair patients was 7.7%, and none of the resection patients died. There was similar in-hospital mortality rate between operative and nonoperative treatment groups (p = 0.96). Propensity-matching analysis showed equal morbidity (p = 0.74) and 30-day mortality (p = 0.35) between operative and nonoperative treatment groups. CONCLUSIONS Our study represents a large series of patients treated for esophageal perforation. The results demonstrate that the overall mortality from esophageal perforation can be less than 10%. Primary repair should be considered as first-line treatment when appropriate even in patients who present more than 24 hours after perforation. Nonoperative management, in appropriate patients, can also lead to good success rates and low mortality.

Radiofrequency Ablation of Barrett's Esophagus: Short-Term Results

BACKGROUND Skeletal chest wall reconstruction can be a challenge, depending on the indication, location, and health of the patient; various materials are available. Recently, biomaterials that are remodelable (bovine pericardium patch; Veritas, Synovis Life Technologies Inc, St Paul, MN) or absorbable (polylactic acid [PLA] bar; BioBridge, Acute Innovations, Hillsboro, OR) have been introduced for reconstruction procedures. METHODS We performed a retrospective review of all patients who underwent chest wall stabilization or reconstruction between July 1, 2009, and March 31, 2011. RESULTS Biomaterials were used in 25 of 112 patients (22%) who underwent chest wall stabilization or reconstruction, and they form the basis of this review. Indication for reconstruction was malignant disease in 17 patients (68%). Overall, 10 (40%) resection sites were infected preoperatively. Reconstruction was performed with a combination of bovine pericardium and PLA bars in 11 patients (44%), bovine pericardium alone in 10, and PLA bars alone in 4; muscle flaps were interposed in 7 patients (28%). There were no operative deaths. Complications occurred in 6 patients (24%). Median follow-up was 12 months (range, 6 to 27 months). Three patients required removal of their biomaterials. Two bovine pericardial patches were removed prophylactically at the time of debridement of a partially necrotic muscle flap, and 1 PLA bar was removed because of an inflammatory reaction. None of the patients with an infected resection site required removal of their biomaterial. CONCLUSIONS Chest wall reconstruction with biomaterials is a valuable option in the management of patients with chest wall abnormalities. Early results are promising. Biomaterials may be the preferred method of reconstruction for infected chest wall sites.