Shawn S. Groth

Surgery for Early-Stage Non-Small Cell Lung Cancer: A Systematic Review of the Video-Assisted Thoracoscopic Surgery Versus Thoracotomy Approaches to Lobectomy

Video-assisted thoracoscopic surgery (VATS) for lobectomy has been touted to provide superior outcomes, compared with thoracotomy, for patients with early-stage non-small-cell lung cancer (NSCLC). However, supporting data are limited to case series and small observational studies. We hypothesized that a systematic review of the literature would enable a more objective evaluation of the evidence in order to determine the potential superiority of the VATS approach, compared with thoracotomy, in terms of short-term morbidity and long-term survival. To identify relevant articles for inclusion in our analysis, we performed a systematic review of the MEDLINE database. We looked for randomized controlled trials, observational studies, and case series that reported outcomes after VATS or thoracotomy lobectomy for NSCLC. For statistical testing, we used a two-sided approach (alpha = 0.05) under the hypothesis that VATS lobectomy is superior to thoracotomy lobectomy. We screened 17,923 studies. After independent review of the abstracts by 2 reviewers, we included 39 studies (only one randomized controlled trial) in our analysis. In aggregate, these 39 studies involved 3256 thoracotomy and 3114 VATS patients. The characteristics of the two groups were not significantly different. Compared with thoracotomy, VATS lobectomy was associated with shorter chest tube duration, shorter length of hospital stay, and improved survival (at 4 years after resection), all statistically significant. Compared with lobectomy performed by thoracotomy, VATS lobectomy for patients with early-stage NSCLC is appears to favor lower morbidity and improved survival rates.

Survival After Lobectomy Versus Segmentectomy for Stage I Non-Small Cell Lung Cancer: A Population-Based Analysis

BACKGROUND Data comparing survival after lobectomy versus that after segmentectomy for stage I non-small cell lung cancer (NSCLC) are limited to single-institution observational studies and 1 clinical trial. We sought to determine if lobectomy offers a survival advantage over segmentectomy for stage I NSCLC based on population-based data. METHODS Using the Surveillance Epidemiology and End Results (SEER) database (1998 to 2007), we identified patients who underwent either anatomic segmentectomy or lobectomy. Wedge resections were excluded. Analysis was limited to patients with stage I adenocarcinoma or squamous cell carcinoma. After stratifying patients based on tumor size (less than or equal to 2.0 cm, 2.1 to 3.0 cm, and 3.1 to 7.0 cm), we assessed for association between extent of resection and survival using the Kaplan-Meier method. To adjust for potential confounding variables, we used Cox proportional hazards regression models. RESULTS There were 14,473 patients who met our inclusion criteria. Lobectomy conferred superior unadjusted overall (p < 0.0001) and cancer-specific (p = 0.0053) 5-year survival compared with segmentectomy. Even after adjusting for patient factors, tumor characteristics, and geographic location, we noted that patients who underwent lobectomy had superior overall and cancer-specific survival rates, regardless of tumor size. Squamous cell histologic type, male sex, low lymph node counts, and increasing age, tumor size, and grade were all independent negative prognostic factors. CONCLUSIONS Using a population-based data set, we found that lobectomy confers a significant survival advantage compared with segmentectomy. Our results provide additional evidence supporting the role of lobectomy as the standard of care for resection of stage I NSCLC regardless of tumor size.

Endobronchial Ultrasound-Guided Fine-Needle Aspiration of Mediastinal Lymph Nodes: A Single Institution's Early Learning Curve

BACKGROUND The gold standard for mediastinal lymph node evaluation is mediastinoscopy, which is invasive and allows access to only a limited number of mediastinal lymph node (MLN) stations (1, 2, 3, 4, and 7). Endobronchial ultrasound-guided fine-needle aspiration (EBUS-FNA) is emerging as a useful, less invasive technique that offers access to a wider range of MLN stations (2, 3, 4, 7, 10, and 11). We report our initial experience with this procedure. METHODS Using our prospectively maintained database, we performed a single-institution retrospective chart review. Our study group consisted of all patients at the University of Minnesota who underwent EBUS-FNA for evaluation of mediastinal lymphadenopathy or for thoracic malignancy staging from September 1, 2006, through December 15, 2007. To assess our learning curve, we plotted the cumulative sensitivity (%) and accuracy (%) of our EBUS-FNA results as a function of the number of procedures we performed. RESULTS During the study period, 100 patients underwent EBUS, 92 with FNA. Of these, 56 patients (34 women, 22 men; mean age, 60.4 +/- 13.7 years) met our inclusion criteria. We found no complications. After our first 10 procedures, the sensitivity of our EBUS-FNA results was 96.2%; accuracy was 97.8% (rates comparable with other large series in the literature). CONCLUSIONS We conclude that the learning curve for EBUS-FNA for thoracic surgeons is about 10 procedures.

Thoracoscopic Versus Thoracotomy Approaches to Lobectomy: Differential Impairment of Cellular Immunity

BACKGROUND Video-assisted thoracoscopic surgery (VATS) for patients with early-stage non-small-cell lung cancer is associated with lower stress responses and potentially improved outcomes, as compared with thoracotomy. The goal of our study was to examine the cellular components of the postoperative immune response. Specifically, we assessed the cytotoxic capacity of peripheral blood mononuclear cells (PBMCs) of patients undergoing lobectomy for non-small-cell lung cancer by either VATS or thoracotomy. METHODS We performed a prospective cohort study of lobectomy patients undergoing either VATS or thoracotomy. We isolated PBMCs from perioperative blood samples, and performed cytokine analysis on plasma fractions. Using flow cytometry, we analyzed PBMC phenotype (CD3, CD16/56, CD4, CD8) and T-cell activation markers (CD25, CD69, HLA-DR). Using a chromium release assay, we quantified cellular cytotoxicity. To assess gene expression differences, we used Affymetrix messenger ribonucleic acid microarray and polymerase chain reaction analysis. RESULTS A total of 13 patients enrolled in our study: 6, VATS; 7, thoracotomy. On postoperative day 1, interleukin-6 and matrix metalloproteinase-9 were significantly different between the two groups. On day 2, cellular cytotoxicity (0.34) was significantly greater (p < 0.05) after VATS, as compared with thoracotomy (0.18). In both groups, cytotoxicity returned to baseline and was equivalent at first follow-up (VATS, 29.4 days versus thoracotomy, 29.3 days; p > 0.05). We noted minimal yet significant differences in PBMC phenotype, but no differences in T-cell activation makers. A 9-gene polymerase chain reaction-validated subset clustered the two groups with complete concordance. CONCLUSIONS Video-assisted thoracoscopic surgery lobectomy for non-small-cell lung cancer is associated with less impairment of cellular cytotoxicity, as compared with thoracotomy. We found that this difference was not accounted for by PBMC phenotypic changes. Instead, PBMC gene expression changes likely represent the molecular basis of this differential immune response.

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.

Determination of the minimum number of lymph nodes to examine to maximize survival in patients with esophageal carcinoma: data from the Surveillance Epidemiology and End Results database.

OBJECTIVE We used a population-based cancer registry to examine the association between lymph node counts and mortality to determine the minimum number of lymph nodes that should be examined as part of esophageal resection. METHODS Using the Surveillance Epidemiology and End Results database, we identified patients who had an esophagectomy for invasive esophageal carcinoma from 1988 through 2005 and who had a known number of lymph nodes examined pathologically. After stratifying patients (0, 1-11, 12-29, and 30 or more lymph nodes examined) based on a recursive partitioning analysis, we assessed the association between lymph nodes counts and mortality using the Kaplan-Meier method. To adjust for potential confounding covariates, we used a Cox proportional hazards regression model. RESULTS Of the patients in the Surveillance Epidemiology and End Results database with esophageal cancer, 4882 met our inclusion criteria. We noted a significant difference between the lymph node groups with regards to unadjusted all-cause (P < .0001) and cancer-specific mortality (P = .004). After adjusting for cancer registry, patient factors, tumor characteristics, and timing of radiation therapy, we noted a significant difference between the lymph node groups with regards to all-cause and cancer-specific mortality. Compared with patients who had no lymph node evaluation, only patients who had more than 12 lymph nodes examined had a significant improvement in mortality; patients who had 30 or more lymph nodes examined had significantly lower mortality rates than the other groups. CONCLUSION To maximize all-cause and cancer-specific survival, esophageal cancer patients should have at least 30 lymph nodes examined pathologically as part of esophageal resection.

Diaphragm Plication for Eventration or Paralysis: A Review of the Literature

Although etiology and pathology of symptomatic diaphragm paralysis and eventration are distinct, their treatments are the same: to reduce dysfunctional caudal excursion of the diaphragm during inspiration by plication. Minimally invasive diaphragm plication techniques have emerged as equally effective and less morbid alternatives to open plication. This review focuses on the etiology, pathophysiology, diagnosis, and treatment of diaphragmatic eventration or paralysis in adults.

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.

Protocolized management of infants with congenital diaphragmatic hernia: effect on survival.

BACKGROUND/PURPOSE In 2006, we introduced a new protocol for congenital diaphragmatic hernia (CDH) management featuring nitric oxide in the delivery room, gentle ventilation, lower criteria for extracorporeal membrane oxygenation (ECMO), and appropriately timed operative repair on ECMO. Our goals were to assess outcomes after institution of this protocol and to compare results with historical controls. METHODS Charts were reviewed of all newborns admitted to a large metropolitan childrens hospital from 2002 to 2009 with a diagnosis of CDH. Data were recorded regarding delivery, ECMO, operative repair, length of stay, comorbidities/anomalies, complications, and survival. Postprotocol outcomes were compared to those from the preprotocol era and to data from the international CDH Registry. RESULTS Comparison of the protocolized group (n = 43) to the historical group (n = 51) revealed no significant differences in gestational age, birth weight, Apgar scores, or comorbidities. New treatment strategies substantially improved survival to discharge (67% preprotocol, 88% postprotocol; P = .015). Among ECMO patients, survival increased to 82% (20% preprotocol; P = .002). CONCLUSIONS Our new protocol significantly improved survival to discharge for newborns with CDH. Institution of such a protocol is valuable in improving outcomes for patients with CDH and merits consideration for widespread adoption.

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.