Sudhir Sundaresan

Risk of Pneumonectomy After Induction Therapy for Locally Advanced Non-Small Cell Lung Cancer

BACKGROUNDnRecent data from prospective multimodality trials have documented an unacceptable early mortality with pneumonectomy after induction chemotherapy. This finding has raised skepticism toward pneumonectomy as a surgical option for patients with regionally advanced nonsmall-cell lung cancer. In the current study, perioperative outcomes after pneumonectomy with or without neoadjuvant therapy are compared to determine the impact of induction therapy on perioperative mortality in this setting. Variables associated with increased perioperative risk are identified.nnnMETHODSnA review of 315 nonsmall-cell lung cancer patients (196 male [62%]) undergoing pneumonectomy over a 15-year period was undertaken. Patients were well matched for clinical variables other than receiving induction chemotherapy. Complications and operative mortality were analyzed for associations with laterality and induction chemotherapy.nnnRESULTSnMedian age was 64 years, (range, 25 to 82). Age was predictive of mortality in 13 of 86 patients (15%) more than 70 years old, compared with 16 of 229 patients (7%) less than 70 years old (hazard ratio = 1.77, p = 0.046). Overall operative mortality was 9.2% (29 of 315). There were 115 left-sided (37%) and 200 right-sided (63%) pneumonectomies. Sixty-eight patients (22% [left = 31, right = 37]) received induction chemotherapy. Surgery alone was performed in 247 patients. Mortality among patients undergoing induction chemotherapy was 21% (odds ratio = 4.01; p = 0.0007). After induction chemotherapy, postoperative bronchopleural fistula associated with respiratory failure was predictive of operative mortality (hazard ratio = 148, p = 0.0001). Left-side pneumonectomy did appear to a have a greater incidence of postoperative arrhythmia.nnnCONCLUSIONSnMorbidity and mortality after pneumonectomy is substantial. Patients greater than 70 years old appear to be at increased risk. Induction chemotherapy also increases the risk of operative mortality after pneumonectomy. Patients should be advised of this increased operative risk, and the multidisciplinary team must consider this when pneumonectomy appears necessary after induction therapy for locally advanced nonsmall-cell lung cancer.

Mucosal Tube Technique for Creation of Esophageal Anastomosis After Esophagectomy

BACKGROUNDnThe definitive treatment of esophageal cancer remains surgical resection. Morbidity and mortality are highly influenced by the success of the anastomosis created in the reconstruction of the resected esophagus. The results of an anastomotic technique that creates an esophageal mucosal tube are analyzed.nnnMETHODSnThe medical records of all patients undergoing esophagectomy at a single institution by 3 surgeons between January 2002 and July 2008 were reviewed. Patients who underwent a 2-layer, hand-sewn, esophageal anastomosis using a mucosal tube were included. The unique aspect of the anastomosis was the creation of an esophageal mucosal tube that facilitates a tension-free, precise mucosal approximation.nnnRESULTSnOf the 61 patients who underwent esophageal reconstructions (60 gastric, 1 colonic), 49 (80%) had a diagnosis of esophageal neoplasm. Of those with cancer, 20 (41%) had neoadjuvant therapy before the resection. Two patients presented with perforation. The anastomoses were intrathoracic in 57 of 61 (93%) and cervical in 4 cervical. There were no operative deaths. All patients underwent contrast study at an average of 5 days postoperatively. The anastomotic leak rate was 2% (1 of 61). Postoperative dilations (mean, 1.3 dilations) were done in 12 of 61 patients (20%), using a low symptom threshold for endoscopy and dilation.nnnCONCLUSIONSnThe use of the esophageal mucosal tube and 2-layer anastomosis is a robust technique that results in a low leak rate. Strictures are minimal and easily dilated if they occur. Use of a gastrotomy larger than 2.5 cm may decrease stricture rates.

Impact of Adverse Events and Length of Stay on Patient Experience After Lung Cancer Resection

BACKGROUNDnPostoperative adverse events (AEs), prolonged length of stay (PLOS), and patient experience are common quality measures after thoracic surgical procedures. Our objective was to investigate the relationship of postoperative AEs on patient experience and hospital length of stay (LOS) after lung cancer resection.nnnMETHODSnAEs (using Thoracic Morbidity and Mortality system based on Clavien-Dindo schema) and LOS were prospectively collected for all patients undergoing lung cancer resection. A 21-item questionnaire, retrospectively asking about patient experience, was mailed to patients twice (October 2015 and January 2016). The impact of AEs on experience was investigated and stratified by hospital LOS, with PLOS defined as the 75th percentile. Univariate analysis used parametric (t test) and nonparametric (Mann-Whitney) tests according to test conditions.nnnRESULTSnOf 288 patients who responded to the survey (70% response rate), 175 (61%) had no AEs, 113 (39%) hadxa0experienced at least one AE, and 52 (18%) had experienced PLOS. Lung cancer patients who experienced PLOS showed significantly decreased experience on several questionnaire items, including their impression of comprehensiveness of surgeons information provision during inpatient period (pxa0= 0.008), inpatient recovery from operation (pxa0= 0.001), quality of life 30 days after operation (pxa0= 0.032), follow-up care, (pxa0= 0.022), and satisfaction with outcome 1 year after operation during follow-up care (pxa0= 0.022). The presence of postoperative AEs led only to reduced impression about inpatient recovery from the operation (pxa0= 0.01).nnnCONCLUSIONSnIn this cohort, postoperative AEs were minimally associated with negative patient experience. However, patients who experienced PLOS demonstrated a marked reduction in experience after thoracic surgical procedures.

Urgent care access: finding solutions that match causation

The recent research article by McIsaac and colleagues[1][1] has generated some important discussions and reflections within our perioperative and quality teams, some of which we would like to share with the readership.nnFirst and foremost, although press coverage may vary with regard to highlighting

Boerhaave’s syndrome secondary to an incarcerated inguinal hernia: A case report

Highlights • Boerhaave’s syndrome is defined as the spontaneous perforation of the esophagus typically after forceful emesis.• Although Boerhaave’s syndrome has been reported in association with different pathologies, there are no previous reports describing the concurrent surgical repair of an incarcerated inguinal hernia.• A thoracotomy and two layered esophageal repair, followed by a groin exploration, small bowel resection and repair of an inguinal hernia were involved in the surgical management of this patient.