Thomas J. Birdas

Treatment of esophageal leaks, fistulae, and perforations with temporary stents: Evaluation of efficacy, adverse events, and factors associated with successful outcomes

BACKGROUNDnFactors associated with successful endoscopic therapy with temporary stents for esophageal leaks, fistulae, and perforations (L/F/P) are not well known.nnnOBJECTIVESnTo evaluate the safety, efficacy, and outcomes of esophageal stenting in these patients and identify factors associated with successful closure.nnnDESIGNnRetrospective.nnnSETTINGnAcademic tertiary referral center.nnnPATIENTSnAll patients with attempted stent placement for esophageal L/F/P between January 2003 and May 2012.nnnINTERVENTIONnEsophageal stent placement and removal.nnnMAIN OUTCOME MEASUREMENTSnFactors predictive of therapeutic success defined as complete closure after index stent removal (primary closure) or after further endoscopic stenting (secondary closure).nnnRESULTSnSixty-seven patients with 132 attempted stents for esophageal L/F/P were considered; 13 patients were excluded. Among the remaining 54 patients, 117 stents were placed for leaks (29 patients; 64 stents), fistulae (15 patients; 36 stents), and perforations (10 patients; 17 stents). Procedural technical success was achieved in all patients (100%). Primary closure was successful in 40 patients (74%) and secondary closure in an additional 5 (83% overall). On short-term (<3 months) follow-up, 27 patients (50%) were asymptomatic, whereas 22 (41%) had technical adverse events, including stent migration in 15 patients (28%). Factors associated with successful primary closure include a shorter time between diagnosis of esophageal L/F/P and initial stent insertion (9.03 vs 22.54 days; P = .003), and a smaller luminal opening size (P = .002).nnnLIMITATIONSnRetrospective, single-center study.nnnCONCLUSIONSnTemporary stents are safe and effective in treating esophageal L/F/P. Defect opening size and time from diagnosis to stent placement appear to be candidate predictors for successful closure.

Thymic carcinoma: Outcomes after surgical resection

BACKGROUNDnThymic carcinoma is a rare malignancy with little information regarding outcomes after therapy with curative intent. We undertook a retrospective analysis of all patients who underwent resection of thymic carcinoma at 2 hospitals.nnnMETHODSnFrom 1990 to 2011, 16 patients (9 men, 7 women) underwent surgical resection of thymic carcinoma at a mean age of 52 years. Patient demographics, extent of surgical resection, and outcomes were compiled.nnnRESULTSnThe distribution of Masaoka stages at presentation was I in 3 (19%), II in 4 (25%), III in 8 (50%), and IV in 1 (6%). Neoadjuvant chemotherapy was administered to 6 patients (38%) whose tumors were deemed to be more locally invasive. Surgical resection included en bloc extrapleural pneumonectomy in 1, lobectomy in 2, and superior vena cava resection and reconstruction in 4. There were no perioperative deaths. Complete resection was achieved in 14 (88%), and of these patients, only 1 experienced local recurrence. At last follow-up, 10 patients were alive and well, 1 patient was alive with disease, and 5 patients had died. Mean survival was 4.2 years.nnnCONCLUSIONSnAlthough considered to have greater malignant potential, long-term survival can be achieved in patients with thymic carcinoma who are amenable to surgical therapy. With increased use of computed tomography imaging, patients with early-stage disease are being identified more frequently, and complete surgical resection appears to have favorable cure rates in these patients. Select patients with locally advanced disease can experience long-term survival with a multimodality approach.

Prognostic indicators after surgery for thymoma.

BACKGROUNDnWe undertook a 20-year retrospective institutional study to investigate prognostic indicators after surgery for thymoma.nnnMETHODSnFrom 1989 to 2009, 83 patients underwent surgical resection of thymoma or thymic carcinoma at our institution. Twelve of these patients were determined to have either World Health Organization type C disease or Masaoka stage IV-B disease and were excluded from analysis. The remaining 71 patients were reviewed.nnnRESULTSnThe majority of patients in this series were female 64.7% (n=46) with an overall average age of 51.0 years. The distribution of Masaoka stages I, II, III, and IV-A was 40.8% (n=29), 19.7% (n=14), 18.3% (n=13), and 21.1% (n=15), respectively. Thirteen of the 28 (46.2%) patients who presented with stage III or IV-A disease received preoperative chemotherapy. After a mean follow-up of 66 months (range, 6 to 241 months), 54 (75.3%) patients are alive and well while six are alive with disease. Eleven (16.0%) patients have died, but only 3 (4.3%) of these patients died of thymoma. The overall disease-specific survival was 97% and 89% at 5 and 10 years. Of the variables analyzed, only age was predictive of overall survival (p=0.03). Masaoka stages I to III as compared with stage IV-A was significantly predictive of disease-free survival (p<0.01).nnnCONCLUSIONSnLong-term disease-specific survival can be expected not only after surgery for early stage thymoma but also after surgery for advanced disease, including patients with pleural metastases. However, patients who undergo surgery for stage IV-A disease have reduced disease-free survival. Late mortality due to secondary cancers and associated immunologic disorders was more frequent than mortality from thymoma in this series.

Support service use and interest in support services among distressed family caregivers of lung cancer patients

This study examined support service use and interest in support services among distressed family caregivers of patients recently entering comprehensive cancer care facilities.

Economic and social changes among distressed family caregivers of lung cancer patients.

PurposeAlthough costs of lung cancer care have been documented, economic and social changes among lung cancer patients’ family caregivers have yet to be fully examined. In addition, research has not focused on caregivers with greater need for support services. This study examined various economic and social changes among distressed family caregivers of lung cancer patients during the initial months of cancer care in the USA.MethodsLung cancer patients’ primary family caregivers with significant anxiety or depressive symptoms were recruited from three medical centers within 12xa0weeks of the patient’s new oncology visit. Caregivers (Nu2009=u200983) reported demographic and medical information and caregiving burden at baseline. Seventy-four caregivers reported anxiety and depressive symptoms and economic and social changes 3xa0months later.ResultsSeventy-four percent of distressed caregivers experienced one or more adverse economic or social changes since the patient’s illness. Common changes included caregivers’ disengagement from most social and leisure activities (56xa0%) and, among employed caregivers (nu2009=u200949), reduced hours of work (45xa0%). In 18xa0% of cases, a family member quit work or made another major lifestyle change due to caregiving. Additionally, 28xa0% of caregivers reported losing the main source of family income, and 18xa0% reported losing most or all of the family savings. Loss of the main source of family income and disengagement from most social and leisure activities predicted greater caregiver distress.ConclusionsFindings suggest that distressed caregivers of lung cancer patients experience high rates of adverse economic and social changes that warrant clinical and research attention.

“Supercharged” Isoperistaltic Colon Interposition for Long-Segment Esophageal Reconstruction

BACKGROUNDnWhen the stomach is not available, long-segment esophageal reconstruction remains a surgical challenge. Since 2005, we have used a supercharged isoperistaltic colon interposition conduit for long-segment esophageal reconstruction that reestablishes a dual blood supply.nnnMETHODSnAn institutional database search of 449 patients who underwent esophagectomy from 2005 to 2012 identified 11 consecutive patients who underwent long-segment esophageal reconstruction using an isoperistaltic supercharged right (n=9) or left (n=2) colon conduit. All conduits were routed through the anterior mediastinum, maintaining the middle colic (right) or ascending left colic vessels (left) in situ, with reimplantation of the ileocolic vessels (right) or middle colic vessels (left) into the left internal thoracic artery and brachiocephalic vein to improve distal conduit blood flow.nnnRESULTSnPatients were a mean age of 64 years (range, 47 to 76 years). Seven patients had a history of malignancy and 4 had a benign process. The stomach was unavailable for reconstruction due to prior gastric operations (n=9) or neoplastic involvement (n=2). All reimplanted vessels demonstrated excellent flow by Doppler evaluation. Esophagocolonic healing was successful in all patients; however, 1 patient required a temporary stent.nnnCONCLUSIONSnSupercharged isoperistaltic colon interposition appears to be an excellent option for the challenging situation where long-segment esophageal reconstruction is needed and the stomach is not available. The additional effort required to reestablish a dual blood supply appears justified to minimize ischemic-related morbidity. Unlike long-segment small bowel supercharged techniques, adequate blood supply to the distal conduit may still be present in case thrombosis of the reimplanted vessels occurs.

Results of Superior Vena Cava Reconstruction With Externally Stented-Polytetrafluoroethylene Vascular Prostheses

BACKGROUNDnResection and reconstruction of the superior vena cava (SVC) is occasionally required in the surgical treatment of intrathoracic neoplasms or symptomatic occlusion secondary to benign causes. We reviewed our institutional experience with SVC reconstruction using externally stented-polytetrafluoroethylene vascular prostheses.nnnMETHODSnFrom 1991 to 2009, medical records of 38 patients who underwent SVC resection and reconstruction with externally stented-polytetrafluoroethylene vascular prostheses were reviewed. Indications for surgery were malignancy in 34 (89%) patients (germ cell, 13; thymoma, 10; lung cancer, 9; sarcoma, 2) and benign symptomatic occlusion in 4 (11%) patients.nnnRESULTSnEighteen patients (47%) underwent right innominate vein to SVC interposition graft reconstruction, which became the favored approach during the study interval when resection of the innominate confluence was necessary. Eight patients (21%) had left innominate vein to SVC interposition grafts, earlier in the series or when the right innominate vein was unavailable. Nine patients (24%) received graft interposition of the proximal to distal SVC. The remaining 3 patients had a Y reconstruction. There were 2 perioperative mortalities. Follow-up averaged 15 months (range, 1 to 113 months), including 11 (29%) patients who died of disease. All patients demonstrated minimal to no brachiocephalic swelling at last follow-up. Twenty (53%) patients underwent imaging after an average of 24 months (range, 1 to 113 months) with only two grafts demonstrating complete occlusion.nnnCONCLUSIONSnAlthough several SVC reconstructive techniques have been described, externally stented-polytetrafluoroethylene vascular prostheses are readily available for off-the-shelf use. In our experience, patency rates are high, and patients who do demonstrate graft thrombosis have minimal to no symptoms.

Barriers to mental health service use and preferences for addressing emotional concerns among lung cancer patients

This study examined barriers to mental health service use and preferences for addressing emotional concerns among lung cancer patients (Nu2009=u2009165) at two medical centers in the Midwestern United States.

Risk Factors for Bronchopleural Fistula After Right Pneumonectomy: Does Eliminating the Stump Diverticulum Provide Protection?

PurposeBronchopleural fistula (BPF) remains an important source of morbidity and mortality after right pneumonectomy. We reviewed our 18-year institutional experience with right pneumonectomy to identify risks factors for BPF.MethodsFrom 1992 to 2010, a total of 145 patients who underwent right pneumonectomy were identified from an institutional database. Median age was 56xa0years. Most patients (66.2%) underwent surgery for non–small cell lung cancer. Sixty-seven patients (46.2%) received either chemotherapy or radiotherapy before surgery. Medical records were reviewed for 14 variables potentially predictive for BPF, including two airway closure techniques (standard bronchial closure and carinal closure). Variables predictive of BPF by univariate analysis were entered into a logistic regression model.ResultsThe overall mortality rate was 13.1% (nxa0=xa019), with 15.9 and 10.5% mortality in the bronchial closure and carinal closure groups, respectively (Pxa0=xa00.33). The overall BPF rate was 7.6% (nxa0=xa011), with a 3.9% (3 of 76) rate in the carinal closure group compared to 11.6% (8 of 69) in the bronchial closure group (Pxa0=xa00.08). Seven of eight bronchial closure patients who developed BPF required operative repair. Only one of three patients who developed BPF after carinal closure did not spontaneously heal after open drainage. Multivariate analysis identified preoperative radiation dose (Pxa0=xa00.042) and bronchial closure (Pxa0=xa00.041) as independent risk factors for BPF, while the length of postoperative ventilation before development of BPF approached significance (Pxa0=xa00.057).ConclusionsIn our experience, higher preoperative radiation doses are a risk factor for BPF after right pneumonectomy, while carinal closure exerts a protective effect.

Treatment of clinical T2N0M0 esophageal cancer.

BackgroundManagement of clinical T2N0M0 (cT2N0M0) esophageal cancer remains controversial. We reviewed our institutional experience over 21xa0years (1990–2011) to determine clinical staging accuracy, optimal treatment approaches, and factors predictive of survival in this patient population.MethodsPatients with cT2N0M0 esophageal cancer determined by endoscopic ultrasound (EUS) were identified through a prospectively collected database. Demographics, perioperative data, and outcomes were examined. Cox regression model and Kaplan–Meier plots were used for statistical survival analysis.ResultsA total of 731 patients underwent esophagectomy, of whom 68 cT2N0M0 patients (9xa0%) were identified. Fifty-seven patients (84xa0%) had adenocarcinoma. Thirty-three patients (48.5xa0%) were treated with neoadjuvant chemoradiation followed by surgery, and 35 underwent surgical resection alone. All resections except one included a transthoracic approach with two-field lymph node dissection. Thirty-day operative mortality was 2.9xa0%. Only 3 patients (8.5xa0%) who underwent surgery alone had T2N0M0 disease identified by pathology: the disease of 15 (42.8xa0%) was found to be overstaged and 17 (48.5xa0%) understaged after surgery. Understaging was more common in poorly differentiated tumors (pxa0=xa00.03). Nine patients (27.2xa0%) had complete pathologic response after chemoradiotherapy. Absence of lymph node metastases (pN0) was significantly more frequent in the neoadjuvant group (29 of 33 vs. 21 of 35, pxa0=xa00.01). Median follow-up was 44.2xa0months. Overall 5-year survival was 50.8xa0%. On multivariate analysis, adenocarcinoma (pxa0=xa00.001) and pN0 after resection (pxa0=xa00.01) were significant predictors of survival.ConclusionsEUS was inaccurate in staging cT2N0M0 esophageal cancer in this study. Poorly differentiated tumors were more frequently understaged. Adenocarcinoma and absence of lymph node metastases (pN0) were independently predictive of long-term survival. pN0 status was significantly more common in patients undergoing neoadjuvant therapy, but long-term survival was not affected by neoadjuvant therapy. A strategy of neoadjuvant therapy followed by resection may be optimal in this group, especially in patients with disease likely to be understaged.