Yun-Hen Liu

Management of lung metastases from colorectal cancer: video-assisted thoracoscopic surgery versus thoracotomy--a case-matched study.

OBJECTIVES The benefits of video-assisted thoracoscopic surgery (VATS) for performing pulmonary metastasectomy are considered controversial. This case-matched study aimed to compare long-term outcomes after surgical resection of pulmonary metastases from colorectal cancer using different approaches (VATS vs. thoracotomy). METHODS Between 1997 and 2008, 143 patients with colorectal cancer who had received their first pulmonary metastasectomy were selected. Fifty-three patients underwent a surgical procedure that utilized a thoracotomy approach (Group 1), and 90 patients underwent a surgical procedure that used a VATS-based approach (Group 2). After being matched for tumor number, diameter (measured by computed tomography), and surgical procedure (wedge resection or lobectomy), 35 pairs of patients were finally enrolled. Study endpoints included tumor recurrence and survival. RESULTS There was no hospital mortality in both groups. Within the mean follow-up period of 50 months, 47.1% patients developed a recurrence (52% at the pulmonary level and 48% at systemic level), and 52.9% of the patients were alive at the time of analysis. There was no difference between Groups 1 and 2 in terms of overall recurrences (54 vs. 40%, p = 0.23), all pulmonary recurrences (25.7 vs. 22.9%, p = 0.78), and same side lung recurrences (14.3 vs. 20%, p = 0.75). The 5-year overall survival (OS) after lung resection was 43 and 51% in Groups 1 and 2, respectively (p = 0.21). CONCLUSIONS Our case-matched study showed that survival outcome of pulmonary metastasectomy using VATS is not inferior to that of open thoracotomy in selected cases.

Pretreatment T3-4 Stage is an Adverse Prognostic Factor in Patients with Esophageal Squamous Cell Carcinoma Who Achieve Pathological Complete Response Following Preoperative Chemoradiotherapy

Background:Preoperative chemoradiotherapy (CRT) followed by esophagectomy is becoming one of the standard treatment strategies for esophageal cancer. Pathologic complete response (pCR) after CRT is the best predictor of survival in squamous cell carcinoma (SCC) of the esophagus. Although no adjuvant treatment is recommended for individuals who achieve pCR, approximately 30% of these patients develop recurrence. Herein we sought to retrospectively investigate the independent predictors of tumor recurrence in this patient group. Methods:Between 1995 and 2004, we investigated seventy patients (69 males and 1 female; mean age: 56.1 years) with esophageal SCC who achieved pCR following preoperative chemoradiotherapy. Study end points included tumor recurrence, disease-specific survival (DSS), and disease-free survival (DFS). Univariate and multivariate analyses were used to identify risk factors for the study end points. Results:Mean follow-up time for patients who survived was 65.8 months. At the time of analysis, 18 patients (25.7%) died of the disease and 22 patients (31.4%) developed recurrence. Multivariate analysis showed that pretherapy T3-4 disease was the most important adverse factor for tumor recurrence (P = 0.007), DFS (P = 0.005), and DSS (P = 0.026). The 5-year DFS was 45% for patients with clinical T3-4 disease and 85% for those with clinical T1-2 disease (P = 0.02). Conclusions:We have shown that up to 31.4% of patients with esophageal SCC who achieve pCR develop tumor recurrence thereafter. Pretherapy T3-4 disease was a strong and independent adverse risk factor for 5-year tumor recurrence, DSS and DFS. High-risk patients with T3-4 disease should be followed with a strict surveillance protocol.

Delayed pneumothorax complicating minor rib fracture after chest trauma

OBJECTIVE Pneumothorax (PTX) after trauma is a preventable cause of death. Drainage procedures such as chest tube insertion have been traditionally advocated to prevent fatal tension PTX. We evaluated the safety of close observation in patients with delayed PTX complicating rib fracture after minor chest trauma. MATERIALS AND METHODS Adult patients (>18 years) with a diagnosis of chest trauma and 3 or fewer fractured ribs were reviewed. Case patients were divided according to age, location and number of fractured ribs, mechanism of trauma, and initial pulmonary complication after thoracic trauma for comparative analysis. RESULTS There were 207 male (70.2%) and 88 female (29.8%) patients whose ages ranged from 18 to 93 years (median, 55 years). The mechanisms of trauma were a motor vehicle accident in 207 patients, falls in 66, pedestrian injury in 10, and assaults in 14. Ninety-five patients sustained 1 rib fracture, 95 had 2 rib fractures, and 105 suffered 3 rib fractures. Right-sided injury occurred in 164 cases, left-sided injury did in 127, and bilateral injury did in 4. The most frequent location of rib fractures was from the fourth rib to the ninth rib. The initial pulmonary complications after trauma were PTX in 16 patients, hemothorax in 43, pneumohemothorax in 14, lung contusion in 75, and isolated subcutaneous emphysema (SubcEmph) in 33. Thirty percent of the patients (n = 5/16) who presented with traumatic PTX were observed safely without drainage. Delayed PTX was recorded in 16 patients, occurring mostly during the first 2 days of their admission. Associated extrathoracic injury was recorded in 189 patients. The mean hospital stay of the patients was 7.66 days. Longer hospital stay was related to increasing number of fractured ribs, need for thoracic drainage, and the presence of associated extrathoracic injury. The mortality rate for the entire group was 2%. The presence of SubcEmph was the only risk factor associated with the development of delayed PTX. CONCLUSIONS Patients sustaining blunt chest trauma and minor rib fractures should be admitted for close observation when presenting with SubcEmph because of possible delayed presentation of PTX.

Treatment of esophageal perforation in a referral center in taiwan.

PurposeThe high mortality associated with esophageal perforation can be reduced by aggressive surgery and good critical care. We report our experience of treating esophageal perforation in a clinic in Taiwan.MethodsThe subjects were 28 patients who underwent surgery for a benign esophageal perforation.ResultsThe esophageal perforation was iatrogenic in 11 patients, spontaneous in 8, and caused by foreign body injury in 9. Most (22/28) of the patients were seen longer than 24 h after perforation, and 77% had empyema preoperatively. The perforation was located in the cervical area in 5 patients and in the thoracic esophagus in 23. We performed primary repair in 24 patients, esophagectomy in 3, and drainage in 1. Leakage occurred after primary repair in ten (41%) patients, resulting in one death, and two patients died of other diseases. Postoperative leakage prolonged the hospital stay but had no impact on mortality. Overall survival was 90%. Univariate analysis revealed that age, timing of treatment, and cause and location of the perforation influenced outcome, but multivariate analysis failed to identify a predictor of mortality.ConclusionsEarly diagnosis and intervention are crucial to prevent morbidity and mortality in patients with esophageal perforation. Primary repair is feasible even if the diagnosis is delayed.

High expression of phosphorylated 4E-binding protein 1 is an adverse prognostic factor in esophageal squamous cell carcinoma

Cell signaling pathways play important roles in oncogenesis. Among a large number of signaling regulators in different pathways, 4E-binding protein 1 (4E-BP1) was found to be a key factor, which converges several oncogenic signals, phosphorylates the molecules, and drives the downstream proliferative signals. Recent studies showed that high expression of phosphorylated 4E-BP-1 (p-4E-BP1) is associated with poor prognosis, tumor progression, or nodal metastasis in different human cancers, but its prognostic significance in esophageal cancer remains undefined. In this study, we investigated the expression levels of p-4E-BP1 with two different phosphorylation sites Thr37/46 and Thr70 by immunohistochemistry and their prognostic significance in 78 cases of surgically resected esophageal squamous cell carcinoma (SCC) for the first time. We found no correlation of p-4E-BP1 expression with age, gender, preoperative concurrent chemoradiotherapy, tumor grade, pT classification, pN, pM, or pStage. Multivariate Cox regression analysis showed that high expression of p-4E-BP-1 Thr37/46 was an independent adverse prognostic factor, with a hazard ratio of 1.73 (95% confidence interval = 1.03–2.90) and a p value of 0.038. Stratifying the patients with other prognostic factors, we found that the effect of p-4E-BP1 Thr37/46 on survival was significant only in patients with relatively early stage disease (pT1/pT2, pN0, or pStage I/II; p = 0.0047, 0.012, and 0.011, respectively). Our data suggest that assessment of p-4E-BP1 expression could identify a subpopulation of earlier stage esophageal SCC patients with poor prognosis. These patients could be possible candidates for future studies on more aggressive treatment or target therapy.

Surgical Thrombectomy for Thrombosed Dialysis Grafts: Comparison of Adjunctive Treatments

BackgroundVascular surgeons often encounter dialysis graft failure in hemodialysis patients during their daily practice. Despite advances in percutaneous treatment, there remains a role for surgical thrombectomy of thrombosed dialysis grafts. This study was designed to investigate the long-term outcome of dialysis graft thrombectomy and to examine the indications for and effectiveness of therapies adjuvant to Fogarty thrombectomy.MethodsSurgical outcomes of 590 consecutive dialysis graft thrombectomies performed between 2001 and 2003 were retrospectively reviewed. The 590 cases were classified into four groups based on the procedure performed adjuvant to Fogarty thrombectomy: group A, surgical thrombectomy by Fogarty thrombectomy catheter alone; group B, thrombectomy plus intraoperative angioplasty of graft outlet; group C, thrombectomy plus sequential balloon angioplasty in subsequent intervention; group D, thrombectomy plus graft outlet surgical revision. Age, gender, co-morbidity, and primary patency of grafts were reviewed and analyzed.ResultThe four groups exhibited similar demographic features and comorbidities (p > 0.05). Mean primary patency in the four groups was 1.99 ± 4.02, 7.21 ± 7.61, 8.35 ± 9.53, and 7.26 ± 6.99 (months), respectively. Survival curves for each group were determined by Kaplan-Meier methods. Primary patency in group A was statistically inferior to all of the other three groups, whereas groups B, C, and D did not significantly differ with regard to graft patency.ConclusionsSurgical thrombectomy alone is inadequate for treating a thrombosed dialysis graft. The underlying graft outlet stricture requires direct surgical revision or balloon angioplasty during surgery or intervention in the angiography suite to ensure long-term patency of the graft.

Feasibility of Endoscopic Transoral Thoracic Surgical Lung Biopsy and Pericardial Window Creation

BACKGROUND The thoracic cavity approach for natural orifice transluminal endoscopic surgery (NOTES) is technically challenging. The aim of this study was to evaluate the feasibility of a transoral endoscopic technique for a surgical lung biopsy and pericardial window creation METHODS Under general anesthesia, a 12 mm incision was made over the vestibulum oris region. Under video guidance, a homemade metallic tube was introduced through the incision, extending along the pre-tracheal space to the substernal space with blunt dissection technique, and used as the entrance into the thoracic cavity. A surgical lung biopsy and a pericardial window creation were performed in 12 canines, using the transoral NOTES technique. RESULTS The transoral endoscopic surgical lung biopsy and pericardial window creation were successfully completed in 11 of the 12 canines. Intraoperative bleeding and death from an injury to the pulmonary hilum developed in one animal during the electrosurgical excision of lung tissue. CONCLUSIONS Transoral surgical lung biopsy and pericardial window creation in canine models is technically feasible and can be used as a novel experimental platform for studies of NOTES for intra-thoracic surgery.

Feasibility of transtracheal surgical lung biopsy in a canine animal model

Successful natural orifice transluminal endoscopic surgery (NOTES) procedures have been reported in animal studies. However, very little is known about the optimal approach for the application of these surgeries in the thoracic cavity. This study presents the feasibility of transtracheal evaluation of pleural cavity in a canine model using the NOTES technique.

Predictors of pathological complete response to neoadjuvant chemoradiotherapy for esophageal squamous cell carcinoma.

BackgroundsIn this study, we evaluated the factors associated with a pathologic complete response (pCR) after neoadjuvant chemoradiotherapy (nCRT) for esophageal squamous cell carcinoma (ESCC).MethodsPre-nCRT parameters in ESCC patients treated between 1999 and 2006 were analyzed to identify predictors of pCR. All patients received 5-fluorouracil/cisplatin-based chemotherapy and external beam radiation followed by scheduled esophagectomy. Variables were analyzed using univariate and multivariate analyses with pCR as the dependent variable. Estimated pCR rate was calculated with a regression model.ResultsFifty-nine (20.9%) of 282 patients achieved pCR. Univariate analysis identified four patient factors (age, smoking status, drinking history and hypertension), one pre-nCRT parameter (tumor length) as significant predictors of pCR (all P <0.05). On multivariate analysis, tumor length ≤3 cm (favorable, odds ratio (OR): 4.85, P = 0.001), patient age >55 years (favorable, OR: 1.95, P = 0.035), and being a non-smoker (favorable, OR: 3.6, P = 0.003) were independent predictors of pCR. The estimated pCR rates based on a logistic regression including those three predictors were 71%, 35 to approximately 58%, 19 to approximately 38%, and 12% for patients with 3, 2, 1 and 0 predictors, respectively.ConclusionAge, smoking habit and tumor length were important pCR predictors. These factors may be used to predict outcomes for ESCC patients receiving nCRT, to develop risk-adapted treatment strategies, and to select patients who could participate in trials on new therapies.

AIRWAY STENTS IN MANAGEMENT OF TRACHEAL STENOSIS: HAVE WE IMPROVED?

Background:  Airway stenting is an alternative approach for relieving airway stenosis when lesions are inappropriate for single‐stage reconstruction. The aim of this study was to present our experience using airway stent in the management of patients with tracheal stenosis.