Outcome of Emergency Pulmonary Lobectomy under ECMO Support in Patients with COVID-19.

BACKGROUND: Not much is known about the results of nonelective anatomical lung resections in coronavirus disease 2019 (COVID-19) patients put on extracorporeal membrane oxygenation (ECMO). The aim of this study was to analyze the outcome of lobectomy under ECMO support in patients with acute respiratory failure due to severe COVID-19. METHODS: All COVID-19 patients undergoing anatomical lung resection with ECMO support at a German university hospital were included into a prospective database. Study period was April 1, 2020, to April 30, 2021 (first, second, and third waves in Germany). RESULTS: A total of nine patients (median age 61 years, interquartile range 10 years) were included. There was virtually no preexisting comorbidity (median Charlson score of comorbidity 0.2). The mean interval between first positive COVID-19 test and surgery was 21.9 days. Clinical symptoms at the time of surgery were sepsis (nine of nine), respiratory failure (nine of nine), acute renal failure (five of nine), pleural empyema (five of nine), lung artery embolism (four of nine), and pneumothorax (two of nine). Mean intensive care unit (ICU) and ECMO days before surgery were 15.4 and 6, respectively. Indications for surgery were bacterial superinfection with lung abscess formation and progressive septic shock (seven of nine) and abscess formation with massive pulmonary hemorrhage into the abscess cavity (two of nine). All patients were under venovenous ECMO with femoral-jugular configuration. Operative procedures were lobectomy (eight) and pneumonectomy (one). Weaning from ECMO was successful in four of nine. In-hospital mortality was five of nine. Mean total ECMO days were 10.3 ± 6.2 and mean total ICU days were 27.7 ± 9.9. Mean length of stay was 28.7 ± 8.8 days. CONCLUSION: Emergency surgery under ECMO support seems to open up a perspective for surgical source control in COVID-19 patients with bacterial superinfection and localized pulmonary abscess.

[Delphi Expert Consensus of the German Thoracic Surgery Society on the Management of Chest Tube Drainage]. / Delphi-Konsens der Deutschen Gesellschaft für Thoraxchirurgie über das Management von Thoraxdrainagen.

BACKGROUND: Chest tubes are a valuable instrument and are used on a daily basis - not only by thoracic surgeons but also by a variety of medical specialists who treat pneumothorax or pleural effusions. The goal of the working group of the German Thoracic Society (DGT) was to achieve a consensus on the management of chest tube/drainage using the Delphi process. METHODS: The assigned group of the DGT designed and conducted two electronic rounds of questions in all major thoracic and lung cancer centres. Consensus was considered as rate of ≥ 75%. After statistical analysis of the results, an expert meeting took place and a final Delphi process poll was used in order to reach consensus for controversial topics. RESULTS: Thirteen questions on the management of chest tubes were proposed and voted on. A consensus was reached for the following topics: conditions for chest tube insertion, size of drainage/tube, technique of insertion, diagnostic measures after insertion and prior to removal, post-interventional management, documentation, number of chest tubes after anatomical lung resection, use of fibrinolytic agents, type of negative pressure. No consensus was reached for the following topics: autologous blood pleurodesis, reduction of suction in cases of persistent air leakage. CONCLUSION: Our manuscript depicts the results of a Delphi process in 2017 - 1018 involving experts of the German Thoracic Society from high volume departments certified for thoracic surgery. A very high rate of consensus was documented for topics such as chest tube insertion, peri-interventional management and removal algorithm. The most important topic for which there was no consensus was the case of persistent air leakage. The resulting expert recommendations of the Delphi process could be used as a starting point for internal clinical procedures.

Predictors of Outcome in Modern Surgery for Lung Abscess.

Background Surgery for lung abscess is a challenging task. Timing and indications for surgery are not well established. Identification of predictors of outcome could help to clarify the role of surgery. Methods Patients who underwent major thoracic surgery for infectious lung abscess were identified at six centers for general thoracic surgery in Germany, Spain, the United Kingdom, and the United States. Study period was 2000 to 2016. Results There were 91 patients. Pulmonary sepsis (48), pleural empyema (43), persistent air leakage (25), acute renal failure (12), and respiratory failure with mechanical ventilation (25) were already preoperatively present. The mean Charlson index of comorbidity was 3.0 (median: 2.0; interquartile range: 3). Procedures were segmentectomy (18), lobectomy (58), and pneumonectomy (15). The 30-day mortality following surgery was 13/91.Preoperative sepsis (odds ratio [OR]: 13.69; 95% confidence interval [CI]: 1.86-610.53; p < 0.01), preoperative persistent air leak (OR: 13.46, 95% CI: 3.00-85.37, p < 0.01), respiratory failure (OR: 5.60; 95% CI: 1.41-24.84; p < 0.01), acute renal failure (OR: 6.15 ; 95% CI: 1.24-29.56 ; p = 0.01), and Charlson index of comorbidity ≥ 3 (OR: 7.19 ; 95% CI: 1.43-71.21 ; p < 0.01) are associated with higher mortality, whereas age > 70 years (p = 0.46) and the extent of pulmonary resection (segmentectomy, lobectomy, pneumonectomy) have no significant influence on mortality. Patients with fatal outcome have significantly higher Charlson index of comorbidity (p < 0.01). Conclusions Delayed referral for surgery is common. Significant predictors for fatal outcome are pulmonary sepsis, septic complications (air leak, pleural empyema), septic organ failure (respiratory, acute renal failure), and preexisting comorbidity (Charlson index of comorbidity ≥ 3). The extent of surgical resection shows no significant influence.

Surgery for parapneumonic pleural empyema--What influence does the rising prevalence of multimorbidity and advanced age has on the current outcome?

OBJECTIVE: Pleural empyema is a critical condition. In the western world the share of sufferers with multiple comorbidities and advanced age is rapidly increasing. METHODS: This retrospective study comprises all patients who underwent surgery for parapneumonic pleural empyema at a major center for thoracic surgery in Germany between January 2006 and April 2013. RESULTS: A total of 335 patients (mean age 60.4 years) were included. The average ASA grade was 2.8. Empyema stage 1, 2 and 3 (classification of the American Thoracic Society) was encountered in 30, 230 and 75 cases, respectively. The most common comorbidities were cardiac disorders (124), diabetes mellitus (76), COPD (66) and alcoholism (54). The mean Charlson index of comorbidity score was 2. Minimally invasive surgery was feasible in 290 cases. A total of 88 patients sustained pulmonary sepsis. The overall mortality was 29/335 (8.7%). The occurrence of pulmonary sepsis (OR: 17.95; 95% CI: 6.38-62.69; p < 0.001), respiratory failure (OR: 23.08; 95% CI: 8.52-73.35; p < 0.001) and acute renal failure (OR: 8.20; 95% CI: 3.18-20.80; p < 0.001) and Charlson score ≥ 3 (OR: 6.65; 95% CI: 2.76-17.33; p < 0.001) were associated with higher mortality. On the other hand, very elderly sufferers (≥80 years) showed neither higher odds for pulmonary sepsis (OR: 0.78) nor for fatal outcome (OR: 0.92; 95% CI: 0.22-2.86; p = 1). CONCLUSIONS: Parapneumonic pleural empyema is still associated with considerable morbidity and mortality. Pre-existing comorbidity, the occurrence of pulmonary sepsis and sepsis related complications have a determining influence on the results whereas advanced age itself shows no higher risk for adverse outcome. Further improvement seems achievable by earlier surgical intervention before the onset of pulmonary sepsis.

Case of functional paraganglioma with intraoperative hypertensive crisis during robot-assisted thoracoscopic resection.

BACKGROUND: Mediastinal paragangliomas are rare. Their dangerousness may unfold during surgery, especially if hormonal activity was previously unknown. We report our experience with this case in context to the incidence and localization of atypically located mediastinal paragangliomas in the literature. CASE PRESENTATION: A 69-year-old female patient who was scheduled for thoracoscopic resection due to a posterior mediastinal tumor that had been progressing in size for several years and increasing symptoms. The induction of anesthesia, the ventilation of the lungs and the gas exchange after lung separation was uneventful. After initially stable circulatory conditions, there was a sudden increase in blood pressure up to 300/130 mmHg and tachycardia up to 130/min. This hypertensive phase was difficult to influence and required a rapid and consistent use of antihypertensive medication to bring down the blood pressure to reasonable values. The patient stabilized after tumor resection. The postoperative course was unremarkable. During the intraoperative blood pressure crisis, blood was drawn for analysis. These samples showed elevated concentrations of normetanephrine and metanephrine. The tumor subsequently presented as a catecholamine-secreting paraganglioma. CONCLUSION: In order to avoid life-threatening blood pressure crises, hormone activity should be ruled out preoperatively in the case of mediastinal tumor, in which a paraganglioma could be considered in the differential diagnosis, especially if there are indications of hypertension in the medical history. Robotic-assisted thoracoscopic resection of the posterior mediastinal tumor was a feasible surgical method, even in the case of unexpected functional paraganglioma.

Comparative effects of variable versus conventional volume-controlled one-lung ventilation on gas exchange and respiratory system mechanics in thoracic surgery patients: A randomized controlled clinical trial.

BACKGROUND: Mechanical ventilation with variable tidal volumes (V-VCV) has the potential to improve lung function during general anesthesia. We tested the hypothesis that V-VCV compared to conventional volume-controlled ventilation (C-VCV) would improve intraoperative arterial oxygenation and respiratory system mechanics in patients undergoing thoracic surgery under one-lung ventilation (OLV). METHODS: Patients were randomized to V-VCV (n = 39) or C-VCV (n = 39). During OLV tidal volume of 5 mL/kg predicted body weight (PBW) was used. Both groups were ventilated with a positive end-expiratory pressure (PEEP) of 5 cm H2O, inspiration to expiration ratio (I:E) of 1:1 (during OLV) and 1:2 during two-lung ventilation, the respiratory rate (RR) titrated to arterial pH, inspiratory peak-pressure ≤ 40 cm H2O and an inspiratory oxygen fraction of 1.0. RESULTS: Seventy-five out of 78 Patients completed the trial and were analyzed (dropouts were excluded). The partial pressure of arterial oxygen (PaO2) 20 min after the start of OLV did not differ among groups (V-VCV: 25.8 ± 14.6 kPa vs C-VCV: 27.2 ± 15.3 kPa; mean difference [95% CI]: 1.3 [-8.2, 5.5], P = 0.700). Furthermore, intraoperative gas exchange, intraoperative adverse events, need for rescue maneuvers due to desaturation and hypercapnia, incidence of postoperative pulmonary and extra-pulmonary complications, and hospital free days at day 30 after surgery did not differ between groups. CONCLUSIONS: In thoracic surgery patients under OLV, V-VCV did not improve oxygenation or respiratory system mechanics compared to C-VCV. Ethical Committee: EK 420092019. TRIAL REGISTRATION: at the German Clinical Trials Register: DRKS00022202 (16.06.2020).

Surgical therapy for necrotizing pneumonia and lung gangrene.

OBJECTIVE: Necrotizing pneumonia, pulmonary abscess, and lung gangrene are rare complications of severe pulmonary infection with devitalization and sloughing of lung tissue. Pulmonary necrosis is often associated with alcoholism and other chronic disorders with known immunodeficiency. Mortality is significant and both treatment strategies as well as the role of surgery are controversially debated. METHODS: In a retrospective review at a German tertiary referral hospital, 20 patients with pulmonary resection for necrotizing lung disorders were identified since 2008. At hospital admission, all patients suffered from pulmonary sepsis and despite adequate medical treatment progressing parenchymal destruction and devitalization took place. The majority of the patients sustained pleural empyema (13/20) and five patients a persisting air leak. On account of failing medical therapy, eight patients (40%) developed severe sepsis with septic shock and four patients (20%) were already preoperatively ventilated. Chronic alcoholism was present in 10 patients (50%). RESULTS: Gangrene of a complete lung was seen in four cases. Lobar gangrene or necrotizing pneumonia complicated by fulminate abscess was seen in the right lower lobe (8/20), middle lobe (4/20), right upper lobe (2/20), and left lower lobe (2/20). Procedures included pneumectomy (4/20), lobectomy (13/20), and limited resection (3/20). The bronchial stump was reinforced with a pedicle muscle flap in seven cases. There were three postoperative deaths due to septic shock with multiorgan failure. The remaining 17 patients (85%) recovered well and were transferred to rehabilitation clinics specialized on pulmonary disorders. CONCLUSION: Necrotizing pulmonary infections are infrequent but are life-threatening disease entities. Patients often present with severe comorbidity and chronic disorders causing immunodeficiency. If initial medical therapy fails surgery offers a reasonable therapeutic approach. Aim of surgical therapy is resection of all gangrenous lung parenchyma and effective drainage of pleural empyema. Then recovery is feasible in up to 80%.

Pancreaticopleural fistula-induced empyema thoracis: principles and results of surgical management.

OBJECTIVE: Pancreaticopleural fistula is a very uncommon complication of pancreatitis resulting from pancreatic duct disruption with leakage of pancreatic secretions into the pleural cavity. Fistulization occurs either through the esophageal hiatus or straight through the diaphragm. Pleural effusion with dyspnea is the main presenting symptom, and delayed diagnosis is frequent. Initial conservative treatment fails in a significant number of cases. Ascending infection via the fistulous tract results in empyema and life-threatening sepsis. METHODS: All patients who underwent surgery for pancreaticopleural fistula-induced empyema thoracis at a tertiary referral hospital from 2008 to 2011 were included in a retrospective case study. RESULTS: Altogether six patients with pancreaticopleural fistula and associated pleural empyema were identified. All patients suffered from pancreatitis and received initial medical and endoscopic treatment. Despite all nonsurgical treatment efforts, superinfection led to left-sided pleural empyema in four and bilateral empyema in two cases. The contagious spread took place through the fistulous tract connecting the pancreatic duct with the pleural cavity. The patients were referred for surgery with considerable delay and already advanced pleural empyema. Minimally invasive thoracic surgery with pleural debridement was performed in all cases. Furthermore, left pancreatic resection was mandatory in five cases and cystostomy in one case. All patients recovered well and upon follow-up there were no further complications. CONCLUSION: Surgical management combining minimally invasive thoracic surgery and removal of the fistulous tract is highly effective. If initial medical treatment fails, surgery should be considered early to prevent severe sepsis. Further improvement seems achievable by reducing the time between fruitless conservative efforts and surgical intervention.

Aspiration of a Blister Pack Tablet with Tracheal Obstruction and Perforation: Emergency Tracheal Repair with Extracorporeal Membrane Oxygenation Support.

Background Airway management in case of acute tracheal injury is a challenging situation where the use of Extracorporeal Membrane Oxygenation (ECMO) has recently gained more importance. Case Description We report the case of a 60-year old women with aspiration of a large blister pack tablet causing acute tracheal obstruction with asphyxia as well as tracheal perforation with tension pneumothorax. As bronchoscopy failed to retrieve the blister pack, emergency tracheal reconstruction with Extracorporeal Membrane Oxygenation (ECMO) support was carried out. Conclusion The application of ECMO instantly alleviated the acute situation and provided excellent conditions for technically demanding emergency tracheal repair.

Video-assisted thoracoscopic surgery for posttraumatic hemothorax in the very elderly.

OBJECTIVE: Thoracic injury is a life-threatening condition with advanced age being an independent risk factor for both higher morbidity and mortality. Furthermore, elderly patients often have severe comorbidity and in case of chest trauma with rib fractures and hemothorax, their clinical condition is likely to deteriorate fast. Aim of this study is to investigate the feasibility and results of video-assisted thoracoscopy for the treatment of posttraumatic hemothorax in very elderly patients of 80 years or more. METHODS: The outcomes of 60 consecutive patients who received video-assisted thoracoscopic surgery for posttraumatic hemothorax in a German tertiary referral hospital between 2006 and 2010 were reviewed in a retrospective case study. Patients older than 80 years were identified. RESULTS: There were 39 male and 21 female patients. The median age was 63.2 years. The in-hospital-mortality was 1.7% (1/60). Fifteen of the 60 patients were 80 years or older (80-91). Main reason for hemothorax was blunt chest trauma. Altogether 23 patients had fractures of three or more ribs including six octogenarians. Elderly patients suffered from preexisting cardiopulmonary disease and were often referred to the thoracic surgeon with considerable delay. Video-assisted thoracoscopic surgery was feasible and all octogenarian patients finally recovered well without in-hospital-mortality. CONCLUSIONS: Video-assisted thoracoscopic surgery for treatment of posttraumatic hemothorax shows excellent results in very elderly patients of 80 years or more. Despite severe comorbidity and often delayed surgery all patients recovered. We therefore conclude that advanced age is no contraindication for surgical management of posttraumatic hemothorax by means of video-assisted thoracoscopy.

Management of ERCP-related small bowel perforations: the pivotal role of physical investigation.

BACKGROUND: Management of endoscopic retrograde cholangiopancreatography (ERCP)-associated duodenal perforation remains controversial. Some recommend surgery, while others recommend conservative treatment. METHODS: A retrospective chart review was conducted to identify patients treated at our institution for ERCP-related duodenal perforations. Study variables included indication for ERCP, clinical presentation, diagnostic procedures, time to diagnosis and treatment, location of injury, management, length of stay in hospital and survival. RESULTS: Between January 2000 and October 2009, 12 232 ERCP procedures were performed at our centre, and perforation occured in 11 patients (0.08%; 5 men, 6 women, mean age 71 yr). Six of the perforations were discovered during ERCP; 5 required radiologic imaging for diagnosis. Three perforations were diagnosed incidentally by follow-up ERCP. In 1 patient, perforation occurred 3 years after the procedure owing to a dislocated stent. Four of 11 perforations were stent-related; in 2 patients ERCP was performed in a nonanatomic situation (Billroth II gastroenterostomy). Free peritoneal perforation occurred in 4 patients; 1 was successfully managed conservatively. Four patients (36%) were treated surgically and none died. Five patients were managed conservatively with a successful outcome, and 2 patients died after conservative treatment (18%). Operative treatment included hepaticojejunostomy and duodenostomy (1 patient), suture of the perforation with T-drain (1 patient) and suture only (2 patients). The mean length of stay in hospital for all patients was 20 days. CONCLUSION: Post-ERCP duodenal perforations are associated with significant morbidity and mortality. Immediate surgical evaluation and close monitoring is needed. Management should be individually tailored based on clinical findings only.

Extrapleural Pneumonectomy for Sarcoma of the Lung in a Pediatric Patient.

Pediatric sarcomas are rare entities. Bone sarcomas and rhabdomyosarcoma are most common, whereas primary sarcoma of the lung is extremely uncommon. Pneumonectomy is only very infrequently performed in the pediatric population. We report on a 16-year-old girl with an undifferentiated high-grade pleomorphic sarcoma of the left lung. There was no comorbidity and no history of previous malignant disease. The huge tumor originated from the left lower lobe and had spread to the left pleura. As part of a multimodal approach, she underwent extrapleural pneumonectomy with en bloc resection of the pleura, lung, pericardium, and diaphragm.

Use of extracorporeal membrane oxygenation in non-elective major thoracic surgery for infectious lung abscess.

OBJECTIVES: Extracorporeal membrane oxygenation (ECMO) support for elective cardiothoracic surgery is well established. In contrast, there are not much data regarding the usefulness and outcome of ECMO in non-elective major lung resections for infectious lung abscess. METHODS: All patients undergoing non-elective major lung surgery for infectious lung abscess at 5 centres in Germany, UK and Spain were enrolled in a prospective database. Malignant disorders and intrathoracic complications of other procedures were excluded. RESULTS: There were 127 patients. The median age was 59 years (interquartile range 18.75). The mean Charlson index of comorbidity was 2.83 (standard deviation 2.57). Surgical procedures were lobectomy (89), pneumectomy (20) and segmentectomy (18). ECMO was used for 10 patients (pneumectomy 2, lobectomy 8) and several more received pre-ECMO treatment. Mortality was 17/127. Intraoperatively no ECMO-associated complications were encountered. EMCO [1/10 vs 16/117; odds ratio (OR): 0.70, 95% confidence interval (CI) 0.08-5.91, P = 0.74] and the extent of pulmonary resection were not associated with higher mortality. Preoperative sepsis (OR: 17.84, 95% CI 2.29-139.28, P < 0.01), preoperative air leak (OR: 13.12, 95% CI 4.10-42.07, P < 0.001), acute renal failure (OR: 7.00, 95% CI 2.19-22.43, P < 0.01) and Charlson index of comorbidity ≥3 (OR: 10.83, 95% CI 2.36-49.71, P < 0.01) were associated with significantly higher mortality. CONCLUSIONS: The application of ECMO is widening the possibilities for successful surgical management of infectious, non-malignant lung abscesses. Particularly, patients with marginal functional operability benefit from the availability and readiness to use ECMO. Mortality is determined by the burden of pre-existent comorbidity, severe sepsis and septic shock.

Endovascular stent--graft repair of a symptomatic superior mesenteric artery aneurysm.

BACKGROUND: Aneurysms of the visceral branches of the abdominal aorta are uncommon and potential life-threatening entities. Although hepatic and splenic artery aneurysms have the highest prevalence among splanchnic aneurysms, superior mesenteric artery aneurysms are even more uncommon. For ruptured visceral arteries aneurysms, a mortality rate of between 20% and 100% has been reported. Besides rupture, the aneurysms can also erode into adjacent visceral organs, which results in severe hemorrhage. Emergency surgery of visceral artery aneurysms is related with significant mortality. In recent years, endovascular therapies have been successfully established in the elective setting. Therefore, we adopted the endovascular stent-graft insertion technique for dealing with an acute symptomatic aneurysm of the superior mesenteric artery. METHOD: We report the case of a 79-year-old male patient with a symptomatic aneurysm of the proximal superior mesenteric artery. Using an endovascular approach, the aneurysm was excluded with an endoluminal stent--graft. RESULT: The endoluminal stent--graft repair resulted in total exclusion of the aneurysm. Patency of the superior mesenteric artery continued and no ischemic complications occurred. Pain and other symptoms disappeared and the patient recovered entirely. CONCLUSIONS: Endovascular management of symptomatic superior mesenteric artery aneurysm is feasible and may display excellent results in selected cases. Therefore, endoluminal stent--graft repair should be considered as an alternative to traditional surgical treatment. However, in each patient, the individual anatomy of the mesenteric circulation and the location of the aneurysm play a major role in determining whether endovascular management is possible or surgical repair should be preferred.

Traumatic oesophageal perforation: a successful management based on the Pittsburgh Perforation Severity Score.

Oesophageal perforation is a severe life-threatening clinical condition with high mortality and morbidity needing rapid interdisciplinary approach to be effectively managed. Recently, on the basis of multicentric retrospective data, we proposed a decision tree for the treatment of oesophageal perforations based on the Pittsburgh Perforation Severity Score (PSS). We now report the first case of a traumatic oesophageal perforation, which was successfully treated according to the application of the PSS decision tree.

Life-threatening pulmonary haemorrhage during cryoballoon ablation for atrial fibrillation.

Cryoballoon ablation is a recently introduced treatment option for patients with symptomatic, drug-refractory atrial fibrillation. The rate of complications is low and comprises mainly vascular-access-site complications and phrenic nerve palsy. We report a case of life-threatening pulmonary haemorrhage occurring during the procedure.

Spotlight on esophageal perforation: A multinational study using the Pittsburgh esophageal perforation severity scoring system.

OBJECTIVE: The Pittsburgh group has suggested a perforation severity score (PSS) for better decision making in the management of esophageal perforation. Our study aim was to determine whether the PSS can be used to stratify patients with esophageal perforation into distinct subgroups with differential outcomes in an independent study population. METHODS: In a retrospective study cases of esophageal perforation were collected (study-period, 1990-2014). The PSS was analyzed using logistic regression as a continuous variable and stratified into low, intermediate, and high score groups. RESULTS: Data for 288 patients (mean age, 59.9 years) presenting with esophageal perforation (during the period 1990-2014) were abstracted. Etiology was spontaneous (Boerhaave; n = 119), iatrogenic (instrumentation; n = 85), and traumatic perforation (n = 84). Forty-three patients had coexisting esophageal cancer. The mean PSS was 5.82, and was significantly higher in patients with fatal outcome (n = 57; 19.8%; mean PSS, 9.79 vs 4.84; P < .001). Mean PSS was also significantly higher in patients receiving operative management (n = 200; 69%; mean PSS, 6.44 vs 4.40; P < .001). Using the Pittsburgh strata, patients were assigned to low PSS (≤2; n = 63), intermediate PSS (3-5; n = 86), and high PSS (>5; n = 120) groups. Perforation-related morbidity, length of stay, frequency of operative treatment, and mortality increased with increasing PSS strata. Patients with high PSS were 3.37 times more likely to have operative management compared with low PSS. CONCLUSIONS: The Pittsburgh PSS reliably reflects the seriousness of esophageal perforation and stratifies patients into low-, intermediate-, and high-risk groups with differential morbidity and mortality outcomes.

Predictors of Lymph Node Metastasis in Surgically Resected T1 Esophageal Cancer.

BACKGROUND: The application of endoscopic therapies for early cancers of the esophagus is limited by the possible presence of regional lymph node metastases. Our objective was to determine the prevalence and predictors of lymph node metastases in patients with pT1 carcinoma of the esophagus and the gastric cardia. METHODS: The National Cancer Institute's Surveillance Epidemiology and End Results Database (2004 to 2010) was used to identify all patients with pT1 carcinomas who underwent primary surgical resection for squamous cell carcinoma (SCC) or adenocarcinoma (EAC) of the esophagus and of the esophagogastric junction (AEG). Prevalence of lymph node metastases was assessed, and survival in all types of cancer was calculated. Multivariate logistic regression was used to identify factors predicting positive lymph node status. RESULTS: There were 1,225 patients (84% male), with a mean age of 64 ± 10 years, and 90% were white. Intramucosal disease was present in 44% of patients, and submucosal invasion (T1b) was present in 692 (56%). Prevalence of lymph node metastases in EAC, SCC, and AEG was 6.4%, 6.9%, and 9.5% for pT1a tumors and 19.6%, 20%, and 22.9% for pT1b tumors, respectively. In patients with more than 23 lymph nodes removed during resection, prevalence of lymph node metastases in EAC, SCC, and AEG was 8.1%, 25%, and 7.4% for pT1a tumors and 27.8%, 33.3%, and 22% for pT1b tumors, respectively. Positive lymph node status was associated with worse overall 5-year survival in EAC (N0 vs N+: 78% vs 52%) and AEG (N0 vs N+: 83% vs 44%) but did not have a significant effect on the long-term survival of patients with SCC. Infiltration of the submucosa, tumor size exceeding 10 mm, and poor tumor differentiation were independently associated with the risk of nodal disease. Prevalence of lymph node metastasis negative for these three risk factors was only 4.8%. CONCLUSIONS: Prevalence of lymph node metastasis in early esophageal cancer is high in patients with T1 cancer. Inadequate lymphadenectomy underestimates lymph node status. Endoscopic treatment can be considered only in a select group of patients with early esophageal cancer.

Investigation of pulmonary function among employees exposed to low levels of monomeric isocyanates and solvents at an automobile finishings plant.

There have been reports in the literature of decrements in pulmonary function associated with long-term, low-level monomeric isocyanate exposure combined with solvent exposure. This cross-sectional study examines the relationship between these exposures and pulmonary function in an automobile paint and coating (finishes) plant. A job exposure matrix was developed for isocyanate and solvent exposure; years in a work task were used as a surrogate for exposure. Recent pulmonary function tests were used as the outcome variables; specifically the difference between predicted and actual FEV1 and FVC. The results of the analysis demonstrated no statistically significant relationship between combined isocyanate and solvent exposure and decline in pulmonary function. There was a statistically significant negative correlation between solvent exposure and FEV1 and FVC.