Community-Based Multidisciplinary Computed Tomography Screening Program Improves Lung Cancer Survival.

BACKGROUND: Lung cancer is the most common cause of cancer deaths in the United States. Overall survival is less than 20%, with the majority of patients presenting with advanced disease. The National Lung Screening Trial, performed mainly in academic medical centers, showed that cancer mortality can be reduced with computed tomography (CT) screening compared with chest radiography in high-risk patients. To determine whether this survival advantage can be duplicated in a community-based multidisciplinary thoracic oncology program, we initiated a CT scan screening program for lung cancer within an established health care system. METHODS: In 2008, we launched a lung cancer CT screening program within the WellStar Health System (WHS) consisting of five hospitals, three health parks, 140 outpatient medical offices, and 12 imaging centers that provide care in a five-county area of approximately 1.4 million people in Metro-Atlanta. Screening criteria incorporated were the International Early Lung Cancer Action Program (2008 to 2010) and National Comprehensive Cancer Network guidelines (2011 to 2013) for moderate- and high-risk patients. RESULTS: A total of 1,267 persons underwent CT lung cancer screening in WHS from 2008 through 2013; 53% were men, 87% were 50 years of age or older, and 83% were current or former smokers. Noncalcified indeterminate pulmonary nodules were found in 518 patients (41%). Thirty-six patients (2.8%) underwent a diagnostic procedure for positive findings on their CT scan; 30 proved to have cancer, 28 (2.2%) primary lung cancer and 2 metastatic cancer, and 6 had benign disease. Fourteen patients (50%) had their lung cancer discovered on their initial CT scan, 11 on subsequent scans associated with indeterminate pulmonary nodules growth and 3 patients who had a new indeterminate pulmonary nodules. Only 15 (54%) of these 28 patients would have qualified as a National Lung Screening Trial high-risk patient; 75% had stage I or II disease. Overall 5-year survival was 64% and 5-year cancer specific survival was 71% in the screened patients, whereas nonscreened lung cancer patients during that time in WHS had an overall survival of only 19% (p < 0.001). CONCLUSIONS: A community-based multidisciplinary lung cancer screening program can improve survival of patients with lung cancer outside of a large multicenter study. This survival advantage was caused by a significant stage shift to earlier disease. Lung cancer CT screening may also benefit patients not meeting the National Lung Screening Trial criteria who are at moderate or high risk for lung cancer.

Intrapyloric botulinum injection increases postoperative esophagectomy complications.

BACKGROUND: Intrapyloric botulinum toxin injection has emerged as a possible alternative to standard pyloric drainage procedures. Possible advantages include decreased operative time and less postoperative dumping and bile reflux symptoms. However, data are lacking to show its effectiveness versus standard drainage procedures. The purpose of this review is to compare the results in a prospective cohort of patients who received pyloric botulinum injection versus patients who received pyloromyotomy or pyloroplasty with esophagectomy. METHODS: We performed a retrospective review of a prospective database of all patients who underwent an open esophageal resection at a single institution from 2005 through 2010. Three hundred twenty-two patients were divided into 3 groups for analysis: botulinum injection (n = 78), pyloromyotomy (n = 45), and pyloroplasty (n = 199). We compared these groups with respect to duration of the procedure, presence of delayed gastric emptying on postoperative swallow studies, requirement of anastomotic dilation, requirement of pyloric dilation, use of postoperative promotility agents, and patient experience of postoperative symptoms of reflux or dumping, or both. RESULTS: Patients receiving botulinum injections experienced similar delayed gastric emptying on postoperative radiologic evaluation as did patients undergoing pyloromyotomy and pyloroplasty (16% versus 5% and 13%, respectively; p = 0.14). Mean operative time was significantly shorter for the patients receiving botulinum as expected (239 minutes versus 312 minutes and 373 minutes, respectively; p < 0.001). However, more patients receiving botulinum and pyloric dilation (22% versus 4% and 2%, respectively; p < 0.001) experienced postoperative reflux symptoms (32% versus 12% and 13%, respectively; p = 0.001) and used postoperative promotility agents (22% versus 5% and 15%, respectively; p = 0.04). There was no statistical difference between the groups regarding postoperative dumping. CONCLUSIONS: Use of intrapyloric botulinum injection significantly decreased operative time. However, the patients receiving botulinum experienced more postoperative reflux symptoms, had increased use of promotility agents as well as a requirement for postoperative endoscopic interventions, and postoperative dumping was not reduced by the reversible procedure. Intrapyloric botulinum injection should not be used as an alternative to standard drainage procedures. Pyloromyotomy appears to be the drainage procedure of choice to accompany an esophagectomy.

Surgery for recurrent pectus deformities.

BACKGROUND: Pectus repair in adults can be challenging. Standard repair has been the modified Ravitch procedure. More recently the minimally invasive Nuss procedure, used exclusively in children, has been introduced for correction of pectus deformities in adults. There is a paucity of data on which procedure is most appropriate for adults and even less information on the most appropriate operation for pectus recurrence in adults. The purpose of this study is to determine if any specific patient characteristic exists that places patients at an increased risk for recurrence and describe our management of recurrent pectus defects in adults. METHODS: We retrospectively reviewed the records of all patients (>16 years of age) who underwent primary or recurrent repair of pectus deformities from April 1999 through December 2006. RESULTS: Forty-eight patients, 37 (77%) men and 11 women, underwent pectus repair with a median age of 28 years (range, 16 to 54 years). Indication for initial repair was pectus excavatum in 39 (81%) and pectus carinatum in 9. The primary procedure was a modified Ravitch repair in 40 patients and a Nuss procedure in 8. Thirteen patients (27%) underwent reoperation for recurrence; 8 (62%) patients had undergone a previous Nuss procedure and 5 had a modified Ravitch repair. All reoperative patients had a primary pectus index (PI) greater than 4.0, while 8 (62%) also had an asymmetrical defect. All failed Nuss procedure patients underwent a modified Ravitch repair for correction, while the recurrent open repair patients required complex reconstructions. Results were good or excellent in greater than 90% of patients undergoing a reoperative procedure. CONCLUSIONS: Adults with severe pectus deformities (PI > 4.0) and asymmetric defects are at a greater risk of recurrence after a Nuss procedure. These patients may better be served with a modified Ravitch repair initially. Reoperation for failed pectus repair in adults can be performed safely with outstanding results.

Neoadjuvant chemoradiation versus chemotherapy for patients undergoing esophagectomy for esophageal cancer.

BACKGROUND: Neoadjuvant chemoradiation followed by esophagectomy is currently the standard of care for locally advanced esophageal cancer. This intense preoperative regimen delays definitive resection and increases perioperative risks. With the improvement of chemotherapy agents, chemotherapy alone may be better suited for patients awaiting esophagectomy because of shorter preoperative treatment time and less associated perioperative complications. No recent study has compared chemoradiation to chemotherapy alone before esophageal resection with respect to operative morbidity and mortality and overall survival. METHODS: A retrospective review was performed of all patients (281) who underwent an esophagectomy for cancer at our institution from July 1995 through June 2005; 122 patients (43%) had neoadjuvant treatment and form the basis of this study. RESULTS: Preoperative chemoradiation (CR) was administered in 64 patients and chemotherapy only (CO) in 58 patients. Operative mortality was 6% (4 patients) in the CR group and 0% in the CO group (p = 0.12). Overall postoperative complications rate was 48% in CR patients and 33% in CO patients (p = 0.09). Complete pathologic response occurred in 11 CR patients (17%) and in 2 CO patients (4%; p = 0.02). There was no difference in recurrences between the two groups (p = 0.43). Median survival was 17 months in the CR patients and 21 months in the CO patients (p = 0.14). One-, 3-, and 5-year survivals were 76%, 46%, and 41%, respectively, in the CR patients and 70%, 40%, and 31%, respectively, in the CO patients (p = 0.31). CONCLUSIONS: Although neoadjuvant chemoradiation resulted in a significantly better complete pathologic response rate when compared with chemotherapy alone, that did not translate into a long-term survival advantage. Chemotherapy alone may be the preferred neoadjuvant modality to expedite resection, decrease operative mortality and postoperative complications, and improve survival in patients with locally advanced esophageal cancer.

Gastric rupture associated with diaphragmatic hernia during pregnancy.

Diaphragmatic hernia complicating pregnancy rarely occurs, but it is frequently misdiagnosed. A strangulated diaphragmatic hernia in a pregnant patient presents a true surgical emergency, and delay in operative intervention can result in fetal and maternal mortality in as many as 50% of cases. We describe a case report of a pregnant patient and her fetus surviving after a spontaneous gastric rupture from a strangulated diaphragmatic hernia.