Lack of Lymphocyte Recovery After Esophagectomy Predicts Overall and Recurrence-Free Survival.

BACKGROUND: Lymphocytes have become the target of cancer interventions through engineering or immune checkpoint antibodies. We previously found decreased lymphocyte counts to be a predictor of mortality and complications in trauma and cardiac surgery patients. We hypothesized lack of lymphocyte count recovery postoperatively would predict outcomes in esophagectomy patients. METHODS: A retrospective review of all patients undergoing esophagectomy for adenocarcinoma performed over 13 y at our center by a single surgeon after institutional review board approval was performed. Patients were grouped by postoperative lymphocytes counts: never low, low with recovery, and low without recovery. Resolution of lymphopenia was assessed by day 4. Primary end points were overall and recurrence-free survival. RESULTS: In total, 198 patients were included with a minimum 6-mo follow-up. Collectively the 5-y recurrence and overall survival rates were 36% and 50%, respectively. Recurrence was significantly higher at 5 y in patients with persistent lymphopenia (43%) compared with those who recovered (14% P = 0.0017) and those who never dropped (0% P = 0.0009). The persistent lymphopenia group had significantly lower survival (45%) compared with the two other groups (67% P = 0.0232). CONCLUSIONS: There is a significant decrease in the overall and recurrence-free survival in those patients whose lymphocyte count drops without recovery after their esophagectomy. These data imply differences in immune responses to the stress of surgery that can be measured with routine postoperative laboratory values and are indicative of overall outcomes.

Performance of the transoral circular stapler for oesophagogastrectomy after induction therapy.

OBJECTIVES: Patients undergoing oesophageal anastomosis may be at an increased risk for leak after induction therapy for oesophageal cancer, with intrathoracic leaks having significant morbidity. The outcomes of utilizing transoral circular stapler for the creation of a thoracic anastomosis have not been well studied in this patient population. METHODS: Patients with oesophageal cancer undergoing induction chemotherapy/radiation followed by Ivor Lewis oesophagogastrectomy were evaluated. All thoracic anastomoses were constructed with transoral circular stapler. Primary outcomes evaluated were the rates of anastomotic leak and stricture. RESULTS: Over 7 years, 87 consecutive patients were evaluated, among whom 69 (79%) were male. The median age was 63 years, median body mass index (BMI) was 27 kg/m2 and median age-adjusted comorbidity index was 5. Median operative blood loss was 400 ml and median operative time was 300 min. Major complications (grade ≥3) were seen in 19 (22%), including anastomotic leak in 2 (2.3%), both successfully treated with temporary covered metal stent. The median duration of hospital stay was 10 days, and 1 (1.2%) death was reported at 90 days due to cancer recurrence. Stricture occurred in 8 (9.2%), and median time to dilation was 109 days and median number of dilations was 1. Univariable analysis found BMI to be significantly higher in patients with an anastomotic leak versus those without (43 vs 27 kg/m2, P = 0.002). No variables were found to be predictive of anastomotic stricture. CONCLUSIONS: The use of the transoral circular stapler for thoracic anastomosis results in a consistent formation of the anastomosis, with low leak and stricture rates in the setting of induction chemotherapy/radiation. Leaks that do occur appear to be amenable to stent therapy.

Atrio-oesophageal fistula after the cryomaze procedure.

We report a case of an atrio-oesophageal fistula after biatrial cryomaze ablation for atrial fibrillation, a complication that has not yet been described in the literature for the cryomaze method. Our report also serves as a reminder of this rare but lethal complication- that it can occur after any method of ablation for atrial fibrillation and a high index of suspicion for its diagnosis must be maintained to allow for early surgical treatment which offers the best chance of survival.

Risk factors for reinsertion of urinary catheter after early removal in thoracic surgical patients.

OBJECTIVES: To reduce the incidence of urinary tract infection, Surgical Care Improvement Project 9 mandates the removal of urinary catheters within 48 hours postoperatively. In patients with thoracic epidural anesthesia, we sought to determine the rate of catheter reinsertion, the complications of reinsertion, and the factors associated with reinsertion. METHODS: We conducted a prospective observational study of consecutive patients undergoing major pulmonary or esophageal resection with thoracic epidural analgesia over a 2-year period. As per Surgical Care Improvement Project 9, all urinary catheters were removed within 48 hours postoperatively. Excluded were patients with chronic indwelling catheter, patients with urostomy, and patients requiring continued strict urine output monitoring. Multivariable logistic regression analysis was used to identify independent risk factors for urinary catheter reinsertion. RESULTS: Thirteen patients met exclusion criteria. Of the 275 patients evaluated, 60 (21.8%) required reinsertion of urinary catheter. There was no difference in the urinary tract infection rate between patients requiring reinsertion (1/60 [1.7%]) versus patients not requiring reinsertion (1/215 [0.5%], P = .389). Urethral trauma during reinsertion was seen in 1 of 60 patients (1.7%). After reinsertion, discharge with urinary catheter was required in 4 of 60 patients (6.7%). Multivariable logistic regression analysis found esophagectomy, lower body mass index, and benign prostatic hypertrophy to be independent risk factors associated with catheter reinsertion after early removal in the presence of thoracic epidural analgesia. CONCLUSIONS: When applying Surgical Care Improvement Project 9 to patients undergoing thoracic procedures with thoracic epidural analgesia, consideration to delayed removal of urinary catheter may be warranted in patients with multiple risk factors for reinsertion.

Lobectomy for Lung Cancer at Veterans Administration Medical Center Versus Academic Medical Center.

BACKGROUND: Hospital and surgeon volume each have an association with postoperative outcomes. The volume of lung cancer surgery at our Veterans Administration Medical Center (VAMC) is lower than at our academic medical center (AMC). We compared the outcomes after lobectomy at VAMC versus AMC to identify specific areas of clinical care requiring quality improvement. METHODS: To keep surgeon experience constant, data were derived from a prospective database from a single surgeon. Included were all male patients undergoing lobectomy for non-small cell lung cancer. Postoperative morbidity, mortality, and overall survival were compared after propensity score matching. RESULTS: From 2004 to 2013, 419 patients were evaluated (338 AMC, 81 VAMC). Outcomes comparison after propensity score matching of 81 AMC patients with 81 VAMC patients found a higher rate of major complications (12% versus 27%, p = 0.02) and longer hospital stay (median 6.0 versus 7.5 days, p < 0.001) for VAMC, but no difference in 90-day mortality (AMC 5% versus VAMC 6%, p > 0.99). Pneumonia was the specific complication found to be higher at VAMC (11% versus AMC 1.2%, p = 0.01). There was no difference in 5-year overall survival for stage I disease (AMC 68% versus VAMC 69%, p = 0.95). CONCLUSIONS: Keeping surgeon experience constant, and after adjusting for patient factors, the rate of major complication after lobectomy is higher at VAMC. The difference is largely attributable to a higher rate of postoperative pneumonia at VAMC. Complications after pulmonary resection at VAMC could be reduced by implementing quality improvement initiatives aimed at reducing the rate of postoperative pneumonia.

Efficacy of pre-operative nasal staphylococcus aureus screening and chlorhexidine chest scrub in decreasing the incidence of post-resection empyema.

BACKGROUND: We evaluated the efficacy of pre-operative Staphylococcus aureus (SA) screening and chlorhexidine chest scrub in decreasing the incidence of empyema after major pulmonary resections. METHODS: For two years, a strategy aimed at decreasing post-resection empyema was instituted. This entailed pre-operative screening for nasal SA and chlorhexidine chest scrub the night before surgery (Group Swab-Scrub, n=192). Patients screened positive for SA, methicillin-resistant (MRSA) and methicillin-sensitive (MSSA), received 5 d of nasal mupirocin. Group Swab-Scrub was compared with patients two years earlier, who did not receive this pre-operative maneuver (Group Control, n=173). The extent of resection considered was lobectomy or greater. All patients received cefazolin (or clindamycin if allergic) prior to incision and 24 h postoperatively, except for patient in Group Swab-Scrub screening positive for MRSA, who received vancomycin. All patients had povidone-iodine skin preparation. RESULTS: In Group Swab-Scrub, prevalence of nasal SA was 8.9% (17/192) two with MRSA and 15 with MSSA. There was no difference in patient demographics or operative characteristics between the Group Swab-Scrub and Group Control. There was also no difference in prolonged air-leak, empyema, wound infection, pneumonia, or mortality rates between the two groups. When stratifying for the extent of procedure, there was no difference in the incidence of empyema after lobectomy (Group Swab-Scrub, 3.9% [7/177] versus Group Control, 2.0% [3/151]; p=0.352) or pneumonectomy (Group Swab-Scrub, 6.7% [1/15] versus Group Control, 13.6% [3/22]; p=0.633). In both univariate and multivariable analysis, prolonged air-leak and pneumonectomy were significant risk factors for empyema. CONCLUSIONS: Preoperative screening for nasal SA and chlorhexidine chest scrub does not seem to decrease empyema rates after major pulmonary resection. Prolonged air-leak and pneumonectomy continue to be significant risk factors for developing empyema. The number of patients undergoing pneumonectomy in this study is small and further studies are needed for this patient population.

Enucleation of a giant esophageal gastrointestinal stromal tumor.

Despite development of novel chemotherapy for gastrointestinal stromal tumors (GISTs), complete resection remains the gold standard treatment. Because of the small number of reported esophageal gastrointestinal stromal tumors, the optimal extent of resection is not well defined. We present a case of an 82-year-old man with an 11-cm esophageal gastrointestinal stromal tumor who was successfully treated with enucleation.

The incidence of perioperative anastomotic complications after sleeve lobectomy is not increased after neoadjuvant chemoradiotherapy.

BACKGROUND: Concurrent neoadjuvant chemoradiotherapy can potentially impact on the results of sleeve lobectomy. The purpose of this study was to examine this effect in terms of morbidity, mortality, and long-term survival in patients with non-small cell lung cancer. METHODS: Clinical records of patients with non-small cell lung cancer undergoing sleeve lobectomy between 1983 and 2008 were reviewed for age, sex, type of sleeve resection, clinicopathologic TNM stage, complications, and 90-day mortality. Chemotherapy and radiation therapy regimens were recorded for the patients undergoing neoadjuvant treatment. Kaplan-Meier survival curves were compared. RESULTS: There were 64 patients identified as having undergone sleeve resection for non-small cell lung cancer. Of the 64 total patients, 43 did not receive concurrent neoadjuvant chemoradiotherapy [NCR] versus 21 patients who did [CRS]. All of the CRS patients underwent platinum-based chemotherapy and radiation (range, 2,000 to 6,100 cGy). Thirteen patients (62%) were downstaged, with 4 complete responders. The 90-day mortality was 2.7% (2 patients) in the NCR group and 0% in the CRS group. The incidence of major complications in the NCR group was 46.5% (20 of 43) with 4.7% (2 of 43) anastomosis-related complications (stenosis, 1; bronchovascular fistula, 1). The incidence of major complications in the CRS group was 42.9% (9 of 21) with no anastomosis-related problems. Five-year survival in the NCR group was 48% compared with 41% in the CRS group (p = 0.63). There were 9% (4 of 43) of patients with local recurrence in the NCR group versus 10% (2 of 21) of patients in the CRS group (p = 0.65). CONCLUSIONS: Anastomosis-related complications were not increased among the patients receiving neoadjuvant therapy compared with those who did not. In addition, local recurrence was also similar between the two groups. Furthermore, the survival of the two groups was not statistically different. Sleeve lobectomy after chemoradiotherapy for advanced non-small cell lung cancer can be performed with acceptable morbidity and mortality.

Initial clinical outcomes after completion of training in a Canadian Royal College thoracic surgery program.

BACKGROUND: Thoracic procedures are currently performed by general and thoracic surgeons. Initial clinical outcome after training is a good measure of the quality of the surgical training received. METHODS: We examined the morbidity and mortality for pneumonectomy, lobectomy and esophagectomy during one surgeon's first 2 years of practice; we collected data prospectively. The results were based on the experience of the only dedicated thoracic surgeon (5 years of general surgery and 3 years of thoracic surgery training with certification from the Royal College of Physicians and Surgeons of Canada) at the largest tertiary care hospital of Brown University School of Medicine. RESULTS: During the 2-year period, 154 major pulmonary resections (20 pneumonectomies, 134 lobectomies) and 25 esophagectomies (18 transhiatal, 4 Ivor-Lewis, 2 thoracoabdominal, one 3-incision) were performed. Mortality for major lung resection was 1.9% (pneumonectomy 5%, lobectomy 1.5%), and morbidity was 27% (pneumonectomy 35%, lobectomy 26%). Mortality for esophagectomy was 4%, and morbidity was 36% (anastamotic leak 12%). CONCLUSIONS: These results compare favourably with clinical outcomes published from several large series. Thoracic surgical training in Canada is adequate and prepares surgeons well to perform major thoracic procedures. A database of the initial results from all graduates of thoracic surgery training in Canada is needed. Such a database could be used to compare the initial results of thoracic procedures performed by general and thoracic surgery graduates from Canada and the United States.