Impact of surgical approach on perioperative and long-term outcomes following esophagectomy for esophageal cancer.

BACKGROUND: Surgical resection remains a critical component of esophageal cancer treatment with curative-intent. The aim of this study was to compare open (OE) to minimally invasive Ivor Lewis esophagectomy (MIE) with respect to perioperative and oncologic outcomes. METHODS: Retrospective single-institution review of MIE and OE patients operated between 2001 and 2015 was conducted. Univariable and multivariable models were created using Cox regression. The Kaplan-Meier method was used to compare oncologic outcomes. Propensity score matching was used to compare oncological outcomes in MIE and OE patients. RESULTS: Of 210 esophageal resection patients, 47% had OE (137/291) and 25% had MIE (73/291). The MIE and OE groups were comparable with respect to patient factors and operative details. Fewer OE patients received neoadjuvant chemoradiation. MIE was associated with improved lymph node yield, (MIE = 30 [IQR:22-39]; OE = 14 [IQR:7-19], p < 0.001), less intraoperative blood loss (MIE = 312 mL [100-400]; OE = 657 mL [350-700], p < 0.001), and shorter median length of stay (MIE = 10 days [IQR = 8-14]; OE = 14 days [IQR = 11-22] p < 0.01). The OE group had significantly more adverse events resulting in reoperation or intensive care unit admission (MIE = 21%; OE = 34%; p < 0.01). On multivariable analysis, age and positive resection margins were associated with decreased odds of survival. The number of lymph nodes retrieved, positive resection margins, and pathologic stage were significant predictors of disease-free survival. Analysis of 69 matched pairs showed equivalent median overall survival (MIE = 49 months [18-67]; OE = 29 months [17-69]; p = 0.26) and disease-free survival (MIE = 9 [6-22]; OE = 13 [6-22]; p = 0.45) between the two groups. CONCLUSIONS: Although long-term oncologic outcomes appear to be similar, MIE is associated with significantly less intraoperative blood loss, improved lymph node yield, less risk of severe postoperative adverse events, and shorter length of stay.

Sepsis in the Postpneumonectomy Space: Pathogenesis, Recognition, and Management.

Empyema may occur in the pleural space after pulmonary resection. Subsequent bacterial contamination results in infection and development of frank empyema. Pneumonectomy-surgical removal of the entire lung-is the treatment of choice for centrally located bronchogenic carcinoma, diffuse malignant mesothelioma, and chronic inflammatory lung diseases with destroyed lung from pulmonary tuberculosis, fungal infections, and bronchiectasis. In the uncomplicated case, on the pneumonectomy side, the diaphragm becomes elevated as the air-fluid level decreases with chest wall deformation and gradual disappearance of hydrothorax. The pneumonectomy space is at potential risk for getting infected from bacterial contamination and developing empyema.

Controversies in Lung Cancer: When to Resect with Compromised Pulmonary Function.

Lung cancer is the most common cause of cancer-related death worldwide among both men and women. Patients with lung cancer frequently have impaired pulmonary function, usually secondary to smoking-related chronic obstructive lung disease. Numerous techniques have been used to evaluate the postsurgical risk. These techniques include preoperative pulmonary function test, 6-minute walk test, stage 1 cardiopulmonary exercise test, 2D echocardiography, and quantitative ventilation-perfusion scintigraphy.

Assessment of Operability and Resectability in Lung Cancer.

Lung cancer is a lethal disease, and chronic cigarette smoking is the most common cause. The selection of treatment is based on the histologic cell type, accurate staging, and adequacy of cardiopulmonary functional reserve. The risk for surgery is highest in patients over the age of 80 years.

Delays in Managing Lung Cancer: The Importance of Fast-Tracking in the Clinical Care.

Early diagnosis in lung cancer is desirable, because surgical resection offers the only hope of cure. In the face of suggestive symptoms, a normal plain chest radiograph does not exclude the diagnosis, and investigation is essential. The various imaging changes seen on computerized tomography and PET scan provide strong suggestive evidence of lung cancer, but proof of diagnosis rests on histologic examination, material that may be obtained by one of the following diagnostic procedures: bronchoscopy, mediastinoscopy, fine needle aspiration biopsy, thoracentesis and pleural biopsy, lymph node biopsy, and exploratory thoracotomy.

Ethics for Thoracic Surgeons in the Management of Lung Cancer.

Lung cancer is a terrible disease, with less than 20% of patients with a diagnosis of lung cancer able to have a resection but many relapsing, making it one of the most biologically aggressive cancers known. Thoracic surgeons do not see all the other 80% but are often consulted and have to make recommendations, and sometimes have to intervene. Thoracic surgeons should be well informed about the ethical framework and participate actively in the discussion. Ethics is an important aspect of surgical practice and has implications for patients, surgeons, and surgical teams, as well as for society.

Can Biologic Aggressiveness and Metastatic Potential of Primary Lung Cancer Be Predicted from Clinical Staging Alone?

The future biologic aggressiveness and metastatic potential of lung cancer, as in other cancers, cannot be predetermined from the current clinical information, imaging studies, and pathologic examination whose purpose is to provide diagnosis and mutation studies and molecular drivers only in making decision for treatment. There is a need for better understanding of the biologic characteristics and aggressiveness of lung cancer. The most that is achieved from clinical staging and pathologic staging is in the planning of treatment of lung cancer and predicting prognosis. Aggressive biologic behavior to come is not within the domain of clinical staging or pathologic staging.

Superior Vena Cava Resection and Reconstruction with Resection of Primary Lung Cancer and Mediastinal Tumor.

The superior vena cava is a short ∼7-cm valveless vessel that brings blood from the upper half of the body to the heart but has connections to the infracardiac venous structures as well. It can become obstructed, mostly by advanced lung cancer but benign conditions account for one-fourth of cases. When possible, reconstruction can be by biological material or via ring reinforced grafts. When perfomed, replacement should be with small caliber grafts to allow for rapid flow of blood, which, with the addition of anticoagulants, reduces the risk of thrombosis. Even with advanced malignancy, treatment may confer reasonable survival.

The History and Evolution of Surgical Instruments in Thoracic Surgery.

Surgery is as old as man, and its evolution has been moulded in every age by current technical and scientific advances, not forgetting the demands made upon it by social circumstances and religion. It is both an art and a science, while its practice largely depends on the human relations between doctor and patient. It is extremely difficult to define where surgery begins or ends, and its separation from medicine is largely based on the very different paths which the two disciplines took in ancient times.

Medical Audit to Improve the Quality of Patient Care in Thoracic Surgery.

The purpose and conduct of medical audit is a means of quality control for medical practice by which the profession shall regulate its activities with the intention of improving overall patient care. The quality assurance depends on patient and physician satisfaction. The medical profession needs to be educated about the structure, process, and outcome. The structure equates to resources found within the hospital. The outcome is when quality of care becomes preeminent.

Oligometastatic Lung Cancer Defined by Biology, Science, and Secondary Growths.

Breast cancer was the first malignant tumor for which TNM classification was proposed by the International Union Against Cancer. Volume and distribution of tumor burden were considered clinically important in this cancer. Lung cancer is caused by excessive cigarette smoking. Prognosis is worst in small cell lung cancer and in non-small cell lung cancer measuring over 3 cm in size and having regional lymphatic spread. Metastatic spread from lung cancer is favored by lymphatic spread to the locoregional lymph nodes and blood-borne spread to 5 sites-lung, brain, bone, liver, and adrenal-all of which are unfavorable prognostic indicators.

The Lymphatic Spread of Lung Cancer: An Investigation of the Anatomy of the Lymphatic Drainage of the Lungs and Preoperative Mediastinal Staging.

The knowledge of lymphatic spread of lung cancer permitted the study of anatomy of lymphatic drainage of the lungs. The history of anatomy of lymphatic drainage of the lungs began in the 15th century. In the human, pulmonary lymph flows to the lymph nodes around the lobar bronchi and thence to extrapulmonary lymph nodes located around the main bronchi and trachea and its bifurcation (tracheobronchial lymph nodes). These send their efferents to a right and left mediastinal lymph trunks, which may join the thoracic duct, but usually drain opening directly into the brachiocephalic vein of their own side.

Standardized Postoperative Adverse Event Data Collection to Document, Inform, and Improve Patient Care.

There is great potential for standardized postoperative adverse events data collection to document, inform, audit, and feedback, all to optimize patient care. Adverse events, defined as any deviation from expected recovery from surgery, have harmful implications for patients, their families, and clinicians. Postoperative adverse events occur frequently in thoracic surgery, predominately due to the high-stakes (ie, high potential for cure) and high-risk (ie, vital physiology and anatomy and preexisting disease) nature of the surgery. As discussed, engaging surgeons in audit and feedback practices informed by standardized data collection would generate consensus recommendations to reduce adverse events and improve patient outcomes.

Paraneoplastic Syndromes in Lung Cancers: Manifestations of Ectopic Endocrinological Syndromes and Neurologic Syndromes.

Paraneoplastic syndromes are clinical entities associated with cancers and often overlap with metabolic and endocrine syndromes. The cell types of lung cancer involved are frequently small cell, squamous cell, adenocarcinoma, large cell, and carcinoid tumor. A number of neurologic paraneoplastic syndromes have been described for which the tumor product remains unknown. These include peripheral neuropathies, a myasthenia-like syndrome, and subacute cerebellar degeneration. Although all of these syndromes may improve with successful treatment of the primary tumor, complete resolution is rare.

How to Design and Foster Thoracic Oncology Multidisciplinary Cancer Conferences.

In this chapter, the authors review and discuss the literature on multidisciplinary cancer conferences (MCCs, aka tumor boards), clarifying the terminology, showing the evolution of the field, and providing an evidence-based perspective on positive outcomes, best practices, factors influencing the quality of MCCs, evaluation tools to assess the quality of MCCs, and quality improvement interventions for MCCs. The authors then discuss some perspectives from their MCC and initiatives that they undertook to improve the work of their team and the care that they provide to patients in the area of thoracic oncology.

Guiding Principles on the Importance of Thoracic Surgical Education on Establishing Integrated Thoracic Surgery Program, Interdisciplinary Thoracic Oncology Conferences, and an Interdisciplinary Approach to Management of Thoracic Malignancies.

The objective of these notes is to stress the principles underlying the management of primary lung cancers and other types of malignancies in the thorax-diffuse malignant mesothelioma, invasive mediastinal tumors, chest wall sarcoma, and tracheal neoplasms-and from these considerations to outline a routine scheme for management, which can be followed easily by all staff. It is hoped that by adherence to this routine, adequate and efficient management of all cases will be obtained, both in the very important matter of preoperative preparation, as well in the postoperative management.

Role of the Thoracic Radiologist in the Evaluation and Management of Solid and Subsolid Lung Nodules.

In this review, the authors describe the imaging characteristics of solid and subsolid nodules as well as their management recommendations including the use of image-guided percutaneous biopsy and preoperative coil localization. Using case presentations, they offer practical management tips for the most commonly encountered nodule nodules in a thoracic surgical practice.

Long-term Symptom Control After Laparoscopic Heller Myotomy and Dor Fundoplication for Achalasia.

BACKGROUND: Achalasia is a primary esophageal motility disorder in which there is incomplete relaxation of the lower esophageal sphincter and absence of peristalsis in the lower two thirds of the esophagus. A favored treatment is laparoscopic modified Heller myotomy with Dor fundoplication (LHMDor) with more than 90% immediate beneficial effect. The short-term outcomes of LHMDor are well documented, but stability and durability of postoperative symptom control over time is less understood. METHODS: Between 2004 and 2016, 54 patients with achalasia underwent LHMDor (single center). Using validated questionnaires, patients rated their symptoms in five domains: pain, gastroesophageal reflux disease (GERD), dysphagia, regurgitation, and quality of life. Symptom ratings were done preoperatively, 4 weeks postoperatively, 6 months postoperatively, and yearly after the operation. RESULTS: As expected, patients reported marked improvement in dysphagia, odynophagia, regurgitation, GERD, and quality of life after the operation (P < .001). From then on, the symptom control remained durable with respect to absence of pain, regurgitation, and odynophagia; however, we observed a recurrence of GERD symptoms beginning 3 to 5 years postoperatively (P = .001 and P = .04, respectively), with associated increased antireflux medication use. After initial LHMDor, 5 patients required endoscopic dilatation an average of 1.5 years postoperatively, and no patient required reoperation. Patients reported preserved improved quality of life to 11 years after the operation (P = .001). CONCLUSIONS: These results demonstrate the durability of LHMDor in the definitive management of achalasia, offering consistent symptomatic relief and significant improvement in quality of life over the decade after surgery, despite some increase in GERD symptoms and antireflux medication use.

Adjuvant melatonin for the prevention of recurrence and mortality following lung cancer resection (AMPLCaRe): A randomized placebo controlled clinical trial.

BACKGROUND: Despite curative intent resection in patients with non-small cell lung cancer (NSCLC), recurrence leading to mortality remains too common. Melatonin has shown promise for the treatment of patients with lung cancer; however, its effect following cancer resection has not been studied. We evaluated if melatonin taken after complete resection reduces lung cancer recurrence and mortality, or impacts quality of life (QOL), symptomatology or immune function. METHODS: Participants received melatonin (20 mg) or placebo nightly for one year following surgical resection of primary NSCLC. The primary outcome was two-year disease-free survival (DFS). Secondary outcomes included five-year DFS, adverse events, QOL, fatigue, sleep, depression, anxiety, pain, and biomarkers assessing for immune function/inflammation. This study is registered at https://clinicaltrials.gov NCT00668707. FINDINGS: 709 patients across eight centres were randomized to melatonin (n = 356) versus placebo (n = 353). At two years, melatonin showed a relative risk of 1·01 (95% CI 0·83-1·22), p = 0·94 for DFS. At five years, melatonin showed a hazard ratio of 0·97 (95% CI 0·86-1·09), p = 0·84 for DFS. When stratified by cancer stage (I/II and III/IV), a hazard reduction of 25% (HR 0·75, 95% CI 0·61-0·92, p = 0·005) in five-year DFS was seen for participants in the treatment arm with advanced cancer (stage III/IV). No meaningful differences were seen in any other outcomes. INTERPRETATION: Adjuvant melatonin following resection of NSCLC does not affect DFS for patients with resected early stage NSCLC, yet may increase DFS in patients with late stage disease. Further study is needed to confirm this positive result. No beneficial effects were seen in QOL, symptoms, or immune function. FUNDING: This study was funded by the Lotte and John Hecht Memorial Foundation and the Gateway for Cancer Research Foundation.

Substantial variation of both opinions and practice regarding perioperative fluid resuscitation.

BACKGROUND: There are no current standards of care guiding perioperative fluid administration, and clinicians continue to debate restrictive versus liberal fluid administration. We sought to simultaneously evaluate the opinions and practice of surgeons, intensivists and anesthesiologists in a single centre regarding perioperative fluid resuscitation. METHODS: A postal survey sent to surgeons, intensivists and anesthesiologists in a single academic health care centre presented case-based scenarios followed by questions on fluid requirements and 5-point Likert scales involving statements about resuscitation. We performed a retrospective chart review to evaluate amount and type of intra-and postoperative (72-h) fluid administration, urine output and postoperative ventilation time in patients undergoing uncomplicated esophagectomy or pneumonectomy. RESULTS: Seventy-four of 77 respondents (96%) agreed that precise fluid resuscitation diminishes the risk of adverse events. Surgeons overall gave less fluids than anesthesiologists or intensivists and used fewer resuscitation end points to estimate fluid requirements perioperatively. For right hemicolectomies, only 3% of surgeons chose a fluid rate greater than 150 mL/h, compared with 55% of intensivists. We reviewed 49 patients' charts (25 who had pneumonectomies, 24 who had esophagectomies) retrospectively. The coefficient of variation (COV = standard deviation divided by its mean) of fluid administration intraoperatively was 0.56 for pneumonectomy and 0.35 for esophagectomy; postoperatively, the COV was greater than 0.50 for the first 24 hours, but less than 0.50 after 24 hours postoperatively. CONCLUSION: The presence of substantial variability of both opinion and practice of perioperative fluid resuscitation in a single centre supports the need for further research to identify objective methods to define perioperative fluid requirements and standards of perioperative resuscitation.