Patterns of Use and Short-Term Outcomes of Minimally Invasive Surgery for Malignant Pheochromocytoma: A Population-Level Study.

BACKGROUND: Malignant pheochromocytoma is rare, and there is a scarcity of data on the use of minimally invasive surgery (MIS) for treatment. The aims of this study were to analyze patterns of use of MIS for malignant pheochromocytoma in the U.S. and compare short-term outcomes to those of open adrenalectomy. METHODS: Patients with malignant pheochromocytoma undergoing MIS, including laparoscopy, robotic assisted, laparoscopy converted to open, or open adrenalectomy, were culled from the National Cancer Database, from 1998 to 2011. Data were examined using simple summary statistics, Χ2 and student's t tests, Mann-Whitney test, and logistic regression. RESULTS: A total of 36 MIS and 67 open adrenalectomies were identified in 2010-2011. No significant differences were observed between the two treatment groups in demographic characteristics or comorbidities. Preoperative diagnosis of malignancy was made in 52.8% of MIS and 48.5% of open patients (p=NS). MIS and open adrenalectomies did not differ with respect to lymph node metastases, vascular invasion, extra-adrenal-extension, and distant metastases (all p=NS). MIS tended to more often be used to perform partial adrenalectomy (38.9 vs. 20.4% open, p=0.061); surgical margins, 30-day readmission and mortality rates were similar to open adrenalectomy (all p=NS). Tumors removed via MIS were smaller (48.7 vs. 73.3 mm open, p=0.003) and associated with a shorter length of stay. CONCLUSIONS: A significant proportion of patients with malignant pheochromocytomas underwent MIS, with short-term outcomes which are comparable to those of open surgery. Further studies focused on long-term survival and recurrence are needed to assess the role of MIS in the management of these rare tumors.

Predicting survival after coronary revascularization for ischemic cardiomyopathy.

BACKGROUND: The success of coronary revascularization for ischemic cardiomyopathy (left ventricular ejection fraction of 0.25 or less) has been unpredictable. We and others have demonstrated that the hospital operative mortality rate for these operations has been surprisingly low, particularly if evidence of ischemia is present. We subsequently liberalized our selection criteria based on our hypothesis that coronary artery bypass grafting is safe in this subset of patients regardless of the status of their distal coronary vasculature. METHODS: To examine this hypothesis, we studied retrospectively our patients undergoing coronary artery bypass grafting from 1983 to 1993. Ninety-six patients with ejection fractions of 0.25 or lower underwent this operation, with 88 hospital survivors (mortality 8%). All of the patients had clinical symptoms of heart failure. The male to female ratio was 4.6:1. The average age was 63.1 +/- 0.9 years (mean +/- standard error of the mean). Patients were excluded if they had valvular heart disease other than mild to moderate mitral regurgitation, required resection of a ventricular aneurysm, or required an emergency operation for acute coronary occlusion. Possible predictors of death were examined retrospectively. The catheterization films were reviewed retrospectively by a cardiovascular surgeon who was blinded to patient outcome and was never involved in the clinical management of any of the patients. Vessel quality was described as good, fair, or poor. RESULTS: Increased age and poor vessel quality were the only significant predictors of poor outcome. Sex, presence or absence of angina, preoperative angina, preoperative ejection fraction, preoperative arrhythmia disorder, aortic cross-clamp time, and the number of bypass grafts had no significant effect on outcome in the perioperative period. CONCLUSION: These results demonstrate that poor vessel quality and older age are predictors of poor outcome in patients with low ejection fractions undergoing myocardial revascularization. We conclude that poor distal coronary vasculature is a contraindication to coronary artery bypass grafting in patients with an ejection fraction of 0.25 or less, even if angina is present.