Efficacy and patient satisfaction of single-session transoral incisionless fundoplication and laparoscopic hernia repair.

BACKGROUND AND AIMS: Transoral incisionless fundoplication (TIF) is an effective endoscopic treatment for refractory GERD with small or absent hiatal hernia (< 2 cm in length and width). The single-session laparoscopic hernia repair followed by transoral incisionless fundoplication (HH + TIF) aims to repair mechanical defects in the lower esophageal sphincter that leads to GERD in patients with hiatal hernias ≥ 2 cm. The procedure effectively treats GERD without causing added post-surgical dysphagia and gas bloating commonly associated with partial laparoscopic fundoplication. We aimed to assess patient satisfaction, symptom resolution, safety, and proton pump inhibitor use following the HH + TIF procedure. METHODS: Thirty-three patients underwent single-session laparoscopic hernia repair with intraoperative TIF using the EsophyX Z device (EndoGastric Solutions, Inc.) between June 2015 and June 2018. The presence of GERD and normal esophageal motility were confirmed with pH testing and manometry prior to the procedure. Data were collected on pre- and post-procedure symptoms, patient satisfaction, PPI use, and complications. Median post-procedure follow-up with symptom surveys was 9 months (11-29 months). RESULTS: Patients reported significant decreases in common GERD symptoms including heartburn, regurgitation, cough, and hoarse voice. Eighty-one percent (27/33) of patients were off daily PPIs. Ninety-four percent (31/33) of patients reported 75% or greater satisfaction with the procedure and outcomes. One patient had a superficial mucosal laceration after the procedure, likely due to vomiting, which was treated conservatively. CONCLUSIONS: The majority of patients reported 75% or greater satisfaction with the procedure and had an improvement in GERD symptoms as well as decreased PPI use. There were no serious adverse events.

Video-assisted thoracoscopic surgery lobectomy for stage I lung cancer.

The literature shows that, in the hands of experienced thoracoscopic surgeons, VL is a safe operation that offers patients at least comparable complication and survival rates compared with lobectomy by thoracotomy. VL can be performed safely with proven advantages over conventional thoracotomy for lobectomy: smaller incisions, decreased postoperative pain, decreased LOS, decreased chest tube output and duration, decreased blood loss, better preservation of pulmonary function, and earlier return to normal activities. These results are obtained without sacrificing the oncologic principles of thoracic surgery, and, in fact, the evidence in the literature is mounting that VATS may offer reduced rates of complications and better survival.

VATS anatomic pulmonary resection in octogenarians.

Although modern techniques in anesthesia and surgery have reduced morbidity and mortality for pulmonary resection, some physicians still consider advanced age a contraindication to resection of lung cancer. We examined our experience with VATS lobectomy in octogenarians at Cedars-Sinai Medical Center over 12 years (1992-2004). There were 159 patients. Mean age was 83 years (range, 80-94 years) consisting of 61 males (38%) and 96 females (62%). Operations included 153 lobectomies (96%), 3 bilobectomies (2%), and 3 pneumonectomies (2%). Two operations were converted to thoracotomy (1%), one due to bleeding, and one due to poor visualization. Median hospital stay was 4.00 +/- 6.39 days. One hundred thirty-one patients (82%) had no complications. The most common complication was arrhythmias occurring in 8/159 (5%) patients. There were three perioperative deaths (1.8%). Pathology revealed 104 adenocarcinomas (65%), 25 squamous cell carcinomas (16%), 5 adeno-squamous carcinomas (3%), 7 bronchoalveolar carcinomas (4%), 7 large cell carcinomas (4%), 4 carcinoid tumors (3%), 4 non-small cell lung cancer (NSCLC) (3%), 1 mucoepidermoid carcinoma (< 1%), 1 lymphoma (< 1%), and 1 pulmonary metastasis (< 1%). Median follow-up was 29 months. The results of this series show that age alone is not a contraindication to the surgical treatment of lung cancer.

Perforating Barrett's ulcer resulting in a life-threatening esophagobronchial fistula.

Perforating benign ulcer is a very rare complication of Barrett's esophagus. This report presents the management of a patient with a Barrett's ulcer that penetrated into the left mainstem bronchus resulting in a life-threatening bronchial esophageal fistula. This rare complication was successfully managed by using a staged surgical approach, which combined the principles used for treating benign esophagorespiratory fistulas and perforating Barrett's ulcers.

Reduction of intraoperative air leaks with Progel in pulmonary resection: a comprehensive review.

Intraoperative alveolar air leaks (IOALs) occur in 75% of patients during pulmonary resection. Despite routine use of sutures and stapling devices, they remain a significant problem in the daily practice of thoracic surgery. Air leaks that persist beyond postoperative day 5 often result in increased costs and complications. Several large meta-analyses have determined that sealants as a class reduce postoperative air leak duration and time to chest drain removal, but these results did not necessarily correlate with a reduction in length of postoperative hospital stay. These analyses grouped surgical sealants together of necessity, but differences in efficacy may exist due to the differing product characteristics, study protocols, surgical procedures, and study endpoints. Progel, currently the only pleural surgical sealant FDA-approved for use in lung resection, has demonstrated efficacy and safety in two controlled clinical studies and superiority over standard air leak closure methods in reducing IOALs and length of hospital stay. This paper will review these findings and report on real-world experience with this recently approved pleural sealant.

High prevalence of lung cancer in a surgical cohort of lung cancer patients a decade after smoking cessation.

BACKGROUND: This study was designed to assess the prevalence of smoking at time of lung cancer diagnosis in a surgical patient cohort referred for cardiothoracic surgery. METHODS: Retrospective study of lung cancer patients (n = 626) referred to three cardiothoracic surgeons at a tertiary care medical center in Southern California from January 2006 to December 2008. Relationships among years of smoking cessation, smoking status, and tumor histology were analyzed with Chi-square tests. RESULTS: Seventy-seven percent (482) had a smoking history while 11.3% (71) were current smokers. The length of smoking cessation to cancer diagnosis was <1 year for 56 (13.6%), 1-10 years for 110 (26.8%), 11-20 years for 87 (21.2%), 21-30 years for 66 (16.1%), 31-40 years for 44 (10.7%), 41-50 years for 40 (9.7%) and 51-60 years for 8 (1.9%). The mean cessation was 18.1 ± 15.7 years (n = 411 former smokers). Fifty-nine percent had stage 1 disease and 68.0% had adenocarcinoma. Squamous cell carcinoma was more prevalent in smokers (15.6% vs. 8.3%, p = 0.028); adenocarcinoma was more prevalent in never-smokers (79.9% versus 64.3%, p = 0.0004). The prevalence of adenocarcinoma varied inversely with pack year (p < 0.0001) and directly with years of smoking cessation (p = 0.0005). CONCLUSIONS: In a surgical lung cancer cohort, the majority of patients were smoking abstinent greater than one decade before the diagnosis of lung cancer.

Intestinopericardial fistula presenting as cardiac tamponade.

The investigators describe 2 cases of intestinopericardial fistula. The patients presented with cardiac tamponade and underwent pericardiocentesis, followed by surgical intervention. Both patients survived and were discharged in stable condition. In conclusion, intestinopericardial fistula is a rare and life-threatening disorder that can present in a variety of manners, including pneumopericardium, cardiac tamponade, and pericarditis. Early identification of the disease coupled with prompt surgical intervention maximizes a patient's chance of survival and reduced morbidity.

Video-assisted thoracic surgery sleeve lobectomy: a case series.

BACKGROUND: As thoracic surgery moves towards more minimally invasive procedures, such as video-assisted thoracic surgery (VATS) lobectomy, conversion from a VATS to open thoracotomy has been required for a sleeve resection. This article reports a large experience of VATS sleeve lobectomy. METHODS: We reviewed our thoracic surgery database of more than 1500 VATS lobectomies for VATS sleeve resections. Preoperative, operative, and perioperative outcome variables, including morbidity and mortality were examined. RESULTS: Identified were 13 patients (median age, 59 years; range, 16 to 82 years) who underwent VATS sleeve lobectomy. There were no conversions to thoracotomy. Diagnoses included non-small cell lung cancer in 8 patients, typical carcinoid in 4, and metastatic sarcoma in 1 patient. Median tumor size was 2.1 cm (range, 0 to 6.6 cm). Median data were operative time, 167 minutes (range, 90 to 300 minutes); blood loss, 250 mL (range, 75 to 800 mL); chest tube drainage, 692 mL (range, 459 to 1590 mL); and chest tube duration, 3 days (range, 2 to 6 days). Median intensive care unit stay was 0 days (range, 0 to 4 days), and median hospital stay was 3 days (range, 2 to 8 days). No complications occurred in 9 patients (69%). Morbidity in the remaining 4 patients included 1 patient each with atrial fibrillation, anastomotic stricture, reintubation, and bronchial tear requiring repair. There were no deaths at 30 days. CONCLUSIONS: In experienced centers, VATS sleeve lobectomy is possible with acceptable morbidity and mortality as well as short length of stay.

Photodynamic therapy followed by thoracoscopic sleeve lobectomy for locally advanced lung cancer.

Photodynamic therapy is an effective technique for debulking endobronchial tumors over an acceptably short time-course; however, to be effective, numerous treatment cycles may be required to achieve the desired results. We present a case in which photodynamic therapy was used with curative intent to downsize an obstructing endobronchial non-small cell lung cancer in advance of resection via video-assisted thoracoscopic surgery with right upper lobe sleeve lobectomy.

Wedge resection and brachytherapy for lung cancer in patients with poor pulmonary function.

BACKGROUND: Although lobectomy is the standard for lung cancer because a wedge resection has a 3 to 5 times greater incidence of local recurrence, poor pulmonary function may preclude lobectomy. For these patients, low-dose-rate brachytherapy has recently been used to decrease local recurrence after sublobar resection. Current techniques expose operating room personnel and patient contacts to unnecessary radioactivity risks. We present our technique of sublobar resection combined with afterload catheters for high-dose-rate brachytherapy for patient benefit with minimal risk to others. METHODS: Forty-eight patients (25 women, 23 men) underwent wedge resection, node dissection, and brachytherapy. A remote-afterloading high-dose-rate unit for radiation produced a median dose of 2450 cGy (350 cGy per fraction over 7 fractions twice daily for 4 days). The dose was prescribed to 1 cm deep to the stapled line. Biologically, this dose is approximately 5000 cGy and above (180 cGy/d equivalent) at the depth of 5 mm in reference to the resection margin. RESULTS: Two patients died. The length of mean stay was 5.5 days (median, 5 days). Complications included prolonged air leak in 5 patients, atrial fibrillation in 5, pneumonia in 3, trapped lung in 2, and 1 each with empyema, bleeding, and recurrent laryngeal nerve injury. Three patients required a blood transfusion. Within the follow-up of 1 to 27 months, there were four recurrences. CONCLUSIONS: Wedge resection and brachytherapy appears to be a reasonable treatment for patients with lung cancer and pulmonary function that prohibits a lobectomy.

Fast-tracking after video-assisted thoracoscopic surgery lobectomy, segmentectomy, and pneumonectomy.

BACKGROUND: In the era of cost containment, a fast-tracking protocol was developed to reduce cost and shorten the length of stay after a lobectomy. The purpose of our study was to see whether a fast-tracking protocol provided a short length of stay without compromising morbidity and mortality or leading to readmission to the hospital. METHODS: The protocol was to perform lobectomies by means of video-assisted thoracoscopic surgery with no routine postoperative laboratory work or chest roentgenograms. The chest tubes were discontinued once the output was less than 300 mL in a 24-hour period and there was no air leak present. If the chest tube output was low, but there was an air leak, the patient was discharged home with a Heimlich valve. RESULTS: Two hundred eighty-two consecutive video-assisted thoracoscopic surgery lobectomies were performed by a single surgeon during 18 months in 158 women (56%) and 124 men (44%), with a mean age of 71.2 years. Following this protocol, the mean length of stay was 3.26 days, and the median was 3 days. Seven of 282 patients (2.5%) were discharged with a Heimlich valve. There was 1 mortality. There were no complications in 251 patients (89%). Two patients were readmitted to the hospital. No chest tubes were reinserted. CONCLUSIONS: Using a fast-tracking protocol, video-assisted thoracoscopic surgery lobectomy with anatomic dissection can be performed with minimal complication, a short postoperative length of stay, and reduced costs.

Video-assisted thoracic surgery lobectomy: experience with 1,100 cases.

BACKGROUND: Although many video-assisted thoracic surgery (VATS) lobectomies have been performed over the 12 years since the first VATS lobectomy, controversies about the procedure remain regarding the safety and associated morbidity and mortality of that procedure. This series is reviewed to assess these issues. METHODS: Between 1992 and 2004, we performed 1,100 VATS lobectomies in 595 women (54.1%) and 505 men (45.9%), with a mean age of 71.2 years. Diagnoses were as follows: benign disease (53), pulmonary metastases (27), lymphoma (5), and lung cancer (1,015). Of the primary lung cancers, 641 (63.1%) were adenocarcinoma. With visualization on a monitor, anatomic hilar dissection and lymph node sampling or dissection were performed, primarily through a 5-cm incision without spreading the ribs. RESULTS: There were 9 deaths (0.8%), and none was intraoperative or due to bleeding; 932 patients had no postoperative complications (84.7%). Blood transfusion was required in 45 of 1,100 patients (4.1%). Length of stay was median 3 days (mean, 4.78). One hundred eighty patients (20%) were discharged on postoperative day 1 or 2. Conversion to a thoracotomy occurred in 28 patients (2.5%). Recurrence developed in the incisions in 5 patients (0.57%). In 2003, 89% of 224 lobectomies were performed with VATS. CONCLUSIONS: VATS lobectomy with anatomic dissection can be performed with low morbidity and mortality rates. The risk of intraoperative bleeding or recurrence in an incision seems minimal.

Swyer-James (MacLeod) syndrome with placental transmogrification of the lung: a case report and review of the literature.

Swyer-James (MacLeod) syndrome is an acquired form of unilateral hyperlucency of the lung and is characterized by the development of severe emphysema, bronchiectasis, and/or bronchiolitis obliterans. It may develop as a complication of repeated episodes of pulmonary infection resulting in bronchiolitis obliterans and obstruction of small airways. Most patients with Swyer-James (MacLeod) syndrome can be managed clinically, and the pathologic features of the syndrome have been described in only a few reports. Placental transmogrification of the lung is a rare histopathologic finding that has been described in patients with severe emphysema associated with cigarette smoking, congenital bullous emphysema, and fibrochondromatous hamartomas of the lung and is characterized by the development of peculiar structures in the pulmonary parenchyma that resemble placental villi. To our knowledge, placental transmogrification of the lung has not been previously described in patients with Swyer-James (MacLeod) syndrome. We encountered a 32-year-old man with a history of childhood asthma who presented with progressively severe exertional dyspnea and had unilateral right lung hyperlucency. The patient underwent a right pneumonectomy. Examination of the lung revealed severe mixed centriacinar-panacinar emphysema in all lobes, bullous emphysema in the upper lobe, bronchiectases, mild interstitial pneumonia with fibrosis, and placental transmogrification of the pulmonary parenchyma of all 3 lobes. Here, we review the pathology of Swyer-James (MacLeod) syndrome and the possible pathogenesis of villous-like changes in the lung tissues.

Video-assisted thoracic surgery upper lobe trisegmentectomy for early-stage left apical lung cancer.

Resection of the left upper lobe with preservation of the lingula is the anatomic equivalent of a right upper lobectomy with preservation of the right middle lobe. Therefore, our standard operation for a small apical tumor in the left upper lobe has been an apical trisegmentectomy. The purpose of this article is to review our experience with the procedure by video-assisted thoracic surgery (VATS) and to describe the operative technique for a VATS apical trisegmentectomy. Eleven patients underwent the procedure with no deaths, low morbidity, and good initial disease-free survival. A VATS apical trisegmentectomy seems to be a feasible and reasonable treatment for small stage I lung cancers at the apex of the left upper lobe.

Mediastinal epithelioid solitary fibrous tumor.

We describe the case of a 74-year-old man with a mediastinal tumor composed predominantly of epithelioid cells exhibiting histopathologic and immunohistochemical features intermediate between those of a solitary fibrous tumor and those of a cellular adenomatoid tumor. We discuss the differential diagnosis and possible histogenesis of this unusual neoplasm, and we propose the term epithelioid solitary fibrous tumor for this entity.

Frozen section diagnoses of small pulmonary nodules: accuracy and clinical implications.

BACKGROUND: Pulmonary nodules are frequently first diagnosed by frozen section, immediately followed by lobectomy or other procedures. The frozen section diagnosis of pulmonary nodules can be difficult, as inflammatory and fibrotic lesions can be confused for malignancy, creating intraoperative dilemmas for pathologists and thoracic surgeons. METHODS: We reviewed our experience at Cedars-Sinai Medical Center with the frozen section diagnoses of 183 consecutive pulmonary nodules smaller than 1.5 cm in diameter and calculated the sensitivity, specificity, and predictive values of this diagnostic procedure. RESULTS: One hundred and seventy four nodules were correctly classified by frozen section as neoplastic or nonneoplastic, six lesions were diagnosed equivocally, and two neoplasms were missed owing to sampling errors. The equivocal frozen section diagnoses included two bronchioloalveolar carcinomas (BAC) interpreted as "atypical hyperplasia, favor BAC," two BAC diagnosed as "alveolar hyperplasia," and two carcinoid tumors labeled as "atypical carcinoma" and "spindle cell lesion, carcinoid versus sclerosing hemangioma," respectively. The sensitivities for a diagnosis of neoplasia were 86.9% and 94.1% for nodules smaller than 1.1 cm in diameter and measuring 1.1 to 1.5 cm, respectively. The diagnostic accuracy of frozen sections was significantly better in nodules larger than 1.0 cm in diameter (p = 0.05). There were no false-positive diagnoses of malignancy, resulting in 100% specificity. CONCLUSIONS: Intraoperative consultation with frozen section is a sensitive and specific procedure for the diagnosis of malignancy from small pulmonary nodules. The distinction between BAC and atypical adenomatous hyperplasia, and of small peripheral carcinoid tumors from other lesions, can be difficult by frozen section. Thoracic surgeons need to become aware of these problems and develop appropriate therapeutic strategies.