Neoadjuvant chemotherapy for resectable non-small-cell lung cancer.

Lung cancer generally has an unfavorable prognosis. For those with resectable disease, the use of neoadjuvant chemotherapy has the potential to reduce tumor volume, address micrometastatic disease early, and improve outcomes. Randomized trials comparing neoadjuvant platinum-based regimens with surgery alone were able to demonstrate the feasibility and safety of this modality. These trials supported evidence found in phase II trials that utilized third-generation chemotherapies. Still, limitations to these studies exist, such as the inclusion of various disease stages in one study, inter- and intratrial variability of the chemotherapy regimens used, and lack of phase III data comparing neoadjuvant to adjuvant chemotherapy. These heterogeneous factors make it difficult to offer firm recommendations about neoadjuvant chemotherapy. Other matters of contention include the role of postoperative radiation and the concern for increased postoperative complications, especially when a right pneumonectomy is being considered after neoadjuvant chemotherapy. To clarify these issues, well-structured phase III trials comparing adjuvant to neoadjuvant chemotherapy are needed.

Minimally invasive surgical treatment of sigmoidal esophagus in achalasia.

BACKGROUND: The appropriate surgical intervention for sigmoidal esophagus in the setting of achalasia remains controversial. The objective of this study is to review our experience with minimally invasive myotomy (MIM) and minimally invasive esophagectomy (MIE) in the treatment of these patients. METHODS: We reviewed the records of 30 patients (19 men, 11 women); mean age 59.1 years (range 25-83 years) who underwent MIM (n = 24) or MIE (n = 6). Primary variables included perioperative and long-term outcomes. Univariate and multivariate analyses were performed to identify clinical variables predictive of myotomy failure. RESULTS: The operative mortality was zero and median hospital stay was 2 days (MIM) and 7 days (MIE). On follow-up (mean 30.5 months), nine (37.5%) patients undergoing primary MIM had failure requiring redo myotomy (n = 1) or esophagectomy (n = 8). Univariate analysis showed that previous myotomy and duration of symptoms were significant predictors of failure of MIM, with patient age trending toward significance. Multivariate analysis showed age and longer symptom duration to be significant. CONCLUSIONS: MIM affords symptomatic improvement in many patients. Age and symptom duration may be preoperative indicators of MIM failure. MIE offers similar symptom relief but is associated with a longer hospital stay. Further prospective studies are required to define the optimum treatment algorithm in the management of these patients.

Revisional surgery after esophagectomy: an analysis of 43 patients.

BACKGROUND: Reflux and postprandial fullness are common after esophagectomy. On occasion, these symptoms have an anatomic basis that requires operative correction. Two such conditions are the following: (1) a diaphragmatic hernia in which bowel herniates into the chest; and (2) a redundant conduit that impairs gastric emptying. The recognition of these conditions and the results of operative correction are the subject of this analysis. METHODS: A retrospective review from 1995 to 2007 identified patients who developed either a diaphragmatic hernia or a redundant gastric conduit after esophagectomy. The presenting symptoms, operative approach, and outcomes after surgery were recorded. RESULTS: Forty-three patients (representing 4% of the esophagectomy volume in this time period) were identified with a diaphragmatic hernia (n = 21), redundant gastric conduit (n = 19), or both (n = 3). Mean time from esophagectomy to diagnosis was 32 months for diaphragmatic hernia and 18 months for redundant conduit. The majority of hernias occurred to the left of the gastric conduit. A mechanical obstruction to gastric emptying was noted in 54% of patients with a redundant conduit. Forty patients underwent revisional surgery (minimally invasive: 35; open: 5). The recurrence rate after repair of a diaphragmatic hernia was 29%. Symptoms improved in 85% of patients after revision of a redundant conduit. CONCLUSIONS: A diaphragmatic hernia or redundant conduit may occur years after esophagectomy. Hernias almost always occur adjacent to the greater curve of the stomach. The development of a redundant conduit may be associated with a functional outflow obstruction. Surgical correction of these conditions can alleviate symptoms in the majority of patients.

Cervical pharyngostomy: an old technique revisited.

OBJECTIVE: To review our experience with pharyngostomy tubes used to manage complications following foregut surgery and to discuss technical aspects of insertion. SUMMARY BACKGROUND DATA: Cervical pharyngostomy tubes are percutaneously placed through the hypopharynx and directed into the stomach or small bowel. Historically, these tubes were placed during resection of head and neck cancer for postoperative nutrition. The technique may also be used to manage a variety of complications following esophagectomy or gastric surgery. METHODS: A retrospective review identified all patients who underwent pharyngostomy tube placement at the University of Pittsburgh Medical Center from 1995 to 2007. Indications, procedure-related complications, and duration of tube placement were recorded. RESULTS: Thirty-eight patients were identified. Indications for tube placement were: access for enteral nutrition (n = 18), drainage of mediastinal abscess (n = 4), gastric decompression (n = 13), and other (n = 3). Procedure-related complications included: cellulitis (n = 1), esophagitis (n = 1), aspiration pneumonia (n = 1), and tube migration (n = 9). Duration of tube placement was 51 days (range 1-279). No major complications occurred. CONCLUSIONS: Pharyngostomy tubes may be useful in the management of complications following esophageal or gastric surgery. They are more comfortable than nasogastric tubes and may be kept in place for several months if necessary. Bleeding or other major complications have not occurred in our experience.

Polyflex expandable stents in the treatment of esophageal disease: initial experience.

BACKGROUND: The new generation of expandable plastic esophageal stents (Polyflex; Boston Scientific, Natick, MA), combine the features of plastic and self-expanding metallic stents. The main objective of this study is to evaluate our initial experience with Polyflex expandable stents in the treatment of esophageal disease from two institutions. METHODS: A total of 58 Polyflex stents were placed in 38 patients over a two-year period. There were 24 men and 14 women, with a median age of 63 years (range, 25 to 83). The most common indication for placement was an esophageal stricture in 25 patients (66%); other causes included leak in 8 (21%) and tracheoesophageal fistula (TEF) in 5 (13%). We evaluated the hospital course, complications, and outcomes. RESULTS: The median postoperative stay was one day. Complications included migration in 38 stents (63%) (28 patients; 73%), retrosternal chest discomfort in nine, reflux in four, airway obstruction in one, and food impaction in three. Continued leak or a persistent TEF occurred in five patients (38%). Reintervention was required predominantly due to migration of the stent at a mean interval of 46 days (range, 1 to 353). Patients with dysphagia improved significantly with dysphagia scores (1 = no dysphagia; 5 = unable to swallow saliva) improving from 3.44 to 2.15 (p < 0.0001). CONCLUSIONS: Polyflex stents were effective in the relief of dysphagia due to strictures. They were less effective in esophageal perforations or leaks. Their primary disadvantage is a high migration rate and further improvements in design are required to decrease this high incidence of migration.

Minimally-invasive esophagomyotomy in 200 consecutive patients: factors influencing postoperative outcomes.

BACKGROUND: The primary objective of this study was to review our experience with minimally-invasive esophagomyotomy as primary therapy for achalasia, and to identify those clinical variables most predictive of myotomy failure. METHODS: We reviewed our experience with all patients who underwent minimally-invasive Heller myotomy from 1992 to 2005. Outcome variables analyzed included perioperative morbidity and mortality, symptomatic improvement, and requirement for postoperative interventions. Multivariate analysis was performed to identify clinical variables predictive of myotomy failure. RESULTS: A total of 200 consecutive patients (104 men and 96 women) underwent minimally-invasive laparoscopic (n = 194) or thoracoscopic (n = 6) Heller myotomy with partial fundoplication. Mean follow-up was 31.6 months. Median hospital stay was 2 days, with no operative mortality. There were 119 patients (59.5%) who had undergone prior endoscopic treatment (endoscopic dilation or botulinum toxin injection). An increased failure rate was noted in patients with prior endoscopic therapies (16.8% versus 3.7% with no prior treatment, p = 0.003). Multivariate analysis also revealed that longer duration of symptoms, sigmoidal esophageal changes, and low preoperative lower esophageal sphincter pressures impact adversely on the success of myotomy. CONCLUSIONS: There was an increase in treatment failures among patients undergoing preoperative endoscopic treatment. Other factors associated with failure during long-term follow-up include longer duration of symptoms, sigmoidal esophagus, and low baseline lower esophageal sphincter pressure. Although endoscopic modalities remain an important component of the armamentarium in the treatment of patients with achalasia, consideration should be given to minimally-invasive Heller myotomy as primary therapy for this condition.

Minimally invasive myotomy for achalasia in the elderly.

BACKGROUND: Elderly patients with achalasia are more frequently being referred for minimally invasive Heller myotomy (MIM). The associated morbidity and mortality of MIM in the elderly are not well defined. The objective of this study was to review our experience with MIM in the elderly. METHODS: We identified a total of 57 patients (32 men, 25 women) 70 years or older (mean age 78 years, range 70 to 96 years) who underwent MIM [55 laparoscopically (LAP), 2 videothoracoscopically (VATS)] for achalasia at our institution. Clinical outcomes were analyzed including postoperative surgical interventions (redo myotomy, esophagectomy), and dysphagia scores (range: 1, no dysphagia to 5, dysphagia to saliva). RESULTS: Thirty-seven (59.6%) patients had prior endoscopic therapy. There was no perioperative mortality and median hospital stay was 3 days. There were three (5.3%) conversions to open due to adhesions and concern regarding the viability of the myotomy following repair of a small perforation. A total of 11 (19.3%) patients had complications, including three (5.3%) intraoperative esophageal perforations, three pleural effusions, one (1.8%) pneumonia, one intraoperative gastric perforation, one C. difficile infection, one ileus, and one postoperative intubation. Mean follow-up was 23.5 months. Mean dysphagia score improved from 3.38 preoperatively to 1.36 following MIM (p < 0.0001), with 55 (96.5%) patients experiencing an improvement. Reoperation for recurrent dysphagia was required in four (7.0%) of the patients. CONCLUSIONS: MIM can be performed safely in elderly patients with achalasia in centers with significant experience in laparoscopic foregut surgery. MIM affords similar symptomatic improvement in the elderly as compared to younger patients. MIM should be seriously considered as a therapeutic strategy in elderly achalasia patients.

Comparison of surgical approaches to recalcitrant gastroesophageal reflux disease in the patient with scleroderma.

BACKGROUND: Scleroderma is associated with severe esophageal dysmotility and gastroesophageal reflux disease (GERD). Results after antireflux surgery have been suboptimal due to the profound esophageal dysmotility seen in this disease. We hypothesized that laparoscopic Roux-en-Y gastric bypass (RYGBP) would lead to less dysphagia and better control of GERD symptoms. This report summarizes our initial results of RYGBP compared with other surgical approaches. METHODS: A retrospective review identified scleroderma patients who underwent surgical management of GERD from 1995 to 2006. Complications and reinterventions were recorded. Symptom control was assessed by validated questionnaires that measured dysphagia (0 to 5; 0 = no dysphagia), GERD-heartburn-related quality of life index (0 to 45; 0 = best, 45 = worst), and overall quality of life with the Medical Outcomes Study 36-Item Short Form Health Survey. RESULTS: Twenty-three scleroderma patients underwent surgical treatment for GERD (fundoplication, n = 10; RYGBP, n = 8; esophagectomy, n = 5). One patient died after esophagectomy and major morbidity occurred in 3 of the remaining 4 patients. No major complications occurred in any patient undergoing either fundoplication or RYGBP. Eighteen patients underwent evaluation by questionnaire at a median of 21 months postoperatively. Decreased dysphagia (0.42 versus 1.86, p = 0.05) and improved control of reflux (GERD-heartburn-related quality of life index score 4 versus 15.6, p = 0.05) were observed in the RYGBP patients compared with those undergoing fundoplication. CONCLUSIONS: A high complication rate was seen among patients undergoing esophagectomy. Both reflux control and dysphagia rates were improved in the RYGBP group compared with fundoplication. This finding suggests that RYGBP may be an option for the primary management of scleroderma-associated gastroesophageal reflux.

Minimally invasive resection of benign esophageal tumors.

OBJECTIVE: Benign tumors of the esophagus are uncommon. Traditionally, resection has required thoracotomy or laparotomy. In this study we present our experience with resection of these tumors using a minimally invasive approach. METHODS: A retrospective review of patients who underwent resection of benign esophageal tumors between 1990 and 2005 was conducted. Operative approach, tumor size, and outcomes after surgery were recorded. RESULTS: Twenty patients were identified (leiomyoma: n = 15; stromal tumor: n = 3; granular cell tumor, n = 1; schwannoma: n = 1). Four patients underwent an open approach (right thoracotomy); the remainder were resected using minimally invasive techniques (thoracoscopy, n = 9; laparoscopy, n =7). There were no postoperative leaks or other major complications after surgery. Two patients required repair of a mucosal injury during resection. Mean tumor size in the open group was 8.1 cm (range 7-10 cm) compared with 3.5 cm (range 0.9-8 cm) in the minimally invasive group. Median length of stay was 5.5 days in the open group compared with 2.75 days in the minimally invasive group. Five patients subsequently required fundoplication for worsening (n = 3) or new-onset (n = 2) gastroesophageal reflux disease after tumor resection. CONCLUSIONS: Minimally invasive resection of benign esophageal tumors is technically safe and associated with a shorter length of stay compared with open approaches. Although no specific cutoff for size could be identified, most tumors greater than 7 cm were removed by thoracotomy. The subsequent development of reflux may be related to the esophageal myotomy required for resection.

Minimally invasive management of Boerhaave's syndrome.

We report the case of a 42-year-old man with Boerhaave's syndrome. His medical history was significant only for a long-standing history of dysphagia. The patient presented to the emergency department with vomiting, followed by severe retrosternal and epigastric pain of sudden onset. An esophagogram showed evidence of free extravasation of contrast from the left posterolateral aspect of the distal esophagus just above the level of the hiatus. A minimally invasive technique was used to repair this injury.

Initial experience with minimally invasive Ivor Lewis esophagectomy.

BACKGROUND: We have previously reported our experience with minimally invasive esophagectomy. Our standard approach involves laparoscopic and thoracoscopic mobilization of the esophagus with a cervical esophagogastric anastomosis. In the present study we report our early experience with a modification of this technique, in which a high intrathoracic anastomosis is performed. METHODS: From 2002 to 2005, a minimally invasive Ivor Lewis esophagectomy was performed in 50 patients. The planned approach included a totally laparoscopic abdominal procedure and either a minithoracotomy or thoracoscopy. Indications for esophagectomy included short segment Barrett's esophagus with high-grade dysplasia or resectable adenocarcinoma of the gastroesophageal junction (GEJ) with minimal proximal esophageal extension. . RESULTS: The median age was 62.3 years (range, 38 to 79). Twenty-five patients (50%) received either preoperative chemotherapy or chemoradiation. There was one nonemergent conversion to an open procedure during laparoscopy. Planned minithoracotomy was successful in 35 patients; an additional 15 patients had the entire thoracic component performed thoracoscopically. A circular stapled anastomosis was performed in all patients. The operative mortality was 6%. Three patients (6%) developed an anastomotic leak; all were successfully managed nonoperatively. Four patients (8%) developed postoperative pneumonia. There were no recurrent laryngeal nerve injuries. CONCLUSIONS: Minimally invasive Ivor Lewis esophagectomy was technically feasible and resulted in good initial results in our center, which is experienced in minimally invasive and open esophagectomy. This approach minimizes the degree of gastric mobilization, almost eliminates recurrent laryngeal nerve injury and pharyngeal dysfunction, and allows additional gastric resection margin in the case of cardia extension of GEJ tumors.

Minimally invasive operation for esophageal diverticula.

BACKGROUND: Mid and lower esophageal diverticula are rare entities usually managed by open operation. Morbidity can be significant with these complex procedures. This study evaluates our results of minimally invasive surgery for esophageal diverticula. METHODS: Over a 5-year period, 20 patients underwent operation for esophageal diverticula. Median age was 70.5 years. There were 16 epiphrenic and 4 midesophageal diverticula with a median size of 7.5 cm (range, 2-11 cm). Symptoms included dysphagia (14), regurgitation (12), weight loss (8), heartburn (4), aspiration pneumonia (3), chest pain (2), and vomiting (2). Dysphagia scores (1 = none, 5 = severe) were recorded before and after operation. RESULTS: Surgical approaches were laparoscopy (10), video-assisted thoracic surgery (VATS) (7), laparoscopic/VATS (2), and laparoscopic/thoracotomy (1). The most common operation performed was a diverticulectomy, myotomy, and partial fundoplication (12). Complications occurred in 9 (45%) patients and included 4 (20%) esophageal leaks. Three leak patients had successful outcomes; the fourth patient died 61 days after operation. Median hospital stay was 5.0 (1-61) days. Detailed follow-up was available in 18 patients at a median of 15 (1-70) months. Dysphagia scores improved significantly (p < 0.001) from 2.3 to 1.3 postoperatively. Symptomatic improvement was excellent in 13 (72%), good in 2 (11%), fair in 1 (6%), and poor in 2 (11%) patients. CONCLUSIONS: Minimally invasive operations for esophageal diverticula are feasible but also challenging. The potential for morbidity is significant. Patients should be selected and evaluated carefully before undertaking repair. Open surgery should remain the standard except in centers experienced with minimally invasive esophageal surgery.

Thoracic epidural versus intercostal nerve catheter plus patient-controlled analgesia: a randomized study.

BACKGROUND: Pain control is an important issue after thoracotomy. Ideal methods should have a high success rate, with easy implementation and minimal complications. Debate exists over the optimal pain control method. This randomized trial was designed to compare epidural (EPI) and intercostal nerve catheter with patient-controlled analgesia (ICN-PCA) for pain control after thoracotomy. METHODS: The study included 124 randomized patients; 91 had sufficient data for analysis (44 EPI, 47 ICN-PCA). The primary endpoint was pain measurement using a composite of a visual analogue scale, numerical rating, and categorical rating. A second endpoint was the success rate of each method. Pulmonary function tests, antibiotics, intensive care unit (ICU), and hospital days, and use of nonprotocol pain medications were also compared. RESULTS: There were 12 pain observations per patient (90% completed on days 1 to 5). The pain composite revealed an average postoperative pain score of 2.4 on a scale from 0 (no pain) to 10 (worst pain). There was no difference between the groups. Failures of the planned method of analgesia included 9 in the EPI group and 4 in the ICN group (p = 0.23). Another 20 patients were excluded (no difference between groups) due to unsuspected mediastinal metastases precluding thoracotomy (n = 13), and other miscellaneous factors precluding follow-up (n = 7). The EPI group had an increased number of urinary catheter days (2.5 days vs 1.7, p = 0.002) and increased narcotic supplements (p = 0.03) compared with ICN. Mean ICU days (0.9) and hospital days (6.2) were similar for both groups, and there were no differences in arrhythmias, pneumonias, transfusions, and antibiotic use. Significant differences were seen (p = 0.001) between preoperative and postoperative pulmonary function tests in both groups. However, there were no differences in pulmonary function when the groups were compared with each other. CONCLUSIONS: Satisfactory pain control was achieved after thoracotomy using either EPI or ICN-PCA. The ICN-PCA achieved equivalent pain control compared with EPI, and was placed by the surgeon with no delays in surgery, and demonstrated a decreased requirement for Foley catheter duration.

Photodynamic therapy as palliation for esophageal cancer: experience in 215 patients.

BACKGROUND: Photodynamic therapy (PDT) utilizes a photosensitizing agent, light, and oxygen to endoscopically ablate cancer cells. This review summarizes our experience with PDT for the palliation of bleeding or obstructing esophageal cancer (EC). METHODS: All patients with bleeding or obstructing EC treated with PDT from November 1996 through June 2002, were reviewed. After Photofrin II injection, nonthermal light treatment was delivered endoscopically. Dysphagia scores, duration of palliation, reinterventions, complications, and survival after treatment were reviewed. RESULTS: A total of 215 patients underwent 318 courses of PDT for bleeding (n = 15), obstruction (n = 277), bleeding and obstruction (n = 18), or other indications (n = 8). Tumor histology included 179 adenocarcinomas, 33 squamous cell carcinomas, and 3 undifferentiated. Seventy-five percent of EC were in the distal esophagus. In 85% of courses for obstruction, mean dysphagia scores improved pre- and post-PDT. The mean dysphagia-free interval was 66 days. Supplemental nutrition was discontinued after PDT in 8 of 27 patients (30%). Thirty-five patients required stent placement after PDT with a mean interval to reintervention of 58.5 days. PDT complications included perforation (2% of treatment courses), stricture (2%), Candida esophagitis (2%), pleural effusions (4%), and sunburn (6%). The procedure-related mortality rate was 1.8%, and median survival was 4.8 months. CONCLUSIONS: PDT offers effective palliation for patients with obstructing EC in 85% of treatment courses. The ideal EC patient for PDT palliation has an obstructing endoluminal cancer. Patients living more than 2 months may require reintervention to maintain palliation of malignant dysphagia, and a multimodality treatment approach is common.

Minimally invasive esophagectomy: outcomes in 222 patients.

OBJECTIVE: To assess our outcomes after minimally invasive esophagectomy (MIE). SUMMARY BACKGROUND DATA: Esophagectomy has traditionally been performed by open methods. Results from most series include mortality rates in excess of 5% and hospital stays frequently greater than 10 days. MIE has the potential to improve these results, but only a few small series have been reported. This report summarizes our experience of 222 cases. METHODS: From 1996 to 2002, MIE was performed in 222 patients. Indications for operation included high-grade dysplasia (n = 47) and cancer (n = 175). Neoadjuvant chemotherapy was used in 78 (35.1%) and radiation in 36 (16.2%). Initially, a laparoscopic transhiatal approach was used (n = 8), but subsequently our approach evolved to include thoracoscopic mobilization (n = 214). RESULTS: There were 186 men and 36 women. Median age was 66.5 years (range, 39-89). Nonemergent conversion to open procedure was required in 16 patients (7.2%). MIE was successfully completed in 206 (92.8%) patients. The median intensive care unit stay was 1 day (range, 1-30); hospital stay was 7 days (range, 3-75). Operative mortality was 1.4% (n = 3). Anastomotic leak rate was 11.7% (n = 26). At a mean follow-up of 19 months (range, 1-68), quality of life scores were similar to preoperative values and population norms. Stage specific survival was similar to open series. CONCLUSIONS: MIE offers results as good as or better than open operation in our center with extensive minimally invasive and open experience. In this single institution experience, we observed a lower mortality rate (1.4%) and shorter hospital stay (7 days) than most open series. Given these results, we are now developing an intergroup trial (ECOG 2202) to assess MIE in a multicenter setting.