RESUMO
BACKGROUND: With the increasing use of computed tomography scans for lung cancer screening and surveillance of other cancers, thoracic surgeons are being referred patients with lung lesions for biopsies. Electromagnetic navigational bronchoscopy-guided lung biopsy is a relatively new technique for bronchoscopic biopsy. Our objective was to evaluate the diagnostic yields and safety of electromagnetic navigational bronchoscopy-guided lung biopsy. METHODS: We conducted a retrospective review of patients who underwent an electromagnetic navigational bronchoscopy biopsy, performed by a thoracic surgical service, and evaluated its safety and diagnostic accuracy. RESULTS: In total, 110 patients (men 46, women 64) underwent electromagnetic navigational bronchoscopy sampling of pulmonary lesions (n = 121; median size 27 mm; interquartile range 17-37 mm). There was no procedure-related mortality. Pneumothorax requiring pigtail drainage occurred in 4 patients (3.5%). Ninety-three (76.9%) of the lesions were malignant. Eighty-seven (71.9%) of the 121 lesions had an accurate diagnosis. Accuracy increased with increased lesion size (P = .0578) with a yield of 50% for lesions <2 cm, increasing to 81% for lesions ≥2 cm. The lesions that demonstrated a positive "bronchus sign" had a yield of 87% (45/52) compared with 61% (42/69) in lesions with a negative "bronchus sign" (P = .0359). CONCLUSION: Thoracic surgeons can perform electromagnetic navigational bronchoscopy safely, with minimal morbidity and with good diagnostic yields. Accuracy increases with the presence of a bronchus sign and increasing lesion size. Patients with larger tumors and the bronchus sign may be candidates for this approach to biopsy. Further work is required to define the role of electromagnetic navigational bronchoscopy in the diagnosis of pulmonary lesions.
Assuntos
Broncoscopia , Neoplasias Pulmonares , Masculino , Humanos , Feminino , Broncoscopia/métodos , Neoplasias Pulmonares/diagnóstico , Neoplasias Pulmonares/cirurgia , Neoplasias Pulmonares/patologia , Detecção Precoce de Câncer , Biópsia/métodos , Pulmão/diagnóstico por imagem , Pulmão/patologia , Fenômenos EletromagnéticosRESUMO
OBJECTIVE: Robotic-assisted minimally invasive esophagectomy accounts for a growing proportion of esophagectomies, potentially due to improved technical capabilities simplifying the challenging aspects of standard minimally invasive esophagectomy. However, there is limited evidence directly comparing both operations. The objective is to evaluate the short-term and long-term outcomes of robotic-assisted minimally invasive esophagectomy in comparison with the minimally invasive esophagectomy approach for patients with esophageal cancer over a 7-year period at a high-volume center. The primary end points of this study were overall survival and disease-free survival. Secondary end points included operation-specific morbidity, lymph node yield, readmission status, and in-hospital, 30-day, and 90-day mortality. METHODS: Patients who underwent robotic-assisted minimally invasive esophagectomy or standard minimally invasive esophagectomy over a 7-year period were identified from a prospectively maintained database. Inclusion criteria were patients with stage I to III disease, operations performed past the learning curve, and no evidence of scleroderma or cirrhosis. A 1:3 propensity match (robotic-assisted minimally invasive esophagectomy:minimally invasive esophagectomy) for multiple clinical covariates was performed to identify the final study cohort. Perioperative outcomes were compared between the 2 operations. RESULTS: A total of 734 patients undergoing minimally invasive esophagectomy (n = 630) or robotic-assisted minimally invasive esophagectomy (n = 104) for esophageal cancer were identified. After exclusions and matching, a total cohort of 246 patients undergoing robotic-assisted minimally invasive esophagectomy (n = 65) or minimally invasive esophagectomy (n = 181) were identified. There was no difference in overall survival (P = .69) or disease-free survival (P = .70). There were no significant differences in rates of major morbidity: pneumonia (17% vs 17%, P = .34), chylothorax (8% vs 9%, P = .95), recurrent laryngeal nerve injury (0% vs 1.5%, P = 1), anastomotic leak (5% vs 4%, P = .49), intraoperative complications (9% vs 8%, P = .73), or complete resection rates (99% vs 96%, P = .68). There was no difference in in-hospital (P = .89), 30-day (P = .66) or 90-day mortality (P = .73) between both cohorts. The robotic-assisted minimally invasive esophagectomy cohort yielded a higher median lymph node harvest in comparison with the minimally invasive esophagectomy cohort (32 vs 29, P = .02). CONCLUSIONS: Robotic-assisted minimally invasive esophagectomy may improve lymphadenectomy in patients undergoing esophagectomy for cancer. Minimally invasive esophagectomy and robotic-assisted minimally invasive esophagectomy are otherwise associated with similar mortality, morbidity, and perioperative outcomes. Further prospective study is required to investigate whether improved lymph node resection may translate to improved oncologic outcomes.
Assuntos
Neoplasias Esofágicas , Procedimentos Cirúrgicos Robóticos , Humanos , Esofagectomia/efeitos adversos , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Resultado do Tratamento , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Neoplasias Esofágicas/patologia , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Estudos RetrospectivosRESUMO
BACKGROUND: Esophagectomy is a complex operation and is associated with significant morbidity and mortality. In an attempt to lower morbidity, we have adopted a minimally invasive approach to esophagectomy. OBJECTIVES: Our primary objective was to evaluate the outcomes of minimally invasive esophagectomy (MIE) in a large group of patients. Our secondary objective was to compare the modified McKeown minimally invasive approach (videothoracoscopic surgery, laparoscopy, neck anastomosis [MIE-neck]) with our current approach, a modified Ivor Lewis approach (laparoscopy, videothoracoscopic surgery, chest anastomosis [MIE-chest]). METHODS: We reviewed 1033 consecutive patients undergoing MIE. Elective operation was performed on 1011 patients; 22 patients with nonelective operations were excluded. Patients were stratified by surgical approach and perioperative outcomes analyzed. The primary endpoint studied was 30-day mortality. RESULTS: The MIE-neck was performed in 481 (48%) and MIE-Ivor Lewis in 530 (52%). Patients undergoing MIE-Ivor Lewis were operated in the current era. The median number of lymph nodes resected was 21. The operative mortality was 1.68%. Median length of stay (8 days) and ICU stay (2 days) were similar between the 2 approaches. Mortality rate was 0.9%, and recurrent nerve injury was less frequent in the Ivor Lewis MIE group (P < 0.001). CONCLUSIONS: MIE in our center resulted in acceptable lymph node resection, postoperative outcomes, and low mortality using either an MIE-neck or an MIE-chest approach. The MIE Ivor Lewis approach was associated with reduced recurrent laryngeal nerve injury and mortality of 0.9% and is now our preferred approach. Minimally invasive esophagectomy can be performed safely, with good results in an experienced center.
Assuntos
Esofagectomia/métodos , Idoso , Anastomose Cirúrgica , Esofagectomia/efeitos adversos , Feminino , Humanos , Estimativa de Kaplan-Meier , Laparoscopia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Cirurgia Torácica VídeoassistidaRESUMO
Lung nodule and ground-glass opacity localization for diagnostic and therapeutic purposes is often a challenge for thoracic surgeons. While there are several adjuncts and techniques in the surgeon's armamentarium that can be helpful, accurate localization persists as a problem without a perfect solution. The last several decades have seen tremendous improvement in our ability to perform major operations with minimally invasive procedures and resulting lower morbidity. However, technological advances have not been as widely realized for lung nodule localization to complement minimally invasive surgery. This review describes the latest advances in lung nodule localization technology while also demonstrating that more efforts in this area are needed.
RESUMO
OBJECTIVE: A recent meta-analysis of 3 randomized controlled trials reported reduced incidence and severity of postesophagectomy anastomotic dehiscence with anastomotic omentoplasty. Unfortunately, these trials excluded neoadjuvant patients who received chemoradiation. We aimed to determine whether anastomotic omentoplasty was associated with differential postesophagectomy anastomotic complications after neoadjuvant chemoradiotherapy. METHODS: Data for patients who underwent minimally invasive esophagectomy following neoadjuvant chemoradiotherapy were abstracted (n = 245; 2001-2016; omentoplasty = 147 [60%]). Propensity for omentoplasty was estimated on 21 pretreatment variables, using augmented inverse probability of treatment weights, and used to determine the adjusted proportion of adverse anastomotic outcomes, major morbidity, and 30-day/in-hospital mortality. RESULTS: Overall, anastomotic leak rate was 15%; leak-associated mortality was 13% (n = 5 out of 37). Leak rates (omentoplasty n = 24 [16%] vs no omentoplasty n = 13 [13%]; P = .512) and incidence of any major complications (48% vs 48%; P = .958) were similar. Leaks requiring surgical intervention occurred in 12 patients (5% vs 5%; P = .904). Propensity weighting achieved excellent balance across all 21 pretreatment variables (before weighting, standardized differences ranged from -0.23 to 0.35; postweighting standardized differences ranged from -0.09 to 0.07). In propensity-weighted data, omentoplasty was not associated with differential adjusted risk of anastomotic leak (13.2% vs 14.3%; P = .83), major morbidity (27.9% vs 32.6%; P = .44), or mortality (6.7% vs 4.8%; P = .61). CONCLUSIONS: Within the limits of our sample size and statistical approach, our study failed to find evidence that anastomotic omentoplasty during esophagectomy after neoadjuvant chemoradiation reduced anastomotic leak rate or need for leak-related reoperation.
Assuntos
Fístula Anastomótica , Neoplasias Esofágicas/terapia , Esofagectomia/efeitos adversos , Omento/cirurgia , Idoso , Fístula Anastomótica/mortalidade , Fístula Anastomótica/cirurgia , Quimiorradioterapia/efeitos adversos , Quimiorradioterapia/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Terapia Neoadjuvante/efeitos adversos , Terapia Neoadjuvante/estatística & dados numéricos , Pontuação de Propensão , Estudos Prospectivos , Procedimentos de Cirurgia PlásticaRESUMO
BACKGROUND: Epiphrenic diverticula are rare outpouchings of the distal esophagus that infrequently require surgical intervention for the treatment of symptoms. In cases where surgical therapy is indicated, the traditional approach is through a thoracotomy. Advances in minimally invasive techniques have led to thoracoscopic and more recently laparoscopic management of epiphrenic diverticula. The purpose of this article is to review the literature on minimally invasive surgery for epiphrenic diverticula with particular attention to the operative approach and technique, surgical mortality and morbidity, and symptomatic outcomes. METHODS: A review of the literature limited to studies in the English language and performed on humans was conducted on PubMed using the following key words: "esophageal diverticula" and "epiphrenic". Articles retrieved by the PubMed search were reviewed. CONCLUSIONS: A minimally invasive approach to epiphrenic diverticula offers reduced operative mortality, decreased length of stay, and similar symptom relief compared with open surgery in the hands of experienced laparoscopic surgeons.
Assuntos
Procedimentos Cirúrgicos do Sistema Digestório/métodos , Divertículo Esofágico/cirurgia , Cirurgia Torácica Vídeoassistida , Divertículo Esofágico/mortalidade , Fundoplicatura , Humanos , Laparoscopia , Tempo de InternaçãoRESUMO
Recurrent symptomatic paraesophageal hernias (PEHs) can lead to significant morbidity if untreated. Surgical treatment of recurrent PEH can pose a great challenge. Several different surgical options are available and need to be considered on an individual basis. Before embarking on the repair of a recurrent hernia, a thorough work-up needs to be completed. Although recurrent PEHs have traditionally been repaired through an open approach, a minimally invasive approach can be performed by surgeons with extensive experience in minimally invasive esophageal surgery. Repair of recurrent PEH provides excellent patient satisfaction and symptoms resolution. Routine follow-up with surveillance imaging can assist in treating recurrent symptoms.
Assuntos
Hérnia Hiatal/cirurgia , Herniorrafia/métodos , Reoperação/métodos , Humanos , Laparoscopia , Satisfação do Paciente , Recidiva , Resultado do TratamentoRESUMO
OBJECTIVES: Anatomic lung resection provides the best opportunity for long-term survival in the setting of early-stage non-small cell lung cancer (NSCLC). However, 20-30% of patients develop recurrent disease following complete (R0) resection for Stage I disease. In the current study, we analyze the impact of patient, surgical and pathologic variables upon recurrence patterns following anatomic lung resection for clinical stage I NSCLC. PATIENTS AND METHODS: A total of 1132 patients (384 segmentectomies, 748 lobectomies) with clinical stage I NSCLC were evaluated. Predictors of recurrence were identified by proportional hazards regression. Differences in recurrence patterns between groups are illustrated by log rank tests applied to Kaplan-Maier estimates. RESULTS: A total of 227 recurrences (20.0%) were recorded at a median follow-up of 36.8 months (65 locoregional, 155 distant). There was no significant difference in recurrence patterns when comparing segmentectomy and lobectomy. Multivariate analysis demonstrated that angiolymphatic invasion, tumor size, tumor grade and the presence of only mild-moderate tumor inflammation were independent predictors of recurrence risk. CONCLUSIONS: Recurrence following anatomic lung resection is influenced predominantly by pathological variables (tumor size, tumor grade, angiolymphatic invasion, tumor inflammation). Optimization of surgical margin in relation to tumor size may improve outcomes. Extent of resection (segmentectomy vs. lobectomy) does not appear to have an impact on recurrence-free survival when adequate margins are obtained.
Assuntos
Carcinoma Pulmonar de Células não Pequenas/patologia , Carcinoma Pulmonar de Células não Pequenas/cirurgia , Neoplasias Pulmonares/patologia , Neoplasias Pulmonares/cirurgia , Pneumonectomia , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma Pulmonar de Células não Pequenas/mortalidade , Comorbidade , Feminino , Seguimentos , Humanos , Neoplasias Pulmonares/mortalidade , Masculino , Margens de Excisão , Pessoa de Meia-Idade , Recidiva Local de Neoplasia , Estadiamento de Neoplasias , Pneumonectomia/efeitos adversos , Pneumonectomia/métodos , Prognóstico , Modelos de Riscos Proporcionais , Fatores de Risco , Resultado do Tratamento , Adulto JovemRESUMO
INTRODUCTION: Electromagnetic navigation bronchoscopy (ENB)-guided pleural dye marking is useful to localize small peripheral pulmonary nodules for sublobar resection. OBJECTIVE: To report findings on the use of ENB-guided dye marking among participants in the NAVIGATE study. METHODS: NAVIGATE is a prospective, multicentre, global and observational cohort study of ENB use in patients with lung lesions. The current subgroup report is a prespecified 1-month interim analysis of ENB-guided pleural dye marking in the NAVIGATE United States cohort. RESULTS: The full United States cohort includes 1215 subjects from 29 sites (April 2015 to August 2016). Among those, 23 subjects (24 lesions) from seven sites underwent dye marking in preparation for surgical resection. ENB was conducted for dye marking alone in nine subjects while 14 underwent dye marking concurrent with lung lesion biopsy, lymph node biopsy and/or fiducial marker placement. The median nodule size was 10 mm (range 4-22) and 83.3% were <20 mm in diameter. Most lesions (95.5%) were located in the peripheral third of the lung, at a median of 3.0 mm from the pleura. The median ENB-specific procedure time was 11.5 minutes (range 4-38). The median time from dye marking to resection was 0.5 hours (range 0.3-24). Dye marking was adequate for surgical resection in 91.3%. Surgical biopsies were malignant in 75% (18/24). CONCLUSION: In this study, ENB-guided dye marking to localize lung lesions for surgery was safe, accurate and versatile. More information is needed about surgical practice patterns and the utility of localization procedures.
Assuntos
Broncoscopia/métodos , Corantes/administração & dosagem , Campos Eletromagnéticos/efeitos adversos , Neoplasias Pulmonares/diagnóstico por imagem , Pulmão/diagnóstico por imagem , Idoso , Idoso de 80 Anos ou mais , Biópsia , Broncoscopia/tendências , Fenômenos Eletromagnéticos , Feminino , Marcadores Fiduciais , Humanos , Pulmão/patologia , Neoplasias Pulmonares/patologia , Neoplasias Pulmonares/cirurgia , Linfonodos/patologia , Masculino , Pessoa de Meia-Idade , Pleura/metabolismo , Pleura/patologia , Estudos Prospectivos , Cirurgia Torácica Vídeoassistida/métodos , Estados Unidos/epidemiologiaRESUMO
OBJECTIVES: Computed tomography-guided fine needle aspiration (CT-FNA) biopsy is a well-established diagnostic technique in the evaluation of lung nodules that is performed by radiologists in most centers. In this series, we analyzed the diagnostic and perioperative outcomes following CT-FNA performed by a dedicated group of thoracic surgeons. METHODS: We conducted a retrospective analysis of 955 patients undergoing CT-FNA by the thoracic surgery service. Primary outcome variables included diagnostic yield and accuracy, number of needle passes, complication rates, and adequacy of specimen for molecular testing. RESULTS: A satisfactory diagnostic specimen was obtained in 94.1% of cases. The average number of needle passes was 3.2 ± 1.5 (range, 1-10 passes). Diagnostic yield was significantly improved by increasing the number of passes from 1 to 2 to 3 passes (P = .0003). CT-FNA diagnostic accuracy was 88.8%. Diagnostic accuracy did not significantly improve with ≥4 passes (P = .20). Molecular testing was successful in 43.1%, and did not improve with ≥4 passes (P = .5). Molecular testing success did improve with the addition of core needle biopsy (P = .005). The pneumothorax rate for CT-FNA alone was 26.4%, and increased with ≥4 passes (P = .009). The median length of stay for CT-FNA alone was 0 days (range, 0-74 days), with same-day discharge in 67.5% of patients. CONCLUSIONS: Thoracic surgeons can perform CT-FNA with excellent diagnostic yield and accuracy. Diagnostic yield, accuracy, and success in molecular testing do not improve with ≥4 CT-FNA passes. Pneumothorax rates do increase with ≥4 passes. The addition of core needle biopsy enhances success with molecular testing.
RESUMO
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.
Assuntos
Nutrição Enteral/métodos , Faringostomia/métodos , Complicações Pós-Operatórias/cirurgia , Adulto , Idoso , Estudos de Coortes , Nutrição Enteral/instrumentação , Esofagectomia/efeitos adversos , Esofagectomia/métodos , Feminino , Seguimentos , Gastrectomia/efeitos adversos , Gastrectomia/métodos , Neoplasias de Cabeça e Pescoço/patologia , Neoplasias de Cabeça e Pescoço/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Faringostomia/efeitos adversos , Complicações Pós-Operatórias/diagnóstico , Estudos Retrospectivos , Medição de Risco , Sensibilidade e Especificidade , Resultado do TratamentoRESUMO
BACKGROUND: We present a case of a morbidly obese patient with previous laparoscopic Nissen fundoplication (LNF) who was successfully treated by revision to a laparoscopic Roux-en-Y gastric bypass (RYGB) and discuss our collective experience. METHODS: Between June 2000 and April 2006 seven morbidly obese patients with mean body mass index (BMI) of 39.4 kg/m(2) underwent laparoscopic revision of LNF to RYGB by our group. Important steps of the revision include lysis of all adhesions between the liver and the stomach, dissection of the diaphragmatic crura and gastroesophageal fat pad, reduction and repair of hiatal hernia and complete take-down of the wrap to avoid stapling over the fundoplication which can create an obstructed, septated pouch. RESULTS: There was one (14.3%) conversion. Mean operative time (OT) was 324 (206-419) minutes and length of stay was 4.9 (3-8) days. Early complications occurred in 3/7 (42.9%) patients including a staple line hemorrhage without a need for re-exploration, a small pulmonary embolism without hemodynamic instability and a small-bowel obstruction due to a pre-existing incisional ventral hernia that was not repaired on original operation. There were no anastomotic leaks or deaths. At a mean follow-up of 32.9 (12-39) months, mean percentage excess weight loss was 79.5% and 18/28 (64.3%) comorbid conditions were improved or resolved. Gastroesophageal reflux disease (GERD) evaluation with the GERD health-related quality of life (GERD-HRQL) scale showed a significant reduction of GERD scores postoperatively (16.7 versus 4.4). CONCLUSIONS: Although laparoscopic RYGB after antireflux surgery is technically difficult and carries higher morbidity, it is feasible and effective in the treatment of recurrent GERD in morbidly obese patients.
Assuntos
Fundoplicatura/métodos , Derivação Gástrica/métodos , Refluxo Gastroesofágico/cirurgia , Laparoscopia/métodos , Obesidade Mórbida/cirurgia , Adulto , Comorbidade , Estudos de Viabilidade , Feminino , Seguimentos , Derivação Gástrica/estatística & dados numéricos , Refluxo Gastroesofágico/complicações , Hérnia Hiatal/complicações , Hérnia Hiatal/cirurgia , Humanos , Laparoscopia/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Obesidade Mórbida/complicações , Complicações Pós-Operatórias/epidemiologia , Recidiva , Reoperação/métodos , Reoperação/estatística & dados numéricos , Aderências Teciduais/cirurgiaRESUMO
Esophageal cancer is one of the most common malignancies in the world today and the sixth-leading cause of cancer-related mortality. Accurate preoperative staging of esophageal cancer is imperative to the selection of appropriate treatments. Patients with esophageal carcinomas typically undergo a multimodality staging process including noninvasive imaging techniques, such as computed tomography (CT) and positron emission tomography (PET), as well as endoscopic ultrasound (EUS), which is slightly more invasive. Minimally invasive surgical staging, with laparoscopy, occasionally in combination with video-assisted thoracoscopy, is used in the staging process at select institutions and has been shown to be more accurate than noninvasive staging modalities. Two major advantages of minimally invasive surgical staging over conventional techniques are the improved assessment of locoregional disease and enhanced identification of distant metastases. These advantages decrease the likelihood that the patient will undergo a nontherapeutic laparotomy. Currently, no clear consensus exists regarding which patients with esophageal cancer would benefit most from the addition of minimally invasive surgical staging. We have, however, found that minimally invasive surgical staging with laparoscopy is particularly valuable in detection of occult distant metastases. In this article, we summarize the staging modalities for esophageal cancer including minimally invasive surgical staging.
RESUMO
BACKGROUND: Equipoise still exists regarding routine mesh cruroplasty during laparoscopic paraesophageal hernia (PEH). We aimed to determine whether selective mesh cruroplasty is associated with differences in recurrence and patient-reported outcomes. METHODS: We compared symptom outcomes (n = 688) and radiographic recurrences (n = 101; at least 10% [or 2 cm] of stomach above hiatus) for 795 non-emergent PEH repair with fundoplication (n = 106 with mesh). RESULTS: Heartburn, regurgitation, epigastric pain, and anti-reflux medication use decreased significantly in both groups while postoperative dysphagia (mesh; p = 0.14), and bloating (non-mesh; p = 0.32), were unchanged. Radiographic recurrence rates were similar (15 mesh [22%] versus 86 non-mesh [17%]; p = 0.32; median 27 [IQR 14, 53] months), but was associated with surgical dissatisfaction (13% vs 4%; p = 0.007). CONCLUSIONS: Selective mesh cruroplasty was not associated with differences in symptom outcomes or radiographic recurrence rates during laparoscopic PEH repair. Radiographic recurrence was associated with dissatisfaction, emphasizing the need for continued focus on reducing recurrences.
Assuntos
Hérnia Hiatal/cirurgia , Herniorrafia/métodos , Laparoscopia , Telas Cirúrgicas , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Satisfação do Paciente , Complicações Pós-Operatórias , Qualidade de Vida , Recidiva , Estudos Retrospectivos , Fatores de Risco , Resultado do TratamentoRESUMO
INTRODUCTION: Patients undergoing non-elective paraesophageal hernia repair (PEHR) have worse perioperative outcomes. Because they are usually older and sicker, however, these patients may be more prone to adverse events, independent of surgical urgency. Our study aimed to determine whether non-elective PEHR is associated with differential postoperative outcome compared to elective repair, using propensity-score weighting. METHODS: We abstracted data for patients undergoing PEHR (n = 924; non-elective n = 171 (19 %); 1997-2010). Using boosted regression, we generated a propensity-weighted dataset. Odds of 30-day/in-hospital mortality and major complications after non-elective surgery were determined. RESULTS: Patients undergoing non-elective repair were significantly older, had more adverse prognostic factors, and significantly more major complications (38 versus 18 %; p < 0.001) and death (8 versus 1 %; p < 0.001). After propensity weighting, median absolute percentage bias across 28 propensity-score variables improved from 19 % (significant imbalance) to 5.6 % (well-balanced). After adjusting propensity-weighted data for age and comorbidity score, odds of major complications were still nearly two times greater (OR 1.67, CI 1.07-2.61) and mortality nearly three times greater (OR 2.74, CI 0.93-8.1) than for elective repair. CONCLUSIONS: Even after balancing significant differences in baseline characteristics, non-elective PEHR was associated with worse outcomes than elective repair. Symptomatic patients should be referred for elective repair by experienced surgeons.
Assuntos
Hérnia Hiatal/cirurgia , Herniorrafia/efeitos adversos , Complicações Pós-Operatórias , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Pontuação de Propensão , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Computed tomography scans are increasingly used not only for lung cancer screening but also for staging and evaluation of other cancers. As a result, more patients with pulmonary nodules, many with subcentimeter lesions, are being referred to thoracic surgeons, some with concern for primary lung neoplasm and others with possible metastatic lung lesions. Obtaining a definitive diagnosis of these lesions is difficult. Electromagnetic navigational bronchoscopy (ENB)-guided pleural dye marking followed by thoracoscopic resection is a novel alternative technique for definitive diagnosis. The main objective of this study was to evaluate the feasibility and our initial experience with ENB-guided dye localization and minimally invasive resection for diagnosis of lung lesions. METHODS: Selected patients with lung lesions underwent ENB-guided dye marking and minimally invasive resection. The primary end points were the rate of nodule localization and definitive diagnosis of the nodule. RESULTS: We performed ENB-guided localization and minimally invasive resection in 29 patients. The median lesion size was 10 mm, with a median distance from pleural surface of 13 mm. The operative mortality was 0%. The median hospital stay was 3 days. The nodule was localized and resected, and a definitive diagnosis was obtained in all patients (29 of 29; 100%). The nodule was neoplastic in 19 patients. All malignant lesions were completely resected with negative microscopic margins. CONCLUSIONS: Our initial experience with ENB-guided dye localization and minimally invasive resection found that the technique was feasible, safe, and successful in the diagnosis of small lung lesions. Thoracic surgeons should further investigate this method and incorporate it into their armamentarium.
Assuntos
Broncoscopia/métodos , Detecção Precoce de Câncer , Neoplasias Pulmonares/diagnóstico , Nódulos Pulmonares Múltiplos/diagnóstico , Pneumonectomia/métodos , Toracoscopia/métodos , Idoso , Fenômenos Eletromagnéticos , Feminino , Humanos , Neoplasias Pulmonares/cirurgia , Masculino , Nódulos Pulmonares Múltiplos/cirurgia , Estudos Retrospectivos , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND: Postoperative infection increases cancer recurrence and worsens survival in colorectal cancer, but the relationship for esophagogastric adenocarcinoma after esophagectomy is not well defined. We aimed to determine whether recurrence and survival after minimally invasive esophagectomy for esophagogastric adenocarcinoma were influenced by postoperative infection using propensity-matched analysis. METHODS: We abstracted data for 810 patients (1997-2010) and defined exposure as at least 1 in-hospital or 30-day infectious complication (n = 206 [25%]). Using 29 pretreatment/intraoperative variables, patients were propensity-score matched (caliper = 0.05). Time to cancer recurrence and survival (Kaplan-Meier curves and the Breslow test), and associated factors (Cox regression with shared frailty) were assessed. RESULTS: After propensity matching (n = 167 pairs), median bias across propensity-score variables was reduced from 12.9% (p < 0.001) to 4.4% (p = 1.000). Postoperative infection was not associated with rate (n = 60 versus 63; McNemar p = 0.736) or time to recurrence in those in whom disease recurred (median, 10.7 versus 11.1 months; Wilcoxon signed-rank p = 0.455) but was associated with shorter overall survival (n = 124 versus 102 deaths; median, 26 versus 41 months; Breslow p = 0.002). After adjusting for age, body mass index, neoadjuvant therapy, sex, comorbidity score, positive resection margins, pathologic stage, R0 resection, and recurrence, postoperative infection was associated with a 44% greater hazard for death (hazard ratio, 1.44; 95% confidence interval, 1.10-1.89). CONCLUSIONS: In patients with esophagogastric adenocarcinoma, infections after esophagectomy were not associated with an increased rate or earlier time to recurrence when baseline characteristics associated with infection risk were balanced using propensity-score matching. Despite this, overall survival was shorter in patients with infectious complications. After adjusting for other important survival predictors, infections after esophagectomy continued to be independently associated with worse survival.
Assuntos
Adenocarcinoma/cirurgia , Neoplasias Esofágicas/cirurgia , Esofagectomia/efeitos adversos , Recidiva Local de Neoplasia/etiologia , Estadiamento de Neoplasias , Infecção da Ferida Cirúrgica/complicações , Adenocarcinoma/diagnóstico , Idoso , Neoplasias Esofágicas/diagnóstico , Esofagectomia/métodos , Feminino , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Recidiva Local de Neoplasia/diagnóstico , Recidiva Local de Neoplasia/epidemiologia , Pennsylvania/epidemiologia , Pontuação de Propensão , Estudos Retrospectivos , Infecção da Ferida Cirúrgica/epidemiologia , Taxa de Sobrevida/tendências , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: To report the presentation and management of early complete proximal small bowel obstruction from intraluminal clot after laparoscopic Roux-en-Y gastric bypass. METHODS: We performed a retrospective chart review of 5 female patients who developed small bowel obstruction at the jejunojejunostomy (JJ) secondary to intraluminal clot from January 2001 to January 2003. We analyzed the signs and symptoms, etiology of bowel obstruction, and operative treatment. RESULTS: From January 2001 to January 2003, 5 patients who had undergone successful laparoscopic Roux-en-Y gastric bypass developed proximal small bowel obstruction from a solid intraluminal clot secondary to staple line bleeding. All patients were women, with an average age and body mass index of 37 years and 43.41 kg/m(2), respectively. All patients underwent an upper gastrointestinal series on postoperative day 1, which revealed no leak, and all became symptomatic on postoperative day 2. Tachycardia and a "sense of impending doom" were both observed in 80% of the patients with this clinical syndrome. The intraoperative findings consistently revealed intraluminal clot obstructing the JJ. After reexploration and anastomotic revision, all patients had an uneventful recovery, with an average hospital length of stay of 9.8 days (range 8-11). CONCLUSION: Staple line bleeding potentially exacerbated by perioperative subcutaneous heparin use can cause proximal small bowel obstruction at the JJ after laparoscopic Roux-en-Y gastric bypass. It presents on postoperative day 2 most commonly as tachycardia and a "sense of impending doom." Prompt recognition and immediate reexploration will lead to an uneventful recovery. The need for complete anastomotic JJ revision is discussed.
Assuntos
Derivação Gástrica/efeitos adversos , Hematoma/etiologia , Obstrução Intestinal/etiologia , Intestino Delgado , Obesidade Mórbida/cirurgia , Adulto , Feminino , Humanos , Laparoscopia , Estudos RetrospectivosRESUMO
OBJECTIVES: Prognosis for patients with locally advanced esophagogastric adenocarcinoma (EAC) is poor with surgery alone, and adjuvant therapy after open esophagectomy is frequently not tolerated. After minimally invasive esophagectomy (MIE); however, earlier return to normal function may render patients better able to receive adjuvant therapy. We examined whether primary MIE followed by adjuvant chemotherapy influenced survival compared with propensity-matched patients treated with neoadjuvant therapy. METHODS: Patients with stage II or higher EAC treated with MIE (N = 375) were identified. Using 30 pretreatment covariates, propensity for assignment to either neoadjuvant followed by MIE (n = 183; 54%) or MIE as primary therapy (n = 156; 46%) was calculated, generating 97 closely matched pairs. Hazard ratios were adjusted for age, sex, body mass index, smoking, comorbidity, and final pathologic stage. RESULTS: In propensity-matched pairs, adjusted hazard ratio for death did not differ significantly for primary MIE compared with neoadjuvant (hazard ratio, 0.83; 95% confidence interval, 0.60-1.16). Recurrence patterns were similar between groups and 65% of patients with IIb or greater pathologic stage received adjuvant therapy. Clinical staging was inaccurate in 37 out of 105 patients (35%) who underwent primary MIE (n = 18 upstaged and n = 19 downstaged). CONCLUSIONS: Primary MIE followed by adjuvant chemotherapy guided by pathologic findings did not negatively influence survival and allowed for accurate staging compared with clinical staging. Our data suggest that primary MIE in patients with resectable EAC may be a reasonable approach, improving stage-based prognostication and potentially minimizing overtreatment in patients with early stage disease through accurate stage assignments. A randomized controlled trial testing this hypothesis is needed.
Assuntos
Adenocarcinoma/cirurgia , Neoplasias Esofágicas/cirurgia , Esofagectomia/métodos , Neoplasias Gástricas/cirurgia , Adenocarcinoma/mortalidade , Adenocarcinoma/patologia , Idoso , Diagnóstico por Imagem , Neoplasias Esofágicas/mortalidade , Neoplasias Esofágicas/patologia , Feminino , Humanos , Excisão de Linfonodo , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos , Terapia Neoadjuvante , Estadiamento de Neoplasias , Prognóstico , Pontuação de Propensão , Fatores de Risco , Neoplasias Gástricas/mortalidade , Neoplasias Gástricas/patologia , Taxa de SobrevidaRESUMO
BACKGROUND: Thoracic esophageal diverticula are uncommon, and controversies exist regarding their management. The objective of this study was to evaluate the outcomes of a relatively large cohort of patients with thoracic esophageal diverticula treated with minimally invasive surgical techniques. METHODS: We conducted a retrospective review of patients who underwent minimally invasive surgical treatment for symptomatic esophageal diverticula during a 15-year period. The primary end point was 30-day mortality. In addition, we evaluated the morbidity, improvement in dysphagia (score: 1, best to 5, worst), and quality of life (Gastroesophageal Reflux Disease-Health-Related Quality of Life score: 0, best to 50, most symptoms). RESULTS: Fifty-seven patients underwent minimally invasive surgical treatment of symptomatic thoracic esophageal diverticula. The most common symptom was dysphagia (45 of 57; 79%). A motility disorder or distal mechanical obstruction was identified in 49 patients (86%). Approaches used included video-assisted thoracoscopic surgery (n = 33), laparoscopy (n = 18), and combined video-assisted thoracoscopic surgery and laparoscopy (n = 6). The most common procedure performed was diverticulectomy and myotomy (47 of 57 patients; 82.5%). The 30-day mortality was 0%. There were 4 patients (7%) with postoperative leaks requiring reoperation. During follow-up, the median dysphagia score improved from 3 to 1 (p < 0.001). The median Gastroesophageal Reflux Disease-Health-Related Quality of Life score after surgery was 5 (excellent). CONCLUSIONS: A minimally invasive surgical approach for the management of thoracic esophageal diverticula is safe and effective during intermediate-term follow-up when performed by surgeons experienced in esophageal surgery and minimally invasive techniques. Further follow-up is required to assess the durability of these results. The optimal approach and procedures performed should be determined on an individualized basis after a thorough investigation.