Advanced age does not exclude lobectomy for non-small cell lung carcinoma.

STUDY OBJECTIVES: Localized non-small cell lung carcinoma (NSCLC) is best treated by complete surgical resection, commonly requiring lobectomy. The impact of lobectomy on the health status of the elderly patient is not well-characterized. The aim of this study was to compare the effect of lobectomy in elderly patients (> or = 70 years of age) and younger patients (< 70 years of age) on their pulmonary function and functional status 1 year following surgery. DESIGN: One hundred forty patients underwent lobectomy for NSCLC at the Minneapolis Veterans Affairs Medical Center from January 1999 to December 2003. All patients underwent pulmonary function tests (PFTs) and functional status assessment using Karnofsky scores (KS) that were assessed preoperatively. Sixty-three of 140 lobectomy patients were available 1 year postoperatively for reevaluation by PFTs and KS. RESULTS: There was no statistical difference between groups in either the pulmonary function or functional status testing results at 1 year after undergoing lobectomy. FVC decreased by 14% in the elderly patient and by 9% in the younger patient group. FEV1 decreased by 19% in elderly patients and by 13% in younger patients. Functional status declined for two older patients (8%), who dropped their KS from 80 to 100% (normal activity without limitation) to 40 to 70% (unable to work, but able to care of self at home). Nine of the younger patients (24%) had KS drop from 80 to 100% to 40 to 70%. There was one perioperative death (30-day mortality rate for the study groups, 1.5%). CONCLUSIONS: Elderly patients > or = 70 years of age undergoing lobectomy for NSCLC had similar PFT results and functional status as younger patients < 70 years of age 1 year after undergoing surgery. Curative resection should not be denied based on age alone.

Short esophagus and esophageal stricture.

Short esophagus and peptic esophageal stricture are complications of chronic severe GERD. Short esophagus is properly diagnosed by an objective,intraoperative assessment after appropriate dissection of the GEJ. A laparoscopic Collis gastroplasty combined with an antireflux procedure comprises effective therapy. Peptic stricture should be addressed with an initial course of dilator therapy and optimization of antiacid medication. Consideration is given to an antireflux procedure if conservative therapy fails. Laparoscopic techniques have proven to be safe and effective in treating short esophagus and peptic stricture.

Functional assessment of the cervical esophagus after gastric transposition and cervical esophagogastrostomy.

OBJECTIVES: The aim of this exploratory study was to investigate swallowing and function of the cervical esophagus after esophageal resection and reconstruction. METHODS: Nine patients (8 males, 1 female; median age 63 years), who underwent esophageal resection for adenocarcinoma, were studied from 6 to 40 months (median 18 months) postoperatively. For all patients, the upper gastrointestinal tract was reconstructed by transposing a narrow gastric tube through the posterior mediastinum to the left neck, where a semi-mechanical anastomosis to the cervical esophagus was performed. No patient had an anatomic obstruction to swallowing or stricture. The oral and pharyngeal phases of deglutition and function of the cervical esophagus were evaluated objectively by video barium swallow, esophagogastroscopy, velopharyngeal examination, manometry and balloon inflation in the cervical esophagus. RESULTS: The median length of the cervical esophagus was 5 cm (range 3-7 cm). Mild reflux laryngopharyngitis was seen in all patients. Although all patients had an objective functional dysphagia measurement (American Speech-Language-Hearing Association) of 7 (normal), five reported subjective dysphagia. Four (of the five symptomatic) patients were found to have high pressure peristalitic activity (mean >100 mmHg) following balloon distention (10-30 ml) of the cervical esophagus, which was painful in three cases. CONCLUSIONS: We conclude that in the absence of an anatomic cause for dysphagia after cervical esophagogastrostomy, a functional etiology may be explained by hypertensive peristalsis resulting from distention of the remaining cervical esophageal remnant. These findings may further explain anecdotal reports of the efficacy of empiric dilation after upper gastrointestinal reconstruction when no stricture is seen.

Atypical presentation of lymphomatoid granulomatosis in a patient with longstanding sarcoidosis.

A patient was recently evaluated who had longstanding sarcoidosis with lymphadenopathy and multiple, small lung nodules, and who developed a new, 9 cm solitary pulmonary mass in the right lower lobe. After thoracotomy, this lesion was ultimately found to be lymphomatoid granulomatosis, a rare lymphoproliferative disorder. Radiographic evaluations of patients with this disorder characteristically show multiple, bilateral reticulonodular opacities that follow the bronchovascular bundles; however, presentation with a solitary, large pulmonary mass is rare. The present case illustrates the need for complete evaluation of new clinical and radiographic findings in the setting of chronic lung disease.