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Background: While robotic-assisted lung resection has seen a significant rise in adoption, concerns remain regarding initial programmatic outcomes and potential increased costs. We present our initial outcomes and cost analysis since initiation of a robotic lung resection program., Methods: Patients undergoing either video-assisted thoracoscopic lobectomy or segmentectomy (VATS) or robotic-assisted lobectomy or segmentectomy (RALS) between August of 2014 and January of 2017 underwent retrospective review. Patients underwent 1:1 propensity matching based on preoperative characteristics. Perioperative and 30-day outcomes were compared between groups. Detailed activity-based costing analysis was performed on individual patient encounters taking into effect direct and indirect controllable costs, including robotic operative supplies., Results: There were no differences in 30-day mortality between RALS (n = 74) and VATS (n = 74) groups (0% vs 1.4%; P = 1). RALS patients had a decreased median length of stay (4 days vs 7 days; P < .001) and decreased median chest tube duration (3 days vs 5 days, P < .001). Total direct costs, including direct supply costs, were not significantly different between RALS and VATS ($6621 vs $6483; P = .784). Median total operating costs and total unit support costs, which are closely correlated to length of stay, were lower in the RALS group. Overall median controllable costs were significantly different between RALS and VATS ($16,352 vs $21,154; P = .025)., Conclusions: A potentially cost-advantageous robotic-assisted pulmonary resection program can be initiated within the context of an existing minimally invasive thoracic surgery program while maintaining good clinical outcomes when compared with traditional VATS. Process-of-care changes associated with RALS may account for decreased costs in this setting., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Segmentectomy for well-selected early stage non-small-cell lung carcinoma (NSCLC) has been shown to have similar oncologic outcomes and survival to lobectomy. However, these data are based on the presumption that the disease is node negative. Few data exist regarding the risk factors for and the outcomes of patients with disease treated with segmentectomy that is found to be node positive. We sought to determine the risk factors for and outcomes of clinical stage I NSCLC patients who are treated with segmentectomy but are determined to be node positive., Patients and Methods: We queried patients with clinical stage I NSCLC ≤ 3 cm within the National Cancer Data Base between 2004 and 2014 who were treated with segmentectomy or lobectomy and found to have positive nodes. Kaplan-Meier curves with log-rank tests were used to compare overall survival (OS) between segmentectomy and lobectomy. For comparison only, segmentectomy patients with pathologically node-negative disease were identified to determine predictors of node positivity after segmentectomy via multivariable logistic regression., Results: A total of 4556 patients with node-positive disease were identified, comprising 115 segmentectomy patients and 4441 lobectomy patients. Multivariable analysis identified increasing tumor size, squamous-cell histology, and increasing number lymph nodes sampled as significant predictors of node positivity after segmentectomy. There was no difference in OS between segmentectomy and lobectomy, with 3-year OS rates of 66.3% and 68.1%, respectively (P = .723)., Conclusion: There are discrete risk factors for discovering positive nodes after segmentectomy. Segmentectomy is associated with similar OS compared to lobectomy for clinical stage I NSCLC found to be node positive., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Checkpoint inhibitors (eg, programmed cell death protein 1 [PD-1], programmed cell death ligand 1 [PD-L1], cytotoxic T-lymphocyte associated protein 4 [CTLA-4] antibodies) are changing how we understand cancer and provide a means to develop modern immunotherapies. An emergent notion relates success with checkpoint inhibitors with high mutational load tumors. There are few studies that examine checkpoint protein expression and relate these to clinical outcomes after the conventional treatment of patients with esophageal cancer, which has a high mutational load. The objective of this review is to summarize the literature that examines checkpoint expression and clinical outcomes, as well as propose an accelerated approach to introducing these therapies into the clinic to treat patients with esophageal cancer., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Although the role for endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for metastatic lung cancer is well described, the usefulness of EBUS-TBNA for diagnosing lymphoma is less well defined. We aimed to determine the diagnostic accuracy for lymphoma of EBUS-TBNA with rapid, on-site evaluation in the evaluation of mediastinal lymphadenopathy in patients with a low-suspicion for lung cancer., Methods: Medical records for all EBUS-TBNA (381 total procedures) from 2007 to 2013 were reviewed, and procedure indication, prior workup, cytologic diagnosis, histologic follow-up, and available ancillary studies were abstracted. Intraoperative rapid on-site evaluation was performed for 170 of 173 patients (98%), and evaluations for 133 (78%) were adequate for diagnosis., Results: Of 381 patients, 173 (45.4%) underwent mediastinal tissue sampling to evaluate indeterminate mediastinal lymphadenopathy; 208 patients with known or suspected lung cancer were excluded. EBUS-TBNA provided a definitive diagnosis (predominantly carcinoma and granulomatous inflammation) in 71%. EBUS-TBNA was diagnostic in 8 of 16 patients (50%) where the final diagnosis of lymphoma in 16 was confirmed (9 non-Hodgkin, 6 Hodgkin, and 1 posttransplant lymphoproliferative disorder). EBUS-TBNA was indeterminate in 3 (19%), inadequate in 4 (25%), and falsely negative in 1 (6%). Histologic follow-up was available in 10 patients (63%). When the specimen was adequate for diagnosis, sensitivity for lymphoma was 89%., Conclusions: EBUS-TBNA has high sensitivity and a low false-negative rate for lymphoproliferative disorders when specimens are adequate for analysis and provides alternative diagnoses in most cases, thus reducing the need for mediastinoscopy. Rapid, on-site evaluation was nondiagnostic in approximately 25% of patients; performing EBUS-TBNA in the operating room facilitated conversion to mediastinoscopy and definitive diagnosis in this setting., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: A significant number of patients have recurrent or persistent lung cancer despite complete resection or treatment with definitive chemoradiation. Stereotactic radiosurgery (SRS)/stereotactic body radiation therapy is emerging as an important modality for the treatment of early-stage lung neoplasm; SRS may also offer an alternative treatment option for patients with recurrent lung disease. We evaluated outcomes after treatment with SRS for recurrent lung neoplasm in a large series of patients., Methods: Selected patients with limited recurrent, persistent, or progressive disease after one or more prior treatments for lung cancer were offered SRS. Thoracic surgeons evaluated all patients, placed fiducials when needed, and planned treatment in close collaboration with radiation oncologists and medical physicists. In our early experience, a single fraction of 20 Gy radiation was prescribed and was subsequently increased to 45 to 60 Gy in three to five fractions. The primary endpoint evaluated was overall survival., Results: We treated 100 patients with recurrent lung cancer (median age 72 years) with SRS. The postprocedure 30-day mortality rate was 0%; median follow-up was 51 months (range, 5 to 123). The median overall survival for the entire group was 23 months (95% confidence interval: 19 to 41). The probability of 2-year and 5-year overall survival was 49% (95% confidence interval: 40% to 60%) and 31% (95% confidence interval: 23% to 43%), respectively., Conclusions: Our experience indicates that SRS is safe, and offers an alternative modality for selected patients with recurrent oligometastatic or persistent lung cancer. Thoracic surgeons should actively participate in SRS and continue to evaluate the efficacy of this treatment strategy., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Intractable gastroesophageal reflux disease (GERD) after antireflux operations presents a challenge-particularly in obese patients and patients with esophageal dysmotility-and increases the complexity of the redo operation. This study evaluated the results of Roux-en-Y near esophagojejunostomy (RNYNEJ) in the management of recurrent GERD after antireflux operations., Methods: We conducted a retrospective review of overweight patients with intractable GERD who underwent RNYNEJ for failed antireflux operations. We evaluated perioperative outcomes, dysphagia (ranging from 1 = no dysphagia to 5 = unable to swallow saliva), and quality of life (QOL) (assessed using the GERD health-related quality-of-life instrument (HRQOL)., Results: Over a 12-year period, 105 patients with body mass index (BMI) greater than 25 underwent RNYNEJ for failed antireflux operations. Most were obese (BMI > 30; 82 patients [78%]); esophageal dysmotility was demonstrated in more than one-third of patients. Forty-eight (46%) patients had multiple antireflux operations before RNYNEJ, and 27 patients had undergone a previous Collis gastroplasty. There was no perioperative mortality. Major complications, including anastomotic leak requiring surgical intervention (n = 3 [2.9%]), were noted in 25 patients (24%).The median length of stay was 6 days. During follow-up (mean, 23.39 months), median BMI decreased from 35 to 27.6 (p < 0.0001), and the mean dysphagia score decreased from 2.9 to 1.5 (p < 0.0001). The median GERD HRQOL score, assessed in a subset of patients, was 9 (classified as excellent)., Conclusions: RNYNEJ for persistent GERD after antireflux operations in appropriately selected patients can be performed safely with good results in experienced centers. RNYNEJ should be considered an important option for the treatment of intractable recurrent symptoms after antireflux operations, particularly in obese patients., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Thoracic surgeons are commonly consulted to provide anterior thoracic exposure for infection and malignant neoplasms involving the thoracolumbar spine. These cases can present significant technical and management challenges secondary to the underlying pathology, associated anatomic inflammation, and impaired functional status. In this study, we review the perioperative outcomes in patients undergoing anterior spinal exposure for infection and neoplasm., Methods: 130 consecutive patients (61 women, 69 men) undergoing corpectomy, debridement, or debulking for osteomyelitis (n=50) or neoplasms (n=80) with decompression/stabilization at a single institution were analyzed. Primary endpoints included morbidity, mortality, and perioperative neurologic outcomes., Results: The mean age was 61.1 years. A cervical/sternotomy (n=8) approach was used for levels C7 to T2, thoracotomy (n=79) for levels T3 to T10, and thoracoabdominal (n=43) for T11 to L2 involvement. Primary spinal neoplasms (n=22, 16.9 %) and metastases (n=58, 44.6%) were treated with corpectomy and prosthetic stabilization and were associated with increased operative time (310 vs 243 minutes, p=0.02) and blood loss (825 vs 500 mL, p=0.002). Osteomyelitis was associated with longer hospital stays (12 vs 7 days, p<0.001). The 30-day and 90-day mortality was 9.2% and 20.8%, respectively. The major complication rate was 27.7%. The median length of stay was 9 days. Surgical intervention resulted in significant improvement in pain, numbness, weakness, and bowel and bladder dysfunction., Conclusions: Anterior spinal exposure represents an important modality in facilitating the treatment of patients with osteomyelitis, pathologic fractures, and spinal cord compression syndromes. These procedures are associated with a significant risk of morbidity and mortality, but they are effective in achieving spinal stabilization and alleviating neurologic symptoms., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Anatomic segmentectomy is a versatile sublobar resection approach that can be both diagnostic and therapeutic in the setting of the indeterminate pulmonary nodule (IPN), metastasectomy, as well as small, peripheral cancers. We analyzed the clinical indications and perioperative outcomes after anatomic segmentectomy and explored its utility in the diagnosis and treatment of IPNs and small stage IA lung cancers., Methods: This study is a retrospective review of 785 consecutive patients undergoing anatomic segmentectomy from 2002 to 2010. Primary outcome variables include perioperative course, morbidity, mortality, recurrence patterns, and survival., Results: Surgical indications included IPN (62.4%), known lung cancer (27.6%), suspected metastasis (4.1%), bullous disease (3.7%), or other (2.2%). Video-assisted thoracic surgery was employed in 468 (59.6%) and open thoracotomy in 317 (40.4%) patients. Median length of stay was 6 days. Overall complication rate was 34.9%. Thirty-day mortality was 1.1%. Among 490 patients with an IPN, 381 (77.7%) were found to have lung cancer, 41 (8.4%) metastatic cancer, and 68 (13.9%) benign disease. Among patients with pathologic stage IA lung cancer, there was no difference in recurrence rates (14.5% vs 13.9%) or 5-year freedom from recurrence estimates (78% in each group, p=0.738) when comparing segmentectomy and lobectomy., Conclusions: Anatomic segmentectomy provides acceptable morbidity and mortality when approaching the IPN. Cancer is identified in 86% of lesions. Complete surgical resection can be achieved with generous parenchymal margins and thorough nodal staging for small, peripheral stage IA non-small cell lung cancer. The use of anatomic segmentectomy should be considered in this era of competing image-guided diagnostic and therapeutic approaches to peripheral lung pathology., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: We present the perioperative outcomes of patients undergoing an anterior "extended Chamberlain" minithoracotomy as an alternative approach to a hemi-clamshell sternotomy or extended lateral thoracotomy for safe and reliable access to the pulmonary hilum and subsequent anatomic pulmonary resection., Methods: This study is a retrospective review of 162 patients undergoing anatomic lung resection through a mini anterior thoracotomy from 2002 to 2010. An 8-cm anterior thoracotomy was performed with the patient in a supine position, entering the chest through the second intercostal space. The pectoralis muscle fibers were split with preservation of the mammary artery medially and the thoracoacromial neurovascular bundle laterally. Primary outcome variables included hospital course, complications, and mortality rate., Results: The mean age was 63.9 (range, 20 to 85 years); female to male ratio was 71:91. Neoadjuvant therapy was used in 49 (30.2%) patients. Proposed resections were successful in 161 of 162 (99%) patients. Conversion to hemi-clamshell was required in 1 patient for vascular control. Complications occurred in 48 (29.6%) patients. Three (1.9%) perioperative deaths (2 pneumonectomies [6.3%], 1 lobectomy [1.0%]) occurred. Median length of stay was 8 days., Conclusions: The "extended Chamberlain" mini anterior thoracotomy provides direct and expeditious, less-invasive access to the pulmonary hilum. This approach preserves muscle function and avoids partial sternotomy or extended lateral thoracotomy, and their associated incisional-related morbidity., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Chylothorax is a rare but potentially lethal complication of esophagectomy. This study evaluated the rate of postesophagectomy chylothorax, identified associated risk factors, and compared postoperative outcomes in patients with and without chylothorax., Methods: We reviewed 892 consecutive patients who underwent esophagectomy (1997 to 2008). Preoperative, operative, and postoperative details, including adverse outcomes and mortality, were analyzed., Results: Postesophagectomy chylothorax occurred in 34 patients (3.8%). Chylothorax was significantly associated with 30-day major complications (85% vs 46%; p<0.001), including an increased likelihood of sepsis (p=0.001), pneumonia (p=0.009), reintubation (p=0.002) or reoperation (p<0.001), and death (17.7% vs 3.9%, p<0.001). Median length of stay was 17 vs 8 days (p=0.005). Median time to chylothorax diagnosis was 5 days. Thoracic duct ligation was performed in 21 (62%) at a median 13 days after esophagectomy. Two patients required repeat duct ligation for persistent chylothorax. Squamous cell cancer histology (9 of 34; 26%) was an independent predictor of postoperative chylothorax (odds ratio, 4.18; 95% confidence interval, 1.39 to 12.6). Odds of chylothorax were 36 times greater with average daily chest tube output exceeding 400 mL in the first 6 postoperative days (odds ratio, 35.9; 95% confidence interval, 8.2 to 157.8)., Conclusions: Postoperative chylothorax is associated with significant postoperative morbidity and mortality. Patients with squamous cell cancer may be at increased risk. In addition, average daily chest tube output exceeding 400 mL in the early postoperative period should prompt fluid analysis for chylothorax to facilitate early diagnosis and consideration of thoracic duct ligation., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Anatomic segmentectomy has been proposed as a reasonable alternative to lobectomy in the management of small early-stage non-small cell lung cancers. We reviewed our outcomes with anatomic segmentectomy versus lobectomy for stages IA and IB non-small cell lung cancer stratified by age and stage., Methods: We conducted a retrospective review of prospectively-collected data analyzing outcomes after anatomic segmentectomy (n=305) for stage IA (n=187) or IB (n=118) NSCLC from 1999 to 2010. Lobectomy was performed in 594 patients for stage IA (n=290) and IB (n=304) disease during the same period. Surgical approach was stratified by stage and by the following age groups: less than 70, 70 to 79, and 80 or greater. Primary outcome variables included complications, mortality, recurrence patterns, and survival. Mean follow-up was 37 months., Results: Segmentectomy was associated with reduced complications (43.6% vs 58.7%) and mortality (0% vs 7.8%) in patients greater than 80 years old, without a difference in recurrence rates. There was no difference in complications or mortality in the younger age groups. Freedom from recurrence was similar between segmentectomy and lobectomy for stage IA tumors across all age groups. A reduced recurrence-free survival was seen with segmentectomy for stage IB tumors, especially with visceral pleural invasion (median 22.7 vs 29.6 months), p=0.048)., Conclusions: Segmentectomy appears to be a reasonable approach for early-stage NSCLC in patients 80 years of age or greater due to reduced morbidity and mortality with equivalent freedom from recurrence. Although equivalent survival was seen in all age groups for stage IA, these data further support the use of lobectomy for resection of stage IB tumors., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Collis gastroplasty is an important component of laparoscopic giant paraesophageal hernia (GPEH) repair in patients with persistent shortened esophagus after aggressive laparoscopic mobilization. Concerns remain, however, regarding symptomatic outcomes compared with fundoplication alone. This study assessed the impact of Collis gastroplasty on quality of life after laparoscopic GPEH repair., Methods: We performed 795 nonemergent laparoscopic GPEH repairs with fundoplication (with Collis, n = 454; fundoplication alone, n = 341). Radiographic follow-up and symptom assessment were obtained a median 22 months and 20 months, respectively, after fundoplication alone and 36 and 33 months, respectively, after Collis (p < 0.001). Radiographic recurrence, reoperation for recurrent hernia or intolerable symptoms, overall symptom improvement, and quality of life were examined., Results: Compared with fundoplication alone, Collis patients had significantly larger GPEH (p = 0.027) and fewer comorbidities (p = 0.002). Radiographic recurrences were similar (p = 0.353). Symptom improvement was significant for both (p < 0.001), although Collis was associated with better pain resolution (p < 0.001) and less gas bloat (p = 0.003). Quality of life was good to excellent in 88% (90% Collis versus 86% fundoplication alone, p = 0.17)., Conclusions: Symptomatic outcomes after laparoscopic fundoplication with Collis gastroplasty are excellent and comparable with those of fundoplication alone. These results confirm that utilization of Collis gastroplasty, based on intraoperative assessment for shortened esophagus, is not detrimental to the overall outcome or quality of life associated with the laparoscopic approach to GPEH. Collis gastroplasty is recommended as an important procedure in the surgeon's armamentarium for laparoscopic repair of GPEH., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: With an increase in the performance of laparoscopic antireflux procedures, more patients with a failed primary antireflux operation are being referred to thoracic surgeons for complex redo procedures. The objective of this study was to evaluate our results of redo antireflux surgery., Methods: We conducted a retrospective review of patients who underwent redo surgery for failed fundoplication. The primary endpoint was failure of the redo operation; other endpoints included gastroesophageal reflux disease-health-related quality of life (HRQOL) after redo fundoplication., Results: A total of 275 patients (median age, 52 years; range, 17 to 88 years; men 82, women 193) underwent redo antireflux surgery. The most common pattern of failure of the initial operation was transmediastinal migration-recurrent hernia in 177 patients (64%). Redo surgery included Nissen fundoplication in 200 (73%), Collis gastroplasty in 119 (43%), and partial fundoplication in 41 (15%). There was no perioperative mortality. At a median follow-up of 39.6 months, 31 patients (11.2%) had a failure of the redo surgery, requiring reoperation. The two-year estimated probability of freedom from failure was 93% (95% confidence interval 89% to 96%). The HRQOL scores, available for 186 patients, were excellent to satisfactory in 85.5%, and poor in 14.5%., Conclusions: Redo antireflux surgery can be performed safely in experienced centers with outcomes that are similar to published open results. Complete takedown and reestablishment of the normal anatomy, recognition of a short esophagus, and proper placement of the wrap are essential components of the procedure. Thoracic surgeons with significant laparoscopic and open esophageal surgical experience can perform minimally invasive, complex redo esophageal antireflux procedures safely with good results., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The recent initiation of screening protocols and greater utilization of computed tomography has led to an increasing proportion of non-small cell lung cancer (NSCLC) patients presenting with subcentimeter stage IA tumors. The aim of this study was to compare the oncologic outcomes of lobectomy, segmentectomy, and wedge resection in patients with NSCLC tumors 1 cm or less in diameter., Methods: Data were extracted from medical records of patients undergoing surgical resection for stage IA NSCLC and a pathologically confirmed tumor diameter measuring 1 cm or less. Primary oncologic outcomes were disease recurrence and disease-free survival. Statistical comparisons were performed using Fisher's exact test and unpaired t test. Kaplan-Meier curves were compared using the log rank test. Significance was defined as a two-tailed p value less than 0.05., Results: A total of 107 patients underwent complete (R0) surgical resection for stage IA NSCLC 1 cm or less in diameter (lobectomy, 32; segmentectomy, 40; wedge, 35). Age, sex distribution, tumor size, and histology were similar between groups. There was 1 perioperative mortality in the lobectomy group (3%). At a mean follow-up of 42.5 months, overall disease recurrence was equivalent, occurring in 3 lobectomy patients (9%), 4 segmentectomy patients (10%), and 3 wedge resection patients (9%; p=0.99). Estimated 5-year disease-free survival was comparable among cohorts (lobectomy, 87%; segmentectomy, 89%; wedge, 89%; p>0.402)., Conclusions: Sublobar resections are associated with oncologic outcomes that are comparable to those of lobectomy for subcentimeter stage IA NSCLC, suggesting that they may be appropriate surgical interventions in this patient cohort. The validity of these observations needs to be assessed in a prospective setting., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: In the current study, we analyze the impact of pathologic variables (angiolymphatic invasion, visceral pleural invasion, and tumor inflammation) upon survival outcomes after segmentectomy or lobectomy for stage I non-small cell lung cancer., Methods: A retrospective review was made of 524 patients undergoing resection of stage I non-small cell lung cancer through either lobectomy (n = 285) or anatomic segmentectomy (n = 239). Primary outcome variables include recurrence-free and overall survival. Statistical comparisons were performed with the t test and Fisher's exact test. Recurrence-free and overall survival was estimated utilizing the Kaplan-Maier method, with statistical significance being assessed by the log rank test., Results: The incidence of angiolymphatic invasion, visceral pleural invasion, and degree of tumor inflammation, as well as morbidity, mortality, and length of stay were similar between segmentectomy and lobectomy. The presence of angiolymphatic invasion or visceral pleural invasion was associated with a significant decrease in recurrence-free survival (p < 0.01) and overall survival (p < 0.01). There was a trend for decreased recurrence with increasing tumor inflammation (mild versus severe, p = 0.066). There was no difference in rates of local recurrence (5.6% versus 7.9%, p = 0.59) or survival (p = 0.455) between segmentectomy and lobectomy, respectively., Conclusions: Angiolymphatic and visceral pleural invasion appear to be strong adverse prognostic factors after anatomic resection by segmentectomy or lobectomy for stage I non-small cell lung cancer. Overall survival is not affected by the extent of anatomical surgical resection. These data may have implications regarding the role of adjuvant systemic therapy after surgical resection for tumors with these pathologic characteristics., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Surgical resection is the standard of care for patients with resectable non-small cell lung cancer or selected patients with pulmonary metastases. Stereotactic radiosurgery may offer an alternative option for high-risk patients who are not surgical candidates. We report our initial experience with stereotactic radiosurgery in the treatment of lung neoplasm in 100 consecutive patients., Methods: Patients who were medically inoperable were offered stereotactic radiosurgery. Thoracic surgeons evaluated all patients, placed fiducials, and performed treatment planning in collaboration with radiation oncologists. Initially, a median dose of 20 Gy prescribed to the 80% isodose line was administered in a single fraction, and this was subsequently increased to a total of 60 Gy in three fractions. The primary end point evaluated was overall survival., Results: We treated 100 patients (median age, 70 years; 51 men, 49 women) with stereotactic radiosurgery: 46 (46%) with primary lung neoplasm, 35 (35%) with recurrent cancer, and 19 (19%) with pulmonary metastases. The median follow-up was 20 months. The median overall survival was 24 months. Local recurrence occurred in 25 patients. The probability of 2-year overall survival was 50% for the entire group, 44% for primary lung cancer, 41% for recurrent cancer, and 84% for metastatic cancer., Conclusions: Our initial experience indicates that stereotactic radiosurgery has reasonable results in these high-risk patients. Resection continues to remain the standard treatment; however, stereotactic radiosurgery may offer an alternative in high-risk patients. Further prospective studies with different dose schema are needed to evaluate the efficacy of stereotactic radiosurgery.

Background: Surgical resection is the standard of care for patients with resectable non-small cell lung cancer or selected patients with pulmonary metastases. However, for high-risk patients radiofrequency ablation (RFA) may offer an alternative option. The objective of this study was to evaluate computed tomography-guided RFA for high-risk patients and report our initial experience in 100 consecutive patients by a thoracic surgical service., Methods: Medically inoperable patients were offered RFA. Thoracic surgeons evaluated and performed RFA under computed tomography guidance. Patients were followed in the thoracic surgery clinic. The primary end point evaluated was overall survival., Results: One hundred patients underwent image-guided RFA for lung neoplasm (40 men, 60 women; median age, 73.5 years; range, 26 to 95 years). Forty-six patients (46%) with primary lung neoplasm, 25 patients (25%) with recurrent cancer, and 29 patients (29%) with pulmonary metastases underwent RFA. The mean follow-up for alive patients was 17 months. The median overall survival for the entire group of patients was 23 months. The probabilities of 2-year overall survival for the entire group, primary lung cancer patients, recurrent cancer patients, and metastatic cancer patients were 49% (95% confidence interval, 37 to 60), 50% (95% confidence interval, 33 to 65), 55% (95% confidence interval, 25 to 77), and 41% (95% confidence interval, 19 to 62), respectively., Conclusions: Our experience indicates that image-guided RFA done by the thoracic surgeons is feasible and safe in high-risk patients with lung neoplasm with reasonable results in patients who are not fit for surgery. Thoracic surgeons can perform RFA safely, and should continue to investigate this new image-guided modality that may offer an alternative option in medically inoperable patients.

Background: Recent data from prospective multimodality trials have documented an unacceptable early mortality with pneumonectomy after induction chemotherapy. This finding has raised skepticism toward pneumonectomy as a surgical option for patients with regionally advanced nonsmall-cell lung cancer. In the current study, perioperative outcomes after pneumonectomy with or without neoadjuvant therapy are compared to determine the impact of induction therapy on perioperative mortality in this setting. Variables associated with increased perioperative risk are identified., Methods: A review of 315 nonsmall-cell lung cancer patients (196 male [62%]) undergoing pneumonectomy over a 15-year period was undertaken. Patients were well matched for clinical variables other than receiving induction chemotherapy. Complications and operative mortality were analyzed for associations with laterality and induction chemotherapy., Results: Median age was 64 years, (range, 25 to 82). Age was predictive of mortality in 13 of 86 patients (15%) more than 70 years old, compared with 16 of 229 patients (7%) less than 70 years old (hazard ratio = 1.77, p = 0.046). Overall operative mortality was 9.2% (29 of 315). There were 115 left-sided (37%) and 200 right-sided (63%) pneumonectomies. Sixty-eight patients (22% [left = 31, right = 37]) received induction chemotherapy. Surgery alone was performed in 247 patients. Mortality among patients undergoing induction chemotherapy was 21% (odds ratio = 4.01; p = 0.0007). After induction chemotherapy, postoperative bronchopleural fistula associated with respiratory failure was predictive of operative mortality (hazard ratio = 148, p = 0.0001). Left-side pneumonectomy did appear to a have a greater incidence of postoperative arrhythmia., Conclusions: Morbidity and mortality after pneumonectomy is substantial. Patients greater than 70 years old appear to be at increased risk. Induction chemotherapy also increases the risk of operative mortality after pneumonectomy. Patients should be advised of this increased operative risk, and the multidisciplinary team must consider this when pneumonectomy appears necessary after induction therapy for locally advanced nonsmall-cell lung cancer.

Background: The diagnostic yield and accuracy of new approaches to diagnose cancer should focus on comparison with established surgical techniques. Our objective was to evaluate the diagnostic performance of endobronchial ultrasound (EBUS) to detect cancer in patients with radiographically abnormal mediastinal lymph nodes., Methods: The medical records of patients who underwent EBUS and had abnormal mediastinal lymph nodes (short-axis >1 cm and [or] positron emission topography-positive) over a 25 month period at the University of Pittsburgh were reviewed. Demographic and clinical data, cytology, and pathology results were entered in a database and analyzed., Results: A total of 172 patients [male to female = 1.8:1; median age, 67 years (range, 20 to 90]) were included. The diagnostic yield of EBUS cytology was 79.7% (137 of 172). Pathologic testing was available in 68% (117 of 172) and 82% (96 of 117) had a diagnostic EBUS. The diagnostic accuracy of EBUS was 91.7%. The sensitivity, specificity, positive (PPV) and negative (NPV) predictive values were 88.1% (95% confidence interval [CI], 77.3 to 94.3), 100% (95% CI, 85.9 to 100), 100% (95% CI, 92.4 to 100), and 80.6% (95% CI, 63.4 to 91.2), respectively. In 67 patients who had a suspected or biopsy-proven primary lung cancer, diagnostic yield was 86.6% and accuracy was 94.8%. In this subgroup the sensitivity, specificity, PPV, and NPV were 93% (95% CI, 76.5 to 98.9), 100% (95% CI, 69.9 to 100), 100% (95% CI, 85 to 100), and 83.3% (95% CI, 56.2 to 97.5)., Conclusions: Diagnostic performance data support the clinical usefulness of EBUS in the evaluation of patients with a radiographically abnormal mediastinum. It should be considered complementary to mediastinoscopy rather than substitutive.

Background: Anatomic segmentectomy for stage I non-small cell lung cancer (NSCLC) offers the potential of surgical cure with preservation of lung function. This may be of particular importance in elderly NSCLC patients with declining cardiopulmonary status and a limited life expectancy., Methods: The study compared outcomes of 78 elderly patients (aged > 75 years) with stage I NSCLC undergoing segmentectomy and 106 undergoing lobectomy for stage I NSCLC from 2002 to 2007. Primary outcome variables included perioperative morbidity and mortality, hospital course, recurrence patterns, and survival., Results: Age, gender, tumor histology, and surgical approach were similar between groups. Comorbidities were similar except for a higher incidence of chronic obstructive pulmonary disease and diabetes in segmentectomy patients. The tumors in the lobectomy group were significantly larger (3.5 vs 2.5 cm, p = 0.0001). Operative mortality was 1.3% for segmentectomy and 4.7% for lobectomy. Segmentectomy patients had fewer major complications (11.5% vs 25.5%, p = 0.02). There were no differences in median hospitalization (7 vs 6 days). The estimated overall survival at 2, 3, and 5 years was 76%, 69%, and 46% for segmentectomy patients and 68%, 59%, and 47% for lobectomy patients (p = 0.28). The 5-year disease-free survival was equivalent (segmentectomy, 49.8%; lobectomy, 45.5%; p = 0.80)., Conclusions: Anatomic segmentectomy can be performed safely in elderly patients with early-stage NSCLC. This approach is associated with reduced perioperative complications and comparable oncologic efficacy compared with lobectomy in older patients with a limited life expectancy.

Pneumocephalus after resection of intrathoracic tumors is an extremely rare event. A delayed presentation of iatrogenic subarachnoid pleural fistula resulted in symptomatic pneumocephalus after resection of a locally recurrent T4N0 nonsmall cell lung cancer involving the chest wall, T2 to T4 rib heads, and intercostal vertebral foramina. Progressive neurologic decline was noted 3 weeks after discharge. Computed tomography of the head and chest confirmed the presence of an apical pleural space, thoracic subarachnoid air, and pneumocephalus. Immediate clinical improvement followed chest tube decompression of the pleural space.

Objectives: Surgical resection is the preferred treatment in selected patients with pulmonary metastases. In high-risk patients, radiofrequency ablation (RFA) may offer an alternative option. RFA may be used alone or combined with surgical resection as a lung parenchymal-sparing approach. Our objectives were to evaluate the intermediate term outcomes after RFA and to determine the prognostic variables associated with outcome in patients with pulmonary metastases., Methods: Thoracic surgeons evaluated and performed RFA under computed tomography (CT) guidance or combined with surgical resection. Patients were monitored in the thoracic surgery clinic for recurrence and survival., Results: Twenty-two patients (10 men, 12 women; median age, 63 years [range, 37 to 88]) underwent RFA. The primary cancer was colorectal in 9 (41%), renal in 2 (9%), sarcoma in 4 (18%), and other in 7 (32%). CT-guided RFA was the sole treatment in 17 patients (77%) and combined with surgical resection in 5 (23%). No procedurally related deaths occurred. At a mean follow-up of 27 months (range, 13.3 to 53.6 months), 9 patients are alive. The median survival was 29 months (95% confidence interval, 9.1 to 33.8). Lesion size was an important prognostic variable associated with overall and disease-free survival (p < 0.05)., Conclusions: RFA is safe in this group of pulmonary metastases patients, with reasonable results. Surgical resection remains the standard for resectable patients, but RFA offers an alternative in selected patients or may be used as a parenchymal-sparing approach in combination with surgical resection in selected patients.

Pancreaticopleural fistula represents a rare complication of pancreatitis. We report the case of a pancreaticopleural fistula presenting as recurrent right-sided hemothorax in a 43-year-old man. The patient was successfully treated with open surgical drainage and decortication, followed by octreotide, total parenteral nutrition, and stent placement in the pancreatic duct.

Objectives: Esophagectomy is the standard treatment for T1 esophageal cancer (EC). Interest in endoscopic therapies, particularly for T1 EC, is increasing. We evaluated the long-term outcomes after esophagectomy and examined the pathologic features of T1 cancer to determine the suitability for potential endoscopic therapy., Methods: We reviewed the outcomes of esophagectomy in 100 consecutive patients with T1 EC. The primary end points studied were overall survival (OS) and disease-free survival (DFS). In addition to detailed pathology review, we evaluated prognostic variables associated with survival., Results: Esophagectomy was performed in 100 patients (79 men, 21 women; median age, 68 years) for T1 EC, comprising adenocarcinoma, 91; squamous, 9; intramucosal (T1a), 29; and submucosal (T1b), 71. The 30-day mortality was 0%. Resection margins were microscopically negative in 99 patients (99%). N1 disease was present in 21 (T1a, 2 of 29 [7%]; T1b, 19 of 71 [27%]), associated high-grade dysplasia in 64 (64%), and angiolymphatic invasion in 19 (19%). At a median follow-up of 66 months, estimated 5-year OS was 62% and 3-year DFS was 80% for all patients (including N1). Nodal status and tumor size were significantly associated with OS and DFS, respectively., Conclusions: Esophagectomy can be performed safely in patients with T1 EC with good long-term results. Many patients with T1 EC have several risk factors that may preclude adequate treatment with endoscopic therapy. Further prospective studies are required to evaluate endoscopic therapies. Esophagectomy should continue to remain the standard treatment in patients with T1 EC.

Background: Abnormal body mass index has been targeted as a predictor of complications after major surgery. The aim of this study was to review the impact of obesity on perioperative outcomes after minimally invasive esophagectomy., Methods: This study was a single-institution retrospective review of patients undergoing minimally invasive esophagectomy for high-grade dysplasia or cancer of the esophagus between 1999 and 2004. A body mass index of 30 or greater was considered obese. Patients with a body mass index less than 18.5 were excluded because of the potentially adverse effects of malnutrition on outcomes., Results: A total of 282 eligible patients were identified. There were 84 obese and 198 nonobese patients (mean body mass index = 34.5 versus 25.5; p < 0.0001). Preoperative demographics, comorbidities, and cancer status were similar, except for a higher prevalence of diabetes (p = 0.002), lower prevalence of peripheral vascular disease (p = 0.045), and lower prevalence of stage III disease in the obese group (p = 0.044). Operative time was significantly longer in obese patients (375 versus 301 minutes; p = 0.0001), and estimated blood loss was similar (433 versus 377 mL, obese versus nonobese, respectively). There were 5 (1.8%) overall 30-day perioperative mortalities, with no differences between the groups. Overall major (obese, 23 [27.5%] versus nonobese, 68 [34.3%]) and minor (obese, 23 [27.5%] versus nonobese, 65 [32.8%]) complication rates were also similar. Furthermore, there were no significant differences in any individual complications. There was no difference in median intensive care unit stay (obese, 1 day versus nonobese, 2 days) or overall hospital stay (obese, 7 days versus nonobese, 8 days)., Conclusions: Obesity was associated with longer operative times. Our review suggests that obesity is not a risk factor for mortality, postoperative complications, or length of hospitalization after minimally invasive esophagectomy.

Background: Thoracic surgeons are frequently called upon to provide exposure to the anterior cervicothoracic, thoracic, and proximal lumbar spine. We reviewed our surgical experience and the perioperative outcomes of these spinal approaches. Relevant technical and anatomic considerations of each procedure are highlighted., Methods: A total of 213 patients (116 female, 97 male) undergoing anterior thoracic spinal exposures over an 11-year period at a single institution were analyzed. Primary endpoints include morbidity, mortality, and perioperative outcomes., Results: Mean age was 53.7 years. Surgical approaches were determined based on the location and length of spinal involvement, and included cervicothoracic (5), thoracotomy (117), and thoracoabdominal (91) techniques. Malignant etiologies were associated with the highest perioperative mortality (6.7%, p = 0.08). Procedures for infection were associated with a significantly higher complication rate (p = 0.041) and length of stay (p = 0.033). Correction of scoliosis required longer operative times (p < 0.001) and resulted in a trend toward higher blood loss (p = 0.16). Thoracoabdominal approaches were associated with increased operative times (386 vs 316 minutes) and length of stay (8 vs 6 days) compared with thoracotomy., Conclusions: The increased use of anterior approaches to spinal pathology necessitates greater involvement by thoracic surgeons. Familiarity with the anatomic and technical features of the anterior spinal exposure is required by thoracic surgeons to optimize surgical outcomes.

Background: Intractable gastroesophageal reflux disease (GERD) after prior antireflux operation presents a difficult challenge. Our objective was to investigate the role of Roux-en-Y near esophagojejunostomy (RNYNEJ) in the management of intractable reflux symptoms after prior antireflux surgery., Methods: Between June 2000 and October 2005, 25 patients with GERD after antireflux surgery underwent RNYNEJ. The endpoints evaluated were improvement in GERD symptoms using the GERD-Health Related Quality of Life (HRQL) scale, overall patient satisfaction, overall patient weight loss, and improvement of comorbid conditions., Results: There were 4 men and 21 women (mean age 51 years; range, 35 to 74). Seventy two percent had a body mass index (BMI) greater than 30. Forty-four percent had more than one antireflux surgery and 40% had a previous Collis gastroplasty. The perioperative mortality was 0%. Six patients (24%) developed major postoperative complications, including anastomotic leak (n = 2) and Roux-limb obstruction (n = 1). The median length of stay was 6 days. Eighty percent of the patients reported satisfaction at mean follow-up time of 16.5 months. Their BMI reduced from 35.8 to 27.7 (p < 0.001). Seventy three percent of comorbid conditions were improved and the GERD HRQL score improved from 29.9 to 7.3 (p < 0.001)., Conclusions: The RNYNEJ for persistent GERD after prior antireflux surgery is technically challenging with significant morbidity. However, the majority of the patients reported satisfaction with significant improvement in symptoms. Many patients had associated benefits of weight loss and improvement in comorbid conditions. Roux-en-Y near esophagojejunostomy should be considered as an important option for the treatment of intractable GERD after prior antireflux surgery, particularly in the obese.

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.

Although lobectomy should continue to be regarded as the procedure of choice for NSCLC, certain subsets of patients who have favorable characteristics may be treated appropriately with segmentectomy without adversely affecting oncologic outcome as long as an adequate assessment of intraoperative nodal status and surgical margin is performed. The use of anatomic segmentectomy may be particularly useful for small, peripheral tumors less than 2 cm in diameter located within anatomic segmental boundaries, as well as for elderly patients who have impaired cardiopulmonary function. Ground-glass opacities and lesions displaying bronchoalveolar histology also may be appropriate target lesions for segmentectomy because of their low metastatic potential. Prospective, randomized studies (such as the CALGB/Altorki trial and the brachytherapy mesh trial) will be necessary to delineate fully the utility of segmentectomy in patients who have NSCLC.

Background: We describe a novel laparoscopic "clam shell" partial fundoplication, incorporating a modified Toupet with an anterior fundic flap for the management of medically recalcitrant gastroesophageal reflux disease. We hypothesize that this clam-shell-like mechanism allows a dynamic rather than rigid circumferential antireflux barrier allowing effective reflux control (compared with partial fundoplication) with reduced occurrence of postoperative dysphagia, gas bloating and vagal nerve injury (compared with Nissen fundoplication)., Methods: Between November 2002 and May 2006, 140 patients (82 female; mean age, 53 years) underwent this laparoscopic clam shell fundoplication procedure for medically recalcitrant gastroesophageal reflux disease (n = 94) or large paraesophageal hernias (n = 46). Preoperative invasive studies (endoscopy, manometry, pH monitoring) and noninvasive studies (barium swallow and radionuclide gastroesophageal motility) revealed esophageal dysmotility in 26 patients. Routine barium swallow and radionuclide studies were performed 6 months postoperatively and then at yearly intervals., Results: There was no mortality or conversions to open procedures. Mean operative time was 45 minutes; median hospital stay was 1 day (range, 1 to 4). Overall control of reflux symptoms was seen in 95% of patients. Postoperative gas bloating and significant dysphagia occurred in only 11% and 6% of patients, respectively. Three patients (2%) experienced postoperative complications (pneumonia, 2; pleural effusion requiring drainage, 1). Postoperative studies demonstrated reflux in 8 patients (5%) and the presence of small hiatal hernias in 5 patients (4%) during a mean follow-up 19 months (range, 7 to 42). Twenty five patients (17%) underwent postoperative esophageal dilation (median dilations, 1; range, 1 to 3) for dysphagia (11 of these patients had preoperative esophageal dysmotility). Five patients underwent repeat fundoplication (recurrent reflux, 2; gas bloating, 1; dysphagia, 2)., Conclusions: Clam shell near-circumferential fundoplication may be considered as an attractive alternative antireflux approach to Nissen fundoplication, particularly among patients at risk for postoperative dysphagia or gas bloating.

Background: Segmentectomy for early-stage non-small cell lung cancer (NSCLC) remains controversial and has been previously associated with high local recurrence rates. We compared the outcomes of anatomic segmentectomy with lobectomy for stage I NSCLC and investigated the impact of surgical resection margins on recurrence., Methods: From 2002 to 2006, 182 anatomic segmentectomies (114 open, 68 video-assisted thoracic surgery [VATS]), were performed for stage 1A (n = 109) or IB (n = 73) NSCLC. These were compared with 246 lobectomies (1A, 114; 1B, 132). Variables analyzed included hospital course, mortality, and patterns of recurrence and survival., Results: All segmentectomy surgical margins were free of tumor (average margin, 18.2 mm). Operative time (147 versus 216 minutes; p < 0.0001) and estimated blood loss (185 versus 291 mL; p = 0.0003) were significantly reduced after segmentectomy compared with lobectomy. Thirty-day mortality (1.1% versus 3.3%), total complications, disease-free recurrence, and survival were similar between segmentectomy and lobectomy at a mean follow-up of 18.1 and 28.5 months, respectively. There were 32 recurrences after segmentectomy (17.6%) at a mean of 14.3 months (14 locoregional [7.7%], 18 distant [9.9%]), and 89% of recurrences were seen when tumor margins were 2 cm or less. Margin/tumor diameter ratios exceeding 1 were associated with a significant reduction in recurrence rates compared with ratios of less than 1 (25.0% versus 6.2%; p = 0.0014)., Conclusions: Anatomic segmentectomy can be performed safely by an open or VATS approach. Segmentectomy outcomes compare favorably with standard lobectomy for stage I NSCLC. Margin/tumor ratios of less than 1 are associated with a higher rate of recurrence. Lobectomy should be considered as primary therapy when such margins are not obtainable with segmentectomy in the good-risk patient.

Segmentectomy demands a thorough knowledge of the three-dimensional bronchovascular anatomy of the lung. This anatomic detail makes segmentectomy significantly more challenging than lobectomy. Several principles must be applied when performing segmental lung resection: (1) the surgeon should avoid dissection in a poorly developed fissure, (2) use the transected bronchus as the base of the segmental resection during the division of the lung parenchymal in the intersegmental plane, (3) consider the use of endostapler division of the pulmonary parenchyma to reduce the air leak complications related to "finger fracture" dissection of the intersegmental plane, and (4) consider the use of adjuvant iodine 125 brachytherapy as a means of reducing local recurrence following sublobar resection. Increasing evidence supports the use of anatomic segmentectomy in the treatment of primary lung cancer for appropriately selected patients. This resection approach seems most appropriate in the management of the small (<2 cm in diameter) peripheral stage I NSCLC in which a generous margin of resection can be obtained. Accurate intraoperative nodal staging is important to estimate the relative use of these approaches compared with more aggressive resection and to determine the need for adjuvant systemic therapy if metastatic lymphadenopathy is identified. Future investigations comparing the results of sublobar resection with lobectomy will more clearly define the role of segmentectomy among good-risk patients with clinical stage I NSCLC. At the present time, it seems that sublobar resection is an appropriate therapy for the management of stage I NSCLC identified in the elderly patient, those individuals with significant cardiopulmonary dysfunction, and for the management of peripheral solitary metastatic disease to the lung. Because the primary disadvantage of sublobar resection is that of local recurrence, intraoperative adjuvant iodine 125 brachytherapy may be considered to minimize this local recurrence risk.

RFA and SRS have been demonstrated to be safe with reasonable efficacy in the treatment of small lung tumors. It is unclear which option is the most effective in the treatment of NSCLC, with both RFA and SRS demonstrating similar early response and progression rates. RFA can be performed in one treatment session, whereas it now seems that SRS is more effective if larger doses of radiation over two to three fractions are performed. RFA is not recommended for centrally based tumors. There are also some tumors (eg, small apical tumors, posteriorly positioned tumors close to the diaphragm, and tumors close to the scapula) where it may be difficult percutaneously to position an active electrode. Such patients are more optimally treated with SRS. In certain circumstances, a combined approach may be beneficial (RFA and SRS). At this point in time, MWA is the least well developed modality. Although treatment times and heat-sink effect may be less compared with RFA, larger trials are needed to understand better the impact of this factor on effectiveness and safety. The heat-sink effect may be protective, minimizing the necrosis of large blood vessels and the risk of subsequent fatal hemoptysis. Future studies need to address long-term outcomes using standardized assessments of treatment response between centers. Comparisons between different RFA systems and ablation modalities need to be undertaken to delineate the optimal use of these strategies in the treatment of early stage lung cancer. Until long-term data with these ablative techniques become available, surgical resection should be performed when clinically possible.

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.

Bone marrow cells are composed of pluripotent stem cells to terminally differentiated cells, with a wide variety of abundance of each cell type. In the past, many of the cell types within this heterogeneous population have been characterized either by expression of specific proteins or using functional markers. In spite of promising results obtained with the latter method, various cell types within bone marrow have not been well characterized due to the low abundance of a specific cell type. Considering the demand for a reliable technique to enrich cell types, a wide variety of approaches, ranging from simple nylon wool columns to high-speed cell sorting, have evolved. Only limited success has been obtained with approaches ranging from the detection of MHC antigen to positron emission tomography to track the ontogeny of specific bone marrow-derived cells in studies of syngeneic or allogeneic transplantation. The present study describes a relatively simple method to enrich and track a rare bone marrow cell (facilitating cell, FC), which can facilitate allogeneic bone marrow stem cell transplantation in mice. The isolation technique is comprised of enrichment of FC by magnetic activated cell sorting (MACS) system followed by purification through high-speed cell sorter. An initial inoculation of 30,000 FC obtained from male mice was detected in the thymus, spleen, and bone marrow of allogeneic female recipients, by using 32P-labeled dCTP in a specific PCR for Y-chromosome. This technique may improve the efficiency of isolation of other rare cells from the bone marrow.