Search

Objectives: Thoracic sympathectomy has been shown to be effective in reducing implantable cardioverter-defibrillator (ICD) shocks and ventricular tachycardia recurrence in patients with channelopathies, but the evidence supporting its use for refractory ventricular arrhythmias in patients without channelopathies is limited. This is a single-centre cohort study of bilateral R1-R4 thoracoscopic sympathectomy for medically refractory ventricular arrhythmias., Methods: Clinical information was examined for all bilateral thoracoscopic R1-R4 sympathectomies for ventricular arrhythmias at our institution from 2016 through 2020., Results: Thirteen patients underwent bilateral thoracoscopic R1-R4 sympathectomy. All patients had prior ICD implant. Patients had a recent history of multiple ICD discharges (12/13), catheter ablation (10/13) and cardiac arrest (3/13). Ten patients were urgently operated on following transfer to our centre for sustained ventricular tachycardia. Seven patients had ventricular tachycardia ablations preoperatively during the same admission. Five patients were in intensive care immediately preoperatively, with 3 requiring mechanical ventilation. Three patients suffered in-hospital mortality. Kaplan-Meier analysis estimated 73% overall survival at 24-month follow-up. Among the 10 patients who survived to discharge, all were alive at a median follow-up of 8.7 months (interquartile range 0.6-26.7 months). Six of 10 patients had no further ICD discharges. Kaplan-Meier analysis estimated 27% ICD shock-free survival at 24 months follow-up for all patients. Three of 10 patients had additional ablations, while 2 patients underwent cardiac transplantation., Conclusions: Bilateral thoracoscopic sympathectomy is an effective option for patients with life-threatening ventricular arrhythmia refractory to pharmacotherapy and catheter ablation., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Objectives: Our study examined attitudes towards initial management of hyperhidrosis, willingness to seek surgical consultation and knowledge of an appropriate specialty for surgical consultation among primary care physicians and the general public., Methods: An online survey was sent to all general medicine and paediatric residents and attending physicians at our academic medical centre. Participants were provided with a clinical scenario of palmar hyperhidrosis and were asked to select among initial management options and preferences for surgical consultation if patients failed non-operative management. To assess the general public's perspective, workers from Amazon Mechanical Turk were recruited to complete a similar survey., Results: The majority of primary care physicians (31/53; 58%) would prescribe topical aluminium chloride for palmar hyperhidrosis, whereas 28 of 53 (53%) would refer such patients to dermatology. Twenty-three of 53 (43%) physicians would refer such patients to surgery if conservative management failed: 18 (78%) to plastic surgery, 4 (17%) to general surgery and none to thoracic surgery. The majority of workers (130/205; 63.4%) would seek primary care treatment for palmar hyperhidrosis. Over half (113/205; 55%) would seek surgical consultation if conservative management failed: 65 (58%) general surgery and 15 (13%) neurosurgery, with only 8 (7%) selecting thoracic surgery., Conclusions: Neither primary care physicians nor the general public recognize the role of thoracic surgeons in managing primary focal hyperhidrosis when medical management fails. Education of physicians and the public may mitigate this knowledge gap., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Dr. David Skinner, the 4th President of the ISDE, was a world-renowned surgeon, educator, scholar, and leader. He participated in the formation of the ISDE, hosted two international congresses in 1983 and 1989, and made important advances in the ISDE during his presidential tenure 1992-1995., (© The Author(s) 2019. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Achalasia is a relatively rare primary motor esophageal disorder, characterized by absence of relaxations of the lower esophageal sphincter and of peristalsis along the esophageal body. As a result, patients typically present with dysphagia, regurgitation and occasionally chest pain, pulmonary complication and malnutrition. New diagnostic methodologies and therapeutic techniques have been recently added to the armamentarium for treating achalasia. With the aim to offer clinicians and patients an up-to-date framework for making informed decisions on the management of this disease, the International Society for Diseases of the Esophagus Guidelines proposed and endorsed the Esophageal Achalasia Guidelines (I-GOAL). The guidelines were prepared according the Appraisal of Guidelines for Research and Evaluation (AGREE-REX) tool, accredited for guideline production by NICE UK. A systematic literature search was performed and the quality of evidence and the strength of recommendations were graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Given the relative rarity of this disease and the paucity of high-level evidence in the literature, this process was integrated with a three-step process of anonymous voting on each statement (DELPHI). Only statements with an approval rate >80% were accepted in the guidelines. Fifty-one experts from 11 countries and 3 representatives from patient support associations participated to the preparations of the guidelines. These guidelines deal specifically with the following achalasia issues: Diagnostic workup, Definition of the disease, Severity of presentation, Medical treatment, Botulinum Toxin injection, Pneumatic dilatation, POEM, Other endoscopic treatments, Laparoscopic myotomy, Definition of recurrence, Follow up and risk of cancer, Management of end stage achalasia, Treatment options for failure, Achalasia in children, Achalasia secondary to Chagas' disease.

Obesity has been variously associated with reduced or similar rates of postoperative complications compared to normal weight patients undergoing esophagectomy for cancer. In contrast, little is known about esophagectomy risks in the underweight population. The relationship between the extremes of body mass index (BMI) and postoperative complications after esophagectomy was evaluated. Consecutive esophagectomy patients (2000-2013) were reviewed. The patients were stratified based on BMI at the time of diagnosis: underweight (<18.5), normal (18.5-24.9), overweight (25-29.9), obese I (30-34.9), and obese II or III (≥35). Hospital length of stay as well as postoperative complications and their accordion severity grading were evaluated according to the BMI category. Of 388 patients, 78.6% were male with a median age of 62 years at the time of operation. Pathologic cancer stage was 0 to I in 53%. BMI distribution was as follows: 5.6% underweight, 28.7% normal, 31.4% overweight, 22.8% obese I, and 11.5% obese II or III. Performance status was 0 or 1 in 99.2%. Compared to normal BMI patients, underweight patients had increased pulmonary complications (odds ratio (OR) 3.32, P = 0.014) and increased other postoperative complications (OR 3.00, P = 0.043). Patients who were overweight did not have increased complications compared to normal BMI patients. BMI groups did not differ in mortality rates or complication accordion severity grading. Hospital length of stay trended toward a longer duration in the underweight population (P = 0.06). Underweight patients are at increased risk for postoperative pulmonary and other complications. Underweight patients may benefit from preoperative nutritional repletion and mitigation for sarcopenia. Aggressive postoperative pulmonary care may help reduce complications in these patients. In contrast, the operative risk in overweight and obese patients is similar to normal BMI patients., (© The Authors 2017. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

To address uncertainty of whether clinical stage groupings (cTNM) for esophageal cancer share prognostic implications with pathologic groupings after esophagectomy alone (pTNM), we report data-simple descriptions of patient characteristics, cancer categories, and non-risk-adjusted survival-for clinically staged patients from the Worldwide Esophageal Cancer Collaboration (WECC). Thirty-three institutions from six continents submitted data using variables with standard definitions: demographics, comorbidities, clinical cancer categories, and all-cause mortality from first management decision. Of 22,123 clinically staged patients, 8,156 had squamous cell carcinoma, 13,814 adenocarcinoma, 116 adenosquamous carcinoma, and 37 undifferentiated carcinoma. Patients were older (62 years) men (80%) with normal body mass index (18.5-25 mg/kg 2 , 47%), little weight loss (2.4 ± 7.8 kg), 0-1 ECOG performance status (67%), and history of smoking (67%). Cancers were cT1 (12%), cT2 (22%), cT3 (56%), cN0 (44%), cM0 (95%), and cG2-G3 (89%); most involved the distal esophagus (73%). Non-risk-adjusted survival for squamous cell carcinoma was not distinctive for early cT or cN; for adenocarcinoma, it was distinctive for early versus advanced cT and for cN0 versus cN+. Patients with early cancers had worse survival and those with advanced cancers better survival than expected from equivalent pathologic categories based on prior WECC pathologic data. Thus, clinical and pathologic categories do not share prognostic implications. This makes clinically based treatment decisions difficult and pre-treatment prognostication inaccurate. These data will be the basis for the 8th edition cancer staging manuals following risk adjustment for patient characteristics, cancer categories, and treatment characteristics and should direct 9th edition data collection., (© 2016 International Society for Diseases of the Esophagus.)

To address uncertainty of whether pathologic stage groupings after neoadjuvant therapy (ypTNM) for esophageal cancer share prognostic implications with pathologic groupings after esophagectomy alone (pTNM), we report data-simple descriptions of patient characteristics, cancer categories, and non-risk-adjusted survival-for pathologically staged cancers after neoadjuvant therapy from the Worldwide Esophageal Cancer Collaboration (WECC). Thirty-three institutions from six continents submitted data using variables with standard definitions: demographics, comorbidities, clinical cancer categories, and all-cause mortality from first management decision. Of 7,773 pathologically staged neoadjuvant patients, 2,045 had squamous cell carcinoma, 5,686 adenocarcinoma, 31 adenosquamous carcinoma, and 11 undifferentiated carcinoma. Patients were older (61 years) men (83%) with normal (40%) or overweight (35%) body mass index, 0-1 Eastern Cooperative Oncology Group performance status (96%), and a history of smoking (69%). Cancers were ypT0 (20%), ypT1 (13%), ypT2 (18%), ypT3 (44%), ypN0 (55%), ypM0 (94%), and G2-G3 (72%); most involved the distal esophagus (80%). Non-risk-adjusted survival for yp categories was unequally depressed, more for earlier categories than later, compared with equivalent categories from prior WECC data for esophagectomy-alone patients. Thus, survival of patients with ypT0-2N0M0 cancers was intermediate and similar regardless of ypT; survival for ypN+ cancers was poor. Because prognoses for ypTNM and pTNM categories are dissimilar, prognostication should be based on separate ypTNM categories and groupings. These data will be the basis for the 8th edition cancer staging manuals following risk adjustment for patient, cancer, and treatment characteristics and should direct 9th edition data collection., (© 2016 International Society for Diseases of the Esophagus.)

We report data-simple descriptions of patient characteristics, cancer categories, and non-risk-adjusted survival-for patients with pathologically staged cancer of the esophagus and esophagogastric junction after resection or ablation with no preoperative therapy from the Worldwide Esophageal Cancer Collaboration (WECC). Thirty-three institutions from six continents submitted de-identified data using standard definitions: demographics, comorbidities, clinical cancer categories, and all-cause mortality from first management decision. Of 13,300 patients, 5,631 had squamous cell carcinoma, 7,558 adenocarcinoma, 85 adenosquamous carcinoma, and 26 undifferentiated carcinoma. Patients were older (62 years) men (80%) with normal body mass index (51%), little weight loss (1.8 kg), 0-2 ECOG performance status (83%), and a history of smoking (70%). Cancers were pT1 (24%), pT2 (15%), pT3 (50%), pN0 (52%), pM0 (93%), and pG2-G3 (78%); most involved distal esophagus (71%). Non-risk-adjusted survival for both squamous cell carcinoma and adenocarcinoma was monotonic and distinctive across pTNM. Survival was more distinctive for adenocarcinoma than squamous cell carcinoma when pT was ordered by pN. Survival for pTis-1 adenocarcinoma was better than for squamous cell carcinoma, although monotonic and distinctive for both. WECC pathologic staging data is improved over that of the 7th edition, with more patients studied and patient and cancer variables collected. These data will be the basis for the 8th edition cancer staging manuals following risk adjustment for patient, cancer, and treatment characteristics, and should direct 9th edition data collection. However, the role of pure pathologic staging as the principal point of reference for esophageal cancer staging is waning., (© 2016 International Society for Diseases of the Esophagus.)

Objectives: Pulmonary complications remain a frequent cause of morbidity in patients undergoing oesophagectomy. Risk screening tools assist in patient stratification. Ferguson proposed a risk score system to predict major pulmonary complications after oesophagectomy. Our objective was to externally validate this risk score system., Methods: We analysed our institutional database for patients undergoing oesophagectomy for cancer from August 2009 to December 2012. We analysed patients who had complete documentation of variables used in the Ferguson risk score calculation: forced expiratory volume in the 1 s, diffusion capacity of the lung for carbon monoxide, performance status and age. One hundred and thirty-six patients qualified for analysis in the validation study. Outcome variables measured included major pulmonary complications, defined as need for reintubation for respiratory failure and pneumonia. The risk score was then calculated for each individual based on the model. Incidence of major pulmonary events was assessed in the five risk class groupings to assess the discriminative ability of the Ferguson score., Results: Major pulmonary complications occurred in 35% of patients (47/136). Overall mortality was 6% (8/136). Patients were grouped into five risk categories according to their Ferguson pulmonary risk score: 0-2, 8 patients (6%); 3-4, 24 patients (18%); 5-6, 49 patients (36%); 29 patients (21%); 9-14, 26 patients (19%). The incidence of major pulmonary complications in these categories was 0, 17, 20, 41 and 77%, respectively. The accuracy of the risk score system for predicting major pulmonary complications was 76% (P < 0.0001)., Conclusions: This pulmonary risk scoring system is a reliable instrument to be used during the preoperative phase to differentiate patients who may be at higher risk for pulmonary complications after oesophagectomy. These data can assist in patient selection, and in patient education/informed consent and can guide postoperative management., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Obesity has been thought to predispose patients to excess morbidity after lung resection because of decreased diaphragm excursion, reduced lung volumes and relative immobility. We assessed the relationship of body mass index (BMI) to acute outcomes after major lung resection., Methods: Information from our database of lung resections was evaluated for the period 1980-2011. Univariate analysis for adverse events (pulmonary, cardiovascular, other and overall) was used to select variables for inclusion in multivariate logistic regression analyses. Missing values were imputed. BMI was categorized as underweight (<18.5), normal (18.5-24.9), overweight (25-29.9), obese (30-34.9) and very obese (≥ 35)., Results: Among 1369 patients, there were 703 males (51%) and the mean age was 62 ± 11 years. Complications included the following: pulmonary 12%, cardiovascular 15%, other 16%, mortality 5% and any 29%. The incidence of complications decreased during each decade of study (40, 30, 26, 20%; P < 0.0001) and the incidence of obese/very obese increased during the same intervals (11, 22, 30, 25%; P = 0.0007). Adjusting for age, performance status, coronary artery disease, smoking status, diffusing capacity of the lung for carbon monoxide, forced expiratory volume in 1 s and operation year, being overweight/obese/very obese did not increase the risk of postoperative complications in any category. In fact, patients in this group showed a lower rate of cardiovascular complications than those with BMI ≤ 25 (odds ratio (OR): 0.72; 95% confidence interval (CI): 0.51-1.00; P = 0.048). However, being underweight was importantly associated with an increased risk of pulmonary complications (OR: 2.5; 95% CI: 1.3-4.9; P = 0.0087) and of operative mortality (OR: 2.96; 95% CI: 1.28-6.86; P = 0.011)., Conclusion: Being overweight or obese does not increase the risk of complications after major lung resection. In contrast, patients who are underweight are at significantly increased risk of pulmonary complications and mortality. Knowledge of the relationship of BMI to perioperative risk for major lung resection is essential in proper risk stratification.

Objectives: Preoperative lung function is an independent predictor of long-term survival after lung resection for non-small-cell lung cancer (NSCLC). The extent of resection has an impact on operative mortality, determines postoperative lung function and may influence both overall- and cancer-specific survival. We sought to determine the impact of predicted postoperative (ppo) lung function on long-term survival after lung cancer resection., Methods: We previously reported long-term survival analyses for patients who underwent major lung resection for NSCLC 1980-2006. For this study, we calculated ppo spirometry (forced expiratory volume in the first second, FEV1) and diffusing capacity of the lung for carbon monoxide (DLCO) in the same cohort using the functional segment technique or quantitative perfusion scans when available, and updated survival data; missing data were imputed. We assessed the relationship of ppoFEV1 and ppoDLCO to long-term survival using Cox regression., Results: Of 854 patients, 471 (55%) were men, the mean age was 63 years and median survival was 42 months. At the time of analysis, 70% of patients had died. On regression analysis, all-cause mortality was related to age, stage, performance status, renal function and prior myocardial infarction. Preoperative lung function was marginally associated with mortality [DLCO (10-percentage point decrease): HR (hazard ratio) 1.04, 95% confidence interval (95% CI) 1.00-1.08, P = 0.056; FEV1 (10-percentage point decrease): HR 1.04, 95% CI 1.00-1.09, P = 0.067]. In contrast, ppo lung function was strongly associated with mortality (ppoDLCO: HR 1.06, 95% CI 1.01-1.12, P = 0.024; ppoFEV1: HR 1.06, 95% CI 1.01-1.12, P = 0.031)., Conclusions: Ppo lung function is strongly associated with long-term survival after major lung resection and is more strongly related to survival than preoperative lung function. Surgeons struggle with challenging decisions about the appropriate extent of resection for early-stage cancer, balancing factors such as operative morbidity/mortality, local recurrence and postoperative quality of life. Ppo lung function and its relation to survival also should be taken into consideration during such deliberations.

Objectives: Predictors of long-term survival for patients with lung cancer assist in individualizing treatment recommendations. Diffusing capacity (DLCO) is a predictor of complications after resection for lung cancer. We sought to determine whether DLCO is also prognostic for long-term survival after lung resection for cancer., Methods: We assessed survival among patients in our prospective database who underwent lung resection for cancer between 1980-2006. Potential prognostic factors for all-cause mortality were evaluated by computing average annual hazard rates, and variables significantly associated with survival were included in multivariable Cox modelling. Multiple imputation was used to address missing values., Results: Among 854 unique patients, there were 587 deaths. The median follow-up time from surgery was 9.6 years. Predictors of survival included age, stage, performance status, body mass index, history of myocardial infarction, renal function and DLCO. On univariate analysis, the hazard ratio increased incrementally compared with those with a DLCO of ≥ 80% (70-79%, 1.12; 60-69%, 1.29; <60%, 1.35). On multivariable analysis, DLCO was an independent predictor of long-term survival for all patients (corrected for all other important covariates; HR 1.04 per 10-point decrement; 95% CI 1.00-1.08; P = 0.05). Its prognostic ability for long-term survival was above and beyond its influence on operative mortality., Conclusions: DLCO is an independent and clinically important determinant of long-term survival after major lung resection for cancer, a finding that is not generally known. Knowledge of this may help improve selection of patients for lung resection and may help tailor the extent of resection, when possible, in order to appropriately balance operative risk with long-term outcomes.

Objectives: The well-known revised cardiac risk index (RCRI) has recently been modified based on factors and outcomes specific to thoracic surgery patients (ThRCRI). We explored the accuracy of this modified scoring system in predicting cardiovascular morbidity after major lung resection., Methods: We analyzed outcomes from a prospective database of patients undergoing major lung resection 1980-2009. ThRCRI score was based on weighted factors for serum creatinine, coronary artery disease, cerebrovascular disease and extent of lung resection. Target adverse outcomes included pulmonary embolism, myocardial infarction, cardiac arrest, pulmonary edema and cardiac death., Results: A total of 1255 patients (mean age 61.8 years; 649 men) underwent lobectomy or bilobectomy (1070; 85%) or pneumonectomy (185; 15%) for cancer (1037; 83%) or other problems. Severe cardiovascular complications occurred in 30 patients (2.4%), an incidence similar to that in the published derivation group (3.3%). ThRCRI median scores in patients without and with severe CV complications were 0 and 1.5 (P < 0.001). Score categories yielded incremental risks of cardiovascular complications (0: 0.9%; 1-1.5: 4.5%; ≥ 2: 12.8%; P < 0.001). The Hosmer-Lemeshow test demonstrated no significant difference between expected and observed outcomes (P = 0.11)., Conclusions: The incidences of severe postoperative cardiovascular complications were similar in the published derivation group and the current validation group. The ThRCRI score successfully stratified risk for postoperative cardiovascular events after major lung resection in the validation group. The expected risk in the validation group was similar to the observed risk, indicating that ThRCRI accurately predicted specific risk rather than just relative risk. Further evaluation of the utility of this scoring system is warranted.

Complications occur frequently after esophagectomy. Identifying the risk of complications preoperatively may help in patient selection and postoperative management. We performed a retrospective review of patients who underwent esophagectomy between 1980 and 2009. A previously reported scoring system was used to estimate risk, and its ability to predict complications was assessed. A total of 514 patients (382 men; 74%) with a mean age of 59.0 ± 12.5 years underwent esophagectomy for cancer (398; 77%) or benign disease. Minor complications occurred in 224 patients (44%) and severe complications occurred in 134 patients (26%). The calculated risk score was based on weighted values for age, coronary artery disease, cerebrovascular disease, type of operation, and forced expiratory volume in the first second expressed as a percent of predicted (FEV1%). Increasing risk score was associated with a linear increase in the incidence of complications (P < 0.001 for either severe complications or any complications). The scoring system predicted severe complications with an accuracy of 65.3% (P < 0.001). Score groups identified an incremental risk of severe complications (0 to 6 = 12%; 7 to 13 = 18%; 14 to 20 = 28%; 21 to 27 = 36%; >27 = 52%; P < 0.001). Complications are frequent after esophagectomy and can be predicted using a previously reported scoring system. This scoring system may assist in patient selection for esophagectomy and in providing appropriate resources for postoperative management of higher risk patients., (© 2011 Copyright the Authors. Journal compilation © 2011, Wiley Periodicals, Inc. and the International Society for Diseases of the Esophagus.)

Background: The objective of this investigation was to compare postoperative morbidity and early and late mortality in patients after pneumonectomy for non-small-cell lung cancer (NSCLC) with or without induction neo-adjuvant therapy., Methods: This is an observational study performed on prospectively collected data at four tertiary referral centres (2000-2007). Of 225 pneumonectomies for NSCLC, 81 patients underwent neo-adjuvant chemotherapy. Several perioperative variables were used in identifying propensity score-matched pairs of patients with and without induction treatment. The matched groups were then compared in terms of morbidity, early (30-day or in-hospital) and 90-day mortality., Results: The overall cardiopulmonary morbidity, early mortality and 90-day mortality rates were 30% (67 patients), 7.1% (16 patients) and 9.8% (22 patients), respectively. Propensity score analysis yielded 56 well-matched pairs of patients with and without induction chemotherapy. The two groups had similar early and late mortality rates: four versus four (p=1) and seven versus seven (p=1), respectively. Moreover, the incidence of cardiopulmonary morbidity and bronchopleural fistula were also similar in both the groups: 19 versus 17 patients (Fisher's exact test p=0.7) and two versus three patients (Fisher's exact test, p=0.7), respectively. Twenty-one patients with induction chemo-radiotherapy were analysed separately and compared with well-matched counterparts without any induction treatment. No significant differences were identified in terms of early mortality (1 vs 0, p=1), 90-day mortality (1 vs 0, p=1), cardiopulmonary complications (5 vs 5, p=1) and bronchopleural fistula (1 vs 1, p=1)., Conclusions: Current regimens of induction treatment do not seem to increase the risk of morbidity, early mortality and late mortality after pneumonectomy in properly selected patients. This study warrants confirmation from future multicentre prospective randomised trials powered on early outcomes., (Copyright (c) 2009 European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objective: Modeling of operative risks associated with major lung resection is potentially inaccurate and inefficient because of incomplete observations for predictor variables (covariates). Missing values do not usually occur randomly, potentially introducing an important source of bias in modeling. Deletion of cases with missing data also results in loss of precision. The current study analyzes incomplete variables as potential predictors of outcomes after major lung resection using imputation techniques., Methods: We analyzed major lung resection patients treated from 1980 to 2006 for predictors of pulmonary, cardiovascular, and overall complications, as well as mortality. Predictive variables were initially determined using classification and regression tree (CART) methods. Imputation models were developed and variables with missing values were multiply imputed. We fit a logistic regression model for each outcome using CART variables and any covariates that were of interest clinically., Results: Of 1046 resected patients, serum albumin and diffusing capacity (DLCO%) had a large number of missing values (32% and 13% missing, respectively). Models included 10 covariates for pulmonary complications (p<0.05 for DLCO% and forced expiratory volume in the first second [FEV1%]), 12 covariates for cardiovascular complications (p<0.05 for FEV1%, extent of resection, year of operation, and age), 15 covariates for overall complications (p<0.05 for DLCO%, performance status, serum albumin, and FEV1/FVC ratio), and 12 covariates for death (p<0.05 for DLCO%, extent of resection, and operation year)., Conclusions: We identified serum albumin as a previously under-reported and strong predictor of overall complications. Serum albumin was marginally significantly related to pulmonary and cardiovascular outcomes after major lung surgery. Use of imputation techniques for modeling surgical risks has potential value in identifying important predictive variables that may ordinarily be eliminated from analysis or not identified as predictors because of incomplete observations in clinical databases.

Objective: Growing scrutiny of surgical results for lung cancer has prompted increased evaluation of risk factors and outcomes of resection. We determined how patient preoperative status and outcomes of resection have changed over time to identify opportunities for improving these results., Methods: We reviewed a prospectively collected database of patients undergoing major lung resection 1980-2006. Patient characteristics and immediate outcomes of resection were compared for three-decade periods (1980-1989, 1990-1999, 2000-2006). Data were compared using the Kruskal-Wallis test, chi squared analysis, and logistic regression analysis., Results: One thousand and forty-six patients underwent resection for cancer (862) and other problems. The percentage of female patients increased over time. Some elements of preoperative status worsened, with significant increases in hypertension rate, mean performance status, obesity incidence, mean risk score, and use of induction therapy. Pneumonectomy rates, immediate preoperative tobacco use, and surgery for advanced stages of disease decreased over time. Outcomes improved over time, with significant decreases in operative mortality, cardiopulmonary complications, and overall complications. Risk factors for categories of complications including operative mortality varied according to the time period studied., Conclusions: Outcomes of major lung resection have improved over time despite a worsening of some elements of preoperative status. Maintenance of surgical databases is essential to enable surgeons to provide data consonant with growing demand from payers and patients. The use of current rather than historical lung resection outcomes is vital in assessing risk. Identification of changes in surgical practice patterns helps identify opportunities for improving future outcomes.

A variety of strategies, using chemotherapy, radiation therapy, and surgical resection have been employed in the treatment of locally advanced esophageal cancer. No strategy has proven superior, and poor long-term survival is anticipated. A survival benefit has been suggested for patients who achieve a pathologic complete response (pCR) following neoadjuvant chemoradiation therapy. We examined the collective results at three institutions of patients who achieved a pCR following neoadjuvant chemoradiation therapy. A retrospective, chart-based review was conducted. Kaplan-Meier calculations were used to determine overall and disease-free survival. Between 1995 and 2002, 229 patients were treated with neoadjuvant chemoradiation followed by surgery as a planned approach for locally advanced esophageal cancer. Forty-one patients (18%) demonstrated pCR and were the focus of this study. Histology was adenocarcinoma in 29, squamous in 10, and adenosquamous/undifferentiated in two patients. Forty patients were staged by endoscopic ultrasound prior to neoadjuvant therapy and all demonstrated a T-stage of 2 or higher, while 19 had evidence of nodal metastasis. Four patients died in the perioperative period. The remaining patients have been followed for an average of 46 months. Overall survival at 5 years was 56.4% and a median survival has not been reached. Esophageal cancer patients who demonstrate a pCR following neoadjuvant chemoradiation are a select subset who demonstrate excellent long-term survival. Identification of clinical variables or biomarkers predictive of pCR may therefore optimize treatment strategies of patients with locally advanced esophageal cancer.

Objectives: Although complications occur frequently after major lung resection, current predictive models are not entirely satisfactory. We devised a new predictive scoring system and compared it to two existing systems., Methods: We performed an initial retrospective review of 400 patients who underwent major resection for lung cancer from 1980 to 1995. Predictive covariates (age, spirometry, diffusing capacity) associated with three or more complication groups were used to develop a scoring system. This system (EVAD) was then evaluated against the Physiological and Operative Severity Score for Enumeration of Mortality and Morbidity (POSSUM) and Cardiopulmonary Risk Index (CPRI) systems for patients operated between 1996 and 2001., Results: Major resection for lung cancer included lobectomy (188) and pneumonectomy (30). Complication categories were: pulmonary (23; 10.5%); cardiovascular (24; 11.0%); infectious (8; 3.6%); other (29; 13.2%); nonfatal (45; 20.6%); and any (53; 24.2%). Death occurred in ten patients (4.6%). Mean EVAD scores were significantly different between groups with and without complications in all categories except infectious complications and death, whereas mean CPRI scores differed only for pulmonary complications, nonfatal complications, and death, and mean POSSUM scores did not appropriately differ for any complications. EVAD predicted incremental risk in all complication categories except cardiovascular, infectious, and death, whereas CPRI predicted incremental risk only for nonfatal and possibly any complications, and POSSUM did not predict incremental risk for any complication category. Receiver operating characteristic analysis demonstrated the EVAD system to be equivalent to or better than CPRI and POSSUM for all complication categories., Conclusions: A simple scoring system (EVAD) that utilizes pulmonary function test data and patient age predicts the likelihood of complications after major lung resection. It is easier to use and at least as accurate as other scoring systems currently in use.

Objectives: We sought to determine the long-term survival of patients treated for bronchial carcinoid tumors and whether lesser resections have had an effect on outcomes., Methods: We conducted a retrospective, multi-institutional review of patients treated surgically for primary bronchial carcinoid tumors since 1980. Operative approach, pathologic stage, histology, surgical complications, tumor recurrence, and long-term survival were assessed., Results: There were 50 men and 89 women with a mean age of 52.2+/-17.4 and 58.9+/-13.3 years, respectively (P=0.021). Men were more likely to be current or former smokers than were women. Operations included lobectomy or bilobectomy in 110, pneumonectomy in four, wedge resection in 22, and bronchial sleeve resection only in three patients; resection was performed thoracoscopically in six patients. One patient died postoperatively. Stages were I, 121; II, nine; III, six; and IV, three. Typical carcinoid tumors were stage I in 100 and more advanced (stages II-IV) in nine, whereas atypical carcinoid tumors were stage I in 18 and more advanced in eight (P=0. 002). Median follow-up was 43 months (range 1-149) during which 21 (15%) patients died (four from recurrent cancer) and 19 patients (14%) were lost to follow-up. Recurrent cancer developed in 2/98 patients with typical and 5/25 patients with atypical subtypes (P<0. 001; log-rank test). The likelihood of recurrence was related to histological subtype (relative risk 7.9 for atypical carcinoid; 95% confidence interval 1.4-43.5). Five-year survival was 88% for stage I patients and was 70% for patients with more advanced stages. When stratified by stage, survival was related to age (relative risk=1.9 for a 10 year increase in age; 95% confidence interval 1.2-2.9) and possibly to the histological subtype, but not to patient gender, year of operation, or type of operation performed., Conclusions: Either major lung resection or wedge resection is appropriate treatment for patients with early stage typical bronchial carcinoid tumors. Survival is favorable for early stage tumors regardless of histological subtype. Local recurrence is more common among patients with atypical subtypes, suggesting that a formal resection may improve long-term outcome.

Perforation of esophageal cancer is an unusual complication that most often results from instrumentation. The management of this condition must be individualized on the basis of the patient's condition and the stage of the cancer. For patients who are otherwise well and have localized disease, a standard resection is performed. Stent placement and esophageal exclusion are sometimes used for patients in good condition but in whom resection is not feasible. Supportive care alone is reserved for patients who have end-stage disease or are otherwise not candidates for aggressive therapy. Although the overall mortality rate is 50%, the risk for patients who undergo resection is less than 10%. This risk is similar to that found in patients undergoing elective resection and supports the concept that aggressive therapy should be pursued in highly selected patients with perforated esophageal cancers.

A retrospective review was performed of 51 patients operated on for giant paraesophageal hiatal hernia to compare the transthoracic and transabdominal approaches and to assess the value of a concomitant fundoplication. Operative repair was performed using open transthoracic, transabdominal, and thoracoabdominal approaches. Laparoscopic techniques were used in one patient. Fundoplication was performed in 45 patients. There was no operative mortality, but early postoperative complications occurred in 29% of patients. The presence of commonly associated symptoms was used to derive preoperative and postoperative symptom scores. Follow-up was available in 48 patients. Excellent results were reported in 69% of patients and 17% had good results. The symptom score improved significantly regardless of the operative approach selected or whether a fundoplication was performed. We conclude that outcome after open paraesophageal hiatal hernia repair is satisfactory in most patients, irrespective of the route chosen or techniques used for repair.