Surgeons' Role in Local Palliation of Esophageal Cancer

Esophageal cancer commonly presents in advanced stage, and many patients will require palliative intervention. Endoscopic stenting remains an excellent first-line therapy; however, this should be discussed in a multidisciplinary setting, considering expectations for long-term survival.

Minimally invasive esophagectomy: a teaching hospital's first year experience

Surgical resection of the esophagus remains the mainstay of treatment for esophageal cancer. However, esophagectomy is associated with significant morbidity and mortality in the postoperative period. We have recently altered our practice pattern to include minimally invasive esophagectomy (MIE) as the approach of choice in the hope of minimizing morbidity associated with this procedure. In this retrospective analysis, we compare outcomes of our first year performing MIE to the previous 3 years of open esophagectomy (OE) at a single teaching hospital. Sixty-five patients underwent esophagectomy between June 2002 and July 2006. Among these, 22 patients underwent MIE between June 2005 and July 2006 and 43 patients underwent OE. The two groups were comparable with regards to age, comorbidities and pathologic stage. The MIE group had less operative blood loss (178 mL vs. 356 mL), decreased respiratory complications requiring mechanical ventila-tion (5% vs. 23%), increased number of lymph nodes procured per procedure (15 vs. 8), and increased number of patients discharged within 10 days (72% vs. 28%) when compared to the OE group. No difference was identified in mortality, complications, or length of stay.

Prone thoracoscopic esophageal mobilization for minimally invasive esophagectomy

BACKGROUND

Minimally invasive esophagectomy is a complex surgical procedure. We recently began performing thoracic mobilization of the esophagus with the patient in the prone position, not the left lateral decubitus position, in the hope of minimizing the number of technical challenges.

METHODS

Six consecutive minimally invasive esophagectomies were performed using prone thoracoscopic esophageal mobilization with creation of cervical anastamosis. Our esophagectomy database was evaluated for outcomes, including operative time, estimated blood loss, complications, and length of hospital stay.

RESULTS

We were successful in our first six attempts, with a mean blood loss of 61 cc. Mean operative time for thoracoscopy was 80 min. Operative times were steady over the first six prone cases at 105, 85, 70, 55, 80, and 85 min. Three of the six patients had no complications. Median postoperative length of hospital stay was 11.5 days, and there were no deaths.

CONCLUSIONS

This technical report and case series demonstrates that prone thoracoscopic esophageal mobilization appears to be a reasonable alternative to the same procedure performed with the patient in the decubitus position. We find the technique to simplify portions of an otherwise difficult surgical procedure. Further evaluation with larger number of patients should be performed.

Fibrin glue in pulmonary resection: a prospective, randomized, blinded study

BACKGROUND

In contrast to the rare large-airway bronchopleural fistulas after lung resection, peripheral or alveolar air leaks (AAL) are very common, often prolong hospital stay, increase utilization of resources, and on occasion result in significant morbidity. Various adjuncts have been used in attempts to reduce AAL. One of these, the topical application of fibrin glue, has to date failed to demonstrate efficacy in small clinical trials. This study reexamines the role of fibrin glue in routine lobar and wedge pulmonary resections.

METHODS

Of 113 patients enrolled, 13 became ineligible because of intraoperative findings. The remaining 100 patients were randomly assigned to one of two groups at the conclusion of lung resection, regardless of the presence or absence of identifiable air leak. The control group received no additional intervention. The experimental group underwent application of 5 mL of fibrin glue delivered by a pressurized, aerosolized spraying mechanism. Postoperatively a blinded clinical observer recorded outcomes including the incidence and duration of AAL, prolonged AAL (PAAL), the volume of pleural drainage, the time to tube removal, and the postoperative length of stay (LOS), as well as any complications related to treatment.

RESULTS

Both groups were comparable with regard to demographics, diagnoses, and procedures. Statistically significant reductions were found in the experimental group in the overall incidence of AAL (34% versus 68%, p = 0.001), mean duration of AAL (1.1 versus 3.1 days, p = 0.005), mean time to chest tube removal (3.5 versus 5.0 days, p = 0.02), and the incidence of PAAL (2% versus 16%, p = 0.015). There was no significant difference in the volume of chest tube drainage or LOS (4.6 days glue and 4.9 days control, p = 0.318). There were no complications related to the use of fibrin glue.

CONCLUSIONS

Aerosolized fibrin glue appears to be safe and effective in reducing AAL. The overall incidence of AAL was reduced by 50% and PAAL occurred in only 1 treated patient (2% versus the usually reported 15%). Further studies with this and other methods are required to delineate routine versus selective use, to compare methods, and clarify cost benefit.

Pulmonary resection for malignancy in the elderly: is age still a risk factor?

OBJECTIVE

There is an increasing number of elderly patients presenting with potentially-resectable lung malignancy. The objective of this study is to evaluate the modern perioperative morbidity and mortality in patients undergoing oncologic lung resection and to analyse the trend over a 26-year period in our experience.

METHODS

Between 1971 and 1996, 1506 patients underwent lung resection for malignancy. We reviewed the 30-day perioperative risk in a group of 385 (25.6%) patients aged 70 years and older operated on for intended cure of lung malignancy. Operations included 293 (77%) lobectomies, 24 pneumonectomies (6%), 16 bilobectomies (4%) and 52 wedge or segmental resections (13%). The pathology was bronchogenic carcinoma in 89% and metastasis or other tumours in 11% of patients. We compared the 30-day perioperative risk between the elderly group (age 70 or greater) and a cohort of 180 patients (control) 69 years and younger.

RESULTS

The mortality for all resections in elderly group was 4.2% (16/385) and was 1.6% for the control group. Mortality in the octogenarian group was 2.8%. Female gender correlated with a decreased risk of death, with only two of 16 deaths in females (P < 0.005). Overall morbidity was higher in the study than in control patients (34% vs. 25%, n.s.), although major morbidity was similar in both groups (13.2% vs. 13%). Abnormal pulmonary-function testing and positive cardiac history did not correlate with increase overall or specific risk. Pneumonectomy carried a higher risk for death, with three of 24 deceased (12.5%; P < 0.05). Changes in outcome were analysed over two time periods: the mortality in the early period (1971-1982), 11.1% (8/72), was significantly elevated above the control group, while mortality in the modern period (1983-1994) was not, with a rate of 2.6% (8/313).

CONCLUSIONS

In our series, mortality associated with operative treatment for lung malignancy in the elderly declined, so age alone no longer appears to be a risk factor. Age remains a risk factor for overall, but not major, morbidity. Pneumonectomy should undertaken cautiously in this age group. Based on this data, functional elderly patients should not be denied curative lung resection based on age alone.

Outpatient chest tube management

BACKGROUND

Patients with indwelling chest tubes inserted for the purpose of evacuating pleural air traditionally are treated in the hospital. The current emphasis on cost-effective medical care and a recent report describing the early discharge of patients who had undergone lung volume reduction operations and had a persistent air leak prompted us to review our overall experience with outpatient tubes in a general thoracic surgical practice.

METHODS

We reviewed the records of patients who had been discharged from the hospital with chest tubes and Heimlich valves in place for venting pleural air over the past 7 years. Ambulatory tube management was used on a total of 240 occasions in three diagnostic groups: pneumothorax (176 cases), prolonged postresection air leak (45 cases), and outpatient thoracoscopic pulmonary wedge excision (19 cases). Failure was defined as hospital admission for complications of tube insertion or function.

RESULTS

There were 10 failures in the entire group (4.2%), 4.5% for pneumothorax, 2% for postresection air leak, and 5.3% for outpatient thoracoscopy. There were no deaths or instances of life-threatening problems. The cost of at least 1,263 inpatient hospital days was saved.

CONCLUSIONS

The presence of a chest tube, with or without an air leak, does not always require hospitalization. Admission can be avoided in most patients with primary spontaneous pneumothorax and in selected patients with pneumothorax of other causes. The postoperative hospital stay can be shortened for many patients who have a prolonged air leak after pulmonary resection. Ambulatory tube management also makes feasible outpatient thoracoscopy for noneffusive processes.

Pulmonary resection for lung cancer in octogenarians

BACKGROUND

Octogenarians often present with potentially resectable bronchogenic carcinoma. Older reports noting prohibitive mortality and recent surveys documenting continued substantial risk raise concerns about the applicability of operation in this age group.

METHODS

We reviewed the short-term and long-term results of pulmonary resection for intended cure of lung cancer in patients 80 years and older operated on from 1980 through 1995. Our surgical philosophy favored lobectomy over lesser resection and generally avoided pneumonectomy in the elderly.

RESULTS

Fifty-four octogenarians underwent resection: 43 lobectomies, 2 extended lobectomies, 2 bilobectomies, 3 segmentectomies, 3 wedge excisions, and 1 pneumonectomy. There were two perioperative deaths (3.7%). The overall nonfatal complication rate was 42%, with a major complication rate of 11%. Postoperative stay decreased from 8.1 days overall to 6.3 days in the last 3 years. Only 3 patients required temporary convalescent care after discharge. Actuarial survival at 1,3, and 5 years was 86%, 62%, and 43%, respectively, for all discharged patients (n = 52) and 97%, 78%, and 57% for stage I cases (n = 39). Patients with tumors beyond stage I fared poorly.

CONCLUSIONS

Advanced age per se in neither a contraindication to curative resection nor a routine indication for nonanatomic operations in healthy octogenarians with stage I lung cancer. With proper selection, acute risk should be low. Pneumonectomy, extended resection, and operation for stage II or III disease should be considered only in exceptional cases.

Blunt hepatic trauma. Nonoperative management in adults

Fifty-six adults were identified with blunt hepatic trauma. Sixteen patients (29%) were treated successfully with nonoperative management. There were no delayed laparotomies or deaths in the nonoperative group. All patients required close observation. Eight (50%) of 16 patients required transfusion of no more than 3 U of packed red blood cells. There were two significant late complications requiring readmission. Four (25%) of 16 patients had complex fractures, yet were treated successfully without laparotomy. The quantity of fluid in the abdomen, as estimated by computed tomography, did not predict failure of treatment. Nonoperative management of blunt hepatic injuries is a useful alternative in selected patients when the course of therapy is based on the hemodynamic stability of the patient and supported by computed tomographic findings.