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Nayak MM, Mazzola E, Jaklitsch MT, Drehmer JE, Nabi-Burza E, Bueno R, Winickoff JP, Cooley ME. Effectiveness of a computer-facilitated intervention on improving provider delivery of tobacco treatment in a thoracic surgery and oncology outpatient setting: A pilot study. Tob Induc Dis 2024; 22:TID-22-66. [PMID: 38650848 PMCID: PMC11033978 DOI: 10.18332/tid/186272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 03/19/2024] [Accepted: 03/22/2024] [Indexed: 04/25/2024] Open
Abstract
INTRODUCTION Effective tobacco treatments are available but are often not delivered to individuals with an actual or potential diagnosis of thoracic malignancy. The specific aims of this study were to identify the prevalence of tobacco use and examine the effectiveness of the Clinical and community Effort Against Smoking and secondhand smoke Exposure (CEASE), a system-level computer-facilitated intervention, to improve provider delivery of tobacco treatment in a thoracic surgery and oncology outpatient setting. METHODS A pre-post-test design was used to assess the effectiveness of CEASE. A 3-step approach was used to integrate tobacco treatment into routine care: ask about tobacco use, assist with cessation, and refer to a quitline. An end-of-visit survey was conducted to collect prevalence of tobacco use and delivery of tobacco treatment. Descriptive statistics and Fisher's exact test were used for analysis. RESULTS A total of 218 individuals were enrolled; 105 participants were in usual care (UC) and 113 were in the CEASE group. Of those who enrolled, 27.6% were never smokers in UC and 27.7% in CEASE, 60% were former smokers in UC and 50% in CEASE, and 12.4% were current smokers in UC and 21.4% in CEASE. Significant differences were noted in delivery of tobacco treatment with 15.4% having received tobacco treatment in UC compared to 62.5% in CEASE (p<0.004). CONCLUSIONS A computer-facilitated intervention increased provider delivery of tobacco treatment in a thoracic surgery and oncology outpatient setting. This intervention provided a low-resource approach that has the potential to be scaled and implemented more broadly.
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Affiliation(s)
- Manan M. Nayak
- Phyllis F. Cantor Center for Research in Nursing and Patient Care Services, Dana-Farber Cancer Institute, Boston, United States
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, United States
| | - Emanuele Mazzola
- Department of Data Science, Dana-Farber Cancer Institute, Boston, United States
| | - Michael T. Jaklitsch
- Division of Thoracic Surgery, Brigham and Women’s Hospital, Boston, United States
| | - Jeremy E. Drehmer
- Division of General Academic Pediatrics, Massachusetts General Hospital for Children, Boston, United States
- Tobacco Research and Treatment Center, Massachusetts General Hospital, Boston, United States
| | - Emara Nabi-Burza
- Division of General Academic Pediatrics, Massachusetts General Hospital for Children, Boston, United States
- Tobacco Research and Treatment Center, Massachusetts General Hospital, Boston, United States
| | - Raphael Bueno
- Division of Thoracic Surgery, Brigham and Women’s Hospital, Boston, United States
| | - Jonathan P. Winickoff
- Division of General Academic Pediatrics, Massachusetts General Hospital for Children, Boston, United States
- Tobacco Research and Treatment Center, Massachusetts General Hospital, Boston, United States
| | - Mary E. Cooley
- Phyllis F. Cantor Center for Research in Nursing and Patient Care Services, Dana-Farber Cancer Institute, Boston, United States
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Pezeshkian F, Leo R, McAllister MA, Singh A, Mazzola E, Hooshmand F, Herrera-Zamora J, Silvestri M, Ribeiro Barcelos R, Bueno R, Ugalde Figueroa P, Jaklitsch MT, Swanson SJ. Predictors of Prolonged Hospital Stay After Segmentectomy. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00365-9. [PMID: 38688448 DOI: 10.1016/j.jtcvs.2024.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 04/14/2024] [Accepted: 04/15/2024] [Indexed: 05/02/2024]
Abstract
OBJECTIVE Segmentectomy is becoming the standard of care for small, peripheral non-small cell lung cancer. To improve perioperative management in this population, this study aims to identify factors influencing hospital length of stay after segmentectomy. METHODS Patients who underwent segmentectomy for any indication between 01/2018-05/2023 were identified using a prospectively maintained institutional database. Multivariable logistic regression models were used to estimate associations between clinical features and prolonged (≥ 3days) hospital stay. A nomogram was designed to understand better, and possibly calculate the individual risk of prolonged hospital stays. RESULTS In total, 533 cases were included; 337 (63%) were females. Median age was 66 years (IQR: 63-75). The median size of resected lesions was 1.6cm (IQR 1.3-2.1). Median hospital stay was 3 days (IQR: 2-4). Major adverse events occurred in 31 (5.8%) cases. The 30-day readmission rate was 5.8% (n=31). There was no 30-day mortality; 90-day mortality was <1%. Patients older than 75 years (OR=2.01, 95%CI: 1.15-3.57, P=0.02), those with FEV1 < 88% predicted (OR = 1.99, 95%CI: 1.38-2.89, P<0.001), or positive smoking history (OR=1.72, 95%CI: 1.15-2.60, P=0.01) were more likely to have prolonged hospital stays after segmentectomy. A nomogram accounting for age, sex, FEV1, body mass index, smoking history, and comorbidities was created to predict the probability of prolonged hospital stay with an AUC of 0.66. CONCLUSIONS Older patients, those with reduced pulmonary function, current, and past smokers have elevated risk for prolonged hospital stays after segmentectomy. Validation of our nomogram could improve perioperative risk stratification in segmentectomy patients.
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Affiliation(s)
| | - Rachel Leo
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA
| | | | - Anupama Singh
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA
| | - Emanuele Mazzola
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA
| | - Fatemeh Hooshmand
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA
| | | | - Mia Silvestri
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA
| | | | - Raphael Bueno
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA
| | | | | | - Scott J Swanson
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA
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Feingold PL, Kennedy-Shaffer L, Wee JO, Jaklitsch MT, Marshall MB. Supporting the Use of Institutional Data to Improve Outcomes. Ann Thorac Surg 2024; 117:875-876. [PMID: 37827350 DOI: 10.1016/j.athoracsur.2023.09.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 09/24/2023] [Indexed: 10/14/2023]
Affiliation(s)
- Paul Lawrence Feingold
- Division of Thoracic Surgery, Department of Surgery, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY 14642.
| | - Lee Kennedy-Shaffer
- Department of Mathematics and Statistics, Vassar College, Poughkeepsie, New York
| | - Jon O Wee
- Division of Thoracic Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Michael T Jaklitsch
- Division of Thoracic Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Margaret Blair Marshall
- Division of Thoracic Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
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Steimer D, Coughlin JM, Yates E, Xie Y, Mazzola E, Jaklitsch MT, Swanson SJ, Orgill D, Marshall MB. Empiric flap coverage for the pneumonectomy stump: How protective is it? A single-institution cohort study. J Thorac Cardiovasc Surg 2024; 167:849-858. [PMID: 37689236 DOI: 10.1016/j.jtcvs.2023.08.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 07/31/2023] [Accepted: 08/23/2023] [Indexed: 09/11/2023]
Abstract
OBJECTIVE To evaluate the impact of empiric tissue flaps on bronchopleural fistula (BPF) rates after pneumonectomy. METHODS Patients who underwent pneumonectomy between January 2001 and December 2019 were included. Primary end point was development of BPF. Secondary end points were impact of flap type on BPF rates, time to BPF development, and perioperative mortality. RESULTS During the study period, 383 pneumonectomies were performed; 93 were extrapleural pneumonectomy. Most pneumonectomy cases had empiric flap coverage, with greater use in right-sided operations (right: 97%, 154/159; left: 80%, 179/224, P < .001). Empiric flaps harvested included intercostal, latissimus dorsi, serratus anterior, omentum, pectoralis major, pericardial fat/thymus, pericardium, and pleura. BPF occurred in 10.4% of the entire cohort but decreased to 6.6% when extrapleural pneumonectomy cases were excluded; 90% (36/40) of BPFs occurred on the right side (P < .001). Median time to develop BPF was 63 days, and 90-day mortality was greater in patients with BPF (12.5% BPF vs 7.4% non-BPF, P < .0001). Intercostal muscle had the lowest rate of BPF (4.5%), even in right-sided operations (8.7%). In contrast, larger muscle flaps such as latissimus dorsi (21%) and serratus anterior (33%) had greater rates of BPF, but the sample size was small in these cohorts. CONCLUSIONS Empiric bronchial stump coverage should be performed in all right pneumonectomy cases due to greater risk of BPF. In our series, intercostal muscle flaps had low BPF rates, even in right-sided operations. Coverage of the left pneumonectomy stump is unnecessary due to low incidence of BPF in these cases.
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Affiliation(s)
- Desiree Steimer
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Mass.
| | - Julia M Coughlin
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Elizabeth Yates
- Department of Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Yue Xie
- Department of Data Sciences, Dana Farber Cancer Institute, Boston, Mass
| | - Emanuele Mazzola
- Department of Data Sciences, Dana Farber Cancer Institute, Boston, Mass
| | | | - Scott J Swanson
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Dennis Orgill
- Division of Plastic Surgery, Brigham and Women's Hospital, Boston, Mass
| | - M Blair Marshall
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Mass
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McAllister MA, Rochefort MM, Ugalde Figueroa P, Leo R, Sugarbaker EA, Singh A, Herrera-Zamora J, Barcelos RR, Mazzola E, Heiling H, Jaklitsch MT, Bueno R, Swanson SJ. Complete anatomic segmentectomy shows improved oncologic outcomes compared to incomplete anatomic segmentectomy. Eur J Cardiothorac Surg 2024; 65:ezae089. [PMID: 38457605 DOI: 10.1093/ejcts/ezae089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 02/27/2024] [Accepted: 03/06/2024] [Indexed: 03/10/2024] Open
Abstract
OBJECTIVES To compare oncologic outcomes after segmentectomy with division of segmental bronchus, artery and vein (complete anatomic segmentectomy) versus segmentectomy with division of <3 segmental structures (incomplete anatomic segmentectomy). METHODS We conducted a single-centre, retrospective analysis of patients undergoing segmentectomy from March 2005 to May 2020. Operative reports were audited to classify procedures as complete or incomplete anatomic segmentectomy. Patients who underwent neoadjuvant therapy or pulmonary resection beyond indicated segments were excluded. Survival was estimated with Kaplan-Meier models and compared using log-rank tests. Cox proportional hazards models were used to estimate hazard ratios (HRs) for death. Cumulative incidence functions for loco-regional recurrence were compared with Gray's test, with death considered a competing event. Cox and Fine-Gray models were used to estimate cause-specific and subdistribution HRs, respectively, for loco-regional recurrence. RESULTS Of 390 cases, 266 (68.2%) were complete and 124 were incomplete anatomic segmentectomy. Demographics, pulmonary function, tumour size, stage and perioperative outcomes did not significantly differ between groups. Surgical margins were negative in all but 1 case. Complete anatomic segmentectomy was associated with improved lymph node dissection (5 vs 2 median nodes sampled; P < 0.001). Multivariable analysis revealed reduced incidence of loco-regional recurrence (cause-specific HR = 0.42; 95% confidence interval 0.22-0.80; subdistribution HR = 0.43; 95% confidence interval 0.23-0.81), and non-significant improvement in overall survival (HR = 0.66; 95% confidence interval: 0.43-1.00) after complete versus incomplete anatomic segmentectomy. CONCLUSIONS This single-centre experience suggests complete anatomic segmentectomy provides superior loco-regional control and may improve survival relative to incomplete anatomic segmentectomy. We recommend surgeons perform complete anatomic segmentectomy and lymph node dissection whenever possible.
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Affiliation(s)
- Miles A McAllister
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | | | | | - Rachel Leo
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Evert A Sugarbaker
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Anupama Singh
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Rafael R Barcelos
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Emanuele Mazzola
- Department of Data Science, Dana Farber Cancer Institute, Boston, MA, USA
| | - Hillary Heiling
- Department of Data Science, Dana Farber Cancer Institute, Boston, MA, USA
| | | | - Raphael Bueno
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Scott J Swanson
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA, USA
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Singh A, Mazzola E, Xie Y, Marshall MB, Jaklitsch MT, Wilder FG. Lung cancer outcomes in the elderly: potential disparity in screening. Eur J Cardiothorac Surg 2024; 65:ezae080. [PMID: 38445715 DOI: 10.1093/ejcts/ezae080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 02/20/2024] [Accepted: 03/01/2024] [Indexed: 03/07/2024] Open
Abstract
OBJECTIVES The aim of this study was to analyse outcomes of lung cancer in the elderly. METHODS A retrospective analysis was performed of patients in the National Cancer Database with NSCLC from 2004 to 2017 grouped into 2 categories: 70-79 years (A) and 80-90 years (B). Patients with multiple malignancies were excluded. Kaplan-Meier curves estimated the overall survival for each age group based on stage. RESULTS In total, 466 051 patients were included. Less-invasive techniques (imaging and cytology) diagnosed cancer as a function of age: 14.6% in A vs 21.3% in B [P < 0.001, standardized mean difference (SMD) 0.175]. Clinical stage IA was least common in B (15%) compared to 17.3% in A (P < 0.001, SMD 0.079). Approximately 83.0% in B did not receive surgery compared to 70.0% in A (P < 0.001, SMD 0.299). Of the 83.0%, 8.0% were considered poor surgical candidates because of age or comorbidities compared with 6.2% in A (P < 0.001, SMD 0.299) For 71.0% in B, surgery was not the first treatment plan compared to 62.0% in A (P < 0.001, SMD 0.299). Survival curves showed worse prognosis for each clinical and pathologic stage for B compared to A. CONCLUSIONS Patients older than 80 years present less frequently as clinical stage IA, are less commonly offered surgical intervention and are more frequently diagnosed using less accurate measures. They also have worse outcomes for each stage compared to younger patients.
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Affiliation(s)
- Anupama Singh
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Emanuele Mazzola
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Yue Xie
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - M Blair Marshall
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Fatima G Wilder
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA, USA
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Singh A, McAllister M, De León LE, Kücükak S, Rochefort MM, Mazzola E, Maldonado L, Hartigan PM, Jaklitsch MT, Swanson SJ, Bueno R, Deeb AL, Patil N. Liposomal bupivacaine intercostal block placed under direct vision reduces morphine use in thoracic surgery. J Thorac Dis 2024; 16:1161-1170. [PMID: 38505026 PMCID: PMC10944765 DOI: 10.21037/jtd-23-1405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 12/29/2023] [Indexed: 03/21/2024]
Abstract
Background Thoracic epidural analgesia (TEA) and liposomal bupivacaine (LB) are two methods used for postoperative pain control after thoracic surgery. Some studies have compared LB to standard bupivacaine. However, data comparing the outcomes of LB to TEA after minimally invasive lung resection is limited. Therefore, the objective of our study was to compare postoperative pain, opioid usage, and outcomes between patients who received TEA vs. LB. Methods We conducted a retrospective chart review of patients who underwent minimally invasive lung resections over an 8-month period. Intraoperatively, patients received either LB under direct vision or a TEA. Pain scores were obtained in the post-anesthesia care unit (PACU) and at 12, 24, and 48 hours postoperatively. Morphine milligram equivalents (MMEs) were calculated at 24 and 48 hours postoperatively. Postoperative outcomes were then compared between groups. Results In total, 391 patients underwent minimally invasive lung resection: 236 (60%) wedge resections, 51 (13%) segmentectomies, and 104 (27%) lobectomies. Of these, 326 (83%) received LB intraoperatively. Fewer patients in the LB group experienced postoperative complications (18% vs. 34%, P=0.004). LB patients also had lower median pain scores at 24 (P=0.03) and 48 hours (P=0.001) postoperatively. There was no difference in MMEs at 24 hours (P=0.49). However, at 48 hours, patients who received LB required less narcotics (P=0.02). Median hospital length of stay (LOS) was significantly shorter in patients who received LB (2 vs. 4 days, P<0.001). On multivariable analysis, increasing age, postoperative complications, and use of TEA were independently associated with a longer hospital LOS. Conclusions Compared to TEA, LB intercostal block placed under direct vision reduced morphine use 48 hours after thoracic surgery. It was also associated with fewer postoperative complications and shorter median hospital LOS. LB is a good alternative to TEA for pain management after minimally invasive lung resection.
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Affiliation(s)
- Anupama Singh
- Department of Thoracic Surgery, Brigham and Women’s Hospital, Boston, MA, USA
| | - Miles McAllister
- Department of Thoracic Surgery, Brigham and Women’s Hospital, Boston, MA, USA
| | - Luis E. De León
- Department of Thoracic Surgery, Brigham and Women’s Hospital, Boston, MA, USA
| | - Suden Kücükak
- Department of Thoracic Surgery, Brigham and Women’s Hospital, Boston, MA, USA
| | | | - Emanuele Mazzola
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Luisa Maldonado
- Department of Thoracic Surgery, Brigham and Women’s Hospital, Boston, MA, USA
| | | | | | - Scott J. Swanson
- Department of Thoracic Surgery, Brigham and Women’s Hospital, Boston, MA, USA
| | - Raphael Bueno
- Department of Thoracic Surgery, Brigham and Women’s Hospital, Boston, MA, USA
| | - Ashley L. Deeb
- Department of Thoracic Surgery, Brigham and Women’s Hospital, Boston, MA, USA
| | - Namrata Patil
- Department of Thoracic Surgery, Brigham and Women’s Hospital, Boston, MA, USA
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Kim S, Lee SY, Vaz N, Leo R, Barcelos RR, Mototani R, Lozano A, Sugarbaker EA, Oh SS, Jacobson F, Wee JO, Jaklitsch MT, Marshall MB. Association of conduit dimensions with perioperative outcomes and long-term quality of life after esophagectomy for malignancy. JTCVS Open 2024; 17:306-319. [PMID: 38420534 PMCID: PMC10897658 DOI: 10.1016/j.xjon.2023.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 11/16/2023] [Accepted: 11/27/2023] [Indexed: 03/02/2024]
Abstract
Objective The impact of conduit dimensions and location of esophagogastric anastomosis on long-term quality of life after esophagectomy remains unexplored. We investigated the association of these parameters with surgical outcomes and patient-reported quality of life at least 18 months after esophagectomy. Methods We identified all patients who underwent esophagectomy for cancer from 2018 to 2020 in our institution. We reviewed each patient's initial postoperative computed tomography scan measuring the gastric conduit's greatest width (centimeters), linear staple line length (centimeters), and relative location of esophagogastric anastomosis (vertebra). Quality of life was ascertained using patient-reported outcome measures. Perioperative complications, length of stay, and mortality were collected. Multivariate regressions were performed. Results Our study revealed that a more proximal anastomosis was linked to an increased risk of pulmonary complications, a lower recurrence rate, and greater long-term insomnia. Increased maximum intrathoracic conduit width was significantly associated with trouble enjoying meals and reflux long term after esophagectomy. A longer conduit stapled line correlated with fewer issues related to insomnia, improved appetite, less dysphagia, and significantly enhanced "social," "role," and "physical'" aspects of the patient's long-term quality of life. Conclusions The dimensions of the gastric conduit and the height of the anastomosis may be independently associated with outcomes and long-term quality of life after esophagectomy for cancer.
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Affiliation(s)
- SangMin Kim
- Harvard Medical School, Boston, Mass
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Sun Yeop Lee
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Mass
| | - Nuno Vaz
- Department of Radiology, Brigham and Women's Hospital, Boston, Mass
| | - Rachel Leo
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Rafael R Barcelos
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Mass
| | | | - Antonio Lozano
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Mass
| | | | - Sarah S Oh
- Department of Social & Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Mass
| | | | - Jon O Wee
- Harvard Medical School, Boston, Mass
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Michael T Jaklitsch
- Harvard Medical School, Boston, Mass
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Mass
| | - M Blair Marshall
- Harvard Medical School, Boston, Mass
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Mass
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Pezeshkian F, McAllister M, Singh A, Theeuwen H, Abdallat M, Figueroa PU, Gill RR, Kim AW, Jaklitsch MT. What's new in thoracic oncology. J Surg Oncol 2024; 129:128-137. [PMID: 38031889 DOI: 10.1002/jso.27535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 11/08/2023] [Accepted: 11/08/2023] [Indexed: 12/01/2023]
Abstract
Many changes have occurred in the field of thoracic surgery over the last several years. In this review, we will discuss new diagnostic techniques for lung cancer, innovations in surgery, and major updates on latest treatment options including immunotherapy. All these have significantly started to change our approach toward the management of lung cancer and have great potential to improve the lives of our patients afflicted with this disease.
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Affiliation(s)
- Fatemehsadat Pezeshkian
- Division of Thoracic Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Miles McAllister
- Division of Thoracic Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Anupama Singh
- Division of Thoracic Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Hailey Theeuwen
- Division of Thoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Mohammad Abdallat
- Division of Thoracic Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Paula Ugalde Figueroa
- Division of Thoracic Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ritu R Gill
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Anthony W Kim
- Division of Thoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Michael T Jaklitsch
- Division of Thoracic Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Pezeshkian F, McAllister M, Singh A, Jaklitsch MT, Gill RR, Bueno R, Coppolino A. Image-guided video-assisted thoracoscopic surgery (iVATS): a single center experience and review. J Thorac Dis 2023; 15:7035-7041. [PMID: 38249864 PMCID: PMC10797359 DOI: 10.21037/jtd-23-1461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 11/17/2023] [Indexed: 01/23/2024]
Abstract
Lung cancer screening techniques using low-dose computed tomography (LDCT) scans have improved over the last decade. This means that there is an increased rate of detection of small, often non-palpable, nodules and ground-glass opacities. Obtaining a definitive diagnosis of these nodules using techniques such as percutaneous image-guided biopsy or intraoperative localization is challenging, and these nodules have traditionally undergone routine surveillance. Image-guided video-assisted thoracoscopic surgery (iVATS), which is performed in a hybrid operating room, has made it more feasible to biopsy and resect these nodules. The first thoracic surgery hybrid operative room was introduced at our institution at Brigham and Women's Hospital. Herein, we describe our experience implementing this technique including the methods we used to train key personnel such as radiologists, surgeons, and anesthesiologists to ensure that this technique successfully translated to a clinical setting. We review the benefits of iVATS, which includes decreased rate of fiducial dislodgement, real-time imaging which facilitates successful fiducial placement, and smaller sized resection of lung parenchyma. We will also describe the comparisons between traditional diagnostic methods and iVATS, patient selection criteria and important technical details. Some centers describe alternative techniques for several of the technical aspects, including patient positioning, which we also mention. Lastly, we describe adverse events after iVATS, which are comparable to those seen after a standard VATS.
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Affiliation(s)
| | - Miles McAllister
- Division of Thoracic Surgery, Brigham and Women’s Hospital, Boston, MA, USA
| | - Anupama Singh
- Division of Thoracic Surgery, Brigham and Women’s Hospital, Boston, MA, USA
| | | | - Ritu R. Gill
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Raphael Bueno
- Division of Thoracic Surgery, Brigham and Women’s Hospital, Boston, MA, USA
| | - Antonio Coppolino
- Division of Thoracic Surgery, Brigham and Women’s Hospital, Boston, MA, USA
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Montroni I, Ugolini G, Saur NM, Rostoft S, Spinelli A, Van Leeuwen BL, De Liguori Carino N, Ghignone F, Jaklitsch MT, Kenig J, Garutti A, Zingaretti C, Foca F, Vertogen B, Nanni O, Wexner SD, Audisio RA. Predicting Functional Recovery and Quality of Life in Older Patients Undergoing Colorectal Cancer Surgery: Real-World Data From the International GOSAFE Study. J Clin Oncol 2023; 41:5247-5262. [PMID: 37390383 DOI: 10.1200/jco.22.02195] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 03/10/2023] [Accepted: 05/09/2023] [Indexed: 07/02/2023] Open
Abstract
PURPOSE The GOSAFE study evaluates risk factors for failing to achieve good quality of life (QoL) and functional recovery (FR) in older patients undergoing surgery for colon and rectal cancer. METHODS Patients age 70 years and older undergoing major elective colorectal surgery were prospectively enrolled. Frailty assessment was performed and outcomes, including QoL (EQ-5D-3L) recorded (3/6 months postoperatively). Postoperative FR was defined as a combination of Activity of Daily Living ≥5 + Timed Up & Go test <20 seconds + MiniCog >2. RESULTS Prospective complete data were available for 625/646 consecutive patients (96.9%; 435 colon and 190 rectal cancer), 52.6% men, and median age was 79.0 years (IQR, 74.6-82.9 years). Surgery was minimally invasive in 73% of patients (321/435 colon; 135/190 rectum). At 3-6 months, 68.9%-70.3% patients experienced equal/better QoL (72.8%-72.9% colon, 60.1%-63.9% rectal cancer). At logistic regression analysis, preoperative Flemish Triage Risk Screening Tool ≥2 (3-month odds ratio [OR], 1.68; 95% CI, 1.04 to 2.73; P = .034, 6-month OR, 1.71; 95% CI, 1.06 to 2.75; P = .027) and postoperative complications (3-month OR, 2.03; 95% CI, 1.20 to 3.42; P = .008, 6-month OR, 2.56; 95% CI, 1.15 to 5.68; P = .02) are associated with decreased QoL after colectomy. Eastern Collaborative Oncology Group performance status (ECOG PS) ≥2 is a strong predictor of postoperative QoL decline in the rectal cancer subgroup (OR, 3.81; 95% CI, 1.45 to 9.92; P = .006). FR was reported by 254/323 (78.6%) patients with colon and 94/133 (70.6%) with rectal cancer. Charlson Age Comorbidity Index ≥7 (OR, 2.59; 95% CI, 1.26 to 5.32; P = .009), ECOG ≥2 (OR, 3.12; 95% CI, 1.36 to 7.20; P = .007 colon; OR, 4.61; 95% CI, 1.45 to 14.63; P = .009 rectal surgery), severe complications (OR, 17.33; 95% CI, 7.30 to 40.8; P < .001), fTRST ≥2 (OR, 2.71; 95% CI, 1.40 to 5.25; P = .003), and palliative surgery (OR, 4.11; 95% CI, 1.29 to 13.07; P = .017) are risk factors for not achieving FR. CONCLUSION The majority of older patients experience good QoL and stay independent after colorectal cancer surgery. Predictors for failing to achieve these essential outcomes are now defined to guide patients' and families' preoperative counseling.
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Affiliation(s)
- Isacco Montroni
- U.O. Department of Surgery, Colorectal Surgery Unit Ospedale S. Maria delle Croci, Ravenna, AUSL Romagna, Italy
| | - Giampaolo Ugolini
- U.O. Department of Surgery, Colorectal Surgery Unit Ospedale S. Maria delle Croci, Ravenna, AUSL Romagna, Italy
| | - Nicole M Saur
- University of Pennsylvania, Perelman School of Medicine, Department of Surgery, Division of Colon and Rectal Surgery, Philadelphia, PA
| | - Siri Rostoft
- Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Antonino Spinelli
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center, Rozzano (MI), Italy
| | - Barbara L Van Leeuwen
- Department of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Federico Ghignone
- U.O. Department of Surgery, Colorectal Surgery Unit Ospedale S. Maria delle Croci, Ravenna, AUSL Romagna, Italy
| | - Michael T Jaklitsch
- Division of Surgery, Division of Aging, Brigham and Women's Hospital, Boston, MA
| | - Jakub Kenig
- Department of General, Oncologic and Geriatric Surgery Jagiellonian University Medical College, Krakov, Poland
| | - Anna Garutti
- U.O. Department of Surgery, Colorectal Surgery Unit Ospedale S. Maria delle Croci, Ravenna, AUSL Romagna, Italy
| | - Chiara Zingaretti
- IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori," Meldola, Italy
| | - Flavia Foca
- IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori," Meldola, Italy
| | - Bernadette Vertogen
- IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori," Meldola, Italy
| | - Oriana Nanni
- IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori," Meldola, Italy
| | - Steven D Wexner
- Cleveland Clinic Florida, Department of Colorectal Surgery, Weston, FL
| | - Riccardo A Audisio
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska University Hospital, Göteborg, Sweden
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12
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Solomon D, Deeb AL, Tarabine K, Xie Y, Mazzola E, Zhao L, Hammer MM, Jaklitsch MT, Swanson SJ, Bueno R, Wee JO. Predicting outcomes in esophageal adenocarcinoma following neoadjuvant chemoradiation: Interactions between tumor response and survival. J Thorac Cardiovasc Surg 2023:S0022-5223(23)01091-7. [PMID: 37967764 DOI: 10.1016/j.jtcvs.2023.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 10/04/2023] [Accepted: 11/05/2023] [Indexed: 11/17/2023]
Abstract
OBJECTIVES The prognostic value of tumor regression scores (TRS) in patients with esophageal adenocarcinoma (EAC) who underwent neoadjuvant chemoradiation remains unclear. We sought to investigate the prognostic value of pathologic and metabolic treatment response among EAC patients undergoing neoadjuvant chemoradiation. METHODS Patients who underwent esophagectomy for EAC after neoadjuvant CROSS protocol between 2016 and 2020 were evaluated. TRS was grouped according to the modified Ryan score; metabolic response, according to the PERCIST criteria. Variables from endoscopic ultrasound, endoscopic biopsies, and positron emission tomography (primary and regional lymph node standardized uptake values [SUVs]) were collected. RESULTS The study population comprised 277 patients. A TRS of 0 (complete response) was identified in 66 patients (23.8%). Seventy-eight patients (28.1%) had TRS 1 (partial response), 97 (35%) had TRS 2 (poor response), and 36 (13%) had TRS 3 (no response). On survival analysis for overall survival (OS), patients with TRS 0 had longer survival compared to those with TRS 1, 2, or 3 (P = .010, P < .001, and P = .005, respectively). On multivariable logistic regression, the presence of signet ring cell features on endoscopic biopsy (odds ratio [OR], 7.54; P = .012) and greater SUV uptake at regional lymph nodes (OR, 1.42; P = .007) were significantly associated with residual tumor at pathology (TRS 1, 2, or 3). On multivariate Cox regression for predictors of OS, higher SUVmax at the most metabolically active nodal station (hazard ratio [HR], 1.08; P = .005) was independently associated with decreased OS, whereas pathologic complete response (HR, 0.61; P = .021) was independently associated with higher OS. CONCLUSIONS Patients with pathologic complete response had prolonged OS, whereas no difference in survival was detected among other TRS categories. At initial staging, the presence of signet ring cells and greater SUV uptake at regional lymph nodes predicted residual disease at pathology and shorter OS, suggesting the need for new treatment strategies for these patients.
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Affiliation(s)
- Daniel Solomon
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Boston, Mass.
| | - Ashley L Deeb
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Kamal Tarabine
- Department of Radiology, Brigham and Women's Hospital, Boston, Mass
| | - Yue Xie
- Department of Data Sciences, Dana Farber Cancer Institute, Boston, Mass
| | - Emanuele Mazzola
- Department of Data Sciences, Dana Farber Cancer Institute, Boston, Mass
| | - Lei Zhao
- Department of Pathology, Brigham and Women's Hospital, Boston, Mass
| | - Mark M Hammer
- Department of Radiology, Brigham and Women's Hospital, Boston, Mass
| | - Michael T Jaklitsch
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Scott J Swanson
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Raphael Bueno
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Jon O Wee
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Boston, Mass
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13
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Kehl KL, Jaklitsch MT. Quality Surgical Care and Outcomes for Patients With Non-Small-Cell Lung Cancer. J Clin Oncol 2023:JCO2300745. [PMID: 37267584 DOI: 10.1200/jco.23.00745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 04/05/2023] [Accepted: 04/11/2023] [Indexed: 06/04/2023] Open
Affiliation(s)
- Kenneth L Kehl
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
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14
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Deeb AL, Garrity M, Cooper L, Frain LN, Jaklitsch MT, DuMontier C. Implementing 4-meter gait speed as a routine vital sign in a thoracic surgery clinic. J Geriatr Oncol 2023; 14:101481. [PMID: 37060720 PMCID: PMC10445274 DOI: 10.1016/j.jgo.2023.101481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 02/06/2023] [Accepted: 03/13/2023] [Indexed: 04/17/2023]
Affiliation(s)
- Ashley L Deeb
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, 15 Francis St, Boston, MA, USA.
| | - Matthew Garrity
- University of New England College of Osteopathic Medicine, 11 Hills Beach Rd, Biddeford, ME, USA
| | - Lisa Cooper
- Division of Aging, Brigham and Women's Hospital, 75 Francis St, Boston, MA, USA; Department of Geriatric Medicine, Rabin Medical Center, Campus Beilinson, 39 Jabotinski St, Petah Tikva, Israel
| | - Laura N Frain
- Division of Aging, Brigham and Women's Hospital, 75 Francis St, Boston, MA, USA
| | - Michael T Jaklitsch
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, 15 Francis St, Boston, MA, USA
| | - Clark DuMontier
- Division of Aging, Brigham and Women's Hospital, 75 Francis St, Boston, MA, USA; New England GRECC (Geriatrics Research, Education and Clinical Center), VA Boston Healthcare System, 150 S Huntington Ave, Boston, MA, USA
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15
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Cooper L, Deeb A, Dezube AR, Mazzola E, Dumontier C, Bader AM, Theou O, Jaklitsch MT, Frain LN. Validation of the Pictorial Fit-Frail Scale in a Thoracic Surgery Clinic. Ann Surg 2023; 277:e1150-e1156. [PMID: 35129471 PMCID: PMC9300765 DOI: 10.1097/sla.0000000000005381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE Examine feasibility and construct validity of Pictorial Fit-Frail scale (PFFS) for the first time in older surgical patients. BACKGROUND The PFFS uses visual images to measure health state in 14 domains and has been previously validated in outpatient geriatric clinics. METHODS Patients ≥65 year-old who were evaluated in a multidisciplinary thoracic surgery clinic from November 2020 to May 2021 were prospectively included. Patients completed an in-person PFFS and Vulnerable Elders Survey (VES-13) during their visit, and a frailty index was calculated from the PFFS (PFFStrans). A geriatrician performed a comprehensive geriatric assessment (CGA) either in-person or virtually, from which a Frailty Index (FI-CGA) and Frailty Questionnaire (FRAIL) scale were obtained. To assess the validity of the PFFS in this population, the Spearman rank correlations (r spearman ) between PFFS trans and VES-13, FI-CGA, FRAIL were calculated. RESULTS All 49 patients invited to participate agreed, of which 46/49 (94%) completed the PFFS so a score could be calculated. The majority of patients (59%) underwent an in-person CGA and the reminder (41%) a virtual CGA. The cohort was mainly female (59.0%), with a median age of 77 (range: 67-90). The median PFFS trans was 0.27 (interquartile range [IQR] 0.12-0.34), PFFS was 11 (IQR 5-14), and 0.24 (IQR 0.13-0.32) for FI-CGA. We observed a strong correlation between the PFFS trans and FI-CGA (r spearman = 0.81, P < 0.001) and a moderate correlation between PFFS trans and VES-13 and FRAIL score (r spearman = 0.68 and 0.64 respectively, P < 0.001). CONCLUSIONS PFFS had good feasibility and construct validity among older surgical patients when compared to previously validated frailty measurements.
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Affiliation(s)
- Lisa Cooper
- Division of Aging, Brigham and Women’s Hospital, Boston, MA
- Geriatric Medicine, Rabin Medical Center, Petach Tikva, Israel
| | - Ashley Deeb
- Division of Thoracic and Cardiac Surgery, Brigham and Women’s Hospital, Boston, MA
| | - Aaron R Dezube
- Division of Thoracic and Cardiac Surgery, Brigham and Women’s Hospital, Boston, MA
| | - Emanuele Mazzola
- Department of Data Science, Dana Farber Cancer Institute, Boston, MA
| | - Clark Dumontier
- Division of Aging, Brigham and Women’s Hospital, Boston, MA
- New England GRECC (Geriatrics Research, Education and Clinical Center), VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Angela M Bader
- Department of Anesthesiology, Brigham and Women’s Hospital, Boston, MA
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA
| | - Olga Theou
- Physiotherapy, Dalhousie University, Halifax, Nova Scotia, Canada
- Geriatric Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Michael T Jaklitsch
- Division of Thoracic and Cardiac Surgery, Brigham and Women’s Hospital, Boston, MA
| | - Laura N Frain
- Division of Aging, Brigham and Women’s Hospital, Boston, MA
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16
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Shields PG, Bierut L, Arenberg D, Balis D, Cinciripini PM, Davis J, Edmondson D, Feliciano J, Hitsman B, Hudmon KS, Jaklitsch MT, Leone FT, Ling P, McCarthy DE, Ong MK, Park ER, Prochaska J, Sandoval AJ, Sheffer CE, Spencer S, Studts JL, Tanvetyanon T, Tindle HA, Tong E, Triplette M, Urbanic J, Videtic G, Warner D, Whitlock CW, McCullough B, Darlow S. Smoking Cessation, Version 3.2022, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2023; 21:297-322. [PMID: 36898367 DOI: 10.6004/jnccn.2023.0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
Abstract
Although the harmful effects of smoking after a cancer diagnosis have been clearly demonstrated, many patients continue to smoke cigarettes during treatment and beyond. The NCCN Guidelines for Smoking Cessation emphasize the importance of smoking cessation in all patients with cancer and seek to establish evidence-based recommendations tailored to the unique needs and concerns of patients with cancer. The recommendations contained herein describe interventions for cessation of all combustible tobacco products (eg, cigarettes, cigars, hookah), including smokeless tobacco products. However, recommendations are based on studies of cigarette smoking. The NCCN Smoking Cessation Panel recommends that treatment plans for all patients with cancer who smoke include the following 3 tenets that should be done concurrently: (1) evidence-based motivational strategies and behavior therapy (counseling), which can be brief; (2) evidence-based pharmacotherapy; and (3) close follow-up with retreatment as needed.
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Affiliation(s)
- Peter G Shields
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | - Laura Bierut
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | | | - David Balis
- UT Southwestern Simmons Comprehensive Cancer Center
| | | | | | | | - Joy Feliciano
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | - Brian Hitsman
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | - Karen S Hudmon
- Indiana University Melvin and Bren Simon Comprehensive Cancer Center
| | | | - Frank T Leone
- Abramson Cancer Center at the University of Pennsylvania
| | - Pamela Ling
- UCSF Helen Diller Family Comprehensive Cancer Center
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Gregory Videtic
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
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17
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Dolan DP, Polhemus E, Lee DN, Mazzola E, Jaklitsch MT, Wee JO, Bueno R, Swanson SJ, White A. Hyperthermic intraoperative chemotherapy (HIOC) for Stage IVa thymic malignancy may improve 5-year disease-free survival. J Surg Oncol 2023; 127:734-740. [PMID: 36453475 DOI: 10.1002/jso.27150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 11/08/2022] [Accepted: 11/11/2022] [Indexed: 12/05/2022]
Abstract
BACKGROUND AND OBJECTIVES Stage IVa thymic malignancy has limited treatments. This study evaluated whether hyperthermic intraoperative chemotherapy (HIOC) after radical resection of Stage IVa thymic malignancy improves survival. METHODS All patients who underwent resection, with or without HIOC, for Stage IVa thymic malignancy at a single center from 1990 to 2021 were reviewed. RESULTS Thirty-four patients were identified; 22 surgery-only versus 12 surgery and HIOC (60 min cisplatin regimen 175 mg/m2 ). Demographics and comorbidities were similar between groups. Three patients in each group were carcinomas; remainder were thymomas. Thirty-two patients underwent attempted macroscopic complete resection; 22 operations succeeded, 68.8%. Significant complications were similar between groups, 18.2% surgery-only versus 25.0% HIOC, p = 0.68. Median time to recurrence trended longer for HIOC patients (42.9 vs. 32.9 months in surgery-only, p = 0.77). Overall survival, 5-year, was similar (75.8% HIOC vs. 76.2% surgery-only, p = 0.91). On stratified analysis, thymoma patients with macroscopic complete resection and HIOC experienced similar 5-year Overall (80.0% vs. 100.0% surgery-only, p = 0.157) but longer trending 5-year disease-free (85.7% vs. 40.0%, p = 0.18) and 5-year locoregional recurrence-free survival (85.7% vs. 68.6%, p = 0.75). CONCLUSIONS This retrospective cohort study treating Stage IVa thymic malignancy with radical pleurectomy, with or without HIOC, found addition of HIOC-signaled delayed recurrence and improved disease-free survival.
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Affiliation(s)
- Daniel P Dolan
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Emily Polhemus
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Daniel N Lee
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Emanuele Mazzola
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Michael T Jaklitsch
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jon O Wee
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Raphael Bueno
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Scott J Swanson
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Abby White
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
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18
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Paajanen J, Jaklitsch MT, Bueno R. Contemporary issues in the surgical management of pleural mesothelioma. J Surg Oncol 2023; 127:343-354. [PMID: 36630097 PMCID: PMC9839311 DOI: 10.1002/jso.27152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/10/2022] [Accepted: 11/11/2022] [Indexed: 01/12/2023]
Abstract
The surgical management of pleural mesothelioma (PM) can be divided into diagnostic, staging, palliation, and cytoreductive surgery. In the cytoreductive surgical setting, the combination of different treatment modalities has led to better outcomes than surgery alone. The scarcity of high-quality studies has led to heterogeneity in management of PM across the mesothelioma treatment centers. Here, we review the literature regarding the most important open questions and ongoing clinical trials.
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Affiliation(s)
- Juuso Paajanen
- The Thoracic Surgery Oncology laboratory and the International Mesothelioma Program (www.impmeso.org), Division of Thoracic Surgery and the Lung Center, Brigham and Women’s Hospital, and Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Michael T. Jaklitsch
- The Thoracic Surgery Oncology laboratory and the International Mesothelioma Program (www.impmeso.org), Division of Thoracic Surgery and the Lung Center, Brigham and Women’s Hospital, and Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Raphael Bueno
- The Thoracic Surgery Oncology laboratory and the International Mesothelioma Program (www.impmeso.org), Division of Thoracic Surgery and the Lung Center, Brigham and Women’s Hospital, and Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
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19
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Kim AW, Jaklitsch MT. The evolving landscape of thoracic surgical oncology. J Surg Oncol 2023; 127:217-220. [PMID: 36630095 PMCID: PMC10107667 DOI: 10.1002/jso.27174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 12/02/2022] [Indexed: 01/12/2023]
Abstract
The history of Thoracic Surgical Oncology warrants attribution to the strong foundational contributions of the past. Current surgical approaches and techniques along with newer systemic therapies are the product of iterative modifications to prior successes. Progress also fosters traditional thinking to be challenged and other classic topics to be revisited with a contemporary perspective. Cumulatively, past and present clinical and scientific efforts point toward a promising future in the evolving landscape of Thoracic Surgical Oncology.
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Affiliation(s)
- Anthony W Kim
- Division of Thoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Michael T Jaklitsch
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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20
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Singh A, Jaklitsch MT. Lymph node sampling-what are the numbers? J Surg Oncol 2023; 127:308-318. [PMID: 36630092 DOI: 10.1002/jso.27157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/05/2022] [Accepted: 11/11/2022] [Indexed: 01/12/2023]
Abstract
Lung cancer is a deadly disease. Lymph node staging is the most important prognostic factor, and lymphatic drainage of the lung is complex. Major advances have been made in this field over the last several decades, but there is much left to understand and improve upon. Herein, we review the history of the lymphatic system and the creation of lymph node maps, the evolution of tumor, node, and metastasis lung cancer classification, the importance of lung cancer staging, techniques for lymph node dissection, and our recommendations regarding a minimum number of nodes to sample during pulmonary resection.
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Affiliation(s)
- Anupama Singh
- Division of Thoracic Surgery, Harvard Medical School Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michael T Jaklitsch
- Division of Thoracic Surgery, Harvard Medical School Brigham and Women's Hospital, Boston, Massachusetts, USA
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21
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Dolan DP, Lee DN, Polhemus E, Kucukak S, De León LE, Wiener D, Jaklitsch MT, Swanson SJ, White A. Report on lung cancer surgery during COVID-19 pandemic at a high volume US institution. J Thorac Dis 2022; 14:2874-2879. [PMID: 36071771 PMCID: PMC9442535 DOI: 10.21037/jtd-22-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 05/30/2022] [Indexed: 01/18/2023]
Abstract
Background The impact of COVID-19 has been felt in every field of medicine. We sought to understand how lung cancer surgery was affected at a high volume institution. We hypothesized that patients would wait longer for surgery, have more advanced tumors, and experience more complications during the COVID-19 crisis. Methods A retrospective review was conducted, comparing pathologically confirmed non-small cell lung cancer (NSCLC) surgical cases performed in 2019 to cases performed from March to May 2020, during the height of the COVID-19 crisis. Clinical and pathologic stage, tumor size, time to surgery, follow up time, and complications were evaluated. Results A total of 375 cases were performed in 2019 vs. 58 cases in March to May 2020. Overall, there were no differences in the distribution of clinical stages or in the distribution of median wait times to surgery between groups (COVID-19 16.5 days vs. pre-COVID-19 17 days, P=0.54), nor were there differences when subdivided into Stage I-II and Stage III-IV. Case volume was lowest in April 2020 with 6 cases vs. 37 in April 2019, P<0.01. Tumor size was clinically larger in the COVID-19 group (median 2.1 vs. 1.9 cm, P=0.05) but not at final pathology. No differences in complications were observed between groups (COVID-19 31.0% vs. pre-COVID-19 30.9%, P=1.00). No patients from the COVID-19 group tested positive for the disease during their hospital stay or by the median 15 days to first follow-up. Conclusions Surgical wait time, pathologic tumor size, and complications were not different among patients undergoing surgery before vs. during the pandemic. Importantly, no patients became infected as a result of their hospital stay. The significant decrease in surgical cases is concerning for untreated cancers that may progress without proper treatment.
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Affiliation(s)
- Daniel P Dolan
- Division of Thoracic and Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
| | - Daniel N Lee
- Division of Thoracic and Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
| | - Emily Polhemus
- Division of Thoracic and Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
| | - Suden Kucukak
- Division of Thoracic and Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
| | - Luis E De León
- Division of Thoracic and Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
| | - Daniel Wiener
- Division of Thoracic and Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
| | - Michael T Jaklitsch
- Division of Thoracic and Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
| | - Scott J Swanson
- Division of Thoracic and Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
| | - Abby White
- Division of Thoracic and Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
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22
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Montroni I, Ugolini G, Saur NM, Rostoft S, Spinelli A, Van Leeuwen BL, De Liguori Carino N, Ghignone F, Jaklitsch MT, Somasundar P, Garutti A, Zingaretti C, Foca F, Vertogen B, Nanni O, Wexner SD, Audisio RA. Quality of Life in Older Adults After Major Cancer Surgery: The GOSAFE International Study. J Natl Cancer Inst 2022; 114:969-978. [PMID: 35394037 PMCID: PMC9275771 DOI: 10.1093/jnci/djac071] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 01/11/2022] [Accepted: 03/23/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Accurate quality of life (QoL) data and functional results after cancer surgery are lacking for older patients. The international, multicenter Geriatric Oncology Surgical Assessment and Functional rEcovery after Surgery (GOSAFE) Study compares QoL before and after surgery and identifies predictors of decline in QoL. METHODS GOSAFE prospectively collected data before and after major elective cancer surgery on older adults (≥70 years). Frailty assessment was performed and postoperative outcomes recorded (30, 90, and 180 days postoperatively) together with QoL data by means of the three-level version of the EuroQol five-dimensional questionnaire (EQ-5D-3L), including 2 components: an index (range = 0-1) generated by 5 domains (mobility, self-care, ability to perform the usual activities, pain or discomfort, anxiety or depression) and a visual analog scale. RESULTS Data from 26 centers were collected (February 2017-March 2019). Complete data were available for 942/1005 consecutive patients (94.0%): 492 male (52.2%), median age 78 years (range = 70-95 years), and primary tumor was colorectal in 67.8%. A total 61.2% of all surgeries were via a minimally invasive approach. The 30-, 90-, and 180-day mortality was 3.7%, 6.3%, and 9%, respectively. At 30 and 180 days, postoperative morbidity was 39.2% and 52.4%, respectively, and Clavien-Dindo III-IV complications were 13.5% and 18.7%, respectively. The mean EQ-5D-3L index was similar before vs 3 months but improved at 6 months (0.79 vs 0.82; P < .001). Domains showing improvement were pain and anxiety or depression. A Flemish Triage Risk Screening Tool score greater than or equal to 2 (odds ratio [OR] = 1.58, 95% confidence interval [CI] = 1.13 to 2.21, P = .007), palliative surgery (OR = 2.14, 95% CI = 1.01 to 4.52, P = .046), postoperative complications (OR = 1.95, 95% CI = 1.19 to 3.18, P = .007) correlated with worsening QoL. CONCLUSIONS GOSAFE shows that older adults' preoperative QoL is preserved 3 months after cancer surgery, independent of their age. Frailty screening tools, patient-reported outcomes, and goals-of-care discussions can guide decisions to pursue surgery and direct patients' expectations.
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Affiliation(s)
- Isacco Montroni
- Colorectal surgery Unit, Ospedale “per gli Infermi”, AUSL Romagna, Faenza, Italy
| | - Giampaolo Ugolini
- Colorectal surgery Unit, Ospedale “per gli Infermi”, AUSL Romagna, Faenza, Italy
| | - Nicole M Saur
- Perelman School of Medicine, Department of Surgery, Division of Colon and Rectal Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Siri Rostoft
- Department of Geriatric Medicine, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Barbara L Van Leeuwen
- Department of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Federico Ghignone
- Colorectal surgery Unit, Ospedale “per gli Infermi”, AUSL Romagna, Faenza, Italy
| | - Michael T Jaklitsch
- Division of Thoracic Surgery and Division of Aging, Brigham and Women’s Hospital, Boston, MA, USA
| | - Ponnandai Somasundar
- Department of Surgery, Roger Williams Medical Center, Boston University, Providence, RI, USA
| | - Anna Garutti
- Colorectal surgery Unit, Ospedale “per gli Infermi”, AUSL Romagna, Faenza, Italy
| | - Chiara Zingaretti
- Unit of Biostatistics and Clinical Trials, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Flavia Foca
- Unit of Biostatistics and Clinical Trials, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Bernadette Vertogen
- Unit of Biostatistics and Clinical Trials, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Oriana Nanni
- Unit of Biostatistics and Clinical Trials, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Riccardo A Audisio
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska University Hospital, Göteborg, Sweden
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23
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Nayak MM, Mazzola E, Jaklitsch MT, Drehmer JE, Nabi-Burza E, Bueno R, Winickoff JP, Cooley ME. Feasibility of collecting computer-facilitated patient-reported
tobacco use, interest, and preferences for smoking cessation
in an outpatient thoracic surgery and oncology setting. Tob Induc Dis 2022; 20:63. [PMID: 35854879 PMCID: PMC9251647 DOI: 10.18332/tid/150335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 05/13/2022] [Accepted: 05/23/2022] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Effective strategies are needed to facilitate collection of tobacco use information and integrate smoking cessation treatment into the routine care of all high-risk patient populations to improve clinical outcomes. The objective of this study was to establish the feasibility of collecting computer-facilitated patient-reported tobacco use, identify patient interest and preferences for smoking cessation in an outpatient thoracic surgery and oncology setting with higher prevalence of tobacco use than the general population. METHODS A brief patient-administered tobacco screening survey was handed out on an iPad in the waiting room of a thoracic surgery and oncology practice setting to sequential patients with varying diagnoses. Tobacco use, household exposure to tobacco, and interest and preferences for smoking cessation treatment were recorded. Descriptive statistics and Pearson’s chi-squared test were used for analysis. RESULTS Of the 599 surveys administered, 594 (99%) were completed. Self-reported smoking status included 36.4% (n=218) never smokers, 53.3% (n=319) former smokers, and 10.4% (n=62) current smokers. Among current smokers, 45.2% (n=28) were interested in receiving smoking cessation treatment. Preferences for treatment included: 21.4% (n=6) who wanted Quitline only, 25% (n=7) medication alone, and 53.6% (n=15) combined Quitline plus medication. Current smokers (55.7%, n=34) were more likely to live in households with tobacco exposure compared to those with former (11.4%, n=36) or never smokers (8.3%, n=18) (p<0.0001). CONCLUSIONS Implementing a computer-facilitated system to screen for current smoking and provide smoking cessation services was feasible in the outpatient thoracic surgery and oncology setting. Almost half of the smokers indicated an interest in receipt of smoking cessation treatment. Household exposure was more frequent among current smokers, therefore routine screening for secondhand smoke exposure from other household members is an important consideration in developing smoking cessation treatment plans to mitigate health risks among vulnerable patient populations.
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Affiliation(s)
- Manan M. Nayak
- The Phyllis F. Cantor Center Research in Nursing and Patient Care Services, Dana-Farber Cancer Institute, Boston, United States
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, United States
| | - Emanuele Mazzola
- Department of Data Science, Dana-Farber Cancer Institute, Boston, United States
| | - Michael T. Jaklitsch
- Division of Thoracic and Cardiac Surgery, Brigham and Women’s Hospital, Boston, United States
| | - Jeremy E. Drehmer
- Division of General Academic Pediatrics, Massachusetts General Hospital for Children, Boston, United States
- Tobacco Research and Treatment Center, Massachusetts General Hospital, Boston, United States
| | - Emara Nabi-Burza
- Division of General Academic Pediatrics, Massachusetts General Hospital for Children, Boston, United States
- Tobacco Research and Treatment Center, Massachusetts General Hospital, Boston, United States
| | - Raphael Bueno
- Division of Thoracic and Cardiac Surgery, Brigham and Women’s Hospital, Boston, United States
| | - Jonathan P. Winickoff
- Division of General Academic Pediatrics, Massachusetts General Hospital for Children, Boston, United States
- Tobacco Research and Treatment Center, Massachusetts General Hospital, Boston, United States
| | - Mary E. Cooley
- The Phyllis F. Cantor Center Research in Nursing and Patient Care Services, Dana-Farber Cancer Institute, Boston, United States
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24
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Dezube AR, Cooper L, Mazzola E, Dolan DP, Lee DN, Kucukak S, De Leon LE, Dumontier C, Ademola B, Polhemus E, Bueno R, White A, Swanson SJ, Jaklitsch MT, Frain L, Wee JO. Long-term Outcomes Following Esophagectomy in Older and Younger Adults with Esophageal Cancer. J Gastrointest Surg 2022; 26:1119-1131. [PMID: 35357674 PMCID: PMC9474270 DOI: 10.1007/s11605-022-05295-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 03/02/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Patterns of overall and disease-free survival after esophagectomy for esophageal cancer in older adults have not been carefully studied. METHODS Retrospective analysis of all patients with esophageal cancer undergoing esophagectomy from 2005 to 2020 at our institution was performed. Differences in outcomes were stratified by age groups, < 75 and ≥ 75 years old, and two time periods, 2005-2012 and 2013-2020. RESULTS A total of 1135 patients were included: 979 (86.3%) patients were < 75 (86.3%), and 156 (13.7%) were ≥ 75 years old. Younger patients had fewer comorbidities, better nutritional status, and were more likely to receive neoadjuvant and adjuvant therapy (all p < 0.05). However, tumor stage and operative approach were similar, except for increased performance of the McKeown technique in younger patients (p = 0.02). Perioperatively, younger patients experienced fewer overall and grade II complications (both p < 0.05). They had better overall survival (log-rank p-value < 0.001) and median survival, 62.2 vs. 21.5 months (p < 0.05). When stratified by pathologic stage, survival was similar for yp0 and pathologic stage II disease (both log-rank p-value > 0.05). Multivariable Cox models showed older age (≥ 75 years old) had increased hazard for reduced overall survival (HR 2.04 95% CI 1.5-2.8; p < 0.001) but not disease-free survival (HR 1.1 95% CI 0.78-1.6; p = 0.54). Over time, baseline characteristics remained largely similar, while stage became more advanced with a rise in neoadjuvant use and increased performance of minimally invasive esophagectomy (all p < 0.05). While overall complication rates improved (p < 0.05), overall and recurrence-free survival did not. Overall survival was better in younger patients during both time periods (both log-rank p < 0.05). CONCLUSIONS Despite similar disease-free survival rates, long-term survival was decreased in older adults as compared to younger patients. This may be related to unmeasured factors including frailty, long-term complications after surgery, and competing causes of death. However, our results suggest that survival is similar in those with complete pathologic responses.
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Affiliation(s)
- Aaron R Dezube
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02115, USA.
| | - Lisa Cooper
- Division of Aging, Brigham and Women's Hospital, Boston, MA, USA
| | - Emanuele Mazzola
- Division of Data Sciences, Dana Farber Cancer Institute, Boston, MA, USA
| | - Daniel P Dolan
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02115, USA
| | - Daniel N Lee
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02115, USA
| | - Suden Kucukak
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02115, USA
| | - Luis E De Leon
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02115, USA
| | - Clark Dumontier
- Division of Aging, Brigham and Women's Hospital, Boston, MA, USA
- New England GRECC, VA Boston Healthcare System, Boston, MA, USA
| | - Bayonle Ademola
- Division of Aging, Brigham and Women's Hospital, Boston, MA, USA
| | - Emily Polhemus
- Division of Aging, Brigham and Women's Hospital, Boston, MA, USA
| | - Raphael Bueno
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02115, USA
| | - Abby White
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02115, USA
| | - Scott J Swanson
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02115, USA
| | - Michael T Jaklitsch
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02115, USA
| | - Laura Frain
- Division of Aging, Brigham and Women's Hospital, Boston, MA, USA
| | - Jon O Wee
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02115, USA
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25
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Dolan DP, Lee DN, Kucukak S, De León LE, Bueno R, Jaklitsch MT, Swanson SJ, White A. Salvage surgery for local recurrence after sublobar surgery in Stages I and II non‐small cell lung cancer. J Surg Oncol 2022; 126:814-822. [DOI: 10.1002/jso.26925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 04/06/2022] [Accepted: 05/08/2022] [Indexed: 11/10/2022]
Affiliation(s)
- Daniel P. Dolan
- Division of Thoracic Surgery Brigham and Women's Hospital Boston Massachusetts USA
| | - Daniel N. Lee
- Division of Thoracic Surgery Brigham and Women's Hospital Boston Massachusetts USA
| | - Suden Kucukak
- Division of Thoracic Surgery Brigham and Women's Hospital Boston Massachusetts USA
| | - Luis E. De León
- Division of Thoracic Surgery Brigham and Women's Hospital Boston Massachusetts USA
| | - Raphael Bueno
- Division of Thoracic Surgery Brigham and Women's Hospital Boston Massachusetts USA
| | - Michael T. Jaklitsch
- Division of Thoracic Surgery Brigham and Women's Hospital Boston Massachusetts USA
| | - Scott J. Swanson
- Division of Thoracic Surgery Brigham and Women's Hospital Boston Massachusetts USA
| | - Abby White
- Division of Thoracic Surgery Brigham and Women's Hospital Boston Massachusetts USA
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26
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Cooper L, Gong Y, Dezube AR, Mazzola E, Deeb AL, Dumontier C, Jaklitsch MT, Frain LN. Thoracic surgery with geriatric assessment and collaboration can prepare frail older adults for lung cancer surgery. J Surg Oncol 2022; 126:372-382. [PMID: 35332937 PMCID: PMC9276553 DOI: 10.1002/jso.26866] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 03/04/2022] [Accepted: 03/13/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND OBJECTIVES We assessed frailty, measured by a comprehensive geriatric assessment-based frailty index (FI-CGA), and its association with postoperative outcomes among older thoracic surgical patients. METHODS Patients aged ≥65 years evaluated in the geriatric-thoracic clinic between June 2016 through May 2020 who underwent lung surgery were included. Frailty was defined as FI-CGA > 0.2, and "occult frailty", a level not often recognized by surgical teams, as 0.2 < FI-CGA < 0.4. A qualitative analysis of geriatric interventions was performed. RESULTS Seventy-three patients were included, of which 45 (62%) were nonfrail and 28 (38%) were frail. "Occult frailty" was present in 23/28 (82%). Sixty-one (84%) had lung malignancy. Geriatric interventions included delirium management, geriatric-specific pain and bowel regimens, and frailty optimization. More sublobar resections versus lobectomies (61% vs. 25%) were performed among frail patients. Frailty was not significantly associated with overall complications (odds ratio [OR]: 2.4; 95% confidence interval [CI]: 0.88-6.44; p = 0.087), major complications (OR: 2.33; 95% CI: 0.48-12.69; p = 0.293), discharge disposition (OR: 2.8; 95% CI: 0.71-11.95; p = 0.141), or longer hospital stay (1.3 more days; p = 0.18). CONCLUSION Frailty and "occult frailty" are prevalent in patients undergoing lung surgery. However, with integrated geriatric management, these patients can safely undergo surgery.
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Affiliation(s)
- Lisa Cooper
- Division of Aging, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Yusi Gong
- Carle Illinois College of Medicine, Urbana, Illinois, USA
| | - Aaron R Dezube
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Emanuele Mazzola
- Department of Data Science, Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Ashley L Deeb
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Clark Dumontier
- Division of Aging, Brigham and Women's Hospital, Boston, Massachusetts, USA.,VA New England Geriatric Research Education and Clinical Center, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Michael T Jaklitsch
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Laura N Frain
- Division of Aging, Brigham and Women's Hospital, Boston, Massachusetts, USA
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27
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Jaklitsch MT, Deeb AL. Foreword to Venous Surgery of the Mediastinum. Mediastinum 2022; 6:2. [PMID: 35340834 PMCID: PMC8841538 DOI: 10.21037/med-21-55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/28/2021] [Indexed: 06/14/2023]
Affiliation(s)
- Michael T Jaklitsch
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ashley L Deeb
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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28
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Dezube AR, Cooper L, Mazzola E, Dolan DP, Lee DN, Kucukak S, De Leon LE, Dumontier C, White A, Swanson SJ, Jaklitsch MT, Frain LN, Wee JO, Ademola B, Polhemus E. Perioperative Esophagectomy Outcomes in Older Esophageal Cancer Patients in Two Different Time Eras. Semin Thorac Cardiovasc Surg 2022; 35:412-426. [PMID: 35248724 PMCID: PMC10049881 DOI: 10.1053/j.semtcvs.2021.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 10/29/2021] [Indexed: 11/11/2022]
Abstract
To investigate perioperative outcomes of esophagectomies by age groups. Retrospective analysis of esophageal cancer patients undergoing esophagectomy from 2005 to 2020 at a single academic institution. Baseline characteristics and outcomes were analyzed by 3 age groups: <70, 70-79, and ≥80 years-old. Sub-analysis was done for 2 time periods: 2005-2012 and 2013-2020. Of 1135 patients, 789 patients were <70, 294 were 70-79, and 52 were ≥80 years-old. Tumor characteristics, and operative technique were similar, except positive longitudinal margins rates (all <3%) (P = 0.008). Older adults experienced increased complications (53.6% vs 69.7% vs 65.4% respectively; P < 0.001) attributable to grade II complications (41.4% vs 62.2% vs 63.5% respectively; P < 0.001). Hospital length of stay (LOS) and rehabilitation requirements were higher in older adults (both P < 0.05). 30-day readmissions, reoperation, and 30-day mortality rates (all <2%) showed no association with age group. Overall complications, LOS, discharge disposition and re-operative rates improved from 2005 to 2012 to 2013-2020 for all (P < 0.05). Increasing age was an independent risk factor for cardiovascular complications (OR 1.7, 95% CI 1.23-2.46 for ages 70-79 and OR 2.7, 95% CI 1.37-5.10 for ages ≥80 ), inpatient rehabilitation (OR 3.3, 95% CI 2.26-5.05 for ages 70-79 and OR 12.1 95% CI 5.83-25.04 for ages ≥80), and prolonged LOS (OR 1.64 95% CI 1.16-2.31 for ages 70-79 and OR 3.6 95% CI 1.71-7.67 for ≥80. After adjusting for time period, older age remained associated with complications (P < 0.05). Highly selected older adults at a large volume esophagectomy center can undergoesophagectomy with increased minor complication and rehabilitation needs.
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Affiliation(s)
- Aaron R Dezube
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
| | - Lisa Cooper
- Division of Aging, Brigham and Women's Hospital, Boston, Massachusetts
| | - Emanuele Mazzola
- Division of Data Sciences, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Daniel P Dolan
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Daniel N Lee
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Suden Kucukak
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Luis E De Leon
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Clark Dumontier
- Division of Aging, Brigham and Women's Hospital, Boston, Massachusetts; New England GRECC, VA Boston Healthcare System, Boston, Massachusetts
| | - Abby White
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Scott J Swanson
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Michael T Jaklitsch
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Laura N Frain
- Division of Aging, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jon O Wee
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Bayonle Ademola
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Emily Polhemus
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
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29
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Cooper L, Dezube AR, De León LE, Fox S, Bravo-Iñiguez CE, Mazzola E, Tarascio J, Cardin K, DuMontier C, Jaklitsch MT, Frain LN. Polypharmacy and frailty in older adults evaluated at a multidisciplinary geriatric-thoracic clinic prior to surgery. J Geriatr Oncol 2022; 13:249-252. [PMID: 34366275 PMCID: PMC9169667 DOI: 10.1016/j.jgo.2021.07.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 07/29/2021] [Accepted: 07/31/2021] [Indexed: 12/15/2022]
Affiliation(s)
- Lisa Cooper
- Division of Aging, Brigham and Women's Hospital, Boston, MA, United States of America.
| | - Aaron R. Dezube
- Division of Thoracic Surgery, Brigham and Women’s Hospital, Boston, MA, United States of America
| | - Luis E. De León
- Division of Thoracic Surgery, Brigham and Women’s Hospital, Boston, MA, United States of America
| | - Sam Fox
- Division of Thoracic Surgery, Brigham and Women’s Hospital, Boston, MA, United States of America
| | - Carlos E. Bravo-Iñiguez
- Division of Thoracic Surgery, Brigham and Women’s Hospital, Boston, MA, United States of America
| | - Emanuele Mazzola
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA, United States of America
| | - Jeffrey Tarascio
- Division of Thoracic Surgery, Brigham and Women’s Hospital, Boston, MA, United States of America
| | - Kristin Cardin
- Division of Aging, Brigham and Women’s Hospital, Boston, MA, United States of America
| | - Clark DuMontier
- Division of Aging, Brigham and Women’s Hospital, Boston, MA, United States of America,New England GRECC, VA Boston Healthcare System, Boston, MA, United States of America
| | - Michael T. Jaklitsch
- Division of Aging, Brigham and Women’s Hospital, Boston, MA, United States of America
| | - Laura N. Frain
- Division of Aging, Brigham and Women’s Hospital, Boston, MA, United States of America
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30
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Dezube AR, Mazzola E, Cooper L, Deeb AL, De-Leon LE, Singer L, Jacobson FL, Jaklitsch MT, Wiener D. Geographic differences in therapy for stage I non-small-cell lung cancer in older adults. J Surg Oncol 2022; 125:1053-1060. [PMID: 35099822 DOI: 10.1002/jso.26809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 01/08/2022] [Accepted: 01/16/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Geographic and socioeconomic factors impact patient treatment choices for certain cancers. Whether they impact treatment in older adults with lung cancer is unknown. We investigated geographic differences in treatment for stage I non-small-cell lung cancer (NSCLC) in older adults in the United States. METHODS Using the Surveillance, Epidemiology and End Results Database 18th submission, a cohort of stage I NSCLC patients ≥60-years-old was created. Treatment differences (surgery or radiation alone) by geographic location and socioeconomic factors were analyzed. RESULTS Forty-three thousand three hundred and eighty-seven stage I NSCLC patients were analyzed. Demographics and socioeconomic factors varied across all 13 states (p < 0.001). Surgery was the most common treatment in all states (range 58.6% in AK to 86.5% in CT) (all p < 0.001). Our multivariable analysis found older individuals had higher odds of getting radiation as compared to surgery (odds ratio [OR]: 1.22 for 65-69 years-old to OR: 8.95 for 85+ years-old; p < 0.001). Multiple states (LA, HI, IA, MI, WA, NM) were associated with increased odds of radiation use (vs. surgery alone) (all p < 0.05). People with lower education level (OR: 0.98) and median income (OR: 0.99) and non-Black race (OR: 0.52 for "other" to OR: 0.68 for "White" race with respect to Black race) were associated with lower odds of radiation (p < 0.05). CONCLUSIONS Our study identified treatment differences for stage I NSCLC patients in the United States related to demographics, socioeconomic factors, and geographic location.
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Affiliation(s)
- Aaron R Dezube
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Emanuele Mazzola
- Department of Data Sciences, Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Lisa Cooper
- Division of Aging, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ashley L Deeb
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Luis E De-Leon
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Lisa Singer
- Department of Radiation Oncology, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Division of Radiation Oncology, University of California, San Francisio, San Francisco, California, USA
| | - Francine L Jacobson
- Division of Thoracic Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michael T Jaklitsch
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Daniel Wiener
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Division of Thoracic Surgery, VA Healthcare System, Boston, Massachusetts, USA
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Dezube AR, Dolan DP, Mazzola E, Kucukak S, De Leon LE, Bueno R, Marshall MB, Jaklitsch MT, Rochefort MM. Risk factors for prolonged air leak and need for intervention following lung resection. Interact Cardiovasc Thorac Surg 2022; 34:212-218. [PMID: 34536000 PMCID: PMC8766207 DOI: 10.1093/icvts/ivab243] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 07/14/2021] [Accepted: 08/02/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Prolonged air leak (PAL; >5 days) following lung resection is associated with postoperative morbidity. We investigated factors associated with PAL and PAL requiring intervention. METHODS Retrospective review of all patients undergoing lobectomy, segmentectomy or wedge resection from 2016 to 2019 at our institution. Bronchoplastic reconstructions and lung-volume reduction surgeries were excluded. Incidence and risk factors for PAL and PAL requiring intervention were evaluated. RESULTS In total, 2384 patients were included. PAL incidence was 5.4% (129/2384); 22.5% (29/129) required intervention. PAL patients were more commonly male (56.6% vs 39.7%), older (mean age 69 vs 65 years) and underwent lobectomy or thoracotomy (all P < 0.001). Patients with PAL had longer length of stay (9 vs 3 days), more discharge needs and increased odds of complication (all P < 0.050).Twenty-nine patients required intervention (9 chest tubes; 4 percutaneous drains; 16 operations). In 50% of operative interventions, an air leak source was identified; however, the median time from intervention to resolution was 13 days. Patients requiring intervention had increased steroid use, lower diffusion capacity for carbon monoxide and twice the length of stay versus PAL patients (all P < 0.050).On univariable analysis, forced expiratory volume in 1 s (FEV1) <40%, diffusion capacity for carbon monoxide <50%, steroid use and albumin <3 had increased odds of intervention (P < 0.050). CONCLUSIONS Age, gender and operative technique were related to PAL development. Patients with worse forced expiratory volume in 1 s or diffusion capacity for carbon monoxide, steroid use or poor nutrition were less likely to heal on their own, indicating a population that could benefit from earlier intervention.
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Affiliation(s)
- Aaron R Dezube
- Division of Thoracic and Cardiac Surgery, Brigham and Women’s Hospital, Boston, MA, USA
| | - Daniel P Dolan
- Division of Thoracic and Cardiac Surgery, Brigham and Women’s Hospital, Boston, MA, USA
| | - Emanuele Mazzola
- Department of Data Sciences, Dana Farber Cancer Institute, Boston, MA, USA
| | - Suden Kucukak
- Division of Thoracic and Cardiac Surgery, Brigham and Women’s Hospital, Boston, MA, USA
| | - Luis E De Leon
- Division of Thoracic and Cardiac Surgery, Brigham and Women’s Hospital, Boston, MA, USA
| | - Raphael Bueno
- Division of Thoracic and Cardiac Surgery, Brigham and Women’s Hospital, Boston, MA, USA
| | - M Blair Marshall
- Division of Thoracic and Cardiac Surgery, Brigham and Women’s Hospital, Boston, MA, USA
| | - Michael T Jaklitsch
- Division of Thoracic and Cardiac Surgery, Brigham and Women’s Hospital, Boston, MA, USA
| | - Matthew M Rochefort
- Division of Thoracic and Cardiac Surgery, Brigham and Women’s Hospital, Boston, MA, USA
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Dezube AR, Hirji S, Shah R, Axtell A, Rodriguez M, Swanson S, Jaklitsch MT, Mody GN. Pre-COVID19 National Mortality Trends in Open and Video-Assisted Lobectomy for Non-Small Cell Lung Cancer. J Surg Res 2022; 274:213-223. [DOI: 10.1016/j.jss.2021.12.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 11/04/2021] [Accepted: 12/27/2021] [Indexed: 10/19/2022]
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Dezube AR, Deeb A, De Leon LE, Kucukak S, Marshall MB, Jaklitsch MT, Rochefort MM. Routine Chest X-ray After Chest Tube Removal Is Not Indicated for Minimally Invasive Lung Resection. Ann Thorac Surg 2021; 114:2108-2114. [PMID: 34798074 DOI: 10.1016/j.athoracsur.2021.10.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 09/18/2021] [Accepted: 10/05/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Chest x-rays after chest tube removal are common practice in post-operative thoracic surgery patients. Whether these x-rays change clinical management is debatable. We investigated prevalence and management of post-pull pneumothoraces following lung resection. METHODS Retrospective review of minimally-invasive wedge-resections, segmentectomies, and lobectomies between March 2018 and September 2018. Baseline factors, operative technique, chest tube management, and outcomes following post-pull chest x-ray and factors associated with post-pull pneumothoraces were analyzed. RESULTS 200 consecutive patients were analyzed: 117 wedge-resections (59%), 24 segmentectomies (12%), and 59 lobectomies (30%). Wedge-resections compared to segmentectomy or lobectomy had lower rates of chest tube usage, drain duration, air-leaks, and need for clamp-trial, with Blake drains most often removed last compared to segmentectomy or lobectomy (all <0.001). 110 patients (55%) experienced a post-pull pneumothorax, which were largely small/tiny/trace (96%). 5 patients experienced symptoms and no patients required intervention. Resection type was associated with pneumothorax rate, need for additional imaging, and discharge timing (all p<0.05). Those with pneumothoraces compared to those without differed in type of resection and chest drain, presence of air-leak within 24 hours of removal, need for clamp trial, order of tube removal, and hospital length of stay (all p<0.05). Multivariable regression showed only clamp trial was associated with post-pull pneumothorax development (OR 2.48 95% CI 1.13-5.45; p=0.024). CONCLUSIONS While routine use of post-pull chest x-ray identified a high prevalence of pneumothorax, no intervention was required. Our study demonstrates post-pull imaging may not be indicated in asymptomatic patients without prior air leak or clamp trial.
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Affiliation(s)
- Aaron R Dezube
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Boston, MA.
| | - Ashley Deeb
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Boston, MA
| | - Luis E De Leon
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Boston, MA
| | - Suden Kucukak
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Boston, MA
| | - M Blair Marshall
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Boston, MA
| | - Michael T Jaklitsch
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Boston, MA
| | - Matthew M Rochefort
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Boston, MA
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Lapidot M, Mazzola E, Freyaldenhoven S, De León LE, Jaklitsch MT, Bueno R. Postoperative empyema after pleurectomy decortication for malignant pleural mesothelioma. Ann Thorac Surg 2021; 114:1214-1219. [PMID: 34619137 DOI: 10.1016/j.athoracsur.2021.08.063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 08/11/2021] [Accepted: 08/30/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Postoperative empyema following pleurectomy decortication (PDC) for malignant pleural mesothelioma (MPM) is a serious complication that necessitates prolonged hospitalization. The aim of this study was to determine the incidence, risk factors and prognosis in patients who develop postoperative empyema following PDC. METHODS The background, type of PDC, neo-adjuvant treatment, date of empyema, pleural fluid cultures, post empyema treatment and prognosis from a series of consecutive 355 patients treated over 9 years at a single high-volume center were investigated. Fisher's exact test, Kaplan Meier estimators and log rank test were used to identify significant risk factors for postoperative empyema and compare the overall survival. RESULTS 355 patients underwent PDC for MPM in a 9-year period. There were 263 males and median age at surgery was 69. Neoadjuvant therapy was given to 87 and 282 received intraoperative heated chemotherapy (IOHC). During the study 24 patients (6.8%) developed empyema. The length of stay (LOS) of patients who developed postoperative empyema was significantly longer. Median survival for patients who developed postoperative empyema was 11.7 months and 21.3 months for patients without empyema (HR-1.78, p=0.009). Postoperative empyema was associated with male sex, prolonged air leak and use of prosthetic mesh. CONCLUSIONS Postoperative empyema following PDC is associated with prolonged length of stay and higher mortality. The rates of this serious postoperative complication might decrease by developing better strategies to avoid prolonged air leak after PDC.
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Affiliation(s)
- Moshe Lapidot
- Brigham & Women's Hospital, The International Mesothelioma Program, Harvard Medical School Boston, MA.
| | - Emanuele Mazzola
- Dana Farber Cancer Institute, T.H Chan School of Public Health Boston, Harvard Medical School Boston, MA
| | - Samuel Freyaldenhoven
- Brigham & Women's Hospital, The International Mesothelioma Program, Harvard Medical School Boston, MA
| | - Luis E De León
- Brigham & Women's Hospital, The International Mesothelioma Program, Harvard Medical School Boston, MA
| | - Michael T Jaklitsch
- Brigham & Women's Hospital, The International Mesothelioma Program, Harvard Medical School Boston, MA
| | - Raphael Bueno
- Brigham & Women's Hospital, The International Mesothelioma Program, Harvard Medical School Boston, MA
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Cooper L, Dezube AR, De León LE, Kucukak S, Mazzola E, Dumontier C, Mamon H, Enzinger P, Jaklitsch MT, Frain LN, Wee JO. Outcomes of trimodality CROSS regimen in older adults with locally advanced esophageal cancer. Eur J Surg Oncol 2021; 47:2667-2674. [PMID: 33895020 PMCID: PMC8448942 DOI: 10.1016/j.ejso.2021.04.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/29/2021] [Accepted: 04/11/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Chemoradiotherapy for Esophageal cancer followed by Surgery (CROSS regimen) is standard of care for locally-advanced esophageal cancer. We evaluated CROSS completion rates, toxicity, and postoperative outcomes between older and younger adults receiving trimodality therapy. METHODS Retrospective analysis of patients with locally-advanced esophageal cancer who underwent CROSS regimen from May 2016 to January 2020 at a single academic center. Outcomes of those aged ≥70-years-old and <70 years-old were analyzed. RESULTS Of 201 patients, 136 were <70 and 65 were ≥70 years. Older adults were more likely to be male (91% vs. 79%; p = 0.045), have higher ECOG scores (median 1 vs. 0; p = 0.003), Charlson-comorbidity index (median 6 vs. 4; p < 0.001), and undergo open procedures (20% vs. 8% p = 0.008). Most completed CROSS regimen (78% vs. 84% respectively) with similar rates of treatment discontinuation and dose reduction (all p > 0.05). Time to surgery following neoadjuvant therapy was similar between age groups, except in those ≥80-years-old as compared to <70-years-old (p < 0.05). Overall toxicity rates were similar (68% vs. 71% respectively; p = 0.676). Only rates of delirium (19% vs. 5%) and urinary retention (9% vs. 0%) were higher in older adults (both p < 0.05). Length of stay, discharge disposition, mortality, and overall survival were similar. Age was not an independent risk factor for complication, neoadjuvant toxicity or completion, surgery timing, nor worse overall or recurrence-free survival (p > 0.05). CONCLUSION Trimodality CROSS regimen for esophageal cancer in older adults is feasible, with similar completion rates and postoperative outcomes as compared to their younger counterparts.
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Affiliation(s)
- Lisa Cooper
- Division of Aging, Brigham and Women's Hospital, Boston, MA, USA.
| | - Aaron R Dezube
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Luis E De León
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Suden Kucukak
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Emanuele Mazzola
- Department of Data Science, Dana Farber Cancer Institute, Boston, MA, USA
| | - Clark Dumontier
- Division of Aging, Brigham and Women's Hospital, Boston, MA, USA; Marcus Institute of Aging Research, Boston, MA, USA
| | - Harvey Mamon
- Department of Radiation Oncology, Brigham and Women's Hospital, Boston, MA, USA
| | - Peter Enzinger
- Center for Esophageal and Gastric Cancer, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | | | - Laura N Frain
- Division of Aging, Brigham and Women's Hospital, Boston, MA, USA
| | - Jon O Wee
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA, USA
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Dezube AR, Kucukak S, De Leon LE, Wiener D, Rochefort MM, Jaklitsch MT. Internal Staging Discordance in National Cancer Databases for Non-Small-Cell Lung Cancer. Ann Thorac Surg 2021; 114:1269-1275. [PMID: 34461072 DOI: 10.1016/j.athoracsur.2021.07.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 06/17/2021] [Accepted: 07/22/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND The Surveillance, Epidemiology and End Results (SEER) and the National Cancer Database (NCDB) are databases for cancer analysis which may be subject to error in data reporting. We examined rates and impact of discordant data for non-small cell lung cancer. METHODS NCDB and SEER were queried for non-small cell lung cancer pathologic Tumor, Node, Metastasis data (NCDB) or "derived" data (SEER). Discordancy between descriptors with stage and impact of outlier data were analyzed. RESULTS Incomplete staging was noted in 71.5% of NCDB and 10.3% of SEER. 174,829 patients from NCDB and 117,114 from SEER were analyzed. NCDB had 97 cases with ≥20 positive lymph nodes recorded vs. 27 in SEER (p<0.001). Mean and median sampled lymph nodes were skewed with inclusion of these data-points (p<0.001). NCDB misclassified 0.99% tumors >5cm as stage I vs. 0.04% in SEER (p<0.001). NCDB mis-staged positive lymph nodes as pathologic N0 (0.59%) or Stage 0/Stage I (0.65%). NCDB misclassified pathologic N1 as < Stage II (0.91%) or N2 as < Stage III (0.36%). NCDB misclassified Stage I with documentation of pathologic N1-N3 disease (0.24%) or Stage II with evidence of N2 or N3 disease (0.50%). NCDB misclassified pathologic M1 as pathologic Stage <IV in 0.9% of cases and misclassified 19.8% of stage IV as pathologic M0. SEER collaborative staging had no discordancy (p<0.001). CONCLUSIONS NCDB and SEER are two powerful cancer databases. However, cumulative discordancy rate was 4.9% for NCDB and 0.008% for SEER with more mistaging and outliers in NCDB.
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Affiliation(s)
- Aaron R Dezube
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA, USA.
| | - Suden Kucukak
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Luis E De Leon
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Daniel Wiener
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA, USA; Division of Thoracic Surgery, Boston VA Healthcare System
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Jacobson FL, Dezube AR, Bravo-Iñiguez C, Kucukak S, Bay CP, Wee JO, Coppolino AA, Jaklitsch MT, Ducko CT. Preserving NLST mortality benefits and acceptable morbidity for lung cancer surgery in a community hospital. J Surg Oncol 2021; 124:124-134. [PMID: 33844848 DOI: 10.1002/jso.26483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 03/22/2021] [Accepted: 03/22/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVES The aim of this study was to demonstrate whether academic thoracic surgeons could achieve morbidity and mortality rates in community hospitals equivalent to those seen in National Lung Screening Trial (NLST). METHODS This was a retrospective review of community hospital lung cancer procedures for clinical Stage I-III non-small-cell lung cancers from 2007 through 2014. Variables include age, comorbidities, computed tomography (CT) characterization, and operative techniques. RESULTS There were 177 patients who had lung cancers removed by a minimally invasive approach (79%), including lobectomy in 127 (72%), segmentectomy in 4 (2%), and wedge-resections in 46 (26%). The median patient age was 71 years (interquartile range [IQR], 63-76). The cohort was primarily female (58%), clinical Stage I (82%), with a median tumor size of 2.3 cm (IQR, 1.5-3.3). The median length of stay was 6 days (range: 1-35). Complications were experienced by 78 (44.1%) patients, most commonly atrial fibrillation in 20 (11.3%) followed by air-leak in 19 (10.7%). There were no in-hospital deaths. Tumor location and extent of resection were associated with complications, while larger tumor size, margin contour, and resection method were associated with air-leak (all p < 0.05). Higher clinical stage and larger tumor size were associated with occult Stage III disease (both p < 0.05). CONCLUSIONS The low morbidity and mortality rates from the NLST were achievable in a community setting for early-stage lung cancer. Characterization of cancers using CT imaging identified factors most commonly associated with postoperative complications and the presence of occult Stage III disease.
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Affiliation(s)
- Francine L Jacobson
- Division of Thoracic Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Aaron R Dezube
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Carlos Bravo-Iñiguez
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Suden Kucukak
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Camden P Bay
- Division of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jon O Wee
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Antonio A Coppolino
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michael T Jaklitsch
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Christopher T Ducko
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
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De León LE, Rochefort MM, Bravo-Iñiguez CE, Fox SW, Tarascio JN, Cardin K, DuMontier C, Frain LN, Jaklitsch MT. Opportunities for quality improvement in the morbidity pattern of older adults undergoing pulmonary lobectomy for cancer. J Geriatr Oncol 2021; 12:416-421. [PMID: 32980269 PMCID: PMC8011279 DOI: 10.1016/j.jgo.2020.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 06/01/2020] [Accepted: 09/16/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND There is limited information on the frequency of complications among older adults after oncological thoracic surgery in the modern era. We hypothesized that morbidity and mortality in older adults with lung cancer undergoing lobectomy is low and different than that of younger patients undergoing thoracic surgery. METHODS All patients undergoing lobectomy at a large volume academic center between May 2016 and May 2019 were included. Patients were prospectively monitored to grade postoperative morbidity by organ system, based on the Clavien-Dindo classification. Patients were divided into two groups: Group 1 included patients 65-91 years of age, and Group 2 included those <65 years. RESULTS Of 680 lobectomies in 673 patients, 414(61%) were older than 65 years of age (group 1). Median age at surgery was 68 years (20-91). Median hospital stay was 4 days (1-38) and longer in older adults. Older adults experienced higher rates of grade II and IV complications, mostly driven by an increased incidence of delirium, atrial fibrillation, prolonged air leak, respiratory failure and urinary retention. In this modern cohort, there was only 1 stroke (0.1%), and delirium was reduced to 7%. Patients undergoing minimally invasive (MI) surgery had a lower rate of Grade IV life-threatening complications. Older adults were more likely to be discharged to a rehabilitation facility, however this difference also disappeared with MI surgical procedures. CONCLUSIONS Current morbidity of older adults undergoing lobectomy for cancer is low and is different than that of younger patients. Thoracotomy may be associated with postoperative complications in these patients. Our findings suggest the need to consider MI approaches and broad-based, geriatric-focused perioperative management of older adults undergoing lobectomy.
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Affiliation(s)
- Luis E De León
- Division of Thoracic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Matthew M Rochefort
- Division of Thoracic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Carlos E Bravo-Iñiguez
- Division of Thoracic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sam W Fox
- Division of Thoracic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jeffrey N Tarascio
- Division of Thoracic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kristin Cardin
- Division of Aging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Clark DuMontier
- Division of Aging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Laura N Frain
- Division of Aging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael T Jaklitsch
- Division of Thoracic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Dezube AR, Kucukak S, De León LE, Kostopanagiotou K, Jaklitsch MT, Wee JO. Risk of chyle leak after robotic versus video-assisted thoracoscopic esophagectomy. Surg Endosc 2021; 36:1332-1338. [PMID: 33660122 DOI: 10.1007/s00464-021-08410-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 02/15/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND We investigate the incidence and risk factors for post-operative outcomes including chyle leak following minimally invasive esophagectomy (MIE). METHODS Patients undergoing MIE from May 2016 until August 2020 were prospectively followed. Outcomes of robotic and video-assisted thoracoscopic surgery (VATS) esophagectomy were analyzed. RESULTS 347 esophagectomies were performed: 70 cases were done robotically by 2 surgeons and 277 by VATS by 14 surgeons. Patients had similar demographics, surgical technique, length of stay (LOS), and re-operation rates. Overall complication rates between robotic and VATS MIE were statistically similar (61% vs. 50%; p = 0.082). The majority of complications for either VATS (41.5%) or robotic-assisted minimally invasive esophagectomy (RAMIE) (51.4%) were grade II. Nineteen patients developed a chyle leak. Patients with a chyle leak were similar in age, gender, and hospital LOS (all p > 0.05), but were more likely to undergo a three-hole or robotic esophagectomy (both p < 0.05) as well as have higher rehabilitation requirements on discharge (26% vs. 10%; p = 0.05). Among the two surgeons who each performed > 20 robotic esophagectomies (n = 70), nine chyle leaks occurred. Rates varied by surgeon (7 vs. 2; p = 0.003). Lower leak rates occurred in the surgeon with more robotic esophagectomy experience (n = 47 vs. 23). Patients were similar in age, and gender (p > 0.05), but those with a chyle leak were more likely to undergo three-hole esophagectomies, prophylactic thoracic duction ligations, undergo the abdominal portion via laparotomy, and not have a prophylactic omental flap (all p < 0.05). CONCLUSION Robotic and VATS esophagectomy have similar rates of re-operation, length of stay, discharge needs and complications. Differences in outcomes between VATS and Robotic esophagectomy appears to be related to surgeon experience with the robot but may also be associated with techniques such as anastomotic height, omental flap utilization and performance of laparoscopy.
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Affiliation(s)
- Aaron R Dezube
- Division of Thoracic Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA.
| | - Suden Kucukak
- Division of Thoracic Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA
| | - Luis E De León
- Division of Thoracic Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA
| | | | - Michael T Jaklitsch
- Division of Thoracic Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA
| | - Jon O Wee
- Division of Thoracic Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA
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Kandilis A, Iniguez CB, Khalil H, Mazzola E, Jaklitsch MT, Swanson SJ, Bueno R, Wee JO. Residual lymph node disease and mortality following neoadjuvant chemoradiation and curative esophagectomy for distal esophageal adenocarcinoma. JTCVS Open 2021; 5:135-147. [PMID: 36003158 PMCID: PMC9390677 DOI: 10.1016/j.xjon.2020.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 12/08/2020] [Indexed: 11/30/2022]
Abstract
Objectives Neoadjuvant chemoradiation has been shown to improve survival in locally advanced esophageal and gastroesophageal junction cancer. The purpose of our study was to examine the effects of posttreatment persistent lymph node (LN) disease on overall survival (OS) and recurrence in patients with esophageal adenocarcinoma after neoadjuvant chemoradiation as well as the effect of LN harvest and the potential benefit of adjuvant chemotherapy. Methods The records of patients who underwent esophagectomy in our hospital from January 2005 until December 2016 were analyzed. Our study group consisted of 509 patients. Results Patient groups were created based on pathologic staging after esophagectomy (ypT N) as 22.0% of patients were ypT0 N0, 46.2% had incomplete response only at the primary tumor level (ypT + N0), and 31.8% had at least 1 metastatic lymph node (ypTx N+). Median OS was 58.3 months. The ypTx N+ group was divided into ypTx N1 and ypTx N2 or N3 subgroups based on the number of metastatic lymph nodes. The OS between the 2 groups was not significantly different (median OS, 37.6 vs 29.8 months; P = .097). The disease-free survival did show a statistically significant difference (median disease-free survival, 27.6 vs 13.7 months; P = .007). The LN harvest was not found to be significantly associated with OS. However, administration of adjuvant chemotherapy was a significant prognosticator for increased OS (hazard ratio, 0.590; P = .043). Conclusions Our results demonstrate that residual LN disease after neoadjuvant chemoradiation is associated with increased mortality. Adjuvant chemotherapy, but not number of LNs resected, was correlated with increased OS in this subset of patients.
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Affiliation(s)
- Apostolos Kandilis
- Department of Thoracic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Carlos Bravo Iniguez
- Department of Thoracic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Hassan Khalil
- Department of Thoracic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Emanuele Mazzola
- Department of Data Science, Dana-Farber Cancer Institute, Boston, Mass
| | - Michael T. Jaklitsch
- Department of Thoracic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Scott J. Swanson
- Department of Thoracic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Raphael Bueno
- Department of Thoracic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Jon O. Wee
- Department of Thoracic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
- Address for reprints: Jon O. Wee, MD, Division of Thoracic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115
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White A, Kucukak S, Lee DN, Mazzola E, Dolan D, Bueno R, Jaklitsch MT, Swanson SJ. Chemotherapy and Surgical Resection for N1 Positive Non-small Cell Lung Cancer: Better Than Expected Outcomes. Semin Thorac Cardiovasc Surg 2021; 33:1105-1111. [PMID: 33600992 DOI: 10.1053/j.semtcvs.2021.01.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 01/05/2021] [Indexed: 11/11/2022]
Abstract
N1-positive (T1-3, N1, M0) non-small cell lung cancer (NSCLC) represents a minority distribution (∼8%) of the approximately 234,000 diagnosed cases per year. As such, there is a paucity of modern high-quality data regarding outcomes following surgically-resected, stage N1-positive NSCLC. Randomized controlled trials from more than a decade ago have demonstrated a modest 5.4% survival benefit with adjuvant chemotherapy but have included heterogenous patient populations and stage distributions. Large database analyses have questioned the role of perioperative chemotherapy in resected patients with N1 disease, but without much granular detail regarding staging, quality of surgery, and chemotherapy. This single-institution study sought to evaluate the role of perioperative chemotherapy, specifically in N1-positive NSCLC patients. Data for all patients with surgically resected N1-positive NSCLC (T1-3, N1, M0) between 2006 and 2016 were collected for this study. Patients who underwent pneumonectomy were excluded from analysis. A retrospective chart review was conducted, and comprehensive clinicopathologic data were collected relative to staging, surgery, pathologic review, and perioperative oncology treatment. After exclusion criteria were applied, 148 patients with surgically resected, N1-positive disease (T1-3, N1, M0) remained for analysis. The majority of patients underwent lobectomy (75.0%), of which 55.4% underwent minimally invasive resection. There were no differences in postoperative complications, length of stay, number of lymph nodes sampled, or mortality associated with the surgery only and surgery with adjuvant therapy subgroups. 107 patients (72.3%) received adjuvant therapy, and this was associated with higher 5-year overall survival (62.8%) and disease-free survival (45.1%) than patients who underwent surgery only (33.9% overall survival at 5 years, P = 0.01; 22.4% disease-free survival at 5 years, P = 0.04). The presence of multistation N1 nodal metastases in patients was associated with lower 5-year overall survival (22.7%) and disease-free survival (5.6%) than patients with single-station N1 nodal metastasis (60.4% overall survival at 5 years, P = 0.003; 46.0% disease-free survival at 5 years, P < 0.001). On multivariable analysis, receiving any adjuvant chemotherapy was associated with improved overall survival and disease-free survival (Overall Survival HR 0.47, P < 0.01 | Disease-Free Survival HR 0.46, P <0.01). Multistation N1 disease was associated with significantly worse disease-free survival (HR 2.11, P = 0.04). Perioperative chemotherapy was associated with improved survival in N1-positive NSCLC, and the potential magnitude of benefit exceeded 25% in this study. Patients with single-station N1 lymph node metastasis were observed to have better disease-free survival.
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Affiliation(s)
- Abby White
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
| | - Suden Kucukak
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Daniel N Lee
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Emanuele Mazzola
- Department of Data Sciences, Division of Biostatistics, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Daniel Dolan
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Raphael Bueno
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Michael T Jaklitsch
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Scott J Swanson
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
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Dezube AR, Mazzola E, Bravo-Iñiguez CE, De León LE, Rochefort MM, Bueno R, Wiener DC, Jaklitsch MT. Analysis of Lymph Node Sampling Minimums in Early Stage Non-Small-Cell Lung Cancer. Semin Thorac Cardiovasc Surg 2021; 33:834-845. [DOI: 10.1053/j.semtcvs.2020.11.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 11/05/2020] [Indexed: 12/18/2022]
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Weiss KD, Coppolino A, Wiener DC, McNamee C, Riviello R, Ng JM, Jaklitsch MT, Marshall MB, Rochefort MM. Controlled apneic tracheostomy in patients with coronavirus disease 2019 (COVID-19). JTCVS Tech 2020; 6:172-177. [PMID: 33319213 PMCID: PMC7720733 DOI: 10.1016/j.xjtc.2020.11.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 11/18/2020] [Indexed: 12/14/2022] Open
Abstract
Objective To develop a team-based institutional infrastructure for navigating management of a novel disease, to determine a safe and effective approach for performing tracheostomies in patients with COVID-19 respiratory failure, and to review outcomes of patients and health care personnel following implementation of this approach. Methods An interdisciplinary Task Force was constructed to develop innovative strategies for management of a novel disease. A single-institution, prospective, nonrandomized cohort study was then conducted on patients with coronavirus disease 2019 (COVID-19) respiratory failure who underwent tracheostomy using an induced bedside apneic technique at a tertiary care academic institution between April 27, 2020, and June 30, 2020. Results In total, 28 patients underwent tracheostomy with induced apnea. The median lowest procedural oxygen saturation was 95%. The median number of ventilated days following tracheostomy was 11. There were 3 mortalities (11%) due to sepsis and multiorgan failure; of 25 surviving patients, 100% were successfully discharged from the hospital and 76% are decannulated, with a median time of 26 days from tracheostomy to decannulation (range 12-57). There was no symptomatic disease transmission to health care personnel on the COVID-19 Tracheostomy Team. Conclusions Patients with respiratory failure from COVID-19 disease may benefit from tracheostomy. This can be completed effectively and safely without viral transmission to health care personnel. Performing tracheostomies earlier in the course of disease may expedite patient recovery and improve intensive care unit resource use. The creation of a collaborative Task Force is an effective strategic approach for management of novel disease.
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Affiliation(s)
- Kathleen D Weiss
- Division of Thoracic Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Antonio Coppolino
- Division of Thoracic Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Daniel C Wiener
- Division of Thoracic Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Ciaran McNamee
- Division of Thoracic Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Robert Riviello
- Division of Trauma, Burn, Surgical and Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Ju-Mei Ng
- Department of Anesthesiology, Brigham and Women's Hospital, Boston, Mass
| | - Michael T Jaklitsch
- Division of Thoracic Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Margaret B Marshall
- Division of Thoracic Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Matthew M Rochefort
- Division of Thoracic Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Mass
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Dolan DP, White A, Mazzola E, Lee DN, Gill R, Kucukak S, Bueno R, Jaklitsch MT, Mentzer SJ, Swanson SJ. Outcomes of superior segmentectomy versus lower lobectomy for superior segment Stage I non-small-cell lung cancer are equivalent: An analysis of 196 patients at a single, high volume institution. J Surg Oncol 2020; 123:570-578. [PMID: 33259656 DOI: 10.1002/jso.26304] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 10/27/2020] [Accepted: 11/02/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVES To determine if superior segmentectomy has equivalent overall (OS), disease-free (DFS), and locoregional-recurrence-free survival (LRFS) to lower lobectomy for early-stage non-small-cell lung cancer (NSCLC) in the superior segment. METHODS We retrospectively reviewed all Stage 1 lower lobectomies for superior segment lesions and superior segmentectomies at our hospital from 2000 to 2018. Comparison statistics and Cox hazard modeling were performed to determine differences between groups and attempt to identify risk factors for OS, DFS, and LRFS. RESULTS Superior segmentectomy patients, compared with lower lobectomy patients, had more current smokers, worse forced expiratory volume in 1 s percentage, radiologic emphysema scores, clinically and pathologically smaller tumors, and more occurrences of 0 lymph nodes examined. Outcomes for superior segmentectomy compared with lower lobectomy were equivalent for 5-year OS (67.0% vs. 75.1%, p = 0.70), DFS (56.9% vs. 60.4%, p = 0.59), and LRFS (87.9% vs. 91.3%, p = 0.46). Multivariable Cox modeling lacked utility due to no outcome differences. CONCLUSIONS In well-selected patients, superior segmentectomies can have equivalent OS, DFS, and LRFS compared with lower lobectomies of superior segment tumors for early stage lung cancer. Further data are needed to provide better risk estimates.
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Affiliation(s)
- Daniel P Dolan
- Department of Surgery, Division of Thoracic Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Abby White
- Department of Surgery, Division of Thoracic Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Emanuele Mazzola
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Daniel N Lee
- Department of Surgery, Division of Thoracic Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Ritu Gill
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Suden Kucukak
- Department of Surgery, Division of Thoracic Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Raphael Bueno
- Department of Surgery, Division of Thoracic Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Michael T Jaklitsch
- Department of Surgery, Division of Thoracic Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Steven J Mentzer
- Department of Surgery, Division of Thoracic Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Scott J Swanson
- Department of Surgery, Division of Thoracic Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts, USA
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White AA, Lee DN, Mazzola E, Kucukak S, Polhemus E, Jaklitsch MT, Mentzer SJ, Wee JO, Bueno R, Swanson SJ. Adjuvant therapy following induction therapy and surgery improves survival in N2-positive non-small cell lung cancer. J Surg Oncol 2020; 123:579-586. [PMID: 33259637 DOI: 10.1002/jso.26305] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 10/30/2020] [Accepted: 11/05/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate treatment strategies and factors influencing overall survival (OS) and disease-free survival (DFS) in resectable, non-small cell lung cancer (NSCLC) with mediastinal (N2) lymph node metastasis. METHODS All patients undergoing surgery for NSCLC with N2 disease between 2006 and 2016 were included. Treatment approaches included surgery only, neoadjuvant therapy followed by surgery, surgery followed by adjuvant therapy, and neoadjuvant therapy followed by surgery and adjuvant therapy (triple therapy). Patient clinical and pathologic data were retrospectively collected. RESULTS A total of 281 patients were included in the study. In total, 209 patients had neoadjuvant therapy, 47.4% of which went on to received additional adjuvant therapy. The pathologic complete response rate was 12.9%. The treatment strategy which included triple therapy was isolated as a significant contributor to improved OS and DFS. Nodal downstaging (N0) after induction therapy conferred an OS benefit (38.3% vs. 15.6%, p = .03). Patients with single-station N2 disease experienced higher DFS. Video-assisted thoracic surgery (VATS) lobectomy completion rates were higher at the end of the study period compared to the beginning (p < .001). CONCLUSIONS Patients who undergo neoadjuvant therapy for N2-positive NSCLC may benefit from additional adjuvant therapy. Single-station N2 disease confers higher DFS. VATS completion rates for lobectomy increase as experience increases.
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Affiliation(s)
- Abby A White
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Daniel N Lee
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Emanuele Mazzola
- Division of Biostatistcs, Department of Data Sciences, Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Suden Kucukak
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Emily Polhemus
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michael T Jaklitsch
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Steven J Mentzer
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jon O Wee
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Raphael Bueno
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Scott J Swanson
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Cooper L, Frain L, Jaklitsch MT. Prehabilitation vs Postoperative Rehabilitation for Frail Patients. JAMA Surg 2020; 155:898-899. [PMID: 32584938 DOI: 10.1001/jamasurg.2020.1813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Lisa Cooper
- Division of Aging, Brigham and Women's Hospital, Boston, Massachusetts
| | - Laura Frain
- Division of Aging, Brigham and Women's Hospital, Boston, Massachusetts
| | - Michael T Jaklitsch
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
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De León LE, Patil N, Hartigan PM, White A, Bravo-Iñiguez CE, Fox S, Tarascio J, Swanson SJ, Bueno R, Jaklitsch MT. Risk of Urinary Recatheterization for Thoracic Surgical Patients with Epidural Anesthesia. J Surg Res (Houst) 2020; 3:163-171. [PMID: 32776012 PMCID: PMC7409986 DOI: 10.26502/jsr.10020068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background: Current quality guidelines recommend the removal of urinary catheters on or before postoperative day two, to prevent catheter-associated urinary tract infections (CAUTI). The goal of this study was to evaluate the impact urinary catheter removal on the need for urinary recatheterization (UR) of patients with epidural anesthesia undergoing thoracic surgery. Materials and Methods: All patients undergoing thoracic surgery between November 4th, 2017 and January 9th, 2018 who had a urinary catheter placed at the time of intervention were prospectively evaluated. Patient characteristics including: history of benign prostatic hyperplasia (BPH), catheter related variables and rates of UR were collected through chart review and daily visits to the wards. BPH was defined as history of transurethral resection of the prostate or treatment with selective α1-adrenergic receptor antagonists. Results: Over a two-month period 267 patients were included, 124 (46%) were male. Epidural catheters were placed in 88 (33%) patients. Median duration of urinary catheters for the cohort was 1 day (0 days – 18 days), and it was significantly higher in patients with epidural anesthesia (Table 1). Overall 20 (7%) patients required UR. On initial analysis, there was no statistical difference in the rate of UR among patients with and without epidural catheters [9/88 (10%) vs 11/179 (6%), p=0.23). The rate of UR was higher in males than in females (14/124 (11%) vs 6/143 (4%), p=0.03). Fifteen (12%) patients had a diagnosis of BPH. The rate of UR was three-times higher in this group than in those without BPH [4/15 (27%) vs 10/109 (9%) p=0.05]. Four (1%) patients developed a CAUTI during follow-up, and the rate of CAUTI was not different between those with and without epidural catheters. Conclusion: Urinary catheters in patients with thoracic epidural anesthesia can be safely removed, as evidenced by low reinsertion and infection rates. Removal of urinary catheters in patients with a history of BPH should be carefully evaluated, as over 1/4 will require urinary recatheterization in this subgroup. Further study of this group is needed to avoid unnecessary patient discomfort associated with recatheterization.
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Affiliation(s)
- Luis E. De León
- Division of Thoracic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Namrata Patil
- Division of Thoracic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Philip M. Hartigan
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Abby White
- Division of Thoracic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Carlos E. Bravo-Iñiguez
- Division of Thoracic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sam Fox
- Division of Thoracic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeffrey Tarascio
- Division of Thoracic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Scott J. Swanson
- Division of Thoracic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Raphael Bueno
- Division of Thoracic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael T. Jaklitsch
- Division of Thoracic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Jaklitsch MT, Jacobson FL. The future of lung cancer screening with low-dose computed tomography. J Thorac Cardiovasc Surg 2020; 160:289-294. [DOI: 10.1016/j.jtcvs.2019.11.141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 10/28/2019] [Accepted: 11/03/2019] [Indexed: 11/16/2022]
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