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Background: Perforation of the esophagus remains a challenging clinical problem. Methods: A retrospective review was performed of patients diagnosed with an esophageal perforation admitted to the London Health Sciences Centre from 1981 to 2007. Univariate and multivariate logistic regression was used to determine which factors had a statistically significant effect on mortality. Results: There were 119 patients; 15 with cervical, 95 with thoracic, and 9 with abdominal perforations. Fifty-one percent of all the perforations were iatrogenic and 33% were spontaneous. Multivariate logistic regression analysis revealed that patients with preoperative respiratory failure requiring mechanical ventilation had a mortality odds ratio of 32.4 (95% confidence interval [CI] 3.1 to 272.0), followed by malignant perforations with 20.2 (95% CI 5.4 to 115.6), a Charlson comorbidity index of 7.1 or greater with 19.6 (95% CI 4.8 to 84.9), the presence of a pulmonary comorbidity with 13.9 (95% CI 2.9 to 97.4), and sepsis with 3.1 (95% CI 1.0 to 10.1). A wait time of greater than 24 hours was not associated with an increased risk of mortality (p = 0.52). Conclusions: Malignant perforations, sepsis, mechanical ventilation at presentation, a higher overall burden of comorbidity, and a pulmonary comorbidity have a significant impact on the overall survival. Time to treatment is not as important. Restoration of intestinal continuity, either by primary repair or by excision and reanastomosis can be attempted even in patients with a greater time from perforation to treatment with respectable morbidity and mortality rates. [ABSTRACT FROM AUTHOR]

Objective: To determine whether mediastinal lymph node dissection improves survival compared with mediastinal lymph node sampling in patients undergoing resection for N0 or nonhilar N1, T1, or T2 non–small cell lung cancer. Methods: Patients with non–small cell lung cancer underwent sampling of 2R, 4R, 7, and 10R for right-sided tumors and 5, 6, 7, and 10L for left-sided tumors. If all tumors were negative for malignancy, patients were randomized to no further lymph node sampling (mediastinal lymph node sampling) or complete mediastinal lymph node dissection. Results: Of 1111 patients randomized, 1023 (mediastinal lymph node sampling in 498, mediastinal lymph node dissection in 525) were eligible and evaluable. There were no significant differences between the 2 groups in terms of demographics, Eastern Cooperative Oncology Group status, histology, cancer location, type or extent of resection, and pathologic stage. Occult N2 disease was found in 21 patients in the mediastinal lymph node dissection group. At a median follow-up of 6.5 years, 435 patients (43%) have died: mediastinal lymph node sampling in 217 (44%) and mediastinal lymph node dissection in 218 (42%). The median survival is 8.1 years for mediastinal lymph node sampling and 8.5 years for mediastinal lymph node dissection (P = .25). The 5-year disease-free survival was 69% (95% confidence interval, 64–74) in the mediastinal lymph node sampling group and 68% (95% confidence interval, 64–73) years in the mediastinal lymph node dissection group (P = .92). There was no difference in local (P = .52), regional (P = .10), or distant (P = .76) recurrence between the 2 groups. Conclusions: If systematic and thorough presection sampling of the mediastinal and hilar lymph nodes is negative, mediastinal lymph node dissection does not improve survival in patients with early stage non–small cell lung cancer, but these results are not generalizable to patients staged radiographically or those with higher stage tumors. [Copyright &y& Elsevier]

Rationale and Objectives: Lung resection for primary bronchogenic carcinoma in the setting of chronic obstructive pulmonary disease often requires a detailed assessment of lung function to avoid perioperative complications and long-term disability. The aim of this study was to test the hypothesis that a novel technique of spiral computed tomographic (CT) subtraction imaging provides accuracy equal to the current standard of radioisotope perfusion scintigraphy in predicting postoperative lung function. Methods and Materials: Preoperative lung function, radioisotope perfusion scintigraphy, spiral CT subtraction imaging, and assessment of postoperative lung function were performed in 25 patients with surgically resectable primary bronchogenic carcinoma. Comparisons of predicted postoperative lung function between the two modalities and to true postoperative lung function were performed using Pearson's correlation and linear regression analysis. Results: Among the 25 patients enrolled in the study, there was a high degree of agreement between the predicted value of postoperative forced expiratory lung volume in 1 second (FEV(1)) generated on novel contrast CT subtraction imaging and that on radioisotope perfusion scintigraphy (r = 0.96, P < .001). Furthermore, there was a strong correlation between the predicted and actual postoperative FEV(1) values for both imaging modalities (r = 0.87, P < .001, and r = 0.88, P < .001, respectively), among the 14 patients completing the study protocol. Conclusion: A novel technique of CT subtraction imaging is equally accurate at predicting postoperative lung function as radioisotope perfusion scintigraphy, which may obviate the need for additional nuclear imaging in the context of the preoperative assessment of resectable lung cancer in high-risk patients. [ABSTRACT FROM AUTHOR]

Rationale and Objectives: Lung resection for primary bronchogenic carcinoma in the setting of chronic obstructive pulmonary disease often requires a detailed assessment of lung function to avoid perioperative complications and long-term disability. The aim of this study was to test the hypothesis that a novel technique of spiral computed tomographic (CT) subtraction imaging provides accuracy equal to the current standard of radioisotope perfusion scintigraphy in predicting postoperative lung function. Methods and Materials: Preoperative lung function, radioisotope perfusion scintigraphy, spiral CT subtraction imaging, and assessment of postoperative lung function were performed in 25 patients with surgically resectable primary bronchogenic carcinoma. Comparisons of predicted postoperative lung function between the two modalities and to true postoperative lung function were performed using Pearson''s correlation and linear regression analysis. Results: Among the 25 patients enrolled in the study, there was a high degree of agreement between the predicted value of postoperative forced expiratory lung volume in 1 second (FEV1) generated on novel contrast CT subtraction imaging and that on radioisotope perfusion scintigraphy (r = 0.96, P < .001). Furthermore, there was a strong correlation between the predicted and actual postoperative FEV1 values for both imaging modalities (r = 0.87, P < .001, and r = 0.88, P < .001, respectively), among the 14 patients completing the study protocol. Conclusion: A novel technique of CT subtraction imaging is equally accurate at predicting postoperative lung function as radioisotope perfusion scintigraphy, which may obviate the need for additional nuclear imaging in the context of the preoperative assessment of resectable lung cancer in high-risk patients. [Copyright &y& Elsevier]

Objective: Video-assisted thoracoscopic lobectomy remains controversial. We compared outcomes from participants in a randomized study comparing lymph node sampling versus dissection for early-stage lung cancer who underwent either video-assisted thoracoscopic or open lobectomy. Methods: Data from 964 participants in the American College of Surgeons Oncology Group Z0030 trial were used to construct propensity scores for video-assisted thoracoscopic versus open lobectomy (based on age, gender, histology, performance status, tumor location, and T1 vs T2). Propensity scores were used to estimate the adjusted risks of short-term outcomes of surgery. Patients were classified into 5 equal-sized groups and compared using conditional logistic regression or repeated measures analysis of variance. Results: A total of 752 patients (66 video-assisted and 686 open procedures) were analyzed on the basis of propensity score stratification. Median operative time was shorter for video-assisted thoracoscopic lobectomy (video-assisted thoracoscopy 117.5 minutes vs open 171.5 minutes; P < .001). Median total number of lymph nodes retrieved (dissection group only) was similar (video-assisted thoracoscopy 15 nodes vs open 19 nodes; P = .147), as were instances of R1/R2 resection (video-assisted thoracoscopy 0% vs open 2.3%; P = .368). Patients undergoing video-assisted thoracoscopic lobectomy had less atelectasis requiring bronchoscopy (0% vs 6.3%, P = .035), fewer chest tubes draining greater than 7 days (1.5% vs 10.8%; P = .029), and shorter median length of stay (5 days vs 7 days; P < .001). Operative mortality was similar (video-assisted thoracoscopy 0% vs open 1.6%, P = 1.0). Conclusion: Patients undergoing video-assisted lobectomy had fewer respiratory complications and shorter length of stay. These data suggest video-assisted thoracoscopic lobectomy is safe in patients with resectable lung cancer. Longer follow-up is needed to determine the oncologic equivalency of video-assisted versus open lobectomy. [Copyright &y& Elsevier]

Background: Little prospective, multiinstitutional data exist regarding the morbidity and mortality after major pulmonary resections for lung cancer or whether a mediastinal lymph node dissection increases morbidity and mortality. Methods: Prospectively collected 30-day postoperative data was analyzed from 1,111 patients undergoing pulmonary resection who were enrolled from July 1999 to February 2004 in a randomized trial comparing lymph node sampling versus mediastinal lymph node dissection for early stage lung cancer. Results: Of the 1,111 patients randomized, 1,023 were included in the analysis. Median age was 68 years (range, 23 to 89 years); 52% were men. Lobectomy was performed in 766 (75%) and pneumonectomy in 42 (4%). Pathologic stage was IA in 424 (42%), IB in 418 (41%), IIA in 37 (4%), IIB in 97 (9%), and III in 45 (5%). Lymph node sampling was performed in 498 patients and lymph node dissection in 525. Operative mortality was 2.0% (10 of 498) for lymph node sampling and 0.76% (4 of 525) for lymph node dissection. Complications occurred in 38% of patients in each group. Lymph node dissection had a longer median operative time and greater total chest tube drainage (15 minutes, 121 mL, respectively). There was no difference in the median hospitalization, which was 6 days in each group (p = 0.404). Conclusions: Complete mediastinal lymphadenectomy adds little morbidity to a pulmonary resection for lung cancer. These data from a current, multiinstitutional cohort of patients who underwent a major pulmonary resection constitute a new baseline with which to compare results in the future. [Copyright &y& Elsevier]