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Background Approximately 40% of patients with esophageal cancer present with metastatic disease. Survival with palliative treatment is poor, and the benefit of aggressive focal therapies is unclear. This study aimed to identify a subset of patients with metastatic esophageal cancer with favorable outcomes after curative doses of radiation therapy, esophagectomy, or both. Methods Between 2004 and 2015, the study investigators found 28,101 patients with metastatic esophageal cancer in the National Cancer Database and identified those who underwent chemotherapy and definitive radiation therapy with or without surgery over the study period. The study compared the estimated median overall survival (OS) of all patients with metastatic esophageal cancer with the estimated median OS of patients with metastatic esophageal cancer who underwent radiation therapy with or without surgery. Multivariable analysis was used to examine clinical and pathologic factors associated with OS. Results At a median follow-up of 11.1 months, 3219 patients with a median age of 64 years and a radiation dose of 50.4 Gy were identified. Only 202 (6.2%) patients undergoing definitive-dose radiation therapy underwent esophagectomy, with a median age of 60 years. The median OS durations for all patients, for patients treated with radiation, and for patients treated with radiation therapy in combination with esophagectomy were 6.6, 11.5, and 30.2 months, respectively. Among patients undergoing surgery, median OS after surgery was 23.7 months. Patients with lung, liver, or bone metastases were less likely to undergo esophagectomy. On multivariable analysis, esophagectomy and low tumor grade were associated with higher OS, whereas liver and bone metastases at diagnosis were associated with worse OS. Conclusions This analysis suggests that select subsets of patients with primarily nonvisceral, nonosseous metastatic esophageal cancer have favorable survival and may potentially benefit from aggressive local therapies.

Background/Aims: Peroral endoscopic myotomy (POEM) is a novel procedure for the treatment of achalasia and spastic esophageal disorders. Experience with POEM is limited, but its reported outcomes are excellent. It is deemed safe even for patients with prior interventions. Methods: This retrospective review included patients who underwent POEM at a tertiary US center. POEM was performed in a multidisciplinary approach by advanced endoscopists and foregut surgeons. Clinical success was defined as a post-POEM Eckardt score ≤3. Results: A total of 125 patients were included. Median follow-up period was 18 months (interquartile range, 10-22 months). Clinical success was achieved in 92% of patients and persisted at 12 months in 88% of patients. Mucosal barrier failure (MBF) occurred in 7 patients, 2 of whom required surgical intervention. MBF was more common in patients with prior laparoscopic Heller myotomy (19% vs. 3%, p=0.015). MBF requiring surgical intervention occurred early in the learning curve. Conclusions: POEM is safe and effective in the treatment of achalasia and spastic esophageal disorders even after failed prior interventions. Clin Endosc 2020;53:321-327

Summary Peroral endoscopic myotomy (POEM) in patients with achalasia who are status post bariatric surgery may be technically challenging due to postsurgical scarring and altered anatomy. The aim of the study was to assess the efficacy and safety of POEM for achalasia in patients with prior bariatric surgery. A review of prospectively maintained databases at three tertiary referral centers from January 2015 to January 2021 was performed. The primary outcome of interest was clinical success, defined as a post-treatment Eckardt score ≤ 3 or improvement in Eckardt score by ≥ 1 when the baseline score was

Esophagectomy following preoperative chemoradiation provides the best outcomes in the treatment of early stage esophageal carcinoma. The exposure of the mediastinum during transhiatal esophagectomy is limited. We describe our technique of mediastinal dissection during the transhiatal esophagectomy using a newly developed transhiatal retractor.

Background Neoadjuvant chemoradiation therapy (nCRT) has become the standard of care for esophageal cancer patients prior to esophagectomy. However, the optimal timing for surgery after completion of nCRT remains unclear. Methods A retrospective review was performed of patients who underwent esophagectomy with cervical anastomosis for esophageal cancer at a single institution between January 2000 and June 2015. Patients were categorized into 3 cohorts: those who did not receive nCRT prior to esophagectomy (no nCRT), those who underwent esophagectomy within 35 days after nCRT (≤35d), and those who underwent esophagectomy more than 35 days after nCRT (>35d). Results A total of 366 esophagectomies were performed during the study period, and 348 patients met the inclusion criteria. Anastomotic leaks occurred in 11.8% of all patients included in the study (41 of 348). Within each cohort, anastomotic leaks were detected in 14.7% of patients (17 of 116) in the no nCRT cohort, 7.3% (13 of 177) in the ≤35d cohort, and 20.0% (11 of 55) in the >35d cohort (p=0.020). Significant differences in the occurrence of anastomotic leaks were observed between the no nCRT and ≤35d cohorts (p=0.044), and between the ≤35d and >35d cohorts (p=0.007). Conclusion Esophagectomy with cervical anastomosis within 35 days of nCRT resulted in a lower percentage of anastomotic leaks.

BackgroundRegional analgesic techniques such as paravertebral blocks (PVBs) have been popularized for analgesia following video-assisted thoracoscopic surgery (VATS). In this single center retrospective propensity matched cohort of subjects, we investigate the impact of paravertebral blocks on the analgesic and non-analgesic outcomes.MethodsInstitutional database was queried to identify all patients undergoing VATS between January 2013 and July 2019 and these patients were divided into those who received paravertebral blocks in combination with general anesthesia (GA) [PVB group] and those who received GA without paravertebral blocks [GA group]. Propensity score matching based on common patient confounders were used to identify patients in each group. Primary outcomes of the study were average pain scores and opioid consumption in the first 24 hours. Secondary analgesic outcomes included pain scores and opioid requirements at other timepoints over the first 48 hours. Non analgesic outcomes were obtained from STS General Thoracic Surgery Database and included length of hospital stay, need for ICU admission, composite outcome of any complication during the hospital course and 30-day mortality. Exploratory analyses were conducted to investigate the impact of PVB on analgesia following different types of surgery and as to whether any other covariates had a greater influence on the included patient centered outcomes.Main resultsAfter propensity score matching, a total of 520 patients (260 per group) were selected for the study out of 1095 patients. The opioid consumption in terms of oral morphine milligram equivalent (MME) [Median (IQR)] for the first 24 hours was significantly lower with the use of PVB [PVB group– 78.5 (96.75); GA group—127.0 (111.5); pConclusionParavertebral blocks reduced the length of stay and opioid consumption up to 48 hours after VATS without significantly impacting pain scores.

BACKGROUND: The tolerability of adjuvant chemotherapy in esophageal cancer is unclear. PATIENTS AND METHODS: This was a phase II trial of adjuvant paclitaxel in patients with esophageal cancer after trimodality treatment. Patients with residual viable tumor after resection were eligible for study inclusion. Treatment was 80 mg/m(2) paclitaxel intravenously on days 1, 8, and 15 every 28 days for total of two cycles. The primary objective was to determine whether 75% or more of the patients would tolerate 240 mg/m(2) or more of paclitaxel, which corresponded to 50% or more of the total planned dose. RESULTS: Eleven out of the 12 enrolled patients (92%, 95% confidence interval (CI)=62–100%) were able to complete at least 50% of the planned paclitaxel dose. Median progression-free survival was 7 months (95% CI=2–28 months). Median overall survival was 28 months (95% CI=12–36 months). Only one patient experienced a grade 4 adverse event. CONCLUSION: Screening patients with esophageal cancer after trimodality treatment might improve completion of adjuvant trials.

Chronic lung diseases are a major global health concern—accounting for approximately 13.5% of all deaths world-wide (1). Lung transplantation is an effective therapy for end-stage lung diseases when medical therapies fail.

Obesity is public health problem of epidemic proportions. Esophageal dysmotility including achalasia is more commonly seen in an obese population. Standard therapy for achalasia can be complicated by hepatomegaly and a post-surgical anatomy in a pre- and post-bariatric population. Peroral endoscopic myotomy (POEM) has not been adequately studied in this population. A retrospective review of a prospectively collected database was completed. Patients who had undergone a Roux-en-y gastric bypass (RYGB) prior to or following a POEM were enrolled. Patient demographics, operative information and post-operative course data was collected. Six patients underwent POEM prior to or after RYGB. There were no peri-operative complications with an average length of stay of 1.2 days. Five patients experienced a clinical success with excellent symptom resolution. The one failure was in the setting of type III achalasia, but did have objective evidence of lower esophageal sphincter (LES) relaxation post-operatively. POEM in the setting of bariatric surgery is safe and feasible. The potential increase in GERD following POEM is obviated by RYGB anatomy. In an obese individual, a staged POEM prior to or following a RYGB is an appropriate treatment algorithm for obese and achalasia.

The optimal surgery for resectable pulmonary typical carcinoid (TC), e.g., lobar resection (L-R)The Surveillance, Epidemiology, and End Results (SEER) Program was used to select patients ≥66 years old, and diagnosed between 2000 and 2012 with pulmonary TC. A similar cohort was developed using the SEER-Medicare database (diagnosed from 2000-2007) to identify chemotherapy (CTX) use and co-morbidity. Five-year survival was calculated using univariate and multivariate analysis.A total of 1,506 and 512 patients were identified from SEER and SEER-Medicare, respectively. In the SEER cohort, 49%, 29% and 21% received L-R, SL-R, and no surgery (NS), respectively. Those who received NS were older (P0.001), had a higher stage (P0.001), greater comorbidity (P0.001), and were more likely to receive radiotherapy (XRT) (P0.001) and CTX (P0.001). Relative survival was nearly 100% for those who received L-R or SL-R as opposed to 72% for those who received NS (P0.001). Cox models showed no survival difference for L-RSL-R was better than NS, and similar to L-R in terms of survival. SL-R should be considered over NS if L-R is unfeasible. Role of adjuvant CTX and XRT is unclear as these did not improve survival in this study.

In emphysema airway resistance can exceed collateral airflow resistance, causing air to flow preferentially through collateral pathways. In severe emphysema ventilation through openings directly through the chest wall into the parenchyma (spiracles) could bypass airway obstruction and increase alveolar ventilation via transpleural expiration. During lung transplant operations, spiracles occasionally can occur inadvertently. We observed transpleural expiration via spiracles in three subjects undergoing lung transplant for emphysema. During transpleural spiracle ventilation, inspiratory tidal volumes (TV) were unchanged; however, expiration was entirely transpleural in two patients whereas the expired TV to the ventilator circuit was reduced to 25% of the inspired TV in one. At baseline, mean PCO2 was 61 ± 5 mm Hg, which decreased to a mean PCO2 of 49 ± 5 mm Hg (P = .05) within minutes after transpleural spiracle ventilation and further decreased at 1 to 2 h (36 ± 4 mm Hg; P = .002 compared with baseline) on unchanged ventilator settings. This observation of increased alveolar ventilation supports further studies of spiracles as a possible therapy for advanced emphysema.

Background: Barium swallow is performed following esophagectomy to evaluate the anastomosis for detection of leaks and to assess the emptying of the gastric conduit. The aim of this study was to evaluate the reliability of the barium swallow study in diagnosing anastomotic leaks following esophagectomy. Methods: Patients who underwent esophagectomy from January 2000 to December 2013 at our institution were investigated. Barium swallow was routinely done between days 5–7 to detect a leak. These results were compared to clinically determined leaks (defined by neck wound infection requiring jejunal feeds and or parenteral nutrition) during the postoperative period. The sensitivity and specificity of barium swallow in diagnosing clinically significant anastomotic leaks was determined. Results: A total of 395 esophagectomies were performed (mean age, 62.2 years). The indications for the esophagectomy were as follows: malignancy (n=320), high-grade dysplasia (n=14), perforation (n=27), benign stricture (n=7), achalasia (n=16), and other (n=11). A variety of techniques were used including transhiatal (n=351), McKeown (n=35), and Ivor Lewis (n=9) esophagectomies. Operative mortality was 2.8% (n=11). Three hundred and sixty-eight patients (93%) underwent barium swallow study after esophagectomy. Clinically significant anastomotic leak was identified in 36 patients (9.8%). Barium swallow was able to detect only 13/36 clinically significant leaks. The sensitivity of the swallow in diagnosing a leak was 36% and specificity was 97%. The positive and negative predictive values of barium swallow study in detecting leaks were 59% and 93%, respectively. Conclusion: Barium swallow is an insensitive but specific test for detecting leaks at the cervical anastomotic site after esophagectomy.

Rationale: Obliterative bronchiolitis (OB) is a major cause of mortality after lung transplantation. Depletion of airway stem cells (SCs) may lead to fibrosis in OB. Objectives: Two major SC compartments in airways are submucosal glands (SMGs) and surface airway p63 (also known as TP63 [tumor protein 63])-positive/K5 (also known as KRT5 [keratin 5])-positive basal cells (BCs). We hypothesized that depletion of these SC compartments occurs in OB. Methods: Ferret orthotopic left lung transplants were used as an experimental model of OB, and findings were corroborated in human lung allografts. Morphometric analysis was performed in ferret and human lungs to evaluate the abundance of SMGs and changes in the expression of phenotypic BC markers in control, lymphocytic bronchiolitis, and OB airways. The abundance and proliferative capacity of proximal and distal airway SCs was assessed using a clonogenic colony-forming efficiency assay. Measurements and Main Results: Ferret allografts revealed significant loss of SMGs with development of OB. A progressive decline in p63(+)/K5(+) and increase in K5(+)/K14(+) and K14(+) BC phenotypes correlated with the severity of allograft rejection in large and small ferret airways. The abundance and proliferative capacity of basal SCs in large allograft airways declined with severity of OB, and there was complete ablation of basal SCs in distal OB airways. Human allografts mirrored phenotypic BC changes observed in the ferret model. Conclusions: SMGs and basal SC compartments are depleted in large and/or small airways of lung allografts, and basal SC proliferative capacity declines with progression of disease and phenotypic changes. Global airway SC depletion may be a mechanism for pulmonary allograft failure.

Lung transplantation is an effective therapy for many patients with end-stage lung disease. Few centers across the United States offer this therapy, as a successful lung transplant program requires significant institutional resources and specialized personnel. Analysis of the United Network of Organ Sharing database reveals that the failure rate of new programs exceeds 40%. These data suggest that an accurate assessment of program viability as well as a strategy to continuously assess defined quality measures is needed. As part of strategic planning, regional availability of recipient and donors should be assessed. Additionally, analysis of institutional expertise at the physician, support staff, financial, and administrative levels is necessary. In May of 2007, we started a new lung transplant program at the University of Iowa Hospitals and Clinics and have performed 101 transplants with an average recipient 1-year survival of 91%, placing our program among the top in the country for the past 5 years. Herein, we review internal and external factors that impact the viability of a new lung transplant program. We discuss the use of four prospectively identified quality measures: volume, recipient outcomes, financial solvency, and academic contribution as one approach to achieve programmatic excellence.

A patient presents with a new bronchogenic carcinoma 5 years after laryngectomy for recurrent laryngeal tumor and 13 years after chemoradiation for concurrent lung cancer with synchronous base-of-tongue tumor. Due to his complex history and perceived limited respiratory reserve, he was felt high risk for the completion pneumonectomy needed for resection of this new tumor. The attending surgeon requested a full cardiopulmonary exercise test for risk assessment prior to surgery. We found that there was no commercially available connector that would allow our CPET equipment to reliably collect respiratory gases from a patient with tracheostomy stoma or tube. We report here a simple coupling devised “in house” that allowed for the performance of an interpretable test leading to a significant change in medical care.

Per oral endoscopic myotomy (POEM) has gained increasing popularity for treating achalasia. A multidisciplinary approach may allow safe and early adoption of POEM into clinical practice. We performed a retrospective review of our initial POEM cases. All procedures were performed by a team of interventional gastroenterologist and thoracic surgeon. We analyzed demographics, comorbidities, achalasia subtypes, length of hospital stay, duration of surgery, morbidity, mortality, length of myotomy, preoperative and postoperative Eckardt scores. Thirty-one consecutive patients underwent POEM during the 24-month period from January 2014 to December 2015. Eighteen patients (58%) had prior non-operative interventions. Average duration of follow-up was 9.6 months. Seventeen patients (66.8%) had follow-up of 12 months and longer. Average preoperative Eckardt score was 6.3 (3–10), median 6. Average postoperative Eckardt score was 1.4 (0–8), median 1, in 1 month and an average 2.2, median 1, in 1 year. Patients with type III achalasia were most refractory to treatment, while patients with type II had the best results. Average LOS was 1.3 days (1–5), median 1 day. Average DOS was 106 min (60–148), median 106. Average LOM was 13 cm (10–15), with median of 13 cm. We had one 30-day mortality secondary to coronary artery disease. Four patients had prior Heller myotomies and underwent a posterior myotomy during POEM, with outcomes similar to patients with no prior myotomy. We demonstrated safety and efficiency of a multispecialty approach for achalasia with POEM with a low rate of complications.

Background The goal of this study was to detect the predictors of chronic pain at 6 months after thoracic surgery from a comprehensive evaluation of demographic, psychosocial, and surgical factors. Methods Thoracic surgery patients were enrolled 1 week before surgery and followed up 6 months postsurgery in this prospective, observational study. Comprehensive psychosocial measurements were assessed before surgery. The presence and severity of pain were assessed at 3 and 6 months after surgery. One hundred seven patients were assessed during the first 3 days after surgery, and 99 (30 thoracotomy and 69 video-assisted thoracoscopic surgery, thoracoscopy) patients completed the 6-month follow-up. Patients with versus without chronic pain related to thoracic surgery at 6 months were compared. Results Both incidence (P = 0.37) and severity (P = 0.97) of surgery-related chronic pain at 6 months were similar after thoracotomy (33%; 95% CI, 17 to 53%; 3.3 ± 2.1) and thoracoscopy (25%; 95% CI, 15 to 36%; 3.3 ± 1.7). Both frequentist and Bayesian multivariate models revealed that the severity of acute pain (numerical rating scale, 0 to 10) is the measure associated with chronic pain related to thoracic surgery. Psychosocial factors and quantitative sensory testing were not predictive. Conclusions There was no difference in the incidence and severity of chronic pain at 6 months in patients undergoing thoracotomy versus thoracoscopy. Unlike other postsurgical pain conditions, none of the preoperative psychosocial measurements were associated with chronic pain after thoracic surgery.

The choice of the approach for esophagectomy (Ivor Lewis vs McKeown vs transhiatal esophagectomy) depends on the location of the tumor, prior operations, radiation treatment, body habitus, and surgeon’s preference. A transthoracic approach (Ivor Lewis and McKeown) allows dissection of the difficult esophagus under direct vision and may improve extent of lymphadenectomy and radial margin for midesophageal tumors. Cervical anastomosis in the McKeown and transhiatal approach allows for anastomosis healing outside of the radiated field for middle- and lower-third esophageal tumors, but a thoracic anastomosis (Ivor Lewis) puts less tension on the gastric conduit. There is no oncologic survival difference between these approaches. The Ivor Lewis resection combines a thoracic dissection with a thoracic anastomosis and is described in this chapter. This chapter lists the indications, essential steps, variations, and complications of Ivor Lewis esophagectomy. It includes a detailed template operative dictation note.

A transthoracic approach (Ivor Lewis and McKeown) allows dissection of the difficult esophagus under direct vision and may improve extent of lymphadenectomy and radial margin for midesophageal tumors. Cervical anastomosis in the McKeown esophagectomy allows for a greater length of the proximal esophagus to be resected. Thus many surgeons prefer this approach for middle and upper esophageal tumors. This chapter describes indications, essential steps, variations, and complications of this procedure. It provides a detailed template operative note for the procedure.

Background Oversizing the lung allograft, as estimated by a donor-to-recipient predicted total lung capacity (pTLC) ratio > 1.0, was associated with improved long-term survival after lung transplantation (LTx) but could be associated with increased post-operative complications and higher resource utilization. Methods The prospectively maintained LTx database at The Johns Hopkins Hospital was retrospectively reviewed for bilateral LTx patients in the post-Lung Allocation Score (LAS) era. Patients were grouped by pTLC ratio ≤ 1.0 (undersized) or > 1.0 (oversized). Post-operative complications and hospital charges were analyzed. Results The pTLC ratio was available for 70 patients: 31 were undersized and 39 oversized. Undersized patients had a higher LAS (40.4 vs 35.8, p = 0.009), were more often in the intensive care unit (ICU) pre-LTx (35% vs 10%, p = 0.01), and had a higher occurrence of primary graft dysfunction (PGD; 25% vs 5%, p = 0.013) and tracheostomy (32% vs 10%, p = 0.02), longer index hospitalizations (20 [interquartile range (IQR), 10–46] vs 16 [IQR, 12–25] days, p = 0.048), and higher index hospitalization charges ($176,247 [IQR, $137,646–$284,012] vs $158,492 [IQR, $136,250–$191,301], p = 0.04). After adjusting for LAS and pre-LTx ICU stay, a lower pTLC ratio remained associated with higher hospital charges ( p = 0.049). Airway complications were more frequent and severe in undersized patients. Conclusion Oversized allografts were not associated with an increase in post-LTx complications. However, LTx recipients of undersized allografts were more likely to experience PGD, tracheostomy, and had higher resource utilization. Higher acuity in the undersized group might explain these findings; however, multivariate models suggest an independent association between undersizing, PGD, and resource utilization.

Transmyocardial laser revascularization is an established therapy for refractory coronary artery disease. However, utilization of the technology is not as widespread as expected. This is despite the fact that the efficacy of the technology has been established in multiple prospective randomized trials. Furthermore, only about 5% of transmyocardial laser revascularization cases annually are performed in a minimally invasive fashion. We report a case of a female patient treated in a minimally invasive thoracoscopic fashion.

Left hilar exposure can be challenging during bilateral sequential lung transplantation particularly in patients with idiopathic pulmonary fibrosis due to the overlying heart and limited space. In this manuscript we describe a cost-effective technique that has been used in off-pump cardiopulmonary bypass to retract the heart away from the left hilum without causing hemodynamic instability thereby allowing implantation of the left lung without use of cardiopulmonary bypass.

Esophagectomy is an acceptable treatment option for esophageal cancer and various end-stage benign esophageal conditions. However, it still has a significantly high morbidity and mortality. In this review, the most common complications are analyzed using evidenced based data and when applicable, special consideration to operative technique is reviewed.

Mechanical ventilation (MV) is an important aspect in the intraoperative and early postoperative management of lung transplant (LTx) recipients. There are no randomized-controlled trials of LTx recipient MV strategies; however, there are LTx center experiences and international survey studies reported. The main early complication of LTx is primary graft dysfunction (PGD), which is similar to the adult respiratory distress syndrome (ARDS). We aim to summarize information pertinent to LTx-MV, as well as PGD, ARDS, and intraoperative MV, and to synthesize these available data into recommendations. Based on the available evidence, we recommend lung-protective MV with low tidal volumes (≤6 mL/kg predicted body weight [PBW]) and positive end-expiratory pressure for the LTx recipient. In our opinion, the MV strategy should be based on donor characteristics (donor PBW as a parameter of actual allograft size), rather than based on recipient characteristics; however, this donor characteristics-based protective MV is based on indirect evidence and requires validation in prospective clinical studies.

Background The clinical results of lung transplantation and concomitant cardiac surgery are unclear. The effect of cardiopulmonary bypass on the pulmonary allograft is controversial, and the effect of cardiac arrest and cardiac surgery in this setting is unknown. Our aim was to review the operative results and long-term survival in this group of patients. Methods A retrospective review of all lung transplantations between 1988 and 2003 was performed. Patients who had concomitant cardiac surgery during lung transplantation were compared with those who underwent lung transplantation alone. The variables analyzed included allograft ischemic times, use of cardiopulmonary bypass, early graft dysfunction, postoperative morbidity, survival, length of mechanical ventilation, length of stay in the intensive care unit, and overall hospital stay. Results During this period, 35 of 700 lung transplant recipients (15 single and 20 bilateral transplantations) underwent concomitant cardiac surgery. The cardiac procedures were for patent foramen ovale (n = 18), atrial septal defect (n = 9), ventricular septal defect (n = 2), coronary bypass (n = 4), and "other" (n = 2). Allograft ischemic time, use of extracorporeal membrane oxygenation, length of hospital stay, operative mortality, and survival were not significantly different between the 2 groups. Ventilator time and intensive care unit stay were longer in the cardiac surgery group. Conclusions Cardiac surgery at the time of lung transplantation can be performed with acceptable morbidity and mortality. The immediate and long-term survival in these patients is similar to that of other lung transplant recipients. Lung transplantation should continue to be offered to patients with normal ventricular function who require concomitant limited cardiac surgery.

Rationale: Patients who progress to brain death after resuscitation from cardiac arrest have been hypothesized to represent an underused source of potential organ donors; however, there is a paucity of data regarding the viability of lung allografts after a period of cardiac arrest in the donor.

140 Background: Disease control and survival outcomes for LAEC are poor despite multimodality treatment with CRT with or without esophagectomy. Without comparative trial data, oncologists select a chemotherapy regimen based on clinical experience and toxicity profile. The present investigation compares LAEC progression free survival (PFS) and overall survival (OS) for CF versus CT. Methods: A retrospective analysis was performed for patients with LAEC from 2003-2012, treated with curative-intent neoadjuvant or definitive concurrent CRT with either CF or CT. Chi-squared tests, Fisher’s exact tests, and t-tests were used to identify significant differences between treatment groups. The Kaplan-Meier method was used to estimate PFS and OS. Results: Of 149 patients with non-metastatic LAEC, 82 met inclusion criteria (n=38 CF, n=44 CT), with 63, 2, and 2 excluded for non-CF/CT CRT, missing data, and

Objective Compensatory hyperhidrosis is a common devastating adverse effect after endoscopic thoracic sympathectomy for patients undergoing surgical treatment of primary hyperhidrosis. We sought to determine whether a correlation existed in our patient population between the level and extent of sympathetic chain resection and the subsequent development of compensatory hyperhidrosis. Methods All patients undergoing endoscopic thoracic sympathectomy in the T2-T3, T2-T4, T2-T5, or T2-T6 levels for palmar or axillary hyperhidrosis at the University of Iowa Hospital and Clinics (n = 97) from January 2004 to January 2013 were retrospectively reviewed. Results Differences in the preoperative patient characteristics were not statistically significant among the patients receiving T2-T3, T2-T4, T2-T5, or T2-T6 level resections. Of the 97 included patients, 28 (29%) experienced transient compensatory hyperhidrosis and 4 (4%) complained of severe compensatory hyperhidrosis and required additional treatment. No operative mortalities occurred, and the morbidity was similar among the groups. Conclusions Most patients had successful outcomes after undergoing extensive resection without changes in the incidence of compensatory hyperhidrosis. Therefore, we recommend performing complete and adequate resection for relief of symptoms in patients with primary hyperhidrosis.

Objective: This study aimed to determine the long-term viability of innominate artery resection and tracheotomy for a patient at high risk of developing a tracheoinnominate fistula (TIF) in the setting of subglottic stenosis and a high-riding innominate artery. Methods: Chart review with 2-year follow-up. Results: A 45-year-old diabetic man with obstructive sleep apnea and multiple admissions for coma and delirium tremens associated with alcohol abuse developed subglottic stenosis. He was found to have a palpable supraclavicular pulse during preoperative examination for a tracheotomy. Computed tomography examination revealed a high-riding innominate artery at the level of stenosis along with granulation tissue and disruption of the cartilaginous trachea, suggesting a high risk of impending TIF. The patient underwent a sternotomy-approach resection of the innominate artery with closure of the distal stump with a sternohyoid muscle flap. Intraoperatively, a plane of adhesions between the posterior innominate artery and trachea was dissected. The anterior tracheal wall appeared calcified but without evidence of erosion of either the trachea or the artery. Six weeks later, a tracheotomy was performed. Follow-up at 27 months did not identify complications from the innominate artery resection. Conclusion: Resection of the innominate artery is an option for some patients either to address the warning signs of TIF or to permit a tracheotomy to be performed in the presence of a high innominate artery.

Video-assisted thoracic surgery (VATS) has become an accepted approach for the diagnosis and treatment of thoracic malignancies. Port site tumor recurrence is a reported complication of VATS. However, the true incidence of this problem is unknown. To try to determine the incidence of port site recurrence, we analyzed our experience with patients undergoing VATS wedge resection for malignancy.Data were obtained from our prospective VATS database. The analysis was confined to patients undergoing VATS wedge resection for malignancy, excluding those having a pleural biopsy only. Parameters analyzed included demographic factors, surgical technique, and port site recurrences identified by physical examination, CT scan, or both.From 1992 to 1996, 410 patients (182 men, 228 women; median age = 61 years) underwent a VATS wedge resection for malignancy. The procedure was performed for diagnosis or staging in 90% of cases. Access incisions plus port sites were used in 97 (24%) patients; port sites only were used in 313 (76%) patients. Conversion to thoracotomy was necessary in 102 patients (25%) either for definitive resection (58 patients) or because VATS was not technically adequate (44 patients). Specimens were retrieved via access incisions or port sites with or without a specimen bag. The operative mortality was 0.25%. With long-term follow-up (median = 25 months) available for 374 patients (91%), only one port site recurrence was identified (0.26%).Our experience confirms the safety of VATS wedge resection in cancer patients. The incidence of port site tumor recurrence is low when oncologic principles are respected. In our institution, these principles include performing VATS wedge resection only for lesions that can be widely removed; converting to thoracotomy for definitive or extensive cancer operation; and using meticulous technique for the extraction of specimens from the pleural space.

Background: The treatment of superior sulcus lung cancers is evolving and preoperative chemotherapy is increasingly used. To establish a historical benchmark against which new therapies can be assessed, we reviewed our 24-year experience with patients undergoing thoracotomy for lung cancers of the superior sulcus. Methods: Data were acquired through retrospective chart review. Overall survival was calculated by the method of Kaplan and Meier, and prognostic factors were examined by log rank and Cox proportional hazards modeling. Results: From 1974 to 1998, 225 patients underwent thoracotomy. The patients included 144 men (64%) and 81 women with a median age of 55 years. The majority of patients (55%) received preoperative radiation, but 35% did not have any preoperative treatment. Tumor stages were IIB (T3 N0) in 52%, IIIA in 15%, and IIIB in 27% of patients. Complete resection was achieved in 64% of T3 N0 tumors, 54% of T3 N2 tumors, and 39% of T4 N0 tumors. Operative mortality was 4%. Median survival was 33 months for stage IIB and 12 months for both stages IIIA and IIIB. Actuarial 5-year survivals were 46% for stage IIB, 0% for stage IIIA, and 13% for stage IIIB. By univariate and multivariable analyses, T and N status and complete resection had a significant impact on survival. Locoregional disease was the most common form of relapse. Conclusions: Our results provide a benchmark against which new treatment regimens can be evaluated. Control of locoregional disease remains the major challenge in treating lung cancers of the superior sulcus. The potential benefit of preoperative chemotherapy or chemoradiotherapy must be assessed by whether it leads to higher rates of complete resection and a lower risk of local relapse. (J Thorac Cardiovasc Surg 2000;119:1147-53)

A higher predicted total lung capacity (pTLC)-ratio (=pTLC donor/pTLC recipient), suggestive of oversized allografts, is associated with improved survival after lung transplantation. It is unknown whether the pTLC-ratio has a different association with survival in bilateral (BLT) versus single lung transplantation (SLT).The pTLC-ratio was calculated for all adult patients in the United Network of Organ Sharing lung transplant (LTx) registry who underwent first-time LTx in the post lung allocation score era, between May 2005 and April 2010. The LTx recipients were stratified according to procedure (BLT vs SLT). Risk of death at 1 year after LTx was analyzed using Kaplan-Meier survival and Cox proportional hazards models.In the 4,520 BLT patients, each 0.1 increase in pTLC-ratio conferred a 7% decrease in the hazard for death at 1 year (p0.001) in univariate analysis. This association remained significant after controlling for diagnosis, comorbidities, acuity, donor, and transplant factors (hazard ratio [HR] 0.93, 95% confidence interval [CI] 0.88 to 0.98, p = 0.01). Additional adjustment by a propensity score to account for biases to oversizing showed similar results (HR 0.94, 95% CI 0.90 to 0.99, p = 0.018). In the 2,477 SLT patients, each 0.1 increase in pTLC-ratio conveyed a 6% decrease in the hazard for death at 1 year (p = 0.002) in univariate analysis, which did not persist in the multivariate model (HR 1.00, p = 0.8).A higher pTLC-ratio, suggestive of an oversized allograft, is associated with improved survival after lung transplantation. This association is primarily evident in BLT patients.

Obliterative bronchiolitis (OB) is the primary cause of late morbidity and mortality following lung transplantation. Current animal models do not reliably develop OB pathology. Given the similarities between ferret and human lung biology, we hypothesized an orthotopic ferret lung allograft would develop OB. Orthotopic left lower lobe transplants were successfully performed in 22 outbred domestic ferrets in the absence of immunosuppression (IS; n = 5) and presence of varying IS protocols (n = 17). CT scans were performed to evaluate the allografts. At intervals between 3–6 months the allografts were examined histologically for evidence of acute/chronic rejection. IS protects allografts from acute rejection and early graft loss. Reduction of IS dosage by 50% allowed development of controlled rejection. Allografts developed infiltrates on CT and classic histologic acute rejection and lymphocytic bronchiolitis. Cycling of IS, to induce repeated episodes of controlled rejection, promoted classic histologic hallmarks of OB including fibrosis-associated occlusion of the bronchiolar airways in all allografts of long-term survivors. In conclusion, we have developed an orthotopic lung transplant model in the ferret with documented long-term functional allograft survival. Allografts develop acute rejection and lymphocytic bronchiolitis, similar to humans. Long-term survivors develop histologic changes in the allografts that are hallmarks of OB.

Background The majority of costs associated with esophagectomy are related to the initial 3 days of hospital stay requiring intensive care unit stays, ventilator support, and intraoperative time. Additional costs arise from hospital-based services. The major cost increases are related to complications associated with the procedure. We attempted to define these costs and identify expense management by streamlining care through strict adherence to patient care maps, operative standardization, and rapid discharge planning to reduce variability. Methods Utilizing methods of Kaizen philosophy we evaluated all processes related to the entire experience of esophageal resection. This process has taken over 5 years to achieve, with quality and cost being tracked over this time period. Cost analysis included expenses related to intensive care unit, anesthesia, disposables, and hospital services. Quality improvement measures were related to intraoperative complications, in-hospital complications, and postoperative outcomes. The Institutional Review Board approved the use of anonymous data from standard clinical practice because no additional treatment was planned (observational study). Results Utilizing a continuous process improvement methodology, a 43% reduction in cost per case has been achieved with a significant increase in contribution margin for esophagectomy. The length of stay has been reduced from 14 days to 5. With intraoperative and postoperative standardization the leak rate has dropped from 12% to less than 3% to no leaks in our current Kaizen modification of care in our last 64 patients. Conclusions Utilizing lean manufacturing techniques and continuous process evaluation we have attempted to eliminate variability, standardized the phases of care resulting in improved outcomes, decreased length of stay, and improved contribution margins. These Kaizen improvements require continuous interventions, strict adherence to care maps, and input from all levels for quality improvements.

Background Neoadjuvant chemotherapy alone or with concurrent radiation is often used for stage IIIA non–smallcell lung cancer but is often tried in patients with stage IIIB and at times in patients with stage I or II disease. Newer neoadjuvant regimens would need to be compared with currently used programs to see if they increased toxicity. For such a comparison, a baseline estimate is needed of the mortality of currently used regimens. Patients and Methods In this review, we searched PubMed and associated references, and data on mortality were identified in 34 publications. Results The mortality of neoadjuvant chemotherapy or chemotherapy plus radiation has been estimated in 2015 patients was 0.7%, and the postsurgical mortality in 2195 patients was 4.3%. Conclusion These estimates might provide a benchmark for comparison for innovative trials.

Most of the attempted lung transplantation procedures before 1983 failed because of high incidence of primary graft failure, and airway and infectious complications resulting from the use of steroids. Experimental studies done at the University of Toronto showed that steroids impaired bronchial healing 2 while cyclosporine did not impair bronchial healing 3 and that use of omental wrapping improved bronchial healing. 4 Translation of these studies into clinical practice led to the first successful lung transplant. Following success with single lung transplantation, en bloc double lung transplantation was developed for patients with septic lung diseaseandemphysema. 5 However,thistechnicallychallenging procedure had a significantly high rate of tracheal anastomotic complications resulting from ischemia 6 and was givenupinfavorofbilateralsequentiallungtransplantation. 7 Currently, this is the procedure of choice at the authors’ institution. The technical details of lung transplantation have evolved significantly. Omental wrapping is no longer used to cover the bronchial anastomoses and perioperative steroids are routinely used. 8 Bronchial artery revascularization is rarely performed. 9 Selection of suture material for the bron

Prior to the cyclosporine (CsA) era, there were no long-term survivors from lung transplantation as the immunosuppressive drugs made patients very susceptible to opportunistic infections and anastomotic complications. CsA is a calcineurin inhibitor that binds to cyclophilins and inhibits transcription of interleukin 2 in T cells, thereby preventing proliferation of activated T cells. The initial immunosuppressive regimen at our institution includes CsA, azathioprine, and steroids. Blood levels of CsA (whole blood, TDx assay) are maintained between 250 and 350 ng/mL for 0 to 6 months, 200 to 300 ng/mL for 6 to 12 months, and around 200 ng/mL beyond 12 months following lung transplantation. Nephrotoxicity, hypertension, susceptibility to infections, and malignancy are some of the serious side effects of CsA that limit its therapeutic usefulness. Acute rejection is relatively common with this regimen, and about 60% of all lung transplant recipients are treated for an episode of acute rejection within the first 12 months after lung transplantation. Acute rejection is a probable risk factor for chronic rejection, and obliterative bronchiolitis develops in about 50% of the patients who survive 5 years. Treatment of chronic rejection continues to be a challenge in lung transplantation. CsA and tacrolimus seem to have equivalent results in lung transplantation, although a few patients may benefit from the use of tacrolimus.

Purpose: Extracellular matrix (ECM) proteins play a significant role in the survival and metastasis of cancer cells. Tenascin-C (TN-C) is an extracellular matrix protein and its large isoform has been implicated in tumor progression. Goal of this study was to analyze the expression of the small and large isoforms of TN-C in non-small cell lung cancer (NSCLC) and determine its functional significance. Experimental design: TN-C expression was studied in tumor and non-tumor tissue of patients with NSCLC at the mRNA and protein level. Immunomodulatory properties of the large isoform of TN-C were analyzed by determining its effect on lymphocyte proliferation and cytokine secretion by tumor-infiltrating lymphocytes (TIL). Results: Quantitative real-time PCR analysis showed an eight-fold increase in the amount of large isoform in cancer cells compared to adjacent normal tissue. Expression at the protein level by Western blot analysis using a murine monoclonal anti-TN-C antibody detected increased expression of the large isoform in the tumor tissue that was correlated with the development of recurrent disease. A 18-fold increase in the expression of the large TN-C isoform was observed in patients with recurrent NSCLC compared to non-recurrent NSCLC. Large isoform of TN-C significantly inhibited anti-CD3 and mitogen-induced proliferation of human peripheral blood lymphocytes and interferon-gamma production by TIL isolated from the lung cancer specimens. Conclusions: Increased expression of TN-C observed at the site of tumor in NSCLC correlates with recurrence. TN-C inhibits TIL proliferation and cytokine thereby may promote tumor immune evasion and recurrence.