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Background: We hypothesized that academic facilities and high-volume facilities would be independently associated with improved survival and a greater propensity for performing surgery in locally advanced esophageal cancer., Methods: We identified patients diagnosed with stage IB-III esophageal cancer during 2004-2016 from the National Cancer Database. Facility type was categorized as academic or community, and facility volume was based on the number of times a facility's unique identification code appeared in the dataset. Each facility type was dichotomized into high- and low-volume subgroups using the cutoff of 20 esophageal cancers treated/year. We fitted multivariable regression models in order to assess differences in surgery selection and survival between facilities according to type and volume., Results: Compared to patients treated at high-volume community hospitals, those at high-volume academic facilities were more likely to undergo surgery (odds ratio: 1.865, p  < 0.001) and were associated with lower odds of death (odds ratio: 0.784, p  = 0.004). For both academic and community hospitals, patients at high-volume facilities were more likely to undergo surgery compared to those at low-volume facilities, p  < 0.05. For patients treated at academic facilities, high-volume facilities were associated with lower odds of death (odds ratio: 0.858, p  = 0.02) compared to low-volume facilities, while there was no significant difference in the odds of death between high- and low-volume community hospitals (odds ratio: 1.018, p  = 0.87)., Conclusions: Both facility type and case volume impact surgery selection and survival in locally advanced esophageal cancer. Compared to community hospitals, academic facilities were more likely to perform surgery and were associated with improved survival., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Current recommendations for segmentectomy for non-small cell lung cancer (NSCLC) include size ≤2 cm, margins ≥ 2 cm, and no nodal involvement. This study further stratifies the selection criteria for segmentectomy using the National Cancer Database (NCDB)., Methods: The NCDB was queried for patients with high-grade (poorly/undifferentiated) T1a/b peripheral NSCLC (tumor size ≤2 cm), who underwent either lobectomy or segmentectomy. Patients with pathologic node-positive disease or who received neoadjuvant/adjuvant treatments were excluded. Propensity score analysis was used to adjust for differences in pretreatment characteristics., Results: 11 091 patients were included with 10 413 patients (93.9%) treated with lobectomy and 678 patients (6.1%) underwent segmentectomy. In a propensity matched pair analysis of 1282 patients, lobectomy showed significantly improved median survival of 88.48 months vs 68.30 months for segmentectomy, P = .004. On multivariate Cox regression, lobectomy was associated with significantly improved survival (hazard ratio (HR): .81, 95% CI .72-.92, P = .001). Subgroup analysis of propensity score matched patients with a Charlson-Deyo comorbidity score (CDCC) of 0 also demonstrated a trend of improved survival with lobectomy., Discussion: Lobectomy may confer significant survival advantage over segmentectomy for high-grade NSCLC (≤2 cm). More work is needed to further stratify various NSCLC histologies with their respective grades allowing more comprehensive selection criteria for segmentectomy.

Background: Treatment delays in lung cancer care in the United States may be attributable to a diverse range of patient, provider, and institutional factors, the precise contributions of which remain unclear. The objective of our study was to use the National Cancer Database to investigate specific predictors of increased time-to-treatment initiation., Methods: We identified 567 783 patients undergoing treatment for stage I to stage IV non-small cell lung cancer during 2010 to 2018. Time-to-treatment initiation was defined as the number of days from radiologic diagnosis to initiation of first treatment. We used mixed effect negative binomial regression to determine predictors of time-to-treatment initiation., Results: We noted a steady rise in the overall mean time-to-treatment initiation interval from 33 days (2010) to 39 days (2018; P < .01). Black race, a later year at diagnosis, nonprivate insurance, and diagnosis and treatment at different facilities were independent predictors of increased time-to-treatment initiation, irrespective of disease stage. Compared with White race, Black race corresponded to a 15% to 20% increase in time-to-treatment initiation, depending on disease stage (P < .01). For stages I and II, radiation as first course of therapy corresponded with a 69% and 33% increase in time-to-treatment initiation, respectively, compared with surgery (P < .01)., Conclusions: Lung cancer treatment initiation times have seen an upward trajectory in recent years. Black patients encountered significantly longer treatment initiation times, regardless of treatment modality or disease stage. Prolonged initiation times appear to contribute to existing health care disparities by disproportionately affecting medically underserved communities., (Copyright © 2023 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: Safety-net hospitals deliver a significant level of care to uninsured patients, Medicaid-enrolled patients, and other vulnerable patients. Little is known about the impact of safety-net hospital status on outcomes in non-small cell lung cancer. We aimed to compare treatment characteristics and outcomes between hospitals categorized according to their relative burden of uninsured or Medicaid-enrolled patients with non-small cell lung cancer., Methods: We queried the National Cancer Database for patients with clinical stage I and II non-small cell lung cancer presenting from 2004 to 2018. We categorized hospitals on the basis of their relative burden of uninsured or Medicaid-enrolled patients with non-small cell lung cancer into low-burden (<8.2%), medium-burden (8.2%-12.0%), high-burden (12.1%-16.8%), and highest burden (>16.8%) quartiles. We investigated the impact of care at these hospitals on outcomes while controlling for sociodemographic, clinical, and facility characteristics., Results: We identified 204,189 patients treated at 1286 facilities. There were 592 low-burden, 297 medium-burden, 219 high-burden, and 178 highest burden hospitals. Patients at highest burden hospitals were more likely to be younger, male, Black, and Hispanic ( P  < .01), and to reside in rural, low-income, and low-educated regions ( P  < .01). Patients at these facilities had a greater likelihood of not receiving surgery, undergoing an open procedure, undergoing a regional lymph node examination involving less than 10 lymph nodes, having a length of stay more than 4 days, and not receiving treatment ( P  < .05)., Conclusions: Our results indicate reduced treatment quality and higher mortality in patients undergoing surgery for early non-small cell lung cancer at hospitals with an increased burden of uninsured or Medicaid-enrolled patients with non-small cell lung cancer. There is a need to raise the standard of care to improve outcomes in vulnerable populations., (© 2022 The Author(s).)

Objective : We aimed to identify predictors of conversion to thoracotomy and test the hypothesis that conversion is associated with inferior perioperative outcomes in non-small cell lung cancer (NSCLC). Methods : We queried the National Cancer Database for patients with stage I to III NSCLC undergoing minimally invasive surgery (MIS) during 2010 to 2016. We compared clinicopathologic factors between patients undergoing MIS with and without conversion. We fitted multivariable regression models to identify independent predictors of conversion and compare perioperative outcomes between the 2 groups. Results : A rising trend in the use of MIS was accompanied by a declining trend in the rate of conversion to thoracotomy. A total of 11.3% of the 83,219 cases were converted. Conversion was associated with a higher Charlson-Deyo score, squamous histology, nodal involvement, high tumor grade, tumor size ≥5 cm, and a higher T stage ( P  < 0.05). Successful MIS without conversion was predicted by advanced age, sublobar resection, robotic approach, and treatment at an academic high-volume facility ( P  < 0.05). Conversion was linked to longer hospital stays, higher 30-day and 90-day mortality, and unplanned readmission ( P  < 0.05), irrespective of the type of MIS approach. Conclusions : Conversion rates for video-assisted and robot-assisted thoracoscopic surgery have seen a decline in recent years. Irrespective of the type of MIS approach, conversion was associated with inferior perioperative outcomes. The robotic approach and treatment at an academic high-volume facility were associated with a lower likelihood of conversion. Early recognition of the individual risk factors for conversion may help to counsel patients about the likelihood of, and detriments associated with, conversion and ultimately reduce conversion rates.

Background: The association of hospital volume with outcomes has been assessed previously for patients with non-small cell lung cancer (NSCLC), but there are limited data on the cumulative effect of travel burden and hospital volume on treatment decisions and survival outcomes. We used the National Cancer Database to evaluate this relationship in early-stage NSCLC., Methods: Outcomes of interest were compared between 2 propensity-matched groups with stage I NSCLC: patients in the bottom quartile of distance travelled who underwent surgery at low-volume centers (Local) and those in the top quartile of distance travelled who received surgery at high-volume centers (Distant). Outcomes included type of resection (anatomic or nonanatomic), time to resection (< or ≥8 weeks), number of lymph nodes examined (< or ≥10 nodes) and R0 resection., Results: We identified 3325 Local patients who travelled 2.3 miles (interquartile range [IQR]: 1.4-3.3 miles) to centers that treated 10.5 (IQR: 6.5-16.5) stage I NSCLCs/year and 3361 Distant patients who travelled 40.0 miles (IQR: 29.1-63.4 miles) to centers treating 56.9 (IQR: 40.1-84.7) stage I NSCLCs/year. Local patients were less likely to receive surgery <8 weeks post-diagnosis, have ≥10 lymph nodes examined during surgery, and undergo an R0 resection (all P < .01). Distant patients had shorter hospital stays and superior median survival, both P < .01., Conclusions: Patients travelling longer distances to high-volume centers receive better and more timely surgical care, leading to shorter hospital stays and improved survival outcomes. Regionalization of lung cancer care by improving travel support to larger treatment facilities may help improve early-stage NSCLC outcomes., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: We aimed to identify patient- and facility-specific predictors of collective adherence to 4 recommended best treatment practices in operable IIIAN2 non-small-cell lung cancer (NSCLC) and test the hypothesis that collective adherence is associated with superior survival., Methods: We queried the National Cancer Database for clinical stage IIIAN2 NSCLC patients undergoing surgery during 2010-2015. The following best practices were examined: performance of an anatomic resection, performance of an R0 resection, examination of regional lymph nodes and administration of induction therapy. Multivariable regression models were fitted to identify independent predictors of guideline-concordance., Results: We identified 7371 patients undergoing surgical resection for IIIAN2 lung cancer, of whom 90.8% underwent an anatomic resection, 88.2% received an R0 resection, 92.5% underwent a regional lymph node examination, 41.6% received induction therapy and 33.7% received all 4 best practices. Higher income, private insurance and treatment at an academic facility were independently associated with adherence to all 4 best practices (P < 0.01). A lower level of education and residence in a rural county were associated with a lack of adherence (P < 0.05). Adherence to all 4 practices correlated with improved survival (P < 0.01)., Conclusions: National adherence to best treatment practices in operable IIIAN2 lung cancer was variable as evidenced by the majority of patients not receiving recommended induction therapy. Socioeconomic factors and facility type are important determinants of guideline-concordance. Future efforts to improve outcomes should take this into account since guideline concordance, in the form of collective adherence to all 4 best practices, was associated with improved survival., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: The aim of this study is to identify patients with thymoma who should receive post-operative radiotherapy., Methods: The Surveillance, Epidemiology, and End Results database was queried for stage IIB-IV thymoma patients diagnosed during 1988-2015. We analyzed the prognostic implications of various clinical-pathological factors by comparing the outcomes of those who received surgery with and without post-operative radiotherapy., Results: A total of 1120 patients were identified; 62% received post-operative radiotherapy and 38% underwent surgery alone. In a propensity-matched cohort of 812 patients, no survival difference was seen in World Health Organization A, AB, B1, B2, or B3 tumors with the addition of post-operative radiotherapy to surgery (p>0.05). Post-operative radiotherapy also did not improve survival over surgery alone for tumors ≥ or < less than the 4 cm, 7 cm, 10 cm, and 13 cm cutoffs, all p>0.05. Post-operative radiotherapy was an independent, positive prognostic indicator only in the subgroup with stage III disease and in those receiving chemotherapy in addition to post-operative radiotherapy, both p<0.05., Conclusions: Patients with stage III thymoma are most likely to benefit from the addition of post-operative radiotherapy to surgical treatments. Tumor size or World Health Organization histology alone should not be criteria for determining the need for post-operative radiotherapy in locally advanced thymoma. Masaoka-Koga stage, which has traditionally been used to help make such decisions, appears to be the most reliable determinant of the use of post-operative radiotherapy.

Objectives: The extent of surgical resection for early-stage second primary lung cancer (SPLC) in patients with a previous lobectomy is unclear. We sought to compare anatomic lung resections (lobectomy and segmentectomy) and wedge resections for small peripheral SPLC using a population-based database., Methods: The Surveillance, Epidemiology and End Results database was queried for all patients with ≤2 cm peripheral SPLC diagnosed between 2004 and 2015 who underwent prior lobectomy for the first primary and surgical resection only for the SPLC. American College of Chest Physicians guidelines were used to classify SPLC. Kaplan-Meier analysis and multivariable Cox regression were used to compare overall survival., Results: A total of 356 patients met the inclusion criteria with 203 (57%) treated with wedge resection and 153 (43%) treated with anatomic resection. Significantly better median survival was observed with anatomic resection than with wedge resection using a Kaplan-Meier analysis (124 vs 63 months; P < 0.001). With multivariable Cox regression, improved long-term survival was observed for anatomic resection (hazard ratio: 0.44, confidence interval: 0.27-0.70; P = 0.001). Improvement in survival was demonstrated with wedge resection when lymph node sampling was done. Lastly, we calculated the average treatment effect on the treated with inverse probability weighting for a subgroup of patients and found that those with wedge resection and lymph node sampling had shorter long-term survival times., Conclusions: Anatomic resections may provide better long-term survival than wedge resections for patients with early-stage peripheral SPLC after prior lobectomy. Significant improvement in survival was observed with wedge resection for SPLC when adequate lymph node dissection was performed., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Current practice guidelines recommend the following criteria for segmentectomy for non-small cell lung cancer (NSCLC): size ≤2 cm, margins ≥2 cm and no lymph node involvement. We sought to further stratify the selection criteria for segmentectomy for small peripheral high-grade tumors., Methods: This retrospective database study was conducted using the Surveillance, Epidemiology and End Results (SEER) database. We queried for patients with high-grade (poorly differentiated/undifferentiated) pathological (p)T1a/b peripheral NSCLC (tumor size ≤2 cm), who underwent either lobectomy or segmentectomy between 2004 and 2015. Patients with node-positive disease or those who received any form of induction or adjuvant treatments were excluded., Results: A total of 4,332 patients met the inclusion criteria, with 3,977 patients (91.8%) treated with lobectomy and 355 patients (8.2%) who underwent segmentectomy. In a propensity matched pair analysis of 640 patients, lobectomy (n=320) showed significantly improved 5-year survival of 45.9% vs. 33.8% for segmentectomy (n=320), P<0.01. In a multivariate Cox regression analysis, lobectomy was associated with significantly improved survival (HR: 0.84, 95% CI: 0.714-0.989, P=0.036). Interestingly, married status, adenocarcinoma histology, number of lymph nodes sampled were associated with better survival (P<0.05), while advanced age and male gender had worse survival outcomes (P<0.05)., Conclusions: For small peripheral NSCLC ≤2 cm and high grades of tumor differentiation, lobectomy is associated with better long-term survival outcomes as compared to segmentectomy. Additional data is needed to further stratify various NSCLC histologies with their respective grades to allow for better selection for segmentectomy., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/jtd-20-1530). The authors have no conflicts of interest to declare., (2020 Journal of Thoracic Disease. All rights reserved.)

Purpose: Primary hyperhidrosis is a pathological disorder of unknown etiology, affecting 0.6-5% of the population, and causing severe functional and social handicaps. As the etiology is unknown, it is not possible to treat the root cause. Recently some differences between affected and non-affected people have been reported. The aim of this review is to summarize these new etiological data., Methods: Search of the literature was performed in the PubMed/Medline Database and pertinent articles were retrieved and reviewed. Additional publications were obtained from the references of these articles., Results: Some anatomical and pathophysiological characteristics (as well as enzymatic, metabolic, and neurological dysfunctions) have been observed in hyperhidrotic subjects; three main possible etiological factors predominate. A familial trait seems to exist, and genetic loci associated with hyperhidrosis have been identified. Histological differences were observed in sympathetic ganglia of hyperhidrotic subjects: the ganglia were larger and contained a higher number of ganglion cells. A higher expression of acetylcholine and alpha-7 neuronal nicotinic receptor subunit in the sympathetic ganglia of patients with hyperhidrosis has been reported., Conclusions: Despite these accumulated data, the etiology of primary hyperhidrosis remains obscure. Nevertheless, three main lines for future research seem to be delineated: genetics, histological observations, and enzymatic studies.

There is a small subset of patients who have undergone endoscopic thoracic sympathectomy for hyperhidrosis or facial blushing who are dissatisfied and would wish reversal. Compensatory sweating is the most common side effect that causes a person to regret surgery. Treatment options are limited and usually not effective in patients with severe side effects from sympathectomy. Nerve graft interposition has been proven to be effective in experimental models and small clinical series. Da Vinci robotic nerve graft reconstruction with interposition graft and direct suturing of nerve and high magnification dissection most closely mirrors standard nerve reconstruction principles when done as a minimally invasive procedure., (Copyright © 2016 Elsevier Inc. All rights reserved.)

OBJECTIVE. Appropriate radiologic interpretation of screening CT can minimize unnecessary workup and intervention. This is particularly challenging in the baseline round. We report on the quality assurance process we developed for the International Early Lung Cancer Action Program. MATERIALS AND METHODS. After initial training at the coordinating center, radiologists at 10 participating institutions and at the center independently interpreted the first 100 baseline screenings. The radiologist at the institutions had access to the center interpretations before issuing the final reports. After the first 100 screenings, the interpretations were jointly discussed. This report summarizes the results of the initial 100 dual interpretations at the 10 institutions. RESULTS. The final institution interpretations agreed with the center in 895 of the 1000 interpretations. Compared with the center, the frequency of positive results was higher at eight of the 10 institutions. The most frequent reason of discrepant interpretations was not following the protocol (n = 55) and the least frequent was not identifying a nodule (n = 3). CONCLUSION. The quality assurance process helped focus educational programs and provided an excellent vehicle for review of the protocol with participating physicians. It also suggests that the rate of positive results can be reduced by such measures.

Internal mammary lymphadenopathy can be caused by a variety of disease processes and is a difficult diagnostic dilemma. We report a case of internal mammary lymphadenopathy, in a patient with a significant history of malignancy, requiring a tissue diagnosis. Robotic thoracoscopic lymphadenectomy was used to facilitate excisional biopsy. Pathology was significant for silicone granulomatous lymphadenitis secondary to silicone breast implants inserted after mastectomy for breast cancer.

Background: The hallmark of lung ischemia-reperfusion injury (IRI) is the production of reactive oxygen species (ROS), and the resultant oxidant stress has been implicated in apoptotic cell death as well as subsequent development of inflammation. Dietary flaxseed (FS) is a rich source of naturally occurring antioxidants and has been shown to reduce lung IRI in mice. However, the mechanisms underlying the protective effects of FS in IRI remain to be determined., Methods: We used a mouse model of IRI with 60 min of ischemia followed by 180 min of reperfusion and evaluated the anti-apoptotic and anti-inflammatory effects of 10% FS dietary supplementation., Results: Mice fed 10% FS undergoing lung IRI had significantly lower levels of caspases and decreased apoptotic activity compared with mice fed 0% FS. Lung homogenates and bronchoalveolar lavage fluid analysis demonstrated significantly reduced inflammatory infiltrate in mice fed with 10% FS diet. Additionally, 10% FS treated mice showed significantly increased expression of antioxidant enzymes and decreased markers of lung injury., Conclusions: We conclude that dietary FS is protective against lung IRI in a clinically relevant murine model, and this protective effect may in part be mediated by the inhibition of apoptosis and inflammation., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Significant controversies surround the optimal treatment of primary hyperhidrosis of the hands, axillae, feet, and face. The world's literature on hyperhidrosis from 1991 to 2009 was obtained through PubMed. There were 1,097 published articles, of which 102 were clinical trials. Twelve were randomized clinical trials and 90 were nonrandomized comparative studies. After review and discussion by task force members of The Society of Thoracic Surgeons' General Thoracic Workforce, expert consensus was reached from which specific treatment strategies are suggested. These studies suggest that primary hyperhidrosis of the extremities, axillae or face is best treated by endoscopic thoracic sympathectomy (ETS). Interruption of the sympathetic chain can be achieved either by electrocautery or clipping. An international nomenclature should be adopted that refers to the rib levels (R) instead of the vertebral level at which the nerve is interrupted, and how the chain is interrupted, along with systematic pre and postoperative assessments of sweating pattern, intensity and quality-of-life. The recent body of literature suggests that the highest success rates occur when interruption is performed at the top of R3 or the top of R4 for palmar-only hyperhidrosis. R4 may offer a lower incidence of compensatory hyperhidrosis but moister hands. For palmar and axillary, palmar, axillary and pedal and for axillary-only hyperhidrosis interruptions at R4 and R5 are recommended. The top of R3 is best for craniofacial hyperhidrosis., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The survival of patients with malignant central airway obstruction is very limited. Although airway stenting results in significant palliation of symptoms, data regarding improved survival after stenting for advanced thoracic cancer with central airway obstruction are lacking., Methods: Fifty patients received a total of 72 airway stents for malignant central airway obstruction over a two-year period at a single institution. The Medical Research Council (MRC) dyspnea scale and Eastern Cooperative Oncology Group (ECOG) performance status were used to divide patients into a poor performance group (MRC = 5, ECOG = 4) and an intermediate performance group (MRC ≤ 4, ECOG ≤ 3). The SPSS version 16.0 (SPSS Inc, Chicago, IL) and Microsoft Excel (Microsoft, Redmond, WA) were used to analyze the data. Survival curves were constructed using the Kaplan-Meier survival analysis method and a log-rank test was used to compare the survival distributions among different groups., Results: Successful patency of the airway was achieved in all patients with no procedure-related mortality. Stenting resulted in significant improvement in MRC and ECOG performance scores (p < 0.01). Significantly improved survival was observed only in patients in the intermediate performance group compared with patients in the poor performance group (p < 0.05)., Conclusions: Airway stenting resulted in significant palliation of symptoms in both groups as evaluated by MRC dyspnea scale and ECOG performance status. Compared with historic controls, a significant survival advantage was seen only in the intermediate performance group. We postulate that timely stenting of the airway, before the morbid complications of malignant central airway obstruction have set in, results in improved survival., (Copyright © 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Endoscopic tracheoplasty is used for the relief of airway obstruction because of several benign conditions such as postintubation stenosis, inflammatory disorders such as Wegener granulomatosis, and benign neoplastic processes. Several endoscopic treatment modalities exist for these conditions, all with good initial results. However, recurrence is common and often requires frequent reintervention. Endoscopic segmental tracheal ring resection is a novel therapeutic approach that could potentially provide a durable solution. Endoscopic segmental tracheal ring resection was performed in 3 Yorkshire pigs under general anesthesia. A combination of bipolar cautery and sharp dissection was used to resect 25% to 33% of the circumference of a single tracheal ring. Technical success was achieved in all 3 animals with no intraoperative complications. Full-thickness excision, including the anterior perichondrium, was performed in 1 animal without violation of the pretracheal fascia, with no subcutaneous emphysema or clinically apparent pneumothorax. Average operative time was 31 minutes and estimated blood loss was minimal. Heart rate, oxygen saturation, and peak airway pressures were maintained within normal ranges during the procedure and for the 60-minute postoperative period. Histologic analysis of the resected specimen confirmed complete thickness excision of the segment of tracheal cartilage. Endoscopic tracheoplasty by segmental tracheal ring resection is a safe and feasible technique in a porcine model. Long-term durability could potentially outlast other endoscopic techniques for the treatment of bening tracheal stenosis. Survival studies in a porcine model of tracheal stenosis must be performed to assess the long-term outcomes of this approach.

Background: Chronic obstructive pulmonary disease (COPD) has been conventionally associated with increased operative mortality and morbidity after coronary artery bypass grafting. Some studies, however, challenge this association. Moreover, the effect of COPD on long-term survival after coronary artery bypass grafting has not been adequately assessed. Thus, in this clinical setting, both early and late outcome require further examination., Methods: We studied 3,760 consecutive patients who underwent isolated coronary artery bypass grafting between 1992 and 2002. The propensity for COPD was determined by logistic regression analysis, and each patient with COPD was matched with 3 patients without COPD. Matched groups were compared for early outcome and long-term survival (mean follow-up, 7.6 years). Long-term survival data were obtained from the National Death Index., Results: There were 550 patients (14.6%) with COPD. Multivariate analysis showed that patients with COPD were older and sicker. However, propensity-matched groups did not differ in terms of hospital mortality or major morbidity, although COPD was associated with a slightly longer hospital stay. In contrast, COPD patients had increased long-term mortality, with a hazard ratio of 1.28 (95% confidence intervals, 1.11 to 1.47; p=0.001). Freedom from all-cause mortality at 7 years after CABG was 65% and 72% in matched patients with and without COPD, respectively (p=0.008). In patients with COPD, the hazard estimate was consistently increased up to 9 years postoperatively., Conclusions: Chronic obstructive pulmonary disease, although not an independent predictor of increased early mortality and morbidity in this series, is a continuing detrimental risk factor for long-term survival., (Copyright (c) 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Sublobar lung resection and brachytherapy seed placement is gaining acceptance for T1 non-small cell lung cancer (NSCLC) in select patients with comorbidities precluding lobectomy. Our institution first reported utilization of the da Vinci system for robotic brachytherapy developed experimentally in swine and applied to high-risk patients 5 years ago. We now report seed dosimetrics and midterm follow-up., Methods: Eleven high-risk patients with stage IA NSCLC who were not candidates for conventional lobectomy underwent limited resection of 12 primary tumors. To reduce locoregional recurrence, (125)I brachytherapy seeds were robotically sutured intracorporeally over resection margins to deliver 14,400 cGy 1 cm from the implant plane. Patients were followed with dosimetric computed tomography scans at 30 +/- 16 days. Survival and sites of recurrence were documented., Results: Resected tumor size averaged 1.48 +/- 0.38 cm (range, 1.1 to 2.1 cm). Perioperative mortality was 0% and recurrence was 9% (1 of 11 [margin recurrence at 6 months with resultant mortality at 1 year]). Follow-up duration was 31.82 +/- 17.35 months. Dosimetrics confirmed 14,400 cGy delivery using 24.21 +/- 4.6 (125)I seeds (range, 17 to 30 seeds) over a planning target volume of 10.29 +/- 2.39 cc(3). Overall, 84.1% of the planning target volume was covered by 100% of the prescription dose (V100), and 88.2% was covered by 87% of the prescription dose (V87), comparable to open dosimetric data at our institution. Follow-up imaging confirmed seed stability in all patients., Conclusions: Robotic (125)I brachytherapy seed placement is a feasible adjuvant procedure to reduce the incidence of recurrence after sublobar resection in medically compromised patients. Tailored robotic seed placement delivers an exact dosing regimen in a minimally invasive fashion with equivalent precision to open surgery., (2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

A rare but important constellation of musculoskeletal and cutaneous symptoms, including synovitis, acne, pustulosis, hyperostosis, and osteitis, has recently been designated the SAPHO syndrome. The exact etiology is unknown, although various infectious agents have been proposed. The most common site of osteoarticular involvement is the sternoclavicular joint, and therefore, recognition of this syndrome and appropriate workup and management is crucial in the differential diagnosis of an anterior chest wall mass.

Sclerosing hemangioma is a rare pulmonary tumor that usually grows as a peripheral intraparenchymal lesion in the lungs. Although some case series have described this rare tumor, endobronchial growth of sclerosing hemangioma is extremely rare, with only 3 reported cases in the literature to date. We describe a patient who presented with respiratory arrest secondary to bilateral mechanical airway obstruction caused by this tumor. Such a presentation has never been described in the literature before and, as such, proved to be a challenging diagnosis.

Objective: Endoscopic thoracic sympathectomy (ETS) remains the definitive treatment for primary focal hyperhidrosis. Compensatory hyperhidrosis (CH) is a significant drawback of ETS. We sought to identify the predictors for the development of severe CH after ETS, its anatomic locations, and its frequency of occurrence, and we analyzed the impact of CH on patient satisfaction with ETS., Methods: Bilateral ETS for primary focal hyperhidrosis was performed in 220 patients, and a retrospective chart review was conducted. Follow-up evaluation was conducted using a telephone questionnaire, and 73% of all patients were contacted. Patients' responses regarding CH and their level of satisfaction after ETS were analyzed. Statistical analysis was performed using SPSS software (Version 14.0; SPSS, Inc., Chicago, IL). A P value of <0.05 was considered statistically significant., Results: Some degree of CH developed in 94% of patients. The number of levels treated was not related to the occurrence of severe CH. Isolated T3 ganglionectomy led to a significantly lower incidence of severe CH, when compared with all other levels (P < 0.03). Ninety percent of patients were satisfied with the procedure. The development of severe CH, as opposed to mild or moderate CH, significantly correlated with a lower satisfaction rate (P = 0.003)., Conclusion: CH is common after ETS procedures, and the occurrence of severe, but not mild or moderate, CH is a major source of dissatisfaction after ETS. The overall occurrence of severe CH is reduced after T3 ganglionectomy as opposed to ganglionectomies performed at all other levels. The level of satisfaction with ETS is high.

Background: A hypothetical advantage of the da Vinci console is its ability to integrate multiple visual data sources. Current platforms for augmented reality surgery fuse pre-operative radiographic studies but are limited with their ability to update with intra-operative imaging. The aim of our study was to evaluate the feasibility of real-time radiographic image overlay with current technology., Methods: S-video composite output from a fluoroscopic C-arm was superimposed onto the video output of the da Vinci device. Image superimposition disparity measurements were evaluated in a bench model. The feasibility of robotic dissection assisted by real-time cholangiogram and intravenous pyelogram was evaluated., Results: Image alignment resulted in a radiographic blind spot and image disparity with severely limited application in an in vivo model., Conclusions: External collisions of the robotic device and visual disparity in multiple planes negate the current implementation of fluoroscopic overlay and will require more elegant methods of computer-assisted registration.

Background: A subset of patients who undergo video-assisted thoracoscopic sympathectomy for hyperhydrosis develop post-procedure compensatory sweating that is perceived as more debilitating than their initial complaints. We propose a novel treatment to reverse sympathectomy by implantation of an intercostal nerve graft using the da Vinci robot., Methods: A robotic swine model was established using single-lung ventilation and four ports. The pleura was incised and a representative segment of sympathetic chain was transected. A nearby intercostal nerve was harvested and sutured to the sympathetic chain using four interrupted 10-0 nylon sutures on the epineurium., Results: The intercostal nerve was an excellent size match and post-procedure necropsy yielded successful anastomoses without apparent complications., Conclusions: Robotic intercostal nerve grafting for reversal of thoracic sympathectomy is technically feasible. The robotic device allows the principles of neural microsurgery to be maintained and provides a minimally invasive option for reconstruction of the sympathetic chain.

The term "amyloidoma" has been used to describe localized pulmonary nodular amyloidosis when it is a solitary lesion. Amyloidoma is an uncommon and infrequently reported cause of benign pulmonary lesions. We report the case of a 45-year-old man with hemoptysis, eosinophilia, and a large mass involving both lobes of the left lung, the chest wall, and, via extension through the diaphragm, the liver. Clinical suspicion of echinococcal cyst led to treatment via en bloc excision rather than attempting tissue biopsy for diagnosis. Complete resection of the isolated pulmonary amyloidoma was achieved with no evidence of recurrence.

Objective: Thoracoscore is the first multivariate model for the prediction of in-hospital mortality after general thoracic surgery. We aimed to evaluate the performance of Thoracoscore in predicting in-hospital and midterm all-cause mortality., Methods: We retrospectively evaluated 1675 patients who underwent thoracic surgery (lung resections [n = 626], mediastinum [n = 535], pleura and pericardium [n = 268], esophagus [n = 88], chest wall [n = 90], trachea [n = 45], and other procedures [n = 23]) from October 2002 to March 2006 at a single institution. Midterm survival data (mean follow-up 25 +/- 16 months) were obtained from the National Death Index. Kaplan-Meier survival plots of the quartiles of Thoracoscore were constructed and compared with the log-rank test with adjustment for trend., Results: Starting from the lower-risk to the higher-risk quartile, the in-hospital mortality rates were 0% (0/418), 1% (4/415), 2.5% (11/435), and 9.6% (54/407). Thoracoscore was a strong independent predictor for in-hospital mortality (odds ratio 1.20, 95% confidence intervals 1.15-.25; P < .001). The 2-year survivals of the Thoracoscore quartiles were 98.7% +/- 0.6%, 87.0% +/- 1.8%, 73.8% +/- 2.3%, and 54.8% +/- 2.7%, respectively (P < .0001). Thoracoscore was a strong independent predictor for midterm mortality (hazard ratio 1.12, 95% confidence intervals 1.11-1.14; P < .001)., Conclusion: Thoracoscore is a good and useful clinical tool for preoperative prediction of in-hospital and midterm mortality among patients undergoing general thoracic surgery.

Background: The purpose of the present study was to determine independent predictors for early and midterm mortality for the whole context of thoracic surgery., Methods: We studied 1453 consecutive patients who underwent thoracic surgery between 2002 and 2005. Operations included lung resections (n = 504), mediastinal (n = 468), pleural and pericardial (n = 226), esophageal (n = 83), chest wall (n = 85), tracheal (n = 50) and other procedures (n = 37). Midterm survival data (mean follow-up 2.0 +/- 1.1 years) were obtained from the National Death Index. Multivariate logistic regression was used to assess in-hospital mortality. Independent predictors for midterm mortality were determined by multivariate Cox regression analysis., Results: There were 47 (3.2 %) in-hospital and 312 (21.5 %) late deaths. Independent predictors for in-hospital mortality included Zubrod score (OR 2.72, P < 0.001), ASA score (OR 3.42, P < 0.001), pneumonectomy (OR 20.71, P = 0.001) and no history of cerebrovascular events (OR 0.27, P = 0.011). Independent predictors for midterm mortality included age (HR 1.03, P < 0.001), weight loss (HR 1.57, P = 0.005), Zubrod score (HR 1.47, P < 0.001), primary lung cancer (HR 1.98 P < 0.001), intrathoracic extrapulmonary metastases (HR 2.78, P < 0.001), primary chest wall tumor (HR 0.14, P = 0.008), diabetes requiring insulin (HR 1.71, P = 0.017), no preoperative renal failure (HR 0.57, P = 0.004), no comorbidities (HR 0.54, P = 0.009), ASA score (HR 1.69, P < 0.001), postoperative radiation treatment (HR 1.90, P = 0.016), pneumonectomy (HR 2.18, P = 0.040), reoperation for bleeding and/or postoperative transfusion (HR 3.10, P = 0.027) and postoperative pulmonary complications (HR 1.89, P = 0.013)., Conclusions: We determined independent predictors for in-hospital and midterm mortality for the whole context of thoracic surgery. Zubrod and ASA scores affect both early and midterm mortality.

Objective: Neurogenic paravertebral tumors are uncommon neoplasms arising from neurogenic elements within the thorax. These tumors may be dumbbell shaped, extending into the spinal canal or exclusively paraspinal. Generally encapsulated, they are located in the posterior mediastinum. In this report, we present our experience in the thoracoscopic resection of these tumors, including surgical technique and potential pitfalls., Methods: A retrospective review of patients undergoing endoscopic surgery for paravertebral tumors was undertaken. Patient demographics, charts, operative reports, and pre- and postoperative images were reviewed., Results: Between 1997 and 2004, 13 patients were treated thoracoscopically for paravertebral tumors in our departments. Our population consisted of four men and nine women. The median age was 44.9 years (range, 29-66 yr). Eight patients presented with pain, dyspnea, cough, and weakness. Five patients had tumors found incidentally. Sizes of the tumors varied from 3 to 9 cm. Final pathology included four neurofibromas, eight schwannomas, and one unclassified granular cell tumor. Gross total resection was achieved endoscopically in all cases. Three patients required a hemilaminectomy for resection of the intraspinal dumbbell component of the tumor during the same operation. The mean operative time was 229.5 minutes. The mean estimated blood loss was 371.1 ml. Postoperative morbidities included one each of tongue swelling, ulnar neuropathy, and intercostal hyperesthesia. The mean hospital stay was 2.8 days., Conclusion: Paravertebral tumors in the posterior mediastinum are amenable to endoscopic removal, even in hard to reach locations. Tumors with intraspinal extension can be removed concurrently by performing a hemilaminectomy, followed by thoracoscopy, without the need for a thoracotomy.

Background: : Robotic technology has facilitated the evaluation and treatment of anterior mediastinal pathology. We describe a 3-year experience using the da Vinci Robotic Surgical System to perform thymectomies for a range of diseases., Methods: : From March 2002 to November 2004, 9 patients (3 myasthenia gravis, 3 mediastinal mass, 2 myasthenia gravis plus thymoma, 1 hyperparathyroidism) underwent totally endoscopic robotic thymectomy. Medical records and operative databases were reviewed. The cohort was divided into an early experience (group A) and a later experience (group B). Data were analyzed with the Fisher exact test and Mann-Whitney test., Results: : Complete robotic resection of the thymus was accomplished in all 9 patients. The mean age for the entire cohort was 40 ± 12 years (range 28-66 years) and 78% of the patients were women. No significant differences in age, gender, or operative conversions were detected between the groups. Patients in group A were more likely to have a bilateral approach. Group B demonstrated statistically significant reductions in operating room and operation time and a trend toward decreased chest tube days and length of stay. No morbidity or mortality associated with the procedure was noted in either group., Conclusions: : Robotic thymectomy is a safe and effective procedure. Its steep learning curve promises to allow more surgeons to adopt minimally invasive approaches to the mediastinum safely and efficiently.

Background: We present the first prospective randomized study of primary coronary artery bypass grafting (CABG) patients who were analyzed for postoperative infections after undergoing blood and/or blood product transfusion (BBPT) with a Pall Purecell leukoreducing filter., Methods and Results: One hundred and four patients were enrolled between March 1998 and March 1999. Seventy-two of the patients received BBPT (average 5.6 units BBPT/filter patient and 5.6 units/control patient). Three patients who had CABG without extracorporeal circulation or mixed transfusions of filtered and unfiltered BBPT were excluded. The remaining 69 transfused patients (38 filtered, 31 control) were analyzed and the incidence of culture proven infections was recorded. Mid-term survival data were obtained from the National Death Index and Kaplan-Meier survival plots were constructed. All patients were stratified and matched according to the EuroSCORE.Thirty-day mortality was 2.6% and 3.2% for the filtered and control patients, respectively. There were 5 cases of culture proven infections in 38 filtered patients (13.2%) and 8 in 31 controls (25.8%), P = 0.224. No pulmonary tract infections were recorded in the filter group vs. 4 (12.9%) in controls, P = 0.048. Reduced length for mechanical ventilation (16.3 hours vs. 57.8, P = 0.103), length of stay (9.1 vs. 10.8 days, P = 0.685), as well as increased 50-month actuarial survival, (45.5 vs. 42.3 months, P=0.695) in filtered vs. control, respectively, were recorded., Conclusions: The use of leukoreduced BBPT reduced the incidence of pulmonary tract infections in patients undergoing CABG.

Background: Traditionally, a thoractomy incision is used for pulmonary complications of tuberculosis. An attractive alternative is being presented by the use of midline sternotomy in such patients, which is the aim of this study., Methods: Five patients (four male, one female) with pulmonary complications of tuberculosis requiring surgical therapy in 1993 and 1994 were treated through a median sternotomy. The median patient age at time of surgery was 40.2 years and the median patient follow-up was 4.0 years (range 1.0 to 5.0 years) in this retrospective review., Results: All patients had uncomplicated operative courses and were discharged from the hospital. One patient's in-hospital postoperative course was complicated by prolonged ventilator dependency requiring temporary tracheostomy; he died 1 year postoperatively after hospital discharge due to recurrent multidrug-resistant tuberculosis. Sternal wound infections and bronchopleural fistulas were not observed in any patients., Conclusions: Surgical treatment of pulmonary complications of tuberculosis was traditionally performed through a thoracotomy approach. Many patients with tuberculous lungs have pulmonary adhesions or intrathoracic scarring from previous surgery, which would require extrapleural resection. Bleeding was a frequent complication of this procedure. Sternotomy offers excellent exposure of the intrapericardial vessels, and reduced postoperative disability compared to the standard thoracotomy, which may be an advantage given that the majority of patients in this population have poor pulmonary function. We recommend median sternotomy as an alternative operative approach in selected patients with pulmonary complications of tuberculosis.

The current recommendations for treating myasthenia gravis include surgical thymectomy for patients between puberty and 60 years of age. This is a report of a new method for surgical thymectomy using the robotic da Vinci surgical system for a totally endoscopic approach. This new procedure combines the potential advantages of minimally invasive methods with the efficacy of open procedures.

The diagnosis and management of mediastinal masses frequently necessitates biopsy and surgical resection. The use of videothorascopic techniques has broadened the surgeon's ability to evaluate and treat such tumors using a minimally invasive approach. We describe herein the use of the da Vinci Robotic Surgical System for evaluating a mediastinal mass in a young woman.

Background: Postoperative bleeding in aortic root aneurysms had represented a challenge., Methods: Intraoperative testing of the annular or subannular aortic anastomosis, during procedures involving replacement of the aortic root, with either synthetic tube graft, a composite graft or an allograft is described. By reversing the flow of the LV vent and delivering cardioplegia into the left ventricle and thereby pressurizing the left ventricle and its outflow, this technique enables the surgeon to simulate the volume loaded heart, prior to completion of the distal anastomosis. A systematic assessment of the proximal suture line can then be undertaken. Portions of the proximal suture line, particularly the posterior aspect, are obscured if the inspection takes place after completion of both aortic anastomoses, the coronary attachments, as well as from the presence of the main pulmonary artery and by the distended aorta itself., Results: The use of this method in 34 patients is described without untoward events related to this technique., Conclusions: The advantages of this technique are a rapid and safe assessment of the integrity of the proximal suture line bed.

A possible new functional mechanism of atheromatous embolus is presented resulting from reversed aortic blood flow during diastolic augmentation by balloon counterpulsation. This mechanism is different from mechanical disruption during insertion. Despite this, intra-aortic balloon remains an important asset in the management of hemodynamically challenged patients.

Objectives: We examined whether bilateral internal thoracic artery (BITA) revascularization is associated with any increased in-hospital mortality and complications compared with single internal thoracic artery (SITA) revascularization., Background: Despite proven long-term benefits, BITA revascularization has been slow to be adopted because of fear of increased early morbidity., Methods: We evaluated 1,697 consecutive patients undergoing BITA (n = 867) or SITA (n = 830) revascularization. We used propensity score analyses and adjusted risk models to address differences between arms., Results: There were 20 (2.3%) deaths in the BITA group versus 26 (3.1%) in the SITA group (odds ratio 0.73, p = 0.30). Propensity analysis identified several parameters that affected the decision to use BITA. Adjusting for propensity score and all potential risk factors, the odds ratio for death with BITA versus SITA was practically 1. Bilateral internal thoracic artery revascularization did not increase the number of in-hospital complications with the possible exception of deep sternal wound infections (11 [1.3%] vs. 3 [0.4%], p = 0.057). In multivariate modeling BITA increased the risk of deep sternal wound infections only in emergent cases and in older patients; the excess risk was negligible among 1,206 patients (71.1% of total) who did not have emergent revascularization and were < or =70 years old (risk difference 0.3%, p = 0.74). There was no difference in length of stay after adjustment for propensity factors (mean 11.3 vs. 11.7 days, p = 0.66)., Conclusions: Bilateral internal thoracic artery revascularization grafting confers no increased risk for early death and does not prolong hospital stay. The small increase in the risk of deep sternal wound infections does not affect the majority of patients.