The advent of lung cancer screening and detection of smaller nodules amplifies the need to clarify the oncological quality of sublobar resections. Furthermore, studies comparing sublobar resections ...to lobectomies offer conflicting conclusions. We hypothesize that this is driven, in part, by inconsistency in reporting; that is, variable interpretation of what constitutes an operative segment. Without an established standard, 2 very different operations may be reported as segmental resections, leaving the data on sublobar approaches subject to interpretative variability.
A retrospective audit was performed on all segmental resections from May 2016 to December 2019 at Brigham and Women's Hospital. Pathology and operative reports were reviewed, with particular attention to the dissection of the component artery, vein, and bronchus. Resections with dissection and division of at least 1 major vascular structure (the segmental artery or vein), as well as the segmental bronchus, met operative criteria for anatomic segmentectomy. Surgical quality metrics were compared between the 2 groups.
There were 271 segmental resections: 219 (80.8%) were anatomic segmentectomies and 52 (19.2%) were nonanatomic segmentectomies. For the entire cohort, nonanatomic segmentectomies had smaller margins (1.0 vs 1.5 cm; P = .02), fewer lymph nodes (2.0 vs 6.0; P < .001), and fewer mediastinal lymph node stations sampled (1.0 vs 2.0; P < .001). Similarly, there were smaller margins (1.5 vs 1.8 cm; P = .03), fewer lymph nodes (2.0 vs 6.0; P < .001), and fewer mediastinal lymph node stations sampled (1.0 vs 2.0; P < .001) in nonanatomic segmentectomies for non–small cell lung cancer.
Nearly 20% of reported segmentectomies may not meet criteria for true segmental resection. Therefore, prior studies may need further scrutiny to clarify outcomes and results. Establishing a professional standard may help mitigate ambiguity in published data on this subject.
Graphical representation of the conclusion that if 20% of reported segmentectomies are nonanatomic, then professional societal standards are needed to ensure that all patients receive the same quality of care. Display omitted
The mediastinum is the central compartment in the thoracic cavity that lies between the lungs. It extends from the thoracic inlet superiorly to the diaphragm inferiorly and sternum anteriorly to the ...vertebral column posteriorly. It is commonly divided into four compartments-superior, anterior, middle and posterior mediastinum. However, some have started to classify it into the more recent three compartments-anterior (prevascular), middle (visceral) and posterior (paravertebral). The mediastinum is of clinical significance because many vital structures, such as the heart, great vessels, esophagus, lymphatics, and trachea, lie within these compartments. Disease presentation can greatly vary depending on the structures involved, and the differential diagnosis can range widely. Therefore, knowledge of the anatomy and subdivisions of the mediastinum is vital for thoracic surgeons. Herein, we have provided a brief review of the mediastinal anatomy. Utilizing the four-compartment model, we detail the contents of each compartment of the mediastinum with special attention to its veins and nerves. There are also several venous junctions that are important for mediastinal surgery, such as the internal jugular-subclavian venous junction and the left-right brachiocephalic venous junction. We describe useful superficial landmarks, such as the sternocleidomastoid and manubrium, and how they relate to some of the key venous junctions.
The prognostic value of tumor regression scores (TRS) in patients with esophageal adenocarcinoma (EAC) who underwent neoadjuvant chemoradiation remains unclear. We sought to investigate the ...prognostic value of pathologic and metabolic treatment response among EAC patients undergoing neoadjuvant chemoradiation.
Patients who underwent esophagectomy for EAC after neoadjuvant CROSS protocol between 2016 and 2020 were evaluated. TRS was grouped according to the modified Ryan score; metabolic response, according to the PERCIST criteria. Variables from endoscopic ultrasound, endoscopic biopsies, and positron emission tomography (primary and regional lymph node standardized uptake values SUVs) were collected.
The study population comprised 277 patients. A TRS of 0 (complete response) was identified in 66 patients (23.8%). Seventy-eight patients (28.1%) had TRS 1 (partial response), 97 (35%) had TRS 2 (poor response), and 36 (13%) had TRS 3 (no response). On survival analysis for overall survival (OS), patients with TRS 0 had longer survival compared to those with TRS 1, 2, or 3 (P = .010, P < .001, and P = .005, respectively). On multivariable logistic regression, the presence of signet ring cell features on endoscopic biopsy (odds ratio OR, 7.54; P = .012) and greater SUV uptake at regional lymph nodes (OR, 1.42; P = .007) were significantly associated with residual tumor at pathology (TRS 1, 2, or 3). On multivariate Cox regression for predictors of OS, higher SUVmax at the most metabolically active nodal station (hazard ratio HR, 1.08; P = .005) was independently associated with decreased OS, whereas pathologic complete response (HR, 0.61; P = .021) was independently associated with higher OS.
Patients with pathologic complete response had prolonged OS, whereas no difference in survival was detected among other TRS categories. At initial staging, the presence of signet ring cells and greater SUV uptake at regional lymph nodes predicted residual disease at pathology and shorter OS, suggesting the need for new treatment strategies for these patients.
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Manubrium Reconstruction Tarascio, Jeffrey; Deeb, Ashley L.; Dezube, Aaron R. ...
The Annals of thoracic surgery,
11/2022, Letnik:
114, Številka:
5
Journal Article
Recenzirano
To date, there is no standard approach for manubrial reconstruction. We had previously utilized mesh; however, this resulted in breakage, infection, and poor cosmesis. In this case series, we ...describe our transition to iliac wing autograft reconstruction. We examined 7 patients who underwent manubrial resection and reconstruction: 2 with mesh and methyl methacrylate and 5 with an iliac wing autograft. The outcomes of the autograft patients were overall favorable with no short-term complications or instances of breakage. We conclude that an iliac wing autograft for manubrial reconstruction is feasible and effective alternative to methyl methacrylate mesh.
Background and Objectives
We assessed frailty, measured by a comprehensive geriatric assessment‐based frailty index (FI‐CGA), and its association with postoperative outcomes among older thoracic ...surgical patients.
Methods
Patients aged ≥65 years evaluated in the geriatric‐thoracic clinic between June 2016 through May 2020 who underwent lung surgery were included. Frailty was defined as FI‐CGA > 0.2, and "occult frailty", a level not often recognized by surgical teams, as 0.2 < FI‐CGA < 0.4. A qualitative analysis of geriatric interventions was performed.
Results
Seventy‐three patients were included, of which 45 (62%) were nonfrail and 28 (38%) were frail. “Occult frailty” was present in 23/28 (82%). Sixty‐one (84%) had lung malignancy. Geriatric interventions included delirium management, geriatric‐specific pain and bowel regimens, and frailty optimization. More sublobar resections versus lobectomies (61% vs. 25%) were performed among frail patients. Frailty was not significantly associated with overall complications (odds ratio OR: 2.4; 95% confidence interval CI: 0.88–6.44; p = 0.087), major complications (OR: 2.33; 95% CI: 0.48–12.69; p = 0.293), discharge disposition (OR: 2.8; 95% CI: 0.71–11.95; p = 0.141), or longer hospital stay (1.3 more days; p = 0.18).
Conclusion
Frailty and “occult frailty” are prevalent in patients undergoing lung surgery. However, with integrated geriatric management, these patients can safely undergo surgery.
Background
Geographic and socioeconomic factors impact patient treatment choices for certain cancers. Whether they impact treatment in older adults with lung cancer is unknown. We investigated ...geographic differences in treatment for stage I non‐small‐cell lung cancer (NSCLC) in older adults in the United States.
Methods
Using the Surveillance, Epidemiology and End Results Database 18th submission, a cohort of stage I NSCLC patients ≥60‐years‐old was created. Treatment differences (surgery or radiation alone) by geographic location and socioeconomic factors were analyzed.
Results
Forty‐three thousand three hundred and eighty‐seven stage I NSCLC patients were analyzed. Demographics and socioeconomic factors varied across all 13 states (p < 0.001). Surgery was the most common treatment in all states (range 58.6% in AK to 86.5% in CT) (all p < 0.001). Our multivariable analysis found older individuals had higher odds of getting radiation as compared to surgery (odds ratio OR: 1.22 for 65–69 years‐old to OR: 8.95 for 85+ years‐old; p < 0.001). Multiple states (LA, HI, IA, MI, WA, NM) were associated with increased odds of radiation use (vs. surgery alone) (all p < 0.05). People with lower education level (OR: 0.98) and median income (OR: 0.99) and non‐Black race (OR: 0.52 for “other” to OR: 0.68 for “White” race with respect to Black race) were associated with lower odds of radiation (p < 0.05).
Conclusions
Our study identified treatment differences for stage I NSCLC patients in the United States related to demographics, socioeconomic factors, and geographic location.
Thoracic epidural analgesia (TEA) and liposomal bupivacaine (LB) are two methods used for postoperative pain control after thoracic surgery. Some studies have compared LB to standard bupivacaine. ...However, data comparing the outcomes of LB to TEA after minimally invasive lung resection is limited. Therefore, the objective of our study was to compare postoperative pain, opioid usage, and outcomes between patients who received TEA
. LB.
We conducted a retrospective chart review of patients who underwent minimally invasive lung resections over an 8-month period. Intraoperatively, patients received either LB under direct vision or a TEA. Pain scores were obtained in the post-anesthesia care unit (PACU) and at 12, 24, and 48 hours postoperatively. Morphine milligram equivalents (MMEs) were calculated at 24 and 48 hours postoperatively. Postoperative outcomes were then compared between groups.
In total, 391 patients underwent minimally invasive lung resection: 236 (60%) wedge resections, 51 (13%) segmentectomies, and 104 (27%) lobectomies. Of these, 326 (83%) received LB intraoperatively. Fewer patients in the LB group experienced postoperative complications (18%
. 34%, P=0.004). LB patients also had lower median pain scores at 24 (P=0.03) and 48 hours (P=0.001) postoperatively. There was no difference in MMEs at 24 hours (P=0.49). However, at 48 hours, patients who received LB required less narcotics (P=0.02). Median hospital length of stay (LOS) was significantly shorter in patients who received LB (2
. 4 days, P<0.001). On multivariable analysis, increasing age, postoperative complications, and use of TEA were independently associated with a longer hospital LOS.
Compared to TEA, LB intercostal block placed under direct vision reduced morphine use 48 hours after thoracic surgery. It was also associated with fewer postoperative complications and shorter median hospital LOS. LB is a good alternative to TEA for pain management after minimally invasive lung resection.
Reported advantages to robotic thoracic surgery include shorter length of stay (LOS), improved lymphadenectomy, and decreased complications. It is uncertain if these benefits occur when introducing ...robotics into a well-established video-assisted thoracoscopy (VATS) practice. We compared the two approaches to investigate these advantages.
IRB approval was obtained for this project. Patients who underwent segmentectomy or lobectomy from May 2016–December 2018 were propensity-matched 2: 1 (VATS: robotic) and compared using weighted logistic regression with age, gender, Charlson Comorbidity Index, surgery type, stage, Exparel, and epidural as covariates. Complication rates, operation times, number of sampled lymph nodes, pain level, disposition, and LOS were compared using Wilcoxon rank-sum and with Rao-Scott Chi-squared tests.
213 patients (142 VATS and 71 robot) were matched. Duration of robotic cases was longer than VATS (median 186 min (IQR 78) vs. 164 min (IQR 78.75); p < 0.001). Significantly more lymph nodes (median 11 (IQR 7.50) vs. 8 (IQR 7.00); p = 0.004) and stations were sampled (median 4 (IQR 2.00) vs. 3 (IQR 1.00); p < 0.001) with the robot. Interestingly, robotic resections had higher 72-hour pain scores (median 3 (IQR 3.25) vs. 2 (IQR 3.50); p = 0.04) and 48-hour opioid usage (median 37.50 morphine milligram equivalents (MME) (IQR 45.50) vs. 22.50 MME (IQR 37.50); p = 0.01). Morbidity, LOS, and disposition were similar (all p > 0.05).
The robotic approach facilitates better lymph node sampling, even in an established VATS practice.
•Benefits of robotic surgery are seen even in well-established VATS practice.•Robotic-assisted lung resection results in better lymph node sampling.•Patients with robotic resection had higher 72-hour pain scores and 48-hour narcotic use.•Morbidity and length of stay were equivalent between the two approaches.
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