Purpose The efficacy of neoadjuvant chemoradiotherapy (NCRT) plus surgery for locally advanced esophageal squamous cell carcinoma (ESCC) remains controversial. In this trial, we compared the survival ...and safety of NCRT plus surgery with surgery alone in patients with locally advanced ESCC. Patients and Methods From June 2007 to December 2014, 451 patients with potentially resectable thoracic ESCC, clinically staged as T1-4N1M0/T4N0M0, were randomly allocated to NCRT plus surgery (group CRT; n = 224) and surgery alone (group S; n = 227). In group CRT, patients received vinorelbine 25 mg/m
intravenously (IV) on days 1 and 8 and cisplatin 75 mg/m
IV day 1, or 25 mg/m
IV on days 1 to 4 every 3 weeks for two cycles, with a total concurrent radiation dose of 40.0 Gy administered in 20 fractions of 2.0 Gy on 5 days per week. In both groups, patients underwent McKeown or Ivor Lewis esophagectomy. The primary end point was overall survival. Results The pathologic complete response rate was 43.2% in group CRT. Compared with group S, group CRT had a higher R0 resection rate (98.4% v 91.2%; P = .002), a better median overall survival (100.1 months v 66.5 months; hazard ratio, 0.71; 95% CI, 0.53 to 0.96; P = .025), and a prolonged disease-free survival (100.1 months v 41.7 months; hazard ratio, 0.58; 95% CI, 0.43 to 0.78; P < .001). Leukopenia (48.9%) and neutropenia (45.7%) were the most common grade 3 or 4 adverse events during chemoradiotherapy. Incidences of postoperative complications were similar between groups, with the exception of arrhythmia (group CRT: 13% v group S: 4.0%; P = .001). Peritreatment mortality was 2.2% in group CRT versus 0.4% in group S ( P = .212). Conclusion This trial shows that NCRT plus surgery improves survival over surgery alone among patients with locally advanced ESCC, with acceptable and manageable adverse events.
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.
Data from selected centers show that robotic lobectomy is safe and effective and has 30-day mortality comparable to that of video-assisted thoracoscopic surgery (VATS). However, widespread adoption ...of robotic lobectomy is controversial. We used The Society of Thoracic Surgeons General Thoracic Surgery (STS-GTS) Database to evaluate quality metrics for these 2 minimally invasive lobectomy techniques.
A database query for primary clinical stage I or stage II non-small cell lung cancer (NSCLC) at high-volume centers from 2009 to 2013 identified 1,220 robotic lobectomies and 12,378 VATS procedures. Quality metrics evaluated included operative morbidity, 30-day mortality, and nodal upstaging, defined as cN0 to pN1. Multivariable logistic regression was used to evaluate nodal upstaging.
Patients undergoing robotic lobectomy were older, less active, and less likely to be an ever smoker and had higher body mass index (BMI) (all p < 0.05). They were also more likely to have coronary heart disease or hypertension (all p < 0.001) and to have had preoperative mediastinal staging (p < 0.0001). Robotic lobectomy operative times were longer (median 186 versus 173 minutes; p < 0.001); all other operative measurements were similar. All postoperative outcomes were similar, including complications and 30-day mortality (robotic lobectomy, 0.6% versus VATS, 0.8%; p = 0.4). Median length of stay was 4 days for both, but a higher proportion of patients undergoing robotic lobectomy had hospital stays less than 4 days (48% versus 39%; p < 0.001). Nodal upstaging overall was similar (p = 0.6) but with trends favoring VATS in the cT1b group and robotic lobectomy in the cT2a group.
Patients undergoing robotic lobectomy had more comorbidities and robotic lobectomy operative times were longer, but quality outcome measures, including complications, hospital stay, 30-day mortality, and nodal upstaging, suggest that robotic lobectomy and VATS are equivalent.
Our objective is to report the world's largest series with the longest follow-up of robotic lobectomy for non–small cell lung cancer (NSCLC).
This was a multi-institutional retrospective review of a ...consecutive series of patients from 4 institutions' prospective robotic databases.
There were 1339 patients (men 55%, median age 68 years). The median operative time was 136 minutes, median number of lymph nodes was 13 (5 N2 stations and 1 N1), median blood loss was 50 cc, and 4 (0.005%) patients received intraoperative transfusions. Conversions occurred in 116 patients (9%) and for bleeding in 24 (2%). Median length of stay was 3 days. Major morbidity occurred in 8%. The 30-day and 90-day operative mortality was 0.2% and 0.5%, respectively. Follow-up was complete in 99% of patients with a median follow-up of 30 months (range 1-154 months). The 5-year stage-specific survival was: 83% for the 672 patients with stage IA NSCLC, 77% for the 281 patients with stage IB, 68% for the 118 patients with stage IIA, 70% for 99 patients with IIB, 62% for 143 patients with stage IIIA (122 had N2 disease, 73%), and 31% for 8 patients with stage IIIB (none had N3 disease). The cumulative incidence of metastatic NSCLC was 15% (128 patients, 95% confidence interval, 13%-18%). The cumulative incidence of local recurrence in the ipsilateral operated chest was 3% only (26 patients, 95% confidence interval, 2%-5%).
The oncologic results of robotic lobectomy for NSCLC are promising, especially for patients with pathologic N2 disease. However, further follow-up and studies are needed.
AbstractObjectiveTo describe outcomes of people admitted to hospital with coronavirus disease 2019 (covid-19) in the United States, and the clinical and laboratory characteristics associated with ...severity of illness.DesignProspective cohort study.SettingSingle academic medical center in New York City and Long Island.Participants5279 patients with laboratory confirmed severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) infection between 1 March 2020 and 8 April 2020. The final date of follow up was 5 May 2020.Main outcome measuresOutcomes were admission to hospital, critical illness (intensive care, mechanical ventilation, discharge to hospice care, or death), and discharge to hospice care or death. Predictors included patient characteristics, medical history, vital signs, and laboratory results. Multivariable logistic regression was conducted to identify risk factors for adverse outcomes, and competing risk survival analysis for mortality.ResultsOf 11 544 people tested for SARS-Cov-2, 5566 (48.2%) were positive. After exclusions, 5279 were included. 2741 of these 5279 (51.9%) were admitted to hospital, of whom 1904 (69.5%) were discharged alive without hospice care and 665 (24.3%) were discharged to hospice care or died. Of 647 (23.6%) patients requiring mechanical ventilation, 391 (60.4%) died and 170 (26.2%) were extubated or discharged. The strongest risk for hospital admission was associated with age, with an odds ratio of >2 for all age groups older than 44 years and 37.9 (95% confidence interval 26.1 to 56.0) for ages 75 years and older. Other risks were heart failure (4.4, 2.6 to 8.0), male sex (2.8, 2.4 to 3.2), chronic kidney disease (2.6, 1.9 to 3.6), and any increase in body mass index (BMI) (eg, for BMI >40: 2.5, 1.8 to 3.4). The strongest risks for critical illness besides age were associated with heart failure (1.9, 1.4 to 2.5), BMI >40 (1.5, 1.0 to 2.2), and male sex (1.5, 1.3 to 1.8). Admission oxygen saturation of <88% (3.7, 2.8 to 4.8), troponin level >1 (4.8, 2.1 to 10.9), C reactive protein level >200 (5.1, 2.8 to 9.2), and D-dimer level >2500 (3.9, 2.6 to 6.0) were, however, more strongly associated with critical illness than age or comorbidities. Risk of critical illness decreased significantly over the study period. Similar associations were found for mortality alone.ConclusionsAge and comorbidities were found to be strong predictors of hospital admission and to a lesser extent of critical illness and mortality in people with covid-19; however, impairment of oxygen on admission and markers of inflammation were most strongly associated with critical illness and mortality. Outcomes seem to be improving over time, potentially suggesting improvements in care.
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