Lobectomy in octogenarians with non-small cell lung cancer: ramifications of increasing life expectancy and the benefits of minimally invasive surgery.

BACKGROUND: As the population ages, clinicians are increasingly confronted with octogenarians with resectable non-small cell lung cancer (NSCLC). We reviewed the outcomes of octogenarians who underwent lobectomy for NSCLC by video-assisted thoracic surgery (VATS) versus open thoracotomy, to determine if there was a benefit to the VATS approach in this group. METHODS: We conducted a retrospective single-institution review of patients age 80 years or greater who underwent a lobectomy for NSCLC from 1998 to 2009. Outcomes including complication rates, length of stay, disposition, and long-term survival were analyzed. RESULTS: One hundred twenty-one octogenarians underwent lobectomy: 40 VATS and 81 through open thoracotomy. Compared with thoracotomy, VATS patients had fewer complications (35.0% vs 63.0%, p = 0.004), shorter length of stay (5 vs 6 days, p = 0.001), and were less likely to require admission to the intensive care unit (2.5% vs 14.8%, p = 0.038) or rehabilitation after discharge (5% vs 22.5%, p = 0.015). In multivariate analysis, VATS was an independent predictor of reduced complications (odds ratio, 0.35; 95% confidence interval, 0.15 to 0.84; p = 0.019). Survival comparisons demonstrated no significant difference between the two techniques, either in univariate analysis of stage I patients (5-year VATS, 76.0%; thoracotomy, 65.3%; p = 0.111) or multivariate analysis of the entire cohort (adjusted hazard ratio, 0.59; 95% confidence interval, 0.27 to 1.28; p = 0.183). CONCLUSIONS: Octogenarians with NSCLC can undergo resection with low mortality and survival among stage I patients, which is comparable with the general lung cancer population. The VATS approach to resection reduces morbidity in this age demographic, resulting in shorter, less intensive hospitalization, and less frequent need for postoperative rehabilitation.

Prevalence, outcomes, and a risk-benefit analysis of diaphragmatic hernia admissions: an examination of the National Inpatient Sample database.

OBJECTIVE: Current practice is to repair uncomplicated diaphragmatic hernias (UDHs) to avoid complications such as obstruction or gangrene. However, practice patterns are based on limited data. We analyzed the National Inpatient Sample to compare outcomes of patients with obstructed (ODH) or gangrenous (GDH) diaphragmatic hernias and those who underwent repair of UDHs to perform a risk-benefit analysis of observation versus elective repair. PATIENTS AND METHODS: We queried the National Inpatient Sample for hospitalized patients who underwent a UDH repair as the principal procedure during their admission. To this repair group, we compared the outcomes of those patients who had a diagnosis of GDH or ODH. A risk-benefit analysis of observation versus elective repair was performed based on these data. RESULTS: Over a 10-year period, 193,554 admissions for the diagnosis of diaphragmatic hernia were identified. A UDH was the diagnosis in 161,777 (83.6%) admissions with 38,764 (24.0%) admissions for elective repair. ODH or GDH was the reason for admission in 31,127 (16.1%) and 651 (0.3%), respectively. Compared with patients who underwent elective repair, mortality was higher in patients with ODH or GDH (1% vs 4.5%; P < .001; and 1% vs 27.5%; P < .001). Risk-benefit analysis suggested a small but real benefit to elective repair in patients aged 50 to 70 years or if the operative mortality is 1% or less. CONCLUSIONS: Elective UDH repair is associated with better outcomes than admissions for ODH or GDH with a favorable risk-benefit profile than observation if the operative mortality is low.

Predictors of recurrence and disease-free survival in patients with completely resected esophageal carcinoma.

OBJECTIVE: The goal of this study was to analyze factors predictive of recurrence and disease-free survival in patients with completely resected esophageal carcinoma. METHODS: We conducted a retrospective review of a prospective database to identify patients with completely resected esophageal carcinoma. Medical records were reviewed. Recurrence rates, time to recurrence, and disease-free survival were analyzed. The Kaplan-Meier method was used for time to event estimation, and multivariate Cox regression models were constructed to analyze factors thought to be significant in determining both freedom from recurrence and disease-free survival. RESULTS: From 1988 to 2009, 465 of 500 patients underwent complete resection for esophageal carcinoma. Median follow-up for living patients was 49 months; 197 patients (42.4%) had recurrence, leading to 175 patients dying of cancer and 22 patients living with recurrent disease. Multivariate regression adjusted for P stage identified the following variables as independent predictors of freedom from recurrence: performance status greater than 0 (hazard ratio [HR], 1.84; 95 confidence interval [CI], 1.35-2.49]; P < .001), poor differentiation (HR, 1.50; CI, 1.12-2.01; P = .006), induction therapy (HR, 1.65; CI, 1.21-2.25]; P = .002), en bloc resection (HR, 0.61; CI, 0.43-0.88; P = .007), and advanced pathologic stages (II/III/IV) (HR, 5.46; CI, 3.05-9.78; P < .001). Independent predictors of disease-free survival adjusted for P stage were performance status greater than 0 (HR, 1.73; CI, 1.34-2.23; P < .001), en bloc resection (HR, 0.63; CI, 0.47-0.84; P = .002), induction therapy (HR, 1.34; CI, 1.02-1.76; P = .033), and advanced pathologic stages (II/III/IV) (HR, 3.16; CI, 2.15-4.65; P < .001). CONCLUSIONS: For patients with completely resected esophageal cancer, independent predictors of improved freedom from recurrence and disease-free survival include good performance status, en bloc resection, and early pathologic stage.