Reconstruction of Oncologic Sternectomy Defects: Lessons Learned from 60 Cases at a Single Institution.

Oncologic sternectomy results in complex defects where preoperative planning is paramount to achieve best reconstructive outcomes. Although pectoralis major muscle flap (PMF) is the workhorse for sternal soft tissue coverage, additional flaps can be required. Our purpose is to evaluate defects in which other flaps beside PMF were required to achieve optimal reconstruction. METHODS: A retrospective review of consecutive patients at our institution who underwent reconstruction after sternal tumor resection was performed. Demographics, surgical characteristics, and outcomes were evaluated. Further analysis was performed to identify defect characteristics where additional flaps to PMF were needed to complete reconstruction. RESULTS: In 11 years, 60 consecutive patients were identified. Mean age was 58 (28-81) years old, with a mean follow-up of 40.6 (12-64) months. The majority were primary sternal tumors (67%) and the mean defect size was 148 cm2 (±81). Fourteen (23%) patients presented with postoperative complications, and the 30-day mortality rate was 1.6%. In 19 (32%) cases, additional flaps were required; the most common being the rectus abdominis muscle flaps. Larger thoracic defects (P = 0.011) and resections involving the inferior sternum (P = 0.021) or the skin (P = 0.011) were more likely to require additional flaps. CONCLUSIONS: Reconstruction of oncologic sternal defects requires a multidisciplinary team approach. Larger thoracic defects, particularly those that involve the skin and the inferior sternum, are more likely to require additional flaps for optimal reconstruction.

Fibrosing mediastinitis: clinical presentation, therapeutic outcomes, and adaptive immune response.

Fibrosing mediastinitis (FM) is a rare disorder characterized by the invasive proliferation of fibrous tissue within the mediastinum. FM frequently results in the compression of vital mediastinal structures and has been associated with substantial morbidity and mortality. Its pathogenesis remains unknown. However, in North America most cases are thought to represent an immune-mediated hypersensitivity response to Histoplasma capsulatum infection. To characterize the clinical disease spectrum, natural disease progression, responses to therapy, and overall survival, we retrospectively analyzed all 80 consecutive patients with a diagnosis of FM evaluated at Mayo Clinic, Rochester, MN, from 1998 to 2007. Furthermore, we characterized the adaptive immune response in 15 representative patients by immunohistochemistry. The majority of patients presented with nonspecific respiratory symptoms due to the compression of mediastinal broncho-vascular structures. Chest radiographic imaging most frequently revealed localized, invasive, and frequently calcified right-sided mediastinal masses. Most patients had radiographic or serologic evidence of previous histoplasmosis. In contrast to earlier reports summarizing previously reported FM cases, the clinical course of our patients appeared to be more benign and less progressive. The overall survival was similar to that of age-matched controls. There were only 5 deaths, 2 of which were attributed to FM. These differences may reflect publication bias associated with the preferential reporting of more severely affected FM patients in the medical literature, as well as the more inclusive case definition used in our consecutive case series. Surgical and nonsurgical interventions effectively relieved symptoms caused by the compression of mediastinal vascular structures in these carefully selected patients. In contrast, antifungal and antiinflammatory agents appeared ineffective. Histologic examination and immunostaining revealed mixed inflammatory infiltrates consistent with a fibroinflammatory tissue response in these histoplasmosis-associated FM cases. The immune cell infiltrates included large numbers of CD20-positive B lymphocytes. As B lymphocytes may contribute to the pathogenesis of the disease, therapeutic B-cell depletion should be investigated as a therapeutic strategy for FM.

Solitary fibrous tumors of the pleura: results of surgical treatment and long-term prognosis.

OBJECTIVE: We sought to define the long-term outcome of surgically treated solitary fibrous tumors of the pleura. METHODS: We performed a retrospective review from December 1972 through December 2002. RESULTS: There were 84 patients (39 men and 45 women) with a median age of 57 years (range, 34-83 years). Forty-six patients were symptomatic. Surgical resection included pulmonary wedge excision in 62 patients, lobectomy in 4 patients, segmentectomy in 2 patients, chest wall resection in 3 patients, isolated pleural resection in 7 patients, and chest wall resection with pulmonary wedge excision, lobectomy, or pneumonectomy in 3, 2, and 1 patients, respectively. Tumors were polypoid in 57 patients, sessile in 20 patients, and intrapulmonary in 7 patients. Histopathology was benign in 73 and malignant in 11 patients. Nine (82%) patient with malignant tumors and 37 (54%) patients with benign tumors were symptomatic (P = .11). The median tumor diameters for malignant and benign tumors were 12.0 and 4.5 cm, respectively (P = .001). Operative mortality and morbidity occurred in 3 (3.6%) and 7 (8.1%) patients, respectively. Median follow-up in survivors was 146 months (range, 23-387 months). Median survival for patients with benign and malignant tumors was 284 and 55 months, respectively, and 5-year survival was 88.9% and 45.5%, respectively (P = .0005). Eight (9.5%) patients had recurrent solitary fibrous tumors of the pleura. Recurrences were malignant in 6 and benign in 2 patients. Localized chest recurrences occurred in 3 patients, all of whom had reresection, with 2 patients again having recurrence. CONCLUSION: Resection of benign solitary fibrous tumors of the pleura carries an excellent prognosis. Larger tumors are more likely to be malignant. Both benign and malignant tumors can recur. Although prolonged survival after resection of malignant tumors is possible, recurrence is common.

Patient-centered quality indicators for pulmonary resection.

BACKGROUND: Quality of care is increasingly scrutinized. However, no standard quality measures exist for surgical care of patients undergoing pulmonary resection. METHODS: Our thoracic surgical team developed a set of patient-centered quality of care measures specific to patients undergoing pulmonary resection. Measures were chosen that demonstrated evidence-based preoperative assessment, adequate mediastinal staging, and interventions to prevent and expeditiously treat postoperative morbidity. Medical records of all patients undergoing pulmonary resection in 2005 were analyzed. RESULTS: In all, 606 patients (men:women = 330:276) underwent 628 pulmonary resections. Median age was 65.8 years (range, 2 to 93). Operative mortality was 2.1%. Pulmonary function testing within 1 year before surgery was documented in 74.2%. Electrocardiogram within 90 days before surgery was documented in 81.6% of patients 50 years and older. Smoking history was documented in all patients, and smoking cessation consultation was offered to 85.7% of current smokers. Deep venous thrombosis prophylaxis was implemented in 99.7%. Mediastinal staging was documented in 94.0% of patients undergoing lung cancer resection (n = 333). Postoperatively, 92.4% of patients used incentive spirometry. Atrial fibrillation treatment occurred within 45 minutes of onset in 70.5%. Postoperative analog pain scores were above 6 in only 7.4% of assessments; treatment and reassessment occurred within 2 hours in 81.0%. Follow-up planning was documented at hospital discharge in 100%. No National Quality Forum "never events" occurred. CONCLUSIONS: Patient-centered and clinically relevant quality measures can be developed and evaluated in general thoracic surgery. This panel of quality indicators highlights and guide areas for potential improvement in the care of patients undergoing pulmonary resection.

Combined transabdominal gastroplasty and fundoplication for shortened esophagus: impact on reflux-related and overall quality of life.

BACKGROUND: Transabdominal gastroplasty for shortened esophagus at the time of fundoplication results in a segment of aperistaltic, acid-secreting neoesophagus above the fundoplication. We hypothesized that transabdominal gastroplasty impairs quality of life (QOL). METHODS: This was a matched paired analysis with retrospective chart review and follow-up questionnaire of 116 patients undergoing transabdominal fundoplication with gastroplasty with 116 matched controls undergoing transabdominal fundoplication alone from January 1997 to June 2005. Medical Outcomes Study Short-Form 36-Item Health Survey (SF-36) and Quality Of Life in Reflux And Dyspepsia (QOLRAD) instruments were used to measure overall and reflux-related QOL. Overall response rate was 75%; including 65 matched pairs used for long-term follow-up and QOL analysis. RESULTS: Groups were similar in age, sex, duration of hospitalization, and complications (p > 0.05). Gastroplasty patients had larger hiatal hernias and were more likely to have undergone a previous fundoplication (p < 0.01). No perioperative deaths or major morbidity occurred in 18% of both groups. Survey respondents were older than nonrespondents (p < 0.01). Complications did not impact response rates (p = 0.11). Median follow-up was 14 months in the gastroplasty group and 17 months in controls (p = 0.02). The groups had similar scores on the SF-36 and QOLRAD (p > 0.05) and similar overall frequency of patient satisfaction, perceived health status, and self-reported symptoms of reflux, dysphagia, bloating, diarrhea, and excessive flatus (p > 0.05). Control patients were more likely to require rehospitalization or reinterventions (p = 0.04). CONCLUSIONS: Transabdominal gastroplasty and fundoplication for shortened esophagus is safe and results in similar overall and reflux-related QOL compared with fundoplication alone.

Malignant pleural mesothelioma: surgical management in 285 patients.

BACKGROUND: Malignant pleural mesothelioma is a rare, aggressive, and deadly malignancy. Despite increasing incidence, no treatment modality is accepted standard of care. This report analyzes our experience with surgical management of mesothelioma. METHODS: All patients with surgery for mesothelioma from January 1985 through December 2003 were retrospectively reviewed. RESULTS: There were 285 patients with a median age of 66 years (range, 26 to 91 years). One hundred forty-six patients (51%) had biopsy only, 73 (26%) had extrapleural pneumonectomy, 34 (12%) had subtotal parietal pleurectomy, 22 (8%) underwent exploration without resection, and 10 (3%) had total pleurectomy. Histopathology was epithelial, nonepithelial, and unclassified in 134, 108, and 43 patients, respectively. Twenty patients were stage IA, 82 patients were stage IB, 24 patients were stage II, 75 patients were stage III, 60 patients were stage IV, and 24 patients were of unknown stage. Fifty-three patients (19%) had chemotherapy alone, 16 (5.6%) had radiation alone, and 42 (14.7%) had both. Thirty-day operative mortality was 6.3% and was not significantly associated with the operative procedure (p = 0.79). Fifty-one percent of extrapleural pneumonectomy patients had major complications, significantly greater than patients having any other procedure (p < 0.001). Median follow-up was 11 months (range, 0 to 7 years). Overall median survival was 10.7 months; however, for patients having extrapleural pneumonectomy, median survival was 16 months. One-, 2-, and 3-year survival after extrapleural pneumonectomy was 61%, 25%, and 14%, respectively. CONCLUSIONS: Extrapleural pneumonectomy can be performed with similar 30-day mortality as other procedures for malignant pleural mesothelioma with a median survival better than subtotal pleurectomy, exploration without resection, and biopsy alone. However, extrapleural pneumonectomy has significant morbidity and a 3-year survival of only 14%.

Thoracic surgery certification in the United States of America.

As we enter the 21st century, thoracic surgeons can look back with pride and gratitude to their predecessors who placed a high premium on clinical practice and certification. Thoracic surgery, however, is dynamic, not static. So, too, should be thoracic surgery recertification. In recent years, considerable effort has been expended to move thoracic surgery recertification from a 10-year reexamination cycle to a dynamic, multiyear cycle in an effort to ensure the public that board-certified thoracic surgeons remain current with evolving knowledge and technology. It is in this milieu that Maintenance of Certification (American Board of Medical Specialties, Evanston, Illinois) has evolved.

Lung cancer in octogenarians: factors affecting long-term survival following resection.

OBJECTIVE: To identify factors associated with long-term survival following pulmonary resection for lung cancer in patients 80 years of age or older. METHODS: The medical records of all patients >or=80 years, who underwent pulmonary resection for lung cancer from 1985 to 2002, were reviewed. RESULTS: There were 294 patients (192 men, 102 women). Median age was 82 years (range 80-94 years). Overall 1-, 2-, and 5-year survival was 80%, 62%, and 34%, respectively. Histologic subtype, diabetes, renal insufficiency, prior myocardial infarction, congestive heart failure or stroke were not significantly associated with differences in 5-year survival. Female gender was associated with increased survival (36.2% vs 32.7% at 5 years, p=0.04). Extent of preoperative forced expiratory volume in 1s (FEV1) limitation did not influence survival. However, there were no 5-year survivors amongst patients with dyspnea as their presenting chief complaint, whereas there was a 35% 5-year survival in patients presenting without dyspnea (p<0.001). Five-year survival by pathologic stage was IA, 48%; IB, 39%; IIA, 17%; IIB, 23%; IIIA, 9%; and IIIB, 0% (p<0.001). Five-year survival of patients undergoing a lobectomy was 42% versus 11% for pneumonectomy (p<0.001). CONCLUSIONS: Meaningful long-term survival is obtainable in elderly patients undergoing surgical resection for lung cancer. Careful patient evaluation and selection is necessary to identify patients who will benefit most from resection. Shorter survival was observed in male patients and those presenting with dyspnea. As could be expected, survival was also dependent on extent of resection and initial pathologic stage.

The influence of transabdominal gastroplasty: early outcomes of hiatal hernia repair.

OBJECTIVE: The aim of our study was to review our experience with transabdominal gastroplasty to determine the safety and short-term efficacy of the procedure. METHODS: Retrospective review of all patients that underwent transabdominal hiatal hernia repair with concurrent gastroplasty for shortened esophagus between October 1999 and May 2004. RESULTS: There were 63 patients, 27 men and 36 women. Median age was 68 years. The hiatal hernia was classified as type-I in 6 patients, type-II in 10, type-III in 43, and type-IV in 4. The operative approach was laparoscopic in 44 patients and laparotomy in 19. A Nissen fundoplication was performed in 62 patients and a Toupet fundoplication in 1. Wedge gastroplasty was performed in 47 patients and modified Collis gastroplasty in 16. Median hospitalization was 3 days (range, 2-10). Intraoperative complications occurred in 11 patients (17%). One laparoscopic approach (2%) was converted to laparotomy. Postoperative complications occurred in 12 patients (19%), there were no operative deaths. Median follow-up was 12 months (range, 0 to 64). One patient (2%) was found to have a recurrent hiatal hernia diagnosed 14 months, postoperatively. Functional results were excellent in 41 (68%), good in 6 (10%), fair in 12 (20%), and poor in 1 (2%). CONCLUSION: Transabdominal gastroplasty can be performed safely, with good functional results and a low incidence of recurrent herniation during the short-term follow-up period.

Survival after recurrent nonsmall-cell lung cancer after complete pulmonary resection.

BACKGROUND: Survival characteristics of patients who have recurrent nonsmall-cell lung cancer after surgical resection are not well understood. Little objective evidence exists to justify treatment for these patients. METHODS: We prospectively followed 1,361 consecutive patients with nonsmall-cell lung cancer who underwent complete surgical resection at our institution from January 1997 to December 2001. Only patients having recurrent cancer were included in the analysis. Multivariable Cox proportional hazards models were used to evaluate the effect of prognostic factors on postrecurrence survival. RESULTS: Follow-up was achieved in 1,073 patients, and recurrent cancer developed in 445. Complete information was available on 390 patients for analysis. There were 262 men and 128 women. Median age at time of recurrence was 69 years. Median time from surgical resection to recurrence was 11.5 months, and median postrecurrence survival was 8.1 months. Recurrence was intrathoracic in 171 patients, extrathoracic in 172, and a combination of both in 47. Treatments after recurrence included surgery in 43 patients, chemotherapy in 59, radiation in 73, and a combination in 96. All patients who received treatment survived longer than those who received no treatment. Preoperative chemotherapy and postoperative radiotherapy for the primary lung cancer, poor Eastern Cooperative Oncology Group Performance Status, decreased disease-free interval from initial resection to recurrence, symptoms at recurrence, and certain location of recurrence significantly decreased postrecurrence survival. CONCLUSIONS: In our experience, treatment for recurrent nonsmall-cell lung cancer significantly prolongs survival. Various treatment modalities including surgery should be considered in patients with postoperative recurrent nonsmall-cell lung cancer.

Conventional resection of pulmonary metastases.

We present an overview of surgical technique for the resection of secondary tumor metastases to the lungs. Issues addressed include the optimal surgical approach, the requirement to remove all lesions while preserving unaffected lung parenchyma and the advantages of the available surgical staplers and devices. In selected patients, resection of metastatic lesions to the lung or chest wall offers a survival benefit. Although pulmonary metastases without further tumor spread may represent unique host or tumor biology, approximately 40% of patients survive 5 years. As it is not uncommon to repeat metastasectomy, consideration of technical aspects is important.

Lung cancer in octogenarians: factors affecting morbidity and mortality after pulmonary resection.

BACKGROUND: Predictors of morbidity and mortality after pulmonary resection for lung cancer in patients 80 years of age or older are unknown. METHODS: The medical records of all patients 80 years of age or older who had pulmonary resection for lung cancer from January 1985 through September 2004 were reviewed. RESULTS: There were 379 patients (248 men, 131 women). Median age was 82 years (range, 80 to 95 years). Pneumonectomy was performed in 25 patients (6.6%), bilobectomy in 7 (1.8%), lobectomy in 240 (63.3%), segmentectomy in 29 (7.7%), and wedge excision in 78 (20.6%). The cancer was squamous cell carcinoma in 143 patients (37.7%), adenocarcinoma in 166 (43.8%), bronchoalveolar cell carcinoma in 47 (12.4%), and other in 23 (6.1%). Complications occurred in 182 patients (48.0%). These included atrial fibrillation in 75 patients, pneumonia in 27, and retained secretions requiring bronchoscopy in 37. Morbidity predictors were male sex (odds ratio [OR], 1.6), hemoptysis (OR, 2.3), and previous stroke (OR, 3.8). Asymptomatic patients had a significantly decreased probability of complications (OR, 0.56). Operative mortality was 6.3% (24 of 379); significant predictors were congestive heart failure (OR, 6.0) and prior myocardial infarction (OR, 4.3). Factors not associated with mortality included previous myocardial revascularization, renal insufficiency (creatinine >1.5 mg/dL), and diabetes mellitus. CONCLUSIONS: Pulmonary resection for lung cancer in octogenarians is feasible. Congestive heart failure and myocardial infarction, however, correlated with a significant increase in mortality. Prior myocardial revascularization, renal insufficiency, and diabetes were not associated with increased morbidity and mortality.

Surgical treatment of tumors of the proximal stomach with involvement of the distal esophagus: a 26-year experience with Siewert type III tumors.

OBJECTIVE: A paucity of outcome data exists regarding patients with proximal stomach cancer involving the distal esophagus (Siewert type III tumors). This is especially true with regard to long-term survival rates after surgical intervention. METHODS: Medical records were reviewed of all patients who underwent total gastrectomy and distal esophagectomy with Roux-en-Y esophagojejunostomy for Siewert type III tumors from January 1975 through December 2000. RESULTS: There were 116 patients (93 men and 23 women). The median age was 66 years (range, 22-87 years). Pathologic stage was 0 (carcinoma in situ) in 1 patient, IB in 13 patients, II in 17 patients, IIIA in 34 patients, IIIB in 10 patients, and IV in 41 patients. Complete resection was achieved in 69 (59.5%) patients. Eleven (9.5%) patients were treated with neoadjuvant therapy, 49 (42.2%) received adjuvant therapy, and 6 (5.2%) received intraoperative radiation. Follow-up was complete in 114 (98.3%) patients, ranging from 1 to 281 months (median, 14 months). Operative mortality was 5.2%. Complications occurred in 51 (43.9%) patients. Clinically significant anastomotic leaks occurred in 15 (12.9%) patients. Median hospitalization was 13 days (range, 8-70 days). Median follow-up was 14 months (range, 1-281 months). Overall median survival was 434 days, with 1-, 5-, and 10-year survivals of 56.2%, 19.0%, and 13.5%, respectively. The only factor associated with increased hospital mortality was anastomotic leakage (P = .002). Incomplete resection, increased tumor stage and grade, and splenic involvement significantly worsened long-term survival. CONCLUSIONS: Total gastrectomy and distal esophagectomy for Siewert type III tumors is associated with reasonable mortality and significant morbidity. Although often palliative, surgical intervention can provide long-term survival, especially in patients with completely resected, early-stage, low-grade tumors.

Completely resected N1 non-small cell lung cancer: factors affecting recurrence and long-term survival.

OBJECTIVE: N1 disease in non-small cell lung cancer represents a heterogeneous patient subgroup with a 5-year survival of approximately 40%. Few reports have evaluated the correlation between N1 disease and tumor recurrence or which subgroup of patients would most benefit from adjuvant chemotherapy. METHODS: From 1997 through 2002, all patients with pathologic T1-4 N1 M0 non-small cell lung cancer who had a complete resection with systematic mediastinal lymphadenectomy were retrospectively analyzed and evaluated for factors associated with recurrence and long-term survival. RESULTS: One hundred eighty patients with N1 disease were evaluated. Sixty-six (37%) patients had either locoregional recurrence (n = 39 [22%]), distant metastasis (n = 41 [23%]), or both during follow-up. Univariate analysis demonstrated that visceral pleural invasion and age were associated with locoregional recurrence, whereas visceral pleural invasion, distinct N1 metastasis (as opposed to direct N1 invasion by the primary tumor), and multistation lymph node involvement were associated with distant metastasis (P < .05). Multivariable analysis demonstrated that visceral pleural invasion, multistation N1 involvement, and distinct N1 metastasis were the only independent predisposing factors for locoregional recurrence and distant metastasis. Overall 5-year survival was 42.5%. Survival was significantly decreased by advanced pathologic T classification (P = .015), visceral pleural invasion (P < .0001), and higher tumor grade (P = .014). CONCLUSIONS: In patients with N1-positive non-small cell lung cancer, visceral pleural invasion, multistation N1 disease, and distinct N1 metastasis are independent predictors of subsequent locoregional recurrence and distant metastasis. Advanced T classification, visceral pleural invasion, and higher tumor grade were predictors of poor survival. These patients represent a subgroup of patients with N1 disease who might benefit from additional therapy, including adjuvant chemotherapy.

Postpneumonectomy empyema: results after the Clagett procedure.

BACKGROUND: The purpose of this study was to analyze our experience with the management of patients with postpneumonectomy empyema treated by the Clagett procedure. METHODS: Data were analyzed from our prospective database on 84 consecutive patients with postpneumonectomy empyema from July 1988 to June 2004. RESULTS: There were 73 men and 11 women. Median age was 62 years (range, 35 to 77). Indications for pneumonectomy were malignancy in 77 patients and benign disease in 7. The pneumonectomy was done at our institution in 43 patients and elsewhere in 41. A right pneumonectomy was performed in 66 patients and a left in 18. All patients were managed with the Clagett procedure consisting of open pleural drainage, serial operative debridements, and eventual chest closure after filling the pleural cavity with antibiotic solution. A bronchopleural fistula was present in 55 patients and was closed in all. A muscle flap was used to reinforce the bronchial stump in 60 patients (71%), 51 with a bronchopleural fistula, and 9 without. Operative mortality was 7.1%. Median follow-up was 1.5 years (range, 0 to 22). Overall, 81% of patients had a healed chest wall without evidence of recurrent infection. The bronchopleural fistula remained closed in all patients. Median overall survival was 3.4 years with a 5-year survival of 44.5%. Age less than 65 years and an interval between pneumonectomy and empyema of greater than 15 weeks were independent predictors of improved long-term survival. CONCLUSIONS: The Clagett procedure remains safe and successful in the majority of patients with postpneumonectomy empyema. Age less than 65 years and a long interval between pneumonectomy and empyema are important determinants of outcome.

The role of pulmonary resection in small cell lung cancer.

OBJECTIVE: To analyze the outcome of surgical resection for patients with small cell lung cancer (SCLC). PATIENTS AND METHODS: We identified all patients who underwent thoracotomy for SCLC at our institution from January 1985 to July 2002. All patients were staged using the American Joint Committee on Cancer TNM system. RESULTS: The median age of the 77 patients (44 men and 33 women) was 65 years (range, 35-85 years). Operations performed included thoracotomy with biopsy of hilar mass in 10 patients, wedge excision in 30 (6 with talc pleurodesis), segmentectomy in 4, lobectomy in 28, bilobectomy in 3, and pneumonectomy in 2. Mediastinal lymphadenectomy was performed in 50 patients and lymph node sampling in 19. Postoperative therapy Included chemotherapy alone in 20 patients, radiation therapy in 3, and combined chemotherapy and radiation therapy in 40. Median tumor diameter was 4 cm (range, 1.0-10.0 cm). Postsurgical tumor stage was IA in 7 patients, IB in 11, IIA in 8, IIB in 7, IIIA in 30, IIIB in 10, and IV in 4. A total of 19 patients (25%) had complications: atrial arrhythmia in 7 patients, pneumonia in 6, prolonged air leak in 3, and myocardial infarction, postoperative bleeding, and cerebrovascular accident in 1 each. Operative mortality was 3% (2/77). Follow-up ranged from 4 days to 170 months (median, 19 months). At last follow-up, 20 patients were alive. The estimated overall 5-year survival was 27% when excluding the 10 patients who underwent a biopsy without additional surgery. Five-year survival for stage I and II combined (n=33) was 38% compared with only 16% for stage III and IV combined (n=34) (P=.02). Overall median survival was 24 months; median survival for patients who underwent curative surgery was 25 months compared with 16 months for those who had a palliative procedure (P=.34). CONCLUSION: Pulmonary resection in patients with stage I or stage II SCLC is safe with low mortality and morbidity. Curative resection is associated with long-term survival in early stage SCLC in some patients and should be considered in selected patients.

Gynecologic cancers: factors affecting survival after pulmonary metastasectomy.

BACKGROUND: Little information is available regarding long-term survival after pulmonary metastasectomy for gynecologic malignancies. METHODS: All patients who underwent pulmonary resection for gynecologic malignancies at our institution between January 1985 and June 2001 were reviewed. Factors affecting long-term survival were analyzed. RESULTS: There were 103 patients, 70 of whom had metastatic disease limited to the lungs. Median age of these 70 patients was 59.4 years (range, 31 to 80 years). The primary tumor originated in the uterine corpus in 37 patients, endometrium in 23, cervix in 7, ovaries in 2, and vagina in 1. Histopathology was leiomyosarcoma in 29 patients, adenocarcinoma in 23, other sarcoma in 11, squamous cell carcinoma in 5, and choriocarcinoma and endolymphatic stromal myosis in 1 each. The median time interval between the first gynecologic procedure and pulmonary resection was 24 months (range, 0 to 237 months). A wedge excision was performed in 44 patients, lobectomy in 14, bilobectomy in 2, pneumonectomy in 1, and a combination in 9. Five patients (7%) had an incomplete resection. Eighteen patients (25.7%) developed at least one complication and 1 died (operative mortality, 1.4%). At last follow-up, 35 had died, and the median follow-up among those who were still alive was 36 months (range, 6 months to 13 years). Five-year and 10-year survival was 46.8% (95% confidence interval, 34.2% to 63.0%) and 34.3% (95% confidence interval, 19.7% to 52.5%), respectively. Factors that adversely affected survival include a disease-free interval between the first gynecologic procedure and pulmonary resection of less than 24 months (p = 0.004) and a primary site located in the cervix (p < 0.001). CONCLUSIONS: Pulmonary resection for metastatic gynecologic cancer in selected patients is safe and effective. Both a short disease-free interval between the primary gynecologic procedure and pulmonary metastasectomy, and a primary cervical tumor had an adverse effect on survival.

Failed antireflux surgery: results after reoperation.

BACKGROUND: Since laparoscopy has become a common surgical approach for antireflux surgery, little is known regarding reoperation for failed antireflux surgery. METHODS: Records of all patients who underwent reoperation without esophageal resection for symptoms of recurrent gastroesophageal reflux disease or hiatal hernia between July 1, 1995 and April 1, 2004 were reviewed. There were 126 patients. Two patients declined research participation. The remaining 124 patients (71 women and 53 men) formed the basis for this study. Median age was 53 years (range, 19 to 83 years). The initial operation was a laparoscopic antireflux procedure in 76 patients (61.3%) and an open repair in 48 (38.7%). A single previous operation had been done in 100 patients, two operations in 20, and three operations in 4. The median interval between the most recent reoperation and the previous operation was 28 months. All patients were symptomatic. The surgical approach was a thoracotomy in 83 patients, laparotomy in 36, laparoscopy in 4, and thoracoabdominal in 1. A Nissen fundoplication was performed in 86 patients (69.4%), Belsey fundoplication in 31(25.0%), and others in 7. RESULTS: There were no operative deaths. Complications occurred in 27 patients (21.7%). Median hospitalization was 6 days (range, 5 to 58 days). Follow-up ranged from 10 days to 10 years (median, 9.7 months). Improvement was observed in 114 patients (91.9%). Functional results were classified as excellent in 69 patients (55.6%), good in 19 (15.4%), fair in 26 (20.9%), and poor in 10 (8.1%). No single operative approach was functionally superior. CONCLUSIONS: We conclude that reoperation for failed antireflux surgery is safe and effective. Results of reoperation were not affected by the type of reoperation or whether the previous approach was laparoscopic or open.

Predicting postrecurrence survival among completely resected nonsmall-cell lung cancer patients.

BACKGROUND: Survival after recurrence subsequent to complete resection of nonsmall-cell lung cancer (NSCLC) has been considered a multifactorial process dependent on demographic, clinical, biological, and treatment characteristics. This study sought to quantify the prognostic effects of these characteristics on postrecurrence survival. METHODS: Three hundred ninety NSCLC patients who underwent complete resection and subsequently had recurrent cancer were studied. The associations between characteristics of both the initial and recurrent disease with postrecurrence survival were evaluated by Cox proportional hazards models. A multivariable Cox model determined those factors most strongly associated with postrecurrence survival . A simple algorithm based on this model facilitates estimating risk of postrecurrence mortality, as quantified by risk score points. RESULTS: The factors most strongly associated with postrecurrence survival were performance status at recurrence (3 or 4, 4.2 points; 2, 2.8 points; and 1, 1.5 points), symptoms at recurrence (3.6 points), liver recurrence (2.3 points), initial lung cancer stage IIB or worse (1.8 points), and multiple recurrences (1.0 points). Based on these factors, patients were stratified as low risk (4.0 or fewer total points), moderate-low risk (4.1 to 6.1 points), moderate-high risk (6.1 to 8.0 points), and high risk (more than 8.0 points), with 12-month survival of 75%, 51%, 25%, and 9%, respectively. Postrecurrence survival was significantly different across groups (p < 0.01). CONCLUSIONS: The proposed prediction instrument offers clinicians a succinct tool for rapidly evaluating mortality risk after recurrence. The characteristics comprising this instrument can be easily ascertained and measured, making it of potential clinical value.

Esophagogastrectomy: the influence of stapled versus hand-sewn anastomosis on outcome.

Successful anastomosis is essential for favorable esophagogastrectomy outcomes. Before July 2002, almost all esophagogastric anastomoses at our institution were hand-sewn. We then began using linear stapled anastomotic techniques. This review compares patient outcomes with both techniques. From July 2001 to June 2004, 280 consecutive esophagogastrectomy patients (235 men and 45 women) were reviewed (median age, 65 years). The anastomosis was intrathoracic in 206 patients (74%) and cervical in 74 (26%). Anastomoses were hand-sewn in 205 patients (73%) and linear stapled in 75 (27%). Stapled anastomoses were intrathoracic in 33 patients (16%) and cervical in 42 (57%). Anastomotic leaks occurred in 30 patients (11%); 26 (12.7%) in the hand-sewn and 4 (5.3%) in the linear stapled group (P = .008). Leaks were asymptomatic in 17 patients (57%). Dilatation was required in 70 hand-sewn anastomoses (34%) and in 11 stapled (14.6%) (P = .001). Hand-sewn anastomoses were more likely to leak and require dilatation; odds ratios and 95% confidence intervals were 5.35 (1.67-19.27) and 3.58 (1.66-8.34), respectively. A linear stapled anastomosis is safe and associated with both a significantly lower leak rate and the need for dilatation compared with hand-sewn anastomosis. This nonrandomized series suggests that linear stapled anastomosis is the preferred technique regardless of anastomotic location.