Transcervical Mediastinoscopic Closure of Left-Sided Postpneumonectomy Bronchial Stump Fistula.

INTRODUCTION: This article presents a series of patients on which the transcervical approach was used to close a left-sided postpneumonectomy fistula. MATERIALS AND METHODS: The series comprises nine patients with a left pneumonectomy performed for a tuberculosis-related suppurative disease in five cases and for lung cancer in the remaining four. This procedure can be performed under certain conditions, the most important one being the length of the bronchial stump, which should be at least 1 cm, ideally 1.5 cm. The transcervical stump closure was successfully achieved in all patients, having been more technically demanding in cancer cases with previous lymphadenectomy. The postpneumonectomy infected cavity was subsequently treated. RESULTS: The follow-up continued for at least 1 year; one individual from the cancer patients group died from an uncontrolled sepsis during the postoperative period, another one died 17 months later from metastatic cancer and two of them are alive, with no signs of neoplastic or infectious relapse 15 and 37 months, respectively, after the cervical procedure. One patient from the suppurative disease group had a relapse of the fistula 2 months after surgery, requiring additional surgical procedures to deal with this issue; all the other patients are alive, with no signs of recurrence. CONCLUSIONS: The transcervical approach is a very suitable maneuver in selected patients with a bronchial stump at least 1 cm long, ideally 1.5 cm.

Evolution in the Surgical Care of Patients With Non-Small Cell Lung Cancer in the Mid-South Quality of Surgical Resection Cohort.

Surgery is the most important curative treatment modality for patients with early-stage non-small cell lung cancer (NSCLC). We examined the pattern of surgical resection for NSCLC in a high incidence and mortality region of the United States over a 10-year period (2004-2013) in the context of a regional surgical quality improvement initiative. We abstracted patient-level data on all resections at 11 hospitals in 4 contiguous Dartmouth Hospital Referral Regions in North Mississippi, East Arkansas, and West Tennessee. Surgical quality measures focused on intraoperative practice, with emphasis on pathologic nodal staging. We used descriptive statistics and trend analyses to assess changes in practice over time. To measure the effect of an ongoing regional quality improvement intervention with a lymph node specimen collection kit, we used period effect analysis to compare trends between the preintervention and postintervention periods. Of 2566 patients, 18% had no preoperative biopsy, only 15% had a preoperative invasive staging test, and 11% underwent mediastinoscopy. The rate of resections with no mediastinal lymph nodes examined decreased from 48%-32% (P < 0.0001), whereas the rate of resections examining 3 or more mediastinal stations increased from 5%-49% (P < 0.0001). There was a significant period effect in the increase in the number of N1, mediastinal, and total lymph nodes examined (all P < 0.0001). A quality improvement intervention including a lymph node specimen collection kit shows early signs of having a significant positive effect on pathologic nodal examination in this population-based cohort. However, gaps in surgical quality remain.

Mediastinoscopy-assisted oesophagectomy in T1 oesophageal cancer patients with serious comorbidities: a 5-year long-term follow-up.

OBJECTIVES: Transthoracic oesophagectomy is associated with high morbidity and mortality. Some oesophageal cancer (OC) patients with serious comorbidities cannot tolerate transthoracic oesophagectomy. Therefore, we have adopted a minimally invasive approach to oesophagectomy for such patients. METHODS: Eighty-five OC patients, who could not tolerate transthoracic oesophagectomy, received mediastinoscopy-assisted oesophagectomy (MAO) from January 2007 to January 2010 in our hospital. Seventy patients were confirmed to be in T1 stage by postoperative pathological diagnosis, and their complications and outcomes were retrospectively analysed in this study. The impact of invasion depth, tumour length and lymph node metastases on the 5-year survival rate of these patients was also analysed. RESULTS: The operation time was 150.0 ± 15.0 min, and the perioperative bleeding volume was 202.0 ± 12.8 ml. Some patients had anastomotic leakage (5 cases), pneumonia (4 cases) and chylothorax (1 case). No patient died during hospitalization. The median postoperative hospital stay was 10 (7-22) days. The number of lymph nodes resected was 13.8 ± 4.4. The overall 5-year survival rate was 71%. Kaplan-Meier estimates revealed that tumour length (<2 vs ≥ 2 cm), lymph node metastasis (N0 vs N1) and depth of invasion (T1a vs T1b) could influence the 5-year survival rate (P <0.05). Multivariate analysis by Cox regression showed that lymph node metastasis and tumour length were independent prognostic factors for the 5-year survival rate (P <0.05). CONCLUSIONS: MAO could be performed for T1 OC patients with serious comorbidities who cannot tolerate transthoracic oesophagectomy. Lymph node metastasis and tumour length were independent prognostic factors for these patients.

Outcomes and efficacy of thoracic surgery biopsy for tumor molecular profiling in patients with advanced lung cancer.

BACKGROUND: Molecular testing of patients with advanced non-small cell lung cancer for personalized therapy often is limited by insufficient specimen from nonsurgical biopsies. We measured the feasibility, patient safety, and clinical impact of thoracic surgical tumor biopsy in patients with stage IV non-small cell lung cancer. METHODS: This is a single institution retrospective analysis. Patients with stage IV non-small cell lung cancer undergoing elective surgical tissue biopsy for molecular analysis were evaluated from March 2011 to November 2012. Perioperative specific variables were measured. RESULTS: Twenty-five patients with known or suspected stage IV non-small cell lung cancer undergoing surgical biopsy were identified. All cases were discussed at a multidisciplinary thoracic oncology conference or a multidisciplinary thoracic oncology clinic. Preoperative histologies included adenocarcinoma in 20 patients (80.0%) and squamous cell carcinoma in 2 patients (8.0%). Surgical procedures consisted of video-assisted thoracic surgery wedge biopsy (16, 64%), video-assisted thoracic surgery pleural biopsy (4, 16.0%), mediastinoscopy (2, 8.0%), supraclavicular/cervical lymph node excisional biopsy (3, 12.0%), and rib/chest wall resection (2, 8.0%). There were no deaths and 5 postoperative complications (20.0%). Surgery identified potentially targetable molecular information in 19 of the total patients undergoing operation (76.0%) and changed the treatment strategy in 14 patients (56.0%); 10 of the total cohort (40.0%) were enrolled into therapeutic targeted clinical trials. CONCLUSIONS: These data suggest that thoracic surgical biopsy can be safely performed in appropriately selected patients with stage IV non-small cell lung cancer and direct personalized therapy and enrollment into relevant clinical trials. Patients with advanced-stage non-small cell lung cancer should be discussed in a multidisciplinary setting to determine the need and strategy for thoracic surgical biopsy for molecular analysis.

Video-assisted mediastinoscopic lymphadenectomy is associated with better survival than mediastinoscopy in patients with resected non-small cell lung cancer.

OBJECTIVES: We aimed to analyze the accuracy of video-assisted mediastinoscopic lymphadenectomy (VAMLA) as a tool for preoperative staging and the impact of the technique on survival in patients with non-small cell lung cancer (NSCLC) undergoing pulmonary resection. METHODS: Between May 2006 and December 2010, 433 patients underwent pulmonary resection for NSCLC, 89 (21%) had VAMLA before resection and 344 (79%) had standard mediastinoscopy. The patients who had negative VAMLA/mediastinoscopy results underwent anatomic pulmonary resection and systematic lymph node dissection. RESULTS: The median and mean numbers of resected lymph node stations were 5 and 4.9 in the VAMLA group and 4 and 4.2 in the mediastinoscopy group (P = .9). The mean number of lymph nodes per biopsy specimen using standard mediastinoscopy was 10.1, whereas it was 30.4 using VAMLA (P < .001). VAMLA unveiled N2 or N3 disease in 30 (33.7%) and in 6 (6.7%) of patients, respectively. The negative predictive value, sensitivity, false-negative value, and accuracy of VAMLA were statistically higher in the VAMLA groups compared with those of standard mediastinoscopy. The 5-year survival was 90% for VAMLA patients and 66% for mediastinoscopy patients (P = .01). By multivariable analysis, VAMLA was associated with better survival (odds ratio, 1.34; 95% confidence interval, 1.1-3.2; P = .02). CONCLUSIONS: VAMLA was associated with improved survival in NSCLC patients who had resectional surgery.

Minimally invasive esophagectomy for esophageal squamous cell carcinoma: a case-control study of thoracoscope versus mediastinoscope assistance.

OBJECTIVE: Minimally invasive esophagectomy (MIE) has been widely applied for esophageal carcinoma treatment. Thoracoscope-assisted transthoracic esophagectomy (TATTE) and mediastinoscope-assisted transhiatal esophagectomy (MATHE) are two kinds of MIE. The objective of this study is to compare these two methods with respect to surgical safety and survival. METHODS: Single-institution experience with MATHE and TATTE was analyzed to assess morbidity, adequacy of tumor clearance, and survival. A pair-matched case-control study was performed to compare 54 patients who underwent either MATHE or TATTE between July 2000 and December 2009. Patients were matched by age, sex, comorbidity, forced expiratory volume in 1 s (FEV1), tumor location, and stage. RESULTS: Statistically significant differences between the MATHE group and the TATTE group were: shorter operative time for MATHE (194.4 min) versus TATTE (228.1 min), less blood loss during operation in the TATTE group (142.6 ml) versus the MATHE group (214.6 ml), and more lymph nodes retrieved in the TATTE group (19.1 nodes) versus the MATHE group (11.4 nodes). There was no difference in survival between the groups. CONCLUSIONS: MATHE and TATTE are both technically feasible. TATTE can provide better visibility. TATTE has less blood loss compared with MATHE. More adequate tumor clearance in terms of lymph node dissection can be achieved with TATTE.

[Mediastinoscopy in Iceland: indications and surgical outcome]. / Miomaetisspeglanir á Islandi: árangur og ábendingar.

INTRODUCTION: Mediastinoscopy is an important tool for staging lung cancer and evaluating mediastinal pathology. The objective of this retrospective study was to investigate the indications and safety of mediastinoscopy in a well defined cohort of patients. MATERIAL AND METHODS: All patients that underwent mediastinoscopy in Iceland between 1983-2007 were included. Clinical information was obtained from patient charts and pathology reports rewied. The study-period was divided into 5-year periods for comparison. RESULTS: Altogether 278 operations were performed but in 17 cases data was missing, leaving 261 patients for analysis (mean age 59 yrs, range 11-89, 159 males). A steady increase was seen in the number of operations, or from 16 to 85 during the first and last periods, respectively (p<0.01). Staging of lung cancer (61,3%), evaluation of mediastinal tumors (24,5%), and suspected sarcoidosis (8,8%) were the most common indications. Mean operating time was 30 minutes (range 10-320) and median hospital stay 1 day (range 0,5-26). The most common histological diagnosis were nonspecific changes (33,6%), lung cancer (23,8%) and sarcoidosis (12,7%). Seven patients (2.7%) had complications; including 4 (1.5%) with hoarsness due to left recurrent nerve injury, one (0,3%) with pneumothorax and two with >500 ml hemorrhage (1.1%). There were two operative deaths (<30 days), one due to major intraoperative bleeding. CONCLUSIONS: The number of mediastinoscopies is increasing in Iceland, especially as a part of lung cancer staging. Mediastinoscopy is a safe procedure with low mortality and morbidity, where a specific diagnosis is obtained in most cases.

Accuracy and survival of repeat mediastinoscopy after induction therapy for non-small cell lung cancer in a combined series of 104 patients.

OBJECTIVE: Precise restaging of non-small cell lung cancer after induction therapy is of utmost importance. Remediastinoscopy remains a controversial procedure. In a combined, updated series of two thoracic centres, accuracy and survival of remediastinoscopy were determined. METHODS: From November 1994 to August 2005, remediastinoscopy was performed in 104 patients (98 men, 6 women) after induction therapy for locally advanced non-small cell lung cancer. Mean age was 64.3 years (range 38-85). Neoadjuvant chemotherapy was given in 79 patients and chemoradiotherapy in 25. Follow-up data were completed in January 2007. RESULTS: Remediastinoscopy was technically feasible in all patients except for one who died due to perioperative haemorrhage. Remediastinoscopy was positive in 40 patients and negative in 64; the latter group underwent thoracotomy. There were 17 false-negative remediastinoscopies. Sensitivity of remediastinoscopy was 71%, specificity 100% and accuracy 84%. Follow-up was complete for all patients. Sixty-nine died, mostly of distant metastases. Median survival time for the whole group was 18 months (95% confidence interval 11-25). Median survival time in patients with a positive remediastinoscopy was 14 months (95% confidence interval 8-20), with a negative remediastinoscopy 28 months (95% confidence interval 15-41) and with a false-negative remediastinoscopy 24 months (95% confidence interval 3-45). In univariate analysis the difference between positive and negative remediastinoscopies was highly significant (p=0.001). In a multivariate analysis including sex, age, histology, centre, and nodal status at remediastinoscopy, only nodal status was a significant independent prognostic factor (p=0.008). CONCLUSIONS: Remediastinoscopy is a valuable restaging procedure after induction therapy. Persisting mediastinal nodal involvement proven at remediastinoscopy heralds a poor prognosis.

Natural orifice transluminal endoscopic surgery (NOTES) in the mediastinum: long-term survival animal experiments in transesophageal access, including minor surgical procedures.

BACKGROUND AND STUDY AIMS: Natural orifice transluminal endoscopic surgery (NOTES) within the peritoneal cavity is rapidly evolving, using transgastric, transcolonic, or transvaginal access. There is little experience with transesophageal NOTES access to the mediastinum. This prospective long-term animal survival study was performed to explore the feasibility and safety of transesophageal intrathoracic procedures including minor surgery. MATERIAL AND METHODS: Nine pigs were used for acute (n = 2) and up to 6-week survival studies (n = 7), followed by autopsy and histological investigation. The esophageal incision site was chosen using EUS; this was followed by endoscopic mediastinoscopy and therapeutic procedures such as mediastinal lymph node removal, saline injection into myocardium, and pericardial fenestration. The wall was closed using a suturing system or endoscopic clips. RESULTS: No acute complications were recorded with respect to mediastinal structures, pericardium, cardiac rhythm, or circulatory parameters. Removal of small mediastinal lymph nodes (n = 2) was feasible, but proved to be difficult. Other procedures, specifically at the heart were all successfully performed. Endoscopy after 4 - 6 weeks showed a well-healed esophageal incision. Autopsy with histology revealed no signs of mediastinitis, infection, bleeding, or pericarditis. The esophageal scar was found to be well healed in all cases, but with a muscular gap where clip closure had been used. CONCLUSIONS: Transmural esophageal incision and endoscopic partial mediastinoscopy including therapeutic procedures on the heart or mediastinum proved feasible in long-term survival animal studies. Clip closure of the defect was effective, but did not close the esophageal muscle layer. Other means such as endoscopic suturing appear to be preferable.