Biomedical subjects

Cameron D Wright

Publications and source records attributed to Cameron D Wright.

At least 19 recordsLinked to original sources

PubMed2007

Physician payment for 2007: a description of the process by which major changes in valuation of cardiothoracic surgical procedures occurred.

Throughout the last 3 years, the Society of Thoracic Surgeons (STS) has put forth a major effort towards more accurate valuation of the work performed by cardiothoracic surgeons. The culmination of these efforts was realized on November 1, 2006, when the Centers for Medicare & Medicaid Services published the Final Rule which markedly increased the physician work values for the most frequently performed cardiothoracic surgery procedures. This article recounts the innovative approach taken by the STS during these extended efforts.

Cardiac Surgical Procedures↗

PubMed2006

Post-esophagectomy gastric outlet obstruction: role of pyloromyotomy and management with endoscopic pyloric dilatation.

OBJECTIVE: Gastric outlet obstruction is common after esophagectomy. Our goal was to determine the incidence of gastric outlet obstruction after esophagectomy with or without pyloromyotomy and analyze its management by endoscopic pyloric dilatation. METHODS: Two hundred forty-two patients underwent esophagectomy with gastric conduit from January 2002 to June 2006. Subjects were divided into two groups: Group A had no pyloromyotomy (n=83) and Group B had a pyloromyotomy (n=159). Gastric outlet obstruction was strictly defined to include patients with clinical delayed gastric emptying supported by symptoms, barium swallow studies, persistent air-fluid level and dilated conduit on radiography, or endoscopic or surgical intervention to improve gastric drainage. RESULTS: The groups were similar except for a higher percentage of cervical anastomosis and older age (64- vs 61-year-old) in Group A. The overall incidence of gastric outlet obstruction was 15.3% (37/242). Pyloromyotomy did not reduce the incidence of gastric outlet obstruction (Group A 9.6% vs Group B 18.2%, p=0.078). One patient required a late pyloroplasty. Successful management of gastric outlet obstruction with pyloric dilatation (96.7%, 28/29) was unaffected by pyloromyotomy. There was no difference in length of stay, pneumonia (Group A 27.7% vs Group B 19.5%, p=0.15), respiratory failure or anastomotic stricture. There was no difference in anastomotic leaks when controlling for the anatomic location of the anastomosis (p=0.36). Mortality was equivalent between groups (2.4 vs 2.5%, p=0.96). CONCLUSION: Pyloromyotomy does not reduce the incidence of symptomatic delayed gastric emptying after esophagectomy. Post-operative gastric outlet obstruction can be effectively managed with endoscopic pyloric dilatation. Routine pyloromyotomy for the prevention of post-esophagectomy gastric outlet obstruction may be unwarranted.

Adult↗

PubMed2006

Transthoracic Heller myotomy for esophageal achalasia: analysis of long-term results.

BACKGROUND: Swallowing deteriorates over time in some patients after transthoracic esophagomyotomy for achalasia. The causes of decline are poorly understood. METHODS: We report a retrospective analysis of transthoracic esophagomyotomy for achalasia. Symptom relief, patient satisfaction, and late intervention were determined during short- and long-term follow-up. Predictors of long-term outcome were identified by logistic regression. RESULTS: From 1962 to 1999, 64 patients underwent transthoracic esophagomyotomy. Five patients had repeat myotomy. Sigmoid esophagus was present in 12 (18%). Fundoplication was absent in 50 patients (myotomy only) and added in 15 (myotomy plus fundoplication). Follow-up was complete in 86% (56 of 65); mean follow-up was 154 months. Thirty-one patients (48%) were followed for more than 10 years. Short-term results were good to excellent in 91% (51 of 56) and long-term in 63% (33 of 52; p < 0.0005). Late peptic stricture occurred in 4 patients (myotomy only, 2 of 38 [5%]; myotomy plus fundoplication, 2 of 14 [14%]). Fewer patients had reflux symptoms after fundoplication (myotomy only, 16 of 38 [42%]; myotomy plus fundoplication, 4 of 14 [29%]), whereas late dysphagia was not reduced (myotomy only, 13 of 38 [34%]; myotomy plus fundoplication, 5 of 14 [36%]). Two patients after myotomy plus fundoplication and 1 after myotomy only had esophagectomy. Early recurrence of symptoms predicted late poor outcome (p < 0.001), whereas sigmoid esophagus, fundoplication, or early postoperative reflux did not. CONCLUSIONS: Early good results after esophagomyotomy for achalasia deteriorate over time. Recurring dysphagia early after operation predicts late failure, while sigmoid esophagus does not. Fundoplication reduces reflux symptoms, but not late poor results. These data should be considered in the evaluation of newer, minimally invasive procedures.

Adolescent↗

PubMed2006

Uncommon primary tracheal tumors.

BACKGROUND: Primary tracheal tumors other than adenoid cystic or squamous cell carcinoma are uncommon and have a heterogeneous histologic appearance. The experience regarding their treatment and long-term outcome is limited, and alternatives to segmental tracheal resection, including endoscopic treatment or radiation, continue to be explored. METHODS: A retrospective analysis was performed of uncommon tracheal tumors among 360 primary tracheal tumors seen over 40 years, excluding adenoid cystic and squamous cell carcinoma. RESULTS: Of 90 patients, 34 (38%) had benign tumors and 56 malignant: 11 carcinoid tumors, 14 mucoepidermoid carcinomas, 13 sarcomas, 15 nonsquamous bronchogenic carcinomas, 2 lymphomas, and 1 melanoma. Three patients had a second tracheal malignancy. Dyspnea was the most common symptom in benign tumors and hemoptysis in malignant tumors. Twelve patients did not undergo tracheal resection (13.3%) and 1 died before resection. Surgical therapy in 77 patients (85%) consisted of laryngectomy in 3, laryngotracheal resection in 9, tracheal resection in 46, and carinal resection in 19. Hospital mortality was 2.6% (2 of 77 patients) and major complications occurred in 16% (12 of 77 patients). Mean follow-up was 9.7 years. After resection, survival at 10 years was 94% for benign and 83% for carcinoid tumors, and at 5 years survival was 60% for bronchogenic carcinoma, 100% for mucoepidermoid tumors, and 78% for sarcomas. Patients with lymphomas and melanoma are alive more than 8 years after resection. Ten patients experienced recurrence (14%). CONCLUSIONS: Surgical resection of uncommon primary tracheal tumors alleviates airway obstruction, is curative in patients with benign or slow-growing malignant lesions, and prolongs survival in highly malignant lesions.

Adolescent↗

PubMed2006

Acute presentation of thymoma with infarction or hemorrhage.

The presentation of thymomas is variable; most are asymptomatic and others present with local compression symptoms or a parathymic syndrome. Rarely thymomas present as an acute emergency with severe chest pain from either infarction or hemorrhage of the tumor. This rare presentation usually leads the clinician initially away from the diagnosis of thymoma. We present 4 patients who presented with infarction (3 patients) and hemorrhage (1 patient) who were initially believed to have a lymphoma. Preoperative biopsies were unrevealing. All had a complete resection and were in the early Masaoka stage. There have been no recurrences in follow-up. The astute clinician should be aware of this unusual presentation. The prognosis seems to be good in patients who present with infarction or hemorrhage.

Adult↗

PubMed2006

Pleuropneumonectomy for the treatment of Masaoka stage IVA thymoma.

BACKGROUND: The treatment of locally advanced Masaoka stage IVA thymoma is not standardized and is problematic. METHODS: A single-institution retrospective study was made of 5 patients with World Health Organization B3 thymomas who underwent pleuropneumonectomy for locally advanced thymoma. Two patients had recurrent thymoma and 3 presented de novo with stage IVA disease. Patients had a variety of induction and adjuvant treatments. RESULTS: There was no operative mortality, and only 1 patient had a major complication. Several patients had relatively prolonged disease-free survival. The median survival was 86 months, and the Kaplan-Meier survival was 75% (95% confidence interval: 53% to 97%) at 5 years and 50% (95% confidence interval: 25% to 75%) at 10 years. CONCLUSIONS: Pleuropneumonectomy can be performed safely in patients with advanced thymomas and may improve survival. Highly selected patients might be cured with this approach if a complete resection is performed. While the optimal multimodality strategy for these patients is unknown, induction chemotherapy followed by resection then chemoradiotherapy seems promising.

Adult↗

PubMed2006

Feasibility and outcomes of an early extubation policy after esophagectomy.

BACKGROUND: Although early extubation of esophagectomy patients has been found to be feasible, safe, and associated with low morbidity, there is no uniform standard of care among high volume centers. Our objective is to examine a contemporary series of esophagectomies and identify the feasibility and outcome of an early extubation policy. METHODS: This study is a retrospective review of all patients who underwent esophagectomy between January 2003 and December 2004 at the Massachusetts General Hospital. One hundred and two patients were analyzed from 129 consecutive patients who underwent esophagectomy and subsequently divided in two groups: The early extubation group was extubated in the operating room and the late extubation group was extubated in the intensive care unit (ICU). RESULTS: Ninety percent were extubated early. Although most patients underwent a transthoracic or thoracoabdominal esophagectomy, the operative approach did not influence failure to extubate. Neoadjuvant therapy was not predictive of extubation failure. Most patients age 70 or greater (86%) were extubated early. There were three nonelective reintubations in the early extubation group secondary to acute respiratory distress syndrome. The median length of stay was 11 days and median ICU stay was one day. The 30-day mortality was 1.9% and the median survival was 28 months. CONCLUSIONS: Attention to restricted intraoperative fluid balance, limited blood loss, anesthetic technique, and epidural use permit most patients undergoing esophageal resection to be safely extubated immediately postresection in the operating room.

Device Removal↗

PubMed2006

Recurrent laryngeal nerve injuries after esophagectomy.

Unilateral vocal-cord paralysis after esophagectomy involving a cervical anastomosis is uncommon in experienced hands but can cause marked morbidity because of pulmonary complications. It is important for the surgeon to understand the anatomy of the recurrent laryngeal nerve to avoid this complication. The diagnosis is usually easily made at the bedside and can be confirmed by visualization of the glottis. Early treatment may include supportive care with a speech pathologist or injection of the vocal-cord with temporary material to improve glottic closure. Definitive treatment can best be performed by medialization thyroplasty.

Esophagectomy↗

PubMed2006

Sleeve lobectomy in lung cancer.

Sleeve lobectomy for lung cancer is now commonly performed around the world for central lung cancers that are anatomically suitable regardless of lung function. The morbidity and mortality are low, especially when compared with pneumonectomy. Bronchial complications are quite low. Local control seems to be at least as good as that obtained with pneumonectomy. Survival in most series is better with sleeve lobectomy than with pneumonectomy. Although there is still controversy with the use of sleeve lobectomy in patients with N1 disease, several recent series suggest better survival compared with pneumonectomy. Sleeve lobectomy can be safely performed after induction therapy. Quality of life is better with sleeve lobectomy compared with pneumonectomy.

Anastomosis, Surgical↗

PubMed2005

Predictors of recurrence in thymic tumors: importance of invasion, World Health Organization histology, and size.

OBJECTIVE: This study sought to define predictors of recurrence after resection of thymic tumors. METHODS: A single-institution retrospective study was performed of 179 patients who underwent resection of a thymic tumor from 1972 through 2003. RESULTS: Resection was complete in 90% (161/179) of patients. After a median follow-up of 115 months, the recurrence rate was 11% (20/179), the tumor-related death rate was 7.8% (14/179), and the overall death rate was 36.3% (65/179). Tumor recurrence correlated with advanced stage and histology (P < .0001). The difference in recurrence between Masaoka stage I (0) and II (1.7% [1/59]) was insignificant. Recurrence rates correlated with World Health Organization tumor type: A and AB, 0%; B1 and B2, 8% (4/51); B3, 27% (14/51); and C, 50% (2/4; P < .0001). Tumor size separation into quintiles demonstrated a step-up of recurrence at 8 cm (<8 cm, 1.8% [2/113]; > or =8 cm, 28% [18/64]; P < .003). Multivariate Cox modeling demonstrated that Masaoka stage (odds ratio, 5.70; P < .001), World Health Organization histology (odds ratio, 5.77; P = .003), and size (odds ratio, 1.16; P = .001) were independent predictors of recurrence. CONCLUSION: The Masaoka staging system could be collapsed to 3 degrees of invasion by combining stages I and II. The World Health Organization histologic type can be simplified for clinical use into A (A, AB), early B (B1, B2), advanced B (B3), and C tumors. Size of 8 cm or larger is an independent risk factor, even when patients with Masaoka stage III tumors are considered alone, and might identify candidates for preoperative therapy.

Adult↗

PubMed2005

Esophageal leiomyoma: a 40-year experience.

BACKGROUND: Esophageal leiomyomas, although infrequent, are the most common benign intramural tumors of the esophagus. They represent 10% of all gastrointestinal leiomyomas and frequently cause symptoms, necessitating resection. METHODS: The Massachusetts General Hospital Pathologic Database was reviewed over a 40-year period for patients who underwent surgical resection of esophageal leiomyomas. Data analyzed included demographic information, presenting symptoms, tumor location, tumor characteristics and histology, diagnostic procedures, and treatment modalities/outcomes. Fifty-three patients were identified; 31 patients were symptomatic from their leiomyomas. RESULTS: Symptomatic patients presented at a mean age of 44 years old and exhibited a twofold male predominance. Mean tumor diameter among symptomatic patients was 5.3 cm, as compared to 1.5 cm in asymptomatic patients (p < 0.0001). Thirty of the symptomatic patients had solitary leiomyomas, and 1 patient had five separate leiomyomas. Eighty-four percent of the lesions in symptomatic patients occurred in the lower two-thirds of the esophagus, with epigastric discomfort being the most common presenting symptom. Among patients operated on solely for leiomyoma, 97% were enucleated without an esophageal resection. None of the leiomyomas showed malignant transformation or recurrence. All symptomatic patients had relief of symptoms, with no perioperative morbidity or mortality. CONCLUSIONS: In a large pathologic series, over half of all patients with esophageal leiomyomas were symptomatic. Larger tumors were significantly more likely to be symptomatic. Local enucleation by a variety of surgical approaches was accomplished in most patients. All symptomatic patients had relief of symptoms, with no perioperative morbidity or mortality. There was no observed tendency for malignant transformation or recurrence.

Adult↗

PubMed2005

Surgical treatment of esophageal high-grade dysplasia.

BACKGROUND: Barrett's esophagus, high-grade dysplasia (HGD), and invasive cancer are steps in the progression of esophageal adenocarcinoma. While surgery is recommended for resectable invasive adenocarcinoma, a number of treatment modalities are advocated for HGD. The purpose of this study is to determine the outcomes after surgery for HGD. METHODS: We identified cases of HGD based on endoscopic biopsy in a single institution's databases from 1980 through 2001. Records were reviewed for patient characteristics, treatments, staging, and outcomes. RESULTS: In a 22-year period, 869 cases of esophageal adenocarcinoma and 1,614 cases of Barrett's esophagus were diagnosed. Of these, 115 had HGD without pretreatment evidence of invasion. Forty-nine patients with HGD underwent resection (mean age, 59 years) as initial treatment. Forty-seven had endoscopic treatment (mean age, 70 years) by photodynamic therapy or endoscopic mucosal resection. Seven of the endoscopically treated patients failed, with three undergoing surgery and four observation. Nineteen patients were initially observed, with six eventually having surgery. For the 49 initially treated surgically, one (2%) operative mortality occurred. Invasive adenocarcinoma was present in 18 (37%). The five-year survival was 83% for all resected HGD patients (91% for those without invasion, 68% with invasion). Three of the eight deaths in those with invasion were from recurrent adenocarcinoma. CONCLUSIONS: Surgical resection of esophageal HGD can be performed with low mortality and allows long-term survival. A significant percentage with an initial diagnosis of HGD will have invasive disease at resection. Surgery is the optimal treatment for HGD unless contraindicated by severe comorbidities.

Adenocarcinoma↗

PubMed2005

Airway obstruction owing to tracheopathia osteoplastica: treatment by linear tracheoplasty.

BACKGROUND: Tracheopathia osteoplastica is a rare disease that may involve the entire trachea and progress to critical airway obstruction. It is not dilatable and does not respond to laser therapy or bronchoscopic curettage. Stents usually cannot be inserted. METHODS: Lack of involvement of the membranous wall by the disease allows tracheal widening after complete linear tracheoplasty. Opening is preserved during healing by prolonged stenting with a T or T-Y silicone tube. RESULTS: Stent removal after firm healing produced long-term correction of stenosis in 3 of 4 patients, examined up to 12 years. CONCLUSIONS: Severe, symptomatic tracheal obstruction by tracheopathia osteoplastica is definitively surgically correctible.

Adult↗

PubMed2005

Adjuvant radiation of stage III thymoma: is it necessary?

BACKGROUND: The criteria for administration of adjuvant radiation therapy after thymoma resection remains controversial, and it is unclear whether patients with Masaoka stage III thymoma benefit from adjuvant radiation. The goal of this report was to determine whether or not this group benefits from radiation therapy in disease-specific survival and disease-free survival. METHODS: Case records of the Massachusetts General Hospital were retrospectively reviewed from 1972 to 2004. One hundred and seventy-nine patients underwent resection for thymoma, of which 45 had stage III disease. RESULTS: Forty-five stage III patients underwent resection and in 36 it was complete. Thirty-eight stage III patients received radiation therapy. Baseline prognostic factors between radiated and nonradiated groups were similar. The addition of adjuvant radiotherapy did not alter local or distant recurrence rates in patients with stage III thymoma. Disease-specific survival at 10 years in stage III patients who did not receive radiation was 75% (95% confidence interval, 32% to 100%) and in patients who did receive radiation therapy it was 79% (95% confidence interval, 64% to 94%) (p = 0.21). The most common site of relapse was the pleura. CONCLUSIONS: Most patients who have stage III thymoma undergo complete resection. Some patients enjoy prolonged disease-free survival without adjuvant radiation after resection of stage III thymoma. Radiation does not seem to prevent pleural recurrences when given after resection of stage III thymomas. The use of routine adjuvant radiation after a complete resection of stage III thymoma needs to be re-addressed. There may be a role for the use of chemotherapy to reduce pleural recurrences.

Adolescent↗

PubMed2005

Tracheoplasty for expiratory collapse of central airways.

BACKGROUND: Severe central airway obstruction due to expiratory collapse occurs with malacia of intrathoracic trachea and main bronchi, often with chronic obstructive pulmonary disease. Bronchoscopically observed, it is confirmed by inspiratory-expiratory computerized tomographic chest scans. Prior attempts at surgical stabilization have not given dependable results. METHODS: Posterior tracheobronchial splinting with polypropylene mesh (Marlex) holds cartilages in more normal configuration, and fixes redundant membranous walls. Fourteen consecutive patients were so treated for severe dyspnea. Prior trials of various autologous and exogenous splints failed. RESULTS: All felt subjectively improved early, with decreased dyspnea, cough, and secretion retention, and with increased activities. Mean forced expiratory volume in 1 second rose from 51% predicted to 73% (p = 0.009), and peak expiratory flow rate from 49% to 70% (p < 0.00001). One patient was lost to follow-up (1 year), 1 died of unrelated cause (5 years), 1 died of chronic obstructive pulmonary disease (3 years), and 1 had decreased respiratory function over 5 years. Ten patients were available for long-term follow-up: 6 were judged to have an excellent result, 2 were good, and 2 were poor due to collapse of unsplinted main bronchi. CONCLUSIONS: Complete splinting of all malacic central airways with Marlex restores anatomic configuration and permanently prevents expiratory collapse, with relief of extreme dyspnea, cough, and secretion retention.

Adult↗

PubMed2005

Tracheal compression caused by straight back syndrome, chest wall deformity, and anterior spinal displacement: techniques for relief.

BACKGROUND: Straight back syndrome and other causes of extreme narrowing of the space between sternal notch and vertebrae can cause critical tracheal obstruction. Additional points of compression may result from the brachiocephalic artery and from anterior vertebral displacement. METHODS: Individualized surgical maneuvers are necessary to correct all points of obstruction. Techniques include sternoplasty, sternal division, reimplantation of brachiocephalic artery, correction of severe pectus excavatum, and posterior wall tracheoplasty. RESULTS: Four patients were successfully treated by individualized techniques with complete long-term relief of critical tracheal obstruction. CONCLUSIONS: Severe tracheal compression caused by straight back syndrome and other causes of narrowed sternospinal channel is surgically correctable.

Adult↗

PubMed2005

Laryngotracheoplastic resection for primary tumors of the proximal airway.

BACKGROUND: Primary tumors of the airway with proximity to vocal cords and recurrent laryngeal nerves can be resected with sparing of the larynx. Long-term data on survival and local recurrence after laryngotracheal resection are scarce. METHODS: We conducted a retrospective study of laryngotracheal resection and reconstruction for primary tumors of the airway since 1972. RESULTS: Twenty-five patients aged 15 to 77 years presented with adenoid cystic carcinomas (n = 9), squamous cell carcinomas (n = 6), and other airway tumors (n = 10). Subglottic resection consisted of anterior cricoid in 5 patients; posterior cricoid mucosa in 9 patients, with resection of the posterior cricoid plate in 3 patients; lateral resection in 7 patients; and combined anterior and posterior elements in 4 patients. Vascularized trachea was tailored to reconstruct the defect. Seven patients without hoarseness required resection of the recurrent laryngeal nerve, and 4 other patients with hoarseness did not. There were no operative deaths. Two (8.0%) patients who had received prior high-dose cervical radiation had anastomotic separation, one requiring laryngectomy. One patient needed permanent tracheostomy, and temporary (<2 months) airway tubes were used in 5 patients. Sixteen patients received postoperative radiation. Median follow-up was 101 months. Four (16%) patients died of disease. Overall survival at 5 and 10 years was 79% and 64%, respectively. No patient underwent laryngectomy for recurrence. CONCLUSION: Laryngotracheal resection and immediate reconstruction for subglottic tumors is achieved with good preservation of voice, low morbidity, and no compromise of long-term survival.

Adolescent↗

PubMed2005

Surgical treatment of thymic tumors.

Thymoma is a rare neoplasm usually with an indolent growth pattern; however, local invasion and/or metastases may occur. The association with several paraneoplastic syndromes, especially myasthenia gravis, makes thymoma an interesting biologic tumor model. Surgery has been the standard of care for early stage disease with high cure rates anticipated. Multimodality therapy can result in long-term disease-free survival for patients presenting with locally advanced disease.

Disease-Free Survival↗