Technique of right single-lung transplantation for idiopathic pulmonary fibrosis using cross-field ventilation.
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Humans↗
Biomedical subjects
Daniel L Miller
Publications and source records attributed to Daniel L Miller.
Outcomes of delayed chest closure after bilateral lung transplantation.
BACKGROUND: Delayed chest closure (DCC) may be used after bilateral lung transplantation when significant bleeding/coagulopathy or severe pulmonary edema exists. Primary chest closure (PCC) in these patients can lead to heart and lung compression causing cardiopulmonary instability. The purpose of this study is to describe factors associated with DCC and evaluate outcomes after DCC. METHODS: We performed a retrospective review of all patients undergoing bilateral lung transplantation between September 2003 and March 2005. Statistical significance was determined by two-tailed t test or Fisher's exact test. RESULTS: Twenty-eight bilateral lung transplantations were performed. Indication for transplant was chronic obstructive pulmonary disease (13), pulmonary fibrosis (5), cystic fibrosis (5), sarcoidosis (3), and pulmonary hypertension (1). Seven patients (25%) required DCC. Mean time to DCC was 5.3 days. Six patients (86%) with DCC required tracheostomy versus 4 patients (20%) with PCC (p = 0.003). Mean days to discharge was 44 in the DCC group and 21 in the PCC group (p = 0.03). Thirty-day survival was 100% in the DCC group and 95% in the PCC group (p = 1.0). There were no wound infections in either group, and 1 patient in the PCC group had sternal nonunion. Delayed chest closure was associated with cardiopulmonary bypass use (p = 0.006), cardiopulmonary bypass time longer than mean cardiopulmonary bypass time (mean, 224 minutes; p = 0.04), PaO2/FiO2 less than mean + 1 SD (value = 4.63, p = 0.0002), evidence of moderate/severe reperfusion injury on chest radiograph (p = 0.0002), and PaO2/FiO2 less than mean plus moderate/severe reperfusion injury on chest radiograph (p = 0.002). CONCLUSIONS: Cardiopulmonary bypass use, prolonged cardiopulmonary bypass time, and significant reperfusion injury, as determined by chest radiograph and a low PaO2/FiO2 ratio were all associated with an increased incidence of DCC in our bilateral lung transplantation patients. These patients had no wound infections or sternal complications, and although they had longer hospital stays than PCC patients, DCC did not affect operative survival. Delayed chest closure can be employed safely, when necessary, after bilateral lung transplantation with outcomes similar to patients with PCC.
Blood Loss, Surgical↗
Gastric rupture associated with diaphragmatic hernia during pregnancy.
Diaphragmatic hernia complicating pregnancy rarely occurs, but it is frequently misdiagnosed. A strangulated diaphragmatic hernia in a pregnant patient presents a true surgical emergency, and delay in operative intervention can result in fetal and maternal mortality in as many as 50% of cases. We describe a case report of a pregnant patient and her fetus surviving after a spontaneous gastric rupture from a strangulated diaphragmatic hernia.
Adult↗
Satellite pulmonary nodule in the same lobe (T4N0) should not be staged as IIIB non-small cell lung cancer.
BACKGROUND: Treatment of non-small cell lung cancer depends on stage. Patients with T4 lesions represent a heterogeneous group. METHODS: A case-control study of patients with pathologically proven, node-negative T4 lesions (T4 N0 M0) was conducted. Patients with T4 disease were stratified as T4 from a satellite nodule (T4-satellite) or T4 from local invasion (T4-invasion). T4-satellite patients were matched 1:4 for sex and histology with resected control patients with stage IA, IB, and IIA non-small cell lung cancer and matched 1:3 with stage II non-small cell lung cancer. Survival and the maximal standardized uptake value on F-18 fluorodeoxyglucose-positron emission tomography scans were compared. RESULTS: There were 337 patients, 26 patients with T4-satellite lesions, 25 with T4-invasion lesions, and 286 controls (104 patients with T1 N0 M0, 104 with T2 N0 M0, and 78 with T1 N1 M0 or T2 N1 M0 lesions). The two T4 groups were similar for age, race, sex, and neoadjuvant therapy rates. The 5-year survival was 80% for the T1 N0 M0 patients, 68% for T2 N0 M0, 57% for T4-satellite N0 M0, 45% for T1 N1 M0 or T2 N1 M0, and 30% for the T4-invasion N0 M0 patients (p = 0.016). Multivariate analysis showed that only the type of T4 impacted survival (p = 0.011). The median maximal standardized uptake values of the cancers were 4.2 for T1 N0 M0, 4.8 for T4-satellite, 5.4 for T2 N0 M0, 7.8 for T1 N1 M0 or T2 N1 M0, and 8.8 for the T4-invasion patients. CONCLUSIONS: Larger studies are needed; however, patients with T4-satellite non-small cell lung cancer who undergo complete resection have survival and maximal standardized uptake values similar to patients with stage IB and stage IIA lesions. Their survival is significantly better than those with T4-invasion. Patients with T4-satellite N0 M0 lesions should not be classified as stage IIIB and should not be grouped with patients with T4-invasion, and resection should be considered.
Aged↗
Role of thoracic surgeons in the diagnosis of idiopathic interstitial lung disease.
The interstitial lung disorders are a heterogenous group of pulmonary disorders in which the interstitium is the predominant tissue type involved in the disease process. The idiopathic interstitial pneumonias represent a subgroup of these disorders that can be distinguished by unique clinical, radiologic, and pathologic features. Recent changes have been made in the classification system, with important distinctions between idiopathic pulmonary fibrosis and the other idiopathic interstitial pneumonias. Surgical lung biopsy remains the gold standard for diagnosis. However, controversy exists regarding the methods and indications for biopsy. In this article, we review the salient clinical, radiologic, and pathologic features of these unique disorders as well as the updated classification scheme. We also discuss the current methods, approaches, and indications for biopsy.
Biopsy↗
Incidence of deep sternal wound infections after tracheostomy in cardiac surgery patients.
BACKGROUND: Tracheostomy after median sternotomy is associated with an increased risk of deep sternal wound infection (DSWI). However, associated comorbidities in these patients make the exact risk of tracheostomy difficult to discern. Therefore, we performed a retrospective review to determine the risk of DSWI in our cardiac surgery patients who underwent postoperative tracheostomy. METHODS: Our cardiac surgery database was queried from January 1996 to July 2003. Perioperative morbidities were identified for all patients who underwent tracheostomy after cardiac surgery. Statistical analysis was performed using chi2 analysis and Fisher's exact test. RESULTS: During the study period, 16,277 cardiac procedures were performed through a median sternotomy. Tracheostomy was performed in 291 patients (1.8%). Deep sternal wound infections occurred in 0.8% of all patients and in 3.4% of patients (9 of 268) who underwent tracheostomy. Mean number of days to tracheostomy was 14.2 in the DSWI group and 15.8 in the non-DSWI group (p = 0.45). In patients with a tracheostomy, preoperative renal failure was the only perioperative comorbidity found to be significantly associated with DSWI (p = 0.03). Overall operative mortality was 3.6%. Mortality was 16.5% for patients with DSWI, 22.7% for patients requiring tracheostomy, and 55% for patients with DSWI and tracheostomy. CONCLUSIONS: The incidence of DSWI after tracheostomy, in our experience, is not as high as previously reported. Tracheostomy can be performed safely after median sternotomy with a low morbidity and mortality rate. However, if DSWI occurs after tracheostomy, mortality is significant.
Aged↗
Postoperative survival and the number of lymph nodes sampled during resection of node-negative non-small cell lung cancer.
STUDY OBJECTIVE: To examine the association between postoperative survival and the number of lymph nodes (LNs) examined during surgery among persons who underwent definitive resection of node-negative (stage IA or stage IB) non-small cell lung cancer (NSCLC). DESIGN AND SETTING: Information on postoperative survival and the number of LNs examined during surgery for stage I NSCLC treated with definitive surgical resection was retrieved from the population-based Surveillance, Epidemiology and End Results database for the period from 1990 to 2000. The association between survival and the number of LNs was examined using multivariate Cox proportional hazard models with adjustment for age, race, sex, type of surgery performed, and tumor size, grade, and histology. RESULTS: A total of 16,800 patients were included in the study. The overall survival analysis for patients without radiation therapy (RT) demonstrated that in comparison to the reference group (one to four LNs), patients with five to eight LNs examined during surgery had a modest but statistically significant increase in survival, with a proportionate hazard ratio (HR) of 0.90 and a 95% confidence interval (CI) of 0.84 to 0.97. Similar results for 9 to 12 LNs and 13 to 16 LNs examined produced further increases in survival, with HRs of 0.86 (95% CI, 0.79 to 0.95) and 0.78 (95% CI, 0.68 to 0.90), respectively. There appeared to be no incremental improvement after evaluating > 16 LNs. The corresponding results for lung cancer-specific mortality and for patients receiving RT were not substantially different. The highest median survival (97 months) occurred in patients with 10 to 11 LNs evaluated. CONCLUSIONS: Our results indicate that patient survival following resection for NSCLC is associated with the number of LNs evaluated during surgery. This is likely due to reduction of staging error: a decreased likelihood of missing positive LNs with an increasing number of LNs sampled. Although we are reluctant to recommend a definitive "optimal number," our data support the conclusion that an evaluation of nodal status should include somewhere from 11 to 16 LNs.
Adult↗
Preoperative chemoradiation therapy does not improve early survival after esophagectomy for patients with clinical stage III adenocarcinoma of the esophagus.
BACKGROUND: The optimal treatment for locally advanced esophageal cancer remains controversial. The objective of this study was to determine if preoperative chemoradiation therapy (P-CRT) followed by esophagectomy for patients with clinical stage III adenocarcinoma of the esophagus offered any survival advantage as compared with esophagectomy alone. METHODS: Between January 1998 and June 2001, 75 nonrandomized patients with clinical stage III adenocarcinoma of the esophagus underwent either P-CRT and esophagectomy or esophagectomy alone. All patients were staged before initiation of treatment with computed tomography and endoscopic ultrasound. RESULTS: P-CRT followed by esophagectomy was performed in 47 patients (63%) and esophagectomy alone in 28 patients (37%). Although the P-CRT group was younger (median age, 61 years versus 67 years), the two groups were otherwise similar for gender, comorbidities, and symptoms. Overall operative mortality was 4%. Follow-up was complete in all patients and ranged from 5 to 40 months (median, 20 months). Overall, one-, two-, and three-year survivals were 72%, 44%, and 42%, respectively. Three-year survival was identical (42%) for both the P-CRT and surgery alone patients (p = 0.70). Three-year disease-free survival for the P-CRT group was 29% as compared with 33% for the surgery only group (p = 0.51). CONCLUSIONS: Patients with clinical stage III adenocarcinoma of the esophagus do not appear to gain an early overall or disease-free survival advantage when treated with P-CRT followed by surgery as compared with surgery alone. However, long-term follow-up is needed. A large, prospective, randomized trial is warranted to address the question of whether P-CRT offers any survival benefit or impact on pattern of recurrence in patients undergoing esophagectomy for locally advanced disease.
Adenocarcinoma↗
Prospective randomized study evaluating a biodegradable polymeric sealant for sealing intraoperative air leaks that occur during pulmonary resection.
BACKGROUND: To evaluate the safety and effectiveness of a new biodegradable polymeric sealant to close intraoperative air leaks after pulmonary resection. METHODS: In a multicenter prospective randomized trial, 161 patients with a median age of 67 years old (range 18-85 years old), were randomized in a 2:1 ratio to receive sealant or control for at least one significant air leak (> or = 2.0 mm in size) after pulmonary resection. In the sealant group, all significant air leaks underwent attempted repair by standard methods (sutures, staples, or cautery) prior to the application of sealant. The control group underwent only standard methods. Blood was analyzed for immunologic response. Patients were followed up 1 month after surgery. RESULTS: Intraoperative air leaks were sealed in 77% of the sealant group compared with 16% in the control group (p < 0.001). The sealant group had significantly fewer patients with postoperative air leaks compared with the control group (65% vs 86%, p = 0.005). Median length of hospitalization was 6 days (range, 3-23 days) for the sealant group compared with 7 days (range 4-38 days) for controls (p = 0.028). There was no difference in mortality, morbidity, duration of chest tubes, or immune responses between the two groups. CONCLUSIONS: This study demonstrates the effectiveness of a biodegradable polymer when used as an adjunct to standard closure methods for sealing significant intraoperative air leaks that develop from pulmonary surgery. Use of the sealant led to a reduction in postoperative air leaks, which may have decreased the length of hospitalization.
Adolescent↗
Prognostic significance of lymph node metastasis found during pulmonary metastasectomy for extrapulmonary carcinoma.
BACKGROUND: The prognostic significance of lymph node metastasis in cancer patients is well documented. Pulmonary metastasectomy in selected patients is associated with improved survival. Little is known about the prognostic significance of lymph node metastases found during pulmonary metastasectomy for extrapulmonary carcinoma metastatic to the lung. METHODS: The records of all patients who underwent pulmonary metastasectomy and complete mediastinal lymph node dissection for extrapulmonary carcinomas at our institution from November 1985 through July 1999 were reviewed. RESULTS: Eight hundred eighty-three patients underwent pulmonary metastasectomy. Of these, 70 patients (7.9%) (44 men, 26 women) had concomitant complete lymphadenectomy. Median age was 64 years (range, 33 to 83 years). Median time interval between primary tumor resection and metastasectomy was 34 months (range, 0 to 188 months). Wedge excision was performed in 46 patients, lobectomy in 16, both in 7, and pneumonectomy in 1. Lymph node metastases were found in 20 patients (28.6%) and were classified as intrapulmonary or hilar (N1) in 9, mediastinal (N2) in 8, and both in 3. There were no operative deaths. Median follow-up was 6.6 years (range, 1.1 to 14.6 years). Three-year survival for patients with negative lymph nodes was 69% as compared with only 38% for those with positive lymph nodes (p < 0.001). CONCLUSIONS: The presence of lymph node metastases at the time of pulmonary metastasectomy for extrapulmonary carcinoma has an adverse effect on prognosis. Complete mediastinal lymph node dissection should be considered at the time of pulmonary metastasectomy for carcinoma to improve staging and guide treatment.
Adult↗
Barrett's esophagus: the role of laparoscopic fundoplication.
BACKGROUND: To review our early operative results and endoscopic findings after laparoscopic fundoplication for Barrett's esophagus (BE). METHODS: From January 1995 through December 2000, 49 patients with BE (35 men and 14 women) underwent laparoscopic antireflux surgery. Median age was 54 years (range, 28 to 85 years). No patient had high-grade dysplasia; 6, however, had low-grade dysplasia. All 49 patients had gastroesophageal reflux symptoms. Heartburn was present in 41 patients (84%), dysphagia in 16 (33%), epigastric or chest pain in 9 (18%), and other symptoms in 16 (33%). A Nissen fundoplication was performed in 48 patients and a partial posterior fundoplication in 1. Forty-one patients (84%) had concomitant hiatal hernia repair. RESULTS: There were no deaths. Complications occurred in 2 patients (4%). Follow-up was complete in 48 patients (98%) and ranged from 1 to 81 months (median, 29 months). Functional results were classified as excellent in 33 patients (69%), good in 9 (19%), fair in 5 (10%), and poor in 1 (2%). Thirty-three patients (67%) underwent postoperative surveillance esophagoscopy with biopsy. Nine patients (18%) had total regression of BE and 3 (6%) had a decrease in total length. In the 6 patients with preoperative low-grade dysplasia, dysplasia was not found in 4, remained unchanged in 1, and progressed to in situ adenocarcinoma in 1. CONCLUSIONS: Laparoscopic fundoplication is effective in controlling symptoms in the majority of patients with BE. While disappearance of BE may occur in some patients, the possibility of developing esophageal adenocarcinoma is not eliminated by laparoscopic fundoplication. Therefore, endoscopic surveillance should continue.
Adenocarcinoma↗
Thoracic presentations of posttransplant lymphoproliferative disorders.
BACKGROUND: Posttransplant lymphoproliferative disorders (PTLDs) are rare complications following transplantation. Although organ-specific cases have been reported, primary presentation in the thoracic cavity has not been fully characterized. METHODS: Eleven cases of PTLD with a primary thoracic presentation were identified among 3,085 solid-organ transplant patients and 1,662 bone marrow transplant patients from 1990 to 2001. RESULTS: There were eight men and three women with a mean age of 49 years. Transplanted organs included lungs (three patients), kidneys (three patients), kidney/pancreas (two patients), allogeneic bone marrow (two patients), and heart (one patient). The time to presentation ranged from 1 to 97 months (median time, 8 months). Six patients developed PTLD within 1 year of undergoing transplantation. Pretransplant serology for Epstein-Barr virus (EBV) and cytomegalovirus was negative in 80% and 78% of cases, respectively. Radiographic evaluation revealed mediastinal adenopathy in 45% of patients, and pulmonary parenchymal lesions in 55%. Fifty-five percent of patients also had extrathoracic involvement. Diagnosis was achieved by CT-guided transthoracic needle biopsy in eight patients, and by open biopsy in three patients. Pathologic analysis revealed monomorphic PTLD (ie, diffuse large B-cell lymphoma) in seven patients, polymorphic PTLD in two patients, anaplastic large cell lymphoma in one patient, and Hodgkin lymphoma in one patient. Eighty-four percent of the specimens evaluated for EBV were determined to be positive by in situ hybridization and/or immunohistochemistry. All patients were initially treated with a reduction in immunosuppression therapy, and six patients (55%) received adjuvant chemotherapy. The overall mortality rate was 64%. Four patients died from complications of PTLD (kidney, two patients; heart, one patient; bone marrow, one patient), and three patients (all lung transplant recipients) died from rejection or infectious complications. The median interval from diagnosis to death was 13 months (range, 1 to 42 months). CONCLUSIONS: Thoracic PTLD can occur in any transplant patient and must be regarded as a potentially fatal complication in the immunosuppressed patient. Heart and lung allograft recipients have the worst prognosis because of the mortality that accompanies rejection with subtherapeutic immunosuppression therapy. Earlier diagnosis and improvements in immunosuppression and chemotherapy may improve survival for these inherently high-risk patients.
Adult↗
Management of the irradiated bronchus after lobectomy for lung cancer.
BACKGROUND: Radiation effects make operative dissection difficult, impair subsequent healing, and increase morbidity. This study evaluates tissue reinforcement of the irradiated bronchus as a modality to reduce morbidity after lobectomy for lung cancer. METHODS: We retrospectively reviewed all patients who had preoperative radiotherapy before lobectomy for lung cancer between May 1977 and June 2000. RESULTS: There were 56 patients (33 men and 23 women) who ranged in age from 42 to 80 years (median, 59 years). Bronchial stump reinforcement included no coverage in 24 patients (42.8%), mediastinal tissue (parietal pleura, pericardial fat, or azygos vein) in 16 (28.6%), and muscle (serratus anterior) in 16 (28.6%). Median preoperative radiation dose was 4,600 cGy (range, 3,000 to 9,810 cGy) and did not differ between the groups. There were three deaths (13%) in the no coverage group, one (6%) in the mediastinal tissue group, and one (6%) in the muscle group (NS). Pulmonary complication rate was 67% in the no coverage group, 44% in the mediastinal group, and 25% in the muscle group (p = 0.03). Median duration of chest tube drainage was 8 days in the no coverage group, 6 days in the mediastinal group, and 5 days in the muscle group (p = 0.006). Median hospital stay was 13 days in the no coverage group, 9 days in the mediastinal group, and 7 days in the muscle group (p = 0.02). Patients in the muscle group had reduced hospital stay, duration of chest tube drainage, and pulmonary complications compared with the other two groups (p < 0.05). Subjectively, presence and magnitude of postoperative pain, range of motion, and strength of the upper extremity of the muscle flap side were not different between the groups (p = NS). Follow-up was complete and ranged from 4 to 147 months (median, 17 months). CONCLUSIONS: Tissue reinforcement of the irradiated bronchus after lobectomy reduces postoperative morbidity and hospitalization. Transposition muscle flap may be preferred.
Adult↗
Thirty-year experience with repair of pectus deformities in adults.
BACKGROUND: A plethora of studies have described repair of pectus deformities in children, but only few reports have described this repair in adults. The purpose of this study was to review our 30-year experience with surgical repair of pectus deformities in adults. METHODS: A retrospective review of all adult patients (> 16 years old) who underwent repair of congenital pectus deformities from 1971 through 2001. RESULTS: There were 77 patients, 64 men and 13 women. Sixty-eight patients underwent surgery for pectus excavatum and 9 for pectus carinatum; median age was 22 years old (range, 16 to 68 years old). Indication for repair was medical concerns in all patients. Preoperative symptoms were dyspnea on exertion in 43 patients, shortness of breath at rest in 22 patients, chest pain in 8 patients, and palpitations in 8 patients. Preoperative electrocardiogram findings included right bundle branch block in 9 patients, sinus bradycardia in 8 patients, left atrial enlargement in 6 patients, and right atrial dilatation in 5 patients. Patterns of the pectus defect were symmetric and localized in 29 patients, symmetric and diffuse in 21, asymmetric and localized in 18, and asymmetric and diffuse in 9 patients. Intraoperative classifications were severe in 38 patients, moderate in 33 patients, and mild in 6 patients. There were no operative deaths. Complications occurred in 11 patients (14.3%). Mean hospital stay was 4 days (range, 2 to 8 days). Mean follow-up was 12 +/- 7 years (range, 4 months old to 24 years old); 1 patient (1.3%) required reoperation for recurrent pectus excavatum. Patient satisfaction and relief of medical symptoms was excellent in 70 patients (90.9%), good in 6 patients, and fair in 1 patient. CONCLUSIONS: Repair of congenital defects of the sternum in adults can be performed safely with low morbidity and no mortality. Long-term results are excellent with requirement for reoperation rare.
Adult↗
Tumor response to induction chemoradiation: influence on survival after esophagectomy.
OBJECTIVE: Preoperative chemoradiation is becoming standard of care for locally advanced esophageal cancer. The objective of this study was to determine if the degree of pathologic response to preoperative chemoradiation could predict survival and recurrence after resection in patients with adenocarcinoma of the distal esophagus. METHODS: Between January 1998 and December 2001, 366 patients underwent esophagectomy for adenocarcinoma of the esophagus; 108 (30%) had induction chemoradiation prior to surgery. The records of these 108 patients were reviewed. RESULTS: Histologic examination of the resected specimens documented complete pathologic response (CR) in 24 patients (22%) and residual tumor (RT) in 84 (78%). Operative mortality was 3.7%. Follow-up was complete in all patients and ranged from 1 to 46 months (median, 11 months). Three-year survival for patients with CR was 64% as compared to 34% for patients with RT (P=0.17). Median survival for patients with CR has not yet been reached; however, median survival for patients with RT was 19 months. Three-year cancer free survival for patients with CR was 57% compared to 30% for patients with RT (P=0.03). While median survival free of recurrence for patients with CR has not yet been reached, median survival free of recurrence for patients with RT was 9 months. CONCLUSION: Complete pathologic response to induction chemoradiation is associated with improved early overall and disease-free survival following esophagectomy for adenocarcinoma of the distal esophagus. Because recurrent cancer still develops in many of these patients, even after complete pathologic response, the search for the optimal treatment continues.
Adenocarcinoma↗
Surgical management of sternoclavicular joint infections.
OBJECTIVE: Sternoclavicular joint infections are rare, and their management is controversial. We reviewed our experience with the surgical management of this condition. METHODS: From August 1988 to August 2001, 26 patients (16 men and 10 women) were treated surgically for infected sternoclavicular joints. The median age was 56 years (range, 20-77 years). Patients who had a recent previous median sternotomy were excluded. RESULTS: All patients were symptomatic. Pain was present in 21 patients, swelling in 14 patients, fever in 11 patients, and erythema in 9 patients. Associated conditions included recent or ongoing infections in other areas in 12 patients (pneumonia in 4 patients, multiple joint infections in 2 patients, and other in 6 patients) and an indwelling central venous catheter in 1 patient. Five patients had a history of trauma in the region of the joint. Four patients had prior joint incision and drainage. Unilateral sternoclavicular joint resection was done in 18 patients, bilateral resection in 2 patients, and incision and drainage with debridement in 6 patients. Wound culture results were positive in 24 patients, and the most common organism isolated was Staphylococcus aureus (n = 17). Eleven patients had transposition of the ipsilateral pectoralis major muscle to obliterate residual space and to reconstruct the chest wall. Two (7.7%) patients had complications, and 1 died (operative mortality, 3.8%). Follow-up was complete in all 25 operative survivors and ranged from 2 months to 10 years (median, 25 months). Twenty-one patients are alive without symptoms, infection, or limitations in range of motion. Four patients have died as a result of causes unrelated to their joint infections. CONCLUSIONS: Symptomatic sternoclavicular joint infections often require surgical intervention. Surgical resection combined with muscle transposition provides effective long-term outcome.
Adult↗
Effects of antireflux procedures on respiratory symptoms.
BACKGROUND: Antireflux surgery can reduce respiratory symptoms associated with gastroesophageal reflux. However, there is a paucity of data on the durability of this benefit. To evaluate the long-term effects of antireflux surgery on respiratory complaints associated with gastroesophageal reflux, we reviewed our experience. METHODS: Retrospective review of 2,123 antireflux procedures completed between 1986 and 1998 identified 65 patients (3.1%) with associated respiratory symptoms. There were 32 men and 33 women, ranging in age from 20 to 80 years (median 59 years). Respiratory symptoms included wheezing in 43 patients, sputum production in 37, cough in 30, choking episodes in 24, and hoarseness in 17. Preoperative medication use included steroids in 23 patients and bronchodilators in 18. RESULTS: Antireflux operations included the uncut Collis-Nissen fundoplication in 29 patients, Belsy Mark IV repair in 13, open Nissen fundoplication in 13, and laparoscopic Nissen fundoplication in 10. Perioperative complications occurred in 19 patients who underwent open procedures and in none who had laparoscopic procedures. There was one death in the open-operation group and none in the laparoscopic group. Median follow-up was 65 months (range 1 to 174 months) and was complete in 62 patients (96.9%). Improvement in respiratory symptoms (83%) and reduction in-respiratory medication use (78%) were significant as compared to a calculated 33% placebo-effect improvement (p < 0.05). CONCLUSIONS: Antireflux operations significantly reduce respiratory complaints associated with gastroesophageal reflux. This benefit appears to be long term.
Adult↗
High-grade esophageal dysplasia: long-term survival and quality of life after esophagectomy.
BACKGROUND: Esophagectomy for high-grade dysplasia in Barrett's esophagus has been advocated. Although long-term survival data exist, little is known about functional outcome and quality of life in this particular subset of patients. METHODS: The records of all patients who underwent esophageal resection for high-grade dysplasia from June 1991 through July 1997 were reviewed. Long-term functional outcome and quality of life were assessed using a two-part written survey. RESULTS: There were 54 patients (48 men, 6 women). Median age was 64 years (range, 36 to 83 years). Ivor Lewis esophagogastrectomy was performed in 34 patients (63%), transhiatal esophagectomy in 10 (18%), extended esophagectomy in 8 (15%), and other in 2 (4%). Invasive carcinoma was found in 19 patients (35%). Five patients (9%) were stage 0, 7 (13%) stage I, 3 (6%) stage IIA, 1 (2%) stage IIB, and 3 patients (6%) stage III. There was one operative death (1.8%). Complications occurred in 31 patients (57%). Median hospitalization was 13 days (range, 11 to 44 days). Follow-up was complete in all patients and ranged from 6 months to 9 years (median, 63 months). Overall 5-year survival was 86% and did not differ significantly from a population matched for age and gender. Five-year survival for patients with only high-grade dysplasia was 96% and 68% for patients with cancer (p = 0.017). Quality of life was measured by the Medical Outcomes Study 36-Item Short-Form Health Survey. For patients with only high-grade dysplasia, the role-physical and role-emotional scores were better than for the control population (p < 0.03). For patients with cancer, the health perception score was worse than for the control population (p < 0.03). Scores measuring physical-function, social function, mental health, bodily pain, and energy/fatigue were similar. CONCLUSIONS: Although perioperative morbidity is significant, surgical resection of high-grade dysplasia in Barrett's esophagus provides excellent long-term survival with acceptable function and quality of life.
Adult↗