Biomedical subjects
Publications and source records attributed to Francis C Nichols.
Esophageal diverticula can cause disabling symptoms. The authors describe here our preferred surgical approach for Zenker's and epi-phrenic diverticula. For most patients, excision of the diverticulum and addition of a myotomy will result in a favorable functional outcome and a low recurrence rate.
Esophagectomy is the treatment of choice for cancer or high-grade dysplasia. Although the patients frequently experience symptoms postoperatively, their quality of life is most often comparable to that of a control population. This article provides details of post-esophagectomy symptomatology and examines how quality of life can be measured in these patients.
Previous laboratory and pilot clinical trial data suggest that vitamin and/or mineral supplementation may prevent tumor growth in small cell lung cancer. However, rates of supplementation and their major purported clinical effects have never before been studied in patients with small cell lung cancer. This study was undertaken to explore associations between vitamin/mineral supplementation and survival and quality of life within a cohort of small cell lung cancer patients. This study focused on a small cell lung cancer patient cohort from a tertiary care medical center. Small cell lung cancer patients who responded to a follow-up questionnaire on vitamin/mineral use were included. Associations between vitamin/mineral use and both survival and quality of life (Lung Cancer Symptom Scale) were assessed. A total of 178 patients or their proxies responded to one or more vitamin/mineral questionnaires. One hundred seven (60%) were vitamin/mineral users of either multivitamins or other more specific vitamin/mineral supplements, and the rest were nonusers. Two different survival analyses were performed. In the first, median survival was 1.8 vs. 1.3 yr for vitamin/mineral users and nonusers, respectively. The relative risk of death was 0.63 (95% confidence interval [CI]: 0.43, 0.92; P = 0.02) in favor of vitamin/mineral use. After adjustment for multiple prognostic factors, including tumor stage, the relative risk for death was 0.65 (95% CI: 0.43, 1.00; P = 0.05). The second analysis was based on an alternative definition of vitamin/mineral use and showed only a trend to suggest an association between vitamin/mineral use and improved survival (P = 0.09). There were no significant improvements in quality of life in any of the analyses. Vitamin/mineral supplementation is common within this cohort of small cell lung cancer patients. These data suggest an association between vitamin/mineral supplementation and improved survival and point to a need for future studies on vitamin and mineral supplementation in small cell lung cancer patients.
OBJECTIVES: To characterize the etiology of chylothorax in patients encountered at a single tertiary referral center and to compare the findings with those from previous studies. PATIENTS AND METHODS: The medical records of all patients with chylothorax seen at the Mayo Clinic in Rochester, Minn, over a 21-year period, from January 1, 1980, to December 31, 2000, were retrospectively reviewed to ascertain the underlying cause of their condition. RESULTS: We identified 203 patients with chylothorax; 92 were females (male-female ratio, 1.21). The median age was 54.5 years (range, 21 weeks' gestation to 93 years). Dyspnea, the most common presenting symptom, occurred in 98 (56.6%) of 173 patients in whom initial symptoms were recorded, whereas 64 (37.0%) had no respiratory symptoms. Median duration of symptoms before diagnosis was 7.5 weeks (range, 1 day to 4.5 years). Causes of chylothorax included surgery or trauma in 101 patients (49.8%), various medical conditions in 89 (43.8%), and unknown in 13 (6.4%). Among surgical procedures, esophagectomy (29 patients) and surgery for congenital heart disease (28 patients) were the most common causes of chylothorax. Among medical conditions, lymphoma (23 patients), lymphatic disorders (19 patients), and chylous ascites (16 patients) were the most common causes. CONCLUSIONS: Chylothorax has numerous causes. In contrast to previous studies, surgery or trauma was the most common cause of chylothorax at our institution, accounting for nearly 50% of cases. Lymphoma and other malignancies caused chylothorax in only 16.7% of cases. These numbers are possibly related to the high volume of cardiothoracic surgical procedures performed at our tertiary referral center.
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.
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.
BACKGROUND: Gender has been reported as a predictor for nonsmall cell lung cancer (NSCLC) survival. Most of the reports are limited to selected groups of patients. The magnitude of gender effect on NSCLC survival across disease stage, tumor histology, and therapies needs to be further characterized. METHODS: A cohort of 4,618 patients diagnosed with NSCLC was prospectively enrolled and actively followed. Vital status of each patient was verified through multiple complementary sources. Cox proportional hazards models were developed to compare postdiagnosis survival between genders adjusting for age at diagnosis, tumor histology and grade, stage, pack-years smoked, and treatment received (resection, radiation, or chemotherapy). RESULTS: There were 2,724 men (59%) and 1,894 women (41%), with a median age at diagnosis of 68 years in men and 66 in women (p < 0.01). More men smoked and were heavier smokers than women. Adenocarcinoma was the most frequent histology in both genders. No difference was found in stage and treatment between genders. The estimated survival in men was 51% (95% CI: 49%, 53%) and 15% (95% CI: 12%, 17%) at one and five years, respectively, and in women was 60% (95% CI: 58%, 62%) and 19% (95% CI: 16%, 22%). Men were at a significantly increased risk of mortality compared to women following a diagnosis of NSCLC (adjusted relative risk: 1.20, 95% CI: 1.11, 1.30), particularly for patients with stage III/IV disease or adenocarcinoma. CONCLUSIONS: Male gender is confirmed to be an independent unfavorable prognostic indicator for NSCLC survival.
BACKGROUND: We are analyzing our experience with treatment of desmoid tumors of the chest wall and adjacent structures. METHODS: A retrospective review was undertaken of the records of all patients who underwent surgical management for a desmoid tumor of the chest between January 1980 and December 2001 at one institution. Fifty-three patients (24 men and 29 women) were identified, whose median age was 39 years (range 10 to 78 years). RESULTS: The desmoid tumor involved the chest wall exclusively in 25 patients (47%) and both the chest wall and adjacent structures in 28 (53%). Twenty-eight patients (53%) had previous resections for a desmoid tumor. Three patients also had previous radiation therapy. A wide radical resection was attempted in all 53 patients; resection was complete in 44. Seven patients had positive microscopic margins and 2 had gross residual disease. Complications were noted in 6 patients (11%); no operative deaths occurred. Median hospitalization was 6 days (range 1 to 124 days). Nineteen patients (36%) had postoperative radiation therapy (12 had complete resection and 7 had positive margins). Follow-up was complete in 51 patients (96%) and ranged from 2 weeks to 21 years (median 53 months). At the end of the review 46 patients were alive with no recurrence; 3 were alive with local recurrence and 2 died (1 from metastatic breast cancer and 1 from unknown cause). Five-year overall probability of developing a local recurrence was 37.5% (95% confidence interval, 20.2% to 53.3%). Recurrence occurred in 8 of 9 patients with positive margins (89%) and 8 of 44 with negative margins (18%). Factors adversely affecting the rate of postoperative recurrence were reoperation (p = 0.0199), positive margins (p < 0.0001), and postoperative radiation therapy (p = 0.0027). Eleven patients (22%) required reoperation at a median of 24.6 months postoperatively (range 11 to 78 months). CONCLUSIONS: Desmoid tumors involving the chest and adjacent structures are locally aggressive tumors with a high recurrence rate. Wide radical resection should be attempted whenever possible. Positive margins at resection, reoperation and postoperative radiation are associated with a high risk of local recurrence.
OBJECTIVE: Screening for lung cancer with computed tomography may detect cancers at an earlier stage but may also result in overdiagnosis. We reviewed the thoracic surgical operations performed on patients enrolled in our computed tomographic screening program. METHODS: From January 1999 through December 2002, screening computed tomography for lung cancer was performed annually on 1520 participants. All participants were at least 50 years old and smoked more than 20 pack/y. We found 3130 indeterminate pulmonary nodules in 1112 participants (73%). Fifty-five participants (3.6%) underwent 60 thoracic operations for a variety of indications. The medical records of these 55 patients were reviewed. RESULTS: Indications for operation included suspicious pulmonary nodules, mediastinal adenopathy, and a spontaneous pneumothorax. Operations performed included a lobectomy in 37 cases, wedge resection in 11, segmentectomy in 6, video-assisted thoracoscopic surgical talc pleurodesis in 1, bilobectomy in 2, mediastinoscopy in 2, and anterior mediastinotomy in 1. Benign disease was found in 10 patients (18.1%), and lung cancer was found in 45 (81.9%), 2 of whom had metachronous lung cancers. Cell types were adenocarcinoma in 15 cancers, bronchioloalveolar cell carcinoma in 13, squamous cell in 13, carcinoid in 2, small cell in 2, and large cell and undifferentiated non-small cell in 1 case each. Twenty-eight cancers were classified as stage IA, 4 as IB, 4 as IIA, 1 as IIB, 4 as IIIA, 3 as IIIB, 1 as IV, and 2 as limited small cell carcinoma. Complications occurred in 27% of patients. Operative mortality was 1.7%. CONCLUSION: Computed tomographic screening finds a large number of indeterminate pulmonary nodules in smokers 50 years old or older, most of which are observed and not operated on. Although 47 cancers were detected thus far in this highly selected group of patients, this represents only 1.5% of the pulmonary nodules identified.
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.
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.
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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.
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.
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.
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.
OBJECTIVE: Lung cancer invading the chest wall without lymph node metastasis has recently been downstaged to stage IIb. To validate this reclassification, we reviewed our experience with en bloc lung and chest wall resection for bronchogenic carcinoma. METHODS: From February 1985 to November 1999, 95 en bloc lung and chest wall resections were performed on 94 patients (62 men and 32 women). The median age was 66 years (range, 38-93 years). Pancoast tumors were excluded. Factors that may affect survival were analyzed with univariate analysis, and factors found to be significant univariately were analyzed multivariately to determine whether the significant association remained after adjusting for other significant factors. RESULTS: Presenting symptoms included chest wall pain in 42 patients, cough in 17 patients, and "other" in 16 patients. Twenty patients were asymptomatic. Ninety-two patients were current or former smokers (median pack-years, 50; range, 8-150 pack-years). Seventy-five lobectomies, 12 pneumonectomies, 5 bilobectomies, 2 wedge excisions, and 1 segmentectomy were performed. The number of ribs resected ranged from 1 to 5 (median, 3). Sixty-one patients required chest wall reconstruction (prostheses in 60 and bovine pericardium in 1). Operative morbidity and mortality were 44.2% and 6.3%, respectively. Sixty-five cancers were classified as T3 N0 M0, 16 as T3 N1 M0, and 14 as T3 N2 M0. Squamous cell carcinoma was present in 56 tumors, adenocarcinoma in 25, large cell carcinoma in 11, and "other" in 3. Follow-up was complete in 86 (96.6%) of 89 operative survivors and ranged from 1 month to 15 years (median, 19 months). Overall 5-year actuarial survival was 38.7%. Five-year survival for patients with stage IIb disease (T3 N0 M0) was 44.3% compared with only 26.3% for those with stage IIIa disease (T3 N1 M0 or T3 N2 M0, P =.0082). Women had a better 5-year survival than men (52.9% vs 31.0%, P =.0122). The best 5-year survival was observed in women with stage IIb disease (61.2%). All other variables (age, tumor size, histopathology, forced expiratory volume in 1 second, extent of operation, depth of invasion, and adjuvant therapy) did not significantly affect survival. CONCLUSIONS: En bloc resection of lung cancer invading the chest wall is safe but associated with significant morbidity. Long-term survival is stage and sex dependent. The best survival is observed in women who have T3 N0 M0 disease (stage IIb).