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Biomedical subjects

Mark S Allen

Publications and source records attributed to Mark S Allen.

At least 19 recordsLinked to original sources
PubMed2007

The utility of fluorodeoxyglucose positron emission tomography in the evaluation of carcinoid tumors presenting as pulmonary nodules.

BACKGROUND: Fluorodeoxyglucose positron emission tomography (FDG-PET) is sensitive for detection of neoplastic solitary pulmonary nodules but may have decreased sensitivity for detection of carcinoid tumors. Our purpose was to determine the sensitivity of FDG-PET to detect pulmonary carcinoid tumors. METHODS: We performed a retrospective review of our institutional results regarding FDG-PET in the setting of thoracic carcinoid neoplasms. We identified 16 patients with a pathologic diagnosis of bronchial carcinoid who had an antecedent FDG-PET (from 2000 to 2004). All patients but one presented with pulmonary nodule(s). RESULTS: Sixteen patients had a diagnosis of carcinoid tumor, typical in 11 patients and atypical in 5 patients. The mean greatest pathologic dimension was 2.08 cm (range, 1.0 to 8.3 cm). Overall positron emission tomography (PET) sensitivity was 75% (12 true-positive and 4 false-negative results). The mean (+/- SD) size of carcinoids with false-negative PET results was not significantly different from carcinoids with true-positive results (1.6 +/- 0.81 cm and 2.35 +/- 1.87 cm, p = 0.54). Fifteen of 16 patients were staged pathologically, and positive nodes were found in 2 of these patients. PET lymph node staging agreed with pathologic staging in one stage 4 patient with positive lymph nodes and distant metastasis, but PET results were false negative in the other patient who had N2 with micrometastatic disease; stage IIIA. CONCLUSIONS: FDG-PET imaging is useful for evaluation of typical and atypical thoracic carcinoid tumors. Although overall PET sensitivity for detection of carcinoid tumors is somewhat reduced as compared to non-small cell lung cancer, it is much higher than prior reports suggest.

Adult↗
PubMed2006

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

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

Adenocarcinoma↗
PubMed2006

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

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

Adult↗
PubMed2006

Morbidity and mortality of major pulmonary resections in patients with early-stage lung cancer: initial results of the randomized, prospective ACOSOG Z0030 trial.

BACKGROUND: Little prospective, multiinstitutional data exist regarding the morbidity and mortality after major pulmonary resections for lung cancer or whether a mediastinal lymph node dissection increases morbidity and mortality. METHODS: Prospectively collected 30-day postoperative data was analyzed from 1,111 patients undergoing pulmonary resection who were enrolled from July 1999 to February 2004 in a randomized trial comparing lymph node sampling versus mediastinal lymph node dissection for early stage lung cancer. RESULTS: Of the 1,111 patients randomized, 1,023 were included in the analysis. Median age was 68 years (range, 23 to 89 years); 52% were men. Lobectomy was performed in 766 (75%) and pneumonectomy in 42 (4%). Pathologic stage was IA in 424 (42%), IB in 418 (41%), IIA in 37 (4%), IIB in 97 (9%), and III in 45 (5%). Lymph node sampling was performed in 498 patients and lymph node dissection in 525. Operative mortality was 2.0% (10 of 498) for lymph node sampling and 0.76% (4 of 525) for lymph node dissection. Complications occurred in 38% of patients in each group. Lymph node dissection had a longer median operative time and greater total chest tube drainage (15 minutes, 121 mL, respectively). There was no difference in the median hospitalization, which was 6 days in each group (p = 0.404). CONCLUSIONS: Complete mediastinal lymphadenectomy adds little morbidity to a pulmonary resection for lung cancer. These data from a current, multiinstitutional cohort of patients who underwent a major pulmonary resection constitute a new baseline with which to compare results in the future.

Adult↗
PubMed2006

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

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

Adult↗
PubMed2006

Failed antireflux surgery: results after reoperation.

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

Adult↗
PubMed2006

Postpneumonectomy empyema: results after the Clagett procedure.

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

Adult↗
PubMed2006

Gynecologic cancers: factors affecting survival after pulmonary metastasectomy.

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

Adenocarcinoma↗
PubMed2006

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

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

Adenocarcinoma↗
PubMed2006

Nontraumatic disruption of the fibrocartilaginous trachea: causes and clinical outcomes.

BACKGROUND: Nontraumatic disruption of the fibrocartilaginous trachea is rare, and the appropriate management of this condition is not well-characterized. METHODS: Retrospective analysis of the clinical features, causes, and outcomes with surgical and nonsurgical management in nine adult patients with nontraumatic fibrocartilaginous tracheal disruption identified by bronchoscopy from January 1, 1975, to December 31, 2004, at a single institution. RESULTS: The most common cause was external beam radiotherapy (RT) in five patients. Other causes included postoperative complications of cervical and superior mediastinal operations in three patients and Aspergillus fumigatus-induced ulcerative tracheobronchitis in one patient post-lung transplantation. Four patients were treated surgically; three because of significant pneumomediastinum and one because the size of the tracheal defect made spontaneous healing seem unlikely. A silicone stent was placed in one patient for concomitant tracheal narrowing, and one patient was treated medically with antifungal agents. The remaining three patients were followed up serially without any intervention. With these treatments, only one patient died as a consequence of tracheal disruption. Repeat bronchoscopies were performed in seven of the remaining eight patients and confirmed healing of the necrotic defect in all. CONCLUSION: Nontraumatic disruption of the fibrocartilaginous trachea occurs most commonly as a consequence of external beam RT. It can also occur as a complication of cervical and superior mediastinal operations or from A fumigatus-induced ulcerative tracheobronchitis post-lung transplantation. Although surgical treatment has been generally recommended for patients with this condition, patients with contained disruptions without evidence of pneumomediastinum may be managed nonoperatively.

Aged↗
PubMed2006

The role of pulmonary resection in small cell lung cancer.

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

Adult↗
PubMed2005

Pulmonary carcinoid tumors with Cushing's syndrome: an aggressive variant or not?

BACKGROUND: Adrenocorticotropic hormone (ACTH)-secreting pulmonary carcinoid is considered an aggressive variant of carcinoid tumors. Current knowledge is based upon a limited number of reports with few patients. METHODS: All patients with Cushing's syndrome (CS) resulting from pulmonary carcinoid (PC) who underwent pulmonary resection at our institution from November 1966 through April 1998 were reviewed. RESULTS: The group studied consisted of 10 males and 13 females. The median age was 39 years (range: 14-71). Pulmonary symptoms were present in 4 patients. Chest radiographs identified an abnormality in 13 patients (57%) and chest computerized tomography (CT) identified an abnormality in all 20 patients examined. Before pulmonary resection, hypophysectomy and bilateral adrenalectomy were performed in 7 patients (30%) each. Median time interval from presentation to pulmonary resection was 17 months (range: 1-228). Lobectomy was performed in 16 patients, segmentectomy was performed in 4 patients, and bilobectomy, pneumonectomy, and wedge excision was performed in 1 patient each. There were no operative deaths. Typical carcinoid was identified in 21 patients (91%) and atypical carcinoid was identified in 2 patients (9%). The median tumor diameter was 1.3 cm (range: 0.3-10). Nineteen patients (83%) underwent mediastinal lymphadenectomy and lymph node metastasis was found in 6 patients (32%) (N1 in 4 patients, N2 in 2 patients). The median follow-up was 78 months (range: 1-432). CS resolved in all of the patients. CS with PC recurred in 4 patients and CS alone recurred in 1 patient. Two patients underwent curative re-resection. Two patients, one with disseminated PC, died at last follow-up. CONCLUSIONS: Despite long delays in surgical therapy, pulmonary resection for ACTH-secreting PCs results in a favorable prognosis. Anatomic resection with complete mediastinal lymphadenectomy decreases local recurrence. Although rare these tumors do not seem to be as aggressive a variant of typical carcinoid tumors as previously reported.

Adolescent↗
PubMed2005

Locally recurrent esophageal carcinoma: when is re-resection indicated?

BACKGROUND: Limited locally recurrent esophageal carcinoma is rare, and little is known regarding effectiveness of re-resection. METHODS: Medical records of 27 consecutive patients with locally recurrent esophageal carcinoma who underwent reoperation at our institution between February 1974 and January 2003 were analyzed. RESULTS: The original and recurrent cancer cell types were identical in all patients. Median disease-free interval was 19.4 months (range, 2.5 to 170 months). Recurrence was at the anastomosis in 23 patients (85%), esophageal remnant in 3 (11%), and stomach in 1 (4%). Ten patients had completion gastrectomy and partial esophagectomy, and 9 had resection of the anastomosis. The remaining 8 patients were found intraoperatively to have unresectable disease and underwent biopsy only. Re-resection was complete in 15 of the 19 patients resected (79%). Four patients had microscopic cancer at the resection margins. Reconstruction was with colon in 10 patients and esophagogastrostomy in 9. There were 2 deaths (operative mortality, 7%). Complications occurred in 16 patients (59%). Arrhythmia and anastomotic leak were the most common complications and each occurred in 7 patients (26%). Factors favorably associated with survival were disease-free interval greater than 2 years (p < or = 0.05) and complete re-resection (p < or = 0.02). Two-, three-, and five-year survival for patients completely re-resected was 62%, 44%, and 35%, respectively. Survival for patients who had incomplete re-resections was 18% at 2 years and zero at 3 years. CONCLUSIONS: Re-resection of locally recurrent esophageal carcinoma is associated with considerable morbidity. However, long-term survival is possible in patients with a long disease-free interval or a complete re-resection.

Adult↗
PubMed2005

Laparoscopic esophageal myotomy for achalasia: factors affecting functional results.

BACKGROUND: We reviewed our experience and analyzed factors affecting functional results after laparoscopic esophageal myotomy (LEM) for achalasia. METHODS: From January 1996 through October 2003, the records of 211 patients (110 men and 101 women) who had LEM for achalasia were reviewed, and factors affecting morbidity and functional results were analyzed. RESULTS: Median age was 47 years (range, 12 to 85). One hundred and twenty-five patients (59%) had prior esophageal dilatation and/or botulinum toxin injection and 19 (9%) had a prior myotomy. A partial fundoplication was performed in 198 patients (94%); posterior in 135 and anterior in 63. Median operative time was 208 minutes (range, 90 to 527). Intraoperative complications occurred in 37 patients (17.5%), and included mucosal perforation in 32, pneumothorax in 2, and retained needle, splenic capsular tear, and gastric short vessel bleeding in 1 each. Five patients (2%) required conversion to an open procedure. Postoperative complications occurred in 17 patients (8%) including 2 patients who required reoperation for leak. There were no perioperative deaths. Median hospitalization was 3 days (range, 1 to 48). Follow-up was complete in 167 patients (79%) and ranged from 1 to 70.5 months (median, 5.3). Functional results were classified as excellent in 105 patients (63%), good in 43 (26 %), and fair or poor in 19 (11%). Previous esophageal surgery for achalasia adversely affected functional results (p = 0.0139). Preoperative bougie dilatation (p = 0.9851), pneumatic dilatation (p = 0.8548), botulinum toxin injection (p = 0.1724), and the type of fundoplication (p = 0.5904) did not affect functional results. Preoperative bougie dilatation (p = 0.441), pneumatic dilatation (p = 0.1060), and botulinum toxin injection (p = 0.3938) did not affect the incidence of intraoperative perforation. As experience is gained, the incidence of intraoperative complications has decreased significantly (p = 0.0075). CONCLUSIONS: Laparoscopic myotomy for achalasia is safe and effective in the majority of patients. The incidence of intraoperative complications decreases as experience is gained. Preoperative endoscopic treatment does not preclude successful surgical outcome. Excellent or good functional results are achieved in the majority of patients although previous surgical treatment adversely affects functional results.

Adolescent↗
PubMed2005

Pulmonary resection for metastatic malignant fibrous histiocytoma: an analysis of prognostic factors.

BACKGROUND: Factors affecting recurrence and survival after pulmonary resection for metastatic malignant fibrous histiocytoma (MFH) are not well known. METHODS: Records of patients undergoing pulmonary metastasectomy for MFH between January 1976 and January 2000 were analyzed. RESULTS: There were 103 patients (46 men and 57 women). Median age was 60 years (range, 20 to 86). Malignant fibrous histiocytoma metastasis was solitary in 29 patients (28%), multiple/unilateral in 33 (32%), and multiple/bilateral in 41 (40%). Median time interval from primary tumor resection to metastasectomy was 11 months (range, 0 to 86). Wedge resection was carried out in 87 patients (84%), segmentectomy in 3 (3%), lobectomy in 3 (3%), pneumonectomy in 2 (2%), and a combination of resections in 8 (8%). Resection was complete in 93 patients (90%). Complications occurred in 11 patients (11%) and included prolonged air leak in 7, and pneumonia, empyema, atelectasis, and sepsis in 1 each. One patient died (operative mortality, 1%). Follow-up ranged from 2 weeks to 153 months (median, 18 months). Five-year survival was 21% (95% confidence interval, 14% to 31%). In the 103 patients, incomplete resection (p < 0.0001) was associated with decreased survival. Among the 93 patients with complete resection, factors associated with decreased survival included the presence of extrapulmonary disease at time of metastasectomy (p = 0.01), more than two nodules resected (p = 0.001), and adjuvant therapy after metastasectomy (p = 0.0007). CONCLUSIONS: Pulmonary resection of metastatic MFH is safe. Improved survival was associated with the absence of extrapulmonary disease at time of metastasectomy, with fewer than three pulmonary nodules resected, and with a complete resection.

Adult↗
PubMed2005

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

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

Adult↗
PubMed2005

Selective management of intrathoracic anastomotic leak after esophagectomy.

OBJECTIVE: We sought to analyze our experience with management of intrathoracic anastomotic leak after esophagectomy. METHODS: All patients who had intrathoracic anastomotic leaks after esophagectomy were reviewed. Management and factors affecting outcome were analyzed. RESULTS: From March 1993 through February 2003, 761 patients had esophagectomy with intrathoracic anastomosis at our institution. Forty-eight (6.3%) patients had an anastomotic leak; one refused authorization to review his medical record and was excluded from further analysis. Twenty-four (51.1%) patients had a contained leak. Twenty-seven (57.4%) patients were managed nonoperatively. Twenty (42.6%) patients required surgical intervention that included primary anastomotic repair in 14 patients, reinforcement of the anastomosis with viable tissue in 6 patients, and esophageal diversion in 2 patients. A single reoperation was done in 15 patients, and 5 patients had 2 reoperations. Median hospitalization in the reoperative group was 31 days (range, 15-97 days) and 20 days (range, 10-42 days) in the nonoperative group ( P = .0037). Four (8.5%) patients died. Cause of death was sepsis in 2 patients and multiorgan failure and myocardial infarction in 1 patient each. At follow-up (median, 8 months; range, 1-120 months), 10 (58.8%) patients in the reoperative group were eating a normal diet and 5 (29.4%) patients required at least one dilatation compared with 20 (76.9%) patients in the nonoperative group who were eating a normal diet and 9 (34.6%) who required at least one dilatation. A noncontained leak had an adverse effect on long-term survival ( P = .04). CONCLUSION: Intrathoracic anastomotic leak after esophagectomy is associated with significant morbidity and mortality. Contained leaks often can be managed nonoperatively. When surgical management is required, esophagogastric continuity can often be maintained in the majority of patients. Long-term functional results are satisfactory and similar in both the reoperative and nonoperative groups. However, a noncontained leak adversely affected long-term survival.

Adenocarcinoma↗