Case 4. Pulmonary stent migration and ingestion in a lung cancer patient.
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Aged↗
Biomedical subjects
Neil A Christie
Publications and source records attributed to Neil A Christie.
Minimally invasive operation for esophageal diverticula.
BACKGROUND: Mid and lower esophageal diverticula are rare entities usually managed by open operation. Morbidity can be significant with these complex procedures. This study evaluates our results of minimally invasive surgery for esophageal diverticula. METHODS: Over a 5-year period, 20 patients underwent operation for esophageal diverticula. Median age was 70.5 years. There were 16 epiphrenic and 4 midesophageal diverticula with a median size of 7.5 cm (range, 2-11 cm). Symptoms included dysphagia (14), regurgitation (12), weight loss (8), heartburn (4), aspiration pneumonia (3), chest pain (2), and vomiting (2). Dysphagia scores (1 = none, 5 = severe) were recorded before and after operation. RESULTS: Surgical approaches were laparoscopy (10), video-assisted thoracic surgery (VATS) (7), laparoscopic/VATS (2), and laparoscopic/thoracotomy (1). The most common operation performed was a diverticulectomy, myotomy, and partial fundoplication (12). Complications occurred in 9 (45%) patients and included 4 (20%) esophageal leaks. Three leak patients had successful outcomes; the fourth patient died 61 days after operation. Median hospital stay was 5.0 (1-61) days. Detailed follow-up was available in 18 patients at a median of 15 (1-70) months. Dysphagia scores improved significantly (p < 0.001) from 2.3 to 1.3 postoperatively. Symptomatic improvement was excellent in 13 (72%), good in 2 (11%), fair in 1 (6%), and poor in 2 (11%) patients. CONCLUSIONS: Minimally invasive operations for esophageal diverticula are feasible but also challenging. The potential for morbidity is significant. Patients should be selected and evaluated carefully before undertaking repair. Open surgery should remain the standard except in centers experienced with minimally invasive esophageal surgery.
Adult↗
Radiofrequency ablation for the treatment of non-small cell lung cancer in marginal surgical candidates.
OBJECTIVE: Treatment options for patients with non-small cell lung cancer who are not surgical candidates or who refuse operation are limited. Radiofrequency ablation represents a potential less invasive option for these patients. Our initial experience with radiofrequency ablation for peripheral, primary non-small cell lung cancer is reported. METHODS: We treated 21 tumors in 18 patients. Median age was 75 (range 58-86) years. Cancer stages were I (n = 9), II (n = 2), III (n = 3), and IV (n = 4). Patients with stage IV disease included 3 with recurrence after previous lobectomies and 1 with a synchronous liver metastasis also treated with radiofrequency ablation. Median tumor diameter was 2.8 cm (range 1.2-4.5 cm). Radiofrequency ablation was delivered by minithoracotomy in 2 cases and by a computed tomography-guided percutaneous approach in 16 patients. Computed tomographic and positron emission tomographic scans were used to evaluate recurrence and radiographic response in ablated nodules. RESULTS: One postoperative death occurred from pneumonia after open radiofrequency ablation. Median hospital stay was 2.5 days. A chest tube or pigtail catheter was required in 7 patients (38.9%) for procedure-related pneumothoraces. At a median follow-up of 14 months, 15 patients (83.3%) were alive. Local progression occurred in 8 nodules (38.1%). Mean and median progression-free intervals were 16.8 and 18 months, respectively. For stage I cancers, mean progression-free interval was 17.6 months. Median progression-free interval was not reached. CONCLUSION: This study demonstrates the feasibility of radiofrequency ablation for small, peripheral non-small cell lung cancer tumors. Local control is comparable to, if not better than, that provided by radiotherapy. Radiofrequency ablation should continue to be evaluated by thoracic surgeons as a noninvasive therapy for the high-risk patient with non-small cell lung cancer.
Aged↗
Esophageal palliation--photodynamic therapy/stents/brachytherapy.
The optimal treatment for malignant dysphagia should be safe, effective,cost-effective, and have minimal morbidity. Photodynamic therapy,brachytherapy, and esophageal stenting all represent viable options for the palliation of malignant dysphagia. Characterization of the patients and their tumors allows individualization of the treatment and the selection of the optimal treatment for each individual patient. Institutional resources and expertise also are significant factors in treatment. Further comparative studies may help further delineate the relative merits of these treatments and the optimal treatment of patients with malignant obstruction.
Brachytherapy↗
Efficacy of laparoscopic fundoplication in controlling pulmonary symptoms associated with gastroesophageal reflux disease.
BACKGROUND: Gastroesophageal reflux disease (GERD)-induced pulmonary symptoms (PS) can be difficult to control. The effectiveness of laparoscopic fundoplication (LF) in controlling PS among patients with medically recalcitrant GERD is poorly documented. We evaluated our results in controlling important PS in patients with GERD undergoing LF. METHODS: Seventy-four patients (28 men, 46 women) were identified with clinically important PS from a prospective cohort of 155 patients undergoing elective LF for recalcitrant GERD. Median age was 52.5 years (range, 29-84 years). Sixty-seven (91%) patients were taking proton pump inhibitors at the time of operation. Quality of life by using the SF36 physical (PCS) and mental (MCS) component summary scores (normal, 50) and heartburn severity by using the health-related quality of life (HRQOL) (best score, 0; worst score, 45) were measured. RESULTS: All 74 patients with PS survived operation, and minor morbidity occurred in 5 (7%) patients. Median hospital stay was 2 days (range, 1-6 days), and return to normal activity was seen at 2.2 weeks (range, 1-8 weeks). Median follow-up was 12 months. PS were improved significantly (P < .01) for hoarseness (62% to 17.6%), bronchospasm (60% to 9.5%), and aspiration (22% to 1.4%). Before LF, 11 (14.9%) patients required bronchodilators or oral steroids. Postoperatively such therapy was required in only 3 (4.2%) patients (P = .019), with no patient requiring oral steroids. Patients with poorer control of their GERD on the basis of high HRQOL scores had significantly more PS after operation. CONCLUSIONS: A significant number of patients with medically recalcitrant GERD (46% from our prospective database) have important PS. LF can improve PS, decrease requirement for pulmonary medications, as well as improve typical reflux symptoms and quality of life.
Adult↗
Biliary pleural fistula detected by hepatobiliary scintigraphy.
A biliary pleural fistula is a rare complication secondary to trauma, infection, malignancy, biliary disease, malignancies, or percutaneous procedures. Its presence may be suggested by the development of a right pleural effusion in a patient with such history and can be confirmed with a hepatobiliary scan or endoscopic retrograde cholangiopancreatography. Patients are treated with antibiotics and the fistula usually spontaneously closes. If after 2 weeks the fistula persists, percutaneous drainage, sphincterotomy, or biliary stent placement can be performed to promote healing of the fistula. In complicated cases, open thoracic surgery or video-assisted thoracic surgery may be required.
Aged↗
Nicotine signals through muscle-type and neuronal nicotinic acetylcholine receptors in both human bronchial epithelial cells and airway fibroblasts.
BACKGROUND: Non-neuronal cells, including those derived from lung, are reported to express nicotinic acetylcholine receptors (nAChR). We examined nAChR subunit expression in short-term cultures of human airway cells derived from a series of never smokers, ex-smokers, and active smokers. METHODS AND RESULTS: At the mRNA level, human bronchial epithelial (HBE) cells and airway fibroblasts expressed a range of nAChR subunits. In multiple cultures of both cell types, mRNA was detected for subunits that constitute functional muscle-type and neuronal-type pentomeric receptors. Two immortalized cell lines derived from HBE cells also expressed muscle-type and neuronal-type nAChR subunits. Airway fibroblasts expressed mRNA for three muscle-type subunits (alpha1, delta, and epsilon) significantly more often than HBE cells. Immunoblotting of HBE cell and airway fibroblast extracts confirmed that mRNA for many nAChR subunits is translated into detectable levels of protein, and evidence of glycosylation of nAChRs was observed. Some minor differences in nAChR expression were found based on smoking status in fibroblasts or HBE cells. Nicotine triggered calcium influx in the immortalized HBE cell line BEAS2B, which was blocked by alpha-bungarotoxin and to a lesser extent by hexamethonium. Activation of PKC and MAPK p38, but not MAPK p42/44, was observed in BEAS2B cells exposed to nicotine. In contrast, nicotine could activate p42/44 in airway fibroblasts within five minutes of exposure. CONCLUSIONS: These results suggest that muscle-type and neuronal-type nAChRs are functional in airway fibroblasts and HBE cells, that prior tobacco exposure does not appear to be an important variable in nAChR expression, and that distinct signaling pathways are observed in response to nicotine.
Bronchi↗
Comparison of mutational changes in involved N1 lymph nodes with those in primary tumors in stage II non-small cell lung cancer: a pilot study.
OBJECTIVES: Surgical resection is the standard treatment for stage II non-small cell lung cancer, but recurrence rates approach 60%. This study compared mutational changes in involved lymph nodes and primary tumors from patients with stage II non-small cell lung cancer to determine whether risk factors for recurrence could be identified. METHODS: Forty patients with resected stage II non-small cell lung cancer (excluding T3 N0 disease) were studied. Microdissection was performed on primary tumors and lymph nodes. Analysis was performed across 9 genomic loci by using polymerase chain reaction amplification. The ratio of fractional allelic loss between involved lymph nodes and primary tumors was used to stratify patients into high-risk (fractional allelic loss ratio of >or=1) and low-risk (fractional allelic loss ratio of <1) groups. RESULTS: The median age of the patients was 68 years (range, 42-85 years). Median follow-up was 30 months. Fractional allelic loss was greater in patients with squamous carcinomas compared with that in adenocarcinomas, but survival was similar (35 vs 39 months). The median survival was 35 months in high-risk patients and was not reached in low-risk patients (P =.3). Disease-free survival was 24 months in high-risk patients and was not reached in low-risk patients (P =.35). In the subset with adenocarcinoma (n = 18), median survival was 24 months in the high-risk group; no deaths occurred in low-risk patients (P =.01). Also, disease-free survival was 14 months in high-risk patients and was not reached in the low-risk patients (P =.05). CONCLUSIONS: Squamous cancers demonstrate greater mutational changes than adenocarcinomas; this does not affect outcome. The patients with low-risk adenocarcinomas demonstrated superior outcomes compared with those of other patients. These results should be confirmed in larger studies.
Adult↗
Fluorescent bronchoscopy.
Detection of clinically occult lung neoplasms may represent an opportunity for early curative intervention. Fluorescent bronchoscopy is a sensitive technique for detecting early endobronchial tumors that may be combined with CT scanning as part of a comprehensive lung cancer screening program. Identification and longitudinal follow-up of dysplastic endobronchial changes with fluorescent bronchoscopy should facilitate studies of chemoprevention and further knowledge regarding the natural history of these lesions. Analysis of bronchial epithelium with novel techniques such as genomic hybridization and gene expression arrays might provide even better predictors of progression of dysplastic endobronchial lesions.
Bronchial Neoplasms↗
Photodynamic therapy for endobronchial metastases from nonbronchogenic primaries.
BACKGROUND: Endobronchial metastases (EBM) occur in 2% of nonbronchogenic malignancies and frequently present with hemoptysis or dyspnea. This report summarizes our recent experience with photodynamic therapy (PDT) for EBM. METHODS: All patients who have undergone PDT for the treatment of symptomatic EBM from nonbronchogenic primaries were identified in the Division of Thoracic Surgery database to determine number of treatments, frequency of symptom relief, and patient survival. RESULTS: Endobronchial PDT was administered to 27 patients from April 1997 through December 2000. The predominant primary tumor was renal cell (44%). Endobronchial metastases presented metachronously in 74% of patients. Patients underwent a median of two PDT treatments. Local anesthesia with sedation was used in 76% of treatments. Four patients (15%) developed immediate postoperative respiratory distress. Follow-up bronchoscopy 24 to 48 hours after initial treatment demonstrated tumor necrosis in all cases. Acute relief of hemoptysis and dyspnea was achieved in 85% of patients. Seven patients died within 6 weeks of treatment. Median survival time after PDT was 4 months (range 0.2 to 30 months). CONCLUSIONS: Patients with EBM treated with PDT had a median survival of 4 months and patients with limited metastatic disease survived up to 30 months. Photodynamic therapy was effective in palliating hemoptysis or dyspnea from EBM with an acceptable morbidity, although the 30-day mortality was 22%.
Adult↗
Photodynamic therapy as palliation for esophageal cancer: experience in 215 patients.
BACKGROUND: Photodynamic therapy (PDT) utilizes a photosensitizing agent, light, and oxygen to endoscopically ablate cancer cells. This review summarizes our experience with PDT for the palliation of bleeding or obstructing esophageal cancer (EC). METHODS: All patients with bleeding or obstructing EC treated with PDT from November 1996 through June 2002, were reviewed. After Photofrin II injection, nonthermal light treatment was delivered endoscopically. Dysphagia scores, duration of palliation, reinterventions, complications, and survival after treatment were reviewed. RESULTS: A total of 215 patients underwent 318 courses of PDT for bleeding (n = 15), obstruction (n = 277), bleeding and obstruction (n = 18), or other indications (n = 8). Tumor histology included 179 adenocarcinomas, 33 squamous cell carcinomas, and 3 undifferentiated. Seventy-five percent of EC were in the distal esophagus. In 85% of courses for obstruction, mean dysphagia scores improved pre- and post-PDT. The mean dysphagia-free interval was 66 days. Supplemental nutrition was discontinued after PDT in 8 of 27 patients (30%). Thirty-five patients required stent placement after PDT with a mean interval to reintervention of 58.5 days. PDT complications included perforation (2% of treatment courses), stricture (2%), Candida esophagitis (2%), pleural effusions (4%), and sunburn (6%). The procedure-related mortality rate was 1.8%, and median survival was 4.8 months. CONCLUSIONS: PDT offers effective palliation for patients with obstructing EC in 85% of treatment courses. The ideal EC patient for PDT palliation has an obstructing endoluminal cancer. Patients living more than 2 months may require reintervention to maintain palliation of malignant dysphagia, and a multimodality treatment approach is common.
Adult↗
Radiofrequency ablation of pulmonary malignant tumors in nonsurgical candidates.
OBJECTIVE: Radiofrequency ablation applies thermal energy with a catheter delivery system, resulting in coagulation necrosis. Radiofrequency ablation is frequently used for hepatic malignant tumors, but few reports exist regarding its use for lung tumors. We report our experience with radiofrequency ablation for the treatment of pulmonary malignant tumors. METHODS: We evaluated the results of lung radiofrequency ablation for patients not considered surgical candidates. Indications for radiofrequency ablation were pulmonary malignant tumors in patients with medical comorbidities, pulmonary compromise, or refusal of surgery. RESULTS: Thirty-three lung tumors in 18 patients (12 male, 6 female) were treated with radiofrequency ablation. Tumors included metastatic carcinoma (n = 8), sarcoma (n = 5), and lung cancer (n = 5). Mean age was 60 years (range 27-95 years). Thoracic surgeons performed radiofrequency ablation by minithoracotomy (n = 5) or computed tomography-guided percutaneous methods (n = 13) with patients under general anesthesia in the operating room. Mean length of stay was 3 days (range 1-7 days). Complications included procedure-related pneumothorax in 7 of 13 percutaneous procedures (53.8%), delayed pneumothorax (1/18), pneumonitis/pneumonia (4/18), small pleural effusion (9/18) and transient renal failure (1/18). One death occurred as a result of hemoptysis 19 days after radiofrequency ablation of a central nodule. This patient had also received recent brachytherapy. After a mean follow-up of 6 months (range 1-14 months), radiofrequency ablation had achieved a radiographically determined response in 8 of 12 patients with treated tumors smaller than 5 cm (66.6%). Death with progressive metastatic disease occurred in 7 of 18 patients (38%) during follow-up. CONCLUSION: This pilot study demonstrates the feasibility of radiofrequency ablation for small peripheral lung tumors. Larger tumors responded poorly. Additional trials are needed to determine safety and efficacy.
Adult↗
Minimally invasive esophagectomy: outcomes in 222 patients.
OBJECTIVE: To assess our outcomes after minimally invasive esophagectomy (MIE). SUMMARY BACKGROUND DATA: Esophagectomy has traditionally been performed by open methods. Results from most series include mortality rates in excess of 5% and hospital stays frequently greater than 10 days. MIE has the potential to improve these results, but only a few small series have been reported. This report summarizes our experience of 222 cases. METHODS: From 1996 to 2002, MIE was performed in 222 patients. Indications for operation included high-grade dysplasia (n = 47) and cancer (n = 175). Neoadjuvant chemotherapy was used in 78 (35.1%) and radiation in 36 (16.2%). Initially, a laparoscopic transhiatal approach was used (n = 8), but subsequently our approach evolved to include thoracoscopic mobilization (n = 214). RESULTS: There were 186 men and 36 women. Median age was 66.5 years (range, 39-89). Nonemergent conversion to open procedure was required in 16 patients (7.2%). MIE was successfully completed in 206 (92.8%) patients. The median intensive care unit stay was 1 day (range, 1-30); hospital stay was 7 days (range, 3-75). Operative mortality was 1.4% (n = 3). Anastomotic leak rate was 11.7% (n = 26). At a mean follow-up of 19 months (range, 1-68), quality of life scores were similar to preoperative values and population norms. Stage specific survival was similar to open series. CONCLUSIONS: MIE offers results as good as or better than open operation in our center with extensive minimally invasive and open experience. In this single institution experience, we observed a lower mortality rate (1.4%) and shorter hospital stay (7 days) than most open series. Given these results, we are now developing an intergroup trial (ECOG 2202) to assess MIE in a multicenter setting.
Adult↗
Outcomes after minimally invasive reoperation for gastroesophageal reflux disease.
BACKGROUND: Reoperative antireflux surgery is complex and traditionally performed by open methods. Increasingly, surgeons are performing minimally invasive reoperations. This report summarizes our experience with laparoscopic reoperative antireflux surgery (LRAS). METHODS: A retrospective review (1996 to 2001) identified 80 LRAS cases. Median age was 49 (22 to 80) years with 52 females and 28 males. Primary symptoms included heartburn (53%), regurgitation (22%), and dysphagia (25%). Detailed outcomes recorded at follow-up included heartburn severity using the Gastroesophageal Reflux Disease-Health Related Quality of Life scale (HRQOL) and SF36 physical (PCS) and mental (MCS) component summary scores. RESULTS: LRAS was completed in 97.5% of cases (two conversions). The most common problems identified were mediastinal migration of the wrap in 48 (60%) and misplaced wrap in 11 (13.8%). LRAS operations included Collis-Nissen (42), Nissen (26), Toupet (six), and six others. Pyloroplasty was required in nine (11%). Complications occurred in 16 patients. These included nine minor gastric perforations (all repaired intraoperatively) and two reoperations for complications (1 patient with a bile leak and the second with a pyloroplasty site leak). Median length of stay was 2.5 days. Median follow-up was 18 (1 to 52) months; 18 (23%) required proton-pump inhibitors. Detailed outcomes were available in 50 patients. Mean PCS and MCS scores were 42 and 47, respectively (normals = 50). HRQOL scores were excellent in 35 (65%), satisfactory in 9 (17%), and poor in 10 (18%). Ten patients (18%) reported that they were dissatisfied. CONCLUSIONS: LRAS can be performed safely with complication and success rates similar to open operations in a center with extensive laparoscopic experience.
Adult↗
Results of laparoscopic repair of giant paraesophageal hernias: 200 consecutive patients.
BACKGROUND: Giant paraesophageal hernias (GPEH) have traditionally required open operations. Increasingly, a laparoscopic approach is being applied to more complex esophageal surgery. Our objective was to update our growing experience with laparoscopic repair of GPEH. METHODS: We performed a retrospective review at our institution of patients undergoing laparoscopic repair of GPEH from July 1995 to July 2001. The GPEH was defined as greater than one-third of the stomach in the chest. RESULTS: Elective laparoscopic repair of a GPEH was attempted in 203 patients. Mean age was 67 years. The most common symptoms included heartburn (96 patients), dysphagia (72), epigastric pain (56), and vomiting (47 patients). Laparoscopic procedures included 69 Nissens, 112 Collis-Nissens, and 19 other procedures. There were three open conversions due to adhesions, but no intraoperative emergencies. Median length of stay was 3 days (range, 1 to 120 days). Minor or major complications occurred in 57 patients (28%). There were six postoperative esophageal leaks (3%), and 1 death. Median follow-up was 18 months. Five patients required reoperation for recurrent hiatal hernia. Excellent results were reported in 128 (84%) patients, 12 (8%) had a good result, 7 (5%) fair, and 5 (3%) poor (based on postoperative follow-up and GERD questionnaire). The mean postoperative GERD Health-related Quality of Life Score was 2.4 (scale 0 to 45; 0 = no symptoms, 45 = worst). CONCLUSIONS: Laparoscopic repair of GPEH is possible in the majority of patients with acceptable morbidity, a median length of hospital stay of 3 days and excellent intermediate-term results in an experienced center.
Adult↗
Minimally invasive esophagectomy in the elderly.
OBJECTIVES: In recent years, older patients are being referred for esophagectomy, and the associated morbidity and mortality is not well defined. Advances in minimally invasive techniques now allow minimally invasive esophagectomy (MIE) to be performed that may minimize the morbidity of this procedure. The objective of this report was to summarize our experience with MIE in the elderly. METHODS: From February 1997 through February 2001, 41 patients (14 women, 27 men) 75 years of age or older (mean age 78, range 75 to 89) underwent esophagectomy (28 for adenocarcinoma, 7 squamous, 6 Barrett's with high-grade dysplasia). RESULTS: Esophagectomy was performed in a minimally invasive fashion in 41 patients. No open conversions were necessary. The median ICU stay was 1 day (range 1 to 34). The median hospital stay was 7 days (range 5 to 50). Major morbidity occurred in 19% of the cases and included 1 persistent air leak, 1 case of pneumonia with acute respiratory failure, 1 tracheal tear, 1 chylothorax, and 1 myocardial infarction. Three anastomotic leaks and 1 small bowel perforation occurred. All were recognized early and treated surgically. No perioperative mortalities took place. CONCLUSION: In our center, MIE was performed in elderly patients with an acceptable morbidity, low mortality, and reduced length of hospital stay compared with that in previous reports.
Adenocarcinoma↗
Outcomes of minimally invasive antireflux operations in the elderly: a comparative review.
BACKGROUND AND OBJECTIVES: The objectives of this study were to assess the impact of age following laparoscopic fundoplication (LF). METHODS: From March 1993 to November 1998, 193 patients underwent LF. Patients comprised 150 young individuals (age<60; median 41) and 43 older individuals (age>60; median 68). Follow-up included heartburn scores, dysphagia scores, and quality of life determined by the Short Form 36 Health Survey (SF36). RESULTS: Older patients had more cardiac disease, psychiatric disorders, prior cancers, and upper abdominal operations (P<0.05). DeMeester scores were similar (young 70/older 69). Complications occurred in 13 (8.7%) of the young and 5 (11.6%) of the older patients (P=0.142). No perioperative deaths occurred. Length of stay was longer (P<0.000) in older patients (2.9 versus 1.6 days); resumption of oral intake (young-1.2; older-1.3 days) and return to normal activity (young-3.6; older-4.4 weeks) were similar. Follow-up was available in 102 young (median 17 months) and 35 older (median 18 months) patients. Heartburn and dysphagia scores were excellent in both groups. SF36 scores were similar in both groups. Only 6 (5.9%) of the young group and 1 (2.9%) of the older group were dissatisfied (P=0.652). CONCLUSIONS: Despite differences in comorbid disease, outcomes were similar in both groups. LF should be considered a therapeutic option in the older patient with reflux.
Adolescent↗