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Ketel MHM, Klarenbeek BR, Eddahchouri Y, Cheong E, Cuesta MA, van Daele E, Ferri LE, Gisbertz SS, Gutschow CA, Hubka M, Hölscher AH, Law S, Luyer MDP, Merritt RE, Morse CR, Mueller CL, Nieuwenhuijzen GAP, Nilsson M, Pattyn P, Shen Y, van den Wildenberg FJH, Abma IL, Rosman C, van Workum F. A Video-Based Procedure-Specific Competency Assessment Tool for Minimally Invasive Esophagectomy. JAMA Surg 2024; 159:297-305. [PMID: 38150247 PMCID: PMC10753443 DOI: 10.1001/jamasurg.2023.6522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 09/11/2023] [Indexed: 12/28/2023]
Abstract
Importance Minimally invasive esophagectomy (MIE) is a complex procedure with substantial learning curves. In other complex minimally invasive procedures, suboptimal surgical performance has convincingly been associated with less favorable patient outcomes as assessed by peer review of the surgical procedure. Objective To develop and validate a procedure-specific competency assessment tool (CAT) for MIE. Design, Setting, and Participants In this international quality improvement study, a procedure-specific MIE-CAT was developed and validated. The MIE-CAT contains 8 procedural phases, and 4 quality components per phase are scored with a Likert scale ranging from 1 to 4. For evaluation of the MIE-CAT, intraoperative MIE videos performed by a single surgical team in the Esophageal Center East Netherlands were peer reviewed by 18 independent international MIE experts (with more than 120 MIEs performed). Each video was assessed by 2 or 3 blinded experts to evaluate feasibility, content validity, reliability, and construct validity. MIE-CAT version 2 was composed with refined content aimed at improving interrater reliability. A total of 32 full-length MIE videos from patients who underwent MIE between 2011 and 2020 were analyzed. Data were analyzed from January 2021 to January 2023. Exposure Performance assessment of transthoracic MIE with an intrathoracic anastomosis. Main Outcomes and Measures Feasibility, content validity, interrater and intrarater reliability, and construct validity, including correlations with both experience of the surgical team and clinical parameters, of the developed MIE-CAT. Results Experts found the MIE-CAT easy to understand and easy to use to grade surgical performance. The MIE-CAT demonstrated good intrarater reliability (range of intraclass correlation coefficients [ICCs], 0.807 [95% CI, 0.656 to 0.892] for quality component score to 0.898 [95% CI, 0.846 to 0.932] for phase score). Interrater reliability was moderate (range of ICCs, 0.536 [95% CI, -0.220 to 0.994] for total MIE-CAT score to 0.705 [95% CI, 0.473 to 0.846] for quality component score), and most discrepancies originated in the lymphadenectomy phases. Hypothesis testing for construct validity showed more than 75% of hypotheses correct: MIE-CAT performance scores correlated with experience of the surgical team (r = 0.288 to 0.622), blood loss (r = -0.034 to -0.545), operative time (r = -0.309 to -0.611), intraoperative complications (r = -0.052 to -0.319), and severe postoperative complications (r = -0.207 to -0.395). MIE-CAT version 2 increased usability. Interrater reliability improved but remained moderate (range of ICCs, 0.666 to 0.743), and most discrepancies between raters remained in the lymphadenectomy phases. Conclusions and Relevance The MIE-CAT was developed and its feasibility, content validity, reliability, and construct validity were demonstrated. By providing insight into surgical performance of MIE, the MIE-CAT might be used for clinical, training, and research purposes.
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Affiliation(s)
- Mirte H. M. Ketel
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Yassin Eddahchouri
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Edward Cheong
- The PanAsia Surgery Group, Mount Elizabeth Hospital, Singapore
| | - Miguel A. Cuesta
- Department of Surgery, Amsterdam University Medical Centers, Location VUmc, Amsterdam, the Netherlands
| | - Elke van Daele
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Lorenzo E. Ferri
- Department of Surgery, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | - Suzanne S. Gisbertz
- Amsterdam UMC location University of Amsterdam, Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands
| | - Christian A. Gutschow
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Michal Hubka
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, Washington
| | - Arnulf H. Hölscher
- Department for General, Visceral and Trauma Surgery, Elisabeth-Krankenhaus-Essen GmbH, Essen, Germany
| | - Simon Law
- Department of Surgery, Queen Mary Hospital, School of Clinical Medicine, The University of Hong Kong, Hong Kong
| | - Misha D. P. Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Robert E. Merritt
- Department of Surgery, Ohio State University Wexner Medical Center, Columbus
| | | | - Carmen L. Mueller
- Department of Surgery, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | | | - Magnus Nilsson
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Piet Pattyn
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Yaxing Shen
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | | | - Inger L. Abma
- IQ Healthcare, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Frans van Workum
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
- Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
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Sachdeva UM, Axtell AL, Kroese TE, Chang DC, Mathisen DJ, Morse CR. Contributing factors to lymph node recovery with esophagectomy by thoracic surgeons: an analysis of the Society of Thoracic Surgeons General Thoracic Surgery Database. Dis Esophagus 2022; 35:6517027. [PMID: 35091737 DOI: 10.1093/dote/doab101] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 11/23/2021] [Accepted: 12/30/2021] [Indexed: 12/11/2022]
Abstract
Given the association between lymphadenectomy and survival after esophagectomy, and the ongoing development of effective adjuvant protocols for identified residual disease, we determined factors contributing to lymph node yield and effects on postoperative morbidity following esophagectomy by thoracic surgeons. Using the Society of Thoracic Surgeons General Thoracic Surgery Database, all patients who underwent esophagectomy for primary esophageal cancer with gastric conduit reconstruction from 2012 to 2016 were identified. Patient demographics, technical factors, and tumor characteristics associated with lymph node yield were determined using a multivariable multilevel mixed-effects regression model. Associations between lymph node yield and perioperative morbidity and mortality were similarly assessed. A total of 8480 patients were included. The median number of nodes harvested was 16 [Interquartile Range 11-22]. Factors associated with fewer nodes included female gender (b=-0.53, P=0.032), body mass index <18.5 (b=-1.46, P=0.012), prior cardiothoracic surgery (b=-0.73, P=0.015), intraoperative blood transfusion (b=-1.43, P<0.001), squamous cell histology (b=-0.86, P=0.006), and neoadjuvant treatment (b=-1.41, P<0.001). Operative approach significantly affected lymph node yield, with minimally invasive approaches demonstrating higher lymph node counts, and open transhiatal esophagectomy recovering the fewest nodes. Findings were independent of clinical center. There was no association of higher lymph node yield with 30-day mortality, with only slightly increased risk for chyle leak (odds ratio [OR] 1.02, P=0.012). In conclusion, several patient and tumor factors affect lymph node recovery with esophagectomy, independent of hospital center. Technical aspects, specifically minimally invasive approach, play a significant role in quantified lymph node yield. Higher operative lymph node yield was associated with minimal increased morbidity.
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Affiliation(s)
- Uma M Sachdeva
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Andrea L Axtell
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Tiuri E Kroese
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
- Department of Surgery, UMC Utrecht, Utrecht, The Netherlands
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Douglas J Mathisen
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Christopher R Morse
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
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3
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Nandy S, Raphaely RA, Muniappan A, Shih A, Roop BW, Sharma A, Keyes CM, Colby TV, Auchincloss HG, Gaissert HA, Lanuti M, Morse CR, Ott HC, Wain JC, Wright CD, Garcia-Moliner ML, Smith ML, VanderLaan PA, Berigei SR, Mino-Kenudson M, Horick NK, Liang LL, Davies DL, Szabari MV, Caravan P, Medoff BD, Tager AM, Suter MJ, Hariri LP. Reply to Kalverda et al.: Endobronchial Optical Coherence Tomography: Shining New Light on Diagnosing Usual Interstitial Pneumonitis? Am J Respir Crit Care Med 2022; 205:968-971. [PMID: 35148493 PMCID: PMC9838623 DOI: 10.1164/rccm.202112-2737le] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
- Sreyankar Nandy
- Massachusetts General HospitalBoston, Massachusetts,Harvard Medical SchoolBoston, Massachusetts
| | - Rebecca A. Raphaely
- Massachusetts General HospitalBoston, Massachusetts,Harvard Medical SchoolBoston, Massachusetts
| | - Ashok Muniappan
- Massachusetts General HospitalBoston, Massachusetts,Harvard Medical SchoolBoston, Massachusetts
| | - Angela Shih
- Massachusetts General HospitalBoston, Massachusetts,Harvard Medical SchoolBoston, Massachusetts
| | | | - Amita Sharma
- Massachusetts General HospitalBoston, Massachusetts,Harvard Medical SchoolBoston, Massachusetts
| | - Colleen M. Keyes
- Massachusetts General HospitalBoston, Massachusetts,Harvard Medical SchoolBoston, Massachusetts
| | | | - Hugh G. Auchincloss
- Massachusetts General HospitalBoston, Massachusetts,Harvard Medical SchoolBoston, Massachusetts
| | - Henning A. Gaissert
- Massachusetts General HospitalBoston, Massachusetts,Harvard Medical SchoolBoston, Massachusetts
| | - Michael Lanuti
- Massachusetts General HospitalBoston, Massachusetts,Harvard Medical SchoolBoston, Massachusetts
| | - Christopher R. Morse
- Massachusetts General HospitalBoston, Massachusetts,Harvard Medical SchoolBoston, Massachusetts
| | - Harald C. Ott
- Massachusetts General HospitalBoston, Massachusetts,Harvard Medical SchoolBoston, Massachusetts
| | - John C. Wain
- Massachusetts General HospitalBoston, Massachusetts,Harvard Medical SchoolBoston, Massachusetts,St. Elizabeth’s Medical CenterBoston, Massachusetts
| | - Cameron D. Wright
- Massachusetts General HospitalBoston, Massachusetts,Harvard Medical SchoolBoston, Massachusetts
| | | | | | - Paul A. VanderLaan
- Harvard Medical SchoolBoston, Massachusetts,Beth Israel Deaconess Medical CenterBoston, Massachusetts
| | | | - Mari Mino-Kenudson
- Massachusetts General HospitalBoston, Massachusetts,Harvard Medical SchoolBoston, Massachusetts
| | - Nora K. Horick
- Massachusetts General HospitalBoston, Massachusetts,Harvard Medical SchoolBoston, Massachusetts
| | | | | | - Margit V. Szabari
- Massachusetts General HospitalBoston, Massachusetts,Harvard Medical SchoolBoston, Massachusetts
| | - Peter Caravan
- Harvard Medical SchoolBoston, Massachusetts,Athinoula A. Martinos Center for Biomedical ImagingCharlestown, Massachusetts,Massachusetts General HospitalCharlestown, Massachusetts
| | - Benjamin D. Medoff
- Massachusetts General HospitalBoston, Massachusetts,Harvard Medical SchoolBoston, Massachusetts
| | - Andrew M. Tager
- Massachusetts General HospitalBoston, Massachusetts,Harvard Medical SchoolBoston, Massachusetts
| | - Melissa J. Suter
- Massachusetts General HospitalBoston, Massachusetts,Harvard Medical SchoolBoston, Massachusetts
| | - Lida P. Hariri
- Massachusetts General HospitalBoston, Massachusetts,Harvard Medical SchoolBoston, Massachusetts,Corresponding author (e-mail: )
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Tobert DG, Yeung CM, Morse CR, Lee SG, Schwab JH. Anterior Column Reconstruction with Vascularized Rib After Thoracic Spondylectomy: A Case Report. JBJS Case Connect 2022; 12:01709767-202203000-00021. [PMID: 35050933 DOI: 10.2106/jbjs.cc.21.00564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 35-year-old man with a chondrosarcoma of the thoracic spine was treated with neoadjuvant proton radiotherapy (RT), total en bloc spondylectomy (TES), and adjuvant RT. Multiple vertebrae were removed to ensure negative margins, which created a sizable midthoracic defect. A vascularized rib autograft was harvested and intussuscepted within a femoral allograft for reconstruction of the anterior column and supplemented with posterior and lateral instrumentation. CONCLUSION This report demonstrates the feasibility of using a rib autograft within a femoral allograft sleeve to achieve immediate robust biomechanical support and eventual osseous union after thoracic TES for malignant tumors.
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Affiliation(s)
- Daniel G Tobert
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Caleb M Yeung
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Christopher R Morse
- Department of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Sang-Gil Lee
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
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5
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Axtell AL, Gaissert HA, Morse CR, Premkumar A, Schumacher L, Muniappan A, Ott H, Allan JS, Lanuti M, Mathisen DJ, Wright CD. Management and outcomes of esophageal perforation. Dis Esophagus 2022; 35:6312958. [PMID: 34212186 DOI: 10.1093/dote/doab039] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/13/2021] [Accepted: 05/22/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Esophageal perforation is a morbid condition and remains a therapeutic challenge. We report the outcomes of a large institutional experience with esophageal perforation and identify risk factors for morbidity and mortality. METHODS A retrospective analysis was conducted on 142 patients who presented with a thoracic or gastroesophageal junction esophageal perforation from 1995 to 2020. Baseline characteristics, operative or interventional strategies, and outcomes were analyzed by etiology of the perforation and management approach. Multivariable cox and logistic regression models were constructed to identify predictors of mortality and morbidity. RESULTS Overall, 109 (77%) patients underwent operative intervention, including 80 primary reinforced repairs and 21 esophagectomies and 33 (23%) underwent esophageal stenting. Stenting was more common in iatrogenic (27%) and malignant (64%) perforations. Patients who presented with a postemetic or iatrogenic perforation had similar 90-day mortality (16% and 16%) and composite morbidity (51% and 45%), whereas patients who presented with a malignant perforation had a 45% 90-day mortality and 45% composite morbidity. Risk factors for mortality included age >65 years (hazard ratio [HR] 1.89 [1.02-3.26], P = 0.044) and a malignant perforation (HR 4.80 [1.31-17.48], P = 0.017). Risk factors for composite morbidity included pleural contamination (odds ratio [OR] 2.06 [1.39-4.43], P = 0.046) and sepsis (OR 3.26 [1.44-7.36], P = 0.005). Of the 33 patients who underwent stent placement, 67% were successfully managed with stenting alone and 30% required stent repositioning. CONCLUSIONS Risk factors for morbidity and mortality after esophageal perforation include advanced age, pleural contamination, septic physiology, and malignant perforation. Primary reinforced repair remains a reasonable strategy for patients with an esophageal perforation from a benign etiology.
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Affiliation(s)
- Andrea L Axtell
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Henning A Gaissert
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Christopher R Morse
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Akash Premkumar
- Department of Surgery, Harvard Medical School, Boston, MA, USA
| | - Lana Schumacher
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Ashok Muniappan
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Harald Ott
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - James S Allan
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Michael Lanuti
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Douglas J Mathisen
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Cameron D Wright
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
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6
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Predina JD, Morse CR. Minimally invasive esophagectomy for esophageal carcinoma. Video-assist Thorac Surg 2021. [DOI: 10.21037/vats-2019-mie-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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7
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Nandy S, Raphaely RA, Muniappan A, Shih A, Roop BW, Sharma A, Keyes CM, Colby TV, Auchincloss HG, Gaissert HA, Lanuti M, Morse CR, Ott HC, Wain JC, Wright CD, Garcia-Moliner ML, Smith ML, VanderLaan PA, Berigei SR, Mino-Kenudson M, Horick NK, Liang LL, Davies DL, Szabari MV, Caravan P, Medoff BD, Tager AM, Suter MJ, Hariri LP. Diagnostic Accuracy of Endobronchial Optical Coherence Tomography for the Microscopic Diagnosis of Usual Interstitial Pneumonia. Am J Respir Crit Care Med 2021; 204:1164-1179. [PMID: 34375171 PMCID: PMC8759308 DOI: 10.1164/rccm.202104-0847oc] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 08/10/2021] [Indexed: 11/16/2022] Open
Abstract
Rationale: Early, accurate diagnosis of interstitial lung disease (ILD) informs prognosis and therapy, especially in idiopathic pulmonary fibrosis (IPF). Current diagnostic methods are imperfect. High-resolution computed tomography has limited resolution, and surgical lung biopsy (SLB) carries risks of morbidity and mortality. Endobronchial optical coherence tomography (EB-OCT) is a low-risk, bronchoscope-compatible modality that images large lung volumes in vivo with microscopic resolution, including subpleural lung, and has the potential to improve the diagnostic accuracy of bronchoscopy for ILD diagnosis. Objectives: We performed a prospective diagnostic accuracy study of EB-OCT in patients with ILD with a low-confidence diagnosis undergoing SLB. The primary endpoints were EB-OCT sensitivity/specificity for diagnosis of the histopathologic pattern of usual interstitial pneumonia (UIP) and clinical IPF. The secondary endpoint was agreement between EB-OCT and SLB for diagnosis of the ILD fibrosis pattern. Methods: EB-OCT was performed immediately before SLB. The resulting EB-OCT images and histopathology were interpreted by blinded, independent pathologists. Clinical diagnosis was obtained from the treating pulmonologists after SLB, blinded to EB-OCT. Measurements and Main Results: We enrolled 31 patients, and 4 were excluded because of inconclusive histopathology or lack of EB-OCT data. Twenty-seven patients were included in the analysis (16 men, average age: 65.0 yr): 12 were diagnosed with UIP and 15 with non-UIP ILD. Average FVC and DlCO were 75.3% (SD, 18.5) and 53.5% (SD, 16.4), respectively. Sensitivity and specificity of EB-OCT was 100% (95% confidence interval, 75.8-100.0%) and 100% (79.6-100%), respectively, for both histopathologic UIP and clinical diagnosis of IPF. There was high agreement between EB-OCT and histopathology for diagnosis of ILD fibrosis pattern (weighted κ: 0.87 [0.72-1.0]). Conclusions: EB-OCT is a safe, accurate method for microscopic ILD diagnosis, as a complement to high-resolution computed tomography and an alternative to SLB.
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Affiliation(s)
- Sreyankar Nandy
- Division of Pulmonary and Critical Care Medicine
- Wellman Center for Photomedicine
- Harvard Medical School, Boston, Massachusetts
| | - Rebecca A. Raphaely
- Division of Pulmonary and Critical Care Medicine
- Harvard Medical School, Boston, Massachusetts
| | - Ashok Muniappan
- Division of Thoracic Surgery
- Harvard Medical School, Boston, Massachusetts
| | - Angela Shih
- Department of Pathology
- Harvard Medical School, Boston, Massachusetts
| | - Benjamin W. Roop
- Division of Pulmonary and Critical Care Medicine
- Wellman Center for Photomedicine
| | - Amita Sharma
- Department of Radiology, and
- Harvard Medical School, Boston, Massachusetts
| | - Colleen M. Keyes
- Division of Pulmonary and Critical Care Medicine
- Harvard Medical School, Boston, Massachusetts
| | - Thomas V. Colby
- Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona, Scottsdale, Arizona
| | | | | | - Michael Lanuti
- Division of Thoracic Surgery
- Harvard Medical School, Boston, Massachusetts
| | | | - Harald C. Ott
- Division of Thoracic Surgery
- Harvard Medical School, Boston, Massachusetts
| | - John C. Wain
- Division of Thoracic Surgery
- Harvard Medical School, Boston, Massachusetts
- St. Elizabeth’s Medical Center, Boston, Massachusetts
| | - Cameron D. Wright
- Division of Thoracic Surgery
- Harvard Medical School, Boston, Massachusetts
| | - Maria L. Garcia-Moliner
- Department of Pathology, Rhode Island Hospital and Alpert Medical School, Providence, Rhode Island
| | - Maxwell L. Smith
- Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona, Scottsdale, Arizona
| | - Paul A. VanderLaan
- Harvard Medical School, Boston, Massachusetts
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Sarita R. Berigei
- Division of Pulmonary and Critical Care Medicine
- Wellman Center for Photomedicine
| | | | - Nora K. Horick
- Biostatistics Center, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | | | | | - Margit V. Szabari
- Division of Pulmonary and Critical Care Medicine
- Wellman Center for Photomedicine
- Harvard Medical School, Boston, Massachusetts
| | - Peter Caravan
- Harvard Medical School, Boston, Massachusetts
- Athinoula A. Martinos Center for Biomedical Imaging, Charlestown, Massachusetts; and
- Institute for Innovation in Imaging (i), Department of Radiology, Massachusetts General Hospital, Charlestown, Massachusetts
| | - Benjamin D. Medoff
- Division of Pulmonary and Critical Care Medicine
- Harvard Medical School, Boston, Massachusetts
| | - Andrew M. Tager
- Division of Pulmonary and Critical Care Medicine
- Harvard Medical School, Boston, Massachusetts
| | - Melissa J. Suter
- Division of Pulmonary and Critical Care Medicine
- Wellman Center for Photomedicine
- Harvard Medical School, Boston, Massachusetts
| | - Lida P. Hariri
- Division of Pulmonary and Critical Care Medicine
- Wellman Center for Photomedicine
- Department of Pathology
- Harvard Medical School, Boston, Massachusetts
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8
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D'Journo XB, Boulate D, Fourdrain A, Loundou A, van Berge Henegouwen MI, Gisbertz SS, O'Neill JR, Hoelscher A, Piessen G, van Lanschot J, Wijnhoven B, Jobe B, Davies A, Schneider PM, Pera M, Nilsson M, Nafteux P, Kitagawa Y, Morse CR, Hofstetter W, Molena D, So JBY, Immanuel A, Parsons SL, Larsen MH, Dolan JP, Wood SG, Maynard N, Smithers M, Puig S, Law S, Wong I, Kennedy A, KangNing W, Reynolds JV, Pramesh CS, Ferguson M, Darling G, Schröder W, Bludau M, Underwood T, van Hillegersberg R, Chang A, Cecconello I, Ribeiro U, de Manzoni G, Rosati R, Kuppusamy M, Thomas PA, Low DE. Risk Prediction Model of 90-Day Mortality After Esophagectomy for Cancer. JAMA Surg 2021; 156:836-845. [PMID: 34160587 PMCID: PMC8223144 DOI: 10.1001/jamasurg.2021.2376] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 03/13/2021] [Indexed: 02/06/2023]
Abstract
Importance Ninety-day mortality rates after esophagectomy are an indicator of the quality of surgical oncologic management. Accurate risk prediction based on large data sets may aid patients and surgeons in making informed decisions. Objective To develop and validate a risk prediction model of death within 90 days after esophagectomy for cancer using the International Esodata Study Group (IESG) database, the largest existing prospective, multicenter cohort reporting standardized postoperative outcomes. Design, Setting, and Participants In this diagnostic/prognostic study, we performed a retrospective analysis of patients from 39 institutions in 19 countries between January 1, 2015, and December 31, 2019. Patients with esophageal cancer were randomly assigned to development and validation cohorts. A scoring system that predicted death within 90 days based on logistic regression β coefficients was conducted. A final prognostic score was determined and categorized into homogeneous risk groups that predicted death within 90 days. Calibration and discrimination tests were assessed between cohorts. Exposures Esophageal resection for cancer of the esophagus and gastroesophageal junction. Main Outcomes and Measures All-cause postoperative 90-day mortality. Results A total of 8403 patients (mean [SD] age, 63.6 [9.0] years; 6641 [79.0%] male) were included. The 30-day mortality rate was 2.0% (n = 164), and the 90-day mortality rate was 4.2% (n = 353). Development (n = 4172) and validation (n = 4231) cohorts were randomly assigned. The multiple logistic regression model identified 10 weighted point variables factored into the prognostic score: age, sex, body mass index, performance status, myocardial infarction, connective tissue disease, peripheral vascular disease, liver disease, neoadjuvant treatment, and hospital volume. The prognostic scores were categorized into 5 risk groups: very low risk (score, ≥1; 90-day mortality, 1.8%), low risk (score, 0; 90-day mortality, 3.0%), medium risk (score, -1 to -2; 90-day mortality, 5.8%), high risk (score, -3 to -4: 90-day mortality, 8.9%), and very high risk (score, ≤-5; 90-day mortality, 18.2%). The model was supported by nonsignificance in the Hosmer-Lemeshow test. The discrimination (area under the receiver operating characteristic curve) was 0.68 (95% CI, 0.64-0.72) in the development cohort and 0.64 (95% CI, 0.60-0.69) in the validation cohort. Conclusions and Relevance In this study, on the basis of preoperative variables, the IESG risk prediction model allowed stratification of an individual patient's risk of death within 90 days after esophagectomy. These data suggest that this model can help in the decision-making process when esophageal cancer surgery is being considered and in informed consent.
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Affiliation(s)
- Xavier Benoit D'Journo
- Department of Thoracic Surgery, Aix-Marseille University, North Hospital, Marseille, France
| | - David Boulate
- Department of Thoracic Surgery, Aix-Marseille University, North Hospital, Marseille, France
| | - Alex Fourdrain
- Department of Thoracic Surgery, Aix-Marseille University, North Hospital, Marseille, France
| | - Anderson Loundou
- Department of Thoracic Surgery, Aix-Marseille University, North Hospital, Marseille, France
| | - Mark I van Berge Henegouwen
- Department of Gastrointestinal Surgery, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Suzanne S Gisbertz
- Department of Gastrointestinal Surgery, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - J Robert O'Neill
- Department of Oesophago-Gastric Cancer Surgery, Cambridge Oesophago-Gastric Centre, Addenbrookes Hospital, Cambridge, United Kingdom
| | - Arnulf Hoelscher
- Center for Esophageal Diseases, Elisabeth Hospital Essen, University Medicine Essen, Essen, Germany
| | - Guillaume Piessen
- Department of Digestive and Oncological Surgery, Claude Huriez University Hospital, Lille, France
| | - Jan van Lanschot
- Department of Digestive Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Bas Wijnhoven
- Department of Digestive Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Blair Jobe
- Esophageal and Lung Institute, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Andrew Davies
- Department of Digestive Surgery, Guy's & St Thomas' National Health Service Foundation Trust, London, United Kingdom
| | - Paul M Schneider
- Department of Digestive and Oncological Surgery, Hirslanden Medical Center, Zurich, Switzerland
| | - Manuel Pera
- Department of Digestive Surgery, Hospital Universitario del Mar, Barcelona, Spain
| | - Magnus Nilsson
- Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Philippe Nafteux
- Department of Digestive Surgery, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Yuko Kitagawa
- Department of Thoracic Surgery, Keio University, Tokyo, Japan
| | | | - Wayne Hofstetter
- Department of Thoracic Surgery, MD Anderson Cancer Center, Houston, Texas
| | - Daniela Molena
- Department of Thoracic and Cardiovascular Surgery, Memorial Sloan Kettering Cancer Center, New York City, New York
| | - Jimmy Bok-Yan So
- Department of Thoracic Surgery, National University Hospital, Singapore, Singapore
| | - Arul Immanuel
- Department of Surgery, Northern Oesophagogastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Simon L Parsons
- Department of Upper Gastrointestinal Surgery, Nottingham University Hospitals National Health Service Trust, Nottingham, United Kingdom
| | | | - James P Dolan
- Digestive Health Center, Oregon Health and Science University, Portland
| | - Stephanie G Wood
- Digestive Health Center, Oregon Health and Science University, Portland
| | - Nick Maynard
- Oesophagogastric Cancer Multidisciplinary Team, Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
| | - Mark Smithers
- Department of Surgery, Princess Alexandra Hospital, University of Queensland, Brisbane, Australia
| | - Sonia Puig
- Department of Gastrointestinal Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham Foundation Trust, Birmingham, United Kingdom
| | - Simon Law
- Department of Gastrointestinal Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Ian Wong
- Department of Gastrointestinal Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Andrew Kennedy
- Department of Gastrointestinal Surgery, Royal Victoria Hospital, Belfast, Northern Ireland
| | - Wang KangNing
- Department of Thoracic Surgery, Sichuan Cancer Hospital & Institute, Chengdu, China
| | - John V Reynolds
- Department of Surgery, St James's Hospital Trinity College, Dublin, Ireland
| | - C S Pramesh
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India
| | - Mark Ferguson
- Department of Thoracic Surgery, The University of Chicago Medicine, Chicago, Illinois
| | - Gail Darling
- Department of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Wolfgang Schröder
- Department of Digestive Surgery, University Hospital of Cologne, Cologne, Germany
| | - Marc Bludau
- Department of Digestive Surgery, University Hospital of Cologne, Cologne, Germany
| | - Tim Underwood
- Department of Gastrointestinal Surgery, University Hospital Southampton National Health Service Foundation Trust, Southampton, United Kingdom
| | | | - Andrew Chang
- Department of Thoracic Surgery, University of Michigan Health System, Ann Arbor
| | - Ivan Cecconello
- Department of Digestive Surgery, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Ulysses Ribeiro
- Department of Digestive Surgery, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Giovanni de Manzoni
- Department of Upper Gastrointestinal Surgery, University of Verona, Verona, Italy
| | - Riccardo Rosati
- Department of Upper Gastrointestinal Surgery, Vita-Salute San Raffaele University, Milan, Italy
| | | | | | - Donald E Low
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, Washington
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9
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Wo JY, Clark JW, Eyler CE, Mino-Kenudson M, Klempner SJ, Allen JN, Keane FK, Parikh AR, Roeland E, Drapek LC, Ryan DP, Corcoran RB, Van Seventer E, Fetter IJ, Shahzade HA, Khandekar MJ, Lanuti M, Morse CR, Heist RS, Ulysse CA, Christopher B, Baglini C, Yeap BY, Mullen JT, Hong TS. Results and molecular correlates from a pilot study of neoadjuvant induction FOLFIRINOX followed by chemoradiation and surgery for gastroesophageal adenocarcinomas. Clin Cancer Res 2021; 27:6343-6353. [PMID: 34330715 DOI: 10.1158/1078-0432.ccr-21-0331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 04/08/2021] [Accepted: 07/28/2021] [Indexed: 11/16/2022]
Abstract
PURPOSE We performed a NCI-sponsored, prospective study of neoadjuvant FOLFIRINOX followed by chemoradiation (CRT) with carboplatin/paclitaxel followed by surgery in patients with locally advanced gastric or gastroesophageal (GEA) cancer. EXPERIMENTAL DESIGN The primary objective was to determine completion rate of neoadjuvant FOLFIRINOX x 8 followed by CRT. Secondary endpoints were toxicity and pathologic complete response (pCR) rate. Exploratory analysis was performed of ctDNA to treatment response. RESULTS From Oct 2017 to June 2018, 25 patients were enrolled. All patients started FOLFIRINOX, 92% completed all 8 planned cycles, and 88% completed CRT. Twenty (80%) patients underwent surgical resection, and 7 had a pCR (35% in resected cohort, 28% ITT ). Tumor-specific mutations were identified in 21 (84%) patients, of whom 4 and 17 patients had undetectable and detectable ctDNA at baseline, respectively. Presence of detectable post-CRT ctDNA (p=0.004) and/or postoperative ctDNA (p=0.045) were associated with disease recurrence. CONCLUSIONS Here we show neoadjuvant FOLFIRINOX followed by CRT for locally advanced GEA is feasible and yields a high rate of pCR. ctDNA appears to be a promising predictor of postoperative recurrence.
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Affiliation(s)
- Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School
| | | | | | - Mari Mino-Kenudson
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School
| | | | - Jill N Allen
- Hematology Oncology, Massachusetts General Hospital
| | | | - Aparna R Parikh
- Division of Hematology and Oncology, Massachusetts General Hospital
| | - Eric Roeland
- Division of Hematology and Oncology, Massachusetts General Hospital
| | | | - David P Ryan
- Massachusetts General Hospital Cancer Center, Harvard Medical School
| | | | | | | | | | | | | | | | | | | | | | | | - Beow Y Yeap
- Department of Medicine, Massachusetts General Hospital
| | - John T Mullen
- Surgery, Massachusetts General Hospital, Harvard Medical School
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital
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10
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Andrew CD, Madariaga MLL, Mathisen DJ, Morse CR, Gaissert HA. Surgical intervention for late gastric conduit obstruction. Eur J Cardiothorac Surg 2021; 60:1268-1276. [PMID: 34259860 DOI: 10.1093/ejcts/ezab318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 06/01/2021] [Accepted: 06/22/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Gastric emptying delay after oesophagectomy may occur in conduits exposed to pleural forces of respiration or anatomic obstruction. Remedial operations addressing both causes are rarely reported. The study aim was to categorize severe gastric conduit obstruction (GCO) and report the outcome of surgical revision. METHODS A single-institution, retrospective study of gastric conduit revision following oesophagectomy for oesophageal cancer investigated incidence, risk factors and categories of conduit obstruction. Evaluation consisted of contrast studies, computed tomogram and endoscopy. Interventions were categorized according to obstructive cause and included pyloroplasty, hiatal hernia reduction and thoraco-abdominal conduit repositioning. RESULTS Among 1246 oesophagectomies over a 17-year period, 14 patients (1.1%) required post-oesophagectomy relief of GCO. Two additional patients presented after oesophagectomy elsewhere. Before oesophagectomy, 18.8% (3/16) and 62.5% (10/16) of patients were on chronic opioid and psychotropic medications, respectively. Distinct anatomic features separated obstruction into 3 categories: pyloric in 31% (5/16), extrinsic in 12.5% (2/16) and combined in 56.3% (9/16). Operative revision led to complete symptom resolution in 50% (8/16) of patients and symptom improvement in 43.8% (7/16) of patients. One patient (1/16, 6.25%) in the combined obstruction group did not improve with surgical revision. CONCLUSIONS GCO after oesophagectomy rarely requires surgical revision. Potential association with medications affecting oesophageal and gastric motility requires further investigation. Classification of obstruction identifies a patient subset with lower success after surgical revision.
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Affiliation(s)
- Caroline D Andrew
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | | | - Douglas J Mathisen
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Christopher R Morse
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Henning A Gaissert
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
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11
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Müller PC, Kapp JR, Vetter D, Bonavina L, Brown W, Castro S, Cheong E, Darling GE, Egberts J, Ferri L, Gisbertz SS, Gockel I, Grimminger PP, Hofstetter WL, Hölscher AH, Low DE, Luyer M, Markar SR, Mönig SP, Moorthy K, Morse CR, Müller-Stich BP, Nafteux P, Nieponice A, Nieuwenhuijzen GAP, Nilsson M, Palanivelu C, Pattyn P, Pera M, Räsänen J, Ribeiro U, Rosman C, Schröder W, Sgromo B, van Berge Henegouwen MI, van Hillegersberg R, van Veer H, van Workum F, Watson DI, Wijnhoven BPL, Gutschow CA. Fit-for-Discharge Criteria after Esophagectomy: An International Expert Delphi Consensus. Dis Esophagus 2021; 34:5909885. [PMID: 32960264 DOI: 10.1093/dote/doaa101] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 07/03/2020] [Accepted: 08/15/2020] [Indexed: 12/11/2022]
Abstract
There are no internationally recognized criteria available to determine preparedness for hospital discharge after esophagectomy. This study aims to achieve international consensus using Delphi methodology. The expert panel consisted of 40 esophageal surgeons spanning 16 countries and 4 continents. During a 3-round, web-based Delphi process, experts voted for discharge criteria using 5-point Likert scales. Data were analyzed using descriptive statistics. Consensus was reached if agreement was ≥75% in round 3. Consensus was achieved for the following basic criteria: nutritional requirements are met by oral intake of at least liquids with optional supplementary nutrition via jejunal feeding tube. The patient should have passed flatus and does not require oxygen during mobilization or at rest. Central venous catheters should be removed. Adequate analgesia at rest and during mobilization is achieved using both oral opioid and non-opioid analgesics. All vital signs should be normal unless abnormal preoperatively. Inflammatory parameters should be trending down and close to normal (leucocyte count ≤12G/l and C-reactive protein ≤80 mg/dl). This multinational Delphi survey represents the first expert-led process for consensus criteria to determine 'fit-for-discharge' status after esophagectomy. Results of this Delphi survey may be applied to clinical outcomes research as an objective measure of short-term recovery. Furthermore, standardized endpoints identified through this process may be used in clinical practice to guide decisions regarding patient discharge and may help to reduce the risk of premature discharge or prolonged admission.
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Affiliation(s)
- P C Müller
- Department of Visceral and Transplant Surgery, University Hospital Zurich, Zurich, Switzerland
| | - J R Kapp
- Department of Visceral and Transplant Surgery, University Hospital Zurich, Zurich, Switzerland
| | - D Vetter
- Department of Visceral and Transplant Surgery, University Hospital Zurich, Zurich, Switzerland
| | - L Bonavina
- IRCCS Policlinico San Donato, Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - W Brown
- Oesophago-Gastric and Bariatric Unit, Department of General Surgery, The Alfred Hospital, Melbourne, Australia
| | - S Castro
- Department of Surgery, Vall d'Hebron Hospital, Barcelona, Spain
| | - E Cheong
- Department of General Surgery, Norfolk and Norwich University Hospital, Norwich, UK
| | - G E Darling
- Division of Thoracic Surgery, Department of Surgery, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - J Egberts
- Department of General, Visceral-, Thoracic-, Transplantation-, and Pediatric Surgery, Kurt-Semm Center for Laparoscopic and Robotic Assisted Surgery, University Hospital Schleswig Holstein, Campus Kiel, Kiel, Germany
| | - L Ferri
- Departments of Surgery and Oncology, Montreal General Hospital, McGill University, Montreal, Canada
| | - S S Gisbertz
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - I Gockel
- Department of Visceral, Thoracic, Transplant and Vascular surgery, University Hospital of Leipzig, Leipzig, Germany
| | - P P Grimminger
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - W L Hofstetter
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, USA
| | - A H Hölscher
- Center for Oesophageal and Gastric Surgery, AGAPLESION Markus Krankenhaus, Frankfurt am Main, Germany
| | - D E Low
- Department of General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, Seattle, USA
| | - M Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - S R Markar
- Imperial College Healthcare NHS Trust and Imperial College, London, UK
| | - S P Mönig
- Division of Visceral Surgery, Department of Surgery, University of Geneva, Hospitals and School of Medicine, Geneva, Switzerland
| | - K Moorthy
- Imperial College Healthcare NHS Trust and Imperial College, London, UK
| | - C R Morse
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, USA
| | - B P Müller-Stich
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - P Nafteux
- Department of Thoracic Surgery, University Hospital Leuven, Leuven, Belgium
| | - A Nieponice
- Esophageal Institute, Hospital Universitario Fundacion Favaloro, Buenos Aires, Argentina
| | | | - M Nilsson
- Division of Surgery, Department of Clinical Science Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - C Palanivelu
- Department of Surgical Gastroenterology, GEM Hospital & Research Centre, Coimbatore, India
| | - P Pattyn
- Department of Surgery, University Center Ghent, Ghent, Belgium
| | - M Pera
- Department of Surgery, Section of Gastrointestinal Surgery, Hospital Universitario del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - J Räsänen
- Department of General Thoracic and Esophageal Surgery, Heart and Lung Centre, Helsinki University Hospital, Helsinki, Finland
| | - U Ribeiro
- Department of Gastroenterology, Cancer Institute, University of São Paulo Medical School, São Paulo, Brazil
| | - C Rosman
- Department of Surgical Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - W Schröder
- Department of General, Visceral and Cancer Surgery, University of Cologne, Germany
| | - B Sgromo
- Department of Upper GI Surgery, Oxford University Hospitals, UK
| | | | - R van Hillegersberg
- Department of Surgical Oncology, University Medical Center Utrecht, The Netherlands
| | - H van Veer
- Department of Thoracic Surgery, University Hospital Leuven, Leuven, Belgium
| | - F van Workum
- Department of Surgical Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - D I Watson
- Flinders University Department of Surgery, Flinders Medical Centre, Bedford Park, Australia
| | - B P L Wijnhoven
- Department of Surgery, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - C A Gutschow
- Department of Visceral and Transplant Surgery, University Hospital Zurich, Zurich, Switzerland
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12
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Sachdeva UM, Axtell AL, Kroese TE, Chang DC, Morse CR. Impact of Obesity on Treatment Approach for Resectable Esophageal Cancer. Ann Thorac Surg 2020; 112:1059-1066. [PMID: 33345782 DOI: 10.1016/j.athoracsur.2020.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 09/18/2020] [Accepted: 12/02/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND With the prevalence of obesity and its known association with esophageal cancer, there is increasing need to understand how obesity affects treatment. METHODS Using The Society of Thoracic Surgeons General Thoracic Surgery Database, we retrospectively evaluated all patients who underwent esophagectomy with gastric conduit reconstruction between 2012 and 2016. Patients were categorized into five body mass index groups. Associations between body mass index and surgical technique, resection, lymphadenectomy, staging, and neoadjuvant treatment were evaluated using multivariable logistic regression models. RESULTS In all, 8547 patients were included in the analysis. Obese and morbidly obese patients were more likely to undergo open procedures compared with normal-weight patients (odds ratio [OR] 1.18, P = .016; and OR 1.45, P = .007), with longer operative times. Morbidly obese patients had a higher rate of intraoperative conversion from minimally invasive to open approaches (OR 3.75, P = .001). There were no differences in R0 resection or lymphadenectomy, and staging workup was similar. Obese patients were less likely to receive neoadjuvant therapy (OR 0.75, P = .048), and overweight and obese patients were less likely to receive preoperative radiation (OR 0.75, P = .017; and OR 0.71, P = .010). Analyzing by stage, overweight and obese patients with cT2N0 disease were less likely to receive neoadjuvant treatment (OR 0.54, P = .016; and OR 0.37, P < .001). There were no differences in neoadjuvant therapy for cT3 or node-positive disease. CONCLUSIONS Higher body mass index is associated with increased use of open versus minimally invasive esophagectomy and intraoperative conversion. Whereas staging workup and oncologic outcomes of surgery are similar, overweight and obese patients with cT2N0 disease are less likely to undergo neoadjuvant treatments.
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Affiliation(s)
- Uma M Sachdeva
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Andrea L Axtell
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Tiuri E Kroese
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - David C Chang
- Codman Center for Clinical Effectiveness in Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Christopher R Morse
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts.
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13
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Panda N, Morse CR. Commentary: Practice makes perfect in cervical esophagogastric anastomosis. J Thorac Cardiovasc Surg 2020; 160:1611-1612. [DOI: 10.1016/j.jtcvs.2020.04.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 04/11/2020] [Accepted: 04/11/2020] [Indexed: 11/16/2022]
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14
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Kroese TE, Tapias L, Olive JK, Trager LE, Morse CR. Routine intraoperative jejunostomy placement and minimally invasive oesophagectomy: an unnecessary step?†. Eur J Cardiothorac Surg 2020; 56:746-753. [PMID: 30907417 DOI: 10.1093/ejcts/ezz063] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 01/30/2019] [Accepted: 02/07/2019] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES Adequate nutrition is challenging after oesophagectomy. A jejunostomy is commonly placed during oesophagectomy for nutritional support. However, some patients develop jejunostomy-related complications and the benefit over oral nutrition alone is unclear. This study aims to assess jejunostomy-related complications and the impact of intraoperative jejunostomy placement on weight loss and perioperative outcomes in patients with oesophageal cancer treated with minimally invasive Ivor Lewis oesophagectomy (MIE). METHODS From a prospectively maintained database, patients were identified who underwent MIE with gastric reconstruction. Between 2007 and 2016, a jejunostomy was routinely placed during MIE. After 2016, a jejunostomy was not utilized. Postoperative feeding was performed according to a standardized protocol and similar for both groups. The primary outcomes were jejunostomy-related complications, relative weight loss at 3 and 6 months postoperative and perioperative outcomes, including anastomotic leak, pneumonia and length of stay, respectively. RESULTS A total of 188 patients were included, of whom 135 patients (72%) received a jejunostomy. Ten patients (7.4%) developed jejunostomy-related complications, of whom 30% developed more than 1 complication. There was no significant difference in weight loss between groups at 3 months (P = 0.73) and 6 months postoperatively (P = 0.68) and in perioperative outcomes (P-value >0.999, P = 0.591 and P = 0.513, respectively). CONCLUSIONS The use of a routine intraoperative jejunostomy appears to be an unnecessary step in patients undergoing MIE. Intraoperative jejunostomy placement is associated with complications without improving weight loss or perioperative outcomes. Its use should be tailored to individual patient characteristics. Early oral nutrition allows patients to maintain an adequate nutritional status.
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Affiliation(s)
- Tiuri E Kroese
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA.,Department of Surgery, Utrecht University Medical Center, Utrecht, the Netherlands
| | - Leonidas Tapias
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Jacqueline K Olive
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Lena E Trager
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Christopher R Morse
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
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15
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Bongers MER, Shin JH, Srivastava SD, Morse CR, Lee SG, Schwab JH. Free Vascularized Fibula Graft with Femoral Allograft Sleeve for Lumbar Spine Defects After Spondylectomy of Malignant Tumors: A Case Report. JBJS Case Connect 2020; 10:e2000075. [PMID: 32773710 DOI: 10.2106/jbjs.cc.20.00075] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE We present a 65-year-old man with an L4 conventional chordoma. Total en bloc spondylectomy (TES) of the involved vertebral bodies and surrounding soft tissues with reconstruction of the spine using a free vascularized fibula autograft (FVFG) is a proven technique, limiting complications and recurrence. However, graft fracture has occurred only in the lumbar spine in our institutional cases. We used a technique in our patient to ensure extra stability and support, with the addition of a femoral allograft sleeve encasing the FVFG. CONCLUSIONS Our technique for the reconstruction of the lumbar spine after TES of primary malignant spinal disease using a femoral allograft sleeve encasing the FVFG is viable to consider.
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Affiliation(s)
- Michiel E R Bongers
- 1Department of Orthopedic Surgery, Orthopedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 2Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 3Department of Vascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 4Division of Thoracic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 5Department of Orthopedic Surgery, Hand and Upper Extremity Service, Orthopedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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16
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Morse CR. Commentary: Custom-printed Y stent in the management of tracheoesophageal fistula following esophagectomy: A new weapon in a difficult fight? J Thorac Cardiovasc Surg 2020; 161:1673. [PMID: 32448699 DOI: 10.1016/j.jtcvs.2020.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 04/01/2020] [Accepted: 04/01/2020] [Indexed: 12/01/2022]
Affiliation(s)
- Christopher R Morse
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass.
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17
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Konradsson M, van Berge Henegouwen MI, Bruns C, Chaudry MA, Cheong E, Cuesta MA, Darling GE, Gisbertz SS, Griffin SM, Gutschow CA, van Hillegersberg R, Hofstetter W, Hölscher AH, Kitagawa Y, van Lanschot JJB, Lindblad M, Ferri LE, Low DE, Luyer MDP, Ndegwa N, Mercer S, Moorthy K, Morse CR, Nafteux P, Nieuwehuijzen GAP, Pattyn P, Rosman C, Ruurda JP, Räsänen J, Schneider PM, Schröder W, Sgromo B, Van Veer H, Wijnhoven BPL, Nilsson M. Diagnostic criteria and symptom grading for delayed gastric conduit emptying after esophagectomy for cancer: international expert consensus based on a modified Delphi process. Dis Esophagus 2019; 33:5585602. [PMID: 31608938 PMCID: PMC7150655 DOI: 10.1093/dote/doz074] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 06/25/2019] [Accepted: 07/14/2019] [Indexed: 12/11/2022]
Abstract
Delayed gastric conduit emptying (DGCE) after esophagectomy for cancer is associated with adverse outcomes and troubling symptoms. Widely accepted diagnostic criteria and a symptom grading tool for DGCE are missing. This hampers the interpretation and comparison of studies. A modified Delphi process, using repeated web-based questionnaires, combined with live interim group discussions was conducted by 33 experts within the field, from Europe, North America, and Asia. DGCE was divided into early DGCE if present within 14 days of surgery and late if present later than 14 days after surgery. The final criteria for early DGCE, accepted by 25 of 27 (93%) experts, were as follows: >500 mL diurnal nasogastric tube output measured on the morning of postoperative day 5 or later or >100% increased gastric tube width on frontal chest x-ray projection together with the presence of an air-fluid level. The final criteria for late DGCE accepted by 89% of the experts were as follows: the patient should have 'quite a bit' or 'very much' of at least two of the following symptoms; early satiety/fullness, vomiting, nausea, regurgitation or inability to meet caloric need by oral intake and delayed contrast passage on upper gastrointestinal water-soluble contrast radiogram or on timed barium swallow. A symptom grading tool for late DGCE was constructed grading each symptom as: 'not at all', 'a little', 'quite a bit', or 'very much', generating 0, 1, 2, or 3 points, respectively. For the five symptoms retained in the diagnostic criteria for late DGCE, the minimum score would be 0, and the maximum score would be 15. The final symptom grading tool for late DGCE was accepted by 27 of 31 (87%) experts. For the first time, diagnostic criteria for early and late DGCE and a symptom grading tool for late DGCE are available, based on an international expert consensus process.
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Affiliation(s)
- M Konradsson
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden,Department of Gastroenterology, Landspitali National University Hospital, Reykjavik, Iceland,Address correspondence to: Magnus Konradsson, MD, Department of Clinical Science, Investigation and Technology (CLINTEC), Karolinska Institutet, 14186 Stockholm, Sweden.
| | - M I van Berge Henegouwen
- Amsterdam UMC, location AMC, University of Amsterdam, Department of Surgery, Cancer Center Amsterdam
| | - C Bruns
- Department of General, Visceral and Cancer Surgery, University of Cologne, Cologne, Germany
| | - M A Chaudry
- Department of Surgery, Royal Marsden Hospital, London, UK
| | - E Cheong
- Norfolk and Norwich University Hospital, Norwich, UK
| | - M A Cuesta
- Department of Surgery, Amsterdam UMC, location VUmc, Amsterdam, Netherlands
| | - G E Darling
- Department of Surgery, Division of Thoracic Surgery, University Health Network, University of Toronto, Toronto, Canada
| | - S S Gisbertz
- Amsterdam UMC, location AMC, University of Amsterdam, Department of Surgery, Cancer Center Amsterdam
| | - S M Griffin
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - C A Gutschow
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | | | - W Hofstetter
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - A H Hölscher
- Centre for Esophageal and Gastric Surgery, AGAPLESION Markus Krankenhaus, Frankfurt, Germany
| | - Y Kitagawa
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - J J B van Lanschot
- Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - M Lindblad
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden,Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - L E Ferri
- Department of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - D E Low
- Virginia Mason Medical Center, Seattle, WA, USA
| | - M D P Luyer
- Department of Surgery, Catharina Ziekenhuis, Eindhoven, The Netherlands
| | - N Ndegwa
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - S Mercer
- Queen Alexandra Hospital Portsmouth, United Kingdom
| | - K Moorthy
- The Center for Visceral, Thoracic and Specialized Tumor Surgery, Hirslanden Medical Center, Zurich, Switzerland
| | - C R Morse
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - P Nafteux
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium,Department of Chronic Diseases, Metabolism and Aging, KU Leuven, Belgium
| | | | - P Pattyn
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - C Rosman
- Department of surgery, Radboud university center Nijmegen, The Netherlands
| | - J P Ruurda
- Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
| | - J Räsänen
- Department of General, Thoracic and Esophageal Surgery, Heart and Lung Center, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - P M Schneider
- The Center for Visceral, Thoracic and Specialized Tumor Surgery, Hirslanden Medical Center, Zurich, Switzerland
| | - W Schröder
- Department of General, Visceral and Cancer Surgery, University of Cologne, Cologne, Germany
| | - B Sgromo
- Oxford University Hospitals, Oxford, UK
| | - H Van Veer
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium,Department of Chronic Diseases, Metabolism and Aging, KU Leuven, Belgium
| | - B P L Wijnhoven
- Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - M Nilsson
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden,Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden,Department of Surgery and Cancer, Imperial College London, London, UK
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Affiliation(s)
- Nikhil Panda
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Christopher R Morse
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
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Panda N, Rattner DW, Morse CR. Third-time ("redo-redo") anti-reflux surgery: patient-reported outcomes after a thoracoabdominal approach. Surg Endosc 2019; 34:3092-3101. [PMID: 31388809 DOI: 10.1007/s00464-019-07059-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 07/31/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Approximately 3-6% of patients undergoing anti-reflux surgery require "redo" surgery for persistent gastroesophageal reflux disease (GERD). Further surgery for patients with two failed prior anti-reflux operations is controversial due to the morbidity of reoperation and poor outcomes. We examined our experience with surgical revision of patients with at least two failed anti-reflux operations. METHODS Adults undergoing at least a second-time revision anti-reflux surgery between 1999 and 2017 were eligible. The primary outcomes were general and disease-specific quality-of-life (QoL) scores determined by Short-Form-36 (SF36) and GERD-Health-Related QoL (GERD-HRQL) instruments, respectively. Secondary outcomes included perioperative morbidity and mortality. RESULTS Eighteen patients undergoing redo-redo surgery (13 with 2 prior operations, 5 with 3 prior operations) were followed for a median of 6 years [IQR 3, 12]. Sixteen patients (89%) underwent open revisions (14 thoracoabdominal, 2 laparotomy) and two patients had laparoscopic revisions. Indications for surgery included reflux (10 patients), regurgitation (5 patients), and dysphagia (3 patients). Intraoperative findings were mediastinal wrap herniation (9 patients), misplaced wrap (2 patients), mesh erosion (1 patient), or scarring/stricture (6 patients). Procedures performed included Collis gastroplasty + fundoplication (6 patients), redo fundoplication (5 patients), esophagogastrectomy (4 patients), and primary hiatal closure (3 patients). There were no deaths and 13/18 patients (72%) had no postoperative complications. Ten patients completed QoL surveys; 8 reported resolution of reflux, 6 reported resolution of regurgitation, while 4 remained on proton-pump inhibitors (PPI). Mean SF36 scores (± standard deviation) in the study cohort in the eight QoL domains were as follows: physical functioning (79.5 [± 19.9]), physical role limitations (52.5 [± 46.3]), emotional role limitations (83.3 [± 36.1]), vitality (60.0 [± 22.7]), emotional well-being (88.4 [± 8.7]), social functioning (75.2 [± 31.0]), pain (66.2 [± 30.9]), and general health (55.0 [± 39.0]). CONCLUSION An open thoracoabdominal approach in appropriately selected patients needing third-time anti-reflux surgery carries low morbidity and provides excellent results as reflected in QoL scores.
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Affiliation(s)
- Nikhil Panda
- Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, GRB-425, Boston, MA, 02114, USA.
| | - David W Rattner
- Division of General and Gastrointestinal Surgery, Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Christopher R Morse
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
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21
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Mao Y, Yu Z, You B, Fang W, Badgwell B, Berry MF, Ceppa DP, Chen C, Chen H, Cuesta MA, D'Journo XB, Eslick GD, Fu J, Fu X, Gao S, He J, He J, Huang Y, Jiang G, Jiang Z, Kim JY, Li D, Li H, Li S, Liu D, Liu L, Liu Y, Li X, Li Y, Mao W, Molena D, Morse CR, Novoa NM, Tan L, Tan Q, Toker A, Tong T, Wang Q, Weksler B, Xu L, Xu S, Yan T, Zhang L, Zhang X, Zhang X, Zhang Z, Zhi X, Zhou Q. Society for Translational Medicine Expert consensus on the selection of surgical approaches in the management of thoracic esophageal carcinoma. J Thorac Dis 2019; 11:319-328. [PMID: 30863610 DOI: 10.21037/jtd.2018.12.07] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Yousheng Mao
- Department of Thoracic Surgical Oncology, Cancer Institute & Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College; National Cancer Center, Beijing 100021, China
| | - Zhentao Yu
- Department of Esophageal Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin 300060, China
| | - Bin You
- Department of Thoracic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Wentao Fang
- Department of Thoracic Surgery, Shanghai Chest Hospital, Jiao Tong University, Shanghai 200030, China
| | - Brian Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mark F Berry
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
| | - DuyKhanh P Ceppa
- Division of Cardiothoracic Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Chun Chen
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, China
| | - Haiquan Chen
- Department of Thoracic Surgery, Shanghai Chest Hospital, Jiao Tong University, Shanghai 200030, China.,Department of Thoracic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China
| | - Miguel A Cuesta
- Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | | | - Guy D Eslick
- The Whiteley-Martin Research Centre, Discipline of Surgery, The University of Sydney, Nepean Hospital, Kingswood, Australia
| | - Jianhua Fu
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou 510060, China
| | - Xiangning Fu
- Department of Thoracic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Shugeng Gao
- Department of Thoracic Surgical Oncology, Cancer Institute & Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College; National Cancer Center, Beijing 100021, China
| | - Jianxing He
- Department of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China.,Guangzhou Institute of Respiratory Disease & China State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease, Guangzhou 510120, China
| | - Jie He
- Department of Thoracic Surgical Oncology, Cancer Institute & Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College; National Cancer Center, Beijing 100021, China
| | - Yunchao Huang
- Department of Thoracic and Cardiovascular Surgery, The Third Affiliated Hospital of Kunming Medical University (Yunnan Tumor Hospital), Kunming 650118, China
| | - Gening Jiang
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital of Tongji University, Shanghai 200433, China
| | - Zhongmin Jiang
- Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan 250014, China
| | - Jae Y Kim
- Department of Surgery, Division of Thoracic Surgery, City of Hope Cancer Center, Duarte, CA, USA
| | - Danqing Li
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Beijing 100730, China
| | - Hui Li
- Department of Thoracic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Shanqing Li
- Department of Thoracic Surgery, China and Japan Friendship Hospital, Beijing 100029, China
| | - Deruo Liu
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medicine, Beijing 100730, China
| | - Lunxu Liu
- Department of Cardiovascular and Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Yongyu Liu
- Department of Thoracic Surgery, Liaoning Cancer Hospital and Institute Shenyang 110042, China
| | - Xiaofei Li
- Department of Thoracic Surgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an 710038, China
| | - Yin Li
- Department of Thoracic Surgery, Henan Cancer Hospital, Zhengzhou 450008, China
| | - Weimin Mao
- Department of Thoracic Surgery, Zhejiang Cancer Hospital, Hangzhou 310022, China
| | - Daniela Molena
- Director of Esophageal Surgery, Thoracic Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, Los Angeles, CA, USA
| | - Christopher R Morse
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nuria M Novoa
- Thoracic Surgery Service, University Hospital of Salamanca, Salamanca, Spain
| | - Lijie Tan
- Department of Thoracic Surgery, Shanghai Zhongshan Hospital of Fudan University, Shanghai 200032, China
| | - Qunyou Tan
- Department of Thoracic Surgery, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing 400042, China
| | - Alper Toker
- Department of Thoracic Surgery, Istanbul Medical School, Istanbul University, Istanbul, Turkey
| | - Ti Tong
- Department of Thoracic Surgery, Second Hospital of Jilin University, Changchun 130041, China
| | - Qun Wang
- Department of Thoracic Surgery, Shanghai Zhongshan Hospital of Fudan University, Shanghai 200032, China
| | - Benny Weksler
- Division of Thoracic Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Lin Xu
- Department of Thoracic Surgery, Nanjing Medical University Affiliated Cancer Hospital, Jiangsu Key Laboratory of Molecular and Translational Cancer Research, Cancer Institute of Jiangsu Province, Nanjing 210009, China
| | - Shidong Xu
- Department of Thoracic surgery, Harbin Medical University Cancer Hospital, Harbin 150086, China
| | - Tiansheng Yan
- Department of Thoracic Surgery, Peking University Third Hospital, Beijing 100191, China
| | - Lanjun Zhang
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou 510060, China
| | - Xingyi Zhang
- Department of Thoracic Surgery, Second Hospital of Jilin University, Changchun 130041, China
| | - Xun Zhang
- Department of Thoracic Surgery, Tianjin Chest Hospital, Tianjin 300051, China
| | - Zhu Zhang
- Department of Thoracic Surgery, First Affiliated Hospital of Xinjiang Medical University, Urumqi 830054, China
| | - Xiuyi Zhi
- Department of Thoracic Surgery, Xuanwu Hospital of Capital Medical University, Beijing 100053, China
| | - Qinghua Zhou
- Department of Lung Cancer Center, West China Hospital, Sichuan University, Chengdu 610041, China
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Morse CR. Minimally Invasive Ivor Lewis Esophagectomy: How I Teach It. Ann Thorac Surg 2018; 106:1283-1287. [DOI: 10.1016/j.athoracsur.2018.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 09/06/2018] [Accepted: 09/07/2018] [Indexed: 10/28/2022]
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Abstract
Laryngotracheal trauma is a rare but potentially life-threatening injury. It is usually seen in multiple-trauma patients and can go unrecognized and undertreated due to its scarcity. The presenting symptoms often do not correlate with the severity of the injury and injuries may range from an endolaryngeal hematoma to a complete tracheal transection. Accurate diagnosis of the extent of the injury can be achieved with a combination of high resolution computed tomography, flexible fiber optic laryngoscopy and flexible bronchoscopy. Treatment may include observation with symptomatic management, reduction and repair of laryngeal skeletal fractures, or complete tracheal or laryngeal reconstruction. Endolaryngeal stents are reserved for use in cases of significant mucosal trauma or injuries that disrupt the anterior commissure of the larynx. The most important goal in management is to first secure and reconstruct the airway. Once this has been achieved, the long-term goal of treatment is to restore the voice and swallowing mechanism.
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Affiliation(s)
- Philicia Moonsamy
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Uma M Sachdeva
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Christopher R Morse
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
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Sachdeva U, Fong ZV, Wright CD, Wain JC, Lanuti M, Gaissert HA, Muniappan A, Chang DC, Mathisen DJ, Morse CR. Pre-Existing Comorbidity Status Is a More Robust Predictor of Postoperative Complication Risk than Advanced Age in Patients Undergoing Esophagectomy. J Am Coll Surg 2016. [DOI: 10.1016/j.jamcollsurg.2016.06.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Udelsman BV, Eaton J, Muniappan A, Morse CR, Wright CD, Mathisen DJ. Repair of large airway defects with bioprosthetic materials. J Thorac Cardiovasc Surg 2016; 152:1388-1397. [PMID: 27751243 DOI: 10.1016/j.jtcvs.2016.07.074] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 07/11/2016] [Accepted: 07/15/2016] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Patients with complicated airway defects that exceed the limits of primary repair represent a challenging clinical problem and require alternative techniques for repair. The aim of this study was to evaluate bioprosthetic reconstruction of large tracheal and bronchial defects. METHODS Retrospective chart review of patients treated at a single tertiary center from 2008 to 2015 who underwent repair of tracheal or bronchial defects with a bioprosthetic device, namely aortic homograft or acellular dermal matrix. RESULTS Eight patients, 3 men and 5 women with a mean age of 54 ± 13 years, underwent closure of complex central airway defects with bioprosthetic material. All but 1 patient underwent prior operative or stenting procedures. Three patients had isolated airway defects, whereas 5 had fistulas between the airway and enteric tract. Defects involved the membranous wall of the trachea (n = 5), the anterior wall of the trachea (n = 1), or the main stem bronchus (n = 2). Five reconstructions were with aortic homograft and 3 with acellular dermal matrix. Bioprosthetic material was buttressed with muscle flap (n = 4), omentum (n = 2), or left unbuttressed (n = 2). The airway defect was successfully closed in all patients. There was no postoperative mortality or recurrence of the airway defect in short-term follow-up. Two patients required debridement of granulation tissue and 1 additional patient required airway balloon dilation. Progression of underlying metastatic disease explained the majority of long-term mortality (75%). CONCLUSIONS Bioprosthetic materials represent a viable option for management of large airway defects, including airway-enteric fistulae, that exceed the limits of primary repair.
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Affiliation(s)
- Brooks V Udelsman
- Division of General Surgery, Massachusetts General Hospital, Boston, Mass.
| | - Jessica Eaton
- University of Louisville School of Medicine, Louisville, Ky
| | - Ashok Muniappan
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Mass
| | | | - Cameron D Wright
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Mass
| | - Douglas J Mathisen
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Mass
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26
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Morse CR, Wang H, Donahue DM, Garrity JM, Allan JS. Use of Proteolytic Enzymes in the Treatment of Proteinaceous Esophageal Food Impaction. J Emerg Med 2016; 50:183-6. [DOI: 10.1016/j.jemermed.2015.07.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 07/20/2015] [Accepted: 07/25/2015] [Indexed: 10/23/2022]
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Tapias LF, Mathisen DJ, Wright CD, Wain JC, Gaissert HA, Muniappan A, Lanuti M, Donahue DM, Morse CR. Outcomes With Open and Minimally Invasive Ivor Lewis Esophagectomy After Neoadjuvant Therapy. Ann Thorac Surg 2015; 101:1097-103. [PMID: 26652140 DOI: 10.1016/j.athoracsur.2015.09.062] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 07/21/2015] [Accepted: 09/21/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Neoadjuvant therapy is integral in the treatment of locally advanced esophageal cancer. Despite increasing acceptance of minimally invasive approaches to esophagectomy, there remain concerns about the safety and oncologic soundness after neoadjuvant therapy. We examined outcomes in patients undergoing open and minimally invasive (MIE) Ivor Lewis esophagectomy after neoadjuvant therapy. METHODS This was a retrospective series of 130 consecutive patients with esophageal cancer undergoing Ivor Lewis esophagectomy with curative intention after neoadjuvant therapy at a tertiary academic center (2008 to 2012). RESULTS An open procedure was performed in 74 patients (56.9%), and 56 (43.1%) underwent MIE after neoadjuvant therapy. MIE patients had shorter median intensive care unit (p = 0.002) and hospital lengths of stay (p < 0.0001). The incidence of postoperative complications was similar (open: 54.8% vs MIE: 41.1%, p = 0.155). However, observed respiratory complications were significantly reduced after MIE (8.9%) compared with open (29.7%; p = 0.004). Anastomotic leak rates were similar (open: 1.4% vs. MIE: 0%, p = 1.00). Mortality at 30 and 90 days was comparable (open: 2.7% and 4.1% vs MIE: 0% and 1.8%, p = 0.506 and p = 0.634, respectively). Complete resection rates and the number of collected lymph nodes was similar. Overall survival rates at 5 years were similar (open: 61% vs MIE: 50%, p = 0.933). MIE was not a significant predictor of overall survival (hazard ratio, 1.07; 95% confidence interval, 0.61 to 1.87; p = 0.810). CONCLUSIONS MIE proves its safety after neoadjuvant therapy because it leads to faster progression during the early postoperative period while reducing pulmonary complications. Open and MIE approaches appear equivalent with regards to perioperative oncologic outcomes after neoadjuvant therapy. Long-term outcomes need further validation.
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Affiliation(s)
- Luis F Tapias
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Douglas J Mathisen
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Cameron D Wright
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - John C Wain
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Henning A Gaissert
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Ashok Muniappan
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Michael Lanuti
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Dean M Donahue
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Christopher R Morse
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts.
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28
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Predina JD, Morse CR. Minimally invasive esophagectomy and its current role in esophageal cancer. MINERVA CHIR 2014; 69:363-370. [PMID: 25300696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The incidence of esophageal cancer has increased over the previous 4 decades. In 2014 alone, it is estimated that there will be 18,000 patients diagnosed with esophageal cancer, and 15,000 deaths from the disease.Esophagectomy, most commonly with adjuvant chemotherapy and radiation to treat locoregional spread, is the primary vehicle to offer patients cure. Open approaches (transthoracic Ivor Lewis, transhiatal, left thoracoabdominal, and 'three phase' McKeown esophagectomy) have been the most common, and are associated with significant morbidity and mortality.With this morbidity in mind, minimally invasive esophagectomy (MIE) has gained enthusiasm from the surgical community as an approach to minimize post-operative morbidity without sacrificing long-term outcomes. In this article, we review the basic steps of the three major approaches to MIE. We also review the recent data which supports the surgical field's growing enthusiasm for this approach to esophageal cancer. Based on our review of current data, we conclude that patients undergoing MIE have improved short-term outcomes with regard to morbidity and quality of life, with no adverse effects of the quality of oncologic resection.
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Affiliation(s)
- J D Predina
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA -
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29
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Tapias LF, Muniappan A, Wright CD, Gaissert HA, Wain JC, Morse CR, Donahue DM, Mathisen DJ, Lanuti M. Short and long-term outcomes after esophagectomy for cancer in elderly patients. Ann Thorac Surg 2013; 95:1741-8. [PMID: 23500043 DOI: 10.1016/j.athoracsur.2013.01.084] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Revised: 01/13/2013] [Accepted: 01/28/2013] [Indexed: 12/19/2022]
Abstract
BACKGROUND As worldwide life expectancy rises, the number of candidates for surgical treatment of esophageal cancer over 70 years will increase. This study aims to examine outcomes after esophagectomy in elderly patients. METHODS This study is a retrospective review of 474 patients undergoing esophagectomy for cancer during 2002 to 2011. A total of 334 (70.5%) patients were less than 70 years old (group A), 124 (26.2%) 70 to 79 years (group B), and 16 (3.4%) 80 years or greater (group C). We analyzed the effect of age on outcome variables including overall and disease specific survival. RESULTS Major morbidity was observed to occur in 115 (35.6%) patients of group A, 58 (47.9%) of group B, and 10 (62.5%) of group C (p = 0.010). Mortality, both 30-day and 90-day was observed in 2 (0.6%) and 7 (2.2%) of group A, 4 (3.2%) and 7 (6.1%) of group B, and 1 (6.3%) and 2 (14.3%) of group C, respectively (p = 0.032 and p = 0.013). Anastomotic leak was observed in 16 (4.8%) patients of group A, 6 (4.8%) of group B, and 0 (0%) of group C (p = 0.685). Anastomotic stricture (defined by the need for ≥ 2 dilations) was observed in 76 (22.8%) of group A, 13 (10.5%) of group B, and 1 (6.3%) of group C (p = 0.005). Five-year overall and disease specific survival was 64.8% and 72.4% for group A, 41.7% and 53.4% for group B, 49.2% and 49.2% for group C patients (p = 0.0006), respectively. CONCLUSIONS Esophagectomy should be carefully considered in patients 70 to 79 years old and can be justified with low mortality. Outcomes in octogenarians are worse suggesting esophagectomy be considered on a case by case basis. Stricture rate is inversely associated to age.
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Affiliation(s)
- Luis F Tapias
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
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Abstract
With several small series examining minimally invasive Ivor Lewis esophagectomies, we look to contribute to a growing experience. In reporting our initial results, safety, initial oncologic completeness, and preliminary outcomes with a minimally invasive Ivor Lewis esophagectomy were demonstrated. From 2007 to 2010, 40 minimally invasive Ivor Lewis esophagectomies were carried out. The approach was a laparoscopic mobilization of the stomach and a thoracoscopic esophageal mobilization and creation of a high intrathoracic anastomosis. Indications included esophageal cancer in 39 patients and esophageal gastrointestinal stromal tumor in one patient. Median age was 62 (range 39-77) with 31 (78%) male patients. Non-emergent conversion was required in two (5%) patients. Twenty-five (63%) patients underwent neoadjuvant therapy. Mean operative time was 364 minutes (range 285-455), and mean blood loss was 205 cc (range 100-400). All patients underwent an R0 resection including the removal of all Barrett's esophagus, and mean number of nodes harvested was 21 (range 11-41). Median intensive care unit stay was 1 day (range 1-3), and hospital stay was 7 days (range 6-19). There were no anastomotic leaks and no 30-day mortality. Postoperative complications included eight (21%) patients with atrial fibrillation and two (5%) chylothorax, one requiring ligation. At a mean follow-up of 16.5 months (range 1-39 months), five (13%) patients have had a distant recurrence; there have been no local recurrences. Minimally invasive Ivor Lewis esophagectomy, although technically challenging, can be carried out with reasonable operative times, a short length of stay, and minimal complication. Final oncologic validity is pending longer follow-up and a larger series.
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Affiliation(s)
- L F Tapias
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
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31
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Sihag S, Wright CD, Wain JC, Gaissert HA, Lanuti M, Allan JS, Mathisen DJ, Morse CR. Comparison of perioperative outcomes following open versus minimally invasive Ivor Lewis oesophagectomy at a single, high-volume centre. Eur J Cardiothorac Surg 2012; 42:430-7. [PMID: 22345284 DOI: 10.1093/ejcts/ezs031] [Citation(s) in RCA: 88] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES With the increasing popularity of minimally invasive oesophageal resections, equivalence, if not superiority, to open techniques must be demonstrated. Here we compare our open and minimally invasive Ivor Lewis oesophagectomy (MIE) experience. METHODS A prospective database of all oesophagectomies performed at Massachusetts General Hospital in Boston, MA between November 2007 and January 2011 was analysed. A total of 38 MIE and 76 open Ivor Lewis (OIE) oesophagectomies were performed for oesophageal carcinoma. Sixty-day surgical, oncological and postoperative outcomes were examined between the two groups. RESULTS Groups had similar demographics in terms of age, gender, tumour histology, clinical stage, preoperative comorbidities and neoadjuvant therapy. No difference was found with respect to adequacy of oncological resections. The median number of lymph nodes retrieved (OIE: 21, inter-quartile range (IQR): (16, 27) versus MIE: 19, IQR: (15, 28)), resection margins (OIE: 6.6% positive versus MIE: no positive margins) and 60-day mortality (OIE: 2.6% versus MIE: no deaths) were comparable. However, rates of pulmonary complications were significantly lower in the MIE group (OIE: 43.4 versus MIE: 2.6%, P < 0.001). Additionally, the median length of ICU and hospital stay, intraoperative blood loss and amount of intravenous fluids infused intraoperatively were also significantly decreased with MIE, while median operative times and the requirement for intraoperative blood transfusion were not significantly different between the two groups. Multivariate logistic regression analysis identified MIE as the only variable associated with a significant reduction in the rate of pulmonary complications in our study, while pre-existing pulmonary comborbidity was associated with an increased risk of pulmonary complications. CONCLUSIONS Open and MIE appear equivalent with regard to early oncological outcomes. A minimally invasive approach, however, appears to lead to a significant reduction in the rate of postoperative pulmonary complications. Length of ICU and hospital stay, as well as intraoperative blood loss and intravenous fluid requirements are also reduced in the setting of MIE. Long-term survival data will need to be followed closely. A large, multi-centred, randomized, controlled trial is warranted to confirm these results.
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Affiliation(s)
- Smita Sihag
- Department of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
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Affiliation(s)
- Jon O Wee
- Brigham andWomen’s Hospital, 75 Francis St, Boston, MA 02115, USA.
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Tapias LF, Morse CR. Minimally Invasive Ivor Lewis Esophagectomy after Induction Therapy Yields Similar Early Outcomes to Surgery Alone. Innovations 2011. [DOI: 10.1177/155698451100600508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Luis F. Tapias
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA USA
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Awais O, Luketich JD, Schuchert MJ, Morse CR, Wilson J, Gooding WE, Landreneau RJ, Pennathur A. Reoperative Antireflux Surgery for Failed Fundoplication: An Analysis of Outcomes in 275 Patients. Ann Thorac Surg 2011; 92:1083-9; discussion 1089-90. [DOI: 10.1016/j.athoracsur.2011.02.088] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Revised: 02/24/2011] [Accepted: 02/24/2011] [Indexed: 11/30/2022]
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Lanuti M, DeDelva P, Morse CR, Wright CD, Wain JC, Gaissert HA, Donahue DM, Mathisen DJ. Management of Delayed Gastric Emptying After Esophagectomy With Endoscopic Balloon Dilatation of the Pylorus. Ann Thorac Surg 2011; 91:1019-24. [DOI: 10.1016/j.athoracsur.2010.12.055] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2010] [Revised: 12/28/2010] [Accepted: 12/30/2010] [Indexed: 10/18/2022]
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Gethin-Jones TL, Noble VE, Morse CR. Quantification of diaphragm function using ultrasound: evaluation of a novel technique. Ultrasound Med Biol 2010; 36:1965-1969. [PMID: 20870347 DOI: 10.1016/j.ultrasmedbio.2010.08.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2010] [Revised: 07/27/2010] [Accepted: 08/11/2010] [Indexed: 05/29/2023]
Abstract
A novel method of image analysis for quantifying diaphragmatic motion is described using ultrasound. Nineteen patients scheduled for thoracic surgery were evaluated with ultrasound preoperatively and through their postoperative hospital stay. Diaphragmatic motion was measured using a horizontal on-screen ruler, allowing for quantification and tracking of dynamic diaphragm function. A percentage (73.5%) of all attempted measurements was quantifiable. Preoperative measurements of left and right diaphragm movement were correlated and there was no significant difference between the two. Postoperative diaphragm movement ipsilateral to the incision was statistically significantly less when compared to the contralateral side (p = 0.02 vs. p = 0.19). While not universally feasible in all patients, this method for quantifying diaphragmatic function is the only known imaging technique that can be performed at the bedside. Further evaluation of the impact of diaphragmatic dysfunction on patients undergoing thoracic surgery and its correlation with dyspnea is planned.
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Affiliation(s)
- Thomas L Gethin-Jones
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA 02114, USA.
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Gethin-Jones TL, Evans NR, Morse CR. Surgical management of mediastinal liposarcoma extending from hypopharynx to carina: case report. World J Surg Oncol 2010; 8:13. [PMID: 20196857 PMCID: PMC2842265 DOI: 10.1186/1477-7819-8-13] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2009] [Accepted: 03/02/2010] [Indexed: 11/14/2022] Open
Abstract
We describe the complete resection of a giant, well-differentiated mediastinal liposarcoma extending retropharynx to envelop the aortic arch, trachea and esophagus following preoperative radiotherapy.
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Affiliation(s)
- Thomas L Gethin-Jones
- Division of Thoracic Surgery, Massachusetts General Hospital, Blake 1570, 55 Fruit St, Boston, MA 02114, USA.
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Merritt RE, Mathisen DJ, Wain JC, Gaissert HA, Donahue D, Lanuti M, Allan JS, Morse CR, Wright CD. Long-term results of sleeve lobectomy in the management of non-small cell lung carcinoma and low-grade neoplasms. Ann Thorac Surg 2009; 88:1574-81; discussion 1581-2. [PMID: 19853115 DOI: 10.1016/j.athoracsur.2009.07.060] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2009] [Revised: 07/27/2009] [Accepted: 07/28/2009] [Indexed: 12/16/2022]
Abstract
BACKGROUND The objective of this study was to evaluate the operative mortality, morbidity, and long-term survival of sleeve lobectomy for non-small cell lung cancer and low-grade neoplasms. We evaluated the effects of neoadjuvant therapy on the bronchial anastomotic complication rate and determined whether sleeve lobectomy performed in patients with N1 disease resulted in decreased overall survival. METHODS This study is a retrospective review of 196 patients who underwent sleeve lobectomy. One hundred twenty-five patients had non-small cell lung cancer. There were 117 men (59.7%) and 79 women (40.3%) with a mean age of 54 years. Sixteen patients (13%) received neoadjuvant therapy. Fifty-six patients with N1 disease underwent sleeve lobectomy. RESULTS There were 4 (2.0%) postoperative deaths. The postoperative morbidity rate was 36.7%. Four patients (2.0%) experienced bronchopleural fistulas. Multivariate analysis demonstrated that age older than 70 years (p = 0.02) and the diagnosis of non-small cell lung cancer (p = 0.0002) were risk factors for postoperative complications. Multivariate analysis also demonstrated that neoadjuvant therapy predicted anastomotic complications (p = 0.01). For non-small cell lung cancer patients, the 5-year survival rate was 44%. The 5-year survival rates for patients with pathologic N0 disease and N1 disease were 52.6% versus 39.3%, respectively (p = 0.205). CONCLUSIONS Sleeve lobectomy can be performed with minimal bronchial anastomotic complications and low postoperative mortality. In our study, neoadjuvant therapy for non-small cell lung cancer adversely influenced the rate of anastomotic complications. Performing sleeve lobectomy for patients with N1 disease was not associated with decreased overall survival rates.
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Affiliation(s)
- Robert E Merritt
- General Thoracic Surgery Division, Massachusetts General Hospital, Boston, Massachusetts 02114, USA
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Affiliation(s)
- Parsia A Vagefi
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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de Delva PE, Morse CR, Austen WG, Gaissert HA, Lanuti M, Wain JC, Wright CD, Mathisen DJ. Surgical management of failed colon interposition. Eur J Cardiothorac Surg 2008; 34:432-7; discussion 437. [PMID: 18501622 DOI: 10.1016/j.ejcts.2008.04.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2007] [Revised: 03/31/2008] [Accepted: 04/02/2008] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Complications following colon interposition may be acute or chronic and often devastating. Creative strategies are needed to preserve the conduit or develop alternatives when the conduit cannot be salvaged. METHODS The records of patients undergoing revision surgery of colon interposition between 1965 and 2005 were reviewed. RESULTS Thirty-five patients underwent 48 operative revisions. Nineteen patients underwent one operation, nine required multiple operations to manage one problem and seven developed more than one distinct problem requiring several operative interventions. The most common indications for revision surgery were redundancy (n=13), stricture (n=11), and loss of intestinal continuity (n=8). The most common revisional operations were anastomotic revision (n=13), segmental colonic resection (n=6), and stricturoplasty (n=4). Swallowing function was restored in 32 of 35 patients. Loss of intestinal continuity was successfully reversed in six of seven patients. There were no intraoperative deaths. Four patients required re-operation after a failed revision at our institution. Swallowing was restored in three of four patients. CONCLUSIONS Complications that develop after colon bypass present major challenges for surgeons to maintain swallowing and quality of life. We present successful strategies to manage these devastating complications. It is the largest report dealing with a wide variety of complications of colon bypass.
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Affiliation(s)
- Pierre E de Delva
- Division of Thoracic Surgery, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA, USA
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Morse CR, Fernando HC, Ferson PF, Landreneau RJ, Luketich JD. Preliminary experience by a thoracic service with endoscopic transoral stapling of cervical (Zenker's) diverticulum. J Gastrointest Surg 2007; 11:1091-4. [PMID: 17623265 DOI: 10.1007/s11605-007-0191-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2007] [Accepted: 05/15/2007] [Indexed: 01/31/2023]
Abstract
Recently endoscopic transoral stapling (ES) of cervical (Zenker's) diverticulum (ZD) has been reported. In a 10-year retrospective review, we identified 47 patients undergoing ES or open surgery (OS) for ZD. ES was attempted in 28 patients and OS in 19. Using an intention to treat analysis, outcomes examined included operative time, length of stay, and dysphagia severity using a scale from 1 (no dysphagia) to 5 (severe dysphagia). ES was completed in 24/28 patients with four conversions to OS. The mean age was 75 years for the ES group and 70 years for the OS group (p = 0.079). Mean operative time (1.57 versus 2.35 h.) was less (p < 0.03) in the ES group. Length of stay (2.12 versus 2.44 days) was shorter for ES but not significant (P = 0.49). Mean follow up was 17 (1-103) months for both groups. Dysphagia scores were comparable between the two groups preoperatively (2.78 ES versus 2.79 OS; p = 0.98) and improved significantly (p = 0.001) to 1.1 after ES and 1.0 after OS. The time to oral intake was 1.38 days in the ES group and 1.29 days in the OS group (p = 0.80). We conclude that ES is feasible and can be performed with shorter operative times and comparable short-term results to OS.
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Affiliation(s)
- Christopher R Morse
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA 02114, USA
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Morse CR, Ishitani MB, Cassivi SD. Video-assisted resection of bilateral intralobar pulmonary sequestrations. J Thorac Cardiovasc Surg 2006; 131:917-8. [PMID: 16580457 DOI: 10.1016/j.jtcvs.2005.12.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2005] [Revised: 12/07/2005] [Accepted: 12/09/2005] [Indexed: 11/19/2022]
Affiliation(s)
- Christopher R Morse
- Division of General Thoracic Surgery, Mayo Clinic College of Medicine, Rochester, Minn 55905, USA
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Kabakibi A, Morse CR, Laposata M. Fatty acid ethyl esters and HepG2 cells: intracellular synthesis and release from the cells. J Lipid Res 1998; 39:1568-82. [PMID: 9717716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Fatty acid ethyl esters (FAEE), esterification products of fatty acid and ethanol, have been implicated as mediators of ethanol-induced organ damage. To understand the molecular and cellular events in FAEE synthesis and secretion, we developed a system in which HepG2 cells synthesize and release FAEE into the culture medium upon incubation with ethanol. The synthesis of FAEE was observed within 5 min of the addition of ethanol, with a plateau for FAEE synthesis after 2 h of incubation. It was also observed that FAEE are synthesized by both a microsomal FAEE synthase, which preferentially uses fatty acyl-CoA as a substrate, and a cytosolic FAEE synthase, which accepts both unesterified fatty acid and fatty acyl-CoA as substrates with a slight preference for fatty acyl-CoA. Although the kinetics of cellular FAEE synthesis await further characterization, the intracellular fatty acid substrate appears to be derived principally from glycerolipids and other esters. FAEE were released into the culture medium by a mechanism independent of the vesicular transport pathway. Lipoprotein particles and albumin were found to be carriers of FAEE after FAEE secretion from the cell.
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Affiliation(s)
- A Kabakibi
- Department of Pathology, Massachusetts General Hospital/Harvard Medical School, Boston 02114, USA
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Doyle KM, Cluette-Brown JE, Dube DM, Bernhardt TG, Morse CR, Laposata M. Fatty acid ethyl esters in the blood as markers for ethanol intake. JAMA 1996; 276:1152-6. [PMID: 8827968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine the clinical utility of fatty acid ethyl esters (FAEEs) in the blood as a short-term confirmatory marker for ethanol intake and a longer-term marker for ethanol intake after ethanol is no longer detectable. DESIGN Single-center controlled clinical trial and a blinded comparison involving 48 blood samples that were positive, negative, or equivocal for blood ethanol. PARTICIPANTS Seven healthy subjects (4 men and 3 women, aged 21 to 23 years) participated in the clinical trial. Blood samples from participants for the blinded comparison portion of the study were numbered from 1 to 48 and not identified by name. INTERVENTION The 7 healthy subjects ingested a known amount of ethanol at a fixed rate. The concentration of FAEEs in the blood after ethanol intake was determined for a period of up to 24 hours. There was no intervention in the blinded comparison study. MAIN OUTCOME MEASURES In the clinical trial, a pharmacokinetic analysis of FAEE concentration in the blood after ethanol intake was completed for 7 individuals whose blood ethanol level was elevated from 25 to 35 mmol/L. In the blinded comparison, the 48 blood samples that were positive, negative, or equivocal for blood ethanol were analyzed for FAEE concentration. RESULTS In the clinical trial, the disappearance of FAEEs from the blood followed a decay curve that initially resembled the decay curve for blood ethanol. However, because of a very slow secondary elimination phase, the FAEEs were found to persist in the blood for at least 24 hours after ethanol intake was completed. In the blinded comparison, all 20 samples that were positive for ethanol were positive for FAEEs, 7 of 7 samples equivocal for ethanol were positive for FAEEs, and 21 of 21 negative samples for ethanol were negative for FAEEs. CONCLUSIONS Serum concentration of FAEEs can serve as an excellent short-term confirmatory test for ethanol intake as well as a longer-term marker of ethanol ingestion. Measurement of FAEEs in the blood may be a more sensitive indicator of ethanol ingestion than the measurement of blood ethanol .
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Affiliation(s)
- K M Doyle
- Department of Pathology, Massachusetts General Hospital, Boston 02114, USA
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Heith AM, Morse CR, Tsujita T, Volpacelli SA, Flood JG, Laposata M. Fatty acid ethyl ester synthase catalyzes the esterification of ethanol to cocaine. Biochem Biophys Res Commun 1995; 208:549-54. [PMID: 7695606 DOI: 10.1006/bbrc.1995.1373] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Fatty acid ethyl esters (FAEE), esterification products of ethanol and fatty acids, have been implicated as mediators of ethanol induced organ damage. It has been shown that FAEE synthase, the enzyme responsible for the formation of FAEE, is present selectively in the organs damaged by ethanol abuse. Cocaethylene is a cocaine metabolite generated in the presence of ethanol which has been established as enhancing cocaine toxicity. In the present study we show that purified FAEE synthase also catalyzes the formation of cocaethylene. A linear relationship (r = 0.998) was demonstrated between the amount of purified FAEE synthase (microgram) and cocaethylene synthesis (nmol/hr). We further showed a correlation (r = 0.804) between the two enzyme activities in selected tissues. These findings provide evidence that purified FAEE synthase has cocaethylene synthetic ability and FAEE synthase may be responsible for a portion of cocaethylene synthesis in vivo.
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Affiliation(s)
- A M Heith
- Department of Pathology, Massachusetts General Hospital, Boston 02114
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