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Alvarado CE, Worrell SG. Pathologic Response is Negatively Impacted by Diabetes for Esophageal Cancer. Ann Thorac Surg 2024:S0003-4975(24)00258-3. [PMID: 38604392 DOI: 10.1016/j.athoracsur.2024.03.028] [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: 03/20/2024] [Accepted: 03/22/2024] [Indexed: 04/13/2024]
Affiliation(s)
- Christine E Alvarado
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH
| | - Stephanie G Worrell
- Section of Thoracic Surgery, Department of Surgery, University of Arizona, 1501 N. Campbell Ave, Tucson, AZ 85724.
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2
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Riall TS, Worrell SG. Communication in your department and beyond. Surgery 2024; 175:1237-1239. [PMID: 38049361 DOI: 10.1016/j.surg.2023.11.005] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 11/04/2023] [Indexed: 12/06/2023]
Abstract
Technical skills and clinical acumen are necessary for success in a surgical career. However, these skills alone are not sufficient. A surgeon's emotional intelligence and ability to communicate, manage conflict, and cultivate relationships may be even more critical to success. Health care environments are increasingly complex. An individual surgeon's or surgical department's success depends highly on the teams around them, including anesthesia, nursing, hospital administration, clinic teams, and many more. The surgeon's ability to communicate across the organization and lead by influence is critical.
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Affiliation(s)
- Taylor S Riall
- Department of Surgery, University of Arizona, Tucson, AZ.
| | - Stephanie G Worrell
- Department of Surgery, University of Arizona, Tucson, AZ. https://twitter.com/sgworrell
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3
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Conrad H, Worrell SG. Commentary: A universal patient-reported outcome measure. J Thorac Cardiovasc Surg 2024; 167:1500-1501. [PMID: 37683722 DOI: 10.1016/j.jtcvs.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 08/30/2023] [Accepted: 09/01/2023] [Indexed: 09/10/2023]
Affiliation(s)
- Hope Conrad
- Section of Thoracic Surgery, Department of Surgery, University of Arizona, Tucson, Ariz
| | - Stephanie G Worrell
- Section of Thoracic Surgery, Department of Surgery, University of Arizona, Tucson, Ariz.
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4
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Towe CW, Servais EL, Brown LM, Blasberg JD, Mitchell JD, Worrell SG, Seder CW, David EA. The Society of Thoracic Surgeons General Thoracic Surgery Database: 2023 Update on Outcomes and Research. Ann Thorac Surg 2024; 117:489-496. [PMID: 38043852 DOI: 10.1016/j.athoracsur.2023.11.021] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 11/15/2023] [Accepted: 11/20/2023] [Indexed: 12/05/2023]
Abstract
The Society of Thoracic Surgeons General Thoracic Surgery Database (GTSD) continues its trajectory of growth and enhancement, solidifying its stature as a premier global thoracic surgical database. The past year witnessed a notable expansion with the inclusion of 10 additional participating sites, now totaling 287, augmenting the database's repository to more than 800,000 procedures. A significant stride was made in refining the data audit process, thereby elevating the accuracy and completeness metrics, a testament to the relentless pursuit of data integrity. The GTSD further broadened its research apparatus, with 15 scholarly publications, a 50% uptick from the preceding year. These publications underscore the database's instrumental role in advancing thoracic surgical knowledge. In a concerted effort to alleviate data entry exigencies, the GTSD Task Force also instituted streamlined data submission protocols, a move lauded by participant sites. This report delineates the recent advancements, volume trajectories, and outcome metrics and encapsulates the prolific research output emanating from the GTSD, reflecting a year of substantial progress and academic fecundity.
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Affiliation(s)
- Christopher W Towe
- Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio.
| | - Elliot L Servais
- Division of Thoracic and Cardiovascular Surgery, Lahey Hospital & Medical Center, Burlington, Massachusetts; Department of Surgery, Tufts University School of Medicine, Boston, Massachusetts
| | - Lisa M Brown
- Section of General Thoracic Surgery, UC Davis Health, Sacramento, California
| | - Justin D Blasberg
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - John D Mitchell
- Section of General Thoracic Surgery, Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado, Aurora, Colorado
| | | | - Christopher W Seder
- Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Elizabeth A David
- Section of General Thoracic Surgery, Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado, Aurora, Colorado
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Fick CN, Dunne EG, Sihag S, Molena D, Cytryn SL, Janjigian YY, Wu AJ, Worrell SG, Hofstetter WL, Jones DR, Gray KD. Immunotherapy for Resectable Locally Advanced Esophageal Carcinoma. Ann Thorac Surg 2024:S0003-4975(24)00125-5. [PMID: 38408631 DOI: 10.1016/j.athoracsur.2024.02.021] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 01/16/2024] [Accepted: 02/05/2024] [Indexed: 02/28/2024]
Abstract
BACKGROUND The current standard of care for locally advanced esophageal and gastroesophageal junction (GEJ) cancers includes neoadjuvant chemoradiotherapy or perioperative chemotherapy with surgical resection; however, disease-free survival in these patients remains poor. Immune checkpoint inhibitors (ICIs) are approved for adjuvant treatment of locally advanced esophageal and GEJ cancers, but their benefit in the perioperative and neoadjuvant settings remains under investigation. METHODS We used the PubMed online database to conduct a literature search to identify studies that investigated immunotherapy for locally advanced esophageal and GEJ carcinoma. A review of ClinicalTrials.gov yielded a list of ongoing trials. RESULTS Adjuvant nivolumab for residual disease after neoadjuvant chemoradiotherapy and surgery is the only approved immunotherapy regimen for locally advanced esophageal cancer. Early-phase trials investigating the addition of neoadjuvant or perioperative ICIs to standard-of-care multimodality approaches have observed pathologic complete response rates as high as 60%. Response rates are highest for ICIs plus chemoradiotherapy for esophageal squamous cell carcinoma and dual checkpoint inhibition in mismatch repair-deficient adenocarcinomas. Safety profiles are acceptable, with a pooled adverse event rate of 27%. Surgical morbidity and mortality with immunotherapy are similar to historical controls with no immunotherapy, and R0 resection rates are high. When reported, disease-free survival among patients treated with perioperative immunotherapy is promising. CONCLUSIONS Outside of clinical trials, immunotherapy for resectable esophageal carcinoma is limited to the adjuvant setting. Phase III trials investigating neoadjuvant and perioperative immunotherapy are now underway and will provide much-needed data on survival that may ultimately lead to practice-changing recommendations.
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Affiliation(s)
- Cameron N Fick
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Elizabeth G Dunne
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Smita Sihag
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniela Molena
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Samuel L Cytryn
- Gastrointestinal Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Yelena Y Janjigian
- Gastrointestinal Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Abraham J Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Stephanie G Worrell
- Section of Thoracic Surgery, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Wayne L Hofstetter
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David R Jones
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.
| | - Katherine D Gray
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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Alvarado CE, Worrell SG. Neoadjuvant Treatment for Stage IIA Esophageal Adenocarcinoma, No Harm No Foul? Ann Surg Oncol 2024; 31:718-719. [PMID: 38091147 DOI: 10.1245/s10434-023-14678-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 11/12/2023] [Indexed: 01/05/2024]
Affiliation(s)
- Christine E Alvarado
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Stephanie G Worrell
- Section of Thoracic Surgery, Department of Surgery, University of Arizona, Tucson, AZ, USA.
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Towe CW, Bachman KC, Ho VP, Pieracci F, Worrell SG, Moorman ML, Linden PA, Badrinathan A. Early Repair of Rib Fractures Is Associated with Superior Length of Stay and Total Hospital Cost: A Propensity Matched Analysis of the National Inpatient Sample. Medicina (Kaunas) 2024; 60:153. [PMID: 38256413 PMCID: PMC10819862 DOI: 10.3390/medicina60010153] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 11/01/2023] [Accepted: 01/02/2024] [Indexed: 01/24/2024]
Abstract
Background and Objectives: Previous studies have suggested that early scheduling of the surgical stabilization of rib fractures (SSRF) is associated with superior outcomes. It is unclear if these data are reproducible at other institutions. We hypothesized that early SSRF would be associated with decreased morbidity, length of stay, and total charges. Materials and Methods: Adult patients who underwent SSRF for multiple rib fractures or flail chest were identified in the National Inpatient Sample (NIS) by ICD-10 code from the fourth quarter of 2015 to 2016. Patients were excluded for traumatic brain injury and missing study variables. Procedures occurring after hospital day 10 were excluded to remove possible confounding. Early fixation was defined as procedures which occurred on hospital day 0 or 1, and late fixation was defined as procedures which occurred on hospital days 2 through 10. The primary outcome was a composite outcome of death, pneumonia, tracheostomy, or discharge to a short-term hospital, as determined by NIS coding. Secondary outcomes were length of hospitalization (LOS) and total cost. Chi-square and Wilcoxon rank-sum testing were performed to determine differences in outcomes between the groups. One-to-one propensity matching was performed using covariates known to affect the outcome of rib fractures. Stuart-Maxwell marginal homogeneity and Wilcoxon signed rank matched pair testing was performed on the propensity-matched cohort. Results: Of the 474 patients who met the inclusion criteria, 148 (31.2%) received early repair and 326 (68.8%) received late repair. In unmatched analysis, the composite adverse outcome was lower among early fixation (16.2% vs. 40.2%, p < 0.001), total hospital cost was less (USD114k vs. USD215k, p < 0.001), and length of stay was shorter (6 days vs. 12 days) among early SSRF patients. Propensity matching identified 131 matched pairs of early and late SSRF. Composite adverse outcomes were less common among early SSRF (18.3% vs. 32.8%, p = 0.011). The LOS was shorter among early SSRF (6 days vs. 10 days, p < 0.001), and total hospital cost was also lower among early SSRF patients (USD118k vs. USD183k late, p = 0.001). Conclusion: In a large administrative database, early SSRF was associated with reduced adverse outcomes, as well as improved hospital length of stay and total cost. These data corroborate other research and suggest that early SSRF is preferred. Studies of outcomes after SSRF should stratify analyses by timing of procedure.
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Affiliation(s)
- Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| | - Katelynn C Bachman
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| | - Vanessa P Ho
- MetroHealth Medical Center, Department of Surgery, Division of Trauma, Critical Care, Burns, & Acute Care Surgery, Cleveland, OH 44109, USA
| | - Fredric Pieracci
- Department of Surgery Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO 80045, USA
| | - Stephanie G Worrell
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| | - Matthew L Moorman
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| | - Avanti Badrinathan
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
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Worrell SG, Goodman KA, Altorki NK, Ashman JB, Crabtree TD, Dorth J, Firestone S, Harpole DH, Hofstetter WL, Hong TS, Kissoon K, Ku GY, Molena D, Tepper JE, Watson TJ, Williams T, Willett C. The Society of Thoracic Surgeons/American Society for Radiation Oncology Updated Clinical Practice Guidelines on Multimodality Therapy for Locally Advanced Cancer of the Esophagus or Gastroesophageal Junction. Pract Radiat Oncol 2024; 14:28-46. [PMID: 37921736 DOI: 10.1016/j.prro.2023.10.001] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2023] [Indexed: 11/04/2023]
Abstract
Outcomes for patients with esophageal cancer have improved over the last decade with the implementation of multimodality therapy. There are currently no comprehensive guidelines addressing multidisciplinary management of esophageal cancer that have incorporated the input of surgeons, radiation oncologists, and medical oncologists. To address the need for multidisciplinary input in the management of esophageal cancer and to meet current best practices for clinical practice guidelines, the current guidelines were created as a collaboration between The Society of Thoracic Surgeons (STS), American Society for Radiation Oncology (ASTRO), and the American Society of Clinical Oncology (ASCO). Physician representatives chose 8 key clinical questions pertinent to the care of patients with locally advanced, resectable thoracic esophageal cancer (excluding cervical location). A comprehensive literature review was performed identifying 227 articles that met the inclusion criteria covering the use of induction chemotherapy, chemotherapy vs chemoradiotherapy before surgery, optimal radiation dose, the value of esophagectomy, timing of esophagectomy, the approach and extent of lymphadenectomy, the use of minimally invasive esophagectomy, and the value of adjuvant therapy after resection. The relevant data were reviewed and voted on by the panel with 80% of the authors, with 75% agreement on class and level of evidence. These data were then complied into the guidelines document.
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Affiliation(s)
- Stephanie G Worrell
- Section of Thoracic Surgery, Department of Surgery, University of Arizona College of Medicine, Tucson, Arizona.
| | - Karyn A Goodman
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Nasser K Altorki
- Division of Thoracic Surgery, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, New York
| | | | - Traves D Crabtree
- Division of Cardiothoracic Surgery, Department of Surgery, Southern Illinois University School of Medicine, Springfield, Illinois
| | - Jennifer Dorth
- Department of Radiation Oncology, Seidman Cancer Center, University Hospitals, Cleveland, Ohio
| | | | - David H Harpole
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Wayne L Hofstetter
- Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Geoffrey Y Ku
- Gastrointestinal Medical Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniela Molena
- Division of Thoracic Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Joel E Tepper
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina
| | - Thomas J Watson
- Thoracic Surgery Group, Beaumont Health, Royal Oak, Michigan
| | - Terence Williams
- Department of Radiation Oncology, Beckman Research Institute, City of Hope National Medical Center, Duarte, California
| | - Christopher Willett
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
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Worrell SG, Alvarado CE, Thibault D, Towe CW, Mitchell JD, Vekstein A, Kosinski AS, Hartwig MG, Linden PA. Impact of Diabetes on Pathologic Response to Multimodality Therapy for Esophageal Cancer. Ann Thorac Surg 2024; 117:190-196. [PMID: 35970230 DOI: 10.1016/j.athoracsur.2022.07.046] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 01/19/2022] [Revised: 06/03/2022] [Accepted: 07/23/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND The incidence of esophageal cancer has increased faster than that of most cancers. Evidence from other malignant neoplasms suggests that diabetic patients have a worse response to multimodality therapy. We hypothesized that diabetic patients with esophageal cancer will have a decreased response to neoadjuvant chemotherapy and radiation therapy compared with nondiabetic patients. METHODS A retrospective study of The Society of Thoracic Surgeons General Thoracic Surgery Database identified all patients who had an esophagectomy after neoadjuvant therapy for esophageal cancer between 2012 and 2019. Patients were compared on the basis of the presence of diabetes. A pathologic complete response (pCR) was defined as ypT0 N0. The χ2 and Wilcoxon rank sum tests were used to compare patients' demographic and clinical characteristics between those with and those without diabetes. Multivariable logistic regression was used to evaluate the predictors of response to neoadjuvant therapy. RESULTS Of the 9171 patients who met inclusion criteria, 2011 (22%) patients were diabetic and 7160 (78%) patients were nondiabetic. Patients with diabetes were older, more likely to be male, and more likely to have all comorbidities. Univariate analysis revealed that diabetic patients were less likely to have pCR (16% vs 18%; P = .026). Although multivariable analysis showed a trend toward diabetic patients' having lower odds of achieving pCR, diabetes was not independently associated with pCR (odds ratio, 0.89; 95% CI, 0.78-1.01; P = .075). CONCLUSIONS Diabetic patients may be less likely than nondiabetic patients to achieve pCR after neoadjuvant treatment of esophageal cancer. This suggests the need for further exploration as diabetic patients with esophageal cancer can potentially benefit from different treatment paradigms compared with their nondiabetic counterparts.
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Affiliation(s)
- Stephanie G Worrell
- Division of Cardiothoracic Surgery, Section of Thoracic Surgery, Department of Surgery, University of Arizona, Tucson, Arizona.
| | - Christine E Alvarado
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Dylan Thibault
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - John D Mitchell
- Division of Cardiothoracic Surgery, Section of General Thoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Andrew Vekstein
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Andrzej S Kosinski
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Matthew G Hartwig
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
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10
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Worrell SG, Goodman KA, Altorki NK, Ashman JB, Crabtree TD, Dorth J, Firestone S, Harpole DH, Hofstetter WL, Hong TS, Kissoon K, Ku GY, Molena D, Tepper JE, Watson TJ, Williams T, Willett C. The Society of Thoracic Surgeons/American Society for Radiation Oncology Updated Clinical Practice Guidelines on Multimodality Therapy for Locally Advanced Cancer of the Esophagus or Gastroesophageal Junction. Ann Thorac Surg 2024; 117:15-32. [PMID: 37921794 DOI: 10.1016/j.athoracsur.2023.09.021] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 08/23/2023] [Accepted: 09/05/2023] [Indexed: 11/04/2023]
Abstract
Outcomes for patients with esophageal cancer have improved over the last decade with the implementation of multimodality therapy. There are currently no comprehensive guidelines addressing multidisciplinary management of esophageal cancer that have incorporated the input of surgeons, radiation oncologists, and medical oncologists. To address the need for multidisciplinary input in the management of esophageal cancer and to meet current best practices for clinical practice guidelines, the current guidelines were created as a collaboration between The Society of Thoracic Surgeons (STS), American Society for Radiation Oncology (ASTRO), and the American Society of Clinical Oncology (ASCO). Physician representatives chose 8 key clinical questions pertinent to the care of patients with locally advanced, resectable thoracic esophageal cancer (excluding cervical location). A comprehensive literature review was performed identifying 227 articles that met the inclusion criteria covering the use of induction chemotherapy, chemotherapy vs chemoradiotherapy before surgery, optimal radiation dose, the value of esophagectomy, timing of esophagectomy, the approach and extent of lymphadenectomy, the use of minimally invasive esophagectomy, and the value of adjuvant therapy after resection. The relevant data were reviewed and voted on by the panel with 80% of the authors, with 75% agreement on class and level of evidence. These data were then complied into the guidelines document.
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Affiliation(s)
- Stephanie G Worrell
- Section of Thoracic Surgery, Department of Surgery, University of Arizona College of Medicine, Tucson, Arizona.
| | - Karyn A Goodman
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Nasser K Altorki
- Division of Thoracic Surgery, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, New York
| | | | - Traves D Crabtree
- Division of Cardiothoracic Surgery, Department of Surgery, Southern Illinois University School of Medicine, Springfield, Illinois
| | - Jennifer Dorth
- Department of Radiation Oncology, Seidman Cancer Center, University Hospitals, Cleveland, Ohio
| | | | - David H Harpole
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Wayne L Hofstetter
- Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Geoffrey Y Ku
- Gastrointestinal Medical Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniela Molena
- Division of Thoracic Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Joel E Tepper
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina
| | - Thomas J Watson
- Thoracic Surgery Group, Beaumont Health, Royal Oak, Michigan
| | - Terence Williams
- Department of Radiation Oncology, Beckman Research Institute, City of Hope National Medical Center, Duarte, California
| | - Christopher Willett
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
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Alvarado CE, Worrell SG, Sarode AL, Jiang B, Halloran SJ, Argote-Greene LM, Linden PA, Towe CW. Comparing Thoracoscopic and Robotic Lobectomy Using a Nationally Representative Database. Am Surg 2023; 89:5340-5348. [PMID: 36573595 DOI: 10.1177/00031348221148347] [Citation(s) in RCA: 1] [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] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
BACKGROUND Studies of robotic lobectomy (Robot-L) have been performed using data from high-volume, specialty centers which may not be generalizable. The purpose of this study was to compare mortality, length of stay (LOS), and cost between Robot-L and thoracoscopic lobectomy (VATS-L) using a nationally representative database hypothesizing they would be similar. METHODS The Premier Healthcare Database was used to identify patients receiving elective lobectomy for lung cancer from 2009 to 2019. Patients were categorized as receiving Robot-L or VATS-L using ICD-9/10 codes. Survey methodology and patient level weighting were used to correct for sampling error and estimation of a nationally representative sample. A propensity match analysis was performed to reduce bias between the groups. Primary outcome of interest was in-hospital mortality. Secondary outcomes were LOS and patient charges. RESULTS Among 62 698 patients, 19 506 (31.1%) underwent Robot-L and 43 192 (68.9%) underwent VATS-L. Differences between the groups included age, race, comorbidities, and insurance type. A propensity matched cohort demonstrated similar in-hospital mortality for Robot-L and VATS-L (.9% vs .9%, respectively, P = .91). Patients who underwent Robot-L had a shorter LOS (4 vs 5d, respectively, P < .001) but higher patient charges (90 593.0 vs 72 733.3 USD, respectively, P < .001). CONCLUSIONS In a nationally representative database, Robot-L and VATS-L had similar mortality. Although Robot-L was associated with shorter hospitalization, it was also associated with excess charges of almost $20,000. As Robot-L is now the most common approach for lobectomy in the U.S., further study into the cost and benefit of robotic surgery is warranted.
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Affiliation(s)
- Christine E Alvarado
- Division of Thoracic and Esophageal Surgery, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Stephanie G Worrell
- Section of Thoracic Surgery, Department of Surgery, University of Arizona, Tucson, AZ, USA
| | - Anuja L Sarode
- UH-RISES: Research in Surgical Outcomes and Effectiveness, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Boxiang Jiang
- Division of Thoracic and Esophageal Surgery, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Sean J Halloran
- Department of Surgery, University of Toledo School College of Medicine and Life Sciences, Toledo, OH, USA
| | - Luis M Argote-Greene
- Division of Thoracic and Esophageal Surgery, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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12
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Wang KJ, Worrell SG. Invited Commentary: Disparity and Variation in Esophageal Cancer Surgery. J Am Coll Surg 2023; 237:785-787. [PMID: 37646434 DOI: 10.1097/xcs.0000000000000805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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13
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Alvarado CE, Worrell SG, Sarode AL, Bassiri A, Jiang B, Linden PA, Towe CW. Disparities and access to thoracic surgeons among esophagectomy patients in the United States. Dis Esophagus 2023; 36:doad025. [PMID: 37163475 DOI: 10.1093/dote/doad025] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 01/27/2023] [Accepted: 03/29/2023] [Indexed: 05/12/2023]
Abstract
Esophagectomy is a complex operation with significant morbidity and mortality. Previous studies have shown that sub-specialization is associated with improved esophagectomy outcomes. We hypothesized that disparities would exist among esophagectomy patients regarding access to thoracic surgeons based on demographic, geographic, and hospital factors. The Premier Healthcare Database was used to identify adult inpatients receiving esophagectomy for esophageal and gastric cardia cancer, Barrett's esophagus, and achalasia from 2015 to 2019 using ICD-10 codes. Patients were categorized as receiving their esophagectomy from a thoracic versus non-thoracic provider. Survey methodology was used to correct for sampling error. Backwards selection from bivariable analysis was used in a survey-weighted multivariable logistic regression to determine predictors of esophagectomy provider specialization. During the study period, 960 patients met inclusion criteria representing an estimated population size of 3894 patients. Among them, 1696 (43.5%) were performed by a thoracic surgeon and 2199 (56.5%) were performed by non-thoracic providers. On multivariable analysis, factors associated with decreased likelihood of receiving care from a thoracic provider included Black (OR 0.41, p < 0.001), Other (OR 0.21, p < 0.001), and Unknown race (OR 0.22, p = 0.04), and uninsured patients (OR 0.53, p = 0.03). Urban hospital setting was associated with an increased likelihood of care by a thoracic provider (OR 4.43, p = 0.001). In this nationally representative study, Nonwhite race, rural hospital setting, and lower socioeconomic status were factors associated with decreased likelihood of esophagectomy patients receiving care from a thoracic surgeon. Efforts to address these disparities and provide appropriate access to thoracic surgeons is warranted.
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Affiliation(s)
- Christine E Alvarado
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Stephanie G Worrell
- Section of Thoracic Surgery, Department of Surgery, University of Arizona, Tucson, AZ, USA
| | - Anuja L Sarode
- UH-RISES: Research in Surgical Outcomes and Effectiveness, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Aria Bassiri
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Boxiang Jiang
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
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Kanagasegar N, Alvarado CE, Lyons JL, Rivero MJ, Vekstein C, Levine I, Towe CW, Worrell SG, Marks JM. Risk factors for adverse outcomes following paraesophageal hernia repair among obese patients. Surg Endosc 2023; 37:6791-6797. [PMID: 37253871 DOI: 10.1007/s00464-023-10115-9] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 05/08/2023] [Indexed: 06/01/2023]
Abstract
BACKGROUND Although obesity is an established risk factor for adverse outcomes after paraesophageal hernia repair (PEHR), many obese patients nonetheless receive PEHR. The purpose of this study was to explore risk factors for adverse outcomes of PEHR among this high-risk cohort. We hypothesized that obese patients may have other risk factors for adverse outcomes following PEHR. METHODS A retrospective study of adult obese patients who underwent minimally invasive PEHR from 2017 to 2019 was performed. Patients were excluded for BMI < 30 or if they had concomitant bariatric surgery at time of PEHR. The primary outcome of interest was a composite adverse outcome (CAO) defined as having any of the four following outcomes after PEHR: persistent GERD > 30 d, persistent dysphagia > 30 d, recurrence, or reoperation. Chi-square and t-test analysis was used to compare demographic and clinical characteristics. Multivariable logistic regression analysis was used to evaluate independent predictors of CAO. RESULTS In total, 139 patients met inclusion criteria with a median follow-up of 19.7 months (IQR 8.8-81). Among them, 51/139 (36.7%) patients had a CAO: 31/139 (22.4%) had persistent GERD, 20/139 (14.4%) had persistent dysphagia, 24/139 (17.3%) had recurrence, and 6/139 (4.3%) required reoperation. On unadjusted analysis, patients with a CAO were more likely to have a history of prior abdominal surgery (86.3% vs 70.5%, p = 0.04) and were less likely to have undergone a preoperative CT scan (27.5% vs 45.5%, p = 0.04). On multivariable analysis, previous abdominal surgery was independently associated with an increased likelihood of CAO whereas age and preoperative CT scan had a decreased likelihood of CAO. CONCLUSIONS Although there were adverse outcomes among obese patients, minimally invasive PEHR may be feasible in a subset of patients at specialized centers. These findings may help guide the appropriate selection of obese patients for PEHR.
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Affiliation(s)
- Nithya Kanagasegar
- Case Western Reserve University School of Medicine, Cleveland, OH, 44106, USA
| | - Christine E Alvarado
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, 44106, USA
| | - Joshua L Lyons
- Division of General and Minimally Invasive Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, 44106, USA
| | - Marco-Jose Rivero
- Case Western Reserve University School of Medicine, Cleveland, OH, 44106, USA
| | - Carolyn Vekstein
- Case Western Reserve University School of Medicine, Cleveland, OH, 44106, USA
| | - Iris Levine
- The Ohio State University College of Medicine, Columbus, OH, 43210, USA
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, 44106, USA
| | - Stephanie G Worrell
- Section of Thoracic Surgery, Department of Surgery, University of Arizona, Tucson, AZ, 85724, USA
| | - Jeffrey M Marks
- Division of General and Minimally Invasive Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, 44106, USA.
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15
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Worrell SG, Molena D. Controversies in the surgical management of esophageal adenocarcinoma. J Gastrointest Oncol 2023; 14:1919-1926. [PMID: 37720430 PMCID: PMC10502542 DOI: 10.21037/jgo-22-713] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 08/15/2023] [Indexed: 09/19/2023] Open
Abstract
The incidence of esophageal adenocarcinoma (EAC) has risen dramatically over the last decade. Over this same period, our understanding and treatments have been revolutionized. Just over a decade ago, the majority of patients with locally advanced esophageal cancer went directly to surgery and our overall survival was bleak. Our current strategy for locally advanced esophageal adenocarcinoma is a multi-disciplinary approach. This approach consists of chemotherapy plus or minus radiation followed by surgical resection followed by adjuvant immunotherapy with the presence of any residual disease. Therefore, now more than ever, the goals of surgery are to minimize morbidity, provide aggressive local control and allow patients to receive to quickly recover so they can receive adjuvant systemic therapy. Surgery continues to play a crucial role in the multi-disciplinary approach to EAC. This review will highlight the on-going areas of controversy in surgical treatment. These controversies are around surgical selection, perioperative decision making and the role of surgery. Specifically, there are controversies in the type of surgical approach offered. This review will discuss the benefits of minimally invasive versus open esophagectomy. The indications for gastrectomy versus esophagectomy in patients with gastroesophageal junction EAC. Further, at the time of operation, there is still debate and on-going trials addressing the addition of a pyloric intervention. Lastly, as we push the limits of systemic therapy, there are those who may not even need a surgical resection. This review will cover the most recent data on selective esophageal resection and the concerns regarding this approach.
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Affiliation(s)
- Stephanie G. Worrell
- Department of Surgery, Section of Thoracic Surgery, University of Arizona, Tucson, AZ, USA
| | - Daniela Molena
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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16
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Alvarado CE, Worrell SG. Proceed With Caution, Benign Is Not Always Benign. Ann Thorac Surg 2023; 116:437-438. [PMID: 36642258 DOI: 10.1016/j.athoracsur.2023.01.012] [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: 01/03/2023] [Accepted: 01/08/2023] [Indexed: 01/15/2023]
Affiliation(s)
- Christine E Alvarado
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Stephanie G Worrell
- Section of Thoracic Surgery, Department of Surgery, University of Arizona, 1501 N Campbell Ave, Tucson, AZ 85724.
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17
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Wang N, Bachman KC, Linden PA, Ho VP, Moorman ML, Worrell SG, Argote-Greene LM, Towe CW. Age as a Barrier to Surgical Stabilization of Rib Fractures in Patients with Flail Chest. Am Surg 2023; 89:927-934. [PMID: 34732075 PMCID: PMC9061890 DOI: 10.1177/00031348211047490] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Although randomized trials demonstrate a benefit to surgical stabilization of rib fractures (SSRF), SSRF is rarely performed. We hypothesized older patients were less likely to receive SSRF nationally. METHODS The 2016 National Inpatient Sample was used to identify adults with flail chest. Comorbidities and receipt of SSRF were categorized by ICD-10 code. Univariable testing and Multivariable regression were performed to determine the association of demographic characteristics and comorbidities to receipt of SSRF. RESULTS 1021 patients with flail chest were identified, including 244 (23.9%) who received SSRF. Patients ≥70 years were less likely to receive SSRF. (<70 yrs 201/774 [26.0%] vs ≥70 43/247 [17.4%], P = .006) and had higher risk of death (<70 yrs 39/774 [5.0%] vs ≥70 33/247 [13.4%], P < .001) In multivariable modeling, only age ≥70 years was associated with SSRF (OR .591, P = .005). CONCLUSION Despite guideline-based support of SSRF in flail chest, SSRF is performed in <25% of patients. Age ≥70 years is associated with lower rate of SSRF and higher risk of death. Future study should examine barriers to SSRF in older patients.
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Affiliation(s)
- Naomi Wang
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Katelynn C Bachman
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Vanessa P Ho
- Division of Trauma, Critical Care, Burns, & Acute Care Surgery, Department of Surgery, MetroHealth Medical Center, Cleveland, OH, USA
| | - Matthew L Moorman
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Stephanie G Worrell
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Luis M Argote-Greene
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
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18
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Cao L, Linden PA, Biswas T, Worrell SG, Sinopoli JN, Miller ME, Shenk R, Montero AJ, Towe CW. Modeling the COVID Pandemic: Do Delays in Surgery Justify Using Stereotactic Radiation to Treat Low-Risk Early Stage Non-Small Cell Lung Cancer? J Surg Res 2023; 283:532-539. [PMID: 36436290 PMCID: PMC9686123 DOI: 10.1016/j.jss.2022.10.081] [Citation(s) in RCA: 1] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 08/02/2022] [Accepted: 10/08/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION It was suggested that stereotactic radiation (SBRT) is an "alternative if no surgical capacity is available" for non-small cell lung cancer (NSCLC) care during the COVID-19 pandemic. The purpose of this study was to compare the oncologic outcomes of delayed surgical resection and early SBRT among operable patients with early stage lung cancer. METHODS The National Cancer Database was queried for patients with cT1aN0M0 NSCLC who underwent surgery or SBRT (2010-2016) with no comorbidity. Patients with any comorbidities or age >80 were excluded. The outcome of interest was overall survival. Delays in surgical care were modeled using different times from diagnosis to surgery. A 1:1 propensity match was performed and survival was analyzed using multivariable Cox regression. RESULTS Of 6720 healthy cT1aN0M0 NSCLC patients, 6008 (89.4%) received surgery and 712 (10.6%) received SBRT. Among surgery patients, time to surgery >30 d was associated with inferior survival (HR > 1.4, P ≤ 0.013) compared with patients receiving surgery ≤14 d. Relative to SBRT, surgery demonstrated superior survival at all time points evaluated: 0-30 d, 31-60 d, 61-90 d, and >90 d (all P < 0.001). Among a propensity-matched cohort of 256 pairs of patients, delayed surgery (>90 d) remained association with better overall survival relative to early SBRT (5-year survival 76.9% versus 32.3%, HR = 0.266, P < 0.001). CONCLUSIONS Although longer time to surgery is associated with inferior survival among surgery patients, delayed surgery is superior to early SBRT. Surgical resection should remain the standard of care to treat operable early stage lung cancer despite delays imposed by the COVID-19 pandemic.
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Affiliation(s)
- Lifen Cao
- Division of Hematology and Oncology, Department of Medicine, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio,Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio,University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), Cleveland, Ohio
| | - Philip A. Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio,University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), Cleveland, Ohio
| | - Tithi Biswas
- Division of Hematology and Oncology, Department of Medicine, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Stephanie G. Worrell
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio,University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), Cleveland, Ohio
| | - Jillian N. Sinopoli
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio,University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), Cleveland, Ohio
| | - Megan E. Miller
- University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), Cleveland, Ohio,Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Robert Shenk
- University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), Cleveland, Ohio,Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Alberto J. Montero
- Division of Hematology and Oncology, Department of Medicine, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Christopher W. Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio,University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), Cleveland, Ohio,Corresponding author. Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH, 44106-5011. Tel.: +1 216 844 0405
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19
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Worrell SG, Gupta S, Alvarado CE, Sarode A, Luo X, Towe CW, Linden PA. Morbidity After Esophagectomy Is Higher for Benign Than Malignant Disease. Ann Thorac Surg 2023; 115:363-369. [PMID: 36126720 DOI: 10.1016/j.athoracsur.2022.08.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 01/29/2022] [Revised: 08/15/2022] [Accepted: 08/29/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Esophagectomy carries a high risk of morbidity and mortality. The most common indication for esophagectomy is esophageal cancer, with fewer than 5% of esophagectomies performed for benign disease. We hypothesized that esophagectomy for benign disease is associated with a higher risk of operative and postoperative complications. METHODS A retrospective study of The Society of Thoracic Surgeons database was performed to identify all patients who had an esophagectomy from 2010 to 2018. Patients who had an emergent or palliative esophagectomy were excluded. Patients were compared based on the indication for operation, malignant vs benign disease. A 1:1 propensity score matching of The Society of Thoracic Surgeons risk factors was performed and outcomes compared between the matched cohorts. RESULTS Of 16,392 patients, 14,871 (91%) had malignant disease and 1521 (9%) had benign disease that met inclusion criteria. Patients with malignant disease were older (P < .001), more likely to be male (83% vs 56%, P < .001), and had more comorbidities (P < .001). There were 1362 propensity-matched pairs. Malignant esophagectomies were more likely to be performed with a minimally invasive vs an open approach (P < .001). Benign operations had more intraoperative blood transfusions (P < .001). Patients undergoing esophagectomy for benign disease had more prolonged intubations (P = .02) and postoperative blood transfusions (P = .001). Benign disease had more major morbidities (P = .001) but similar postoperative mortality (P = .62). CONCLUSIONS Esophagectomy for benign disease is associated with worse perioperative morbidity compared with esophagectomy for malignant disease. Given these findings patients should be counseled on expected outcomes, and this variable should be considered for inclusion in the composite score for risk assessment.
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Affiliation(s)
- Stephanie G Worrell
- Division of Cardiothoracic Surgery, Department of Surgery, University of Arizona, Tucson, Arizona.
| | - Shreya Gupta
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals/Case Western Reserve University, Cleveland, Ohio
| | - Christine E Alvarado
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals/Case Western Reserve University, Cleveland, Ohio
| | - Anuja Sarode
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals/Case Western Reserve University, Cleveland, Ohio
| | - Xun Luo
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals/Case Western Reserve University, Cleveland, Ohio
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals/Case Western Reserve University, Cleveland, Ohio
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals/Case Western Reserve University, Cleveland, Ohio
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20
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Fairbairn K, Worrell SG. Esophageal Perforation. Thorac Surg Clin 2023; 33:117-123. [PMID: 37045480 DOI: 10.1016/j.thorsurg.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2023]
Abstract
Esophageal perforation is a rare but fatal disease process that requires prompt diagnosis and treatment. Surgery has historically been required for treatment; however, there is currently a shift toward endoscopic management. Although no randomized controlled trials exist to compare patient outcomes, many case series and systematic analyses describe their indications, efficacy, and safety profile. Endoscopic stenting and endoscopic vacuum therapy are the 2 therapies most widely described across a diverse patient population and appear to be safe and effective when treating esophageal perforation, in the proper clinical setting. Guidelines and scoring systems exist to help direct management and stratify patient risk.
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21
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Papageorge MV, Alvarado CE, Kane L, Worrell SG, Antonoff MB. Seeking Mentors: Experience with the Women in Thoracic Surgery Mentorship Program. JTCVS Open 2022; 13:468-472. [PMID: 37063151 PMCID: PMC10091275 DOI: 10.1016/j.xjon.2022.12.005] [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] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 11/29/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022]
Affiliation(s)
| | - Christine E. Alvarado
- Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Lauren Kane
- Department of Cardiothoracic Surgery, Children's Hospital, New Orleans, La
| | - Stephanie G. Worrell
- Department of Thoracic Surgery, The University of Arizona College of Medicine, Tucson, Ariz
| | - Mara B. Antonoff
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Tex
- Address for reprints: Mara B. Antonoff, MD, Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030.
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22
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Halloran S, Dingillo G, Badrinathan A, Alvarado CE, Worrell SG, Sinopoli JN, Argote-Greene LM, Linden PA, Towe CW. YouTube Videos Contain Poor and Biased Thoracic Surgery Educational Content. Surgery in Practice and Science 2022. [DOI: 10.1016/j.sipas.2022.100133] [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: 10/14/2022] Open
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23
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Gray KE, Sarode A, Jiang B, Alvarado CE, Sinopoli J, Linden PA, Worrell SG, Ho VP, Argote-Greene LM, Towe CW. Surgical Repair Versus Stent for Esophageal Perforation: A Multi-institutional Database Analysis. Ann Thorac Surg 2022; 115:1378-1384. [PMID: 35921860 DOI: 10.1016/j.athoracsur.2022.07.023] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 04/17/2022] [Accepted: 07/19/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Endoscopic esophageal stenting is used as an alternative to surgical repair for esophageal perforation. Multi-institutional studies supporting stenting are lacking. The purpose of this study was to compare the outcomes of surgical repair and esophageal stenting in patients with esophageal perforation using a nationally representative database. We hypothesized that mortality between these approaches would not be different. METHODS The Premier Healthcare Database was used to compare adult inpatients with esophageal perforation receiving either surgical repair or esophageal stenting from 2009 to 2019. Patients receiving intervention ≤7 days of admission were included in the analysis. Patients receiving both stent and repair on the same day were excluded. The composite outcome of interest was death or discharge to hospice. Logistic regression was used to evaluate independent predictors of death or hospice, adjusting for comorbidities. RESULTS There were 2543 patients with esophageal perforation identified who received repair (1314 [51.7%]) or stenting (1229 [48.3%]). Stenting increased from 7.0% in 2009 to 78.1% in 2019. Patients receiving repair were more likely to be female and White and had fewer Elixhauser comorbidities. Death or discharge to hospice was more common after stent (134/1314 [10.2%] repair vs 199/1229 [16.2%] stent; P < .001); however, after adjustment for comorbidities, logistic regression suggested that death or hospice discharge was similar between approaches (stent vs repair: odds ratio, 1.074; 95% CI, 0.81-1.42; P = .622). Hospital length of stay was shorter after stenting (stent vs repair coefficient, -4.09; P < .001). CONCLUSIONS In patients with esophageal perforation, the odds for death or discharge to hospice were similar for esophageal stenting compared with surgical repair.
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Affiliation(s)
- Kelsey E Gray
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio.
| | - Anuja Sarode
- Department of Surgery, University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Boxiang Jiang
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Christine E Alvarado
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Jillian Sinopoli
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Phillip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Stephanie G Worrell
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Vanessa P Ho
- Division of Trauma, Critical Care, Burns and Acute Care Surgery, Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Luis M Argote-Greene
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
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24
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Chang C, Linden PA, Jiang B, Sarode A, Bachman K, Towe CW, Argote-Greene L, Worrell SG. Monitoring for Recurrence After Esophagectomy. Ann Thorac Surg 2022; 114:211-217. [PMID: 34793765 DOI: 10.1016/j.athoracsur.2021.10.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 01/29/2021] [Revised: 09/20/2021] [Accepted: 10/05/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Current guidelines for follow-up after esophagectomy suggest only history and physical examination (HPE). With recent advances in chemotherapy and immunotherapy for patients with recurrent esophageal cancer, we hypothesized that surveillance imaging (SI) would identify patients with cancer recurrence earlier and improve long-term survival. METHODS A retrospective review of all patients undergoing esophagectomy for esophageal cancer at a single institution between 2007 and 2018 was conducted. Patients were categorized as recurrence detected through SI or recurrence detected through HPE alone. Patients were excluded if recurrence occurred within 3 months of esophagectomy. RESULTS During the study period, 225 esophageal cancer patients underwent an esophagectomy. Among these, 101 (44.9%) had SI and 124 (55.1%) had routine follow-up with HPE. There were 88 recurrences (39.1%) with median follow-up of 12 months. Rate of recurrence was similar based on screening method: 41 of 101 (40.6%) by SI and 47 of 124 (37.9%) by HPE (P = .68). Among patients with recurrence, recipients of additional treatment were also similar between groups, 36 of 41 (87.8%) by SI and 34 of 47 (72.3%) by HPE (P = .468). Among those who had a recurrence, the median overall survival was significantly longer in those undergoing SI at 23 months compared with those who received HPE at 16 months (P = .047). CONCLUSIONS SI after esophagectomy is not associated with improved detection of recurrence, but is associated with improved overall survival once recurrence is detected. These data suggest that earlier identification of esophageal cancer recurrence may have survival benefit. Standardizing SI may prove beneficial for patients after esophagectomy.
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Affiliation(s)
- Carolyn Chang
- Case Western Reserve School of Medicine, Cleveland, Ohio
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Boxiang Jiang
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Anuja Sarode
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Katelynn Bachman
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Luis Argote-Greene
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Stephanie G Worrell
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio.
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Alvarado CE, Kapcio KC, Lada MJ, Linden PA, Towe CW, Worrell SG. The effect of diabetes on pathologic complete response among patients with esophageal cancer. Semin Thorac Cardiovasc Surg 2022; 35:429-436. [DOI: 10.1053/j.semtcvs.2021.10.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 10/04/2021] [Indexed: 01/04/2023]
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Coffey MR, Bachman KC, Ho VP, Worrell SG, Moorman ML, Linden PA, Towe CW. Iatrogenic rib fractures and the associated risks of mortality. Eur J Trauma Emerg Surg 2022; 48:231-241. [PMID: 33496799 PMCID: PMC8310895 DOI: 10.1007/s00068-020-01598-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 08/11/2020] [Accepted: 12/27/2020] [Indexed: 02/03/2023]
Abstract
PURPOSE Rib fractures, though typically associated with blunt trauma, can also result from complications of medical or surgical care, including cardiopulmonary resuscitation. The purpose of this study is to describe the demographics and outcomes of iatrogenic rib fractures. METHODS Patients with rib fractures were identified in the 2016 National Inpatient Sample. Mechanism of injury was defined as blunt traumatic rib fracture (BTRF) or iatrogenic rib fracture (IRF). IRF was identified as fractures from the following mechanisms: complications of care, drowning, suffocation, and poisoning. Differences between BTRF and IRF were compared using rank-sum test, Chi-square test, and multivariable regression. RESULTS 34,644 patients were identified: 33,464 BTRF and 1180 IRF. IRF patients were older and had higher rates of many comorbid medical disorders. IRF patients were more likely to have flail chest (6.1% versus 3.1%, p < 0.001). IRF patients were more likely to have in-hospital death (20.7% versus 4.2%, p < 0.001) and longer length of hospitalization (11.8 versus 6.9 days, p < 0.001). IRF patients had higher rates of tracheostomy (30.2% versus 9.1%, p < 0.001). In a multivariable logistic regression of all rib fractures, IRF was independently associated with death (OR 3.13, p < 0.001). A propensity matched analysis of IRF and BTRF groups corroborated these findings. CONCLUSION IRF injuries are sustained in a subset of extremely ill patients. Relative to BTRF, IRF is associated with greater mortality and other adverse outcomes. This population is understudied. The etiology of worse outcomes in IRF compared to BTRF is unclear. Further study of this population could address this disparity.
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Affiliation(s)
- Max R. Coffey
- Case Western Reserve University School of Medicine, Cleveland, OH, United States,University Hospitals Cleveland Medical Center, Department of Surgery, Cleveland, OH, United States
| | - Katelynn C. Bachman
- Case Western Reserve University School of Medicine, Cleveland, OH, United States,University Hospitals Cleveland Medical Center, Department of Surgery, Cleveland, OH, United States
| | - Vanessa P. Ho
- Case Western Reserve University School of Medicine, Cleveland, OH, United States,MetroHealth Medical Center, Department of Surgery, Division of Trauma, Critical Care, Burns, & Acute Care Surgery, Cleveland, OH, United States
| | - Stephanie G. Worrell
- Case Western Reserve University School of Medicine, Cleveland, OH, United States,University Hospitals Cleveland Medical Center, Department of Surgery, Cleveland, OH, United States
| | - Matthew L. Moorman
- Case Western Reserve University School of Medicine, Cleveland, OH, United States,University Hospitals Cleveland Medical Center, Department of Surgery, Cleveland, OH, United States
| | - Philip A. Linden
- Case Western Reserve University School of Medicine, Cleveland, OH, United States,University Hospitals Cleveland Medical Center, Department of Surgery, Cleveland, OH, United States
| | - Christopher W. Towe
- Case Western Reserve University School of Medicine, Cleveland, OH, United States,University Hospitals Cleveland Medical Center, Department of Surgery, Cleveland, OH, United States
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Jiang B, Worrell SG. Commentary: Test drive in cardiothoracic surgery. J Thorac Cardiovasc Surg 2021; 163:1429-1430. [PMID: 34565585 DOI: 10.1016/j.jtcvs.2021.08.063] [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: 08/26/2021] [Revised: 08/26/2021] [Accepted: 08/27/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Boxiang Jiang
- The Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Stephanie G Worrell
- The Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio.
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Linden PA, Towe CW, Worrell SG, Jiang B, Ho VP, Argote-Greene L, Bachman K, Perry Y. Drain Amylase: A Simple and Versatile Method of Detecting Esophageal Anastomotic Leaks. Ann Thorac Surg 2021; 113:1794-1800. [PMID: 34437855 DOI: 10.1016/j.athoracsur.2021.07.062] [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: 03/01/2021] [Revised: 06/15/2021] [Accepted: 07/19/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Anastomotic leak following esophagectomy is a significant cause of morbidity. Perianastomotic drain amylase is accurate in detecting leaks, but it is unclear whether its accuracy is affected by comorbid conditions, anastomotic method, or anastomotic location. We hypothesized that drain amylase would accurately discriminate leak in a variety of settings. METHODS We reviewed 290 consecutive patients undergoing esophagectomy with gastric conduit reconstruction. Patient comorbidities, operative variables, and drain amylase were collected. The diagnosis of a leak was based on the level of intervention required, and was characterized as "clinically significant" if it required wound opening, endoscopic or surgical intervention. Receiver operating characteristic curves analysis was performed to determine the accuracy of amylase to detect leak for each patient variable. RESULTS 53/290 (18.3%) esophagectomies had an anastomotic leak, of which 33/290 (11.4%) were clinically significant. Drain amylase was a strong predictor of anastomotic leak on postoperative days 3-7, regardless of patient comorbidities, location of anastomosis, or technique of anastomosis, but was less accurate in the diagnosis of leak in current smokers (AUC 0.530 vs 0.752, p= 0.006). A maximum drain amylase value no higher than 35 on postoperative 3, 4 or 5 was 88% sensitive in detecting leak at any point postoperatively. A value >=150 was 88% specific in diagnosing leak CONCLUSIONS: Drain amylase is a versatile method for early detection of anastomotic leaks. Its accuracy is unaffected by neoadjuvant treatment, location or type of anastomosis or patient comorbidities, but may be less accurate in active smokers.
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Affiliation(s)
- Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH.
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH
| | - Stephanie G Worrell
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH
| | - Boxiang Jiang
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH
| | - Vanessa P Ho
- Department of Surgery, Metrohealth Hospital and Case Western Reserve School of Medicine, Cleveland, OH
| | - Luis Argote-Greene
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH
| | - Katelynn Bachman
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH
| | - Yaron Perry
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH
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Alvarado CE, Worrell SG. Commentary: A "Watch"Ful Eye On The Future. Semin Thorac Cardiovasc Surg 2021; 34:1140-1141. [PMID: 34320393 DOI: 10.1053/j.semtcvs.2021.07.026] [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] [Received: 07/21/2021] [Accepted: 07/23/2021] [Indexed: 01/10/2023]
Affiliation(s)
- Christine E Alvarado
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, Ohio
| | - Stephanie G Worrell
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, Ohio.
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Alvarado CE, Worrell SG, Bachman KC, Gray K, Perry Y, Linden PA, Towe CW. Surgery following neoadjuvant chemoradiation therapy in clinical N3 esophageal cancer results in improved survival: a propensity-matched analysis. Dis Esophagus 2021; 34:6042247. [PMID: 33341903 DOI: 10.1093/dote/doaa118] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Esophageal cancer patients with extensive nodal metastases have poor survival, and benefit of surgery in this population is unclear. The aim of this study is to determine if surgery after neoadjuvant chemoradiotherapy (nCRT) improves overall survival (OS) in patients with clinical N3 (cN3) esophageal cancer relative to chemoradiation therapy (CRT) alone. The National Cancer Database was queried for all patients with cN3 esophageal cancer between 2010 and 2016. Patients who met inclusion criteria (received multiagent chemotherapy and radiation dose ≥30 Gy) were divided into two cohorts: CRT alone and nCRT + surgery. 769 patients met inclusion criteria, including 560 patients who received CRT alone, and 209 patients who received nCRT + surgery. The overall 5-year survival was significantly lower in the CRT alone group compared to the nCRT + surgery group (11.8% vs 18.0%, P < 0.001). A 1:1 propensity matched cohort of CRT alone and nCRT + surgery patients also demonstrated improved survival associated with surgery (13.11 mo vs 23.1 mo, P < 0.001). Predictors of survival were analyzed in the surgery cohort, and demonstrated that lymphovascular invasion was associated with worse survival (HR 2.07, P = 0.004). Despite poor outcomes of patients with advanced nodal metastases, nCRT + surgery is associated with improved OS. Of those with cN3 disease, only 27% underwent esophagectomy. Given the improved OS, patients with advanced nodal disease should be considered for surgery. Further investigation is warranted to determine which patients with cN3 disease would benefit most from esophagectomy, as 5-year survival remains low (18.0%).
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Affiliation(s)
- Christine E Alvarado
- University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH, USA
| | - Stephanie G Worrell
- University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH, USA
| | - Katelynn C Bachman
- University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH, USA
| | - Kelsey Gray
- University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH, USA
| | - Yaron Perry
- University of Buffalo School of Medicine, Buffalo, NY, USA
| | - Philip A Linden
- University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH, USA
| | - Christopher W Towe
- University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH, USA
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Alvarado CE, Worrell SG. Commentary: How far would you go? J Thorac Cardiovasc Surg 2021; 163:1698-1699. [PMID: 34274143 DOI: 10.1016/j.jtcvs.2021.06.055] [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: 06/25/2021] [Revised: 06/25/2021] [Accepted: 06/25/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Christine E Alvarado
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, Ohio
| | - Stephanie G Worrell
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, Ohio.
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Alvarado CE, Worrell SG, Bachman KC, Jiang B, Janko M, Gray KE, Argote-Greene LM, Linden PA, Towe CW. Robotic approach has improved outcomes for minimally invasive resection of mediastinal tumors. Ann Thorac Surg 2021; 113:1853-1858. [PMID: 34217691 DOI: 10.1016/j.athoracsur.2021.05.090] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 01/29/2021] [Revised: 04/20/2021] [Accepted: 05/24/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND The optimal minimally invasive surgical (MIS) approach to mediastinal tumors is unknown. There are limited reports comparing the outcomes of resection with robotic-assisted and video-assisted thoracoscopy (RATS vs VATS). We hypothesized that patients who underwent RATS would have improved outcomes. METHODS The National Cancer Database was queried for all patients who underwent MIS for any mediastinal tumor from 2010-2016. Patients were determined to have an adverse composite outcome if they had any of the adverse perioperative outcomes; conversion to open procedure, 90-day mortality, 30-day readmission, and positive pathologic margins. Secondary outcomes of interest were length-of-stay (LOS) and overall survival. Multivariable logistic regression was used to assess likelihood of having a composite adverse outcome based on surgical approach. RESULTS 856 patients were included: 402 (47%) underwent VATS and 454 (53%) underwent RATS. RATS resections were associated with fewer conversions (4.9% vs 14.7%, p<0.001), fewer positive margins (24.3% vs 31.6%, p=0.02), shorter LOS (3.8d vs 4.3d, p=0.01) and less composite adverse events (36.7% vs 51.3%, p<0.001). Multivariate analysis showed RATS (OR 0.44, p<0.001) was independently associated with decreased likelihood of composite adverse outcome, even among tumors >4 cm (OR 0.45, p=0.001). Overall survival was similar between the two groups. CONCLUSIONS Among patients who underwent MIS for a mediastinal tumor, RATS had fewer adverse outcomes than VATS, even for tumors ≥4 cm. These data suggests that RATS may be the preferred technique for patients who are candidates for minimally invasive resection of mediastinal tumors.
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Affiliation(s)
- Christine E Alvarado
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, 11100 Euclid Avenue Cleveland, OH 44106
| | - Stephanie G Worrell
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, 11100 Euclid Avenue Cleveland, OH 44106
| | - Katelynn C Bachman
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, 11100 Euclid Avenue Cleveland, OH 44106
| | - Boxiang Jiang
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, 11100 Euclid Avenue Cleveland, OH 44106
| | - Matthew Janko
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, 11100 Euclid Avenue Cleveland, OH 44106
| | - Kelsey E Gray
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, 11100 Euclid Avenue Cleveland, OH 44106
| | - Luis M Argote-Greene
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, 11100 Euclid Avenue Cleveland, OH 44106
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, 11100 Euclid Avenue Cleveland, OH 44106
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, 11100 Euclid Avenue Cleveland, OH 44106.
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Coffey MR, Bachman KC, Worrell SG, Argote-Greene LM, Linden PA, Towe CW. Palliative Surgery Outcomes for Patients with Esophageal Cancer: An NCDB Analysis. J Surg Res 2021; 267:229-234. [PMID: 34161839 DOI: 10.1016/j.jss.2021.05.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 03/02/2021] [Revised: 04/26/2021] [Accepted: 05/07/2021] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Many patients with esophageal cancer are not candidates for surgical resection with curative intent, given the advanced stage of disease at presentation. Palliative surgery is one treatment option, but relative survival of palliative surgery has not been described. This study aims to describe the outcomes of palliative surgery in patients with esophageal cancer. METHODS We used the National Cancer Database to identify patients with esophageal cancer who received palliative surgery or non-surgical palliation-which consisted of palliative radiation and palliative chemotherapy without any surgery. The outcome of interest was overall survival. Characteristics of patients were compared between the palliative surgery group and the non-surgical group using rank sum test or chi square test. Survival differences between groups were compared using Kaplan Meier estimate and log rank test, and Cox proportional hazards model. RESULTS A total of 14,589 patients were included in the analysis, including 2,812 (19.2%) receiving palliative surgery and 11,777 (80.7%) receiving non-surgical palliation (6,512 palliative radiation and 5,265 palliative chemotherapy). Median overall survival in palliative surgery patients was 5.5 mo, shorter than non-surgical palliation (6.4 mo, P = 0.004). However, when correcting for age, sex, nodal status, metastases, Charlson score, histology, academic center, and private insurance, there was no difference in survival between palliative surgery and non-surgical palliation in Cox proportional hazard modeling (HR 1.03 (0.975-1.090), P = 0.281). CONCLUSIONS Palliative surgery in advanced esophageal cancer is associated with poor overall survival but is similar to other palliative modalities. Palliative Surgery for esophageal cancer patients should be used sparingly given these poor outcomes.
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Affiliation(s)
- Max R Coffey
- Division of Thoracic and Esophageal Surgery, Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio; Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Katelynn C Bachman
- Division of Thoracic and Esophageal Surgery, Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio; Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Stephanie G Worrell
- Division of Thoracic and Esophageal Surgery, Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio; Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Luis M Argote-Greene
- Division of Thoracic and Esophageal Surgery, Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio; Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio; Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio; Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio.
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Coffey MR, Bachman KC, Worrell SG, Argote-Greene LM, Linden PA, Towe CW. Concurrent diagnosis of anxiety increases postoperative length of stay among patients receiving esophagectomy for esophageal cancer. Psychooncology 2021; 30:1514-1524. [PMID: 33870580 DOI: 10.1002/pon.5707] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 12/23/2020] [Revised: 04/06/2021] [Accepted: 04/12/2021] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Psychiatric comorbidities disproportionately affect patients with cancer. While identified risk factors for prolonged length of stay (LOS) after esophagectomy are primarily medical comorbidities, the impact of psychiatric comorbidities on perioperative outcomes is unclear. We hypothesized that psychiatric comorbidities would prolong LOS in patients with esophageal cancer. METHODS The 2016 National Inpatient Sample (NIS) was used to identify patients with esophageal cancer receiving esophagectomy. Concurrent psychiatric illness was categorized using Clinical Classifications Software Refined for ICD-10, creating 34 psychiatric diagnosis groups (PDGs). Only PDGs with >1% prevalence in the cohort were included in the analysis. The outcome of interest was hospital LOS. Bivariable testing was performed to determine the association of PDGs and demographic factors on LOS using rank sum test. Multivariable regression analysis was performed using backward selection from bivariable testing (α ≤ 0.05). RESULTS We identified 1,730 patients who underwent esophagectomy for esophageal cancer in the 2016 NIS. The median LOS was 8 days (IQR 5-12). In bivariable testing, a concurrent diagnosis of anxiety was the only PDG associated with LOS (9 days (IQR 6-14) with anxiety diagnosis versus 8 days (IQR 5-12) with no anxiety diagnosis, p = 0.022). Multivariable modeling showed an independent association between anxiety diagnosis and increased LOS (OR 4.82 (1.25-25.23), p = 0.022). Anxiety was not associated with increased hospital cost or in-hospital mortality. CONCLUSIONS This analysis demonstrates an independent effect of anxiety prolonging postoperative LOS after esophagectomy in the United States. These findings may influence perioperative care, patient expectations, and resource allocation.
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Affiliation(s)
- Max R Coffey
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Katelynn C Bachman
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Stephanie G Worrell
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Luis M Argote-Greene
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Philip A Linden
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Christopher W Towe
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
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Ceppa DP, Antonoff MB, Tong BC, Timsina L, Ikonomidis JS, Worrell SG, Stephens EH, Gillaspie EA, Schumacher L, Molena D, Kane LC, Blackmon S, Donington JS. 2020 Women in Thoracic Surgery update on the status of women in cardiothoracic surgery. Ann Thorac Surg 2021; 113:918-925. [PMID: 33857495 DOI: 10.1016/j.athoracsur.2021.03.091] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [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: 02/16/2021] [Revised: 03/26/2021] [Accepted: 03/27/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Women in Thoracic Surgery (WTS) has previously reported on the status of women in cardiothoracic (CT) surgery. We sought to provide a 10-year update on women in CT. METHODS An anonymous REDCap survey link was emailed to female diplomats of the ABTS. Survey questions queried respondents regarding demographics, training, accolades, practice details, and career satisfaction. The survey link was open for 30 days. Results were compared to the 2019 Society of Thoracic Surgeons work force survey. Descriptive analyses were performed using frequency and proportions. Comparisons were performed using Student's t-tests, Fisher exact and chi-squared tests. RESULTS Of 354 female diplomats, 309 were contacted and 176 (57%) responded. The majority of respondents were age 36-50 (59%), Caucasian (67.4%), and graduated from traditional-track programs (91.4%). Most respondents reported practicing in an urban (64%) and academic setting (73.1%). 36.4% and 23.9% reported a general thoracic and adult cardiac practice (22.7% mixed practice, 9.6% congenital). Fifty percent of respondents reported salaries between $400,000-700,000 annually; 37.7% reported salaries <90% of their male colleagues. 21.6% of respondents in academia are full professor; 53.4% report having a leadership role. While 74.1% would pursue a career in CT again, only 27.3% agreed that CT surgery is a healthy and positive environment for women. CONCLUSIONS The number of women in CT surgery has steadily increased. While women are rising in academic rank and into leadership positions, salary disparities and the CT surgery work environment remain important issues in achieving a diverse work force.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Daniela Molena
- Memorial Sloan Kettering Cancer Center, New York, New York
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Towe CW, Worrell SG, Finley DJ. One day is here to stay. Ann Thorac Surg 2021; 113:380. [PMID: 33744218 DOI: 10.1016/j.athoracsur.2021.03.020] [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: 03/03/2021] [Accepted: 03/05/2021] [Indexed: 11/01/2022]
Affiliation(s)
- Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Lakeside 6200, Cleveland, OH 44106
| | - Stephanie G Worrell
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Lakeside 6200, Cleveland, OH 44106
| | - David J Finley
- Section of Thoracic Surgery, Department of Surgery, Dartmouth-Hitchcock Medical, Dartmouth, NH
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Bachman KC, Worrell SG, Linden PA, Gray KE, Argote-Greene LM, Towe CW. Wedge Resection Offers Similar Survival to Segmentectomy for Typical Carcinoid Tumors. Semin Thorac Cardiovasc Surg 2021; 34:293-298. [PMID: 33711461 DOI: 10.1053/j.semtcvs.2021.03.005] [Citation(s) in RCA: 3] [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: 02/08/2021] [Accepted: 03/04/2021] [Indexed: 11/11/2022]
Abstract
Current guidelines recommend anatomic lung resection of typical bronchopulmonary carcinoids. Typical carcinoid tumors have excellent prognosis and sublobar resection has been associated with noninferior long-term survival. It's unclear whether wedge resection is acceptable for small typical carcinoid tumors. We hypothesize there is no difference in survival between wedge resection and segmentectomy for Stage I typical bronchopulmonary carcinoid tumors. Using the National Cancer Database from 2010 to 2016, we identified clinical T1N0M0 typical bronchopulmonary carcinoid tumors by wedge resection or segmentectomy. Short-term outcomes included length of stay, lymph nodes evaluated, pathologic node status, positive margin status, and 90-day mortality. Primary outcome was overall survival and estimated using Kaplan-Meier survival analysis. 821 patients were identified: 677 receiving wedge resection, 144 receiving segmentectomy. Segmentectomy was more commonly performed in an academic setting (70.0% vs 57.3%, P = 0.005). The mean tumor size for segmentectomy was 1.7 cm versus 1.4 cm for wedge resection (P < 0.001). There was no difference in LOS, positive margin status, and 90-day mortality between groups. There were significantly more lymph nodes evaluated in segmentectomy patients (median 4 vs 0, P < 0.001), but there was no difference in positive lymph node status (5.3% vs 2.6%, P = 0.165). The OS was similar between wedge and segmental resection (P = 0.613): 3-year survival (93.5% vs 92.8%) and 5-year survival (83.8% vs 84.9%). Wedge resection and segmentectomy have similar survival for Stage I typical bronchopulmonary carcinoids in a large national database. This analysis suggests nonanatomic, parenchymal-sparing resection should be considered an appropriate alternative for Stage I typical bronchopulmonary carcinoids.
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Affiliation(s)
- Katelynn C Bachman
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, Ohio.
| | - Stephanie G Worrell
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, Ohio
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, Ohio
| | - Kelsey E Gray
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, Ohio
| | - Luis Marcello Argote-Greene
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, Ohio
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, Ohio
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Worrell SG. Commentary: The Increasing Presence of Women Cardiothoracic Surgeons. Semin Thorac Cardiovasc Surg 2021; 33:625-626. [PMID: 33600982 DOI: 10.1053/j.semtcvs.2021.01.024] [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] [Received: 12/03/2020] [Accepted: 01/05/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Stephanie G Worrell
- Department of Surgery and Division of Thoracic and Esophageal Surgery, University Hospitals and Case Western Reserve University, Cleveland, Ohio.
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Alvarado C, Worrell SG. Commentary: A shot through the heart and perc to blame-an atrioesophageal fistula. JTCVS Tech 2020; 6:170-171. [PMID: 34318187 PMCID: PMC8300926 DOI: 10.1016/j.xjtc.2020.12.014] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 12/01/2020] [Accepted: 12/15/2020] [Indexed: 11/19/2022] Open
Affiliation(s)
| | - Stephanie G. Worrell
- Address for reprints: Stephanie G. Worrell, MD, FACS, Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals and Case Western Reserve University, 11100 Euclid Ave, Cleveland, OH 44106.
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Hue JJ, Bachman KC, Gray KE, Linden PA, Worrell SG, Towe CW. Does Timing of Robotic Esophagectomy Adoption Impact Short-Term Postoperative Outcomes? J Surg Res 2020; 260:220-228. [PMID: 33360305 DOI: 10.1016/j.jss.2020.11.077] [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] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 10/13/2020] [Accepted: 11/15/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Robotic esophagectomies are increasingly common and are reported to have superior outcomes compared with an open approach; however, it is unclear if all institutions can achieve such outcomes. We hypothesize that early adopters of robotic technique would have improved short-term outcomes. METHODS The National Cancer Database (2010-2016) was used to identify robotic esophagectomies. Early adopters were defined as programs which performed robotic esophagectomies in 2010-2011, late adopters in 2012-2013. Outcomes of esophagectomies performed between 2014 and 2016 were compared and included length of stay, number of lymph nodes evaluated, readmission, conversion rate, and 90-day mortality. Multivariable regressions, accounting for robotic esophagectomy volume, were used to control for confounding factors. RESULTS There were 37 early adopters and 35 late adopters. Between 2014 and 2016, 683 robotic esophagectomies were performed: 446 (65.3%) by early adopters and 237 (34.7%) by late adopters. Early adopters were more likely to be academic programs (96.2 versus 72.8%, P < 0.01). Other clinical and demographic variables were similar. Late adopters were found to have decreased a number of lymph nodes evaluated (coefficient -2.407, P = 0.004) compared with early adopters. There were no significant differences in length of stay, readmissions, rate of positive margins, conversion from robotic to open, or 90-day mortality. CONCLUSIONS When accounting for robotic esophagectomy volume, late adoption of robotic esophagectomy was associated with a reduced lymph node harvest, but other postoperative outcomes were similar. These data suggest that programs can safely start new robotic esophagectomy programs, but must ensure an adequate case load.
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Affiliation(s)
- Jonathan J Hue
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, Ohio
| | - Katelynn C Bachman
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, Ohio
| | - Kelsey E Gray
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, Ohio
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, Ohio
| | - Stephanie G Worrell
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, Ohio
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, Ohio.
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Abstract
Esophageal adenocarcinoma (EAC) has had the fastest increasing incidence of any solid tumor in the United States in the last 30 years. Long standing gastroesophageal reflux disease is a well-established risk factor with strong associations with obesity, alcohol and tobacco. However, there are likely additional contributing factors. Viruses such as human papillomavirus, ebstein-barr virus and herpes simplex virus have been implicated in the pathogenesis of esophageal cancer. This review will discuss the known literature linking viruses to esophageal adenocarcinoma and consider future relationships such as identifying prognostic and predictive molecular biomarkers to guide therapies.
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Affiliation(s)
- Carolyn Chang
- Case Western Reserve School of Medicine, Cleveland, OH, USA
| | - Stephanie G Worrell
- Case Western Reserve School of Medicine, Cleveland, OH, USA.,University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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Ali AM, Bachman KC, Worrell SG, Gray KE, Perry Y, Linden PA, Towe CW. Robotic minimally invasive esophagectomy provides superior surgical resection. Surg Endosc 2020; 35:6329-6334. [PMID: 33174098 DOI: 10.1007/s00464-020-08120-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 04/10/2020] [Accepted: 10/21/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Robotic minimally invasive esophagectomy (RMIE) and "traditional" minimally invasive esophagectomy techniques (tMIE) have reported superior outcomes relative to open techniques. Differences in the outcomes of these two approaches have not been examined. We hypothesized that short-term outcomes of RMIE would be superior to tMIE. METHODS AND PROCEDURES The National Cancer Database was used to analyze outcomes of patients undergoing RMIE and tMIE from 2010 to 2016. Patients with clinical metastatic disease were excluded. Trends in the number of procedures performed with each approach were described using linear regression testing. Primary outcome of interest was 90-day mortality rate. Secondary outcomes of interest were positive surgical margin rate, number of lymph nodes (LN) removed, adequate lymphadenectomy (> 15 LNs), length of hospitalization (LOS), readmission rate, and conversion to open rate. Outcomes of RMIE and tMIE were compared using Wilcoxon rank sum test and chi square test as appropriate. Multivariable regression was also performed to reduce the impact of differences in the cohorts of patients receiving RMIE and tMIE. RESULTS 6661 minimally invasive esophagectomies were performed from 2010 to 2016 (1543/6661 (23.2%) RMIE and 5118/6661 (76.8%) tMIE). Over the study period, the proportion of RMIE increased from 10.4% (64/618) in 2010 to 27.2% (331/1216) in 2016 (p < 0.001) (Fig. 1). The primary outcome of 90-day mortality was similar between RMIE and tMIE (92/1170 (7.4%) vs 305/4148 (7.9%), p = 0.558) (Table 2). RMIE and tMIE also had similar readmission rate (6.3 vs 7%, p = 0.380). There was no difference between the cohorts based on sex, age, race, insurance, and tumor size. The cohorts of patients receiving RMIE and tMIE differed in that RMIE patients had lower rates of elevated Charlson scores, were more likely to be treated at an academic institution, had a higher rate of advanced clinical T-stage and clinical nodal involvement, and had received neoadjuvant therapy. In a univariate analysis, RMIE had a lower rate of positive margin (3.9 vs 6.1%, p = 0.001), more mean lymph nodes evaluated (16.6 ± 9.74 vs 16.1 ± 10.08 p = 0.018), lower conversion to open rate (5.4 vs 11.4%, p < 0.001), and a shorter mean length of stay (12.1 ± 10.39 vs 12.8 ± 11.18 days, p < 0.001). In multivariable analysis, RMIE was associated with lower risk of conversion to open (OR 0.51, 95% CI: 0.37-0.70, p < 0.001) and lower rate of positive margin (OR 0.62, 95% CI: 0.41-0.93, p = 0.021).). Additionally, in a multivariable logistic regression, RMIE demonstrated superior adequate lymphadenectomy (> 15 LNs) (OR 1.18, 95% CI 1.02-1.37, p < 0.032). CONCLUSION In the National Cancer Database, robotic esophagectomy is associated with superior rate of conversion to open and positive surgical margin status. We speculate enhanced dexterity and visualization of RMIE facilitates intraoperative performance leading to improvement in these outcomes.
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Affiliation(s)
- Ahmed M Ali
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH, USA, 44106-5011, 11100 Euclid Avenue
| | - Katelynn C Bachman
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH, USA, 44106-5011, 11100 Euclid Avenue
| | - Stephanie G Worrell
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH, USA, 44106-5011, 11100 Euclid Avenue
| | - Kelsey E Gray
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH, USA, 44106-5011, 11100 Euclid Avenue
| | - Yaron Perry
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH, USA, 44106-5011, 11100 Euclid Avenue
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH, USA, 44106-5011, 11100 Euclid Avenue
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH, USA, 44106-5011, 11100 Euclid Avenue.
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Worrell SG, Bachman KC, Sarode AL, Perry Y, Linden PA, Towe CW. Minimally invasive esophagectomy is associated with superior survival, lymphadenectomy and surgical margins: propensity matched analysis of the National Cancer Database. Dis Esophagus 2020; 33:5811019. [PMID: 32206801 DOI: 10.1093/dote/doaa017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 12/29/2019] [Revised: 02/11/2020] [Indexed: 12/11/2022]
Abstract
Despite excellent short-term outcomes of minimally invasive esophagectomy (MIE), there is minimal data on long-term outcomes compared to open esophagectomy. MIE's superior visualization may have improved lymphadenectomy and complete resection rate and therefore improved long-term outcomes. We hypothesized that MIE would have superior long-term survival. Patients undergoing an esophagectomy for cancer between 2010 and 2016 were identified in the National Cancer Database. MIE included laparoscopic/robotic approach, and conversions were categorized as open. A 1:1 propensity match was performed. Lymphadenectomy and margin status were compared between MIE and open using Stuart Maxwell marginal homogeneity and Wilcoxon matched-pair signed-rank test. Survival was compared using log-rank test. 13,083 patients were identified: 8,906 (68%) open and 4,177 (32%) MIE. Propensity matching identified 3,659 'pairs' of MIE and open esophagectomy patients. Among them, MIE was associated with higher number lymph nodes examined (16 vs. 14, P < 0.001) and similar number of positive lymph nodes (0 vs. 0, P = 0.33). MIE had higher rate of negative pathologic margin (95 vs. 93.5%, P < 0.001). MIE was also associated with shorter hospitalization (9 vs. 10 days, P < 0.001). Survival was improved among MIE patients (46.6 vs. 41.4 months for open, P = 0.003) and among pathologic node-negative patients (71.4 vs. 61.5 months, P = 0.005). These data suggest that MIE has improved short-term outcomes (improved lymphadenectomy, pathologic margins, and length of stay) and also associated improved overall survival. The etiology of superior overall survival is likely secondary to many factors related and unrelated to surgical approach.
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Affiliation(s)
- Stephanie G Worrell
- Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Katelynn C Bachman
- Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Anuja L Sarode
- Department of Surgery, University Hospitals Research in Surgical Outcomes & Effectiveness Center (UH-RISES), University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Yaron Perry
- Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
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Bachman KC, Ho VP, Moorman ML, Worrell SG, Argote-Greene LM, Towe CW. Age Is a Barrier to Surgical Stabilization of Rib Fracture in Patients with Flail Chest. J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.07.626] [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: 10/23/2022]
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Linden PA, Towe CW, Watson TJ, Low DE, Cassivi SD, Grau-Sepulveda M, Worrell SG, Perry Y. Mortality After Esophagectomy: Analysis of Individual Complications and Their Association with Mortality. J Gastrointest Surg 2020; 24:1948-1954. [PMID: 31410819 DOI: 10.1007/s11605-019-04346-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [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: 04/23/2019] [Accepted: 07/25/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND The relationship between individual complications and esophagectomy mortality is unclear. The influence of comorbidities on the impact of complications on operative mortality is also unknown. We sought to assess the impact of individual complications and the effect of coexisting comorbidities on operative mortality following esophagectomy. METHODS All gastric conduit esophagectomies performed for cancer from 2008 to 2017 in the Society of Thoracic Surgery database were identified. Chi square was utilized to identify postoperative events associated with operative mortality. Multivariable logistic regression analysis was performed, utilizing postoperative events, to determine the risk-adjusted effect on operative mortality for each postoperative event. To assess the effect of preoperative comorbidities, a second logistic regression analysis was performed, incorporating preoperative characteristics. RESULTS Of 11,943 esophagectomy patients, 63.9% had a postoperative event and 3.3% died, which did not change over the study period. The postoperative events with the highest impact on operative mortality were respiratory distress syndrome (OR 7.48 (95% CI 5.23-10.7)), reintubation (OR 6.55 (4.61-9.30)), and renal failure (OR 5.97 (4.08-8.75)). Anastomotic leak requiring reoperation was associated with increased operative mortality (OR 1.48 (1.03-2.14)), but medically managed leak was not. Incorporating preoperative characteristics into the operative mortality model had little effect on odds ratio for death for individual postoperative events. CONCLUSIONS In the Society of Thoracic Surgery database, 64% of patients suffer postoperative events and 3.3% die following esophagectomy. The independent association of certain postoperative events with mortality is an objective method of terming a complication "major" and may aid efforts to reduce mortality.
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Affiliation(s)
- Philip A Linden
- University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, 11100 Euclid Avenue, Cleveland, OH, 44106-501, USA
| | - Christopher W Towe
- University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, 11100 Euclid Avenue, Cleveland, OH, 44106-501, USA
| | | | | | | | | | - Stephanie G Worrell
- University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, 11100 Euclid Avenue, Cleveland, OH, 44106-501, USA
| | - Yaron Perry
- University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, 11100 Euclid Avenue, Cleveland, OH, 44106-501, USA.
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Towe CW, Srinivasan S, Ho VP, Bachmann K, Worrell SG, Perry Y, Argote-Green LM, Linden PA. Antibiotic Resistance Is Associated With Morbidity and Mortality After Decortication for Empyema. Ann Thorac Surg 2020; 111:206-213. [PMID: 32857996 DOI: 10.1016/j.athoracsur.2020.06.056] [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: 10/29/2019] [Revised: 05/22/2020] [Accepted: 06/15/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Previous studies of decortication for empyema demonstrated that patient characteristics are associated with mortality, but the relationship of infectious pathogen to outcome has not been described. Our objective was to analyze the association of microbiology and antibiotic resistance with postoperative mortality after decortication for empyema. We hypothesized that bacterial pathogens, antibiotic resistance, and patient characteristics would all contribute to perioperative morbidity and mortality. METHODS Patients undergoing pulmonary decortication for empyema from January 1, 2010 to October 1, 2017 were reviewed retrospectively. Cases were matched with microbiology cultures. Outcomes of interest were a composite of death, tracheostomy, initial ventilator support greater than 48 hours, or unexpected intensive care unit readmission. Antibiotic resistance was categorized as present or absent, and the number of antibiotics with resistance was counted for each patient. We describe the relationship of patient characteristics, antibiotic resistance, and microbiology to mortality. RESULTS During the study period, 185 patients underwent decortication, 118 of whom had a diagnosis of primary empyema (63.8%). Positive culture results were present in 79 of 185 patients (43%). The most common isolate was Streptococcus, which was present in 29 of 79 (37%), followed by Staphylococcus in 19 of 79 (24%). Of 79 patients, 11 had fungal infections (13.9%). In addition, 16 of 79 patients had polymicrobial empyema (20%). Of 185 patients, 30 experienced the composite adverse outcome (16.2%). In multivariable regression, the composite adverse outcome was associated with emphysema, Candida in pleural culture, and antibiotic resistance count. CONCLUSIONS Perioperative mortality and morbidity after decortication for empyema is considerable. In this cohort, infections with increasing antibiotic resistance are associated with morbidity and mortality among patients with empyema.
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Affiliation(s)
- Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, Ohio.
| | - Sudershan Srinivasan
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, Ohio
| | - Vanessa P Ho
- Division of Trauma, Critical Care, Burns, and Emergency General Surgery, MetroHealth Medical Center and Case Western Reserve School of Medicine, Cleveland, Ohio
| | - Katelynn Bachmann
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, Ohio
| | - Stephanie G Worrell
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, Ohio
| | - Yaron Perry
- University of Buffalo School of Medicine, Buffalo, New York
| | - Luis M Argote-Green
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, Ohio
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, Ohio
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Hue JJ, Bachman KC, Worrell SG, Gray KE, Linden PA, Towe CW. Outcomes of robotic esophagectomies for esophageal cancer by hospital volume: an analysis of the national cancer database. Surg Endosc 2020; 35:3802-3810. [PMID: 32789587 DOI: 10.1007/s00464-020-07875-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 08/05/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Robotic minimally invasive esophagectomies (RMIE) have been associated with superior outcomes; however, it is unclear if these are specific to robotic technique or are present only at high-volume institutions. We hypothesize that low-volume RMIE centers would have inferior outcomes. METHODS The National Cancer Database (NCDB) identified patients receiving RMIE from 2010 to 2016. Based on the total number of RMIE performed by each hospital system, the lowest quartile performed ≤ 9 RMIE over the study period. Ninety-day mortality, number of lymph nodes evaluated, margins status, unplanned readmissions, length of stay (LOS), and overall survival were compared. Regression models were used to account for confounding. RESULTS 1565 robotic esophagectomies were performed by 212 institutions. 173 hospitals performed ≤ 9 RMIE (totaling 478 operations over the study period, 30.5% of RMIE) and 39 hospitals performed > 9 RMIE (1087 operations, 69.5%). Hospitals performing > 9 RMIE were more likely to be academic centers (90.4% vs 66.2%, p < 0.001), have patients with advanced tumor stage (65.3% vs 59.8%, p = 0.049), andadministered preoperative radiation (72.8% vs 66.3%, p = 0.010). There were no differences based on demographics, nodal stage, or usage of preoperative chemotherapy. On multivariable regressions, hospitals performing ≤ 9 RMIE were associated with a greater likelihood of experiencing a 90-day mortality, a reduced number of lymph nodes evaluated, and a longer LOS; however, there was no association with rates of positive margins or unplanned readmissions. Median overall survival was decreased at institutions performing ≤ 9 RMIE (37.3 vs 51.5 months, p < 0.001). Multivariable Cox regression demonstrated an association with poor survival comparing hospitals performing ≤ 9 to > 9 RMIE (HR 1.327, p = 0.018). CONCLUSION Many robotic esophagectomies occur at institutions which performed relatively few RMIE and were associated with inferior short- and long-term outcomes. These data argue for regionalization of robotic esophagectomies or enhanced training in lower volume hospitals.
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Affiliation(s)
- Jonathan J Hue
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, 11100 Euclid Avenue, Cleveland, OH, 44106-5011, USA
| | - Katelynn C Bachman
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, 11100 Euclid Avenue, Cleveland, OH, 44106-5011, USA
| | - Stephanie G Worrell
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, 11100 Euclid Avenue, Cleveland, OH, 44106-5011, USA
| | - Kelsey E Gray
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, 11100 Euclid Avenue, Cleveland, OH, 44106-5011, USA
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, 11100 Euclid Avenue, Cleveland, OH, 44106-5011, USA
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, 11100 Euclid Avenue, Cleveland, OH, 44106-5011, USA.
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Fiedler AG, Emerson D, Gillaspie EA, Hermsen JL, Levack MM, McCarthy DP, Sihag S, Worrell SG, Antonoff MB. Multi-institutional collaborative mock oral (mICMO) examination for cardiothoracic surgery trainees: Results from the pilot experience. ACTA ACUST UNITED AC 2020; 3:128-135. [PMID: 34173545 PMCID: PMC7381400 DOI: 10.1016/j.xjon.2020.07.007] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 07/18/2020] [Accepted: 07/21/2020] [Indexed: 11/24/2022]
Abstract
Objective The American Board of Thoracic Surgery–certifying examination is challenging for applicants. Single institutions have reported good results with a mock oral examination (MOE) for trainees. General surgery literature has demonstrated success with in-person multi-institutional MOE examinations. Due to small numbers of cardiothoracic training programs and significant geographic variability, we hypothesized that a multi-institutional, collaborative remotely administered MOE (mICMO) pairing faculty with trainees from different institutions would provide an important educational experience. Methods mICMOs were conducted via the Zoom virtual platform across 6 institutions. Descriptive results via post-experience survey were analyzed and reported. Results In total, 100% of trainees found mICMO useful. The majority would recommend to a peer, and 100% of faculty examiners found mICMO useful and would participate in another examination. Conclusions Faculty and trainees found the experience to be effective with respect to creating a high-stakes environment, educationally beneficial, and productive. These results support the continued use of mICMO and encourage expansion and collaboration with additional institutions across the country.
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Affiliation(s)
- Amy G Fiedler
- Division of Cardiothoracic Surgery, Department of Surgery, University of Wisconsin, Madison, Wis
| | - Dominic Emerson
- Department of Cardiac Surgery, Cedars Sinai Medical Center, Smidt Heart Institute, Los Angeles, Calif
| | | | - Joshua L Hermsen
- Division of Cardiothoracic Surgery, Department of Surgery, University of Wisconsin, Madison, Wis
| | | | - Daniel P McCarthy
- Division of Cardiothoracic Surgery, Department of Surgery, University of Wisconsin, Madison, Wis
| | - Smita Sihag
- Department of Surgery, Memorial Sloan Kettering, Thoracic Service, New York, NY
| | - Stephanie G Worrell
- Division of Thoracic Surgery, Case Western Reserve University, Cleveland, Ohio
| | - Mara B Antonoff
- Department of Thoracic and Cardiovascular Surgery, UT MD Anderson Cancer Center, Houston, Tex
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Hue JJ, Linden PA, Bachman KC, Worrell SG, Gray KE, Towe CW. Conversion from thoracoscopic to open pneumonectomy is not associated with short- or long-term mortality. Surgery 2020; 168:948-952. [PMID: 32680746 DOI: 10.1016/j.surg.2020.05.042] [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: 02/03/2020] [Revised: 05/11/2020] [Accepted: 05/21/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Thoracoscopic pneumonectomy commonly requires conversion to thoracotomy. We hypothesize that conversion would lead to worse short- and long-term outcomes compared with operations completed thoracoscopically. METHODS The National Cancer Database identified patients who underwent a pneumonectomy from 2010 to 2016. Trends in conversion were described using linear regression. Multivariable regression of factors associated with conversion was performed. Short-term outcomes included duration of stay, number of lymph nodes harvested, margin status, readmission, and 90-day mortality. Long-term outcome was evaluated as overall survival. RESULTS A total of 8,037 patients underwent a pneumonectomy. The rate of attempted thoracoscopic pneumonectomies increased from 11% to 22% (P < .001) and the rate of conversion decreased from 39% to 33% (P = .011). On multivariable analysis, a greater patient comorbidity index and pathologic nodal-stage 2 disease were associated with an increased rate of conversion. The mean number of lymph nodes evaluated was greater as was the duration of stay in the conversion group, but conversion to open thoracotomy was not associated with positive surgical margins, readmission rate, 90-day mortality, or survival. CONCLUSION Thoracoscopic pneumonectomy is performed with increasing frequency and decreasing conversion rate. Conversion is associated with a greater duration of stay but other short- and long-term outcomes are similar. This observation suggests minimal harm in conversion from minimally invasive to open pneumonectomy.
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Affiliation(s)
- Jonathan J Hue
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, OH
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, OH
| | - Katelynn C Bachman
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, OH
| | - Stephanie G Worrell
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, OH
| | - Kelsey E Gray
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, OH
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, OH.
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Towe CW, Worrell SG, Bachman K, Sarode AL, Perry Y, Linden PA. Neoadjuvant Treatment Is Associated With Superior Outcomes in T4 Lung Cancers With Local Extension. Ann Thorac Surg 2020; 111:448-455. [PMID: 32663471 DOI: 10.1016/j.athoracsur.2020.05.084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 12/05/2019] [Revised: 05/01/2020] [Accepted: 05/11/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Neoadjuvant chemoradiation is associated with improved survival of superior sulcus cancers, but little data exists regarding clinical T4 lung cancers with mediastinal invasion. We hypothesized that neoadjuvant treatment would be associated with improved survival in T4 lung cancer patients with mediastinal invasion. METHODS Clinical T4-N0/1-M0 non-small cell lung cancers from 2006-2015 were identified in the National Cancer Database. Patients with T4 extension to mediastinal structures undergoing lobectomy, bilobectomy, or pneumonectomy were included. Neoadjuvant treatment was defined as preoperative chemotherapy and/or radiation. Patients receiving surgery >120 days after radiation were excluded. Study endpoints were pathologic margin status and overall survival. To adjust for heterogeneity, a 1:1 propensity match analysis was performed. RESULTS A total of 1101 patients with cT4N0/1M0 cancers were analyzed; 595 (54.0%) received primary surgery and 506 (46.0%) received neoadjuvant treatment. Neoadjuvant therapy was associated with fewer positive surgical margins (46 of 506 [9.3%] vs 186 of 595 [33.1%], P < .001). Multivariate analysis showed an association of neoadjuvant therapy with a lower rate of positive margin (odds ratio 0.220, P < .001). Overall survival was longer among patients receiving neoadjuvant treatment (65.9 vs 27.5 months, P < .001). Propensity matching identified 331 matched pairs of patients. Among these, positive margins were less likely after receiving neoadjuvant treatment (10.5% vs 31.3%, P < .001). Overall survival among the matched pairs was improved in those receiving neoadjuvant treatment (57.0 vs 27.5 months, P < .001). CONCLUSIONS In the NCDB, T4N0/1 mediastinal invasion patients who receive neoadjuvant treatment have decreased rates of positive surgical margins and improved overall survival. The use of neoadjuvant treatment should be considered in these patients.
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Affiliation(s)
- Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, Ohio.
| | - Stephanie G Worrell
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, Ohio
| | - Katelynn Bachman
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, Ohio
| | - Anuja L Sarode
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, Ohio
| | - Yaron Perry
- Division of Thoracic Surgery, University of Buffalo and Jacobs SOM and Biomedical Sciences, Buffalo, New York
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, Ohio
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