RESUMEN
BACKGROUND: The potential advantages of clinical variation reduction are improved patient outcomes and cost reduction through optimizing and standardizing care. Malignant pleural effusion (MPE) is a common condition encountered by thoracic surgeons that has significant variation in cost and outcomes. The purpose of this investigation was to assess the opportunity of improving patient outcomes and reducing cost by using a standardized treatment algorithm based on evidenced-based care. METHODS: Patients treated for MPE using a standardized treatment algorithm at the study institution over a 2 year period were identified and propensity matched to MPE patients from 1 of 6 affiliated hospitals with comprehensive oncology and thoracic surgery services. Matched patients were treated at their physicians' discretion. Factors used in propensity matching were age, performance status, and tumor histology. The 2 cohorts were then compared for interventions, admissions and readmissions, morbidity, and pleural effusion-associated costs. Patients who desired only comfort or hospice care were excluded. RESULTS: From 2016 through 2018, 60 patients were treated using the standardized algorithm. These patients were propensity matched and the 2 cohorts compared. Patients treated with the algorithm experienced significantly fewer hospital admissions, readmissions, interventions, and costs while having a comparable procedural morbidity. CONCLUSIONS: An evidence-based treatment algorithm for MPE produces superior clinical outcomes to individualized therapy while significantly reducing the costs of care.
Asunto(s)
Algoritmos , Derrame Pleural Maligno/economía , Derrame Pleural Maligno/terapia , Anciano , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Puntaje de Propensión , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Esophageal stent placement for acute esophageal perforation has become part of the treatment algorithm for many thoracic surgery programs. Despite high success rates, there are patients for which stent placement is not successful. This investigation summarizes the outcomes of a relatively large group of such patients. METHODS: Patients who underwent esophageal stent placement for an acute perforation but required conversion to another form of therapy were identified from a prospectively collected institutional database. Excluded were patients whose perforation was associated with a malignancy. Patient demographics, operative and nonoperative invasive procedures, morbidities, mortality, and 6-month follow-up after discharge were reviewed. RESULTS: Between 2008 and 2015, 26 patients who failed to seal their esophageal leak after stent placement were identified. Eighteen (69%) of these patients required an operative repair with primary closure of the perforation. Four (15%) primary repairs had a persistent leak controlled with subsequent stent placement. Four (15%) patients required an esophagectomy with cervical esophagostomy. Three patients (11%), because of comorbid conditions, were referred for hospice care. One patient (3%) refused operative repair and developed a chronic fistula that resolved with subsequent stent placement. CONCLUSIONS: Esophageal stent placement continues to be a safe and effective treatment for acute esophageal perforation. Patients whose perforation does not seal with initial stent placement can be treated with primary surgical repair or esophagectomy without increasing their morbidity or mortality or compromising their prognosis.
Asunto(s)
Fuga Anastomótica/prevención & control , Conversión a Cirugía Abierta/métodos , Perforación del Esófago/mortalidad , Perforación del Esófago/cirugía , Esofagoscopía/métodos , Stents , Enfermedad Aguda , Adulto , Anciano , Anastomosis Quirúrgica/efectos adversos , Anastomosis Quirúrgica/métodos , Estudios de Cohortes , Conversión a Cirugía Abierta/mortalidad , Bases de Datos Factuales , Educación Médica Continua , Perforación del Esófago/diagnóstico por imagen , Esofagectomía/efectos adversos , Esofagectomía/métodos , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/diagnóstico por imagen , Complicaciones Posoperatorias/cirugía , Estudios Prospectivos , Reoperación/métodos , Medición de Riesgo , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
OBJECTIVES: Palliative care is a medical specialty focused on improving the quality of life of patients and their families with life threatening illness by preventing or relieving suffering. An assessment of a thoracic surgery service was performed to identify the scope and frequency of care that was considered palliative and any implications the findings might have on the current thoracic surgery residency curriculum. METHODS: A retrospective review of a prospectively collected database of general thoracic surgery procedures performed over a 5-year period at a single institution was performed. Procedures considered palliative were reviewed for demographics, diagnoses, palliative prognosis score, treatment, morbidity, operative mortality, and survival. Excluded were referrals from thoracic surgery to other specialties for palliative procedures. RESULTS: During the study period, 3842 procedures were performed of which 884 (23%) were palliative. Indications included pleural or pericardial effusion or both, dysphagia, hemoptysis, tracheobronchial obstruction, bronchopleural fistula, and tracheoesophageal fistula. The majority was related to a malignancy. Only 127 patients (14%) had a palliative care assessment before thoracic surgery consultation. Mean survival following thoracic surgery intervention was 110 days for patients with malignancy. CONCLUSIONS: This investigation found that thoracic surgeons commonly care for patients when the intention or indication or both is palliation. Most of these patients have an associated malignancy, a poor performance status and a projected significantly decreased survival compared with the general population. Thoracic surgeons should be familiar with the concepts of palliative care and consideration should be given to expanding exposure to the principles of palliative care in the cardiothoracic residency training curriculum.
Asunto(s)
Evaluación de Resultado en la Atención de Salud , Cuidados Paliativos/estadística & datos numéricos , Procedimientos Quirúrgicos Torácicos/educación , Procedimientos Quirúrgicos Torácicos/métodos , Adulto , Curriculum , Bases de Datos Factuales , Educación de Postgrado en Medicina/organización & administración , Femenino , Mortalidad Hospitalaria , Humanos , Incidencia , Internado y Residencia/organización & administración , Masculino , Persona de Mediana Edad , Cuidados Paliativos/métodos , Estudios Retrospectivos , Tasa de Supervivencia , Estados UnidosRESUMEN
BACKGROUND: A prospective, multidisciplinary care conference (MDC) has been shown to result in measurable benefits for patients with non-small cell lung cancer (NSCLC). However whether a MDC also results in a difference in resource utilization and cost as well as whether these benefits persist across a multiinstitutional system has not been reported. This investigation compared propensity-matched patients with NSCLC whose care was coordinated through a MDC to patients without access to an MDC across a geographically diverse system of hospitals. METHODS: The Premiere database (Premier Inc, Charlotte, NC) for a health system's 70 hospitals was used to identify patients undergoing treatment for NSCLC during a 5-year period. Propensity matching was used to populate an MDC and non-MDC cohort. The two cohorts were compared for the costs of staging and diagnosis as well as the timeliness and quality of care metrics. RESULTS: Between 2008 and 2013, 13,254 patients were propensity matched. Patient demographics and Charlson comorbidity scores were comparable after matching. Significant differences were identified in adherence to national guidelines (p < 0.0001) for staging and treatment (p < 0.0001), timeliness of care (p < 0.0001), and costs (p < 0.0001) between the two groups. CONCLUSIONS: This investigation found that patients with NSCLC realize improved quality and timeliness of care when that care is coordinated through an MDC. The use of an MDC was also associated with a significant reduction in cost. These differences persisted across a geographically diverse set of hospitals, providers, and patients. Prospective MDCs should be considered integral and compulsory for patients with NSCLC.
Asunto(s)
Carcinoma de Pulmón de Células no Pequeñas/economía , Carcinoma de Pulmón de Células no Pequeñas/terapia , Costos de la Atención en Salud , Neoplasias Pulmonares/economía , Neoplasias Pulmonares/terapia , Grupo de Atención al Paciente , Calidad de la Atención de Salud , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
BACKGROUND: Esophageal stent for the treatment of a perforation or anastomotic leak has been shown to be effective and safe. However, the optimal timing for stent removal is in question. This purpose of this investigation was to identify a time for stent removal in patients treated for an acute perforation or anastomotic leak that resulted in sealing of the leak while minimizing the incidence of stent-related complications. METHODS: Patients undergoing esophageal stent placement for the treatment of an acute perforation or intrathoracic anastomotic leak were identified from a single institution's prospectively collected database. Patient outcomes were recorded and analyzed. Complications were segregated by stent dwell time. RESULTS: During the study period, 162 patients underwent esophageal stent placement for an acute perforation (n = 117) or anastomotic leak (n = 45). Patients whose stent was removed in less than 28 days after placement for an acute perforation realized a stent complication rate that was independently reduced by 39% (odds ratio, 0.61; 95% confidence interval, 0.54 to 0.78; p < 0.01), whereas patients whose stent was removed in less than 14 days after placement for an acute perforation realized a stent complication rate that was independently reduced by 56% (odds ratio, 0.44; 95% confidence interval, 0.38 to 0.69; p < 0.001). CONCLUSIONS: Endoluminal esophageal stent placement is a safe and effective treatment for patients with an acute esophageal perforation or intrathoracic anastomotic leak after esophagectomy. Removal of stents at 2 weeks for anastomotic leak or 4 weeks for perforation has the potential to significantly decrease the incidence of complications associated with stent use.
Asunto(s)
Fuga Anastomótica/cirugía , Remoción de Dispositivos/normas , Perforación del Esófago/cirugía , Esófago/cirugía , Stents , Adulto , Anciano , Anciano de 80 o más Años , Humanos , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Tiempo , Adulto JovenRESUMEN
OBJECTIVES: Esophageal stent placement has been shown to be a safe and effective treatment for acute esophageal perforation in selected patients. However, a comparison between surgical repair and stent placement has not been reported. This investigation compares the outcomes and costs of the 2 treatment modalities. METHODS: The Premiere database for a single health system's hospitals was used to identify patients undergoing treatment for an acute intrathoracic esophageal perforation over a 4-year period. Patient cohorts for stent placement or surgical repair were formed using propensity matching. The 2 cohorts were compared for length of stay, morbidity, mortality, and costs. RESULTS: Between 2009 and 2012, 60 patients undergoing esophageal stent placement or surgical repair were propensity matched. Mean patient age and Charlson comorbidity scores did not differ significantly (P = .4 and P = .4, respectively). Significant differences in morbidity (4% vs 43%; P = .02), mean length of stay (6 vs 11 days; P = .0007), time to oral intake (3 vs 8 days; P = .0004), and cost ($91,000 vs $142,000; P < .0001) were identified in the esophageal stent cohort when compared with patients receiving surgical repair. Operative mortality did not differ significantly. CONCLUSIONS: Esophageal stent placement for the treatment of an acute esophageal perforation seems to be as effective as surgical repair when compared between propensity-matched patients. However, stent placement resulted in a shorter length of stay, lower rates of morbidity, and lower costs when compared with traditional surgical repair.
Asunto(s)
Procedimientos Quirúrgicos del Sistema Digestivo/economía , Perforación del Esófago/terapia , Costos de Hospital , Enfermedad Iatrogénica , Evaluación de Procesos y Resultados en Atención de Salud/economía , Stents/economía , Adulto , Anciano , Anciano de 80 o más Años , Ahorro de Costo , Análisis Costo-Beneficio , Bases de Datos Factuales , Procedimientos Quirúrgicos del Sistema Digestivo/efectos adversos , Procedimientos Quirúrgicos del Sistema Digestivo/mortalidad , Perforación del Esófago/diagnóstico , Perforación del Esófago/etiología , Perforación del Esófago/mortalidad , Perforación del Esófago/cirugía , Femenino , Humanos , Tiempo de Internación/economía , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/economía , Puntaje de Propensión , Estudios Retrospectivos , Factores de Riesgo , Stents/efectos adversos , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos , Adulto JovenRESUMEN
BACKGROUND: Patients with severe heart failure often have recurrent pleural effusions that produce dyspnea and shortness of breath. It is unclear whether chemical pleurodesis or the placement of a tunneled pleural catheter that can be used for intermittent pleural drainage produces superior palliation, a shorter hospital stay, and less morbidity. This investigation compares these two treatments. METHODS: Patients with a recurrent, symptomatic, pleural effusion secondary to advanced heart failure who had undergone at least two unilateral thoracenteses were identified. Two patient groups were formed by propensity matching patients who received either talc pleurodesis or a tunneled pleural catheter. Patient demographics, length of stay, need for further intervention for the pleural effusion, and procedural morbidity and mortality were collected and compared. Patients who had undergone ventricular assist device placement or cardiac transplant were excluded. RESULTS: Over a 5-year period, 80 patients undergoing treatment were identified and propensity matched. All 80 patients were classified as having class III or IV heart failure. No significant differences in palliation from their effusion were identified. However, the group treated with a tunneled pleural catheter realized a significantly shorter hospital stay as well as a lower rate of operative morbidity and readmissions than patients undergoing talc pleurodesis. CONCLUSIONS: This investigation found that a tunneled pleural catheter provided palliation of patients' pleural effusions and freedom from reintervention equal to that of talc pleurodesis using thoracoscopy while resulting in a shorter mean length of hospital stay. Lower rates of operative morbidity and readmission related to the pleural effusion were also seen in the tunneled catheter treatment group. This method of palliation of recurrent pleural effusion should be considered for symptomatic patients with advanced heart failure.
Asunto(s)
Catéteres , Drenaje/instrumentación , Insuficiencia Cardíaca/complicaciones , Derrame Pleural/terapia , Pleurodesia/métodos , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Cuidados Paliativos , Puntaje de Propensión , RecurrenciaRESUMEN
BACKGROUND: Surgical repair of esophageal perforation has been the mainstay of therapy for patients without associated esophageal malignancy or diffuse mediastinal necrosis. However, the leak rate after primary surgical repair is reported to range between 15% and 20% and increases to 45% and 70% in patients whose repair is delayed beyond 24 hours. This analysis reviews patients who experienced a leak after the operative repair of an esophageal perforation treated with esophageal stent placement. METHODS: Patients undergoing esophageal stent placement for the treatment of a leak after the operative repair of an intrathoracic esophageal perforation were identified from a single institution's database, which included patients initially treated at other facilities. Patient outcomes were recorded and analyzed. RESULTS: During a 7-year period, 32 esophageal stents were placed in 29 patients who experienced an esophageal leak after operative repair. Associated surgical procedures were simultaneously performed in 7 (24%) patients. Leak occlusion occurred in 27 patients (93%). Two patients required a reoperative repair. Twenty-five patients (86%) were able to initiate oral nutrition within 72 hours of stent placement. Stent migration in 5 patients (19%) required repositioning (n=2) or replacement (n=3). Stents were removed at a mean of 22±16 days after placement. Mean hospital length of stay was 8±11 days. CONCLUSIONS: Endoluminal esophageal stent placement is a safe and effective treatment for the majority of leaks after the operative repair of an intrathoracic esophageal perforation. Stent placement resulted in rapid leak occlusion and provided the opportunity for early oral nutrition while eliminating the need for reoperative repair or esophageal exclusion in the majority of patients.
Asunto(s)
Fuga Anastomótica/cirugía , Perforación del Esófago/diagnóstico , Perforación del Esófago/cirugía , Esofagoscopía/métodos , Stents , Adulto , Anciano , Anciano de 80 o más Años , Anastomosis Quirúrgica/efectos adversos , Anastomosis Quirúrgica/métodos , Fuga Anastomótica/diagnóstico , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Seguridad del Paciente , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Estadísticas no Paramétricas , Toracoscopía/métodos , Factores de Tiempo , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: Readmission to the hospital has become a focus for payers with the threat of nonpayment for preventable readmissions and a global penalty for excessive readmissions rates. This study compares readmission rates with lengths of stay (LOS) for patients undergoing lobectomy of the lung and the potential impact on reimbursement. METHODS: The Premier database for a single health system's hospitals was used to identify patients undergoing lobectomy for non-small cell lung cancer by cardiothoracic surgeons over a 5-year period. Charlson comorbidity scores were also calculated. Regression analysis was used to study the relationship between length of stay and readmission rates. A comparison of the effects of LOS and readmission on reimbursement was also performed. RESULTS: During the study period, 4,296 lobectomies were performed in 61 hospitals within the healthcare system that met the study's inclusion criteria. A readmission was recorded for 289 patients (7%). Factors associated with readmission were length of stay less than 5 days or more than 16 days and age more than 78 years (p = 0.001). An analysis of the effects of LOS and readmission on reimbursement found an extension of LOS was more cost effective than a readmission. CONCLUSIONS: This review found that mean LOS after lobectomy is negatively associated with readmission rates, with the maximal effect being before postoperative day 5. Furthermore, facility reimbursement was optimized when LOS was extended to minimize the risk of readmission.
Asunto(s)
Economía Hospitalaria/estadística & datos numéricos , Tiempo de Internación/estadística & datos numéricos , Readmisión del Paciente/estadística & datos numéricos , Neumonectomía , Mecanismo de Reembolso/estadística & datos numéricos , Anciano , Femenino , Humanos , MasculinoRESUMEN
BACKGROUND: Patients with a suspected malignant pleural effusion occasionally require thoracoscopy to achieve a diagnosis. It is unclear whether chemical pleurodesis or the placement of a tunneled pleural catheter (TPC) that can be used for intermittent pleural drainage produces superior palliation, a shorter hospital stay, and less morbidity. This investigation compares these 2 treatment groups. METHODS: Patients with a recurrent, symptomatic, pleural effusion suspected of having a malignant etiology who underwent a thoracoscopic exploration after at least 2 nondiagnostic thoracenteses were identified. Two patient groups were formed, comprised of patients who received either talc pleurodesis or a TPC at the conclusion of the procedure, using propensity matching. Patient demographics, length of stay, interval until the initiation of systemic therapy, need for further intervention for the pleural effusion, and procedural morbidity and mortality were collected and compared. RESULTS: Over a 6-year period, 60 patients undergoing treatment were identified and propensity matched. No significant differences in mean age or palliation from their effusion were identified. However, the group treated with TPC realized a significantly shorter hospital stay and interval to systemic therapy for their malignancy as well as a lower rate of operative morbidity than patients undergoing talc pleurodesis. CONCLUSIONS: This investigation found that a TPC provided palliation of patients' malignant pleural effusions and freedom from reintervention equal to that of talc pleurodesis after thoracoscopy while resulting in a shorter mean length of hospital stay and interval to the initiation of systemic therapy. Lower rates of operative morbidity were also seen in the TPC treatment group. This method of palliation of a malignant pleural effusion should be considered when diagnostic thoracoscopy reveals a malignant pleural effusion.
Asunto(s)
Cateterismo/instrumentación , Catéteres , Derrame Pleural Maligno/diagnóstico , Pleurodesia/métodos , Succión/métodos , Cirugía Torácica Asistida por Video , Anciano , Diagnóstico Diferencial , Diseño de Equipo , Femenino , Estudios de Seguimiento , Humanos , Indiana/epidemiología , Masculino , Morbilidad/tendencias , Cuidados Paliativos , Derrame Pleural Maligno/epidemiología , Derrame Pleural Maligno/cirugía , Puntaje de Propensión , Reproducibilidad de los Resultados , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVES: This investigation compared patients undergoing lobectomy for non-small cell lung cancer by either a general surgeon or a cardiothoracic surgeon across a geographically diverse system of hospitals to see whether a significant difference in quality or cost was present. METHODS: The Premiere administrative database and tumor registry data of a single health system's hospitals was used to compare adherence to national treatment guidelines, patient outcomes, and charges for patients undergoing lobectomy for non-small cell lung cancer in a 5-year period. Surgeons performing lobectomy were designated as a general surgeon or cardiothoracic surgeon according to their national provider number and board certification status. Excluded from analysis were centers that performed fewer than 50 lobectomies during the study period. RESULTS: During the study period, 2823 lobectomies were performed by 46 general surgeons and 3653 lobectomies were performed by 29 cardiothoracic surgeons in 54 hospitals in a single health care system. Significant differences were found between general and cardiothoracic surgeons with respect to adherence to national guidelines in staging and treatment, mean length of stay, significant morbidity, and operative mortality. Mean charges for lobectomy of the lung were also found to differ significantly between general and cardiothoracic surgeons. CONCLUSIONS: This review found that currently measurable indicators for quality of care were significantly superior and overall charges were significantly reduced when a lobectomy for non-small cell lung cancer was performed by a cardiothoracic surgeon rather than by a general surgeon.
Asunto(s)
Carcinoma de Pulmón de Células no Pequeñas/cirugía , Cirugía General , Costos de Hospital , Neoplasias Pulmonares/cirugía , Evaluación de Procesos y Resultados en Atención de Salud , Neumonectomía , Indicadores de Calidad de la Atención de Salud , Cirugía Torácica , Anciano , Anciano de 80 o más Años , Carcinoma de Pulmón de Células no Pequeñas/mortalidad , Educación de Postgrado en Medicina , Femenino , Cirugía General/economía , Cirugía General/educación , Cirugía General/normas , Adhesión a Directriz , Mortalidad Hospitalaria , Humanos , Modelos Logísticos , Neoplasias Pulmonares/mortalidad , Masculino , Persona de Mediana Edad , Análisis Multivariante , Oportunidad Relativa , Evaluación de Procesos y Resultados en Atención de Salud/economía , Evaluación de Procesos y Resultados en Atención de Salud/normas , Neumonectomía/efectos adversos , Neumonectomía/economía , Neumonectomía/educación , Neumonectomía/mortalidad , Neumonectomía/normas , Complicaciones Posoperatorias/economía , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/terapia , Guías de Práctica Clínica como Asunto , Pautas de la Práctica en Medicina , Indicadores de Calidad de la Atención de Salud/economía , Indicadores de Calidad de la Atención de Salud/normas , Sistema de Registros , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Cirugía Torácica/economía , Cirugía Torácica/educación , Cirugía Torácica/normas , Resultado del Tratamiento , Estados UnidosRESUMEN
Most patients diagnosed with carcinoma of the esophagus do not undergo therapy with curative intent. The focus of treatment for these patients is to maximize their progression-free survival and palliate the most common sequelae of their disease: dysphagia, malnutrition, pain, and intraluminal tumor bleeding. This article discusses the available treatment options for palliation of patients with unresectable esophageal cancer.
Asunto(s)
Neoplasias Esofágicas/terapia , Cuidados Paliativos/métodos , Técnicas de Ablación , Quimioradioterapia , Trastornos de Deglución/etiología , Trastornos de Deglución/terapia , Neoplasias Esofágicas/complicaciones , Esofagoscopía/instrumentación , Esofagoscopía/métodos , Humanos , Manejo del Dolor , StentsRESUMEN
BACKGROUND: Esophageal stent placement for the treatment of a perforation, anastomotic leak, or fistula has been adopted by some thoracic surgeons. Results have been reported for this technique, but little discussion has focused on treatment failures. This analysis reviews patients in whom esophageal stent placement was not successful in an attempt to identify factors that may increase the likelihood of failure of this technique. METHODS: Patients undergoing esophageal stent placement for the treatment of an esophageal perforation, anastomotic leak, or fistula in which the stent failed to adequately seal the esophageal leak were identified from a single institution's database. The anatomic location, chronicity, and cause of the esophageal leak were recorded using a newly developed classification system. Comparison was made to patients in whom stent placement was successful. RESULTS: Over a 7-year period, 187 patients had an esophageal stent placed for esophageal leaks. Fifteen (8%) of these patients required traditional operative repair when the esophageal stent failed to resolve the esophageal leak after an average of 3 days. A comparison of the 2 patient groups found that stent failure was significantly more frequent in patients who had an esophageal leak of the proximal cervical esophagus, 1 that traversed the gastroesophageal junction, an esophageal injury longer than 6 cm, or an anastomotic leak associated with a more distal conduit leak (p<0.05). Malignancy or previous radiation therapy was not associated with treatment failure. CONCLUSIONS: This investigation identified 4 factors that significantly reduce the effectiveness of esophageal stent placement for the treatment of esophageal perforation, fistula, or anastomotic leak. These potential contraindications should be considered when developing a treatment plan for individual patients and may prompt traditional operative repair as initial therapy.
Asunto(s)
Fuga Anastomótica/terapia , Fístula Esofágica/terapia , Perforación del Esófago/terapia , Esofagoscopía/métodos , Falla de Prótesis , Stents , Adulto , Anciano , Fuga Anastomótica/diagnóstico , Estudios de Cohortes , Bases de Datos Factuales , Fístula Esofágica/diagnóstico , Perforación del Esófago/diagnóstico , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Retratamiento , Estudios Retrospectivos , Medición de Riesgo , Insuficiencia del Tratamiento , Resultado del TratamientoRESUMEN
BACKGROUND: Thymic carcinoma is a rare malignancy with little information regarding outcomes after therapy with curative intent. We undertook a retrospective analysis of all patients who underwent resection of thymic carcinoma at 2 hospitals. METHODS: From 1990 to 2011, 16 patients (9 men, 7 women) underwent surgical resection of thymic carcinoma at a mean age of 52 years. Patient demographics, extent of surgical resection, and outcomes were compiled. RESULTS: The distribution of Masaoka stages at presentation was I in 3 (19%), II in 4 (25%), III in 8 (50%), and IV in 1 (6%). Neoadjuvant chemotherapy was administered to 6 patients (38%) whose tumors were deemed to be more locally invasive. Surgical resection included en bloc extrapleural pneumonectomy in 1, lobectomy in 2, and superior vena cava resection and reconstruction in 4. There were no perioperative deaths. Complete resection was achieved in 14 (88%), and of these patients, only 1 experienced local recurrence. At last follow-up, 10 patients were alive and well, 1 patient was alive with disease, and 5 patients had died. Mean survival was 4.2 years. CONCLUSIONS: Although considered to have greater malignant potential, long-term survival can be achieved in patients with thymic carcinoma who are amenable to surgical therapy. With increased use of computed tomography imaging, patients with early-stage disease are being identified more frequently, and complete surgical resection appears to have favorable cure rates in these patients. Select patients with locally advanced disease can experience long-term survival with a multimodality approach.
Asunto(s)
Terapia Neoadyuvante/métodos , Recurrencia Local de Neoplasia/patología , Timectomía/métodos , Timoma/cirugía , Neoplasias del Timo/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Quimioradioterapia/métodos , Estudios de Cohortes , Supervivencia sin Enfermedad , Femenino , Estudios de Seguimiento , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Invasividad Neoplásica/patología , Recurrencia Local de Neoplasia/mortalidad , Recurrencia Local de Neoplasia/cirugía , Estadificación de Neoplasias , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/fisiopatología , Enfermedades Raras , Estudios Retrospectivos , Medición de Riesgo , Análisis de Supervivencia , Timoma/mortalidad , Timoma/patología , Timoma/terapia , Neoplasias del Timo/mortalidad , Neoplasias del Timo/patología , Neoplasias del Timo/terapia , Factores de Tiempo , Resultado del TratamientoAsunto(s)
Fuga Anastomótica/terapia , Fístula Esofágica/terapia , Perforación del Esófago/terapia , Esofagectomía/efectos adversos , Esofagoscopía/instrumentación , Stents , Fuga Anastomótica/diagnóstico , Fuga Anastomótica/etiología , Fístula Esofágica/diagnóstico , Fístula Esofágica/etiología , Perforación del Esófago/diagnóstico , Perforación del Esófago/etiología , Esofagoscopía/efectos adversos , Humanos , Selección de Paciente , Guías de Práctica Clínica como Asunto , Diseño de Prótesis , Resultado del TratamientoRESUMEN
BACKGROUND: There is a paucity of data evaluating whether a multidisciplinary conference coordinating surgery, chemotherapy and radiation therapy translates into better patient care. This review compares the experiences of patients with esophageal cancer before and after the formation of a prospective, multidisciplinary thoracic malignancy conference (TMC). METHODS: The records of patients with carcinoma of the esophagus at a tertiary care hospital were reviewed for completeness of staging, multidisciplinary evaluation before the initiation of therapy, time from pathologic diagnosis to treatment, multimodality therapy, and adherence to national treatment guidelines. Summary data were compared for patients treated before and after the TMC was initiated. RESULTS: Between 2001 and 2007, 117 patients were treated before the initiation of the TMC and 138 patients within the TMC. The number of patients receiving, respectively, a complete staging evaluation (67% and 97%, p < 0.0001), multidisciplinary evaluation before therapy (72% and 98%, p < 0.0001), and adherence to National Comprehensive Cancer Network treatment guidelines (83% and 98%, p < 0.0001) all increased significantly, whereas mean days from diagnosis to treatment significantly decreased (27 and 16, respectively; p < 0.0001). CONCLUSIONS: A multidisciplinary TMC increased the percentage of patients receiving complete staging, a multidisciplinary evaluation, and adherence to nationally accepted care guidelines while decreasing the interval from diagnosis to treatment significantly. While the ultimate goal of treatment is to improve patient survival, the surrogate variables examined in this review indicate that patients with esophageal cancer benefit from being evaluated in a prospective, multidisciplinary manner.
Asunto(s)
Carcinoma/terapia , Conferencias de Consenso como Asunto , Neoplasias Esofágicas/terapia , Guías de Práctica Clínica como Asunto , Adulto , Anciano , Carcinoma/diagnóstico , Terapia Combinada , Neoplasias Esofágicas/diagnóstico , Femenino , Estudios de Seguimiento , Adhesión a Directriz , Humanos , Indiana , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Estudios Retrospectivos , Neoplasias Torácicas/diagnóstico , Neoplasias Torácicas/terapiaRESUMEN
BACKGROUND: Thymectomy is recognized as a significant component in the treatment of myasthenia gravis. However, controversy exists as to the optimal surgical approach. This investigation summarizes our experience performing extended thymectomy using a robotic technique in a large group of patients with significant follow-up. METHODS: Data collection for patients undergoing robotic thymectomy for nonthymomatous myasthenia gravis over a 6-year period was prospectively performed. Patients were assessed using the Myasthenia Gravis Foundation of America's quantitative disease severity score and the post intervention status classification. RESULTS: During the study period, 75 patients underwent thymectomy by this method. Mean preoperative myasthenia gravis severity score was 2.7. Mean operative time was 113±46 minutes. Extubation in the operating room occurred in 73 (98%) patients. Mean intensive care stay and total hospital length of stay were 0.9 and 2.2 days respectively. Mean interval between surgery and return to work (or prethymectomy activities of daily living) was 15±6 days. Significant improvement of myasthenia gravis symptoms occurred in 65 (87%) patients with a mean follow-up of 45±14 months. CONCLUSIONS: Robotic-assisted thymectomy is a safe and effective technique for patients with symptomatic myasthenia gravis. It allowed an extended thymectomy to be performed without the associated length of stay or recovery period of a transsternal approach while producing comparable rates of symptom improvement.
Asunto(s)
Miastenia Gravis/cirugía , Robótica/métodos , Timectomía/métodos , Adolescente , Adulto , Progresión de la Enfermedad , Femenino , Estudios de Seguimiento , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Miastenia Gravis/diagnóstico , Estudios Prospectivos , Índice de Severidad de la Enfermedad , Factores de Tiempo , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: Anastomotic leak after intrathoracic esophagogastrostomy remains a dreaded complication of esophagectomy. Traditional therapy has most often consisted of reoperative repair or observation and drainage, each prolonging hospitalization and the initiation of oral nutrition. This investigation summarizes our experiences treating these patients using an occlusive, removable esophageal stent. METHODS: Over a 4-year period, patients found to have an acute, significant intrathoracic anastomotic leak after esophagectomy for benign or malignant disease undergoing surgery at or transferred to a single institution were offered endoluminal esophageal stent placement as initial therapy. Stents were placed endoscopically utilizing general anesthesia and fluoroscopy. Leak occlusion was confirmed by esophagram. Patients were followed until their stent was removed and their anastomotic leak had resolved. RESULTS: Seventeen patients had an esophageal stent placed for an anastomotic leak during the study period. Leak occlusion occurred in all 17 patients. One patient was found to also have a perforation of the gastric conduit and underwent operative repair. Fourteen patients (82%) were able to initiate oral nutrition within 72 hours of stent placement. Stent migration occurred in 3 patients (18%), requiring repositioning in 2 and replacement in 1. All stents were removed at a mean of 17±9 days after placement. CONCLUSIONS: Endoluminal esophageal stent placement is a safe and effective method for the treatment of an intrathoracic anastomotic leak after esophagectomy. This treatment resulted in rapid leak occlusion, provided the opportunity for earlier oral nutrition, and avoided the potential morbidity of reoperative repair or esophageal diversion.
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Fuga Anastomótica/cirugía , Esofagectomía/efectos adversos , Esofagoscopía/métodos , Stents , Anciano , Anastomosis Quirúrgica/efectos adversos , Fuga Anastomótica/diagnóstico , Estudios de Cohortes , Educación Médica Continua , Neoplasias Esofágicas/patología , Neoplasias Esofágicas/cirugía , Estenosis Esofágica/diagnóstico , Estenosis Esofágica/cirugía , Esofagectomía/métodos , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Procedimientos Quirúrgicos Mínimamente Invasivos/instrumentación , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/cirugía , Estudios Retrospectivos , Medición de Riesgo , Toracotomía/efectos adversos , Toracotomía/métodos , Resultado del TratamientoRESUMEN
INTRODUCTION: There is a paucity of data evaluating whether a multidisciplinary conference coordinating surgery, chemotherapy and radiation therapy translates into better patient care. This article compares the experiences of patients with lung cancer before and after the formation of a prospective, multidisciplinary thoracic malignancy care conference (TMC). METHODS: The records of patients with a non-small-cell lung cancer at a tertiary care hospital were reviewed for completeness of staging, multidisciplinary evaluation prior to the initiation of therapy, time from pathologic diagnosis to treatment, multimodality therapy and adherence to national treatment guidelines. The summary data of patients treated before and after the TMC were initiated, and then compared. RESULTS: Between 2001 and 2007, 535 patients were treated prior to the initiation of the TMC and 687 patients within the TMC. The number of patients receiving a complete staging evaluation (79%/93%: p<0.0001), multidisciplinary evaluation prior to therapy (62%/96%: p<0.0001) and adherence to the National Comprehensive Cancer Network (NCCN) treatment guidelines (81%/97%: p<0.0001) all increased significantly while mean days from diagnosis to treatment significantly decreased (29/17: p<0.0001) following the initiation of a TMC. CONCLUSION: A multidisciplinary thoracic malignancy conference increased the percentage of patients receiving complete staging, a multidisciplinary evaluation and adherence to nationally accepted care guidelines while decreasing the interval from diagnosis to treatment significantly. While the ultimate goal of treatment is to improve patient survival, the surrogate variables examined in this review indicate that patients with non-small-cell lung cancer benefit from being evaluated in a prospective, multidisciplinary care conference.
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Carcinoma de Pulmón de Células no Pequeñas/terapia , Neoplasias Pulmonares/terapia , Carcinoma de Pulmón de Células no Pequeñas/patología , Terapia Combinada , Conferencias de Consenso como Asunto , Adhesión a Directriz , Humanos , Neoplasias Pulmonares/patología , Estadificación de Neoplasias , Guías de Práctica Clínica como AsuntoRESUMEN
BACKGROUND: Patients with lifestyle-limiting dyspnea attributable to unilateral diaphragm paralysis have been shown to experience a decrease in their dyspnea and an improvement in their pulmonary spirometry and functional status with diaphragm plication acutely after surgery. This investigation summarizes these patients' outcomes with long-term follow-up. METHODS: Adult patients undergoing plication of the hemidiaphragm for lifestyle-limiting dyspnea secondary to unilateral diaphragm paralysis were assessed preoperatively, 6 month after surgery and then annually using the Medical Research Council dyspnea score, pulmonary spirometry, activities of daily living questionnaire, and a chest radiograph. Patients with at least 48 months of follow-up were included in this investigation. RESULTS: Forty-one patients underwent plication of the hemidiaphragm through video-assisted thoracoscopy (30) or thoracotomy (11). Mean follow-up was 57 +/- 10 months. Mean forced vital capacity, forced expiratory volume at 1 second, functional residual capacity, and total lung capacity all improved by 19%, 23%, 21%, and 19% (p < 0.005), respectively, when measured 6 months after surgery, as were mean Medical Research Council dyspnea scores (p < 0.0001). These mean values remained constant over the follow-up period. Four patients did not show improvement in their Medical Research Council dyspnea scores nor functional status despite improvements in their pulmonary spirometry values. Two of these patients had a body mass index greater than 35 kg/m(2) and 3 had documented unilateral diaphragm paralysis for at least 4 years before plication. CONCLUSIONS: Plication of the hemidiaphragm produces improvement for the vast majority of patients in pulmonary spirometry, dyspnea, and functional status that endures over long-term follow-up. Patients who are morbidly obese or who have longstanding unilateral diaphragm paralysis may not realize the same benefits of plication.