Publications by authors named "Cliff P Connery"

35 Publications

Social determinants and facility type impact adherence to best practices in operable IIIAN2 lung cancer.

Interact Cardiovasc Thorac Surg 2021 Aug 19. Epub 2021 Aug 19.

Department of Thoracic Surgery, Nuvance Health System, Danbury, CT, USA.

Objectives: We aimed to identify patient- and facility-specific predictors of collective adherence to 4 recommended best treatment practices in operable IIIAN2 non-small-cell lung cancer (NSCLC) and test the hypothesis that collective adherence is associated with superior survival.

Methods: We queried the National Cancer Database for clinical stage IIIAN2 NSCLC patients undergoing surgery during 2010-2015. The following best practices were examined: performance of an anatomic resection, performance of an R0 resection, examination of regional lymph nodes and administration of induction therapy. Multivariable regression models were fitted to identify independent predictors of guideline-concordance.

Results: We identified 7371 patients undergoing surgical resection for IIIAN2 lung cancer, of whom 90.8% underwent an anatomic resection, 88.2% received an R0 resection, 92.5% underwent a regional lymph node examination, 41.6% received induction therapy and 33.7% received all 4 best practices. Higher income, private insurance and treatment at an academic facility were independently associated with adherence to all 4 best practices (P < 0.01). A lower level of education and residence in a rural county were associated with a lack of adherence (P < 0.05). Adherence to all 4 practices correlated with improved survival (P < 0.01).

Conclusions: National adherence to best treatment practices in operable IIIAN2 lung cancer was variable as evidenced by the majority of patients not receiving recommended induction therapy. Socioeconomic factors and facility type are important determinants of guideline-concordance. Future efforts to improve outcomes should take this into account since guideline concordance, in the form of collective adherence to all 4 best practices, was associated with improved survival.
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http://dx.doi.org/10.1093/icvts/ivab209DOI Listing
August 2021

Invasive thymoma - Which patients benefit from post-operative radiotherapy?

Asian Cardiovasc Thorac Ann 2021 May 11:2184923211017094. Epub 2021 May 11.

Department of Thoracic Surgery, Nuvance Health System, Connecticut & New York, USA.

Background: The aim of this study is to identify patients with thymoma who should receive post-operative radiotherapy.

Methods: The Surveillance, Epidemiology, and End Results database was queried for stage IIB-IV thymoma patients diagnosed during 1988-2015. We analyzed the prognostic implications of various clinical-pathological factors by comparing the outcomes of those who received surgery with and without post-operative radiotherapy.

Results: A total of 1120 patients were identified; 62% received post-operative radiotherapy and 38% underwent surgery alone. In a propensity-matched cohort of 812 patients, no survival difference was seen in World Health Organization A, AB, B1, B2, or B3 tumors with the addition of post-operative radiotherapy to surgery (p>0.05). Post-operative radiotherapy also did not improve survival over surgery alone for tumors ≥ or < less than the 4 cm, 7 cm, 10 cm, and 13 cm cutoffs, all p>0.05. Post-operative radiotherapy was an independent, positive prognostic indicator only in the subgroup with stage III disease and in those receiving chemotherapy in addition to post-operative radiotherapy, both p<0.05.

Conclusions: Patients with stage III thymoma are most likely to benefit from the addition of post-operative radiotherapy to surgical treatments. Tumor size or World Health Organization histology alone should not be criteria for determining the need for post-operative radiotherapy in locally advanced thymoma. Masaoka-Koga stage, which has traditionally been used to help make such decisions, appears to be the most reliable determinant of the use of post-operative radiotherapy.
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http://dx.doi.org/10.1177/02184923211017094DOI Listing
May 2021

Lobectomy Demonstrates Superior Survival Than Segmentectomy for High-Grade Non-Small Cell Lung Cancer: The National Cancer Database Analysis.

Am Surg 2021 Apr 20:31348211011116. Epub 2021 Apr 20.

Division of Thoracic Surgery, Rudy L Ruggles Biomedical Research Institute, Nuvance Health System, Danbury, CT, USA.

Background: Current recommendations for segmentectomy for non-small cell lung cancer (NSCLC) include size ≤2 cm, margins ≥ 2 cm, and no nodal involvement. This study further stratifies the selection criteria for segmentectomy using the National Cancer Database (NCDB).

Methods: The NCDB was queried for patients with high-grade (poorly/undifferentiated) T1a/b peripheral NSCLC (tumor size ≤2 cm), who underwent either lobectomy or segmentectomy. Patients with pathologic node-positive disease or who received neoadjuvant/adjuvant treatments were excluded. Propensity score analysis was used to adjust for differences in pretreatment characteristics.

Results: 11 091 patients were included with 10 413 patients (93.9%) treated with lobectomy and 678 patients (6.1%) underwent segmentectomy. In a propensity matched pair analysis of 1282 patients, lobectomy showed significantly improved median survival of 88.48 months vs 68.30 months for segmentectomy, = .004. On multivariate Cox regression, lobectomy was associated with significantly improved survival (hazard ratio (HR): .81, 95% CI .72-.92, = .001). Subgroup analysis of propensity score matched patients with a Charlson-Deyo comorbidity score (CDCC) of 0 also demonstrated a trend of improved survival with lobectomy.

Discussion: Lobectomy may confer significant survival advantage over segmentectomy for high-grade NSCLC (≤2 cm). More work is needed to further stratify various NSCLC histologies with their respective grades allowing more comprehensive selection criteria for segmentectomy.
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http://dx.doi.org/10.1177/00031348211011116DOI Listing
April 2021

Travelling to a High-Volume Center Confers Improved Survival in Stage I Non-small Cell Lung Cancer.

Ann Thorac Surg 2021 Mar 1. Epub 2021 Mar 1.

Division of Thoracic Surgery, Rudy L. Ruggles Biomedical Research Institute, Nuvance Health, Danbury, Connecticut.

Background: The association of hospital volume with outcomes has been assessed previously for patients with non-small cell lung cancer (NSCLC), but there are limited data on the cumulative effect of travel burden and hospital volume on treatment decisions and survival outcomes. We used the National Cancer Database to evaluate this relationship in early-stage NSCLC.

Methods: Outcomes of interest were compared between 2 propensity-matched groups with stage I NSCLC: patients in the bottom quartile of distance travelled who underwent surgery at low-volume centers (Local) and those in the top quartile of distance travelled who received surgery at high-volume centers (Distant). Outcomes included type of resection (anatomic or nonanatomic), time to resection (< or ≥8 weeks), number of lymph nodes examined (< or ≥10 nodes) and R0 resection.

Results: We identified 3325 Local patients who travelled 2.3 miles (interquartile range [IQR]: 1.4-3.3 miles) to centers that treated 10.5 (IQR: 6.5-16.5) stage I NSCLCs/year and 3361 Distant patients who travelled 40.0 miles (IQR: 29.1-63.4 miles) to centers treating 56.9 (IQR: 40.1-84.7) stage I NSCLCs/year. Local patients were less likely to receive surgery <8 weeks post-diagnosis, have ≥10 lymph nodes examined during surgery, and undergo an R0 resection (all P < .01). Distant patients had shorter hospital stays and superior median survival, both P < .01.

Conclusions: Patients travelling longer distances to high-volume centers receive better and more timely surgical care, leading to shorter hospital stays and improved survival outcomes. Regionalization of lung cancer care by improving travel support to larger treatment facilities may help improve early-stage NSCLC outcomes.
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http://dx.doi.org/10.1016/j.athoracsur.2021.02.028DOI Listing
March 2021

Anatomic resection has superior long-term survival compared with wedge resection for second primary lung cancer after prior lobectomy.

Eur J Cardiothorac Surg 2021 05;59(5):1014-1020

Division of Thoracic Surgery, Rudy L Ruggles Biomedical Research Institute, Nuvance Health Systems, Danbury, CT, USA.

Objectives: The extent of surgical resection for early-stage second primary lung cancer (SPLC) in patients with a previous lobectomy is unclear. We sought to compare anatomic lung resections (lobectomy and segmentectomy) and wedge resections for small peripheral SPLC using a population-based database.

Methods: The Surveillance, Epidemiology and End Results database was queried for all patients with ≤2 cm peripheral SPLC diagnosed between 2004 and 2015 who underwent prior lobectomy for the first primary and surgical resection only for the SPLC. American College of Chest Physicians guidelines were used to classify SPLC. Kaplan-Meier analysis and multivariable Cox regression were used to compare overall survival.

Results: A total of 356 patients met the inclusion criteria with 203 (57%) treated with wedge resection and 153 (43%) treated with anatomic resection. Significantly better median survival was observed with anatomic resection than with wedge resection using a Kaplan-Meier analysis (124 vs 63 months; P < 0.001). With multivariable Cox regression, improved long-term survival was observed for anatomic resection (hazard ratio: 0.44, confidence interval: 0.27-0.70; P = 0.001). Improvement in survival was demonstrated with wedge resection when lymph node sampling was done. Lastly, we calculated the average treatment effect on the treated with inverse probability weighting for a subgroup of patients and found that those with wedge resection and lymph node sampling had shorter long-term survival times.

Conclusions: Anatomic resections may provide better long-term survival than wedge resections for patients with early-stage peripheral SPLC after prior lobectomy. Significant improvement in survival was observed with wedge resection for SPLC when adequate lymph node dissection was performed.
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http://dx.doi.org/10.1093/ejcts/ezaa443DOI Listing
May 2021

Lobectomy is superior to segmentectomy for peripheral high grade non-small cell lung cancer ≤2 cm.

J Thorac Dis 2020 Oct;12(10):5925-5933

Division of Thoracic Surgery, Rudy L. Ruggles Biomedical Research Institute, Nuvance Health Systems, Danbury, CT, USA.

Background: Current practice guidelines recommend the following criteria for segmentectomy for non-small cell lung cancer (NSCLC): size ≤2 cm, margins ≥2 cm and no lymph node involvement. We sought to further stratify the selection criteria for segmentectomy for small peripheral high-grade tumors.

Methods: This retrospective database study was conducted using the Surveillance, Epidemiology and End Results (SEER) database. We queried for patients with high-grade (poorly differentiated/undifferentiated) pathological (p)T1a/b peripheral NSCLC (tumor size ≤2 cm), who underwent either lobectomy or segmentectomy between 2004 and 2015. Patients with node-positive disease or those who received any form of induction or adjuvant treatments were excluded.

Results: A total of 4,332 patients met the inclusion criteria, with 3,977 patients (91.8%) treated with lobectomy and 355 patients (8.2%) who underwent segmentectomy. In a propensity matched pair analysis of 640 patients, lobectomy (n=320) showed significantly improved 5-year survival of 45.9% 33.8% for segmentectomy (n=320), P<0.01. In a multivariate Cox regression analysis, lobectomy was associated with significantly improved survival (HR: 0.84, 95% CI: 0.714-0.989, P=0.036). Interestingly, married status, adenocarcinoma histology, number of lymph nodes sampled were associated with better survival (P<0.05), while advanced age and male gender had worse survival outcomes (P<0.05).

Conclusions: For small peripheral NSCLC ≤2 cm and high grades of tumor differentiation, lobectomy is associated with better long-term survival outcomes as compared to segmentectomy. Additional data is needed to further stratify various NSCLC histologies with their respective grades to allow for better selection for segmentectomy.
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http://dx.doi.org/10.21037/jtd-20-1530DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7656350PMC
October 2020

The Etiology of Primary Hyperhidrosis: A Systematic Review.

Clin Auton Res 2017 Dec 19;27(6):379-383. Epub 2017 Aug 19.

Department of Cardiothoracic Surgery, Odense University Hospital, Odense, 5000, Denmark.

Purpose: Primary hyperhidrosis is a pathological disorder of unknown etiology, affecting 0.6-5% of the population, and causing severe functional and social handicaps. As the etiology is unknown, it is not possible to treat the root cause. Recently some differences between affected and non-affected people have been reported. The aim of this review is to summarize these new etiological data.

Methods: Search of the literature was performed in the PubMed/Medline Database and pertinent articles were retrieved and reviewed. Additional publications were obtained from the references of these articles.

Results: Some anatomical and pathophysiological characteristics (as well as enzymatic, metabolic, and neurological dysfunctions) have been observed in hyperhidrotic subjects; three main possible etiological factors predominate. A familial trait seems to exist, and genetic loci associated with hyperhidrosis have been identified. Histological differences were observed in sympathetic ganglia of hyperhidrotic subjects: the ganglia were larger and contained a higher number of ganglion cells. A higher expression of acetylcholine and alpha-7 neuronal nicotinic receptor subunit in the sympathetic ganglia of patients with hyperhidrosis has been reported.

Conclusions: Despite these accumulated data, the etiology of primary hyperhidrosis remains obscure. Nevertheless, three main lines for future research seem to be delineated: genetics, histological observations, and enzymatic studies.
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http://dx.doi.org/10.1007/s10286-017-0456-0DOI Listing
December 2017

Reconstruction of the Sympathetic Chain.

Authors:
Cliff P Connery

Thorac Surg Clin 2016 Nov 4;26(4):427-434. Epub 2016 Aug 4.

Dyson Center, Thoracic Oncology, Vassar Brothers Medical Center, 3rd Floor, 45 Reade Place, Poughkeepsie, NY 12601, USA. Electronic address:

There is a small subset of patients who have undergone endoscopic thoracic sympathectomy for hyperhidrosis or facial blushing who are dissatisfied and would wish reversal. Compensatory sweating is the most common side effect that causes a person to regret surgery. Treatment options are limited and usually not effective in patients with severe side effects from sympathectomy. Nerve graft interposition has been proven to be effective in experimental models and small clinical series. Da Vinci robotic nerve graft reconstruction with interposition graft and direct suturing of nerve and high magnification dissection most closely mirrors standard nerve reconstruction principles when done as a minimally invasive procedure.
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http://dx.doi.org/10.1016/j.thorsurg.2016.06.007DOI Listing
November 2016

CT screening for lung cancer: value of expert review of initial baseline screenings.

AJR Am J Roentgenol 2015 Feb 28;204(2):281-6. Epub 2014 Oct 28.

1 Department of Radiology, Mount Sinai School of Medicine, One Gustave L. Levy Pl, Box 1234, New York, NY 10029.

OBJECTIVE. Appropriate radiologic interpretation of screening CT can minimize unnecessary workup and intervention. This is particularly challenging in the baseline round. We report on the quality assurance process we developed for the International Early Lung Cancer Action Program. MATERIALS AND METHODS. After initial training at the coordinating center, radiologists at 10 participating institutions and at the center independently interpreted the first 100 baseline screenings. The radiologist at the institutions had access to the center interpretations before issuing the final reports. After the first 100 screenings, the interpretations were jointly discussed. This report summarizes the results of the initial 100 dual interpretations at the 10 institutions. RESULTS. The final institution interpretations agreed with the center in 895 of the 1000 interpretations. Compared with the center, the frequency of positive results was higher at eight of the 10 institutions. The most frequent reason of discrepant interpretations was not following the protocol (n = 55) and the least frequent was not identifying a nodule (n = 3). CONCLUSION. The quality assurance process helped focus educational programs and provided an excellent vehicle for review of the protocol with participating physicians. It also suggests that the rate of positive results can be reduced by such measures.
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http://dx.doi.org/10.2214/AJR.14.12526DOI Listing
February 2015

Have robots a future in sympathetic operations?

Ann Thorac Surg 2014 Apr;97(4):1480-1

Columbia University College, New York, New York.

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http://dx.doi.org/10.1016/j.athoracsur.2013.09.113DOI Listing
April 2014

Transumbilical thoracic sympathectomy with an ultrathin flexible endoscope in a series of 38 patients.

Surg Endosc 2014 Apr 8;28(4):1380-1. Epub 2013 Nov 8.

Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel,

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http://dx.doi.org/10.1007/s00464-013-3279-7DOI Listing
April 2014

Internal mammary silicone lymphadenopathy diagnosed by robotic thoracoscopic lymphadenectomy.

J Robot Surg 2013 Jun 25;7(2):209-11. Epub 2012 Sep 25.

Division of Thoracic Surgery, Department of Surgery, St. Luke's-Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, 1000 10th Avenue, Suite 2B-07, New York, NY, 10019, USA.

Internal mammary lymphadenopathy can be caused by a variety of disease processes and is a difficult diagnostic dilemma. We report a case of internal mammary lymphadenopathy, in a patient with a significant history of malignancy, requiring a tissue diagnosis. Robotic thoracoscopic lymphadenectomy was used to facilitate excisional biopsy. Pathology was significant for silicone granulomatous lymphadenitis secondary to silicone breast implants inserted after mastectomy for breast cancer.
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http://dx.doi.org/10.1007/s11701-012-0368-xDOI Listing
June 2013

Dietary flaxseed protects against lung ischemia reperfusion injury via inhibition of apoptosis and inflammation in a murine model.

J Surg Res 2011 Nov 7;171(1):e113-21. Epub 2011 Jul 7.

Department of Surgery, St. Luke's-Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, New York, New York 10019, USA.

Background: The hallmark of lung ischemia-reperfusion injury (IRI) is the production of reactive oxygen species (ROS), and the resultant oxidant stress has been implicated in apoptotic cell death as well as subsequent development of inflammation. Dietary flaxseed (FS) is a rich source of naturally occurring antioxidants and has been shown to reduce lung IRI in mice. However, the mechanisms underlying the protective effects of FS in IRI remain to be determined.

Methods: We used a mouse model of IRI with 60 min of ischemia followed by 180 min of reperfusion and evaluated the anti-apoptotic and anti-inflammatory effects of 10% FS dietary supplementation.

Results: Mice fed 10% FS undergoing lung IRI had significantly lower levels of caspases and decreased apoptotic activity compared with mice fed 0% FS. Lung homogenates and bronchoalveolar lavage fluid analysis demonstrated significantly reduced inflammatory infiltrate in mice fed with 10% FS diet. Additionally, 10% FS treated mice showed significantly increased expression of antioxidant enzymes and decreased markers of lung injury.

Conclusions: We conclude that dietary FS is protective against lung IRI in a clinically relevant murine model, and this protective effect may in part be mediated by the inhibition of apoptosis and inflammation.
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http://dx.doi.org/10.1016/j.jss.2011.06.017DOI Listing
November 2011

The Society of Thoracic Surgeons expert consensus for the surgical treatment of hyperhidrosis.

Ann Thorac Surg 2011 May;91(5):1642-8

Division of Thoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama 35294, USA.

Significant controversies surround the optimal treatment of primary hyperhidrosis of the hands, axillae, feet, and face. The world's literature on hyperhidrosis from 1991 to 2009 was obtained through PubMed. There were 1,097 published articles, of which 102 were clinical trials. Twelve were randomized clinical trials and 90 were nonrandomized comparative studies. After review and discussion by task force members of The Society of Thoracic Surgeons' General Thoracic Workforce, expert consensus was reached from which specific treatment strategies are suggested. These studies suggest that primary hyperhidrosis of the extremities, axillae or face is best treated by endoscopic thoracic sympathectomy (ETS). Interruption of the sympathetic chain can be achieved either by electrocautery or clipping. An international nomenclature should be adopted that refers to the rib levels (R) instead of the vertebral level at which the nerve is interrupted, and how the chain is interrupted, along with systematic pre and postoperative assessments of sweating pattern, intensity and quality-of-life. The recent body of literature suggests that the highest success rates occur when interruption is performed at the top of R3 or the top of R4 for palmar-only hyperhidrosis. R4 may offer a lower incidence of compensatory hyperhidrosis but moister hands. For palmar and axillary, palmar, axillary and pedal and for axillary-only hyperhidrosis interruptions at R4 and R5 are recommended. The top of R3 is best for craniofacial hyperhidrosis.
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http://dx.doi.org/10.1016/j.athoracsur.2011.01.105DOI Listing
May 2011

Timely airway stenting improves survival in patients with malignant central airway obstruction.

Ann Thorac Surg 2010 Oct;90(4):1088-93

Division of Thoracic Surgery, St. Luke's-Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, New York, New York, USA.

Background: The survival of patients with malignant central airway obstruction is very limited. Although airway stenting results in significant palliation of symptoms, data regarding improved survival after stenting for advanced thoracic cancer with central airway obstruction are lacking.

Methods: Fifty patients received a total of 72 airway stents for malignant central airway obstruction over a two-year period at a single institution. The Medical Research Council (MRC) dyspnea scale and Eastern Cooperative Oncology Group (ECOG) performance status were used to divide patients into a poor performance group (MRC = 5, ECOG = 4) and an intermediate performance group (MRC ≤ 4, ECOG ≤ 3). The SPSS version 16.0 (SPSS Inc, Chicago, IL) and Microsoft Excel (Microsoft, Redmond, WA) were used to analyze the data. Survival curves were constructed using the Kaplan-Meier survival analysis method and a log-rank test was used to compare the survival distributions among different groups.

Results: Successful patency of the airway was achieved in all patients with no procedure-related mortality. Stenting resulted in significant improvement in MRC and ECOG performance scores (p < 0.01). Significantly improved survival was observed only in patients in the intermediate performance group compared with patients in the poor performance group (p < 0.05).

Conclusions: Airway stenting resulted in significant palliation of symptoms in both groups as evaluated by MRC dyspnea scale and ECOG performance status. Compared with historic controls, a significant survival advantage was seen only in the intermediate performance group. We postulate that timely stenting of the airway, before the morbid complications of malignant central airway obstruction have set in, results in improved survival.
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http://dx.doi.org/10.1016/j.athoracsur.2010.06.093DOI Listing
October 2010

Endoscopic tracheoplasty: segmental tracheal ring resection in a porcine model.

J Bronchology Interv Pulmonol 2010 Jul;17(3):232-5

*Divisions of Thoracic Surgery, Department of Surgery †Department of Otolaryngology, St Luke's-Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, New York, NY.

Endoscopic tracheoplasty is used for the relief of airway obstruction because of several benign conditions such as postintubation stenosis, inflammatory disorders such as Wegener granulomatosis, and benign neoplastic processes. Several endoscopic treatment modalities exist for these conditions, all with good initial results. However, recurrence is common and often requires frequent reintervention. Endoscopic segmental tracheal ring resection is a novel therapeutic approach that could potentially provide a durable solution. Endoscopic segmental tracheal ring resection was performed in 3 Yorkshire pigs under general anesthesia. A combination of bipolar cautery and sharp dissection was used to resect 25% to 33% of the circumference of a single tracheal ring. Technical success was achieved in all 3 animals with no intraoperative complications. Full-thickness excision, including the anterior perichondrium, was performed in 1 animal without violation of the pretracheal fascia, with no subcutaneous emphysema or clinically apparent pneumothorax. Average operative time was 31 minutes and estimated blood loss was minimal. Heart rate, oxygen saturation, and peak airway pressures were maintained within normal ranges during the procedure and for the 60-minute postoperative period. Histologic analysis of the resected specimen confirmed complete thickness excision of the segment of tracheal cartilage. Endoscopic tracheoplasty by segmental tracheal ring resection is a safe and feasible technique in a porcine model. Long-term durability could potentially outlast other endoscopic techniques for the treatment of bening tracheal stenosis. Survival studies in a porcine model of tracheal stenosis must be performed to assess the long-term outcomes of this approach.
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http://dx.doi.org/10.1097/LBR.0b013e3181ea9a9bDOI Listing
July 2010

Postoperative and long-term outcome of patients with chronic obstructive pulmonary disease undergoing coronary artery bypass grafting.

Ann Thorac Surg 2010 Apr;89(4):1112-8

Department of Cardiothoracic Surgery, Athens University School of Medicine, Attikon University Hospital, Athens, Greece.

Background: Chronic obstructive pulmonary disease (COPD) has been conventionally associated with increased operative mortality and morbidity after coronary artery bypass grafting. Some studies, however, challenge this association. Moreover, the effect of COPD on long-term survival after coronary artery bypass grafting has not been adequately assessed. Thus, in this clinical setting, both early and late outcome require further examination.

Methods: We studied 3,760 consecutive patients who underwent isolated coronary artery bypass grafting between 1992 and 2002. The propensity for COPD was determined by logistic regression analysis, and each patient with COPD was matched with 3 patients without COPD. Matched groups were compared for early outcome and long-term survival (mean follow-up, 7.6 years). Long-term survival data were obtained from the National Death Index.

Results: There were 550 patients (14.6%) with COPD. Multivariate analysis showed that patients with COPD were older and sicker. However, propensity-matched groups did not differ in terms of hospital mortality or major morbidity, although COPD was associated with a slightly longer hospital stay. In contrast, COPD patients had increased long-term mortality, with a hazard ratio of 1.28 (95% confidence intervals, 1.11 to 1.47; p=0.001). Freedom from all-cause mortality at 7 years after CABG was 65% and 72% in matched patients with and without COPD, respectively (p=0.008). In patients with COPD, the hazard estimate was consistently increased up to 9 years postoperatively.

Conclusions: Chronic obstructive pulmonary disease, although not an independent predictor of increased early mortality and morbidity in this series, is a continuing detrimental risk factor for long-term survival.
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http://dx.doi.org/10.1016/j.athoracsur.2010.01.009DOI Listing
April 2010

Robotic brachytherapy and sublobar resection for T1 non-small cell lung cancer in high-risk patients.

Ann Thorac Surg 2010 Feb;89(2):360-7

Department of Surgery, St. Luke's-Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, New York, USA.

Background: Sublobar lung resection and brachytherapy seed placement is gaining acceptance for T1 non-small cell lung cancer (NSCLC) in select patients with comorbidities precluding lobectomy. Our institution first reported utilization of the da Vinci system for robotic brachytherapy developed experimentally in swine and applied to high-risk patients 5 years ago. We now report seed dosimetrics and midterm follow-up.

Methods: Eleven high-risk patients with stage IA NSCLC who were not candidates for conventional lobectomy underwent limited resection of 12 primary tumors. To reduce locoregional recurrence, (125)I brachytherapy seeds were robotically sutured intracorporeally over resection margins to deliver 14,400 cGy 1 cm from the implant plane. Patients were followed with dosimetric computed tomography scans at 30 +/- 16 days. Survival and sites of recurrence were documented.

Results: Resected tumor size averaged 1.48 +/- 0.38 cm (range, 1.1 to 2.1 cm). Perioperative mortality was 0% and recurrence was 9% (1 of 11 [margin recurrence at 6 months with resultant mortality at 1 year]). Follow-up duration was 31.82 +/- 17.35 months. Dosimetrics confirmed 14,400 cGy delivery using 24.21 +/- 4.6 (125)I seeds (range, 17 to 30 seeds) over a planning target volume of 10.29 +/- 2.39 cc(3). Overall, 84.1% of the planning target volume was covered by 100% of the prescription dose (V100), and 88.2% was covered by 87% of the prescription dose (V87), comparable to open dosimetric data at our institution. Follow-up imaging confirmed seed stability in all patients.

Conclusions: Robotic (125)I brachytherapy seed placement is a feasible adjuvant procedure to reduce the incidence of recurrence after sublobar resection in medically compromised patients. Tailored robotic seed placement delivers an exact dosing regimen in a minimally invasive fashion with equivalent precision to open surgery.
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http://dx.doi.org/10.1016/j.athoracsur.2009.09.052DOI Listing
February 2010

Uncommon etiology of an anterior chest wall mass.

Ann Thorac Surg 2009 Nov;88(5):e58-9

Department of Surgery, Division of Thoracic Surgery, St. Luke's-Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, New York, New York 10019, USA.

A rare but important constellation of musculoskeletal and cutaneous symptoms, including synovitis, acne, pustulosis, hyperostosis, and osteitis, has recently been designated the SAPHO syndrome. The exact etiology is unknown, although various infectious agents have been proposed. The most common site of osteoarticular involvement is the sternoclavicular joint, and therefore, recognition of this syndrome and appropriate workup and management is crucial in the differential diagnosis of an anterior chest wall mass.
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http://dx.doi.org/10.1016/j.athoracsur.2009.07.090DOI Listing
November 2009

Respiratory arrest caused by endobronchial sclerosing hemangioma of the left main bronchus.

J Bronchology Interv Pulmonol 2009 Jul;16(3):188-90

Chief Division of Thoracic Surgery, St Luke's Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, New York, NY.

Sclerosing hemangioma is a rare pulmonary tumor that usually grows as a peripheral intraparenchymal lesion in the lungs. Although some case series have described this rare tumor, endobronchial growth of sclerosing hemangioma is extremely rare, with only 3 reported cases in the literature to date. We describe a patient who presented with respiratory arrest secondary to bilateral mechanical airway obstruction caused by this tumor. Such a presentation has never been described in the literature before and, as such, proved to be a challenging diagnosis.
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http://dx.doi.org/10.1097/LBR.0b013e3181ab3198DOI Listing
July 2009

Impact of compensatory hyperhidrosis on patient satisfaction after endoscopic thoracic sympathectomy.

Neurosurgery 2009 Mar;64(3):511-8; discussion 518

Department of Neurological Surgery, Roosevelt Hospital, New York, New York 10019, USA.

Objective: Endoscopic thoracic sympathectomy (ETS) remains the definitive treatment for primary focal hyperhidrosis. Compensatory hyperhidrosis (CH) is a significant drawback of ETS. We sought to identify the predictors for the development of severe CH after ETS, its anatomic locations, and its frequency of occurrence, and we analyzed the impact of CH on patient satisfaction with ETS.

Methods: Bilateral ETS for primary focal hyperhidrosis was performed in 220 patients, and a retrospective chart review was conducted. Follow-up evaluation was conducted using a telephone questionnaire, and 73% of all patients were contacted. Patients' responses regarding CH and their level of satisfaction after ETS were analyzed. Statistical analysis was performed using SPSS software (Version 14.0; SPSS, Inc., Chicago, IL). A P value of <0.05 was considered statistically significant.

Results: Some degree of CH developed in 94% of patients. The number of levels treated was not related to the occurrence of severe CH. Isolated T3 ganglionectomy led to a significantly lower incidence of severe CH, when compared with all other levels (P < 0.03). Ninety percent of patients were satisfied with the procedure. The development of severe CH, as opposed to mild or moderate CH, significantly correlated with a lower satisfaction rate (P = 0.003).

Conclusion: CH is common after ETS procedures, and the occurrence of severe, but not mild or moderate, CH is a major source of dissatisfaction after ETS. The overall occurrence of severe CH is reduced after T3 ganglionectomy as opposed to ganglionectomies performed at all other levels. The level of satisfaction with ETS is high.
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http://dx.doi.org/10.1227/01.NEU.0000339128.13935.0EDOI Listing
March 2009

Invited commentary.

Authors:
Cliff P Connery

Ann Thorac Surg 2009 Feb;87(2):431

Department of Thoracic Surgery, St. Lukes-Roosevelt Hospital Center, 1000 Tenth Ave, Suite 2B07, New York, NY 10019, USA.

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http://dx.doi.org/10.1016/j.athoracsur.2008.11.026DOI Listing
February 2009

Transdiaphragmatic amyloidoma.

Ann Thorac Surg 2008 Jul;86(1):310-2

Department of Thoracic Surgery, St. Luke's-Roosevelt Hospital Center, New York, NY 10019, USA.

The term "amyloidoma" has been used to describe localized pulmonary nodular amyloidosis when it is a solitary lesion. Amyloidoma is an uncommon and infrequently reported cause of benign pulmonary lesions. We report the case of a 45-year-old man with hemoptysis, eosinophilia, and a large mass involving both lobes of the left lung, the chest wall, and, via extension through the diaphragm, the liver. Clinical suspicion of echinococcal cyst led to treatment via en bloc excision rather than attempting tissue biopsy for diagnosis. Complete resection of the isolated pulmonary amyloidoma was achieved with no evidence of recurrence.
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http://dx.doi.org/10.1016/j.athoracsur.2007.10.016DOI Listing
July 2008

Thoracoscore predicts midterm mortality in patients undergoing thoracic surgery.

J Thorac Cardiovasc Surg 2007 Oct;134(4):883-7

Department of Cardiothoracic Surgery, University of Athens School of Medicine, Attikon Hospital Center, Athens, Greece.

Objective: Thoracoscore is the first multivariate model for the prediction of in-hospital mortality after general thoracic surgery. We aimed to evaluate the performance of Thoracoscore in predicting in-hospital and midterm all-cause mortality.

Methods: We retrospectively evaluated 1675 patients who underwent thoracic surgery (lung resections [n = 626], mediastinum [n = 535], pleura and pericardium [n = 268], esophagus [n = 88], chest wall [n = 90], trachea [n = 45], and other procedures [n = 23]) from October 2002 to March 2006 at a single institution. Midterm survival data (mean follow-up 25 +/- 16 months) were obtained from the National Death Index. Kaplan-Meier survival plots of the quartiles of Thoracoscore were constructed and compared with the log-rank test with adjustment for trend.

Results: Starting from the lower-risk to the higher-risk quartile, the in-hospital mortality rates were 0% (0/418), 1% (4/415), 2.5% (11/435), and 9.6% (54/407). Thoracoscore was a strong independent predictor for in-hospital mortality (odds ratio 1.20, 95% confidence intervals 1.15-.25; P < .001). The 2-year survivals of the Thoracoscore quartiles were 98.7% +/- 0.6%, 87.0% +/- 1.8%, 73.8% +/- 2.3%, and 54.8% +/- 2.7%, respectively (P < .0001). Thoracoscore was a strong independent predictor for midterm mortality (hazard ratio 1.12, 95% confidence intervals 1.11-1.14; P < .001).

Conclusion: Thoracoscore is a good and useful clinical tool for preoperative prediction of in-hospital and midterm mortality among patients undergoing general thoracic surgery.
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http://dx.doi.org/10.1016/j.jtcvs.2007.06.020DOI Listing
October 2007

Endoscopic resection of thoracic paravertebral and dumbbell tumors.

Neurosurgery 2006 Dec;59(6):1195-201; discussion 1201-2

Minimally Invasive Spine Surgery Center, Department of Neurosurgery, St. Luke's/Roosevelt, and Beth Israel Medical Centers, New York, New York 10019, USA.

Objective: Neurogenic paravertebral tumors are uncommon neoplasms arising from neurogenic elements within the thorax. These tumors may be dumbbell shaped, extending into the spinal canal or exclusively paraspinal. Generally encapsulated, they are located in the posterior mediastinum. In this report, we present our experience in the thoracoscopic resection of these tumors, including surgical technique and potential pitfalls.

Methods: A retrospective review of patients undergoing endoscopic surgery for paravertebral tumors was undertaken. Patient demographics, charts, operative reports, and pre- and postoperative images were reviewed.

Results: Between 1997 and 2004, 13 patients were treated thoracoscopically for paravertebral tumors in our departments. Our population consisted of four men and nine women. The median age was 44.9 years (range, 29-66 yr). Eight patients presented with pain, dyspnea, cough, and weakness. Five patients had tumors found incidentally. Sizes of the tumors varied from 3 to 9 cm. Final pathology included four neurofibromas, eight schwannomas, and one unclassified granular cell tumor. Gross total resection was achieved endoscopically in all cases. Three patients required a hemilaminectomy for resection of the intraspinal dumbbell component of the tumor during the same operation. The mean operative time was 229.5 minutes. The mean estimated blood loss was 371.1 ml. Postoperative morbidities included one each of tongue swelling, ulnar neuropathy, and intercostal hyperesthesia. The mean hospital stay was 2.8 days.

Conclusion: Paravertebral tumors in the posterior mediastinum are amenable to endoscopic removal, even in hard to reach locations. Tumors with intraspinal extension can be removed concurrently by performing a hemilaminectomy, followed by thoracoscopy, without the need for a thoracotomy.
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http://dx.doi.org/10.1227/01.NEU.0000245617.39850.C9DOI Listing
December 2006

Three-year experience with totally endoscopic robotic thymectomy.

Innovations (Phila) 2006 ;1(3):111-4

St. Luke's-Roosevelt Hospital Center, College of Physicians and Surgeons, Columbia University, New York, NY.

Background: : Robotic technology has facilitated the evaluation and treatment of anterior mediastinal pathology. We describe a 3-year experience using the da Vinci Robotic Surgical System to perform thymectomies for a range of diseases.

Methods: : From March 2002 to November 2004, 9 patients (3 myasthenia gravis, 3 mediastinal mass, 2 myasthenia gravis plus thymoma, 1 hyperparathyroidism) underwent totally endoscopic robotic thymectomy. Medical records and operative databases were reviewed. The cohort was divided into an early experience (group A) and a later experience (group B). Data were analyzed with the Fisher exact test and Mann-Whitney test.

Results: : Complete robotic resection of the thymus was accomplished in all 9 patients. The mean age for the entire cohort was 40 ± 12 years (range 28-66 years) and 78% of the patients were women. No significant differences in age, gender, or operative conversions were detected between the groups. Patients in group A were more likely to have a bilateral approach. Group B demonstrated statistically significant reductions in operating room and operation time and a trend toward decreased chest tube days and length of stay. No morbidity or mortality associated with the procedure was noted in either group.

Conclusions: : Robotic thymectomy is a safe and effective procedure. Its steep learning curve promises to allow more surgeons to adopt minimally invasive approaches to the mediastinum safely and efficiently.
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http://dx.doi.org/10.1097/01243895-200600130-00003DOI Listing
October 2012
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