Publications by authors named "Michael T Jaklitsch"

120 Publications

Preserving NLST mortality benefits and acceptable morbidity for lung cancer surgery in a community hospital.

J Surg Oncol 2021 Apr 12. Epub 2021 Apr 12.

Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA.

Background And Objectives: The aim of this study was to demonstrate whether academic thoracic surgeons could achieve morbidity and mortality rates in community hospitals equivalent to those seen in National Lung Screening Trial (NLST).

Methods: This was a retrospective review of community hospital lung cancer procedures for clinical Stage I-III non-small-cell lung cancers from 2007 through 2014. Variables include age, comorbidities, computed tomography (CT) characterization, and operative techniques.

Results: There were 177 patients who had lung cancers removed by a minimally invasive approach (79%), including lobectomy in 127 (72%), segmentectomy in 4 (2%), and wedge-resections in 46 (26%). The median patient age was 71 years (interquartile range [IQR], 63-76). The cohort was primarily female (58%), clinical Stage I (82%), with a median tumor size of 2.3 cm (IQR, 1.5-3.3). The median length of stay was 6 days (range: 1-35). Complications were experienced by 78 (44.1%) patients, most commonly atrial fibrillation in 20 (11.3%) followed by air-leak in 19 (10.7%). There were no in-hospital deaths. Tumor location and extent of resection were associated with complications, while larger tumor size, margin contour, and resection method were associated with air-leak (all p < 0.05). Higher clinical stage and larger tumor size were associated with occult Stage III disease (both p < 0.05).

Conclusions: The low morbidity and mortality rates from the NLST were achievable in a community setting for early-stage lung cancer. Characterization of cancers using CT imaging identified factors most commonly associated with postoperative complications and the presence of occult Stage III disease.
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http://dx.doi.org/10.1002/jso.26483DOI Listing
April 2021

Impact of radial margins after esophagectomy for esophageal cancer.

Eur J Surg Oncol 2021 Mar 2. Epub 2021 Mar 2.

Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA, USA. Electronic address:

Introduction: The prognostic significance of radial margin (RM) involvement in esophagectomy cancer specimens is unclear. Our study investigated survival and recurrence rates between different depths of RM involvement.

Materials And Methods: We retrospectively analyzed 1103 esophagectomies at our institution from 2005 to 2019. Patients were grouped by three-tier stratification: negative RM > 1 mm away, direct RM involvement at 0 mm, and close RM between 0 mm and 1 mm. Survival, loco-regional and distant recurrences were analyzed.

Results: 1103 esophageal cancer patients were analyzed. 389 patients had recurrence (35.3%). Median survival (13.2 months) and recurrence rates (71%) were worst with direct RM (p < 0.001) as compared to negative RM (median survival not achieved within 5-years from surgery and 30%). Without nodal involvement, RM involvement of <1 mm was associated with decreased overall survival, and overall, loco-regional and distant recurrence-free survival compared to negative RM (log rank p-value <0.05). In those with persistent nodal disease, only direct RM was associated with decreased overall and loco-regional recurrence-free survival as compared to negative margins (p < 0.05). Direct RM tended to do worse compared to close RM in terms of median survival and trended worse for recurrence. Direct RM (baseline negative RM), but not close RM, was an independent RF in a multivariable Cox model for worse overall survival (HR 2.74; p < 0.001), recurrence-free survival (HR 1.96; p = 0.019), and loco-regional recurrence-free survival (HR 3.19; p = 0.011).

Conclusion: RM involvement affects survival and recurrence. Tumor at 0 mm remained an independent RF for worse survival and overall and loco-regional recurrence.
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http://dx.doi.org/10.1016/j.ejso.2021.02.014DOI Listing
March 2021

Risk of chyle leak after robotic versus video-assisted thoracoscopic esophagectomy.

Surg Endosc 2021 Mar 3. Epub 2021 Mar 3.

Division of Thoracic Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA.

Background: We investigate the incidence and risk factors for post-operative outcomes including chyle leak following minimally invasive esophagectomy (MIE).

Methods: Patients undergoing MIE from May 2016 until August 2020 were prospectively followed. Outcomes of robotic and video-assisted thoracoscopic surgery (VATS) esophagectomy were analyzed.

Results: 347 esophagectomies were performed: 70 cases were done robotically by 2 surgeons and 277 by VATS by 14 surgeons. Patients had similar demographics, surgical technique, length of stay (LOS), and re-operation rates. Overall complication rates between robotic and VATS MIE were statistically similar (61% vs. 50%; p = 0.082). The majority of complications for either VATS (41.5%) or robotic-assisted minimally invasive esophagectomy (RAMIE) (51.4%) were grade II. Nineteen patients developed a chyle leak. Patients with a chyle leak were similar in age, gender, and hospital LOS (all p > 0.05), but were more likely to undergo a three-hole or robotic esophagectomy (both p < 0.05) as well as have higher rehabilitation requirements on discharge (26% vs. 10%; p = 0.05). Among the two surgeons who each performed > 20 robotic esophagectomies (n = 70), nine chyle leaks occurred. Rates varied by surgeon (7 vs. 2; p = 0.003). Lower leak rates occurred in the surgeon with more robotic esophagectomy experience (n = 47 vs. 23). Patients were similar in age, and gender (p > 0.05), but those with a chyle leak were more likely to undergo three-hole esophagectomies, prophylactic thoracic duction ligations, undergo the abdominal portion via laparotomy, and not have a prophylactic omental flap (all p < 0.05).

Conclusion: Robotic and VATS esophagectomy have similar rates of re-operation, length of stay, discharge needs and complications. Differences in outcomes between VATS and Robotic esophagectomy appears to be related to surgeon experience with the robot but may also be associated with techniques such as anastomotic height, omental flap utilization and performance of laparoscopy.
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http://dx.doi.org/10.1007/s00464-021-08410-4DOI Listing
March 2021

Chemotherapy and Surgical Resection for N1 Positive Non-small Cell Lung Cancer: Better Than Expected Outcomes.

Semin Thorac Cardiovasc Surg 2021 Feb 16. Epub 2021 Feb 16.

Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts.

N1-positive (T1-3, N1, M0) non-small cell lung cancer (NSCLC) represents a minority distribution (∼8%) of the approximately 234,000 diagnosed cases per year. As such, there is a paucity of modern high-quality data regarding outcomes following surgically-resected, stage N1-positive NSCLC. Randomized controlled trials from more than a decade ago have demonstrated a modest 5.4% survival benefit with adjuvant chemotherapy but have included heterogenous patient populations and stage distributions. Large database analyses have questioned the role of perioperative chemotherapy in resected patients with N1 disease, but without much granular detail regarding staging, quality of surgery, and chemotherapy. This single-institution study sought to evaluate the role of perioperative chemotherapy, specifically in N1-positive NSCLC patients. Data for all patients with surgically resected N1-positive NSCLC (T1-3, N1, M0) between 2006 and 2016 were collected for this study. Patients who underwent pneumonectomy were excluded from analysis. A retrospective chart review was conducted, and comprehensive clinicopathologic data were collected relative to staging, surgery, pathologic review, and perioperative oncology treatment. After exclusion criteria were applied, 148 patients with surgically resected, N1-positive disease (T1-3, N1, M0) remained for analysis. The majority of patients underwent lobectomy (75.0%), of which 55.4% underwent minimally invasive resection. There were no differences in postoperative complications, length of stay, number of lymph nodes sampled, or mortality associated with the surgery only and surgery with adjuvant therapy subgroups. 107 patients (72.3%) received adjuvant therapy, and this was associated with higher 5-year overall survival (62.8%) and disease-free survival (45.1%) than patients who underwent surgery only (33.9% overall survival at 5 years, P = 0.01; 22.4% disease-free survival at 5 years, P = 0.04). The presence of multistation N1 nodal metastases in patients was associated with lower 5-year overall survival (22.7%) and disease-free survival (5.6%) than patients with single-station N1 nodal metastasis (60.4% overall survival at 5 years, P = 0.003; 46.0% disease-free survival at 5 years, P < 0.001). On multivariable analysis, receiving any adjuvant chemotherapy was associated with improved overall survival and disease-free survival (Overall Survival HR 0.47, P < 0.01 | Disease-Free Survival HR 0.46, P <0.01). Multistation N1 disease was associated with significantly worse disease-free survival (HR 2.11, P = 0.04). Perioperative chemotherapy was associated with improved survival in N1-positive NSCLC, and the potential magnitude of benefit exceeded 25% in this study. Patients with single-station N1 lymph node metastasis were observed to have better disease-free survival.
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http://dx.doi.org/10.1053/j.semtcvs.2021.01.012DOI Listing
February 2021

Controlled apneic tracheostomy in patients with coronavirus disease 2019 (COVID-19).

JTCVS Tech 2021 Apr 7;6:172-177. Epub 2020 Dec 7.

Division of Thoracic Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Mass.

Objective: To develop a team-based institutional infrastructure for navigating management of a novel disease, to determine a safe and effective approach for performing tracheostomies in patients with COVID-19 respiratory failure, and to review outcomes of patients and health care personnel following implementation of this approach.

Methods: An interdisciplinary Task Force was constructed to develop innovative strategies for management of a novel disease. A single-institution, prospective, nonrandomized cohort study was then conducted on patients with coronavirus disease 2019 (COVID-19) respiratory failure who underwent tracheostomy using an induced bedside apneic technique at a tertiary care academic institution between April 27, 2020, and June 30, 2020.

Results: In total, 28 patients underwent tracheostomy with induced apnea. The median lowest procedural oxygen saturation was 95%. The median number of ventilated days following tracheostomy was 11. There were 3 mortalities (11%) due to sepsis and multiorgan failure; of 25 surviving patients, 100% were successfully discharged from the hospital and 76% are decannulated, with a median time of 26 days from tracheostomy to decannulation (range 12-57). There was no symptomatic disease transmission to health care personnel on the COVID-19 Tracheostomy Team.

Conclusions: Patients with respiratory failure from COVID-19 disease may benefit from tracheostomy. This can be completed effectively and safely without viral transmission to health care personnel. Performing tracheostomies earlier in the course of disease may expedite patient recovery and improve intensive care unit resource use. The creation of a collaborative Task Force is an effective strategic approach for management of novel disease.
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http://dx.doi.org/10.1016/j.xjtc.2020.11.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7720733PMC
April 2021

Pleurectomy Decortication in the Treatment of Malignant Pleural Mesothelioma: Encouraging Results and Novel Prognostic Implications Based on Experience in 355 Consecutive Patients.

Ann Surg 2020 Dec 3. Epub 2020 Dec 3.

BWH, Harvard Medical School, Boston, Massachusetts.

Objective: We report a series of 355 consecutive patients treated over 9 years in a single institution with intended PDC.

Background: Surgery for MPM has shifted from extra-pleural pneumonectomy to PDC with the goal of MCR.

Methods: Clinical and outcome data were reviewed. Kaplan-Meier estimators and log rank test were used to compare the overall survival, and logistic regression models were used.

Results: MCR was achieved in 304. There were 223 males, median age was 69 and histology was epithelioid in 184. The 30 and 90-day mortality were 3.0% and 4.6%.Most complications were low grade. Prolonged air leak in 141, deep venous thrombosis in 64, Atrial fibrillation in 42, chylothorax in 24, Empyema in 23, pneumonia in 21, Hemothorax in 12 and pulmonary embolus in 8.Median/5-year survival were 20.7 months/17.9% in the intent-to-treat cohort and 23.2 months/21.2% in the MCR group. The survivals were best for patients with T1stage and epithelioid histology (69.8 months/54.1%). In a multivariable analysis, factors that were found to be associated with longer patient overall survival included epithelioid histology, T stage, quantitative clinical stage/tumor volume staging, adjuvant chemotherapy, intraoperative heated chemo, female sex, and length of stay shorter than 14 days.

Conclusions: PDC is feasible with low mortality and is associated with manageable complication rates. 5-year survival of patients undergoing PDC with MCR in multi-modality setting is approaching 25% depending on quantitative and clinical stage, sex and histological subtype and is better than PDC without- MCR.
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http://dx.doi.org/10.1097/SLA.0000000000004306DOI Listing
December 2020

Outcomes of superior segmentectomy versus lower lobectomy for superior segment Stage I non-small-cell lung cancer are equivalent: An analysis of 196 patients at a single, high volume institution.

J Surg Oncol 2021 Feb 1;123(2):570-578. Epub 2020 Dec 1.

Department of Surgery, Division of Thoracic Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts, USA.

Objectives: To determine if superior segmentectomy has equivalent overall (OS), disease-free (DFS), and locoregional-recurrence-free survival (LRFS) to lower lobectomy for early-stage non-small-cell lung cancer (NSCLC) in the superior segment.

Methods: We retrospectively reviewed all Stage 1 lower lobectomies for superior segment lesions and superior segmentectomies at our hospital from 2000 to 2018. Comparison statistics and Cox hazard modeling were performed to determine differences between groups and attempt to identify risk factors for OS, DFS, and LRFS.

Results: Superior segmentectomy patients, compared with lower lobectomy patients, had more current smokers, worse forced expiratory volume in 1 s percentage, radiologic emphysema scores, clinically and pathologically smaller tumors, and more occurrences of 0 lymph nodes examined. Outcomes for superior segmentectomy compared with lower lobectomy were equivalent for 5-year OS (67.0% vs. 75.1%, p = 0.70), DFS (56.9% vs. 60.4%, p = 0.59), and LRFS (87.9% vs. 91.3%, p = 0.46). Multivariable Cox modeling lacked utility due to no outcome differences.

Conclusions: In well-selected patients, superior segmentectomies can have equivalent OS, DFS, and LRFS compared with lower lobectomies of superior segment tumors for early stage lung cancer. Further data are needed to provide better risk estimates.
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http://dx.doi.org/10.1002/jso.26304DOI Listing
February 2021

Adjuvant therapy following induction therapy and surgery improves survival in N2-positive non-small cell lung cancer.

J Surg Oncol 2021 Feb 1;123(2):579-586. Epub 2020 Dec 1.

Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA.

Background: The purpose of this study was to evaluate treatment strategies and factors influencing overall survival (OS) and disease-free survival (DFS) in resectable, non-small cell lung cancer (NSCLC) with mediastinal (N2) lymph node metastasis.

Methods: All patients undergoing surgery for NSCLC with N2 disease between 2006 and 2016 were included. Treatment approaches included surgery only, neoadjuvant therapy followed by surgery, surgery followed by adjuvant therapy, and neoadjuvant therapy followed by surgery and adjuvant therapy (triple therapy). Patient clinical and pathologic data were retrospectively collected.

Results: A total of 281 patients were included in the study. In total, 209 patients had neoadjuvant therapy, 47.4% of which went on to received additional adjuvant therapy. The pathologic complete response rate was 12.9%. The treatment strategy which included triple therapy was isolated as a significant contributor to improved OS and DFS. Nodal downstaging (N0) after induction therapy conferred an OS benefit (38.3% vs. 15.6%, p = .03). Patients with single-station N2 disease experienced higher DFS. Video-assisted thoracic surgery (VATS) lobectomy completion rates were higher at the end of the study period compared to the beginning (p < .001).

Conclusions: Patients who undergo neoadjuvant therapy for N2-positive NSCLC may benefit from additional adjuvant therapy. Single-station N2 disease confers higher DFS. VATS completion rates for lobectomy increase as experience increases.
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http://dx.doi.org/10.1002/jso.26305DOI Listing
February 2021

Analysis of Lymph Node Sampling Minimums in Early Stage Non-Small-Cell Lung Cancer.

Semin Thorac Cardiovasc Surg 2020 Nov 9. Epub 2020 Nov 9.

Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts.

Analyze "number of nodes" as an integer-valued variable to identify possible minimum lymph node (LN) number to sample during lung cancer resection. The National Cancer Database (NCDB) queried 2004-14 for surgically treated clinical stage I/II non-small-cell lung cancer (NSCLC). Overall survival (OS) by number of LN sampled was examined for the complete dataset, by adenocarcinoma, and by degree of resection using number of sampled LN both as integer-valued (0-30 nodes) variable and collapsed into classes. A total of 102,225 patients were analyzed. Median sampled LNs were 7. Median overall survival was 59 months if no LNs were sampled (95% confidence interval [CI]: 57.0-62.4), 74.7 months for 1 sampled LN (95% CI: 69.6-78.1), 80.2 (95% CI: 74.2-85.6) for 2 sampled LN, up to 81.5 mos. for 29 sampled LN. A Cox regression model using "0 LN" as baseline level, showed association with increased overall survival starting at 1 LN (hazard ratio [HR] 0.81, 95% CI 0.76-0.87; P <0.001). A "moving baseline" Cox regression model, showed no additional benefit when sampling additional nodes. We noticed a decreasing, linear association between OS and a number of 0-5 sampled LNs, most pronounced between 0 and 1 LN sampled, using a martingale residual plot from a null Cox model; no association was observed for more sampled LNs. For patients undergoing lobectomy, difference in OS was noted between 0 and 1LN sampled but not between 2 and 30 LN. These differences were not statistically significant until the number of 4 removed LN (respectively 3 for wedge-resections). For segmentectomies, median survival was not statistically associated with number of LN sampled. Based on NCDB data, LN sampling for lung cancer resections is recommended. Lobectomy survival is positively associated with 4 LN sampled, but ideal sampling may lie at 5LN in most cases. NCDB data does not seem to justify the quality metric of minimum 10 LNs.
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http://dx.doi.org/10.1053/j.semtcvs.2020.11.007DOI Listing
November 2020

Impact of Neoadjuvant Chemoradiation On Adverse Events Following Bronchial Sleeve Resection.

Ann Thorac Surg 2020 Nov 7. Epub 2020 Nov 7.

Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, USA.

Background: We analyzed the association between neoadjuvant chemoradiation in patients undergoing bronchial sleeve resection with incidence of postoperative pulmonary and airway complications.

Methods: After IRB approval, we performed a retrospective review of a prospectively maintained database of 136 patients who underwent sleeve resection in our institution between January 1998 and December 2016. Administration of neoadjuvant chemoradiation treatment was the studied exposure. Outcomes of interest were rates of postoperative pulmonary and airway complications. Nonparametric testing of demographic, surgical, pathologic characteristics and morbidity was performed. Logistic regression models evaluated postoperative pulmonary complications and airway complications. Analysis was performed using Stata/IC 15.

Results: We analyzed 136 patients (18 underwent neoadjuvant chemoradiation). 77 of the 136 patients (57%) had Non-Small-Cell Lung Cancer. Postoperative pulmonary complications were observed in 44/136 patients (32%). Incidence of pulmonary complications were higher in the neoadjuvant chemoradiation group compared to those without neoadjuvant radiation [15/18 patients (83%) vs. 29/118 patients (25%), p=0.000]. Likewise, rates of pneumonia, atelectasis, respiratory insufficiency, bronchial stenosis, prolonged air leak, broncho-pleural fistula and completion pneumonectomy [2/18 (11%)] were higher in the neoadjuvant chemoradiation group, reaching statistical significance in all cases except bronchial stenosis and prolonged air leak. Only neoadjuvant chemoradiation therapy remained significant for postoperative pulmonary and airway complications on logistic regression (both p <0.05) CONCLUSIONS: Patients who undergo neoadjuvant chemoradiation prior to sleeve resection are at an increased risk of pulmonary and airway complications.
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http://dx.doi.org/10.1016/j.athoracsur.2020.10.020DOI Listing
November 2020

Discussion.

J Thorac Cardiovasc Surg 2021 Mar 3;161(3):799-802. Epub 2020 Oct 3.

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http://dx.doi.org/10.1016/j.jtcvs.2020.08.110DOI Listing
March 2021

Opportunities for quality improvement in the morbidity pattern of older adults undergoing pulmonary lobectomy for cancer.

J Geriatr Oncol 2021 Apr 23;12(3):416-421. Epub 2020 Sep 23.

Division of Thoracic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.

Background: There is limited information on the frequency of complications among older adults after oncological thoracic surgery in the modern era. We hypothesized that morbidity and mortality in older adults with lung cancer undergoing lobectomy is low and different than that of younger patients undergoing thoracic surgery.

Methods: All patients undergoing lobectomy at a large volume academic center between May 2016 and May 2019 were included. Patients were prospectively monitored to grade postoperative morbidity by organ system, based on the Clavien-Dindo classification. Patients were divided into two groups: Group 1 included patients 65-91 years of age, and Group 2 included those <65 years.

Results: Of 680 lobectomies in 673 patients, 414(61%) were older than 65 years of age (group 1). Median age at surgery was 68 years (20-91). Median hospital stay was 4 days (1-38) and longer in older adults. Older adults experienced higher rates of grade II and IV complications, mostly driven by an increased incidence of delirium, atrial fibrillation, prolonged air leak, respiratory failure and urinary retention. In this modern cohort, there was only 1 stroke (0.1%), and delirium was reduced to 7%. Patients undergoing minimally invasive (MI) surgery had a lower rate of Grade IV life-threatening complications. Older adults were more likely to be discharged to a rehabilitation facility, however this difference also disappeared with MI surgical procedures.

Conclusions: Current morbidity of older adults undergoing lobectomy for cancer is low and is different than that of younger patients. Thoracotomy may be associated with postoperative complications in these patients. Our findings suggest the need to consider MI approaches and broad-based, geriatric-focused perioperative management of older adults undergoing lobectomy.
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http://dx.doi.org/10.1016/j.jgo.2020.09.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8011279PMC
April 2021

Risk of Urinary Recatheterization for Thoracic Surgical Patients with Epidural Anesthesia.

J Surg Res (Houst) 2020 22;3(3):163-171. Epub 2020 Jun 22.

Division of Thoracic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Background: Current quality guidelines recommend the removal of urinary catheters on or before postoperative day two, to prevent catheter-associated urinary tract infections (CAUTI). The goal of this study was to evaluate the impact urinary catheter removal on the need for urinary recatheterization (UR) of patients with epidural anesthesia undergoing thoracic surgery.

Materials And Methods: All patients undergoing thoracic surgery between November 4, 2017 and January 9, 2018 who had a urinary catheter placed at the time of intervention were prospectively evaluated. Patient characteristics including: history of benign prostatic hyperplasia (BPH), catheter related variables and rates of UR were collected through chart review and daily visits to the wards. BPH was defined as history of transurethral resection of the prostate or treatment with selective α-adrenergic receptor antagonists.

Results: Over a two-month period 267 patients were included, 124 (46%) were male. Epidural catheters were placed in 88 (33%) patients. Median duration of urinary catheters for the cohort was 1 day (0 days - 18 days), and it was significantly higher in patients with epidural anesthesia (Table 1). Overall 20 (7%) patients required UR. On initial analysis, there was no statistical difference in the rate of UR among patients with and without epidural catheters [9/88 (10%) vs 11/179 (6%), p=0.23). The rate of UR was higher in males than in females (14/124 (11%) vs 6/143 (4%), p=0.03). Fifteen (12%) patients had a diagnosis of BPH. The rate of UR was three-times higher in this group than in those without BPH [4/15 (27%) vs 10/109 (9%) p=0.05]. Four (1%) patients developed a CAUTI during follow-up, and the rate of CAUTI was not different between those with and without epidural catheters.

Conclusion: Urinary catheters in patients with thoracic epidural anesthesia can be safely removed, as evidenced by low reinsertion and infection rates. Removal of urinary catheters in patients with a history of BPH should be carefully evaluated, as over 1/4 will require urinary recatheterization in this subgroup. Further study of this group is needed to avoid unnecessary patient discomfort associated with recatheterization.
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http://dx.doi.org/10.26502/jsr.10020068DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7409986PMC
June 2020

Prehabilitation of the Thoracic Surgery Patient.

Thorac Surg Clin 2020 Aug 22;30(3):249-258. Epub 2020 May 22.

Division of Thoracic Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.

Outcomes after thoracic surgery are better predicted by preoperative evaluation of patients' physiologic reserve (also known as personal biologic age rather than chronologic age), using validated assessment tools in multidisciplinary collaboration with geriatricians. Targetable risk factors should be identified, and methods should be utilized to minimize these risks. Prehabilitation has been validated as a tool to increase functional and nutritional status of patients undergoing surgery in other specialties and improve outcomes. Although research is still limited in thoracic surgery, early results are promising.
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http://dx.doi.org/10.1016/j.thorsurg.2020.04.004DOI Listing
August 2020

Prehabilitation vs Postoperative Rehabilitation for Frail Patients.

JAMA Surg 2020 09;155(9):898-899

Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jamasurg.2020.1813DOI Listing
September 2020

The future of lung cancer screening with low-dose computed tomography.

J Thorac Cardiovasc Surg 2020 Jul 19;160(1):289-294. Epub 2020 Feb 19.

Division of Thoracic Radiology, Department of Radiology, Brigham and Women's Hospital, Boston, Mass.

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http://dx.doi.org/10.1016/j.jtcvs.2019.11.141DOI Listing
July 2020

Image-guided video-assisted thoracoscopic resection (iVATS): Translation to clinical practice-real-world experience.

J Surg Oncol 2020 Jun 12;121(8):1225-1232. Epub 2020 Mar 12.

Department of Surgery, Brigham & Women's Hospital, Boston, Massachusetts.

Objective: We developed a novel approach for localization and resection of lung nodules, using image-guided video-assisted thoracoscopic surgery (iVATS). We report our experience of translating iVATS into clinical care.

Methods: Methodology and workflow for iVATS developed as part of the Phase I/II trial were used to train surgeons, radiologists, anesthesiologists, and radiology technologists. Radiation dose, time from induction to incision, placement of T-bar to incision and incision to closure, hospital stay, and complication rates were recorded.

Results: Fifty patients underwent iVATS for resection of 54 nodules in a clinical hybrid operating room (OR) by six surgeons. Fifty-two (97%) nodules were successfully resected. Forty-two (84%) patients underwent wedge resection, four (7%) lobectomies, and two (4%) segmentectomy all with lymph node dissection. Median time from induction to incision was 89 minutes (range: 13-256 minutes); T-bar placement was 14 minutes (10-29 minutes); and incision to closure, 107 minutes (41-302 minutes). Average and total procedure radiation dose were: median = 6 mSieverts (range: 2.9-35 mSieverts). No deaths were reported and median length of stay was 3 days (range: 1-12 days).

Conclusions: Translation of iVATS into clinical practice has been initiated using a safe step-wise process, combining intraoperative C-arm computed tomography scanning and thoracoscopic surgery in a hybrid OR.
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http://dx.doi.org/10.1002/jso.25897DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7383497PMC
June 2020

Letter to the editor and response for risk factors for delirium after esophagectomy.

J Surg Oncol 2020 06 9;121(7):1164. Epub 2020 Mar 9.

Division of Thoracic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

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http://dx.doi.org/10.1002/jso.25884DOI Listing
June 2020

New evidence supporting lung cancer screening with low dose CT & surgical implications.

Eur J Surg Oncol 2020 06 19;46(6):982-990. Epub 2020 Feb 19.

Brigham and Women's Hospital Division of Thoracic Surgery, 75 Francis St, Boston, MA, 02115, USA.

Introduction: Lung cancer is the leading cause of cancer-death worldwide. The U.S. Preventative Services Task Force (USPTSF) approved screening for current or former smokers aged 55-80 based on the results of the National Lung Screening trial (NLST). Following the NLST, new evidence has emerged from clinical trials and updates to previous trials prior to the anticipated update to the USPSTF guideline. We review the new evidence on lung cancer screening with low dose computed tomography (LDCT) and the surgical implications.

Methods: A review of new literature was performed pertaining to lung cancer screening since implementation of UPSTF guidelines. Articles for inclusion were identified by both authors', then search of the Pubmed and Cochrane database was performed from January 1st, 2013 through February 4th, 2020 using the MeSH search terms: "lung cancer"; "screening"; "low dose CT". The results of these studies are summarized.

Results: We identified multiple prospective randomized control trials and meta-analysis since the NLST supporting lung cancer-specific mortality with screening. We identified new nodule classification systems and the development of risk-models which may reduce false positive rates and identify high risk patients not currently eligible for screening. Finally, we discussed the surgical implications of screening.

Conclusion: New data supports NLST findings and show ongoing benefit to LDCT for lung cancer screening. Standardized LDCT screening classification has been shown to reduce harm and lower false positive rates. Further study is needed regarding use of risk-modeling. Screening will require an increase in the thoracic workforce to accommodate the amount of surgically operable cancers.
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http://dx.doi.org/10.1016/j.ejso.2020.02.015DOI Listing
June 2020

Routine surveillance for diagnosis of venous thromboembolism after pleurectomy for malignant pleural mesothelioma.

J Thorac Cardiovasc Surg 2020 Oct 30;160(4):1064-1073. Epub 2020 Jan 30.

Division of Thoracic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.

Objective: The purpose of this study was to determine the incidence of venous thromboembolism and utility of a routine surveillance program in patients undergoing surgery for mesothelioma.

Methods: Patients undergoing pleurectomy from May 2016 to August 2018 were included. A standardized surveillance program to look for venous thromboembolism in this group included noninvasive studies every 7 days postoperatively or earlier if symptomatic. All patients received external pneumatic compression sleeves in addition to prophylactic heparin. If deep vein thrombosis or pulmonary embolus was discovered, heparin drip was initiated until conversion to therapeutic anticoagulation.

Results: A total of 100 patients underwent pleurectomy for mesothelioma. Seven patients were found to have preoperative deep vein thrombosis, and as such only 93 patients were included for analysis. The median age of patients at surgery was 71 years (30-85 years). During the study, 30 patients (32%) developed evidence of thrombosis; 20 patients (22%) developed only deep vein thrombosis without embolism, 3 patients (3%) developed only pulmonary embolism, and 7 patients (7%) developed both deep vein thrombosis and pulmonary embolus. Of the 27 patients who developed deep vein thrombosis, 9 (33%) were asymptomatic at the time of diagnosis, and none of these developed a pulmonary embolus or other bleeding complications. There were 2 (2%) events of major postoperative bleeding related to therapeutic anticoagulation.

Conclusions: The incidence of venous thromboembolism is high (32%) among patients undergoing surveillance after pleurectomy for mesothelioma. Up to 33% of patients with deep vein thrombosis are asymptomatic at the time of diagnosis, and the incidence of complications related to anticoagulation is low. Routine surveillance may be useful to diagnose and treat deep vein thrombosis before it progresses to symptomatic or fatal pulmonary embolus.
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http://dx.doi.org/10.1016/j.jtcvs.2019.12.115DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7390678PMC
October 2020

Minimizing residual occult nodal metastasis in NSCLC: recent advances, current status and controversies.

Expert Rev Anticancer Ther 2020 02 5;20(2):117-130. Epub 2020 Feb 5.

Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA, USA.

: Nodal involvement in lung cancer is a significant determinant of prognosis and treatment management. New evidence exists regarding the management of occult lymph node metastasis and residual disease in the fields of imaging, mediastinal staging, and operative management.: This review summarizes the latest body of knowledge on the identification and management of occult lymph node metastasis in NSCLC. We focus on tumor-specific characteristics; imaging modalities; invasive mediastinal staging; and operative management including, technique, degree of resection, and lymph node examination.: Newly identified risk-factors associated with nodal metastasis including tumor histology, location, radiologic features, and metabolic activity are not included in professional societal guidelines due to the heterogeneity of their reporting and uncertainty on how to adopt them into practice. Imaging as a sole diagnostic method is limited. We recommend confirmation with invasive mediastinal staging. EBUS-FNA is the best initial method, but adoption has not been uniform. The diagnostic algorithm is less certain for re-staging of mediastinal nodes after neoadjuvant therapy. Mediastinal node sampling during lobectomy remains the gold-standard, but evidence supports the use of minimally invasive techniques. More study is warranted regarding sublobar resection. No consensus exists regarding lymph node examination, but new evidence supports reexamination of current quality metrics.
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http://dx.doi.org/10.1080/14737140.2020.1723418DOI Listing
February 2020

Risk factors for delirium after esophagectomy.

J Surg Oncol 2020 Mar 9;121(4):645-653. Epub 2020 Jan 9.

Division of Thoracic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

Introduction: Postoperative delirium is a common complication after major surgical procedures and affects outcomes and long-term survival. We identified factors associated with postoperative delirium in patients undergoing esophagectomy.

Methods: Retrospective cohort analysis of 378 patients undergoing esophagectomy. We examined the association between postoperative delirium (DSM-V) criteria with respect to baseline variables and postoperative complications.

Results: Postoperative delirium was diagnosed in 64 (16.93%) patients and associated with increasing age (P < .05), chronic obstructive pulmonary disease (P = .07), pneumonia (P = .01), transfusion intraoperatively or within 72 hours of surgery (P < .001), and sepsis (P = .001). Unplanned intubation and increased length of stay (median, 14 days) were significant in patients with delirium (P = .001 and P < .001, respectively). In a secondary analysis, surgical technique and operative approach were associated with delirium. Modified McKeown (three-hole) esophagectomy was twice more likely to develop delirium compared with Ivor Lewis (odds ratio [OR], 2.09; 95% confidence interval [CI], 1.03-4.23). The strongest association was found between delirium and open techniques (thoracotomy and laparotomy) as compared with minimally invasive techniques (thoracoscopy and laparoscopy) (OR, 2.66; 95% CI, 1.22-5.76). Survival was similar between both groups.

Conclusions: Postoperative delirium is common and associated with complications following esophagectomy. Identification of predisposing factors such as age and pre-existing pulmonary diseases and proper selection of surgical treatment may reduce delirium and improve surgical outcomes.
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http://dx.doi.org/10.1002/jso.25835DOI Listing
March 2020

GOSAFE - Geriatric Oncology Surgical Assessment and Functional rEcovery after Surgery: early analysis on 977 patients.

J Geriatr Oncol 2020 03 3;11(2):244-255. Epub 2019 Sep 3.

U.O. Chirurgia Generale, Ospedale "per gli Infermi", Faenza, AUSL Romagna, Italy.

Objective: Older patients with cancer value functional outcomes as much as survival, but surgical studies lack functional recovery (FR) data. The value of a standardized frailty assessment has been confirmed, yet it's infrequently utilized due to time restrictions into everyday practice. The multicenter GOSAFE study was designed to (1) evaluate the trajectory of patients' quality of life (QoL) after cancer surgery (2) assess baseline frailty indicators in unselected patients (3) clarify the most relevant tools in predicting FR and clinical outcomes. This is a report of the study design and baseline patient evaluations.

Materials & Methods: GOSAFE prospectively collected a baseline multidimensional evaluation before major elective surgery in patients (≥70 years) from 26 international units. Short-/mid-/long-term surgical outcomes were recorded with QoL and FR data.

Results: 1003 patients were enrolled in a 26-month span. Complete baseline data were available for 977(97.4%). Median age was 78 years (range 70-94); 52.8% males. 968(99%) lived at home, 51.6% without caregiver. 54.4% had ≥ 3 medications, 5.9% none. Patients were dependent (ADL < 5) in 7.9% of the cases. Frailty was either detected by G8 ≤ 14(68.4%), fTRST ≥ 2(37.4%), TUG > 20 s (5.2%) or ASAIII-IV (48.8%). Major comorbidities (CACI > 6) were detected in 36%; 20.9% of patients had cognitive impairment according to Mini-Cog.

Conclusion: The GOSAFE showed that frailty is frequent in older patients undergoing cancer surgery. QoL and FR, for the first time, are going to be primary outcomes of a real-life observational study. The crucial role of frailty assessment is going to be addressed in the ability to predict postoperative outcomes and to correlate with QoL and FR.
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http://dx.doi.org/10.1016/j.jgo.2019.06.017DOI Listing
March 2020

Cumulative nonsmoking risk factors increase the probability of developing lung cancer.

J Thorac Cardiovasc Surg 2019 10 18;158(4):1248-1254.e1. Epub 2019 May 18.

Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.

Background: It is estimated that 20% of lung cancer cases in the United States are among never smokers, yet current screening recommendations only include a small subset of high-risk patients. In this study, 2 models were used to predict the risk of developing lung cancer in subgroups of never smoking patients with additional risk variables.

Methods: The Liverpool Lung Project (LLP) and the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCO) were 2 models used to calculate risk of developing lung cancer. Risk was calculated as a function of age for developing lung cancer within the next 5 to 10 years.

Results: PLCO estimated a peak risk of 16.20% at age 75 for 30-pack-year smokers with a first-degree relative with lung cancer. LLP estimated a peak risk of 7.3% over the next 5 years at age 79 for men with 30-pack-year and a first-degree relative with early-onset lung cancer (<60 years). Female never smokers with cumulative variables other than smoking had a peak risk of 3.40% for age 74 to 75 years. In contrast, women with only 30-pack-year smoking history and no other variable had a peak risk of 2.20% at age 74 to 75 years.

Conclusions: Models such as LLP and PLCO might be used to identify risk for patients who would otherwise not receive lung cancer screening. These individual risk assessments can be used by patients and providers to assess if one is at substantial risk for developing lung cancer.
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http://dx.doi.org/10.1016/j.jtcvs.2019.04.098DOI Listing
October 2019

A Phase I Trial of Surgical Resection and Intraoperative Hyperthermic Cisplatin and Gemcitabine for Pleural Mesothelioma.

J Thorac Oncol 2018 09 9;13(9):1400-1409. Epub 2018 May 9.

Department of Surgery, Division of General Thoracic Surgery, Baylor College of Medicine, Houston, Texas. Electronic address:

Introduction: The primary objective of this single-institution phase I clinical trial was to establish the maximum tolerated dose of gemcitabine added to cisplatin and delivered as heated intraoperative chemotherapy after resection of malignant pleural mesothelioma.

Methods: The extrapleural pneumonectomy (EPP) and pleurectomy/decortication (P/D) treatment arms were based on investigators' assessment of patient fitness and potential for macroscopic complete resection. Previously established intracavitary dosing of cisplatin (range 175-225 mg/m) with systemic cytoprotection was used in combination with escalating doses of gemcitabine, following a 3-plus-3 design from 100 mg/m in 100-mg increments.

Results: From 2007 to 2011, 141 patients were enrolled and 104 completed treatment. The median age of those completing treatment was 65 years (range 43-85 years), and 22 (21%) were female. In the EPP arm (n = 59), 31 patients (53%) had the epithelioid histologic type and the median radiographic tumor volume was 236 cm (range 16-4285 cm). In the P/D arm (n = 41), 29 patients (71%) had the epithelioid histologic type and the median tumor volume was 79 cm (range 6-1107 cm). The operative mortality rate was 2%, and 35 and 22 serious adverse events were encountered among 27 patients (46%) and 16 patients (39%) in the EPP and P/D arms, respectively. Dose-limiting toxicity (grade 3 leukopenia) was observed in two patients who were receiving 1100 mg/m of gemcitabine, thus establishing the maximum tolerated dose at 1000 mg/m, in combination with 175 mg/m of cisplatin. The median overall and recurrence-free survival times in treated patients were 20.3 and 10.7 months, respectively.

Conclusions: Combination cisplatin and gemcitabine heated intraoperative chemotherapy can be administered safely and feasibly in the context of complete surgical resection of malignant pleural mesothelioma by EPP or P/D.
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http://dx.doi.org/10.1016/j.jtho.2018.04.032DOI Listing
September 2018

Graft-Versus-Tumor Effect in Adenocarcinoma of the Lung.

Ann Thorac Surg 2018 04;105(4):e145-e147

Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts.

Donor T cells after allogeneic hematopoietic cell transplantation can give rise to the graft-versus-tumor (GVT) effect in hematologic malignancies. GVT effect has been reported previously to cause regression of some solid tumors. However, none have reported a documented case of GVT effect leading to complete resolution of adenocarcinoma of the lung. Here, we present the case of complete regression of a pathologically proven adenocarcinoma of the lung in a patient undergoing myeloablative-matched unrelated donor peripheral blood stem cell transplantation for the treatment of acute myelogenous leukemia.
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http://dx.doi.org/10.1016/j.athoracsur.2017.11.002DOI Listing
April 2018

Role of Thoracic Surgeons in Lung Cancer Screening: Opportune Time for Involvement.

J Thorac Oncol 2018 03;13(3):298-300

Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine, Philadelphia, Pennsylvania. Electronic address:

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http://dx.doi.org/10.1016/j.jtho.2017.11.136DOI Listing
March 2018

Paraneoplastic Neuromyelitis Optica Spectrum Disorder as Presentation of Esophageal Adenocarcinoma.

Ann Thorac Surg 2018 03;105(3):e133-e135

Division of Thoracic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

Neuromyelitis optica spectrum disorders are a group of relapsing, inflammatory, demyelinating neurologic syndromes involving the central nervous system associated with antibodies against aquaporin-4. Although most commonly an idiopathic autoimmune condition, neuromyelitis optica may occur as a paraneoplastic syndrome in rare instances. We report a case of transverse myelitis caused by paraneoplastic neuromyelitis optica as the presenting clinical syndrome in a patient with esophageal adenocarcinoma.
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http://dx.doi.org/10.1016/j.athoracsur.2017.10.015DOI Listing
March 2018

Computed Tomography Scanning for Early Detection of Lung Cancer.

Annu Rev Med 2018 01;69:235-245

Departments of Radiology and Thoracic Surgery, Brigham and Women's Hospital, Boston, MA 02115; email: ,

Parallel and often unrelated developments in health care and technology have all been necessary to bring about early detection of lung cancer and the opportunity to decrease mortality from lung cancer through early detection of the disease by computed tomography. Lung cancer screening programs provide education for patients and clinicians, support smoking cessation as primary prevention for lung cancer, and facilitate health care for tobacco-associated diseases, including cardiovascular and chronic lung diseases. Guidelines for lung cancer screening will need to continue to evolve as additional risk factors and screening tests are developed. Data collection from lung cancer screening programs is vital to the further development of fiscally responsible guidelines to increase detection of lung cancer, which may include small groups with elevated risk for reasons other than tobacco exposure.
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http://dx.doi.org/10.1146/annurev-med-020917-053556DOI Listing
January 2018