Surgery News - March 2009 - (Page 8) THORACIC MARCH 2009 • SURGERY NEWS Hybrid Aortic Arch Procedures Appear Promising repairs using extrathoracic approaches, said Dr. Koullias at the annual meeting of the Society of Thoracic Surgeons. A total of 55 studies, comprising 28 retS A N F R A N C I S C O — Disease of the aortic arch can now be treated by com- rospective studies and 27 case reports, bining open surgical procedures with was identified. These included 582 paendovascular repair—a hybrid technique tients (412 men and 170 women). Based that offers a less invasive option for the on sample size criteria, a final total of 15 patient. But the novelty of such tech- studies with 463 patients (320 men and 143 women) was included in niques raises questions about the meta-analysis. The 40 reprocedural indications and maining studies included up outcomes. to 119 patients (92 men and 27 In an attempt to come up women) and comprised case with benchmarks for this reports and small retrospecevolving approach, Dr. tive studies (fewer than 11 paGeorge J. Koullias and Dr. tients per study). These were G.H. Wheatley performed a analyzed descriptively, acmeta-analysis of the pubcording to Dr. Koullias, who is lished literature to date rewith a cardiac surgery pracgarding hybrid repair of aorOutcomes of tic arch. They reviewed a total hybrid procedures tice in Peoria, Ill., and Dr. of 718 retrospective studies compare favorably Wheatley, of a cardiac group practice in Phoenix. and case reports of hybrid with those of Meta-analysis end points arch procedures that were standard operative were perioperative mortality, listed in PubMed through repair. 30-day mortality, permanent May 2008. DR. KOULLIAS and temporary stroke rate, Excluded from their analysis were reports involving only left com- permanent and temporary paraplegia mon carotid to left subclavian artery by- rate, and endoleak rate. On the meta-analysis of the 463 papass; landing of the covered portion of the stent-graft in zones 2-4; and arch tients undergoing hybrid arch procedures, B Y M A R K S. L E S N E Y Else vier Global Medical Ne ws The hybrid approach was used to repair an ascending arch and descending aneurysm (L), and a type A aortic dissection. the overall perioperative mortality was 6.4% and the 30-day mortality was 8.3%. The overall endoleak rate was 9.2%, the permanent and temporary stroke rate was 4.4%, and the permanent and temporary paraplegia rate was 3.9%, with an average follow-up of about 19 months. The 463 patients were divided into two groups: one consisting of 324 patients who had their procedure done on cardiopulmonary bypass (CPB), and a second group of 139 patients who had their procedure off CPB. Secondary meta-analysis between those two patient groups showed no statistically significant differences in any of the end points. These operative results for the hybrid procedures compare favorably with standard operative repair, according to the investigators. However, they indicated that there was a need for long-term follow-up and additional study. The investigators had nothing to disclose with regard to this study. Routine Mediastinoscopy Specialty Training Tied to For Early NSCLC Questioned Lung Cancer Outcomes B Y S H E R RY B O S C H E R T Else vier Global Medical Ne ws S A N F R A N C I S C O — Only 4% of 968 patients with early-stage non–small cell lung cancer had occult lymph node metastases, and invasive mediastinoscopy was unlikely to detect the metastases, a retrospective study found. The results challenge the utility of routine mediastinoscopy in patients with clinical stage T1 non–small cell lung cancer (NSCLC), Dr. Sebastian DeFranchi and his associates reported in a prize-winning poster at the annual meeting of the Society of Thoracic Surgeons. Postoperative pathology reports showed positive mediastinal lymph nodes (N2 disease) in 59 (6%) of the 968 consecutive patients who underwent lung resection for T1 lesions in 1998-2005. The patients’ records showed that noninvasive staging using CT or PET scans identified 23 patients with positive nodes, leaving 36 patients (4% of all patients) with occult disease in lymph nodes. Mediastinoscopy performed in 16 patients with negative results on noninvasive imaging found lymph node metastases in 3 patients (19% of those who underwent mediastinoscopy), said Dr. DeFranchi of the Mayo Clinic, Rochester, Minn. Among 66 lymph node stations with metastases identified on pathology, 24 (36%) were in locations not accessible by routine mediastinoscopy. The rates of occult N2 disease in various stages of NSCLC have been unknown, and the optimal strategy for mediastinal staging is unclear. “Routine mediastinoscopy in clinical T1N0 NSCLC results in a low yield of occult N2 disease in patients with negative noninvasive staging,” Dr. DeFranchi concluded. Of the 23 patients with positive nodes on noninvasive imaging, CT scans showed adenopathy in 17 patients, and PET scans identified positive lymph nodes in 9 patients. Overall, 17 patients had CT scans, and 29 patients had PET scans. Among 66 diseased lymph node stations found on pathology in 59 patients, the most frequent site of metastases was station 7, in 22 (37%) of the 59 patients. Stations 5 or 6 each were positive in 18 patients (31%), and station 4R was positive in 15 patients (25%). Right-sided tumors were seen in 29 lymph node stations in 25 patients, and left-sided tumors were found in 38 lymph node stations in 25 patients. Survival rates in patients with stage T1 NSCLC and positive lymph nodes undetected by noninvasive techniques were 87% at 1 year, 71% at 2 years, 56% at 3 years, 46% at 4 years, and 41% at 5 years. That’s better than mean survival rates for patients with stage IIIA NSCLC, Dr. DeFranchi noted. Patients in the study had a mean age of 69 years, and 83% had a history of smoking. The 59 patients with T1N0 disease had adenocarcinoma in 46 cases (78%), squamous cell carcinoma in 8 (14%), large cell carcinoma in 2 (3%), and mucinous adenocarcinoma in 1 (2%). The investigators had no potential conflicts of interest related to this study. B Y M A R K S. L E S N E Y Else vier Global Medical Ne ws S A N F R A N C I S C O — Patients with operable lung cancer appear to experience better long-term outcomes when treated by a specialist in general thoracic surgery, according to large database study. This study is the first description of an association between surgeon specialty and long-term survival in operable lung cancer, according to Dr. Farood Farjah, who presented his study as the J. Maxwell Chamberlain Memorial Paper for General Thoracic Surgery at the annual meeting of the Society of Thoracic Surgeons. “There have long been studies [that] show that specialists have better outcomes than generalists,” said Dr. Douglas Wood, an ACS Fellow and one of the paper’s coauthors, in an interview. “But this is the first study of outcomes that shows a significant impact on lung cancer survival.” A cohort study of 19,754 patients from 1992 to 2002, with a follow-up through 2005 was conducted using the National Cancer Institute’s Surveillance, Epidemiology, and End Results data, which were linked to the American Board of Thoracic Surgery Diplomates List. Board-certified thoracic surgeons were designated as cardiothoracic surgeons (CTS) if they performed cardiac procedures and as general thoracic surgeons (GTS) if they did not, according to the researchers and from the University of Washington, Seattle. Results showed that surgeons not board certified in thoracic surgery (NBTS) cared for 4,677 (24%) of the patients, and a total of 8,807 (45%) patients were cared for by CTS, and 6,261 (32%) were cared for by GTS. Of the 1,848 surgeons who cared for the cohort, 770 (42%) were NBTS, 687 (37%) were CTS, and 391 (21%) were GTS. Patient age, comorbidity index, and resection type did not significantly vary by surgeon specialty. After adjustment for patient, disease, and management characteristics, hospital teaching status, and surgeon and hospital volume, patients who were treated by GTS had an 11% lower hazard ratio of death, compared with those who underwent resection by NBTS, for an HR of 0.89 (with a 99% confidence interval of 0.82-0.97). However, the risk of death did not vary significantly between CTS and NBTS or between CTS and GTS. “Lung cancer patients treated by general thoracic surgeons had better long-term outcomes than [did] those treated by surgeons without board certification in thoracic surgery,” according to Dr. Farjah. These findings have important implications for regionalization of care and pay for performance in lung cancer care, he said. The investigators reported no conflicts with regard to this study. IMAGES COURTESY DR. GEORGE J. KOULLIAS/DR. G.H. WHEATLEY
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