William Burfeind - Academia.edu (original) (raw)

Papers by William Burfeind

Operative Techniques in Thoracic and Cardiovascular Surgery, 2004

European Journal of Cardio-Thoracic Surgery, 1998

Objective: Mechanical cardiac stabilization is beneficial for precise coronary anastomoses on the... more Objective: Mechanical cardiac stabilization is beneficial for precise coronary anastomoses on the beating heart. However, the effect of mechanical cardiac stabilization on hemodynamics, left ventricular performance, and the degree of injury to underlying tissue are uncertain. Methods: Twelve swine (20-30 kg) underwent median sternotomy and a mechanical stabilizing device (United States Surgical, Norwalk, CT) was positioned astride a segment of left anterior descending coronary artery (LAD). Coronary blood flow was measured by Doppler. Sonomicrometry crystals were placed distal to the stabilizer in a region of myocardium subtended by the LAD, and a left ventricular micromanometer was inserted. Regional myocardial function was determined using the preload recruitable stroke work (PRSW) relationship. Data were acquired at three time points: 20 min before (PRE) and after placing the stabilizer (EXPT); and 20 min after removing the stabilizer (POST). Tissue subjacent to the stabilizer was then biopsied. Means ± standard deviation are reported. Results: The mechanical stabilizer caused a decrease in cardiac output from 4.2 ± 1.5 to 3.6 ± 1.3 l/min (P Ͻ 0.05), which returned to baseline values after its removal. Regional myocardial function (percent systolic shortening and M w and x-intercept of the PRSW relationship) was unchanged. Blood pressure, heart rate, and LAD blood flow remained constant. Histologic findings included a layer of myocyte necrosis less than 1 mm in depth immediately beneath the stabilizer. Conclusions: These data demonstrate that mechanical stabilization of the LAD may temporarily decrease cardiac output. This is not attributed to impaired contractility or ischemia, but is secondary to direct ventricular compression with reduced stroke volume. Injury to underlying tissue is negligible.

The Thoracic and cardiovascular surgeon, Jan 18, 2015

Background Racial and ethnic differences in lung cancer care have been previously documented. The... more Background Racial and ethnic differences in lung cancer care have been previously documented. These differences may be related to access to care, cultural differences, or fewer patients presenting with operable lung cancer. The relationship between race and pathologic stage of patients who undergo lung cancer resection has not been defined. This study estimates racial disparities in lung cancer stage among patients who undergo surgical resection. Methods The Society of Thoracic Surgeons (STS) database was queried for patients who underwent resection of non-small cell lung cancer and had complete pathologic staging and racial identification. Univariate and multivariate analyses were performed. Study end point was the pathologic stage and we evaluated its association with the racial and ethnic origins of the patients. Results Of 19,173 eligible patients with non-small cell lung cancer of known pathological stage who underwent surgery between 2002 and 2008, the majority were Caucasian ...

Seminars in thoracic and cardiovascular surgery, 2005

Surgery as the sole therapy for locally advanced non-small cell lung cancer (NSCLC) is usually no... more Surgery as the sole therapy for locally advanced non-small cell lung cancer (NSCLC) is usually not curative. Adjuvant chemotherapy has been evaluated by several randomized Phase III trials and found to confer a survival benefit over surgery alone for stage IB-IIIA NSCLC. Induction therapy applies a cytoreductive and systemic therapy before definitive locoregional therapy. Theoretical advantages include improved diffusion of chemotherapy agents into the tumor, improved compliance, and a higher complete resection rate. Results from multiple Phase II and III studies have been encouraging, but the role of surgery after induction therapy remains inconclusively defined. Randomized trials are underway to better define the role of induction therapy, and enrollment of patients into such trials should be encouraged.

Annals of surgery, 2006

Advantages of thoracoscopic lobectomy for early stage non-small cell lung cancer (NSCLC), as comp... more Advantages of thoracoscopic lobectomy for early stage non-small cell lung cancer (NSCLC), as compared with lobectomy by conventional thoracotomy, include less postoperative pain and shorter length of hospitalization. The outcomes after thoracoscopic lobectomy in patients with more complex pulmonary conditions are analyzed to determine safety, efficacy, and versatility. A prospective database of 500 consecutive patients who underwent thoracoscopic lobectomy between June 1999 and January 2006 was queried. Demographic, histopathologic, perioperative, and outcome variables were assessed using standard descriptive statistics and Kaplan-Meier survival analyses. Thoracoscopic lobectomy was successfully performed in 492 patients (conversion rate, 1.6%). Pathologic analysis included primary NSCLC in 416 patients (83.2%), centrally located secondary pulmonary malignancy in 37 patients (7.4%), and a variety of benign conditions in 45 patients (9%). Among the 416 patients with NSCLC, pathologic...

Thoracic surgery clinics, 2011

The incorporation of research into a career in thoracic surgery is a complex process. Ideally, th... more The incorporation of research into a career in thoracic surgery is a complex process. Ideally, the preparation for a career in academic thoracic surgery begins with a research fellowship during training. In the academic setting, a research portfolio might include clinical research, translational research, or basic research. Using strategies for developing collaboration, thoracic surgeons in community-based programs may also be successful clinical investigators. In addition to the rigors of conducting research, strategies for reserving protected time and obtaining grant support must be considered to be successful in academic surgery.

The Journal of Thoracic and Cardiovascular Surgery, 2007

with pulmonary metastatic melanoma Improved survival with pulmonary metastasectomy: An analysis o... more with pulmonary metastatic melanoma Improved survival with pulmonary metastasectomy: An analysis of 1720 patients Supplemental material is available online.

The Journal of Thoracic and Cardiovascular Surgery, 2008

Objective: Prospective analyses of quality of life in elderly patients after lobectomy are limite... more Objective: Prospective analyses of quality of life in elderly patients after lobectomy are limited, yet surgeons often recommend suboptimal therapy to these patients on the basis of the belief that lobectomy is poorly tolerated. Surgical decision making in elderly patients with lung cancer is better informed when the benefits to survival and quality of life after lobectomy are understood.

The Journal of Thoracic and Cardiovascular Surgery, 2009

Objectives: Advantages of thoracoscopic lobectomy include less postoperative pain, shorter hospit... more Objectives: Advantages of thoracoscopic lobectomy include less postoperative pain, shorter hospitalization, and improved delivery of adjuvant chemotherapy. The incidence of postoperative complications has not been thoroughly assessed. This study analyzes morbidity after lobectomy to compare the thoracoscopic approach and thoracotomy.

The Journal of Thoracic and Cardiovascular Surgery, 2014

Women with lung cancer have superior long-term survival outcomes compared with men, independent o... more Women with lung cancer have superior long-term survival outcomes compared with men, independent of stage. The cause of this disparity is unknown. For patients undergoing lung cancer resection, these survival differences could be due, in part, to relatively better perioperative outcomes for women. This study was undertaken to determine differences in perioperative outcomes after lung cancer surgery on the basis of sex. The Society of Thoracic Surgeons' General Thoracic Database was queried for all patients undergoing resection of lung cancer between 2002 and 2010. Postoperative complications were analyzed with respect to sex. Univariable analysis was performed, followed by multivariable modeling to determine significant risk factors for postoperative morbidity and mortality. A total of 34,188 patients (16,643 men and 17,545 women) were considered. Univariable analysis demonstrated statistically significant differences in postoperative complications favoring women in all categories of postoperative complications. Women also had lower in-hospital and 30-day mortality (odds ratio, 0.56; 95% confidence interval, 0.44-0.71; P < .001). Multivariable analysis demonstrated that several preoperative conditions independently predicted 30-day mortality: male sex, increasing age, lower diffusion capacity, renal insufficiency, preoperative radiation therapy, cancer stage, extent of resection, and thoracotomy as surgical approach. Coronary artery disease was an independent predictor of mortality in women but not in men. Thoracotomy as the surgical approach and preoperative radiation therapy were predictive of mortality for men but not for women. Postoperative prolonged air leak and empyema predicted mortality in men but not in women. Women have lower postoperative morbidity and mortality after lung cancer surgery. Some risk factors are sex-specific with regard to mortality. Further study is warranted to determine the cause of these differences and to determine their effect on survival.

European Journal of Cardio-Thoracic Surgery, 2010

Recent evidence suggests that lobectomy performed either through thoracoscopy (TL) or via a poste... more Recent evidence suggests that lobectomy performed either through thoracoscopy (TL) or via a posterolateral thoracotomy (PLT) produces equivalent oncologic outcomes in appropriately selected patients. Advantages of thoracoscopic lobectomy include decreased postoperative pain, shorter length of stay, fewer postoperative complications and better compliance with adjuvant chemotherapy. This study evaluates the costs associated with lobectomy performed thoracoscopically or via thoracotomy. This is a retrospective analysis of actual costing and prospectively collected health-related quality of life (QOL) outcomes. Between 2002 and 2004, 113 patients underwent lobectomy (PLT: n=37; TL: n=76) and completed QOL assessments both preoperatively and 1-year postoperatively. Actual fixed and variable direct costs from the preoperative, hospitalisation and 30-day postoperative phases were captured using a T1 cost accounting system and were combined with actual professional collections. Cost-utility analysis was performed by transforming a global QOL measurement to an estimate of utility and calculating a quality-adjusted life year (QALY) for each patient. Baseline characteristics were similar in the two groups. Total costs (USD) were significantly greater for the strategy of PLT (USD 12,119) than for TL (USD 10,084; p=0.0012). Even when only stage I and II lung cancers were included (n=32 PLT, n=69 TL), total costs for PLT were still higher than that for TL (USD 11,998 vs USD 10,120; p=0.005). The mean QALY for the PLT group was 0.74+/-0.22 and for the TL group was 0.72+/-0.18 (p=0.68). In this retrospective analysis, TL was significantly less expensive than PLT from the preoperative evaluation through 30 days postoperatively, with overall savings of approximately USD 2000 per patient. In light of equivalent QALY outcomes, this cost-utility analysis supports increased adoption of TL as a cost-minimisation strategy. The use of TL for the 50,000 lobectomies performed in the United States each year would represent a savings of approximately USD 100 million.

CHEST Journal, 2004

... SMOKING AND THE LINK TO CARDIAC DISEASE IN PA-TIENTS UNDERGOING TREATMENT FOR TOBACCO DEPEN-D... more ... SMOKING AND THE LINK TO CARDIAC DISEASE IN PA-TIENTS UNDERGOING TREATMENT FOR TOBACCO DEPEN-DENCE Virginia C. Reichert, NP*; Pat Folan, RN; Lynn Villano, NP; Nina Kohn, MA; Alan M. Fein, MD; Arunabh Talwar, MD; Center For Tobacco Control ...

The Annals of Thoracic Surgery, 2013

Clinical staging of esophageal cancer has improved with positron-emission tomography/computed tom... more Clinical staging of esophageal cancer has improved with positron-emission tomography/computed tomography and endoscopic ultrasound imaging. Despite such progress, small single-center studies have questioned the reliability of clinical staging of T2 N0 esophageal cancer. This study broadly examines the adequacy of clinical staging of T2 N0 disease using The Society of Thoracic Surgeons database. We retrospectively studied 810 clinical stage T2 N0 patients from 2002 to 2011, with 58 excluded because of incomplete pathologic staging data. Clinical stage, pathologic stage, and preoperative characteristics were recorded. Logistic regression analysis was used to identify factors associated with upstaging at the time of surgical intervention. Among 752 clinical stage T2 N0 patients, 270 (35.9%) received induction therapy before the operation. Of 482 patients who went directly to surgical intervention, 132 (27.4%) were confirmed as pathologic T2 N0, 125 (25.9%) were downstaged (ie, T0-1 N0), and 225 (46.7%) were upstaged at the operation (T3-4 N0 or Tany N1-3). Exclusive tumor upstaging (ie, pathologic T3-4 N0) accounted for 41 patients (18.2%), whereas exclusive nodal upstaging (ie, pathological T1-2 N1-3) accounted for 100 (44.5%). Combined tumor and nodal upstaging (ie, pathological T3-4 N1-3) accounted for 84 patients (37.3%). Among patients who received induction therapy, 103 (38.1%) were upstaged vs 225 (46.7%) without induction therapy (p = 0.026). Comparing the induction therapy group and the primary surgical group, postoperative 30-day mortality (3.7% vs 3.7%, p > 0.99) and morbidity (46.3% vs 45%, p = 0.76) were similar. Despite advances in staging techniques, clinical staging of T2 N0 esophageal cancer remains unreliable. Recognizing T2 N0 as a threshold for induction therapy in esophageal cancer, many surgeons have opted to treat T2 N0 disease with induction therapy, even though one-quarter of these patients will be pathologic T1 N0. Although this study demonstrated similar perioperative morbidity and mortality with and without induction therapy, further study is needed to examine the effect of upstaging on long-term survival.

The Annals of Thoracic Surgery, 2009

Studies evaluating risk factors for complications after lobectomy in elderly patients have not ad... more Studies evaluating risk factors for complications after lobectomy in elderly patients have not adequately analyzed the effect of using minimally invasive approaches. A model for morbidity including published preoperative risk factors and surgical approach was developed by multivariable logistic regression. All patients aged 70 years or older who underwent lobectomy for primary lung cancer without chest wall resection or airway procedure between December 1999 and October 2007 at a single institution were reviewed. Preoperative, histopathologic, perioperative, and outcome variables were assessed using standard descriptive statistics. Morbidity was measured as a patient having any perioperative complication. The impact of bias in the selection of surgical approach was assessed using propensity scoring. During the study period, 338 patients older than 70 years (mean age, 75.7 +/- 0.2) underwent lobectomy (219 thoracoscopy, 119 thoracotomy). Operative mortality was 3.8% (13 patients) and morbidity was 47% (159 patients). Patients with at least one complication had increased length of stay (8.3 +/- 0.6 versus 3.8 +/- 0.1 days; p < 0.0001) and mortality (6.9% [11 of 159] versus 1.1% [2 of 179]; p = 0.008). Significant predictors of morbidity by multivariable analysis included age (odds ratio, 1.09 per year; p = 0.01) and thoracotomy as surgical approach (odds ratio, 2.21; p = 0.004). Thoracotomy remained a significant predictor of morbidity when the propensity to undergo thoracoscopy was considered (odds ratio, 4.9; p= 0.002). Patients older than 70 years of age can undergo lobectomy for lung cancer with low morbidity and mortality. Advanced age and the use of a thoracotomy increased the risk of complications in this patient population.

The Annals of Thoracic Surgery, 2007

The Annals of Thoracic Surgery, 2005

The safety of bronchoplastic procedures after induction chemoradiotherapy is uncertain. This stud... more The safety of bronchoplastic procedures after induction chemoradiotherapy is uncertain. This study examines short- and long-term outcomes after bronchoplastic procedures with and without induction therapy. Between January 1997 and September 2004, more than 1,300 anatomic pulmonary resections for cancer were performed at a single institution. Of these, 73 patients required either sleeve lobectomy (57) or bronchoplasty (16), and were retrospectively analyzed. Nineteen patients (26%) received induction therapy; 15 received chemotherapy and radiation therapy and 4 received chemotherapy alone. Fifty-four patients underwent the bronchoplastic procedure without induction therapy. Mortality and early and late morbidity were analyzed. Mean follow-up was 25 months. Histology was nonsmall cell cancer in 62 (85%), carcinoid in 8 (11%), and renal cell cancer, schwannoma, and mucoepidermoid cancer in 1 patient each. There were 2 (2.7%) 30-day deaths, both in the group not receiving induction therapy. Of the surviving 71 patients, 70 had functional reconstructions at last follow-up. The overall 30-day complication rate was 30% (19 of 54) in patients not receiving induction therapy (no bronchopleural fistulas) and 42% (8 of 19) occurring in those receiving induction therapy (1 bronchopleural fistula). The long-term complication rate was 20% (11 of 54) among patients not receiving induction therapy and 5% (1 of 19) among those receiving induction therapy (completion pneumonectomy). There were no bronchovascular complications. Interventional bronchoscopy was required in 7 patients not receiving induction therapy, and was required in none of the patients receiving induction therapy. Anatomic pulmonary resections utilizing bronchoplastic techniques can be performed with low morbidity and mortality rates even after induction therapy.

The Annals of Thoracic Surgery, 2005

Malignant central airway obstruction is difficult to manage and is associated with poor outcome. ... more Malignant central airway obstruction is difficult to manage and is associated with poor outcome. We sought to identify the short (< 30 days) and intermediate (> 30 days) benefits and risks of tracheobronchial stents in patients with malignant airway disease. Two hundred and twenty-five tracheobronchial stents were placed in 172 patients for benign (n = 32) and malignant (n = 140) disease from January 1, 1997, to May 31, 2003. The records of the patients with malignant disease were retrospectively analyzed to determine complication rate, reintervention rate, and survival. The malignant diagnoses included nonsmall cell cancer, small cell cancer, esophageal cancer, and metastatic disease. There were 172 stents placed in 140 patients with malignant disease, with no intraoperative mortality. The mean follow-up period was 142 +/- 12 days. There were 23 complications, including tumor ingrowth (n = 9), excessive granulation tissue (n = 7), stent migration (n = 5), and restenosis (n = 2). Five of the complications occurred during the short-term period (< 30 days) with the remaining complications (n = 18) occurring after 30 days. The complications required interventions including laser debridement (n = 14), dilation (n = 4), and stent removal (n = 5). Tracheobronchial stents offer minimally invasive palliative therapy for patients with unresectable malignant central airway obstruction. The benefit of airway stents is particularly seen in the short-term period where they provide symptomatic improvement and have low complication risk. The major impediment is excessive granulation tissue and tumor ingrowth, which occur primarily after 30 days.

The Annals of Thoracic Surgery, 2007

Background. Previous studies have discouraged limited pulmonary resection for primary lung cancer... more Background. Previous studies have discouraged limited pulmonary resection for primary lung cancer, but pulmonary segmentectomy has advantages for some patients. Furthermore, while thoracoscopic lobectomy has been increasingly applied with well-demonstrated advantages compared with thoracotomy, few data exist regarding thoracoscopic approaches to pulmonary segmentectomy. This study compares thoracoscopic segmen-

The Annals of Thoracic Surgery, 2010

Video-assisted thoracoscopic surgical decortication (VATSD) is widely used for treatment of early... more Video-assisted thoracoscopic surgical decortication (VATSD) is widely used for treatment of early empyema and hemothorax, but conversion to open thoracotomy for decortication (OD) is more frequent in the setting of complex, chronic empyema. This study compared indications for and outcomes associated with VATSD and OD. The outcomes of 420 consecutive patients undergoing VATSD or OD for benign conditions from 1996 to 2006 were reviewed and compared with respect to baseline characteristics, preoperative management, and operative and postoperative course. Patients were analyzed on an intention-to-treat basis. The cohort consisted of 326 VATSD and 94 OD patients. The conversion rate from VATSD to OD was 11.4%. The operative time and median in-hospital length of stay were shorter for the VATSD group: 97 vs 155 minutes (p < 0.001), and 15 vs 21 days (p = 0.03), respectively. The median postoperative length of stay was 7 days for the VATSD group vs 10 days for the OD group (p < 0.001). Significantly fewer postoperative complications occurred in the VATSD group in the following categories: atelectasis, prolonged air leak, reintubation, ventilator dependence, need for tracheostomy, blood transfusion, sepsis, and 30-day mortality. Thoracoscopic decortication for empyema, complex pleural effusion, and hemothorax yields results that are at least equivalent to open decortication. Patients undergoing VATSD have fewer postoperative complications. The conversion and reoperation rates are low, suggesting that a thoracoscopic approach is an effective and reasonable first option for most patients with complex pleural effusions and empyema.

The Annals of Thoracic Surgery, 2006

Thoracoscopic lobectomy is an accepted oncologic approach for early stage non-small cell lung can... more Thoracoscopic lobectomy is an accepted oncologic approach for early stage non-small cell lung cancer (NSCLC). We conducted a retrospective study of patients who underwent lobectomy after induction therapy to determine the feasibility of thoracoscopic lobectomy compared with conventional thoracotomy lobectomy. The outcomes of 97 consecutive patients with NSCLC who received induction therapy followed by lobectomy from 1996 to 2005 were reviewed. Outcome variables analyzed included complete resection, chest tube duration, length of hospitalization, 30-day mortality, hemorrhage, pneumonia, respiratory failure, and other major complications. The Student t test and chi2 or RxC contingency tables were used to compare continuous and categoric variables, respectively. Lobectomy was performed by thoracotomy in 85 patients and thoracoscopically in 12 patients (1 conversion), with complete resection in all patients. All patients received induction chemotherapy, and 74 (76%) received induction radiotherapy as well: 66 of 85 (78%) in the thoracotomy group and 8 of 12 (67%) in the thoracoscopy group. The overall median survival was 2.3 years, with no difference between the groups. Patients undergoing a thoracoscopic lobectomy had a shorter median hospital stay (3.5 vs 5 days, p = 0.0024) and chest tube duration (2 vs 4 days, p < 0.001). There were no significant differences in 30-day mortality, hemorrhage, pneumonia, or respiratory failure. Thoracoscopic lobectomy is a feasible approach for selected patients undergoing resection after induction therapy, and is associated with shorter hospital stay and chest tube duration. Long-term follow-up of survival will determine the role of thoracoscopic lobectomy in the management of patients after induction therapy.

Operative Techniques in Thoracic and Cardiovascular Surgery, 2004

European Journal of Cardio-Thoracic Surgery, 1998

Objective: Mechanical cardiac stabilization is beneficial for precise coronary anastomoses on the... more Objective: Mechanical cardiac stabilization is beneficial for precise coronary anastomoses on the beating heart. However, the effect of mechanical cardiac stabilization on hemodynamics, left ventricular performance, and the degree of injury to underlying tissue are uncertain. Methods: Twelve swine (20-30 kg) underwent median sternotomy and a mechanical stabilizing device (United States Surgical, Norwalk, CT) was positioned astride a segment of left anterior descending coronary artery (LAD). Coronary blood flow was measured by Doppler. Sonomicrometry crystals were placed distal to the stabilizer in a region of myocardium subtended by the LAD, and a left ventricular micromanometer was inserted. Regional myocardial function was determined using the preload recruitable stroke work (PRSW) relationship. Data were acquired at three time points: 20 min before (PRE) and after placing the stabilizer (EXPT); and 20 min after removing the stabilizer (POST). Tissue subjacent to the stabilizer was then biopsied. Means ± standard deviation are reported. Results: The mechanical stabilizer caused a decrease in cardiac output from 4.2 ± 1.5 to 3.6 ± 1.3 l/min (P Ͻ 0.05), which returned to baseline values after its removal. Regional myocardial function (percent systolic shortening and M w and x-intercept of the PRSW relationship) was unchanged. Blood pressure, heart rate, and LAD blood flow remained constant. Histologic findings included a layer of myocyte necrosis less than 1 mm in depth immediately beneath the stabilizer. Conclusions: These data demonstrate that mechanical stabilization of the LAD may temporarily decrease cardiac output. This is not attributed to impaired contractility or ischemia, but is secondary to direct ventricular compression with reduced stroke volume. Injury to underlying tissue is negligible.

The Thoracic and cardiovascular surgeon, Jan 18, 2015

Background Racial and ethnic differences in lung cancer care have been previously documented. The... more Background Racial and ethnic differences in lung cancer care have been previously documented. These differences may be related to access to care, cultural differences, or fewer patients presenting with operable lung cancer. The relationship between race and pathologic stage of patients who undergo lung cancer resection has not been defined. This study estimates racial disparities in lung cancer stage among patients who undergo surgical resection. Methods The Society of Thoracic Surgeons (STS) database was queried for patients who underwent resection of non-small cell lung cancer and had complete pathologic staging and racial identification. Univariate and multivariate analyses were performed. Study end point was the pathologic stage and we evaluated its association with the racial and ethnic origins of the patients. Results Of 19,173 eligible patients with non-small cell lung cancer of known pathological stage who underwent surgery between 2002 and 2008, the majority were Caucasian ...

Seminars in thoracic and cardiovascular surgery, 2005

Surgery as the sole therapy for locally advanced non-small cell lung cancer (NSCLC) is usually no... more Surgery as the sole therapy for locally advanced non-small cell lung cancer (NSCLC) is usually not curative. Adjuvant chemotherapy has been evaluated by several randomized Phase III trials and found to confer a survival benefit over surgery alone for stage IB-IIIA NSCLC. Induction therapy applies a cytoreductive and systemic therapy before definitive locoregional therapy. Theoretical advantages include improved diffusion of chemotherapy agents into the tumor, improved compliance, and a higher complete resection rate. Results from multiple Phase II and III studies have been encouraging, but the role of surgery after induction therapy remains inconclusively defined. Randomized trials are underway to better define the role of induction therapy, and enrollment of patients into such trials should be encouraged.

Annals of surgery, 2006

Advantages of thoracoscopic lobectomy for early stage non-small cell lung cancer (NSCLC), as comp... more Advantages of thoracoscopic lobectomy for early stage non-small cell lung cancer (NSCLC), as compared with lobectomy by conventional thoracotomy, include less postoperative pain and shorter length of hospitalization. The outcomes after thoracoscopic lobectomy in patients with more complex pulmonary conditions are analyzed to determine safety, efficacy, and versatility. A prospective database of 500 consecutive patients who underwent thoracoscopic lobectomy between June 1999 and January 2006 was queried. Demographic, histopathologic, perioperative, and outcome variables were assessed using standard descriptive statistics and Kaplan-Meier survival analyses. Thoracoscopic lobectomy was successfully performed in 492 patients (conversion rate, 1.6%). Pathologic analysis included primary NSCLC in 416 patients (83.2%), centrally located secondary pulmonary malignancy in 37 patients (7.4%), and a variety of benign conditions in 45 patients (9%). Among the 416 patients with NSCLC, pathologic...

Thoracic surgery clinics, 2011

The incorporation of research into a career in thoracic surgery is a complex process. Ideally, th... more The incorporation of research into a career in thoracic surgery is a complex process. Ideally, the preparation for a career in academic thoracic surgery begins with a research fellowship during training. In the academic setting, a research portfolio might include clinical research, translational research, or basic research. Using strategies for developing collaboration, thoracic surgeons in community-based programs may also be successful clinical investigators. In addition to the rigors of conducting research, strategies for reserving protected time and obtaining grant support must be considered to be successful in academic surgery.

The Journal of Thoracic and Cardiovascular Surgery, 2007

with pulmonary metastatic melanoma Improved survival with pulmonary metastasectomy: An analysis o... more with pulmonary metastatic melanoma Improved survival with pulmonary metastasectomy: An analysis of 1720 patients Supplemental material is available online.

The Journal of Thoracic and Cardiovascular Surgery, 2008

Objective: Prospective analyses of quality of life in elderly patients after lobectomy are limite... more Objective: Prospective analyses of quality of life in elderly patients after lobectomy are limited, yet surgeons often recommend suboptimal therapy to these patients on the basis of the belief that lobectomy is poorly tolerated. Surgical decision making in elderly patients with lung cancer is better informed when the benefits to survival and quality of life after lobectomy are understood.

The Journal of Thoracic and Cardiovascular Surgery, 2009

Objectives: Advantages of thoracoscopic lobectomy include less postoperative pain, shorter hospit... more Objectives: Advantages of thoracoscopic lobectomy include less postoperative pain, shorter hospitalization, and improved delivery of adjuvant chemotherapy. The incidence of postoperative complications has not been thoroughly assessed. This study analyzes morbidity after lobectomy to compare the thoracoscopic approach and thoracotomy.

The Journal of Thoracic and Cardiovascular Surgery, 2014

Women with lung cancer have superior long-term survival outcomes compared with men, independent o... more Women with lung cancer have superior long-term survival outcomes compared with men, independent of stage. The cause of this disparity is unknown. For patients undergoing lung cancer resection, these survival differences could be due, in part, to relatively better perioperative outcomes for women. This study was undertaken to determine differences in perioperative outcomes after lung cancer surgery on the basis of sex. The Society of Thoracic Surgeons' General Thoracic Database was queried for all patients undergoing resection of lung cancer between 2002 and 2010. Postoperative complications were analyzed with respect to sex. Univariable analysis was performed, followed by multivariable modeling to determine significant risk factors for postoperative morbidity and mortality. A total of 34,188 patients (16,643 men and 17,545 women) were considered. Univariable analysis demonstrated statistically significant differences in postoperative complications favoring women in all categories of postoperative complications. Women also had lower in-hospital and 30-day mortality (odds ratio, 0.56; 95% confidence interval, 0.44-0.71; P < .001). Multivariable analysis demonstrated that several preoperative conditions independently predicted 30-day mortality: male sex, increasing age, lower diffusion capacity, renal insufficiency, preoperative radiation therapy, cancer stage, extent of resection, and thoracotomy as surgical approach. Coronary artery disease was an independent predictor of mortality in women but not in men. Thoracotomy as the surgical approach and preoperative radiation therapy were predictive of mortality for men but not for women. Postoperative prolonged air leak and empyema predicted mortality in men but not in women. Women have lower postoperative morbidity and mortality after lung cancer surgery. Some risk factors are sex-specific with regard to mortality. Further study is warranted to determine the cause of these differences and to determine their effect on survival.

European Journal of Cardio-Thoracic Surgery, 2010

Recent evidence suggests that lobectomy performed either through thoracoscopy (TL) or via a poste... more Recent evidence suggests that lobectomy performed either through thoracoscopy (TL) or via a posterolateral thoracotomy (PLT) produces equivalent oncologic outcomes in appropriately selected patients. Advantages of thoracoscopic lobectomy include decreased postoperative pain, shorter length of stay, fewer postoperative complications and better compliance with adjuvant chemotherapy. This study evaluates the costs associated with lobectomy performed thoracoscopically or via thoracotomy. This is a retrospective analysis of actual costing and prospectively collected health-related quality of life (QOL) outcomes. Between 2002 and 2004, 113 patients underwent lobectomy (PLT: n=37; TL: n=76) and completed QOL assessments both preoperatively and 1-year postoperatively. Actual fixed and variable direct costs from the preoperative, hospitalisation and 30-day postoperative phases were captured using a T1 cost accounting system and were combined with actual professional collections. Cost-utility analysis was performed by transforming a global QOL measurement to an estimate of utility and calculating a quality-adjusted life year (QALY) for each patient. Baseline characteristics were similar in the two groups. Total costs (USD) were significantly greater for the strategy of PLT (USD 12,119) than for TL (USD 10,084; p=0.0012). Even when only stage I and II lung cancers were included (n=32 PLT, n=69 TL), total costs for PLT were still higher than that for TL (USD 11,998 vs USD 10,120; p=0.005). The mean QALY for the PLT group was 0.74+/-0.22 and for the TL group was 0.72+/-0.18 (p=0.68). In this retrospective analysis, TL was significantly less expensive than PLT from the preoperative evaluation through 30 days postoperatively, with overall savings of approximately USD 2000 per patient. In light of equivalent QALY outcomes, this cost-utility analysis supports increased adoption of TL as a cost-minimisation strategy. The use of TL for the 50,000 lobectomies performed in the United States each year would represent a savings of approximately USD 100 million.

CHEST Journal, 2004

... SMOKING AND THE LINK TO CARDIAC DISEASE IN PA-TIENTS UNDERGOING TREATMENT FOR TOBACCO DEPEN-D... more ... SMOKING AND THE LINK TO CARDIAC DISEASE IN PA-TIENTS UNDERGOING TREATMENT FOR TOBACCO DEPEN-DENCE Virginia C. Reichert, NP*; Pat Folan, RN; Lynn Villano, NP; Nina Kohn, MA; Alan M. Fein, MD; Arunabh Talwar, MD; Center For Tobacco Control ...

The Annals of Thoracic Surgery, 2013

Clinical staging of esophageal cancer has improved with positron-emission tomography/computed tom... more Clinical staging of esophageal cancer has improved with positron-emission tomography/computed tomography and endoscopic ultrasound imaging. Despite such progress, small single-center studies have questioned the reliability of clinical staging of T2 N0 esophageal cancer. This study broadly examines the adequacy of clinical staging of T2 N0 disease using The Society of Thoracic Surgeons database. We retrospectively studied 810 clinical stage T2 N0 patients from 2002 to 2011, with 58 excluded because of incomplete pathologic staging data. Clinical stage, pathologic stage, and preoperative characteristics were recorded. Logistic regression analysis was used to identify factors associated with upstaging at the time of surgical intervention. Among 752 clinical stage T2 N0 patients, 270 (35.9%) received induction therapy before the operation. Of 482 patients who went directly to surgical intervention, 132 (27.4%) were confirmed as pathologic T2 N0, 125 (25.9%) were downstaged (ie, T0-1 N0), and 225 (46.7%) were upstaged at the operation (T3-4 N0 or Tany N1-3). Exclusive tumor upstaging (ie, pathologic T3-4 N0) accounted for 41 patients (18.2%), whereas exclusive nodal upstaging (ie, pathological T1-2 N1-3) accounted for 100 (44.5%). Combined tumor and nodal upstaging (ie, pathological T3-4 N1-3) accounted for 84 patients (37.3%). Among patients who received induction therapy, 103 (38.1%) were upstaged vs 225 (46.7%) without induction therapy (p = 0.026). Comparing the induction therapy group and the primary surgical group, postoperative 30-day mortality (3.7% vs 3.7%, p > 0.99) and morbidity (46.3% vs 45%, p = 0.76) were similar. Despite advances in staging techniques, clinical staging of T2 N0 esophageal cancer remains unreliable. Recognizing T2 N0 as a threshold for induction therapy in esophageal cancer, many surgeons have opted to treat T2 N0 disease with induction therapy, even though one-quarter of these patients will be pathologic T1 N0. Although this study demonstrated similar perioperative morbidity and mortality with and without induction therapy, further study is needed to examine the effect of upstaging on long-term survival.

The Annals of Thoracic Surgery, 2009

Studies evaluating risk factors for complications after lobectomy in elderly patients have not ad... more Studies evaluating risk factors for complications after lobectomy in elderly patients have not adequately analyzed the effect of using minimally invasive approaches. A model for morbidity including published preoperative risk factors and surgical approach was developed by multivariable logistic regression. All patients aged 70 years or older who underwent lobectomy for primary lung cancer without chest wall resection or airway procedure between December 1999 and October 2007 at a single institution were reviewed. Preoperative, histopathologic, perioperative, and outcome variables were assessed using standard descriptive statistics. Morbidity was measured as a patient having any perioperative complication. The impact of bias in the selection of surgical approach was assessed using propensity scoring. During the study period, 338 patients older than 70 years (mean age, 75.7 +/- 0.2) underwent lobectomy (219 thoracoscopy, 119 thoracotomy). Operative mortality was 3.8% (13 patients) and morbidity was 47% (159 patients). Patients with at least one complication had increased length of stay (8.3 +/- 0.6 versus 3.8 +/- 0.1 days; p < 0.0001) and mortality (6.9% [11 of 159] versus 1.1% [2 of 179]; p = 0.008). Significant predictors of morbidity by multivariable analysis included age (odds ratio, 1.09 per year; p = 0.01) and thoracotomy as surgical approach (odds ratio, 2.21; p = 0.004). Thoracotomy remained a significant predictor of morbidity when the propensity to undergo thoracoscopy was considered (odds ratio, 4.9; p= 0.002). Patients older than 70 years of age can undergo lobectomy for lung cancer with low morbidity and mortality. Advanced age and the use of a thoracotomy increased the risk of complications in this patient population.

The Annals of Thoracic Surgery, 2007

The Annals of Thoracic Surgery, 2005

The safety of bronchoplastic procedures after induction chemoradiotherapy is uncertain. This stud... more The safety of bronchoplastic procedures after induction chemoradiotherapy is uncertain. This study examines short- and long-term outcomes after bronchoplastic procedures with and without induction therapy. Between January 1997 and September 2004, more than 1,300 anatomic pulmonary resections for cancer were performed at a single institution. Of these, 73 patients required either sleeve lobectomy (57) or bronchoplasty (16), and were retrospectively analyzed. Nineteen patients (26%) received induction therapy; 15 received chemotherapy and radiation therapy and 4 received chemotherapy alone. Fifty-four patients underwent the bronchoplastic procedure without induction therapy. Mortality and early and late morbidity were analyzed. Mean follow-up was 25 months. Histology was nonsmall cell cancer in 62 (85%), carcinoid in 8 (11%), and renal cell cancer, schwannoma, and mucoepidermoid cancer in 1 patient each. There were 2 (2.7%) 30-day deaths, both in the group not receiving induction therapy. Of the surviving 71 patients, 70 had functional reconstructions at last follow-up. The overall 30-day complication rate was 30% (19 of 54) in patients not receiving induction therapy (no bronchopleural fistulas) and 42% (8 of 19) occurring in those receiving induction therapy (1 bronchopleural fistula). The long-term complication rate was 20% (11 of 54) among patients not receiving induction therapy and 5% (1 of 19) among those receiving induction therapy (completion pneumonectomy). There were no bronchovascular complications. Interventional bronchoscopy was required in 7 patients not receiving induction therapy, and was required in none of the patients receiving induction therapy. Anatomic pulmonary resections utilizing bronchoplastic techniques can be performed with low morbidity and mortality rates even after induction therapy.

The Annals of Thoracic Surgery, 2005

Malignant central airway obstruction is difficult to manage and is associated with poor outcome. ... more Malignant central airway obstruction is difficult to manage and is associated with poor outcome. We sought to identify the short (< 30 days) and intermediate (> 30 days) benefits and risks of tracheobronchial stents in patients with malignant airway disease. Two hundred and twenty-five tracheobronchial stents were placed in 172 patients for benign (n = 32) and malignant (n = 140) disease from January 1, 1997, to May 31, 2003. The records of the patients with malignant disease were retrospectively analyzed to determine complication rate, reintervention rate, and survival. The malignant diagnoses included nonsmall cell cancer, small cell cancer, esophageal cancer, and metastatic disease. There were 172 stents placed in 140 patients with malignant disease, with no intraoperative mortality. The mean follow-up period was 142 +/- 12 days. There were 23 complications, including tumor ingrowth (n = 9), excessive granulation tissue (n = 7), stent migration (n = 5), and restenosis (n = 2). Five of the complications occurred during the short-term period (< 30 days) with the remaining complications (n = 18) occurring after 30 days. The complications required interventions including laser debridement (n = 14), dilation (n = 4), and stent removal (n = 5). Tracheobronchial stents offer minimally invasive palliative therapy for patients with unresectable malignant central airway obstruction. The benefit of airway stents is particularly seen in the short-term period where they provide symptomatic improvement and have low complication risk. The major impediment is excessive granulation tissue and tumor ingrowth, which occur primarily after 30 days.

The Annals of Thoracic Surgery, 2007

Background. Previous studies have discouraged limited pulmonary resection for primary lung cancer... more Background. Previous studies have discouraged limited pulmonary resection for primary lung cancer, but pulmonary segmentectomy has advantages for some patients. Furthermore, while thoracoscopic lobectomy has been increasingly applied with well-demonstrated advantages compared with thoracotomy, few data exist regarding thoracoscopic approaches to pulmonary segmentectomy. This study compares thoracoscopic segmen-

The Annals of Thoracic Surgery, 2010

Video-assisted thoracoscopic surgical decortication (VATSD) is widely used for treatment of early... more Video-assisted thoracoscopic surgical decortication (VATSD) is widely used for treatment of early empyema and hemothorax, but conversion to open thoracotomy for decortication (OD) is more frequent in the setting of complex, chronic empyema. This study compared indications for and outcomes associated with VATSD and OD. The outcomes of 420 consecutive patients undergoing VATSD or OD for benign conditions from 1996 to 2006 were reviewed and compared with respect to baseline characteristics, preoperative management, and operative and postoperative course. Patients were analyzed on an intention-to-treat basis. The cohort consisted of 326 VATSD and 94 OD patients. The conversion rate from VATSD to OD was 11.4%. The operative time and median in-hospital length of stay were shorter for the VATSD group: 97 vs 155 minutes (p < 0.001), and 15 vs 21 days (p = 0.03), respectively. The median postoperative length of stay was 7 days for the VATSD group vs 10 days for the OD group (p < 0.001). Significantly fewer postoperative complications occurred in the VATSD group in the following categories: atelectasis, prolonged air leak, reintubation, ventilator dependence, need for tracheostomy, blood transfusion, sepsis, and 30-day mortality. Thoracoscopic decortication for empyema, complex pleural effusion, and hemothorax yields results that are at least equivalent to open decortication. Patients undergoing VATSD have fewer postoperative complications. The conversion and reoperation rates are low, suggesting that a thoracoscopic approach is an effective and reasonable first option for most patients with complex pleural effusions and empyema.

The Annals of Thoracic Surgery, 2006

Thoracoscopic lobectomy is an accepted oncologic approach for early stage non-small cell lung can... more Thoracoscopic lobectomy is an accepted oncologic approach for early stage non-small cell lung cancer (NSCLC). We conducted a retrospective study of patients who underwent lobectomy after induction therapy to determine the feasibility of thoracoscopic lobectomy compared with conventional thoracotomy lobectomy. The outcomes of 97 consecutive patients with NSCLC who received induction therapy followed by lobectomy from 1996 to 2005 were reviewed. Outcome variables analyzed included complete resection, chest tube duration, length of hospitalization, 30-day mortality, hemorrhage, pneumonia, respiratory failure, and other major complications. The Student t test and chi2 or RxC contingency tables were used to compare continuous and categoric variables, respectively. Lobectomy was performed by thoracotomy in 85 patients and thoracoscopically in 12 patients (1 conversion), with complete resection in all patients. All patients received induction chemotherapy, and 74 (76%) received induction radiotherapy as well: 66 of 85 (78%) in the thoracotomy group and 8 of 12 (67%) in the thoracoscopy group. The overall median survival was 2.3 years, with no difference between the groups. Patients undergoing a thoracoscopic lobectomy had a shorter median hospital stay (3.5 vs 5 days, p = 0.0024) and chest tube duration (2 vs 4 days, p < 0.001). There were no significant differences in 30-day mortality, hemorrhage, pneumonia, or respiratory failure. Thoracoscopic lobectomy is a feasible approach for selected patients undergoing resection after induction therapy, and is associated with shorter hospital stay and chest tube duration. Long-term follow-up of survival will determine the role of thoracoscopic lobectomy in the management of patients after induction therapy.