Minimally invasive approach to management of malignant pericardial effusion

Minimally invasive approach to management of malignant pericardial effusion

S24 Surgical Forum Abstracts METHODS: We analyzed a prospective database, including all patients age 70 and older who underwent esophagectomy from 2...

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Surgical Forum Abstracts

METHODS: We analyzed a prospective database, including all patients age 70 and older who underwent esophagectomy from 20002006 (n⫽52). Preoperative comorbidities, operative approach, length of stay, morbidity and mortality were compared between those undergoing minimally invasive (laparoscopic or thoracoscopic component or both) versus open esophagectomy. RESULTS: No significant differences in preoperative comorbidities were identified between the two groups. Median length of stay was 12 days for both groups. (p⫽0.42) There were no differences in sepsis (p⫽0.47), pneumonia (p⫽0.19), prolonged intubation (p⫽0.27), anastomotic leak (p⫽0.56), reintubation (p⫽ 1.0), and readmission (p ⫽0.37) between the two groups. The open group had a decreased incidence of atrial arrhythmia requiring treatment (p⫽ 0.04). Overall 30 day mortality was 2% and was similar in both groups. (p ⫽ 1.0). CONCLUSIONS: Minimally invasive esophagectomy can be performed safely in elderly patients with rates of morbidity and mortality comparable to those of open esophagectomy. Potential association of minimally invasive approaches and atrial arrhythmia merits further investigation.

Outcomes of lung cancer surgery in HIV-positive smokers: Initial findings Robert A Meguid, MD, Craig M Hooker, MPH, Justin A DeAngelis, Marc Sussman, MD, Stephen C Yang, MD, Malcolm V Brock, MD The Johns Hopkins University School of Medicine, Baltimore, MD INTRODUCTION: While the incidence of Lung Cancer (LC) in HIV⫹ patients is increasing, few have disease amenable to curative resection. Only 24 HIV⫹LC patients in the literature have undergone resection. In the 1998-2003 Nationwide Inpatient Sample of ⬎42million records, 23 HIV⫹LC patients received surgery. Since these 2 datasets lack detailed patient-outcomes, and our institution has a high-volume HIV clinic, we examined our HIV⫹LC surgical experience. METHODS: A hospital-based retrospective study of lung cancer patients from 1986-2006 was performed. Overall survival was compared between HIV⫹LC and HIV-indeterminate patients undergoing pulmonary resection. RESULTS: Thirteen of 105 HIV⫹LC patients underwent pulmonary resection versus 1343 of 4972 HIV-indeterminate LC patients(12.4%vs. 27.0%;p⫽0.001). Median age between groups differed significantly(see table). Controlling for gender, age, race, smoking status, stage, procedure and histology, the risk of mortality for HIV⫹LC was 2.23x greater than for HIV-indeterminate patients(95%CI:0.98-5.04). This elevated risk for HIV⫹LC patients persisted even when patients were matched by preoperative morbidity to a subset of 46 HIV-indeterminate LC surgery patients using detailed inpatient records(Hazard Ratio⫽2.31;95%CI:0.767.04). Although median length of stay was greater in HIV⫹ than HIV-indeterminate cohorts(7 vs. 5days,p⫽0.05), PFTs and ASA were comparable and there was no significant difference in postoperative complications.

J Am Coll Surg

Median Age % Ever Smoked Median Pack Years Smoked % Stage I Tumor % Underwent Lobectomy 30-day Mortality Median Survival

HIVⴙ Cohort

HIV-Indeterminate Cohort

P-Value

47.2 years 100% 45

65.8 years 88.6% 47

0.002 0.20 0.78

46% 92.3%

54.1% 74.6%

0.85 0.40

0% 10.4 months

2.5% 31.0 months

0.56 0.16

CONCLUSIONS: We report the largest single-institution series of surgically treated HIV⫹LC patients. Although surgical treatment remains the best option for localized disease, results suggest an elevated mortality in these patients, despite adequate pulmonary function and relatively well maintained immune status. The few HIV⫹LC patients at any single institution require collaboration to examine definitively variables that adversely affect outcome.

Minimally invasive approach to management of malignant pericardial effusion Casandra A Anderson, MD, Hellan Minia, MD, Carey Cullinane, MD, Frederic Grannis, MD City of Hope, Duarte, CA INTRODUCTION: To assess durability of video-assisted thorascopic pericardial drainage for malignant pericardial effusions. METHODS: Between December 1991 and December 2006, 48 patients (15 men, 33 female; median age 53) underwent thorascopic pericardial drainage. The primary malignant diagnoses included breast (n⫽21), non-small cell lung (n⫽ 8), hematologic (n⫽15), and other solid organ malignancies (n⫽4). Preoperative echocardiograms showed evidence of tamponade in 21 patients, of which 60% required emergent treatment. Procedures were performed under general anesthesia with single lung ventilation using 3 port sites. The thoracic side used was determined by the patient’s history of previous thoracic operations and need for pleural drainage RESULTS: A thorascopic pericardial window was attempted in 57 patients. Conversion rate was 15%; 5 due to adhesions, 3 due to poor visualization secondary to an inflammatory reaction, and 1 due to hypotension. 75% of patients had concomitant pleural effusions of which 19% underwent pleurax catheter placement. In addition, 32 patients had non-pericardial procedures performed. The median operative time was 120 minutes. A median of 400 ml of pericardial effusion was drained. There were no procedural related deaths. Overall procedural-related morbidity was 4%. Follow-up echocardiograms or CT scans were obtained post-operatively to track recurrences. Only one patient developed a recurrent pericardial effusion requiring operative intervention. Median survival was 8.7 months. CONCLUSIONS: Our 16-yr review revealed minimally invasive thorascopic management of malignant pericardial effusions to be a safe technique even in the face of tamponade, and allows for adequate

Vol. 205, No. 3S, September 2007

control of pericardial effusions in terminally ill patients with limited life expectancy.

Porcine valve as a model for age-specific human heart valve disease: Analysis of collagen turnover throughout development and aging

Surgical Forum Abstracts

S25

erone HSP47, hydroxylating enzyme prolyl 4-hydroxylase (P4H), crosslinking enzyme lysyl oxidase (LOX)] and collagen degradation (matrix metalloproteinase (MMP)-13), and a marker of an ’activated’ cellular phenotype, smooth muscle alpha-actin (SMaA). Analysis of variance was used to compare staining intensities.

INTRODUCTION: The 6-month-old pig is commonly used to study human heart valve biology and several age-specific valve diseases. Correlation of porcine valve biology and development with that of humans has not been thoroughly assessed. Given the matrix’s important role in valve function, we characterized porcine valve matrix structure and collagen turnover during development and aging.

RESULTS: Cell density measurements showed layer differentiation in the 1st trimester (p⬍0.003) and decreased ten-fold from 2nd trimester to 6-year-old (p⬍0.025). Matrix turnover was identified by co-localization of P4H, HSP47, and MMP13 and correlated to an ’activated’ cellular phenotype. SMaA expression was noted on the inflow surface of both valves. P4H and LOX were maximally expressed around mature collagen (p⬍0.001). P4H increased during fetal development (p⬍0.01) and in the 6-year-old AV fibrosa (p⬍0.05). Collagen-related markers were consistently higher in the AV than MV (HSP47 in fetal; P4H, Col III, and LOX in 6-year-old).

METHODS: Porcine aortic (AV) and mitral valves (MV) throughout fetal development and at 6-weeks, 6-months, and 6-years, were examined using Movat pentachrome stain and immunohistochemistry for collagen III, markers of collagen synthesis [molecular chap-

CONCLUSIONS: Substantial changes occur in porcine valve matrix throughout life. These changes should be considered when comparing clinical studies with the porcine model for studying age-specific diseases.

Elizabeth H Stephens, BS, K. Jane Grande-Allen, PhD Rice University, Houston, TX