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J D Luketich

Publications and source records attributed to J D Luketich.

At least 19 recordsLinked to original sources
PubMed2006

Minimally invasive esophagectomy: state of the art.

Open esophagectomy is associated with significant mortality and morbidity, even in experienced centers. Two of the more frequent complications following esophagectomy are pneumonia and respiratory failure. Single-institution series have suggested that the incidence of these complications may be decreased with minimally invasive esophagectomy, with equivalent survival compared to open esophagectomy. However, this operation is technically challenging. In this review we detail the procedure as performed in our center, and also discuss some recent developments.

Endoscopy, Digestive System↗
PubMed2005

Laparoscopic esophagectomy.

Minimally invasive esophagectomy is emerging as an alternative option to open esophagectomy for benign and malignant esophageal diseases. This article provides a detailed review of the history of minimally invasive esophagectomy and an update on the currently accepted techniques for minimally invasive esophagectomy and its outcomes.

Esophagectomy↗
PubMed2004

Current status of minimally invasive esophagectomy.

Minimally invasive esophagectomy is emerging as an option in the management of benign and malignant esophageal diseases. With minimally invasive esophagectomy, the conventional laparotomy is substituted with laparoscopy and the open thoracotomy with thoracoscopy. This article discusses the surgical techniques and outcomes for a variety of minimally invasive esophagectomy options.

Esophageal Neoplasms↗
PubMed2002

Results of a randomized trial of HERMES-assisted versus non-HERMES-assisted laparoscopic antireflux surgery.

BACKGROUND: Speech recognition technology is a recent development in minimally invasive surgery. This study was designed to assess the impact of HERMES on operating room efficiency and user satisfaction. METHODS: Patients undergoing laparoscopic antireflux operations by surgeons experienced in minimally invasive surgery were randomized to HERMES-assisted or standard laparoscopic operations. The variables of interest were circulating nurse's time spent adjusting devices that are voice-controlled by HERMES, number of adjustments to devices requested, and surgeon and nurse satisfaction measured on a scale from 1 (dissatisfied) to 10 (satisfied). RESULTS: A total of 30 cases were studied. In the non-HERMES cases, nurses were interrupted to make device adjustments an average of 15.3 times per case versus 0.33 times per case in the with-HERMES cases (p < 0.01). The interruptions during the non-HERMES cases averaged 4.35 min per case versus 0.16 min per case in the with-HERMES cases (p = 0.03). Average satisfaction scores for HERMES operations as opposed to non-HERMES operations were 9.2 versus 5.3 for nurses (p < 0.01) and 9.0 versus 5.1 for surgeons (p < 0.01). CONCLUSIONS: Physician and nurse acceptance of HERMES was very high because of the smoother interruption-free environment.

Fundoplication↗
PubMed2002

Outcomes of laparoscopic Toupet compared to laparoscopic Nissen fundoplication.

BACKGROUND: Recent reports suggest that partial fundoplications such as the laparoscopic Toupet (LT) ultimately suffer from a higher recurrence rate compared to complete wraps such as the laparoscopic Nissen fundoplication (LNF). This article summarizes our experience with LT and LNF. METHODS: Over a 45-month period (February 1995 to November 1998), 206 patients underwent laparoscopic antireflux operations. The LNF group included 163 patients and the LT group included 43 patients. Global quality of life was measured using the Medical outcomes short form 36 (SF36). RESULTS: There were no differences in disease severity, except that the LT group had a higher incidence of esophageal dysmotility (37.2% 8.6%, p < 0.05). Early outcomes were similar, with no perioperative deaths and morbidity occurring in 15 (9.2%) LNF and 5 (11.6%) LT patients (p = not significant). Long-term follow-up was available in 142 patients at a mean of 19.7 months. A greater number of LT patients required proton pump inhibitors (38 vs 20%) and were dissatisfied (21 vs 7%) with their surgery (p < 0.05). SF36 physical function scores were better in the LNF group (85 vs 74; p < 0.05). Significantly more (p < 0.05) of the LT patients complained of dysphagia (34.5 vs 15%) on follow-up. There were no differences in the incidence of symptoms related to the gas-bloat syndrome. The observed differences between the LT and LNF groups did not appear to be related to differences in esophageal motility. CONCLUSIONS: Short-term results were similar for LT and LNF, but with longer follow-up, better results were seen with LNF. Even in the setting of moderate decreases of esophageal motility, complete fundoplication yields superior results.

Adult↗
PubMed2002

Outcomes of minimally invasive esophagectomy (MIE) for high-grade dysplasia of the esophagus.

OBJECTIVE: The management of high-grade dysplasia (HGD) of the esophagus is controversial with some clinicians advocating non-operative ablation or surveillance. Minimally invasive esophagectomy (MIE) allows re-section of the esophagus and may minimize morbidity. This report summarizes our experience with MIE for HGD. METHODS: A retrospective review of 28 patients who underwent MIE for a pre-operative diagnosis of HGD. MIE initially involved a laparoscopic transhiatal approach (n=1), but subsequently evolved to laparoscopy with VATS mobilization (n=27) of the esophagus. RESULTS: From August 1996 to March 2001, 28 patients underwent MIE. There were 23 males and five females; median age was 61 (40-78) years. Median hospital stay was 5 (3-20) days and ICU stay was 1 (1-20) day. One patient required conversion to laparotomy because of dense adhesions. There were ten other patients who had successful MIE despite prior laparotomy. Median operating time was 8 (5.8-13) h. One death occurred from sepsis, pneumonia and multi-system organ failure. Complications occurred in 15 patients. In addition to the patient who died, five re-operations were required for: small bowel perforation (n=1), jejunostomy leak (n=1), pyloric dilation for gastric outlet obstruction (n=1), cholecystectomy (n=1), incision and drainage of an abdominal abscess (n=1). Final pathologies were HGD (n=17), in situ cancer (n=6) and invasive cancer (n=5). At a median follow-up of 13 (2-41) months all hospital survivors are alive and free of disease. CONCLUSIONS: This report confirms the risk of occult cancer in patients with HGD (39% in this series) supporting the recommendation for esophagectomy. MIE can be performed with acceptable results and may minimize morbidity compared to previous reports of open esophagectomy for HGD.

Adult↗
PubMed2002

The role of tumor suppressor genes in esophageal cancer.

Esophageal cancer remains one of the 10 most common cancers worldwide. Although patients with early lesions have a reasonable prognosis, most patients present with advanced disease resulting in an overall 5-year survival of 5-10%. Therefore, the current challenges in the management of esophageal cancer are to obtain a better understanding of the underlying molecular biological alterations to provide new treatment options. During the development of esophageal cancer, there is progression from a premalignant epithelium to a neoplasm that frequently demonstrates a heterogeneous mix of genetic alterations. The vast majority of esophageal cancers have inactivation of the p53 and p16 genes at an early stage followed by defects in genes such as APC, Rb and cyclin D1 at later stages of progression. There is also mounting evidence that numerous, specific regions throughout the genome are frequently lost in these cancers. As a result, we will in the next decade, likely see the discovery and characterizations of novel tumor suppressor genes that may be important in the development of esophageal cancer. The accumulating knowledge about the inactivation of the tumor suppressor genes could ultimately provide us with objective diagnostic tools, more accurate markers for prediction of malignant transformation from premalignant epithelium and facilitate the introduction of novel therapeutic options for the management of esophageal cancer.

Esophageal Neoplasms↗
PubMed2001

Topographic analysis of K- ras mutations in histologically normal lung tissues and tumours of lung cancer patients.

Mutations in the K- ras gene are very common in lung tumours and are implicated in the development of lung cancer, but the timing of their occurrence remains poorly understood. We investigated K- ras mutations in cell samples microdissected by laser capture microscopy at multiple sites from lung tissue sections representing tumour tissue and matched histologically normal tissue obtained from 48 lung cancer patients. K- ras mutations were detected in cell samples from 10 of 38 (26.3%) lung adenocarcinomas and in none of the histologically normal or tumour cell samples taken from 10 lung squamous cell carcinomas. Of the K- ras mutation-positive adenocarcinomas, in 4 cases a mutation was found in only the tumour tissue, in 1 case a mutation was found only in the histologically normal tissue, and in 5 cases mutations were found in both the tumour tissue and histologically normal tissue. Among these 5 cases, 2 had identical mutations in both the tumour tissue and histologically normal tissue, 2 had 1 mutation in the tumour tissue and 2 mutations in the histologically normal tissue, 1 of which was identical to the mutation found in the tumour, and 1 case had 2 codon 12 mutations in tumour tissue and 2 mutations, in codons 9 and 11, in histologically normal tissue. These results showed that K- ras mutations are frequent in histologically normal cells taken from outside lung adenocarcinomas and suggest that some of these mutations may represent early events which could pave the way of lung carcinogenesis.

Adenocarcinoma↗
PubMed2001

Postoperative fluorescence bronchoscopic surveillance in non-small cell lung cancer patients.

BACKGROUND: Second lung primaries occur at a rate of 1% to 3% per patient-year after complete resections for non-small cell lung carcinoma (NSCLC). Fluorescence bronchoscopy appears to be a sensitive tool for surveillance of the tracheobronchial tree for early neoplasias. METHODS: Patients who were disease-free after complete resection of a NSCLC were entered into a fluorescence bronchoscopy surveillance program. All suspicious lesions were biopsied along with two areas of normal mucosa to serve as negative controls. RESULTS: A total of 73 fluorescence bronchoscopies were performed after conventional bronchoscopy in 51 patients at a median of 13 months postresection. The majority (46 of 51) of patients had stage I or II NSCLC, whereas 10% (5 of 51) had stage IIIA. Three intraepithelial neoplasias and one invasive carcinoma were identified in 3 of 51 patients (6%), all current or former smokers. Of the four lesions identified, three were in the 20 patients with prior squamous cell carcinomas. No intraepithelial neoplasias were identified by white-light bronchoscopy, whereas two of three were detected by fluorescence examination. The one invasive cancer detected was apparent on both white-light and fluorescence bronchoscopic examinations. CONCLUSIONS: Surveillance with fluorescence bronchoscopy identified lesions in 6% of postoperative NSCLC patients thought to be disease-free. Patients with prior squamous cell carcinomas appear to be a population that may warrant future prospective study of postoperative fluorescence bronchoscopic surveillance.

Adult↗
PubMed2001

CALGB 9380: a prospective trial of the feasibility of thoracoscopy/laparoscopy in staging esophageal cancer.

BACKGROUND: The staging of esophageal cancer is imprecise. Thoracoscopic/laparoscopic (TS/LS) staging has been proposed as a more accurate lymph node (LN) staging method. We report the experience of an Intergroup NCI trial (CALGB 9380) evaluating the feasibility and accuracy of this staging modality. PATIENTS AND METHODS: From February 1995 to September 1999, 134 patients were entered in the study. This study represents the analysis of final data on 113 patients. TS/LS was considered feasible if TS and 1 LN sampled at least 3 LN by LS; a confirmed positive node was found; or T4 or M1 disease was documented. If this was accomplished in more than 70% of patients, TS/LS was believed to be feasible. RESULTS: The LN stations most frequently sampled in the thorax (134 patients) were levels 2 (33%), 3 (38%), 4 (40%), 7 (76%), 8 (69%), 9 (55%), and 10 (43%) and in the abdomen levels 17 (70%) and 20 (55%). The frequency of positive LN by level were as follows: 2 (10%), 3 (8%), 4 (10%), 7 (10%), 8 (25%), 9 (10%), 10 (10%), 17 (34%), and 20 (27%). Noninvasive tests (computed tomographic scan, magnetic resonance imaging, esophageal ultrasound scan) each incorrectly identified TN staging as noted by missed positive or false-negative LN or metastatic disease found at TS/LS staging in 50%, 40%, and 30% of patients, respectively. Median operating time was 210 minutes (range, 40 to 865 minutes). Median postoperative hospital stay was 3 days (range, 1 to 35 days). There were no deaths or major complications. Seventy-three percent of patients met the definition for feasibility. In 30 patients TS was not feasible. Positive LN disease was found in 43 patients; 32 were deemed N0. Ten patients had T4/M1 disease. Of the 32 potentially resectable N0 patients, 14 patients had preoperative induction therapy; 13 patients went directly to operation with N0 confirmed in 9 patients, NX in 1 and N1 in 3. Three patients were unresectable, 1 patient died, and 1 was lost to follow-up. CONCLUSIONS: In summary, the feasibility of TS/LS was confirmed. It doubled the number of positive LNs identified by conventional, noninvasive staging. The overall accuracy remains to be defined by analysis of the LN negative group in follow-up. Although the positive predictive value was high, further study is warranted to confirm the role of TS/LS in the staging algorithm of esophageal cancer.

Adenocarcinoma↗
PubMed2001

Results of expandable metal stents for malignant esophageal obstruction in 100 patients: short-term and long-term follow-up.

BACKGROUND: Expandable metal stents palliate malignant dysphagia in most cases, but early complications and outcomes in long-term survivors have not been well described. This report summarizes our experience with expandable metal stents for malignant dysphagia. METHODS: Over a 48-month period, 127 stents were placed in 100 patients with dysphagia from esophageal cancer (93%) or lung cancer. Most had undergone prior treatment. Dysphagia scores, duration of palliation, complications, and reintervention were evaluated. RESULTS: Immediate improvement in dysphagia was observed in 85% of patients with no procedure-related deaths. Dysphagia score decreased from 3.3 before stent to 2.3 (p < 0.005). Average interval to reintervention was 80 days. In 40 patients surviving more than 120 days, 31 (78%) required reintervention. Major complications occurred in 3 patients receiving poststent chemoradiation (tracheoesophageal fistula, T1 vertebral body abscess, mediastinal abscess). Other complications included unsatisfactory deployment requiring immediate removal (3 patients), migration (11 patients), pain requiring removal (2 patients), food impaction (10 patients), and tumor ingrowth (37 patients). CONCLUSIONS: Expandable metal stents offer excellent short-term palliation of malignant dysphagia. In long-term survivors, recurrent dysphagia requiring reintervention is common. In a small subset of patients receiving chemoradiation after stent placement, major complications were observed.

Adult↗
PubMed2001

Correlation between dysplasia and mutations of six tumor suppressor genes in Barrett's esophagus.

BACKGROUND: Barrett's esophagus (BE) may progress to adenocarcinoma through dysplastic progression. Classification of dysplasia in BE has significant interobserver variability. Our objective was to determine whether genetic alterations in BE correlate with degrees of histologic dysplasia. METHODS: Fixed tissue from 37 patients with BE and adenocarcinoma was studied for six tumor suppressor genes. Tissues were microdissected and analyzed for loss of heterozygosity. Microdissection of individual crypts showing metaplasia and dysplasia were performed and analyzed for 23 of the 37 patients whose tumors were heterozygous for at least four of the six genes studied. RESULTS: Frequency of alterations for MXI1, hOGG1, p53, MTS1, DCC, and APC were 7 of 32 (22%), 12 of 35 (34%), 12 of 26 (46%), 17 of 30 (57%), 17 of 27 (63%), and 23 of 36 (64%), respectively. Analysis of BE demonstrated that crypts with metaplasia, low-grade dysplasia, and high-grade dysplasia strongly correlated with alterations in tumor suppressor genes (p < 0.0001). CONCLUSIONS: This pilot study demonstrates that genetic analysis can be performed on individual crypts in patients with BE, and that alterations may facilitate objective classification of the severity of dysplasia.

Adenocarcinoma↗
PubMed2001

Outcomes after minimally invasive esophagomyotomy.

BACKGROUND: Thoracic surgeons traditionally performed thoracotomy and myotomy for achalasia. Recently minimally invasive approaches have been reported with good success. This report summarizes our single-institution experience using video-assisted thoracoscopy (VATS) or laparoscopy (LAP) for the treatment of achalasia. METHODS: A review of 62 patients undergoing minimally invasive myotomy for achalasia was performed. There were 27 male and 35 female patients. Mean age was 53 years (range 14 to 86). Thirty-seven (59.7%) had failed prior treatments (balloon dilation, botulinim toxin injection, or prior surgery). Outcomes studied were dysphagia score (1 = none, 5 = severe), Short-Form 36 quality of life (SF36 QOL) score, and heartburn-related QOL index (HRQOL). RESULTS: Surgery included myotomy and partial fundoplication (5 VATS and 57 LAP). Mortality was zero, and complications occurred in 9 (14.5%) patients. There were 6 perforations (4 repaired by LAP and 2 open). Median length of stay was 2 days, time to oral intake was 1 day. At a mean of 19 months follow-up, 92.5% of patients were satisfied with outcome. Dysphagia scores improved from 3.6 to 1.5 (p < 0.01) but 3 patients ultimately required esophagectomy for recurrent dysphagia. HRQOL scores for heartburn and SF-36 QOL scores were comparable with control populations. CONCLUSIONS: Minimally invasive myotomy and partial fundoplication for achalasia improved dysphagia in 92.5% of patients with heartburn and QOL scores were comparable with normal values at 19-month follow-up. The laparoscopic approach offers excellent results and was the preferred approach by our thoracic group for treating achalasia. Thoracic residency training should strive to include laparoscopic esophageal experience.

Adolescent↗
PubMed2001

Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement.

OBJECTIVE: Provide explicit expert-based consensus recommendations for the management of adults with primary and secondary spontaneous pneumothoraces in an emergency department and inpatient hospital setting. The use of opinion was made explicit by employing a structured questionnaire, appropriateness scores, and consensus scores with a Delphi technique. The guideline was designed to be relevant to physicians who make management decisions for the care of patients with pneumothorax. OPTIONS: Decisions for observation, chest tube placement, surgical interventions, and radiographic imaging. OUTCOMES: Effectiveness of pneumothorax resolution, duration of and patient tolerance of care, and pneumothorax recurrence. EVIDENCE: Literature review from 1967 to January 1999 and Delphi questionnaire submitted in three iterations to a multidisciplinary physician panel. VALUES: The guideline development group determined by consensus the relevant outcomes to be considered in developing the Delphi questionnaire. BENEFITS, HARMS, AND COSTS: The type and magnitude of benefits, harms, and costs expected for patients from guideline implementation. RECOMMENDATIONS: Management decisions vary between patients with primary or secondary pneumothoraces, with observation of small pneumothoraces being appropriate only for primary pneumothoraces. The level of consensus varies regarding the specific interventions indicated, but agreement exists for the general principles of care. VALIDATION: Recommendations were peer reviewed by physician experts and were reviewed by the American College of Chest Physicians (ACCP) Health and Science Policy Committee. IMPLEMENTATION: The guideline recommendations will be published in printed and electronic form with distribution of synopses for patients and health care providers. Contents of the guideline will be incorporated into continuing medical education programs. SPONSORS: The ACCP.

Adult↗
PubMed2001

The role of positron emission tomography in evaluating mediastinal lymph node metastases in non-small-cell lung cancer.

Positron emission tomography (PET) is a modality that differentiates malignant from benign processes based upon metabolism rather than anatomy. A number of studies have confirmed improved accuracy of PET over computed tomography (CT), but until a few recent studies, most had failed to include satisfactory histologic confirmation. The objective of this study was to compare PET and CT to histologic staging of the mediastinum in patients with non-small-cell lung cancer (NSCLC). Histologic examination of mediastinal lymph nodes (MLNs) was performed on 40 patients with NSCLC at mediastinoscopy and/or at surgical resection. PET scans were interpreted by one of two nuclear medicine physicians, blinded to histology, using CT scans for anatomic localization. CT scans were independently evaluated for mediastinal lymphadenopathy. The overall accuracy, sensitivity, and specificity of PET were 78% (31 of 40), 67% (four of six), and 79% (27 of 34), respectively. The overall accuracy, sensitivity, and specificity of CT were 68% (27 of 40), 50% (three of six), and 71% (24 of 34), respectively. PET was superior to CT at correctly identifying mediastinal nodal metastases; however, both modalities were inferior to the gold standard of surgical staging. PET is more accurate than CT in staging the mediastinum of patients with NSCLC. PET failed to identify lymph node metastasis in 33% of patients with histologically proven MLN involvement, and false positives were present in 15%. At present, mediastinoscopy should remain the standard of care for preoperative mediastinal staging for NSCLC.

Journal Article↗