Sir:FigureWe appreciate the kind comments regarding our recent article and congratulate the authors on their innovation of a portable system and successful outcome in this very challenging case. Since the description of Argenta and Morykwas in 1997 of vacuum-assisted closure,1 many clinicians have reported remarkable and unexpected outcomes in a variety of complex wounds with negative pressure. We, along with many investigators throughout the world, have studied the mechanism of action2 of these devices and have also thought of device modifications to further improve efficacy and to allow this technology to be more readily available throughout the world. A portable negative-pressure wound therapy device that is low cost, nonelectrical, and reusable could have a dramatic effect, particularly in the developing world. One of us (D.R.Z.) has developed such a device that can be fabricated using blow-molding technology and that achieves suction values up to 75 mmHg (Fig. 1). This device has been used on eight patients in Haiti and 12 patients in Rwanda and currently is being studied in a prospective fashion in Rwinkwavu Hospital and the Central University Teaching Hospital in Kigali, Rwanda. Conditions in these countries vary significantly from those seen in the United States or Brazil, and we hope that through carefully designed clinical trials, we will be able to learn the most effective applications of these technologies and avoid wounds where these devices can possibly cause harm.3 Once a final device is realized, the appropriate approvals, distribution, and training will need to be achieved for widespread clinical application.Fig. 1: The Wound-Pump, a simplified negative-pressure wound therapy device, applied to an ankle wound during the Haiti earthquake relief effort.This is an exciting time for the development of wound care devices that can make dramatic differences for our patients. We believe that further research into the mechanism of action, innovation in device design, and careful clinical trials will lead to better treatments for specific wound types for patients worldwide. Dennis P. Orgill, M.D., Ph.D. Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass. Danielle R. Zurovcik, M.S. Massachusetts Institute of Technology, Cambridge, Mass. Gita N. Mody, M.D. Brigham and Women's Hospital, Boston, Mass. DISCLOSURE Dr. Orgill has been an investigator on a grant to Brigham and Women's Hospital from Kinetic Concepts, Inc., and served as an expert witness and consultant for Kinetic Concepts, Inc. Ms. Zurovcik is an inventor of the device described in this communication. Dr. Mody has no conflicts of interest to disclose.
Patients with metastatic melanoma to the lung typically have poor outcomes. Although a pulmonary metastasectomy for selected patients has been shown to improve survival, the role of surgical resection following the introduction of immunotherapy for metastatic melanoma is unknown. The objective of this study was to determine predictors of survival for patients with melanoma metastatic to the lung in the era of immunotherapy. In this retrospective study, data from the National Cancer Database were abstracted for patients with melanoma lung metastases. The overall survival was evaluated using Kaplan-Meier and Cox proportional hazard analysis, adjusting for previously described risk factors for mortality. Patients with concomitant metastases to organs other than the lung were excluded from the study. A total of 625 patients with lung metastases at the time of a skin melanoma diagnosis were identified. A total of 280 patients underwent a pulmonary metastasectomy, 267 received immunotherapy, and 78 were treated with both a metastasectomy and immunotherapy. During a median follow-up time of 34.6 months [IQR: 14.2, 75.9], a metastasectomy was found to offer significantly improved survival compared to immunotherapy alone. No difference was noted between a metastasectomy and a combination of a metastasectomy and immunotherapy in the adjusted Cox proportional hazard model. When statistical models were adjusted for risk factors, a metastasectomy maintained a significant survival advantage compared to immunotherapy. The addition of immunotherapy to the treatment of patients treated with a pulmonary metastasectomy did not improve survival. Our findings support the role of surgery for patients with pulmonary metastatic melanoma.
Background and Objectives: Previous studies have demonstrated superior patient outcomes for thoracic oncology patients treated at high-volume surgery centers compared to low-volume centers. However, the specific role of overall hospital size in open esophagectomy morbidity and mortality remains unclear. Materials and Methods: Patients aged >18 years who underwent open esophagectomy for primary malignant neoplasia of the esophagus between 2002 and 2014 were identified using the National Inpatient Sample. Minimally invasive procedures were excluded. Discharges were stratified by hospital size (large, medium, and small) and analyzed using trend and multivariable regression analyses. Results: Over a 13-year period, a total of 69,840 open esophagectomy procedures were performed nationally. While the proportion of total esophagectomies performed did not vary by hospital size, in-hospital mortality trends decreased for all hospitals (large (7.2% to 3.7%), medium (12.8% vs. 4.9%), and small (12.8% vs. 4.9%)), although this was only significant for large hospitals (P < 0.01). After controlling for patient demographics, comorbidities, admission, and hospital-level factors, hospital length of stay (LOS), total inflation-adjusted costs, in-hospital mortality, and complications (cardiac, respiratory, vascular, and bleeding) did not vary by hospital size (all P > 0.05). Conclusions: After risk adjustment, patient morbidity and in-hospital mortality appear to be comparable across all institutions, including small hospitals. While there appears to be an increased push for referring patients to large hospitals, our findings suggest that there may be other factors (such as surgeon type, hospital volume, or board status) that are more likely to impact the results; these need to be further explored in the current era of episode-based care.
