title: The "cut-in patch-out" technique for Pancoast tumor resections results in postoperative pain reduction: a case control study.
abstract: BACKGROUND
  Since 2001 we have utilized a novel surgical approach for Pancoast tumors in which lobectomy and mediastinal lymph node dissection are performed directly though the chest wall defect. The defect is then patched at the completion of the procedure ("cut-in patch-out") thereby avoiding a separate thoracotomy with rib spreading. We undertook a study to compare outcomes of this novel "cut-in patch-out" technique with traditional thoracotomy for patients with Pancoast tumors.
  
  
  METHODS
  We retrospectively identified 41 patients undergoing surgical resection of Pancoast tumors requiring en-bloc removal of at least 3 ribs at our institution from 1999 to 2012. Surgery was accomplished by either a "cut-in patch-out" technique (n = 25) or traditional posterolateral thoracotomy and separate chest wall resection (n = 16). Multiple variables including patient demographics, neoadjuvant therapy, extent of resection, and pathology were analyzed with respect to outcomes from morbidity, narcotic use, and oncologic perspectives.
  
  
  RESULTS
  Baseline demographics, neoadjuvant therapy, and perioperative factors including extent of surgery, complete resections (R0), nodal status and lymph node number, morbidity, and mortality were similar between the two groups. The mean duration of out-patient narcotic use was significantly lower in the "cut-in patch-out" group compared to the thoracotomy group (80.6 days ± 62.4 vs. 158.2 days ± 119.2, p < 0.01). Using multivariate regression analysis, the traditional thoracotomy technique (OR 7.72; p = 0.01) was independently associated with prolonged oral narcotic requirements (>100 days). Additionally, five year survival for the "cut-in patch-out" group was 48% versus the traditional group at 12.5% (p = 0.04).
  
  
  CONCLUSIONS
  Compared with a traditional thoracotomy and separate chest wall resection approach for P-NSCLC, a "cut-in patch-out" technique offers an alternative approach that appears to have at least oncologic equivalence while decreasing pain. We have more recently adapted this technique to select patients with pulmonary neoplasms involving chest wall invasion and believe further investigation is warranted.
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Weber
authors.forename: Ikenna C
authors.initials: IC
authors.lastname: Okereke
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Birdas
authors.forename: DuyKhanh P
authors.initials: DP
authors.lastname: Ceppa
authors.forename: Karen M
authors.initials: KM
authors.lastname: Rieger
authors.affiliation: Division of Cardiothoracic Surgery, Department of Surgery, Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, IN, USA. kkesler@iupui.edu.
authors.forename: Kenneth A
authors.initials: KA
authors.lastname: Kesler
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002289:Carcinoma, Non-Small-Cell Lung / Q000601:surgery*; D016022:Case-Control Studies; D005260:Female; D006801:Humans; D008197:Lymph Node Excision; D008297:Male; D008482:Mediastinum; D008875:Middle Aged; D010149:Postoperative Pain / Q000517:prevention & control*; D010178:Pancoast Syndrome / Q000601:surgery*; D011013:Pneumonectomy / Q000379:methods*; D012189:Retrospective Studies; D035441:Thoracic Wall / Q000601:surgery*; D013908:Thoracotomy; D016896:Treatment Outcome