The treatment of mesothelioma has evolved slowly over the last 20 years. While surgery as a standalone treatment has fallen out of favor, the importance of multimodality treatment consisting of ...combinations of chemotherapy, radiotherapy, and surgery have become more common in operable, fit patients. In this review, we discuss trials in surgery, chemotherapy, and radiation that have shaped contemporary multimodality treatment of this difficult malignancy, and we touch on the new and emerging immunotherapeutic and targeted agents that may change the future treatment of this disease. We also review the multimodality treatment regimens, with particular attention to trimodality therapy and neoadjuvant hemithoracic radiation strategies.
The extraordinary demands of managing the COVID-19 pandemic has disrupted the world's ability to care for patients with thoracic malignancies. As a hospital's COVID-19 population increases and ...hospital resources are depleted, the ability to provide surgical care is progressively restricted, forcing surgeons to prioritize among their cancer populations. Representatives from multiple cancer, surgical, and research organizations have come together to provide a guide for triaging patients with thoracic malignancies as the impact of COVID-19 evolves as each hospital.
Introduction Oesophageal discontinuity remains a challenge for thoracic and foregut surgeons globally. Whether arising emergently after catastrophic oesophageal or gastric disruption or arising in ...the elective setting in the case of staged reconstruction for esophagectomy or long gap atresia in the paediatric population, comprehensive review of this patient population remains unexplored within the surgical literature. The goal of this scoping review is to map the landscape of literature exploring the creation and takedown of cervical oesophagostomy with the intent to answer four questions (1) What are the primary indications for oesophageal discontinuity procedures? (2) What are the disease-specific and healthcare utilisation outcomes for oesophageal discontinuity procedures? (3) What is the primary indication for reversal procedures? (4) What are the disease-specific and healthcare utilisation outcomes for reversal procedures? Methods This review will follow the Arksey and O’Malley (2005) framework for scoping reviews. Paediatric (<18 years old) and adult (>18 years old) patients, who have received a cervical oesophagostomy in the context of a gastrointestinal discontinuity procedure or those who have had reversal of a cervical oesophagostomy, will be included for analysis. We will search MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL) databases for papers from 1990 until 2023. Interventional trials, prospective and retrospective observational studies, reviews, case series and qualitative study designs will be included. Two authors will independently review all titles, abstracts and full texts to determine which studies meet the inclusion criteria. Ethics and dissemination No ethics approval is required for this review. Results will be disseminated through scientific presentations and relevant conferences targeted for researchers examining upper gastrointestinal/foregut surgery. Registration details This protocol is registered with Open Science Framework (osf.io/s3b4g).
Commentary: John Snow, pneumonectomy, and complication epidemiology Wakeam, Elliot
Journal of thoracic and cardiovascular surgery/The Journal of thoracic and cardiovascular surgery/The journal of thoracic and cardiovascular surgery,
07/2020, Volume:
160, Issue:
1
Journal Article
The extraordinary demands of managing the COVID-19 pandemic has disrupted the world's ability to care for patients with thoracic malignancies. As a hospital's COVID-19 population increases and ...hospital resources are depleted, the ability to provide surgical care is progressively restricted, forcing surgeons to prioritize among their cancer populations. Representatives from multiple cancer, surgical, and research organizations have come together to provide a guide for triaging patients with thoracic malignancies as the impact of COVID-19 evolves as each hospital.
Adjuvant mediastinal radiotherapy (AMR) is used after surgical resection for patients with small cell lung cancer (SCLC), but data guiding its use are scant. We sought to examine whether AMR was ...associated with an improvement in survival for resected SCLC patients and to define subpopulations who should be selected for AMR.
Patients undergoing lobectomy, pneumonectomy, and sublobar resection for SCLC were identified in the National Cancer Database (2004 to 2013). Kaplan-Meier survival curves and Cox proportional hazards were used to evaluate associations between AMR and survival. Hazard ratios were adjusted for patient comorbidity, demographics, tumor characteristics, such as stage, grade, histology, and margin status, and receipt of adjuvant chemotherapy.
We identified 3,101 patients. Those receiving AMR were younger, more likely to have greater pathologic T and N stage, to undergo sublobar resection, and to have a positive margin. Kaplan-Meier curves showed better median survival for patients with pN1 or pN2 disease who received AMR. After adjustment, Cox models showed AMR was associated with a lower risk of death for pN1 (hazard ratio, 0.79; 95% confidence interval, 0.63 to 1.00; p = 0.05) and pN2 (hazard ratio, 0.60; 95% confidence interval, 0.48 to 0.75; p < 0.0001). In the overall cohort, AMR was not associated with better survival in node-negative patients. AMR was, however, associated with improved survival for patients receiving sublobar resection (hazard ratio, 0.72; 95% confidence interval, 0.57 to 0.90; p = 0.004).
AMR is associated with longer survival for node-positive patients after resection for SCLC, especially those with pN2. AMR may also be associated with longer survival in patients undergoing sublobar resections.
Summary Surgeon unemployment has become a crisis within Canadian surgery in recent years. Without dedicated governmental workforce planning, ensuring that new residency graduates can find employment ...will require new models of employment. Practice sharing, whereby a new graduate and a senior surgeon partner to divide their practices, allows the senior surgeon to wind down and the newer surgeon to ramp up. Importantly, this arrangement builds in formal mentoring, which is so important in the early years of starting a surgical practice. Practice sharing may be a solution for the workforce issues currently afflicting new surgical graduates across Canada.
Abstract Background Informed consent is important for limited English proficient (LEP) patients undergoing surgery, as many surgical procedures are complicated, making patient comprehension difficult ...even without language barriers. The study objectives were to (1) understand surgeons' preoperative consenting process with LEP patients, (2) examine how surgeons self assess their non-English language proficiency levels using a standardized scale, and (3) identify the relationship between self assessed non-English language proficiency and surgeons' self-reported use of interpreters during preoperative informed consent. Materials and methods A thirty-two item survey assessing surgeons' reported preoperative informed consent process, with questions related to demographics, level of medical training, non-English language skills and their clinical use, language learning experiences, and hypothetical scenarios with LEP patients. Results Surgeons who were not fluent in non-English languages reported they often used those limited skills to obtain informed consent from their LEP patients. Many surgeons reported relying on bilingual hospital staff members, family members, and/or minors to serve as ad-hoc interpreters when obtaining informed consent. If a professional interpreter was not available in a timely manner, surgeons more frequently reported using ad-hoc interpreters or their own nonfluent language skills. Surgeons reported deferring to patient and family preferences when deciding whether to use professional interpreters and applied different thresholds for different clinical scenarios when deciding whether to use professional interpreters. Conclusions Surgeons reported relying on their own non-English language skills, bilingual staff, and family and friends of patients to obtain informed consent from LEP patients, suggesting that further understanding of barriers to professional interpreter use is needed.
Accountable care organizations are designed to improve value by decreasing costs and maintaining quality. Strategies to maximize value are needed for high-risk surgery. We wanted to understand ...whether certain patient groups were differentially associated with better outcomes at high-volume hospitals in terms of quality and cost.
In all, 37,746 patients underwent elective major lung resection in 1,273 hospitals in the Nationwide Inpatient Sample from 2007 to 2011. Patients were stratified by hospital volume quartile and substratified by preoperative mortality risk, age, and chronic obstructive pulmonary disease status. Mortality was evaluated using clustered multivariable hierarchical logistic regression controlling for patient comorbidity, demographics, and procedure. Adjusted cost was evaluated using generalized linear models fit to a gamma distribution.
Patients were grouped into volume quartiles based on cases per year (less than 21, 21 to 40, 40 to 78, and more than 78). Patient characteristics and procedure mix differed across quartiles. Overall, mortality decreased across volume quartiles (lowest 1.9% versus highest 1.1%, p < 0.0001). Patients aged more than 80 years were associated with greater absolute and relative mortality rates than patients less than 60 years old in highest volume versus lowest volume hospitals (age more than 80 years, 4.2% versus 1.3%, p < 0.0001, odds ratio 3.31, 95% confidence interval: 1.89 to 5.80; age less than 60 years, 1.0% versus 0.8%, p = 0.19, odds ratio 1.38, 95% confidence interval: 0.74 to 2.56). Patients with high preoperative risk (more than 75th percentile) were also associated with lower absolute mortality in high-volume hospitals. Adjusted costs were not significantly different across quartiles or patient strata.
Older patients show a significantly stronger volume-outcome relationship than patients less than 60 years of age. Costs were equivalent across volume quartile and patient strata. Selective patient referral may be a strategy to improve outcomes for elderly patients undergoing lung resection.
Background Surgical patients and their physicians currently have tools to provide individualized prognostication for morbidity and mortality. For improved shared decision making, formal prediction of ...patient-centered outcomes is necessary. We derived and validated a simple, interview-based method to predict discharge home after surgery. Study Design We used the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Patient User File for 2011. Derivation in general and vascular surgery patients undergoing inpatient surgery was completed using serial multiple logistic regression. Validation was performed within multiple surgical specialties. Results The derivation cohort included 88,068 patients, of whom 11,771 (13.4%) were not discharged home. The derived Home Calculator had excellent discrimination (c-statistic = 0.864) using 4 variables: age, American Society of Anesthesiologists' performance status, elective surgery, and preadmission residence. Validation cohorts had varying rates of home discharge as follows: general (63,826 of 71,591, 89.2%), vascular (12,319 of 16,102, 76.5%), gynecologic (16,603 of 17,005, 97.6%), urologic (13,662 of 14,435, 94.6%), orthopaedic (12,000 of 19,514, 61.5%), thoracic (4,467 of 5,092, 87.7%). The Home Calculator provided good to excellent discrimination in validation cohorts: general (c = 0.866), vascular (c = 0.800), gynecologic (c = 0.793), urologic (c = 0.814), orthopaedic (c = 0.876), and thoracic (c = 0.800). Comparable discrimination was demonstrated in sensitivity analyses in surgical patients admitted exclusively from home. Conclusions We derived and validated a simple Home Calculator that reliably predicts discharge to home after surgery and may be useful when counseling patients about postoperative course. Patient-centered tools such as this may allow physicians to better prepare patients and families for surgery and the recovery process.
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