A critical gap in The Society of Thoracic Surgeons (STS) Database is the absence of patient-reported outcomes (PRO), which are of increasing importance in outcomes and performance measurement. Our ...aim was to demonstrate the feasibility of integrating PRO into the STS Database for patients undergoing lung cancer operations.
The National Institutes of Health Patient Reported Outcome Measurement Information System (PROMIS) includes reliable, precise measures of PRO. We used validated item banks within PROMIS to develop a survey for patients undergoing lung cancer resection. PRO data were prospectively collected electronically on tablet devices and merged with our institutional STS data. Patients were enrolled over 18 months (November 2014 to May 2016). The survey was administered preoperatively and at 1 and 6 months after lung cancer resection.
The study included 127 patients. All patients completed the initial postoperative survey, and 108 reached the 6-month follow-up. The most common procedure was video-assisted thoracic lobectomy (55%). At the first postoperative visit, there was a significant increase in pain, fatigue, and sleep impairment and a decrease in physical function. By 6 months, these PRO measures had generally improved toward baseline.
Collecting PRO data from lung cancer surgical patients and integrating the results into an institutional database is feasible. This pilot serves as a model for widespread incorporation of PRO data into the STS Database. Future integration of such data will continue to position the STS National Database as the gold standard for clinical registries. This will be necessary for assessing overall patient responses to different surgical therapies.
The advent of high-resolution computed tomography scanning and increase in use of chest imaging for high-risk patients has led to an increase in the identification of small pulmonary nodules. The ...ability to locate and remove these nodules through a thoracoscopic approach is difficult. The purpose of this study is to report our experience with fiducial localization and percutaneous thoracoscopic wedge resection of small pulmonary nodules.
This is a retrospective analysis of our patients who underwent computed tomography-guided fiducial localization of pulmonary nodules. Nodules were identified with intraoperative fluoroscopy and removed by thoracoscopic wedge resection.
Sixty-five nodules were removed in 58 patients. Removal was successful in 98% of patients (57 of 58); 79% of the nodules (53 of 65) were cancers; 20% of these were primary lung cancers of which 9 were pure ground-glass opacities. Mean size of the nodules was 9.9 ± 4.6 mm (range, 3 to 24 mm). Mean depth from visceral pleural surface was 18.7 ± 12 mm (range, 2 to 35 mm). Mean procedure time was 58.7 ± 20.1 minutes (range, 30 to 120), and mean length of stay was 2 days (range, 1 to 6). Complications occurred in 3 patients and included fiducial embolization, fiducial migration, and parenchymal hematoma.
Fiducial localization facilitates identification and removal of small pulmonary nodules and alleviates the need for direct nodule palpation. As shown by our series, thoracoscopic wedge resection with fiducial localization is an accurate and efficient technique. This method provides a standardized means by which to resect small and deep pulmonary nodules or ground-glass opacities.
Chest wall reconstruction using biomaterials Miller, Daniel L; Force, Seth D; Pickens, Allan ...
The Annals of thoracic surgery,
03/2013, Letnik:
95, Številka:
3
Journal Article
Recenzirano
Skeletal chest wall reconstruction can be a challenge, depending on the indication, location, and health of the patient; various materials are available. Recently, biomaterials that are remodelable ...(bovine pericardium patch; Veritas, Synovis Life Technologies Inc, St Paul, MN) or absorbable (polylactic acid PLA bar; BioBridge, Acute Innovations, Hillsboro, OR) have been introduced for reconstruction procedures.
We performed a retrospective review of all patients who underwent chest wall stabilization or reconstruction between July 1, 2009, and March 31, 2011.
Biomaterials were used in 25 of 112 patients (22%) who underwent chest wall stabilization or reconstruction, and they form the basis of this review. Indication for reconstruction was malignant disease in 17 patients (68%). Overall, 10 (40%) resection sites were infected preoperatively. Reconstruction was performed with a combination of bovine pericardium and PLA bars in 11 patients (44%), bovine pericardium alone in 10, and PLA bars alone in 4; muscle flaps were interposed in 7 patients (28%). There were no operative deaths. Complications occurred in 6 patients (24%). Median follow-up was 12 months (range, 6 to 27 months). Three patients required removal of their biomaterials. Two bovine pericardial patches were removed prophylactically at the time of debridement of a partially necrotic muscle flap, and 1 PLA bar was removed because of an inflammatory reaction. None of the patients with an infected resection site required removal of their biomaterial.
Chest wall reconstruction with biomaterials is a valuable option in the management of patients with chest wall abnormalities. Early results are promising. Biomaterials may be the preferred method of reconstruction for infected chest wall sites.
Data regarding risk factors for readmissions after surgical resection for lung cancer are limited and largely focus on postoperative outcomes, including complications and hospital length of stay. The ...current study aims to identify preoperative risk factors for postoperative readmission in early stage lung cancer patients.
The National Cancer Data Base was queried for all early stage lung cancer patients with clinical stage T2N0M0 or less who underwent lobectomy in 2010 and 2011. Patients with unplanned readmission within 30 days of hospital discharge were identified. Univariate analysis was utilized to identify preoperative differences between readmitted and not readmitted cohorts; multivariable logistic regression was used to identify risk factors resulting in readmission.
In all, 840 of 19,711 patients (4.3%) were readmitted postoperatively. Male patients were more likely to be readmitted than female patients (4.9% versus 3.8%, p < 0.001), as were patients who received surgery at a nonacademic rather than an academic facility (4.6% versus 3.6%; p = 0.001) and had underlying medical comorbidities (Charlson/Deyo score 1+ versus 0; 4.8% versus 3.7%; p < 0.001). Readmitted patients had a longer median hospital length of stay (6 days versus 5; p < 0.001) and were more likely to have undergone a minimally invasive approach (5.1% video-assisted thoracic surgery versus 3.9% open; p < 0.001). In addition to those variables, multivariable logistic regression analysis identified that median household income level, insurance status (government versus private), and geographic residence (metropolitan versus urban versus rural) had significant influence on readmission.
The socioeconomic factors identified significantly influence hospital readmission and should be considered during preoperative and postoperative discharge planning for patients with early stage lung cancer.
Anatomic sublobar resection is currently being assessed as an alternative to lobectomy for primary lung cancers less than 2 cm in size. Open segmentectomy is a proven oncologic procedure for patients ...with reduced cardiopulmonary reserve and significant comorbidities. With the increased use of thoracoscopy, a video-assisted thoracoscopic surgery (VATS) segmentectomy may be as safe and effective as an open segmentectomy.
We performed a retrospective review of patients who underwent a segmentectomy between May 2002 and March 2009 at Emory University Hospital.
Forty-one patients underwent pulmonary segmentectomy; 26 through thoracotomy (open) and 15 by a thoracoscopic (VATS) approach. Both groups were well matched for age, gender, and preoperative risk factors. Segmentectomy was performed for primary lung cancer in 25 (61%) patients. There was no difference in tumor size, number of lymph node stations sampled, or number of lymph nodes removed based upon approach. The remaining indications for surgery were metastatic disease in 12 patients and benign disease in 4 patients. All patients underwent R0 resections. There was no significant difference in operative time, but patients undergoing a VATS segmentectomy had significantly reduced chest tube durations and hospital stays. Major complications occurred in 19% of patients in the open group and none in the VATS group. There were two operative deaths (4.8%), both in the open group.
Video-assisted thoracoscopic surgery segmentectomy is a safe procedure which has fewer complications and a reduced hospital stay when compared with an open segmentectomy. This approach may be the ideal oncologic procedure for patients with small lung cancers (<2 cm) and (or) limited cardiopulmonary reserve and significant comorbidities.
Questions remain regarding differences in nodal evaluation and upstaging between thoracotomy (open) and video-assisted thoracic surgery (VATS) approaches to lobectomy for early-stage lung cancer. ...Potential differences in nodal staging based on operative approach remain the final significant barrier to widespread adoption of VATS lobectomy. The current study examines differences in nodal staging between open and VATS lobectomy.
The National Cancer Data Base was queried for patients with clinical stage T2N0M0 or lower lung cancer who underwent lobectomy in 2010–2011. Propensity score matching was performed to compare the rate of nodal upstaging in VATS with that in open approaches. Additional subgroup analysis was performed to assess whether rates of upstaging differed by specific clinical setting.
A total of 16,983 lobectomies were analyzed; 4935 (29.1%) were performed using VATS. Nodal upstaging was more frequent in the open group (12.8% versus 10.3%; p < 0.001). In 4437 matched pairs, nodal upstaging remained more common for open approaches. For a subgroup of patients who had seven lymph or more nodes examined, propensity matching revealed that nodal upstaging remained more common after an open approach than after VATS (14.0% versus 12.1%; p = 0.03). For patients who were treated in an academic/research facility, however, the difference in nodal upstaging between an open and VATS approach was no longer significant (12.2% versus 10.5%, p = 0.08).
For early-stage lung cancer, nodal upstaging was observed more frequently with thoracotomy than with VATS. However, nodal upstaging appears to be affected by facility type, which may be a surrogate for expertise in minimally invasive surgical procedures.
Esophagectomy is an important, but potentially morbid, operation used to treat benign and malignant conditions that may significantly impact patient quality of life (QOL). Patient-reported outcomes ...(PROs) are measures of QOL that come directly from patient self-report. This study characterizes patterns of change and recovery in PROs in the first year after esophagectomy.
Longitudinal QOL scores measuring physical function, pain, and dyspnea were obtained from esophagectomy patients during all clinic visits. PRO scores were obtained using the National Institutes of Health-sponsored Patient-Reported Outcomes Measurement Information System from April 2018 to February 2021. Mean PRO scores over 100 days after surgery were compared with baseline PRO scores using mixed-effects modeling with compound symmetry correlational structure.
One hundred three patients with PRO results were identified. Reasons for esophagectomy were malignancy (87.4%), achalasia (5.8%), stricture (5.8%), and dysplasia (1.0%). When comparing mean PRO scores at visits ≤ 50 days after surgery with preoperative PRO scores, physical function scores declined by 27.3% (P < .001), whereas dyspnea severity and pain interference scores had increased by 24.5% (P < .001) and 17.1% (P < .001), respectively. Although recovery occurred over the course of the 100 days after surgery, mean physical function scores and dyspnea scores were still 12.7% (P = .02) and 26.4% (P = .001) worse, respectively, than mean preoperative levels.
Despite declines in QOL scores immediately after esophagectomy, recovery back toward baseline was observed during the first 100 days. These findings are of considerable importance when counseling patients regarding esophagectomy, tracking recovery, and implementing quality improvement initiatives. Further long-term follow-up is needed to determine recovery beyond 100 days.
Hospital readmissions are costly and associated with inferior patient outcomes. There is limited knowledge related to readmissions after esophagectomy for malignancy. Our aim was to determine the ...impact on survival of readmission after esophagectomy.
This cohort study utilizes Surveillance, Epidemiology, and End Results-Medicare data (2002 to 2009). Survival, length of stay, 30-day readmissions, and discharge disposition were determined. Multivariate logistic regression models were created to examine risk factors associated with readmission.
In all, 1,744 patients with esophageal cancer underwent esophagectomy: 80% of patients (1,390) were male, and mean age was 73 years; 71.8% of tumors (1,251) were adenocarcinomas, and 72.5% (1,265) were distal esophageal tumors; 38% of patients (667) received induction therapy. Operative approach was transthoracic in 52.6% of patients (918) and transhiatal in 37.4% (653), and required complex reconstruction (intestinal interposition) in 9.9% (173). Stage distribution was as follows: stage I, 35.3% (616); stage II, 32.5% (566); stage III, 27.9% (487); and stage IV, 2.3% (40). Median length of stay was 13 days, hospital mortality was 9.3% (158 patients), and 30-day readmission rate was 18.6% (212 of 1,139 home discharges); 25.4% of patients (443) were discharged to institutional care facilities. Overall survival was significantly worse for patients who were readmitted (p < 0.0001, log rank test). Risk factors for readmission were comorbidity score of 3+, urgent admission, and urban residence.
Hospital readmissions after esophagectomy for cancer occur frequently and are associated with worse survival. Improved identification of patients at risk for readmission after esophagectomy can inform patient selection, discharge planning, and outpatient monitoring. Optimization of such practices may lead to improved outcomes at reduced cost.
Symptomatic pericardial cysts requiring operative management are rare entities. We present a patient with a symptomatic intra-pericardial cystic lesion with intermittent syncope who underwent ...treatment using a laparoscopic approach, thus minimizing pain and allowing quick recovery.
Proposed changes in health care will place an increasing burden on surgeons to care for patients more efficiently to minimize cost. We reviewed costs surrounding video-assisted thoracoscopic surgery ...(VATS) lobectomies to see where changes could be made to ensure maximum value.
We queried The Society of Thoracic Surgeons database for all VATS lobectomies performed for lung cancer from January 2011 to December 2013. Clinical data were linked with hospital financial data to determine hospital expenditures for each patient.
In all, 263 VATS lobectomies were included. Mean operating room time was 236 minutes, and median length of stay was 4 days. Mean hospital cost was $19,769. The majority of cost (58%) was attributed to operating room and floor costs (length of stay), and the majority of operating room costs were secondary to room rate and staplers. A total of 77 complications, as defined by STS, occurred in the cohort; 41 patients had only one complication, 11 patients had two complications, and 6 patients had three or more complications. The occurrence of one complication was associated with a net loss of $496 whereas two complications in a patient led to a $3,882 net loss. Overall, complications were independently correlated with significant cost increases.
Our study shows that the most significant costs associated with VATS lobectomies relate to operating room time, stapler use, floor charges, and cost associated with complications. Cost-reducing strategies will need to concentrate on optimizing operating room times and reducing length of stay while simultaneously minimizing complications.
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