Open esophagectomy results in significant morbidity and mortality. Minimally invasive esophagectomy (MIE) has become increasingly popular at specialized centers with the aim of improving ...perioperative outcomes. Numerous single-institution studies suggest MIE may offer lower short-term morbidity. The two approaches are compared using a large, multiinstitutional database.
The Society of Thoracic Surgeons (STS) National Database (v2.081) was queried for all resections performed for esophageal cancer between 2008 and 2011 (n = 3,780). Minimally invasive approaches included both transhiatal (n = 214) and Ivor Lewis (n = 600), and these were compared directly with open transhiatal (n = 1,065) and Ivor Lewis (n = 1,291) procedures, respectively. Thirty-day outcomes were examined using nonparametric statistical testing.
Both open and MIE groups were similar in terms of preoperative risk factors. Morbidity and all-cause mortality were equivalent at 62.2% and 3.8%. MIE was associated with longer median procedure times (443.0 versus 312.0 minutes; p < 0.001), but a shorter median length of hospital stay (9.0 versus 10.0 days; p < 0.001). Patients who underwent MIE had higher rates of reoperation (9.9% versus 4.4%; p < 0.001) and empyema (4.1% versus 1.8%; p < 0.001). Open technique led to an increased rate of wound infections (6.3% versus 2.3%; p < 0.001), postoperative transfusion (18.7% versus 14.1%; p = 0.002), and ileus (4.5% versus 2.2%; p = 0.002). Propensity score-matched analysis confirmed these findings. High- and low-volume centers had similar outcomes.
Early results from the STS National Database indicate that MIE is safe, with comparable rates of morbidity and mortality as open technique. Longer procedure times and a higher rate of reoperation following MIE may reflect a learning curve.
Objective Our objective was to investigate the surgical management of primary lung cancer by board-certified thoracic surgeons participating in the general thoracic surgery portion of The Society of ...Thoracic Surgeons database. Methods We identified all pulmonary resections recorded in the general thoracic surgery prospective database from 1999 to 2006. Among the 49,029 recorded operations, 9033 pulmonary resections for primary lung cancer were analyzed. Results There were 4539 men and 4494 women with a median age of 67 years (range 20–94 years). Comorbidity affected 79% of patients and included hypertension in 66%, coronary artery disease in 26%, body mass index of 30 kg/m2 or more in 25.7%, and diabetes mellitus in 13%. The type of resection was a wedge resection in 1649 (18.1%), segmentectomy in 394 (4.4%), lobectomy in 6042 (67%), bilobectomy in 357 (4.0%), and pneumonectomy in 591 (6.5%). Mediastinal lymph nodes were evaluated in 5879 (65%) patients; via mediastinoscopy in 1928 (21%), nodal dissection 3722 (41%), nodal sampling in 1124 (12.4%), and nodal biopsy in 729 (8%). Median length of stay was 5 days (range 0–277 days). Operative mortality was 2.5% (179 patients). One or more postoperative events occurred in 2911 (32%) patients. Conclusion The patients in the general thoracic surgery database are elderly, gender balanced, and afflicted by multiple comorbid conditions. Mediastinal lymph node evaluation is common and the pneumonectomy rate is low. The length of stay is short and operative mortality is low, despite frequent postoperative events.
Sarcopenia represented by low psoas muscle area is associated with increased hospital length of stay (LOS), postoperative complications, and mortality. We studied whether thoracic skeletal muscle ...area (TSMA) derived from computed tomography (CT) predicts morbidity after pneumonectomy for lung cancer.
Consecutive patients who underwent pneumonectomy for lung cancer from 2005 to 2017 were retrospectively analyzed. TSMA was defined as the sum of muscle area at the level of the eighth and the 12th thoracic vertebral bodies on preoperative CT. Patients were stratified into sex-specific TSMA quartiles for univariate time-to-event analyses. The effect of continuous TSMA measurements on operative complications, hospital and intensive care unit (ICU) LOS, discharge disposition, and hospital readmission within 90 days was estimated using multivariable models adjusted for age, sex, body mass index, forced expiratory volume in 1 second, Zubrod score, and pneumonectomy type.
Standard (n = 102, 78.5%) or high-risk (n = 28, 21.5%; extrapleural: n = 3, 2.3%; carinal: n = 9, 6.9%; completion: n = 16, 12.3%) pneumonectomy was performed in 130 patients (60.8 ± 10.6 years; 43.1% women). Major complications occurred in 33.1% (n = 43 of 130) and readmission in 17.7% (n = 23 of 130) of patients. In multivariable models, patients with high TSMA experienced fewer overall (odds ratio OR, 0.87; P = .04) and cardiopulmonary (OR, 0.86; P = .04) complications, and fewer readmissions (OR, 0.78; P = .01). Associations with ICU LOS (hazard ratio, 1.08; P = .051) and hospital LOS (hazard ratio, 1.05; P = .18) did not reach significance.
TSMA predicts adverse outcome after pneumonectomy for lung cancer. This marker, readily derived from standard chest CT, identifies patients at increased risk for postoperative complications and may help select patients appropriate for focused rehabilitation before pneumonectomy.
The Society of Thoracic Surgeons General Thoracic Surgery Database (STS GTSD) is a voluntary effort that provides participants with risk-adjusted semiannual performance reports that allow comparison ...of institutional outcomes against national benchmarks. With nearly 1,000 surgeons contributing data from more than 300 centers across North America, the STS GTSD now includes almost a half million cases. In 2016, updated risk models for lung resection and esophagectomy for cancer were reported, and composite quality measures for lobectomy and esophagectomy were developed. Ongoing efforts include upgrading the STS GTSD, establishing public reporting of lobectomy for lung cancer composite scores, creating an on-line dashboard, and strengthening international collaboration with the European Society of Thoracic Surgery Registry. With these initiatives, the STS GTSD aims to continue to improve quality of care and support research endeavors in general thoracic surgery. This article summarizes current aggregate national outcomes in general thoracic surgery and reviews related activities in the areas of quality measurement, performance improvement, and transparency from the STS GTSD during the past 12 months.
To determine the effect of the introduction of low dose computed tomography screening in 2013 on lung cancer stage shift, survival, and disparities in the stage of lung cancer diagnosed in the United ...States.
Quasi-experimental study using Joinpoint modeling, multivariable ordinal logistic regression, and multivariable Cox proportional hazards modeling.
US National Cancer Database and Surveillance Epidemiology End Results program database.
Patients aged 45-80 years diagnosed as having non-small cell lung cancer (NSCLC) between 1 January 2010 and 31 December 2018.
Annual per cent change in percentage of stage I NSCLC diagnosed among patients aged 45-54 (ineligible for screening) and 55-80 (potentially eligible for screening), median all cause survival, and incidence of NSCLC; multivariable adjusted odds ratios for year-to-year changes in likelihood of having earlier stages of disease at diagnosis and multivariable adjusted hazard ratios for changes in hazard of death before versus after introduction of screening.
The percentage of stage I NSCLC diagnosed among patients aged 55-80 did not significantly increase from 2010 to 2013 (from 27.8% to 29.4%) and then increased at 3.9% (95% confidence interval 3.0% to 4.8%) per year from 2014 to 2018 (from 30.2% to 35.5%). In multivariable adjusted analysis, the increase in the odds per year of a patient having one lung cancer stage lower at diagnosis during the time period from 2014 to 2018 was 6.2% (multivariable adjusted odds ratio 1.062, 95% confidence interval 1.048 to 1.077; P<0.001) higher than the increase in the odds per year from 2010 to 2013. Similarly, the median all cause survival of patients aged 55-80 did not significantly increase from 2010 to 2013 (from 15.8 to 18.1 months), and then increased at 11.9% (8.9% to 15.0%) per year from 2014 to 2018 (from 19.7 to 28.2 months). In multivariable adjusted analysis, the hazard of death decreased significantly faster after 2014 compared with before 2014 (P<0.001). By 2018, stage I NSCLC was the predominant diagnosis among non-Hispanic white people and people living in the highest income or best educated regions. Non-white people and those living in lower income or less educated regions remained more likely to have stage IV disease at diagnosis. Increases in the detection of early stage disease in the US from 2014 to 2018 led to an estimated 10 100 averted deaths.
A recent stage shift toward stage I NSCLC coincides with improved survival and the introduction of lung cancer screening. Non-white patients and those living in areas of greater deprivation had lower rates of stage I disease identified, highlighting the need for efforts to increase access to screening in the US.
The Society of Thoracic Surgeons (STS) National Database was established in 1989 as an initiative for quality improvement and patient safety among cardiothoracic surgeons. As of January 1, 2018, the ...STS National Database has four components, each focusing on a different area of cardiothoracic surgery-adult cardiac surgery, general thoracic surgery, and congenital heart surgery, as well as mechanical circulatory support through the STS Intermacs Database. In December 2015, The Annals of Thoracic Surgery began publishing a monthly series of scholarly articles on outcomes analysis, quality improvement, and patient safety. As part of that series, this article provides an annual summary of the status of the STS National Database as of October 2018 and provides a synopsis of related articles that appeared in The Annals of Thoracic Surgery 2018 series entitled: "Outcomes Analysis, Quality Improvement, and Patient Safety".
Few reliable estimations of operative risk exist for lung cancer patients undergoing lobectomy. This study identified risk factors associated with prolonged length of hospital stay (PLOS) after ...lobectomy for lung cancer as a surrogate for perioperative morbid events.
The Society of Thoracic Surgeons (STS) General Thoracic Surgery Database was queried for patients with lobectomy for lung cancer. A model of preoperative risk factors was developed by multivariate stepwise logistic regression setting the threshold for PLOS at 14 days. Morbidity was measured as postoperative events as defined in the STS database. Risk-adjusted results were reported to participating sites.
From January 2002 to June 2006, 4979 lobectomies were performed for lung cancer at 56 STS sites, and 351 (7%) had a PLOS. They had more postoperative events than patients without PLOS (3.4 vs 1.2; p < 0.0001). Patients with PLOS also had higher mortality than those with normal LOS, at 10.8% (38 of 351) vs 0.7% (33 of 4628; p < 0.0001). Significant predictors of PLOS included age per 10 years (odds ratio OR, 1.30, p < 0.001), Zubrod score (OR, 1.51; p < 0.001), male sex (OR, 1.45; p = 0.002), American Society of Anesthesiology score (OR, 1.54; p < 0.001), insulin-dependent diabetes (OR. 1.71; p = 0.037), renal dysfunction (OR, 1.79; p = 0.004), induction therapy (OR, 1.65; p = 0.001), percentage predicted forced expiratory volume in 1 second in 10% increments (OR, 0.88; p < 0.001), and smoking (OR, 1.33; p = 0.095). After risk adjustment, twofold interhospital variability existed in PLOS among STS sites
We identified significant predictors of PLOS, a surrogate morbidity marker after lobectomy for lung cancer. This model may be used to provide meaningful risk-adjusted outcome comparisons to STS sites for quality improvement purposes.
As worldwide life expectancy rises, the number of candidates for surgical treatment of esophageal cancer over 70 years will increase. This study aims to examine outcomes after esophagectomy in ...elderly patients.
This study is a retrospective review of 474 patients undergoing esophagectomy for cancer during 2002 to 2011. A total of 334 (70.5%) patients were less than 70 years old (group A), 124 (26.2%) 70 to 79 years (group B), and 16 (3.4%) 80 years or greater (group C). We analyzed the effect of age on outcome variables including overall and disease specific survival.
Major morbidity was observed to occur in 115 (35.6%) patients of group A, 58 (47.9%) of group B, and 10 (62.5%) of group C (p = 0.010). Mortality, both 30-day and 90-day was observed in 2 (0.6%) and 7 (2.2%) of group A, 4 (3.2%) and 7 (6.1%) of group B, and 1 (6.3%) and 2 (14.3%) of group C, respectively (p = 0.032 and p = 0.013). Anastomotic leak was observed in 16 (4.8%) patients of group A, 6 (4.8%) of group B, and 0 (0%) of group C (p = 0.685). Anastomotic stricture (defined by the need for ≥ 2 dilations) was observed in 76 (22.8%) of group A, 13 (10.5%) of group B, and 1 (6.3%) of group C (p = 0.005). Five-year overall and disease specific survival was 64.8% and 72.4% for group A, 41.7% and 53.4% for group B, 49.2% and 49.2% for group C patients (p = 0.0006), respectively.
Esophagectomy should be carefully considered in patients 70 to 79 years old and can be justified with low mortality. Outcomes in octogenarians are worse suggesting esophagectomy be considered on a case by case basis. Stricture rate is inversely associated to age.
Sampling of ≥10 lymph nodes during lobectomy for non-small cell lung cancer (NSCLC) was a previous surveillance metric and potential quality metric of the American College of Surgeons Commission on ...Cancer. We sought to determine guideline adherence and its relationship to hospital lobectomy volume within The Society of Thoracic Surgeons General Thoracic Surgery Database.
Participant centers providing elective lobectomy for NSCLC within The Society of Thoracic Surgeons General Thoracic Surgery Database (2012-2019) were divided into tertiles according to annual volume. Average hospital nodal harvest of ≥10 nodes per lobectomy defined the primary outcome. Univariable analysis compared average patient and operative characteristics between the participant centers. Multivariable logistic regression was used to determine independent factors associated with average clinical center nodal harvest of ≥10 nodes.
Median annual lobectomy volume was 6.2, 19.9, and 42.7 for low-, medium-, and high-volume participant centers. Among 305 centers and 43 597 patients, 5.6% of lobectomies occurred in low-volume centers, 24.0% in medium-volume centers, and 70.4% in high-volume centers. Average rates of ≥10 nodes per lobectomy were excised in 44.0% of low-volume centers, 70.6% of medium-volume centers, and 75.2% of high-volume centers (P < .001). On multivariable analysis, average nodal excision of ≥10 nodes was strongly associated with medium-volume (odds ratio, 2.94; CI, 1.57-5.50, P < .01) and high-volume (odds ratio, 3.82; CI, 1.95-7.46; P < .001) participant centers.
Although higher center volume and increased nodal harvest are associated, 25% of high-volume centers average a rate of <10 lymph nodes per lobectomy for NSCLC. Low nodal yield may underestimate stage, with implications for adjuvant therapy and long-term survival.
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