Background Data from selected centers show that robotic lobectomy is safe and effective and has 30-day mortality comparable to that of video-assisted thoracoscopic surgery (VATS). However, widespread ...adoption of robotic lobectomy is controversial. We used The Society of Thoracic Surgeons General Thoracic Surgery (STS-GTS) Database to evaluate quality metrics for these 2 minimally invasive lobectomy techniques. Methods A database query for primary clinical stage I or stage II non-small cell lung cancer (NSCLC) at high-volume centers from 2009 to 2013 identified 1,220 robotic lobectomies and 12,378 VATS procedures. Quality metrics evaluated included operative morbidity, 30-day mortality, and nodal upstaging, defined as cN0 to pN1. Multivariable logistic regression was used to evaluate nodal upstaging. Results Patients undergoing robotic lobectomy were older, less active, and less likely to be an ever smoker and had higher body mass index (BMI) (all p < 0.05). They were also more likely to have coronary heart disease or hypertension (all p < 0.001) and to have had preoperative mediastinal staging ( p < 0.0001). Robotic lobectomy operative times were longer (median 186 versus 173 minutes; p < 0.001); all other operative measurements were similar. All postoperative outcomes were similar, including complications and 30-day mortality (robotic lobectomy, 0.6% versus VATS, 0.8%; p = 0.4). Median length of stay was 4 days for both, but a higher proportion of patients undergoing robotic lobectomy had hospital stays less than 4 days (48% versus 39%; p < 0.001). Nodal upstaging overall was similar ( p = 0.6) but with trends favoring VATS in the cT1b group and robotic lobectomy in the cT2a group. Conclusions Patients undergoing robotic lobectomy had more comorbidities and robotic lobectomy operative times were longer, but quality outcome measures, including complications, hospital stay, 30-day mortality, and nodal upstaging, suggest that robotic lobectomy and VATS are equivalent.
Background Pulmonary function tests predict respiratory complications and mortality after lung resection through thoracotomy. We sought to determine the impact of pulmonary function tests upon ...complications after thoracoscopic lobectomy. Methods A model for morbidity, including published preoperative risk factors and surgical approach, was developed by multivariable logistic regression. All patients who underwent lobectomy for primary lung cancer between December 1999 and October 2007 with preoperative forced expiratory volume in 1 second (FEV1 ) or diffusion capacity to carbon monoxide (D lco ) 60% or less predicted were reviewed. Preoperative, histopathologic, perioperative, and outcome variables were assessed using standard descriptive statistics. Pulmonary complications were defined as atelectasis requiring bronchoscopy, pneumonia, reintubation, and tracheostomy. Results During the study period, 340 patients (median age 67) with D lco or FEV1 60% or less (mean % predicted FEV1 , 55 ± 1; mean % predicted D lco , 61 ± 1) underwent lobectomy (173 thoracoscopy, 167 thoracotomy). Operative mortality was 5% (17 patients) and overall morbidity was 48% (164 patients). At least one pulmonary complication occurred in 57 patients (17%). Significant predictors of pulmonary complications by multivariable analysis for all patients included D lco (odds ratio 1.03, p = 0.003), FEV1 (odds ratio 1.04, p = 0.003), and thoracotomy as surgical approach (odds ratio 3.46, p = 0.0007). When patients were analyzed according to operative approach, D lco and FEV1 remained significant predictors of pulmonary morbidity for patients undergoing thoracotomy but not thoracoscopy. Conclusions In patients with impaired pulmonary function, preoperative pulmonary function tests are predictors of pulmonary complications when lobectomy for lung cancer is performed through thoracotomy but not through thoracoscopy.
Objectives Advantages of thoracoscopic lobectomy include less postoperative pain, shorter hospitalization, and improved delivery of adjuvant chemotherapy. The incidence of postoperative complications ...has not been thoroughly assessed. This study analyzes morbidity after lobectomy to compare the thoracoscopic approach and thoracotomy. Methods By using a prospective database, the outcomes of patients who underwent lobectomy from 1999–2009 were analyzed with respect to postoperative complications. Propensity-matched groups were analyzed based on preoperative variables and stage. Results Of the 1079 patients in the study, 697 underwent thoracoscopic lobectomy, and 382 underwent lobectomy by means of thoracotomy. In the overall analysis thoracoscopic lobectomy was associated with a lower incidence of atrial fibrillation ( P = .01), atelectasis ( P = .0001), prolonged air leak ( P = .0004), transfusion ( P = .0001), pneumonia ( P = .001), sepsis ( P = .008), renal failure ( P = .003), and death ( P = .003). In the propensity-matched analysis based on preoperative variables, when comparing 284 patients in each group, 196 (69%) patients who underwent thoracoscopic lobectomy had no complications versus 144 (51%) patients who underwent thoracotomy ( P = .0001). In addition, thoracoscopic lobectomy was associated with a lower incidence of atrial fibrillation (13% vs 21%, P = .01), less atelectasis (5% vs 12%, P = .006), fewer prolonged air leaks (13% vs 19%, P = .05), fewer transfusions (4% vs 13%, P = .002), less pneumonia (5% vs 10%, P = .05), less renal failure (1.4% vs 5%, P = .02), shorter chest tube duration (median of 3 vs 4 days, P < .0001), and shorter length of hospital stay (median of 4 vs 5 days, P < .0001). Conclusions Thoracoscopic lobectomy is associated with a lower incidence of major complications, including atrial fibrillation, compared with lobectomy by means of thoracotomy. The underlying factors responsible for this advantage should be analyzed to improve the safety and outcomes of other thoracic procedures.
Background The purpose of this analysis was to revise the model for perioperative risk for esophagectomy for cancer utilizing The Society of Thoracic Surgeons General Thoracic Surgery Database to ...provide enhanced risk stratification and quality improvement measures for contributing centers. Methods The Society of Thoracic Surgeons General Thoracic Surgery Database was queried for all patients treated for esophageal cancer with esophagectomy between July 1, 2011, and June 30, 2014. Multivariable risk models for major morbidity, perioperative mortality, and combined morbidity and mortality were created with the inclusion of surgical approach as a risk factor. Results In all, 4,321 esophagectomies were performed by 164 participating centers. The most common procedures included Ivor Lewis (32.5%), transhiatal (21.7%), minimally invasive esophagectomy, Ivor Lewis type (21.4%), and McKeown (10.0%). Sixty-nine percent of patients received induction therapy. Perioperative mortality (inpatient and 30-day) was 135 of 4,321 (3.4%). Major morbidity occurred in 1,429 patients (33.1%). Major morbidities include unexpected return to operating (15.6%), anastomotic leak (12.9%), reintubation (12.2%), initial ventilation beyond 48 hours (3.5%), pneumonia (12.2%), renal failure (2.0%), and recurrent laryngeal nerve paresis (2.0%). Statistically significant predictors of combined major morbidity or mortality included age more than 65 years, body mass index 35 kg/m2 or greater, preoperative congestive heart failure, Zubrod score greater than 1, McKeown esophagectomy, current or former smoker, and squamous cell histology. Conclusion Thoracic surgeons participating in The Society of Thoracic Surgeons General Thoracic Surgery Database perform esophagectomy with low morbidity and mortality. McKeown esophagectomy is an independent predictor of combined postoperative morbidity or mortality. Revised predictors for perioperative outcome were identified to facilitate quality improvement processes and hospital comparisons.
Background Studies evaluating risk factors for complications after lobectomy in elderly patients have not adequately analyzed the effect of using minimally invasive approaches. Methods A model for ...morbidity including published preoperative risk factors and surgical approach was developed by multivariable logistic regression. All patients aged 70 years or older who underwent lobectomy for primary lung cancer without chest wall resection or airway procedure between December 1999 and October 2007 at a single institution were reviewed. Preoperative, histopathologic, perioperative, and outcome variables were assessed using standard descriptive statistics. Morbidity was measured as a patient having any perioperative complication. The impact of bias in the selection of surgical approach was assessed using propensity scoring. Results During the study period, 338 patients older than 70 years (mean age, 75.7 ± 0.2) underwent lobectomy (219 thoracoscopy, 119 thoracotomy). Operative mortality was 3.8% (13 patients) and morbidity was 47% (159 patients). Patients with at least one complication had increased length of stay (8.3 ± 0.6 versus 3.8 ± 0.1 days; p < 0.0001) and mortality (6.9% 11 of 159 versus 1.1% 2 of 179; p = 0.008). Significant predictors of morbidity by multivariable analysis included age (odds ratio, 1.09 per year; p = 0.01) and thoracotomy as surgical approach (odds ratio, 2.21; p = 0.004). Thoracotomy remained a significant predictor of morbidity when the propensity to undergo thoracoscopy was considered (odds ratio, 4.9; p = 0.002). Conclusions Patients older than 70 years of age can undergo lobectomy for lung cancer with low morbidity and mortality. Advanced age and the use of a thoracotomy increased the risk of complications in this patient population.
Background We conducted a study of patients who underwent anatomic resection with adjuvant chemotherapy to determine if thoracoscopic lobectomy enables more effective administration of adjuvant ...chemotherapy than lobectomy by thoracotomy. Methods We reviewed the outcomes of 100 consecutive patients with non-small cell lung cancer (NSCLC) who underwent lobectomy and received adjuvant chemotherapy (1999 to 2004). The variables analyzed were time to initiation of chemotherapy, percentage of planned regimen received, number of delayed or reduced chemotherapy doses, toxicity grade, length of hospitalization, chest tube duration, 30-day mortality, and major complications (pneumonia, respiratory failure, atrial fibrillation). The χ2 test and Student t test were used to compare dichotomous and continuous variables, respectively. Results Complete resection was performed by thoracotomy in 43 patients and by thoracoscopy in 57 (no conversions). All patients received adjuvant chemotherapy, and 20 (20%) received adjuvant radiation therapy: 13 (30%) of 43 in the thoracotomy group and 7 (12%) of 57 in the thoracoscopy group ( p = 0.04). Patients undergoing thoracoscopic lobectomy had significantly fewer delayed (18% versus 58%, p < 0.001) and reduced (26% versus 49%, p = 0.02) chemotherapy doses. A higher percentage of patients undergoing thoracoscopic resection received 75% or more of their planned adjuvant regimen without delayed or reduced doses (61% versus 40%, p = 0.03). There were no significant differences in time to initiation of chemotherapy or toxicity. Patients undergoing a thoracoscopic lobectomy had a shorter median length of hospitalization (4 days versus 5 days, p = 0.02). Conclusions Thoracoscopy was associated with an overall higher compliance rate and fewer delayed or reduced doses of chemotherapy in patients receiving adjuvant chemotherapy.
Objectives The outcomes of patients with metastatic melanoma are poor. Although prognostic models have been developed to predict the occurrence of pulmonary metastasis from cutaneous melanoma, few ...data exist to define the outcomes of these patients once metastasis has occurred. The objective of this study was to discriminate predictors of survival for patients with pulmonary metastatic melanoma. Methods We found 1720 patients with pulmonary metastasis listed in a prospective comprehensive cancer center database of 14,057 consecutive patients with melanoma (Jan 1, 1970–June 1, 2004). Demographic and histopathologic data, time and location of recurrences, number of pulmonary nodules, and subsequent therapies were collected. Univariate and multivariate Cox proportional hazards models were used to identify predictors of survival for patients with pulmonary metastatic melanoma. Results The median survival was 7.3 months after development of pulmonary metastasis. Significant predictors of survival from the multivariate model included nodular histologic type ( P = .033), disease-free interval ( P < .001), number of pulmonary metastases ( P = .012), presence of extrathoracic metastasis ( P < .001), and performance of pulmonary metastasectomy ( P < .001). Interactions were identified between metastasectomy and disease-free interval and presence of extrathoracic metastasis. Surgery was associated with a survival advantage of 12 months for patients with a disease-free interval longer than 5 years (19 vs 7 months, P < .01) and of 10 months for patients without extrathoracic metastasis (18 vs 8 months, P < .01). Conclusions When all other identified risk factors were controlled for mathematically, metastasectomy maintained a significant survival advantage for patients with pulmonary metastatic melanoma. These data support the role of surgery for a select subset of patients with pulmonary metastasis.
Background Previous studies have discouraged limited pulmonary resection for primary lung cancer, but pulmonary segmentectomy has advantages for some patients. Furthermore, while thoracoscopic ...lobectomy has been increasingly applied with well-demonstrated advantages compared with thoracotomy, few data exist regarding thoracoscopic approaches to pulmonary segmentectomy. This study compares thoracoscopic segmentectomy (TS) with open segmentectomy (OS). Methods This is a retrospective review of prospectively collected data for 77 consecutive segmentectomy patients treated between 2000 and 2006 at a single center. Preoperative, intraoperative, and postoperative variables for patients undergoing TS (n = 48) were compared with those undergoing OS (n = 29). Student’s t tests were used for continuous data and Fisher’s exact tests for dichotomous data. Results Baseline demographics were similar between groups. Indications for pulmonary resection included non-small cell lung cancer (n = 39), metastatic disease (n = 30), and other diagnoses (n = 8). All common segmentectomies were represented. No thoracoscopic cases required conversion to open procedures. Operative times, estimated blood loss, and chest tube duration were similar between groups. Outcomes were similar except that hospital length of stay was significantly less among TS patients (length of stay 6.8 ± 6 days OS versus 4.3 ± 3 days TS; p = 0.03). Thirty-day mortality was 6.9% (2 of 29) for the OS group compared with 0% for the TS group. Long-term survival rates were significantly better in the TS group ( p = 0.0007). Conclusions Thoracoscopic segmentectomy is a safe and feasible procedure, comparing favorably with OS by reducing hospital length of stay. For experienced thoracoscopic surgeons, TS appears to be a sound option for lung-sparing, anatomic pulmonary resections.
Objectives Women with lung cancer have superior long-term survival outcomes compared with men, independent of stage. The cause of this disparity is unknown. For patients undergoing lung cancer ...resection, these survival differences could be due, in part, to relatively better perioperative outcomes for women. This study was undertaken to determine differences in perioperative outcomes after lung cancer surgery on the basis of sex. Methods The Society of Thoracic Surgeons' General Thoracic Database was queried for all patients undergoing resection of lung cancer between 2002 and 2010. Postoperative complications were analyzed with respect to sex. Univariable analysis was performed, followed by multivariable modeling to determine significant risk factors for postoperative morbidity and mortality. Results A total of 34,188 patients (16,643 men and 17,545 women) were considered. Univariable analysis demonstrated statistically significant differences in postoperative complications favoring women in all categories of postoperative complications. Women also had lower in-hospital and 30-day mortality (odds ratio, 0.56; 95% confidence interval, 0.44-0.71; P < .001). Multivariable analysis demonstrated that several preoperative conditions independently predicted 30-day mortality: male sex, increasing age, lower diffusion capacity, renal insufficiency, preoperative radiation therapy, cancer stage, extent of resection, and thoracotomy as surgical approach. Coronary artery disease was an independent predictor of mortality in women but not in men. Thoracotomy as the surgical approach and preoperative radiation therapy were predictive of mortality for men but not for women. Postoperative prolonged air leak and empyema predicted mortality in men but not in women. Conclusions Women have lower postoperative morbidity and mortality after lung cancer surgery. Some risk factors are sex-specific with regard to mortality. Further study is warranted to determine the cause of these differences and to determine their effect on survival.
Background Surgical lung biopsy contributes to establishing a specific diagnosis among many patients with interstitial lung disease (ILD). The risks of death and respiratory failure associated with ...elective thoracoscopic surgical lung biopsy, and patient characteristics associated with these outcomes, are not well understood. Methods This is a retrospective cohort study of patients who underwent elective thoracoscopic lung biopsy for ILD between 2008 and 2014, according to The Society of Thoracic Surgeons database. The study determined the incidence of operative mortality and of postoperative respiratory failure. Multivariable models were used to identify risk factors for these adverse outcomes. Results Among 3,085 patients, 46 (1.5%) died before hospital discharge or within 30 days of thoracoscopic lung biopsy. Postoperative respiratory failure occurred in 90 (2.9%) patients. Significant risk factors for operative mortality among patients with ILD included a diagnosis of pulmonary hypertension, preoperative corticosteroid treatment, and low diffusion capacity. Conclusions Elective thoracoscopic lung biopsy among patients with ILD is associated with a low risk of operative mortality and postoperative respiratory failure. Attention to the presence of pulmonary hypertension, preoperative corticosteroid treatment, and diffusion capacity may help inform risk stratification for thoracoscopic lung biopsy among patients with ILD.
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