Background
The relationship between individual complications and esophagectomy mortality is unclear. The influence of comorbidities on the impact of complications on operative mortality is also ...unknown. We sought to assess the impact of individual complications and the effect of coexisting comorbidities on operative mortality following esophagectomy.
Methods
All gastric conduit esophagectomies performed for cancer from 2008 to 2017 in the Society of Thoracic Surgery database were identified. Chi square was utilized to identify postoperative events associated with operative mortality. Multivariable logistic regression analysis was performed, utilizing postoperative events, to determine the risk-adjusted effect on operative mortality for each postoperative event. To assess the effect of preoperative comorbidities, a second logistic regression analysis was performed, incorporating preoperative characteristics.
Results
Of 11,943 esophagectomy patients, 63.9% had a postoperative event and 3.3% died, which did not change over the study period. The postoperative events with the highest impact on operative mortality were respiratory distress syndrome (OR 7.48 (95% CI 5.23–10.7)), reintubation (OR 6.55 (4.61–9.30)), and renal failure (OR 5.97 (4.08–8.75)). Anastomotic leak requiring reoperation was associated with increased operative mortality (OR 1.48 (1.03–2.14)), but medically managed leak was not. Incorporating preoperative characteristics into the operative mortality model had little effect on odds ratio for death for individual postoperative events.
Conclusions
In the Society of Thoracic Surgery database, 64% of patients suffer postoperative events and 3.3% die following esophagectomy. The independent association of certain postoperative events with mortality is an objective method of terming a complication “major” and may aid efforts to reduce mortality.
Psychopathology is rooted in neurodevelopment. However, clinical and biological heterogeneity, together with a focus on case-control approaches, have made it difficult to link dimensions of ...psychopathology to abnormalities of neurodevelopment. Here, using the Philadelphia Neurodevelopmental Cohort, we built normative models of cortical volume and tested whether deviations from these models better predicted psychiatric symptoms compared to raw cortical volume. Specifically, drawing on the p-factor hypothesis, we distilled 117 clinical symptom measures into six orthogonal psychopathology dimensions: overall psychopathology, anxious-misery, externalizing disorders, fear, positive psychosis symptoms, and negative psychosis symptoms. We found that multivariate patterns of deviations yielded improved out-of-sample prediction of psychopathology dimensions compared to multivariate patterns of raw cortical volume. We also found that correlations between overall psychopathology and deviations in ventromedial prefrontal, inferior temporal, and dorsal anterior cingulate cortices were stronger than those observed for specific dimensions of psychopathology (e.g., anxious-misery). Notably, these same regions are consistently implicated in a range of putatively distinct disorders. Finally, we performed conventional case-control comparisons of deviations in a group of individuals with depression and a group with attention-deficit hyperactivity disorder (ADHD). We observed spatially overlapping effects between these groups that diminished when controlling for overall psychopathology. Together, our results suggest that modeling cortical brain features as deviations from normative neurodevelopment improves prediction of psychiatric symptoms in out-of-sample testing, and that p-factor models of psychopathology may assist in separating biomarkers that are disorder-general from those that are disorder-specific.
Despite declining lung cancer mortality in the United States, survival differences remain among racial and ethnic minorities in addition to those with limited health care access. Improvements in lung ...cancer treatment can be obtained through clinical trials, yet there are disparities in clinical trial enrollment of other cancer types. This study aims to evaluate disparities in lung cancer clinical trial enrollment to inform future enrollment initiatives.
We analyzed patients with non-small cell lung cancer from the National Cancer Database (2004-2018), categorizing them as enrolled or not enrolled in clinical trials based on "rx_summ_other" data element. Clinical, demographic, and institutional factors associated with trial enrollment were assessed using bivariate and multivariate analysis, adjusting for institutional-level clustering.
A total of 1924 (0.12%) patients with lung cancer were enrolled in clinical trials. Enrolled patients were predominantly non-Hispanic White (82%), with greater socioeconomic status, treated at academic programs (67%), and had private insurance (42%) or Medicare (44%). They also traveled further for treatment compared with unenrolled patients (56 vs 27 miles, P < .001). After adjusting for demographic and clinical factors, lung cancer trial enrollment was significantly less likely among Black (odds ratio, 0.55; 95% confidence interval, 0.5-0.7, P < .001) and Hispanic (0.66; 95% confidence interval, 0.5-0.9, P = .01) patients. Patients with Medicaid or uninsured, in the lowest socioeconomic status group, and those treated at community-based cancer programs were the least likely to enroll.
Enrollment in lung cancer trials disproportionally excludes minority patients, those in the lowest socioeconomic status, community cancer programs, and the underinsured. These disparities in demographic and access for trial participation show a need for improved enrollment strategies.
Although minimally invasive techniques have led to shorter hospitalizations, discharge on postoperative day 1 is still uncommon. We hypothesized that day 1 discharge could be performed safely and ...that there might be significant variation in day 1 discharge rates between hospitals.
We identified patients with lung cancer who underwent lobectomy and segmentectomy in the Society of Thoracic Surgeons Database from 2012 to 2017. The 10% longest hospital stay outliers were excluded. A multivariable regression model was created to assess for factors associated with day 1 discharge and readmission.
A total of 46,325 patients were examined, and 1821 patients (3.9%) were discharged on day 1. This rate increased from 3.4% to 5.3% over the course of the study (P < .0001). In multivariable analysis, factors associated with day 1 discharge included age, Zubrod score, body mass index greater than 25, forced expiration value at 1 second, middle or upper lobectomy, minimally invasive technique, and procedure time. Outpatient 30-day mortality was similar (0.3% vs 0.4%, P = .472). Patients discharged on day 1 were not at increased risk of readmission. Readmission after day 1 discharge was associated with male sex, coronary artery disease, chronic obstructive pulmonary disease, and longer procedure time. There was substantial variation in day 1 discharge rate between institutions, with 11 centers (4.0%) discharging more than 20% of their patients on day 1, whereas 102 centers (36.7%) had no day 1 discharges.
Day 1 discharge after anatomic lung resection is uncommon but is becoming more common. Carefully selected patients may be discharged on day 1 without an increased risk of readmission or death.
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Lung lobectomy is the standard of care for early-stage lung cancer. Studies have suggested improved outcomes associated with lobectomy performed by specialized thoracic surgery providers. We ...hypothesized that disparities would exist regarding access to thoracic surgeons among patients receiving lung lobectomy for cancer.
The Premier Hospital Database was used to identify adult inpatients receiving lung lobectomy from 2009 to 2019. Patients were categorized as receiving their lobectomy from a thoracic surgeon, cardiovascular surgeon, or general surgeon. Sample-weighted multivariable analysis was performed to identify factors associated with provider type.
When adjusted for sampling, 121,711 patients were analyzed, including 71,709 (58.9%) who received lobectomy by a thoracic surgeon, 36,630 (30.1%) by a cardiovascular surgeon, and 13,373 (11.0%) by a general surgeon. Multivariable analysis showed that thoracic surgeon provider type was less likely with Black patients, Medicaid insurance, smaller hospital size, in the western region, and in rural areas. In addition, non-thoracic surgery specialty was less likely to perform minimally-invasive (MIS) lobectomy (cardiovascular OR 0.80,
< 0.001, general surgery OR 0.85,
= 0.003).
In this nationally representative analysis, smaller, rural, non-teaching hospitals, and certain regions of the United States are less likely to receive lobectomy from a thoracic surgeon. Thoracic surgeon specialization is also independently associated with utilization of minimally invasive lobectomy. Combined, there are significant disparities in access to guideline-directed surgical care of patients receiving lung lobectomy.
Wedge resection is often used instead of anatomic resection in an attempt to mitigate perioperative risk. In propensity-matched populations, we sought to compare the perioperative outcomes of ...patients undergoing wedge resection with those undergoing anatomic resection.
The Society of Thoracic Surgery database was reviewed for stage I and II non-small cell lung cancer patients undergoing wedge resection and anatomic resection to analyze postoperative morbidity and mortality. Propensity scores were estimated using a logistic model adjusted for a variety of risk factors. Patients were then matched by propensity score using a greedy 5- to 1-digit matching algorithm, and compared using McNemar's test.
Between 2009 and 2011, 3,733 wedge resection and 3,733 anatomic resection patients were matched. The operative mortality was 1.21% for wedge resection versus 1.93% for anatomic resection (p=0.0118). Major morbidity occurred in 4.53% of wedge resection patients versus 8.97% of anatomic resection patients (p<0.0001). A reduction was noted in the incidence of pulmonary complications, but not cardiovascular or neurologic complications. There was a consistent reduction in major morbidity regardless of age, lung function, or type of incision. Mortality was reduced in patients with preoperative forced expiratory volume in 1 second less than 85% predicted.
Wedge resection has a 37% lower mortality and 50% lower major morbidity rate than anatomic resection in these propensity-matched populations. The mortality benefit is most apparent in patients with forced expiratory volume in 1 second less than 85% predicted. These perioperative benefits must be carefully weighed against the increase in locoregional recurrence and possible decrease in long-term survival associated with the use of wedge resection for primary lung cancers.
Introduction
Robotic minimally invasive esophagectomy (RMIE) and “traditional” minimally invasive esophagectomy techniques (tMIE) have reported superior outcomes relative to open techniques. ...Differences in the outcomes of these two approaches have not been examined. We hypothesized that short-term outcomes of RMIE would be superior to tMIE.
Methods and procedures
The National Cancer Database was used to analyze outcomes of patients undergoing RMIE and tMIE from 2010 to 2016. Patients with clinical metastatic disease were excluded. Trends in the number of procedures performed with each approach were described using linear regression testing. Primary outcome of interest was 90-day mortality rate. Secondary outcomes of interest were positive surgical margin rate, number of lymph nodes (LN) removed, adequate lymphadenectomy (> 15 LNs), length of hospitalization (LOS), readmission rate, and conversion to open rate. Outcomes of RMIE and tMIE were compared using Wilcoxon rank sum test and chi square test as appropriate. Multivariable regression was also performed to reduce the impact of differences in the cohorts of patients receiving RMIE and tMIE.
Results
6661 minimally invasive esophagectomies were performed from 2010 to 2016 (1543/6661 (23.2%) RMIE and 5118/6661 (76.8%) tMIE). Over the study period, the proportion of RMIE increased from 10.4% (64/618) in 2010 to 27.2% (331/1216) in 2016 (
p
< 0.001) (Fig.
1
). The primary outcome of 90-day mortality was similar between RMIE and tMIE (92/1170 (7.4%) vs 305/4148 (7.9%),
p
= 0.558) (Table
2
). RMIE and tMIE also had similar readmission rate (6.3 vs 7%,
p
= 0.380). There was no difference between the cohorts based on sex, age, race, insurance, and tumor size. The cohorts of patients receiving RMIE and tMIE differed in that RMIE patients had lower rates of elevated Charlson scores, were more likely to be treated at an academic institution, had a higher rate of advanced clinical T-stage and clinical nodal involvement, and had received neoadjuvant therapy. In a univariate analysis, RMIE had a lower rate of positive margin (3.9 vs 6.1%,
p
= 0.001), more mean lymph nodes evaluated (16.6 ± 9.74 vs 16.1 ± 10.08
p
= 0.018), lower conversion to open rate (5.4 vs 11.4%,
p
< 0.001), and a shorter mean length of stay (12.1 ± 10.39 vs 12.8 ± 11.18 days,
p
< 0.001). In multivariable analysis, RMIE was associated with lower risk of conversion to open (OR 0.51, 95% CI: 0.37–0.70,
p
< 0.001) and lower rate of positive margin (OR 0.62, 95% CI: 0.41–0.93,
p
= 0.021).). Additionally, in a multivariable logistic regression, RMIE demonstrated superior adequate lymphadenectomy (> 15 LNs) (OR 1.18, 95% CI 1.02–1.37,
p
< 0.032).
Conclusion
In the National Cancer Database, robotic esophagectomy is associated with superior rate of conversion to open and positive surgical margin status. We speculate enhanced dexterity and visualization of RMIE facilitates intraoperative performance leading to improvement in these outcomes.
Esophagectomy carries a high risk of morbidity and mortality. The most common indication for esophagectomy is esophageal cancer, with fewer than 5% of esophagectomies performed for benign disease. We ...hypothesized that esophagectomy for benign disease is associated with a higher risk of operative and postoperative complications.
A retrospective study of The Society of Thoracic Surgeons database was performed to identify all patients who had an esophagectomy from 2010 to 2018. Patients who had an emergent or palliative esophagectomy were excluded. Patients were compared based on the indication for operation, malignant vs benign disease. A 1:1 propensity score matching of The Society of Thoracic Surgeons risk factors was performed and outcomes compared between the matched cohorts.
Of 16,392 patients, 14,871 (91%) had malignant disease and 1521 (9%) had benign disease that met inclusion criteria. Patients with malignant disease were older (P < .001), more likely to be male (83% vs 56%, P < .001), and had more comorbidities (P < .001). There were 1362 propensity-matched pairs. Malignant esophagectomies were more likely to be performed with a minimally invasive vs an open approach (P < .001). Benign operations had more intraoperative blood transfusions (P < .001). Patients undergoing esophagectomy for benign disease had more prolonged intubations (P = .02) and postoperative blood transfusions (P = .001). Benign disease had more major morbidities (P = .001) but similar postoperative mortality (P = .62).
Esophagectomy for benign disease is associated with worse perioperative morbidity compared with esophagectomy for malignant disease. Given these findings patients should be counseled on expected outcomes, and this variable should be considered for inclusion in the composite score for risk assessment.
Micro-Abstract The incidence and overall clinical course of combined small-cell lung cancer (C-SCLC), a disease with both components of small-cell lung cancer (SCLC) and non–small-cell lung cancer ...(NSCLC) is not clear. We describe our experience with 22 patients with C-SCLC. C-SCLC occurs in 5% of SCLCs and frequently presents with early stage disease and is potentially curable.
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