To examine whether there is an association between prehospital transfer distance and surgical mortality in emergency thoracic aortic surgery.
A retrospective cohort study using a national clinical ...database in Japan was conducted. Patients who underwent emergency thoracic aortic surgery from January 1, 2014, to December 31, 2016, were included. Patients with type B dissection were excluded. A multilevel logistic regression analysis was performed to examine the association between prehospital transfer distance and surgical mortality. In addition, an instrumental variable analysis was performed to address unmeasured confounding.
A total of 12,004 patients underwent emergency thoracic aortic surgeries at 495 hospitals. Surgical mortality was 13.8%. The risk-adjusted mortality odds ratio for standardized distance (mean 12.8 km, standard deviation 15.2 km) was 0.94 (95% confidence interval, 0.87-1.01; P = .09). Instrumental variable analysis did not reveal a significant association between transfer distance and surgical mortality as well.
No significant association was found between surgical mortality and prehospital transfer distance in emergency thoracic aortic surgery cases. Suspected cases of acute thoracic aortic syndrome may be transferred safely to distant high-volume hospitals.
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Lung injury is a serious complication of surgery. We did a systematic review and meta-analysis to assess whether incidence, morbidity, and in-hospital mortality associated with postoperative lung ...injury are affected by type of surgery and whether outcomes are dependent on type of ventilation.
We searched MEDLINE, CINAHL, Web of Science, and Cochrane Central Register of Controlled Trials for observational studies and randomised controlled trials published up to April, 2014, comparing lung-protective mechanical ventilation with conventional mechanical ventilation during abdominal or thoracic surgery in adults. Individual patients' data were assessed. Attributable mortality was calculated by subtracting the in-hospital mortality of patients without postoperative lung injury from that of patients with postoperative lung injury.
We identified 12 investigations involving 3365 patients. The total incidence of postoperative lung injury was similar for abdominal and thoracic surgery (3·4% vs 4·3%, p=0·198). Patients who developed postoperative lung injury were older, had higher American Society of Anesthesiology scores and prevalence of sepsis or pneumonia, more frequently had received blood transfusions during surgery, and received ventilation with higher tidal volumes, lower positive end-expiratory pressure levels, or both, than patients who did not. Patients with postoperative lung injury spent longer in intensive care (8·0 SD 12·4 vs 1·1 3·7 days, p<0·0001) and hospital (20·9 18·1 vs 14·7 14·3 days, p<0·0001) and had higher in-hospital mortality (20·3% vs 1·4% p<0·0001) than those without injury. Overall attributable mortality for postoperative lung injury was 19% (95% CI 18-19), and differed significantly between abdominal and thoracic surgery patients (12·2%, 95% CI 12·0-12·6 vs 26·5%, 26·2-27·0, p=0·0008). The risk of in-hospital mortality was independent of ventilation strategy (adjusted HR 0·71, 95% CI 0·41-1·22).
Postoperative lung injury is associated with increases in in-hospital mortality and durations of stay in intensive care and hospital. Attributable mortality due to postoperative lung injury is higher after thoracic surgery than after abdominal surgery. Lung-protective mechanical ventilation strategies reduce incidence of postoperative lung injury but does not improve mortality.
None.
Plication of diaphragm (DP) for eventration (DE) can be done using thoracic or abdominal approaches. The purpose of our study was to compare outcomes between these approaches based on our experience ...and on systematic literature review.
Retrospective records of children <16 years who underwent DP (single-center, 2004–2018) were recorded and analyzed. Systematic review and meta-analysis of related studies was undertaken. Data are reported as median (range).
Eighty-nine cases were identified in thoracic (Congenital = 5, Acquired = 84) and 13 (Congenital = 10, Acquired = 3) in abdominal group aged 5.88 (0.36–184.44) and 10.0 (0.12–181.8) months. Improvement in diaphragm level post-DP was significantly higher in abdominal 2(0–4) than chest 1.5(0–5) group (p = 0.04). On Cox regression analysis, there was a non-significant trend to a longer time to extubation in the chest group (Hazard ratio (HR) = 0.5390.208–1.395, p = 0.203). Patients operated transthoracically left intensive care unit after a significantly longer time (HR = 0.3390.119–0.966, p = 0.043). Patients operated transabdominally tended to be fed later, although this was not significant (HR = 1.8010.762–4.253, p = 0.043). On Kaplan–Meier analysis, there was a non-significant trend to a lower rate of recurrence in the abdominal group (HR = 0.31960.061–1.675, p = 0.1876). In the meta-analysis including three published studies as well as our data (total n = 181, Thoracic = 139, Abdominal = 42), no difference was found in the incidence of recurrence amongst the 2 groups (RD = -0.04, 95%CI = -0.25, 0.18, p = 0.74).
This is one of the largest reports on outcomes of children undergoing DP for DE. There is no significant difference in recurrence rate, even though all recurrences in our series (15.7%) were in the acquired cases operated using a thoracic approach.
Treatment Retrospective Comparative Study.
Level III.
Objectives
Though clear‐guidelines are set by the American Board of Thoracic Surgery (ABTS) for the operative cases that cardiothoracic surgery residents must perform to be board‐eligible, no such ...recommendations exist to assess competency for the wide range of high‐risk bedside procedures. Our department created and implemented a multidisciplinary course designed to standardize common high‐risk bedside procedures and credential our trainees. The aim of this study was to survey the attitudes of residents towards and query the efficacy of such a course.
Methods
The course was designed with the goal of standardizing endotracheal intubation, arterial line insertion (radial and femoral), central venous line insertion, pigtail tube thoracostomy, thoracentesis and nasogastric tube placement. The course consisted of an online module followed by a 4‐hour hands‐on simulation session. Knowledge‐based pre‐ and post‐evaluations were administered as well as a Likert‐based survey regarding multiple aspects of the residents′ perceptions of the course and the procedures.
Results
Twenty‐three (7 traditional and 16 integrated) cardiothoracic surgical residents participated in the course. Residents reported that 48% of the time, bedside procedures were historically taught by other trainees rather than by faculty. All residents endorsed increased standardization of all procedures after the course. Likewise, residents showed increased confidence in all procedures except for pigtail tube thoracostomy, thoracentesis as well as nasogastric tube placement. 43.5% of the participants demonstrated improvement in the pretest and posttest knowledge‐based evaluations.
Conclusion
Cardiothoracic residents have favorable attitudes towards standardization and credentialing for high‐risk bedside procedures and utilizing such courses may help standardize procedural techniques.
There are 2 main treatment paradigms recognized by the National Comprehensive Cancer Network for resectable malignant pleural mesothelioma (MPM): induction chemotherapy followed by resection (IC/R), ...and up-front resection with postoperative chemotherapy (R/PC). These paradigms are being compared in an accruing randomized phase II trial. In the absence of such completed trials, in this study we evaluated overall survival (OS) and postoperative outcomes of IC/R and R/PC.
The National Cancer Database was queried for newly diagnosed epithelioid/biphasic MPM. Metastatic, node-positive, and/or cT4 disease was excluded, along with nondefinitive surgery and lack of chemotherapy. Multivariable logistic regression ascertained factors independently associated with induction chemotherapy delivery. Kaplan–Meier analysis was used to evaluate OS between cohorts; multivariable Cox proportional hazards modeling was used to assess factors associated with OS. Survival was also evaluated between propensity-matched populations. Last, postoperative outcomes were assessed between groups.
Overall, 361 patients (182 IC/R, 179 R/PC) were analyzed. Temporal trends revealed that IC/R is decreasing over time. Survival of the IC/R cohort was similar to that of R/PC patients (20.9 vs 21.7 months; P = .500); this persisted after propensity matching (20.8 vs 22.0 months; P = .270). However, patients who underwent IC/R experienced longer postoperative hospitalization (median 7 days vs 6 days; P = .001) and higher 30-day mortality (3.3% vs 0%; P = .020).
To our knowledge, this is the only comparative investigation of the 2 major management paradigms of operable MPM. IC/R regimens are decreasing over time in the United States. Although associated with survival similar to R/PC, IC/R might be associated with worse postoperative outcomes. Careful induction chemotherapy patient selection is thus highly recommended.
Background
Frailty assessment has not been thoroughly assessed in thoracic surgery. Our primary objective was to assess the feasibility of comprehensive frailty testing prior to lung and esophageal ...surgery for cancer. The secondary objective was to assess the utility of frailty indices in risk assessment prior to thoracic surgery.
Methods
Prospectively recruited patients completed multiple physiotherapy tests (6-min walk, gait speed, hand-grip strength), risk stratification (Charlson Comorbidity Index, Revised Cardiac Risk Index, Modified Frailty Index), and quality of life questionnaires. Lean psoas area was also assessed by a radiologist using positron emission tomography/computed tomography scans. Data was analyzed using Fisher’s exact, Mann-Whitney
U
and independent
t
tests.
Results
The feasibility of comprehensive frailty assessment was assessed over a 4-month period among 40 patients (esophagus
n
= 20; lung
n
= 20). Risk stratification questionnaires administered in clinic had 100% completion rates. Physiotherapy testing required a trained physiotherapist and an additional visit to the pre-admission clinic; these tests proved difficult to coordinate and had lower completion rates (63–75%). Although most measures were not significantly associated with occurrence of complications, the Modified Frailty Index approached statistical significance (
p
= 0.06).
Conclusions
Frailty assessment is feasible in the pre-operative outpatient setting and had a high degree of acceptance among surgeons and patients. Of the risk stratification questionnaires, the Modified Frailty Index may be useful in predicting outcomes as per this feasibility study. Pre-operative frailty assessment can identify vulnerable oncology patients to aid in treatment planning with the goal of optimizing clinical outcomes and resource allocation.
Although robotic-assisted thoracic surgery (RATS) provides improved dexterity, the effect of RATS on pain compared with video-assisted thoracoscopic surgery (VATS) or open lobectomy is poorly ...understood. This study evaluated acute and chronic pain following RATS, VATS, and open anatomic pulmonary resection.
A retrospective review of 498 patients (502 procedures) who underwent RATS (74), VATS (227), and open (201) anatomic pulmonary resection including lobectomy and segmentectomy from 2010 to 2014 was performed to identify factors related to acute and chronic pain. Acute pain scores were analyzed over the first 9 postoperative days. Chronic pain was assessed using the validated PainDETECT survey.
There were no significant differences in acute or chronic pain between RATS and VATS. There was a significant decrease in acute pain for patients with minimally invasive surgery (P = .0004). Chronic numbness was significantly higher after open resection (25.5% vs 11.6%; P = .0269) but with no difference in other symptoms of chronic pain. Despite no significant difference in pain scores, 69.2% of patients who received RATS felt the approach affected pain versus 44.2% VATS (P = .0330). On multivariable analysis, younger age (P < .0001), female gender (P = .0364), and baseline narcotic use (P = .0142) were associated with acute pain, whereas younger age (P = .0021) and major complications (P = .0003) were associated with chronic numbness in patients who received MIS.
Although minimally invasive approaches resulted in less acute pain and chronic numbness, there were no significant differences between RATS and VATS. In contrast, more RATS patients believed the approach affected their pain, suggesting a difference between reality and perception.
Malignant pleural mesothelioma (MPM) is a rare malignancy with few treatment options. Recent advances have led to US Food and Drug Administration approvals and changes in the standard of care with a ...novel biomedical device approved for use with platinum-pemetrexed, and also for immunotherapy agents to be included as a frontline treatment option in unresectable disease. Although predictive biomarkers for systemic therapy are not currently in use in clinical practice, it is essential to correctly identify the MPM histology to determine an optimal treatment plan. Patients with nonepithelioid MPM may have a greater magnitude of benefit to dual immunotherapy checkpoint inhibitors and this regimen should be preferred in the frontline setting for these patients. However, all patients with MPM can derive benefit from immunotherapy treatments, and these agents should ultimately be used at some point during their treatment journey. There are ongoing studies in the frontline unresectable setting that may further define the frontline therapy space, but a critical area of research will need to focus on the immunotherapy refractory population. This review article will describe the new developments in the areas of biology with genomics and chromothripsis, and also focus on updates in treatment strategies in radiology, surgery, radiation, and medical oncology with cellular therapies. These recent innovations are generating momentum to find better therapies for this disease.
Precise medical billing is essential for decreasing hospital liability, upholding environmental stewardship and ensuring fair costs for patients. We instituted a multifaceted approach to improve the ...billing accuracy of our robotic-assisted thoracic surgery programme by including an educational component, updating procedure cards and removing the auto-populating function of our electronic medical record. Overall, we saw significant improvements in both the number of inaccurate billing cases and, specifically, the number of cases that overcharged patients.
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