An International Consensus on Actions to Improve Lung Cancer Survival: A Modified Delphi Method Among Clinical Experts in the International Cancer Benchmarking Partnership.

BACKGROUND: Research from the International Cancer Benchmarking Partnership (ICBP) demonstrates that international variation in lung cancer survival persists, particularly within early stage disease. There is a lack of international consensus on the critical contributing components to variation in lung cancer outcomes and the steps needed to optimise lung cancer services. These are needed to improve the quality of options for and equitable access to treatment, and ultimately improve survival. METHODS: Semi-structured interviews were conducted with 9 key informants from ICBP countries. An international clinical network representing 6 ICBP countries (Australia, Canada, Denmark, England, Ireland, New Zealand, Northern Ireland, Scotland & Wales) was established to share local clinical insights and examples of best practice. Using a modified Delphi consensus model, network members suggested and rated recommendations to optimise the management of lung cancer. Calls to Action were developed via Delphi voting as the most crucial recommendations, with Good Practice Points included to support their implementation. RESULTS: Five Calls to Action and thirteen Good Practice Points applicable to high income, comparable countries were developed and achieved 100% consensus. Calls to Action include (1) Implement cost-effective, clinically efficacious, and equitable lung cancer screening initiatives; (2) Ensure diagnosis of lung cancer within 30 days of referral; (3) Develop Thoracic Centres of Excellence; (4) Undertake an international audit of lung cancer care; and (5) Recognise improvements in lung cancer care and outcomes as a priority in cancer policy. CONCLUSION: The recommendations presented are the voice of an expert international lung cancer clinical network, and signpost key considerations for policymakers in countries within the ICBP but also in other comparable high-income countries. These define a roadmap to help align and focus efforts in improving outcomes and management of lung cancer patients globally.

The Effect of Major and Minor Complications After Lung Surgery on Length of Stay and Readmission.

The effect of post-operative adverse events (AEs) on patient outcomes such as length of stay (LOS) and readmissions to hospital is not completely understood. This study examined the severity of AEs from a high-volume thoracic surgery center and its effect on the patient postoperative LOS and readmissions to hospital. This study includes patients who underwent an elective lung resection between September 2018 and January 2020. The AEs were grouped as no AEs, 1 or more minor AEs, and 1 or more major AEs. The effects of the AEs on patient LOS and readmissions were examined using a survival analysis and logistic regression, respectively, while adjusting for the other demographic or clinical variables. Among 488 patients who underwent lung surgery, (Wedge resection [n = 100], Segmentectomy [n = 51], Lobectomy [n = 310], Bilobectomy [n = 10], or Pneumonectomy [n = 17]) for either primary (n = 440) or secondary (n = 48) lung cancers, 179 (36.7%) patients had no AEs, 264 (54.1%) patients had 1 or more minor AEs, and 45 (9.2%) patients had 1 or more major AEs. Overall, the median of LOS was 3 days which varied significantly between AE groups; 2, 4, and 8 days among the no, minor, and major AE groups, respectively. In addition, type of surgery, renal disease (urinary tract infection [UTI], urinary retention, or acute kidney injury), and ASA (American Society of Anesthesiology) score were significant predictors of LOS. Finally, 58 (11.9%) patients were readmitted. Readmission was significantly associated with AE group (P = 0.016). No other variable could significantly predict patient readmission. Overall, postoperative AEs significantly affect the postoperative LOS and readmission rates.

Contemporary trends in the level of evidence in general thoracic surgery clinical research.

OBJECTIVES: The large volume of scientific publications and the increasing emphasis on high-quality evidence for clinical decision-making present daily challenges to all clinicians, including thoracic surgeons. The objective of this study was to evaluate the contemporary trend in the level of evidence (LOE) for thoracic surgery clinical research. METHODS: All clinical research articles published between January 2010 and December 2017 in 3 major general thoracic surgery journals were reviewed. Five authors independently reviewed the abstracts of each publication and assigned a LOE to each of them using the 2011 Oxford Centre for Evidence-Based Medicine classification scheme. Data extracted from eligible abstracts included study type, study size, country of primary author and type of study designs. Three auditing processes were conducted to establish working definitions and the process was validated with a research methodologist and 2 senior thoracic surgeons. Intra-class correlation coefficient was calculated to assess inter-rater agreement. Chi-square test and Spearman correlation analysis were then used to compare the LOE between journals and by year of publication. RESULTS: Of 2028 publications reviewed and scored, 29 (1.4%) were graded level I, 75 (3.7%) were graded level II, 471 (23.2%) were graded level III, 1420 (70.2%) were graded level IV and 33 (1.6%) were graded level V (lowest level). Most publications (94.9%) were of lower-level evidence (III-V). There was an overall increasing trend in the lower LOE (P < 0.001). Inter-rater reliability was substantial with 95.5% (95%, confidence interval: 0.95-0.96) level of agreement between reviewers. CONCLUSIONS: General thoracic surgery literature consists mostly of lower LOE studies. The number of lower levels of evidence is dominating the recent publications, potentially indicating a need to increase the commitment to produce and disseminate higher-level evidence in general thoracic surgery.

Robotic vs Thoracoscopic Anatomic Lung Resection in Obese Patients: A Propensity-Adjusted Analysis.

BACKGROUND: Minimally invasive lung resections can be particularly challenging in obese patients. We hypothesized robotic surgery (RTS) is associated with less conversion to thoracotomy than video-assisted thoracoscopic surgery (VATS) in obese populations. METHODS: The Society of Thoracic Surgeons General Thoracic Surgery Database, Epithor French National Database, and McMaster University Thoracic Surgical Database were queried for obese (body mass index ≥30 kg/m2) patients who underwent VATS or RTS lobectomy or segmentectomy for clinical T1-2, N0-1 non-small cell lung cancer between 2015 and 2019. Propensity score adjusted logistic regression analysis was used to compare the rate of conversion to thoracotomy between the VATS and RTS cohorts. RESULTS: Overall, 8108 patients (The Society of Thoracic Surgeons General Thoracic Surgery Database: n = 7473; Epithor: n = 572; McMaster: n = 63) met inclusion criteria with a mean (SD) age of 66.6 (9) years and body mass index of 34.7 (4.5) kg/m2. After propensity score adjusted multivariable analysis, patients who underwent VATS were >5-times more likely to experience conversion to thoracotomy than those who underwent RTS (odds ratio, 5.33; 95% CI, 4.14-6.81; P < .001). There was a linear association between the degree of obesity and odds ratio of VATS conversion to thoracotomy compared with RTS. VATS patients had a longer mean length of stay (5.0 vs 4.3 days, P < .001), higher rate of respiratory failure (2.8% [168 of 5975] vs 1.8% [39 of 2133], P = .026), and were less likely to be discharged to their home (92.5% [5525 of 5975] vs 94.3% [2012 of 2133]; P = .013) compared with RTS patients. CONCLUSIONS: In obese patients, RTS anatomic lung resection is associated with a lower rate of conversion to thoracotomy than VATS.

Endobronchial Ultrasound Staging of Operable Non-small Cell Lung Cancer: Do Triple-Normal Lymph Nodes Require Routine Biopsy?

BACKGROUND: Staging guidelines for lung cancer recommend endobronchial ultrasound (EBUS) and systematic biopsy of at least three mediastinal lymph node (LN) stations for accurate staging. A four-point ultrasonographic score (Canada Lymph Node Score [CLNS]) was developed to determine the probability of malignancy in each LN. A LN with a CLNS of < 2 is considered low probability for malignancy. We hypothesized that, in patients with cN0 non-small cell lung cancer, LNs with CLNS of < 2 may not require routine biopsy because they represent true node-negative disease. RESEARCH QUESTION: Do LNs considered triple normal on CT scanning, PET scanning, and CLNS evaluation require routine biopsy? STUDY DESIGN AND METHODS: LNs were evaluated for ultrasonographic features at the time of EBUS and the CLNS was applied. Triple-normal LNs were defined as cN0 on CT scanning (short axis, < 1 cm), PET scanning (no hypermetabolic activity), and EBUS (CLNS, < 2). Specificity and negative predictive value (NPV) were calculated against the gold standard pathologic diagnosis from surgically excised specimens. RESULTS: In total, 143 LNs from 57 cN0 patients were assessed. Triple-normal LNs showed a specificity and NPV of 60% (95% CI, 51.2%-68.3%) and 93.1% (95% CI, 85.6%-97.4%), respectively. After pathologic assessment, only 5.6% (n = 8/143) of triple-normal nodes were proven to be malignant. INTERPRETATION: At the time of staging for lung cancer, combining CT scanning, PET scanning, and CLNS criteria can identify triple-normal LNs that have a high NPV for malignancy. This raises the question of whether triple-normal LNs require routine sampling during EBUS and transbronchial needle aspiration. A prospective trial is required to confirm these findings.

Incentive Spirometry After Lung Resection: A Randomized Controlled Trial.

BACKGROUND: Incentive spirometry (IS) is thought to reduce the incidence of postoperative pulmonary complications (PPC) after lung resection. We sought to determine whether the addition of IS to routine physiotherapy following lung resection results in a lower rate of PPC, as compared with physiotherapy alone. METHODS: A single-blind prospective randomized controlled trial was conducted in adults undergoing lung resection. Individuals with previous lung surgery or home oxygen were excluded. Participants randomized to the control arm (PHY) received routine physiotherapy alone (deep breathing, ambulation and shoulder exercises). Those randomized to the intervention arm (PHY/IS) received IS in addition to routine physiotherapy. The trial was powered to detect a 10% difference in the rate of PPC (ß = 80%). Student's t test and chi-square were utilized for continuous and categorical variables, respectively, with a significance level of p = 0.05. RESULTS: A total of 387 participants (n = 195 PHY/IS; n = 192 PHY) were randomized between 2014 and 2017. Baseline characteristics were comparable for both arms. The majority of patients underwent a pulmonary lobectomy (PHY/IS = 59.5%, PHY = 61.0%; p = 0.84), with no difference in the rates of minimally invasive and open procedures. There were no differences in the incidence of PPC at 30 days postoperatively (PHY/IS = 12.3%, PHY = 13.0%; p = 0.88). There were no differences in rates of pneumonia (PHY/IS = 4.6%, PHY = 7.8%; p = 0.21), mechanical ventilation (PHY/IS = 2.1%, PHY = 1.0%; p = 0.41), home oxygen (PHY/IS = 13.8%, PHY = 14.6%; p = 0.89), hospital length of stay (PHY/IS = 4 days, PHY = 4 days; p = 0.34), or rate of readmission to hospital (PHY/IS = 10.3%, PHY = 9.9%; p = 1.00). CONCLUSIONS: The addition of IS to routine postoperative physiotherapy does not reduce the incidence of PPC after lung resection.

The effect of colchicine administration on postoperative pleural effusion following lung resection: a randomized blinded placebo-controlled feasibility pilot study.

OBJECTIVES: This substudy of the colchicine for prevention of perioperative atrial fibrillation (COP-AF) pilot trial seeks to assess the effect of colchicine administration on the volume of postoperative pleural drainage, duration of chest tube in situ and length of stay following lung resection. METHODS: Between April 2014 and April 2015, 100 patients undergoing lung resection at 2 tertiary care centres participated in a pilot blinded randomized trial comparing perioperative twice daily 0.6 mg of colchicine orally (n = 49) or placebo (n = 51) twice daily for 10 days. The primary outcome was total pleural drainage volume, which was recorded in 8-h intervals for the first 2 postoperative days per standardized protocol. RESULTS: Only 1 patient did not complete the trial. The mean volume of pleural drainage at 40-h mark postoperation was significantly less in the colchicine group (550.9 ml) compared with the placebo group (741.3 ml, P = 0.039). Compared with the placebo group, the colchicine group showed significantly less mean pleural drainage on postoperative Day 2 (583.8 vs 763.3 ml, P = 0.039) and beyond. There were no differences in mean time to chest tube removal (6.8 days for the colchicine group vs 5.9 days for the placebo group, P = 0.585) and mean hospital length of stay (7.4 vs 6.9 days, P = 0.641). CONCLUSIONS: Oral colchicine is potentially effective in diminishing the amount of pleural drainage following lung resection and can be considered in patients at high risk of large postoperative pleural effusion. A full-scale, prospective placebo-controlled randomized trial is needed to assess the clinical significance of perioperative colchicine administration following oncological lung resection.

Does the usage of digital chest drainage systems reduce pleural inflammation and volume of pleural effusion following oncologic pulmonary resection?-A prospective randomized trial.

BACKGROUND: Prolonged air leak and high-volume pleural drainage are the most common causes for delays in chest tube removal following lung resection. While digital pleural drainage systems have been successfully used in the management of post-operative air leak, their effect on pleural drainage and inflammation has not been studied before. We hypothesized that digital drainage systems (as compared to traditional analog continuous suction), using intermittent balanced suction, are associated with decreased pleural inflammation and postoperative drainage volumes, thus leading to earlier chest tube removal. METHODS: One hundred and three [103] patients were enrolled and randomized to either analog (n=50) or digital (n=53) drainage systems following oncologic lung resection. Chest tubes were removed according to standardized, pre-defined protocol. Inflammatory mediators [interleukin-1B (IL-1B), 6, 8, tumour necrosis factor-alpha (TNF-α)] in pleural fluid and serum were measured and analysed. The primary outcome of interest was the difference in total volume of postoperative fluid drainage. Secondary outcome measures included duration of chest tube in-situ, prolonged air-leak incidence, length of hospital stay and the correlation between pleural effusion formation, degree of inflammation and type of drainage system used. RESULTS: There was no significant difference in total amount of fluid drained or length of hospital stay between the two groups. A trend for shorter chest tube duration was found with the digital system when compared to the analog (P=0.055). Comparison of inflammatory mediator levels revealed no significant differences between digital and analog drainage systems. The incidence of prolonged post-operative air leak was significantly higher when using the analog system (9 versus 2 patients; P=0.025). Lobectomy was associated with longer chest tube duration (P=0.001) and increased fluid drainage when compared to sub-lobar resection (P<0.001), regardless of drainage system. CONCLUSIONS: Use of post-lung resection digital drainage does not appear to decrease pleural fluid formation, but is associated with decreased prolonged air leaks. Total pleural effusion volumes did not differ with the type of drainage system used. These findings support previously established benefits of the digital system in decreasing prolonged air leaks, but the advantages do not appear to extend to decreased pleural fluid formation.

Practice patterns in venous thromboembolism (VTE) prophylaxis in thoracic surgery: a comprehensive Canadian Delphi survey.

BACKGROUND: The incidence of venous thromboembolic events (VTE) after resection of thoracic malignancies can reach 15%, but prophylaxis guidelines are yet to be established. We aimed to survey Canadian practitioners regarding perioperative risk factors for VTE, impact of those factors on extended prophylaxis selection, type of preferred prophylaxis, and timing of initiation and duration of thromboprophylaxis. METHODS: A modified Delphi survey was undertaken over three rounds with thoracic surgeons, thoracic anesthesiologists and thrombosis experts across Canada. Participants were asked to rate each parameter on a ten-point scale. Agreement was determined a priori as an item reaching a coefficient of variation of ≤30% (0.3), with the item then discontinued from later rounds. RESULTS: In total, 72, 57 and 50 respondents participated in three consecutive rounds, respectively. Consensus was reached on previous VTE, age, cancer diagnosis, thrombophilia, poor mobilization, extended resections, and pre-operative chemotherapy as risk factors. Consensus on risk factors impacting extended prophylaxis decisions was achieved on cancer diagnosis, obesity, previous VTE and poor mobilization. With respect to perioperative prophylaxis, once daily low-molecular-weight heparin (LMWH) was the only parameter that demonstrated agreement as a common practice pattern. No agreement was achieved regarding the role of mechanical prophylaxis, unfractionated heparin (UFH) or timing of initiation of peri-operative treatment. VTE prophylaxis until discharge reached agreement but there was substantial variability regarding the role of extended prophylaxis. CONCLUSIONS: There is agreement between Canadian clinicians treating patients with thoracic malignancies regarding most risk factors for VTE, but there is no agreement on timing of initiation of prophylaxis, the agents used or factors mandating usage of extended prophylaxis.

Comprehensive Clinical Staging for Resectable Lung Cancer: Clinicopathological Correlations and the Role of Brain MRI.

INTRODUCTION: In our model of comprehensive clinical staging (CCS) for lung cancer, patients with a computerized tomography scan of the chest and upper abdomen not showing distant metastases will then routinely undergo whole body positron emission tomography/computerized tomography and magnetic resonance imaging (MRI) of the brain before any therapeutic decision. Our aim was to determine the accuracy of CCS and the value of brain MRI in this population. METHODS: A retrospective analysis of a prospectively entered database was performed for all patients who underwent lung cancer resection from January 2012 to June 2014. Demographics, clinical and pathological stage (seventh edition of the American Joint Committee on Cancer/Union for International Cancer Control tumor, node, and metastasis staging manual), and costs of staging were collected. Correlation between clinical and pathological stage was determined. RESULTS: Of 315 patients with primary lung cancer, 55.6% were female and the mean age was 70 ± 9.6 years. When correlation was analyzed without consideration for substages A and B, 49.8% of patients (158 of 315) were staged accurately, 39.7% (125 of 315) were overstaged, and 10.5% (32 of 315) were understaged. Only 4.7% of patients (15 of 315) underwent surgery without appropriate neoadjuvant treatment. Preoperative brain MRI detected asymptomatic metastases in four of 315 patients (1.3%). At a median postoperative follow-up of 19 months (range 6-43), symptomatic brain metastases developed in seven additional patients. The total cost of CCS in Canadian dollars was $367,292 over the study period, with $117,272 (31.9%) going toward brain MRI. CONCLUSION: CCS is effective for patients with resectable lung cancer, with less than 5% of patients being denied appropriate systemic treatment before surgery. Brain MRI is a low-yield and high-cost intervention in this population, and its routine use should be questioned.

The Integrated Comprehensive Care Program: A Novel Home Care Initiative After Major Thoracic Surgery.

The objective of the study was to evaluate the Integrated Comprehensive Care (ICC) program, a novel health system integration initiative that coordinates home care and hospital-based clinical services for patients undergoing major thoracic surgery relative to traditional home care delivery. Methods included a pilot retrospective cohort analysis that compared the intervention cohort (ICC), composed of all patients undergoing major thoracic surgery in the 2012-2013 fiscal year with a control cohort, who underwent surgery in the year before the initiation of ICC. Length of stay, hospital costs, readmission, and emergency room visit data were stratified by degree and approach of resection and compared using univariate logistic regression analysis. A total of 331 patients under ICC and 355 control patients were enrolled. Hospital stay was significantly shorter in patients under video-assisted thoracoscopic surgery (VATS) ICC (sublobar median 3 vs 4 days, P = 0.013; lobar median 4 vs 5 days, P = 0.051) but not for open resections. The frequency of emergency room visits within 60 days of surgery was lower for all stratification groups in the ICC cohort, except for VATS sublobar (25.7% control vs 13.9% ICC, P = 0.097). There were no significant differences in 60-day readmission frequency in any subcohort. The mean inpatient case cost was significantly lower for ICC VATS sublobar resections ($8505.39 vs $11,038.18, P = 0.007), with the other resection types trending lower for ICC but nonsignificant. In conclusion, a hospital-based, postdischarge, patient-centered program could potentially result in shorter hospital stay, fewer readmission and emergency room visits, costsavings, and no increase in adverse postdischarge outcomes after major thoracic surgery.

Postdischarge venous thromboembolic complications following pulmonary oncologic resection: An underdetected problem.

OBJECTIVES: To determine the prevalence of delayed postoperative venous thromboembolism (VTE) in patients undergoing oncologic lung resections, despite adherence to current in-hospital VTE prophylaxis guidelines. METHODS: Patients undergoing lung resection for malignancy in 2 tertiary-care centers were recruited between June 2013 and December 2014. All patients received guideline-based VTE prophylaxis until hospital discharge. Patients underwent computed tomography chest angiography with pulmonary embolism (PE) protocol and bilateral lower extremity venous Doppler ultrasonography at 30 ± 5 days after surgery to determine the incidence of postoperative VTE. Univariate analysis was used to compare the VTE and non-VTE groups. RESULTS: A total of 157 patients were included, 45.9% were men with a mean age of 66.7 years. VTE prevalence was 12.1% with a total of 19 VTE events, including 14 PEs (8.9%), 3 deep venous thromboses (DVTs) (1.9%), 1 combined PE/DVT, and 1 massive left atrial thrombus originating from the pulmonary vein stump after pulmonary lobectomy. PE events occurred in the operated lung 64% of the time and 4 patients (21.1%) were symptomatic at diagnosis. The 30-day mortality rate of VTE events was 5.2%, with 1 patient who died secondary to massive in situ ipsilateral PE following readmission to the hospital. Univariate analysis did not demonstrate significant differences between the VTE and non-VTE populations with regard to baseline characteristics. CONCLUSIONS: Despite adherence to in-hospital standard prophylaxis guidelines, VTE events are frequent, often asymptomatic, and with associated significant morbidity and mortality. More research into the potential role of predischarge screening and extended prophylaxis is warranted.

The effect of surgeon volume on procedure selection in non-small cell lung cancer surgeries.

OBJECTIVES: Procedure selection by the surgeon can greatly affect patients' operative and long-term survival. This selection potentially reflects comfort with technically challenging surgeries. This study aims to examine surgeon choices for non-small cell lung cancer and whether surgeon volume predicts the type of procedure chosen, controlling for patient demographics, comorbidity, year of surgery, and institutional factors. METHODS: Data were abstracted from an Ontario population-based linked database from 2004 to 2011. Patient demographics, comorbidities, year of surgery, and institutional and surgical factors were evaluated. Three-level, random-effect, multilevel regression analyses were performed to examine factors influencing operative selection. RESULTS: Over the interval, 8070 patients (50.4% were male) underwent surgical resection, including pneumonectomy (n = 842), lobectomy (n = 6212), and wedge resection (n = 1002). Resections were performed by 124 unique physicians in 45 institutions. The proportion of patients undergoing pneumonectomy decreased from 14.8% in 2004 to 7.6% in 2011. Multilevel regression analysis showed physician volume, age, year of procedure, gender, and comorbidities were predictive of performing a pneumonectomy. By adjusting for these variables, the results indicated that for each 10-unit increase in physician volume, the relative risk of performing a pneumonectomy decreased by 9.1% (95% confidence interval, 8.2-10.0, P = .04). CONCLUSIONS: Although patient and temporal factors influence the type of resection a patient receives for non-small cell lung cancer, surgeon volume also is a strong predictor. This study may be limited by minimal stage data, but the suggestion that a surgeon's total procedural volume for non-small cell lung cancer significantly influences procedure selection has implications on how we deliver care to this patient population.

The burden of death following discharge after lobectomy†.

OBJECTIVES: Pulmonary lobectomy is the most commonly performed surgery for lung cancer and remains the gold standard operative treatment. The reported surgical mortality from this procedure rarely differentiates between in-hospital mortality (IHM) and early post-discharge mortality (PDM). We aimed to examine the IHM and 90-day PDM over time and identify outcome predictors including patient characteristics, comorbidity and system-level factors. METHODS: Data for patients who underwent lobectomy from 2005 to 2011 were acquired from a linked Ontario population-based database. Exclusions included patients undergoing sleeve lobectomy, resections for synchronous lesions, previous lung malignancy and extended length of stay (LOS) over 30 days. We reported proportional mortality and cumulative survival attributable to IHM and PDM with confidence intervals. Multivariate logistic and Cox regression analyses were performed to examine the role of variables associated with IHM and 90-day PDM. RESULTS: For 5389 patients who underwent lobectomy for non-small-cell lung cancer, the median LOS was 6 (1-30) days. IHM (n = 73) was 1.4% (1.1-1.6%) and PDM (n = 101) was an additional 1.9% (1.6-2.3%) within 90 days post-lobectomy discharge. Logistic regression suggested that age [odds ratio (OR): 1.5 (1.3-1.8)], myocardial infarction [OR: 3.6 (1.8-7.0)], congestive heart failure [OR: 5.8 (2.4-13.8)], chronic obstructive pulmonary disease [OR: 1.9 (1.1-3.2)], preoperative positron emission tomography [OR: 2.7 (1.1-7.0)], peptic ulcer disease [OR: 22.1 (4.1-117.4)], hemiplegia [OR: 15.8 (1.8-141.1)], other primary cancer [OR: 0.5 (0.3-0.8)] and year of surgery [OR: 1.0 (0.8-1.0)] were potential predictors of IHM. Length of hospital stay [hazard ratio (HR): 1.1 (1.0-1.1)], male gender [HR: 1.5 (1.0-2.3)], age [HR: 1.1 (1.0-1.3)] and metastatic cancer [HR: 2.6 (1.7-4.0)] were potential predictors of PDM. CONCLUSIONS: PDM represents a substantive, under-reported burden of mortality due to lobectomy. More than half of post-lobectomy mortality occurs post-discharge and the annual rate remained unchanged, while IHM decreased with time, suggesting that the improvement seen in mortality might be exclusive to the smaller IHM. Patient factors play a significant role in both IHM and PDM. We emphasize that this identifies the importance of appropriate patient selection, further investigation of risk factors and particular attention to these risk factors during regular follow-up visits to improve PDM in this high-risk patient population.

Pneumonectomy: the burden of death after discharge and predictors of surgical mortality.

BACKGROUND: Pneumonectomy has the highest mortality rate among resections for lung cancer, with limited literature differentiating predictors of postpneumonectomy in-hospital mortality (IHM) from early postdischarge mortality (PDM). This study aims to examine the burden of death over time and to identify potential predictive factors, including patient comorbidities and hospital and surgeon volumes. METHODS: Data were abstracted from an Ontario population-based linked database from 2005 to 2011. Proportional mortality and cumulative survival attributable to IHM and 90-day PDM is reported. Logistic and Cox regression analyses examined the role of potential factors related to death. Odds ratios (ORs) and hazard ratios (HRs) and 95% confidence intervals (CIs) were reported. RESULTS: Of 505 patients who underwent pneumonectomy, the median length of stay was 6 days (1-30 days). IHM was 4.4% (2.9%-6.5%), and 90-day PDM was an additional 6.4% (4.6%-9.0%). Logistic regression showed that congestive heart failure (CHF) (OR, 23.5; range, 4.0-136.0), cerebrovascular disease (OR, 12.5; range, 1.2-128.0), renal disease (OR, 8.8; range, 1.3-60.5), and previous myocardial infarction (MI) (OR, 5.4; range, 1.5-20.0) were predictive of IHM, whereas age (HR, 1.4; range, 1.1-1.7) per year and CHF (HR, 18.0; range, 4.0-79.0) were predictive of PDM. All other factors were not significant. CONCLUSIONS: PDM represents a distinct and underrecognized burden of postoperative death. More than half of postpneumonectomy mortality occurred after discharge, and the rate remained unchanged over the study period. Patient factors play a major role in both IHM and PDM, whereas institutional and physician volume do not influence outcome, suggesting the importance of patient selection and the need for continued evaluation of mortality.

Design of a consensus-derived synoptic operative report for lung cancer surgery.

BACKGROUND: For lung cancer surgery, a narrative operative report is the standard reporting procedure, whereas a synoptic-style report is increasingly utilized by healthcare professionals in various specialties with great success. A synoptic operative report more succinctly and accurately captures vital information and is rapidly generated with good intraobserver reliability. The objective of this study was to systematically develop a synoptic operative report for lung cancer surgery following a modified Delphi consensus model with the support of the Canadian thoracic surgery community. METHODS: Using online survey software, thoracic surgeons and related physicians were asked to suggest and rate data elements for a synoptic report following the modified Delphi consensus model. The consensus exercise-derived template was forwarded to a small working group, who further refined the definition and priority designation of elements until the working group had reached a satisfactory consensus. RESULTS: In all, 139 physicians were invited to participate in the consensus exercise, with 36.7%, 44.6%, and 19.5% response rates, respectively, in the three rounds. Eighty-nine elements were agreed upon at the conclusion of the exercise, but 141 elements were forwarded to the working group. The working group agreed upon a final data set of 180 independently defined data elements, with 72 mandatory and 108 optional elements for implementation in the final report. CONCLUSIONS: This study demonstrates the process involved in developing a multidisciplinary, consensus-based synoptic lung cancer operative report. This novel report style is a quality improvement initiative to improve the capture, dissemination, readability, and potential utility of critical surgical information.

The effect of regionalization on outcome in esophagectomy: a Canadian national study.

BACKGROUND: Regionalization of specialized surgical services has been proposed to improve outcomes based on the reported association between volume and outcomes. The effect of regionalization of esophagectomy on in-hospital mortality (IHM) and length of stay (LOS) was examined. METHODS: Data from a Canadian database for 6985 patients (74% men; median age, 66 years) who underwent esophagectomy (1998 to 2007) were analyzed with a multivariable mixed model regression controlling for age, sex, Charlson comorbidity index, and year of esophagectomy to evaluate the effect of hospital volume. Volume changes were evaluated within and between hospitals. RESULTS: From 1998 to 2007, the number of hospitals performing esophagectomies decreased (101 to 85). The percentage of patients treated in large-volume (>20 cases/year) centers increased (29% to 61%) and IHM decreased (9.1% to 3.6%). The odds of IHM decreased 64% (95% confidence interval [CI], 51% to 74%), and LOS decreased 38% (95% CI, 34% to 43%). Comparing between hospitals, an increase of 10 cases was associated with a 15% decrease in IHM (95% CI, 6% to 23%, p=0.001) and a 10% increase in LOS (95% CI, 2% to 19%, p=0.01). Within an individual hospital, the relationship between increasing volume and LOS or IHM was not significant. CONCLUSIONS: In-hospital mortality for esophagectomy has decreased in Canada but was not significantly reduced when volume was increased within a given hospital. Improved IHM may be related to selective referral of patients to high-volume hospitals. Although, decreased IHM is not solely attributable to volume changes, our results support regionalization policies for esophagectomy.

The effect of regionalization on outcome in pulmonary lobectomy: a Canadian national study.

OBJECTIVE: To examine the effect of regionalization of thoracic surgery services in Canada by evaluating change over time in hospital volumes of pulmonary lobectomy and its impact on length of stay and in-hospital mortality. METHODS: Data on pulmonary lobectomy between 1999 and 2007 were abstracted from the Canadian Institute for Health Information Discharge Abstract Database. In-hospital mortality was analyzed by logistic regression, and log-transformed length of stay was analyzed by linear regression. Cross-sectional analysis of hospital volume, in-hospital mortality, and length of stay was performed, controlling for clustering. Within-hospital changes in annual volume on outcome was analyzed using multivariable logistic regression, controlling for Charlson comorbidity index and other confounders. RESULTS: Of 19,732 patients, 10, 281 (52%) were male, with an average age of 63.3 years. There was a 45% (95% confidence interval, 21-61; P = .001) relative risk reduction in in-hospital mortality with a 19% reduction in length of stay (95% confidence interval, 12-25; P < .0001). On comparison of volume between hospitals, an increase of 20 cases was associated with a 15% relative risk reduction (95% confidence interval, 9-19; P < .0001) in in-hospital mortality and a 5% relative decrease (95% confidence interval, 3-7; P < .001) in length of stay. Within hospitals there was a nonsignificant relationship between volume and in-hospital mortality. CONCLUSIONS: In-hospital mortality and length of stay for lobectomies have decreased in Canada. In multivariate analysis, volume was associated with improved in-hospital mortality, but there was no reduction in mortality when volume was increased within a given hospital. However, the proportion of patients treated in high-volume centers has increased over time, inferring the importance of high-volume centers in improved outcomes. This supports regionalization policies for pulmonary lobectomy.

Factors associated with postoperative symptoms after laparoscopic Heller myotomy.

BACKGROUND: Our objective is to ascertain if preoperative and perioperative treatments affect the short- and long-term symptom frequency or symptom scores for dysphagia, regurgitation, and heartburn in patients with laparoscopic Heller myotomy for achalasia. METHODS: From 1994 to 2008, 261 patients undergoing laparoscopic esophageal myotomy were enrolled prospectively. The diagnosis of classic achalasia was made on clinical history, barium swallow, endoscopy, and manometry. A validated symptom questionnaire and history was taken for each patient at the preoperative visit and at each postoperative visit. RESULTS: In all, 261 patients had laparoscopic Heller myotomy during the study period. Preoperatively, 137 patients (62.3%) tried medications, 101 (38.7%) were treated with pneumatic dilation, and 29 (11.1%) were treated initially with at least one injection of botulinum toxin into the lower esophageal sphincter. In all, 134 patients (51.3%) received a Dor anterior fundoplication. On multivariate regression controlling for age and sex, preoperative dilation (p = 0.031), injection of botulinum toxin (p = 0.044), and a fundoplication (p = 0.005) were associated with significantly worse early postoperative dysphagia, with odds ratios of 2.11, 2.56, and 2.80, respectively; previous botulinum toxin injection was associated with worse late postoperative dysphagia (p = 0.001), regurgitation (p = 0.031), and heartburn (p = 0.049), with odds ratios of 5.24, 2.87, and 2.52, respectively. There was a trend for no fundoplication to be associated with late postoperative heartburn (p = 0.077) with an odds ratio of 1.80. CONCLUSIONS: Many patients presenting for Heller myotomy have previously undergone a different form of treatment. Early postoperative dysphagia was affected by dilation, botulinum toxin injection, and fundoplication. Only botulinum toxin injection was associated with late symptoms.