Effects of dexmedetomidine on inflammation and pulmonary function after thoracoscopic surgery for lung cancer: a systematic review and meta-analysis.

Background: Surgical resection is the most effective treatment for lung cancer, but it can also lead to adverse stress reactions in the body. The minimization of lung function damage caused by one-lung ventilation and inflammatory reactions caused by surgery are new challenges faced by the field of anesthesiology. Dexmedetomidine (Dex) has been found to be effective in improving perioperative lung function. In this study, we aimed to conduct a systematic review and meta-analysis to examine the effect of Dex on inflammation and pulmonary function after thoracoscopic surgery for lung cancer. Methods: A computer-based search was performed to retrieve controlled trials (CTs) about the effects of Dex on inflammation and lung function after thoracoscopic surgery for lung cancer from the databases of PubMed, Embase, Cochrane Library, and Web of Science. The time period for retrieval was set from inception to 1 August 2022. The articles were strictly screened according to the inclusion and exclusion criteria, and data analysis was conducted using the software Stata 15.0. Results: A total of 11 CTs were included, involving 1,026 patients overall, with 512 assigned to the Dex group and 514 to the control group. The meta-analysis showed that after Dex treatment, the inflammatory factors of patients with lung cancer who underwent radical resection were all decreased: interleukin-6 (IL-6) [standardized mean difference (SMD) =-2.09; 95% confidence interval (CI): -3.03, -1.14; P=0.003], interleukin-8 (IL-8) (SMD =-1.12; 95% CI: -1.54, -0.71; P=0.001), and tumor necrosis factor-α (TNF-α) (SMD =-2.04; 95% CI: -3.24, 0.84; P=0.001). The pulmonary function of the patients was also improved: forced expiratory volume in the first second (FEV1) (SMD =0.50; 95% CI: 0.24, 0.76; P=0.003), and partial pressure of oxygen (PaO2) (SMD =1.00; 95% CI: 0.40, 1.59; P=0.001). However, there was no significant difference between the two groups regarding adverse reactions [relative risk (RR) =0.68; 95% CI: 0.41, 1.14; P=0.27]. Conclusions: In summary, the use of Dex in lung cancer patients after radical surgery can reduce serum inflammatory factors, and this may play an important role in postoperative inflammatory reaction and improving lung function.

One hundred cases of primary spontaneous pneumomediastinum: leukocytosis is common, pleural effusions and age over 40 are rare.

Background: Primary spontaneous pneumomediastinum (PSPM) is a benign condition, but it can be difficult to discriminate from Boerhaave syndrome. The diagnostic difficulty is attributable to a shared constellation of history, signs, and symptoms combined with a poor understanding of the basic vital signs, labs, and diagnostic findings characterizing PSPM. These challenges likely contribute to high resource utilization for diagnosis and management of a benign process. Methods: Patients aged 18 years or older with PSPM were identified from our radiology department's database. A retrospective chart review was performed. Results: Exactly 100 patients with PSPM were identified between March 2001 and November 2019. Demographics and histories correlated well with prior studies: mean age (25 years); male predominance (70%); association with cough (34%), asthma (27%), retching or emesis (24%), tobacco abuse (11%), and physical activity (11%); acute chest pain (75%), and dyspnea (57%) as the first and second most frequent symptoms and subcutaneous emphysema (33%) as the most common sign. We provide the first robust data on presenting vital signs and laboratory values of PSPM, showing that tachycardia (31%) and leukocytosis (30%) were common. No pleural effusion was found in the 66 patients who underwent computed tomography (CT) of the chest. We provide the first data on inter-hospital transfer rates (27%). 79% of transfers were due to concern for esophageal perforation. Most patients were admitted (57%), with an average length of stay (LOS) of 2.3 days, and 25% received antibiotics. Conclusions: PSPM patients frequently present in their twenties with chest pain, subcutaneous emphysema, tachycardia, and leukocytosis. Approximately 25% have a history of retching or emesis and it is this population that must be discriminated from those with Boerhaave syndrome. An esophagram is rarely indicated and observation alone is appropriate in patients under age 40 with a known precipitating event or risk factors for PSPM (e.g., asthma, smoking) if they have no history of retching or emesis. Fever, pleural effusion, and age over 40 are rare in PSPM and should raise concern for esophageal perforation in a patient with a history of retching, emesis, or both.

Consequences of anastomotic leaks after minimally invasive esophagectomy: A single-center experience.

Background: Anastomotic leak (AL) after minimally invasive esophagectomy (MIE) is a well-described source of morbidity for patients undergoing surgical treatment of esophageal neoplasm. With improved early recognition and endoscopic management techniques, the long-term impact remains unclear. Methods: A retrospective review was conducted of patients who underwent MIE for esophageal neoplasm between January 2015 and June 2021 at a single institution. Cohorts were stratified by development of AL and subsequent management. Baseline demographics, perioperative data, and post-operative outcomes were examined. Results: During this period, 172 MIEs were performed, with 35 of 172 (20.3%) complicated by an AL. Perioperative factors independently associated with AL were post-operative blood transfusion (leak rate 52.9% versus 16.8%; p = 0.0017), incompleteness of anastomotic rings (75.0% vs 19.1%; p = 0.027), and receiving neoadjuvant therapy (18.5% vs 30.8%; p < 0.0001). Inferior short-term outcomes associated with AL included number of esophageal dilations in the first post-operative year (1.40 vs 0.46, p = 0.0397), discharge disposition to a location other than home (22.9% vs 8.8%, p = 0.012), length of hospital stay (17.7 days vs 9.6 days; p = 0.002), and time until jejunostomy tube removal (134 days vs 79 days; p = 0.0023). There was no significant difference in overall survival between patients with or without an AL at 1 year (79% vs 83%) or 5 years (50% vs 47%) (overall log rank p = 0.758). Conclusions: In this large single-center series of MIEs, AL was associated with inferior short-term outcomes including hospital length of stay, discharge disposition other than to home, and need for additional endoscopic procedures, without an accompanying impact on 1-year or 5-year survival. Key message: In this large, single-center series of minimally invasive esophagectomies, anastomotic leak was associated with worse short-term outcomes including hospital length of stay, discharge disposition other than to home, and need for additional endoscopic procedures, but was not associated with worse long-term survival. The significant association between neoadjuvant therapy and decreased leak rates is difficult to interpret, given the potential for confounding factors, thus careful attention to modifiable pre- and peri-operative patient factors associated with anastomotic leak is warranted.

Evaluation of Prescribing Patterns Following Surgical Procedures in Opioid Naïve Patients at a Veterans Affairs Teaching Hospital.

OBJECTIVES: To evaluate facility postoperative opioid prescribing patterns in comparison to published guidelines and adherence to opioid safety mandates. METHODS: This quality analysis was performed between November 2019 and March 2020. Patients were identified to have been opioid naïve prior to receiving a new opioid prescription postoperatively during the study period. Patient charts were reviewed, and patients were contacted to collect desired data. Statistical analysis was performed to evaluate distributions of morphine equivalent daily dose and opioid day supply prescribed across study subpopulations. RESULTS: Ninety-four of 100 prescriptions evaluated were determined to be within quantity or duration recommendations of the selected guideline. Statistical analysis found no significantly different distributions between the duration and quantity of opioid prescribed at discharge and patient-specific risk factors. Forty-eight patients did not use the entire quantity of the initial opioid prescription dispensed. Of those patients, 26 still had opioids within the home. Opioid risk review documentation was completed in 19 of 65 patients indicated for documentation. CONCLUSION: Most opioid prescriptions provided within the study period aligned with recommendations from author-selected guidelines. However, a review of risk prior to opioid prescribing frequently was not performed. The number of patients utilizing less than 50% of prescribed opioids, and few refills indicate that reductions in opioids prescribed would improve safety for both patients and the surrounding community without increasing the risk for the under-treatment of postoperative pain. Improved prescribing habits and patient safety will be targeted through provider education regarding risk review documentation in opioid naïve patients.

Successful Lung Transplantation for Severe Post-COVID-19 Pulmonary Fibrosis.

Lung transplantation has been well described for patients with coronavirus disease 2019 (COVID-19) in the acute setting, but less so for the resulting pulmonary sequelae. This report describes a case of lung transplantation for post-COVID-19 pulmonary fibrosis. A 52-year-old woman contracted COVID-19 in July 2020 and mounted a partial recovery, but she went on to have declining function over the ensuing 3 months, with development of fibrocystic lung changes. She underwent bilateral lung transplantation and recovered rapidly, was discharged home on postoperative day 14, and has done well in follow-up. This case report demonstrates that lung transplantation is an acceptable therapy for post-COVID-19 pulmonary fibrosis.

A narrative review of primary spontaneous pneumomediastinum: a poorly understood and resource-intensive problem.

Primary spontaneous pneumomediastinum (PSPM) is a benign self-limited condition that can be difficult to discriminate from esophageal perforation. This may trigger costly work-up, transfers and hospital admissions. To better understand this diagnostic dilemma and current management, we undertook the most comprehensive and up to date review of PSPM. The PubMed database was searched using the MeSH term "Mediastinal Emphysema"[Mesh], to identify randomized controlled trials, meta-analyses and case series (including 10 or more patients) relevant to the clinical presentation and management of patients with PSPM. There were no relevant randomized controlled trials or meta-analyses. Nineteen case series met our criteria, including a total of 535 patients. The average mean age was 23 years with a 3:1 male predominance. Chest pain was the most common symptom, found in 70.9% of the patients. Dyspnea and neck pain were the second and third most common symptoms, found in 43.4% and 32% of the patients, respectively. Subcutaneous emphysema was the most common sign (54.2%). Common histories included smoking (29.6%), cough (27.7%), asthma (25.9%), physical exertion (21.1%) and recent retching or emesis (13%). Nearly all patients (96.9%) underwent chest X-ray (CXR). Other diagnostic studies included computed tomography (65%) and esophagram (35.6%). Invasive studies were common, with 13% of patients undergoing esophagogastroduodenoscopy and 14.6% undergoing bronchoscopy. The rate of hospital admission was 86.5%, with an average length of stay of 4.4 days. No deaths were reported. Notably, we identified a dearth of information regarding the vitals, laboratory values and imaging findings specific to patients presenting with PSPM. We conclude that PSPM is a benign clinical entity that continues to present a resource-intensive diagnostic challenge and that data on the vitals, labs, and imaging findings specific to PSPM patients is scant. An improved understanding of these factors may lead to more efficient diagnosis and management of these patients.

Role of procedural intervention and acute illness in veterans affairs smoking cessation program referrals: A retrospective study.

INTRODUCTION: Tobacco use remains pervasive amongst veterans. Unfortunately, the negative impact on postoperative outcomes may preclude surgeons from offering operative intervention to veterans who smoke. As such, a major health event may provide added incentive to quit. We sought to describe the role of acute illness and interventional specialist involvement in Veterans Affairs Smoking Cessation Program referrals compared to primary care wellness initiatives. METHODS: We retrospectively reviewed consultations to the pharmacy-led Smoking Cessation Program (SCP) at the Middleton Memorial VA Hospital from 2017 to 2019. Consultations placed during the last three months were categorized based on the source of referral: primary care, acute care, and interventional specialties. Descriptive statistics were used to assess rates of veteran engagement based on referral source. Consultation completion was used as a proxy for veteran engagement. RESULTS: A total of 2993 new SCP consultations were placed during the study period. Overall, veteran engagement rose from 43% in 2017 to 53% in 2019. In recent months, there were 282 SCP referrals. While only 19 (7%) of these referrals were placed by interventional specialties - primarily cardiology and thoracic surgery - the rate of veteran engagement was 63%. The majority of referrals (65%) were placed by primary care providers with an engagement rate of 68%. In contrast, only 42% of consultations placed in the context of an acute illness were completed. CONCLUSIONS: In our study, primary care directed smoking cessation referrals were most prevalent and resulted in the highest completion rates. The presence of an acute illness in isolation failed to impact program success. However, while surgeon-initiated referrals were meager in number, the engagement rate approached that of primary care. This finding suggests that surgeons play a powerful role in influencing patient behavior that may be harnessed to augment success of existing smoking cessation programs.

Cavitary lung lesions and pneumothorax in a healthy patient with active coronavirus-19 (COVID-19) viral pneumonia.

Severe respiratory sequelae drive morbidity-associated with coronavirus 2019 (COVID-19) disease. We report a case of COVID-19 pneumonia complicated by cavitary lesions and pneumothorax in a young healthy male. Pneumothorax management with catheter thoracostomy and rapid resolution of the cavitary lesions are described. An extensive work-up for other causes a cavitation was negative and the temporal correlation of the cavities with COVID-19 infection plus their rapid resolution suggest a direct relationship. We propose a mechanism for cavitation secondary to microangiopathy, a cause of cavitation in the vasculitides and a known feature of COVID-19.

Cardiac Toxicity in Operable Esophageal Cancer Patients Treated With or Without Chemoradiation.

PURPOSE: The purpose of this study was to evaluate predictors of cardiac events in esophageal cancer patients treated with neoadjuvant chemoradiotherapy (NA CRT) followed by surgery compared with surgery alone. MATERIALS AND METHODS: We retrospectively identified patients treated for esophageal cancer between 2006 and 2016. A total of 123 patients were identified; 70 were treated with surgery alone, and 53 were treated with NA CRT. Cardiac events were scored based on Common Terminology Criteria for Adverse Events (version 4.03), and dosimetric data was compiled for all patients who received radiation. Univariate analysis and multivariable analysis (MVA) were performed to identify predictors of cardiac events. Competing risk of death regression was performed to a model the cumulative incidence of cardiac events. RESULTS: The overall rates of grade ≥3 cardiac events were 24.5% in the NA CRT group versus 10% in the surgery group (P=0.04). On MVA, use of NA CRT (P<0.01, hazard ratio [HR]: 3.45, 95% confidence interval [CI]: 1.35-9.09) predicted for grade ≥3 cardiac events, though no dosimetric variable predicted for grade ≥3 cardiac events or overall survival. On MVA, NA CRT predicted for pericardial effusions of any grade (P<0.01, HR: 3.70, 95% CI: 1.67-8.33). The V45 Gy was the most significant predictor of pericardial effusions (P=0.012, HR: 1.03, 95% CI: 1.01-1.06) CONCLUSIONS:: NA CRT significantly increased the rate of grade ≥3 cardiac events compared with patients treated with surgery alone. Although no dosimetric parameter predicted for grade ≥3 cardiac events or survival, the V45 Gy predicted for pericardial effusions.

Deficiencies in postoperative surveillance for veterans with gastrointestinal cancer.

BACKGROUND AND OBJECTIVES: National guidelines for gastrointestinal (GI) cancers offer surveillance algorithms to facilitate detection of recurrent disease, yet adherence rates are unknown. We sought to characterize postoperative surveillance patterns for veterans with GI cancer at a tertiary care Veterans Affairs Hospital. METHODS: A single-center retrospective cohort study identified patients who underwent surgical resection for colorectal, gastroesophageal or hepatopancreaticobiliary malignancy from 2010-2016. We calculated the annual rate of cancer-directed clinic visits and abdominal imaging and used National Comprehensive Cancer Network guidelines as a benchmark by which to assess adequate surveillance. RESULTS: Ninety-seven patients met inclusion criteria. Median surveillance time was 1203 days. Overall, 44% of patients had insufficient surveillance. Specifically, 11% received no postoperative imaging and 7% had no cancer-directed clinic visits. An additional 30% received less than recommended surveillance imaging and 12% attended fewer than recommended clinic visits. By disease site, insufficient imaging was most common for patients with hepatopancreaticobiliary cancer (63%), while inadequate clinic follow-up was highest for colorectal cancer (24%). CONCLUSION: A significant proportion of veterans with GI cancer received either inadequate postoperative surveillance based on national guidelines. This deficiency represents an opportunity for improvement through targeted efforts, including telemedicine and education of patients and providers.

Predictive value of pulmonary function measures for short-term outcomes following lung resection: analysis of a single high-volume institution.

Despite the importance of preoperative risk-stratification, there is a lack of consensus on how to identify high-risk patients for pulmonary resection. Enrollment criteria for national trials propose one definition based on preoperative pulmonary function tests. We sought to examine the value of preoperative forced expiratory volume in 1 second (FEV1) and diffusion capacity for carbon monoxide (DLCO) to predict short-term outcomes following pulmonary resection. Using our institutional Society of Thoracic Surgeons (STS) database we identified 419 consecutive lung cancer patients who presented to our institution for pulmonary resection between 2012 and 2016. We identified patients as "high risk" based on the national trial criteria of FEV1 or DLCO ≤50%. Our primary outcome was any postoperative complication within 30 days of surgery. Secondary outcomes included cardiac and pulmonary complications, 30-day readmission, and discharge disposition. DLCO ≤50% was associated with any postoperative complication (P=0.03), but not predictive of cardiac events, pulmonary complications, or 30-day readmission. There were no significant differences in any of these short-term outcomes for patients with FEV1 ≤50%. On multivariable analysis, neither FEV1 nor DLCO ≤50% were significantly associated with occurrence of postoperative complication (OR =1.67, 95% CI: 0.60-4.63; OR =1.66, 95% CI: 0.96-2.86, respectively). Notably, DLCO ≤50%-but not FEV1-was associated with discharge to a skilled facility on univariate (P=0.01) and multivariable analysis (OR =2.54; 95% CI: 1.08-5.99; P=0.03). This association between DLCO and discharge to a skilled facility persisted when DLCO was used as a continuous variable. For all-comers presenting to our institution for lung cancer resection, classification based on FEV1 or DLCO ≤50% may not reliably identify those at highest risk for short-term postoperative complications. While our findings suggest caution when using pulmonary parameters in isolation, the potential value of DLCO as a proxy for underlying comorbidity warrants further investigation.

Financial and Temporal Advantages of Virtual Consultation in Veterans Requiring Specialty Care.

Background: Access to specialty health care in the Veterans Affairs (VA) system continues to be problematic. Given the potential temporal and fiscal benefits of telehealth, the Madison VA developed a virtual consultation (VC) mechanism to expedite diagnostic and therapeutic interventions for Veterans with incidentally discovered pulmonary nodules. Materials and. Methods: VC, a remote encounter between referring provider and thoracic surgeon for incidentally discovered pulmonary nodules, was implemented at the Madison VA between 2009 and 2011. Time from request to completion of consultation, hospital cost, and travel costs were determined for 157 veterans. These endpoints were then compared with in-person consultations over a concurrent 6-mo period. Results: For the entire study cohort, the mean time to completion of VC was 3.2 d (SD ± 4.4 d). For the 6-mo period of first VC availability, the mean time to VC completion versus in-person consultation was 2.8 d (SD ± 2.8 d) and 20.5 d (SD ± 15.6 d), respectively (p < 0.05). Following initial VC, 84 (53%) veterans were scheduled for virtual follow-up alone; no veteran required an additional office visit before further diagnostic or therapeutic intervention. VA hospital cost was $228 per in-person consultation versus $120 per episode for VC - a 47.4% decrease. The average distance form veteran home to center was 86 miles, with an average travel reimbursement of $112 per in-person consultation, versus no travel cost associated with VC. Conclusions: VC for incidentally discovered pulmonary nodules significantly decreases time to consultation completion, hospital cost, and veteran travel cost. These data suggest that a significant opportunity exists for expansion of telehealth into additional practice settings within the VA system.

Utilization of surgical treatment for local and locoregional esophageal cancer: Analysis of the National Cancer Data Base.

BACKGROUND: Previous studies have suggested that esophagectomy is severely underused for patients with resectable esophageal cancer. The recent expansion of endoscopic local therapies, advances in surgical techniques, and improved postoperative outcomes have changed the therapeutic landscape. The impact of these developments and evolving treatment guidelines on national practice patterns is unknown. METHODS: Patients diagnosed with clinical stage 0 to III esophageal cancer were identified from the National Cancer Database (2004-2013). The receipt of potentially curative surgical treatment over time was analyzed, and multivariate logistic regression was used to identify factors associated with surgical treatment. RESULTS: The analysis included 52,122 patients. From 2004 to 2013, the overall rate of potentially curative surgical treatment increased from 36.4% to 47.4% (P < .001). For stage 0 disease, the receipt of esophagectomy decreased from 23.8% to 17.9% (P < .001), whereas the use of local therapies increased from 34.3% to 58.8% (P < .001). The use of surgical treatment increased from 43.4% to 61.8% (P < .001), from 36.1% to 45.0% (P < .001), and from 30.8% to 38.6% (P < .001) for patients with stage I, II, and III disease, respectively. In the multivariate analysis, divergent practice patterns and adherence to national guidelines were noted between academic and community facilities. CONCLUSIONS: The use of potentially curative surgical treatment has increased for patients with stage 0 to III esophageal cancer. The expansion of local therapies has driven increased rates of surgical treatment for early-stage disease. Although the increased use of esophagectomy for more advanced disease is encouraging, significant variation persists at the patient and facility levels. Cancer 2017;123:410-419. © 2016 American Cancer Society.

Minimally Invasive Esophagectomy in a Patient With Tetralogy of Fallot and Right-Sided Aortic Arch.

Improvements in surgical technique and perioperative care have resulted in increased long-term survival for patients with congenital heart disease. As these patients begin to reach their later years, clinicians are challenged with determining optimal management of noncardiac diseases in this complex patient population, including surgically treatable malignancies. We present a case of esophageal cancer in a patient with previously repaired tetralogy of Fallot and right-sided aortic arch, treated with neoadjuvant therapy followed by laparoscopic and left thoracoscopic esophagectomy.

Lung transplantation for high-risk patients with idiopathic pulmonary fibrosis.

BACKGROUND: Survival for patients with idiopathic pulmonary fibrosis (IPF) and high lung allocation score (LAS) values may be significantly reduced in comparison to those with lower LAS values. OBJECTIVES: To evaluate outcomes for high-risk IPF patients as defined by LAS values ≥46 (N=42) versus recipients with LAS values <46 (N=89). METHODS: We retrospectively reviewed records of 131 consecutive patients with IPF who received lung transplants at our institution between 1999 and 2013. RESULTS: The mean LAS was significantly higher (59.5, interquartile range 43.9-75.9 vs. 39.3, interquartile range 37.7-44.3; p<0.01) for the high-risk cohort. The higher LAS cohort had significantly lower percent predicted forced vital capacity (FVC) versus recipients with LAS <46 (41.3±14.1% vs. 53.2±16.2%; p<0.01) and required more supplemental oxygen (7±5 vs. 4±2 L/min, p<0.01) prior to transplant versus recipients with LAS <46. Although the incidence of early post-LTX pulmonary complications was increased for the higher LAS group versus recipients with LAS <46, 30-day mortality and actuarial survival did not differ between the two cohorts. CONCLUSIONS: Although lung transplantation in patients with IPF and high LAS values is associated with increased risk of early post-transplant complications, long-term post-transplant survival for our high-LAS cohort was equivalent to that for the lower LAS recipients.

Video-Assisted Thoracoscopic Lobectomy for Lung Cancer: Current Practice Patterns and Predictors of Adoption.

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) lobectomy has been shown to be a safe, minimally invasive approach for the surgical management of lung cancer. Despite evidence supporting oncologic efficacy, recent reports indicate that less than half of lobectomies are performed by VATS. We examined nationwide lobectomy practice patterns to identify specific predictors for VATS adoption. METHODS: Premier hospital data (2010 to 2014) were used to identify open and VATS lobectomy procedures performed for the treatment of primary lung cancer. Propensity score method was used to match VATS and open operations (1:1) on clinical characteristics. Variables associated with VATS lobectomy were assessed by logistic regression to evaluate independent predictors. Secondary outcomes included postoperative complications, readmission, and mortality. RESULTS: Patients with primary lung cancer (n = 17,304) that underwent VATS (n = 6,670, 38.5%) or open (n = 10,634, 61.5%) lobectomy were identified; 6,670 patients in each group were matched for analysis. VATS performance increased significantly from 2010 to 2014, (39.6% versus 43.8%, p = 0.0004), particularly for thoracic surgeons (50.3% versus 54.7%, p < 0.0001), those performing 15 or more lobectomies per year (53.6% versus 59.8%, p < 0.0001), and for surgeons practicing in the Northeast (54.8% versus 59.9%, p = 0.0001). Independent predictors of VATS utilization included surgeon volume and specialty training, hospital type and size, and region. Multivariate analysis demonstrated a significant association between VATS and surgeon volume, independent of specialty. CONCLUSIONS: National rates of VATS lobectomy continue to increase, particularly for thoracic surgeons, high-volume surgeons, and surgeons in the Northeast. Surgeon volume and specialty are strong independent predictors of VATS lobectomy. Efforts that support centralization of care may improve VATS lobectomy rates and decrease the regional variability identified in this analysis.

Outpatient air leak management after lobectomy: a CMS cost analysis.

BACKGROUND: Air leaks after lobectomy are associated with increased length of stay (LOS) and protracted resource utilization. Portable drainage systems (PDS) allow for outpatient management of air leaks in patients otherwise meeting discharge criteria. We evaluated the safety and cost efficiency of a protocol for outpatient management of air leaks with a PDS. METHODS: We retrospectively assessed patients who underwent lobectomy for non-small-cell lung cancer at our institution between 2004 and 2014. All patients discharged with a PDS for air leak were included in the analysis. The study group was compared to an internally matched cohort of patients undergoing lobectomy for non-small-cell lung cancer managed without the need for outpatient PDS. Study end points included resource utilization, postoperative complications, and readmission. RESULTS: A total of 739 lobectomies were performed during the study period, 73 (10%) patients with air leaks were discharged with a PDS after fulfilling postoperative milestones. Shorter LOS was observed in the study group (3.88 ± 2.4 versus 5.68 ± 5.7 d, P = 0.014) without significant differences in 30-d readmission (11.7% versus 9.0%, P = 0.615). PDS-related complications occurred in 6.8% of study patients (5/73), and 2.7% (2/73) required overnight readmission. PDSs were used for 8.30 ± 4.5 outpatient days. A CMS-based cost analysis predicted an overall savings of $686.72/patient (4.9% of Medicare reimbursement for a major thoracic procedure), associated with significantly fewer hospital days and resources used. CONCLUSIONS: In patients otherwise meeting discharge criteria, outpatient management of air leaks is safe and effective. This strategy is associated with improved efficiency of postoperative care and a modest reduction in hospital costs. This model may be applicable to other thoracic procedures associated with protracted LOS.