Transthoracic versus transhiatal resection for esophageal adenocarcinoma of the lower esophagus: A value-based comparison.

BACKGROUND AND OBJECTIVE: Our objective was to compare clinical outcomes, costs, and resource use based on operative approach, transthoracic (TT) or transhiatal (TH), for resection of esophageal cancer. METHODS: This cohort analysis utilized the Surveillance, Epidemiology, and End Results--Medicare linked data from 2002 to 2009. Only adenocarcinomas of the lower esophagus were examined to minimize confounding. Medicare data was used to determine episode of care costs and resource use. Propensity score matching was used to control for identified confounders. Kaplan-Meier method and Cox-proportional hazard modeling were used to compare long-term survival. RESULTS: 537 TT and 405 TH resections were identified. TT and TH esophagectomy had similar complication rates (46.7% vs. 50.8%), operative mortality (7.9% vs 7.1%), and 90 days readmission rates (30.5% vs. 32.5%). However, TH was associated with shorter length of stay (11.5 vs. 13.0 days, P = 0.006) and nearly $1,000 lower cost of initial hospitalization (P = 0.03). No difference in 5-year survival was identified (33.5% vs. 36%, P = 0.75). CONCLUSIONS: TH esophagectomy was associated with lower costs and shorter length of stay in an elderly Medicare population, with similar clinical outcomes to TT. The TH approach to esophagectomy for distal esophageal adenocarcinoma may, therefore, provide greater value (quality/cost).

Robotic Surgery in Thoracic Training Programs: A National Needs Assessment.

BACKGROUND: Cardiothoracic surgical trainees perceive a need for more instruction and exposure to robotic-assisted thoracoscopic surgery during their training. We sought to assess use and trainee exposure to robotic surgery in thoracic residency programs to identify areas for improvement. METHODS: A voluntary electronic survey of 10 questions was distributed to surgeons working in all thoracic surgery residency programs in the United States. The survey asked respondents to provide the size of the residency, the availability and use of robots, and the trainee's adoption of robotic surgery in their practice after graduation. Multivariable logistic regression was performed. RESULTS: Of a total of 76 cardiothoracic surgery training programs, surgeons from 69 training programs (90.8%) completed the survey. Most pulmonary lobectomy was performed using robotic surgery (55%). Approximately half of the training programs (35 of 69) have a formal robotic curriculum for the residents. Of 121 thoracic track trainees, 118 (97.5%) performed robotic surgery as part of their practice, whereas 62 of 110 (56.4%) cardiothoracic track and 16 of 158 (10.1%) cardiac track trainees performed robotic surgery. In a multivariate analysis, the adoption of robotic surgery was associated with having an established robotic training curriculum (odds ratio, 5.82; 95% CI, 1.32-35.7) and a larger training program (odds ratio, 3.78; 95% CI, 1.34-10.6). CONCLUSIONS: A disparity exists in robotic surgical training among the training programs. A standardized curriculum and formal case requirements may be needed to ensure optimal preparation for future graduates.

Management of Complications in Robotic Thoracic Surgery.

The rapid adoption of robotic-assisted thoracic surgery has led to increased interest in the management of complications. Overall rates of complication during robotic-assisted thoracic surgery are low. Reported complications include pulmonary vascular injury; great vessel injury; thoracic duct injury; erroneous transection; tracheobronchial injury; and esophageal, diaphragmatic, and abdominal organ injury. A robotic thoracic surgeon should understand and have a management plan for any potential complication. When a complication occurs, the priority is to stabilize the patient. Then, after stabilization, an assessment of the situation will determine whether the procedure can be continued robotically or whether conversion to thoracotomy or sternotomy is required.

Differences Between Attending and Trainee Surgeon Performance Using Objective Performance Indicators During Robot-Assisted Lobectomy.

OBJECTIVE: Existing approaches for assessing surgical performance are subjective and prone to bias. In contrast, utilizing digital kinematic and system data from the surgical robot allows the calculation of objective performance indicators (OPIs) that may differentiate technical skill and competency. This study compared OPIs of trainees and attending surgeons to assess differences during robotic lobectomy (RL). METHODS: There were 50 cardiothoracic surgery residents and 7 attending surgeons who performed RL on a left upper lobectomy of an ex vivo perfused model. A novel recorder simultaneously captured video and data from the system and instruments. The lobectomy was annotated into discrete tasks, and OPIs were analyzed for both hands during 6 tasks: exposure of the superior pulmonary vein, upper division of the pulmonary artery and bronchus, and the stapling of these structures. RESULTS: There were significant differences between attendings and trainees in all tasks. Among 20 OPIs during exposure tasks, significant differences were observed for the left hand in 31 of 60 (52%) of OPIs and for the right hand in 42 of 60 (70%). During stapling tasks, significant differences were observed for the stapling hand in 28 of 60 (47%) of OPIs and for the nonstapling hand in 14 of 60 (25%). CONCLUSIONS: Use of a novel data and video recorder to generate OPIs for both hands revealed significant differences in the operative gestures performed by trainees compared to attendings during RL. This method of assessing performance has potential for establishing objective competency benchmarks and use for tracking progress.

Routine Implementation of Patient-Reported Outcomes Assessment Into Thoracic Surgery Practice.

BACKGROUND: Patient-reported outcomes (PROs) assessment is a necessary component of surgical outcome assessment and patient care. This study examined the success of routine PROs assessment in an academic-based thoracic surgery practice. METHODS: PROs, measuring pain intensity, physical function, and dyspnea, were routinely obtained using the National Institutes of Health-sponsored Patient-Reported Outcomes Measurement Information System (PROMIS) on all thoracic surgery patients beginning in April 2018 through January 2021. Questionnaires were administered electronically through a web-based platform at home or during the office visit. Completion rates and barriers were measured. RESULTS: A total of 9725 thoracic surgery office visits occurred during this time frame. PROs data were obtained in 6899 visits from a total of 3551 patients. The mean number of questions answered per survey was 22.4 ± 2.2. Overall questionnaire completion rate was 65.7%. A significant decline in survey completion was noted in April 2020, after which adjustments were made to allow for questionnaire completion through a mobile health platform. Overall monthly questionnaire completion rates ranged from 20% (April 2020) to 90% (October 2018). Mean T scores were dyspnea, 41.6 ± 12.3; physical function, 42.7 ± 10.5; and pain intensity, 52.8 ± 10.3. CONCLUSIONS: PROs can be assessed effectively in a thoracic surgery clinic setting, with minimal disruption of clinical activities. Future efforts should focus on facilitating PROs collection from disadvantaged patient populations and scaling implementation across programs.

Objective performance indicators of cardiothoracic residents are associated with vascular injury during robotic-assisted lobectomy on porcine models.

Surgical training relies on subjective feedback on resident technical performance by attending surgeons. A novel data recorder connected to a robotic-assisted surgical platform captures synchronized kinematic and video data during an operation to calculate quantitative, objective performance indicators (OPIs). The aim of this study was to determine if OPIs during initial task of a resident's robotic-assisted lobectomy (RL) correlated with bleeding during the procedure. Forty-six residents from the 2019 Thoracic Surgery Directors Association Resident Boot Camp completed RL on an ex vivo perfused porcine model while continuous video and kinematic data were recorded. For this pilot study, RL was segmented into 12 tasks and OPIs were calculated for the initial major task. Cases were reviewed for major bleeding events and OPIs of bleeding cases were compared to those who did not. Data from 42 residents were complete and included in the analysis. 10/42 residents (23.8%) encountered bleeding: 10/40 residents who started with superior pulmonary vein exposure and 0/2 residents who started with pulmonary artery exposure. Twenty OPIs for both hands were assessed during the initial task. Six OPIs related to instrument usage or smoothness of motion were significant for bleeding. Differences were statistically significant for both hands (p < 0.05). OPIs showing bimanual asymmetry indicated lower proficiency. This study demonstrates that kinematic and video analytics can establish a correlation between objective performance metrics and bleeding events in an ex vivo perfused lobectomy. Further study could assist in the development of focused exercises and simulation on objective domains to help improve overall performance and reducing complications during RL.

Recovery of Patient-reported Quality of Life After Esophagectomy.

BACKGROUND: Esophagectomy is an important, but potentially morbid, operation used to treat benign and malignant conditions that may significantly impact patient quality of life (QOL). Patient-reported outcomes (PROs) are measures of QOL that come directly from patient self-report. This study characterizes patterns of change and recovery in PROs in the first year after esophagectomy. METHODS: Longitudinal QOL scores measuring physical function, pain, and dyspnea were obtained from esophagectomy patients during all clinic visits. PRO scores were obtained using the National Institutes of Health-sponsored Patient-Reported Outcomes Measurement Information System from April 2018 to February 2021. Mean PRO scores over 100 days after surgery were compared with baseline PRO scores using mixed-effects modeling with compound symmetry correlational structure. RESULTS: One hundred three patients with PRO results were identified. Reasons for esophagectomy were malignancy (87.4%), achalasia (5.8%), stricture (5.8%), and dysplasia (1.0%). When comparing mean PRO scores at visits ≤ 50 days after surgery with preoperative PRO scores, physical function scores declined by 27.3% (P < .001), whereas dyspnea severity and pain interference scores had increased by 24.5% (P < .001) and 17.1% (P < .001), respectively. Although recovery occurred over the course of the 100 days after surgery, mean physical function scores and dyspnea scores were still 12.7% (P = .02) and 26.4% (P = .001) worse, respectively, than mean preoperative levels. CONCLUSIONS: Despite declines in QOL scores immediately after esophagectomy, recovery back toward baseline was observed during the first 100 days. These findings are of considerable importance when counseling patients regarding esophagectomy, tracking recovery, and implementing quality improvement initiatives. Further long-term follow-up is needed to determine recovery beyond 100 days.

Comparison of Global Evaluative Assessment of Robotic Surgery with objective performance indicators for the assessment of skill during robotic-assisted thoracic surgery.

BACKGROUND: The Global Evaluative Assessment of Robotic Skills is a popular but ultimately subjective assessment tool in robotic-assisted surgery. An alternative approach is to record system or console events or calculate instrument kinematics to derive objective performance indicators. The aim of this study was to compare these 2 approaches and correlate the Global Evaluative Assessment of Robotic Skills with different types of objective performance indicators during robotic-assisted lobectomy. METHODS: Video, system event, and kinematic data were recorded from the robotic surgical system during left upper lobectomy on a standardized perfused and pulsatile ex vivo porcine heart-lung model. Videos were segmented into steps, and the superior vein dissection was graded independently by 2 blinded expert surgeons with Global Evaluative Assessment of Robotic Skills. Objective performance indicators representing categories for energy use, event data, movement, smoothness, time, and wrist articulation were calculated for the same task and compared to Global Evaluative Assessment of Robotic Skills scores. RESULTS: Video and data from 51 cases were analyzed (44 fellows, 7 attendings). Global Evaluative Assessment of Robotic Skills scores were significantly higher for attendings (P < .05), but there was a significant difference in raters' scores of 31.4% (defined as >20% difference in total score). The interclass correlation was 0.44 for 1 rater and 0.61 for 2 raters. Objective performance indicators correlated with Global Evaluative Assessment of Robotic Skills to varying degrees. The most highly correlated Global Evaluative Assessment of Robotic Skills domain was efficiency. Instrument movement and smoothness were highly correlated among objective performance indicator categories. Of individual objective performance indicators, right-hand median jerk, an objective performance indicator of change of acceleration, had the highest correlation coefficient (0.55). CONCLUSION: There was a relatively poor overall correlation between the Global Evaluative Assessment of Robotic Skills and objective performance indicators. However, both appear strongly correlated for certain metrics such as efficiency and smoothness. Objective performance indicators may be a potentially more quantitative and granular approach to assessing skill, given that they can be calculated mathematically and automatically without subjective interpretation.

Surgical Outcomes for Early Stage Non-small Cell Lung Cancer at Facilities With Stereotactic Body Radiation Therapy Programs.

BACKGROUND: Patients undergoing surgery for early stage non-small cell lung cancer (NSCLC) may be at high risk for postoperative mortality. Access to stereotactic body radiation therapy (SBRT) may facilitate more appropriate patient selection for surgery. RESEARCH QUESTION: Is postoperative mortality associated with early stage NSCLC lower at facilities with higher use of SBRT? STUDY DESIGN AND METHODS: Patients with early stage NSCLC reported to the National Cancer Database between 2004 and 2015 were included. Use of SBRT was defined by each facility's SBRT experience (in years) and SBRT to surgery volume ratios. Multivariate logistic regression was used to test for the associations between SBRT use and postoperative mortality. RESULTS: The study cohort consisted of 202,542 patients who underwent surgical resection of cT1-T2N0M0 NSCLC tumors. The 90-day postoperative mortality rate declined during the study period from 4.6% to 2.6% (P < .001), the proportion of facilities that used SBRT increased from 4.6% to 77.5% (P < .001), and the proportion of patients treated with SBRT increased from 0.7% to 15.4% (P < .001). On multivariate analysis, lower 90-day postoperative mortality rates were observed at facilities with > 6 years of SBRT experience (OR, 0.84; 95% CI, 0.76-0.94; P = .003) and SBRT to surgery volume ratios of more than 17% (OR, 0.85; 95% CI, 0.79-0.92; P < .001). Ninety-day mortality also was associated with surgical volume, region, year, age, sex, and race, among other covariates. Interaction testing between these covariates showed negative results. INTERPRETATION: Patients who underwent resection for early stage NSCLC at facilities with higher SBRT use showed lower rates of postoperative mortality. These findings suggest that the availability and use of SBRT may improve the selection of patients for surgery who are predicted to be at high risk of postoperative mortality.

Community Size and Lung Cancer Resection Outcomes: Studying The Society of Thoracic Surgeons Database.

BACKGROUND: Socioeconomic factors play key roles in surgical outcomes. Socioeconomic data within The Society of Thoracic Surgeons (STS) General Thoracic Surgery Database (GTSD) are limited. Therefore, we utilized community size as a surrogate to understand socioeconomic differences in lung cancer resection outcomes. METHODS: We retrospectively reviewed all lung cancer resections from January 2012 to January 2017 in the STS GTSD. This captured 68,722 patients from 286 centers nationwide. We then linked patient zip codes with 2013 Rural-Urban Continuum Codes to understand the association between community size and postoperative outcomes. Demographic and clinical variables were evaluated for relationships with 30-day mortality, major morbidity, and readmission. RESULTS: Zip codes were included in 47.2% of patients. Zip-coded patients were older, were more comorbid, had less advanced disease, and were more commonly treated with minimally invasive approaches than were those without zip code classification. For geocoded patients, multivariable analyses demonstrated that sex, insurance payor, and hospital region were associated with all 3 major endpoints. Community size, based on Rural-Urban Continuum Codes coding, was not associated with any primary endpoint. Invasive mediastinal staging was related to morbidity, greater pathological stage predicted mortality, and worsened clinical stage was associated with readmission. More invasive surgery and greater extent of lung resection were associated with all primary endpoints. CONCLUSIONS: Incomplete data capture can promote selection bias within the STS GTSD and skew outcomes reporting. Moreover, community size is an insufficient surrogate, compared with sex, insurance payor, hospital region, for understanding socioeconomic differences in lung cancer resection outcomes.

Safety and Feasibility of Thoracoscopic Lung Resection for Non-Small-Cell Lung Cancer in Octogenarians.

OBJECTIVE: Octogenarians comprise an increasing proportion of patients presenting with non-small-cell lung cancer (NSCLC). This study examines postoperative morbidity and mortality, and long-term survival in octogenarians undergoing thoracoscopic anatomic lung resection for NSCLC, compared with younger cohorts. METHODS: We conducted a retrospective review of our institutional Society of Thoracic Surgeons General Thoracic Surgery Database of all patients ≥60 years old undergoing elective lobectomy or segmentectomy for pathologic stage I, II, and IIIA NSCLC between 2009 and 2018. Results were compared between octogenarians (n = 71) to 2 younger cohorts of 60- to 69-year-olds (n = 359) and 70- to 79-year-olds (n = 308). Long-term survival among octogenarians was graphically summarized using the Kaplan-Meier method. Cox regression analysis was used to identify preoperative risk factors for mortality. RESULTS: A greater proportion of octogenarians required intensive care unit admission and discharge to extended-care facilities; however, postoperative length of stay was similar between groups. Among postoperative complications, arrhythmia and renal failure were more likely in the older cohort. Compared to the youngest cohort, in-hospital and 30-day mortality were highest among octogenarians. Overall survival among octogenarians at 1, 3, and 5 years was 87.3%, 61.8%, and 50.5%, respectively. On multivariable Cox regression analysis of baseline demographic variables, presence of stroke (hazard ratio [HR] = 28.5, 95% confidence interval [CI]: 6.1 to 132.7, P < 0.001) and coronary artery disease (HR = 2.5, 95% CI: 1.2 to 5.3, P = 0.02) were significant predictors of overall mortality among octogenarians. CONCLUSIONS: Thoracoscopic resection can be performed with favorable early postoperative outcomes among octogenarians. Long-term survival, although comparable to their healthy peers, is worse than those of younger cohorts. Further study into preoperative risk stratification and alternative therapies among octogenarians is needed.

Association Between Patient Physical Function and Length of Stay After Thoracoscopic Lung Cancer Surgery.

Patient-reported outcomes (PRO) are an ideal method for measuring patient functional status. We sought to evaluate whether preoperative PRO were associated with resource utilization. We hypothesize that higher preoperative physical function PRO scores, measured via the NIH-sponsored Patient Reported Outcome Measurement Information System (PROMIS), are associated with shorter length of stay (LOS). Preoperative physical function scores were obtained using NIH PROMIS in a prospective observational study of patients undergoing minimally invasive surgery for lung cancer. Poisson regression models were constructed to estimate the association between the length of stay and PROMIS physical function T-score, adjusting for extent of resection, age, gender, and race. Due to the significant interaction between postoperative complications and physical function T-score, the relationship between physical function and LOS was described separately for each complication status. A total of 123 patients were included; 88 lobectomy, 35 sublobar resections. Mean age was 67 years, 35% were male, 65% were Caucasian. Among patients who had a postoperative complication, a lower preoperative physical function T-score was associated with progressively increasing LOS (P  value = 0.006). In particular, LOS decreased by 18% for every 10-point increase in physical function T-score. Among patients without complications, T-score was not associated with LOS (P = 0.86). Preoperative physical function measured via PRO identifies patients who are at risk for longer LOS following thoracoscopic lung cancer surgery. In addition to its utility for preoperative counseling and planning, these data may be useful in identifying patients who may benefit from risk-reduction measures.

Preoperative Lung Function Is Associated With Patient-Reported Outcomes After Lung Cancer Surgery.

BACKGROUND: Patient quality of life (QOL) is a critical outcomes measure in lung cancer surgery. Patient-reported outcomes (PROs) provide valuable insight into the patient experience and allow measurement of preoperative and postoperative QOL. Our objective was to determine which clinical factors predict differences in QOL, as measured by patient-reported physical function and pain intensity among patients undergoing minimally invasive lung cancer surgery. METHODS: PRO surveys assessing physical function and pain intensity were conducted using instruments from the National Institutes of Health Patient-Reported Outcomes Measurement Information System. PRO surveys were administered to patients undergoing minimally invasive lung cancer resections at preoperative, 1-month, and 6-month postoperative time points, in an academic institution. Linear mixed-effects regression models were constructed to assess the association between clinical variables on PRO scores over time. RESULTS: A total of 123 patients underwent a thoracoscopic lung resection for cancer. Mean age of the cohort was 67 ± 9.6 years, 43% were male, and 80% were White. When comparing clinical variables with PRO scores after surgery, lower diffusing capacity of the lungs for carbon monoxide (Dlco) was associated with significantly worse physical function (P < .01) and greater pain intensity scores (P < .01) at 6 months, with no differences identified at 1 month. No other studied clinical factor was associated with significant differences in PRO scores. CONCLUSIONS: Low preoperative Dlco was associated with significant decreases in PRO after minimally invasive lung cancer surgery. Dlco may be of utility in identifying patients who experience greater decline in QOL after surgery and for guiding surgical decision making.

Robotic-Assisted Surgical Treatment of Catamenial Pneumothorax.

Two young female patients presented with clinical findings of catamenial pneumothorax and thoracic endometriosis syndrome. Despite attempts at conservative management, thoracoscopic pleurodesis, and hormonal therapy, both women experienced recurrent pneumothoraces coincident with menses. Each patient subsequently underwent robotic-assisted mechanical pleurectomy and diaphragm reconstruction with durable results.

Robotic Thoracic Surgery.

Minimally invasive surgery for diseases of the chest offsets the morbidity of painful thoracic incisions while allowing for meticulous dissection of major anatomic structures. This benefit translates to improved outcomes and recovery following the surgical management of benign and malignant esophageal pathologic condition, mediastinal tumors, and lung resections. This anatomic region is particularly amenable to a robotic approach given the fixed space and need for complex intracorporeal dissection. As robotic platforms continue to evolve, more complex thoracic surgical interventions will be facilitated, translating to improved outcomes for our patients.

Preoperative Computed Tomography-Guided Pulmonary Lesion Marking in Preparation for Fluoroscopic Wedge Resection-Rates of Success, Complications, and Pathology Outcomes.

PURPOSE: In this study, we describe our experience of lesion marking with fiducial markers (FM) and microcoils (MC) facilitating same-day surgical wedge resection, including success rates, pathology outcomes, and complications. We also explored patient/nodular characteristics associated with developing complications. MATERIALS AND METHODS: An IRB-approved single-institutional retrospective study of 136 patients who had 148 pulmonary nodules was conducted. All patients had CT-guided pulmonary nodule labeling with either FM (121) or MC (15) patients with plan for same-day fluoroscopic-guided wedge resection. RESULTS: Of 136 (98%) patients, 133 had successful same-day wedge resection as planned; 2 had delayed but successful wedge resection surgery due to complications at the time of marker placement (fiducial embolization and hemorrhage/pneumothorax, respectively). A third patient ultimately needed lobectomy due to deep lesion location. Eighty percent [118/148] of resected nodules were malignant. Further, 68% of the total group of patients [93/136] had mild complications of various types including hemorrhage [44/136, 32%], pneumothorax [35/136, 26%], a combination of both hemorrhage and pneumothorax [10/136, 7%], or migration/embolization [4/136, 3%]. Depth of nodule from skin (P = 0.011) and pleura (P = 0.027) was significantly associated with complications. CONCLUSION: CT-guided marking of small or deep pulmonary lesions using either fiducial markers or microcoils provides an effective means to aid surgeons to accomplish minimally invasive wedge resection. The importance of the success of this technique is supported by the high incidence (80%) of malignant lesion etiology found at postresection pathology. Although complications occurred, the vast majority were mild and did not alter planned same-day resection.

Hospitalization Costs After Surgery in High-Risk Patients With Early Stage Lung Cancer.

BACKGROUND: We previously reported that early stage lung cancer patients who are considered high risk for surgery can undergo resection with favorable perioperative results and long-term mortality. To further elucidate the role of surgical resection in this patient cohort, this study evaluated the length of stay and total hospitalization cost among patients classified as standard or high risk with early stage lung cancer who underwent pulmonary resection. METHODS: A total of 490 patients from our institutional Society of Thoracic Surgeons data from 2009 to 2013 underwent resection for clinical stage I lung cancer. High-risk patients were identified by American College of Surgeons Oncology Group z4032-z4099 criteria. Demographics, length of stay, and hospitalization cost between high-risk and standard-risk patients undergoing lobectomy and sublobar resection were compared. Univariate analysis was performed using the chi-square test or Fisher's exact test. Multivariate analysis was performed using a linear regressions model. RESULTS: A total of 180 (37%) of patients were classified as high risk. These patients were older (70 years of age vs. 65 years of age; p < 0.0001), had worse forced expiratory volume in 1 second (57% vs. 85%; p < 0.0001), and had worse diffusion capacity of carbon dioxide (47% vs. 77%; p < 0.0001). The baseline cost and length of stay was represented by a thoracoscopic wedge resection in a standard-risk patient. A larger extent of resection, thoracotomy, or high-risk classification increased the cost and length of stay. CONCLUSIONS: Our previous study showed that good clinical outcomes after surgery for early stage lung cancer can be achieved in patients classified as high risk. In this study, although surgery in high-risk patients led to slightly increased costs, these costs seemed negligible when viewed along with the patients' excellent short-term and long-term results. This study suggests that surgical resection on high-risk patients with early stage lung cancer is associated with acceptable hospital lengths of stay and overall cost when compared with standard-risk patients.

Excess Cost and Predictive Factors of Esophagectomy Complications in the SEER-Medicare Database.

BACKGROUND: Postoperative complications result in significantly increased health care expenditures. The objective of this study was to examine 90-day excess costs associated with inpatient complications after esophagectomy and their predictive factors, by using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. METHODS: The study examined patients older than 65 years of age with a diagnosis from 2002 to 2009 and who were undergoing esophagectomy for cancer in the SEER-Medicare database. Quantile regression models were fit at 5% intervals for excess 90-day cost associated with perioperative complications while controlling for baseline characteristics. Excess cost was defined as the difference in total cost for patients with versus without the complication. Analyses were stratified by patients' characteristics to identify factors predictive of excess cost. RESULTS: A total of 1,462 patients were identified in the cohort; 51% had at least one complication. Significant excess cost was associated with pulmonary and mechanical wound complications across all quantiles (p < 0.05). Infectious (0.35 to 0.75 quantiles), intraoperative (0.05 to 0.85 quantiles), and systemic (0.30 to 0.85 quantiles) complications were associated with higher costs. Further, excess costs were significantly elevated in the higher quantiles. At the 0.50 quantile (median) of total cost distribution, excess cost in patients with any complication were significantly higher in patients with the following characteristics: transthoracic esophagectomy, emergency esophagectomy, Charlson Comorbidity Index >0, living in a nonmetropolitan area or poorer community, or treated in larger hospitals; no such difference was identified in patients without complications. CONCLUSIONS: Complications after esophagectomy result in significant excess 90-day cost. Efforts at cost reduction and quality improvement will need to focus on reducing complications, in particular pulmonary and infectious, as well as risk factors for higher complication costs.

Pilot Study to Integrate Patient Reported Outcomes After Lung Cancer Operations Into The Society of Thoracic Surgeons Database.

BACKGROUND: A critical gap in The Society of Thoracic Surgeons (STS) Database is the absence of patient-reported outcomes (PRO), which are of increasing importance in outcomes and performance measurement. Our aim was to demonstrate the feasibility of integrating PRO into the STS Database for patients undergoing lung cancer operations. METHODS: The National Institutes of Health Patient Reported Outcome Measurement Information System (PROMIS) includes reliable, precise measures of PRO. We used validated item banks within PROMIS to develop a survey for patients undergoing lung cancer resection. PRO data were prospectively collected electronically on tablet devices and merged with our institutional STS data. Patients were enrolled over 18 months (November 2014 to May 2016). The survey was administered preoperatively and at 1 and 6 months after lung cancer resection. RESULTS: The study included 127 patients. All patients completed the initial postoperative survey, and 108 reached the 6-month follow-up. The most common procedure was video-assisted thoracic lobectomy (55%). At the first postoperative visit, there was a significant increase in pain, fatigue, and sleep impairment and a decrease in physical function. By 6 months, these PRO measures had generally improved toward baseline. CONCLUSIONS: Collecting PRO data from lung cancer surgical patients and integrating the results into an institutional database is feasible. This pilot serves as a model for widespread incorporation of PRO data into the STS Database. Future integration of such data will continue to position the STS National Database as the gold standard for clinical registries. This will be necessary for assessing overall patient responses to different surgical therapies.

Nodal Upstaging Is More Common with Thoracotomy than with VATS During Lobectomy for Early-Stage Lung Cancer: An Analysis from the National Cancer Data Base.

INTRODUCTION: Questions remain regarding differences in nodal evaluation and upstaging between thoracotomy (open) and video-assisted thoracic surgery (VATS) approaches to lobectomy for early-stage lung cancer. Potential differences in nodal staging based on operative approach remain the final significant barrier to widespread adoption of VATS lobectomy. The current study examines differences in nodal staging between open and VATS lobectomy. METHODS: The National Cancer Data Base was queried for patients with clinical stage T2N0M0 or lower lung cancer who underwent lobectomy in 2010-2011. Propensity score matching was performed to compare the rate of nodal upstaging in VATS with that in open approaches. Additional subgroup analysis was performed to assess whether rates of upstaging differed by specific clinical setting. RESULTS: A total of 16,983 lobectomies were analyzed; 4935 (29.1%) were performed using VATS. Nodal upstaging was more frequent in the open group (12.8% versus 10.3%; p < 0.001). In 4437 matched pairs, nodal upstaging remained more common for open approaches. For a subgroup of patients who had seven lymph or more nodes examined, propensity matching revealed that nodal upstaging remained more common after an open approach than after VATS (14.0% versus 12.1%; p = 0.03). For patients who were treated in an academic/research facility, however, the difference in nodal upstaging between an open and VATS approach was no longer significant (12.2% versus 10.5%, p = 0.08). CONCLUSIONS: For early-stage lung cancer, nodal upstaging was observed more frequently with thoracotomy than with VATS. However, nodal upstaging appears to be affected by facility type, which may be a surrogate for expertise in minimally invasive surgical procedures.