Tackling complex thoracic surgical operations with robotic solutions: a narrative review.

Background and Objective: The adoption of robotic surgery for general thoracic surgery has rapidly progressed over the last two decades from its application in basic operations to complex pathologies. As such, the purpose of this narrative review is to highlight the collective experience of tackling complex thoracic surgical operations with minimally invasive robotic solutions. Methods: Electronic searches of PubMed were conducted for each subtopic, using specific keywords and inclusion criteria. Once identified, the articles were screened through the abstract, introduction, results and conclusion for relevancy, and included based on a standard narrative review inclusion criteria. Key Content and Findings: The role of the robotic approach has increased in thoracic outlet syndrome, chest wall resection, tracheobronchomalacia, airway and sleeve lung surgery, lobectomy after neoadjuvant therapy, complex segmentectomy, giant paraesophageal hernia repair, esophagectomy and esophageal enucleation, mediastinal masses and thymectomy and lung transplantation. Robotic surgery has several advantages when compared to video-assisted and open thoracoscopic surgery. These include better pain control and aesthetic outcome, improved handling of complex anatomy, enhanced access to lymph nodes, and faster recovery rates. Although it is associated with longer operative time, robotic surgery has comparable morbidity rates. Conclusions: The robotic approach to complex thoracic problems is safe, effective, and associated with improved patient outcomes. To encourage wider adoption of robotic technology, increased training and expanded research efforts are essential, alongside improved worldwide access to this technology.

Impact of Federal Lung Cancer Screening Policy on the Incidence of Early-stage Lung Cancer.

BACKGROUND: In December 2013 the US Preventative Services Task Force (USPSTF) recommended annual lung cancer screening for high-risk patients. The Centers for Medicare & Medicaid Services (CMS) later announced coverage in 2015. The impact of these federal decisions at the population level is unknown. METHODS: Using the Surveillance, Epidemiology, and End Results database, we studied changes in lung cancer incidence by stage and linked to US census data to obtain age-adjusted estimates standardized to the US population. Based on age at diagnosis we stratified patients as age-eligible or age-ineligible for screening. We used difference-in-differences regression to determine the effect of screening on lung cancer incidence by stage. RESULTS: For all age groups the incidence of early-stage lung cancer both before and after the USPSTF guidelines remained relatively stable at 12.8 ± 0.52 and 13.5 ± 0.92 per 100,000 patients, respectively (P = .068). However the difference-in-differences analysis estimated an absolute increase in the age-adjusted incidence by 3.4 per 100,000 persons in the age-eligible group after the announcement of the guidelines (P = .007). The effect was even larger after the CMS decision (4.3/100,000 persons, P < .001). Similarly there was a 14.2 per 100,000 persons absolute reduction in the incidence of advanced-stage lung cancer (P < .001). CONCLUSIONS: The 2013 USPSTF lung cancer screening guidelines and CMS coverage decisions were associated with an increased incidence of early-stage lung cancer and decreased incidence of advance-staged lung cancer at the population level.

Assessment of Textbook Outcome After Surgery for Stage I/II Non-small Cell Lung Cancer.

Outcomes after cancer resection are traditionally measured individually. Composite metrics, or textbook outcomes, bundle outcomes into a single value to facilitate assessments of quality. We propose a composite outcome for non-small cell lung cancer resections, examine factors associated with the outcome, and evaluate its effect on overall survival. We queried the National Cancer Database for patients with stage I/II non-small cell lung cancer who underwent sublobar resection, lobectomy, or pneumonectomy from 2010 to 2016. We defined the metric as margin-negative resection, sampling of ≥10 lymph nodes, length of stay <75th percentile, no 30-day mortality, no readmission, and receipt of indicated adjuvant therapy. Multivariable logistic regression, Cox proportional hazards modeling, survival analyses, and propensity score matching were used to identify factors associated with the outcome and overall survival. Of 88,208 patients, 70,149 underwent lobectomy, 14,922 underwent sublobar resection, and 3,137 underwent pneumonectomy. Textbook outcome was achieved in 26.3% of patients. Failure to achieve the outcome was most commonly driven by inadequate nodal assessment. Textbook outcome was more likely after minimally invasive surgical approaches (aOR = 1.47; P< 0.001) relative to open resection and less likely after sublobar resection (aOR = 0.20; P< 0.001) relative to lobectomy. Achievement of textbook outcome was associated with an 9.6% increase in 5-year survival (P< 0.001), was independently associated with improved survival (aHR = 0.72; P < 0.001), and remained strongly associated with survival independent of resection extent after propensity matching. One in 4 patients undergoing non-small cell lung cancer resection achieve textbook outcome. Textbook outcome is associated with improved survival and has value as a quality metric.

Clinical Variation Reduction in Propensity-matched Patients Treated for Malignant Pleural Effusion.

BACKGROUND: The potential advantages of clinical variation reduction are improved patient outcomes and cost reduction through optimizing and standardizing care. Malignant pleural effusion (MPE) is a common condition encountered by thoracic surgeons that has significant variation in cost and outcomes. The purpose of this investigation was to assess the opportunity of improving patient outcomes and reducing cost by using a standardized treatment algorithm based on evidenced-based care. METHODS: Patients treated for MPE using a standardized treatment algorithm at the study institution over a 2 year period were identified and propensity matched to MPE patients from 1 of 6 affiliated hospitals with comprehensive oncology and thoracic surgery services. Matched patients were treated at their physicians' discretion. Factors used in propensity matching were age, performance status, and tumor histology. The 2 cohorts were then compared for interventions, admissions and readmissions, morbidity, and pleural effusion-associated costs. Patients who desired only comfort or hospice care were excluded. RESULTS: From 2016 through 2018, 60 patients were treated using the standardized algorithm. These patients were propensity matched and the 2 cohorts compared. Patients treated with the algorithm experienced significantly fewer hospital admissions, readmissions, interventions, and costs while having a comparable procedural morbidity. CONCLUSIONS: An evidence-based treatment algorithm for MPE produces superior clinical outcomes to individualized therapy while significantly reducing the costs of care.

Patient Outcomes After Stent Failure for the Treatment of Acute Esophageal Perforation.

BACKGROUND: Esophageal stent placement for acute esophageal perforation has become part of the treatment algorithm for many thoracic surgery programs. Despite high success rates, there are patients for which stent placement is not successful. This investigation summarizes the outcomes of a relatively large group of such patients. METHODS: Patients who underwent esophageal stent placement for an acute perforation but required conversion to another form of therapy were identified from a prospectively collected institutional database. Excluded were patients whose perforation was associated with a malignancy. Patient demographics, operative and nonoperative invasive procedures, morbidities, mortality, and 6-month follow-up after discharge were reviewed. RESULTS: Between 2008 and 2015, 26 patients who failed to seal their esophageal leak after stent placement were identified. Eighteen (69%) of these patients required an operative repair with primary closure of the perforation. Four (15%) primary repairs had a persistent leak controlled with subsequent stent placement. Four (15%) patients required an esophagectomy with cervical esophagostomy. Three patients (11%), because of comorbid conditions, were referred for hospice care. One patient (3%) refused operative repair and developed a chronic fistula that resolved with subsequent stent placement. CONCLUSIONS: Esophageal stent placement continues to be a safe and effective treatment for acute esophageal perforation. Patients whose perforation does not seal with initial stent placement can be treated with primary surgical repair or esophagectomy without increasing their morbidity or mortality or compromising their prognosis.

Hospital Readmission Following Thoracic Surgery.

Hospital readmission costs the health care system in excess of 1 billion dollars a year. The Hospital Readmission Reduction Program was instituted as part of the Affordable Care Act in 2012 and penalizes hospitals with high rates of readmission. Strategies exist to minimize hospital readmissions and should be implemented by thoracic surgeons.

Endoscopic management of esophageal leaks.

Traditionally, gold standard treatment for an acute esophageal perforation has been operative repair. Over the past two decades, there has been a paradigm shift towards the use of esophageal stents. Recent advances in biomaterial allowed a new generation of stents to be manufactured that combined (I) a non-permeable covering; (II) radial force sufficient to occlude a transmural esophageal injury and (III) improved ease of removability. The amalgamation of these developments set the stage for utilizing esophageal stents as part of the management algorithm of an acute esophageal perforation. This provides a safe and less invasive treatment route in lieu of direct primary repair and its well-documented significant failure rate. Esophageal stent placement for failed operative repair or esophageal leaks also had the potential to minimize the need for esophageal resection and diversion. When included in a multimodality hybrid treatment protocol, esophageal stents can optimize healing success rates and minimize the risks of adverse complications. This review summarizes the modern history of esophageal stent use in the treatment of esophageal perforation as well as the evidenced based recommendations for the use of esophageal stent placement in the treatment of acute esophageal perforation.

An Assessment of the Frequency of Palliative Procedures in Thoracic Surgery.

OBJECTIVES: Palliative care is a medical specialty focused on improving the quality of life of patients and their families with life threatening illness by preventing or relieving suffering. An assessment of a thoracic surgery service was performed to identify the scope and frequency of care that was considered palliative and any implications the findings might have on the current thoracic surgery residency curriculum. METHODS: A retrospective review of a prospectively collected database of general thoracic surgery procedures performed over a 5-year period at a single institution was performed. Procedures considered palliative were reviewed for demographics, diagnoses, palliative prognosis score, treatment, morbidity, operative mortality, and survival. Excluded were referrals from thoracic surgery to other specialties for palliative procedures. RESULTS: During the study period, 3842 procedures were performed of which 884 (23%) were palliative. Indications included pleural or pericardial effusion or both, dysphagia, hemoptysis, tracheobronchial obstruction, bronchopleural fistula, and tracheoesophageal fistula. The majority was related to a malignancy. Only 127 patients (14%) had a palliative care assessment before thoracic surgery consultation. Mean survival following thoracic surgery intervention was 110 days for patients with malignancy. CONCLUSIONS: This investigation found that thoracic surgeons commonly care for patients when the intention or indication or both is palliation. Most of these patients have an associated malignancy, a poor performance status and a projected significantly decreased survival compared with the general population. Thoracic surgeons should be familiar with the concepts of palliative care and consideration should be given to expanding exposure to the principles of palliative care in the cardiothoracic residency training curriculum.

How Is Physician Work Valued?

Strategies to value physician work continue to evolve. The Society of Thoracic Surgeons and The Society of Thoracic Surgeons National Database have an increasingly important role in this evolution. An understanding of the Current Procedural Terminology (CPT) system (American Medical Association [AMA], Chicago, IL) and the Relative Value Scale Update Committee (RUC) is necessary to comprehend how physician work is valued. In 1965, with the dawn of increasingly complex medical care, immense innovation, and the rollout of Medicare, the need for a common language describing medical services and procedures was recognized as being of critical importance. In 1966, the AMA, in cooperation with multiple major medical specialty societies, developed the CPT system, which is a coding system for the description of medical procedures and medical services. The RUC was created by the AMA in response to the passage of the Omnibus Budget Reconciliation Act of 1989, legislation of the United States of America Federal government that mandated that the Centers for Medicare & Medicaid Services adopt a relative value methodology for Medicare physician payment. The role of the RUC is to develop relative value recommendations for the Centers for Medicare & Medicaid Services. These recommendations include relative value recommendations for new procedures or services and also updates to relative value recommendations for previously valued procedures or services. These recommendations pertain to all physician work delivered to Medicare beneficiaries and propose relative values for all physician services, including updates to those based on the original resource-based relative value scale developed by Hsaio and colleagues. In so doing, widely differing work and services provided can be reviewed and comparisons of their relative value (to each other) can be established. The resource-based relative value scale assigns value to physician services using relative value units (RVUs), which consist of three components: work RVU, practice expense RVU, and malpractice RVU, also known as professional liability insurance RVU. The Centers for Medicare & Medicaid Services retains the final decision-making authority on the RVUs associated with each procedure or service. The purpose of this article is to discuss the role that the CPT codes and the RUC play in the valuation of physician work and to provide an example of how the methodology for valuation of physician work continues to evolve.

The Evolution and Current Utility of Esophageal Stent Placement for the Treatment of Acute Esophageal Perforation.

Esophageal stent placement was used primarily for the treatment of malignant strictures until the development of a new generation of biomaterials allowed the production of easily removable, occlusive stents in 2001. Since then, thoracic surgeons have gained experience using esophageal stents for the treatment of acute esophageal perforation. As part of a hybrid treatment strategy, including surgical drainage of infected spaces, enteral nutrition, and aggressive supportive care, esophageal stent placement has produced results that can exceed those of traditional surgical repair. This review summarizes the evolution of esophageal stent use for acute perforation and provides evidence-based recommendations for the technique.

Implementing effective and sustainable multidisciplinary clinical thoracic oncology programs.

Three models of care are described, including two models of multidisciplinary care for thoracic malignancies. The pros and cons of each model are discussed, the evidence supporting each is reviewed, and the need for more (and better) research into care delivery models is highlighted. Key stakeholders in thoracic oncology care delivery outcomes are identified, and the need to consider stakeholder perspectives in designing, validating and implementing multidisciplinary programs as a vehicle for quality improvement in thoracic oncology is emphasized. The importance of reconciling stakeholder perspectives, and identify meaningful stakeholder-relevant benchmarks is also emphasized. Metrics for measuring program implementation and overall success are proposed.

The Effects of a Multidisciplinary Care Conference on the Quality and Cost of Care for Lung Cancer Patients.

BACKGROUND: A prospective, multidisciplinary care conference (MDC) has been shown to result in measurable benefits for patients with non-small cell lung cancer (NSCLC). However whether a MDC also results in a difference in resource utilization and cost as well as whether these benefits persist across a multiinstitutional system has not been reported. This investigation compared propensity-matched patients with NSCLC whose care was coordinated through a MDC to patients without access to an MDC across a geographically diverse system of hospitals. METHODS: The Premiere database (Premier Inc, Charlotte, NC) for a health system's 70 hospitals was used to identify patients undergoing treatment for NSCLC during a 5-year period. Propensity matching was used to populate an MDC and non-MDC cohort. The two cohorts were compared for the costs of staging and diagnosis as well as the timeliness and quality of care metrics. RESULTS: Between 2008 and 2013, 13,254 patients were propensity matched. Patient demographics and Charlson comorbidity scores were comparable after matching. Significant differences were identified in adherence to national guidelines (p < 0.0001) for staging and treatment (p < 0.0001), timeliness of care (p < 0.0001), and costs (p < 0.0001) between the two groups. CONCLUSIONS: This investigation found that patients with NSCLC realize improved quality and timeliness of care when that care is coordinated through an MDC. The use of an MDC was also associated with a significant reduction in cost. These differences persisted across a geographically diverse set of hospitals, providers, and patients. Prospective MDCs should be considered integral and compulsory for patients with NSCLC.

An Assessment of the Optimal Time for Removal of Esophageal Stents Used in the Treatment of an Esophageal Anastomotic Leak or Perforation.

BACKGROUND: Esophageal stent for the treatment of a perforation or anastomotic leak has been shown to be effective and safe. However, the optimal timing for stent removal is in question. This purpose of this investigation was to identify a time for stent removal in patients treated for an acute perforation or anastomotic leak that resulted in sealing of the leak while minimizing the incidence of stent-related complications. METHODS: Patients undergoing esophageal stent placement for the treatment of an acute perforation or intrathoracic anastomotic leak were identified from a single institution's prospectively collected database. Patient outcomes were recorded and analyzed. Complications were segregated by stent dwell time. RESULTS: During the study period, 162 patients underwent esophageal stent placement for an acute perforation (n = 117) or anastomotic leak (n = 45). Patients whose stent was removed in less than 28 days after placement for an acute perforation realized a stent complication rate that was independently reduced by 39% (odds ratio, 0.61; 95% confidence interval, 0.54 to 0.78; p < 0.01), whereas patients whose stent was removed in less than 14 days after placement for an acute perforation realized a stent complication rate that was independently reduced by 56% (odds ratio, 0.44; 95% confidence interval, 0.38 to 0.69; p < 0.001). CONCLUSIONS: Endoluminal esophageal stent placement is a safe and effective treatment for patients with an acute esophageal perforation or intrathoracic anastomotic leak after esophagectomy. Removal of stents at 2 weeks for anastomotic leak or 4 weeks for perforation has the potential to significantly decrease the incidence of complications associated with stent use.

Treatment options for patients with recurrent, symptomatic pleural effusions secondary to heart failure.

PURPOSE OF REVIEW: Pleural effusions are a common finding in the nearly six million Americans diagnosed with heart failure. This review focuses on the historical, present and potential future trends in the management of such benign pleural effusions. RECENT FINDINGS: The management of symptomatic pleural effusions, in general, and in heart failure, specifically, has evolved in the last two decades. With more options, the treatment is often individualized for patients. Newer forms of therapy are also less invasive, resulting in less procedural morbidity, recuperation and cost. SUMMARY: The majority of patients with a pleural effusion resulting from heart failure will resolve their symptoms with medical therapy. Patients who experience symptoms from reaccumulation of their effusion have a selection of treatment options that can be individualized based on the patient's prognosis, functional status, need for future intervention and desires.

A propensity-matched comparison of cost and outcomes after esophageal stent placement or primary surgical repair for iatrogenic esophageal perforation.

OBJECTIVES: Esophageal stent placement has been shown to be a safe and effective treatment for acute esophageal perforation in selected patients. However, a comparison between surgical repair and stent placement has not been reported. This investigation compares the outcomes and costs of the 2 treatment modalities. METHODS: The Premiere database for a single health system's hospitals was used to identify patients undergoing treatment for an acute intrathoracic esophageal perforation over a 4-year period. Patient cohorts for stent placement or surgical repair were formed using propensity matching. The 2 cohorts were compared for length of stay, morbidity, mortality, and costs. RESULTS: Between 2009 and 2012, 60 patients undergoing esophageal stent placement or surgical repair were propensity matched. Mean patient age and Charlson comorbidity scores did not differ significantly (P = .4 and P = .4, respectively). Significant differences in morbidity (4% vs 43%; P = .02), mean length of stay (6 vs 11 days; P = .0007), time to oral intake (3 vs 8 days; P = .0004), and cost ($91,000 vs $142,000; P < .0001) were identified in the esophageal stent cohort when compared with patients receiving surgical repair. Operative mortality did not differ significantly. CONCLUSIONS: Esophageal stent placement for the treatment of an acute esophageal perforation seems to be as effective as surgical repair when compared between propensity-matched patients. However, stent placement resulted in a shorter length of stay, lower rates of morbidity, and lower costs when compared with traditional surgical repair.

A propensity-matched comparison of pleurodesis or tunneled pleural catheter for heart failure patients with recurrent pleural effusion.

BACKGROUND: Patients with severe heart failure often have recurrent pleural effusions that produce dyspnea and shortness of breath. It is unclear whether chemical pleurodesis or the placement of a tunneled pleural catheter that can be used for intermittent pleural drainage produces superior palliation, a shorter hospital stay, and less morbidity. This investigation compares these two treatments. METHODS: Patients with a recurrent, symptomatic, pleural effusion secondary to advanced heart failure who had undergone at least two unilateral thoracenteses were identified. Two patient groups were formed by propensity matching patients who received either talc pleurodesis or a tunneled pleural catheter. Patient demographics, length of stay, need for further intervention for the pleural effusion, and procedural morbidity and mortality were collected and compared. Patients who had undergone ventricular assist device placement or cardiac transplant were excluded. RESULTS: Over a 5-year period, 80 patients undergoing treatment were identified and propensity matched. All 80 patients were classified as having class III or IV heart failure. No significant differences in palliation from their effusion were identified. However, the group treated with a tunneled pleural catheter realized a significantly shorter hospital stay as well as a lower rate of operative morbidity and readmissions than patients undergoing talc pleurodesis. CONCLUSIONS: This investigation found that a tunneled pleural catheter provided palliation of patients' pleural effusions and freedom from reintervention equal to that of talc pleurodesis using thoracoscopy while resulting in a shorter mean length of hospital stay. Lower rates of operative morbidity and readmission related to the pleural effusion were also seen in the tunneled catheter treatment group. This method of palliation of recurrent pleural effusion should be considered for symptomatic patients with advanced heart failure.