Assessment of the well-being of significant others of cardiothoracic surgeons.

OBJECTIVES: We aimed to evaluate how the current working climate of cardiothoracic surgery and burnout experienced by cardiothoracic surgeons influences their spouses and significant others (SOs). METHODS: A 33-question well-being survey was developed by the American Association for Thoracic Surgery Wellness Committee and distributed by e-mail to the SOs of cardiothoracic surgeons and to all surgeon registrants of the 2020 and 2021 American Association for Thoracic Surgery Annual Meetings with a request to share it with their SO. The 5-item Likert-scale survey questions were dichotomized, and associations were determined by χ2 or independent samples t tests, as appropriate. RESULTS: Responses from 238 SOs were analyzed. Sixty-six percent reported that the stress on their cardiothoracic surgeon partner had a moderate to severe influence on their family, and 63% reported that their partner's work demands didn't leave enough time for family. Fifty-one percent reported that their partner rarely had time for intimacy, 27% reported poor work-life balance, and 23% reported that interactions at home were usually or always not good-natured. SOs were most affected when their partner was <5 years out from training, worked in private vs academic practice, and worked longer hours. Having children, particularly younger than age 19 years, and a lack of workplace support resources further diminished well-being. CONCLUSIONS: The current work culture of cardiothoracic surgeons adversely affects their SOs, and the risk for families is concerning. These data present a major area for exploration as we strive to understand and mitigate the factors that lead to burnout among cardiothoracic surgeons.

Incidence, Management, and Outcomes of Patients With COVID-19 and Pneumothorax.

BACKGROUND: Our objective was to report the incidence, management, and outcomes of patients who developed a secondary pneumothorax while admitted for coronavirus disease 2019 (COVID-19). METHODS: A single-institution, retrospective review of patients admitted for COVID-19 with a diagnosis of pneumothorax between March 1, 2020, and April 30, 2020, was performed. The primary assessment was the incidence of pneumothorax. Secondarily, we analyzed clinical outcomes of patients requiring tube thoracostomy, including those requiring operative intervention. RESULTS: From March 1, 2020, to April 30, 2020, 118 of 1595 patients (7.4%) admitted for COVID-19 developed a pneumothorax. Of these, 92 (5.8%) required tube thoracostomy drainage for a median of 12 days (interquartile range 5-25 days). The majority of patients (95 of 118, 80.5%) were on mechanical ventilation at the time of pneumothorax, 17 (14.4%) were iatrogenic, and 25 patients (21.2%) demonstrated tension physiology. Placement of a large-bore chest tube (20 F or greater) was associated with fewer tube-related complications than a small-bore tube (14 F or less) (14 vs 26 events, P = .011). Six patients with pneumothorax (5.1%) required operative management for a persistent alveolar-pleural fistula. In patients with pneumothorax, median hospital stay was 36 days (interquartile range 20-63 days) and in-hospital mortality was significantly higher than for those without pneumothorax (58% vs 13%, P < .001). CONCLUSIONS: The incidence of secondary pneumothorax in patients admitted for COVID-19 is 7.4%, most commonly occurring in patients requiring mechanical ventilation, and is associated with an in-hospital mortality rate of 58%. Placement of large-bore chest tubes is associated with fewer complications than small-bore tubes.

Applying Systems Engineering to Increase Operating Room Efficiency.

Systems engineering is an interdisciplinary approach to creating, evaluating, and managing a complex process in order to increase reliability, cost-effectiveness, and quality. The operating room is a complex environment that requires human-human interaction, human-device interaction, planning, and coordination of scarce resources for the purpose of providing surgery to patients in a safe and efficient manner. The operating room is an important revenue generator, but it can also be responsible for unsustainable costs if not managed effectively. Reducing costs and increasing the efficiency of surgical cases is important for generating health care value. Efficiency efforts that aim for standardization of surgical protocols must be balanced by flexibility in the unpredictable operating room environment. This paper reviews systems engineering efforts to improve efficiency in the operating room including operating room scheduling, personnel factors, resource management, orthopedicspecific initiatives, and future innovations.

Incidence, Management, and Outcomes of Intraoperative Catastrophes During Robotic Pulmonary Resection.

BACKGROUND: Intraoperative catastrophes during robotic anatomical pulmonary resections are potentially devastating events. The present study aimed to assess the incidence, management, and outcomes of these intraoperative catastrophes for patients with primary lung cancers. METHODS: This was a retrospective, multiinstitutional study that evaluated patients who underwent robotic anatomical pulmonary resections. Intraoperative catastrophes were defined as events necessitating emergency thoracotomy or requiring an additional unplanned major surgical procedure. Standardized data forms were collected from each institution, with questions on intraoperative management strategies of catastrophic events. RESULTS: Overall, 1810 patients underwent robotic anatomical pulmonary resections, including 1566 (86.5%) lobectomies. Thirty-five patients (1.9%) experienced an intraoperative catastrophe. These patients were found to have significantly higher clinical TNM stage (P = .031) and lower forced expiratory volume in 1 second (81% vs 90%; P = .004). A higher proportion of patients who had a catastrophic event underwent preoperative radiotherapy (8.6% vs 2.3%; P = .048), and the surgical procedures performed differed significantly compared with noncatastrophic patients. Patients in the catastrophic group had higher perioperative mortality (5.7% vs 0.5%; P = .018), longer operative duration (195 minutes vs 170 minutes; P = .020), and higher estimated blood loss (225 mL vs 50 mL; P < .001). The most common catastrophic event was intraoperative hemorrhage from the pulmonary artery, followed by injury to the airway, pulmonary vein, and liver. Detailed management strategies were discussed. CONCLUSIONS: The incidence of catastrophic events during robotic anatomical pulmonary resections was low, and the most common complication was pulmonary arterial injury. Awareness of potential intraoperative catastrophes and their management strategies are critical to improving clinical outcomes.

Incorporating Innovation and New Technology Into Cardiothoracic Surgery.

The appropriate implementation of new technology, root cause analysis of "imperfect" outcomes, and the continuous reappraisal of postgraduate training are needed to improve the care of tomorrow's patients. Healthcare delivery remains one of the most expensive sectors in the United States, and the application of new and expensive technology that is necessary for the advancement of this complex specialty must be aligned with providing the best care for our patients. There are a several pathways to innovation: One is partnering with industry and the other is the investigational laboratory. Innovation and the funding thereof come from both the public and private sector. Most new trials that are likely to impact cardiothoracic surgery are industry-sponsored trials to meet the requirements necessary for regulatory approval. Cost considerations are paramount when considering integration of innovative technology and treatments into a clinical cardiothoracic surgical practice. The value of any new innovation is determined by the quality divided by the cost, and lean initiatives maximize this equation. The importance and implications of conflict of interest have been a concern for physicians, particularly when new technology or procedures are incorporated into clinical practice, and full disclosures by medical professionals and others involved are essential. Our societies and associations provide a platform for presentation and peer-reviewed discussion of new procedures, innovations, and trials and provide a venue for the sharing of knowledge on the highest quality patient care through education and research.

Cost Savings of Standardization of Thoracic Surgical Instruments: The Process of Lean.

BACKGROUND: Our objective is to show the effect that standardization of surgical trays has on the number of instruments sterilized and on cost. METHODS: We reviewed our most commonly used surgical trays with the 3 general thoracic surgeons in our division and agreed upon the least number of surgical instruments needed for mediastinoscopy, video-assisted thoracoscopic surgery, robotic thoracic surgery, and thoracotomy. RESULTS: We removed 59 of 79 instruments (75%) from the mediastinoscopy tray, 45 of 73 (62%) from the video-assisted thoracoscopic surgery tray, 51 of 84 (61%) from the robotic tray, and 50 of 113 (44%) from the thoracotomy tray. From January 2016 to December 2016, the estimated savings by procedure were video-assisted thoracoscopic surgery (n = 398) $21,890, robotic tray (n = 231) $19,400, thoracotomy (n = 163) $15,648, and mediastinoscopy (n = 162) $12,474. Estimated total savings were $69,412. The weight of the trays was reduced 70%, and the nonsteamed sterilization rate (opened trays that needed to be reprocessed) decreased from 2% to 0%. None of the surgeons requested any of the removed instruments. CONCLUSIONS: Standardization of thoracic surgical trays is possible despite having multiple thoracic surgeons. This process of lean (the removal of nonvalue steps or equipment) reduces the number of instruments cleaned and carried and reduces cost. It may also reduce the incidence of "wet loads" that require the resterilization of instruments.

The incidence and management of postoperative chylothorax after pulmonary resection and thoracic mediastinal lymph node dissection.

BACKGROUND: Our objective was to determine the incidence and optimal management of chylothorax after pulmonary resection with complete thoracic mediastinal lymph node dissection (MLND). METHODS: This is a retrospective review of patients who underwent pulmonary resection with MLND. RESULTS: Between January 2000 and December 2012, 2,838 patients underwent pulmonary resection with MLND by one surgeon (RJC). Forty-one (1.4%) of these patients experienced a chylothorax. Univariate analysis showed that lobectomy (p<0.001), a robotic approach (p=0.03), right-sided operations (p<0.001), and pathologic N2 disease (p=0.007) were significantly associated with the development of chylothorax. Multivariate analysis showed that lobectomy (p=0.011), a robotic approach (p=0.032), and pathologic N2 disease (p=0.027) remained predictors. All patients were initially treated with cessation of oral intake and 200 µg subcutaneous somatostatin every 8 hours. If after 48 hours the chest tube output was less than 450 mL/day and the effluent was clear, patients was given a medium-chain triglyceride (MCT) diet and were observed for 48 hours in the hospital. If the chest tube output remained below 450 mL/day, the chest tube was removed, they were discharged home with directions to continue the MCT diet and to return in 2 weeks. Patients were instructed to consume a high-fat meal 24 hours before their clinic appointment. If the patient's chest roentgenogram was clear at that time, they were considered "treated." This approach was successful in 37 (90%) patients. The 4 patients in whom the initial treatment was unsuccessful underwent reoperation with pleurodesis and duct ligation. CONCLUSIONS: Chylothorax after pulmonary resection and MLND occurred in 1.4% of patients. Its incidence was higher in those with pathologic N2 disease and those who underwent robotic resection. Nonoperative therapy is almost always effective.

Performing robotic lobectomy and segmentectomy: cost, profitability, and outcomes.

BACKGROUND: The primary objective of this study was to evaluate our experience using a completely portal (no access incision) robotic pulmonary lobectomy or segmentectomy. METHODS: This was a retrospective review of a consecutive series of patients. RESULTS: From February 2010 until October 2013, 862 robotic operations were performed by 1 surgeon. Of these, 394 were for a planned anatomic pulmonary resection, comprising robotic lobectomy in 282, robotic segmentectomy in 71, and conversions to open in 41 (10 for bleeding, 1 patient required transfusion; and no conversions for bleeding in the last 100 patients). Indications were malignancy in 88%. A median of 17 lymph nodes were removed. Median hospital stay was 2 days. Approximate financial data yielded: median hospital charges, $32,000 per patient (total, $12.6 million); collections, 23.7%; direct costs, $13,800 per patient; and $4,750 profit per patient (total, $1.6 million). Major morbidity occurred in 9.6%. The 30-day operative mortality was 0.25%, and 90-day mortality was 0.5%. Patients reported a median pain score of 2/10 at their 3-week postoperative clinic visit. CONCLUSIONS: Robotic lobectomy for cancer offers outstanding results, with excellent lymph node removal and minimal morbidity, mortality, and pain. Despite its costs, it is profitable for the hospital system. Disadvantages include capital costs, the learning curve for the team, and the lack of lung palpation. Robotic surgery is an important tool in the armamentarium for the thoracic surgeon, but its precise role is still evolving.

Starting a robotic program in general thoracic surgery: why, how, and lessons learned.

BACKGROUND: We report our experience in starting a robotic program in thoracic surgery. METHODS: We retrospectively reviewed our experience in starting a robotic program in general thoracic surgery on a consecutive series of patients. RESULTS: Between February 2009 and September 2010, 150 patients underwent robotic operations. Types of procedures were lobectomy in 62, thymectomy in 30, and benign esophageal procedures in 6. No thymectomy or esophageal procedures required conversion. One conversion was needed for suspected bleeding for a mediastinal mass. Twelve patients were converted for lobectomy (none for bleeding, 1 in the last 24). Median operative time for robotic thymectomy was 119 minutes, and median length of stay was 1 day. The median time for robotic lobectomy was 185 minutes, and median length of stay was 2 days. There were no operative deaths. Morbidity occurred in 23 patients (15%). All patients with cancer had R0 resections and resection of all visible mediastinal and hilar lymph nodes. CONCLUSIONS: Robotic surgery is safe and oncologically sound. It requires training of the entire operating room team. The learning curve is steep, involving port placement, availability of the proper instrumentation, use of the correct robotic arms, and proper patient positioning. The robot provides an ideal surgical approach for thymectomy and other mediastinal tumors. Its advantage over thoracoscopy for pulmonary resection is unproven; however, we believe complete thoracic lymph node dissection and teaching is easier. Importantly, defined credentialing for surgeons and cost analysis studies are needed.

Optimal care of patients with non-small cell lung cancer reduces perioperative morbidity.

OBJECTIVE: The objective is to test the concept of "pay for performance" for patients with non-small cell lung cancer. METHODS: We constructed 53 benchmark performance standards (10 labeled "critical") and prospectively assessed the effect of adherence to these standards on morbidity and mortality for patients undergoing resection of non-small cell lung cancer. RESULTS: Between January 1, 2007, and December 31, 2009, 778 patients with non-small cell lung cancer underwent thoracotomy by 1 surgeon. Ninety-seven percent of patients received all 26 of the "day of surgery" and "intraoperative" benchmarks, and those were the easiest to deliver. The 469 patients who had all 53 benchmarks delivered, compared with the 309 who did not, had a lower mortality (2.0% vs 2.3%) and morbidity (16% vs 44%; P < .001). The 693 patients who received all 10 "critical" benchmarks, compared with the 85 who did not, had a lower mortality (1.9% vs 4.7%) and morbidity (25% vs 41%; P = .003). Low household income and fewer than 2 people in the household were predictors of overall morbidity on univariate analysis. CONCLUSIONS: Most benchmarks, especially "day of surgery" and "intraoperative" ones, can be delivered in more than 97% of patients. The delivery of benchmarks reduces perioperative morbidity but not mortality. Socioeconomic factors are predictors of overall morbidity. Operative mortality is related to the "quality of the patient" and the "quality of the health care provider."

The benefits of continuous and digital air leak assessment after elective pulmonary resection: a prospective study.

BACKGROUND: Air leaks remain the most common pulmonary complication after elective pulmonary resection, yet their assessment, unlike other clinical bedside indicators, remains analogue and not digital. METHODS: This prospective randomized study compared a digital air leak system with the current analogue air leak system in 100 patients that underwent elective pulmonary resection. RESULTS: The digital and analogue patient groups each had 50 patients. Pulmonary function, types of pulmonary resection, number of chest tubes, and pathology were not statistically different between the groups. The digital system confirmed the air leak status in 5 patients that were equivocal on the analogue system. The ability to assess the air leak status continuously afforded quicker chest tube removal in the digital group (mean, 3.1 vs 3.9 days, p = 0.034) and reduced hospital stay (mean, 3.3 vs 4.0 days, p = 0.055). Three patients were discharged home with the device, without complications. CONCLUSIONS: The digital and continuous measurement of air leaks instead of the currently used static analogue systems reduces hospital length of stay by more accurately and reproducibly measuring air leaks. This leads to quicker chest tube management decisions because the average size of an air leak during the last several hours can be determined. Intrapleural pressure curves may also help predict the optimal chest tube setting for each patient's air leak and eliminate the need for chest roentgenograms. Further studies on the pleural pressure curves and this device are needed.

Endoscopic ultrasound-guided fine-needle aspiration in patients with non-small cell lung cancer and prior negative mediastinoscopy.

BACKGROUND: Mediastinoscopy and endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA) are complementary for staging non-small cell lung cancer (NSCLC) patients. We assessed (1) the yield of EUS-FNA of malignant lymph nodes in NSCLC patients with combined anterior and posterior lymph nodes that had already undergone mediastinoscopy and (2) the cost implications associated with alternative initial strategies. METHODS: All patients underwent chest computed tomography (CT) and/or positron emission tomography (PET), and mediastinoscopy. Then, the posterior mediastinal stations (7, 8, and 9) or station 5 were targeted with EUS-FNA. The reference standard included thoracotomy with complete thoracic lymphadenectomy, repeat clinical imaging, or long-term clinical follow-up. A Monte Carlo cost-analysis model evaluated the expected costs and outcomes associated with staging of NSCLC. RESULTS: Thirty-five NSCLC patients met inclusion criteria (median age 65 years; 80% men). Endoscopic ultrasound-guided FNA was performed in 53 lymph nodes in various stations, the subcarinal station (7) being the most common (47.3%). Of the 35 patients who had a prior negative mediastinoscopy, 13 patients (37.1%) had malignant N2 or N3 lymph nodes. Accuracy of EUS-FNA (98.1%) was significantly higher than that of CT (41.5%; p < 0.001) and PET (40%; p < 0.001). Initial EUS-FNA resulted in average costs per patient of 1,867 dollars (SD +/- 4,308 dollars) while initial mediastinoscopy cost 12,900 dollars (SD +/- 4,164.40 dollars). If initial EUS-FNA is utilized rather than initial mediastinoscopy, an average cost saving of 11,033 dollars per patient would result. CONCLUSIONS: In patients with NSCLC and combined anterior and posterior lymph nodes, starting with EUS-FNA would preclude mediastinoscopy in more than one third of the patients. Endoscopic ultrasound-guided FNA is a safe outpatient procedure that is less invasive and less costly than mediastinoscopy.