Association between prehospital transfer distance and surgical mortality in emergency thoracic aortic surgery.

OBJECTIVE: To examine whether there is an association between prehospital transfer distance and surgical mortality in emergency thoracic aortic surgery. METHODS: A retrospective cohort study using a national clinical database in Japan was conducted. Patients who underwent emergency thoracic aortic surgery from January 1, 2014, to December 31, 2016, were included. Patients with type B dissection were excluded. A multilevel logistic regression analysis was performed to examine the association between prehospital transfer distance and surgical mortality. In addition, an instrumental variable analysis was performed to address unmeasured confounding. RESULTS: A total of 12,004 patients underwent emergency thoracic aortic surgeries at 495 hospitals. Surgical mortality was 13.8%. The risk-adjusted mortality odds ratio for standardized distance (mean 12.8 km, standard deviation 15.2 km) was 0.94 (95% confidence interval, 0.87-1.01; P = .09). Instrumental variable analysis did not reveal a significant association between transfer distance and surgical mortality as well. CONCLUSIONS: No significant association was found between surgical mortality and prehospital transfer distance in emergency thoracic aortic surgery cases. Suspected cases of acute thoracic aortic syndrome may be transferred safely to distant high-volume hospitals.

Clinical features and outcomes of thoracic surgery patients during the COVID-19 pandemic.

OBJECTIVES: The goal of this study was to describe the clinical features and outcomes of thoracic surgery patients during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: Thirty-five patients were treated at the 12 de Octubre University Hospital in Madrid between 1 March 2020 and 24 April 2020 during the COVID-19 pandemic. Patient demographics, surgical procedures, complications, COVID-19 symptoms and outcomes were recorded. A protocol was introduced to reduce the risk of operating on patients with COVID-19, including symptom screening, a polymerase chain reaction test for severe acute respiratory syndrome coronavirus 2 and computed tomography scans of the chest. Surgical activity changed significantly during this time, from an initial period of near-normal activity, through an emergency-only period and finally a recovery period when some oncological surgical cases were restarted. Selection criteria for surgical patients are also described. RESULTS: A total of 34 patients underwent surgery during the pandemic period. We performed 22 lung resections (11 lobectomies and 11 sublobar resections). No hospital deaths were recorded. An elective surgery patient and an emergency surgery patient were diagnosed with COVID-19 (5.88%). The former died within 30 days after surgery. CONCLUSIONS: Severe acute respiratory syndrome coronavirus 2 represents a tremendous limitation for thoracic surgical practice. Preoperative practices to exclude asymptomatic cases infected with the virus allowed us to perform thoracic surgical procedures.

Extracorporeal membrane oxygenation as a rescue measure after thoracic surgery.

Background Extracorporeal membrane oxygenation is used for many different conditions including respiratory distress, cardiogenic shock, and trauma. In these patient groups, extracorporeal membrane oxygenation has been extensively studied. Recently, it has been used as a rescue measure in patients experiencing acute respiratory distress after thoracic surgery. The goal of our study was to examine the efficacy and cost-effectiveness of extracorporeal membrane oxygenation as a rescue measure after thoracic surgery at a single center. Methods We conducted a retrospective review of all patients who received extracorporeal membrane oxygenation after thoracic surgery at the University of Kentucky from January 9, 2012 to January 9, 2017. Eight patients were identified. Results The average time on extracorporeal membrane oxygenation was 9.125 days, and the average hospital stay was 65.125 days. Of the 8 patients placed on extracorporeal membrane oxygenation, 3 survived to discharge. Of the 3 patients who survived to discharge, 1 died within 6 months and 2 have been followed up for less than 4 months. The average total charge per patient was calculated to be $1,053,551, and the average charge per day was $16,177. The contribution margin was $109,200 per case. Conclusions Extracorporeal membrane oxygenation is a tool that saves lives in many different patient populations but it does not appear to be as effective in patients experiencing acute respiratory distress syndrome after thoracic surgery. Extracorporeal membrane oxygenation in this group also uses a tremendous amount of hospital resources.

Goals of surgery and assessment tools for elderly patients referred for cardiac and noncardiac surgery.

Surgery in elderly patients is associated with the risk of death, complications, functional decline and disability. Prior to surgery, therefore, an assessment of the health-related priorities, a realistic evaluation of the surgical risks, and individualized optimization of the procedural pathway to follow are mandatory.

National Survey of UK Consultant Surgeons' Opinions on Surgeon-Specific Mortality Data in Cardiothoracic Surgery.

BACKGROUND: In the United Kingdom, cardiothoracic surgeons have led the outcome reporting revolution seen over the last 20 years. The objective of this survey was to assess cardiothoracic surgeons' opinions on the topic, with the aim of guiding future debate and policy making for all subspecialties. METHODS AND RESULTS: A questionnaire was developed using interviews with experts in the field. In January 2015, the survey was sent out to all consultant cardiothoracic surgeons in the United Kingdom (n=361). Logistic regression, bivariate correlation, and the χ(2) test were used to assess whether there was a relationship between answers and demographic variables. Free-text responses were analyzed using the grounded theory approach. The response rate was 73% (n=264). The majority of respondents (58.1% oppose, 34.1% favor, and 7.8% neither) oppose the public release of surgeon-specific mortality data and associate it with several adverse consequences. These include risk-averse behavior, gaming of data, and misinterpretation of data by the public. Despite this, the majority overwhelmingly supports publication of team-based measures of outcome. The free-text responses suggest that this is because most believe that quality of care is multifactorial and not represented by an individual's mortality rate. CONCLUSIONS: There is evident opposition to surgeon-specific mortality data among UK cardiothoracic surgeons who associate this with several unintended consequences. Policy makers should refine their strategy behind publication of surgeon-specific mortality data and possibly consider shift toward team-based results for which there will be the required support. Stakeholder feedback and inclusive strategy should be completed before introducing major initiatives to avoid unforeseen consequences and disagreements.

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

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

Cardiovascular disease in Europe--epidemiological update 2015.

This article provides an update for 2015 on the burden of cardiovascular disease (CVD), with a particular focus on coronary heart disease (CHD) and stroke, across the countries of Europe. Cardiovascular disease is still the most common cause of death within Europe, causing almost two times as many deaths as cancer across the continent. Although there is clear evidence, where data are available, that mortality from CHD and stroke has decreased substantially over the last 5-10 years, there are still large inequalities found between European countries, in both current rates of death and the rate at which these decreases have occurred. Similarly, rates of treatment, particularly surgical intervention, differ widely between those countries for which data are available, indicating a range of inequalities between them. This is also the first time in the series that we use the 2013 European Standard Population (ESP) to calculate age-standardized death rates (ASDRs). This new standard results in ASDRs around two times as large as the 1976 ESP for CVD conditions such as CHD but changes little the relative rankings of countries according to ASDR.

Readmission destination and risk of mortality after major surgery: an observational cohort study.

BACKGROUND: Hospital readmissions are common after major surgery, although it is unknown whether patients achieve improved outcomes when they are readmitted to, and receive care at, the index hospital where their surgical procedure was done. We examined the association between readmission destination and mortality risk in the USA in Medicare beneficiaries after a range of common operations. METHODS: By use of claims data from Medicare beneficiaries in the USA between Jan 1, 2001, and Nov 15, 2011, we assessed patients who needed hospital readmission within 30 days after open abdominal aortic aneurysm repair, infrainguinal arterial bypass, aortobifemoral bypass, coronary artery bypass surgery, oesophagectomy, colectomy, pancreatectomy, cholecystectomy, ventral hernia repair, craniotomy, hip replacement, or knee replacement. We used logistic regression models incorporating inverse probability weighting and instrumental variable analysis to measure associations between readmission destination (index vs non-index hospital) and risk of 90 day mortality for patients who underwent surgery who needed hospital readmission. FINDINGS: 9,440,503 patients underwent one of 12 major operations, and the number of patients readmitted or transferred back to the index hospital where their operation was done varied from 186,336 (65·8%) of 283,131 patients who were readmitted after coronary artery bypass grafting, to 142,142 (83·2%) of 170,789 patients who were readmitted after colectomy. Readmission was more likely to be to the index hospital than to a non-index hospital if the readmission was for a surgical complication (189,384 [23%] of 834,070 patients readmitted to index hospital vs 36,792 [13%] of 276,976 patients readmitted non-index hospital, p<0·0001). Readmission to the index hospital was associated with a 26% lower risk of 90 day mortality than was readmission to a non-index hospital, with inverse probability weighting used to control for selection bias (odds ratio [OR] 0·74, 95% CI 0·66-0·83). This effect was significant (p<0·0001) for all procedures in inverse probability-weighted models, and was largest for patients who were readmitted after pancreatectomy (OR 0·56, 95% CI 0·45-0·69) and aortobifemoral bypass (OR 0·69, 95% CI 0·61-0·77). By use of hospital-level variation among regional index hospital readmission rates as an instrument, instrumental variable analysis showed that the patients with the highest probability of returning to the index hospital had 8% lower risk of mortality (OR 0·92 95% CI 0·91-0·94) than did patients who were less likely to be readmitted to the index hospital. INTERPRETATION: In the USA, patients who are readmitted to hospital after various major operations consistently achieve improved survival if they return to the hospital where their surgery took place. These findings might have important implications for cost-effectiveness-driven regional centralisation of surgical care. FUNDING: None.

Benchmarking clinical practice in surgery: looking beyond traditional mortality rates.

This paper proposes two new measures to assess performance of surgical practice based on observed mortality: reliability, measured as the area under the ROC curve and a living score, the sum of individual risk among surviving patients, divided by the total number of patients. A Monte Carlo simulation of surgeons' practice was used for conceptual validation and an analysis of a real-world hospital department was used for managerial validation. We modelled surgical practice as a bivariate distribution function of risk and final state. We sampled 250 distributions, varying the maximum risk each surgeon faced, the distribution of risk among dead patients, the mortality rate and the number of surgeries performed yearly. We applied the measures developed to a Portuguese cardiothoracic department. We found that the joint use of the reliability and living score measures overcomes the limitations of risk adjusted mortality rates, as it enables a different valuation of deaths, according to their risk levels. Reliability favours surgeons with casualties, predominantly, in high values of risk and penalizes surgeons with deaths in relatively low levels of risk. The living score is positively influenced by the maximum risk for which a surgeon yields surviving patients. These measures enable a deeper understanding of surgical practice and, as risk adjusted mortality rates, they rely only on mortality and risk scores data. The case study revealed that the performance of the department analysed could be improved with enhanced policies of risk management, involving the assignment of surgeries based on surgeon's reliability and living score.

Developing a genetic fuzzy system for risk assessment of mortality after cardiac surgery.

Cardiac events could be taken into account as the leading causes of death throughout the globe. Such events also trigger an undesirable increase in what treatment procedures cost. Despite the giant leaps in technological development in heart surgery, coronary surgery still carries the high risk of the mortality. Besides, there is still a long way ahead to accurately predict and assess the mortality risk. This study is an attempt to develop an expert system for the risk assessment of mortality following the cardiac surgery. The developed system involves three main steps. In the first step, a filtering feature selection method is applied to select the best features. In the second step, an ad hoc data-driven method is utilized to generate the preliminary fuzzy inference system. Finally, a hybrid optimization method is presented to select the optimum subset of the rules. The study relies on 1,811 samples to evaluate the diagnosis performance of the proposed system. The obtained classification accuracy is very promising with regard to other benchmark classification methods including binary logistic regression (LR) and multilayer perceptron neural network (MLP) with the same attributes. The developed system leads to 100% sensitivity and 84.7% specificity, while LR and MLP methods statistically come up with lower figures (65, 78.6 and 65%, 75.8%), respectively. Now, a fuzzy supportive tool can be potentially taken as an alternative for the current mortality risk assessment system that are applied in coronary surgeries, and are chiefly based on crisp database.

Sex differences in early outcomes after lung cancer resection: analysis of the Society of Thoracic Surgeons General Thoracic Database.

OBJECTIVES: Women with lung cancer have superior long-term survival outcomes compared with men, independent of stage. The cause of this disparity is unknown. For patients undergoing lung cancer resection, these survival differences could be due, in part, to relatively better perioperative outcomes for women. This study was undertaken to determine differences in perioperative outcomes after lung cancer surgery on the basis of sex. METHODS: The Society of Thoracic Surgeons' General Thoracic Database was queried for all patients undergoing resection of lung cancer between 2002 and 2010. Postoperative complications were analyzed with respect to sex. Univariable analysis was performed, followed by multivariable modeling to determine significant risk factors for postoperative morbidity and mortality. RESULTS: A total of 34,188 patients (16,643 men and 17,545 women) were considered. Univariable analysis demonstrated statistically significant differences in postoperative complications favoring women in all categories of postoperative complications. Women also had lower in-hospital and 30-day mortality (odds ratio, 0.56; 95% confidence interval, 0.44-0.71; P < .001). Multivariable analysis demonstrated that several preoperative conditions independently predicted 30-day mortality: male sex, increasing age, lower diffusion capacity, renal insufficiency, preoperative radiation therapy, cancer stage, extent of resection, and thoracotomy as surgical approach. Coronary artery disease was an independent predictor of mortality in women but not in men. Thoracotomy as the surgical approach and preoperative radiation therapy were predictive of mortality for men but not for women. Postoperative prolonged air leak and empyema predicted mortality in men but not in women. CONCLUSIONS: Women have lower postoperative morbidity and mortality after lung cancer surgery. Some risk factors are sex-specific with regard to mortality. Further study is warranted to determine the cause of these differences and to determine their effect on survival.

Frailty assessment in thoracic surgery.

A best evidence topic in thoracic surgery was performed according to a structured protocol. The question addressed was the role of frailty scores in predicting outcomes of patients undergoing thoracic surgery. Seventy-one papers were found using the reported search, of which three studies and one conference abstract represented the best evidence to answer the clinical question. The authors, journal date, country of publication, patient group, study type, relevant outcomes and results are tabulated. Despite an extensive literature search, few studies were identified which addressed the clinical dilemma posed, all of which were retrospective observational series. A study analysed 971 434 patients across a wide range of surgical specialties, 4648 of which were classified as thoracic. A statistically significant relationship was demonstrated between increasing frailty and higher rates of postoperative complications and mortality (P < 0.0001). Another study reported a similar association between modified frailty index (mFI) scores and postoperative outcomes in patients undergoing lobectomies. Morbidity increased uniformly with mFI and multivariant analysis found an mFI of >0.27 (P = 0.002) to be an independent predictor of mortality. Another paper demonstrated higher rates of major postoperative complications and increased mortality (P < 0.001) in patients with higher preoperative dependency. A study examined geriatric frailty assessment tools for the prediction of postoperative outcomes in patients over 70 undergoing thoracic surgery for neoplasms. The Geriatric Depression Screen, Mini Mental State Examination, Fatigue Inventory, Eastern Co-Operative Oncology Group Performance Scale and Instrumental Activities of Daily Living were used as a means of determining preoperative frailty. Their conclusion supported the conclusions drawn from the larger studies that a single frailty measure alone did not predict an increase in morbidity or mortality, but in combination several measures may have a role in predicting postoperative outcomes. The clinical bottom line is that there is a paucity of evidence to either fully support or fully refute the use of preoperative frailty scoring as a reliable means of predicting morbidity and mortality in thoracic surgery. The evidence presented does however indicate the potentially important clinical role that frailty scores may have in the future.

Data Resource Profile: adult cardiac surgery database of the Netherlands Association for Cardio-Thoracic Surgery.

In 2007 The Netherlands Association for Cardio-Thoracic Surgery (Nederlandse Vereniging voor Thoraxchirurgie, NVT) instituted the Adult Cardiac Surgery Database. The dataset comprises demographic factors, type of intervention, in-hospital mortality and 18 risk factors for mortality after cardiac surgery, according to the European System for Cardiac Operative Risk Evaluation definitions. Currently, this procedural database contains over 60 000 interventions. Completeness of data is excellent and national coverage of all 16 Dutch cardio-thoracic surgery centres has been achieved since the start. The primary goal of the database is to control and maintain the quality of care by evaluation of outcomes. This is accomplished by regular feedback and comparison of outcomes. For a subset of the database (procedures from 10 out of 16 centres) longer-term follow-up has been established by means of data linkage to two national registries. This provides information on survival status, causes of death and readmissions. The database has recently been used for research, resulting in methodological papers aimed at optimizing comparison of outcomes. In future, clinical issues will also be addressed, for example survival after coronary artery bypass grafting and valve surgery.

Gender and its implications for cardiothoracic perioperative care and anesthesia.

Differences in gender can influence perioperative outcome, with men and women being differently affected by adverse events in the perioperative period. Differences relating to specific drug effects, comorbidities and outcomes after anesthesia or intensive care have been demonstrated. There is a gender bias in diagnosis and therapy. While knowledge regarding this field is still growing, certain aspects have already been integrated into clinical practice (prevention of postoperative nausea and vomiting, target-controlled infusion, male-only policy with production of blood products). There is a need to study the influence of gender, age, and race on perioperative outcome to optimize treatment and move toward more individualized therapy. This article highlights already identified differences and discusses potential underlying mechanisms.

Specialty matters in the treatment of lung cancer.

The effect of surgeon volume, hospital volume, and surgeon specialty on operative outcomes has been reported in numerous studies. Short-term and long-term outcome comparisons for pulmonary resection for lung cancer have been performed between general surgeons (GS), cardiothoracic surgeons (CTS), and general thoracic surgeons (TS), using large administrative and inpatient databases. In the United States, general surgeons perform more pulmonary resection than thoracic surgeons. Studies have found that in cases involving thoracic surgeons, there is a lower operative mortality and morbidity, improved long-term survival, better adherence to established practice standards, and a lower cost compared with cases involving general surgeons. Some specific processes of care that account for these improved economic, operative, and oncological outcomes have been identified. Others are not yet specifically known and associated with specialization in thoracic surgery.

The society of thoracic surgeons 30-day predicted risk of mortality score also predicts long-term survival.

BACKGROUND: The Society of Thoracic Surgeons Predicted Risk of Mortality (PROM) score is a well-validated predictor of 30-day mortality after cardiac procedures. This study investigated the ability of PROM to predict longer-term survival. METHODS: From January 1, 1996, to December 31, 2009, 24,222 patients with PROM scores underwent cardiac procedures at an academic center. Long-term all-cause mortality was determined from the Social Security Death Index. Logistic and Cox survival regression analyses evaluated the long-term predictive utility of the PROM. Area under the receiver operator characteristic curve measured the discrimination of PROM at 1, 3, 5, and 10 years. Kaplan-Meier curves were stratified by quartiles of PROM risk to compare long-term survival. All analyses were performed for the whole sample and for 30-day survivors. RESULTS: The overall 30-day mortality was 2.78% (674 of 24,222). PROM predicted 30-day mortality extremely well (area under the receiver operator characteristic, 0.794) and predicted longer-term survival almost as well. Among all patients and 30-day survivors, area under the receiver operator characteristic values for PROM at 1, 3, 5, and 10 years were remarkably similar to the 30-day end point for which PROM is calibrated. PROM was highly predictive of Kaplan-Meier survival for patients surviving beyond 30 days. Among 30-day survivors, each percent increase in PROM score was associated with a 9.6% increase (95% confidence interval, 9.3% to 10.0%) in instantaneous hazard of death (p<0.001). CONCLUSIONS: The PROM algorithm accurately predicts death at 30-days and during 14 years of follow-up with almost equally strong discriminatory power. This may have profound implications for informed consent and for longitudinal comparative effectiveness studies.

Successful linking of the Society of Thoracic Surgeons database to social security data to examine survival after cardiac operations.

BACKGROUND: Long-term evaluation of cardiothoracic surgical outcomes is a major goal of The Society of Thoracic Surgeons (STS). Linking the STS Database to the Social Security Death Master File (SSDMF) allows for the verification of "life status." This study demonstrates the feasibility of linking the STS Database to the SSDMF and examines longitudinal survival after cardiac operations. METHODS: For all operations in the STS Adult Cardiac Surgery Database performed in 2008 in patients with an available Social Security Number, the SSDMF was searched for a matching Social Security Number. Survival probabilities at 30 days and 1 year were estimated for nine common operations. RESULTS: A Social Security Number was available for 101,188 patients undergoing isolated coronary artery bypass grafting, 12,336 patients undergoing isolated aortic valve replacement, and 6,085 patients undergoing isolated mitral valve operations. One-year survival for isolated coronary artery bypass grafting was 88.9% (6,529 of 7,344) with all vein grafts, 95.2% (84,696 of 88,966) with a single mammary artery graft, 97.4% (4,422 of 4,540) with bilateral mammary artery grafts, and 95.6% (7,543 of 7,890) with all arterial grafts. One-year survival was 92.4% (11,398 of 12,336) for isolated aortic valve replacement (95.6% [2,109 of 2,206] with mechanical prosthesis and 91.7% [9,289 of 10,130] with biologic prosthesis), 86.5% (2,312 of 2,674) for isolated mitral valve replacement (91.7% [923 of 1,006] with mechanical prosthesis and 83.3% [1,389 of 1,668] with biologic prosthesis), and 96.0% (3,275 of 3,411) for isolated mitral valve repair. CONCLUSIONS: Successful linkage to the SSDMF has substantially increased the power of the STS Database. These longitudinal survival data from this large multi-institutional study provide reassurance about the durability and long-term benefits of cardiac operations and constitute a contemporary benchmark for survival after cardiac operations.

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.