Chatbot Reliability in Managing Thoracic Surgical Clinical Scenarios.

BACKGROUND: Chatbot use in medicine is growing, and concerns have been raised regarding their accuracy. This study assessed the performance of 4 different chatbots in managing thoracic surgical clinical scenarios. METHODS: Topic domains were identified and clinical scenarios were developed within each domain. Each scenario included 3 stems using Key Feature methods related to diagnosis, evaluation, and treatment. Twelve scenarios were presented to ChatGPT-4 (OpenAI), Bard (recently renamed Gemini; Google), Perplexity (Perplexity AI), and Claude 2 (Anthropic) in 3 separate runs. Up to 1 point was awarded for each stem, yielding a potential of 3 points per scenario. Critical failures were identified before scoring; if they occurred, the stem and overall scenario scores were adjusted to 0. We arbitrarily established a threshold of ≥2 points mean adjusted score per scenario as a passing grade and established a critical fail rate of ≥30% as failure to pass. RESULTS: The bot performances varied considerably within each run, and their overall performance was a fail on all runs (critical mean scenario fails of 83%, 71%, and 71%). The bots trended toward "learning" from the first to the second run, but without improvement in overall raw (1.24 ± 0.47 vs 1.63 ± 0.76 vs 1.51 ± 0.60; P = .29) and adjusted (0.44 ± 0.54 vs 0.80 ± 0.94 vs 0.76 ± 0.81; P = .48) scenario scores after all runs. CONCLUSIONS: Chatbot performance in managing clinical scenarios was insufficient to provide reliable assistance. This is a cautionary note against reliance on the current accuracy of chatbots in complex thoracic surgery medical decision making.

A Rare Occurrence of Rotational Retro-Esophageal Gastric Body Herniation Through a Nissen Fundoplication.

Anti-reflux procedures have become a mainstay in managing gastroesophageal reflux disease (GERD) and hiatal hernia. Unfortunately, post-operative events such as breakdown of the wrap, downward slippage, or transdiaphragmatic herniation of an intact wrap cause these procedures to fail and create complications such as recurrent hiatal hernia and reflux dysphagia, regurgitation, and obstruction requiring revision surgery. We discuss a case of a rotational retro-esophageal herniation of the gastric body through a Nissen fundoplication presenting as obstruction, dysphagia, and regurgitation, highlighting the peculiar nature of this presentation and the ease of misdiagnosis given its rarity.

In Memoriam: George Charles Kaiser, MD, 1928-2020: 32nd President of The Society of Thoracic Surgeons.

This article is a brief remembrance of the life and career of George Charles Kaiser, MD, the 32nd president of The Society of Thoracic Surgeons.

Critical Analysis of the National Emphysema Treatment Trial Results for Lung-Volume-Reduction Surgery.

The National Emphysema Treatment Trial compared medical treatment of severe pulmonary emphysema with lung-volume-reduction surgery in a multiinstitutional randomized prospective fashion. Two decades later, this trial remains one of the key sources of information we have on the treatment of advanced emphysematous lung disease. The trial demonstrated the short- and long-term effectiveness of surgical intervention as well as the need for strict patient selection and preoperative workup. Despite these findings, the key failure of the trial was an inability to convince the medical community of the value of surgical resection in the treatment of advanced emphysema.

Managing Otolaryngologic Complications in Cardiothoracic Surgery.

BACKGROUND: Cardiothoracic procedures are often lifesaving operations, and because of their complexity they are not without complications. Although major complications are often recognized and treated immediately, there are many less commonly identified complications that can and frequently should be addressed by otolaryngology colleagues during a patient's hospital course. METHODS: This comprehensive review describes otolaryngologic complications of cardiac and thoracic surgery. RESULTS: Dysphonia, dysphagia, stridor, tracheotomy hemorrhage, and pharyngeal tear are all complications of cardiothoracic procedures. Indications for treatment and treatment options are reviewed. The impact on quality of life and long-term morbidity is also discussed. CONCLUSIONS: Otolaryngologic complications are common after cardiothoracic procedures. An otolaryngologist should be asked to evaluate a patient with dysphonia, dysphagia, or stridor while the patient is an inpatient. Patients experiencing persistent or nonacute problems should be referred to otolaryngologists to discuss more long-term interventions.

Sexual Harassment and Cardiothoracic Surgery: #UsToo?

BACKGROUND: Fifty-eight percent of women in science, engineering, and medicine report being affected by sexual harassment (SH). This study sought to determine the extent of SH in cardiothoracic surgery. METHODS: The study developed a survey that was based on the Sexual Experience Questionnaire-Workplace, physician wellness, and burnout surveys. The survey was open to responses for 45 days and was disseminated through The Society of Thoracic Surgeons, Women in Thoracic Surgery, and Thoracic Surgery Residents Association listservs. A reminder email was issued at 28 days. Student t tests, Fisher exact tests, and χ2 tests were used to compare results. RESULTS: Of 790 respondents, 75% were male and 82% were attending surgeons. A total of 81% of female surgeons vs 46% of male attending surgeons experienced SH (P < .001). SH also was reported by trainees (90% female vs 32% male; P < .001). According to women, the most common offenders were supervising leaders and colleagues; for men, it was ancillary staff and colleagues. Respondents reported SH at all levels of training. A total of 75% of women surgeons vs 51% of men surgeons witnessed a colleague be subjected to SH; 89% of respondents reported the victim as female (male 2%, both 9%; P < .001). A total of 49% of female witnesses (50% of male witnesses) reported no intervention; less than 5% of respondents reported the offender to a governing board. SH was positively associated with burnout. CONCLUSIONS: SH is present in cardiothoracic surgery among faculty and trainees. Although women surgeons are more commonly affected, male surgeons also are subjected to SH. Despite witnessed events, intervention currently is limited. Policies, safeguards, and bystander training should be instituted to decrease these events.

The National Emphysema Treatment Trial: summary and update.

Surgery for severe emphysema involves a cohort of patients who are already at risk for increased perioperative morbidity and mortality. Through the careful screening and selection process, improved intraoperative techniques and rigorous attention to postoperative care, the NETT managed to yield acceptable improvements in survival and functional outcomes in this fragile patient cohort and these benefits were sustained over the long-term. Identification of the characteristics associated with a higher risk of death has provided tangible patient selection criteria for the ongoing application of LVRS. Because the NETT was such a large-scale study, the protocols that were developed had to be standardized across several centers. This produced reliable and reproducible standards for evaluation and treatment that can be applied to the surgical treatment of emphysema. When considering these criteria, although individualized patient selection is important, only patients with upper-lobe predominant disease on chest CT and possibly those with non-upper-lobe predominant disease who also have low baseline exercise capacity are appropriate candidates for LVRS. Expectedly, questions remain regarding the exact mechanism whereby the benefits derived from LVRS are obtained. Additionally, the benefit of LVRS in patients with heterogeneous but non-upper-lobe predominant disease remains to be further elucidated. In spite of the limitations of the study, the NETT, through a tremendous coordinated effort, provided valuable outcomes data, answered the pressing questions regarding lung volume reduc-tion surgery that existed at the time, and provided valuable insight into other facets of emphysema physiology and management through direct observation. Based on the NETT findings, in November 2003, CMS published criteria for expanded coverage for LVRS to include non-high-risk patients who demonstrated either upper-lobe predominant emphysema, or non-upper-lobe predominant emphysema and low baseline exercise capacity and who met the screening guidelines.29 This study not only provided data regarding the clinical efficacy of LRVS, but it was instrumental in determining health policy guidelines for the surgical management of emphysema.

Disparity between recent graduates' and experienced surgeons' assessment of time to operative independence.

BACKGROUND: In cardiothoracic surgery, little data exist on the transition to operative independence. We aimed to compare current perceptions of operative autonomy of junior cardiothoracic surgeons and senior colleagues who oversee transitional years. METHODS: An anonymous online survey was sent to currently practicing North American board-certified/eligible cardiothoracic surgeons to assess reported time to operative independence and comfort with cardiothoracic operations. The χ2 test, Fisher exact test, and Mann-Whitney U test were used to compare junior surgeons' self-reported experience to the junior experience as reported by the midcareer and senior surgeons with whom they practiced. Logistic regression was performed to assess factors associated with operative independence. RESULTS: Responses from 436 completed surveys were analyzed (82 juniors and 354 midcareer/seniors). Two hundred fifty-four midcareer/senior surgeons reported on the experience of 531 junior partners. Juniors reported high immediate posttraining comfort with basic cardiac cases and moderate comfort with all other categories. Time to operative independence was significantly different between juniors' self-report and midcareer/senior reports of junior partners except for complex thoracic cases. In multivariable logistic regression analysis, senior, and not midcareer, surgeon status was independently associated with junior operative independence status for cardiac cases and for basic thoracic cases. CONCLUSIONS: Most junior surgeons perceived operative independence with basic thoracic, basic cardiac, and complex cardiac operations earlier in their surgical career than that reported by senior colleagues. Objective measures of operative independence may clarify this discrepancy. This study establishes a baseline by which to compare the effects of integrated 6-year programs on operative independence. The discrepant perceptions may have implications for how training programs prepare graduates for the transition to independent practice.

Advancing the Legislative Priorities of Cardiothoracic Surgeons: The Society of Thoracic Surgeons Political Action Committee.

In the late 1990s, several federal government health policy decisions threatened the viability of thoracic surgery as a specialty. To respond to such decisions, active participation in political processes was given extremely high priority by the Executive Committee of The Society of Thoracic Surgeons (STS). Creation of the STS Political Action Committee (STS-PAC) in 1997 was a part of the platform of participation. The purpose of the STS-PAC is to enhance the Society's voice and stature in health care policymaking. Although the STS-PAC receives voluntary contributions from STS members, on average, only 10% of STS members contribute to the STS-PAC. For the 2015-2016 election cycle, there were 542 contributors to the STS-PAC totaling $273,000. An annual contribution of $100 from every STS member would put the STS-PAC into the top 10 for medical PACs (whereas currently it is ranked 22nd of 28 in the group of physician and dental association PACs). Despite the relatively small dollar amount the STS-PAC directs, its strategic disbursement of these dollars has yielded impressive results. For example, the STS-PAC was able to use its influence to effectively stop the Centers for Medicare and Medicaid Services from implementing a potentially calamitous rule that would effectively end traditional global surgical payments. Other advocacy successes include providing guidance to the Centers for Medicare and Medicaid Services in developing the national coverage determination for transcatheter aortic valve replacement and structuring its complex reimbursement schedule, and ensuring that a provision was included in the bill that would give the STS National Database access to claims data. The STS-PAC is a principal component of the STS' advocacy armamentarium. Despite the many successes of the STS-PAC, with even modest contributions by more STS members, the STS-PAC could become a leading medical PAC, and would give the STS an even stronger presence and voice in Washington, DC. Clearly, contributing to the STS-PAC provides STS members the opportunity to have a voice and an impact on health policy and the care of their patients.

The Society of Thoracic Surgeons National Database 2018 Annual Report.

The Society of Thoracic Surgeons (STS) National Database was established in 1989 as an initiative for quality improvement and patient safety among cardiothoracic surgeons. As of January 1, 2018, the STS National Database has four components, each focusing on a different area of cardiothoracic surgery-adult cardiac surgery, general thoracic surgery, and congenital heart surgery, as well as mechanical circulatory support through the STS Intermacs Database. In December 2015, The Annals of Thoracic Surgery began publishing a monthly series of scholarly articles on outcomes analysis, quality improvement, and patient safety. As part of that series, this article provides an annual summary of the status of the STS National Database as of October 2018 and provides a synopsis of related articles that appeared in The Annals of Thoracic Surgery 2018 series entitled: "Outcomes Analysis, Quality Improvement, and Patient Safety".

Traumatic diaphragmatic injuries.

Although numerous articles have been written over the past two decades with regard to the treatment of traumatic diaphragmatic hernia, little has actually changed during that time. The ability to make the diagnosis has somewhat improved because of the technologic advances in CT; however, it remains true that the best tool to guide the clinician toward the appropriate diagnosis is a high index of suspicion in patients with blunt or appropriate penetrating trauma. Although laparoscopic or thoracoscopic management of such patients may become prevalent with increasing experience, at present the open approach and simple repair remain the mainstays of management. The patient's survival still depends more on the severity of concomitant nondiaphragmatic injuries and in many cases the diaphragmatic laceration is the least worrisome and least morbid of the patient's injuries. Operative repair results in a good outcome in most patients in the absence of other serious injuries.

Surgeon Involvement in Transcatheter Aortic Valve Replacement in the United States: A 2016 Society of Thoracic Surgeons Survey.

BACKGROUND: The Society of Thoracic Surgeons (STS) surveyed cardiothoracic surgeon participants in its Adult Cardiac Surgery Database (ACSD) to learn the extent of surgeon involvement in transcatheter aortic valve replacement (TAVR) procedures. METHODS: An electronic survey was delivered to 2,594 surgeons in June 2016. When the survey closed 2 weeks later, 487 completed surveys had been submitted for a response rate of 18.8%. RESULTS: Among the 487 participants in the ACSD who responded to the survey, 410 (84.2%) reported that TAVR was performed at their institutions. Approximately three-quarters reported that they performed TAVR procedures as part of a heart team (77.5%; 313 of 404), cardiologists and cardiothoracic surgeons were jointly responsible for TAVR referrals (83.7%; 339 of 405), and TAVR programs were administered either jointly by the cardiology and cardiac surgery departments or exclusively by the cardiac surgery department (73.3%; 297 of 405). A majority were involved in the pre-, intra-, and postoperative care of patients undergoing TAVR, with 91.4% (370 of 405) reporting participation in multidisciplinary meetings, at least 50% regularly performing technical aspects in 10 of 11 conduct of operation categories, and 86.6% (266 of 307) caring for patients undergoing TAVR after the procedure. CONCLUSIONS: Cardiac surgeons in the United States are active participants in the management of patients with aortic stenosis as part of the heart team. The STS survey found that not only were they actively involved in the treatment decision-making process but they also played a significant role in the valve procedure, including deployment and postprocedural care. The heart team model continues to evolve and should be expanded into other areas of structural heart disease.

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.

Preoperative workup and postoperative surveillance for patients undergoing pulmonary metastasectomy.

The workup of patients suspected of having pulmonary metastases is complicated by the fact that a high percentage of pulmonary metastases are 6mm or less at presentation. Helical CT scans and high-resolution CT scans currently miss many of the lesions eventually detected at thoracotomy and many of the lesions detected are benign. The follow-up of patients after pulmonary metastasectomy is a controversial topic because of the lack of evidence-based practice guidelines. Though it is unlikely that current follow-up recommendations will ever be tested in randomized controlled trials, meta-analyses of existing retrospective data could improve the quality of the existing literature.

Cutaneous metastatic lung cancer detected with 18F-FDG PET.

A 48-year-old male smoker presented with a chief complaint of persistent cough for three months. A CT scan revealed only a large right paratracheal mass. The plan was to obtain histological confirmation of suspected lung cancer via bronchoscopy and mediastinoscopy. A whole body 18F-FDG (2-deoxy-2-[18F]fluoro-D-glucose) PET Scan was ordered for staging and localization of the most accessible biopsy site. There was a large, intense hypermetabolic focus corresponding to the paratracheal lesion seen on CT, as well as a lesion in the right adrenal gland. There was also a superficial, subcutaneous hypermetabolic lesion in the mid-back. The subcutaneous lesion, which previously had not been noted, was biopsied and proved to be metastatic adenocarcinoma consistent with the lung primary. This case illustrates the clinical utility of reporting soft tissue abnormalities, which may provide an alternative, more readily accessible location for biopsy that is both safer and less expensive than bronchoscopy or mediastinoscopy.

Partial versus complete fundoplication: is there a correct answer?

Gastroesophageal reflux disease is a common disorder, and patients diagnosed with GERD face a lifelong treatment requirement. A surgical antireflux procedure may be offered as an alternative to lifelong treatment with proton-pump inhibitors. Many investigations have been performed to help discover the best surgical alternative to medical management. An ideal antireflux procedure should be safe, effective, durable, and result in minimal complications. Total fundoplication in the form of Nissen fundoplication is the most widely used antireflux operation worldwide. Although its efficacy is well documented, the clinical success rate in terms of reflux control is occasionally compromised by troublesome mechanical side effects. Because of these unsatisfactory symptoms and continued hindered quality of life, the Nissen fundoplication has undergone many modifications. The current standard appears to be the 2 cm floppy Nissen; however, the alternative approach has been the use of a partial fundoplication, most frequently the Toupet procedure. Both the Nissen and Toupet fundoplications have proven to provide relief in the majority of patients, but each has its own drawback. Patients undergoing Nissen fundoplication have a higher incidence of dysphagia early after operation, although this appears to resolve in most. The Toupet, on the other hand, may not be as durable, and may lead to the early re-emergence of symptoms. The problem of post-Nissen dysphagia led many surgeons to believe that the Nissen night be contraindicated in patients who have dysmotility,because it would cause even greater dysphagia; however, recent articles have not demonstrated this to be the case. It seems that the floppy Nissen performed over a large bougie (56-60 Fr) with division of short gastrics and crural closure is an acceptable operation for reflux in both those who have normal motility and those who have mild to moderate dysmotility. Thus, for most patients who have GERD and normal motility, either procedure appears effective in the majority of patients; however, those patients who have severe dysmotilty disorders and who require an antireflux procedure(ie, scleroderma, postmyotomy achalasia) are likely best served with a partial fundoplication.

Lung cancer. Special treatment issues.

This chapter of the Lung Cancer Guidelines addresses patients with particular forms of non-small cell lung cancer that require special considerations. This includes patients with Pancoast tumors, T4N0,1M0 tumors, satellite nodules in the same lobe, synchronous and metachronous multiple primary lung cancers (MPLC), and solitary metastases. For patients with a Pancoast tumor, a multimodality approach, involving chemoradiotherapy and surgical resection, appears optimal provided appropriate staging has been carried out. Patients with central T4 tumors that do not have mediastinal node involvement are uncommon. When carefully staged and selected, however, such patients appear to benefit from resection as part of the treatment as opposed to chemoradiotherapy alone. Patients with a satellite lesion in the same lobe as the primary tumor have a good prognosis and require no modification of the approach to evaluation and treatment from what would be dictated by the primary tumor alone. On the other hand, it is difficult to know how best to treat patients with a focus of the same type of cancer in a different lobe. Although MPLC do occur, the survival results after resection for either a synchronous presentation or a metachronous presentation with an interval of < 4 years between tumors are variable and generally poor, suggesting that many of these patients may have had a pulmonary metastasis rather than a second primary lung cancer. A thorough and careful evaluation of these patients is warranted to try to differentiate between patients with a metastasis and those with a second primary lung cancer, although criteria to distinguish them have not been defined. Finally, some patients with a solitary focus of metastatic disease in the brain or adrenal gland appear to benefit substantially from resection.