Protocol for the derivation and external validation of a 30-day postoperative pulmonary complications (PPCs) risk prediction model for elderly patients undergoing thoracic surgery: a cohort study in southern China.

INTRODUCTION: Postoperative pulmonary complications (PPCs) occur after up to 60% of non-cardiac thoracic surgery (NCTS), especially for multimorbid elderly patients. Nevertheless, current risk prediction models for PPCs have major limitations regarding derivation and validation, and do not account for the specific risks of NCTS patients. Well-founded and externally validated models specific to elderly NCTS patients are warranted to inform consent and treatment decisions. METHODS AND ANALYSIS: We will develop, internally and externally validate a multivariable risk model to predict 30-day PPCs in elderly NCTS patients. Our cohort will be generated in three study sites in southern China with a target population of approximately 1400 between October 2021 and December 2023. Candidate predictors have been selected based on published data, clinical expertise and epidemiological knowledge. Our model will be derived using the combination of multivariable logistic regression and bootstrapping technique to lessen predictors. The final model will be internally validated using bootstrapping validation technique and externally validated using data from different study sites. A parsimonious risk score will then be developed on the basis of beta estimates derived from the logistic model. Model performance will be evaluated using area under the receiver operating characteristic curve, max-rescaled Brier score and calibration slope. In exploratory analysis, we will also assess the net benefit of Probability of PPCs Associated with THoracic surgery in elderly patients score in the complete cohort using decision curve analysis. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the Institutional Review Board of the Affiliated Cancer Hospital and Institute of Guangzhou Medical University, the Second Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine and the University of Hongkong-Shenzhen Hospital, respectively. The final risk prediction model will be published in an appropriate journal and further disseminated as an online calculator or nomogram for clinical application. Approved and anonymised data will be shared. TRIAL REGISTRATION NUMBER: ChiCTR2100051170.

Preoperative evaluation in thoracic surgery: limits of the patient's functional operability and consequence for perioperative anaesthesiologic management.

PURPOSE OF REVIEW: Preoperative evaluation of older and more morbid patients in thoracic surgery is getting more advanced. In this context, early risk stratification has a crucial role for adequate informed decision-making, and thus for generating favourable effects of clinical outcome. RECENT FINDINGS: Recent findings confirm that many risk factors impair mortality and morbidity beyond classical medical findings like results of lung function tests and values of the revised cardiac risk index. Especially results from holistic views on patients' functional status like frailty assessments are linked with long-term survival after lung resection. SUMMARY: A comprehensive risk stratification by anaesthesiologists generates valuable guidance for the best strategy of clinical treatment. This includes preoperative, peri-operative and postoperative interventions, provided by interdisciplinary healthcare providers, resulting in an Early Risk Stratification and Strategy ('ERSAS') pathway.

Impact of a Thoracic Multidisciplinary Conference on Lung Cancer Outcomes.

BACKGROUND: With the complexity of cancer treatment rising, the role of multidisciplinary conferences (MDCs) in making diagnostic and treatment decisions has become critical. This study evaluated the impact of a thoracic MDC (T-MDC) on lung cancer care quality and survival. METHODS: Lung cancer cases over 7 years were identified from the Roswell Park cancer registry system. The survival rates and treatment plans of 300 patients presented at the MDC were compared with 300 matched patients. The National Comprehensive Cancer Network (NCCN) guidelines were used to define the standard of care. The compliance of care plans with NCCN guidelines was summarized using counts and percentages, with comparisons made using the Fisher exact test. Survival outcomes were summarized using Kaplan-Meier methods. RESULTS: There was improvement in median overall survival (36.9 vs 19.3 months; P < .001) and cancer-specific survival (48 vs 28.1 months; P < .001) for lung cancer patients discussed at the T-MDC compared with controls. These differences were statistically significant in patients with stages III/IV disease but not in patients with stages I/II disease. The NCCN guidelines compliance rate of treatment plans improved from 80% to 94% (P < .001) after MDC discussion. MDC recommendations resulted in treatment plan changes in 123 of 300 patients (41%). CONCLUSIONS: Our results suggest that lung cancer patients have a survival benefit from MDC discussion compared with controls. Patients with advanced disease (stages III and IV) benefited the most. Further research is necessary to understand the precise mechanisms that drive these results.

Autologous blood pleurodesis for the treatment of postoperative air leaks. A systematic review and meta-analysis.

BACKGROUND: Postoperative air leaks are a common complication after lung surgery. They are associated with prolonged hospital stay, increased postoperative pain and treatment costs. The treatment of prolonged air leaks remains controversial. Several treatments have been proposed including different types of sealants, chemical pleurodesis, or early surgical intervention. The aim of this review was to analyze the impact of autologous blood pleurodesis in a systematic way. METHODS: A systematic review of the literature was conducted until July 2020. Studies with more than five adult patients undergoing lung resections were included. Studies in patients receiving blood pleurodesis for pneumothorax were excluded. The search strategy included proper combinations of the MeSH terms "air leak", "blood transfusion" and "lung surgery". RESULTS: Ten studies with a total of 198 patients were included in the analysis. The pooled success rate for sealing the air leak within 48 h of the blood pleurodesis was 83.7% (95% CI: 75.7; 90.3). The pooled incidence of the post-interventional empyema was 1.5%, with a pooled incidence of post-interventional fever of 8.6%. CONCLUSIONS: Current evidence supports the idea that autologous blood pleurodesis leads to a faster healing of postoperative air leaks than conservative treatment. The complication rate is very low. Formal recommendations on how to perform the procedure are not possible with the current evidence. A randomized controlled trial in the modern era is necessary to confirm the benefits.

Effects of Inspiratory Muscle Training Using an Electronic Device on Patients Undergoing Cardiac Surgery: A Randomized Controlled Trial

Abstract Background Cardiac surgery causes pathophysiological changes that favor the occurrence of pulmonary and functional complications. Objective To investigate the effects of inspiratory muscle training (IMT) with an electronic device on patients undergoing cardiac surgery. Methods A randomized controlled trial was conducted with 30 adult patients undergoing elective cardiac surgery. A control group (CG) received conventional physical therapy care, and an intervention group (IG) received IMT using the POWERbreathe K5® electronic device. Two daily sessions of physical therapy were performed at the intensive care unit and one daily session at the ward until the sixth postoperative day. The following variables were measured preoperatively and on the sixth postoperative day, in both groups: inspiratory muscle strength, dynamic inspiratory muscle strength, and peak inspiratory flow. Data distribution was evaluated by the Shapiro-Wilk test. Analysis of variance was used, and the results were considered statistically significant when p < 0.05. Results Maximal inspiratory pressure (71.7 ± 17.1 cmH2O vs 63.3 ± 21.3 cmH2O; p = 0.11], S-index (52.61 ± 18.61 vs 51.08 ± 20.71), and peak inspiratory flow [(2.94 ± 1.09 vs 2.79 ± 1.26)] were maintained in the IG but had a significant reduction in the CG. Conclusion IMT performed with an electronic device was effective at maintaining inspiratory muscle strength, dynamic inspiratory muscle strength, and peak inspiratory flow when compared to conventional physical therapy. Int J Cardiovasc Sci. 2020; [online].ahead print, PP.0-0

Impact of the integrated comprehensive care program post-thoracic surgery: A propensity score-matched study.

OBJECTIVE: Thoracic surgery is associated with significant rates of postoperative morbidity and postdischarge return to the hospital or emergency department (ED). This study aims to assess the impact of a novel integrated patient-centered, hospital-based multidisciplinary community program (Integrated Comprehensive Care [ICC]) on postdischarge outcomes in patients undergoing thoracic surgery compared to routine care. METHODS: This was a retrospective cohort study of patients who underwent surgical resection for lung malignancies at a tertiary care center from 2010 to 2014. Patients were divided into 2 cohorts based on their enrollment in the ICC program (intervention cohort; 2012-2014) or routine postoperative care (control cohort; 2010-2012). Propensity score matching was performed to match the 2 cohorts. The impact of the ICC program on postoperative length of stay (LOS), rate of ED visits, readmissions, and mortality within the first 60 days was assessed. RESULTS: Of the 1288 patients included in this study, 658 (51.1%) were male patients with mean age of 64 years (standard deviation 14.1 years). After propensity score matching, 478 patients were enrolled in the ICC cohort and 592 were enrolled as controls. The ICC cohort had significantly shorter LOS (4 days, vs 5 days in controls, P = .001), lower rate of 60-day ED visits (9.8% vs 28.4% in controls, P < .001), and readmissions (6.9% vs 8.6% in controls, P < .001). The 60-day mortality was also significantly lower in the ICC cohort compared with the control group (0.6% vs 0.8% in controls, P < .001). CONCLUSIONS: The ICC program is associated with shorter LOS, fewer ED visits and readmissions after discharge, and ultimately may decrease postoperative mortality.

Characteristics of Matriculants to Thoracic Surgery Residency Training Programs.

BACKGROUND: Thoracic surgery (TS) residency positions are in high demand. There is no study describing the nationwide attributes of successful matriculants in this specialty. We examined the characteristics of TS resident applicants and identified factors associated with acceptance. METHODS: Applicant data from 2014 to 2017 application cycles was extracted from the Electronic Residency Application System and stratified by matriculation status. Medical education, type of general surgery residency, and research achievements were analyzed. The number of peer-reviewed publications and the corresponding impact factor for the journals where they were published were quantified. RESULTS: There were 492 applicants and 358 matriculants. The overall population was primarily male (79.5%), white (55.1%), educated at United States allopathic medical schools (66.5%), and trained at university-based general surgery residencies (59.6%). Education at United States allopathic schools (odds ratio [OR], 2.54; P < .0001), being a member of the American Osteopathic Association (OR, 3.27; P = .021), general surgery residency affiliation with a TS residency (OR, 2.41; P = .0003) or National Cancer Institute designated Comprehensive Cancer Center (OR, 1.76; P = .0172), and being a first-time applicant (OR, 4.71, P < .0001) were independently associated with matriculation. Matriculants published a higher number of manuscripts than nonmatriculants (median of 3 vs 2, P < .0001) and more frequently published in higher impact journals (P < .0001). CONCLUSIONS: Our study includes objective and quantifiable data from recent application cycles and represents an in-depth examination of applicants to TS residency. The type of medical school and residency, as well as academic productivity, correlate with successful matriculation.

Therapeutic Application of Cannabis in Medicine and Its Relevance to Thoracic Surgery.

BACKGROUND: Cannabis is the most commonly used illicit substance in the United States. As cannabis use rises in popularity and its legalization continues to expand, the scientific community must address the controversy between beneficial and adverse effects of cannabis consumption. METHODS: We performed a comprehensive literature review to study the medicinal and pathologic effects of cannabis use, with emphasis on its association with cancer pathophysiology and thoracic surgery. RESULTS: We found evidence that cannabis products often contain carcinogenic materials and that their use is associated with the development of certain head and neck cancers, but not lung cancer. Indeed, several in vitro and in vivo studies have demonstrated that cannabis may have a therapeutic role in cancer given the antiproliferative effects of its active compounds such as δ-9-tetrahydrocannabinol. Cannabis-derived products have also been shown to be effective treatments for chronic pain, neuropathy, spasticity, and as antiemetics. CONCLUSIONS: We acknowledge that additional studies are required to elucidate the long-term effects of cannabis products and that many potential biases and limitations exist in the literature due to self-reporting and limited survey studies. Appropriate stewardship over cannabis use among our patient population will likely determine its full implications in both oncologic and perioperative outcomes.

Thoracic Surgery during Coronavirus Disease 2019 (COVID-19): The Experience of a Level 1 Trauma Center.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a novel coronavirus primarily affecting the respiratory system, was initially diagnosed in Wuhan, China, in late 2019. Identified as coronavirus disease 2019 (COVID-19) by the World Health Organization, the virus rapidly became a global pandemic. The effects on health care worldwide were unprecedented as countries adapted services to treat masses of critically ill patients.The aim of this study is to analyze the effect that the COVID-19 pandemic had on thoracic surgery at a major trauma center during peak prevalence. METHODS: Prospective unit data were collected for all patients who underwent thoracic surgery during March 2020 until May 2020 inclusive. Retrospective data were collected from an earlier comparable time period as a comparison. RESULTS: In the aforementioned time frame, 117 thoracic surgical operations were performed under the care of four thoracic surgeons. Six operations were performed on three patients who were being treated for SARS-CoV-2. One operation was performed on a patient who had recovered from SARS-CoV-2. There were no deaths due to SARS-CoV-2 in any patient undergoing thoracic surgery. CONCLUSION: This study demonstrates that during the first surge of SARS-CoV-2, it was possible to adapt a thoracic oncology and trauma service without increase in mortality due to COVID-19. This was only possible due to a significant reduction in trauma referrals, cessation of benign and elective work, and the more stringent reprioritization of cancer surgery. This information is vital to learn from our experience and prepare for the predicted second surge and any similar future pandemics we might face.

COVID-19 guidance for triage of operations for thoracic malignancies: A consensus statement from Thoracic Surgery Outcomes Research Network.

The extraordinary demands of managing the COVID-19 pandemic has disrupted the world's ability to care for patients with thoracic malignancies. As a hospital's COVID-19 population increases and hospital resources are depleted, the ability to provide surgical care is progressively restricted, forcing surgeons to prioritize among their cancer populations. Representatives from multiple cancer, surgical, and research organizations have come together to provide a guide for triaging patients with thoracic malignancies as the impact of COVID-19 evolves as each hospital.

Enhanced Recovery After Thoracic Surgery.

Enhanced recovery pathways (ERPs), used across multiple surgical subspecialties, is a multidisciplinary delivery of perioperative care designed to lessen the psychological stress of patients undergoing surgery. Thoracic ERP has been implemented but is not widespread, and variations exist between programs. Evidence of the benefit of thoracic ERP is emerging. This article presents common components of a thoracic surgery ERP and reviews contemporary outcomes.

Surgical treatment of pleural recurrence of thymoma: is hyperthermic intrathoracic chemotherapy worthwhile?

OBJECTIVES: Recurrence of thymoma is described in 10-30% of cases after surgical resection. Iterative surgery for thymoma pleural relapses (TPRs) is often part of a multimodal treatment. Hyperthermic intrathoracic chemotherapy (HITHOC) following macroscopic radical surgery is an option that combines the effects of mild hyperthermia with those of chemotherapeutic agents. We evaluated the effectiveness of surgery + HITHOC, compared with surgery alone, in the treatment of TPR. METHODS: We retrospectively collected data of all patients who underwent surgery for TPR in our centre from 2005 to 2017. Relapses were treated by partial pleurectomy with radical intent, followed by HITHOC when not contraindicated. Patients were divided into 2 groups: surgery + HITHOC and surgery alone. We collected demographic and clinical data and analysed postoperative results together with oncological outcomes. RESULTS: Forty patients (27: surgery + HITHOC, 13: surgery alone), mean age 49.8 (±13.7) years, were included in this study. There were no perioperative deaths. We experienced 33.3% perioperative morbidity in the surgery + HITHOC group compared with 23.1% in the surgery alone group (P = 0.71). The overall survival rate was comparable between the 2 groups (P = 0.139), whereas the local disease-free interval was 88.0 ± 15 months in the surgery + HITHOC group and 57 ± 19.5 months in the surgery alone group (P = 0.046). The analysis of factors affecting the outcomes revealed that radical surgery is related with a better survival rate whereas the local disease-free interval was significantly influenced by HITHOC. CONCLUSIONS: The safety and feasibility of HITHOC in the treatment of TPR are already known, even if it should be reserved for selected patients. Surgery + HITHOC seems to be associated with a longer local disease-free time compared to surgery alone.

The effect of inhalation aromatherapy in patients undergoing cardiac surgery: A systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: The goal of this study was to synthesize evidence regarding the efficacy of inhalation aromatherapy in patients undergoing cardiac surgery. METHODS: We conducted an electronic search of four authentic databases. Randomized controlled trials (RCTs), which compared inhalation aromatherapy versus control in patients undergoing cardiac surgery, were included. Data were extracted from eligible studies and pooled in a meta-analysis model. We sought to evaluate anxiety, pain, stress, and vital signs including heart rate, systolic and diastolic blood pressure. RESULTS: Nine RCTs were included in this study with a total of 656 patients. Our analysis showed inhalation aromatherapy was significantly effective in reducing anxiety (MD= -3.11, 95 % CI [-5.26, -0.96], p = 0.005), and pain (MD= -0.83, 95 % CI [-1.59, -0.07], p = 0.03) in patients undergoing cardiac surgery. Additionally, inhalation aromatherapy significantly reduced heart rate compared to control group (MD= -5.49, 95 % CI [-9.07, -1.81], p = 0.003). However, no significant differences were found between both groups in mental stress, systolic and diastolic blood pressure. CONCLUSION: Inhalation aromatherapy administration especially with lavender can significantly reduce anxiety, pain, and heart rate in patients performed cardiac surgery. However, it is not associated with significant differences in systolic and diastolic blood pressure. Further studies are needed to confirm our results.

The Role of Regional Collaboratives in Quality Improvement: Time to Organize, and How?

Over the last 12 years, surgeon representatives from the 33 participating hospitals of the Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative (MSTCVS-QC), along with data specialists, surgical and quality improvement (QI) teams, have met at least 4 times a year to improve health-care quality and outcomes of cardiac and general thoracic surgery patients. The MSTCVS-QC nature of interactive learning has allowed all members to examine current data from each site in an unblinded manner for benchmarking, learn from their findings, institute clinically meaningful changes in survival and health-related quality of life, and carefully follow the effects. These meetings have resulted in agreement on various interventions to improve patient selection, periprocedural strategies, and adherence with evidence-based directed medication regimens, Factors contributing to the quality movement across hospitals include statewide-recognized clinicians who are eager to involve themselves in QI initiatives, dedicated health-care professionals at the hospital level, trusting environments in which failure is only a temporary step on the way toward achieving QI goals, real-time analytics of accurate data, and payers who strongly support QI efforts designed to improve outcomes.

Acupressure on Anxiety and Sleep Quality After Cardiac Surgery: A Randomized Controlled Trial.

PURPOSE: To determine the effect of acupressure on anxiety and sleep quality after cardiac surgery. DESIGN: A randomized pre-post test control group design. METHODS: Patients after cardiac surgery were divided into two groups: the intervention group (n = 50), who received acupressure on four different acupoints plus standard care, and the control group (n = 50), who received only standard care. Patients were admitted to the surgical clinic from the intensive care unit after 3 or 4 days of surgery. The levels of anxiety and sleep quality were evaluated during three postoperative days starting from their first day in the surgical clinic. FINDINGS: Among the patients in the intervention group, the usage of acupressure decreased the level of anxiety and increased the sleep quality significantly compared with the control group (P < .05). CONCLUSIONS: Our findings showed that acupressure decreased the level of anxiety and improved the sleep quality in the surgical clinic after cardiac surgery.

Intervention Development Process for a Pragmatic Randomized Controlled Trial: The Thoracic Peri-Operative Integrative Surgical Care Evaluation Trial.

BACKGROUND: Use of complementary therapies is high among people with cancer despite research gaps. The Thoracic Peri-Operative Integrative Surgical Care Evaluation (POISE) Trial will evaluate the impact of an integrative care intervention delivered by naturopathic doctors (NDs) in conjunction with usual care for patients undergoing surgery for lung, gastric, and esophageal cancer. OBJECTIVES: To describe the multistep, multidisciplinary process of defining the integrative care intervention to be used in the Thoracic POISE trial using a principle-based approach that is pragmatic, holistic, safe, feasible, evidence driven, and consensus based. METHODS: An Intervention Development Committee (IDC) made up of a multidisciplinary team of health care providers (NDs, surgeons, oncologists, nurses, dietitians, physiotherapists, pharmacists, and psychologists), researchers, and patients was established to oversee the process. Potential intervention components were identified through a clinical practice survey and expert opinion. Systematic literature reviews were conducted and scores assigned based on the following criteria: usage, safety, goals, feasibility/scalability, and evidence. The IDC selected an intervention to be piloted that consists of a standard palette including core and optional components. Safety, known risks, and interactions with pharmaceuticals were evaluated using industry and professional monographs, a scoping literature review, and consultations with hospital pharmacists. RESULTS: The clinical practice survey and expert opinion identified 28 components for consideration. Following literature reviews, scoring, consensus from the IDC, and safety and interaction considerations, an intervention palette consisting of core and optional components was defined. The intervention options vary based on the patient's phase of treatment and symptom-specific needs. The intervention includes supplements, physical recommendations (exercise), nutritional counseling, and psychological support (audio scripts). CONCLUSION: Through a multistep, multidisciplinary process an integrative care intervention was developed for the Thoracic POISE trial. The intervention will be piloted in a single-arm feasibility study, followed by a single-center randomized controlled trial (RCT), and finally a multicenter RCT.

Treatment of malignant pleural mesothelioma with chemotherapy preceding versus after surgical resection.

OBJECTIVES: There are 2 main treatment paradigms recognized by the National Comprehensive Cancer Network for resectable malignant pleural mesothelioma (MPM): induction chemotherapy followed by resection (IC/R), and up-front resection with postoperative chemotherapy (R/PC). These paradigms are being compared in an accruing randomized phase II trial. In the absence of such completed trials, in this study we evaluated overall survival (OS) and postoperative outcomes of IC/R and R/PC. METHODS: The National Cancer Database was queried for newly diagnosed epithelioid/biphasic MPM. Metastatic, node-positive, and/or cT4 disease was excluded, along with nondefinitive surgery and lack of chemotherapy. Multivariable logistic regression ascertained factors independently associated with induction chemotherapy delivery. Kaplan-Meier analysis was used to evaluate OS between cohorts; multivariable Cox proportional hazards modeling was used to assess factors associated with OS. Survival was also evaluated between propensity-matched populations. Last, postoperative outcomes were assessed between groups. RESULTS: Overall, 361 patients (182 IC/R, 179 R/PC) were analyzed. Temporal trends revealed that IC/R is decreasing over time. Survival of the IC/R cohort was similar to that of R/PC patients (20.9 vs 21.7 months; P = .500); this persisted after propensity matching (20.8 vs 22.0 months; P = .270). However, patients who underwent IC/R experienced longer postoperative hospitalization (median 7 days vs 6 days; P = .001) and higher 30-day mortality (3.3% vs 0%; P = .020). CONCLUSIONS: To our knowledge, this is the only comparative investigation of the 2 major management paradigms of operable MPM. IC/R regimens are decreasing over time in the United States. Although associated with survival similar to R/PC, IC/R might be associated with worse postoperative outcomes. Careful induction chemotherapy patient selection is thus highly recommended.