The Society of Thoracic Surgeons Expert Consensus Document on the Management of Pleural Drains After Pulmonary Lobectomy: Expert Consensus Document.

The Society of Thoracic Surgeons Workforce on Evidence-Based Surgery provides this document on management of pleural drains after pulmonary lobectomy. The goal of this consensus document is to provide guidance regarding pleural drains in 5 specific areas: (1) choice of drain, including size, type, and number; (2) management, including use of suction vs water seal and criteria for removal; (3) imaging recommendations, including the use of daily and postpull chest roentgenograms; (4) use of digital drainage systems; and (5) management of prolonged air leak. To formulate the consensus statements, a task force of 15 general thoracic surgeons was invited to review the existing literature on this topic. Consensus was obtained using a modified Delphi method consisting of 2 rounds of voting until 75% agreement on the statements was reached. A total of 13 consensus statements are provided to encourage standardization and stimulate additional research in this important area.

Routine Implementation of Patient-Reported Outcomes Assessment Into Thoracic Surgery Practice.

BACKGROUND: Patient-reported outcomes (PROs) assessment is a necessary component of surgical outcome assessment and patient care. This study examined the success of routine PROs assessment in an academic-based thoracic surgery practice. METHODS: PROs, measuring pain intensity, physical function, and dyspnea, were routinely obtained using the National Institutes of Health-sponsored Patient-Reported Outcomes Measurement Information System (PROMIS) on all thoracic surgery patients beginning in April 2018 through January 2021. Questionnaires were administered electronically through a web-based platform at home or during the office visit. Completion rates and barriers were measured. RESULTS: A total of 9725 thoracic surgery office visits occurred during this time frame. PROs data were obtained in 6899 visits from a total of 3551 patients. The mean number of questions answered per survey was 22.4 ± 2.2. Overall questionnaire completion rate was 65.7%. A significant decline in survey completion was noted in April 2020, after which adjustments were made to allow for questionnaire completion through a mobile health platform. Overall monthly questionnaire completion rates ranged from 20% (April 2020) to 90% (October 2018). Mean T scores were dyspnea, 41.6 ± 12.3; physical function, 42.7 ± 10.5; and pain intensity, 52.8 ± 10.3. CONCLUSIONS: PROs can be assessed effectively in a thoracic surgery clinic setting, with minimal disruption of clinical activities. Future efforts should focus on facilitating PROs collection from disadvantaged patient populations and scaling implementation across programs.

Tracheostomies of Patients With COVID-19: A Survey of Infection Reported by Health Care Professionals.

BACKGROUND: Health care professionals (HCPs) performing tracheostomies in patients with COVID-19 may be at increased risk of infection. OBJECTIVE: To evaluate factors underlying HCPs' COVID-19 infection and determine whether tracheostomy providers report increased rates of infection. METHODS: An anonymous international survey examining factors associated with COVID-19 infection was made available November 2020 through July 2021 to HCPs at a convenience sample of hospitals, universities, and professional organizations. Infections reported were compared between HCPs involved in tracheostomy on patients with COVID-19 and HCPs who were not involved. RESULTS: Of the 361 respondents (from 33 countries), 50% (n = 179) had performed tracheostomies on patients with COVID-19. Performing tracheostomies on patients with COVID-19 was not associated with increased infection in either univariable (P = .06) or multivariable analysis (odds ratio, 1.48; 95% CI, 0.90-2.46; P = .13). Working in a low- or middle-income country (LMIC) was associated with increased infection in both univariable (P < .001) and multivariable analysis (odds ratio, 2.88; CI, 1.50-5.53; P = .001). CONCLUSIONS: Performing tracheostomy was not associated with COVID-19 infection, suggesting that tracheostomies can be safely performed in infected patients with appropriate precautions. However, HCPs in LMICs may face increased infection risk.

Preoperative Lung Function Is Associated With Patient-Reported Outcomes After Lung Cancer Surgery.

BACKGROUND: Patient quality of life (QOL) is a critical outcomes measure in lung cancer surgery. Patient-reported outcomes (PROs) provide valuable insight into the patient experience and allow measurement of preoperative and postoperative QOL. Our objective was to determine which clinical factors predict differences in QOL, as measured by patient-reported physical function and pain intensity among patients undergoing minimally invasive lung cancer surgery. METHODS: PRO surveys assessing physical function and pain intensity were conducted using instruments from the National Institutes of Health Patient-Reported Outcomes Measurement Information System. PRO surveys were administered to patients undergoing minimally invasive lung cancer resections at preoperative, 1-month, and 6-month postoperative time points, in an academic institution. Linear mixed-effects regression models were constructed to assess the association between clinical variables on PRO scores over time. RESULTS: A total of 123 patients underwent a thoracoscopic lung resection for cancer. Mean age of the cohort was 67 ± 9.6 years, 43% were male, and 80% were White. When comparing clinical variables with PRO scores after surgery, lower diffusing capacity of the lungs for carbon monoxide (Dlco) was associated with significantly worse physical function (P < .01) and greater pain intensity scores (P < .01) at 6 months, with no differences identified at 1 month. No other studied clinical factor was associated with significant differences in PRO scores. CONCLUSIONS: Low preoperative Dlco was associated with significant decreases in PRO after minimally invasive lung cancer surgery. Dlco may be of utility in identifying patients who experience greater decline in QOL after surgery and for guiding surgical decision making.

Association Between Patient Physical Function and Length of Stay After Thoracoscopic Lung Cancer Surgery.

Patient-reported outcomes (PRO) are an ideal method for measuring patient functional status. We sought to evaluate whether preoperative PRO were associated with resource utilization. We hypothesize that higher preoperative physical function PRO scores, measured via the NIH-sponsored Patient Reported Outcome Measurement Information System (PROMIS), are associated with shorter length of stay (LOS). Preoperative physical function scores were obtained using NIH PROMIS in a prospective observational study of patients undergoing minimally invasive surgery for lung cancer. Poisson regression models were constructed to estimate the association between the length of stay and PROMIS physical function T-score, adjusting for extent of resection, age, gender, and race. Due to the significant interaction between postoperative complications and physical function T-score, the relationship between physical function and LOS was described separately for each complication status. A total of 123 patients were included; 88 lobectomy, 35 sublobar resections. Mean age was 67 years, 35% were male, 65% were Caucasian. Among patients who had a postoperative complication, a lower preoperative physical function T-score was associated with progressively increasing LOS (P  value = 0.006). In particular, LOS decreased by 18% for every 10-point increase in physical function T-score. Among patients without complications, T-score was not associated with LOS (P = 0.86). Preoperative physical function measured via PRO identifies patients who are at risk for longer LOS following thoracoscopic lung cancer surgery. In addition to its utility for preoperative counseling and planning, these data may be useful in identifying patients who may benefit from risk-reduction measures.

Percutaneous Tracheostomy With Apnea During Coronavirus Disease 2019 Era: A Protocol and Brief Report of Cases.

OBJECTIVE: To assess feasibility of modified protocol during percutaneous tracheostomy in coronavirus disease 2019 pandemic era. DESIGN: A retrospective review of cohort who underwent percutaneous tracheostomy with modified protocol. SETTINGS: Medical, surgical, and neurologic ICUs. SUBJECTS: Patients admitted in medical, surgical, and neurologic units with prolonged need of mechanical ventilation or inability to liberate from the ventilator. INTERVENTIONS: A detailed protocol was written. Steps were defined to be performed before apnea and during apnea. A feasibility study of 28 patients was conducted. The key aerosol-generating portions of the procedure were performed with the ventilator switched to standby mode with the patient apneic. MEASUREMENTS AND MAIN RESULTS: Data including patient demographics, primary diagnosis, age, body mass index, and duration of apnea time during the tracheostomy were collected. Average ventilator standby time (apnea) during the procedure was 238 seconds (3.96 min) with range 149 seconds (2.48 min) to 340 seconds (5.66 min). Single-use (disposable) bronchoscopes (Ambu A/S [Ballerup, Denmark] or Glidescope [Verathon, Inc., Bothell, WA]) were used during all procedures except in nine. No desaturation events occurred during any procedure. CONCLUSIONS: Percutaneous tracheostomy performed with apnea protocol may help minimize aerosolization, reducing risk of exposure of coronavirus disease 2019 to staff. It can be safely performed with portable bronchoscopes to limit staff and minimize the surfaces requiring disinfection post procedure.

ERAS and patient reported outcomes in thoracic surgery: a review of current data.

Quality-focused, cost-effective, patient-centered care is at the forefront of current healthcare reform. Recent data show that enhanced recovery after surgery (ERAS) results in improved surgical outcomes and decreased hospital costs. As a result, ERAS has been widely accepted among multiple surgical subspecialties as a modality for increasing the value of healthcare delivered to our patients. While this objective data is convincing for practitioners and administrators alike, how ERAS directly impacts the patient experience is unclear. Patient reported outcomes (PRO) are starting to drive patterns of healthcare delivery and influence surgical decision-making. In order to improve surgical outcomes and deliver patient-centered care, it is imperative that clinicians start reviewing objective metrics contained within morbidity and mortality data alongside subjective data regarding patients' experience. This article reviews the current data surrounding both ERAS and PROs within thoracic surgery and investigates how the two concepts are ultimately related.

Patient-Reported Outcomes: Time to Integrate Into Outcomes Reporting?

Historically, surgical outcomes research has focused on objective endpoints that are straightforward to measure and interpret using patient medical records, institutional databases, and national registries. In recent years, such data have been used to drive quality improvement, influence healthcare reform, and impact reimbursement of healthcare spending. In order to continue improving outcomes and deliver high-quality patient-centered care, it is imperative that clinicians review not only objective morbidity and mortality data, but also subjective data regarding patients' experience. Patient-reported outcomes (PRO) are starting to drive patterns of healthcare delivery and influence surgical decision-making. The current article reviews the historical background of PRO, tools for integrating it into surgical outcomes research, current data reported within the literature, and future implications within thoracic surgery.

Patient-Reported Outcomes in Cardiothoracic Surgery.

BACKGROUND: Current studies in cardiothoracic clinical research frequently fail to use end points that are most meaningful to patients, including measures associated with quality of life. Patient-reported outcomes (PROs) represent an underused but important component of high-quality patient-centered care. Our objective was to highlight important principles of PRO measurement, describe current use in cardiothoracic operations, and discuss the potential for and challenges associated with integration of PROs into large clinical databases. METHODS: We performed a literature review by using the PubMed/EMBASE databases. Clinical articles that focused on the use of PROs in cardiothoracic surgical outcomes measurement or clinical research were included in this review. RESULTS: PROs measure the outcomes that matter most to patients and facilitate the delivery of patient-centered care. When effectively used, PRO measures have provided detailed and nuanced quality-of-life data for comparative effectiveness research. However, further steps are needed to better integrate PROs into routine clinical care. CONCLUSIONS: Incorporation of PROs into routine clinical practice is essential for delivering high-quality patient-centered care. Future integration of PROs into prospectively collected registries and databases, including that The Society of Thoracic Surgeons National Database, has the potential to enrich comparative effectiveness research in cardiothoracic surgery.

Excess Cost and Predictive Factors of Esophagectomy Complications in the SEER-Medicare Database.

BACKGROUND: Postoperative complications result in significantly increased health care expenditures. The objective of this study was to examine 90-day excess costs associated with inpatient complications after esophagectomy and their predictive factors, by using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. METHODS: The study examined patients older than 65 years of age with a diagnosis from 2002 to 2009 and who were undergoing esophagectomy for cancer in the SEER-Medicare database. Quantile regression models were fit at 5% intervals for excess 90-day cost associated with perioperative complications while controlling for baseline characteristics. Excess cost was defined as the difference in total cost for patients with versus without the complication. Analyses were stratified by patients' characteristics to identify factors predictive of excess cost. RESULTS: A total of 1,462 patients were identified in the cohort; 51% had at least one complication. Significant excess cost was associated with pulmonary and mechanical wound complications across all quantiles (p < 0.05). Infectious (0.35 to 0.75 quantiles), intraoperative (0.05 to 0.85 quantiles), and systemic (0.30 to 0.85 quantiles) complications were associated with higher costs. Further, excess costs were significantly elevated in the higher quantiles. At the 0.50 quantile (median) of total cost distribution, excess cost in patients with any complication were significantly higher in patients with the following characteristics: transthoracic esophagectomy, emergency esophagectomy, Charlson Comorbidity Index >0, living in a nonmetropolitan area or poorer community, or treated in larger hospitals; no such difference was identified in patients without complications. CONCLUSIONS: Complications after esophagectomy result in significant excess 90-day cost. Efforts at cost reduction and quality improvement will need to focus on reducing complications, in particular pulmonary and infectious, as well as risk factors for higher complication costs.

Hospitalization Costs After Surgery in High-Risk Patients With Early Stage Lung Cancer.

BACKGROUND: We previously reported that early stage lung cancer patients who are considered high risk for surgery can undergo resection with favorable perioperative results and long-term mortality. To further elucidate the role of surgical resection in this patient cohort, this study evaluated the length of stay and total hospitalization cost among patients classified as standard or high risk with early stage lung cancer who underwent pulmonary resection. METHODS: A total of 490 patients from our institutional Society of Thoracic Surgeons data from 2009 to 2013 underwent resection for clinical stage I lung cancer. High-risk patients were identified by American College of Surgeons Oncology Group z4032-z4099 criteria. Demographics, length of stay, and hospitalization cost between high-risk and standard-risk patients undergoing lobectomy and sublobar resection were compared. Univariate analysis was performed using the chi-square test or Fisher's exact test. Multivariate analysis was performed using a linear regressions model. RESULTS: A total of 180 (37%) of patients were classified as high risk. These patients were older (70 years of age vs. 65 years of age; p < 0.0001), had worse forced expiratory volume in 1 second (57% vs. 85%; p < 0.0001), and had worse diffusion capacity of carbon dioxide (47% vs. 77%; p < 0.0001). The baseline cost and length of stay was represented by a thoracoscopic wedge resection in a standard-risk patient. A larger extent of resection, thoracotomy, or high-risk classification increased the cost and length of stay. CONCLUSIONS: Our previous study showed that good clinical outcomes after surgery for early stage lung cancer can be achieved in patients classified as high risk. In this study, although surgery in high-risk patients led to slightly increased costs, these costs seemed negligible when viewed along with the patients' excellent short-term and long-term results. This study suggests that surgical resection on high-risk patients with early stage lung cancer is associated with acceptable hospital lengths of stay and overall cost when compared with standard-risk patients.

Long-term outcomes after near-infrared sentinel lymph node mapping in non-small cell lung cancer.

OBJECTIVE: To report the first analysis of long-term outcomes using near-infrared (NIR) image-guided sentinel lymph node (SLN) mapping in non-small cell lung cancer (NSCLC). METHODS: Retrospective analysis of patients with NSCLC enrolled in 2 prospective phase 1 NIR-guided SLN mapping trials, including an indocyanine green (ICG) dose-escalation trial, was performed. All patients underwent NIR imaging for SLN identification followed by multistation mediastinal lymph node sampling (MLNS) and pathologic assessment. Disease-free (DFS) and overall survival (OS) were compared between patients with NIR+ SLN (SLN group) and those without (non-SLN group). RESULTS: SLN detection, recurrence, DFS, and OS were assessed in 42 patients with NSCLC who underwent intraoperative peritumoral ICG injection, NIR imaging, and MLNS. NIR+ SLNs were identified in 23 patients (SLN group), whereas SLNs were not identified in 19 patients enrolled before ICG dose and camera optimization (non-SLN group). Median follow-up was 44.5 months. Pathology from NIR+ SLNs was concordant with overall nodal status in all 23 patients. Sixteen patients with SLN were deemed pN0 and no recurrences were, whereas 4 of 15 pN0 non-SLN patients developed nodal or distant recurrent disease. Comparing SLN versus non-SLN pN0 patients, the probability of 5-year OS is 100% versus 70.0% (P = .062) and 5-year DFS is statistically significantly improved at 100% versus 66.1% (P = .036), respectively. Among the 11 pN+ patients, 7 were in the SLN group, with >40% showing metastases in the SLN alone. CONCLUSIONS: Patients with pN0 SLNs showed favorable disease-free and overall survival. This preliminary review of NIR SLN mapping in NSCLC suggests that pN0 SLNs may better represent true N0 status. A larger clinical trial is planned to validate these findings.

Patient-Reported Outcomes in Thoracic Surgery.

The existing thoracic surgical literature contains several retrospective and observational studies that include patient-reported outcomes. To deliver true patient-centered care, it will be necessary to universally gather patient-reported outcomes prospectively, including them in routine patient care, clinical registries, and clinical trials.

Pilot Study to Integrate Patient Reported Outcomes After Lung Cancer Operations Into The Society of Thoracic Surgeons Database.

BACKGROUND: A critical gap in The Society of Thoracic Surgeons (STS) Database is the absence of patient-reported outcomes (PRO), which are of increasing importance in outcomes and performance measurement. Our aim was to demonstrate the feasibility of integrating PRO into the STS Database for patients undergoing lung cancer operations. METHODS: The National Institutes of Health Patient Reported Outcome Measurement Information System (PROMIS) includes reliable, precise measures of PRO. We used validated item banks within PROMIS to develop a survey for patients undergoing lung cancer resection. PRO data were prospectively collected electronically on tablet devices and merged with our institutional STS data. Patients were enrolled over 18 months (November 2014 to May 2016). The survey was administered preoperatively and at 1 and 6 months after lung cancer resection. RESULTS: The study included 127 patients. All patients completed the initial postoperative survey, and 108 reached the 6-month follow-up. The most common procedure was video-assisted thoracic lobectomy (55%). At the first postoperative visit, there was a significant increase in pain, fatigue, and sleep impairment and a decrease in physical function. By 6 months, these PRO measures had generally improved toward baseline. CONCLUSIONS: Collecting PRO data from lung cancer surgical patients and integrating the results into an institutional database is feasible. This pilot serves as a model for widespread incorporation of PRO data into the STS Database. Future integration of such data will continue to position the STS National Database as the gold standard for clinical registries. This will be necessary for assessing overall patient responses to different surgical therapies.

Prosthetic Reconstruction of the Chest Wall.

Large chest wall resections can result in skeletal instability, altered respiratory mechanics, and significant cosmetic defects. Here the authors review a variety of prostheses that can be used to reconstruct these defects, the indications for their use, the technique for implantation, and the available data regarding their clinical outcomes.

A novel technique for tumor localization and targeted lymphatic mapping in early-stage lung cancer.

OBJECTIVE: To investigate safety and feasibility of navigational bronchoscopy (NB)-guided near-infrared (NIR) localization of small, ill-defined lung lesions and sentinel lymph nodes (SLN) for accurate staging in patients with non-small cell lung cancer (NSCLC). METHODS: Patients with known or suspected stage I NSCLC were enrolled in a prospective pilot trial for lesion localization and SLN mapping via NB-guided NIR marking. Successful localization, SLN detection rates, histopathologic status of SLN versus overall nodes, and concordance to initial clinical stage were measured. Ex vivo confirmation of NIR+ SLNs and adverse events were recorded. RESULTS: Twelve patients underwent NB-guided marking with indocyanine green of lung lesions ranging in size from 0.4 to 2.2 cm and located 0.1 to 3 cm from the pleural surface. An NIR+ "tattoo" was identified in all cases. Ten patients were diagnosed with NSCLC and 9 SLNs were identified in 8 of the 10 patients, resulting in an 80% SLN detection rate. SLN pathologic status was 100% sensitive and specific for overall nodal status with no false-negative results. Despite previous nodal sampling, one patient was found to have metastatic disease in the SLN alone, a 12.5% rate of disease upstaging with NIR SLN mapping. SLN were detectable for up to 3 hours, allowing time for obtaining a tissue diagnosis and surgical resection. There were no adverse events associated with NB-labeling or indocyanine green dye itself. CONCLUSIONS: NB-guided NIR lesion localization and SLN identification was safe and feasible. This minimally invasive image-guided technique may permit the accurate localization and nodal staging of early stage lung cancers.

Midesophageal Pulsion Diverticulum Resulting From Hypercontractile (Jackhammer) Esophagus.

We report a patient with significant dysphagia from hypercontractile "jackhammer" esophagus and a midesophageal pulsion diverticulum. This was treated with a thoracoscopic diverticulectomy and a long esophageal myotomy sparing the lower esophageal sphincter (LES). We describe the clinical diagnosis and surgical treatment of this uncommon esophageal motility disorder. To our knowledge, this is the first report in the literature of a midesophageal diverticulum caused by jackhammer esophagus. We propose that in the setting of normal LES function, successful treatment should include diverticulectomy with an LES-sparing myotomy.

Time is Money: Hospital Costs Associated With Video-Assisted Thoracoscopic Surgery Lobectomies.

BACKGROUND: Proposed changes in health care will place an increasing burden on surgeons to care for patients more efficiently to minimize cost. We reviewed costs surrounding video-assisted thoracoscopic surgery (VATS) lobectomies to see where changes could be made to ensure maximum value. METHODS: We queried The Society of Thoracic Surgeons database for all VATS lobectomies performed for lung cancer from January 2011 to December 2013. Clinical data were linked with hospital financial data to determine hospital expenditures for each patient. RESULTS: In all, 263 VATS lobectomies were included. Mean operating room time was 236 minutes, and median length of stay was 4 days. Mean hospital cost was $19,769. The majority of cost (58%) was attributed to operating room and floor costs (length of stay), and the majority of operating room costs were secondary to room rate and staplers. A total of 77 complications, as defined by STS, occurred in the cohort; 41 patients had only one complication, 11 patients had two complications, and 6 patients had three or more complications. The occurrence of one complication was associated with a net loss of $496 whereas two complications in a patient led to a $3,882 net loss. Overall, complications were independently correlated with significant cost increases. CONCLUSIONS: Our study shows that the most significant costs associated with VATS lobectomies relate to operating room time, stapler use, floor charges, and cost associated with complications. Cost-reducing strategies will need to concentrate on optimizing operating room times and reducing length of stay while simultaneously minimizing complications.

Survival After Sublobar Resection versus Lobectomy for Clinical Stage IA Lung Cancer: An Analysis from the National Cancer Data Base.

BACKGROUND: Recent data have suggested possible oncologic equivalence of sublobar resection with lobectomy for early-stage non-small-cell lung cancer (NSCLC). Our aim was to evaluate and compare short-term and long-term survival for these surgical approaches. METHODS: This retrospective cohort study utilized the National Cancer Data Base. Patients undergoing lobectomy, segmentectomy, or wedge resection for preoperative clinical T1A N0 NSCLC from 2003 to 2011 were identified. Overall survival (OS) and 30-day mortality were analyzed using multivariable Cox proportional hazards models, logistic regression models, and propensity score matching. Further analysis of survival stratified by tumor size, facility type, number of lymph nodes (LNs) examined, and surgical margins was performed. RESULTS: A total of 13,606 patients were identified. After propensity score matching, 987 patients remained in each group. Both segmentectomy and wedge resection were associated with significantly worse OS when compared with lobectomy (hazard ratio: 1.70 and 1.45, respectively, both p < 0.001), with no difference in 30-day mortality. Median OS for lobectomy, segmentectomy, and wedge resection were 100, 74, and 68 months, respectively (p < 0.001). Finally, sublobar resection was associated with increased likelihood of positive surgical margins, lower likelihood of having more than three LNs examined, and significantly lower rates of nodal upstaging. CONCLUSION: In this large national-level, clinically diverse sample of clinical T1A NSCLC patients, wedge and segmental resections were shown to have significantly worse OS compared with lobectomy. Further patients undergoing sublobar resection were more likely to have inadequate lymphadenectomy and positive margins. Ongoing prospective study taking into account LN upstaging and margin status is still needed.