Exploring the landscape of oesophageal discontinuity procedures and creation of cervical oesophagostomy in the modern era: a scoping review protocol.

INTRODUCTION: Oesophageal discontinuity remains a challenge for thoracic and foregut surgeons globally. Whether arising emergently after catastrophic oesophageal or gastric disruption or arising in the elective setting in the case of staged reconstruction for esophagectomy or long gap atresia in the paediatric population, comprehensive review of this patient population remains unexplored within the surgical literature.The goal of this scoping review is to map the landscape of literature exploring the creation and takedown of cervical oesophagostomy with the intent to answer four questions (1) What are the primary indications for oesophageal discontinuity procedures? (2) What are the disease-specific and healthcare utilisation outcomes for oesophageal discontinuity procedures? (3) What is the primary indication for reversal procedures? (4) What are the disease-specific and healthcare utilisation outcomes for reversal procedures? METHODS: This review will follow the Arksey and O'Malley (2005) framework for scoping reviews. Paediatric (<18 years old) and adult (>18 years old) patients, who have received a cervical oesophagostomy in the context of a gastrointestinal discontinuity procedure or those who have had reversal of a cervical oesophagostomy, will be included for analysis. We will search MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL) databases for papers from 1990 until 2023. Interventional trials, prospective and retrospective observational studies, reviews, case series and qualitative study designs will be included. Two authors will independently review all titles, abstracts and full texts to determine which studies meet the inclusion criteria. ETHICS AND DISSEMINATION: No ethics approval is required for this review. Results will be disseminated through scientific presentations and relevant conferences targeted for researchers examining upper gastrointestinal/foregut surgery. REGISTRATION DETAILS: This protocol is registered with Open Science Framework (osf.io/s3b4g).

The Lung Microbiome Predicts Mortality and Response to Azithromycin in Lung Transplant Recipients with Chronic Rejection.

Rationale: Chronic lung allograft dysfunction (CLAD) is the leading cause of death after lung transplant, and azithromycin has variable efficacy in CLAD. The lung microbiome is a risk factor for developing CLAD, but the relationship between lung dysbiosis, pulmonary inflammation, and allograft dysfunction remains poorly understood. Whether lung microbiota predict outcomes or modify treatment response after CLAD is unknown. Objectives: To determine whether lung microbiota predict post-CLAD outcomes and clinical response to azithromycin. Methods: Retrospective cohort study using acellular BAL fluid prospectively collected from recipients of lung transplant within 90 days of CLAD onset. Lung microbiota were characterized using 16S rRNA gene sequencing and droplet digital PCR. In two additional cohorts, causal relationships of dysbiosis and inflammation were evaluated by comparing lung microbiota with CLAD-associated cytokines and measuring ex vivo P. aeruginosa growth in sterilized BAL fluid. Measurements and Main Results: Patients with higher bacterial burden had shorter post-CLAD survival, independent of CLAD phenotype, azithromycin treatment, and relevant covariates. Azithromycin treatment improved survival in patients with high bacterial burden but had negligible impact on patients with low or moderate burden. Lung bacterial burden was positively associated with CLAD-associated cytokines, and ex vivo growth of P. aeruginosa was augmented in BAL fluid from transplant recipients with CLAD. Conclusions: In recipients of lung transplants with chronic rejection, increased lung bacterial burden is an independent risk factor for mortality and predicts clinical response to azithromycin. Lung bacterial dysbiosis is associated with alveolar inflammation and may be promoted by underlying lung allograft dysfunction.

Epidemiology of Postoperative Complications After Esophagectomy: Implications for Management.

BACKGROUND: Despite advances in operative techniques and postoperative care, esophagectomy remains a morbid operation. Leveraging complication epidemiology and the correlation of these complications may improve rescue and refine early recovery pathways. METHODS: This study retrospectively reviewed all esophagectomies performed at a tertiary academic center from 2014 to 2021 and quantified the timing of the most common complications. Daily incidence values for index complications were calculated, and a covariance matrix was created to examine the correlation of the complications with each other. Study investigators performed a Cox proportional hazards analysis to clarify the association between early diagnosis of postoperative atrial fibrillation and pneumonia with subsequent anastomotic leak. RESULTS: The study analyzed 621 esophagectomies, with 580 (93.4%) cervical anastomoses and 474 (76%) patients experiencing complications. A total of 159 (25.6%) patients had postoperative atrial fibrillation, and 155 (25.0%) had an anastomotic leak. The median (interquartile range [IQR]) postoperative day of these complications was day 2 (IQR, days 2-3) and day 8 (IQR, days 7-11), respectively. Our covariance matrix found significant associations in the variance of the most common postoperative complications, including pneumonia, atrial fibrillation, anastomotic leak, and readmissions. Early postoperative atrial fibrillation (hazard ratio, 8.1; 95% CI, 5.65-11.65) and postoperative pneumonia (hazard ratio, 3.8; 95% CI, 1.98-7.38) were associated with anastomotic leak. CONCLUSIONS: Maintaining a high index of suspicion for early postoperative complications is crucial for rescuing patients after esophagectomy. Early postoperative pneumonia and atrial fibrillation may be sentinel complications for an anastomotic leak, and their occurrence may be used to prompt further clinical investigation. Early recovery protocols should consider the development of early complications into postoperative feeding and imaging algorithms.

Current Practices in Airway Stent Management: A National Survey of US Practitioners.

BACKGROUND: Despite a growing number of tracheobronchial stent types and indications, complications remain frequent, and high-quality evidence on practices to prevent stent-related complications is lacking. Understanding current management practice is a first step to designing prospective studies to assess whether specific practices aimed at mitigating stent-related complications improve patient-centered outcomes. OBJECTIVES: In this study, we aimed to understand current management strategies following tracheobronchial stenting. METHOD: We performed a nationwide survey of members of the American Association of Bronchology and Interventional Pulmonology (AABIP) and the General Thoracic Surgical Club (GTSC) who place airway stents. The electronic survey captured data on practitioners' demographics, practice setting, airway stent volume, and standard post-stent practices (if any) including the use of medications, mucus clearance devices, surveillance imaging, and surveillance bronchoscopy. RESULTS: One hundred thirty-eight physicians completed the survey. Respondents were majority male (75.4%) and had diverse training (50.0% completed interventional pulmonary fellowship; 18.1% thoracic surgery; 31.9% other stent training). Post-stent management strategies varied markedly across respondents; 75.4% prescribe at least one medication to prevent post-stent complications, 52.9% perform routine surveillance bronchoscopy in asymptomatic patients, 26.1% prescribe mucus clearance regimens, 16.7% obtain routine computed tomography scans in asymptomatic patients, and 8.3% routinely replace their stents prior to stent failure. CONCLUSIONS: In this national survey of practitioners who place airway stents, there was marked heterogeneity in post-stent management approaches. Further studies are needed to identify which, if any, of these strategies improve patient-centered outcomes.

Quantitative assessment of gastric ischemic preconditioning on conduit perfusion in esophagectomy: propensity score weighting study.

BACKGROUND: Gastric ischemic preconditioning prior to esophagectomy has been studied as a method to improve gastric conduit perfusion and reduce anastomotic complications, without conclusive results. The aim of this study is to evaluate the feasibility and safety of gastric ischemic preconditioning in terms of post-operative outcomes and quantitative gastric conduit perfusion. METHODS: Patients who underwent an esophagectomy with gastric conduit reconstruction between January 2015 and October 2022 at a single high-volume academic center were reviewed. Patient characteristics, surgical approach, post-operative outcomes, and indocyanine green fluorescence angiography data (ingress index for arterial inflow and ingress time for venous outflow, and the distance from the last gastroepiploic branch to the perfusion assessment point) were analyzed. Two propensity score weighting methods were used to investigate whether gastric ischemic preconditioning reduces anastomotic leaks. Multiple linear regression analysis was used to evaluate the conduit perfusion quantitatively. RESULTS: There were 594 esophagectomies with gastric conduit performed, with 41 having a gastric ischemic preconditioning. Among 544 with cervical anastomoses, leaks were seen in 2/30 (6.7%) in the ischemic preconditioning group and 114/514 (22.2%) in the control group (p = 0.041). Gastric ischemic preconditioning significantly reduced anastomotic leaks on both weighting methods (p = 0.037 and 0.047, respectively). Ingress index and time of the gastric conduit with ischemic preconditioning were significantly better than those without preconditioning (p = 0.013 and 0.025, respectively) after removing the effect of the distance from the last gastroepiploic branch to the perfusion assessment point. CONCLUSION: Gastric ischemic preconditioning results in a statistically significant improvement in conduit perfusion and reduction in post-operative anastomotic leaks.

Stereotactic ablative radiotherapy before resection to avoid delay for early-stage lung cancer or oligometastases during the COVID-19 pandemic: Pathologic outcomes from the SABR-BRIDGE protocol.

BACKGROUND: During coronavirus disease 2019 (COVID-19)-related operating room closures, some multidisciplinary thoracic oncology teams adopted a paradigm of stereotactic ablative radiotherapy (SABR) as a bridge to surgery, an approach called SABR-BRIDGE. This study presents the preliminary surgical and pathological results. METHODS: Eligible participants from four institutions (three in Canada and one in the United States) had early-stage presumed or biopsy-proven lung malignancy that would normally be surgically resected. SABR was delivered using standard institutional guidelines, with surgery >3 months following SABR with standardized pathologic assessment. Pathological complete response (pCR) was defined as absence of viable cancer. Major pathologic response (MPR) was defined as ≤10% viable tissue. RESULTS: Seventy-two patients underwent SABR. Most common SABR regimens were 34 Gy/1 (29%, n = 21), 48 Gy/3-4 (26%, n = 19), and 50/55 Gy/5 (22%, n = 16). SABR was well-tolerated, with one grade 5 toxicity (death 10 days after SABR with COVID-19) and five grade 2-3 toxicities. Following SABR, 26 patients underwent resection thus far (13 pending surgery). Median time-to-surgery was 4.5 months post-SABR (range, 2-17.5 months). Surgery was reported as being more difficult because of SABR in 38% (n = 10) of cases. Thirteen patients (50%) had pCR and 19 (73%) had MPR. Rates of pCR trended higher in patients operated on at earlier time points (75% if within 3 months, 50% if 3-6 months, and 33% if ≥6 months; p = .069). In the exploratory best-case scenario analysis, pCR rate does not exceed 82%. CONCLUSIONS: The SABR-BRIDGE approach allowed for delivery of treatment during a period of operating room closure and was well-tolerated. Even in the best-case scenario, pCR rate does not exceed 82%.

Lung transplantation for lung cancer: A systematic review of the literature.

BACKGROUND: Lung transplant (LTx) is an accepted treatment for end-stage pulmonary failure. A small proportion of explanted lungs harbor incidentally identified nonsmall cell lung cancers (NSCLC). We review the literature on studies assessing LTx patients found to have NSCLC lung cancer in their explanted lungs, and perform a pooled analysis of outcomes. METHODS: MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials were searched. We included studies assessing outcomes of patients with incidentally identified NSCLC following LTx, or following LTx for diffuse lepidic adenocarcinoma as a primary indication. RESULTS: A total of 1404 articles were reviewed. 17 eligible studies were identified: 14 studies on incidental NSCLC (N = 169), 4 on diffuse lepidic adenocarcinoma (N = 70). Overall survival (OS) for patients with incidentally identified lung cancer at 1-year, 3-year, and 5-year was 60.8% (95%CI 43.7%-77.9%, I2 =81.8%), 25.5% (95%CI 1.6%-49.5%, I2 =93.6%), and 23.0% (95%CI 2.0%-44.0%, I2 =92.0%) respectively. When restricted to those with earlier stage disease, those with stage I or II NSCLC had better 1-year, 3-year, and 5-year OS at 72.7% (95%CI 57.2%-88.2%, I2 =67.3%), 41.6% (95%CI 14.0%-69.1%, I2 =89.1%), and 34.5% (95%CI 8.1%-61.0%, I2 =89.8%), respectively. A sensitivity analysis limited to stage I showed 1-year, 3-year, and 5-year survival of 73.0% (95%CI 56.3%-89.7%), 40.4% (95%CI 110.3%-70.6%), and 35.4% (95%CI 6.2%-64.5%), respectively. The 4 studies on diffuse lepidic adenocarcinoma were too heterogeneous for pooled analysis. CONCLUSIONS: We present a review and pooled analysis examining survival following LTx with incidentally identified NSCLC. Patients with earlier stage incidentally explanted NSCLC had better survival outcomes. OS in the stage I population approximates that of LTx without incidental NSCLC.

Food Deserts Increase Readmission After Esophagectomy for Cancer: A Multi-institutional Study.

BACKGROUND: Food deserts are low-income census tracts with poor access to supermarkets and are associated with worse outcomes in breast, colon, and a small number of esophageal cancer patients. This study investigated residency in food deserts on readmission rates in a multi-institutional cohort of esophageal cancer patients undergoing trimodality therapy. METHODS: A retrospective review of patients who underwent trimodality therapy at 6 high-volume institutions from January 2015 to July 2019 was performed. Food desert status was defined by the United States Department of Agriculture by patient ZIP Code. The primary outcome was 30-day readmission after esophagectomy. Multilevel, multivariable logistic regression was used to model readmission on food desert status adjusted for diabetes, insurance type, length of stay, and any complication, treating the institution as a random factor. RESULTS: Of the 453 records evaluated, 425 were included in the analysis. Seventy-three patients (17.4%) resided in a food desert. Univariate analysis demonstrated food desert patients had significantly increased 30-day readmission. No differences were seen in length of stay, complications, or 30-day mortality. In the adjusted logistic regression model, residing in a food desert remained a significant risk factor for readmission (odds ratio, 2.11; 95% CI, 1.07-4.15). There were no differences in 30-day, 90-day, or 1-year mortality based on food desert status, although readmission was associated with worse 90-day and 1-year mortality. CONCLUSIONS: Food desert residence was associated with 30-day readmission after esophagectomy in patients undergoing trimodality treatment for esophageal cancer in this multi-institutional population. Identification of patients residing in a food desert may allow surgeons to focus preventative interventions during treatment and postoperatively to improve outcomes.

The intersection of race and ethnicity, gender, and primary diagnosis on lung transplantation outcomes.

BACKGROUND: Reducing racial disparities in lung transplant outcomes is a current priority of providers, policymakers, and lung transplant centers. It is unknown how the combined effect of race and ethnicity, gender, and diagnosis group is associated with differences in 1-year mortality and 5-year survival. METHODS: This is a longitudinal cohort study using Standard Transplant Analysis Research files from the United Network for organ sharing. A total of 25,444 patients undergoing first time lung transplantation between 2006 and 2019 in the United States. The primary exposures were lung transplant recipient race and ethnicity, gender, and primary diagnosis group at listing. Multivariable regression models and cox-proportional hazards models were used to determine adjusted 1-year mortality and 5-year survival. RESULTS: Overall, 25,444 lung transplant patients were included in the cohort including 15,160 (59.6%) men, 21,345 (83.9%) White, 2,318 (9.1%), Black and Hispanic/Latino (7.0%). Overall, men had a significant higher 1-year mortality than women (11.87%; 95% CI 11.07-12.67 vs 12.82%; 95% CI 12.20%-13.44%). Black women had the highest mortality of all race and gender combinations (14.51%; 95% CI 12.15%-16.87%). Black patients with pulmonary vascular disease had the highest 1-year mortality (19.77%; 95% CI 12.46%-27.08%) while Hispanic/Latino patients with obstructive lung disease had the lowest (7.42%; 95% CI 2.8%-12.05%). 5-year adjusted survival was highest among Hispanic/Latino patients (62.32%) compared to Black (57.59%) and White patients (57.82%). CONCLUSIONS: There are significant differences in 1-year and 5-year mortality between and within racial and ethnic groups depending on gender and primary diagnosis. This demonstrates the impact of social and clinical factors on lung transplant outcomes.

Wider Gastric Conduit Morphology Is Associated with Improved Blood Flow During Esophagectomy.

BACKGROUND: It remains unclear what is the ideal conduit shape. The aim of this study was to evaluate association between specific gastric conduit morphology, considering width and length, with its perfusion and the incidence of anastomotic leaks after esophagectomy. METHODS: Patients who underwent an esophagectomy with cervical esophagogastric anastomosis between 2015 and 2021 were evaluated. Indocyanine green angiography was performed to evaluate gastric conduit perfusion, and ingress index (arterial inflow) and ingress time (venous outflow) were measured. The conduit width at the middle of the conduit and the short gastric length as the length from the last gastroepiploic branch to the perfusion assessment point were measured. Propensity score matching was performed to compare wide conduits with narrow conduits. Narrow and wide conduits were defined as < 4 and ≥ 5 cm, respectively. RESULTS: Three hundred fifty-eight patients were reviewed. After applying matching, the wide conduits had higher ingress index (48.2 vs 33.3%, p < 0.001) and shorter ingress time (51.2 vs 66.3 s, p = 0.004) compared to the narrow conduits. Including the short gastric length in analysis, creating a wide conduit is a significant factor for better ingress index (p = 0.001), especially when the perfusion assessment point is 5 cm or farther from the last gastroepiploic branch. Anastomotic leaks did not differ between the groups. CONCLUSIONS: Conduit width is a significant factor of gastric conduit perfusion, especially when the estimated anastomotic site was > 5 cm from the last gastroepiploic branch. Wide conduits seem to have better perfusion and creating a wider conduit might reduce anastomotic leaks.

Understanding Racial Differences in Lung Cancer Surgery Through a Statewide Quality Collaborative.

BACKGROUND: Persistent racial disparities in lung cancer incidence, treatment, and survival are well documented. Given the importance of surgical resection for lung cancer treatment, racial disparities in surgical quality were investigated using a statewide quality collaborative. METHODS: This retrospective study used data from the Michigan Society of Cardiothoracic Surgeons General Thoracic database, which includes data gathered for the Society of Thoracic Surgeons General Thoracic Surgery Database at 17 institutions in Michigan. Adult patients undergoing resection for lung cancer between 2015 and 2021 were included. Propensity score-weighting methodology was used to assess differences in surgical quality, including extent of resection, adequate lymph node evaluation, 30-day mortality, and 30-day readmission rate between white and black patients. RESULTS: The cohort included 5073 patients comprising 357 (7%) black and 4716 (93%) white patients. The black patients had significantly higher unadjusted rates of wedge resection than the white patients, but after propensity score-weighting for clinical factors, wedge resection did not differ from lobectomy (odds ratio [OR], 1.07; 95% confidence interval [CI], 0.78-1.49; P = 0.67). The black patients had fewer lymph nodes collected (incidence rate ratio [IRR], 0.77; 95% CI, 0.73-0.81; P < 0.0001) and lymph node stations sampled (IRR, 0.89; 95% CI, 0.84-0.94; P < 0.0001). The black patients did not differ from the white patients in terms of mortality (OR, 0.65; 95% CI, 0.19-2.34; P = 0.55) or readmission (OR, 0.79; 95 % CI, 0.49-1.27; P = 0.32). The black patients had longer hospital stays (OR, 1.08; 95% CI, 1.02-1.14; P = 0.01). CONCLUSION: In a statewide quality collaborative that included high-volume centers, black patients received a less extensive lymph node evaluation, with fewer non-anatomic wedge resections performed, and a more limited lymph node evaluation with lobectomy.

A 44-Year-Old Woman with Dyspnea and Hemoptysis in the Setting of Remote Bariatric Surgery.

CASE PRESENTATION: A 44-year-old woman was transferred to the ED from an outside hospital because of hemoptysis and concern for left-sided pulmonary infiltrate with associated pleural effusion. The patient presented to this outside hospital multiple times over the past 3 months because of left-sided shoulder pain, diffuse myalgias, and supraventricular tachycardia. On her third visit, she was found to have a left-sided pleural effusion and underwent diagnostic and therapeutic thoracentesis; 1.5 L of fluid was removed. Fluid studies reportedly demonstrated an exudative pleural effusion with negative bacterial cultures and no evidence of neoplastic process. The patient was referred to the Rheumatology Department by the outside hospital for suspected underlying autoimmune process. In the months leading up to her current presentation, the patient had been prescribed one prednisone burst and two prednisone tapers. She was then placed on a regimen of 10 mg prednisone daily and 200 mg hydroxychloroquine bid by her primary care doctor. This was tapered by the Rheumatology Department such that the patient was on 7.5 mg of prednisone daily on arrival to this ED. Rheumatologic workup until this point revealed only low titer (1:80) positive antinuclear antibody. Prior to these ED visits, the patient had been otherwise healthy with only a history of a Roux-en-Y gastric bypass 17 years earlier. Aside from recent daily low-dose prednisone use, the patient did not have other preexisting immune compromise or risk factors for aspiration such as seizure disorder, chronic alcohol use, or cognitive impairment. Before her transfer, the patient experienced foul-smelling, maroon-colored hemoptysis as well as anemia that required a higher level of care. On arrival to the ED, she was in acute hypoxic respiratory failure. The patient was intubated emergently and was admitted to the medical critical care unit for further treatment.

Ongoing Controversies in Esophageal Cancer I: Feeding Tubes, Pyloroplasty, Thoracic Duct Clipping.

Reducing perioperative morbidity and mortality following esophagectomy remains central to surgeons' intraoperative decision-making. There remains wide variation in the technical approaches to esophagectomy and the employment of prophylactic strategies to reduce postoperative complications. In this article, we discuss the ongoing controversies related to feeding tube placement, pyloroplasty, and thoracic duct clipping and the evidence regarding these procedures.

Explanted malignancies after lung transplantation: the University of Michigan experience.

The management of patients with an explanted malignancy after lung transplantation is not well understood. We reviewed our institutional experience and outcomes at a single academic medical centre between December 1997 and April 2021 for patients with malignancies of all histologic types identified on explant pathology. Primary lung cancers were reclassified using the 8th Edition TNM staging and the 2021 World Health Organization histologic classification of lung cancers. Of the 733 patients undergoing lung transplantation, 15 (2.05%) were found to have malignancy on the explanted lungs, including 6 (0.82%) primary lung cancers. Four patients were found to have early-stage lung cancers, while 2 patients had advanced-stage IV disease. Survival ranged from 0 to 109 months for the entire cohort with median 23.2 [49.9] months in those with primary lung cancers. There were 2 recurrences following explanted stage I (15 months) and stage IV (53 months) diseases. Other explant pathologies included carcinoid tumourlets in 6 patients, lymphoma in 2 and metastatic leiomyosarcoma in 1. In conclusion, explanted lung malignancies are an infrequent but significant finding on explant pathology. Further data are needed to better characterize and stratify this patient cohort.

Translation of Legislation: Effect Analysis of Michigan Opioid Law on Clinical Practice.

BACKGROUND: To combat almost 450,000 Americans dying of opioid overdose between 1999 and 2018, the Michigan Opioid Laws were implemented on July 1, 2018, to reduce overprescription of opioids. This retrospective study evaluated the effect of this legislation on prescribing patterns after thoracic operations at an academic, tertiary care center. METHOD: Charts of 776 patients undergoing lobectomy, paraesophageal hiatal hernia repair, Nissen fundoplication, or esophagectomy between July 1, 2017, and July 1, 2019, were reviewed. Populations were identified before and after the July 1, 2018 implementation of the Michigan Opioid Laws. Procedure type, analgesic type, total pills, morphine equivalents, and refills and their pill number were independent variables. Patients using opioids for >30 days before operations were excluded. RESULTS: Overall, 629 patients were included in the analysis (324 pre-legislation patients, 305 post-legislation patients). The average number of opioids prescribed to patients at discharge before the legislation was 28.0 pills vs 21.4 pills after (P < .01). Before implementation of the Michigan Opioid Laws, 14.5% of patients received refills, whereas only 5.9% received refills after implementation, reducing the average number of refills per patient from 0.19 to 0.07 (P < .001). Average morphine equivalents and percentage of patients receiving opioids showed no statistical difference. CONCLUSIONS: The implementation of the Michigan Opioid Laws correlated with a change in clinical practice, potentially by reducing the number of pills and refills prescribed per patient, and did not deter providers from prescribing opioids acutely. This suggests that the Michigan Opioid Laws allow prescribing freedom while giving legislative structure encouraging time-conscious tapering. The Michigan Opioid Laws may serve as a model for other states to emulate.

One-Year Mortality Is Not a Reliable Indicator of Lung Transplant Center Performance.

BACKGROUND: In the United States, the Organ Procurement and Transplant Network (OPTN) uses 1-year mortality as the primary measure of transplant center quality. We sought to evaluate the reliability of mortality outcomes in lung transplantation and to compare statistical methods of program performance evaluation. METHODS: We used the Standard Transplant Analysis and Research files from the United Network for Organ Sharing to identify lung transplant recipients from 2013 to 2018 in the United States. We stratified hospitals on the basis of 30-day, 1-year, and 5-year survival by risk adjustment, reliability adjustment with empirical Bayes technique, and hierarchical bayesian mixed effects models currently used by the OPTN. We measured variation in mortality rates and identification of performance outliers between techniques. RESULTS: We identified 12,769 recipients in 69 centers. Reliability adjustment reduced variation in hospital outcomes and had a large impact on hospital mortality rankings. For example, with 1-year mortality, 28% (5 hospitals) of the "best" hospitals (top 25%) and 18% (3 hospitals) of the "worst" hospitals (bottom 25%) were reclassified after reliability adjustment. The overall reliability of 1-year mortality was low at 0.42. Compared with the bayesian method used by the OPTN, reliability adjustment identified fewer outliers. The 5-year survival reached a higher reliability plateau with a lower volume of cases required. CONCLUSIONS: The reliability of 1-year mortality in lung transplantation is low, whereas 5-year survival estimates may be more reliable at lower case volumes. Reliability adjustment yielded more conservative measures of center performance and fewer outliers compared with current bayesian methods.