Does Race or Ethnicity Impact Complications After Pulmonary Lobectomy for Patients With Lung Cancer?

BACKGROUND: Racial disparity in surgical access and postoperative outcomes after pulmonary lobectomy continues to be a concern and target for improvement; however, evidence of independent impact of race on complications is lacking. The objective of this study was to investigate the impact of race/ethnicity on surgical outcomes after lobectomy for lung cancer and estimate the distribution of racial/ethnic groups among expected resectable lung cancer cases using a large national database. METHODS: Patients who underwent lobectomy for lung cancer between 2005 and 2016 were identified in the American College of Surgeon National Surgical Quality Improvement Program. Preoperative characteristics and postoperative outcomes were compared between race/ethnicity groups in all patients and in propensity-matched cohorts, controlling for pertinent risk factors. Distribution of each race/ethnicity in the database was calculated relative to estimated numbers of patients with resectable lung cancer in the United States. RESULTS: A total of 10,202 patients (age 67.6 ± 9.7, 46.7% male, 86.4% white) underwent nonemergent lobectomy (46.8% thoracoscopic). Blacks had higher rates of baseline risk factors. In propensity score-matched cohorts of whites, blacks, and Hispanics/Asians (n = 498 each), postoperatively, blacks had higher rates of prolonged intubation and longer hospital stay while whites had a higher rate of pneumonia. Race was independently associated with these adverse outcomes on multivariate analysis. Proportion of blacks and Hispanics in the American College of Surgeon National Surgical Quality Improvement Program was lower than their respective proportion of resectable lung cancer in the United States. CONCLUSIONS: In a large national-level surgical database, there was lower than expected representation of black and Hispanic patients. Black race was independently associated with extended length of stay and prolonged intubation, whereas white was independently associated with postoperative pneumonia.

Five-Year Experience with VATS Versus Thoracotomy Segmentectomy for Lung Tumor Resection.

OBJECTIVE: Segmentectomy for lung tumors has been performed with either video-assisted thoracoscopic surgery (VATS) or thoracotomy; however, there is a lack of contemporary, multicenter study that compares both approaches. The aim of this study was to compare the 30-day surgical outcomes of VATS versus thoracotomy for segmentectomy using a large national database. METHODS: We performed a retrospective analysis of prospectively maintained American College of Surgeons National Surgical Quality Improvement Program database. Patients who underwent segmentectomy for benign or malignant tumors between 2013 and 2017 were included and divided into 2 groups based on whether they received a thoracotomy or VATS approach. All VATS patients were then into 2 subgroups: early (2013 to 2015) and late (2016 to 2017). Propensity-matched analysis was conducted, and the perioperative variables and outcomes were compared. RESULTS: A total of 1,785 patients met the inclusion criteria. VATS segmentectomy was associated with shorter hospital stays (3.9 vs 5.8 days, P < 0.001) and higher rates of home discharge (94% vs 89%, P = 0.002) compared to thoracotomy segmentectomy. VATS was also associated with less postoperative pneumonia (2.8% vs 5.8%, P = 0.007), unplanned intubation (1.5% vs 3.5%, P = 0.016), prolonged intubation (0.6% vs 2.7%, P = 0.001), transfusion requirement (1.7% vs 5.8%, P < 0.001), and deep venous thrombosis (0.1% vs 1.1%, P = 0.03). Compared to the earlier VATS group, the late group was associated with less cardiac arrests (0% vs 0.8%, P = 0.025) and shorter hospital stays (3.3 vs 4.2 days, P < 0.001). CONCLUSIONS: When compared with thoracotomy, VATS segmentectomy is associated with less postoperative complications and shorter hospital length of stay. VATS segmentectomy has been used more frequently and with improved outcomes.

Predictors of retained hemothorax in trauma: Results of an Eastern Association for the Surgery of Trauma multi-institutional trial.

BACKGROUND: The natural history of traumatic hemothorax (HTX) remains unclear. We aimed to describe outcomes of HTX following tube thoracostomy drainage and to delineate factors that predict progression to a retained hemothorax (RH). We hypothesized that initial large-volume HTX predicts the development of an RH. METHODS: We conducted a prospective, observational, multi-institutional study of adult trauma patients diagnosed with an HTX identified on computed tomography (CT) scan with volumes calculated at time of diagnosis. All patients were managed with tube thoracostomy drainage within 24 hours of presentation. Retained hemothorax was defined as blood-density fluid identified on follow-up CT scan or need for additional intervention after initial tube thoracostomy placement for HTX. RESULTS: A total of 369 patients who presented with an HTX initially managed with tube thoracostomy drainage were enrolled from 17 trauma centers. Retained hemothorax was identified in 106 patients (28.7%). Patients with RH had a larger median (interquartile range) HTX volume on initial CT compared with no RH (191 [48-431] mL vs. 88 [35-245] mL, p = 0.013) and were more likely to be older with a higher burden of thoracic injury. After controlling for significant differences between groups, RH was independently associated with a larger HTX on presentation, with a 15% increase in risk of RH for each additional 100 mL of HTX on initial CT imaging (odds ratio, 1.15; 95% confidence interval, 1.08-1.21; p < 0.001). Patients with an RH also had higher rates of pneumonia and longer hospital length of stay than those with successful initial management. Retained hemothorax was also associated with worse functional outcomes at discharge and first outpatient follow-up. CONCLUSION: Larger initial HTX volumes are independently associated with RH, and unsuccessful initial management with tube thoracostomy is associated with worse patient outcomes. Future studies should use this experience to assess a range of options for reducing the risk of unsuccessful initial management. LEVEL OF EVIDENCE: Therapeutic/care management study, level III.

The postoperative use of Impella as a ventricular assist device in high-risk patients undergoing coronary artery bypass surgery: A case series and comparison.

INTRODUCTION: Prophylactic placement of intra-aortic balloon pumps (IABPs) for hemodynamic support has been used in high-risk patients undergoing coronary artery bypass grafting (CABG) surgery. The use of the Impella CP (ICP) heart pump in high-risk patients undergoing CABG has not been reported. In this study, we report our experience using ICP and IABP devices in high-risk patients during the postoperative period. METHODS: This is a case series and retrospective comparison of ICP vs IABP at a single institution using data from 2017. Twenty-eight patients underwent postoperative placement of either the ICP or an IABP. Nineteen patients received IABP and nine received the ICP heart pump. Patient characteristics, comorbidities, and complications were compared using bivariate analysis. Exact logistic regression was used to compare risk-adjusted mortality. RESULTS: There were no statistically significant differences in epidemiologic characteristics, risk factors, or outcomes between both groups, except the ICP group had a lower preoperative left ventricular ejection fraction (22.5 vs 35; P = .028). Exact logistic regression analysis did not show a difference in 30-day mortality between both groups (P = .086). CONCLUSION: The postoperative use of the ICP heart pump, to support high-risk patients undergoing CABG, is a safe option. This practice has allowed us to perform CABG on sicker patients, specifically with depressed ejection fractions, with comparable results to the IABP. Further studies with larger patient populations are needed to draw definitive conclusions, but this pilot study demonstrates a possible expanded use of the Impella device.

Identification of unique characteristics and the management of blunt traumatic aortic injuries occurring at unusual locations in the descending thoracic aorta.

BACKGROUND: The usual location of thoracic blunt traumatic aortic injury (BTAI) is just distal to the left subclavian artery; however, injuries can also be found in other locations in the descending thoracic aorta (DTA). METHODS: This is a single-institution, retrospective study, using 74 consecutive BTAI in the DTA. The patients were separated into two groups based on the location of the injury. The proximal group included injuries within 5 cm of the left subclavian artery, whereas the distal group included injuries in the rest of the DTA. A total of 27 factors were compared. RESULTS: Between 2010 and July 2017, we identified 14 of 74 patients (19%) with BTAI in the distal zone. Females were 9 of the 14 (64%) in the distal zone group, whereas females were 16 of 60 (27%) in the proximal zone group (P < .012). Thoracic spine fractures occurred in 7 of the 14 patients (50%) with injuries at the distal zone, whereas they occurred in 12 of the 60 patients (20%) in the proximal zone group (P < .038). Eleven of the 14 distal zone injuries (79%) were grade 1 or 2 compared with 15 of 60 injuries (25%) at the proximal zone (P = .016). Only 2 of the 14 injuries (14%) in the distal zone required an endovascular repair as opposed to 39 of 60 (65%) in the proximal zone (P < .001). The mean hospital duration of stay in patients with BTAI at the distal zone was 8.5 days compared with 20.3 days for patients in the proximal zone group (P < .004). Mortality occurred in 5 of 14 patients (36%) in the distal zone group compared with 5 of 60 patients (8%) in the proximal zone group (P = .017). The odds of mortality from an injury in the distal zone were almost 6-fold greater than the odds of mortality from an injury in the proximal zone (odds ratio, 5.9; 95% confidence interval, 1.2-31.8). No mortalities were related to the BTAI itself. The association of location with mortality remained significant even after adjusting for other significant factors like Injury Severity Score and patient age. Patients who died from injuries in the distal zone had a shorter duration of stay (5 days vs 20 days; P = .0002). CONCLUSIONS: BTAI in the distal zone of DTA are associated with unique characteristics. They are (1) more frequently associated with thoracic spine fractures, (2) more common in women, (3) tend to be lower grade, (4) less likely to require intervention, and (5) seem to have a higher mortality owing to other associated traumatic injuries.

Does serum albumin explain observed racial disparities in mortality for cancer patients undergoing esophagectomy?

BACKGROUND: African Americans with esophageal cancer have a higher mortality rate than Caucasians. We hypothesized that nutritional status, as reflected by preoperative albumin, might explain these disparities. METHODS: The National Surgical Quality Improvement Program database was queried for patients undergoing esophagectomy for esophageal cancer between 2005 and 2015. Preoperative albumin was divided into five categories (<3.0, 3.0-3.4, 3.5-3.9, 4.0-4.4, and >4.4). Univariate and multivariable regression statistics were performed to determine an association between preoperative albumin levels on mortality. RESULTS: 3228 patients were studied. While preoperative albumin was associated with lower body mass index, more severe preoperative weight loss, and more respiratory comorbidities (p-values <0.05), albumin levels were not associated with race. On multivariable models including race and other covariates, we found no association of serum albumin and mortality. CONCLUSIONS: We found that race was an independent predictor of mortality for patients undergoing esophagectomy. However, preoperative albumin did not explain these disparities.

How Safe Is the Safety Net? Comparison of Ivor-Lewis Esophagectomy at a Safety-Net Hospital Using the NSQIP Database.

BACKGROUND: Recent data suggest that surgical outcomes at hospitals caring for low-income, vulnerable populations are suboptimal compared with outcomes from nonsafety-net hospitals. Therefore, the purpose of our study was to compare outcomes for patients who underwent an Ivor-Lewis esophagectomy at a safety-net hospital with the National Surgical Quality Improvement Program (NSQIP) database. STUDY DESIGN: We retrospectively reviewed the medical records of consecutive patients who underwent an Ivor-Lewis esophagectomy, between September 2013 and January 2017, at a single safety-net hospital. Patient characteristics and outcomes were compared with the 2013 to 2015 NSQIP database. Continuous variables were compared using Student's t-test, and categorical variables were analyzed using chi-square tests. Values of p < 0.05 were considered significant. RESULTS: We identified 78 patients from the safety-net hospital and 1,825 patients in the NSQIP database who underwent an Ivor-Lewis esophagectomy. Baseline characteristics were similar, except the safety-net hospital patients were more likely to have COPD (19.2% vs 8.1%; p = 0.001) and be current smokers (42.3% vs 26.0%; p = 0.001); patients in the NSQIP group had a higher BMI (28 kg/m2 vs 26 kg/m2; p = 0.001). There were no differences between groups for mortality, readmission, discharge destination, or mean operative time. Safety-net hospital patients had significantly fewer complications (16.7% vs 33.3%; p = 0.003), fewer reoperations (6.4% vs 14.5%; p = 0.046), and shorter hospital length of stay (10.3 vs 13.1 days; p = 0.001). CONCLUSIONS: Patients who underwent an Ivor-Lewis esophagectomy at a safety-net hospital had fewer complications and reoperations, and a shorter hospital length of stay compared with a national cohort. These findings illustrate the value of clinical pathways in optimizing the patient outcomes at safety-net hospitals and providing excellent care to their vulnerable patient population.

The effects of neoadjuvant therapy on morbidity and mortality of esophagectomy for esophageal cancer: American college of surgeons national surgical quality improvement program (ACS-NSQIP) 2005-2012.

OBJECTIVE: This study used a multi-center database to evaluate the impact of neoadjuvant therapy on the 30-day morbidity and mortality following esophagectomy for esophageal cancer. METHODS: The NSQIP database was queried for 2005-2012 for patients, who had esophagectomy for esophageal cancer. Patients were divided into two groups: neoadjuvant therapy and esophagectomy only. RESULTS: The neoadjuvant group had a lower rates of sepsis (8% vs. 13%, unadjusted P = 0.004) and acute renal failure (0.4% vs. 2%, unadjusted P = 0.01), and a higher rate of pulmonary embolism (PE) (3% vs. 1%, unadjusted P = 0.04). The adjusted odds of PE for patients, who received neoadjuvant therapy were 2.8 times the odds of PE for patients in the esophagectomy group, controlling for BMI. The association with renal failure was not significant, when one adjusted for race. There was no difference in the rates of reoperation, readmission, stroke, cardiac arrest, MI, surgical site and deep organ infections, anastomosis failure, blood transfusions, DVT, septic shock, pneumonia, UTI, respiratory failure, and 30-day mortality between the two groups. CONCLUSIONS: We conclude that neoadjuvant therapy followed by esophagectomy for esophageal cancer does not have a negative impact on 30-day mortality. Neoadjuvant therapy is associated with increased odds of PE. J. Surg. Oncol. 2017;115:296-300. © 2016 Wiley Periodicals, Inc.

Pulmonary embolism and deep venous thrombosis following laparoscopic cholecystectomy.

There is considerable uncertainty related to the thromboembolic risk after laparoscopic cholecystectomy. Patients with pulmonary embolism (PE), deep venous thrombosis (DVT), or venous thromboembolism (VTE) at hospital discharge following laparoscopic cholecystectomy were identified from the Nationwide Inpatient Sample. From 1998 through 2009, 4 107 430 laparoscopic cholecystectomies were performed. The in-hospital prevalence of PE was 0.15%, DVT was 0.40%, and VTE was 0.53%. The prevalence of PE increased from 0.04% in patients aged 21 to 30 years to 0.31% in patients aged 71 to 80 years. Deaths due to in-hospital PE were 780 (0.02%) of the 4 107 430 laparoscopic cholecystectomies. The rate of death increased with age. The prevalence of VTE following laparoscopic cholecystectomy is low and fatal PE is rare. The risk of VTE increased with age, as did the risk of death in those who had PE. These data may be useful in assessing the use of thromboprophylaxis in patients undergoing laparoscopic cholecystectomy.

Specificity of quantitative latex agglutination assay for D-dimer in exclusion of pulmonary embolism in the emergency department.

We assessed the prevalence of elevated quantitative latex agglutination assay for D-dimer in patients in the emergency department in whom pulmonary embolism (PE) was excluded. D-dimer was normal (<230 ng/mL) in 435 (83%) of the 522 patients. D-dimer was normal in 88% of the patients with musculoskeletal or related chest pain, 74% with pleurisy or pleuritic chest pain, and 85% with upper respiratory tract infection. D-dimer was 230 to 500 ng/mL in 65 (75%) of the 87 in whom D-dimer was elevated. Clinical probability was low in 31 (48%) of the 65 patients with D-dimer levels of 230 to 500 ng/mL. D-dimer was 230 to 500 ng/mL and clinical probability was low in 31 (36%) of the 87 patients who had computed tomographic (CT) angiograms because of elevated D-dimer. Negative likelihood ratio for PE is sufficiently low that PE can be excluded with reasonable certainty in such patients. Tailoring cutoff value to 500 ng/mL in patients with low clinical probability would have reduced CT angiograms by 36%.

Relation of electrocardiographic changes in pulmonary embolism to right ventricular enlargement.

The electrocardiographic (ECG) findings in patients with pulmonary embolism (PE) and no previous cardiopulmonary disease are well documented; however, investigation of the relation of ECG abnormalities to right ventricular (RV) enlargement has been limited. The purpose of the present investigation was to assess further the relation of ECG changes in acute PE to RV cavity enlargement (dilation). The records of patients hospitalized from January 2009 to December 2012 with acute PE and no previous cardiopulmonary disease were reviewed. A total of 289 patients were included. RV cavity enlargement was present in 141 patients (49%). Normal ECG findings were less prevalent in patients with PE and RV enlargement than those with PE and no RV enlargement (35 of 141 [25%] vs 56 of 148 [38%]; p = 0.02). One or more of the traditional ECG manifestations of acute cor pulmonale (S1Q3T3, complete right bundle branch block, P pulmonale, or right axis deviation) was found in 18 of 141 patients (13%) with RV enlargement and 13 of 148 (8.8%) with a normal size RV (p = NS). None of the ECG abnormalities was sensitive for RV enlargement. The specificity of P and QRS abnormalities was high. The positive predictive values were ≤83% or had wide 95% confidence intervals. The negative predictive values ranged from 50% to 61%. In conclusion, ECG findings were not useful for the detection or exclusion of RV cavity enlargement in patients with acute PE.

Case fatality rate with vena cava filters in hospitalized stable patients with cancer and pulmonary embolism.

BACKGROUND: In view of the high risk of pulmonary embolism in patients with cancer, we tested the hypothesis that stable patients with pulmonary embolism who have cancer might be a subset of patients who would show a lower case fatality rate with vena cava filters than without filters. METHODS: Stable patients with pulmonary embolism and cancer at discharge from short-stay hospitals throughout the US from 1998-2009 were identified from the Nationwide Inpatient Sample. Patients with pulmonary embolism who had a diagnostic code for shock, ventilatory support, thrombolytic therapy, or pulmonary embolectomy were excluded because such patients have been shown to have lower case fatality rate with filters. RESULTS: In-hospital all-cause case fatality rate was lower with vena cava filters in stable patients with pulmonary embolism and solid malignant tumors providing they were aged >30 years, but there was variability according to type of tumor and age of patient. On average, case fatality rate among those >30 years with filters was 7070 of 69,350 (10.2%) (95% confidence interval, 10.0-10.4) versus 36,875 of 247,125 (14.9%) (95% confidence interval, 14.8-15.1) without filters (P <.0001) (relative risk 0.68). Among stable patients with hematological malignancies, case fatality rate, except in the elderly, was higher among those with vena cava filters than those without filters. CONCLUSION: Stable patients with pulmonary embolism and solid malignant tumors who are older than age 30 years appear to be a subset of patients with pulmonary embolism who would benefit from vena cava filters, but this needs to be tested prospectively.