RESUMEN
PURPOSE OF REVIEW: Lung cancer is the leading cause of cancer-related death in the United States. Pulmonary resection, in addition to perioperative systemic therapies, is a cornerstone of treatment for operable patients with early-stage and locoregional disease. In recent years, increased emphasis has been placed on surgical quality metrics: specific and evidence-based structural, process, and outcome measures that aim to decrease variation in lung cancer care and improve long term outcomes. These metrics can be divided into potential areas of intervention or improvement in the preoperative, intraoperative, and postoperative phases of care and form the basis of guidelines issued by organizations including the National Cancer Center Network (NCCN) and Society of Thoracic Surgeons (STS). This review focuses on established quality metrics associated with lung cancer surgery with an emphasis on the most recent research and guidelines. RECENT FINDINGS: Over the past 18âmonths, quality metrics across the peri-operative care period were explored, including optimal invasive mediastinal staging preoperatively, the extent of intraoperative lymphadenectomy, surgical approaches related to minimally invasive resection, and enhanced recovery pathways that facilitate early discharge following pulmonary resection. SUMMARY: Quality metrics in lung cancer surgery is an exciting and important area of research. Adherence to quality metrics has been shown to improve overall survival and guidelines supporting their use allows targeted quality improvement efforts at a local level to facilitate more consistent, less variable oncologic outcomes across centers.
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Neoplasias Pulmonares , Neumonectomía , Mejoramiento de la Calidad , Humanos , Neoplasias Pulmonares/cirugía , Neumonectomía/normas , Guías de Práctica Clínica como Asunto , Estados Unidos , Estadificación de Neoplasias , Escisión del Ganglio Linfático/normas , Atención Perioperativa/normas , Atención Perioperativa/métodosRESUMEN
Surgical resection is a principal treatment modality in the early stages of non-small cell lung cancer. The risks of surgical procedures are decreasing due to advancements in surgical techniques. However, optimal treatment strategy in locally advanced stages is unclear. Neoadjuvant immunotherapy could be a future treatment alternative.
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Neoplasias Pulmonares/cirugía , Neumonectomía/métodos , Neumonectomía/normas , Humanos , Neoplasias Pulmonares/patologíaRESUMEN
BACKGROUND: Previous literature in other surgical disciplines regarding the impact of resident and fellow involvement on operative time and outcomes has yielded mixed results. The impact of trainee involvement on minimally invasive thoracic surgery is unknown. This study compared risk-adjusted differences in operative time and outcomes of video-assisted thoracoscopic lobectomy for cancer between cases performed with and without residents and fellows involved. METHODS: All patients undergoing elective video-assisted thoracoscopic lobectomy for cancer between 2008 and 2018 were identified in the Veterans Affairs Surgical Quality Improvement Program database. Patients were stratified into 2 cohorts: cases with residents and fellows involved, and cases performed only by attending surgeons. Primary outcomes included operative time, postoperative hospital length of stay, and composite 30-day morbidity and mortality. Secondary outcomes included factors associated with high and low trainee operative autonomy. RESULTS: A total of 3678 patients met study inclusion criteria. In all, 1780 cases were performed with residents and fellows involved (median postgraduate year, 5; interquartile range, 4-7). Multivariate analysis showed that operative time was significantly shorter in resident- and fellow-involved cases compared with attending-only cases (mean [SD], 3.6 [1.4] versus 3.8 [1.6] hours; P < .001). There were no significant differences in composite 30-day morbidity and mortality (16.0% versus 17.1%; adjusted odds ratio = 0.93; 95% confidence interval, 0.77-1.11; P = .40) or length of stay. Substratification of trainees by postgraduate year resulted in similar findings. Cases performed in July through October and those in the Northeastern United States were associated with low autonomy. CONCLUSIONS: Current training paradigms in thoracic surgery are safe, and the involvement of motivated and skilled trainees with appropriate supervision may benefit operative duration.
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Educación de Postgrado en Medicina/métodos , Docentes Médicos/normas , Internado y Residencia/métodos , Neoplasias Pulmonares/cirugía , Neumonectomía/educación , Cirugía Torácica Asistida por Video/educación , Cirugía Torácica/educación , Anciano , Competencia Clínica , Femenino , Humanos , Neoplasias Pulmonares/mortalidad , Masculino , Neumonectomía/métodos , Neumonectomía/normas , Mejoramiento de la Calidad , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Cirugía Torácica Asistida por Video/normas , Estados Unidos/epidemiologíaRESUMEN
Surgery is the best treatment for early lung cancer but requires a preoperative functional evaluation to identify patients who may be at a high risk of complications or death. Guideline algorithms include a cardiological evaluation, a cardiopulmonary assessment to calculate the predicted residual lung function, and identify patients needing exercise testing to complete the evaluation. According to most expert opinion, exercise tests have a very high predictive value of complications. However, since the publication of these guidelines, minimally-invasive surgery, sublobar resections, prehabilitation and enhanced recovery after surgery (ERAS) programmes have been developed. Implementation of these techniques and programs is associated with a decrease in postoperative mortality and complications. In addition, the current guidelines and the cut-off values they identified are based on early series of patients, and are designed to select patients before major lung resection (lobectomy-pneumonectomy) performed by thoracotomy. Therefore, after a review of the current guidelines and a brief update on prehabilitation (smoking cessation, exercise training and nutritional aspects), we will discuss the need to redefine functional criteria to select patients who will benefit from lung surgery.
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Prueba de Esfuerzo , Neoplasias Pulmonares/cirugía , Aptitud Física/fisiología , Ejercicio Preoperatorio/fisiología , Prueba de Esfuerzo/métodos , Prueba de Esfuerzo/normas , Humanos , Neoplasias Pulmonares/epidemiología , Neoplasias Pulmonares/fisiopatología , Neoplasias Pulmonares/rehabilitación , Modalidades de Fisioterapia/normas , Neumonectomía/efectos adversos , Neumonectomía/rehabilitación , Neumonectomía/normas , Complicaciones Posoperatorias/prevención & control , Guías de Práctica Clínica como Asunto , Cuidados Preoperatorios/métodos , Cuidados Preoperatorios/normas , Periodo Preoperatorio , Fenómenos Fisiológicos Respiratorios , Factores de Riesgo , Toracotomía/efectos adversos , Toracotomía/rehabilitación , Toracotomía/normasAsunto(s)
Lupus Eritematoso Sistémico/complicaciones , Neumonectomía/métodos , Neumonectomía/normas , Guías de Práctica Clínica como Asunto , Enfisema Pulmonar/etiología , Enfisema Pulmonar/cirugía , Femenino , Humanos , Persona de Mediana Edad , Pruebas de Función Respiratoria , Resultado del TratamientoAsunto(s)
Medicina Basada en la Evidencia/métodos , Neoplasias Pulmonares/cirugía , Selección de Paciente , Neumonectomía/métodos , Oncología Quirúrgica/métodos , Cirugía Torácica Asistida por Video/métodos , Medicina Basada en la Evidencia/historia , Medicina Basada en la Evidencia/instrumentación , Medicina Basada en la Evidencia/normas , Historia del Siglo XX , Historia del Siglo XXI , Humanos , Neoplasias Pulmonares/diagnóstico por imagen , Neumonectomía/historia , Neumonectomía/instrumentación , Neumonectomía/normas , Guías de Práctica Clínica como Asunto , Oncología Quirúrgica/historia , Oncología Quirúrgica/instrumentación , Oncología Quirúrgica/normas , Cirugía Torácica Asistida por Video/historia , Cirugía Torácica Asistida por Video/instrumentación , Cirugía Torácica Asistida por Video/normasRESUMEN
BACKGROUND: The Society of Thoracic Surgeons (STS) General Thoracic Surgery Database (GTSD) has developed composite quality measures for lobectomy and esophagectomy. This study sought to develop a composite measure including all resections for lung cancer. METHODS: The STS lung cancer composite score is based on 2 outcomes: risk-adjusted mortality and morbidity. GTSD data were included from January 2015 to December 2017. "Star ratings" were created for centers with 30 or more cases by using 95% Bayesian credible intervals. The Bayesian model was performed with and without inclusion of the minimally invasive approach to assess the impact of approach on the composite measure. RESULTS: The study population included 38,461 patients from 256 centers. Overall operative mortality was 1.3% (495 of 38,461). The major complication rate was 7.9% (3045 of 38,461). The median number of nodes examined was 10 (interquartile range, 5 to 16); the median number of nodal stations sampled was 4 (interquartile range, 3 to 5). Positive resection margins were identified in 3.7% (1420 of 38,461). A total of 214 centers with 30 or more cases were assigned star ratings. There were 7 1-star, 194 2-star, and 13 3-star programs; 70.6% of resections were performed through a minimally invasive approach. Inclusion of minimally invasive approach, which was adjusted for in previous models, altered the star ratings for 3% (6 of 214) of the programs. CONCLUSIONS: Participants in the STS GTSD perform lung cancer resection with low morbidity and mortality. Lymph node data suggest that participants are meeting contemporary staging standards. There is wide variability among participants in application of minimally invasive approaches. The study found that risk adjustment for approach altered ratings in 3% of participants.
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Carcinoma de Pulmón de Células no Pequeñas/cirugía , Neoplasias Pulmonares/cirugía , Evaluación de Resultado en la Atención de Salud/métodos , Neumonectomía/normas , Sociedades Médicas , Cirugía Torácica , Anciano , Carcinoma de Pulmón de Células no Pequeñas/diagnóstico , Carcinoma de Pulmón de Células no Pequeñas/epidemiología , Femenino , Humanos , Neoplasias Pulmonares/diagnóstico , Neoplasias Pulmonares/epidemiología , Masculino , Morbilidad/tendencias , Estadificación de Neoplasias , Complicaciones Posoperatorias/epidemiología , Reproducibilidad de los Resultados , Tasa de Supervivencia/tendencias , Estados Unidos/epidemiologíaRESUMEN
OBJECTIVE: In this study we present historic data on adherence to and survival outcomes associated with recently introduced quality measures for the management of non-small-cell lung cancer. METHODS: The National Cancer Data Base was queried to identify all patients with non-small-cell lung cancer from 1998 to 2011. Adherence to guidelines was assessed for each of 3 Commission on Cancer-defined quality measures: (1) sampling 10 regional lymph nodes at surgery; (2a) surgery within 120 days of neoadjuvant chemotherapy or, (2b) 180 days of adjuvant chemotherapy; and (3) nonsurgical primary therapy in cN2 disease. The likelihood of measure adherence and the association of measure adherence with all-cause mortality were analyzed controlling for patient, hospital, and time period characteristics. RESULTS: Regional lymph node sampling was inadequate in 72.7% of cases. Only 28.7% began adjuvant chemotherapy within 180 days of surgery. However, 96.5% of patients who received neoadjuvant chemotherapy proceeded to surgery within 120 days and surgery was first-line treatment for cN2 disease in only 3.7% of patients. Uninsured or Medicaid status was an independent risk factor for a prolonged delay between neoadjuvant chemotherapy and surgery (odds ratio, 1.36; 95% confidence interval, 1.08-1.72) and surgery and adjuvant treatment (odds ratio, 1.92; 95% confidence interval, 1.69-2.19). Overall survival was significantly better in patients whose care conformed to quality standards for nodal sampling (measure 1), and timing of chemotherapy. CONCLUSIONS: Adherence rates for nodal sampling at the time of surgery and receipt of adjuvant chemotherapy were low. These findings highlight opportunities for improvement efforts, but more measures are needed to more broadly assess the quality of lung cancer care.
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Carcinoma de Pulmón de Células no Pequeñas/terapia , Neoplasias Pulmonares/terapia , Escisión del Ganglio Linfático/normas , Terapia Neoadyuvante/normas , Evaluación de Procesos y Resultados en Atención de Salud/normas , Neumonectomía/normas , Indicadores de Calidad de la Atención de Salud/normas , Adulto , Anciano , Anciano de 80 o más Años , Carcinoma de Pulmón de Células no Pequeñas/mortalidad , Carcinoma de Pulmón de Células no Pequeñas/patología , Quimioterapia Adyuvante/normas , Bases de Datos Factuales , Femenino , Adhesión a Directriz/normas , Disparidades en Atención de Salud/normas , Humanos , Neoplasias Pulmonares/mortalidad , Neoplasias Pulmonares/patología , Escisión del Ganglio Linfático/efectos adversos , Escisión del Ganglio Linfático/mortalidad , Masculino , Persona de Mediana Edad , Terapia Neoadyuvante/efectos adversos , Terapia Neoadyuvante/mortalidad , Neumonectomía/efectos adversos , Neumonectomía/mortalidad , Guías de Práctica Clínica como Asunto/normas , Pautas de la Práctica en Medicina/normas , Factores de Riesgo , Factores de Tiempo , Tiempo de Tratamiento/normas , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
OBJECTIVE: The objective of this project was to assess the best measure for postoperative outcomes by comparing 30-day and 90-day mortality rates after surgery for non-small cell lung cancer using the National Cancer Database. Secondarily, hospital performance was examined at multiple postoperative intervals to assess changes in ranking based on mortality up to 1 year after surgery. METHODS: Patients who had undergone surgery for non-small cell lung cancer between 2004 and 2013 were identified in the National Cancer Database. Mortality rates at 30 days and 90 days were compared after adjusting for several patient characteristics, tumor variables, and hospital procedural volume using generalized logistic mixed models. Subsequently, mixed model logistic regression models were employed to evaluate hospital performance based on calculated mortality at prespecified time points. RESULTS: A total of 303,579 patients with non-small cell lung cancer were included for analysis. The 90-day mortality was almost double the 30-day mortality (3.0% vs 5.7%). Several patient characteristics, tumor features, and hospital volume were significantly associated with mortality at both 30 days and 90 days. Hospital rankings fluctuate appreciably between early mortality time points, which is additional evidence that quality metrics need to be based on later mortality time points. CONCLUSIONS: Thirty-day mortality is the commonly accepted quality measure for thoracic surgeons; however, hospital rankings may be inaccurate if based on this variable alone. Mortality after 90 days appears to be a threshold after which there is less variability in hospital ranking and should be considered as an alternative quality metric in lung cancer surgery.
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Carcinoma de Pulmón de Células no Pequeñas/mortalidad , Neoplasias Pulmonares/mortalidad , Indicadores de Calidad de la Atención de Salud , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Carcinoma de Pulmón de Células no Pequeñas/cirugía , Bases de Datos como Asunto , Femenino , Humanos , Neoplasias Pulmonares/cirugía , Masculino , Persona de Mediana Edad , Neumonectomía/mortalidad , Neumonectomía/normas , Calidad de la Atención de Salud/normas , Adulto JovenAsunto(s)
Carcinoma de Pulmón de Células no Pequeñas/cirugía , Neoplasias Pulmonares/cirugía , Pulmón , Tratamientos Conservadores del Órgano , Neumonectomía , Carcinoma de Pulmón de Células no Pequeñas/patología , Diagnóstico por Imagen/métodos , Diagnóstico por Imagen/tendencias , Humanos , Invenciones , Pulmón/diagnóstico por imagen , Pulmón/patología , Pulmón/cirugía , Neoplasias Pulmonares/patología , Márgenes de Escisión , Tratamientos Conservadores del Órgano/métodos , Tratamientos Conservadores del Órgano/normas , Órganos en Riesgo , Neumonectomía/métodos , Neumonectomía/normas , Cirugía Torácica/tendenciasRESUMEN
BACKGROUND: Parameters defining attainment and maintenance of proficiency in thoracoscopic video-assisted thoracic surgery (VATS) lobectomy remain unknown. To address this knowledge gap, this study investigated the institutional performance curve for VATS lobectomy by using risk-adjusted cumulative sum (Cusum) analysis. METHODS: Using The Society of Thoracic Surgeons General Thoracic Surgery Database, the study investigators identified centers that had performed a total of 30 or more VATS lobectomies. Major morbidity, mortality, and blood transfusion were deemed primary outcomes, with expected incidence derived from risk-adjusted regression models. Acceptable and unacceptable failure rates for outcomes were set a priori according to clinical relevance and informed by regression model output. RESULTS: Between 2001 and 2016, 24,196 patients underwent VATS lobectomy at 159 centers with a median volume of 103 (range, 30 to 760). Overall rates of operative mortality, major morbidity, and transfusion were 1% (244 of 24,189), 17.1% (4,145 of 24,196), and 4% (975 of 24,196), respectively. Of the highest-volume centers (≥100 cases), 84% (65 of 77) and 82 % (63 of 77) (p = 0.48) were proficient by major morbidity standards by their 50th and 100th cases, respectively. Similarly, 92% (71 of 77) and 90% (69 of 77) (p = 0.41) of centers showed proficiency by transfusion standards by their 50th and 100th cases, respectively. Three performance patterns were observed: (1) initial and sustained proficiency, (2) crossing unacceptability thresholds with subsequent improved performance; and (3) crossing unacceptability thresholds without subsequent improved performance. CONCLUSIONS: VATS lobectomy outcomes have improved with lower mortality and transfusion rates. The majority of high-volume centers demonstrated proficiency after 50 cases; however, maintenance of proficiency is not ensured. Cusum provides a simple yet powerful tool that can trigger internal audits and performance improvement initiatives.
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Competencia Clínica , Neoplasias Pulmonares/cirugía , Neumonectomía/educación , Cirujanos/educación , Cirugía Torácica Asistida por Video/educación , Anciano , Bases de Datos Factuales , Femenino , Humanos , Masculino , Neumonectomía/normas , Cirugía Torácica Asistida por Video/normasRESUMEN
BACKGROUND: Nontechnical skills are important for safe and efficient surgery. Teams performing video-assisted thoracoscopic surgery (VATS) lobectomy express that it is of utmost importance to have a shared mental model (SMM) of the patient, current situation, and team resources. However, these SMMs have never been explored in a clinical setting. The aim of this observational study was to measure the similarity of SMMs within teams performing VATS lobectomy. METHODS: In this national, multicenter study, SMMs of teams performing VATS lobectomy (n = 64) were measured by preoperative and postoperative questionnaires that were completed by all team members (n = 172). Participants' responses were compared within each team to explore SMMs of risk assessment, familiarity, technical skills, nontechnical skills, and problems. RESULTS: Analysis showed poor agreement between team members with respect to risk assessment, but higher levels of agreement were found for assessments of familiarity, technical skills, and nontechnical skills within the team (Cronbach's alpha = 0.90), most notably for surgical subteams (ie, surgeon plus assistant surgeon plus surgical nurses). During the surgical procedure, the most frequent problems were related to anesthesia, and these were most often recognized by the surgeons. The operating room nurses were the least aware of each other's and the surgeons' problems. CONCLUSIONS: Significant variation exists in the SMMs among VATS team members, with poor agreement regarding the patient and current situation, but better agreement with respect to team resources. Focus on preoperative and perioperative team reflexivity, in addition to explicit communication within unfamiliar teams, may provide opportunities to enhance SMMs, with possible downstream effects on team performance.
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Competencia Clínica , Neoplasias Pulmonares/terapia , Modelos Psicológicos , Grupo de Atención al Paciente/normas , Neumonectomía/normas , Cirujanos/psicología , Cirugía Torácica Asistida por Video/normas , Anciano , Comunicación , Femenino , Humanos , Neoplasias Pulmonares/cirugía , MasculinoRESUMEN
The NCCN Guidelines for Small Cell Lung Cancer (SCLC) address all aspects of disease management. These NCCN Guidelines Insights focus on recent updates to the NCCN Guidelines for SCLC regarding immunotherapy, systemic therapy, and radiation therapy. For the 2018 update, new sections were added on "Signs and Symptoms of SCLC" and "Principles of Pathologic Review."
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Neoplasias Encefálicas/prevención & control , Neoplasias Pulmonares/terapia , Oncología Médica/normas , Carcinoma Pulmonar de Células Pequeñas/terapia , Antineoplásicos Inmunológicos/uso terapéutico , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Neoplasias Encefálicas/secundario , Quimioradioterapia/métodos , Quimioradioterapia/normas , Irradiación Craneana/métodos , Irradiación Craneana/normas , Relación Dosis-Respuesta en la Radiación , Humanos , Neoplasias Pulmonares/diagnóstico , Neoplasias Pulmonares/patología , Oncología Médica/métodos , Estadificación de Neoplasias , Neumonectomía/métodos , Neumonectomía/normas , Dosificación Radioterapéutica , Ensayos Clínicos Controlados Aleatorios como Asunto , Carcinoma Pulmonar de Células Pequeñas/diagnóstico , Carcinoma Pulmonar de Células Pequeñas/mortalidad , Carcinoma Pulmonar de Células Pequeñas/secundario , Sociedades Médicas/normas , Análisis de Supervivencia , Resultado del Tratamiento , Estados UnidosAsunto(s)
Neoplasias Encefálicas/terapia , Carcinoma de Pulmón de Células no Pequeñas/terapia , Neoplasias Pulmonares/terapia , Oncología Médica/normas , Cuidados Posteriores/métodos , Cuidados Posteriores/normas , Protocolos de Quimioterapia Combinada Antineoplásica/normas , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Biomarcadores de Tumor/genética , Biopsia , Neoplasias Encefálicas/diagnóstico , Neoplasias Encefálicas/epidemiología , Neoplasias Encefálicas/secundario , Broncoscopía/métodos , Broncoscopía/normas , Carcinoma de Pulmón de Células no Pequeñas/diagnóstico , Carcinoma de Pulmón de Células no Pequeñas/epidemiología , Carcinoma de Pulmón de Células no Pequeñas/secundario , Europa (Continente) , Humanos , Incidencia , Pulmón/diagnóstico por imagen , Pulmón/patología , Pulmón/cirugía , Neoplasias Pulmonares/diagnóstico , Neoplasias Pulmonares/epidemiología , Neoplasias Pulmonares/patología , Imagen por Resonancia Magnética , Oncología Médica/métodos , Tasa de Mutación , Estadificación de Neoplasias , Neumonectomía/métodos , Neumonectomía/normas , Tomografía de Emisión de Positrones , Medicina de Precisión/métodos , Medicina de Precisión/normas , Pronóstico , Radiocirugia/métodos , Radiocirugia/normas , Sociedades Médicas/normas , Supervivencia , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
Colorectal cancer (CRC) is a frequently occurring disease, yet diagnosed at a local stage in only 40% of cases. Lung metastases (LM) appear in 5-15% of patients and, left untreated, carry a very poor prognosis. Some CRC patients may benefit from a potentially curative LM resection, but success and benefit are difficult to predict. We discuss prognostic factors of survival after lung metastasectomy in CRC patients under several scenarios (with/ without prior liver metastases; repetitive pulmonary resections). We reviewed all studies (2005-2015) about pulmonary metastases surgical management with curative intent in CRC patients, with a minimum threshold on the number of patients reported (without prior liver metastases: n ≥ 100; with prior resection of liver metastases: n ≥ 50; repetitive thoracic surgery: n ≥ 30). The picture of the prognostic factors of survival is nuanced: surgical management demonstrates clear successes and steady progress, yet there is no single success criterion; stratification of patients and selection bias impact the conclusions. Surgical management of liver and lung metastases may prolong life or cure CRC patients, provided the lesions are fully resected and patients carefully selected. Repeat lung metastasectomy is a safe approach to treat patients in selected cases. In conclusion, there is no standard for surgical management in CRC patients with pulmonary metastases. Patients with isolated unilateral lung metastasis with normal CEA level and no lymph node involvement benefit the most from surgery. Most series report good results in highly selected patients, but instances of long-term disease-free survival remain exceptional.
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Neoplasias Colorrectales/secundario , Neoplasias Colorrectales/cirugía , Neoplasias Pulmonares/patología , Neoplasias Pulmonares/cirugía , Metastasectomía/métodos , Neumonectomía/métodos , Pautas de la Práctica en Medicina , Supervivencia sin Enfermedad , Humanos , Metastasectomía/normas , Neumonectomía/normas , Guías de Práctica Clínica como Asunto , Pautas de la Práctica en Medicina/estadística & datos numéricos , PronósticoRESUMEN
This report highlights the results of the Italian video-assisted thoracoscopic surgery (VATS) Group, launched in mid 2013, which now has a website and an established database with over 4000 VATS lobectomy cases recruited from 67 thoracic surgery units across Italy. The year 2016 has been crucial for the following steps: inclusion of a dedicated biostatistician and a 'Survey Analysis & Data Quality Check'; the First Consensus Meeting with statements consequently adopted as Recommendations for the Italian Thoracic Surgery Society and published in a peer-reviewed journal; two papers published under the logo Italian VATS Group and seven abstracts accepted at annual international meetings (European Society of Thoracic Surgeons, European Association of Cardio-Thoracic Surgeons, European Lung Cancer Conference and European Respiratory Society); the institution of a Master Course on VATS lobectomy; the partnership with AME Publishing Company.
Asunto(s)
Neoplasias Pulmonares/cirugía , Sistemas en Línea/estadística & datos numéricos , Neumonectomía/normas , Sistema de Registros/estadística & datos numéricos , Cirugía Torácica Asistida por Video/normas , Conferencias de Consenso como Asunto , Bases de Datos como Asunto , Humanos , Italia/epidemiología , Pulmón/patología , Pulmón/cirugía , Neoplasias Pulmonares/epidemiología , Neoplasias Pulmonares/patología , Neumonectomía/efectos adversos , Neumonectomía/economía , Neumonectomía/métodos , Cirugía Torácica Asistida por Video/efectos adversos , Cirugía Torácica Asistida por Video/economía , Cirugía Torácica Asistida por Video/métodos , Resultado del TratamientoRESUMEN
Stage IIIA is a very heterogeneous group encompassing locally advanced disease with T3 and T4 tumors without any nodal involvement and very small T1a primary tumors with unilateral mediastinal lymphatic disease. Tailored management defines interdisciplinary management requiring board decisions, which can sometimes be difficult particularly in stage IIIa non-small-cell lung cancer (NSCLC). Lobectomy still is standard of care even for stage I NSCLC, which increasingly is implemented using minimally invasive surgical technique. On the other hand even locally extended tumors are today safely resected with low morbidity and mortality. According to the 2015 guidelines of the European Society of Thoracic Surgeons any kind of anatomical lung resection for lung cancer with curative intent has to be accompanied by formal mediastinal lymph node dissection. The transcervical route for complete bilateral mediastinal lymphadenectomy offers improved completeness of resection without the need for single lung ventilation and ideally supports the concept of minimally invasive surgery.
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Carcinoma de Pulmón de Células no Pequeñas/terapia , Neoplasias Pulmonares/terapia , Neoplasias del Mediastino/terapia , Cirugía Torácica Asistida por Video/métodos , Carcinoma de Pulmón de Células no Pequeñas/mortalidad , Carcinoma de Pulmón de Células no Pequeñas/secundario , Humanos , Pulmón/patología , Pulmón/cirugía , Neoplasias Pulmonares/mortalidad , Neoplasias Pulmonares/patología , Escisión del Ganglio Linfático/métodos , Escisión del Ganglio Linfático/normas , Ganglios Linfáticos/patología , Neoplasias del Mediastino/mortalidad , Neoplasias del Mediastino/secundario , Mediastino/patología , Estadificación de Neoplasias , Grupo de Atención al Paciente/normas , Neumonectomía/métodos , Neumonectomía/normas , Neumonectomía/tendencias , Guías de Práctica Clínica como Asunto , Nivel de Atención , Cirugía Torácica Asistida por Video/normas , Cirugía Torácica Asistida por Video/tendencias , Resultado del TratamientoRESUMEN
BACKGROUND: Specific assessment tools can accelerate trainees' learning through structured feedback and ensure that trainees attain the knowledge and skills required to practice as competent, independent surgeons (competency-based surgical education). The objective was to develop an assessment tool for video-assisted thoracoscopic surgery (VATS) lobectomy by achieving consensus within an international group of VATS experts. METHOD: The Delphi method was used as a structured process for collecting and distilling knowledge from a group of internationally recognized VATS experts. Opinions were obtained in an iterative process involving answering repeated rounds of questionnaires. Responses to one round were summarized and integrated into the next round of questionnaires until consensus was reached. RESULTS: Thirty-one VATS experts were included and four Delphi rounds were conducted. The response rate for each round were 68.9% (31/45), 100% (31/31), 96.8% (30/31), and 93.3% (28/30) for the final round where consensus was reached. The first Delphi round contained 44 items and the final VATS lobectomy Assessment Tool (VATSAT) comprised eight items with rating anchors: (1) localization of tumor and other pathological tissue, (2) dissection of the hilum and veins, (3) dissection of the arteries, (4) dissection of the bronchus, (5) dissection of lymph nodes, (6) retrieval of lobe in bag, (7) respect for tissue and structures, and (8) technical skills in general. CONCLUSION: A novel and dedicated assessment tool for VATS lobectomy was developed based on VATS experts' consensus. The VATSAT can support the learning of VATS lobectomy by providing structured feedback and help supervisors make the important decision of when trainees have acquired VATS lobectomy competencies for independent performance.
Asunto(s)
Competencia Clínica/normas , Educación Basada en Competencias/normas , Neumonectomía/educación , Cirugía Torácica Asistida por Video/educación , Educación Basada en Competencias/métodos , Técnica Delphi , Salud Global , Humanos , Neumonectomía/métodos , Neumonectomía/normas , Cirugía Torácica Asistida por Video/métodos , Cirugía Torácica Asistida por Video/normasRESUMEN
Video-assisted thoracoscopic surgery may be associated with less morbidity than open lobectomy or segmentectomy, but some studies have questioned the benefit of thoracoscopic surgery. This study aimed to determine trends and factors associated with patient's likelihood of undergoing thoracoscopic lobectomy or segmentectomy and to compare outcomes with each approach. This retrospective study included adult patients undergoing pulmonary lobectomy or segmentectomy from the American College of Surgeons National Surgical Quality Improvement Project from 2007 to 2015 (n = 14,717). Logistic regression analysis was conducted to determine the association of patient demographics, clinical characteristics, and surgeon specialty with thoracoscopic lobectomy or segmentectomy. Propensity score matching was performed to evaluate outcomes for thoracoscopic and open lobectomy or segmentectomy. Use of thoracoscopic lobectomy or segmentectomy increased from 11.6% in 2007 to 60.6% in 2015 (P< 0.0001). Older patients, females, and Hispanics were more likely to undergo thoracoscopic lobectomy, whereas morbidly obese patients, patients with higher American Society of Anesthesiology class, and patients with 4-6 frailty conditions had a lower likelihood of receiving thoracoscopic lobectomy or segmentectomy. Thoracic surgeons had 57% (odds ratio 1.57, 95% confidence interval 1.36-1.81) higher odds of performing thoracoscopic surgery than other surgeons. Thoracoscopic lobectomy or segmentectomy reduced risk of 30-day mortality (1.0% vs 1.9%; odds ratio 0.51, 95% confidence interval 0.37-0.70) and resulted in shorter length of stay (4 days vs 6 days; Beta coefficient = -0.37, P < 0.0001), and fewer complications. The frequency of thoracoscopic lobectomy or segmentectomy has increased substantially over the last 10 years and now accounts for over half of lobectomies. Video-assisted thoracoscopic surgery showed better outcomes than open lobectomy or segmentectomy.
Asunto(s)
Neumonectomía/tendencias , Pautas de la Práctica en Medicina/tendencias , Evaluación de Procesos, Atención de Salud/tendencias , Mejoramiento de la Calidad/tendencias , Indicadores de Calidad de la Atención de Salud/tendencias , Cirugía Torácica Asistida por Video/tendencias , Factores de Edad , Anciano , Comorbilidad , Femenino , Estado de Salud , Humanos , Masculino , Persona de Mediana Edad , Neumonectomía/efectos adversos , Neumonectomía/mortalidad , Neumonectomía/normas , Complicaciones Posoperatorias/epidemiología , Pautas de la Práctica en Medicina/normas , Evaluación de Procesos, Atención de Salud/normas , Mejoramiento de la Calidad/normas , Indicadores de Calidad de la Atención de Salud/normas , Estudios Retrospectivos , Factores de Riesgo , Factores Sexuales , Cirugía Torácica Asistida por Video/efectos adversos , Cirugía Torácica Asistida por Video/mortalidad , Cirugía Torácica Asistida por Video/normas , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
OBJECTIVE: The adoption of Enhanced Recovery After Surgery programs in thoracic surgery is relatively recent with limited outcome data. This study aimed to determine the impact of an Enhanced Recovery After Surgery pathway on morbidity and length of stay in patients undergoing lung resection for primary lung cancer. METHODS: This prospective cohort study collected data on consecutive patients undergoing lung resection for primary lung cancer between April 2012 and June 2014 at a regional referral center in the United Kingdom. All patients followed a standardized, 15-element Enhanced Recovery After Surgery protocol. Key data fields included protocol compliance with individual elements, pathophysiology, and operative factors. Thirty-day morbidity was taken as the primary outcome measure and classified a priori according to the Clavien-Dindo system. Logistic regression models were devised to identify independent risk factors for morbidity and length of stay. RESULTS: A total of 422 consecutive patients underwent lung resection over a 2-year period, of whom 302 (71.6%) underwent video-assisted thoracoscopic surgery. Lobectomy was performed in 297 patients (70.4%). Complications were experienced by 159 patients (37.6%). The median length of stay was 5 days (range, 1-67), and 6 patients (1.4%) died within 30 days of surgery. There was a significant inverse relationship between protocol compliance and morbidity after adjustment for confounding factors (odds ratio, 0.72; 95% confidence interval, 0.57-0.91; P < .01). Age, lobectomy or pneumonectomy, more than 1 resection, and delayed mobilization were independent predictors of morbidity. Age, lack of preoperative carbohydrate drinks, planned high dependency unit/intensive therapy unit admission, delayed mobilization, and open approach were independent predictors of delayed discharge (length of stay >5 days). CONCLUSIONS: Increased compliance with an Enhanced Recovery After Surgery pathway is associated with improved clinical outcomes after resection for primary lung cancer. Several elements, including early mobilization, appear to be more influential than others.