Video-Assisted Thoracoscopic Lobectomy for Lung Cancer: Current Practice Patterns and Predictors of Adoption

Enhanced Recovery With Aggressive Ambulation Decreases Length of Stay in Lung Cancer Surgery

OBJECTIVE

Thoracic Enhanced Recovery with Ambulation after Surgery (T-ERAS) protocol at our institution includes ambulation into the operating room and 250-feet ambulation within 1 hour of extubation. We compared the average length of stay (LOS) between T-ERAS patients and that predicted using a validated surgical risk calculator.

METHODS

We retrospectively reviewed patients undergoing lung cancer resection with minimally invasive approach from 2012 to 2022. Patients aged ≥ 18 were included if early ambulation was documented. Patient information were entered into the American College of Surgeon's National Surgical Quality Improvement Program Risk Calculator (NSQIP) to obtain the predicted LOS. Descriptive statistics, comparisons of observed versus predicted LOS (O/P ratio), and nonparametric testing were conducted.

RESULTS

Of 940 patients reviewed, 886 met eligibility. For the study cohort, average age was 68, and 514 (58.0%) were female. By procedure, there were 631(71.2%) lobectomy, 204 (23.0%) wedge, 26 (2.9%) segmentectomy, 20 (2.3%) bilobectomy, and 5 (0.6%) pneumonectomy. The average LOS observed for the entire cohort was 1.2 days (median 1.0 day) compared to the predicted LOS of 3.4 days with the NSQIP (median 4.0). Overall, 842 (95%) of patients had LOS better than predicted (O/P ratio < 1), 19 (2.1%) had LOS as predicted (O/P ratio = 1), and 25 (2.8%) had LOS longer than predicted (O/P ratio > 1). The mean O/P ratio was 0.34.

CONCLUSION

Average LOS with T-ERAS protocol was 1.2 days compared to the predicted average of 3.6 days in patients undergoing minimally invasive lung cancer resections. Our study provides a potential protocol to shorten the LOS beyond what is predicted by NSQIP.

Adoption of Minimally Invasive Lung Resection: A National Cancer Database Study

INTRODUCTION

Minimally invasive lung resection has been associated with improved outcomes; however, institutional characteristics associated with utilization are unclear. We hypothesized that the presence of surgical robots at institutions would be associated with increased utilization of minimally invasive techniques .

METHODS

Patients with cT1/2N0M0 non-small cell lung cancer who underwent lung lobectomy between 2010 and 2020 in the National Cancer Database were identified. Patients were categorized by operative approach as minimally invasive surgery (MIS) versus open. Institutions were categorized as "high utilizers" of MIS technique if their proportion of MIS lobectomies was >50%. Multivariate logistic regressions were used to determine factors associated with proportion of procedures performed minimally invasively. Further multivariate models were used to evaluate the association of proportion of MIS procedures with 90-d mortality, hospital length of stay, and hospital readmission.

RESULTS

In multivariate analysis, passage of time by year (odds ratio [OR] 1.26; confidence interval [CI] 1.22-1.30) and presence of a robot at the facility (OR 3.48; CI 2.84-4.24) were associated with high MIS-utilizing facilities. High utilizers of MIS were associated with lower 90-d mortality (OR 0.89; CI 0.83-0.97) and hospital length of stay (coeff -0.88; CI -1.03 to -0.72). Hospital readmission was similar between high and low MIS-utilizing facilities (compared to low MIS-utilizing facilities: OR 1.06; CI 0.95-1.09).

CONCLUSIONS

Passage of time and the presence of surgical robots were independently associated with increased utilization of MIS lobectomy. In addition to being associated with improved patient-level outcomes, robotic surgery is correlated with a higher proportion of procedures being performed minimally invasively.

Risk Factors for Chronic Atrial Fibrillation Following Lung Lobectomy

INTRODUCTION

Postoperative atrial fibrillation (POAF) is a common complication following lung lobectomy and is associated with increased risk of stroke, mortality, and prolonged hospital length of stay. The purpose of this study was to define the risk factors for POAF after lobectomy, hypothesizing that operative approach would be associated with risk of chronic POAF.

METHODS

The TriNetX database was used to identify adult patients with no history of arrythmia receiving elective lung lobectomy for cancer from 7/6/2003-7/6/2023. Patients were categorized by approach: video-assisted thoracoscopic surgery (VATS) or open. The outcome of interest was the presence of POAF occurring at 1-3 months ("early") and 12-24 months postop ("chronic"). Propensity matching was performed to reduce bias between cohorts.

RESULTS

We identified 22,998 patients: 8472 (36.8%) who received open and 14,526 (63.2%) VATS lobectomy. The rate of early POAF was 3.7% of VATS and 5.3% of open patients. The rate of chronic POAF was 5.5 % of VATS patients and 6.2% of open lobectomy patients. Propensity matching decreased bias between the approach groups, creating 7942 pairs for analysis. After matching, the risk of early POAF was greater in the open approach (5.5% open vs 3.4% VATS, risk ratio 1.607 (95% confidence interval 1.385-1.865), P < 0.001). Chronic POAF was (also) higher in the open approach (6.3% open vs 5.2% VATS, Risk Ratio 1.211 (95%CI 1.067-1.374), P = 0.003).

CONCLUSIONS

Postoperative atrial fibrillation (POAF) occurs more commonly after open lobectomy, both acutely and chronically. Providers should counsel patients about the risk of chronic arrythmia after lung resection.

Non-traditional pulmonary function tests in risk stratification of anatomic lung resection: a retrospective review

BACKGROUND

Guidelines advocate pulmonary function testing (PFT) in preoperative evaluation before lung resection. Although forced expiratory volume in 1 s (FEV1) and diffusing capacity of the lungs for carbon monoxide (DLCO) are recommended, they are often poor predictors of complications.

OBJECTIVES

Determine if PFT testing results other than FEV1 and DLCO are associated with post-operative complications. We hypothesized that other PFT test results may improve the prediction of post-operative complications.

DESIGN

Retrospective cohort study of a single institution.

METHODS

We analyzed patients who underwent anatomic lung resections from 1/2007 to 1/2017. Percent predicted post-operative (ppo) PFT values were calculated for each test result. Outcome of interest was any post-operative complication. Wilcoxon rank-sum and multivariable regression were used to determine the relationship of PFT results to post-operative complications.

RESULTS

We analyzed 922 patients who underwent anatomic lung resections. Complications occurred in 240 (26.0%) patients, and mortality occurred in 12 (1.3%) patients. In univariate analysis, predicted and percent predicted post-operative (ppo) forced vital capacity (FVC), FEV1, FEF2575, DLCO, DLCO/VA, and VC values were predictors of post-operative complications. Multivariable logistic regression found no independent relationship of test results to post-operative complications, likely reflecting the collinearity of PFT results.

CONCLUSION

Our findings suggest that non-traditional PFTs, such as FVC, may enhance risk stratification for post-operative complications following anatomic lung resection. Notably, traditional parameters like FEV1 and DLCO were not independently predictive, highlighting the need to reconsider their role in isolation. These findings highlight the need to reconsider how PFT are used in surgical risk stratification given high levels of collinearity.

Affordable Care Act Medicaid Expansion is Associated With Increased Utilization of Minimally Invasive Lung Resection for Early Stage Lung Cancer

OBJECTIVE

Minimally invasive lung resection (MILR) is underutilized in the United States. Under the Affordable Care Act (ACA), 39 states adopted Medicaid expansion, while 12 did not. Although Medicaid expansion has been associated with improved access to cancer care, its effect on utilization of MILR is unclear. We hypothesize that MILR would increase in Medicaid expansion states.

METHODS

The National Cancer Database was queried for adult patients from 2010 to 2018 with cT1/2N0M0 non-small cell lung cancer who received surgical resection by wedge, segmentectomy, or lobectomy. Patients were grouped by whether they received care in a state without Medicaid expansion vs expansion in January 2014. The outcome of interest was MILR (defined as video-assisted or robotic-assisted thoracoscopy) relative to open. Multivariable difference in differences (DID) cross-sectional analysis was used to estimate the average treatment effect (ATE) of Medicaid expansion.

RESULTS

There were 41,439 patients who met inclusion criteria: 20,446 (49.3%) in expansion states and 20,993 (50.7%) in non-expansion states. Multivariable DID analysis showed that Medicaid expansion was associated with an increase in Medicaid insurance type with an ATE of 7.4% (95% CI 7.1-7.7%, P = .002). Medicaid expansion was also associated with increased MILR utilization in unadjusted analysis (10,278/20,446 (50.3%) vs 9,953/20,993 (47.4%), p < .001) and in multivariable DID analysis (ATE 0.6%, 95% CI 0.3-0.8%, P = .008).

CONCLUSIONS

Although Medicaid expansion was associated with increased utilization of MILR for early stage lung cancer, the treatment effect was modest. This suggests that barriers in access to MILR are larger than simply access to care.

Trends in Comprehensive Thoracic Case Experience Among General Surgery Residents in the Modern Integrated Cardiothoracic Residency Era: Review of Twenty Years of Resident Case Logs

BACKGROUND

Thoracic surgery training among general surgery residents in the United States is regulated by the Accreditation Council for Graduate Medical Education (ACGME) to ensure exposure to subspecialty fields during residency. Thoracic surgery training has changed over time with the placement of work hour restrictions, the emphasis on minimally invasive surgery, and increased subspecialization of training like integrated six-year cardiothoracic surgery programs. We aim to investigate how these changes over the past twenty years have affected thoracic surgery training among general surgery residents.

METHODS

ACGME general surgery resident case logs from 1999 to 2019 were reviewed. Data included exposure to the thorax via thoracic, cardiac, vascular, pediatric, trauma, and alimentary tract procedures. Cases from the above categories were consolidated to determine the comprehensive experience. Descriptive statistics were performed over four 5-year Eras (Era 1:1999-2004, Era 2: 2004-2009, Era 3: 2009-2014, Era 4: 2014-2019).

RESULTS

Between Era 1 and Era 4, there was an increase in thoracic surgery experience (37.6 ± 1.03 vs 39.3 ± .64; P = .006). The mean total thoracic experience for thoracoscopic, open, and cardiac procedures was 12.89 ± 3.76, 20.09 ± 2.33, and 4.98 ± 1.28, respectively. There was a difference between Era 1 and Era 4 in thoracoscopic (8.78 ± .961 vs 17.18 ± .75; P < .001) and open thoracic experience (22 ± .97 vs 17.06 ± .88; P < .001), and a decrease in thoracic trauma procedures (3.7 ± .06 vs 3.2 ± .32; P = .03).

DISCUSSION

Over twenty years there has been a similar, to slight increase in thoracic surgery exposure among general surgery residents. The changes seen in thoracic surgery training reflect the overall movement of surgery towards minimally invasive surgery.

Comparing Thoracoscopic and Robotic Lobectomy Using a Nationally Representative Database

BACKGROUND

Studies of robotic lobectomy (Robot-L) have been performed using data from high-volume, specialty centers which may not be generalizable. The purpose of this study was to compare mortality, length of stay (LOS), and cost between Robot-L and thoracoscopic lobectomy (VATS-L) using a nationally representative database hypothesizing they would be similar.

METHODS

The Premier Healthcare Database was used to identify patients receiving elective lobectomy for lung cancer from 2009 to 2019. Patients were categorized as receiving Robot-L or VATS-L using ICD-9/10 codes. Survey methodology and patient level weighting were used to correct for sampling error and estimation of a nationally representative sample. A propensity match analysis was performed to reduce bias between the groups. Primary outcome of interest was in-hospital mortality. Secondary outcomes were LOS and patient charges.

RESULTS

Among 62 698 patients, 19 506 (31.1%) underwent Robot-L and 43 192 (68.9%) underwent VATS-L. Differences between the groups included age, race, comorbidities, and insurance type. A propensity matched cohort demonstrated similar in-hospital mortality for Robot-L and VATS-L (.9% vs .9%, respectively, P = .91). Patients who underwent Robot-L had a shorter LOS (4 vs 5d, respectively, P < .001) but higher patient charges (90 593.0 vs 72 733.3 USD, respectively, P < .001).

CONCLUSIONS

In a nationally representative database, Robot-L and VATS-L had similar mortality. Although Robot-L was associated with shorter hospitalization, it was also associated with excess charges of almost $20,000. As Robot-L is now the most common approach for lobectomy in the U.S., further study into the cost and benefit of robotic surgery is warranted.

Disparities in Access to Thoracic Surgeons among Patients Receiving Lung Lobectomy in the United States

Objective: Lung lobectomy is the standard of care for early-stage lung cancer. Studies have suggested improved outcomes associated with lobectomy performed by specialized thoracic surgery providers. We hypothesized that disparities would exist regarding access to thoracic surgeons among patients receiving lung lobectomy for cancer. Methods: The Premier Hospital Database was used to identify adult inpatients receiving lung lobectomy from 2009 to 2019. Patients were categorized as receiving their lobectomy from a thoracic surgeon, cardiovascular surgeon, or general surgeon. Sample-weighted multivariable analysis was performed to identify factors associated with provider type. Results: When adjusted for sampling, 121,711 patients were analyzed, including 71,709 (58.9%) who received lobectomy by a thoracic surgeon, 36,630 (30.1%) by a cardiovascular surgeon, and 13,373 (11.0%) by a general surgeon. Multivariable analysis showed that thoracic surgeon provider type was less likely with Black patients, Medicaid insurance, smaller hospital size, in the western region, and in rural areas. In addition, non-thoracic surgery specialty was less likely to perform minimally-invasive (MIS) lobectomy (cardiovascular OR 0.80, p < 0.001, general surgery OR 0.85, p = 0.003). Conclusions: In this nationally representative analysis, smaller, rural, non-teaching hospitals, and certain regions of the United States are less likely to receive lobectomy from a thoracic surgeon. Thoracic surgeon specialization is also independently associated with utilization of minimally invasive lobectomy. Combined, there are significant disparities in access to guideline-directed surgical care of patients receiving lung lobectomy.

Impact of Volume on Mortality and Hospital Stay After Lung Cancer Surgery in a Single-Payer System

BACKGROUND

There is a literature gap for hospitals in single-payer healthcare systems quantifying the influence of hospital volume on outcomes following major lung cancer resection. We aimed to determine the effect of hospital volume on mortality, and length of stay (LOS).

METHODS

A retrospective cohort study using administrative, population-based data from a single-payer universal healthcare system was performed in adults with non-small cell lung cancer who underwent lobectomy or pneumonectomy between 2008 and 2017. Hospital volume was defined as the average annual number of major lung resections performed at each institution. Length of stay and post-operative mortality was compared using multivariable linear and non-linear regression between hospital volume categories and continuously. Adjusted association between hospital volume and post-operative mortality was determined by multivariable logistic regression.

RESULTS

10,831 lung resections were performed: 1237 pneumonectomies; 9594 lobectomies. Patients undergoing lobectomy at high-volume hospitals had shorter median LOS (6 vs 8 days, p = 0.001) compared with low-volume hospitals. After adjusting for confounders, surgery at a high-volume center was significantly associated with shorter LOS after lobectomy and overall resections (p=<0.001), but not after pneumonectomy (p=0.787). Surgery at a high-volume center was positively associated with improved 90-day mortality in lobectomy and overall procedures (OR 0.607; [0.399-0.925]; and 0.632 [0.441-0.904], respectively). Volume was not a predictor of 90-day mortality after pneumonectomy (OR 0.533 [0.257-1.104], p=0.090).

CONCLUSIONS

Surgery at a high-volume center was positively correlated with improved 90-day survival and shorter hospital LOS. The results support regionalized lung cancer care in a single-payer healthcare system.

When Is It Safe to Operate for Lung Cancer? Selection of Fiscally Responsible Cardiopulmonary Function Tests for Limited Resection (Wedge Resection and Segmentectomy), Standard Lobectomy, Sleeve Lobectomy, and Pneumonectomy

Pulmonary function testing remains the central determinant of candidacy for pulmonary resection and indicator of perioperative risk. For patients with borderline pulmonary function, exercise testing can help determine surgical candidacy either via stair climbing or by obtaining a maximum oxygen consumption. The Thoracic Revised Cardiac Risk Index should be used to select patients for further cardiac testing. Patient comorbidities, medications, functional limitations, and smoking status are also requisite assessments of the preoperative evaluation that influence perioperative outcomes. A minimally invasive approach to pulmonary resection reduces perioperative risk and may be of most benefit to patients with borderline pulmonary function.

The Impact of Expedited Discharge on 30-Day Readmission Following Lung Resection: A National Study

BACKGROUND

Expedited discharge (within 24 hours) following lung resection has received scrutiny due to concerns for higher readmissions and paradoxically increased costs. The present study examined the impact of expedited discharge on hospitalization costs and unplanned readmissions using a nationally-representative sample. In addition, we sought to determine inter-hospital practice variation.

METHODS

Adults undergoing elective lobar or sublobar resection were identified using the 2016-2018 Nationwide Readmissions Database, while those with postoperative duration of hospitalization >5 days or experienced any perioperative complication, were excluded. Patients were classified as Expedited if postoperative hospitalization was 0 or 1 day and otherwise as Routine. Inverse probability of treatment weighing was utilized to adjust for intergroup differences. Hospitals were ranked according to risk-adjusted early discharge rates. Multivariable regression models were developed to assess the association of expedited discharge on nonelective 30-day readmissions as well as associated mortality and costs.

RESULTS

Of an estimated 84,152 patients, 13,834 (16.4%) comprised the Expedited group. Compared to Routine, Expedited were younger, less likely to have chronic obstructive pulmonary disease and undergo open procedures. Following adjustment, early discharge was associated with lower incremental costs (β coefficient: -$3.6K, 95%CI: -4.4 - -2.8) as well as similar readmissions (odds ratio: 0.89, 95%CI: 0.70 - 1.13) and related-mortality. Nearly half (48.1%) of all hospitals performed zero early discharges.

CONCLUSIONS

Expedited discharge following lung resection is a feasible management strategy and is associated with decreased costs and similar readmission risk compared to the norm. Select individuals should be strongly considered for expedited discharge following lung resection.

Failure to rescue after surgical re-exploration in lung resection

BACKGROUND

Surgical re-exploration after lung resection remains poorly characterized, although institutional series have previously reported its association with greater mortality and complications. The present study sought to examine the impact of institutional lung-resection volume on the incidence of and short-term outcomes after surgical re-exploration.

METHODS

The 2007 to 2018 National Inpatient Sample was used to identify all adults who underwent lobectomy or pneumonectomy. Hospitals were divided into tertiles based on institutional lung-resection caseload. Multivariable regressions were used to identify associations between independent covariates on clinical outcomes.

RESULTS

Of an estimated 329,273 patients, 3,592 (1.09%) were re-explored with decreasing incidence over time. Open and minimal access pneumonectomy among other factors were associated with greater odds of reoperation. Those re-explored had greater odds of mortality and complications as well as increased duration of stay and adjusted costs. Although risk of re-exploration was similar across hospital tertiles, reoperative mortality was significantly lower at high-volume hospitals.

CONCLUSION

Re-exploration after lung resection is uncommon; however, when occurring, it is associated with worse clinical outcomes. After re-exploration, high-volume center status was associated with reduced odds of mortality relative to low volume. Failure to rescue at lower-volume centers suggests the need for optimization of perioperative factors to decrease incidence of reoperation.

Uptake and survival effects of minimally invasive surgery for lung cancer: A population-based study

INTRODUCTION

Despite growing evidence supporting the safety of minimally invasive surgery (MIS) in the treatment of lung cancer, its uptake is still variable and its outcomes debated. This study examines the factors associated with MIS uptake and its effects on survival in patients with non-small cell lung cancer (NSCLC).

METHODS

All patients in the Canadian province of Ontario with early stage NSCLC (stage I/II) from 2007 to 2017 were included. A logistic regression identified the predictors of MIS uptake, and a flexible parametric model was used to estimate survival rates based on MIS versus open resection.

RESULTS

In total, 8,988 patients underwent surgical resection; 53.6% had MIS. Year of diagnosis was associated with MIS uptake (OR = 1.33, p < 0.001); patients in later years were more likely to receive MIS. Rurality was a significant predictor of MIS, though distance from nearest regional cancer center did not predict MIS utilization. Patients with stage II disease were less likely to receive MIS compared to those with stage I disease (OR = 0.44, p < 0.001). MIS had a significantly higher 5-year survival compared to open resection for stage I and II disease. Patients >70 years had the greatest 5-year survival benefit from MIS.

CONCLUSIONS

We observed a substantial long-term survival benefit in patients undergoing MIS for early stage NSCLC. This difference was most pronounced in the oldest age group. These findings support the use of MIS in the treatment of lung cancer and challenge the notion that MIS compromises oncologic outcomes.

Mid-term results of completely portal robotic lobectomy for stage I & II non-small cell lung cancer

Background

Minimally invasive robotic-assisted thoracic surgery is an increasingly popular platform for oncological thoracic resection. The aim of this study is to evaluate the feasibility of completely portal robotic lobectomy for patients with early non-small cell lung cancer (NSCLC), analysing the perioperative and mid-term results.

Methods

This is a single-institution retrospective cohort study of consecutive patients who underwent completely portal robotic lobectomy for early stage NSCLC over a 53-month period.

Results

A total of 59 consecutive patients were included in this study. Median operative time was 155 min (range, 80–313 min). Conversion rate was 13.6%. Median intensive care/high dependency unit stay, chest tube duration and length of hospital stay were 1 day (range, 0–4 days), 2 days (range, 1–20 days) and 4 days (range, 2–30 days) respectively; 98.2% of patients achieved R0 resection. Overall, 23.7% had minor complications. There was no perioperative (30-day) mortality in this study. Final pathological staging distribution was 55.9% stage 1A, 23.7% stage 1B, 10.2% stage 2A and 10.2% stage 2B; 23% were upstaged after pathological staging. Median follow-up was 33 months (range, 3–70 months). The 3-year overall survival and recurrence-free survival were 86.2% (95% CI, 72.0–96.8) and 69% (95% CI, 56.1–81.9) respectively. The 3-year overall survival and recurrence free survival for stage 1 patients were 88.4% (95% CI, 77.4–99.4) and 75.6% (95% CI, 62.3–88.9) respectively.

Conclusions

By clearly defining completely portal robotic lobectomy, it is possible to delivery promising perioperative and mid-term results for early stage primary lung cancer, even in a geographical location that has yet to assimilate this technology.

Robotic-assisted tracheobronchial surgery

Robotic technology is positioned to transform the approach to tracheobronchial surgery. With its magnified 3D view, intuitive controls, wristed-instruments, high-fidelity simulation platforms, and the steady implementation of new technical improvement, the robot is well-suited to manage the careful dissection and delicate handling of the airway in tracheobronchial surgery. This innovative technology has the potential to promote the widespread adoption of minimally invasive techniques for this complex thoracic surgery.

Why comprehensive adoption of robotic assisted thoracic surgery is ideal for both simple and complex lung resections

Minimally invasive thoracoscopic surgical techniques have grown increasingly popular due to improved outcome measures compared to conventional rib-spreading thoracotomy. However, video-assisted thoracoscopic surgery (VATS) presents with unique technical challenges that have limited its role in certain cases. Here, we discuss our perspectives on the implementation of a successful robotic thoracic program. We will then present the case for how the adoption of robotic assisted thoracic surgery (RATS) provides the benefits of minimally invasive VATS while still retaining the technical finesse of bimanual articulating instruments and 3-dimensional imaging that is a universal component of any open surgery. We will also discuss how to overcome some of the perceived disadvantages to RATS in regard to the higher cost, lack of tactile feedback and potential safety concerns.

Is less really more? Reexamining video-assisted thoracoscopic versus open lobectomy in the setting of an enhanced recovery protocol

OBJECTIVES

Video-assisted thoracoscopic surgery lobectomy has been associated with improved pain, length of stay, and outcomes compared with open lobectomy. However, enhanced recovery protocols improve outcomes after both procedures. We aimed to compare video-assisted thoracoscopic surgery and open lobectomy in the setting of a comprehensive enhanced recovery protocol.

METHODS

All patients undergoing lobectomy for lung cancer at a single institution since the adoption of an enhanced recovery protocol (May 2016 to December 2018) were stratified by video-assisted thoracoscopic surgery versus open status and compared. Demographics and outcomes, including length of stay, daily pain scores, and short-term operative complications, were compared using standard univariate statistics and multivariable models.

RESULTS

A total of 130 patients underwent lobectomy, including 71 (54.6%) undergoing video-assisted thoracoscopic surgery and 59 (45.4%) undergoing open surgery. Video-assisted thoracoscopic surgery versus open cases exhibited similar length of stay (median 4 days for both, P = .07), opioid requirement (33.2 vs 30.8 mg morphine equivalents, P = .86), and pain scores at 0, 1, 2, and 3 days after surgery (4.3 vs 2.8, P = .12; 4.4 vs 3.7, P = .27; 3.9 vs 3.5, P = .83; and 3.4 vs 3.5, P = .98, respectively). Patients undergoing video-assisted thoracoscopic surgery lobectomy exhibited lower rates of readmission (1.4% vs 17.0%, P < .01), postoperative transfusion requirement (0% vs 10.2%, P < .01), and pneumonia (1.4% vs 10.2%, P = .05). After risk adjustment, an open procedure (vs video-assisted thoracoscopic surgery status) did not significantly affect the length of stay (effect 0.18; P = .10) or overall complication rate (odds ratio, 1.9; P = .12).

CONCLUSIONS

In the setting of a comprehensive enhanced recovery protocol, patients undergoing video-assisted thoracoscopic surgery versus open lobectomy exhibited similar short-term outcomes. Surgical incision may have less impact on outcomes in the setting of a comprehensive thoracic enhanced recovery protocol.

Disparities in guideline-concordant treatment for node-positive, non-small cell lung cancer following surgery

OBJECTIVES

To examine guideline concordance across a national sample and determine the relationship between socioeconomic factors, use of recommended postoperative adjuvant therapy, and outcomes for patients with resected pN1 or pN2 non-small cell lung cancer.

METHODS

All margin-negative pT1-3 N1-2 M0 non-small cell lung cancers treated with lobectomy or pneumonectomy without induction therapy in the National Cancer Database between 2006 and 2013 were included. Use of guideline-concordant adjuvant treatment, defined as chemotherapy for pN1 disease and chemotherapy with or without radiation for pN2 disease, was examined. Multivariable regression models were developed to determine associations of clinical factors with guideline adherence. Survival was estimated using Kaplan-Meier and Cox proportional hazard analyses.

RESULTS

Of 13,462 patients, 10,113 had pN1 disease and 3349 had pN2 disease. Guideline-concordant adjuvant therapy was used in 6844 (67.7%) patients with pN1 disease and 2622 (78.3%) patients with pN2 disease. After multivariable adjustment, insurance status, older age, pneumonectomy, readmission, and longer postoperative stays were associated with lower likelihood of guideline concordance. Conversely, increased education level, later year of diagnosis, and greater nodal stage were associated with greater concordance. Overall, patients treated with guideline-concordant therapy had superior survival (5-year survival: 51.6 vs 36.0%; hazard ratio, 0.66; 95% confidence interval, 0.62-0.70, P < .001).

CONCLUSIONS

Socioeconomic factors, including insurance status and geographic region, are associated with disparities in use of adjuvant therapy as recommended by National Comprehensive Cancer Network guidelines. These disparities significantly impact patient survival. Future work should focus on improving access to appropriate adjuvant therapies among the under insured and socioeconomically disadvantaged.

Postoperative day 1 discharge after anatomic lung resection: A Society of Thoracic Surgeons database analysis

OBJECTIVE

Although minimally invasive techniques have led to shorter hospitalizations, discharge on postoperative day 1 is still uncommon. We hypothesized that day 1 discharge could be performed safely and that there might be significant variation in day 1 discharge rates between hospitals.

METHODS

We identified patients with lung cancer who underwent lobectomy and segmentectomy in the Society of Thoracic Surgeons Database from 2012 to 2017. The 10% longest hospital stay outliers were excluded. A multivariable regression model was created to assess for factors associated with day 1 discharge and readmission.

RESULTS

A total of 46,325 patients were examined, and 1821 patients (3.9%) were discharged on day 1. This rate increased from 3.4% to 5.3% over the course of the study (P < .0001). In multivariable analysis, factors associated with day 1 discharge included age, Zubrod score, body mass index greater than 25, forced expiration value at 1 second, middle or upper lobectomy, minimally invasive technique, and procedure time. Outpatient 30-day mortality was similar (0.3% vs 0.4%, P = .472). Patients discharged on day 1 were not at increased risk of readmission. Readmission after day 1 discharge was associated with male sex, coronary artery disease, chronic obstructive pulmonary disease, and longer procedure time. There was substantial variation in day 1 discharge rate between institutions, with 11 centers (4.0%) discharging more than 20% of their patients on day 1, whereas 102 centers (36.7%) had no day 1 discharges.

CONCLUSIONS

Day 1 discharge after anatomic lung resection is uncommon but is becoming more common. Carefully selected patients may be discharged on day 1 without an increased risk of readmission or death.

Association of tumor location with economic outcomes and air leak complications in thoracic lobectomies: results from a national hospital billing dataset

Purpose: To assess whether tumor location during thoracic lobectomies affects economic outcomes or air leak complications.

Patients and methods: Retrospective, observational study using Premier Healthcare Database. The study included patients aged ≥18 years who underwent elective inpatient thoracic lobectomy for lung cancer between 2012 and 2014 (first qualifying=index admission). Three mutually exclusive tumor location groups were formed: upper lobe, middle lobe, and lower lobe. Primary outcomes were index admission’s length of stay (LOS), total hospital costs, and operating room time; in-hospital air leak complications (composite of air leak/pneumothorax) served as an exploratory outcome. Multivariable models were used to examine the association between tumor location and the study outcomes, accounting for covariates and hospital-level clustering.

Results: 8,750 thoracic lobectomies were identified: upper lobe (n=5,284), middle lobe (n=512), and lower lobe (n=2,954). Compared with the upper lobe, the middle and lower lobe groups had statistically significant (p<0.05): shorter adjusted LOS (7.0 days upper vs 5.8 days middle, 6.6 days lower), lower adjusted mean total hospital costs ($26,177 upper vs $23,109 middle, $24,557 lower), and lower adjusted odds of air leak complications (odds ratio middle vs upper=0.81, 95% CI=0.74–0.89; odds ratio lower vs upper=0.60, 95% CI=0.46–0.78). Findings were similar but varied in statistical significance when stratified by open and video-assisted thoracoscopic surgery approach.

Conclusion: Among patients undergoing elective thoracic lobectomy for lung cancer in real-world clinical practice, upper lobe tumors were significantly associated with increased in-hospital resource use and air leak complications as compared with lower or middle lobe tumors.

Big data, big contributions: outcomes research in thoracic surgery

In recent years, analysis of registry data has defined clinically significant practice patterns and treatment strategies that optimize cancer care for thoracic surgery patients. These higher-order outcome studies rely on large patient cohorts that minimize the risk of selection bias and allow for a powered analysis that is not achievable with single- or multi-institutional data. This review uses recent study examples to highlight important contributions to our knowledge of thoracic surgery and describes how outcomes research using large data can address high impact clinical questions.

ICD-10-CM/PCS: potential methodologic strengths and challenges for thoracic surgery researchers and reviewers

The recent implementation of the International Classification of Diseases, 10^th Revision, Clinical Modification and Procedure Coding System (ICD-10-CM/PCS) provides a robust classification of diagnoses and procedures for hospital systems. As researchers begin using ICD-10-CM/PCS for outcomes research from administrative datasets, it is important to understand ICD-10-CM/PCS, as well as the strengths and challenges of these new classifications. In this review, we describe the development of ICD-10-CM/PCS and summarize how it applies specifically to thoracic surgery patients undergoing pulmonary lobectomy, sublobar resection (segmentectomy or wedge resection) and esophagectomy. This myriad of ICD-10-CM/PCS codes presents challenges and questions for thoracic surgery researchers and medical journal reviewers and editors when evaluating thoracic surgical outcomes research utilizing ICD-10-CM/PCS. Additional work is needed to develop consensus guidelines and uniformity for accurate and coherent research methods to utilize ICD-10-CM/PCS in future outcomes research efforts.

Latest technology in minimally invasive thoracic surgery

From the introduction of video-assisted thoracoscopic surgery (VATS) in the 1990s, to performing major lung resections using a uniportal VATS approach, technology has paved the way for the development of minimally invasive thoracic surgery. Natural orifice access to achieve a 'no port' approach, is also on the rise, with advancements in bronchoscopic techniques for diagnosis and therapy, as well as development of soft robotics to achieve desired flexibility, dexterity and stability in future platforms, which may involve in vivo deployment to bring the surgeon totally inside the body. Development of haptic feedback in robotic platforms to enhance the surgical experience is also a major goal, with vibrotactile and mechanical feedback generation, to replicate the traditional touch. In addition, the aid of technology in the form of procedural guidance mechanisms, like augmented reality, will further improve the safety and accuracy of future operations.

Post-treatment mortality after definitive chemoradiotherapy versus trimodality therapy for locally advanced non-small cell lung cancer

PURPOSE

Locally advanced non-small cell lung cancer (NSCLC) is commonly managed with either definitive chemoradiation (dCRT) or neoadjuvant chemoradiation followed by surgery (nCRT + S). This study sought to compare 30- and 90-day mortality between nCRT + S and dCRT for these patients.

METHODS

The National Cancer Database was queried (2004-2014) for clinicall staged T1-3N2 or T3-4N0-1 (except T3N0) NSCLC that received nCRT + S or dCRT. Statistics included cumulative incidence analysis of 30- and 90-day mortality (before and following propensity score matching) and Cox proportional hazards regressions.

RESULTS

Of 28,379 patients, 4063 (14.3%) underwent nCRT-S, and 24,316 (85.6%) dCRT. Of the trimodality patients, 79.2% received lobectomy, 8.2% sublobar resection, and 12.5% pneumonectomy. Trimodality therapy and age, in addition to several soceiodempographic and oncologic variables, were associated with 30- and 90-day mortality. Short-term mortality was significantly higher with nCRT + S compared to dCRT at both 30 (3.4% vs. 0.8%, p < 0.001) and 90days (7.5% vs. 6.6%, p = 0.017), which persisted following propensity matching (3.4% vs. 0.4% and 7.5% vs. 5.3% respectively, both p < 0.001). At both 30 and 90 days, pneumonectomy was associated with higher mortality than lobectomy (6.1% vs. 2.9% and 11.1% vs. 6.9% respectively, both p < 0.001).

CONCLUSIONS

Treatment with nCRT + S was associated with greater 30- and 90- day post-treatment mortality when compared to treatment with dCRT, with larger differences in observed in 30-day post-treatment mortality. These data may inform shared-decsion making among patients eligible for both aproaches.

Early discharge after lung resection is safe: 10-year experience

Background

The average hospitalization after lung resection is 6 days, but some patients are discharged early in the post-operative period. The patient factors associated with early discharge (ED) and the safety of this approach are unknown. We hypothesized that specific patient populations are associated with ED, and that complications in this practice are low.

Methods

A prospective database of lung resections performed at an academic medical center between Jan 1, 2007 and Jan 1, 2017 was queried. Demographic and outcome variables were assessed using standard techniques. ED was defined as the length of stay (LOS) for the quintile with the lowest LOS for patients with anatomic resection (AR) or patients with wedge resection (WR). We then compared clinical factors between patients with ED to those patients discharged by day 7, to determine factors associated with ED (relative to "average" discharge).

Results

During the study period, there were 922 AR and 1,150 WR performed. A total of 448 (39.0%) patients had WRED and 211 patients (22.9%) had ARED. The rate of WRED varied by surgeon, but ARED did not. ARED and WRED patients was associated with several factors, including younger age, better lung function, and were less likely to have elevated American Society of Anesthesiologist (ASA) class. Multivariable analysis suggested that patient factors and primary surgeon influence ED. WRED was associated with 30-day mortality of 0.22% vs. 1.14% for longer LOS (P=0.08). After AR, there were no post-operative deaths within 30 days among 211 patients discharged on postoperative day 1 or 2 [(vs. 2/541, 0.4%, P=0.376) with longer LOS, P=0.048].

Conclusions

ED after lung resection is multifactorial but is safe among selected patients. Age, lung function, procedure duration, and surgeon all influence ED. Complications after ED were rare. Individual surgeon comfort with ED likely impacts LOS, and education or enhanced recovery protocols may help overcome this barrier. Standardized pathways would likely help identify low-risk patients for expeditious discharge.

Oncologic Equivalence of Minimally Invasive Lobectomy: The Scientific and Practical Arguments

BACKGROUND

Despite the slow adoption of minimally invasive lobectomy (MIL), it is now a preferred approach for early lung cancer. Nevertheless, ongoing concerns about MIL oncologic effectiveness has led to calls for prospective, randomized trials.

METHODS

Retrospective analysis of on-line databases, collected readings, and other scholarly experiences of the experienced authors were used to construct this review. All available reports that contained long-term survival comparisons for open versus MIL were tabulated.

RESULTS

The preponderance of limited randomized and numerous large propensity-matched database analyses indicate equivalent or improved long-term MIL survival for early-stage disease. MIL lymph node dissection quality has been challenged; however, this was attributed to MIL avoidance of central tumors in early reports. Although technical inadequacies for MIL should be amplified for advanced cancer resections, early reports show no such concern. In fact, for special populations such as older, frail patients, evidence is much stronger that MIL confers a survival advantage.

CONCLUSIONS

MIL is an oncologically equivalent operation with substantially less morbidity, especially in frail populations. It is reasonable to suggest that MIL should be the technique of choice, even a quality indicator, for lobectomy.

Timing and Risk Factors Associated With Venous Thromboembolism After Lung Cancer Resection

BACKGROUND

Few studies have examined the risk factors for and timing of venous thromboembolism (VTE) in patients undergoing surgical procedures for lung cancer, and there are limited data to formulate guidelines for extended VTE prophylaxis after hospital discharge. This study sought to identify risk factors for postdischarge VTE after lung resection.

METHODS

Patients undergoing anatomic resection for lung cancer were identified in the National Surgical Quality Improvement Program database from 2005 to 2015. Patients' demographic and clinical characteristics were evaluated for any association with postdischarge VTE. Predictors of postdischarge VTE were identified using multivariable analysis.

RESULTS

VTE occurred in 1.6% (234) of the 14,308 patients identified; 44% (102) VTE events occurred after hospital discharge. Undergoing pneumonectomy was associated with a threefold increased risk for postdischarge VTE compared with lobectomy (2.0% versus 0.6%, p < 0.01), as was open resection compared with minimally invasive resection (0.8% versus 0.6%, p < 0.01). Prolonged operative time (>75th percentile) was also associated with an increased risk for postdischarge VTE compared with shorter operative time. Multivariable analysis identified older age, obesity, pneumonectomy, and prolonged operative time as independent predictors of postdischarge VTE.

CONCLUSIONS

Significant proportions of VTE events occur after hospital discharge. Although there are data to suggest that the risk for VTE extends beyond this period, few patients are managed with postdischarge prophylaxis. These data suggest that postdischarge prophylaxis should be considered for those patients at high risk for VTE, particularly for older patients, those who are obese, and after extended or lengthy resections.

Phase 1 Trial Evaluating Safety of Pulmonary Artery Sealing With Ultrasonic Energy in VATS Lobectomy

BACKGROUND

Energy-sealing devices may be useful to divide small pulmonary arteries (PAs) during video-assisted thoracoscopic surgery (VATS) lobectomy. We evaluated the safety of PA branch sealing with an ultrasonic energy vessel-sealing device during VATS lobectomy.

METHODS

The study consisted of a phase 1 trial. Patients planned to undergo VATS lobectomy were prospectively enrolled. Target sample size was 20 patients. Branches of 7 mm or less were sealed and cut with an ultrasonic energy vessel-sealing device. The remainder of the lobectomy was performed in a standard fashion. Intraoperative, in-hospital, and 30-day postoperative bleeding were prospectively recorded.

RESULTS

Thirty-three patients were prospectively enrolled. Thirteen patients were not amenable to PA sealing with the vessel-sealing device because all PA branch diameters exceeded 7 mm (n = 10), conversion to thoracotomy (n = 2), and lobectomy not performed (n = 1). A minimum of one PA branch was sealed with the device in 20 patients. Fifty-eight PA branches were divided in 20 patients: 31 with ultrasonic device, 24 with endostaplers, 2 with clips, and 1 with sutures. The mean vessel diameter sealed with the device was 4 mm. Two patients were converted to thoracotomy (1 with PA injury during dissection, 1 with PA tumor invasion). No intraoperative or postoperative bleeding was related to ultrasonic PA branch sealing. No postoperative deaths occurred.

CONCLUSIONS

PA branch sealing for vessels 7 mm or less was safely achieved using an ultrasonic energy vessel-sealing device in VATS lobectomy. Large-scale, prospective, multi-institutional studies are necessary before widespread clinical application of energy for PA branch sealing in VATS lobectomy.

What we know about surgical therapy in early-stage non-small-cell lung cancer: a guide for the medical oncologist

Lung cancer remains the leading cause of death in cancer patients. The gold standard for the treatment of early-stage non-small-cell lung cancer is lobectomy with mediastinal lymph-node dissection or systematic lymph-node sampling. The evidence behind this recommendation is based on the sole randomized controlled trial conducted to date, done by the Lung Cancer Study Group and published in 1995, which found a superiority for lobectomy over sublobar resection with regard to local recurrence rate and improved survival. The population studied at that time were medically fit patients at low risk for surgery with a stage IA non-small-cell lung carcinoma, ie, a solitary tumor less than 3 cm in size. In practice, however, thoracic surgeons have continued to push the limit of a more conservative surgical resection in this patient population. Since then, several retrospective studies have attempted to identify the ideal population to benefit from sublobar resection without it affecting survival or local recurrence. Several variables have been studied, including tumor size, patient age, surgical approach, histological and radiological properties, and optimal surgical resection margin, as well as promising prognostic biomarkers. In this review, we summarize the data available in the literature regarding the surgical approach to patients with stage IA non-small-cell lung cancer studying all the aforementioned variables.

Video-assisted thoracic lobectomy for lung cancer in Italy: the ‘VATS Group’ Project

As part of the third Mediterranean Symposium in Thoracic Surgical Oncology, we introduce the Italian VATS Group ( http://vatsgroup.org/sito/index.php ). This national collaborative initiative was established in 2013 and started to recruit patients in January 2014; as of July 2016, 3680 patients have been enrolled in the database. Three different video-assisted thoracic surgery approaches have been predominantly used by Italian thoracic surgery centers, 71% of them preferentially adopting a multi-portal approach, with a 20% recorded morbidity. The majority of the cases were stage I adenocarcinomas of the lung. Conversion to open surgery occurred in 9% of the cases. The study suggests video-assisted thoracic surgery lobectomy as a ‘gold standard’ for the surgical treatment of early-stage lung cancer in Italy.