The Society of Thoracic Surgeons General Thoracic Surgery Database: 2023 Update on Outcomes and Research

Robotic Lung Transplantation: Feasibility, Initial Experience, and 3-Year Outcomes

BACKGROUND

Lung transplantation is performed through clamshell or sternotomy incisions, which may contribute to morbidity and limit patient eligibility. Robotic lung transplantation offers a less-invasive alternative, but data informing treatment choice are limited. This study was therefore designed to evaluate midterm outcomes of robotic and minimally invasive lung transplantation.

METHODS

Consecutive patients undergoing robotic or minimally invasive lung transplant (defined by <6-cm minithoracotomy) from October 2021 to February 2025 were included in a prospective registry. The primary end point was 1-year survival. A linear mixed-effects regression model compared postoperative pulmonary function. Median follow-up time was 1.8 years (interquartile range, 1-4 years).

RESULTS

During the study period, 209 lung transplants, including 111 (53.1%) minimally invasive (21 robotic [10%] and 90 nonrobotic [43.1%]), were performed at a single center. Three patients were converted from robotic to nonrobotic approaches. The robotic cohort had similar risk factors and lung allocation scores but longer median waiting list times (50 days vs 22.5 days, P = .02) compared with nonrobotic minimally invasive recipients, and mean ischemic time was 486 minutes vs 406 minutes (P = .02), respectively. There were no significant differences in postoperative ventilator support <48 hours (76.2% vs 75.6%, P = .79), early severe primary graft dysfunction (4.8% vs 8.9%, P = .53), hospital stay (14.1 vs 14.3 days, P = .95), postoperative pulmonary function, or 1-year unadjusted survival (95.0% vs 95.5%, log-rank P = .84) in robotic compared with nonrobotic minimally invasive recipients.

CONCLUSIONS

This experience with robotic lung transplantation suggests it is associated with midterm outcomes similar to nonrobotic lung transplantation, despite longer ischemic times.

Impact of Frozen Section Pathology Examination of Surgical Margins in Sublobar Pulmonary Resections for Clinical Stage IA Non-small Cell Lung Cancer

BACKGROUND

Sublobar resections are a valid surgical option for many patients with clinical stage IA non-small cell lung cancer (NSCLC). However, assessment of planned lines of resection can be limited when done using robotic technology. Further, incomplete resections are associated with worse outcomes. This study evaluated routine frozen section pathology (FSP) evaluation of margins during sublobar resections for clinical IA NSCLC.

METHODS

Patients with clinical stage IA NSCLC who underwent lung resections during 2018 to 2023 were reviewed. Only patients with a preoperative intention to undergo sublobar resection were included. FSP reports were compared with final pathology. Operative notes were reviewed to determine changes in surgical plan based on intraoperative FSP evaluation of margins.

RESULTS

Of 1008 patients who underwent surgery, 642 (63.7%) had a preoperative plan to undergo sublobar resection. Median preoperative tumor size was 1.5 cm (interquartile range, 1.1-2.0 cm). A positive margin was identified in 8 patients (1.25%) intraoperatively or postoperatively. FSP successfully identified 7 of 8 patients (87.5%) intraoperatively, all corresponding to the parenchymal margin. In 5 of 7 patients (71.4%), the surgeon could alter the procedure to achieve a final negative margin. The final rate of non-R0 resection was 3 of 642 (0.47%). Therefore, FSP decreased the potential rate of non-R0 resection from 1.25% to 0.47% (62% reduction).

CONCLUSIONS

FSP is a valuable tool to assess resection margins during intended sublobar resections of clinical stage IA NSCLC. Intraoperative margin analysis can identify most patients with positive margins, allowing the surgeon to alter the planned procedure, if appropriate, minimizing non-R0 resections.

Protective Coronary Artery Bypass Grafting Improves Surgical Outcomes in Acute Type A Aortic Dissection With Coronary Ostial Involvement

BACKGROUND

Acute type A aortic dissection (ATAAD) with coronary ostial involvement poses significant surgical challenges. We describe two surgical approaches to managing coronary involvement and assess their outcomes.

METHODS

Between January 2019 and December 2023, 617 acute type A aortic dissection patients with coronary involvement were enrolled. Based on our institutional surgical protocol, 507 patients underwent isolated coronary ostial reconstruction, whereas 110 received protective coronary artery bypass grafting (CABG) after coronary ostial reconstruction or closure in cases of severe coronary involvement (defined as Neri A with >50% ostial margin involvement, Neri B with distal entry, or Neri C). Serious adverse events were defined as operative mortality, mechanical support, or stroke. Logistic regression identified factors associated with serious adverse events.

RESULTS

Operative mortality occurred in 23 patients (3.73%), and 44 patients (7.13%) experienced serious adverse events. Despite more severe coronary involvement (P < .001) and coronary malperfusion (P < .001) at baseline, the protective CABG group showed significantly lower procedural myocardial injury (2.73% vs 9.27%, P = .037) and a trend toward fewer serious adverse events (2.73% vs 8.09%, P = .076). Logistic regression identified that protective CABG was associated with a reduced risk of serious adverse events (odds ratio, 0.24; 95% CI, 0.07-0.86; P = .028). The median follow-up was 25.95 months. Kaplan-Meier analysis revealed no significant difference in cumulative survival between the 2 groups (log-rank P = .70).

CONCLUSIONS

Our institutional surgical protocol demonstrates safety and effectiveness. The protective CABG approach was associated with a reduced risk of serious adverse events without impacting overall survival, supporting its more aggressive use in acute type A aortic dissection with severe coronary involvement.

The Society of Thoracic Surgeons General Thoracic Surgery Database: 2024 Update on Outcomes and Research

The Society of Thoracic Surgeons General Thoracic Surgery Database (STS GTSD) remains the largest and most comprehensive audited thoracic surgical database in the world. As the STS GTSD grows to nearly 1 million cases, the pulmonary resection for cancer and esophagectomy short-term risk models have been refined to provide participants with benchmarked performance reports to facilitate quality improvement efforts. New for 2025 will be the development of long-term risk models and the online release of both short- and long-term risk calculators. A voluntary module to collect neoadjuvant targeted and immunotherapy data has been created and accepted by participants and is rapidly accruing data. STS GTSD participant public reporting has increased 50% over the last 2 years after the application of the U.S. News & World Report 3% transparency credit. All GTSD data analyses are now performed internally by the STS Research and Analytic Center, resulting in multiple publications through the Access & Publication, Task Force on Funded Research and Participant User File mechanisms. Future initiatives include the incorporation of patient-reported outcomes into the STS GTSD, revision of the data collection form to incorporate variables associated with long-term outcomes, and focused efforts to increase the value of STS GTSD participation. This report delineates volume trends, recent initiatives, and the prolific research output emanating from the STS GTSD, reflecting a year of substantial progress and academic productivity.

Single-Port Robot-Assisted Minimally Invasive Esophagectomy Using the Single-Port Robotic System via the Subcostal Approach: A Single-Center Retrospective Study

BACKGROUND

Robot-assisted minimally invasive esophagectomy (RAMIE) has gained global popularity. Recent randomized controlled trials have demonstrated that RAMIE results in reduced operative times and a greater number of dissected lymph nodes compared to conventional minimally invasive esophagectomy (MIE). This study provides an initial analysis of single-port (SP) robot-assisted minimally invasive esophagectomy (SRAMIE) using the SP robotic system via the subcostal approach. The primary objective is to examine perioperative outcomes of SRAMIE compared to multi-port RAMIE (MRAMIE) using the Xi robotic system and video-assisted thoracoscopic esophagectomy (VAE).

METHODS

In this retrospective study, patients who underwent MIE at a single center between February 2017 and December 2024 were analyzed. Patients were divided into SRAMIE (n = 17), MRAMIE (n = 13), and VAE (n = 23) groups. The primary outcome was the incidence of postoperative complications. Secondary outcomes included chest tube duration, length of postoperative hospital stay, postoperative pain levels, and 30-day mortality.

RESULTS

The SRAMIE group did not experience conversions to thoracotomy or VAE. Compared with VAE, SRAMIE resulted in significantly shorter chest tube duration (p = 0.038), shorter postoperative hospital stays (p = 0.036), and lower peak postoperative pain (p = 0.003). No significant differences were observed among the groups regarding the total operative time, number of resected lymph nodes, or incidence of postoperative complications.

CONCLUSIONS

SRAMIE is a feasible approach offering advantages over VAE in recovery and postoperative pain. The comparable perioperative outcomes suggest that SRAMIE may be a viable alternative to conventional MIE, warranting further large-scale studies.

Minimally Invasive Pneumonectomy vs Open Pneumonectomy: Outcomes and Predictors of Conversion

BACKGROUND

In the modern era, whether minimally invasive pneumonectomy for non-small cell lung cancer (NSCLC) provides a survival advantage over open pneumonectomy is unknown.

METHODS

Patients who underwent pneumonectomy for NSCLC between 2015 and 2020 were queried from the National Cancer Database. Surgical approach was categorized as robot-assisted thoracoscopic surgery (RATS), video-assisted thoracoscopic surgery (VATS), or open pneumonectomy on an intention-to-treat basis. Propensity score matching was performed to balance patient cohorts. Univariate and multivariate regression analyses were used to examine the association between surgical approach and 30- and 90-day mortality, and a Cox proportional hazards model was used to assess overall survival.

RESULTS

We identified 3784 patients, including 73% open (n = 2776), 19% VATS (n = 725), and 8% RATS (n = 283). The overall conversion rate from minimally invasive to open was 29.5% (n = 298). After propensity matching 212 patients per cohort, there were no differences between open, VATS, and RATS 30-day (9.4% vs 8.5% vs 7.5%, respectively; P = .807) or 90-day mortality (14.2% vs 12.3% vs 10.4%, respectively; P = .516). Median overall survival was similar among open (48 months; 95% CI, 35.6-64.1 months), VATS (51.0 months; 95% CI, 34.9-72.3 months), and RATS approaches (50 months; 95% CI, 42.6-NA months; P = .560). Multivariate analysis of the matched cohort found no association between approach and overall survival. RATS (odds ratio, 0.67; 95% CI, 0.47-0.94; P = .020) and neoadjuvant chemotherapy (odds ratio, 0.52, 95% CI, 0.27-0.98; P = .045) were found to be protective against conversion to open.

CONCLUSIONS

Minimally invasive pneumonectomy can be performed with short-term and long-term survival that are equivalent to open pneumonectomy.

Predictors of Opioid Prescription Refill After Lung Cancer Resection

INTRODUCTION

Thoracic surgery patients are among the least likely to be on opioids before surgery but have the highest rate of new persistent opioid use after surgery compared to other surgical cohorts. Nearly 27% of opioid-naïve lung cancer resection patients become new persistent opioid users. We aimed to identify risk factors for postdischarge opioid prescription refill within 90 ds of surgery for lung cancer resection patients.

METHODS

Retrospective cohort study of all opioid-naïve patients undergoing lung cancer resection from July 2018 to May 2021 at an academic medical center. Multivariable logistic regression was used to identify risk factors for opioid prescription refill between discharge and 90 ds after surgery.

RESULTS

The cohort included 152 patients, 100 (65.8%) women with a median (IQR) age of 71 (65 - 75) and 115 (75.7%) of whom lived with family or friends (versus. alone). Twenty-nine (19.1%) patients had an opioid prescription refill after discharge. Risk factors for opioid prescription refill included living with others (adjusted odds ratio [aOR] 5.31, 95% CI 1.06-26.64), thoracotomy (4.31, 1.37-13.52), chest tube duration (days) (1.14, 1.02-1.27), age (1.08, 1.01-1.16), and morphine milligram equivalents (MME) on the day before discharge (1.07, 1.02-1.11).

CONCLUSIONS

We identified risk factors for opioid prescription refill after lung cancer resection: living with family or friend (versus alone), thoracotomy, chest tube duration, increasing age, and MME on the day before discharge. Some of these, namely thoracotomy, chest tube duration, and MME on the day before discharge, may aid patient-centered opioid prescribing.

Practical Guide to Clinical Big Data Sources

This Guide to Statistics and Methods summarizes the limitations and considerations when using large datasets comprising patient-level data, typically abstracted from institutional electronic health records, in health services research.

2024 Update of The Society of Thoracic Surgeons Short-term Esophagectomy Risk Model: More Inclusive and Improved Calibration

BACKGROUND

The Society of Thoracic Surgeons General Thoracic Surgery Database (STS-GTSD) previously reported short-term risk models for esophagectomy for esophageal cancer. We sought to update existing models using more inclusive contemporary cohorts, with consideration of additional risk factors based on clinical evidence.

METHODS

The study population consisted of adult patients in the STS-GTSD who underwent esophagectomy for esophageal cancer between January 2015 and December 2022. Separate esophagectomy risk models were derived for 3 primary end points: operative mortality, major morbidity, and composite morbidity or mortality. Logistic regression with backward selection was used, with predictors retained in models if P < .10. All derived models were validated using 9-fold cross-validation. Model discrimination and calibration were assessed for the overall cohort and specified subgroups.

RESULTS

A total of 18,503 patients from 254 centers underwent esophagectomy for esophageal cancer. Operative mortality, morbidity, and composite morbidity or mortality rates were 3.4%, 30.5%, and 30.9%, respectively. Novel predictors of short-term outcomes in the updated models included body surface area and insurance payor type. Overall discrimination was similar or superior to previous STS-GTSD models for operative mortality (C statistic = 0.72) and for composite morbidity or mortality (C statistic = 0.62), Model discrimination was comparable across procedure- and demographic-specific subcohorts. Model calibration was excellent in all patient subgroups.

CONCLUSIONS

The newly derived esophagectomy risk models showed similar or superior performance compared with previous models, with broader applicability and clinical face validity. These models provide robust preoperative risk estimation and can be used for shared decision making, assessment of provider performance, and quality improvement.

Initial experience with the da Vinci single-port system in patients with an anterior mediastinal mass

OBJECTIVES

The da Vinci single-port system is a novel robotic system that has gained popularity and demonstrated favourable outcomes in various surgical fields. Nevertheless, its application in thoracic surgery is relatively rare. In this study, we report our initial experiences with the da Vinci single-port system via a subxiphoid approach in patients with an anterior mediastinal mass.

METHODS

We retrospectively reviewed patients with an anterior mediastinal mass who underwent surgery using the da Vinci single-port system via a subxiphoid approach between October 2020 and April 2024. Clinicopathological, intraoperative, and postoperative data were retrospectively collected.

RESULTS

A total of 14 patients were included in this study. The median age was 55 years (interquartile range 48-62 years), with 4 (28.6%) patients being male. All patients underwent complete resection without conversion to multiport or open surgery. The median operation time was 135 min (interquartile range 113-155 min). Nine (64.3%) patients were diagnosed with thymoma, and 2 (14.3%) patients had myasthenia gravis. The median pathologic size of the mass was 32.5 mm (interquartile range 25.3-38.0 mm), and the median peak Numerical Rating Scale score was 3 (interquartile range 2-4). The median duration of chest drainage and hospital stay were 2 (interquartile range 1-3) and 3 (interquartile range 2-3) days, respectively. No complications were reported following surgery.

CONCLUSIONS

The da Vinci single-port system for anterior mediastinal mass was deemed safe and feasible. To expand indications in thoracic surgery, further accumulation of experience and additional technological advancements are necessary.

A case report of a bleeding case after removal of chest drain after lung surgery

RATIONALE

Postoperative bleeding after lobectomy is relatively rare. By analyzing and discussing the case history and management of hemorrhagic shock caused by chest tube removal after lobectomy, we can achieve the purpose of preventing postoperative bleeding after thoracic surgery and reducing postoperative complications, which can help avoid the risk of second surgery, shorten the patient's hospital stay, reduce the cost of medical care, and improve the patient's quality of life.

PATIENT CONCERNS

A case of bleeding from tube removal after lobectomy. The bleeding from chest drain removal on the 3rd day after thoracoscopic lobectomy resulted in hemorrhagic shock, which was stopped by thoracoscopic exploration again under active antishock, and there was no recurrence of bleeding after the operation, and the patient was discharged from the hospital after chest drain removal.

DIAGNOSES

Enhanced computed tomography of the chest revealed a space-occupying lesion in the middle lobe of the right lung.

INTERVENTIONS

Thoracoscopy was performed again on the condition of active anti-shock.

OUTCOMES

On the third day after thoracoscopic lobectomy, the patient underwent removal of the chest drain and subsequently experienced hemorrhagic shock. Given the necessity of maintaining anti-shock measures, the patient was subjected to a second thoracoscopic exploration with the objective of halting the hemorrhage. Following this procedure, the patient did not present with any further episodes of bleeding. Subsequently, a new chest drain was placed, and once the drainage flow had diminished to an acceptable level, the chest drain was removed. The patient subsequently made a full recovery and was discharged from the hospital.

LESSONS

Even if the safely inserted drain tube is removed, the thoracic surgeon must be aware of possible vascular bleeding.

Lobar or sublobar resection of peripheral stage I non-small cell lung cancer

PURPOSE OF REVIEW

We aim to highlight two recent clinical trials that have altered the approach of the management of stage I nonsmall cell lung cancer.

RECENT FINDINGS

The JCOG 0802 and CALGB 140503 trials demonstrated that sublobar resection is noninferior to lobectomy for overall and disease-free survival in patients with stage I nonsmall cell lung cancer.

SUMMARY

Since 1962, lobectomy has been deemed the gold standard treatment for operable lung cancer. However, two recent clinical trials have demonstrated that, for select patients, sublobar resection is oncologically noninferior; results, which are leading us into a new era for the surgical management of lung cancer. Notwithstanding the progress made by these studies and the opportunities that have been put forth, questions remain. This review aims at reviewing the results of both trials and to discuss future perspectives for the surgical treatment of lung cancer.

Video-Assisted vs Robotic-Assisted Lung Lobectomies for Operating Room Resource Utilization and Patient Outcomes

Importance

With increased use of robots, there is an inadequate understanding of minimally invasive modalities' time costs. This study evaluates the operative durations of robotic-assisted vs video-assisted lung lobectomies.

Objective

To compare resource utilization, specifically operative time, between video-assisted and robotic-assisted thoracoscopic lung lobectomies.

Design, Setting, and Participants

This retrospective cohort study evaluated patients aged 18 to 90 years who underwent minimally invasive (robotic-assisted or video-assisted) lung lobectomy from January 1, 2020, to December 31, 2022, with 90 days' follow-up after surgery. The study included multicenter electronic health record data from 21 hospitals within an integrated health care system in Northern California. Thoracic surgery was regionalized to 4 centers with 14 board-certified general thoracic surgeons.

Exposures

Robotic-assisted or video-assisted lung lobectomy.

Main Outcomes and Measures

The primary outcome was operative duration (cut to close) in minutes. Secondary outcomes were length of stay, 30-day readmission, and 90-day mortality. Comparisons between video-assisted and robotic-assisted lobectomies were generated using the Wilcoxon rank sum test for continuous variables and the χ2 test for categorical variables. The average treatment effects were estimated with augmented inverse probability treatment weighting (AIPTW). Patient and surgeon covariates were adjusted for and included patient demographics, comorbidities, and case complexity (age, sex, race and ethnicity, neighborhood deprivation index, body mass index, Charlson Comorbidity Index score, nonelective hospitalizations, emergency department visits, a validated laboratory derangement score, a validated institutional comorbidity score, a surgeon-designated complexity indicator, and a procedural code count), and a primary surgeon-specific indicator.

Results

The study included 1088 patients (median age, 70.1 years [IQR, 63.3-75.8 years]; 704 [64.7%] female), of whom 446 (41.0%) underwent robotic-assisted and 642 (59.0%) underwent video-assisted lobectomy. The median unadjusted operative duration was 172.0 minutes (IQR, 128.0-226.0 minutes). After AIPTW, there was less than a 10% difference in all covariates between groups, and operative duration was a median 20.6 minutes (95% CI, 12.9-28.2 minutes; P < .001) longer for robotic-assisted compared with video-assisted lobectomies. There was no difference in adjusted secondary patient outcomes, specifically for length of stay (0.3 days; 95% CI, -0.3 to 0.8 days; P = .11) or risk of 30-day readmission (adjusted odds ratio, 1.29; 95% CI, 0.84-1.98; P = .13). The unadjusted 90-day mortality rate (1.3% [n = 14]) was too low for the AIPTW modeling process.

Conclusions and Relevance

In this cohort study, there was no difference in patient outcomes between modalities, but operative duration was longer in robotic-assisted compared with video-assisted lung lobectomy. Given that this elevated operative duration is additive when applied systematically, increased consideration of appropriate patient selection for robotic-assisted lung lobectomy is needed to improve resource utilization.