Nationwide Outcomes After Neoadjuvant Chemotherapy for Locally Advanced Sigmoid Colon Cancer-A Propensity Score-Matched Analysis

BACKGROUND

The role of neoadjuvant chemotherapy (NAC) in advanced sigmoid colon carcinoma remains to be further characterized. Rationale for NAC includes downstaging on final pathology and optimization of microscopically negative margins (R0 resection). We investigated rates of neoadjuvant chemotherapy use in advanced sigmoid colon cancer at academic cancer centers and assessed factors associated with likelihood of NAC administration.

METHODS

The National Cancer Database was queried from 2004 to 2017 for patients with clinical T3 or T4, N0-2, M0 sigmoid colon cancer who underwent surgical resection. Those with neoadjuvant radiation or metastatic disease were excluded. The outcomes of patients who did and did not receive neoadjuvant chemotherapy were evaluated for this retrospective cohort study.

RESULTS

There were 23,597 patients of whom 364 (1.5%) received NAC. More patients received NAC at academic (41%, P < .001) and high-volume centers (27%, P < .001). Patients with Medicare/Medicaid (39%) and private insurance (52%) were more likely to receive NAC (P < .001). There was a significantly higher rate of N2 to N1 downstaging in the NAC group. Propensity-score matching demonstrated comprehensive community cancer programs (CCCP) were less likely to provide NAC (OR 0.4; 95% CI 0.23, 0.70, P < .001). There was no difference in survival (P = .20), R0 resection (P = .090), or 30-day readmission rates (P = .30) in the NAC cohort compared to the non-NAC cohort.

CONCLUSIONS

Access to centers offering multi-disciplinary care with NAC prior to surgical resection is important. This care was associated with academic and high-volume centers and private or government-sponsored insurance. There was no difference in survival between NAC and non-NAC cohort.

Outcomes Among Malnourished Patients With Crohn's Disease Undergoing Elective Ileocecectomy: A Nationwide Analysis

BACKGROUND

Crohn's patients' nutritional status can be suboptimal given disease pathophysiology; the effect of a malnourished state prior to elective surgery on post-operative outcomes remains to be more clearly elucidated. This study aims to characterize the effect of malnutrition on post-operative outcomes and readmission patterns for Crohn's patients undergoing elective ileocecectomy using a nationally representative cohort.

METHODS

The colectomy-targeted National Surgical Quality Improvement Program Database (2016-2020) was used to identify patients with Crohn's disease without systemic complications who underwent elective ileocecectomy; emergency surgeries were excluded. Malnourished status was defined as pre-operative hypoalbuminemia <3.5 g/dL, weight loss >10% in 6 months, or body mass index <18.5 kg/m2 prior to surgery.

RESULTS

Of 1464 patients (56% female) who met inclusion criteria, 1137 (78%) were well-nourished and 327 (22%) were malnourished. Post-operatively, malnourished patients had more organ space surgical site infections (SSI) (9% vs 4% nourished groups, P < .001) and more bleeding events requiring transfusion (9% vs 3% nourished, P < .001). 30-day unplanned readmission was higher in the malnourished group (14% vs 9% nourished, P = .032). Index admission length of stay was significantly longer in the malnourished group (4 days [3-7 days] vs the nourished cohort: 4 days [3-5 days], P < .001).

DISCUSSION

Poor nutritional status is associated with organ space infections and bleeding as well as longer hospitalizations and more readmissions in Crohn's patients undergoing elective ileocecectomy. A detailed nutritional risk profile and nutritional optimization is important prior to elective surgery.

Outcomes of minimally invasive isolated tricuspid valve repair and replacement through right mini-thoracotomy

Objective

Isolated tricuspid valve surgery is uncommon and associated with high perioperative morbidity and mortality. We aimed to study the overall outcomes of patients who underwent minimally invasive right thoracotomy tricuspid valve surgery (Mini-TVS), consisting of either tricuspid valve repair (TVre) or replacement (TVR).

Methods

We performed a retrospective analysis of all Mini-TVS procedures (2017-2022), through which we identified isolated tricuspid valve surgeries. We examined in-hospital outcomes, survival analysis over a 4-year period, and competing risk analysis for reoperative surgery.

Results

Among a total of 51 patients, the average age was 60 ± 16 years, and 67% (n = 34) were female. Severe tricuspid regurgitation was present in all cases. Infective endocarditis was noted in 7.8% (n = 4), and 24% (n = 12) had preexisting pacemakers. Mini-TVS included TVre in 18 patients (35%) and TVR in 33 patients (65%). The in-hospital and 30-day mortality rates were 4% (n = 2) and 6% (n = 3), respectively. At 4 years, the overall TVS survival was 76% (confidence interval, 62-93%), with no significant difference between TVre and TVR (91% vs 69%, P = .16). At follow-up, 3 patients required repeat surgery for recurrent regurgitation after 2.6, 3.3, and 11 months, with a reoperation rate of 7.3% (confidence interval, 2.4-22%) at 2 years. Factors associated with worse overall survival included nonelective surgery, right ventricular dysfunction, serum creatinine >2 g/dL, and concomitant left-sided valve disease.

Conclusions

A nonsternotomy minimally invasive approach is a feasible option for high-risk patients. Midterm outcomes were similar in repair or replacement. Patients with right ventricular dysfunction and left-sided disease had worse outcomes.

Neoadjuvant vs Adjuvant Chemoimmunotherapy for Stage II-IIIB Non-Small Cell Lung Cancer

BACKGROUND

In patients with resectable non-small cell lung cancer (NSCLC), recent trials demonstrate survival benefit of chemoimmunotherapy over chemotherapy alone in both the neoadjuvant and adjuvant settings. To date, there is no direct comparison between neoadjuvant and adjuvant protocols. We compared neoadjuvant vs adjuvant chemoimmunotherapy for resectable stage II-IIIB NSCLC.

METHODS

We queried the National Cancer Database for patients who had undergone an operation for stage II-IIIB NSCLC and who had received neoadjuvant or adjuvant chemoimmunotherapy between 2015 and 2020. We used inverse probability weighting to adjust for confounding variables and used Kaplan-Meier survival curves and Cox regression to explore the relationship between treatment groups and overall survival (OS) at 3 years postoperatively.

RESULTS

The inverse probability-weighted cohort represented 2119 weighted patient cases (neoadjuvant, 1034; adjuvant, 1085). Kaplan-Meier analysis demonstrated a significant OS benefit for neoadjuvant chemoimmunotherapy compared with adjuvant chemoimmunotherapy in the weighted cohort (3-year OS: 77% [95% CI, 71%-83%] vs 68% [95% CI, 64%-72%]; P = .035). On adjusted Cox regression, neoadjuvant chemoimmunotherapy was associated with a significant OS benefit (hazard ratio, 0.70; 95% CI, 0.50-0.96; P = .027). Among patients for whom pathologic stage data were available, 25% of patients receiving neoadjuvant chemoimmunotherapy had a pathologic complete response, with an additional 32.5% being downstaged.

CONCLUSIONS

Neoadjuvant chemoimmunotherapy confers a significant OS benefit over adjuvant chemoimmunotherapy for patients with resectable stage II-IIIB NSCLC. Although randomized trials are needed to confirm our findings, strong consideration should be given to administering neoadjuvant chemoimmunotherapy to patients who are predetermined to receive systemic treatment.

The impact of social determinants of health on textbook oncological outcomes and overall survival in locally advanced non-small cell lung cancer

Objectives

Textbook oncological outcome (TOO) is a composite metric for surgical outcomes, including non-small cell lung cancer (NSCLC). We hypothesized that social determinants of health (SDH) can affect both the attainment of TOO and the overall survival (OS) in surgically resected NSCLC patients with pathological nodal disease.

Methods

We queried the National Cancer Database (2010-2017) for preoperative therapy-naïve lobectomies for NSCLC with tumor size <7 cm and pathologic N1/N2. Socioeconomic factors comprised SDH scores, where SDH negative (-) was considered if SDH ≥2 (disadvantage); otherwise, SDH was positive (+). TOO+ was defined as R0 resection, ≥5 lymph nodes resected, hospital stay <75th percentile, no 30-day mortality, adjuvant chemotherapy initiation ≤3 months, and no unplanned readmission. If one of these parameters was not achieved, the case was considered TOO-.

Results

Of 11,274 patients, 48% of cases were TOO+ and 38% were SDH+. A total of 15% of patients were SDH- and were less likely (adjusted odds ratio, 0.85; 95% confidence interval [CI], 0.78-0.92) to achieve TOO+ than patients with SDH+. After accounting for confounders, patients with TOO+ had 22% lower overall mortality than patients with TOO- (adjusted hazard ratio, 0.78; CI, 0.73-0.82). In contrast, SDH- remained an independently significant risk factor, reducing survival by 24% compared with SDH+ (adjusted hazard ratio, 1.24; CI, 1.17-1.32). The impact of SDH on OS was significant for both patients with TOO+ and TOO-: SDH+/TOO+ had the best OS and SDH-/TOO-had the worst OS.

Conclusions

SDH score has a significant association with TOO achievement and TOO-driven overall posttreatment survival in patients with lobectomy-resected NSCLC with postoperative pathologic N1/N2 nodal metastasis. Addressing SDH is important to optimize care and long-term survival of this patient population.

Postoperative day 1 discharge following robotic thoracoscopic pulmonary anatomic resections in the era of enhanced recovery protocol: A single-institution experience

Objective

Implementation and continuing optimization of enhanced recovery protocol after thoracic surgery results in significant improvement of postoperative outcomes. We observed a 10-fold increase in the rate of postoperative day (POD) 1 discharges following robotic thoracoscopic anatomic resections over time. We aimed to determine factors associated with safe POD1 discharges.

Methods

We performed a retrospective analysis of a prospectively maintained database of robotic anatomic pulmonary resections between July 1, 2012, and June 30, 2022, with patients of the last 2.5 years forming the basis of this study. Data collected included demographics, insurance types, Area Deprivation Index (indicator of poverty), and operative and postoperative variables including length of stay, opioid use, daily pain levels, readmissions, and outpatient interventions. Factors associated with POD1 were analyzed using a logistic regression module.

Result

In total, 279 patients met inclusion criteria (91 POD1 discharges, 32.6%; none discharged with a pleural catheter). There was neither an increase of postdischarge interventions for pleural complications nor readmission in early discharge patients. After adjusting for relevant factors, younger age, right middle lobectomy, lower opioid use on POD1, operating room finish before 4 PM, and low Area Deprivation Index were significantly associated with POD1 discharge. A subanalysis of 49 patients, who could have been discharged on POD1, identified hypoxemia requiring home oxygen, atrial fibrillation, and poorly controlled pain being common mitigatable clinical factors delaying POD1 discharge.

Conclusions

Safe POD1 discharge following robotic thoracoscopic anatomic resection was achieved in 32% of cases. Identification of positive and negative factors affecting early discharge provides guidance for further modifications to increase the number of POD1 discharges.

Impact of Bariatric Surgery on Mortality of Mitral Valve Surgery: A National Analysis

OBJECTIVE

Obesity is a common comorbidity of cardiac surgery patients. The goal of this study is to determine if a lower weight achieved through bariatric surgery has any association with mitral valve (MV) replacement or repair surgery mortality.

METHODS

This study used a retrospective analysis of the National Inpatient Sample dataset from 2012 to 2020. Adult patients who underwent MV surgery with normal weight following bariatric surgery (n = 1,125) and patients with obesity (n = 48,555) were compared. The primary outcome was in-hospital mortality.

RESULTS

This study included 49,680 patients. The median age was 64 (55 to 71) years, and the majority were female (55%). Bariatric surgery was found to significantly decrease the odds of mortality, even after adjusting for important covariates, indicating a reduction of mortality risk by 54% (adjusted odds ratio = 0.46, p = 0.024). Other significant protective factors include isolated and elective surgery. Significant risk factors were older age, female sex, and diabetes mellitus. Patients who were obese demonstrated longer lengths of stay (LOS), greater transfers to other facilities, and higher hospital costs.

CONCLUSIONS

In patients receiving MV surgery, bariatric surgery demonstrated significant survival benefits during hospitalization, in addition to reducing LOS and cost. Our data support prior evidence of bariatric surgery improving cardiovascular outcomes. Therefore, bariatric surgery may be a meaningful method of weight loss to improve surgical patient outcomes in patients with obesity. However, longer-term data are needed.

The essential role of non-steroidal anti-inflammatory drugs in pain control following robotic thoracoscopic lung resections

Background

Enhanced recovery after thoracic surgery (ERATS) protocols use a combination of analgesics for pain control. We investigated the effect of non-steroidal analgesic drugs (NSAIDs) on pain control by comparing patient levels and opioid requirements after robotic pulmonary resections.

Methods

We retrospectively analyzed our prospectively maintained institutional database for elective, opioid-naïve robotic thoracoscopic pulmonary resections. All patients received postoperative NSAIDs unless contraindicated or at the discretion of the attending surgeons. Our original protocol (ERATS-V1) was modified to optimize opioid-sparing effect without affecting pain control (ERATS-V2). Demographics, operative outcomes, and postoperative opioid dispensed [morphine milligram equivalent (MME)] were collected.

Results

A total of 491 patients (147 ERATS-V1; 344 ERATS-V2) were included in this study. There was no difference in patient characteristics or operative outcomes between ERATS cohorts. Protocol optimization was associated with a 2- to 10-fold reduction of postoperative opioid use without compromising pain control. In ERATS-V1 cohort, there was no difference in pain levels and opioid requirements with NSAID usage. In ERATS-V2 cohort, while pain levels were similar, higher in-hospital opioid consumption was observed in no-NSAID subgroup {MME: 20.5 [interquartile range (IQR), 4.8-40.5] vs. 12.0 (IQR, 2.0-32.2), P=0.0096, schedule II: 14.2 (IQR, 3.0-36.4) vs. 6.8 (IQR, 1.4-24.0), P=0.012} as well as total postoperative schedule II opioid requirement [17.8 (IQR, 3.0-43.5) vs. 8.8 (IQR, 1.5-30), P=0.032].

Conclusions

The opioid-sparing effect of NSAIDs was observed only in optimized ERATS patients. Modifications of our pre-existing ERATS was associated with a significant reduction of opioid consumption without affecting pain levels. This revealed the role of NSAIDs in postoperative pain management otherwise masked by excessive opioids use.

Predictors of outcomes in patients with obesity following mitral valve surgery

Objective

Few studies have assessed the outcomes of mitral valve surgery in patients with obesity. We sought to study factors that determine the in-hospital outcomes of this population to help clinicians provide optimal care.

Methods

A retrospective analysis of adult patients with obesity who underwent open mitral valve replacement or repair between January 1, 2012, and December 31, 2020, was conducted using the National Inpatient Sample. Weighted logistic regression and random forest analyses were performed to assess factors associated with mortality and the interaction of each variable.

Results

Of the 48,775 patients with obesity, 34% had morbid obesity (body mass index ≥40), 55% were women, 66% underwent elective surgery, and 55% received isolated open mitral valve replacement or repair. In-hospital mortality was 5.0% (n = 2430). After adjusting for important covariates, a greater risk of mortality was associated with older patients (adjusted odds ratio [aOR], 1.24; 95% CI, 1.08-1.43), higher Elixhauser comorbidity score (aOR, 2.10; 95% CI, 1.87-2.36), prior valve surgery (aOR, 1.63; 95% CI, 1.01-2.63), and more than 2 concomitant procedures (aOR, 2.83; 95% CI, 2.07-3.85). Lower mortality was associated with elective admissions (aOR, 0.70; 95% CI, 0.56-0.87) and valve repair (aOR, 0.58; 95% CI, 0.46-0.73). Machine learning identified several interactions associated with early mortality, such as Elixhauser score, female sex, body mass index ≥40, and kidney failure.

Conclusions

The complexity of presentation, comorbidities in older and female patients, and morbid obesity are independently associated with an increased risk of mortality in patients undergoing open mitral valve replacement or repair. Morbid obesity and sex disparity should be recognized in this population, and physicians should consider older patients and females with multiple comorbidities for earlier and more opportune treatment windows.

Achieving opioid-free discharge following robotic thoracic surgery: A single-institution experience

Objectives

Enhanced recovery after thoracic surgery (ERATS) protocols use a combination of analgesics for pain control and have been associated with decreased opioid requirements. We investigated the impact of continual ERATS refinement on the incidence of opioid-free discharge.

Methods

We retrospectively analyzed our prospectively maintained institutional database for elective, opioid-naive robotic thoracoscopic procedures. Demographics, operative outcomes, postoperative opioid dispensed (morphine milligram equivalent), and opioid discharge status were collected. Our primary outcome of interest was factors associated with opioid-free discharge; our secondary objective was to determine the incidence of new persistent opioid users.

Results

In total, 466 patients from our optimized ERATS protocol were included; 309 (66%) were discharged without opioids. However, 34 (11%) of patients discharged without opioids required a prescription postdischarge. Conversely, 7 of 157 patients (11%), never filled their opioid prescriptions given at discharge. Factors associated with opioid-free discharges were nonanatomic resections, mediastinal procedures, minimal pain, and lack of opioid usage on the day of discharge. More importantly, 3.2% of opioid-free discharge patients became new persistent opioid users versus 10.8% of patients filling opioid prescriptions after discharges (P = .0013). Finally, only 2.3% of opioid-naive patients of the entire cohort became chronic opioid users; there was no difference in the incidence of chronic use by opioid discharge status.

Conclusions

Optimized opioid-sparing ERATS protocols are highly effective in reducing opioid prescription on the day of discharge. We observed a very low rate of new persistent or chronic opioid use in our cohort, further highlighting the role ERATS protocols in combating the opioid epidemic.

Twenty-year survival following lung transplantation

Background

Lung transplantation median survival has seen improvements due to recognition of short-term survival factors but continues to trail behind other solid organs due to limited understanding of long-term survivorship. Given the creation of the United Network for Organ Sharing (UNOS) database in 1986, it was difficult to accrue data on long-term survivors until recently. This study characterizes factors impacting lung transplant survival beyond 20 years, conditional to 1-year survival.

Methods

Lung transplant recipients listed in UNOS from 1987 to 2002 who survived to 1 post-transplant year were reviewed. Kaplan-Meier and adjusted Cox regression analyses were performed at 20 and 10 years to identify risk factors associated with long-term outcomes independent of their short-term effects.

Results

A total of 6,172 recipients were analyzed, including 472 (7.6%) recipients who lived 20+ years. Factors associated with increased likelihood of 20-year survival were female-to-female gender match, recipient age 25-44, waitlist time >1 year, human leukocyte antigen (HLA) mismatch level 3, and donor cause of death: head trauma. Factors associated with decreased 20-year survival included recipient age ≥55, chronic obstructive pulmonary disease/emphysema (COPD/E) diagnosis, donor smoking history >20 pack-years, unilateral transplant, blood groups O&AB, recipient glomerular filtration rate (GFR) <10 mL/min, and donor GFR 20-29 mL/min.

Conclusions

This is the first study identifying factors associated with multiple-decade survival following lung transplant in the United States. Despite its challenges, long-term survival is possible and more likely in younger females in good waitlist condition without COPD/E who receive a bilateral allograft from a non-smoking, gender-matched donor of minimal HLA mismatch. Further analysis of the molecular and immunologic implications of these conditions are warranted.

Disparities in Survival Due to Social Determinants of Health and Access to Treatment in US Patients With Operable Malignant Pleural Mesothelioma

Importance

Outcomes of localized malignant pleural mesothelioma (MPM) remain poor despite multimodality therapy. It is unclear what role disparities have in the overall survival (OS) of patients with operable MPM.

Objective

To examine survival disparities associated with social determinants of health (SDOHs) and treatment access in patients with malignant pleural mesothelioma.

Design, Setting, and Participants

In this observational, retrospective cohort study, patients with MPM diagnosed between January 1, 2004, and December 31, 2017, were identified from the National Cancer Database with a maximum follow-up time of 13.6 years. The analysis was conducted from February 16, 2022, to July 29, 2022. Patients were included if they were diagnosed with potentially resectable clinical stage I to IIIA MPM, had epithelioid and biphasic histologic subtypes, and received chemotherapy. Patients were excluded if they could not receive curative surgery, were 75 years or older, or had metastasis, unknown stage, or tumor extension to the chest wall, mediastinal tissues, or organs.

Exposures

Chemotherapy alone vs chemotherapy with curative surgery in the form of pleurectomy and decortication or extrapleural pneumonectomy.

Main Outcomes and Measures

The primary end point was OS. Cox proportional hazards regression models were used to determine hazard ratios (HRs) for OS, including univariable and multivariable models controlling for potential confounders, including demographic, comorbidity, clinical, treatment, tumor, and hospital-related variables, as well as SDOHs.

Results

A total of 1389 patients with MPM were identified (median [IQR] age, 66 [61-70] years; 1024 [74%] male; 12 [1%] Asian, 49 [3%] Black, 74 [5%] Hispanic, 1233 [89%] White, and 21 [2%] of other race). The median OS was 1.7 years (95% CI, 1.6-1.8). Risk factors associated with worse OS included older age, male sex, Black race, low income, and low educational attainment. Factors associated with greater odds of survival included receipt of surgical therapy, recent year of treatment, increased distance to travel, and treatment at high-volume academic hospitals. The risk factors most strongly associated with poor OS included Black race (HR, 1.96; 95% CI, 1.43-2.69) and male sex (HR, 1.60; 95% CI, 1.38-1.86). Surgical treatment in addition to systemic chemotherapy (HR, 0.70; 95% CI, 0.61-0.81) was independently associated with improved OS, as were chemotherapy initiation (HR, 0.93; 95% CI, 0.87-0.99) and greater travel distance from the hospital (HR, 0.92; 95% CI, 0.86-0.98).

Conclusions and Relevance

In this retrospective cohort study of patients with operable MPM, there was significant variability in access to care by SDOHs. Addressing disparities in access to multimodality therapy can help ensure equity of care for patients with MPM.

Isolated Tricuspid Valve Repair Versus Replacement: Predictors of Mortality on the National Level

OBJECTIVE

Isolated tricuspid valve surgery (TVR) is rarely performed, and literature reports are confined to small sample sizes and old studies. Thus, the advantage of repair over replacement could not be determined. We aimed to evaluate repair and replacement outcomes along with predictors of mortality for TVR on a national level.

METHODS

All adult patients (18+ years old) who underwent TVR from 2011 to 2020 were identified using the National Inpatient Sample dataset. The primary outcome was in-hospital mortality. Secondary outcomes included complications, length of stay (LOS), hospitalization cost, and discharge disposition.

RESULTS

Over a 10-year period, 37,931 patients had TVR and predominantly underwent repair (n = 25,027, 66.0%). In comparison with patients who underwent tricuspid replacement, more patients with a history of liver disease and pulmonary hypertension presented for repair surgery, and fewer patients had endocarditis and rheumatic valve disease (P < 0.001). The repair group had less mortality, less stroke, shorter LOS, and reduced cost, while the replacement group had fewer myocardial infarctions (P < 0.05). However, the outcomes were not different for cardiac arrest, wound complications, or bleeding. After excluding congenital TV disease and adjusting for relevant factors, TV repair was associated with a reduced in-hospital mortality by 28% (adjusted odds ratio [aOR] = 0.72, P = 0.011). Older age increased mortality risk by 3-fold, prior stroke by 2-fold, and liver diseases by 5-fold (P < 0.001). Patients undergoing TVR in recent years had a better chance of survival (aOR = 0.92, P < 0.001).

CONCLUSIONS

TV repair has better outcomes than replacement does. Patient comorbidities and late presentation play an independently significant role in determining outcomes.

Surgical versus transcatheter aortic valve replacement: Impact of patient-prosthesis mismatch on outcomes

BACKGROUND

The hemodynamics of most prosthetic valves are often inferior to that of the normal native valve, and a significant proportion of patients undergoing surgical (SAVR) or transcatheter aortic valve replacement (TAVR) have high residual transaortic pressure gradients due to prosthesis-patient mismatch (PPM). As the experience with TAVR has increased and long-term outcomes are reported, a close look at the PPM literature is required in light of new evidence.

METHODS

For this review, we searched the Embase, Medline, and Cochrane databases from 2000 to 2022. Articles reporting PPM as an outcome following aortic valve replacements were identified and reviewed.

RESULTS

The impact of PPM on clinical outcomes in aortic valve replacement has not been clear as multiple studies failed to report PPM incidence. However, the PPM outcomes after SAVR vary more widely than after TAVR, ranging from 8% to 80% in SAVR and from 24% to 35% in TAVR. Incidence of severe PPM following redo SAVR ranges from 2% to 9% and following valve-in-valve TAVR is from 14% to 33%, however, while PPM is higher in valve-in-valve TAVR, patients had better survival rates.

CONCLUSIONS

The gap between valve performance and clinical outcomes in SAVR and TAVR could be reduced by carefully selecting patients for either treatment option. Understanding predictors of PPM can add to the safety, effectiveness, and increased survival benefit of both SAVR and TAVR.

Does valve morphological type impact TAVR outcomes?

Appropriate treatment for the bicuspid aortic valve demands attention to detail across the spectrum of bicuspid morphological types. Transcatheter aortic valve replacement outcomes, while encouraging, require in-depth evaluation before generalization to improve the precision of care.

Effect of COVID-19 on the delivery of care for thoracic surgical patients

Objective

In this study we aimed to determine the effect of the COVID-19 pandemic on the delivery of care for thoracic surgical patients at an urban medical center.

Methods

A retrospective analysis of all thoracic surgical cases from May 1, 2019, to December 31, 2020, was conducted. Demographic characteristics, preoperative surgical indications, procedures, final pathologic diagnoses, and perioperative outcomes were recorded. A census of operative cases, relevant ancillary services, and outpatient thoracic clinics were obtained from our institutional database.

Results

Six hundred nineteen cases were included in this study (329 pre-COVID-19 and 290 COVID-19, representing an 11.8% reduction). There were no differences in type of thoracic procedures or perioperative outcomes among the 2 cohorts. Prolonged reduction of thoracic surgical cases (50% of baseline) during the first half of the COVID-19 period was followed by a resurgence of surgical volumes to 110% of baseline in the second half. A similar incidence of cases were performed for oncologic indications during the first half whereas more benign cases were performed in the second half, coinciding with the launch of our robotic foregut surgery program. After undergoing surgery during the pandemic, none of our patients reported COVID-19 symptoms within 14 days of discharge.

Conclusions

During the initial surge of COVID-19, while there was temporary closure of operative services, our health care system continued to provide safe care for thoracic surgery patients, particularly those with oncologic indications. Since phased reopening, we have experienced a rebound of surgical volume and case mix, ultimately mitigating the initial negative effect of the pandemic on delivery of thoracic surgical care.

Optimization of an Enhanced Recovery After Surgery protocol for opioid-free pain management following robotic thoracic surgery

Objectives

Our Enhanced Recovery After Thoracic Surgery protocol was implemented on February 1, 2018, and firmly established 7 months later. We instituted protocol modifications on January 1, 2020, aiming to further reduce postoperative opioid consumption. We sought to evaluate the influence of such efforts on clinical outcomes and the use of both schedule II and schedule IV opioids following robotic thoracoscopic procedures.

Methods

A retrospective study of patients undergoing elective robotic procedures between September 1, 2018, and December 31, 2020, was conducted. Essential components of pain management in the original protocol included nonopioid analgesics, intercostal nerve blocks with long-acting liposomal bupivacaine diluted with normal saline, and opioids (ie, scheduled tramadol administration and as-needed schedule II narcotics). Protocol optimization included replacing saline diluent with 0.25% bupivacaine and switching tramadol to as needed, keeping other aspects unchanged. Demographic characteristics, type of robotic procedures, postoperative outcomes, and in-hospital and postdischarge opioids prescribed (ie, milligrams of morphine equivalent [MME]) were extracted from electronic medical records.

Results

Three hundred twenty-four patients met the inclusion criteria (159 in the original and 183 in the optimized protocol). There was no difference in postoperative outcomes or acute postoperative pain; there was a significant reduction of in-hospital and postdischarge opioid requirements in the optimized cohort. For anatomic resections: mean, 60.0 MME (range, 0-60.0 MME) versus mean, 105.0 MME (range, 60.0-150.0 MME), and other procedures: mean, 0 MME (range, 0-60 MME) versus mean, 140.0 (range, 60.0-150.0 MME) (P < .00001) with median schedule II opioids prescribed = 0.

Conclusions

Small modifications to our protocol for pain management strategies are safe and associated with significant decrease of opioid requirements, particularly schedule II narcotics, during the postoperative period without influencing acute pain levels.

Size does matter: Yet BMI extremes are manageable in minimally invasive cardiac surgery

The obesity paradox has been recently challenged in the literature to spotlight a vague and ill-defined relationship between obesity extremes and cardiac morbidity and mortality. Patient size and incision size both remain important determinants of outcomes. Today, with obesity rates rising around the world, extremely obese patients require experienced teams and substantially improved care.

Implementation of an enhanced recovery after thoracic surgery care pathway for thoracotomy patients-achieving better pain control with less (schedule II) opioid utilization

Background

Enhanced recovery after surgery protocols incorporate evidence-based practices of pre-, intra- and post-operative care to achieve the most optimal surgical outcome, safe on-time discharge, and surgical cost efficiency. Such protocols have been adapted for specialty-specific needs and are implemented by a variety of surgical disciplines including general thoracic surgery. This study aims to evaluate the impact of our enhanced recovery after thoracic surgery (ERATS) protocol on postoperative outcomes, pain, and opioid utilization following thoracotomy.

Methods

This is a retrospective analysis of patients undergoing elective resection of intrathoracic neoplasms via posterolateral thoracotomy between 1/1/2016 and 3/1/2020. Our enhanced recovery protocol, with a focus on multimodal pain management (opioid-sparing analgesics, infiltration of local anesthetics into intercostal spaces and surgical wounds, and elimination of thoracic epidural analgesia) was initiated on 2/1/2018. Demographics, clinicopathology data, subjective pain levels, peri-operative outcomes, in-hospital and post-discharge opioid utilization were obtained from the electronic medical record.

Results

A total of 98 patients (43 pre- and 55 post-protocol implementation) were included in this study. There was no difference in perioperative outcomes or percentage of opioid utilization between the two cohorts. The enhanced recovery group had significantly less acute pain. A significant reduction of in-hospital potent schedule II opioid use was noted following ERATS implementation [average MME: 10.5 (3.5–16.5) (ERATS) vs. 19.5 (12.6–36.0) (pre-ERATS), P<0.0001]. More importantly, a drastic reduction of total and schedule II opioids dispensed at discharge was noted in the ERATS group [total MME: 150 (100.0–330.0) vs. 800.0 (450.0–975.0), P<0.0001 and schedule II MME: 90.0 (0–242.2) vs. 800.0 (450.0–975.0), P<0.0001; ERATS vs. pre-ERATS respectively]. A shorter hospital stay (median difference of 1 day, P=0.0012 and a mean difference of 2.4 days, P=0.0054) was observed in the enhanced recovery group.

Conclusions

Implementation of an enhanced recovery protocol for thoracotomy patients is safe and associated with elimination of thoracic epidural analgesia, decreased postoperative pain, shorter hospitalization, drastic reduction of post-discharge opioid dispensed and decreased dependence on addiction-prone schedule II narcotics.

Preparing end-stage heart failure patients and care providers in the era of climate change-driven hurricanes

Patients with end-stage congestive heart failure are at elevated risk for harm when extreme storms threaten and strike their communities. Individuals with compromised heart function require customized hurricane protection and preparedness approaches. We provide mitigation strategies for providers and their teams, as well as the patients themselves to ensure their safety and uninterrupted access to healthcare resources and quality care during hurricane impact and in the aftermath.

Left Pulmonary Artery Patch Augmentation for Lung Transplant in a Patient With Situs Inversus

Kartagener syndrome is characterized by situs inversus and defective cilia motion, the latter of which can lead to chronic infections and respiratory failure. If lung transplant is indicated, dextrocardia can pose surgical challenges. We report a rare case of sequential bilateral lung transplant in a 58-year-old man with Kartagener syndrome whose left pulmonary artery was abnormal in length, location, and direction. After placing the donor lungs in their orthotopic position, we augmented the recipient left pulmonary artery with a bovine pericardial patch. After 17 months of follow-up, the patient was in good condition with excellent graft function.

Comparative Analysis of Robotic Segmentectomy For Non-Small Cell Lung Cancer: A National Cancer Database Study

OBJECTIVE

The use of segmentectomy for peripheral T ≤2 cm, N0 non-small cell lung cancer (NSCLC) has increased in the last decade. We sought to compare clinical outcomes and overall survival between robotic, video-assisted thoracoscopic surgery (VATS), and open segmentectomy.

METHODS

The National Cancer Database was queried for patients with clinical T ≤2 cm, N0 NSCLC who underwent segmentectomy via robotic, thoracoscopic (VATS), and open approaches (2010 to 2015). Univariate and Cox regression analyses were used to compare surgical approaches and to evaluate predictors of overall survival. Statistical analyses were done using SPSS Version 21.0.

RESULTS

Segmentectomy was performed in 3,888 patients during the study period with 406 robotic, 1,837 VATS, and 1,645 open patients. VATS and robotic segmentectomy were performed more often at academic or comprehensive community cancer programs as compared to community programs (P < 0.05). Conversion to open thoracotomy was similar between robotic and VATS groups when stratified by hospital volume. Lymph node yield was significantly higher for robotic (median = 6), compared to VATS (median = 5) or open (median = 4; P < 0.001). Length of stay was decreased for robotic versus open (P < 0.01). No differences in 30-day readmissions (P = 0.12) were observed among the 3 modalities. Overall survival was similar among groups (P = 0.18).

CONCLUSIONS

Robotic segmentectomy provides similar clinical outcomes compared to other standardized approaches for clinical T ≤2 cm, N0 NSCLC. A higher lymph node yield in robotic segmentectomy was not associated with improved survival in this study population.

Current Surgical Risk Scores Overestimate Risk in Minimally Invasive Aortic Valve Replacement

OBJECTIVE

Risk-scoring systems for surgical aortic valve replacement (AVR) were largely derived from sternotomy cases. We evaluated the accuracy of current risk scores in predicting outcomes after minimally invasive AVR (mini-AVR). Because transcatheter AVR (TAVR) is being considered for use in low-risk patients with aortic stenosis, accurate mini-AVR risk assessment is necessary.

METHODS

We reviewed 1,018 consecutive isolated mini-AVR cases (2009 to 2015). After excluding patients with Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) scores ≥4, we calculated each patient's European System for Cardiac Operative Risk Evaluation (EuroSCORE) II, TAVR Risk Score (TAVR-RS), and age, creatinine, and ejection fraction score (ACEF). We compared all 4 scores' accuracy in predicting mini-AVR 30-day mortality by computing each score's observed-to-expected mortality ratio (O:E). Area under the receiver operating characteristic (ROC) curves tested discrimination, and the Hosmer-Lemeshow goodness-of-fit tested calibration.

RESULTS

Among 941 patients (mean age, 72 ± 12 years), 6 deaths occurred within 30 days (actual mortality rate, 0.6%). All 4 scoring systems overpredicted expected mortality after mini-AVR: ACEF (1.4%), EuroSCORE II (1.9%), STS-PROM (2.0%), and TAVR-RS (2.1%). STS-PROM best estimated risk for patients with STS-PROM scores 0 to <1 (0.6 O:E), ACEF for patients with STS-PROM scores 2 to <3 (0.6 O:E), and TAVR-RS for patients with STS-PROM scores 3 to <4 (0.7 O:E). ROC curves showed only fair discrimination and calibration across all risk scores.

CONCLUSIONS

In low-risk patients who underwent mini-AVR, current surgical scoring systems overpredicted mortality 2-to-3-fold. Alternative dedicated scoring systems for mini-AVR are needed for more accurate outcomes assessment.

Review of cerebral perfusion strategies for aortic surgery with application for minimally invasive approaches

Aortic arch and hemiarch surgery necessitate the temporary interruption of blood perfusion to the brain. Despite its complexity, hemiarch and ascending aortic surgery can be performed via a minimally invasive approach. Due to the higher risk of neurological injury during a circulatory arrest, several techniques were developed to further protect the brain during this surgery. We searched the Embase, Medline, and Cochrane databases and identified articles reporting outcomes of antegrade and retrograde cerebral perfusion strategies. Herein, we outline surgical approaches, intra-operative technical considerations, and clinical outcomes of hemiarch and ascending aortic surgery. Hemiarch and ascending aortic surgery is associated with a higher risk of mortality and morbidity. Attention to the optimal approach and cerebral protection strategy has been shown to significantly affect outcomes and mitigate risk.

Lobectomy Versus Stereotactic Body Radiotherapy in Healthy Octogenarians With Stage I Lung Cancer

BACKGROUND

Stereotactic body radiation therapy (SBRT) is increasingly being offered for early stage non-small cell lung cancer (NSCLC). We sought to evaluate long-term survival outcomes after lobectomy and SBRT in patients aged 80 years or more with stage I NSCLC.

METHODS

The National Cancer Database was queried for patients with clinical stage IA and IB (size 40 mm or smaller) NSCLC who underwent SBRT or lobectomy. Only patients with no comorbidities were selected. Number of lymph nodes (LN) examined was used to stratify lobectomy patients into 0 LN, 1 to 6 LN, and 7 or more LN. Propensity score analysis was used to adjust treatment groups. Kaplan-Meier and multivariate Cox regression analysis were used for survival analysis.

RESULTS

A total of 8964 patients with stage I NSCLC treated with lobectomy were compared with 286 patients who received SBRT. Using propensity matched pairs, lobectomy (7 LN or more) had significantly improved survival as compared with SBRT (median 74 vs 53.2 months, P < .05); however, no survival differences were observed when 0 LN were sampled (median 53.8 vs 52.3 months, P = .88). In multivariate analysis, lobectomy was associated with significantly improved survival (hazard ratio 0.726; 95% confidence interval; 0.580 to 0.910; P = .005). In addition, age, sex, high grade, and tumor size were independent predictors of survival.

CONCLUSIONS

Among healthy octogenarians with clinical stage I NSCLC who are good surgical candidates, lobectomy offers better survival than SBRT. Adequate LN dissection allows true nodal staging and opportunity for adjuvant treatment when unsuspected nodal metastases are found.

Minimally invasive, simplified double-layer left atrial appendage closure

The left atrial appendage (LAA) has been identified as a site of thrombus formation in the heart and as a source of embolism in patients with atrial fibrillation, leading to stroke. Studies suggest that LAA closure may reduce the risk for stroke and the need for anticoagulation; conversely, incomplete closure can increase the stroke risk almost 12-fold. Because open heart surgery is associated with increased risk for subsequent stroke, surgeons generally prefer to close the LAA during heart surgery, as recommended in current atrial fibrillation management guidelines. Building on trends toward minimally invasive approaches in cardiac surgery, we developed a simple, unique, and reproducible method for complete LAA closure during mitral valve surgery that has proven to be safe and efficacious: Our first three patients remained completely free from stroke and minor neurological manifestations 27 months after surgery.

Cannulation Strategies for Minimally Invasive Cardiac Surgery

OBJECTIVE

Operative techniques for minimally invasive cardiac surgery (MICS) have evolved dramatically over the past decade to include a wide demographic of patients. Mastering a variety of cannulation techniques is of paramount importance in performing a safe perfusion strategy and operation. Our aim is to describe cannulation strategies utilized in various MICS procedures.

METHODS

We review numerous cannulation strategies and their application in different minimally invasive procedures.

RESULTS

Cannulation strategies will vary depending on the MICS procedure and other anatomical variations and obstacles. Utilizing the appropriate cannulation strategy will allow for a safe and effective operation.

CONCLUSIONS

Mastering the art of cannulation will provide surgeons with a toolbox to choose from when performing MICS in a wide variety of procedures.

Device exchange from Heartmate II to HeartWare HVAD

BACKGROUND

Despite technological advancements, pump durability and pump-related complications continue to affect and adversely impact the lives of patients with end-stage heart failure on left ventricular assist device (LVAD) support. In an attempt to avoid recurrent LVAD-related complications, there may be circumstances where it is clinically advantageous to exchange a patient's device from HeartMate II to HeartWare HVAD. However, there is a paucity of data that describes the safety and feasibility of such an approach.

OBJECTIVE

We present the largest single-center series of HeartMate II (HMII) to HeartWare (HVAD) device exchanges.

METHODS

A retrospective review of 11 patients who underwent HMII to HVAD exchange from 2012 to 2017 was conducted to evaluate patient characteristics, incidence of postoperative complications, and survival.

RESULTS

Eleven male patients (mean age 55 ± 14.4 years) underwent HMII to HVAD device exchange. One patient expired on postoperative day 7 secondary to sepsis. One patient was lost-to-follow-up after 23 months. An additional three patients died at 5, 7, and 24 months. Mean follow-up after device exchange was 1555 ± 311 days for the remaining six patients. None of the 11 study patients underwent LVAD explant, further device exchange, or heart transplant.

CONCLUSION

Exchange of an HMII LVAD to an HVAD can be performed safely with acceptable perioperative morbidity and mortality.