Manu S. Sancheti

Nodal Upstaging Is More Common with Thoracotomy than with VATS During Lobectomy for Early-Stage Lung Cancer: An Analysis from the National Cancer Data Base

Introduction: Questions remain regarding differences in nodal evaluation and upstaging between thoracotomy (open) and video‐assisted thoracic surgery (VATS) approaches to lobectomy for early‐stage lung cancer. Potential differences in nodal staging based on operative approach remain the final significant barrier to widespread adoption of VATS lobectomy. The current study examines differences in nodal staging between open and VATS lobectomy. Methods: The National Cancer Data Base was queried for patients with clinical stage T2N0M0 or lower lung cancer who underwent lobectomy in 2010–2011. Propensity score matching was performed to compare the rate of nodal upstaging in VATS with that in open approaches. Additional subgroup analysis was performed to assess whether rates of upstaging differed by specific clinical setting. Results: A total of 16,983 lobectomies were analyzed; 4935 (29.1%) were performed using VATS. Nodal upstaging was more frequent in the open group (12.8% versus 10.3%; p < 0.001). In 4437 matched pairs, nodal upstaging remained more common for open approaches. For a subgroup of patients who had seven lymph or more nodes examined, propensity matching revealed that nodal upstaging remained more common after an open approach than after VATS (14.0% versus 12.1%; p = 0.03). For patients who were treated in an academic/research facility, however, the difference in nodal upstaging between an open and VATS approach was no longer significant (12.2% versus 10.5%, p = 0.08). Conclusions: For early‐stage lung cancer, nodal upstaging was observed more frequently with thoracotomy than with VATS. However, nodal upstaging appears to be affected by facility type, which may be a surrogate for expertise in minimally invasive surgical procedures.

Nonclinical Factors Associated with 30-Day Mortality after Lung Cancer Resection: An Analysis of 215,000 Patients Using the National Cancer Data Base

BACKGROUND Clinical variables associated with 30-day mortality after lung cancer surgery are well known. However, the effects of nonclinical factors, including insurance coverage, household income, education, type of treatment center, and area of residence, on short-term survival are less appreciated. We studied the National Cancer Data Base, a joint endeavor of the Commission on Cancer of the American College of Surgeons and the American Cancer Society, to identify disparities in 30-day mortality after lung cancer resection based on these nonclinical factors. STUDY DESIGN We performed a retrospective cohort analysis of patients undergoing lung cancer resection from 2003 to 2011 using the National Cancer Data Base. Data were analyzed using a multivariable logistic regression model to identify risk factors for 30-day mortality. RESULTS During our study period, 215,645 patients underwent lung cancer resection. We found that clinical variables, such as age, sex, comorbidity, cancer stage, preoperative radiation, extent of resection, positive surgical margins, and tumor size were associated with 30-day mortality after resection. Nonclinical factors, including living in lower-income neighborhoods with a lesser proportion of high school graduates, and receiving cancer care at a nonacademic medical center were also independently associated with increased 30-day postoperative mortality. CONCLUSIONS This study represents the largest analysis of 30-day mortality for lung cancer resection to date from a generalizable national cohort. Our results demonstrate that, in addition to known clinical risk factors, several nonclinical factors are associated with increased 30-day mortality after lung cancer resection. These disparities require additional investigation to improve lung cancer patient outcomes.

Pilot Study to Integrate Patient Reported Outcomes After Lung Cancer Operations Into The Society of Thoracic Surgeons Database

BACKGROUND A critical gap in The Society of Thoracic Surgeons (STS) Database is the absence of patient-reported outcomes (PRO), which are of increasing importance in outcomes and performance measurement. Our aim was to demonstrate the feasibility of integrating PRO into the STS Database for patients undergoing lung cancer operations. METHODS The National Institutes of Health Patient Reported Outcome Measurement Information System (PROMIS) includes reliable, precise measures of PRO. We used validated item banks within PROMIS to develop a survey for patients undergoing lung cancer resection. PRO data were prospectively collected electronically on tablet devices and merged with our institutional STS data. Patients were enrolled over 18 months (November 2014 to May 2016). The survey was administered preoperatively and at 1 and 6 months after lung cancer resection. RESULTS The study included 127 patients. All patients completed the initial postoperative survey, and 108 reached the 6-month follow-up. The most common procedure was video-assisted thoracic lobectomy (55%). At the first postoperative visit, there was a significant increase in pain, fatigue, and sleep impairment and a decrease in physical function. By 6 months, these PRO measures had generally improved toward baseline. CONCLUSIONS Collecting PRO data from lung cancer surgical patients and integrating the results into an institutional database is feasible. This pilot serves as a model for widespread incorporation of PRO data into the STS Database. Future integration of such data will continue to position the STS National Database as the gold standard for clinical registries. This will be necessary for assessing overall patient responses to different surgical therapies.

Outcomes After Surgery in High-Risk Patients With Early Stage Lung Cancer

BACKGROUND Patients with early stage lung cancer considered high risk for surgery are increasingly being treated with nonsurgical therapies. However, consensus on the classification of high risk does not exist. We compared clinical outcomes of patients considered to be high risk with those of standard-risk patients, after lung cancer surgery. METHODS A total of 490 patients from our institutional Society of Thoracic Surgeons data from 2009 to 2013 underwent resection for clinical stage I lung cancer. High-risk patients were identified by ACOSOG z4032/z4099 criteria: major: forced expiratory volume in 1 second (FEV1) 50% or less or diffusing capacity of lung for carbon monoxide (Dlco) 50% or less; and minor: (two of the following), age 75 years or more, FEV1 51% to 60%, or Dlco 51% to 60%. Demographics, perioperative outcomes, and survival between high-risk and standard-risk patients undergoing lobectomy and sublobar resection were compared. Univariate analysis was performed using the χ(2) test/Fishers exact test and the t test/Mann-Whitney U test. Survival was studied using a Cox regression model to calculate hazard ratios, and Kaplan-Meier survival curves were drawn. RESULTS In all, 180 patients (37%) were classified as high risk. These patients were older than standard-risk patients (70 years versus 65 years, respectively; p < 0.0001) and had worse FEV1 (57% versus 85%, p < 0.0001), and Dlco (47% versus 77%, p < 0.0001). High-risk patients also had more smoking pack-years than standard-risk patients (46 versus 30, p < 0.0001) and a greater incidence of chronic obstructive pulmonary disease (72% versus 32%, p < 0.0001), and were more likely to undergo sublobar resection (32% versus 20%, p = 0.001). Length of stay was longer in the high-risk group (5 versus 4 days, p < 0.0001), but there was no difference in postoperative mortality (2% versus 1%, p = 0.53). Nodal upstaging occurred in 20% of high-risk patients and 21% of standard-risk patients (p = 0.79). Three-year survival was 59% for high-risk patients and 76% for standard-risk patients (p < 0.0001). CONCLUSIONS Good clinical outcomes after surgery for early stage lung cancer can be achieved in patients classified as high risk. In our study, surgery led to upstaging in 20% of patients and acceptable 1-, 2-, and 3-year survival as compared with historical rates for nonsurgical therapies. This study suggests that empiric selection criteria may deny patients optimal oncologic therapy.

Transthoracic versus transhiatal resection for esophageal adenocarcinoma of the lower esophagus: A value-based comparison

Our objective was to compare clinical outcomes, costs, and resource use based on operative approach, transthoracic (TT) or transhiatal (TH), for resection of esophageal cancer.

Management of T2 Esophageal Cancer

Patients with clinically staged T2N0 esophageal cancer are a small subset of patients for whom therapy is not standardized. Current clinical staging modalities are lacking in providing accurate staging for the presumed T2N0 subset. Problems with overstaging and understaging can each have adverse consequences for the patient. Furthermore, the benefit of induction therapy versus esophagectomy followed by adjuvant therapy for upstaged patients is unproven. The management of this challenging group of patients is reviewed.

Anatomic resection to manage donor partial anomalous pulmonary venous return during lung transplantation: a case report and review.

INTRODUCTION Rare vascular malformations are discovered infrequently in donor lungs before implantation into recipients. However, the proper handling of such malformations can influence ischemic time, implantation strategies, and subsequent patient outcomes. CASE REPORT We report a simplified method for addressing the technical challenges of anomalous pulmonary venous return in a donor lung before implantation. CONCLUSIONS We demonstrate that anatomic resection is a safe and efficient method for managing this rare congenital vascular malformation.

Endotracheal Tube Management and Obstructed Airway

Thoracic surgery encompasses a wide array of surgical techniques, most of which require lung isolation for surgical exposure in the pleural cavity; this, in turn, demands an extensive knowledge of respiratory mechanics and modalities of airway control. Likewise, effective treatment of an acute central airway obstruction calls for a systematic approach using clear communication between teams and a comprehensive knowledge of available therapeutic modalities by the surgeon.

Preoperative Computed Tomography-Guided Pulmonary Lesion Marking in Preparation for Fluoroscopic Wedge Resection—Rates of Success, Complications, and Pathology Outcomes

PURPOSE In this study, we describe our experience of lesion marking with fiducial markers (FM) and microcoils (MC) facilitating same-day surgical wedge resection, including success rates, pathology outcomes, and complications. We also explored patient/nodular characteristics associated with developing complications. MATERIALS AND METHODS An IRB-approved single-institutional retrospective study of 136 patients who had 148 pulmonary nodules was conducted. All patients had CT-guided pulmonary nodule labeling with either FM (121) or MC (15) patients with plan for same-day fluoroscopic-guided wedge resection. RESULTS Of 136 (98%) patients, 133 had successful same-day wedge resection as planned; 2 had delayed but successful wedge resection surgery due to complications at the time of marker placement (fiducial embolization and hemorrhage/pneumothorax, respectively). A third patient ultimately needed lobectomy due to deep lesion location. Eighty percent [118/148] of resected nodules were malignant. Further, 68% of the total group of patients [93/136] had mild complications of various types including hemorrhage [44/136, 32%], pneumothorax [35/136, 26%], a combination of both hemorrhage and pneumothorax [10/136, 7%], or migration/embolization [4/136, 3%]. Depth of nodule from skin (P = 0.011) and pleura (P = 0.027) was significantly associated with complications. CONCLUSION CT-guided marking of small or deep pulmonary lesions using either fiducial markers or microcoils provides an effective means to aid surgeons to accomplish minimally invasive wedge resection. The importance of the success of this technique is supported by the high incidence (80%) of malignant lesion etiology found at postresection pathology. Although complications occurred, the vast majority were mild and did not alter planned same-day resection.

Freeze the pain away: The role of cryoanalgesia during a Nuss procedure.

From the Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga. Disclosures: Author has nothing to disclose with regard to commercial support. Received for publication Nov 2, 2015; accepted for publication Nov 2, 2015; available ahead of print Dec 6, 2015. Address for reprints: Manu Sancheti, MD, 5569 Peachtree Dunwoody Rd, Suite 200, Atlanta, GA 30342 (E-mail: msanch2@emory.edu). J Thorac Cardiovasc Surg 2016;151:889-90 0022-5223/