Wellness Strategies Among Bad Outcomes and Complications.

Surgery of the chest is high stakes, and adverse events are common. Given the frequency and severity of such complications, cardiothoracic surgeons are at particularly high risk of becoming second victims. Even though our primary commitment as doctors is to take care of our patients, surgeons may fall into the emotional and intellectual trap of taking on the whole responsibility of a patient's poor outcome. This viewpoint may lead the physician to develop a heightened self-doubt, greater insecurity, and imposter syndrome, further affecting their ability to prevent complications and tackle difficult cases in the future.

Defining Pathologic Upstaging in cT1b Esophageal Cancer: Should We Consider Neoadjuvant Therapy?

INTRODUCTION: Neoadjuvant chemoradiation therapy (NCRT) for cT1b esophageal cancer is not recommended despite the risk of pathologic upstaging with increased depth of penetration. We aimed to (1) define the rate of and factors associated with pathologic upstaging, (2) describe current trends in treatments, and (3) compare overall survival (OS) with and without NCRT for surgically resected cT1b lesions. METHODS: We used the 2020 National Cancer Database to identify patients with cT1b N0 esophageal cancer with or without pathologic upstaging who underwent removal of their tumor. We built multivariable logistic regression models to assess factors associated with pathologic upstaging. Survival was compared using log-rank analysis and modeled using multivariable Cox proportional hazards regressions. RESULTS: Out of 1106 patients with cT1b esophageal cancer, 17.3% (N = 191) had pathologic upstaging. A higher tumor grade (P = 0.002), greater tumor size (P < 0.001), and presence of lympho-vascular invasion (P < 0.001) were associated with pathologic upstaging. 8.0% (N = 114) of patients were treated with NCRT. Five-y OS was 49.4% for patients who received NCRT compared to 67.2% for upfront esophagectomy (P < 0.05). Pathologic upstaging was associated with decreased OS (pathologic upstaging 43.7% versus no pathologic upstaging 67.7%) (hazard ratio 2.12 [95% confidence interval, 1.70-2.65; P < 0.001]). Compared to esophagectomy, endoscopic local tumor excision was associated with a decreased OS (hazard ratio 1.50 [95% confidence interval, 1.19-1.89; P = 0.001]). CONCLUSIONS: Pathologic upstaging of cT1b lesions is associated with decreased OS. Esophagectomy is associated with a survival benefit over endoscopic local tumor excision for these lesions. NCRT is not associated with an increase in OS in cT1b lesions compared to upfront esophagectomy.

Barriers to Parental Leave During Training: Time for Change.

BACKGROUND: Standardized parental leave policies for medical trainees are lacking, and barriers may differ among specialties. We aimed to characterize experiences of physicians who became parents during training and to identify particular issues for surgical trainees compared to their non-surgical peers. METHODS: We distributed an electronic survey to physician parents via social media platforms from 10/2019 to 02/2020. Inclusion required becoming a parent during training. Responses were collected and standard descriptive and comparative analyses were performed. RESULTS: Surveys were received from 64 physicians representing diverse specialties: 48 (74%) non-surgical respondents (NSR) and 16 (26%) surgical respondents (SR). Among all respondents, 25 (39%) reported a formal institutional policy for parental leave and 49 (76%) wished for more time off. Overall, respondents took a mean of 7.5 ± 5.2 (range 0-14) weeks of parental leave. However, NSR took 8.7 ± 5.8 weeks, while SR took 4.7 ± 2.7 (P = .006). Reported barriers to parental leave across specialties included graduation requirements (NSR 58% vs. SR 68% P = .46), peer pressure/perception (NSR 59% vs. SR 58% P = .97), and pressure from institutional leadership (NSR 31% vs. SR 35% P = .77). A substantial portion (28, 43%) of respondents had additional children during training, taking less time off for the second child (5.1 ± 7.4 weeks; 0-12). CONCLUSION: A minority of respondents reported formal institutional parental leave policies, while an overwhelming majority felt that their time off was inadequate. Surgical trainees took shorter parental leaves than their non-surgical counterparts. Cultural and professional changes are crucial in promoting wellness and healthy transitions into parenthood.

Risk of recipient age on 1-year mortality after simultaneous heart-lung transplantation.

BACKGROUND: Heart-lung transplantation (HLTx) is relatively uncommon, and there is a paucity of literature to suggest an age at which older recipients may be exposed to excess risk for mortality. This analysis aimed to identify a threshold of age that predicts adverse outcomes after HLTx. METHODS: The United Network of Organ Sharing registry was used to identify adult patients undergoing HLTx from 2005 to 2021. The primary outcome was 1-year mortality. Threshold regression was used to identify the threshold at which age impacts 1-year mortality. Kaplan-Meier analysis was used to model survival, and Cox proportional hazards modeling was used for risk-adjustment. RESULTS: We identified 453 patients undergoing HLTx. Threshold analysis identified that the risk for 1-year mortality was significantly elevated beyond an age of 58 years, and 47 (10.38%) patients were older than this threshold. On Kaplan-Meier analysis, 1-year survival was significantly lower in patients > 58 years compared to younger recipients (64.7% vs. 82.0%, p = .007). After risk adjustment, the hazard ratio for 1-year mortality in recipients older than 58 years was 2.27 (95% confidence interval [1.21-4.28], p = .011). CONCLUSION: A threshold for recipient age of 58 years of age may avoid excess 1-year mortality after HLTx. However, patients older than this threshold demonstrate acceptable early and midterm survival, and the majority survive to 1 year. Advanced age should be considered in patient selection for HLTx, but may not be a contraindication for candidacy particularly in the absence of other risk factors.

Prolonged neutrophilia is associated with worse outcomes after Esophagectomy.

Neutrophilia is a potential biomarker for postoperative complications and oncologic outcomes. There is a paucity of data regarding neutrophilia in patients with esophageal adenocarcinoma. Our Institutional Database was queried for esophageal adenocarcinoma patients who underwent esophagectomy from 2006 to 2019. Complete blood counts (CBC), demographic characteristics, perioperative and oncologic outcomes were evaluated. Two groups were created based on the presence of prolonged neutrophilia (PN, >7,000 absolute neutrophils 90 days after surgery). Univariate, multivariable, and survival analysis were performed (P-value < 0.05). We identified 686 patients with complete CBC data: 565 in the no prolonged neutrophilia (NPN) and 121 in the PN groups (17.6%). The mean age was 54 versus 48 years in the NPN and PN groups (P = 0.01). There was no difference in height, weight, gender, race, tumor size, histology, pTNM, PS, ASA, salvage procedure, neoadjuvant treatment and comorbidities. On multivariable analysis, the PN group had increased transfusions (19.8% vs. 11.9%; P = 0.02), aspiration (13.2% vs. 2.5%; P = 0.002), pulmonary embolus (3.3% vs. 0.4%; P = 0.02), cardiac arrest (5% vs. 0.4%; P = 0.02) and hematologic complications (23.1% vs. 12.6%; P = 0.01). After controlling for any postoperative complication, PN had increased distant recurrence (24% vs. 12.7%; hazard ration [HR]: 2.3, 95% confidence interval [CI] 1.42-3.9; P = 0.001) and decreased OS (33.8% vs. 49.7%, HR: 1.83, 95% CI: 1.19-2.81; P = 0.006); median follow up 77 months (46-109). PN was predictive of distant recurrence and decreased overall survival. Further work investigating these neutrophil populations represents a potential area for biomarker research, immunomodulation, and may guide postoperative surveillance strategies.

Social Disparities in Thoracic Surgery Database Research: Implications and Impact.

A complex relationship exists between health care disparities and large databases among the thoracic surgical patient population. Using the example of thoracic malignancies, the ability of investigations leveraging large databases and novel analytical approaches to highlight disparate access to care and discordant outcomes following treatment is illustrated. Large, widely used databases may not be representative of the thoracic surgical patient population as a whole, and caution must be used when interpreting and generalizing results gleaned from such database analyses. Ensuring appropriate representation of all relevant patient subgroups in research databases will improve external generalizability and scientific validity of future investigations.

Barriers to surveillance imaging adherence in early-staged lung cancer.

BACKGROUND: Frequency of post-treatment surveillance is highly variable following curative resection of non-small cell lung cancer (NSCLC). We sought to characterize surveillance practices after lobectomy for early-stage NSCLC and to identify the impact of various demographic factors on patterns of surveillance. METHODS: We included patients who underwent anatomic lobectomy for pathologic stage I NSCLC from 2007-2017. Demographic characteristics, post-operative imaging studies (internal and external), and travel distance were recorded. We defined the minimal standard of surveillance imaging studies (MSSIS) as ≥7 studies in the first 5 years (computed tomography/positron emission tomography). Patient sex, ethnicity, marital status, and distance traveled were evaluated as predictors of imaging receipt. Standard descriptive statistics, univariate, and multivariate analysis (MVR) were performed. RESULTS: A total of 1,288 patients were included. The mean age was 65.5±10.1 years, 589 (45.7%) were male, 1,081 (83.9%) were Caucasian, and 924 (71.7%) were married. Only 464 (36%) achieved MSSIS; being married [75.6% (351/464) vs. 68.8% (567/824), P=0.01] and having larger tumor size (2.63±0.04 vs. 2.49±0.05 cm, P=0.03) were both associated with MSSIS. Patients residing <100 miles from the hospital were more likely to have MSSIS, and more imaging at 24 months (4.1±2.2 vs. 3.7±2.0; P=0.006), 60 months (8.0±5.1 vs. 6.6±4.2, P=0.001) and overall (10±7.3 vs. 8.2±6.3; P=0.001). On MVR, tumor size and marital status were associated with MSSIS. CONCLUSIONS: Two-thirds of patients at our institution did not undergo recommended surveillance imaging. Tumor size, being married, and living <100 miles from the medical center were associated with an increased number of imaging studies and greater adherence to guidelines.

National practice trends for the surgical management of lung cancer in the CMS population: an atlas of care.

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) has been established as a safe and effective alternative to an open approach for the treatment of early-stage lung cancer. Despite this, differences in utilization across the nation are present. The aims of this study were to: (I) characterize trends in the use of open surgery and VATS for the management of lung cancer across the United States, and (II) describe if particular regions of the country utilize minimally invasive surgery more frequently. METHODS: We studied all Medicare beneficiaries from the ages of 65 to 99 years with full Part A and B coverage and no HMO coverage for the years of 2006 and 2014 (the most recent year available at the time of this analysis). Beneficiaries with a diagnosis of lung cancer (ICD-9 codes: 162.0 162.2 162.3 162.4 162.5 162.8 162.9) were selected. Rates of thoracoscopic surgery (CPT codes: 32663, 32666, 32667, 32668, 32669, 32670, 32671) and open lung resections (32505, 32506, 32507, 32608, 32440, 32442, 32445, 32480, 32482, 32484, 32486, 32488) were calculated by year and region. Rates in 2006 and 2014 with descriptive statistics and a univariate analysis were performed using Student's t-test and chi-square, as appropriate. A two-sided P value <0.05 was considered statistically significant. RESULTS: A total of 24,368,333 and 23,921,059 beneficiaries for the years of 2006 and 2014 were analyzed. A diagnosis of lung cancer was detected in claims of 167,418 patients (0.7%) in 2006 and 167,506 patients in 2014 (0.7%), which was not significantly different (P=0.7). Among these lung cancer patients, a surgical intervention was performed in 17,249 patients (10.3%) during 2006 and 18,603 patients (11.1%) in 2014 (P=0.01). Among those undergoing surgery, a VATS approach was performed in 2,512 patients (15%) during 2006 and 9,578 patients (54%) during 2014 (P=0.001). In 2006, California, New York, and New Jersey performed the most VATS procedures, in comparison to 2014, when New York, Florida, and California performed the highest number of VATS procedures. CONCLUSIONS: While the prevalence of lung cancer in the United States was unchanged between 2006 and 2014, the use of VATS techniques increased five-fold. Further studies to better understand the adoption or availability of new surgical techniques in lung cancer populations across geographic regions and patient populations are necessary.

Extending endovascular aneurysm repair to more patients without better outcomes.

OBJECTIVE: This study quantifies the survival and outcomes associated with endovascular aneurysm repair (EVAR) patients treated in two eras. We hypothesized that both end points will improve over time. METHODS: Patients receiving EVAR between January 2003 and May 2017 contained within the Vascular Quality Initiative data set were examined. Those patients treated between January 2003 and December 2007 were included in the early era, and those treated between January 2012 and December 2015 were considered late era. Baseline demographics, technical variables, and outcomes were compared with appropriate statistical tests. Survival was estimated with Kaplan-Meier life-table analysis. Cox proportional hazards modeling analyzed the relationship between repair era and survival; the repair era's significance was further examined in matched cohorts generated by coarsened exact matching and propensity scoring. RESULTS: Early era (n = 787) patients demonstrate decreased estimated survival in comparison to those treated in the late era (n = 20,066; log-rank, P < .001). Repair in the late era was not an independent predictor of survival in the Cox model (hazard ratio, 1.06; 95% confidence interval, 0.23-4.95; P = .94). Three different matching methods confirmed a nonsignificant contribution of treatment era to survival suggested by the initial Cox model (all P > .05). Total hospital stays were longer in the late era (3.1 vs 4.2 days; P < .001). Postoperative myocardial infarction and surgical site infections decreased in frequency in the late group, although postoperative vasopressor use became more frequent (all P < .05). Operations became 20% faster, required 27% less contrast material and 29% less crystalloid, and lost 30% less blood over time (all P < .05). CONCLUSIONS: Although EVAR volume increased significantly over time, post-EVAR outcomes of patients do not differ between the early era, 2003 to 2007, and the late era, 2012 to 2015. Aspects of surgical performance improved, but this did not translate into a measurable benefit to patients. Length of hospital stay unexpectedly increased over time.

Contemporary outcomes of surgical management of complex thoracic infections.

BACKGROUND: Surgery plays an important role in the management of complex thoracic infections (CTIs). We aimed to describe the contemporary surgical outcomes of CTIs. METHODS: The 2014-2017 National Surgical Quality Improvement Program (NSQIP) database was queried for patients with the following procedures: bilobectomy, decortication, lung release, lobectomy, thoracoscopic lobectomy, thoracoscopic pleurodesis, thoracoscopic wedge resection, thoracoscopic biopsy, thoracoscopy, thoracotomy, thoracotomy with wedge resection, thoracotomy with decortication, and thoracotomy with lobectomy. Patients were classified into: drainage procedures (DP) and lung resection (LR). Descriptive statistics and univariate/multivariate analysis were executed. A P value <0.05 was considered significant. RESULTS: A total of 1,275 patients (30.3%) underwent surgical management for a CTI. Nine hundred and seven patients (71.1%) underwent a DP, and 368 patients (28.9%) underwent a LR. A thoracic surgeon performed 64% and 79% of cases in the DP and LR groups, respectively. On univariate analysis, the patients in the LR group were less likely to be male, diabetic, active smokers, dyspneic on exertion, hypertensive, malnourished, or American Society of Anesthesiologist (ASA) >3. There was no difference in overall postoperative complications, re-intubation, or reoperation between groups. The patients in the LR group were less likely to develop sepsis or respiratory failure. There was no difference in 30-day mortality between groups (5.3% vs. 3.8%, P=0.26). The total length of stay was 13.82±10.17 and 8.7±15.05 days, in the DP and LR groups, respectively (P=0.001). Multivariate analysis revealed increased risk of 30-day mortality was associated with age, preoperative steroid use, renal failure, leukocytosis, pulmonary embolism, and sepsis. CONCLUSIONS: CTI's are a common indication for thoracic surgical management. This contemporary, national sampling demonstrates that approximately one third of identified cases were associated with a LR. These cases demonstrated a comparable morbidity and mortality with surgical DP, but shorter hospital stays. To aid in the management of these complex disease processes, early consultation of a multidisciplinary management service for these patients should be considered. Furthermore, the appropriate use of LR for infectious etiologies may lead to safer postoperative outcomes than previously thought.

Outcomes and Risk Factors Associated with Prolonged Intubation after EVAR.

BACKGROUND: Time to discharge has decreased for aortic surgery since the advent of endovascular aortic aneurysm repair (EVAR), partially due to improved perioperative management. We aimed to investigate outcomes and risk factors associated with prolonged intubation following EVAR. METHODS: The Vascular Study Group of New England (VSGNE) database was queried to select all patients who underwent elective EVAR between January 2003 and December 2014. Patients who were not extubated in the operating room were classified as having prolonged intubation. Patients requiring prolonged intubation were compared with those extubated in the operating room using t-test and chi-square statistics. Kaplan-Meier survival analyses estimated all-cause mortality. Independent predictors associated with prolonged intubation, including postoperative pneumonia or respiratory failure, were examined using multivariable logistic regression. RESULTS: A total of 3,979 patients were identified within the elective EVAR VSGNE data set, among whom 5.2% required prolonged intubation. Patients with prolonged intubation were older, more frequently female, non-Hispanic, had larger aneurysms, and had a more frequent diagnoses of diabetes, congestive heart failure, coronary artery disease, ejection fraction < 50%, and chronic obstructive pulmonary disease (all P < 0.05). Respiratory complications occurred in 25.5% of patients with prolonged intubation vs. 1.8% of patients who were extubated in the operating room (P < 0.001). Kaplan-Meier survival estimates suggested patients requiring prolonged intubation after EVAR had significantly lower survivals than those who extubated in the operating room (P < 0.05). On multivariable analysis, independent risk factors associated with prolonged intubation included subjective lack of fitness for open procedure (OR: 4.8, 95% confidence interval [CI]: 3.5-8.7), ejection fraction < 50% (1.8, 1.3-2.8), and ASA class >3 (1.5, 1.1-1.7). CONCLUSIONS: Prolonged intubation following EVAR is associated with increased risk of postoperative respiratory complications, as well as decreased long-term survival. High-risk patients for prolonged intubation, including those deemed subjectively unfit for an open procedure, ejection fraction < 50% and ASA class >3, may not benefit from an elective EVAR.

The evolution of minimally invasive cardiac surgery: from minimal access to transcatheter approaches.

The field of minimally invasive cardiac surgery has undergone rapid transformation over recent years. In this review, we provide a summary of the most current evidence supporting the use of minimally invasive aortic and mitral valve replacement techniques, as well as transcatheter approaches for aortic and mitral valve disease. As an adjunct, the use of robotically assisted coronary bypass surgery and hybrid coronary revascularization procedures is discussed. In order to obtain optimal patient outcomes, a collaborative, heart-team approach between cardiac surgeons and interventional cardiologists is necessary.

Mortality after emergency Hartmann's procedure in octogenarians: a propensity score-matched analysis.

BACKGROUND: Complicated diverticulitis is associated with a postoperative mortality rate of 20%. We hypothesized that age ≥80 was an independent risk factor for mortality after Hartmann's procedure for diverticular disease when controlling for baseline comorbidities. METHODS: Patients who underwent an urgent or emergent Hartmann's procedure (Current Procedural Terminology codes 44143 and 44206) for diverticular disease (International Classification of Diseases-9:562.xx) were identified using the American College of Surgeons National Surgical Quality Improvement Project 2005-2013 user file. Using propensity score matching to control for baseline comorbidities, a group of patients ≥80 years old was matched to a group of those <80 years old. Univariate and multivariable logistic regression were performed. A P value <0.05 was considered statistically significant with a confidence interval (CI) of 95%. RESULTS: From a total of 2986 patients, 464 patients (15.5%) were ≥80 years old. Two groups of 284 patients in each study arm were matched using propensity-matching. The mean age of the ≥80 group and <80 group was 84.4 ± 3.3 versus 63.77 ± 911.8; P < 0.0001, respectively. There was no statistical difference in baseline comorbidities or operative time between the groups. There was a significant difference in mortality with 19% and 9.2% in the >80 group versus <80 groups, respectively (P = 0.001). Factors associated with mortality included ascites (odds ratio [OR] 4.95, confidence interval [CI] 1.64-14.93, P = 0.005), previous cardiac surgery (OR 3.68, CI 1.46-9.26, P = 0.006), partially dependent or fully dependent functional status (OR 2.51, CI 1.12-5.56, P = 0.02), albumin <3 (OR 2.49, CI 1.18-5.29, P = 0.01), and American Society of Anesthesiologist class >3 (OR 2.10, CI 1.10-4.46, P = 0.05). CONCLUSIONS: Octogenarians presenting with complicated diverticulitis requiring an emergent Hartmann's procedure have a higher mortality rate compared to those <80, even after controlling for baseline comorbidities. STUDY TYPE: This is a retrospective, descriptive study.

Intensive care unit admission after endovascular aortic aneurysm repair is primarily determined by hospital factors, adds significant cost, and is often unnecessary.

BACKGROUND: A large proportion of endovascular aortic aneurysm repair (EVAR) patients are routinely admitted to the intensive care unit (ICU) for postoperative observation. In this study, we aimed to describe the factors associated with ICU admission after EVAR and to compare the outcomes and costs associated with ICU vs non-ICU observation. METHODS: All patients undergoing elective infrarenal EVAR in the Premier database (2009-2015) were included. Patients were stratified as ICU vs non-ICU admission according to location on postoperative day 0. Both patient-level (sociodemographics, comorbidities) and hospital-level (teaching status, hospital size, geographic location) factors were analyzed using univariate and multivariable logistic regression to determine factors associated with ICU vs non-ICU admission. Overall outcomes and hospital costs were compared between groups. RESULTS: Overall, 8359 patients underwent elective EVAR during the study period, including 4791 (57.3%) ICU and 3568 (42.7%) non-ICU admissions. Patients admitted to ICU were more frequently nonwhite and had more comorbidities, including congestive heart failure, coronary artery disease, chronic kidney disease, chronic obstructive pulmonary disease, diabetes, and hypertension, than non-ICU patients (all, P < .03). ICU admissions were more common in small (<300 beds), urban, and nonteaching hospitals and varied greatly depending on surgeon specialty and geographic region (P < .001). A pattern emerged when admission location was clustered by hospital; ICU patients were treated at hospitals where 96.7% (interquartile range, 84.5%-98.9%) of patients were admitted to ICU after EVAR, whereas non-ICU patients were treated at hospitals where only 7.5% (interquartile range, 4.9%-25.8%) were admitted to ICU after EVAR. A multivariable logistic regression model accounting for patient-, operative-, and hospital-level differences had a significantly lower area under the curve for predicting ICU admission after EVAR than a model accounting only for hospital factors (area under the curve, 0.76 vs 0.95; P < .001). The overall rate of adverse events was higher for ICU vs non-ICU patients (16.3% vs 13.7%; P < .001). Failure to rescue (2.9% vs 3.9%; P = .42) and in-hospital mortality (0.4% vs 0.4%; P = .81) were similar between groups. After adjusting for patient and hospital factors as well as for postoperative adverse events, ICU admission after EVAR cost $1475 (95% confidence interval, $768-2183) more than non-ICU admission (P < .001). CONCLUSIONS: Among patients undergoing elective EVAR, postoperative ICU admission is more closely associated with hospital practice patterns than with individual patient risk. Routine ICU admission after EVAR adds significant cost without reducing failure to rescue or in-hospital mortality.