Preoperative nutrition-enhanced recovery after surgery protocol for thoracic neoplasms.

OBJECTIVES: Because patients' preoperative nutritional status influences the outcomes, we have used a preoperative nutrition program for surgical patients for a 2-year period and compared the results with those from a cohort treated in the previous 2 years. METHODS: We retrospectively reviewed curative thoracic neoplasm resections from July 15, 2016, to July 15, 2018, in patients who had received a preoperative nutritional-enhanced recovery after surgery (N-ERAS) protocol. The protocol consisted of 5 days of an oral immunonutrition drink 3 times daily, daily receipt of probiotics, and a carbohydrate-loading drink the night before surgery. The historical control cohort (standard group) included those patients who had undergone surgery by the same surgeon during the previous 24 months. We excluded patients who had undergone esophageal, diagnostic, benign, emergency, or palliative procedures. Nonparametric and parametric statistical tests were used to analyze the data. RESULTS: The data from 462 patients were analyzed: 229 N-ERAS patients and 233 standard patients. No significant demographic or caseload differences were found between the 2 groups. The major significant outcome differences included fewer postoperative complications (30 [13.1%] in the N-ERAS group vs 60 [25.8%] in the standard group; P < .001) and shorter hospital stays (3.8 ± 1.9 days for the N-ERAS group vs 4.4 ± 2.6 days for the standard group; P = .001). Use of the N-ERAS protocol resulted in a 16% reduction ($2198; P < .001) in the mean direct hospital costs/patient. Consequently, for the N-ERAS cohort, the hospital was likely saved $503,342 during the 2-year period for the 229 patients just by using the N-ERAS protocol. CONCLUSIONS: Thoracic surgeons should consider using the nontoxic, patient-compliant N-ERAS protocol for their patients, with an expectation of improved clinical results at lower hospital costs-an important consideration when exploring methods to decrease costs because hospitals are increasingly being paid by a negotiated prospective bundled payment reimbursement model.

Induction chemoradiotherapy versus chemotherapy alone for superior sulcus lung cancer.

OBJECTIVES: Although treatment of superior sulcus tumors with induction chemoradiotherapy (CRT) followed by surgery employed in the Intergroup INT-0160 trial is widely adopted as a standard of care, there may be significant associated morbidity and mortality. We describe our experience using standard and alternative induction regimens to assess survival rates and treatment toxicity in these patients. MATERIALS AND METHODS: Electronic medical records of all patients who underwent multimodality treatment including resection of lung cancer invading the superior pulmonary sulcus between 1994 and 2016 were retrospectively reviewed. Multivariable Cox Proportional Hazards model was constructed. RESULTS: Of 102 consecutive patients, 53 (52%) underwent induction CRT, 34 (33%) underwent induction chemotherapy only (Ch) followed by adjuvant radiotherapy, and 15 (15%) underwent no induction therapy followed by adjuvant therapy. There were 2 postoperative deaths (1.9%). To date, 42 patients are alive with a median follow-up 72.5 months. Overall 5-year survival rate was 45.4%. Survival was significantly influenced by age, FEV1, positive resection margins, surgical complications, but not the induction regimen. CRT resulted in higher complete pathological response rate than Ch: 38% vs. 3% (p < 0.001). CRT was associated with higher post-operative re-intubation rate: 13% vs. 0% (p = 0.03). CONCLUSIONS: Our single-institutional experience indicated that while induction CRT produced greater complete pathological response than Ch, it also increased the risk of post-operative complications. With careful patient selection, induction Ch followed by adjuvant radiotherapy may provide comparable survival outcomes to induction CRT. Since induction Ch is associated with lower risk of complications, it may be a particularly desirable choice for patients with impaired performance status.

Using "Rebar" to Stabilize Rigid Chest Wall Reconstruction.

After major chest wall resection, reconstruction of the bony defect with a rigid prosthesis is mandatory to protect the underlying thoracic organs, and to prevent flail chest physiology. Although many methods have been described for chest wall reconstruction, a commonly used technique employs a composite Marlex (polypropylene) mesh with methyl-methacrylate cement sandwiched between two layers of mesh (MMS), which is tailored to the defect size and shape. In building construction, steel "rebar" is used to strengthen and reinforce masonry structures. To avoid the initial residual motion of the rigid prosthesis used to reconstruct very large defects, particularly the sternum, we devised a simple technique of adding one or more Steinmann steel pins as "rebar" to strengthen and immediately stabilize the prosthesis to the surrounding ribs and sternum. For the very large defects, particularly over the heart and great vessels, titanium mesh may also be readily added into the sandwich construction for increased strength and to prevent late prosthetic fractures. Short- and long-term results of this inexpensive modification of the MMS reconstruction technique are excellent. This modified MMS tailor-made prosthesis is only one-third the cost of the recently popular prosthetic titanium systems, takes much less operative time to create and implant, and avoids the well-described complications of late titanium bar fracture and erosion/infection as well as loosening of screws and/or titanium bars.