Society Of Thoracic Surgeons Guidelines Research Articles

Lobe-specific lymph node sampling is associated with lower risk of cancer recurrence

ObjectiveAdequate intraoperative lymph node (LN) assessment is a critical component of early-stage non–small cell lung cancer (NSCLC) resection. The National Comprehensive Cancer Network and the American College of Surgeons Commission on Cancer (CoC) recommend station-based sampling minimums agnostic to tumor location. Other institutions advocate for lobe-specific LN sampling strategies that consider the anatomic likelihood of LN metastases. We examined the relationship between lobe-specific LN assessment and long-term outcomes using a robust, highly curated cohort of stage I NSCLC patients. MethodsWe performed a cohort study using a uniquely compiled dataset from the Veterans Health Administration and manually abstracted data from operative and pathology reports for patients with clinical stage I NSCLC (2006-2016). For simplicity in comparison, we included patients who had right upper lobe (RUL) or left upper lobe (LUL) tumors. Based on modified European Society of Thoracic Surgeons guidelines, lobe-specific sampling was defined for RUL tumors (stations 2, 4, 7, and 10 or 11) and LUL tumors (stations 5 or 6, 7, and 10 or 11). Our primary outcome was the risk of cancer recurrence, as assessed by Fine and Gray competing risks modeling. Secondary outcomes included overall survival (OS) and pathologic upstaging. Analyses were adjusted for relevant patient, disease, and treatment variables. ResultsOur study included 3534 patients with RUL tumors and 2667 patients with LUL tumors. Of these, 277 patients (7.8%) with RUL tumors and 621 patients (23.2%) with LUL tumors met lobe-specific assessment criteria. Comparatively, 34.7% of patients met the criteria for count-based assessment, and 25.8% met the criteria for station-based sampling (ie, any 3 N2 stations and 1 N1 station). Adherence to lobe-specific assessment was associated with lower cumulative incidence of recurrence (adjusted hazard ratio [aHR], 0.83; 95% confidence interval [CI], 0.70-0.98) and a higher likelihood of pathologic upstaging (aHR, 1.49; 95% CI, 1.20-1.86). Lobe-specific assessment was not associated with OS. ConclusionsAdherence to intraoperative LN sampling guidelines is low. Lobe-specific assessment is associated with superior outcomes in early-stage NSCLC. Quality metrics that assess adherence to intraoperative LN sampling, such as the CoC Operative Standards manual, also should consider lobe-specific criteria.

Changes in outcomes over time in intermediate-risk patients treated for severe aortic stenosis.

The advent of transcatheter aortic valve replacement (TAVR) has changed the practice of treating patients with severe aortic stenosis (AS). Heart-Teams have improved their decision-making process to refer patients to the best and safest treatment. The evidence allowed centers to increase funding and TAVR volume and extend indications to different risk categories of patients. This study evaluates the outcomes of intermediate-risk patients treated for severe AS in an academic center. Between 2012 and 2019, 812 patients with AS underwent TAVR or surgical aortic valve replacement (SAVR). A propensity score-matching analytic strategy was used to balance groups and adjust for time periods. Outcomes were recorded according to the Society of Thoracic Surgeons Guidelines; the primary outcome being 30-day mortality and the secondary outcomes being perioperative course and complications. No difference in mortality was seen but complications differed: more postoperative transient ischemic attacks, permanent pacemaker implantations, and perivalvular leaks in the transcatheter group, while more acute kidney injuries, atrial fibrillation, delirium, postoperative infections and bleeding, tamponade and need for reoperation in the surgical group as well as a longer hospital length-of-stay. However, over the years, morbidities/mortality decreased for all patients treated for AS. Data showed an improvement in morbidities/mortality for intermediate-risk patients treated with SAVR or TAVR. Increased funding allowed for a higher TAVR volume by increasing access to this technology. Also, the difference in complications could impact healthcare costs. By incorporating important metrics such as length-of-stay, readmission rates, and complications into decision-making, the Heart-Team can improve clinical outcomes, healthcare economics, and resource utilization.

Right or Left Internal Thoracic Artery to the Left Anterior Descending Artery: Informed Choice or Flip a Coin

Neither of the two seminal coronary artery bypass grafting studies from the Cleveland Clinic that established the superiority of the internal thoracic artery (ITA) grafts over saphenous veins specified which ITA was used to bypass the left anterior descending artery (LAD).1,2 However, the in situ left ITA (LITA) to the LAD was the most popular configuration based on comments made by the authors and their direct feedback. The Society of Thoracic Surgeons guidelines encourage the use of bilateral ITA (BITA) grafting and leaves the options open when it comes to choosing which ITA to use for bypassing the LAD.

Cardiac Arrest After Cardiac Surgery: An Evidence-Based Resuscitation Protocol.

More than 250 000 cardiac surgical procedures are performed annually in the United States. Postoperative cardiac arrest rates range from 0.7% to 5.2%. This article reviews current evidence for cardiac arrest resuscitation after cardiac surgery. The evaluation included resuscitation guidelines and 22 studies identified through a MEDLINE search. Evidence-based resuscitation differs from advanced cardiovascular life support guidelines. European Resuscitation Council guidelines include correcting reversible causes of arrest, applying defibrillation/pacing before external cardiopulmonary resuscitation, resternotomy within 5 minutes if electrical therapies fail, and restricting epinephrine use to avoid rebound hypertension. A 2017 Society of Thoracic Surgeons protocol derived from European Resuscitation Council guidelines is now standard of care in the United States. Evidence-based practices can improve survival and reduce resternotomy rates. This article describes the clinical implementation of the Society of Thoracic Surgeons guidelines.

Surgical Atrial Fibrillation Ablation Improves Long-Term Survival: A Multicenter Analysis

The Society of Thoracic Surgeons guidelines recommend surgical ablation (SA) at the time of concomitant mitral operations, aortic valve replacement, coronary artery bypass grafting (CABG), and aortic valve replacement plus CABG for patients in atrial fibrillation (AF). The goal of this analysis was to assess the influence of SA on long-term survival. A retrospective analysis of 20,407 consecutive CABG or valve procedures from 2008 to 2015 among seven centers reporting to a prospectively maintained clinical registry was conducted. Patients undergoing operation with documented preoperative AF were included (n= 2,740). Patients receiving SA were compared with patients receiving no SA. The primary end point was all-cause mortality. Secondary end points included in-hospital morbidity and mortality. The frequency of SA was 23.1% (n= 634), and an increase was seen in the rate of SA over the study period (p < 0.001). Concomitant SA was performed in 16.2% of CABG, 30.6% of valve, and 24.3% of valve plus CABG procedures. A substantial improvement was found in unadjusted survival among patients undergoing SA (hazard ratio 0.54, 95% confidence interval: 0.42 to 0.70). Moreover, no differences were found in postoperative complications. SA did have longer bypass times (p < 0.001) but a shorter overall length of stay (p<0.001). After risk adjustment, SA patients had an improved 5-year survival (hazard ratio 0.69, 95% confidence interval: 0.51 to 0.92), and the effect was observed across all operations. In a multicenter cohort of patients with AF, concomitant SA resulted in substantially improved long-term survival across patients who underwent CABG, valve, and valve plus CABG. These findings support current guidelines from The Society of Thoracic Surgeons that recommend broader application of concomitant SA.

Quality of Endoscopy Reports for Esophageal Cancer Patients: Where Do We Stand?

Backgrounds and AimsAs treatment for esophageal cancer often involves a multidisciplinary approach, the initial endoscopic report is essential for communication between providers. Several guidelines have been established to standardize endoscopic reporting. This study evaluates the compliance of esophagogastroduodenoscopy (EGD) and endoscopic ultrasound (EUS) reporting with the current national guidelines. MethodsCombining the National Comprehensive Cancer Network and Society of Thoracic Surgeons guidelines, 11 quality indicators (QIs) for EGD and 8 for EUS were identified. We evaluated initial EGD and EUS reports from our institution (Memorial Sloan Kettering [MSK]) and outside hospitals (OSHs) and calculated individual and overall quality measure scores. Scores between locations were compared using the Wilcoxon signed-rank test and McNemar’s test for paired data. ResultsIn total, 115 initial EGD reports and 105 EUS reports were reviewed for patients who underwent surgery for esophageal cancer between 2014 and 2016. The median number of QIs reported for the initial EGD was 4 (IQR, 3–6)—only 34% of reports qualified as “good quality” (those with ≥ 6 QIs). None of the reports included all QIs. For patients who underwent EGD at both MSK and an OSH, 32% of reports from OSHs were good quality, compared with 68% from MSK (p < 0.001). Compliance with QIs was better for EUS reports: 71% of OSH reports and 72% of MSK reports were good quality. ConclusionsDetailed information on the initial endoscopic assessment is essential in today’s age of multidisciplinary care. Identification and adoption of QIs for endoscopic reporting is warranted to ensure the provision of appropriate treatment.

Evaluating the effectiveness of pre-operative platelet inhibition testing to reduce costs and pre-operative length of stay

This was a retrospective study to assess the effectiveness of Society of Thoracic Surgeons (STS) Guidelines in reducing resource utilization at Washington Adventist Hospital, Takoma Park, Maryland. Pre and post operative stay (days), platelets and other blood product use, along with hospital costs were compared in elective Cardiac Surgical patients receiving P2Y12 inhibitors in the year prior to and year following the implementation of the STS guidelines of preoperative monitoring of platelet inhibition with VerifyNow.Our results demonstrated a significant decrease in length of stay, and although there was no discernible impact on other blood product use, there was a meaningful reduction in platelet use following implementation of the VerifyNow PRUTest assay for routine use in directing the timing of cardiac surgical procedures in this patient population.

Invited Commentary

Invited Commentary

Uniportal video-assisted thoracic surgery for pneumothorax and blebs/bullae

The last British Society of Thoracic Surgeons guidelines of 2010 for the management of primary spontaneous pneumothorax (PSP) stated that, after the first recurrence, the treatment of PSP should be a surgical operation, like a bullectomy accompanying with a procedure for inducing pleural adhesions. Therefore, the surgical approach is considered the best treatment to minimise the risk of recurrence in patients who experienced a PSP. There is substantial evidence in the literature demonstrating that the minimally invasive approach should be preferred to the thoracotomic procedure since it can reduce the postoperative pain and it is associated with a faster recovery of the physical and working activity. The video-assisted thoracic surgery (VATS) approach has been shown to offer greater advantages about patient pain and respiratory function when compared to thoracotomic incisions. A single port or single incision or uniportal approach was developed as an alternative to the standard multi-port VATS. Uniportal technique has shown to be safe and efficient not only for pulmonary resections and biopsies but also for lobectomy. When used for PSP, the bullectomy/blebectomy and pleural abrasion/pleurectomy is performed through the single incision through which the chest drain is then inserted. In this perspective, evidence showed that the minimally invasive approach should be preferred, confirming the advantages in comparison with traditional techniques.

Effect of Preoperative Beta-Blocker Use on Outcomes Following Cardiac Surgery

Recent studies suggest that the use of preoperative β blockers in cardiac surgery may not provide improved mortality rates and may even contribute to negative clinical outcomes. We therefore assessed the role of β blockers on several outcomes after cardiac surgery (delirium, acute kidney injury [AKI], stroke, atrial fibrillation (AF), mortality, and hospital length of stay) in 4,076 patients who underwent elective coronary artery bypass grafting, coronary artery bypass grafting + valve, or valve cardiac surgery from November 1, 2009, to September 30, 2015, at Vanderbilt Medical Center. Clinical data from 2 prospectively collected datasets at our institution were reviewed: the Cardiac Surgery Perioperative Outcomes Database and the Society of Thoracic Surgeons Database. Preoperative β-blocker use was defined by Society of Thoracic Surgeons guidelines as patients receiving a β blocker within 24 hours preceding surgery. Of the included patients, 2,648 (65.0%) were administered a β blocker within 24 hours before surgery. Adjusting for possible confounders, preoperative β-blocker use was associated with increased odds of AKI stage 2 (odds ratio 1.96, 95% confidence interval 1.19 to 3.24, p <0.01). There was no evidence that β-blocker use had an independent association with postoperative delirium, AKI stages 1 and 3, stroke, AF, mortality, or prolonged length of stay. A secondary propensity score analysis did not show a marginal association between β-blocker use and any outcome. In conclusion, we did not find significant evidence that preoperative β-blocker use was associated with postoperative delirium, AF, AKI, stroke, or mortality.

SC01.04 The Role of Mediastinoscopy in Induction Therapy of N2 NSCLC

SC01.04 The Role of Mediastinoscopy in Induction Therapy of N2 NSCLC

“What’s the Risk?” Assessing and Mitigating Risk in Cardiothoracic Surgery

“What’s the Risk?” Assessing and Mitigating Risk in Cardiothoracic Surgery

Current Approaches to Surgical Management of Lung Cancer

Accurate clinical staging of patients with non—small cell lung cancer (NSCLC) is essential to optimize treatment and outcomes. This article discusses current perspectives on the surgical treatment of lung cancer, including the revised European Society of Thoracic Surgeons guidelines for preoperative mediastinal lymph node staging for NSCLC. Also discussed are how improvements in imaging and the use of computed tomography imaging for diagnostic workup and screening have led to many small lung cancers being found.

Review of the evidence supports role for routine prophylaxis against postoperative supraventricular arrhythmia in patients undergoing pulmonary resection: Table 1:

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was 'Is there an indication for routine prophylaxis against postoperative supraventricular arrhythmia in patients undergoing pulmonary resection surgery?' Altogether almost 150 papers were found as a result of the reported search, of which 14 represented the best evidence to reach conclusions regarding the issues of interest for this review. The major outcome of interest that was investigated was the incidence of supraventricular arrhythmia (SVA), notably atrial fibrillation (AF). The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weakness of the papers were tabulated. Current guidance from the Society of Thoracic Surgeons (STS) supports the use of diltiazem and amiodarone in most patients undergoing major pulmonary resection. Robust data from a large randomized, controlled trial (RCT) showed a reduction from 25 to 15% in the incidence of clinically significant atrial arrhythmia with diltiazem; P<0.03. Moreover, numerous RCTs have shown that there is a clear benefit with the use of amiodarone in reducing the incidence of postoperative SVA. Of note, one prospective clinical trial randomized 242 patients into a treatment group with amiodarone (n = 122) and a placebo group (n = 120). The incidence of postoperative AF was reduced from 32 to 9% in the active arm; P < 0.001. The risk of acute lung injury with amiodarone has not been substantiated further in more recent clinical trials and has in fact been shown to be safe. The STS guidelines do, however, advise against the use of amiodarone in extensive lung resection such as pneumonectomy. We conclude that there is an indication for routine prophylaxis against postoperative supraventricular arrhythmia in patients undergoing pulmonary resection. However, further data are needed to ascertain the impact of said anti-arrhythmic medications on the length of postoperative hospital stay, intensive care unit stay and cost. Those patients deemed high-risk need to be promptly identified, so the anti-arrhythmic therapy can be tailored to the cohort thus optimizing on cost and safety.

Reply to Rubino et al.

We thank Rubino et al. for their interest in our recently published paper [1, 2]. We agree with them that the correct timing for discontinuing double antiplatelet therapy is still controversial. The Society of Thoracic Surgeons guidelines recommend withholding clopidogrel at least 5 days prior to surgery in elective cases and a few days in acute coronary syndromes, while maintaining aspirin up to surgery in both scenarios [3]. On the contrary, previous European guidelines suggest discontinuing clopidogrel 5–7 days before surgery even in patients who need urgent cardiac surgery. Aspirin should be stopped 2–10 days before surgery in elective patients but continued up to the day of surgery in patients with acute coronary syndrome [4]. Furthermore, the timing of discontinuing double antiplatelet treatment might be different in patients with previous stent implantation in less than one year. We strongly believe that the choice of withholding the double antiplatelet therapy should be tailored to the individual patient according to the risk of bleeding and thrombosis and possibly guided by a point-of-care testing. Currently, in the setting of an acute coronary syndrome, our policy is to continue aspirin and discontinue clopidogrel at least 2–3 days before surgery. In the presence of severe critical lesions, we prefer to administrate an intravenous short acting glycoprotein IIb/IIIa inhibitor. Our study confirms that patients receiving clopidogrel in combination with aspirin up to the time of surgery are at risk of increased blood loss, reoperation for bleeding and transfusions. Interestingly, these patients also had higher incidence of postoperative myocardial infarction, something previously reported in the literature and discussed in our paper. We recognize that in our study the three groups examined had a different risk profile and probably more complex coronary artery lesions; however, we reduced potential confounding factors using a multivariate analysis. The use of SYNTAX score might have been helpful in the risk stratification, but the SYNTAX trial data became available only in March 2009. Finally, we did not consider patients referred to surgery after failed PCI as our database did not account for this preoperative variable [5]. We agree that an accurate point-of-care test of platelet function in association with other clinical parameters may be better to identify high-risk patients for postoperative bleeding and reducing postoperative morbidity [6].

Platelet function testing to time surgery in patients on dual antiplatelet therapy?

In patients pretreated with P2Y12 receptor inhibitors who need to undergo non-emergent cardiac or major non-cardiac surgery, current guidelines of the European Society of Cardiology recommend postponing surgery for at least five days after last intake of clopidogrel or ticagrelor, and for seven days after last intake of prasugrel, unless there is high risk of ischemic events. However, a fixed five to seven days preoperative waiting period may be challenged, in the presence of inter-individual variability in on-treatment platelet reactivity. Therefore, Society of Thoracic Surgeons guidelines suggest to base decisions about a surgical delay on platelet function although both, the optimal platelet function assay and a bleeding cutoff have not yet been defined by large scale multicenter trials. This review aims to provide an overview on current knowledge of P2Y12 receptor induced platelet inhibition and surgery related bleeding and the potential role of platelet function analysis to time surgery.

Survival of Patients With Unsuspected pN2 Non-Small Cell Lung Cancer After an Accurate Preoperative Mediastinal Staging

The aim of this study is to analyze the survival of patients with non-small cell lung cancer (NSCLC) without clinical suspicion of mediastinal lymph node involvement who underwent complete resection and whose tumors were finally proven to be pathologic N2 (pN2). This is a retrospective study of a prospective database from January 2004 to December 2010. A total of 621 patients with NSCLC were staged and operated according to the European Society of Thoracic Surgeons guidelines. After exclusions (previous induction treatment, carcinoid tumors, small cell carcinomas), 540 patients were analyzed; 406 (75%) required surgical exploration of the mediastinum and 134 (25%) underwent surgery directly. Survival analysis was performed by the Kaplan-Meier method and the log-rank test was used for comparisons. Thirty (5.5%) patients had unsuspected pN2 and complete resection was achieved in 27 (90%). Three- and 5-year survival rates were 87% and 81%, respectively, for patients with a true negative result of the protocol (pN0-1), and 79% and 40%, respectively, for those with a false negative result (unsuspected pN2) (p < 0.0001). The rate of unsuspected pN2 in patients whose tumors were staged according to the European Society of Thoracic Surgeons guidelines was low. The survival of this group of patients was better than expected. Therefore, resection of properly staged unsuspected pN2 NSCLC is reasonable and should not be avoided if complete resection can be achieved.

Systematic mediastinal nodal dissection and video-assisted thoracic surgery

A recent study by Amer et al. [1] investigated the role of systematic mediastinal nodal dissection performed during videoassisted major pulmonary resection as a staging approach for non-small-cell lung cancer versus preoperative staging by computed tomography (CT) and positron emission tomography (PET). Precise staging is essential to provide accurate knowledge of disease progression in patients with non-small-cell lung cancer; in effect, the valuable editorial comment on the mentioned trial remarked that the authors ‘ignored the data that support the use of mediastinoscopy prior to VATS lobectomy, even in clinical stage I disease’ [2]. In reality, the American College of Chest Physicians clinical practice guidelines are open to the possibility that invasive staging is probably not needed in patients with peripheral tumours with no nodal involvement on CT and PET scans [3]. The coeval European Society of Thoracic Surgeons guidelines indicated that invasive staging can be omitted for patients with stage I lung cancer and negative mediastinal PET imaging on the condition that the tumour is peripheral [4]. From a formal point of view, the colleagues from Southampton could not be blamed for their preoperative protocol. Moreover, standard cervical mediastinoscopy usually only biopsies the paratracheal and subcarinal stations [4]; but, in order to reach every mediastinal station, transcervical extended mediastinal lymphadenectomy (TEMLA) [5] should be carried out. In addition, when positive lynphnodes are found, TEMLA should be redone for restaging after chemotherapy even if such a procedure seems excessive in a patient with a peripheral pulmonary nodule of a few millimetres plus negative mediastinal imaging. As an alternative, the endoscopic ultrasonography transbronchial needle aspiration (EBUS-TBNA) provides accurate mediastinal staging; such a technique is accepted by the American College of Chest Physicians and European Society of Thoracic Surgeons guidelines for clinical N2–3 lung cancer, but EBUS-TBNA has been proposed in the staging of CTand PET-negative mediastinum [6] our 6-year-long experience in EBUS-TBNA suggests that the biopsy of a few millimetre lymph-node is a hard duty especially in paratracheal stations. In conclusion, we consider that the Amer et al. preoperative behaviour is shareable and in good equilibrium between idealism and pragmatism [1]. Amer et al. underline the effectiveness of video-assisted thoracic surgery in the systematic mediastinal nodal dissection [1]. A number of studies had validated the video-assisted mediastinal dissection, but more explanatory is the simple photograph included in the article: during video-assisted thoracic surgery, the vision on mediastinal structures is so close and clear that surgeons can work in the best conditions. We conclude ‘nullus est liber tam malus, ut non aliqua parte prosit’ (There is no book so bad that it is not profitable in some part, Pliny); the article from Southampton highlights an up-to-date clinical practice based on good common sense and, moreover, restates the feasibility of a complete mediastinal dissection during video-assisted thoracic surgery.

Does Body Mass Index Affect Outcomes for Aortic Valve Replacement Surgery for Aortic Stenosis?

Obesity is a worldwide healthcare concern, and its association with several chronic diseases is well documented. However, the effect obesity may have on the acute care delivery is not well understood, and in cardiac surgery, reports are conflicting. The purpose of this study is to evaluate the effect of obesity in an isolated aortic valve replacement population. The hypothesis is that increasing body mass index (BMI) will portend worse long-term outcomes and greater short-term resource utilization secondary to perioperative complications but will not affect perioperative mortality. Data were collected on 1,066 patients undergoing isolated AVR between January 2000 and December 2010. All definitions follow The Society of Thoracic Surgeons guidelines. Body mass indexes were calculated and used both as a continuous independent variable and to categorize patients into three BMI groups. Long-term mortality follow-up was by Social Security Death Index search. Standard bivariate and multivariate comparisons were performed with hierarchical models used for odds ratios. When controlling for standard covariates that negatively impact outcome (sex, age, renal failure needing dialysis, diabetes mellitus, and current smoker), BMI was not predictive for either operative mortality or a composite morbidity-mortality outcome. When divided into three equal-sized groups, there was again no statistical difference among groups for mortality or for the composite variable. Separate analyses for females and males yielded the same lack of correlation. Long-term follow-up out to 12 years shows that the low BMI group has statistically worse survival than the moderate or high BMI groups. Increasing BMI has no independent association with worsened outcomes in the short or long term, and overweight patients have a survival benefit after surgery. Patients who are at the lower end of the BMI scale, however, are at increased risk for poor long-term survival.

Abstract P331: The Impact of In-Hospital Postoperative Complications on Health Related Quality of Life in Cardiac Surgery Patients

Background: Reports of successful cardiac surgical outcomes have focused on mortality and morbidity. However, health related quality of life (HRQL) is now being recognized as an important outcome measure. The objective of this study was to assess the impact of in-hospital postoperative complications on physical and mental HRQL in cardiac surgery patients from baseline to 6 and 12 months after surgery. Methods: Patients who underwent cardiac surgery since September 2005 were included (n=702). All patients completed the Short Form Health Survey (SF-12) prior to surgery, and at 6 and 12 months after surgery. Norm-based physical and mental components of HRQL were calculated, with higher scores indicating better HRQL. In-hospital postoperative complications were defined using the Society of Thoracic Surgeons guidelines. Results: Group 1 (n=533) had no in-hospital postoperative complications and Group 2 (n=169) experienced complications. The groups did not differ at baseline on physical or mental HRQL. There were significant main effects of time (F=32.9, p&lt;0.001) and group (F=14.9, p&lt;0.001) for physical HRQL, which showed an increase in scores over time and higher scores in Group 1. The significant interaction of time by group (F=6.6, p&lt;0.02) indicated that physical HRQL increased more in Group 1 from baseline to 6 months and more in Group 2 from 6 to 12 months. The main effect of time was significant for mental HRQL (F=4.7, p&lt;0.04), which showed an increase from baseline to 6 months and a slight decrease between 6 and 12 months. The interaction of time by group was not significant for mental HRQL. It is interesting to note, however, that the groups increased similarly from baseline to 6 months, but Group 1 showed a decline from 6 to 12 months and Group 2 continued to show an increase in mental HRQL from 6 to 12 months. Conclusion: In-hospital postoperative complications significantly affect improvements in HRQL. Patients that did not experience postoperative complications had a significantly better and faster improvement in physical HRQL from baseline to 1 year. Despite these differences in physical HRQL, the two groups increased similarly on mental HRQL. Further study is needed to explore this finding with a larger sample and longer follow-up time points after surgery.