Society Of Thoracic Surgery Database Research Articles

Enhanced recovery after surgery may mitigate the risks associated with robotic-assisted fundoplication in lung transplant patients.

A history of lung transplantation is a risk factor for poor outcomes in patients undergoing laparoscopic fundoplication. We wanted to determine whether enhanced recovery after a robotic-assisted surgery program would mitigate these risks. We performed a single-center retrospective analysis of the Society of Thoracic Surgery database for patients who underwent elective antireflux procedures from 1/2018 to 2/2021 under the enhanced recovery after surgery program using robotic assistance. We identified the patient and surgical characteristics, morbidity, length of stay, and 30-day readmission rates. Among 386 patients who underwent barrier creation, 41 had previously undergone a lung transplant, either bilateral (n = 28) or single (n = 13). There were no significant differences in postoperative complications (9.8% vs. 5.2%, p = 0.27), median hospital length of stay (1 d vs. 1 d, p = 0.28), or 30-day readmission (7.3% vs. 4.9%, p = 0.46). Bivariate analysis showed that older age (p = 0.03), history of DVT/PE (p < 0.001), history of cerebrovascular events (p = 0.03), opioid dependence (p = 0.02), neurocognitive dysfunction (p < 0.001), and dependent functional status (p = 0.02) were associated with postoperative complications. However, lung transplantation was not associated with an increased risk of postoperative complications (p = 0.28). The risk of surgical complications in patients with a history of lung transplantation may be mitigated by the combination of ERAS and minimally invasive surgery such as robot-assisted surgery.

Sleeve lobectomy in patients with non-small-cell lung cancer: a report from the European Society of Thoracic Surgery database 2021.

For centrally located lung tumours, sleeve lobectomy is preferred over pneumectomy. We report on the surgical practices and perioperative outcomes of sleeve resections based on data from the European Society of Thoracic Surgeons database. We retrieved data of patients undergoing sleeve lobectomy or bilobectomy from 2007 to 2021. We evaluated baseline characteristics, surgical approach, neoadjuvant treatments, morbidity and postoperative outcomes of open and video-assisted thoracoscopic surgery (VATS) procedures. In total, 1652 patients (median age: 63 years; females/males: 446/1206) underwent sleeve lobectomy (n = 1536) or bilobectomy (n = 116) by open thoracotomy (n = 1491; 90.2%) or VATS (n = 161; 9.8%) with a thoracotomy conversion rate of 21.1% (n = 34); 398 (24.1%) patients received neoadjuvant treatment. Overall morbidity and 30-day mortality were 40.6% and 2.2%, respectively. Bronchial anastomotic complications occurred in 29 patients (1.8%) with conservative treatment in 6 cases (20.7%) and operative management in 23 (79.3%). On multivariable analysis, factors related to the elevated risk of cardiopulmonary complications were body mass index &lt; 20 [odds ratio (OR): 2.26; P &lt; 0.001] and bilobectomy (OR : 2.28, P &lt; 0.001). Age &lt;60 years (OR: 0.71, P = 0.013), female sex (OR: 0.54, P &lt; 0.001) and VATS (0.64, P &lt; 0.001) were associated with decreased risk. Neoadjuvant treatment was not associated with increased risks of cardiopulmonary complications (OR: 1.05; P = 0.664). Compared to open thoracotomy, VATS was associated with significantly decreased overall morbidity (30.4% vs 41.7%, P = 0.006) and length of stay (median: 5 days vs 8 days; P &lt; 0.001). Sleeve lobectomies can be safely performed after neoadjuvant treatment. The VATS approach fosters shorter length of stay and decreased morbidity.

Surgical Gastrostomy in Pediatric Patients Undergoing Cardiac Surgery

BackgroundPractices of performing gastrostomy tubes vary across institutions for patients undergoing cardiac surgery. We aim to elucidate the outcomes of gastrostomy and the duration of feeding assistance in these patients. Materials and methodsPatients undergoing cardiac surgery (CS) at our institution from 2013 to 2017 were retrospectively reviewed using the Society of Thoracic Surgery database. A cohort of non-CS patients undergoing gastrostomy tube (g-tube) placement from 2013 to 2015 was used as control. Technical complications and postoperative feeding intolerance were analyzed. Duration of need for g-tube was also analyzed in patients undergoing CS. ResultsThe CS group had 144 patients, and the non-CS group had 677 patients. CS patients had a higher incidence of feeding intolerance (18.8% versus 5.6%, P < 0.001) and took longer to attain full feeds (median of 2 versus 1 d, P < 0.001), and this was confirmed on propensity matched analysis. In addition, technical g-tube complications were similar in the two groups. No mortality in CS was attributed to the g-tube. 58% of patients undergoing CS were able to wean from g-tube feeding by 6-12 mo after g-tube placement. ConclusionsG-tube placement in patients undergoing CS by any technique is safe without increased complications. A significant portion of these patients was able to wean off supplemental enteral feeding assistance by a year after g-tube placement.

Early Postoperative Functional Assessment Predicts Non-Home Discharge After Pulmonary Lobectomy

Non-home hospital disposition is an important patient-centric quality measure, and is increasingly tied to reimbursements. We sought to determine the value of early postoperative functional assessment to predict non-home discharge. Patients undergoing elective pulmonary lobectomy between May 2017 and December 2018 were identified from The Society of Thoracic Surgery database at a single institution. Early postoperative functional assessment using the Boston University Activity Measure for Post-Acute Care (AM-PAC) basic mobility short form was routinely performed by the inpatient rehabilitation services. The association of baseline patient characteristics and AM-PAC scores with nonhospital discharge was analyzed. A total of 241 patients (median age 65 years, 59% female) underwent lobectomy. First postoperative functional assessment was performed at a median of 1 day (interquartile range, 1 to 2) after surgery. Median AM-PAC score was 18 (interquartile range, 17 to 19), correlating to a 47% functional impairment in daily activities. Thirteen patients (5.4%) were discharged to an extended care facility instead of home. Non-home discharge was more commonly observed for patients of older age or with prior history of stroke. First postoperative AM-PAC score was able to discriminate hospital disposition (area under the curve 0.714; 95% confidence interval, 0.594 to 0.834; P= .009). Adjusted for patient factors and performance status, first postoperative AM-PAC score was independently associated with non-home discharge (odds ratio 0.54, 95% confidence interval, 0.36 to 0.81; P= .003). Early postoperative functional impairment assessment using AM-PAC may be useful to predict non-hospital discharge after pulmonary lobectomy. Attention to these factors may be used to aid early disposition planning, and adjust preventative strategies.

Evaluation of Pediatric Cardiac ICU Advanced Practice Provider Education and Practice Variation.

The education, training, and scope of practice of cardiac ICU advanced practice providers is highly variable. A survey was administered to cardiac ICU advanced practice providers to examine specific variations in orientation format, competency assessment during and at the end of orientation, and scope of clinical practice to determine gaps in resources and need for standardization. This study was a cross-sectional descriptive study utilizing survey responses. Pediatric cardiac ICUs in the United States. The survey was delivered to a convenience sample of advanced practice providers currently practicing in pediatric cardiac ICUs. A list of pediatric cardiothoracic surgery programs was generated from the Society of Thoracic Surgery database. A self-administered, electronic survey was delivered via email to advanced practice providers at those institutions. Descriptive data were compared using a chi-square test or Fisher exact test depending on the normalcy of data. Continuous data were compared using a Student t test or Mann-Whitney U test. Eighty-three of 157 advanced practice providers responded (53% response rate, representing 36 institutions [35% of institutions]). Sixty-five percent of respondents started as new graduates. Ninety-three to one-hundred percent obtain a history and physical, order/interpret laboratory, develop management plans, order/titrate medications, and respiratory support. Ability to perform invasive procedures was highly variable but more likely for those in a dedicated cardiac ICU. Seventy-seven percent were oriented by another advanced practice provider, with a duration of orientation less than 4 months (66%). Fifty percent of advanced practice providers had no guidelines in place to guide learning/competency during orientation. Sixty-seven percent were not evaluated in any way on their knowledge or skills during or at the end of orientation. Orientation was rated as poor/fair by the majority of respondents for electrophysiology (58%) and echocardiography (69%). Seventy-one percent rated orientation as moderately effective or less. Respondents stated they would benefit from more structured didactic education with clear objectives, standardized management guidelines, and more simulation/procedural practice. Eighty-five percent were very/extremely supportive of a standardized cardiac ICU advanced practice provider curriculum. Orientation for cardiac ICU advanced practice providers is highly variable, content depends on the institution/preceptor, and competency is not objectively defined or measured. A cardiac ICU advanced practice provider curriculum is needed to standardize education and promote the highest level of advanced practice provider practice.

Primary graft dysfunction after heart transplantation: Outcomes and resource utilization.

A unified definition of primary graft dysfunction (PGD) after heart transplantation was adopted in 2014, with moderate and severe PGD defined as a need for mechanical circulatory support. While risk factors for PGD are well identified, outcomes and resource utilization have not been well-studied. We examined the resource utilization and associated costs with PGD. All adult heart transplantations (2001-2016) from a statewide Society of Thoracic Surgery database were analyzed by dividing them into two groups-with PGD (requiring mechanical circulatory support) and without PGD. Of the 718 heart transplants, 110 (15.3%) patients developed PGD. Prevalence of PGD for the study duration ranged from 3.7% to 22.7% with no significant trend. The most frequently used mechanical circulatory support device was intra-aortic balloon pump (88%), followed by extracorporeal membrane oxygenation (17%), and catheter-based circulatory support devices (3%). There were no significant differences in demographics or preoperative variables between the two groups. Resource utilization such as total intensive care unit hours, ventilation hours, reoperation for bleeding, blood product transfusions, and length of stay were significantly higher in the PGD group. Postoperative complications were also higher in PGD group including operative mortality (31.8% vs 3.8%, P < .0001). The median cost of heart transplantation was significantly higher in the PGD group $229 482 ($126 044-$388 889) vs $101 788 ($72 638-$181 180) P < .0001. Primary graft dysfunction following heart transplantation developed in 15% of patients. Patients with PGD had significantly higher complications, resource utilization, and mortality. Preventive measures to address the development of PGD would reduce resource utilization and improve outcomes.

Mortality After Esophagectomy: Analysis of Individual Complications and Their Association with Mortality

BackgroundThe relationship between individual complications and esophagectomy mortality is unclear. The influence of comorbidities on the impact of complications on operative mortality is also unknown. We sought to assess the impact of individual complications and the effect of coexisting comorbidities on operative mortality following esophagectomy. MethodsAll gastric conduit esophagectomies performed for cancer from 2008 to 2017 in the Society of Thoracic Surgery database were identified. Chi square was utilized to identify postoperative events associated with operative mortality. Multivariable logistic regression analysis was performed, utilizing postoperative events, to determine the risk-adjusted effect on operative mortality for each postoperative event. To assess the effect of preoperative comorbidities, a second logistic regression analysis was performed, incorporating preoperative characteristics. ResultsOf 11,943 esophagectomy patients, 63.9% had a postoperative event and 3.3% died, which did not change over the study period. The postoperative events with the highest impact on operative mortality were respiratory distress syndrome (OR 7.48 (95% CI 5.23–10.7)), reintubation (OR 6.55 (4.61–9.30)), and renal failure (OR 5.97 (4.08–8.75)). Anastomotic leak requiring reoperation was associated with increased operative mortality (OR 1.48 (1.03–2.14)), but medically managed leak was not. Incorporating preoperative characteristics into the operative mortality model had little effect on odds ratio for death for individual postoperative events. ConclusionsIn the Society of Thoracic Surgery database, 64% of patients suffer postoperative events and 3.3% die following esophagectomy. The independent association of certain postoperative events with mortality is an objective method of terming a complication “major” and may aid efforts to reduce mortality.

Robot-assisted hiatal hernia repair demonstrates favorable short-term outcomes compared to laparoscopic hiatal hernia repair

We postulated that the use of robotics may improve outcomes in hiatal hernia repair. We performed a retrospective analysis of a prospectively collected Society of Thoracic Surgery database at a single institution of patients who underwent elective hiatal hernia repair from 2012 to 2017 using either laparoscopy or the da Vinci Xi robot. We compared patient characteristics and outcomes and then performed univariate and multivariate logistic regression modeling to determine the factors associated with postoperative morbidity. There were 293 consecutive patients who underwent elective hiatal hernia repair using either a laparoscopic (n = 151) or a robotic (n = 142) technique. There were no significant differences in age, gender, BMI, smoking history, presence of comorbidity, or hiatal hernia type. Seventy percent of the cases were a repair of either type III or type IV hiatal hernia. There were significantly higher ASA III and IV (7.9% vs. 4.2%, P = 0.03), higher Toupet fundoplication (83.4% vs. 44.4%, P < 0.001), and lower redo-repair (7.3% vs. 20.4%, P = 0.001) in the laparoscopic group compared to the robotic group. The hospital length of stay was significantly shorter (1.3 ± 1.8 vs. 1.8 ± 1.5days, P = 0.003) and there were significantly lower rates of complications (6.3 vs. 19.2%, P = 0.001) after robotic compared to laparoscopic hiatal hernia repair. There was no difference in readmission rate and mortality. Multiple logistic regression analysis showed that older age and laparoscopic technique were associated with higher complications after surgery. The use of the Da Vinci Xi robot in our institution was associated with improved outcomes compared to laparoscopic hiatal hernia repair despite a higher incidence of re-operative cases in the robotic group. Thus, short-term outcomes of Da Vinci Xi robot-assisted hiatal hernia repair are not inferior to laparoscopic hiatal hernia repair. Further studies are needed to determine if Da Vinci Xi robot provides superior short-term and long-term outcome in treatment of symptomatic hiatal hernia.

Biomarkers improve prediction of 30-day unplanned readmission or mortality after paediatric congenital heart surgery.

To evaluate the association between novel pre- and post-operative biomarker levels and 30-day unplanned readmission or mortality after paediatric congenital heart surgery. Children aged 18 years or younger undergoing congenital heart surgery (n = 162) at Johns Hopkins Hospital from 2010 to 2014 were enrolled in the prospective cohort. Collected novel pre- and post-operative biomarkers include soluble suppression of tumorgenicity 2, galectin-3, N-terminal prohormone of brain natriuretic peptide, and glial fibrillary acidic protein. A model based on clinical variables from the Society of Thoracic Surgery database was developed and evaluated against two augmented models. Unplanned readmission or mortality within 30 days of cardiac surgery occurred among 21 (13%) children. The clinical model augmented with pre-operative biomarkers demonstrated a statistically significant improvement over the clinical model alone with a receiver-operating characteristics curve of 0.754 (95% confidence interval: 0.65-0.86) compared to 0.617 (95% confidence interval: 0.47-0.76; p-value: 0.012). The clinical model augmented with pre- and post-operative biomarkers demonstrated a significant improvement over the clinical model alone, with a receiver-operating characteristics curve of 0.802 (95% confidence interval: 0.72-0.89; p-value: 0.003). Novel biomarkers add significant predictive value when assessing the likelihood of unplanned readmission or mortality after paediatric congenital heart surgery. Further exploration of the utility of these novel biomarkers during the pre- or post-operative period to identify early risk of mortality or readmission will aid in determining the clinical utility and application of these biomarkers into routine risk assessment.

Bilateral Internal Thoracic Artery Bypass Grafting in a High Risk Population - A Four Year Experience with STS Database Derived Clinical Outcomes

The purpose of this retrospective review was to examine the morbidity and mortality associated with the routine use of skeletonized bilateral internal thoracic arteries (BITA) in coronary bypass surgery (CABG). The current rate of BITA use is reported to be 5% in the US. The literature reflects an increased incidence of wound complications, especially in obese, diabetic, and female patients. Our policy has been to use skeletonized BITA in patients regardless of comorbidities. Using the Society of Thoracic Surgery (STS) database, the postoperative markers of prolonged ventilation (PV), length of stay (LOS), wound infection, death, and 30 day readmission were evaluated for all isolated coronary bypass operations (isocab) to allow comparison of bilateral and single internal thoracic artery (ITA) use during this four year period. The incidence of BITA use was 60%. The groups had similar comorbities and postop complications were similar regardless of single or bilateral thoracic artery use. Specifically, there were no wound complications in the BITA group. Adjuncts such as ITA skeletonization, platelet rich plasma, negative pressure wound dressing, and absence of bone wax were utilized in all cases. The added expense is justified to allow the expanded use of BITA.

Video-assisted thoracic surgery segmentectomies: Brazilian experience

There is growing enthusiasm with lung resections by video-assisted thoracic surgery (VATS) technique in Brazil. The benefits of these minimally invasive procedures and their incorporation in the routine of many Brazilian centers produced a significant increase of sublobar and lobar resections in the country. The changes in our daily practice, including improvements in lung cancer staging, the rising of lung cancer screening programs and the analysis of several recent studies showing equivalent long-term outcomes with sublobar resections, while we treat often an elderly and poor performance population, have made the thoracic surgeon to look to a sublobar resection as a potentially curative procedure. We sought to analyze the Brazilian and institutional experience with VATS sublobar anatomical resections for treatment of benign and malignant diseases, and discuss technical aspects as well. Even though is much underreported, the outcomes of VATS segmentectomies resemble what is observed around the world and constitute in an effective surgery when well indicated. The Brazilian Society of Thoracic Surgery database is improving the notification by many centers and this better quality of data will provide us a deep knowledge about the results of our procedures national-wide.

Blood Pressure Coefficient of Variation and Its Association With Cardiac Surgical Outcomes.

Multiple studies completed in the ambulatory nonsurgical setting show a significant association between short- and long-term blood pressure variability and poor outcomes. However, perioperative blood pressure variability outcomes have not been well studied, especially in the cardiac surgical setting. In this study, we sought to assess whether systolic and mean arterial blood pressure variability were associated with 30-day mortality and in-hospital renal failure in patients undergoing cardiac surgery requiring cardiopulmonary bypass. Furthermore, blood pressure variability has not been evaluated specifically during each phase of surgery, namely in the pre-, intra- and postbypass phases; thus, we aimed also to assess whether outcomes were associated with phase-specific systolic and mean arterial blood pressure variability. All patients undergoing cardiac surgery from January 2008 to June 2014 were enrolled in this retrospective, single-center study. Demographic, intraoperative, and postoperative outcome data were obtained from the institution's Society of Thoracic Surgery database and Anesthesia Information Management System. Systolic and mean arterial blood pressure variability were assessed using the coefficient of variation (CV). The primary outcomes were 30-day mortality and in-hospital renal failure in relation to the entire duration of a case, while the secondary outcomes assessed phase-specific surgical periods. In an effort to control the family-wise error rate, P values <.0125 were considered significant for the primary outcomes. Of the 3687 patients analyzed, 2.7% of patients died within 30 days of surgery and 2.8% experienced in-hospital renal failure. After adjusting for significant covariates, we found a statistically significant association between increasing CV for systolic blood pressure (CVSBP) and 30-day mortality and in-hospital renal failure. For every 0.10 increase in CVSBP, there was a 150% increase in the odds of death (odds ratio, 2.50; 95% confidence interval, 1.60-3.92; P < .0001) and there was a 104% increase in odds of experiencing renal failure (odds ratio, 2.04; 95% confidence interval, 1.33-3.14; P = .001). The association with mortality was driven primarily by the prebypass period, because the association between CVSBP and mortality during the prebypass phase was significant (P = .01), and not during the postbypass phase (P = .08). There was no significant association between CV for mean arterial blood pressure and either death or renal failure during any period of surgery, including the bypass phase. Increasing systolic blood pressure variability was associated with 30-day mortality and development of renal failure, with surgery phase-specific relationships observed. Further research is required to determine how to prospectively detect blood pressure variability and elucidate opportunities for intervention.

Beyond borders-international database collaboration in thoracic surgery.

Thoracic surgery databases continue to emerge as pillars for institutional quality improvement and research endeavors. This paper reviews the current state of the largest thoracic surgery databases: the Thoracic Surgeons General Thoracic Surgery Database (STS-GTSD) and the European Society of Thoracic Surgery Database (ESTSD). In addition, we utilize these as a platform to evaluate the role and key ingredients for successful international database collaborations. Ultimately, collaborative efforts among large databases unify research efforts, foster cohesion, serve as benchmarks for quality improvement locally, nationally and internationally, promote comparative innovation, and ultimately improve patient outcomes.

Re: Video-assisted thoracoscopic surgery yields better outcomes than thoracotomy for anatomical lung resection in Brazil: a propensity score-matching analysis using the Brazilian Society of Thoracic Surgery database.

Re: Video-assisted thoracoscopic surgery yields better outcomes than thoracotomy for anatomical lung resection in Brazil: a propensity score-matching analysis using the Brazilian Society of Thoracic Surgery database.

Evaluation of Prophylactic Antibiotic Use for Delayed Sternal Closure After Cardiothoracic Operation

Clinical practice guidelines provide recommendations for surgical prophylaxis in patients undergoing cardiothoracic procedures. However, currently no recommendations guide the management of antibiotic prophylaxis in patients who require delayed sternal closure after cardiothoracic operation. This is a single-center, retrospective analysis. Data were extracted from The Society of Thoracic Surgery database and electronic medical record from July 2011 through January 2016. Patients included are adults (≥18 years old) after cardiothoracic operation with delayed sternal closure. A total of 167 patients were included for analysis. The majority of patients (131, 78.4%) were continued on routine antibiotics and 36 patients (21.6%) were switched to broad-spectrum antibiotics for prophylaxis. Of patients on routine antibiotic prophylaxis, 6 (4.6%) experienced a sternal surgical site infection, whereas 3 patients (8.3%) switched to broad-spectrum agents before chest closure experienced a sternal surgical site infection (p= 0.407). Eleven patients (6.6%) received an abbreviated duration of antibiotics, 52 patients (31.1%) were continued on antibiotics until the time of sternal closure, and 104 patients (62.3%) were continued on antibiotics past the time of sternal closure. The incidence of infection based on duration of prophylactic antibiotic was 0, 1 (1.9%), and 8 (7.7%), respectively (p= 0.352). Substantial variation was found in the duration and selection of antibiotic prophylaxis for patients with delayed sternal closure after cardiothoracic operation. Broad-spectrum antimicrobial agents and extended durations of antibiotic prophylaxis were not associated with benefits in the incidence of sternal wound infection and may increase the risk of adverse effects.

Video-assisted thoracoscopic surgery yields better outcomes than thoracotomy for anatomical lung resection in Brazil: a propensity score-matching analysis using the Brazilian Society of Thoracic Surgery database†

The use of video-assisted anatomical lung resection is increasingly widespread for lung cancer and non-neoplastic diseases, showing excellent results. Nonetheless, a comparative analysis of the benefits of this technique has yet to be conducted in Latin America, a region with a completely different case mix from the USA or Europe. The purpose of this study was to compare the outcomes of video-assisted thoracoscopic surgery (VATS) and open thoracotomy (OT) for anatomical lung resection in patients included on the Brazilian Society of Thoracic Surgery (BSTS) database. Using propensity score matching, we conducted an analysis of 1355 patients who underwent anatomical lung resection (704 OT and 651 VATS) registered in the BSTS database between August 2015 and December 2016. Propensity score matching was performed using the following baseline characteristics: age at surgery, gender, comorbidities, pulmonary lung function, type of resection and cancer and non-cancer diagnosis. The propensity score-matched sample comprised a well-matched group of 890 patients. The main outcomes tested were mortality, complications and major cardiopulmonary complications based on the European Society of Thoracic Surgeons (ESTS) database definitions and terminology. Standardized differences of means and proportions suggested that an adequate balance had been achieved. Major cardiopulmonary complications were shown to be more frequent in patients who underwent OT (16.0% compared with 9.2% in VATS patients; odds ratio = 1.87, 95% confidence interval 1.25-2.80) and the overall complications rate was higher among patients who underwent OT (30.1% compared with 21.8% in VATS patients; odds ratio = 1.55, 95% confidence interval 1.17-2.05). No statistically significant difference in mortality rate was observed between OT (2.5%) and VATS (1.8%) (odds ratio = 1.38, 95% confidence interval 0.54-3.50). In Brazil, the rate of complications associated with minimally invasive surgery (VATS) for anatomical lung resection is significantly lower than that of conventional OT.

Incidence and Outcomes of Surgical Pulmonary Embolectomy in the United States: An Analysis of the Society of Thoracic Surgery Database

Kon, Zachary N. MD; Bittle, Gregory J.; Pasrija, Chetan; Vemulapalli, Sreekanth; Grau-Sepulveda, Maria V. MD, MPH; Matsouaka, Roland A. PhD; Taylor, Bradley MD; Gammie, James S.; Griffith, Bartley P. Author Information

Thymic minimally invasive surgery: state of the art across the world: Central-South America.

Literature suggests that, for thymectomy in myasthenia or resection of thymic tumors, minimally invasive surgery is equivalent to open surgery with regard to long-term outcomes. However, it could bring some benefits in the immediate results as complication rate or length-of-stay. There are doubts about the worldwide adoption of the method, though. In Latin America, the implementation of video-assisted thoracic surgery (VATS) started in the 1990s, but it progressed slowly. The main barriers were associated costs and training. Thymic surgery poses a bigger challenge due to its rarity, so just a few reports mention the use of the method in the region. Nonetheless, in recent years we observe a faster dissemination of the method both in number and in complexity of the procedures performed. Confirming this fact, half of the patients registered in the Brazilian Society of Thoracic Surgery database in the last 2 years as undergoing resection of thymic tumors, underwent a minimally invasive procedure. Although promising, robotic surgery is still in its early days in Latin America.

Methylene Blue for Vasoplegic Syndrome After Cardiac Operation: Early Administration Improves Survival

Vasoplegic syndrome, defined by hypotension despite normal or increased cardiac output, is associated with high mortality rate after cardiopulmonary bypass. Methylene blue (MB) is reported to ameliorate vasoplegic syndrome through the nitric oxide pathway. We hypothesized that early administration of MB would improve outcomes in patients with vasoplegic syndrome after cardiopulmonary bypass. All patients that underwent cardiopulmonary bypass at our institution (Jan 1, 2011 to Jun 30, 2016) were identified through our Society of Thoracic Surgery database. Pharmacy records identified patients receiving MB within 72 hours of cardiopulmonary bypass. Multivariate logistic regression identified predictors of major adverse events among patients receiving MB. A total of 118 cardiopulmonary bypass patients (3.3%) received MB for vasoplegic syndrome. These patients had a higher incidence of comorbidities, and these cases were more commonly reoperative (76.1% versus 41.2%, p < 0.0001) and complex (70.3% versus 31.8%, p < 0.0001). The only difference in preoperative medications was that MB patients had a higher rate of amiodarone use (15.3% versus 2.2%, p < 0.0001). MB patients had significantly higher rates of postoperative complications, except atrial fibrillation. Early (operating room, 40.7%) versus late (intensive care unit, 59.3%) administration of MB was associated with significantly reduced operative mortality rate (10.4% versus 28.6%, p=0.018) and risk-adjusted major adverse events (odd ratio 0.35, p= 0.037). Operative mortality rate is high in patients receiving MB for the treatment of vasoplegia after cardiopulmonary bypass. Early administration of MB improves survival and reduces the risk-adjusted rate of major adverse events in these patients.

Invited Commentary

The adoption rate of thoracoscopic lobectomy varies widely throughout the world, and some of this variation can be attributed to economic and cultural issues. The variation in the adoption rate of thoracoscopic lobectomy in the United States is equally large, and it can be attributed only to resistance to innovation. This study by Abdelsattar and colleagues [1Abdelsattar Z.M. Allen M.S. Shen K.R. et al.Variation in hospital adoption rates of video-assisted thoracoscopic lobectomy for lung cancer and the effect on outcomes.Ann Thorac Surg. 2017; 103: 454-461Abstract Full Text Full Text PDF Scopus (24) Google Scholar] analyzes the National Cancer Database to assess the variation in adoption of thoracoscopic lobectomy and to identify factors that might explain this variation. In this study, adoption rates in the highest and lowest quintiles were 76% versus 0.6%, respectively. This finding is similar to a recent publication using the National Inpatient Sample Database, demonstrating that the mean hospital utilization of thoracoscopic lobectomy ranged from 3% to 66%, that discordance (actual versus predicted utilization) was as high as 250%, and that complications were less common with the thoracoscopic approach versus open (17% versus 25%; p < 0.05) [2Cooper M.A. Hutfless S. Segev D.L. et al.Hospital level under-utilization of minimally invasive surgery in the United States: retrospective review.BMJ. 2014; 349: g4198Crossref PubMed Scopus (61) Google Scholar]. In the Society of Thoracic Surgeons General Thoracic Surgery Database, the most recent publication demonstrated that approximately 50% of lobectomies are performed thoracoscopically [3Ceppa D.P. Kosinski A.S. Berry M.F. Tong B.C. et al.Thoracoscopic lobectomy has increasing benefit in patients with poor pulmonary function: a Society of Thoracic Surgeons database analysis.Ann Surg. 2012; 256: 487-493Crossref PubMed Scopus (193) Google Scholar]; in the European Society of Thoracic Surgery Database, less than 25% of lobectomies are performed thoracoscopically [4Falcoz P.-E. Puyraveau M. Thomas P.-A. Decaluwe H. et al.Video-assisted thoracoscopic surgery versus open lobectomy for primary non-small-cell lung cancer; a propensity-matched analysis of outcome from the European Society of Thoracic Surgeon database.Eur J Cardiothorac Surg. 2016; 49: 602-609Crossref PubMed Scopus (269) Google Scholar]. Considering that the adoption rate of thoracoscopic lobectomy since introduction approximately 20 years ago is so low in the United States and worldwide, it can be concluded that we have not yet made it through the “early majority” phase of adoption, with the “late majority” barely on the horizon. In light of the overwhelming evidence of outcome advantages of thoracoscopic lobectomy, continued focus on teaching and training is paramount—in training programs, in regional courses, and in national and international meetings [5Zwischenberger B. D’Amico T.A. Tong B.C. How I teach it: thoracoscopic lobectomy.Ann Thorac Surg. 2016; 101: 846-849Abstract Full Text Full Text PDF Scopus (10) Google Scholar]. It is possible that the development of improved instrumentation, alternate robotic platforms, and three-dimensional optics will improve the conversion of surgeons to “minimally invasive” and increase the adoption rate of thoracoscopic lobectomy and other minimally invasive approaches. The advent of publicly reported outcomes will expose the surgeons “late majority” and “laggard” phases to patients, referring physicians, and payors, which unfortunately may be the most effective force to reduce the practice variation and to improve the outcomes associated with thoracoscopic lobectomy. Variation in Hospital Adoption Rates of Video-Assisted Thoracoscopic Lobectomy for Lung Cancer and the Effect on OutcomesThe Annals of Thoracic SurgeryVol. 103Issue 2PreviewThis study examined the variation in the adoption of video-assisted thoracoscopic surgery (VATS) for lobectomy across United States hospitals from a population-based national database. Full-Text PDF