Practice Of Thoracic Surgery Research Articles

Covid-19 Pandemisinde Göğüs Cerrahisi Pratiği

Covid-19 disease was declared a pandemic by the World Health Organization in 2020, leaving all hospitals in a difficult situation. In this period, when resource management in hospitals is of critical importance, elective operations in many specialties have been postponed, and there are many opinions about which operations can be performed. Although thoracic surgery is a specialty involved in the complication management of Covid-19 disease, unlike other specialties, it deals with oncological diseases where the timing of the surgery is vital. In this review, how the thoracic surgery practice should be in the Covid-19 pandemic is presented in the light of the literature.

What to Take Care About Thoracic Surgery Practice During COVID-19 Pandemic

What to Take Care About Thoracic Surgery Practice During COVID-19 Pandemic

The Scope of Clinical Thoracic Surgery Practice in Nigeria: 13-Year Single Center Review

Background: Thoracic surgery as one of the oldest surgical specialties to have branched off from general surgeryhas a relatively wide scope, covering the diagnosis and treatment of the diseases affecting the various regions ofthechest. The practice of this specialty and challenges affecting it in Nigeria is hereby reviewed. Aims/Objective: To review the scope of clinical thoracic surgery practice in Nigeria including its challenges and compare same with international standard. Methods: For a period of 13 years (2007-2019), the practice of clinical thoracic surgery in Nigeria was reviewed with data from the National Cardiothoracic Center of Excellence (NCTCE). The social-demography profile of the involved patients, the congenital and acquired pathologies of the various anatomic regions of the chest, diagnosis and treatmentmethodologies including outcomes and challenges were extracted from the database, reviewed and analyzed. Results: A total of 1883 general thoracic pathologies in 1200 patients were managed. Of this number, pleural pathology accounted for the highest number (n=687, 35.6%). 657 males and 543 females were involved with aM: F ratio of 1:0.8. Of 1883 cases, 1283 (68.1%) had some form of surgical interventions. Within this group, chest tube drainage± pleural biopsy/pleurodesiswasthehighest (n=611, 47.6%). Late presentations of malignant lung diseases, lack of expertise and equipment for minimal access techniques were some of the challenges. Conclusion: General thoracic surgery as a mono-specialty should be embraced, encouraged and upgraded by the training institutions in our sub-region since the workload for experts in the specialty is enormous.

External validity of a model to predict postoperative atrial fibrillation after thoracic surgery.

A prediction model developed by Passman et al. stratifies patients' risk of postoperative atrial fibrillation (POAF) after major non-cardiac thoracic surgery using 3 simple factors (sex, age and preoperative resting heart rate). The model has neither undergone external validation nor proven to be relevant in current thoracic surgery practice. A retrospective single-centre analysis of all patients who underwent major non-cardiac thoracic surgery (2008-2017) with prospective documentation of incidence and severity of POAF was used for external validation of Passman's derivation sample (published in 2005 with 856 patients). The model calibration was assessed by evaluating the incidence of POAF and patients' risk scores (0-6). A total of 2054 patients were included. Among them, POAF occurred in 164 (7.9%), compared to 147 (17.2%) in Passman's study. Differences in our sample compared to Passman's sample included mean heart rate (75.7 vs 73.7 bpm, P < 0.001), proportion of patients with hypertension (46.1 vs 29.4%, P < 0.001), proportion of extensive lung resections, particularly pneumonectomy (6.1 vs 21%, P < 0.001) and proportion of minimally invasive surgeries (56.6% vs 0%). The model demonstrated a positive correlation between risk scores and POAF incidence (risk score 1.2% vs 6.16%). The POAF model demonstrated good calibration in our population, despite a lower overall incidence of POAF compared to the derivation study. POAF rates were higher among patients with a higher risk score and undergoing procedures with greater intrathoracic dissection. This tool may be useful in identifying patients who are at risk of POAF when undergoing major thoracic surgery and may, therefore, benefit from targeted prophylactic therapy.

PMD38 THE CLINICAL AND ECONOMIC ANALYSES OF VIDEO ASSISTED THORACOSCOPIC SURGERY FOR LOBECTOMY: EXPERIENCE FROM A TOP ACADEMIC MEDICAL CENTER IN CHINA

Pulmonary lobectomy remains the most commonly performed operation in general thoracic surgery practice. The video assisted thoracoscopic surgery (VATS) for lobectomy which is newly developed technology represents an important option for lung cancer due to less morbidity and mortality compare with open lobectomy. This study aims to investigate the economic and clinical outcomes of VATS lobectomy versus open lobectomy in Chinese real-world setting. A retrospective cohort analysis was conducted using the hospital EMR database of the first affiliated hospital of University of Science and Technology of China. The patient inclusion criteria were specified: 1) hospitalized in thoracic surgery department between 2016 and 2017; 2) performed open lobectomy (116 patients) or VATS lobectomy (710 patients). The primary endpoint was length of stay (LOS), operation time, and interoperative blood loss, along with total hospitalization cost, cost breakdowns, hemorrhage volume and re-operation rate as the exploratory outcomes. Where applicable, t-test and the Kruskal-Wallis test for continuous variables and the Chi-Square test for categorical variables would be determined if the different groups are significant. There were no statistically differences in baseline characteristics. Compared with open lobectomy group, VATS group has shorter LOS (12.26 vs. 15.27, P＜0.001) and less interoperative blood loss (91.15 vs. 255.6, P＜0.001), while its operation time were no statistical significance. Although the total hospitalization costs were similar, CNY46,799.70 in VATS lobectomy group vs CNY45,321.98 in open group (P=0.478), the proportion of material cost in VATS was higher (44% vs. 37%, P＜0.001). Besides, VATS group was associated with significantly less hemorrhage volume, and similar re-operation rate. The VATS lobectomy shows benefits in LOS and interoperative blood loss compare to open lobectomy. Meanwhile, although the consumable material cost proportion is higher in VATS group, the total hospitalization cost will not increase due to cost-savings in medicine and treatment costs.

Four-arm robotic lung resection versus muscle-sparing mini-thoracotomy: retrospective experience.

Robotic surgery was introduced in the early 2000s but its use remains limited, particularly in thoracic surgery. Here we compare the first consecutive 185 four-arm robotic procedures carried out in our institution vs. muscle-sparing video-assisted mini-thoracotomy (MSMT), our previous minimally invasive approach for anatomical lung resection. One hundred and eighty-five consecutive patients undergoing surgery using the four-arm robotic technique between February 2014 and December 2016 were compared to a control historical series of 136 consecutive patients undergoing surgery by MSMT in the same institution. The same senior surgeon performed all surgical procedures. Comparisons between the two groups were performed using the Chi2 test for qualitative data and the Wilcoxon, Mann-Whitney or Student's t-test for quantitative data. The demographic and clinical characteristics of the patients were similar in the two groups. In the robotic group, median (min-max) length of hospital stay (LOS) was significantly shorter (by 2 days) than in the MSMT group {7 days [3-63] vs. 9 days [5-63], respectively; P<0.0001}. The rate of complications was similar in the two groups, but the complications appeared to be less severe in patients undergoing robotic surgery (switch from Clavien-Dindo grade III and IV to grade II) although further studies are required to confirm this due to the large number of missing data. In a senior thoracic surgery practice, the switch from a minimally invasive technique to robotic surgery was safe and beneficial in patients undergoing anatomical lung resection in terms of LOS and possible complication severity.

Improving Self-Reported Preoperative Anxiety Through a Preoperative Education Program: A Quality Improvement Project

Preoperative education is an important component of preparing patients for surgery. Preoperative anxiety is one of the most important problems for patients, because it causes emotional and psychiatric problems as well as physical problems. Anxiety has been associated with several pathophysiological responses such as hypertension and dysrhythmias, which can increase perioperative morbidity. Estimates suggest that between 11% and 80% of adult presurgical patients experience heightened levels of anxiety. The purpose of this pilot project was to develop a preoperative education program for thoracic surgery patients and to assess the effectiveness of the program in decreasing patient's self-reported anxiety levels using the validated Patient-Reported Outcomes Measurement Information System (PROMIS) tool. This quality improvement project used a pre- and posttest improvement design to evaluate patient's self-reported anxiety levels at three different timepoints during the preoperative and postoperative period. A total of 15 patients from a thoracic surgery practice participated in the study. The study showed no statistically significant change in patients' self-reported anxiety levels after completion of the preoperative education program (p = .538). Patients reported improvements in parameters such as expectations, pain, and preparedness. Although some studies have found that preoperative patient education decreases anxiety, this study supports others that indicate that anxiety is not affected by or associated with educational preparation prior to thoracic surgery. Though no statistical improvement in anxiety levels was demonstrated in this study, a majority of patients reported improvements in parameters such as expectations, pain, and preparedness. As patient education is largely provided by the nursing profession, this article will help the profession to better understand what is important for patients to know in the preoperative setting. Setting patient expectations has a great impact on the patient's recovery and satisfaction with their surgical experience. As this is a pilot study, the goal is for continued research in the area of decreasing preoperative anxiety and preparing patients for surgery.

Da Vinci Xi robot decreases the number of thoracotomy cases in pulmonary resection.

Minimally invasive pulmonary resection has been shown to provide superior outcomes compared to open thoracotomy. We sought to determine if adding a robot to a general thoracic surgery practice would decrease the total number of open thoracotomy cases. We performed a retrospective analysis of prospectively collected data from the Society of Thoracic Surgeons (STS) database from 2012-2017. We grouped patients before and after the date of first robot usage with the vascular stapler in pulmonary resections. We analyzed the number of patients who underwent either an elective thoracotomy or were converted to thoracotomy from a planned minimally invasive approach. There were 389 patients who underwent pulmonary resection between the two time periods. There were 220 patients (56.6%) from 2012-2015 prior to the first use of the robot with vascular stapler and 169 patients (43.4%) from 2016-2017 after the addition of the robot. During the pre-robot time period, 194 of 220 cases (88.2%) were performed with video-assisted thoracoscopic surgery (VATS) while during the post-robot time period, 118 of 169 cases (69.8%) were performed with the robot. A significantly higher number of patients (41 total, 19%) required a thoracotomy in the pre-robot time period compared to the post-robot time period (8 total, 5%, P<0.001). Multivariate analysis showed that adding a robot to the general thoracic surgery program could decrease up to 75% the odds of having thoracotomy [odds ratio=0.25 (95% CI 0.12-0.55, P<0.001)]. The adoption of a robot with a vascular stapler may decrease the number of patients who require a thoracotomy. Potential explanations include an improved ability to perform complex minimally invasive pulmonary resections.

Uniportal VATS approach for treatment of empyema: Challenges and recommendations

The uniportal VATS approach is now taking the lead in the practice of thoracic surgery and is transforming the way we operate. We describe here how to perform a uniportal VATS debridement and decortication, with a special focus on tips and tricks for getting inside an empyema pouch and identifying the optimal plane of cleavage for decortication.

Using the Hybrid Operating Room in Thoracic Surgery: A Paradigm Shift.

We describe the integration of the hybrid operation room cone-beam computed tomography (CT) scan technology into the practice of general thoracic surgery. The combination of the following three techniques: (1) cone-beam CT scan augmented navigational bronchoscopy, (2) cone-beam CT-guided percutaneous biopsy and/or fiducial placement, and (3) fiducial or image-guided video-assisted thoracic surgery resection, into a single-stage, single-provider procedure allows for diagnosis and treatment in one setting. Rapid on-site evaluation of cytological or pathology specimens is key to this "all-in-one" approach. The time from diagnosis to curative treatment can significantly be reduced using the hybrid operation room technology, leading to decreased upstaging, increased survival and facilitating the otherwise difficult intraoperative detection and resection of small and deeper lesions. Not only does this benefit the overall thoracic healthcare of the community but also provides a cost-effective paradigm for the institution.

NextGen training assessment tools in thoracic surgery

For trainees in a thoracic surgery fellowship, the development of thoracoscopic skills is a principle focus. Not only is minimally invasive lobectomy rapidly becoming the treatment of choice for early stage lung cancer (1), but the sound performance of this operation provides a competitive edge in markets where lung resections are commonly performed via thoracotomy. While competency in this operation is one of the main goals of a general thoracic training program, there are few well-established, standardized, and widely-accepted assessment tools available to help educators prepare their trainees for practice in thoracic surgery.

What is the role of wedge resection for T1a lung cancer?

Since 1995, lobar resection became the standard of care for medically fit patients with early stage lung cancer. This was based on the results of a single randomized trial comparing lobectomy and sublobar resection (SLR) in stage I lung cancer conducted by the lung cancer study group between 1982 and 1988. The conclusions of the study included a statistically significant tripling in loco-regional recurrence (LR) after limited resection but no difference between the two arms of the trial in systemic recurrence. Although both overall survival and cancer specific survival favored lobectomy, neither achieved statistical significance. Regardless, this landmark trial established lobectomy as the preferred oncological resection for early stage lung cancer. The practice of thoracic surgery has evolved significantly since the study period of the Lung Cancer Study Group, and this has led some surgeons to question its relevance to contemporary practice. The increased detection of smaller more precisely staged tumors combined with the rising segment of the population that is elderly with limited cardiopulmonary reserve has renewed interest in sub-lobar resection including wedge resection as either a definitive therapeutic strategy or as a compromise approach in patients with poor performance status. The interest in wedge resections is also to some extent further fueled by the emergence and increased utilization of competing technologies of local control such as stereotactic radiation or percutaneous and trans-bronchial ablative techniques. Although the results of the LCSG still cast a long shadow over the soundness of wedge resection as a cancer operation, much literature has been published in the subsequent years on this topic. We present in this review an overview of the conflicting data and offer our perspective on the role of wedge resection in early stage lung cancer.

Principles and indications of extracorporeal life support in general thoracic surgery.

The role of extracorporeal life support (ECLS) has expanded rapidly over the past 15 years to become an important tool in advanced general thoracic surgery practice. Intra-operative and in some cases continued post-operative ECLS is redefining the scope of complex surgical care. ECLS encompasses a spectrum of temporary mechanical support that may remove CO2, oxygenate or provide hemodynamic support or a combination thereof. The most common modalities used in general thoracic surgery include extracorporeal membrane oxygenation (ECMO), interventional lung assist device (iLA® Novalung®, Heilbronn, Germany), and extracorporeal CO2 removal (ECCO2R). The ECMO and Novalung® devices can be used in different modes for the short term or long-term support depending on the situation. In this review, the principles and current applications of ECLS in general thoracic surgery are presented.

‘Pandora’s box’ of the developing world-perioperative implications of pulmonary infections

Infective pathologies of the lung such as tuberculosis, aspergillosis, hydatid cyst, empyema thoracis etc. are quite prevalent in the developing countries of the world and their sequelae are the norm rather than the exception. Poor financial resources and lack of adequate healthcare facilities in the third world add to the compendium of healthcare problems faced by the general population. They have their unique share of pulmonary diseases not otherwise encountered routinely in the western world. Lack of screening facilities allows these diseases to progress unnoticed. Often the first presentation in the hospital is when the disease has advanced and the management is challenging. A significant percentage of these patients are then referred to the thoracic surgeon for definitive management. These include chest drain insertion, thoracoscopy, decortication, segmentectomy, lobectomy or pneumonectomy. Lung isolation and management of one lung anaesthesia are fundamental to thoracic surgery practice. But trained thoracic anaesthesiologists with expertise in dealing with such high-risk procedures and physicians with good ICU backup to look after the patient during the perioperative period are mainly concentrated in the large government and private hospitals of metro cities. Smaller hospitals and cities do not have access to a good thoracic surgeon. General surgeons perform most thoracic procedures. Due to mismatch of equity, straightforward cases that can be managed surgically are management conservatively with a trial of medical therapy. Referral for surgery is delayed leading to advanced cases with irreversible lung damage. Our article deals with the problem of infective pathologies of the lung especially in reference to the developing world and their perioperative management concerns and the role of video assisted thoracic surgery in such scenarios.

Current practice of thoracic outlet decompression surgery in the United States

BackgroundThoracic outlet syndrome (TOS) and its management are relatively controversial topics. Most of the literature reporting the outcomes of surgical decompression for TOS derives from single-center experiences. The objective of our study was to describe the current state of TOS surgery among hospitals that participate in the American College of Surgeons National Surgical Quality Improvement Program database. MethodsOur study sample consisted of patients from the 2005 to 2014 American College of Surgeons National Surgical Quality Improvement Program database who underwent first or cervical rib resection as their index procedure and whose constellation of diagnosis and procedure codes identified them as having neurogenic, arterial, or venous TOS. Patient and procedure characteristics were determined, as were the 30-day incidence of specific complications including nerve injury. Multimodel inference was used for multivariable analysis of the composite outcome of readmission or reoperation ≤30 days. ResultsWe identified 1431 patients undergoing operation for TOS: 83% for neurogenic TOS, 3% for arterial TOS, and 12% for venous TOS. Vascular surgeons performed 90% of procedures. Only four patients (0.3%) demonstrated evidence of nerve injury. The rate of bleeding complication requiring transfusion was also quite low, at 1.4%. The 30-day incidence of readmission or reoperation, or both, in our study cohort was 8.6%. The risk of this outcome was increased in patients with a higher American Society of Anesthesiologists Physical Status Classification, those whose procedure was for non-neurogenic symptoms, and those whose procedure took longer to complete. ConclusionsThe findings of our study will provide surgeons who advocate for the surgical management of TOS with reassurance that such intervention is associated with an extremely low risk of disability resulting from iatrogenic nerve injury and major bleeding events.

Robotic lung resections: video-assisted thoracic surgery based approach.

Advances in technology cause major developments in minimally invasive thoracic surgery practice. The expected benefits of minimally invasive pulmonary surgery are clear and mostly as follows; shorter hospital stay, fast recovery, less pain, and decreased morbidity and mortality. Robotic surgery with improved visualization and instrumental technical capabilities has become an attractive tool for surgeons who are performing lung resections. However, robotic surgery still seems far away from standardization even in the basic fundamental which is "the best approach for docking". In this article, we would like to share our experience in robotic surgery with video-assisted thoracic surgery (VATS) based or in other terms "robotic-assisted" approach, and discuss its advantages and disadvantages. We speculate that, especially at early experience, VATS based approach or "robotic-assisted approach" may provide a smooth start up with the support of the experienced table surgeon.

NU02.02 Preoperative Thoracic Surgery Patient Education Program Development

NU02.02 Preoperative Thoracic Surgery Patient Education Program Development

P2.06-041 TeleNursing: A Thoracic Surgery Nursing Initiative Aimed at Decreasing Hospital Readmissions and Increasing Patient Satisfaction: Topic: LAB, Other

In the USA there is a national initiative in healthcare to decrease hospital readmissions, decrease the cost of care while patients are hospitalized and to increase patient. A recent study evaluating mortality rates in the lung cancer resection patients reported a 30-day readmission was associated with a 6-fold increase in the 90-day mortality of this patient population (14.4% vs 2.5%). This report not only forces thoracic surgery teams to extend their operative mortality focus and reporting beyond the traditional 30-day time period but it also emphasizes the critical value and positive impact continued post-operative care for the first three months after discharge can have on patient outcomes. The expert care delivered by thoracic surgery nurses plays a critical role in decreasing post-operative complications and ensuring patients are safely discharged from the hospital. The valuable impact thoracic surgery nurses have on preventing hospital readmissions and improving patient satisfaction is the intended focus of this clinical trial. The positive impact telehealth interventions have on multiple different disease processes supports investigation of this care modality for the thoracic surgery patient population. We have designed a clinical trial focused on implementing a TeleNursing program with the specific aims of preventing hospital readmissions and improving patient satisfaction. Our thoracic surgery practice currently has a “day-after-discharge” follow-up phone call program that is directed by the thoracic surgery nurses in the practice. Pertinent clinical details of each patient’s post-operative course are relayed to the thoracic surgery nurses. The nurses call patients 2-3 days after discharge and asked questions related to medications, pain management, sign or symptoms of infection, activity level and expectations, sleep, appetite and general understanding of all discharge instructions. This interaction is documented in the electronic medical record. This program has been expanded to compare the efficacy of the phone calls vs scheduled video-calls between nurses and patients. Patients are randomized to standard of care day after discharge phone calls vs the TeleNursing follow-up video-call; discharge day 2, 1-month, 2-month and 3-month. All patients complete a patient satisfaction questionnaire at predetermined time points. The primary objective is to decrease hospital readmission rates and the secondary objective is to improve patient satisfaction. Although the results of this clinical trial are pending, interim analysis indicates that patients are willing to participate in this program and are pleased with the nurse-patient interaction beyond their hospital stay. This clinical investigation is ongoing.

The Society of Thoracic Surgeons Thoracic Surgery Practice and Access Task Force: 2014 Workforce Report

The Society of Thoracic Surgeons (STS) has intermittently surveyed its workforce, providing isolated accounts of the current state of thoracic surgical practice. The 63-question survey instrument was received by 4,343 surgeon members of the STS, and responses were gathered between October 1 and November 5, 2014. The return rate was 29.1%. The median age of the active United States thoracic surgeons is 54 years. Women comprise 6.9% of the responders, constituting 6.3% of adult cardiac, 6.1% of congenital heart, and 11.8% of general thoracic surgeons. The decision to pursue a career in thoracic surgery was made before or in medical school by 48.3% of surgeons. Most survey respondents had a mean of 8.7 years of residency training after medical school graduation. The cumulative average educational debt was $62,815. Overall career satisfaction was 43.5% (very or extremely satisfied). STS Database participation greatly increased (89.9%) compared with the 2009 survey. Operative volume over the past 12 months decreased for 26% of surgeons. Malpractice premiums over the past 5 years have averaged between $54,310 and $$57,281. Of those who responded, 43.8% plan to retire between the age of 66 and 70 years. These data provide a current, detailed profile of the specialty. Ongoing challenges remain length of training and educational debt. Case volumes, scope of practice, malpractice costs, and career satisfaction have remained relatively constant. With contraction of the current resident pool and the workforce ages, significant cardiothoracic surgeon shortages may develop as the United States population expands.

Minimally invasive lobectomy for early stage non-small cell lung cancer—it can be done without sacrificing oncologic outcomes

The introduction of minimally invasive surgical techniques to perform lobectomy for non-small cell lung cancer (NSCLC) has significantly changed the practice of general thoracic surgery over the past two decades. Since the first reports of the use of video-assisted thoracic surgery (VATS) to perform lobectomy for NSCLC in the early 1990s (1), many more studies across a wide array of cohorts have reported on short-term and long-term outcomes. Initial studies focused on the feasibility and reproducibility of the procedure (2), and then subsequent studies demonstrated VATS lobectomy had less morbidity compared to thoracotomy (3). Over time, studies have shown that a minimally invasive approach may be particularly beneficial in those patients with higher peri-operative risk due to advanced age or poor pulmonary function (4,5). More recently, experience with robotic-assisted lobectomy has been increasingly reported and a robotic approach appears to provide similar advantages over thoracotomy as a VATS approach (6). Despite these demonstrated benefits, universal adoption of minimally invasive lobectomy for early-stage NSCLC has not occurred (4,7,8).