81.20 Electromagnetic Navigational Bronchoscopy in the Hands of a Thoracic Surgeon

Posted on January 26, 2017

A. Cheng4, C. C. Moodie1, J. R. Garrett1, E. M. Toloza1,2,3  1Moffitt Cancer Center,Thoracic Oncology,Tampa, FL, USA 2University Of South Florida Morsani College Of Medicine,Surgery,Tampa, FL, USA 3University Of South Florida Morsani College Of Medicine,Oncologic Sciences,Tampa, FL, USA 4University Of South Florida,Morsani College Of Medicine,Tampa, FL, USA

Introduction:   We evaluated outcomes of electromagnetic navigational bronchoscopy (ENB) performed by a thoracic surgeon.

Methods:   We retrospectively analyzed all patients who underwent ENB by one thoracic surgeon.  ENB was performed for transbronchial biopsies (TBBx) of or for metal or dye-mark fiducial placement at peripheral lung nodules, the latter immediately followed by minimally invasive resection.

Results:  Of 142 pts who underwent ENB from November 2013 to October 2015, 40 (28.2%) and 111 (78.1%) pts underwent ENB for TBBx or for fiducial placement, respectively.  Only 4/142 (2.8%) pts underwent ENB with C-arm fluoroscopy.  A total of 303 lung nodules were targeted in the right upper lobe [RUL] (83/303, 27.4%), right middle lobe (41/303, 13.5%), right lower lobe [RLL] (77/303, 25.4%), left upper lobe (44/303, 14.5%), and left lower lobe (58/303, 19.1%), with a mean of 2.1+0.1 (range 1-8) lung nodules per pt.  Of these lung nodules, 62/303 (20.5%) and 237/303 (78.2%) were targeted for TBBx or for fiducial placement, respectively, while 4/303 (1.3%) lung nodules were targeted for both TBBx and fiducial placement.  Navigation was successful to 298/303 (98.3%) lung nodules, with 5/303 (1.7%) unsuccessful navigations to the RUL (3/5, 60%) and the RLL (2/5, 40%).  Of 40 pts who underwent ENB-guided TBBx, 5/40 (12.5%) pts also underwent transbronchial confocal laser endomicroscopy.  A mean of 1.6+0.1 (range 1-4) lung nodules were biopsied per pt, with needle aspiration used in 29/40 (72.5%) pts, brushings in 38/40 (95.0%) pts, forceps biopsies in 41/41 (100%) pts, and bronchial lavage in 29/40 (72.5%) pts.  One pt (1/40, 2.5%) had a pneumothorax, and two pts (2/40, 5.0%) had endobronchial bleeding requiring bronchial lavage with cold saline containing 1:100,000 dilution of epinephrine.  Of 111 pts who underwent ENB for fiducial placement, 22/111 (19.8%) pts also underwent intraoperative ultrasound.  Two of 111 (1.8%) and 111/111 (100%) pts underwent metal or dye-mark fiducial placement, respectively, with a mean of 2.2+0.1 (range 1-7) dye-marks per pt.  Indigo carmine was used in 1/111 (0.9%) pts, methylene blue in 111/111 (100%) pts, and indocyanine green in 91/111 (82.0%) pts.  Eight of 111 (7.2%) and 104/111 (93.7%) pts underwent video-assisted thoracoscopy (VATS) or robotic-assisted VATS wedge resection, respectively, with a mean of 1.1+0.1 (range 1-3) wedge resections per lung nodule target.  The only ENB-related complication occurring in this latter group of pts was retention of a metal fiducial that was later coughed up by the pt.  No pts underwent VATS anatomic resection, but 10/111 (9.0%) and 21/111 (18.9%) pts underwent immediate robotic-assisted segmentectomy or lobectomy, respectively.

Conclusions:  ENB to small peripheral lung nodules is safe and useful for thoracic surgeons to perform TBBx or to place metal or dye-mark fiducials, the latter immediately followed by VATS lung resection without or with robotic assistance.

81.17 Outcomes of Adult Veno-Arterial Extracorporeal Membrane Oxygenation at a High Volume Center

Posted on January 26, 2017

D. Ranney1, B. Yerokun1, J. Meza1, D. Bonadonna1, J. Schroder1, J. Haney1, C. Milano1, M. Daneshmand1  1Duke University Medical Center,Durham, NC, USA

Introduction:  Veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) is an adaptation of cardiopulmonary bypass that provides circulatory support during cardiac failure for an extended period of time. The utilization of ECMO in the adult population has continued to increase both nationally and globally, yet outcomes vary widely across institutions. The purpose of this study was to characterize the clinical outcomes of adult patients undergoing VA ECMO support at a single high volume institution. 

Methods:  A single-center retrospective review was performed of adult patients undergoing ECMO cannulation between January 2009 and December 2014. Demographics, details of ECMO deployment, and incidence of clinical events were acquired from the medical record. Primary outcomes included survival to decannulation and survival to hospital discharge. Standard analysis was performed to depict patient outcomes. 

Results: During the study period, 240 adult patients underwent cannulation for ECMO. Of these, 131 were veno-arterial (VA) cannulations, 75 (57.3%) of whom were transferred from outside facilities. Of 131 VA ECMO patients, primary cannulations were via the femoral artery (N=79, 60.3%), axillary artery (N=16, 12.2%), and aorta (N=36, 27.5%). Indications for ECMO included cardiogenic shock (N=122, 93.1%), respiratory failure with hemodynamic instability (N=13, 9.9%), and mixed shock/sepsis (N=4, 3.1%). The most common etiologies of cardiogenic shock were cardiac arrest (N=50), post-cardiotomy cardiogenic shock (N=44), and acute myocardial infarction (N=27). Prior to ECMO, 56 patients had an intra-aortic balloon pump in place. Vascular complications occurred in 29 patients (22.1%), GI complications in 8 patients (6.1%), stroke in 19 (14.5%), clinically significant coagulopathy in 25 (19.1%), cannula site bleeding in 28 (21.4%), new onset dialysis in 19 (14.5%), and dialysis at discharge in 2 of 55 hospital survivors (3.6%). Left ventricular assist devices were placed in 21 patients, and 12 patients underwent heart transplantation. Survival to decannulation was 61.6% and survival to hospital discharge was 43.2%. 

Conclusion: Favorable clinical outcomes and survival can be achieved with adult ECMO when performed at a high volume center. Further study will be needed to assess predictors of survival and optimization of patient selection. 

 

81.16 The Use of Antegrade Limb Perfusion Decreases the Risk of Limb Ischemia in Patients on V-A ECMO

Posted on January 26, 2017

R. Lyons1, D. Dexter1, R. Lyons1  1Eastern Virginia Medical School,Surgery,Norfolk, VA, USA

Introduction:  Extracorporeal membrane oxygenation (ECMO) is an increasingly used modality in patients with complete cardiopulmonary collapse. The etiology of collapse varies from pulmonary embolism to cardiogenic shock post-cardiotomy. Two cannulation schemes exist for the placement of patients on ECMO, central and peripheral. One of the known complications of peripheral VA cannulation is distal limb ischemia. The objective of this study was to determine if antegrade perfusion of the ipsilateral limb leads to decreased limb ischemia in patients on peripheral VA ECMO. 

Methods:  A retrospective chart review of patients that underwent ECMO from 2014-2015 were included in the study. We examined patient demographics, medical comorbidities, cannula size, technique of cannulation (open Vs percutaneous), Average ACT, vasopressor use, development of ipsilateral limb ischemia, and overall outcome. 

Results: We examined all patients that underwent ECMO during the study period. Of the 36 patients that underwent ECMO, 20 where cannulated peripherally and were eligible for the study. Of these, 4 developed limb ischemia. Three patients were cannulated via a chimney graft and one patient had an antegrade perfusion catheter. Three of these patients required fasciotomies for compartment syndrome and all patients that developed limb ischemia died. The strongest predictor of development of distal limb ischemia was the chimney end-to-side technique. Of the patients that underwent antegrade perfusion, only one of the 15 developed distal limb ischemia. Only one patient had percutaneous access without antegrade perfusion and they did not develop limb ischemia. 

Conclusion: Various techniques exist for peripheral ECMO cannulation that include open and percutaneous, both of which have their own drawbacks. Although it is felt that an open end to side chimney technique would decrease the incidence of distal limb ischemia because there is no cannula present to block antegrade flow, we have found that at our institution it increased the risk of distal limb ischemia. We postulate that this may be due a steal phenomenom causing ipsilateral limb ischemia. In patients that underwent percutaneous access, distal perfusion of the ipsilateral limb was noted to be protective and should be utilized in all patients undergoing this form of access.

 

81.15 Outcomes after Bilateral Thoracoscopic Splanchnicectomy for Treatment of Chronic Pancreatitis Pain

Posted on January 26, 2017

I. Qureshi1, K. Bartels2, M. Bronsert3, J. D. Mitchell1, M. J. Weyant1, R. J. Shah4, B. H. Edil1, R. A. Meguid1  1University Of Colorado Denver,Surgery/Medicine,Aurora, CO, USA 2University Of Colorado Denver,Critical Care/Anesthesiology/Medicine,Aurora, CO, USA 3University Of Colorado Denver,Adult And Child Center For Health Outcomes Research And Delivery Science,Aurora, CO, USA 4University Of Colorado Denver,Gastroenterology/Internal Medicine/Medicine,Aurora, CO, USA

Introduction: Bilateral thoracoscopic splanchnicectomy (BTS) is an option for pain from chronic pancreatitis. Mixed short term results are reported but long term results are not well known. However, by the time of referral for surgery patients have often failed medical therapy. BTS may be a reasonable alternative to total pancreatectomy. We evaluated long term outcomes of a recent single institution experience using of BTS for patients with chronic pancreatitis-associated pain

Methods: A retrospective review was conducted of all patients who underwent BTS for chronic pancreatitis-associated pain between 2013 and 2016 at a single institution. Retrospective assessment of levels of pre- & postoperative pain (scale of 0-10) was performed. Patient outcomes are compared using the Wilcoxon signed-rank test to compare decrease in pain level and change in pain medication use in daily oral morphine equivalents (OME) from before to after surgery. Long term outcomes including progression to pancreatic surgery are assessed

Results:Ten patients were evaluated with a median follow up of 12.7 months. Median age was 44 years and 6 (60%) were female. Of them, 6 (60%) reported successful BTS, 4 (40%) thought it was not. Patients reporting success trended towards having larger decreases in pain levels after surgery vs patients reporting no success [median pain level change (IQR), 4.0(3.0:7.0) vs 1.0(0.5:2.0);p=0.06]. There was no significant difference in change in pain medication between pre- & postoperative doses (OME) between patients reporting success vs no success [median difference (IQR)=0.0(-96:82.5) vs -200.5(-491:90),p=0.9]. 2 (22%) patients underwent further surgery (pancreatectomy & Puestow procedure) for non-resolving pain; mean interval after BTS=306 days

Conclusion:We studied long term outcomes of BTS in patients to determine if this is a viable alternative to more morbid surgical management, such as total pancreatectomy. BTS remains a feasible option for treating chronic pancreatitis-pain. Most patients report subjective improvement, independent of quantitative outcomes. A minority of patients proceed to pancreatic resection for pain management. Future research should compare standardized medical therapy + BTS to medical therapy alone to more rigorously assess the benefit of surgical intervention in this challenging patient population

 

81.14 Surgical management of pulmonary artery sarcoma: 11 years' experience

Posted on January 26, 2017

K. YIN1, Y. Lin1, Z. Zhang1, C. Wang1  1Zhongshan Hospital Fudan University,Department Of Cardiac Surgery,Shanghai, SHANGHAI, China

Introduction:  Pulmonary artery sarcoma (PAS) is a rare and poorly understood malignancy that arises from the intimal layer of pulmonary artery. There is lack of consensus on the diagnosis and treatment because of its rarity. We reviewed our experience of surgically management of PAS patients during the past 11 years. 

Methods:  From 2005 to 2016, 12 patients (age 51±14 years, 5 males) were ultimately diagnosed as PAS and underwent surgical treatment at our center. Chest pain (10/12) and asthenia (7/12) were two most common symptoms with all the patients presenting different extent of pulmonary artery hypertension. Six patients were initially misdiagnosed as pulmonary embolism. Ten patients underwent pulmonary endarterectomy (PEA) with cardiopulomonary bypass (83 ± 39 mins), among which three patients required pneumonectomy as the tumors invaded distal pulmonary arteries. The rest two underwent exploratory thoracotomy (including one emergency case) without being able to resect the tumors.

Results: There was one in-hospital mortality who underwent emergent thoracotomy for prominent internal bleeding and died at postoperative day 15. Follow-up was 100% complete. One patients underwent reoperation 52 months after the first operation but died four months later. The median overall survival was 18.5 months. All late death (7/12) were related to cancer recurrence or metastasis. PAS with myofibroblastic differentiation (5/12) and postoperative adjuvant treatment (isolated chemotherapy, isolated radiotherapy, or combined chemotherapy and radiotherapy, 7/12) carried better overall survival but neither of which reached statistical significance (p = 0.094 and 0.164, respectively).

Conclusion: PAS has a very poor prognosis. Surgical treatment, PEA combined with pneumonectomy, provides the only chance of long-term survival. Particular histological type and postoperative adjuvant treatment may be associated with better survival but still require further studies.

 

81.13 Assessing Autonomic Tone via ECG Markers to Predict Postoperative Atrial Fibrillation

Posted on January 26, 2017

K. Kim1, P. Frank2, W. Toppen3, S. Barajas Nuno1, L. Mukdad1, P. Benharash1,4  1David Geffen School Of Medicine, University Of California At Los Angeles,Los Angeles, CA, USA 2University Of California – Los Angeles,Anesthesiology,Los Angeles, CA, USA 3University Of California – Los Angeles,Medicine,Los Angeles, CA, USA 4University Of California – Los Angeles,Cardiac Surgery,Los Angeles, CA, USA

Introduction:  Postoperative atrial fibrillation (POAF) is the most common complication following cardiac surgery and is associated with increased morbidity and mortality. Successful reduction of POAF by administration of beta-blockers suggests that sympathetic activity is a significant driver of atrial fibrillation following cardiac surgery. Due to practical difficulties of measuring cardiac autonomic tone, surrogate markers using ECG have been developed and validated. Given the putative impact of sympathetic tone in POAF, we hypothesized that shortening of RR and QT intervals would precede the onset of POAF. 

Methods:  Telemetric ECG data were collected for adult patients without a history of atrial arrhythmias undergoing coronary artery bypass or valve operations at our institution from February to May 2016. Patients were grouped into POAF or non-POAF categories based on in-hospital telemetry results. A custom LabView® program was created to determine RR and QT intervals adjusted for heart rate. Resulting values were continuously recorded and plotted on a Poincaré plot, demonstrating short (SD1) and long-term (SD2) variability and their ratio, SD1/SD2 indicative of sympatho-vagal balance. Telemetry data was analyzed for up to 48 hours postoperatively for non-POAF patients or until the occurrence of POAF for others. With baseline values defined as the first hour of un-paced, postoperative ECG, patients were compared using an unpaired two tailed, Student’s T-test. 

Results: After exclusion for poor signal quality and pacing, a total of 20 patient data sets were analyzed hourly (10 POAF, 10 non-POAF). The groups were similar in demographics including age, incidence of hypertension, diabetes, heart failure, and cerebrovascular disease. Compared to baseline, SD1/SD2 did not show a statistically significant difference (Figure) in the POAF and non-POAF groups (%Δ = 69.7±184.9% vs. 12.7±24.7%, p=0.48). No significant trends were observed when comparing normalized QT intervals (POAF: 1.5±11.3% vs. non-POAF: -8.7±7.5%, p=0.15) 

Conclusion: In this study, changes in heart rate variability and QT interval parameters were not predictive of the onset of postoperative atrial fibrillation. Although previous studies have shown ARI and HRV parameters to vary predictably with changes in sympathetic tone, surface ECG markers may not have the ability to accurately detect such changes. POAF may be a complex process and may have other driving factors.  Due to the large fluctuations in QT and heart rate variability parameters, our findings warrant further investigation in a larger patient cohort.

 

81.12 Liver Dysfunction Predicts Poor Outcomes in Adult Extracorporeal Membrane Oxygenation Support

Posted on January 26, 2017

N. Dobrilovic1, L. Michalak1, O. Lateef2, B. Mohamedali2, D. Smego1, R. March1, M. Alimohamed2, M. Delibasic1, D. Radovanovic1, J. R. Raman1  1Rush University Medical Center,Cardiovascular And Thoracic Surgery,Chicago, IL, USA 2Rush University Medical Center,Internal Medicine,Chicago, IL, USA

INTRODUCTION

Extracorporeal membrane oxygenation (ECMO) support can provide critically ill patients an opportunity to survive otherwise lethal illness.  With roughly half of patients surviving ECMO, it remains unclear how and when to apply this labor-intensive, costly resource.  Clear predictors of outcomes have yet to be defined.  We examine the role of liver dysfunction in adult ECMO patients as a potential prognostic marker.

 

METHODS

This study reports a five-year, retrospective, single institution experience examining all adult patients for whom ECMO support was utilized.  Trends in liver function were examined (albumin, PT-INR, total bilirubin, AST, and ALT). 

 

RESULTS

A database of 105 ECMO patients was reviewed, and all adult patients (n=66) were included.  Mean age was 53 (range 19-82) years, 35 male, 31 female.  Fifty-three percent (35/66) of adult patients met at least one criterion for liver dysfunction.  Mean duration of ECMO support was 8 days.  Overall hospital mortality was 68% (45/66).

(Table)

 

CONCLUSION

Increases in total bilirubin, ALT, and AST levels all correlated with early mortality despite good cardio-pulmonary support.  Profound liver dysfunction in patients supported with ECMO is a poor prognostic sign associated with exceedingly high mortality.  It is expected that liver function studies will play a significant role in patient selection criteria regarding 1) initiation of ECMO, 2) as a criterion for termination of ECMO, and 3) possibly as a trigger for use of liver support devices.

 

81.11 Safety of Left Thoracoscopic Lung Resection after Previous Coronary Artery Bypass Grafting

Posted on January 26, 2017

S. L. Hall1, K. Attwood1, A. Battoo1, E. Dexter1, M. Hennon1, M. Huang1, C. Nwogu1, S. Yendamuri1, T. Demmy1, A. Picone1  1Roswell Park Cancer Institute,Thoracic Surgery,Buffalo, NY, USA

Introduction:
Operating in the left pleural space after previous coronary artery bypass grafting (CABG), especially if the left internal mammary artery (LIMA) was used as a bypass conduit, entails risk due to possible injury to the conduit and myocardial infarction. Over the last decade, we have used VATS to improve visualization and adopted a strategy of leaving a sliver of lung on the graft in order to minimize conduit injury. In this study, we sought to assess the peri-operative outcomes of this strategy.

Methods:
All patients undergoing left sided thoracoscopic surgery from 1998 to 2016 at a single institution were reviewed. Perioperative morbidity and mortality, cancer staging, and long-term survival were compared between patients receiving (1) left-sided VATS with previous CABG, (2) right-sided VATS with previous CABG, and (3) thoracoscopy or thoracotomy with no history of previous CABG.

Results:

During the study period, 25 patients underwent left-sided thoracoscopic resection after CABG; 19 of the left upper lobe (LUL) and 6 of the left lower lobe (LLL). Of these patients, 19 (76%) had confirmed LIMA grafts. During this period, 27 patients underwent right sided resections after previous CABG and 1174 patients underwent lobectomy (VATS and Open) without previous CABG.

A comparison of pre-operative characteristics among the three groups demonstrated that patients with a history of CABG were older, more likely to be diabetic, more likely to be smokers, and have a greater prevalence of peripheral vascular disease and a history of congestive heart failure (Table 1). Surprisingly, patients having left sided resections also had a higher T stage and were more likely to have N1 disease (Table 1). Despite these characteristics, there were no significant differences in perioperative mortality (p=1.000), incidence of post-operative myocardial infarction (p=1.000), atrial fibrillation (p=0.208), conversion to thoracotomy (p=0.189), or pulmonary morbidities such as pneumonia (p=0.480) or prolonged air leak (p=0.817) between the comparison groups (Table 1). However, patients undergoing left sided resection were more likely to need a blood transfusion (p=0.010) when compared to the study groups, probably indicating the presence of extensive adhesions from previous surgery.

Conclusion:
Left sided thoracoscopic lung resection after CABG can be performed safely with perioperative outcomes approaching those without a history of CABG.

81.10 Safety and Feasibility of Trileaflet Aortic Valve Reconstruction: A Case Control Study

Posted on January 26, 2017

P. Chan1, E. Chan1, D. Chu1  1University Of Pittsburgh School Of Medicine,Cardiothoracic Surgery,Pittsburgh, PA, USA

Introduction: Aortic valve replacement (AVR) has been considered the gold standard for surgical treatment of calcific aortic stenosis (AS).  However, the prostheses used for replacement are not perfect.  Recently, there has been an influx of techniques to reconstruct the aortic valve.  We hypothesize trileaflet aortic valve reconstruction using autologous pericardium (AVRec) is safe and feasible compared to conventional AVR with prostheses. 

Methods: In a single quaternary referral institution, 8 patients underwent AVRec with autologous pericardium between January 2015 and July 2016.  6 patients underwent isolated AVRec and 2 patients underwent AVRec + coronary artery bypass grafting (CABG).  After initiating cardiopulmonary bypass and excising the native diseased valve cusps, the glutaraldehyde-treated pericardium is fashioned into neo-cusps following a template after measurements are done with sizers.  To compare AVRec vs. AVR, we performed 1:1 matched AVRec patients with those undergoing conventional AVR+/-CABG according to age, preoperative ejection fraction (EF), aortic valve area (AVA) and baseline creatinine (Cr).

Results: The mean age, preoperative EF, AVA and baseline Cr for AVRec was 68.1±3.6 years, 60.8±1.2%, 0.79±0.07 cm² and 0.96±0.05 vs. for AVR, 65.5±4.4 years, 57.5±1.2%, 0.83±0.02 cm² and 1.0±0.07, respectively.  AVRec required longer perfusion and myocardial ischemic times compared to AVR (178.1 and 153.5 minutes, p=.50 vs. 119.6 and 97.6 minutes, p=.015).  Post-operative EF did not change significantly in all patients undergoing either AVRec or AVR.  Length of stay (LOS) was also not statistically different, with both groups being discharged in a mean of 6.5 days (p=.959).  All AVRec patients had either none or trace aortic insufficiency (AI) on immediate and 1 to 3 month postoperative echocardiography, with no valvular failures or reoperations.  Aortic valve gradients were slightly improved with AVRec compared to AVR with peak gradients being 11 vs 17.4 mmHg (p=.093), respectively, and mean gradients being 6.75 vs, 9.4 mmHg (p=.171), respectively (Table 1).  There were no differences in postoperative complications such as atrial fibrillation, acute kidney injury and pleural effusions.       

Conclusions: Aortic valve reconstruction requires no use of foreign material.  Short-term postoperative results for AVRec were comparable to conventional AVR with none or trace AI.  This novel technique is a feasible and safe option for the treatment of calcified AS.

 

81.09 Optimal Monitoring Frequency for Warfarin Dosing Adjustment Following Cardiac Surgery

Posted on January 26, 2017

K. Kim1, C. Bowles1, Y. Juo1, R. Ou1, L. Mukdad1, S. Barajas Nuno1, H. Laks1,2, R. Shemin1,2, P. Benharash1,2  1David Geffen School Of Medicine, University Of California At Los Angeles,Los Angeles, CA, USA 2University Of California – Los Angeles,Cardiac Surgery,Los Angeles, CA, USA

Introduction:  Thrombotic and embolic events as well as anticoagulation related bleeding continue to be the greatest contributor to postoperative complications following valve operations. Warfarin is considered a high-risk medication and among hospitalized patients, 7% of all medication errors are associated with anticoagulants increasing the risk of death in these patients by 20%. Beginning In 2008, the Joint commission required hospitals to develop and implement standardized anticoagulation practices to reduce adverse drug events and improve outcomes. To date, a simple and widely adapted warfarin protocol is lacking likely due to the heterogeneous metabolism of warfarin. This study aimed to evaluate the effect of INR monitoring and warfarin dosing in the immediate postoperative period. 

Methods:  All adult patients undergoing valvular heart surgery between January 2013 and December 2015 at our institution were identified using the local Society of Thoracic Surgeons (STS) Database. Patients were included if they were supposed to receive warfarin in the immediate postoperative period. Patient who received twice-daily INR checks and warfarin dosing were considered the intervention group and were propensity matched to those who received the standard daily dosing in the control group.The data was analyzed to determine length of hospital stay, days required to reach therapeutic INR, and the proportion of days during admission in which the INR was within therapeutic range.  

Results: A total 76 patients (23 intervention group, 53 control group) were identified that met the inclusion criteria. None of the patients in the study had postoperative complications related to anticoagulation treatment. Analysis of data showed a statistically significant difference in the hospital length of stay (intervention: 13±7 days, control: 9±5 days; p=0.028) and time to reach therapeutic INR (intervention: 4±2 days, control: 6±4 days; p=0.013) between the intervention and control groups (Figure). The proportion of days during admission in which the INR was within therapeutic range for intervention and control groups 0.32 and 0.23 respectively, and this difference was not statistically significant. 

Conclusion: In this single-center study, intensive anticoagulation monitoring and warfarin dosing following cardiac valve operations was associated with a longer hospital length of stay and less time to reach therapeutic INR. Our findings suggest that although intensive warfarin monitoring regimens may expedite therapeutic INR levels, they may not be cost efficient and may increase resource utilization. Given variations in practice, our findings warrant investigation in a randomized trial.

81.08 Chest Wall Dimensions and Perioperative Outcomes after Robotic-Assisted Pulmonary Lobectomy

Posted on January 26, 2017

K. Ratnasamy4, M. R. Kuhns1, F. O. Velez-Cubian2, K. Rodriguez4, C. C. Moodie1, J. R. Garrett1, J. P. Fontaine1,2,3, E. M. Toloza1,2,3  1Moffitt Cancer Center,Thoracic Oncology,Tampa, FL, USA 2University Of South Florida Morsani College Of Medicine,Surgery,Tampa, FL, USA 3University Of South Florida Morsani College Of Medicine,Oncologic Sciences,Tampa, FL, USA 4University Of South Florida,Morsani College Of Medicine,Tampa, FL, USA

Introduction:   During robotic-assisted video-thoracoscopic (RAVT) pulmonary lobectomy, we observed that patients with small body habitus results in increased collisions between robotic arms and restricted robotic arm movement.  We investigated whether smaller chest wall dimensions affected perioperative outcomes after RAVT pulmonary lobectomy.

Methods:   We retrospectively studied all patients who underwent RAVT pulmonary lobectomy between September 2010 and July 2014 by one surgeon at our institution.  Chest wall dimensions (transverse radius from carina to lateral chest wall; anterior-posterior [AP] chest wall diameter at level of carina; height from 1st rib to dome of diaphragm) ipsilateral to the lung tumor were measured from patients’ CT scans.  Patients were grouped based on chest wall dimensions, and perioperative outcomes, including estimated blood loss (EBL), skin-to-skin operative time, conversion to open lobectomy, postoperative complications, chest tube duration, hospital length of stay (LOS), and in-hospital mortality were compared.  Student’s t-test and Chi-square test were used, with p≤0.05 as significant.

Results:  We identified 289 patients, who were grouped by chest wall dimensions.  No differences were noted in EBL, operative times, intraoperative complications, conversion to open lobectomy, chest tube duration, or hospital LOS between groups.  More patients (70.6%) with chest AP diameter ≥19cm experienced postoperative complications versus 35.8% of those with AP diameter <16cm (p<0.05).  Patients with chest transverse diameter ≥25.9cm had more postoperative complications (68%) compared to 37.8% of patients with chest transverse diameter <25.9 cm (p<0.05).  Complications did not differ by chest height.  In-hospital mortality increased with increasing AP:transverse diameter ratio (p=0.02).

Conclusions: Smaller chest wall dimensions did not result in increased intraoperative or postoperative complications.  On the contrary, patients with larger chest wall dimensions, specifically larger chest AP and transverse diameters, did have more postoperative complications than those with smaller chest wall dimensions.  Higher AP:transverse diameter ratio, or “barrel chest”, correlated with higher mortality risk.

81.07 Sinus of Valsalva aneurysms with concomitant aortic insufficiency: what to do with the valve?

Posted on January 26, 2017

K. YIN1, Y. Lin1, Z. Zhang1, Y. Wang1, C. Wang1  1Zhongshan Hospital Fudan University,Department Of Cardiac Surgery,Shanghai, SHANGHAI, China

Introduction:  

Sinus of Valsalva aneurysms (SVAs) are rare and often complicated by aortic valve insufficiency (AI). While aneurysms can be repaired successfully by various techniques, treating aortic regurgitation is the key to achieving good long-term results. We summarized our experience on the surgical management of concomitant AI in this patient population. 

 

Methods:

 

We identified 178 patients (age 37.4±13.1 years old, 114 males) who underwent SVAs repair in our institution from 2008-2015, of whom 87 (48.9%) had at least mild AI preoperatively. Concurrent aortic valve (AV) surgery was performed in 70 patients (39.3%), divided into 63 AVRs (61 mechanical vs 2 tissue valves, including 6 root replacement) and 7 AV repairs (3 subcommissural annuloplasty, 2 valve resuspension, 2 David I procedure). Seventeen patients had aneurysm repair only. Mean follow-up time was 44.4 ± 33.8 months.

Results:

Compared to patients with normal AV, the group with AI has a higher incidence of right coronary sinus aneurysm with concomitant VSD (50/91 vs 70/87, p < 0.05). Among the AVR patients, 6 were redo cases: 5 of which presented with moderate to severe to severe AI after their first SVAs ± VSD repair procedure, while the other one underwent redo-sternotomy, root replacement for chronic type A dissection 15.2 months after his initial SVAs repair. All AV repair patients (7/7) had trivial to mild AI during follow up (mean follow up time 36.1 ± 37.9 months, 3.6-100.0 months), while 3 of the 17 “aneurysm repair only” patients presented with moderate AI (mean follow-up time 44.6 ± 36.2 months, 1.1-99.8 months). There was no early death in our series, but with one late mortality in a patient who had sudden death 8 weeks after his SVAs + VSD patch closure. 

Conclusion:

Concomitant aortic insufficiency can be managed by various surgical techniques without compromising short-term outcomes. Although valve replacement has been known to have good long-term results, AV repair techniques, especially valve sparing procedure in young patients is an acceptable option when performed by experienced surgeons. 

81.06 Factors Affecting Likelihood of Obtaining Thoracoscopic Versus Open Lobectomy: A NSQIP Analysis

Posted on January 26, 2017

A. Osasona2, H. Mehta2, J. Goodwin3, K. Brown2, I. Okereke1  1University Of Texas Medical Branch,Cardiothoracic,Galveston, TX, USA 2University Of Texas Medical Branch,Surgery,Galveston, TX, USA 3University Of Texas Medical Branch,Internal Medicine,Galveston, TX, USA

Introduction:
Nationwide, video assisted thoracoscopic surgery (VATS) is being utilized with increasing frequency for pulmonary resection.  VATS lobectomy is associated with less morbidity than open lobectomy.  There appears to be a disparate rate of utilization of VATS across different patient populations, however.  Our goal was to determine which factors affect a patient’s likelihood of undergoing VATS versus open lobectomy.

Methods:
The National Surgical Quality Improvement Program (NSQIP) database was queried from 2005 through 2014 to identify all patients undergoing pulmonary lobectomy.  Multivariable logistic regression was conducted to identify patient demographics, clinical characteristics and surgeon specialty associated with an increased likelihood of receiving a VATS lobectomy versus an open approach.

Results:
From 2005 through 2014, 11,977 patients in the NSQIP database underwent lobectomy (open, 6,391; VATS, 5,586).  The mean age was 64.4 years and females comprised 53.4% of cases. The use of VATS lobectomy increased significantly over time, increasing from 17.5% in 2005—2008 to 53.1% in 2012—2014 (p<0.001).  On multivariable analysis, male gender (odds ratio [OR], 1.20; 95% confidence interval [CI], 1.12-1.30), African-American race (OR, 1.22; 95% CI, 1.04-1.43), age under 75 years (OR, 1.21; 95% CI, 1.11-1.32), worse frailty index (OR, 1.56; 95% CI, 1.06-2.28) and performance of the lobectomy by someone other than a non-cardiac thoracic surgeon (OR, 1.37; 95% CI, 1.25-1.51) were associated with an increased likelihood of receiving an open lobectomy.

Conclusion:
The frequency of VATS lobectomy has increased substantially over the last 10 years, and now accounts for over half of the lobectomies performed at NSQIP hospitals. Demographics, clinical characteristics, and specialty of surgeon influences a patient’s likelihood of receiving VATS versus open lobectomy. Identifying such disparities in surgical approach may help to direct the focus of interventions at the individual, hospital or organizational level to increase the use of VATS lobectomy.
 

81.05 Evaluation Of Navigational Bronchoscopic(ENB) biopsy of Lung lesions performed by a surgical service

Posted on January 26, 2017

T. D. Witek1, A. Pennathur1, J. D. Luketich1, M. Scaife1, D. Azar1, M. J. Schuchert1, W. E. Gooding2, O. Awais1  1University Of Pittsburgh Medical Center,Department Of Cardiothoracic Surgery,Pittsburgh, PA, USA 2University Of Pittsburgh Cancer Institute Biostatistics Facility,Pittsburgh, PA, USA

Introduction:

With increasing utilization of CT scans for lung cancer screening, and for surveillance of other cancers, thoracic surgeons are being referred patients with lung lesions for biopsies. While CT-guided biopsies have been used for biopsies of peripheral lesions, electromagnetic navigational bronchoscopy (ENB) guided lung biopsy is a relatively new technique for bronchoscopic biopsies of peripheral lesions.  Our objective was to evaluate the diagnostic yields and safety of electromagnetic navigational bronchoscopy (ENB) guided lung biopsy.

Methods:

We conducted a retrospective review of patients who underwent an ENB for diagnostic purposes, performed by a thoracic surgical service. We collected data on patient characteristics, lesion characteristics, procedure outcomes, and pathology information. General anesthesia and rapid on-site examination (ROSE) of cytopathology was used during all ENBs. All patients that were diagnosed with a malignancy from ENB findings were considered true positives. Lesions that did not reveal malignancy from ENB sampling were considered true negatives if sequential surgical or CT guided biopsy also revealed benign tissue or if serial imaging revealed stability or improvement; otherwise they were classified as false negatives.

Results:

A total of 121 lesions in 111 patients (men 46, women 65) underwent ENB guided bronchoscopic sampling of pulmonary lesions. The median size of the lesion was 27mm (Range 9-115 mm, IQR = 17 – 37 mm). Ninety-four (78%) of the lesions were malignant. Eighty-five (70%) of the 121 lesions had an accurate diagnosis. Accuracy increased with increased lesion size (odds ratio = 2.9, 95% CI = 1.3 – 6.3). The presence of “bronchus sign” was associated with 3 fold increase in odds of  accurate diagnosis (odds ratio 3.1, 95% CI= 1.1 – 8.2). Among patients with a “bronchus sign”, the predicted accuracy of the biopsies for 1 cm lesions was 66% (95% CI 40% – 85%; the predicted accuracy for 2 cm lesions was 77% (95% CI = 58% – 89%) for 3 cm lesions 85% (95% CI = 71% – 93%).  There was no procedure-related mortality. There were four (3%) instances of pneumothoraxes, requiring pigtail pleural catheters.

Conclusion:

Thoracic surgeons can perform ENB safely, with minimal morbidity and with good diagnostic yields. Accuracy increases with the presence of "bronchus sign" and increasing lesion size. Lesions larger than 2 cm have a higher likelihood of an accurate diagnosis.
 

81.04 Lung Resection for Non-Small Cell Lung Cancer: Does Perioperative Fluids Affect Outcomes?

Posted on January 26, 2017

M. Asai1, A. X. Samayoa1, C. Hodge1, Y. Shan1, H. Pak1, T. Vu1  1Abington Memorial Hospital,General Surgery,Abington, PA, USA

Introduction:
Intraoperative intravenous (IV) fluid infusion has been controversial in thoracic surgery. There has been some studies showing correlation of intravenous fluid infusion and acute lung injury in the perioperative phase. Although this is the case, there is limited evidence suggesting volume of perioperative IV fluids and any correlation with outcomes in patients undergoing thoracic surgery. In our study, we investigated outcome measures associated with patients undergoing lung resection for non-small cell lung cancer (NSCLC) and the correlation with perioperative IV fluids.

Methods:
A retrospective review of consecutive patients undergoing open lobectomy for primary NSCLC from January 2010 to June 2016. Exclusion criteria were patients who had previous lung resection(s), blood loss more than 500cc during surgery and patients receiving intraoperative blood transfusions. Patient were divided into those receiving intraoperative IV fluid greater or less than 7 cc/kg/hr, and another group receiving greater or less than 10 cc/kg/hr. Perioperative (intraoperative + 24 hour postop) IV fluid were also recorded. We compared this against patient’s demographics, intraoperative parameters and complication rate within 30 days of surgery. Complications were categorized as pulmonary, cardiac, renal complications as well as hemorrhage, death and reoperation.

Results:
142 patients (69 male and 73 female) with the mean age of 66.5 years were identified following inclusion criteria were met. There was no significant difference in the hospital or ICU stay between any of the intraoperative or perioperative fluid groups.
Patients receiving greater than 10cc/kg/hr intraoperative IV fluid has higher rate of total complication, especially postoperative hemorrhage and reoperation rate. Patients receiving less than 7 cc/kg/hr intraoperative IV fluid has higher risk of developing acute renal injury. Patient who had greater than 1.5 cc/kg/hr perioperative fluid has significantly higher duration of chest tube in-situ, pulmonary complications and total complication rates.

Conclusion:
In our study, giving high amount of intraoperative and perioperative IV fluid has adverse effects on postoperative complications. Conversely, giving less (<7cc/kg/hr) intraoperative IV fluid has higher risk of renal dysfunction. We propose the optimal amount of intraoperative and perioperative IV fluid given should be in between these two extremes. To highlight these points further, a larger prospective randomized study should be performed.

81.03 Efficacy of Preoperative MRSA Screening and Decolonization in a Thoracic Surgical Oncology Clinic

Posted on January 26, 2017

G. M. Fitzpatrick6, H. Frum1, R. Quilitz2,5, R. L. Sandin7, D. Ruge7, J. L. Greene2,5, J. R. Garrett1, C. C. Moodie1, E. M. Toloza1,3,4  1Moffitt Cancer Center,Thoracic Oncology,Tampa, FL, USA 2Moffitt Cancer Center,Infectious Diseases,Tampa, FL, USA 3University Of South Florida Morsani College Of Medicine,Surgery,Tampa, FL, USA 4University Of South Florida Morsani College Of Medicine,Oncologic Sciences,Tampa, FL, USA 5University Of South Florida Morsani College Of Medicine,Medicine,Tampa, FL, USA 6University Of South Florida,Morsani College Of Medicine,Tampa, FL, USA 7Moffitt Cancer Center,Pathology,Tampa, FL, USA

Objective:   To study the efficacy of preoperative (preop) screening for methicillin-resistant Staphylococcus aureus (MRSA) and of decolonization of MRSA-positive (MRSA-POS) patients (pts) by a trimodality antibiotic regimen aimed at reducing postoperative (postop) MRSA infections.

Methods:   At preop clinic evaluation, pts scheduled for thoracic surgery were screened for MRSA via polymerase chain reaction (PCR) of nasal swab specimens.  Preop MRSA-POS pts were given oral doxycycline 100 mg twice daily, mupirocin 2% ointment to both nares, and chlorhexidine showers for 5 days for MRSA-decolonization preop, with doxycycline continued 7 more days postop.  Pts who were admitted to intensive care had a second MRSA screen immediately postop.  We retrospective analyzed 1106 consecutive thoracic surgery pts to determine prevalence of preop MRSA colonization, rates of POS-to-negative(NEG) and NEG-to-POS conversion between preop and immediate postop MRSA screens, and rates of postop MRSA and non-MRSA infections in MRSA-POS and in MRSA-NEG pts.  MRSA screens within 60 days prior to surgery and infections within 30 days after surgery were included.  Fisher Exact Probability Test was used, with significance at p<0.05.

Results:  Of 960 pts who had preop MRSA screen, 4.0% (38/960) were MRSA-POS.  Of these MRSA-POS pts, 15.8% (6/38) developed postop infections, compared to 18.8% (173/922) of MRSA-NEG pts (p=0.68).  The most common postop infection in each group was an uncomplicated urinary tract infection (UTI).  Excluding UTIs, 7.9% (3/38) of MRSA-POS pts and 11.8% (109/922) of MRSA-NEG pts had postop infections, respectively (p=0.61).  The only postop MRSA infection in this study was a case of MRSA pneumonia diagnosed on postop day 16 in a pt who was MRSA-NEG preop.  Of 530 pts who had both preop and postop MRSA screens, 95.1% (511/530) were MRSA-NEG preop, of which 1.4% (7/511) converted to being MRSA-POS on immediate postop screen.  Of the remaining 19/530 pts (3.6%) who were MRSA-POS preop, 68.4% (13/19) converted to being MRSA-NEG on immediate postop screen.  Of 15 MRSA-POS pts receiving the complete decolonization antibiotic regimen, 73.3% (11/15) converted to being MRSA-NEG on immediate postop screen, while of the 4 MRSA-POS pts who did not complete the decolonization antibiotic regimen, 50% (2/4) converted to being MRSA-NEG on immediate postop screen (p=0.56).

Conclusions:  Prevalence of MRSA colonization in thoracic surgery pts who were screened by PCR of preop nasal swab specimens is similar to those previously published.  Rates of conversion from preop MRSA-POS to immediate postop MRSA-NEG indicate overall efficacy of our trimodality decolonization regimen.  With adequate decolonization via trimodality treatment, risk of postop MRSA infections or even for non-MRSA infections is not increased in pts screened preop as MRSA-POS versus those screened as MRSA-NEG.

81.02 Aortic Z-Scores As Indicators for Aortic Repair

Posted on January 26, 2017

M. R. Helder1, H. V. Schaff1, A. Pochettino1, H. Connolly1  1Mayo Clinic,Cardiovascular Surgery And Cardiovascular Diseases,Rochester, MN, USA

Introduction: Practice guidelines recommend repair for aortic root aneurysms in adult patients with Marfan syndrome based on absolute diameter despite the recognized variation based on age, sex, and body surface area. Echocardiographic Z-scores have been used in multiple pediatric patient studies outlining a “normal z-score” range.  However, the aortic Z-score at which adult patients should be offered an operation has not been defined.

Methods: After IRB approval, we retrospectively examined the preoperative echocardiography data of all patients with Marfan syndrome who underwent elective aortic root repair from February 11, 2005 to September 3, 2010 based on either aortic root diameter threshold or increase in aneurysm diameter over time.  Aortic root diameters were measured at sinus level in all but two patients where the mid-ascending aorta was the largest diameter.  Age, sex, and body surface area were gathered from the electronic medical record and used to calculate a Z-score based using the following equation: Z = (measure diameter – predicted diameter)/0.261 cm.  Predicted diameter (cm) = 2.423 + (age X 0.009) + (BSA X 0.461) − (sex X 0.267), where male sex = 1, female sex = 2. 

Results: Fifty-eight adult patients, average age of 36±13 years (71% male), underwent aortic root repair.  Median aortic root diameter was 52 mm, range of 32 – 71 mm.  Average aortic root diameter was 54±5 mm.  This corresponded to a median aortic Z-score of 6 (range, -1.6 to 14).  Average aortic Z-scores were 6±3.  Mean ejection fraction, preoperatively, was 58±7%.  Eleven patients had an aortic root diameter < 45 mm; 4 of these patients (36%) had corresponding Z-scores greater than 4.

Conclusion: This study describes aortic of Z-scores of patients that underwent aortic root repair based on indications dictated by current practice guidelines.  Z-scores of some patients indicated a larger relative aneurysm than would have been clear by aneurysm diameter alone.  Aortic Z-scores should be studied further and incorporated into the clinical decision making of whether or not to offer a patient aortic repair.  Based on this descriptive data, a z-score > 3 could be used as an operative indication for aortic repair in patients with Marfan syndrome.

 

81.01 Factors That Alter the Relationship Between Peak Postoperative CKMB and Troponin T After CABG

Posted on January 26, 2017

K. M. Mehta1, J. Pruszynski1, M. Peltz1, L. C. Huffman1, P. Bajona1, M. A. Wait1, R. Correa1, W. Ring1, M. Jessen1  1UT Southwestern Medical Center,Department Of Cardiovascular And Thoracic Surgery,Dallas, TX, USA

Introduction: Peak postoperative creatine kinase MB fraction (CKMB) and Troponin T (TnT) levels have been measured after cardiac surgery to assess perioperative myocardial damage, evaluate myocardial protective strategies and predict adverse events.  However, the relationship between peak levels of both enzymes has not been fully established in this setting.  We compared peak levels of CKMB and TnT in patients after CABG to test the hypothesis that patient and operative characteristics influence the correlation between the values of these biomarkers.

Methods: Data were prospectively collected from 171 consecutive patients undergoing on-pump CABG at a single institution between July 1, 2014 and Dec 31, 2015. Peak values were selected from all serum levels of CKMB and TnT collected during the hospital stay following surgery.  Clinical variables were collected based on definitions in the STS Adult Cardiac Surgery Database version 2.181.  Linear regression models were used to statistically compare the slope of the linear relationship between peak postoperative CKMB and TnT for the patient cohort. Models were created to compare the slopes by pre-defined clinical variables including (1) gender, (2) age (< or >70), (3) race, (4) tobacco use, presence or absence of (3) hypertension, (4) dyslipidemia, (5) diabetes, (6) renal dysfunction (GFR<60), (7) MI within 21 days, (8) EF (< or > 40%), preoperative use of (9) ACE-inhibitors, (10) beta-blockers, and (11) anticoagulants; and operative variables including (1) cross clamp time (< or > 70 min), (2) CPB time (< or > 100 min), and (3) whether or not intra-operative blood products were received. A lower slope implies less change in CKMB compared to the change in TnT.

Results: Overall, the correlation between peak postoperative CKMB and TnT was robust in patients undergoing CABG (m = 19.6, r= 0.783).  However, the slope of the relationship was significantly lower in males, patients > 70 years, diabetics, non-smokers, patients with renal dysfunction, patients with lower EF, patients receiving anticoagulants, and patients undergoing CABG following a recent MI.  The slope was significantly greater in patients with longer clamp times and who were receiving beta blockers and ACE-inhibitors (Table I). In all other models, the slope of the relationship was similar. 

Conclusion: The relationship between CKMB and TnT following CABG appears to be influenced by patient and operative characteristics. These data do not assess which enzyme more accurately reflects myocardial injury, but does suggest conclusions about myocardial damage may be affected by the biomarker selected in the presence of certain variables. Further study to assess the association between these biomarkers and patient outcomes is warranted.

64.10 Documentation Initiative Leads to Improved Quality Metrics in Cardiac Surgical Patients

Posted on January 26, 2017

J. R. Gillen1, L. Jin2, J. M. Isbell3  1University Of Michigan,Surgery,Ann Arbor, MI, USA 2University Of Virginia,Surgery,Charlottesville, VA, USA 3Memorial Sloan-Kettering Cancer Center,Thoracic Surgery,New York, NY, USA

Introduction:
Hospitals are increasingly being judged by risk-adjusted quality metrics, which are directly influenced by the completeness and accuracy of medical documentation. This study evaluated the impact of a multi-faceted documentation improvement initiative. We hypothesized that this initiative would lead to improvement in risk-adjusted quality metrics.

Methods:
The prospective cohort consisted of all cardiac surgical patients over a 2-year period, divided into pre-intervention (2013) and post-intervention (2014) groups. The intervention took place in the cardiac surgery intensive care unit and consisted of 1) templated problem-based admission notes and daily progress notes, 2) distribution of pocket cards with diagnoses important to risk stratification, and 3) education of residents and faculty with documentation tips. Operative demographics and several indicators of patient acuity were compared between 2013 and 2014. 

Results:
The pre- and post-intervention cohorts consisted of 768 and 791 patients, respectively. The distribution of procedure types performed were similar between groups (p=0.51). For the intervention group, there was a significant improvement in case-mix index (CMI) (6.86 vs 6.56, <0.001) and several University HealthSystem Consortium (UHC) quality indicators, including Severity of Illness (p<0.001) and Risk of Mortality scores (p=0.0014). However, there was no change in UHC expected mortality (3.69% vs 3.54%, p=0.49) or Society of Thoracic Surgeons (STS) Predicted Risk of Mortality (3.28% vs 3.11%, p=0.21). Additionally, documentation of complications increased in UHC data (11.76% vs 8,07%, p=0.018), but no similar increase was observed in STS data (11.81% vs 10.27%, p=0.25), suggesting a higher capture of complications rather than an actual increase in complication rates. The increase in CMI generated by this initiative correlated with an increase in hospital revenue of $3,849 per case, totaling over $3 million for 1 year. 

Conclusion:
This documentation initiative was effective at improving CMI and UHC risk of mortality, which appears to have been primarily driven by improved documentation of complications. This study demonstrates that attention to accurate documentation can be an effective method to improve publicly reported quality indices as well as increase hospital revenues. Future interventions targeting clinic personnel documenting present-on-admission diagnoses may further improve these quality metrics.
 

64.09 Radiation Therapy Did Not Improve Survival Over Surgery Alone for Stage-3A(N2) Lung Cancer in SEER

Posted on January 26, 2017

D. T. Nguyen4, C. C. Moodie1, J. R. Garrett1, J. P. Fontaine1,2,3, R. J. Keenan1,2,3, L. A. Robinson1,2,3, E. M. Toloza1,2,3  1Moffitt Cancer Center,Thoracic Oncology,Tampa, FL, USA 2University Of South Florida Morsani College Of Medicine,Surgery,Tampa, FL, USA 3University Of South Florida Morsani College Of Medicine,Oncologic Sciences,Tampa, FL, USA 4University Of South Florida,Morsani College Of Medicine,Tampa, FL, USA

Introduction:   Stage-IIIA nonsmall-cell lung cancer (NSCLC) includes T1N2M0 and T2N2M0 in the current Tumor-Nodal-Metastases (TNM) classification, indicating mediastinal lymph node involvement.  We evaluated postoperative survival of T1N2/T2N2 patients (pts) who underwent lobectomy without or with radiation therapy (RT) between 1988 and 2013.

Methods:   Using the Surveillance, Epidemiology, and End Results (SEER) database, we identified pts who underwent surgery (SURG) without or with RT before (RT+SURG) or after (SURG+RT) surgery for T1N2 and T2N2 NSCLC during 1988-2013.  We included pts with Adenocarcinoma (AD) and Squamous Cell (SQ) histology and excluded those with multiple primary NSCLC tumors.  Log-rank test was used to compare Kaplan-Meier survival of pts who had SURG vs. SURG+RT as well as of AD vs. SQ pts and of T1N2 vs. T2N2 pts during 1988-2003 and 2004-2013.

Results:  Of 2,271 pts, 142 (6.25%) had RT+SURG, 777 (34.2%) had SURG+RT, and 1352 (59.5%) had SURG.  During 1988-2013, there were 1681 AD pts (74.0%) and 590 SQ pts (25.9%), while 696 pts were T1N2 (30.6%) and 1,575 pts were T2N2 (69.4%).  There was no significant difference in 5-yr survivals between RT and no RT pts or between RT+SURG and SURG+RT during 1988-2013 (p=0.171), in 1988-2003 (p=0.408), or in 2004-2013 (p=0.822).  For 1988-2013, AD pts had better 5-yr survival (p=0.016) and median survival time (MST; 36.0±1.4 mon vs. 27.0±1.6 mon; p<0.01) than SQ pts.  For 1988-2003, 5-yr survival for AD pts and SQ pts did not differ (p=0.181).  However, for 2004-2013, AD pts had better 5-yr survival (36.0% vs. 31.6%; p<0.01) and MST (41.0±2.1 mon vs. 27.0±2.2 mon; p<0.01) than SQ pts.  As expected, T1N2 had better 5-yr survival than T2N2 during 1988-2013 (39.1% vs. 29.8%; p<0.01), during 1988-2003 (34.7% vs. 25.7%; p=0.002), and during 2004-2013 (41.5% vs. 31.9%; p<0.01).  Similarly, AD pts had better MST than SQ pts for 1988-2013 (44.0±3.2 mon vs. 30.0±1.2 mon; p<0.001), for 1988-2003 (41.0±3.6 mon vs. 26.0±1.1 mon; p<0.01), and for 2004-2013 (47.0±4.2 mon vs. 33.0±1.8 mon; p<0.01).  With AD T1N2, AD T2N2, SQ T1N2, or SQ T2N2 pts, we found no differences in 5-yr survival between RT+SURG vs. SURG+RT (p>0.05).

Conclusion:  Pts with RT+SURG or SURG+RT did not have better survival than SURG alone in T1N2 and T2N2 pts.  Of these pts, AD pts had better survival than SQ pts during 1988-2013, but this advantage was due to improved survival during 2004-2013.  As expected, T1N2 pts had better survival than T2N2 pts across all time periods.

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