7.07 Primary Tumor Sidedness Differentially Affects Overall Survival for Stage I-IV Colon Adenocarcinoma

Posted on January 18, 2018

J. Watson1, M. Turner1, Z. Sun1, D. Becerra1, J. Migaly1, C. Mantyh1, D. Blazer1  1Duke University Hospital,Department Of General Surgery,Durham, NC, USA

Introduction: Recent studies have observed differences in overall survival and response to chemotherapy in left compared to right-sided colon cancer. This suggests biologic differences within tumor laterality. We evaluated the impact of left compared to right-sided primary tumors on overall survival for patients with stage I-III and stage IV colon cancer in both operative and non-operative cohorts, utilizing a large national cancer database.

Methods: The 2006-2013 National Cancer Data Base was queried for patients with single primary, stage I-IV colon adenocarcinoma. Patients were grouped by stage and tumor location based on embryologic boundaries. Left side was defined as splenic flexure to the sigmoid colon, and right side was defined as cecum to transverse colon. Patients with appendiceal, overlapping, or unspecified tumor locations were excluded. Overall survival was compared using Cox Proportional Hazard modeling while adjusting for demographic, clinical, and tumor characteristics. The analysis was conducted separately for patients who had operative and non-operative management (stage IV) of the primary tumor.

Results: For stage I-II tumors, 114,839 patients underwent resection, 62% for right and 38% for left-sided tumors. After adjustment for patient and tumor characteristics, patients with right-sided tumors had superior survival compared to those with left-sided tumors (HR for left-sided tumors, right-sided reference [HR]: 1.13, p<0.001). For Stage III tumors, 71,024 patients underwent resection (59% right-sided, 41% left-sided tumors). Of 60,788 patients with stage IV tumors, 41,371 (68%) patients underwent resection (57% right-sided, 43% left-sided). For the 19,417 patients with stage IV cancer who did not undergo surgery, 56% were right-sided tumors, and 44% were left-sided tumors. After adjustment for patient and tumor characteristics, left-sided tumors had superior survival compared to right-sided tumors in Stage III tumors, Resected Stage IV tumors, and Unresected  Stage IV Tumors with respective Hazard Ratios of Stage III 0.90, p<0.001, Stage IV Resected HR 0.71, p<0.001, and Stage IV Unresected HR 0.77, p<0.001.

Conclusion: Primary tumor laterality affects overall survival across stages for colon adenocarcinoma. In this analysis, patients with right-sided tumors have superior survival for stage I-II disease. However, left-sided tumors have superior survival in advanced disease, stage III-IV. These results from a large, national cancer database reinforce and extend previous subgroup analyses of large cooperative group trials.  These findings provide investigators better prognostication tools and provide a possible avenue to better understand the molecular mechnisms in patients with colon adenocarcinoma.

7.08 Coping Strategies Among Colorectal Cancer Patients Undergoing Surgery: A Qualitative Study

Posted on January 18, 2018

J. S. Abelson1, A. Chait2, M. J. Shen3, M. Charlson4, A. Dickerman2, H. L. Yeo1,5  2Weill Cornell Medical College,Psychiatry,New York, NY, USA 3Weill Cornell Medical College,Psychology,New York, NY, USA 4Weill Cornell Medical College,Integrative Medicine,New York, NY, USA 5Weill Cornell Medical College,Healthcare Policy And Research,New York, NY, USA 1Weill Cornell Medical College,Surgery,New York, NY, USA

Introduction: Distress is common among cancer patients and is associated with worse post-operative outcomes. Surgeons are often the first physicians to have in-depth conversations with patients about new diagnoses of colorectal cancer. As a result, it is important for them to understand ways patients cope with their diagnosis in order to offer them support as needed to minimize distress.  However, there are no clear data on how these patients cope with their diagnoses, surgery and recovery.  We performed qualitative in-depth interviews trying to explore their coping mechanisms throughout the surgical experience.

Methods:  Patients diagnosed with colorectal cancer were recruited from an outpatient surgery clinic at a single academic medical center. Purposive sampling was used to recruit both patients who were planning to undergo surgery or had undergone surgery within six months. Validated qualitative methods were used, including in-depth, open-ended, individual interviews; demographic data were also collected. Constant comparative methodology and grounded theory were used to develop themes regarding patients’ coping strategies and beliefs regarding patients’ view of the role of the surgeon in helping them cope. 

Results: A total of 24 patients were interviewed. Most participants were interviewed during the post-operative period (n=15; 62%), were White (n=18; 75%), and had a diagnosis of rectal cancer (n=15; 62%). Three major themes emerged from the data that described how patients with colorectal cancer cope throughout the surgical experience. First, patients cited their own internal coping strategies such as problem-focused, emotion-focused, and meaning-focused techniques. Second, patients cited their social support network including family, friends, and cancer support groups as being helpful. Third, patients believed surgeons and their teams should be involved in helping patients cope with the cancer diagnosis and surgical experience, especially if patients were experiencing high levels of distress or had inadequate coping skills. They did not believe surgeons themselves should be primarily responsible.

Conclusion: This is the first study to evaluate coping strategies used by colorectal cancer patients as they undergo surgical treatment. These findings are important for surgeons to guide initial management of distress in patients with a new diagnosis of colorectal cancer, as mandated by the National Comprehensive Cancer network and the American College of Surgeons Commission on Cancer. Surgeons should screen patients for distress, identify and strengthen a patient’s own coping strategies, facilitate a strong social support network, and provide patients with the option to obtain further support from the surgeon’s office. Future research should evaluate the impact of a comprehensive strategy to enhance coping strategies in colorectal cancer patients undergoing surgery on post-operative outcomes.

 

 

7.05 Statin Use Does Not Decrease Disease Severity or Mortality among Patients with C. difficile Infection

Posted on January 18, 2018

A. S. Kulaylat1, J. S. Kim1, C. S. Hollenbeak1, D. B. Stewart1  1Penn State University College Of Medicine,Surgery,Hershey, PA, USA

Introduction:  Clostridium difficile infection (CDI) is more commonly encountered among older, comorbid patients who frequently require the use of statins for hyperlipidemia. Recent observational data has suggested that statins have pleiotropic effects which may decrease spore germination, thus decreasing the risk of developing CDI. There have been no studies, however, evaluating whether statins affect outcomes in patients who already have CDI. The aim of this study was to evaluate whether the use of statins among inpatients with CDI was associated with measurable decreases in mortality and severity of CDI. 

Methods:  All patients admitted to a single tertiary referral center with an admission diagnosis of CDI (2005 to 2015) were identified, limiting the study cohort to subjects with a positive C. difficile stool test within 24 hours of admission. Hospital records were examined to identify use of statins at the time of hospital admission. The primary study outcome was inpatient mortality; secondary outcomes included admission for recurrent CDI within 60 days, the need for admission to a monitored care setting, the need for vasopressors and the need for an emergent total abdominal colectomy. Multivariable logistic regression was used to control for underlying comorbidities and disease-related factors to isolate associations between statin usage and study outcomes. 

Results: A total of 957 patients meeting inclusion criteria were identified. Of these, 318 (33.2%) were receiving statin therapy at the time of hospital admission. After controlling for underlying patient and disease-related factors, statin therapy was not associated with differences in inpatient mortality (odds ratio [OR] 0.90, 95% confidence interval [CI] 0.43 to 1.86), the need for admission to a monitored setting (OR 1.07, 95% CI 0.74 to 1.54), the need for vasopressors (OR 0.92, 95% CI 0.52 to 1.62) or the need for total colectomy (OR 0.51, 95% CI 0.17 to 1.53). Furthermore, statin use was not found to be a significant risk factor for admission for recurrent disease (OR 2.13, 95% CI 0.91 to 5.03). Proton pump inhibitor (PPI) therapy was observed in 447 (46.7%) study patients, and controlling for the use of PPI therapy did not reveal an association between statin use and study outcomes.

Conclusion: While prior reports suggest that statin therapy reduces the risk of developing CDI, the current study suggests that statin-pleiotropy does not influence disease mortality and severity. 

 

7.04 Black and Uninsured Patients Have Delayed and Decreased Rates of Stoma Reversal After Hartmann’s

Posted on January 18, 2018

C. R. Reed1, M. C. Turner1, M. Talbott1, Z. Sun1, K. Sherman1, C. R. Mantyh1, J. Migaly1  1Duke University Medical Center,Durham, NC, USA

Introduction:

Although stoma reversal following Hartmann’s procedure is associated with improved quality of life, existing reports suggest that reversal rates and timing to reversal are not optimal. Therefore, we aimed to evaluate the impacts of race and insurance coverage on ostomy reversal following Hartmann’s procedure for diverticulitis.

Methods:

The Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (2007-2010) were queried for patients who underwent Hartmann’s procedure in the setting of diverticulitis. Patients who died during their index hospitalization were excluded. Patients were grouped by race and insurance status. After multivariable adjustment for demographic and clinical variables, rate and timing of colostomy takedown at one year were evaluated.

Results:

Among 11,018 patients who underwent a Hartmann’s procedure, 6,900 (63%) patients underwent ostomy reversal at one year, with a median time to reversal of 18 weeks.

 Compared to white patients with private insurance, combinations of black race and non-private insurance had reduced likelihood of ostomy reversal at one year (black patients with private insurance: OR: 0.64, 95% CI: 0.44-0.93, p=0.021; white patients with Medicaid: OR: 0.79, 95% CI: 0.67-0.93, p=0.005; black patients with Medicaid: OR: 0.62, 95% CI: 0.43-0.89, p=0.009; black patients with Medicare: OR: 0.33, 95% CI: 0.18-0.59, p<0.001; white patients without insurance: OR: 0.30, 95% CI: 0.24-0.37, p<0.001; white patients with Medicare: OR: 0.29 95% CI: 0.21-0.38, p<0.001; black patients without insurance: OR: 0.24 95% CI: 0.13-0.45, p<0.001).

For patients who underwent ostomy reversal, combinations of black race and non-private insurance also had a delay to reversal compared to white patients with private insurance (white patients with Medicaid: 1.5 weeks 95% CI 0.71-2.4, p<0.001; black patients with private insurance: 1.7 weeks, 95% CI: -0.14-3.5, p=0.07; white patients with Medicare: 2.8 weeks, 95% CI: 1.2-4.4, p=0.001; black patients with Medicaid: 3.4 weeks, 95% CI: 1.3-5.6, p=0.002; white patients without insurance: 3.7 weeks, 95% CI: 2.6-4.8, p<0.001; black patients with Medicare: 3.7 weeks, 95% CI: 0.58-6.9, p=0.02; black patients without insurance: 8.0 weeks, 95% CI: 4.5-11.4, p<0.001).

Conclusion:

Race and insurance coverage have complex, significant interactions with rate and timing of ostomy reversal after Hartmann's procedure for diverticulitis. Black patients and those without private insurance receive suboptimal care compared to white patients with private insurance. These disparities are important to consider for allocation of surgical resources in marginalized communities.

7.01 Facility Variation in Upstaging and Adjuvant Chemoradiation in Clinical Stage I Rectal Cancer

Posted on January 18, 2018

D. S. Swords1,2, D. E. Skarda1,2, H. Kim2, W. T. Sause3, G. J. Stoddard4, C. L. Scaife1  1University Of Utah,Surgery,Salt Lake City, UT, USA 2Intermountain Healthcare,Surgical Services,Salt Lake City, UT, USA 3Intermountain Healthcare,Oncology Services,Salt Lake City, UT, USA 4University Of Utah,Division Of Epidemiology,Salt Lake City, UT, USA

Introduction:  The Commission-on-Cancer (CoC) rectal cancer quality measure (QM) states that patients with clinical stage I/pathologic stage II-III rectal cancer (“upstaged”) should receive adjuvant chemoradiation. Notably, the QM does not consider upstaging to be guideline discordant care. We hypothesized that there is facility variation in delivery of adjuvant chemoradiation to such patients, and that there is also variation among facilities in rates of upstaging. 

Methods:  This retrospective study of the 2009-2014 National Cancer Database examined patients < 80 years with clinical stage I rectal adenocarcinoma. Exclusion criteria included: previous cancer, no surgery, local tumor destruction/excision only, neoadjuvant therapy, surgery not at the reporting facility, and unknown clinical or pathologic stage. Outcomes were (1) being upstaged and (2) receipt of adjuvant chemoradiation among upstaged patients who survived ≥ 180 days post-diagnosis. Covariates with univariate p-values < 0.2 for each outcome were entered into multivariable poisson regression models with robust variance estimates. An imputed analysis of 50 data sets obtained through multiple imputation by chained equations was used to account for missing data. Risk- and reliability-adjusted estimates for each facility were generated to examine facility rates of outcomes.

Results: Among 6,031 patients the median age was 60 years, 57.7% were male, and 83.0% were white. Upstaging occurred in 1,607 patients (26.6%). Of pathologic stage II-III patients, 712 (67.2%) received adjuvant chemoradiation. Upstaging was independently predicted by age < 50, Hispanic ethnicity, higher grade, mucinous/signet ring histology, larger size, and elevated CEA. Treatment at > 1 CoC facility was associated with upstaging, but facility type and volume were not. Receipt of adjuvant chemoradiation among upstaged patients was independently associated with age < 70, short travel distance, pathologic stage III (vs. II), and abdominoperineal resection (vs. low anterior resection). Surprisingly, treatment at academic and high volume facilities was associated with omission of adjuvant chemoradiation. Adjusted facility rates of upstaging ranged from 15.4% to 52.7%, and adjuvant chemoradiation rates ranged from 25.3% to 84.0% (Figure).

Conclusion: There is 3-fold variation in adjusted facility rates of adjuvant chemoradiation for patients with clinical stage I/pathologic stage II-III rectal adenocarcinoma, which verifies the utility of this part of the CoC rectal cancer QM. However, there is also significant facility-level variation in rates of upstaging. Providing feedback to facilities with high outlier rates of upstaging should be considered as a quality improvement strategy.

 

7.02 Role of Process and Surgical Judgment in Incidence of Surgical Site Infection following Colectomy

Posted on January 18, 2018

A. C. Antonacci1, D. Armellino1, K. Cifu-Tursellino1, M. Schilling1, S. Dechario1, J. Nicastro1, M. Jarrett1  1North Shore University And Long Island Jewish Medical Center,Surgery,Manhasset, NY, USA

Introduction:

In addition to increased patient morbidity and mortality, the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data suggest that surgical site Infection (SSI) accounts for a 9.2% increase in hospital costs above uncomplicated colectomy cases.  This project, which included 12 acute care facilities ,  was designed to  reduce the  incidence  of post-colectomy SSI by implementing a system-wide standardized surgical bundle, monthly communication of outcome data to practitioners  and analysis of factors contributing to an organ space Infection, as defined by the National Healthcare Safety Network (NHSN),  following elective colectomy. 

Methods:

A colectomy bundle linked survey was utilized to gather information on clinical practice from 125 surgeons within our system. The data suggested specific deficiencies in bundle adherence particularly with respect to oral and mechanical bowel prep compliance. Postoperative compliance data was collected from  post-colectomy SSIs into a relational database analyzing over 50 patient, procedure, SSI and bundle compliance elements.  Data was evaluated at the system, hospital and surgeon level.  Breaches in compliance were shared to the provider level.

Results:

Two years of historical data was utilized to establish the baseline incidence of SSI and compared to six months following implementation.  A twenty-eight percent reduction in SSI was achieved in association with an 30% increase in the use of oral and mechanical bowel preparation. Elective and emergent procedures were analyzed separately with respect to organ space infection.  Despite an 80% compliance rate with oral and mechanical bowel preparation in elective cases, 62% of the cases were identified as having infection present at the time of surgery (PATOS) and 67.5% of the cases were identified as having Class III or Class IV wounds.

Conclusion:

These data suggest that bundle compliance is important in reducing SSIs, particularly with respect to oral and mechanical bowel preparation. However, the high incidence of PATOS and Class III/IV wounds found at elective colectomy suggest that surgeons may be operating on patients too early during the course of an on-going inflammatory process and that surgical judgment and decision making should be included as bundle compliance elements.

 

                                                                                                                       

7.03 Emergency Presentations for Colorectal Cancer 2008-2014: In-hospital Mortality and Discharge Status

Posted on January 18, 2018

Y. A. Zerhouni1,3, N. Melnitchouk1, E. B. Schneider2  1Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 2Ohio State University,Columbus, OH, USA 3UCSF- East Bay,Surgery,Oakland, CA, USA

Introduction:
Emergent presentations of colorectal cancer (CRC) are associated with worse outcomes. We examined patient factors associated with in-hospital death and discharge to continuing care.

Methods:
We queried the 2008–2013 Nationwide Emergency Department Sample, a 20% stratified sample of United States (US) ED visits, and identified all visits with a primary ICD-9-CM diagnosis of CRC. Multivariable logistic regression was used to identify factors associated with in-hospital death or discharge to continuing care (skilled nursing facility, long-term hospital, or home health care).

Results:
Approximately 312,105 ED visits were made for a primary diagnosis of CRC. 70.9% of patients were aged ≥60 years and 58.3%% were covered by Medicare. Over one-third had proximal disease (proximal 36.3%, distal 16.6%, rectum 22.7%, unspecified 24.4%). Nearly 1 in 3 patients had metastatic CRC. 89.0% of patients were admitted to the hospital. 50.5% of patients underwent a surgical procedure (colon resection, ostomy, stent, dilation). At discharge, 49.0% required continuing care. 5.6% died during the hospitalization. The average total charges for the encounter were $83,904 and average length of stay was 10.1 days. Factors associated with discharge to continuing care can be seen in Figure 1. Factors significantly associated with in-hospital death included moderate to severe liver disease (OR 4.82), metastatic CRC (OR 2.12), malnutrition (OR 1.81), mild liver disease (OR 1.78), history of myocardial infarction (OR 1.65), congestive heart failure (OR 1.59), cerebrovascular disease (OR 1.59), and chronic renal disease (1.43).

Conclusion:
ED visits for a primary diagnosis of CRC consume substantial resources with nearly 90% of patients admitted to the hospital and over half (50.5%) requiring surgical intervention. Nearly half of the patients who survive to discharge (49.0%) require some form of additional care. Factors that increase likelihood of in-hospital death or discharge to continuing care should inform patient care.
 

6.17 National Practice Trends for the Management of Lung Cancer: A Dartmouth Atlas Study

Posted on January 18, 2018

I. C. Bostock1, F. Sheikh1, T. M. Millington1, D. J. Finley1, J. D. Philips1  1Dartmouth Hitchcock Medical Center,Thoracic Surgery,Lebanon, NH, USA

Introduction:
Anatomic resection is the standard of care for early-stage lung cancer. Video-assisted thoracoscopic surgery (VATS) has been established as a safe and effective alternative to an open approach. The aims of this study were to: 1) Characterize open versus VATS surgical practice trends for the management of lung cancer in the United States, and 2) Describe if particular regions of the country utilize minimally invasive surgery more frequently.

Methods:
Using the Dartmouth Atlas Rate Generator, the population of Medicare beneficiaries from the ages of 65 to 99 years with full Part A and B coverage and no HMO coverage for the years of 2006 and 2014 was selected. The diagnosis of lung cancer (ICD-9 codes: 162.0 162.2 162.3 162.4 162.5 162.8 162.9) with subsequent selection of CPT codes to describe thoracoscopic (32601, 32607, 32655, 32663, 32666, 32667, 32668, 32669, 32670, 32671) and open lung resections (32096, 32097, 32141, 32505, 32506, 32507, 32608, 32440, 32442, 32445, 32480, 32482, 32484, 32486, 32488) were queried. Comparison of data between 2006 and 2014 with descriptive statistics and a univariate analysis were performed using student’s t-test and chi-square, as appropriate. A p-value <0.05 was considered statistically significant. Heat maps were generated based on the distribution of cases by geographic region.

Results:
A total of 24,368,333 and 23,921,059 patients for the years of 2006 and 2014, were analyzed. A diagnosis of lung cancer was made in 167,418 patients (0.7%) and 167,506 patients (0.7%) in 2006 and 2014 (p=0.7), respectively. A surgical intervention was performed in 17,249 patients (10.3%) during 2006 and 18,603 patients (11.1%) in 2014 (p=0.01). A VATS approach was performed in 2,512 patients (15%) during 2006 and 9,578 patients (54%) during 2014 (p=0.01). In 2006, California, New York, and New Jersey performed the most VATS procedures, in comparison to 2014, when New York, Florida, and California performed the most VATS procedures. 

Conclusion:
The incidence of lung cancer in the United States was unchanged from the period of 2006 to 2014. A change in surgical practice patterns was evident, with a significant increase in the use of VATS techniques in more than 50% of cases after this eight-year period. This indicates that VATS has become the preferred technique in the population studied.  
 

6.18 ~~Factors During Training Which Predict Future Use Of Minimally Invasive Thoracic Surgery

Posted on January 18, 2018

P. E. Rothenberg1, B. D. Hughes2, I. C. Okereke1  1University Of Texas Medical Branch,Cardiothoracic Surgery,Galveston, TX, USA 2University Of Texas Medical Branch,Department Of Surgery,Galveston, TX, USA

Introduction:
~~Although the use of minimally invasive thoracic surgery has increased with time, the majority of patients undergoing lung and esophageal resections still receive an open approach.  We performed a national survey to analyze factors associated with a propensity to perform minimally invasive thoracic surgery after completing a cardiothoracic training program.

Methods:
~~All cardiothoracic surgery trainees in standard 2 or 3 year programs from 2012 to 2016 were sent an online survey regarding numbers and types of cases performed during their training, current practice patterns as attending surgeons and comfort level with minimally invasive thoracic surgery.  Responses were recorded and analyzed.

Results:
~~Sixty-one trainees responded.  Trainees performed a mean of 113 lobectomies (30-250) during their training, with a mean minimally invasive rate of 53 percent.  Trainees performed a mean of 42 esophagectomies (10-110) during training, with a mean minimally invasive rate of 29 percent.  A higher percentage of minimally invasive lobectomies, compared to all lobectomies, performed during training was associated with a higher percentage of minimally invasive lobectomies performed as an attending physician (p = 0.04) and a greater comfort level with minimally invasive lobectomy (p = 0.01).  A higher percentage of minimally invasive esophagectomies performed during training was associated with a higher rate of minimally invasive esophagectomies performed as an attending physician (p = 0.01) and a greater comfort level with minimally invasive esophagectomy (p < 0.01).  A trainee’s overall case number did not influence their rate of adoption of minimally invasive surgery as attendings for either lobectomy (p = 0.11) or esophagectomy (p = 0.06).

Conclusion:
~~Recent graduates who performed a greater number of overall cases during their training were not more likely to adopt minimally invasive techniques as attending physicians if those cases during training were not performed minimally invasively.  Identifying other factors during the early years of an attending physician’s career which make adoption of minimally invasive techniques more likely may help to increase further the overall prevalence of minimally invasive thoracic surgery nationwide.
 

6.15 Risk Factors Contributing to Cardiac Events Following Thoracic Endovascular Aneurysm Repair (TEVAR)

Posted on January 18, 2018

D. Acheampong1, P. Paul1, P. Boateng1, I. Leitman1  1Mount Sinai School Of Medicine,New York, NY, USA

Introduction:  Cardiac events (CE) following TEVAR have been associated with morbidity and mortality. A large risk-adjusted database was used to understand contributing factors. 

Methods:  A retrospective analysis was performed for completed procedures done from 2010-2015 using the American College of Surgeons -National Surgical Quality Improvement Program (ACS-NSQIP) participant user file. Adult patients (≥18 years) who underwent TEVAR were identified and 30-day outcomes were examined. Initial univariate analysis was conducted on all pre-operative risk factors. Univariate and multivariate analyses were performed to assess risk factors for CE following TEVAR. A P-value of < 0.05 was considered statistically significant.

Results: The study identified 130 out of 2403 (5.4%) patients who underwent TEVAR that developed cardiac events as defined by ACS-NSQIP. Pre-operative leukocytosis, ASA score ³3 and functional dependence were associated with CE post-TEVAR. Underlying major risk factors for CE included emergency operation (53.43% vs 18.58%, p<0.01), ventilator dependence (15.38% vs 0.17%, p<0.01), currently on dialysis (11.53% vs 3.77%, p<0.01), SIRS (19.23% vs 6.30%, p<0.01), sepsis (3.84% vs 0.87%, p<0.01) and septic shock (2.3% vs 0.01%, p<0.01). Patients with postoperative renal failure (3.84% vs 0.99%, p<0.01), unplanned return to operating room (21.53% vs 9.37%, p<0.01) and operation time >180mins (37.7% vs 26.8%, p<0.01) also had increased associated post-operative cardiac events.  CE greatly increased mortality (60.8% vs 2.2%).

Conclusion: CE following TEVAR is associated with significant mortality. Patients with identified risk factors should carefully observed following intervention.  

 

 

6.16 SURGICAL STAGING SUPERIOR TO PET SCAN FOR ASSESSMENT OF DISEASE RESPONSE FOR MEDIASTINAL LYMPHOMA

Posted on January 18, 2018

L. Kane1, H. Savas1, M. DeCamp1, A. Bharat1  1Feinberg School Of Medicine – Northwestern University,Chicago, IL, USA

Introduction:

Mediastinal lymphoma affects young individuals, typically in the second through fourth decades of life, and constitutes over 7% of all lymphomas. The primary treatment modality remains systemic chemotherapy with or without radiation. Response to therapy is determined using PET scan. Unfortunately, in over 25% of patients, PET remains positive and it is unclear whether persistent PET avidity in the mediastinum represents residual disease or inflammatory changes resulting from therapy. Percutaneous image guided biopsy has typically resulted in poor accuracy due to the heterogeneity of the residual mass as well as the difficult nature of needle access. We hypothesized that minimally invasive thoracoscopic techniques would enable better sampling of the PET avid mediastinal lesion, allowing accurate assessment of residual disease following first-line treatment of mediastinal lymphomas.

Methods:
This is a retrospective analysis of a prospectively maintained database. Between January 2009 and December 2015, all patients (n=77) who underwent initial surgical incisional biopsy for diagnosis were included. The surgical biopsies were performed using minimally invasive techniques (video-thoracoscopy or robotic surgery) and required the surgeon to keep performing the biopsy until frozen section was positive or at least until the mass on the ipsilateral hemi-mediastinum was resected. Statistical analysis was performed by a biostatistician using SPSS software. 

Results:
Of the study cohort, 34 patients underwent surgical restaging for PET avid residual mass while 43 either had a complete response with no PET activity or were lost to follow up. The cohort of 34 patients included 76% Caucasians, 50% females, and had a median age of 28 years. The types of lymphoma were predominantly Hodgkins (32%) and Diffuse Large B cell Lymphoma (38%). In these 34 patients with residual PET activity, surgical biopsy revealed presence of lymphoma in 53% of patients. Patients detected to have persistent lymphoma revealed no significant difference in tumor volume reduction compared to those with no residual disease (51% versus 39%) and no significant difference in reduction in PET SUV (68% versus 60%). In all biopsies, significant adhesions between lung and mediastinum were noted, and the median length of the surgical procedure was 75 minutes. However, there were no surgical complications. The length of stay for all patients was less than 24 hours. All patients detected to have residual lymphoma underwent second-line therapy guided by the pathological analysis. 

Conclusion:
While the current standard for patients with mediastinal lymphoma presenting with residual PET activity after completion of first line therapy is surveillance alone, our data suggests that a large number of these patients have residual lymphoma which can be safely diagnosed using minimally invasive surgery. Detection of residual lymphoma has significant implications in further treatment of these patients. 

6.13 Using Mathematical Modeling To Define The Learning Curve In Robot-assisted Thoracoscopic Lobectomy

Posted on January 18, 2018

B. N. Arnold1, D. C. Thomas1, V. Bhatnagar1, J. D. Blasberg1, Z. Wang2, D. J. Boffa1, F. C. Detterbeck1, A. W. Kim3  1Yale University School Of Medicine,Section Of Thoracic Surgery,New Haven, CT, USA 2Yale University School Of Medicine,School Of Public Health,New Haven, CT, USA 3University Of Southern California,Division Of Thoracic Surgery,Los Angeles, CA, USA

Introduction:  Robot-assisted thoracoscopic (RobAT) lobectomy has been shown to be a safe approach to pulmonary lobectomy. There is a learning curve associated with integrating the robotic platform into thoracic surgery. This study sought to define, mathematically, the learning curve for RobAT lobectomy.

Methods:  All patients undergoing RoBAT lobectomy at a single academic medical center from 2010 through 2016 were considered. Covariates included patient demographics, comorbidities, operating time (ORT), length of hospital stay (LOS), estimated blood loss (EBL), and post-operative complications. A cumulative sum (CUSUM) analysis of ORT was performed to identify three distinct phases of the learning curve. Procedures converted to open were omitted from the analysis, but the number of conversions within each phase of RoBAT lobectomy was tallied.

Results: 101 patients met criteria for inclusion. CUSUM analysis identified two inflection points which stratified the population into three phases: cases 1-22, cases 23-63, and cases 64-101. There was a statistically significant difference in operating time and estimated blood loss between phases 1 and 2 (ORT p<0.05, EBL p=0.016), and between phases 1 and 3 (ORT p<0.05, EBL p=0.006). There was no difference in ORT or EBL between phases 2 and 3. There was no statistically significant difference in comorbidities, chest tube duration, LOS, or post-operative complications across the learning curve. Conversion rates in phase 1, 2, and 3 were 12% (3/25), 9% (4/45), and 3% (1/39), respectively. Of these conversions, 2/8 were emergent and occurred in phases 1 and 2.

Conclusion: Based on ORT, the learning curve for RoBAT lobectomy appears to be 22 cases, with mastery achieved after 63 cases. Differences in length of stay, chest tube duration, conversion rate, or complication rate were not observed during the learning phase. Other factors not measured in this study may play a role in the learning process and warrant further study. 
 

6.14 Minimally Invasive Versus Full Sternotomy AVR In Low-risk Patients — Which Will Stand Against TAVR?

Posted on January 18, 2018

S. A. Hirji1, F. Ramirez Del Val1, A. A. Kolkailah1, J. Lee1, S. F. Aranki1, P. S. Shekar1, T. Kaneko1  1Brigham And Women’s Hospital,Division Of Cardiac Surgery, Department Of Surgery,Boston, MA, USA

Introduction: Compared to aortic valve replacement (AVR) via full sternotomy (fAVR), minimally invasive AVR (mAVR) has been associated with improved results. The likely expansion of Transcatheter AVR (TAVR) to low-risk patients demands contemporary outcomes for fAVR versus mAVR in this population. We compared the postoperative outcomes and mid-term survival of these two approaches in a large cohort of low-risk patients. 

Methods:  Between 2002 and 2015, 2,095 low-risk patients (Society of Thoracic Surgeons Predicted Risk of Mortality score (STS PROM ≤  4)) underwent elective isolated AVR, including 1029 (49%) mAVR and 1066 (51%) fAVR. Median follow-up was 5.3 years. 

Results: Compared to mAVR patients, fAVR patients had a significantly higher burden of comorbidities such as diabetes (23% vs 11%), stroke (4% vs 2%), congestive heart failure (CHF) (41% vs 24%) and STS-PROM (1.91±0.95 vs 1.81±0.99), all p ≤  0.05.  However, both groups were similar in terms of gender, age, and preoperative creatinine, p > 0.05. Notably, operative mortality (1.1% vs.1.3%), stroke (3% vs. 2%), and re-operation rates for bleeding (1% vs. 2%) were similar between fAVR and mAVR, respectively, all p > 0.05. Median intensive care unit (ICU) stay (31 hours (interquartile range (IQR) 23,61) vs 42 hours (IQR 24, 68); p=0.075) and hospital length of stay (LOS) (6 days (IQR 5,7) vs 6 days (IQR 5,8); p ≤ 0.001) were significantly shorter among mAVR patients. Adjusted survival analysis identified age (Hazard Ratio (HR) 1.05), chronic kidney disease (HR 4.96), prior sternotomy (HR 1.56), and CHF (HR 2.00) as significant predictors of decreased survival (all p ≤  0.030), while type of intervention, mAVR vs fAVR, was non-contributory (HR 1.58; p=0.49).

Conclusion: In low-risk patients, mAVR results in shorter ICU and hospital LOS, while maintaining similar rate of mortality, stroke, reoperation for bleeding and mid-term survival, compared to fAVR. Therefore, mAVR should stand as a benchmark against TAVR in the low-risk patients.

 

6.10 Financial Impact of Access Site Pseudoaneurysm after Transcatheter Aortic Valve Replacement

Posted on January 18, 2018

A. Iyengar1, E. Aguayo1, Y. Seo1, Y. Sanaiha3, O. Kwon2, R. Satou2, P. Benharash2  1University Of California – Los Angeles,David Geffen School Of Medicine,Los Angeles, CA, USA 2University Of California – Los Angeles,Cardiac Surgery,Los Angeles, CA, USA 3University Of California – Los Angeles,General Surgery,Los Angeles, CA, USA

Introduction:

Vascular injuries are the most common complication following transcatheter aortic valve replacement (TAVR), and significantly contribute to morbidity and mortality in the perioperative period. While reducing the risk of vascular rupture, percutaneous access and smaller delivery devices may adversely impact the incidence of pseudoaneurysms. Although typically benign, the effect of access site pseudoaneurysms on resource utilization remain poorly defined. The purpose of this study was to characterize the impact of access site pseudoaneurysms on hospital costs and readmission rates. 

Methods:  

Retrospective analysis of the National Readmissions Database was performed between January 2012 & December 2014 using the International Classification of Diseases, Ninth Revision procedural codes for TAVR (35.05 and 35.06) and pseudoaneurysm formation (442.3). Costs were standardized to the 2014 US gross domestic product using US Department of Commerce consumer price indices and adjusted for diagnosis related group–based severity. The Kruskal-Wallis and chi-squared tests were used for comparisons between all cohorts.

Results:

Of the 32,976 patients who underwent TAVR, 542 (1.6%) were identified as having the complication of pseudoaneurysm. Development of a pseudoaneurysm was associated with older age (84 vs. 82 years, p=0.009), higher prevalence of peripheral vascular disease (39% vs. 26%, p<0.001), and a higher Elixhauser Comorbidity Index (7 vs 6, p=0.033). While 295 (0.9%) patients were diagnosed with pseudoaneurysms at the index hospitalization, 246 (0.6%) were discovered during a readmission.

At index hospitalization, pseudoaneurysm formation was associated with significantly increased length of stay (8 vs. 5 days, p<0.001) and increased total costs ($68,379 vs. $58,871, p<0.001). Endovascular intervention was utilized in 13% of pseudoaneurysms, while open surgical intervention was required in 2% of cases. Readmissions for pseudoaneurysms were also associated with significantly increased length of stay (5 vs. 4 days, p=0.012) and hospital costs ($20,464 vs. $14,835). Among readmissions, endovascular intervention was utilized in 4.4% of pseudoaneurysms, while open surgical intervention was required in 0.7% of cases.

Conclusion:

Pseudoaneurysm formation is more prevalent in older patients with pre-existing peripheral vascular disease. During both index hospitalization and readmissions, lengths of stay and hospital costs are significantly increased by presence of pseudoaneurysms despite low rates of endovascular or open surgical intervention. Strategies to reduce the formation of pseudoaneurysms after TAVR may serve as a suitable target for improvement in the delivery of quality care.

6.11 Readmissions After Mitral Valve Repair Vs. Replacement in the United States, 2010-2014

Posted on January 18, 2018

Y. Sanaiha1, A. Mantha1,2, Y. Seo1, L. Mukdad1, V. Dobaria1, Y. Juo1, R. Morchi2, P. Benharash1  1David Geffen School Of Medicine, University Of California At Los Angeles,Cardiac Surgery,Los Angeles, CA, USA 2University Of California – Irvine,Cardiothoracic Surgery,Orange, CA, USA

Introduction:
Background: Mitral valve replacement and repair have been debated as the optimal strategy to treat mitral regurgitation. While several studies have demonstrated the superiority of repair strategies from a clinical perspective, readmissions and resource utilization with each modality remains ill defined. Since readmission rates are considered indicators of quality, the present study aimed to evaluate the overall costs of care and rehospitalization rates of the respective strategies in a large representative national sample.

Methods:
Patients who underwent isolated mitral valve repair or replacement from Jan. through June in the 2010-2014 National Readmission Database (NRD) were analyzed. The NRD is an all-payer inpatient database maintained by the Healthcare Cost and Utilization Project (HCUP) that estimates more than 35 million annual U.S. hospitalizations. The primary outcomes were index mortality, length of stay, 30-day and 6-month readmission and GDP-adjusted costs. We utilized hierarchical linear models adjusting for demographics, cardiovascular risk factors,  and Elixhauser Comorbidity Index.

Results:
Of the 54,858 patients enrolled, 29,845 (54%) received replacement and 25,013 (46%) repair. Patients undergoing replacement were more likely to be female (57 vs 40%, P<0.001), older (66 vs. 63 yr, P<0.001), have Medicare (56 vs 42%, p<0.001) and have lower Elixhauser score (5.0 vs. 4.0, P<0.001). Replacement was associated with higher adjusted in-hospital mortality (5.4% vs. 1.2%, OR= 2.6, P<0.001),  higher adjusted costs ($64,158 vs. $43,643, β=0.16, P<0.001), longer hospitalization (14.4 days vs. 8.8 days, IRR:1.17, P<0.001). All-cause readmission at 30 days (19.6% vs 13.5%, OR=1.21, P<0.001) and cost of care 30-day readmission ($17,391 vs. $12,744, β=0.16, p<0.001) were significantly higher after replacement, most commonly due to 1) atrial fibrillation, 2) heart failure exacerbation, and 3) pleural effusion. Similarly replacement had higher adjusted odds of readmission at 6 months (34% vs. 22%, OR:1.26 P<0.001).

Conclusion:
In this study of  U.S. patients who underwent isolated mitral valve surgery from 2011-2014, readmission rates remain high. After adjustment for demographics, comorbidities, and hospital level variation, replacement was associated with greater length of stay, mortality and 30-day readmission. Repair first approach may be beneficial during the index hospitalization and in follow up. Based on available literature and our findings, strategies to maximize repair warrant implementation at the national level and beyond centers of excellence.
 

6.09 Embedding Real-Time Measure of Surgeons’ Cognitive Load into Cardiac Surgery Process Modeling

Posted on January 18, 2018

R. Dias2,7, M. Zenati5,7, H. Conboy6, J. Gabany5, D. Arney3,4, J. Goldman3,4,7, L. Osterweil6, G. Avrunin6, L. Clarke6, S. Yule1,2,7  1Brigham And Women’s Hospital,Department Of Surgery,Boston, MA, USA 2Brigham And Women’s Hospital,STRATUS Center For Medical Simulation,Boston, MA, USA 3Massachusetts General Hospital,Department Of Anesthesia,Boston, MA, USA 4Massachusetts General Hospital,MD PnP Program,Boston, MA, USA 5VA Boston Healthcare System,Division Of Cardiac Surgery,West Roxbury, MA, USA 6University Of Massachusetts,Amherst, MA, USA 7Harvard Medical School,Boston, MA, USA

Introduction:
Surgeons constantly deal with a high-demand operative environment that requires simultaneously processing a large amount of information. In certain situations, high demands imposed by surgical tasks may exceed surgeons’ cognitive resources, leading to a state of cognitive overload. This state may impact negatively on performance, increasing the risk of patient harm. The aim of this study was to investigate the concurrent validity of heart rate variability (HRV) analysis as a real-time and objective measure of surgeons’ cognitive load during cardiothoracic surgery. We also aimed to develop a behavioral framework that embeds surgeons’ physiological data into surgical process modeling for 14 unique high-level stages of cardiothoracic surgery.

Methods:
A heart rate sensor chest strap was used by a cardiac surgeon during 16 consecutive cardiothoracic procedures. Inter-beat intervals (R-R intervals) were captured via a validated smartphone app using a Bluetooth connection, and HRV parameters were calculated using spectral analysis. At the end of each procedure, a modified version of the SURG-TLX questionnaire, a validated tool assessing self-perceived cognitive load, was completed by the surgeon. Using audio-video recordings from real-life cardiac surgeries, the HRV parameters were embedded into the surgical workflow, enabling synchronized visualization of video, audio and cognitive load metrics during specific contexts and stages of cardiothoracic surgery. 

Results:
The HRV parameters presenting statistically significant correlation with SURG-TLX score were standard deviation of normal to normal R-R intervals (SDNN) (r = -0.61, p < 0.001), HRV triangulation index (r = -0.69, p < 0.001), maximum low frequency (LF)/ high frequency (HF) ratio (r = 0.55, p < 0.027), and LF/HF ratio episodes > 2.0 (r = 0.80, p < 0.001). A total of 14 unique stages of coronary artery bypass graft (CABG) were identified and we built a behavioral analysis system incorporating video and physiological data (Figure 1).

Conclusion:
A statistically significant association between HRV parameters and SURG-TLX was found, validating HRV analysis as an objective method of measuring surgeons’ cognitive load. We also developed a framework that enables the synchronization of physiological-based cognitive metrics into the surgical process analysis.  This behavioral framework can be used to monitor surgeons’ cognition in real-time, enhancing the understanding of how specific mental states can impact surgical performance and patient safety. Once this relationship is established, approaches seeking to mitigate the deleterious effects of cognitive overload can be developed.
 

6.06 Correlation of Anastomotic Leak and Neoadjuvant Chemoradiotherapy in Esophageal Cancer

Posted on January 18, 2018

D. Lee1, C. Takahashi2, R. Shridhar3, J. Huston4, K. Meredith1  1Florida State University College Of Medicine,Gastrointestinal Oncology,Sarasota, FL, USA 2Midwestern University,Phoenix, AZ, USA 3University Of Central Florida,Orlando, FL, USA 4Sarasota Memorial Health Care System,Sarasota, FLORIDA, USA

Introduction:  Anastomotic leaks (AL) causes significant morbidity after esophagectomy. Most patients receive neoadjuvant chemoradiation (NCR) prior to esophagectomy which has been associated with increase perioperative complications and mortality. We report on a comparison of AL rates in upfront surgical (US) and NCR patients. 

Methods:  A prospectively managed esophagectomy database was queried for US and NCR patients treated between 1996-2015. Predictors of AL rate were identified using multivariate (MVA) analysis and propensity score matching (PSM). 

Results: We identified 820 patients (US – 288; NCR – 532). Overall AL rate was 5.4%.  Decreased AL rate was observed in NCR patients on MVA (8% vs 4.1%; p = 0.04) but no difference was seen after PSM (7.7% vs 4.2%; p=0.14). MVA of factors associated with decreased AL in US patients included distal esophageal tumors and body mass index (BMI) >25. Age, gender, year of surgery, histology, anastomotic location, and diabetes were not prognostic.  Before PSM, MVA of NCR patients of factors associated with decreased AL revealed that only thoracic anastomosis was prognostic. However, this was not observed after PSM.  MVA of factors associated with decreased AL in all patients revealed thoracic anastomosis, NCR, and BMI 25-30. After PSM, only distal esophageal tumors and thoracic anastomosis were prognostic for decreased AL. 

Conclusion: There is no difference in the AL rate between US and NCR patients.  Decreased AL rate was observed in patients with distal esophageal tumors and thoracic anastomosis.

 

6.07 Perioperative Outcomes Following Esophagectomy With Gastric vs. Non-Gastric Reconstruction?

Posted on January 18, 2018

M. Varasteh Kia2, J. K. Canner1, R. J. Battafarano1, S. C. Yang1, E. L. Bush1, M. V. Brock1, E. R. Haut1,3, S. R. Broderick1  1Johns Hopkins University School Of Medicine,Baltimore, MD, USA 2Johns Hopkins Bloomberg School Of Public Health,Epidemiology And Biostatistics,Baltimore, MD, USA 3Johns Hopkins Bloomberg School Of Public Health,Health Policy And Management,Baltimore, MD, USA

Introduction

To restore gastrointestinal continuity following esophagectomy, tubularized stomach is the preferred conduit.  In scenarios where the stomach cannot be used non-gastric conduits such as jejunal or colonic interpositions are employed. There are inconsistencies between previous studies examining outcomes associated with the use of non-gastric conduits. Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, we examined perioperative outcomes in patients reconstructed with gastric and non-gastric conduits to better characterize the relative risks of morbidity and mortality associated with these procedures. 

 

Methods

2006 – 2015 ACS-NSQIP esophagectomy cases were separated into gastric and non-gastric conduits based on CPT codes. Emergent and non-cancer resections were excluded. We examined perioperative differences between the two groups using chi-square and nonparametric Wilcoxon rank sum tests. Unadjusted and adjusted risk ratios of postoperative complications were estimated using Poisson regression with robust error variance.

 

Results

After exclusions, there were 6,321 and 210 patients in the gastric and non-gastric groups, respectively.  In unadjusted comparisons, significant differences were identified in 30-day mortality rate (3.32% vs 10.48%, p < 0.001), prolonged hospitalizations (5.30% vs 10.26%; p = 0.02), median length of stay (10% vs 13%; p < 0.001), reoperation rate (14.27% vs 30.43%, p < 0.001) and operative time (342 vs 384 minutes; p < 0.001) between the gastric and non-gastric groups.  No significant differences were identified in the occurrence of superficial, deep or organ/space surgical site infection, pneumonia, or readmission. After adjusting for age, gender, ethnicity, history of diabetes, smoking status, history of COPD, weight loss >10% in prior 6 months and BMI, there remained significant differences between groups in 30-day mortality (RR 0.33 [0.22-0.50]) for gastric vs non-gastric conduit), prolonged hospitalization (RR 0.51 [0.30-0.90]), and reoperation (RR 0.46 [0.35-0.61]), respectively (Table 1). 

 

Conclusion

The use of non-gastric conduit interposition following esophagectomy for carcinoma is associated with higher chance of mortality. However, the underlying reasons for this difference could not be identified using ACS-NSQIP data. Limitations of this study include its retrospective nature and the inherent limitations of the ACS-NSQIP dataset.  This analysis may help to inform shared decision making when considering alternate conduits for reconstruction for esophageal cancer patients in whom the gastric conduit is not feasible.

6.08 Innominate versus Axillary Artery Cannulation for Hemiarch Repair

Posted on January 18, 2018

M. Eldeiry1, M. Aftab1, K. Yamanaka1, M. S. Mosca1, C. Ghincea1, J. C. Cleveland1, D. Fullerton1, T. B. Reece1  1University Of Colorado Denver,Cardiothoracic Surgery,Aurora, CO, USA

Introduction:

Innominate artery cannulation has gained some popularity over the last decade as an alternative to axillary artery cannulation for providing antegrade cerebral perfusion (ACP) during repair of the ascending aorta and arch. Innominate artery cannulation provides several advantages including avoidance of an additional incision and use of a larger caliber artery to provide ACP. We hypothesize that these advantages make innominate artery cannulation superior to axillary artery cannulation as it can decrease operative times and potentially decrease blood loss.

Methods:

This was a single center retrospective analysis of 177 patients who underwent hemiarch replacement between 2009 and 2016. All patients qualified including emergent cases. Groups were separated by mode of cannulation: axillary vs innominate. Outcomes evaluated included cardiopulmonary bypass (CPB) time, cross-clamp (XC) time, circulatory arrest (CA) time, post-operative transfusions, intensive care unit length of stay, development of any neurological complications, end organ failure, and mortality. Sub-group analysis was performed for elective and emergent cases.

Results:

Axillary and innominate artery cannulation accounted for 42.4% (n=75) and 57.6% (n=102) of cases, respectively. There was no difference in patient characteristics except for a higher incidence of lung disease in the axillary group (21% vs. 9%, p=0.029). More emergent cases were performed in the axillary group (60% vs. 18%, p<0.001).

Operative times are summarized in Figure 1. Innominate cases had shorter CPB and CA times. In the elective subgroup, CA times were shorter for the innominate cases. However, the emergent subgroup displayed no difference.

Less transfusions were given in the innominate group including RBC (2[0,14] vs. 0[0,8], p<0.001), PLT (2[0,7] vs. 2[0,4], p=0.030) and FFP (6[0,20] vs. 3[0,11], p<0.001). A similar trend was observed for RBC and FFP in the elective subgroup. No difference was observed in the emergent subgroup.

There was no statistical difference in remaining outcomes between cases of axillary and innominate cannulation in the combined, elective, and emergent groups.

Conclusions:

Alternate cannulation strategies for open arch anastomoses are evolving with a trend towards utilizing the innominate artery. These data suggest that innominate cannulation is at least equivalent to, and may be superior to, axillary cannulation. The innominate artery provides a larger conduit vessel for perfusion and this decrease in resistance to flow, allowing for faster cooling and rewarming, maybe why CPB times were lower in this group. Innominate cannulation is a safe and potentially advantageous technique for hemiarch repair.

6.04 Poor Pulmonary Function Tests Potentiate The Impact Of Comorbidities After Lobectomy For Lung Cancer

Posted on January 18, 2018

D. C. Thomas1, B. N. Arnold1, M. DeLuzio1, F. C. Detterbeck1, D. J. Boffa1, J. D. Blasberg1, A. W. Kim2  1Yale School Of Medicine,Section Of Thoracic Surgery,New Haven, CT, USA 2University Of Southern California,Division Of Thoracic Surgery,Los Angeles, CA, USA

Introduction: Patients with poor pulmonary function tests (PFTs) and more comorbid conditions, identified by the Charlson comorbidity index (CCI), have been associated independently with an increased risk of perioperative complications after lung cancer surgery. Many large national databases currently available lack PFT data and consequently often rely on surrogates such as comorbidity indices.  This study sought to evaluate the interaction of PFTs and comorbidities on postoperative complications in a large single institution dataset of patients undergoing lobectomy for lung cancer. 

Methods: Patients undergoing lobectomy for lung cancer at an academic medical center from 2008-14 were examined. Patients were stratified by predicted postoperative FEV1 and DLCO:1) low PFTs (either FEV1 or DLCO ≤40%),2) moderate PFTs (both >40%, but not >80%), and 3) high PFTs (both ≥80%). The primary outcome was incidence of any complication in the postoperative period. Variables were analyzed using the χ2 test and predictors of complications using a multivariate model.

Results: A total of 376 patients were identified as having undergone lobectomy for lung cancer.  Low ppoPFTs comprised 9% (34) of patients, while 76% (286) had moderate ppoPFTs, and 15% (56) had high ppoPFTs.  Forty-one percent (154) of patients had a CCI=0, 32% (121) had CCI=1, and 27% (101) had a CCI≥2.  The overall incidence of complications was 36% (136).  Bivariate analysis demonstrated that among patients with high ppoPFFTs and moderate ppoPFTs, as CCI increased from 0 to 1 to ≥2, the incidence of complications increased then plateaued (Figure 1).  However, in patients with low ppoPFTs, increasing CCI from 0 to 1 to ≥2 continued to increase the incidence of complications.  On multivariable, low and moderate ppoPFTs independently predicted complications compared to patients with high ppoPFTs (OR=5.4, P<0.001 and OR=2.2, P=0.05, respectively), while CCI was not independently predictive.

Conclusion: Poor PFTs remain an independent predictor of complications after lobectomy for lung cancer and this finding alone supports utilization of PFTs in the analysis of outcomes. However, poor PFTs appear to have a greater negative impact when the number of comorbidities increases. This effect is distinctly different and not observed among patients with superior PFTs.  Therefore, while the absence of PFT data may not be as impactful when the comorbidities are minimal, the impact of absent PFT data may be more profound when their values are poor and found in patients with a greater number of comorbidities. 

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