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Objectives: Prior studies have associated morbidity following anatomic lung resection with prolonged postoperative length of stay; however, each complication's individual impact on length of stay as a continuous variable has not been studied. The purpose of this study was to determine the risk-adjusted increase in length of stay associated with each individual postoperative complications following anatomic lung resection., Methods: Patients who underwent anatomic lung resection cataloged in the prospectively collected American College of Surgeons National Surgical Quality Improvement Program participant use file, 2005-2018, were targeted. The association between preoperative characteristics, postoperative complications and length of stay in days was tested. A negative binomial model adjusting for the effect of preoperative characteristics and 18 concurrent postoperative complications was used to generate incidence rate ratios. This model was fit to generate risk-adjusted increases in length of stay by complication., Results: Of 32 133 patients, 5065 patients (15.8%) experienced at least one post-operative complication. The most frequent complications were pneumonia (n = 1829, 5.7%), the need for transfusion (n = 1794, 5.6%) and unplanned reintubation (n = 1064, 3.3%). The occurrence of each of the 18 individual complications was associated with significantly increased length of stay. This finding persisted after risk-adjustment, with the greatest risk-adjusted increases being associated with prolonged ventilation (+17.4 days), followed by septic shock (+17.2 days), acute renal failure (+16.5 days) and deep surgical site infection (+13.2 days)., Conclusions: All 18 postoperative complications studied following anatomic lung resection were associated with significant risk-adjusted increases in length of stay, ranging from an increase of 17.4 days with prolonged ventilation to 2.6 days following the need for transfusion., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objective: We sought to evaluate how implementing a thoracic enhanced recovery after surgery (ERAS) protocol impacted surgical outcomes after elective anatomic lung resection., Background: The effect of implementing the ERAS Society/European Society of Thoracic Surgery thoracic ERAS protocol on postoperative outcomes throughout an entire health care system has not yet been reported., Methods: This was a prospective cohort study within one health care system (January 2019-March, 2023). A thoracic ERAS protocol was implemented on May 1, 2021 for elective anatomic lung resections, and postoperative outcomes were tracked using the electronic health record and Vizient data. The primary outcome was overall morbidity; secondary outcomes included individual complications, length of stay, opioid use, chest tube duration, and total cost. Patients were grouped into pre-ERAS and post-ERAS cohorts. Bivariable comparisons were performed using independent t -test, χ 2 , or Fisher exact tests, and multivariable logistic regression was performed to control for confounders., Results: There were 1007 patients in the cohort; 450 (44.7%) were in the post-ERAS group. Mean age was 66.2 years; most patients were female (65.1%), white (83.8%), had a body mass index between 18.5 and 29.9 (69.7%), and were ASA class 3 (80.6%). Patients in the postimplementation group had lower risk-adjusted rates of any morbidity, respiratory complication, pneumonia, surgical site infection, arrhythmias, infections, opioid usage, ICU use, and shorter postoperative length of stay (all P <0.05)., Conclusions: Postoperative outcomes were improved after the implementation of an evidence-based thoracic ERAS protocol throughout the health care system. This study validates the ERAS Society/European Society of Thoracic Surgery guidelines and demonstrates that simultaneous multihospital implementation can be feasible and effective., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Inadvertent perioperative hypothermia has been associated with poor surgical outcomes. The purpose of this study was to evaluate the incidence and associated postoperative complications of inadvertent perioperative hypothermia in patients undergoing robotic-assisted thoracic surgery lung resections., Methods: This was a single-center, retrospective cohort study evaluating all consecutive patients who underwent robotic-assisted thoracic surgery lung resection between January 1, 2021, and November 30, 2022. Temperatures were measured at 5 time points: preprocedure unit, anesthesia induction, 30 minutes postinduction, extubation, and recovery room arrival. Temperature changes were calculated at each interval. Adjusted and unadjusted comparison was performed between those who experienced varying levels of inadvertent perioperative hypothermia (Hypothermia I: <36 °C, Hypothermia II: <35.5 °C, and Hypothermia III: <35 °C) and those who did not., Results: A total of 313 patients were included, and 201 (64.2%) lobectomies, 50 (16.0%) segmentectomies, and 62 (19.8%) wedge resections were performed. Across all patients, 291 (93.0%) had a temperature less than 36 °C, 195 (62.3%) had a temperature less than 35.5 °C, and 100 (31.9%) had a temperature less than 35.0 °C. Patients experienced significant temperature change at all intervals (P < .001), with the greatest loss occurring during the preprocedure interval (between leaving preprocedure unit and anesthesia induction). On adjusted analysis, patients who experienced inadvertent perioperative hypothermia less than 35.5 °C were older (odds ratio, 1.03; 95% CI, 1.01-1.05), had lower body mass index (odds ratio, 0.95; 95% CI, 0.87-0.98), and had increasing operative time (odds ratio, 1.00; 95% CI, 1.00-1.01). Patients who experienced inadvertent perioperative hypothermia had higher risk-adjusted rates of overall morbidity and infectious postoperative complications., Conclusions: The majority of patients undergoing robotic-assisted thoracic surgery lung resections experience some degree of inadvertent perioperative hypothermia and have associated increased rates of 30-day morbidity. Structured and interval-specific interventions should be implemented to decrease rates of inadvertent perioperative hypothermia and subsequent complications., Competing Interests: Conflict of Interest Statement R.A.M. consults for Medtronic. J.D.M. consults for Intuitive. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Patients express strong opinion regarding discharge destination, preferring discharge home vs elsewhere. As focus on patient satisfaction increases, we sought to understand differences in postoperative discharge destination after minimally invasive vs open anatomic lung resection for lung cancer to guide patient education and management and better understand the postoperative patient experience., Methods: Procedures were identified by Current Procedural Terminology and International Classification of Diseases codes using the 2012-2017 American College of Surgeons National Surgical Quality Improvement Program dataset. Propensity score analysis was used to assess the relationship between the surgical approach and nonhome discharge destination (primary outcome) and postoperative complications; related, unplanned readmission; and mortality (secondary outcomes)., Results: A total of 17,303 patients underwent anatomic lung resection for lung cancer, including 10,121 (58.5%) minimally invasive and 7182 (41.5%) open resections. Patients undergoing open resection had 60% greater odds of nonhome discharge (P < .001), 58% greater odds of postoperative mortality (P = .003), 36% greater odds of postoperative complication (P < .001), and 17% greater odds of readmission (P = .04) compared with patients undergoing minimally invasive resection., Conclusions: The minimally invasive approach to lung resection for lung cancer offers patients a more desirable patient-centered postoperative experience, as well as more favorable clinical outcomes, and should be favored when feasible., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Hospital readmissions are viewed as a mark of inferior health care quality and are penalized. Unplanned postoperative readmission reason and timing after lung resection are not well understood. We examine related, unplanned readmissions after thoracoscopic versus open anatomic lung resections to identify opportunities to improve patient care., Methods: We analyzed the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data set, 2012 to 2015, characterizing 30-day related, unplanned postoperative readmissions after anatomic lung resections for primary lung cancer. Risk-adjusted comparison of readmission after thoracoscopic and open resection was performed using propensity matching., Results: Patients (n = 9,510) underwent anatomic lung resections; 4,935 (51.9%) were thoracoscopic resections and 4,575 (48.1%) were open resections. Of the thoracoscopic patients, 10.9% experienced one or more complications, versus 19.4% of patients with open resection (p < 0.0001). Of the thoracoscopic patients 5.5% experienced related, unplanned readmissions versus 7.2% of the patients with open resection (p < 0.001). 24.8% of complications after thoracoscopic approach occurred after discharge, versus 15.5% after open approach (p < 0.0001). Timing of unplanned readmission was similar for both groups. The propensity-matched odds ratio of risk of readmission after thoracoscopic versus open resection was 1.16 (95% confidence interval, 0.949 to 1.411, p = 0.15)., Conclusions: Open anatomic lung resections for primary lung cancer had nearly twice the complication rate but only a slightly higher readmission rate than thoracoscopic resection. More complications occurred after discharge after thoracoscopic than open resections. Most readmissions occurred within 2 weeks after both thoracoscopic and open resections. Risk-adjusted comparison identified no statistically significant difference in risk of related, unplanned readmission after thoracoscopic versus open resections. Future studies should focus on identification of processes of care to decrease complications and unplanned readmissions after lung cancer resection., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The purpose of this study was to assess the effect of human immunodeficiency virus (HIV) infection on postoperative survival among non-small cell lung cancer (NSCLC) patients., Methods: A retrospective cohort study compared 22 HIV-infected lung cancer patients to 2,430 lung cancer patients with HIV-unspecified status who underwent resection at Johns Hopkins Hospital from 1985 to 2009. Subcohort comparative analyses were performed using individual matching methods., Results: Thirty-day mortality rates did not differ between HIV-infected and HIV-unspecified patients. Survival rates for HIV-infected lung cancer patients were significantly shorter than for HIV-unspecified patients (median, 26 versus 48 months; p=0.001). After adjustment, the relative hazard of mortality among HIV-infected NSCLC patients was more than threefold that of HIV-unspecified patients (adjusted hazard ratio, 3.08; 95% confidence interval: 1.85 to 5.13). When additional surgical characteristics were modeled in a matched subcohort, the association remained statistically significant (adjusted hazard ratio, 2.31; 95% confidence interval: 1.11 to 4.81). Moreover, HIV-infected lung cancer patients with CD4 counts less than 200 cells/mm3 had shortened median survival compared with patients whose CD4 counts were 200 cells/mm3 or greater (8 versus 40 months; p=0.031). Postoperative pulmonary and infectious complications were also elevated in the HIV-infected group (p=0.001 and p<0.001, respectively). After surgery, median time to cancer progression was shorter among HIV-infected patients (20.4 months) versus HIV-unspecified patients (p=0.061)., Conclusions: The HIV-infected NSCLC patients have more postoperative complications, rapid progression to disease recurrence, and poorer postoperative survival. Optimizing immune status before surgery and careful patient selection based on diffusion capacity of lung for carbon monoxide may improve patient outcomes., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Defining centers of excellence for complex surgical procedures, including pulmonary resection, reveals lower mortality at high-volume centers. We postulate that short-term outcome after lung cancer resection is better at teaching hospitals (TH) compared with nonteaching hospitals (non-TH), independent of volume., Methods: Lung cancer resections in the Nationwide Inpatient Sample (NIS) dataset from 1998 to 2004 were stratified by resection type (segmentectomy, lobectomy, and pneumonectomy). The TH identified in the NIS include those with Accreditation Council for Graduate Medical Education-approved general surgery (GSTH) and thoracic surgery (TSTH) residency programs. The association of hospital teaching status with in-hospital mortality was assessed by multivariate logistic regression, adjusting for patient demographics and comorbidities., Results: Of 46,951 lung resections (5,651 segmentectomies, 37,027 lobectomies, 4,273 pneumonectomies), 56% were performed at TH. Overall mortality was significantly lower at TH versus non-TH (3.2% vs 4.0%; p < 0.001). Subgroup analysis for GSTH and TSTH confirmed this decrease. On multivariate regression, overall odds of death was independently reduced by 17% at TH versus non-TH (95% confidence interval: 0.73 to 0.93; p = 0.002). At TH, odds of death for pneumonectomy and lobectomy were significantly reduced independent of surgical volume, except for the latter at the highest hospital volume strata., Conclusions: In-hospital mortality is reduced for patients undergoing lung cancer resections at teaching hospitals, with results prominent at all but the highest volume institutions. Lower mortality rates persisted at GSTH and TSTH. Understanding and disseminating the processes of care associated with these settings may improve quality of care for lung cancer patients, and decrease patient bias against teaching hospitals.