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BACKGROUND Airway release (AR) maneuvers performed during airway resection to reduce anastomotic tension have not been thoroughly studied. METHODS This study retrospectively analyzed consecutive resections for postintubation stenosis (PITS) and primary tracheal neoplasms (PTNs) at Massachusetts General Hospital (Boston, MA). Anastomotic complications were defined as stenosis, separation, necrosis, granulation tissue, and air leak. Logistic regression modeling was used to identify factors associated with AR and adverse outcome. RESULTS From 1993 to 2019, 545 patients with PITS (375; 68.8%) and PTNs (170; 31.2%) underwent laryngotracheal, tracheal, or carinal (resections and reconstructions; 5.7% (31 of 545) were reoperations. AR was performed in 11% (60 of 545): in 3.8% of laryngotracheal resections (6 of 157; all laryngeal), in 9.8% of tracheal resections (34 of 347; laryngeal, 12, and hilar, 22), and in 49% of carinal resections (20 of 41; laryngeal, 1, and hilar, 19). Mean resected length was 3.5 cm (range, 1to- 6.3 cm) with AR and 3.0 cm (range, 0.8 to 6.5 cm) without AR (P < .01). Operative mortality was 0.7% (4 of 545); all 4 anastomoses were intact until death. Anastomotic complications were present in 5% of patients who underwent AR (3 of 60) and in 9.3% (45 of 485) of patients who did not. AR was associated with resection length of 4 cm or longer (odds ratio [OR], 6.15; 95% confidence interval [CI], 1.37 to 27.65), PTNs (OR, 7.81; 95% CI, 3.31 to 18.40), younger age (OR, 0.96; 95% CI, 0.94 to 0.98), and lung resection (OR, 6.09; 95% CI, 1.33 to 27.90). Anastomotic complications in patients with tracheal anastomoses were associated with preexisting tracheostomy (OR, 2.68; 95% CI, 1.50 to 4.80), but not release. CONCLUSIONS Tracheal reconstruction succeeds, even when anastomotic tension requires AR. Because intraoperative assessment may underestimate tension, lowering the threshold for AR seems prudent, particularly in patients with diabetes.

Teaching multiple, evolving surgical approaches to thoracic surgical residents at a time of decreasing surgeon volume, increasing scrutiny of quality, greater demands on surgical efficiency, and reduced resident work hours requires a new mindset and new methods of education. The challenge presented to general thoracic surgeon educators and residents is explained, and encouragement is drawn from the examples of previous educational crises and their solutions.

Clinical staging of lung cancer may not reliably predict nodal disease, and its accuracy in The Society of Thoracic Surgeons General Thoracic Surgery Database is not described.Among anatomic pulmonary resections for stages I to III lung cancer with complete clinical and pathologic staging (2012-2017), the accuracy of invasive mediastinal staging (IMS) was compared with noninvasive mediastinal staging only. Accuracy, defined as concordance between clinical and pathologic nodal status, was examined using logistic regression to determine factors associated with clinical nodal (cN) accuracy. Variation in accuracy across centers was recorded and categorized.We included 39,516 patients with stages I to III pulmonary cancer (adenocarcinoma, 66%; squamous, 23%; neuroendocrine, 5%; mixed, 3.3%; other, 2.4%), of whom 90.4% had cN0 disease. IMS was performed in 32.4%. The IMS group had more central tumors (14.8% vs 6.0%, P.001) and cN1-2 (15.7% vs 6.8%, P.001). Nodal accuracy was 79.8%. Although IMS had a lower nodal accuracy for cN0-2 disease (74.6% vs 82.6%, P .001), IMS had higher accuracy when comparing patients with cN1-2 disease (53.9% vs 46.9%, P.001). In multivariable analysis central tumors (odds ratio, 0.47; 95% confidence interval, 0.43-0.51) andcN0 disease (odds ratio, 0.25; 95% confidence interval, 0.22-0.29) were associated with lower accuracy. Accuracy of IMS in the top 20 centers was 94.4% and in the bottom 20, 70.9%.Staging accuracy in lung cancers selected for initial resection declines withcN0 and central tumors. Noninvasive staging in tumors without cN involvement misses nearly 20% of cN1-2. Center-specific accuracy is a target for quality improvement.

Objective To investigate the impact of thoracic body composition on outcomes after lobectomy for lung cancer. Summary and background data Preoperative identification of patients at risk for adverse outcomes permits treatment modification. The impact of body composition on lung resection outcomes has not been investigated in a multicenter setting. Methods A total of 958 consecutive patients undergoing lobectomy for lung cancer at 3 centers from 2014 to 2017 were retrospectively analyzed. Muscle and adipose tissue cross-sectional area at the fifth, eighth, and tenth thoracic vertebral body was quantified. Prospectively collected outcomes from a national database were abstracted to characterize the association between sums of muscle and adipose tissue and hospital length of stay (LOS), number of any postoperative complications, and number of respiratory postoperative complications using multivariate regression. A priori determined covariates were forced expiratory volume in 1 second and diffusion capacity of the lungs for carbon monoxide predicted, age, sex, body mass index, race, surgical approach, smoking status, Zubrod and American Society of Anesthesiologists scores. Results Mean patient age was 67 years, body mass index 27.4 kg/m and 65% had stage I disease. Sixty-three percent underwent minimally invasive lobectomy. Median LOS was 4 days and 34% of patients experienced complications. Muscle (using 30 cm increments) was an independent predictor of LOS (adjusted coefficient 0.972; P = 0.002), any postoperative complications (odds ratio 0.897; P = 0.007) and postoperative respiratory complications (odds ratio 0.860; P = 0.010). Sarcopenic obesity was also associated with LOS and adverse outcomes. Conclusions Body composition on preoperative chest computed tomography is an independent predictor of LOS and postoperative complications after lobectomy for lung cancer.

Objectives The study objectives were to evaluate the immediate, short-, and medium-term efficacy and safety of pulmonary artery branch sealing using an ultrasonic vessel-sealing device in minimally invasive anatomic lung resection. Methods This study consists of a prospective, phase 2, multicenter, international clinical trial (clinicaltrials.gov: NCT02719717) that enrolled patients planned for video-assisted thoracoscopic surgery/robotic anatomic lung resection in 7 centers (United States, Canada, United Kingdom). Pulmonary artery branches of 7 mm or less were sealed and divided with an ultrasonic energy vessel-sealing device. The remainder of the lobectomy was performed according to surgeon preference. Intraoperative, in-hospital, and 30-day postoperative bleeding and complications were prospectively recorded. Results A total of 150 patients with a minimum of 1 pulmonary artery branch sealed with an ultrasonic vessel-sealing device were prospectively enrolled in the trial. Resections included 139 lobectomies and 11 segmentectomies. A total of 424 pulmonary artery branches were divided: 239 with the ultrasonic vessel-sealing device, 181 with endostaplers, and 4 with endoscopic clips. The mean and median pulmonary artery diameters were 4.7 mm/5.0 mm, 10.3 mm/10.0 mm, and 6.5 mm/6.5 mm for each method, respectively. Three of the pulmonary artery branches divided with the ultrasonic vessel-sealing device (1.3%) and 4 pulmonary artery branches divided with endostaplers (2.2%) bled intraoperatively. Among the patients with seal failures, 1 patient required conversion to thoracotomy. There was no postoperative bleeding from divided pulmonary artery branches with either sealing method. There was no mortality at 30 days. Conclusions Pulmonary artery branch sealing with ultrasonic energy during video-assisted thoracoscopic surgery lobectomy is safe for vessels 7 mm or less. The use of an ultrasonic device is a reasonable sealing method for pulmonary artery branches 7 mm or less.

Sampling of ≥10 lymph nodes during lobectomy for non-small cell lung cancer (NSCLC) was a previous surveillance metric and potential quality metric of the American College of Surgeons Commission on Cancer. We sought to determine guideline adherence and its relationship to hospital lobectomy volume within The Society of Thoracic Surgeons General Thoracic Surgery Database.Participant centers providing elective lobectomy for NSCLC within The Society of Thoracic Surgeons General Thoracic Surgery Database (2012-2019) were divided into tertiles according to annual volume. Average hospital nodal harvest of ≥10 nodes per lobectomy defined the primary outcome. Univariable analysis compared average patient and operative characteristics between the participant centers. Multivariable logistic regression was used to determine independent factors associated with average clinical center nodal harvest of ≥10 nodes.Median annual lobectomy volume was 6.2, 19.9, and 42.7 for low-, medium-, and high-volume participant centers. Among 305 centers and 43 597 patients, 5.6% of lobectomies occurred in low-volume centers, 24.0% in medium-volume centers, and 70.4% in high-volume centers. Average rates of ≥10 nodes per lobectomy were excised in 44.0% of low-volume centers, 70.6% of medium-volume centers, and 75.2% of high-volume centers (P.001). On multivariable analysis, average nodal excision of ≥10 nodes was strongly associated with medium-volume (odds ratio, 2.94; CI, 1.57-5.50, P.01) and high-volume (odds ratio, 3.82; CI, 1.95-7.46; P.001) participant centers.Although higher center volume and increased nodal harvest are associated, 25% of high-volume centers average a rate of10 lymph nodes per lobectomy for NSCLC. Low nodal yield may underestimate stage, with implications for adjuvant therapy and long-term survival.

Reintubation after lung cancer resection is an important quality metric because of increased disability, mortality and cost. However, no validated predictive instrument is in use to reduce reintubation after lung resection. This study aimed to create and validate the PRediction Of REintubation After Lung cancer resection (PROREAL) score.The study analyzed lung resection cases from 2 university hospitals. The primary end point was reintubation within 7 days after surgery. Predictors were selected through backward stepwise logistic regression and bootstrap resampling. The investigators used reclassification and receiver-operating characteristic (ROC) curve analyses to assess score performance and compare it with an established score for all surgical patients (Score for Prediction of Postoperative Respiratory Complications [SPORC]).The study included 2672 patients who underwent resection for lung cancer (1754, development cohort; 918, validation cohort) between 2008 and 2020, of whom 71 (2.7%) were reintubated within 7 days after surgery. Identified score variables were surgical extent and approach, American Society of Anesthesiologists physical status, heart failure, renal disease, and diffusing capacity of the lung for carbon monoxide. The score achieved excellent discrimination in the development cohort (ROC AUC, 0.90; 95% CI, 0.87-0.94) and good discrimination in the validation cohort (ROC AUC, 0.74, 95% CI; 0.66-0.82), thus outperforming the SPORC in both cohorts (P.001 and P = .018, respectively; validation cohort net reclassification improvement, 0.39; 95% CI, 0.18-0.60; P = .001). The score cutoff of ≥5 yielded a sensitivity of 88% (95% CI, 72-95) and a specificity of 81% (95% CI,79-83) in the development cohort.A simple score (PROREAL) specific to lung cancer predicts postoperative reintubation more accurately than the nonspecific SPORC score. Operative candidates at risk may be identified for preventive intervention or alternative oncologic therapy.

The perioperative risk of pulmonary lobectomy as a solitary procedure has been extensively studied, yet the differences in outcomes between lobes, which have unique anatomy and a different amount of lung parenchyma, are entirely unknown. The purpose of this study was to define the risk of each of the 5 lobectomies.The Society of Thoracic Surgeons Database was queried for patients undergoing lobectomy between 2008 and 2018. Patient and disease characteristics, operative variables, major morbidity, and 30-day mortality were examined. A multivariable logistic regression model (using the same variables in the current Society of Thoracic Surgeons lobectomy risk model) was developed to assess the contribution of lobectomy site to adverse outcomes.There were 65 006 patients analyzed. Adjusted perioperative mortality rate is lowest for right middle lobe (RML), 0.63%; intermediate for right upper lobe (RUL), left upper lobe (LUL), and left lower lobe (LLL), 1.08 to 1.24%; and highest for right lower lobe (RLL), 1.63%. The adjusted major morbidity rate is lowest for RML, 5.36%; intermediate for LLL and LUL, 7.82% to 8.33%; and highest for RUL and RLL, 8.94% to 9.32%. Adjusted intraoperative transfusion rate is lowest for RML, 1.37%; intermediate for RLL and LLL, 1.81% to 1.94%; and highest for RUL and LUL, 2.47% to 2.72%.There are clear differences in postoperative outcomes by lobectomy location. Mortality, major morbidity, and transfusion rate are lowest for RML but vary across other lobectomies. These differences should be appreciated in evaluating risk of operation, deciding on best therapy, counseling patients, and comparing outcomes.

The clinical impact of a positive radial margin after esophagectomy for cancer has not been clearly identified. The goal of this study was to identify risk factors for a positive radial margin and determine the impact on recurrence and survival. Retrospective review of 196 patients with pathological T3 N0-3 esophageal adenocarcinoma undergoing esophagectomy between 2002 and 2017. Mortality data was extracted from Electronic Medical Records and Social Security Death Index. Mean age was 63.7 ± 11.4 years, and there were 166 (84.7%) men. Neoadjuvant therapy was given in 141(71.9%) patients. We identified 29(14.8%) patients with a positive radial margin. Factors significantly associated with a positive radial margin include not receiving neoadjuvant therapy and presence of lymphatic, vascular, or perineural invasion. Overall, there were 94(48%) recurrences during a mean follow-up of 24.7 months. Involvement of the radial margin was not significantly associated with recurrence-free survival (HR 1.24, CI 95% 0.73–2.12, p = 0.425). Overall survival for the entire cohort was 41.6% and 28.9% at 3 and 5 years, respectively. Involvement of the radial margin did not have a significant impact on overall survival (HR 1.23, CI 95% 0.68–2.22, p = 0.493). The likelihood of encountering a positive margin is associated with lack of neoadjuvant treatment and the presence of lymphatic, vascular, or perineural invasion in the esophagectomy specimen. An involved radial margin after esophagectomy for locally advanced cancer was not associated with tumor recurrence or overall survival in our cohort, and other factors such as lymph node involvement are stronger in determining outcome.

Background Parameters defining attainment and maintenance of proficiency in thoracoscopic video-assisted thoracic surgery (VATS) lobectomy remain unknown. To address this knowledge gap, this study investigated the institutional performance curve for VATS lobectomy by using risk-adjusted cumulative sum (Cusum) analysis. Methods Using The Society of Thoracic Surgeons General Thoracic Surgery Database, the study investigators identified centers that had performed a total of 30 or more VATS lobectomies. Major morbidity, mortality, and blood transfusion were deemed primary outcomes, with expected incidence derived from risk-adjusted regression models. Acceptable and unacceptable failure rates for outcomes were set a priori according to clinical relevance and informed by regression model output. Results Between 2001 and 2016, 24,196 patients underwent VATS lobectomy at 159 centers with a median volume of 103 (range, 30 to 760). Overall rates of operative mortality, major morbidity, and transfusion were 1% (244 of 24,189), 17.1% (4,145 of 24,196), and 4% (975 of 24,196), respectively. Of the highest-volume centers (≥100 cases), 84% (65 of 77) and 82 % (63 of 77) (p = 0.48) were proficient by major morbidity standards by their 50th and 100th cases, respectively. Similarly, 92% (71 of 77) and 90% (69 of 77) (p = 0.41) of centers showed proficiency by transfusion standards by their 50th and 100th cases, respectively. Three performance patterns were observed: (1) initial and sustained proficiency, (2) crossing unacceptability thresholds with subsequent improved performance; and (3) crossing unacceptability thresholds without subsequent improved performance. Conclusions VATS lobectomy outcomes have improved with lower mortality and transfusion rates. The majority of high-volume centers demonstrated proficiency after 50 cases; however, maintenance of proficiency is not ensured. Cusum provides a simple yet powerful tool that can trigger internal audits and performance improvement initiatives.

The purpose of this study was to quantify the cost impact of complications of esophagectomy and identify opportunities for reducing costs while optimizing outcomes. Patients undergoing esophagectomy at a single institution between 2002 and 2017 were included. Complications were tabulated from clinical data. Direct hospital costs were determined for all encounters between the day of surgery and postoperative day 90. Risk factors were assessed using logistic regression. The relative incremental cost of complications was assessed using multivariable linear regression. A total of 761 patients were included in this study. 428 patients (56%) experienced at least 1 complication. Factors associated with increased likelihood of complications included age (P0.001), female sex (P = 0.005), pack-years (P = 0.006), cerebrovascular disease (P = 0.021), and diabetes (P = 0.052). The most common complications were atrial arrhythmia (18%), transfusion (15%), and atelectasis requiring bronchoscopy (8%). The complications incurring the greatest incremental cost per event were anastomotic complications requiring surgical treatment (200%, P0.001) or those treated nonoperatively (96%, P0.001), and renal failure (178%, P0.001). Pneumonia increased costs by 40% (P0.001) and other major pulmonary complications increased costs by 75% (P0.001). Though the cost of complications was unaffected by surgical approach (minimally invasive esophagectomy vs open), MIE was associated with decreased cost vis-à-vis a lower complication rate (41% vs 60%, P0.001). Complications accounted for 28% of the aggregate 90-day direct hospital cost for all patients. Pulmonary complications accounted for 35% of all complication-attributable costs, while anastomotic complications accounted for 17%. Anastomotic and pulmonary complications after esophagectomy with gastric conduit reconstruction represent high-yield targets for cost reduction and quality improvement.

Background Post-esophagectomy tracheo-bronchial-esophageal fistula (PETEF) most often develops after anastomotic disruption or gastric conduit necrosis. Ideal surgical management and outcomes for this complication are uncertain. Methods A retrospective review of 11 patients undergoing surgical repair of PETEF was performed. Results The median time between esophagectomy and surgical repair of PETEF was 61 days (range, 7 days to 28 years). Anastomotic leak or gastric conduit necrosis was responsible for PETEF in 6 patients (54.5%), whereas other causes were erosion of a tracheal appliance (n = 2), gastric conduit staple line erosion (n = 1), anastomotic stricture dilation (n = 1), and recurrent esophageal cancer (n = 1). Membranous airway defects were repaired primarily and buttressed with muscle or omental flaps in 8 patients (72.7%), whereas two (18.2%) were repaired with bio-prosthetic patches and one (9.1%) was repaired with a sleeve resection of the bronchus. Anastomotic and neo-esophageal conduit defects were repaired primarily in 3 patients (27.3%), whereas 7 patients (63.6%) underwent conduit take-down and esophageal or pharyngeal diversion, and 1 patient (9.1%) underwent simultaneous fistula repair and colon interposition. Two patients (18.2%) had recurrent fistulas, with 1 patient dying after second fistula closure and the other was discharged with no further attempt at repair. Three patients (27.3%) died postoperatively. Only 3 patients (27.3%) resumed an oral diet after fistula repair. Conclusions Surgical treatment is effective for most patients undergoing operative repair of PETEF, notwithstanding a considerable risk of postoperative morbidity and death. Although fistula repair is life saving and prevents further respiratory deterioration, return to oral alimentation is not ensured.

The Society of Thoracic Surgeons (STS) National Database was established in 1989 as an initiative for quality improvement and patient safety among cardiothoracic surgeons. As of January 1, 2018, the STS National Database has four components, each focusing on a different area of cardiothoracic surgery-adult cardiac surgery, general thoracic surgery, and congenital heart surgery, as well as mechanical circulatory support through the STS Intermacs Database. In December 2015, The Annals of Thoracic Surgery began publishing a monthly series of scholarly articles on outcomes analysis, quality improvement, and patient safety. As part of that series, this article provides an annual summary of the status of the STS National Database as of October 2018 and provides a synopsis of related articles that appeared in The Annals of Thoracic Surgery 2018 series entitled: "Outcomes Analysis, Quality Improvement, and Patient Safety".

OBJECTIVES Gastric emptying delay after oesophagectomy may occur in conduits exposed to pleural forces of respiration or anatomic obstruction. Remedial operations addressing both causes are rarely reported. The study aim was to categorize severe gastric conduit obstruction (GCO) and report the outcome of surgical revision. METHODS A single-institution, retrospective study of gastric conduit revision following oesophagectomy for oesophageal cancer investigated incidence, risk factors and categories of conduit obstruction. Evaluation consisted of contrast studies, computed tomogram and endoscopy. Interventions were categorized according to obstructive cause and included pyloroplasty, hiatal hernia reduction and thoraco-abdominal conduit repositioning. RESULTS Among 1246 oesophagectomies over a 17-year period, 14 patients (1.1%) required post-oesophagectomy relief of GCO. Two additional patients presented after oesophagectomy elsewhere. Before oesophagectomy, 18.8% (3/16) and 62.5% (10/16) of patients were on chronic opioid and psychotropic medications, respectively. Distinct anatomic features separated obstruction into 3 categories: pyloric in 31% (5/16), extrinsic in 12.5% (2/16) and combined in 56.3% (9/16). Operative revision led to complete symptom resolution in 50% (8/16) of patients and symptom improvement in 43.8% (7/16) of patients. One patient (1/16, 6.25%) in the combined obstruction group did not improve with surgical revision. CONCLUSIONS GCO after oesophagectomy rarely requires surgical revision. Potential association with medications affecting oesophageal and gastric motility requires further investigation. Classification of obstruction identifies a patient subset with lower success after surgical revision.

Summary Background Esophageal perforation is a morbid condition and remains a therapeutic challenge. We report the outcomes of a large institutional experience with esophageal perforation and identify risk factors for morbidity and mortality. Methods A retrospective analysis was conducted on 142 patients who presented with a thoracic or gastroesophageal junction esophageal perforation from 1995 to 2020. Baseline characteristics, operative or interventional strategies, and outcomes were analyzed by etiology of the perforation and management approach. Multivariable cox and logistic regression models were constructed to identify predictors of mortality and morbidity. Results Overall, 109 (77%) patients underwent operative intervention, including 80 primary reinforced repairs and 21 esophagectomies and 33 (23%) underwent esophageal stenting. Stenting was more common in iatrogenic (27%) and malignant (64%) perforations. Patients who presented with a postemetic or iatrogenic perforation had similar 90-day mortality (16% and 16%) and composite morbidity (51% and 45%), whereas patients who presented with a malignant perforation had a 45% 90-day mortality and 45% composite morbidity. Risk factors for mortality included age >65 years (hazard ratio [HR] 1.89 [1.02–3.26], P = 0.044) and a malignant perforation (HR 4.80 [1.31–17.48], P = 0.017). Risk factors for composite morbidity included pleural contamination (odds ratio [OR] 2.06 [1.39–4.43], P = 0.046) and sepsis (OR 3.26 [1.44–7.36], P = 0.005). Of the 33 patients who underwent stent placement, 67% were successfully managed with stenting alone and 30% required stent repositioning. Conclusions Risk factors for morbidity and mortality after esophageal perforation include advanced age, pleural contamination, septic physiology, and malignant perforation. Primary reinforced repair remains a reasonable strategy for patients with an esophageal perforation from a benign etiology.

Approximately 10% to 15% of patients with solitary fibrous tumors of the pleura (SFTP) have recurrence after resection. Many are not candidates for reresection and lack effective treatments. We explored the expression of programmed death ligand 1 (PD-L1) as a biomarker for candidacy for treatment with immune checkpoint inhibitors.We reviewed the medical records of 52 patients with primary SFTP and 5 with recurrent SFTP. We performed immunohistochemistry on tumor tissue to determine the expression of PD-L1 and infiltration by cluster of differentiation 8 (CD8)-positive immune cells.Any PD-L1 expression was observed in 11 primary SFTP (21.2%). Overall, PD-L1 expression level was less than 1% in 10 patients (19.2%) and greater than 1% in 1 (1.9%). Tumor infiltration by CD8-positive immune cells was absent or rare in 13 patients (25%), less than 5% in 31 (59.6%), and 5% to 25% in 8 (15.4%). There were no associations between PD-L1 expression or immune cell infiltrates and known risk factors for recurrence or a prognostic risk score classification. Time to recurrence was strongly associated with the risk score classification (P.001), but it was not associated with PD-L1 expression (P = .296) or immune cell infiltrates (P = .619). In recurrent SFTP, PD-L1 was expressed in 4 of 10 tumors (40%; all1% expression). There was no correlation in PD-L1 expression between primary and recurrent SFTP samples.A small subset of SFTP express PD-L1 at low levels (1%) but exhibit colocalization of CD8-positive immune cells suggesting an inducible expression mechanism. The role of PD-L1 merits exploration in the clinical setting in patients with advanced SFTP when alternative treatments or clinical trials are considered.

Background Simulation-based training is a valuable component of cardiothoracic surgical education. Effective curriculum development requires consensus on procedural components and focused attention on specific learning objectives. Through use of a Delphi process, we established consensus on the steps of video-assisted thoracoscopic surgery (VATS) left upper lobectomy and identified targets for simulation. Methods Experienced thoracic surgeons were randomly selected for participation. Surgeons voted and commented on the necessity of individual steps comprising VATS left upper lobectomy. Steps with greater than 80% of participants in agreement of their necessity were determined to have established "consensus." Participants voted on the physical or cognitive complexity of each, or both, and chose steps most amenable to focused simulation. Results Thirty thoracic surgeons responded and joined in the voting process. Twenty operative steps were identified, with surgeons reaching consensus on the necessity of 19. Components deemed most difficult and amenable to simulation included those related to dissection and division of the bronchus, artery, and vein. Conclusions Through a Delphi process, surgeons with a variety of practice patterns can achieve consensus on the operative steps of left upper lobectomy and agreement on those most appropriate for simulation. This information can be implemented in the development of targeted simulation for VATS lobectomy.

Background Assessment of risk associated with lung cancer resection is primarily based on evaluation of cardiopulmonary function and remains imprecise. We investigated the relationship between thoracic muscle and early outcomes after lobectomy. Methods Cross-sectional area of skeletal muscle was measured at the level of the fifth thoracic vertebra on computed tomography in 135 consecutive patients before lobectomy for lung cancer. Patients were stratified into low and high muscle groups using the sex-specific muscle median. Primary outcome was a composite of any postoperative complication as per The Society of Thoracic Surgeons General Thoracic Surgical Database. Secondary outcomes included postoperative respiratory complications, postoperative intensive care unit admission, hospital length of stay, and hospital readmission within 30 days of hospital discharge. The χ2 test, adjusted multivariable regression analysis, and likelihood ratio test were performed. Results Patients with low muscle were significantly more likely to have any postoperative complication and respiratory postoperative complications. Although postoperative intensive care unit admission was similar for low muscle and high muscle groups, low muscle patients had longer hospital length of stay and a higher rate of hospital readmission. Adjusted multivariable regression revealed the independent association of thoracic muscle with all outcomes. The likelihood ratio test suggested that thoracic muscle adds predictive capability to information captured by preoperative pulmonary function testing. Conclusions Low thoracic muscle is independently associated with increased postoperative complications and health care utilization among patients undergoing lobectomy for lung cancer. Evaluation of thoracic muscle may enhance risk prediction models.

For nearly 15 years The Society of Thoracic Surgeons General Thoracic Surgery Database (STS GTSD) has provided participating institutions with risk-adjusted feedback reports that allow outcome comparisons relative to national benchmarks. With more than 300 contributing centers across North America, the STS GTSD now includes more than 530,000 cases. In 2017 the STS GTSD Task Force revised the data collection form with the goal of collecting more detailed and accurate information for the most important thoracic surgical cases without increasing the workload of registrars. In addition, the learning curve for thoracoscopic lobectomy was examined, online public reporting was initiated, institutional feedback reports were made more user-friendly, and collaboration with the European Society of Thoracic Surgery continued. The STS GTSD Task Force continues to work to improve the quality of care and support research initiatives in general thoracic surgery. This report summarizes current aggregate national outcomes in general thoracic surgery and reviews related activities in the areas of quality measurement, performance improvement, and transparency from the STS GTSD during the past 12 months.

Malignant airway tumors present particular challenges for surgeons, namely: to distinguish symptoms from those of the more frequent benign airway diseases; to separate metastatic disease from the uncommon primary tumors; and to consider curative resection in appropriate candidates. Here, we present a critical review of tracheal malignant obstruction, focusing on the evaluation of a patient with malignant airway tumor, patient selection for resection and the predictors of long-term survival. The new development in primary tracheal tumors is an old story, that of making physicians aware that resection rates in epidemiologic studies remain low, mainly because opportunities for resection are missed.

The outcomes research efforts based on The Society of Thoracic Surgeons (STS) General Thoracic Surgery Database include two established research programs with dedicated task forces and with data analyses conducted at the STS data analytic center: (1) The STS-sponsored research by the Access and Publications program, and (2) grant and institutionally funded research by the Longitudinal Follow-Up and Linked Registries Task Force. Also, the STS recently introduced the research program enabling investigative teams to apply for access to deidentified patient-level General Thoracic Surgery Database data sets and conduct related analyses at their own institution. Last year's General Thoracic Surgery Database-based research publications and the new Participant User File research program are reviewed.

Background Epiphrenic esophageal diverticula are infrequent. Although surgical treatment is generally recommended, technique varies widely and optimal management remains controversial. This study evaluated a single-institution experience for surgical treatment of epiphrenic diverticula. Methods A retrospective review was made of medical records of 31 patients undergoing surgical treatment for epiphrenic diverticula from 1974 to 2016. Results There were 17 men (55%); median age was 65 years. Dysphagia (87%) and regurgitation (71%) were the most common symptoms. Three patients (10%) presented acutely: 2 with ruptured diverticula and 1 with hematemesis. All patients underwent an open transthoracic approach. Diverticulectomy was performed in 28 patients (90%), myotomy in 28 (90%), and a concomitant antireflux procedure in 6 (19%). A total of 22 patients (71%) underwent diverticulectomy and myotomy, 4 (13%) underwent diverticulectomy with myotomy and antireflux procedure, 2 (6%) had myotomy and antireflux, 2 had diverticulectomy alone, and 1 patient had imbrication of the diverticulum after myotomy. Overall, morbidity occurred in 11 patients (35.5%), with major morbidity in 6 (19.4%). There was one postoperative esophageal leak (3%). Ninety-day mortality was zero. Mean follow-up was 30 ± 43 months in 28 patients. Additional procedures (ie, reoperation, balloon dilation) were needed in 7 patients (25%). An excellent outcome (ie, absence of symptoms) was accomplished in 21 patients (75%). Acute presentation was associated with need for further procedures ( p = 0.011) and symptoms at follow-up ( p = 0.011). Conclusions A tailored transthoracic approach to the surgical management of epiphrenic diverticula can provide excellent results. The need for a concomitant antireflux procedure remains controversial and may not be routinely necessary. Acute presentation is associated with poor functional outcome.

Background Surgical lung biopsy contributes to establishing a specific diagnosis among many patients with interstitial lung disease (ILD). The risks of death and respiratory failure associated with elective thoracoscopic surgical lung biopsy, and patient characteristics associated with these outcomes, are not well understood. Methods This is a retrospective cohort study of patients who underwent elective thoracoscopic lung biopsy for ILD between 2008 and 2014, according to The Society of Thoracic Surgeons database. The study determined the incidence of operative mortality and of postoperative respiratory failure. Multivariable models were used to identify risk factors for these adverse outcomes. Results Among 3,085 patients, 46 (1.5%) died before hospital discharge or within 30 days of thoracoscopic lung biopsy. Postoperative respiratory failure occurred in 90 (2.9%) patients. Significant risk factors for operative mortality among patients with ILD included a diagnosis of pulmonary hypertension, preoperative corticosteroid treatment, and low diffusion capacity. Conclusions Elective thoracoscopic lung biopsy among patients with ILD is associated with a low risk of operative mortality and postoperative respiratory failure. Attention to the presence of pulmonary hypertension, preoperative corticosteroid treatment, and diffusion capacity may help inform risk stratification for thoracoscopic lung biopsy among patients with ILD.

The art and science of outcomes analysis, quality improvement, and patient safety continue to evolve, and cardiothoracic surgery leads many of these advances. The Society of Thoracic Surgeons (STS) National Database is one of the principal reasons for this leadership role, as it provides a platform for the generation of knowledge in all of these domains. Understanding these topics is a professional responsibility of all cardiothoracic surgeons. Therefore, beginning in January 2016, The Annals of Thoracic Surgery began publishing a monthly series of scholarly articles on outcomes analysis, quality improvement, and patient safety. This article provides a summary of the status of the STS National Database as of October 2016 and summarizes the articles about the STS National Database that appeared in The Annals of Thoracic Surgery 2016 series, "Outcomes Analysis, Quality Improvement, and Patient Safety."

OBJECTIVESPost-lobectomy bleeding is uncommon and rarely studied. In this study, we aimed to determine the incidence of post-lobectomy haemorrhage and compare the outcomes of reoperation and non-operative management.METHODSWe conducted a single-institution review of lobectomy cases from 2009 to 2018. The patients were divided into two groups based on the treatment for postoperative bleeding: reoperation or transfusion of packed red blood cells with observation. Transfusion correcting intraoperative blood loss was excluded. One or more criteria defined postoperative bleeding: (i) drop in haematocrit ≥10 or (ii) frank, sustained chest tube bleeding with or without associated hypotension. Covariates included demographics, comorbidities and operative characteristics. Outcomes were operative mortality, complications, length of hospital stay and readmission within 30 days.RESULTSFollowing 1960 lobectomies (92% malignant disease, 8% non-malignant), haemorrhage occurred in 42 cases (2.1%), leading to reoperation in 27 (1.4%), and non-operative management in 15 (0.8%). The median time to reoperation was 17 h. No source of bleeding was identified in 44% of re-explorations. Patients with postoperative haemorrhage were more often male (64.3% vs 41.2%; P CONCLUSIONSHaemorrhage after lobectomy is associated with multiple risk factors. Reoperation may avoid transfusion. A prospective study should optimize timing and selection of operative and non-operative management.

Background Sarcopenia represented by low psoas muscle area is associated with increased hospital length of stay (LOS), postoperative complications, and mortality. We studied whether thoracic skeletal muscle area (TSMA) derived from computed tomography (CT) predicts morbidity after pneumonectomy for lung cancer. Methods Consecutive patients who underwent pneumonectomy for lung cancer from 2005 to 2017 were retrospectively analyzed. TSMA was defined as the sum of muscle area at the level of the eighth and the 12th thoracic vertebral bodies on preoperative CT. Patients were stratified into sex-specific TSMA quartiles for univariate time-to-event analyses. The effect of continuous TSMA measurements on operative complications, hospital and intensive care unit (ICU) LOS, discharge disposition, and hospital readmission within 90 days was estimated using multivariable models adjusted for age, sex, body mass index, forced expiratory volume in 1 second, Zubrod score, and pneumonectomy type. Results Standard (n = 102, 78.5%) or high-risk (n = 28, 21.5%; extrapleural: n = 3, 2.3%; carinal: n = 9, 6.9%; completion: n = 16, 12.3%) pneumonectomy was performed in 130 patients (60.8 ± 10.6 years; 43.1% women). Major complications occurred in 33.1% (n = 43 of 130) and readmission in 17.7% (n = 23 of 130) of patients. In multivariable models, patients with high TSMA experienced fewer overall (odds ratio [OR], 0.87; P = .04) and cardiopulmonary (OR, 0.86; P = .04) complications, and fewer readmissions (OR, 0.78; P = .01). Associations with ICU LOS (hazard ratio, 1.08; P = .051) and hospital LOS (hazard ratio, 1.05; P = .18) did not reach significance. Conclusions TSMA predicts adverse outcome after pneumonectomy for lung cancer. This marker, readily derived from standard chest CT, identifies patients at increased risk for postoperative complications and may help select patients appropriate for focused rehabilitation before pneumonectomy.

The Society of Thoracic Surgeons General Thoracic Surgery Database (STS GTSD) remains the most robust thoracic surgical database in the world, providing participating institutions semiannual risk-adjusted performance reports and facilitating multiple quality improvement initiatives each year. In 2018, the STS GTSD Data Collection Form was substantially revised to acquire the most important variables with the least data manager burden. In addition, a composite quality measure for all pulmonary resections for cancer was developed, and the impact that minimally invasive approaches have on the model was assessed. The 2018 database audit found that the accuracy of the database remains high, ranging from 92.5% to 98.4%. In 2019, the STS GTSD Task Force plans to focus on increasing generalizability of the database, initiating esophagectomy outcome public reporting, and creating customizable real-time dashboards. This review summarizes all national aggregate outcome, quality measurement, and improvement initiatives from the STS GTSD over the past 12 months.

Background To evaluate the management, complications of treatment, and outcomes of postintubation tracheal stenosis. Methods A retrospective review was performed of records from a prospective database of all patients undergoing tracheal or laryngotracheal resection from 1993 to 2017 for postintubation tracheal stenosis. Redo operations after failure of initial resection and reconstruction for postintubation tracheal stenosis were included. Results There were 392 patients whose ages ranged from 3 months to more than 84 years. A tracheostomy was performed in 275 as part of their care before surgery (present at time of resection in 123), dilations in 201, laser treatment in 82, T tubes in 66, and stents in 44 patients. Median length of resection was 3 cm. Laryngeal release was required in 15 of 392 (3.8%). Operative mortality was 0.8% (3 of 392); T tubes, tracheostomy present at resection, requirement for postoperative tracheostomy, and laryngeal involvement adversely impacted outcomes. Patients having tracheal resection and reconstruction had good or satisfactory outcomes in 96% (289 of 301) compared with 85% (77 of 91) having laryngotracheal resection. Complications within 30 days and at more than 30 days occurred in 116 patients and 14 patients, respectively. There were 96 anastomotic complications—68% minor (65 of 96), and 32% major (31 of 96). Necrosis of cartilage occurred in 12 patients and dehiscence in 14 patients. Conclusions Despite advances in care postintubation tracheal stenosis remains a challenging problem. Laryngotracheal resection and tracheostomy lead to worse outcomes. Excellent surgical results can be obtained for postintubation tracheal stenosis. Good results require careful evaluation, management of comorbid conditions, meticulous technique, minimizing tension, and preservation of blood supply.

The perioperative management of diaphragmatic weakness and phrenic nerve dysfunction is complex, due to varied etiologies and clinical presentations. The factors leading to diaphragmatic weakness may culminate after the operation with transient or persistent respiratory failure. This review discusses diaphragmatic disorders and postoperative respiratory failure caused by unilateral or bilateral diaphragmatic impairment. The origins of neuromuscular weakness involving the diaphragm are diverse, and often lie within the domains of different medical specialties, with only a portion of the condition related to surgical intervention. Consideration of underlying etiologies for any individual patient requires thorough multidisciplinary review. The most important clinical scenarios compounding diaphragmatic weakness, including acute myasthenic states, persistent neuromuscular blockade, and surgical injury to the phrenic nerve or diaphragm, are accessible to attentive surgeons. Awareness of the signs and symptoms of undiagnosed weakness, preoperative pursuit of its diagnosis, knowledge of surgical alternatives to phrenic nerve resection, and cooperative skills in the multidisciplinary management of myasthenia all are crucial to improve patient outcomes.

The Society of Thoracic Surgeons General Thoracic Surgery Database has grown to more than 500,000 case records. Clinical research supported by the database is increasingly used to advance patient outcomes. This research review from the General Thoracic Surgery Database in 2014 and 2015 discusses 6 recent publications and an ongoing study on longitudinal outcomes in lung cancer surgery from The Society of Thoracic Surgeons Task Force for Linked Registries and Longitudinal Follow-up. A lack of database variables specific for certain uncommon procedures limits the ability to study these operations; inclusion of clinical descriptors for selected infrequent but clinically important thoracic disorders is suggested.

Open esophagectomy results in significant morbidity and mortality. Minimally invasive esophagectomy (MIE) has become increasingly popular at specialized centers with the aim of improving perioperative outcomes. Numerous single-institution studies suggest MIE may offer lower short-term morbidity. The two approaches are compared using a large, multiinstitutional database.The Society of Thoracic Surgeons (STS) National Database (v2.081) was queried for all resections performed for esophageal cancer between 2008 and 2011 (n = 3,780). Minimally invasive approaches included both transhiatal (n = 214) and Ivor Lewis (n = 600), and these were compared directly with open transhiatal (n = 1,065) and Ivor Lewis (n = 1,291) procedures, respectively. Thirty-day outcomes were examined using nonparametric statistical testing.Both open and MIE groups were similar in terms of preoperative risk factors. Morbidity and all-cause mortality were equivalent at 62.2% and 3.8%. MIE was associated with longer median procedure times (443.0 versus 312.0 minutes; p0.001), but a shorter median length of hospital stay (9.0 versus 10.0 days; p0.001). Patients who underwent MIE had higher rates of reoperation (9.9% versus 4.4%; p0.001) and empyema (4.1% versus 1.8%; p0.001). Open technique led to an increased rate of wound infections (6.3% versus 2.3%; p0.001), postoperative transfusion (18.7% versus 14.1%; p = 0.002), and ileus (4.5% versus 2.2%; p = 0.002). Propensity score-matched analysis confirmed these findings. High- and low-volume centers had similar outcomes.Early results from the STS National Database indicate that MIE is safe, with comparable rates of morbidity and mortality as open technique. Longer procedure times and a higher rate of reoperation following MIE may reflect a learning curve.

Neoadjuvant therapy is integral in the treatment of locally advanced esophageal cancer. Despite increasing acceptance of minimally invasive approaches to esophagectomy, there remain concerns about the safety and oncologic soundness after neoadjuvant therapy. We examined outcomes in patients undergoing open and minimally invasive (MIE) Ivor Lewis esophagectomy after neoadjuvant therapy.This was a retrospective series of 130 consecutive patients with esophageal cancer undergoing Ivor Lewis esophagectomy with curative intention after neoadjuvant therapy at a tertiary academic center (2008 to 2012).An open procedure was performed in 74 patients (56.9%), and 56 (43.1%) underwent MIE after neoadjuvant therapy. MIE patients had shorter median intensive care unit (p = 0.002) and hospital lengths of stay (p0.0001). The incidence of postoperative complications was similar (open: 54.8% vs MIE: 41.1%, p = 0.155). However, observed respiratory complications were significantly reduced after MIE (8.9%) compared with open (29.7%; p = 0.004). Anastomotic leak rates were similar (open: 1.4% vs. MIE: 0%, p = 1.00). Mortality at 30 and 90 days was comparable (open: 2.7% and 4.1% vs MIE: 0% and 1.8%, p = 0.506 and p = 0.634, respectively). Complete resection rates and the number of collected lymph nodes was similar. Overall survival rates at 5 years were similar (open: 61% vs MIE: 50%, p = 0.933). MIE was not a significant predictor of overall survival (hazard ratio, 1.07; 95% confidence interval, 0.61 to 1.87; p = 0.810).MIE proves its safety after neoadjuvant therapy because it leads to faster progression during the early postoperative period while reducing pulmonary complications. Open and MIE approaches appear equivalent with regards to perioperative oncologic outcomes after neoadjuvant therapy. Long-term outcomes need further validation.

The Society of Thoracic Surgeons (STS) National Database is the foundation for most of the Society's quality, research, and patient safety activities. Beginning in January 2016 and repeating each year, The Annals of Thoracic Surgery will publish a monthly Database series of scholarly articles on outcomes analysis, quality improvement, and patient safety. Six articles will be directly derived from the STS National Database and will be published every other month: three articles on outcomes and quality (one each from the STS Adult Cardiac Surgery Database, the STS Congenital Heart Surgery Database, and the STS General Thoracic Surgery Database), and three articles on research (one from each of these three specialty databases). These six articles will alternate with five additional articles on topics related to patient safety. The final article, to be published in December, will provide a summary of the prior 11 manuscripts. This series will allow STS and its Workforces on National Databases, Research Development, and Patient Safety to convey timely information aimed at improving the quality and safety of cardiothoracic surgery.

Objective Pulmonary nodules found incidentally or by lung cancer screening differ in prevalence, risk profile, and diagnostic intervention. The results of surgical intervention for incidental versus screening lung nodules during multidisciplinary Pulmonary Nodule and Lung Cancer Screening Clinic (PNLCSC) follow-up have not been reported. Methods All patients evaluated at a PNLCSC from 2012 to 2018 following referral by primary care physicians, specialist physicians, or self-referral after computed tomography (CT) identified nodules on routine diagnostic CT (incidental group) or lung cancer screening CT (screening group) were included. Follow-up interval, invasive intervention, histology, postoperative events, survival, and recurrence were compared. Results Of 747 patients evaluated in the PNLCSC, 129 (17.2%) underwent surgical intervention. The surgical cohort consisted of 104 (80.6%) incidental and 25 (19.3%) screening patients followed over a mean of 122 and 70 days, respectively. More benign lesions were excised in the incidental group (20.2%, 21/104)—representing 3.3% (21/632) of all incidental nodules evaluated—than in the screening group (4%, 1/25) (P = .038). Operative mortality was zero. Among 99 patients with primary lung cancer, 87% (screening) and 86.8% (incidental) were pathologic stage Ia. Complete follow-up was available in 725 of 747 (97%), and no patient developed progressive disease. Disease-free survival at 5 years was 74.9% (incidental) and 89.3% (screening) (P = .48). Conclusions A unique multidisciplinary PNLCSC for incidental and lung cancer screening–detected nodules with individualized risk assessment reliably identifies primary and metastatic tumors while exposing few patients to diagnostic excision for benign disease. Longer-term outcomes, strategies to limit radiation exposure, and cost control need further study.

Objectives To assess the prognostic role of thoracic muscle as quantified on preoperative computed tomography (CT) for the estimation of overall survival (OS) following pneumonectomy. Methods Muscle cross-sectional area (CSA) at the level of the fifth (T5) and eighth (T8) thoracic vertebra was measured on CT scans of consecutive patients with lung cancer prior to pneumonectomy. We stratified patients into high and low muscle groups using the gender-specific median of muscle CSA as separator and estimated associations of muscle CSA and OS using the Kaplan-Meier analysis. Multivariable logistic regression adjusted for body mass index, Charlson comorbidity index (includes age), forced expiratory volume in the first second as a % of predicted, sex, race, smoking status, tumour stage and prior lung cancer treatment was performed. Results A total of 128 patients were included (61.0 ± 10.6 years of age, mean body mass index of 26.9 kg/m2, 55.5% men). The T8 level showed fewer artefacts and strong correlation with the T5 level (Pearson's rho = 0.904). T8 CSA was therefore used for subsequent analyses. Mean T8 CSA was 118.5 cm2 (median 115.3 cm2) in men and 75.2 cm2 (median 74.0 cm2) in women. During a median follow-up of 23.6 months (interquartile range 39.3), 65 patients (50.8%) died, of whom 41 were in the low muscle group. The Kaplan-Meier analysis showed significantly longer OS in the high muscle group (log-rank P = 0.02). Multivariable analysis showed an independent association of muscle CSA and OS (P = 0.02) with a hazard ratio of 0.80 (confidence interval 0.67-0.98) per 10-cm2 increment. Conclusions Thoracic muscle is independently associated with long-term overall survival following pneumonectomy for lung cancer and may contribute to refined survival estimates in this population. Irb protocol Protocol #2017P000650, approved 21 April 2017.

Background: Secondary tracheal tumors arise from mural invasion by primary tumors in adjacent organs, metastatic lymph nodes or blood-born metastasis from distant sites. This systematic review aims to assess the presentation, management options, and clinical outcomes of these uncommon non-tracheal malignancies. Methods: Electronic searches of the MEDLINE database were performed to identify case series and individual case reports of tracheal invasion by primary non-tracheal tumors or metastatic disease. All English-language studies with available abstracts or articles containing primary data were included. Results: From 1978 to 2017, a total of 160 case reports or case series identified 2,242 patients with invasion of the trachea by tumors of adjacent organs (n=1,853) or by metastatic lymph nodes or hematogenous spread (n=389). Common primary sites of origin were thyroid, esophagus, and lung, and the most common presentation was metachronous (range of interval: 0 to 564 months) with dyspnea, neck mass, voice change and/or hemoptysis. A majority of patients in case reports (77.9%) and case series (66.0%) underwent resection and the most common reported operation was segmental tracheal resection. Fewer patients underwent bronchoscopic intervention (21.7%) and radiation was used in 32.2% of patients. Complications after bronchoscopic treatment included bleeding, granulation tissue, and retained secretions, while anastomotic leak, unplanned tracheostomy, and new recurrent laryngeal nerve paralysis were observed after surgical resection. The rate of 30-day mortality was low (0.01–1.80%). Median survival was higher in patients with thyroid malignancy and in patients who underwent surgical management. Follow-up time ranged from 0.03 to 183 months. Conclusions: Patients with tracheal invasion by metastatic or primary non-tracheal malignancies should be assessed for symptoms, tumor grade, tumor recurrence and concurrent metastases to decide on optimal surgical, bronchoscopic or noninterventional therapy. Clinical experience suggests that palliative endoscopic intervention for tracheal obstruction by metastasis-bearing lymph nodes is underreported.

The objective of this study was to evaluate the influence of total number of resected lymph nodes, lymph node ratio, and the number of lymph node stations sampled on prognosis in patients with early stage non-small cell lung cancer (NSCLC) treated with video-assisted thoracoscopic surgery (VATS).Five hundred and fifty patients who underwent VATS lobectomy or segmentectomy for early clinical stage NSCLC were retrospectively analyzed from 2006 to 2012. Disease-free survival (DFS) and overall survival (OS) were compared for cutoff values of total number of resected lymph nodes (RNs) and lymph node stations (LNS) using Kaplan-Meier methods and Cox proportional hazard models.Lobectomy was performed in 493 (90%) patients with a median follow-up of 2.7 years. Median age was 68 (range, 29 to 92 years) and 342 (62%) were female. Pathologic stage I, II, and III was observed in 434 (79%), 80 (14.5%) and 36 (6.5%) patients, respectively. The N0, N1, and N2 pathologic nodal status was observed in 485 (88%), 38 (7%), and 27 (5%) patients, respectively. Nodal upstaging was observed in 11.3% (59 of 550) in the total cohort and 15% (49 of 332) in patients who underwent LNS greater than 3 compared with 5% (10 of 218) in patients with LNS 3 or less (p0.01). Multivariate analysis identified LNS greater than 3 as a negative independent predictor for DFS (hazard ratio 2.36, p = 0.003) and OS (hazard ratio 1.77, p = 0.046).Sampling greater than 3 LNS and greater than 10 RNs was associated with an increase in nodal upstaging. Only LNS greater than 3 was found to be an independent predictor of mortality in VATS lobectomy and segmentectomy in clinical early-stage NSCLC.

The Society of Thoracic Surgeons (STS) National Database has three major component databases: the STS Adult Cardiac Surgery Database (ACSD), the STS Congenital Heart Surgery Database (CHSD), and the STS General Thoracic Surgery Database (GTSD). Beginning in January 2016, The Annals of Thoracic Surgery began publishing a monthly series of scholarly articles on outcomes analysis, quality improvement, and patient safety. This article summarizes the status of the STS National Database as of October 2017 and summarizes the articles about the STS National Database that appeared in The Annals of Thoracic Surgery 2017 series "Outcomes Analysis, Quality Improvement, and Patient Safety."

Background Resection of posterior mediastinal tumors may be complicated by bleeding or neurologic injury. Preoperative spinal angiography of mediastinal tumors has been underreported or not commonly practiced. This study evaluated the selection criteria and outcomes of patients with posterior mediastinal tumors who underwent preoperative angiography and embolization. Methods This was a single-institution retrospective study of patients with posterior mediastinal tumors from 2002 to 2016. Multilevel spinal angiography was performed, with or without selective arterial embolization of vascular supply, in patients selected by thoracic or neurologic surgeons. Results Ten of 87 patients (11%) with posterior mediastinal tumors underwent preoperative angiography. A mean of 11 arteries (range, 2 to 25) were studied. Embolization in 7 of 10 patients successfully occluded 1 to 3 arteries. There was no significant difference in age, sex, body mass index, American Society of Anesthesiologists Physical Status Classification, operative time, operative blood loss, complications, or death between patients with or without angiography. Patients who underwent angiography had larger tumors (1,490 vs 97 cm3, p Conclusions Selective preoperative angiography for evaluation of posterior mediastinal tumors identifies arterial variations, threatened spinal arteries, and targets for embolization. The specific role of angiography and embolization requires further investigation to standardize indications and protocols for the number of arteries examined.

The Society of Thoracic Surgeons General Thoracic Surgery Database (STS GTSD) is a voluntary effort that provides participants with risk-adjusted semiannual performance reports that allow comparison of institutional outcomes against national benchmarks. With nearly 1,000 surgeons contributing data from more than 300 centers across North America, the STS GTSD now includes almost a half million cases. In 2016, updated risk models for lung resection and esophagectomy for cancer were reported, and composite quality measures for lobectomy and esophagectomy were developed. Ongoing efforts include upgrading the STS GTSD, establishing public reporting of lobectomy for lung cancer composite scores, creating an on-line dashboard, and strengthening international collaboration with the European Society of Thoracic Surgery Registry. With these initiatives, the STS GTSD aims to continue to improve quality of care and support research endeavors in general thoracic surgery. This article summarizes current aggregate national outcomes in general thoracic surgery and reviews related activities in the areas of quality measurement, performance improvement, and transparency from the STS GTSD during the past 12 months.

Background Pulmonary aspergilloma is resected to control life-threatening complications such as massive hemoptysis. The role of prophylactic resection in asymptomatic patients is unclear. Methods A retrospective review was conducted of 60 patients treated at a tertiary center from 1980 to 2010. Results The mean age in 34 (56.7%) men and 26 (43.3%) women was 51 years. Immunosuppression, most commonly from chronic steroid use, was present in 17 (28.3%) patients, and preexisting lung disease was present in 47 (78.3%) patients. Hemoptysis occurred in 33 (55%) patients, whereas 9 (15.0%) patients were asymptomatic. Aspergilloma was simple in 13 (21.7%) patients and complex in 47 (78.3%) patients. Surgical approach was by thoracotomy (n = 51 [85.0%]), video-assisted thoracoscopic surgery (n = 7 [11.7%]), or a cavernostomy (n = 2 [3.3%]). Sublobar resections (n = 28 [46.7%]) were most common, followed by lobectomy (n = 27 [45%]) and pneumonectomy (n = 3 [5%]). Postoperative morbidity occurred in 18 (30%) patients, with prolonged air leak the most frequent complication (n = 9 [15%]). Two (3.3%) patients experienced empyema, and 4 (6.7%) patients had bronchopleural fistulas (BPFs). Two patients died within 30 days (3.3%). During a mean follow-up of 54.1 ± 62.2 months, 3 patients had recurrent aspergillomas (5.0%). Actuarial 10-year survival was 62.5% for simple and 68.5% for complex aspergillomas (p = 0.858). Comorbid conditions (human immunodeficiency virus [HIV] positivity, malignancy) and male sex were associated with lower survival. Conclusions Selective surgical treatment favoring lesser pulmonary resection results in fungal eradication and control in most patients. Overall survival is similar after surgical management of simple and complex aspergillomas.