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OBJECTIVES The aim of the present study was to evaluate the usefulness of the Thoracic Morbidity and Mortality (TMM) scoring system in auditing the quality of care of our unit. METHODS We analysed the performance of our unit comparing the incidence of complications and mortality occuring after anatomic lung resections during two different periods: early period (January 2000 to December 2009: 830 lobectomy, 134 pneumonectomy and 78 segmentectomy) and recent period (January 2010 to August 2012: 191 lobectomy, 8 pneumonectomy and 19 segmentectomy). The cardiopulmonary complications as traditionally defined in the European Society of Thoracic Surgeons (ESTS) database were also classified according to the TMM system: this method grades the postoperative adverse events from 1 to 5 reflecting an increasing severity of management regardless the type of complication. Complications graded higher than 2 are regarded as major complications. To account for confounders, several baseline and surgical factors were used to build a propensity score that was applied to match the patients of the most recent group with their early-group counterparts. These two matched groups were compared in terms of cardiopulmonary morbidity (codified by ESTS definitions) and mortality rates and incidence of major complications according to the TMM system. RESULTS The propensity score analysis yielded 209 well-matched pairs of patients operated on in the two periods. The two groups had similar rates of ESTS-defined cardiopulmonary complications (recent: 38 patients vs early: 37 patients, P = 0.9). The use of the TMM system revealed a higher incidence of major (grade > 2) complications rate in the recent period (recent: 29 patients vs early: 14 patients, P = 0.02). CONCLUSIONS The TMM scoring system for classifying the postoperative complications revealed a decline of quality of care of our unit otherwise undetected by applying traditional outcome measures. This tool can be used as an additional graded outcome endpoint to refine internal audit of performance. [ABSTRACT FROM AUTHOR]

OBJECTIVES The most recent evolution of patient management after thoracic surgery implies the concept of fast-tracking. Since 2008, our unit has implemented a programme based on clinical protocols and standardized pathways of care aimed to reduce the postoperative stay after major lung resection. The objective of this study was to verify the safety of this policy by monitoring the patient readmission rate. METHODS This is a prospective observational study on 914 consecutive pulmonary lobectomies performed at our institution from January 2000 to October 2010. Since we started the fast-tracking program in January 2008, we divided the patients into two groups: early period (678 patients, 2000–2007) and recent period (236 patients, 2008–October 2010). Several baseline and operative factors were used to build a propensity score that was applied to match the recent group patients with their early group counterparts. These two matched groups were then compared in terms of early outcomes and readmission rate. Readmission was defined as a re-hospitalization for any cause related to the operation within 30 days after discharge. We excluded from the analysis those patients with in-hospital mortality. RESULTS Propensity score yielded 232 well-matched pairs operated on in the early (non-fast-tracked patients) and most recent period (fast-tracked patients). The fast-tracking management resulted in a postoperative stay reduction of 2.8 days (P < 0.0001), with a 3-fold higher proportion of patients discharged before the sixth postoperative day (P < 0.0001). Nevertheless, we did not observe any differences in terms of readmission rate between the two periods. CONCLUSIONS In our experience, the implementation of a fast-tracking program after pulmonary lobectomy was very effective and safe. It led to a postoperative reduction of hospital stay without an increase in the readmission rate. [ABSTRACT FROM AUTHOR]

Abstract: Objective: In pulmonary lobectomy, the dissection through the fissure to gain access to the pulmonary artery may increase the risk of postoperative air leak. For several anatomic reasons, this risk is especially high after right upper lobectomies (RULs). The objective of this investigation was to verify the efficacy of an anterior fissureless lobectomy (FL) technique in reducing the incidence and duration of air leak after RUL. Methods: An observational analysis was performed of 206 consecutive patients (2002–2009) submitted to RUL for non-small-cell lung cancer. Operations were performed through a muscle-sparing lateral thoracotomy. Patients with completely developed fissures were excluded. No sealants or buttressing material were used. For group TR (traditional resection, 146 patients), RUL was performed by traditional intra-fissure dissection of the pulmonary artery; for group FL (60 patients), RUL was carried out by fissureless division of all hilar vascular structures. Several perioperative variables were used in identifying propensity score-matched pairs of patients undergoing traditional and fissureless lobectomies. The matched groups were then compared in terms of incidence of prolonged air leak, air leak duration, operation time, chest tubes duration, hospital stay and costs. Results: Propensity score analysis yielded 58 well-matched pairs of patients operated by traditional or fissureless RUL. Compared to those in the traditional group, patients in group FL had a mean reduction in air leak duration, duration of chest tube and postoperative stay of 1.1, 1.4 and 1.2 days, respectively. This translated into an average hospital cost saving of 569€ per patient. Conclusions: The use of an anterior fissureless technique during RUL reduced the duration of air leak and hospital costs without increasing the surgical time. Given its simplicity and efficacy, we regard it as a useful tool for implementing fast-tracking policies and cutting hospital costs. [Copyright &y& Elsevier]

Abstract: Background: The objective of this investigation was to assess the quality of life (QoL) before and after pulmonary lobectomy in patients with chronic obstructive pulmonary disease (COPD) and to compare these values with a case-matched population of patients with normal respiratory function. Methods: This is an observational analysis performed on a prospective dataset of 220 consecutive patients submitted to pulmonary lobectomy for lung cancer (2006–2008). Patients submitted to extended procedures (chest wall resection and superior sulcus) were excluded from the analysis. Pre- and postoperative (3 months) QoL were assessed in all patients through the administration of the Short Form 36v2 (SF36v2) health survey, a generic QoL instrument assessing eight health physical and mental concepts. Propensity score was used to match COPD patients (according to the NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria: forced expiratory volume in 1s/forced expiratory vital capacity (FEV1/FVC) ratio <0.7 and FEV1 <80%) with counterparts without COPD. QoL scales were compared between the two matched groups by means of the Mann–Whitney test. Results: Propensity score yielded 50 well-matched pairs of patients with and without COPD. Compared with non-COPD patients, those with COPD had a threefold higher rate of cardiopulmonary morbidity (14 cases vs 5 cases, 28% vs 10%, p =0.04), lower reduction in FEV1 (6% vs 13%, p =0.0002), but lower residual postoperative FEV1 values (62% vs 74%, p <0.0001). Postoperative carbon monoxide lung diffusion capacity (DLCO) (69% vs 65%, p =0.1) and VO2max (15.3mlkg−1 min−1 vs 14.3mlkg−1 min−1 p =0.4) values were similar between the groups. Although most of the preoperative and postoperative QoL domains in both groups were reduced compared with normal population (<50), we were not able to find differences between the groups in any of the preoperative and postoperative physical and mental QoL scales. Conclusions: The evidence of an acceptable QoL in COPD patients may help both patients and physicians in the surgical decision-making process in the face of high rates of complications. [Copyright &y& Elsevier]