Volume Standards for Thoracic Surgeries
Few studies have assessed whether or not minimum volume standards for surgeries are associated with differences in outcomes in thoracic surgical procedures. For a study, researchers compared the incidence of complications and mortality between patients who underwent lobectomy/pneumonectomy or esophagectomy for cancer at high-volume hospitals (<40 lung resections per year) and low-volume hospitals (<20 esophagectomies per year). Upon propensity matching, no major differences were observed between low- and high-volume hospitals regarding in-hospital mortality or major complications for lung or esophageal cancer resection. Length of stay (LOS) was 1 day longer in low-volume hospitals following lung resection (6 vs 5 days), but there were no differences in LOS for esophageal resection.
Weighing the Benefits of Pneumonectomy for Non-Small Cell Lung Cancer
Whether or not the long-term survival benefit of pneumonectomy following induction chemotherapy for locally advances non-small cell lung cancer (NSCLC) outweighs operative risks is a difficult clinical decision for which there is little evidence to guide. Using machine learning methods, study investigators sought to develop a prediction model that allows estimation of survival among patients with NSCLC who undergo pneumonectomy after induction therapy. Overall survival of patients with stage I-IIIA NSCLC treated with pneumonectomy after induction chemotherapy was compared to that of matched patients treated with chemoradiation only. Patients treated with pneumonectomy after induction therapy had a 5-year survival rate of 44.3%, compared with a rate of just 20.1% for those treated with chemoradiation alone. Age, race, T-status, N-status, and induction radiation use independently predicted overall survival and were used to create a nomogram.
BMI’s Impact on Lung Transplant Survival
Previous studies have provided unclear results on the impact of BMI on lung transplant survival, either including patients prior to implementation of the lung allocation score (LAS) or using traditional, broad BMI classes. The impact of BMI as a continuous variable on 90-day and 1-year lung transplant mortality was evaluated in the largest study to date following the institution of LAS. Among more than 17,000 adult lung recipients, a BMI of 25 kg/m3 was associated with the lowest probability of 90-day mortality. The probability of mortality rose steadily for each BMI unit increase or decrease from 25 kg/m3, achieving statistical significance at 27 kg/m3 and continuously increasing until the maximum BMI of 43 kg/m3. The probability of mortality also achieved significance at a BMI of 21 kg/m3, increasing until the lowest unit of 11 kg/m3. These findings were similar for 1-year mortality, with the lowest probability of death found to be a BMI of 26 kg/m3.
Cost-Effectiveness of Robotic-Assisted Thoracic Surgery
Although robotic-assisted surgery has been shown to be more beneficial than conventional surgery for many procedures, some studies suggest that robotic-assisted thoracic surgical procedures (RATS) is more expensive than conventional endoscopic or open surgery. For a study, researchers assessed data on surgical volume, operative time, length of stay (LOS), case mix index (CMI), direct and indirect costs, hospital charges, surgical charges, and contribution margin (CM) for thoracic surgery and other services that performed more than 20 robotic cases per year. Inpatient RATS performed in fiscal year 2014 had an average CMI of 2.94, an average LOS of 5.96 days, a net revenue of more than $3.0 million, direct costs of about $1.8 million, indirect costs about $1.5 million, a CM of about $1.1 million, and a net gain of about $35,600. Three other high-volume services had net losses or smaller gains. Inpatient RATS performed in fiscal year 2015 had even better financial outcomes, and four other high-volume services performed that year had net losses or smaller gains. Outpatient RATS procedures performed during both fiscal years had a negative CM of about $1,000 and net loss of about $63,000.
Venovenous Extracorporeal Membrane Oxygenation for Influenza-Associated Adult Respiratory Distress Syndrome
Few studies have examined the characteristics linked to survival benefits among patients who develop adult respiratory distress syndrome (ARDS) secondary to influenza and who are treated with venovenous extracorporeal membrane oxygenation (ECMO). To address this research gap, investigators examined a sample of patients who required ECMO support for ARDS secondary to influenza infection and looked at their 30- and 90-day survival rates. In total, 76% of patients were weaned from ECMO and successfully decannulated, and 57% of these individuals survived to discharge. Of those who were discharged, survival was 100% at both 30 and 90 days. Patients cannulated within 48 hours of admission had a long-term survival of 80%, compared with rates of 50% for those cannulated between 2 and 5 days and 29% for those cannulated after 5 days.
Induction Therapy for Esophageal Cancer
While previous studies indicate that induction chemotherapy alone (ICA) and induction chemoradiation (ICR) both have survival benefits over primary surgery in patients with locally advanced adenocarcinoma of the distal esophagus or gastroesophageal junction, few have directly compared the two induction strategies to one another. Researchers tested the hypothesis that survival after ICR is better than after ICA for patients with distal esophageal adenocarcinoma who had undergone induction therapy followed by surgery. No statistically significant differences were observed in postoperative hospitalizations, 30-day readmissions, 30-day mortality, or 90-mortality between those receiving ICR or ICA. Whereas higher rates of T downstaging, N downstaging, and complete pathologic response occurred in ICR patients and positive margins were seen more often in ICA patients, no differences were observed between the groups in 5-year survival.
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