Article

Thoracic Surgery in the Real World: Does Surgical Specialty Affect Outcomes in Patients Having General Thoracic Operations?

Department of Surgery, University of Kentucky, Lexington, Kentucky 40536-0284, USA.
The Annals of thoracic surgery (Impact Factor: 3.65). 03/2012; 93(4):1041-7; discussion 1047-8. DOI: 10.1016/j.athoracsur.2011.12.061
Source: PubMed

ABSTRACT Most general thoracic operations in the United States are performed by general surgeons. Results obtained by those identified as general surgeons are often compared with those identified as thoracic surgeons.
We interrogated the American College of Surgeons National Surgical Quality Improvement Project database over a 5-year period to compare outcomes in patients who underwent similar operations by surgeons identified as either thoracic surgeons or general surgeons. We employed propensity-score matching to minimize confounding when estimating the effect of surgeon identity on postoperative outcomes.
During the study period, thoracic surgeons performed 3,263 major pulmonary or esophageal operations, and general surgeons performed 15,057 similar operations. Compared with patients operated on by general surgeons, patients operated on by thoracic surgeons had significant excess multivariate comorbidities, including insulin-dependent diabetes mellitus, chronic obstructive pulmonary disease, concurrent pneumonia, congestive heart failure, previous cardiac surgery, dialysis-dependent renal failure, disseminated cancer, prior sepsis, and previous operation within 30 days. Likewise, patients in highest risk categories had operations performed by thoracic surgeons more commonly than by general surgeons. Unadjusted comparisons for mortality and serious morbidity showed significantly worse mortality and pulmonary complications in patients operated on by thoracic surgeons. However, with propensity matching according to surgeon type, thoracic surgeons had significantly fewer serious adverse outcomes compared with general surgeons, and this decreased morbidity occurred in a higher risk cohort.
Our results show that patients operated on by thoracic surgeons have higher acuity compared with patients operated on by general surgeons. When patients are matched for comorbidities and serious preoperative risk factors, thoracic surgeons have improved outcomes, especially with regard to infectious complications and composite morbidity.

0 Followers
 · 
91 Views
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Study Design. Multicenter retrospective cohort study.Objective. To investigate the impact of spine surgeon specialty on 30-day complication rates in patients undergoing single-level lumbar fusion.Summary of Background Data. Operative care of the spine is delivered by surgeons who undergo either orthopaedic or neurosurgical training. It is currently unknown whether surgeon specialty has an impact on 30-day complication rates in patients undergoing single-level lumbar fusion.Methods. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was retrospectively reviewed to identify all patients who underwent single-level lumbar fusion procedures during 2006-2011. Propensity-score matching analysis was employed to reduce baseline differences in patient characteristics. Univariate and multivariate analyses were performed to assess the impact of spine surgeon specialty on 30-day complication rates.Results. A total of 2,970 patients were included for analysis. After propensity matching, 1,264 pairs of well-matched patients remained. Overall complication rates in the unadjusted dataset were 7.3% and 7.1% for the neurosurgery (NS) and orthopaedic surgery (OS) cohort, respectively. Our multivariate analysis revealed that compared to the NS cohort, the OS cohort did not have statistically significant differences in odds ratios (OR) for development of any complication (OR 0.95, 95% CI 0.69-1.30, p = 0.740). Similarly, spine surgeon specialty was not a risk factor in any of the specific complications studiedincluding medical complications (OR 1.11, 95% CI 0.77-1.60, p = 0.583), surgical complications (OR 0.76, 95% CI 0.46-1.26, p = 0.287), or re-operation (OR 1.10, 95% CI 0.76-1.60, p = 0.618).Conclusion. Our analysis demonstrates that spine surgeon specialty is not a risk factor for any of the reported 30-day complications in patients undergoing single-level lumbar fusion. This data supports the currently dichotomous paradigm of training for spine surgeons. Further research is warranted to validate this relationship in other spine procedures and for other outcomes.
    Spine 05/2014; 39(15). DOI:10.1097/BRS.0000000000000394 · 2.45 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: According to the International Agency for Research on Cancer (IARC) GLOBOCAN World Cancer Report, lung cancer affects more than 1 million people a year worldwide. In Greece according to the 2008 GLOBOCAN report, there were 6,667 cases recorded, 18% of the total incidence of all cancers in the population. Furthermore, there were 6,402 deaths due to lung cancer, 23.5% of all deaths due to cancer. Therefore, in our country, lung cancer is the most common and deadly form of cancer for the male population. The most important prognostic indicator in lung cancer is the extent of disease. The Union Internationale Contre le Cancer (UICC) and the American Joint Committee for Cancer Staging (AJCC) developed the tumour, node, and metastases (TNM) staging system which attempts to define those patients who might be suitable for radical surgery or radical radiotherapy, from the majority, who will only be suitable for palliative measures. Surgery has an important part for the therapy of patients with lung cancer. "Lobectomy is the gold standard treatment". This statement may be challenged in cases of stage Ia cancer or in patients with limited pulmonary function. In these cases an anatomical segmentectomy with lymph node dissection is an acceptable alternative. Chest wall invasion is not a contraindication to resection. En-bloc rib resection and reconstruction is the treatment of choice. N2 disease represents both a spectrum of disease and the interface between surgical and non-surgical treatment of lung cancer Evidence from trials suggests that multizone or unresectable N2 disease should be treated primarily by chemoradiotherapy. There may be a role for surgery if N2 is downstaged to N0 and lobectomy is possible, but pneumonectomy is avoidable. Small cell lung cancer (SCLC) is considered a systemic disease at diagnosis, because the potential for hematogenous and lymphogenic metastases is very high. The efficacy of surgical intervention for SCLC is not clear. Lung cancer resection can be performed using several surgical techniques. Video-assisted thoracoscopic surgery (VATS) lobectomy is a safe, efficient, well accepted and widespread technique among thoracic surgeons. The 5-year survival rate following complete resection of lung cancer is stage dependent. Incomplete resection rarely is useful and cures the patient.
    09/2013; 5(Suppl 4):S425-S439. DOI:10.3978/j.issn.2072-1439.2013.09.17
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: The treatment of stage I and II non-small cell lung cancer (NSCLC) in patients with good or low surgical risk is primarily surgical resection. However, this area is undergoing many changes. With a greater prevalence of CT imaging, many lung cancers are being found that are small or constitute primarily ground-glass opacities. Treatment such as sublobar resection and nonsurgical approaches such as stereotactic body radiotherapy (SBRT) are being explored. With the advent of minimally invasive resections, the criteria to classify a patient as too ill to undergo an anatomic lung resection are being redefined. The writing panel selected topics for review based on clinical relevance to treatment of early-stage lung cancer and the amount and quality of data available for analysis and relative controversy on best approaches in stage I and II NSCLC: general surgical care vs specialist care; sublobar vs lobar surgical approaches to stage I lung cancer; video-assisted thoracic surgery vs open resection; mediastinal lymph node sampling vs lymphadenectomy at the time of surgical resection; the use of radiation therapy, with a focus on SBRT, for primary treatment of early-stage NSCLC in high-risk or medically inoperable patients as well as adjuvant radiation therapy in the sublobar and lobar resection settings; adjuvant chemotherapy for early-stage NSCLC; and the impact of ethnicity, geography, and socioeconomic status on lung cancer survival. Recommendations by the writing committee were based on an evidence-based review of the literature and in accordance with the approach described by the Guidelines Oversight Committee of the American College of Chest Physicians. Surgical resection remains the primary and preferred approach to the treatment of stage I and II NSCLC. Lobectomy or greater resection remains the preferred approach to T1b and larger tumors. The use of sublobar resection for T1a tumors and the application of adjuvant radiation therapy in this group are being actively studied in large clinical trials. Every patient should have systematic mediastinal lymph node sampling at the time of curative intent surgical resection, and mediastinal lymphadenectomy can be performed without increased morbidity. Perioperative morbidity and mortality are reduced and long-term survival is improved when surgical resection is performed by a board-certified thoracic surgeon. The use of adjuvant chemotherapy for stage II NSCLC is recommended and has shown benefit. The use of adjuvant radiation or chemotherapy for stage I NSCLC is of unproven benefit. Primary radiation therapy remains the primary curative intent approach for patients who refuse surgical resection or are determined by a multidisciplinary team to be inoperable. There is growing evidence that SBRT provides greater local control than standard radiation therapy for high-risk and medically inoperable patients with NSCLC. The role of ablative therapies in the treatment of high-risk patients with stage I NSCLC is evolving. Radiofrequency ablation, the most studied of the ablative modalities, has been used effectively in medically inoperable patients with small (< 3 cm) peripheral NSCLC that are clinical stage I.
    Chest 05/2013; 143(5 Suppl):e278S-313S. DOI:10.1378/chest.12-2359 · 7.13 Impact Factor