Clinical Variation Reduction in Propensity-matched Patients Treated for Malignant Pleural Effusion.

Background: The potential advantages of clinical variation reduction are improved patient outcomes and cost reduction through optimizing and standardizing care. Malignant pleural effusion (MPE) is a common condition encountered by thoracic surgeons that has significant variation in cost and outcomes. The purpose of this investigation was to assess the opportunity of improving patient outcomes and reducing cost by using a standardized treatment algorithm based on evidenced-based care.

Patient Outcomes After Stent Failure for the Treatment of Acute Esophageal Perforation.

Background: Esophageal stent placement for acute esophageal perforation has become part of the treatment algorithm for many thoracic surgery programs. Despite high success rates, there are patients for which stent placement is not successful. This investigation summarizes the outcomes of a relatively large group of such patients.

An Assessment of the Frequency of Palliative Procedures in Thoracic Surgery.

Objectives: Palliative care is a medical specialty focused on improving the quality of life of patients and their families with life threatening illness by preventing or relieving suffering. An assessment of a thoracic surgery service was performed to identify the scope and frequency of care that was considered palliative and any implications the findings might have on the current thoracic surgery residency curriculum.

Methods: A retrospective review of a prospectively collected database of general thoracic surgery procedures performed over a 5-year period at a single institution was performed.

The Effects of a Multidisciplinary Care Conference on the Quality and Cost of Care for Lung Cancer Patients.

Background: A prospective, multidisciplinary care conference (MDC) has been shown to result in measurable benefits for patients with non-small cell lung cancer (NSCLC). However whether a MDC also results in a difference in resource utilization and cost as well as whether these benefits persist across a multiinstitutional system has not been reported. This investigation compared propensity-matched patients with NSCLC whose care was coordinated through a MDC to patients without access to an MDC across a geographically diverse system of hospitals.

An Assessment of the Optimal Time for Removal of Esophageal Stents Used in the Treatment of an Esophageal Anastomotic Leak or Perforation.

Background: Esophageal stent for the treatment of a perforation or anastomotic leak has been shown to be effective and safe. However, the optimal timing for stent removal is in question. This purpose of this investigation was to identify a time for stent removal in patients treated for an acute perforation or anastomotic leak that resulted in sealing of the leak while minimizing the incidence of stent-related complications.

A propensity-matched comparison of cost and outcomes after esophageal stent placement or primary surgical repair for iatrogenic esophageal perforation.

Objectives: Esophageal stent placement has been shown to be a safe and effective treatment for acute esophageal perforation in selected patients. However, a comparison between surgical repair and stent placement has not been reported. This investigation compares the outcomes and costs of the 2 treatment modalities.

A propensity-matched comparison of pleurodesis or tunneled pleural catheter for heart failure patients with recurrent pleural effusion.

Background: Patients with severe heart failure often have recurrent pleural effusions that produce dyspnea and shortness of breath. It is unclear whether chemical pleurodesis or the placement of a tunneled pleural catheter that can be used for intermittent pleural drainage produces superior palliation, a shorter hospital stay, and less morbidity. This investigation compares these two treatments.

An analysis of esophageal stent placement for persistent leak after the operative repair of intrathoracic esophageal perforations.

Background: Surgical repair of esophageal perforation has been the mainstay of therapy for patients without associated esophageal malignancy or diffuse mediastinal necrosis. However, the leak rate after primary surgical repair is reported to range between 15% and 20% and increases to 45% and 70% in patients whose repair is delayed beyond 24 hours. This analysis reviews patients who experienced a leak after the operative repair of an esophageal perforation treated with esophageal stent placement.

A comparison of length of stay, readmission rate, and facility reimbursement after lobectomy of the lung.

Background: Readmission to the hospital has become a focus for payers with the threat of nonpayment for preventable readmissions and a global penalty for excessive readmissions rates. This study compares readmission rates with lengths of stay (LOS) for patients undergoing lobectomy of the lung and the potential impact on reimbursement.

Methods: The Premier database for a single health system's hospitals was used to identify patients undergoing lobectomy for non-small cell lung cancer by cardiothoracic surgeons over a 5-year period.

A propensity-matched comparison of pleurodesis or tunneled pleural catheter in patients undergoing diagnostic thoracoscopy for malignancy.

Background: Patients with a suspected malignant pleural effusion occasionally require thoracoscopy to achieve a diagnosis. It is unclear whether chemical pleurodesis or the placement of a tunneled pleural catheter (TPC) that can be used for intermittent pleural drainage produces superior palliation, a shorter hospital stay, and less morbidity. This investigation compares these 2 treatment groups.

A comparison of quality and cost indicators by surgical specialty for lobectomy of the lung.

Objectives: This investigation compared patients undergoing lobectomy for non-small cell lung cancer by either a general surgeon or a cardiothoracic surgeon across a geographically diverse system of hospitals to see whether a significant difference in quality or cost was present.

Methods: The Premiere administrative database and tumor registry data of a single health system's hospitals was used to compare adherence to national treatment guidelines, patient outcomes, and charges for patients undergoing lobectomy for non-small cell lung cancer in a 5-year period. Surgeons performing lobectomy were designated as a general surgeon or cardiothoracic surgeon according to their national provider number and board certification status.

Palliative therapy for patients with unresectable esophageal carcinoma.

Most patients diagnosed with carcinoma of the esophagus do not undergo therapy with curative intent. The focus of treatment for these patients is to maximize their progression-free survival and palliate the most common sequelae of their disease: dysphagia, malnutrition, pain, and intraluminal tumor bleeding. This article discusses the available treatment options for palliation of patients with unresectable esophageal cancer.

Analysis of unsuccessful esophageal stent placements for esophageal perforation, fistula, or anastomotic leak.

Background: Esophageal stent placement for the treatment of a perforation, anastomotic leak, or fistula has been adopted by some thoracic surgeons. Results have been reported for this technique, but little discussion has focused on treatment failures. This analysis reviews patients in whom esophageal stent placement was not successful in an attempt to identify factors that may increase the likelihood of failure of this technique.

Thymic carcinoma: outcomes after surgical resection.

Background: Thymic carcinoma is a rare malignancy with little information regarding outcomes after therapy with curative intent. We undertook a retrospective analysis of all patients who underwent resection of thymic carcinoma at 2 hospitals.

Methods: From 1990 to 2011, 16 patients (9 men, 7 women) underwent surgical resection of thymic carcinoma at a mean age of 52 years.

Long-term follow-up after robotic thymectomy for nonthymomatous myasthenia gravis.

Background: Thymectomy is recognized as a significant component in the treatment of myasthenia gravis. However, controversy exists as to the optimal surgical approach. This investigation summarizes our experience performing extended thymectomy using a robotic technique in a large group of patients with significant follow-up.

The effect of a multidisciplinary thoracic malignancy conference on the treatment of patients with esophageal cancer.

Background: There is a paucity of data evaluating whether a multidisciplinary conference coordinating surgery, chemotherapy and radiation therapy translates into better patient care. This review compares the experiences of patients with esophageal cancer before and after the formation of a prospective, multidisciplinary thoracic malignancy conference (TMC).

Methods: The records of patients with carcinoma of the esophagus at a tertiary care hospital were reviewed for completeness of staging, multidisciplinary evaluation before the initiation of therapy, time from pathologic diagnosis to treatment, multimodality therapy, and adherence to national treatment guidelines.

Esophageal stent placement for the treatment of acute intrathoracic anastomotic leak after esophagectomy.

Background: Anastomotic leak after intrathoracic esophagogastrostomy remains a dreaded complication of esophagectomy. Traditional therapy has most often consisted of reoperative repair or observation and drainage, each prolonging hospitalization and the initiation of oral nutrition. This investigation summarizes our experiences treating these patients using an occlusive, removable esophageal stent.

The effect of a multidisciplinary thoracic malignancy conference on the treatment of patients with lung cancer.

Introduction: There is a paucity of data evaluating whether a multidisciplinary conference coordinating surgery, chemotherapy and radiation therapy translates into better patient care. This article compares the experiences of patients with lung cancer before and after the formation of a prospective, multidisciplinary thoracic malignancy care conference (TMC).

Methods: The records of patients with a non-small-cell lung cancer at a tertiary care hospital were reviewed for completeness of staging, multidisciplinary evaluation prior to the initiation of therapy, time from pathologic diagnosis to treatment, multimodality therapy and adherence to national treatment guidelines.

Long-term follow-up of the functional and physiologic results of diaphragm plication in adults with unilateral diaphragm paralysis.

Background: Patients with lifestyle-limiting dyspnea attributable to unilateral diaphragm paralysis have been shown to experience a decrease in their dyspnea and an improvement in their pulmonary spirometry and functional status with diaphragm plication acutely after surgery. This investigation summarizes these patients' outcomes with long-term follow-up.

Methods: Adult patients undergoing plication of the hemidiaphragm for lifestyle-limiting dyspnea secondary to unilateral diaphragm paralysis were assessed preoperatively, 6 month after surgery and then annually using the Medical Research Council dyspnea score, pulmonary spirometry, activities of daily living questionnaire, and a chest radiograph.

Reoperative endoscopic sympathectomy for persistent or recurrent palmar hyperhidrosis.

Background: Sympathectomy for severe palmar hyperhidrosis occasionally fails. This investigation reviews our experience with reoperative thoracoscopic sympathectomy (RS) for patients with persistent or recurrent palmar hyperhidrosis after sympathectomy.

Methods: A retrospective analysis of patients undergoing RS for palmar hyperhidrosis was conducted.

Esophageal stent placement for the treatment of spontaneous esophageal perforations.

Background: Traditional therapy for spontaneous esophageal perforation has most often been urgent operative repair. This investigation summarizes the treatment of spontaneous perforations of the esophagus using an occlusive removable esophageal stent.

Methods: During a 48-month period, patients with a spontaneous esophageal perforation were offered endoluminal esophageal stent placement as the initial therapy instead of operation.

Esophageal stent placement for the treatment of iatrogenic intrathoracic esophageal perforation.

Background: Iatrogenic esophageal perforation after endoscopy or surgery can be a devastating event. Traditional therapy has most often consisted of operative repair of the esophagus. This investigation summarizes our experiences treating iatrogenic intrathoracic perforations of the esophagus using an occlusive removable esophageal stent.

Postoperative esophageal leak management with the Polyflex esophageal stent.

Objective: Leak after esophageal anastomosis or perforation repair prolongs hospitalization, prevents oral hydration and nutrition, and can produce localized infection or sepsis. This investigation reviews our experience treating postoperative esophageal leaks with the Polyflex esophageal stent (Boston Scientific, Natick, Mass).

Methods: Over a 30-month period, patients with a postoperative esophageal leak were treated with the Polyflex stent for leak occlusion.

Long-segment, supercharged, pedicled jejunal flap for total esophageal reconstruction.

Objective: Many patients with cancer have limited esophageal reconstruction options when the stomach is unavailable as a replacement conduit or when long-segment discontinuity exists. Jejunum has been used as an alternative conduit, both as a pedicled or free flap interposition; however, reports of this are usually limited to short-segment repairs. Microvascular augmentation of a pedicled jejunal flap allows creation of a longer conduit, making it possible to replace the entire esophagus with jejunum.