Thoracoscopic lobectomy is applicable to a spectrum of malignant and benign pulmonary disease and is associated with a low perioperative morbidity and mortality rate. Survival rates are comparable to those for lobectomy with thoracotomy.

Thoracoscopic lobectomy is associated with a lower incidence of major complications, including atrial fibrillation, compared with lobectomy by means of thoracotomy. The underlying factors responsible for this advantage should be analyzed to improve the safety and outcomes of other thoracic procedures.

Background The Society of Thoracic Surgeons (STS) creates risk adjustment models for common cardiothoracic operations for quality improvement purposes. Our aim was to update the lung cancer resection risk model utilizing the STS General Thoracic Surgery Database (GTSD) with a larger and more contemporary cohort. Methods We queried the STS GTSD for all surgical resections of lung cancers from January 1, 2012 through December 31, 2014 Logistic regression was used to create three risk models for adverse events: operative mortality, major morbidity and composite mortality and major morbidity. Results 27,844 lung cancer resections were performed at 231 centers. 62% (n=17,153) were performed via thoracoscopy. The mortality rate was 1.4% (n=401), major morbidity rate was 9.1% (n=2,545) and the composite rate was 9.5% (2,654). Predictors of mortality included age, male gender, FEV1, body mass index, cerebrovascular disease, steroids, coronary disease, peripheral vascular disease, renal dysfunction, Zubrod score, American Society of Anesthesiologists rating, thoracotomy approach, induction therapy, reoperation, tumor stage, and greater extent of resection. (all p<0.05). For major morbidity and the composite measure, cigarette smoking becomes a risk factor while stage, renal dysfunction, congestive heart failure, and cerebrovascular disease lose significance. Conclusions Operative mortality and complication rates are low for lung cancer resection among surgeons participating in the GTSD. Risk factors from the prior lung cancer resection model are refined and new risk factors such as prior thoracic surgery are identified. The GTSD risk models continue to evolve as more centers report and data is audited for quality assurance.

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Background Data from selected centers show that robotic lobectomy (RL) is safe, effective and has comparable 30-day mortality to video assisted lobectomy (VATS). However, widespread adoption of RL is controversial. We used the STS-GTS-Database to evaluate quality metrics for these two minimally invasive lobectomy techniques. Methods A database query for primary clinical stage I or II NSCLC at high volume centers from 2009 to 2013 identified 1,220 RLs and 12,378 VATS. Quality metrics evaluated included operative morbidity, 30-day mortality and nodal upstaging (NU), defined as cN0 to pN1. Multivariable logistic regression was used to evaluate NU. Results RL patients were older, less active, less likely to be an ever smoker, and had higher BMI (all p<0.05). They were also more likely to have coronary heart disease or hypertension (all p<0.001) and to have had preoperative mediastinal staging (p<0.0001). RL operative times were longer (median 186 vs 173 min, p<0.001); all other operative parameters were similar. All postoperative outcomes were similar including complications and 30-day mortality (RL 0.6% vs VATS 0.8%, p=0.4). Median length of stay was 4 days for both, but a higher proportion of RLs stayed < 4 days: 48% vs 39%, p<0.001. NU overall was similar (p=0.6), but with trends favoring VATS in the cT1b group, and RL in the cT2a group. Conclusions RL patients had more co-morbidities and RL operative times were longer, but quality outcome measures including complications, hospital stay, 30-day mortality, and NU suggest RL and VATS are equivalent.

Background To revise the model for perioperative risk for esophagectomy for cancer utilizing the Society of Thoracic Surgeons General Thoracic Surgery Database in order to provide enhanced risk stratification and quality improvement measures for contributing centers. Methods The Society of Thoracic Surgeons General Thoracic Surgery Database was queried for all patients treated for esophageal cancer with esophagectomy between July 1, 2011 and June 30, 2014. Multivariable risk models for major morbidity, perioperative mortality and combined morbidity and mortality were created with the inclusion of surgical approach as a risk factor. Results 4321 esophagectomies were performed by 164 participating centers. The most common procedures included: Ivor Lewis (32.5%), Transhiatal (21.7%), Minimally Invasive esophagectomy, Ivor Lewis type (21.4%) and McKeown (10.0%). Sixty-nine percent of patients received induction therapy. Perioperative mortality (inpatient and 30-day) was 135/4321 (3.4%). Major morbidity occurred in 1429 patients (33.1%). Major morbidities include unexpected return to OR (15.6%), anastomotic leak (12.9%), reintubation (12.2%), initial ventilation beyond 48 hours (3.5%), pneumonia (12.2%), renal failure (2.0%), recurrent laryngeal nerve paresis (2.0%). Statistically significant predictors of combined major morbidity or mortality included: age >65, BMI ≥35, preoperative congestive heart failure, Zubrod score >1, McKeown Esophagectomy, current or former smoker and squamous cell histology. Conclusion Thoracic surgeons participating in the Society of Thoracic Surgeons General Thoracic Surgery Database perform esophagectomy with low morbidity and mortality. McKeown esophagectomy is an independent predictor of combined postoperative morbidity or mortality. Revised predictors for perioperative outcome were identified to facilitate quality improvement processes and hospital comparisons.

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When all other identified risk factors were controlled for mathematically, metastasectomy maintained a significant survival advantage for patients with pulmonary metastatic melanoma. These data support the role of surgery for a select subset of patients with pulmonary metastasis.