Publications by authors named "Manu Sancheti"

22 Publications

  • Page 1 of 1

Safety and Feasibility of Thoracoscopic Lung Resection for Non-Small-Cell Lung Cancer in Octogenarians.

Innovations (Phila) 2021 Jan-Feb;16(1):68-74. Epub 2020 Nov 27.

1371 Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, USA.

Objective: Octogenarians comprise an increasing proportion of patients presenting with non-small-cell lung cancer (NSCLC). This study examines postoperative morbidity and mortality, and long-term survival in octogenarians undergoing thoracoscopic anatomic lung resection for NSCLC, compared with younger cohorts.

Methods: We conducted a retrospective review of our institutional Society of Thoracic Surgeons General Thoracic Surgery Database of all patients ≥60 years old undergoing elective lobectomy or segmentectomy for pathologic stage I, II, and IIIA NSCLC between 2009 and 2018. Results were compared between octogenarians ( = 71) to 2 younger cohorts of 60- to 69-year-olds ( = 359) and 70- to 79-year-olds ( = 308). Long-term survival among octogenarians was graphically summarized using the Kaplan-Meier method. Cox regression analysis was used to identify preoperative risk factors for mortality.

Results: A greater proportion of octogenarians required intensive care unit admission and discharge to extended-care facilities; however, postoperative length of stay was similar between groups. Among postoperative complications, arrhythmia and renal failure were more likely in the older cohort. Compared to the youngest cohort, in-hospital and 30-day mortality were highest among octogenarians. Overall survival among octogenarians at 1, 3, and 5 years was 87.3%, 61.8%, and 50.5%, respectively. On multivariable Cox regression analysis of baseline demographic variables, presence of stroke (hazard ratio [HR] = 28.5, 95% confidence interval [CI]: 6.1 to 132.7, < 0.001) and coronary artery disease (HR = 2.5, 95% CI: 1.2 to 5.3, = 0.02) were significant predictors of overall mortality among octogenarians.

Conclusions: Thoracoscopic resection can be performed with favorable early postoperative outcomes among octogenarians. Long-term survival, although comparable to their healthy peers, is worse than those of younger cohorts. Further study into preoperative risk stratification and alternative therapies among octogenarians is needed.
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http://dx.doi.org/10.1177/1556984520971620DOI Listing
November 2020

Community Size and Lung Cancer Resection Outcomes: Studying The Society of Thoracic Surgeons Database.

Ann Thorac Surg 2021 10 13;112(4):1076-1082. Epub 2020 Nov 13.

Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia.

Background: Socioeconomic factors play key roles in surgical outcomes. Socioeconomic data within The Society of Thoracic Surgeons (STS) General Thoracic Surgery Database (GTSD) are limited. Therefore, we utilized community size as a surrogate to understand socioeconomic differences in lung cancer resection outcomes.

Methods: We retrospectively reviewed all lung cancer resections from January 2012 to January 2017 in the STS GTSD. This captured 68,722 patients from 286 centers nationwide. We then linked patient zip codes with 2013 Rural-Urban Continuum Codes to understand the association between community size and postoperative outcomes. Demographic and clinical variables were evaluated for relationships with 30-day mortality, major morbidity, and readmission.

Results: Zip codes were included in 47.2% of patients. Zip-coded patients were older, were more comorbid, had less advanced disease, and were more commonly treated with minimally invasive approaches than were those without zip code classification. For geocoded patients, multivariable analyses demonstrated that sex, insurance payor, and hospital region were associated with all 3 major endpoints. Community size, based on Rural-Urban Continuum Codes coding, was not associated with any primary endpoint. Invasive mediastinal staging was related to morbidity, greater pathological stage predicted mortality, and worsened clinical stage was associated with readmission. More invasive surgery and greater extent of lung resection were associated with all primary endpoints.

Conclusions: Incomplete data capture can promote selection bias within the STS GTSD and skew outcomes reporting. Moreover, community size is an insufficient surrogate, compared with sex, insurance payor, hospital region, for understanding socioeconomic differences in lung cancer resection outcomes.
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http://dx.doi.org/10.1016/j.athoracsur.2020.08.076DOI Listing
October 2021

Association Between Patient Physical Function and Length of Stay After Thoracoscopic Lung Cancer Surgery.

Semin Thorac Cardiovasc Surg 2021 Summer;33(2):559-566. Epub 2020 Nov 11.

Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia. Electronic address:

Patient-reported outcomes (PRO) are an ideal method for measuring patient functional status. We sought to evaluate whether preoperative PRO were associated with resource utilization. We hypothesize that higher preoperative physical function PRO scores, measured via the NIH-sponsored Patient Reported Outcome Measurement Information System (PROMIS), are associated with shorter length of stay (LOS). Preoperative physical function scores were obtained using NIH PROMIS in a prospective observational study of patients undergoing minimally invasive surgery for lung cancer. Poisson regression models were constructed to estimate the association between the length of stay and PROMIS physical function T-score, adjusting for extent of resection, age, gender, and race. Due to the significant interaction between postoperative complications and physical function T-score, the relationship between physical function and LOS was described separately for each complication status. A total of 123 patients were included; 88 lobectomy, 35 sublobar resections. Mean age was 67 years, 35% were male, 65% were Caucasian. Among patients who had a postoperative complication, a lower preoperative physical function T-score was associated with progressively increasing LOS (P  value = 0.006). In particular, LOS decreased by 18% for every 10-point increase in physical function T-score. Among patients without complications, T-score was not associated with LOS (P = 0.86). Preoperative physical function measured via PRO identifies patients who are at risk for longer LOS following thoracoscopic lung cancer surgery. In addition to its utility for preoperative counseling and planning, these data may be useful in identifying patients who may benefit from risk-reduction measures.
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http://dx.doi.org/10.1053/j.semtcvs.2020.10.003DOI Listing
July 2021

Preoperative Lung Function Is Associated With Patient-Reported Outcomes After Lung Cancer Surgery.

Ann Thorac Surg 2021 08 29;112(2):415-422. Epub 2020 Oct 29.

Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.

Background: Patient quality of life (QOL) is a critical outcomes measure in lung cancer surgery. Patient-reported outcomes (PROs) provide valuable insight into the patient experience and allow measurement of preoperative and postoperative QOL. Our objective was to determine which clinical factors predict differences in QOL, as measured by patient-reported physical function and pain intensity among patients undergoing minimally invasive lung cancer surgery.

Methods: PRO surveys assessing physical function and pain intensity were conducted using instruments from the National Institutes of Health Patient-Reported Outcomes Measurement Information System. PRO surveys were administered to patients undergoing minimally invasive lung cancer resections at preoperative, 1-month, and 6-month postoperative time points, in an academic institution. Linear mixed-effects regression models were constructed to assess the association between clinical variables on PRO scores over time.

Results: A total of 123 patients underwent a thoracoscopic lung resection for cancer. Mean age of the cohort was 67 ± 9.6 years, 43% were male, and 80% were White. When comparing clinical variables with PRO scores after surgery, lower diffusing capacity of the lungs for carbon monoxide (Dlco) was associated with significantly worse physical function (P < .01) and greater pain intensity scores (P < .01) at 6 months, with no differences identified at 1 month. No other studied clinical factor was associated with significant differences in PRO scores.

Conclusions: Low preoperative Dlco was associated with significant decreases in PRO after minimally invasive lung cancer surgery. Dlco may be of utility in identifying patients who experience greater decline in QOL after surgery and for guiding surgical decision making.
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http://dx.doi.org/10.1016/j.athoracsur.2020.09.016DOI Listing
August 2021

Robotic Thoracic Surgery.

Surg Clin North Am 2020 Apr 6;100(2):237-248. Epub 2020 Feb 6.

Yale School of Medicine, Lauder Hall, 310 Cedar Street, New Haven, CT 06510, USA.

Minimally invasive surgery for diseases of the chest offsets the morbidity of painful thoracic incisions while allowing for meticulous dissection of major anatomic structures. This benefit translates to improved outcomes and recovery following the surgical management of benign and malignant esophageal pathologic condition, mediastinal tumors, and lung resections. This anatomic region is particularly amenable to a robotic approach given the fixed space and need for complex intracorporeal dissection. As robotic platforms continue to evolve, more complex thoracic surgical interventions will be facilitated, translating to improved outcomes for our patients.
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http://dx.doi.org/10.1016/j.suc.2019.12.001DOI Listing
April 2020

Robotic-Assisted Surgical Treatment of Catamenial Pneumothorax.

Ann Thorac Surg 2020 03 10;109(3):e191-e192. Epub 2019 Aug 10.

Section of Cardiothoracic Surgery, Emory University, Atlanta, Georgia.

Two young female patients presented with clinical findings of catamenial pneumothorax and thoracic endometriosis syndrome. Despite attempts at conservative management, thoracoscopic pleurodesis, and hormonal therapy, both women experienced recurrent pneumothoraces coincident with menses. Each patient subsequently underwent robotic-assisted mechanical pleurectomy and diaphragm reconstruction with durable results.
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http://dx.doi.org/10.1016/j.athoracsur.2019.06.069DOI Listing
March 2020

Excess Cost and Predictive Factors of Esophagectomy Complications in the SEER-Medicare Database.

Ann Thorac Surg 2018 11 23;106(5):1484-1491. Epub 2018 Jun 23.

Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia. Electronic address:

Background: Postoperative complications result in significantly increased health care expenditures. The objective of this study was to examine 90-day excess costs associated with inpatient complications after esophagectomy and their predictive factors, by using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database.

Methods: The study examined patients older than 65 years of age with a diagnosis from 2002 to 2009 and who were undergoing esophagectomy for cancer in the SEER-Medicare database. Quantile regression models were fit at 5% intervals for excess 90-day cost associated with perioperative complications while controlling for baseline characteristics. Excess cost was defined as the difference in total cost for patients with versus without the complication. Analyses were stratified by patients' characteristics to identify factors predictive of excess cost.

Results: A total of 1,462 patients were identified in the cohort; 51% had at least one complication. Significant excess cost was associated with pulmonary and mechanical wound complications across all quantiles (p < 0.05). Infectious (0.35 to 0.75 quantiles), intraoperative (0.05 to 0.85 quantiles), and systemic (0.30 to 0.85 quantiles) complications were associated with higher costs. Further, excess costs were significantly elevated in the higher quantiles. At the 0.50 quantile (median) of total cost distribution, excess cost in patients with any complication were significantly higher in patients with the following characteristics: transthoracic esophagectomy, emergency esophagectomy, Charlson Comorbidity Index >0, living in a nonmetropolitan area or poorer community, or treated in larger hospitals; no such difference was identified in patients without complications.

Conclusions: Complications after esophagectomy result in significant excess 90-day cost. Efforts at cost reduction and quality improvement will need to focus on reducing complications, in particular pulmonary and infectious, as well as risk factors for higher complication costs.
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http://dx.doi.org/10.1016/j.athoracsur.2018.05.062DOI Listing
November 2018

Preoperative Computed Tomography-Guided Pulmonary Lesion Marking in Preparation for Fluoroscopic Wedge Resection-Rates of Success, Complications, and Pathology Outcomes.

Curr Probl Diagn Radiol 2019 Jan 6;48(1):27-31. Epub 2017 Nov 6.

Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA. Electronic address:

Purpose: In this study, we describe our experience of lesion marking with fiducial markers (FM) and microcoils (MC) facilitating same-day surgical wedge resection, including success rates, pathology outcomes, and complications. We also explored patient/nodular characteristics associated with developing complications.

Materials And Methods: An IRB-approved single-institutional retrospective study of 136 patients who had 148 pulmonary nodules was conducted. All patients had CT-guided pulmonary nodule labeling with either FM (121) or MC (15) patients with plan for same-day fluoroscopic-guided wedge resection.

Results: Of 136 (98%) patients, 133 had successful same-day wedge resection as planned; 2 had delayed but successful wedge resection surgery due to complications at the time of marker placement (fiducial embolization and hemorrhage/pneumothorax, respectively). A third patient ultimately needed lobectomy due to deep lesion location. Eighty percent [118/148] of resected nodules were malignant. Further, 68% of the total group of patients [93/136] had mild complications of various types including hemorrhage [44/136, 32%], pneumothorax [35/136, 26%], a combination of both hemorrhage and pneumothorax [10/136, 7%], or migration/embolization [4/136, 3%]. Depth of nodule from skin (P = 0.011) and pleura (P = 0.027) was significantly associated with complications.

Conclusion: CT-guided marking of small or deep pulmonary lesions using either fiducial markers or microcoils provides an effective means to aid surgeons to accomplish minimally invasive wedge resection. The importance of the success of this technique is supported by the high incidence (80%) of malignant lesion etiology found at postresection pathology. Although complications occurred, the vast majority were mild and did not alter planned same-day resection.
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http://dx.doi.org/10.1067/j.cpradiol.2017.10.012DOI Listing
January 2019

Hospitalization Costs After Surgery in High-Risk Patients With Early Stage Lung Cancer.

Ann Thorac Surg 2018 Jan 24;105(1):263-270. Epub 2017 Nov 24.

Department of Surgery, Emory University School of Medicine, Atlanta, Georgia; Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia.

Background: We previously reported that early stage lung cancer patients who are considered high risk for surgery can undergo resection with favorable perioperative results and long-term mortality. To further elucidate the role of surgical resection in this patient cohort, this study evaluated the length of stay and total hospitalization cost among patients classified as standard or high risk with early stage lung cancer who underwent pulmonary resection.

Methods: A total of 490 patients from our institutional Society of Thoracic Surgeons data from 2009 to 2013 underwent resection for clinical stage I lung cancer. High-risk patients were identified by American College of Surgeons Oncology Group z4032-z4099 criteria. Demographics, length of stay, and hospitalization cost between high-risk and standard-risk patients undergoing lobectomy and sublobar resection were compared. Univariate analysis was performed using the chi-square test or Fisher's exact test. Multivariate analysis was performed using a linear regressions model.

Results: A total of 180 (37%) of patients were classified as high risk. These patients were older (70 years of age vs. 65 years of age; p < 0.0001), had worse forced expiratory volume in 1 second (57% vs. 85%; p < 0.0001), and had worse diffusion capacity of carbon dioxide (47% vs. 77%; p < 0.0001). The baseline cost and length of stay was represented by a thoracoscopic wedge resection in a standard-risk patient. A larger extent of resection, thoracotomy, or high-risk classification increased the cost and length of stay.

Conclusions: Our previous study showed that good clinical outcomes after surgery for early stage lung cancer can be achieved in patients classified as high risk. In this study, although surgery in high-risk patients led to slightly increased costs, these costs seemed negligible when viewed along with the patients' excellent short-term and long-term results. This study suggests that surgical resection on high-risk patients with early stage lung cancer is associated with acceptable hospital lengths of stay and overall cost when compared with standard-risk patients.
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http://dx.doi.org/10.1016/j.athoracsur.2017.08.038DOI Listing
January 2018

Pilot Study to Integrate Patient Reported Outcomes After Lung Cancer Operations Into The Society of Thoracic Surgeons Database.

Ann Thorac Surg 2017 Jul 5;104(1):245-253. Epub 2017 May 5.

Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia. Electronic address:

Background: A critical gap in The Society of Thoracic Surgeons (STS) Database is the absence of patient-reported outcomes (PRO), which are of increasing importance in outcomes and performance measurement. Our aim was to demonstrate the feasibility of integrating PRO into the STS Database for patients undergoing lung cancer operations.

Methods: The National Institutes of Health Patient Reported Outcome Measurement Information System (PROMIS) includes reliable, precise measures of PRO. We used validated item banks within PROMIS to develop a survey for patients undergoing lung cancer resection. PRO data were prospectively collected electronically on tablet devices and merged with our institutional STS data. Patients were enrolled over 18 months (November 2014 to May 2016). The survey was administered preoperatively and at 1 and 6 months after lung cancer resection.

Results: The study included 127 patients. All patients completed the initial postoperative survey, and 108 reached the 6-month follow-up. The most common procedure was video-assisted thoracic lobectomy (55%). At the first postoperative visit, there was a significant increase in pain, fatigue, and sleep impairment and a decrease in physical function. By 6 months, these PRO measures had generally improved toward baseline.

Conclusions: Collecting PRO data from lung cancer surgical patients and integrating the results into an institutional database is feasible. This pilot serves as a model for widespread incorporation of PRO data into the STS Database. Future integration of such data will continue to position the STS National Database as the gold standard for clinical registries. This will be necessary for assessing overall patient responses to different surgical therapies.
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http://dx.doi.org/10.1016/j.athoracsur.2017.01.110DOI Listing
July 2017

Socioeconomic Factors Are Associated With Readmission After Lobectomy for Early Stage Lung Cancer.

Ann Thorac Surg 2016 Nov 29;102(5):1660-1667. Epub 2016 Jul 29.

Section of General Thoracic Surgery, School of Medicine, Emory University, Atlanta, Georgia. Electronic address:

Background: Data regarding risk factors for readmissions after surgical resection for lung cancer are limited and largely focus on postoperative outcomes, including complications and hospital length of stay. The current study aims to identify preoperative risk factors for postoperative readmission in early stage lung cancer patients.

Methods: The National Cancer Data Base was queried for all early stage lung cancer patients with clinical stage T2N0M0 or less who underwent lobectomy in 2010 and 2011. Patients with unplanned readmission within 30 days of hospital discharge were identified. Univariate analysis was utilized to identify preoperative differences between readmitted and not readmitted cohorts; multivariable logistic regression was used to identify risk factors resulting in readmission.

Results: In all, 840 of 19,711 patients (4.3%) were readmitted postoperatively. Male patients were more likely to be readmitted than female patients (4.9% versus 3.8%, p < 0.001), as were patients who received surgery at a nonacademic rather than an academic facility (4.6% versus 3.6%; p = 0.001) and had underlying medical comorbidities (Charlson/Deyo score 1+ versus 0; 4.8% versus 3.7%; p < 0.001). Readmitted patients had a longer median hospital length of stay (6 days versus 5; p < 0.001) and were more likely to have undergone a minimally invasive approach (5.1% video-assisted thoracic surgery versus 3.9% open; p < 0.001). In addition to those variables, multivariable logistic regression analysis identified that median household income level, insurance status (government versus private), and geographic residence (metropolitan versus urban versus rural) had significant influence on readmission.

Conclusions: The socioeconomic factors identified significantly influence hospital readmission and should be considered during preoperative and postoperative discharge planning for patients with early stage lung cancer.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5077657PMC
http://dx.doi.org/10.1016/j.athoracsur.2016.05.060DOI Listing
November 2016

Time is Money: Hospital Costs Associated With Video-Assisted Thoracoscopic Surgery Lobectomies.

Ann Thorac Surg 2016 Sep 19;102(3):940-947. Epub 2016 May 19.

Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia. Electronic address:

Background: Proposed changes in health care will place an increasing burden on surgeons to care for patients more efficiently to minimize cost. We reviewed costs surrounding video-assisted thoracoscopic surgery (VATS) lobectomies to see where changes could be made to ensure maximum value.

Methods: We queried The Society of Thoracic Surgeons database for all VATS lobectomies performed for lung cancer from January 2011 to December 2013. Clinical data were linked with hospital financial data to determine hospital expenditures for each patient.

Results: In all, 263 VATS lobectomies were included. Mean operating room time was 236 minutes, and median length of stay was 4 days. Mean hospital cost was $19,769. The majority of cost (58%) was attributed to operating room and floor costs (length of stay), and the majority of operating room costs were secondary to room rate and staplers. A total of 77 complications, as defined by STS, occurred in the cohort; 41 patients had only one complication, 11 patients had two complications, and 6 patients had three or more complications. The occurrence of one complication was associated with a net loss of $496 whereas two complications in a patient led to a $3,882 net loss. Overall, complications were independently correlated with significant cost increases.

Conclusions: Our study shows that the most significant costs associated with VATS lobectomies relate to operating room time, stapler use, floor charges, and cost associated with complications. Cost-reducing strategies will need to concentrate on optimizing operating room times and reducing length of stay while simultaneously minimizing complications.
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http://dx.doi.org/10.1016/j.athoracsur.2016.03.024DOI Listing
September 2016

Nodal Upstaging Is More Common with Thoracotomy than with VATS During Lobectomy for Early-Stage Lung Cancer: An Analysis from the National Cancer Data Base.

J Thorac Oncol 2016 Feb 11;11(2):222-33. Epub 2016 Jan 11.

Section of General Thoracic Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA. Electronic address:

Introduction: Questions remain regarding differences in nodal evaluation and upstaging between thoracotomy (open) and video-assisted thoracic surgery (VATS) approaches to lobectomy for early-stage lung cancer. Potential differences in nodal staging based on operative approach remain the final significant barrier to widespread adoption of VATS lobectomy. The current study examines differences in nodal staging between open and VATS lobectomy.

Methods: The National Cancer Data Base was queried for patients with clinical stage T2N0M0 or lower lung cancer who underwent lobectomy in 2010-2011. Propensity score matching was performed to compare the rate of nodal upstaging in VATS with that in open approaches. Additional subgroup analysis was performed to assess whether rates of upstaging differed by specific clinical setting.

Results: A total of 16,983 lobectomies were analyzed; 4935 (29.1%) were performed using VATS. Nodal upstaging was more frequent in the open group (12.8% versus 10.3%; p < 0.001). In 4437 matched pairs, nodal upstaging remained more common for open approaches. For a subgroup of patients who had seven lymph or more nodes examined, propensity matching revealed that nodal upstaging remained more common after an open approach than after VATS (14.0% versus 12.1%; p = 0.03). For patients who were treated in an academic/research facility, however, the difference in nodal upstaging between an open and VATS approach was no longer significant (12.2% versus 10.5%, p = 0.08).

Conclusions: For early-stage lung cancer, nodal upstaging was observed more frequently with thoracotomy than with VATS. However, nodal upstaging appears to be affected by facility type, which may be a surrogate for expertise in minimally invasive surgical procedures.
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http://dx.doi.org/10.1016/j.jtho.2015.10.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4729646PMC
February 2016

Freeze the pain away: The role of cryoanalgesia during a Nuss procedure.

Authors:
Manu Sancheti

J Thorac Cardiovasc Surg 2016 Mar 6;151(3):889-890. Epub 2015 Nov 6.

Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2015.11.001DOI Listing
March 2016

Outcomes After Surgery in High-Risk Patients With Early Stage Lung Cancer.

Ann Thorac Surg 2016 Mar 10;101(3):1043-50; Discussion 1051. Epub 2015 Nov 10.

Department of Surgery, Emory University School of Medicine, Atlanta, Georgia; Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia.

Background: Patients with early stage lung cancer considered high risk for surgery are increasingly being treated with nonsurgical therapies. However, consensus on the classification of high risk does not exist. We compared clinical outcomes of patients considered to be high risk with those of standard-risk patients, after lung cancer surgery.

Methods: A total of 490 patients from our institutional Society of Thoracic Surgeons data from 2009 to 2013 underwent resection for clinical stage I lung cancer. High-risk patients were identified by ACOSOG z4032/z4099 criteria: major: forced expiratory volume in 1 second (FEV1) 50% or less or diffusing capacity of lung for carbon monoxide (Dlco) 50% or less; and minor: (two of the following), age 75 years or more, FEV1 51% to 60%, or Dlco 51% to 60%. Demographics, perioperative outcomes, and survival between high-risk and standard-risk patients undergoing lobectomy and sublobar resection were compared. Univariate analysis was performed using the χ(2) test/Fisher's exact test and the t test/Mann-Whitney U test. Survival was studied using a Cox regression model to calculate hazard ratios, and Kaplan-Meier survival curves were drawn.

Results: In all, 180 patients (37%) were classified as high risk. These patients were older than standard-risk patients (70 years versus 65 years, respectively; p < 0.0001) and had worse FEV1 (57% versus 85%, p < 0.0001), and Dlco (47% versus 77%, p < 0.0001). High-risk patients also had more smoking pack-years than standard-risk patients (46 versus 30, p < 0.0001) and a greater incidence of chronic obstructive pulmonary disease (72% versus 32%, p < 0.0001), and were more likely to undergo sublobar resection (32% versus 20%, p = 0.001). Length of stay was longer in the high-risk group (5 versus 4 days, p < 0.0001), but there was no difference in postoperative mortality (2% versus 1%, p = 0.53). Nodal upstaging occurred in 20% of high-risk patients and 21% of standard-risk patients (p = 0.79). Three-year survival was 59% for high-risk patients and 76% for standard-risk patients (p < 0.0001).

Conclusions: Good clinical outcomes after surgery for early stage lung cancer can be achieved in patients classified as high risk. In our study, surgery led to upstaging in 20% of patients and acceptable 1-, 2-, and 3-year survival as compared with historical rates for nonsurgical therapies. This study suggests that empiric selection criteria may deny patients optimal oncologic therapy.
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http://dx.doi.org/10.1016/j.athoracsur.2015.08.088DOI Listing
March 2016

Transthoracic versus transhiatal resection for esophageal adenocarcinoma of the lower esophagus: A value-based comparison.

J Surg Oncol 2015 Oct 16;112(5):517-23. Epub 2015 Sep 16.

Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.

Background And Objective: Our objective was to compare clinical outcomes, costs, and resource use based on operative approach, transthoracic (TT) or transhiatal (TH), for resection of esophageal cancer.

Methods: This cohort analysis utilized the Surveillance, Epidemiology, and End Results--Medicare linked data from 2002 to 2009. Only adenocarcinomas of the lower esophagus were examined to minimize confounding. Medicare data was used to determine episode of care costs and resource use. Propensity score matching was used to control for identified confounders. Kaplan-Meier method and Cox-proportional hazard modeling were used to compare long-term survival.

Results: 537 TT and 405 TH resections were identified. TT and TH esophagectomy had similar complication rates (46.7% vs. 50.8%), operative mortality (7.9% vs 7.1%), and 90 days readmission rates (30.5% vs. 32.5%). However, TH was associated with shorter length of stay (11.5 vs. 13.0 days, P = 0.006) and nearly $1,000 lower cost of initial hospitalization (P = 0.03). No difference in 5-year survival was identified (33.5% vs. 36%, P = 0.75).

Conclusions: TH esophagectomy was associated with lower costs and shorter length of stay in an elderly Medicare population, with similar clinical outcomes to TT. The TH approach to esophagectomy for distal esophageal adenocarcinoma may, therefore, provide greater value (quality/cost).
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http://dx.doi.org/10.1002/jso.24024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4664447PMC
October 2015

Endotracheal Tube Management and Obstructed Airway.

Thorac Surg Clin 2015 Aug;25(3):279-88

General Thoracic Surgery, Division of Cardiothoracic Surgery, Emory University Hospital, Emory University School of Medicine, 1365A Clifton Road Northeast, Atlanta, GA 30322, USA. Electronic address:

Thoracic surgery encompasses a wide array of surgical techniques, most of which require lung isolation for surgical exposure in the pleural cavity; this, in turn, demands an extensive knowledge of respiratory mechanics and modalities of airway control. Likewise, effective treatment of an acute central airway obstruction calls for a systematic approach using clear communication between teams and a comprehensive knowledge of available therapeutic modalities by the surgeon.
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http://dx.doi.org/10.1016/j.thorsurg.2015.04.002DOI Listing
August 2015

Nonclinical Factors Associated with 30-Day Mortality after Lung Cancer Resection: An Analysis of 215,000 Patients Using the National Cancer Data Base.

J Am Coll Surg 2015 Aug 16;221(2):550-63. Epub 2015 Apr 16.

Department of Surgery, Emory University School of Medicine, Atlanta, GA; Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA. Electronic address:

Background: Clinical variables associated with 30-day mortality after lung cancer surgery are well known. However, the effects of nonclinical factors, including insurance coverage, household income, education, type of treatment center, and area of residence, on short-term survival are less appreciated. We studied the National Cancer Data Base, a joint endeavor of the Commission on Cancer of the American College of Surgeons and the American Cancer Society, to identify disparities in 30-day mortality after lung cancer resection based on these nonclinical factors.

Study Design: We performed a retrospective cohort analysis of patients undergoing lung cancer resection from 2003 to 2011 using the National Cancer Data Base. Data were analyzed using a multivariable logistic regression model to identify risk factors for 30-day mortality.

Results: During our study period, 215,645 patients underwent lung cancer resection. We found that clinical variables, such as age, sex, comorbidity, cancer stage, preoperative radiation, extent of resection, positive surgical margins, and tumor size were associated with 30-day mortality after resection. Nonclinical factors, including living in lower-income neighborhoods with a lesser proportion of high school graduates, and receiving cancer care at a nonacademic medical center were also independently associated with increased 30-day postoperative mortality.

Conclusions: This study represents the largest analysis of 30-day mortality for lung cancer resection to date from a generalizable national cohort. Our results demonstrate that, in addition to known clinical risk factors, several nonclinical factors are associated with increased 30-day mortality after lung cancer resection. These disparities require additional investigation to improve lung cancer patient outcomes.
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http://dx.doi.org/10.1016/j.jamcollsurg.2015.03.056DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4514912PMC
August 2015

Percutaneous fiducial localization for thoracoscopic wedge resection of small pulmonary nodules.

Ann Thorac Surg 2014 Jun 12;97(6):1914-8; discussion 1919. Epub 2014 Apr 12.

Department of Surgery, Division of Cardiothoracic Surgery, Emory University, Emory University Hospital, Atlanta, Georgia.

Background: The advent of high-resolution computed tomography scanning and increase in use of chest imaging for high-risk patients has led to an increase in the identification of small pulmonary nodules. The ability to locate and remove these nodules through a thoracoscopic approach is difficult. The purpose of this study is to report our experience with fiducial localization and percutaneous thoracoscopic wedge resection of small pulmonary nodules.

Methods: This is a retrospective analysis of our patients who underwent computed tomography-guided fiducial localization of pulmonary nodules. Nodules were identified with intraoperative fluoroscopy and removed by thoracoscopic wedge resection.

Results: Sixty-five nodules were removed in 58 patients. Removal was successful in 98% of patients (57 of 58); 79% of the nodules (53 of 65) were cancers; 20% of these were primary lung cancers of which 9 were pure ground-glass opacities. Mean size of the nodules was 9.9 ± 4.6 mm (range, 3 to 24 mm). Mean depth from visceral pleural surface was 18.7 ± 12 mm (range, 2 to 35 mm). Mean procedure time was 58.7 ± 20.1 minutes (range, 30 to 120), and mean length of stay was 2 days (range, 1 to 6). Complications occurred in 3 patients and included fiducial embolization, fiducial migration, and parenchymal hematoma.

Conclusions: Fiducial localization facilitates identification and removal of small pulmonary nodules and alleviates the need for direct nodule palpation. As shown by our series, thoracoscopic wedge resection with fiducial localization is an accurate and efficient technique. This method provides a standardized means by which to resect small and deep pulmonary nodules or ground-glass opacities.
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http://dx.doi.org/10.1016/j.athoracsur.2014.02.028DOI Listing
June 2014

Thoracoscopy without lung isolation utilizing single lumen endotracheal tube intubation and carbon dioxide insufflation.

Ann Thorac Surg 2013 Aug 21;96(2):439-44. Epub 2013 Jun 21.

Emory University Department of Surgery, Division of Cardiothoracic Surgery, Atlanta, Georgia, USA.

Background: This study evaluated the feasibility of performing thoracoscopy without lung isolation employing single lumen endotracheal tube (SLET) intubation and carbon dioxide insufflation.

Methods: Eighty-two patients underwent a variety of thoracoscopic procedures without lung isolation using SLET intubation and carbon dioxide (CO2) insufflation between January and December 2012. Sixty-five of these patients underwent wedge resections and were isolated for analysis. Operations were accomplished using percutaneously placed laparoscopic trocars and insufflation up to 15 mm Hg. Operative times, length of stay, and vital signs were compared with 52 patients who underwent thoracoscopic wedge resections with double lumen endotracheal tube (DLET) intubation.

Results: A retrospective analysis was performed on 65 patients (30 females, mean age 58) who underwent thoracoscopic wedge resections with SLET intubation compared with 52 patients undergoing the same procedure with DLET intubation. Operating room time (111 ± 4.74 minutes), time to incision (49 ± 1.91 minutes), and operative time (48 ± 2.89 minutes) were significantly decreased in the SLET group (p < 0.05). Intraoperative hemodynamic parameters showed no significant aberrations. Two postoperative complications (3.1%) were identified in the SLET group. Length of stay was similar (3 ± 0.49 days versus 3 ± 0.23 days).

Conclusions: Single lumen endotracheal tube intubation is a feasible and safe airway management alternative for thoracoscopic procedures. This method resulted in shorter operative times, no aberrant hemodynamic shifts, low complication rates, and similar hospital stays as compared with traditional DLET intubation.
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http://dx.doi.org/10.1016/j.athoracsur.2013.04.060DOI Listing
August 2013

Management of T2 esophageal cancer.

Surg Clin North Am 2012 Oct 11;92(5):1169-78. Epub 2012 Aug 11.

Division of Cardiothoracic Surgery, Emory University School of Medicine, Emory University Hospital, Atlanta, GA 30322, USA.

Patients with clinically staged T2N0 esophageal cancer are a small subset of patients for whom therapy is not standardized. Current clinical staging modalities are lacking in providing accurate staging for the presumed T2N0 subset. Problems with overstaging and understaging can each have adverse consequences for the patient. Furthermore, the benefit of induction therapy versus esophagectomy followed by adjuvant therapy for upstaged patients is unproven. The management of this challenging group of patients is reviewed.
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http://dx.doi.org/10.1016/j.suc.2012.07.003DOI Listing
October 2012

Timely airway stenting improves survival in patients with malignant central airway obstruction.

Ann Thorac Surg 2010 Oct;90(4):1088-93

Division of Thoracic Surgery, St. Luke's-Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, New York, New York, USA.

Background: The survival of patients with malignant central airway obstruction is very limited. Although airway stenting results in significant palliation of symptoms, data regarding improved survival after stenting for advanced thoracic cancer with central airway obstruction are lacking.

Methods: Fifty patients received a total of 72 airway stents for malignant central airway obstruction over a two-year period at a single institution. The Medical Research Council (MRC) dyspnea scale and Eastern Cooperative Oncology Group (ECOG) performance status were used to divide patients into a poor performance group (MRC = 5, ECOG = 4) and an intermediate performance group (MRC ≤ 4, ECOG ≤ 3). The SPSS version 16.0 (SPSS Inc, Chicago, IL) and Microsoft Excel (Microsoft, Redmond, WA) were used to analyze the data. Survival curves were constructed using the Kaplan-Meier survival analysis method and a log-rank test was used to compare the survival distributions among different groups.

Results: Successful patency of the airway was achieved in all patients with no procedure-related mortality. Stenting resulted in significant improvement in MRC and ECOG performance scores (p < 0.01). Significantly improved survival was observed only in patients in the intermediate performance group compared with patients in the poor performance group (p < 0.05).

Conclusions: Airway stenting resulted in significant palliation of symptoms in both groups as evaluated by MRC dyspnea scale and ECOG performance status. Compared with historic controls, a significant survival advantage was seen only in the intermediate performance group. We postulate that timely stenting of the airway, before the morbid complications of malignant central airway obstruction have set in, results in improved survival.
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http://dx.doi.org/10.1016/j.athoracsur.2010.06.093DOI Listing
October 2010
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