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With the publication of CALGB 140503, an increase in wedge resections for small, peripheral non-small cell lung cancer is expected; however, a relative paucity of data exists as to what defines a high quality oncologic wedge resection. The Thoracic Surgery Outcomes Research Network (ThORN), through expert discussion, guided by review of what limited data does exist, and through use of a modified Delphi process, provides these consensus statements defining an oncologically sound, high quality wedge resection. The statements are classified into five categories: 1) Preoperative Considerations 2) Technical Aspects 3) Lymph Node Assessment 4) Margin Assessment and 5) Tissue Handling by Pathology., (Copyright © 2025. Published by Elsevier Inc.)

Background: The contemporary management and resectability of locally advanced lung cancer are undergoing significant changes as new data emerge regarding immunotherapy and targeted treatments. The objective of this document is to review the literature and present consensus among a group of multidisciplinary experts to guide the determination of resectability and management of locally advanced non-small cell lung cancer (NSCLC) in the context of contemporary evidence., Methods: The Society of Thoracic Surgeon Workforce on Thoracic Surgery assembled a multidisciplinary expert panel composed of thoracic surgeons and medical and radiation oncologists with established expertise in the management of lung cancer. A focused literature review was performed, and expert consensus statements were developed using a modified Delphi process to address 3 major themes: (1) assessing resectability and multidisciplinary management of locally advanced lung cancer, (2) neoadjuvant (including perioperative) therapy, and (3) adjuvant therapy., Results: A consensus was reached on 19 recommendations. These consensus statements reflect updated insights on resectability and multidisciplinary management of locally advanced lung cancer based on the latest literature and current clinical experience, mainly focusing on the appropriateness of surgical therapy and emerging data regarding neoadjuvant and adjuvant therapies., Conclusions: Despite the complex decision-making process in managing locally advanced lung cancer, this expert panel agreed on several key recommendations. This document provides guidance for thoracic surgeons and other medical professionals in the optimal management of locally advanced lung cancer based on the most updated evidence and literature., Competing Interests: Disclosures Samuel S. Kim reports a relationship with Intuitive Surgical Inc that includes: funding grants and speaking and lecture fees. David T. Cooke reports a relationship with Bristol-Myers Squibb Co that includes: speaking and lecture fees. Biniam Kidane reports a relationship with AstraZeneca Pharmaceuticals LP that includes: consulting or advisory and speaking and lecture fees; with Merck & Co Inc that includes: consulting or advisory and speaking and lecture fees; with Roche that includes: consulting or advisory and speaking and lecture fees; with Medtronic that includes: consulting or advisory and speaking and lecture fees; and with Olympus Corporation that includes: consulting or advisory and speaking and lecture fees. Samuel S. Kim reports a relationship with AstraZeneca Pharmaceuticals LP that includes: consulting or advisory. Luis Tapia Vargas reports a relationship with AstraZeneca Pharmaceuticals LP that includes: consulting or advisory. Jyoti Patel reports a relationship with AbbVie Inc that includes: consulting or advisory; with AstraZeneca Pharmaceuticals LP that includes: consulting or advisory; with Bristol-Myers Squibb Co that includes: consulting or advisory; with Gilead Sciences Inc that includes: consulting or advisory; with Guardant Health Inc that includes: consulting or advisory; with Sanofi that includes: consulting or advisory; with Tempus that includes: consulting or advisory; with AnHeart Therapeutics that includes: consulting or advisory; with Blueprint Genetics that includes: consulting or advisory; and with Black Diamond Therapeutics that includes: consulting or advisory. Joel Neal reports a relationship with AstraZeneca Pharmaceuticals LP that includes: consulting or advisory; with Genetec Inc that includes: consulting or advisory; with Exelixis Inc that includes: consulting or advisory; with Takeda Pharmaceutical Company Ltd that includes: consulting or advisory; with Eli Lilly and Company that includes: consulting or advisory; with Amgen Inc that includes: consulting or advisory; with Sanofi that includes: consulting or advisory; and with Bristol-Myers Squibb Co that includes: consulting or advisory. Joseph Shrager reports a relationship with AstraZeneca Pharmaceuticals LP that includes: consulting or advisory and with Becton Dickinson and Company that includes: consulting or advisory. The other authors have no conflicts of interest to disclose., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Before lung cancer resection, patients inquire about dyspnea and the potential need for supplemental oxygen. The objective of this study was to identify predictors of discharge with supplemental oxygen for patients undergoing lobectomy for lung cancer., Methods: Using The Society of Thoracic Surgeons General Thoracic Surgery Database, study investigators conducted a retrospective cohort study of patients who underwent lobectomy for lung cancer from July 2018 to December 2021. Multivariable logistic regression was used to determine the adjusted association of pulmonary function with discharge on supplemental oxygen and identify independent predictors of discharge with supplemental oxygen. Pulmonary function was modeled as the minimum of either predicted postoperative forced expiratory volume in 1 second or predicted postoperative diffusing capacity of lung for carbon monoxide., Results: Overall, 2100 (8.4%) patients who underwent lobectomy were discharged with supplemental oxygen. Those patients with a minimum of either predicted postoperative forced expiratory volume in 1 second or predicted postoperative diffusing capacity of lung for carbon monoxide ≤60% had a progressively increased risk of discharge with supplemental oxygen than patients with minimum function >60%. The 2 strongest predictors of discharge with supplemental oxygen were increasing body mass index (25-29 kg/m 2 : adjusted odds ratio [aOR], 1.38; 95% CI, 1.21-1.57; 30-39 kg/m 2 : aOR, 2.14; 95% CI, 1.88-2.45; ≥40 kg/m 2 : aOR, 3.51; 95% CI, 2.79-4.39; reference, 18.5-24 kg/m 2 ) and former (aOR, 2.04; 95% CI, 1.67-2.52) or current (aOR, 2.61; 95% CI, 2.10-3.26) smoking status (reference, never smoker)., Conclusions: Of those patients who underwent lobectomy for lung cancer, 8.4% were discharged with supplemental oxygen. The study identified preoperative independent predictors of discharge with supplemental oxygen that may be useful during shared decision-making discussions of treatment options for lung cancer and setting expectations with patients., Competing Interests: Disclosures Brian Mitzman reports a relationship with Intuitive Surgical that includes: consulting or advisory, speaking and lecture fees, and travel reimbursement; and reports membership on The Annals of Thoracic Surgery editorial board. Luis Godoy reports a relationship with Intuitive Surgical that includes: consulting or advisory, speaking and lecture fees, and travel reimbursement. All other authors declare that they have no conflicts of interest., (Copyright © 2024 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: With robotic technology's rapid growth and integration, an urgent need to bridge the educational gap in thoracic surgical training has emerged. This document, a result of consensus among a group of experts in the practice and training of robotic surgery from the Society of Thoracic Surgeons (STS), aims to provide a framework for a standardized national robotic curriculum for thoracic surgery trainees., Methods: The STS Task Force on Robotic Thoracic Surgery and Workforce on E-learning and Educational Innovation assembled an expert group with the input of the Thoracic Surgery Director's Association (TSDA). A focused literature review was performed, and expert consensus statements were developed using a modified Delphi process to address three major themes: (1) Program expectations, (2) Components of training, and (3) Assessment and feedback., Results: A consensus was reached on 12 recommendations. These consensus statements reflect updated insights on developing a standardized robotics curriculum based on the latest literature and current educational experience, focusing on program expectations and educational guidelines to develop an optimal training curriculum., Conclusions: The expert panel provides several key recommendations to provide a framework for developing a standardized national robotic thoracic curriculum, which would improve resident education and abridge any educational disparity that may exist among programs., (Copyright © 2024. Published by Elsevier Inc.)

Background: Cardiothoracic surgery lacks gender and racial/ethnic diversity. Recent studies have highlighted disparities based on gender and race/ethnicity among academic cardiothoracic surgeons. The impact of the intersection of these factors on representation and salary is unknown., Methods: A cross-sectional analysis of Accreditation Council for Graduate Medical Education and Association of American Medical Colleges data was performed on the number of trainees and clinical faculty stratified by race/ethnicity and gender using χ 2 testing., Results: The number of women and underrepresented minorities was low in cardiothoracic surgery compared with other specialties, with lowest representation at the intersection of race/ethnicity and gender. Among trainees, 8% were Asian, 2% were Black/African American , and 1.5% were Hispanic/Latina women. Among cardiothoracic faculty, 3.4% were Asian, 0.8% were Black/African American, and 0.4% were Hispanic/Latina women. Women in academic medicine, surgery, and cardiothoracic surgery earned 80%-87% the salary of men of equal academic rank. White assistant professors earned more than their colleagues (all clinical faculty, surgeons, and cardiothoracic surgeons), this difference was further compounded by gender., Conclusions: Salary disparities exist among cardiothoracic surgeons at the intersection of gender and race/ethnicity. Women experience salary disparity across all academic ranks and specialties. When considering the intersection of gender and race/ethnicity, gender is the predominant factor driving salary inequity., Competing Interests: Disclosures The authors have no conflicts of interest to disclose., (Copyright © 2024. Published by Elsevier Inc.)

Background: Diversity in the physician workforce improves patient care, physician well-being, and innovation. Workforce diversity is dependent on fair compensation that is unbiased by race or ethnicity. The purpose of this study was to determine whether a disparity of representation and salary on the basis of race or ethnicity exists in academic cardiothoracic surgery., Methods: Study investigators performed a cross-sectional analysis of data collected by the Accreditation Council of Graduate Medical Education (ACGME) and the Association of American Medical Colleges (AAMC) faculty data for US medical school faculty 2021 and 2022. Salary data were not available if an academic rank and race or ethnicity had fewer than 6 cardiothoracic surgeons. Study investigators performed a descriptive analysis of the number of faculty and compared median and mean salaries according to academic rank using a paired t test., Results: Of the 758 academic cardiothoracic surgeons, 64.9% were White, 25.2% were Asian, 3.3% were Black or African American, 4.9% were Hispanic or Latino, and 1.7% were of other race or ethnicity. Cardiothoracic surgeons at the academic rank of professor were 74.6% White, 17.7% Asian, 3.4% Black or African American, 3.9% Hispanic or Latino, and 0.4% other races. Asian faculty earned 89% to 171%, Black or African American faculty earned 59% to 94%, and Hispanic or Latino faculty earned 84% to 165% of the median salary earned by White faculty. Black or African American faculty consistently and significantly (P = .002) earned lower median salaries compared with White faculty at each academic rank measured., Conclusions: The academic cardiothoracic surgery workforce lacks diversity, especially at the highest academic ranks. Salary equity among races or ethnicities is complex, requiring additional study. However, Black or African American cardiothoracic surgeons experience low representation and salary disparity at every academic rank measured., Competing Interests: Disclosures Cherie P. Erkmen reports financial support from the National Cancer Institute, National Institutes of Health. All other authors declare that they have no conflicts of interest., (Copyright © 2024 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Gender disparity in the cardiothoracic surgery workforce is challenging to enumerate and quantify. The purpose of our work is to use the most current data to quantify the percentage of women in academic cardiothoracic surgery and salary disparity between women and men., Methods: We performed a cross-sectional analysis of data collected by the Accreditation Council for Graduate Medical Education Data Resource Book 2021 and Association of American Medical Colleges Faculty Data for U.S. Medical School Faculty 2019, 2020, and 2021. We used descriptive analysis of the number of faculty and mean salaries of academic cardiothoracic surgeons according to academic rank and gender. Salary disparity in cardiothoracic surgery was compared with salary disparities seen among surgical specialties and academic clinicians., Results: Over the past 3 years, women comprised 11.5% of the cardiothoracic workforce. In 2021, cardiothoracic surgeons who were women earned $0.71 to $0.86 for every $1.00 earned by cardiothoracic surgeons who were men. Ascending academic rank correlated with greater gender salary disparity; women professors earned less than men of equal and lower academic rank. From 2019 to 2021, women of the academic ranks of associate professor, professor, and chief of cardiothoracic surgery experienced a decrease in mean salaries, whereas men of equivalent academic ranks experienced an increase in mean salaries., Conclusions: Gender disparity in cardiothoracic surgery persists, with low representation of women and salary disparity at every academic rank., (Copyright © 2024. Published by Elsevier Inc.)

Background: The integrated 6-year thoracic surgery (I-6) residency model was developed in part to promote early interest in cardiothoracic surgery in diverse trainees. To determine gaps in and opportunities for recruitment of women and minority groups in the pipeline for I-6 residency, we quantified rates of progression at each training level and trends over time., Methods: We obtained 2015 to 2019 medical student, I-6 applicant, and I-6 resident gender and race/ethnicity demographic data from the American Association of Medical Colleges and Electronic Residency Application Service public databases and Accreditation Council for Graduate Medical Education Data Resource Books. We performed χ 2 , Fisher exact, and Cochran-Armitage tests for trend to compare 2015 and 2019., Results: Our cross-sectional analysis found increased representation of women and all non-White races/ethnicities, except Native American, at each training level from 2015 to 2019 (P < .001 for all). The greatest trends in increases were seen in the proportions of women (28% vs 22%, P = .46) and Asian/Pacific Islander (25% vs 15%, P = .08) applicants. There was also an increase in the proportions of women (28% vs 24%, P = .024) and White (61% vs 58%, P = .007) I-6 residents, with a trend for Asian/Pacific Islanders (20% vs 17%, P = .08). The proportions of Hispanic (5%) and Black/African American (2%) I-6 residents in 2019 remained low., Conclusions: I-6 residency matriculation is not representative of medical student demographics and spotlights a need to foster early interest in cardiothoracic surgery among all groups underrepresented in medicine while ensuring that we mitigate bias in residency recruitment., (Copyright © 2023 The Society of Thoracic Surgeons. All rights reserved.)

Background: Despite demonstration of its clear benefits relative to open approaches, a video-assisted thoracic surgery technique for pulmonary lobectomy has not been universally adopted. This study aims to overcome potential barriers by establishing the essential components of the operation and determining which steps are most useful for simulation training., Methods: After randomly selecting experienced thoracic surgeons to participate, an initial list of components to a lower lobectomy was distributed. Feedback was provided by the participants, and modifications were made based on anonymous responses in a Delphi process. Components were declared essential once at least 80% of participants came to an agreement. The steps were then rated based on cognitive and technical difficulty followed by listing the components most appropriate for simulation., Results: After 3 rounds of voting 18 components were identified as essential to performance of a video-assisted thoracic surgery for lower lobectomy. The components deemed the most difficult were isolation and division of the basilar and superior segmental branches of the pulmonary artery, isolation and division of the lower lobe bronchus, and dissection of lymphovascular tissue to expose the target bronchus. The steps determined to be most amenable for simulation were isolation and division of the branches of the pulmonary artery, the lower lobe bronchus, and the inferior pulmonary vein., Conclusions: Using a Delphi process a list of essential components for a video-assisted thoracic surgery for lower lobectomy was established. Furthermore 3 components were identified as most appropriate for simulation-based training, providing insights for future simulation development., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Women and racial and ethnic minorities are underrepresented among U.S. physicians, but are limited data on cardiothoracic surgery diversity. This study characterizes current racial and ethnic and gender diversity in academic cardiothoracic surgery., Methods: Accreditation Council for Graduate Medical Education and Association of American Medical Colleges databases were queried for racial and ethnic and gender demographics of residents and faculty. Cardiothoracic surgery was compared with other surgical subspecialties and medicine overall., Results: A total of 17% of cardiothoracic faculty were women, compared with 27% of surgical faculty (P < .01) and 43% of clinical faculty (P < .01). A total of 63% of cardiothoracic faculty were White, compared with 70% of surgical faculty (P < .01) and 66% of clinical faculty (P = .10). A total of 24% of cardiothoracic faculty were Asian American/Pacific Islander, compared with 18% of surgical faculty (P < .01) and 20% of clinical faculty (P = .03). Black/African American and Hispanic physicians composed 3% and 5% of cardiothoracic faculty, respectively, similar to surgical and clinical faculty. A total of 24% of cardiothoracic trainees were women, compared with 36% of surgical residents (P < .01) and 46% of all residents (P < .01). A total of 66% of cardiothoracic residents were White, compared with 55% of residents overall (P < .01) and 65% of surgery residents (P = .68). A total of 18% of cardiothoracic residents were Asian American/Pacific Islander, compared with 17% of surgery residents (P = .87) and 24% of residents overall (P < .01). Black/African American and Hispanic residents composed 4% and 5% of cardiothoracic residents, respectively, similar to surgery and residents overall., Conclusions: Women and racial and ethnic minorities are significantly underrepresented among trainees and faculty in academic cardiothoracic surgery compared with surgery and medicine overall, demonstrating a need for concerted action., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Simulation-based training is a valuable component of cardiothoracic surgical education. Effective curriculum development requires consensus on procedural components and focused attention on specific learning objectives. Through use of a Delphi process, we established consensus on the steps of video-assisted thoracoscopic surgery (VATS) left upper lobectomy and identified targets for simulation., Methods: Experienced thoracic surgeons were randomly selected for participation. Surgeons voted and commented on the necessity of individual steps comprising VATS left upper lobectomy. Steps with greater than 80% of participants in agreement of their necessity were determined to have established "consensus." Participants voted on the physical or cognitive complexity of each, or both, and chose steps most amenable to focused simulation., Results: Thirty thoracic surgeons responded and joined in the voting process. Twenty operative steps were identified, with surgeons reaching consensus on the necessity of 19. Components deemed most difficult and amenable to simulation included those related to dissection and division of the bronchus, artery, and vein., Conclusions: Through a Delphi process, surgeons with a variety of practice patterns can achieve consensus on the operative steps of left upper lobectomy and agreement on those most appropriate for simulation. This information can be implemented in the development of targeted simulation for VATS lobectomy., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Executive Summary: While the United States (US) population at large is rapidly diversifying, cardiothoracic surgery is among the least diverse specialties in terms of racial and gender diversity. Lack of diversity is detrimental to patient care, physician well-being, and the relevance of cardiothoracic surgery on our nation's health. Recent events, including the coronavirus disease 2019 pandemic and the Black Lives Matter protests, have further accentuated the gross inequities that underrepresented minorities face in our country and have reignited conversations on how to address bias and systemic racism within our institutions. The field of cardiothoracic surgery has a responsibility to adopt a culture of diversity and inclusion. This kind of systemic change is daunting and overwhelming. With bias ubiquitously entangled with everyday experiences, it can be difficult to know where to start. The Society of Thoracic Surgeons Workforce on Diversity and Inclusion presents this approach for addressing diversity and inclusion in cardiothoracic surgery. This framework was adapted from a model developed by the National Institute on Minority Health and Health Disparities and includes information and recommendations generated from our literature review on diversity and inclusion. A MEDLINE search was conducted using keywords "diversity," "inclusion," and "surgery," and approaches to diversity and inclusion were drawn from publications in medicine as well as non-healthcare fields. Recommendations were generated and approved by The Society of Thoracic Surgeons Executive Committee. We present an overarching framework that conceptualizes diversity and inclusion efforts in a series of concentric spheres of influence, from the global environment to the cardiothoracic community, institution, and the individual surgeon. This framework organizes the approach to diversity and inclusion, grouping interventions by level while maintaining a broader perspective of how each sphere is interconnected. We include the following key recommendations within the spheres of influence: It is important to note that each of the spheres of influence is interconnected. Interventions to improve diversity must be coordinated across spheres for concerted change. Altogether, this multilevel framework (global environment, cardiothoracic community, institution, and individual) offers an organized approach for cardiothoracic surgery to assess, improve, and sustain progress in diversity and inclusion., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The Thoracic Surgery Social Media Network (TSSMN) is a collaborative effort of leading journals in cardiothoracic surgery to highlight publications via social media. This study aims to evaluate the 1-year results of a prospective randomized social media trial to determine the effect of tweeting on subsequent citations and nontraditional bibliometrics., Methods: A total of 112 representative original articles were randomized 1:1 to be tweeted via TSSMN or a control (non-tweeted) group. Measured endpoints included citations at 1 year compared with baseline, as well as article-level metrics (Altmetric score) and Twitter analytics. Independent predictors of citations were identified through univariable and multivariable regression analyses., Results: When compared with control articles, tweeted articles achieved significantly greater increase in Altmetric scores (Tweeted 9.4 ± 5.8 vs Non-tweeted 1.0 ± 1.8, P < .001), Altmetric score percentiles relative to articles of similar age from each respective journal (Tweeted 76.0 ± 9.1 percentile vs Non-tweeted 13.8 ± 22.7 percentile, P < .001), with greater change in citations at 1 year (Tweeted +3.1 ± 2.4 vs Non-Tweeted +0.7 ± 1.3, P < .001). Multivariable analysis showed that independent predictors of citations were randomization to tweeting (odds ratio [OR] 9.50; 95% confidence interval [CI] 3.30-27.35, P < .001), Altmetric score (OR 1.32; 95% CI 1.15-1.50, P < .001), open-access status (OR 1.56; 95% CI 1.21-1.78, P < .001), and exposure to a larger number of Twitter followers as quantified by impressions (OR 1.30, 95% CI 1.10-1.49, P < .001)., Conclusions: One-year follow-up of this TSSMN prospective randomized trial importantly demonstrates that tweeting results in significantly more article citations over time, highlighting the durable scholarly impact of social media activity., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Lung cancer surgery has a significant impact on health-related quality of life (HRQOL). In prior studies of HRQOL after lung cancer surgery, researchers selected the HRQOL domains of interest. To increase the patient-centeredness of these studies, we conducted a qualitative study to ascertain which aspects of HRQOL are most relevant to them postoperatively and to identify Patient-Reported Outcome Measurement Information System measures most germane to patients undergoing lobectomy for lung cancer., Methods: We conducted in-depth semistructured interviews with 25 patients after lobectomy for lung cancer to solicit input regarding the physical, social, and emotional HRQOL domains relevant after surgery. Interviews were transcribed verbatim, and a thematic content analysis to identify HRQOL themes was performed. Themes were integrated to create a conceptual framework to guide outcome measurement selection., Results: Qualitative analysis indicated that within the physical health domain, patients were most concerned about general physical function (100% of participants), pain (96%), fatigue (96%), and dyspnea (76%). Neuropathic pain was reported by 28% of participants. Instrumental (100%) and emotional social support (88%) and positive emotions/relief/hope (96%) were also important. Two cross-cutting themes were the desire to maintain independence (32%) and preparing for surgery/expectations (92%)., Conclusions: Our results indicate that a number of physical, social, and emotional HRQOL domains are relevant after lobectomy for lung cancer. These domains are currently represented by Patient-Reported Outcome Measurement Information System measures and can be readily assessed for clinical or research purposes., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The Thoracic Surgery Social Media Network (TSSMN) represents a collaborative effort of leading journals in cardiothoracic surgery to highlight publications via social media, specifically Twitter. We conducted a prospective randomized trial to determine the effect of scheduled tweeting on nontraditional bibliometrics of dissemination., Methods: A total of 112 representative original articles (2017-2018) were selected and randomized 1:1 to an intervention group to be tweeted via TSSMN or a control (non-tweeted) group. Four articles per day were tweeted by TSSMN delegates for 14 days. Primary endpoints included change in article-level metrics (Altmetric) score pre-tweet and post-tweet compared with the control group. Secondary endpoints included change in Twitter analytics day 1 post-tweet and day 7 post-tweet for each article compared with baseline., Results: Tweeting via TSSMN significantly improved article Altmetric scores (pre-tweet 1 vs post-tweet 8; P < .001), Mendeley reads (pre-tweet 1 vs post-tweet 3; P < .001), and Twitter impressions (day 1 post-tweet 1599 vs day 7 post-tweet 2296; P < .001). Subgroup analysis demonstrates that incorporating photos into the tweets trended toward increased link clicks to the full-text article (P = .08) whereas tweeting at 1 pm Eastern Standard Time and 9 pm Eastern Standard Time generated the highest and lowest audience reach (P = .022), respectively. Articles published in adult cardiac surgery achieved the highest change in Altmetric score (P = .028) and Mendeley reads (P = .028), and were more likely to be retweeted (P = .042) than were those published on education, general thoracic surgery, and congenital surgery., Conclusions: Social media highlights of scholarly literature via TSSMN Twitter activity improves article Altmetric scores, Mendeley reads, and Twitter analytics, with dissemination to a greater audience., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Diversity within health care organizations has many proven benefits, yet women and other groups remain underrepresented in cardiothoracic surgery. We sought to explore responses from a Society of Thoracic Surgeons (STS) survey to identify myths and barriers for informing organizational strategies in the STS and cardiothoracic surgery. We performed a qualitative review of narrative survey responses within three domains surrounding diversity in cardiothoracic surgery: myths, barriers, and strategies for improvement. Common diversity myths included diversity as a pipeline problem (24%), diversity equated to exclusivity (21%), and diversity not supporting meritocracy (18%). The most frequent barrier code was perceived prejudice (22%). Suggested strategies toward improvement were culture change prioritizing diversity (22%) and training the leaders (14%). Notably, 15% of response codes reflected the belief that disparities do not exist; thus, the issue should not be prioritized by the organization. The results do not necessarily reflect the beliefs of most of the STS membership; nonetheless, they provide important insight critical to guide any efforts toward eliminating disparities within cardiothoracic surgery and improving the care of our patients., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Diversity and inclusion within The Society of Thoracic Surgeons is paramount to the growth and excellence of our specialty. As such, discussions about challenges that prevent our Society from achieving this goal are necessary. The Workforce on Diversity and Inclusion has been tasked with understanding our membership's comprehension and experience with bias, which is known to have a negative impact on those of female gender, minority race, sexual orientation status, and religious status. Bias contributes to the fact that we are far from gender parity within our Society's leadership and that we must make significant changes in order to achieve a diverse membership. Within this report, we discuss the literature regarding experience with gender- and racial/ethnic-directed implicit and explicit bias during surgical training and within the cardiothoracic surgical workforce. We also share survey results on members' experience with racial/ethnic-, gender-, and other minority demographic-directed bias., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Cardiopulmonary assessment for lung resection is important for risk stratification, and the American College of Chest Physicians (ACCP) guidelines provide decision support. We ascertained the cardiopulmonary assessment practices of thoracic surgeons and determined whether they are guideline concordant., Methods: An anonymous survey was emailed to 846 thoracic surgeons who participate in The Society of Thoracic Surgeons General Thoracic Surgery Database. We analyzed survey responses by practice type (general thoracic [GT] versus cardiothoracic [CT]) and years in practice (0-9, 10-19, and ≥20) with the use of contingency tables. We compared adherence of survey responses with the guidelines., Results: The response rate was 24.0% (n = 203). Most surgeons (n = 121, 59.6%) cited a predicted postoperative forced expiratory volume in 1 second or diffusing capacity of lung for carbon monoxide threshold of 40% for further evaluation. Experienced surgeons (≥20 years) were more likely to have a threshold that varies by surgical approach (31.3% versus 23.5% with 10-19 years of experience and 15.9% for 0-9 years of experience, P = .007). Overall, 52.2% refer patients with cardiovascular risk factors to cardiology and 42.9% refer patients with abnormal stress testing. CT surgeons were more likely to refer all patients to cardiology than GT surgeons (17.6% versus 2.4%, P < .001). Only one respondent (0.5%) was 100% adherent to the ACCP guidelines, and 4.4% and 45.8% were 75% and 50% adherent, respectively., Conclusions: Among thoracic surgeons, there is variation in preoperative cardiopulmonary assessment practices, with differences by practice type and years in practice, and marked discordance with the ACCP guidelines. Further study of guideline adherence linked to postoperative morbidity and mortality is warranted to determine whether adherence affects outcomes., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Despite an ever-diversifying United States population, women and underrepresented minorities lack proportionate membership in the cardiothoracic surgery workforce. Many Society of Thoracic Surgeons (STS) members view achieving a diverse cardiothoracic surgery workforce as important. To address the needs of our specialty to better reflect and understand (cultural competence) our evolving communities, the STS created the Workforce on Diversity and Inclusion. The Workforce's mission is to cultivate an environment of inclusion and diversity within the STS as well as the cardiothoracic surgical specialty. This report will discuss the background for the creation of the Workforce on Diversity and Inclusion, describe the "return on investment" in diversity, the current state of diversity in surgery, illustrate STS members' views on the importance of a diverse specialty, and present current and future activities of the Workforce on Diversity and Inclusion., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The Thoracic Surgery Social Media Network (TSSMN) is a social media collaborative formed in 2015 by The Annals of Thoracic Surgery and The Journal of Thoracic and Cardiovascular Surgery to bring social media attention to key publications from both journals and to highlight major accomplishments in the specialty. Our aim is to describe TSSMN's preliminary experience and lessons learned., Methods: Twitter analytics was used to obtain information regarding the @TSSMN Twitter handle and #TSSMN hashtag. TweetChat and general hashtag #TSSMN analytics were measured using Symplur (Symplur LLC, Los Angeles, CA). A TSSMN Tweeter App was created, and its use and downloads were analyzed., Results: Hashtag #TSSMN has a total of 17,181 tweets, 2,100 users, and 32,226,280 impressions, with peaks in tweeting activity corresponding to TweetChats. Thirteen 1-hour TweetChats drew a total of 489 participants, 5195 total tweets, and 17,297,708 total impressions. The top demographic category of TweetChat participants included Doctors (47%), Advocates/Supports (11%), and Unknown (10%), with 3% characterized as patients. The TSSMN Tweeter iTunes App (Apple, Cupertino, CA) was downloaded 3319 times with global representation. A total of 859 articles were viewed through the App, with 450 articles from The Annals of Thoracic Surgery and 409 from The Journal of Thoracic and Cardiovascular Surgery., Conclusions: We demonstrate that TSSMN further enhances the ability for the journals to connect with their readership and the cardiothoracic community. Ongoing studies to correlate social media attention with article reads, article-level metrics, citations, and journal impact factor are eagerly awaited., (Copyright © 2019 The Society of Thoracic Surgeons and The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Smoking is a risk factor for complications after lung resection. Our primary aim was to ascertain thoracic surgeons' beliefs and practices on smoking cessation before lung resection., Methods: An anonymous survey was emailed to 846 thoracic surgeons who participate in The Society of Thoracic Surgeons General Thoracic Surgery Database., Results: The response rate was 23.6% (n = 200). Surgeons were divided when asked whether it is ethical to require that patients quit smoking (yes, n = 96 [48%]) and whether it is fair to have their outcomes affected by patients who do not quit (yes, n = 87 [43.5%]). Most do not require smoking cessation (n = 120 [60%]). Of those who require it, the most common required period of cessation is 2 weeks or more. Most believe that patient factors are the main barrier to quitting (n = 160 [80%]). Risk of disease progression (39% vs 17.5%, p = 0.02) and alienating patients (17.5% vs 8.8%, p = 0.04) were very important considerations of those who do not require smoking cessation versus those who do. Only 19 (9.5%) always refer to a smoking cessation program and prescribe nicotine replacement therapy and even fewer, 9 (4.5%), always refer to a program and prescribe medical therapy., Conclusions: Thoracic surgeons are divided on their beliefs and practices regarding smoking cessation before lung resection. Most believe patient factors are the main barrier to quitting and have concerns about disease progression while awaiting cessation. Very few surgeons refer to a smoking cessation program and prescribe nicotine replacement therapy or medical therapy., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The optimal extent of lung resection and lymph node (LN) assessment for surgical treatment of clinical stage T1aN0M0 typical carcinoid tumors is unclear. Using a cohort including only these patients, we aimed to determine the impact of extent of lung resection and LN assessment on overall survival., Methods: Patients undergoing lobectomy or sublobar resection for clinical stage T1aN0M0 intraparenchymal typical carcinoid tumor were identified in the National Cancer Data Base from 1998 to 2012. Kaplan-Meier analysis was used to determine overall survival. A multivariable Cox proportional hazards model was used to determine independent predictors of mortality., Results: Of 1,495 patients, 536 (35.9%) had sublobar resection (wedge resection, n = 429; segmentectomy, n = 91) and 959 (64.2%) had lobectomy. There were 366 patients (24.5%) with no LN assessment. As tumor size increased, sublobar resection decreased and LN assessment increased. Overall, 60 patients (4.0%) were upstaged. Fifty-two patients were upstaged because of LN metastases (40 pN1, 11 pN2, and 1 pN3). The 5-year overall survival rate was 87%. It was 88% for lobectomy versus 87% for sublobar resection (p = 0.3), 65% for LN upstaging versus 89% for patients without LN upstaging, and 86% for patients with no LN assessment (p = 0.002). Independent predictors of mortality included LN upstaging, age, male sex, and Charlson comorbidity index., Conclusions: For patients with clinical stage T1aN0M0 typical carcinoid, sublobar resection results in similar overall survival compared with lobectomy. However, regardless of resection type, LN assessment is important to identify LN upstaging, the strongest independent predictor of overall mortality., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The National Comprehensive Cancer Network recommends adjuvant chemotherapy (AC) for patients with completely resected (R0) pT3N0M0 non-small cell lung cancer (NSCLC) with chest wall invasion. There is minimal evidence to support this recommendation. We aimed to determine whether there is a survival benefit with AC and if so whether it depends on tumor size., Methods: Patients who had undergone R0 resection for pT3N0M0 NSCLC with chest wall invasion were identified in the National Cancer Data Base from 2008 to 2012. Multivariable Cox proportional hazards modeling was used to determine independent predictors of overall mortality., Results: Of 247 patients, 92 (37.3%) received AC. The median tumor size without AC was 42 mm (interquartile range [IQR], 30 to 60 mm) and with AC was 56 mm (IQR, 40 to 70 mm; p = 0.003). Median follow-up was 21.7 months (IQR, 10.6 to 29.1 months). There was no difference in AC based on tumor grade, but the 3-year overall survival for those with well-differentiated or moderately differentiated tumors was 68% versus 55% in those with poorly differentiated or undifferentiated tumors. Three-year overall survival for the entire cohort was 59%. There was no difference in overall survival between those who received AC and those who did not. The only significant predictor of mortality in both univariable and multivariable analyses was poorly or undifferentiated tumor grade., Conclusions: For patients with pT3N0M0 NSCLC with chest wall invasion there is no survival benefit with AC, regardless of tumor size or grade, after R0 resection. Poorly differentiated or undifferentiated tumor grade is an independent predictor of mortality., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: For advanced-stage non-small cell lung cancer, chemotherapy and chemoradiotherapy are the primary treatments. Although surgical intervention in these patients is associated with improved survival, the effect of selection bias is poorly defined. Our objective was to characterize selection bias and identify potential surgical candidates by constructing a Surgical Selection Score (SSS)., Methods: Patients with clinical stage IIIA, IIIB, or IV non-small cell lung cancer were identified in the National Cancer Data Base from 1998 to 2012. Logistic regression was used to develop the SSS based on clinical characteristics. Estimated area under the receiver operating characteristic curve was used to assess discrimination performance of the SSS. Kaplan-Meier analysis was used to compare patients with similar SSSs., Results: We identified 300,572 patients with stage IIIA, IIIB, or IV non-small cell lung cancer without missing data; 6% (18,701) underwent surgical intervention. The surgical cohort was 57% stage IIIA (n = 10,650), 19% stage IIIB (n = 3,483), and 24% stage IV (n = 4,568). The areas under the receiver operating characteristic curve from the best-fit logistic regression model in the training and validation sets were not significantly different, at 0.83 (95% confidence interval, 0.82 to 0.83) and 0.83 (95% confidence interval, 0.82 to 0.83). The range of SSS is 43 to 1,141. As expected, SSS was a good predictor of survival. Within each quartile of SSS, patients in the surgical group had significantly longer survival than nonsurgical patients (p < 0.001)., Conclusions: A prediction model for selection of patients for surgical intervention was created. Once validated and prospectively tested, this model may be used to identify patients who may benefit from surgical intervention., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The prognostic significance of the number of lymph nodes sampled (NLNS) during resection for non-small cell lung cancer (NSCLC) is unclear. The NLNS is influenced by many factors, and some have argued that it should be a surrogate for quality. We sought to determine the influence of the NLNS on overall survival and cancer-specific survival for surgically resected NSCLC., Methods: The California Cancer Registry was queried from 2004 to 2011 for cases of stage I to III NSCLC treated with surgical resection, identifying 16,393 patients. Kaplan-Meier and Cox proportional hazards modeling were used to determine the influence of NLNS on overall survival and cancer-specific survival., Results: In all, 15,195 patients had information regarding nodal sampling. Eighty percent (13,167 of 15,195) were treated with lobectomy. Patients who were younger, male, non-Hispanic white, highest socioeconomic status, higher stage, or larger size tumor had more nodes removed. Sampling fewer than 10 nodes was associated with poorer overall survival when compared with sampling 10 or more nodes after adjustment for demographic and clinical factors for stage I: overall survival hazard ratio 1.78 (95% confidence interval: 1.54 to 2.05, p < 0.0001), hazard ratio 1.43 (95% confidence interval: 1.27 to 1.59, p < 0.0001), and hazard ratio 1.16 (95% confidence interval: 1.05 to 1.28, p = 0.004), for 0, 1 to 3, and 4 to 10 nodes, respectively. Of patients who underwent sublobar resection, 43.8% had no nodes sampled., Conclusions: For NSCLC, the NLNS influenced both overall survival and cancer-specific survival, but the influence is dependent on stage. Surgeons should perform mediastinal lymphadenectomy to maximize patient survival, but the optimal NLNS remains unclear., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: For patients with advanced stage non-small cell lung cancer (NSCLC), chemotherapy and chemoradiation are the principal treatment modalities, and the role of surgical resection remains unclear. Our objective was to evaluate current trends and oncologic outcomes for advanced stage NSCLC. We hypothesized that surgery is associated with increased survival and may be an underutilized treatment modality., Methods: The California Cancer Registry was queried from 2004 to 2012 for cases of stage IIIA, IIIB, and IV NSCLC, and we identified 34,016 cases. Patients were categorized by treatment group, and linear regression was used to calculate trends in treatment and predictors of treatment group. Kaplan-Meier and Cox regression modeling were used to determine the influence of treatment group on overall survival., Results: Twenty-seven percent of patients (9,223 of 34,016) received no treatment. For the entire cohort, treatment with chemotherapy alone increased (p < 0.001), but treatment with radiation alone, surgery alone, or in any combination decreased (p = 0.011, p < 0.001, p = 0.021, p = 0.007, and p = 0.094). Treatment group, age, sex, race, socioeconomic status, stage, histology, and tumor size were all significant predictors of overall survival. Overall survival was significantly longer for patients who had surgery as part of their treatment regimen (p < 0.001)., Conclusions: For patients with advanced stage NSCLC, the use of multimodality regimens that include surgery are decreasing despite longer overall survival. Future studies are needed to identify the demographics and clinical characteristics of patients with advanced stage NSCLC who may benefit from surgery., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: We hypothesized that general thoracic surgeons (GTS) predominantly perform complex noncardiac thoracic surgery in academic hospitals compared with cardiac surgeons (CS), general surgeons, and surgical oncologists., Methods: Fiscal year 2007-2008 to 2009-2010 coding and work relative value unit data from the University Health System Consortium and Association of American Medical Colleges Faculty Practice Solutions Center database, which includes 86 academic institutions, was analyzed. Procedural groups for pneumonectomy, other pulmonary resection (including lobectomy, bilobectomy, segmentectomy, sleeve lobectomy, and video-assisted thoracoscopic surgery lobectomy-segmentectomy), and esophagectomy were evaluated., Results: Of the 1,989,055.3 total work relative value units generated for complex noncardiac thoracic surgical procedures during the study period, 77.5% were generated by GTS, compared with 9.9% by CS, 8.9% by general surgeons, and 3.7% by surgical oncologists (p<0.001). General thoracic surgeons averaged 2.1 pneumonectomies, 51.1 other pulmonary resections, and 12.2 esophagectomies per year compared with 2.1 pneumonectomies, 9.4 other pulmonary resections, and less than 1 esophagectomy per year for CS. General surgeons and surgical oncologists averaged no more than 1.6 cases per year for all categories (all p<0.001, except for pneumonectomy, in which GTS versus CS was not significantly different). To determine the use of parenchymal-sparing operations, we looked at the ratio of sleeve lobectomy to pneumonectomy and found higher usage of parenchymal-sparing techniques by GTS, relative to pneumonectomy, compared with all other groups (p<0.001). General thoracic surgeons averaged 16.0 video-assisted thoracoscopic surgery lobectomies per year compared with approximately 1 per year for all other groups (p<0.001). General thoracic surgeons had a 47.1% increase in video-assisted thoracoscopic surgery lobectomies per year compared with 27.4% for CS., Conclusions: In academic hospitals, noncardiac thoracic surgery is performed mostly by GTS, supporting academic GTS as a distinct specialty. These results may help determine hospital referral and credentialing policies, and plan general and cardiothoracic surgery residency curriculum., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The repair of nonmalignant postlaryngectomy pharyngotracheal fistulae is not commonly encountered in medical literature. This rare complication can occur years after laryngectomy for cancer and reconstruction of a neopharynx, and is often associated with adjuvant radiation to the area, making the choice of method for surgical repair critical for success. Optimally, a pedicled myofascial flap from the pectoralis major muscle, from outside the field of radiation, is used to reinforce the repair of the fistula. We present 2 rare cases., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Primary adenosquamous carcinoma (ASC) of the lung is a rare tumor that may carry a poor prognosis. We examined a national database to see if ASC exhibited distinct clinical behavior from squamous cell (SC) and adenocarcinoma (AC) of the lung., Methods: This is a retrospective study querying the Surveillance, Epidemiology, and End Results database to identify 872 surgical patients diagnosed with ASC, 7888 with SC, and 12,601 with AC of the lung from 1998 to 2002. Analysis characterized clinical variables to determine patterns of presentation and compared survival among the above three histologic groups after lobectomy for stage I and II disease., Results: ASC represented 4.1% of the 21,361 patients examined. ASC tended toward right side (56.9%) laterality and upper lobe (60.0%) location. Compared with AC, patients with ASC and SC were more likely to be male (p < 0.0001), and ASC patients had worse histologic grade (p< 0.0001). Survival after lobectomy for stage I and II disease was significantly reduced in ASC and SC compared with AC (p < 0.0001). ASC had a significantly increased hazard ratio of 1.35 and 1.27 relative to AC and SC, respectively. Other significant negative predictors of survival included tumor grade of III and IV, stage II, age, and black ethnicity., Conclusions: This large review demonstrates that ASC is an uncommon tumor with distinct clinical behavior and worse prognosis than AC and SC. Further insight into the molecular profile of ASC is needed to determine the cause of its biologic aggressiveness., (2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Concerns regarding ample employment opportunities for graduating cardiothoracic surgery residents may affect perceptions of the field and recruitment into residency programs. We present the results of the Thoracic Surgery Residents Association/Thoracic Surgery Directors Association (TSRA/TSDA) 2008 Resident Survey, and compare them with the 2007 TSRA/TSDA survey and the 2006 interim report of the Society of Thoracic Surgeons Task Force on Job Opportunities., Methods: In April 2008, the TSRA/TSDA conducted an anonymous survey, linked to the cardiothoracic surgery resident online In-training Exam, with questions germane to resident job seeking and perceptions of the specialty. Results were compared with resident surveys from 2007 and 2006., Results: Response rates for the 2008 and 2007 surveys were 100%, and 54.2% for 2006. Of graduating residents looking for employment, 61.6% had one or more job offers, compared with 64.6% and 83.5% from the 2007 and 2006 surveys, respectively. Of the respondents completing their job search, 24.5% entered private practice and 26.3% academia, compared with 12.1% and 30.1%, respectively, in the 2007 survey. Overall, 57.7% of all respondents had more than $50,000 education-related debt, compared with 54.2% of 2007 respondents. However, 71.5% of all 2008 respondents would recommend cardiothoracic surgery to a potential trainee, compared with 63.7% and 46.0% from 2007 and 2006 survey respondents, respectively., Conclusions: The 2008 survey suggests that although the majority of respondents found employment on completing residency, the percentage is less than 65%, reinforcing a need for formal networking programs or changes in residency training. Despite continued limited employment opportunities, resident impressions of cardiothoracic surgery have improved from 2006 to 2008., (2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Transhiatal esophagectomy with cervical esophagogastric anastomosis is a common approach in patients requiring esophagectomy. Factors for developing cervical esophagogastric anastomosis leaks (CEGAL), their presentation, and the value of a routine postoperative screening barium swallow in detecting CEGALs and other complications were analyzed., Methods: This single-institution retrospective study used medical records and an esophagectomy database to assess results in 1,133 patients who underwent transhiatal esophagectomy and a cervical esophagogastric anastomosis, 241 for benign disease and 892 for cancer, between January 1996 and December 2006., Results: Esophagectomy patients who experienced CEGALs included 127 (14.2%) with cancer and 23 (9.5%) with benign disease. Logistic regression analysis identified increasing number of preoperative comorbidities (p < 0.001), active smoking history (p = 0.044), and postoperative arrhythmia (p = 0.002) as risk factors for CEGALs, and a side-to-side stapled cervical esophagogastric anastomosis compared with a manually sewn one as protective (p < 0.001). For cancer patients, higher pathologic stage disease (p = 0.050) was a risk factor for CEGALs. For patients with benign disease, a higher number of prior esophagogastric operations (p = 0.007) is a risk factor for CEGALs. Of the 90.7% of CEGALs that occurred on or before postoperative day 10, cervical wound drainage (63.3%) was the most common presenting symptom. Screening barium swallow identified postoperative complications and influenced outcome in 39 patients (3.8%)., Conclusions: Higher number of preoperative comorbidities, advanced pathologic stage, postoperative arrhythmia, an increased number of prior esophagogastric surgeries, and active smoking history are risk factors for developing CEGAL, and a side-to-side stapled cervical esophagogastric anastomosis is protective. Screening barium swallow identifies few postoperative complications, but provides quality control.