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Background: Collaborative quality consortia can facilitate implementation of quality measures arising from clinical databases. Our statewide general thoracic surgery (GTS) collaborative investigated the influences of cigarette smoking status on mortality and major morbidity following lobectomy for lung cancer., Methods: Society of Thoracic Surgeons General Thoracic Surgery Database records were identified from 14 institutions participating in a statewide thoracic surgical quality collaborative between 2012 and 2017. We excluded patients with nonelective procedures, stage 0 tumors, American Society of Anesthesiologists class VI disease, and missing clinical characteristics. Outcomes analysis included the combined mortality and major postoperative morbidity rates and the influence of patient characteristics, including smoking status, on composite rate and on postoperative complications., Results: The study cohort included 2267 patient records for analysis. Overall combined mortality and major morbidity rate was 10.2% (n = 231). Postoperative 30-day mortality was 1.5%, and major morbidity 9.6%. Significant predictors of the combined outcome included male sex (P = .004), body mass index (P < .001), Zubrod score (P = .02), smoking pack-years (P = .03), and thoracotomy (P < .001). Higher American Society of Anesthesiologists disease class and advanced tumor stage were marginally associated with worse combined outcome (P = .06). Smoking status; that is, current, past (no smoking within 30 days), or never smoked, was not associated with worse combined outcome (P = .56) and had no significant influence on major complications., Conclusions: Smoking status was not associated with worse outcomes; however, smoking dose (pack-years) was associated with worse combined mortality and major morbidity. A statewide quality collaborative provides constructive feedback for participating institutions and surgeons, promoting quality improvement in perioperative patient care strategies and improved outcomes., (Copyright © 2020. Published by Elsevier Inc.)

Introduction: Endoscopic therapy (ET) and esophagectomy result in similar survival for Barrett's esophagus (BE) with high-grade dysplasia (HGD) or T1a esophageal adenocarcinoma (EAC), but the long-term quality of life (QOL) has not been compared., Aims: We aimed to compare long-term QOL between patients who had undergone ET versus esophagectomy., Methods: Patients were included if they underwent ET or esophagectomy at the University of Michigan since 2000 for the treatment of HGD or T1a EAC. Two validated survey QOL questionnaires were mailed to the patients. We compared QOL between and within groups (ET = 91, esophagectomy = 62), adjusting for covariates., Results: The median time since initial intervention was 6.8 years. Compared to esophagectomy, ET patients tended to be older, had a lower prevalence of EAC, and had a shorter duration since therapy. ET patients had worse adjusted physical and role functioning than esophagectomy patients. However, the adjusted odds ratio (OR) of having symptoms was significantly less with ET for diarrhea (0.287; 95% confidence interval [CI] = 0.114, 0.724), trouble eating (0.207; 0.0766, 0.562), choking (0.325; 0.119, 0.888), coughing (0.291; 0.114, 0.746), and speech difficulty (0.306; 0.0959, 0.978). Amongst the ET patients, we found that the number of therapy sessions and need for dilation were associated with worse outcomes., Discussion: Multiple measures of symptom status were better with ET compared to esophagectomy following treatment of BE with HGD or T1a EAC. We observed worse long-term physical and role functioning in ET patients which could reflect unmeasured baseline functional status rather than a causal effect of ET.

Background: Esophageal cancer, chemotherapy, and radiation are all associated with an increased incidence of thromboembolic events (TEE). Development of a TEE during neoadjuvant treatment for esophageal cancer can alter the treatment course, as surgery may be delayed or cancelled because patients require anticoagulation therapy. We evaluated the incidence of preoperative TEE among esophageal cancer patients undergoing neoadjuvant treatment and the impact on morbidity, mortality, and timing of surgery., Methods: We performed a retrospective review of a prospectively collected database of 1,057 patients who underwent esophagectomy for esophageal cancer between January 1999 and May 2010. Of these patients, 534 were treated with neoadjuvant chemotherapy and radiation., Results: Preoperative thromboembolic events occurred in 75 of 534 patients (14.0%). The only preoperative factor associated with increased risk of TEE was increased preoperative weight (p=0.02). Fluorouracil significantly increased the risk of TEE (p=0.028, odds ratio 2.12, 95% confidence interval: 1.09 to 4.26), whereas there was no difference in patients receiving cisplatin (p=0.299). There was a trend toward an association between infectious complications during neoadjuvant therapy and TEE development (p=0.076). Patients with TEEs had a delay from neoadjuvant therapy to surgery (p=0.0004). The TEE group had a trend toward the increased onset of postoperative atrial fibrillation (p=0.0688, odds ratio 1.77, 95% confidence interval: 0.96 to 3.27). There was no difference in respiratory complications (p=0.934), overall complications (p=0.859), 30-day mortality (p=0.899), or overall survival (p=0.790)., Conclusions: Thromboembolic events in the preoperative period delay the time to surgery for patients with esophageal cancer. Despite this delay, there is no demonstrable effect on postoperative complications or mortality., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: For recalcitrant cervical esophagogastric anastomotic strictures after transhiatal esophagectomy, a protocol of self-dilatation was developed at the University of Michigan Medical Center, as previously described. This study was undertaken to determine the outcomes of this treatment., Methods: Self-dilatation was required in 158 (7.6%) of 2075 patients with cervical esophagogastric anastomotic strictures after transhiatal esophagectomy. An esophageal-specific survey evaluated the frequency and duration of dilatation, swallowing function, and satisfaction with treatment. The relationship among anastomotic leak, subsequent stricture, and the need for self-dilatation was assessed. A validated survey tool, the Short Form 36-item, version 2, was used to assess quality of life., Results: At the time of this study, 78 of 158 patients were alive; 34 (43%) participated in the esophageal-specific survey. Median duration of self-dilatation was 10 years. The majority were satisfied with their ability to eat. No adverse events were reported. All patients said they would use self-dilatation therapy again under similar circumstances. Of these patients, 20 (59%) responded to the Short Form 36-item, version 2. Compared with the general population, 55% and 70% of participants scored at or above the norm for physical health and mental health status, respectively. Patients who required self-dilatation were twice as likely to have a history of cervical esophagogastric anastomotic leak as those who did not require this therapy (P=.0002)., Conclusions: Refractory cervical esophagogastric anastomotic strictures are best managed initially with frequent outpatient dilatations, then transitioning to self-dilatation. Home use of Maloney dilators is a safe, well-tolerated, convenient, and cost-effective way to maintain comfortable swallowing. The effectiveness of self-dilatation therapy is reflected in this cohort's good quality of life and level of functioning., (Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

As with other high-risk surgical procedures demonstrated to have a wide variance in perioperative survival among centers, there appears to be a relationship between operation volume and patient survival following lung transplantation. Two recent studies evaluated this relationship using the United Network for Organ Sharing transplant registry and are highlighted in this article. While increasing lung transplantation volume is associated with improved early and longer-term patient survival, the impact of this relationship may be no greater than other patient and donor risk factors, and may be a surrogate for other as yet unidentified center-specific processes of care., (Copyright © 2010 Elsevier Inc. All rights reserved.)

To ascertain the prevalence of carcinoma in esophagi resected for high-grade dysplasia (HGD) using current criteria and to evaluate histologic features that may predict concurrent carcinoma, we studied specimens from 127 esophagectomies performed for HGD, or HGD "suspicious" for carcinoma (HGD/S) in Barrett mucosa. Corresponding biopsy specimens in 69 cases were reviewed and reclassified. Based on original diagnoses, carcinoma was present in 15 (17%) of 89 HGD and 28 (74%) of 38 HGD/S cases. By reclassification, only 1 (5%) of 21 cases with HGD had carcinoma in the resection specimen. Of 25 cases reclassified as HGD/S, 18 (72%) had carcinoma in the resection specimen, as did 17 (74%) of 23 reclassified as adenocarcinoma. With 1 additional select histologic feature, the risk of carcinoma was 39%; with 2 or more features, the risk increased to 83% to 88%. Based on current criteria, no more than 5% of esophagectomies performed for a biopsy diagnosis of Barrett HGD harbor carcinoma. When HGD/S is diagnosed based on certain additional features, carcinoma is found in nearly 40% of cases with 1 feature and more than 80% with 2 or more features. Our findings highlight the evolution of diagnostic criteria for Barrett dysplasia.