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J Thorac Cardiovasc Surg 2008;135:247-254
© 2008 The American Association for Thoracic Surgery
a Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
b Division of General Thoracic Surgery, Mayo Clinic School of Medicine, Rochester, Minn
c The Duke Clinical Research Institute, Duke University, Durham, NC
d The Department of General Thoracic Surgery, Massachusetts General Hospital, Boston, Mass
e Department of General Thoracic Surgery, Duke University, Durham, NC.
Received for publication May 4, 2007; revisions received July 20, 2007; accepted for publication July 26, 2007. * Address for reprints: Mark S. Allen, MD, Mayo Clinic School of Medicine, Division of General Thoracic Surgery, Mayo Clinic, 200 First St, SW, Rochester, MN 55905. (Email: allen.mark{at}mayo.edu).
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Abstract |
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 Top Abstract IntroductionPatients and MethodsResultsDiscussionReferences |
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Methods: We identified all pulmonary resections recorded in the general thoracic surgery prospective database from 1999 to 2006. Among the 49,029 recorded operations, 9033 pulmonary resections for primary lung cancer were analyzed.
Results: There were 4539 men and 4494 women with a median age of 67 years (range 20–94 years). Comorbidity affected 79% of patients and included hypertension in 66%, coronary artery disease in 26%, body mass index of 30 kg/m2 or more in 25.7%, and diabetes mellitus in 13%. The type of resection was a wedge resection in 1649 (18.1%), segmentectomy in 394 (4.4%), lobectomy in 6042 (67%), bilobectomy in 357 (4.0%), and pneumonectomy in 591 (6.5%). Mediastinal lymph nodes were evaluated in 5879 (65%) patients; via mediastinoscopy in 1928 (21%), nodal dissection 3722 (41%), nodal sampling in 1124 (12.4%), and nodal biopsy in 729 (8%). Median length of stay was 5 days (range 0–277 days). Operative mortality was 2.5% (179 patients). One or more postoperative events occurred in 2911 (32%) patients.
Conclusion: The patients in the general thoracic surgery database are elderly, gender balanced, and afflicted by multiple comorbid conditions. Mediastinal lymph node evaluation is common and the pneumonectomy rate is low. The length of stay is short and operative mortality is low, despite frequent postoperative events.
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Introduction |
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TopAbstractIntroductionPatients and MethodsResultsDiscussionReferences |
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The operative mortality of pulmonary resection for lung cancer reported by several national databases (4%–5%) is substantially higher than that indicated in recent reports from databases that only include operations performed by dedicated thoracic surgeons (2%).1-3 Although incompletely studied, clinical training and board certification are thought to affect outcomes of surgical procedures.4 To further examine this hypothesis, we queried the general thoracic surgery portion of The Society of Thoracic Surgeons (GTS-STS) database to study the patient population, types of procedures being performed, and short-term outcomes of patients undergoing pulmonary resection for primary lung cancer by board-certified thoracic surgeons. |
Patients and Methods |
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TopAbstractIntroductionPatients and MethodsResultsDiscussionReferences |
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In 1999 the database was expanded to include data for general thoracic surgery operations. Submission to the database is voluntary and not restricted to members of the STS. Thus far, 225 surgeons have contributed to the database. The group consists of 220 (97%) board-certified thoracic surgeons, 4 (1.8%) surgeons who are in a thoracic surgery residency program accredited by the Accreditation Council for Graduate Medical Education (ACGME), and 1 (0.4%) who is not board certified in thoracic surgery. The institutional review board of each participating site has approved the use of the database for research. Data are harvested from participants on a yearly basis, and each participant received a quality report and the opportunity to amend missing or aberrant data. Data submissions are checked for completeness as well as compliance with preset limits on individual data fields. Harvested data are maintained and analyzed within the Duke Clinical Research Institute (DCRI) in full compliance with the Health Insurance Portability and Accountability Act (HIPAA) of 1996. Variables are collected on a data form that includes information about patient demographics, medical history, surgical procedures, cancer staging, and outcome (http://www.ctsnet.org/file/ThoracicDCFV2_07_Nonannotated.pdf).
Between January 1999 and July 2006, a total of 49,029 operations were entered into the GTS-STS database, including 9077 pulmonary resections for primary lung cancer. Patients without data for age, gender, or surgery date were excluded from the present study. We also excluded patients with a recorded age of 17 years or less and more than100 years. These requirements excluded 44 patients; thus 9033 patients were examined. Additional limits were imposed on individual data fields to exclude analysis of highly improbable data. We excluded body mass index data if the recorded height was less than 97 cm, forced expiratory volume in 1 second data if less than 5% of predicted, diffusion capacity of carbon monoxide data if less than 10% of predicted, and data for operative time if less than 10 minutes. Missing data were excluded from calculations. Postoperative complications occurring during the same hospitalization as the resection were defined by the STS database guidelines.5 Operative mortality is defined as death during the same hospitalization for the pulmonary resection or within 30 days of the procedure. Cancer staging was done in accordance with the American Joint Committee on Cancer (AJCC).6
For categorical variables, the prevalence was calculated from the patient records with complete data for each respective variable. For continuous variables, median values are given with the range. To estimate the annual lung resection volume among GTS-STS database participants, we averaged the number of lobectomies done per year for primary lung cancer for each participant.
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Results |
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TopAbstractIntroductionPatients and MethodsResultsDiscussionReferences |
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At least one comorbidity was present in 7173 (79%) of patients. The most prevalent comorbidities were hypertension (66%) and coronary artery disease (26%) (Table 2). A Zubrod score of 0 or 1 was present in 92% of patients. Conversely, 70% (5642) of patients were in American Society of Anesthesia (ASA) class III or greater. The median body mass index was 26.4 kg/m2 (range 15- 2 kg/m2); 25.7% of patients had a body mass index greater than 30 kg/m2.
Preoperative chemotherapy was given to 557 (6.2%) patients and 373 (4.1%) received preoperative radiotherapy. Prior thoracic surgery had been performed in 1290 (19%), but only 293 (4.3%) resections were considered as a reoperative procedure (implying that other procedures did not involve the hemithorax of the resection being reported to the database).
The procedure was considered elective in 7971 (93%) and urgent or emergency in 610 (7%). The types of procedures are listed in Table 3. Operative time (skin incision to skin closure) was available for 7833 (87%) patients. The median operative time was 152 minutes (range 10-840 minutes) and varied with the type of resection (Table 3). The surgical approach consisted of thoracotomy in 6087 patients (70%), video-assisted thoracic surgery (VATS) in 2429 (28%), and others in 230 (2%). Lobectomy was performed via VATS in 1040 patients or 20% of all lobectomies. Over the past 3 years the percentage of lobectomies performed by VATS has increased (21.6% in 2004, 28.6% in 2005, and 32% in 2006).
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Complete pathologic surgical stage was recorded in 4864 (54%) resections and is listed in Table 4. A T stage was available in 7369 (82%): T0 in 61, T1 in 3493, T2 in 2921, T3 in 493, and T4 in 401. An N stage was recorded in 6936 (77%): N0 in 5155, N1 in 1020, N2 in 740 (10.7%), and N3 in 21. Of note, 177 of the N2-positive patients received induction chemotherapy, 133 received induction radiotherapy, and 125 received both. M stage was listed for 5022 resections (56%). A total of 188 resections took place in patients with M1 disease.
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Discussion |
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TopAbstractIntroductionPatients and MethodsResultsDiscussionReferences |
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The prevalence and duration of smoking is consistent with the patient population with non–small cell lung cancer. However, more than a quarter of patients smoked within 2 weeks of their resection. Although continued smoking has been reported to increase complications after pulmonary resection, the optimal smoke-free interval remains unclear.7,8 Ideally, with database maturation a more complete data analysis will be able to yield an evidence-based recommendation on whether or not to postpone pulmonary resection in current smokers.
Lobectomies were the most common type of lung cancer resection, 20% of which were approached minimally invasively via VATS.9 This high proportion of VATS may reflect the selective participation in the GTS-STS database.
The current pneumonectomy rate of 6.5% is less than half the rate of 13.3% reported by the CCACS study.2 Although patient selection and surgical staging may influence the pneumonectomy rate, advanced oncologic knowledge allows for tailoring of the appropriate resection and reduces the number of unnecessary pneumonectomies.
Operative volume of the hospital in which resection is performed has been demonstrated to be important factor toward patient outcome.10 In the study by Bach and associates,1 the 30-day mortality for pulmonary resection was 6% in centers that performed 14 or fewer thoracic procedures per year whereas it was only 3% in centers that performed more than 19 procedures. More recently, Little and colleagues2 found the transition in outcomes associated with low- and high-volume centers to occur at much higher hospital volumes. The 30-day mortality rate among hospitals performing 90 or fewer resections was 4.8% compared with 3.2% among hospitals with more than 90 resections. Birkmeyer and coworkers,11 who reviewed Medicare claims data from 1998 to 1999, found adjusted mortality of 6.1% for institutions that performed fewer than 7 lobectomies per year, 5.6% for those that did between 7 and 17, and 5.0% for those that did more than 17 per year. Our nonadjusted 30-day mortality of 2.3% and nonadjusted in-hospital mortality of 1.8% are far below these figures; however, in the current study, since participants average 39 ± 28 lobectomies per year, very few participants were in the low-volume group.
The prevalence of preresection mediastinoscopy of 21% in the present study is slightly lower than that of the CCACS study (27%).2 One mechanism to gauge the success of clinical and surgical staging before resection is prevalence of "unsuspected" N2 disease or the failure to identify N2 disease before performing a lung resection for cancer. Among two large series of mediastinoscopy performed before resection, 5% to 8% of patients were found to have metastasis to N2 nodes that were not identified by mediastinoscopy.12,13 The rate of pathologic N2 disease in the current study is 740/6936 (10.7%), and 435 of these patients received preoperative therapy. The status of N2 lymph nodes is known to be an important prognostic factor that is dependent on the extent of mediastinal lymph node evaluation. Although the rate of mediastinal lymph node evaluation in the current study (65% of the operations) is substantially higher than the rate of 48.1% reported to occur at community cancer centers by Little and associates,2 N2 status was not adequately determined in a considerable number of patients.
The stage distribution among patients undergoing resection in the current study is similar to that reported by the American College of Surgeons (ACS) National Cancer Database during a similar time period.14 In the current report, 66.3% of the patients were in stage I compared with 59.5% in the ACS study. Mediastinal lymph nodes were evaluated less frequently in the ACS study (57.8%) than in our study (65%), raising the possibility that the ACS patients may have been understaged. However, with just over half of our patients staged in accordance with AJCC guidelines, it is difficult to make meaningful comparisons to other database reports. A significant factor contributing to the paucity of staged patients was the absence of M stage in 3128 resections. Although the majority of patients were likely to have M0 disease, it was not possible to generate an accurate stage without recorded data.
The median length of stay after pulmonary resection is typically reported around 9 days.1,15 The patients in the present study had considerably shorter hospital stays (median 5 days). Although complications certainly prolong the length of stay, many other factors, including cultural and economic, which are unrelated to the patient’s recovery from surgery, can affect the duration of hospitalization. Thus comparison among different database reports is difficult.
The majority of patients were highly functional (Zubrod score of 
1 in 92% of patients); however, the ASA classification was elevated in the majority, with 70% of patients having ASA class III disease or higher. Although ASA class was not designed to predict anesthesia or operative risk, an increasing ASA class has recently been shown to predict mortality after pulmonary resection.16 Our database includes a high percentage of patients with other comorbidities. Therefore, this patient mix would be expected to have a higher morbidity and mortality than the "average" patient.
Mortality after pulmonary resection has recently been evaluated in several large databases: The National Veterans Affairs Surgical Quality Improvement Program (3516 patients), The National Hospital Discharge Survey (512,758 patients), the CCACS 2001 Patient Care Evaluation (11,668 patients), and the Nationwide Inpatient Sample (2118 patients) (Table 7).
1,2,15,17 Among these reports, the 30-day mortality for all lung resections ranged from 4% to 5.4%, for lobectomy 4% to 4.5%, and for pneumonectomy 8.5% to 11.5%. All of these values are considerably higher than the mortality reported in the present study. Several factors attributable to the surgeon and hospital have been shown to influence the perioperative outcome after pulmonary resection for bronchogenic carcinoma. As previously mentioned, hospital volume may be an important determinant of outcome. The type of hospital (teaching versus private) also may influence outcome.18 The training and experience of the surgeon also are thought to influence operative mortality. Lung cancer resections by dedicated thoracic surgeons have previously been reported to offer advantages over those performed by less specialized surgeons.19,20 This finding is consistent with reports in other surgical areas such as foregut surgery,4 colorectal surgery,21 and vascular surgery,22 where subspecialty training has been shown to decrease operative mortality and morbidity. The current study re-emphasizes this fact. The operative mortality for pulmonary resections by board-certified thoracic surgeons in the GTS-STS database is approximately half that reported by databases populated with resections performed by less specialized surgeons.
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In conclusion, the GTS-STS database is a useful platform to evaluate the surgical management of lung cancer by board-certified thoracic surgeons. The patient demographics and comorbid afflictions appear similar to those in larger reports from national databases. STS surgeons are likely to evaluate mediastinal lymph nodes but less likely to perform a pneumonectomy. The operative mortality is low and length of stay is short despite numerous postoperative events. Long-term survival of this group of patients awaits maturation of the database.
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Footnotes |
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C. J. Finley, A. Bendzsak, G. Tomlinson, S. Keshavjee, D. R. Urbach, and G. E. Darling The effect of regionalization on outcome in pulmonary lobectomy: A Canadian national study J. Thorac. Cardiovasc. Surg., October 1, 2010; 140(4): 757 - 763. [Abstract] [Full Text] [PDF]
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B. D. Kozower, S. Sheng, S. M. O'Brien, M. J. Liptay, C. L. Lau, D. R. Jones, D. M. Shahian, and C. D. Wright STS Database Risk Models: Predictors of Mortality and Major Morbidity for Lung Cancer Resection Ann. Thorac. Surg., September 1, 2010; 90(3): 875 - 883. [Abstract] [Full Text] [PDF]
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M. Shapiro, S. J. Swanson, C. D. Wright, C. Chin, S. Sheng, J. Wisnivesky, and T. S. Weiser Predictors of Major Morbidity and Mortality After Pneumonectomy Utilizing The Society for Thoracic Surgeons General Thoracic Surgery Database Ann. Thorac. Surg., September 1, 2010; 90(3): 927 - 935. [Abstract] [Full Text] [PDF]
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S. S. Groth, N. M. Rueth, J. S. Hodges, E. B. Habermann, R. S. Andrade, J. D'Cunha, and M. A. Maddaus Conditional Cancer-Specific Versus Cardiovascular-Specific Survival After Lobectomy for Stage I Non-Small Cell Lung Cancer Ann. Thorac. Surg., August 1, 2010; 90(2): 375 - 382. [Abstract] [Full Text] [PDF]
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 D. S. Ettinger, W. Akerley, G. Bepler, M. G. Blum, A. Chang, R. T. Cheney, L. R. Chirieac, T. A. D'Amico, T. L. Demmy, A. K. P. Ganti, et al. Non-Small Cell Lung Cancer J Natl Compr Canc Netw, July 1, 2010; 8(7): 740 - 801. [Abstract] [Full Text] [PDF]
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T. A. D'Amico Operative Techniques in Early-Stage Lung Cancer J Natl Compr Canc Netw, July 1, 2010; 8(7): 807 - 813. [Abstract] [Full Text] [PDF]
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A. S. Bryant, K. Rudemiller, and R. J. Cerfolio The 30- Versus 90-Day Operative Mortality After Pulmonary Resection Ann. Thorac. Surg., June 1, 2010; 89(6): 1717 - 1723. [Abstract] [Full Text] [PDF]
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M. G. Hartwig and T. A. D'Amico Thoracoscopic Lobectomy: The Gold Standard for Early-Stage Lung Cancer? Ann. Thorac. Surg., June 1, 2010; 89(6): S2098 - S2101. [Abstract] [Full Text] [PDF]
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N. M. Rueth and R. S. Andrade Is VATS Lobectomy Better: Perioperatively, Biologically and Oncologically? Ann. Thorac. Surg., June 1, 2010; 89(6): S2107 - S2111. [Abstract] [Full Text] [PDF]
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E. Marret, F. Miled, B. Bazelly, S. El Metaoua, J. de Montblanc, C. Quesnel, J.-P. Fulgencio, and F. Bonnet Risk and protective factors for major complications after pneumonectomy for lung cancer Interact CardioVasc Thorac Surg, June 1, 2010; 10(6): 936 - 939. [Abstract] [Full Text] [PDF]
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R. R. Gopaldas, F. G. Bakaeen, T. K. Dao, G. L. Walsh, S. G. Swisher, and D. Chu Video-Assisted Thoracoscopic Versus Open Thoracotomy Lobectomy in a Cohort of 13,619 Patients Ann. Thorac. Surg., May 1, 2010; 89(5): 1563 - 1570. [Abstract] [Full Text] [PDF]
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M. Anraku, R. Miyata, C. Compeau, and Y. Shargall Video-Assisted Mediastinoscopy Compared With Conventional Mediastinoscopy: Are We Doing Better? Ann. Thorac. Surg., May 1, 2010; 89(5): 1577 - 1581. [Abstract] [Full Text] [PDF]
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N. R. Evans III, S. Li, C. D. Wright, M. S. Allen, and H. A. Gaissert The impact of induction therapy on morbidity and operative mortality after resection of primary lung cancer J. Thorac. Cardiovasc. Surg., April 1, 2010; 139(4): 991 - 996. [Abstract] [Full Text] [PDF]
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M. F. Berry, N. R. Villamizar-Ortiz, B. C. Tong, W. R. Burfeind Jr, D. H. Harpole, T. A. D'Amico, and M. W. Onaitis Pulmonary Function Tests Do Not Predict Pulmonary Complications After Thoracoscopic Lobectomy Ann. Thorac. Surg., April 1, 2010; 89(4): 1044 - 1052. [Abstract] [Full Text] [PDF]
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W. R. Burfeind Jr., N. P. Jaik, N. Villamizar, E. M. Toloza, D. H. Harpole Jr., and T. A. D'Amico A cost-minimisation analysis of lobectomy: thoracoscopic versus posterolateral thoracotomy Eur J Cardiothorac Surg, April 1, 2010; 37(4): 827 - 832. [Abstract] [Full Text] [PDF]
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G. Cusumano, A. Cesario, and S. Margaritora Pneumonectomy after induction radiochemotherapy: Is it time for a meta-analysis? J. Thorac. Cardiovasc. Surg., March 1, 2010; 139(3): 806 - 807. [Full Text] [PDF]
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K. Yamamoto, A. Ohsumi, F. Kojima, N. Imanishi, K. Matsuoka, M. Ueda, and Y. Miyamoto Long-Term Survival After Video-Assisted Thoracic Surgery Lobectomy for Primary Lung Cancer Ann. Thorac. Surg., February 1, 2010; 89(2): 353 - 359. [Abstract] [Full Text] [PDF]
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S. L. Meyerson, F. LoCascio, S. S. Balderson, and T. A. D'Amico An Inexpensive, Reproducible Tissue Simulator for Teaching Thoracoscopic Lobectomy Ann. Thorac. Surg., February 1, 2010; 89(2): 594 - 597. [Abstract] [Full Text] [PDF]
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S. Paul, N. K. Altorki, S. Sheng, P. C. Lee, D. H. Harpole, M. W. Onaitis, B. M. Stiles, J. L. Port, and T. A. D'Amico Thoracoscopic lobectomy is associated with lower morbidity than open lobectomy: A propensity-matched analysis from the STS database J. Thorac. Cardiovasc. Surg., February 1, 2010; 139(2): 366 - 378. [Abstract] [Full Text] [PDF]
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J. R. Handy Jr., J. W. Asaph, E. C. Douville, G. Y. Ott, G. L. Grunkemeier, and Y. Wu Does video-assisted thoracoscopic lobectomy for lung cancer provide improved functional outcomes compared with open lobectomy? Eur J Cardiothorac Surg, February 1, 2010; 37(2): 451 - 455. [Abstract] [Full Text] [PDF]
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F. Leo, P. Scanagatta, F. Vannucci, D. Brambilla, D. Radice, and L. Spaggiari Impaired quality of life after pneumonectomy: Who is at risk? J. Thorac. Cardiovasc. Surg., January 1, 2010; 139(1): 49 - 52. [Abstract] [Full Text] [PDF]
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F. Farjah, D. E. Wood, T. K. Varghese, N. N. Massarweh, R. G. Symons, and D. R. Flum Health Care Utilization Among Surgically Treated Medicare Beneficiaries With Lung Cancer Ann. Thorac. Surg., December 1, 2009; 88(6): 1749 - 1756. [Abstract] [Full Text] [PDF]
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C. Vergani, F. Varoli, L. Despini, S. Harari, E. Mozzi, and G. Roviaro Routine surgical videothoracoscopy as the first step of the planned resection for lung cancer J. Thorac. Cardiovasc. Surg., November 1, 2009; 138(5): 1206 - 1212. [Abstract] [Full Text] [PDF]
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J.-B. Stern and Y. Pean Antibiotic Prophylaxis for Lung Surgery: Bronchial Colonization is the Critical Issue? Ann. Thorac. Surg., September 1, 2009; 88(3): 1051 - 1051. [Full Text] [PDF]
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H. A. Gaissert, D. Y. Keum, C. D. Wright, M. Ancukiewicz, E. Monroe, D. M. Donahue, J. C. Wain, M. Lanuti, J. S. Allan, N. C. Choi, et al. POINT: Operative risk of pneumonectomy--influence of preoperative induction therapy. J. Thorac. Cardiovasc. Surg., August 1, 2009; 138(2): 289 - 294. [Abstract] [Full Text] [PDF]
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M. J. Krasna COUNTERPOINT: Pneumonectomy after chemoradiation: The risks of trimodality therapy J. Thorac. Cardiovasc. Surg., August 1, 2009; 138(2): 295 - 299. [Abstract] [Full Text] [PDF]
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N. R. Villamizar, M. D. Darrabie, W. R. Burfeind, R. P. Petersen, M. W. Onaitis, E. Toloza, D. H. Harpole, and T. A. D'Amico Thoracoscopic lobectomy is associated with lower morbidity compared with thoracotomy. J. Thorac. Cardiovasc. Surg., August 1, 2009; 138(2): 419 - 425. [Abstract] [Full Text] [PDF]
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R. M. Flores, B. J. Park, J. Dycoco, A. Aronova, Y. Hirth, N. P. Rizk, M. Bains, R. J. Downey, and V. W. Rusch Lobectomy by video-assisted thoracic surgery (VATS) versus thoracotomy for lung cancer J. Thorac. Cardiovasc. Surg., July 1, 2009; 138(1): 11 - 18. [Abstract] [Full Text] [PDF]
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C. W. Seder, K. Hanna, V. Lucia, J. Boura, S. W. Kim, R. J. Welsh, and G. W. Chmielewski The Safe Transition from Open to Thoracoscopic Lobectomy: A 5-Year Experience Ann. Thorac. Surg., July 1, 2009; 88(1): 216 - 226. [Abstract] [Full Text] [PDF]
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C. D. Wright, H. A. Gaissert, J. D. Grab, S. M. O'Brien, E. D. Peterson, and M. S. Allen Predictors of Prolonged Length of Stay after Lobectomy for Lung Cancer: A Society of Thoracic Surgeons General Thoracic Surgery Database Risk-Adjustment Model Ann. Thorac. Surg., June 1, 2008; 85(6): 1857 - 1865. [Abstract] [Full Text] [PDF]
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