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a Department of Thoracic Surgery, Cedars Sinai Medical Center, Los Angeles, California
b Department of Cardiothoracic Surgery, University of Michigan, Ann Arbor, Michigan
Accepted for publication May 22, 2007.
* Address correspondence to Dr McKenna, 8635 West Third, Suite 975W, Los Angeles, CA 90048 (Email: mckennar{at}cshs.org).
Presented at the Forty-third Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 29–31, 2007.
| Dr McKenna discloses that he has a financial relationship with Ethicon.
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Abstract |
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Methods: The protocol was to perform lobectomies by means of video-assisted thoracoscopic surgery with no routine postoperative laboratory work or chest roentgenograms. The chest tubes were discontinued once the output was less than 300 mL in a 24-hour period and there was no air leak present. If the chest tube output was low, but there was an air leak, the patient was discharged home with a Heimlich valve.
Results: Two hundred eighty-two consecutive video-assisted thoracoscopic surgery lobectomies were performed by a single surgeon during 18 months in 158 women (56%) and 124 men (44%), with a mean age of 71.2 years. Following this protocol, the mean length of stay was 3.26 days, and the median was 3 days. Seven of 282 patients (2.5%) were discharged with a Heimlich valve. There was 1 mortality. There were no complications in 251 patients (89%). Two patients were readmitted to the hospital. No chest tubes were reinserted.
Conclusions: Using a fast-tracking protocol, video-assisted thoracoscopic surgery lobectomy with anatomic dissection can be performed with minimal complication, a short postoperative length of stay, and reduced costs.
Health care in the United States is in an era of cost containment and entering an era of pay for performance. Insurance companies and Medicare will increasingly pay more attention to outcomes. Although length of hospital stay, postoperative testing, and the use of intensive care after lobectomy has decreased, surgeons must pay attention to and further improve their outcomes.
During the years, a minimalist approach that included no routine chest roentgenograms or laboratory tests after lobectomy has evolved. There was not a specific time that could be identified as the time when we switched from testing to minimal testing. Our clinical impression was that the routine use of postoperative laboratory tests and chest roentgenograms was not necessary. Therefore, we prospectively collected clinical data to assess the safety and impact of this minimalist approach to postoperative chest roentgenograms and laboratory tests. This paper reports the results of patient outcomes with this approach.
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Material and Methods |
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The series included video-assisted thoracoscopic surgery (VATS) lobectomies, segmentectomies, and pneumonectomies performed 2004 through 2005. The operations all involved standard anatomic hilar dissection and lymph node sampling or dissection with visualization on a monitor. The dissection was performed through a 5-cm incision without spreading the ribs.
A VATS major pulmonary resection has become the standard at Cedars Sinai Medical Center. A thoracotomy is used for patients after chemotherapy and radiation, for tumors invading the chest wall, vascular sleeve resections, and tumors larger than 6 cm. All other resections were performed by VATS. We perform VATS sleeve resections and VATS lobectomy after preoperative chemotherapy. During this period, 94% of our lobectomies, segmentectomies, and pneumonectomies were performed by VATS. Major pulmonary resections were performed by means of a thoracotomy for the following reasons: preoperative chemotherapy and radiation (n = 10), sleeve resection (n = 5), chest wall resection (n = 2), and pneumonectomy (n = 1).
Postoperatively, there was no routine postoperative laboratory work or chest roentgenograms. There were no chest roentgenograms routinely performed in the recovery room after the procedure or after removal of the chest tube before discharge.
Postoperative care was routinely in a nonmonitored, non–intensive care unit bed. After a pneumonectomy, patients were routinely sent to the intensive care unit. Because chest tubes were not used after pneumonectomy, the hematocrit was checked through the night to make sure that there was no bleeding. Monitors were used for patients with a history of arrhythmias. Vital signs, checked at 4-hour intervals, included pulse oximetry. If the heart rate was rapid or irregular, the nurses notified the surgeon and an electrocardiogram was checked.
The chest drainage system was not placed on suction after the operation unless there was excessive output. The chest tubes were discontinued once the output was less than 300 mL in a 24-hour period and there was no air leak present. If the chest tube output was low, but there was an air leak, the patient was discharged home with a Heimlich valve. Atrial fibrillation prophylaxis was not routinely used except for a calcium-channel blocker given to patients who underwent pneumonectomy. Postoperative pain relief was routinely accomplished with acetaminophen and hydrocodone pills (Abbott Laboratories, North Chicago, IL) and hydromorphone shots (Abbott Laboratories) subcutaneously. No epidural catheters were used.
There were no laboratory tests that were routinely ordered after the operations. They were ordered for clinical indications, such as fever and use of diuretics. For example, if the chest tube drainage was significant, then the hemoglobin was checked. If the patient had diabetes, then the blood glucose levels were monitored.
Costs
The costs are the averages for each of those CDMLs (ie, all the charges for the patient) in the case on the basis of the relative value units developed, and these costs are ultimately reconciled to the medical center’s general ledger. The costs can be split among the direct variable costs, the direct fixed costs, the direct academic costs (net faculty costs), and the indirect costs.
The proportion of costs split between fixed and variable costs is different for every CDML and for every case because most cases will have a different assortment of CDMLs. If there is a particular case or patient population, we can look at the proportion of fixed and variable costs for that case or patient population.
The charges and costs that come from the hospital’s data warehouse are only those from the hospital’s perspective. Thus, the charges and costs do include the faculty costs for the faculty surgeons, but the costs do not include private surgeons or the private anesthesiologist group that Cedars Sinai uses. The private surgeons and the anesthesiologist fees are billed by those entities separately. For these operations, the surgeon is not full-time faculty so the professional fees are not included.
All costs for all CDMLs associated with a patient are included, including operating room costs, surgical supplies, and intraoperative and postoperative charges. The only costs not included are those the hospital does not incur, such as the private surgeons and the anesthesiologists.
Procedure
Under single-lung anesthesia, the VATS procedures were anatomic dissections with individual ligation of the vessels and bronchi. A 5-mm trocar for the 5-mm 30-degree thoracoscope was placed through the eighth intercostal space in the midaxillary line. A 2-cm incision was made in the sixth intercostal space in the midclavicular line. A ring forceps through that incision displaces the lung posteriorly to expose the superior pulmonary vein. A utility incision is made directly lateral from the vein for upper lobectomies or one intercostal space lower for middle or lower lobectomies. This incision starts on the anterior border of the latissimus muscle and extends anteriorly for 4 to 6 cm. In some cases, another 1-cm incision is made in the auscultatory triangle. The vessels and bronchi are individually ligated, as previously reported [1]. Lymph nodes were either sampled or dissected.
The data for postoperative stay were prospectively entered into a database. This series includes consecutive patients for whom the preoperative intention was to perform a VATS segmentectomy, lobectomy, or pneumonectomy. This does not include patients for whom the intention was to perform a thoracotomy, but the procedure was started with VATS to determine whether the tumor was resectable or to optimize the location of the incision for a chest wall resection.
The standard follow-up was to see patients 1 week after discharge, 1 month after discharge, and at 6-month intervals for cancer follow-up. There was follow-up on all patients in the series. If the patients did not return for that standard follow-up, their follow-up information was obtained through patient contact.
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Results |
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Mortality and Morbidity
There were no intraoperative deaths. There was 1 (0.6%) postoperative death caused by respiratory failure or pneumonia.
There were no complications in 251 patients (89%). In 31 patients, there were 37 complications, as presented in Table 6. Blood transfusions were needed for 11 patients (3.9%), including 1 patient who was returned to the operating room for bleeding and 1 patient who was converted to a thoracotomy for bleeding. There were 2 readmissions to the hospital for transient ischemic attack and for subcutaneous emphysema in a patient who had a prolonged air leak and had been discharged with a Heimlich valve. No patients underwent reinsertion of a chest tube for pneumothorax or pleural effusion.
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Cost Effect of Length of Stay
The hospital length of stay (LOS) impacted the hospital’s gross margin for a patient with Medicare coverage, as presented in Figure 1
and Table 7. The table shows the gross margin for the hospital per case after a lobectomy, and the much larger impact for the gross margin per room for the year if the hospital LOS is reduced from 7 days to 2 days.
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Comment |
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The current series shows what the postoperative course can potentially be when major pulmonary resections are performed by VATS and with laboratory tests and chest roentgenograms performed only as clinically indicated. During that period, 94% of major pulmonary resections were performed with VATS. That included 16 bronchoplasties and sleeve resections, 6 patients after neoadjuvant treatment for stage 3A cancer, and tumors up to 8 cm in diameter.
The results of this series support the minimalist approach to the use of laboratory tests and chest roentgenograms after major pulmonary surgery. When clinically indicated, tests should be ordered, but routine use of tests may not be necessary. Chest roentgenograms in the recovery room and after chest tube removal do not appear to be necessary. The presence of a chest tube is not an indication for a chest roentgenogram.
There are many factors that led to these good results. Although there is no large randomized, prospective study to compare the results of pulmonary resections by VATS versus thoracotomy, several series show very good results that may be better than the results for pulmonary resection by thoracotomy [2–6]. For several procedures, the overall level of care appears to be better at higher volume centers. At Cedars Sinai Medical Center, 1,200 general thoracic procedures are performed per year. Centers with a high volume of procedures generally have better outcomes than low-volume centers. That may contribute to the results reported in this series.
To reduce the cost and improve profitability of hospital stay after lobectomy, fast-tracking protocols after lobectomy have previously been developed. In 1997, Massachusetts General Hospital used a fast-tracking protocol to produce a median LOS of 7 days and a mean LOS of 7.5 days [7]. In 1998, the Johns Hopkins Hospital protocol reduced the median LOS to 6 days [8]. The University of Alabama at Birmingham protocol further reduced median LOS to 4 days [9]. A total of 327 patients (65%) left the hospital on postoperative day 4 or sooner.
Cerfolio and colleagues [9] reported in their protocol, "Patients were extubated in the operating room and sent directly to their hospital room. Chest tubes were placed to water seal and removed on postoperative day 2 if there was no air leak and drainage was less then 400 mL/d. Epidural catheters were used and removed by postoperative day 2. The plan for each day and discharge on postoperative day 3 or 4 was reviewed with the patients and families daily during rounds. The patient went home the day the last chest tube was removed. Persistent air leaks were treated with Heimlich valves."
We previously reported our initial experience with 1,100 VATS lobectomies [10, 11]. The median LOS was 3 days and the mean LOS was 4.78 days. Our current protocol included using VATS for the lobectomy and using no laboratory tests or chest roentgenograms after lobectomy. This produced further reduction in the cost and LOS for patients after lobectomy. The results show that a minimalist approach to the use of an intensive care unit bed, blood tests, and chest roentgenograms after a lobectomy do not compromise patient care. Morbidity and mortality remain low. Despite the lack of chest roentgenogram after removal of chest tubes, there was no reinsertion of a chest tube or readmission to the hospital for pulmonary collapse. Laboratory work and chest roentgenograms should be used for clinical indications, such as fever. These results confirm the results of Cerfolio and associates [9] that the routine use of the intensive care unit and laboratory tests after a lobectomy are not necessary.
Current care must be cost effective. Both protocols and limiting complications shorten LOS. Figure 1 shows that the Medicare diagnosis-related group (DRG) 075 pays approximately $24,000 for a lobectomy, whether the LOS is 2 days or 7 days. The hospital cost for the stay increases slightly with each additional day in the hospital. That reduced the gross margin slightly for each additional day in the hospital. Table 7 compares the revenue, direct costs, and gross margin for an LOS of 2 and 7 days after a lobectomy. The gross margin for 1 patient was slightly better if the LOS was shorter. However, over the course of an entire year, this makes a large difference in gross margin. An LOS of 2 days means that 3.5 lobectomy patients can use that hospital room instead of 1 patient if the LOS is 7 days. The shorter LOS makes a huge difference in the gross margin for that hospital room. In the era of decreasing reimbursement and cost containment, this makes a huge difference in the financial bottom line for hospitals.
This study shows that a fast-tracking protocol can produce shorter LOS and improve hospital gross margin, without compromising quality of care. The routine use of chest roentgenograms and laboratory tests after a lobectomy does not appear to be necessary. Additionally, the routine use of a chest roentgenogram after chest tube removal does not appear to be necessary.
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Discussion |
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Exactly how do you define complications? For instance, what about urinary tract infections or fever or atelectasis? What about atrial fibrillation? If you are not monitoring the patients, then I guess they don’t get it. And if you send them home soon enough you miss many—so I think the definition is a critical standpoint.
What about recidivism in follow-up? I have noticed that since I hired somebody in my practice to do a better job of follow-up, I have become a much worse surgeon. More people seem to be coming to the emergency room than I was aware of in the past. Our mortality has gone up because now we report a 90-day mortality instead of a 30-day mortality—so it has gone up because before we weren’t aware of some problems at home. So tell us about your definition.
My next question is about outlines and protocols. In our fast-track paper that you mentioned in your talk, we give a specific protocol of what we did on each postoperative day. We take the epidural out on the second day, removed the chest tube on the second or third day, and we removed chest tubes when there was less than 450 mL. I see that you are using 300 mL; we have used 450 mL in more than 700 patients with good results. Tell us a little bit about your protocol. Do you use epidurals; do you use pain pumps?
Finally, I think that the vast majority of lobectomies that are done across the world are done open, via thoracotomy, and I want to make sure that you agree that all of these postoperative protocols and results that you have described here can be applied to patients who had a thoracotomy as well as those who have undergone a VATS lobectomy. Can you tell us about what you do for the patients that you open? What are your protocols in those cases and how do they differ?
And finally, our experience has changed a little in that we used to not check any laboratory values. However, we have had a few problems with patients going home with high creatinines and low sodiums that weren’t noticed until they went back home. And so we are now checking the creatinine and the potassium and the sodium at least once in the postoperative period and getting a discharge chest roentgenogram when they go home. Have you had a similar experience?
Thank you again for the privilege of discussing this outstanding manuscript.
DR MCKENNA: In terms of the definition of complications, I am there every single day watching our patients. We do not routinely send the patients to the ICU (intensive care unit), they go to the floor, but they all go to the same place. Our nurses are used to our patients and our protocols. Vital signs are checked with a portable unit that is checking the blood pressure, and the patients do have their [heart] rhythm checked. So I really don’t think we are missing cases of atrial fibrillation.
For follow-up, I routinely see patients 1 week after discharge from the hospital. We do have patients fly in from all around the country and the world, but I do see them on the day before they leave to go elsewhere to make sure that they are doing well. For the patients who are from Southern California, my routine is to see them in the office 1 week and 1 month after discharge. I really do keep track of what they are doing, and I am aware if they have been readmitted to the hospital. I do not track visits to the emergency room, so I don’t know that. We can try to find out about that.
Regarding chest tube management, I have been pushing the limit higher and higher for the amount of chest tube drainage that I accept in a 24-hour period. So like you, I have pushed it up higher. I am not quite as bold as Dr Woods, but I will go up to 450 mL for a day and take the chest tubes out.
Postoperative pain management has been with Vicodin and with subcutaneous Dilaudid. I cannot tell you the exact number, but my sense is maybe 10% of patients get a patient controlled analgesia pump if they are not comfortable enough with that pain management. We do not routinely use epidurals after VATS lobectomies.
I think the protocol certainly is applicable to open and closed procedures.
There are discussions regarding the exact definition of a VATS lobectomy, how big the incision can be and rib spreading, but I do not think the arguments regarding the exact definition matter. Smaller incisions and not spreading the ribs are beneficial for patients. What matters most is that we do a good job for our patients and we reduce hospital stay, we do cost-effective care, and certainly I think reducing the stay in the hospital, reducing the tests that we order, is applicable to both open and VATS procedures.
You bring up a very good point about the creatinine. I guess I better go back home and check creatinine levels to make sure that that the postoperative levels are unchanged. But in the past, it has been just like my lack of use for a chest roentgenogram. I am sure some patients have a tiny apical pneumothorax. You get that chest roentgenogram, and then you are going to have to get serial roentgenograms to watch it. The bottom line is the patient. When the patient is doing well and you get your follow-up chest roentgenograms and computed tomographic scans on a regular basis after their cancer, the lung is fully expanded and the patients have been doing well. It sounds like a good idea to check the creatinine. I think I will start doing that.
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References |
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This article has been cited by other articles:
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  R. J. Cerfolio, D. J. Minnich, and A. S. Bryant The Removal of Chest Tubes Despite an Air Leak or a Pneumothorax. Ann. Thorac. Surg., June 1, 2009; 87(6): 1690 - 1696. [Abstract] [Full Text] [PDF]
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 J. Loscertales, R. Jimenez-Merchan, M. Congregado, F. J. Ayarra, G. Gallardo, and A. Trivino Video-Assisted Surgery for Lung Cancer. State of the Art and Personal Experience Asian Cardiovasc Thorac Ann, June 1, 2009; 17(3): 313 - 326. [Abstract] [Full Text] [PDF]
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 R. Nakanishi, Y. Fujino, T. Yamashita, and S. Oka A prospective study of the association between drainage volume within 24 hours after thoracoscopic lobectomy and postoperative morbidity. J. Thorac. Cardiovasc. Surg., June 1, 2009; 137(6): 1394 - 1399. [Abstract] [Full Text] [PDF]
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F. Farjah, D. E. Wood, M. S. Mulligan, B. Krishnadasan, P. J. Heagerty, R. G. Symons, and D. R. Flum Safety and efficacy of video-assisted versus conventional lung resection for lung cancer. J. Thorac. Cardiovasc. Surg., June 1, 2009; 137(6): 1415 - 1421. [Abstract] [Full Text] [PDF]
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 S. C. Tomaszek, S. D. Cassivi, K. R. Shen, M. S. Allen, F. C. Nichols III, C. Deschamps, and D. A. Wigle Clinical Outcomes of Video-Assisted Thoracoscopic Lobectomy Mayo Clin. Proc., June 1, 2009; 84(6): 509 - 513. [Abstract] [Full Text] [PDF]
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B. A. Whitson, S. S. Groth, S. J. Duval, S. J. Swanson, and M. A. Maddaus Surgery for Early-Stage Non-Small Cell Lung Cancer: A Systematic Review of the Video-Assisted Thoracoscopic Surgery Versus Thoracotomy Approaches to Lobectomy Ann. Thorac. Surg., December 1, 2008; 86(6): 2008 - 2018. [Abstract] [Full Text] [PDF]
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