Difficult Decisions in Thoracic Surgery: An Evidence-Based Approach

Preface to the First Edition
Preface to the Fourth Edition
Contents
1: Introduction
	Introduction
	Early Surgical Decision Making
	Evidence-Based Surgical Decisions
	The Age of Information
	The Age of Data
	What Lies in the Future?
	Conclusion
	References
2: Evidence Based Medicine: Quality of Evidence and Evaluation Systems
	Introduction
	The GRADE Approach
		Defining the Clinical Question
			What Outcomes Should We Consider for Clinical Decision Making?
		Grading the Quality of Evidence
			Rating the Quality of Evidence from Randomized Controlled Trials
				Limitations in Study Design
				Inconsistency of Study Results
				Indirectness of Evidence
				Imprecision
				Publication Bias
			Rating Up the Quality of Evidence from Observational Studies
		Moving from Quality of Evidence to Formulating Recommendations
		Resource Use
		Presenting Summary of Findings
		How Should Clinical Guidance Be Worded?
	Applying GRADE
	Conclusion
	References
3: Decision Analytic Techniques and Other Decision Processes
	Introduction
	Application of Decision Analytic Techniques
		Action Versus Inaction
		Choice Among Various Actions That Seem Plausible
		Optimizing Timing or Interval of Action
	Technical Aspects
		P: Problem(s)—Define Problem Explicitly
		R: Reframe
		O: Objective—Focus on the Objective(s)
		A: Alternatives
		C: Consequences/Chances
		T: Trade-Offs
		I: Integrate
		V: Value
		E: Explore/Evaluate
	Creating a Decision Tree
		Special Situations
			Cost-Effectiveness Analysis (CEA)
			Markov Modeling
	Other Clinical Applications of Decision Analysis
		Healthcare Policy
		Clinical Protocols
		Patient Decision Aids
	Benefits of Decision Analysis
	Drawbacks and Limitations of Decision Analysis
	Conclusion
	References
4: Decision Making: The Surgeon’s Perspective
	Introduction
	Models of the Surgeon-Patient Relationship
	Methodology for Evaluating Decision-Making Factors
	Surgeon Factors Related to Clinical Decision-Making
		Impact of Risk-Taking Attitude on Clinical Decision-Making
		Impact of Surgeon Age
		Impact of Surgeon Gender
		Impact of Specialty Training
	Healthcare System Factors Related to Clinical Decision Making
		Impact of Practice Environment
		Impact of Political Environment
		Impact of the Medico-Legal Environment
	Summary
	References
5: Involving Patients in Difficult Decisions About Having Surgery
	Introduction
	What Is Shared Decision Making?
		Call for Shared Decision Making
		Meeting the Requirement of Informed Patients in SDM
		Impact of SDM on Clinical Outcomes
	The Need for SDM in Surgical Care
		Problems with SDM and Surgery
			Patient Clinical Complexity
			Difficulties in Patient Comprehension
			Surgical Practice
	The Way Forward
	Summary
	References
Part I: Lung
	6: EBUS vs. Mediastinoscopy for Initial Pathologic Mediastinal Staging in NSCLC
		Introduction
		Search Strategy
		Results
			Is EBUS-TBNA More Accurate than Mediastinoscopy for Mediastinal Staging?
			Should Sampling of N1 Nodes Using EBUS TBNA Be Routinely Performed as Part of Pre-operative Staging?
			Should Routine EBUS-TBNA of the Contralateral Hilar and Interlobar Nodes Be Performed as Part of Pre-operative Staging?
			Should EBUS-TBNA or Mediastinoscopy Be Used as the Initial Procedure for Pre-operative Staging in Patients with Clinical N1 (cN1) Disease?
			What Are the Relevant Complication Rates for EBUS-TBNA and Mediastinoscopy?
			Should Endoscopic Ultrasound Fine Needle Aspiration (EUS-FNA) Be Performed in Addition to EBUS-TBNA for Routine Pre-operative Mediastinal Staging?
		Conclusions and Recommendations
		A Personal View of the Data
		References
	7: Does Preoperative Smoking Cessation Reduce Surgical Morbidity After Lung Resection?
		Introduction
		Search Strategy
		Results
		Conclusions and Recommendations
		A Personal View of the Data
		References
	8: Is Low Tech as Good as High Tech Exercise Testing in Assessing Healthy Candidates for Lung Resection?
		Introduction
		Search Strategy
		Results
			6 Min Walk Test (6MWT)
			Shuttle Walk Test (SWT)
			Stair Climbing Test
			Cardiopulmonary Exercise Test
		Conclusions and Recommendations
		A Personal View of the Data
		References
	9: Does Assessment of Frailty and Sarcopenia in Lung Resection Candidates Affect Patient Selection?
		Introduction
		Search Strategy
		Results
			Frailty and Lung Resection Outcomes (Table 9.2)
			Sarcopenia and Lung Resection Outcomes (Table 9.3)
		Conclusions and Recommendations
		A Personal View of the Data
		References
	10: Can Frailty and Sarcopenia Be Mitigated in Lung Resection Candidates?
		Introduction
		Search Strategy
		Results
		Conclusions and Recommendations
		A Personal View of the Data
		References
	11: Is Antibiotic Prophylaxis Necessary for Major Lung Resection?
		Introduction
		Search Strategy
		Results
			Overall Risk Reduction
			Wound Infection
			Pneumonia and Empyema
			Existing Guideline Recommendations
		Conclusions and Recommendations
		A Personal View of the Data
		References
	12: Uniportal Versus Multiportal VATS Lobectomy
		Introduction
		Search Strategy
		Results
			Safety and Feasibility
			Surgical Outcomes
			Oncological Efficacy
		Conclusions and Recommendations
			If I Am Already Performing mVATS, Can I Safely Switch to uVATS?
			If I Am Already Performing mVATS, Should I Switch to uVATS?
		A Personal View of the Data
		References
	13: Robotic Versus Video-Assisted Thoracoscopic Surgery (VATS) Major Lung Resection for Early Stage NSCLC
		Introduction
		Search Strategy
		Results
			Safety
			Length of Stay
			Oncologic Effectiveness
			Survival
			Cost
		Conclusions and Recommendations
		A Personal View of the Data
		References
	14: Does Blood Patch for Persistent Postoperative Air Leak Reduce Air Leak Duration
		Introduction
		Search Strategy
		Results
			Blood Patch Pleurodesis for Persistent Air Leak Following Pulmonary Resection
				Time to Resolution of Air Leak and Length of Stay
				Complications
				Limitations
			Blood Patch Pleurodesis for Persistent Air Leak Following Spontaneous Pneumothorax
		Conclusions and Recommendations
		A Personal View of the Data
		References
	15: Is Resection of Persistent N2 Disease After Induction Therapy Effective?
		Introduction
		Search Strategy
		Results
			Evidence for Multimodality Therapy
			Oncologic Outcomes of Surgery for N2 Disease
			Impact of Mediastinal Downstaging on Outcomes
			Outcomes for Persistent Mediastinal Disease
			Other Considerations
			Alternatives to Surgery
			Resection Extent: Is Pneumonectomy Acceptable?
			Impact of Induction Therapy Choice
			Risks of Major Pulmonary Resection After Induction Therapy
		Conclusions and Recommendations
		A Personal View of the Data
		References
	16: N2 Disease Discovered at the Time of Vats Lung Resection: Resect or Abort?
		Introduction
		Search Strategy
		Results
			Resection
			Neoadjuvant Treatments (Chemotherapy + Surgery or Chemoradiation Therapy + Surgery)
			Chemoradiotherapy Alone
		Conclusions and Recommendation
		A Personal View of the Data
		References
	17: Does Induction Immunotherapy Confer Increased Operative Risk for Lung Resection?
		Introduction
		Search Strategy
		Results
			Hilar and Mediastinal Inflammatory/Fibrotic Disease
			Complications
			Future Studies
		Conclusions and Recommendations
		A Personal View of the Data
		References
	18: Does an Enhanced Recovery Program for Lobectomy Improve Surgical Outcomes?
		Introduction
		Search Strategy
		Results
			Complication Rates, LOS, Readmissions, Costs
			Opioid Use Reduction
			Other Outcomes
			Limitations
		Conclusions and Recommendations
		A Personal View of the Data
		References
	19: Resection vs. SBRT for Stage I NSCLC in Patients with Good Pulmonary Function
		Introduction
		Search Strategy
		Results
			Surgical Resection
			Radiotherapy
			Surgical Resection vs. Radiotherapy
		Conclusions and Recommendations
		A Personal View of the Data
		References
	20: Do Endobronchial Valves Assist in Resolution of Postoperative Persistent Air Leak?
		Introduction
		Search Strategy
		Results
		Conclusions and Recommendations
		A Personal View of the Data
		References
	21: Is Long-Term Surveillance Effective After Resection of Stage I Non-small Cell Lung Cancer?
		Introduction
		Search Strategy
		Results
			Overall Survival
			Recurrence
			Metachronous Second Primary Lung Cancer
			Cost
			Summary of Clinical Guidelines
		Conclusions and Recommendations
		A Personal View of the Data
		References
	22: Does ECMO for Lung Failure in ICU Patients Improve Survival?
		Introduction
		Search Strategy
		Results
			Hypoxaemic Lung Failure
			Hypercarbic Lung Failure
			Lung Failure Due to Refractory/Decompensated Pre-capillary Pulmonary Hypertension
		Conclusions and Recommendations
		A Personal View of the Data
		References
	23: Does Local Therapy for Oligometastatic Disease in Lung Cancer Patients Improve Survival?
		Introduction
		Search Strategy
		Results
			Local Consolidative Therapy
			Surgery
				Isolated Brain Metastasis
				Isolated Adrenal Metastasis
				Isolated Lung Metastasis
			Population-Based Analyses
		Conclusions and Recommendations
		A Personal View of the Data
		References
	24: Is Pulmonary Metastasectomy Effective in Prolonging Survival?
		Introduction
		Search Strategy
		Description of Published Data
			Survival
			Thoracic Nodal Dissection
			Extent of Resection
			Lung-Directed Chemotherapy
			Surgical Approach
		Conclusions and Recommendations
		A Personal View of the Data
		References
Part II: Esophagus
	25: Surgical Resection Versus Endoscopic Therapy for T1bN0 Esophageal Adenocarcinoma
		Introduction
		Search Strategy
		Results
			Outcomes of Endoscopic Therapy Versus Esophagectomy
				Morbidity and Oncologic Outcomes After Endoscopic Therapy
				Morbidity and Oncologic Outcomes After Esophagectomy
				Overall Survival Comparison Between ET and Esophagectomy
			Lymph Node Metastasis
		Conclusions and Recommendations
		A Personal View of the Data
		References
	26: Does Induction Therapy for T2N0 Esophageal Adenocarcinoma Patients Improve Survival?
		Introduction
		Search Strategy
		Results
		Sources of Bias in the Literature Base
		Characteristics of Patients Most Likely to Be Upstaged with cT2N0 Disease
		Decision Analysis
		Conclusions and Recommendations
		A Personal View of the Data
		References
	27: Can Frailty and Sarcopenia Be Mitigated in Esophagectomy Candidates?
		Introduction
			Sarcopenia and Frailty as Predictors of Post-operative Outcomes
			“Prehabilitation”: A Fundamental Principle of ERAS
		Search Strategy
		Results
			Exercise
			Nutrition and Immunonutrition
			Multimodal Prehabilitation
		Conclusions and Recommendations
		A Personal View of the Data
		References
	28: Do Enhanced Recovery Programs for Esophagectomy Patients Improve Outcomes?
		Introduction
		Search Strategy
		Results
			General Outcomes
			Complications
			Effects of Individual Components of ERAS
		Conclusions and Recommendations
		A Personal View of the Data
		References
	29: Does Jejunostomy Tube Feeding Improve Outcomes After Esophagectomy?
		Introduction
		Search Strategy
		Results and Recommendations
			Jejunostomy Versus Nasoenteric Tube Feeding
			Jejunostomy Tube Versus Total Parenteral Nutrition
			Jejunostomy Tube Feeding Versus ‘No Jejunostomy Tube Feeding’
			Jejunostomy Tube Feeding ‘Versus’ Early Oral Feeding
		Conclusions and Recommendations
		A Personal View of the Data
		References
	30: Surgery Versus Definitive Chemoradiotherapy for Regionally Advanced Esophageal Squamous Cell Cancer
		Introduction
		Search Strategy
		Results
			Definitive CRT Versus CRT Plus Surgery
		Conclusions and Recommendations
		A Personal View of the Data
		References
	31: Robotic Minimally Invasive Esophagectomy (RAMIE) vs. Open Esophagectomy (OE) for Resectable Esophageal Cancer
		Introduction
		Search Strategy
		Results
			Post-operative Complications
			Oncologic Outcomes
			Quality of Life
		Conclusions and Recommendations
		A Personal View of the Data
		References
	32: Two-Field vs. Three-Field Lymphadenectomy for Esophageal Adenocarcinoma
		Introduction
		Search Strategy
		Results
			Randomized Trials
			Meta-Analyses
			Propensity Matched Comparison
			Key Case Series
			Current Treatment Paradigms
		Conclusions and Recommendations
		A Personal View of the Data
		References
	33: What Is the Appropriate Extent of Lymph Node Dissection in Esophageal Cancer
		Introduction
		Search Strategy
		Results
			Extent of Lymphadenectomy
				Without Neoadjuvant Therapy
				With Neoadjuvant Therapy
			Lymph Node Ratio
			Surgical Approach During Lymphadenectomy
			Standardization of Lymph Node Analysis
		Conclusions and Recommendations
		A Personal View of the Data
		References
	34: Salvage Esophagectomy for Persistent or Recurrent Disease After Chemoradiation
		Introduction
		Search Strategy
		Results
			Studies That Combined Esophageal Adenocarcinoma and Squamous Cell Carcinoma
				Survival
				Morbidity
			Studies with only Esophageal Adenocarcinoma
				Patients
				Survival
				Morbidity
			Esophageal Squamous Cell Carcinoma
				Patients
				Survival
				Morbidity
		Conclusions and Recommendations
		A Personal View of the Data
		References
	35: Early Oral Feeding After Esophagectomy
		Introduction
		Search Strategy
		Results
			Enteral Feeding After Esophagectomy: Why?
			Early Oral Feeding After Esophagectomy: Why Not?
			Early Oral Feeding After Esophagectomy: Where We Are?
			Early Oral Feeding After Esophagectomy: Ongoing Problems
		Conclusions and Recommendations
		A Personal View of the Data
		References
	36: Stent vs. Primary Repair for Esophageal Perforation
		Introduction
		Search Strategy
		Results
		Conclusions and Recommendations
		A Personal View of the Data
		References
	37: Endoluminal Vacuum Therapy vs. Stenting for Esophageal Anastomotic Leaks
		Introduction
		Search Strategy
		Results
			Evidence Quality
			Findings
		Conclusions and Recommendations
		A Personal View of the Data
		References
	38: Thoracoscopic Versus Endoscopic Therapy for Small Sub-epithelial Esophageal Tumors
		Introduction
		Search Strategy
		Minimally Invasive Approaches for Esophageal SETs
			Minimally Invasive Surgical Enucleation
			Robotic Assisted Thoracoscopic Surgery for Resection/Enucleation
		Endoscopic Approaches for Esophageal SETs
			Non-exposed EFTR of Esophageal SETs
			Non-tunneled, Exposed EFTR of Esophageal SETs
			STER of Esophageal SETs
			Limitations with Endoscopic EFTR Techniques
		Comparison of SET Resection Using Thoracoscopic Surgery vs. Endoscopy
		Conclusions and Recommendations
		A Personal View of the Data
		References
	39: Laparoscopic vs. Endoscopic Therapy for Achalasia
		Introduction
		Search Strategy
		Results
			Clinical Response
			Adverse Events
			Length of Stay
			Postoperative Reflux
		Conclusions and Recommendations
		A Personal View of the Data
		References
	40: Laparoscopy or Endoscopic Therapy for Recurrent Symptoms from Achalasia
		Introduction
		Search Strategy
		Results
			Definition of Failure and Patient Evaluation
			Management of Recurrent Symptoms After Laparoscopic Heller Myotomy
				Pneumatic Dilation
				Re-do Laparoscopic Heller Myotomy
				POEM
			Management of Recurrent Symptoms After POEM
		Conclusions and Recommendations
		A Personal View of the Data
		References
	41: Laparoscopy or Thoracotomy for Symptomatic Recurrent Paraesophageal Hernia
		Introduction
		Search Strategy
		Results
		Conclusions and Recommendations
		A Personal View of the Data
		References
Part III: Diaphragm
	42: Does Diaphragm Pacing for Bilateral Phrenic Nerve Paralysis Improve Function or Quality of Life?
		Introduction
		Search Strategy
		Results
		Conclusions and Recommendations
		A Personal View of the Data
		References
	43: Does Phrenic Nerve Reconstruction for Unilateral Diaphragm Paralysis Improve Function or Quality of Life
		Introduction
		Search Strategy
		Results
			Patient Selection
			Results of Intervention for Unilateral Diaphragm Paralysis
				Diaphragm Plication
				Phrenic Nerve Reconstruction
				Diaphragm Pacemakers
		Conclusions and Recommendations
		A Personal Approach to the Data
		References
	44: Is Plication for Diaphragmatic Eventration Effective in Improving Lung Function?
		Introduction
		Search Strategy
		Results
			Outcomes After Open Diaphragmatic Plication
		Outcomes After Minimally Invasive Diaphragmatic Plication
		Conclusions and Recommendations
		A Personal View of the Data
		References
Part IV: Airways
	45: Is Long-Term Stenting for Benign Airway Obstruction Effective?
		Introduction
		Search Strategy
		Results
		Silicone Stents
		Metallic Stents
		Long Term Use of Airway Stents
		Long Term Airway Stenting May Complicate Surgery
		Conclusions and Recommendations
		A Personal View of the Data
		References
	46: Are Engineered Tissues Useful for Tracheal Reconstruction?
		Introduction
		Search Strategy
		Results
			Tracheal Tissue Engineering
			Alternatives to Tissue Engineering in Tracheal Repair
				Tracheal Allotransplantation
				Autologous Tissue Reconstruction
				Bioprosthetic Reconstruction
		Conclusions and Recommendations
		A Personal View of the Data
		References
	47: Management of Positive Margins After Resection of Primary Tracheal Malignancies
		Introduction
		Search Strategy
		Results
			Description of Published Data
			Historical Base of Knowledge
			Recent Retrospective Analyses
			An Attempt to Utilize Big Data
		Conclusions and Recommendations
		A Personal View of the Data
		References
	48: Optimal Management of Posttransplant Bronchial Stenosis: Stenting or Reoperation
		Introduction
		Search Strategy
		Results
			Background
			Treatment Strategies
				Dilation
				Stenting
				Surgery
		Conclusions and Recommendations
		A Personal View of the Data
		References
Part V: Pleura and Pleural Spaces
	49: Is tPA/DNase Effective in the Management of Pleural Empyema?
		Introduction
		Search Strategy
		Results
			Combined t-PA and DNase vs Monotherapy and Placebo
			Combined tPA-DNase After Failed Thoracostomy Drainage
			Fibrinolytics vs Surgery
			Predicting Failure of tPA-DNase Therapy
			Complications of tPA-DNase Therapy
		Conclusions and Recommendations
		A Personal View of the Data
		References
	50: VATS vs Open Management of Pleural Empyema
		Introduction
		Search Strategy
		Results
			VATS vs Thoracotomy: Current Consensus
			Procedure Success
			Mortality
			Postoperative Morbidity
			Robotic Approach
		Conclusions and Recommendations
		A Personal View of the Data
		References
	51: Indwelling Pleural Catheters Versus Talc Pleurodesis for Recurrent Symptomatic Malignant Pleural Effusions
		Introduction
		Search Strategy
		Results
			Dyspnea
			Number of Hospital Days
			Reinterventions
			Adverse Events
		Conclusions and Recommendations
		A Personal View of the Data
		References
	52: Quality of Life: Extended Pleurectomy/Decortication vs Extrapleural Pneumonectomy
		Introduction
		Search Strategy
		Results
			Quality of Life After EPP
			Quality of Life After EPD
			EPP vs. EPD
		Conclusions and Recommendations
		A Personal View of the Data
		References
Part VI: Mediastinum
	53: Does Thymectomy Improve Outcomes in Patients with Nonthymomatous Myasthenia Gravis?
		Introduction
		Search Strategy
		Results
			MGTX Trial
			The Approach
			Subtypes
		Conclusions and Recommendations
		A Personal View of the Data
		References
	54: Magnetic Resonance Imaging for Evaluation of Suspected Encapsulated Thymoma
		Introduction
		Search Strategy
		Results
			Differentiation of Thymoma from Benign Thymic Conditions
			Differentiation Between Early Stage and Advanced Stage Thymoma by MRI
			Differentiation Among Histologic Subtypes by MRI
		Conclusions and Recommendations
		A Personal View of the Data
		References
	55: Robotic vs. Thoracoscopic Thymectomy for Thymoma
		Introduction
		Search Strategy
		Results
			Short-Term Outcomes
			Oncologic and Long Term Outcomes
		Conclusions and Recommendations
		A Personal View of the Data
		References
	56: VATS for Resection of Mediastinal Parathyroid Adenomas
		Introduction
		Search Strategy
		Results
			Pre-operative Imaging Modalities
			Comparison of Different Surgical Approaches
			Peri-operative Hormone Monitoring
		Conclusions and Recommendations
		A Personal View of the Data
		References
	57: Thymectomy in the Setting of Pleural Metastasis
		Introduction
		Search Strategy
		Results
			Historical Results
			Results of EPP
			Prognostic Factors
			Information from Large Databases
			Hyperthermic Perfusion
		Conclusions and Recommendations
		A Personal View of the Data
		References
	58: Sympathectomy for Malignant Ventricular Arrhythmias
		Introduction
		Search Strategy
		Results
			Observational Studies
			Complications of CSD
			Extent of CSD
			Left vs. Bilateral CSD
		Conclusions and Recommendations
		A Personal View of the Data
		References
	59: The Extent of Surgery for Palmar Hyperhidrosis
		Introduction
		Search Strategy
		Results
			Location of Interruption of the Sympathetic Chain
			Method of Interruption
			Number of Ports
		Conclusions and Recommendations
		A Personal View of the Data
		References
Part VII: Chest Wall
	60: Synthetic Versus Biologic Reconstruction of Bony Chest Wall Defects
		Introduction
		Search Strategy
		Results
		Conclusions and Recommendations
		A Personal View of the Data
		References
	61: Traumatic Rib Fracture in the Absence of Flail Chest: Conservative Therapy or Surgical Fixation?
		Introduction
		Search Strategy
		Results
			Acute Outcomes
			Frequency of Use
			Long-Term Outcomes
		Conclusions and Recommendations
		A Personal View of the Data
		References
	62: Is Surgical Management of Flail Chest Effective?
		Introduction
		Search Strategy
		Results
			Selecting Appropriate Patients for Rib Fixation
			The Efficacy of Rib Fixation vs. Non-Operative Care for Severe Flail Chest
			Contraindications to Rib Fixation for Flail Chest
		Conclusions and Recommendations
		A Personal View of the Data
		References
	63: Epidural vs Regional Blocks for VATS and Thoracotomy
		Introduction
		Search Strategy
		Results
			Direct Blockade of Spinal Roots: Neuraxial and Paraneuraxial Blocks
				Thoracic Epidural for Analgesia (TEA)
				Paravertebral Block (PVB)
			Direct and Indirect Regional Block Techniques: Fascial Plane and Intercostal Nerve Blocks
				Erector Spinae Plane (ESP) Block
				Retrolaminar Block (RLB)
				Serratus Anterior Plane (SAP) Block
				Surgically Placed Intercostal Nerve Blocks (ICNB)
		Conclusions and Recommendations
		A Personal View of the Data
		References
	64: The Nuss Procedure Versus the Modified Ravitch Repair for Pectus Excavatum in Adults
		Introduction
		Search Strategy
		Results
		Conclusions and Recommendations
		A Personal View of the Data
		References
Index