Thoracic surgery audit update

Doug West, Thoracic Audit Lead

Over recent months thoracic surgeons have been validating data for the 2018 Lung Cancer Clinical Outcomes (LCCOP) report, covering lung cancer resections in the English NHS during 2016. This is the the fourth LCCOP report that the Society has supported the National Lung Cancer Team to produce.

Readers will notice some changes when the report comes out later this year. Firstly, we have removed small cell lung cancer resections from LCCOP. This follows last year’s introduction of one-year outcomes reporting for units. There were concerns that units may be discouraged from taking on clinically appropriate small cell resections, given that there may be some impact on one year outcomes. Only 1.6% of last year’s LCCOP resections were for small cell, so this is expected to have minimal effect overall.

Reporting of resection rates alongside peri-operative mortality is supported by the Society. Feedback on this policy from SCTS members at the BORS and annual meetings has been positive. Last year we simply

asked surgical units which Trust MDTs they served, and then copied the NLCA resection rates for these Trusts into the LCCOP report. This year we are trialling a new method of calculating a compound resection rate for surgical units. For many units this is straightforward, since the trusts that they serve send all of their cases to one surgical unit. The total number of cases operated upon will be divided by the total number of cases seen in the referring MDTs, to derive the resection rate for the surgical unit. In two areas this will be more complex. Firstly, Trusts sending cases to two or more units will need their activity “split” between the surgical units involved. Secondly, some Trust MDTs, known as “tertiary MDTs” in the NLCA report, have unusual referral patterns and often artificially high resection rates as a result. These are identified in the NLCA report, with some narrative included for explanation. We anticipate taking a similar approach in LCCOP. The main survival measures remain for 2018; 30, 90 and 365 day mortality. These are the outcomes which are outlier managed, with units Figure 1: Surgical approach for lobectomy by stage 2015 at negative alert and alarm levels compared to the national pooled results required to submit formal responses to the data and action plans where appropriate through the SCTS and NLCA. This year we have updated the SCTS/NLCA guidance to outliers (https://scts.org/outcomes/thoracic/), reflecting changes to LCCOP in recent years. We have also added a response template, to guide units who are required to respond to an outlier notification.

Median length of stay by unit will stay in this year’s report, and for context we are adding in 90 day readmission rates, derived from Hospital Episode Statistics (HES) data. We are hopeful that making these data available will help units to target quality improvement initiatives, but these data are not currently outlier analysed and there is no audit standard set for them.

The picture that is emerging from several years of LCCOP reports is one of increasing activity in lung cancer surgery, increasing specialisation of surgeons (evidenced by a significant rise in the median number of cases performed per surgeon) in lung cancer, and of a gradual decline in peri-operative mortality risk. Last year we reported on the use of minimal access approaches for the first time, and showed that videothoracoscopic (VATS) approaches are now the commonest approach for lobectomy in early stage lung cancers (figure 1).

Lastly, if your hunger for thoracic audit and quality improvement is not sated by LCCOP, please look out for the third Thoracic Blue Book later this year, which will include the three years of the SCTS database project. Also have a look at the thoracic components of the Getting it Right First Time (GIRFT) report if you haven’t done so already http:// gettingitrightfirsttime.co.uk/surgicalspecialty/cardiothoracic-surgery/. This has used multiple data sources including LCCOP and the NLCA together with HES and NHS financial data to provide an overall quality and safety report for individual units. n

“Foil” Retractor helps with an unusual mass in the left ventricle

Background

A 67 year old male patient with no significant past medical history had an echocardiogram, because his doctor suspected a cardiac murmur. This revealed an incidental left ventricular apical mass, which was very mobile (Picture 1).

Cardiac MRI confirmed the presence of the mass with a differential diagnosis of thrombus or myxoma, because of its location far away from the valves.

Operative procedure

A periareolar approach was used to access the mass. Once peripheral bypass was established and the heart arrested with aortic occlusion using an Endoclamp the left ventricular cavity was approached via a left atriotomy and passing an endoscope through the mitral valve.

The exposure of the left ventricular cavity was improved by using the “Foil” retractor and the mass was identified and excised (Pictures 2,3,4). It had a characteristic appearance when submerged in fluid. Histology was reported to be papillary fibroelastoma. Patient spent one night in the intensive care, one night on the ward, and was discharged home on the second postoperative day. He was very happy with the cosmetic result at 6 weeks.

Picture 1: Echo shows (A) left ventricular cavity, (B) mass

Picture 2: Mass in LV with foil retractor in place

Picture 3: Mass being removed from heart

Conclusion

Fibroelastoma should be considered in the differential diagnosis of intra ventricular masses and minimal access excision of ventricular fibroelastoma is safe.

Picture 4: Inspection of LV after excision

Thanks to A Kenawy, G Laskawski, J Zacharias. Lancashire Cardiac Centre, Blackpool, for permission to reproduce this case report.

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