The Society for Cardiothoracic Surgery in Great Britain & Ireland

Transcription

1 Thoracic Surgery The Society for Cardiothoracic Surgery in Great Britain & Ireland First National Thoracic Surgery Activity & Outcomes Report 2008 Prepared by Richard Page ChM FRCS (CTh) Bruce Keogh KBE, MD, FRCS, FRCP on behalf of the Society for Cardiothoracic Surgery in Great Britain & Ireland Robin Kinsman BSc PhD Dendrite Clinical Systems

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3 The Society for Cardiothoracic Surgery in Great Britain & Ireland First National Thoracic Surgery Activity & Outcomes Report 2008 Prepared by Prepared by Richard Page ChM FRCS (CTh) Bruce Keogh KBE MD FRCS FRCP Society for Cardiothoracic Surgery in Great Britain & Ireland Robin Kinsman BSc PhD Dendrite Clinical Systems

4 gratefully acknowledge the assistance of Dendrite Clinical Systems for data presentation and publishing this report. Dendrite Clinical Systems Ltd is registered under the Data Protection Act; Data Protection Act Registration Register Number Z This document is proprietary information that is protected by copyright. All rights reserved. No part of this document may be photocopied, stored in a retrieval system, transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the permission of the publishers and without prior written consent from the Society for Cardiothoracic Surgery in Great Britain & Ireland c /o The Royal College of Surgeons, 35 / 43 Lincoln's Inn Fields, London, WC2A 3PN. VERITY is a national venous thromboembolism registry provided as a service to medicine by sanofi-aventis. Windows and Excel are registered trademarks of the Microsoft Corporation. Crystal Reports is a registered trademark of Business Objects. InDesign CS2 is a registered trademark of Adobe Systems Inc. January 2008 A catalogue record for this book is available from the British Library. ISBN Published by DENDRITE CLINICAL SYSTEMS Dendrite Clinical Systems Ltd 59A Bell Street, Henley-on-Thames, Oxfordshire RG9 2BA, United Kingdom Phone: Fax: publishing@e-dendrite.com Printed & bound by

5 Preface Cardiothoracic surgeons primarily provide surgery for the heart, lung and oesophagus. We have a 25-year history of collecting activity and outcome data on the operations we perform but we have, frankly, not used the data to maximum utility. The international explosive growth in cardiac surgery coupled with events in Bristol encouraged us to take a robust and transparent approach with our cardiac surgical outcome data. This has led to a remarkable improvement in the understanding of factors influencing results and has enriched clinical audit and review in every unit in the United Kingdom. Over the last few years we have grappled with how to do the same for thoracic surgery surgery of the lungs and oesophagus. This report is the first step along this path. Thoracic surgery is more difficult because there are more diseases, more operative options and less clear endpoints, or measures of success. So, in this report we have simply looked at variations in activity and surgical approach between thoracic surgical units. Our early discussions were contentious in that there was concern that this publication would expose considerable and significant variations and it has. My hypothesis is that this is good. Variation is good. Without variation in practice and outcomes there would be no progress. All science, whether molecular or clinical, exploits observation of variation to seek discovery and understanding. Variation in clinical practice is only an issue when those who observe a variation fail to adopt a neutral spirit of enquiry which seeks to establish which end of the spectrum represents better treatment for the sick. All too often we adopt a defensive approach which inhibits beneficial changes in clinical practice at one end and inhibits innovation through anxiety at the other. This report highlights several differences in approach which reflect differing philosophical approaches to some difficult diseases. For example, on pages 46 and 63, one can see considerable differences in the open and close rate for lung and gastrointestinal cancer surgery between units. In other words, some patients are being subjected to exploratory operations to see whether anything can be done surgically. The open and close rate represents the proportion of patients who undergo an exploratory operation for whom nothing can be done. Some surgeons argue that these operations are avoidable by good pre-operative screening whilst others argue that these operations are for cancer and it is better to seek every chance rather than eliminate all hope prematurely. I hope the publication of this sort of information will stimulate debate not only on agreeing the very best screening investigations before surgery but also on the ethics and philosophy of these different approaches. This discussion will be enriched by opening the debate to the public. There are other examples of variation which I hope will serve to stimulate debate and help us improve the quality of care we offer. But all should be seen within the context that on all the outcome measures presented in this report UK practice is of the highest international standard. The challenge is to continue to improve. Bruce Keogh KBE, MD, FRCS, FRCP

6 Introduction Introduction Thoracic Surgery in the United Kingdom and Ireland Thoracic surgery was initially developed in the early twentieth century to aid the treatment of suppurative chest diseases principally tuberculosis, bronchiectasis and empyema. Because of the particular needs of patients undergoing surgery within the chest, surgical activity gradually became concentrated in specialist hospitals serving a distinct geographical region. These Units, which came into existence in the middle part of the twentieth century, form the infrastructure for current cardiothoracic surgical services. Following the development of antibiotics after the second world war the focus of thoracic surgical activity gradually moved away from suppurative chest disease to the management of intra-thoracic malignancies, principally lung and oesophageal cancer. With the widespread increase of cardiac surgical activity in the 1970s, thoracic surgical activity declined in many parts of the country and some diseases previously treated by thoracic surgeons were transferred to other surgical specialties. More recently there has been a resurgence in thoracic surgery. The reasons for this are multi-factorial, but include the introduction of the NHS cancer plan in the UK, developments in the non-surgical treatment of ischaemic heart disease and changes occurring within cardiothoracic surgical practice as a whole. Traditionally all cardiothoracic surgeons were practitioners of all aspects of the speciality, a specialty encompassing the management of many varied diseases. In the early 1980s a cardiothoracic surgeon in addition to looking after patients with ischaemic heart disease and lung cancer, would also be expected (for example) to treat congenital cardiac defects, oesophageal cancer and chest wall abnormalities. As with many areas of medicine developments in the treatment of cardiothoracic conditions over the last quarter century has meant that it is impossible for a single surgeon to provide advice of a sufficiently expert nature to adequately treat all conditions within cardiothoracic surgical practice. Thus the speciality has developed to include surgeons who not only specialise in thoracic surgery alone but who have special expertise within the wider field of general thoracic surgery (e.g. oesophagogastric cancer, tracheal disease, and mesothelioma). Currently around half of the patients seen by thoracic surgeons have proven or suspected primary lung cancer. As surgical resection is currently the best therapy for curing this disease much of the focus of thoracic surgical activity surrounds the selection and treatment of patients for resection of patients lung cancers. Although the surgical resection of a primary lung cancer is a major activity for all thoracic surgeons, a considerable time is spent aside from this work, not only in the clinics and multi-disciplinary lung cancer team meetings, but also in the operating theatre carrying out invasive surgical staging procedures necessary for lung cancer management (bronchoscopy, mediastinoscopy etc). The other half of thoracic surgical time is spent on the remainder of general thoracic surgery. Each of the conditions treated has its own presentation, diagnostic pathway, work-up for surgery and choice of surgical procedures and non-surgical therapies available. Thus although thoracic surgeons are often thought of as lung cancer surgeons the reality is quite different. This diversity of practice makes for an interesting and stimulating specialty for surgeons to engage in throughout their lives. Thoracic surgical data collection Although less easily measurable than cardiac activity, the Society of Cardiothoracic Surgeons Thoracic Surgical Register was instituted soon after the Cardiac Surgical Register, the first reported year of activity being This initiative has been very well supported by Society members over the years, and always captured in the order of 95% of the total thoracic surgical activity occurring within the UK and Ireland. The Register has been available to members and although never published in a peer-review journal has been a useful source of reference to many groups with an interest in thoracic diseases. The Register remained largely unchanged until 2002 when the emphasis changed from a report based on pathological disease group to a summary of activity based on anatomical procedures. For example in the old Register (Appendix 1) there were ten different sites where the operation of pulmonary lobectomy could be entered, representing ten different underlying pathologies. Some of these diseases were so rare within overall thoracic surgical activity that they became of curiosity value only and did not justify the effort required for their recording. In addition there were undoubtedly inaccuracies in the collection of activity in these areas because of inconsistencies of definition between surgical Units. Nevertheless it is obviously important to capture overall activity, which is still a feature within the new Register (Appendix 2). As always the only outcome measure remains in-hospital mortality. National activity only has been reported previously by the Society, although with this current report, Unit-specific activity is now available. 4

7 Between the years 1998 and 2001, the Society asked for surgeon specific data returns relating to in-hospital mortality for pulmonary lobectomy for primary lung cancer. This operation was chosen as the marker for thoracic surgery as part of a wider initiative by the Society to try to standardise surgical performance for its members. However there has been a great deal of disagreement amongst clinicians as to whether this piece of data could be the used in the way it was intended. All cardiothoracic and thoracic surgeons have a high operative workload and yet may carry out comparatively few lobectomies for primary cancer. Comparisons of surgical performance are therefore flawed because of lack of numbers and the resulting very wide confidence limits when attempting to make a comparison of an individual surgeon s results with a standard. Also there was a strong feeling that imposition of this standard by the Society would paradoxically result in poorer care for patients to ensure a surgeon s figures could pass muster. An example of this is for the surgeon to carry out a limited resection or even a pneumonectomy in a patient at perceived high risk for surgery, when a lobectomy would be more appropriate. Also an in-hospital death after lobectomy is only rarely due to a technical error by a surgeon and is much more closely related to a patient s pulmonary reserve prior to surgery, a factor outside the control of a surgeon. Thus principally in order to ensure that higher risk patients who could benefit from surgery were treated appropriately, the Society discontinued surgeon specific data collection for thoracic surgery. The task of collecting the data for thoracic surgical returns to the Society has always been the responsibility of individual surgeons, with a lead surgeon in each Unit collating returns on behalf of each hospital. This has entailed a great deal of effort by many people and the Register is something that the Society and its members can rightly be proud of. Despite its limitations the Thoracic Surgical Register (along with its cardiac counterpart) has been at the vanguard of surgical data collection. Only recently have other surgical specialties turned their attention to this essential area of practice. Introduction Guide to the report As will be seen from the following pages the report is in two parts. The first is on overall national activity from the Register s inception in 1980 to the end of March The second section deals with Unit-specific activity for the three-year period from 1 st April 2002 to 31 st March In both sections the report is split into the following sections: Total activity with breakdown between open and minimally-invasive (VATS) surgery Lung resections with details on activity for primary lung cancer Pneumothorax surgery Oesophagogastric (upper GI) surgery with details on activity for primary oesophagogastric cancer Limitations of the report One of the major problems of data collection with regard to surgery is one of definitions. Even whether a postoperative death has occurred or not can be a subject for debate, for example whether the death occurs at base hospital, at another hospital where a patient has been transferred for convalescence or at home within (say) thirty days after the procedure. For the purposes of this report death after thoracic surgery (as after a cardiac operation) is defined as a death occurring at any time after primary surgery within the patient s base hospital. Another area which can be a problem is what constitutes major as opposed to minor thoracic surgery, a concern almost never an issue in cardiac surgery where all operations are major ones! Similarly there may be a doubt as to which category a particular operation should be assigned. A good example of this dilemma is the operation of pleuropneumonectomy for mesothelioma, which encompasses resection of pleura, lung, pericardium and diaphragm; a single entry into the category pneumonectomy for other lung conditions doesn t seem to do justice to such a mammoth operation and can confound attempts to compare activity between Units. Minimally invasive or video-assisted thoracic surgery (VATS) is a variable feast; one surgeon s definition of what constitutes VATS may be quite different to another s. The Society relies on the common sense of individual surgeons when allocating operations to categories for the Register. As will be seen the data contains no patient specific information such as age, pulmonary reserve or associated co-morbidity, all of which are known to be highly predictive of outcomes after thoracic surgery. Initiatives are already in place to include this type of data in future reports. 5

8 Completeness of data collection The Society can rightly be proud of the enthusiasm of surgeons in making returns from their Units for compilation of the Register; never has the number of returns from Units as a proportion of the total number of active Units fallen below 90%. The following chart illustrates the variation in this number. Returns submitted to the Register Introduction 100% 80% 60% 40% 20% 0% Percentage of units that submitted returns to the register Period Unfortunately a figure for the number of active Units in thoracic surgery is surprisingly difficult to pin down at any one time, even for such a small specialty as cardiothoracic surgery. In addition it is self evident that some patients are having surgery of a similar nature to that reported by thoracic surgeons, but under the care of a different specialty group. A good example of this is oesophageal surgery being carried out by non-thoracic surgeons such as general or ear-nose-and-throat surgeons. Several other specialty groups occasionally carry out surgery around or within the thoracic cavity, in the same way as thoracic surgeons occasionally operate outside its boundaries. There is nothing inherently wrong with this in terms of patient care although the result is a slightly skewed picture when trying to extrapolate the data contained within the Register, to activity within the United Kingdom and Ireland as a whole. From the point of view of the Register the only activity that can be analysed is that which is sent in by surgeons working in thoracic surgical Units. The number of active thoracic surgical Units that do not send activity returns as in the preceding chart has necessarily been an estimate. Richard Page Thoracic Surgical Audit Lead The Society for Cardiothoracic Surgery in Great Britain & Ireland 6

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10 Contents Preface 3 Introduction 4 Table of contents Thoracic Surgery in the United Kingdom and Ireland 4 Thoracic surgical data collection 4 Guide to the report 5 Limitations of the report 5 Completeness of data collection 6 National activity Total activity 12 Total surgical activity 12 Total major procedures 12 Open versus VATS procedures 13 Lung resections 14 Total lung resections 14 VATS as a proportion of all lung resections 14 Pathology for patients undergoing lung resections 15 Primary lung cancer 16 Resections for primary lung cancer 16 Type of resections for primary lung cancer 17 Open / close rates in primary lung cancer surgery 18 Mortality following surgery for primary lung cancer 19 VATS resections for primary lung cancer 21 Sleeve resections 23 Mediastinoscopy / mediastinotomy 24 Conditions other than primary lung cancer 25 Resections for other conditions 25 Surgery for pneumothorax 26 Total procedures for pneumothorax 26 Open versus VATS procedures 27 Mortality after procedures for pneumothorax 28 Surgery for upper GI disorders 29 Total activity for upper GI disorders 29 Minimally invasive resections 32 Operative mortality 32 Open / close rates in upper GI surgery 33 8

11 Unit-specific activity Contributing Units 36 Organisation of the report 37 Total activity 38 Total surgical activity 38 Total major procedures 39 Open versus VATS procedures 40 Lung resections 41 Total lung resections 41 VATS as a proportion of all lung resections 42 Pathology for patients undergoing lung resections 43 Primary lung cancer 44 Resections for primary lung cancer 44 Type of resections for primary lung cancer 45 Open / close rates in primary lung cancer surgery 46 Mortality following surgery for primary lung cancer 47 VATS resections for primary lung cancer 49 Sleeve resections 52 Mediastinoscopy / mediastinotomy 53 Conditions other than primary lung cancer 54 Resections for other conditions 54 Surgery for pneumothorax 56 Table of contents Total procedures for pneumothorax 56 Open versus VATS procedures 57 Mortality after procedures for pneumothorax 58 Surgery for upper GI disorders 59 Total activity for upper GI disorders 59 Minimally invasive resections 62 Operative mortality 63 Open / close rates in upper GI surgery 63 The future of thoracic surgical data collection in the United Kingdom and Ireland 66 Appendices Appendix 1 The Thoracic Surgical Register ( ) submission form 70 Appendix 2 The Thoracic Surgical Register (2002-date) submission form 79 Appendix 3 National minimum dataset for thoracic surgery & lung cancer surgery 82 9

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13 National activity

14 National activity Total activity Total surgical activity This chart includes all procedures recorded excluding endoscopies. There is a trend to increased activity over the years, although this increase appears to have plateaued from onwards. Total surgical activity (n=340,422) 18,000 16,000 National activity Number of procedures 14,000 12,000 10,000 8,000 6,000 4,000 2, Period Total major procedures A fairly static activity. Major procedures performed (n=263,345) 12,000 10,000 8,000 6,000 4,000 2, Number of procedures Period 12

15 Open versus VATS procedures Open surgery implies operations carried out using standard major incisions such as thoracotomy. Minimally invasive surgery means much smaller incisions are used and has been part of the armamentarium of thoracic surgeons for many decades, ever since thoracoscopy was invented in the early twentieth century. In the 1980s fibre-optic endoscopy was enhanced by the addition of a video link hence the acronym VATS, which stands for Video Assisted Thoracic Surgery; as in other branches of surgery this opened up the range of procedures which became possible using minimally invasive techniques. For the sake of continuity and simplicity throughout this report, all minimally invasive procedures are described as VATS operations. These data (which includes minor as well as major activity) shows a clear increase in the number of minimally invasive procedures carried out within thoracic surgery. 30% 25% 20% 15% 10% 5% VATS as a proportion of total workload (n=340,422) National activity 0% Percentage of procedures that were VATS Period 13

16 Lung resections Total lung resections This includes resections of lung for any reason both diagnostic and therapeutic, and for all pathologies. 6,000 Lung resections performed (n=120,521) National activity Number of lung resections 5,000 4,000 3,000 2,000 1, Period VATS as a proportion of all lung resections A clear increase in VATS resections is seen throughout the 1990s. A major reason for this is the introduction of diagnostic VATS lung biopsy. 21% VATS as a proportion of all lung resections performed (n=120,521) 18% 15% 12% 9% 6% 3% 0% Percentage of lung resections that were VATS Period 14

17 Pathology for patients undergoing lung resections Although the majority of patients undergo lung resections for primary cancer, there has been a steady increase in the proportion suffering from other pathologies. Among the many and varied underlying diseases involved are included therapeutic resection for secondary cancer, benign tumours and suppurative lung disease, as well as a diagnostic resection for diffuse lung disease. 85% Proportion resections for patients with primary lung cancer (n=120,384) 80% 75% 70% 65% 60% 55% National activity 50% Percentage of patients with primary lung cancer Period 15

18 Primary lung cancer Resections for primary lung cancer A slight downward trend is seen, the reasons for which are likely to be multi-factorial. Improved selection of patients for surgery is one possibility, such that patients who cannot benefit from resection of their cancer because of spread of the tumour are not subjected to surgery. A more worrying possibility is the potential effect of the rapid increase in cardiac surgical activity throughout this time period. It may be that the greater proportion of time spent by cardiothoracic surgeons on cardiac surgery led to a reduced access for patients with lung cancer to a surgeon who was prepared to help treat them. Resections for primary lung cancer (n=87,367) 4,000 National activity 3,500 3,000 2,500 2,000 1,500 1, Number of resections for primary lung cancer Period 16

19 Type of resections for primary lung cancer There are three basic operations used to treat lung cancer. The lung is divided into anatomical lobes; lobectomy means removal of one or occasionally two lobes along with the cancer. Thus the category of lobectomy in this report includes the operation of bilobectomy - the removal of two lobes, as well as the much more commonly performed operation of removal of a single lobe. Pneumonectomy means removal of the whole of a patient s lung and is a more dangerous and destructive operation than a lobectomy. A limited resection includes the techniques of wedge and segmentectomy and means removal of less than a lobe. These operations are considered to have a reduced chance of curing a patient s lung cancer than a lobectomy. They are generally reserved for patients with poor pulmonary reserve or other comorbidity, for whom a surgeon considers that a lobectomy would carry an inordinately high risk. The chart shows a clear trend to a reduction in the proportion of pneumonectomies, implying recognition of its dangers by surgeons and better selection of patients for surgery to treat their cancer. There has been a slight rise in the proportion of limited resections; this is likely to be due to a willingness by surgeons to offer higher risk patients a chance of cure of their cancer given improvements in surgical and anaesthetic techniques and post-operative care. 100% Type of resection for primary lung cancer (n=86,160) Pneumonectomy Lobectomy Wedge / segmentectomy National activity 80% 60% 40% 20% 0% Percentage of procedures Period 17

20 Open / close rates in primary lung cancer surgery This describes a situation when a patient is taken to the operating theatre with the intention of removing their lung cancer, but this proves impossible or inappropriate. The patient therefore undergoes a general anaesthetic and major chest incision without any therapeutic benefit. There has always been vigorous discussion surrounding the issue of open and close surgery for cancer. On the one hand it is a painful and potentially dangerous undertaking with devastating emotional consequences and should be avoided at all costs; the opposite view is that an open and close rate of zero reflects some patients being denied the possibility of potentially curative surgery. The open and close rate for lung cancer surgery has reduced dramatically throughout the life of the Register. This undoubtedly reflects more accurate pre-operative staging, especially with the introduction of routine CT scanning in the late 1980s. National activity 28% 24% 20% 16% 12% 8% Open / close rates in surgery for primary lung cancer (n=87,367) 4% 0% Open / close rate Period 18

21 Mortality following surgery for primary lung cancer As described previously, operative death is defined as death occurring after surgery within base hospital. The higher operative mortality after pneumonectomy is well shown. Limited resections have the lowest death rates despite the likelihood that these patients had a higher incidence of limited pulmonary reserve. There is a suggestion from the charts that hospital death rates have declined over the years, presumably reflecting more appropriate selection of patients for surgery, improving surgical and anaesthetic techniques, and better post-operative care. 12% Mortality after pneumonectomy for primary lung cancer (n=26,363) Crude mortality rate 10% 8% 6% 4% 2% National activity 0% Period Mortality after lobectomy for primary lung cancer (n=52,663) 6% 5% 4% 3% 2% 1% 0% Crude mortality rate Period 19

22 6% Mortality after wedge resection for primary lung cancer (n=7,134) 5% National activity Crude mortality rate 4% 3% 2% 1% 0% Period 20

23 VATS resections for primary lung cancer Although VATS wedge resections constitute a significant minority of resections for lung cancer resections, the more technically demanding VATS lobectomy has remained a rarity when considering activity throughout the country as a whole. 5% VATS as a proportion of all resections for primary lung cancer (n=87,367) Percentage of procedures that were VATS 4% 3% 2% 1% 0% National activity Period 21

24 5% VATS as a proportion of all lobectomies for primary lung cancer (n=51,615) National activity 4% 3% 2% 1% 0% VATS as a proportion of all wedge resections / segmetectomies for primary lung cancer (n=7,134) 24% 20% 16% 12% 8% 4% 0% Percentage of procedures that were VATS Period Percentage of procedures that were VATS Period 22

25 Sleeve resections This refers to an operation where in addition to a lobectomy a section of the main air passage to the lung is also removed. Although this can be a more technically demanding operation than a standard lobectomy it has the major advantage of preventing the need for a pneumonectomy, with its potential for adverse short and longterm sequelae. Despite being an ideal compromise operation for some patients the anatomical situations for which it can be used are unusual when set against the overall activity. Specific data on sleeve resections has only been collected since the year % Sleeve resections as a proportion of all resections for primary lung cancer (n=54,434) 4% 3% 2% 1% National activity 0% Percentage of ressections that were sleeve resections Period 23

26 Mediastinoscopy / mediastinotomy These two diagnostic operations are carried out through small incisions, principally to biopsy lymph nodes within the chest. This can be of major importance when selecting patients for lung cancer surgery.. Mediastinoscopy / mediastinotomy as a proportion of all resections for primary lung cancer (n=56,865) National activity Mediatinoscopy / mediatinotomy rate compared with total numbers of resections for primary lung cancer 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Period The Register collects activity for these procedures without differentiation as to the disease the patient is ultimately proved to be suffering from. Although lung cancer may represent the largest disease group of patients undergoing mediastinoscopy or mediastinotomy, many other conditions may be diagnosed, both malignant and non-malignant in nature. Therefore the mediastinoscopy / mediastinotomy rate as a proportion overall number of lung cancer resections should be interpreted with caution. Nevertheless there has been a marked increase in the number of procedures carried out, which will in part reflect more thorough lung cancer staging prior to resection. The increasing rate mirrors the decreasing rate of open / close operations for lung cancer. 24

27 Conditions other than primary lung cancer Resections for other conditions As described earlier in the report (see page 15), there has been a steady increase in this activity. The increasing number of VATS resections reflects confidence in the technique of VATS lung biopsy for diffuse disease as well as the excision biopsy of indeterminate and often benign pulmonary nodules. 2,100 Lung resections for conditions other than primary lung cancer (n=33,017) 1,800 1,500 1, National activity Number of lung resections Period VATS as a proportion of all resections for conditions other than primary lung cancer (n=33,017) 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Percentage of procedures that were VATS Period 25

28 Surgery for pneumothorax Total procedures for pneumothorax The number of procedures carried out to either prevent recurrent pneumothoraces or to repair a persistent air leak from the lung has risen steadily, especially since the introduction of VATS techniques, the latter forming the majority of operations soon after introduction of VATS in the mid 1990s. This increase in overall activity probably reflects awareness of the safety and advantages of pneumothorax surgery by thoracic surgeons, as well as increasing referrals from physicians for consideration of surgery. It is likely also that the advent of VATS techniques was responsible for an increase in referrals, despite continued debate within the thoracic surgical community as to whether or not VATS techniques can offer similar long-term results to more traditional open surgery. Procedures for pneumothorax (n=26,566) National activity 1,800 1,600 1,400 1,200 1, Number of procedures Period 26

29 Open versus VATS procedures VATS as a proportion of all procedures for pneumothorax (n=26,566) 80% Percentage of procedures that were VATS 70% 60% 50% 40% 30% 20% 10% 0% Period National activity 27

30 Mortality after procedures for pneumothorax Although at first sight VATS seems to be a safer technique than open surgery for pneumothorax, this difference in operative mortality undoubtedly reflects differences in the type of patient being subjected to the two techniques. Primary spontaneous pneumothorax occurs in young otherwise fit patients without underlying lung disease, and can easily be treated with VATS with almost no deaths. In contrast a secondary pneumothorax occurring in conditions such as emphysema frequently requires open surgery to be successful and the higher death rate reflects the increased comorbidity in these patients. Mortality after surgery for pneumothorax (n=18,362 & n=8,204 respectively) 5% Open VATS National activity Crude mortality rate 4% 3% 2% 1% 0% Period 5% 4% 3% 2% 1% 0% Crude mortality rate Period 28

31 Surgery for upper GI disorders Although surgical treatment of diseases of the proximal gastrointestinal organs (upper GI surgery) has become a subspecialty of general surgery over the last decade, surgery of the oesophagus has historically been part of the practice of cardiothoracic surgeons. As well as treating oesophageal cancer thoracic surgeons have been active in the management of benign oesophageal diseases such as hiatus hernia, reflux disease and oesophageal motility disorders. Total activity for upper GI disorders There has been a marked decrease in overall activity in this area in thoracic surgical Units, especially since the mid-1990s when upper GI surgeons began to take responsibility for treating oesophageal as well as gastric cancer. However there are many more influences at work here. The introduction of the flexible gastroscope in the 1970s allowed the development of the medical sub-specialty of gastroenterology. There followed rapid access endoscopy services which diverted the necessity for diagnosis of oesophageal diseases away from increasingly centralised thoracic surgeons working in specialised Units. Referrals for surgical opinions with regard to all types of oesophageal disease became diverted away from thoracic surgeons to more easily accessible upper GI surgeons working alongside gastroenterologists in local hospitals. As well as changing medical specialisation, these changes reflect changing patterns of treatment for some diseases. With the development of superior medical therapies for peptic ulcer and gastro-oesophageal reflux disease, the need for surgery in these conditions has become much less common. To compensate for this reducing workload, general and latterly specialist upper GI surgeons have extended their practice to include the treatment of oesophageal cancer which has shown a marked increase in incidence over the last thirty years. These important developments explain the reduction of upper GI activity in the thoracic surgical community, particularly over the last decade. National activity 29

32 3,000 Total procedures for upper GI disorders (n=44,883) National activity Number of procedures 2,500 2,000 1,500 1, Period Resections for upper GI cancer (n=19,131) 1, Number of procedures Period 30

33 2,000 Other major upper GI procedures (n=25,704) Number of procedures 1,600 1, Period National activity 31

34 Minimally invasive resections Minimally invasive surgery for oesophageal cancer treatment using a combination of thoracoscopy and laparoscopy remains a novel therapy at the present time. As will be seen later in the report, this technique is only carried out in one thoracic Unit within the UK. VATS as a proportion of all resections for upper GI cancer (n=19,131) 16% National activity Percentage of procedures that were VATS 14% 12% 10% 8% 6% 4% 2% 0% Period Operative mortality Generally speaking the procedure of oesophageal cancer resection carries the highest operative mortality of any elective operation. Despite falling activity, operative mortality for oesophagectomy when carried out under the auspices of thoracic surgery has steadily fallen over the lifetime of the Register and remains enviably very low. Undoubtedly this is less to do with surgical technique than the well-developed infrastructure for looking after patients undergoing chest surgery in thoracic surgical Units. 20% Mortality after procedures for upper GI disorders (n=19,131) 16% 12% 8% 4% 0% Crude mortality rate Period 32

35 Open / close rates in upper GI surgery As explained in the section on lung cancer open and close, the appropriate rate for this intervention is somewhat debatable. With respect to the Register, open and close in the context of upper GI cancer is vulnerable to the problem of variability of definition. For example some surgeons carry out a laparoscopy or thoracoscopy prior to an oesophageal resection and if the examination appears unfavourable will then not proceed to a major incision; thus the patient suffers very little following the intervention. Nevertheless, the Society feels that this is an important end-point to report in the context of surgical management of cancer.. 20% Open / close rates in surgery for upper GI disorders (n=19,131) 16% 12% 8% 4% National activity 0% Open / close rate Period 33

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37 Unit-specific report

38 Unit-specific activity Contributing Units The following data form a report on activity for the three-year period running from the beginning of April 2002 to the end of March Thirty-six out of a possible forty Units were able to send data returns for this period. Although some of the non-returning Units carry out a substantial amount of thoracic surgery, the Society estimates that the report encompasses at least 95% of the activity carried out within the United Kingdom and Ireland in terms of the number of patient-based procedures. Unit-specific activity City Hospital Thoracic surgical audit lead Aberdeen Royal Infirmary Mr Hussein El Shafei Belfast Royal Victoria Hospital Mr Alastair Graham Birmingham Heartlands Hospital Mr Pala Rajesh Blackpool Victoria Hospital Mr John Au Bristol Royal Infirmary Mr Anthony Morgan Cardiff University Hospital of Wales Mr Peter O Keefe Cork University Hospital Mr Tom Aherne Coventry University Hospital Mr Joseph Marzouk Dublin St James s Hospital Mr Vincent Young Edinburgh Royal Infirmary Mr William Walker Exeter Royal Devon and Exeter Mr Richard Berrisford Glasgow Western Infirmary Mr Alan Kirk Hull Castle Hill Hospital Mr Michael Cowen Leeds St James s Hospital Mr Kostas Papagiannopoulos Leicester Glenfield Hospital Mr David Waller Liverpool The Cardiothoracic Centre Mr Richard Page London Barts and the London Mr Alan Wood London Guys and St Thomas s Mr Robert Cameron London Hammersmith Hospital Mr Prakash Punjabi London Harefield Hospital Mr Edward Townsend London King s College Hospital Mr Michael Marrinan London Royal Brompton Hospital Mr George Ladas London St George s Hospital Mr Robin Kanagasaby London St Mary s Hospital Mr Rex Stanbridge London The Heart Hospital Mr Shyam Kolvekar Manchester Royal Infirmary Mr Daniel Keenan Manchester South Manchester University Mr Rajesh Shah Middlesbrough James Cook Hospital Mr Andrew Owens Newcastle Freeman Hospital Mr Sion Barnard Norwich University Hospital Mr Marc Van Leuvan Nottingham City Hospital Mr David Beggs Oxford John Radcliffe Hospital Mr Chandi Ratnatunga Papworth Papworth Hospital Mr Andrew Ritchie Sheffield Northern General Hospital Mr David Hopkinson Southampton General Hospital Mr Khalid Amer Stoke-on-Trent North Staffordshire University Mr Christopher Smallpeice 36

39 The following four hospitals were unable to contribute to the Register, although the Society is aware of significant thoracic surgical activity being carried out for the period : Bradford Royal Infirmary (ceased activity in 2004) Glasgow Royal Infirmary Hairmyers Hospital, Glasgow Plymouth Royal Infirmary Organisation of the report When constructing the charts the hospital Units are sorted according to activity, starting with hospitals having the least activity progressing downwards to those with the highest activity. This order changes depending on a Unit s contribution to a specific operation. For example Birmingham Heartlands Hospital carries out the most procedures for lung cancer, whereas Guy s and St Thomas s is by far the most active in terms of pneumothorax surgery. Thus data points on the appropriate charts for these two hospitals are located at the foot of the y- axes. This order is maintained when comparing differences in types of surgery; for example when comparing open versus VATS surgery between Units the busiest Units overall in the area of concern remain at the foot of the charts. Caution should be used when attempting to interpret differences in activity between Units for the following reasons: 1. Some Units cover a much wider geographical area and/or population than others so will inevitable carry out more procedures. 2. The report has made no distinction between Units carrying out cardiac surgery in addition to thoracic surgery and those with a solely thoracic practice. 3. It is known that respiratory diseases in general are more prevalent in some parts of the country than others, which will govern the need for thoracic surgery within a particular Unit serving that area. For example, cities such as Liverpool and Glasgow have some of the highest incidences of lung cancers, not only in the United Kingdom, but also throughout the world so it is entirely appropriate that Units located in these areas should have a busier thoracic surgical practice. 4. It may well be that differences in activity reflect different resources available for thoracic surgery, i.e. a post-code lottery of treatment. This concern cannot be explored further in this report. As with activity within any specialised area of medicine although the numerator (e.g. the number of resections carried out for lung cancer per thoracic surgical Unit) may be easily measurable, the denominator (in this example the number of cases of lung cancer within the base population) is usually unknown with any real accuracy. Although it is tempting and indeed important to reflect on this issue the Society urges that this report is only used as a guide when comparing lung cancer resection rates or indeed any area of thoracic surgical practice throughout the country. The charts follow exactly the same order as in the section on national activity; the accompanying text in that section should be used to aid interpretation as necessary. Additional text is supplied for clarity as needed. Unit-specific activity 37

40 Total activity Total surgical activity Total surgical activity; financial years (n=45,429) Oxford Kings College Hospital St Mary's Cork Middlesborough Stoke Unit-specific activity Aberdeen Manchester Royal Informary Hammersmith Bart's & the London Dublin Coventry Exeter Glasgow Leicester Blackpool Papworth Unit Cardiff Nottingham The Heart Hospital St Georges Bristol Wythenshawe Norwich Sheffield Belfast Leeds Guy's / St Thomas's Harefield Southampton Hull Newcastle Brompton Edinburgh Liverpool Birmingham ,000 1,500 2,000 2,500 3,000 3,500 Number of procedures 38

41 Total major procedures Major procedures performed; financial years (n=45,429) Oxford Kings College Hospital Cork St Mary's Stoke Aberdeen Hammersmith Manchester Royal Informary Middlesborough Coventry Dublin Glasgow Bart's & the London Exeter Leicester Unit-specific activity Blackpool Papworth Unit Cardiff St Georges Norwich Nottingham The Heart Hospital Bristol Leeds Wythenshawe Sheffield Belfast Newcastle Hull Guy's / St Thomas's Harefield Southampton Brompton Edinburgh Liverpool Birmingham ,000 1,500 2,000 2,500 3,000 Number of procedures 39

42 Open versus VATS procedures There is substantial variation in the adoption of VATS techniques throughout the UK. This variation becomes even more marked when assessing individual operations such as pneumothorax operations or limited lung resections. This phenomenon has been reported previously by Sedrakyan and colleagues 1 in a publication analysing data taken from the Register. It is likely that the variation in the use of VATS relates more to individual surgeon preference rather than availability of facilities VATS as a proportion of total workload; financial years (n=45,429) Unit-specific activity Unit Oxford Kings College Hospital St Mary's London Cork Middlesborough Stoke Aberdeen Manchester Royal Informary Hammersmith Bart's & the London Dublin Coventry Exeter Glasgow Leicester Blackpool Papworth Cardiff Nottingham The Heart Hospital St Georges Bristol Wythenshawe Norwich Sheffield Belfast Leeds Guy's / St Thomas's Harefield Southampton Hull Newcastle Brompton Edinburgh Liverpool Birmingham 0% 10% 20% 30% 40% 50% 60% 70% Percentage of lung resections that were VATS 40

43 Lung resections Total lung resections. Lung resections performed; financial years (n=15,654) Unit Oxford Kings College Hospital Cork St Mary's London Manchester Royal Informary Exeter Stoke Aberdeen Middlesborough Hammersmith Coventry Blackpool Dublin Glasgow St Georges Leeds Norwich Belfast The Heart Hospital Wythenshawe Guy's / St Thomas's Nottingham Bristol Bart's & the London Papworth Leicester Harefield Southampton Cardiff Sheffield Hull Newcastle Edinburgh Brompton Liverpool Birmingham Unit-specific activity ,000 1,200 1,400 Number of lung resections 41

44 VATS as a proportion of all lung resections There appears to be no relationship between the number of lung resections carried out per Unit and the frequency of the use of minimally invasive techniques. VATS as a proportion of all lung resections performed; financial years (n=14,990) Oxford Kings College Hospital Cork St Mary's London Manchester Royal Informary Stoke Exeter Unit-specific activity Aberdeen Hammersmith Middlesborough Coventry Dublin Blackpool Glasgow St Georges Leeds Wythenshawe Unit Belfast Norwich The Heart Hospital Guy's / St Thomas's Nottingham Bristol Papworth Bart's & the London Leicester Harefield Southampton Cardiff Sheffield Hull Newcastle Edinburgh Brompton Liverpool Birmingham 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% Percentage of lung resections that were VATS 42

45 Pathology for patients undergoing lung resections This chart shows wide variation in the pathology of lung resections. Although definitions may have a bearing on this undoubtedly some Units are much more active than others in their involvement lung resections for secondary malignancy, suppurative lung disease and lung biopsies. Proportion resections for patients with primary lung cancer; financial years (n=15,654) Unit Oxford Kings College Hospital Cork St Mary's London Manchester Royal Informary Exeter Stoke Aberdeen Middlesborough Hammersmith Coventry Blackpool Dublin Glasgow St Georges Leeds Norwich Belfast The Heart Hospital Wythenshawe Guy's / St Thomas's Nottingham Bristol Bart's & the London Papworth Leicester Harefield Southampton Cardiff Sheffield Hull Newcastle Edinburgh Brompton Liverpool Birmingham Unit-specific activity 0% 20% 40% 60% 80% 100% Percentage of patients with primary lung cancer 43

46 Primary lung cancer Resections for primary lung cancer Resections for primary lung cancer; financial years (n=10,047) Unit-specific activity Unit Kings College Hospital Oxford Hammersmith St Mary's London Aberdeen Cork Stoke Manchester Royal Informary Exeter Coventry The Heart Hospital Dublin Blackpool Middlesborough Papworth Glasgow Norwich Brompton Nottingham St Georges Belfast Southampton Leicester Bristol Harefield Wythenshawe Leeds Bart's & the London Cardiff Guy's / St Thomas's Edinburgh Hull Newcastle Sheffield Liverpool Birmingham Number of resections for primary lung cancer 44

47 Type of resections for primary lung cancer Pneumonectomy rates are generally low throughout the country. However there are some major differences in the proportion of limited (i.e. wedge or segmentectomy) resections throughout the country. This may reflect a greater proportion of patients with poor pulmonary reserve in Units such as Leeds, which has the highest proportion of limited resections. Or it may reflect greater belief in the value of a limited resection in smaller lung cancers as a way of preserving pulmonary parenchyma. Type of resection for primary lung cancer; financial years (n=9,816) Pneumonectomy Lobectomy Wedge / segmentectomy Unit Kings College Hospital Oxford Hammersmith St Mary's London Aberdeen Cork Stoke Manchester Royal Informary Exeter Coventry The Heart Hospital Dublin Blackpool Middlesborough Glasgow Papworth Brompton Norwich Belfast Nottingham St Georges Southampton Leicester Harefield Bristol Wythenshawe Leeds Bart's & the London Cardiff Guy's / St Thomas's Edinburgh Hull Newcastle Sheffield Liverpool Birmingham Unit-specific activity 0% 20% 40% 60% 80% 100% Percentage of procedures 45

48 Unit-specific activity Open / close rates in primary lung cancer surgery This chart shows wide variations across the country. Some Units report zero open / close operations with others reporting rates as high as 20% of the total number of lung resections. Given that the overall average for the country is in the order of 6% there are a number of explanations for this variation: 1. As explained in the section on national activity (see page 18) there is always vigorous debate as to what the appropriate rate for open / close operations should be in lung cancer surgery. Those surgeons who argue for a high rate say that it is better to carry out a thoracotomy and see if a patient is operable, but, if not, to avoid the additional trauma and morbidity of a lung resection when it can be of no benefit to the patient, for example because of extensive lymph node metastases. They argue that a zero rate is likely to be due to some patients having aggressive and ultimately unhelpful surgery. The opposite view is that it is virtually always beneficial to a patient who has undergone a thoracotomy to have their tumour resected as long as it can be achieved with safety. 2. The national open / close rate has fallen steadily throughout the last twenty-five years (see page 18); it is likely that this is due to improvements in the pre-operative selection of patients for surgery. It also likely that these improvements have been adopted at differing rates throughout the country. The data in this report extend between the years 2002 and 2005, and much will have happened to improve patient management throughout this time and since, with innovations such as lung cancer multi-disciplinary teams, higher resolution CT scanners and the introduction of PET-CT scanning. As these innovations extend across the country it is likely that the open / close rates will become less variable relative to the national mean. 3. Especially in small volume Units a small change in the number of open / close operations will make a large impact on the percentage reported. Data collection inaccuracies could be responsible for an exaggeration of this effect. Open / close rate 20% 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% Open / close rates in surgery for primary lung cancer; financial years (n=10,046) Unit 99% lower alert 99.9% lower alarm average rate 99% upper alert 99.9% upper alarm Number of procedures 46

49 Mortality following surgery for primary lung cancer Encouragingly there is very little difference in operative mortality throughout the country, and no apparent volume effect. Treasure 2 has shown this in a previous publication based on data taken from the Register. The Society agrees with his conclusion that thoracic or cardiothoracic surgeons who are adept in carrying out major chest operations on a regular basis within high-volume cardiothoracic surgical Units can produce equally low mortalities for lung cancer resections irrespective of the volume of individual procedures carried out per surgeon. This presumably implies that it is principally the selection of the patients for surgery rather than the technical skill of a surgeon which determines the operative result. This has long been recognised by thoracic surgeons, but unfortunately is beyond the scope of this report to investigate further. Mortality after pneumonectomy for primary lung cancer; financial years (n=1,510) Unit 99% lower alert 99.9% lower alarm average rate 99% upper alert 99.9% upper alarm Mortality rate 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Number of procedures Unit-specific activity 47

50 Mortality after lobectomy for primary lung cancer; financial years (n=6,932) Unit 99% lower alert 99.9% lower alarm average rate 99% upper alert 99.9% upper alarm 8% 7% 6% Unit-specific activity Mortality rate 5% 4% 3% 2% 1% 0% Number of procedures Mortality after wedge resection / segmentectomy for primary lung cancer; financial years (n=1,371) Unit 99% lower alert 99.9% lower alarm average rate 99% upper alert 99.9% upper alarm Mortality rate 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% Number of procedures 48

51 VATS resections for primary lung cancer Although some Units (notably Edinburgh and St Mary s) are obviously enthusiastic practitioners of VATS lobectomy this remains a rare activity in most Units. VATS wedge resection is more popular and more evenly distributed throughout the country. VATS as a proportion of all resections for primary lung cancer; financial years (n=6,932) Unit Oxford Kings College Hospital Aberdeen Hammersmith St Mary's London Cork Exeter Coventry Stoke The Heart Hospital Manchester Royal Informary Blackpool Dublin Middlesborough Leeds Papworth Norwich Glasgow Belfast Nottingham Bristol Brompton St Georges Southampton Harefield Leicester Cardiff Bart's & the London Wythenshawe Hull Guy's / St Thomas's Edinburgh Sheffield Newcastle Birmingham Liverpool Unit-specific activity 0% 20% 40% 60% 80% 100% Percentage of procedures that were VATS 49

52 VATS as a proportion of all lobectomies for primary lung cancer; financial years (n=6,932) Unit-specific activity Unit Oxford Kings Aberdeen Hammersmith StMary's Cork Exeter Coventry Stoke UCLH/Middsx Manch RI Blackpool Dublin StJam Middlesborough Leeds Papworth Norwich Glasgow West Belfast Nottingham Bristol Brompton StGeorges Southampton Harefield Leicester Cardiff Bart's/London Manch Wyth Hull Guy's/StThom Edinburgh Sheffield Newcastle Birm'hamHeartlands Liverpool 0% 20% 40% 60% 80% 100% Percentage of procedures that were VATS 50

53 VATS as a proportion of all wedge resections / segmetectomies for primary lung cancer; financial years (n=1,371) St Mary's London Dublin Kings College Hospital Cork Edinburgh Aberdeen Stoke Hammersmith Middlesborough Papworth Unit Blackpool Wythenshawe Glasgow Bart's & the London Norwich Exeter Brompton St Georges Coventry Unit-specific activity Newcastle Southampton Nottingham Leicester Belfast Liverpool The Heart Hospital Guy's / St Thomas's Harefield Cardiff Hull Bristol Sheffield Birmingham Leeds 0% 20% 40% 60% 80% 100% Percentage of procedures that were VATS 51

54 Sleeve resections Sleeve resections as a proportion of all resections for primary lung cancer; financial years (n=10,047) Kings College Hospital Oxford Hammersmith St Mary's London Aberdeen Cork Stoke Unit-specific activity Manchester Royal Informary Exeter Coventry The Heart Hospital Dublin Blackpool Middlesborough Papworth Glasgow Norwich Unit Brompton Nottingham St Georges Belfast Southampton Leicester Bristol Harefield Wythenshawe Leeds Bart's & the London Cardiff Guy's / St Thomas's Edinburgh Hull Newcastle Sheffield Liverpool Birmingham 0% 2% 4% 6% 8% 10% 12% 14% 16% Percentage of resections that were sleeve resections 52

55 Mediastinoscopy / mediastinotomy Some interesting variations between Units although in all likelihood being due to the frequency of procedures for investigating conditions other than primary lung cancer as explained in the section on national activity. Mediastinoscopy / mediastinotomy as a proportion of all resections for primary lung cancer; financial years (n=10,047 resections) Kings College Hospital Oxford Hammersmith St Mary's London Aberdeen Cork Stoke Unit Manchester Royal Informary Exeter Coventry The Heart Hospital Dublin Blackpool Middlesborough Papworth Glasgow Norwich Brompton Nottingham St Georges Belfast Southampton Leicester Increasing numbers of lung resections Unit-specific activity Bristol Harefield Wythenshawe Leeds Bart's & the London Cardiff Guy's / St Thomas's Edinburgh Hull Newcastle Sheffield Liverpool Birmingham Ratio of mediatinoscopy or mediastinotomy to total resections 53

56 Conditions other than primary lung cancer Resections for other conditions Lung resections for conditions other than primary lung cancer; financial years (n=5,607) Unit-specific activity Unit Cork Middlesborough Leeds Oxford Kings College Hospital Guy's / St Thomas's Exeter Manchester Royal Informary St Mary's London St Georges Stoke Wythenshawe Blackpool Glasgow Dublin Coventry Aberdeen Belfast Norwich Sheffield Hammersmith Bart's & the London Bristol Cardiff Leicester Nottingham Harefield Hull Newcastle The Heart Hospital Papworth Edinburgh Southampton Liverpool Brompton Birmingham Number of lung resections 54

57 VATS as a proportion of all resections for conditions other than primary lung cancer; financial years (n=5,607) Unit Cork Middlesborough Leeds Oxford Kings College Hospital Guy's / St Thomas's Exeter Manchester Royal Informary St Mary's London St Georges Stoke Wythenshawe Blackpool Glasgow Dublin Coventry Aberdeen Belfast Norwich Sheffield Hammersmith Bart's & the London Bristol Cardiff Leicester Nottingham Harefield Hull Newcastle The Heart Hospital Papworth Edinburgh Southampton Liverpool Brompton Birmingham Unit-specific activity 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Percentage of procedures that were VATS 55

58 Surgery for pneumothorax Total procedures for pneumothorax Most surgeons are agreeable on the indications for surgical intervention for pneumothorax, i.e. persisting air leak, two or more episodes, and certain occupational groups. Nevertheless there is probably a large unmet need in pneumothorax surgery throughout the country as a whole, especially with respect to secondary pneumothorax. Guys and St Thomas are a clear outlier in this comparison, and presumably reflects the commitment of this Unit to providing a comprehensive pneumothorax service for patients rather than differing indications for surgery. This chart also highlights the inconsistencies in data collection and recording of activity. It is inconceivable that Wythenshawe and Exeter carried out almost no surgery for pneumothorax, but for whatever reason their data returns haven t reflected this. Hopefully as data collection improves anomalies such as this will disappear. Procedures for pneumothorax; financial years (n=4,334) Unit-specific activity Unit Wythenshawe Exeter Oxford Kings College Hospital Stoke Papworth St Mary's London Glasgow Cork Leicester Manchester Royal Informary Aberdeen Blackpool Bristol Coventry Dublin Nottingham Bart's & the London Norwich St Georges Middlesborough Sheffield The Heart Hospital Belfast Cardiff Edinburgh Brompton Southampton Hull Newcastle Harefield Liverpool Leeds Birmingham Guy's / St Thomas's Number of procedures 56

59 Open versus VATS procedures There is a suggestion of a trend to more VATS surgery being carried out in the Units with higher activity. VATS as a proportion of all procedures for pneumothorax; financial years (n=4,334) Unit Wythenshawe Exeter Oxford Kings College Hospital Stoke Papworth St Mary's London Glasgow Cork Leicester Manchester Royal Informary Aberdeen Blackpool Bristol Coventry Dublin Nottingham Bart's & the London Norwich St Georges Middlesborough Sheffield The Heart Hospital Belfast Cardiff Edinburgh Brompton Southampton Hull Newcastle Harefield Liverpool Leeds Birmingham Guy's / St Thomas's Unit-specific activity 0% 20% 40% 60% 80% 100% Percentage of procedures that were VATS 57

60 Mortality after procedures for pneumothorax 35% 30% Mortality after open procedures for pneumonectomy; financial years (n=1,200) Unit 99% lower alert 99.9% lower alarm average rate 99% upper alert 99.9% upper alarm 25% Unit-specific activity Mortality rate 20% 15% 10% 5% 0% Number of procedures Mortality after VATS procedures for pneumonectomy; financial years (n=3,134) Unit 99% lower alert 99.9% lower alarm average rate 99% upper alert 99.9% upper alarm 8% 7% 6% Mortality rate 5% 4% 3% 2% 1% 0% Number of procedures 58

61 Surgery for upper GI disorders Total activity for upper GI disorders As explained in the previous section, oesophagogastic surgery is field of reducing activity for thoracic surgery as a whole. Many Units previously very active in this area have stopped contributing altogether and the service has been absorbed by upper GI surgeons in the locality. In contrast other Units have continued their involvement and activity for remains as high as anywhere in the country. The organisation of this type of surgery continues to change. The Society for Cardiothoracic Surgery believes that an integrated approach to patient management, drawing on the expertise of multiple specialty groups, is the best way for optimising patient care and improving outcomes; the Association of Upper Gastrointestinal Surgeons shares this view. Thus the model of thoracic surgeons working alongside and not in competition with upper GI surgeon has to be an improved way of working; achieving this multi-disciplinary model remains a difficult goal to achieve in many parts of the country. Unit Stoke Newcastle Dublin Bart's & the London Manchester Royal Informary Cork The Heart Hospital Wythenshawe Middlesborough Brompton Leicester Bristol Glasgow Sheffield Aberdeen Guy's / St Thomas's Leeds Blackpool Papworth Hull St Georges Southampton Edinburgh Coventry Harefield Birmingham Norwich Belfast Exeter Liverpool Nottingham Total major procedures for upper GI disease; financial years (n=1,775) Unit-specific activity Number of procedures 59

62 As can be seen from the charts, fewer Units carry out surgery for upper GI disorders than contribute to the totality of general thoracic surgery. Some thoracic Units have contributed only very small volumes of activity in the period reported. In the field of oesophageal surgery where there is an accepted and proven relationship between hospital volume and outcome (regardless of the specialty of the operating surgeon) a very low volume of activity should probably not be sustained independently. Nevertheless, thoracic surgeons and other staff working in thoracic Units will always have particular areas of expertise which colleagues in other specialties can draw on in optimising the care of patients with all types of oesophagogastric disease. Resections for upper GI cancer; financial years (n=1,001) The Heart Hospital Newcastle Sheffield Unit-specific activity Unit Leicester Brompton Wythenshawe Aberdeen Leeds Glasgow Guy's / St Thomas's St Georges Blackpool Papworth Hull Southampton Edinburgh Belfast Exeter Birmingham Harefield Coventry Norwich Nottingham Liverpool Number of procedures 60

63 Major procedures for upper GI disorders other than cancer; financial years (n=663) Unit Stoke Dublin Bart's & the London The Heart Hospital Manchester Royal Informary Glasgow Cork Brompton Middlesborough Leicester Aberdeen Sheffield Guy's / St Thomas's Bristol Blackpool Hull Coventry Papworth Leeds Southampton Edinburgh Harefield St Georges Norwich Liverpool Birmingham Nottingham Exeter Belfast Unit-specific activity Number of procedures 61

64 Minimally invasive resections Exeter is one of the most active Units in the country in this new area of practice. VATS as a proportion of all resections for upper GI cancer; financial years (n=1,001) The Heart Hospital Newcastle Sheffield Leicester Brompton Wythenshawe Aberdeen Unit-specific activity Unit Leeds Glasgow Guy's / St Thomas's St Georges Blackpool Papworth Hull Southampton Edinburgh Belfast Exeter Birmingham Harefield Coventry Norwich Nottingham Liverpool 0% 20% 40% 60% 80% 100% Percentage of procedures that were VATS 62

65 Operative mortality 30% 25% Mortality after resections for upper GI cancer; financial years (n=1,001) Unit 99% lower alert 99.9% lower alarm average rate 99% upper alert 99.9% upper alarm Mortality rate 20% 15% 10% 5% 0% Number of procedures Unit-specific activity Open / close rates in upper GI surgery 30% 25% Open close rates in resections for upper GI Cancer; financial years (n=1,001) Unit 99% lower alert 99.9% lower alarm average rate 99% upper alert 99.9% upper alarm Open / close rate 20% 15% 10% 5% 0% Number of procedures 63

66

67 Conclusions

68 The future of thoracic surgical data collection in the United Kingdom and Ireland In recent years there has been a great deal of debate in the cardiac surgical community as to what type of data should be collected and to how that data could be utilised for the benefit of patients and the health professions as a whole. Thoracic surgeons have (at times somewhat thankfully!) been on the sidelines of this debate as have surgeons form other specialties and have observed the debate with some trepidation. Nevertheless, the vast majority of thoracic surgeons believe that the methods of collection of data on operative activity established over the last twenty-five years are very useful in many ways and that they should continue. The current report is based on activity at a national and hospital level collected as a register with no patientspecific details such as age, pulmonary reserve, pathology or other factors known to impact on the outcome of an operation in terms of complications or death after surgery. The Society has agreed a dataset (see Appendix 3) to allow for a report on such issues within United Kingdom and Ireland thoracic surgical practice. This dataset is very similar to that used by other national and international organisations 3, 4, some of whom have already produced initial reports. Already a substantial number of Units in both Great Britain and Ireland have the facilities to collect information for the Society dataset, allowing for a future report with a comparable level of detail as is currently available for cardiac surgery activity. Unit-specific activity References 1. Sedrakyan A, van der Meulen J, Lewsey J, Treasure T. Variations in use of video assisted thoracic surgery in the United Kingdom. BMJ. 2004; 329 (7473): Treasure T, Utley M, Bailey A. Assessment of whether in-hospital mortality for lobectomy is a useful standard for the quality of lung cancer surgery: retrospective study. BMJ. 2003; 327 (7409): Berrisford R, Brunelli A, Rocco G, Treasure T, Utley M, audit and guidelines committee of the European Society of Thoracic Surgeons; European Association of Cardiothoracic Surgeons. The European thoracic Surgery Database project: modelling the risk of in-hospital death following lung resection. Eur J Cardiothoracic Surg. 2005; 28 (2): Wright CD, Edwards FH. The Society of Thoracic Surgeons general thoracic surgery database. Ann Thorac Surg. 2007; 83 (2):

69 Unit-specific activity 67

70

71 Appendices

72 Appendices Appendix 1 The Thoracic Surgical Register ( ) submission form Name of hospital Total Deaths Appendices A Lung tumours - Primary malignant 1 Pneumonectomy including sleeve pneumonectomy 2 Lobectomy, bilobectomy 3 Sleeve resection lobectomy 4 Segmentectomy, wedge resection 5 Any pulmonary resection with resection of chest wall 6 Exploratory thoracotomy - no resection B Lung tumours - Secondary malignant 1 Pneumonectomy including sleeve pneumonectomy 2 Lobectomy, bilobectomy 3 Sleeve resection lobectomy 4 Segmentectomy, wedge resection 5 Exploratory thoracotomy - no resection C Lung tumours - Benign i 1 Pneumonectomy 2 Lobectomy, bilobectomy 3 Sleeve resection ± lobectomy 4 Segmentectomy, wedge resection 5 Exploratory thoracotomy - no resection D1 Mesothelioma 1 Thoracotomy with insertion of pleuro-peritoneal shunt 2 Thoracotomy with pleural biopsy pleurodesis 3 Thoracotomy + resection of tumour 4 Thoracotomy + resection of tumour + lung ± diaphragm D2 Other pleural malignancy ii 1 Thoracotomy with insertion of pleuro-peritoneal shunt 2 Thoracotomy with pleural biopsy ± pleurodesis 3 Thoracotomy + resection of tumour Thoracotomy + resection of tumour + resection of lung tissue ± diaphragm 4 (including pleuropneumectomy) i. Including those of intermediate malignancy e.g. carcinoid not hamartoma; see K1. ii. Including chylothorax, but excluding empyema. 70

73 Name of hospital Total Deaths E Benign pleural pathology iii 1 Thoracotomy with insertion of pleuro-peritoneal shunt 2 Thoracotomy with pleural biopsy ± pleurodesis 3 Thoracotomy + resection of tumour 4 Thoracotomy + resection of lung tissue (includes pleuropneumonectomy) F Pneumothorax 1 Thoracotomy with closure of air leak (i.e. staple,glue,suture etc) 2 Thoracotomy with closure of air leak + pleurodesis 3 Thoracotomy with closure of air leak + pleurectomy 4 Thoracotomy with closure of air leak + decortication 5 Thoracotomy with closure of air leak + excision of bulla or bullae 6 Tube thoracostomy and pleurectomy 7 Median sternotomy & bilateral proc's (not volume reduction surgery; see K8) G Pleuropulmonary sepsis iv 1 Rib resection +/- open drainage ( include fenestration) 2 Empyema - decortication 3 Lung abscess - resection ie segment,wedge,lobe etc. 4 Bronchiectasis - resection 5 Resection and decortication 6 Thoracoplasty 7 Tube thoracostomy and fibrinolysis 8 Pedicled muscle flap transfer for empyema 9 Closure of broncho-pleural fistula H Tuberculosis 1 Thoracotomy and biopsy (incl.excision biopsy) 2 Pulmonary resection (less than a pneumectomy) 3 Pulmonary resection i.e.pneumonectomy +/-pleura 4 Thoracoplasty 5 Pulmonary resection and thoracoplasty 6 Open pleural biopsy 7 Thoracotomy and decortication for empyema 8 Thoracotomy and resection for aspergillus Appendices iii. iv. Including chylothorax, but excluding empyema. Excluding TB. 71

74 Name of hospital Total Deaths Appendices I Other inflammatory lung conditions v 1 Pneumonectomy 2 Lobectomy, bilobectomy 3 Segmentectomy, wedge resection 4 Thoracotomy with biopsy (include open lung biopsy) 5 Thoracotomy for infolded lung, Blesovsky's syndrome 6 Thoracotomy for hydatid disease J Trauma 1 Thoracotomy for haemorrhage 2 Thoracotomy for lung injury 3 Thoracotomy for tracheobronchial injury 4 Thoracotomy for diaphragamatic rupture 5 Thoracotomy for cardiac injury 6 Thoracotomy for injury to aorta and or great vessels 7 Thoracotomy for fixation of rib or sternal fracture 8 Thoracotomy for endobronchial foreign body 9 Management of chest wall trauma with or without ventilatory support 10 Thoracotomy and decortication of haemothorax (delayed) 11 Thoracotomy for traumatic chylothorax K Other lung conditions 1 Thoracotomy for hamartoma 2 Thoracotomy for all lung cysts and congenital lobar emphysema 3 Thoracotomy for sequestration 4 Thoracotomy for A/V malformations 5 Thoracotomy for congenital vascular bands 6 Other specify i.e., bronchoplasty 7 Thoracotomy unilateral for lung reduction surgery 8 Median sternotomy for bilateral lung reduction surgery 9 Clamshell bilateral thoracotomy for lung reduction surgery L Lung transplantation vi v. Excluding TB and those specified in section H. vi. Please see cardiac register. 72

75 Name of hospital Total Deaths M Chest wall conditions 1 Correction of pectus deformity 2 Primary chest wall tumours 2a Chest wall etc 2b Chest wall and any lung resection 3 Secondary chest wall tumours vii 3a Excision of chest wall 3b Excision of chest wall and any lung resection 4 Excision of costal cartilage/s 5 Excision of xyphoid 6 Resection of sternum ± cartilage ± chest wall ( for primary tumour ) 7 Removal of pectus bar 8 Biopsy of chest wall lesion 9 Excision of chest wall sepsis (include sternum ± cartilage, ribs etc.) 10 Surgery for cervical rib / thoracic inlet syndrome N Diaphragmatic conditions viii Diaphragamatic tumour Diaphragamatic hernia, congenital Thoracotomy and plication of diaphragm O Mediastinal condition 1 Neurogenic tumour excision 2 Foregut reduplication cysts (bronchial and oesophageal) 3 Other mediastinal cysts - specify 4 Retrosternal goitre 5 Thymoma with myasthenia 6 Thymoma without myasthenia 7 Other medistinal tumour excision - specify 8 Thymectomy for myasthenia gravis 9 Surgery for pleuro-pericardial cyst 10 Thoracotomy for thoracic duct ligation 11 Surgery for terato-dermoid of mediastinum 12 Surgery for lipoma or liposarcoma of mediastinum 13 Surgery of giant lymphoma of mediastinum 14 Surgery for mediastinal parathyroid adenoma 15 Other tumours not otherwise specified Appendices vii. Excluding direct invasion by lung cancer; see A5. viii. Excluding trauma. 73

76 Name of hospital Total Deaths Appendices P Trachial conditions ix 1 Tracheal tumours primary and secondary resection 2 Tracheal tumours primary & secondary resection & carina (+ any lung resection) 3 Tracheal stenosis resection (acquired / benign / congenital ) 4 Tracheal stenosis resection (acquired / benign / congenital ± carinal resection) Q Other conditions (specify) x 1 Pericardial window 2 Pericardectomy (also see cardiac surgery return) 3.1 Dorsal spine discectomy / decompression 3.2 Spinal fusion 3.3 Excision of dorsal spine tumour 4 Dorsal sympathectomy 5 Correction of kyphoscoliosis R Oesophageal malignant tumours 1 Oesophageal resection 2 Oesophageal resection,pharynx ± larynx 3 Bypasss procedure using any conduit 4 Oesophageal resection with interpositon of colon or jejunum (not free graft) 5 Intubation pulsion (inoperable laparotomy etc) 6 Intubation traction 7 Exploration only by any route, i.e., inoperable 8 Staging laparotomy S Oesophageal benign tumours 1 Excision without oesophagectomy 2 Oesophagectomy 3 Exploration only ± biopsy T Achlasia and other motility disorders 1 Myotomy 2 Myotomy with anti-reflux operation 3 Diverticulectomy ± myotomy U Upper sphincter disorders 1 Excision of pouch ± myotomy 2 Myotomy alone with or without divertulopexy 3 Per oral stapling - DOHLMANS procedure ix. Includes carinal resection. x. Not performed thorascopically. 74

77 Name of hospital Total Deaths V1 Reflux conditions 1 Hiatus hernia repair (all techniques) 2 Hiatus hernia repair with gastroplasty 3 Oesophageal resection 4 Oesophageal bypass 5 Biliary diversion 6 Circumferential myotomy V11 Recurrent reflux conditions 1 Hiatus hernia repair (all techniques) 2 Hiatus hernia repair with gastroplasty 3 Oesophageal resection 4 Oesophageal bypass 5 Biliary diversion 6 Circumferential myotomy W Oesophageal injury 1 Thoracotomy for removal of foreign body 2 Thoracotomy for perforation / spontaneous / other trauma 3 Repair of spontaneous rupture (Boerhaave's) 4 Resection of spontaneous rupture 5 Repair of instrumental perforation (rigid or flexible scope / bougie / balloon etc.) 6 Resection of instrumental perforation 7 Other specify 8 Chest drain and or local drainage (i.e., neck) + conservative treatment X Oesophageal atresia / fistula (congenital) 1 Closure of fistula +/- defunctioning gastrotomy 2 Primary anastomosis 3 Staged reconstruction using any conduit Y Gastric conditions xi 1 Resection of any gastric malignancy - partial or total gastrectomy 2 Bypass for gastric malignancy (ie linitis plastica) 3 Feeding jejunostomy or gastrostomy 4 Gastrostomy 5 Pyloroplasty (for delayed gastric emptying ) Appendices xi. Formerly other oesophageal conditions (specify). 75

78 Name of hospital Total Deaths Appendices Z Z1120 Z1121 Z1122 Z1123 Z1124 Z1125 Z1126 Z1127 Z1128 Z1129 Z1220 Z1221 Z1222 Z1223 Z1224 Z1225 Z1226 Z1321 Z1322 Z221 Z222 Z223 Z224 Z225 Z226 Endoscopic section xii Diagnostic bronchoscopy (includes biopsy) Therapeutic bronchoscopy total Foreign body removal Dilatations Curettage with diathermy and / or forceps Laser resections Brachytherapy i.e., endobronchial radiotherapy Stenting Cryotherapy Other Glue to BPF Upper GI endoscopies Diagnostic (includes biopsy) Therapeutic total Foreign body removal Dilatations Curettage with diathermy ± forceps Laser resections Brachytherapy Pulsion intubation any type of stent Mediastinal Mediastinoscopy (cervical) Anterior mediastinotomy Minor procedures Tracheostomy (standard) Mini-tracheostomy Per-cutaneous tracheostomy Removal of sternal wires Intercostal drains Secondary resuture of any wound xii. Not VATS; see separate section. 76

79 Name of hospital Total Deaths Video Assisted Surgery (VATS); pulmonary PU1 PU2 PU3 PU4 PU5 LR1 LR2 LR3 LR4 LR5 LR6 VB1 LVR1 LVR2 PL1 PL2 PL3 PL4 PL5 PL6 PL7 PL8 PL9 PL10 Wedge resection total Lung biopsy for diffuse disease Biopsy of isolated pulmonary nodule Resection of primary lung neoplasm total Benign Malignant Resection of metastasis Major lung resections Lobectomy totals Primary neoplasm Secondary neoplasm Inflammatory disease Pneumonectomy totals Primary neoplasm Secondary neoplasm Inflammatory disease Bullae / empyema Bullectomy Lung volume reduction surgery unilateral Lung volume reduction surgery bilateral (same anaesthetic) Pleural Pneumothorax total Closure of air leak xiii + blebectomy Closure of air leak xiii + blebectomy +chemical pleurodesis Closure of air leak xiii + blebectomy+mechanical abrasion Closure of air leak xiii + blebectomy+pleurectomy Pleural effusion / pleural neoplasm total Pleural biopsy Pleural biopsy + chemical pleurodesis ie plain or iodised talc Pleurectomy Drainage of empyema ± debridement Removal of tumour Insertion of shunt ± any procedure Appendices xiii. Staple, stitch, glue etc. 77

80 Name of hospital Total Deaths Pericardial Appendices PE1 PE2 PE3 ME1 ME2 ME3 ME4 TR1 TR2 NE1 NE2 OE1 OE2 OE3 OE4 OE5 OE6 OE7 OE8 OE9 OE10 Pericardial fenestration Excision of pericardial cyst Pericardiectomy Mediastinal Mediastinal gland biopsy / staging Mediastinal tumour biopsy Mediastinal tumour excision Thoracic duct ligation (clip) Trauma Assesment of intrathoracic trauma Evacuation of haematoma ± clot Neural Sympathectomy Splanchnic nerve ablation Video Assisted Surgery (VATS); oesophageal Heller's myotomy Extended myotomy Laparoscopic Heller's Laparoscopic Nissen fundoplication ± repair of hiatus hernia Laparoscopic hiatus hernia repair Thoracoscopic mobilisation of oesophagus Thoracoscopic / laparoscopic oesophagectomy Repair of ruptured oesophagus Excision of leiomyoma Laparoscopy for staging of gastric / oesophageal cancer ± biopsy 78

81 Appendix 2 The Thoracic Surgical Register (2002-date) submission form Name of hospital Total Deaths A Lung resections - Primary malignant 1 Pneumonectomy including sleeve pneumonectomy 2 Lobectomy, bilobectomy 3 Sleeve resection lobectomy 4 Segmentectomy, wedge resection 5 Any pulmonary resection with resection of chest wall, diaphragm etc 6 Exploratory thoracotomy - no resection B Lung resections - Other 1 Pneumonectomy 2 Lobectomy, bilobectomy 3 Sleeve resection lobectomy 4 Segmentectomy, wedge resection 5 Any pulmonary resection with resection of chest wall, diaphragm etc C Pleural procedures 1 Thoracotomy + decortication 2 Thoracotomy + pleural symphysis ± closure of air leak 3 Thoracotomy + other pleural procedures D Chest wall / diaphragmatic procedures 1 Major 2 Minor E Mediastinal 1 Resection of mediastinal mass / tumour 2 Mediastinoscopy / mediastinotomy 3 Other mediastinal procedure D Oesophageal / gastric procedures 1 Oesophago-gastric resection/bypass - malignant 2 Oesophago-gastric resection/bypass - non-malignant 3 Other major oesophagogastric 4 Exploration only by any route, ie inoperable 5 Minor oesophagogastric E Other procedures 1 Major 2 Minor Appendices 79

82 Name of hospital Total Death Appendices VATS A Lung resections - Primary malignant 1 Wedge resection 2 Lobectomy 3 Pneumonectomy VATS B Lung resections - Other 1 Wedge resection 2 Lobectomy 3 Pneumonectomy VATS C Pleural procedures 1 Closure of air leak ± pleural symphysis 2 Any other pleural procedures VATS D Chest wall / diaphragmatic procedures 1 All VATS E Mediastinal conditions 1 Resection of mediastinal mass / tumour 2 Other mediastinal procedure VATS F Oesophageal / gastric procedures 1 Therapeutic 2 Diagnostic VATS G Other procedures 1 All Z Endoscopic procedures (not VATS) 1 Diagnostic bronchoscopy / oesophagoscopy 2 Therapeutic bronchoscopy / oesophagoscopy 80

83 Appendices 81

84 Appendix 3 National minimum dataset for thoracic surgery & lung cancer surgery Ground rules and guiding principles The unit of entry is an operative episode, but this may include more than one procedure. Thus if the patient has any combination of bronchoscopy / mediastinoscopy / lung resection VATS / thoracotomy the individual procedures are recorded and can be retrieved, but are within the operative episode. There are two levels of detail Core data is collected on all cases. More detailed information is collected on lung cancer cases. In due course more detail may be collected on any subsets of interest and these may be chosen locally. Data should be "1" for the item if applicable. There is no need for "0" or "N". If there is date required enter in the DDMMYYYY format. Appendices Core data Collected on all cases; lines 1-76 and Centre identification 2. NHS number 3. Hospital number 4. Post code 5. Date of Birth 6. Sex 7. Date of Operation 8. Date of surgical referral 9. Date of first surgical assessment 10. No longer required 11. No longer required Operative priority Select a single choice from: Surgical strategy 12. Elective standard booked admission for surgery 13. Urgent decision to operate on next available list 14. Emergency operation arranged outside scheduled list Reasons for the operation taking place; there may be more than one: 15. Diagnostic - to diagnose the condition 16. Staging or assessment to stage a neoplasm or to assess the progress of the condition 17. Therapeutic to cure, alleviate or palliate More than one is allowed, for example: Mediastinoscopy maybe diagnostic and staging VATS pleural biopsy and pleural biopsy diagnostic and therapeutic Thoracotomy, frozen section and proceed - diagnostic and therapeutic 82

85 Pathological category It is the pathological category (based on what used to be called the surgical sieve) of the aetiology of the condition for which surgery is being performed. They include specific commonly occurring thoracic diagnoses. This is visited twice, at the time of the surgical procedure and again at discharge when it is revised. Multiple answers are allowed. Enter "1" if applicable: 18. Congenital 19. Trauma / accident 20. Primary cancer lung (known or probable) 21. Oesophageal cancer 22. Mesothelioma 23. Other primary thoracic malignancy 24. Malignant disease other (secondary, recurrent or metastatic) 25. Carcinoid 26. Benign neoplasms 27. Empyema (include all aetiologies of pleural sepsis) 28. Parenchymal lung disease 29. Vascular lesion 30. Pneumothorax 31. Pleural effusion 32. Other Multiple entries are allowed. You may have to deal with an empyema where the initiating problem was trauma (stabbing for example). Both are worth retrieving to count trauma and to count empyema so enter both. The data analyst can recognise that the operative episode was single. Appendices Procedure type Multiple entries are appropriate if performed in the same session. Select the options that best describe the operation as a whole if there was more than one procedure, enter each. The data analyst can see that they are part of a single operative episode. The purpose of the data collected here is to indicate service volume and workload. 33. Endoscopy; bronchoscopy / oesophagoscopy ± biopsy 34. Endoscopy; bronchoscopy / oesophagoscopy + any other procedure 35. Drain insertion 36. Other minor procedure (of the scale of node biopsies) 37. Mediastinoscopy and / or mediastinotomy 38. Other intermediate procedure (of the scale of rib resection) 39. VATS 40. Thoracotomy 41. Median sternotomy 42. Other major incision 83

86 Appendices Primary organ / system targeted Select the main target organ(s) of the operation. This is an anatomical list More than one may be entered, but coincidental surgery, such as chest wall if that is purely the route of access, will not be helpful in data analysis. 43. Aorta and / or great vessels 44. Chest wall 45. Diaphragm 46. Lung 47. Mediastinum 48. Oesophagus 49. Pericardium 50. Pleura 51. Thymus 52. Thyroid 53. Trachea and / or main bronchi 54. Other Named operations Select the procedure(s) performed at this operation. Thus pleural biopsy and pleurodesis can both be entered. This is not a comprehensive list but is derived from the registry list of operations performed more than about fifty or so times per annum and/or which are well defined set piece procedures. 55. Lobectomy (any indication) 56. Lobectomy (complex) with chest wall etc or bilobectomy 57. Pneumonectomy (any indication) 58. Sub lobar lung resection wedge or segmentectomy 59. Mediastinoscopy / mediastinotomy 60. Pneumothorax surgery (any technique) 61. Lung volume reduction and / or bullectomy 62. Pleurodesis for effusion 63. Pleural biopsy (any technique) 64. Decortication 65. Oesophageal resection (any) 66. Hiatus hernia surgery (any) 67. Pectus surgery 68. Sympathectomy 69. Thymectomy for myasthenia 70. Thymectomy for thymoma 71. Thyroid surgery 72. Bronchoscopy 73. Oesophagoscopy 74. Chest drain insertion 75. Other (enter) 84

87 Lung cancer data set (76-123) 76. Is this operation for Lung cancer (core dataset) If the answer is "No" proceed to Discharge section. If the answer is "Yes" answer specialised questions for lung cancer surgery. Omit where data is not available. Do not estimate. If data are too incomplete to analyse it s better that we know that. Pre-operative diagnostic staging of primary lung cancer 77. CT 78. MRI 79. PET 80. Tissue diagnosis pre-operatively (includes bronchoscopic, FNA, CT needle and cytology as long as it is regarded as proof of cancer) Histological diagnosis 81. Small cell 82. NSCLC 83. Squamous 84. Adeno 85. Undifferentiated 86. Broncheoalveolar 87. Other or further information (write in) Preoperative staging 88. T stage 89. N stage 90. M stage Appendices Neoadjuvant therapy 91. Chemotherapy pre-operatively 92. Radiotherapy pre -operatively Pulmonary risk factors 93. Measured FEV1 94. %predicted FEV1 (an algorithm can be included to calculated this) 95. Measured FVC 96. % Predicted FVC 97. Diffusion capacity by DLCO 98. Never smoked 99. Pack years 85

88 Non-pulmonary risk factors 100. Height (the patient s height in centimetres enter as whole number) Weight (the patient s weight in kilograms enter to one decimal place) Urea (mmol l -1 ) 103. Creatinine (mmol l -1 ) 104. Hb (g dl -1 ) 105. Insulin dependent diabetes 106. Ischaemic heart disease 107. Cardiac failure 108. Previous stroke 109. Steroid therapy 110. Anticoagulation with warfarin or equivalent therapy 111. Performance (ECOG) 112. ASA Grade (American Society of Anaesthetists grade) Appendices Surgical resection performed 113. Frozen section taken for diagnosis 114. Frozen section for staging 115. Left upper lobe 116. Left lower lobe 117. Right upper lobe 118. Middle lobe 119. Right lower lobe 120. Sublobar resection (whether wedge or segment) ptnm staging 121. T stage 122. N stage 123. M stage Core data continued Discharge (core and lung cancer datasets) 124. No complications 125. Reintubation or ITU admission; DDMMYYYY 126. Date of discharge from ITU; DDMMYYYY 127. IPPV 128. Air leak >7 days 129. Infection requiring longer hospital stay 130. Further surgery within the same admission 131. Date of discharge / death (core dataset) 132. Death; "Yes" or "No" (provide cause on death certificate) 86

89 Notes Appendices 87

90 Notes Appendices 88

91

92 The Society for Cardiothoracic Surgery Mr Richard Page Consultant Thoracic Surgeon The Cardiothoracic Centre Thomas Drive Liverpool L14 3PE United Kingdom Phone +44 (0) **** *** *** Fax +44 (0) **** *** *** Dendrite Clinical Systems Dr Peter K.H. Walton Managing Director 59A Bell Street Henley-on-Thames Oxfordshire RG9 2BA United Kingdom Phone +44 (0) Fax +44 (0)