The Society for Cardiothoracic Surgery in Great Britain & Ireland · 2016-10-10 · or by any means, electronic, mechanical, photocopying, recording or otherwise, without the permission

Thoracic Surgery

The Society for Cardiothoracic Surgery in Great Britain & Ireland

FirstNational 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


FirstNational Thoracic Surgery

Activity & Outcomes Report

2008

Prepared by

Richard Page ChM FRCS (CTh)

Bruce Keogh KBE MD FRCS FRCP

Society for Cardiothoracic Surgery in Great Britain & Ireland

Prepared by

Robin Kinsman BSc PhD


�

The Society for Cardiothoracic Surgery in Great Britain & Ireland gratefully acknowledge the assistance of Dendrite Clinical Systems for

• data presentation and

• publishing this report.

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PrefaceCardiothoracic surgeons primarily provide surgery for the heart, lung and oesophagus. We have a �5-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

The Society for Cardiothoracic Surgery in Great Britain & IrelandFirst National Thoracic Surgery Database Report 2008

4

Intr

od

uct

ion

4

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 1980. 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 �00� 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 �). 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.


5

Intro

du

ction

Between the years 1998 and �001, 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.

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 �005. The second section deals with Unit-specific activity for the three-year period from 1st April �00� to 31st March �005. 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 post-operative 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.


6

Intr

od

uct

ion

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.

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


Returns submitted to the Register

0%

20%

40%

60%

80%

100%

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Per

cen

tag

e o

f un

its

that

su

bm

itte

d r

etu

rns

to t

he

reg

iste

r

0%

20%

40%

60%

80%

100%

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Per

cen

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f un

its

that

su

bm

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d r

etu

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to t

he

reg

iste

r


8

Tab

le o

f co

nte

nts

Preface 3

Introduction 4

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


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

Contents


9

Table o

f con

tents

Unit-specific activity

Contributing Units 36

Organisation of the report 37

Total activity 38

Total surgical activity 38

Total major procedures 39


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

Total procedures for pneumothorax 56


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 (1980-2002) 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

National activity


1�

Nat

ion

al a

ctiv

ity

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 �000-�001 onwards.

Total major procedures

A fairly static activity.

Total surgical activity (n=340,422)

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

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3

2003

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4

2004

-200

5

Period

Nu

mb

er o

f pro

ced

ure

s

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

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2

2002

-200

3

2003

-200

4

2004

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5

Period

Nu

mb

er o

f pro

ced

ure

s

Major procedures performed (n=263,345)

0

2,000

4,000

6,000

8,000

10,000

12,000

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

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5

1995

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6

1996

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7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Nu

mb

er o

f pro

ced

ure

s

0

2,000

4,000

6,000

8,000

10,000

12,000

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

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6

1996

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7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

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2

2002

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3

2003

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4

2004

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5

Period

Nu

mb

er o

f pro

ced

ure

s


13

Natio

nal activity

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.

VATS as a proportion of total workload (n=340,422)

0%

5%

10%

15%

20%

25%

30%

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

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5

1995

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6

1996

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7

1997

-199

8

1998

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9

1999

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0

2000

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1

2001

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2

2002

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3

2003

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4

2004

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5

Period

Per

cen

tag

e o

f pro

ced

ure

s th

at w

ere

VA

TS

0%

5%

10%

15%

20%

25%

30%

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

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6

1996

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7

1997

-199

8

1998

-199

9

1999

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0

2000

-200

1

2001

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2

2002

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3

2003

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4

2004

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Period

Per

cen

tag

e o

f pro

ced

ure

s th

at w

ere

VA

TS


14

Nat

ion

al a

ctiv

ity

Lung resections

Total lung resections

This includes resections of lung for any reason both diagnostic and therapeutic, and for all pathologies.

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.

Lung resections performed (n=120,521)

0

1,000

2,000

3,000

4,000

5,000

6,000

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

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5

1995

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6

1996

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7

1997

-199

8

1998

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9

1999

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0

2000

-200

1

2001

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2

2002

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3

2003

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4

2004

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Period

Nu

mb

er o

f lu

ng

res

ecti

on

s

0

1,000

2,000

3,000

4,000

5,000

6,000

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

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2

1992

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3

1993

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4

1994

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5

1995

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6

1996

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7

1997

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8

1998

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9

1999

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0

2000

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1

2001

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2

2002

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3

2003

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4

2004

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5

Period

Nu

mb

er o

f lu

ng

res

ecti

on

s

VATS as a proportion of all lung resections performed (n=120,521)

0%

3%

6%

9%

12%

15%

18%

21%

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

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3

1993

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4

1994

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5

1995

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6

1996

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7

1997

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8

1998

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9

1999

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0

2000

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1

2001

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2

2002

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3

2003

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4

2004

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5

Period

Per

cen

tag

e o

f lu

ng

res

ecti

on

s th

at w

ere

VA

TS

0%

3%

6%

9%

12%

15%

18%

21%

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

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6

1996

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7

1997

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8

1998

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9

1999

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0

2000

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1

2001

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2

2002

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2003

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2004

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Period

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res

ecti

on

s th

at w

ere

VA

TS


15

Natio

nal activity

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.

Proportion resections for patients with primary lung cancer (n=120,384)

50%

55%

60%

65%

70%

75%

80%

85%

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

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5

1995

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6

1996

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7

1997

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8

1998

-199

9

1999

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0

2000

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1

2001

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2

2002

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3

2003

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4

2004

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5

Period

Per

cen

tag

e o

f pat

ien

ts w

ith

pri

mar

y lu

ng

can

cer

50%

55%

60%

65%

70%

75%

80%

85%

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

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5

1995

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6

1996

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7

1997

-199

8

1998

-199

9

1999

-200

0

2000

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1

2001

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2

2002

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3

2003

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4

2004

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5

Period

Per

cen

tag

e o

f pat

ien

ts w

ith

pri

mar

y lu

ng

can

cer


16

Nat

ion

al a

ctiv

ity

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)

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Nu

mb

er o

f res

ecti

on

s fo

rp

rim

ary

lun

g c

ance

r

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Nu

mb

er o

f res

ecti

on

s fo

rp

rim

ary

lun

g c

ance

r


17

Natio

nal activity

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.

Type of resection for primary lung cancer (n=86,160)

Pneumonectomy Lobectomy

Wedge / segmentectomy

0%

20%

40%

60%

80%

100%

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Per

cen

tag

e o

f pro

ced

ure

s

0%

20%

40%

60%

80%

100%

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Per

cen

tag

e o

f pro

ced

ure

s


18

Nat

ion

al a

ctiv

ity

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.

Open / close rates in surgery for primary lung cancer (n=87,367)

0%

4%

8%

12%

16%

20%

24%

28%

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Op

en /

clo

se r

ate

0%

4%

8%

12%

16%

20%

24%

28%

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Op

en /

clo

se r

ate


19

Natio

nal activity

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.

Mortality after pneumonectomy for primary lung cancer (n=26,363)

0%

2%

4%

6%

8%

10%

12%

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Cru

de

mo

rtal

ity

rate

0%

2%

4%

6%

8%

10%

12%

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Cru

de

mo

rtal

ity

rate

Mortality after lobectomy for primary lung cancer (n=52,663)

0%

1%

2%

3%

4%

5%

6%

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Cru

de

mo

rtal

ity

rate

0%

1%

2%

3%

4%

5%

6%

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Cru

de

mo

rtal

ity

rate


�0

Nat

ion

al a

ctiv

ity

Mortality after wedge resection for primary lung cancer (n=7,134)

0%

1%

2%

3%

4%

5%

6%

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Cru

de

mo

rtal

ity

rate

0%

1%

2%

3%

4%

5%

6%

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Cru

de

mo

rtal

ity

rate


�1

Natio

nal activity

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.

VATS as a proportion of all resections for primary lung cancer (n=87,367)

0%

1%

2%

3%

4%

5%

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Per

cen

tag

e o

f pro

ced

ure

s th

at w

ere

VA

TS

0%

1%

2%

3%

4%

5%

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Per

cen

tag

e o

f pro

ced

ure

s th

at w

ere

VA

TS


��

Nat

ion

al a

ctiv

ity

VATS as a proportion of all wedge resections / segmetectomies for primary lung cancer (n=7,134)

0%

4%

8%

12%

16%

20%

24%

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Per

cen

tag

e o

f pro

ced

ure

s th

at w

ere

VA

TS

0%

4%

8%

12%

16%

20%

24%

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Per

cen

tag

e o

f pro

ced

ure

s th

at w

ere

VA

TS

VATS as a proportion of all lobectomies for primary lung cancer (n=51,615)

0%

1%

2%

3%

4%

5%

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Per

cen

tag

e o

f pro

ced

ure

s th

at w

ere

VA

TS

0%

1%

2%

3%

4%

5%

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Per

cen

tag

e o

f pro

ced

ure

s th

at w

ere

VA

TS


�3

Natio

nal activity

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 long-term 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 1989-1990

Sleeve resections as a proportion of all resections for primary lung cancer (n=54,434)

0%

1%

2%

3%

4%

5%

1989

-90

1990

-199

1

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Per

cen

tag

e o

f res

sect

ion

sth

at w

ere

slee

ve r

esec

tio

ns

0%

1%

2%

3%

4%

5%

1989

-90

1990

-199

1

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Per

cen

tag

e o

f res

sect

ion

sth

at w

ere

slee

ve r

esec

tio

ns


�4

Nat

ion

al a

ctiv

ity

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..

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.

Mediastinoscopy / mediastinotomy as a proportion of all resections for primary lung cancer (n=56,865)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%19

80

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Med

iati

no

sco

py

/ med

iati

no

tom

y ra

teco

mp

ared

wit

h t

ota

l nu

mb

ers

of

rese

ctio

ns

for

pri

mar

y lu

ng

can

cer

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%19

80

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Med

iati

no

sco

py

/ med

iati

no

tom

y ra

teco

mp

ared

wit

h t

ota

l nu

mb

ers

of

rese

ctio

ns

for

pri

mar

y lu

ng

can

cer


�5

Natio

nal activity

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.

Lung resections for conditions other than primary lung cancer (n=33,017)

0

300

600

900

1,200

1,500

1,800

2,100

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Nu

mb

er o

f lu

ng

res

ecti

on

s

0

300

600

900

1,200

1,500

1,800

2,100

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Nu

mb

er o

f lu

ng

res

ecti

on

s

VATS as a proportion of all resections for conditions other than primary lung cancer (n=33,017)

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Per

cen

tag

e o

f pro

ced

ure

s th

at w

ere

VA

TS

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Per

cen

tag

e o

f pro

ced

ure

s th

at w

ere

VA

TS


�6

Nat

ion

al a

ctiv

ity

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)

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

1980

-198

1

1981

-198

2

1982

-198

3

1983

-198

4

1984

-198

5

1985

-198

6

1986

-198

7

1987

-198

8

1988

-198

9

1989

-199

0

1990

-199

1

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Nu

mb

er o

f pro

ced

ure

s

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

1980

-198

1

1981

-198

2

1982

-198

3

1983

-198

4

1984

-198

5

1985

-198

6

1986

-198

7

1987

-198

8

1988

-198

9

1989

-199

0

1990

-199

1

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Nu

mb

er o

f pro

ced

ure

s


�7

Natio

nal activity


VATS as a proportion of all procedures for pneumothorax (n=26,566)

0%

10%

20%

30%

40%

50%

60%

70%

80%

1980

-198

1

1981

-198

2

1982

-198

3

1983

-198

4

1984

-198

5

1985

-198

6

1986

-198

7

1987

-198

8

1988

-198

9

1989

-199

0

1990

-199

9

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Per

cen

tag

e o

f pro

ced

ure

s th

at w

ere

VA

TS

0%

10%

20%

30%

40%

50%

60%

70%

80%

1980

-198

1

1981

-198

2

1982

-198

3

1983

-198

4

1984

-198

5

1985

-198

6

1986

-198

7

1987

-198

8

1988

-198

9

1989

-199

0

1990

-199

9

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Per

cen

tag

e o

f pro

ced

ure

s th

at w

ere

VA

TS


�8

Nat

ion

al a

ctiv

ity

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)

Open VATS

0%

1%

2%

3%

4%

5%

1980

-198

1

1981

-198

2

1982

-198

3

1983

-198

4

1984

-198

5

1985

-198

6

1986

-198

7

1987

-198

8

1988

-198

9

1989

-199

0

1990

-199

1

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Cru

de

mo

rtal

ity

rate

0%

1%

2%

3%

4%

5%

1980

-198

1

1981

-198

2

1982

-198

3

1983

-198

4

1984

-198

5

1985

-198

6

1986

-198

7

1987

-198

8

1988

-198

9

1989

-199

0

1990

-199

1

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Cru

de

mo

rtal

ity

rate

0%

1%

2%

3%

4%

5%

1980

-198

1

1981

-198

2

1982

-198

3

1983

-198

4

1984

-198

5

1985

-198

6

1986

-198

7

1987

-198

8

1988

-198

9

1989

-199

0

1990

-199

1

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Cru

de

mo

rtal

ity

rate

0%

1%

2%

3%

4%

5%

1980

-198

1

1981

-198

2

1982

-198

3

1983

-198

4

1984

-198

5

1985

-198

6

1986

-198

7

1987

-198

8

1988

-198

9

1989

-199

0

1990

-199

1

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Cru

de

mo

rtal

ity

rate


�9

Natio

nal activity

Surgery for upper GI disordersAlthough 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.


30

Nat

ion

al a

ctiv

ity

Total procedures for upper GI disorders (n=44,883)

0

500

1,000

1,500

2,000

2,500

3,00019

80

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Nu

mb

er o

f pro

ced

ure

s

0

500

1,000

1,500

2,000

2,500

3,00019

80

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Nu

mb

er o

f pro

ced

ure

s

Resections for upper GI cancer (n=19,131)

0

200

400

600

800

1,000

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Nu

mb

er o

f pro

ced

ure

s

0

200

400

600

800

1,000

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Nu

mb

er o

f pro

ced

ure

s


31

Natio

nal activity

Other major upper GI procedures (n=25,704)

0

400

800

1,200

1,600

2,000

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Nu

mb

er o

f pro

ced

ure

s

0

400

800

1,200

1,600

2,000

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Nu

mb

er o

f pro

ced

ure

s


3�

Nat

ion

al a

ctiv

ity

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.

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.

VATS as a proportion of all resections for upper GI cancer (n=19,131)

0%

2%

4%

6%

8%

10%

12%

14%

16%

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Per

cen

tag

e o

f pro

ced

ure

sth

at w

ere

VA

TS

0%

2%

4%

6%

8%

10%

12%

14%

16%

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Per

cen

tag

e o

f pro

ced

ure

sth

at w

ere

VA

TS

Mortality after procedures for upper GI disorders (n=19,131)

0%

4%

8%

12%

16%

20%

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Cru

de

mo

rtal

ity

rate

0%

4%

8%

12%

16%

20%

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Cru

de

mo

rtal

ity

rate


33

Natio

nal activity

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..

Open / close rates in surgery for upper GI disorders (n=19,131)

0%

4%

8%

12%

16%

20%

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Op

en /

clo

se r

ate

0%

4%

8%

12%

16%

20%

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

-199

2

1992

-199

3

1993

-199

4

1994

-199

5

1995

-199

6

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

Period

Op

en /

clo

se r

ate

Unit-specific report


36

Un

it-s

pec

ific

acti

vity

Unit-specific activity

Contributing UnitsThe following data form a report on activity for the three-year period running from the beginning of April �00� to the end of March �005. 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.

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


37

Un

it-specifi

c activity

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 �00�-�005:

• Bradford Royal Infirmary (ceased activity in �004)

• Glasgow Royal Infirmary

• Hairmyers Hospital, Glasgow

• Plymouth Royal Infirmary

Organisation of the reportWhen 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.

�. 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.


38

Un

it-s

pec

ific

acti

vity

Total activity

Total surgical activity

Total surgical activity; financial years 2003-2005 (n=45,429)

0 500 1,000 1,500 2,000 2,500 3,000 3,500

Birmingham

Liverpool

Edinburgh

Brompton

Newcastle

Hull

Southampton

Harefield

Guy's / St Thomas's

Leeds

Belfast

Sheffield

Norwich

Wythenshawe

Bristol

St Georges

The Heart Hospital

Nottingham

Cardiff

Papworth

Blackpool

Leicester

Glasgow

Exeter

Coventry

Dublin

Bart's & the London

Hammersmith

Manchester Royal Informary

Aberdeen

Stoke

Middlesborough

Cork

St Mary's

Kings College Hospital

Oxford

Un

it

Number of procedures

0 500 1,000 1,500 2,000 2,500 3,000 3,500

Birmingham

Liverpool

Edinburgh

Brompton

Newcastle

Hull

Southampton

Harefield

Guy's / St Thomas's

Leeds

Belfast

Sheffield

Norwich

Wythenshawe

Bristol

St Georges

The Heart Hospital

Nottingham

Cardiff

Papworth

Blackpool

Leicester

Glasgow

Exeter

Coventry

Dublin

Bart's & the London

Hammersmith


Aberdeen

Stoke

Middlesborough

Cork

St Mary's


Oxford

Un

it



39

Un

it-specifi

c activity

Total major procedures

Major procedures performed; financial years 2003-2005 (n=45,429)

0 500 1,000 1,500 2,000 2,500 3,000

Birmingham

Liverpool

Edinburgh

Brompton

Southampton

Harefield

Guy's / St Thomas's

Hull

Newcastle

Belfast

Sheffield

Wythenshawe

Leeds

Bristol

The Heart Hospital

Nottingham

Norwich

St Georges

Cardiff

Papworth

Blackpool

Leicester

Exeter

Bart's & the London

Glasgow

Dublin

Coventry

Middlesborough


Hammersmith

Aberdeen

Stoke

St Mary's

Cork


Oxford

Un

it


0 500 1,000 1,500 2,000 2,500 3,000

Birmingham

Liverpool

Edinburgh

Brompton

Southampton

Harefield

Guy's / St Thomas's

Hull

Newcastle

Belfast

Sheffield

Wythenshawe

Leeds

Bristol

The Heart Hospital

Nottingham

Norwich

St Georges

Cardiff

Papworth

Blackpool

Leicester

Exeter

Bart's & the London

Glasgow

Dublin

Coventry

Middlesborough


Hammersmith

Aberdeen

Stoke

St Mary's

Cork


Oxford

Un

it



40

Un

it-s

pec

ific

acti

vity


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 2003-2005 (n=45,429)

0% 10% 20% 30% 40% 50% 60% 70%

Birmingham

Liverpool

Edinburgh

Brompton

Newcastle

Hull

Southampton

Harefield

Guy's / St Thomas's

Leeds

Belfast

Sheffield

Norwich

Wythenshawe

Bristol

St Georges

The Heart Hospital

Nottingham

Cardiff

Papworth

Blackpool

Leicester

Glasgow

Exeter

Coventry

Dublin

Bart's & the London

Hammersmith


Aberdeen

Stoke

Middlesborough

Cork

St Mary's London


Oxford

Un

it

Percentage of lung resections that were VATS

0% 10% 20% 30% 40% 50% 60% 70%

Birmingham

Liverpool

Edinburgh

Brompton

Newcastle

Hull

Southampton

Harefield

Guy's / St Thomas's

Leeds

Belfast

Sheffield

Norwich

Wythenshawe

Bristol

St Georges

The Heart Hospital

Nottingham

Cardiff

Papworth

Blackpool

Leicester

Glasgow

Exeter

Coventry

Dublin

Bart's & the London

Hammersmith


Aberdeen

Stoke

Middlesborough

Cork

St Mary's London


Oxford

Un

it



41

Un

it-specifi

c activity

Lung resections

Total lung resections

.

Lung resections performed; financial years 2003-2005 (n=15,654)

0 200 400 600 800 1,000 1,200 1,400

Birmingham

Liverpool

Brompton

Edinburgh

Newcastle

Hull

Sheffield

Cardiff

Southampton

Harefield

Leicester

Papworth

Bart's & the London

Bristol

Nottingham

Guy's / St Thomas's

Wythenshawe

The Heart Hospital

Belfast

Norwich

Leeds

St Georges

Glasgow

Dublin

Blackpool

Coventry

Hammersmith

Middlesborough

Aberdeen

Stoke

Exeter


St Mary's London

Cork


Oxford

Un

it

Number of lung resections

0 200 400 600 800 1,000 1,200 1,400

Birmingham

Liverpool

Brompton

Edinburgh

Newcastle

Hull

Sheffield

Cardiff

Southampton

Harefield

Leicester

Papworth

Bart's & the London

Bristol

Nottingham

Guy's / St Thomas's

Wythenshawe

The Heart Hospital

Belfast

Norwich

Leeds

St Georges

Glasgow

Dublin

Blackpool

Coventry

Hammersmith

Middlesborough

Aberdeen

Stoke

Exeter


St Mary's London

Cork


Oxford

Un

it



4�

Un

it-s

pec

ific

acti

vity

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 2003-2005 (n=14,990)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

Birmingham

Liverpool

Brompton

Edinburgh

Newcastle

Hull

Sheffield

Cardiff

Southampton

Harefield

Leicester

Bart's & the London

Papworth

Bristol

Nottingham

Guy's / St Thomas's

The Heart Hospital

Norwich

Belfast

Wythenshawe

Leeds

St Georges

Glasgow

Blackpool

Dublin

Coventry

Middlesborough

Hammersmith

Aberdeen

Exeter

Stoke


St Mary's London

Cork


Oxford

Un

it


0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

Birmingham

Liverpool

Brompton

Edinburgh

Newcastle

Hull

Sheffield

Cardiff

Southampton

Harefield

Leicester

Bart's & the London

Papworth

Bristol

Nottingham

Guy's / St Thomas's

The Heart Hospital

Norwich

Belfast

Wythenshawe

Leeds

St Georges

Glasgow

Blackpool

Dublin

Coventry

Middlesborough

Hammersmith

Aberdeen

Exeter

Stoke


St Mary's London

Cork


Oxford

Un

it



43

Un

it-specifi

c activity

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 2003-2005 (n=15,654)

0% 20% 40% 60% 80% 100%

Birmingham

Liverpool

Brompton

Edinburgh

Newcastle

Hull

Sheffield

Cardiff

Southampton

Harefield

Leicester

Papworth

Bart's & the London

Bristol

Nottingham

Guy's / St Thomas's

Wythenshawe

The Heart Hospital

Belfast

Norwich

Leeds

St Georges

Glasgow

Dublin

Blackpool

Coventry

Hammersmith

Middlesborough

Aberdeen

Stoke

Exeter


St Mary's London

Cork


Oxford

Un

it

Percentage of patients with primary lung cancer

0% 20% 40% 60% 80% 100%

Birmingham

Liverpool

Brompton

Edinburgh

Newcastle

Hull

Sheffield

Cardiff

Southampton

Harefield

Leicester

Papworth

Bart's & the London

Bristol

Nottingham

Guy's / St Thomas's

Wythenshawe

The Heart Hospital

Belfast

Norwich

Leeds

St Georges

Glasgow

Dublin

Blackpool

Coventry

Hammersmith

Middlesborough

Aberdeen

Stoke

Exeter


St Mary's London

Cork


Oxford

Un

it

Percentage of patients with primary lung cancer


44

Un

it-s

pec

ific

acti

vity

Primary lung cancer

Resections for primary lung cancer

Resections for primary lung cancer; financial years 2003-2005 (n=10,047)

0 100 200 300 400 500 600 700 800

Birmingham

Liverpool

Sheffield

Newcastle

Hull

Edinburgh

Guy's / St Thomas's

Cardiff

Bart's & the London

Leeds

Wythenshawe

Harefield

Bristol

Leicester

Southampton

Belfast

St Georges

Nottingham

Brompton

Norwich

Glasgow

Papworth

Middlesborough

Blackpool

Dublin

The Heart Hospital

Coventry

Exeter


Stoke

Cork

Aberdeen

St Mary's London

Hammersmith

Oxford


Un

it

Number of resections for primary lung cancer

0 100 200 300 400 500 600 700 800

Birmingham

Liverpool

Sheffield

Newcastle

Hull

Edinburgh

Guy's / St Thomas's

Cardiff

Bart's & the London

Leeds

Wythenshawe

Harefield

Bristol

Leicester

Southampton

Belfast

St Georges

Nottingham

Brompton

Norwich

Glasgow

Papworth

Middlesborough

Blackpool

Dublin

The Heart Hospital

Coventry

Exeter


Stoke

Cork

Aberdeen

St Mary's London

Hammersmith

Oxford


Un

it

Number of resections for primary lung cancer


45

Un

it-specifi

c activity

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 2003-2005 (n=9,816)

Pneumonectomy Lobectomy

Wedge / segmentectomy

0% 20% 40% 60% 80% 100%

Birmingham

Liverpool

Sheffield

Newcastle

Hull

Edinburgh

Guy's / St Thomas's

Cardiff

Bart's & the London

Leeds

Wythenshawe

Bristol

Harefield

Leicester

Southampton

St Georges

Nottingham

Belfast

Norwich

Brompton

Papworth

Glasgow

Middlesborough

Blackpool

Dublin

The Heart Hospital

Coventry

Exeter


Stoke

Cork

Aberdeen

St Mary's London

Hammersmith

Oxford


Un

it

Percentage of procedures

0% 20% 40% 60% 80% 100%

Birmingham

Liverpool

Sheffield

Newcastle

Hull

Edinburgh

Guy's / St Thomas's

Cardiff

Bart's & the London

Leeds

Wythenshawe

Bristol

Harefield

Leicester

Southampton

St Georges

Nottingham

Belfast

Norwich

Brompton

Papworth

Glasgow

Middlesborough

Blackpool

Dublin

The Heart Hospital

Coventry

Exeter


Stoke

Cork

Aberdeen

St Mary's London

Hammersmith

Oxford


Un

it

Percentage of procedures


46

Un

it-s

pec

ific

acti

vity

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 �0% 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.

�. 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 �00� and �005, 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 rates in surgery for primary lung cancer;financial years 2003-2005 (n=10,046)

Unit 99% lower alert 99.9% lower alarm

average rate 99% upper alert 99.9% upper alarm

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

0 100 200 300 400 500 600 700 800


Op

en /

clo

se r

ate

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

0 100 200 300 400 500 600 700 800


Op

en /

clo

se r

ate


47

Un

it-specifi

c activity

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 � 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 2003-2005 (n=1,510)



0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

0 20 40 60 80 100 120 140


Mo

rtal

ity

rate

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

0 20 40 60 80 100 120 140


Mo

rtal

ity

rate


48

Un

it-s

pec

ific

acti

vity

Mortality after wedge resection / segmentectomy for primary lung cancer; financial years 2003-2005 (n=1,371)



0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

0 20 40 60 80 100 120 140 160 180 200


Mo

rtal

ity

rate

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

0 20 40 60 80 100 120 140 160 180 200


Mo

rtal

ity

rate

Mortality after lobectomy for primary lung cancer; financial years 2003-2005 (n=6,932)



0%

1%

2%

3%

4%

5%

6%

7%

8%

0 100 200 300 400 500 600


Mo

rtal

ity

rate

0%

1%

2%

3%

4%

5%

6%

7%

8%

0 100 200 300 400 500 600


Mo

rtal

ity

rate


49

Un

it-specifi

c activity

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)

0% 20% 40% 60% 80% 100%

Liverpool

Birmingham

Newcastle

Sheffield

Edinburgh

Guy's / St Thomas's

Hull

Wythenshawe

Bart's & the London

Cardiff

Leicester

Harefield

Southampton

St Georges

Brompton

Bristol

Nottingham

Belfast

Glasgow

Norwich

Papworth

Leeds

Middlesborough

Dublin

Blackpool


The Heart Hospital

Stoke

Coventry

Exeter

Cork

St Mary's London

Hammersmith

Aberdeen


Oxford

Un

it

Percentage of procedures that were VATS

0% 20% 40% 60% 80% 100%

Liverpool

Birmingham

Newcastle

Sheffield

Edinburgh

Guy's / St Thomas's

Hull

Wythenshawe

Bart's & the London

Cardiff

Leicester

Harefield

Southampton

St Georges

Brompton

Bristol

Nottingham

Belfast

Glasgow

Norwich

Papworth

Leeds

Middlesborough

Dublin

Blackpool


The Heart Hospital

Stoke

Coventry

Exeter

Cork

St Mary's London

Hammersmith

Aberdeen


Oxford

Un

it



50

Un

it-s

pec

ific

acti

vity

VATS as a proportion of all lobectomies for primary lung cancer; financial years 2003-2005 (n=6,932)

0% 20% 40% 60% 80% 100%

Liverpool

Birm'hamHeartlands

Newcastle

Sheffield

Edinburgh

Guy's/StThom

Hull

Manch Wyth

Bart's/London

Cardiff

Leicester

Harefield

Southampton

StGeorges

Brompton

Bristol

Nottingham

Belfast

Glasgow West

Norwich

Papworth

Leeds

Middlesborough

Dublin StJam

Blackpool

Manch RI

UCLH/Middsx

Stoke

Coventry

Exeter

Cork

StMary's

Hammersmith

Aberdeen

Kings

Oxford

Un

it


0% 20% 40% 60% 80% 100%

Liverpool

Birm'hamHeartlands

Newcastle

Sheffield

Edinburgh

Guy's/StThom

Hull

Manch Wyth

Bart's/London

Cardiff

Leicester

Harefield

Southampton

StGeorges

Brompton

Bristol

Nottingham

Belfast

Glasgow West

Norwich

Papworth

Leeds

Middlesborough

Dublin StJam

Blackpool

Manch RI

UCLH/Middsx

Stoke

Coventry

Exeter

Cork

StMary's

Hammersmith

Aberdeen

Kings

Oxford

Un

it



51

Un

it-specifi

c activity

VATS as a proportion of all wedge resections / segmetectomies for primary lung cancer; financial years 2003-2005 (n=1,371)

0% 20% 40% 60% 80% 100%

Leeds

Birmingham

Sheffield

Bristol

Hull

Cardiff

Harefield

Guy's / St Thomas's

The Heart Hospital

Liverpool

Belfast

Leicester

Nottingham

Southampton

Newcastle

Coventry

St Georges

Brompton

Exeter

Norwich

Bart's & the London

Glasgow

Wythenshawe

Blackpool

Papworth

Middlesborough

Hammersmith

Stoke

Aberdeen

Edinburgh

Cork


Dublin

St Mary's London

Un

it


0% 20% 40% 60% 80% 100%

Leeds

Birmingham

Sheffield

Bristol

Hull

Cardiff

Harefield

Guy's / St Thomas's

The Heart Hospital

Liverpool

Belfast

Leicester

Nottingham

Southampton

Newcastle

Coventry

St Georges

Brompton

Exeter

Norwich

Bart's & the London

Glasgow

Wythenshawe

Blackpool

Papworth

Middlesborough

Hammersmith

Stoke

Aberdeen

Edinburgh

Cork


Dublin

St Mary's London

Un

it



5�

Un

it-s

pec

ific

acti

vity

Sleeve resections

Sleeve resections as a proportion of all resections for primary lung cancer; financial years 2003-2005 (n=10,047)

0% 2% 4% 6% 8% 10% 12% 14% 16%

Birmingham

Liverpool

Sheffield

Newcastle

Hull

Edinburgh

Guy's / St Thomas's

Cardiff

Bart's & the London

Leeds

Wythenshawe

Harefield

Bristol

Leicester

Southampton

Belfast

St Georges

Nottingham

Brompton

Norwich

Glasgow

Papworth

Middlesborough

Blackpool

Dublin

The Heart Hospital

Coventry

Exeter


Stoke

Cork

Aberdeen

St Mary's London

Hammersmith

Oxford


Un

it

Percentage of resections that were sleeve resections

0% 2% 4% 6% 8% 10% 12% 14% 16%

Birmingham

Liverpool

Sheffield

Newcastle

Hull

Edinburgh

Guy's / St Thomas's

Cardiff

Bart's & the London

Leeds

Wythenshawe

Harefield

Bristol

Leicester

Southampton

Belfast

St Georges

Nottingham

Brompton

Norwich

Glasgow

Papworth

Middlesborough

Blackpool

Dublin

The Heart Hospital

Coventry

Exeter


Stoke

Cork

Aberdeen

St Mary's London

Hammersmith

Oxford


Un

it

Percentage of resections that were sleeve resections


53

Un

it-specifi

c activity

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 2003-2005 (n=10,047 resections)

0.0 0.5 1.0 1.5 2.0 2.5

Birmingham

Liverpool

Sheffield

Newcastle

Hull

Edinburgh

Guy's / St Thomas's

Cardiff

Bart's & the London

Leeds

Wythenshawe

Harefield

Bristol

Leicester

Southampton

Belfast

St Georges

Nottingham

Brompton

Norwich

Glasgow

Papworth

Middlesborough

Blackpool

Dublin

The Heart Hospital

Coventry

Exeter


Stoke

Cork

Aberdeen

St Mary's London

Hammersmith

Oxford


Un

it

Ratio of mediatinoscopy or mediastinotomy to total resections

0.0 0.5 1.0 1.5 2.0 2.5

Birmingham

Liverpool

Sheffield

Newcastle

Hull

Edinburgh

Guy's / St Thomas's

Cardiff

Bart's & the London

Leeds

Wythenshawe

Harefield

Bristol

Leicester

Southampton

Belfast

St Georges

Nottingham

Brompton

Norwich

Glasgow

Papworth

Middlesborough

Blackpool

Dublin

The Heart Hospital

Coventry

Exeter


Stoke

Cork

Aberdeen

St Mary's London

Hammersmith

Oxford


Un

it

Ratio of mediatinoscopy or mediastinotomy to total resections

Increasing numb

ers of lung resections


54

Un

it-s

pec

ific

acti

vity

Conditions other than primary lung cancer

Resections for other conditions

Lung resections for conditions other than primary lung cancer; financial years 2003-2005 (n=5,607)

0 100 200 300 400 500

Birmingham

Brompton

Liverpool

Southampton

Edinburgh

Papworth

The Heart Hospital

Newcastle

Hull

Harefield

Nottingham

Leicester

Cardiff

Bristol

Bart's & the London

Hammersmith

Sheffield

Norwich

Belfast

Aberdeen

Coventry

Dublin

Glasgow

Blackpool

Wythenshawe

Stoke

St Georges

St Mary's London


Exeter

Guy's / St Thomas's


Oxford

Leeds

Middlesborough

Cork

Un

it


0 100 200 300 400 500

Birmingham

Brompton

Liverpool

Southampton

Edinburgh

Papworth

The Heart Hospital

Newcastle

Hull

Harefield

Nottingham

Leicester

Cardiff

Bristol

Bart's & the London

Hammersmith

Sheffield

Norwich

Belfast

Aberdeen

Coventry

Dublin

Glasgow

Blackpool

Wythenshawe

Stoke

St Georges

St Mary's London


Exeter

Guy's / St Thomas's


Oxford

Leeds

Middlesborough

Cork

Un

it



55

Un

it-specifi

c activity

VATS as a proportion of all resections for conditions other than primary lung cancer; financial years 2003-2005 (n=5,607)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Birmingham

Brompton

Liverpool

Southampton

Edinburgh

Papworth

The Heart Hospital

Newcastle

Hull

Harefield

Nottingham

Leicester

Cardiff

Bristol

Bart's & the London

Hammersmith

Sheffield

Norwich

Belfast

Aberdeen

Coventry

Dublin

Glasgow

Blackpool

Wythenshawe

Stoke

St Georges

St Mary's London


Exeter

Guy's / St Thomas's


Oxford

Leeds

Middlesborough

Cork

Un

it


0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Birmingham

Brompton

Liverpool

Southampton

Edinburgh

Papworth

The Heart Hospital

Newcastle

Hull

Harefield

Nottingham

Leicester

Cardiff

Bristol

Bart's & the London

Hammersmith

Sheffield

Norwich

Belfast

Aberdeen

Coventry

Dublin

Glasgow

Blackpool

Wythenshawe

Stoke

St Georges

St Mary's London


Exeter

Guy's / St Thomas's


Oxford

Leeds

Middlesborough

Cork

Un

it



56

Un

it-s

pec

ific

acti

vity

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 2003-2005 (n=4,334)

0 100 200 300 400 500 600 700

Guy's / St Thomas's

Birmingham

Leeds

Liverpool

Harefield

Newcastle

Hull

Southampton

Brompton

Edinburgh

Cardiff

Belfast

The Heart Hospital

Sheffield

Middlesborough

St Georges

Norwich

Bart's & the London

Nottingham

Dublin

Coventry

Bristol

Blackpool

Aberdeen


Leicester

Cork

Glasgow

St Mary's London

Papworth

Stoke


Oxford

Exeter

Wythenshawe

Un

it


0 100 200 300 400 500 600 700

Guy's / St Thomas's

Birmingham

Leeds

Liverpool

Harefield

Newcastle

Hull

Southampton

Brompton

Edinburgh

Cardiff

Belfast

The Heart Hospital

Sheffield

Middlesborough

St Georges

Norwich

Bart's & the London

Nottingham

Dublin

Coventry

Bristol

Blackpool

Aberdeen


Leicester

Cork

Glasgow

St Mary's London

Papworth

Stoke


Oxford

Exeter

Wythenshawe

Un

it



57

Un

it-specifi

c activity


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 2003-2005 (n=4,334)

0% 20% 40% 60% 80% 100%

Guy's / St Thomas's

Birmingham

Leeds

Liverpool

Harefield

Newcastle

Hull

Southampton

Brompton

Edinburgh

Cardiff

Belfast

The Heart Hospital

Sheffield

Middlesborough

St Georges

Norwich

Bart's & the London

Nottingham

Dublin

Coventry

Bristol

Blackpool

Aberdeen


Leicester

Cork

Glasgow

St Mary's London

Papworth

Stoke


Oxford

Exeter

Wythenshawe

Un

it


0% 20% 40% 60% 80% 100%

Guy's / St Thomas's

Birmingham

Leeds

Liverpool

Harefield

Newcastle

Hull

Southampton

Brompton

Edinburgh

Cardiff

Belfast

The Heart Hospital

Sheffield

Middlesborough

St Georges

Norwich

Bart's & the London

Nottingham

Dublin

Coventry

Bristol

Blackpool

Aberdeen


Leicester

Cork

Glasgow

St Mary's London

Papworth

Stoke


Oxford

Exeter

Wythenshawe

Un

it



58

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ific

acti

vity

Mortality after procedures for pneumothorax

Mortality after open procedures for pneumonectomy; financial years 2003-2005 (n=1,200)



0%

5%

10%

15%

20%

25%

30%

35%

0 20 40 60 80 100 120 140


Mo

rtal

ity

rate

0%

5%

10%

15%

20%

25%

30%

35%

0 20 40 60 80 100 120 140


Mo

rtal

ity

rate

Mortality after VATS procedures for pneumonectomy; financial years 2003-2005 (n=3,134)



0%

1%

2%

3%

4%

5%

6%

7%

8%

0 100 200 300 400 500 600


Mo

rtal

ity

rate

0%

1%

2%

3%

4%

5%

6%

7%

8%

0 100 200 300 400 500 600


Mo

rtal

ity

rate


59

Un

it-specifi

c activity

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 �003-�005 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.

Total major procedures for upper GI disease;financial years 2003-2005 (n=1,775)

0 50 100 150 200 250

Nottingham

Liverpool

Exeter

Belfast

Norwich

Birmingham

Harefield

Coventry

Edinburgh

Southampton

St Georges

Hull

Papworth

Blackpool

Leeds

Guy's / St Thomas's

Aberdeen

Sheffield

Glasgow

Bristol

Leicester

Brompton

Middlesborough

Wythenshawe

The Heart Hospital

Cork


Bart's & the London

Dublin

Newcastle

Stoke

Un

it


0 50 100 150 200 250

Nottingham

Liverpool

Exeter

Belfast

Norwich

Birmingham

Harefield

Coventry

Edinburgh

Southampton

St Georges

Hull

Papworth

Blackpool

Leeds

Guy's / St Thomas's

Aberdeen

Sheffield

Glasgow

Bristol

Leicester

Brompton

Middlesborough

Wythenshawe

The Heart Hospital

Cork


Bart's & the London

Dublin

Newcastle

Stoke

Un

it



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ific

acti

vity

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 2003-2005 (n=1,001)

0 20 40 60 80 100 120 140 160

Liverpool

Nottingham

Norwich

Coventry

Harefield

Birmingham

Exeter

Belfast

Edinburgh

Southampton

Hull

Papworth

Blackpool

St Georges

Guy's / St Thomas's

Glasgow

Leeds

Aberdeen

Wythenshawe

Brompton

Leicester

Sheffield

Newcastle

The Heart Hospital

Un

it


0 20 40 60 80 100 120 140 160

Liverpool

Nottingham

Norwich

Coventry

Harefield

Birmingham

Exeter

Belfast

Edinburgh

Southampton

Hull

Papworth

Blackpool

St Georges

Guy's / St Thomas's

Glasgow

Leeds

Aberdeen

Wythenshawe

Brompton

Leicester

Sheffield

Newcastle

The Heart Hospital

Un

it



61

Un

it-specifi

c activity

Major procedures for upper GI disorders other than cancer;financial years 2003-2005 (n=663)

0 10 20 30 40 50 60 70 80 90

Belfast

Exeter

Nottingham

Birmingham

Liverpool

Norwich

St Georges

Harefield

Edinburgh

Southampton

Leeds

Papworth

Coventry

Hull

Blackpool

Bristol

Guy's / St Thomas's

Sheffield

Aberdeen

Leicester

Middlesborough

Brompton

Cork

Glasgow


The Heart Hospital

Bart's & the London

Dublin

Stoke

Un

it


0 10 20 30 40 50 60 70 80 90

Belfast

Exeter

Nottingham

Birmingham

Liverpool

Norwich

St Georges

Harefield

Edinburgh

Southampton

Leeds

Papworth

Coventry

Hull

Blackpool

Bristol

Guy's / St Thomas's

Sheffield

Aberdeen

Leicester

Middlesborough

Brompton

Cork

Glasgow


The Heart Hospital

Bart's & the London

Dublin

Stoke

Un

it



6�

Un

it-s

pec

ific

acti

vity

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 2003-2005 (n=1,001)

0% 20% 40% 60% 80% 100%

Liverpool

Nottingham

Norwich

Coventry

Harefield

Birmingham

Exeter

Belfast

Edinburgh

Southampton

Hull

Papworth

Blackpool

St Georges

Guy's / St Thomas's

Glasgow

Leeds

Aberdeen

Wythenshawe

Brompton

Leicester

Sheffield

Newcastle

The Heart Hospital

Un

it


0% 20% 40% 60% 80% 100%

Liverpool

Nottingham

Norwich

Coventry

Harefield

Birmingham

Exeter

Belfast

Edinburgh

Southampton

Hull

Papworth

Blackpool

St Georges

Guy's / St Thomas's

Glasgow

Leeds

Aberdeen

Wythenshawe

Brompton

Leicester

Sheffield

Newcastle

The Heart Hospital

Un

it



63

Un

it-specifi

c activity

Operative mortality

Open / close rates in upper GI surgery

Mortality after resections for upper GI cancer; financial years 2003-2005 (n=1,001)



0%

5%

10%

15%

20%

25%

30%

0 20 40 60 80 100 120 140


Mo

rtal

ity

rate

0%

5%

10%

15%

20%

25%

30%

0 20 40 60 80 100 120 140


Mo

rtal

ity

rate

Open close rates in resections for upper GI Cancer; financial years 2003-2005 (n=1,001)



0%

5%

10%

15%

20%

25%

30%

0 20 40 60 80 100 120 140


Op

en /

clo

se r

ate

0%

5%

10%

15%

20%

25%

30%

0 20 40 60 80 100 120 140


Op

en /

clo

se r

ate

Conclusions


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vity

1. Sedrakyan A, van der Meulen J, Lewsey J, Treasure T. Variations in use of video assisted thoracic surgery in the United Kingdom. BMJ. �004; 329 (7473): 1011-101�.

�. 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. �003; 327 (7409): 73.

3. 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. �005; 28 (2): 306-311

4. Wright CD, Edwards FH. The Society of Thoracic Surgeons general thoracic surgery database. Ann Thorac Surg. �007; 83 (2): 893-4.

References

The future of thoracic surgical data collection in the United Kingdom and IrelandIn 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 patient-specific 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.


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Appendices


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Appendices

Appendix 1 The Thoracic Surgical Register (1980-2002) submission form

Name of hospital

Total Deaths

A Lung tumours - Primary malignant

1 Pneumonectomy including sleeve pneumonectomy

� 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






C Lung tumours - Benign i

1 Pneumonectomy


3 Sleeve resection ± lobectomy



D1 Mesothelioma

1 Thoracotomy with insertion of pleuro-peritoneal shunt

� Thoracotomy with pleural biopsy pleurodesis

3 Thoracotomy + resection of tumour

4 Thoracotomy + resection of tumour + lung ± diaphragm

D2 Other pleural malignancy ii


� Thoracotomy with pleural biopsy ± pleurodesis


4Thoracotomy + resection of tumour + resection of lung tissue ± diaphragm (including pleuropneumectomy)

i. Including those of intermediate malignancy e.g. carcinoid not hamartoma; see K1.

ii. Including chylothorax, but excluding empyema.


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pen

dices

iii. Including chylothorax, but excluding empyema.

iv. Excluding TB.

Name of hospital

Total Deaths

E Benign pleural pathology iii


� Thoracotomy with pleural biopsy ± pleurodesis


4 Thoracotomy + resection of lung tissue (includes pleuropneumonectomy)

F Pneumothorax

1 Thoracotomy with closure of air leak (i.e. staple,glue,suture etc)

� 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)

� 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)

� 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


7�

Ap

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dic

es

v. Excluding TB and those specified in section H.vi. Please see cardiac register.

Name of hospital

Total Deaths

I Other inflammatory lung conditions v

1 Pneumonectomy



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

� 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

� 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


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Ap

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dices

vii. Excluding direct invasion by lung cancer; see A5.

viii. Excluding trauma.

Name of hospital

Total Deaths

M Chest wall conditions

1 Correction of pectus deformity

� Primary chest wall tumours

�a Chest wall etc

�b 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

� 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

1� 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


74

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ix. Includes carinal resection.

x. Not performed thorascopically.

Name of hospital

Total Deaths

P Trachial conditions ix

1 Tracheal tumours primary and secondary resection

� 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

� Pericardectomy (also see cardiac surgery return)

3.1 Dorsal spine discectomy / decompression

3.� Spinal fusion

3.3 Excision of dorsal spine tumour

4 Dorsal sympathectomy

5 Correction of kyphoscoliosis

R Oesophageal malignant tumours

1 Oesophageal resection

� 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

� Oesophagectomy

3 Exploration only ± biopsy

T Achlasia and other motility disorders

1 Myotomy

� Myotomy with anti-reflux operation

3 Diverticulectomy ± myotomy

U Upper sphincter disorders

1 Excision of pouch ± myotomy

� Myotomy alone with or without divertulopexy

3 Per oral stapling - DOHLMANS procedure


75

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Name of hospital

Total Deaths

V1 Reflux conditions

1 Hiatus hernia repair (all techniques)

� Hiatus hernia repair with gastroplasty


4 Oesophageal bypass

5 Biliary diversion

6 Circumferential myotomy

V11 Recurrent reflux conditions

1 Hiatus hernia repair (all techniques)

� Hiatus hernia repair with gastroplasty


4 Oesophageal bypass

5 Biliary diversion

6 Circumferential myotomy

W Oesophageal injury

1 Thoracotomy for removal of foreign body

� 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

� Primary anastomosis

3 Staged reconstruction using any conduit

Y Gastric conditions xi

1 Resection of any gastric malignancy - partial or total gastrectomy

� Bypass for gastric malignancy (ie linitis plastica)

3 Feeding jejunostomy or gastrostomy

4 Gastrostomy

5 Pyloroplasty (for delayed gastric emptying )

xi. Formerly other oesophageal conditions (specify).


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Name of hospital

Total Deaths

Z Endoscopic section xii

Z11�0 Diagnostic bronchoscopy (includes biopsy)

Therapeutic bronchoscopy total

Z11�1 Foreign body removal

Z11�� Dilatations

Z11�3 Curettage with diathermy and / or forceps

Z11�4 Laser resections

Z11�5 Brachytherapy i.e., endobronchial radiotherapy

Z11�6 Stenting

Z11�7 Cryotherapy

Z11�8 Other

Z11�9 Glue to BPF

Upper GI endoscopies

Z1��0 Diagnostic (includes biopsy)

Therapeutic total

Z1��1 Foreign body removal

Z1�� Dilatations

Z1��3 Curettage with diathermy ± forceps

Z1��4 Laser resections

Z1��5 Brachytherapy

Z1��6 Pulsion intubation any type of stent

Mediastinal

Z13�1 Mediastinoscopy (cervical)

Z13�� Anterior mediastinotomy

Minor procedures

Z��1 Tracheostomy (standard)

Z�� Mini-tracheostomy

Z��3 Per-cutaneous tracheostomy

Z��4 Removal of sternal wires

Z��5 Intercostal drains

Z��6 Secondary resuture of any wound

xii. Not VATS; see separate section.


77

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Name of hospital

Total Deaths

Video Assisted Surgery (VATS); pulmonary

Wedge resection total

PU1 Lung biopsy for diffuse disease

PU� Biopsy of isolated pulmonary nodule

Resection of primary lung neoplasm total

PU3 Benign

PU4 Malignant

PU5 Resection of metastasis

Major lung resections

Lobectomy totals

LR1 Primary neoplasm

LR� Secondary neoplasm

LR3 Inflammatory disease

Pneumonectomy totals

LR4 Primary neoplasm

LR5 Secondary neoplasm

LR6 Inflammatory disease

Bullae / empyema

VB1 Bullectomy

LVR1 Lung volume reduction surgery unilateral

LVR� Lung volume reduction surgery bilateral (same anaesthetic)

Pleural

Pneumothorax total

PL1 Closure of air leak xiii + blebectomy

PL� Closure of air leak xiii + blebectomy +chemical pleurodesis

PL3 Closure of air leak xiii + blebectomy+mechanical abrasion

PL4 Closure of air leak xiii + blebectomy+pleurectomy

Pleural effusion / pleural neoplasm total

PL5 Pleural biopsy

PL6 Pleural biopsy + chemical pleurodesis ie plain or iodised talc

PL7 Pleurectomy

PL8 Drainage of empyema ± debridement

PL9 Removal of tumour

PL10 Insertion of shunt ± any procedure

xiii. Staple, stitch, glue etc.


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Name of hospital

Total Deaths

Pericardial

PE1 Pericardial fenestration

PE� Excision of pericardial cyst

PE3 Pericardiectomy

Mediastinal

ME1 Mediastinal gland biopsy / staging

ME� Mediastinal tumour biopsy

ME3 Mediastinal tumour excision

ME4 Thoracic duct ligation (clip)

Trauma

TR1 Assesment of intrathoracic trauma

TR� Evacuation of haematoma ± clot

Neural

NE1 Sympathectomy

NE� Splanchnic nerve ablation

Video Assisted Surgery (VATS); oesophageal

OE1 Heller's myotomy

OE� Extended myotomy

OE3 Laparoscopic Heller's

OE4 Laparoscopic Nissen fundoplication ± repair of hiatus hernia

OE5 Laparoscopic hiatus hernia repair

OE6 Thoracoscopic mobilisation of oesophagus

OE7 Thoracoscopic / laparoscopic oesophagectomy

OE8 Repair of ruptured oesophagus

OE9 Excision of leiomyoma

OE10 Laparoscopy for staging of gastric / oesophageal cancer ± biopsy


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Appendix 2 The Thoracic Surgical Register (2002-date) submission form

Name of hospital

Total Deaths

A Lung resections - Primary malignant





5 Any pulmonary resection with resection of chest wall, diaphragm etc


B Lung resections - Other

1 Pneumonectomy




5 Any pulmonary resection with resection of chest wall, diaphragm etc

C Pleural procedures

1 Thoracotomy + decortication

� Thoracotomy + pleural symphysis ± closure of air leak

3 Thoracotomy + other pleural procedures

D Chest wall / diaphragmatic procedures

1 Major

� Minor

E Mediastinal

1 Resection of mediastinal mass / tumour

� Mediastinoscopy / mediastinotomy

3 Other mediastinal procedure

D Oesophageal / gastric procedures

1 Oesophago-gastric resection/bypass - malignant

� 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

� Minor


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Name of hospital

Total Death

VATS A Lung resections - Primary malignant

1 Wedge resection

� Lobectomy

3 Pneumonectomy

VATS B Lung resections - Other

1 Wedge resection

� Lobectomy

3 Pneumonectomy

VATS C Pleural procedures

1 Closure of air leak ± pleural symphysis

� Any other pleural procedures

VATS D Chest wall / diaphragmatic procedures

1 All

VATS E Mediastinal conditions

1 Resection of mediastinal mass / tumour

� Other mediastinal procedure

VATS F Oesophageal / gastric procedures

1 Therapeutic

� Diagnostic

VATS G Other procedures

1 All

Z Endoscopic procedures (not VATS)

1 Diagnostic bronchoscopy / oesophagoscopy

� Therapeutic bronchoscopy / oesophagoscopy


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8�

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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.

Core data

Collected on all cases; lines 1-76 and 1�4-13�

1. Centre identification

�. 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:

1�. Elective – standard booked admission for surgery

13. Urgent – decision to operate on next available list

14. Emergency – operation arranged outside scheduled list

Surgical strategy

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


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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

�0. Primary cancer lung (known or probable)

�1. Oesophageal cancer

��. Mesothelioma

�3. Other primary thoracic malignancy

�4. Malignant disease other (secondary, recurrent or metastatic)

�5. Carcinoid

�6. Benign neoplasms

�7. Empyema (include all aetiologies of pleural sepsis)

�8. Parenchymal lung disease

�9. Vascular lesion

30. Pneumothorax

31. Pleural effusion

3�. 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.

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

4�. Other major incision


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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

5�. 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

6�. 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

7�. Bronchoscopy

73. Oesophagoscopy

74. Chest drain insertion

75. Other (enter)


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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

8�. 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

Neoadjuvant therapy

91. Chemotherapy pre-operatively

9�. 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


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Non-pulmonary risk factors

100. Height (the patient’s height in centimetres – enter as whole number).

101. Weight (the patient’s weight in kilograms – enter to one decimal place).

10�. 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)

11�. ASA Grade (American Society of Anaesthetists grade)

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

1�0. Sublobar resection (whether wedge or segment)

pTNM staging

1�1. T stage

1��. N stage

1�3. M stage

Core data continued …

Discharge (core and lung cancer datasets)

1�4. No complications

1�5. Reintubation or ITU admission; DDMMYYYY

1�6. Date of discharge from ITU; DDMMYYYY

1�7. IPPV

1�8. Air leak >7 days

1�9. Infection requiring longer hospital stay

130. Further surgery within the same admission

131. Date of discharge / death (core dataset)

13�. Death; "Yes" or "No" (provide cause on death certificate)


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Notes


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Notes

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) **** *** ***

email [email protected]


Dr Peter K.H. Walton

Managing Director

59A Bell Street

Henley-on-Thames

Oxfordshire RG9 2BA

United Kingdom

Phone +44 (0) 1491 411 288

Fax +44 (0) 1491 411 377

email [email protected]

www.e-dendrite.com

Documents

The Society for Cardiothoracic Surgery in Great Britain & Ireland · 2016-10-10 · or by any means, electronic, mechanical, photocopying, recording or otherwise, without the permission