Chamberlain Papers Represent the Best in New Research

Enhanced recovery after surgery, regionalization of congenital heart surgery centers, and surgical atrial fibrillation ablation are the focus of this year’s prestigious J. Maxwell Chamberlain Memorial Papers.

Robert M. Van Haren, MD

The Chamberlain Papers are considered by the Workforce on Annual Meeting Program Task Force to be among the best scientific abstracts submitted for the meeting.

ERAS Pathway Decreases Perioperative Morbidity Following Thoracotomy for Primary Lung Cancer

J. Maxwell Chamberlain Memorial Papers

Monday, January 29
7:15 a.m. – 8:15 a.m.
Grand Ballroom

Enhanced recovery after surgery (ERAS) programs are safe, feasible, and effective for reducing postoperative morbidity in patients undergoing a thoracotomy for primary lung cancer. Thoracic surgeons should move forward with confidence in implementing ERAS, according to Robert M. Van Haren, MD, of MD Anderson Cancer Center in Houston, who will present the Chamberlain Paper for General Thoracic Surgery.

Dr. Van Haren and colleagues compared outcomes for all patients undergoing pulmonary resection for primary lung cancer at MD Anderson between 2006 and 2016. Patients were evaluated at the pre-ERAS stage, during a transitional period with elements of ERAS, and after full implementation of an ERAS pathway.

ERAS components included limited pre-anesthetic fasting, preemptive analgesia, intraoperative regional analgesia with liposomal bupivacaine intercostal blocks, drain minimization, postoperative opioid-sparing multimodal analgesia, early ambulation, and oral intake.

The pathway’s benefits included reducing complications, such as atrial fibrillation and pneumonia, and opioid-sparing drug treatment. Opioid-sparing benefits are particularly valuable at a time of a global opioid epidemic, Dr. Van Haren said.

“ERAS hasn’t been looked at in thoracic surgery until now,” he said. “Our goal with ERAS is to give patients better pain control and shorten their stay. We’re seeing a reduction in hospital stays from 5 days to 4, with no increase in readmissions. It’s clear from our analysis that ERAS is effective, but it needs buy-in and collaboration from the entire team—from the thoracic surgeons and anesthesiologists to nursing and pharmacy.”

Patients Will Travel Long Distances for Better Care

Regionalization of care has been hypothesized to be an ideal model for the delivery of congenital heart surgery (CHS); however, it has not been investigated in the United States. The Chamberlain Paper for Congenital Heart Surgery details the current network of hospitals at which patients undergo CHS as the basis for designing a regionalized system.

Tara B. Karamlou, MD, of Phoenix Children’s Hospital, was among a team of researchers who examined congenital heart surgery referral patterns throughout the United States. Some states, such as California, Florida, New York, and Texas, had many CHS centers, while other states had none. California, for example, had 25 centers, many of which were located in close proximity to one another.

“We have to be good stewards of our patients’ care,” Dr. Karamlou said. “It’s important for centers to collaborate and discuss partnerships with other centers. Our data would suggest that providers and stakeholders should look critically at models in their states and, if possible, collaborate with local or regional centers of excellence.”

In addition to describing the distribution of CHS centers in the United States and demonstrating national referral patterns, the researchers sought to characterize the demographic currently traveling for CHS and the incurred travel burden. The results showed that patients often travel long distances to high-volume centers perceived as high quality, regardless of patient age or case complexity. Patients without insurance traveled the least for care.

“One of the major unanticipated findings of this initial study was that many patients are already traveling a fair distance to perceived centers of excellence for surgery. Our study shows that 84% of patients already bypass the nearest center, which suggests that regionalization of care already exists to a certain extent,” Dr. Karamlou said.

While higher case complexity was primarily concentrated in larger volume hospitals, very low-volume hospitals still performed important numbers of complex cases. Researchers accounted for case complexity using the RACHS-1 system and hospital volume.

According to Dr. Karamlou, if more hospitals were consolidated, such that only those centers with an annual case volume greater than 150 surgeries, travel distance would increase by a median of about 100 miles.

Significant Long-Term Survival Benefits Are Associated With SAFA

Surgical atrial fibrillation ablation (SAFA) was previously proven to be highly effective in reducing atrial fibrillation. Now, it appears to have a more lasting influence, affecting long-term survival.

Alexander Iribarne, MD, of Dartmouth-Hitchcock Medical Center in Lebanon, NH, and colleagues performed an extended look at SAFA, which can be performed without additional risk of operative mortality or major morbidity and is recommended at the time of concomitant mitral operations, as well as aortic valve and coronary bypass surgery, to restore sinus rhythm.

“The effectiveness of this technique in achieving freedom from atrial fibrillation is well documented in the literature,” said Dr. Iribarne, who will present the Chamberlain Paper for Adult Cardiac Surgery. “Unfortunately, it remains an underutilized procedure. Our paper shows a significant long-term survival benefit associated with SAFA.”

This new, multicenter analysis is consistent with a recent STS Clinical Practice Guideline recommending SAFA for concomitant mitral operations, as well as isolated aortic valve replacement (AVR), isolated coronary artery bypass grafting (CABG) surgery, and AVR plus CABG.

The study, conducted between 2008 and 2015, analyzed more than 2,000 patients undergoing CABG, valve, and CABG/valve operations with preoperative atrial fibrillation across seven hospitals. There was a significant improvement in unadjusted survival among patients undergoing concomitant SAFA, and at 5 years, patients undergoing SAFA had a 26% improvement in adjusted survival, compared to those who had no ablation. While SAFA patients had longer bypass times, they had a shorter overall length of admission.

“The takeaway is that we not only have new guidelines based on the efficacy of SAFA in achieving freedom from atrial fibrillation, but we now also have additional data showing that SAFA has a real impact on how long patients live,” Dr. Iribarne said. “We hope this information will encourage more surgeons to incorporate SAFA in their practice.”

The Chamberlain Papers honor the scientific contributions of Dr. Chamberlain, a renowned cardiothoracic surgeon who chaired the steering committee tasked with creating The Society of Thoracic Surgeons.