News & Media

Two papers recently published in The Annals of Thoracic Surgery aim to guide the management of thymoma¹ and pleural drains following pulmonary lobectomy² – thoracic conditions and treatments that lack widely accepted guidelines. Recognizing this need, the Society of Thoracic Surgeons (STS) Workforce on Evidenced-Based Surgery convened a task force to develop expert consensus documents to help alleviate this knowledge gap.

Thymoma, a rare epithelial tumor – but also the most common anterior mediastinal tumor in adult patients – is a condition thoracic surgeons will likely encounter as clinicians. However, there is a lack of evidence covering all aspects of treatment due to its relatively low incidence. Managing pleural drains following pulmonary lobectomy is standard practice, yet there are no established guidelines on this topic despite abundant published literature.

Management of thymoma
The STS Workforce on Evidence-Based Surgery, which includes general thoracic surgeons with expertise in thoracic surgical oncology, and medical and radiation oncologists with expertise in neoadjuvant and adjuvant therapies, evaluated existing literature about surgical considerations in managing thymomas, such as:

•    Imaging characteristics
•    Diagnostic tests 
•    Staging 
•    Surgical approach and technique
•    Neoadjuvant and adjuvant therapy 
•    Surgery for advanced or recurrent disease, and 
•    Postoperative surveillance

Consensus statements were drafted using the modified Delphi method. Votes for each proposed statement were tallied using a 5-point Likert scale, with the option to abstain on those not within the specific authors’ expertise. Statements with 75% of responding authors selecting “agree” or “strongly agree” were considered to have reached a consensus. 

Unlike broader guidelines encompassing various aspects of thymoma management, including medical oncology, radiology, and pathology, this paper addresses thymoma from a surgical perspective by guiding surgical interventions, especially in metastatic and recurrent diseases.

"Given the scarcity of randomized controlled trials due to the rarity of thymoma, this document is framed as an expert consensus rather than strict evidence-based clinical practice guidelines," said the study's lead author, Dr. Douglas Liou, clinical associate professor at Stanford Medicine. "Our findings rely more heavily on the combined experience and judgment of experts in the field rather than solely on data from large-scale studies." 

Read the Annals article. 

Management of pleural drains following pulmonary lobectomy

Similarly, the consensus document developed by the STS Workforce on Evidence-Based Surgery to manage pleural drains includes:

•    Choice of drain, including size, type, and number
•    Management, such as use of suction versus waterseal and criteria for removal
•    Imaging recommendations, including the use of daily and post-pull chest x-rays
•    Use of digital drainage systems, and
•    Management of prolonged air leak

Workforce members reviewed existing literature on the condition. A consensus using a modified Delphi method consisting of two rounds of voting until 75% agreement on the statements was reached, with a total of thirteen statements that encouraged standardization and stimulated additional research in this critical area. 

“Optimal management of these drains should reduce patient discomfort, length of stay, and complications.”  said study investigator Dr. Michael Kent, associate professor of surgery at Harvard Medical School. “However, despite how commonly chest tubes are used in practice, the literature must provide more clarity on this subject. Many important questions have yet to be addressed and may require well-designed, prospective randomized trials.”

Read the Annals article. 

1. Reference: Liou DZ, Berry MF, Brown LM, Demmy TL, Huang J, Khullar OV, Padda SK, Shah RD, Taylor MD, Toker SA, Weiss E, Wightman SC, Worrell SG, Hayanga JWA, The Society of Thoracic Surgeons Expert Consensus Document on the Surgical Management of Thymomas, The Annals of Thoracic Surgery (2024)

2. Reference: Kent MS, Mitzman B, Diaz-Gutierrez, I, Khullar OV, Fernando H, Backus L, Brunelli A, Cassivi SD, Cerfolio RJ, Crabtree TD, Kakuturu J, Martin LW, Worrell SG, Raymond DP, Schumacher L, Hayanaga JWA, The Society of Thoracic Surgeons Expert Consensus Document on the Management of Pleural Drains following Pulmonary Lobectomy, The Annals of Thoracic Surgery (2024)

^{Authored by: Andrew Acker, MD, Marisa Cevasco, MD, MPH, Tsuyoshi Kaneko, MD}

There have been several paradigm-shifting breakthroughs in cardiac transplantation since Dr. Christiaan Barnard performed the first orthotopic heart transplant (OHT) in 1967. The current paradigm shift is the use of novel technologies allowing for enhanced organ preservation. They allow heart surgeons to travel further for donor hearts and allow them to utilize donor hearts from deceased circulatory donation (DCD). Here we will review the use of several novel technologies – the Transmedics Organ Care System (OCS), the Paragonix SherpaPak, the XVIVO Heart Assist Transport, and normothermic regional perfusion (NRP).

Transmedics Organ Care System

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The OCS system is a portable, warm-perfusion and monitoring system that can resuscitate, perfuse, and allow for the evaluation of the beating donor heart for greater than four hours making it possible for the transplant teams to expand the donor pool. You can monitor aortic root pressure, coronary blood flow, and lactate levels. To attach the donor heart to the OCS system the SVC and IVC are ligated. There is a reservoir where blood collects from the LV vent and the cannula that is placed in the PA. The blood from the reservoir is pumped through a gas exchanger and a warmer and then returned via a cannula in the ascending aorta. The left atrium is opened. This system was initially FDA approved in extended criteria donors (ECD) that were deemed otherwise unsuitable for transplantation as a result of the EXPAND trial. 

Paragonix SherpaPak

The SherpaPak provides static hypothermic preservation of hearts in a more controlled environment than the cold preservation utilized traditionally, thus preventing both freezing injury that can lead to protein denaturation and irreversible damage to the heart and hypoxic injury if the organ were to get too warm. To attach the donor heart to the SherpaPak system the heart connector and temperature probe are attached to the aorta and the organ cannister is filled with cold cardioplegia. The cannister of the system suspends and cools the donor heart evenly utilizing their proprietary SherpaCool technology - an isolated pressure-controlled cold liquid solution. It continuously monitors the internal and ambient temperatures for the ideal temperature of 4°C to 8°C. Like traditional cold preservation, it's intended to be used for up to four hours. 

XVIVO Heart Assist Transport

The XVIVO system is a hybrid of the previous two systems described in that it is a static hypothermic oxygenated perfusion system. The XVIVO system consists of a heart box, perfusion unit, perfusion solution, and perfusate supplement. The reservoir is primed with the albumin-based hyper-oncotic perfusion solution and O-negative blood. The donor heart sits in the reservoir and the perfusion solution is pumped out through an oxygenator and back into the aorta, which is cannulated. Additionally, there is a LV vent that is placed across the mitral valve. The pressure and temperature of the perfusate is monitored with a goal of 20mmHg at 8°C.  

Normothermic Regional Perfusion

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Normothermic regional perfusion (NRP) is an approach to organ preservation that reanimates the heart in the deceased donor with the use of extracorporeal membrane oxygenation (ECMO) or cardiopulmonary bypass (CPB) and perfuses the donor organs prior to explantation and recovery. The advantage of this approach is that it reduces warm ischemic time and allows for the assessment of the donor organs prior to explantation. Typically, these patients are cannulated via the ascending aorta and the femoral vein or the right atrium before re-establishing circulation the head vessels are clamped or ligated to prevent reanimation of the brain. 
 

This afternoon the Centers for Medicare & Medicaid Services (CMS) released the CY 2025 Medicare Physician Fee Schedule Proposed Rule. STS has compiled a summary of key provisions affecting thoracic surgery in the rule. 

Payment Cuts

CMS is again proposing significant cuts to cardiothoracic surgery reimbursement, this time by 2.8%. CMS estimates the CY 2025 conversion factor (CF) to be $32.36. Unlike hospital payments with a built-in yearly increase, physician payments do not have such adjustments. STS will continue lobbying Congress and CMS for systematic reforms and an inflationary update to Medicare payments.

Changes to physician reimbursement often stem from the budget neutrality requirement, which lacks a mechanism for inflationary adjustments. Disruptions occur when the value of specific services change, affecting the reimbursement of other services to maintain budget neutrality. STS and the physician community are advocating for Congress to legislate an inflationary update to the CF and adjust budget neutrality thresholds. For more details, see our recent response to the Senate Finance Committee’s request for information on physician payment. 

Quality Payment Program (QPP)

Thanks to advocacy efforts from STS and other stakeholders, Congress has stepped in to extend a 3.5% incentive payment for Advanced Alternative Payment Model (APM) participation in CY 2025 (based on CY 2023 participation). Additionally, starting in payment year 2026, APM participants will be eligible for a higher CF update than other clinicians: 0.75% compared to 0.25%. 

STS previously worked with CMS to provide specialty-specific, meaningful measures for our members who participate in the Bundled Payments for Care Improvement (BPCI) Advanced APM. Additionally, this will be relevant for CT surgeons performing CABG procedures under the new TEAM payment model proposed in the inpatient payment rule. CMS is considering, with STS support, allowing TEAM participation to count towards Advanced APM participation under the QPP.

Global Surgical Codes 

CMS is proposing to expand the use of transfer of care modifiers for global packages. They would require the use of modifiers (-54, -55, and -56) for all 90-day global surgical packages in cases where a practitioner (or another from the same group) expects to provide only the pre-operative (-56), procedure (-54), or post-operative (-55) portions. This applies to both formally documented and informally expected transfers of care. CMS aims to use the information collected to refine global surgical codes in the future.  

In the past, STS has actively promoted the benefits of maintaining the 90-day global code and has refuted flawed data used to advocate for their repeal. We will continue to promote the value of these bundled payments and urge policymakers to extend the increased reimbursement for E/M visits to those packaged in procedural global payments.  

Telehealth

CMS has extended telehealth flexibilities where possible, including adding new services to the telehealth list and permitting two-way and real-time audio-only communication technology for any telehealth service. Absent congressional intervention, the future of telemedicine hangs in the balance as the current telehealth flexibilities are scheduled to expire on December 31, 2024. STS urges Congress to permanently extend telehealth flexibilities established during the COVID-19 public health emergency. 

On June 21, 2024, The Society of Thoracic Surgeons, The American College of Radiology®, and the GO2 Foundation for Lung Cancer submitted joint letters to the Centers for Medicare & Medicaid Services and the US Preventive Services Taskforce that include recommendations to improve existing lung cancer screening eligibility requirements. 

The organizations formally requested reconsideration of the National Coverage Determination (NCD) for screening lung cancer with low-dose computed tomography and asked to eliminate the exclusion criteria of current smokers or people who have quit smoking within the last 15 years and the upper age limit. This would align the NCD with the updated American Cancer Society and the National Comprehensive Care Network evidence-based guidelines. 

Removing these criteria would significantly increase the number of high-risk individuals eligible for screening from 14.2 million to 19.2 million. Annual lung cancer screening with low-dose computed tomography in high-risk patients significantly reduces lung cancer deaths and may help identify cancers at an early, treatable, and curable stage.  

If you have questions about STS’s lung cancer screening advocacy efforts, contact Haley Brown, senior manager, political affairs and advocacy.