Version 2.41

The Society of Thoracic Surgeons General Thoracic Surgery Database Analyzed Procedure Data Collection Form Version 2.41

©2018 The Society of Thoracic Surgeons Revised 5/31/2018  An Analyzed Procedure Data Collection Form (DCF) is required for all suspected or diagnosed Lung and Esophageal Cancer Resections and one should be initiated every time the patient enters the operating room. These cases are risk adjusted and are included in the Data Analysis Reports.  Fields that appear underlined and in blue are required for analyzed procedure record inclusion. If any of these fields are missing data, the entire record will be excluded from analysis.  Completion of the Thymus/Mediastinal Mass, Tracheal Resection and Hiatal Hernia/GERD sections is optional for analyzed procedures.  Procedures highlighted below, if performed as isolated procedures or with only other highlighted procedures, are not collected unless the Surgeon Participant chooses to track them. If collected, use the Non-analyzed Procedure DCF.  Highlighted procedures done in conjunction with analyzed (major) procedures should be included on this Analyzed Procedure DCF.

A. Demographics Patient ID: ______PatID (80) Medical Record #:______MedRecN (90)

First Name:______Middle Name:______Last Name:______SSN#:______PatFName (100) PatMName(110) PatLName (120) SSN (130)

Patient participating in STS-related clinical trial: ClinTrial (140)  None  Trial 1  Trial 2  Trial 3  Trial 4  Trial 5  Trial 6 (If not “None” →) Clinical trial patient ID: ______ClinTrialPatID (150) Date of Birth:____/____/______Age: ______Patient Postal Code:______Gender:  Male  Female DOB (160) (mm/dd/yyyy) Age (170) PostalCode (180) Gender (190) Is the Patient's Race Documented? � Yes � No � Patient Declined to Disclose RaceDocumented (200) White/Caucasian  Yes  No Black/African American  Yes  No Race: If Yes select all that apply RaceCaucasian (210) RaceBlack (220) Asian  Yes  No American Indian/Alaskan Native  Yes  No

RaceAsian (230) RaceNativeAm (240) Native Hawaiian/Pacific Islander  Yes  No Other  Yes  No

RacNativePacific (250) RaceOther (260) Hispanic or Latino Ethnicity:  Yes  No  Not Documented Ethnicity (270)

B. Admission Admission Status:  Inpatient  Outpatient / Observation If Inpatient → Admission Date: ____/___/_____ AdmissionStat (280) AdmitDt (290) If Primary Payor is not None/Self→ Payor: Indicate the Primary payor: PayorPrim (300) Indicate the Secondary (supplemental) payor: PayorSecond (320)  None/self  None/self  Medicare  Medicare If Medicare → Fee For Service:  Yes  No PrimMCareFFS If Medicare → Fee For Service:  Yes  No (310) SecondMCareFFS (330)  Medicaid  Medicaid  Military Health  Military Health  Indian Health Service  Indian Health Service  Correctional Facility  Correctional Facility  State Specific Plan  State Specific Plan  Other Government Insurance  Other Government Insurance  Commercial Health Insurance  Commercial Health Insurance  Health Maintenance Organization  Health Maintenance Organization  Non U.S. Plan  Non U.S. Plan Surgeon Name:______Surgeon’s National Provider ID: ______Surgeon (340) SurgNPI (350)

Taxpayer ID#: ______Hospital Name:______TIN (360) HospName (370) Hospital Postal Code:______Hospital Region:______Hospital’s National Provider ID:______HospZIP (380) HospStat (390) HospNPI (400) C. Pre-Operative Evaluation Height: ______(cm) HeightCm (410) Weight: ______(kg) WeightKg (420)

Unintentional Wt loss over past 3 months? (Enter “0” if none) - ______(kg) WtLoss3Kg (430)

CardioPulmonary History Congestive Heart Failure(CHF) If Yes→ EF ______% Hypertension Hypertn (440)  Yes  No  Yes  No CHF (450) EF (460) Coronary Artery Disease (CAD)  Yes  No Myocardial Infarction  Yes  No PreMI (480) CAD (470) Location – check all that apply: Afib per EKG within the last year; Valvular Heart AV  Yes  No PV  Yes  No  Yes  No with or without treatment AFIB  Yes  No Disease VHDLocAV (510) VHDLocPV (530) If Yes→ (490) VHD (500) MV  Yes  No TV  Yes  No VHDLocMV (520) VHDLocTV (540) Pulmonary Hypertension:  Yes  No  Unknown PulmHypertn (550) Interstitial Fibrosis/ Interstitial Lung Disease InterstitialFib (560)  Yes  No Vascular History Major Vascular Disease  Yes  No MVD (580) DVT/PE  Yes  No DVTPE (590) Cerebral Vascular Disease History Cerebrovascular History:  No CVD history  Known disease, no events  Transient Ischemic Attack (TIA) CerebroHx (610) If CVA→ Permanent Neurologic impairment  Yes  No  Cerebrovascular Accident (CVA) PNI (620) Neuromuscular Disease Neurologic symptoms present  Yes  No NeuroSymptPres (630) Myasthenia Gravis  Yes  No MyasGravis (640) Endocrine / GI / Renal History Diabetes If Yes→ Type of therapy:  None  Diet Only Oral  Insulin  Yes  No Diabetes (650) DiabCtrl (660)  Other Subcutaneous Medication  Other Unknown Liver Dysfunction  Yes  No LiverDys (670) On Dialysis  Yes  No Dialysis (680) Cancer History Coexisting Cancer  Yes  No CoexisCancer (690)  Same disease, ≤ 6 months PreopChemoCurWhen (710) Preoperative Chemotherapy /  Same disease,> 6 months Immunotherapy  Yes  No If Yes →  Unrelated disease, ≤ 6 months PreopChemoCur (700)  Unrelated disease, >6 months  Same disease, ≤ 6 months PreopXRTDisWhen (730)  Same disease,> 6 months  Unrelated disease, ≤ 6 months Preop Thoracic Radiation Therapy  Yes  No If Yes →  Unrelated disease, >6 months PreopXRT (720)

If Same disease, ≤ 6 months → Completion Date ______PreopXRTCompDt (740) Prior Surgical History (check all that apply) Prior Cardiothoracic Surgery  Yes  No If Yes → Sternotomy  Yes  No PriorStern (760) PriorCTS (750)

VATS/Robotic  Yes  No (check all that apply) PriorVATS (770) If Yes →  Right  Left  Bilateral PriorVATSLoc (780) Pulmonary resection  Yes  No PriorPulmRes (790) If Yes →  Right  Left  Bilateral PriorPulmResLoc (800) Thoracotomy  Yes  No PriorThora (810) If Yes →  Right  Left  Bilateral PriorThoraLoc (820) PreOp Medication History Chronic Immunosuppressive Therapy  Yes  No PreOpImmunoThx (830) Chronic anticoagulation  Yes  No (defined as any anticoagulation medication other than ASA) PreOpAnticoagThx (840) Home O2

PreOpHomeO2 (850)  Yes  No

Pre-Operative Testing Creatinine level measured  Yes  No If Yes → Last creatinine level ______CreatLst (880) CreatMeasured (870) Hemoglobin level measured  Yes  No If Yes → Last hemoglobin level ______HemoglobinLst (900) HemoglobinMeasured (890) Pulmonary Function Tests performed?  Yes  No PFT (910) PFT Not Performed Reason  Not a Major Lung Resection  Never smoked, no lung disease If No →  Pt. Unable to perform PFTNotPerReas(920)  Tracheostomy or Ventilator  Urgent or Emergent Status

If Yes → FEV1 test performed? If Yes→ FEV1 % predicted: ______ Yes  No  Not Applicable FEV (930) FEVPred (940) DLCO test performed? If Yes→ DLCO % predicted: ______ Yes  No  Not Applicable DLCO (950) DLCOPred (960) Psychosocial History Cigarette smoking:  Past smoker (stopped >1 month  Never smoked  Current smoker  Unknown CigSmoking (970) prior to operation If ‘Past smoker’ or Pack Year Known or can be If Yes → Pack-Years ______ Yes  No ‘Current Smoker’ → estimated PackYearKnown (980) PackYear (990) Narcotic dependency  Yes  No Alcohol Abuse  Yes  No NarcoticDepend (1000) AlcoholAbuse (1010) Dementia/neurocognitive dysfunction  Yes  No DemNeroDys (1020) Major Psychiatric Disorder  Yes  No PsychDisorder (1030) Living Status:  Lives alone  Lives with family or friend  Assisted Living  Nursing Home LiveStat (1040) Functional Status:  Totally  Independent  Partially Dependent  Unknown FuncStat (1050) Dependent  1 - Restricted in physically  2 - Ambulatory and capable of  0 - Fully active, able to carry strenuous activity but ambulatory all self-care but unable to carry on all pre-disease performance and able to carry out work of a out any work activities. Up and without restriction light or sedentary nature, e.g., about more ECOG Score: light house work, office work than 50% of waking hours ECOGScore (1070)  3 - Capable of only limited  4 - Completely disabled. self-care, confined to bed or Cannot carry on any self-care.  5 - Dead chair more than 50% of waking Totally confined to bed or chair hours

D. Diagnosis (Category of Disease) Category of Disease: Check both Primary and Secondary Diagnosis (Category of Disease) (ICD-9, ICD-10). Indicate (circle) the Primary Diagnosis. CategoryPrim (1250) CategorySecond (1280) Note: Diagnosis is based on final pathology report.  No Secondary Diagnosis (for Category of Disease - Secondary field only) Lung Cancer

 Lung cancer, main bronchus, carina (162.2, C34.00)  Lung cancer, lower lobe (162.5, C34.30)  Lung cancer, upper lobe (162.3, C34.10)  Lung cancer, location unspecified (162.9, C34.90)  Lung cancer, middle lobe (162.4, C34.2)  Lung tumor, metastatic (197.0, C78.00)  Personal history of malignant neoplasm of bronchus and lung  Malignant neoplasm other parts of bronchus or lung (162.8, C34.8) (V10.11, Z85.118)  Neoplasm of uncertain behavior of trachea, bronchus and lung (235.7,

DM38.1) Esophagus Cancer  Esophageal cancer, esophagogastric junction (cardia) (151.0, C16.0)  Malignant neo stomach unspecified (151.9, C16.9)  Malignant neoplasm of the esophagus, unspecified (150.9,  Esophageal cancer, upper third (150.3, C15.3) C15.9)  Esophageal cancer, middle third (150.4, C15.4)  Malignant other part esophagus, specified (150.8, C15.8)  Esophageal cancer-lower third (150.5, C15.5) Thymus / Mediastinal Mass  Anterior mediastinal tumor primary(germ cell cancer, seminoma)  Anterior mediastinal tumor-thymus tumor (thymoma, thymic (164.2, C38.1) carcinoma) (164.0, C37)  Anterior mediastinal tumor-metastatic (197.1, C78.1)  Posterior mediastinal tumor-metastatic (197.1, C78.1)  Neoplasm of uncertain behavior of pleura, thymus, mediastinum  Posterior mediastinal malignant tumor- primary (164.3, C38.2) (235.8, D38.2-D38.4)  Anterior mediastinal tumor-benign-(e.g., teratoma) (212.5, D15.2)  Myasthenia gravis (358.0, G70.00) Trachea  Tracheal tumor, malignant (162.0, C33)  Tracheal stenosis, congenital (748.3, Q32.1)  Tracheal tumor, benign (212.2, D14.2)  Subglottic stenosis-congenital (748.3, Q31.1)  Tracheal tumor, metastatic (197.3, C78.30)  Subglottic stenosis-acquired (post intubation) (478.74, J38.6)  Tracheal stenosis, acquired (519.19, J39.8)  Tracheostomy related stenosis (519.02, J95.03) Hiatal Hernia / GERD  Diaphragmatic hernia, with obstruction, without gangrene  Esophageal reflux (GERD) (530.81, K21.9) (552.3, K44.0)  Reflux esophagitis (530.11, K21.0)  Diaphragmatic hernia with gangrene (551.3, K44.1)  Diaphragmatic hernia without obstruction or gangrene (553.3,  Barrett’s esophagus (530.85, K22.70) K44.9)  Barrett’s esophagus with High Grade Dysplasia (530.85, K22.711)

Cardiovascular  Abdominal aneurysm without rupture (441.4, I171.4)  Pericarditis, constrictive (432.2, I31.1)  Cardiac tamponade (423.3, I31.4)  SVC Syndrome (459.2, I87.1)  Pericardial effusion, malignant (198.89, C79.89)  Unspecified disease of the pericardium (423.9, I31.9)  Pericarditis with effusion (420.9, I30.9) Chest Wall  Pectus carinatum (754.82, Q67.7)  Sternal tumor, benign (213.3, D16.7)  Pectus excavatum (754.81, Q67.6)  Sternal tumor, malignant (170.3, C41.3)  Rib tumor, benign-(e.g., fibrous dysplasia) (213.3, D16.7)  Sternal tumor, metastatic (198.5, C79.51)  Rib tumor, malignant-(e.g., osteosarcoma, chondrosarcoma) (170.3,  Thoracic outlet syndrome (353.0, G54.0) C41.3)  Rib tumor, metastatic (198.5, C79.51) Diaphragm  Diaphragm tumor, benign (215.4, D21.3)  Diaphragm tumor, metastatic (198.89, C79.89)  Diaphragm tumor, malignant (171.4, C49.3)  Diaphragmatic paralysis (519.4, J98.6) Esophagus - Other  Achalasia of esophagus (530.0, K22.0)  Foreign body esophagus (935.1, T18.108a)  Acquired absence of esophagus ( post esophagectomy) (V45.79,  Gastric outlet obstruction, pyloric stenosis, acquired (537.0, Z90.89) K31.1)

 Dyskinesia/spasm of esophagus (530.5, K22.4)  Mallory Weiss tear (530.7, K22.6)  Epiphrenic diverticulum (530.6, K22.5)  Stricture and stenosis of esophagus (530.3, K22.2)  Esophageal perforation (530.4, K22.3)  Tracheoesophageal fistula (530.84, J86.0)  Esophageal stricture (530.3, K22.2)  Ulcer esophagus with bleeding (530.21, K22.11)  Esophageal tumor-benign (i.e., leiomyoma) (211.0, D13.0)  Ulcer esophagus without bleeding (530.2, K22.10)  Esophagitis (530.1, K20.9)  Zenkers diverticulum (530.6, K22.5)  Other disease of the esophagus (530.89, K22.8)  Other digestive system complication (997.49, K91.XX) Lung – Other  Acute respiratory failure (518.81, J96.00)  Lung tumor, benign (e.g., hamartoma) (212.3, D14.30)  Aspergillosis (117.3, B44.9)  Pneumonia (486.0, J18.9)  Bronchiectasis (494.0, J47.9)  Post inflammatory pulmonary fibrosis (515, J84.89)  Cystic fibrosis with pulmonary manifestations (277.02, E84.0)  Primary pulmonary hypertension ( 416.0, I 27.0)  Pulmonary insufficiency following surgery/trauma (ARDS)  Emphysema (492.8, J43.8) (518.5, J95.82)  Emphysematous bleb (492.0, J43.9)  Pulmonary sequestration (748.5, Q33.2)  Lung abscess (513.0, J85.2)  Transplanted lung complication(s) (996.84, T86.8XX)  Interstitial lung disease/fibrosis (516.3, J84.1)  Gangrene and necrosis of lung (513.0, J85.0)  Pneumothorax (512.8, J93.1)  Hemothorax (511.8, J94.2)  Solitary pulmonary nodule (not a tumor, e.g., granuloma, subpleural lymph node, pulmonary infarct) (793.11, R91.1) Mediastinum  Mediastinal nodes, metastatic (196.1, C77.1)  Mediastinal cyst, Pericardial (519.3, J98.5)  Benign neoplasm of thymus (212.6, D15.0)  Mediastinal cyst, Thymic (519.3, J98.5)  Lymphoma, intrathoracic (202.82, C85.92)  Mediastinal nodes, benign (229.0, D36.0)  Mediastinal abscess (513.1, J85.3)  Mediastinitis (519.2, J98.5)  Mediastinal cyst, Bronchogenic (519.3, J98.5)  Posterior mediastinal tumor-benign(neurogenic)(212.5,D15.2)  Mediastinal cyst, Foregut duplication (519.3, J98.5)  Unspecified disease of thymus gland (254.9, E32.9) Pleura  Empyema with fistula (510.0, J86.0)  Pleural thickening (511.0, J94.9)  Empyema without fistula (510.9, J86.9)  Pleural tumor, benign (212.4, D19.0)  Empyema, tuberculosis (A15.6)  Pleural tumor, metastatic (197.2, C78.2)  Malignant neoplasm other specified sites of pleura (163.8,  Pleural effusion, infected- (empyema) (511.1, J86.9) C38.4)  Malignant tumor of pleura, unspecified (e.g., mesothelioma)  Pleural effusion, malignant (197.2, C78.2) (163.9, C45)  Pleural effusion sterile (511.9, J90)  Pleural effusion, TB; (Tuberculous pleurisy) (012.0, A15.6)  Pleural effusion, other specified, except TB (511.89, J90) Thyroid  Goiter, nodular (241.9, E04.9)  Thyroid neoplasm, malignant (193.0, C73)  Thyroid neoplasm, benign (226.0, D34) Trachea & Larynx  Dysphagia, unspecified (787.2, R13.10)  Vocal cord paralysis unspecified (478.3, J38.00)  Tracheomalacia-congenital (748.3, Q32.0)  Vocal cord paralysis , unilateral (478.31, J38.01)  Tracheomalacia-acquired (519.1, J39.8)  Vocal cord paralysis, bilateral (478.33, J38.02)  Tracheostomy-hemorrhage (519.09, J95.01) Trauma  Flail chest (807.4, S22.5xxa)  Sternal fracture (807.2, S22.20xa)  Rib fracture (807.0, S22.39xa)  Tracheal injury (807.5, S12.8xxa)  Rib fractures, multiple (807.0, S22.49xa)  Traumatic pneumothorax (860.0, S27.0xxa) Miscellaneous

 Other non-infectious disorders of lymphatic channels (457.8,  Abnormal radiologic finding (793.1, R91) I89.8)  Malignant neoplasm of connective tissue and other soft tissue of  Chronic airway obstruction not elsewhere classified (496, J44.9) the thorax (171.4, C49.3)  Malignant poorly differentiated neuroendocrine carcinoma, any  Chylothorax (457.8, 189.8) site (209.3, C74.1)  Disruption of internal operation, surgical wound (998.31, T81.32XA)  Non-healing surgical wound (998.83, T81.89XA)  Hemorrhage complicating a procedure (998.11, multiple codes)  Other post- op infection (998.59, T81.4XXA)  Persistent post-op fistula not otherwise classified (998.6,  Hematoma complicating a procedure (998.12, multiple codes) T81.83XA)  Hemoptysis unspecified (786.3, R04.2)  Post-operative air leak (512.2, J95.812)  Secondary malignant neoplasm of other specified sites (198.89,  Hyperhidrosis, focal axilla (705.21, L74.510) C79.89)  Hyperhidrosis, focal, face (705.21, L74.511)  Shortness of breath (786.05, R06.02)  Hyperhidrosis, focal, palms (705.21, L74.512)  Swelling, mass or lump in chest (786.6, R22.2)  Lymphadenopathy (785.6, R59.9)  Other unlisted category of disease

Other Primary Specify: If diagnosis not listed, free text here:______CategoryPrimOth (1260) Other Primary ICD: Enter ICD-9 or ICD-10 of unlisted primary diagnosis, if known:______CategoryPrimOthICD (1270) Secondary, Other Secondary Specify: If secondary diagnosis not listed, free text here:______CategorySecondOth (1290) Secondary, Other Secondary ICD: Enter ICD-9 or ICD-10 of unlisted secondary diagnosis, if known :______CategorySecondOthICD (1300)

E. Operative Date of Surgery:______/______/______SurgDt (1310) OR Entry Time: ______:______Anesthesia Start Time: ______:______Procedure Start Time: ______:______OREntryT (1320) AnesthStartT (1340) ProcStartT (1360) OR Exit Time: ______:______Anesthesia End Time: ______:______Procedure End Time: ______:______ORExitT (1330) AnesthEndT (1350) ProcEndT (1370)

Multi-Day Operation (operation continued through midnight)  Yes  No MultiDay (1380) Planned, staged procedure?  Yes  No PlanStageProc (1390) Status of Operation  Emergent  Urgent  Elective  Palliative Status (1400) Reoperation (any prior cardiothoracic surgery Assisted by Robotic Technology that affects operative field)  Yes  No  Yes  No Reop (1410) Robotic (1420) Surgical Approach Conversion:  VATS→ Open  Robotic → VATS  Robotic→ Open  No UnanticConv (1430) Conversion Type:  Elective  Emergent UnanticConvTy (1440) If Yes→ Conversion Reason:  Vascular  Anatomy  Lymph Nodes  Technical UnanticConvRsn (1450) Blood transfusion intraoperatively (packed red blood cells) If Yes→ #Red Blood Cell Units: ______ Yes  No IntraopPRBC (1460) IntraopPRBCNum (1470)  V  III  IV  VI ASA  I  II Moribund, not Severe Life threatening Declared brain dead, Classification: Normal, Mild systemic expected to systemic severe systemic organ donor ASA (1480) healthy disease survive without disease disease operation

Check ALL of the procedures performed. Indicate (circle) the Primary Procedure. Proc (1490) Primary (1500) Analyzed Procedures Lung Cancer Resection

 Thoracoscopy, surgical; with lobectomy (32663)  Removal of lung, single lobe (lobectomy) (32480)  Thoracoscopy with therapeutic wedge resection (eg mass or  Removal of lung, two lobes (bilobectomy) (32482) nodule, initial, unilateral (32666)  Thoracoscopy with therapeutic wedge resection(eg mass or nodule) each additional resection, ipsilateral (32667) List separately in  Removal of lung, single segment (segmentectomy) (32484) addition to primary procedure code  Thoracoscopy with diagnostic wedge resection followed by anatomic lung resection (32668), List separately in addition to primary  Removal of lung, sleeve lobectomy (32486) procedure code  Thoracoscopy with removal of a single lung segment  Removal of lung, completion pneumonectomy (32488) (segmentectomy) (32669)  Resection and repair of portion of bronchus (bronchoplasty) when  Thoracoscopy with removal of two lobes (bilobectomy) (32670) performed at time of lobectomy or segmentectomy (32501)  Resection of apical lung tumor (e.g., Pancoast tumor), including  Thoracoscopy with removal of lung, pneumonectomy (32671) chest wall resection, without chest wall reconstruction(s) (32503)  Thoracotomy with therapeutic wedge resection (eg mass nodule)  Resection of apical lung tumor (e.g., Pancoast tumor), including initial (32505) chest wall resection, with chest wall reconstruction (32504)  Thoracotomy with therapeutic wedge resection (eg mass nodule)  Removal of lung, total pneumonectomy; (32440) each additional resection, ipsilateral (+32506)List separately in addition to primary procedure code  Thoracotomy with diagnostic wedge resection followed by anatomic  Removal of lung, sleeve (carinal) pneumonectomy (32442) lung resection (+32507), List separately in addition to primary proc code  Thoracoscopy with mediastinal and regional lymphadenectomy  Thoracic lymphadenectomy, regional, including mediastinal and (+32674) List separately in addition to primary procedure code peritracheal nodes (38746) Esophagus Resection  Transhiatal-Total esophagectomy, without thoracotomy, with  Partial esophagectomy, distal two-thirds, with thoracotomy only cervical esophagogastrostomy (43107) (43121)  Total esophagectomy without thoracotomy; with colon interposition  Thoracoabdominal-Partial esophagectomy, thoracoabdominal or small intestine reconstruction (43108) approach (43122)  Three Incision -Total esophagectomy with thoracotomy; with  Partial esophagectomy, thoracoabdominal with colon interposition cervical esophagogastrostomy (43112) or small intestine (43123)  Total esophagectomy with thoracotomy; with colon interposition or  Total or partial esophagectomy, without reconstruction with cervical small intestine reconstruction (43113) esophagostomy (43124)  Partial esophagectomy, cervical, with free intestinal graft, including  Minimally invasive three incision esophagectomy (McKeown) microvascular anastomosis (43116) (43288)  Ivor Lewis-Partial esophagectomy, distal two-thirds, with  Minimally invasive esophagectomy, Ivor Lewis approach (43287) thoracotomy and separate abdominal incision (43117)  Partial esophagectomy, with thoracotomy and separate abdominal  Minimally invasive esophagectomy, Abdominal and neck approach incision with colon interposition or small intestine (43118) (43286) Hiatal Hernia / GERD Procedures  Laparoscopy, surgical, esophagogastric fundoplasty (e.g., Nissen,  Repair, paraesophageal hiatal hernia via laparotomy with mesh Toupet procedures) (43280) (43333)  Laparoscopy, surgical with repair of paraesophageal hernia  Repair, paraesophageal hiatal hernia via thoracotomy without (fundoplasty) without mesh (43281) mesh (43334)  Laparoscopy, surgical with repair of paraesophageal hernia  Repair, paraesophageal hiatal hernia via thoracotomy with mesh (fundoplasty) with mesh (43282) (43335)  Nissen fundoplasty- laparotomy (includes partial  Repair, paraesophageal hiatal hernia via thoracoabdominal fundoplication/wrap) (43327) approach without mesh (43336)  Transthoracic Fundoplication- open thoracotomy (includes  Repair, paraesophageal hiatal hernia via thoracoabdominal Belsey/Nissen) (43328) approach with mesh (43337)  Repair, paraesophageal hiatal hernia via laparotomy without mesh

(43332) Tracheal Resection  Carinal reconstruction (31766)  Tracheal tumor or carcinoma excision; cervical (31785)  Excision tracheal stenosis, cervical (31780)  Tracheal tumor or carcinoma excision; thoracic (31786)  Excision tracheal stenosis, thoracic (31781) Thymus / Mediastinal Mass Resection  Thoracoscopy, surgical; with excision of mediastinal cyst, tumor, or  Thymectomy, transcervical approach (60520) mass (32662)  Thymus, resection via Thoracoscopy unilateral or bilateral (32673)  Thymectomy, transthoracic approach (60521)  Thymectomy, transthoracic approach, with radical mediastinal  Mediastinal tumor, excision, open, Transthoracic approach (39220) dissection (60522)

Non-analyzed Procedures Trachea, Bronchi, Larynx  Laryngectomy, partial (31370)  Tracheostomy replacement (tube change) prior to est. of fistula  Tracheal wound or injury suture repair; cervical (31800) tract (31502)  Tracheostomy, planned (31600)  Tracheal wound or injury suture repair; intrathoracic (31805)  Tracheostomy revision simple, without flap (31613)  Unlisted procedure, trachea, bronchi (31899)  Tracheostomy revision complex, with flap (31614)  Bronchopleural fistula closure (32906)  Tracheoplasty; cervical (31750)  Bronchogenic cyst removal  Tracheoplasty; intrathoracic (31760)  Bronchial laceration suture  Bronchial sleeve resection  Bronchoplasty, graft repair (31770)  Tracheostomy mediastinal  Bronchoplasty; excision stenosis and anastomosis (31775)  Rigid stent removal

Bronchoscopy  Tracheobronchoscopy through established tracheostomy incision  Bronchoscopy, with transbronchial lung biopsy(s), each additional (31615) lobe (31632)  Endobronchial ultrasound (EBUS) during bronchoscopy diagnostic  Bronchoscopy, with transbronchial needle aspiration biopsy(s), or therapeutic intervention(s) (31620) each additional lobe (31633)  Bronchoscopy, diagnostic, with or without cell washing (31622)  Bronchoscopy, with removal of foreign body (31635)  Bronchoscopy, with placement of bronchial stent(s) (includes  Bronchoscopy, with brushing or protected brushings (31623) tracheal/bronchial dilation as required), initial bronchus (31636)  Bronchoscopy, with bronchial alveolar lavage (BAL) (31624)  Bronchoscopy, each additional major bronchus stented (31637)  Bronchoscopy, with bronchial or endobronchial biopsy(s), single or  Bronchoscopy, with revision of tracheal or bronchial stent inserted multiple sites (31625) at previous session (31638)  Bronchoscopy, with placement of Fiducial markers (31626)  Bronchoscopy, with excision of tumor (31640)  Bronchoscopy, with destruction of tumor or relief of stenosis by any  Bronchoscopy, navigational (31627) method other than excision (e.g., laser therapy) (31641)  Bronchoscopy, with transbronchial lung biopsy(s), single lobe  Bronchoscopy, with placement of catheter(s) for intracavitary (31628) radioelement application (31643)  Bronchoscopy, with transbronchial needle aspiration biopsy(s)  Bronchoscopy, with therapeutic aspiration of tracheobronchial tree, (31629) initial (drainage of lung abscess) (31645)  Bronchoscopy, with tracheal/bronchial dilation or closed reduction  Bronchoscopy, with therapeutic aspiration of tracheobronchial tree, of fracture (31630) subsequent (31646)  Bronchoscopy, with placement of tracheal stent(s) (includes tracheal/bronchial dilation as required) (31631) Pleural Space and Lung  Thoracostomy; with rib resection for empyema (32035)  Insertion indwelling tunneled pleural catheter (32550)  Thoracoscopy, diagnostic lungs and pleural space, without biopsy  Thoracostomy; with open flap drainage for empyema (32036) (32601)  Thoracotomy with biopsy(s) lung infiltrate(s) (e.g. wedge), unilateral  Thoracoscopy, diagnostic; with biopsy(s) of lung infiltrate(s) (e.g. (32096) wedge), unilateral (32607)  Thoracotomy with biopsy(s) lung nodule(s) or masses (e.g.  Thoracoscopy, diagnostic; with biopsy(s) of lung nodule(s) or incisional), unilateral (32097) mass(es) (eg incisional), unilateral (32608)  Thoracotomy with biopsy(s) of pleura (32098)  Thoracoscopy, diagnostic; with biopsy(s) of pleura (32609)  Thoracoscopy, surgical; with pleurodesis (e.g., mechanical or  Thoracotomy, with exploration (32100) chemical) (32650)  Thoracotomy, major; with control of traumatic hemorrhage and/or  Thoracoscopy, surgical; with partial pulmonary decortication repair of lung tear (32110) (32651)  Thoracotomy, major; for postoperative complications (32120)  Thoracoscopy, surgical; with total pulmonary decortication (32652)  Thoracoscopy, surgical; with removal of intrapleural foreign body or  Thoracotomy with open intrapleural pneumolysis (32124) fibrin deposit (32653)  Thoracotomy, major; with cyst(s) removal, with or without a pleural  Thoracoscopy, surgical; with control of traumatic hemorrhage procedure (32140) (32654)  Thoracotomy, major; with excision-plication of bullae, with or  Thoracoscopy, surgical; with excision-plication of bullae, including without any pleural procedure (32141) any pleural procedure (32655)  Thoracotomy, major; with removal of intrapleural foreign body or  Thoracoscopy, surgical; with parietal pleurectomy (32656) hematoma (32150)

 Thoracoscopy with resection-plication for emphysematous lung  Thoracotomy with cardiac massage (32160) (bullous or non-bullous) for lung volume reduction- LVRS, unilateral including any pleural procedure (32672)  Decortication, pulmonary, total (32220)  Repair lung hernia through chest wall (32800)  Closure of chest wall following open flap drainage for empyema  Pleural scarification for repeat pneumothorax (32215) (Clagett type procedure) (32810)  Decortication, pulmonary, partial (32225)  Total lung lavage (for alveolar proteinosis) (32997)  Pleurectomy, parietal (32310)  Radio-frequency ablation (RFA) lung tumor (32998)  Decortication and parietal pleurectomy (32320)  Removal of lung, total pneumonectomy; extrapleural (32445)  Removal of lung, excision-plication of emphysematous lung(s) for  Unlisted procedure, lung (32999) lung volume reduction (LVRS) (32491) Lung Other Procedures  Open closure of major bronchial fistula (32815)  Double lung transplant (32853)  Single lung transplant (32851)  Double lung transplant with CPB (32854)  Thoracoplasty with closure of bronchopleural fistula (32906)  Single lung transplant with CPB (32852)

Mediastinum and Diaphragm  Diaphragmatic hernia repair (other than neonatal), traumatic; acute  Thoracoscopy, diagnostic; mediastinal space, with biopsy (32606) (39540)  Mediastinotomy with exploration or biopsy; cervical approach  Diaphragmatic hernia repair (other than neonatal), traumatic; (39000) chronic (39541)  Mediastinotomy with exploration or biopsy; transthoracic approach  Diaphragm imbrication (i.e., plication) of (39545) (39010)  Diaphragm; resection with simple repair (e.g., primary suture)  Mediastinal cyst, excision, open, Transthoracic approach (39200) (39560)  Diaphragm; resection with complex repair (e.g., prosthetic material,  Mediastinoscopy, with or without biopsy (39400) local muscle flap) (39561)  Unlisted procedure, mediastinum (39499)  Unlisted procedure, diaphragm (39599)  Diaphragm, laceration repair, any approach (39501) Esophagoscopy  Upper gastrointestinal endoscopy with endoscopic ultrasound  Esophagoscopy (43200) examination limited to the esophagus (43237)  Upper gastrointestinal endoscopy with transendoscopic ultrasound-  Esophagoscopy with biopsy (43202) guided FNA (43238)  Esophagoscopy with removal of foreign body (43215)  Upper gastrointestinal endoscopy with biopsy (43239)  Upper gastrointestinal endoscopy with dilation of gastric outlet for  Esophagoscopy with insertion of stent (43219) obstruction (43245)  Upper gastrointestinal endoscopy with directed placement of  Esophagoscopy with balloon dilation (43220) percutaneous gastrostomy tube (43246)  Esophagoscopy with insertion of guide wire followed by dilation  Upper gastrointestinal endoscopy with removal of foreign body over guide wire (43226) (43247)  Upper gastrointestinal endoscopy with insertion of guide wire  Esophagoscopy with ablation of tumor (43228) followed by dilation of esophagus (43248)  Esophagoscopy with endoscopic ultrasound examination (EUS)  Upper gastrointestinal endoscopy with balloon dilation of (43231) esophagus (43249)  Esophagoscopy with transendoscopic ultrasound-guided fine  Upper gastrointestinal endoscopy with transendoscopic stent needle aspiration (43232) placement (43256)  Upper gastrointestinal endoscopy, diagnostic (43235)  Upper gastrointestinal endoscopy with ablation of tumor (43258) Esophagus Other Procedures  Thoracoscopy, surgical; with esophagomyotomy (Heller type)  Esophagostomy, fistulization of esophagus, external; cervical (32665) approach (43352)  Gastrointestinal reconstruction for previous esophagectomy with  Cricopharyngeal myotomy (43030) stomach (43360)  Excision esophageal lesion with primary repair, cervical approach  Gastrointestinal reconstruction for previous esophagectomy with (43100) colon interposition or small intestine (43361)  Excision Esophageal lesion with primary repair, thoracic approach  Suture of esophageal wound or injury; cervical approach (43410) (eg: leiomyoma) (43101)  Diverticulectomy of hypopharynx or esophagus, with or without  Suture of esophageal wound or injury; transthoracic or myotomy; cervical approach (43130) transabdominal approach (43415)  Diverticulectomy of esophagus, with or without myotomy; thoracic  Closure of esophagostomy or fistula; cervical approach (43420) approach (43135)

 Laparoscopic esophageal myotomy (Heller Myotomy, with or  Total gastrectomy with esophagoenterostomy (43620) without fundoplication ) (43279)  Laparoscopy, surgical, esophageal lengthening procedure (Collis)  Total gastrectomy with Roux-en-Y reconstruction (43621) (43283) Secondary Procedure code  Unlisted laparoscopy, esophagus (43289 )  Conduit revision s/p esophagectomy  Esophagoplasty with repair of TEF, cervical approach (43305)  Per oral endoscopic myotomy (POEM)  Esophagoplasty with repair TEF, thoracic approach (43312)  Trans oral fundoplication  Esophageal lengthening procedure - open (Collis) Secondary  Esophagomyotomy (Heller type); thoracic approach (43331) Procedure code (43338)  Ligation or stapling at gastroesophageal junction for esophageal  Free jejunum transfer with microvascular anastomosis (43496) perforation (43405)  Unlisted procedure, esophagus (43499) Chest Wall and Neck  Muscle flap, neck (15732)  Radical resection of sternum (21630)  Muscle flap; trunk (i.e., intercostal, pectoralis or serratus muscle)  Radical resection of sternum; with mediastinal lymphadenectomy (15734) (21632)  Hyoid myotomy and suspension (21685) secondary procedure  Excision of chest wall tumor including ribs (19260) code  Excision of chest wall tumor involving ribs, with reconstruction  Division of scalenus anticus; without resection of cervical rib (19271) (21700)  Excision tumor, soft tissue of neck or thorax; subcutaneous (21555)  Division of scalenus anticus; with resection of cervical rib (21705)  Excision tumor, soft tissue of neck or thorax; deep, subfascial,  Reconstructive repair of pectus excavatum or carinatum; open intramuscular (21556) (21740)  Radical resection of tumor (e.g., malignant neoplasm), soft tissue  Reconstructive repair of pectus, minimally invasive approach (Nuss of neck or thorax (21557) procedure), without thoracoscopy (21742)  Open treatment of sternum fracture with or without skeletal fixation  Excision of rib, partial (21600) (21825)  Excision first and/or cervical rib (21615)  Removal of sternal wire(s)  Reconstructive repair of pectus, minimally invasive approach (Nuss  Excision first and/or cervical rib; with sympathectomy (21616) procedure), with thoracoscopy (21743)  Major reconstruction, chest wall (posttraumatic) (32820)  Unlisted procedure, neck or thorax (21899) Miscellaneous  Thoracoscopy, diagnostic pericardial sac, with biopsy (32604)  SVC resection and reconstruction (34502)  Thoracoscopy, surgical; with removal of clot or foreign body from  Ligation thoracic duct (38381) pericardial sac (32658)  Thoracoscopy, surgical; with creation of pericardial window or  Intraoperative jejunostomy (44015) partial resection of pericardial sac for drainage (32659)  Thoracoscopy, surgical; with total pericardiectomy (32660)  Omental flap (49904)  Thoracoscopy, surgical; with excision of pericardial cyst, tumor, or  Transthoracic thyroidectomy (60270) mass (32661)  Thoracoscopy, surgical; with thoracic sympathectomy (32664)  Removal substernal thyroid, cervical approach (60271)  Stereotactic radiosurgery (SRS) and stereotactic body radiotherapy  Application of wound vac (97605, 97606) (SBRT),surgeon participation (32701)  Tube pericardiostomy (33015)  Pericardial window (33025)  Other Minor Procedure  Other

Enter Name of unlisted Procedure(s): ProcOth (1510) Enter 5 digit CPT code(s) of unlisted procedure, if known: ProcOthCPT (1520)

Surgical Procedure for Lung Cancer or Suspected  Yes  No if yes, complete Section F Lung Cancer? LungCancer (1580) Surgical Procedure for Esophageal Cancer?  Yes  No if yes, complete Section G EsophCancer (1590) Are you collecting data for Thymus / Mediastinal  Yes  No if yes, complete Section H Mass Resection? ThymusMediastinalData (1600) Are you collecting data for Tracheal Resection?  Yes  No if yes, complete Section I TrachealData (1610) Are you collecting data for Hiatal Hernia / GERD?  Yes  No if yes, complete Section J HiatalHerniaData (1620)

F. Lung Cancer Diagnosis:

Was there a pathological diagnosis of lung cancer prior to the lung resection? (yes: lung cancer was  Yes  No diagnosed preoperatively; no: lung cancer was only suspected preoperatively) LungCancerSus (1630) How was lung cancer diagnosed? Bronchoscopy Needle Biopsy Attempted or Completed  Yes  No  Yes  No ClinStagLungBronc (1640) ClinStagLungNeedle (1650) Clinical Staging: Pre-treatment Lung cancer staging- to be completed if lung cancer suspected or documented AND lung resection performed. Clinical staging determines the treatment plan. Clinical Staging Done ClinStagDoneLung (1660)  Yes  No Pre-Op Positive Tissue diagnosis  Yes  No If Yes→ Obtained PreopPosTisOb (1670) Clinical Staging Methods : Choose all that apply Radiographic Staging Procedures PET or PET/CT Brain CT Scan  Yes  No  Yes  No ClinStagLungPET (1680) ClinStagLungBrainCT (1700) CT Brain MRI  Yes  No  Yes  No ClinStagLungCT (1690) ClinStagLungBMRI (1710) Was invasive mediastinal staging  Yes, reason documented  Yes, reason not documented  No performed? ClinStagInvasive (1720) If Documented → Operative/Clinic Note indicates Invasive Mediastinal Staging performed for the following reasons: (check all that apply) Lesion size > 3cm ClinStagInvasiveSize (1730)  Yes  No Mediastinal Lymphadenopathy on CT > 1cm  Yes  No ClinStagInvasiveLymphCT (1740) Ipsilateral hilar mediastinal node FDG uptake on PET  Yes  No ClinStagInvasiveHilar (1750) Central Tumor ClinStagInvasiveTumor (1760)  Yes  No Other ClinStagInvasiveOther (1770)  Yes  No Mediastinal Tissue Sampling/Staging EBUS VATS  Yes  No  Yes  No ClinStagLungEBUS (1780) ClinStagLungVATS (1790) EUS Other  Yes  No  Yes  No ClinStagLungEUS (1800) ClinStagLungOth (1810) Mediastinoscopy/Chamberlain  Yes  No ClinStagLungMedia (1830) Tumor size known?  Yes  No If Yes ↓

LungCaTumSzKnown (1850) Lung CA tumor size in cm (the dominanat/most concerning lesion per CT ______cm (ex. 2.3cm) Scan) LungCaTumSz (1860) Invasion of Adjacent Structures LCInvAdjStr (1870)  Yes  No Lung CA T Stage (tumor stage)  Tis  T1  T2  T3  T4 ClinStageLungTumor (1880)  N0  N1 Lung CA Nodes: No regional lymph node metastasis Metastasis in ipsilateral peribronchial or hilar ClinStageLungN (1890) and intrapulmonary nodes. Includes direct extension.  N2  N3 Metastasis in ipsilateral mediastinal Metastasis in contralateral mediastinal or

and/or subcarinal lymph nodes contralateral hilar nodes, ipsilateral or contralateral scalene or supraclavicular nodes Lung CA Metastases:  M0 M1 ClinStageLungM (1900) No distant metastasis Distant Metastasis

Lung - FINAL Pathological Staging To be completed if lung cancer suspected or documented AND lung resection performed. (8th Edition) Lung Cancer Results

ClinStageLungResult (1910)  No cancer found, benign tumor  Lung Cancer Tumor present:  TX  T0  Tis If Cancer Tumor Primary Tumor cannot be assessed, or tumor No evidence of Carcinoma in situ; squamous cell Present→ proven by the presence of malignant cells in primary tumor carcinoma in situ (SCIS); PathStageLungT sputum or bronchial washings but not visualized Adenocarcinoma in situ (AIS): (1920) by imaging or bronchoscopy adenocarcinoma with pure lepidic pattern, <3 cm in greatest dimension  T1mi  T1a  T1b Minimally invasive adenocarcinoma: Tumor <1 cm in greatest dimension. A Tumor > 1 cm but < 2 adenocarcinoma (<3 cm in greatest dimension) superficial, spreading tumor of any size cm in greatest with a predominantly lepidic pattern and <5 mm whose invasive component is limited to the dimension invasion in greatest dimension. bronchial wall and may extend proximal to the main bronchus also is classified as T1a, but these tumors are uncommon.  T1c  T2a  T2b Tumor > 2 cm but < Tumor > 3 cm but < 4 cm at greatest dimension, or having any of the Tumor > 4 cm but 3 cm in greatest following features: 1. involves the main bronchus regardless of distance to < 5 cm at dimension the carina, 2. but without involvement of the carina; invades visceral pleura greatest (PL1 or PL2); 3. associated with atelectasis or obstructive pneumonitis that dimension extends to the hilar region, involving part or all of the lung.

 T3  T4 Tumor > 5 cm but < 7 cm in greatest dimension or directly Tumor > 7 cm or tumor of any size invading one or invading any of the following: parietal pleura (PL3), chest more of the following: diaphragm, mediastinum, heart, wall (including superior sulcus tumors), phrenic nerve, great vessels, trachea, recurrent laryngeal nerve, parietal pericardium; or separate tumor nodule(s) in the esophagus, vertebral body, or carina; separate tumor same lobe as the primary nodule(s) in an ipsilateral lobe different from that of the primary

If tumor is T2a or T2b → Visceral Pleura Invasion  Yes  No VisPleuraInv (1930)  NX  N0  N1 Lung CA Nodes: Regional lymph nodes No regional lymph node Metastasis in ipsilateral peribronchial PathStageLungN cannot be assessed metastasis and/or ipsilateral hilar lymph nodes and (1940) intrapulmonary nodes, includes involvement by direct extension  N2  N3 Metastasis in ipsilateral Metastasis in contralateral mediastinal, contralateral hilar, ipsilateral mediastinal and/or or contralateral scalene or supraclavicular lymph node(s) subcarinal lymph node(s) If N2 → Multi-station N2  Yes  No PathStageLungMultiN2 (1950) Lung CA Metastases:  M0  M1 PathStageLungM No distant metastasis Distant metastasis (1960) Lung CA Histology: Carcinoma in situ-  Adenocarcinoma  Squamous cell  Large cell LungCAHist (1970)  Intermediate grade  Low Grade Neuroendocrine  Small cell neuroendocrine, atypical  Mixed (typical carcinoid) carcinoid  Other  Low grade (well differentiated)  High grade (poorly  Unknown / Not Grade:  Intermediate grade LungCAHistGrade (1980) differentiated) reported Total # of Lymph Nodes Total # of Nodal Stations sampled/harvested: ______sampled/harvested:______LungCANodStat (2000) LungCANodes (1990)

If Yes→ Lung CA Resection LungCAPath  R1 (microscopic  R2 (macroscopic (gross) Margins Positive:  Yes  No MargPosR residual tumor present) residual tumor present) LungCAPathMarg (2010) (2020)

G. Esophageal Cancer Clinical Staging: Pre-treatment Esophageal cancer staging - to be completed if esophageal cancer suspected, documented OR esophagus resection performed. Clinical staging determines the treatment plan. Clinical Staging Done ClinStagDoneEsoph (2030)  Yes  No Radiologic / Endoscopic Staging Procedures PET or PET/CT CT  Yes  No  Yes  No If Clinical Staging ClinStagEsophPET (2040) ClinStagEsophCT (2050) Done is Yes → Bronchoscopy EUS  Yes  No  Yes  No ClinStagEsophBronc (2060) ClinStagEsophEUS (2090) Invasive Staging Procedures VATS – for staging Laparoscopy – for staging  Yes  No  Yes  No ClinStagEsophVATS (2100) ClinStagEsophLap (2110) Endoscopic Mucosal Resection Other:  Yes  No  Yes  No ClinStagEsophEMR (2120) ClinStagEsophOth (2130)  T0  Tis  T1 Esophageal Tumor: No evidence of primary High grade dysplasia Tumor invades lamina propria, ClinStageEsophT tumor mucosa or submucosa (2150)

 T2  T3  T4 Tumor invades Tumor invades adventitia Tumor invades adjacent muscularis propria structures

Clinical Diagnosis of Nodal Involvement:  Yes (N1, N2 or N3)  No ClinStageEsophNode (2160) Esophageal CA Metastases  M0 No Distant Metastasis  M1 Distant Metastasis ClinStageEsophM (2170) Tumor Location (check all that apply): Cervical Esophagus (15 – < 20 cm)  Yes  No

TumorEsopCervical (2180) Upper Thoracic (20 - < 25 cm)  Yes  No

TumorEsopUpThorac (2190) Middle Thoracic (25 - < 30 cm)  Yes  No TumorEsopMidThorac (2200) Lower Thoracic, including EG Junction (30 – 42 cm)  Yes  No TumorEsopLowThorac (2210)

Pathological Staging - Esophagus Esophagus to be completed if esophageal cancer documented AND esophageal resection performed (Pre-Operative Evaluation – Esophageal Cancer = Yes) (8th Edition) Esophageal Cancer Results ClinStageEsophResult (2220)  No cancer found, benign tumor  Esophageal cancer present

Esophageal Tumor: PathStageEsophT (2230) If cancer present →  TX  T0  Tis Tumor cannot be assessed No evidence of primary tumor High Grade dysplasia, defined as malignant cells confined to the epithelium by the basement membrane  T1a  T1b  T2 Tumor invades lamina propria or Tumor invades Tumor invades muscularis muscularis mucosa submucosa propria

 T3  T4a  T4b Tumor invades Tumor invades pleura, pericardium, Tumor invades other adjacent structures adventitia azygos vein, diaphragm or peritoneum such as aorta, vertebral body, or airway.

Esophageal CA Nodes:  NX  N0  N1 PathStageEsophN Regional lymph nodes No regional lymph node Metastasis in 1-2 regional nodes (2240) cannot be assessed metastasis  N2  N3 Metastasis in 3-6 regional lymph Metastasis in 7 or more regional lymph nodes nodes Esophageal CA Metastases:  M0  M1 PathStageEsophM (2250) No distant metastasis Distant metastasis Esoph Histopathologic Type:  H1Squamous Carcinoma  H2 Adenocarcinoma  Other PathStageEsophH (2260)  GX Grade  G1 Well  G2 Moderately  G3 Poorly Esophageal CA Histologic Grade: cannot be differentiated differentiated differentiated, PathStageEsophG (2270) assessed undifferentiated Total # of Lymph Nodes sampled/harvested: ______Esophageal CA Resection Margins Positive:  Yes  No EsophCANodes (2280) EsophCAPathMarg (2290)

H. Thymus / Mediastinal Mass Resection Pre-Operative Symptomatic myasthenia  Yes  No MyastheniaSympt (2300) Mestinon If Yes → Chronic Medical Treatment:  Yes  No TxMestinon (2310) Steroids  Yes  No TxSteroids (2320) Other Immunosuppressive Therapy  Yes  No TxImmunoSuppress (2330) Pre-operative management IVIG  Yes  No IVIG (2340) Plasmaphereis Plasmaphereis  Yes  No (2350) Size of mass known:  Yes  No MassSizeKnown (2360) If yes → Largest diameter in mm derived from preop axial, coronal or sagittal image ______mm MassSize (2370) Initial Surgical Approach ThyInitSurgAp (2380)  Full Sternotomy  Clamshell or Hemiclamshell  Transcervical  Partial Sternotomy  Robotic  VATS If “Robotic” or “VATS” → Location:  Right  Left  Bilateral ThyRobVATSLoc (2390) If “Transcervical”, “Partial Sternotomy”, ”Robotic” or “VATS” → Conversion to open approach during procedure?

ThyConvToOpen (2400)  Yes, Planned  Yes, Unplanned  No

If Yes →  Sternotomy  Clamshell  Thoracotomy ThyConvA p (2410) Intentional resection of functioning phrenic nerve  Yes  No PhrenicNerveResect (2420) Pathologic Staging PathRptStage (2430)  Stage II The thymoma invades beyond the  Stage I  Stage IIa  Stage IIb capsule (outer boundary of the Grossly and microscopically encapsulated. Also Microscopic Macroscopic capsular thymus) and into the nearby fatty called a noninvasive thymoma. That is, it has not transcapsular invasion invasion tissue or to the pleura (outer spread beyond the thymus. covering of the lung). Sometimes divided into:

 Stage III  Stage IVa Macroscopic invasion of neighboring organs. The thymoma  Stage IVb Pleural or pericardial dissemination. extends into the neighboring tissues or organs of the lower neck Hematogenous or lymphatic The thymoma has spread widely or upper chest area, including the pericardium (covering of the dissemination. The thymoma has throughout the pleura and/or heart), the lungs, or the main blood vessels leading into or spread to distant organs. pericardium. exiting from the heart.

WHO classification (from path report – Thymoma only) ThymomaType (2440)  Type A  Type AB  Type B1  Type B2  Type B3  Thymic Carcinoma or Type C  Not Thymoma Completeness of resection (from operative note or pathology report)  R0  R1  R2 ResectCompleteness (2450) Patient alive at 30 days post op  Yes  No PtAlive30Day (2460) If Yes → Post – operative Event (30 day) Myasthenic crisis requiring return to ICU or intervention (intubation, plasmapheresis)  Yes  No MYAL (2470) Unintentional phrenic nerve palsy  Yes  No PhrenicNervePalsy (2480) Patient alive at 90 days post op  Yes  No PtAlive90Day (2490)

If Yes → 90 Day Post – Operative Variable Adjuvant thoracic radiation  Yes  No ThoracicRadiation (2500) Persistent unintentional phrenic nerve palsy  Yes  No PhrenNrvPalsyPersis (2510)

I. Tracheal Resection Pre-Operative Current Airway AirwayCurr (2520)  Native  Oral ETT  Trach  T-Tube Prior tracheostomy TracheostomyPrior (2530)  Yes  No Prior intubation IntubatePrior (2540)  Yes  No Prior Tracheal Resection TrachealResectPrior (2550)  Yes  No Recent Bronchoscopic Intervention (within 6 weeks)  Yes  No (includes: core out, dilation, ablation, stent) BronchInt6Wks (2560) Recurrent nerves intact RecurrNervesIntact (2570)  Yes  No  Unknown If not intact → Which nerve?  Right  Left  Both RecurrNervNotIntact (2580) Airway management during resection (check all that apply) Cross – table ventilation VA ECMO  Yes  No Jet ventilation  Yes  No  Yes  No CrossTableVent (2590) VaECMO (2600) JetVent (2610) VV ECMO Cardiopulmonary bypass  Yes  No  Yes  No VvECMO (2620) CardoPulmBypass (2630) Incision (check all that apply, must have at least one indicated)

Cervical  Yes  No Partial sternotomy  Yes  No Full sternotomy  Yes  No TrachIncisCerv (2640) TrachIncisPartStern (2650) TrachIncisFullStern (2660) Right thoracotomy  Yes  No Clamshell  Yes  No TrachIncisRight (2670) TrachIncisClam (2680) Length of tracheal resection ______mm (Surgical or pathological measurement acceptable) TrachealResectLen (2690) Cricoid resection required  Yes  No CricoidResect (2700) Carinal resection required  Yes  No CarinalResect (2710) Release Maneuvers  Yes  No ReleaseManeuver (2720) If yes → ReleaseManeuverT  Suprahyoid  Suprathyroid  Hilar ype (2730) Additional Post-Operative Events Anastomotic dehiscence requiring drainage, revision, stent, tracheostomy, T-tube  Yes  No AnastomoticDehiscen (2740) Anastomotic stricture requiring intervention  Yes  No AnastomoticStricture (2750) Airway obstruction requiring intervention (e.g., unscheduled bronchoscopy)  Yes  No AirwayObstruct (2760) Recurrent nerve palsy  Right  Left  Both  Neither NervePalsyRecurr (2770) Did the patient leave the hospital with tracheal appliance? (tracheostomy, T-tube or  Yes  No  Patient Died In Hospital stent) TrachealAppliance (2780) At 30 Days Post – Operative Patient is: Stent/tube free StentTubeFree30days (2790)  Yes  No  Patient Died Within 30 Days of Procedure At 90 Days Post – Operative Patient is: Stent/tube free StentTubeFree90days (2800)  Yes  No  Patient Died Within 90 Days of Procedure

J. Hiatal Hernia / GERD Symptoms Heartburn  Yes  No Cough  Yes  No Heartburn (2810) Cough (2820) Regurgitation  Yes  No Hoarseness  Yes  No Regurgitate (2830) Hoarse (2840) Dysphagia  Yes  No Sore throat  Yes  No Dysphagia (2850) SoreThroat (2860) Epigastric/chest pain  Yes  No Asthma  Yes  No Ephigastric (2870) Asthma (2880) Early satiety  Yes  No Reflux laryngitis  Yes  No EarlySatiety (2890) RefluxLaryngitis (2900) Anemia  Yes  No Anemia (2910) PPIs PPI relief PPI use  Yes  No If Yes → PPIRelief  Complete  Partial  No PPIUse (2920) (2930) EGD Esophagitis LA Grade: Esophagitis  Yes  No If Yes →  A  B  C  D LAGrade (2950) (2940) Barrett’s metaplasia  Yes, with low grade dysplasia  Yes, with high grade dysplasia  No MetaplasiaBarrett (2960) pH Testing Manometry pHTest (2970)  Yes  No If Yes ↓ Manometry DeMeester score Motility: performed: DeMeesterScore ______ Yes  No If Yes → Motility  normal  decreased  aperistalsis Manometry (2980) (3000) (2990) LES resting pressure _____ RestPressure (3010) % of failed swallows ______SwallowFail (3020) Imaging Imaging performed If Yes → Type of imaging  Yes  No  bariums swallow/ upper GI  CT Scan  CXR ImagePerform (3030) ImageType (3040)

Hiatal hernia size (cm) Hiatal hernia type: ______ I  II  III  IV HerniaSize (3050) HerniaType (3060) Hernia repair status  Primary repair  Re-operation HerniaRepStat (3065) If re-operation → Surgical approach used in the initial procedure:  Laparoscopic  Laparotomy  Thoracotomy  Not documented HerniaReopApp (3066) Procedure Approach (check all that apply) Laparoscopic Robotic GERDAppLaparo  Yes  No GERDAppRob  Yes  No scopic (3070) otic (3080) Laparotomy Thoracotomy GERDAppLaparo  Yes  No GERDAppThor  Yes  No tomy (3090) (3100) If Yes → Type Fundoplication  Yes  No FundoplicateType  Partial  Complete ProcFundoplicate (3110) (3120) Gastroplasty  Yes  No ProcGastroplasty (3130) Mesh  Yes  No ProcMesh (3140) Relaxing incision  Yes  No ProcRelaxIncision (3150) Is patient alive at 1 month post – Op? Is patient alive at 1 year post – Op? GERDPtAliveMth (3160)  Yes  No GERDPtAliveYr (3210)  Yes  No If Yes → 1 Month Post – Operative Follow Up If Yes → 1 Year Post – Operative Follow Up Radiographic recurrence Radiographic recurrence RadiographRecurr1Mon  Yes  No  Yes  No RadiographRecurr1Year (3220) (3170) Symptomatic recurrence Symptomatic recurrence SymptomRecurr1Mon  Yes  No  Yes  No SymptomRecurr1Year (3230) (3180) Endoscopic Intervention Endoscopic Intervention  Yes  No  Yes  No EndoInt1Mon (3190) EndoInt1Year (3240) Redo Operation Redo operation  Yes  No  Yes  No RedoOperate1Mon (3200) RedoOperate1Year (3250)

K. Disposition Patient Disposition:  ICU  Intermediate Care Unit  Regular Floor Bed PatDisp (3260)  Not Applicable (Expired in OR)  Outpatient or Observation Status ICU Admit this admission:  Yes  No ICUVisitInit (3270) If Yes → Initial ICU Days: ______ICUVisitInitDays (3280) ICU Readmit:  Yes  No ICUVisitAdd (3290) If Yes → Additional ICU Days: ______ICUVisitAddDays (3300)

L. Post-Operative Events Indicate all adverse events that occurred within 1 month of surgery if discharged from the hospital or those that occur during the same admission, regardless of the length of stay. Postoperative Events?  Yes  No If Yes, select all that occurred: ↓ POEvents (3310)

If Post-Operative Unanticipated post-operative invasive procedure?  Yes  No PostOpInvProc (3330) Events Yes → If unanticipated post-operative Primary Reason for Procedure: ReturnORRsn (3340) invasive procedure→  Bleeding  Bronchopleural Fistula  Empyema  Middle lobectomy for torsion

 Conduit necrosis/failure following esophageal surgery  Other

Anastomotic leak following esophageal Surgical drainage and repair  Yes  No If Yes →  Yes  No surgery PosOpProcALRepair (3360) PosOpProcAL (3350) Stent placement  Yes  No PosOpProcALStent (3370) Additional chest tube placement  Yes  No PosOpProcALTube (3380)

Chylothorax Present Chylothorax req. surgical ligation of thoracic duct  Yes  No  Yes  No If Yes → PosOpProcChylotho (3400) ChyloPres (3390) If No → Thoracic duct embolization attempted  Yes  No

PosOpProcEmboli (3410) If Yes → Was Thoracic duct embolization successful?  Yes  No

PosOpProcDuctSucc (3420) Pulmonary Air leak > 5 days Atelectasis req. Pleural Effusion duration  Yes  No bronchoscopy  Yes  No req. drainage  Yes  No AirLeak5 (3430) Atelectasis (3440) CPlEff (3450) Acute Respiratory Pneumonia Distress Syndrome Respiratory Failure  Yes  No  Yes  No  Yes  No Pneumonia (3460) (ARDS) RespFail (3480) ARDS (3470) Bronchopleural Pulmonary Pneumothorax req. Fistula  Yes  No Embolus  Yes  No CT reinsertion  Yes  No Bronchopleural PE (3500) Pneumo (3510) (3490)

Initial Vent Support > Tracheostomy 48 Hr  Yes  No  Yes  No Other Pulmonary Event  Yes  No Trach (3530) Vent (3520) OtherPul (3550)

Cardiovascular Atrial arrhythmia req.  Yes  No Ventricular arrhythmia  Yes  No Myocardial infarct  Yes  No treatment req. treatment MI (3580) AtrialArryth (3560) VentArryth (3570) Deep venous  Yes  No Other CV event  Yes  No thrombosis (DVT) OtherCV (3600) req. treatment DVT (3590) Gastrointestinal Ileus  Yes  No Anastomotic leak  Yes  No Dilation esophagus  Yes  No Ileus (3610) requiring medical DilationEsoph treatment only (3630) AnastoMed (3620) Conduit Necrosis  Yes  No Delayed conduit emptying requiring intervention (pyloric  Yes  No Requiring Surgery dilatation or botox) or maintenance of NG drainage > 7days CondNecSurg post op DelayCondEmp (3650) (3640) Clostridium Difficile  Yes  No Other GI event  Yes  No infection OtherGI (3670) CDiff (3660)

Hematology Packed red blood *transfusions documented here do not If Yes→ # Units ______cells  Yes  No include blood given in OR* PostopPRBCUnits (3690) PostopPRBC (3680) Urologic Urinary tract Urinary retention req. Discharged with infection  Yes  No Catheterization  Yes  No Foley catheter  Yes  No UTI (3700) UrinRetent (3710) DischFoley (3720) Infection Empyema req.  Yes  No Surgical Site Infection  None  Superficial  Deep treatment SurgSiteInfect (3740)  Organ space Empyema (3730) Sepsis  Yes  No Another infection req. IV antibiotics  Yes  No Sepsis (3750) OtherInfect (3760) Neurology

Recurrent laryngeal nerve New central neurological event  Yes  No paresis -unexpected  Yes  No CentNeuroEvt (3770) LaryngealNerve (3780) Delirium Other neurological event  Yes  No  Yes  No Delirium (3790) OtherNeuro (3800) Miscellaneous New renal failure per RIFLE criteria Chylothorax req. medical intervention  Yes  No  Yes  No RenFailRIFLE (3810) ChyloMed (3820) Other events req. OR with gen. Unexpected Admission to ICU anesthesia  Yes  No  Yes  No UnexpectAdmitICU (3840) OtherSurg (3830)

M. Discharge Patient is still in the hospital  Yes  No StillInHosp (3860)

If No → Date of Discharge: DischDt (3870)______/______/______

Discharge Status: MtDCStat (3880)  Alive  Dead

If Discharged Alive → Discharge location:  Home  Extended Care/Transitional Care Unit /Rehab DisLoctn (3890)  Other Hospital  Nursing Home  Hospice  Other Discharged with chest tube:  Yes  No CTubeDis (3900) Discharged with home O2 (new; not using O2 pre-op)  Yes  No DischHomeO2 (3910) If Yes → On O2 at 30 days postoperative?  Yes  No  Unknown  Patient Died Within 30 Days Post Op OnOxygen30DayPOp (3920) Readmit to any hospital within 30 days of discharge:  Yes  No  Unknown Readm30Dis (3930) If Yes → Readmission related to operative procedure?  Yes  No  Unknown Readm30DisRel (3940) Status at 30 days after surgery: Mt30Stat (3950)  Alive  Dead  Unknown

N. Follow Up Date of Last Follow-Up: ____/___/_____ LFUDate (3960) Mortality Status at Last Follow-Up:  Alive  Dead LFUMortStat (3970) Mortality Date: ____/___/_____ MortDate (3980)

O. Quality Measures IV antibiotics ordered to be given within 1 hour before incision:  Yes  No  Not indicated for procedure IVAntibioOrdered (3990) IV antibiotics given within 1 hour before incision:  Yes  No  Not indicated for procedure IVAntibioGiven (4000) Cephalosporin Antibiotic Ordered  Documented allergy or indication for  Yes  No  Not indicated for procedure CephalAntiOrdered (4010) therapeutic substitution Prophylactic Antibiotic Discontinuation Ordered within 24 hour  Yes  No  Not indicated for procedure  No, due to documented infection AntibioticDiscOrdered (4020) Smoking Cessation Counseling  Yes  No  Patient refused  Nonsmoker SmokCoun (4030) DVT Prophylaxis Measures  Yes  No  Not applicable DVTProphylaxis (4040)