Prehabilitation for Older Adults Undergoing Lung Cancer Surgery: A Literature Review and Needs Assessment.

Early-stage lung cancer patients are increasingly considered for preoperative systemic therapy. Older adults in particular are among the most vulnerable patients, with little known on how preoperative therapies affect the risk-benefit of surgery. We sought to summarize the current literature and elucidate existing evidence gaps on the effects of prehabilitation interventions relative to age-related functional impairments and the unique needs of older patients undergoing lung cancer surgery. A literature review was performed using PubMed and Google Scholar databases, of all scientific articles published through April 2022 which report on the effects of prehabilitation on patients undergoing lung cancer surgery. We extracted current prehabilitation protocols and their impact on physical functioning, resilience, and patient-reported outcomes of older patients. Emerging evidence suggests that prehabilitation may enhance functional capacity and minimize the untoward effects of surgery for patients following lung resection similar to, or potentially even better than, traditional postoperative rehabilitation. The impact of preoperative interventions on surgical risk due to frailty remains ill-defined. Most studies evaluating prehabilitation include older patients, but few studies report on activities of daily living, self-care, mobility activities, and psychological resilience in older individuals. Preliminary data suggest the feasibility of physical therapy and resilience interventions in older individuals concurrent with systemic therapy. Future research is needed to determine best prehabilitation strategies for older lung cancer patients aimed to optimize age-related impairments and minimize surgical risk.

Conduit Selection for Reconstruction After Esophagectomy for Esophageal Cancer.

The reconstruction of the esophagus after esophagectomy presents many technical and management challenges to surgeons. An effective gastrointestinal conduit that replaces the resected esophagus must have adequate length to reach the upper thoracic space or the neck, have robust vascular perfusion, and provide sufficient function for an adequate swallowing mechanism. The stomach is currently the preferred conduit for esophageal reconstruction after esophagectomy. However, there are circumstances, where the stomach cannot be utilized as a conduit. In these cases, an alternative conduit must be considered. The current alternative conduits include colon, jejunum, and tubed skin flaps.

Long-term cardiovascular disease outcomes in non-hospitalized medicare beneficiaries diagnosed with COVID-19: Population-based matched cohort study.

BACKGROUND: SARS-CoV2, the virus that causes coronavirus disease 2019 (COVID-19), can affect multiple human organs structurally and functionally, including the cardiovascular system and brain. Many studies focused on the acute effects of COVID-19 on risk of cardiovascular disease (CVD) and stroke especially among hospitalized patients with limited follow-up time. This study examined long-term mortality, hospitalization, CVD and stroke outcomes after non-hospitalized COVID-19 among Medicare fee-for-service (FFS) beneficiaries in the United States. METHODS: This retrospective matched cohort study included 944,371 FFS beneficiaries aged ≥66 years diagnosed with non-hospitalized COVID-19 from April 1, 2020, to April 30, 2021, and followed-up to May 31, 2022, and 944,371 propensity score matched FFS beneficiaries without COVID-19. Primary outcomes were all-cause mortality, hospitalization, and incidence of 15 CVD and stroke. Because most outcomes violated the proportional hazards assumption, we used restricted cubic splines to model non-proportional hazards in Cox models and presented time-varying hazard ratios (HRs) and Bonferroni corrected 95% confidence intervals (CI). RESULTS: The mean age was 75.3 years; 58.0% women and 82.6% non-Hispanic White. The median follow-up was 18.5 months (interquartile range 16.5 to 20.5). COVID-19 showed initial stronger effects on all-cause mortality, hospitalization and 12 incident CVD outcomes with adjusted HRs in 0-3 months ranging from 1.05 (95% CI 1.01-1.09) for mortality to 2.55 (2.26-2.87) for pulmonary embolism. The effects of COVID-19 on outcomes reduced significantly after 3-month follow-up. Risk of mortality, acute myocardial infarction, cardiomyopathy, deep vein thrombosis, and pulmonary embolism returned to baseline after 6-month follow-up. Patterns of initial stronger effects of COVID-19 were largely consistent across age groups, sex, and race/ethnicity. CONCLUSIONS: Our results showed a consistent time-varying effects of COVID-19 on mortality, hospitalization, and incident CVD among non-hospitalized COVID-19 survivors.

Hypertension in Pregnancy: Current Challenges and Future Opportunities for Surveillance and Research.

Hypertension in pregnancy (HP) includes eclampsia/preeclampsia, chronic hypertension, superimposed preeclampsia, and gestational hypertension. In the United States, HP prevalence doubled over the last three decades, based on birth certificate data. In 2019, the estimated percent of births with a history of HP varied from 10.1% to 15.9% for birth certificate data and hospital discharge records, respectively. The use of electronic medical records may result in identifying an additional third to half of undiagnosed cases of HP. Individuals with gestational hypertension or preeclampsia are at 3.5 times higher risk of progressing to chronic hypertension and from 1.7 to 2.8 times higher risk of developing cardiovascular disease (CVD) after childbirth compared with individuals without these conditions. Interventions to identify and address CVD risk factors among individuals with HP are most effective if started during the first 6 weeks postpartum and implemented during the first year after childbirth. Providing access to affordable health care during the first 12 months after delivery may ensure healthy longevity for individuals with HP. Average attendance rates for postpartum visits in the United States are 72.1%, but the rates vary significantly (from 24.9% to 96.5%). Moreover, even among individuals with CVD risk factors who attend postpartum visits, approximately 40% do not receive counseling on a healthy lifestyle. In the United States, as of the end of September 2023, 38 states and the District of Columbia have extended Medicaid coverage eligibility, eight states plan to implement it, and two states proposed a limited coverage extension from 2 to 12 months after childbirth. Currently, data gaps exist in national health surveillance and health systems to identify and monitor HP. Using multiple data sources, incorporating electronic medical record data algorithms, and standardizing data definitions can improve surveillance, provide opportunities to better track progress, and may help in developing targeted policy recommendations.

Fostering Governance and Information Partnerships for Chronic Disease Surveillance: The Multi-State EHR-Based Network for Disease Surveillance.

CONTEXT: Electronic health records (EHRs) are an emerging chronic disease surveillance data source and facilitating this data sharing is complex. PROGRAM: Using the experience of the Multi-State EHR-Based Network for Disease Surveillance (MENDS), this article describes implementation of a governance framework that aligns technical, statutory, and organizational requirements to facilitate EHR data sharing for chronic disease surveillance. IMPLEMENTATION: MENDS governance was cocreated with data contributors and health departments representing Texas, New Orleans, Louisiana, Chicago, Washington, and Indiana through engagement from 2020 to 2022. MENDS convened a governance body, executed data-sharing agreements, and developed a master governance document to codify policies and procedures. RESULTS: The MENDS governance committee meets regularly to develop policies and procedures on data use and access, timeliness and quality, validation, representativeness, analytics, security, small cell suppression, software implementation and maintenance, and privacy. Resultant policies are codified in a master governance document. DISCUSSION: The MENDS governance approach resulted in a transparent governance framework that cultivates trust across the network. MENDS's experience highlights the time and resources needed by EHR-based public health surveillance networks to establish effective governance.

National learning curves among robotic thoracic surgeons in the United States: Quantifying the impact of procedural experience on efficiency and productivity gains.

OBJECTIVE: This study aims to characterize the aggregate learning curves of US surgeons for robotic thoracic procedures and to quantify the impact on productivity. METHODS: National average console times relative to cumulative case number were extracted from the My Intuitive application (Version 1.7.0). Intuitive da Vinci robotic system data for 56,668 lung resections performed by 870 individual surgeons between 2021 and 2022 were reviewed. Console time and hourly productivity (work relative value units/hour) were analyzed using linear regression models. RESULTS: Average console times improved for all robotic procedures with cumulative case experience (P = .003). Segmentectomy and thymectomy had the steepest initial learning curves with a 33% and 34% reduction of the average console time for proficient (51-100 cases) relative to novice surgeons (1-10 cases), respectively. The hourly productivity increase for proficient surgeons ranged from 11.4 work relative value units/hour (+26%) for lobectomy to 17.0 work relative value units/hour (+50%) for segmentectomy. At the expert level (101+ cases), average console times continued to decrease significantly for esophagectomy (-18%) and lobectomy (-23%), but only minimally for wedge resections (-1%) (P = .003). The work relative value units/hour increase at the expert level reached 50% for lobectomy and 40% for esophagectomy. Surgeon experience level, dual console use, system model, and robotic stapler use were factors independently associated with console time for robotic lobectomy. CONCLUSIONS: The aggregate learning curve for robotic thoracic surgeons in the United States varies significantly by procedure type and demonstrate continued improvements in efficiency beyond 100 cases for lobectomy and esophagectomy. Improvements in efficiency with growing experiences translate to substantial productivity gains.

Incident Atrial Fibrillation and Survival Outcomes in Esophageal Cancer following Radiotherapy.

PURPOSE: Radiation therapy (RT) associates with long-term cardiotoxicity. In preclinical models, RT exposure induces early cardiotoxic arrhythmias including atrial fibrillation (AF). Yet, whether this occurs in patients is unknown. METHODS AND MATERIALS: Leveraging a large cohort of consecutive patients with esophageal cancer treated with thoracic RT from 2007 to 2019, we assessed incidence and outcomes of incident AF. Secondary outcomes included major adverse cardiovascular events (MACE), defined as AF, heart failure, ventricular arrhythmias, and sudden death, by cardiac RT dose. We also assessed the relationship between AF development and progression-free and overall survival. Observed incident AF rates were compared with Framingham predicted rates, and absolute excess risks were estimated. Multivariate regression was used to define the relationship between clinical and RT measures, and outcomes. Differences in outcomes, by AF status, were also evaluated via 30-day landmark analysis. Furthermore, we assessed the effect of cardiac substructure RT dose (eg, left atrium, LA) on the risk of post RT-related outcomes. RESULTS: Overall, from 238 RT treated patients with esophageal cancer, 21.4% developed incident AF, and 33% developed MACE with the majority (84%) of events occurring ≤2 years of RT initiation (median time to AF, 4.1 months). Cumulative incidence of AF and MACE at 1 year was 19.5%, and 25.7%, respectively; translating into an observed incident AF rate of 824 per 10,000 person-years, compared with the Framingham predicted rate of 92 (relative risk, 8.96; P < .001, absolute excess risk 732). Increasing LA dose strongly associated with incident AF (P = .001); and those with AF saw worse disease progression (hazard ratio, 1.54; P = .03). In multivariate models, outside of traditional cancer-related factors, increasing RT dose to the LA remained associated with worse overall survival. CONCLUSIONS: Among patients with esophageal cancer, radiation therapy increases AF risk, and associates with worse long-term outcomes.

A Video-Based Procedure-Specific Competency Assessment Tool for Minimally Invasive Esophagectomy.

Importance: Minimally invasive esophagectomy (MIE) is a complex procedure with substantial learning curves. In other complex minimally invasive procedures, suboptimal surgical performance has convincingly been associated with less favorable patient outcomes as assessed by peer review of the surgical procedure. Objective: To develop and validate a procedure-specific competency assessment tool (CAT) for MIE. Design, Setting, and Participants: In this international quality improvement study, a procedure-specific MIE-CAT was developed and validated. The MIE-CAT contains 8 procedural phases, and 4 quality components per phase are scored with a Likert scale ranging from 1 to 4. For evaluation of the MIE-CAT, intraoperative MIE videos performed by a single surgical team in the Esophageal Center East Netherlands were peer reviewed by 18 independent international MIE experts (with more than 120 MIEs performed). Each video was assessed by 2 or 3 blinded experts to evaluate feasibility, content validity, reliability, and construct validity. MIE-CAT version 2 was composed with refined content aimed at improving interrater reliability. A total of 32 full-length MIE videos from patients who underwent MIE between 2011 and 2020 were analyzed. Data were analyzed from January 2021 to January 2023. Exposure: Performance assessment of transthoracic MIE with an intrathoracic anastomosis. Main Outcomes and Measures: Feasibility, content validity, interrater and intrarater reliability, and construct validity, including correlations with both experience of the surgical team and clinical parameters, of the developed MIE-CAT. Results: Experts found the MIE-CAT easy to understand and easy to use to grade surgical performance. The MIE-CAT demonstrated good intrarater reliability (range of intraclass correlation coefficients [ICCs], 0.807 [95% CI, 0.656 to 0.892] for quality component score to 0.898 [95% CI, 0.846 to 0.932] for phase score). Interrater reliability was moderate (range of ICCs, 0.536 [95% CI, -0.220 to 0.994] for total MIE-CAT score to 0.705 [95% CI, 0.473 to 0.846] for quality component score), and most discrepancies originated in the lymphadenectomy phases. Hypothesis testing for construct validity showed more than 75% of hypotheses correct: MIE-CAT performance scores correlated with experience of the surgical team (r = 0.288 to 0.622), blood loss (r = -0.034 to -0.545), operative time (r = -0.309 to -0.611), intraoperative complications (r = -0.052 to -0.319), and severe postoperative complications (r = -0.207 to -0.395). MIE-CAT version 2 increased usability. Interrater reliability improved but remained moderate (range of ICCs, 0.666 to 0.743), and most discrepancies between raters remained in the lymphadenectomy phases. Conclusions and Relevance: The MIE-CAT was developed and its feasibility, content validity, reliability, and construct validity were demonstrated. By providing insight into surgical performance of MIE, the MIE-CAT might be used for clinical, training, and research purposes.

Bystander CPR and Long-Term Survival in Older Adults With Out-of-Hospital Cardiac Arrest.

BACKGROUND: Most studies on bystander cardiopulmonary resuscitation (CPR) for out-of-hospital cardiac arrest (OHCA) have focused on in-hospital or short-term survival. OBJECTIVES: The purpose of this study was to examine the association between bystander CPR and long-term survival outcomes for OHCA. METHODS: Within the Cardiac Arrest Registry to Enhance Survival, we identified 152,653 patients with OHCA ≥65 years of age or older. Using multivariable hierarchical logistic regression, we first examined the association between bystander CPR and in-hospital survival. Then, among those surviving to discharge and linked to Medicare files, we evaluated the association between bystander CPR and long-term mortality over 5 years using multivariable Cox regression. RESULTS: Overall, 58,464 (38.3%) received bystander CPR. Patients receiving bystander CPR were more likely to have an OHCA that was witnessed, in a public location, and with an initial shockable rhythm. Bystander CPR was associated with a 24% higher likelihood of surviving to hospital discharge (10.2% vs 5.5%; adjusted relative risk: 1.24 [95% CI: 1.19-1.29]; P < 0.001), and this survival benefit was similar (interaction P = 0.24) for those who were 65 to 74, 75 to 84, and ≥85 years of age. Among patients surviving to hospital discharge (median follow-up of 31 months), bystander CPR was additionally associated with lower long-term mortality vs those without bystander CPR (adjusted hazard ratio: 0.78 [95% CI: 0.73-0.84]; P < 0.001), and this benefit was also consistent across age groups (interaction P = 0.13). CONCLUSIONS: In older adults with OHCA, bystander CPR was associated with higher rates of in-hospital survival. This survival benefit was not attenuated by competing mortality risks but increased in magnitude after hospital discharge.

Depressive Symptoms and Mortality Among US Adults.

Importance: Depression is a common mental health disorder in the US. Depressive symptoms have been associated with increased cardiovascular disease incidence and mortality, but studies have largely focused on narrow population subgroups. Objective: To examine the association between depressive symptoms and mortality in a large, diverse, nationally representative sample of US adults, and to examine how lifestyle factors mediate this association. Design, Setting, and Participants: This was a prospective cohort study of a nationally representative sample of US adults using National Health and Nutrition Examination Survey 2005 to 2018 data linked with the National Death Index through 2019 for adults aged 20 years and older. Data were analyzed between March 1 and May 26, 2023. Main Outcomes and Measures: All-cause, cardiovascular disease, and ischemic heart disease mortality. Depressive symptoms were defined by Patient Health Questionnaire-9 scores and were categorized as none or minimal, mild, and moderate to severe. Secondarily, we assessed degree of mediation by lifestyle factors. Results: A total of 23 694 participants were included (unweighted n = 11 862 male [weighted 49.8%]; mean [SE] age, 44.7 [0.24] years). Prevalences of mild and moderate to severe depression were 14.9% and 7.2%, respectively. For all-cause mortality, hazard ratios were 1.35 (95% CI, 1.07-1.72) for mild depressive symptoms vs none and 1.62 (95% CI, 1.24-2.12) for moderate to severe depressive symptoms vs none. The corresponding hazard ratios were 1.49 (95% CI, 1.11-2.00) and 1.79 (95% CI, 1.22-2.62) for cardiovascular disease mortality and 0.96 (95% CI, 0.58-1.60) and 2.21 (95% CI, 1.24-3.91) for ischemic heart disease mortality. The associations were largely consistent across subgroups. Approximately 11.0% to 16.1% of the associations between depression and mortality could be explained by lifestyle factors. Feeling tired or having little energy, poor appetite or overeating, and having little interest in doing things were independently associated with all-cause and cardiovascular disease mortality but not with ischemic heart disease mortality. Conclusions and Relevance: In this prospective cohort study of a nationally representative sample of US adults, there was a graded positive association between depressive symptoms and mortality. Public health efforts to improve awareness and treatment of depression and associated risk factors could support a comprehensive, nationwide strategy to reduce the burden of depression.

Crowd-sourced and expert video assessment in minimally invasive esophagectomy.

BACKGROUND: Video-based assessment by experts may structurally measure surgical performance using procedure-specific competency assessment tools (CATs). A CAT for minimally invasive esophagectomy (MIE-CAT) was developed and validated previously. However, surgeon's time is scarce and video assessment is time-consuming and labor intensive. This study investigated non-procedure-specific assessment of MIE video clips by MIE experts and crowdsourcing, collective surgical performance evaluation by anonymous and untrained laypeople, to assist procedure-specific expert review. METHODS: Two surgical performance scoring frameworks were used to assess eight MIE videos. First, global performance was assessed with the non-procedure-specific Global Operative Assessment of Laparoscopic Skills (GOALS) of 64 procedural phase-based video clips < 10 min. Each clip was assessed by two MIE experts and > 30 crowd workers. Second, the same experts assessed procedure-specific performance with the MIE-CAT of the corresponding full-length video. Reliability and convergent validity of GOALS for MIE were investigated using hypothesis testing with correlations (experience, blood loss, operative time, and MIE-CAT). RESULTS: Less than 75% of hypothesized correlations between GOALS scores and experience of the surgical team (r < 0.3), blood loss (r = - 0.82 to 0.02), operative time (r = - 0.42 to 0.07), and the MIE-CAT scores (r = - 0.04 to 0.76) were met for both crowd workers and experts. Interestingly, experts' GOALS and MIE-CAT scores correlated strongly (r = 0.40 to 0.79), while crowd workers' GOALS and experts' MIE-CAT scores correlations were weak (r = - 0.04 to 0.49). Expert and crowd worker GOALS scores correlated poorly (ICC ≤ 0.42). CONCLUSION: GOALS assessments by crowd workers lacked convergent validity and showed poor reliability. It is likely that MIE is technically too difficult to assess for laypeople. Convergent validity of GOALS assessments by experts could also not be established. GOALS might not be comprehensive enough to assess detailed MIE performance. However, expert's GOALS and MIE-CAT scores strongly correlated indicating video clip (instead of full-length video) assessments could be useful to shorten assessment time.

MG53 Mitigates Nitrogen Mustard-Induced Skin Injury.

Sulfur mustard (SM) and nitrogen mustard (NM) are vesicant agents that cause skin injury and blistering through complicated cellular events, involving DNA damage, free radical formation, and lipid peroxidation. The development of therapeutic approaches targeting the multi-cellular process of tissue injury repair can potentially provide effective countermeasures to combat vesicant-induced dermal lesions. MG53 is a vital component of cell membrane repair. Previous studies have demonstrated that topical application of recombinant human MG53 (rhMG53) protein has the potential to promote wound healing. In this study, we further investigate the role of MG53 in NM-induced skin injury. Compared with wild-type mice, mg53-/- mice are more susceptible to NM-induced dermal injuries, whereas mice with sustained elevation of MG53 in circulation are resistant to dermal exposure of NM. Exposure of keratinocytes and human follicle stem cells to NM causes elevation of oxidative stress and intracellular aggregation of MG53, thus compromising MG53's intrinsic cell membrane repair function. Topical rhMG53 application mitigates NM-induced dermal injury in mice. Histologic examination reveals the therapeutic benefits of rhMG53 are associated with the preservation of epidermal integrity and hair follicle structure in mice with dermal NM exposure. Overall, these findings identify MG53 as a potential therapeutic agent to mitigate vesicant-induced skin injuries.

Stroke Mortality Among Black and White Adults Aged ≥35 Years Before and During the COVID-19 Pandemic - United States, 2015-2021.

Stroke is the fifth leading cause of death and a leading cause of long-term disability in the United States (1). Although stroke death rates have declined since the 1950s, age-adjusted rates remained higher among non-Hispanic Black or African American (Black) adults than among non-Hispanic White (White) adults (1,2). Despite intervention efforts to reduce racial disparities in stroke prevention and treatment through reducing stroke risk factors, increasing awareness of stroke symptoms, and improving access to treatment and care for stroke (1,3), Black adults were 45% more likely than were White adults to die from stroke in 2018.* In 2019, age-adjusted stroke death rates (AASDRs) (stroke deaths per 100,000 population) were 101.6 among Black adults and 69.1 among White adults aged ≥35 years. Stroke deaths increased during the early phase of the COVID-19 pandemic (March-August 2020), and minority populations experienced a disproportionate increase (4). The current study examined disparities in stroke mortality between Black and White adults before and during the COVID-19 pandemic. Analysts used National Vital Statistics System (NVSS) mortality data accessed via CDC WONDER† to calculate AASDRs among Black and White adults aged ≥35 years prepandemic (2015-2019) and during the pandemic (2020-2021). Compared with that during the prepandemic period, the absolute difference in AASDR between Black and White adults during the pandemic was 21.7% higher (31.3 per 100,000 versus 38.0). During the pandemic period, an estimated 3,835 excess stroke deaths occurred among Black adults (9.4% more than expected) and 15,125 among White adults (6.9% more than expected). These findings underscore the importance of identifying the major factors contributing to the widened disparities; implementing prevention efforts, including the management and control of hypertension, high blood cholesterol, and diabetes; and developing tailored interventions to reduce disparities and advance health equity in stroke mortality between Black and White adults. Stroke is a serious medical condition that requires emergency care. Warning signs of a stroke include sudden face drooping, arm weakness, and speech difficulty. Immediate notification of Emergency Medical Services by calling 9-1-1 is critical upon recognition of stroke signs and symptoms.

Prevalence and Predictability of Occult Satellite Nodules in Clinical Stage Ia Non-small Cell Lung Cancer following Lobectomy.

INTRODUCTION: We sought to assess the prevalence and clinical predictors of satellite nodules in patients undergoing lobectomy for clinical stage Ia disease. PATIENTS AND METHODS: The National Cancer Database was queried for patients who underwent lobectomy for clinical stage cT1N0 NSCLC. Collaborative staging information was used to identify patients who were pathologically upstaged based on having separate tumor nodules in the same lobe as the primary tumor. Multivariable logistic regression was used to assess the association of clinical factors with the detection of separate nodules. RESULTS: A separate tumor nodule was recorded in 2.8% (n = 1284) of 45,842 clinical stage Ia patients treated with lobectomy or bilobectomy. Female gender (3.1% vs. male 2.5%; P = .002) and non-squamous histology (adenocarcinoma 3.2% and large cell neuroendocrine 3.0% vs. squamous cell 1.9% tumors; P < .001) were associated with the presence of separate nodules. The frequency increased for tumors larger than 3 cm (≤ 3cm, 2.7% vs. > 3cm, 3.8%; P < .001). Other factors associated with separate nodules were upper lobe location, pleural and/or lymphovascular invasion and occult lymph node disease. The best predictive model for separate nodules based on the available clinical variables resulted in an area under the curve of 0.645 (95% CI 0.629-0.660). CONCLUSION: Separate tumor nodules may be detected with a low but relatively consistent frequency across the spectrum of patients with clinical stage Ia NSCLC. The predictive ability using basic clinical factors in the database is limited.

Analysis of trends in perioperative outcomes in over 1000 robotic-assisted anatomic lung resections.

Robotic-assisted surgery is gaining popularity as a minimally invasive approach for anatomic lung resection. We investigated the temporal changes in case volume, costs, and postoperative outcomes for robotic-assisted anatomic lung resection in over 1000 cases. We reviewed our institutional STS database for patients who had undergone robotic-assisted lobectomy, bi-lobectomy, or segmentectomy as the primary procedure between years 2009-2021. The patients were divided into two groups: first 500 cases (n = 501) and second 500 cases (n = 500). Temporal trends of case volume, surgical indications, hospital length of stay, costs, and perioperative outcomes were analyzed. A total of 1001 patients were analyzed, of which 968 (96.7%) patients underwent robotic-assisted lobectomy, 21 (2.1%) patients underwent bi-lobectomy, 10 (1.0%) patients underwent segmentectomy, and 3 (0.3%) patients underwent sleeve lobectomy. Primary lung cancer was the most common indication (87.7%), followed by metastatic lung tumors (7.1%), and benign diagnosis (5.2%). The overall postoperative complication rate decreased from 46.1% for the first 500 cases compared to 29.6% for the second 500 cases (p < 0.0001). The median hospital length of stay was down trending, which was 4 days [IQR: 3-7] for the first 500 cases and 3 days [IQR: 3-5] (p = 0.0001) for the second. The inflation-adjusted direct and indirect hospital costs were significantly lower in the second 500 cases (p < 0.0001). The complications rates, hospital costs, and hospital length of stay for robotic-assisted anatomic pulmonary resection decreased significantly over time at a single institution. Continuous improvement in perioperative outcomes may be observed with increasing institutional experience.

Lymph Node Upstaging for Robotic, Thoracoscopic, and Open Lobectomy for Stage T2-3N0 Lung Cancer.

BACKGROUND: There may be equivalent efficacy of the lymph node evaluation for minimally invasive lobectomy compared with open lobectomy for stage I non-small cell lung cancer. We sought to compare the lymph node evaluation for lobectomy by approach for patients with larger tumors who are clinically node negative. METHODS: This retrospective study analyzed 24 257 patients with clinical stage T2-3N0M0 non-small cell lung cancer from the National Cancer Database. Inverse probability of treatment weighting (IPTW) was applied to balance baseline characteristics. The rates of pathologic lymph node upstaging were compared. A Cox multivariable regression model was performed to test the association with overall survival. RESULTS: After IPTW adjustment 20 834 patients were included in the analysis. Of these, 1996 patients underwent robotic lobectomy, 5122 patients underwent thoracoscopic lobectomy, and 13 725 patients underwent open lobectomy from 2010 to 2017. The IPTW-adjusted N1 upstaging rate was similar for robotic (11.79%), thoracoscopic (11.49%), and open (11.85%) lobectomy (P = .274). The adjusted N2 upstaging rates were 5.03%, 5.66%, and 6.15% for robotic, thoracoscopic, and open lobectomy, respectively (P = .274). On IPTW-adjusted multivariable analysis, robotic and thoracoscopic lobectomy were associated with improved survival compared with open lobectomy (P < .001). CONCLUSIONS: There was no significant difference in N1 and N2 lymph node upstaging rates between surgical approaches for patients with clinical stage T2-3N0 non-small cell lung cancer, indicating similarly effective lymph node evaluation. Overall survival after robotic and thoracoscopic lobectomy was significantly better compared with open lobectomy in this patient population with a high propensity for occult nodal disease.

Analysis of Outcomes for Robotic-assisted Lobectomy With an Enhanced Recovery After Surgery Protocol.

BACKGROUND: The impact on cost relative to clinical efficacy of enhanced recovery after surgery (ERAS) protocols for patients who undergo robotic-assisted lobectomy is currently unknown. The objective of this study was to compare cost and perioperative outcomes of robotic-assisted lobectomy before and after implementation of an ERAS protocol. METHODS: This was a retrospective analysis of 574 patients who underwent robotic-assisted lobectomy for primary lung carcinoma from May 1, 2017 to June 1, 2021. The ERAS protocol was implemented on October 17, 2019. Inverse probability of treatment weighting of propensity scores was used to balance baseline characteristics. The primary outcomes of the study were mean direct and indirect hospital costs, complication rates, and hospital length of stay. RESULTS: Three hundred fifteen patients underwent robotic-assisted lobectomy before implementation of the ERAS protocol, and 259 patients were enrolled on the protocol. A significantly higher percentage of patients were discharged home in less than 3 days after the ERAS protocol implementation (24.5% vs 9.8%, P = .001). There were significant decreases in the inverse probability of treatment weighting-adjusted mean direct hospital costs (P < .001) and mean indirect costs (P = .018) for the total hospital stay after ERAS protocol implementation. The mean initial discharge opioid medication dose (morphine equivalent dose) was significantly lower (P < .001) after the ERAS protocol. CONCLUSIONS: Increased early discharge and decreased hospital costs were observed for robotic-assisted lobectomy after implementation of an ERAS protocol. There was also an observed significant decrease in the discharge opioid medication doses prescribed.