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1.
Ann Surg ; 277(3): 528-533, 2023 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-34534988

RESUMO

OBJECTIVE: The aim of this study was to analyze outcomes of open lobectomy (OL), VATS, and robotic-assisted lobectomy (RL). SUMMARY BACKGROUND DATA: Robotic-assisted lobectomy has seen increasing adoption for treatment of early-stage lung cancer. Comparative data regarding these approaches is largely from single-institution case series or administrative datasets. METHODS: Retrospective data was collected from 21 institutions from 2013 to 2019. All consecutive cases performed for clinical stage IA-IIIA lung cancer were included. Neoadjuvant cases were excluded. Propensity-score matching (1:1) was based on age, sex, race, smoking-status, FEV1%, Zubrod score, American Society of Anesthesiologists score, tumor size, and clinical T and N stage. RESULTS: A total of 2391 RL, 2174 VATS, and 1156 OL cases were included. After propensity-score matching there were 885 pairs of RL vs OL, 1,711 pairs of RL vs VATS, and 952 pairs of VATS vs OL. Operative time for RL was shorter than VATS ( P < 0.0001) and OL ( P = 0.0004). Compared to OL, RL and VATS had less overall postoperative complications, shorter hospital stay (LOS), and lower transfusion rates (all P <0.02). Compared to VATS, RL had lower conversion rate ( P <0.0001), shorter hospital stay ( P <0.0001) and a lower postoperative transfusion rate ( P =0.01). RL and VATS cohorts had comparable postoperative complication rates. In-hospital mortality was comparable between all groups. CONCLUSIONS: RL and VATS approaches were associated with favorable perioperative outcomes compared to OL. Robotic-assisted lobectomy was also associated with a reduced length of stay and decreased conversion rate when compared to VATS.


Assuntos
Neoplasias Pulmonares , Procedimentos Cirúrgicos Robóticos , Humanos , Estudos Retrospectivos , Pneumonectomia , Cirurgia Torácica Vídeoassistida , Complicações Pós-Operatórias , Tempo de Internação
2.
Ann Surg ; 277(6): 1002-1009, 2023 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-36762564

RESUMO

OBJECTIVE: The aim of this study was to analyze overall survival (OS) of robotic-assisted lobectomy (RL), video-assisted thoracoscopic lobectomy (VATS), and open lobectomy (OL) performed by experienced thoracic surgeons across multiple institutions. SUMMARY BACKGROUND DATA: Surgeons have increasingly adopted RL for resection of early-stage lung cancer. Comparative survival data following these approaches is largely from single-institution case series or administrative data sets. METHODS: Retrospective data was collected from 21 institutions from 2013 to 2019. Consecutive cases performed for clinical stage IA-IIIA lung cancer were included. Induction therapy patients were excluded. The propensity-score method of inverse-probability of treatment weighting was used to balance baseline characteristics. OS was estimated using the Kaplan-Meier method. Multivariable Cox proportional hazard models were used to evaluate association among OS and relevant risk factors. RESULTS: A total of 2789 RL, 2661 VATS, and 1196 OL cases were included. The unadjusted 5-year OS rate was highest for OL (84%) followed by RL (81%) and VATS (74%); P =0.008. Similar trends were also observed after inverse-probability of treatment weighting adjustment (RL 81%; VATS 73%, OL 85%, P =0.001). Multivariable Cox regression analyses revealed that OL and RL were associated with significantly higher OS compared with VATS (OL vs. VATS: hazard ratio=0.64, P <0.001 and RL vs. VATS: hazard ratio=0.79; P =0.007). CONCLUSIONS: Our finding from this large multicenter study suggests that patients undergoing RL and OL have statistically similar OS, while the VATS group was associated with shorter OS. Further studies with longer follow-up are necessary to help evaluate these observations.


Assuntos
Carcinoma Pulmonar de Células não Pequenas , Neoplasias Pulmonares , Procedimentos Cirúrgicos Robóticos , Humanos , Carcinoma Pulmonar de Células não Pequenas/cirurgia , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/métodos , Pneumonectomia/métodos , Cirurgia Torácica Vídeoassistida/métodos , Neoplasias Pulmonares/cirurgia , Análise de Sobrevida
3.
Surg Endosc ; 36(12): 9113-9122, 2022 12.
Artigo em Inglês | MEDLINE | ID: mdl-35773604

RESUMO

BACKGROUND: The purpose of this randomized controlled trial was to determine if enhanced recovery after surgery (ERAS) would improve outcomes for three-stage minimally invasive esophagectomy (MIE). METHODS: Patients with esophageal cancer undergoing MIE between March 2016 and August 2018 were consecutively enrolled, and were randomly divided into 2 groups: ERAS+group that received a guideline-based ERAS protocol, and ERAS- group that received standard care. The primary endpoint was morbidity after MIE. The secondary endpoints were the length of stay (LOS) and time to ambulation after the surgery. The perioperative results including the Surgical Apgar Score (SAS) and Visualized Analgesia Score (VAS) were also collected and compared. RESULTS: A total of 60 patients in the ERAS+ group and 58 patients in the ERAS- group were included. Postoperatively, lower morbidity and pulmonary complication rate were recorded in the ERAS+ group (33.3% vs. 51.7%; p = 0.04, 16.7% vs. 32.8%; p = 0.04), while the incidence of anastomotic leakage remained comparable (11.7% vs. 15.5%; p = 0.54). There was an earlier ambulation (3 [2-3] days vs. 3 [3-4] days, p = 0.001), but comparable LOS (10 [9-11.25] days vs. 10 [9-13] days; p = 0.165) recorded in ERAS+ group. The ERAS protocol led to close scores in both SAS (7.80 ± 1.03 vs. 8.07 ± 0.89, p = 0.21) and VAS (1.74 ± 0.85 vs. 1.78 ± 1.06, p = 0.84). CONCLUSIONS: Implementation of an ERAS protocol for patients undergoing MIE resulted in earlier ambulation and lower pulmonary complications, without a change in anastomotic leakage or length of hospital stay. Further studies on minimizing leakage should be addressed in ERAS for MIE.


Assuntos
Neoplasias Esofágicas , Esofagectomia , Humanos , Esofagectomia/métodos , Fístula Anastomótica/cirurgia , Resultado do Tratamento , Neoplasias Esofágicas/cirurgia , Neoplasias Esofágicas/complicações , Tempo de Internação , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos/métodos
4.
Clin Infect Dis ; 72(7): 1241-1243, 2021 04 08.
Artigo em Inglês | MEDLINE | ID: mdl-32594114

RESUMO

Coronavirus disease 2019 (COVID-19) reverse-transcription polymerase chain reaction employee testing was implemented across New York University Langone Health. Over 8 weeks, 14 764 employees were tested; 33% of symptomatic employees, 8% of asymptomatic employees reporting COVID-19 exposure, and 3% of employees returning to work were positive. Positivity rates declined over time, possibly reflecting the importance of community transmission and efficacy of personal protective equipment.


Assuntos
COVID-19 , SARS-CoV-2 , Centros Médicos Acadêmicos , Pessoal de Saúde , Humanos , Cidade de Nova Iorque/epidemiologia , Reação em Cadeia da Polimerase
5.
Dis Esophagus ; 33(2)2020 Mar 05.
Artigo em Inglês | MEDLINE | ID: mdl-31022725

RESUMO

Lymph node dissection (LND) along the left recurrent laryngeal nerve (RLN) is a technically challenging part of esophageal cancer surgery, especially after chemoradiotherapy (CRT). Robotic surgery holds promise to increase its safety and feasibility. The aim of this study was to describe a single thoracoscopic surgeon's experience related to the transition from video-assisted esophagectomy (VATE) to robotic esophagectomy (RE)-with a special focus on the safety of left RLN LND. Patients who underwent minimally invasive esophagectomy and RLN dissection following CRT were dichotomized according to the use of robotic surgery (robotic esophagectomy [RE] versus video-assisted thoracoscopic esophagectomy [VATE]). The following parameters were determined: (1) number of dissected nodes, (2) rates of RLN palsy, (3) rates of perioperative complications, and (4) learning curve. Learning curve analysis was performed using the 10-patient moving average (MA) for operation times and with the cumulative sum (CUSUM) method for left RLN LND (target failure rate: 15%). The RE and VATE groups consisted of 39 and 67 patients, respectively. The intraoperative identification of the left RLN was more common in the RE group (97.4%) than in the VATE group (68.7%; P < 0.001). Postoperative left RLN palsy was significantly more frequent in the VATE group (26.9%) than in the RE group (10.3%; P = 0.042), with a higher rate of pneumonia in the former (16.4% versus 2.6%; P = 0.03). The MA chart revealed a downward trend followed by a flattening of the RE operation time at operation number 17 and 29, respectively. CUSUM analysis showed that the left RLN palsy rate decreased to the target rate after 12 operations. We conclude that at least 12 cases are required for a surgeon with prior experience in VATE to safely accomplish left RLN LND through a robotic approach.


Assuntos
Esofagectomia/métodos , Complicações Intraoperatórias/prevenção & controle , Excisão de Linfonodo/métodos , Complicações Pós-Operatórias/prevenção & controle , Traumatismos do Nervo Laríngeo Recorrente/prevenção & controle , Procedimentos Cirúrgicos Robóticos/métodos , Cirurgia Torácica Vídeoassistida/métodos , Adulto , Idoso , Feminino , Humanos , Complicações Intraoperatórias/epidemiologia , Curva de Aprendizado , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Projetos Piloto , Complicações Pós-Operatórias/epidemiologia , Traumatismos do Nervo Laríngeo Recorrente/complicações , Traumatismos do Nervo Laríngeo Recorrente/epidemiologia , Estudos Retrospectivos , Resultado do Tratamento , Paralisia das Pregas Vocais/epidemiologia , Paralisia das Pregas Vocais/etiologia , Paralisia das Pregas Vocais/prevenção & controle
6.
Ann Surg ; 267(3): 435-442, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-28549015

RESUMO

OBJECTIVE: Our objective was to evaluate the impact of early oral feeding (EOF) on postoperative cardiac, respiratory, and gastrointestinal (CRG) complications after McKeown minimally invasive esophagectomy for esophageal cancer. SUMMARY BACKGROUND DATA: Nil-by-mouth with enteral tube feeding is routinely practiced after esophagectomy. METHODS: Patients were randomly allocated to receive oral feeding on the first postoperative day (EOF group) or late oral feeding (LOF group) 7 days after surgery. The primary endpoint was the occurrence of postoperative CRG complications, and the secondary outcomes included bowel function recovery and short-term quality of life (QOL). RESULTS: Between February 2014 and October 2015, 280 patients were enrolled in this study. There were 140 patients in the EOF group and 140 patients in the LOF group. EOF was noninferior to LOF for CRG complications (30.0% in the EOF group vs. 32.9% in the LOF group; 95% confidence interval of the difference: -13.8% to 8.0%). Compared with the LOF group, the EOF group showed significantly shorter time to first flatus (median of 2 days vs. 3 days, P = 0.001) and bowel movement (median of 3 vs. 4 days, P < 0.001). Two weeks after the operation, patients in the EOF group reported higher global QOL and function scores and lower symptom scores than patients in the LOF group. CONCLUSIONS: In patients after McKeown minimally invasive esophagectomy is noninferior to the standard of care with regard to postoperative CRG complications. In addition, patients in the EOF group had a quicker recovery of bowel function and improved short-term QOL.


Assuntos
Nutrição Enteral/métodos , Neoplasias Esofágicas/cirurgia , Esofagectomia , Idoso , Feminino , Humanos , Excisão de Linfonodo , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Estudos Prospectivos , Qualidade de Vida , Recuperação de Função Fisiológica , Resultado do Tratamento
7.
Ann Surg ; 265(1): 122-129, 2017 01.
Artigo em Inglês | MEDLINE | ID: mdl-28009736

RESUMO

OBJECTIVES: To identify the associations of lymph node metastases (pN+), number of positive nodes, and pN subclassification with cancer, treatment, patient, geographic, and institutional variables, and to recommend extent of lymphadenectomy needed to accurately detect pN+ for esophageal cancer. SUMMARY BACKGROUND DATA: Limited data and traditional analytic techniques have precluded identifying intricate associations of pN+ with other cancer, treatment, and patient characteristics. METHODS: Data on 5806 esophagectomy patients from the Worldwide Esophageal Cancer Collaboration were analyzed by Random Forest machine learning techniques. RESULTS: pN+, number of positive nodes, and pN subclassification were associated with increasing depth of cancer invasion (pT), increasing cancer length, decreasing cancer differentiation (G), and more regional lymph nodes resected. Lymphadenectomy necessary to accurately detect pN+ is 60 for shorter, well-differentiated cancers (<2.5 cm) and 20 for longer, poorly differentiated ones. CONCLUSIONS: In esophageal cancer, pN+, increasing number of positive nodes, and increasing pN classification are associated with deeper invading, longer, and poorly differentiated cancers. Consequently, if the goal of lymphadenectomy is to accurately define pN+ status of such cancers, few nodes need to be removed. Conversely, superficial, shorter, and well-differentiated cancers require a more extensive lymphadenectomy to accurately define pN+ status.


Assuntos
Adenocarcinoma/patologia , Carcinoma de Células Escamosas/patologia , Neoplasias Esofágicas/patologia , Excisão de Linfonodo/métodos , Linfonodos/patologia , Adenocarcinoma/cirurgia , Adulto , Idoso , Carcinoma de Células Escamosas/cirurgia , Conjuntos de Dados como Assunto , Neoplasias Esofágicas/cirurgia , Esofagectomia , Feminino , Humanos , Metástase Linfática , Aprendizado de Máquina , Masculino , Pessoa de Meia-Idade , Invasividade Neoplásica , Estadiamento de Neoplasias
8.
J Card Surg ; 30(2): 135-9, 2015 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-25533017

RESUMO

Cardiac paragangliomas are rare tumors arising from chromaffin cells. Two patients with cardiac paragangliomas underwent surgical resection with no evidence of recurrence three and 13 years following surgery. This report describes these two patients with cardiac paragangliomas and discusses their management.


Assuntos
Células Cromafins , Neoplasias Cardíacas/cirurgia , Paraganglioma/cirurgia , Adulto , Biomarcadores Tumorais/análise , Procedimentos Cirúrgicos Cardíacos , Seguimentos , Neoplasias Cardíacas/diagnóstico , Neoplasias Cardíacas/patologia , Humanos , Imageamento por Ressonância Magnética , Masculino , Paraganglioma/diagnóstico , Paraganglioma/patologia , Esternotomia , Toracotomia , Tomografia Computadorizada por Raios X
9.
Ann Thorac Surg ; 2024 May 23.
Artigo em Inglês | MEDLINE | ID: mdl-38789008

RESUMO

BACKGROUND: Our objective is to assess the feasibility, safety, and outcomes for patients discharged home with a chest tube connected to a digital drainage system after robotic pulmonary resection. METHODS: This was a retrospective analysis of a prospectively collected database as a quality improvement initiative. All patients had planned discharge on postoperative day one (POD1) after robotic pulmonary resection. Those with an air leak were discharge home with a chest tube connected to a digital drainage system with daily communication with the surgeon. RESULTS: From January 2019 to February 2023 there were 580 consecutive robotic resections, of which 69 (12%) patients had an air leak on POD1; 38 of 276 (14%) after lobectomy, 24 of 226 (11%) after segmentectomy, and 7 of 78 (9%) after wedge resection. Of these 69 patients, 52 patients (75%) were discharged on POD1, 15 patients (22%) on POD2, and 2 patients (3%) on POD3. Chest tubes were removed a median outpatient chest tube duration was 4 days (interquartile range, 3-5 days). Of the 69 patients sent home with a digital drainage system, there was 1 complication requiring readmission for increasing subcutaneous emphysema. Five patients (7%) had system malfunctions that required return to our clinic for problem-solving. There were no 30- or 90-day mortalities. CONCLUSIONS: Patients who undergo robotic pulmonary resection and have an air leak can be safely and effectively discharged on the first postoperative day and managed as an outpatient by using daily texts and or videos with pulse oximetry data on a digital drainage system with limited morbidity.

10.
Ann Thorac Surg ; 2024 May 07.
Artigo em Inglês | MEDLINE | ID: mdl-38723882

RESUMO

The Society of Thoracic Surgeons Workforce on Evidence Based Surgery provides this document on management of pleural drains following pulmonary lobectomy. The goal of this consensus document is to provide guidance regarding pleural drains in five specific areas: 1) choice of drain including size, type, and number, 2) management including use of suction versus water seal and criteria for removal, 3) imaging recommendations including the use of daily and post-pull chest x-rays, 4) use of digital drainage systems and 5) management of prolonged air leak. To formulate the consensus statements a task force of 15 general thoracic surgeons were invited to review the existing literature on this topic. Consensus was obtained using a modified Delphi method consisting of two rounds of voting until 75% agreement on the statements was reached. A total of thirteen consensus statements are provided to encourage standardization and stimulate additional research in this important area.

11.
JTCVS Open ; 16: 909-915, 2023 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-38204643

RESUMO

Objective: Chest tubes cause pain and morbidity. Methods: This is a quality initiative study and review of patients who underwent robotic pulmonary resection by 1 surgeon (R.J.C.). The goal was to remove chest tubes within 4 to 12 hours after robotic segmentectomy and lobectomy. Primary outcome was removal without the need for reinsertion, thoracentesis, or any morbidity due to early removal of the chest tube. Secondary outcomes were symptomatic pneumothorax, pleural effusion, chylothorax, subcutaneous emphysema, and chest tube reinsertion or thoracentesis within 60 days of surgery. Results: Between January 2018 and December 2022, 590 patients underwent robotic lobectomy or segmentectomy. Chest tubes were removed within 4 to 12 hours postoperatively in 63.5% of patients (375/590). In 2022, this was achieved in 91% after lobectomy (119/128) and 94% after segmentectomy (75/80). There were significantly more chest tubes removed within 4 to 12 hours postoperatively from 2020 to 2022 than pre-2020 (P < .001). Forty patients (6.8%) were discharged home on postoperative day 1 with a chest tube. Sixteen patients (2.7%) had post-chest tube removal increasing pneumothorax and subcutaneous emphysema; none required tube reinsertion. There was no 30-day or 90-day mortality. Twelve patients (2%) had an outpatient thoracentesis for effusion within 60 days. Twenty patients (3.3%) were readmitted, none seemingly related to effusions. Nonsmokers (P = .04) and segmentectomy (P = .001) were associated with chest tube removal within 4 to 12 hours of surgery. Conclusions: Chest tubes can be safely removed within 4 to 12 hours after robotic segmentectomy and lobectomy. Factors associated with successful early chest tube removal are nonsmoking, segmentectomy, and team members becoming comfortable with the process.

12.
JTCVS Open ; 16: 1004-1007, 2023 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-38204665

RESUMO

Objective: Chest tubes are frequently placed after thymectomy, without data to support this common practice. We report our experience in eliminating them after robotic thymectomy. Methods: This is a retrospective database review of patients who underwent robotic thymectomy performed by a single surgeon in which intraoperative chest tube insertion was not planned. Patient characteristics and postoperative outcomes are presented. Results: Between January 2018 and October 2022, 75 patients underwent robotic thymectomy performed by a single surgeon. Of those, 64 (85.3%) underwent a left-sided thoracic approach. The most common indication for resection was a suspicious anterior mediastinal mass. There were no conversions to an open operation. The median operative time was 72 minutes (range, 38-164 minutes), and the median estimated blood loss was 20 cc (range, 10-60 cc). Ten patients (13.3%) went home on the day of surgery, and all others (86.7%) were discharged on postoperative day 1. A chest tube was placed in 1 patient at time of closure because of a persistent air leak after extensive adhesiolysis from a prior thoracotomy; the tube was removed on the day of surgery after resolution of the air leak. No other patient required chest tube placement intraoperatively, immediately postoperatively, or within 60 days postoperation. Two patients underwent outpatient thoracentesis within 1 month postoperation for effusions. There were no 30- or 90-day mortality and no major morbidities. Conclusions: A chest tube after robotic thymectomy is not necessary in almost all patients and can be safely omitted. The dogmatic routine practice of chest tube placement should be questioned.

13.
J Cardiothorac Surg ; 18(1): 79, 2023 Feb 24.
Artigo em Inglês | MEDLINE | ID: mdl-36823638

RESUMO

Solitary fibrous tumors (SFTs) are rare mesenchymal pleural neoplasms with an overall good prognosis and low recurrence rate if completely resected and if degree of differentiation is favorable. Within the last decade, advances in research have led to more reliable methods of differentiating SFTs from other soft tissue tumors. Historically, several markers were used to distinguish SFTs from similar tumors, but these markers had poor specificity. Recent evidence showed NAB2-STAT6 fusion gene to be a distinct feature of SFTs with 100% specificity and sensitivity. Surgical resection, with an emphasis on obtaining negative margins, is the mainstay of treatment for SFTs. Preoperative planning with detailed imaging is imperative to delineate the extent of disease and vascular supply. One important radiologic distinction to aid delineation of a pleural-based tumor compared to a pulmonary parenchymal-based tumor is the angle that the tumor forms with the chest wall, which is obtuse for a pleural-based tumor, and acute for tumors of the lung parenchyma. Often, preoperative tissue diagnosis is not available, and surgery is both diagnostic and curative. Intraoperatively, emphasis should be on complete resection with negative margins. SFTs are resected via several approaches: thoracotomy, sternotomy with the option of hemi-clamshell extension, video-assisted thoracoscopic surgery, and robotic approach, which is increasingly being used and is our preference. We recommend a minimally invasive approach for most lesions, and have resected SFTs of the pleura that are up to 12 cm with the robotic approach. However, the current literature often cites 5 cm as the cut off for an open thoracotomy. Nevertheless, even with larger tumors, a minimally invasive robotic approach is our preference and practice. For giant SFTs (> 20 cm), an open approach may be preferable. Multiple thoracotomies and rib resection may be required to gain adequate exposure and ensure complete resection in these tumors. However, it is noteworthy that most of these tumors have a soft consistency and thus, once bagged, can easily be removed minimally invasively, and thus minimally invasive approach should not be completely ruled out. Recurrence in SFTs usually results from incomplete resection and redo surgery may portend a favorable prognosis.


Assuntos
Neoplasias Pleurais , Febre Grave com Síndrome de Trombocitopenia , Tumores Fibrosos Solitários , Humanos , Pleura/patologia , Tumores Fibrosos Solitários/diagnóstico por imagem , Tumores Fibrosos Solitários/cirurgia , Neoplasias Pleurais/diagnóstico , Neoplasias Pleurais/cirurgia , Neoplasias Pleurais/patologia , Prognóstico
14.
Gynecol Oncol ; 125(3): 646-8, 2012 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-22370597

RESUMO

OBJECTIVES: We evaluated the indications and outcomes of patients with known gynecologic malignancies that underwent video-assisted thoracoscopic surgery (VATS) and pleurodesis for malignant pleural effusion. METHODS: After IRB approval was obtained, a retrospective study of patients with gynecologic malignancies who underwent planned VATS/pleurodesis between 1/2000 and 7/2010 was performed. Abstracted data included demographics, diagnosis, disease status, treatment history, indication for VATS, complications, and outcomes. RESULTS: Forty-two patients with a gynecologic malignancy underwent VATS/pleurodesis. Median age was 63 years. Twenty-nine patients (69%) had ovarian cancer. Fifty-seven percent had recurrent disease at the time of VATS and 57% were undergoing chemotherapy at the time of VATS. Eight patients (19%) underwent perioperative VATS to improve pulmonary status. Seven patients (17%) underwent a palliative VATS. The median length of stay was 7 days (range 1-53). Sixty-two percent had gross disease noted at the time of VATS. A mean of 1650 cc of fluid was drained at time of surgery (range 300-4500), and the majority (88%) of patients had a talc pleurodesis performed. Seven patients (17%) were readmitted within 30 days; 6 were for complications unrelated to their VATS. One patient was readmitted with hospital-acquired pneumonia and died during readmission. Median time to death after VATS was 104 days (range 4-1062). Patients who underwent a perioperative VATS had the longest survival (845 days). CONCLUSION: Patients with gynecologic malignancies may require a VATS/pleurodesis for symptomatic pleural effusions. This procedure appears to be safe and effective in this patient population.


Assuntos
Neoplasias dos Genitais Femininos/terapia , Derrame Pleural Maligno/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Terapia Combinada , Feminino , Neoplasias dos Genitais Femininos/patologia , Neoplasias dos Genitais Femininos/cirurgia , Humanos , Pessoa de Meia-Idade , Derrame Pleural Maligno/patologia , Derrame Pleural Maligno/cirurgia , Pleurodese/métodos , Estudos Retrospectivos , Cirurgia Torácica Vídeoassistida/métodos , Resultado do Tratamento , Adulto Jovem
15.
Ann Thorac Surg ; 114(1): 234-240, 2022 07.
Artigo em Inglês | MEDLINE | ID: mdl-34389302

RESUMO

BACKGROUND: Our objective is to assess the feasibility and safety of discharging patients by postoperative day one (POD1) after robotic segmentectomy and lobectomy, and to describe outcomes for patients. METHODS: A retrospective analysis was made of a prospectively collected database of a quality improvement initiative by a single surgeon. Factors associated with discharge by POD1 were evaluated using a multivariate logistic regression model. RESULTS: From January 2018 to July 2020, of 253 patients who underwent robotic anatomic pulmonary resection, 134 (53%) were discharged by POD1, 67% after segmentectomy and 41% after lobectomy. Discharge by POD1 improved with experience and was achieved in 97% of patients after segmentectomy and 68% after lobectomy in the final quartile. Thirty-one patients (12%) were discharged home with a chest tube, including 7 (2.8%) on POD1. On multivariate analysis, never smokers and segmentectomy were associated with discharge by POD1. Conversely, decreased baseline performance status and perioperative complications were associated with discharge after POD1. There were 10 minor morbidities (4%), 6 major morbidities (2.4%), and no 30- or 90-day mortality. There were 4 readmissions (1.6%), of which 1 (0.4%) was after POD1 discharge. Patient satisfaction remained high throughout the study period. CONCLUSIONS: With experience and communication, select patients can be discharged home on POD1 after robotic segmentectomy and lobectomy with excellent outcomes and high satisfaction. Discharge by POD1 was associated with never smokers and segmentectomy, and inversely associated with decreased baseline performance status and perioperative complications.


Assuntos
Neoplasias Pulmonares , Procedimentos Cirúrgicos Robóticos , Humanos , Tempo de Internação , Neoplasias Pulmonares/complicações , Alta do Paciente , Pneumonectomia/efeitos adversos , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/efeitos adversos
16.
J Thorac Dis ; 14(9): 3145-3153, 2022 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-36245636

RESUMO

Background: The Thoraguard Surgical Drainage System is a novel device for drainage of air and fluid after cardiothoracic surgery. Methods: A three-part study was conducted: a prospective observational safety and feasibility study, a retrospective comparison of patients managed with an analogue drainage system, and a clinician user-feedback survey. Results: Fifty patients underwent robotic pulmonary resection utilizing the Thoraguard system for postoperative drainage. The Thoraguard system detected a higher number of air leaks than an analogue system (36/50, 72% vs. 45/200, 23%; P<0.001) and was associated with decreased chest tube duration of 1 day [interquartile range (IQR) 0-2] vs. 2 days (IQR 2-3) (P=0.042) and hospital length of stay of 2 days (IQR 2-3) vs. 3 days (IQR 2-4) (P=0.027). Patients with a peak air leak less than 100 mL/min (32 patients, 64%), had a decreased median chest tube duration of 1 day (IQR 0-1) vs. 2.8 days (IQR 1-3) (P=0.004). Compared to an analogue system, the Thoraguard system had superior user-reported ability to detect air-leaks (17/23, 74%), better ease of patient ambulation (14/23, 61%), and better display of clinically relevant information (22/23, 96%). Conclusions: The Thoraguard Surgical Drainage System provides safe and effective drainage post pulmonary resection. Compared to an analogue system, the Thoraguard system detected a higher number of air leaks and was associated with decreased chest tube duration and hospital length of stay. User survey data reported superior air leak detection, display of clinical data, and ease of use of the Thoraguard system.

17.
Ann Thorac Surg ; 114(2): 401-407, 2022 08.
Artigo em Inglês | MEDLINE | ID: mdl-34481799

RESUMO

BACKGROUND: Our objective was to report the incidence, management, and outcomes of patients who developed a secondary pneumothorax while admitted for coronavirus disease 2019 (COVID-19). METHODS: A single-institution, retrospective review of patients admitted for COVID-19 with a diagnosis of pneumothorax between March 1, 2020, and April 30, 2020, was performed. The primary assessment was the incidence of pneumothorax. Secondarily, we analyzed clinical outcomes of patients requiring tube thoracostomy, including those requiring operative intervention. RESULTS: From March 1, 2020, to April 30, 2020, 118 of 1595 patients (7.4%) admitted for COVID-19 developed a pneumothorax. Of these, 92 (5.8%) required tube thoracostomy drainage for a median of 12 days (interquartile range 5-25 days). The majority of patients (95 of 118, 80.5%) were on mechanical ventilation at the time of pneumothorax, 17 (14.4%) were iatrogenic, and 25 patients (21.2%) demonstrated tension physiology. Placement of a large-bore chest tube (20 F or greater) was associated with fewer tube-related complications than a small-bore tube (14 F or less) (14 vs 26 events, P = .011). Six patients with pneumothorax (5.1%) required operative management for a persistent alveolar-pleural fistula. In patients with pneumothorax, median hospital stay was 36 days (interquartile range 20-63 days) and in-hospital mortality was significantly higher than for those without pneumothorax (58% vs 13%, P < .001). CONCLUSIONS: The incidence of secondary pneumothorax in patients admitted for COVID-19 is 7.4%, most commonly occurring in patients requiring mechanical ventilation, and is associated with an in-hospital mortality rate of 58%. Placement of large-bore chest tubes is associated with fewer complications than small-bore tubes.


Assuntos
COVID-19 , Pneumotórax , COVID-19/epidemiologia , Tubos Torácicos/efeitos adversos , Drenagem , Humanos , Incidência , Pneumotórax/epidemiologia , Pneumotórax/etiologia , Pneumotórax/cirurgia , Estudos Retrospectivos , Toracostomia/efeitos adversos
18.
Ann Thorac Surg ; 114(1): 70-75, 2022 07.
Artigo em Inglês | MEDLINE | ID: mdl-35282865

RESUMO

BACKGROUND: Severe coronavirus disease 2019 (COVID-19) can cause acute respiratory failure requiring mechanical ventilation. Venovenous (VV) extracorporeal membrane oxygenation (ECMO) has been used in patients in whom conventional mechanical ventilatory support has failed. To date, published data have focused on survival from ECMO and survival to discharge. In addition to survival to discharge, this study reports 1-year follow-up data for patients who were successfully discharged from the hospital. METHODS: A single-institution, retrospective review of all patients with severe COVID-19 who were cannulated for VV-ECMO between March 10, 2020 and May 1, 2020 was performed. A multidisciplinary ECMO team evaluated, selected, and managed patients with ECMO support. The primary outcome of this study was survival to discharge. Available 1-year follow-up data are also reported. RESULTS: A total of 30 patients were supported with VV-ECMO, and 27 patients (90%) survived to discharge. All patients were discharged home or to acute rehabilitation on room air, except for 1 patient (3.7%), who required supplemental oxygen therapy. At a median follow-up of 10.8 months (interquartile range [IQR], 8.9-14.4 months) since ECMO cannulation, survival was 86.7%, including 1 patient who underwent lung transplantation. Of the patients discharged from the hospital, 44.4% (12/27) had pulmonary function testing, with a median percent predicted forced expiratory volume of 100% (IQR, 91%-110%). For survivors, a 6-minute walk test was performed in 59.3% (16/27), with a median value of 350 m (IQR, 286-379 m). CONCLUSIONS: A well-defined patient selection and management strategy of VV-ECMO support in patients with severe COVID-19 resulted in exceptional survival to discharge that was sustained at 1-year after ECMO cannulation.


Assuntos
COVID-19 , Oxigenação por Membrana Extracorpórea , Síndrome do Desconforto Respiratório , COVID-19/terapia , Oxigenação por Membrana Extracorpórea/métodos , Humanos , Respiração Artificial , Estudos Retrospectivos
19.
Artigo em Inglês | MEDLINE | ID: mdl-36244627

RESUMO

The prevalence of burnout among physicians has been increasing over the last decade, but data on burnout in the specialty of cardiothoracic surgery are lacking. We aimed to study this topic through a well-being survey. A 54-question well-being survey was developed by the Wellness Committee of the American Association for Thoracic Surgery (AATS) and sent by email from January through March of 2021 to AATS members and participants of the 2021 annual meeting. The 5-item Likert-scale survey questions were dichotomized, and associations were determined by Chi-square tests or independent samples t-tests, as appropriate. The results from 871 respondents (17% women) were analyzed. Many respondents reported at least moderately experiencing: 1) a sense of dread coming to work (50%), 2) physical exhaustion at work (58%), 3) a lack of enthusiasm at work (46%), and 4) emotional exhaustion at work (50%). Most respondents (70%) felt that burnout affected their personal relationships at least "some of the time," and many (43%) experienced a great deal of work-related stress. Importantly, most respondents (62%) reported little to no access to workplace resources for emotional support, but those who reported access reported less burnout. Most respondents (57%) felt that the COVID-19 pandemic has negatively affected their well-being. On a positive note, 80% felt their career was fulfilling and enjoyed their day-to-day job at least "most of the time." Cardiothoracic surgeons experience high levels of burnout, similar to that of other medical professionals. Interventions aimed at mitigating burnout in this profession are discussed.

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