Outcomes of 350 Robotic-assisted Esophagectomies at a High-volume Cancer Center: A Contemporary Propensity-score Matched Analysis.

OBJECTIVE: To evaluate perioperative and oncologic outcomes in our RAMIE cohort and compare outcomes with contemporary OE controls. SUMMARY OF BACKGROUND DATA: RAMIE has emerged as an alternative to traditional open or laparoscopic approaches. Described in all esophagectomy techniques, rapid adoption has been attributed to both enhanced visualization and technical dexterity. METHODS: We retrospectively reviewed patients who underwent RAMIE for malignancy. Patient characteristics, perioperative outcomes, and survival were evaluated. For perioperative and oncologic outcome comparison, contemporary OE controls were propensity-score matched from NSQIP and NCDB databases. RESULTS: We identified 350 patients who underwent RAMIE between 2010 and 2019. Median body mass index was 27.4, 32% demonstrated a Charlson Comorbidity Index >4. Nodal disease was identified in 50% of patients and 74% received neoadjuvant chemoradiotherapy. Mean operative time and blood loss were 425 minutes and 232 mL, respectively. Anastomotic leak occurred in 16% of patients, 2% required reoperation. Median LOS was 9 days, and 30-day mortality was 3%. A median of 21 nodes were dissected with 96% achieving an R0 resection. Median survival was 67.4 months. 222 RAMIE were matched 1:1 to the NSQIP OE control. RAMIE demonstrated decreased LOS (9 vs 10 days, P = 0.010) and reoperative rates (2.3 vs 12.2%, P = 0.001), longer operative time (427 vs 311 minutes, P = 0.001), and increased rate of pulmonary embolism (5.4% vs 0.9%, P = 0.007) in comparison to NSQIP cohort. There was no difference in leak rate or mortality. Three hundred forty-three RAMIE were matched to OE cohort from NCDB with no difference in median overall survival (63 vs 53 months; P = 0.130). CONCLUSION: In this largest reported institutional series, we demonstrate that RAMIE can be performed safely with excellent oncologic outcomes and decreased hospital stay when compared to the open approach.

The effect of histologic grade on neoadjuvant treatment outcomes in esophageal cancer.

BACKGROUND AND OBJECTIVES: The gold standard for locoregional esophageal cancer (LEC) treatment includes preoperative chemoradiation and surgical resection, with possible perioperative or adjuvant systemic therapy. With few data associating histologic grade and prognosis in LEC patients receiving neoadjuvant chemoradiation followed by resection, we seek to evaluate this association. METHODS: Our institutional esophagectomy database between 1999 and 2019 was queried, selecting esophageal adenocarcinoma patients who completed neoadjuvant therapy (NAT), followed by esophagectomy. Propensity-score matching of low- and high-histologic grade groups was performed to assess survival metrics using initial clinical grade (cG) and final pathologic grade (pG). We performed a multivariable logistic regression to study predictors of pathologic complete response as a secondary objective. RESULTS: A total of 518 patients met the inclusion criteria. Kaplan-Meier analysis of the matched dataset showed no difference in initial or 5-year recurrence-free survival or overall survival (OS) between cG1 and cG2 versus cG3 based on original grade. When matched according to pG, cG1-2 had improved median survival parameters compared to cG3, with 5-year OS for cG1-2 of 45% versus 27% (p = 0.001). Higher pG, pathologic N stage, and poor response to NAT are predictors of poor survival. CONCLUSION: Patients with post-NAT pG1-2 demonstrated improved survival. Integrating histologic grade into postneoadjuvant staging may be warranted.

Impact of histology classification on pathologic treatment response and overall survival in distal esophageal cancer patients: a propensity matched analysis.

BACKGROUND: Esophageal squamous cell carcinoma (ESCC) has been linked to superior pathologic treatment response compared to esophageal adenocarcinoma (EAC) after neoadjuvant chemoradiation. However, the impact of histology on survival remains unclear. It has been suggested, based on epidemiologic similarities, that distal EAC should be grouped with gastric cancers as an entity distinct from distal ESCC, but there is little data to support this recommendation. We therefore aim to compare pathologic treatment response (PTR) and overall survival (OS) in patients with distal EAC versus distal ESCC. METHODS: This retrospective cohort study included patients who underwent esophagectomy for distal esophageal malignancy. Histologic sub-groups were matched (1:1) using a propensity-score matching approach. Pre-operative clinical parameters, oncologic outcomes and survival were compared between groups. RESULTS: 1031 distal EC patients, with a median age of 64.4 years and a male preponderance (86.5%), underwent esophagectomy at our institution between 1999 and 2019. 939 (91.1%) patients had a diagnosis of EAC and 92 (8.9%) had ESCC. A higher proportion of ESCC patients were female (26.1% vs. 12.1%; P < 0.01) and non-white (12.0% vs. 3.8%; P < 0.01). Propensity-score sub-analysis identified 75 matched pairs. Rates of pathologic complete response (58.0% vs. 48.9%; P = 0.67) and OS (43.0 vs. 52.0 months; P = 0.808) were not significantly different between matched groups. CONCLUSIONS: Although traditionally known to have a better overall PTR compared to EAC, ESCC patients in our large series did not show any improvement in PTR or OS. Treatment recommendations for patients with EAC and ESCC should consider tumor location in addition to histology.

Is Preoperative G-Tube Use Safe for Esophageal Cancer Patients?

Objective: Gastrostomy tubes (g-tubes) have been used with caution prior to esophageal resection due to the risks of inoculation metastasis and of injury to the gastric conduit used for reconstruction. In this study, we aim to evaluate the safety of preoperative g-tube placement by comparing outcomes in patients undergoing esophageal resection with and without prior g-tube use.Method: We retrospectively reviewed our institution's database of 1113 esophagectomies performed between 1994 and 2018. We included only patients who received neoadjuvant therapy and identified 65 patients who received preoperative nutritional support through a g-tube (GT+) and 657 who did not (GT-). Demographics, postoperative complications, survival, and cancer recurrence rates were compared between GT + and GT- using Chi-squared and Kaplan-Meier survival analyses.Results: Seven-hundred twenty-two patients (122 female, 600 male) with a median age of 63.2 (28.2-86.3) met our inclusion criteria. Between GT+ (n = 65) and GT- (n = 657), there were no significant differences in anastomotic leak rates (11.5% vs 10.9%; p = 0.901), postoperative mortality (3.1% vs 3.9%; p = 0.765), or overall complications (63.1% vs 65.1%; p = 0.746). GT + was associated with a significantly lower overall survival compared to GT- (32.5 m vs 92.9 m; p = 0.003), and tumor recurrence rates were similar (30.6% vs 31.8%; p = 0.851). There were no cases documenting damage to the gastric conduit caused by prior g-tube placement.Conclusions: G-tube usage was not associated with increased tumor recurrence, anastomotic leak rates, or overall complication rates in this study. Our data suggest that g-tube usage is safe for patients with esophageal cancer requiring preoperative nutrition.

Recurrence patterns and associated factors of locoregional failure following neoadjuvant chemoradiation and surgery for esophageal cancer.

BACKGROUND: Despite neoadjuvant chemoradiation (nCRT) followed by esophagectomy for locally advanced esophageal cancer, locoregional recurrence (LRR) is common and factors associated with LRR have not been clearly identified. METHODS: Patients were identified from a single institution, prospectively maintained database (1996-2013). Patterns of recurrence were described and associated factors of LRR were analyzed using competing risks regression models. RESULTS: Of the 456 patients treated with nCRT and surgery, 167 patients developed recurrence. Locoregional and distant recurrences were observed in 69 (15.1%) and 140 (30.9%) patients, respectively. Time to recurrence (13.6 vs 10.4 months, P = 0.20) and median overall survival (29.3 vs 19.1 months, P = 0.12) were no different among the 27 patients (6%) who developed a solitary LRR compared to patients who developed distant recurrence. Univariable analysis identified lymphovascular invasion (HR 1.46, P = 0.07), lymph node ratio >0.5 (HR 2.16, P = 0.02), positive margin (HR 1.95, P = 0.05), lack of response to neoadjuvant therapy (HR 1.99, P < 0.01), clinical T stage (HR 2.62, P < 0.01) and final T3/4 stage (HR 2.06, P < 0.01) as factors significantly associated with LRR. Clinical T stage and response to neoadjuvant treatment were independently associated with LRR on multivariable analysis. CONCLUSIONS: Although aggressive tumor biology plays a significant role in LRR, optimizing neoadjuvant treatments to obtain a complete pathologic response may lead to improved locoregional control.

Effect of Obesity on Perioperative Outcomes After Robotic-Assisted Pulmonary Lobectomy.

OBJECTIVE: We investigated whether higher body mass index (BMI) affects perioperative and postoperative outcomes after robotic-assisted video-thoracoscopic pulmonary lobectomy. METHODS: We retrospectively studied all patients who underwent robotic-assisted pulmonary lobectomy by one surgeon between September 2010 and January 2015. Patients were grouped according to the World Health Organization's definition of obesity, with "obese" being defined as BMI >30.0 kg/m2. Perioperative outcomes, including intraoperative estimated blood loss (EBL) and postoperative complication rates, were compared. RESULTS: Over 53 months, 287 patients underwent robotic-assisted pulmonary lobectomy, with 7 patients categorized as "underweight," 94 patients categorized as "normal weight," 106 patients categorized as "overweight," and 80 patients categorized as "obese." Because of the relatively low sample size, "underweight" patients were excluded from this study, leaving a total cohort of 280 patients. There was no significant difference in intraoperative complication rates, conversion rates, perioperative outcomes, or postoperative complication rates among the 3 groups, except for lower risk of prolonged air leaks ≥7 days and higher risk of pneumonia in patients with obesity. CONCLUSIONS: Patients with obesity do not have increased risk of intraoperative or postoperative complications, except for pneumonia, compared with "normal weight" and "overweight" patients. Robotic-assisted pulmonary lobectomy is safe and effective for patients with high BMI.

Robotic-Assisted Videothoracoscopic Mediastinal Surgery.

BACKGROUND: Tumors of the mediastinum as well as normal thymus glands in patients with myasthenia gravis have traditionally been resected using large and morbid incisions. However, robotic-assisted mediastinal resections are gaining popularity because of the many advantages that the robot provides. However, few comprehensive reviews of the literature on robotic-assisted mediastinal resections exist. METHODS: A systemic review of the current medical literature was performed, excluding cases related to esophageal pathology. These studies were evaluated and their findings are reported in this comprehensive review. Approximately 48 papers met the inclusion criteria for review. RESULTS: Robotic-assisted surgical systems are increasingly being used in mediastinal resections. Based on the available literature, robotic-assisted thoracoscopic surgery in the mediastinum is feasible and safe. Robotic-assisted mediastinal surgery appears to be superior to open approaches of the mediastinum and is comparable with videothoracoscopic surgery when patient outcomes are considered. CONCLUSIONS: Increased robotic experience and more studies, including randomized controlled trials, are needed to validate the findings of the current literature.

Robotic-Assisted Videothoracoscopic Surgery of the Lung.

BACKGROUND: Despite initial concerns about the general safety of videothoracoscopic surgery, minimally invasive videothoracoscopic surgical procedures have advantages over traditional open thoracic surgery via thoracotomy. Robotic-assisted minimally invasive surgery has expanded to almost every surgical specialty, including thoracic surgery. Adding a robotic-assisted surgical system to a videothoracoscopic surgical procedure corrects several shortcomings of videothoracoscopic surgical cameras and instruments. METHODS: We performed a literature search on robotic-assisted pulmonary resections and compared the published robotic series data with our experience at the H. Lee Moffitt Cancer Center & Research Institute. All perioperative outcomes, such as intraoperative data, postoperative complications, chest tube duration, hospital length of stay (LOS), and in-hospital mortality rates were noted. RESULTS: Our literature search found 23 series from multiple surgical centers. We divided the literature into 2 groups based on the year published (2005-2010 and 2011-2014). Operative times from earlier studies ranged from 150 to 240 minutes compared with 90 to 242 minutes for later studies. Conversion rates (to open lung resection) from the earlier studies ranged from 0% to 19% compared with 0% to 11% in the later studies. Mortality rates for the earlier studies ranged from 0% to 5% compared with 0% to 2% for the later studies. Since 2010, our group has performed more than 600 robotic-assisted thoracic surgical procedures, including more than 200 robotic-assisted pulmonary lobectomies, which we also divided into 2 groups. Our median skin-to-skin operative time improved from 179 minutes for our early group (n = 104) to 172 minutes for our later group (n = 104). The overall conversion rate was 9.6% and the emergent conversion rate (for bleeding) was 5% for our robotic-assisted lobectomies. The most common postoperative complications in our cohort were prolonged air leak (> 7 days; 16.8%) and atrial fibrillation (12%). Hospital LOS for the early series ranged from 3 to 11 days compared with 2 to 6 days for the later series. Median hospital LOS decreased from 6 to 4 days. Our mortality rate was 1.4%; 3 in-hospital deaths occurred in the early 40 cases. Mediastinal lymph node (LN) dissection and detection of occult mediastinal LN metastases were improved during robotic-assisted lobectomy for non-small-cell lung cancer, as demonstrated by an overall 30% upstaging rate, including a 19% nodal upstaging rate, in our cohort. CONCLUSIONS: Robotic-assisted videothoracoscopic pulmonary lobectomy appears to be as safe as conventional videothoracoscopic surgical lobectomy, which has decreased perioperative complications and a shorter hospital LOS than open lobectomy. Both mediastinal LN dissection and the early detection of occult mediastinal LN metastatic disease were improved by robotic-assisted videothoracoscopic surgical compared with conventional videothoracoscopic surgical or open thoracotomy.

Robotic-Assisted Esophageal Surgery.

BACKGROUND: The adoption of minimally invasive approaches to the management of esophageal disease has been slow, except for the laparoscopic management of gastroesophageal reflux disease. However, the advent of new surgical technologies - in particular, robotic-assisted surgical systems - has revolutionized esophageal surgery. METHODS: The literature was systematically reviewed using the keywords "robotic," "esophageal surgery," "esophagectomy," "fundoplication," and "esophageal myotomy." The reference lists from these articles were then also analyzed. RESULTS: Forty-nine studies were included in our comprehensive review of robotic-assisted esophageal surgery, and they consisted of literature reviews, case reports, retrospective and prospective case series, and randomized controlled trials. CONCLUSIONS: Robotic-assisted esophageal surgery is a safe and effective way of treating esophageal disorders, including gastroesophageal reflux disease, achalasia, leiomyomas, and cancer. The use of robotic surgical systems has many benefits for managing disorders of the esophagus, but more studies, including randomized controlled trials, are necessary.

The prognostic value of residual nodal disease following neoadjuvant chemoradiation for esophageal cancer in patients with complete primary tumor response.

BACKGROUND: The prognostic significance of residual nodal disease in otherwise complete pathologic responders (ypT0N+) to neoadjuvant chemoradiation (nCRT) for esophageal cancer is unknown. METHODS: ypT0N+ responders were identified from a single institution database of esophageal cancer patients undergoing esophagectomy and were compared to patients without locoregional disease (ypT0N0) and to non-complete responders (ypT+). RESULTS: Out of 487 patients, 196 ypT0N0 and 14 ypT0N+ patients were identified. Pre-treatment stage was similar between ypT0N0 and ypT0N+ patients: 66% versus 73% of patients had uT3 disease (P = 0.50) and 76% versus 55% had nodal involvement (P = 0.49), respectively. Locoregional recurrence (43%) was more common in ypT0N+ patients. Median overall survival (OS) was worse in ypT0N+ patients (14.8 months) compared to ypT0N0 patients (92.2 months) and ypT+ patients (38.0 months, P < 0.001). Median OS of ypT0N+ patients was similar to ypT+ stage II (29.6 months, P = 0.84) and stage III (27.5 months, P = 0.95) disease. No difference in median OS existed in patients with residual nodal disease (n = 163) based on local response (14.8 months in ypT0N+ and 22.5 months in ypT+N+ patients, P = 0.55). CONCLUSIONS: Residual nodal disease in esophageal cancer patients with complete response in the primary tumor following nCRT portends a poor prognosis and behaves similar to pathologic stage II/III disease.

Totally minimally invasive laparoscopic robot-assisted Ivor Lewis esophagectomy: improved technique and outcomes over 200 cases.

Background: Surgical resection of esophageal and gastroesophageal junction cancers is a very complex procedure with step learning curve. New technologies have made minimally invasive surgery possible, but challenges still remain for wide spread adoption of these techniques. This article aims to describe the outcomes and salient technical points of a totally minimally invasive, laparoscopic, robot-assisted Ivor Lewis esophagectomy (LRAMIE). Methods: Retrospective observational cohort study performed at a specialty cancer center using a prospectively maintained institutional database. Patients undergoing LRAMIE (laparoscopic abdomen, robotic chest) from 2014-2023 were included. Patients undergoing transhiatal and three-field esophagectomy were excluded. Operative and postoperative outcomes were compared over the study period to identify potential associations between outcomes over time. Results: Two-hundred patients were identified who underwent LRAMIE. Median age was 65 years and most were male (87.5%). The open conversion rate was 1% (n=2), which occurred within the first 30 cases. Operative time and blood loss were improved at the 60-case mark (P<0.001). Anastomotic stricture rate improved after 50 cases, and leak rate improved after 80 cases. Postoperative length of stay improved at both 50 and 100 cases with a median LOS of 6 days after 100 cases. Rate of postoperative pneumonia, 30- and 90-day mortality were reduced after 100 cases, although not statistically significant for mortality due to too few events. Conclusions: Totally minimally invasive Ivor Lewis esophagectomy at a high-volume center is a safe procedure. Operative outcomes improved significantly after 50-80 cases, followed by improvement in anastomotic results and postoperative outcomes, with corresponding excellent oncologic outcomes.

Effect of Surgical Day of Week on Postoperative Outcomes After Robotic-Assisted Pulmonary Lobectomy.

Introduction Patients who have surgery late in the week could potentially receive different postoperative care due to a reduced weekend staff compared to patients who have surgery early in the week, who will be cared for by a full staff during the work week. Our aim was to determine if patients who underwent robotic-assisted video-thoracoscopic (RAVT) pulmonary lobectomy during the first half of the week had different outcomes than patients who also underwent RAVT pulmonary lobectomy during the second half of the week. Methods We analyzed 344 consecutive patients who underwent RAVT pulmonary lobectomy by one surgeon from 2010 to 2016. Depending on the day of the surgical procedure, these patients were either put into a Monday through Wednesday (M-W) group or a Thursday through Friday (Th-F) group. Patient demographics, tumor histopathology, intraoperative and postoperative complications, and perioperative outcomes were compared between groups using the Student's t-test, Kruskal-Wallis test, or chi-square (or Fisher's exact) test, with p≤0.05 as significant. Results There were more non-small cell lung cancers (NSCLCs) resected in the M-W group than in the Th-F group (p=0.005). Skin-to-skin and total operative times were greater for the Th-F group than for the M-W group (p=0.027 and p=0.017, respectively). There were no significant differences in any other variables assessed. Conclusions Our study showed that, despite reduced weekend staffing and potential differences in postoperative care, there were no significant differences seen in postoperative complications or perioperative outcomes based on surgical day of the week.

Outcomes of robotic lobectomy for non-small cell lung cancer in a National Cancer Institute-Comprehensive Cancer Center vs. National Cancer Database.

Background: There continues to be a rise in the proportion of resectable non-small cell lung cancer (NSCLC) with the recent expansion of criteria for low-dose lung cancer screening. These are increasingly being treated with minimally invasive techniques. Our study aims to compare outcomes of robotic lobectomy (RL) for NSCLC at a National Cancer Institute-designated Comprehensive Cancer Center (NCI-CCC) to those of open lobectomy (OL), video-assisted thoracoscopic lobectomy (VL), or RL as reported in the National Cancer Database (NCDB). Methods: The first 1,021 patients with NSCLC who underwent RL between 2010 and 2020 were matched with peers from the NCDB who had OL, VL, or RL. Matching was performed based on a propensity score calculated by logistic regression using multiple variables. Surgical outcomes included numbers of examined lymph nodes, performance of mediastinal lymphadenectomy, length of stay (LOS), and 30-day mortality. Kaplan-Meier curves and overall survival (OS) were analyzed using log-rank tests. Results: Most common postoperative complications were persistent air leak, atrial fibrillation, and pneumonia. Median LOS was 4 days, and the 30-day mortality rate was 1% (n=10/1,021). Compared to NCDB patients who underwent OL, NCI-CCC patients had a higher mean number of retrieved lymph nodes (P=0.001), higher rate of mediastinal lymphadenectomy (P<0.001), and shorter median LOS (4 vs. 6 days; P<0.001). There was no difference in 30-day mortality (P=0.176). Kaplan-Meier analyses showed no differences in median OS (log-rank P=0.953) or 5-year OS (P=0.774). Compared to NCDB VL, NCI-CCC patients had a higher nodal yield (P<0.001), higher rates of mediastinal lymphadenectomy (P<0.001), and lower conversion rates (4.1% vs. 13.8%, P<0.001). There were no differences in 30-day mortality (P=0.379) or in median LOS (P=0.351). Kaplan-Meier analyses showed no differences in median OS (P=0.720) or 5-year OS (P=0.735). NCI-CCC patients were also matched with NCDB RL patients and had a higher nodal yield (P<0.001), higher rates of mediastinal lymphadenectomy (P<0.001), and lower conversion rates (4.1% vs. 9.5%; P <0.001). There were no differences in 30-day mortality (P=0.899) or in median LOS (P=0.252). Kaplan-Meier analyses showed no differences in median OS (P=0.484) or 5-year OS (P=0.524). Conclusions: RL for NSCLC performed in an NCI-CCC appears to have improved perioperative outcomes with comparable long-term OS compared to national benchmarks in OL and VL.

Association between the Preoperative Standard Uptake Value (SUV) and Survival Outcomes after Robotic-Assisted Segmentectomy for Resectable Non-Small Cell Lung Cancer (NSCLC).

BACKGROUND: Lung-sparing procedures, specifically segmentectomies and wedge resections, have increased over the years to treat early-stage non-small cell lung cancer (NSCLC). We investigate here the perioperative and long-term outcomes of patients who underwent robotic-assisted segmentectomy (RAS) at an NCI-designated cancer center and aim to show associations between the preoperative standard update value (SUV) to tumor stage, recurrence patterns, and overall survival. METHODS: A retrospective analysis was performed on 166 consecutive patients who underwent RAS at a single institution from 2010 to 2021. Of this number, 121 robotic-assisted segmentectomies were performed for primary NSCLC, and a total of 101 patients were evaluated with a PET-CT scan. The SUV from the primary tumor was determined from the PET-CT. The clinical, surgical, and pathologic profiles and perioperative outcomes were summarized via descriptive statistics. Numerical variables were described as the median and interquartile range because all numerical variables were not normally distributed as assessed by the Shapiro-Wilk test of normality. Categorical variables were described as the count and proportion. Chi-square or Fisher's exact test was used for association. The main outcomes were overall survival (OS) and recurrence-free survival (RFS). Kaplan-Meier (KM) curves were constructed to visualize the OS and RFS, which were also stratified according to tumor histology, the pathologic stage, and standard uptake value. A log-rank test for the equality of survival curves was performed to determine significant differences between groups. RESULTS: The most common postoperative complications were atrial fibrillation (8.8%, 9/102), persistent air leak (7.84%, 8/102), and pneumonia (4.9%, 5/102). The median operative duration was 168.5 min (IQR 59), while the median estimated blood loss was 50 mL (IQR 125). The conversion rate to thoracotomy in this cohort was 3.9% (4/102). Intraoperative complications occurred in 2.9% (3/102). The median hospital length of stay was 3 days (IQR 3). The median chest tube duration was 3 days (IQR 2), but 4.9% (5/102) of patients were sent home with a chest tube. The recurrence for this cohort was 28.4% (29/102). The time to recurrence was 353 days (IQR 504), while the time to mortality was 505 days (IQR 761). The NSCLC patients were divided into the following two groups: low SUV (<5, n = 55) and high SUV (≥5, n = 47). Statistically significant associations were noted between SUV and the tumor histology (p = 0.019), tumor grade (p = 0.002), lymph-vascular invasion (p = 0.029), viscera-pleural invasion (p = 0.008), recurrence (p < 0.001) and the site of recurrence (p = 0.047). KM survival analysis showed significant differences in the curves for OS (log-rank p-value 0.0204) and RFS (log-rank p-value 0.0034) between the SUV groups. CONCLUSION: Robotic-assisted segmentectomy for NSCLC has reasonable perioperative and oncologic outcomes. Furthermore, we demonstrate here the prognostic implication of preoperative SUV to pathologic outcomes, recurrence-free survival, and overall survival.

Induction Fluorouracil-Based Chemotherapy and PET-Adapted Consolidation Chemoradiation with Esophagectomy for High-Risk Gastroesophageal Adenocarcinoma.

Background: Neoadjuvant chemoradiation with esophagectomy is standard management for locally advanced esophageal adenocarcinoma. Induction chemotherapy with a tailored approach to chemoradiation based on metabolic response to therapy on PET was explored as an alternative strategy in the CALGB 80803 trial. We sought to describe real-world institutional experience implementing this approach outside of a clinical trial. Methods: Patients who were treated with induction fluorouracil-leucovorin-oxaliplatin (FOLFOX) or fluorouracil-leucovorin-oxaliplatin-docetaxel (FLOT) with tailored chemoradiation based on PET response and subsequent esophagectomy were identified from a prospectively maintained database. Primary outcomes were pathologic complete response (pCR) and overall survival (OS) following completion of all therapy. Results: There were 35 patients who completed induction chemotherapy, chemoradiation, and esophagectomy. Thirty-three completed restaging PET following induction chemotherapy with metabolic response seen in 76% (n = 25/33). The pCR rate was 31% (n = 11/35) and the ypN0 rate was 71% (n = 25/35). Among the patients who demonstrated metabolic response to induction FOLFOX/FLOT and subsequently continued fluorouracil-based chemoradiation, the pCR rate was 39% (n = 9/23). The rate of pathologically negative lymph nodes in this group was high (n = 19/23, 83%) with 100% R0 resection rate (n = 23/23). With the median follow-up of 43 months, the median OS was not reached for this group and was significantly longer than the OS for the remainder of the cohort (p = 0.027, p = 0.046 adjusted for clinical stage). Conclusions: Induction FOLFOX/FLOT chemotherapy with evaluation of sensitivity via metabolic response and tailored chemoradiation seems to lead to high pCR and ypN0 rates in high-risk patients with adenocarcinoma of the esophagus and GE junction. This approach in clinical practice seems to recapitulate encouraging results in clinical trials.

Changes in Perioperative Outcomes after Robotic-Assisted Pulmonary Lobectomy during the COVID-19 Era.

Background: The COVID-19 pandemic presented patients with barriers to receiving healthcare. We sought to determine whether changes in healthcare access and practice during the pandemic affected perioperative outcomes after robotic-assisted pulmonary lobectomy (RAPL). Methods: We retrospectively analyzed 721 consecutive patients who underwent RAPL. With March 1st, 2020, defining the start of the COVID-19 pandemic, we grouped 638 patients as "PreCOVID-19" and 83 patients as "COVID-19-Era" based on surgical date. Demographics, comorbidities, tumor characteristics, intraoperative complications, morbidity, and mortality were analyzed. Variables were compared utilizing Student's t-test, Wilcoxon rank-sum test, and Chi-square (or Fisher's exact) test, with significance at p ≤ 0.05 . Multivariable generalized linear regression was used to investigate predictors of postoperative complication. Results: COVID-19-Era patients had significantly higher preoperative FEV1%, lower cumulative smoking history and higher incidences of preoperative atrial fibrillation, peripheral vascular disease (PVD), and bleeding disorders compared to PreCOVID-19 patients. COVID-19-Era patients had lower intraoperative estimated blood loss (EBL), reduced incidence of new-onset postoperative atrial fibrillation (POAF), but higher incidence of effusion or empyema postoperatively. Overall postoperative complication rates between the groups were similar. Older age, increased EBL, lower preoperative FEV1%, and preoperative COPD are all predictive of an increased risk for postoperative complication. Conclusions: COVID-19-Era patients having lower EBL and less new-onset POAF, despite greater incidences of multiple preoperative comorbidities, demonstrates that RAPL is safe during the COVID-19 era. Risk factors for development of postoperative effusion should be determined to minimize risk of empyema in COVID-19-Era patients. Age, preoperative FEV1%, COPD, and EBL should all be considered when planning for complication risk.

Effects of preoperative pulmonary function on perioperative outcomes after robotic-assisted pulmonary lobectomy.

INTRODUCTION: Effects of pulmonary function test (PFT) results on perioperative outcomes were investigated after robotic-assisted video-thoracoscopic (RAVT) pulmonary lobectomy. METHODS: We retrospectively analyzed 706 consecutive patients who underwent RAVT lobectomy by one surgeon over 10.8 years. Preoperative (preop) forced expiratory volume in 1 s as a percent of predicted (FEV1%) was used to group patients as having normal FEV1% (≥80%) versus reduced FEV1% (<80%). Demographics, preop comorbidities, intraoperative (intraop) and postoperative (postop) complications, perioperative outcomes, and median survival time (MST) were compared across patients with normal vs. reduced FEV1% using Chi-Square (X2), Fisher's Exact test, Student's t-test, Kruskal-Wallis test, or Kaplan-Meier analysis respectively, with significance at p ≤ 0.05. Multivariable analysis was performed for perioperative outcomes to investigate the differences across patients in the FEV1% groups. RESULTS: There were 470 patients with normal FEV1% and 236 patients with reduced FEV1%. The two FEV1% groups did not differ in intraop or postop complication rates, except for higher postop other arrhythmia requiring intervention (p = 0.004), prolonged air leak >5 days (p = 0.002), mucous plug formation (p = 0.009), hypoxia (p < 0.001), and pneumonia (p = 0.002), and total postop complications (p < 0.001) in reduced-FEV1% patients. Reduced FEV1% correlated with increased intraop estimated blood loss (p < 0.0001) and skin-to-skin operative time (p < 0.0001). Median overall survival in patients with normal FEV1% was 93.20 months (95% CI: 76.5-126.0) versus 58.9 months (95% CI: 50.4-68.4) in patients with reduced FEV1% (p = 0.0004). CONCLUSION: Patients should have PFTs conducted before surgery to determine at-risk patients. However, RAVT pulmonary lobectomy is feasible and safe even in patients with reduced FEV1%.

A High Preoperative Blood Urea Nitrogen to Serum Albumin Ratio Does Not Predict Worse Outcomes Following the Robotic-Assisted Pulmonary Lobectomy for Lung Cancer.

BACKGROUND:  The blood urea nitrogen to serum albumin ratio (BAR) is an emerging prognostic parameter of interest. The utility of BAR as a prognostic factor has not been analyzed in lung cancer patients undergoing pulmonary lobectomy. We evaluated the ability of High BAR to predict worse outcomes after robotic-assisted pulmonary lobectomy (RAPL) for lung cancer. METHODS:  We retrospectively analyzed 400 patients who underwent RAPL from September 2010 to March 2022 by one surgeon. Patients were stratified by Low BAR (<6.25 mg/g) and High BAR (≥6.25 mg/g). Patients' demographics, tumor characteristics, comorbidities, surgical complications, outcomes, and survival were collected and compared by High and Low BAR groups. The primary outcome of interest was 30-day mortality. RESULTS:  Receiver operator curves (ROC) confirmed that 6.25 was an optimal threshold for estimating mortality based on Low and High BAR. There were no differences in surgical complications or outcomes between the Low and High BAR groups. The ability of BAR to predict 30-day mortality was evaluated with the area under the curve (AUC) analysis, which showed that higher BAR could not predict mortality (AUC=0.655; 95% CI, 0.435-0.875; p=0.166). Similarly, survival analysis revealed no difference in five-year overall survival between the Low and High BAR groups (p=0.079). CONCLUSION:  High BAR did not predict worse outcomes after RAPL for lung cancer in our study. Further studies are needed to better determine the prognostic ability of BAR in lower-risk populations.

Distance of Residence From the Cancer Center Influences Perioperative Outcomes After Robotic-Assisted Pulmonary Lobectomy?

Introduction Increased distance of residence from the hospital has been previously associated with worse postoperative outcomes, especially increased hospital length of stay (LOS) after elective surgery in the USA as well as after pulmonary lobectomy in Japan. We sought to determine if the distance from our cancer center affects postoperative outcomes after robotic-assisted pulmonary lobectomy. Methods We retrospectively analyzed 449 patients who underwent robotic-assisted pulmonary lobectomy by one surgeon for known or suspected lung cancer. Two patients were excluded due to incomplete data. Each patient's residential ZIP code was used to determine the distance of their primary residence from our cancer center. Group 1 consisted of patients living less than 120 miles away while Group 2 consisted of patients living more than 120 miles away. Demographic factors, preoperative comorbidities, the incidence of postoperative complications, chest tube duration, and hospital LOS were compared by the Pearson chi-square or Kruskal-Wallis tests, and Kaplan-Meier survival was compared by Cox regression. Statistical significance was established as p≤0.05. Results Group 1 was found to have a higher mean body mass index (BMI) (28.3 kg/m2) than Group 2 (27.0 kg/m2; p=.031). Group 1 also tended to have a higher rate of preoperative hypertension (HTN; 59%) than Group 2 (47%; p=.018). No other preoperative comorbidities were significant. Median hospital LOS was found to differ between Group 1 (4 days) and Group 2 (5 days; p=.048). Postoperative complication rates did not differ between Group 1 (35%) and Group 2 (40%; p=.370). Median chest tube durations for Group 1 (4 days) vs. Group 2 (4 days) did not differ (p=.093). Five-year overall survival (OS) did not differ between the two groups (p=.550). Conclusions Longer distance from patient residence to our cancer center was associated with higher BMI, higher rates of preoperative HTN, and longer LOS. Postoperative complication rates, chest tube duration, and five-year OS were not significantly affected by distance. These results supported similar results in a Japanese study that indicated distance extends the LOS, regardless of the type of transportation used by patients. Further research analyzing the effects of socioeconomic status and insurance coverage on perioperative outcomes should be conducted to identify subpopulations in the USA that suffer disparities in access to and delivery of healthcare.

Effect of Socio-Economic Status on Perioperative Outcomes After Robotic-Assisted Pulmonary Lobectomy.

BACKGROUND:  Lower socioeconomic status (SES) has been correlated with poor survival rates and surgical outcomes following lung cancer resection. This study sought to determine whether this disparity exists perioperatively in lung cancer patients following robotic-assisted video-thoracoscopic pulmonary lobectomy.  Methods: We retrospectively reviewed 447 consecutive patients who underwent robotic-assisted pulmonary lobectomy by one surgeon for known or suspected lung cancer. Ten patients were excluded due to incomplete data. We used median income by residential ZIP code as a surrogate for SES status and grouped patients based on whether ZIP-based median income was less than (Group 1) or greater than (Group 2) 300% of the federal poverty income level. The effects of SES status groups on incidence of postoperative complications, chest tube duration, hospital length of stay (LOS), and in-hospital mortality were evaluated by the logistic regression model and Inverse Gaussian regression model, respectively. RESULTS:  Without adjustment, Group 1 tended to have a higher rate of postoperative complications, with 54% of patients experiencing complications compared to 34% of patients in Group 2 (p=0.007). Median chest tube duration and hospital LOS were also significantly longer in Group 1 than in Group 2 (p=0.034). In multivariable logistical regression analysis, while controlling for covariates and considering effect modifications, lower SES was significantly and positively associated with postoperative complications (odds ratio (OR)=1.98, p=0.039). Preoperative chronic obstructive pulmonary disease (COPD) was also a positive and significant predictor of postoperative complications (OR=1.89, p=0.017), chest tube duration (p=0.020), and LOS (p=0.010). CONCLUSIONS:  Lower median income is associated with a greater number of postoperative complications following pulmonary resection for lung cancer when controlling for covariates.