Robotic-assisted tracheobronchoplasty: Quality of life and pulmonary function assessment on intermediate follow-up.

OBJECTIVE: The initial description of robotic tracheobronchoplasty for the treatment of tracheobronchomalacia demonstrated feasibility, safety, and short-term symptomatic and functional improvement. The purpose of the current study was to demonstrate intermediate outcomes in postoperative pulmonary function and quality of life after robotic tracheobronchoplasty. METHODS: We retrospectively reviewed prospectively collected clinical data from 42 patients who underwent robotic tracheobronchoplasty from May 2016 to December 2017. The Institutional Review Board or equivalent ethics committee of the Northwell Health approved the study protocol and publication of data. Patient written consent for the publication of the study data was waived by the Institutional Review Board. RESULTS: A total of 42 patients underwent robotic tracheobronchoplasty during the study period. Median total follow-up is 40 months. There was 1 death since surgery from an unrelated disease. Significant decreases in St George's Respiratory Questionnaire total score (preoperative mean: 64.01, postoperative mean: 38.91, P = .002), St George's Respiratory Questionnaire symptom score (preoperative median: 82.6, postoperative median: 43.99, P < .001), and St George's Respiratory Questionnaire impact score (preoperative median: 55.78, postoperative median: 25.95, P < .001) were apparent at a median follow-up of 13 months. Comparison of preoperative and postoperative pulmonary function tests revealed a significant increase in percent predicted forced expiratory volume in 1 second (preoperative median: 74% vs postoperative median: 82%, P = .001), forced vital capacity (preoperative median: 68.5% vs postoperative median: 80.63%, P < .001), and peak expiratory flow (preoperative median: 61.5% vs postoperative median: 75%, P = .02) measured at a median follow-up of 29 months. CONCLUSIONS: Robotic tracheobronchoplasty is associated with low intermediate-term mortality. Robotic tracheobronchoplasty results in significant improvement in quality of life and postoperative pulmonary function. Longer-term follow-up is necessary to continue to elucidate the effect of robotic tracheobronchoplasty on halting pathologic progression of tracheobronchomalacia and to determine the long-term impact of tracheobronchoplasty on symptomatic and functional improvement.

Robotic Pneumonectomy for Lung Cancer: Perioperative Outcomes and Factors Leading to Conversion to Thoracotomy.

OBJECTIVE: In the tide of robot-assisted minimally invasive surgery, few cases of robot-assisted pneumonectomy exist in the literature. This study evaluates the perioperative outcomes and risk factors for conversion to thoracotomy with an initial robotic approach to pneumonectomy for lung cancer. METHODS: This study is a single-center retrospective review of all pneumonectomies for lung cancer with an initial robotic approach between 2015 and 2019. Patients were divided into 2 groups: surgeries completed robotically and surgeries converted to thoracotomy. Patient demographics, preoperative clinical data, surgical pathology, and perioperative outcomes were compared for meaningful differences between the groups. RESULTS: Thirteen total patients underwent robotic pneumonectomy with 8 of them completed robotically and 5 converted to thoracotomy. There were no significant differences in patient characteristics between the groups. The Robotic group had a shorter operative time (P < 0.01) and less estimated blood loss (P = 0.02). There were more lymph nodes harvested in the Robotic group (P = 0.08) but without statistical significance. There were 2 major complications in the Robotic group and none in the Conversion group. Neither tumor size nor stage were predictive of conversion to thoracotomy. Conversions decreased over time with a majority occurring in the first 2 years. There were no conversions for bleeding and no mortalities. CONCLUSIONS: Robotic pneumonectomy for lung cancer is a safe procedure and a reasonable alternative to thoracotomy. With meticulous technique, major bleeding can be avoided and most procedures can be completed robotically. Larger studies are needed to elucidate any advantages of a robotic versus open approach.

Quality of life outcomes in tracheobronchomalacia surgery.

Tracheobronchomalacia (TBM) is an obstructive airway disease characterized by laxity and redundancy of the posterior membrane of the main airways leading to dynamic airway collapse during exhalation. The gold standard for diagnosis is dynamic computed tomography (DCT) scan and dynamic flexible bronchoscopy (DFB). Patients with complete or near-complete collapse (>90% reduction in cross-sectional area) of the airway are possible candidates for surgical management. Central airway stabilization by tracheobronchoplasty (TBP) effectively corrects malacic airways and has demonstrated significant improvement in objective functional measures, which is often but not uniformly accompanied by equal improvement in health-related quality of life (HRQOL) metrics. This article reviews HRQOL instruments used to report outcomes after TBM surgery.

Switching from Thoracoscopic to Robotic Platform for Lobectomy: Report of Learning Curve and Outcome.

OBJECTIVE: The optimal minimally invasive surgical management for patients with non-small-cell lung cancer (NSCLC) is unclear. For experienced video-assisted thoracoscopic surgery (VATS) surgeons, the increased costs and learning curve are strong barriers for adoption of robotics. We examined the learning curve and outcome of an experienced VATS lobectomy surgeon switching to a robotic platform. METHODS: We conducted a retrospective review to identify patients who underwent a robotic or VATS lobectomy for NSCLC from 2016 to 2018. Analysis of patient demographics, perioperative data, pathological upstaging rates, and robotic approach (RA) learning curve was performed. RESULTS: This study evaluated 167 lobectomies in total, 118 by RA and 49 by VATS. Patient and tumor characteristics were similar. RA had significantly more lymph node harvested (14 versus 10; P = 0.004), more nodal stations sampled (5 versus 4; P < 0.001), and more N1 nodes (8 versus 6; P = 0.010) and N2 nodes (6 versus 4; P = 0.017) resected. With RA, 22 patients were upstaged (18.6%) compared to 5 patients (10.2%) with VATS (P = 0.26). No differences were found in perioperative outcome. Operative time decreased significantly with a learning curve of 20 cases, along with a steady increase in lymph node yield. CONCLUSIONS: RA can be adopted safely by experienced VATS surgeons. Learning curve is 20 cases, with RA resulting in superior lymph node clearance compared to VATS. The potential improvement in upstaging and oncologic resection for NSCLC may justify the associated investments of robotics even for experienced VATS surgeons.

Association Between Inhaled Corticosteroids and Tracheobronchomalacia.

OBJECTIVE: The aim of this study was to assess any association between use of inhaled corticosteroids (ICS) and tracheobronchomalacia (TBM). METHODS: This study was a retrospective analysis of patients with asthma and COPD, with and without TBM. Patients were diagnosed with TBM on the basis of CT imaging, flexible bronchoscopy, or both. Patients were deemed to be on ICS if they had been receiving treatment for at least 3 months. Simple logistic regression models were used to assess the association between TBM status and each proposed factor. A multivariable logistic regression model was used to assess the association between TBM and steroid dose. RESULTS: A total of 463 patients with COPD (n = 153) and asthma (n = 310) were studied. In multivariate analysis, the odds of TBM were 3.5 times higher in patients on high-dose steroids compared with patients not on steroids (OR, 3.5; 95% CI, 1.4-8.5; P = .007). Age (P < .0001), presence of gastroesophageal reflux disease (P < .0001), use of long-acting muscarinic antagonists (P < .0001), and type of pulmonary disease (P = .002) were also associated with TBM. In patients using ICS, the odds of having TBM were 2.9 times greater in patients on high-dose inhaled steroids compared with those on low-dose inhaled steroids (OR, 2.9; 95% CI, 1.2-7.1; P = .02). Age (P = .003), presence of gastroesophageal reflux disease (P = .002), use of long-acting muscarinic antagonists (P = .004), type of ICS (P = .04), and number of months on ICS (P < .0001) were all associated with TBM. CONCLUSIONS: There was a significant association between ICS use in higher doses for a longer duration of time with TBM. Prospective randomized controlled trials are needed to show causality of this observed association.

Minimally invasive robotic-assisted excision of an aortopulmonary mediastinal paraganglioma.

Aortopulmonary paragangliomas are rare, neural crest-derived tumours that arise in the aortopulmonary window and present a significant surgical challenge due to their proximity to major vessels. In the relatively few cases reported in the study, thoracotomy and video-assisted thorascopic surgery (VATS) approaches have been utilized for the treatment of such masses. In this report, we describe the application of a totally endoscopic robotic-assisted VATS approach for the excision of an aortopulmonary paraganglioma.

Necrotizing Infection of the Aortic Arch: Reconstruction Utilizing Unusual Extra-anatomic Bypass Grafts to Reroute Cerebral Blood Flow.

Destructive infections of the aortic arch and great vessels are challenging to manage. We describe a novel technique for debranching the right cerebral and upper extremity arteries via composite extra-anatomic bypasses from the femoral artery, with subsequent homograft in-line reconstruction of the arch, in a patient with Staphylococcus sepsis and necrosis of the arch and great vessels.

First series of minimally invasive, robot-assisted tracheobronchoplasty with mesh for severe tracheobronchomalacia.

OBJECTIVE: Tracheobronchomalacia is a progressive, debilitating disease with limited treatment options. Open tracheobronchoplasty (TBP) is an accepted surgical option for management of severe tracheobronchomalacia. This study examined the outcomes of the first reported series of robot-assisted TBP (R-TBP). METHODS: We retrospectively reviewed the records of patients with clinical suspicion for tracheobronchomalacia who had dynamic computed tomography scan and subsequent R-TBP from May 2016 to December 2017. RESULTS: Four hundred thirty-five patients underwent dynamic computed tomography scan for suspicion of tracheobronchomalacia. Of this group, 42 patients underwent R-TBP. In the surgery group, the median age was 66 years (interquartile range, 39-72 years) and there were 30 women (71%). Respiratory comorbidities included asthma (88%) and chronic obstructive pulmonary disease (52%). The median operative time was 249 minutes (interquartile range, 266-277 minutes). Median hospital length of stay was 3 days (interquartile range, 2-4.75 days), and there were 19 postoperative complications (11 minor and 8 major). There were no mortalities at 90 days. Comparison of preoperative and postoperative pulmonary function testing demonstrated improvement in forced expiratory volume at 1 second by 13.5% (P = .01), forced vital capacity by 14.5% (P < .0001), and peak expiratory flow rate by 21.0% (P < .0001). Quality of life questionnaires also showed improvement with 82% reporting overall satisfaction with the procedure. CONCLUSIONS: R-TBP can be performed with low morbidity and mortality. Early follow-up reveals significant improvement in pulmonary function testing and high patient satisfaction when compared with preoperative baseline. Long-term follow-up is needed to demonstrate the durability of R-TBP and substantiate its role in the management of patients with symptomatic, severe tracheobronchomalacia.