The Surgical Renaissance: Advancements in Video-Assisted Thoracoscopic Surgery and Robotic-Assisted Thoracic Surgery and Their Impact on Patient Outcomes.

Minimally invasive thoracic surgery has advanced the treatment of lung cancer since its introduction in the 1990s. Video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracic surgery (RATS) offer the advantage of smaller incisions without compromising patient outcomes. These techniques have been shown to be safe and effective in standard pulmonary resections (lobectomy and sub-lobar resection) and in complex pulmonary resections (sleeve resection and pneumonectomy). Furthermore, several studies show these techniques enhance patient outcomes from early recovery to improved quality of life (QoL) and excellent oncologic results. The rise of RATS has yielded further operative benefits compared to thoracoscopic surgery. The wristed instruments, neutralization of tremor, dexterity, and magnification allow for more precise and delicate dissection of tissues and vessels. This review summarizes of the advancements in minimally invasive thoracic surgery and the positive impact on patient outcomes.

Robotic-Assisted Pleurectomy is a Safe and Effective Surgical Treatment for Spontaneous Pneumothorax.

INTRODUCTION: Spontaneous pneumothorax is a common thoracic surgical problem. To prevent recurrence, surgical options include blebectomy, mechanical or chemical pleurodesis, pleurectomy, or a combination of these operations. Pleurectomy is associated with lower recurrence rates but may be technically challenging via video-assisted thoracoscopic surgery. We report the first series of robotic-assisted pleurectomy (RAP) for spontaneous pneumothorax. METHODS: A retrospective, single-center analysis was conducted on consecutive patients undergoing RAP for spontaneous pneumothorax from 2017 to 2023. Patients with prior surgery on the same side for pneumothorax were excluded. Demographics, comorbidities, functional status, intraoperative and perioperative variables were collected. 30-d readmission, 30-d mortality, and recurrence were recorded. RESULTS: Thirty-six patients underwent RAP during the study period with a median follow-up of 36 mo. Patients had a median age of 41.5 (interquartile range [IQR] 21.5-68) y and were mostly male (80.6%) and past smokers (44.4%) with 66.6% having a primary spontaneous pneumothorax. The median time to chest tube removal was 3 d (IQR 2-3) and the median length of stay was two days (IQR 2-4). Complications occurred in seven patients with the majority (85.7%) having a grade 2 Clavien-Dindo classification score. There was no 30-d mortality or recurrence. CONCLUSIONS: Robotic-assisted pleurectomy for spontaneous pneumothorax is a safe and effective operation that can be used to prevent future recurrence.

Trends and comparative outcomes between operative approaches for segmentectomy in lung cancer.

BACKGROUND: Segmentectomy is increasingly performed for non-small cell lung cancer. However, comparative outcomes data among open, robotic-assisted, and video-assisted thoracoscopic approaches are limited. METHODS: A retrospective cohort study of non-small cell lung cancer segmentectomy cases (2013-2021) from the Society of Thoracic Surgeons General Thoracic Surgery Database was performed. Baseline characteristics were balanced using inverse probability of treatment weighting and compared by operative approach. Volume trends, outcomes, and nodal upstaging were assessed. RESULTS: Of 9927 patients who underwent segmentectomy, 84.8% underwent minimally invasive surgery, with robotic-assisted thoracoscopic surgery becoming the most common approach in 2019. Open segmentectomy is more likely to be performed at low-volume centers (P < .0001), whereas robotic-assisted thoracoscopic surgery is more likely to be performed at high-volume centers (P < .0001). Video-assisted thoracoscopic surgery had a higher open conversion rate than robotic-assisted thoracoscopic surgery (odds ratio, 11.8; CI, 7.01-21.6; P < .001). Minimally invasive surgery had less 30-day morbidity compared with open segmentectomy (video-assisted thoracoscopic surgery odds ratio, 0.71; 95% CI, 0.55-0.94; P = .013; robotic-assisted thoracoscopic surgery odds ratio, 0.59; CI, 0.43-0.81; P = .001). The number of nodes and stations harvested were highest for robotic-assisted thoracoscopic surgery; however, N1 upstaging was more likely in open compared with robotic-assisted thoracoscopic surgery (odds ratio, 0.63; CI, 0.45-0.89; P < .007) and video-assisted thoracoscopic surgery (odds ratio, 0.61; CI, 0.46-0.83; P = .001). CONCLUSIONS: Segmentectomy volume has increased considerably, with robotic-assisted thoracoscopic surgery becoming the most common approach. Minimally invasive surgery has less major morbidity compared with open segmentectomy, with no difference between video-assisted thoracoscopic surgery and robotic-assisted thoracoscopic surgery. However, risk of open conversion is higher with video-assisted thoracoscopic surgery. Robotic-assisted thoracoscopic surgery had increased nodal harvest, whereas hilar nodal upstaging was highest with thoracotomy. This study reveals significant differences in outcomes exist between segmentectomy operative approach; the impact of approach on survival merits further investigation.

Revolutionizing the effect of Azadirachta indica extracts on edema induced changes in C-reactive protein and interleukin-6 in albino rats: in silico and in vivo approach.

OBJECTIVE: The aim of the present study is to determine the in vivo and in silico anti-inflammatory effect of Azadirachta indica (A. indica) in carrageenan-induced rats and its blood biomarkers. A. indica (Neem) is a widely used medicinal plant across the world, especially in Pakistan. Neem leaves have been traditionally used for the synthesis of drugs and treatment of a wide variety of diseases. MATERIALS AND METHODS: In this study, sixty albino rats (160-200 g) were divided into 4 groups: control (group I), standard (group II), ethanolic and aqueous (group III and IV) at doses of 50, 100, 200 and 400 mg/kg. RESULTS: Ethanolic and aqueous extracts showed maximum inhibition in paw size at the 5th hour (400 mg/kg). Similarly, biomarkers measured, including Interleukin-6 and C-reactive protein, exhibited significant anti-inflammatory activity at the highest dose of 400 mg/kg in both experimental groups but were more distinct in the group treated with ethanolic extracts. Correlation between C-reactive protein (CRP) and inter-leukin-6 (IL-6) showed positive correlation in group III, while negative in group IV. Similarly, positive and negative correlations were observed between CRP biomarkers and paw size in group III and IV, and the same results were also shown in the case of IL-6 and paw size. In molecular docking, the binding energy value of protein CRP and IL-1ß with the identified ligands quercetin and nimbosterol showed (-8.2 kcal/mol and -7.7 kcal/mol) the best binding affinity as compared to standard drug diclofenac with -7.0 kcal/mol binding energy respectively. CONCLUSIONS: In conclusion, in silico and in vivo analysis revealed that the extracts of A. indica leaves can be used as an effective drug to manage inflammation.

Patients' perceptions of the post-pancreatectomy discharge process.

BACKGROUND: Complications after pancreatectomies contribute to poor outcomes. Patients are expected to identify signs/symptoms leading to these complications but may be poorly educated on how to identify them. We assessed the impact of an educational tool on patient perceptions of, and satisfaction with the discharge process, and its effect on readmission rates. METHODS: A prospective cohort study with retrospective chart review including patients who underwent pancreatic resection was undertaken. An interactive educational module (iBook) that provided information about the procedure, possible complications, and peri-discharge information was implemented. English-speaking patients were equally divided into the pre- and post-iBook cohorts. Primary outcome was patients' satisfaction with discharge; Secondary outcomes were 30- and 90-day readmission rates. RESULTS: 100 patients were included. Mean age was 65.5 ± 12.6, 46% were female, and 92.3% were white. Most patients underwent Whipple procedures (72%), and distal pancreatectomies (26%). In the post-implementation group, 92% were satisfied with the discharge process, and 89% reported it was a good tool. There were no statistical differences in 30- and 90-day readmission rates between cohorts. CONCLUSION: The iBook positively impacted patients' satisfaction and preparedness for discharge. Readmission rates were not statistically significantly impacted but could be investigated with further studies of greater sample sizes.

Robotic Mediastinal Surgery.

The robotic platform can be viewed as an advanced thoracoscopic instrument and can be utilized for any pathology amenable to thoracoscopic surgery. This ultimately comes down to surgeon comfort, but many have demonstrated the robotic approach to be useful in benign and malignant mediastinal disease in all compartments with at least equivalent-if not superior-outcomes compared to sternotomy for many metrics. There are various robotic approaches to the same compartments (such as with thymectomy), and no one robotic approach has proven superior to another. Here we describe our robotic approach to common mediastinal pathology.

Pembrolizumab Improves Survival After Resection of Intracardiac Metastatic Cervical Carcinoma.

Intracardiac metastasis of cervical squamous cell carcinoma (C-SCC) is rare, with historically poor long-term survival. We report the case of a 55-year-old woman with prior metastatic C-SCC who was found to have a right ventricular mass causing functional pulmonic stenosis and multiple pulmonary emboli 19 months after her initial diagnosis. She underwent surgical resection to prevent further embolization and heart failure. Pathology confirmed metastatic C-SCC and she was maintained on adjuvant pembrolizumab. She remained well 32 months later without further disease progression. Surgical resection of intracardiac metastasis of C-SCC combined with pembrolizumab therapy may result in improved postoperative life expectancy.

A scoping review of artificial intelligence applications in thoracic surgery.

OBJECTIVES: Machine learning (ML) has great potential, but there are few examples of its implementation improving outcomes. The thoracic surgeon must be aware of pertinent ML literature and how to evaluate this field for the safe translation to patient care. This scoping review provides an introduction to ML applications specific to the thoracic surgeon. We review current applications, limitations and future directions. METHODS: A search of the PubMed database was conducted with inclusion requirements being the use of an ML algorithm to analyse patient information relevant to a thoracic surgeon and contain sufficient details on the data used, ML methods and results. Twenty-two papers met the criteria and were reviewed using a methodological quality rubric. RESULTS: ML demonstrated enhanced preoperative test accuracy, earlier pathological diagnosis, therapies to maximize survival and predictions of adverse events and survival after surgery. However, only 4 performed external validation. One demonstrated improved patient outcomes, nearly all failed to perform model calibration and one addressed fairness and bias with most not generalizable to different populations. There was a considerable variation to allow for reproducibility. CONCLUSIONS: There is promise but also challenges for ML in thoracic surgery. The transparency of data and algorithm design and the systemic bias on which models are dependent remain issues to be addressed. Although there has yet to be widespread use in thoracic surgery, it is essential thoracic surgeons be at the forefront of the eventual safe introduction of ML to the clinic and operating room.

COVID-19 and cardiothoracic surgery: Effects on training and workforce utilization in a global pandemic.

BACKGROUND: The COVID-19 pandemic has disrupted all aspects of healthcare, including cardiothoracic surgery (CTS). We sought to determine the pandemic's impact on CTS trainees' educational experiences. METHODS: A survey was developed and distributed to members of the Thoracic Surgery Residents Association and other international CTS trainees. Trainees were asked to evaluate their cumulative experiences and share their overall perceptions of how CTS training had been impacted during the earliest months of the COVID-19 pandemic (i.e., since March 01, 2020). Surveys were distributed and responses were recorded June 25-August 05, 2020. In total, 748 surveys were distributed and 166 responses were received (overall response rate 22.2%). Of these, 126 of 166 responses (75.9%) met inclusion criteria for final analysis. RESULTS: Final responses analyzed included 45 of 126 (35.7%) United States (US) and 81 of 126 (64.3%) international trainees, including 101 of 126 (80.2%) senior and 25 of 126 (19.8%) junior trainees. Most respondents (76/126, 43.2%) lost over 1 week in the hospital due to the pandemic. Juniors (12/25, 48.0%) were more likely than seniors (20/101, 19.8%) to be reassigned to COVID-19-specific units (p < .01). Half of trainees (63/126) reported their case volumes were reduced by over 50%. US trainees (42/45, 93.3%) were more likely than international trainees (58/81, 71.6%) to report reduced operative case volumes (p < .01). Most trainees (104/126, 83%) believed their overall clinical acumen was not adversely impacted by the pandemic. CONCLUSIONS: CTS trainees in the United States and abroad have been significantly impacted by the COVID-19 pandemic, with time lost in the hospital, decreased operative experiences, less time on CTS services, and frequent reassignment to COVID-19-specific care settings.

Trimodality Approach for Esophageal Malignancies.

Trimodality therapy, or the use of concurrent chemoradiation followed by surgery, is the cornerstone of contemporary management of esophageal cancer. This article discusses the landmark trials and most current data to understand the concepts, applications, and outcomes from trimodality therapy in locally advanced esophageal cancer.

Robotic-Assisted Complex Pulmonary Resection: Sleeve Lobectomy for Cancer.

The use of robotic assistance for complex pulmonary resections such as segmentectomy and sleeve lobectomy has steadily increased in recent years. These operations are technically challenging as they require fine dissection and suturing, which is often difficult to perform using traditional minimally invasive techniques. Robotic surgery is well-suited for complex pulmonary surgery given its specific advantages related to superior optics and precise tissue manipulation and dissection. Herein we describe our technique for robotic-assisted complex pulmonary surgery with a specific focus on right upper sleeve lobectomy for cancer, including associated video case demonstration. The principles discussed are generalizable to other complex lung and tracheobronchial operations and highlight the benefits of the robotic platform.

National Survey of Burnout and Distress Among Cardiothoracic Surgery Trainees.

BACKGROUND: Burnout has been linked to poor job satisfaction and increased medical errors, and is prevalent among health care professionals. We sought to characterize burnout and distress among US cardiothoracic surgery (CTS) trainees. METHODS: A 19-question survey was sent to CTS trainees in collaboration with the Thoracic Surgery Residents Association. We queried sociodemographic variables, balance/quality of life, and indicators of depression and regret. We included questions along the emotional exhaustion, depersonalization, and personal accomplishment subscales of the Maslach Burnout Inventory. RESULTS: The survey was sent to 531 CTS trainees across 76 institutions and there were 108 responses (20.3%). More than 50% of respondents expressed dissatisfaction with balance in their professional life and more than 40% screened positively for signs of depression. More than 25% of respondents (n = 28) would not complete CTS training again, given a choice. More than half met criteria for burnout on emotional exhaustion and depersonalization subscales. The CTS residents with children were more likely to express regret toward pursuing CTS training. A greater proportion of women than men reported poor levels of balance/quality of life during training as measured by missed health appointments, negative impact on relationships, and self-perception. Similarly, those in the final 3 years of training were more likely to report poor levels of balance/quality of life. CONCLUSIONS: High rates of burnout, regret, and depression are present among US CTS trainees. Efforts to promote trainee well-being and implement interventions that support those at high risk for burnout are warranted, to benefit trainees as well as the patients they serve.

Surgical Adjuncts During Esophagectomy.

Esophagectomy is a major operation whereby intraoperative technique and postoperative care must be optimal. Even in expert hands, the complication rate is as high as 59%. Here the authors discuss the role of surgical adjuncts, including enteral access, nasogastric decompression, pyloric drainage procedures, and anastomotic buttressing as adjuncts to esophagectomy and whether they reduce perioperative complications.

Biliary palliation for unresectable pancreatic adenocarcinoma: surgical bypass or self-expanding metal stent?

BACKGROUND: Standard of care guidelines endorse self-expanding metal stents (SEMS) rather than open surgical biliary bypass (OSBB) for biliary palliation in the setting of unresectable pancreatic ductal adenocarcinoma (PDAC). This study used competing risk analysis to compare short- and long-term morbidity and overall survival among patients undergoing SEMS or OSBB after unresectable or metastatic disease is identified at the time of exploration. METHODS: Single institution retrospective cohort study (n = 127) evaluating outcomes after OSBB and SEMS for biliary palliation in patients found to have unresectable PDAC at exploration. Short-term, long-term, and lifetime risk of biliary occlusion and survival were compared after adjustment for stage and comprehensive complication index (CCI). RESULTS: Baseline demographics and tumor characteristics were equivalent between cohorts. Short-term complications were more frequent after OSBB, whereas late complications were greater after SEMS. The cumulative incidence of recurrent biliary obstruction was greater after SEMS, but lifetime complication burden and median survival were equivalent. CONCLUSION: OSBB was associated with longer hospital stays and more short-term complications, and SEMS was associated with a higher risk of recurrent biliary obstruction among surgical patients with unresectable PDAC. Patient preference should be defined pre-operatively in the case the unresectable disease is encountered during attempted resection.

An effective multi-modality model for single-session cricothyroidotomy training for trainees.

BACKGROUND: We piloted a curriculum combining a flipped classroom with two-stage narration, role-play, and partial task trainer simulation to teach this critical skill to trainees. METHODS: This "flipped classroom" module (2012-2018) for open and percutaneous cricothyroidotomy (OC and PC) required participants to watch two 4 min training videos for OC and PC. The simulation session consisted of a 45-min hands-on simulation of OC and PC in which participants rotated between the roles of operator, narrator, and critiquer. Median performance scores were calculated. RESULTS: 103 trainees were evaluated. The median performance score was 14 out of maximum 14 (range: 9-14) across all trainees for OC. The median performance score was 13 out of maximum 13 (range: 3-13) across all trainees for PC. CONCLUSION: A multi-modality approach including the flipped classroom, role-play, and partial task trainer simulation is an efficient and effective method for teaching trainees proficiency in short, single operator procedures.

Transversus abdominis plane block reduces pain and narcotic consumption after robot-assisted distal pancreatectomy.

BACKGROUND: Minimizing pain and disability are key postoperative objectives of robot-assisted distal pancreatectomy (RADP). This study tested effects of bupivacaine transversus abdominis plane (TAP) block on opioid consumption and pain after RADP. METHODS: Retrospective case-control study (June 2012 -Oct 2017) evaluating bilateral intraoperative bupivacaine TAP block as an interrupted time series. Linear regression evaluated opioid consumption in terms of intravenous (IV) morphine milligram equivalents (MME) and controlled for preoperative morbidity. Secondary outcomes included numerical rating scale (NRS) pain scores. RESULTS: 81 RADP patients met eligibility, 48 before and 33 after implementation of TAP. Baseline characteristics were equivalent with a trend toward higher age, Charlson comorbidity, and ASA score among the TAP cohort. TAP patients consumed on average 4.52 fewer IV MME than controls during the first six postoperative hours (p = 0.032) and reported lower mean NRS scores at six (p = 0.009) and 12 h (p = 0.006) but not at 24 h (p = 0.129). Postoperative morbidity and lengths of stay (LOS) were equivalent (5 vs. 6 days, p = 0.428). CONCLUSION: Bupivacaine TAP block was associated with significant reductions in opioid consumption and pain after RADP but did not shorten hospital LOS consistent with bupivacaine's limited half-life.

Braden scale for pressure ulcer risk predicts rehabilitation placement after pancreatic resection.

BACKGROUND: Patients undergoing pancreatic resection frequently require rehabilitation facilities after hospital discharge. We evaluated the predictive role of validated markers of frailty on rehabilitation facility placement to identify patients who may require this service. METHODS: Single-center retrospective cohort study of patients who underwent pancreatic resection from 2010 to 2015. 90-day morbidity and mortality were calculated. Postoperative validated markers of frailty (Activities of Daily Living scale, Braden scale [assesses pressure ulcer risk, lower scores = higher risk] and Morse fall scale) were evaluated via multivariate regression to identify predictors of discharge to rehabilitation facility. RESULTS: 470 patients with complete data were included. Mean age was 62 and 49.2% were male. Postoperative median length of stay (LOS) was 8 (IQR 7-10). 92 (19.66%) patients were discharged to rehabilitation facilities and 138 (29.49%) patients were readmitted within 90 days. On multivariate analysis, age, sex, LOS > 8 days, inpatient Comprehensive Complication Index (CCI) and initial Braden scale were predictive of rehabilitation placement. CONCLUSION: A marker of frailty routinely collected daily by nursing staff, the Braden scale, is available to help surgeons predict the need for postoperative rehabilitation placement after pancreatic resection. Engaging discharge planning services for at-risk patients may help prevent delayed hospital discharge and should be further evaluated.