Discharging Patients Home With a Chest Tube and Digital System After Robotic Lung Resection.

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.

The Society of Thoracic Surgeons Expert Consensus Document on the Management of Pleural Drains following Pulmonary Lobectomy.

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.

The modified Lyon's position: an alternative approach to robotic thymectomy.

The conventional supine position for robotic thymectomy may present challenges in accessing the lower thymic horns, particularly in cases requiring extensive resection of mediastinal fat. To address this issue, the authors advocate for a lateral patient position during the procedure, emphasizing optimized access to the thymic horns and improved procedural efficacy. The lateral approach involves specific trocar placements and port arrangements to minimize conflicts between instruments. This report proposes an innovative approach to robotic thymectomy for patients diagnosed with thymoma or thymic hyperplasia associated with myasthenia gravis.

Comparing Robotic, Thoracoscopic, and Open Segmentectomy: A National Cancer Database Analysis.

INTRODUCTION: Minimally invasive approaches to lung resection have become widely acceptable and more recently, segmentectomy has demonstrated equivalent oncologic outcomes when compared to lobectomy for early-stage non-small cell lung cancer (NSCLC). However, studies comparing outcomes following segmentectomy by different surgical approaches are lacking. Our objective was to investigate the outcomes of patients undergoing robotic, video-assisted thoracoscopic surgery (VATS), or open segmentectomy for NSCLC using the National Cancer Database. METHODS: NSCLC patients with clinical stage I who underwent segmentectomy from 2010 to 2016 were identified. After propensity-score matching (1:4:1), multivariate logistic regression analyses were performed to determine predictors of 30-d readmissions, 90-d mortality, and overall survival. RESULTS: 22,792 patients met study inclusion. After matching, approaches included robotic (n = 2493; 17%), VATS (n = 9972; 66%), and open (n = 2493; 17%). An open approach was associated with higher 30-d readmissions (7% open versus 5.5% VATS versus 5.6% robot, P = 0.033) and 90-d mortality (4.4% open versus 2.2% VATS versus 2.5% robot, P < 0.001). A robotic approach was associated with improved 5-y survival (50% open versus 58% VATS versus 63% robot, P < 0.001). CONCLUSIONS: For patients with clinical stage I NSCLC undergoing segmentectomy, compared to the open approach, a VATS approach was associated with lower 30-d readmission and 90-d mortality. A robotic approach was associated with improved 5-y survival compared to open and VATS approaches when matched. Additional studies are necessary to determine if unrecognized covariates contribute to these differences.

Assessment of the well-being of significant others of cardiothoracic surgeons.

OBJECTIVES: We aimed to evaluate how the current working climate of cardiothoracic surgery and burnout experienced by cardiothoracic surgeons influences their spouses and significant others (SOs). METHODS: A 33-question well-being survey was developed by the American Association for Thoracic Surgery Wellness Committee and distributed by e-mail to the SOs of cardiothoracic surgeons and to all surgeon registrants of the 2020 and 2021 American Association for Thoracic Surgery Annual Meetings with a request to share it with their SO. The 5-item Likert-scale survey questions were dichotomized, and associations were determined by χ2 or independent samples t tests, as appropriate. RESULTS: Responses from 238 SOs were analyzed. Sixty-six percent reported that the stress on their cardiothoracic surgeon partner had a moderate to severe influence on their family, and 63% reported that their partner's work demands didn't leave enough time for family. Fifty-one percent reported that their partner rarely had time for intimacy, 27% reported poor work-life balance, and 23% reported that interactions at home were usually or always not good-natured. SOs were most affected when their partner was <5 years out from training, worked in private vs academic practice, and worked longer hours. Having children, particularly younger than age 19 years, and a lack of workplace support resources further diminished well-being. CONCLUSIONS: The current work culture of cardiothoracic surgeons adversely affects their SOs, and the risk for families is concerning. These data present a major area for exploration as we strive to understand and mitigate the factors that lead to burnout among cardiothoracic surgeons.

Surgical considerations in the resection of solitary fibrous tumors of the pleura.

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.

Pulmonary Open, Robotic, and Thoracoscopic Lobectomy (PORTaL) Study: Survival Analysis of 6646 Cases.

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.

Pulmonary Open, Robotic, and Thoracoscopic Lobectomy (PORTaL) Study: An Analysis of 5721 Cases.

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.

The process and safety of removing chest tubes 4 to 12 hours after robotic pulmonary lobectomy and segmentectomy.

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.

A chest tube after robotic thymectomy is unnecessary.

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.

Well-being of Cardiothoracic Surgeons in the Time of COVID-19: A Survey by the Wellness Committee of the American Association for Thoracic Surgery.

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.

Use of a novel digital drainage system after pulmonary resection.

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.

The Role of Surgery in Patients with COVID-19-Related Thoracic Complications.

Objective: Patients with several thoracic complications induced by SARS-CoV-2 infection may benefit from surgery, but its role in this condition is largely unknown, and many surgeons' advice against any surgical referrals. Our aim is to investigate the efficacy and safety of surgery in COVID-19 patients with thoracic complications requiring surgery. Methods: We designed a multicenter observational study, involving nine thoracic surgery departments, evaluating patients who developed thoracic complications in hospital, surgically managed from March 1, 2020, to May 31, 2021. An overall 30-day mortality was obtained by using the Kaplan-Meier method. Multivariable Cox regression model and logistic models were applied to identify the variables associated with mortality and postoperative complications. Results: Among 83 patients, 33 (40%) underwent surgery for complicated pneumothorax, 17 (20.5%) for pleural empyema, 13 (15.5%) for hemothorax, 8 (9.5%) for hemoptysis, 5 patients (6%) for lung abscess, 4 (5%) for infected pneumatoceles, and 3 (3.5%) for other causes. Within 30 days of surgery, 60 patients (72%) survived. At multivariable analysis, age (HR 1.05 [95% CI, 1.01, 1.09], p = 0.022), pulmonary hypertension (HR 3.98 [95% CI, 1.09, 14.5], p = 0.036), renal failure (HR 2.91 [95% CI, 1.19, 7.10], p-value 0.019), thoracotomy (HR 4.90 [95% CI, 1.84, 13.1], p-value 0.001) and infective affections (HR 0.17 [95% CI, 0.05, 0.58], p-value 0.004) were found to be independent prognostic risk factors for 30-day mortality. Age (OR 1.05 [95% CI, 1.01, 1.10], p = 0.023) and thoracotomy (OR 3.85 [95% CI, 1.35, 12.0] p = 0.014) became significant predictors for 30-day morbidity. Conclusion: Surgical management of COVID-19-related thoracic complications is affected by high mortality and morbidity rates, but a 72% survival rate still seems to be satisfactory with a rescue intent. Younger patients without pulmonary hypertension, without renal insufficiency and undergoing surgery for infectious complications appear to have a better prognosis.

The effect of enhanced recovery after minimally invasive esophagectomy: a randomized controlled trial.

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.

One-Year Outcomes With Venovenous Extracorporeal Membrane Oxygenation Support for Severe COVID-19.

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.