Enhanced recovery after surgery may mitigate the risks associated with robotic-assisted fundoplication in lung transplant patients.

INTRODUCTION: A history of lung transplantation is a risk factor for poor outcomes in patients undergoing laparoscopic fundoplication. We wanted to determine whether enhanced recovery after a robotic-assisted surgery program would mitigate these risks. METHODS: We performed a single-center retrospective analysis of the Society of Thoracic Surgery database for patients who underwent elective antireflux procedures from 1/2018 to 2/2021 under the enhanced recovery after surgery program using robotic assistance. We identified the patient and surgical characteristics, morbidity, length of stay, and 30-day readmission rates. RESULTS: Among 386 patients who underwent barrier creation, 41 had previously undergone a lung transplant, either bilateral (n = 28) or single (n = 13). There were no significant differences in postoperative complications (9.8% vs. 5.2%, p = 0.27), median hospital length of stay (1 d vs. 1 d, p = 0.28), or 30-day readmission (7.3% vs. 4.9%, p = 0.46). Bivariate analysis showed that older age (p = 0.03), history of DVT/PE (p < 0.001), history of cerebrovascular events (p = 0.03), opioid dependence (p = 0.02), neurocognitive dysfunction (p < 0.001), and dependent functional status (p = 0.02) were associated with postoperative complications. However, lung transplantation was not associated with an increased risk of postoperative complications (p = 0.28). DISCUSSION: The risk of surgical complications in patients with a history of lung transplantation may be mitigated by the combination of ERAS and minimally invasive surgery such as robot-assisted surgery.

A systematic review of general surgery robotic training curriculums.

Background: As of the most recent surveys of resident programs in 2018, only slightly more than half of programs have formal robotic training curriculums implemented. Fewer programs have further assessed their own curriculum and its benefit. Method: We conducted a PubMed/MEDLINE literature search for robotic surgery curriculums and those that had assessment of their programs. Results: A total of 11 studies were reviewed. When reviewed in chronological order, there has been a progression towards more robotic specific objective data analysis as opposed to subjective surveying. There is a wide variation in curriculums, but simulation use is pervasive. Conclusions: Our review makes evident two important concepts-there is great variety in training curriculums and there is great benefit in implementation. The importance is in establishment of what makes resident training effective and supports the adaptable and successful surgeon. This may come from an adaptable curriculum but a structured test-out assessment.

Surgical Treatment of Atrioesophageal Fistula: A Systematic Review.

BACKGROUND: Atrioesophageal fistula is a rare and morbid complication of ablation therapy for atrial fibrillation. Surgery provides increased survival; however, which surgical approach provides the best outcome is unclear. METHODS: We performed a retrospective analysis of cases in the literature and at our institution. We characterized patients by presenting symptoms, diagnostic method, surgical therapy with different approaches, and survival. RESULTS: In total, 219 patients were found, with 216 patients identified from 122 papers in the literature and 3 patients from our institutional database (2000-2022). The most common presenting symptoms included fever/chill (71.8%) and neurologic deficiency (62.9%). The overall survival for this cohort was 47%. Patients who had an operation had significantly improved survival compared with those who did not have an operation (71.9.3% vs 11%, P < .001). Patients who survived after surgical intervention typically underwent right thoracotomy (45.1%), patch repair of the left atrium (61.1%), and primary repair of the esophagus (68.3%) on cardiopulmonary bypass (84.8%) with a flap between the 2 organs (84.6%). Patients who had cardiopulmonary bypass had increased survival (39 of 45 [86.7%]) compared with those who did not have cardiopulmonary bypass (7 of 17 [41.2%], P < .001). CONCLUSIONS: Patients with atrioesophageal fistula should undergo surgical intervention. A patch repair of the left atrium and primary repair of the esophagus with a flap between the organs during cardiopulmonary bypass is the most common successful repair. Cardiopulmonary bypass may allow better débridement and repair of the left atrium, which may provide a survival advantage in the treatment of this rare disease.

Stellate ganglion instrumentation for pharmacological blockade, nerve recording, and stimulation in patients with ventricular arrhythmias: Preliminary experience.

BACKGROUND: Stellate ganglion blockade (SGB) can control ventricular arrhythmias (VAs), but outcomes are unclear. Percutaneous stellate ganglion (SG) recording and stimulation in humans has not been reported. OBJECTIVE: The purpose of this study was to assess the outcomes of SGB and the feasibility of SG stimulation and recording in humans with VAs. METHODS: Two patient cohorts were included-group 1: patients undergoing SGB for drug-refractory VAs. SGB was performed by injection of liposomal bupivacaine. Incidence of VAs at 24 and 72 hours and clinical outcomes were collected; group 2: patients undergoing SG stimulation and recording during VA ablation; a 2-F octapolar catheter was placed at the SG at the C7 level. Recording (30 kHz sampling, 0.5-2 kHz filter) and stimulation (up to 80 mA output, 50 Hz, 2 ms pulse width for 20-30 seconds) was performed. RESULTS: Group 1 included 25 patients [age 59.2 ± 12.8 years; 19 (76%) men] who underwent SGB for VAs. Nineteen patients (76.0%) were free of VA up to 72 hours postprocedure. However, 15 (60.0%) had VAs recurrence for a mean of 5.47 ± 4.52 days. Group 2 included 11 patients (mean age 63 ± 12.7 years; 82.7% men). SG stimulation caused consistent increases in systolic blood pressure. We recorded unequivocal signals with temporal association with arrhythmias in 4 of 11 patients. CONCLUSION: SGB provides short-term VA control, but has no benefit in the absence of definitive VA therapies. SG recording and stimulation is feasible and may have value to elicit VA and understand neural mechanisms of VA in the electrophysiology laboratory.

Self-assisting robot-assisted pulmonary lobectomy has favorable outcome compared to VATS lobectomy.

Background: Open and video-assisted thoracoscopic surgery (VATS) pulmonary lobectomy requires a skilled assistant to complete the operation. A potential benefit of a robot is to allow a surgeon to complete the operation autonomously. We sought to determine the safety of performing robotic-assisted pulmonary lobectomy with self-assistance. Methods: We performed a retrospective analysis of self-assisting robot-assisted lobectomy. We evaluated the intraoperative and postoperative outcomes. We compared the outcome to the propensity matched group of patients who had VATS lobectomy. We also compared them to published outcomes of robot-assisted lobectomy. Results: 95 patients underwent self-assisted lobectomies. The median age was 70 years old, predominately female (57%) and white (85%) with 90% of patients undergoing surgery for cancer. The median of estimated blood loss was 25 mL during the operation with no conversions to open thoracotomies. After the operation, 17% of patients had major postoperative complications with a median length of stay of 2 days. At thirty-day follow-up, the readmission rate was 6.5%, with a mortality of 0%. Compared to the propensity matched VATS lobectomy group, there was significantly less conversion to open surgery (n=0, 0% vs. n=10, 12.2%, P=0.002), less intraoperative blood transfusions (n=0, 0% vs. n=6, 7.3%, P=0.03), less any complications (n=20, 24.4% vs. n=41, 50%, P=0.003), and less median length of stay (2 days, IQR 2, 5 days vs. 4 day, IQR 3, 6 days, P<0.001) in the self-assisting robot lobectomy group. Compared to published outcomes of robot-assisted lobectomy, our series had significantly fewer conversions to open (P=0.03), shorter length of stay (P<0.001), more discharges to home (93.7%) without a difference in procedure time (P=0.38), overall complication rates (P=0.16) and mortality (P=0.62). Conclusions: Self-assistance using the robot technology during pulmonary lobectomy had few technical complications and acceptable morbidity, length of stay, and mortality. This group had favorable outcome compared to VATS lobectomy. The ability to self-assist during pulmonary lobectomy is an additional benefit of the robot technology compared to open and VATS lobectomy.

Anatomic Pulmonary Resection is Associated With Improved Survival in Typical Carcinoid Lung Tumor Patients.

BACKGROUND: The optimal extent of resection for a patient with a typical carcinoid tumor has been controversial. Studies suggest that wedge resection is an adequate oncologic operation for this tumor type. MATERIALS AND METHODS: We analyzed the National Cancer Database to determine an optimal surgical resection for patients with a typical carcinoid tumor. We determined the number of patients who had typical carcinoid tumors. We then performed a survival analysis of the propensity-matched group of patients having a pathologic stage I typical carcinoid tumor who had undergone anatomic pulmonary resection (lobectomy and segmentectomy) or wedge resection. RESULTS: A total of 10,265 patients met the inclusion and exclusion criteria: 8956 (87%) had a typical carcinoid tumor, while 1309 patients (13%) had an atypical carcinoid tumor. Among patients with typical carcinoid tumors, there were 7163 patients (80%) who underwent anatomic pulmonary resection (6755 patients with lobectomy, 94% and 408 patients with segmentectomy, 6%) and 1793 patients (20%) who underwent wedge resection. In this cohort, patients who had an anatomic resection had significantly improved 5-y survival compared to patients who had wedge resection (91% versus 84%, P < 0.001). In the propensity score-matched group of stage I typical carcinoid tumors (n = 1348), the patients who had an anatomic resection had significantly improved survival compared to patients who had wedge resections (89% versus 85%, P = 0.01) at 5 y. CONCLUSIONS: The anatomic resection compared to wedge resection was associated with improved survival in patients with early-stage typical carcinoid lung cancer. Surgically fit patients should be considered for anatomic resection for typical carcinoid tumors.

Lobectomy Provides the Best Survival for Stage I Lung Cancer Patients Despite Advanced Age.

BACKGROUND: The Lung Cancer Study Group has shown that lobectomy provides the best survival in patients with non-small cell lung cancer. However, as patients become older, lobectomy may not provide a survival advantage compared with sublobar resection. METHODS: We analyzed the National Cancer Database for octogenarians with pathologic stage I lung cancer from 2004 to 2016. We then evaluated the patients who underwent lobectomy or sublobar (segmentectomy or wedge) resection for the treatment of cancer. We analyzed the 5-year survival rates of the groups as well as a cubic spline plot to determine age cutoffs where lobectomy does not provide improved survival. RESULTS: Among the octogenarians (227 134), there were 25 362 (26%) who had pathologic stage I lung cancer. There were 6370 (30%) patients who had sublobar resections (segmentectomy [n = 1192] and wedge resection [n = 5178]), whereas 14 594 (70%) patients had a lobectomy. There was significantly improved survival at 5 years with lobectomy compared with sublobar resection (48.5% vs 41.1%; P < .001). The cubic spline plot provided evidence that there was no age at which sublobar resection provided survival better than or equal to lobectomy (P < .001). CONCLUSIONS: In octogenarians with pathologic stage I lung cancer, lobectomy provided better 5-year survival compared with sublobar resection regardless of the age at surgical procedure. Hence, all patients with stage I cancer should be considered for a lobectomy if they are medically able to tolerate such a procedure.

Robot-assisted Thoracoscopic Lobectomy of T4 Lung Cancer.

A 79-year-old male former smoker presented with a T4 (>7 cm) adenocarcinoma of the right upper lobe. The patient was staged at clinical T4N0M0 and underwent robot-assisted right upper lobectomy and mediastinal lymph node dissection. The patient was discharged home on postoperative day 3. Larger tumors are a relative contraindication for video-assisted thoracoscopic surgical lobectomy. The robot platform overcomes the technical limitations of video-assisted thoracoscopic surgery and allows for the successful resection of large tumors.

Intraoperative diagnosis and treatment of Achalasia using EndoFLIP during Heller Myotomy and Dor fundoplication.

BACKGROUND: Manometry is the gold standard diagnostic test for achalasia. However, there are incidences where manometry cannot be obtained preoperatively, or the results of manometry is inconsistent with the patient's symptomatology. We aim to determine if intraoperative use of EndoFLIP can provide a diagnosis of achalasia and provide objective information during Heller myotomy and Dor fundoplication. METHODS: To determine the intraoperative diagnostic EndoFLIP values for patients with achalasia, we determined the optimal cut-off points of the distensibility index (DI) between patients with a diagnosis of achalasia and patients with a diagnosis of hiatal hernia. To evaluate the usefulness of EndoFLIP values during Heller myotomy and Dor fundoplication, we obtained a cohort of patients with EndoFLIP values obtained after Heller myotomy and after Dor fundoplication as well as Eckardt score before and after surgery. RESULTS: Our analysis of 169 patients (133 hiatal hernia and 36 achalasia) showed that patients with DI < 0.8 have a >99% probability of having achalasia, while DI > 2.3 have a >99% probability of having hiatal hernia. Patients with a DI 0.8-1.3 have a 95% probability of having achalasia, and patients with a DI of 1.4-2.2 have a 94% probability of having a hiatal hernia. There were 40 patients in the cohort to determine objective data during Heller myotomy and Dor fundoplication. The DI increased from a median of 0.7 to 3.2 after myotomy and decreased to 2.2 after Dor fundoplication (p < 0.001). The median Eckardt score went down from a median of 4.5 to 0 (p < 0.001). CONCLUSIONS: Our study shows that intraoperative use of EndoFLIP can facilitate the diagnosis of achalasia and is used as an adjunct to diagnose achalasia when symptoms are inconsistent. The routine use of EndoFLIP during Heller myotomy and Dor fundoplication provides objective data during the operation in a group of patients with excellent short-term outcomes.

A novel EndoFLIP marker during hiatal hernia repair is associated with short-term postoperative dysphagia.

BACKGROUND: Endoluminal functional lumen imaging probe (EndoFLIP) provides an objective measure of the distensibility index (DI) during different parts of hiatal hernia repair. However, the absolute DI measure above a cut-off after creating a barrier alone has not shown a relationship to dysphagia after surgery. We wanted to determine if the change in DI with volume change is associated with dysphagia. METHODS: We included patients who had hiatal hernia repair with EndoFLIP values, including two values taken at the end of the surgical case with different volumes of fluid in the balloon (30 mL and 40 mL). We compared the absolute and change in DI during hiatal hernia repair and performed an analysis to determine if there was a correlation with short-term clinical outcomes. RESULTS: A total of 103 patients met the inclusion and exclusion criteria. Most of the patients underwent Toupet fundoplication (n = 56, 54%), followed by magnetic sphincter augmentation (LINX, n = 28, 27%) and Nissen fundoplication (n = 19, 18%). There was a significant reduction in the DI from the initial DI taken after mobilization of the hiatus (3 mm2/mmHg) and after the creation of the barrier (1.4 mm2/mmHg, p < 0.001). A minority of patients had a decrease or no change in the DI with an increase in balloon volume increased from 30 to 40 mL (n = 37, 36%). Overall, after 1 month, there was a significant decrease in the GERD-HRQL score from 23 to 4 (p < 0.001) and bloat score from 3 to 2 (p = 0.003) with a non-significant decrease in the dysphagia score from 1 to 0 (p = 0.11). Patients who had a decreased or unchanged DI with an increase in the balloon volume from 30 to 40 mL had a significant decrease in their dysphagia score by 2 points (p = 0.04). CONCLUSION: The decreased or unchanged DI with an increase in the balloon volume on EndoFLIP is associated with a significant reduction in dysphagia after surgery. The decrease in DI denotes the esophagus's ability to create higher pressure relative to the change in the cross-sectional area with a larger bolus across the gastroesophageal junction. This measure may be a new marker that can predict short-term outcomes in patients undergoing hiatal hernia repair.

Video-based curriculum improves resident participation during robot-assisted surgery.

Background: Surgical videos allow residents to prepare for the operating room. We sought to determine if a video-based curriculum improves resident participation during robot-assisted surgery. Methods: We created a video-based surgical curriculum by providing residents with narrated videos of similar cases before participating in the operating room. We obtained information about the average monthly viewings of cases and the total monthly time spent viewing cases. We surveyed the residents after a year of the program. In addition, we used software to track the amount of time the resident spent controlling the robot during the case. We assessed the amount of time the resident had control of the robot for their first robot-assisted hiatal hernia repair of the month with a dual console for 13 months before and after implementing the curriculum. Results: A total of 43 videos were made for the video-based curriculum. On average, 37 videos were viewed during the month, with residents spending 16 hours per month viewing the videos. Twenty residents (83%) completed the survey. 90% of the residents often or always watched the video before surgery. All residents felt videos were better than books to prepare for surgery (100%). Residents thought that the videos helped them prepare for surgery: understanding surgical anatomy (95%), the cognitive aspect of the surgery (95%), and the technical part of surgery (100%). Analysis of the resident console time of the first robot-assisted hiatal hernia repair of the month showed a significant increase in the amount of time the resident participated in the case from 11% to 48% (P<0.001). Conclusions: Video-based curriculum was a valuable tool for residents to prepare for surgical cases. Video-based curriculum significantly increases resident participation during robot-assisted thoracic surgery. Adopting this strategy will improve the resident training experience. A video-based curriculum should be adopted in surgical education.

Surgery provides improved overall survival in surgically fit octogenarians with esophageal cancer after chemoradiation therapy.

BACKGROUND: Multiple randomized controlled trials have shown that multimodal therapy provides the best overall survival for patients who had locally advanced esophageal cancer. However, it is unknown if multimodal therapy offers the best overall survival in octogenarians. METHODS: We performed retrospective cohort study using data obtained from the National Cancer Database (NCDB) for octogenarians who had locally advanced esophageal cancer from 2004 to 2015. We evaluated the 5-year overall survival for patients among different therapies. We compared the 5-year overall survival between patients receiving chemoradiation therapy followed by surgery and a propensity-matched group of patients who underwent chemoradiation only. RESULTS: There were 21,710 octogenarians (15%) with esophageal cancer in the NCDB database. Among octogenarians, there were 6,960 patients (32%) who had clinical stage II-III esophageal cancer. Among 6,922 patients whose treatment data were available, the most common therapy was chemoradiation (n=3,360, 49%). Two of the most common therapies that included surgical resection were surgery only (n=314, 5%) and chemoradiation therapy followed by surgery (n=172, 2%). Among different treatments, the best 5-year overall survival was achieved in patients receiving chemoradiation therapy followed by surgery (P<0.001). In the propensity score-matched cohort between chemoradiation therapy followed by surgery (n=83) to chemoradiation therapy only (n=83), there was an association with improved 5-year overall survival in the patients who had chemoradiation therapy followed by surgery (17.9%) compared to the patients who underwent chemoradiation only (5.7%, P=0.003). CONCLUSIONS: Most octogenarians with locally advanced esophageal cancer underwent definitive chemoradiation therapy. Very few patients underwent chemoradiation followed by surgery; however, the multimodality treatment provided increased overall survival. Surgically fit octogenarians should be considered for chemoradiation therapy followed by surgery.

Surgical Cardiac Sympathetic Denervation for Ventricular Arrhythmias: A Systematic Review.

Ventricular arrhythmias are potentially life-threatening disorders that are commonly treated with medications, catheter ablation and implantable cardioverter defibrillator (ICD). Adult patients who continue to be symptomatic, with frequent ventricular arrhythmia cardiac events or defibrillation from ICD despite medical treatment, are a challenging subgroup to manage. Surgical cardiac sympathetic denervation has emerged as a possible treatment option for people refractory to less invasive medical options. Recent treatment guidelines have recommendedcardiac sympathectomy for ventricular tachycardia (VT) or VT/fibrillation storm refractory to antiarrhythmic medications, long QT syndrome, and catecholaminergic polymorphic VT, with much of the data pertaining to pediatric literature. However, for the adult population, the disease indications, complications, and risks of cardiac sympathectomy are less understood, as are the most effective surgical cardiac denervation techniques for this patient demographic. This systematic review navigates available literature evaluating surgical denervation disease state indications, techniques, and sympathectomy risks for medically refractory ventricular arrhythmia in the adult patient population.

Factors associated with home opioid use after thoracic surgery.

Objective: Enhanced recovery after surgery (ERAS) with a pre-emptive pain management program has been shown to decrease opioid prescriptions after thoracic surgery. We sought to determine which patient or procedural factors were associated with the need for prescription opioid medications after thoracic surgical procedures. Methods: We performed a retrospective analysis of a postoperative pain survey at the time of follow-up in combination with procedural and patient characteristic data. We then performed univariate and multivariate logistic regression to determine factors associated with prescription opioids use. Results: Two hundred twenty-eight patients completed questionnaires at a median of 37 days after surgery. Most patients received minimally invasive surgery (n = 213, 93%) with the 2 most common types of operations being foregut (n = 92, 40%) and pulmonary resection (n = 80, 35%). Thirty-nine percent of patients (n = 89) were taking chronic pain medications preoperatively, with 15% on chronic opioids medication (n = 33). After surgery, 166 patients (72%) did not take opioids at home. Multivariate analysis showed any chronic opioid medications before surgery (odds ratio, 28.8; 95% confidence interval, 9.13-90.8, P < .001) were associated with opioid use postoperatively. In contrast, increase in age was associated with a decrease in opioid use (odds ratio, 0.96; 95% confidence interval, 0.93-0.99, P = .01). Conclusions: ERAS with pre-emptive pain management was associated with patients avoiding opioid prescriptions during recovery. The patient factor of preoperative opioid pain medication(s) and younger age is a significant factor for the patient needing opioids at home after surgery instead of procedural factors. Patient characteristics should be considered when tailoring the patient's pain management after thoracic surgical procedures.

Short-term outcome of routine use of EndoFLIP during hiatal hernia repair.

BACKGROUND: Endoluminal functional lumen imaging probe (EndoFLIP) technology is a tool that can be used to provide intraoperative objective real-time feedback during hiatal hernia repair. We wanted to determine the implication of initial distensibility index (DI) after mobilization of hiatus and final DI after creation of barrier in short-term clinical outcomes. METHODS: We performed a retrospective analysis of prospectively collected data on the intraoperative use of EndoFLIP during hiatal hernia repair at a single institution from 2017 to 2019. We analyzed the initial DI and final DI with the short-term clinical outcomes. RESULTS: There were 163 patients who had Nissen (n = 16), Toupet (n = 79) or magnetic sphincter augmentation (n = 68) with (n = 158) or without (n = 5) hiatal hernia repair with median initial DI was 3.2 mm2/mmHg. We used 3 mm2/mmHg as the cutoff for low (n = 84) vs. high (n = 79) initial DI group. There was no difference in DeMeester score (p = 0.76), the peristalsis on manometry (p = 0.13), type of hiatal hernia (p = 0.98), and GERD-HRQL score prior to surgery (p = 0.73) between the groups. There was significantly higher final DI in the high initial DI group compared to low initial DI group; however, there was no significant difference in the GERD-HRQL score at 1-3 months (p = 0.28). All of the patients had a final DI > 0.5 mm2/mmHg at the end of the case with median final DI of 1.6 mm2/mmHg. None of these patients required steroids (0%) and only one patient (0.6%) required EGD and dilatation as well as re-operation for dysphagia within 3 months. CONCLUSIONS: The initial DI was associated with final DI, but it did not correlate with improvement in short-term GERD-HRQL score. Final DI maintained above the cutoff value led to most of the patients not to require intervention for dysphagia. Use of the EndoFLIP can provide objective data during the operation and prevent severe dysphagia after repair.

Impact of da Vinci Xi robot in pulmonary resection.

BACKGROUND: This study sought to evaluate the impact of a da Vinci Xi surgical robot on perioperative outcomes after pulmonary resections. METHODS: A retrospective analysis of prospectively collected STS data was performed at a single institution for patients who underwent elective lung resections from 2012 to 2019. Patient outcomes were compared at three different time periods: before the adoption of the robot technology (predominately VATS), during the initial robot experience (the first 18 months), and after the mature robot experience (the second 18 months). Univariate and multivariate logistic regression modeling was performed to determine the factors associated with perioperative complications. RESULTS: Five hundred and four patients underwent pulmonary resection between the three time periods: 220 patients (43.7%) had surgery prior to the first use of the robot (predominately VATS), 126 patients (25%) had surgery during the initial experience with robot, and 158 patients (31.1%) had surgery during the mature robot experience. There were significantly less post-operative complications (15.2% vs. 34.9% vs. 39.1%, P<0.001), shorter median length of stay (2 vs. 3 vs. 4 days, P<0.001), and lower hospital readmission rates (1.9% vs. 4% vs. 11.8%, P<0.001) in the mature robot period compared to the initial robot period and the predominately VATS period, respectively. Multivariate analysis showed that the robot was associated with a decrease in post-operative complications (OR 0.36; 95% CI, 0.23-0.57, P<0.001). CONCLUSIONS: The adoption of a da Vinci Xi robot in our institution was associated with improved outcomes in patients having pulmonary resections.

Pre-emptive pain management program is associated with reduction of opioid prescription after minimally invasive pulmonary resection.

BACKGROUND: We developed and implemented a pre-emptive pain management program wherein providers agreed to have non-opioid pain medication as a standard pain management strategy at discharge accompanied by patient education about the program. METHODS: A retrospective case-control study of prospectively collected data of patients who underwent minimally invasive pulmonary resection. We compared the outcomes among patients who were managed with pre-emptive pain management program with enhanced recovery after surgery (Pre-emptive), enhanced recovery program after surgery alone (ERAS) and standard care (control). RESULTS: Of the 443 patients, 132 patients (30%) were in the pre-emptive pain management group, 90 (20%) patients were in the ERAS only group and 221 (50%) in the control group. There were significantly fewer complications (15.9% vs. 23.3% vs. 38%, P<0.001), shorter median length of hospital stay (2 vs. 3 vs. 3 days, P<0.001), lower 30-day readmission rates (2.3% vs. 3.3% vs. 11.3%, P=0.002), and fewer opioid prescriptions at discharge (17.4% vs. 76.7% vs. 83.7%, P<0.001) in the pre-emptive pain management group compared to the ERAS and control groups. Multivariate logistic regression analyses showed that the pre-emptive pain management program (OR 0.06; 95% CI, 0.03, 0.11, P<0.001) and robotic surgery (OR 0.52; 95% CI, 0.3, 0.88, P=0.02) were associated with lower odds of patients being discharged to home with opioid prescriptions. The median pain score in the pre-emptive pain group at 30 days after surgery was 1.5 on a pain scale of 1-10. CONCLUSIONS: The pre-emptive pain management program was associated with a decrease in opioid prescriptions after elective pulmonary resections. Successful implementation of this program can lead to significant decreases in the amount of prescription opioids in the community.

Robot-assisted hiatal hernia repair demonstrates favorable short-term outcomes compared to laparoscopic hiatal hernia repair.

BACKGROUND: We postulated that the use of robotics may improve outcomes in hiatal hernia repair. METHODS: We performed a retrospective analysis of a prospectively collected Society of Thoracic Surgery database at a single institution of patients who underwent elective hiatal hernia repair from 2012 to 2017 using either laparoscopy or the da Vinci Xi robot. We compared patient characteristics and outcomes and then performed univariate and multivariate logistic regression modeling to determine the factors associated with postoperative morbidity. RESULTS: There were 293 consecutive patients who underwent elective hiatal hernia repair using either a laparoscopic (n = 151) or a robotic (n = 142) technique. There were no significant differences in age, gender, BMI, smoking history, presence of comorbidity, or hiatal hernia type. Seventy percent of the cases were a repair of either type III or type IV hiatal hernia. There were significantly higher ASA III and IV (7.9% vs. 4.2%, P = 0.03), higher Toupet fundoplication (83.4% vs. 44.4%, P < 0.001), and lower redo-repair (7.3% vs. 20.4%, P = 0.001) in the laparoscopic group compared to the robotic group. The hospital length of stay was significantly shorter (1.3 ± 1.8 vs. 1.8 ± 1.5 days, P = 0.003) and there were significantly lower rates of complications (6.3 vs. 19.2%, P = 0.001) after robotic compared to laparoscopic hiatal hernia repair. There was no difference in readmission rate and mortality. Multiple logistic regression analysis showed that older age and laparoscopic technique were associated with higher complications after surgery. CONCLUSION: The use of the Da Vinci Xi robot in our institution was associated with improved outcomes compared to laparoscopic hiatal hernia repair despite a higher incidence of re-operative cases in the robotic group. Thus, short-term outcomes of Da Vinci Xi robot-assisted hiatal hernia repair are not inferior to laparoscopic hiatal hernia repair. Further studies are needed to determine if Da Vinci Xi robot provides superior short-term and long-term outcome in treatment of symptomatic hiatal hernia.

Preemptive pain-management program is associated with reduction of opioid prescriptions after benign minimally invasive foregut surgery.

OBJECTIVE: The opioid crisis is partly due to opioids prescribed after elective surgery. We sought to determine if a preemptive pain-management program would be associated with opioid-free discharge after benign foregut surgery. METHODS: A retrospective case-control study of prospectively collected data was conducted at a single institution of patients who underwent elective minimally invasive benign foregut surgery. We compared the outcomes among patients who were managed with standard care (control), enhanced recovery after surgery alone, or a preemptive pain-management program with enhanced recovery after surgery. RESULTS: Among 414 patients, there were significantly fewer opioid medication prescriptions at discharge (9.6% vs 85.2% vs 87%, P < .001) and fewer postoperative complications (3.2% vs 14.8% vs 15.1%, P = .004) in the preemptive pain-management group (n = 94), enhanced recovery after surgery alone (n = 81), and the control group (n = 239), respectively. Multivariable logistic regression analysis showed that the preemptive pain-management program was a factor associated with a decrease in opioid medication prescriptions at discharge (odds ratio, 0.01; 95% confidence interval, 0.01-0.03; P < .001), as well as a decrease in complications after surgery (odds ratio, 0.22; 95% confidence interval, 0.06-0.79; P = .02). Moreover, in the preemptive pain-management group, average self-reported pain level in a subset of patients at 30 days after surgery was 0.9 ± 1.4 on a 0- to 10-point pain scale. CONCLUSIONS: The preemptive pain-management program was associated with opioid-free discharge after minimally invasive foregut surgery. This study provides a strategy to reduce opioid prescriptions after foregut surgery and, if implemented nationally, could decrease the amount of opioids used in the community.