Video-assisted thoracic surgery and robotic-assisted first-rib excision and thoracic outlet syndrome decompression.

Multiple surgical approaches have been used in the management of thoracic outlet syndrome. These approaches have traditionally been "open" approaches and have been associated with the inherent morbidities of an open approach, including a risk of injury to the neurovascular structures due to traction and trauma while resecting the first rib. In addition, there has been concern that recurrence of symptoms may be related to incomplete resection of the rib with conventional open techniques. With the advent of minimally invasive thoracic surgery, surgeons began to explore first-rib resection via a thoracoscopic approach. Unfortunately, the existing video-assisted thoracic surgery technology and equipment was not well suited to working in the apex of the chest. With the introduction and subsequent progress in robotic surgery and instrumentation, this dissection can be performed with all the advantages of robotics, but also with minimal traction and trauma to the neurovascular structures, and incorporates almost complete resection of the rib with minimal residual stump. Robotics has developed as a reliable, safe, and less invasive approach to first-rib resection, yielding excellent results while limiting the morbidity of the procedure.

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.

A Review of Robotic Thoracic Surgery Adoption and Future Innovations.

The embracing of new technology and surgical innovation has been one of the hallmarks of cardiothoracic surgery. The adoption of video-assisted thoracoscopic surgery was the paradigm-changing perspective shift that has enabled an entire culture of minimally invasive cardiothoracic surgery. From this foundation robotically assisted thoracic surgery has developed into mainstream practice. The aim of this review is to recount the technological and academic milestones of the past as well as describe future technological innovations that will shape the future of thoracic robotic surgery.

Does the Halo Effect for Level 1 Trauma Centers Apply to High-Acuity Nonsurgical Admissions?

CONTEXT: The halo effect describes the improved surgical outcomes at trauma centers for nontrauma conditions. OBJECTIVE: To determine whether level 1 trauma centers have improved inpatient mortality for common but high-acuity nonsurgical diagnoses (eg, acute myocardial infarction [AMI], congestive heart failure [CHF], and pneumonia [PNA]) compared with non--level 1 trauma centers. METHODS: The authors conducted a population-based, retrospective cohort study analyzing data from the Healthcare Cost and Utilization Project State Inpatient Database and the American Hospital Association Annual Survey Database. Patients who were admitted with AMI, CHF, and PNA between 2006-2011 in Florida and California were included. Level 1 trauma centers were matched to non-level 1 trauma centers using propensity scoring. The primary outcome was risk-adjusted inpatient mortality for each diagnosis (AMI, CHF, or PNA). RESULTS: Of the 190,474 patients who were hospitalized for AMI, CHF, or PNA, 94,037 patients (49%) underwent treatment at level 1 trauma centers. The inpatient mortality rates at level 1 trauma centers vs non-level 1 trauma centers for patients with AMI was 8.10% vs 8.40%, respectively (P=.73); for patients with CHF, 2.26% vs 2.71% (P=.90); and for patients with PNA, 2.30% vs 2.70% (P=.25). CONCLUSION: Level 1 trauma center designation was not associated with improved mortality for high-acuity, nonsurgical medical conditions in this study.

What are the predictors that can help identify safe removal of drains following pancreatectomy?

BACKGROUND: The management of a drain after Pancreaticoduodenectomy (PD) and distal pancreatectomy (DP) remains a controversial issue. Our aim in this study was to identify a safe time for drain removal. STUDY DESIGN: This is a retrospective study, of a prospective database, of patients who underwent a PD or DP at two tertiary care institutions. RESULTS: A total of 180 patients underwent PD and DP during the observation period. Seventeen patients developed fistulas (9.4%), with 70.6% (n = 12) developing in soft pancreatic remnants vs. 29.4% (n = 5) in firm pancreatic remnants. Patients with amylase levels greater than 173 U/L on a postoperative day three were 11.46 times more likely to form a fistula compared to those with an amylase level at or below 173 U/L (p < .001). CONCLUSION: Fistula formation is associated with pancreas texture, duct size, and drain amylase following PD or DP. Patients with firm pancreatic texture and large ducts are less likely to develop fistulas than those with soft pancreatic texture and small ducts.