Robotic hiatal hernia repair without mesh.

Background: Newer minimally invasive techniques have supplanted laparotomy and thoracotomy for management of hiatal hernias. Limited data exists on outcomes after robotic hiatal hernia repair without mesh despite the increasing popularity of this approach. We report our high-volume experience with durable robotic hiatal hernia repair with gastric fundoplication without mesh. Methods: A retrospective review was conducted on patients with type I-IV hiatal hernias who underwent an elective robotic-assisted repair from 2016 to 2019 using a novel technique of approximating the hiatus with running barbed absorbable (V-locTM) suture and securing it with interrupted silk sutures. Main outcomes included length of stay, readmission rate, and recurrence rate. Results: A total of 144 patients were reviewed. The average age of the patient was 61 years. Most of the patients were female [95 females (66%) to 49 males], and the average body mass index (BMI) was 29.96 kg/m2. The average operating time was 173 minutes (standard deviation 62 minutes). The average length of stay in the hospital was 2 days, and 89% of patients went home within the first 3 days. Ten patients (6.9%) were readmitted within 30 days, there were no mortalities in 30 days, and there were 6 (4.2%) recurrences on follow up requiring reoperation. Conclusions: Elective robotic hiatal hernia repair with fundoplication and primary closure of the hiatus with V-locTM and nonabsorbable suture without mesh is safe and effective. The robotic approach has similar operative times, lengths of stay, and complications compared to nationally published data on laparoscopic hiatal hernia repairs.

Aspergillus pleural empyema in a chronic smoker - A case report and review of literature.

Aspergillus species are ubiquitous saprophytic fungi that are present in the air, water, soil, and decaying vegetables. Clinical features of Aspergillus infection largely depend on the interplay between the fungi and the host immune status. We present a case of a chronic smoker with shortness of breath who was found to have diffuse bronchiectatic changes and empyema of the right lung. Emphysema was also noticed in the left lung. Rare Aspergillus fumigatus was identified in the pleural fluid, while the acid-fast stain and bacterial cultures were negative. The patient's serum Aspergillus fumigatus IgG antibody and galactomannan antigen were negative; however, the pleural galactomannan antigen was elevated. He was treated with video-assisted thoracoscopic surgery (VATS) and partial decortication of the right lung, along with intravenous voriconazole. Despite aggressive therapeutic measures, he died after a prolonged hospital stay. Aspergillus pleural empyema is rare but can be fatal; however, it is not included in the classification for pulmonary aspergillosis. Clinicians should be vigilant to evaluate for fungal empyema in patients with chronic obstructive pulmonary diseases, even without profound immunosuppression.

Impact That Day of the Week has on Length of Stay for Video-assisted Lobectomy.

We aimed to analyze the effect that the day of the week for video-assisted thoracoscopic surgery lobectomy has on length of stay . A retrospective review identified all patients who underwent video-assisted thoracoscopic surgery lobectomy at a single institution from January 2016 to July 2017. In total, 208 patients were divided into 2 groups based on timing of their operation: Operations performed on Monday, Tuesday, or Wednesday were defined as "early in the week" and those performed on Thursday or Friday were defined as "late in the week." We then propensity-matched 81 pairs of patients and analyzed perioperative data and short-term clinical outcomes. A total of 208 patients underwent video-assisted thoracic surgery lobectomy during the study period. Length of stay was significantly decreased by 2.0 days (P <0.0001) for all lobectomies performed "early in the week" compared with those performed "late in the week." Thirty-day mortality and all major morbidities did not significantly different between the 2 matched groups. Our findings suggest that major pulmonary resections should be performed early in the week, when feasible, to facilitate utilization of hospital resources and prompt discharge.

Uniportal VATS Lobectomy and Decortication: Not an Everyday Occurrence.

Management of trapped lung with an underlying lung lesion and hydropneumothorax remains controversial. Furthermore, Aspergillus empyema and aspergilloma are rare pathologies for which uniportal video-assisted thoracoscopic (VATS) surgical management remains controversial. We present a young patient referred to our service after recent hospitalization for pneumonia. The patient was found to have a chronic effusion with a right lower lobe cystic parenchymal lesion and was taken to the operating room. The patient underwent right uniportal VATS surgery with evacuation of empyema, total pulmonary decortication, and right lower lobectomy. His postoperative course was unremarkable, and he was discharged home. Postoperative workup demonstrated lymphocyte variant hypereosinophilia. He continues to follow with thoracic surgery at the time of this report and remains asymptomatic. We conclude that uniportal VATS is a most minimally invasive, safe, and efficient approach for management of complex intrathoracic pathology including total pulmonary decortication and lobectomy.

Robotic-Assisted First Rib Resection: Our Experience and Review of the Literature.

Thoracic outlet syndrome (TOS) comprises a constellation of signs and symptoms that arise from neurologic and vascular compression of the brachial plexus and subclavian vasculature, respectively. Surgical decompression of the neurovascular structures is often indicated to alleviate TOS. We report here our robotic surgical approach and experience for resection of the first rib. Between July 2014 and January 2017, 17 patients who underwent robotic-assisted first rib resection at our institution were reviewed. Nine women and 8 men with a mean age of 45 ± 11 years had a robotic-assisted first rib resection; 8 for neurogenic TOS and 9 for venous TOS. There were no complications or conversion to open surgery. The mean operative time was 113.2 ± 55.3 minutes. Length of stay was a mean of 1.8 ± 1.9 days. Length of rib resected was 5.8 ± 0.5 cm. Anticoagulation for the venous TOS cohort was Xarelto, for a mean of 5.1 ± 1.8 months. Short-term follow-up (mean 10.3 ± 4.9 days) revealed resolution of symptoms in all patients, with patent vasculature on venogram for the entire venous TOS cohort. Further follow-up at 2 months and 6 months revealed that all patients remained symptom free. Based on our institution's experience with the robotic-assisted approach to first rib resection, we feel that it is a feasible approach that could be added to the armamentarium of the thoracic surgeon.

Intermediate oncologic outcomes after uniportal video-assisted thoracoscopic thymectomy for early-stage thymoma.

BACKGROUND: Recent years have seen a trend towards utilizing a video-assisted thoracic surgery (VATS) approach for treatment of thymoma. Although increasing in practice, intermediate- and long-term oncologic outcome data is lacking for the VATS approach. There is no oncologic data for the uniportal VATS approach. We sought to evaluate the feasibility and impact on patient survival of uniportal VATS thymectomy for early-stage thymoma. METHOD: The clinical outcomes for 17 patients with Masaoka stage I to II thymomas treated between January of 2009 and July of 2014 at a single institution were collected retrospectively. Primary endpoint was overall survival (OS) and secondary endpoint was recurrence-free survival (RFS). RESULTS: Ten women and seven men underwent uniportal VATS thymectomy; eleven had stage I thymoma and six had stage II thymoma. There were no conversions to open surgery. Operative mortality was zero. Mean tumor size was 3.8±1.0 centimeters, with a range of 1.9 to 6.0 centimeters. All patients underwent a R0 resection. Five-year survival was 100%, and the estimated RFS was 100%. CONCLUSIONS: Our findings suggest that uniportal VATS thymectomy for early-stage thymoma is feasible, and the intermediate-term oncologic outcomes are comparable to historic standards for open and multi-incision VATS thymectomy. However, additional follow-up is required to evaluate for long-term oncologic outcomes.

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.

Noteworthy Literature Published in 2016 for Thoracic Surgery.

The past year has produced several important articles in the field of thoracic surgery, spanning many different diseases. Thoracic surgeons continue to investigate methods to perform complex operations and procedures less invasively, with the least possible morbidity to our patients. We also continue to critically evaluate new technology and procedures to ensure that they meet our rigorous standards for oncologic efficacy and for management of benign disease. Importantly, as we continue to evolve, thoracic surgeons have remained focused on optimizing processes of care, both inside and outside the operating room. The purpose of this review is to highlight the major advances in thoracic surgical disease in the year 2016.

The efficacy of EBUS-guided transbronchial needle aspiration for molecular testing in lung adenocarcinoma.

BACKGROUND: The purpose of the study was to assess the efficacy of obtaining adequate cytologic specimens by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for molecular testing of lung adenocarcinomas. METHODS: This was an institutional review board-approved study of all patients who had undergone EBUS-TBNA from April 2010 through March 2012 for the diagnosis, staging, or both of lung cancer. Patients with a diagnosis of adenocarcinoma were reflexively tested for molecular markers by polymerase chain reaction, sequencing, and fluorescence in situ hybridization (FISH). All procedures were performed with patients under conscious sedation in the bronchoscopy suite. RESULTS: Of 205 patients who underwent EBUS-TBNA, 56 patients (24 male, 32 female) had a diagnosis of adenocarcinoma warranting molecular analysis. Molecular analysis was available for epidermal growth factor receptor (EGFR), Kirsten rat sarcoma (Kras) mutation, and anaplastic lymphoma kinase (ALK) gene rearrangement. The institution's clinical protocol involved initial testing for EGFR mutation with a reflex Kras test if the EGFR test result was negative. ALK FISH molecular testing was completed if both EGFR and Kras test results were negative. A total of 52 of 56 (93%) patients had sufficient cytologic material for complete or partial molecular testing, whereas 46 of 56 (82%) patients had sufficient material for all clinically indicated testing. EGFR, Kras, and ALK analysis yielded positive results in 5 (10%), 10 (25%), and 5 (12%) tested specimens, respectively. No complications were associated with EBUS-TBNA. CONCLUSIONS: EBUS-TBNA performed with the patient under moderate sedation can be expected to yield sufficient tissue for sequential molecular analysis in the majority of patients. In an era of targeted therapy for lung adenocarcinomas, EBUS-TBNA is effective in clinical practice for complete diagnosis, staging, and treatment planning in these patients.

Extracorporeal membrane oxygenation as a bridge to lung transplantation and recovery.

OBJECTIVE: Respiratory failure develops in many patients on lung transplant waiting lists before a suitable donor organ becomes available. Extracorporeal membrane oxygenation may be used to bridge such patients to recovery or lung transplantation. METHODS: This is a review of a single-institution's experience with placing patients on extracorporeal membrane oxygenation with the intention of bridging them to lung transplantation. End points included successful bridging, duration of extracorporeal membrane oxygenation support, extubation, weaning from extracorporeal membrane oxygenation, overall survival, and extracorporeal membrane oxygenation-related complications. During an approximate 5-year period, acute respiratory failure developed in 18 patients (median age, 34 years) on the institution's lung transplant waiting list (8 hypoxemic, 9 hypercarbic, and 1 combined) who were placed on extracorporeal membrane oxygenation (13 venovenous and 5 venoarterial). RESULTS: All patients achieved appropriate extracorporeal membrane oxygenation blood flow rates (median, 4.05 L/min) and good gas exchange (median, on extracorporeal membrane oxygenation partial pressure of arterial carbon dioxide 43 mm Hg and partial pressure of arterial oxygen 196 mm Hg). Thirteen patients (72%) were successfully bridged: 10 to transplant and 3 returned to baseline function. Eleven patients (61%) survived beyond 3 months, including the 10 (56%) who underwent transplantation and are still alive. The median duration of extracorporeal membrane oxygenation support for patients who underwent transplantation was 6 days (3.5-31 days) versus 13.5 days (11-19 days) for those who did not undergo transplantation (P = .45). Six patients (33%) were extubated on extracorporeal membrane oxygenation, 4 of whom underwent transplantation. Four patients (22%) who were too unstable for conventional interhospital transfer were transported on extracorporeal membrane oxygenation to Columbia University Medical Center. This subgroup had a 75% bridge to transplant or recovery rate and 100% survival in transplanted patients. CONCLUSIONS: Extracorporeal membrane oxygenation is a safe and effective means of bridging well-selected patients with refractory respiratory failure to lung transplantation or return to their baseline condition.

Minimally invasive thymectomy and open thymectomy: outcome analysis of 263 patients.

BACKGROUND: An open thymectomy is a morbid procedure. If a minimally invasive thymectomy is performed without compromising the tenets of thymic surgery, it has the potential for decreasing morbidity and may offer similar clinical and oncologic results. METHODS: This is an institutional review board-approved, retrospective study of a single center's experience with both open (transsternal) and minimally invasive (video-assisted thoracoscopic surgery) thymectomy. Survival estimates and statistical comparisons were calculated using standard software. RESULTS: From 2000 to 2011, 263 patients (93 men; median age, 49 years; interquartile range, 37 to 60 years) underwent thymectomy for indications including myasthenia gravis (n=139) and mediastinal mass (n=108). Seventy-seven thymectomies were performed by minimally invasive approach. Both groups were equally stratified by sex, body mass index, World Health Organization and Masaoka-Koga staging, incidence of myasthenia gravis, and comorbidities except hyperlipidemia and diabetes. The minimally invasive thymectomy cohort had significantly shorter hospital (p<0.01) and intensive care unit lengths of stay (p<0.01) and a lower estimated blood loss (p<0.01). There was an insignificant difference in postoperative cardiac and respiratory complication rates as well as vocal cord paralysis (p=0.60). There was no difference in terms of operative room times (p=0.88) or volume of blood products transfused (p=0.16) between the two groups. Higher estimated blood loss was associated with higher intensive care unit admission rates (p<0.01). All minimally invasive thymoma resections were complete, with negative margins. CONCLUSIONS: Minimally invasive thymectomy is safe and achieves a comparable resection and postoperative complication profile when used selectively for all indications, including myasthenia gravis and small thymomas without vascular invasion.