Sublobar Resection vs Lobectomy for Stage IA Non-Small Cell Lung Carcinoma-Takeaways From Modern Randomized Trials.

Sublobar resection for early-stage non-small cell lung cancer has been an emerging topic of great interest to thoracic surgeons. However, data regarding the efficacy and safety of sublobar resection vs lobectomy was lacking until now. Recently, 3 published randomized controlled trials (Cancer and Leukemia Group B [CALGB]140503/Alliance, Japan Clinical Oncology Group [JCOG]0802 and Das Deutsche Register Klinischer Studien [DRKS]00004897) confirmed the noninferiority of sublobar resection for early-stage non-small cell lung cancer in carefully selected populations. This review aims to summarize and compare these 3 landmark trials and inform surgeons of new best practices.

Discharging Patients by Postoperative Day One After Robotic Anatomic Pulmonary Resection.

BACKGROUND: Our objective is to assess the feasibility and safety of discharging patients by postoperative day one (POD1) after robotic segmentectomy and lobectomy, and to describe outcomes for patients. METHODS: A retrospective analysis was made of a prospectively collected database of a quality improvement initiative by a single surgeon. Factors associated with discharge by POD1 were evaluated using a multivariate logistic regression model. RESULTS: From January 2018 to July 2020, of 253 patients who underwent robotic anatomic pulmonary resection, 134 (53%) were discharged by POD1, 67% after segmentectomy and 41% after lobectomy. Discharge by POD1 improved with experience and was achieved in 97% of patients after segmentectomy and 68% after lobectomy in the final quartile. Thirty-one patients (12%) were discharged home with a chest tube, including 7 (2.8%) on POD1. On multivariate analysis, never smokers and segmentectomy were associated with discharge by POD1. Conversely, decreased baseline performance status and perioperative complications were associated with discharge after POD1. There were 10 minor morbidities (4%), 6 major morbidities (2.4%), and no 30- or 90-day mortality. There were 4 readmissions (1.6%), of which 1 (0.4%) was after POD1 discharge. Patient satisfaction remained high throughout the study period. CONCLUSIONS: With experience and communication, select patients can be discharged home on POD1 after robotic segmentectomy and lobectomy with excellent outcomes and high satisfaction. Discharge by POD1 was associated with never smokers and segmentectomy, and inversely associated with decreased baseline performance status and perioperative complications.

Midterm Results for Robotic Thymectomy for Malignant Disease.

BACKGROUND: There are limited reports on robotic thymectomy for malignant disease. Our objectives are to review our experience and midterm outcomes. METHODS: We reviewed a single-surgeon prospective database for patients who underwent planned robotic resection for malignancy from January 2010 to June 2019. RESULTS: Two hundred thirteen patients underwent resection of an anterior mediastinal mass, all of which were planned for a robotic approach. Of these, 84 (39%) underwent robotic thymectomy for malignant disease. Thymoma was the most common pathology resected (68%). Median tumor size was 4.7 cm (interquartile range, 2.9-6.3), and median operative time was 81.5 minutes (interquartile range, 64-104). All except 1 patient had a complete (R0) resection (98.8%). There were 2 (2.3%) unplanned but elective conversions to open surgery, 1 of which required cardiopulmonary bypass. Median length of stay was 1 day (range, 0-9) with 1 readmission (1.2%). Major morbidity occurred in 3 patients (3.5%), and there were no 30- or 90-day mortalities. In patients with thymoma, follow-up was complete at a median of 32 months (range, 1-98), and 1 patient (1.8%) had an ipsilateral chest recurrence. To date there have been no patient deaths. CONCLUSIONS: Robotic thymectomy for patients with malignant disease is safe with excellent perioperative outcomes. A robotic approach achieves a high rate of complete R0 resection, even for larger tumors. For patients with thymoma local recurrence is low after midterm follow-up, but longer-term analysis is needed to determine oncologic durability.

Developing a Robotic General Surgery Training Curriculum: Identifying Key Elements Through a Delphi Process.

OBJECTIVE: A national robotic surgery curriculum is still developing for general surgery residents as robotic surgery becomes increasingly accessible. One general surgery residency program utilized a Delphi process to optimize a robotic surgery curriculum and to determine key factors that might affect robotic proficiency and intraoperative independence. DESIGN: Delphi methodology was used to gain consensus amongst robotic surgery faculty and trainees. Consensus was defined as agreement of 66.7% or above in factors that would allow a resident to independently operate in a robotic case. A panel of diverse representatives proposed factors that might affect resident robotic learning and operative experience. In a subsequent round, questions were sent through an anonymous online survey for respondents to identify factors that affect resident robotic independence. Respondents were also given the ability to write in pertinent factors. SETTING: This study was conducted from July 2020 to September 2020 via anonymous web-based questionnaires for education researchers, faculty members, and residents of a university-affiliated independent general surgery residency program. PARTICIPANTS: The initial panel consisted of a robotic surgeon, a 2020 graduate, a 2019 graduate and/or robotic fellow, a research resident, and a current resident. The subsequent survey was completed by 8 faculty members, 6 recent graduates, and 15 current residents within the general surgery residency program. RESULTS: Proposed items fell into 3 categories: institutional resources, individual qualities, and curricular elements. Consensus within groups was achieved in the following items: dual robotic console models, robotic-focused faculty, resident interest, PGY level, and resident time spent on a simulator. CONCLUSIONS: This Delphi exercise has informed this general surgery residency program in the development of a robotic surgery curriculum, through contribution from multiple stakeholders. While curricular elements for baseline robotic knowledge are necessary, institutional resources, deliberate practice, resident entrustment and faculty teaching proficiency warrant further study.

Novel Pre- and Postoperative Care Using Telemedicine.

The use of telemedicine and telehealth services has grown exponentially over the past decade and has become increasingly relevant and necessary during the coronavirus 2019 (COVID-19) pandemic. There remains ample opportunity to electronically connect cardiothoracic surgeons with their patients during both preoperative and postoperative visits. In this review, we examine the various implementations of telemedicine within thoracic surgery and explore future applications in this quickly developing field.

Robotic Sleeve Resection of the Airway: Outcomes and Technical Conduct Using Video Vignettes.

BACKGROUND: Our objectives are to report our outcomes and to demonstrate our evolving technique for robotic sleeve resection of the airway, with or without lobectomy, using video vignettes. METHODS: We retrospectively reviewed a single-surgeon prospective database from October 2010 to October 2019. RESULTS: Over 9 years, of 5573 operations 1951 were planned for a robotic approach. There were 755 robotic lobectomies and 306 robotic segmentectomies, and 23 consecutive patients were scheduled for elective completely portal, robotic sleeve resection. Sleeve lobectomy was performed in 18 patients: 10 right upper lobe, 6 left upper lobe, and 2 right lower lobe. Two patients had mainstem bronchus resections and 2 underwent right bronchus intermedius resections that preserved the entire lung. One patient had a robotic pneumonectomy. One operation was converted to open thoracotomy because of concern for anastomotic tension in a patient who received neoadjuvant therapy. All patients had an R0 resection. In the last 10 operations we modified our airway anastomosis, using a running self-locking absorbable suture. The median length of hospital stay was 3 days (range, 1-11), with no 30- or 90-day mortalities. Within a median follow-up of 18 months, there were no anastomotic strictures and no recurrent cancers. CONCLUSIONS: Our early and midterm results show that a completely portal robotic sleeve resection is safe and oncologically effective. Trhe technical aspects of a robotic sleeve resection of the airway are demonstrated using video vignettes.

A Grading System for Invasive Pulmonary Adenocarcinoma: A Proposal From the International Association for the Study of Lung Cancer Pathology Committee.

INTRODUCTION: A grading system for pulmonary adenocarcinoma has not been established. The International Association for the Study of Lung Cancer pathology panel evaluated a set of histologic criteria associated with prognosis aimed at establishing a grading system for invasive pulmonary adenocarcinoma. METHODS: A multi-institutional study involving multiple cohorts of invasive pulmonary adenocarcinomas was conducted. A cohort of 284 stage I pulmonary adenocarcinomas was used as a training set to identify histologic features associated with patient outcomes (recurrence-free survival [RFS] and overall survival [OS]). Receiver operating characteristic curve analysis was used to select the best model, which was validated (n = 212) and tested (n = 300, including stage I-III) in independent cohorts. Reproducibility of the model was assessed using kappa statistics. RESULTS: The best model (area under the receiver operating characteristic curve [AUC] = 0.749 for RFS and 0.787 for OS) was composed of a combination of predominant plus high-grade histologic pattern with a cutoff of 20% for the latter. The model consists of the following: grade 1, lepidic predominant tumor; grade 2, acinar or papillary predominant tumor, both with no or less than 20% of high-grade patterns; and grade 3, any tumor with 20% or more of high-grade patterns (solid, micropapillary, or complex gland). Similar results were seen in the validation (AUC = 0.732 for RFS and 0.787 for OS) and test cohorts (AUC = 0.690 for RFS and 0.743 for OS), confirming the predictive value of the model. Interobserver reproducibility revealed good agreement (k = 0.617). CONCLUSIONS: A grading system based on the predominant and high-grade patterns is practical and prognostic for invasive pulmonary adenocarcinoma.

How to get the most out of your trainees in robotic thoracic surgery-"the coachability languages".

We are honored to have been invited to write this piece entitled, "How to get the most out of your trainees in robotic thoracic surgery". Perhaps a better question is "How can we optimally coach and inspire each resident and/or fellow to maximize their value and potential as people, physicians and surgeons during the span of their career?". As surgeons, we must recognize some of the subtle differences in alignment between ourselves and our trainees, appreciate the value of the trainee within our profession, understand that there is variability to the coaching style that each trainee best responds to, and acknowledge that the success of the people we train-which may be our only true legacy-depends on how we engage and inspire them.

Pseudoaneurysm formation after Pasteurella multocida lower extremity vascular bypass graft infection.

Prosthetic vascular bypass graft infection is a rare complication requiring prompt identification and isolation of the organism. A 66-year-old woman developed left lower extremity pain and a pulsatile pseudoaneurysm 7 months after left common femoral to peroneal artery bypass with prosthetic polytetrafluoroethylene graft, requiring re-exploration and a jump graft. Pasteurella multocida was isolated from blood and tissue culture specimens, and the patient admitted to a new kitten that frequently bit her lower extremities. Treatment included intravenous administration of ertapenem for 6 weeks followed by lifelong oral antibiotic suppression, which may offer the best chance for limb salvage when total graft explantation would result in amputation.

The Utility of Near-Infrared Fluorescence and Indocyanine Green During Robotic Pulmonary Resection.

During minimally invasive pulmonary resection, it is often difficult to localize pulmonary nodules that are small (<2 cm), low-density/subsolid on imaging, or deep to the visceral pleura. The use of near-infrared fluorescence (NIF) imaging for localizing pulmonary nodules using indocyanine green (ICG) contrast is an emerging technology that is increasingly utilized during pulmonary resection. When administered via electromagnetic navigational bronchoscopy (ENB), ICG can accurately localize pulmonary nodules. When injected intravenously (IV), ICG can also help delineate the intersegmental plane. Research is ongoing regarding the utility of ICG for identification of the sentinel lymph node in lung cancer.

Technique, Outcomes With Navigational Bronchoscopy Using Indocyanine Green for Robotic Segmentectomy.

BACKGROUND: The objectives of this study were to present outcomes of robotic segmentectomy and the investigators' preferred technique for nodule localization using indocyanine green both bronchoscopically and intravenously. METHODS: This study was a retrospective review of a consecutive series of patients scheduled for robotic segmentectomy from a single surgeon's prospectively collected database. RESULTS: Between January 2010 and October 2018, there were 245 consecutive patients who underwent planned robotic segmentectomy by one surgeon. Of these 245 patients, 93 (38%) received indocyanine green by electromagnetic navigational bronchoscopy, and all 245 received intravenous indocyanine green. Median time for navigational bronchoscopy was 9 minutes. Navigational bronchoscopy with indocyanine green correctly identified the lesion in 80 cases (86%). The preferred technique was as follows: 0.5 mL of 25 mg of indocyanine green diluted in 10 mL of sterile water given bronchoscopically, followed by a 0.5-mL saline flush, staying at least 4 mm from the pleural surface. The remaining 9.5 mL of indocyanine green was administered intravenously after pulmonary artery ligation. An R0 resection was achieved in all 245 patients, a median of 17 lymph nodes were resected, and the average length of stay was 3.1 days (range, 1 to 21 days). Major morbidity occurred in 3 patients, and there were no 30- or 90-day mortalities. CONCLUSIONS: Robotic segmentectomy is safe, with excellent early clinical outcomes. In this series, electromagnetic navigational bronchoscopy and indocyanine green localization were efficient and effective at identifying the target lesion. Intravenous indocyanine green delineated the intersegmental plane.

Improving Operating Room Turnover Time in a New York City Academic Hospital via Lean.

BACKGROUND: Prolonged operating room turnover time erodes patient and employee satisfaction and value. METHODS: Lean and value stream mapping was applied to three operating room teams at an academic health center in New York City, and a solution called Performance Improvement Team (PIT Crew) was piloted. RESULTS: Overall, 10% of operating room turnover steps were considered nonvalued and were eliminated, and 25% of previously sequential steps were performed synchronously. Seven institutional dogmas were eliminated, and three hospital policies were changed. After 35 pilot turnovers, median operating room turnover time improved from 37 minutes (range, 26 to 167 minutes) in historic matched controls to 14 minutes (range, 10 to 45 minutes, p < 0.0001) for the PIT Crew. Cost of the PIT Crew was $1,298 daily, and estimated return on investment was $19,500 per day. CONCLUSIONS: Lean and value stream mapping identifies nonvalued steps in operating room turnover and affords opportunities for efficiency. Once institutional rules and dogma are changed, culture and workflow improve and turnover time substantially improves. This process adds cost but is profitable. Scalability and sustainability are under further study, as is the "halo effect" on the culture in other non-PIT Crew operating rooms.

Bile Salt Enterolith: An Unusual Etiology Mimicking Gallstone Ileus.

Primary enterolithiasis is a relatively uncommon but important cause of small bowel obstruction. We present a case of a 69-year-old male with a history of laparoscopic Roux-en-Y gastric bypass and asymptomatic duodenal diverticulum diagnosed with small bowel obstruction. CT imaging showed an obstruction distal to the jejunojejunostomy, and surgical intervention was warranted. A 4.5 cm enterolith removed from the distal jejunum was found to contain 100% bile salts, consistent with a primary enterolith. Clinicians should retain a high index of suspicion for enteroliths as a cause of small bowel obstruction, especially if multiple risk factors for enterolith formation are present.