Tackling complex thoracic surgical operations with robotic solutions: a narrative review.

Background and Objective: The adoption of robotic surgery for general thoracic surgery has rapidly progressed over the last two decades from its application in basic operations to complex pathologies. As such, the purpose of this narrative review is to highlight the collective experience of tackling complex thoracic surgical operations with minimally invasive robotic solutions. Methods: Electronic searches of PubMed were conducted for each subtopic, using specific keywords and inclusion criteria. Once identified, the articles were screened through the abstract, introduction, results and conclusion for relevancy, and included based on a standard narrative review inclusion criteria. Key Content and Findings: The role of the robotic approach has increased in thoracic outlet syndrome, chest wall resection, tracheobronchomalacia, airway and sleeve lung surgery, lobectomy after neoadjuvant therapy, complex segmentectomy, giant paraesophageal hernia repair, esophagectomy and esophageal enucleation, mediastinal masses and thymectomy and lung transplantation. Robotic surgery has several advantages when compared to video-assisted and open thoracoscopic surgery. These include better pain control and aesthetic outcome, improved handling of complex anatomy, enhanced access to lymph nodes, and faster recovery rates. Although it is associated with longer operative time, robotic surgery has comparable morbidity rates. Conclusions: The robotic approach to complex thoracic problems is safe, effective, and associated with improved patient outcomes. To encourage wider adoption of robotic technology, increased training and expanded research efforts are essential, alongside improved worldwide access to this technology.

Clinical Variation Reduction in Propensity-matched Patients Treated for Malignant Pleural Effusion.

BACKGROUND: The potential advantages of clinical variation reduction are improved patient outcomes and cost reduction through optimizing and standardizing care. Malignant pleural effusion (MPE) is a common condition encountered by thoracic surgeons that has significant variation in cost and outcomes. The purpose of this investigation was to assess the opportunity of improving patient outcomes and reducing cost by using a standardized treatment algorithm based on evidenced-based care. METHODS: Patients treated for MPE using a standardized treatment algorithm at the study institution over a 2 year period were identified and propensity matched to MPE patients from 1 of 6 affiliated hospitals with comprehensive oncology and thoracic surgery services. Matched patients were treated at their physicians' discretion. Factors used in propensity matching were age, performance status, and tumor histology. The 2 cohorts were then compared for interventions, admissions and readmissions, morbidity, and pleural effusion-associated costs. Patients who desired only comfort or hospice care were excluded. RESULTS: From 2016 through 2018, 60 patients were treated using the standardized algorithm. These patients were propensity matched and the 2 cohorts compared. Patients treated with the algorithm experienced significantly fewer hospital admissions, readmissions, interventions, and costs while having a comparable procedural morbidity. CONCLUSIONS: An evidence-based treatment algorithm for MPE produces superior clinical outcomes to individualized therapy while significantly reducing the costs of care.

Rectal screening for Klebsiella pneumoniae carbapenemases: comparison of real-time PCR and culture using two selective screening agar plates.

Klebsiella pneumoniae carbapenemases (KPCs) have recently been described in Chicago, IL, especially among residents of long-term acute care hospitals (LTACHs). These patients are frequently transferred to local Chicago hospitals for higher acuity of medical care, and rapid detection and isolation of KPC-colonized LTACH residents may interrupt the introduction of KPCs into acute care hospitals. We evaluated the performance of a real-time PCR for bla(KPC) from enrichment broth versus direct plating of rectal surveillance swabs on two selective culture media, CHROMagar extended-spectrum-ß-lactamase (ESBL) and vancomycin, amphotericin B, ceftazidime, and clindamycin (VACC) plates. Rectal surveillance swabs were collected as part of a point prevalence study of KPC carriage rates among 95 residents of two Chicago area LTACHs. Discrepant results between PCR and culture were resolved by subculturing the enrichment broth. Overall, 66 of 95 patients (69.5%) were colonized with KPCs, using the cumulative results of culture as a reference standard. Real-time PCR from enrichment broth was positive in 64 of 66 (97%) colonized patients, including nine surveillance swabs that were missed by both selective culture media. PCR demonstrated higher sensitivity, 97.0%, than culture using either CHROMagar or VACC plates (both with sensitivity of 77.3%). In addition, turnaround time was significantly shorter for the PCR-based method than for culture, with a mean of 24 h versus 64 to 72 h for CHROMagar and VACC plates (P < 0.0001). Overall, PCR for bla(KPC) represents the best screening test for KPCs with significantly higher sensitivity and with less hands-on time, resulting in a shorter time to results.