Outcomes of 350 Robotic-assisted Esophagectomies at a High-volume Cancer Center: A Contemporary Propensity-score Matched Analysis.

OBJECTIVE: To evaluate perioperative and oncologic outcomes in our RAMIE cohort and compare outcomes with contemporary OE controls. SUMMARY OF BACKGROUND DATA: RAMIE has emerged as an alternative to traditional open or laparoscopic approaches. Described in all esophagectomy techniques, rapid adoption has been attributed to both enhanced visualization and technical dexterity. METHODS: We retrospectively reviewed patients who underwent RAMIE for malignancy. Patient characteristics, perioperative outcomes, and survival were evaluated. For perioperative and oncologic outcome comparison, contemporary OE controls were propensity-score matched from NSQIP and NCDB databases. RESULTS: We identified 350 patients who underwent RAMIE between 2010 and 2019. Median body mass index was 27.4, 32% demonstrated a Charlson Comorbidity Index >4. Nodal disease was identified in 50% of patients and 74% received neoadjuvant chemoradiotherapy. Mean operative time and blood loss were 425 minutes and 232 mL, respectively. Anastomotic leak occurred in 16% of patients, 2% required reoperation. Median LOS was 9 days, and 30-day mortality was 3%. A median of 21 nodes were dissected with 96% achieving an R0 resection. Median survival was 67.4 months. 222 RAMIE were matched 1:1 to the NSQIP OE control. RAMIE demonstrated decreased LOS (9 vs 10 days, P = 0.010) and reoperative rates (2.3 vs 12.2%, P = 0.001), longer operative time (427 vs 311 minutes, P = 0.001), and increased rate of pulmonary embolism (5.4% vs 0.9%, P = 0.007) in comparison to NSQIP cohort. There was no difference in leak rate or mortality. Three hundred forty-three RAMIE were matched to OE cohort from NCDB with no difference in median overall survival (63 vs 53 months; P = 0.130). CONCLUSION: In this largest reported institutional series, we demonstrate that RAMIE can be performed safely with excellent oncologic outcomes and decreased hospital stay when compared to the open approach.

Evaluation of Tumor DNA Sequencing Results in Patients with Gastric and Gastroesophageal Junction Adenocarcinoma Stratified by TP53 Mutation Status.

BACKGROUND: Gastric cancer (GC) and gastroesophageal junction adenocarcinomas (GEJ) are molecularly diverse. TP53 is the most frequently altered gene with approximately 50% of patients harboring mutations. This qualitative study describes the distinct genomic alterations in GCs and GEJs stratified by TP53 mutation status. PATIENTS AND METHODS: Tumor DNA sequencing results of 324 genes from 3741 patients with GC and GEJ were obtained from Foundation Medicine. Association between gene mutation frequency and TP53 mutation status was examined using Fisher's exact test. Functional gene groupings representing molecular pathways suggested to be differentially mutated in TP53 wild-type (TP53WT) and TP53 mutant (TP53MUT) tumors were identified. The association of the frequency of tumors containing a gene mutation in the molecular pathways of interest and TP53 mutation status was assessed using Fisher's exact test with a P-value of <.01 deemed statistically significant for all analyses. RESULTS: TP53 mutations were noted in 61.6% of 2946 GCs and 81.4% of 795 GEJs (P < .001). Forty-nine genes had statistically different mutation frequencies in TP53WT vs. TP53MUT patients. TP53WT tumors more likely had mutations related to DNA mismatch repair, homologous recombination repair, DNA and histone methylation, Wnt/B-catenin, PI3K/Akt/mTOR, and chromatin remodeling complexes. TP53MUT tumors more likely had mutations related to fibroblast growth factor, epidermal growth factor receptor, other receptor tyrosine kinases, and cyclin and cyclin-dependent kinases. CONCLUSION: The mutational profiles of GCs and GEJs varied according to TP53 mutation status. These mutational differences can be used when designing future studies assessing the predictive ability of TP53 mutation status when targeting differentially affected molecular pathways.

The effect of histologic grade on neoadjuvant treatment outcomes in esophageal cancer.

BACKGROUND AND OBJECTIVES: The gold standard for locoregional esophageal cancer (LEC) treatment includes preoperative chemoradiation and surgical resection, with possible perioperative or adjuvant systemic therapy. With few data associating histologic grade and prognosis in LEC patients receiving neoadjuvant chemoradiation followed by resection, we seek to evaluate this association. METHODS: Our institutional esophagectomy database between 1999 and 2019 was queried, selecting esophageal adenocarcinoma patients who completed neoadjuvant therapy (NAT), followed by esophagectomy. Propensity-score matching of low- and high-histologic grade groups was performed to assess survival metrics using initial clinical grade (cG) and final pathologic grade (pG). We performed a multivariable logistic regression to study predictors of pathologic complete response as a secondary objective. RESULTS: A total of 518 patients met the inclusion criteria. Kaplan-Meier analysis of the matched dataset showed no difference in initial or 5-year recurrence-free survival or overall survival (OS) between cG1 and cG2 versus cG3 based on original grade. When matched according to pG, cG1-2 had improved median survival parameters compared to cG3, with 5-year OS for cG1-2 of 45% versus 27% (p = 0.001). Higher pG, pathologic N stage, and poor response to NAT are predictors of poor survival. CONCLUSION: Patients with post-NAT pG1-2 demonstrated improved survival. Integrating histologic grade into postneoadjuvant staging may be warranted.

Impact of histology classification on pathologic treatment response and overall survival in distal esophageal cancer patients: a propensity matched analysis.

BACKGROUND: Esophageal squamous cell carcinoma (ESCC) has been linked to superior pathologic treatment response compared to esophageal adenocarcinoma (EAC) after neoadjuvant chemoradiation. However, the impact of histology on survival remains unclear. It has been suggested, based on epidemiologic similarities, that distal EAC should be grouped with gastric cancers as an entity distinct from distal ESCC, but there is little data to support this recommendation. We therefore aim to compare pathologic treatment response (PTR) and overall survival (OS) in patients with distal EAC versus distal ESCC. METHODS: This retrospective cohort study included patients who underwent esophagectomy for distal esophageal malignancy. Histologic sub-groups were matched (1:1) using a propensity-score matching approach. Pre-operative clinical parameters, oncologic outcomes and survival were compared between groups. RESULTS: 1031 distal EC patients, with a median age of 64.4 years and a male preponderance (86.5%), underwent esophagectomy at our institution between 1999 and 2019. 939 (91.1%) patients had a diagnosis of EAC and 92 (8.9%) had ESCC. A higher proportion of ESCC patients were female (26.1% vs. 12.1%; P < 0.01) and non-white (12.0% vs. 3.8%; P < 0.01). Propensity-score sub-analysis identified 75 matched pairs. Rates of pathologic complete response (58.0% vs. 48.9%; P = 0.67) and OS (43.0 vs. 52.0 months; P = 0.808) were not significantly different between matched groups. CONCLUSIONS: Although traditionally known to have a better overall PTR compared to EAC, ESCC patients in our large series did not show any improvement in PTR or OS. Treatment recommendations for patients with EAC and ESCC should consider tumor location in addition to histology.

Preventive use of a topical anti-inflammatory glucocorticoid in atopic dogs without clinical sign of otitis does not affect ear canal microbiota and mycobiota.

BACKGROUND: Otitis externa is associated with a lack of bacterial/fungal diversity in atopic dermatitis. Clinical experience has shown that use of topical corticosteroids in the ear canal (EC) can prevent otitis. No data are available on the impact of this treatment on the EC microbiota. HYPOTHESIS/OBJECTIVES: To observe the bacterial/fungal diversity in the EC and the clinical effect of topical corticosteroids administered over a four week period in atopic dogs without active otitis. ANIMALS: Ten atopic dogs without active otitis. METHODS AND MATERIALS: Mometasone was applied in the right EC, while the left was used as control. A clinical and cytological evaluation of the EC was performed. Swabs of each EC were analysed using next-generation sequencing methods. RESULTS: At the beginning of the trial, variations in microbiota and mycobiota were observed between dogs and also within individuals. Statistically, no significant difference was observed in alpha and beta diversity between the treated and the untreated group over time. Clinically, right and left EC diversities were no different at Day (D)28 (P = 0.28). A significant difference was noted between D0 and D28 for the treated ears (P = 0.012) and not for the untreated ears (P = 0.63). No cytological evidence of microbes was found for treated ECs at D28. CONCLUSIONS AND CLINICAL RELEVANCE: These data suggest that the use of topical corticosteroids as proactive treatment is unlikely to increase the risk of secondary microbial overgrowth. The positive clinical effect of this proactive treatment seems to be supported through cytological and otoscopic improvement.

Is Preoperative G-Tube Use Safe for Esophageal Cancer Patients?

Objective: Gastrostomy tubes (g-tubes) have been used with caution prior to esophageal resection due to the risks of inoculation metastasis and of injury to the gastric conduit used for reconstruction. In this study, we aim to evaluate the safety of preoperative g-tube placement by comparing outcomes in patients undergoing esophageal resection with and without prior g-tube use.Method: We retrospectively reviewed our institution's database of 1113 esophagectomies performed between 1994 and 2018. We included only patients who received neoadjuvant therapy and identified 65 patients who received preoperative nutritional support through a g-tube (GT+) and 657 who did not (GT-). Demographics, postoperative complications, survival, and cancer recurrence rates were compared between GT + and GT- using Chi-squared and Kaplan-Meier survival analyses.Results: Seven-hundred twenty-two patients (122 female, 600 male) with a median age of 63.2 (28.2-86.3) met our inclusion criteria. Between GT+ (n = 65) and GT- (n = 657), there were no significant differences in anastomotic leak rates (11.5% vs 10.9%; p = 0.901), postoperative mortality (3.1% vs 3.9%; p = 0.765), or overall complications (63.1% vs 65.1%; p = 0.746). GT + was associated with a significantly lower overall survival compared to GT- (32.5 m vs 92.9 m; p = 0.003), and tumor recurrence rates were similar (30.6% vs 31.8%; p = 0.851). There were no cases documenting damage to the gastric conduit caused by prior g-tube placement.Conclusions: G-tube usage was not associated with increased tumor recurrence, anastomotic leak rates, or overall complication rates in this study. Our data suggest that g-tube usage is safe for patients with esophageal cancer requiring preoperative nutrition.

Recurrence patterns and associated factors of locoregional failure following neoadjuvant chemoradiation and surgery for esophageal cancer.

BACKGROUND: Despite neoadjuvant chemoradiation (nCRT) followed by esophagectomy for locally advanced esophageal cancer, locoregional recurrence (LRR) is common and factors associated with LRR have not been clearly identified. METHODS: Patients were identified from a single institution, prospectively maintained database (1996-2013). Patterns of recurrence were described and associated factors of LRR were analyzed using competing risks regression models. RESULTS: Of the 456 patients treated with nCRT and surgery, 167 patients developed recurrence. Locoregional and distant recurrences were observed in 69 (15.1%) and 140 (30.9%) patients, respectively. Time to recurrence (13.6 vs 10.4 months, P = 0.20) and median overall survival (29.3 vs 19.1 months, P = 0.12) were no different among the 27 patients (6%) who developed a solitary LRR compared to patients who developed distant recurrence. Univariable analysis identified lymphovascular invasion (HR 1.46, P = 0.07), lymph node ratio >0.5 (HR 2.16, P = 0.02), positive margin (HR 1.95, P = 0.05), lack of response to neoadjuvant therapy (HR 1.99, P < 0.01), clinical T stage (HR 2.62, P < 0.01) and final T3/4 stage (HR 2.06, P < 0.01) as factors significantly associated with LRR. Clinical T stage and response to neoadjuvant treatment were independently associated with LRR on multivariable analysis. CONCLUSIONS: Although aggressive tumor biology plays a significant role in LRR, optimizing neoadjuvant treatments to obtain a complete pathologic response may lead to improved locoregional control.

Ear canal microbiota - a comparison between healthy dogs and atopic dogs without clinical signs of otitis externa.

BACKGROUND: The canine skin microbiota has been evaluated using relatively new microbiological techniques; studies have shown a difference in the composition of bacterial populations between healthy dogs and those with canine atopic dermatitis (cAD). However, little has been reported concerning the ear canal microbiota despite the fact that otitis externa is a common problem in dogs with cAD. HYPOTHESIS/OBJECTIVES: The study evaluated the ear canal microbiota of healthy dogs and atopic dogs without clinical signs of otitis. ANIMALS: Nine healthy privately owned dogs and 11 dogs with a diagnosis of cAD. METHODS AND MATERIALS: Ear swabs from the two groups were used for global bacterial DNA extraction. V1-V3 hypervariable 16S rDNA amplicon libraries were prepared for each sample and sequenced with MiSeq Illumina sequence (V3 kit). Taxonomical assignment and clustering were performed with Mothur using SILVA database. RESULTS: The ear canal microbiota showed changes in diversity similar to those reported for canine skin and seemed to be stable during the period of the study (28 days). Evidence of dysbiosis was observed in the atopic dogs, with increased abundance of Staphylococcus spp. and Ralstonia spp. (P < 0.05). Escherichia spp. also were found to be more abundant in healthy dogs. CONCLUSIONS AND CLINICAL IMPORTANCE: This study demonstrated a shift in bacterial populations between allergic and healthy dogs. The observed results in the ear canal are similar to those reported on the skin and could explain the propensity of allergic dogs to develop bacterial otitis.

Western blot analysis of sera from dogs with suspected food allergy.

BACKGROUND: Food allergy is often suspected in dogs with clinical signs of atopic dermatitis. This diagnosis is confirmed with an elimination diet and a subsequent challenge with regular food. Laboratory tests for the diagnosis of food allergy in dogs are unreliable and/or technically difficult. Cyno-DIAL® is a Western blot method that might assist with the selection of an appropriate elimination diet. HYPOTHESIS/OBJECTIVES: To evaluate the performance of Cyno-DIAL® for the selection of an elimination diet and diagnosis of food allergy. ANIMALS/METHODS: Thirty eight dogs with atopic dermatitis completed an elimination diet. Combining the results of the diet trials and the challenges, 14 dogs were classified as food allergic (FA), 22 as nonfood-allergic and two as ambiguous cases. RESULTS: Amongst all dogs and amongst dogs with a clinical diagnosis of FA, 3% and 7% (respectively) were positive to Royal Canin Anallergenic® , Vet-Concept Kanguru® or Vet-Concept Dog Sana® ; 8% and 7% to Hill's d/d Duck and Rice® ; 8% and 21% to Hill's z/d Ultra Allergen Free® ; 53% and 64% to Eukanuba Dermatosis FP® ; and 32% and 43% to a home-cooked diet of horse meat, potatoes and zucchini. The specificity and sensitivity of Cyno-DIAL® for diagnosing food allergy were 73% and 71%, respectively. CONCLUSIONS AND CLINICAL IMPORTANCE: Although Cyno-DIAL® was considered potentially useful for identifying appropriate foods for elimination diet trials, it cannot be recommended for the diagnosis of food allergy. The Cyno-DIAL® test performed better than some previously evaluated ELISA-based tests.

Effect of Obesity on Perioperative Outcomes After Robotic-Assisted Pulmonary Lobectomy.

OBJECTIVE: We investigated whether higher body mass index (BMI) affects perioperative and postoperative outcomes after robotic-assisted video-thoracoscopic pulmonary lobectomy. METHODS: We retrospectively studied all patients who underwent robotic-assisted pulmonary lobectomy by one surgeon between September 2010 and January 2015. Patients were grouped according to the World Health Organization's definition of obesity, with "obese" being defined as BMI >30.0 kg/m2. Perioperative outcomes, including intraoperative estimated blood loss (EBL) and postoperative complication rates, were compared. RESULTS: Over 53 months, 287 patients underwent robotic-assisted pulmonary lobectomy, with 7 patients categorized as "underweight," 94 patients categorized as "normal weight," 106 patients categorized as "overweight," and 80 patients categorized as "obese." Because of the relatively low sample size, "underweight" patients were excluded from this study, leaving a total cohort of 280 patients. There was no significant difference in intraoperative complication rates, conversion rates, perioperative outcomes, or postoperative complication rates among the 3 groups, except for lower risk of prolonged air leaks ≥7 days and higher risk of pneumonia in patients with obesity. CONCLUSIONS: Patients with obesity do not have increased risk of intraoperative or postoperative complications, except for pneumonia, compared with "normal weight" and "overweight" patients. Robotic-assisted pulmonary lobectomy is safe and effective for patients with high BMI.

Robotic-Assisted Videothoracoscopic Mediastinal Surgery.

BACKGROUND: Tumors of the mediastinum as well as normal thymus glands in patients with myasthenia gravis have traditionally been resected using large and morbid incisions. However, robotic-assisted mediastinal resections are gaining popularity because of the many advantages that the robot provides. However, few comprehensive reviews of the literature on robotic-assisted mediastinal resections exist. METHODS: A systemic review of the current medical literature was performed, excluding cases related to esophageal pathology. These studies were evaluated and their findings are reported in this comprehensive review. Approximately 48 papers met the inclusion criteria for review. RESULTS: Robotic-assisted surgical systems are increasingly being used in mediastinal resections. Based on the available literature, robotic-assisted thoracoscopic surgery in the mediastinum is feasible and safe. Robotic-assisted mediastinal surgery appears to be superior to open approaches of the mediastinum and is comparable with videothoracoscopic surgery when patient outcomes are considered. CONCLUSIONS: Increased robotic experience and more studies, including randomized controlled trials, are needed to validate the findings of the current literature.

Robotic-Assisted Videothoracoscopic Surgery of the Lung.

BACKGROUND: Despite initial concerns about the general safety of videothoracoscopic surgery, minimally invasive videothoracoscopic surgical procedures have advantages over traditional open thoracic surgery via thoracotomy. Robotic-assisted minimally invasive surgery has expanded to almost every surgical specialty, including thoracic surgery. Adding a robotic-assisted surgical system to a videothoracoscopic surgical procedure corrects several shortcomings of videothoracoscopic surgical cameras and instruments. METHODS: We performed a literature search on robotic-assisted pulmonary resections and compared the published robotic series data with our experience at the H. Lee Moffitt Cancer Center & Research Institute. All perioperative outcomes, such as intraoperative data, postoperative complications, chest tube duration, hospital length of stay (LOS), and in-hospital mortality rates were noted. RESULTS: Our literature search found 23 series from multiple surgical centers. We divided the literature into 2 groups based on the year published (2005-2010 and 2011-2014). Operative times from earlier studies ranged from 150 to 240 minutes compared with 90 to 242 minutes for later studies. Conversion rates (to open lung resection) from the earlier studies ranged from 0% to 19% compared with 0% to 11% in the later studies. Mortality rates for the earlier studies ranged from 0% to 5% compared with 0% to 2% for the later studies. Since 2010, our group has performed more than 600 robotic-assisted thoracic surgical procedures, including more than 200 robotic-assisted pulmonary lobectomies, which we also divided into 2 groups. Our median skin-to-skin operative time improved from 179 minutes for our early group (n = 104) to 172 minutes for our later group (n = 104). The overall conversion rate was 9.6% and the emergent conversion rate (for bleeding) was 5% for our robotic-assisted lobectomies. The most common postoperative complications in our cohort were prolonged air leak (> 7 days; 16.8%) and atrial fibrillation (12%). Hospital LOS for the early series ranged from 3 to 11 days compared with 2 to 6 days for the later series. Median hospital LOS decreased from 6 to 4 days. Our mortality rate was 1.4%; 3 in-hospital deaths occurred in the early 40 cases. Mediastinal lymph node (LN) dissection and detection of occult mediastinal LN metastases were improved during robotic-assisted lobectomy for non-small-cell lung cancer, as demonstrated by an overall 30% upstaging rate, including a 19% nodal upstaging rate, in our cohort. CONCLUSIONS: Robotic-assisted videothoracoscopic pulmonary lobectomy appears to be as safe as conventional videothoracoscopic surgical lobectomy, which has decreased perioperative complications and a shorter hospital LOS than open lobectomy. Both mediastinal LN dissection and the early detection of occult mediastinal LN metastatic disease were improved by robotic-assisted videothoracoscopic surgical compared with conventional videothoracoscopic surgical or open thoracotomy.

Robotic-Assisted Esophageal Surgery.

BACKGROUND: The adoption of minimally invasive approaches to the management of esophageal disease has been slow, except for the laparoscopic management of gastroesophageal reflux disease. However, the advent of new surgical technologies - in particular, robotic-assisted surgical systems - has revolutionized esophageal surgery. METHODS: The literature was systematically reviewed using the keywords "robotic," "esophageal surgery," "esophagectomy," "fundoplication," and "esophageal myotomy." The reference lists from these articles were then also analyzed. RESULTS: Forty-nine studies were included in our comprehensive review of robotic-assisted esophageal surgery, and they consisted of literature reviews, case reports, retrospective and prospective case series, and randomized controlled trials. CONCLUSIONS: Robotic-assisted esophageal surgery is a safe and effective way of treating esophageal disorders, including gastroesophageal reflux disease, achalasia, leiomyomas, and cancer. The use of robotic surgical systems has many benefits for managing disorders of the esophagus, but more studies, including randomized controlled trials, are necessary.

The prognostic value of residual nodal disease following neoadjuvant chemoradiation for esophageal cancer in patients with complete primary tumor response.

BACKGROUND: The prognostic significance of residual nodal disease in otherwise complete pathologic responders (ypT0N+) to neoadjuvant chemoradiation (nCRT) for esophageal cancer is unknown. METHODS: ypT0N+ responders were identified from a single institution database of esophageal cancer patients undergoing esophagectomy and were compared to patients without locoregional disease (ypT0N0) and to non-complete responders (ypT+). RESULTS: Out of 487 patients, 196 ypT0N0 and 14 ypT0N+ patients were identified. Pre-treatment stage was similar between ypT0N0 and ypT0N+ patients: 66% versus 73% of patients had uT3 disease (P = 0.50) and 76% versus 55% had nodal involvement (P = 0.49), respectively. Locoregional recurrence (43%) was more common in ypT0N+ patients. Median overall survival (OS) was worse in ypT0N+ patients (14.8 months) compared to ypT0N0 patients (92.2 months) and ypT+ patients (38.0 months, P < 0.001). Median OS of ypT0N+ patients was similar to ypT+ stage II (29.6 months, P = 0.84) and stage III (27.5 months, P = 0.95) disease. No difference in median OS existed in patients with residual nodal disease (n = 163) based on local response (14.8 months in ypT0N+ and 22.5 months in ypT+N+ patients, P = 0.55). CONCLUSIONS: Residual nodal disease in esophageal cancer patients with complete response in the primary tumor following nCRT portends a poor prognosis and behaves similar to pathologic stage II/III disease.

Outcomes and clinical predictors of improved survival in a patients undergoing pulmonary metastasectomy for sarcoma.

BACKGROUND: Pulmonary metastasectomy (PM) for metastatic sarcoma can result in long-term survival. The purpose of this study was to describe factors associated with survival in a series of patients undergoing PM for metastatic sarcoma. METHODS: We reviewed all patients undergoing PM for metastatic sarcoma over a 12-year period (2000-2012). Multivariate analyses were used to identify factors associated with outcomes. Survival was calculated with Kaplan-Meier and Cox proportional hazard models. RESULTS: A total of 120 patients underwent PM with a median follow-up was 48 months. Among 81 (85%) patients who presented with local disease, the median disease free interval (DFI) was 13 months and median overall survival (OS) was 48 months. Fourteen patients (15%) had synchronous metastasis with a median OS of 21 months. On multivariate analysis, synchronous metastasis (P = 0.005), older age (P = 0.02), and number of lung lesions (P = 0.003) were associated with poor survival. The median OS of patients with a DFI ≥12 versus <12 months following primary resection was 93 and 43 months (P = 0.004). CONCLUSION: While patients with a DFI >12 months have the best OS following PM, patients with a DFI <12 months also have excellent outcomes as compared to systemic therapy and should be considered for PM.

Totally minimally invasive laparoscopic robot-assisted Ivor Lewis esophagectomy: improved technique and outcomes over 200 cases.

Background: Surgical resection of esophageal and gastroesophageal junction cancers is a very complex procedure with step learning curve. New technologies have made minimally invasive surgery possible, but challenges still remain for wide spread adoption of these techniques. This article aims to describe the outcomes and salient technical points of a totally minimally invasive, laparoscopic, robot-assisted Ivor Lewis esophagectomy (LRAMIE). Methods: Retrospective observational cohort study performed at a specialty cancer center using a prospectively maintained institutional database. Patients undergoing LRAMIE (laparoscopic abdomen, robotic chest) from 2014-2023 were included. Patients undergoing transhiatal and three-field esophagectomy were excluded. Operative and postoperative outcomes were compared over the study period to identify potential associations between outcomes over time. Results: Two-hundred patients were identified who underwent LRAMIE. Median age was 65 years and most were male (87.5%). The open conversion rate was 1% (n=2), which occurred within the first 30 cases. Operative time and blood loss were improved at the 60-case mark (P<0.001). Anastomotic stricture rate improved after 50 cases, and leak rate improved after 80 cases. Postoperative length of stay improved at both 50 and 100 cases with a median LOS of 6 days after 100 cases. Rate of postoperative pneumonia, 30- and 90-day mortality were reduced after 100 cases, although not statistically significant for mortality due to too few events. Conclusions: Totally minimally invasive Ivor Lewis esophagectomy at a high-volume center is a safe procedure. Operative outcomes improved significantly after 50-80 cases, followed by improvement in anastomotic results and postoperative outcomes, with corresponding excellent oncologic outcomes.

Heart failure due to tension hydrothorax after left pneumonectomy.

Tension hydrothorax is a rare complication of pneumonectomy for pleural mesothelioma and an exceptionally rare cause of heart failure. We describe a patient who had undergone extrapleural pneumonectomy, chemotherapy, and radiation for pleural mesothelioma and who developed heart failure symptoms within months of the completion of treatment. Investigation showed a massive left pleural effusion resulting in tension hydrothorax, mediastinal shift, and evidence of right heart failure with constrictive physiology and low cardiac output. Therapeutic thoracentesis resulted in increase in cardiac output and symptomatic improvement.

Dose tapering for ciclosporin in cats with nonflea-induced hypersensitivity dermatitis.

BACKGROUND: Little information is available on the ciclosporin dose-tapering regimen and clinical response in the treatment of feline hypersensitivity dermatitis. HYPOTHESIS/OBJECTIVES: To test a dose-tapering regimen and assess efficacy and clinical safety for up to 18 weeks. ANIMALS: Eighty-eight client-owned cats with feline hypersensitivity dermatitis. METHODS: Cats that received either a placebo or ciclosporin at 2.5 mg/kg or 7 mg/kg daily for 6 weeks were given 7 mg/kg ciclosporin daily for 4 weeks. Depending on the clinical response, the dose was tapered from daily to every other day over the next 4 weeks and further to twice a week for an additional 4 weeks. RESULTS: After all cats received 7 mg/kg for 4 weeks, the dose could be tapered to every other day for the next 4 weeks in 70% of cats remaining in the study. During the next 4 weeks, 57, 15 and 22% of cats remaining in the study could be treated at twice a week, every other day or daily, respectively. After the first 4 weeks, the mean lesion score and owner-assessed pruritus improved over baseline by 69 and 61%, respectively, and remained stable during the following 8 weeks. Approximately 65% of the cats in the study were reported to have an adverse event (AE), very often mild and resolving spontaneously. The most frequent AEs were gastrointestinal and included primarily vomiting and diarrhoea. Eighty per cent of AEs occurred when cats were on daily treatment. CONCLUSIONS AND CLINICAL IMPORTANCE: Results suggest that the induction dose of 7 mg/kg ciclosporin can be tapered as soon as 4 weeks without deterioration of the clinical response. Establishment of the lowest effective dosing regimen of ciclosporin reduced the frequency of AEs.

The Middle Ear Microbiota in Healthy Dogs Is Similar to That of the External Ear Canal.

Otitis media can be a consequence of chronic otitis externa and could represent a perpetuating factor. While the microbiota of the EEC in healthy dogs and in the presence of otitis externa has been described, only sparse information is available concerning the normal microbiota of the middle ear. The objective was to compare the tympanic bulla (TB) with the external ear canal (EEC) microbiota in healthy dogs. Six healthy experimental Beagle dogs were selected based on the absence of otitis externa, negative cytology and bacterial culture from the TB. Samples from the EEC and TB were collected directly after death using a total ear canal ablation and lateral bulla osteotomy. The hypervariable segment V1-V3 of the 16S rDNA was amplified and sequenced with a MiSeq Illumina. The sequences were analyzed by the Mothur software using the SILVA database. No significant differences between the EEC and TB microbiota for the Chao1 richness index (p = 0.6544), the Simpson evenness index (p = 0.4328) and the reciprocal Simpson alpha diversity (p = 0.4313) were noted (Kruskal-Wallis test). A significant difference (p = 0.009) for the Chao1 richness index between the right and left EEC was observed. The microbiota profile was similar in the EEC and the TB of the Beagles.

Effect of Surgical Day of Week on Postoperative Outcomes After Robotic-Assisted Pulmonary Lobectomy.

Introduction Patients who have surgery late in the week could potentially receive different postoperative care due to a reduced weekend staff compared to patients who have surgery early in the week, who will be cared for by a full staff during the work week. Our aim was to determine if patients who underwent robotic-assisted video-thoracoscopic (RAVT) pulmonary lobectomy during the first half of the week had different outcomes than patients who also underwent RAVT pulmonary lobectomy during the second half of the week. Methods We analyzed 344 consecutive patients who underwent RAVT pulmonary lobectomy by one surgeon from 2010 to 2016. Depending on the day of the surgical procedure, these patients were either put into a Monday through Wednesday (M-W) group or a Thursday through Friday (Th-F) group. Patient demographics, tumor histopathology, intraoperative and postoperative complications, and perioperative outcomes were compared between groups using the Student's t-test, Kruskal-Wallis test, or chi-square (or Fisher's exact) test, with p≤0.05 as significant. Results There were more non-small cell lung cancers (NSCLCs) resected in the M-W group than in the Th-F group (p=0.005). Skin-to-skin and total operative times were greater for the Th-F group than for the M-W group (p=0.027 and p=0.017, respectively). There were no significant differences in any other variables assessed. Conclusions Our study showed that, despite reduced weekend staffing and potential differences in postoperative care, there were no significant differences seen in postoperative complications or perioperative outcomes based on surgical day of the week.