Liposomal Bupivacaine Versus Bupivacaine/Epinephrine Intercostal Nerve Block as Part of an Enhanced Recovery After Thoracic Surgery (ERATS) Care Pathway for Robotic Thoracic Surgery.

OBJECTIVES: To examine how postoperative pain control after robotic thoracoscopic surgery varies with liposomal bupivacaine (LipoB) versus 0.5% bupivacaine/1:200,000 epinephrine (Bupi/Epi) intercostal nerve blocks within the context of an enhanced recovery after thoracic surgery (ERATS) protocol. DESIGN: A retrospective analysis of a prospectively maintained database of patients undergoing robotic thoracoscopic procedures between September 1, 2018 and October 31, 2019 was conducted. SETTING: University of Miami, single-institutional. PARTICIPANTS: Patients. INTERVENTIONS: Two hundred fifty-two patients had either LipoB intercostal nerve blocks (n = 129) or Bupi/Epi intercostal nerve blocks (n = 123) when undergoing robotic thoracic surgery. MEASUREMENTS AND MAIN RESULTS: Comparative analysis of patient-reported pain levels, in-hospital and post-discharge opioid requirements, 90-day operative complications, length of hospital stay, and hospital costs was performed. Data were stratified to either anatomic lung resection or pulmonary wedge resection/mediastinal-pleural procedures. Bupi/Epi patients reported significantly more acute postoperative pain than LipoB patients, which correlated with higher in-hospital and post-discharge opioid requirements. There were no differences in postoperative complications, length of hospital stay, or hospital costs between the two groups. CONCLUSIONS: As part of an ERATS protocol, infiltration of intercostal spaces and surgical wounds with LipoB for robotic thoracoscopic procedures afforded better postoperative subjective pain control and decreased opioid requirements without an increase in hospital costs as compared with use of Bupi/Epi.

Hemoptysis is frequently fatal if blood comes directly from the aorta commentary.

Physicians throughout the world, across various specialties, are faced with diagnostic challenges of appropriately identifying the source of hemotosysis, which could range from a simple treatable infection, to the more ominous massive hemorrhage from the aorta requiring emergency, life saving surgery. Aortobronchopulmonary fistula, which is an abnormal communication between the thoracic aorta and the pulmonary tree, is an uncommon but often lethal condition if not promptly surgically intervened. Over the decades, the underlying cause has shifted, from primarily due to an aortic infection, such as tuberculosis, to now secondarily as a result of endovascular repair of the intrathoracic aorta. The best treatment modality, whether open surgical repair, endovascular management, or hybrid approach continues to be debated given the high operative morbidity and mortality of open repair and need to address the pulmonary communication, with optimal management still undetermined.

Use of venovenous extracorporeal membrane oxygenation for resection of a large paratracheal mass causing critical tracheal stenosis: A case report.

Critical airway stenosis is challenging for surgeons and anesthesiologists to secure a reliable airway for ventilation. The use of venovenous (VV)-extracorporeal membrane oxygenation (ECMO) has been described as a strategy to provide adequate gas exchange in such instances. We present a case of a young female with a complex paratracheal mass significantly compressing the trachea; a planned intraoperative VV-ECMO was instituted to allow safe orotracheal intubation of a double-lumen endotracheal tube for lung isolation and tumor resection.

Enhancement in virtual learning cannot substitute for hands-on training in cardiothoracic surgery.

This program director survey attempts to determine how coronavirus 2019 pandemic is impacting current training in cardiothoracic surgery. A transition to virtual didactic sessions may prove beneficial with increasing attendance. On the other hand, decreasing live simulation and case volumes may jeopardize achieving competency in surgical skills.

Surgical management of mediastinal paraganglioma: All hands on deck!

Mediastinal paragangliomas are very uncommon neuroendocrine neoplasms. Due to their tissue of origin (sympathetic ganglia of the great vessels), they tend to arise deep within pericardial space and, more importantly, intimately attached to great vessels, which makes surgical resection, even with cardiopulmonary bypass, very challenging. This commentary accompanies the case report describing complex surgical management of a paraganglioma located in the anterior mediastinum that was initially thought to be a thymoma.

Rare metastatic patterns after malignant transformation of serous borderline tumor of the ovary.

Serous borderline tumors are rare, benign ovarian neoplasms that may recur and undergo malignant transformation to low-grade serous carcinomas (LGSCs). In this report, a 50-year-old female with a remote history of a serous borderline ovarian tumor experienced a recurrence of LGSC, presenting as a large solitary subcutaneous mass anterior to the sternum after a 33-year disease-free interval. The described case highlights the unpredictable nature of this disease and the importance of implementing lifelong surveillance strategies.

Hypercoagulability After Resection of Thoracic Malignancy: A Prospective Evaluation.

BACKGROUND: Rates of venous thromboembolism are increased in thoracic malignancy; however, coagulation patterns are not established. We hypothesize that patients with esophageal and lung malignancy have similar hypercoagulable pre- and postoperative profiles as defined by rotational thromboelastometry (ROTEM). METHODS: Prospective study was conducted in 47 patients with esophageal and lung cancer undergoing surgical resection. ROTEM evaluated pre/postoperative coagulation status. RESULTS: Patients with thoracic malignancy were hypercoagulable by ROTEM, but not by conventional coagulation tests. Preoperative hypercoagulability was higher in lung versus esophageal cancer (64 vs. 16%, p = 0.001). Lung cancer patients that were hypercoagulable preoperatively demonstrated decreased maximum clot firmness (MCF) (p = 0.044) and increased clot time (p = 0.049) after surgical resection, suggesting reversal of hypercoagulability. Resection of esophageal cancer increased hypercoagulability (16 vs. 56%, p = 0.002) via elevated MCF (reflecting platelet activity). Hypercoagulability remained at follow-up clinic for both lung and esophageal cancer patients. CONCLUSIONS: Hypercoagulability in patients with lung malignancies reversed following complete surgical resection, whereas hypercoagulability occurred only postoperatively in those with esophageal malignancies. In both, hypercoagulability was associated with fibrin and platelet function.

Spontaneous healing of a shredded esophagus after ACDF without direct repair.

Esophageal perforation is a catastrophic complication of anterior cervical discectomy and fusion (ACDF). While direct surgical repair has been reported as optimal for restoration of upper gut function, we present the case of a 58-year-old woman who achieved complete resolution when treated only with debridement and drainage. We find that a supportive approach, surgical management without direct repair, may play a vital role in select patient populations in order to avoid potentially long-term consequences or radical treatments, like esophageal diversion. Decisions regarding direct repair versus debridement and inspection only should be made on a case-by-case basis through a multidisciplinary approach.

Robotic paravertebral schwannoma resection at extreme locations of the thoracic cavity.

Solitary paravertebral schwannomas in the thoracic spine and lacking an intraspinal component are uncommon. These benign nerve sheath tumors are typically treated using complete resection with an excellent outcome. Resection of these tumors is achieved by an anterior approach via open thoracotomy or minimally invasive thoracoscopy, by a posterior approach via laminectomy, or by a combination of both approaches. These tumors most commonly occur in the midthoracic region, for which surgical removal is usually straightforward. The authors of this report describe 2 cases of paravertebral schwannoma at extreme locations of the posterior mediastinum, one at the superior sulcus and the other at the inferior sulcus of the thoracic cavity, for which the usual surgical approaches for safe resection can be challenging. The tumors were completely resected with robot-assisted thoracoscopic surgery. This report suggests that single-stage anterior surgery for this type of tumor in extreme locations is safe and effective with this novel minimally invasive technique.

Arsenic Attenuates GLI Signaling, Increasing or Decreasing its Transcriptional Program in a Context-Dependent Manner.

The metalloid arsenic is a worldwide environmental toxicant, exposure to which is associated with many adverse outcomes. Arsenic is also an effective therapeutic agent in certain disease settings. Arsenic was recently shown to regulate the activity of the Hedgehog (HH) signal transduction pathway, and this regulation of HH signaling was proposed to be responsible for a subset of arsenic's biologic effects. Surprisingly, these separate reports proposed contradictory activities for arsenic, as either an agonist or antagonist of HH signaling. Here we provide in vitro and in vivo evidence that arsenic acts as a modulator of the activity of the HH effector protein glioma-associated oncogene family zinc finger (GLI), activating or inhibiting GLI activity in a context-dependent manner. This arsenic-induced modulation of HH signaling is observed in cultured cells, patients with colorectal cancer who have received arsenic-based therapy, and a mouse colorectal cancer xenograft model. Our results show that arsenic activates GLI signaling when the intrinsic GLI activity is low but inhibits signaling in the presence of high-level GLI activity. Furthermore, we show that this modulation occurs downstream of primary cilia, evidenced by experiments in suppressor of fused homolog (SUFU) deficient cells. Combining our findings with previous reports, we present an inclusive model in which arsenic plays dual roles in GLI signaling modulation: when GLIs are primarily in their repressor form, arsenic antagonizes their repression capacity, leading to low-level GLI activation, but when GLIs are primarily in their activator form, arsenic attenuates their activity.

TRAIL induces autophagic protein cleavage through caspase activation in melanoma cell lines under arginine deprivation.

Arginine deprivation is a promising strategy for treating ASS-negative malignant tumors including melanoma. However, autophagy can potentially counteract the effectiveness of this treatment by acting as a pro-survival pathway. By combining tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) with arginine deprivation using ADI-PEG20 (pegylated arginine deiminase), we achieved enhanced apoptosis and accelerated cell death in melanoma cell lines. This implies a switch from autophagy to apoptosis. In our current investigation, we found that TRAIL could induce the cleavage of two key autophagic proteins, Beclin-1 and Atg5, in the combination treatment. Using specific inhibitors for individual caspases, we found that caspase-8 inhibitor could completely abolish the cleavage. Furthermore, caspase-8 inhibitor was able to fully reverse the enhanced cytotoxicity induced by TRAIL. Inhibitors for caspase-3, 6, 9, and 10 were able to block the cleavage of these two autophagic proteins to some extent and correspondingly rescue cells from the cytotoxicity of the combination of TRAIL and arginine deprivation. In contrast, calpain inhibitor could not prevent the cleavage of either Beclin-1 or Atg5, and was unable to prevent cell death. Overall, our data indicate that the cleavage of Beclin-1 and Atg5 by TRAIL-initiated caspase activation is one of the mechanisms that lead to the enhancement of the cytotoxicity in the combination treatment.

Extracorporeal membrane oxygenation in the surgical management of large mediastinal masses: a narrative review.

Background and Objective: The management of large mediastinal tumors requires a complex multidisciplinary approach, particularly in the perioperative setting due to increased risk of hemodynamic compromise. The utilization of extracorporeal membrane oxygenation (ECMO) provides a useful adjunct in the surgical management for biopsy and resection of these mediastinal masses. The objective of this article is to review indications and implementation of ECMO in the surgical management of mediastinal disease. Methods: A literature review of the PubMed database was completed evaluating articles discussing 'extracorporeal circulation', 'cardiopulmonary bypass', 'anesthesia', 'mediastinal disease', and 'mediastinal cancer'. These articles were evaluated for contribution to the discussion of indications and implementation of ECMO in the management of these patients. Key Content and Findings: Large mediastinal tumors place patients at risk of hemodynamic collapse on induction of anesthesia due to compression of vascular structures, tracheobronchial tree and creation of V/Q mismatch. Patients may be stratified regarding their risk of perioperative complications by evaluation of postural symptoms, cross sectional imaging findings and pulmonary function tests. Those patients at elevated perioperative risk may benefit from the utilization of ECMO, most commonly veno-arterial (V-A) ECMO. Guidewires or ECMO cannulas may be placed under local anesthesia prior to induction. Those patients with hemodynamic compromise may receive mechanical circulatory support to allow completion of the operation. Conclusions: The use of a multidisciplinary team consisting of surgeons, anesthesiologists, perfusionists and OR team is critical to the success in the use of ECMO in the resection of mediastinal masses. With diligent preparation, these high-risk patients may be optimally managed at the time of resection.

Bronchogenic cysts: a narrative review.

Background and Objective: Bronchogenic cysts represent a rare form of cystic malformation of the respiratory tract. Primarily located in the mediastinum if occurring early in gestation as opposed to the thoracic cavity if arising later in development. However, they can arise from any site along the foregut. They exhibit a variety of clinical and radiologic presentations, representing a diagnostic challenge, especially in areas with endemic hydatid disease. Endoscopic drainage has emerged as a diagnostic and potentially therapeutic option but has been complicated by reports of infection. Surgical excision remains the standard of care allowing for symptomatic resolution and definitive diagnosis via pathologic examination; minimally invasive approaches such as robotic and thoracoscopic approaches aiding treatment. Following complete resection, prognosis is excellent with essentially no recurrence. Methods: A review of the available electronic literature was performed from 1975 through 2022, using PubMed and Google Scholar, with an emphasis on more recent series. We included all retrospective series and case reports. A single author identified the studies, and all authors reviewed the selection until there was a consensus on which studies to include. Key Content and Findings: The literature consisted of relatively small series, mixed between adult and pediatric patients, and the consensus remains that all symptomatic lesions should be excised via minimally invasive approach where feasible. Conclusions: Surgical excision of symptomatic bronchogenic cysts remains the gold standard, with endoscopic drainage being reserved for diagnosis or as a temporizing measure in clinically unstable patients.

Achieving opioid-free discharge following robotic thoracic surgery: A single-institution experience.

Objectives: Enhanced recovery after thoracic surgery (ERATS) protocols use a combination of analgesics for pain control and have been associated with decreased opioid requirements. We investigated the impact of continual ERATS refinement on the incidence of opioid-free discharge. Methods: We retrospectively analyzed our prospectively maintained institutional database for elective, opioid-naive robotic thoracoscopic procedures. Demographics, operative outcomes, postoperative opioid dispensed (morphine milligram equivalent), and opioid discharge status were collected. Our primary outcome of interest was factors associated with opioid-free discharge; our secondary objective was to determine the incidence of new persistent opioid users. Results: In total, 466 patients from our optimized ERATS protocol were included; 309 (66%) were discharged without opioids. However, 34 (11%) of patients discharged without opioids required a prescription postdischarge. Conversely, 7 of 157 patients (11%), never filled their opioid prescriptions given at discharge. Factors associated with opioid-free discharges were nonanatomic resections, mediastinal procedures, minimal pain, and lack of opioid usage on the day of discharge. More importantly, 3.2% of opioid-free discharge patients became new persistent opioid users versus 10.8% of patients filling opioid prescriptions after discharges (P = .0013). Finally, only 2.3% of opioid-naive patients of the entire cohort became chronic opioid users; there was no difference in the incidence of chronic use by opioid discharge status. Conclusions: Optimized opioid-sparing ERATS protocols are highly effective in reducing opioid prescription on the day of discharge. We observed a very low rate of new persistent or chronic opioid use in our cohort, further highlighting the role ERATS protocols in combating the opioid epidemic.

The impact of social determinants of health on textbook oncological outcomes and overall survival in locally advanced non-small cell lung cancer.

Objectives: Textbook oncological outcome (TOO) is a composite metric for surgical outcomes, including non-small cell lung cancer (NSCLC). We hypothesized that social determinants of health (SDH) can affect both the attainment of TOO and the overall survival (OS) in surgically resected NSCLC patients with pathological nodal disease. Methods: We queried the National Cancer Database (2010-2017) for preoperative therapy-naïve lobectomies for NSCLC with tumor size <7 cm and pathologic N1/N2. Socioeconomic factors comprised SDH scores, where SDH negative (-) was considered if SDH ≥2 (disadvantage); otherwise, SDH was positive (+). TOO+ was defined as R0 resection, ≥5 lymph nodes resected, hospital stay <75th percentile, no 30-day mortality, adjuvant chemotherapy initiation ≤3 months, and no unplanned readmission. If one of these parameters was not achieved, the case was considered TOO-. Results: Of 11,274 patients, 48% of cases were TOO+ and 38% were SDH+. A total of 15% of patients were SDH- and were less likely (adjusted odds ratio, 0.85; 95% confidence interval [CI], 0.78-0.92) to achieve TOO+ than patients with SDH+. After accounting for confounders, patients with TOO+ had 22% lower overall mortality than patients with TOO- (adjusted hazard ratio, 0.78; CI, 0.73-0.82). In contrast, SDH- remained an independently significant risk factor, reducing survival by 24% compared with SDH+ (adjusted hazard ratio, 1.24; CI, 1.17-1.32). The impact of SDH on OS was significant for both patients with TOO+ and TOO-: SDH+/TOO+ had the best OS and SDH-/TOO-had the worst OS. Conclusions: SDH score has a significant association with TOO achievement and TOO-driven overall posttreatment survival in patients with lobectomy-resected NSCLC with postoperative pathologic N1/N2 nodal metastasis. Addressing SDH is important to optimize care and long-term survival of this patient population.

The essential role of non-steroidal anti-inflammatory drugs in pain control following robotic thoracoscopic lung resections.

Background: Enhanced recovery after thoracic surgery (ERATS) protocols use a combination of analgesics for pain control. We investigated the effect of non-steroidal analgesic drugs (NSAIDs) on pain control by comparing patient levels and opioid requirements after robotic pulmonary resections. Methods: We retrospectively analyzed our prospectively maintained institutional database for elective, opioid-naïve robotic thoracoscopic pulmonary resections. All patients received postoperative NSAIDs unless contraindicated or at the discretion of the attending surgeons. Our original protocol (ERATS-V1) was modified to optimize opioid-sparing effect without affecting pain control (ERATS-V2). Demographics, operative outcomes, and postoperative opioid dispensed [morphine milligram equivalent (MME)] were collected. Results: A total of 491 patients (147 ERATS-V1; 344 ERATS-V2) were included in this study. There was no difference in patient characteristics or operative outcomes between ERATS cohorts. Protocol optimization was associated with a 2- to 10-fold reduction of postoperative opioid use without compromising pain control. In ERATS-V1 cohort, there was no difference in pain levels and opioid requirements with NSAID usage. In ERATS-V2 cohort, while pain levels were similar, higher in-hospital opioid consumption was observed in no-NSAID subgroup {MME: 20.5 [interquartile range (IQR), 4.8-40.5] vs. 12.0 (IQR, 2.0-32.2), P=0.0096, schedule II: 14.2 (IQR, 3.0-36.4) vs. 6.8 (IQR, 1.4-24.0), P=0.012} as well as total postoperative schedule II opioid requirement [17.8 (IQR, 3.0-43.5) vs. 8.8 (IQR, 1.5-30), P=0.032]. Conclusions: The opioid-sparing effect of NSAIDs was observed only in optimized ERATS patients. Modifications of our pre-existing ERATS was associated with a significant reduction of opioid consumption without affecting pain levels. This revealed the role of NSAIDs in postoperative pain management otherwise masked by excessive opioids use.

Disparities in Survival Due to Social Determinants of Health and Access to Treatment in US Patients With Operable Malignant Pleural Mesothelioma.

Importance: Outcomes of localized malignant pleural mesothelioma (MPM) remain poor despite multimodality therapy. It is unclear what role disparities have in the overall survival (OS) of patients with operable MPM. Objective: To examine survival disparities associated with social determinants of health (SDOHs) and treatment access in patients with malignant pleural mesothelioma. Design, Setting, and Participants: In this observational, retrospective cohort study, patients with MPM diagnosed between January 1, 2004, and December 31, 2017, were identified from the National Cancer Database with a maximum follow-up time of 13.6 years. The analysis was conducted from February 16, 2022, to July 29, 2022. Patients were included if they were diagnosed with potentially resectable clinical stage I to IIIA MPM, had epithelioid and biphasic histologic subtypes, and received chemotherapy. Patients were excluded if they could not receive curative surgery, were 75 years or older, or had metastasis, unknown stage, or tumor extension to the chest wall, mediastinal tissues, or organs. Exposures: Chemotherapy alone vs chemotherapy with curative surgery in the form of pleurectomy and decortication or extrapleural pneumonectomy. Main Outcomes and Measures: The primary end point was OS. Cox proportional hazards regression models were used to determine hazard ratios (HRs) for OS, including univariable and multivariable models controlling for potential confounders, including demographic, comorbidity, clinical, treatment, tumor, and hospital-related variables, as well as SDOHs. Results: A total of 1389 patients with MPM were identified (median [IQR] age, 66 [61-70] years; 1024 [74%] male; 12 [1%] Asian, 49 [3%] Black, 74 [5%] Hispanic, 1233 [89%] White, and 21 [2%] of other race). The median OS was 1.7 years (95% CI, 1.6-1.8). Risk factors associated with worse OS included older age, male sex, Black race, low income, and low educational attainment. Factors associated with greater odds of survival included receipt of surgical therapy, recent year of treatment, increased distance to travel, and treatment at high-volume academic hospitals. The risk factors most strongly associated with poor OS included Black race (HR, 1.96; 95% CI, 1.43-2.69) and male sex (HR, 1.60; 95% CI, 1.38-1.86). Surgical treatment in addition to systemic chemotherapy (HR, 0.70; 95% CI, 0.61-0.81) was independently associated with improved OS, as were chemotherapy initiation (HR, 0.93; 95% CI, 0.87-0.99) and greater travel distance from the hospital (HR, 0.92; 95% CI, 0.86-0.98). Conclusions and Relevance: In this retrospective cohort study of patients with operable MPM, there was significant variability in access to care by SDOHs. Addressing disparities in access to multimodality therapy can help ensure equity of care for patients with MPM.

Postoperative day 1 discharge following robotic thoracoscopic pulmonary anatomic resections in the era of enhanced recovery protocol: A single-institution experience.

Objective: Implementation and continuing optimization of enhanced recovery protocol after thoracic surgery results in significant improvement of postoperative outcomes. We observed a 10-fold increase in the rate of postoperative day (POD) 1 discharges following robotic thoracoscopic anatomic resections over time. We aimed to determine factors associated with safe POD1 discharges. Methods: We performed a retrospective analysis of a prospectively maintained database of robotic anatomic pulmonary resections between July 1, 2012, and June 30, 2022, with patients of the last 2.5 years forming the basis of this study. Data collected included demographics, insurance types, Area Deprivation Index (indicator of poverty), and operative and postoperative variables including length of stay, opioid use, daily pain levels, readmissions, and outpatient interventions. Factors associated with POD1 were analyzed using a logistic regression module. Result: In total, 279 patients met inclusion criteria (91 POD1 discharges, 32.6%; none discharged with a pleural catheter). There was neither an increase of postdischarge interventions for pleural complications nor readmission in early discharge patients. After adjusting for relevant factors, younger age, right middle lobectomy, lower opioid use on POD1, operating room finish before 4 PM, and low Area Deprivation Index were significantly associated with POD1 discharge. A subanalysis of 49 patients, who could have been discharged on POD1, identified hypoxemia requiring home oxygen, atrial fibrillation, and poorly controlled pain being common mitigatable clinical factors delaying POD1 discharge. Conclusions: Safe POD1 discharge following robotic thoracoscopic anatomic resection was achieved in 32% of cases. Identification of positive and negative factors affecting early discharge provides guidance for further modifications to increase the number of POD1 discharges.