Pulmonary Open, Robotic, and Thoracoscopic Lobectomy (PORTaL) Study: Survival Analysis of 6646 Cases.

OBJECTIVE: The aim of this study was to analyze overall survival (OS) of robotic-assisted lobectomy (RL), video-assisted thoracoscopic lobectomy (VATS), and open lobectomy (OL) performed by experienced thoracic surgeons across multiple institutions. SUMMARY BACKGROUND DATA: Surgeons have increasingly adopted RL for resection of early-stage lung cancer. Comparative survival data following these approaches is largely from single-institution case series or administrative data sets. METHODS: Retrospective data was collected from 21 institutions from 2013 to 2019. Consecutive cases performed for clinical stage IA-IIIA lung cancer were included. Induction therapy patients were excluded. The propensity-score method of inverse-probability of treatment weighting was used to balance baseline characteristics. OS was estimated using the Kaplan-Meier method. Multivariable Cox proportional hazard models were used to evaluate association among OS and relevant risk factors. RESULTS: A total of 2789 RL, 2661 VATS, and 1196 OL cases were included. The unadjusted 5-year OS rate was highest for OL (84%) followed by RL (81%) and VATS (74%); P =0.008. Similar trends were also observed after inverse-probability of treatment weighting adjustment (RL 81%; VATS 73%, OL 85%, P =0.001). Multivariable Cox regression analyses revealed that OL and RL were associated with significantly higher OS compared with VATS (OL vs. VATS: hazard ratio=0.64, P <0.001 and RL vs. VATS: hazard ratio=0.79; P =0.007). CONCLUSIONS: Our finding from this large multicenter study suggests that patients undergoing RL and OL have statistically similar OS, while the VATS group was associated with shorter OS. Further studies with longer follow-up are necessary to help evaluate these observations.

Pulmonary Open, Robotic, and Thoracoscopic Lobectomy (PORTaL) Study: An Analysis of 5721 Cases.

OBJECTIVE: The aim of this study was to analyze outcomes of open lobectomy (OL), VATS, and robotic-assisted lobectomy (RL). SUMMARY BACKGROUND DATA: Robotic-assisted lobectomy has seen increasing adoption for treatment of early-stage lung cancer. Comparative data regarding these approaches is largely from single-institution case series or administrative datasets. METHODS: Retrospective data was collected from 21 institutions from 2013 to 2019. All consecutive cases performed for clinical stage IA-IIIA lung cancer were included. Neoadjuvant cases were excluded. Propensity-score matching (1:1) was based on age, sex, race, smoking-status, FEV1%, Zubrod score, American Society of Anesthesiologists score, tumor size, and clinical T and N stage. RESULTS: A total of 2391 RL, 2174 VATS, and 1156 OL cases were included. After propensity-score matching there were 885 pairs of RL vs OL, 1,711 pairs of RL vs VATS, and 952 pairs of VATS vs OL. Operative time for RL was shorter than VATS ( P < 0.0001) and OL ( P = 0.0004). Compared to OL, RL and VATS had less overall postoperative complications, shorter hospital stay (LOS), and lower transfusion rates (all P <0.02). Compared to VATS, RL had lower conversion rate ( P <0.0001), shorter hospital stay ( P <0.0001) and a lower postoperative transfusion rate ( P =0.01). RL and VATS cohorts had comparable postoperative complication rates. In-hospital mortality was comparable between all groups. CONCLUSIONS: RL and VATS approaches were associated with favorable perioperative outcomes compared to OL. Robotic-assisted lobectomy was also associated with a reduced length of stay and decreased conversion rate when compared to VATS.

Pre-operative embolization, surgical resection, and follow-up evaluation of a giant intercostal schwannoma.

Intercostal schwannomas can present incidentally and lead to compressive thoracic symptoms. These slow-growing and benign tumors typically arise from intercostal nerves and are supplied by intercostal arteries, which may increase the risk of hemorrhagic complications with surgical resection. Due to the rarity of intercostal schwannomas, there exists no standardized management algorithms. Pre-operative angiography and embolization can supplement surgical thoracotomy and resection by decreasing intra-operative hemorrhage and minimizing the risk of anterior spinal cord hypoperfusion.

Port Strategies for Robot-Assisted Lobectomy by High-Volume Thoracic Surgeons: A Nationwide Survey.

OBJECTIVE: Robot-assisted lobectomy is the fastest growing technique for pulmonary lobectomy, but the diversity of approaches has led to apprehension about port placement among learning surgeons. The aim of this study was to survey high-volume thoracic surgeons who perform robot-assisted lobectomy to understand and consolidate common themes of port placement. METHODS: An electronic online survey was created, and the link was emailed to the 100 highest volume robotic thoracic surgeons in the United States. The survey included an interactive graphical interface, which allowed each respondent to mark the preferential robotic port placement in the chest wall for each of the 5 pulmonary lobectomies. Results were analyzed individually and in aggregate. A heat map was generated to show trends. RESULTS: One hundred surgeons were surveyed (response rate: 62%). Most (90%) respondents utilized a 4-arm approach and 79% used a completely 4-arm portal approach with CO2 insufflation. Exact locations for each robotic port were reported by 60% of the surveyed surgeons and the results varied; however, most surgeons generally used the seventh to ninth interspaces for the camera and instruments. The use of multiple different interspace levels was common. Ninety-four percent of respondents used an additional nonrobotic assistant port. CONCLUSIONS: There is not a universal port strategy for robot-assisted lobectomy. However, placement of the camera and robotic ports low in the seventh to ninth interspaces is the most common approach. There are some nuances of stapling port strategies and sequence of port placement, which are identified.

Atrial fibrillation after transhiatal esophagectomy with transcervical endoscopic esophageal mobilization: one institution's experience.

BACKGROUND: There have been numerous studies regarding atrial fibrillation (AF) associated with cardiac and pulmonary surgery; however, studies looking at esophagectomy and atrial fibrillation are sparse. The goal of this study was to review our institution's atrial fibrillation rate following esophagectomy in order to better define the incidence and predisposing factors in this patient population. METHODS: A retrospective chart review of all patients undergoing esophagectomy with transcervical endoscopic mobilization of the esophagus (TEEM) at the Medical College of Wisconsin and Affiliated Hospitals from July 2009 through December 2012. RESULTS: Seventy-one patients underwent TEEM esophagectomy during the study period. Of those, 23 (32.4%) patients developed new atrial fibrillation postoperatively. ICU (Intensive Care Unit) length of stay was 7.1 days for those that did not receive amiodarone, compared to 5.3 days for those that did receive amiodarone (p < 0.025). Those that went into AF spent on average 9.3 days in the ICU compared to 4.7 days for their counterparts that did not go into AF (p < 0.006). Total length of stay was not statistically different between populations [15.1 +/- 11.3 days compared to 13.5 +/- 9.4 days for those who did not go into AF (p < 0.281)]. Receiving preoperative amiodarone was found to reduce the overall incidence of AF. There was a trend towards decreased risk of going into AF in those who received preoperative amiodarone with an adjusted hazard ratio of 0.555 (p = 0.057). CONCLUSION: Similar to data reported in previous literature, postoperative atrial fibrillation was found to increase ICU length of stay as well as overall length of hospital stay. Preoperative amiodarone administration displayed a trend toward decreasing the rates of atrial fibrillation in patients undergoing TEEM.

Morbidities of lung cancer surgery in obese patients.

BACKGROUND: Obesity is a risk factor for increased perioperative morbidity and mortality in surgical patients. There have been limited studies to correlate the morbidity of lung cancer resection with obesity. METHODS: We performed a retrospective study of patients who underwent surgical resection for lung cancer at the Medical College of Wisconsin, Milwaukee, from 2006 to 2010. Data on patient demographics, weight, pathological findings, and hospital course were abstracted after appropriate institutional review board approval. Perioperative morbidity was defined as atrial fibrillation, heart failure, respiratory failure, pulmonary embolism, or any medical complications arising within 30 days after surgery. The Fisher exact test was used to test the association between body mass index (BMI) and perioperative morbidities. RESULTS: Between 2006 and 2010, 320 lung resections were performed for lung cancer. The median age was 67 (interquartile range, 59-75) years, and 185 (57.8%) were females. A total of 121 (37.8%) of patients had a BMI lower than 25, and 199 (62.18%) patients had a BMI of 25 or higher. The 30-day mortality rate was 1.8% (n = 6) in the whole group; only 2 of these patients had a BMI of 25 or higher. Perioperative morbidity occurred in 28 (23.14%) of patients with a normal BMI and in 47 (23.61%) of patients with a BMI of 25 or higher (P = .54). Specific morbidities encountered by patients with normal versus BMI of 25 or higher were as follows: atrial fibrillation, 11 (9.09%) versus 24 (12.06%) (P = .46); pulmonary embolism, 1 (0.83%) versus 3 (1.51%) (P = 1.0); congestive heart failure, 2 (1.65%) versus 2 (1.01%) (P = .63); renal failure, 4 (3.3%) versus 2 (1.0%) (P = .29); respiratory failure, 12 (9.92%) versus 17 (8.54%) (P = .69); and acute respiratory distress syndrome, 2 (1.65%) versus 1 (0.50%) (P = .55). The median hospital stay was 5 days in the lower BMI group and 4 days in the BMI of 25 or higher group (P = .52). CONCLUSIONS: Overweight and normal weight patients do not differ significantly in rates of perioperative morbidities, 30-day mortality, and length of stay. Our study indicates that potential curative surgical resections can be offered to even significantly overweight patients.

Use of combination chemotherapy for treatment of granulomatous and lymphocytic interstitial lung disease (GLILD) in patients with common variable immunodeficiency (CVID).

PURPOSE: A subset of patients with common variable immunodeficiency (CVID) develops granulomatous and lymphocytic interstitial lung disease (GLILD), a restrictive lung disease associated with early mortality. The optimal therapy for GLILD is unknown. This study was undertaken to see if rituximab and azathioprine (combination chemotherapy) would improve pulmonary function and/or radiographic abnormalities in patients with CVID and GLILD. METHODS: A retrospective chart review of patients with CVID and GLILD who were treated with combination chemotherapy was performed. Complete pulmonary function tests (PFTs) and high-resolution computed tomography (HRCT) scans of the chest were done prior to therapy and >6 months later. HRCT scans of the chest were blinded, randomized, and scored independently (in pairs) by two radiologists. The differences between pre- and post-treatment HRCT scores and PFT parameters were analyzed. RESULTS: Seven patients with CVID and GLILD met inclusion criteria. Post-treatment increases were noted in both FEV1 (p=0.034) and FVC (p=0.043). HRCT scans of the chest demonstrated improvement in total score (p=0.018), pulmonary consolidations (p=0.041), ground-glass opacities (p=0.020) nodular opacities (p=0.024), and both the presence and extent of bronchial wall thickening (p=0.014, 0.026 respectively). No significant chemotherapy-related complications occurred. CONCLUSIONS: Combination chemotherapy improved pulmonary function and decreased radiographic abnormalities in patients with CVID and GLILD.

Impact of a six-year integrated thoracic surgery training program at the Medical College of Wisconsin.

BACKGROUND: Thoracic residency program enrollment continues to decline. While job market and decreasing reimbursements are often cited as the main reasons, length of and format of training may also be significant. METHODS: The Medical College of Wisconsin established an Accreditation Council for Graduate Medical Education-approved 6-year integrated thoracic training program. The number and characteristics of applicants to the 6-year program were then compared with previous applicants applying to the traditional 2-year program. RESULTS: Applicants to the 6-year integrated program scored higher on the United States Medical Licensing Examination part 1 and part 2 than previous applicants to the traditional 2-year program. The 6-year applicants also were more published and a greater percentage of them held other advanced degrees. CONCLUSIONS: Institution of a 6-year integrated thoracic surgery training program at the Medical College of Wisconsin led to a significant increase in number of applications. Additionally, the 6-year applicants appeared to be more academically accomplished than previous applicants to the traditional 2-year program. While early in the experience, it appears that interest in thoracic surgery is high among medical students and institution of a 6-year program has the potential to once again attract the "best and the brightest" to this specialty.

Aortic aneurysms: delayed complications of coarctation of the aorta repair using Dacron patch aortoplasty.

Coarctation of the aorta is a diaphragmlike ridge narrowing the lumen of the proximal descending aorta. Although surgical repair has proven to be a successful treatment of coarctation of the aorta, immediate and delayed postoperative complications are not rare. Of particular interest is the occurrence of aneurysms after Dacron patch aortoplasty--often decades after surgery. Delayed complication rates of up to 50% have been reported. We describe the clinical-radiologic presentations of 3 late complications of Dacron patch angioplasty: aortobronchopleural fistula, leaking pseudoaneurysm, and giant descending aortic aneurysm--all successfully treated with bypass grafts. Because of the high incidence of delayed complications, lifelong surveillance is necessary. The chest x-ray may be the first clue to a delayed complication. Knowledge of radiologic findings is helpful in the detection of complications-before they become symptomatic. Transesophageal echocardiography, computed tomography angiography, or magnetic resonance imaging with multiplanar reconstruction is diagnostic.

Roux-en-Y diversion for debilitating reflux after esophagectomy.

Two patients with debilitating reflux after esophagectomy are reported. Complete relief of symptoms after creation of a Roux-en-Y limb to the gastric conduit is described.

Serratus anterior in vivo contractile force study.

BACKGROUND: A major limitation of functional muscle transfer for facial and intrinsic hand reanimation is the inability to predict the force that will be generated by the transplanted muscle. METHODS: The authors studied the contractile force of the slips of the serratus anterior in situ in 10 patients and tested the gracilis muscle in four subjects as a control. RESULTS: Mean contractile force generated by each serratus slip was 0.178 pound (range, 0.019 to 0.797 pound). This compares favorably with the maximum force generated by smiling (0.307 pound). Muscle strength correlated strongly with age (r = -0.805, p = 0.005). The lowest slip generated less force than those above it (0.133 pound versus 0.191 pound); this difference did not reach statistical significance. When the strength of the lowest slip is compared with the more superior slips as a percentage of total force generated by the slips (to compensate for the effect of age on muscle strength), the lowest slip was significantly weaker (18.6 percent of total force versus 25.5 percent of total force, p = 0.013). Mean contractile force generated by the gracilis was 0.963 pound, significantly different from that generated by a serratus anterior slip (p = 0.009). CONCLUSIONS: Each serratus slip could potentially be used to generate a separate force vector for facial reanimation. Further separation of the flap along preexisting fascial planes may allow generation of up to 10 independent force vectors, making the serratus anterior muscle flap an attractive option for facial reanimation and possibly intrinsic hand muscle reconstruction.

Modified transthecal digital block versus traditional digital block for anesthesia of the finger.

PURPOSE: This study compared the modified transthecal digital block (MTDB) technique with the traditional digital block (TDB) according to the degree of discomfort caused by injection and to the onset and the duration of anesthesia. METHODS: This was a prospective, randomized, double-blinded, and controlled study. The same investigator performed all blocks to the middle fingers of each hand. The hand anesthetized and type of block (TDB or MTDB) received first were both randomized. An orientation was given to the 25 participants detailing how to evaluate their own degree of anesthesia. This orientation included establishing a baseline of sensation with a safety pin, a description and diagram of 12 zones of the finger, an explanation of the 10-cm visual analog pain scale, and an explanation of how to record anesthesia progress in the fingers. On completion of each block, the subjects recorded the degree of pain and time to anesthesia in each finger zone. RESULTS: Twenty-five subjects received 1 TDB and 1 MTDB for a total of 50 blocks. The TDB received a mean rating for pain of 2.972 versus 2.784 for the MTDB (p =.579). The TDB took 3.91 minutes on average to take effect, whereas the MTDB took 7.16 minutes, a difference of 3.25 minutes. This was statistically significant in 11 of the 12 zones. Overall, return to sensation from the MTDB took effect 4.63 minutes sooner than the TDB: on average 85.19 minutes versus 89.82 minutes, respectively. This was statistically significant in 2 of the zones. CONCLUSIONS: The effect of MTDB is equal to that of TDB in terms of pain perception. For the dorsal and radial proximal zones, the TDB appears to have better distribution of anesthesia. The MTDB has slower onset to anesthesia than the TDB.