Disparities and Underutilization of Surgery for Early Stage Small Cell Lung Cancer.

BACKGROUND: The National Comprehensive Cancer Network recommends surgical resection for stage I small cell lung cancer (SCLC). Despite these recommendations and the curative potential of such surgery, many continue to underutilize surgery. Our aim is to investigate factors that contribute to underutilization of surgery for stage I SCLC. METHODS: The National Cancer Database was queried to identify patients with SCLC stage I-IV from 2004 to 2018. Staging was defined by the American Joint Committee on Cancer guidelines. Cochran-Armitage analysis was performed to analyze trends in surgical treatment for patients diagnosed with stage I SCLC. Multivariable logistic regression assessed relationships between patient factors and surgical treatment. RESULTS: A total of 296,583 patients were diagnosed with SCLC. Of the stage I patients (n = 13,003), only 29.4.% (n = 3823) underwent surgery. Trend analysis demonstrated increased frequency of surgical treatment for stage I SCLC over years 2004 to 2017, from 14.9% to 39.6% (P < .0001). Factors that were associated with underutilization of surgery for stage I SCLC include African American race, lower median income, nonprivate insurance or Medicare, community facility, and geographic regions other than the Northeast. CONCLUSIONS: Surgical treatment for stage I SCLC remains underutilized and our study identifies notable associated factors. The recognition of these factors may help patients overcome barriers to receiving recommended treatments, improve guideline adherence, and overall quality of care for stage I SCLC patients.

Single Setting Robotic Lung Nodule Diagnosis and Resection.

Lung cancer remains the leading cause of cancer-related deaths. Early tissue diagnosis followed by timely therapeutic procedures can have a significant impact on overall survival. While robotic-assisted lung resection is an established therapeutic procedure, robotic-assisted bronchoscopy is a more recent diagnostic procedure that improves reach, stability, and precision in the field of bronchoscopic lung nodule biopsy. The ability to combine lung cancer diagnostics with therapeutic surgical resection into a single-setting anesthesia procedure has the potential to decrease costs, improve patient experiences, and most importantly, reduce delays in cancer care.

Trends in segmentectomy for the treatment of stage 1A non-small cell lung cancers: Does the robot have an impact?

OBJECTIVES: Lobectomy may unnecessarily resect healthy lung parenchyma in Stage 1A non-small cell lung cancers (NSCLC). Segmentectomies may provide a lung-sparing option. VATS segmentectomies can be technically challenging; robotics may have features that provide advantages in performing segmentectomies. We describe the association of the robot on national trends in segmentectomies. METHODS: The National Cancer Database (2010-2017) was queried for patients with Stage 1A NSCLC who underwent lobectomies and segmentectomies. The proportion of segmentectomies vs. lobectomies and the proportion of robotic vs. VATS segmentectomies was calculated annually. RESULTS: The proportion of segmentectomies increased compared to lobectomies for all surgical approaches but remained constant for minimally-invasive approaches. The proportion of robotic segmentectomies increased over the years compared to VATS segmentectomies. Descriptive statistics are reported as numbers and proportions. Trends in the proportions of lobectomies and segmentectomies were compared using Chi-squared test for categorical variables and unpaired t-test for independent means. A p-value of <0.05 was considered statistically significant. Statistical analysis was performed using SPSS Statistics Software version 24 (IBM Corp, Armonk, NY). CONCLUSIONS: We demonstrate an increasing trend and proportion of robotic segmentectomies being performed in comparison to VATS segmentectomies. The robotic platform may facilitate the performance of more segmentectomies for early-stage NSCLC.

The lasting footprint of COVID-19 on surgical education: A resident and attending perspective on the global pandemic.

BACKGROUND: The COVID-19 pandemic has impacted surgical training nationwide. Our former curricula will likely not return, and training will need to adapt, so we are able to graduate residents of the same caliber as prior to the pandemic. METHODS: A survey evaluating perceptions of changes made in surgical training was conducted on surgery residents and attendings. RESULTS: Disaster medicine training has become more relevant and 85% residents and 75% attendings agreed it should be incorporated into the curriculum. Safety of family was the most significant concern of residents. Virtual curriculum was perceived to be acceptable by 82% residents and only 22% attendings (p < 0.01). Residents (37%) were less concerned than attendings (61%) of falling behind on their overall training (p = 0.04). Both groups agreed operative skills would be adversely affected (56%vs72%; p = 0.37). CONCLUSIONS: To maintain an effective surgical curriculum, programs will need to implement new educational components to better prepare residents to become surgeons of the future.

Management of Complications in Paraesophageal Hernia Repair.

Paraesophageal hernia repair is a technically challenging operation. Factors that influence morbidity of the operation include the timing of the operation, surgical approach, and patient factors. Medical complications are the most common and usually are respiratory or cardiac related. Perforation, subcutaneous emphysema, pneumothorax, shortened esophagus, and presence of a large hernia all complicate paraesophageal hernia repair. Various strategies of intraoperative management are described. Management of leaks and perforations identified postoperatively are dictated by the clinical status of the patient. Early identification and expeditious intervention are paramount in the overall management of complications.

Does the Approach Matter? Comparing Survival in Robotic, Minimally Invasive, and Open Esophagectomies.

BACKGROUND: Our objective was to determine how surgical approach impacts overall survival and postoperative outcomes when comparing robotic-assisted minimally invasive esophagectomy (RAMIE), minimally invasive esophagectomy (MIE), and open esophagectomy (OE). METHODS: The National Cancer Database was queried for patients diagnosed with pathologic Stage 0 to III esophageal cancer from 2010 to 2015. Primary outcome measures evaluated were length of stay, 30-day unplanned readmissions, mortality rates at 30 and 90 days, and overall survival rates. The surgical cohorts underwent 1:1 propensity score matching, and Kaplan-Meier survival estimates were compared by surgical approach. Cox proportional hazards regression was utilized to estimate factors associated with overall survival. RESULTS: Of 5,553 patients that met criteria, 28.4% were MIE, 7.8% RAMIE, and 63.8% OE. From 2010 to 2015, an increasing trend was seen for both minimally invasive approaches, with MIE surpassing the number of OEs. Unplanned 30-day readmissions and 30-day and 90-day mortality rates were not significantly different between the different groups. Median length of stay was significantly shorter in MIE (9 [interquartile range (IQR), 8 to 14] days) and RAMIE (9 [IQR, 7 to 14] days), compared with OE (10 [IQR, 8 to 15] days; p < 0.001). MIE and RAMIE had comparable survival rates compared with OE, with no significant differences in median overall survival estimates after propensity score matching (log-rank p = 0.603), with a trend for increased survival in MIE (adjusted hazard ratio, 0.97; 95% confidence interval, 0.89 to 1.06; p = 0.530) and RAMIE (hazard ratio, 0.81; 95% confidence interval, 0.69 to 0.95; p = 0.012). Both minimally invasive approaches had a significantly higher median lymph node counts (MIE: 15 [IQR, 9 to 22]; RAMIE: 17 [IQR, 11 to 24]; OE: 13 [IQR, 8 to 20]), which may highlight important differences in postoperative upstaging. CONCLUSIONS: Trends in MIE use is surpassing the open approach. Minimally invasive approaches are becoming the preferred approach, with noninferior long-term results compared with OEs. A significantly higher lymph node yield was seen for RAMIE and MIE.

Versatility of a mini-trapdoor incision in upper mediastinal exposure.

Exposure of the upper mediastinum and thoracic outlet can pose major surgical challenges. We report our application of a previously described mini-trapdoor incision to a variety of surgical problems involving the upper mediastinum and thoracic outlet, including subclavian vein thrombosis, penetrating subclavian artery injury, debridement of subjacent chest wall infection, lymph node excision, and Pancoast tumor resection. This versatile approach provides excellent structural visualization while obviating clavicular resection or sternoclavicular joint disruption, or both.

The use of human acellular dermal matrix for chest wall reconstruction.

BACKGROUND: Reconstruction of chest wall defects has evolved, but challenges remain. This is particularly true when defects are large or contamination is present. Although numerous materials are available for reconstruction, acellular dermal matrix has the advantage of becoming vascularized and incorporated autologously. By its resistance to infection and lack of adhesion formation, it is a promising although expensive alternative to synthetic materials in some circumstances. This report examines our experience with human acellular dermal matrix (HADM) in reconstruction of major chest wall and diaphragmatic defects. METHODS: A retrospective study was conducted of all patients who underwent thoracic reconstruction using HADM between March 2007 and March 2010 at Harbor-University of California-Los Angeles Medical Center. Data acquisition included demographics, surgical indications, operative details, complications, and follow-up evaluation. RESULTS: Ten patients were identified. Indications included thoracic tumor resection in 5, Clagett procedure modification for postpneumonectomy empyema in 2, resection of chest wall osteomyelitis in 2, and pneumonectomy for multiple aspergillomata in 1. Complications occurred in 4 patients and included respiratory failure, pneumonia, and wound seromas. All wounds healed without need to remove or revise the HADM, and sound chest wall closure was achieved in every case. CONCLUSIONS: HADM is an effective but expensive alternative to synthetic mesh in reconstruction of chest wall and diaphragmatic defects. It is particularly attractive for use under conditions of potential or overt contamination.