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OBJECTIVE: To use a customized smartphone application to prospectively measure QOL and the real-time patient experience during neoadjuvant therapy (NT). BACKGROUND: NT is increasingly used for patients with localized gastrointestinal (GI) cancers. There is little data assessing patient experience and quality of life (QOL) during NT for GI cancers. METHODS: Patients with GI cancers receiving NT were instructed on using a customized smartphone application through which the Functional Assessment of Cancer Therapy-General (FACT-G) questionnaire, a validated measure of health-related QOL, was administered at baseline, every 30 days, and at the completion of NT. Participants also tracked their moods and symptoms and used free-text journaling functionalities in the application. Mean overall and subsection health-related QOL scores were calculated during NT. RESULTS: Among 104 enrolled patients, the mean age was 60.5 ± 11.5 years and 55% were males. Common cancer diagnoses were colorectal (40%), pancreatic (37%), and esophageal (15%). Mean overall FACT-G scores did not change during NT ( P = 0.987). While functional well-being scores were consistently the lowest and social well-being scores the highest, FACT subscores similarly did not change during NT (all P > 0.01). The most common symptoms reported during NT were fatigue, insomnia, and anxiety (39.3%, 34.5%, and 28.3% of patient entries, respectively). Qualitative analysis of free-text journaling entries identified anxiety, fear, and frustration as the most common themes, but also the importance of social support systems and confidence in health care providers. CONCLUSIONS: While patient symptom burden remains high, results of this prospective cohort study suggest QOL is maintained during NT for localized GI cancers.
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Neoplasias , Qualidade de Vida , Masculino , Humanos , Pessoa de Meia-Idade , Idoso , Feminino , Terapia Neoadjuvante/métodos , Estudos Prospectivos , Avaliação de Resultados da Assistência ao PacienteRESUMO
BACKGROUND: Segmentectomy is increasingly used for parenchyma sparing anatomical resection for small stage I non-small cell lung cancer (NSCLC). This study characterizes the national outcomes for lymph node assessment and perioperative outcomes of segmentectomy for clinical stage I NSCLC by robotic-assisted surgery (RATS), video-assisted thoracoscopic surgery (VATS), and open thoracotomy approach. METHODS: A retrospective cohort study was conducted of patients who underwent segmentectomy for clinical stage I NSCLC captured in the national Society of Thoracic Surgeons General Thoracic Surgery Database between years 2012 and 2018. Inverse probability of treatment weighting (IPTW) was used to balance baseline characteristics. Lymph node (LN) staging and 30-day outcomes were compared by approach. RESULTS: A total of 3680 patients (VATS 61.9%, RATS 20%, open 18%) underwent segmentectomy. The IPTW adjusted rate of pathologic LN upstaging (pN1/pN2) was 6.2% (RATS 6.3%, VATS 5.6%, open 8.6%; P = .05). On multivariate analysis, there was no differences in pN1/N2 upstaging between RATS (odds ratio [OR], 0.81; 95% confidence interval [CI], 0.44-1.49) or VATS (OR, 0.96; 95% CI, 0.57-1.63) with open segmentectomy. The RATS and VATS approach was associated with fewer postoperative events (RATS 31.3%, VATS 28.8%, open 38.3%; P < .001) and shorter length of stay (RATS 4.3 days, VATS 4.4 days, open 5.2 days; P < .001) as compared with thoracotomy. RATS segmentectomy-specific complications included a higher rate of pneumothorax after chest tube removal and discharge with chest tube. Major complications were lower after RATS and VATS as compared with open segmentectomy (RATS 5.9%, VATS 4.5%, open 7.2%; P = .028). CONCLUSIONS: Segmentectomy by VATS and robotic approach resulted in similar high rates of lymph node upstaging as a global marker of the quality of lymph node dissection and were associated with lower overall morbidity and shorter length of stay as compared with open thoracotomy. These national outcomes may serve as benchmarks for future comparative studies.
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Carcinoma Pulmonar de Células não Pequenas , Neoplasias Pulmonares , Procedimentos Cirúrgicos Robóticos , Benchmarking , Carcinoma Pulmonar de Células não Pequenas/patologia , Carcinoma Pulmonar de Células não Pequenas/cirurgia , Humanos , Neoplasias Pulmonares/patologia , Neoplasias Pulmonares/cirurgia , Estadiamento de Neoplasias , Pneumonectomia/métodos , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Procedimentos Cirúrgicos Robóticos/métodosRESUMO
BACKGROUND: Racial disparities currently exist for the utilization rate of esophagectomy for Black patients with operable esophageal carcinoma. METHODS: A total of 37 271 cases with the American Joint Committee on Cancer clinical stage I, II, and III esophageal carcinoma that were reported to the National Cancer Database were analyzed between 2004 and 2016. A multivariable-adjusted logistic regression model was used to evaluate differences in the odds ratio of esophagectomy not being recommended based on race. Kaplan-Meier curves and log-rank tests were used to evaluate differences in overall survival. Propensity score methodology with inverse probability of treatment weighting (IPTW) was used to balance baseline differences in patient demographics. RESULTS: After IPTW adjustment, we identified 30 552 White patients and 3529 Black patients with clinical stage I-III esophageal carcinoma. Black patients had three times greater odds of not being recommended for esophagectomy (odds ratio: 3.03, 95% confidence interval: 2.67-3.43, p < 0.0001) compared to White patients. Black patients demonstrated significantly worse 3- and 5-year overall survival rates compared to White patients (log-rank p < 0.0001). CONCLUSION: Black patients with clinical stage I-III esophageal cancer were significantly less likely to be recommended for esophagectomy even after adjusting for baseline demographic covariates compared to White patients.
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Negro ou Afro-Americano/estatística & dados numéricos , Neoplasias Esofágicas/cirurgia , Esofagectomia/estatística & dados numéricos , Pessoal de Saúde/psicologia , Disparidades em Assistência à Saúde , Padrões de Prática Médica/estatística & dados numéricos , População Branca/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias Esofágicas/etnologia , Neoplasias Esofágicas/patologia , Esofagectomia/tendências , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Taxa de Sobrevida , Adulto JovemRESUMO
BACKGROUND: Minimally invasive esophagectomy is associated with significant morbidity, which can substantially influence the hospital length of stay for patients. Anastomotic leak is the most devastating complication. Minimizing major postoperative complications can facilitate adherence to a clinical pathway protocol and can decrease hospital length of stay. METHODS: This is a retrospective study of 130 patients who underwent an elective laparoscopic and thoracoscopic Ivor Lewis esophagectomy for esophageal carcinoma between August 2014 and June 2018. A total of 112 patients (86%) underwent neoadjuvant chemoradiation. All of the 130 patients underwent a laparoscopic gastric devascularization procedure a median of 15 days prior to the esophagectomy. The target discharge date was postoperative day number 8. RESULTS: Thirty patients (23.08%) had postoperative complications. Atrial fibrillation (20 patients) [15.38%] was the most frequent complication. Four patients (3.1%) developed an anastomotic leak. There was one postoperative death (0.77%) in the cohort of patients. The median length of stay was 8 days. The mean length of stay for patients without complications was 8 days ± 1.2 days and 12.4 days ± 7.1 days for patients with one or more complications (p = 0.002). CONCLUSION: The development of postoperative complications after minimally invasive Ivor Lewis esophagectomy significantly increases hospital length of stay. Performing the operation with a specialized tandem surgical team and including preoperative ischemic preconditioning of the stomach minimizes overall and anastomotic complications and facilitates on time hospital discharge as defined by a perioperative clinical pathway protocol.
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Carcinoma/cirurgia , Procedimentos Clínicos , Neoplasias Esofágicas/cirurgia , Esofagectomia/métodos , Laparoscopia/métodos , Toracoscopia/métodos , Idoso , Fístula Anastomótica/epidemiologia , Fístula Anastomótica/etiologia , Estudos de Coortes , Esofagectomia/efeitos adversos , Feminino , Humanos , Laparoscopia/efeitos adversos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Terapia Neoadjuvante , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Estudos Retrospectivos , Estômago/cirurgia , Toracoscopia/efeitos adversos , Resultado do TratamentoRESUMO
While better outcomes at high-volume surgical centers have driven the regionalization of complex surgical care, access to high-volume centers often requires travel over longer distances. We sought to evaluate the travel patterns among patients undergoing esophagectomy to assess willingness of patients to travel for surgical care. The California Office of Statewide Health Planning database was used to identify patients who underwent esophagectomy between 2005 and 2016. Total distance traveled, as well as whether a patient bypassed the nearest hospital that performed esophagectomy to get to a higher volume center, was assessed. Overall 3,269 individuals underwent an esophagectomy for cancer in 154 hospitals; only five hospitals were high volume according to Leapfrog standards. Median travel time to a hospital that performed esophagectomy was 26 minutes (IQR: 13.1-50.7). The overwhelming majority of patients (85%) bypassed the nearest providing hospital to seek care at a destination hospital. Among patients who bypassed a closer hospital, only 36% went to a high-volume hospital. Of the 2,248 patients who underwent esophagectomy at a low-volume center, 1,491 patients had bypassed a high-volume hospital. Of the remaining 757 patients who did not bypass a high-volume hospital, half of the individuals would have needed to travel less than an additional hour to reach a high-volume center. Nearly two-thirds of patients undergoing an esophagectomy for cancer received care at a low-volume center; 85% of patients either bypassed a high-volume hospital or would have needed to travel less than an additional hour to reach a high-volume center.
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BACKGROUND: Controversy exists as to what constitutes a learning curve to achieve competency, and how the initial learning period of robotic thoracic surgery should be approached. METHODS: We conducted a systematic review of the literature published prior to December 2018 using PubMed/MEDLINE for studies of surgeons adopting the robotic approach for anatomic lung resection or thymectomy. Changes in operating room time and outcomes based on number of cases performed, type of procedure, and existing proficiency with video-assisted thoracoscopic surgery (VATS) were examined. RESULTS: Twelve observational studies were analyzed, including nine studies on robotic lung resection and three studies on thymectomy. All studies showed a reduction in operative time with an increasing number of cases performed. A steep learning curve was described for thymectomy, with a decrease in operating room time in the first 15 cases and a plateau after 15-20 cases. For anatomic lung resection, the number of cases to achieve a plateau in operative time ranged between 15-20 cases and 40-60 cases. All but two studies had at least some VATS experience. Six studies reported on experience of over one hundred cases and showed continued gradual improvements in operating room time. CONCLUSION: The learning curve for robotic thoracic surgery appears to be rapid with most studies indicating the steepest improvement in operating time occurring in the initial 15-20 cases for thymectomy and 20-40 cases for anatomic lung resection. Existing data can guide a standardized robotic curriculum for rapid adaptation, and aid credentialing and quality monitoring for robotic thoracic surgery programs.
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Curva de Aprendizado , Pneumonectomia/métodos , Procedimentos Cirúrgicos Robóticos/educação , Timectomia/métodos , Humanos , Duração da CirurgiaRESUMO
OBJECTIVE: This study aims to characterize the aggregate learning curves of US surgeons for robotic thoracic procedures and to quantify the impact on productivity. METHODS: National average console times relative to cumulative case number were extracted from the My Intuitive application (Version 1.7.0). Intuitive da Vinci robotic system data for 56,668 lung resections performed by 870 individual surgeons between 2021 and 2022 were reviewed. Console time and hourly productivity (work relative value units/hour) were analyzed using linear regression models. RESULTS: Average console times improved for all robotic procedures with cumulative case experience (P = .003). Segmentectomy and thymectomy had the steepest initial learning curves with a 33% and 34% reduction of the average console time for proficient (51-100 cases) relative to novice surgeons (1-10 cases), respectively. The hourly productivity increase for proficient surgeons ranged from 11.4 work relative value units/hour (+26%) for lobectomy to 17.0 work relative value units/hour (+50%) for segmentectomy. At the expert level (101+ cases), average console times continued to decrease significantly for esophagectomy (-18%) and lobectomy (-23%), but only minimally for wedge resections (-1%) (P = .003). The work relative value units/hour increase at the expert level reached 50% for lobectomy and 40% for esophagectomy. Surgeon experience level, dual console use, system model, and robotic stapler use were factors independently associated with console time for robotic lobectomy. CONCLUSIONS: The aggregate learning curve for robotic thoracic surgeons in the United States varies significantly by procedure type and demonstrate continued improvements in efficiency beyond 100 cases for lobectomy and esophagectomy. Improvements in efficiency with growing experiences translate to substantial productivity gains.
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Procedimentos Cirúrgicos Robóticos , Robótica , Cirurgiões , Humanos , Estados Unidos , Procedimentos Cirúrgicos Robóticos/métodos , Curva de Aprendizado , Pneumonectomia/métodosRESUMO
BACKGROUND: Cardiothoracic surgical trainees perceive a need for more instruction and exposure to robotic-assisted thoracoscopic surgery during their training. We sought to assess use and trainee exposure to robotic surgery in thoracic residency programs to identify areas for improvement. METHODS: A voluntary electronic survey of 10 questions was distributed to surgeons working in all thoracic surgery residency programs in the United States. The survey asked respondents to provide the size of the residency, the availability and use of robots, and the trainee's adoption of robotic surgery in their practice after graduation. Multivariable logistic regression was performed. RESULTS: Of a total of 76 cardiothoracic surgery training programs, surgeons from 69 training programs (90.8%) completed the survey. Most pulmonary lobectomy was performed using robotic surgery (55%). Approximately half of the training programs (35 of 69) have a formal robotic curriculum for the residents. Of 121 thoracic track trainees, 118 (97.5%) performed robotic surgery as part of their practice, whereas 62 of 110 (56.4%) cardiothoracic track and 16 of 158 (10.1%) cardiac track trainees performed robotic surgery. In a multivariate analysis, the adoption of robotic surgery was associated with having an established robotic training curriculum (odds ratio, 5.82; 95% CI, 1.32-35.7) and a larger training program (odds ratio, 3.78; 95% CI, 1.34-10.6). CONCLUSIONS: A disparity exists in robotic surgical training among the training programs. A standardized curriculum and formal case requirements may be needed to ensure optimal preparation for future graduates.
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Failure to provide one-lung ventilation can prohibit minimally invasive thoracic surgeries. Strategies for one-lung ventilation include double-lumen endotracheal tubes or endobronchial blockers, but rarely both. Inability to provide lung isolation after double-lumen endotracheal tube placement requires troubleshooting and sometimes the use of extra equipment. This case describes using a unique Y-shaped endobronchial blocker placed through a left-sided double-lumen endotracheal tube after failure to achieve lung isolation with a double-lumen endotracheal tube alone.
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Ventilação Monopulmonar , Procedimentos Cirúrgicos Torácicos , Humanos , Intubação Intratraqueal , PulmãoRESUMO
In this review article, we aim to provide an overview of common and uncommon general surgery thoracic emergencies as well as basic thoracic anatomy, common diagnostic tests, and operative positioning and access considerations. We also describe specific thoracic procedures. We hope that this article simplifies some of the challenges associated with the management of thoracic emergencies.
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Fraturas das Costelas , Cirurgiões , Traumatismos Torácicos , Ferimentos não Penetrantes , Humanos , Traumatismos Torácicos/complicações , Traumatismos Torácicos/diagnóstico , Traumatismos Torácicos/cirurgia , Emergências , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/diagnóstico , Ferimentos não Penetrantes/cirurgia , Fraturas das Costelas/complicações , Fraturas das Costelas/diagnósticoRESUMO
This case series describes 2 patients who underwent a single anesthesia strategy for definitive management of bilateral ground-glass opacities harboring adenocarcinoma-spectrum lesions using robotic navigational localization paired with robotic thoracoscopic resection.
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Adenocarcinoma , Anestesia , Neoplasias Pulmonares , Procedimentos Cirúrgicos Robóticos , Humanos , Neoplasias Pulmonares/diagnóstico por imagem , Neoplasias Pulmonares/cirurgia , Neoplasias Pulmonares/patologia , Pneumonectomia , Adenocarcinoma/diagnóstico por imagem , Adenocarcinoma/cirurgiaRESUMO
Robotic-assisted surgery is gaining popularity as a minimally invasive approach for anatomic lung resection. We investigated the temporal changes in case volume, costs, and postoperative outcomes for robotic-assisted anatomic lung resection in over 1000 cases. We reviewed our institutional STS database for patients who had undergone robotic-assisted lobectomy, bi-lobectomy, or segmentectomy as the primary procedure between years 2009-2021. The patients were divided into two groups: first 500 cases (n = 501) and second 500 cases (n = 500). Temporal trends of case volume, surgical indications, hospital length of stay, costs, and perioperative outcomes were analyzed. A total of 1001 patients were analyzed, of which 968 (96.7%) patients underwent robotic-assisted lobectomy, 21 (2.1%) patients underwent bi-lobectomy, 10 (1.0%) patients underwent segmentectomy, and 3 (0.3%) patients underwent sleeve lobectomy. Primary lung cancer was the most common indication (87.7%), followed by metastatic lung tumors (7.1%), and benign diagnosis (5.2%). The overall postoperative complication rate decreased from 46.1% for the first 500 cases compared to 29.6% for the second 500 cases (p < 0.0001). The median hospital length of stay was down trending, which was 4 days [IQR: 3-7] for the first 500 cases and 3 days [IQR: 3-5] (p = 0.0001) for the second. The inflation-adjusted direct and indirect hospital costs were significantly lower in the second 500 cases (p < 0.0001). The complications rates, hospital costs, and hospital length of stay for robotic-assisted anatomic pulmonary resection decreased significantly over time at a single institution. Continuous improvement in perioperative outcomes may be observed with increasing institutional experience.
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Neoplasias Pulmonares , Procedimentos Cirúrgicos Robóticos , Humanos , Procedimentos Cirúrgicos Robóticos/métodos , Cirurgia Torácica Vídeoassistida/métodos , Neoplasias Pulmonares/cirurgia , Complicações Pós-Operatórias/etiologia , Pulmão , Estudos RetrospectivosRESUMO
BACKGROUND: There may be equivalent efficacy of the lymph node evaluation for minimally invasive lobectomy compared with open lobectomy for stage I non-small cell lung cancer. We sought to compare the lymph node evaluation for lobectomy by approach for patients with larger tumors who are clinically node negative. METHODS: This retrospective study analyzed 24 257 patients with clinical stage T2-3N0M0 non-small cell lung cancer from the National Cancer Database. Inverse probability of treatment weighting (IPTW) was applied to balance baseline characteristics. The rates of pathologic lymph node upstaging were compared. A Cox multivariable regression model was performed to test the association with overall survival. RESULTS: After IPTW adjustment 20 834 patients were included in the analysis. Of these, 1996 patients underwent robotic lobectomy, 5122 patients underwent thoracoscopic lobectomy, and 13 725 patients underwent open lobectomy from 2010 to 2017. The IPTW-adjusted N1 upstaging rate was similar for robotic (11.79%), thoracoscopic (11.49%), and open (11.85%) lobectomy (P = .274). The adjusted N2 upstaging rates were 5.03%, 5.66%, and 6.15% for robotic, thoracoscopic, and open lobectomy, respectively (P = .274). On IPTW-adjusted multivariable analysis, robotic and thoracoscopic lobectomy were associated with improved survival compared with open lobectomy (P < .001). CONCLUSIONS: There was no significant difference in N1 and N2 lymph node upstaging rates between surgical approaches for patients with clinical stage T2-3N0 non-small cell lung cancer, indicating similarly effective lymph node evaluation. Overall survival after robotic and thoracoscopic lobectomy was significantly better compared with open lobectomy in this patient population with a high propensity for occult nodal disease.
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Carcinoma Pulmonar de Células não Pequenas , Neoplasias Pulmonares , Procedimentos Cirúrgicos Robóticos , Humanos , Neoplasias Pulmonares/patologia , Estudos Retrospectivos , Estadiamento de Neoplasias , Linfonodos/patologia , Pneumonectomia , Cirurgia Torácica VídeoassistidaRESUMO
INTRODUCTION: We sought to assess the prevalence and clinical predictors of satellite nodules in patients undergoing lobectomy for clinical stage Ia disease. PATIENTS AND METHODS: The National Cancer Database was queried for patients who underwent lobectomy for clinical stage cT1N0 NSCLC. Collaborative staging information was used to identify patients who were pathologically upstaged based on having separate tumor nodules in the same lobe as the primary tumor. Multivariable logistic regression was used to assess the association of clinical factors with the detection of separate nodules. RESULTS: A separate tumor nodule was recorded in 2.8% (n = 1284) of 45,842 clinical stage Ia patients treated with lobectomy or bilobectomy. Female gender (3.1% vs. male 2.5%; P = .002) and non-squamous histology (adenocarcinoma 3.2% and large cell neuroendocrine 3.0% vs. squamous cell 1.9% tumors; P < .001) were associated with the presence of separate nodules. The frequency increased for tumors larger than 3 cm (≤ 3cm, 2.7% vs. > 3cm, 3.8%; P < .001). Other factors associated with separate nodules were upper lobe location, pleural and/or lymphovascular invasion and occult lymph node disease. The best predictive model for separate nodules based on the available clinical variables resulted in an area under the curve of 0.645 (95% CI 0.629-0.660). CONCLUSION: Separate tumor nodules may be detected with a low but relatively consistent frequency across the spectrum of patients with clinical stage Ia NSCLC. The predictive ability using basic clinical factors in the database is limited.
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Adenocarcinoma , Carcinoma Pulmonar de Células não Pequenas , Neoplasias Pulmonares , Humanos , Masculino , Feminino , Carcinoma Pulmonar de Células não Pequenas/epidemiologia , Carcinoma Pulmonar de Células não Pequenas/cirurgia , Carcinoma Pulmonar de Células não Pequenas/etiologia , Neoplasias Pulmonares/epidemiologia , Neoplasias Pulmonares/cirurgia , Neoplasias Pulmonares/etiologia , Prevalência , Estadiamento de Neoplasias , Adenocarcinoma/patologia , Estudos Retrospectivos , Pneumonectomia/métodosRESUMO
BACKGROUND: The impact on cost relative to clinical efficacy of enhanced recovery after surgery (ERAS) protocols for patients who undergo robotic-assisted lobectomy is currently unknown. The objective of this study was to compare cost and perioperative outcomes of robotic-assisted lobectomy before and after implementation of an ERAS protocol. METHODS: This was a retrospective analysis of 574 patients who underwent robotic-assisted lobectomy for primary lung carcinoma from May 1, 2017 to June 1, 2021. The ERAS protocol was implemented on October 17, 2019. Inverse probability of treatment weighting of propensity scores was used to balance baseline characteristics. The primary outcomes of the study were mean direct and indirect hospital costs, complication rates, and hospital length of stay. RESULTS: Three hundred fifteen patients underwent robotic-assisted lobectomy before implementation of the ERAS protocol, and 259 patients were enrolled on the protocol. A significantly higher percentage of patients were discharged home in less than 3 days after the ERAS protocol implementation (24.5% vs 9.8%, P = .001). There were significant decreases in the inverse probability of treatment weighting-adjusted mean direct hospital costs (P < .001) and mean indirect costs (P = .018) for the total hospital stay after ERAS protocol implementation. The mean initial discharge opioid medication dose (morphine equivalent dose) was significantly lower (P < .001) after the ERAS protocol. CONCLUSIONS: Increased early discharge and decreased hospital costs were observed for robotic-assisted lobectomy after implementation of an ERAS protocol. There was also an observed significant decrease in the discharge opioid medication doses prescribed.
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Recuperação Pós-Cirúrgica Melhorada , Procedimentos Cirúrgicos Robóticos , Humanos , Estudos Retrospectivos , Analgésicos Opioides/uso terapêutico , Custos HospitalaresRESUMO
BACKGROUND: Sublobar resection is increasingly performed for stage Ia non-small cell lung cancer, but pathologic lymph node upstaging remains a common clinical scenario. This study compares the long-term prognosis of patients with clinical stage Ia disease and occult lymph node disease undergoing wedge resection vs lobectomy. METHODS: The National Cancer Database was queried for patients treated with wedge resection or lobectomy for clinical stage Ia (cT1N0) non-small cell lung cancer and who were pathologically upstaged with either pN1/pN2 disease. Overall survival (OS) was compared by extent of resection using inverse probability treatment weighting-adjusted Cox regression analyses. RESULTS: Of 5437 clinical stage Ia patients included, 3408 (62.7%) were found to have occult pN1 and 2029 (37.3%) to have occult pN2. Of 5437 patients, 93.5% (5082) were treated with lobectomy and 6.5% (355) underwent wedge resection. Lobectomy was associated with improved OS compared with wedge resection for patients with occult pN1 disease (median OS, 70.0 months [95% CI, 66.6-77.4] vs 36.4 months [95% CI, 24.2-45.6]; P < .001) but not for pN2 disease (median OS, 48.2.1 months [95% CI, 43.8-52.9] vs 43.7 months [95% CI, 31.2-62.4]; P = 0.24). On inverse probability treatment weighting-adjusted multivariable analysis, adjusting for demographics, comorbidities, margin status, and pathologic T and N stage, lobectomy remained associated with improved survival (adjusted hazard ratio, 0.73; 95% CI, 0.60-0.89; P = .0016). CONCLUSIONS: Lobectomy is associated with improved survival in clinical stage Ia non-small cell lung cancer patients with occult lymph node disease. These data may aid the decision for completion lobectomy for patients with unanticipated N1 lymph node upstaging.
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Carcinoma Pulmonar de Células não Pequenas , Neoplasias Pulmonares , Linfadenopatia , Humanos , Neoplasias Pulmonares/patologia , Estudos Retrospectivos , Estadiamento de Neoplasias , Pneumonectomia , Linfonodos/patologiaRESUMO
OBJECTIVE: Existing approaches for assessing surgical performance are subjective and prone to bias. In contrast, utilizing digital kinematic and system data from the surgical robot allows the calculation of objective performance indicators (OPIs) that may differentiate technical skill and competency. This study compared OPIs of trainees and attending surgeons to assess differences during robotic lobectomy (RL). METHODS: There were 50 cardiothoracic surgery residents and 7 attending surgeons who performed RL on a left upper lobectomy of an ex vivo perfused model. A novel recorder simultaneously captured video and data from the system and instruments. The lobectomy was annotated into discrete tasks, and OPIs were analyzed for both hands during 6 tasks: exposure of the superior pulmonary vein, upper division of the pulmonary artery and bronchus, and the stapling of these structures. RESULTS: There were significant differences between attendings and trainees in all tasks. Among 20 OPIs during exposure tasks, significant differences were observed for the left hand in 31 of 60 (52%) of OPIs and for the right hand in 42 of 60 (70%). During stapling tasks, significant differences were observed for the stapling hand in 28 of 60 (47%) of OPIs and for the nonstapling hand in 14 of 60 (25%). CONCLUSIONS: Use of a novel data and video recorder to generate OPIs for both hands revealed significant differences in the operative gestures performed by trainees compared to attendings during RL. This method of assessing performance has potential for establishing objective competency benchmarks and use for tracking progress.
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Robótica , Cirurgiões , Humanos , Pneumonectomia/métodos , Competência ClínicaRESUMO
Surgical training relies on subjective feedback on resident technical performance by attending surgeons. A novel data recorder connected to a robotic-assisted surgical platform captures synchronized kinematic and video data during an operation to calculate quantitative, objective performance indicators (OPIs). The aim of this study was to determine if OPIs during initial task of a resident's robotic-assisted lobectomy (RL) correlated with bleeding during the procedure. Forty-six residents from the 2019 Thoracic Surgery Directors Association Resident Boot Camp completed RL on an ex vivo perfused porcine model while continuous video and kinematic data were recorded. For this pilot study, RL was segmented into 12 tasks and OPIs were calculated for the initial major task. Cases were reviewed for major bleeding events and OPIs of bleeding cases were compared to those who did not. Data from 42 residents were complete and included in the analysis. 10/42 residents (23.8%) encountered bleeding: 10/40 residents who started with superior pulmonary vein exposure and 0/2 residents who started with pulmonary artery exposure. Twenty OPIs for both hands were assessed during the initial task. Six OPIs related to instrument usage or smoothness of motion were significant for bleeding. Differences were statistically significant for both hands (p < 0.05). OPIs showing bimanual asymmetry indicated lower proficiency. This study demonstrates that kinematic and video analytics can establish a correlation between objective performance metrics and bleeding events in an ex vivo perfused lobectomy. Further study could assist in the development of focused exercises and simulation on objective domains to help improve overall performance and reducing complications during RL.
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Internato e Residência , Procedimentos Cirúrgicos Robóticos , Cirurgiões , Procedimentos Cirúrgicos Torácicos , Lesões do Sistema Vascular , Suínos , Humanos , Animais , Procedimentos Cirúrgicos Robóticos/métodos , Projetos Piloto , Competência ClínicaRESUMO
BACKGROUND: The Global Evaluative Assessment of Robotic Skills is a popular but ultimately subjective assessment tool in robotic-assisted surgery. An alternative approach is to record system or console events or calculate instrument kinematics to derive objective performance indicators. The aim of this study was to compare these 2 approaches and correlate the Global Evaluative Assessment of Robotic Skills with different types of objective performance indicators during robotic-assisted lobectomy. METHODS: Video, system event, and kinematic data were recorded from the robotic surgical system during left upper lobectomy on a standardized perfused and pulsatile ex vivo porcine heart-lung model. Videos were segmented into steps, and the superior vein dissection was graded independently by 2 blinded expert surgeons with Global Evaluative Assessment of Robotic Skills. Objective performance indicators representing categories for energy use, event data, movement, smoothness, time, and wrist articulation were calculated for the same task and compared to Global Evaluative Assessment of Robotic Skills scores. RESULTS: Video and data from 51 cases were analyzed (44 fellows, 7 attendings). Global Evaluative Assessment of Robotic Skills scores were significantly higher for attendings (P < .05), but there was a significant difference in raters' scores of 31.4% (defined as >20% difference in total score). The interclass correlation was 0.44 for 1 rater and 0.61 for 2 raters. Objective performance indicators correlated with Global Evaluative Assessment of Robotic Skills to varying degrees. The most highly correlated Global Evaluative Assessment of Robotic Skills domain was efficiency. Instrument movement and smoothness were highly correlated among objective performance indicator categories. Of individual objective performance indicators, right-hand median jerk, an objective performance indicator of change of acceleration, had the highest correlation coefficient (0.55). CONCLUSION: There was a relatively poor overall correlation between the Global Evaluative Assessment of Robotic Skills and objective performance indicators. However, both appear strongly correlated for certain metrics such as efficiency and smoothness. Objective performance indicators may be a potentially more quantitative and granular approach to assessing skill, given that they can be calculated mathematically and automatically without subjective interpretation.