Faculty Bibliography

One to two percent of ectopic parathyroid adenomas are found in the lower mediastinum and often these are best accessed via a sternotomy or thoracotomy. Video-assisted thoracoscopic surgery (VATS) is an alternative approach with less surgical trauma, decreased morbidity, shorter hospital stays, and superior cosmetic results. Ten years after the first VATS resection of an ectopic mediastinal parathyroid, a robot-assisted thoracoscopic approach was described. Here we describe a series of five robot assisted complete thymectomies in patients with primary hyperparathyroidism due to mediastinal ectopic parathyroid adenomas. A single surgeon, single institution case series of five consecutive robotic-assisted mediastinal parathyroidectomies was performed between March 2013 and September 2015. The patients' ages ranged from 31 to 65, 80 % were female, and all had primary hyperparathyroidism due to an ectopic parathyroid located in the lower mediastinum. Pre-operative imaging workup included Technetium 99-sestimibi parathyroid scan and CT scan of the chest. An ectopic parathyroid adenoma was successfully removed in all five cases, with intraoperative iOPTH decreasing ~50 % from baseline after 10 minutes. A hypercellular parathyroid was confirmed on pathologic exam in all specimens. Post-operative discharge and follow up calcium levels all returned to normal. There were no intraoperative complications, including no recurrent laryngeal nerve injuries, no postoperative morbidity, and no mortalities. This case series demonstrates that a robot-assisted complete thymectomy for mediastinal parathyroid adenomas causing primary hyperparathyroidism provides excellent visualization of the mediastinum, is effective at reducing PTH and calcium levels, and is safe with no morbidity or mortality.

Background: Covered stents have become part of the armamentarium for treating various esophageal pathologies. A recently available, low profile, fully covered metal stent with symmetrical flares (FCMSF) may offer improved deployment and resistance to migration. Methods: A retrospective review of 58 esophageal FCMSF placed in 47 consecutive patients by a single thoracic surgeon between March 2010 and February 2012 was performed. Pathologies included benign and malignant stricture and leak. Stents were placed endoscopically under general anesthesia using a 6 mm deployment system; bidirectional maneuverability was possible. Dysphagia score (0-4) was prospectively recorded. Leak treatment was assessed with postoperative esophagrams. Results: Mean age was 62.0 years. Sixteen of 58 stents (28%) were placed urgently/emergently. All patients had successful stent deployment with 0% stent-related hospital morbidity/mortality. Overall post-operative morbidity occurred following 12/58 stents, including arrhythmia, pneumonia, pneumothorax, urinary retention, hemodynamic instability, and COPD exacerbation. In patients with stricture (n = 29), mean dysphagia scores were reduced from 3.0 preoperatively to 1.2 post-operatively (p < 0.001). for leak, stent therapy (+/- drainage) avoided formal esophageal operation in 94% (17/18). Fifteen stents were removed during follow-up, 4 after migration. Mean overall survival was 2.3 +/- 2.6 months for stricture (21/35 remain alive) and 8.7 +/- 9.6 months for leak (16/18 remain alive). Mean duration of stent therapy was 4.9 +/- 4.8 months for stricture (29/35 remain in situ) and 3.5 +/- 3.2 months for leak (10/20 remain in situ). Mean hospital stay was 3.9 +/- 7.0 days. Discussion: FCMSF are an effective therapy for both esophageal strictures and leaks. The symmetrical covered flares likely contribute to the low observed migration rate

OBJECTIVE: Current video-assisted thoracoscopic surgery training models rely on animals or mannequins to teach procedural skills. These approaches lack inherent teaching/testing capability and are limited by cost, anatomic variations, and single use. In response, we hypothesized that video-assisted thoracoscopic surgery right upper lobe resection could be simulated in a virtual reality environment with commercial software. METHODS: An anatomy explorer (Maya [Autodesk Inc, San Rafael, Calif] models of the chest and hilar structures) and simulation engine were adapted. Design goals included freedom of port placement, incorporation of well-known anatomic variants, teaching and testing modes, haptic feedback for the dissection, ability to perform the anatomic divisions, and a portable platform. RESULTS: Preexisting commercial models did not provide sufficient surgical detail, and extensive modeling modifications were required. Video-assisted thoracoscopic surgery right upper lobe resection simulation is initiated with a random vein and artery variation. The trainee proceeds in a teaching or testing mode. A knowledge database currently includes 13 anatomic identifications and 20 high-yield lung cancer learning points. The 'patient' is presented in the left lateral decubitus position. After initial camera port placement, the endoscopic view is displayed and the thoracoscope is manipulated via the haptic device. The thoracoscope port can be relocated; additional ports are placed using an external 'operating room' view. Unrestricted endoscopic exploration of the thorax is allowed. An endo-dissector tool allows for hilar dissection, and a virtual stapling device divides structures. The trainee's performance is reported. CONCLUSIONS: A virtual reality cognitive task simulation can overcome the deficiencies of existing training models. Performance scoring is being validated as we assess this simulator for cognitive and technical surgical education