Faculty Bibliography

BACKGROUND:Our objective is to compare the clinical to the pathologic stage in patients with non-small cell lung cancer (NSCLC). METHODS:Review of a prospective database from one surgeon. Patients had NSCLC, chest tomography (CT) and most had positron emissions tomography (PET). Those with suggested N1, N2, central tumors and/or tumors > 5 cm underwent mediastinoscopy and/or endobronchial ultrasound and, if N2 negative, underwent resection with complete thoracic lymphadenectomy. RESULTS:(p=0.034); of N2 disease included African American race (p=0.020) and large tumor size (p=0.047). CONCLUSIONS:Despite advancements in CT, PET and minimally invasive nodal biopsy, there remains significant NSCLC mis-staging, especially for N2 disease. Improved, targeted N2 lymph node biopsy may improve pre-resection staging.

BACKGROUND:Our objective is to show our process to standardize and decrease the time to place and teach double-lumen endotracheal tube (DLETT) intubation. METHODS:Review of a prospective database of patients who underwent lobectomy or segmentectomy by one surgeon. A systematic approach was instituted starting in 2009. A monitor in the room displayed the bronchoscopic view as anesthesia residents were taught how to drive a bronchoscope. The bronchial side was placed above the carina, a bronchoscope went into the desired side and the double-lumen tube slid over it. A head towel protected the ears, face and hair and the DLETT was anchored so that re-bronching after turning was eliminated. All other non-valued steps were eliminated. RESULTS:There were 2,940 patients. Pulmonary lobectomy was performed in 2,421 patients and segmentectomy in 566. Patients were divided into 9 cohorts of 350 consecutive patients except for the last cohort. Median time for DLETT placement decreased from 13 minutes from 1/1997-2/2001 to a median 45 seconds from 6/2016-5/2017 (p<0.001). Anesthesia residents, present for 76% of the operations were able to place the tube independently 80% of the time. There were no airway perforations. CONCLUSIONS:DLETT placement can be standardized and taught efficiently. Factors that may lead to this are: eliminating non-valued steps (process of lean), engaging anesthesiologists and surgeons to teach team standardization, improved tracheal-bronchial anatomy and bronchoscopy skills in residents and displaying the intubation and bronchoscopy on a monitor.

Objective: A 75-year-old woman with New York Heart Association class II heart failure presented with severe mitral and tricuspid regurgitation. Eight years prior, the patient had a large right thoracotomy for resection of a pleural tumor. Our goal was to demonstrate a totally endoscopic resection of an unsuspected recurrent pleural tumor preceding concomitant mitral and tricuspid valve repair.
Method(s): After initially positioning the patient in the left decubitus position via a posterolateral approach, extensive adhesiolysis between the right lower lobe and the diaphragmrevealed a nonimaged 2- to 3-cmmass in the right lower lobe. Limited parenchymal resection was performed. The patient was repositioned in a supine position. Transesophageal echocardiography confirmed severe mitral regurgitation with moderate to severe tricuspid regurgitation. Five lateral thoracic ports were placed for the da Vinci Xi system. Cardiopulmonary bypass was instituted via femoral access with independent femoral and internal jugular venous lines. An endoballoon clamp was positioned with fluorescent guidance and antegrade del Nido cardioplegia was administered. Sondergaard's groove was opened, and the left atrial appendage was oversewn with 2 layers of polytetrafluoroethylene (PTFE) sutures. The mitral valve was nonmyxoid, inconsistent with Barlow's disease. Inspection confirmed mild prolapse of the anterior leaflet, numerous hypertrophied and calcified secondary chordae, and restriction of the posterior leaflet. Secondary chordae were excised below the A2-A3, P1-P2, and P2-P3 clefts. Small triangular excisions were performed at the A2-A3 and P1-P2 junctions, which were both reconstructed with a running PTFE suture. Hydrostatic testing revealed mild central insufficiency due to a lack of coaptation depth. Commissuroplasty was performed with a single PTFE suture, and the P2-P3 cleft was closed with a running PTFE suture. A 30-mmannuloplasty band was inserted. Final hydrostatic testing revealed excellent leaflet coaptation. The cavae were occluded with snares, and the tricuspid valve was exposed via a right atriotomy. A reduction tricuspid annuloplasty with a 26-mm band was performed. With the heart reperfused and the aortic root and left ventricle vented, the atriotomies were closed.
Result(s): Postoperative transesophageal echocardiography demonstrated preserved left ventricular function with trace mitral and tricuspid regurgitation. The patient was discharged on postoperative day 6. Final pathological analysis confirmed a completely resected benign solitary fibrous tumor.
Conclusion(s): A totally endoscopic approach to mitral and tricuspid valve repair can be performed safely and effectively in patients with a prior right thoracotomy

Purpose The efficacy of neoadjuvant chemoradiotherapy (NCRT) plus surgery for locally advanced esophageal squamous cell carcinoma (ESCC) remains controversial. In this trial, we compared the survival and safety of NCRT plus surgery with surgery alone in patients with locally advanced ESCC. Patients and Methods From June 2007 to December 2014, 451 patients with potentially resectable thoracic ESCC, clinically staged as T1-4N1M0/T4N0M0, were randomly allocated to NCRT plus surgery (group CRT; n = 224) and surgery alone (group S; n = 227). In group CRT, patients received vinorelbine 25 mg/m² intravenously (IV) on days 1 and 8 and cisplatin 75 mg/m² IV day 1, or 25 mg/m² IV on days 1 to 4 every 3 weeks for two cycles, with a total concurrent radiation dose of 40.0 Gy administered in 20 fractions of 2.0 Gy on 5 days per week. In both groups, patients underwent McKeown or Ivor Lewis esophagectomy. The primary end point was overall survival. Results The pathologic complete response rate was 43.2% in group CRT. Compared with group S, group CRT had a higher R0 resection rate (98.4% v 91.2%; P = .002), a better median overall survival (100.1 months v 66.5 months; hazard ratio, 0.71; 95% CI, 0.53 to 0.96; P = .025), and a prolonged disease-free survival (100.1 months v 41.7 months; hazard ratio, 0.58; 95% CI, 0.43 to 0.78; P < .001). Leukopenia (48.9%) and neutropenia (45.7%) were the most common grade 3 or 4 adverse events during chemoradiotherapy. Incidences of postoperative complications were similar between groups, with the exception of arrhythmia (group CRT: 13% v group S: 4.0%; P = .001). Peritreatment mortality was 2.2% in group CRT versus 0.4% in group S ( P = .212). Conclusion This trial shows that NCRT plus surgery improves survival over surgery alone among patients with locally advanced ESCC, with acceptable and manageable adverse events.

The objectives of this study are to review the complicated and often confusing technical changes required when converting from the Si robotic system to the Xi when performing pulmonary lobectomy and segmentectomy. We reviewed a prospective database of a consecutive series of patients who intended to undergo robotic lobectomy or segmentectomy by one surgeon. There were 101 lobectomies and 25 segmentectomies performed on the Si robot in 2015-2016, and 95 lobectomies and 28 segmentectomies in 2016 on the Xi robot. The two groups were similar for age, height, weight, pulmonary function, anatomic resections, and co-morbidities. Technical differences in robotic arm numbering, port placement, and instrumentation are shown below. Median docking time was shorter with the Xi robot [7.5 (95% CI 6-8) versus 10 (95% CI 9-12) min, p = 0.003] as was operation duration [114 (95% CI 104-123) versus 119 (95% CI 116-126) min, p = 0.041] and skin closure to room exit [12 (95% CI 10-24) versus 13 (95% CI 12-15) min, p = 0.081]. Anesthesiologists expressed greater comfort with the Xi system, because the patient's head was not covered by the robot. Outcomes for Si and Xi operations such as median blood loss (20 cc versus 20 cc), transfusion rate (0 versus 0), major complication rate (3.2 versus 3.3%), and the 30- and 90-day mortality were no different (one 30-day death in the Si group). The technical changes that are required for robotic Si-to-Xi conversion are shown. The Xi system may offer improved operational efficiency.