Faculty Bibliography

BACKGROUND:Robotic segmentectomy has been suggested as a safe and effective management for early lung cancer and benign lung diseases. However, no large case series have documented the learning curve for this technically demanding procedure. METHODS:We conducted a retrospective study for robotic segmentectomy performed by the same surgeon between June 2015 and November 2017. The learning curve was initially analyzed using the cumulative sum (CUSUM) method to assess changes in the total operative times across the case sequence. Subsequently, an in-depth learning curve was generated using the risk-adjusted cumulative sum (RA-CUSUM) method, which considered perioperative risk factors and surgical failure. RESULTS:This study included 104 cases, and 87 were malignant. The median operative time was 145 min (interquartile range, IQR: 120-180 min) and the median blood loss was 100 ml (IQR: 50-100 ml). The median length of stay was 4 d (IQR: 3-5 d). Based on the CUSUM and RA-CUSUM analyses, the learning curve could be divided into 3 different phases: phase I, the initial learning period (1st-21st operation); phase II, the consolidation period (22nd-46th operation); and phase III, the experienced period (47th-104th operation). The operative time and intraoperative blood loss tended to decrease after the initial learning phase. Other perioperative outcomes were not significantly different among the three phases. CONCLUSIONS:The learning curve of robotic segmentectomy consisted of three phases. The technical competency for assuring feasible perioperative outcomes was achieved in phase II at the 40th operation.

BACKGROUND:Minimally invasive techniques are increasingly being used in pulmonary segmentectomy and combined subsegmentectomy. However, there are no reports as yet on robotic combined anatomic subsegmentectomy(CAS). Herein, we describe related clinical data and operative techniques and present our early results METHODS: Clinical data on patients undergoing robotic CAS were retrospectively reviewed. A combined subsegmentectomy was defined as the resection of ≥2 subsegments that involved ≥2 adjacent segments. Patients subjected to completely portal robotic CAS were enrolled in this study. RESULTS:Between May 2015 and January 2018, a single surgeon performed completely portal robotic CAS for 16 patients. In the CAS-treated patients, most of the lesions (75%) were located in the right upper lobe, and none required conversion to thoracotomy. Median operative time was 175 min (range, 75-294 min) and mean postoperative hospital stay was 4 days (range, 2-11 days). Although one patient experienced a prolonged air leak, the other 15 recovered uneventfully. Within a median follow-up period of 15 months, there were no deaths or tumor recurrences. CONCLUSIONS:Completely portal robotic CAS is a safe and effective procedure in a select subset of patients, proving quite suitable for smaller (<2 cm) multi-segment lung cancers, particularly lesions of right upper lobe. A robotics approach facilitates complex and challenging CAS, the disadvantage being lengthy operative times during early acquisition of skills.

The appropriate implementation of new technology, root cause analysis of "imperfect" outcomes and the continuous reappraisal of postgraduate training are needed to improve the care of tomorrow's patients. Healthcare delivery remains one of the most expensive sectors in the United States and the application of new and expensive technology that is necessary for the advancement of this complex specialty must be aligned with providing the best care for our patients. There are a several pathways to innovation; one is partnering with industry and the other is the investigational laboratory. Innovation and the funding thereof come from both the public and the private sector. The majority of new trials that are likely to impact cardiothoracic surgery are industry sponsored trials to meet the requirements necessary for regulatory approval. Cost considerations are paramount when considering integration of innovative technology and treatments into a clinical cardiothoracic surgical practice. The value of any new innovation is determined by the quality divided by the cost, and lean initiatives maximize this equation. The importance and implications of conflict of interest (COI) has been a concern for physicians particularly when new technology or procedures are being incorporated into clinical practice and full disclosures by medical professionals and others involved are essential. Our "societies" and "associations" provide a platform for presentation and peer-reviewed discussion of new procedures, innovations, and trials, etc. and provide a venue for the sharing of knowledge on the highest quality patient care through education and research.

Enhanced recovery after surgery is well established in specialties such as colorectal surgery. It is achieved through the introduction of multiple evidence-based perioperative measures that aim to diminish postoperative organ dysfunction while facilitating recovery. This review aims to present consensus recommendations for the optimal perioperative management of patients undergoing thoracic surgery (principally lung resection). A systematic review of meta-analyses, randomized controlled trials, large non-randomized studies and reviews was conducted for each protocol element. Smaller prospective and retrospective cohort studies were considered only when higher-level evidence was unavailable. The quality of the evidence base was graded by the authors and used to form consensus recommendations for each topic. Development of these recommendations was endorsed by the Enhanced Recovery after Surgery Society and the European Society for Thoracic Surgery. Recommendations were developed for a total of 45 enhanced recovery items covering topics related to preadmission, admission, intraoperative care and postoperative care. Most are based on good-quality studies. In some instances, good-quality data were not available, and subsequent recommendations are generic or based on data extrapolated from other specialties. In other cases, no recommendation can currently be made because either equipoise exists or there is a lack of available evidence. Recommendations are based not only on the quality of the evidence but also on the balance between desirable and undesirable effects. Key recommendations include preoperative counselling, nutritional screening, smoking cessation, prehabilitation for high-risk patients, avoidance of fasting, carbohydrate loading, avoidance of preoperative sedatives, venous thromboembolism prophylaxis, prevention of hypothermia, short-acting anaesthetics to facilitate early emergence, regional anaesthesia, nausea and vomiting control, opioid-sparing analgesia, euvolemic fluid management, minimally invasive surgery, early chest drain removal, avoidance of urinary catheters and early mobilization after surgery. These guidelines outline recommendations for the perioperative management of patients undergoing lung surgery based on the best available evidence. As the recommendation grade for most of the elements is strong, the use of a systematic perioperative care pathway has the potential to improve outcomes after surgery.

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

OBJECTIVES/OBJECTIVE:Minimally invasive surgery is accepted for early-stage lung cancer, but its role in locally advanced disease is controversial, especially using a robotic platform. The aim of this retrospective study was to assess the safety and effectiveness of robot-assisted resection in patients with Stage IIIA non-small-cell lung cancer (NSCLC) or carcinoid tumours in the series as a whole and in different subgroups according to adjuvant treatment. METHODS:This was a retrospective multicentre study of consecutive patients with clinically evident or occult N2 disease (210 NSCLC and 13 carcinoid) who, in 2007-2016, underwent robot-assisted resection at 7 high-volume centres. Perioperative outcomes, recurrences and overall survival were assessed. RESULTS:N2 disease was diagnosed preoperatively in 72 (32%) patients and intraoperatively in 151 (68%) patients. Surgical margins were negative in 98.4% of cases with available data. Thirty-four (15.2%) patients received neoadjuvant treatment, 140 (63%) patients received postoperative treatment, and 49 (22%) patients underwent surgery only. There were 22 (9.9%) conversions to thoracotomy, 23 (10.3%) had serious (Grades III-IV) postoperative morbidity and the mean hospital stay was 5.3 days. Complications and outcomes did not differ significantly between treatment groups. Of the 34 patients who were given neoadjuvant chemotherapy, all had R0 resection, 5 (15%) patients required conversion but none required conversion because of bleeding and 4 (12%) patients had Grade III or IV postoperative complications. After a median of 18 (interquartile range 8-33) months, 3-year overall survival in NSCLC patients was 61.2% and 60.3% (P = 0.6) of patients in the subgroup were given induction treatment. However, overall survival was significantly better (P = 0.012) in NSCLC patients with ≤2 positive nodes (vs >2). Nineteen (8.5%) patients developed local recurrence. CONCLUSIONS:Robot-assisted lobectomy is safe and effective in patients with Stage III NSCLC or carcinoid tumours with low conversions and complications. Among patients with NSCLC, including those who were given induction chemotherapy, survival was similar to that reported for open surgery.

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.