Faculty Bibliography

Aorto-pulmonary paraganglioma is an exceptionally rare condition, and its diagnosis and treatment are a challenge for the general thoracic surgeon. We describe the case of a 35 years old man who was incidentally diagnosed with a visceral mediastinal mass, deeply encased in the aorto-pulmonary window. To our knowledge this is the first case of its kind to be successfully treated with the adoption of a minimally invasive technique. We conclude that the dissection was made easier by the robotic instrumentation and by the camera system, and a minimally invasive approach would have been more difficult by traditional thoracoscopy.

BACKGROUND:Our objective is to show the effect that standardization of surgical trays has on the number of instruments sterilized and on cost. METHODS:We reviewed our most commonly used surgical trays with the 3 general thoracic surgeons in our division and agreed upon the least number of surgical instruments needed for mediastinoscopy, video-assisted thoracoscopic surgery, robotic thoracic surgery, and thoracotomy. RESULTS:We removed 59 of 79 instruments (75%) from the mediastinoscopy tray, 45 of 73 (62%) from the video-assisted thoracoscopic surgery tray, 51 of 84 (61%) from the robotic tray, and 50 of 113 (44%) from the thoracotomy tray. From January 2016 to December 2016, the estimated savings by procedure were video-assisted thoracoscopic surgery (n = 398) $21,890, robotic tray (n = 231) $19,400, thoracotomy (n = 163) $15,648, and mediastinoscopy (n = 162) $12,474. Estimated total savings were $69,412. The weight of the trays was reduced 70%, and the nonsteamed sterilization rate (opened trays that needed to be reprocessed) decreased from 2% to 0%. None of the surgeons requested any of the removed instruments. CONCLUSIONS:Standardization of thoracic surgical trays is possible despite having multiple thoracic surgeons. This process of lean (the removal of nonvalue steps or equipment) reduces the number of instruments cleaned and carried and reduces cost. It may also reduce the incidence of "wet loads" that require the resterilization of instruments.

OBJECTIVES: Robotic thoracic operations are increasing, and new robotic systems are imminent. A definition of what constitutes a robotic thoracic operation and a nomenclature to detail the technique used is needed to accurately compare outcomes. METHODS: The American Association of Thoracic Surgeons Guideline Committee appointed an expert consensus writing committee to construct definitions and nomenclature for robotic thoracic surgery. A PubMed search was generated and after vetting and review of the literature a consensus statement was reached. RESULTS: The proposed definition is: "A robotic thoracic operation is a minimally invasive surgical procedure that does not spread, lift or remove any part of the chest or abdominal wall and is characterized by: the surgeon and the assistant's vision of the operative field is via a monitor only and the patient's tissue is manipulated by robotic instruments that follow a slave like mimic of human hands or thoughts via a computerized system." In addition, a flexible nomenclature is proposed that should be applicable to current and future robotic systems that details the number of robotic arms used, the types of ports and/or incisions made, the use of insufflation, and the operation performed. CONCLUSIONS: The American Association of Thoracic Surgeons writing committee proposes a definition and nomenclature for robotic thoracic surgery. Definitions are needed to ensure that future studies accurately compare results and outcomes and nomenclatures allow surgeons and scientists from diverse countries and cultures to use the same language to allow accurate communication.

Our purpose is to identify the metrics used by the Society of Thoracic Surgeons (STS) to rank lobectomy and to show our process to improve. This is a review of our STS data for lobectomy and our results using the process of root cause analysis and lean methodology to improve our outcomes. The STS metrics are 30-day mortality, pneumonia, adult respiratory distress syndrome, bronchopleural fistula, pulmonary embolus, initial ventilator support greater than 48 hours, reintubation and respiratory failure, tracheostomy, myocardial infarction, or unexpected return to the operating room. Sixteen of 231 programs (7%) were ranked 3-star over a 3-year period from July 2011 to June 2014. The most common root cause analysis was failure to escalate care. The lean and process improvements we employed that seemed to improve the results were increasing exercise before surgery, adding a respiratory therapist, eliminating Foley catheters and arterial lines to reduce infection and to increase ambulation, offering stereotactic radiotherapy for marginal patients, favoring left upper segmentectomy over left upper lobectomy, and performing 91% of the last 493 lobectomies via a minimally invasive platform. Our major morbidity complications from August 2003 to December 2014 fell from 9.5% to 5.3% (P = 0.001) and mortality decreased from 3.3% to 0.54% (P < 0.0001). The metrics the STS used to rank lobectomy programs are 30-day mortality and predominantly respiratory complications. Root cause analysis, lean methodology, and process improvements allowed us to improve our lobectomy patient outcomes over time and to achieve a 3-star ranking over a 3-year time frame. These results may be obtainable by others.

Robotic-assisted pulmonary lobectomy can be considered for patients fit for conventional lobectomy. Contraindications include prohibitive lung function or medical comorbidities, multistation N2, gross N2 disease, or evidence of N3 disease. Team training, familiarity with equipment, troubleshooting, and preparation are critical for successful robotic lobectomy. Similar to video-assisted thoracoscopic surgery (VATS) lobectomy, robotic lobectomy is associated with decreased blood loss, blood transfusion, air leak, chest tube duration, duration of stay, and mortality compared with thoracotomy. Robotic lobectomy offers many of the same benefits in perioperative morbidity and mortality, and the advantages of optics, dexterity, and surgeon ergonomics compared with VATS lobectomy.

OBJECTIVES: To identify the associations of lymph node metastases (pN+), number of positive nodes, and pN subclassification with cancer, treatment, patient, geographic, and institutional variables, and to recommend extent of lymphadenectomy needed to accurately detect pN+ for esophageal cancer. SUMMARY BACKGROUND DATA: Limited data and traditional analytic techniques have precluded identifying intricate associations of pN+ with other cancer, treatment, and patient characteristics. METHODS: Data on 5806 esophagectomy patients from the Worldwide Esophageal Cancer Collaboration were analyzed by Random Forest machine learning techniques. RESULTS: pN+, number of positive nodes, and pN subclassification were associated with increasing depth of cancer invasion (pT), increasing cancer length, decreasing cancer differentiation (G), and more regional lymph nodes resected. Lymphadenectomy necessary to accurately detect pN+ is 60 for shorter, well-differentiated cancers (<2.5 cm) and 20 for longer, poorly differentiated ones. CONCLUSIONS: In esophageal cancer, pN+, increasing number of positive nodes, and increasing pN classification are associated with deeper invading, longer, and poorly differentiated cancers. Consequently, if the goal of lymphadenectomy is to accurately define pN+ status of such cancers, few nodes need to be removed. Conversely, superficial, shorter, and well-differentiated cancers require a more extensive lymphadenectomy to accurately define pN+ status.