Faculty Bibliography

OBJECTIVE: Our objective was to evaluate the impact of early oral feeding (EOF) on postoperative cardiac, respiratory, and gastrointestinal (CRG) complications after McKeown minimally invasive esophagectomy for esophageal cancer. SUMMARY BACKGROUND DATA: Nil-by-mouth with enteral tube feeding is routinely practiced after esophagectomy. METHODS: Patients were randomly allocated to receive oral feeding on the first postoperative day (EOF group) or late oral feeding (LOF group) 7 days after surgery. The primary endpoint was the occurrence of postoperative CRG complications, and the secondary outcomes included bowel function recovery and short-term quality of life (QOL). RESULTS: Between February 2014 and October 2015, 280 patients were enrolled in this study. There were 140 patients in the EOF group and 140 patients in the LOF group. EOF was noninferior to LOF for CRG complications (30.0% in the EOF group vs. 32.9% in the LOF group; 95% confidence interval of the difference: -13.8% to 8.0%). Compared with the LOF group, the EOF group showed significantly shorter time to first flatus (median of 2 days vs. 3 days, P = 0.001) and bowel movement (median of 3 vs. 4 days, P < 0.001). Two weeks after the operation, patients in the EOF group reported higher global QOL and function scores and lower symptom scores than patients in the LOF group. CONCLUSIONS: In patients after McKeown minimally invasive esophagectomy is noninferior to the standard of care with regard to postoperative CRG complications. In addition, patients in the EOF group had a quicker recovery of bowel function and improved short-term QOL.

OBJECTIVE:Our objective is to report the world's largest series with the longest follow-up of robotic lobectomy for non-small cell lung cancer (NSCLC). METHODS:This was a multi-institutional retrospective review of a consecutive series of patients from 4 institutions' prospective robotic databases. RESULTS:There were 1339 patients (men 55%, median age 68 years). The median operative time was 136 minutes, median number of lymph nodes was 13 (5 N2 stations and 1 N1), median blood loss was 50 cc, and 4 (0.005%) patients received intraoperative transfusions. Conversions occurred in 116 patients (9%) and for bleeding in 24 (2%). Median length of stay was 3 days. Major morbidity occurred in 8%. The 30-day and 90-day operative mortality was 0.2% and 0.5%, respectively. Follow-up was complete in 99% of patients with a median follow-up of 30 months (range 1-154 months). The 5-year stage-specific survival was: 83% for the 672 patients with stage IA NSCLC, 77% for the 281 patients with stage IB, 68% for the 118 patients with stage IIA, 70% for 99 patients with IIB, 62% for 143 patients with stage IIIA (122 had N2 disease, 73%), and 31% for 8 patients with stage IIIB (none had N3 disease). The cumulative incidence of metastatic NSCLC was 15% (128 patients, 95% confidence interval, 13%-18%). The cumulative incidence of local recurrence in the ipsilateral operated chest was 3% only (26 patients, 95% confidence interval, 2%-5%). CONCLUSIONS:The oncologic results of robotic lobectomy for NSCLC are promising, especially for patients with pathologic N2 disease. However, further follow-up and studies are needed.

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.