Faculty Bibliography

Minimally invasive esophagectomy with intrathoracic dissection and anastomosis is increasingly performed. Our objectives are to report our operative technique, early results and lessons learned. This is a retrospective review of 85 consecutive patients who were scheduled for minimally invasive Ivor Lewis esophagectomy (laparoscopic or robotic abdominal and robotic chest) for esophageal cancer. Between 4/2011 and 3/2015, 85 (74 men, median age: 63) patients underwent robotic Ivor Lewis esophageal resection. In all, 64 patients (75%) had preoperative chemoradiotherapy, 99% had esophageal cancer, and 99% had an R0 resection. There were no abdominal or thoracic conversions for bleeding. There was 1 abdominal conversion for the inability to completely staple the gastric conduit. The mean operative time was 6 hours, median blood loss was 35ml (no intraoperative transfusions), median number of resected lymph nodes was 22, and median length of stay was 8 days. Conduit complications (anastomotic leak or conduit ischemia) occurred in 6 patients. The 30 and 90-day mortality were 3/85 (3.5%) and 9/85 (10.6%), respectively. Initial poor results led to protocol changes via root cause analysis: longer rehabilitation before surgery, liver biopsy in patients with history of suspected cirrhosis, and refinements to conduit preparation and anastomotic technique. Robotic Ivor Lewis esophagectomy for cancer provides an R0 resection with excellent lymph node resection. Our preferred port placement and operative techniques are described. Disappointingly high thoracic conduit problems and 30 and 90-day mortality led to lessons learned and implementation of change which are shared.

Robotic esophagectomy is an increasingly used modality. Patients who are candidates for traditional, open esophagectomy are typically also candidates for robotic esophagectomy. Knowledge of and training on the robotic platform is critical for success. Patient and port positioning is described. Either a hand-sewn or stapled intrathoracic anastomosis may be performed. Minimally invasive esophagectomy (MIE) appears to be associated with decreased respiratory complications versus open esophagectomy. Robotic esophagectomy may be performed with excellent perioperative outcomes, though long-term oncologic data regarding the operation are not yet available.

Robotic thymectomy is an increasingly used modality. Patients who are candidates for traditional, open thymectomy are typically also candidates for robotic thymectomy, with the exception of patients with invasion of great vessels. Knowledge of and training on the robotic platform is critical for success. Patient and port positioning is described. Critical steps during robotic thymectomy include attention to careful division of the thymus off the innominate vein, and complete retrieval of bilateral superior horns of the gland. Robotic thymectomy may be performed with excellent perioperative and long-term outcomes for both neoplastic and non-neoplastic indications.

Adenomatoid tumor is an uncommon benign neoplasm of mesothelial differentiation that distinctively arises in and around the genital organs. In rare instances, it has been described in extragenital locations. There have been only two reports documenting its occurrence in the anterior mediastinum, and no reports documenting its occurrence in the posterior mediastinum. We report the first case of posterior mediastinal adenomatoid tumor. A 37-year-old Caucasian woman presented with symptoms of bronchitis. Imaging studies identified a 2.0 cm posterior mediastinal mass abutting the T9 vertebral body, clinically and radiologically most consistent with schwannoma. Histologic sections revealed a lesion composed of epithelioid cells arranged in cords and luminal profiles embedded in a fibrotic to loose stroma and surrounded by a fibrous pseudocapsule. Lesional cells showed vacuolated eosinophilic cytoplasm and peripherally displaced nuclei with prominent nucleoli. There was focal cytologic atypia but no mitotic figures or necrosis was identified. The lesional cells expressed cytokeratin, calretinin, and nuclear WT1 but were negative for PAX8, TTF1, p53, chromogranin, CD31, and CD34, and Ki67 showed <2% proliferation rate, diagnostic of adenomatoid tumor. Three years after resection, the patient is in good health without tumor recurrence. Thus, our encounter effectively expands the differential diagnosis of posterior mediastinal neoplastic entities.

A workshop of experts from France, Germany, Italy, and the United States took place at Humanitas Research Hospital Milan, Italy, on February 10 and 11, 2016, to examine techniques for and applications of robotic surgery to thoracic oncology. The main topics of presentation and discussion were robotic surgery for lung resection; robot-assisted thymectomy; minimally invasive surgery for esophageal cancer; new developments in computer-assisted surgery and medical applications of robots; the challenge of costs; and future clinical research in robotic thoracic surgery. The following article summarizes the main contributions to the workshop. The Workshop consensus was that since video-assisted thoracoscopic surgery (VATS) is becoming the mainstream approach to resectable lung cancer in North America and Europe, robotic surgery for thoracic oncology is likely to be embraced by an increasing numbers of thoracic surgeons, since it has technical advantages over VATS, including intuitive movements, tremor filtration, more degrees of manipulative freedom, motion scaling, and high-definition stereoscopic vision. These advantages may make robotic surgery more accessible than VATS to trainees and experienced surgeons and also lead to expanded indications. However, the high costs of robotic surgery and absence of tactile feedback remain obstacles to widespread dissemination. A prospective multicentric randomized trial (NCT02804893) to compare robotic and VATS approaches to stages I and II lung cancer will start shortly.

OBJECTIVES: In an effort to stimulate residents and trainers to increase their use of simulation training and the Thoracic Surgery Curriculum, a gamification strategy was developed in a friendly but competitive environment. METHODS: "Top Gun." Low-fidelity simulators distributed annually were used for the technical competition. Baseline and final video assessments were performed, and 5 finalists were invited to compete in a live setting from 2013 to 2015. "Jeopardy." A screening examination was devised to test knowledge contained in the Thoracic Surgery Curriculum. The top 6 2-member teams were invited to compete in a live setting structured around the popular game show Jeopardy. RESULTS: "Top Gun." Over 3 years, there were 43 baseline and 34 final submissions. In all areas of assessment, there was demonstrable improvement. There was increasing evidence of simulation as seen by practice and ritualistic behavior. "Jeopardy." Sixty-eight individuals completed the screening examination, and 30 teams were formed. The largest representation came from the second-year residents in traditional programs. Contestants reported an average in-training examination percentile of 72.9. Finalists reported increased use of the Thoracic Surgery Curriculum by an average of 10 hours per week in preparation. The live competition was friendly, engaging, and spirited. CONCLUSIONS: This gamification approach focused on technical and cognitive skills, has been successfully implemented, and has encouraged the use of simulators and the Thoracic Surgery Curriculum. This framework may capitalize on the competitive nature of our trainees and can provide recognition of their achievements.

BACKGROUND: Radiosurgery is becoming an increasingly used modality for the medically inoperable early stage lung cancer patient. The optimal fiducial marker with respect to retention rate has yet to be identified. METHODS: We retrospectively reviewed our experience with electromagnetic navigational bronchoscopic fiducial marker placement in preparation for stereotactic radiosurgery. RESULTS: Forty-eight patients, treated between 2010 and January 2013, were retrospectively reviewed. All patients had a diagnosis of early stage lung cancer. Comparison of initial fiducial placement procedure data with imaging at the time of treatment was accomplished for all patients in this data set. Fiducial retention rates were as follow: VortX coil fiducials were retained in 59 of 61 (96.7%) cases; two-band fiducials were retained in 24 of 33 (72.7%) of instances; and gold seed fiducials were retained in 23 of 33 (69.7%) of cases. Retention was statistically superior when comparing the VortX coil with the two-band fiducial or the gold seed (p = 0.004 and p = 0.0001). Anatomic location by lobe was analyzed, but no statistically significant differences were observed. CONCLUSIONS: The VortX coil fiducial marker showed a statistically significant increase in retention rate compared with gold seeds or two-band fiducials. This may translate to cost savings through placing fewer markers per patient as retention is high.