Faculty Bibliography

OBJECTIVE: Left upper pulmonary lobectomy or segmentectomy after coronary artery bypass grafting (CABG) risks injury to the grafts. We reviewed our experience. METHODS: This is a retrospective review of a prospective database from 1 surgeon, of patients who underwent left upper lobectomy after having previous CABG. RESULTS: Between June 1998 and June 2014, a total of 2207 patients underwent lobectomy by 1 surgeon; 458 (21%) had a left upper lobectomy, and 28 (6.1%) had had a previous CABG. Twenty-seven patients (96.4%) had a left internal mammary artery (LIMA) used for the bypass. Twenty-six patients (96.2%) had significant adhesions between their lung and the bypass grafts. Of patients who had a LIMA graft, 25 (92.6%) had the left upper lobe completely dissected free from their grafts, whereas 2 patients (7.1%) had a sliver of their lung left on the grafts. No patient had a postoperative myocardial infarction, and 30-day and 90-day survival rates were both 100%. All patients had a curative resection, and all had complete thoracic lymphadenectomy. CONCLUSIONS: Left upper lobectomy after CABG, in patients with previous CABG and LIMA grafting, is safe. Usually the entire lung can be safely mobilized off the bypass grafts; if needed, a small sliver of lung can be left on the grafts. A curative resection is possible with minimal perioperative cardiac morbidity, and excellent 30- and 90-day mortality.

Cardiac paragangliomas are rare tumors arising from chromaffin cells. Two patients with cardiac paragangliomas underwent surgical resection with no evidence of recurrence three and 13 years following surgery. This report describes these two patients with cardiac paragangliomas and discusses their management.

INTRODUCTION: Even today, open lobectomy involves significant morbidity. Video-assisted thoracic surgery (VATS) lobectomy results in lesser blood loss, pain, and hospital stay compared to lobectomy by thoracotomy. Despite being an excellent procedure in expert hands, VATS lobectomy is associated with a longer learning curve because of its inherent basic limitations. The da Vinci surgical system was developed essentially to overcome these limitations. In this study, we report our initial experience with robotic pulmonary resections using the Completely Portal approach with four arms. To the best of our knowledge this is the first series of robotic lobectomy reported from India. MATERIAL AND METHODS: Data on patient characteristics, operative details, complications, and postoperative recovery were collected in a prospective manner for patients who underwent Robotic Lung resection at our institution between March 2012 and April 2014 for various indications including both benign and malignant cases. RESULTS: Between March 2012 to April 2014, a total of 13 patients were taken up for Robotic Lobectomy with a median age of 57 years. The median operative time was 210 min with a blood loss of 33 ml. R0 clearance was achieved in all patients with malignant disease. The median lymph node yield in nine patients with malignant disease was 19 (range 11-40). There was one intra-operative complication and two postoperative complications. The median hospital stay was 7 days with median duration to chest tube removal being 3 days. CONCLUSION: Robotic lobectomy is feasible and safe. It appears to be oncologically sound surgical treatment for early-stage lung cancer. Comparable benefits over VATS needs to be further evaluated by long-term studies.

OBJECTIVES/OBJECTIVE:A retrospective database was developed by the European Society of Thoracic Surgeons, collecting patients submitted to surgery for thymic tumours to analyse clinico-pathological prognostic predictors. METHODS:A total of 2151 incident cases from 35 institutions were collected from 1990 to 2010. Clinical-pathological characteristics were analysed, including age, gender, associated myasthenia gravis stage (Masaoka), World Health Organization histology, type of thymic tumour [thymoma, thymic carcinoma (TC), neuroendocrine thymic tumour (NETT)], type of resection (complete/incomplete), tumour size, adjuvant therapy and recurrence. Primary outcome was overall survival (OS); secondary outcomes were the proportion of incomplete resections, disease-free survival and the cumulative incidence of recurrence (CIR). RESULTS:A total of 2030 patients were analysed for OS (1798 thymomas, 191 TCs and 41 NETTs). Ten-year OS was 0.73 (95% confidence interval 0.69-0.75). Complete resection (R0) was achieved in 88% of the patients. Ten-year CIR was 0.12 (0.10-0.15). Predictors of shorter OS were increased age (P < 0-001), stage [III vs I HR 2.66, 1.80-3.92; IV vs I hazard ratio (HR) 4.41, 2.67-7.26], TC (HR 2.39, 1.68-3.40) and NETT (HR 2.59, 1.35-4.99) vs thymomas and incomplete resection (HR 1.74, 1.18-2.57). Risk of recurrence increased with tumour size (P = 0.003), stage (III vs I HR 5.67, 2.80-11.45; IV vs I HR 13.08, 5.70-30.03) and NETT (HR 7.18, 3.48-14.82). Analysis using a propensity score indicates that the administration of adjuvant therapy was beneficial in increasing OS (HR 0.69, 0.49-0.97) in R0 resections. CONCLUSIONS:Masaoka stages III-IV, incomplete resection and non-thymoma histology showed a significant impact in increasing recurrence and in worsening survival. The administration of adjuvant therapy after complete resection is associated with improved survival.

BACKGROUND: Patient selection for surgery after neoadjuvant therapy for locally advanced non-small cell lung cancer depends on accurate restaging of mediastinal (N2) lymph nodes. Our objective is to assess the accuracy of endobronchial ultrasound (EBUS) for restaging N2 lymph nodes after neoadjuvant therapy. METHODS: This is a retrospective review of patients with non-small cell lung cancer who underwent staging with repeat computed tomography and positron emission tomography and had restaging EBUS for sampling of N2 lymph nodes. Endobronchial ultrasound was performed for suspicious nodes in stations 2R, 2L, 4R, 4L, and 7. Selected patients who were N2-negative underwent thoracotomy with complete thoracic lymphadenectomy. RESULTS: There were 32 patients with N2 disease who underwent preoperative chemotherapy or radiotherapy, or both, and subsequently had restaging EBUS. There were 3 patients who had recalcitrant N2 nodal disease detected by EBUS. There were 5 patients with pulmonary function or comorbidities that were prohibitive for surgery. Of the remaining 24 patients with negative EBUS, 3 underwent mediastinoscopy and 2 had recalcitrant N2 disease. The remaining 22 patients underwent thoracotomy. Recalcitrant N2 disease was noted in 1 patient at thoracotomy in the EBUS-assessable nodal stations. Thus EBUS was falsely negative in 3 patients. The sensitivity and negative predictive value of restaging EBUS were 50% and 88%, respectively. CONCLUSIONS: Restaging EBUS is relatively accurate at predicting the absence of metastatic disease in N2 mediastinal lymph node in patients who underwent neoadjuvant therapy for non-small cell lung cancer.

BACKGROUND: The primary objective of this study was to evaluate our experience using a completely portal (no access incision) robotic pulmonary lobectomy or segmentectomy. METHODS: This was a retrospective review of a consecutive series of patients. RESULTS: From February 2010 until October 2013, 862 robotic operations were performed by 1 surgeon. Of these, 394 were for a planned anatomic pulmonary resection, comprising robotic lobectomy in 282, robotic segmentectomy in 71, and conversions to open in 41 (10 for bleeding, 1 patient required transfusion; and no conversions for bleeding in the last 100 patients). Indications were malignancy in 88%. A median of 17 lymph nodes were removed. Median hospital stay was 2 days. Approximate financial data yielded: median hospital charges, $32,000 per patient (total, $12.6 million); collections, 23.7%; direct costs, $13,800 per patient; and $4,750 profit per patient (total, $1.6 million). Major morbidity occurred in 9.6%. The 30-day operative mortality was 0.25%, and 90-day mortality was 0.5%. Patients reported a median pain score of 2/10 at their 3-week postoperative clinic visit. CONCLUSIONS: Robotic lobectomy for cancer offers outstanding results, with excellent lymph node removal and minimal morbidity, mortality, and pain. Despite its costs, it is profitable for the hospital system. Disadvantages include capital costs, the learning curve for the team, and the lack of lung palpation. Robotic surgery is an important tool in the armamentarium for the thoracic surgeon, but its precise role is still evolving.

BACKGROUND: Our objective was to determine the incidence and optimal management of chylothorax after pulmonary resection with complete thoracic mediastinal lymph node dissection (MLND). METHODS: This is a retrospective review of patients who underwent pulmonary resection with MLND. RESULTS: Between January 2000 and December 2012, 2,838 patients underwent pulmonary resection with MLND by one surgeon (RJC). Forty-one (1.4%) of these patients experienced a chylothorax. Univariate analysis showed that lobectomy (p<0.001), a robotic approach (p=0.03), right-sided operations (p<0.001), and pathologic N2 disease (p=0.007) were significantly associated with the development of chylothorax. Multivariate analysis showed that lobectomy (p=0.011), a robotic approach (p=0.032), and pathologic N2 disease (p=0.027) remained predictors. All patients were initially treated with cessation of oral intake and 200 mug subcutaneous somatostatin every 8 hours. If after 48 hours the chest tube output was less than 450 mL/day and the effluent was clear, patients was given a medium-chain triglyceride (MCT) diet and were observed for 48 hours in the hospital. If the chest tube output remained below 450 mL/day, the chest tube was removed, they were discharged home with directions to continue the MCT diet and to return in 2 weeks. Patients were instructed to consume a high-fat meal 24 hours before their clinic appointment. If the patient's chest roentgenogram was clear at that time, they were considered "treated." This approach was successful in 37 (90%) patients. The 4 patients in whom the initial treatment was unsuccessful underwent reoperation with pleurodesis and duct ligation. CONCLUSIONS: Chylothorax after pulmonary resection and MLND occurred in 1.4% of patients. Its incidence was higher in those with pathologic N2 disease and those who underwent robotic resection. Nonoperative therapy is almost always effective.

BACKGROUND: Pathologic nodal upstaging can be considered a surrogate for completeness of nodal evaluation and quality of surgery. We sought to determine the rate of nodal upstaging and disease-free and overall survival with a robotic approach in clinical stage I NSCLC. METHODS: We retrospectively reviewed patients with clinical stage I NSCLC after robotic lobectomy or segmentectomy at three centers from 2009 to 2012. Data were collected primarily based on Society of Thoracic Surgeons database elements. RESULTS: Robotic anatomic lung resection was performed in 302 patients. The majority were right sided (192; 63.6%) and of the upper lobe (192; 63.6%). Most were clinical stage IA (237; 78.5%). Pathologic nodal upstaging occurred in 33 patients (10.9% [pN1 20, 6.6%; pN2 13, 4.3%]). Hilar (pN1) upstaging occurred in 3.5%, 8.6%, and 10.8%, respectively, for cT1a, cT1b, and cT2a tumors. Comparatively, historic hilar upstage rates of video-assisted thoracoscopic surgery (VATS) versus thoracotomy for cT1a, cT1b, and cT2a were 5.2%, 7.1%, and 5.7%, versus 7.4%, 8.8%, and 11.5%, respectively. Median follow-up was 12.3 months (range, 0 to 49). Forty patients (13.2%) had disease recurrence (local 11, 3.6%; regional 7, 2.3%; distant 22, 7.3%). The 2-year overall survival was 87.6%, and the disease-free survival was 70.2%. CONCLUSIONS: The rate of nodal upstaging for robotic resection appears to be superior to VATS and similar to thoracotomy data when analyzed by clinical T stage. Both disease-free and overall survival were comparable to recent VATS and thoracotomy data. A larger series of matched open, VATS and robotic approaches is necessary.