Faculty Bibliography

OBJECTIVE: The use of robotic lung surgery has increased dramatically despite being a new, costly technology with undefined benefits over standard of care. There is a paucity of published comparative articles justifying its use or cost. Furthermore, outcomes regarding robotic lung resection are either from single institutions with in-house historical comparisons or based on limited numbers. We compared consecutive robotic anatomic lung resections performed at two institutions with matched data from The Society of Thoracic Surgeons (STS) National Database for all open and video-assisted thoracoscopic surgery (VATS) resections. We sought to define any benefits to a robotic approach versus national outcomes after thoracotomy and VATS. METHODS: Data from all consecutive robotic anatomic lung resections were collected from two institutions (n = 181) from January 2010 until January 2012 and matched against the same variables for anatomic resections via thoracotomy (n = 5913) and VATS (n = 4612) from the STS National Database. Patients with clinical N2, N3, and M1 disease were excluded. RESULTS: There was a significant decrease in 30-day mortality and postoperative blood transfusion after robotic lung resection relative to VATS and thoracotomy. The patients stayed in the hospital 2 days less after robotic surgery than VATS and 4 days less than after thoracotomy. Robotic surgery led to fewer air leaks, intraoperative blood transfusions, need for perioperative bronchoscopy or reintubation, pneumonias, and atrial arrhythmias compared with thoracotomy. CONCLUSIONS: This is the first comparative analysis using national STS data. It suggests potential benefits of robotic surgery relative to VATS and thoracotomy, particularly in reducing length of stay, 30-day mortality, and postoperative blood transfusion.

OBJECTIVE: The objective of the present study was to determine the long-term fate and factors of compensatory hyperhidrosis (CH) in patients who have undergone video-assisted thoracoscopic sympathotomy for focal hyperhidrosis. METHODS: The same quality-of-life survey was administered 6 months postoperatively and then annually to all patients who underwent video-assisted thoracoscopic sympathotomy for hyperhidrosis. A second rib (R2)/R3 sympathotomy was most commonly performed until September 2007 and then R4/R5 sympathotomy was used. RESULTS: From January 1999 until December 2012, 193 patients underwent video-assisted thoracoscopic sympathotomy for hyperhidrosis, of whom, 173 had provided >/=1 year of postoperative survey information. No operative mortalities occurred. Of the 173 patients, 133 (77%) reported "clinically bothersome" CH. This rate had decreased to an average of 35% at 5 and 12 years postoperatively. Univariate analysis showed the CH incidence was significantly greater for the patients who had undergone R2/R3 versus R4/R5 sympathotomy (P < .001), had had multiple sites of sweating at presentation (P < .001), had used oral medication to control hyperhidrosis preoperatively (P = .022), or were female (P = .002). On multivariate analysis, only R2/R3 versus R4/R5 sympathotomy (P < .021) and multiple sites of sweating at presentation (P < .037) remained statistically significant. Twelve patients (6.2%) regretted having the operation for CH. CONCLUSIONS: Patients who undergo sympathotomy for hyperhidrosis will commonly report "clinically bothersome" compensatory hyperhidrosis. CH will more likely if R2/R3 sympathetic interruption has been performed instead of R4/R5 and in patients who present with multiple areas of sweating. The severity of clinically bothersome CH decreased during the first 3 years postoperatively.

BACKGROUND: Some reports suggest that patients with synchronous multiple foci of nonsmall-cell lung cancers (NSCLC) distributed in multiple lobes have a poor prognosis, even when there is no extrathoracic metastasis. The vast majority of such patients do not receive surgical treatment. For those who undergo surgery, prognostic factors are unclear. PATIENTS AND METHODS: We systematically reviewed the literature on surgery for synchronous NSCLC in multiple lobes published between 1990 and 2011. Individual patient data were used to obtain adjusted hazard ratios (HRs) in each dataset and pooled analyses were carried out. RESULTS: Six studies contributed 467 eligible patients for analysis. The median overall survival was 52.0 months [95% confidence interval 45.6-63.7]. Male gender and advanced age were associated with a decreased survival: HRs 1.64 (1.22, 2.22) and 1.40 (1.20, 1.80) per 20-year increment, respectively. Patients with cancers distributed in one lung had a higher mortality risk than those with bilateral disease: HRs 1.45 (1.06, 2.00). N1 or N2 had a decreased survival compared with N0: HRs 1.68 (1.12, 2.51) and 1.94 (1.33, 2.82), respectively. There was a trend toward increased mortality among patients with different histology: HRs 1.29 (0.96, 1.75). CONCLUSION: Advanced age, male gender, nodal involvement, and unilateral tumor location were poor prognostic factors.

BACKGROUND: Flattening filter-free (FFF) linear accelerators (linacs) are capable of delivering dose rates more than 4-times higher than conventional linacs during SBRT treatments, causing some to speculate whether the higher dose rate leads to increased toxicity owing to radiobiological dose rate effects. Despite wide clinical use of this emerging technology, clinical toxicity data for FFF SBRT are lacking. In this retrospective study, we report the acute and late toxicities observed in our lung radiosurgery experience using a FFF linac operating at 2400 MU/min. METHODS: We reviewed all flattening filter-free (FFF) lung SBRT cases treated at our institution from August 2010 through July 2012. Patients were eligible for inclusion if they had at least one clinical assessment at least 30 days following SBRT. Pulmonary, cardiac, dermatologic, neurologic, and gastrointestinal treatment related toxicities were scored according to CTCAE version 4.0. Toxicity observed within 90 days of SBRT was categorized as acute, whereas toxicity observed more than 90 days from SBRT was categorized as late. Factors thought to influence risk of toxicity were examined to assess relationship to grade > =2 toxicity. RESULTS: Sixty-four patients with >30 day follow up were eligible for inclusion. All patients were treated using 10 MV unflattened photons beams with intensity modulated radiation therapy (IMRT) inverse planning. Median SBRT dose was 48 Gy in 4 fractions (range: 30-60 Gy in 3-5 fractions). Six patients (9%) experienced > = grade 2 acute pulmonary toxicity; no non-pulmonary acute toxicities were observed. In a subset of 49 patients with greater than 90 day follow up (median 11.5 months), 11 pulmonary and three nerve related grade > =2 late toxicities were recorded. Pulmonary toxicities comprised six grade 2, three grade 3, and one each grade 4 and 5 events. Nerve related events were rare and included two cases of grade 2 chest wall pain and one grade 3 brachial plexopathy which spontaneously resolved. No grade > =2 late gastrointestinal, skin, or cardiac toxicities were observed. Tumor size, biologically effective dose (BED10, assuming alpha/beta of 10), and tumor location (central vs peripheral) were not significantly associated with grade > =2 toxicity. CONCLUSIONS: In this early clinical experience, lung SBRT using a FFF linac operating at 2400 MU/min yields minimal acute toxicity. Preliminary results of late treatment related toxicity suggest reasonable rates of grade > =2 toxicities. Further assessment of late effects and confirmation of the clinical efficacy of FFF SBRT is warranted.

Quality of life (QOL) is an important component of the conversation between any physician and patient. It is especially important between a surgeon and an operative candidate when considering treatment of lung cancer. Patients want reassurance that after removal of part of their lung that not only will they be cancer-free but also that they will be able to breathe well even when active. They do not want to be left physically or mentally handicapped. Recent studies have also shown the correlation between QOL and survival after resection. In this article the literature concerning QOL after pulmonary resection is reviewed.

OBJECTIVE: The objective is to determine the optimal manner to remove a chest tube after pulmonary resection. METHOD: This was a prospective, randomized single-institution study. Patients who underwent elective thoracotomy for pulmonary resection by 1 or 2 general thoracic surgeons were randomized to have their chest tube removed on either full inspiration or full expiration. Both patient groups performed a Valsalva maneuver during tube removal. Outcomes included the incidence of clinically nonsignificant pneumothorax (defined as a new or increased pneumothorax on the post-chest tube removal chest roentgenogram in asymptomatic patients), symptoms, delayed discharge, and the need for a new chest tube. RESULTS: Between November 2008 and June 2011, 1189 patients underwent pulmonary resection, and of these 342 met the criteria for the study. Of the 179 patients randomized to have their chest tube removed on full inspiration, 58 (32%) had a larger or new pneumothorax after chest tube removal and 5 (3%) required intervention or delayed discharge. Of the 163 patients randomized to have their chest tube removed on full expiration, 32 (19%; P = .007) had a larger or new pneumothorax after chest tube removal, and only 2 (1%) required intervention or delayed discharge (P = .78). CONCLUSIONS: Removal of chest tubes at the end of expiration leads to a lower incidence of non-clinically significant pneumothorax than at the end of inspiration. Because of these findings, this study was closed early and was thus underpowered for finding a statistically significant difference in the rare (1%-3%) clinically significant pneumothoraces.