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385


Percutaneous Dilational Tracheostomy for Coronavirus Disease 2019 Patients Requiring Mechanical Ventilation

Angel, Luis F; Amoroso, Nancy E; Rafeq, Samaan; Mitzman, Brian; Goldenberg, Ronald; Shekar, Saketh Palasamudram; Troxel, Andrea B; Zhang, Yan; Chang, Stephanie H; Kwak, Paul; Amin, Milan R; Sureau, Kimberly; Nafday, Heidi B; Thomas, Sarun; Kon, Zachary; Sommer, Philip M; Segal, Leopoldo N; Moore, William H; Cerfolio, Robert
OBJECTIVES/OBJECTIVE:To assess the impact of percutaneous dilational tracheostomy in coronavirus disease 2019 patients requiring mechanical ventilation and the risk for healthcare providers. DESIGN/METHODS:Prospective cohort study; patients were enrolled between March 11, and April 29, 2020. The date of final follow-up was July 30, 2020. We used a propensity score matching approach to compare outcomes. Study outcomes were formulated before data collection and analysis. SETTING/METHODS:Critical care units at two large metropolitan hospitals in New York City. PATIENTS/METHODS:Five-hundred forty-one patients with confirmed severe coronavirus disease 2019 respiratory failure requiring mechanical ventilation. INTERVENTIONS/METHODS:Bedside percutaneous dilational tracheostomy with modified visualization and ventilation. MEASUREMENTS AND MAIN RESULTS/RESULTS:Required time for discontinuation off mechanical ventilation, total length of hospitalization, and overall patient survival. Of the 541 patients, 394 patients were eligible for a tracheostomy. One-hundred sixteen were early percutaneous dilational tracheostomies with median time of 9 days after initiation of mechanical ventilation (interquartile range, 7-12 d), whereas 89 were late percutaneous dilational tracheostomies with a median time of 19 days after initiation of mechanical ventilation (interquartile range, 16-24 d). Compared with patients with no tracheostomy, patients with an early percutaneous dilational tracheostomy had a higher probability of discontinuation from mechanical ventilation (absolute difference, 30%; p < 0.001; hazard ratio for successful discontinuation, 2.8; 95% CI, 1.34-5.84; p = 0.006) and a lower mortality (absolute difference, 34%, p < 0.001; hazard ratio for death, 0.11; 95% CI, 0.06-0.22; p < 0.001). Compared with patients with late percutaneous dilational tracheostomy, patients with early percutaneous dilational tracheostomy had higher discontinuation rates from mechanical ventilation (absolute difference 7%; p < 0.35; hazard ratio for successful discontinuation, 1.53; 95% CI, 1.01-2.3; p = 0.04) and had a shorter median duration of mechanical ventilation in survivors (absolute difference, -15 d; p < 0.001). None of the healthcare providers who performed all the percutaneous dilational tracheostomies procedures had clinical symptoms or any positive laboratory test for severe acute respiratory syndrome coronavirus 2 infection. CONCLUSIONS:In coronavirus disease 2019 patients on mechanical ventilation, an early modified percutaneous dilational tracheostomy was safe for patients and healthcare providers and associated with improved clinical outcomes.
PMID: 33826583
ISSN: 1530-0293
CID: 4839312

Commentary: To "Air" is to Leak-To Prevent is Devine [Editorial]

Cerfolio, Robert J
PMID: 32971242
ISSN: 1532-9488
CID: 4650372

Robotic right upper lobectomy: Twelve steps

Sasankan, Prabhu; Chang, Stephanie; Cerfolio, Robert
PMCID:8311674
PMID: 34318270
ISSN: 2666-2507
CID: 4966002

Commentary: Leaders float all boats higher and faster [Editorial]

Cerfolio, Robert J
PMID: 36003579
ISSN: 2666-2736
CID: 5387602

Midterm Results for Robotic Thymectomy for Malignant Disease

Geraci, Travis C; Ferrari-Light, Dana; Pozzi, Natalie; Cerfolio, Robert J
BACKGROUND:There are limited reports on robotic thymectomy for malignant disease. Our objectives are to review our experience and midterm outcomes. METHODS:We reviewed a single-surgeon prospective database for patients who underwent planned robotic resection for malignancy from January 2010 to June 2019. RESULTS:Two hundred thirteen patients underwent resection of an anterior mediastinal mass, all of which were planned for a robotic approach. Of these, 84 (39%) underwent robotic thymectomy for malignant disease. Thymoma was the most common pathology resected (68%). Median tumor size was 4.7 cm (interquartile range, 2.9-6.3), and median operative time was 81.5 minutes (interquartile range, 64-104). All except 1 patient had a complete (R0) resection (98.8%). There were 2 (2.3%) unplanned but elective conversions to open surgery, 1 of which required cardiopulmonary bypass. Median length of stay was 1 day (range, 0-9) with 1 readmission (1.2%). Major morbidity occurred in 3 patients (3.5%), and there were no 30- or 90-day mortalities. In patients with thymoma, follow-up was complete at a median of 32 months (range, 1-98), and 1 patient (1.8%) had an ipsilateral chest recurrence. To date there have been no patient deaths. CONCLUSIONS:Robotic thymectomy for patients with malignant disease is safe with excellent perioperative outcomes. A robotic approach achieves a high rate of complete R0 resection, even for larger tumors. For patients with thymoma local recurrence is low after midterm follow-up, but longer-term analysis is needed to determine oncologic durability.
PMID: 32926846
ISSN: 1552-6259
CID: 4835172

Commentary: Let us raise the bar higher for better patient outcomes [Editorial]

Cerfolio, Robert J
PMID: 32475503
ISSN: 1097-685x
CID: 4474402

Outcomes of robotic surgery in patients with pulmonary nontuberculous mycobacterial disease [Meeting Abstract]

Mcguire, E L; Saini, S; Luoma, K; Zervos, M; Cerfolio, R J; Addrizzo-Harris, D J
Rationale: Treatment for patients with pulmonary nontuberculous mycobacterial (NTM) disease includes long, multi-drug, and toxic medication regimens. Despite medical therapy, the rate of sputum culture conversion is low. Surgical resection is an alternative treatment for patients with localized or refractory NTM infection. Traditionally, resection of the affected lung was achieved via open thoracotomy. Robot-assisted surgery is less invasive and similarly effective, but has not been used routinely in this population. To our knowledge, this is the first report of robotic surgery for patients with complex NTM disease.
Method(s): Using the electronic medical record we identified patients with NTM disease that underwent robotic anatomic pulmonary resection by an experienced surgeon. All surgeries were done at NYU Langone Medical Center between August 2017 and February 2020. We collected data on demographics, NTM species, antibiotic course, pre- and post-operative sputum cultures, and surgical complications.
Result(s): We identified 8 patients that met the criteria. 100% of the patients were female and 88% were white. Mean age at time of surgery was 53 years. The most common indication for surgery was cavitary disease, followed by failure of medical therapy, and hemoptysis. All of the patients had pre-operative sputum cultures positive Mycobacterium avium complex. Prior to surgery, 63% of patients required IV antibiotics. Lobectomy was the most common operation performed and none of the surgeries were converted to open thoracotomy. There were no post-operative bleeds requiring transfusion, pneumonias, pneumothoraces, or bronchopleural fistulas. One patient had an air leak > 5 days. None of the patients required an ICU stay and the median length of hospital stay was 2.5 days. There were no deaths. Patients were considered cured if they had sputum culture conversion or no longer required antibiotics. Partial cure was defined as symptom improvement or de-escalation of medical regimen. Six of the patients were completely cured, one patient was partially cured, and one patient was lost to follow-up.
Conclusion(s): Surgical resection for patients with complex NTM disease can be performed using minimally invasive, robotic techniques safely and without the need for conversion to open thoracotomy, blood transfusions, or ICU stay. In this small cohort of patients, robotic surgery had a high rate of cure, few post-operative complications, and a short length of hospital stay. Larger studies can assist with validating robotic surgery as the preferred approach in these patients
EMBASE:635306725
ISSN: 1535-4970
CID: 4915762

Postoperative Air Leaks After Lung Surgery: Predictors, Intraoperative Techniques, and Postoperative Management

Geraci, Travis C; Chang, Stephanie H; Shah, Savan K; Kent, Amie; Cerfolio, Robert J
Postoperative air leak is one of the most common complications after pulmonary resection and contributes to postoperative pain, complications, and increased hospital length of stay. Several risk factors, including both patient and surgical characteristics, increase the frequency of air leaks. Appropriate intraoperative tissue handling is the most important surgical technique to reduce air leaks. Digital drainage systems have improved the management of postoperative air leak via objective data, portability, and ease of use in the outpatient setting. Several treatment strategies have been used to address prolonged air leak, including pleurodesis, blood patch, placement of endobronchial valves, and reoperative surgery.
PMID: 33926669
ISSN: 1558-5069
CID: 4873812

Early Results from SARS-CoV-2 PCR testing of Healthcare Workers at an Academic Medical Center in New York City

Nagler, Arielle R; Goldberg, Eric R; Aguero-Rosenfeld, Maria E; Cangiarella, Joan; Kalkut, Gary; Monahan, Carolyn Rooke; Cerfolio, Robert J
COVID-19 RT-PCR employee-testing was implemented across NYU Langone. Over eight-weeks, 14,764 employees were tested: 33% of symptomatic employees, 8% of asymptomatic employees reporting COVID-19 exposure, 3% of employees returning to work were positive. Positivity rates declined over time possibly reflecting the importance of community transmission and efficacy of PPE.
PMID: 32594114
ISSN: 1537-6591
CID: 4503762

Robotic Resection of a Combined Capillary and Arteriovenous Malformation in the Mediastinum [Case Report]

Sasankan, Prabhu; Geraci, Travis C; Narula, Navneet; Cerfolio, Robert
The adult presentation of a mediastinal arteriovenous malformation is rare. Resection of these lesions are commonly performed via open thoracotomy, with a risk of bleeding from multiple feeding vessels. This report describes a robotic resection of a mediastinal arteriovenous malformation in a 55-year-old man.
PMID: 32835753
ISSN: 1552-6259
CID: 4798332