Faculty Bibliography

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.

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

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.

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.

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.

BACKGROUND:Coronavirus disease 2019 (Covid-19) remains a worldwide pandemic with a high mortality rate among patients requiring mechanical ventilation. The limited data that exists regarding the utility of extracorporeal membrane oxygenation (ECMO) in these critically ill patients shows poor overall outcomes. This paper describes our institutional practice regarding the application and management of ECMO support for patients with Covid-19 and reports promising early outcomes. METHODS:>60 mmHg with no life-limiting comorbidities. Patients were cannulated at bedside and were managed with protective lung ventilation, early tracheostomy, bronchoscopies and proning as clinically indicated. RESULTS:Of 321 patients intubated for Covid-19, 77 (24%) patients were evaluated for ECMO support with 27 (8.4%) patients placed on ECMO. All patients were placed on veno-venous ECMO. Current survival is 96.3%, with only one mortality to date in over 350 days of total ECMO support. Thirteen patients (48.1%) remain on ECMO support, while 13 patients (48.1%) have been successfully decannulated. Seven patients (25.9%) have been discharged from the hospital. Six patients (22.2%) remain in the hospital of which four are on room-air. No healthcare workers that participated in ECMO cannulation developed symptoms of or tested positive for Covid-19. CONCLUSIONS:The early outcomes presented here suggest that the judicious use of ECMO support in severe Covid-19 may be clinically beneficial.