Faculty Bibliography

BACKGROUND:Our objective is to report our outcomes and demonstrate our evolving technique for robotic sleeve resection of the airway, with or without lobectomy, using video vignettes. METHODS:We retrospectively reviewed a single surgeon prospective database from October 2010 to October 2019. RESULTS:Over 9 years, there were 5,573 operations of which 1951 were planned for a robotic approach. There were 755 robotic lobectomies, 306 robotic segmentectomies, and 23 consecutive patients were scheduled for elective completely portal, robotic sleeve resection. Sleeve lobectomy was performed in 18 patients: 10 right upper lobe, 6 left upper lobe, and 2 right lower lobe. Two patients had mainstem bronchus resections and two underwent right bronchus intermedius resections that preserved all of the lung. One patient had a robotic pneumonectomy. There was one conversion to open thoracotomy due to concern for anastomotic tension in a patient who received neoadjuvant therapy. All patients had an R0 resection. In the last 10 operations, we modified our airway anastomosis, using a running self-locking absorbable suture. The median length of stay was 3 days (range 1-11). There were no 30- or 90-day mortalities. Within a median follow-up of 18 months, there were no anastomotic strictures and no recurrent cancers. CONCLUSIONS:Our early and midterm results show that a completely portal robotic sleeve resection is safe and oncologically effective. The technical aspects of a robotic sleeve resection of the airway are demonstrated using video vignettes.

BACKGROUND:Lymphocytes have become the target of cancer interventions through engineering or immune checkpoint antibodies. We previously found decreased lymphocyte counts to be a predictor of mortality and complications in trauma and cardiac surgery patients. We hypothesized lack of lymphocyte count recovery postoperatively would predict outcomes in esophagectomy patients. METHODS:A retrospective review of all patients undergoing esophagectomy for adenocarcinoma performed over 13 y at our center by a single surgeon after institutional review board approval was performed. Patients were grouped by postoperative lymphocytes counts: never low, low with recovery, and low without recovery. Resolution of lymphopenia was assessed by day 4. Primary end points were overall and recurrence-free survival. RESULTS:In total, 198 patients were included with a minimum 6-mo follow-up. Collectively the 5-y recurrence and overall survival rates were 36% and 50%, respectively. Recurrence was significantly higher at 5 y in patients with persistent lymphopenia (43%) compared with those who recovered (14% P = 0.0017) and those who never dropped (0% P = 0.0009). The persistent lymphopenia group had significantly lower survival (45%) compared with the two other groups (67% P = 0.0232). CONCLUSIONS:There is a significant decrease in the overall and recurrence-free survival in those patients whose lymphocyte count drops without recovery after their esophagectomy. These data imply differences in immune responses to the stress of surgery that can be measured with routine postoperative laboratory values and are indicative of overall outcomes.

Screening for lung cancer has changed substantially in the past decade since The National Lung Screening Trial. The resultant increased discovery of incidental pulmonary nodules has led to a growth in the number of lesions requiring tissue diagnosis. Bronchoscopy is one main modality used to sample lesions, but peripheral lesions remain challenging for bronchoscopic biopsy. Alternatives have included transthoracic biopsy or operative biopsy, which are more invasive and have a higher morbidity than bronchoscopy. In hopes of developing less invasive diagnostic techniques, technologies have come to assist the bronchoscopist in reaching the outer edges of the lung. Navigational bronchoscopy is able to virtually map the lung and direct the biopsy needle where the scope cannot reach. Robotic bronchoscopy platforms have been developed to provide stability and smaller optics to drive deeper into the bronchial tree. While these new systems have not yet proven better outcomes, they may reduce the need for invasive procedures and be valuable armamentarium in diagnosing and treating lung nodules, especially in the periphery.

The use of telemedicine and telehealth services has grown exponentially over the past decade and has become increasingly relevant and necessary during the coronavirus 2019 (COVID-19) pandemic. There remains ample opportunity to electronically connect cardiothoracic surgeons with their patients during both preoperative and postoperative visits. In this review, we examine the various implementations of telemedicine within thoracic surgery and explore future applications in this quickly developing field.

BACKGROUND:Our objectives are to present our outcomes of robotic segmentectomy and our preferred technique for nodule localization using indocyanine green both bronchoscopically and intravenously. METHODS:This is a retrospective review of a consecutive series of patients scheduled for robotic segmentectomy from a single surgeon's prospectively collected database. RESULTS:Between January 2010 and October 2018, there were 245 consecutive patients who underwent planned robotic segmentectomy by one surgeon, of which 93 (38%) received indocyanine green via electromagnetic navigational bronchoscopy and all 245 received intravenous indocyanine green. Median time for navigational bronchoscopy was 9 minutes. Navigational bronchoscopy with indocyanine green correctly identified the lesion in 80 cases (86%). Our preferred technique is: 0.5 mL of 25 mg of indocyanine green diluted in 10 mL of saline given bronchoscopically, followed by a 0.5 mL saline flush, staying at least 4 mm from the pleural surface. The remaining 9.5 mL of indocyanine green is administered intravenously after pulmonary artery ligation. An R0 resection was achieved in all 245 patients, a median of 17 lymph nodes were resected, and the average length of stay was 3.1 days (range 1-21 days). Major morbidity occurred in 3 patients and there were no 30 or 90-day mortalities. CONCLUSIONS:Robotic segmentectomy is safe with excellent early clinical outcomes. In our series, electromagnetic navigational bronchoscopy and indocyanine green localization is efficient and effective at identifying the target lesion. Intravenous indocyanine green delineates the intersegmental plane.

Purpose: Controversy remains over the mortality benefit of single (SLT) versus double lung transplantation (DLT) in idiopathic pulmonary fibrosis (IPF). Independent of this controversy, hesitancy to perform SLT in this population exists on the basis of unclear one year functional status. We compared functional status at one year between IPF patients listed for both who ultimately received SLT or DLT. Method(s): All consecutive adult lung transplants for IPF provided by the Scientific Registry of Transplant Recipients were retrospectively reviewed (2007-2017). Isolated lobar transplants (n=4), patients listed only for SLT (n=1834) or DLT (n=2372), and patients with missing functional status data (n=715) were excluded. Group stratification was based on the ultimate procedure (SLT or DLT). Group propensity matching was performed based on 25 recipient/donor characteristics. We compared 'good functional status' defined as >70%, at one year. Result(s): During the study period, 45% (660/1464) and 55% (804/1464) of patients listed for both procedures ultimately received SLT and DLT, respectively. After propensity matching, 341 matched patients remained in each group. Donor and recipient characteristics were similar (Table). There was no statistically significant difference in 'good functional status' at one year between SLT (77%, 264/341) and DLT (81%, 275/341) (p=0.301). The same trend is present for patients younger than 50 who receive SLT (82%, 23/28) versus DLT (94%, 34/36) (p=0.225), and patients between 50 and 60 who receive SLT (78%, 86/110) versus DLT (84%, 97/115) (p=0.305). The opposite trend is noted in patients older than 70 who receive SLT (72%, 13/18) versus DLT (61%, 11/18) (p=0.725). Conclusion(s): In this cohort of lung transplant recipients listed for both SLT and DLT, functional status was statistically similar between groups, even in younger recipients. This data suggests that SLT should not be precluded in IPF patients on the basis of expected functional status at one year.

During minimally invasive pulmonary resection, it is often difficult to localize pulmonary nodules that are small (<2 cm), low-density/subsolid on imaging, or deep to the visceral pleura. The use of near-infrared fluorescence (NIF) imaging for localizing pulmonary nodules using indocyanine green (ICG) contrast is an emerging technology that is increasingly utilized during pulmonary resection. When administered via electromagnetic navigational bronchoscopy (ENB), ICG can accurately localize pulmonary nodules. When injected intravenously (IV), ICG can also help delineate the intersegmental plane. Research is ongoing regarding the utility of ICG for identification of the sentinel lymph node in lung cancer.