Faculty Bibliography

While lung cancer remains the most common cause of cancer-related mortality in the United States, surgery for curative intent continues to be a mainstay of therapy. The robotic platform for pulmonary resection for non-small cell lung cancer (NSCLC) has been utilized for more than a decade now. With respect to more localized resections, such as wedge resection or lobectomy, considerable data exist demonstrating shorter length of stay, decreased postoperative pain, improved lymph node dissection, and overall lower complication rate. There are a multitude of technical advantages the robotic approach offers, such as improved optics, natural movement of the operator's hands to control the instruments, and precise identification of tissue planes leading to a more ergonomic and safe dissection. Due to the advantages, the scope of robotic resections is expanding. In this review, we will look at the existing data on extended robotic pulmonary resections, specifically post-induction therapy resection, sleeve lobectomy, and pneumonectomy. Additionally, this review will examine the indications for these more complex resections, as well as review the data and outcomes from other institutions' experience with performing them. Lastly, we will share the strategy and outlook of our own institution with respect to these three types of extended pulmonary resections. Though some controversy remains regarding the use and safety of robotic surgery in these complex pulmonary resections, we hope to shed some light on the existing evidence and evaluate the efficacy and safety for patients with NSCLC.

The Coronavirus Disease 2019 (COVID-19) pandemic remains a disruptive force upon the health care system, with particular import for thoracic surgery given the pulmonary pathophysiology and disease implications of the virus. The rapid and severe onset of disease required expedient innovation and change in patient management and novel approaches to care delivery and nimbleness of workforce. In this review, we detail our approaches to patients with COVID-19, including those that required surgical intervention, our expedited and novel approach to bronchoscopy and tracheostomy, and our expansion of telehealth. The pandemic has created a unique opportunity to reflect on our delivery of care in thoracic surgery and apply lessons learned during this time to "rethink" how to optimize resources and deliver excellent and cutting-edge patient care.

OBJECTIVES/OBJECTIVE:The coronavirus disease 2019 (COVID-19) pandemic has resulted in patient reluctance to seek care due to fear of contracting the virus, especially in New York City which was the epicentre during the surge. The primary objectives of this study are to evaluate the safety of patients who have undergone pulmonary resection for lung cancer as well as provider safety, using COVID-19 testing, symptoms and early patient outcomes. METHODS:Patients with confirmed or suspected pulmonary malignancy who underwent resection from 13 March to 4 May 2020 were retrospectively reviewed. RESULTS:Between 13 March and 4 May 2020, 2087 COVID-19 patients were admitted, with a median daily census of 299, to one of our Manhattan campuses (80% of hospital capacity). During this time, 21 patients (median age 72 years) out of 45 eligible surgical candidates underwent pulmonary resection-13 lobectomies, 6 segmentectomies and 2 pneumonectomies were performed by the same providers who were caring for COVID-19 patients. None of the patients developed major complications, 5 had minor complications, and the median length of hospital stay was 2 days. No previously COVID-19-negative patient (n = 20/21) or healthcare provider (n = 9: 3 surgeons, 3 surgical assistants, 3 anaesthesiologists) developed symptoms of or tested positive for COVID-19. CONCLUSIONS:Pulmonary resection for lung cancer is safe in selected patients, even when performed by providers who care for COVID-19 patients in a hospital with a large COVID-19 census. None of our patients or providers developed symptoms of COVID-19 and no patient experienced major morbidity or mortality.

BACKGROUND:COVID-19 is a worldwide pandemic, with many patients requiring prolonged mechanical ventilation. Tracheostomy is not recommended by current guidelines as it is considered a super-spreading event due to aerosolization that unduly risks healthcare workers. METHODS:Patients with severe COVID-19 that were on mechanical ventilation ≥ 5 days were evaluated for percutaneous dilational tracheostomy. We developed a novel percutaneous tracheostomy technique that placed the bronchoscope alongside the endotracheal tube, not inside it. This improved visualization during the procedure and continued standard mechanical ventilation after positioning the inflated endotracheal tube cuff in the distal trachea. This technique offers a significant mitigation for the risk of virus aerosolization during the procedure. RESULTS:From March 10 to April 15, 2020, 270 patients with COVID-19 required invasive mechanical ventilation at New York University Langone Health Manhattan's campus of which 98 patients underwent percutaneous dilational tracheostomy. The mean time from intubation to the procedure was 10.6 days (SD ±5 days). Currently, thirty-two (33%) patients do not require mechanical ventilatory support, 19 (19%) have their tracheostomy tube downsized and 8 (8%) were decannulated. Forty (41%) patients remain on full ventilator support, while 19 (19%) are weaning from mechanical ventilation. Seven (7%) died as result of respiratory and multiorgan failure. Tracheostomy related bleeding was the most common complication (5 patients). None of health care providers have developed symptoms or tested positive for COVID-19. CONCLUSIONS:Our percutaneous tracheostomy technique appears to be safe and effective for COVID-19 patients and safe for healthcare workers.

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.

Aorticopulmonary paragangliomas are rare middle mediastinal masses that are often treated with surgery. In addition to the technical challenge of resection due to location near critical structures, these paragangliomas can have postoperative complications due to resection of cardiac sympathetic innervation. We present a patient with a non-functional aorticopulmonary paraganglioma that suffered from postoperative hypotension and heart block, with inability to tolerate his prior alpha and beta blockade on discharge.

Granulomatous fungal infections are common worldwide, and can result in mediastinal lymphadenopathy. However, infectious pulmonary artery masses are rare and have only been associated with tuberculosis or mucormycosis. Here, we present the first case of histoplasmosis resulting in a pulmonary artery mass, which was treated with debulking and reconstruction of pulmonary vasculature.

PURPOSE: Azole antifungals are commonly prescribed for fungal prophylaxis (ppx) following lung transplant, but have many side effects and drug interactions. Isavuconazole, a new broad-spectrum azole antifungal, may obviate these issues.
METHOD(S): We retrospectively reviewed all lung transplant recipients (LTR) from February 2018 through September 2019 who received either ISA or POS for fungal ppx for 3 months post-transplant. Prior to February 2019 all patients received POS for ppx. Starting February 2019, POS was replaced by ISA at standard dosing. All patients received basiliximab induction and standard triple immunosuppression post-transplant. Surveillance bronchoscopies were performed at 1, 3, 6, and 12 months post-transplant.
RESULT(S): In total, we reviewed 24 LTR who received ISA and 29 who received POS. Baseline characteristics were similar between groups. Median duration of follow-up was significantly shorter for the ISA group (137 vs. 340 days, p<0.01). Breakthrough fungal infections occurred in 3 (13%) and 2 (7%) patients in the ISA and POS groups, respectively (p=0.65). All ISA patients developed oropharyngeal candidiasis; in the POS group there was one each of candida empyema and mold colonization. Post-ppx fungal infections occurred in 1 (4%) and 5 (17%) patients in the ISA and POS groups, respectively (p=0.20). All of these were mold colonization except for one case of oropharyngeal candidiasis. There was no difference between fungal-infection free survival based on Kaplan-Meier analysis (p=0.69). POS was held in two cases and discontinued in 1 patient due to a drug interaction causing hepatotoxicity compared to zero patients receiving ISA (p=0.24).
CONCLUSION(S): Breakthrough fungal infections were similar between LTR receiving ISA or POS for fungal ppx. Longer follow-up of ISA patients is needed for definitive comparison of long-term infection risk. POS was discontinued in more patients due to drug interactions. ISA is a reasonable choice for primary fungal ppx in LTR.
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