Faculty Bibliography

BACKGROUND:Minimally invasive esophagectomy (MIE) is increasingly performed in various ways. The lack of international definitions and nomenclature makes accurate comparison of outcomes difficult. METHODS:An international, multi-specialty consensus-writing committee constructed definitions and nomenclature for MIE. After a PubMed search, vetting, and review with all authors a consensus was reached. RESULTS:The proposed definition for MIE is an operation "that removes part or all of the esophagus, does not retract, lift, spread or remove any part of the chest or abdominal wall and the surgeon's and assistant's vision of the operative field is via a monitor, the patient's tissue is manipulated only by instruments that are controlled by the operating surgeon or team, except for during the neck portion if used." A flexible nomenclature is proposed that attempts to describes current and future operations and systems. CONCLUSIONS:Definitions and nomenclature for MIE are needed to ensure that future studies accurately compare results and outcomes of similar operations. Nomenclatures allow surgeons, researchers and patients from different cultures to use a common language to facilitate communication and compare. This process is required in order to improve patient outcomes globally to drive adoption of best of practice yet is lacking for minimally invasive esophagectomy.

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.

Robotic thoracic surgery continues to gain momentum and is emerging as the optimal method for minimally invasive thoracic surgery. As a rapidly advancing field, continued review of the surgical and anesthetic concerns unique to robotic thoracic operations is necessary to maintain safe and efficient practice. In this review, we discuss the intraoperative concerns as they pertain to pulmonary, esophageal, and mediastinal thoracic robotic operations.

The COVID-19 pandemic has created uncertainty regarding the safety and appropriate utilization of minimally invasive surgery (MIS) during this current outbreak. Surgical governing bodies such as Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and the Royal Colleges of Surgery of Great Britain and Ireland have made statements regarding the possibility of COVID-19 release into CO2 insufflant during MIS. The basis for this concern is prior evidence in the literature of other viral pathogen release during laparoscopic surgery. The recommendations are correctly based on caution given the lack of understanding of how COVID-19 compares to other viruses with regard to transmission and presence in CO2 during MIS. In this review we have investigated the available literature on COVID-19 transmission during MIS, address the implications of current and previously published recommendations and discuss steps to mitigate COVID-19 transmission during MIS for staff and patient safety.

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:Esophagectomy is a pivotal curative modality for localized esophageal or esophagogastric junction cancer (EC or EJC). Postoperative anastomotic leakage (AL) remains problematic. The use of fibrin sealant (FS) may improve the strength of esophageal anastomosis and reduce the incidence of AL. AIM/OBJECTIVE:To assess the efficacy and safety of applying FS to prevent AL in patients with EC or EJC. METHODS:In this single-arm, phase II trial (Clinicaltrial.gov identifier: NCT03529266), we recruited patients aged 18-80 years with resectable EC or EJC clinically staged as T1-4aN0-3M0. An open or minimally invasive McKeown esophagectomy was performed with a circular stapled anastomosis. After performing the anastomosis, 2.5 mL of porcine FS was applied circumferentially. The primary endpoint was the proportion of patients with AL within 3 mo. RESULTS:From June 4, 2018, to December 29, 2018, 57 patients were enrolled. At the data cutoff date (June 30, 2019), three (5.3%) of the 57 patients had developed AL, including two (3.5%) with esophagogastric AL and one (1.8%) with gastric fistula. The incidence of anastomotic stricture and other major postoperative complications was 1.8% and 17.5%, respectively. The median time needed to resume oral feeding after operation was 8 d (Interquartile range: 7.0-9.0 d). No adverse events related to FS were recorded. No deaths occurred within 90 d after surgery. CONCLUSION/CONCLUSIONS:Perioperative sealing with porcine FS appears safe and may prevent AL after esophagectomy in patients with resectable EC or EJC. Further phase III studies are warranted.