Faculty Bibliography

BACKGROUND/UNASSIGNED:Previous studies report a 20% conversion to open thoracotomy and 25% major morbidity rate for minimally invasive thoracic surgery following neoadjuvant chemotherapy or immunotherapy. METHODS/UNASSIGNED:This retrospective review includes a consecutive (non-selected) series of patients from two surgeons who underwent robotic resection after neoadjuvant therapy for non-small cell lung cancer. RESULTS/UNASSIGNED:From January 2018 to October 2024, 150 patients (51% male) underwent surgery following systemic therapy. The median age was 67 years. Preoperatively, 92% received chemotherapy, 65% immunotherapy, and 27% radiation. Median time from therapy to surgery was 6 weeks. The most common tumor type was stage IIIA adenocarcinoma (25%). Median operative time was 152 min, and median blood loss was 20 mL. There were no unplanned conversions to open thoracotomy or from lobectomy to pneumonectomy. Median length of stay was 1 day; 28% had chest tube removed on the day of surgery. Twenty-one patients experienced Clavien-Dindo grade III complications (primarily atrial fibrillation and effusion). There were no 30-day mortalities and two 90-day mortalities. Median follow-up was 19 months, with a median postoperative survival of 513 days. CONCLUSION/UNASSIGNED:Robotic lobectomy and pneumonectomy can be safely performed after neoadjuvant therapy, with conversion rates <1% and minimal 30- and 90-day mortality. Key technical factors include intra-pericardial control of the pulmonary artery, division of the lobar airway prior to pulmonary artery dissection, and performing surgery within 6 weeks of completing neoadjuvant therapy.

OBJECTIVES/OBJECTIVE:Evaluate impact of common pathologic features, single or in combination, in patients with early-stage lung adenocarcinoma, according to lung resection extent. METHODS:Retrospective multicentric cohort study including patients with cT1a-bN0M0 lung adenocarcinoma and with at least: visceral pleural invasion (VPI) under surface (PL1) or up to surface (PL2), lymphovascular invasion (LVI), spread through airspace (STAS), necrosis, or neural invasion, who underwent lobectomy or segmentectomy with systematic lymph nodal dissection (SND) from 2015-2021 in 10 European centers. Overall survival (OS), disease-free survival (DFS) and lung cancer specific death (LCSD) between both groups were assessed before and after stabilized inverse probability of treatment-weighting (IPTW)-matching. Risk factors for oncologic outcomes were analyzed using parsimonious model Cox proportional hazard regression in entire and multiple features datasets. Kaplan Meir and cumulative incidence function assessed outcome. Log-rank and Gray' tests compared the groups. Linearized risk assessed recurrences. RESULTS:Of 1703 patients with cT1a-bN0M0 lung adenocarcinoma, 530 had at least one poor pathological feature and 130 had multiple features. For the 530 patients, 5-year OS lobectomy 83.0%, segmentectomy 89.4%, p=0.2; 5-year DFS lobectomy 78.1%, segmentectomy 83.8%, p=0.06; and 5-year LCSD lobectomy 8.9%, segmentectomy 7.2%, p=0.6 were similar. It was the same in matched cohort. In multivariable analysis, no poor pathological feature impacted outcome more than others. Multiple poor features were not associated with any clinical, pathological trait, but impacted OS (HR:3.24, p=0.002). Locoregional recurrence (linearized risk: lobectomy 0.083, segmentectomy 0.086) was similar in matched entire dataset. CONCLUSION/CONCLUSIONS:Segmentectomy with SND dissection can be indicated in patients with stage IA1-2 lung adenocarcinoma suspected to have poor pathological features. Multiple factors were not predictable but impacted OS.

OBJECTIVE/UNASSIGNED:Mid-to-distal tracheal surgery for cancer can be safely performed minimally invasively with a one-day length of stay, avoiding a guardian chin suture, and ensuring a R0 resection in select patients. METHODS/UNASSIGNED:This is a retrospective technical review of the largest series to date of patients with mid-to-distal tracheal cancers. All were offered a right robotic approach using veno-venous extracorporeal membrane oxygenation (VV ECMO) support via percutaneous right internal jugular vein and right common femoral vein access. RESULTS/UNASSIGNED:From May 2019 to April 2024, five consecutive patients (3 men, 2 women; aged 11, 29, 37, 40, and 74 years) presented with a mid-to-distal tracheal cancer. All underwent right robotic mid-distal tracheal resections on VV ECMO for primary tracheal cancers. All patients had an end-to-end tracheal anastomosis and R0 resection and all avoided: systemic heparinization, suprahyoid release maneuvers and a postoperative guardian chin stitch. Median operative time was 258 min (range 227-292). All patients tolerated the operations well and were discharged home on the morning of postoperative day 1. There was no minor or major morbidity, no 30 or 90-day mortality, and no re-admissions. Two patients complained of cough. All had R0 resections and to date none have evidence of recurrent disease or stricture. CONCLUSION/UNASSIGNED:Resection of mid-to-distal primary tracheal cancers can be performed safely and efficiently via a right robotic approach while on VV ECMO with little to no morbidity or mortality and require only an overnight hospital stay. The techniques used to perform the operation and achieve these results are described.

BACKGROUND/UNASSIGNED:We have previously shown that it is safe to remove chest tubes within four hours after robotic pulmonary resection with aggressive thoracic lymphadenectomy in patients without an air leak. METHODS/UNASSIGNED:This is a prospective quality improvement study that examines the process of removing chest tubes before the patient leaves the operating room (OR) after robotic pulmonary resection. Chest tubes were removed in the OR if the air leak was ≤75 mL/min on a digital drainage system. The tubes were reinserted only for oxygen desaturations from increasing pneumothorax and/or increasing subcutaneous emphysema. RESULTS/UNASSIGNED:Between 1 March 2023 and 12 December 2024, 223 consecutive patients underwent pulmonary resection with complete lymphadenectomy by one surgeon. Overall, 130 patients (58%) had their chest tubes removed in the OR, in 54% (62/114) of lobectomies, 62% (48/78) of segmentectomies, and 65% (20/31) of wedge resections. Thirteen patients (10%) required chest tube reinsertion, 11 after lobectomy and 2 after segmentectomy. The median operative time was 90 min (range 29-244 min), blood loss was 20 mL (range 10-60 mL), and all but one patient went home on postoperative day 1. No 30-day or 90-day mortality rate was recorded. A postoperative thoracentesis was performed in 1% of patients. CONCLUSION/UNASSIGNED:Chest tubes can be safely removed in selective patients before they leave the OR after a robotic pulmonary resection with complete lymphadenectomy. Factors that may lead to these outcomes are the meticulous intraoperative technique and hemo-chylostasis. An air leak threshold of <20 mL/min may be optimal to minimize chest tube reinsertions and reduce failure rates.

OBJECTIVES/OBJECTIVE:Fortunately, operating room deaths and unexpected deaths are infrequent occurrences. However, when they occur, the surgeon is called upon to deliver this news to family and loved ones. There is a paucity of literature on this topic and little guidance preparing cardiothoracic surgeons for this important but difficult situation. Furthermore, the surgeon may very well lack previous experience with this challenging situation. Having contemplated this in advance and having a script in mind will likely benefit both the surgeon and family. METHODS:The American Association for Thoracic Surgery Wellness Committee called upon the available published literature, consultation with experts, and upon their collective experience and cumulative wisdom to address this topic. RESULTS:The result of this process is a narrative discussion of delivering news of an unexpected death and a bullet point guide to speaking with the bereaved family. CONCLUSIONS:In this stressful situation, precontemplation of the surgeon's duties and being armed with a bullet point guide may benefit the surgeon, family, and heath care team. The lessons learned may be applicable to other situations requiring the delivery of distressing information.

Surgical approaches to lung cancer resection are rapidly evolving, particularly for early-stage lung cancer. Advances in chest CT technology and increasing use of CT in patient care have led to detection of smaller nodules, many with ground-glass attenuation that do not require lobectomy for resection. Lung-sparing and minimally invasive techniques have been shown to result in improved patient outcomes compared with those of traditional open thoracotomy and are noninferior in terms of cancer recurrence. As more patients undergo these surgeries, it is important for radiologists to be aware of useful information for surgeons before the operation. It is helpful for radiologists to understand the indications for lung-sparing surgery and have a basic understanding of the techniques involved in video-assisted and robotic thoracic operations. Identification of the location and morphology of the tumor, as well as the pulmonary vasculature that feeds and drains the segment of lung containing the tumor is important. Also, the presence of emphysema, pulmonary fibrosis, and incomplete fissures is useful information. In addition, chest imaging is also progressing, with improvements in multiplanar reformations and three-dimensional imaging allowing for more detailed and accurate image-based localization of tumors and visualization of anatomy. Nodule localization for surgery plays an even larger role given the limited ability to palpate nodules during surgery with minimally invasive surgery approaches. Methods can involve imaging and in vivo localization, with transthoracic and bronchoscopic methods used to label a nodule. Finally, radiologists should be aware of postoperative complications and their imaging characteristics, such as suture line granulomas and bronchopleural fistulas. Supplemental material is available for this article. ^©RSNA, 2025.