Faculty Bibliography

BACKGROUND:Our objective is to assess the feasibility and safety of discharging patients by postoperative day one (POD1) after robotic segmentectomy and lobectomy, and to describe outcomes for patients. METHODS:A retrospective analysis was made of a prospectively collected database of a quality improvement initiative by a single surgeon. Factors associated with discharge by POD1 were evaluated using a multivariate logistic regression model. RESULTS:From January 2018 to July 2020, of 253 patients who underwent robotic anatomic pulmonary resection, 134 (53%) were discharged by POD1, 67% after segmentectomy and 41% after lobectomy. Discharge by POD1 improved with experience and was achieved in 97% of patients after segmentectomy and 68% after lobectomy in the final quartile. Thirty-one patients (12%) were discharged home with a chest tube, including 7 (2.8%) on POD1. On multivariate analysis, never smokers and segmentectomy were associated with discharge by POD1. Conversely, decreased baseline performance status and perioperative complications were associated with discharge after POD1. There were 10 minor morbidities (4%), 6 major morbidities (2.4%), and no 30- or 90-day mortality. There were 4 readmissions (1.6%), of which 1 (0.4%) was after POD1 discharge. Patient satisfaction remained high throughout the study period. CONCLUSIONS:With experience and communication, select patients can be discharged home on POD1 after robotic segmentectomy and lobectomy with excellent outcomes and high satisfaction. Discharge by POD1 was associated with never smokers and segmentectomy, and inversely associated with decreased baseline performance status and perioperative complications.

The number of thoracic surgery cases performed on the robotic platform has increased steadily over the last two decades. An increasing number of surgeons are training on the robotic system, which like any new technique or technology, has a progressive learning curve. Central to establishing a successful robotic program is the development of a dedicated thoracic robotic team that involves anesthesiologists, nurses, and bed-side assistants. With an additional surgeon console, the robot is an excellent platform for teaching. Compared to current methods of video-assisted thoracoscopic surgery (VATS), the robot offers improved wristed motion, a magnified, high definition three-dimensional vision, and greater surgeon control of the operation. These advantages are paired with integrated adjunctive technology such as infrared imaging. For pulmonary resection, these advantages of the robotic platform have translated into several clinical benefits, such as fewer overall complications, reduced pain, shorter length of stay, better postoperative pulmonary function, lower operative blood loss, and a lower 30-day mortality rate compared to open thoracotomy. With increased experience, cases of greater complexity are being performed. This review article details the process of becoming an experienced robotic thoracic surgeon and discusses a series of challenging cases in robotic thoracic surgery that a surgeon may encounter "beyond the learning curve". Nearly all thoracic surgery can now be approached robotically, including sleeve lobectomy, pneumonectomy, resection of large pulmonary and mediastinal masses, decortication, thoracic duct ligation, rib resection, and pulmonary resection after prior chest surgery and/or chemoradiation.

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.

BACKGROUND:Donor to recipient size matching is an essential part of lung transplantation, with significant mismatch leading to worse patient outcomes. The current practice is based on limited data along with broadly accepted themes that have not been articulated in the form of objective and definitive guidelines. The objective of the American Association for Thoracic Surgery (AATS) Clinical Practice Standards Committee (CPSC) expert panel was to develop evidence- and expert-based recommendations for optimal donor to recipient lung allograft size matching based on review of the existing literature. METHODS:The AATS CPSC assembled an expert panel of 18 lung transplant surgeons from 15 centers who developed a consensus document of recommendations. The panel was divided into subgroups covering size-matching in (1) bilateral lung transplantation, (2) single lung transplantation, (3) lobar transplantation, (4) unique situations, and (5) management of complications following severe size mismatch. Following a focused literature review, each subgroup formulated recommendation statements for each subtopic, which were reviewed and further refined using a Delphi process until consensus was achieved on each final statement by the voting group. RESULTS:The expert panel achieved consensus on 20 recommendations for current best practices in donor and recipient size matching. These recommendations include utilization of a ratio of donor-to-recipient predicted total lung capacity between 0.8 to 1.2, with special considerations based on recipient pathology, single lung or lobar transplantation, and anatomic variations such as chest wall abnormalities or significant mediastinal shift. Furthermore, oversized allografts can be reduced in size via non-anatomic or anatomic resection in select cases when required. CONCLUSIONS:Consistent practice guidelines regarding donor to recipient size matching will be helpful and important to achieve optimal outcomes in lung transplantation. The recommendations described here provide guidance for professionals involved in the care of patients with end-stage lung disease considered for transplantation.

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.

The benefits of bilateral lung transplantation (BLT) versus single lung transplantation (SLT) are still debated. One impediment to clinical recommendations is that BLT vs. SLT advantages may vary based on underlying disease. Since both options are clinically tenable in patients with emphysema, we conducted a comprehensive assessment of lung allograft survival in this population. Using U.S. registry data, we studied time to all-cause allograft failure in 8,092 patients 12 years or older transplanted from 2006 to 2022, adjusting for recipient, donor, and transplant factors by inverse propensity weighting. Median allograft survival was 6.6 years in BLT compared to 5.3 years in SLT, a 25% risk-adjusted survival advantage of _0.81.3_1.8 years. Risk-adjusted bilateral survival advantages varied between 0.9 and 2.4 years across eleven subgroups. Median allograft survival in BLT was 1.2 years greater than right SLT and 2.0 years greater than left SLT. During the 16-year study period, allograft survival steadily improved for BLT but not for SLT. Although the 25% BLT survival advantage pre-dated the pandemic, COVID-19 may have contributed to an apparent SLT survival decline. Recognizing the possible influence of residual confounding due to selection biases, these findings may aid offer decision-making when both donor lungs are available.

We describe the case of a 36-year-old woman who underwent redo lung transplantation AFTER a heart-lung transplant 3.5 years prior. The retransplantation was performed through sequential left posterolateral thoracotomy followed by right anterior thoracotomy, without sternal division and without the use of extracorporeal membrane oxygenation or cardiopulmonary bypass support. The patient was found to have undergone an extensive pericardiectomy at the time of the initial heart-lung transplant. The patient recovered uneventfully and complete healing of the airway anastomosis was demonstrated. This novel technique avoids some potential pitfalls of redo lung transplantation after heart-lung transplant.