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.

Objectives/UNASSIGNED:Proning patients with acute respiratory distress syndrome (ARDS) has been associated with increased survival, though little data exists evaluating the safety and feasibility of proning ARDS patients on extracorporeal membrane oxygenation (ECMO). Methods/UNASSIGNED:, 2020 was performed. All proning events were evaluated for complications, as well as change in compliance, sweep, oxygenation and flow. The primary outcome of this study was the rate major morbidity associated with proning while on ECMO. Results/UNASSIGNED:of 86 pre to 103 post (p<0.0001). Mean ECMO flow was unchanged. Conclusions/UNASSIGNED:Proning in patients with ARDS on ECMO is safe with an associated improvement in lung mechanics. With careful planning and coordination, these data support the practice of appropriately proning patients with severe ARDS, even if they are on ECMO.

BACKGROUND/UNASSIGNED:The Thoraguard Surgical Drainage System is a novel device for drainage of air and fluid after cardiothoracic surgery. METHODS/UNASSIGNED:A three-part study was conducted: a prospective observational safety and feasibility study, a retrospective comparison of patients managed with an analogue drainage system, and a clinician user-feedback survey. RESULTS/UNASSIGNED:2.8 days (IQR 1-3) (P=0.004). Compared to an analogue system, the Thoraguard system had superior user-reported ability to detect air-leaks (17/23, 74%), better ease of patient ambulation (14/23, 61%), and better display of clinically relevant information (22/23, 96%). CONCLUSIONS/UNASSIGNED:The Thoraguard Surgical Drainage System provides safe and effective drainage post pulmonary resection. Compared to an analogue system, the Thoraguard system detected a higher number of air leaks and was associated with decreased chest tube duration and hospital length of stay. User survey data reported superior air leak detection, display of clinical data, and ease of use of the Thoraguard system.

BACKGROUND:Our objective was to report the incidence, management, and outcomes of patients who developed a secondary pneumothorax while admitted for coronavirus disease 2019 (COVID-19). METHODS:A single-institution, retrospective review of patients admitted for COVID-19 with a diagnosis of pneumothorax between March 1, 2020, and April 30, 2020, was performed. The primary assessment was the incidence of pneumothorax. Secondarily, we analyzed clinical outcomes of patients requiring tube thoracostomy, including those requiring operative intervention. RESULTS:From March 1, 2020, to April 30, 2020, 118 of 1595 patients (7.4%) admitted for COVID-19 developed a pneumothorax. Of these, 92 (5.8%) required tube thoracostomy drainage for a median of 12 days (interquartile range 5-25 days). The majority of patients (95 of 118, 80.5%) were on mechanical ventilation at the time of pneumothorax, 17 (14.4%) were iatrogenic, and 25 patients (21.2%) demonstrated tension physiology. Placement of a large-bore chest tube (20 F or greater) was associated with fewer tube-related complications than a small-bore tube (14 F or less) (14 vs 26 events, P = .011). Six patients with pneumothorax (5.1%) required operative management for a persistent alveolar-pleural fistula. In patients with pneumothorax, median hospital stay was 36 days (interquartile range 20-63 days) and in-hospital mortality was significantly higher than for those without pneumothorax (58% vs 13%, P < .001). CONCLUSIONS:The incidence of secondary pneumothorax in patients admitted for COVID-19 is 7.4%, most commonly occurring in patients requiring mechanical ventilation, and is associated with an in-hospital mortality rate of 58%. Placement of large-bore chest tubes is associated with fewer complications than small-bore tubes.

BACKGROUND:Severe coronavirus disease 2019 (COVID-19) can cause acute respiratory failure requiring mechanical ventilation. Venovenous (VV) extracorporeal membrane oxygenation (ECMO) has been used in patients in whom conventional mechanical ventilatory support has failed. To date, published data have focused on survival from ECMO and survival to discharge. In addition to survival to discharge, this study reports 1-year follow-up data for patients who were successfully discharged from the hospital. METHODS:A single-institution, retrospective review of all patients with severe COVID-19 who were cannulated for VV-ECMO between March 10, 2020 and May 1, 2020 was performed. A multidisciplinary ECMO team evaluated, selected, and managed patients with ECMO support. The primary outcome of this study was survival to discharge. Available 1-year follow-up data are also reported. RESULTS:A total of 30 patients were supported with VV-ECMO, and 27 patients (90%) survived to discharge. All patients were discharged home or to acute rehabilitation on room air, except for 1 patient (3.7%), who required supplemental oxygen therapy. At a median follow-up of 10.8 months (interquartile range [IQR], 8.9-14.4 months) since ECMO cannulation, survival was 86.7%, including 1 patient who underwent lung transplantation. Of the patients discharged from the hospital, 44.4% (12/27) had pulmonary function testing, with a median percent predicted forced expiratory volume of 100% (IQR, 91%-110%). For survivors, a 6-minute walk test was performed in 59.3% (16/27), with a median value of 350 m (IQR, 286-379 m). CONCLUSIONS:A well-defined patient selection and management strategy of VV-ECMO support in patients with severe COVID-19 resulted in exceptional survival to discharge that was sustained at 1-year after ECMO cannulation.

Background: The effect of prolonged allograft ischemic time on lung transplant outcomes remains controversial, with most studies associating it with increased mortality, but this effect is partly mitigated by center volume. This study sought to evaluate the mechanism of these findings and clarify the impact of ischemic time on short-term outcomes in a national sample. Methods: Data on lung transplants (January 2010-Janary 2017) were extracted from the Scientific Registry of Transplant Recipients database. Ischemic time was dichotomized as prolonged ischemic time (PIT) or no PIT (N-PIT) at 6 hours. High-volume centers were defined as the top quintile. The primary outcome was 30-day, 1-year, and 3-year mortality; secondary outcomes included in-hospital complications and 72-hour oxygenation. Results: Among 11,809 records, there were significant differences between PIT and N-PIT recipients by demographics, lung allocation score, and donor organ metrics. In a 1:1 propensity score"“matched cohort (n = 6422), PIT recipients had reduced survival compared with N-PIT at 3 years (66.5% vs 68.8%, P =.031). On multivariable analysis, this effect persisted among low-volume but not high-volume centers. PIT recipients were more likely to require reintubation, prolonged (>5 days) mechanical ventilation, hemodialysis, longer stay, and acute rejection (all P <.01). Except for reintubation, these disparities were present at both high- and low-volume centers independently. Ischemic time had no effect on 72-hour oxygenation. Conclusions: PIT remains associated with higher rates of postoperative complications and reduced short-term survival. While center volume ameliorated the survival impact, this was not achieved by reducing postoperative complications. Further research is warranted before broadening ischemic time thresholds among low-volume centers.