Faculty Bibliography

Pulmonary function testing remains the central determinant of candidacy for pulmonary resection and indicator of perioperative risk. For patients with borderline pulmonary function, exercise testing can help determine surgical candidacy either via stair climbing or by obtaining a maximum oxygen consumption. The Thoracic Revised Cardiac Risk Index should be used to select patients for further cardiac testing. Patient comorbidities, medications, functional limitations, and smoking status are also requisite assessments of the preoperative evaluation that influence perioperative outcomes. A minimally invasive approach to pulmonary resection reduces perioperative risk and may be of most benefit to patients with borderline pulmonary function.

BACKGROUND:There are limited reports on robotic thymectomy for malignant disease. Our objectives are to review our experience and midterm outcomes. METHODS:We reviewed a single-surgeon prospective database for patients who underwent planned robotic resection for malignancy from January 2010 to June 2019. RESULTS:Two hundred thirteen patients underwent resection of an anterior mediastinal mass, all of which were planned for a robotic approach. Of these, 84 (39%) underwent robotic thymectomy for malignant disease. Thymoma was the most common pathology resected (68%). Median tumor size was 4.7 cm (interquartile range, 2.9-6.3), and median operative time was 81.5 minutes (interquartile range, 64-104). All except 1 patient had a complete (R0) resection (98.8%). There were 2 (2.3%) unplanned but elective conversions to open surgery, 1 of which required cardiopulmonary bypass. Median length of stay was 1 day (range, 0-9) with 1 readmission (1.2%). Major morbidity occurred in 3 patients (3.5%), and there were no 30- or 90-day mortalities. In patients with thymoma, follow-up was complete at a median of 32 months (range, 1-98), and 1 patient (1.8%) had an ipsilateral chest recurrence. To date there have been no patient deaths. CONCLUSIONS:Robotic thymectomy for patients with malignant disease is safe with excellent perioperative outcomes. A robotic approach achieves a high rate of complete R0 resection, even for larger tumors. For patients with thymoma local recurrence is low after midterm follow-up, but longer-term analysis is needed to determine oncologic durability.

Postoperative air leak is one of the most common complications after pulmonary resection and contributes to postoperative pain, complications, and increased hospital length of stay. Several risk factors, including both patient and surgical characteristics, increase the frequency of air leaks. Appropriate intraoperative tissue handling is the most important surgical technique to reduce air leaks. Digital drainage systems have improved the management of postoperative air leak via objective data, portability, and ease of use in the outpatient setting. Several treatment strategies have been used to address prolonged air leak, including pleurodesis, blood patch, placement of endobronchial valves, and reoperative surgery.

Cutibacterium acnes is an anaerobic bacterium commonly thought of as a culture contaminant rather than a pathogen. We present a case of Cutibacterium acnes pericarditis in a 22-year-old immunocompetent woman managed with surgical pericardial window and a 4-week course of penicillin G and review related literature on Cutibacterium acnes pericarditis.

The adult presentation of a mediastinal arteriovenous malformation is rare. Resection of these lesions are commonly performed via open thoracotomy, with a risk of bleeding from multiple feeding vessels. This report describes a robotic resection of a mediastinal arteriovenous malformation in a 55-year-old man.

Patients with severe coronavirus disease 2019 from infection with severe acute respiratory syndrome coronavirus 2 mount a profound inflammatory response and are predisposed to thrombotic complications. Pulmonary vein thrombosis is a rare disease process resulting in pulmonary congestion, infarction, and potential mortality. This report describes a patient with coronavirus disease 2019 requiring venovenous extracorporeal membrane oxygenation for hypoxic respiratory failure who developed hemorrhagic infarction of the right lower lobe. During emergency exploration the patient was found to have a right inferior vein thrombosis and marked lobar hemorrhage mandating lobectomy.

BACKGROUND:Coronavirus disease 2019 (Covid-19) remains a worldwide pandemic with a high mortality rate among patients requiring mechanical ventilation. The limited data that exists regarding the utility of extracorporeal membrane oxygenation (ECMO) in these critically ill patients shows poor overall outcomes. This paper describes our institutional practice regarding the application and management of ECMO support for patients with Covid-19 and reports promising early outcomes. METHODS:>60 mmHg with no life-limiting comorbidities. Patients were cannulated at bedside and were managed with protective lung ventilation, early tracheostomy, bronchoscopies and proning as clinically indicated. RESULTS:Of 321 patients intubated for Covid-19, 77 (24%) patients were evaluated for ECMO support with 27 (8.4%) patients placed on ECMO. All patients were placed on veno-venous ECMO. Current survival is 96.3%, with only one mortality to date in over 350 days of total ECMO support. Thirteen patients (48.1%) remain on ECMO support, while 13 patients (48.1%) have been successfully decannulated. Seven patients (25.9%) have been discharged from the hospital. Six patients (22.2%) remain in the hospital of which four are on room-air. No healthcare workers that participated in ECMO cannulation developed symptoms of or tested positive for Covid-19. CONCLUSIONS:The early outcomes presented here suggest that the judicious use of ECMO support in severe Covid-19 may be clinically beneficial.

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.