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Differentiating Imaging Features of Post-lobectomy Right Middle Lobe Torsion

Tamizuddin, Farah; Ocal, Selin; Toussie, Danielle; Azour, Lea; Wickstrom, Maj; Moore, William H; Kent, Amie; Babb, James; Fansiwala, Kush; Flagg, Eric; Ko, Jane P
PURPOSE/OBJECTIVE:The purpose of this study was to identify differences in imaging features between patients with confirmed right middle lobe (RML) torsion compared to those suspected yet without torsion. MATERIALS AND METHODS/METHODS:This retrospective study entailing a search of radiology reports from April 1, 2014, to April 15, 2021, resulted in 52 patients with suspected yet without lobar torsion and 4 with confirmed torsion, supplemented by 2 additional cases before the search period for a total of 6 confirmed cases. Four thoracic radiologists (1 an adjudicator) evaluated chest radiographs and computed tomography (CT) examinations, and Fisher exact and Mann-Whitney tests were used to identify any significant differences in imaging features (P<0.05). RESULTS:A reversed halo sign was more frequent for all readers (P=0.001) in confirmed RML torsion than patients without torsion (83.3% vs. 0% for 3 readers, one the adjudicator). The CT coronal bronchial angle between RML bronchus and bronchus intermedius was larger (P=0.035) in torsion (121.28 degrees) than nontorsion cases (98.26 degrees). Patients with torsion had a higher percentage of ground-glass opacity in the affected lobe (P=0.031). A convex fissure towards the adjacent lobe on CT (P=0.009) and increased lobe volume on CT (P=0.001) occurred more often in confirmed torsion. CONCLUSION/CONCLUSIONS:A reversed halo sign, larger CT coronal bronchial angle, greater proportion of ground-glass opacity, fissural convexity, and larger lobe volume on CT may aid in early recognition of the rare yet highly significant diagnosis of lobar torsion.
PMID: 37732714
ISSN: 1536-0237
CID: 5614062

Beyond the learning curve: a review of complex cases in robotic thoracic surgery

Geraci, Travis C; Scheinerman, Joshua; Chen, David; Kent, Amie; Bizekis, Costas; Cerfolio, Robert J; Zervos, Michael D
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.
PMID: 34795964
ISSN: 2072-1439
CID: 5049642

Perceptions of Training Pathways from Recent Cardiothoracic Surgery Graduates

Ward, Alison; Ranganath, Neel K; Chen, Stacey; Wallen, Tyler; Kent, Amie J; Smith Iii, Deane E; Kon, Zachary N
BACKGROUND:There are three cardiothoracic surgery (CTS) training pathways-general surgery residency followed by a CTS residency of 2-3 years (traditional), 4 years of general surgery and 3 years of CTS residency (4+3), and an integrated 6-year pathway (I-6). The goal of this study was to survey early career cardiothoracic surgeons regarding their training experiences. METHODS:An email-based survey was sent to cardiothoracic surgeons, who graduated between 2012-2017. Data on training pathway specific variables and overall satisfaction were collected. The primary endpoints were career preparation and satisfaction, scored on a scale from 1-100, 100 being the most positive. RESULTS:Four hundred seventy-seven emails were sent, with a response rate of 95/477 (20%). Seventy-six of the respondents (80%) were male; the mean age was 39. Seventy-seven (81.0%) completed a traditional training pathway, 7 (7.4%) completed a 4+3 pathway, and 11 (11.6%) completed an I-6 pathway. Participants felt prepared for practice with a mean response of 79.8 (range 31-100); mean career satisfaction was 87.6.  When asked which pathway respondents would choose in the current era, 52 (54.7%) would choose a traditional pathway, 17 (17.9%) a 4+3 pathway, and 19 (20.0%) an I-6 program; 7 (7.4%) did not respond. Twenty of 72 (27.8%) traditional pathway trained and 18/18(100%) integrated pathway trained surgeons would choose an integrated pathway. CONCLUSIONS:This is the first survey addressing perceptions of training from early-career cardiothoracic surgeons across all training pathways. Data from this study provides insights to better understand how to improve CTS training for the next generation of surgeons.
PMID: 34473044
ISSN: 1522-6662
CID: 5066992

Commentary: Segmentectomies-The Minimally Invasive Sequel May Be Better Than the Original [Editorial]

Chang, Stephanie H; Kent, Amie J
PMID: 33181291
ISSN: 1532-9488
CID: 4734612

Postoperative Air Leaks After Lung Surgery: Predictors, Intraoperative Techniques, and Postoperative Management

Geraci, Travis C; Chang, Stephanie H; Shah, Savan K; Kent, Amie; Cerfolio, Robert J
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.
PMID: 33926669
ISSN: 1558-5069
CID: 4873812

Safety of patients and providers in lung cancer surgery during the COVID-19 pandemic

Chang, Stephanie H; Zervos, Michael; Kent, Amie; Chachoua, Abraham; Bizekis, Costas; Pass, Harvey; Cerfolio, Robert J
OBJECTIVES/OBJECTIVE:The coronavirus disease 2019 (COVID-19) pandemic has resulted in patient reluctance to seek care due to fear of contracting the virus, especially in New York City which was the epicentre during the surge. The primary objectives of this study are to evaluate the safety of patients who have undergone pulmonary resection for lung cancer as well as provider safety, using COVID-19 testing, symptoms and early patient outcomes. METHODS:Patients with confirmed or suspected pulmonary malignancy who underwent resection from 13 March to 4 May 2020 were retrospectively reviewed. RESULTS:Between 13 March and 4 May 2020, 2087 COVID-19 patients were admitted, with a median daily census of 299, to one of our Manhattan campuses (80% of hospital capacity). During this time, 21 patients (median age 72 years) out of 45 eligible surgical candidates underwent pulmonary resection-13 lobectomies, 6 segmentectomies and 2 pneumonectomies were performed by the same providers who were caring for COVID-19 patients. None of the patients developed major complications, 5 had minor complications, and the median length of hospital stay was 2 days. No previously COVID-19-negative patient (n = 20/21) or healthcare provider (n = 9: 3 surgeons, 3 surgical assistants, 3 anaesthesiologists) developed symptoms of or tested positive for COVID-19. CONCLUSIONS:Pulmonary resection for lung cancer is safe in selected patients, even when performed by providers who care for COVID-19 patients in a hospital with a large COVID-19 census. None of our patients or providers developed symptoms of COVID-19 and no patient experienced major morbidity or mortality.
PMID: 33150417
ISSN: 1873-734x
CID: 4656112

Recent trends in additional training beyond cardiothoracic surgery residency [Meeting Abstract]

Ward, A F; Ranganath, N K; Wallen, T J; Chen, S; Kent, A J; Smith, D E; Kon, Z N
Objective: There are 3 cardiothoracic surgery (CTS) training paradigms-general surgery residency followed by CTS residency, 4 years of general surgery +3 years of CTS residency (4 + 3), and an integrated 6-year pathway (I-6). Studies to assess additional training requirements between paradigms have yet to be well described.
Method(s): An anonymous online survey aimed at collecting demographics, training pathway data, and need for additional training from CTS graduates within the past 5 years (2012 to 2017) was developed. An automated online email list was generated and sent out, with 2 reminder emails resent for nonresponders. The survey was open for a 2-month period.
Result(s): Four hundred seventy- seven emails were sent and received with a 20% response rate (95/477). Eighty percent (76/95) were male, mean age 39.4 years old (range 33 to 50). Eighty-one percent (77/95) completed a traditional training pathway, 7.4% (7/95) a 4 + 3, and 11.6% (11/95) an I-6. Twenty-seven percent (26/95) completed additional training-7.7% (2/26) robotics, 19.2% (5/26) additional thoracic, 3.8% (1/26) additional cardiac, 11.5% (3/26) congenital, 42.3% (11/26) transplant/mechanical circulatory support, and 15.4% (4/26) aortic/endovascular. Of those respondents who completed additional training, 73.0% (19/26) had completed a traditional training pathway, 3.8% (1/26) a 4 + 3, and 7.7% (2/26) an I-6. Twenty-four percent (23/95) completed >=10 years of postgraduate training.
Conclusion(s): There are 3 distinct CTS training pathways offering varying lengths of training and specialization. Among survey respondents, 27% completed additional training after completing CTS residency and 24% of respondents took 10 or more years to complete their training
ISSN: 1559-0879
CID: 4806102

Robotic Sleeve Resection of the Airway: Outcomes and Technical Conduct using Video Vignettes

Geraci, Travis C; Ferrari-Light, Dana; Wang, Simeng; Mitzman, Brian; Chang, Stephanie; Kent, Amie; Pass, Harvey; Bizekis, Costas; Zervos, Michael; Cerfolio, Robert J
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.
PMID: 32151577
ISSN: 1552-6259
CID: 4348742

State of the Art: Robotic Bronchoscopy

Kent, Amie J; Byrnes, Kim A; Chang, Stephanie H
Increased detection of lung nodules has led to trying to improve technologies for localization and/or tissue acquisition. Previous bronchoscopic techniques have limitations that have led to further advancements in technology. Robotic bronchoscopy has emerged as new technology for the localization, diagnosis, and potential treatment of lung nodules. The robotic bronchoscopic platform was developed to improve peripheral reach of lung nodules, provide direct continuous visualization of the periphery, and offer more precise control of the instrumentation. We review the progression of bronchoscopy, evolution to the robotic platform and its early outcomes, with considerations for future advancements.
PMID: 32846232
ISSN: 1532-9488
CID: 4614482

Current Novel Advances in Bronchoscopy

Jiang, Jeffrey; Chang, Stephanie H; Kent, Amie J; Geraci, Travis C; Cerfolio, Robert J
Screening for lung cancer has changed substantially in the past decade since The National Lung Screening Trial. The resultant increased discovery of incidental pulmonary nodules has led to a growth in the number of lesions requiring tissue diagnosis. Bronchoscopy is one main modality used to sample lesions, but peripheral lesions remain challenging for bronchoscopic biopsy. Alternatives have included transthoracic biopsy or operative biopsy, which are more invasive and have a higher morbidity than bronchoscopy. In hopes of developing less invasive diagnostic techniques, technologies have come to assist the bronchoscopist in reaching the outer edges of the lung. Navigational bronchoscopy is able to virtually map the lung and direct the biopsy needle where the scope cannot reach. Robotic bronchoscopy platforms have been developed to provide stability and smaller optics to drive deeper into the bronchial tree. While these new systems have not yet proven better outcomes, they may reduce the need for invasive procedures and be valuable armamentarium in diagnosing and treating lung nodules, especially in the periphery.
PMID: 33304923
ISSN: 2296-875x
CID: 5095292