Background
We investigate the incidence and risk factors for post-operative outcomes including chyle leak following minimally invasive esophagectomy (MIE).
Methods
Patients undergoing MIE from May ...2016 until August 2020 were prospectively followed. Outcomes of robotic and video-assisted thoracoscopic surgery (VATS) esophagectomy were analyzed.
Results
347 esophagectomies were performed: 70 cases were done robotically by 2 surgeons and 277 by VATS by 14 surgeons. Patients had similar demographics, surgical technique, length of stay (LOS), and re-operation rates. Overall complication rates between robotic and VATS MIE were statistically similar (61% vs. 50%;
p
= 0.082). The majority of complications for either VATS (41.5%) or robotic-assisted minimally invasive esophagectomy (RAMIE) (51.4%) were grade II. Nineteen patients developed a chyle leak. Patients with a chyle leak were similar in age, gender, and hospital LOS (all
p
> 0.05), but were more likely to undergo a three-hole or robotic esophagectomy (both
p
< 0.05) as well as have higher rehabilitation requirements on discharge (26% vs. 10%;
p
= 0.05). Among the two surgeons who each performed > 20 robotic esophagectomies (
n
= 70), nine chyle leaks occurred. Rates varied by surgeon (7 vs. 2;
p
= 0.003). Lower leak rates occurred in the surgeon with more robotic esophagectomy experience (
n
= 47 vs. 23). Patients were similar in age, and gender (
p
> 0.05), but those with a chyle leak were more likely to undergo three-hole esophagectomies, prophylactic thoracic duction ligations, undergo the abdominal portion via laparotomy, and not have a prophylactic omental flap (all
p
< 0.05).
Conclusion
Robotic and VATS esophagectomy have similar rates of re-operation, length of stay, discharge needs and complications. Differences in outcomes between VATS and Robotic esophagectomy appears to be related to surgeon experience with the robot but may also be associated with techniques such as anastomotic height, omental flap utilization and performance of laparoscopy.
Background Mechanical staplers are widely employed in minimally invasive anatomic lung resections, but have limitations when managing smaller pulmonary arterial and venous branches. Published data is ...lacking regarding the safety and efficacy of pulmonary vessel ligation using ultrasonic shears. We describe a single-surgeon experience employing ultrasonic shears for the ligation of pulmonary vasculature during lobectomy and segmentectomy, primarily in the setting of video-assisted thoracic surgery (VATS) resection. Methods A retrospective chart review was conducted for all patients, who underwent anatomic resection, between 2008 and 2014. Charts were divided into 2 groups based on method of ligation (energy based or conventional). Dictated operative reports were reviewed and patient demographics, tumor characteristics, and complications were recorded. Results Ultrasonic shears were used for pulmonary vessel ligation (5 to 6 mm) in 82 of 283 anatomic resections. A total of 118 vessels were ligated with ultrasonic shears. The majority of patients (83%) in the energy-based ligation group underwent VATS resection. There were fewer complications in the energy-based ligation group (26% vs 38%; p = 0.05); however, rates of intraoperative transfusion, prolonged air leak, empyema, and return to the operating room were similar across the 2 groups, and no statistically significant difference was found. There were no postoperative complications directly attributable to ultrasonic vessel ligation. Conclusions Energy-based ligation of small-diameter pulmonary vessels is a safe and useful adjunct in anatomic VATS resection and a viable alternative to mechanical stapling. Its narrow profile and thin blades make it ideal for ligation of pulmonary vasculature, particularly where the size and necessary clearance of mechanical staplers prohibit safe dissection.
Thoracic epidural analgesia (TEA) and liposomal bupivacaine (LB) are two methods used for postoperative pain control after thoracic surgery. Some studies have compared LB to standard bupivacaine. ...However, data comparing the outcomes of LB to TEA after minimally invasive lung resection is limited. Therefore, the objective of our study was to compare postoperative pain, opioid usage, and outcomes between patients who received TEA
. LB.
We conducted a retrospective chart review of patients who underwent minimally invasive lung resections over an 8-month period. Intraoperatively, patients received either LB under direct vision or a TEA. Pain scores were obtained in the post-anesthesia care unit (PACU) and at 12, 24, and 48 hours postoperatively. Morphine milligram equivalents (MMEs) were calculated at 24 and 48 hours postoperatively. Postoperative outcomes were then compared between groups.
In total, 391 patients underwent minimally invasive lung resection: 236 (60%) wedge resections, 51 (13%) segmentectomies, and 104 (27%) lobectomies. Of these, 326 (83%) received LB intraoperatively. Fewer patients in the LB group experienced postoperative complications (18%
. 34%, P=0.004). LB patients also had lower median pain scores at 24 (P=0.03) and 48 hours (P=0.001) postoperatively. There was no difference in MMEs at 24 hours (P=0.49). However, at 48 hours, patients who received LB required less narcotics (P=0.02). Median hospital length of stay (LOS) was significantly shorter in patients who received LB (2
. 4 days, P<0.001). On multivariable analysis, increasing age, postoperative complications, and use of TEA were independently associated with a longer hospital LOS.
Compared to TEA, LB intercostal block placed under direct vision reduced morphine use 48 hours after thoracic surgery. It was also associated with fewer postoperative complications and shorter median hospital LOS. LB is a good alternative to TEA for pain management after minimally invasive lung resection.
Reported advantages to robotic thoracic surgery include shorter length of stay (LOS), improved lymphadenectomy, and decreased complications. It is uncertain if these benefits occur when introducing ...robotics into a well-established video-assisted thoracoscopy (VATS) practice. We compared the two approaches to investigate these advantages.
IRB approval was obtained for this project. Patients who underwent segmentectomy or lobectomy from May 2016–December 2018 were propensity-matched 2: 1 (VATS: robotic) and compared using weighted logistic regression with age, gender, Charlson Comorbidity Index, surgery type, stage, Exparel, and epidural as covariates. Complication rates, operation times, number of sampled lymph nodes, pain level, disposition, and LOS were compared using Wilcoxon rank-sum and with Rao-Scott Chi-squared tests.
213 patients (142 VATS and 71 robot) were matched. Duration of robotic cases was longer than VATS (median 186 min (IQR 78) vs. 164 min (IQR 78.75); p < 0.001). Significantly more lymph nodes (median 11 (IQR 7.50) vs. 8 (IQR 7.00); p = 0.004) and stations were sampled (median 4 (IQR 2.00) vs. 3 (IQR 1.00); p < 0.001) with the robot. Interestingly, robotic resections had higher 72-hour pain scores (median 3 (IQR 3.25) vs. 2 (IQR 3.50); p = 0.04) and 48-hour opioid usage (median 37.50 morphine milligram equivalents (MME) (IQR 45.50) vs. 22.50 MME (IQR 37.50); p = 0.01). Morbidity, LOS, and disposition were similar (all p > 0.05).
The robotic approach facilitates better lymph node sampling, even in an established VATS practice.
•Benefits of robotic surgery are seen even in well-established VATS practice.•Robotic-assisted lung resection results in better lymph node sampling.•Patients with robotic resection had higher 72-hour pain scores and 48-hour narcotic use.•Morbidity and length of stay were equivalent between the two approaches.
Uncertainty surrounds the safety and efficacy of pneumonectomy in the setting of induction chemoradiation for non-small cell lung cancer (NSCLC). We sought to evaluate fifteen years of experience ...with pneumonectomy with and without induction therapy.
Over a 15-year period 1999-2014, data were extracted from medical records of patients undergoing pneumonectomy for NSCLC. Primary outcomes were 5-year overall survival and mortality at 30, 60 and 90 days following operation. Morbidity data was also reviewed. Statistical comparisons were performed using the Chi-Square test. Kaplan-Meier curves were compared using the log rank test. Significance was defined as a P value less than 0.05. Patients with a prior cancer history, bilateral lung nodules and oligometastatic disease at presentation were excluded.
After exclusion criteria were applied, 240 patients were analyzed and 137 (57%) underwent induction therapy prior to pneumonectomy. Five-year overall survival was 38.5%. Mortality at 90 days was 7.94%. There was no statistically significant difference in perioperative mortality with the addition of induction therapy. In fact, in the subset of patients with N2 disease (n=65), induction therapy was associated with improved 5-year overall survival (10.7%
32.7%, P=0.014). Thirty-five percent of patients with N2 disease exhibited a complete response in the nodal basin following induction therapy; however, this did not confer a statistically significant overall or disease-free survival benefit.
Pneumonectomy can safely be performed in the setting of induction chemoradiation. In patients with N2 disease, induction therapy may confer a survival benefit when the surgery can be done with limited morbidity and mortality.
Esophagectomy is associated with major morbidity. In this study we sought to assess the learning curve of minimally invasive Ivor Lewis esophagectomy (MIILE) and to evaluate perioperative outcomes, ...including anastomotic leak and hospital readmission, as a function of graduated surgeon experience.
Data were extracted from the electronic medical records of patients who underwent MIILE, performed by a single surgeon over an 8-year period (2009-2017). Primary outcomes were 5-year overall survival, postoperative complications, and 90-day readmission rates. Surgeon experience was divided into 4 quartiles, representing graduated experience. Statistical analysis was performed using univariate and multivariate logistic regression, whereas Kaplan–Meier estimators were used to assess survival outcomes.
A total of 170 patients underwent MIILE and were analyzed after exclusion criteria were applied. Five-year overall survival was 50.1% (95% confidence interval, 39.7%-63.2%). Mortality at 90 days was 3.9% (95% confidence interval, 0.8%-6.9%). Major complications occurred in 25.3% (n = 43) and 25.9% (n = 44) were readmitted to the hospital within 90 days after surgery. Conversion to open surgery, anastomotic leaks, and readmissions decreased over time.
MIILE can be performed safely and effectively with improving results as the surgeon's experience evolves.
Chest roentgenograms after chest tube removal are common practice in postoperative thoracic surgery patients. Whether these roentgenograms change clinical management is debatable. We investigated ...prevalence and management of post-pull pneumothoraces after lung resection.
Patients undergoing minimally invasive wedge resections, segmentectomies, and lobectomies between March 2018 and September 2018 were retrospectively reviewed. Baseline factors, operative technique, chest tube management, and outcomes after post-pull chest roentgenograms, and factors associated with post-pull pneumothoraces were analyzed.
The study analyzed 200 consecutive patients comprising 117 wedge resections (59%), 24 segmentectomies (12%), and 59 lobectomies (30%). Wedge resections compared with segmentectomy or lobectomy had lower rates of chest tube use, drain duration, air leaks, and need for a clamp trial, with Blake drains most often removed last compared with segmentectomy or lobectomy (all P < .001). Post-pull pneumothoraces, which were largely small/tiny/trace (96%), occurred in 110 patients (55%). Five patients experienced symptoms, and no patients required intervention. Resection type was associated with the pneumothorax rate, need for additional imaging, and discharge timing (all P < .05). Those with pneumothoraces compared with those without differed in type of resection and chest drain, presence of air leak within 24 hours of removal, need for clamp trial, order of tube removal, and hospital length of stay (all P < .05). Multivariable regression showed only clamp trial was associated with post-pull pneumothorax development (odds ratio, 2.48; 95% CI, 1.13-5.45; P = .024).
Although routine use of post-pull chest roentgenograms identified a high prevalence of pneumothorax, no intervention was required. Our study demonstrates post-pull imaging may not be indicated in asymptomatic patients without prior air leak or clamp trial.
The Surveillance, Epidemiology and End Results (SEER) and the National Cancer Database (NCDB) are databases for cancer analysis that may be subject to error in data reporting. This study examined the ...rates and impact of discordant data for non-small cell lung cancer.
NCDB and SEER were queried for non-small cell lung cancer pathologic tumor, node, metastasis data (NCDB) or “derived” data (SEER). Discordancy between descriptors with stage and impact of outlier data were analyzed.
Incomplete staging was noted in 71.5% of the NCDB and 10.3% of SEER patients. A total of 174 829 patients from the NCDB and 117 114 from SEER were analyzed. The NCDB had 97 cases with ≥20 positive lymph nodes recorded vs 27 in SEER (P < .001). Mean and median sampled lymph nodes were skewed with inclusion of these data points (P < .001). The NCDB misclassified 0.99% tumors >5 cm as stage I vs 0.04% in SEER (P < .001). The NCDB misstaged positive lymph nodes as pathologic N0 (0.59%) or stage 0 or stage I (0.65%). The NCDB misclassified pathologic N1 as lower than stage II (0.91%) or N2 as lower than stage III (0.36%). The NCDB misclassified stage I with documentation of pathologic N1 or N3 disease (0.24%) or stage II with evidence of N2 or N3 disease (0.50%). The NCDB misclassified pathologic M1 as pathologic stage <IV in 0.9% of cases and misclassified 19.8% of stage IV as pathologic M0. SEER collaborative staging had no discordance (P < .001).
The NCDB and SEER are 2 powerful cancer databases. However, the cumulative discordancy rate was 4.9% for the NCDB and 0.008% for SEER, with more misstaging and outliers in the NCDB.
To determine associations between surgeon volume and esophagectomy outcomes at a high-volume institution. All esophagectomies for esophageal cancer at our institution from August 2005 to August 2019 ...were reviewed. Cases were divided by surgeon into low, <7 cases/year, vs high volume, ≥7 cases/year, based on Leapfrog Group recommendations. Surgeons remained ‘high-volume’ after one year of ≥7 cases. Demographics, comorbidities, course of care, and long-term outcomes were compared. In total, 1029 cases were evaluated; 120 performed by low-volume surgeons vs 909 by high-volume surgeons. Never-smokers, atrial fibrillation, and clinical Stage IVa patients were associated with high-volume surgeons. Other demographics were similar. Low-volume surgeons did more open cases, 45.8% vs 14.5%, P < 0.01. Low-volume surgeons had more complications than high-volume surgeons (71.7% vs 57.6%, P < 0.01), specifically Grade II and III (59.2% vs 46.8%, P = 0.01, and 44.2% vs 27.0%, P <0.01). No differences were seen in anastomotic leak rate, 90-day mortality, recurrences, 5-year overall survival (46.7% low-volume vs 49.3% high-volume, P = 0.64), or 5-year disease-free survival (35.7% low-volume vs 42.2% high-volume, P = 0.27). In multivariable logistic regression for Grade III or higher complications, high-volume surgeons had an odds ratio of 0.56 (95% confidence interval 0.36–0.87) for complications. Our study found higher rates of open esophagectomies and complications in low-volume esophagectomy surgeons compared to high-volume surgeons at the same, high-volume institution. However, low-volume surgeons were not associated with worse survival outcomes compared to high-volume surgeons. Low-volume esophagectomy surgeons may benefit from mentoring and support to improve perioperative outcomes; these efforts are underway at our institution.
Summary of ‘Short and Long-term Outcomes Among High-Volume vs Low-Volume Esophagectomy Surgeons at A High-Volume Center’. Display omitted
To determine if wedge resection is equivalent to lobectomy for Stage I Non-Small Cell Lung Cancer (NSCLC) and to evaluate the impact of radiologic and pathologic variables not available in large ...national databases. Records were reviewed from 2010–2016 for patients with pathologic Stage I NSCLC who underwent wedge resection or lobectomy. Propensity score matching was performed on pre-operative variables and patients with ≥1 lymph node removed. Clinical variables were compared. Kaplan-Meier curves and multivariable Cox proportional hazard models for 5-year overall survival (OS), disease-free (DFS), and locoregional-recurrence-free survival (LRFS) were created. A total of 1086 patients met inclusion criteria; 391 lobectomies and 695 wedge resections. Propensity score matching yielded 167 pairs of lobectomy and wedge resection patients. Complications were fewer for wedge resections than lobectomies, 19.2% for wedge resection patients vs 34.1% for lobectomy patients, p < 0.01. OS was equivalent between groups, 86.2% for lobectomy patients vs 83.4% for wedge resection patients p = 0.47. DFS was similar, 79.0% for lobectomy patients vs 72.5% for wedge resection patients p = 0.10. Overall LRFS was worse in wedge resection patients vs lobectomy patients, 82.0% vs 93.4% p < 0.01. However, in the matched wedge resection patients with a margin >10 mm the LRFS was equal to that of lobectomy patients, 86.4% for wedge resection patients vs 91.8% for lobectomy patients p = 0.140. Patients with Stage I NSCLC can experience similar OS, DFS, and LRFS with wedge resection as compared to lobectomy, when wedge resection margins are >10 mm and appropriate lymph node dissection is performed.
Detailed Summary of Findings Comparing Wedge Resection to Lobectomy for Early Stage Non-Small Cell Lung Cancer. Display omitted
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