Background Data from selected centers show that robotic lobectomy is safe and effective and has 30-day mortality comparable to that of video-assisted thoracoscopic surgery (VATS). However, widespread ...adoption of robotic lobectomy is controversial. We used The Society of Thoracic Surgeons General Thoracic Surgery (STS-GTS) Database to evaluate quality metrics for these 2 minimally invasive lobectomy techniques. Methods A database query for primary clinical stage I or stage II non-small cell lung cancer (NSCLC) at high-volume centers from 2009 to 2013 identified 1,220 robotic lobectomies and 12,378 VATS procedures. Quality metrics evaluated included operative morbidity, 30-day mortality, and nodal upstaging, defined as cN0 to pN1. Multivariable logistic regression was used to evaluate nodal upstaging. Results Patients undergoing robotic lobectomy were older, less active, and less likely to be an ever smoker and had higher body mass index (BMI) (all p < 0.05). They were also more likely to have coronary heart disease or hypertension (all p < 0.001) and to have had preoperative mediastinal staging ( p < 0.0001). Robotic lobectomy operative times were longer (median 186 versus 173 minutes; p < 0.001); all other operative measurements were similar. All postoperative outcomes were similar, including complications and 30-day mortality (robotic lobectomy, 0.6% versus VATS, 0.8%; p = 0.4). Median length of stay was 4 days for both, but a higher proportion of patients undergoing robotic lobectomy had hospital stays less than 4 days (48% versus 39%; p < 0.001). Nodal upstaging overall was similar ( p = 0.6) but with trends favoring VATS in the cT1b group and robotic lobectomy in the cT2a group. Conclusions Patients undergoing robotic lobectomy had more comorbidities and robotic lobectomy operative times were longer, but quality outcome measures, including complications, hospital stay, 30-day mortality, and nodal upstaging, suggest that robotic lobectomy and VATS are equivalent.
Background Pathologic nodal upstaging can be considered a surrogate for completeness of nodal evaluation and quality of surgery. We sought to determine the rate of nodal upstaging and disease-free ...and overall survival with a robotic approach in clinical stage I NSCLC. Methods We retrospectively reviewed patients with clinical stage I NSCLC after robotic lobectomy or segmentectomy at three centers from 2009 to 2012. Data were collected primarily based on Society of Thoracic Surgeons database elements. Results Robotic anatomic lung resection was performed in 302 patients. The majority were right sided (192; 63.6%) and of the upper lobe (192; 63.6%). Most were clinical stage IA (237; 78.5%). Pathologic nodal upstaging occurred in 33 patients (10.9% pN1 20, 6.6%; pN2 13, 4.3%). Hilar (pN1) upstaging occurred in 3.5%, 8.6%, and 10.8%, respectively, for cT1a, cT1b, and cT2a tumors. Comparatively, historic hilar upstage rates of video-assisted thoracoscopic surgery (VATS) versus thoracotomy for cT1a, cT1b, and cT2a were 5.2%, 7.1%, and 5.7%, versus 7.4%, 8.8%, and 11.5%, respectively. Median follow-up was 12.3 months (range, 0 to 49). Forty patients (13.2%) had disease recurrence (local 11, 3.6%; regional 7, 2.3%; distant 22, 7.3%). The 2-year overall survival was 87.6%, and the disease-free survival was 70.2%. Conclusions The rate of nodal upstaging for robotic resection appears to be superior to VATS and similar to thoracotomy data when analyzed by clinical T stage. Both disease-free and overall survival were comparable to recent VATS and thoracotomy data. A larger series of matched open, VATS and robotic approaches is necessary.
Background Knowledge about the cost of open, video-assisted thoracoscopic (VATS), or robotic lung resection and drivers of cost is crucial as the cost of care comes under scrutiny. This study aims to ...define the cost of anatomic lung resection and evaluate potential cost-saving measures. Methods A retrospective review of patients who had anatomic resection for early stage lung cancer, carcinoid, or metastatic foci between 2008 and 2012 was performed. Direct hospital cost data were collected from 10 categories. Capital depreciation was separated for the robotic and VATS cases. Key costs were varied in a sensitivity analysis. Results In all, 184 consecutive patients were included: 69 open, 57 robotic, and 58 VATS. Comorbidities and complication rates were similar. Operative time was statistically different among the three modalities, but length of stay was not. There was no statistically significant difference in overall cost between VATS and open cases (Δ = $1,207) or open and robotic cases (Δ = $1,975). Robotic cases cost $3,182 more than VATS ( p < 0.001) owing to the cost of robotic-specific supplies and depreciation. The main opportunities to reduce cost in open cases were the intensive care unit, respiratory therapy, and laboratories. Lowering operating time and supply costs were targets for VATS and robotic cases. Conclusions VATS is the least expensive surgical approach. Robotic cases must be shorter in operative time or reduce supply costs, or both, to be competitive. Lessening operating time, eradicating unnecessary laboratory work, and minimizing intensive care unit stays will help decrease direct hospital costs.
Background Robotic lung resection is gaining popularity despite limited published evidence. Comparative studies are needed to provide information about the safety and effectiveness of robotic ...resection. Therefore, we compared our initial experience with robotic anatomic resection to our most recent video-assisted thoracoscopic surgery (VATS) cases. Methods A case-control analysis of consecutive anatomic lung resections by robot or VATS from 2009 through 2011 was performed. Results In the robotic group, 52 resections were attempted. Three conversions and 3 wedges were excluded, leaving 40 lobectomies, 5 segments, and 1 conversion to VATS. In the VATS group, 35 resections were attempted with 1 conversion. The distribution of resected lobes or segments and demographics was similar. Clinical outcomes between robotics and VATS were similar in tumor size (2.8 versus 2.3 cm), operative time (213 versus 208 minutes), blood loss (153 versus 134 mL), intensive care unit stay (0.9 versus 0.6 days), and length of stay (4.0 versus 4.5 days). There was no operative mortality. Major (n = 8; 17%) and minor morbidity (n = 12; 26%) with robotics was similar to VATS. The percentage of expected nodal stations sampled was similar. The duration of narcotic use after discharge ( p = 0.039) and the time to return to usual activities ( p = 0.001) was shorter in the robotic group. Conclusions Early experience with robotic resection resulted in similar outcomes compared with mature VATS cases. A potential benefit of robotics may relate to postoperative pain reduction and earlier return to usual activities. Robotic lung resection should be studied further in selected centers and compared with VATS in a randomized fashion to better define its potential advantages and disadvantages.
Background The International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society classification of pulmonary adenocarcinomas identifies indolent lesions ...associated with low recurrence, superior survival, and the potential for sublobar resection. The distinction, however, is determined on the pathologic evaluation, limiting preoperative surgical planning. We sought to determine whether preoperative computed tomography (CT) characteristics could guide decisions about the extent of the pulmonary resection. Methods We reviewed the preoperative CT scans for 136 patients identified to have adenocarcinomas with lepidic features on the final pathologic evaluation. The solid component on CT was substituted for the invasive component, and patients were radiologically classified as adenocarcinoma in situ, 3 cm or less with no solid component; minimally invasive adenocarcinoma, 3 cm or less with a solid component of 5 mm or less; or invasive adenocarcinoma, exceeding 3 cm or solid component exceeding 5 mm, or both. Analysis of variance, t test, χ2 test, and Kaplan-Meier methods were used for analysis. Results The radiologic classification identified 35 adenocarcinomas in situ (26%) and 12 minimally invasive (9%) and 89 invasive adenocarcinoma (65%) lesions. At a 32-month median follow-up, patient outcomes associated with the radiologic classification were similar to the pathologic-based classification: the radiologic classification identified 14 of 16 patients with recurrent disease and all 6 who died of lung cancer. In addition, patients with radiologic adenocarcinoma in situ and minimally invasive adenocarcinoma who underwent sublobar resections had no recurrence and 100% disease-free and overall survival at 5 years. Conclusions The radiologic classification of patients with lepidic adenocarcinomas is associated with similar oncologic and survival outcomes compared with the pathologic classification and may guide decision making in the approach to surgical resection.
Background In 2012 the United States Food and Drug Administration approved implantation of a magnetic sphincter to augment the native reflux barrier based on single-series data. We sought to compare ...our initial experience with magnetic sphincter augmentation (MSA) with laparoscopic Nissen fundoplication (LNF). Methods A retrospective case-control study was performed of consecutive patients undergoing either procedure who had chronic gastrointestinal esophageal disease (GERD) and a hiatal hernia of less than 3 cm. Results Sixty-six patients underwent operations (34 MSA and 32 LNF). The groups were similar in reflux characteristics and hernia size. Operative time was longer for LNF (118 vs 73 min) and resulted in 1 return to the operating room and 1 readmission. Preoperative symptoms were abolished in both groups. At 6 months or longer postoperatively, scores on the Gastroesophageal Reflux Disease Health Related Quality of Life scale improved from 20.6 to 5.0 for MSA vs 22.8 to 5.1 for LNF. Postoperative DeMeester scores (14.2 vs 5.1, p = 0.0001) and the percentage of time pH was less than 4 (4.6 vs 1.1; p = 0.0001) were normalized in both groups but statistically different. MSA resulted in improved gassy and bloated feelings (1.32 vs 2.36; p = 0.59) and enabled belching in 67% compared with none of the LNFs. Conclusions MSA results in similar objective control of GERD, symptom resolution, and improved quality of life compared with LNF. MSA seems to restore a more physiologic sphincter that allows physiologic reflux, facilitates belching, and creates less bloating and flatulence. This device has the potential to allow individualized treatment of patients with GERD and increase the surgical treatment of GERD.
Background A malignant pleural effusion (MPE) is a late complication of malignancy that affects respiratory function and quality of life. A strategy for palliation of the symptoms caused by MPE ...should permanently control fluid accumulation, preclude any need for reintervention, and limit hospital length of stay (LOS). We compared video-assisted thorascopic (VATS) talc insufflation with placement of a tunneled pleural catheter (TPC) to assess which intervention better met these palliative goals. Methods We conducted a retrospective chart review of consecutive MPE at a single institution from 2005 through June 2011. Primary a priori outcomes were reintervention in the ipsilateral hemithorax, postprocedure LOS, and overall LOS. Results One hundred nine patients with MPE were identified. Fifty-nine patients (54%) had TPC placed, and 50 (46%) were treated with VATS talc. Patients who underwent TPC placement had significantly fewer reinterventions for recurrent ipsilateral effusions than patients treated with VATS talc (TPC 2% 1 of 59, talc 16% 8 of 50, p = 0.01). Patients treated with TPC had significantly shorter overall LOS (TPC LOS mean 7 days, mode 1 day; talc mean 8 day, mode 4 days, p = 0.006) and postprocedure LOS (TPC post-procedure LOS mean 3 days, mode 0 days; talc mean 6 days, mode 3 days, p < 0.001). Type of procedure was not associated with differences in complication rate (TPC 5% 3 of 59, talc 14% 7 of 50, p = 0.18), or in-hospital mortality (TPC 3% 2 of 59, talc 8% 4 of 50, p = 0.41). Conclusions TPC placement was associated with a significantly reduced postprocedure and overall LOS compared with VATS talc. Also, TPC placement was associated with significantly fewer ipsilateral reinterventions. Placement of TPC should be considered for palliation of MPE-associated symptoms.
Blunt Tracheobronchial Trauma Shemmeri, Ealaf; Vallières, Eric
Thoracic surgery clinics,
08/2018, Volume:
28, Issue:
3
Journal Article
Peer reviewed
This article provides an overview of current literature on blunt tracheobronchial injury, and discusses the presentation of tracheobronchial injuries in clinical and radiographic forms. A review of ...the current data on repair is provided with an outline of surgical management.
Background Malignant pleural mesothelioma is a fatal disease. The optimal modality and sequence of therapy are controversial. We analyzed the outcomes of a cohort of mesothelioma patients treated ...with induction chemotherapy, followed by extrapleural pneumonectomy (EPP) and adjuvant radiation. Methods The study comprised a retrospective cohort of 46 patients treated with induction chemotherapy, followed by EPP, during a 10-year period. Of these, 24 completed adjuvant external beam radiotherapy (EBRT), and 14 had intensity-modulated radiotherapy (IMRT). Results Mean follow-up was 20.6 months (range, 0.5 to 75 months). Operative mortality after EPP was 4.3% (n = 2). Pathologic stage was p0, 4.3%; pII, 23.9%; pIII, 56.5%; and pIV, 15.2%. Median overall survival was 24 months. On univariate analysis and Cox proportional hazards model, only nodal metastases (hazard ratio, 3.7; 95% confidence interval, 1.6 to 8.7; p = 0.002) was a significant predictor of survival. First site of recurrence was local in 12, the contralateral chest in 5, abdominal in 8, and distant in 5. The incidence of local recurrence was 14.3% with IMRT vs 41.7% with EBRT ( p = 0.03). The time to local recurrence with the use of IMRT was 12 months vs 7 for EBRT ( p = 0.19). Conclusions Induction chemotherapy, followed by EPP and adjuvant radiotherapy for selected patients with mesothelioma, is safe, with acceptable operative mortality. Adjuvant IMRT may be more effective in terms of local control than EBRT.
Background Lobectomy is the standard of care for patients with early-stage non-small cell lung cancer (NSCLC). However, the treatment of choice for patients with prior lung resection and a second ...primary NSCLC has not been established. We compared rates and patterns of recurrence and survival in patients with and without prior lung resection treated by segmentectomy and determined predictors of recurrence. Methods This was a retrospective cohort study of 90 patients who underwent 91 consecutive segmentectomies for early-stage NSCLC between April 2004 and December 2014. Logistic regression was used to determine predictors of recurrence, and Kaplan-Meier curves were used to determine survival. Results Of the 91 segmentectomies, 21 (23%) had a prior lung cancer resection and 70 (77%) were primary resections. There were 18 recurrences (20%): 9 of 21 (43%) in those with prior lung resection and 9 of 70 (13%) in those without. The 90-day mortality was 0%. The recurrence-free survival and 5-year survival were 61% and 55% in those with prior lung resection ( p = 0.09) and 84% and 65% in those without ( p = 0.4). Close parenchymal margin and number of lymph nodes examined were significant modifiable predictors of recurrence. Conclusions Segmentectomy is a reasonable option for patients with early-stage NSCLC who have had a prior lung resection. It results in similar survival but trends toward lower recurrence-free survival compared with patients undergoing primary resection.
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