National trends and perioperative outcomes of robotic resection of thymic tumours in the United States: a propensity matching comparison with open and video-assisted thoracoscopic approaches†.

OBJECTIVES: Despite the recent increased rate of adoption of robotic approaches for the resection of thymic tumours, their use is still limited to large-volume academic centres. To date, a large-scale analysis of the robotic approach has not been performed. We assessed the recent trends and outcomes of robotic thymectomies in the United States compared to those of open and video-assisted thoracoscopic surgical (VATS) approaches. METHODS: The National Cancer Database was queried for patients who underwent resection for thymic tumours (2010-2014). Predictors of using the robotic approach were estimated by logistic regression analysis. Propensity matching analysis (robotic versus open and robotic versus VATS) was done (1:1-caliper 0.05), controlling for age, gender, comorbidity index, induction treatment, tumour size and tumour extension. RESULTS: A total of 2558 thymectomies were performed (robotic = 300, VATS = 280, open = 1978). The use of a robotic approach increased from 6% (2010) to 14% (2014). The number of hospitals performing at least 1 robotic thymectomy increased from 22 (2010) to 52 (2014). Independent predictors influencing the choice of a robotic approach included an academic research/integrated cancer programme [odds ratio (OR) 1.66, confidence interval (CI) 1.22-2.27], later year of diagnosis (2014; OR 2.23, CI 1.31-3.80) and a patient's race (Asian) (OR 1.68, CI 1.05-2.69). A robotic approach was less likely to be utilized in midwestern hospitals (OR 0.65, CI 0.42-0.99), in larger tumours (cm) (OR 0.85, CI 0.80-0.90), with invasion of adjacent organs (OR 0.55, CI 0.37-0.82), thymic carcinoma (OR 0.62, CI 0.40-0.97) and following induction chemotherapy (OR 0.22, CI 0.08-0.61). In a propensity-matched analysis, there were no differences in the incidence of positive margins, nodal dissection, 30-day readmission rates and 30-/90-day mortality rates between the groups. However, a robotic approach was associated with fewer conversions compared to VATS, with a trend towards a shorter length of stay compared to an open approach. There were no differences in the 5-year overall survival rate between the matched groups (robotic 93% vs VATS 94%; P = 0.571; robotic 91% vs open 80%; P = 0.094). CONCLUSIONS: Over a 4-year study period, there was a significant increase in robotic utilization for thymectomies and an increase in the number of hospitals performing the procedure. In a matched analysis, a robotic approach was comparable to a VATS or an open approach. Current trends demonstrate increased robotic utilization for small thymomas with excellent perioperative results.

Comparative study on the analgesic effect of acute ipsilateral shoulder pain after open thoracotomy between preoperative ultrasound guided suprascapular nerve block (SNB) and intraoperative phrenic nerve infiltration (PNI) in cancer lung patients.

INTRODUCTION: Acute ipsilateral shoulder pain (ISP) is a common complaint in patients after thoracotomy. The incidence ranges from 21% to 97%. Unfortunately, clinical studies did not put enough focus on ISP post thoracic surgery. AIM OF THE WORK: This study was designed to compare the effectiveness of suprascapular nerve block (SNB) and phrenic nerve infiltration (PNI) for controlling ISP. PATIENTS AND METHODS: One hundred and thirty-five lung cancer patients (135) scheduled for open-lung surgery were randomly allocated into three equal groups; control group: received thoracic epidural with general anesthesia, suprascapular group: (SNB) one hour before the operation with 10 ml bupivacaine plus thoracic epidural with general anesthesia and phrenic nerve group: (PNI) was performed by the operating surgeon with 10 ml bupivacaine plus thoracic epidural with general anesthesia. The visual analogue score (VAS) of ISP, rescue of ketorolac for break through shoulder pain, peak expiratory flow rate (PEFR) and arterial blood gases were measured every 6 h postoperatively for 48 h. RESULTS: The VAS, rescue doses of ketorolc and PEFR were significantly lower in the phrenic nerve group (P-value <0.05). There was no statistically significant difference between the three groups postoperatively as regards arterial blood gases (P-value >0.05). CONCLUSION: PNI is more effective than SNB for ISP.

Retrosternal goiter: the need for thoracic approach based on CT findings: surgeon's view.

BACKGROUND AND PURPOSE: The incidence of retrosternal goiter (RSG) varies from 2% to 26% of all thyroidectomies, depending on the defining criteria. There are no clear guidelines to identify patients that require an intrathoracic approach. So, we tried to correlate, between the size and/or anatomical site of the RSG based on preoperative CT findings and the surgical approaches used, aiming at defining those patients with RSG who are in need for thoracic approach. PATIENTS AND METHODS: Out of 1481 patients underwent thyroidectomy at the National Cancer Institute (NCI), Cairo University, between January 2000 and December 2009, only 73 (4.93%) of them had retrosternal extension. Demographic, clinical, operative, anatomical, and pathological data of patients with RSG were recorded and analyzed. RESULTS: The intraoperative extension of the goiter correlated with the extension seen in the CT in all except two patients. Laterality and longitudinal extension found in preoperative CT, correlated well with the surgical findings. The approach used was cervical in 66 cases (90.4%); combined approach in six patients (8.2%). Pure thoracic (full sternotomy) was used alone in one case (1.4%). Extension of the RSG down to or below the arch was associated with an increased risk of using a thoracic approach p<0.0001. CONCLUSION: Preoperative CT, can be used effectively to guide the indications for using a thoracic approach. Reaching the aortic arch or beyond and loss of fat planes in CT, recurrent and malignant disease, are significant risk factors for using a thoracic approach.