Robotic-Assisted Bronchoscopy for the Diagnosis of Lung Lesions: Experience With the Use of Frozen Sections as an Aid to Confirm the Localization of Lesions During the Procedure.

CONTEXT.­: Robotic-assisted navigation bronchoscopy (R-ANB) is used to target peripheral pulmonary nodules that are difficult to biopsy using conventional approaches. Frozen sections are requested to confirm these lesions have been localized and/or to diagnose neoplasms that can be immediately resected. OBJECTIVE.­: To estimate diagnostic concordance between frozen section diagnosis (FSD) and formalin-fixed tissue diagnosis (FFTD) in biopsies obtained with R-ANB, calculate the sensitivity and specificity of FSD and FFTD for a diagnosis of malignancy, and evaluate whether the residual tissue that can be fixed in formalin after frozen section still has sufficient material for molecular studies. DATA SOURCES.­: The results of consecutive FSD rendered on biopsies performed with R-ANB during a 30-month period were used to calculate the metrics listed above. FFTD and/or the diagnoses rendered on computed tomography-guided core biopsy subsequently performed in patients with negative R-ANB and/or lung resections in patients with malignancies were used as true-positive results. The overall concordance between FSD and FFTD in 226 lesions from 203 patients was 72%. Frozen section diagnosed 76 of 123 malignancies with 100% specificity and 68% sensitivity. Adequate material was available in 92% of biopsies where next-generation sequencing and other molecular studies were requested. CONCLUSIONS.­: Intraoperative consultations are helpful to diagnose a variety of lung lesions and help surgeons confirm that targets have been accurately reached by R-ANB. Malignancies can be diagnosed with 100% specificity but only 68% sensitivity. The performance of frozen section did not interfere with the subsequent analysis of tissue with molecular studies in most cases.

Robotic navigational bronchoscopy in a thoracic surgery practice: Leveraging technology in the management of pulmonary nodules.

Objectives: Robotic navigational bronchoscopy is increasingly used to improve diagnostic yield for pulmonary nodules compared with the 50% to 60% obtained by standard bronchoscopy; however, safety and efficacy data are limited to small series. The aim of this study was to evaluate diagnostic yield and clinical outcomes in a large multisurgeon single-center cohort. Methods: All patients who underwent robotic navigational bronchoscopy and biopsy from September 2020 to October 2022 were identified from a prospective institutional registry. The primary outcome was diagnostic yield. The secondary outcome was diagnostic yield for molecular testing. Results: A total of 503 nodules were biopsied during the study period. Median nodule size was 2.1 cm. Overall diagnostic yield was 87.9%. Factors associated with increased diagnostic yield were decreased time from date of planning computed tomography to procedure date (odds ratio, 0.98; 95% CI, 0.96-0.99; P = .04) and greater nodule size (odds ratio, 1.03; 95% CI, 1.01-1.07; P = .02) per 0.1-cm increment. Molecular analysis was sent in 101 patients and was sufficient in 90% of cases. Complications occurred in 22 (5%) patients, including 13 (3.1%) with pneumothoraxes (7 patients requiring a chest drain), and 5 (1.2%) patients had bleeding requiring intraprocedural bronchial intervention. A total of 41 patients were consented for biopsy and resection during a single anesthetic event. Four of these cases were stopped at robotic navigational bronchoscopy due to an alternative diagnosis. Mean length of stay was 3.4 ± 1.1 days. There were no major complications. Conclusions: This study suggests robotic navigational bronchoscopy has a high diagnostic yield and obtains adequate tissue for molecular analysis critical for selection of targeted therapies. With careful patient selection robotic navigational bronchoscopy can be combined with surgery to treat lung cancer as a single procedure with low complication rates.

Robotic totally endoscopic triple bypass with bilateral internal mammary arteries and two different anastomotic techniques.

Robotic totally endoscopic coronary artery bypass (TECAB) offers several advantages over conventional sternotomy coronary artery bypass grafting. TECAB allows the increased use of bilateral internal mammary artery grafts independent of gender, body mass index or diabetes, minimizes the risk of wound infection, decreases the length of hospital stay, and improves the postoperative quality of life. Off-pump beating heart TECAB has been used to offer one or two grafts generally on the anterior wall. We describe our approach to perform beating heart, triple-vessel TECAB with targets on the lateral and posterolateral wall of the left ventricle.

A model for continued LVAD patient success: A 4-year readmission-free HeartMate 3 postoperative course.

Unplanned readmissions frequently occur following the implantation of a durable left ventricular assist device (LVAD) due to complications such as gastrointestinal bleeding and driveline infection. There is a paucity of literature describing the incidence of unplanned readmission in patients with a HeartMate 3 (HM3) Left Ventricular Assist System. In this report, we present the successful outcome of a patient with an HM3 LVAD who has experienced no unplanned readmissions in the 4-year post-implant phase. To our knowledge, this is the longest readmission-free case after HM3 implantation. A successful patient outcome was enabled by the use of the modular HM3 device, the postoperative prescription of beta-blockers and omega-3, the presence of strong social support, and open communication between the patient's caregivers and the LVAD team. Reducing the instance of unplanned readmission confers clinical benefits to the patient, as well as reducing the cost burden on the patient and the healthcare system.

Outpatient Thoracoscopic Mediastinal Biopsy: A Safe and Cost-Effective Approach.

BACKGROUND: Most mediastinal biopsy patients are managed with an overnight inpatient stay and chest drainage. We sought to determine the safety, accuracy, and cost of outpatient thoracoscopic mediastinal biopsy by reviewing operative techniques, perioperative outcomes, and admission charges for this procedure. METHODS: This single-institution retrospective study reviewed all patients who underwent elective thoracoscopic mediastinal biopsy between 2012 and 2017. Patients were assigned to outpatient or inpatient management preoperatively based on surgeon judgment and preference. The procedures were performed in the supine or lateral decubitus position using ports only. Patients discharged on postoperative day 0 (outpatient) were compared with those discharged on postoperative day 1 or greater (inpatient). RESULTS: A total of 46 patients were included. Thirty-one patients were outpatients, and 15 were admitted. The outpatient cohort was younger than the inpatient group (48 years of age vs 66 years of age; P = .001). There was no statistically significant difference in other baseline characteristics. The operative time was longer (P = .001) and the total charges were higher (P = .003) in the inpatient cohort. One patient in each group had a nondiagnostic procedure. One patient in the outpatient group returned to the emergency department for pain but was discharged. There were no complications. CONCLUSIONS: Outpatient thoracoscopic mediastinal biopsy is a safe and effective procedure that has lower charges compared with inpatient management and should be considered for patients undergoing this procedure.

Update on Lung Cancer Screening.

Over the past 10 years, there has been substantial progress in the study and implementation of lung cancer screening using low-dose computed tomography (LDCT). The National Lung Screening Trial, the recently reported NELSON (NEderlands-Leuvens Longkanker Screenings ONderzoek) trial, and other European trials provide strong evidence for the efficacy of LDCT to reduce lung cancer mortality. This has resulted in the United State's Preventative Task Force and numerous professional medical societies adopting lung cancer screening recommendations. Despite the general acceptance of the positive effect of screening, low adoption and implementation rates remain nationally. In this article, the authors discuss the evolution and current state of the evidence for LDCT screening for lung cancer. The authors will also review the associated risks, cost, and challenges of implementation of an LDCT screening program.

The spectrum of transcatheter mitral valve replacement devices.

Mitral regurgitation is the most common valvular heart disease. The gold standard for patients not suitable for valve repair is a surgical valve replacement. A significant proportion of patients, however are not referred for surgery due to comorbidities, advanced age or severe LV dysfunction. Transcatheter mitral valve replacement may be a viable therapeutic option for these high risk patients. With improvements in technology and data on the durability of the transcatheter mitral valve, this technology has the potential to be used in a lower risk population. A number of transcatheter systems have emerged recently and are at different stages of investigation. In this review, we outline the key elements and challenges of the transcatheter mitral valve design as well as the status of devices that have reached First in Man status.

Outcomes in Patients with Helicobacter pylori Undergoing Laparoscopic Sleeve Gastrectomy.

BACKGROUND: In vertical sleeve gastrectomy (VSG), the majority of the stomach is resected and much of the tissue colonized with Helicobacter pylori and the bulk of acid producing cells are removed. In addition, the effect of H. pylori colonization of the stomach of patients undergoing stapling procedures is unclear. As a result, the need for detection and treatment of H. pylori in patients undergoing VSG is unknown. METHODS: Four hundred and eighty patients undergoing VSG are the subject of this study. Three surgeons at a single institution performed the procedures. The remnant stomach was sent to pathology and tested for the presence of H. pylori using immunohistochemistry. All patients were discharged on proton pump inhibitors. RESULTS: Of the 480 patients who underwent VSG, 52 were found to be H. pylori positive based on pathology. There was no statistically significant difference in age (p = 0.77), sex (p = 0.48), or BMI (p = 0.39) between the groups. There were 17 readmissions post-op. Five of these were in the H. pylori positive cohort. Six of these complications were classified as severe (anastomotic leak, intra-abdominal collection, or abscess), with two in the H. pylori positive cohort (Table 1). There was no statistically significant difference in the severe complication rates between the two groups (p = 0.67). There were no readmissions for gastric or duodenal ulceration or perforation. CONCLUSIONS: Our data suggests that there is no increase in early complications in patients with H. pylori undergoing VSG. If these findings are confirmed in a long-term follow-up, it would mean that preoperative H. pylori screening in patients scheduled for VSG is not necessary.

Response to glucose tolerance testing and solid high carbohydrate challenge: comparison between Roux-en-Y gastric bypass, vertical sleeve gastrectomy, and duodenal switch.

BACKGROUND: Hyperinsulinemic hypoglycemia is common after Roux-en-Y gastric bypass (RYGB) and may result in weight regain. The purpose of our investigation was to compare the effect of RYGB, vertical sleeve gastrectomy (VSG), and duodenal switch (DS) on insulin and glucose response to carbohydrate challenge. METHODS: Patients meeting National Institutes of Health criteria for bariatric surgery selected their bariatric procedure after evaluation and education in this prospective nonrandomized study. Preoperatively and at 6, 9, and 12 months' follow-up, patients underwent blood draw to determine levels of fasting glucose, fasting insulin, glycated hemoglobin (HbA1c), C-peptide, and 2-h oral glucose challenge test. Homoeostatic Model Assessment (HOMA)-IR, fasting to 1-h and 1- to 2-h ratios of glucose and insulin, were calculated. Statistical analysis was performed using ANOVA and Student's paired t test. All procedures were performed via a laparoscopic technique at a single institution. RESULTS: Data from a total of 38 patients (13 RYGB, 12 VSG, 13 DS) were available for analysis. At baseline, all groups were similar; the only statistically significant difference was that DS patients had a higher preoperative weight and body mass index (BMI). All operations caused weight loss (BMI 47.7 ± 10-30.7 ± 6.4 kg/m(2) in RYGB; 45.7 ± 8.5-31.1 ± 5.5 kg/m(2) in VSG; 55.9 ± 11.4-27.5 ± 5.6 kg/m(2) in DS), reduction of fasting glucose, and improved insulin sensitivity. RYGB patients had a rapid rise in glucose with an accompanying rise in 1-h insulin to a level that exceeded preoperative levels. This was followed by a rapid decrease in glucose level. In comparison, DS patients had a lower increase in glucose and 1-h insulin, and the lowest HbA1c. These differences were statistically significant at various data points. For VSG, the results were intermediary. CONCLUSIONS: Compared to gastric bypass, DS results in greater weight loss and improves insulin sensitivity and glucose homeostasis without causing a hyperinsulinemic response. Because the response to challenge after VSG is intermediary, pyloric preservation alone cannot account for this difference.