Robot-assisted thoracic surgery for stages IIB-IVA non-small cell lung cancer: retrospective study of feasibility and outcome.

Robot-assisted thoracic surgery (RATS) for higher stages non-small cell lung carcinoma (NSCLC) remains controversial. This study reports the feasibility of RATS in patients with stages IIB-IVA NSCLC. A single-institute, retrospective study was conducted with patients undergoing RATS for stages IIB-IVA NSCLC, from January 2015 until January 2020. Unforeseen N2 disease was excluded. Data were collected from the Dutch Lung Cancer Audit database. Conversion rate, radical (R0) resection rate, local recurrence rate and complications were analyzed, as were risk factors for conversion. RATS was performed in 95 patients with NSCLC clinical or pathological stages IIB (N = 51), IIIA (N = 39), IIIB (N = 2) and IVA (N = 3). 10.5% had received neoadjuvant chemoradiotherapy. Pathological staging was T3 in 33.7% and T4 in 34.7%. RATS was completed in 77.9% with a radical resection rate of 94.8%. Lobectomy was performed in 67.4% of the total resections. Conversion was for strategic (18.9%) and emergency (3.2%) reasons. Pneumonectomy (p = 0.001), squamous cell carcinoma (p < 0.001), additional resection of adjacent structures (p = 0.025) and neoadjuvant chemoradiation (p = 0.017) were independent risk factors for conversion. Major post-operative complications occurred in ten patients (10.5%) including an in-hospital mortality of 2.1% (n = 2). Median recurrence-free survival was estimated at 39.4 months (CI 16.4-62.5). Two- and 5-year recurrence-free survival rates were 53.8% and 36.7%, respectively. This study concludes that RATS is safe and feasible in higher staged NSCLC tumors after exclusion of unforeseen N2 disease. It brings new perspective on the potential of RATS in higher stages, dealing with larger and more invasive tumors.

Robotic Mitral Valve Surgery.

Growing interest in minimalizing surgical trauma during heart procedures stimulated the development of robotic mitral valve surgery in the late 1990s. Initially, the new technology was slowly adopted in clinical practice. However, following encouraging results by teams that adopted robotic heart surgery early on, a growing interest in implementation of robotic mitral valve surgery has emerged. Of importance are the technical developments and possibilities that accompany robotic surgery. Robotic arms feature unique characteristics, allowing unparalleled range of motion and allowing complex mitral valve repair techniques to be performed without limitations related to limited surgical incisions. High-quality three-dimensional vision effectively compensates for the lack of tactile feedback. Several technical solutions have been developed to facilitate mitral valve repair in minimal invasive setting, including chordal guiding systems, now available with various annuloplasty rings. On the other hand, precise vision and movements allows accurate determination of the length of implanted neochordae, facilitating precise determination of the length of implanted neochords even without the use of chordal-guiding systems. With robotic mitral valve surgery, leaflet resection techniques can be performed without limitations, ensuring that no compromises of the surgical strategy are made. Nevertheless, careful preoperative planning with appropriate work-up and imaging is of utmost importance to prevent complications. Moreover, the drawbacks of the initial learning curve and higher procedural costs are counterbalanced by less surgical trauma, lower utilization of blood products, and faster patient recovery. Robotic mitral valve surgery is still a young field and evolving technology that is bound to become an important tool in the toolbox of surgical mitral valve approaches.

Quality assessment of robot assisted thoracic surgical resection of non-small cell lung cancer: nodal upstaging and mediastinal recurrence.

BACKGROUND: Robot assisted thoracic surgery (RATS) is the minimally invasive surgical technique of choice for treatment of patients with non-small cell lung cancer (NSCLC), at the Isala Hospital. The aim of this study is to compare clinical and pathological staging results and mediastinal recurrence after RATS for anatomical resections of lung cancer as surrogate markers for quality of mediastinal lymph node dissection (MLND). METHODS: This single institute retrospective study was conducted in patients who underwent RATS for NSCLC. Excluded were patients with a history of concurrent malignant disease, with other previous neoplasms, with small cell lung cancer (SCLC) and patients in whom the robotic technique was converted to thoracotomy, prior to lymph node dissection. Data were obtained from the hospital database. The difference between clinical and pathological staging was expressed as upstaging and downstaging. Computed Tomography scanning was used for follow-up, and diagnosis of mediastinal recurrence. RESULTS: From November 2011 to May 2016, 227 patients underwent RATS at Isala Hospital Zwolle, the Netherlands. Of those, 130 (mean age, 69.5±9.3 years) met the eligibility criteria. Preoperative mediastinal lymph node staging was done by endoscopic ultrasound/endobronchial ultrasound, by positron emission tomography (PET) or mediastinoscopy. In 14 patients (10.8%) unforeseen N2 disease was found, 6 patients (4.6%) were upstaged from cN0 to pN2 and 8 patients (6.2%) were upstaged from cN1 to pN2. Mediastinal recurrence was detected in 7 patients (5.4%) during a median follow-up of 54 months (range, 1.5-102 months). CONCLUSIONS: In patients with NSCLC, who underwent anatomical resection by means of RATS, an unforeseen N2 disease rate of 10.8% was demonstrated and a mediastinal recurrence rate of 5.4%. It is concluded that robotic surgery provides an accurate lymph node dissection.

The usefulness of preoperative exercise therapy in patients scheduled for lung cancer surgery; a survey among Dutch pulmonologists and cardiothoracic surgeons.

BACKGROUND: Preoperative exercise training (PET) studies show promising results in various patient populations. However, the lack of standardised programmes and uniformity in practice guidelines are barriers for implementation. Aim of this study was to assess the current opinions of pulmonologists and cardiothoracic surgeons on the clinical applicability of PET in patients scheduled for lung cancer surgery. METHODS: Dutch pulmonologists and cardiothoracic surgeons were asked to complete a 29-question survey regarding PET as an additional option to further optimise the health status of patients scheduled for lung cancer surgery. RESULTS: In total, 47 respondents (63% response rate), including 30 pulmonologists and 11 cardiothoracic surgeons and 6 residents in training completed the survey. A vast majority of the respondents had a positive attitude towards PET. Home-based exercise was considered less useful, as well as unsupervised exercise. Patient's motivation, improvements in physical capacity and quality of life, and lifestyle adjustments are important factors for the success of PET. The programme should at least contain inspiratory muscle training (95.7%), lifestyle interventions (95.7%), and supervised exercise training (91.5%). Cardiac and pulmonary risk assessment and medication assessment and optimisation were found less important. CONCLUSION: Among pulmonologists and cardiothoracic surgeons, there is a tendency that PET can be a valuable addition to the perioperative care of lung surgery patients. Points of discussion are the contents of PET programmes, and there seems to be a lack of awareness among chest physicians.

Training in robotic thoracic surgery-the European way.

The increasing demand for robot-assisted thoracic surgery (RATS) in Europe requires a structured and standardized training module. Until now, Intuitive Surgical Inc. (Sunnyvale, CA, USA) has delivered the only available robotic surgery platform. Although the training program that is organized by Intuitive is divided in an initial and an advanced course, the success of the training depends on many external factors. Until now the training focused on experienced thoracic surgeons. The aim of this article is to offer a stepwise training module, which can be adopted by experienced open (thoracotomy) surgeons or video-assisted thoracic (VATS) surgeons but is primarily meant for thoracic surgery fellows and residents, as it is our sincere opinion that we should focus on training for this type of surgery as early in their careers as possible. In order to maintain surgical technique and minimize the chance of complications, on-going training and certification of the surgeons and the team is deemed necessary.

Outcomes from the Delphi process of the Thoracic Robotic Curriculum Development Committee.

OBJECTIVES: As the adoption of robotic procedures becomes more widespread, additional risk related to the learning curve can be expected. This article reports the results of a Delphi process to define procedures to optimize robotic training of thoracic surgeons and to promote safe performance of established robotic interventions as, for example, lung cancer and thymoma surgery. METHODS: In June 2016, a working panel was spontaneously created by members of the European Society of Thoracic Surgeons (ESTS) and European Association for Cardio-Thoracic Surgery (EACTS) with a specialist interest in robotic thoracic surgery and/or surgical training. An e-consensus-finding exercise using the Delphi methodology was applied requiring 80% agreement to reach consensus on each question. Repeated iterations of anonymous voting continued over 3 rounds. RESULTS: Agreement was reached on many points: a standardized robotic training curriculum for robotic thoracic surgery should be divided into clearly defined sections as a staged learning pathway; the basic robotic curriculum should include a baseline evaluation, an e-learning module, a simulation-based training (including virtual reality simulation, Dry lab and Wet lab) and a robotic theatre (bedside) observation. Advanced robotic training should include e-learning on index procedures (right upper lobe) with video demonstration, access to video library of robotic procedures, simulation training, modular console training to index procedure, transition to full-procedure training with a proctor and final evaluation of the submitted video to certified independent examiners. CONCLUSIONS: Agreement was reached on a large number of questions to optimize and standardize training and education of thoracic surgeons in robotic activity. The production of the content of the learning material is ongoing.

A randomized controlled trial of postthoracotomy pulmonary rehabilitation in patients with resectable lung cancer.

INTRODUCTION: Little is known about the effects of rehabilitation for patients with lung cancer after thoracotomy. The primary objective of this study was to evaluate the effect of a multidisciplinary rehabilitation program on quality of life (QOL) and secondary objectives were to determine its effects on pain and exercise capacity and the feasibility of combining rehabilitation with adjuvant chemotherapy. METHODS: Patients who had undergone a thoracotomy for lung cancer were randomized between rehabilitation and usual care. Rehabilitation consisted of twice-weekly training for 12 weeks starting 1 month after hospital discharge, scheduled visits to pain specialists, and medical social work. QOL and pain were measured with validated questionnaires at baseline and after 1, 3, 6, and 12 months. Exercise tolerance was assessed at baseline and after 3 months with a 6-minute walking distance test. RESULTS: The study closed prematurely because of the introduction of video-assisted thoracoscopic surgery. Of 57 randomized patients, 49 patients (23 active and 26 control) were analyzed. QOL was not significantly different between groups, although, the active group reported more pain after 3 and 6 months and more limitations because of physical problems after 3 months. In the active group, 6-minute walking distance improved by 35 m from preoperative baseline, as opposed to the control group that showed a decline by 59 m (p = 0.024 for difference). Patients treated with adjuvant chemotherapy showed decreased attendance at training sessions. CONCLUSION: Rehabilitation did not result in a better QOL. Exercise tolerance improved at the cost of more pain and more limitations because of physical problems. We suggest that rehabilitation is better postponed for 3 to 4 months after hospital discharge.

Congenital circumflex artery-coronary sinus fistula in an adult female associated with severe mitral regurgitation and myelodysplasy--case report and review of the literature.

BACKGROUND: Coronary artery fistulas are uncommon anomalies. They occur in 0.1-0.2% of patients undergoing coronary arteriography. The origin of the fistulas is the right coronary artery followed by the left anterior descending and lastly by the circumflex artery (17%). Termination into the right heart side occurs in 90% of cases. Termination into the coronary sinus is rare in 3% of cases. Circumflex artery-coronary sinus fistulas are even rarer. DESIGN: A single case report and literature review between 1993 and 2007. RESULTS: We describe a 76-year-old female, who was analyzed for dyspnea on exertion (DOE) and chronic fatigue, with known myelodysplastic syndrome and an aneurysmal circumflex coronary artery-coronary sinus fistulous connection associated with severe mitral regurgitation. Mitral valve replacement using a bioprosthesis was performed as well as ligation of the fistula. The postoperative course was complicated with cardiac tamponade, which was successfully drained. CONCLUSION: Our patient presented with chronic fatigue and DOE and was found to have a coronary artery fistula and severe mitral regurgitation associated with known myelodysplasia. Conventional coronary angiography failed to demonstrate the entire fistula characteristics (origin, pathway, and outflow). Multidetector computed tomography was complementary to demonstrate the complex anatomy of the fistula. The fistula was surgically ligated in combination with mitral valve replacement. She remains well.

Comparison of EUS-guided fine needle aspiration and integrated PET-CT in restaging after treatment for locally advanced non-small cell lung cancer.

BACKGROUND: After induction treatment restaging of mediastinal disease in patients with stage III non-small cell lung cancer (NSCLC) may lead to selection of candidates for further surgical treatment. Nodal down-staging is the best predictive characteristic for proceeding with surgery. We report our experience in restaging with endoscopic ultrasound-guided fine needle aspirations (EUS-FNA) and with repeated integrated positron emission tomography and computed tomography (PET-CT). METHODS: Twenty-eight patients with stage III NSCLC were staged with integrated PET-CT, cerebral magnetic resonance imaging (MRI) and pathologically proven nodal disease. Restaging was performed with PET-CT and EUS-FNA on the same nodes that showed initially metastatic disease provided these nodal sites determined the tumor stage. Cerebral MRI was not repeated. When restaging EUS-FNA revealed no malignant cells anymore, patients were operated. The postoperative pathologic results were compared with the preoperative restaging EUS-FNA results. Also, patterns of decreased fluoro-2-deoxyglucose (FDG) uptake were compared with the postoperative pathologic results. RESULTS: Restaging EUS-FNA was well tolerated in all patients even in those with clinical signs of radiation esophagitis. Of the 28 patients 15 were down-staged based on cytologic findings with restaging EUS-FNA and in one patient the cytology was not conclusive. Of these 15 patients, down-staging was histologically confirmed after mediastinal exploration in 11 patients and 1 patient had persistent nodal disease at resection. In 3 patients no mediastinal tissue verification was performed. Two subjects were not fit for operation, and in the other patient intraoperative nodal staging was omitted. The negative predictive value for restaging EUS-FNA was 91.6%. The accuracy of EUS-FNA was 92.3%. Concordance between findings of restaging EUS-FNA and metabolic response of lymph node metastases occurred in 17 out of 27 patients. CONCLUSION: Restaging with EUS-FNA after induction chemo(-radiotherapy) is well tolerated and predicts the absence of nodal metastasis reliably. Although changes in mediastinal FDG-PET uptake show a high concordance with EUS-FNA, pathological confirmation is still superior and therefore necessary. EUS-FNA is the procedure of first choice for mediastinal restaging.

Long-term follow-up of mitral valve repair: a single-center experience.

BACKGROUND: Our aim was to conduct a long-term follow-up of patients after mitral valve repair for incompetence. We identified determinants for mortality and compared mortality with standardized mortality rates of the Dutch population. MATERIAL/METHODS: We included in this single-center retrospective study 119 patients operated from March 1976 to February 1981. Patients with previous mitral valve surgery, isolated mitral stenosis, and congenital heart disease were excluded. Routine echocardiography was performed every 6 to 12 months. The cumulative probability of survival was calculated (Kaplan-Meier). The variables that statistically significantly associated with mortality were selected for multivariate analysis. Maximum follow-up was 27 years and complete in 98%. Mean age was 49.4 years, and 55% were preoperatively in New York Heart Association (NYHA) class III. Concomitant cardiac procedures were performed in 49%. RESULTS: The 30-day postoperative mortality was 6.7% and the 20-year overall mortality was 63%. The standardized mortality rate was 30%, which was based on survival rates of the general Dutch population. In 27 cases (22.7%), re-operation was performed. Independent predictors for mortality were, after univariate and multivariate analysis, concomitant coronary artery bypass grafting (p=0.002), renal impairment (p=0.027), age above 60 years (p=0.05), and ejection fraction

The Carpentier-Edwards Classic and Physio mitral annuloplasty rings: a randomized trial.

OBJECTIVE: To evaluate clinical and echocardiographic outcomes for the semi-flexible Carpentier-Edwards Physio and the rigid Classic mitral annuloplasty ring. METHODS: Ninety-six patients were randomized for either a Classic (n = 53) or a Physio (n = 43) ring from October 1995 through July 1997. Mean follow-up was 5.1 years (range .1-6.6). We included standard patient characteristics at baseline and during follow-up. Analyses were adjusted for age and gender, and for factors that differed across groups at baseline. In 2002, echocardiography was performed in 74% of the survivors. RESULTS: We found a 16% difference in mortality: 14% in the Physio group (n = 6) and 30% in the Classic group (n = 16) (adjusted P = .41). Life table analysis shows that the absolute risk of death after 30 months is lower in the Physio group. Intra-operative repair failure occurred in 3 patients (6%) of the Classic group, and in 4 (9%) of the Physio group, resulting in mitral valve replacement. Late failure occurred in 1 patient (2%) in the Classic group, and in 4 (9%) in the Physio group. At follow-up, left ventricular function did not differ across groups (ejection fraction 45% and 48% (adjusted P = .65)). The combined NYHA class III-IV had improved for the Classic group in 42% and for the Physio group in 34%. CONCLUSION: Although the 16% difference in mortality did not reach statistical significance, it is considered clinically important. No differences in morbidity, valve function, and left ventricular function were found. Further research to explain the difference in mortality is required.