Robotic thoracic surgery: a support team to replace the bedside surgeon.

Establishing a new robotics program presents a unique set of challenges that differ from routine operative procedures. These include training robotic staff, operating room logistics, and surgeon training. As the surgeon moves away from the patient bedside, the responsibilities of the bedside team and circulating staff must increase to fill that void. Therefore, a critical element of robotic thoracic surgery is the training of the robotic team to facilitate fluid movement of the patient through the surgical process. We report our process in establishing a thoracic robotics program with an emphasis on the training personnel.

Centralized Lung Nodule Management at A Veterans Hospital Using A Multidisciplinary Lung Nodule Evaluation Team (LNET).

BACKGROUND: Lung nodules are frequently identified on imaging studies and can represent early lung cancers. We instituted the Lung Nodule Evaluation Team (LNET) to optimize management of these nodules by a lung specialist physician. All lung nodules identified by a radiologist prompted a direct consultation to this service. We report our initial experience with this process. METHODS: This is a retrospective review of patients with lung nodules at a single institution from 2008 to 2015. Since October 2014, lung nodules >3 mm identified on computed tomography (CT) scanning of the chest generate an automatic consult to LNET from the radiology service. Demographic, nodule and follow up data was entered into a surveillance database and summarized. RESULTS: There were 1,873 patients identified in the database. Of these, 900 patients were undergoing active surveillance. Consults increased from 5.5 to 93 per month after the start of the new consult program. Lung nodules were identified on 64% of chest CT scans. Prior to the direct radiology consult the average size of a nodule was 1.7 cm and 0.7 cm after. The overall time from initial nodule imaging to initiating a management plan by a thoracic specialist physician was 3.7 days. CONCLUSIONS: Assessment of lung nodules by a specialist physician is important to ensure appropriate long term management and optimize utilization of diagnostic interventions. A direct radiology consult to a specialized team of chest physicians decreased the time in initiating a management plan, identified smaller nodules and may lead to a more judicious use of health care resources in the management of lung nodules.

Using Electromagnetic Navigation Bronchoscopy and Dye Injection to Aid in Video-Assisted Lung Resection.

Small (2 cm) peripheral lung lesions and ground glass opacities remain a difficult subset of lung lesions for the diagnosis and management of lung cancer. Surgical biopsy is more difficult for these lesions because intraoperative localization has to be made without the aid of direct visualization or manual palpation. Electromagnetic navigation bronchoscopy can be used in the operating room to identify a small peripheral lesion and marked using an injection of methylene blue, which can be seen on the visceral pleura of the lung. We present our initial experience using this technique. The sample was eight patients who had peripheral lesions with an average size of 19 mm. Surgical wedge biopsy was diagnostic in all cases, with an average procedure time of 28 minutes. There were no complications from this procedure. In conclusion, these data suggest that electromagnetic navigation bronchoscopy can be performed safely with high diagnostic accuracy by the operating thoracic surgeon, but further data are needed to establish its utility and safety.

Video-assisted thoracoscopy as an important tool for trauma surgeons: a systematic review.

PURPOSE: Trauma patients frequently have serious chest injuries. Retained hemothoraces and persistent pneumothoraces are among the most frequent complications of chest injuries which may lead to major, long-term morbidity and mortality if these complications are not recognized and treated appropriately. Video-assisted thoracoscopy (VATS) is a well-established technique in surgical practice. The usefulness of VATS for treatment of complications after chest trauma has been demonstrated by several authors. However, there is an ongoing debate about the optimal timing of VATS. METHODS: A computerized search was conducted which yielded 450 studies reporting on the use of VATS for thoracic trauma. Eighteen of these studies were deemed relevant for this review. The quality of these studies was assessed using a check-list and the PRISMA guidelines. Outcome parameters were successful evacuation of the retained hemothorax or treatment of other complications as well as reduction of empyema rate, length of hospital stay, and hospital costs. RESULTS: There was only one randomized trial and two prospective studies. Most studies report case series of institutional experiences. VATS was found to be very successful in evacuation of retained hemothoraces and seems to reduce the empyema rate subsequently. Furthermore, the length of hospital stay and costs can be drastically reduced with the early use of VATS. CONCLUSION: Early VATS is an effective treatment for retained hemothoraces or other complications of chest trauma. We propose a clinical pathway, in which VATS is used as an early intervention in order to prevent serious complications such as empyemas or trapped lung.

Cardiac impalement from a rib after blunt trauma.

Blunt chest trauma produces a variety of injuries. We present a case report of a hemodynamically stable patient after blunt chest trauma with radiographic images suggestive of the left fifth rib penetration to the heart. The diagnosis, surgical approach, and course of the patient are discussed.

Complications associated with sentinel lymph node biopsy for melanoma.

BACKGROUND: Sentinel lymph node (SLN) biopsy has become widely accepted as a method of staging the regional lymph nodes for patients with melanoma. Although it is often stated that SLN biopsy is a minimally invasive procedure associated with few complications, a paucity of data exists to specifically determine the morbidity associated with this procedure. This analysis was performed to evaluate the morbidity associated with SLN biopsy compared with completion lymph node dissection (CLND). METHODS: Patients were enrolled in the Sunbelt Melanoma Trial, a prospective multi-institutional study of SLN biopsy for melanoma. Patients underwent SLN biopsy and were prospectively followed up for the development of complications associated with this technique. Patients who had evidence of nodal metastasis in the SLN underwent CLND. Complications associated with SLN biopsy alone were compared with those associated with SLN biopsy plus CLND. RESULTS: A total of 2120 patients were evaluated, with a median follow-up of 16 months. Overall, 96 (4.6%) of 2120 patients developed major or minor complications associated with SLN biopsy, whereas 103 (23.2%) of 444 patients experienced complications associated with SLN biopsy plus CLND. There were no deaths associated with either procedure. CONCLUSIONS: SLN biopsy alone is associated with significantly less morbidity compared with SLN biopsy plus CLND.

Decreasing mortality of bile leaks after elective hepatic surgery.

BACKGROUND: Bile leak is a serious complication following major hepatic surgery. It is associated with significant mortality rates if reoperative management is attempted. We evaluated our experience with aggressive, nonoperative management of postoperative biliary complications. METHODS: All medical records of patients undergoing major liver resection, cryosurgery or radiofrequency ablation from September 1996 through March 1999 were reviewed. RESULTS: Seventy-four patients were identified, and 9 (12%) developed bile leaks. Biliary leaks were investigated with endoscopic retrograde cholangiopancreatography (ERCP) and treated with endoscopic stenting when possible. The bile leak was found to originate from the resected duct stump or ablated surface of the liver in all cases. Patients were treated with ERCP stent placement (5), computed tomography-guided percutaneous drainage (3), and hepaticojejunostomy "chimney" (1). Six of 9 patients had resolution of their bile leak with the mean time of removal of the drain of 4.7 months. There was only 1 death, and that patient died nearly 3 months after surgery from complications not directly related to the bile leak. CONCLUSIONS: Bile leak after liver resection can be managed nonoperatively in most cases with a combination of percutaneous drain placement and biliary stenting. Most bile leaks will close with time, although a drain may be required for many months.

Bilateral giant adrenal myelolipomas: a case report.

Myelolipoma is a relatively rare benign tumor composed of fatty tissue and bone marrow elements. It is frequently associated with the adrenal glands but may exist as a solitary mass elsewhere. Adrenal myelolipomas are typically nonfunctioning and asymptomatic. They may be associated with an endocrine disorder such as Cushing's disease, Addison's disease, or hyperaldosteronism; however they are most often discovered incidentally. Their size is usually less than 5 cm and they are managed nonoperatively. We report a case of bilateral giant adrenal myelolipoma producing abdominal pain in a 54-year-old man, who presented to his primary care physician with complaints of right shoulder pain with vague abdominal discomfort. Imaging studies identified bilateral suprarenal masses measuring 12 x 14 cm on the right and 8 x 10 cm on the left. These masses were consistent with fatty tissue radiographically. In addition a focal 5 x 4-cm mass was identified in the transverse colon. Because the patient was symptomatic and a diagnosis of liposarcoma could not be excluded he was taken to the operating room for exploratory laparotomy with excision of the masses and a transverse colectomy. Final histologic analysis identified bilateral adrenal myelolipomas and a solitary lipoma of the transverse colon. His postoperative course was uneventful with relief of the pain. Despite its benign nature and rare growth beyond 5 cm myelolipoma of the adrenal gland is best managed with excision in the symptomatic patient. Preservation of adrenal tissue is vital so as not to commit patients to a lifetime of steroid replacement.

Interval sentinel lymph nodes in melanoma.

HYPOTHESIS: For patients with melanoma, interval or in-transit sentinel lymph nodes (SLNs) have the same risk for nodal metastasis as SLN in traditional (ie, cervical, axillary, and inguinal) nodal basins. DESIGN: Prospective clinical trial. SETTING: Multicenter study. PATIENTS: Eligible patients were aged 18 to 70 years with melanomas of at least 1.0-mm Breslow thickness and nodes with clinically negative findings. INTERVENTION: Sentinel lymph node biopsy was guided by preoperative lymphoscintigraphy to identify all SLNs. MAIN OUTCOME MEASURES: We evaluated interval nodal sites, including epitrochlear, popliteal, and subcutaneous or intramuscular nodes outside of traditional basins, for the presence of metastases. RESULTS: The SLNs were identified in 2332 nodal basins from 2000 patients. In 62 patients (3.1%), interval SLNs were identified. We found SLN metastases in 442 (19.5%) of 2270 conventional nodal basins and 13 (21.0%) of 62 interval sites. In 11 (84.6%) of the 13 cases in which we found an interval node that was positive for metastatic disease, it was the only site of nodal metastasis. CONCLUSIONS: Although interval SLNs are identified infrequently, they contain metastatic disease at nearly the same frequency as SLNs in cervical, axillary, and inguinal nodal basins. Positive interval SLNs are likely to be the only site of nodal metastasis. Therefore, detailed preoperative lymphoscintigraphy and meticulous intraoperative search for interval nodes should be performed.

C-terminal deletion mutant p21(WAF1/CIP1) enhances E2F-1-mediated apoptosis in colon adenocarcinoma cells.

The present study was designed to investigate the efficacy of combination gene therapy using adenoviral vectors expressing gene products shown to possess apoptotic activity: E2F-1 (Ad-E2F-1) and a C-terminal deletion mutant of p21(WAF1/cIP1) (Ad-p21(-PCNA)), on growth inhibition and apoptosis of human colon cancer cells in vitro and in vivo. Marked E2F-1 and p21(-PCNA) overexpression in response to adenovirus infection was evident by Western blot analysis. IC(25) concentrations of each virus were used for each treatment in vitro to detect cooperative effects on cell death. Coexpression of E2F-1 and p21(-PCNA) resulted in an additive effect on cell death compared to infection with either virus alone. Cell cycle analysis, poly(ADP-ribose) polymerase (PARP) cleavage and analysis of cell morphology also revealed that coinfection with both Ad-E2F-1 and Ad-p21(-PCNA) enhanced cellular apoptosis compared to either virus alone. Interestingly, E2F-1 protein expression was markedly enhanced in the E2F-1/p21(-PCNA) adenovirus combination compared to Ad-E2F-1 infection alone. However, these same effects were not evident in cells coinfected with Ad-E2F-1 and an adenovirus expressing wild-type human p21(WAF1/CIP1) (Ad-p21(WT)). The increase in E2F-1 expression with coexpression of E2F-1 and p21(-PCNA) was not a result of increased E2F-1 protein stability, but was related to increased transcriptional activity from the CMV promoter. Cell cycle analysis revealed G1 arrest 72 hours following single-gene therapy with either the wild-type or mutant p21, whereas increased accumulation of cells in G2/M phase was demonstrated in the E2F-1-overexpressing cells. In the combined therapies, E2F-1/p21(-PCNA) treatment still resulted in G1 arrest, but E2F-1 was able to counteract the G1 arrest when coinfected with p21(WT). These results provide further evidence of the importance of the p21:PCNA-binding domain in mediating the complex cell cycle interaction between E2F-1 and p21. Simultaneous intratumoral injection of Ad-E2F-1 and Ad-p21(-PCNA) dramatically reduced tumor burden of SW620 xenografts compared to either treatment alone in our in vivo model but not in HT-29 colon cancer xenografts. When combined with Ad-p21(-PCNA), E2F-1 adenovirus therapy resulted in approximately 95% decrease in tumor volume of SW620 tumor xenografts compared with controls (P<.05). In conclusion, although simultaneous delivery of E2F-1 and p21(-PCNA) transgenes results in increased E2F-1 expression and enhanced apoptosis of both SW620 and HT-29 colon cancer cells in vitro, this combination was only effective in the treatment of SW620 metastatic colon cancer in vivo. This may represent a potentially useful combination gene therapy strategy for metastatic colon cancer.