Beyond the learning curve: a review of complex cases in robotic thoracic surgery.

The number of thoracic surgery cases performed on the robotic platform has increased steadily over the last two decades. An increasing number of surgeons are training on the robotic system, which like any new technique or technology, has a progressive learning curve. Central to establishing a successful robotic program is the development of a dedicated thoracic robotic team that involves anesthesiologists, nurses, and bed-side assistants. With an additional surgeon console, the robot is an excellent platform for teaching. Compared to current methods of video-assisted thoracoscopic surgery (VATS), the robot offers improved wristed motion, a magnified, high definition three-dimensional vision, and greater surgeon control of the operation. These advantages are paired with integrated adjunctive technology such as infrared imaging. For pulmonary resection, these advantages of the robotic platform have translated into several clinical benefits, such as fewer overall complications, reduced pain, shorter length of stay, better postoperative pulmonary function, lower operative blood loss, and a lower 30-day mortality rate compared to open thoracotomy. With increased experience, cases of greater complexity are being performed. This review article details the process of becoming an experienced robotic thoracic surgeon and discusses a series of challenging cases in robotic thoracic surgery that a surgeon may encounter "beyond the learning curve". Nearly all thoracic surgery can now be approached robotically, including sleeve lobectomy, pneumonectomy, resection of large pulmonary and mediastinal masses, decortication, thoracic duct ligation, rib resection, and pulmonary resection after prior chest surgery and/or chemoradiation.

Use of electromagnetic navigational bronchoscopy in robotic pulmonary resection.

Robotic resection of pulmonary lesions has become a more common approach in the field of thoracic surgery. The greatest drawback of robotic resection is the lack of tactile feedback as compared to open approaches, making identification of intrapulmonary lesion difficult. Electromagnetic navigational bronchoscopy (navibronch) enables pre-incisional marking of pulmonary lesions for intraoperative identification. We sought to determine how effective navibronch was in our institution's robotic cases. Thirty-one patients underwent robotically assisted resection of 35 lesions with the assistance of navibronch from 7/2014 to 9/2015. Retrospective demographic and operative data were collected on these patients, and statistical analysis was conducted using ANOVA means testing, Chi-square, and non-parametric tests. The average age in this patient population was 63.7 ± 13.5 years. Eight patients (25.8%) were male. Twenty-five (80.6%) of the patients had pathology involving one lobe, with six (19.4%) in two lobes. 34 of the resections (97.1%) resulted in dye being localized to the first specimen; 34 (97.1%) were found to have the target pathology in the initial specimen. Further resection was carried out in 22 (62.9%) cases, with the final resection resulting in a segment in 2 (5.7%) and a lobe in 14 (40.0%). The mean number of lung specimens collected was 1.94 ± 0.13. The mean number of tumors in each target resection was 1.46 ± 0.66 in final pathology. Malignancy was found in 19 (54.3%) of final specimens. There were no complications related to navibronch. Navibronch is an effective technique in the identification and localization of pulmonary lesions in robotically assisted lung resections.

Initial Outcomes of Symmetrically Flared Covered Nitinol Stents for Esophageal Pathologies.

BACKGROUND: A recently available, low profile, fully covered metal stent with symmetrical flares (FCMSF) may offer improved resistance to migration in esophageal disease. MATERIALS AND METHODS: A retrospective review of 58 esophageal FCMSF placed in 46 consecutive patients was performed. Pathologies included stricture and leak of benign and malignant etiology. RESULTS: Sixteen of 58 stents (28%) were placed urgently/emergently. All patients had successful stent deployment with 0% stent-related hospital mortality. Postoperative morbidity occurred in 15 of the 58 (26%) stents and included stent migration, atrial fibrillation, pneumonia, pneumothorax, urinary retention, hemodynamic instability, and chronic obstructive pulmonary disease exacerbation. In patients with stricture (n=29), mean dysphagia scores were reduced from 3.1±0.6 preoperatively to 1.1±0.8 postoperatively (P<0.001). For leak, stent therapy (±drainage) avoided formal esophageal operation in 95% (21/22). Four stents (6.9%) were removed for stent migration, 2 of which migrated after adjuvant chemoradiation. Adjuvant chemoradiation therapy was an independent risk factor for stent migration (odds ratio=1.6; P=0.02) by multivariable regression analysis. The mean duration of stent therapy was 65±62 days for stricture (27/34 remain in situ) and 57±57 days for leak (10/22 remain in situ). The median hospital length of stay was 2 days. CONCLUSIONS: FCMSF provide a safe and effective therapy for both benign and malignant esophageal dysphagia and leaks. The symmetrical property may contribute to the overall low observed migration rate while still allowing for simple and safe stent retrieval.

Case report: separation from cardiopulmonary bypass with a rigid bronchoscope airway after hemoptysis and bronchial impaction with clot.

Hemoptysis after cardiopulmonary bypass (CPB) occasionally occurs, and has varying clinical significance based upon amount of bleeding. Hemoptysis resulting in a clot and airway obstruction is an extremely rare event found almost exclusively in the intensive care unit. We describe a unique case of hemoptysis resulting in bronchial impaction from a clot requiring an emergent return to CPB during valve replacement surgery. We used a rigid bronchoscope, without an endotracheal tube, to facilitate airway patency in a patient with diffuse airway bleeding after bronchial disimpaction to separate from CPB.

Severe mediastinal infection with abscess formation after endobronchial ultrasound-guided transbrochial needle aspiration.

Endobronchial, ultrasound-guided, transbronchial needle aspiration has recently been introduced as an alternative to mediastinoscopy for lymph node staging of lung cancer and the diagnosis of respiratory diseases. This procedure is less invasive and more cost-effective, and multiple large studies have reported no associated complications. In this case, an individual presented with descending mediastinitis after having this minimally invasive procedure for mediastinal lymphadenopathy.

Video-assisted thoracoscopic lobectomy for pulmonary aspergilloma after life-threatening hemoptysis in a patient with lupus.

Open thoracotomy procedures serve as the mainstay for surgical resection of pulmonary aspergilloma. These procedures are considered among the most challenging for thoracic surgeons, and postoperative morbidity and mortality rates are high. Here, we present patient who underwent video-assisted thoracoscopic lobectomy for aspergilloma. Based on the success of the operation, we suggest that video-assisted thoracoscopic surgical resection be considered as an option for pulmonary aspergilloma.

Initial experience with endobronchial ultrasound in an academic thoracic surgery program.

BACKGROUND: Mediastinoscopy is considered the gold standard for evaluating mediastinal lymph nodes. However, endobronchial ultrasound-guided transbronchial needle aspiration has lately offered a less invasive alternative, with the ability to obtain nodal samples under direct visualization. Recent literature found an early learning curve for this technique. We present the initial experience of 4 thoracic surgeons with the procedure. MATERIALS AND METHODS: A retrospective chart review was performed on the first 51 patients on whom an endobronchial ultrasound-guided transbronchial needle aspiration was performed from January 5, 2007, to July 24, 2008. This group included 43 patients with a history or known diagnosis of malignancy as well as 8 patients with a presumed sarcoidosis diagnosis. All negative results were confirmed with mediastinoscopy. The technique's sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were assessed. RESULTS: A total of 73 lymph nodes underwent biopsy in 51 patients. These individuals included 34 men and 17 women, with an average age of 62 years (range, 21-89 years). No surgical or postoperative complications were noted. Overall, a correct diagnosis was established in 88% of the patients (45 of 51). After the first 25 cases (a mean of 6 cases per surgeon), a technique modification was adapted to increase diagnostic yield. The first 25 cases had a 72.22% sensitivity and 80% accuracy, whereas the last 26 cases had a 95.45% sensitivity and 96.15% accuracy (P = .07). CONCLUSION: Endobronchial ultrasound-guided transbronchial needle aspiration is a quickly mastered technique that offers a safe, minimally invasive, and accurate means to evaluate mediastinal lymph nodes.

Malignant mesothelioma 2008.

PURPOSE OF REVIEW: Mesothelioma is an aggressive malignancy of the pleura with poor survival. There will be approximately 3000 cases of mesothelioma in the United States annually. Multimodality treatment including neoadjuvant chemotherapy in selected individuals followed by extrapleural pneumonectomy and radiation has been studied in recent trials for its effects on disease free and overall survival This review provides a general overview of malignant mesothelioma with a summary of the most significant articles from within the past year as well as from the past. RECENT FINDINGS: Areas of recent interest include the evaluation of osteopontin and mesothelin as new tumor markers for mesothelioma. New phase III trials have been performed to evaluate the use of combined chemotherapy regimens. SUMMARY: Malignant mesothelioma is a very difficult malignancy to treat. Patients with the disease usually have an occupational asbestos exposure, and in some, viral exposure with SV40. There have been many historical treatments including combinations of local control with surgery and radiation as well as attempts to prevent systemic failure with chemotherapy. Novel therapies including intrapleural chemotherapy, photodynamic therapy and hyperthermic perfusion have also been used with some success. Finally there are several attempts at immunomodulating and targeted treatments, which are in phase I/II trials.