Benjamin E. Lee

Transitioning from video-assisted thoracic surgical lobectomy to robotics for lung cancer: Are there outcomes advantages?

OBJECTIVES To determine if there are advantages to transitioning to robotics by a surgeon who is already proficient in performing video-assisted thoracic surgical (VATS) lobectomy. METHODS A single surgeon proficient in VATS lobectomy initiated a robotic lobectomy program, and a retrospective review was conducted of his patients undergoing minimally invasive lobectomy (robotics or VATS) for lung cancer between 2011 and 2012. Data collected included patient/tumor characteristics, morbidity, mortality, operative times, and length of hospital stay. RESULTS Over a 24-month period, a total of 69 patients underwent minimally invasive lobectomy (35 robotic, 34 VATS). Patients in each group were similar in age and clinical stage. Robotic upper lobectomy operative times were longer than VATS (172 vs 134 minutes; P = .001), with no significant difference in lower lobectomies noted (140 vs 123 minutes; P = .1). Median length of stay was 3 days in both groups, and the median number of lymph nodes harvested was 18 (robotic) versus 16 (VATS; P = .42). Morbidity and mortality for robotic versus VATS were 11% versus 18% (P = .46) and 0% versus 3% (P = .49), respectively. CONCLUSIONS There does not seem to be a significant advantage for an established VATS lobectomy surgeon to transition to robotics based on clinical outcomes. The learning curve for robotic upper lobectomies seems to be more significant than that for lower lobectomies.

Utility of endobronchial ultrasound–guided mediastinal lymph node biopsy in patients with non–small cell lung cancer

OBJECTIVE Invasive mediastinal biopsy is often necessary in the evaluation of non-small cell lung cancer (NSCLC), and mediastinoscopy has long been considered the reference standard. However, the emergence of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has resulted in controversy regarding it represents a suitable replacement for mediastinoscopy. We chose to determine the utility of EBUS-TBNA in evaluating the mediastinum in patients with NSCLC. METHODS The present study was a retrospective review of a prospective database of consecutive patients with NSCLC who underwent EBUS-TBNA for mediastinal evaluation from 2009 to 2011. The sensitivity, specificity, negative predictive value, and accuracy of EBUS-TBNA are reported. Also reported are the size of the lymph nodes biopsied and the number of instances in which EBUS-TBNA obviated the need for cervical mediastinoscopy. RESULTS A total of 73 patients had a total of 140 mediastinal stations biopsied using EBUS-TBNA. Of the 73 patients, 30 had benign findings and underwent surgical resection, 1 of whom was found to have stage N2 disease. Of the remaining patients, 42 had a positive result and 1 had nondiagnostic biopsy findings for which malignancy was confirmed by mediastinoscopy. Mediastinoscopy would have changed the tumor stage and treatment planning in only 2 (2.7%) of the 73 patients. Overall, EBUS-TBNA had a sensitivity of 95%, a specificity of 100%, a negative predictive value of 94%, and an accuracy of 97%. CONCLUSIONS EBUS-TBNA might be a feasible option for most patients with NSCLC for whom histologic assessment of the mediastinum is necessary. The rates of nondiagnostic and false-negative biopsy findings using EBUS-TBNA were low, small subcentimeter nodes could be routinely biopsied, and most patients with a radiographically positive mediastinum had their disease pathologically confirmed.

Effect of hiatal hernia size and columnar segment length on the success of radiofrequency ablation for Barrett’s esophagus: A single-center, phase II clinical trial

OBJECTIVE Hiatal hernia is common in patients with Barretts esophagus. We sought to evaluate the effect of hiatal hernia size and initial columnar segment length on the success of radiofrequency ablation of Barretts esophagus. METHODS A phase II clinical trial was conducted aimed at evaluating the success of radiofrequency ablation in eradicating Barretts esophagus. Success was defined as complete replacement of the columnar lining with squamous mucosa and lack of intestinal metaplasia using light microscopy. Hiatal hernia size and columnar segment length were measured endoscopically. RESULTS Sixty-seven patients were accrued to the protocol. In the 55 patients who completed radiofrequency ablation (43 successes, 12 failures), the mean hiatal hernia size was 3.3 cm (range, 0-10 cm), and the mean columnar segment length was 5.4 cm (range, 1-18 cm). The median length of the columnar segment was 3 cm in the successful cases and 8.5 cm in the failed cases (P = .002). Although the median hiatal hernia size was identical in the successful and failed cases (3 cm, P = .38), the median hiatal hernia size was 7 cm (P = .001) in the 6 patients who experienced nonhealing after the initial ablation. Patients who were successfully ablated but had larger hiatal hernias and longer columnar segment lengths required significantly more radiofrequency ablation sessions than those with smaller hernias and shorter segments (P = .003 and P = .007, respectively). CONCLUSIONS Patients with larger hiatal hernias and longer columnar segments are more likely to experience failure or nonhealing after radiofrequency ablation. These patients also require more radiofrequency ablation treatments to achieve successful eradication of Barretts esophagus.

Patterns of recurrent and persistent intestinal metaplasia after successful radiofrequency ablation of Barrett’s esophagus

OBJECTIVE Radiofrequency ablation can eradicate Barretts esophagus successfully in the majority of cases. We sought to determine (1) how often intestinal metaplasia is detected during follow-up endoscopy after successful ablation and (2) patterns of persistent/recurrent intestinal metaplasia. METHODS Patients ablated successfully during a phase II clinical trial of radiofrequency ablation for Barretts esophagus were followed using endoscopic surveillance according to a defined protocol. Systematic biopsies were performed in all patients throughout the neosquamous epithelium as well as at the gastroesophageal junction, and patterns of recurrent or persistent intestinal metaplasia were documented. RESULTS Fifty-three patients were ablated successfully during this single-institution clinical trial. A total of 151 follow-up endoscopies were performed (range, 1-5 endoscopies per patient) and 2492 biopsies were obtained, of which 604 (24%) were from the gastroesophageal junction. The median follow-up period was 18 months (range, 3-50 months). Recurrent/persistent intestinal metaplasia was detected in 14 patients (26%) in 3 distinct patterns: endoscopically invisible intestinal metaplasia underneath the neosquamous epithelium (buried glands) in 3 patients, visible recurrence in the tubular esophagus in 3 patients, and intestinal metaplasia of the gastroesophageal junction (with a squamous-lined tubular esophagus) in 10 patients. Dysplasia or cancer was not detected in any patient during the follow-up period. CONCLUSIONS Recurrent/persistent intestinal metaplasia after successful radiofrequency ablation of Barretts esophagus is relatively common. This finding has implications for the continued surveillance of patients who are ablated successfully.

Nodal Upstaging in Robotic and Video Assisted Thoracic Surgery Lobectomy for Clinical N0 Lung Cancer

BACKGROUND Recent multiinstitutional published data have demonstrated increased pathologic nodal upstaging by robotic lobectomy compared with historical video-assisted thoracic surgery (VATS) lobectomy data. To eliminate potential variability from multiple surgical techniques, we compared the rate of nodal upstaging at a single institution where robotic and VATS lobectomy are both performed. METHODS We retrospectively reviewed clinically node-negative patients with lung cancer undergoing VATS or robotic lobectomy. Clinical data were recorded in concordance with The Society of Thoracic Surgeons database elements. The rates of pathologic nodal upstaging as well as disease-free and overall survival were calculated. RESULTS A total of 211 patients underwent anatomic lobectomy by VATS (n = 158) or robotics (n = 53) from 2009 to 2014. The two groups were statistically similar in their clinical stage, tumor size, location, and histologic evaluation. Within the VATS group, 24 patients experienced nodal upstaging (15.2%), with 13 patients having pN1 disease, and 11 patients having pN2 disease. The robotics group contained 7 patients (13.2%) with nodal upstaging, with 5 patients exhibiting pN1 disease and 2 patients with pN2 disease. When VATS and robotics were compared, there was no significant difference in pathologic upstaging (p = 0.72), 2-year overall survival (88% vs 95%, respectively; p = 0.40), or 2-year disease-free survival (83% vs 93%, respectively; p = 0.48). CONCLUSIONS In this comparison of robotic and VATS lobectomy for clinically node-negative lung cancer that was managed with consistent surgical technique and pathologic evaluation, the rate of nodal upstaging achieved by robotics appears similar to VATS. In addition, there were no appreciable differences in disease-free or overall survival.

Successful Treatment of an Iatrogenic Tracheal Laceration With a Temporary Polyurethane-Coated Nitinol Stent

We report the case of a 63-year-old woman who required emergent intubation after a choking episode at home. It resulted in a 5-cm tear in the membranous trachea. She was treated by placement of a temporary tracheal stent, which was successfully removed 3 months later.

An Unusual Case of Dysphagia From Intrathoracic Liver

We report an unusual case of heterotopic intrathoracic liver resulting in severe dysphagia and esophageal obstruction.

Survival Following Gastro-Left Ventricular Fistula in a Patient Post Roux-en-Y Gastric Bypass

We report a case of a 55-year old woman with a prior roux-en-Y gastric bypass who survived after surgical repair of a gastro-left ventricular fistula.

Editorial CommentaryRobotic Assisted Thoracic Surgery Lobectomy versus Video Assisted Thoracic Surgery Lobectomy: Is a Randomized Trial Really Necessary?☆

Minimally invasive pulmonary resection (MIPR) for lung cancer has become standard in many centers, and is slowly being adopted throughout the United States. An abundance of literature supports MIPR over traditional thoracotomy in terms of short-term surgical outcomes with no oncologic inferiority, and perhaps benefit. 1 What has become the latest point of contention, however, is not whether or not MIPR should be performed, but what instrumentation should be used to perform it. In this regard, Agzarian et al 2 have performed a systematic review of published literature (no randomized, controlled trials [RCT]) concerning robotic-assisted thoracic surgery (RATS), ultimately comparing it to nonrobotic MIPR (video assisted thoracic surgery (VATS)) as well as traditional thoracotomy. As one would anticipate, RATS appeared to provide superior outcomes compared to traditional thoracotomy. However, no significant differences were appreciated in surgical and oncologic outcomes between RATS and VATS, with the exception that RATS appeared to be more costlier than VATS. The authors concluded (as have other investigators that have evaluated this question) that a prospective randomized trial is needed to investigate differences in outcomes between RATS and VATS. Is this a question that the thoracic surgical community really needs to attempt to answer in a RCT? We would argue “no,” for several reasons. First, any such trial cannot be performed in a blindedfashion.Different surgeons will need to performRATS vs VATS, which will introduce significant surgeon bias. Surgeons have different technical abilities and philosophies regarding how to conduct the operation. Some surgeons have adopted RATS because they are not comfortable in their ability to perform VATS. As a result, even if a significant difference in an outcome variable was detected in a RCT, it may be contested on this basis. Second, what is the hypothesis that would be tested in a RCT? There is no evidence to date that one approach is better than the other (with the possible exception

RATS Versus VATS Lobectomy: is a Randomized Trial Really Necessary?

Minimally invasive pulmonary resection (MIPR) for lung cancer has become standard in many centers, and is slowly being adopted throughout the United States. An abundance of literature supports MIPR over traditional thoracotomy in terms of short-term surgical outcomes with no oncologic inferiority, and perhaps benefit. 1 What has become the latest point of contention, however, is not whether or not MIPR should be performed, but what instrumentation should be used to perform it. In this regard, Agzarian et al 2 have performed a systematic review of published literature (no randomized, controlled trials [RCT]) concerning robotic-assisted thoracic surgery (RATS), ultimately comparing it to nonrobotic MIPR (video assisted thoracic surgery (VATS)) as well as traditional thoracotomy. As one would anticipate, RATS appeared to provide superior outcomes compared to traditional thoracotomy. However, no significant differences were appreciated in surgical and oncologic outcomes between RATS and VATS, with the exception that RATS appeared to be more costlier than VATS. The authors concluded (as have other investigators that have evaluated this question) that a prospective randomized trial is needed to investigate differences in outcomes between RATS and VATS. Is this a question that the thoracic surgical community really needs to attempt to answer in a RCT? We would argue “no,” for several reasons. First, any such trial cannot be performed in a blindedfashion.Different surgeons will need to performRATS vs VATS, which will introduce significant surgeon bias. Surgeons have different technical abilities and philosophies regarding how to conduct the operation. Some surgeons have adopted RATS because they are not comfortable in their ability to perform VATS. As a result, even if a significant difference in an outcome variable was detected in a RCT, it may be contested on this basis. Second, what is the hypothesis that would be tested in a RCT? There is no evidence to date that one approach is better than the other (with the possible exception