Carla Moodie

Effect of small body habitus on peri-operative outcomes after robotic-assisted pulmonary lobectomy: retrospective analysis of 208 consecutive cases

BACKGROUND Patients with smaller body surface area (BSA) have smaller pleural cavities, which limit visualization and instrument mobility during video-assisted thoracoscopic surgery (VATS). We investigated the effects of BSA on outcomes with robotic-assisted VATS lobectomy. METHODS We analyzed 208 consecutive patients who underwent robotic-assisted lobectomy over 34 months. Patients were separated into group A (BSA ≤1.65 m(2)) and group B (BSA >1.65 m(2)). Operative times, estimated blood loss (EBL), conversions to thoracotomy, complications, hospital length of stay (LOS), and in-hospital mortality were compared. RESULTS Group A had 40 patients (BSA 1.25-1.65 m(2)), and group B had 168 patients (BSA 1.66-2.86 m(2)). Median skin-to-skin operative times [± standard error of the mean (SEM)] were 169±16 min for group A and 176±6 min for group B (P=0.34). Group A had median EBL of 150±96 mL compared to 200±24 mL for group B (P=0.37). Overall conversion rate to thoracotomy was 8/40 (20.0%) in group A versus 12/168 (7.1%) in group B (P=0.03); while emergent conversion for bleeding was 2/40 (5.0%) in group A versus 5/168 (3.0%) in group B (P=0.62). Postoperative complications occurred in 12/40 (30.0%) in group A, compared to 66/168 (39.3%) in group B (P=0.28). Patients from both groups had median hospital LOS of 5 days (P=0.68) and had similar in-hospital mortality. CONCLUSIONS Patients with BSA ≤1.65 m(2) have similar perioperative outcomes and complication risks as patients with larger BSA. Patients with BSA ≤1.65 m(2) have a higher overall conversion rate to thoracotomy, but similar conversion rate for bleeding as patients with larger BSA. Robotic-assisted pulmonary lobectomy is feasible and safe in patients with small body habitus.

Effect of gender on perioperative outcomes after robotic-assisted pulmonary lobectomy

BACKGROUND Female gender has been associated with worse outcomes after cardiovascular surgery and critical illness. We investigated the effect of gender on perioperative outcomes following robotic-assisted pulmonary lobectomy. METHODS We retrospectively analyzed 282 consecutive patients who underwent robotic-assisted pulmonary lobectomy by one surgeon over 53 months. Perioperative outcomes and clinically significant intraoperative and postoperative complications, including respiratory and cardiovascular events, were noted. Chi-Square (χ2), Fishers exact test, Analysis of Variance (ANOVA), Students t-test, and Kruskal-Wallis or Moods median test were used to compare variables, with significance at P≤0.05. RESULTS There were 128 men (mean age, 68.8 yr) and 154 women (mean age, 65.9 yr; P=0.02). Women had higher preoperative forced expiratory volume in 1 second as percent of predicted (FEV1%; P=0.001). There were more former smokers in the male cohort (P=0.03) and more nonsmokers in the female cohort (P<0.001). Women had smaller tumors (3.0±0.1 vs. 3.5±0.2 cm, P=0.04), lower estimated blood loss (EBL) (150±34 vs. 250±44 mL, P<0.001), and shorter operative time (168±6 vs. 196±7 min, P=0.01). Rates of intraoperative complications (7.1% vs. 8.6%, P=0.65) and of conversion to open lobectomy (7.8% vs. 8.6%; P=0.81) were similar between genders. Postoperative complications were fewer in women (27.9% vs. 44.5%; P=0.004), the most common of which, in both women and men, were prolonged air leak for ≥7 days (13.0% vs. 22.7%, P=0.03), atrial fibrillation (7.1% vs. 14.8%, P=0.04), and pneumonia (7.8% vs. 10.2%, P=0.49). Hospital length of stay (LOS) (4±0.3 vs. 5±0.5 days) was also shorter for women (P=0.02). Despite the higher postoperative complication rate in men, in-hospital mortality did not differ between genders (P=0.23). Multivariable analyses did not identify female gender as an independent predictor of post-operative complications. CONCLUSIONS Female gender was associated with rates of intraoperative complications and of conversion to open lobectomy as low as those for men, but with better perioperative outcomes, lower risk of intraoperative bleeding, and fewer postoperative complications. Thus, robotic-assisted pulmonary lobectomy is feasible and safe for women.

Surgical outcomes associated with postoperative atrial fibrillation after robotic-assisted pulmonary lobectomy: retrospective review of 208 consecutive cases

BACKGROUND In this study, we sought to investigate the effect of post-operative atrial fibrillation (POAF) after robotic-assisted video-thoracoscopic pulmonary lobectomy on comorbid postoperative complications, chest tube duration, and hospital length of stay (LOS). METHODS We retrospectively analyzed prospectively collected data from 208 consecutive patients who underwent robotic-assisted pulmonary lobectomy by one surgeon for known or suspected lung cancer. Postoperatively, 39 (18.8%) of these patients experienced POAF during their hospital stay. The occurrence of postoperative complications other than POAF, chest tube duration, and hospital LOS were analyzed in patients with POAF and without POAF. Statistical significance (P≤0.05) was determined by unpaired Students t-test or by Chi-square test. RESULTS Of patients with POAF, 46% also had other concurrent postoperative complications, while only 31% of patients without POAF experienced complications. The average number of postoperative complications experienced by patients with POAF was significantly higher than that experienced by those without POAF (0.9 vs. 0.4, P<0.05). Median chest tube duration in POAF patients (6 days) was significantly higher than in patients without POAF (4 days). A similar result was also seen with hospital LOS, with the median hospital LOS of 8 days in POAF patients being significantly longer than in those without POAF, whose median hospital LOS was 4 days. No other significant difference was detected between the two groups of patients. CONCLUSIONS This study demonstrated the association between the incidence of POAF and a more complicated hospital course. Further studies are needed to determine whether confounders were involved in this association.

PD.2.04 Effect of Nodal Skip Metastasis on Outcomes after Robotic-Assisted Pulmonary Lobectomy for Primary Lung Cancer

the blood during the earliest stages of cancer development. EarlyCDT®Lung is a blood test that measures a panel of seven autoantibodies specific for lung cancer-associated antigens and is being utilized by physicians to assess the risk of a pulmonary nodule being malignant. The test’s high specificity and positive predictive value (PPV) complements the high sensitivity of computed tomography (CT). As a ‘rule in’ test, EarlyCDT-Lung helps identify which patients with a pulmonary nodule(s) are most likely to have a lung cancer. Method: A cohort of nearly 2000 patients tested by EarlyCDT-Lung were followed up for clinical outcomes. Medical records were requested from physician offices and reviewed to determine clinical actions, nodule characteristics and any cancer diagnoses. Results: EarlyCDT-Lung was found to complement CT and risk calculators (e.g., Swensen/Mayo nodule malignancy risk calculator), with a positive Moderate or High Level result increasing the pre-test malignancy risk of a nodule by w2-fold (e.g., from 48% to 91%). For a nodule with a calculated pre-test risk that was intermediate (10-65%), a positive High Level result shifted the risk into High/Intervention risk (>65%), and a positive Moderate Level result added more than 25% to the pre-test risk of malignancy, shifting many intermediate risk nodules into the High/Intervention risk category. For those patients with a nodule detected prior to EarlyCDT-Lung who were diagnosed with a lung cancer within 12 months after having a positive EarlyCDT-Lung test, the average time to diagnosis was 45 days after the EarlyCDT-Lung test was reported. A positive EarlyCDT-Lung result was observed as early as 7 years before diagnosis of a stage 2 adenocarcinoma, which corroborates previous data showing autoantibodies are elevated very early in the development of a cancer. Conclusion: As a ‘rule in test,’ EarlyCDT-Lung facilitates the reclassification of indeterminate pulmonary nodules in CT surveillance into a more appropriate category of management, thereby enabling faster diagnosis and earlier treatment.

P12 Lung Tumor Histology as a Prognostic Factor for Short- and Long-Term Postoperative Outcomes

Background: Despite targeted therapies impacted on progression-free survival in EGFR positive metastatic NoneSmall Cell lung carcinoma (NSCLC) these agents are not available in brazilian public health care system (SUS). Polychemotherapy based on platinum still being used in this situation in contrast with international guidelines. This analysis aims to estimate the impact of the lack of access to anti-EGFR therapies on the PFS of these patients. Method: The annual number of patients diagnosed with lung cancer was based on epidemiologic data of Cancer National Institute (INCA). Patients who have access to private health insurances were excluded. Only adenocarcinoma histology was considered. The INCA database, a cohort (Wong, 2016) and four clinical trials: EURTAC, LUX-Lung 3, LUX-Lung 7 and FLAURA were used to estimate stage distribution at diagnosis, recurrence rates and progression free survival in 2 years. The population without mutation in EGFR also was excluded. Results: INCA estimates 28,220 new cases of lung cancer per year in Brazil. Of these, 76.3% are supposed to treated in SUS, totalizing 21,532, upon which 3,790 (40%) have adenocarcinoma histology. Of these, 3,790 (44%) have metastasis at diagnosis, and 3,703 (43%), 603 (7%), 517 (6%) are diagnosed in stages III, II and I, respectively. A recurrences rate of 53.79% in stage III (1,992), 46.49% in II (280) and 26.06% in I (135) in 5 years from diagnosis. Of these, 28% have mutation in EGFR. The outcome of our study was that, if they were treated with polychemotherapy, only 71 would be free of progression after 24 months. In contrast, with the use of inhibitors of tyrosine kinase anti-EGFR, the expectation was 312 patients free from disease for Erlotinib, 377 for Gefitinib, 388 for Afatinib and 720 for Osimertinib. Conclusion: The monthly drug costs, in Brazil, were, approximately, R

Effect of Obesity on Perioperative Outcomes After Robotic-Assisted Pulmonary Lobectomy: Retrospective Study of 287 Patients

4,000 for Gefitinib, R

Effect of advanced age on peri-operative outcomes after robotic-assisted pulmonary lobectomy: Retrospective analysis of 287 consecutive cases

5,000 for Afatinib, R

P1.16: Comparison of Peri-Operative Outcomes After Robotic-Assisted Video-Thoracoscopic Lobectomies Versus Segmentectomies: Track: Early Stage NSCLC (Stage I - III)

8,000 for Erlotinib and R

P1.15: Comparison of Pulmonary Function After Robotic-Assisted Video-Thoracoscopic Lobectomies vs Segmentectomies: Track: Early Stage NSCLC (Stage I - III)

32,000 for Osimertinib. With this, a cost-effectiveness study, presented by Gilberto De Lima Lopes Jr. in ASCO this year, showed that Osimertinib, although its high PFS, was not cost-effective in our country. Larger discounts, pharmaceutics support and more clinical trials are necessary to improve access to Osimertinib. In contrast, the incorporation of Gefitinib, Afatinib and Erlotinib in the public health care system should influence in PFS. Despite this, our study showed that, in two years, should avoid the progression of disease in 378 patients.

Upstaging and survival after robotic-assisted thoracoscopic lobectomy for non-small cell lung cancer

Objective. We investigated whether higher body mass index (BMI) affects perioperative and postoperative outcomes after robotic-assisted video-thoracoscopic pulmonary lobectomy. Methods. We retrospectively studied all patients who underwent robotic-assisted pulmonary lobectomy by one surgeon between September 2010 and January 2015. Patients were grouped according to the World Health Organization’s definition of obesity, with “obese” being defined as BMI >30.0 kg/m2. Perioperative outcomes, including intraoperative estimated blood loss (EBL) and postoperative complication rates, were compared. Results. Over 53 months, 287 patients underwent robotic-assisted pulmonary lobectomy, with 7 patients categorized as “underweight,” 94 patients categorized as “normal weight,” 106 patients categorized as “overweight,” and 80 patients categorized as “obese.” Because of the relatively low sample size, “underweight” patients were excluded from this study, leaving a total cohort of 280 patients. There was no significant difference in intraoperative complication rates, conversion rates, perioperative outcomes, or postoperative complication rates among the 3 groups, except for lower risk of prolonged air leaks ≥7 days and higher risk of pneumonia in patients with obesity. Conclusions. Patients with obesity do not have increased risk of intraoperative or postoperative complications, except for pneumonia, compared with “normal weight” and “overweight” patients. Robotic-assisted pulmonary lobectomy is safe and effective for patients with high BMI.