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The development of an advanced robotic platform in 2014 led to increased adoption of minimally invasive (MI) approaches in thoracic surgery. Due to dataset reporting lag, a comprehensive assessment of trends in thoracic approaches has not been analyzed to date.We queried the National Cancer Database (NCDB) for patients with Stage I-III who underwent lung resection from 2010 to 2018. Most published NCDB analyses on lung cancer using pre-2015 data. Overall treatment trends were analyzed, with geographic, institutional, and socioeconomic characteristics evaluated for approach.There were 162 335 lung resections, and 131 958 were anatomic. Robotic resection saw a steady increase through 2012 but plateaued in 2013-2014. From 2015 to 2018, another increase correlated with the release of a new platform. Video-assisted thoracoscopic surgery lung resection plateaued in 2014 and decreased in 2018. Open resection steadily decreased. Tumors requiring neoadjuvant radiation had an increase in MI approach with corresponding decreases in the open. On multivariable analysis, African-American race, low volume, Medicaid insurance, and nonacademic setting were associated with a lower likelihood of MI surgery.The open approach has decreased since 2010. More than 65% of anatomic resections are now performed in MI. As this trend will continue, it is important that all patients are afforded the opportunity of the least invasive approach.

The use of a robotic surgical platform has become common place in thoracic surgery programs throughout the United States. Formal training paradigms need to be reevaluated to allow for effective and efficient training of thoracic surgery residents and fellows. The utilization of video-based coaching and simulation are effective adjuncts in robotics training.

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Sarcopenia, visceral fat volume, and bone density have been associated with lung cancer survival. We developed a morphomic index based on computed tomographic measurements of these components, and assessed its relationship to survival after lung cancer resection.Patients who underwent lung cancer resection from 1995 to 2014 were evaluated. A morphomic index (range of 0 to 3) was developed as the sum of the scores for three body components-dorsal muscle area, vertebral trabecular bone density, and visceral fat area-measured at vertebral levels T10 to T12, with a point assigned to each component when in the lowest tercile. The relationship of the morphomic index to overall survival was assessed by the log rank test. Overall survival was assessed using Cox proportional hazards models adjusted for relevant covariates.We included 944 patients (451 women; 48%). The mean age was 66.4 ± 10.3 years. Median follow-up was 4.5 years. Median survival was associated with the morphomic index scores on univariate analysis (P.001). Morphomic index scores of 2 (P = .026) and 3 (P = .004) referenced to score 0 or 1 were independent predictors of survival on Cox regression analysis.A morphomic index is an independent predictor of survival after lung cancer resection. The index may help in calibrating patient expectations and in shared decision making regarding lung cancer surgery.

BACKGROUND: Real-world treatment practices for positive mediastinal nodal disease in non-small cell lung cancer (NSCLC) continues to vary despite guidelines. We aim to assess national trends in the treatment of pathologic-N2 disease, and evaluate the association with clinical nodal staging and timing of systemic therapy. METHODS: The National Cancer Database was queried for patients with NSCLC who underwent lobectomy and had pathologic-N2 disease from 2010–2017. National Comprehensive Cancer Network (NCCN) guideline concordance was evaluated. cN2 patients were analyzed based on timing of systemic therapy and response. Multivariable logistic regression evaluated outcomes by type of systemic therapy. Survival analysis utilized Cox proportional hazards regression and Kaplan-Meier methods. RESULTS: 10,225 patients met inclusion criteria. Fifty-four percent of patients were understaged prior to surgery as either cN0 or cN1. Of clinically staged N2 patients, 56% received NCCN recommended neoadjuvant therapy. Annual guideline concordance increased until 2016 to a max of 62.9%. Neoadjuvant and adjuvant systemic therapy showed an overall survival benefit compared with no systemic therapy (HR 0.54 & 0.57), but no difference when compared against each other. Complete response after neoadjuvant therapy was associated with improved survival (5-year OS 56.1%, P

Isolated anomalous drainage of the left pulmonary vein to the left innominate vein is a rare variant of partial anomalous pulmonary venous connection. Here, we describe 2 adult patients with this variant who underwent successful robotic totally endoscopic repair with anastomosis of the pulmonary vein to the left atrial appendage.

OBJECTIVE The aim of this study was to analyze outcomes of open lobectomy (OL), video-assisted thoracoscopic lobectomy (VATS) and robotic-assisted lobectomy (RL). SUMMARY BACKGROUND DATA Robotic-assisted lobectomy has seen increasing adoption for treatment of early-stage lung cancer. Comparative data regarding these approaches is largely from single-institution case series or administrative datasets. METHODS Retrospective data was collected from 21 institutions from 2013-2019. All consecutive cases performed for clinical stage IA-IIIA lung cancer were included. Neoadjuvant cases were excluded. Propensity-score matching (1:1) was based on age, gender, race, smoking-status, FEV1%, Zubrod score, ASA score, tumor size and clinical T and N stage. RESULTS A total of 2,391 RL, 2,174 VATS, and 1,156 OL cases were included. After propensity-score matching there were 885 pairs of RL vs. OL, 1,711 pairs of RL vs. VATS, and 952 pairs of VATS vs. OL. Operative time for RL was shorter than VATS (p < 0.0001) and OL (p = 0.0004). Compared to OL, RL and VATS had less overall postoperative complications, shorter hospital stay (LOS), and lower transfusion rates (all p < 0.02). Compared to VATS, RL had lower conversion rate (p < 0.0001), shorter hospital stay (p < 0.0001) and a lower postoperative transfusion rate (p = 0.01). RL and VATS cohorts had comparable postoperative complication rates. In-hospital mortality was comparable between all groups. CONCLUSIONS RL and VATS approaches were associated with favorable perioperative outcomes compared to OL. Robotic-assisted lobectomy was also associated with a reduced length of stay and decreased conversion rate when compared to VATS.

Highlights • Hemodynamically stable gunshot wound patients may be managed without retrieval of the bullet. • Nearly 90% of patients with cardiac bullet emboli on initial presentation are hemodynamically stable. • Non-operative management of stable patients includes intensive observation and additional imaging to localize the bullet., Gunshot wounds to the cardiac region usually result in devastating injuries. However, if bullets embolize into the myocardium without significant damage to the organ, optimal evaluation and management remains unclear. We present the case of a hemodynamically stable gunshot wound patient who presented with a bullet to the heart. Sternotomy revealed that the bullet had embolized through the superior vena cava and embedded into the apex of the right ventricle. The patient was managed without retrieval of the bullet and continues to be well despite a retained intracardiac bullet. We discuss cases of bullet embolization to the heart and the emergence of minimally-invasive approaches for management.

OBJECTIVES: Publicly reported postoperative 30-day mortality rates are commonly used to compare hospital quality after coronary artery bypass graft (CABG) surgery. We sought to determine whether 90-day mortality rates, which are not publicly reported but better capture post-discharge mortality, are a better determinant of hospital performance. METHODS: Retrospective cohort analysis of 30 versus 90-day risk-standardized mortality rates (RSMR) at adult cardiac surgical centers in NYS from 2008 – 2014. Hospitals were classified as good or poor-performing outliers at each time point based on the bounds of the 95% confidence interval around each hospital’s predicted RSMR, determined via hierarchical models. The primary outcome was change in institutional performance via outlier classification from 30 to 90 days. RESULTS: During the study period, 72,398 adults underwent a CABG procedure at one of 42 institutions. The RSMR increased from 30 to 90 days at all institutions, with a median 30-day RSMR of 2.16% (IQR 0.69%) and median 90-day RSMR of 3.69% (IQR 1.00%). In using a 90 instead of 30-day metric, 3 hospitals changed outlier status. One hospital improved to a good from as expected performer; 2 worsened to as expected from good performers. CONCLUSIONS: In a cohort of patients who underwent CABG surgery from 2008 – 2014 in NYS, use of a 90-day mortality metric resulted in a change in hospital quality assessment for a minority of hospitals. The use of 90-day mortality may not provide additional value when evaluating institutional performance for this population.

OBJECTIVES: To assess the impact of percutaneous dilational tracheostomy in coronavirus disease 2019 patients requiring mechanical ventilation and the risk for healthcare providers. DESIGN: Prospective cohort study; patients were enrolled between March 11, and April 29, 2020. The date of final follow-up was July 30, 2020. We used a propensity score matching approach to compare outcomes. Study outcomes were formulated before data collection and analysis. SETTING: Critical care units at two large metropolitan hospitals in New York City. PATIENTS: Five-hundred forty-one patients with confirmed severe coronavirus disease 2019 respiratory failure requiring mechanical ventilation. INTERVENTIONS: Bedside percutaneous dilational tracheostomy with modified visualization and ventilation. MEASUREMENTS AND MAIN RESULTS: Required time for discontinuation off mechanical ventilation, total length of hospitalization, and overall patient survival. Of the 541 patients, 394 patients were eligible for a tracheostomy. One-hundred sixteen were early percutaneous dilational tracheostomies with median time of 9 days after initiation of mechanical ventilation (interquartile range, 7-12 d), whereas 89 were late percutaneous dilational tracheostomies with a median time of 19 days after initiation of mechanical ventilation (interquartile range, 16-24 d). Compared with patients with no tracheostomy, patients with an early percutaneous dilational tracheostomy had a higher probability of discontinuation from mechanical ventilation (absolute difference, 30%; p < 0.001; hazard ratio for successful discontinuation, 2.8; 95% CI, 1.34-5.84; p = 0.006) and a lower mortality (absolute difference, 34%, p < 0.001; hazard ratio for death, 0.11; 95% CI, 0.06-0.22; p < 0.001). Compared with patients with late percutaneous dilational tracheostomy, patients with early percutaneous dilational tracheostomy had higher discontinuation rates from mechanical ventilation (absolute difference 7%; p < 0.35; hazard ratio for successful discontinuation, 1.53; 95% CI, 1.01-2.3; p = 0.04) and had a shorter median duration of mechanical ventilation in survivors (absolute difference, -15 d; p < 0.001). None of the healthcare providers who performed all the percutaneous dilational tracheostomies procedures had clinical symptoms or any positive laboratory test for severe acute respiratory syndrome coronavirus 2 infection. CONCLUSIONS: In coronavirus disease 2019 patients on mechanical ventilation, an early modified percutaneous dilational tracheostomy was safe for patients and healthcare providers and associated with improved clinical outcomes.

Background Coronavirus 2019 (COVID-19) is a worldwide pandemic, with many patients requiring prolonged mechanical ventilation. Tracheostomy is not recommended by current guidelines as it is considered a superspreading event owing to aerosolization that unduly risks health care workers. Methods Patients with severe COVID-19 who were on mechanical ventilation for 5 days or longer were evaluated for percutaneous dilational tracheostomy. We developed a novel percutaneous tracheostomy technique that placed the bronchoscope alongside the endotracheal tube, not inside it. That improved visualization during the procedure and continued standard mechanical ventilation after positioning the inflated endotracheal tube cuff in the distal trachea. This technique offers a significant mitigation for the risk of virus aerosolization during the procedure. Results From March 10 to April 15, 2020, 270 patients with COVID-19 required invasive mechanical ventilation at New York University Langone Health Manhattan's campus; of those, 98 patients underwent percutaneous dilational tracheostomy. The mean time from intubation to the procedure was 10.6 ± 5 days. Currently, 32 patients (33%) do not require mechanical ventilatory support, 19 (19%) have their tracheostomy tube downsized, and 8 (8%) were decannulated. Forty patients (41%) remain on full ventilator support, and 19 (19%) are weaning from mechanical ventilation. Seven patients (7%) died as a result of respiratory and multiorgan failure. Tracheostomy-related bleeding was the most common complication (5 patients). None of health care providers has had symptoms or tested positive for COVID-19. Conclusions Our percutaneous tracheostomy technique appears to be safe and effective for COVID-19 patients and safe for health care workers.

Primary vascular tumors such as vascular leiomyosarcomas are rare, but exhibit markedly different characteristics than tumors that invade the vasculature from a secondary source. Establishing a diagnosis is essential in determining the appropriate treatment plan, but obtaining a histologic specimen may prove challenging and carry significant risks. Minimally invasive endovascular biopsy techniques can be pivotal in the diagnosis-and thus in the management-of vascular tumors. We present a case of a primary inferior vena cava leiomyosarcoma, not able to be adequately assessed by noninvasive imaging and deemed too risky to be approached with traditional percutaneous biopsy techniques. Accurate diagnosis of such tumors is critical, as the success of surgical resection, although high risk, depends greatly upon the type, location, and extent of malignancy.

Pleural empyema is a common surgical problem. Due to varied clinical scenarios based on the duration and stage of empyema, the optimal approach to management has been uncertain. With advances in thoracoscopic technology and skillsets, the success rate for video assisted thoracoscopic surgery (VATS) decortication has improved in recent years. This data is based on evidence from observational studies and national database reviews. There are no formal randomized clinical trials for approach to decortication. While a minimally invasive approach is optimal, the primary goal is total decortication with complete lung reexpansion and evacuation of infection. A minimally invasive approach is appropriate and feasible in most situations. A low threshold for conversion to thoracotomy is needed if those outcomes cannot be met.

Background Our objectives are to report our outcomes and to demonstrate our evolving technique for robotic sleeve resection of the airway, with or without lobectomy, using video vignettes. Methods We retrospectively reviewed a single-surgeon prospective database from October 2010 to October 2019. Results Over 9 years, of 5573 operations 1951 were planned for a robotic approach. There were 755 robotic lobectomies and 306 robotic segmentectomies, and 23 consecutive patients were scheduled for elective completely portal, robotic sleeve resection. Sleeve lobectomy was performed in 18 patients: 10 right upper lobe, 6 left upper lobe, and 2 right lower lobe. Two patients had mainstem bronchus resections and 2 underwent right bronchus intermedius resections that preserved the entire lung. One patient had a robotic pneumonectomy. One operation was converted to open thoracotomy because of concern for anastomotic tension in a patient who received neoadjuvant therapy. All patients had an R0 resection. In the last 10 operations we modified our airway anastomosis, using a running self-locking absorbable suture. The median length of hospital stay was 3 days (range, 1-11), with no 30- or 90-day mortalities. Within a median follow-up of 18 months, there were no anastomotic strictures and no recurrent cancers. Conclusions Our early and midterm results show that a completely portal robotic sleeve resection is safe and oncologically effective. Trhe technical aspects of a robotic sleeve resection of the airway are demonstrated using video vignettes.

OBJECTIVES Left coronary vessels are the usual targets in totally endoscopic coronary artery bypass (TECAB). Grafting of the right coronary artery (RCA) has been limited using this approach because of anatomic and technical difficulties. We report a first series of robotic beating-heart TECAB to the RCA via a right-chest approach. METHODS From July 2013 to April 2019, patients who underwent robotic beating-heart TECAB with the right internal mammary artery to the RCA were reviewed. Port placement in the right chest mirrored standard left-sided ports. Indications for right internal mammary artery to RCA bypass were RCA disease not amenable to percutaneous intervention and anomalous origin of the RCA. RESULTS Right internal mammary artery–RCA bypass was performed in 16 patients (mean age 60.6 ± 13.5, 75% male). All cases were completed without conversion to sternotomy or mini-thoracotomy. Cardiopulmonary bypass was required in 1 patient to expose the posterior descending artery. Mean procedure time was 223 ± 49 min, with half of the patients extubated in the operating room (50%). Mean intraoperative transit-time graft flow was 87.0 ± 19.3 ml/min, and a pulsatility index of 1.2 ± 0.2. Mean length of stay was 2.3 ± 1.2 days. No mortality was observed at mean follow-up time of 20.6 months. One patient required repeat RCA revascularization for progression of native disease 43.7 months after the surgery. CONCLUSIONS Robotic beating-heart TECAB for isolated RCA disease is a feasible operation in selected patients. This technique is possible even for the posterior descending artery.

Background Body mass index (BMI) is not routinely taken into consideration for risk stratification prior to esophagectomy. Extremes of BMI are associated with adverse surgical outcomes in a variety of surgical specialties. We assessed the relationship of BMI to outcomes after esophagectomy for cancer. Methods Patients in the Society of Thoracic Surgeons General Thoracic Surgery Database (2009 to 2016) who underwent elective esophagectomy for cancer were selected for analysis. Open and minimally invasive approaches were included. Complications were categorized based on the Esophagectomy Complications Consensus Group recommendations. Multivariable logistic regression was used to adjust for confounding variables. Results We evaluated 9,389 patients grouped by BMI: underweight ( Conclusions BMI is associated with postoperative complications after esophagectomy. Postoperative risk assessment and prehabilitation regimens should be adjusted accordingly when planning an esophagectomy for a patient with very low or very high BMI.

The use of minimally invasive esophagectomy (MIE) is increasing despite limited evidence to support its efficacy. We compared overall survival and perioperative mortality for MIE vs open esophagectomy (OE). We queried the National Cancer Database for all patients having esophagectomy as the primary procedure for primary squamous cell cancer and adenocarcinoma from 2010 through 2012. A propensity score analysis was performed. Postoperative pathology and quality, as well as overall patient survival outcomes, were compared between OE and MIE. The use of MIE increased from 26.9% in 2010 to 36.3% in 2012 (P 0.001). Of 3032 patients (2050 OE and 982 MIE) who were identified, propensity score matching (1:1) yielded 977 patients in each group. Mean lymph nodes examined were higher in the MIE group (16.3 vs 14.5, P 0.001). However, final pathologic nodal stage was not significantly different in the matched sample. There was also no difference in pathologic upstaging or margin status between the groups. All other postoperative variables were equivalent, including an average length of stay of 14 days, unplanned readmission rate of 6.5%, and 30-day and 90-day mortality rates of 3% and 7%, respectively. There was no survival difference, with a median survival of 48.7 months for OE and 46.6 months for MIE (Kaplan-Meier analysis, P = 0.376). During the 3-year period analyzed, there were no significant differences in postoperative outcomes and quality metrics between OE and MIE. Although short-term outcomes are limited in the National Cancer Database, MIE appears to have equivalent oncological outcomes and survival when compared with the open approach.

Background For operable patients with clinical stage IIIA non-small cell lung cancer, the optimum neoadjuvant treatment strategy remains unclear. Our aim was to compare perioperative and long-term outcomes for patients receiving neoadjuvant chemoradiotherapy (NCRT) versus neoadjuvant chemotherapy (NCT) alone. Methods We queried the National Cancer Database to identify all patients with N2 and either T1-T2 non-small cell lung cancer who received either NCRT or NCT followed by lobectomy between 2006 and 2012. Patients with T3 tumors were excluded. A propensity match analysis was performed incorporating preoperative variables, and the incidence of postoperative complications, pathologic downstaging, and long-term survival were compared. Results In all, 1,936 patients met criteria, 745 NCT and 1,191 NCRT. The NCRT patients were younger, less likely to be treated at an academic medical center, and more likely to have adenocarcinoma. After propensity matching, patients in the NCT group showed lower 30-day mortality (1.3% versus 2.9%) and 90-day mortality (2.9% versus 6.0%), and were more likely to undergo a minimally invasive resection (25.7% versus 14.1%). The NCRT patients were more likely to have a pathologic complete response (14.2% versus 4.0%) and to be N0 at the time of resection (45.2% versus 38.7%). In the multivariable analysis, NCRT patients were at a greater risk of mortality than NCT patients (hazard ratio 1.18, 95% confidence interval: 1.03 to 1.36). Conclusions In our cohort, combined neoadjuvant chemotherapy and radiation therapy was associated with improved pathologic downstaging but showed increased perioperative mortality with no improvement in long-term overall survival. For stage IIIA patients with smaller tumors without local invasion, chemotherapy alone may be the preferred neoadjuvant treatment.

Although the duodenal switch (DS) has been the most effective weight loss surgical procedure, it is a small minority of the total bariatric surgical cases performed. Modifications that can make the operation technically simpler and reduce a long-term risk of short bowel syndrome would be of benefit. The aim of this study was to detail our initial experience with a modified DS called stomach intestinal pylorus sparing (SIPS) procedure.Data from patients who underwent a primary SIPS procedure performed by two surgeons at two centers from January 2013 to August 2014 were retrospectively analyzed. All revisions of prior bariatric procedures were excluded. Regression analyses were performed for all follow-up weight loss data.One hundred twenty-three patients were available. One hundred two patients were beyond 1 year postoperative, with data available for 64 (62 % followed up). The mean body mass index (BMI) was 49.4 kg/m(2). Two patients had diarrhea (1.6 %), four had abdominal hematoma (3.2 %), and one had a stricture (0.8 %) in the gastric sleeve. Two patients (1.6 %) were readmitted within 30 days. One patient (0.8 %) was reoperated due to an early postoperative ulcer. At 1 year, patients had an average change in BMI of 19 units (kg/m(2)), which was compared to an average of 38 % of total weight loss or 72 % of excess weight loss.Modification of the classic DS to one with a single anastomosis and a longer common channel had effective weight loss results. Morbidity seems comparable to other stapling reconstructive procedures. Future analyses are needed to determine whether a SIPS procedure reduces the risk of future small bowel obstructions and micronutrient deficiencies.

Tracheo-esophageal fistula is a well-described congenital abnormality treated surgically upon diagnosis. Although respiratory-related and reflux-related complications are frequent, recurrent fistula and diverticulum can occur. This case report describes the rare occurrence of a gross type B fistula repaired at birth, which was then asymptomatic for nearly 30 years until presentation with chest pain. Upon workup, the patient was found to have an isolated tracheal diverticulum without recurrent fistula. We highlight the need for a focused workup despite the length of time since fistula repair and the varied treatment modalities described in the literature.

Controversies in bariatric surgery The rationale for a duodenal switch as the primary surgical treatment of advanced type 2 diabetes mellitus and metabolic disease Mitchell S. Roslin, M.D., FACS*, Michel Gagner, M.D., FACS, Richie Goriparthi, M.D., M.Sc., Brian Mitzman, M.D. Department of Surgery, Lenox Hill Hospital, New York, New York Herbert Wertheim College of Medicine, Florida International University, Miami, Florida Department of Surgery, Hopital du Sacre Coeur, Montreal, QC, Canada Received November 18, 2014; accepted November 20, 2014