BACKGROUND Given resource constraints during the coronavirus disease 2019 pandemic, we explored whether minimally invasive anatomic lung resections for early-stage lung cancer could undergo rapid discharge. METHODS All patients with clinical stage I -II non-small cell lung cancer from September 2019 to June 2022 who underwent minimally invasive anatomic lung resection at a single institution were included. Patients discharged without a chest tube <18 hours after operation, meeting preset criteria, were considered rapid discharge. Demographics, comorbidities, operative details, and 30 -day outcomes were compared between rapid discharge patients and nonrapid discharge "control" patients. Multivariable logistic regression was performed for predictors of nonrapid discharge. RESULTS Overall, 430 patients underwent resection (200 lobectomies and 230 segmentectomies); 162 patients (37%) underwent rapid discharge and 268 patients (63%) were controls. The rapid discharge group was younger (66.5 vs 70.0 years; P < .001), was assigned to lower American Society of Anesthesiologists class (P = .02), had more segmentectomies than lobectomies (P = .003), and had smaller tumors (P < .001). There were no differences between groups in distance from home to hospital (P = .335) or readmission rates (P = .39). Increasing age had higher odds for nonrapid discharge (odds ratio, 1.04; 95% CI, 1.02-1.07), whereas segmentectomy had decreased odds (odds ratio, 0.46; 95% CI, 0.28-0.75). CONCLUSIONS Approximately 37% of the patients underwent rapid discharge after operation with similar readmission rate to controls. Increasing age had higher odds for nonrapid discharge; segmentectomy was likely to lead to rapid discharge. Consideration of rapid discharge minimally invasive lung resection for early-stage lung cancer can result in significant reduction in inpatient resources without adverse patient outcomes. (Ann Thorac Surg 2024;117:297-304) (c) 2024 by The Society of Thoracic Surgeons. Published by Elsevier Inc.

INTRODUCTION:Subsolid nodules or those located deep in lung parenchyma are difficult to localize using minimally invasive thoracic surgery. While image-guided percutaneous needle localization has been performed, it is inconvenient and has potential complications. In this study, the role of chemical localization using robotic bronchoscopy to facilitate resection was evaluated. METHODS:Consecutive patients undergoing surgical resection for lung nodules between 8/2019-3/2022 were included. Patients with subsolid lung nodules, or small nodules deep in lung parenchyma that were deemed difficult to localize, were chemically localized (CL) using robotic bronchoscopy before resection. Clinico-demographic data were obtained retrospectively using a prospectively maintained database. RESULTS:Localization of lung nodules before resection was performed in 139 patients while 110 patients were not localized. Daily activity score was higher for localized patients. Nodules in the localized group were smaller (P < 0.001) and had similar solid:ground glass ratio. In the localized group, larger margins were observed, and no re-resection of the parenchymal margin was required. Twenty patients in the non-localized group required re-resection intraoperatively due to close pathological margins or inability to locate the nodule in the resected specimen. Operative time was a median of 10-15 min longer for localized patients, P < 0.001. Length of stay was shorter in the localized group (P < 0.05). CONCLUSIONS:Chemical localization of lung nodules using robotic bronchoscopy appears to be a safe and effective method of identifying the location of nodules with small size and less density and aids increased tumor margins intraoperatively.

OBJECTIVES:Spread through air spaces is defined as tumor cells in air spaces away from the edge of tumor in lung carcinoma. It is associated with higher locoregional recurrence and lower survival in lung adenocarcinoma. The features of spread through air spaces portending worse outcomes are still under investigation. We reviewed our lung cancer experience to define potential factors related to spread through air spaces that influence recurrence and survival. METHODS:Between January 2010 and December 2017, we identified 968 patients who underwent resection for T1-3N0M0 lung adenocarcinoma. Of these, histologic examination was possible in 787 patients. We examined the presence of spread through air spaces, spread through air spaces characteristics (micropapillary, solid nest, or single cell), average density (number per slide), and farthest distance from tumor at which spread through air spaces was detected, or maximal spread distance. Overall survival and recurrence-free survival were estimated using Kaplan-Meier curves, and differences between spread through air spaces positive versus spread through air spaces negative groups were assessed using the log-rank test. RESULTS:Spread through air spaces was present in 389 of 787 of the reviewed cases (49.4%). Overall survival and recurrence-free survival were significantly lower in the spread through air spaces positive group over 10 years (P < .0001). The incidences of locoregional and distant recurrence were nearly doubled over 10 years in the spread through air spaces positive group compared with the spread through air spaces negative group (P = .002 and <.0001, respectively). In a multivariable Cox regression model adjusted for spread through air spaces characteristics, distance, and tumor size, lobar resection did not confer survival advantage in patients with spread through air spaces (hazard ratio of sublobar resection with respect to lobar resection, 1.44; 95% confidence interval, 0.98-2.11; P = .067). In the spread through air spaces positive group, spread through air spaces density was 2.7 ± 1.4 clusters per slide and the maximal spread distance was 2.2 ± 1.7 mm from the tumor edge. There was no observed correlation between spread through air spaces density or maximal spread distance and overall survival or recurrence. CONCLUSIONS:We show increased distant recurrence in spread through air spaces positive lung adenocarcinoma. Quantifiable measures of spread through air spaces do not appear to correlate with recurrence or survival metrics.

To investigate perioperative outcomes of esophagectomies by age groups. Retrospective analysis of esophageal cancer patients undergoing esophagectomy from 2005 to 2020 at a single academic institution. Baseline characteristics and outcomes were analyzed by 3 age groups: <70, 70–79, and ≥80 years-old. Sub-analysis was done for 2 time periods: 2005–2012 and 2013–2020. Of 1135 patients, 789 patients were <70, 294 were 70–79, and 52 were ≥80 years-old. Tumor characteristics, and operative technique were similar, except positive longitudinal margins rates (all <3%) (P = 0.008). Older adults experienced increased complications (53.6% vs 69.7% vs 65.4% respectively; P < 0.001) attributable to grade II complications (41.4% vs 62.2% vs 63.5% respectively; P < 0.001). Hospital length of stay (LOS) and rehabilitation requirements were higher in older adults (both P < 0.05). 30-day readmissions, reoperation, and 30-day mortality rates (all <2%) showed no association with age group. Overall complications, LOS, discharge disposition and re-operative rates improved from 2005 to 2012 to 2013–2020 for all (P < 0.05). Increasing age was an independent risk factor for cardiovascular complications (OR 1.7, 95% CI 1.23–2.46 for ages 70–79 and OR 2.7, 95% CI 1.37–5.10 for ages ≥80 ), inpatient rehabilitation (OR 3.3, 95% CI 2.26–5.05 for ages 70–79 and OR 12.1 95% CI 5.83–25.04 for ages ≥80), and prolonged LOS (OR 1.64 95% CI 1.16–2.31 for ages 70–79 and OR 3.6 95% CI 1.71–7.67 for ≥80. After adjusting for time period, older age remained associated with complications (P < 0.05). Highly selected older adults at a large volume esophagectomy center can undergoesophagectomy with increased minor complication and rehabilitation needs.

Background and Objectives: Stage IVa thymic malignancy has limited treatments. This study evaluated whether hyperthermic intraoperative chemotherapy (HOC) after radical resection of Stage IVa thymic malignancy improves survival. Methods: All patients who underwent resection, with or without HIOC, for Stage IVa thymic malignancy at a single center from 1990 to 2021 were reviewed. Results: Thirty-four patients were identified; 22 surgery-only versus 12 surgery and HIOC (60 min cisplatin regimen 175 mg/m(2)). Demographics and comorbidities were similar between groups. Three patients in each group were carcinomas; remainder were thymomas. Thirty-two patients underwent attempted macroscopic complete resection; 22 operations succeeded, 68.8%. Significant complications were similar between groups, 18.2% surgery-only versus 25.0% HIOC, p = 0.68. Median time to recurrence trended longer for HIOC patients (42.9 vs. 32.9 months in surgery-only, p = 0.77). Overall survival, 5-year, was similar (75.8% HIOC vs. 76.2% surgery-only, p = 0.91). On stratified analysis, thymoma patients with macroscopic complete resection and HIOC experienced similar 5-year Overall (80.0% vs. 100.0% surgery-only, p = 0.157) but longer trending 5-year disease-free (85.7% vs. 40.0%, p = 0.18) and 5-year locoregional recurrence-free survival (85.7% vs. 68.6%, p = 0.75). Conclusions: This retrospective cohort study treating Stage IVa thymic malignancy with radical pleurectomy, with or without HIOC, found addition of HIOC-signaled delayed recurrence and improved disease-free survival.

Patterns of overall and disease-free survival after esophagectomy for esophageal cancer in older adults have not been carefully studied. Retrospective analysis of all patients with esophageal cancer undergoing esophagectomy from 2005 to 2020 at our institution was performed. Differences in outcomes were stratified by age groups, < 75 and ≥ 75 years old, and two time periods, 2005–2012 and 2013–2020. A total of 1135 patients were included: 979 (86.3%) patients were < 75 (86.3%), and 156 (13.7%) were ≥ 75 years old. Younger patients had fewer comorbidities, better nutritional status, and were more likely to receive neoadjuvant and adjuvant therapy (all p < 0.05). However, tumor stage and operative approach were similar, except for increased performance of the McKeown technique in younger patients (p = 0.02). Perioperatively, younger patients experienced fewer overall and grade II complications (both p < 0.05). They had better overall survival (log-rank p-value < 0.001) and median survival, 62.2 vs. 21.5 months (p < 0.05). When stratified by pathologic stage, survival was similar for yp0 and pathologic stage II disease (both log-rank p-value > 0.05). Multivariable Cox models showed older age (≥ 75 years old) had increased hazard for reduced overall survival (HR 2.04 95% CI 1.5–2.8; p < 0.001) but not disease-free survival (HR 1.1 95% CI 0.78–1.6; p = 0.54). Over time, baseline characteristics remained largely similar, while stage became more advanced with a rise in neoadjuvant use and increased performance of minimally invasive esophagectomy (all p < 0.05). While overall complication rates improved (p < 0.05), overall and recurrence-free survival did not. Overall survival was better in younger patients during both time periods (both log-rank p < 0.05). Despite similar disease-free survival rates, long-term survival was decreased in older adults as compared to younger patients. This may be related to unmeasured factors including frailty, long-term complications after surgery, and competing causes of death. However, our results suggest that survival is similar in those with complete pathologic responses.

OBJECTIVES:Prolonged air leak (PAL; >5 days) following lung resection is associated with postoperative morbidity. We investigated factors associated with PAL and PAL requiring intervention. METHODS:Retrospective review of all patients undergoing lobectomy, segmentectomy or wedge resection from 2016 to 2019 at our institution. Bronchoplastic reconstructions and lung-volume reduction surgeries were excluded. Incidence and risk factors for PAL and PAL requiring intervention were evaluated. RESULTS:In total, 2384 patients were included. PAL incidence was 5.4% (129/2384); 22.5% (29/129) required intervention. PAL patients were more commonly male (56.6% vs 39.7%), older (mean age 69 vs 65 years) and underwent lobectomy or thoracotomy (all P < 0.001). Patients with PAL had longer length of stay (9 vs 3 days), more discharge needs and increased odds of complication (all P < 0.050).Twenty-nine patients required intervention (9 chest tubes; 4 percutaneous drains; 16 operations). In 50% of operative interventions, an air leak source was identified; however, the median time from intervention to resolution was 13 days. Patients requiring intervention had increased steroid use, lower diffusion capacity for carbon monoxide and twice the length of stay versus PAL patients (all P < 0.050).On univariable analysis, forced expiratory volume in 1 s (FEV1) <40%, diffusion capacity for carbon monoxide <50%, steroid use and albumin <3 had increased odds of intervention (P < 0.050). CONCLUSIONS:Age, gender and operative technique were related to PAL development. Patients with worse forced expiratory volume in 1 s or diffusion capacity for carbon monoxide, steroid use or poor nutrition were less likely to heal on their own, indicating a population that could benefit from earlier intervention.

To determine associations between surgeon volume and esophagectomy outcomes at a high-volume institution. All esophagectomies for esophageal cancer at our institution from August 2005 to August 2019 were reviewed. Cases were divided by surgeon into low, <7 cases/year, vs high volume, ≥7 cases/year, based on Leapfrog Group recommendations. Surgeons remained 'high-volume' after one year of ≥7 cases. Demographics, comorbidities, course of care, and long-term outcomes were compared. In total, 1029 cases were evaluated; 120 performed by low-volume surgeons vs 909 by high-volume surgeons. Never-smokers, atrial fibrillation, and clinical Stage IVa patients were associated with high-volume surgeons. Other demographics were similar. Low-volume surgeons did more open cases, 45.8% vs 14.5%, P < 0.01. Low-volume surgeons had more complications than high-volume surgeons (71.7% vs 57.6%, P < 0.01), specifically Grade II and III (59.2% vs 46.8%, P = 0.01, and 44.2% vs 27.0%, P <0.01). No differences were seen in anastomotic leak rate, 90-day mortality, recurrences, 5-year overall survival (46.7% low-volume vs 49.3% high-volume, P = 0.64), or 5-year disease-free survival (35.7% low-volume vs 42.2% high-volume, P = 0.27). In multivariable logistic regression for Grade III or higher complications, high-volume surgeons had an odds ratio of 0.56 (95% confidence interval 0.36-0.87) for complications. Our study found higher rates of open esophagectomies and complications in low-volume esophagectomy surgeons compared to high-volume surgeons at the same, high-volume institution. However, low-volume surgeons were not associated with worse survival outcomes compared to high-volume surgeons. Low-volume esophagectomy surgeons may benefit from mentoring and support to improve perioperative outcomes; these efforts are underway at our institution.

Central MessageMultiport video-assisted thoracoscopic surgery: lobectomy of the right middle lobe for non–small cell lung cancer as demonstrated by Dr Scott J. Swanson.See Commentary on page 136. Multiport video-assisted thoracoscopic surgery: lobectomy of the right middle lobe for non–small cell lung cancer as demonstrated by Dr Scott J. Swanson. See Commentary on page 136. Right middle lobe (RML) lobectomy for non–small cell lung cancer (NSCLC) is the least commonly performed lobectomy at 5% to 10%.1Yang C.F. Sun Z. Speicher P.J. Saud S.M. Gulack B.C. Hartwig M.G. et al.Use and outcomes of minimally invasive lobectomy for stage I non–small cell lung cancer in the national cancer data base.Ann Thorac Surg. 2016; 101: 1037-1042https://doi.org/10.1016/j.athoracsur.2015.11.018Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar,2Falcoz P.-E. Puyraveau M. Thomas P.-A. Decaluwe H. Hürtgen M. Petersen R.H. et al.Video-assisted thoracoscopic surgery versus open lobectomy for primary non–small-cell lung cancer: a propensity-matched analysis of outcome from the European Society of Thoracic Surgeon database.Eur J Cardiothorac Surg. 2016; 49: 602-609Crossref PubMed Scopus (245) Google Scholar RML lobectomy is not infrequently performed as a bilobectomy if tumors are located close to the RML anatomy and right upper or lower lobectomy alone is not feasible. Sublobar resection of the RML for small NSCLC is feasible but has worse outcomes as tumor size increases.3Lv X. Cao J. Dai X. Rusidanmu A. Survival rates after lobectomy versus sublobar resection for early-stage right middle lobe non–small cell lung cancer.Thorac Cancer. 2018; 9: 1026-1031https://doi.org/10.1111/1759-7714.12782Crossref PubMed Scopus (9) Google Scholar Current randomized trials are ongoing to prospectively evaluate these retrospective findings.4Comparison of Different Types of Surgery in Treating Patients With Stage IA Non–Small Cell Lung Cancer (Alliance for Clinical Trials in Oncology). 2007https://clinicaltrials.gov/ct2/show/NCT00499330Date accessed: April 13, 2021Google Scholar Video-assisted thoracoscopic surgery (VATS) for RML lobectomy can be difficult due to the infrequency with which the operation is performed. However, using the techniques shown here, the operation can be made relatively straightforward, requiring few additional tools outside of the normal VATS operation. We have previously described the technique elsewhere.5Hirji S.A. Nicastri D.G. Swanson S.J. VATS lobectomy and segmentectomy.in: Sugarbaker D.J. Bueno R. Burt B.M. Groth S.S. Loor G. Wolf A.S. Sugarbaker's Adult Chest Surgery. 3rd ed. McGraw-Hill, 2020https://accesssurgery.mhmedical.com/content.aspx?bookid=2781§ionid=239711113Date accessed: April 14, 2021Google Scholar,6McKenna R. Mahtabifard A. Swanson S. Atlas of Minimally Invasive Thoracic Surgery (VATS).1st ed. Elsevier/Saunders, 2011Google Scholar Here, the VATS RML lobectomy operative technique is explained with videos of the 12 key steps. This procedure can be performed safely using modifications and variations of these steps. The VATS approach to RML lobectomy is described in 12 steps with accompanying video taken from one operation of a patient who presented with a 2 × 2.5-cm right middle lobe opacity (Figure 1). The specific steps were chosen based on the authors' experience and the way the operation is taught in the authors' institution. The instruments used in this procedure are listed in Figure 2.Figure 2A, Echelon 45-mm endoscopic stapler, regular/thick tissue stapler loads (Gold). B, Endoleader (8 Fr catheter with 0 silk). C, Harmonic Ultrasonic scalpel. D, CONMED laparoscopic suction-irrigator. E, CONMED laparoscopic Kittner dissector. F, Echelon 35-mm endoscopic stapler, vascular/thin tissue stapler load (White).View Large Image Figure ViewerDownload Hi-res image Download (PPT) The RML lobectomy presented here was performed in a 60-year-old female patient with chronic obstructive pulmonary disease who, as previously stated, presented with a 2 × 2.5-cm right middle lobe opacity (Figure 1). Biopsy confirmed adenocarcinoma. She underwent uneventful surgical resection. A case instrument card for the procedure with key tools is included in Table 1. The final pathology for the lesion noted overall size of 2.6 × 1.8 × 1.6 cm with an invasive component size of 1.7 cm, staged as pT1bN0. This study, including patient information, was approved by our institutional review board under IRB2006P002482 and informed consent was waived. In addition, the patient consented to deidentified pictures and videos collected during this procedure; Brigham and Women's is a teaching hospital, and this practice is standard and included in procedure consent, which was obtained prior to surgery.Table 1Case card with key tools for video-assisted thoracoscopic surgery of the right middle lobeToolCompanyLocationBovie electrocauteryBovie Medical CorporationClearwater, FlaSet of 3 metal thoracoscopic trocarsSnowden-Pencer, IncTucker, GaRing forcepsSymmetry Surgical, IncAntioch, TebbArmy-Navy retractorsSymmetry Surgical, IncAntioch, TennMedium sized wound protectorApplied MedicalRancho Santa Margarita, CalifLaparoscopic Kittner dissectorsCONMEDUtica, NYLaparoscopic suction-irrigatorCONMEDUtica, NYLong right-angle clampSymmetry Surgical, IncAntioch, TennHarmonic ultrasonic scalpelEthicon, IncRaritan, NJEndoleader (8 Fr catheter with 0 silk)MedtronicFridley, MinnEchelon 45 mm endoscopic stapler, regular/thick tissue stapler loads (Gold)Ethicon, IncRaritan, NJEchelon 35-mm endoscopic stapler, vascular/thin tissue stapler load (White)Ethicon, IncRaritan, NJRight angle clampSymmetry Surgical, IncAntioch, TennLaparoscopic surgical tissue pouchCook Medical, IncBloomington, Ind24-Fr straight chest tubeMedtronicFridley, Minn Open table in a new tab Video 1: The patient is placed in left lateral decubitus position and prepped and draped in a sterile fashion. The first incision is made in the eighth intercostal space posterior to the anterior axillary line and is approximately 2 cm long. The second incision is made in the fifth or sixth intercostal space just anterior to the anterior axillary line, directly over the right middle lobe vein and right major fissure. This incision is approximately 4 cm long, and this port is used for the wound protector and later the endo-stapler. The third incision is made in the sixth or seventh intercostal space, posterior to the tip of the scapula just anterior to the anterior border of latissimus dorsi muscle, and is approximately 2 cm long. Notably, the second incision is typically 1 or 2 interspaces lower than that made for an upper lobectomy, as it facilitates dissection of the middle lobe bronchus and vein. The lesion is then palpated through the anterior incision. Video 2: The lung is retracted from the posterior port site and dissection of the RML vein is begun by identifying it, which is typically a small branch of the superior pulmonary vein. Alternatively, although rarely, the vein can be found as a branch of the inferior pulmonary vein or have its own trunk directly off the left atrium. In this video, the phrenic nerve is swept medially away from the anterior hilar pleura. This manipulation is not always necessary. After dissecting the inferior and superior boundaries of the vein using blunt dissection with a laparoscopic Kittner (Figure 2), the right-angle clamp is used to dissect posteriorly around the RML vein. Video 3: The lung is retracted via the anterior port and careful dissection with a laparoscopic Kittner is used to develop the right major fissure. The ongoing pulmonary artery is uncovered. Identification of the RML bronchus is key to avoid injury during subsequent division of the anterior fissure. The basilar trunk of the pulmonary artery and underlying bronchus denote the lateral extent of the fissure and the major fissure parenchyma is encircled and divided with the endoscopic stapler. Note: The major fissure may not be complete and, to avoid potential alveolar leaks, a fissure-less technique may be used where the lung parenchyma is lifted off the ongoing pulmonary artery and then divided after identification, dissection, and division of the RML vein and bronchus. Video 4: The RML vein can now be seen anterior to the RML bronchus. Through the 4-cm port, the endoscopic stapler is carefully passed around the RML vein, which is then stapled and divided using a vascular/thin staple load. Video 5: The RML bronchus is visualized with the RML artery now clearly seen superior and posterior to the divided RML vein. Careful blunt dissection is carried out between the RML bronchus and artery. The ongoing pulmonary artery is seen traveling down the minor fissure, passing around the bronchus, and progressing anteriorly along the major fissure. Video 6: The right-angle clamp is used to pass the endoleader to facilitate the approach of the endoscopic stapler, again through the 4-cm port. The stapler is guided into position and the RML retracted to allow clean division of the RML bronchus using a regular/thick stapler load. The endoleader allows passage of the stapler safely when the space between the RML artery and bronchus is challenging or if there is difficult angulation of the stapler. Video 7: Blunt dissection is used to encircle the RML artery. The right-angle clamp is used to ensure adequate space to pass the stapler around the artery. Note: Anatomic variation of 2 or more RML arteries can occur, and potential presence of these variants must be assessed before proceeding to arterial division. Care should be taken to isolate the RML artery (or arterial branches) to make sure no upper lobe branches of the right superior pulmonary vein will be divided when the RML artery is divided in the next step. Video 8: The stapler is passed around the RML artery, which is then stapled and divided using a vascular/thin staple load. Video 9: In some rare cases in which the preferred method of individual RML artery dissection and division is not possible, for example, due to an incomplete minor fissure or due to concerns that further dissection would cause damage to surrounding structures, an en bloc division can be done. In this alternate approach, an incomplete minor fissure is noted along with at least 2 small arterial branches. If the tumor is well away from the minor fissure, it may be appropriate to divide the smaller arteries en bloc with the minor fissure, and avoid injury related to the dissection and passage of the large stapler behind smaller vessels. The RML vein and bronchus have previously been divided. Video 10: The RML is reflected inferiorly and the stapler used to complete the division of the minor fissure between the right upper and middle lobes, taking care to ensure that the middle lobe bronchial stump is included in the specimen. Depending on the completeness of the fissure, multiple regular/thick tissue staple loads may be required to divide the remaining parenchyma. The Harmonic scalpel is used to divide the remaining soft tissue connecting the RML specimen to the right upper lobe. Video 11: The LapSac (Cook Medical) is inserted through the anterior port and placed in the right apex with the opening toward the base of the lung. The RML specimen is then guided into the sack and the sack closed. The specimen and sack are then extracted. Video 12: Mediastinal lymph node dissection can be performed at various points of the operation. In the first portion of Video 12, the right lung is reflected anteriorly to facilitate dissection of level 7 lymph nodes. In the next portion of the video, 11R lymph nodes are being removed from the area adjacent to the RML bronchus after the RML specimen has been removed. Finally, a right paratracheal lymph node dissection was performed, 4R. At this point, stations 8R and 9R can be sampled as well, but are not shown in this video. Video 13: The suction-irrigator (CONMED) is used to submerge the RML bronchial stump. The lung is then reinflated to a pressure of 30 cmH2O to perform a stump air-leak check. No bubbling is seen and the air-leak check is negative. The fluid is then removed. A 24-Fr chest tube can be placed through the inferior incision to the right thoracic apex running anterior to the hilum or a new chest tube insertion site can be made as seen in the video for Step 1. Although the air-leak check is negative in this procedure, if it were positive, sutures could be placed to reinforce closure and a second stump check would be performed. VATS lobectomy is the standard of care for early-stage lung cancer, and numerous studies have demonstrated its oncologic efficacy and superiority over thoracotomy with respect to complications and return to function.2Falcoz P.-E. Puyraveau M. Thomas P.-A. Decaluwe H. Hürtgen M. Petersen R.H. et al.Video-assisted thoracoscopic surgery versus open lobectomy for primary non–small-cell lung cancer: a propensity-matched analysis of outcome from the European Society of Thoracic Surgeon database.Eur J Cardiothorac Surg. 2016; 49: 602-609Crossref PubMed Scopus (245) Google Scholar,7Swanson S.J. Herndon II, J.E. D'Amico T.A. Demmy T.L. McKenna Jr., R.J. Green M.R. et al.Video-assisted thoracic surgery lobectomy: report of CALGB 39802—a prospective, multi-institution feasibility study.J Clin Oncol. 2007; 25: 4993-4997https://doi.org/10.1200/JCO.2007.12.6649Crossref PubMed Scopus (435) Google Scholar The National Comprehensive Cancer Network guidelines recommend a minimally invasive approach whenever possible and robotic approaches appear to offer similar advantages.1Yang C.F. Sun Z. Speicher P.J. Saud S.M. Gulack B.C. Hartwig M.G. et al.Use and outcomes of minimally invasive lobectomy for stage I non–small cell lung cancer in the national cancer data base.Ann Thorac Surg. 2016; 101: 1037-1042https://doi.org/10.1016/j.athoracsur.2015.11.018Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar A key hazard to note for VATS RML lobectomy regards damage to the ongoing pulmonary artery and lower lobe bronchus, potentially during division of an incomplete major fissure. This complication is thankfully rare due to thoughtful diligence of surgeons, but attention is drawn to this potential issue to continue the rarity of this complication. Another concern is distorting or obstructing the lower-lobe bronchus while dividing the middle lobe bronchus. This can be avoided by inflating the right lower lobe while clamping the middle lobe bronchus or using bronchoscopic guidance. Also, unlike the typical conduct of other lobectomies, the bronchus is divided after the vein, which inherently means the artery or arteries to the middle lobe have not yet been secured while dissecting the middle lobe bronchus immediately in front of them. Care must be taken to identify and avoid direct or avulsion injuries to the artery while dividing the bronchus. We find the placement of the posterior port to be especially useful for this particular dissection and division. VATS right middle lobectomy can be performed safely and reliably with the steps outlined in this manuscript.

Introduction: The evidence for use of direct oral anticoagulants (DOACs) in the management of post-operative cardiac surgery atrial fibrillation (POAF) is limited and mostly founded on clinical trials that excluded this patient population. Hypothesis: We performed a systematic review and meta-analysis of clinical trials and observational studies to evaluate the hypothesis that DOACs are safe compared to warfarin for the anticoagulation of patients with POAF. Methods: We searched PubMed, EMBASE, Web of Science, clinicaltrials.gov, and the Cochrane Library for clinical trials and observational studies comparing DOAC with warfarin in patients ≥18 years old who had post-cardiac surgery atrial fibrillation. Primary outcomes included stroke, systemic embolization, bleeding, and mortality, with secondary outcome of hospital readmission. We performed a random-effects meta-analysis. Results: We found 3 clinical trials, 1 prospective and 12 retrospective cohort studies eligible for inclusion with a total of 10,538 patients (3,207 DOAC patients and 7,331 warfarin patients). The meta-analysis for the primary outcomes showed significantly lower risk of stroke with DOAC use (6 studies, 7143 patients, RR 0.64; 95% CI 0.50 to 0.81, I2: 0.0%) compared to warfarin, a trend towards lower risk of systemic embolization (4 studies, 7289 patients, RR 0.64, 95% CI 0.41 to 1.01, I2: 31.99%) and similar risks of bleeding (14 studies, 10182 patients, RR 0.91; 95% CI 0.74 to 1.10, I2: 26.6%) and mortality (12 studies, 9843 patients, relative risk [RR] 1.01; 95% CI 0.74 to 1.37, I2: 26.5%) The secondary outcome of hospital readmission had similar risk between groups. Conclusions: Current evidence suggests that DOACs, compared to warfarin, in the management of atrial fibrillation after cardiac surgery is associated with lower risk of stroke and a strong trend for lower risk of systemic embolization, and no evidence of increased risk for hospital readmission, bleeding or mortality.

Background: The impact of COVID-19 has been felt in every field of medicine. We sought to understand how lung cancer surgery was affected at a high volume institution. We hypothesized that patients would wait longer for surgery, have more advanced tumors, and experience more complications during the COVID-19 crisis. Methods: A retrospective review was conducted, comparing pathologically confirmed non-small cell lung cancer (NSCLC) surgical cases performed in 2019 to cases performed from March to May 2020, during the height of the COVID-19 crisis. Clinical and pathologic stage, tumor size, time to surgery, follow up time, and complications were evaluated. Results: A total of 375 cases were performed in 2019 vs. 58 cases in March to May 2020. Overall, there were no differences in the distribution of clinical stages or in the distribution of median wait times to surgery between groups (COVID-19 16.5 days vs. pre-COVID-19 17 days, P=0.54), nor were there differences when subdivided into Stage I-II and Stage III-IV. Case volume was lowest in April 2020 with 6 cases vs. 37 in April 2019, P<0.01. Tumor size was clinically larger in the COVID-19 group (median 2.1 vs. 1.9 cm, P=0.05) but not at final pathology. No differences in complications were observed between groups (COVID-19 31.0% vs. pre-COVID-19 30.9%, P=1.00). No patients from the COVID-19 group tested positive for the disease during their hospital stay or by the median 15 days to first follow-up. Conclusions: Surgical wait time, pathologic tumor size, and complications were not different among patients undergoing surgery before vs. during the pandemic. Importantly, no patients became infected as a result of their hospital stay. The significant decrease in surgical cases is concerning for untreated cancers that may progress without proper treatment.

Central MessageEndoscopic pyloromyotomy for post-lung transplant gastroparesis is a potentially effective treatment, but further work is needed to determine indications and its efficacy over medical modalities.See Article page 711. Endoscopic pyloromyotomy for post-lung transplant gastroparesis is a potentially effective treatment, but further work is needed to determine indications and its efficacy over medical modalities. See Article page 711. Rappaport and colleagues1Rappaport J. Raja S. Gabbard S. Thuita L. Sanaka M.R. Blackstone E.H. et al.Endoscopic pyloromyotomy is feasible and effective in improving post-lung transplant gastroparesis.J Thorac Cardiovasc Surg. 2022; 164: 711-719.e4Abstract Full Text Full Text PDF Scopus (3) Google Scholar report on the use of per-oral endoscopic pyloromyotomy (ie, POP) for refractory gastroparesis in 52 patients after lung transplant. While the reported literature is highly variable, more recent studies suggest an incidence of about 20%.2Raviv Y. D'Ovidio F. Pierre A. Chaparro C. Freeman M. Keshavjee S. et al.Prevalence of gastroparesis before and after lung transplantation and its association with lung allograft outcomes.Clin Transplant. 2012; 26: 133-142https://doi.org/10.1111/j.1399-0012.2011.01434.xCrossref PubMed Scopus (53) Google Scholar, 3Grass F. Schafer M. Cristaudi A. Berutto C. Aubert J.D. Gonzalez M. et al.Incidence and risk factors of abdominal complications after lung transplantation.World J Surg. 2015; 39: 2274-2281Crossref PubMed Scopus (31) Google Scholar, 4Kayawake H. Chen-Yoshikawa T.F. Motoyama H. Hamaji M. Nakajima D. Aoyama A. et al.Gastrointestinal complications after lung transplantation in Japanese patients.Surg Today. 2018; 48: 883-890https://doi.org/10.1007/s00595-018-1666-3Crossref PubMed Scopus (14) Google Scholar, 5Blackett J.W. Benvenuto L. Leiva-Juarez M.M. D'Ovidio F. Arcasoy S. Jodorkovsky D. Risk factors and outcomes for gastroparesis after lung transplantation.Dig Dis Sci. September 15, 2021; ([Epub ahead of print]. https://doi.org/10.1007/s10620-021-07249-y)Crossref Scopus (3) Google Scholar Blackett and colleagues5Blackett J.W. Benvenuto L. Leiva-Juarez M.M. D'Ovidio F. Arcasoy S. Jodorkovsky D. Risk factors and outcomes for gastroparesis after lung transplantation.Dig Dis Sci. September 15, 2021; ([Epub ahead of print]. https://doi.org/10.1007/s10620-021-07249-y)Crossref Scopus (3) Google Scholar failed to identify specific comorbidities and risk factors that are associated with postoperative gastroparesis. Possible etiologies for postlung transplant gastroparesis include iatrogenic vagal nerve injury, immunosuppressive medication use, and the progression of pre-existing gastrointestinal motility disorders. While use of immunosuppressive medication is unavoidable, surgical technique is a potentially modifiable cause. Strict attention to minimizing vagal nerve manipulation during the dissection of the recipient's native lungs is critical. Long-term, chronic lung allograft dysfunction has been strongly associated with gastroparesis.5Blackett J.W. Benvenuto L. Leiva-Juarez M.M. D'Ovidio F. Arcasoy S. Jodorkovsky D. Risk factors and outcomes for gastroparesis after lung transplantation.Dig Dis Sci. September 15, 2021; ([Epub ahead of print]. https://doi.org/10.1007/s10620-021-07249-y)Crossref Scopus (3) Google Scholar Previous work has focused on medical management of gastroparesis with prokinetic medications and pyloric botulinum toxin injections.4Kayawake H. Chen-Yoshikawa T.F. Motoyama H. Hamaji M. Nakajima D. Aoyama A. et al.Gastrointestinal complications after lung transplantation in Japanese patients.Surg Today. 2018; 48: 883-890https://doi.org/10.1007/s00595-018-1666-3Crossref PubMed Scopus (14) Google Scholar,6Hooft N. Smith M. Huang J. Bremner R. Walia R. Gastroparesis is common after lung transplantation and may be ameliorated by botulinum toxin-A injection of the pylorus.J Heart Lung Transplant. 2014; 33: 1314-1316https://doi.org/10.1016/j.healun.2014.08.016Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar The work of Rappaport and colleagues1Rappaport J. Raja S. Gabbard S. Thuita L. Sanaka M.R. Blackstone E.H. et al.Endoscopic pyloromyotomy is feasible and effective in improving post-lung transplant gastroparesis.J Thorac Cardiovasc Surg. 2022; 164: 711-719.e4Abstract Full Text Full Text PDF Scopus (3) Google Scholar is a valuable addition to the literature, like the recent paper of Vitton and colleagues,7Vitton V. Benoît D'Journo X. Reynaud-Gaubert M. Barthet M. Gonzalez J.M. Gastric peroral endoscopic myotomy (GPOEM) for severe gastroparesis after lung transplantation: a promising minimally invasive option.Clin Transplant. 2021; 35: e14434https://doi.org/10.1111/ctr.14434Crossref PubMed Scopus (3) Google Scholar by reporting on procedural interventions to treat postlung transplant gastroparesis. The study by Rappaport and colleagues1Rappaport J. Raja S. Gabbard S. Thuita L. Sanaka M.R. Blackstone E.H. et al.Endoscopic pyloromyotomy is feasible and effective in improving post-lung transplant gastroparesis.J Thorac Cardiovasc Surg. 2022; 164: 711-719.e4Abstract Full Text Full Text PDF Scopus (3) Google Scholar does have some limitations. While offering additional evidence for the use of endoscopic myotomy in this specific patient population, the study did not have a control group against which the intervention group was compared. Most transplant centers likely have experienced endoscopists who can perform endoscopic myotomy; however, not all transplant patients will be cared for at these institutions if they do not live nearby, which limits broad applicability of the technique. Further, as the authors note this report is on their early experience with the technique, and potential confounders may not have been adequately controlled. Nevertheless, this work is a valuable addition to the armamentarium of treatment for postlung transplant gastroparesis. Further trials are needed to clarify endoscopic pyloromyotomy's efficacy compared with standard treatment for postlung transplant gastroparesis. Endoscopic pyloromyotomy is feasible and effective in improving post–lung transplant gastroparesisThe Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 3PreviewGastroparesis is a debilitating and difficult to manage problem that has been reported in 20% to 90% of lung and heart-lung transplant recipients. The primary objective was to evaluate the safety and clinical effectiveness of per-oral endoscopic pyloromyotomy in relieving gastroparesis after lung transplant. Secondary objectives evaluated the effect of per-oral endoscopic pyloromyotomy on gastroesophageal reflux and allograft function. Full-Text PDF

Background and Objectives To examine if patients undergoing salvage surgery for local recurrence following sublobar resection (SLR) have similar perioperative complications and overall survival (OS) compared to lobectomy patients for early stage non-small cell lung cancer (NSCLC). Methods Patients undergoing lobectomy and SLR (segmentectomy or wedge resection) for Stages I and II NSCLC from 2010 to 2016 were reviewed. Lobectomy patients and those who underwent salvage surgery for local recurrence after SLR were compared. Salvage surgeries were curative-intent resections for recurrence. Results Cases included 634 lobectomies and 986 SLR. Fifty-nine SLR patients (6.0%) recurred at a local site compared to 11 lobectomy patients (1.7%; p < 0.001). Twenty-three locally recurrent SLR patients (39.0%) went on to salvage surgery. Peri-operative complications after salvage surgeries were similar to lobectomies (34.8% 8/23 vs. 34.7% 220/634, p = 1.00). OS at 5 years for salvage surgery patients was similar to lobectomy patients (79.6% 13/23 vs. 70.6% 227/634, p = 0.23). OS for patients who underwent salvage surgery was significantly better than those who did not have salvage surgery for recurrence (79.6% vs. 53.0%, p = 0.02). Conclusions Patients who undergo salvage surgery for local recurrence after SLR had similar perioperative complications and OS compared to lobectomy patients but less than half underwent salvage surgery.

N1-positive (T1-3, N1, M0) non-small cell lung cancer (NSCLC) represents a minority distribution (∼8%) of the approximately 234,000 diagnosed cases per year. As such, there is a paucity of modern high-quality data regarding outcomes following surgically-resected, stage N1-positive NSCLC. Randomized controlled trials from more than a decade ago have demonstrated a modest 5.4% survival benefit with adjuvant chemotherapy but have included heterogenous patient populations and stage distributions. Large database analyses have questioned the role of perioperative chemotherapy in resected patients with N1 disease, but without much granular detail regarding staging, quality of surgery, and chemotherapy. This single-institution study sought to evaluate the role of perioperative chemotherapy, specifically in N1-positive NSCLC patients. Data for all patients with surgically resected N1-positive NSCLC (T1-3, N1, M0) between 2006 and 2016 were collected for this study. Patients who underwent pneumonectomy were excluded from analysis. A retrospective chart review was conducted, and comprehensive clinicopathologic data were collected relative to staging, surgery, pathologic review, and perioperative oncology treatment. After exclusion criteria were applied, 148 patients with surgically resected, N1-positive disease (T1-3, N1, M0) remained for analysis. The majority of patients underwent lobectomy (75.0%), of which 55.4% underwent minimally invasive resection. There were no differences in postoperative complications, length of stay, number of lymph nodes sampled, or mortality associated with the surgery only and surgery with adjuvant therapy subgroups. 107 patients (72.3%) received adjuvant therapy, and this was associated with higher 5-year overall survival (62.8%) and disease-free survival (45.1%) than patients who underwent surgery only (33.9% overall survival at 5 years, P = 0.01; 22.4% disease-free survival at 5 years, P = 0.04). The presence of multistation N1 nodal metastases in patients was associated with lower 5-year overall survival (22.7%) and disease-free survival (5.6%) than patients with single-station N1 nodal metastasis (60.4% overall survival at 5 years, P = 0.003; 46.0% disease-free survival at 5 years, P < 0.001). On multivariable analysis, receiving any adjuvant chemotherapy was associated with improved overall survival and disease-free survival (Overall Survival HR 0.47, P < 0.01 | Disease-Free Survival HR 0.46, P <0.01). Multistation N1 disease was associated with significantly worse disease-free survival (HR 2.11, P = 0.04). Perioperative chemotherapy was associated with improved survival in N1-positive NSCLC, and the potential magnitude of benefit exceeded 25% in this study. Patients with single-station N1 lymph node metastasis were observed to have better disease-free survival.

e20556 Background: Invasive mediastinal staging is necessary to identify locally advanced non-small cell lung cancer (NSCLC). We sought to validate NCCN guidelines for invasive mediastinal staging. Methods: We retrospectively reviewed all patients who had curative lung resection for pathologically confirmed NSCLC from October 2018 to December 2019. We excluded patients who had induction therapy without undergoing invasive mediastinal staging first. We evaluated methods of mediastinal staging, staging results, and final pathology. Indications for staging were one or more of the following; mediastinal lymph nodes > 1.0cm in short axis, Standardized Uptake Value of > 3.0 on Positron Emission Tomography, > 50% of tumor on medial side of mid-clavicular line (central vs peripheral), or peripheral lesion > 3.0cm in diameter. Staging methods were mediastinoscopy, endobronchial ultrasound (EBUS), and video-assisted thoracoscopic surgery (VATS) ipsilateral mediastinal staging before resection of main tumor. Results: In total, 457 lung resections were performed. Staging was done in 144/275 indicated cases (52.4%). Mediastinoscopy was completed in 49 patients, with 20.4% (n = 10) N2-positive. The false negative rate of mediastinoscopy was 4.1% (n = 2 at station 7). EBUS was performed in 64 patients and 21.9% (n = 14) were N2 positive. The false negative rate for EBUS was 3.1% (n = 2 at station 7). Two mediastinoscopy and 9 EBUS patients had 0 N2 stations sampled. None of the patients were ultimately N2 positive. Staging of three mediastinal stations (4L, 4R, and 7) was done in 26/49 mediastinoscopies and 15/64 EBUS. Of 20 patients who had VATS ipsilateral mediastinal staging, none were N2 positive and there were 0 false negatives. This left 131 patients who did not received indicated staging. The most common indication in this group was central location, 83.2% (n = 109). Four of these unstaged patients were N2 positive at resection (3.1%). The sole indication for these 4 patients was a centrally located tumor. Clinical tumor sizes were 1.2 cm, 1.3 cm, 1.5 cm, and 1.9 cm. Overall, the N2-positive rate of the staged group was 24/144 (16.7%) vs 4/131 (3.1%) N2 positive in the unstaged group, p < 0.001. Conclusions: The current NCCN staging guidelines accurately reflect the risk of N2 disease for NSCLC. The indication of central location for tumors may benefit from being reevaluated in a larger cohort, particularly given efficacy of adjuvant therapy.

To determine if wedge resection is equivalent to lobectomy for Stage I Non-Small Cell Lung Cancer (NSCLC) and to evaluate the impact of radiologic and pathologic variables not available in large national databases. Records were reviewed from 2010-2016 for patients with pathologic Stage I NSCLC who underwent wedge resection or lobectomy. Propensity score matching was performed on pre-operative variables and patients with ≥1 lymph node removed. Clinical variables were compared. Kaplan-Meier curves and multivariable Cox proportional hazard models for 5-year overall survival (OS), disease-free (DFS), and locoregional-recurrence-free survival (LRFS) were created. A total of 1086 patients met inclusion criteria; 391 lobectomies and 695 wedge resections. Propensity score matching yielded 167 pairs of lobectomy and wedge resection patients. Complications were fewer for wedge resections than lobectomies, 19.2% for wedge resection patients vs 34.1% for lobectomy patients, p < 0.01. OS was equivalent between groups, 86.2% for lobectomy patients vs 83.4% for wedge resection patients p = 0.47. DFS was similar, 79.0% for lobectomy patients vs 72.5% for wedge resection patients p = 0.10. Overall LRFS was worse in wedge resection patients vs lobectomy patients, 82.0% vs 93.4% p < 0.01. However, in the matched wedge resection patients with a margin >10 mm the LRFS was equal to that of lobectomy patients, 86.4% for wedge resection patients vs 91.8% for lobectomy patients p = 0.140. Patients with Stage I NSCLC can experience similar OS, DFS, and LRFS with wedge resection as compared to lobectomy, when wedge resection margins are >10 mm and appropriate lymph node dissection is performed.

The treatment of esophageal cancer has significantly advanced in the last 10 years and now includes multimodal treatment with a continued emphasis on surgical management. Minimally invasive esophagectomy (MIE) has been performed for almost 25 years and, in comparison to open esophagectomy techniques, MIE has shown to be equivalent or better in terms of its perioperative and oncologic outcomes. This paper reviews the evidence for MIE and recommends it should be offered as the first approach for esophagectomy surgery in the modern era.

The treatment of esophageal cancer has significantly advanced in the last 10 years and now includes multimodal treatment with a continued emphasis on surgical management. Minimally invasive esophagectomy (MIE) has been performed for almost 25 years and, in comparison to open esophagectomy techniques, MIE has shown to be equivalent or better in terms of its perioperative and oncologic outcomes. This paper reviews the evidence for MIE and recommends it should be offered as the first approach for esophagectomy surgery in the modern era.

Delay in time to esophagectomy for esophageal cancer has been shown to have worse peri-operative and long-term outcomes. We hypothesized that COVID-19 would cause a delay to surgery, with worse perioperative outcomes, compared to standard operations. All esophagectomies for esophageal cancer at a single institution from March-June 2020, COVID-19 group, and from 2019 were reviewed and peri-operative details were compared between groups. Ninety-six esophagectomies were performed in 2019 vs 37 during March-June 2020 (COVID-19 group). No differences between groups were found for preoperative comorbidities. Wait-time to surgery from final neoadjuvant treatment was similar, median 50 days in 2019 vs 53 days during COVID-19 p=0.601. There was no increased upstaging, from clinical stage to pathologic stage, 9.4% in 2019 vs 7.5% in COVID-19 p=0.841. Fewer overall complications occurred during COVID-19 vs 2019, 43.2% vs 64.6% p=0.031, but complications were similar by specific grades. Readmission rates were not statistically different during COVID-19 than 2019, 16.2% vs 10.4% p=0.38. No peri-operative mortalities or COVID-19 infections were seen in the COVID-19 group. Esophagectomy for esophageal cancer was not associated with worse outcomes during the COVID-19 pandemic with minimal risk of infection when careful COVID-19 guidelines are followed. Prioritization is recommended to ensure no delays to surgery.