Preoperative invasive nodal staging is standard of care for early-stage non-small cell lung cancer (NSCLC). Complications and delays in care are not negligible and diagnostic accuracy varies. In our system, invasive nodal staging is performed for clear radiographic indications (node > 1.0 cm short axis or standardized uptake value > 3.0, tumor > 4.0 cm). This study assessed whether unexpected mediastinal upstaging was less common in patients receiving preoperative invasive nodal staging. This retrospective study evaluated nodal upstaging, defined as pathological N2 or IIIA+ disease, based on receipt or non-receipt of invasive nodal staging. Clinical stage I–II NSCLC patients who underwent resection (2009–2019) were identified from our cancer registry. Stage and preoperative nodal staging information were confirmed through chart review. Associations between patient characteristics, invasive nodal staging receipt, and clinical to pathological stage changes were analyzed. Among 2576 patients, 18.7

BACKGROUND:The efficacy of routine diagnostic laparoscopy with cytologic evaluation for gastroesophageal junction (GEJ) cancer is variable with no set guidelines. We hypothesize that findings from diagnostic laparoscopy in Siewert II and III GEJ tumors may differ, where routine diagnostic laparoscopy with washings yields low upstaging results in Siewert II compared with Siewert III tumors. PATIENTS AND METHODS:We reviewed patients with Siewert II/III GEJ cancer from 2012 through 2022 within our integrated health system. Chi-squared, Fisher's exact, and two-sample Wilcoxon rank-sum tests were utilized. The outcomes measured include likelihood of upstaging, cytology positivity, times to chemotherapy and surgery, and 5-year mortality using a multivariable Cox regression model. RESULTS:Of 265 patients with Siewert II diagnosis, 116 patients underwent a diagnostic laparoscopy while 149 patients did not. Median time to chemotherapy initiation and definitive surgery were increased among patients with diagnostic laparoscopy, with no difference observed in 5-year survival. For patients with Siewert II and III with a diagnostic laparoscopy, 5% of Siewert II were upstaged, compared with 17% of Siewert III (p = 0.025). Obtaining cytologic washings alone were less likely to be upstaged compared with receiving a biopsy with or without washings (5.2% vs. 17.3%, p = 0.039), and those with Siewert II were less likely than Siewert III to be upstaged after diagnostic laparoscopy (5.2% vs. 17.4%, p = 0.025). CONCLUSIONS:Routine diagnostic laparoscopy yields a low upstaging rate in Siewert II GEJ adenocarcinomas (AC) while delaying treatment with no improvement on mortality. Expediting definitive surgery with selective biopsy in lieu of diagnostic laparoscopy may improve oncologic outcomes.

BACKGROUND:Minimally invasive surgical techniques have been widely adopted in colorectal surgery. New technological breakthroughs have led to even less invasive alternatives like single-port surgery, but this has been hindered by technical challenges such as the collision of robotic arms within a limited space. The Intuitive da Vinci Single-Port robotic platform is a novel system that overcomes some of these challenges. IMPACT OF INNOVATION:This study aimed to assess the safety and feasibility of the Intuitive da Vinci Single-Port robotic platform in right segmental colectomies among adult patients. These findings may set the stage for more widespread use of single-port robotic surgery. TECHNOLOGY, MATERIALS, AND METHODS:The Intuitive da Vinci Single-Port robot is a system designed specifically for single-port robotic surgery. This platform enables flexible port location and efficient internal and external range of motion using a single C-shaped arm. In the present study, right colectomies were performed in adult patients using this platform between May 2022 and November 2022, and they were compared to right colectomies in adult patients performed using the standard multiport platform between January 2019 and December 2022. The main outcome measure was safety and quality event rates. PRELIMINARY RESULTS:Of 30 patients, 16.7% of patients (n = 5) underwent single-port robotic right colectomy and 83.3% (n = 25) underwent multiport right colectomy. In the single-port group, 40% of patients (n = 2) developed a safety/quality event (postoperative portal vein thrombosis and excessive postoperative pain). In the multiport group, 32% of patients (n = 8) developed 1 safety/quality event and 8% (n = 2) had more than 1 event. CONCLUSIONS AND FUTURE DIRECTIONS:This preliminary study, one of the first Food and Drug Administration-approved, investigator-initiated uses of this platform in colorectal surgeries, shows that this platform is a safe and feasible option for right colectomies. On preliminary evaluation, it appears comparable in terms of relevant safety/quality events to the multiport platform. CLINICAL TRIAL REGISTRATION:Clinicaltrials.gov NCT05321134.

Although multiple treatment options exist for gastroesophageal junction (GEJ) cancer, surgery remains the mainstay for potential cure. Extended nodal dissection with a D2 lymphadenectomy (LAD) remains controversial for Siewert II GEJ cancer. Although D2 LAD may lead to a greater lymph node harvest, its effect on survival remains elusive. The authors hypothesized that additional D2 dissection in Siewert II GEJ cancer does not lead to increased survival. This study reviewed Siewert II patients who received a D1 or D2 LAD in addition to minimally invasive esophagectomy (MIE) after receiving neoadjuvant chemoradiation or perioperative chemotherapy (2012–2022). The patients were followed for up to 5 years. The outcomes measured were survival, number of nodes sampled, and operative time. The association between D1 or D2 LAD and overall survival was analyzed with Kaplan-Meier methods and a multivariable Cox regression model. Among 155 patients, 74

Background: Limited outcomes data exists regarding whether mediastinal envelope closure during minimally invasive esophagectomy (MIE) is related to outcomes including anastomotic leak and postoperative pyloric dilation. We hypothesized that mediastinal envelope closure would be associated with fewer adverse outcomes. Methods: Patients undergoing MIE between 9/1/2017 and 11/15/2021 were studied. Patients were divided into two groups, complete envelope closure (CC) or partially closed/ not closed (NC), and baseline characteristics and outcomes were compared. Multivariable logistic regression analysis was performed to evaluate variables associated with a composite outcome of anastomotic leak and/or pyloric dilation. Results: We identified 181 patients. Age, sex, race/ethnicity, BMI, smoking history, CCI, ECOG status, operative duration, cancer stage/histology, intraoperative fluids, EBL, and EEA size were not statistically different between the CC and NC groups, though use of indocyanine green-enhanced fluorescence evaluation (ICG) was significantly different (24.5 % versus 67.6 %, p < 0.001). The CC group experienced lower rates of anastomotic leak (2 % vs 14.7 %, p = 0.007), postoperative pyloric dilation (15.6 % vs 32.4 %, p = 0.025), and delayed gastric emptying (6.1 % vs 20.6 %, p = 0.015). Risk factors for a composite outcome defined as anastomotic leak and/or pyloric dilation were evaluated using a multivariable logistic regression, and NC was an independent predictor of this composite outcome (aOR 3.74, p = 0.007). Conclusions: Complete mediastinal envelope closure is associated with decreased rates of anastomotic leak, postoperative pyloric dilation, and delayed gastric emptying. Further prospective trials involving mediastinal envelope closure are warranted to elucidate its positive effect on postoperative outcomes.

Colorectal DiseaseEarly View VIDEO CORRESPONDENCE Robotic transanal minimally invasive repair of a colorectal anastomosis leak—a video vignette Katherine Barnes, Katherine Barnes School of Medicine, University of California San Francisco, San Francisco, California, USA Contribution: Writing - original draft, Writing - review & editing, VisualizationSearch for more papers by this authorFernanda Romero-Hernandez, Fernanda Romero-Hernandez orcid.org/0000-0001-6014-9251 Department of Surgery, University of California San Francisco, San Francisco, California, USA Contribution: Writing - review & editing, Writing - original draft, VisualizationSearch for more papers by this authorYukino Nakamura, Yukino Nakamura Department of Surgery, University of California San Francisco, San Francisco, California, USA Contribution: Project administration, Writing - review & editingSearch for more papers by this authorAnkit Sarin, Corresponding Author Ankit Sarin [email protected] Department of Surgery, University of California Davis, Sacramento, California, USA Correspondence Ankit Sarin, Department of Surgery, UC Davis School of Medicine, 6th Floor, 2335 Stockton Blvd, Sacramento, CA 95817, USA. Email: [email protected] Contribution: Conceptualization, ​Investigation, Writing - review & editing, SupervisionSearch for more papers by this author Katherine Barnes, Katherine Barnes School of Medicine, University of California San Francisco, San Francisco, California, USA Contribution: Writing - original draft, Writing - review & editing, VisualizationSearch for more papers by this authorFernanda Romero-Hernandez, Fernanda Romero-Hernandez orcid.org/0000-0001-6014-9251 Department of Surgery, University of California San Francisco, San Francisco, California, USA Contribution: Writing - review & editing, Writing - original draft, VisualizationSearch for more papers by this authorYukino Nakamura, Yukino Nakamura Department of Surgery, University of California San Francisco, San Francisco, California, USA Contribution: Project administration, Writing - review & editingSearch for more papers by this authorAnkit Sarin, Corresponding Author Ankit Sarin [email protected] Department of Surgery, University of California Davis, Sacramento, California, USA Correspondence Ankit Sarin, Department of Surgery, UC Davis School of Medicine, 6th Floor, 2335 Stockton Blvd, Sacramento, CA 95817, USA. Email: [email protected] Contribution: Conceptualization, ​Investigation, Writing - review & editing, SupervisionSearch for more papers by this author First published: 18 January 2024 https://doi.org/10.1111/codi.16870Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. CONFLICT OF INTEREST STATEMENT No Authors had conflict of interest. Open Research DATA AVAILABILITY STATEMENT Data sharing not applicable to this article as no datasets were generated or analysed during the current study. Supporting Information Filename Description codi16870-sup-0001-AppendixS1.docxWord 2007 document , 13.2 KB Appendix S1. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article. Early ViewOnline Version of Record before inclusion in an issue RelatedInformation

PurposeStudies of medical students suggest they often find the transition from the pre-clinical curriculum to clinical rotations particularly challenging during perioperative clerkships. Educators could add a new perspective into students' clerkship experiences and potential interventions to improve them. The purpose of this study was to examine the educator perspective on students' experiences in perioperative clerkships. The findings could inform potential curricular interventions to facilitate student transition from a didactic environment into perioperative clerkships.MethodsSemi-structured qualitative interviews were conducted with 16 faculty and residents in the departments of anaesthesia, obstetrics and gynaecology (OBGYN), and general surgery across multiple clinical teaching sites at one institution. Interview questions explored their perceptions of the challenges students face during their transition into perioperative clerkships and probed thoughts on curriculum interventions they believed would be the most beneficial. Interviews were recorded, transcribed and analysed thematically.FindingsThree themes were identified. Faculty and residents perceive that student experiences on perioperative clerkships are shaped by (1) students' ability to adapt to the specialty and operating room norms on these clerkships, (2) students' understanding of how they can meaningfully contribute to the clinical team, and (3) dedicated teaching time constraints. Interventions were suggested to address educator expectations and student gaps, such as implementing a pre-clerkship orientation across anaesthesia, general surgery and OBGYN.ConclusionsTo facilitate the medical student transition to perioperative clerkships, interventions should aid students in adapting to clerkship norms for these specialties and clarifying their role and expectations within the care team.

PURPOSE:Staging recommendations for early-stage non-small cell lung cancer (NSCLC) are evolving but invasive mediastinal staging has long been standard of care.Complications, additional physiologic stress, and delays in care from invasive staging are not negligible and diagnostic accuracy varies widely (1).In our large integrated health system, invasive pre-operative mediastinal lymph node staging for early-stage NSCLC is not routinely performed unless there is a clear radiographic indication (node >1.0cm short axis, SUV >3.0, central tumor or peripheral lesion >3.0cm).This retrospective cohort study sought to evaluate the impact of invasive pre-operative staging on management of clinical early-stage NSCLC.METHODS: Newly diagnosed clinical stage I-II NSCLC patients with pre-operative imaging (CT or PET-CT) who underwent surgical resection between 2009-2019 were extracted from our institutional cancer registry.Information on pre-operative invasive mediastinal staging was abstracted from electronic health record databases.Clinical and pathologic stage was confirmed by chart review.Descriptive analyses included frequency of invasive sampling, sampling modalities, and pathological upstaging.We used Chi-square or Fisher's R tests to evaluate for associations between the aforementioned variables. RESULTS:Of 2853 adult patients with NSCLC, 8.7% (n¼249) underwent invasive nodal staging.Nodal staging was most commonly performed by mediastinoscopy (63.9%), although EBUS increased over time (0% in 2009 to 73.1% in 2019, p<0.0001).While 21% of patients were technically upstaged after surgery (e.g., clinical IIA to pathologic IIB), these changes in stage were rarely clinically relevant; only 0.4% (n¼11) of patients were upstaged in a potentially clinically-significant manner (i.e., to stage IIIA or greater).Of these 11 upstaged patients, the majority (63.6%) were upstaged to pathologic stage IIIA for whom appropriate treatment sequencing (surgery first or neoadjuvant chemotherapy) is debated.Lack of pre-operative nodal sampling was not associated with upstaging (p¼0.9728).CONCLUSIONS: Even though 91.3% of early-stage NSCLC patients did not undergo pre-operative invasive nodal sampling, only 0.4% were pathologically upstaged in a potentially clinically-significant manner (stage IIIA+).There was no association between upstaging and lack of pre-operative invasive nodal sampling.This data challenges the notion that pre-operative nodal staging is routinely necessary for appropriate early-stage lung cancer management. CLINICAL IMPLICATIONS:Recent NCCN guidelines rely increasingly on imaging for initial staging of suspected early-stage disease and recommend combining invasive diagnosis, staging and resection into one procedure when possible.Invasive preoperative nodal staging does not necessarily change the management of most patients with clinical stage I-II NSCLC.

Abstract Background Colorectal cancer is a leading cause of morbidity and mortality across U.S. racial/ethnic groups. Existing studies often focus on a particular race/ethnicity or single domain within the care continuum. Granular exploration of disparities among different racial/ethnic groups across the entire colon cancer care continuum is needed. We aimed to characterize differences in colon cancer outcomes by race/ethnicity across each stage of the care continuum. Methods We used the 2010–2017 National Cancer Database to examine differences in outcomes by race/ethnicity across six domains: clinical stage at presentation; timing of surgery; access to minimally invasive surgery; post-operative outcomes; utilization of chemotherapy; and cumulative incidence of death. Analysis was via multivariable logistic or median regression, with select demographics, hospital factors, and treatment details as covariates. Results 326,003 patients (49.6% female, 24.0% non-White, including 12.7% Black, 6.1% Hispanic/Spanish, 1.3% East Asian, 0.9% Southeast Asian, 0.4% South Asian, 0.3% AIAE, and 0.2% NHOPI) met inclusion criteria. Relative to non-Hispanic White patients: Southeast Asian (OR 1.39, p < 0.01), Hispanic/Spanish (OR 1.11 p < 0.01), and Black (OR 1.09, p < 0.01) patients had increased odds of presenting with advanced clinical stage. Southeast Asian (OR 1.37, p < 0.01), East Asian (OR 1.27, p = 0.05), Hispanic/Spanish (OR 1.05 p = 0.02), and Black (OR 1.05, p < 0.01) patients had increased odds of advanced pathologic stage. Black patients had increased odds of experiencing a surgical delay (OR 1.33, p < 0.01); receiving non-robotic surgery (OR 1.12, p < 0.01); having post-surgical complications (OR 1.29, p < 0.01); initiating chemotherapy more than 90 days post-surgery (OR 1.24, p < 0.01); and omitting chemotherapy altogether (OR 1.12, p = 0.05). Black patients had significantly higher cumulative incidence of death at every pathologic stage relative to non-Hispanic White patients when adjusting for non-modifiable patient factors (p < 0.05, all stages), but these differences were no longer statistically significant when also adjusting for modifiable factors such as insurance status and income. Conclusions Non-White patients disproportionately experience advanced stage at presentation. Disparities for Black patients are seen across the entire colon cancer care continuum. Targeted interventions may be appropriate for some groups; however, major system-level transformation is needed to address disparities experienced by Black patients.

As use of robotic surgery continues to grow,1 educators are interested in promoting medical student exposure to robotic procedures.2 Currently, medical student roles in robotic cases are mostly limited to observation.3 As a result, students report that robotic procedures can be difficult to engage with, which impairs learning and motivation.3 Hands-on training increases medical student engagement with surgical procedures,4 but there are significant barriers to student experiential learning with robotic surgery.

Purpose With increasing competency demands within limited training opportunities, instruction must be efficient. We compared intern performance and faculty expectations to identify opportunities to optimize basic surgical skills instruction. Methods After completing a basic surgical skills curriculum, 35 surgical interns were scored (5-point Likert scale) on ten suturing, knot-tying, and vessel ligation tasks. Thirteen surgical faculty was surveyed on their perceptions of difficulty and risk of patient harm associated with each task. Correlation between faculty-perceived difficulty and risk was evaluated using Pearson’s coefficient. The difference between actual score and expected score based on faculty perception of difficulty was assessed for each task. Results Among participating interns, mean scores were lowest for atraumatic tying at-depth, tying under tension, and running subcuticular suturing and highest for simple running suture (superficially). Faculty perceived ligation with suture, tying under tension, atraumatic tying (superficially and at-depth) and tying around clamp to be the hardest and highest-risk tasks. Simple running suture (superficially and at-depth), running subcuticular suture, vertical mattress suture, and 2-handed tie were considered the easiest and lowest-risk tasks. Faculty perceptions of task difficulty and risk were strongly correlated ( r (8) = 0.75, p = 0.01). Interns performed better than expected on ligation with suture and tying around clamp and worse than expected on running subcuticular and vertical mattress sutures. Conclusions Our findings suggest differential task difficulty and misalignment between intern performance and faculty expectations, which may be influenced by risk of patient harm. These findings provide insights for refining learning progression and instruction of these skills.

Purpose During the COVID-19 pandemic, virtual and alternative teaching strategies were developed with subsequent changes in the number of required didactic hours. However, the exact relationship between number of didactic hours and performance on the National Board of Medical Examiners (NBME) Subject Exams is not clear. This study aims to evaluate the impact of reduced didactic hours on medical student NBME performance during the third-year surgery clerkship. Methods This retrospective study evaluated the first-time pass rates and mean scores on the NBME exam for medical students who participated in an eight-week surgery clerkship at a single institution between 2017 and 2022. Didactic schedules, including hours of synchronous and asynchronous content, and de-identified scores were obtained. Analysis of Variance (ANOVA) test, chi-squared test, linear regression, and logistic regression were used to assess for differences in scores and pass rates as a function of didactic hours. Results The cohort included 964 students. The mean NBME score was 72.23 and differed significantly across didactic hours ( p < 0.001). Compared to students who received 15 didactic hours, those who received 25.5, 33, and 37 h had 2.93 ( p = 0.01), 3.44 ( p = 0.004), and 2.41 ( p = 0.049) times odds of failing, respectively. Conclusions Increased didactic hours during surgery clerkships was not associated with higher NBME scores or first-time pass rates. Reducing didactic hours may improve exam performance and allow students more independent study time while decreasing faculty burden. Future research should seek to understand how reduced hours impacts students’ subjective experience and well-being.

Abstract Background Though a myriad of multimodal treatment options exist for gastroesophageal junction (GEJ) cancer, surgical resection remains the mainstay for potential cure. Extended nodal dissection with a D2 lymphadenectomy (LAD) beyond the D1 peri-gastric dissection remains controversial for Siewert II GEJ cancer. Though D2 LAD may lead to increased lymph node harvest, its effect on overall survival remains elusive. We hypothesize that additional D2 dissection in Siewert II GEJ cancer does not lead to increased survival. Methods We reviewed Siewert II GEJ cancer patients who received either a D1 or D2 LAD after receiving neoadjuvant chemoradiation or perioperative chemotherapy from 2012 through 2022. Chi-square and Fisher exact tests were used to compare categorical variables and two-sample Wilcoxon rank sum tests for non-normally distributed continuous variables. The main outcomes measured were 1-year mortality from date of diagnosis, number of nodes sampled, and operative time. Results Among the 155 patients identified, 75% of Siewert II underwent a D1 and 25% underwent a D2 LAD. Patients with a D2 LAD more often had >15 lymph nodes harvested than D1 (83% vs 48%, p < 0.001) but had no significant difference in median number of positive nodes (Figure 1). Patients with a D2 LAD had a median operative time approximately 2 hours longer than D1, 362 min vs 244 min (p < 0.001). On multivariable logistic regression adjusting for patient and clinical characteristics, there was no significant difference in 1-year mortality from patients undergoing a D2 vs D1 LAD. Conclusion Despite the associated high mortality associated with gastroesophageal junction (GEJ) cancer, there remains little consensus guidelines regarding the optimal preoperative and operative management. Though D2 LAD may theoretically lead to more lymph node harvest, its role in staging may be unnecessarily excessive as there is no gain in number of positive nodes leading to increased operative morbidity with no significant change in survival.

Purpose Hands-on operative experience is critical for surgical trainees to achieve proficiency. However, faculty entrustment of residents in the operating room (OR) is variable. We sought to understand faculty perceptions of how participating in surgical simulation influenced entrustment of residents. Methods This explanatory sequential mixed-methods study included surgical faculty who participated as raters or instructors during two simulation sessions: a basic surgical skills assessment for surgical interns and a robotic cholecystectomy for second- and third-year General Surgery residents. Faculty completed post-session surveys on simulation and entrustment. Responses were summarized descriptively. A subset of faculty participated in semi-structured interviews, which probed survey responses. Interviews were transcribed, codes identified using an inductive approach, and themes generated. Results Of 16 faculty who participated in the two simulations, 15 (94%) responded to the post-session survey. Majority of respondents perceived that resident performance during simulation exceeded their expectations; that the simulation helped their understanding of resident competency; that the simulation will affect their entrustment of residents in the OR; and that they will feel more comfortable with residents in their OR after the simulation. Interviews revealed two themes: 1) impact of knowledge on faculty entrustment of residents and 2) limitations of simulation. Conclusion Faculty participation in simulation sessions as assessors and/or instructors may play a role in clarifying faculty understanding of resident competency level, informing decisions around entrustment, and instilling a sense of confidence in faculty.

Background:Optimal therapy for stage II colon cancer remains unclear, and national guidelines recommend "consideration" of adjuvant chemotherapy (ACT) in the presence of high-risk features, including inadequate lymph node yield (LNY, <12 nodes). This study aims to determine whether the survival benefit of ACT in stage II disease varies based on the adequacy of LNY. Methods:We used the National Cancer Database (NCDB) to identify adults who underwent resection for a single primary T3 or T4 colon cancer between 2006 and 2018. Multivariable logistic regression tested for associations between ACT and prespecified demographic and clinical characteristics, including the adequacy of LNY. We used Cox proportional hazards models to assess overall survival and restricted cubic splines to estimate the optimal LNY threshold to dichotomize patients based on overall survival. Results:Unadjusted 5- and 10-year survival rates were 84% and 75%, respectively, among patients who received ACT and 70% and 50% among patients who did not (log-rank P < 0.01). Inadequate LNY was independently associated with both receipt of ACT (odds ratios, 1.50; P < 0.01) and decreased overall survival [hazard ratio (HR), 1.56; P < 0.01]. ACT was independently associated with improved survival (HR, 0.67; P < 0.01); this effect size did not change based on the adequacy of LNY (interaction P = 0.41). Results were robust to re-analysis with our cohort-optimized threshold of 18 lymph nodes. Conclusions:Consistent with contemporary guidelines, patients with inadequate LNY are more likely to receive ACT. LNY adequacy is an independent prognostic factor but, in isolation, should not dictate whether patients receive ACT.

Introduction and importance: Pulmonary sclerosing pneumocytoma (PSP) is a rare tumor thought to originate from respiratory epithelial cells. It is usually benign, but may rarely metastasize to lymph nodes. Surgeons face unique challenges in diagnosis and management of this condition, and ideal surgical management is yet to be established.Case presentation: 48-year-old woman with a 7 x 7 mm pulmonary lesion discovered incidentally on comput-erized tomography (CT) imaging, which grew to 9 mm over the following year. Seven years later, follow-up imaging revealed that the mass had grown to 1.3 cm in largest dimension. Surgery was recommended and the mass was resected via a right video-assisted thoracic surgery (VATS) middle lobectomy with mediastinal lymph node dissection. All lymph nodes were negative and the patient's postoperative course was unremarkable.Clinical discussion: There are few evidence-based guidelines available on the treatment and postoperative sur-veillance of PSP. Research has shown comparable recurrence-free survival rates for sublobar resection and lo-bectomy, though recurrence can occur, especially following sublobar resection in larger or more centrally -located tumors. In absence of established guidelines, it was decided to follow this patient according to NCCN guidelines for surveillance of early-stage non-small cell lung cancer due to potential risk of recurrence.Conclusion: This case report adds to the limited literature on PSP and depicts a possible treatment and post-operative follow-up plan. Right VATS middle lobectomy can effectively treat some cases of central PSP. In absence of established guidelines for postoperative follow-up of PSP, NCCN guidelines may outline one possible strategy for postoperative management.

Introduction and importance: Esophageal leiomyomas are the most common benign esophageal tumors. They are typically smaller than 3 cm, but larger tumors can impede local structures to cause symptoms, including dysphagia and epigastric pain. Surgical treatment of esophageal leiomyomas has historically involved open thoracotomy, but this approach is being replaced by minimally invasive approaches, including video-assisted thoracoscopic surgery (VATS).Case presentation: A 46-year-old female patient presented with upper abdominal pain. Computerized tomography (CT) scanning of the abdomen and chest revealed a large (6.0 x 4.0 x 3.0 cm) gastroesophageal junction (GEJ) mass. An endoscopic ultrasound (EUS) with fine needle aspiration confirmed diagnosis of esophageal leiomyoma. A right VATS esophageal mass resection was performed to enucleate the mass. An intraoperative EGD was performed to check mucosal integrity, ensure adequate lumen patency, and visualization and insufflation was negative for a mucosal leak. The post-operative course was unremarkable.Clinical discussion: This case report adds to the emerging evidence that VATS can be utilized for enucleation of larger leiomyomas (>5 cm in largest dimension). Additionally, the use of direct intraoperative endoscopic evaluation via esophagoscopy suggests that larger esophageal masses could potentially be enucleated with a combined VATS and endoscopic approach.Conclusion: The purpose of this report is to add to the limited literature on minimally invasive surgical treatment of a relatively large GEJ leiomyoma. This case highlights that VATS, in addition to simultaneous endoscopic visualization, is an efficacious and safe option for treatment of larger leiomyomas (>5 cm) and can be associated with minimal risk.

Introduction: Faster time to ambulation (TTA) after video assisted thoracoscopic surgery (VATS) is associated with improved outcomes. We hypothesized that reduced urinary catheter duration leads to shorter TTA after VATS lobectomy. Methods: We studied VATS lobectomy patients from 2014 through 2018. TTA of patients that did not have urinary catheters or whose catheters were removed at the end of the operation (reduced cath) was compared to TTA of those whose catheters were removed the day after surgery (long cath). Results: Overall, 67 and 234 patients were included in the reduced cath and long cath groups, respectively. Median TTA was shorter in the reduced cath group compared to the long cath group (6.5 h Q1-Q3: 4.8-10.7 vs 11.0 h Q1-Q3: 6.8-18.3, p<0.01). Length of stay, urinary complications, and 30-day readmissions were not significantly different between groups. Discussion: While it is possible to ambulate with a urinary catheter in place, the presence of such a catheter nevertheless presents an additional barrier to early mobilization among VATS lobectomy patients. Despite other efforts to promote early ambulation within our integrated health system, we have found that avoiding urinary catheter use or removing them immediately post-operatively is associated with shorter times to initial ambulation. Given the known benefits of early ambulation among VATS lobectomy patients, reduction or omission of urinary catheters may provide an additional tool for surgeons to promote early mobilization. Conclusions: Reduction of urinary catheter duration is associated with reduced TTA after VATS lobectomy.