Achalasia is a rare esophageal motility disorder with two effective surgical interventions: Heller myotomy with fundoplication (Heller) and peroral endoscopic myotomy (POEM). Although both procedures alleviate dysphagia in the short term, there are limited data on long-term outcomes. We sent Eckardt, Dakkak Dysphagia, and GERD-HRQL questionnaires during four time periods between 2020 and 2025 to patients who had Heller or POEM between 2013 and 2016. We compared the final responses to the two interventions. Next, we analyzed electronic medical records to determine long-term PPI use and identify patients who underwent any additional subsequent interventions (dilation, Heller myotomy, POEM, or esophagectomy). We performed Kaplan–Meier analysis to determine the intervention-free survival. A total of 172 patients underwent achalasia surgical intervention, with 81 and 91 patients in the Heller and POEM groups, respectively. There were no relevant significant differences in demographics and comorbidities, except for a higher rate of previous surgery at the gastroesophageal junction (18.7 vs. 4.9 Heller myotomy with fundoplication and POEM provide durable long-term symptom control in patients with achalasia. However, patients in the POEM group required more interventions and PPI to achieve similar results. Heller myotomy with fundoplication may be an ideal operation for treatment of achalasia.

Background Analysis of the Nationwide Readmission Database from 2010 to 2014 showed a clear benefit of a minimally invasive approach to pulmonary lobectomy. We aimed to determine whether the adoption of minimally invasive surgical technology has increased since then. Methods We performed a retrospective cohort analysis of the Nationwide Readmission Database data from 2016 to 2018. We compared the readmission rates and mortality between open lobectomy, video-assisted thoracoscopic surgery (VATS), and robotic lobectomy. We then performed a multivariate analysis of the factors associated with readmission and mortality. Results A total of 62,020 lobectomies were identified, including 43.2% open, 40.0% VATS, and 16.8% robotic. There was a significant increase in minimally invasive procedures over the time period, driven by a tripling of robotic cases compared with 2010-2014 (P < .001). VATS and robotic approaches had significantly lower readmission (open 9.3%, VATS 7.1%, robotic 6.8%; P < .001) and mortality rates (open 2.7%, VATS 0.7%, robotic 0.5%; P < .001). Multivariate analysis showed that VATS (P < .001) and robotic lobectomy (P < .001) were independent factors associated with lower readmission and mortality rates. Conclusions There has been a shift from open to minimally invasive lobectomy due to the increased adoption of robotic technology, resulting in significant improvements in hospital readmission rates and mortality. Further adoption of minimally invasive platforms may improve outcomes after pulmonary lobectomies.

Background and Objective:Post pneumonectomy syndrome (PPS) is a rare but potentially life-threatening complication following pneumonectomy. Progressive mediastinal shift into the post-resection space results in distortion and compression of mediastinal structures, including the tracheobronchial tree, esophagus, and vasculature. Patients often present with dyspnea and recurrent pulmonary infections, with imaging with computed tomography (CT) scan classically showing compression of the distal trachea or remaining bronchus. Diagnosis is confirmed with bronchoscopy demonstrating dynamic airway obstruction with extrinsic compression and airway displacement. While surgical mediastinal repositioning remains the standard of care, multiple operative and minimally invasive strategies exist, and long-term outcomes are poorly reported with relatively high complication and reoperation rates. This review evaluates the current management strategies, compares surgical and endoscopic approaches, and highlights emerging techniques in PPS treatment. Methods:A narrative review was performed of existing literature on PPS diagnosis and management options, including stenting and surgical interventions. A PubMed search was performed of the key terms: "post pneumonectomy syndrome", "post-pneumonectomy syndrome", "postpneumonectomy syndrome", "management of post-pneumonectomy syndrome", "implant-based treatment of post pneumonectomy syndrome", "endobronchial stenting for postpneumonectomy syndrome", and "classic post pneumonectomy syndrome presentation". Novel approaches, reviews that reported long-term results, and those with comparative analysis of current treatment options were prioritized in the literature evaluation. Key Content and Findings:For those patients who are surgical candidates, the most common treatment involves mediastinal repositioning with fixed-volume or tissue expander prostheses. For patients who are not surgical candidates, airway stenting is required to palliate symptoms. Overall, mediastinal repositioning with prosthetic implantation is the current standard of care and provides reasonable short-term and long-term resolution of PPS, though a personalized approach to surgical management remains paramount. Conclusions:Though rare, PPS is a potentially life-threatening complication of pneumonectomy. Identification and diagnosis may be difficult due to the dynamic nature of mediastinal shifting and wide range of symptomatology. Surgical intervention remains the best definitive management to correct mediastinal shifting, though endobronchial stenting may be indicated in some cases. Surgical management should be reviewed on a case-by-case basis with a multi-disciplinary evaluation, usually in conjunction with plastic surgery.

BACKGROUND Robot-assisted hiatal hernia repair has become increasingly popular in high-risk populations as a relatively low-risk, minimally invasive surgical option. As life expectancy rises, more octogenarians are being considered for surgery despite age-related comorbidities. However, data on the safety and efficacy of robotic repair in this population are limited. This single-center retrospective study evaluates postoperative outcomes and complications following robotic hiatal hernia repair in octogenarians. METHODS Patients ≥80 years who underwent repair between 2017 and 2024 were propensity score-matched in a 1:3 ratio to those <80 years based on sex, BMI, hernia type, and surgery type. Multivariable regression analyses were used to assess differences in hospital stay and postoperative outcomes, with significance set at P<0.05. RESULTS A total of 302 patients underwent robotic hiatal hernia repair, including 78 patients aged ≥80 years and 224 aged <80 years. The ≥80 group had a median age of 83 years compared to 69 years (p<0.001), with no differences in sex, BMI, hernia, or surgery type. There were no significant differences in total hospital hours (30 vs. 31, p=0.11), postoperative events (5.4% vs. 7.7%, p=0.42), or 30-day readmissions (0.9% vs. 0%, p=1). No mortality was observed in either group. Age was not a significant factor for postoperative events on multivariable regression analysis. CONCLUSIONS Surgical outcomes did not differ significantly between patients aged ≥ 80 and < 80 years who underwent robot-assisted hiatal hernia repair. Elective robotic-assisted hiatal hernia repair is safe in carefully selected octogenarians.

Background:Benchmarking pulmonary resection outcomes is critical for the evaluation of hospital performance and enhancing the quality of patient care. Both the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) and Society of Thoracic Surgeons General Thoracic Surgical Database (GTSD) provide outcomes after lung resection, but each database had its own limitations. We aimed to determine whether the Vizient database can be used to benchmark lung resection outcomes. Methods:We performed a retrospective cohort analysis of pulmonary resection cases at a single institution using the Vizient dashboard and GTSD. We examined whether all pulmonary resections were captured and if the risks were appropriately measured on the Vizient dashboard. Finally, we compared benchmarking using the Vizient dashboard with that of the GTSD. Results:A total of 184 patients underwent pulmonary resection, all of whom were identified on the Vizient dashboard. Generalized linear modeling showed that the expected length of stay (LOS) was associated with congestive heart failure (P=0.04), pulmonary hypertension (P<0.001), and anatomical resection (P<0.001). Expected mortality was associated with older age (P<0.001), male gender (P<0.001), pulmonary hypertension (P=0.047), and lower forced expiratory volume in 1 second (FEV1) (P=0.03). The mean LOS index was 0.63, and the mortality index was 0. The 30-day readmission rate for the surgery was 2.2%. Pulmonary resection outcomes were better than 95% in similar institutions in the Vizient dashboard, whereas the GTSD showed that the program was similar to 89% of the programs in the GTSD. Conclusions:The Vizient dashboard provides a valid measure of outcomes associated with pulmonary resection. The Vizient dashboard provides better benchmarking information than the GTSD. Vizient dashboards can be used to improve surgical outcomes after pulmonary resection.

BACKGROUND:The endoluminal functional lumen imaging probe (EndoFLIP) provides objective data during Toupet fundoplication. However, it remains unknown whether the values obtained during surgery are associated with long-term dysphagia. METHODS:We performed a retrospective cohort analysis of patients who underwent Toupet fundoplication with or without hiatal hernia repair between 2017 and 2022 at a single institution. The distensibility index (DI) was recorded with 30 mL in the catheter after fundoplication. The patients were divided into three groups: Group 1 (DI < 1.5), Group 2 (DI 1.5-2.0), and Group 3 (DI > 2.0). We then analyzed the rates of dysphagia one year after surgery among the groups. RESULTS:A total of 395 patients (median age, 67 years) were predominantly female (69%, n = 273) and mostly white (85%, n = 336). At 5 weeks post-surgery, all groups showed significant improvement in GERD, dysphagia, and bloating symptoms. In patients with a DI between 1.5 and 2, proton pump inhibitor use was significantly less than that in the other groups. At 1 year, dysphagia was significantly higher in the DI < 1.5 group (8.7%, n = 13/150) than in the DI > 2 group (2.7%, n = 4/146, p = 0.04). Multivariate analysis showed that DI < 1.5 was an independent factor associated with long-term dysphagia. CONCLUSION:Patients with a distensibility index of < 1.5 were associated with a significantly higher rate of dysphagia at one year. EndoFLIP provides objective data during surgery, which may help predict long-term outcomes of dysphagia. Patients undergoing Toupet fundoplication may benefit from a final DI > 1.5.

INTRODUCTION:Quality improvement programs are essential to enhance surgical patient safety and outcomes. However, reliance on administrative data for benchmarking can introduce errors and lack relevant details. We incorporated surgeon-specific data and a group-based strategy for inpatient operations to improve mortality, length of stay (LOS), and readmissions at a tertiary care center with an open surgeon staffing model. METHODS:A dashboard, created using Vizient (Irving, TX) data, included LOS index, mortality index, and procedure-related readmissions with outcomes tracking at individual surgeon-level. Group outcomes data were updated monthly. Individual reports were provided quarterly to surgeons, and designated leaders developed quality improvement programs per surgery type. Practice-specific group data (thoracic, surgical oncology, acute care surgery, bariatric surgery, general surgery, two colorectal surgery units, and minimally invasive surgery) were presented monthly, and leaders shared program implementation details annually or semiannually. Differences over time were calculated via t-test. Improvement strategies were also tracked. RESULTS:Over three years (2021-2023), 33 surgeons conducted 8145 inpatient operations. Quality improvement strategies included refined surgical patient candidate selection, proactive involvement of palliative care for high-risk patients, adoption of standard clinical pathways (enhanced recovery after surgery), more robotic surgery, and documentation improvement. Mortality rate decreased from 0.64 to 0.17 (P = 0.003); LOS index reduced from 0.97 to 0.92 (P = 0.03). Procedure-related readmissions were stable. CONCLUSIONS:Surgeon-specific group-based strategies may help increase adoption of surgical protocols and techniques to improve surgical outcomes. This program highlights the importance of collaborative and data-driven strategies for enhancing patient care quality.

Hypothesis: This study hypothesized that augmented reality (AR) technology has comparable accuracy and safety to conventional CT localization in guiding percutaneous transthoracic lung puncture (PTLP) to localize small pulmonary nodules. Methods: This study was a prospective, non-inferiority randomized clinical trial. Patients were randomly assigned between 23 May 2023, and 26 September 2023. Patients with small peripheral lung nodules (≤2 cm) were recruited. Patients were randomly assigned to either the CT-guided PTLP group or the AR-guided PTLP group, with a 1:1 allocation ratio. The primary outcome was the accuracy of lung nodule localization measured by localization error. The secondary outcomes included procedure duration, radiation exposure dosage and complications. Results: A total of 70 patients underwent either CT- or AR-guided lung nodule localization and subsequent surgeries. Localization error was smaller in the AR-guided group than in the CT-guided group (mean ± SD, 3.1 ± 4.0 mm vs. 5.4 ± 4.2 mm, P = 0.026). The mean difference of localization errors was −2.3 mm (95% CI: − 4.2 to −0.3 mm, P < 0.001 for non-inferiority). Compared to the CT-guided group, the AR-guided group demonstrated significantly lower radiation exposure (mean ± SD, 421 ± 168 vs. 694 ± 229 mGy × cm, P < 0.001) and shorter localization procedure duration (mean ± SD, 8.8 ± 2.3 vs. 14.1 ± 1.8 minutes, P < 0.001), with no statistical difference in complications. Conclusions: The accuracy of the AR-guided approach is comparable to that of the CT-guided approach in localizing small lung nodules. Furthermore, the utilization of AR technology has been demonstrated to reduce procedural time and minimize radiation exposure for patients.

Ivor Lewis esophagectomy, a surgical procedure to treat esophageal cancer, requires gastric conduit creation with an intrathoracic anastomosis. Frequently encountered conduit complications include conduit redundancy, herniation, and dreaded complications of necrosis and anastomotic leak. We present the case of a 71-year-old male with esophageal cancer who underwent robot-assisted laparoscopic and thoracoscopic Ivor Lewis esophagectomy with total portal robotic linear stapled anastomosis with the omentum at the anastomosis and pleural closure. On postoperative imaging, the patient had a straight gastric conduit without redundancy or anastomotic leak. He had excellent long-term clinical outcomes without significant dysphagia and reflux. Pleural closure during robotic Ivor Lewis esophagectomy may aid in achieving excellent functional outcomes.

INTRODUCTION:The management of solitary colorectal cancer metastases to the lungs after resection of the primary colon cancer is controversial. Surgical resection of a metastatic tumor in the lungs may be associated with improved survival. METHODS:A retrospective analysis was performed using the National Cancer Database for patients diagnosed with colon cancer (2010-2020). Patients with solitary colon cancer metastasis to the lungs after resection of the primary site were included in the study. We performed Kaplan-Meier survival analysis among the different treatment modalities. We also performed a multivariable Cox regression analysis to determine the factors associated with all-cause mortality. RESULTS:A total of 2976 patients met the inclusion and exclusion criteria and presented with solitary colorectal cancer metastasizing to the lungs after resection of the primary tumor. Among them, 305 patients (10%) underwent surgical resection of the metastasis, 157 (5%) received radiation therapy, and 2514 (85%) received no local treatment to the metastasis (conservative therapy). Patients who underwent surgical resection had a significant survival advantage, with a 5-y survival rate of 42.7% compared to 29.7% for radiation therapy and 23.9% for conservative management (P < 0.001). On multivariate analysis, surgical resection was associated with improved survival (hazard ratio: 0.68; 95% confidence interval: 0.58, 0.80; P < 0.001). CONCLUSIONS:Surgical resection of a single metastatic colon cancer in the lung after resection of the primary tumor is associated with improved survival. Patients with solitary colorectal lung metastases without any signs of tumors outside the chest should undergo appropriate cardiopulmonary testing and multidisciplinary evaluation for surgical resection.

A pericardial hernia is a rare condition in which a pericardial defect allows an adjacent structure to herniate into the pericardium. A 71-year-old man with idiopathic cardiomyopathy underwent left ventricular assist device placement and subsequent heart transplantation. The patient presented 2 years after transplantation with a pericardial hernia of the transverse colon. The patient underwent robot-assisted laparoscopic reduction of the transverse colon and pericardial repair with a GORE-TEX mesh (W. L. Gore & Associates), with resolution of chest discomfort. A pericardial diaphragmatic hernia is a rare complication of left ventricular assist device placement. A robot-assisted platform can be used to reduce abdominal viscera and repair a pericardial defect.

Background:Perioperative airway management is critical for patient safety and optimal surgical outcomes. Effective airway management reduces postoperative pulmonary complications and accelerates recovery. This expert consensus aims to update the earlier consensus based on the latest research and emphasize aspects that were previously overlooked. Methods:A comprehensive search up to June 2024 was performed. Earlier consensus documents were reviewed to ensure thorough coverage. A modified Delphi method involved 62 domestic experts from various surgical and anesthetic specialties who discussed and voted on preliminary recommendations in face-to-face meetings, requiring ≥70% agreement. Drafts were then reviewed by 18 international experts via email to incorporate diverse insights. Results:Through the modified Delphi method, consensus was achieved with ≥70% agreement among the 62 domestic experts, ensuring that the preliminary recommendations were robust and widely supported. Additionally, feedback from the 18 international experts provided diverse insights that further refined and validated the recommendations. Recommendations were established for preoperative airway preparation, anesthesia management, surgical approach, postoperative airway management, and managing coexisting respiratory diseases. These recommendations update the perspectives of earlier consensus documents based on the latest research and emphasize non-intubated surgery, inhalation therapy, and individualized treatment for patients with coexisting pulmonary diseases. Conclusions:This expert consensus provides a valuable reference for clinical practice. Further technological optimization and clinical research are needed to improve perioperative airway management.

Esophageal duplication cysts are rare benign esophageal masses. We present the case of a 37-year-old man with slowly progressing dysphagia and postprandial pain who was found to have a cystic mass measuring 4.6 cm × 5.4 cm × 4.6 cm above the esophagogastric junction. The manometry results were consistent with esophagogastric outflow obstruction. The patient underwent robot-assisted laparoscopic parasophageal mass resection with intraoperative endoluminal functional lumen imaging probe analysis. This report describes esophageal duplication cysts as a cause of esophagogastric junction obstruction and discusses a management approach for this condition.

Novel therapies for clinical stage IIIA lung cancer are changing the outcomes in advanced clinical stage lung cancer. A 77-year-old female patient diagnosed with clinical T4 or stage IIIA right lower lobe adenocarcinoma with a KRAS mutation. She received neoadjuvant chemoimmunotherapy for an 8 cm tumor, which showed a moderate response on imaging. The patient underwent robotic-assisted thoracoscopic right lower lobectomy and mediastinal lymph node dissection. The final pathology showed a complete response. Novel induction chemoimmunotherapy provides an opportunity to completely eradicate cancer and provides surgical therapy for patients with advanced lung cancer.

Background: Pain after robot-assisted thoracoscopic lung surgery is a contributing factor to postoperative complications and patient satisfaction. Cryoablation of the intercostal nerves temporarily disrupts nerve function and decreases pain. We evaluated the effect of cryoablation of the intercostal nerves on postoperative pain and opioid use. Methods: We performed a retrospective single-institution analysis of patients who underwent robot-assisted thoracoscopic lung surgery, with or without cryoablation between 2019 and 2022. We analyzed demographics, postoperative pain scores using a Likert scale, opioid use, postoperative complications, length of stay, and readmission. Results: Robot-assisted thoracoscopic lung surgery was performed in 230 patients, and 39 (17%) patients underwent cryoablation. Pain scores for the cryoablation group were lower at 12 hours (0 vs 2, P = .04) and higher at 5 weeks (4 vs 1, P = .01). The cryoablation group was more likely to receive an opioid prescription (46.2% vs 29.3%, P = .04) and a higher reported use of narcotics at 5 weeks (61.5% vs 37.7%, P < .01). There were no statistical differences in postoperative morphine milliequivalents per day, minor and major complication rates, total length of hospital stay, and readmission rates. Conclusions: Cryoablation of multilevel intercostal nerves has higher pain levels at 5 weeks without significant differences in the outcomes. This may be due to an increase in neuroma formation at multiple levels from the cryoablation.

Background:Robotic navigational bronchoscopy using shape-sensing technology aids in diagnosing suspicious nodules. It can be used with different imaging modalities to improve accuracy. We aimed to determine the impact of C-arm 3-dimensional (3D) imaging on the diagnostic yield. Methods:In this single-center retrospective study, we assessed the accuracy of robotic navigation bronchoscopy-guided lung nodule biopsy by using C-arm 3D imaging. We collected demographic data, nodule imaging characteristics, procedural details, and pathology reports, analyzed patients with definitive diagnoses and those without, and followed up these patients for at least 1 year. Results:The study included 95 patients (median age, 69 years; 52% female; 67% current or former smokers) who underwent robotic bronchoscopy with C-arm 3D imaging. The median nodule size was 1.70 cm (interquartile range, 1.18-2.40 cm). A total of 55 nodules (58%) were described as spiculated, with most located in the right upper lobe (34%) and right lower lobe (23%). One patient (1%) experienced pneumothorax on postprocedure chest radiography, and it was managed with serial chest roentgenograms without a chest tube. Diagnoses included malignant disease (n = 52; 55%), benign conditions (n = 25; 26%), and no definitive diagnosis (n = 18; 19%). Among those without a definitive diagnosis, 6 patients (6%) were later confirmed to have cancer after surgical resection, whereas 12 patients (13%) showed no malignancy at the 12-month follow-up, resulting in 94% diagnostic accuracy at 12 months. Conclusions:Robotic shape-sensing navigation bronchoscopy combined with advanced C-arm 3D imaging yielded a high diagnostic accuracy with minimal complications. This approach is recommended for patients with suspicious lung nodules to enhance the diagnostic yield.

Background As surgical treatment of lung cancer continues to improve, the focus is now on improving patient outcomes. We aimed to determine the factors that play a role in discharge the day after pulmonary lobectomy. Methods We performed a retrospective cohort study of patients who underwent lobectomy. We compared outcomes between patients who were discharged the next day and those who had longer hospital stays. Logistic regression modeling was performed to determine the characteristics associated with next-day discharges. Results There were 591 patients who underwent lobectomy performed by 5 surgeons, of whom 270 (45.7%) were male with a median age of 69 years. Most patients underwent surgery by the da Vinci Xi robotic system (n = 491 [83.1%]), and 72 (12%) were discharged the next day. Patients who were discharged the next day had significantly fewer complications (6.9% vs 34.9%; P < .01), without a difference in the 30-day readmission rate (6.9% vs 7.3%; P = 1) or 30-day mortality (0% vs 0.4%; P =1). Multivariate logistic regression showed that surgeon (odds ratio, 3.60; 95% CI, 1.94-6.66) and the da Vinci Xi robotic approach (odds ratio, 9.79; 95% CI, 2.25-42.61) were 2 modifiable independent predictors of next-day discharge. Conclusions The next-day discharge after pulmonary lobectomy was safe. Patients operated on by experienced surgeons using the da Vinci Xi robot were more likely to be discharged the following day. Gaining experience in performing robotic lobectomy may help ensure safe, next-day discharge after pulmonary lobectomy.

Background: Anastomotic leaks from esophageal operations are serious life-threatening medical conditions that traditionally require invasive surgery. In this study, we discuss the outcomes of 3 patients who received minimally invasive simultaneous endoluminal wound vacuum therapy and an esophageal stent (sEV+S) treatment for uncontained esophageal leaks into the pleural space after esophagectomy. Methods: Three patients received sEV+S placement between 2016 and 2024. In this technique, a black sponge sutured to the end of a drain is placed endoscopically into the leak cavity. An esophageal stent is then centered around the leak site. Results: Patients were 54 to 71 years old. All 3 patients were men with esophageal cancer who underwent esophagectomy. The sEV+S placement was performed 2, 10, and 12 times. The total number of endoscopic procedures after the discovery of the leak was 3, 29, and 13. Length of time from leak to resolution was 16, 102, and 88 days. Hospital stay was 46, 113, and 105 days. All patients eventually returned to an oral diet (2 patients at discharge and 1 patient 23 days after discharge). A tracheoesophageal fistula developed in 1 patient requiring esophageal diversion with intercostal muscle flap repair, followed by eventual supercharged jejunal interposition graft reconstruction. Two patients were successfully treated with sEV+S placement. No patients required readmission, and no deaths occurred due to the procedures. Conclusions: We demonstrate that sEV+S treatment can successfully treat large uncontained esophageal leaks after esophagectomy.