Switching from Thoracoscopic to Robotic Platform for Lobectomy: Report of Learning Curve and Outcome

Objective The optimal minimally invasive surgical management for patients with non-small-cell lung cancer (NSCLC) is unclear. For experienced video-assisted thoracoscopic surgery (VATS) surgeons, the increased costs and learning curve are strong barriers for adoption of robotics. We examined the learning curve and outcome of an experienced VATS lobectomy surgeon switching to a robotic platform. Methods We conducted a retrospective review to identify patients who underwent a robotic or VATS lobectomy for NSCLC from 2016 to 2018. Analysis of patient demographics, perioperative data, pathological upstaging rates, and robotic approach (RA) learning curve was performed. Results This study evaluated 167 lobectomies in total, 118 by RA and 49 by VATS. Patient and tumor characteristics were similar. RA had significantly more lymph node harvested (14 versus 10; P = 0.004), more nodal stations sampled (5 versus 4; P < 0.001), and more N1 nodes (8 versus 6; P = 0.010) and N2 nodes (6 versus 4; P = 0.017) resected. With RA, 22 patients were upstaged (18.6%) compared to 5 patients (10.2%) with VATS ( P = 0.26). No differences were found in perioperative outcome. Operative time decreased significantly with a learning curve of 20 cases, along with a steady increase in lymph node yield. Conclusions RA can be adopted safely by experienced VATS surgeons. Learning curve is 20 cases, with RA resulting in superior lymph node clearance compared to VATS. The potential improvement in upstaging and oncologic resection for NSCLC may justify the associated investments of robotics even for experienced VATS surgeons.

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Fat clearance of upper gastrointestinal resection specimens increases lymph node yield and may result in nodal upstaging

Journal of Clinical Pathology ◽

10.1136/jclinpath-2018-205457 ◽

2018 ◽

Vol 72 (1) ◽

pp. 86-89

Author(s):

Jon Griffin ◽

Clare Bunning ◽

Asha Dubé

Keyword(s):

Lymph Node ◽

Gastrointestinal Cancers ◽

Historical Cohort ◽

Lymph Node Yield ◽

Patient Demographics ◽

Lymph Node Retrieval ◽

Nodal Upstaging ◽

The Impact ◽

Upper Gastrointestinal ◽

Node Yield

IntroductionLymph node retrieval and quantification is an important element in staging upper gastrointestinal cancers. Our department introduced fat clearance for oesophagectomy and gastrectomy specimens in 2014. This study assessed the impact of this change on lymph node yield and upstaging.MethodsWe reviewed histopathology data for upper gastrointestinal resection specimens. Patient demographics, clinical, macroscopic and microscopic data were compared with a historical cohort who did not undergo fat clearance.ResultsOf 158 patients, 133 resection specimens received fat clearance resulting in a significantly higher lymph node yield than the historical cohort (22 vs 13 lymph nodes, p<0.0001). Fat clearance found additional positive nodes in 24.1% of patients and increased the number of cases achieving a minimum node yield of 15. Nodes found by fat clearance caused upstaging in 15% of the cohort.DiscussionFat clearance increases node yield in upper gastrointestinal resection specimens and may cause nodal upstaging.

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Right Superior Mediastinal Lymph Node Dissection in Thoracoscopic Surgery Using a Bipolar Sealing Device

Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery ◽

10.1097/imi.0b013e3182a7460f ◽

2013 ◽

Vol 8 (4) ◽

pp. 258-263 ◽

Cited By ~ 5

Author(s):

Mitsuhiro Kamiyoshihara ◽

Hitoshi Igai ◽

Takashi Ibe ◽

Natsuko Kawatani ◽

Yoichi Ohtaki ◽

...

Keyword(s):

Lymph Node ◽

Lymph Nodes ◽

Learning Curve ◽

Lymph Node Dissection ◽

Thoracoscopic Surgery ◽

Mediastinal Lymph Node ◽

Mediastinal Lymph Node Dissection ◽

Node Dissection ◽

Chest Drainage ◽

Sealing Device

Objective This study investigated the use of a new bipolar sealing device (BSD) in right superior mediastinal lymph node dissection during thoracoscopic surgery. Methods The study population consisted of 42 consecutive patients undergoing lobectomy with right superior mediastinal lymph node dissection for primary lung cancer. Operative results were compared with those of conventional surgery in 42 background-matched controls. The primary endpoint for the present analysis was the success of right superior mediastinal lymph node dissection during thoracoscopic surgery using a BSD. The secondary endpoints included the duration of the operation, number of dissected lymph nodes, chest drainage volume and duration, postoperative hospital stay, morbidity, and mortality. Results The BSD was used successfully in 42 patients. No significant difference in duration of lymph node dissection, chest drainage volume, drainage duration, or number of dissected lymph nodes was observed between the study group and the controls. Because of a learning curve, the procedure initially took more than 20 minutes to complete, but surgical time was reduced to approximately 15 minutes after the procedure was performed in 15 patients. Conclusions Our method is safe and in no way inferior to the conventional procedure. The tendency of the learning curve suggests that a significantly shorter duration of lymph node dissection is possible using this method.

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Learning Curve to Lymph Node Resection in Minimally Invasive Esophagectomy for Cancer

Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery ◽

10.1097/imi.0000000000000082 ◽

2014 ◽

Vol 9 (4) ◽

pp. 286-291 ◽

Cited By ~ 8

Author(s):

Ankit Dhamija ◽

Joshua E. Rosen ◽

Anish Dhamija ◽

Bonnie E. Gould Rothberg ◽

Anthony W. Kim ◽

...

Keyword(s):

Lymph Node ◽

Minimally Invasive ◽

Learning Curve ◽

Minimally Invasive Esophagectomy ◽

Invasive Approach ◽

Lymph Node Yield ◽

Invasive Esophagectomy ◽

Surgeon Experience ◽

Nodal Yield ◽

The Impact

Objective Minimally invasive esophagectomy (MIE) is a safe alternative to open approaches, yet the impact of the minimally invasive approach on oncologic efficacy is unclear. The objectives of the current study were to compare lymph node yields and surgical margins during a single-surgeon series to examine the learning curve to oncologic aspects of MIE. Methods A retrospective review of a prospectively maintained institutional database was performed. The sequential MIE experience for esophageal cancer was subcategorized into terciles (first 25 MIEs as early, next 24 as middle, and most recent 24 as later). Results Seventy-three patients underwent MIE for cancer between 2008 and 2013. Complete resections (R0) were performed in 71 cases (93%), and there were no significant differences in the number of complete resections with negative margins during the MIE experience ( P = 0.54). The number of lymph nodes harvested during MIE increased significantly with progressive experience, with a mean of 22, 29, and 28 nodes recovered in the early, middle, and late subgroups, respectively ( P = 0.038). On multivariate analysis, only increasing surgeon experience (1.4-fold increase in nodal yield for the latter two thirds relative to the first third, P = 0.0011) and histology of high-grade dysplasia (0.54-fold decrease in nodal yield relative to adenocarcinoma or squamous cell carcinoma, P = 0.025) were significant predictors of lymph node yield. Conclusions The ability to execute a complete lymphadenectomy during MIE is affected by surgeon experience and improves over time, plateauing after the first 25 cases.

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Oncological outcomes after lobe-specific mediastinal lymph node dissection via multiport video-assisted thoracoscopic surgery

European Journal of Cardio-Thoracic Surgery ◽

10.1093/ejcts/ezaa166 ◽

2020 ◽

Vol 58 (Supplement_1) ◽

pp. i92-i99

Author(s):

Mingyon Mun ◽

Masayuki Nakao ◽

Yosuke Matsuura ◽

Junji Ichinose ◽

Sakae Okumura

Keyword(s):

Overall Survival ◽

Lymph Node ◽

Thoracoscopic Surgery ◽

Mediastinal Lymph Node ◽

Survival Rates ◽

Recurrence Free Survival ◽

Vats Lobectomy ◽

Free Survival ◽

Oncological Outcomes ◽

Video Assisted Thoracoscopic Surgery

Abstract OBJECTIVES We retrospectively investigated oncological outcomes after video-assisted thoracoscopic surgery (VATS) lobectomy with lobe-specific mediastinal lymph node dissection (MLND). METHODS Between April 2008 and December 2016, a total of 660 patients underwent VATS lobectomy with lobe-specific MLND for clinical T1-3N0M0 non-small-cell lung cancer, of which 54 (8.2%) patients had pathological node-positive disease (18 N1 and 36 N2). We evaluated their oncological outcomes. RESULTS The predominant histological type was adenocarcinoma (87%). Six (33%) patients in the pN1 and 11 (31%) patients in the pN2 received adjuvant chemotherapy. The median follow-up period was 51.6 months. Postoperative recurrence was observed in 5 (28%) pN1 and 22 (61%) pN2 patients. One (6%) pN1 and 12 (33%) pN2 patients experienced locoregional recurrence. None of the pN1 patient experienced local recurrence at the dissected zone, whereas 11 (31%) pN2 patients had lymph node recurrence, including four at the dissected area and three in the area omitted from dissection in the lobe-specific MLND. The 5-year overall survival rates were 88.1% in the pN1 patients and 80.0% in the pN2 patients; the 5-year recurrence-free survival rates were 63.9% in the pN1 patients and 34.8% in the pN2 patients. In pN2 patients, pathological T classification was a prognostic factor for overall survival (P < 0.001) and recurrence-free survival (P = 0.034), and single-station N2 disease was also prognostic factor for overall survival (P = 0.023). CONCLUSIONS Recurrence at the omitted zone is an issue for this type of MLND. For pN1 patients, adequate MLND is an important factor for curative treatment. However, for pN2 patients, systemic treatment after recurrence may also contribute to survival.

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Lymph node yield in treatment naïve cases of head and neck squamous cell carcinoma: en bloc lymphadenectomy versus level-by-level dissection

The Journal of Laryngology & Otology ◽

10.1017/s0022215121000621 ◽

2021 ◽

pp. 1-8

Author(s):

K Devaraja ◽

K Pujary ◽

B Ramaswamy ◽

D R Nayak ◽

N Kumar ◽

...

Keyword(s):

Squamous Cell Carcinoma ◽

Lymph Node ◽

Cell Carcinoma ◽

Head And Neck ◽

Neck Dissection ◽

Squamous Cell ◽

Neck Squamous Cell Carcinoma ◽

En Bloc ◽

Lymph Node Yield ◽

Node Yield

Abstract Background Lymph node yield is an important prognostic factor in head and neck squamous cell carcinoma. Variability in neck dissection sampling techniques has not been studied as a determinant of lymph node yield. Methods This retrospective study used lymph node yield and average nodes per level to compare level-by-level and en bloc neck dissection sampling methods, in primary head and neck squamous cell carcinoma cases operated between March 2017 and February 2020. Results From 123 patients, 182 neck dissections were analysed, of which 133 were selective and the rest were comprehensive: 55 had level-by-level sampling and 127 had undergone en bloc dissection. The level-by-level method yielded more nodes in all neck dissections combined (20 vs 17; p = 0.097), but the difference was significant only for the subcohort of selective neck dissection (18.5 vs 15; p = 0.011). However, the gain in average nodes per level achieved by level-by-level sampling was significant in both groups (4.2 vs 3.33 and 4.4 vs 3, respectively; both p < 0.001). Conclusion Sampling of cervical lymph nodes level-by-level yields more nodes than the en bloc technique. Further studies could verify whether neck dissection sampling technique has any impact on survival rates.

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Impact of Pancreatic Resection on Survival in Locally Advanced Resectable Gastric Cancer

Cancers ◽

10.3390/cancers13061289 ◽

2021 ◽

Vol 13 (6) ◽

pp. 1289

Author(s):

Shih-Chun Chang ◽

Chi-Ming Tang ◽

Puo-Hsien Le ◽

Chia-Jung Kuo ◽

Tsung-Hsing Chen ◽

...

Keyword(s):

Lymph Node ◽

Pancreatic Resection ◽

Locally Advanced ◽

Survival Rates ◽

Disease Free Survival ◽

Complication Rates ◽

Lymph Node Yield ◽

Whipple’S Operation ◽

Whipple's Operation ◽

The Impact

Whether gastric adenocarcinoma (GC) patients with adjacent organ invasion (T4b) benefit from aggressive surgery involving pancreatic resection (PR) remains unclear. This study aimed to clarify the impact of PR on survival in patients with locally advanced resectable GC. Between 1995 and 2017, patients with locally advanced GC undergoing radical-intent gastrectomy with and without PR were enrolled and stratified into four groups: group 1 (G1), pT4b without pancreatic resection (PR); group 2 (G2), pT4b with PR; group 3 (G3), positive duodenal margins without Whipple’s operation; and group 4 (G4), cT4b with Whipple’s operation. Demographics, clinicopathological features, and outcomes were compared between G1 and G2 and G3 and G4. G2 patients were more likely to have perineural invasion than G1 patients (80.6% vs. 50%, p < 0.001). G4 patients had higher lymph node yield (40.8 vs. 31.3, p = 0.002), lower nodal status (p = 0.029), lower lymph node ratios (0.20 vs. 0.48, p < 0.0001) and higher complication rates (45.2% vs. 26.3%, p = 0.047) than G3 patients. The 5-year disease-free survival (DFS) and overall survival (OS) rates were significantly longer in G1 than in G2 (28.1% vs. 9.3%, p = 0.003; 32% vs. 13%, p = 0.004, respectively). The 5-year survival rates did not differ between G4 and G3 (DFS: 14% vs. 14.4%, p = 0.384; OS: 12.6% vs. 16.4%, p = 0.321, respectively). In conclusion, patients with T4b lesion who underwent PR had poorer survival than those who underwent resection of other adjacent organs. Further Whipple’s operation did not improve survival in pT3–pT4 GC with positive duodenal margins.

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