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F.O. Velez-Cubian



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    MO02 - General Thoracic and Minimally Invasive Surgery (ID 99)

    • Event: WCLC 2013
    • Type: Mini Oral Abstract Session
    • Track: Surgery
    • Presentations: 1
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      MO02.07 - Effect of Obesity on Peri-Operative Outcomes after Robotic-Assisted Pulmonary Lobectomy: Retrospecitve Analysis of 227 Consecutive Patients (ID 2440)

      11:00 - 11:05  |  Author(s): F.O. Velez-Cubian

      • Abstract
      • Presentation
      • Slides

      Background
      Attention has increased over the safety and efficacy of robotic-assisted surgeries in recent years. With rates of obesity on the rise, the impact of excessive body weight on surgical outcomes comprises an important concern for administering care. Our purpose was to determine the relationship between preoperative body mass index (BMI) on perioperative complications following robotic-assisted pulmonary lobectomy for at a high-volume tertiary-care referral cancer center.

      Methods
      We retrospectively studied 227 consecutive patients who underwent robotic-assisted pulmonary lobectomy for known or suspected lung cancer. BMI was calculated as being equal to weight in kilograms divided by height in meters squared. We stratified BMI into 4 groups as defined by the World Health Organization (WHO): Underweight (BMI <18 kg/m2), Normal Weight (BMI 18-25 kg/m2), Overweight (BMI 25.01-30 kg/m2), and Obese (BMI >30 kg/m2). Perioperative complications from surgery to discharge from the hospital were assessed and included respiratory failure, hemothorax, pleural effusion, prolonged air leak, subcutaneous emphysema, aspiration, pneumonia, and hypoxia. Hospital length of stay and in-hospital operative mortality were also assessed. Of 227 total patients studied, there were 6 Underweight patients, 87 Normal Weight patients, 71 Overweight patients, and 63 Obese patients. Initially, with the Underweight group omitted due to small sample size, comparison of the remaining three BMI groups revealed that there were no significant increases in peri-operative complication rates, hospital length of stay, or in-hospital operative mortality among the 3 groups, although there were clear trends toward increased morbidity and mortality when patients had higher BMI. Therefore, we compared the peri-operative complication rates, hospital length of stay, and in-hospital operative mortality between Obese and Non-Obese patients.

      Results
      The results are shown in the following table:

      Surgical Complication Non-Obese BMI ≤30 Obese BMI >30 P-value
      N=162, n (%) N=65, n (%)
      Hypoxia or Respiratory failure 6 (3.7) 7 (10.8) 0.04*
      Hemothorax 3 (1.9) 2 (3.1) 0.57
      Effusion or Empyema 2 (1.2) 2 (3.1) 0.34
      Prolonged air leak 30 (18.5) 5 (7.7) 0.04*
      Subcutaneous emphysema 6 (3.7) 2 (3.1) 0.82
      Aspiration 4 (2.5) 2 (3.1) 0.79
      Pneumonia 17 (10.5) 8 (12.3) 0.69
      In-Hospital Operative Mortality 2 (1.2) 2 (3.1) 0.34
      Median Length of Stay (days+SEM) 5 + 0.3 4 + 0.6 0.54
      *statistically significant, p<0.05

      Conclusion
      Our study shows that obesity increases the risk of peri-operative hypoxia or respiratory failure but results in a lower risk of prolonged air leak after robotic-assisted pulmonary lobectomy. However, we found no significant difference in hospital length of stay or in-hospital mortality between obese and non-obese patients. Thus, our study suggests that robotic-assisted pulmonary lobectomy is feasible and safe in obese patients.

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    P1.07 - Poster Session 1 - Surgery (ID 184)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Surgery
    • Presentations: 1
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      P1.07-014 - Effect of Advanced Age on Peri-Operative Outcomes after Robotic-Assisted Pulmonary Lobectomy: Retrospective Analysis of 180 Consecutive Cases (ID 2992)

      09:30 - 09:30  |  Author(s): F.O. Velez-Cubian

      • Abstract

      Background
      Technological advances and increased life expectancies have resulted in increasingly complex procedures being performed more frequently on patients with advanced age. As surgeons gain competency in robotic-assisted surgery, surgeons are extending the benefits of these minimally-invasive procedures to geriatric patients. Thus, we investigated the complication rates after robotic-assisted pulmonary lobectomy in patients with advanced age.

      Methods
      We retrospectively analyzed 180 consecutive patients who underwent robotic-assisted lobectomy by one surgeon between September 2010 and February 2013. Patients were grouped by age >77 at the time of operation (Group A) versus age <77 (Group B). Clinically significant perioperative complications were noted, including minor complications, such as wound infection and anemia requiring transfusion, and more serious major complications, such as empyema and deep venous thrombosis/pulmonary embolus (DVT/PE). Rates of perioperative complications, conversion to open lobectomy, chest tube days, hospital length of stays (LOS), and in-hospital mortality were compared between the two groups, with p-value <0.05.

      Results
      A total of 180 patients were included (mean age 67yr). Group A had 31 patients with advanced age >77yrs (range 77-86yr; 16 men, 15 women); Group B had 149 patients (range of 29-76yr; 74 men, 75 women). Overall intraoperative complication rate was 17/180 (9%), overall postoperative complication rate was 87/180 (48%), and overall in-hospital mortality was 5/180 (3%). Group A had 7/31 (6%) intra-operative complications, compared to 10/149 (3%) for Group B (p=0.006). The most common intraoperative complication in both groups was bleeding from the pulmonary artery, with 3/31 (10%) in Group A and 3/149 (2%) in Group B. The overall rate of conversion to open lobectomy was 7/31(23%) in Group A versus 13/149 (2%) in Group B (p=0.026); although the rate of emergent conversion to open lobectomy was 3/31 (10%) in Group A compared to 3/149 (2%) in Group B. There were 19/31 (61%) patients in Group A with minor and/or major post-operative complications, compared to 68/149(46%) in Group B (p=0.11). The most common post-operative complications experienced by Group A were prolonged air leak 8/31 (26%), atrial fibrillation 6/31 (19%), pneumonia 4/31 (13%) and mucus plugs requiring intervention 4/31 (9%; p=0.24), while those for Group B were prolonged air leak 26/149 (17%; p=0.28), pneumonia 19/149 (13%; p=0.98), atrial fibrillation 16/149 (11%; p=0.23) and anemia 9/149 (6%). Group A had medians of 5+2.8 (S.E.M.) chest tube days and 7+1.3 (S.E.M.) hospital days, compared to 4+0.3 chest tube days and 5+0.4 hospital days for Group B (p=0.09 and p=0.004, respectively). Interestingly, Group A had 0/31 (0%) in-hospital mortality, compared to an in-hospital mortality rate of 5/149 (3%) for Group B (p=0.30).

      Conclusion
      Patients with advanced age >77 yr and who undergo robotic-assisted lobectomy have a higher risk of perioperative complications and conversion to open lobectomy. In addition, advanced age also resulted in longer hospital LOS. However, advanced age was not associated with increased in-hospital mortality and was actually associated with decreased mortality. Thus, our study suggests that robotic pulmonary lobectomy is feasible and safe in patients with advanced age.

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    P2.07 - Poster Session 2 - Surgery (ID 190)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Surgery
    • Presentations: 2
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      P2.07-027 - Retrospective Analysis of 236 Consecutive Robotic-Assisted Pulmonary Lobectomies at a Single Institution: A Bi-Phasic Learning Curve (ID 2470)

      09:30 - 09:30  |  Author(s): F.O. Velez-Cubian

      • Abstract

      Background
      The treatment of choice for early-stage lung cancer is surgical resection. Over the years, there has been an increase in minimally-invasive surgical (MIS) options for lung resection, including video-assisted thoracoscopic (VATS) lobectomy and robotic-assisted thoracoscopic (RATS) lobectomy. These MIS approaches have reformed lobectomies, decreased overall morbidity as well as decreased post-operative pain and hospital length of stay (LOS) when compared to traditional thoracotomy lobectomies. In spite of the recent rapid surgical expansion of MIS lobectomy, little is known about the learning curve of RATS lobectomy. In order to move forward in this new surgical technologic era while enhancing patient safety, determination of this learning curve is crucial.

      Methods
      We retrospectively analyzed the perioperative outcomes of 236 consecutive patients who underwent robotic lobectomy at our institution between September 2010 and June 2013. Patients were grouped chronologically into four quartiles, with 59 patients in each quartile. A comparison was performed between quartiles with respect to operative times, intraoperative estimated blood loss (EBL), hospital LOS, and in-hospital mortality. Statistical analysis was undertaken using analysis of variance (ANOVA), linear regressions, and t-tests. Significance was set at p-value <0.05.

      Results
      A total of 236 patients with a mean age of 67 ± 10 years underwent RATS lobectomy between September 2010 and June 2013. Each of the four quartiles had overall conversion-to-thoracotomy rates of ≤10% and emergency conversion rates of ≤5%. Although intraoperative EBL and hospital LOS were not significantly different among the quartiles, both EBL and hospital LOS showed a decreasing trend over each chronologic quartile. Operative times increased during the 2nd quartile, but also showed a decreasing trend with subsequent quartiles. There was an overall pathologic upstaging in 39% of the RATS lobectomy patients. Lastly, the in-hospital mortality rate was 5.1% for the 1st quartile and 0% for each subsequent quartile.

      Conclusion
      In contrast to the steep learning curves associated with other MIS procedures, RATS lobectomy may result in only a modest learning curve for surgeons with extensive VATS lobectomy experience, as is suggested from the unchanging and low hospital LOS, intraoperative EBL, and conversion to open lobectomy rates across all quartiles. Additionally, the increase in operative time in the 2nd quartile is most likely associated to the extension of the RATS approach to more difficult lobectomy cases after relative comfort with RATS lobectomy has been achieved. The high percentage of overall pathologic upstaging is likely due to more complete mediastinal lymph node dissection than would be achieved with either deliberate lymph node sampling only or else inadequate lymph node dissection due to limitations in visualization, instrumentation, or technical experience with VATS lobectomy. The decrease in mortality rate from the 1st to subsequent quartiles can be attributed to increased proficiency in RATS lobectomy. Thus, a bi-phasic learning curve is demonstrated by increased operative times after establishment of comfort with RATS lobectomy after initial success and subsequent extension of RATS to more complicated patients (1[st] phase), while operative times, EBL, hospital LOS, and mortality decrease with improved patient selection and more RATS experience (2nd phase).

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      P2.07-043 - Effect of Female Gender on Peri-Operative Outcomes after Robotic-Assisted Pulmonary Lobectomy: Retrospective Analysis of 180 Consecutive Cases (ID 3174)

      09:30 - 09:30  |  Author(s): F.O. Velez-Cubian

      • Abstract

      Background
      Female gender has been associated with worse outcomes in cardiovascular surgery, including vein bypass for limb salvage and coronary artery bypass grafting. Women have also been found to prefer to suffer arthritis pain rather than risk orthopedic surgery and to delay surgery to await better technology and to avoid disrupting caregiving roles for spouses and other dependents. We investigated the effect of gender on perioperative outcomes after robotic-assisted lobectomy.

      Methods
      We retrospectively analyzed 180 consecutive patients who underwent robotic-assisted lobectomy by one surgeon between September 2010 and February 2013. Intraoperative estimated blood loss (EBL), operative times (skin incision to skin closure), conversion to open lobectomy, chest tube days, hospital length of stay (LOS), and in-hospital mortality were analyzed. All clinically significant perioperative complications were noted, including minor complications, such as wound infection and anemia, to more serious major complications, such as empyema and DVT/PE. Comparison of perioperative outcomes between men and women was significant at p-value <0.05.

      Results
      Of 180 total patients, there were 90 men (mean age 68yr; range 37-86yr) and 90 women (mean age 68yr; range 29-85yr; p=0.19). Skin-to-skin operative times were 191+12 min for men and 174+12 min for women. Men had median (+SEM) EBL of 235+60mL compared to 150+48mL for women (p=0.79). Intraoperative complication rates were 7/90 (8%) in men and 10/90 (11%) in women (p=0.45). The most common intraoperative complication in men was bleeding not requiring conversion in 2/90 (2%), compared to pulmonary artery (PA) bleeding in 5/90 (6%) of women. The overall conversion rate to open lobectomy was 14/90 (16%) in women versus 6/90 (7%) in men (p=0.06); although the emergent conversion rate was 5/90 (6%) in women versus 1/90 (1%) in men. The most common reasons for conversion to open lobectomy in women was PA bleeding in 5/90 (6%) and dense hilar pleural and/or tumor adhesions in 5/90 (6%); while the latter was the most common reason for conversion in men, occurring in 3/90 (3%). A minor and/or major postoperative complication occurred in 48/90 (53%) of men, compared to 39/90 (43%) in women (p=0.18). The most common postoperative complications in men were prolonged air leak 20/90 (22%), atrial fibrillation 14/90 (16%), pneumonia 11/90 (12%), and mucus plugs requiring intervention 7/90 (8%), while the most common in women were prolonged air leak 14/90 (16%; p=0.25), pneumonia 12/90 (13%; p=0.82), atrial fibrillation 8/90 (9%; p=0.12), and mucus plugs requiring intervention 7/90 (8%; p=1.00). Women had 4.0+0.5 chest tube days (median+SEM) and 5.0+0.5 hospital days, compared to 4.0+1.1 chest tube days and 5.5+0.6 hospital days for men (p=0.14 and p=0.44, respectively). In-hospital mortality was 4/90 (4%) in men compared to 1/90 (1%) in women (p=0.17).

      Conclusion
      While women had a slightly higher conversion rate to open lobectomy than men, female gender was not associated with increased intraoperative or postoperative complications nor with increased hospital LOS or in-hospital mortality. Our study suggests that robotic-assisted pulmonary lobectomy is feasible and safe in women.