International Society for Minimally Invasive Cardiothoracic Surgery

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Keeping An Open Mind: Exploring The Boundaries Of Minimally-Invasive Thoracic Surgery
M. Jawad Latif, Russell S. Martins, Jeffrey Luo, Kostantinos Poulikidis, Syed S. Razi, Faiz Y. Bhora
Hackensack Meridian Health, Edison, NJ, USA

BACKGROUND: Robotic thoracic surgery has been transformational in thoracic oncologic surgery over the past decade. It has allowed significantly enhanced recovery, shorter hospital length of stay, and decreased complications.
METHODS: We report a case of a 65-year-old male who presented with cough & right-sided chest pain for 4 weeks.​
Chest imaging including PET/CT showed destructive soft tissue mass (4.3 x 3.2 cm) centered around the right anterolateral 3rd rib and GEJ thickening.​ Brain MRI showed no metastases.
EGD showed fungating mass at GEJ (38-43 cm from incisors)​, with pathology showing infiltrating squamous cell carcinoma, poorly differentiated​. CT-guided biopsy of right chest wall mass showed poorly differentiated carcinoma consistent with esophageal primary.
Given the patientís good performance status and our assessment of oligometastatic disease, the multidisciplinary tumor board recommended induction chemoradiation followed by curative intent esophagectomy with concurrent chest wall resection.
RESULTS: We performed a robotic-assisted chest wall resection of right ribs 3 and 4 and associated soft tissue for oligometastatic disease from esophageal carcinoma, concurrently with robotic Ivor Lewis esophagectomy.
No feeding tube was placed at the time of surgery.​ CT esophagogram on postoperative day 3 demonstrated no leak and the patient was advanced on a clear liquid diet. The Jackson-Pratt drains were removed on postoperative day 5, and the patient was advanced on a full liquid diet. The patient was discharged home on postoperative day 6 tolerating a full liquid diet.
CONCLUSIONS:Final pathology showed poorly differentiated adenosquamous carcinoma, 0.3 cm in size and invading the submucosa. Surgical margins were negative and all 22 examiner lymph nodes showed no evidence of tumor. No residual tumor was seen in the ribs and chest wall specimen. Final pathologic staging was ypT1b and ypN0. The final pathology was as interesting as the multidisciplinary and patient-centric approach that was adopted for this complex case.
As an individual surgeonís experience with robotic surgery matures, operations that were traditionally performed open should be considered for minimally invasive resections. Sometimes, this involves minimal innovation from a technical perspective with the most important factor being an open mind.


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