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Discussion

Open AccessPublished:November 18, 2022DOI:https://doi.org/10.1016/j.xjon.2022.09.013
      Presenter: Dr Hope Feldman
      Unidentified speaker 1. Discussion will be opened by Lana Schumacher from the Mass General Hospital.
      Dr Schumacher. Right. Right. I think that these are very valid points. I know that I mentioned that to you. How can we get this information out to the community? Should this be more standard? Should we be asking our radiologists to actually measure the nodal response more frequently and not just be looking at RECIST criteria? So, I think that—can you replicate this in the community, do you think, this type of study? Or you have plans for that?
      Dr Feldman. I think it will be really important to validate the findings of our study. And also, especially to look at the outcomes of these more—what we would anticipate being more challenging dissections in the community setting—to evaluate in a setting that has different resources. Are they seeing the same types of outcomes with regard to complications? Is it safe to still do these procedures? And if so, what resources are going to be needed so that they can plan accordingly?
      Dr Schumacher. Excellent. My last question, are you going to also look at this study with [newer?] agents? I know you had mentioned that, and hopefully, you will continue this.
      Dr Feldman. Yes. Dr Antonoff is definitely continuing this work in the setting of targeted therapies.
      Dr Schumacher. Great. Excellent job.
      Dr Feldman. Thank you.
      Dr Schumacher. Thank you.
      Dr Robert Cerfolio. You have such a unique opportunity to teach so many people in this room. And you have a slide that says, “Nodal adherence to artery forces change in approach to vasculature.” No, it doesn't. It's changing approach to the bronchus. Cut the bronchus. If you just cut the bronchus, you don't have to get around the artery. So, I think that's the big trick. That's why we do—and I know you're not going to believe me, but enough people in the room have seen this—100% of these robotically. Every single one is done robotically, with a conversion rate of less than 2%. And it is better for the patient. So, it's good to say outcomes are the same, but they're not. You'd much rather have those minimally invasive than an open. And we do them together as a team. But I think the unique opportunity here is to teach people when you can't get around an artery, instead of digging around to get—yes, you get proximal control, but just take a bipolar, if you use a robot. You can lower the Fio2 in the inspired air from the anesthesiologist, but you don't have to. Airway fires don't happen. But if you're worried about it, do it. And just cut the B2 or the B3 or the B1 bronchus. They're usually left upper lobes, almost all of these. If you cut the B2 and then start bringing it back down even to the B4 or 5, the artery's just hanging out in the breeze. And then you can go get it.
      Dr Feldman. I appreciate that comment. I'm a second-year general surgery resident completing two years of research [crosstalk]. [applause]
      Dr Feldman. So, I'll use that as a learning opportunity. Thank you.
      Unidentified speaker 1. Wait. Robert, if you still have the node invading the artery, you've got to do the sleeve.
      Dr Cerfolio. [inaudible].
      Dr Mara Antonoff. Just to clarify, if you change the order of the steps that you're doing in the operation, that is technically a change in the approach to the vasculature. You're not taking the artery at the time when you otherwise might have done it. You're taking the bronchus first and then approaching the artery from a different angle.
      Dr Feldman. Thank you.
      Dr Schumacher. Excellent job. [applause]