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Background Studies of robotic lobectomy (Robot-L) have been performed using data from high-volume, specialty centers which may not be generalizable. The purpose of this study was to compare mortality, length of stay (LOS), and cost between Robot-L and thoracoscopic lobectomy (VATS-L) using a nationally representative database hypothesizing they would be similar. Methods The Premier Healthcare Database was used to identify patients receiving elective lobectomy for lung cancer from 2009 to 2019. Patients were categorized as receiving Robot-L or VATS-L using ICD-9/10 codes. Survey methodology and patient level weighting were used to correct for sampling error and estimation of a nationally representative sample. A propensity match analysis was performed to reduce bias between the groups. Primary outcome of interest was in-hospital mortality. Secondary outcomes were LOS and patient charges. Results Among 62 698 patients, 19 506 (31.1%) underwent Robot-L and 43 192 (68.9%) underwent VATS-L. Differences between the groups included age, race, comorbidities, and insurance type. A propensity matched cohort demonstrated similar in-hospital mortality for Robot-L and VATS-L (.9% vs .9%, respectively, P = .91). Patients who underwent Robot-L had a shorter LOS (4 vs 5d, respectively, P < .001) but higher patient charges (90 593.0 vs 72 733.3 USD, respectively, P < .001). Conclusions In a nationally representative database, Robot-L and VATS-L had similar mortality. Although Robot-L was associated with shorter hospitalization, it was also associated with excess charges of almost $20,000. As Robot-L is now the most common approach for lobectomy in the U.S., further study into the cost and benefit of robotic surgery is warranted.

Introduction: Significant liver injury related to acetaminophen overdose is more common in patients with preexisting liver disease. We present a patient with newly diagnosed acute hepatitis C infection with acute liver injury treated successfully with N-acetylcysteine despite negative acetaminophen levels. Case Description/Methods: A 29-year-old male with history of spontaneously cleared HCV two years ago and polysubstance use presented with abdominal pain, anorexia, and jaundice. He admitted to taking less than 2 g of acetaminophen for tooth ache and chronic back pain along with recent IV drug use, alcohol use, and marijuana use. Examination revealed scleral icterus and right upper quadrant tenderness. Labs revealed normal acetaminophen level, elevated bilirubin 9.4, transaminases AST 1,023; ALT 1,941; alkaline phosphatase (ALP) 202, and INR of 1.4. Hepatitis C antibody returned positive. Hepatitis C genotype was 1a or 1b with an HCV RNA level of 10,917. Evaluation for other etiologies for acute liver injury including alpha-1 antitrypsin, ceruloplasmin, autoimmune, and other infectious work up was negative. MRCP was normal without biliary pathology. He was given 140 mg/kg oral N-acetylcysteine for suspected acetaminophen overdose as the etiology for liver injury. His symptoms improved and liver tests showed an improvement in the next few days (total bilirubin 5.1, mg/dL, AST 100, ALT 731, ALKP 218). The patient was prescribed Sofosbuvir-Velpatasvir at discharge for the treatment of acute hepatitis C. Discussion: In patients with hepatitis C infection the rate of liver injury with acute or chronic infection is about 16.7%. This case highlights the importance of having a low threshold for treating patients for acetaminophen toxicity in acute hepatitis C patients based on history. This case also highlights further studies are needed to determine the incidence and implications of acute liver injury in acute hepatitis C patients as there are no studies in this group of patients so far.[3108] Figure 1. Histology slide showing hepatic involvement of sarcoidosis.

Objective: Lung lobectomy is the standard of care for early-stage lung cancer. Studies have suggested improved outcomes associated with lobectomy performed by specialized thoracic surgery providers. We hypothesized that disparities would exist regarding access to thoracic surgeons among patients receiving lung lobectomy for cancer. Methods: The Premier Hospital Database was used to identify adult inpatients receiving lung lobectomy from 2009 to 2019. Patients were categorized as receiving their lobectomy from a thoracic surgeon, cardiovascular surgeon, or general surgeon. Sample-weighted multivariable analysis was performed to identify factors associated with provider type. Results: When adjusted for sampling, 121,711 patients were analyzed, including 71,709 (58.9%) who received lobectomy by a thoracic surgeon, 36,630 (30.1%) by a cardiovascular surgeon, and 13,373 (11.0%) by a general surgeon. Multivariable analysis showed that thoracic surgeon provider type was less likely with Black patients, Medicaid insurance, smaller hospital size, in the western region, and in rural areas. In addition, non-thoracic surgery specialty was less likely to perform minimally-invasive (MIS) lobectomy (cardiovascular OR 0.80, p < 0.001, general surgery OR 0.85, p = 0.003). Conclusions: In this nationally representative analysis, smaller, rural, non-teaching hospitals, and certain regions of the United States are less likely to receive lobectomy from a thoracic surgeon. Thoracic surgeon specialization is also independently associated with utilization of minimally invasive lobectomy. Combined, there are significant disparities in access to guideline-directed surgical care of patients receiving lung lobectomy.

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