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Objectives Locally advanced lung cancers present a significant challenge to minimally invasive thoracic surgeons. An increasing number of centers have adopted robotic-assisted thoracoscopic surgeries for these complex operations. In this study, we compare surgical margins achieved, conversion rates to thoracotomy, perioperative mortality and thirty-day readmission rates for robotic and video-assisted thoracoscopic surgery (VATS) lobectomy for locally advanced lung cancers. Methods Using the National Cancer Database (NCDB), we identified patients with Non-small cell lung cancer (NSCLC) who received neoadjuvant chemotherapy/radiotherapy, had clinical N1/N2 disease or in the absence of these two features had a tumour > 5 cm treated with either robotic or VATS lobectomy between 2010 and 2016. Perioperative outcomes and conversion rates were compared between robotic and VATS lobectomy. Results A total of 9,512 patients met our inclusion criteria with 2,123 (22.3%) treated with robotic lobectomy and 7,389 (77.7%) treated with VATS lobectomy. Comparable R0 resections, thirty and ninety-day mortality and thirty-day readmission rates were observed for robotic and VATS lobectomy while a higher rate of conversion to thoracotomy was observed for VATS (aOR = 1.99, 95% CI = 1.65, 2.39, p < 0.001) Conclusions Our analysis of the NCDB suggests that robotic lobectomy for complex lung resections achieves similar perioperative outcomes and R0 resections as VATS lobectomy with the exception of a lower rate of conversion to thoracotomy.

OBJECTIVES We aimed to identify patient- and facility-specific predictors of collective adherence to 4 recommended best treatment practices in operable IIIAN2 non-small-cell lung cancer (NSCLC) and test the hypothesis that collective adherence is associated with superior survival. METHODS We queried the National Cancer Database for clinical stage IIIAN2 NSCLC patients undergoing surgery during 2010–2015. The following best practices were examined: performance of an anatomic resection, performance of an R0 resection, examination of regional lymph nodes and administration of induction therapy. Multivariable regression models were fitted to identify independent predictors of guideline-concordance. RESULTS We identified 7371 patients undergoing surgical resection for IIIAN2 lung cancer, of whom 90.8% underwent an anatomic resection, 88.2% received an R0 resection, 92.5% underwent a regional lymph node examination, 41.6% received induction therapy and 33.7% received all 4 best practices. Higher income, private insurance and treatment at an academic facility were independently associated with adherence to all 4 best practices (P < 0.01). A lower level of education and residence in a rural county were associated with a lack of adherence (P < 0.05). Adherence to all 4 practices correlated with improved survival (P < 0.01). CONCLUSIONS National adherence to best treatment practices in operable IIIAN2 lung cancer was variable as evidenced by the majority of patients not receiving recommended induction therapy. Socioeconomic factors and facility type are important determinants of guideline-concordance. Future efforts to improve outcomes should take this into account since guideline concordance, in the form of collective adherence to all 4 best practices, was associated with improved survival.

Acute vascular insufficiency of intestines (AVI) is a rare cause of severe abdominal pain contributing to 0.09% to 2% of admissions in surgical emergency. Despite its rarity, it needs early recognition because of its high mortality of 40% to 80% requiring timely diagnosis and prompt intervention. Occlusion of mesenteric vessels by arterial embolism (50%) or thrombosis (15% to 25%) and venous thrombosis (5%) are the predominant underlying causes. However, AVI may be nonocclusive in 20% to 30% of the patients. 1,2 Normally intestinal ischemia is prevented by its high perfusion through celiac mesenteric artery, superior mesenteric artery/inferior mesenteric artery, and a parallel system of venous drainage. 3 Therefore, bowel ischemia can occur only when blood supply is markedly reduced to 75% or more leading to a continuum of intestinal necrosis, perforation, infarction, or gangrene stimulating a severe inflammatory response that may be fatal. 4 Recently, activation of Janus kinase/transducer signaling pathway is proposed as an underlying mechanism for mesenteric ischemia. 5 Bowel ischemia is of interest to the clinical hematologist because of its association with thromboembolism. Hematologists are frequently consulted for anticoagulating patients having AVI with or without concomitant bleeding risks. It is important for the hematologists to know the pathophysiology of bowel ischemia, rationale of anticoagulation, preferred anticoagulants, and the selection of patients for thrombophilia screening. This study was conducted to evaluate the clinicopathological spectrum and outcome of thrombosis in acute mesenteric ischemia at