Management of a Unique Subcarinal Bronchogenic Cyst with Robotic-Assisted Thoracic Surgery

A bronchogenic cyst (BC), although a rare congenital abnormality, represents the most common cystic lesion in the mediastinum and can present with chest pain and shortness of breath, especially due to compression of adjacent vital structures. The most common diagnostic modalities used are computed tomography (CT) and magnetic resonance imaging (MRI). These cysts may elude even a seasoned clinician unless they become symptomatic. For clinicians attempting to give optimum and prompt management for these cysts, robotic-assisted surgical resection is the recommended treatment of choice. Robotic-assisted thoracic surgery (RATS) offers precision and enhanced visualization, making it a safe and accurate approach for the removal of posterior mediastinal BCs. Our patient is a 65-year-old female who presented with symptomatic posterior mediastinal subcarinal BCs and underwent complete surgical resection with RATS. The diagnosis was confirmed with histopathology. Advancements and the clinical impact of RATS for mediastinal BCs including the Da Vinci robotic surgeries have been demonstrated to be minimally invasive, safe, and feasible especially when in difficult-to-reach areas. RATS has also proven to be advantageous in reducing disease burden and improving patient outcomes.

The essential role of non-steroidal anti-inflammatory drugs in pain control following robotic thoracoscopic lung resections

Background

Enhanced recovery after thoracic surgery (ERATS) protocols use a combination of analgesics for pain control. We investigated the effect of non-steroidal analgesic drugs (NSAIDs) on pain control by comparing patient levels and opioid requirements after robotic pulmonary resections.

Methods

We retrospectively analyzed our prospectively maintained institutional database for elective, opioid-naïve robotic thoracoscopic pulmonary resections. All patients received postoperative NSAIDs unless contraindicated or at the discretion of the attending surgeons. Our original protocol (ERATS-V1) was modified to optimize opioid-sparing effect without affecting pain control (ERATS-V2). Demographics, operative outcomes, and postoperative opioid dispensed [morphine milligram equivalent (MME)] were collected.

Results

A total of 491 patients (147 ERATS-V1; 344 ERATS-V2) were included in this study. There was no difference in patient characteristics or operative outcomes between ERATS cohorts. Protocol optimization was associated with a 2- to 10-fold reduction of postoperative opioid use without compromising pain control. In ERATS-V1 cohort, there was no difference in pain levels and opioid requirements with NSAID usage. In ERATS-V2 cohort, while pain levels were similar, higher in-hospital opioid consumption was observed in no-NSAID subgroup {MME: 20.5 [interquartile range (IQR), 4.8-40.5] vs. 12.0 (IQR, 2.0-32.2), P=0.0096, schedule II: 14.2 (IQR, 3.0-36.4) vs. 6.8 (IQR, 1.4-24.0), P=0.012} as well as total postoperative schedule II opioid requirement [17.8 (IQR, 3.0-43.5) vs. 8.8 (IQR, 1.5-30), P=0.032].

Conclusions

The opioid-sparing effect of NSAIDs was observed only in optimized ERATS patients. Modifications of our pre-existing ERATS was associated with a significant reduction of opioid consumption without affecting pain levels. This revealed the role of NSAIDs in postoperative pain management otherwise masked by excessive opioids use.