Video-assisted thoracoscopic surgery (VATS) segmentectomy for small peripheral lung cancer tumors: intermediate results

Uniportal VATS approach to sub-lobar anatomic resections: literature review and personal experience

Surgical scientific literature contains relatively little information regarding the surgical outcomes of anatomic sublobar resections performed with the uniportal video-assisted thoracoscopic surgery (U-VATS) technique. This paper attempts to evaluate the role of U-VATS segmentectomies in the landscape of a minimally invasive approach to the treatment of early stage non small cell lung cancer (NSCLC).

Systematic review and meta-analysis of video-assisted thoracoscopic surgery segmentectomy versus lobectomy for stage I non-small cell lung cancer

BACKGROUND

Whether video-assisted thoracoscopic surgery (VATS) segmentectomy and VATS lobectomy provide similar perioperative and oncological outcomes in stage I non-small cell lung cancer (NSCLC) is still controversial.

METHODS

Meta-analysis of 12 studies comparing outcomes after VATS lobectomy and VATS segmentectomy for stage I NSCLC. Data were analyzed by the RevMan 5.3 software.

RESULTS

Disease-free survival (HR 1.19, 95% CI 0.89 to 1.33, P = 0.39), overall survival (HR 1.11, 95% CI 0.89 to 1.38, P = 0.36), postoperative complications (OR = 1.10, 95% CI 0.69 to 1.75, P = 0.7), intraoperative blood loss (MD = 3.87, 95% CI - 10.21 to 17.94, P = 0.59), operative time (MD = 10.89, 95% CI - 13.04 to 34.82, P = 0.37), air leak > 5 days (OR = 1.20, 95% CI 0.66 to 2.17, P = 0.55), and in-hospital mortality (OR = 1.67, 95% CI 0.39 to 7.16, P = 0.49) were comparable between the groups. Postoperative hospital stay (MD = - 0.69, 95% CI - 1.19 to - 0.19, P = 0.007) and number of dissected lymph nodes (MD = - 6.44, 95%CI - 9.49 to - 3.40, P < 0.0001) were significantly lower in VATS segmentectomy patients.

CONCLUSIONS

VATS segmentectomy and VATS lobectomy provide similar oncological and perioperative outcomes for stage I NSCLC patients. This systematic review was registered on PROSPERO and can be accessed at http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID = CRD42019133398.

From one incision to one port: The surgical technique and the evolution of segmentectomy in patients with pulmonary tuberculosis

OBJECTIVES

We retrospectively reviewed the evolution of segmentectomy for pulmonary tuberculosis (TB) and the feasibility of multi- and single-incision video-assisted thoracoscopic segmentectomy.

METHODS

Of 348 patients undergoing surgery for TB, the medical records of 121 patients undergoing segmentectomy between January 1996 and November 2015 were reviewed. Clinical information and computed tomography (CT) image characteristics were investigated and analyzed.

RESULTS

Eighteen patients underwent direct or intended thoracotomy. Sixty-four underwent video-assisted thoracoscopic segmentectomy (VATS), including 53 multi-incision thoracoscopic segmentectomy (MITS), and 11 single-incision thoracoscopic segmentectomy (SITS). Thirty-nine were converted to thoracotomy. The intended thoracotomy group had more operative blood loss (p = 0.005) and hospital stay (p = 0.001) than the VATS group although the VATS group had higher grade of cavity (p = 0.007). The intended thoracotomy group did not differ from converted thoracotomy in operative time, blood loss, or hospital stay, and the grade of pleural thickening was higher in the converted thoracotomy group (p = 0.001). The converted thoracotomy group had more operative blood loss, hospital stay, and complication rate than the MITS group (p = 0.001, p<0.001, and p = 0.009, respectively). The MITS group had lower pleural thickening, peribronchial lymph node calcification, cavity, and tuberculoma grading than the converted thoracotomy group (p<0.001, p = 0.001, 0.001, and 0.017, respectively). The SITS group had lower grading in pleural thickening, peribronchial lymph node calcification, and aspergilloma grading than the converted thoracotomy group (p = 0.002, 0.010, and 0.031, respectively). Four patients in the intended thoracotomy group and seven in the converted thoracotomy group had complications compared with three patients in the MITS and two in the SITS group. Risk factors of conversion were pleural thickening and peribronchial lymph node calcification.

CONCLUSION

Although segmentectomy is technically challenging in patients with pulmonary TB, it could be safely performed using MITS or SITS and should be attempted in selected patients. Its efficacy for medical treatment failure needs investigation.

Determination of the intersegmental plane using the slip-knot method

Background

Visualization of intersegmental planes in the lung is desirable for precise anatomical lung segmentectomy. We developed the slip-knot method for creating inflation-deflation lines. This study aimed to assess relevant data for thoracoscopic segmentectomy performed using this method.

Methods

In the slip-knot method, the objective segmental bronchus is looped with a monofilament thread. One end of the thread is then pulled during temporary bilateral ventilation, causing the knot to slip toward the bronchus. Thereafter, bronchial ligation is tightened to block the outflow of segmental air, ensuring that the segment remains expanded while the other reserved segments collapse on resumption of unilateral ventilation. Data from 221 patients who underwent thoracoscopic pulmonary segmentectomy between 2010 and 2016 were analyzed.

Results

A total of 147 patients (67%) were indicated for the slip-knot method, and 74 cases (33%) were non-adaptive cases. Ninety six percent of 147 cases were well adapted to the slip-knot method, which allowed us to obtain good inflation-deflation line images to determine the intersegmental plane. The mean operative time was 171±51 min (range, 71-367 min). The mean duration of chest tube insertion was 1.5±1.2 days (range, 1-7 days). Three cases (2.0%) had prolonged air-leakage and one (0.7%) case had readmission for late air-leakage.

Conclusions

Our method enables determination of anatomical intersegmental planes using only one monofilament thread, thus facilitating thoracoscopic pulmonary anatomical segmentectomy.

Evaluation of surgical approaches to anatomical segmentectomies: the transition to minimal invasive surgery improves hospital outcomes

Background

We aim to evaluate the transition process from open to video-assisted thoracoscopic surgery (VATS) anatomical segmentectomies in a regional thoracic surgical unit.

Methods

In a retrospective study from January 2013 to December 2015, we identified all anatomical segmentectomies performed in our unit. Pre, peri and postoperative data were compared between the three years (2013, 2014 and 2015) and according to operative approach. Thoracotomy after VATS intraoperative biopsy was considered a conversion for the purposes of the study.

Results

A total of 86 consecutive cases [56 females and 30 males, median age 70 years (range, 43 to 83 years); median FEV1 of 78% predicted (range, 41% to 126%)] were included. There was a significant change in the surgical approach with time. Fifty-two cases underwent VATS (73% via single-port) and 34 open surgeries, including nine conversions. There were no postoperative deaths in the VATS group and one in the open group. Operative outcomes were similar over time with no haemorrhagic events, equivalent R1 resection and nodal stations explored in all lymph node positive patients. In node negative cases however, open surgery was associated with more extensive mediastinal exploration. Patients in 2015 had a shorter hospital stay in comparison to those in previous years [median 4 days (range, 1-15 days) vs. median 6 days (range, 3-27 days), P=0.01]. There were no differences in the incidence of complications or readmissions to hospital over time.

Conclusions

The transition over a short period of time from open to single-port VATS segmentectomy has allowed us to significantly reduce postoperative hospital stay without compromising operative or postoperative outcomes.

Anatomic thoracoscopic segmentectomy for early-stage lung cancer

Over the past 20 years, there have been significant advancements in thoracoscopic surgical techniques as well as in lung cancer screening protocols, which have identified greater numbers of smaller lung tumors (<2 cm) that are more frequently operable and curable. These advancements have led to new interest in the thoracoscopic (VATS) approach to segmentectomy. This article will discuss the outcomes and technical considerations associated with VATS segmentectomy.

Thoracotomy is better than thoracoscopic lobectomy in the lymph node dissection of lung cancer: a systematic review and meta-analysis

Background

The aim of this study was to investigate which surgical method is better in lymph node (LN) dissection of lung cancer.

Methods

A comprehensive search of PubMed, Ovid MEDLINE, EMBASE, Web of Science, ScienceDirect, the Cochrane Library, Scopus, and Google Scholar was performed to identify studies comparing thoracoscopic lobectomy (video-assisted thoracic surgery (VATS) group) and thoracotomy (open group) in LN dissection.

Results

Twenty-nine articles met the inclusion criteria and involved 2763 patients in the VATS group and 3484 patients in the open group. The meta-analysis showed that fewer total LNs (95% confidence interval [CI] −1.52 to −0.73, p < 0.0001) and N2 LNs (95% CI −1.25 to −0.10, p = 0.02) were dissected in the VATS group. A similar number of total LN stations, N2 LN stations, and N1 LNs were harvested in both groups. Only one study reported that fewer N1 LN stations were dissected in the VATS group (1.4 ± 0.5 vs. 1.6 ± 0.6, p = 0.04).

Conclusions

Open lobectomy could achieve better LN dissection efficacy than thoracoscopic lobectomy in the treatment of lung cancer, especially in the N2 LNs dissection. These findings require validation by high-quality, large-scale randomized controlled trials.

Subxiphoid uniportal video-assisted thoracoscopic middle lobectomy and anterior anatomic segmentectomy (S3)

The video-assisted thoracoscopic surgery (VATS) approach for combined lobectomy and segmentectomy in the same lung is an infrequent procedure, rarely reported in the literature. Currently, Most of the surgeons still use 2-3 thoracic incisions for thoracoscopic anatomic resections. However, the uniportal approach is gaining worldwide acceptance in the recent years. The main advances of uniportal VATS during the last years are related to improvements in surgical technique by implementing new technology. The experience acquired with the uniportal technique allows expert uniportal VATS surgeons to explore new approaches in order to minimize even more the surgical invasiveness. Recently the aim to avoid the intercostal nerve damage created by the transthoracic incision has led to the creation of a novel procedure entitled uniportal VATS subxiphoid approach. Here we report the first case of a lobectomy combined with anatomic segmentectomy performed through a uniportal subxiphoid approach.

Comparison of short-term effect of thoracoscopic segmentectomy and thoracoscopic lobectomy for the solitary pulmonary nodule and early-stage lung cancer

Purpose

To compare the short-term effect of anatomic video-assisted thoracoscopic surgery (VATS) segmentectomy and VATS lobectomy.

Patients and methods

From January 2011 to December 2012, 21 patients underwent VATS segmentectomy and 61 underwent VATS lobectomy. Intraoperative blood loss, operating time, postoperative drainage time, length of hospital stay, postoperative complications, local recurrence, and survival were compared between the two groups.

Results

The intraoperative blood loss and average hospital stay were less in the segmentectomy group than in the lobectomy group (P<0.05). There was no significant difference in the operating time, number of lymph nodes dissected, postoperative drainage time, or 1-year survival between the two groups (P>0.05). Only one patient died because of heart disease. The two groups had a similar incidence of postoperative complications (P>0.05). There was one (4.8%) local recurrence after segmentectomy and two (3.3%) after lobectomy (P>0.05).

Conclusion

VATS segmentectomy could be performed safely and is a method with favorable 1-year survival. It may be the ideal surgical procedure for patients with solitary pulmonary nodules in early stage lung cancer, especially for those with limited cardiopulmonary reserve or significant comorbidities.

Techniques to define segmental anatomy during segmentectomy

Pulmonary segmentectomy is generally acknowledged to be more technically complex than lobectomy. Three-dimensional computed tomography (3D CT) angiography is useful for understanding the pulmonary arterial and venous branching, as well as planning the surgery to secure adequate surgical margins. Comprehension of the intersegmental and intrasegmental veins makes the parenchymal dissection easier. To visualize the segmental border, creation of an inflation-deflation line by using a method of inflating the affected segment has become the standard in small-sized lung cancer surgery. Various modifications to create the segmental demarcation line have been devised to accurately perform the segmentectomy procedure.

Open, thoracoscopic and robotic segmentectomy for lung cancer

While lobectomy is the standard procedure for early stage lung cancer, the role of sublobar resection is currently under investigation for selected patients with small tumors. In this review, studies reporting outcomes on open, thoracoscopic and robotic segmentectomy were analyzed. In patients with stage I lung cancer, with tumors <2 cm in diameter and within segmental anatomic boundaries, segmentectomy appears to have equivalent rates of morbidity, recurrence and survival when compared to lobectomy. Segmentectomy also resulted in greater preservation of lung function and exercise capacity than lobectomy. It appears reasonable to consider segmentectomy for patients with stage I lung cancer (particularly in air-containing tumors with ground glass opacities) where tumors are <2 cm in diameter and acceptable segmental margins are obtainable, especially in patients with advanced age, poor performance status, or poor cardiopulmonary reserve. The results of two ongoing randomized controlled trials (CALGB 140503 and JCOG0802/WJOG4607L) and additional well-designed studies on open, thoracoscopic, and robotic segmentectomy will be important for clarifying the role of segmentectomy for lung cancer.

Analysis of feasibility and safety of complete video-assisted thoracoscopic resection of anatomic pulmonary segments under non-intubated anesthesia

OBJECTIVE

To explore the feasibility and safety of complete video-assisted thoracoscopic surgery (C-VATS) under non-intubated anesthesia for the resection of anatomic pulmonary segments in the treatment of early lung cancer (T1N0M0), benign lung diseases and lung metastases.

METHODS

The clinical data of patients undergoing resection of anatomic pulmonary segments using C-VATS under non-intubated anesthesia in the First Affiliated Hospital of Guangzhou Medical University from July 2011 to November 2013 were retrospectively analyzed to evaluate the feasibility and safety of this technique.

RESULTS

The procedures were successfully completed in 15 patients, including four men and eleven women. The average age was 47 [21-74] years. There were ten patients with adenocarcinoma, one with pulmonary metastases, and four with benign lung lesions. The resected sites included: right upper apical segment, two; right lower dorsal segment, one; right lower basal segment, two; left upper lingular segment, three; left upper apical segment, one; left upper anterior apical segment, two; left upper posterior segment, one; left lower basal segment, one; left upper posterior and apical segments, one; and left upper anterior and apical segments plus wedge resection of the posterior segment, one. One case had intraoperative bleeding, which was controlled with thoracoscopic operation and no blood transfusion was required. No thoracotomy or perioperative death was noted. Two patients had postoperative bleeding without the need for blood transfusions, and were cured and discharged. The pathologic stage for all patients with primary lung cancer was IA. After 4-19 months of follow-up, no tumor recurrence and metastasis was found. The overall mean operative length was 166 minutes (range 65-285 minutes), mean blood loss 75 mL (range 5-1,450 mL), mean postoperative chest drainage 294 mL (range 0-1,165 mL), mean chest drainage time 2 days (range 0-5 days), and mean postoperative hospital stay 5 days (range 3-8 days).

CONCLUSIONS

Complete video-assisted throacoscopic segmentectomy under anesthesia without endotracheal intubation is a safe and feasible technique that can be used to treat a selected group of IA patients with primary lung cancer, lung metastases and benign diseases.

Indication for VATS sublobar resections in early lung cancer

When dealing with early non-small cell lung cancer (NSCLC) sublobar resections still remain part of the surgical armamentarium. In selected patients with lung cancer, the combination of the potential benefits of parenchyma sparing procedures to the limited trauma provided by Video Assisted Thoracic Surgery (VATS) techniques can become very appealing. Two main groups are included: non-anatomical (wedges) and anatomical (segmentectomies) excisions. We describe the techniques, results and potential indications of both of these techniques.

Totally thoracoscopic pulmonary anatomic segmentectomies: technical considerations

BACKGROUND

While video-assisted thoracic surgery (VATS) lobectomies are being increasingly accepted, VATS segmentectomies are still considered as technically challenging. With the renewed interest for sublobar resection in the management of early stage lung carcinomas, the thoracoscopic approach may have a major role in a near future. We report our technique and results.

PATIENTS AND METHODS

Totally thoracoscopic anatomic segmentectomiy, i.e., using only endoscopic instrumentation and video-display without utility incision, was attempted on 117 patients (51 males and 66 females), aged 18 to 81 years (mean: 62 years). The indication was a clinical N0 non-small cell lung carcinoma in 69 cases, a solitary metastasis in 17 cases and a benign lesion in 31 cases. The following segmentectomies were performed: right apicosuperior [26] right superior [10], right basilar [18], lingula sparing left upper lobectomy [15], left apicosuperior [11], lingula [7], left superior [14], left basilar [13] and subsegmental resection [3]. Segmentectomy was associated with a radical lymphadenectomy in 69 cases.

RESULTS

There were 5 conversions to thoracotomy. The mean operative time was 181±52 minutes, the mean intraoperative blood loss was 77±81 cc. There were 12 postoperative complications (11.7%). The median postoperative stay was 5.5±2.2 days. Out of the 69 patients operated on for a cN0 lung carcinoma, 6 were finally upstaged.

CONCLUSIONS

Totally thoracoscopic anatomic pulmonary segmentectomies are feasible and have a low complication rate.

Segmentectomy as a safe and equally effective surgical option under complete video-assisted thoracic surgery for patients of stage I non-small cell lung cancer

BACKGROUND

While video-assisted thoracic surgery lobectomy has been widely accepted for the treatment of non-small cell lung cancer, the debate over video-assisted thoracic surgery segmentectomy still remains. This study compared the clinical outcomes using the two procedures for stage I non-small cell lung cancer patients.

METHODS

Retrospective review was conducted on patients who underwent video-assisted thoracic surgery segmentectomy or lobectomy for clinical stage I non-small cell lung cancer at Shanghai Chest Hospital between November 2009 and May 2012. Video-assisted thoracic surgery segmentectomy was performed on 36 patients and video-assisted thoracic surgery lobectomy on 138 patients. Comparisons between the 2 groups were performed in patient demographic and clinical characteristics, intraoperative parameters and oncology outcomes.

RESULTS

Mean volume of chest tube drainage after operation was smaller for segmentectomy than for lobectomy (1021 ml vs. 1328 ml, P=0.036). Other parameters analysis including blood loss, operation time, chest tube duration and length of hospital stay favors the segmentectomy group numerically without significance. There was no significant difference in distributions in both intra and post operative complications. There was one peri-operative mortality from segmentectomy group and all other patients are alive with a median follow up of 327 days. There were 1 (2.8%) locoregional recurrence after segmentectomy and 6 recurrences (4.4%) after lobectomy (P=1.00). Multivariate survival analysis revealed no significant difference in recurrence-free survivals between the two groups. Two patients successfully underwent bilateral segmentectomies and are free of disease.

CONCLUSIONS

For patients with stage I non-small cell lung cancer, video-assisted thoracic surgery segmentectomy offers a safe and equally effective option and can be applied to complicated operation such as bilateral segmentectomy.

Video-assisted thoracic surgery (VATS) for resection of metastatic adenocarcinoma as an acceptable alternative

BACKGROUND

Adenocarcinomas commonly metastasize to the lungs and can be resected using open thoracotomy or video-assisted thoracic surgery (VATS). This study reviews metastatic resections in primary adenocarcinoma patients, using both thoracotomy and VATS. We aim to compare long-term prognoses to test the efficacy and viability of VATS.

METHODS

A retrospective review of primary adenocarcinoma patients who underwent resection of pulmonary metastases from 1990 to 2006 was carried out. Information was obtained by chart review. Endpoints analyzed were disease-free interval (DFI), survival time, and recurrence-free survival (RFS).

RESULTS

In a total of 42 (16 male, 26 female; median age 58.5 years) primary adenocarcinoma patients, 21 patients underwent first pulmonary metastatic resection using VATS (7 male, 14 female; median age 57 years) and 21 using thoracotomy (9 male, 12 female; median age 59 years). Primary adenocarcinomas were mainly 27 colorectal (64%) and 11 breast (26%). Two VATS (10%) and three open patients (14%) had local recurrences of the original cancer. Median postoperative follow was 13.3 months [interquartile range (IQR) 4.5-32.8 months] for VATS and 36.9 months (IQR 19.3-48.6 months) after thoracotomy. Median DFI-1 was 22.3 months (IQR 13.5-40.6 months) for VATS patients and 35.6 months (IQR 26.7-61.3 months) for open patients. Second thoracic occurrences were noted in six VATS patients (median DFI-2 9.2 months), and in seven open patients (median DFI-2 21.5 months). Third thoracic occurrences were noted in one VATS patient (DFI-3 18.7 months) and in one thoracotomy patient (DFI-3 21.8 months). Odds ratio of recurrence showed 12.5% less chance of developing recurrence in VATS patients. Five-year RFS was 53% in VATS and 57% in thoracotomy patients.

CONCLUSIONS

VATS has become a viable alternative to open thoracotomy for resection of pulmonary metastases. In cases of primary adenocarcinoma, VATS showed no increase in number of thoracic recurrences, and comparable RFS. Short-term follow-up is encouraging; long-term follow-up will be needed to confirm these results.