Segmentectomy for c-T1N0M0 non-small cell lung cancer

"Non-Triangle Plane" Surgical Technique of Video-Assisted Thoracic Surgery Atypical Segmentectomy for Stage IA Non-Small-Cell Lung Cancer: Early Experience

Objectives: To evaluate the safety and feasibility of a novel surgical technique (“non-triangle plane” technique) of two-port (mini-utility) video-assisted thoracic surgery (VATS) atypical segmentectomy (S³+S¹⁺²c) with tunneling stapler for small-sized non-small-cell lung cancers (NSCLCs) located in left S³ close to the intersegmental plane between S³ and S¹⁺²c.

Materials and Methods: This retrospective descriptive study included 16 patients who, between April 2016 and December 2019, underwent a single two-port (mini-utility) VATS atypical segmentectomy (S³+S¹⁺²c) with tunneling stapler technique for small-sized NSCLCs with a ground-glass opacity (GGO) rate of more than 50% by a constant surgical team in two hospitals. Perioperative data and survival data were collected and retrospectively analyzed. Postoperative follow-up was performed every 6 months.

Results: Six patients were with adenocarcinoma in situ, and ten were with minimally invasive adenocarcinoma. The mean surgical margin was 14.06 ± 3.02 mm. The mean operation time was 53.88 ± 9.76 min. The mean duration of chest tube drainage was 4 ± 1.21 days, and the median length of postoperative hospital stay was 4 days. There was no perioperative morbidity and mortality. The median follow-up was 47.5 months (17–61 months). No recurrences occurred, and all patients were still alive at the last registered follow-up (May 31, 2021).

Conclusion: Two-port (mini-utility) VATS atypical segmentectomy (S³+S¹⁺²c) with tunneling stapler technique is a safe and feasible option for the treatment of small-sized NSCLCs located in left S³ close to the intersegmental plane between S³ and S¹⁺²c.

Outcomes of completion lobectomy long after segmentectomy

Background

Completion lobectomy long after segmentectomy in the same lobe is extremely difficult because of severe adhesions around hilar structures, especially in cases involving video-assisted thoracoscopic surgery (VATS) completion lobectomy. We report and compare the surgical outcomes of patients who underwent VATS or thoracotomy completion lobectomy long after radical segmentectomy for lung cancer.

Methods

We retrospectively evaluated the surgical outcomes of completion lobectomies performed at our institute long after radical segmentectomies for lung cancer in the same lobe. The efficacy and safety of VATS completion lobectomy was compared to that of thoracotomy completion lobectomy.

Results

Ten of 228 patients who underwent radical segmentectomy for lung cancer between 2009 and 2018 underwent completion lobectomy at least a month after segmentectomy; five patients underwent VATS completion lobectomy. None of the patients underwent VATS left upper completion lobectomy, and conversion to thoracotomy was required in one patient. There were no significant differences between VATS and thoracotomy completion lobectomies in the median operative times (VATS 295 min, thoracotomy 339 min, p = 0.55), intraoperative blood loss volumes (VATS 350 mL, thoracotomy 500 mL, p = 0.84), intervals between initial segmentectomy and completion lobectomy (VATS 40 months, thoracotomy 48 months, p = 0.55), and number of patients with pulmonary artery injury (VATS 1, thoracotomy 2, p = 0.49). There was no operation-related mortality.

Conclusions

VATS completion lobectomy long after segmentectomy for lung cancer could be performed without fatal complications unless severe adhesions are observed around each main pulmonary artery.

Influence of intersegmental plane size and segment division methods on preserved lung volume and function after pulmonary segmentectomy

OBJECTIVES

We previously reported that the use of a stapler to divide intersegmental planes did not decrease preserved pulmonary volume or function relative to electrocautery. However, preservation of pulmonary volume or function can be compromised when a stapler is used with larger intersegmental planes. Here, we assessed the correlations between preserved lung volume and pulmonary function after segmentectomy and the size of the intersegmental planes, based on the division method.

METHODS

Intersegmental plane sizes in 56 patients were semi-automatically calculated using image analysis software on computed tomography images. The ratios of the remnant segment and ipsilateral lung volumes to their preoperative values (R-seg and R-ips) and the ratio of the postoperative pulmonary function relative to the predicted value were calculated based on three-dimensional volumetry. Correlations between preserved lung volume and pulmonary function and the intersegmental plane sizes were analyzed according to the division method.

RESULTS

Intersegmental planes were divided by either electrocautery or with a stapler (EC/Mixed) in 21 patients and by stapler alone (ST) in 35 patients. There was no difference in the average size of the intersegmental planes between the two groups. The intersegmental plane size negatively correlated with R-seg in the ST group.

CONCLUSIONS

Using the stapler method, as the size of the intersegmental planes increased, the preserved remnant segmental volume decreased; however, relation between the plane size and preserved pulmonary function was unclear. These findings indicate that stapler use is acceptable even for large intersegmental planes.

Management of unexpected intraoperative bleeding during thoracoscopic pulmonary resection: a single institutional experience

PURPOSE

Unexpected intraoperative bleeding during thoracoscopic surgery, necessitating emergency conversion to thoracotomy, is gradually being reported. We reviewed our experience of encountering unexpected bleeding during thoracoscopic surgery.

METHODS

We defined "unexpected intraoperative bleeding" as the need for hemostatic procedures with angiorrhaphy, with or without a sealant. The location, cause, and management of injured vessels, and perioperative outcomes were investigated and compared with those for patients without injured vessels.

RESULTS

Between 2007 and 2014, a total of 241 thoracoscopic anatomical pulmonary resections were performed at our hospital. Twenty (8.3 %) of these patients required hemostatic procedures with angiorrhaphy, with or without a sealant. The main injured vessels were the pulmonary artery (n = 13) and vein (n = 3) and the main causes of injury were related to technical issues with energy devices and staplers. There were no morbidities related to intraoperative bleeding. The operation time and blood loss were significantly greater in the patients with vessel injury than in those without vessel injury, but perioperative morbidities and the duration of chest tube insertion (4.5 vs. 3.5 days, average, p = 0.20) and postoperative hospital stay (12.7 vs. 11.0 days, average, p = 0.08) were not significantly different.

CONCLUSIONS

The frequency of unexpected bleeding was relatively high in this series, but its management and outcomes were satisfactory in terms of safety.

Thirty-day outcomes after lobectomy or segmentectomy for lung cancer surgery

Background

Although lobectomy has been the standard operation for clinical T1aN0M0 non-small cell lung cancer, recent studies have shown that segmentectomy could be a substitute for lobectomy. However, the differences between lobectomy and segmentectomy in terms of perioperative complications have not been fully evaluated.

Methods

Between February 2006 and February 2013, 100 patients underwent lobectomy and 111 underwent segmentectomy for clinical T1aN0M0 non-small-cell lung cancer. We performed a retrospective comparison of perioperative morbidity, age, sex, pulmonary function, and Charlson comorbidity index in the 2 groups. Data were analyzed for all patients and for their propensity score-matched pairs.

Results

The incidence of postoperative complications in the segmentectomy group ( n = 21, 19%) was significantly higher than that in the lobectomy group ( n = 7, 7%; p < 0.01). The average operative time of 263 ± 64 min and estimated blood loss of 133 ± 125 mL for segmentectomy were significantly greater than those for lobectomy (201 ± 61 min and 88 ± 101 mL). In propensity score-matched analysis, the mean operative time of 270 ± 70 min for segmentectomy was longer than that for lobectomy (202 ± 67 min). Postoperative complications were more frequent in the segmentectomy group than in the lobectomy group (19.6% vs. 6.5%, p = 0.03).

Conclusions

Although segmentectomy offers preservation of pulmonary function, significantly more postoperative complications occurred in the segmentectomy group. Surgeons should bear in mind that complications can happen more frequently after segmentectomy than after lobectomy for T1aN0M0 non-small-cell lung cancer.