Minimally invasive pulmonary surgery for lung cancer, up to date

Research and development of the sOLVe Tube™ dual lumen endobronchial tube: from concept to construct

Introduction

Dual lumen endobronchial tubes (DLTs) are frequently used for lung isolation and one lung ventilation in thoracic surgery and other specialized clinical scenarios. Modern DLTs are large and rigid, and account for half of all tracheobronchial injuries. Their 70 year old design has numerous flaws which limit their safety and clinical utility. Our research team set out to design a new and improved DLT to mitigate these shortcomings, and then test the proposed device to ensure proper function.

Methods

Using published airway anatomy data and computed tomography imaging from 195 thoracic surgery patients, we designed a new DLT with a single size/configuration that would fit into adult surgery patients. This single "Universal design" was intended to replace both left and right sided 35Fr-41Fr DLTs (8 total products), while remaining small in diameter (35Fr). Other design goals included: 1) making intubation easier and safer, 2) allowing full sized therapeutic bronchoscopes to fit into this tube, 3) making the DLT more resistant to dislodgement. After design process completion the proposed dimensions were tested against 195 patients' left and right mainstem bronchi for radiographic fit. Once production prototypes were manufactured, they were tested in large adult Yorkshire pigs and fresh human cadavers for anatomic fit and performance.

Results

The proposed design passed the radiographic fit test in all 195 patients for both left and right mainstem endobronchial placement. Intubation was successful and deemed atraumatic in all pigs and cadavers, and the device appropriately fit in both the right and left mainstem bronchi. Lung isolation was successfully achieved and the device proved resistant to axial force dislodgement.

Conclusion

We propose a new design for a novel DLT meant to replace 8 currently supplied adult configurations with a single, one size/configuration fits all product that allows for large bore bronchoscopy and resists axial force dislodgement.

Deep neuromuscular block for minimally invasive lung surgery: a protocol for a systematic review with meta-analysis and trial sequential analysis

INTRODUCTION

Minimally invasive lung surgery (MILS) gradually became the primary surgical therapy for lung cancer, which remains the leading cause of cancer death. Adequate muscle relaxation by deep neuromuscular block (NMB) is particularly necessary for MILS to provide a satisfactory surgical field. However, deep NMB for MILS remains controversial, as one-lung ventilation may provide an acceptable surgical field. Then, we will perform a protocol for a systematic review and meta-analysis to identify the efficacy of deep NMB for MILS.

METHODS AND ANALYSIS

We will search the PubMed, Cochrane Library, Embase, Ovid Medline, Web of Science, Chinese BioMedical Literature, China National Knowledge Infrastructure, VIP and Wanfang databases from inception to March 2022 to identify randomised controlled trials of adult participants undergoing MILS with deep NMB. Studies published in English or Chinese will be considered. The primary outcome will be the surgical conditions according to the surgeon's perspective. Secondary outcomes will be the incidence of perioperative events and perioperative mortality. Heterogeneity will be assessed by the χ² test and I² statistic. Data will be synthesised by both a fixed-effect and a random-effects meta-analysis, with an intention to present the random-effects result if there is no indication of funnel plot asymmetry. Otherwise, metaregression will be used. The Cochrane risk-of-bias tool, trial sequential analysis and Grading of Recommendations Assessment, Development and Evaluation will be used to assess the evidence quality and control the risks of random errors. Funnel plots and Egger's regression test will be used to assess publication bias.

ETHICS AND DISSEMINATION

Ethical approval was not required for this systematic review protocol. The results will be disseminated through peer-reviewed publications.

PROSPERO REGISTRATION NUMBER

CRD42021254016.

Video-assisted thoracoscopy for lung cancer: who is the future of thoracic surgery?

As the computer processing technique and display technology evolved dramatically, the surgical approach to early-stage non-small cell lung cancer (NSCLC) has made a rapid progress within the past few years. Currently, the gold standard for NSCLC is lobectomy. After the introduction of video-assisted thoracoscopic surgery (VATS), lung resection can now be conducted mini-invasively, enabling better prognosis for patients and better operation condition for surgeons. At the very beginning, the conventional two-dimensional (2D) system enabled operators to have a closer, magnified and illuminated view inside the body cavity than open thoracotomy. With the introduction of the glasses-assisted three-dimensional (3D) and glasses-free 3D display system, multiple viewing angles were further enhanced, thus a more stable, easier to master and less invasive video-assisted thoracoscopic surgery (VATS) appeared. However, given that the standard VATS is associated with limited maneuverability and stereoscopy, it restricts the availability in more advanced cases. Hopefully, most of the limitations of standard VATS can be overcome with the robotic-assisted thoracic surgery (RATS). The RATS system consists of a remote console and a robotic unit with 3 or 4 arms that can duplicate surgeons’ movements. Also, it provides a magnified, 3D and high definition (HD) operation field to surgeons, allowing them to perform more complicated procedures. Apart from these, some new technologies are also invented in combination with the existing surgery system to solve difficult problems. It is hoped that the higher costs of innovative surgical technique can be offset by the better patient outcomes and improved benefits in cost-effectiveness.

Compare the prognosis of Da Vinci robot-assisted thoracic surgery (RATS) with video-assisted thoracic surgery (VATS) for non-small cell lung cancer: A Meta-analysis

To determine if there are advantages to transitioning to Da Vinci robotics by a surgeon compared to the video-assisted thoracic surgical lobectomy.A systematic electronic search of online electronic databases: PubMed, Embase, and Cochrane library updated on December 2017. Publications on comparison Da Vinci-robot-assisted thoracic surgery (RATS) and video-assisted thoracic surgery (VATS) for non-small cell lung cancer were collected. Meta-analysis RevMan 5.3 software (The Cochrane collaboration, Oxford, UK) was used to analyze the combined pooled HRs using fixed or random-effects models according to the heterogeneity.Fourteen retrospective cohort studies were included. No statistical difference was found between the 2 groups with respect to conversion to open, dissected lymph nodes number, hospitalization time after surgery, duration of surgery, drainage volume after surgery, prolonged air leak, and morbidity (P > .05).Da Vinci-RATS lobectomy is a feasible and safe technique and can achieve an equivalent surgical efficacy when compared with VATS. There does not seem to be a significant advantage for an established VATS lobectomy surgeon to transition to robotics based on clinical outcomes.

Uniportal video-assisted thoracic surgery could reduce postoperative thorax drainage for lung cancer patients

BACKGROUND

Uniportal video-assisted thoracic surgery (VATS) has undergone significant development in recent years, yet its usefulness and value in the treatment of lung cancer remains controversial. We investigated the effect of uniportal VATS surgery for reducing postoperative thorax drainage in lung cancer patients.

METHODS

The data of primary lung cancer patients who underwent VATS anatomical lung resection at the China National Cancer Center by a single surgeon were retrospectively collected. After propensity score matched analysis, 492 patients (246 uniportal VATS, 246 multiportal VATS) were included in the study. The clinicopathologic and surgery-related features, including drainage volume, were compared. Student's t and chi-square tests were used; all tests were two-sided.

RESULTS

Patients in the two groups had similar demographic and clinicopathological features. Patients who underwent uniportal VATS surgery had significantly lower postoperative thorax drainage (830.0 ± 666.0 mL vs. 1014.5 ± 616.9 mL, P = 0.002) and a comparatively lower rate of unplanned return to the operating room (0 vs. 0.8%; P = 0.156) than multiportal VATS patients. The surgical duration, blood loss, number of lymph nodes dissected, postoperative complications, and length of hospital stay were similar between the groups.

CONCLUSIONS

Uniportal VATS could reduce postoperative thorax drainage and the risk of unplanned return to the operating room for lung cancer patients. This study included the largest sample by a single surgeon and our results suggest the potential value of uniportal VATS for the faster recovery of lung cancer patients.

Comparison of deep or moderate neuromuscular blockade for thoracoscopic lobectomy: a randomized controlled trial

Background

Laparoscopic surgery typically requires deep neuromuscular blockade (NMB), but whether deep or moderate NMB is superior for thoracoscopic surgery remains controversial.

Methods

Patients scheduled for thoracoscopic lobectomy under intravenous anesthesia were randomly assigned to receive moderate [train of four (TOF) 1–2] or deep NMB [TOF 0, post-tetanic count (PTC) 1–5]. Depth of anesthesia was controlled at a Narcotrend rating of 30 ± 5 in both groups. The primary outcome was the need to use an additional muscle relaxant (cisatracurium) during surgery. Secondary outcomes included surgeon satisfaction, recovery time of each stage after drug withdrawal [time from withdrawal until TOF recovery to 20% (antagonists administration), 25, 75, 90, 100%], blood gas data, VAS pain grade after extubation, the time it takes for patients to begin walking after surgery, postoperative complications and hospitalization time. Results were analyzed on an intention-to-treat basis.

Results

Thirty patients were enrolled per arm, and all but one patient in each arm was included in the final analysis. Among patients undergoing moderate NMB, surgeons applied additional cisatracurium in 8 patients because of body movement and 5 because of coughing (13/29, 44.8%). Additional cisatracurium was not applied to any of the patients undergoing deep NMB (p < 0.001). Surgeons reported significantly higher satisfaction for patients undergoing deep NMB (p < 0.001, Wilcoxon rank sum test). The mean difference between the two groups in the time from withdrawal until TOF recovery of 25% or 90% was 10 min (p < 0.001). The two groups were similar in other recovery data, blood gas analysis, VAS pain grade, days for beginning to walk and mean hospitalization time.

Conclusions

Deep NMB can reduce the use of additional muscle relaxant and increase surgeon satisfaction during thoracoscopic lobectomy.

Trial registration

Chinese Clinical Trial Registry, ChiCTR-IOR-15007117, 22 September 2015.

Postoperative pain in thoracic surgery: re-evaluating the benefits of VATS when coupled with epidural analgesia

Background

In order to evaluate the reduced postoperative pain of complete video-assisted thoracoscopic surgery (cVATS), a study was conducted to compare acute postoperative pain between cVATS and open thoracotomy employing continuous epidural analgesia (EA).

Methods

A total of 62 patients, 49 males and 13 females with a mean age of 54.8 years, who had undergone thoracic surgery at our institution from November 2013 to June 2015 were enrolled in this study. We statistically investigated differences in the intensity of postoperative pain between cVATS with or without EA and between cVATS and open thoracotomy under EA. The degree of pain was measured using a visual analog scale, nine times for three days after the surgery.

Results

The mean postoperative pain scores were stronger in the cVATS without EA group than in the group treated with EA at every single observation point, although there were no significant differences. When employing EA, no significant differences were found between cVATS and open thoracotomy.

Conclusions

The use of EA may overshadow the benefits of using cVATS over open thoracotomy.

Long-term Survival Based on the Surgical Approach to Lobectomy For Clinical Stage I Nonsmall Cell Lung Cancer: Comparison of Robotic, Video-assisted Thoracic Surgery, and Thoracotomy Lobectomy

OBJECTIVE

To compare the long-term outcomes among robotic, video-assisted thoracic surgery (VATS), and open lobectomy in stage I nonsmall cell lung cancer (NSCLC).

BACKGROUND

Survival comparisons between robotic, VATS, and open lobectomy in NSCLC have not yet been reported. Some studies have suggested that survival after VATS is superior, for unclear reasons.

METHODS

Three cohorts (robotic, VATS, and open) of clinical stage I NSCLC patients were matched by propensity score and compared to assess overall survival (OS) and disease-free survival (DFS). Univariate and multivariate analyses were performed to identify factors associated with the outcomes.

RESULTS

From January 2002 to December 2012, 470 unique patients (172 robotic, 141 VATS, and 157 open) were included in the analysis. The robotic approach harvested a higher number of median stations of lymph nodes (5 for robotic vs 3 for VATS vs 4 for open; P < 0.001). Patients undergoing minimally invasive approaches had shorter median length of hospital stay (4 d for robotic vs 4 d for VATS vs 5 d for open; P < 0.001). The 5-year OS for the robotic, VATS, and open matched groups were 77.6%, 73.5%, and 77.9%, respectively, without a statistically significant difference; corresponding 5-year DFS were 72.7%, 65.5%, and 69.0%, respectively, with a statistically significant difference between the robotic and VATS groups (P = 0.047). However, multivariate analysis found that surgical approach was not independently associated with shorter OS and DFS.

CONCLUSIONS

Minimally invasive approaches to lobectomy for clinical stage I NSCLC result in similar long-term survival as thoracotomy. Use of VATS and robotics is associated with shorter length of stay, and the robotic approach resulted in greater lymph node assessment.

Robotic-assisted sleeve lobectomy for right upper lobe combining with middle lobe resection of lung cancer

Sleeve lobectomy for lung cancer using the robotic surgical system has been reported, which has widely expanded the indication of this technique. We now describe a sleeve bilobectomy of the right upper and middle lobes for squamous cell carcinoma, meanwhile the branch of vagus nerve sparing using the Da Vinci SI surgical system. In conclusion, complicated sleeve lobectomy with nerve sparing is feasible in robotic thoracic surgery.

Is volumetric 3-dimensional computed tomography useful to predict histological tumour invasiveness? Analysis of 211 lesions of cT1N0M0 lung adenocarcinoma

OBJECTIVES

The purpose of this study was to use Hounsfield unit (HU) thresholds of computed tomography (CT) images to predict pathological lymph node metastasis and tumour invasiveness of cT1N0M0 lung adenocarcinoma on 3D evaluations.

METHODS

Preoperative CT images of 211 lesions of surgically resected cT1N0M0 lung adenocarcinoma were retrospectively examined. The tumour size was calculated in 1D, 2D and 3D views. Tumours with -300 HU and over were defined as 'solid tumours', and those between -800 and -301 HU were defined as 'ground glass opacity tumours'. Tumours with -800 HU and over were assumed to be the whole tumour entity. The proportion of 'solid tumour' within the whole tumour entity was also calculated as the 'solid tumour ratio'. These were compared with pathological information.

RESULTS

Solid tumour size and ratio were positively correlated with microscopic invasion to pleura, vessels and lymphatics in all dimensional evaluations. Pathological lymph node metastases were also well predicted by solid tumour size and ratio in all dimensional evaluations. The P-values for the receiver operating characteristic (ROC) curves of 1D, 1D ×2, 2D and 3D evaluations were: solid tumour size P = 0.013, 0.014 and 0.032; and solid tumour ratio 0.016, 0.0032 and <0.0001. In comparisons of 1D, 2D and 3D evaluations, 'solid tumour size' of the area under the curve (AUC) of ROC to detect pathological lymph node metastases was not significant. However, strikingly, the 3D solid tumour ratio was found to be significantly more accurate for the prediction of pathological lymph node metastases than the 1D and 2D solid tumour ratios on ROC evaluation (AUC: 1D 0.736, 2D 0.803 and 3D 0.882; P-values for the AUC comparisons were P = 0.013 for 3D versus 1D and P = 0.022 for 3D versus 2D). The correlations of subtypes of adenocarcinoma and the 3D solid tumour ratio were also investigated. Subtypes of adenocarcinoma were well correlated with the 3D solid tumour ratio.

CONCLUSIONS

Preoperative 3D CT using threshold values of -800 and -300 HU was useful for predicting pathological lymph node metastases and tumour invasiveness of cT1N0M0 lung adenocarcinoma.

Impact of Lepidic Component Occupancy on Effects of Adjuvant Chemotherapy for Lung Adenocarcinoma

BACKGROUND

The prognosis of lepidic predominant lung adenocarcinoma is favorable. We postulated that lepidic predominant tumors might not require postoperative adjuvant chemotherapy. The present study aims to determine whether lepidic component occupancy affects overall survival after postoperative adjuvant chemotherapy for lung adenocarcinoma.

METHODS

Clinical and pathologic data were collected from a database and from the medical records of 964 patients with completely resected lung adenocarcinoma. We assessed the influence of lepidic component occupancy in the tumor on the outcomes of adjuvant chemotherapy.

RESULTS

Among the patients, 270 received adjuvant chemotherapy and 694 did not, and 415 and 549 had lepidic predominant and non-lepidic predominant tumors, respectively. Adjuvant chemotherapy contributed to better overall survival compared with observation in non-lepidic predominant tumors (p = 0.025). Multivariate analyses revealed age, sex, stage, lepidic component occupancy, and adjuvant chemotherapy as independent prognostic factors for overall survival. The overall survival was significantly longer for patients with non-lepidic predominant tumors at stages IA, IB, and II-III under adjuvant chemotherapy compared with observation (p = 0.040, p = 0.007, and p = 0.012, respectively), whereas survival rates were similar for patients with all stages of lepidic predominant tumors even after propensity score matching study.

CONCLUSIONS

Lepidic component occupancy reflected the effect of adjuvant chemotherapy for lung adenocarcinoma. Adjuvant chemotherapy did not have much impact for lepidic predominant tumors and could be considered for non-lepidic predominant tumors even at stage IA.

Operative outcomes of thoracoscopic lobectomy for non-small-cell lung cancer

Aim

We examined the advantages of thoracoscopy over thoracotomy in terms of perioperative outcomes and toleration of adjuvant chemotherapy.

Methods

Between April 2010 and March 2013, 657 patients with non-small-cell lung cancer who underwent lobectomy were classified into thoracoscopy (308 patients) and thoracotomy (349 patients) groups and compared.

Results

The thoracoscopy group had less blood loss compared to the thoracotomy group ( p < 0.001). When limiting the analysis to pathological stage I patients, the results were similar ( p < 0.001). In addition, the difference in blood loss between the 2 groups was greater in patients with severe pleural adhesions. The postoperative morbidity of the thoracoscopy group was significantly less than that of the thoracotomy group (13.3% vs. 21.2%, p < 0.001), and this result was similar when analyzing the pathological stage I patients (12.6% vs. 20.6%, p = 0.001). A higher percentage of the thoracoscopy group received both the full planned course and dose of adjuvant chemotherapy compared to the thoracotomy group (84.2% vs. 65.8%, p = 0.032).

Conclusions

These results indicate that totally thoracoscopic lobectomy is the more beneficial surgical approach with regard to the incidence of postoperative complications and toleration of adjuvant chemotherapy.

Radiologic findings to predict low-grade malignant tumour among clinical T1bN0 lung adenocarcinomas: lessons from histological subtypes

OBJECTIVE

Some clinical T1bN0 (cT1bN0) lung adenocarcinomas (2-3 cm) are thought to have less-aggressive and less-malignant behaviour although most cT1aN0 tumours (≤2 cm) are indolent. The present study aimed to identify pre-operative radiographic findings that can predict cT1bN0 lung adenocarcinoma with low-malignant aggressiveness in consideration of histological subtypes.

METHODS

The clinicopathological features and prognoses of 224 consecutive patients (histological subtype set, n = 122; prognosis set, n = 224) with cT1bN0 lung adenocarcinoma were retrospectively examined. Adenocarcinoma in situ, minimally invasive adenocarcinoma, lepidic, node-negative papillary and node-negative acinar predominant invasive adenocarcinomas were defined as low-grade malignant, whereas solid, micropapillary, node-positive acinar and node-positive papillary predominant invasive adenocarcinoma were defined as high-grade malignant.

RESULTS

Receiver operating characteristics analysis revealed that the criteria of solid tumour size ≤1.8 cm on high-resolution computed tomography and the maximum standardized uptake value ≤3.2 on positron emission tomography/computed tomography could predict low-grade malignant tumour in the histological subtype set. Among 95 (42.4%) of 224 patients who met the criteria for the prognosis set, 94 (98.9%) had no lymph node metastasis and 93 (97.9%) had no recurrence (median follow-up, 43.6 months). The 3 year recurrence-free survival rates were 94.9 and 79.0% in patients whose pre-operative findings met and did not meet the criteria, respectively.

CONCLUSIONS

Pre-operative radiographic findings of solid tumour size and the maximum standardized uptake value could identify low-grade malignant tumour among cT1bN0 lung adenocarcinomas, which account for about half of all cT1bN0 tumours. Patients with pre-operative lung tumour findings that fulfill the criteria could be candidates for sublobar resection.

Uniportal video-assisted thoracoscopic lobectomy: an alternative to conventional thoracoscopic lobectomy in lung cancer surgery?

OBJECTIVES

Although the standard video-assisted thoracoscopic surgery (VATS) approach is generally performed through two to four incisions, uniportal VATS pulmonary resection has recently been reported to be a promising, less invasive alternative. To evaluate the adequacy of uniportal VATS lobectomy as an alternative to conventional VATS lobectomy in lung cancer, we analysed and compared the outcomes of uniportal and conventional VATS lobectomies.

METHODS

Retrospective observational data for patients who underwent VATS lobectomy at Samsung Medical Center between January 2013 and February 2014 due to a diagnosis of lung cancer were collected. Perioperative factors such as operative time, postoperative chest tube duration, postoperative hospital stay, complication rate, conversion rate, reoperation rate and mortality were compared between the uniportal and conventional VATS groups.

RESULTS

A total of 90 uniportal VATS lobectomies and 60 conventional VATS lobectomies were attempted. Fifty-eight (64.5%) cases were completed as uniportal VATS lobectomies, and 51 (85%) cases as conventional VATS lobectomies. There were 32 (35.5%) conversions of uniportal VATS lobectomy cases, including four conversions to three-port VATS, 18 to two-port VATS and 10 to open thoracotomy. No differences in postoperative complications, postoperative 30-day mortality or reoperation rate were noted between the two groups. There was no difference in operative time, number of removed lymph nodes, chest tube duration or length of postoperative hospital stay between the uniportal VATS group and conventional VATS group.

CONCLUSIONS

The similar perioperative results of uniportal VATS lobectomy compared with conventional VATS lobectomy suggest that uniportal VATS is a viable alternative approach to the conventional VATS approach in selected patients, especially in patients with early peripheral lung cancer with good anatomy and in good general condition.

Feasibility of segmental resection in non-small-cell lung cancer with ground-glass opacity

OBJECTIVES

Recently, lung segmental resection has been increasingly performed in patients with lung cancer. In this study, the results of radical segmentectomy (RS) and palliative segmentectomy (PS) were compared retrospectively.

METHODS

Segmentectomy was performed to remove a primary lung cancer in 87 cases. RS was performed for pure ground-glass opacity (GGO), >50% GGO and diameter less than 2 cm and less than 10 mm solid tumours. PS was performed in patients with poor lung function or relapse, or at high risk for surgery. A total of 84 cases, excluding 3 cases of relapse, were investigated.

RESULTS

The pathological stage of RS was IA in 32 (94.1%) and IB in 2 (5.9%). The pathological stage of PS was IA in 23 (46.0%), IB in 15 (30.0%), IIA in 5 (10.0%), IIB in 1 (2.0%), IIIA in 4 (8.0%) and IV in 2 (4.0%). The preoperative characteristics of RS were compared with those of PS for pathological stage I. The mean age was significantly lower for RS cases (67.4 ± 9.9 years) than for PS cases (73.0 ± 9.0 years; P = 0.013). Tumour size was significantly smaller in RS cases (14.7 ± 4.6 mm) than in PS cases (22.0 ± 8.9 mm; P < 0.001). The tumour standardized uptake value of 18F-fluorodeoxyglucose positron emission tomography was significantly lower in RS cases (1.2 ± 1.6) than in PS cases (6.0 ± 6.1; P < 0.001). Serum carcinoembryonic antigen level was lower in RS cases (2.8 ± 1.8 ng/ml) than in PS cases (4.9 ± 5.0; P = 0.019). The mean duration of drainage was shorter in RS (2.5 ± 0.7 days) than in PS (3.9 ± 2.6 days; P = 0.004). Postoperative complications occurred in 6 RS cases (17.6%) and 12 PS cases (29.3%). Overall 5-year survival was higher in RS (100%) than in PS (66.2%; P = 0.003). Five-year disease-free survival was higher in RS (100%) than in PS (66.2%; P = 0.002). Recurrence was detected in 6 PS patients; 10 PS cases showed tumour with GGO and survived without recurrence.

CONCLUSIONS

Our RS is feasible for stage I lung cancer with specific computed tomography features, such as small size, GGO or peripheral location.