Minithoracotomy combined with mechanically stapled bronchial and vascular ligation for anatomical lung resection

Effect of intraoperative blood loss on postoperative pulmonary complications in patients undergoing video-assisted thoracoscopic surgery

Background

We aimed to investigate the impact of intraoperative blood loss on postoperative pulmonary complications in patients who underwent video-assisted thoracoscopic lobectomy for nonsmall cell lung cancer.

Methods

Data of a total of 409 patients (227 males, 182 females; median age: 62 years; range, 20 to 86 years) who underwent lung resection for Stage I-IIIa non-small cell lung cancer in our clinic between July 2017 and April 2018 were retrospectively analyzed. The receiver operating characteristic analysis was used to confirm the threshold value of intraoperative blood loss for the prediction of postoperative pulmonary complications. Propensity score matching was performed to compare between high-intraoperative blood loss and low-intraoperative blood loss groups. A post-matching conditional logistic regression was conducted to determine the independent risk factors for postoperative pulmonary complications.

Results

Of the patients, 86 (21.03%) developed postoperative pulmonary complications. In the propensity score matching analysis, intraoperative blood loss was shown to be a predictive factor of postoperative pulmonary complications (3.992; 95% confidence interval [CI]: 1.54-10.35; p=0.004). The rate of postoperative pulmonary complications in high-intraoperative blood loss group was significantly higher than that the low-intraoperative blood loss group (37.5% vs. 13.9%, respectively; p=0.003). The postoperative length of stay and duration of postoperative antibiotic use were significantly prolonged in the high-intraoperative blood loss group.

Conclusion

Intraoperative blood loss serves as a significant risk factor for postoperative pulmonary complications after lung resection for non-small cell lung cancer. Surgeons should strive to reduce intraoperative blood loss for better surgical outcomes.

Rationality and necessity of vascular stapler application during liver resection (Review)

Liver resection (LR) is the primary treatment method for patients with hepatocellular carcinoma (HCC). Improving surgical safety and reducing surgical morbidity and mortality is important for patients receiving LR. Various devices have been developed to facilitate vascular transection to reduce intraoperative blood loss, which is considered to be a predictor of poor surgical outcomes in patients undergoing LR. Vascular staplers have been widely applied for the division of major vascular and biliary structures in the process of LR; however, when and how to use these tools remains controversial. This review aims to report the rationality and necessity of using vascular staplers in vessel transection during liver surgery. Due to the risk of intraoperative and postoperative hemorrhage and biliary fistula, the process of transection of the portal pedicle and hepatic vein is a crucial step during LR. Stapling represents a vascular dissection technique that is widely used in laparoscopic LR and has then been popularized in open LR. Advocates argue that stapler transection methods provide several advantages, including diminished blood loss, fewer transfusion requirements and shorter operative times. However, other studies have failed to demonstrate those benefits when using these tools compared with the simple clamp-crushing technique. Using the stapler vascular transection method resulted in smaller surgical margins and similar surgical outcomes compared with those of the clamp-crushing vascular transection method. However, the intraoperative use of vascular staplers may significantly increase the financial burden of liver resection for patients with HCC, while not improving short- and long-term outcomes. Therefore, it has been suggested that vascular staplers should not be routinely used in LR. The current review discussed the above points and recommended that the stapling transection of the portal pedicle and hepatic vein should be applied during laparoscopic LR in a rational manner. However, the suturing ligation method should be routinely used in open LR.

Preoperative Type and Screen is Unnecessary in Elective Anatomic Lung Resection and Esophagectomy

BACKGROUND

Preoperative type and screen (TS) is routinely performed before elective thoracic surgery. We sought to evaluate the utility of this practice by examining our institutional data related to intraoperative and postoperative transfusions for two common, complex procedures.

MATERIALS AND METHODS

A single-center, retrospective review of a prospective thoracic surgery database was performed. Patients who underwent consecutive elective anatomic lung resection (ALR) and esophagectomy from January 2015 to April 2018 were included. Perioperative characteristics between patients who received transfusion of packed red blood cells and those who did not were compared. The rates of emergent and nonemergent transfusions were evaluated. Cost data were derived from institutional charges and Centers for Medicare & Medicaid Services fee schedules.

RESULTS

Of 370 patients, 16 (4.3%) received a transfusion and four (1.1%) were deemed emergent by the surgeons and 0 (0%) by blood bank criteria. For ALR (n = 321), 13 (4.0%) received a transfusion, and four (1.2%) were emergent. For esophagectomies (n = 49), three (6.1%) received a transfusion, and none were emergent. Patients who underwent ALR requiring a transfusion had a lower preoperative hemoglobin (11.7 versus 13.4 gm/dL, P = 0.001), higher estimated blood loss (1325 versus 196 mL, P < 0.001), and longer operative time (291 versus 217 min, P = 0.003) than nontransfused patients. Based on current volumes, eliminating TS in these patients would save at least an estimated $60,100 per year.

CONCLUSIONS

Emergent transfusion in ALR and esophagectomy is rare. Routine preoperative TS is most likely unnecessary for these cases. These results will be used in a quality improvement initiative to change practice at our institution.

Oxidized regenerated cellulose for a clear thoracoscopic view: a single-centre randomized trial

OBJECTIVES

During video-assisted thoracoscopic surgery (VATS), blood oozing from the surface of the access port wound can hamper the surgical view. Although this oozing is difficult to prevent, it can be decreased by placing a wound edge protector with oxidized regenerated cellulose (ORC) on the surface of the access port wound, thereby improving the surgical outcomes and safety of VATS.

METHODS

We conducted a prospective, single-centre, open-label, randomized clinical trial to evaluate the operative outcomes of VATS when using the ORC (ORC group) compared with operative outcomes without using the ORC (non-ORC group). The primary end point was interruption of the operation as a result of blood oozing from the surface of the access port wound. The secondary end points were the other intraoperative and postoperative outcomes.

RESULTS

A total of 108 patients were divided into the ORC group (n = 54) and the non-ORC group (n = 54). Compared with the non-ORC group, the ORC group had fewer patients with an interruption in the operation (11.1% vs 51.8%; P < 0.001), less need for wound haemostasis of the access ports during wound closure (44.4% vs 72.2%; P = 0.003), similar rates of postoperative deaths and complications and a tendency for shorter operation times (149.3 vs 168.8 min, respectively; P = 0.083).

CONCLUSION

The use of an ORC sheet around a wound edge protector for haemostasis can ensure a clear view during VATS.

CLINICAL TRIAL REGISTRATION NUMBER

UMIN000031112.

Minimally Invasive Anterior Thoracotomy for Routine Lung Cancer Resection

Objectives

A 7-year experience with a minimally invasive approach to routine lung cancer resection is compared with standard lateral open thoracotomy.

Methods

All patients undergoing lung resection with curative intent for primary lung cancer between July 1998 and November 2005 by a single surgical team were registered. Surgical access was obtained through a mini 5- to 6-cm anterior thoracotomy with video assistance; direct visualization was also used extensively.

Results

Patients (n = 167) underwent major pulmonary resection for primary lung cancer. The minimally invasive group (MI), 137 patients, included 12 fully endoscopic or robotic approaches. The open lateral (OL) approach included 30 patients (18%). Both groups included pneumonectomies (8 MI, 3 OL), sleeve resections (3 MI, 2 OL), chest wall resections (2 MI, 5 OL), and pancoasts (3 MI, 0 OL) and had full lymph node resections. The Kaplan-Meier estimated overall mean survival was 64.5 months (95% CL, 58 to 71 months). Mean estimate survivals were stage 1a, 66%; stage 1b, 65%; stage 2a, 61%; stage 2b, 55%; stage 3a, 52%; stage 3b, 45%. Mean survival in the MI group was 64.3 months versus 59.3 with standard open access (OL) (X2 = 0.003 Mantel-Cox; significance, 0.959). In-hospital mortality rate was 2.2%; conversion from a mini to open procedure was 1.5%. Avoidance of rib spreading (soft tissue retractor) and small incisions appeared to have reduced pain and improved early recovery.

Conclusions

Kaplan-Meier survival for routine unselected lung cancer resection through a minimal access approach was not significantly different from the open approach and reflects published survival curves.

How to prevent adverse events of vascular stapling in thoracic surgery: recommendations based on a clinical and experimental study

Background

Advances in the development of staplers for pulmonary vessels have contributed to safe and convenient procedures in thoracic surgery. However, adverse events (AEs) can occur during vascular stapling and cause fatal hemorrhage. We aimed to assess the risk level of using the vessel stapling procedure to reduce such AEs.

Methods

First, an animal experiment using pig cardiopulmonary blocks was conducted. Pulmonary arteries were closed with staplers under stressful conditions such as lifting or twisting; vessel stump endurance was analyzed through different methods. Second, AEs associated with clinical stapler use for pulmonary vessels were retrospectively reviewed by studying clinical videos of 263 patients.

Results

In the animal experiment, the pressure resistance was significantly lower in the twisted group than in the no strain group (no strain vs. lifting: P=0.2008, no strain vs. twisting: P=0.002, no strain vs. twisting and lifting: P<0.0001). Regarding clinical stapler use, 754 staplers were used against the vessels. AEs occurred in 9 cases, and 7 cases were suspected to be caused by vessel tension.

Conclusions

The pulmonary vessel stapling causes stress due to twisting and lifting that decreased stump durability. Avoiding such stress when using stapler for vessels leads to a safer thoracic surgery.

Training System for Endoscopic Surgery Aiming to Provide the Sensation of Forceps Operation

In Japan, a rising number of endoscopic surgery operations have boosted an expectation for the development of a training environment for qualified surgeons. The endoscopic surgery operation requires the operator to operate forceps by hand based on two-dimensional operative field information displayed on the monitor. The characteristics of the operation include a lack of stereoscopic visual field information and movement of the tip of the forceps, which is symmetric about the trocar. These are issues that require an empirical solution from the operator. It is desirable that these issues have already been overcome before the operator starts practicing as an operating surgeon. To this end, it is effective to train the operator in the sensation of forceps operation, which associates the operative field vision with the forceps operation by hand. Therefore, this study includes digitizing the forceps operation by qualified surgeons and providing it to the trainee as visual and force information in order to build a training device that facilitates the cultivation of the sensation of forceps operation.

Phase 1 Trial Evaluating Safety of Pulmonary Artery Sealing With Ultrasonic Energy in VATS Lobectomy

BACKGROUND

Energy-sealing devices may be useful to divide small pulmonary arteries (PAs) during video-assisted thoracoscopic surgery (VATS) lobectomy. We evaluated the safety of PA branch sealing with an ultrasonic energy vessel-sealing device during VATS lobectomy.

METHODS

The study consisted of a phase 1 trial. Patients planned to undergo VATS lobectomy were prospectively enrolled. Target sample size was 20 patients. Branches of 7 mm or less were sealed and cut with an ultrasonic energy vessel-sealing device. The remainder of the lobectomy was performed in a standard fashion. Intraoperative, in-hospital, and 30-day postoperative bleeding were prospectively recorded.

RESULTS

Thirty-three patients were prospectively enrolled. Thirteen patients were not amenable to PA sealing with the vessel-sealing device because all PA branch diameters exceeded 7 mm (n = 10), conversion to thoracotomy (n = 2), and lobectomy not performed (n = 1). A minimum of one PA branch was sealed with the device in 20 patients. Fifty-eight PA branches were divided in 20 patients: 31 with ultrasonic device, 24 with endostaplers, 2 with clips, and 1 with sutures. The mean vessel diameter sealed with the device was 4 mm. Two patients were converted to thoracotomy (1 with PA injury during dissection, 1 with PA tumor invasion). No intraoperative or postoperative bleeding was related to ultrasonic PA branch sealing. No postoperative deaths occurred.

CONCLUSIONS

PA branch sealing for vessels 7 mm or less was safely achieved using an ultrasonic energy vessel-sealing device in VATS lobectomy. Large-scale, prospective, multi-institutional studies are necessary before widespread clinical application of energy for PA branch sealing in VATS lobectomy.

Intrapleural Fibrinolytic Therapy for Residual Coagulated Hemothorax After Lung Surgery

BACKGROUND

Many studies have described the use of intrapleural fibrinolytics for the treatment of complex pleural processes and traumatic hemothorax, but data are scarce regarding their use for hemothorax after lung surgery.

OBJECTIVE

To evaluate the utility of intrapleural fibrinolytic therapy with urokinase for residual coagulated hemothorax (blood clot accumulation in the pleural cavity) after lung surgery.

METHODS

From July 2009 to November 2013, 46 patients (33 males; mean age, 56.9 ± 10.7 years) were treated with intrapleural urokinase (250,000 IU per dose) for residual hemothorax after lung surgery. Complete response was defined as clinical improvement with complete drainage of the retained collection shown by chest X-ray, and partial response as substantial resolution with minimal residual opacity (<25 % of the thorax). Follow-up was at least 30 days.

RESULTS

The procedure was successful in 42 patients (91.3 %), with complete response observed in 35/46 patients (76.1 %) and partial response in 7/46 (15.2 %). These 42 patients did not require re-intervention for fluid accumulation in the pleural cavity. Treatment failed in 4 patients (8.7 %): one developed bronchopleural fistula that later resolved spontaneously and three (6.5 %) required thoracoscopic drainage for pleural cavity fluid accumulation and lung collapse. No patient required thoracotomy for total decortication. Intrapleural urokinase administration was not associated with serious adverse events, including bleeding complications or allergic reactions.

CONCLUSIONS

Intrapleural fibrinolytic agents should be considered a useful therapeutic option for the treatment of postoperative residual hemothorax. This method appears to be safe and effective in >90 % of patients with postoperative hemothorax.

The clinical and economic burden of significant bleeding during lung resection surgery: A retrospective matched cohort analysis of real-world data

OBJECTIVES

The objective of this retrospective study was to quantify the clinical and economic burden of significant bleeding in lung resection surgery in the US.

METHODS

This study utilized 2009-2012 data from the Premier Perspective Database^TM. Adult patients with primary pulmonary lobectomy or segmentectomy procedures were categorized by the surgical approach (VATS vs open) and primary diagnosis (primary or metastatic lung cancer vs non-lung cancer). Patients requiring ≥3 units of blood products with at least 1 unit of PRBCs: "significant bleeding" cohort; those requiring <3 units: "non-significant bleeding" cohort; and those not requiring blood products: "no bleeding" cohort. A matched cohort analysis was performed between the "significant bleeding" and the "no bleeding cohort" using matching variables: hospital, lung cancer diagnosis, year of surgery, APR-DRG severity score, procedure type and approach, age, and gender.

RESULTS

The "All-patient" cohort comprised 21,429 patients: 213 "significant bleeding"; 2,780 "non-significant bleeding"; and 18,436 "no bleeding". Overall incidence of significant chest bleeding was 0.99%. Patients from "significant bleeding" cohort and "non-significant bleeding" cohort had 2.5 days and 2 days (p < 0.0001) longer length of stay in the hospital compared to those in the "no bleeding" cohort, respectively. Overall, hospital costs for "significant bleeding" cohort were higher than "no bleeding" cohort for those who were covered under Medicare ($59,871 vs $23,641), were ≥76 years of age ($64,010 vs $24,243), had greater severity of illness ($97,813 vs $51,871) and underwent open segmentectomy ($74,220 vs $21,903). Hospital costs for "significant bleeding" cohort and "non-significant bleeding" were significantly higher ($11,589 and $5,280, respectively, p < 0.0001) than no bleeding cohort.

CONCLUSIONS

Although significant bleeding during lung resection surgery is rare, patients with such complication could stay longer at the hospital and cost an average of $13,103 more than those without.

Modern impact of video assisted thoracic surgery

With advancement in technology, experience and training over the last two decades, video assisted thoracic surgery (VATS) has become widely accepted and utilized all over the world. VATS started as a diagnostic tool in the early 1990s, technique of VATS lobectomy evolved and became safer over the next 10-15 years and now it is being used for more advanced and hybrid operations. VATS has contributed to the development of minimally invasive surgical interventions for other thoracic disorders like mediastinal tumors and esophageal cancer as well. This article looks at the advantages of VATS, technique advancements and its applications in other thoracic operations and its influence on the present and future of thoracic surgery.

Complications of bronchial stapling in thoracic surgery

OBJECTIVE

The use of staplers for thoracic surgery has been widely accepted and regarded as a safe procedure. However, complications of stapling are occasionally experienced. The aim of this retrospective study was to analyze complications of bronchial stapling.

METHODS

A retrospective multi-institutional review was conducted by the Central Japan Lung Cancer Surgery Study Group, comprising 29 institutions. All instances of bronchial stapling in thoracic surgery were reviewed during the research period.

RESULTS

Bronchial stapling was performed 2,030 times, using 36 kinds of staplers. The total number of complications related to stapling was 36 (1.8 %); 31 events occurred intraoperatively and five events occurred postoperatively. The intraoperative complications were air leakage (N = 20) and stapling failure (N = 11), which were caused by stapler-tissue thickness mismatch (N = 17), stapler defect (N = 3), tissue fragility (N = 2), and unknown reasons (N = 9). In all 31 cases, intraoperative complications were recovered intraoperatively with additional suturing, and no further complications were observed postoperatively. The postoperative complications were bronchopleural fistula (BPF) (N = 4) and bleeding from the chest wall (intercostal artery) (N = 1). The rate of BPF was 0.2 % (4 of 2,030). Two of four BPFs induced critical conditions. Postoperative bleeding was caused by the use of Duet TRS(TM). Both total complications and BPF occurred more frequently in the main bronchus than in the lobar or segmental bronchus. No relationship was seen between the incidence of complications and cartridge colors in lobar bronchial stapling. The compression types of staplers were associated with the incidence of complication.

CONCLUSIONS

Intraoperative and postoperative complications of bronchial stapling were studied. Generally, bronchial stapling in recent thoracic surgery was safe, but rare postoperative complications may induce critical conditions. Knowledge of potential complications and causes of bronchial stapling may decrease the incidence of stapling complications.

Recurrence and survival outcomes after anatomic segmentectomy versus lobectomy for clinical stage I non-small-cell lung cancer: a propensity-matched analysis

PURPOSE

Although anatomic segmentectomy has been considered a compromised procedure by many surgeons, recent retrospective, single-institution series have demonstrated tumor recurrence and patient survival rates that approximate those achieved by lobectomy. The primary objective of this study was to use propensity score matching to compare outcomes after these anatomic resection approaches for stage I non-small-cell lung cancer.

PATIENTS AND METHODS

A retrospective data set including 392 segmentectomy patients and 800 lobectomy patients was used to identify matched segmentectomy and lobectomy cohorts (n = 312 patients per group) using a propensity score matching algorithm that accounted for confounding effects of preoperative patient variables. Primary outcome variables included freedom from recurrence and overall survival. Factors affecting survival were assessed by Cox regression analysis and Kaplan-Meier estimates.

RESULTS

Perioperative mortality was 1.2% in the segmentectomy group and 2.5% in the lobectomy group (P = .38). At a mean follow-up of 5.4 years, comparing segmentectomy with lobectomy, no differences were noted in locoregional (5.5% v 5.1%, respectively; P = 1.00), distant (14.8% v 11.6%, respectively; P = .29), or overall recurrence rates (20.2% v 16.7%, respectively; P = .30). Furthermore, when comparing segmentectomy with lobectomy, no significant differences were noted in 5-year freedom from recurrence (70% v 71%, respectively; P = .467) or 5-year survival (54% v 60%, respectively; P = .258). Segmentectomy was not found to be an independent predictor of recurrence (hazard ratio, 1.11; 95% CI, 0.87 to 1.40) or overall survival (hazard ratio, 1.17; 95% CI, 0.89 to 1.52).

CONCLUSION

In this large propensity-matched comparison, lobectomy was associated with modestly increased freedom from recurrence and overall survival, but the differences were not statistically significant. These results will need further validation by prospective, randomized trials (eg, Cancer and Leukemia Group B 140503 trial).

Adverse events of lung tissue stapling in thoracic surgery

PURPOSE

The use of staplers for thoracic surgery has been regarded as a safe procedure though sometimes adverse events (AEs) of stapling are experienced. The aim of this study is to analyze AEs of lung tissue stapling.

METHODS

A retrospective multi-institutional review was conducted by 27 institutions of the Central Japan Lung Cancer Surgery Study Group. During the research period, lung tissue stapling was performed 10908 times.

RESULTS

Total number of AEs related to stapling was 81 (0.74%). Seventy events occurred intraoperatively and 11 events occurred postoperatively. Intraoperative stapling AEs were air leakage (n = 26), laceration of the adjacent lung tissue (n = 23), stapling failure (n = 14), oozing (n = 4), and others (n = 3). The postoperative AEs were prolonged air leakage (n = 9), bleeding from the chest wall (n = 1), and postoperative bleeding (n = 1). Only one case died of acute exacerbation of interstitial pneumonia which was induced after completion lobectomy to cure postoperative bleeding. No relationship was seen between the incidence of AE and cartridge colors or compression types of staplers except the length of cartridges.

CONCLUSION

Lung tissue stapling in thoracic surgery was safe. The most frequent cause of AEs was stapler-tissue thickness mismatch. The appropriate selection of the cartridge color may decrease the AE incidence of the lung tissue stapling.

Adverse events of stapling in thoracic surgery: relations between an incidence of adverse events and a stapling volume

PURPOSE

The use of staplers for thoracic surgery has been widely accepted and regarded as a safe procedure. However, sometimes adverse events (AEs) of stapling are experienced. The aim of the present study was to retrospectively analyze AEs of stapling in thoracic surgery.

METHODS

A retrospective multi-institutional review was conducted by the 27 institutions of the Central Japan Lung Cancer Surgery Study Group. Between January 2009 and December 2010, 4495 patients underwent thoracic surgery using mechanical stapling.

RESULTS

Stapling of various tissues was performed 16403 times. Total number of AEs related to stapling was 126 (0.77%). One hundred and nine events occurred intraoperative and 17 events occurred postoperative. The AE rates ranged from 0% to 1.8%. No relationship was seen between the incidence of AE and a stapling volume of thoracic surgery.

CONCLUSION

We have investigated intraoperative and postoperative AEs of stapling. Generally, stapling in thoracic surgery was safe. An AE rate of stapling in thoracic surgery is not influenced by the numbers of stapling in institutions.

Staplers versus hand-sewing for pulmonary lobectomy: randomized controlled trial

Background

division of the parenchymal lung for lobectomy is performed in patients who have an incomplete fissure. A stapler device can reduce postoperative air leak, but it is expensive.

Objective

to investigate the advantage of using a stapler, in terms of postoperative air leak and cost, compared to hand-sewn techniques.

Method

a non-blinded randomized controlled trial was conducted in Chiang Mai University Hospital, Thailand, from November 15, 2011 to September 30, 2012. Fifty-three adult patients were randomized to undergo a hand-sewn technique (27 patients) or stapler closure (26 patients).

Results

postoperative air leak in the stapler group was less than that in the hand-sewn group (7.7% vs. 29.6%, p = 0.044), and the duration of air leak in the stapler group was significantly shorter than that in the hand-sewn group (1.0 vs. 13.4 days, p = 0.032). The cost of treatment was not significantly different between groups; however, the total cost in the stapler group was less than that in the hand-sewn group (mean difference 4454 Thai baht (US$144.75).

Conclusion

a stapler reduces postoperative air leaks and the duration of air leaks. Furthermore, the total cost of treatment was comparable. Therefore, using staples may provide substantial financial benefits.

Adverse events of pulmonary vascular stapling in thoracic surgery

OBJECTIVES

The use of staplers for thoracic surgery has been widely accepted and regarded as a safe procedure. However, adverse events (AEs) of stapling are occasionally experienced. The aim of this retrospective study was to analyse the AEs of stapling in pulmonary vascular surgery.

METHODS

A retrospective multi-institutional review was conducted by the 29 institutions of the Central Japan Lung Cancer Surgery Study Group. All staplings of the pulmonary artery (PA) and vein in thoracic surgery were reviewed during the research period.

RESULTS

Stapling of the PA and vein was performed 3393 times. The total number of AEs related to stapling was nine (0.27%). Eight events occurred intraoperatively and one occurred immediately after the operation. Intraoperative AE occurred more frequently than postoperative AE. AE in the PA occurred more frequently than in the pulmonary vein. The intraoperative AEs were oozing (n=3), stapling failure (n=2), laceration of the peripheral vasculature at compression (n=2) and technical injury of the vasculature at insertion (n=1). The causes of AEs were reported to be tissue fragility (n=3), stapler rocking during stapling (n=2), stapler-tissue thickness mismatch (n=2) and technical failure (n=1). The only postoperative AE was staple line rupture of the PV stump. No relationship was seen between the incidence of AE and cartridge colours, compression types of staplers or numbers of staple lines.

CONCLUSIONS

Generally, stapling of the pulmonary vasculatures in recent thoracic surgery has been safe. Furthermore, the knowledge of the possible risks of pulmonary vascular stapling may help to decrease the AEs of stapling.

Use of energy-based coagulative fusion technology and lung sealants during anatomic lung resection

OBJECTIVES

Energy-based tissue fusion technology is being increasingly used for vascular division in numerous intra-abdominal applications. Very few data, however, are available regarding the application of this technology in the chest during anatomic lung resection. In the present review, we evaluated the use of energy-based fusion and lung sealants during anatomic lung resection.

METHODS

We performed a review of case series and published studies to evaluate the use of energy-based coagulative fusion technology and lung sealants during anatomic lung resection. We then used energy-based coagulative fusion technology during anatomic lung resection (segmentectomy or lobectomy) in 316 cases from 2008 to 2011. Two energy applications were applied to the arterial and venous branches before vessel division.

RESULTS

In the first 12 cases, we used a device with a small curved jaw (range, 3.3-4.7 mm). Two partial venous dehiscences were noted and controlled intraoperatively. For the remaining cases, we used a larger jaw (6 mm × 22 mm) with no arterial or venous dehiscence occurring (vessels ranged from 0.4 to 1.2 cm). Autologous or synthetic tissue sealants applied to the parenchymal staple lines might reduce the severity and duration of perioperative air leaks. Suture line buttressing with pericardial or absorbable biosynthetic polyester strips might reduce the severity of air leaks in patients with severe emphysema undergoing anatomic lung resection or lung volume reduction surgery.

CONCLUSIONS

The bipolar tissue fusion system provides a safe and effective technique for the division of the pulmonary arterial and venous branches during anatomic lung resection. Surgical sealants and buttressing adjuncts might reduce perioperative air leak potential.

Preliminary results of anatomic lung resection using energy-based tissue and vessel coagulative fusion technology

OBJECTIVES

Mechanical stapling devices have been established as the mainstay of therapy in the selective isolation and division of bronchial and vascular structures during anatomic lung resection. Few data are available regarding the application of energy-based tissue fusion technology during anatomic lung resection. In the present study, we evaluated the use of energy-based instruments for the division of the pulmonary arterial and venous branches during anatomic lung resection.

METHODS

Anatomic lung resection (segmentectomy or lobectomy) was performed using energy-based coagulative fusion technology. A low-profile jaw can be used to facilitate dissection in both open and video-assisted thoracic surgery cases, applying a seal 6 mm wide by 22 mm in length. Two energy applications were applied to the arterial and venous branches before vessel division.

RESULTS

The bipolar tissue fusion system was used in 211 patients between 2008 and 2010 (104 lobectomies and 107 anatomic segmentectomies). Initially, we used a device with a smaller, curved jaw (n = 12), producing a 3.3- to 4.7-cm seal. No arterial dehiscences and 2 partial venous dehiscences that were recognized and controlled intraoperatively occurred. For the remaining cases, we used a new device with a larger jaw that applied a seal 6 mm wide by 22 mm in length. No arterial or venous dehiscences (vessel size range, 0.4-1.2 cm) occurred.

CONCLUSIONS

The bipolar tissue fusion system provided safe and reliable control of pulmonary arterial and venous branches during anatomic lung resection. The use of energy-based tissue fusion technology represents a reasonable alternative to mechanical stapling devices during anatomic lung resection.

Optimal surgical management of Stage I non-small-cell lung cancer in an increasingly aging population: challenges and recent progress

Lung cancer remains the main cause of cancer deaths in the USA. The dismal prognosis for non-small-cell lung cancer (NSCLC) despite current advances in chemotherapy is disappointing. In an increasingly aging population, computed tomography screening allows the detection of very early Stage I NSCLC lesions. Although many retrospective trials have indicated better prognosis for those undergoing lobectomy versus sublobar resection (anatomical segmentectomy or wedge resection), the issue remains equivocal. This is particularly true for patients with significant comorbid cardiorespiratory disease compromising postoperative recovery. This review will describe landmark retrospective studies related to the topic, in an attempt to highlight the difficulties associated with surgical decision making. Key factors in the characteristics of the lesions will be examined equally with the ultimate objective of allowing the decision of lobectomy versus sublobar resection to be centered around the need of the individual patient per se. This review article will also provide an insight into ongoing randomized, prospective clinical trials on the subject, investigating into some of the emerging technologies from the laboratory and the clinic that will hopefully enable the provision of a solidly acceptable treatment plan for the Stage I NSCLC patient, with maximum survival rates and low disease recurrence.

Superselective segmentectomy for deep and small pulmonary nodules under the guidance of three-dimensional reconstructed computed tomographic angiography

BACKGROUND

Three-dimensional computed tomographic angiography (3D-CT angio) allows selective access to peripheral segments. Superselective segmentectomy (SSS) was applied to the surgical management of indeterminate small and deep pulmonary nodules.

METHODS

Thirty patients with indeterminate pulmonary nodules less than 25 mm in diameter and located deeper than 20 mm from the pleural surface were enrolled in this study between 2002 and 2009. All patients underwent exploratory thoracotomy. The SSS with a surgical margin from the nodule larger than the nodule diameter or 20 mm was directed toward the target pulmonary arteries by 3D-CT angio using a multidetector-row CT scanner. The SSS was evaluated for resected area, surgical margin, regional lymph nodes, morbidity, lung function, and survival rate.

RESULTS

Three patients received SSS at the daughter segment, 23 patients that at the subsegment, and the remaining four underwent miscellaneous SSS without major complications. Twenty patients exhibited early lung cancer, one patient stage IIA lung cancer, and the remaining nine patients had metastatic or benign tumors. Five patients with primary cancer subsequently underwent standard lobectomy. The remaining 16 patients with early lung cancer did not undergo lobectomy because of their major comorbidities or refusal of a second thoracotomy. The surgical margins were free of disease in all patients. The actual and disease-free five-year survival rates were 100% for the lung cancer patients, excluding those who subsequently underwent lobectomy. The lung function after SSS was well preserved.

CONCLUSIONS

Superselective segmentectomy is an applicable optional strategy for the surgical management of indeterminate small and deep pulmonary nodules.

Thoracoscopic versus open lobectomy debate: the pro argument

INTRODUCTION

Controversy persists about the role of VATS lobectomy for patients with lung cancer. This is particularly true in Europe, where VATS (video assisted thoracic surgery) lobectomy is performed for lung cancer less often than in the USA or Japan. This article reviews existing data comparing the results of VATS vs. open lobectomy for the treatment of lung cancer in order to provide a scientific basis for a rational assessment of this issue.

METHODS

The review of the data presented here draws heavily from a 2007 metaanalysis by Cheng et al. [1] published in 2007, as it employed rigorous methodology in performing a systematic review and metaanalysis, and involved a detailed analysis of many major and minor endpoints on an intent to treat basis. This included 36 trials, three of them randomized, and 3589 patients, reported between 1995 and 2007. Summary results for individual endpoints are shown as a mean value with 95% confidence intervals (CI). These values are taken from the summary results of the Forrest plots in the source article. Dichotomized variables are expressed as an Odds Ratio, with values <1 being in favor of VATS lobectomy. Continuous variables are reported as weighted mean differences.

RESULTS

The operative time for a VATS lobectomy was statistically longer, but only by 16 minutes. The conversion rate from VATS to open was 6%. There was no significant difference in the rates of major bleeding, blood transfusion or re-operation. VATS lobectomy was associated with a significantly lower rate of complications in general and pulmonary complications in particular. Postoperative pain was reduced, functional outcome was better, whereas overall quality of life was not. Mediastinal staging was equal with regard to the number of nodes or the number of nodal stations sampled. The ability of patients to receive adjuvant chemotherapy was improved following VATS. There was no difference in survival at 1 and 3 years for lung cancer (all stages combined). There was no difference in survival at 5 years for each tumor stage, and no difference in the rate of deaths at maximal follow-up.

CONCLUSION

The data suggests that VATS lobectomy for NSCLC is safe, results in fewer complications, less pain, and more rapid return of normal functioning. There appears to be either no difference or a slight benefit in long term survival after VATS lobectomy. These conclusions are demonstrated by a comprehensive, rigorous metaanalysis of the controlled clinical trials, but are weakened by the fact that most of the studies were not randomized. However, because a large randomized trial is not likely to ever be conducted, this represents the best assessment of the value of VATS lobectomy that is available.

Role of Sublobar Resection (Segmentectomy and Wedge Resection) in the Surgical Management of Non–Small Cell Lung Cancer

Segmentectomy demands a thorough knowledge of the three-dimensional bronchovascular anatomy of the lung. This anatomic detail makes segmentectomy significantly more challenging than lobectomy. Several principles must be applied when performing segmental lung resection: (1) the surgeon should avoid dissection in a poorly developed fissure, (2) use the transected bronchus as the base of the segmental resection during the division of the lung parenchymal in the intersegmental plane, (3) consider the use of endostapler division of the pulmonary parenchyma to reduce the air leak complications related to "finger fracture" dissection of the intersegmental plane, and (4) consider the use of adjuvant iodine 125 brachytherapy as a means of reducing local recurrence following sublobar resection. Increasing evidence supports the use of anatomic segmentectomy in the treatment of primary lung cancer for appropriately selected patients. This resection approach seems most appropriate in the management of the small (<2 cm in diameter) peripheral stage I NSCLC in which a generous margin of resection can be obtained. Accurate intraoperative nodal staging is important to estimate the relative use of these approaches compared with more aggressive resection and to determine the need for adjuvant systemic therapy if metastatic lymphadenopathy is identified. Future investigations comparing the results of sublobar resection with lobectomy will more clearly define the role of segmentectomy among good-risk patients with clinical stage I NSCLC. At the present time, it seems that sublobar resection is an appropriate therapy for the management of stage I NSCLC identified in the elderly patient, those individuals with significant cardiopulmonary dysfunction, and for the management of peripheral solitary metastatic disease to the lung. Because the primary disadvantage of sublobar resection is that of local recurrence, intraoperative adjuvant iodine 125 brachytherapy may be considered to minimize this local recurrence risk.

Efficacy and Safety of En Bloc Ligation of Renal Hilum During Laparoscopic Nephrectomy

OBJECTIVES

To evaluate the feasibility, efficacy, and safety of en bloc ligation of the renal hilum with titanium vascular staplers during laparoscopic nephrectomy. En bloc ligation of the renal hilum has historically been associated with the very rare complication of arteriovenous fistula (AVF) formation, primarily in inflammatory renal pathologic features. Currently, no evidence exists of AVF development in human nephrectomies after ligating the hilum en bloc with titanium staplers.

METHODS

A total of 161 consecutive patients underwent planned laparoscopic radical nephrectomy or nephroureterectomy. A retrospective review was performed to evaluate the operative variables, including the method of hilar ligation, estimated blood loss, and final pathologic findings. The additional postoperative outcomes of diastolic blood pressure, heart rate, and other cardiovascular sequelae were evaluated.

RESULTS

Of the 161 patients, 90 underwent en bloc hilar ligation and 71 underwent individual hilar vessel ligation with the stapler. The blood loss and open conversion rate trended lower in the en bloc group. Postoperatively, no differences were found in blood pressure or heart rate between the two groups, and no instances of bruits or other clinical evidence of AVF were found after mean follow-up of 34 months.

CONCLUSIONS

This series found no evidence of AVF or other adverse clinical events in patients undergoing en bloc ligation of the renal hilum and laparoscopic nephrectomy. En bloc ligation may provide for more secure, expeditious control of the hilum without an increased operative time or the added potential of vascular injury that can be associated with the individual dissection of the vessels.

Postoperative Bleeding: Coagulopathy, Bleeding, Hemothorax

Several issues are involved in determining a patient's risk for postoperative hemorrhage and in managing this potential postoperative complication. The impact of minimally invasive procedures on the incidence of this complication is addressed in this article.

Evolution of surgical skills training

Surgical training is changing: one hundred years of tradition is being challenged by legal and ethical concerns for patient safety, work hours restrictions, the cost of operating room time, and complications. Surgical simulation and skills training offers an opportunity to teach and practice advanced skills outside of the operating room environment before attempting them on living patients.

Simulation training can be as straight forward as using real instruments and video equipment to manipulate simulated “tissue” in a box trainer. More advanced, virtual reality simulators are now available and ready for widespread use. Early systems have demonstrated their effectiveness and discriminative ability. Newer systems enable the development of comprehensive curricula and full procedural simulations.

The Accreditation Council of Graduate Medical Education’s (ACGME) has mandated the development of novel methods of training and evaluation. Surgical organizations are calling for methods to ensure the maintenance of skills, advance surgical training, and to credential surgeons as technically competent.

Simulators in their current form have been demonstrated to improve the operating room performance of surgical residents. Development of standardized training curricula remains an urgent and important agenda, particularly for minimal invasive surgery. An innovative and progressive approach, borrowing experiences from the field of aviation, can provide the foundation for the next century of surgical training, ensuring the quality of the product. As the technology develops, the way we practice will continue to evolve, to the benefit of physicians and patients.

Computer-mediated power stapling for anatomical lung resection: experience in 100 consecutive cases

OBJECTIVES

: Mechanical stapling is widely used for lung resection. Complications related to the stapling are few but not infrequent. This varies from complete disruption of the staples to incomplete sealing of vascular structures. A stapling platform that has a strong clamping force with precise and consistent staple formation suitable for thickness of tissue is likely to be an advance in existing devices and may reduce the complication rate. A new, computer-mediated power stapling is currently available for lung resections, with three types of digital loading units (DLU). Clinical data on its use are limited. We report our experience with this stapling platform (SurgASSIST) in our first 100 patients undergoing anatomic lung resection.

METHODS

: Fifty-four men and forty-six women (mean age, 64 ± 7 years) underwent anatomic lung resections, using a lateral, muscle-sparing mini-thoracotomy, during 2004 to 2005, with the SurgASSIST platform. Three types of DLUs were used for lung resection: a linear cutter, a right-angled vascular cutter, and a right-angled bronchial cutter. Observational data were collected prospectively on the operative procedure, type of staples used, duration of operation, chest tube drainage, and hospital length of stay.

RESULTS

: There were 83 lobectomies, 5 bilobectomies, 5 segmental resections, and 7 pneumonectomies. A total of 502 DLUs (mean, 5 per patient; 102 vascular, 91 bronchial, and 309 linear cutters) were used in this series. There were no major operative complications. The mean operating time was 136 ± 41 minutes. One bronchial dehiscence and one incomplete sealing of the pulmonary vein in the staple line were observed. In one patient, the linear cutter could not be opened in the automatic setting. There were 15% misreads by the computer on the DLU or their inserts. There was one hospital death unrelated to the stapling. Twenty additional complications included prolonged chest tube drainage (n = 8), reoperations (n = 2), atrial fibrillation (n = 5), hemothorax (n = 1), chylothorax (n = 1), C-dif colitis (n = 1), myocardial ischemia (n = 1), and incarcerated ventral hernia (n = 1). The median hospital length of stay was 5 days (range, 3 to 26 days) and the median length of chest tube drainage was 3 days (1 to 22 days).

CONCLUSIONS

: Our experience shows that the computer-mediated power stapling of lung parenchyma and hilar structures during anatomic resection is safe and reproducible.

Hybrid surgical approach of video-assisted minithoracotomy for lung cancer: significance of direct visualization on quality of surgery

STUDY OBJECTIVES

Controversy regarding the most suitable surgical approach for treating malignancies of the lung is a matter of continuous discussions. "Complete" video-assisted thoracic surgery (VATS) that is performed using only the vision of a monitor is generally limited to lung resections of minimal difficulty. With the great interest in minimally invasive techniques for treating various pathologies, we have widely applied an integrated surgical approach that combines muscle-sparing minithoracotomy (incision, 4 to 10 cm) and video assistance using mainly direct visualization of the lung resection, which we have called hybrid VATS. The aim of this study is to evaluate the usefulness of hybrid VATS.

DESIGN

Retrospective single-center study.

INTERVENTIONS

From January 1998 to October 2004, 405 of 678 lobectomies (60%) and 165 of 226 segmentectomies (73%) were performed for primary lung cancer using hybrid VATS.

RESULTS

Bronchoplasty was performed in 93 of the 678 patients (14%) who underwent lobectomy and in 11 of the 226 patients (5%) who underwent segmentectomy. Hybrid VATS was utilized in 33% of sleeve lobectomy procedures and in 27% of sleeve segmentectomy procedures. The mean (+/- SD) surgical time using hybrid VATS was 164 +/- 48 min for lobectomy and 158 +/- 35 min for segmentectomy, and the mean blood loss was 166 +/- 120 and 109 +/- 80 mL, respectively. There was one operative mortality (0.2%) secondary to cardiogenic shock. Postoperative complications developed in 11% of patients with p-stage IA disease after undergoing hybrid VATS, in contrast to 19% of patients after undergoing open thoracotomy. The prognosis of patients treated by hybrid VATS was equivalent to that obtained with open thoracotomy.

CONCLUSIONS

Minithoracotomy combined with video support that is performed predominantly via direct visualization is a secure, integrated, minimally invasive approach to performing major resection for lung cancer, including atypical procedures such as bronchoplasty. This hybrid VATS can be an acceptable and satisfactory option whenever the performance of complete VATS is considered to be challenging.