Higher Long-term Quality of Life Metrics After Video-Assisted Thoracoscopic Surgery Lobectomy Compared With Robotic-Assisted Lobectomy

Quality of life after robotic versus conventional minimally invasive cancer surgery: a systematic review and meta-analysis

Optimizing postoperative quality of life (QoL) is an essential aspect of surgical oncology. Minimally invasive surgery (MIS) decreases surgical morbidity and improves QoL outcomes. This meta-analysis aimed to compare post-operative QoL after oncologic resections using different MIS modalities. The PubMed, Embase, Scopus, and CENTRAL databases were searched for articles that compared post-operative QoL in patients undergoing video-assisted thoracoscopic (VATS) or laparoscopic surgery (LS) versus robotic surgery (RS) for malignancy. Quality assessment was performed using the ROBINS-I and Cochrane Risk of Bias 2 (RoB-2) tools. Meta-analysis was performed using an inverse-variance random effects model. 27 studies met the inclusion criteria, including 5 randomized controlled trials (RCTs). 15 studies had a low risk of bias, while 11 had a moderate risk of bias and 1 had serious risk of bias. 8330 patients (RS: 5090, LS/VATS: 3240) from across 25 studies were included in the meta-analysis. Global QoL was significantly better after robotic surgery in the pooled analysis overall (SMD: - 0.28 [95% CI: - 0.49, - 0.08]), as well as in the prostatectomy and gastrectomy subgroups. GRADE certainty of evidence was low. Analysis of EPIC-26 subdomains also suggested greater sexual function after robotic versus laparoscopic prostatectomy. Robotic and conventional MIS approaches produce similar postoperative QoL after oncologic surgery for various tumor types, although advantages may emerge in some patient populations. Our results may assist surgeons in counseling patients who are undergoing oncologic surgery.

Factors related to post-thoracotomy pain following robotic-assisted thoracic surgery

BACKGROUND

Robotic-assisted thoracic surgery (RATS) is a minimally invasive procedure; however, some patients experience persistent postoperative pain. This study aimed to investigate factors related to postoperative pain following RATS.

METHODS

The data of 145 patients with lung cancer, who underwent RATS with a four-port (one in the sixth intercostal space [ICS] and three in the eighth ICS) lobectomy or segmentectomy between May 2019 and December 2022, were retrospectively analyzed. Factors associated with analgesic use for at least 2 months following postoperative pain (PTP group) were analyzed.

RESULTS

Patients who underwent preoperative pain control for any condition or chest wall resection were excluded. Among the 138 patients, 45 (32.6%) received analgesics for at least 2 months after surgery. Patient height and transverse length of the thorax correlated with PTP in the univariate analysis (non-PTP vs. PTP; height, 166 vs. 160 cm; p < .001; transverse length of the thorax, 270 vs. 260 mm, p = .016). In the multivariate analysis, height was correlated with PTP (p = .009; odds ratio, 0.907; 95% confidence interval, 0.843-0.976). Height correlated with the transverse length of the thorax (r = .407), anteroposterior length of the thorax (r = .294), and width of the eighth ICS in the middle axillary line (r = .210) using Pearson's correlation coefficients. When utilizing a 165-cm cutoff value for height to predict PTP using receiver operating characteristic curve analysis, the area under the curve was 0.69 (95% confidence interval, 0.601-0.779).

CONCLUSION

Short stature is associated with a high risk of postoperative pain following RATS.

Comparison of Quality of Life after Robotic, Video-Assisted, and Open Surgery for Lung Cancer

Post-operative quality of life (QOL) has become crucial in choosing operative approaches in thoracic surgery. However, compared to VATS and thoracotomy, QOL results post-RATS are limited. We compared QOL before and after RATS and between RATS, VATS, and thoracotomy. We conducted a retrospective review of lung cancer surgical patients from 2015 to 2020. Patients completed validated EORTC QOL questionnaires (QLQ-C30 and QLQ-LC13). Results were analysed using the EORTC Scoring Guide, with statistical analysis. A total of 47 (94%) pre- and post-RATS questionnaires were returned. Forty-two patients underwent anatomical lung resections. In addition, 80% of patients experienced uncomplicated recovery. All global and functional QOL domains improved post-operatively, as did most symptoms (13/19). Only four symptoms worsened, including dyspnoea (p = 0.017), with two symptoms unchanged. Of the 148 returned questionnaires for all approaches (open-22/VATS-79/RATS-47), over 70% showed a high pre-operative performance status. Most patients underwent anatomical lung resection, with only VATS patients requiring conversion (n = 6). Complications were slightly higher in RATS, with one patient requiring re-intubation. RATS patients demonstrated the highest global and functional QOL. Physical QOL was lowest after thoracotomy (p = 0.002). RATS patients reported the fewest symptoms, including dyspnoea (p = 0.046), fatigue (p < 0.001), and pain (p = 0.264). Overall, RATS results in a significantly better post-operative QOL and should be considered the preferred surgical approach for lung cancer patients.

Health-Related Quality of Life Following Robotic-Assisted or Video-Assisted Lobectomy in Patients With Non-Small Cell Lung Cancer: Results From the RVlob Randomized Clinical Trial

BACKGROUND

Robot-assisted lobectomy (RAL) is increasingly used as an alternative to video-assisted lobectomy (VAL) for resectable non-small cell lung cancer (NSCLC). However, there is little evidence of any difference in postoperative health-related quality of life (HRQoL) between these two approaches.

RESEARCH QUESTION

Is RAL superior to VAL in improving quality of life in patients with resectable NSCLC?

STUDY DESIGN AND METHODS

We performed a single-center, open-label randomized clinical trial from May 2017 to May 2020 with 320 enrolled patients undergoing RAL or VAL for resectable NSCLC (RVlob trial; NCT03134534). Postoperative pain was evaluated by visual analog score or numeric rating score on postoperative day 1 and at weeks 4, 24, and 48. The European Organization for Research and Treatment of Cancer (EORTC) Core Quality of Life Questionnaire (QLQ-C30), EORTC Quality of Life Questionnaire in Lung Cancer (QLQ-LC13), and the European Quality of Life 5 Dimensions (EQ-5D) questionnaire were also administered at weeks 4, 24, and 48 after surgery.

RESULTS

One hundred and fifty-seven patients underwent RAL and 163 underwent VAL. The mean pain score of patients after RAL was significantly lower at week 4 (2.097 ± 0.111 vs 2.431 ± 0.108; P = .032). QLQ-C30 and QLQ-LC13 summary scores (P > .05) were similar for both RAL and VAL during the first 48 weeks of follow-up. HRQoL scores assessed with the EQ-5D questionnaire were also comparable between the two groups (P > .05) during the whole study period.

INTERPRETATION

Both RAL and VAL showed satisfactory and comparable HRQoL and postoperative pain up to 48 weeks after surgery, despite some minor statistical differences at week 4.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov; No.: NCT03134534; URL: www.

CLINICALTRIALS

gov.

A Comparison of the Differences in Postoperative Chronic Pain Between Video-Assisted and Robotic-Assisted Approaches in Thoracic Surgery

Background and objective In the last decade, there has been significant evolution in thoracic surgery with the advent of robotic surgery. In this study, we aimed to evaluate the incidence of postoperative chronic pain (for six months and beyond) in robotic and video-assisted approaches to analyze the long-term effects of the two different techniques. Methods This was a retrospective study involving 92 patients who underwent various thoracic operations between six months and two years preceding the study. Patients were classified into two groups based on the type of surgery: video-assisted (VATS) (n=51), and robotic-assisted (RATS) (n=41) thoracoscopic Surgery. We employed the EuroQol (EQ-5D-5L) questionnaire to assess the utility values in terms of five quality-of-life measures (self-care, pain/discomfort, mobility, anxiety/depression, and usual activities). Results In the VATS group, the median age was 68 years while it was 57 years in the RATS group (p=0.001). A higher proportion of patients in the VATS group had anatomical lung resection (lobectomy) compared to the RATS group: 61.2 vs. 41.6% respectively (p=0.005). However, the groups were well-matched on other patient characteristics such as relevant past medical history, underlying disease pathology, and final disease staging (if malignant), with no significant differences between groups observed regarding these traits. In the VATS group, 62.7% of patients were pain-free at the time of the questionnaire-based evaluation compared to 51.2% in the RATS group. Additionally, 25.5% vs. 39% of patients had mild pain in the VATS and RATS groups respectively. Neither of these differences was statistically significant. Conclusion Patients who undergo RATS are known to have better recovery and less pain compared to those who have VATS in the immediate postoperative period. However, our results did not find RATS to be superior to VATS in terms of long-term pain. Additionally, robotic surgery is associated with higher hospital costs. In light of these findings, further comparative studies between the two approaches are recommended, while strategies to reduce postoperative pain and financial cost should continue to be explored.

Updated Evaluation of Robotic- and Video-Assisted Thoracoscopic Lobectomy or Segmentectomy for Lung Cancer: A Systematic Review and Meta-Analysis

Objectives

Robot-assisted thoracic surgery (RATS) and video-assisted thoracic surgery (VATS) are the two principal minimally invasive surgical approaches for patients with lung cancer. This study aimed at comparing the long-term and short-term outcomes of RATS and VATS for lung cancer.

Methods

A comprehensive search for studies that compared RATS versus VATS for lung cancer published until November 31, 2021, was conducted. Data on perioperative outcomes and oncologic outcomes were subjected to meta-analysis. PubMed, Web of Science, and EMBASE were searched based on a defined search strategy to identify eligible studies before November 2021.

Results

Twenty-six studies comparing 45,733 patients (14,271 and 31,462 patients who underwent RATS and VATS, respectively) were included. The present meta-analysis showed that there were no significant differences in operative time, any complications, tumor size, chest drain duration, R0 resection rate, lymph station, 5-year overall survival, and recurrence rate. However, compared with the VATS group, the RATS group had less blood loss, a lower conversion rate to open, a shorter length of hospital stay, more lymph node dissection, and better 5-year disease-free survival.

Conclusions

RATS is a safe and feasible alternative to VATS for patients with lung cancer.

Computerized Tomography Image Features under the Reconstruction Algorithm in the Evaluation of the Effect of Ropivacaine Combined with Dexamethasone and Dexmedetomidine on Assisted Thoracoscopic Lobectomy

This research was aimed to study CT image features based on the backprojection filtering reconstruction algorithm and evaluate the effect of ropivacaine combined with dexamethasone and dexmedetomidine on assisted thoracoscopic lobectomy to provide reference for clinical diagnosis. A total of 110 patients undergoing laparoscopic resection were selected as the study subjects. Anesthesia induction and nerve block were performed with ropivacaine combined with dexamethasone and dexmedetomidine before surgery, and chest CT scan was performed. The backprojection image reconstruction algorithm was constructed and applied to patient CT images for reconstruction processing. The results showed that when the overlapping step size was 16 and the block size was 32 × 32, the running time of the algorithm was the shortest. The resolution and sharpness of reconstructed images were better than the Fourier transform analytical method and iterative reconstruction algorithm. The detection rates of lung nodules smaller than 6 mm and 6–30 mm (92.35% and 95.44%) were significantly higher than those of the Fourier transform analytical method and iterative reconstruction algorithm (90.98% and 87.53%; 88.32% and 90.87%) (P < 0.05). After anesthesia induction and lobectomy with ropivacaine combined with dexamethasone and dexmedetomidine, the visual analogue scale (VAS) decreased with postoperative time. The VAS score decreased to a lower level (1.76 ± 0.54) after five days. In summary, ropivacaine combined with dexamethasone and dexmedetomidine had better sedation and analgesia effects in patients with thoracoscopic lobectomy. CT images based on backprojection reconstruction algorithm had a high recognition accuracy for lung lesions.

Internet of Things-Based Ultrasound-Guided Erector Spinae Plane Block Combined with Edaravone Anesthesia in Thoracoscopic Lobectomy

This paper aimed to study the application value of Internet of Things (IoT) edge computing algorithm-based ultrasound-guided erector spinae plane block combined with edaravone anesthesia in thoracoscopic lobectomy. A total of 110 patients undergoing thoracoscopic resection were selected as subjects. The patients were anesthetized with erector spinae plane block combined with edaravone before surgery and underwent chest ultrasound scan. IoT edge computing algorithm was constructed and applied to ultrasound images of patients to enhance and denoise the images. It was found that, in different mixed noise mixtures (Gaussian noise 10% + speckle noise 90%; Gaussian noise 30% + speckle noise 70%), the edge computing algorithm can still maintain the edge information of the output image, showing better performance on edge information detection and denoising compared with the Prewitt and Canny operator. In addition, visual analog scale (VAS) scores decreased with postoperative time after edaravone anesthesia induction and erector spinae plane block lobectomy and reached the lowest level after five days. In short, erector spinae plane block combined with edaravone showed good sedative and analgesic effects on patients undergoing thoracoscopic lobectomy. Ultrasound images processed by IoT edge computing algorithm showed high accuracy in the identification of lung lesions, which was worth applying to clinical diagnosis.

Cost-effectiveness Analysis of Robotic-assisted Lobectomy for Non-small Cell Lung Cancer

BACKGROUND

Robot-assisted thoracic surgery has emerged as an alternative to video-assisted thoracic surgery (VATS) for treating patients with resectable non-small cell lung cancer (NSCLC). The objective of this study was to evaluate the cost-effectiveness of robotic-assisted lobectomy (RAL) compared to VATS and open lobectomy for adults with NSCLC.

METHODS

A decision analysis model was employed to compare the cost-effectiveness of RAL, VATS, and open lobectomy with 1-year time horizon from both healthcare and societal perspectives. Healthcare costs (2020$) and quality-adjusted life-years (QALYs) were compared between the approaches. Incremental cost-effectiveness ratios (ICERs) were calculated in terms of cost per QALY gained. Sensitivity analyses were performed to identify variables driving cost-effectiveness across several willingness-to-pay (WTP) thresholds.

RESULTS

Open thoracotomy was not cost-effective compared to both RAL and VATS lobectomy. From the healthcare sector perspective, RAL was $394.97 more expensive per case than VATS resulting in an ICER of $180,755.10 per QALY. From the societal perspective, RAL was $247.77 more expensive per case than VATS, resulting in an ICER of $113,388.80 per QALY. RAL becomes cost-effective with marginally lower robotic instrument costs, shorter operating room times, lower conversion rates, shorter lengths of stay, higher hospital volumes, and improved quality of life. RAL is also cost-effective if surgeons can increase the proportion of minimally invasive lobectomies using robotic technology.

CONCLUSIONS

Compared to VATS, RAL is not cost-effective for lung cancer lobectomy at lower WTP thresholds. However, several factors may drive RAL to emerge as the more cost-effective approach for minimally invasive lung cancer resection.

Routine Collection of Patient Reported Outcomes in Thoracic Surgery: A Quality Improvement Study

BACKGROUND

Patient reported outcomes (PROs) are critical for delivering high quality surgical care yet they are seldom collected in routine clinical practice. The objective of this quality improvement study was to improve routine PROs collection in a thoracic surgery clinic.

METHODS

Thoracic surgery patients at a single academic institution were prospectively followed from April 2019 to March 2020. The National Institutes of Health (NIH)-validated Patient-Reported Outcomes Measurement Information System (PROMIS) was employed. Using a Model for Improvement design and through multidisciplinary participant observation, multiple plan-do-study-act (PDSA) cycles (an iterative, four-stage model for rapidly testing interventions) were performed to improve routine collection reliability.

RESULTS

Over the study period, a total of 2,315 patient visits occurred. The baseline PROMIS assessment collection rate was 53%. After convening a multidisciplinary stakeholder team, the key drivers for PROMIS collection were having engaged staff, engaged patients, adequate technological capacity, and adequate time for survey completion (including when to complete the survey during the patient visits). Regular meetings between stakeholders were initiated to promote these key drivers. Several PDSA cycles were then employed to test different interventions, resulting in several positive system shifts as demonstrated on statistical process control (SPC) chart. Adherence to survey collection reached 91% of office visits by approximately 7 months, a 72% relative improvement, which was sustained.

CONCLUSIONS

Routine collection of PROs, such as PROMIS, are critical for improving thoracic surgical care. Our study shows that reliably collecting these data is possible in a clinical setting with minimal additional hospital resources.

Similar Quality of Life After Conventional and Robotic Transhiatal Esophagectomy

BACKGROUND

Patient-reported outcomes (PROs) for minimally invasive esophagectomy (MIE) have demonstrated benefits compared to open transthoracic or 3-hole esophagectomy. PROs including quality of life (QoL) and fear of recurrence (FoR) comparing open transhiatal esophagectomy (THE) and transhiatal robotic-assisted MIE (Th-RAMIE) have been limited.

METHODS

At a single, high-volume academic center, patients undergoing THE and Th-RAMIE with gastric conduit for clinical stage I-III esophageal cancer from 2013 to 2018 were evaluated. The European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ-C30), EORTC Quality of Life Questionnaire in Esophageal Cancer (QLQ-OES18), and FoR survey were administered preoperatively, and at 1, 6- and 12-months post-operatively. Linear mixed-effects models were used for QoL and FoR score comparisons. Perioperative outcomes were also compared.

RESULTS

309 patients (212 THE and 97 Th-RAMIE) were included. The Th-RAMIE cohort had a significantly higher number of lymph nodes harvested (14 ±0.8 vs. 11.2 ±0.4; p = 0.01), shorter length of stay (days, 10.0 ± 6.7 vs. 12.1 ±7.0; p = 0.03), lower rates of postoperative ileus (5% vs. 15%; p = 0.02), and had fewer opioids prescribed at discharge (71% vs. 85%; p = 0.03). After adjustment, there were no significant differences in QLQ-C30, QLQ-OES18, and FoR scores between groups out to 1 year following surgery.

CONCLUSIONS

There were no clear patient-reported benefits of Th-RAMIE over THE for esophageal cancer. However, Th-RAMIE conferred a number of perioperative benefits.

A uniportal right upper lobectomy by three-arm robotic-assisted thoracoscopic surgery using the da Vinci (Xi) Surgical System in the treatment of early-stage lung cancer

Minimally invasive techniques, typified by video-assisted thoracoscopic surgery, are widely practiced in the treatment of thoracic diseases all around the world, and video-assisted thoracoscopic surgery has been recognized as a standard treatment method for early staged lung cancer. Among them, robotic-assisted thoracoscopic surgery, which has the advantages of providing a three-dimensional view and better maneuverability, has emerged as a next-generation technique in the field of minimally invasive surgery and is also gaining its popularity with the idea of Enhanced Recovery After Surgery deeply rooted in patients' minds. Up to now, robotic-assisted thoracoscopic surgery usually requires 3 or 4 ports with 1 or 2 additional access incisions. Meanwhile, traditional video-assisted thoracoscopic surgery can now be completed with uniportal method, with less postoperative pain and higher patient satisfaction with respect to the number of incisions in comparison with the multi-port technique. To inform the integration of these new minimally invasive techniques, here, we present a case in which uniportal right upper lobectomy was performed using the 4^th generation da Vinci Robotic Surgical System (Xi). With continuous innovation in robotic minimally invasive techniques and improvements in surgical skills, we believe more patients will benefit from robotic-assisted thoracoscopic surgery with single port in the near future.