Is VATS lobectomy standard of care for operable non-small cell lung cancer?

Comparison of the effectiveness of two different concentrations of ropivacaine for intrapleural analgesia in reducing stimulatory pain caused by chest tubes after uniportal video-assisted thoracoscopic surgery: a randomised controlled study

BACKGROUND

Pain caused by chest tube placed after uniportal video-assisted thoracoscopic surgery (UVATS) is often neglected. Ropivacaine can be used to alleviate pain related to the chest tube, but the current lowest effective concentration of ropivacaine remains unclear.

METHODS

To investigate the analgesic effect of administering two different concentrations of ropivacaine into the pleural cavity via pleural drainage tube bypass after UVATS. Ninety patients were randomly divided into three groups: Control group (PCIA only), Low-dose group (PCIA combined with intrathoracic infusion of 200 ml 0.25% ropivacaine), Medium-dose group (PCIA combined with intrathoracic infusion of 200 ml 0.5% ropivacaine). The analysis included Visual Analogue Scale (VAS) scores for chest tube-related pain and surgical incision pain at 6 h, 12 h, 24 h, and 48 h post-operation for each group. Compare incidence of adverse reactions (respiratory depression, hypotension, nausea/vomiting, arrhythmia, dizziness) within 48 h.

RESULTS

Compared to the control group, both 0.25% and 0.50% ropivacaine effectively reduced chest tube-related pain (P < 0.001) and surgical incision pain (P < 0.001) at 6 h, 12 h, 24 h, and 48 h postoperatively. However, no significant differences were observed between the two concentrations of ropivacaine in alleviating rest and cough pain related to the chest tube (P > 0.05) or surgical incision (P > 0.05) within 48 h postoperatively. Adverse reaction rates were similar among groups within 48 h postoperatively (P = 0.383).

CONCLUSION

The analgesic effect of ropivacaine infusion with concentrations of 0.25% and 0.50% administered via intrathoracic pumps for chest tube-related pain after UVATS showed no significant difference, but both were superior to the sole use of PCIA.

REGISTRATION

Chinese Clinical Trial Registry ChiCTR2200065184.

Dexmedetomidine and Dexamethasone as Adjuvants to the Local Anesthetic Mixture in Rhomboid Intercostal and Sub-Serratus Block for Video-Assisted Thoracoscopic Surgery: A Randomized, Double-Blind, Controlled Trial

Background

The utilization of adjuvants such as dexamethasone and dexmedetomidine in combination with local anesthetics has proven effective in extending analgesia duration. We aimed to investigate the potential efficacy of combining dexmedetomidine and dexamethasone in rhomboid intercostal and sub-serratus (RISS) block for prolonging postoperative analgesia in patients undergoing video-assisted thoracoscopic surgery (VATS).

Methods

We did this randomized, double-blind, controlled trial in two tertiary-care hospitals. A total of eighty-eight patients undergoing VATS under general anesthesia were enrolled in this study. They were randomly assigned into four groups: ropivacaine (R) group, ropivacaine + dexmedetomidine (RM) group, ropivacaine + dexamethasone (RS) group, or ropivacaine + dexmedetomidine + dexamethasone (RSM) group. The primary outcome measure was the duration of analgesia. Secondary outcomes included Numeric Rating Scale (NRS) scores, cumulative oxycodone consumption, and adverse effects.

Results

The RSM group exhibited a significantly prolonged duration of analgesia at 1073.5 min (932.0-1283.3) compared to the R group with a duration of 154.5 min (80.5-199.3) and the RS group with a duration of 282.0 min (195.3-350.0, P < 0 0.001). The cumulative oxycodone consumption during the 0-12 hours and 0-24-hours period was significantly reduced in the RSM group compared to the R group (P < 0.05). There was also a lower incidence of nausea at 48 hours postoperatively in the RSM group compared to the RM group. However, there were no significant differences between the four groups regarding NRS pain scores.

Conclusion

The combination of ropivacaine, dexmedetomidine, and dexamethasone in RISS block significantly prolongs the duration of postoperative analgesia following VATS.

A new vessel filled and heart-beating human corpse model for VATS lobectomy training

BACKGROUND

Nowadays, video-assisted thoracic surgery (VATS) lobectomy represents the treatment of choice for early-stage lung cancer. Over the years, different methods for VATS training have evolved. The aim of this study is to present an innovative beating-heart filled-vessel cadaveric model to simulate VATS lobectomies.

METHODS

Via selective cannulation of the cadaver heart, the pulmonary vessels were filled with a gel to improve their haptic feedback. An endotracheal tube with a balloon on its tip then allowed movement of the heart chambers, transmitting a minimum of flow to the pulmonary vessels. A simulated OR was created, using all instrumentation normally available during surgery on living patients, with trainees constantly mentored by experienced surgeons. At the end of each simulation, the participants were asked 5 questions on a scale of 1 to 10 to evaluate the effectiveness of the training method ("1" being ineffective and "10" being highly effective).

RESULTS

Eight models were set up, each with a median time of 108 min and a cost of €1500. Overall, 50 surgeons were involved, of which 39 (78%) were consultants and 11 (22%) were residents (PGY 3-5). The median scores for the 5 questions were 8.5 (Q1; IQR1-3 8-9), 8 (Q2; IQR1-3 7-9), 9 (Q3; IQR1-3 8-10), 9 (Q4; IQR1-3 8-10), and 9 (Q5; IQR1-3 8-10). Overall, the model was most appreciated by young trainees even though positive responses were also provided by senior surgeons.

CONCLUSIONS

We introduce a new beating-heart filled-vessel cadaveric model to simulate VATS lobectomies. From this initial experience, the model is cost effective, smooth to develop, and realistic for VATS simulation.

Association of neighborhood socioeconomic disadvantage with use of minimally invasive resection for non-small cell lung cancer

OBJECTIVE

Minimally invasive resection for non-small cell lung cancer has been linked to decreased postoperative morbidity. This work sought to characterize factors associated with receiving minimally invasive surgery for surgically resectable non-small cell lung cancer.

METHODS

All adults undergoing lobectomy/sublobar resection for stage I non-small cell lung cancer were identified using the 2010-2020 National Cancer Database. Those undergoing thoracoscopic/robotic procedures comprised the minimally invasive resection cohort (others: open). Hospitals were stratified by minimally invasive resection procedure volume, with the top quartile considered high minimally invasive resection volume centers. Multivariable models were constructed to assess the independent association between the patients, diseases, and hospital factors and the likelihood of receiving minimally invasive resection.

RESULTS

Of 217,762 patients, 112,304 (52%) underwent minimally invasive resection. The proportion of minimally invasive resection procedures increased from 27% in 2010 to 72% in 2020 (P < .001). After adjustment, several factors were independently associated with decreased odds of receiving minimally invasive resection, including lower quartiles of median neighborhood income (51st-75th percentile adjusted odds ratio, 0.92, 95% CI, 0.89-0.94; 26th-50th percentile adjusted odds ratio, 0.86, CI, 0.83-0.89; 0-25th percentile adjusted odds ratio, 0.78, CI, 0.75-0.81; reference: 76th-100th percentile income) and care at community hospitals (adjusted odds ratio, 0.70, CI, 0.68-0.71; reference: academic centers). Among patients receiving care at high minimally invasive resection volume centers, lowest income remained linked with reduced likelihood of undergoing minimally invasive resection from 2010 to 2015 (adjusted odds ratio, 0.85, CI, 0.77-0.94), but did not alter the odds of minimally invasive resection in later years (adjusted odds ratio, 1.01, CI, 0.87-1.16; reference: highest income).

CONCLUSIONS

This study identified significant community income-based disparities in the likelihood of undergoing minimally invasive resection as definitive surgical treatment. Novel interventions are warranted to expand access to high-volume minimally invasive resection centers and ensure equitable access to minimally invasive surgery.

Impact of minimally invasive lung transplantation on early outcomes and analgesia use: A matched cohort study

BACKGROUND

Minimally invasive (MI) approaches to lung transplantation (LTx) offer the prospect of faster recovery compared to traditional incisions, however, little data exist describing the impact of surgical technique on early outcomes and analgesia use.

METHODS

A prospectively maintained institutional registry identified 170 patients who underwent LTx between January, 2017 and June, 2022. Post-COVID acute respiratory distress syndrome, repeat, and multiorgan transplants were excluded (n = 27) leaving 37 MILTx and 106 traditional LTx patients. Propensity score matching by age, sex, body mass index, diagnosis, lung allocation score, double vs. single lung, hypertension, diabetes, and hospitalization status created 37 pairs.

RESULTS

Before matching, MILTx patients were more often male (70% vs 43%) and more likely to receive grafts from younger (31 vs 42 years), circulatory death donors (19% vs 6%) compared with traditional LTx patients (all p < 0.05). After matching, there were no differences in graft warm ischemia or operative duration (both p > 0.05). Postoperatively, MILTx experienced shorter intensive care unit (ICU) (4.3 [IQR 3.1-5.5] vs 8.2 [IQR 3.7-10.8] days) and hospital lengths of stay (LOS) (13 [IQR 11-15] vs 17 [IQR 12-25] days) (both p < 0.05). Among patients surviving to discharge, MILTx patients required fewer opioid prescriptions at discharge (38% vs 66%, p = 0.008) and had improved pulmonary function at 3 months (Forced expiratory volume in 1 second 82 [IQR 72-102] vs 77 [IQR 52-88]% predicted; forced vital capacity 78 [IQR 65-92] vs 70 [IQR 62-80]% predicted] (both p < 0.05).

CONCLUSION

Minimally invasive LTx techniques demonstrate potential advantages over traditional approaches, including reduced ICU and hospital LOS, lower opioid use on discharge, and improved early pulmonary function.

Development of a Risk Scoring Model to Predict Unexpected Conversion to Thoracotomy during Video-Assisted Thoracoscopic Surgery for Lung Cancer

Background

Unexpected conversion to thoracotomy during planned video-assisted thoracoscopic surgery (VATS) can lead to poor outcomes and comparatively high morbidity. This study was conducted to assess preoperative risk factors associated with unexpected thoracotomy conversion and to develop a risk scoring model for preoperative use, aimed at identifying patients with an elevated risk of conversion.

Methods

A retrospective analysis was conducted of 1,506 patients who underwent surgical resection for non-small cell lung cancer. To evaluate the risk factors, univariate analysis and logistic regression were performed. A risk scoring model was established to predict unexpected thoracotomy conversion during VATS of the lung, based on preoperative factors. To validate the model, an additional cohort of 878 patients was analyzed.

Results

Among the potentially significant clinical variables, male sex, previous ipsilateral lung surgery, preoperative detection of calcified lymph nodes, and clinical T stage were identified as independent risk factors for unplanned conversion to thoracotomy. A 6-point risk scoring model was developed to predict conversion based on the assessed risk, with patients categorized into 4 groups. The results indicated an area under the receiver operating characteristic curve of 0.747, with a sensitivity of 80.5%, specificity of 56.4%, positive predictive value of 1.8%, and negative predictive value of 91.0%. When applied to the validation cohort, the model exhibited good predictive accuracy.

Conclusion

We successfully developed and validated a risk scoring model for preoperative use that can predict the likelihood of unplanned conversion to thoracotomy during VATS of the lung.

Performance of the ENSEAL X1 Curved Jaw Tissue Sealer in thoracic procedures in a Japanese cohort: a case series report

BACKGROUND

Advanced vessel sealing electrosurgical systems have been widely adopted for grasping, cutting, and sealing vessels. Data remain sparse with regard to its use in thoracic procedures. Thus, a prospective case series, utilizing the ENSEAL X1 Curved Jaw Tissue Sealer (X1CJ) and its companion energy source, the Generator 11 (GEN11), in thoracic procedures was performed in a Japanese cohort.

METHODS

Subjects were recruited at two Japanese surgical sites. The primary endpoint of this post-market study was the achievement of hemostasis (≤ Grade 3) for each thoracic vessel transection. Performance endpoints included scores for tasks completed with X1CJ (adhesiolysis, lymphatics or tissue bundles divided, tissue grasping, tissue cutting, or tissue dissection); hemostasis grading vessel transected; additional products required to achieve hemostasis for Grade 4 vessel transections. Safety was evaluated by evaluating device-related adverse events. All endpoint data were summarized.

RESULTS

Forty subjects (50.0% female) of Asian ethnicity with a mean age of 67.6 ± 11.3 years underwent a lung resection. Estimated mean blood loss was 39.5 mL. Hemostasis was achieved in 97.5% of vessel transections. Thirty-seven vessel sealings resulted in a hemostatic Grade 1 (92.5%). All surgeons reported satisfaction/neutral in terms of tissue grasping (100.0%) while most reported satisfaction/neutral with tissue cutting (95.7%). One device-related serious adverse event was reported (2.5%), a chylothorax requiring an extension of hospitalization. There was no post-operative bleeding or deaths reported during the study period.

CONCLUSION

The X1CJ demonstrated safe and effective performance without any reports of significant intra-operative or post-operative hemorrhage in thoracic vessel sealing.

Enhanced recovery after surgery in elderly patients with non-small cell lung cancer who underwent video-assisted thoracic surgery

BACKGROUND

This study was designed to investigate the clinical outcomes of enhanced recovery after surgery (ERAS) in the perioperative period in elderly patients with non-small cell lung cancer (NSCLC).

AIM

To investigate the potential enhancement of video-assisted thoracic surgery (VATS) in postoperative recovery in elderly patients with NSCLC.

METHODS

We retrospectively analysed the clinical data of 85 elderly NSCLC patients who underwent ERAS (the ERAS group) and 327 elderly NSCLC patients who received routine care (the control group) after VATS at the Department of Thoracic Surgery of Peking University Shenzhen Hospital between May 2015 and April 2017. After propensity score matching of baseline data, we analysed the postoperative stay, total hospital expenses, postoperative 48-h pain score, and postoperative complication rate for the 2 groups of patients who underwent lobectomy or sublobar resection.

RESULTS

After propensity score matching, ERAS significantly reduced the postoperative hospital stay (6.96 ± 4.16 vs 8.48 ± 4.18 d, P = 0.001) and total hospital expenses (48875.27 ± 18437.5 vs 55497.64 ± 21168.63 CNY, P = 0.014) and improved the satisfaction score (79.8 ± 7.55 vs 77.35 ± 7.72, P = 0.029) relative to those for routine care. No significant between-group difference was observed in postoperative 48-h pain score (4.68 ± 1.69 vs 5.28 ± 2.1, P = 0.090) or postoperative complication rate (21.2% vs 27.1%, P = 0.371). Subgroup analysis showed that ERAS significantly reduced the postoperative hospital stay and total hospital expenses and increased the satisfaction score of patients who underwent lobectomy but not of patients who underwent sublobar resection.

CONCLUSION

ERAS effectively reduced the postoperative hospital stay and total hospital expenses and improved the satisfaction score in the perioperative period for elderly NSCLC patients who underwent lobectomy but not for patients who underwent sublobar resection.

[Modern individualized diagnostics and treatment of non-small cell lung cancer]

Approximately one half of patients with non-small cell lung cancer (NSCLC) are diagnosed at resectable tumor stages (I-IIIA), which can potentially be curatively treated. In the early tumor stages (tumor diameter ≤2 cm) sublobar resection (segmentectomy or atypical wedge resection) leads to a 5‑year long-term survival comparable to lobectomy. The use of immunotherapy, especially within the framework of neoadjuvant treatment, is anticipated to change the surgical treatment of NSCLC in the future. With the introduction of lung cancer screening for certain risk groups in Germany planned for 2024, lung tumors can be expected to be diagnosed at earlier stages and more frequently curatively treated. This article provides an overview of the potential impact of lung cancer screening, modern minimally invasive surgical techniques and neoadjuvant treatment concepts for the surgical treatment of NSCLC.

Perioperative outcomes in redo VATS for pulmonary ipsilateral malignancy: A single center experience

BACKGROUND

The role of video-assisted thoracoscopic surgery for oncological major pulmonary resections is now well established; however, the literature within pulmonary re-operations is still limited. The purpose of this study is to evaluate the safety and efficacy of redo thoracoscopic resections for ipsilateral pulmonary malignancy.

METHODS

Data from patients undergoing video-assisted thoracoscopic surgery at the Unit of Thoracic Surgery of Padua were analyzed, comparing the results between the first and second ipsilateral surgery. The retrospective study included patients who underwent 2 thoracoscopic surgeries for oncological reasons between 2015 and 2022. The variables considered included patients' baseline characteristics, pre, intra, and postoperative data.

RESULTS

The study enrolled 51 patients undergoing ipsilateral thoracoscopic re-operation. The statistical analysis showed that surgical time (95min vs 115min; p = 0.009), the presence of intrapleural adhesions at second surgery (30 % vs 76 %; p < 0.001), overall pleural fluid output (200 vs 560 ml; p = 0.003), time with pleural drainage (2 vs 3 days; p = 0.027), air leaks duration time (p = 0.004) and post-operative day of discharge (3 vs 4 days; p = 0.043) were significantly higher in the re-operation group. No statistical differences were observed between the 2 groups respect to R0 resection rate (90.2 % vs 89.1 %; p=>0.9) and complications (5.8 % vs 15.6 %; p = 0.11). The conversion rate to open surgery was 11.8 %.

CONCLUSION

Although some differences emerged between the first and second intervention, they had minimal impact on the clinical course of the patients. Therefore, thoracoscopic surgery has been shown to be safe and effective in re-operations with satisfying perioperative outcomes. To achieve such results, these procedures should be reserved for experienced surgeons.

A novel, simple near-infrared thoracoscopic technique by a particular route for locating lung nodules

Background

The localization of pulmonary nodules prior to thoracoscopic surgery remains challenging for thoracic surgeons, especially for those nodules that are not visible or palpable on the lung surface. Our study is a simple and effective minimally invasive method using indocyanine green through a special pathway to locate pulmonary nodules and fluorescence thoracoscopic surgery.

Methods

Thoracoscopic surgery was performed for 18 undiagnosed peripheral non-solid nodules no larger than 2 cm after location. After 0.3 mg/kg indocyanine green was injected through the peripheral vein, the puncture needle was pulled out after it reached approximately 1 cm of the pulmonary parenchyma near the nodules. This was followed by transfer to the operating room. The nodule was initially localized by using a near-infrared thoracoscope to visualize indocyanine green fluorescence. Then, thoracoscopic resection was performed.

Results

Eighteen patients received this special and simple localization method, and underwent near-infrared, image-guided, video-assisted thoracoscopic surgery resection. Median computed tomography (CT) tumor size was 1.2 cm. Median depth from the pleural surface is 1.6 cm (range, 0.1-4.6 cm). The median time of CT-guided intervention was 12 min. The duration of thoracoscopic surgery was 67 min. Indocyanine green fluorescence was clearly identified in 17 of 18 patients (94.4%). The surgical margins were all negative on final pathology. The final diagnoses included 17 primary lung cancers, and 1 benign lung tumor.

Conclusions

CT-guided single puncture of indocyanine green after peripheral intravenous injection is a simple, effective, and safe method to locate the nodule. This offers surgeons the ease of localization through direct indocyanine green fluorescence imaging, and it can be used as an effective alternative to other placement methods of locating pulmonary nodules.

Intraoperative lung ultrasound improves subcentimetric pulmonary nodule localization during VATS: Results of a retrospective analysis

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) resection of deep-seated lung nodules smaller than 1 cm is extremely challenging. Several methods have been proposed to overcome this limitation but with not neglectable complications. Intraoperative lung ultrasound (ILU) is the latest minimally invasive proposed technique. The aim of the current study was to analyze the accuracy and efficacy of ILU associated with VATS to visualize solitary and deep-seated pulmonary nodules smaller than 1 cm.

METHODS

Patients with subcentimetric solitary and deep-seated pulmonary nodules were included in this retrospective study from November 2020 to December 2022. Patients who received VATS aided with ILU were considered as group A and patients who received conventional VATS as group B (control group). The rate of nodule identification and the time for localization with VATS alone and with VATS aided with ILU in each group were analyzed.

RESULTS

A total of 43 patients received VATS aided with ILU (group A) and 31 patients received conventional VATS (group B). Mean operative time was lower in group A (p < 0.05). In group A all the nodules were correctly identified, while in group B in one case the localization failed. The time to identify the lesion was lower in group A (7.1 ± 2.2 vs. 13.8 ± 4.6; p < 0.05). During hospitalization three patients (6.5%; p < 0.05) in group B presented air leaks that were conservatively managed.

CONCLUSION

Intracavitary VATS-US is a reliable, feasible, real-time and effective method of localization of parenchymal lung nodules during selected wedge resection procedures.

Video-assisted thoracoscopic surgery simulation and training: a comprehensive literature review

BACKGROUND

Video-assisted thoracic surgery (VATS) has become the standard for lung cancer diagnosis and treatment. However, this surgical technique requires specific and dedicated training. In the past 20 years, several simulator systems have been developed to promote VATS training. Advances in virtual reality may facilitate its integration into the VATS training curriculum. The present review aims to first provide a comprehensive overview of the simulators for thoracoscopic surgery, focused especially on simulators for lung lobectomy; second, it explores the role and highlights the possible efficacy of these simulators in the surgical trainee curriculum.

METHODS

A literature search was conducted in the PubMed, EMBASE, Science Direct, Scopus and Web of Science databases using the following keywords combined with Boolean operators "AND" and "OR": virtual reality, VR, augmented reality, virtual simulation, mixed reality, extended reality, thoracic surgery, thoracoscopy, VATS, video-assisted thoracoscopic surgery, simulation, simulator, simulators, training, and education. Reference lists of the identified articles were hand-searched for additional relevant articles to be included in this review.

RESULTS

Different types of simulators have been used for VATS training: synthetic lung models (dry simulators); live animals or animal tissues (wet simulators); and simulators based on virtual or augmented reality. Their role in surgical training has been generally defined as useful. However, not enough data are available to ascertain which type is the most appropriate.

CONCLUSIONS

Simulator application in the field of medical education could revolutionize the regular surgical training curriculum. Further studies are required to better define their impact on surgeons' training programs and, finally, on patients' quality of care.

Pulmonary function protection by single-port thoracoscopic segmental lung resection in elderly patients with IA non-small cell lung cancer: A differential matched analysis

In patients with stage IA non-small cell lung cancer (NSCLC), uniportal video-assisted thoracic surgery (U-VATS) anatomical segmentectomy removes the lung tumor while preserving lung function as much as possible, and it is therefore an alternative to lobectomy. Patients with stage IA NSCLC receiving U-VATS segmental resection at our institution from September 2017 to June 2019 were compared with patients receiving U-VATS lobectomy. A total of 47 patients received segmentectomy and 209 patients received U-VATS lobectomy in the same period. Propensity score matching was conducted to diminish bias. The final study cohort included 42 patients who received segmentectomy and 42 propensity score matching-matched patients who received lobectomy. Perioperative parameters and postoperative complications, length of hospital stay, postoperative forced expiratory volume in 1 s (FEV1), and forced vital capacity (FVC) were compared between the 2 groups. Surgery was successfully completed in all patients. The mean follow-up was for 8.2 months. The postoperative complication rate was comparable between the 2 groups: 31.0% in segmentectomy patients versus 35.7% in lobectomy patients (P = .643). At 1 month after surgery, FEV1% and FVC% were not significantly different between the 2 groups (P > .05). At 3 months after surgery, FEV1 and FVC were higher in segmentectomy patients than in lobectomy patients (FEV1, 82.79% ± 6.36% vs 78.55% ± 5.42%; FVC, 81.66% ± 6.09% vs 78.90% ± 5.58%, P < .05). Patients receiving segmentectomy suffer less pain and have better postoperative lung function and higher quality of life.

Retroviral Replicating Vector Toca 511 (Vocimagene Amiretrorepvec) for Prodrug Activator Gene Therapy of Lung Cancer

Therapeutic efficacy of retroviral replicating vector (RRV)-mediated prodrug activator gene therapy has been demonstrated in a variety of tumor models, but clinical investigation of this approach has so far been restricted to glioma and gastrointestinal malignancies. In the present study, we evaluated replication kinetics, transduction efficiency, and therapeutic efficacy of RRV in experimental models of lung cancer. RRV delivering GFP as a reporter gene showed rapid viral replication in a panel of lung cancer cells in vitro, as well as robust intratumoral replication and high levels of tumor transduction in subcutaneous and orthotopic pleural dissemination models of lung cancer in vivo. Toca 511 (vocimagene amiretrorepvec), a clinical-stage RRV encoding optimized yeast cytosine deaminase (yCD) which converts the prodrug 5-fluorocytosine (5-FC) to the active drug 5-fluorouracil (5-FU), showed potent cytotoxicity in lung cancer cells upon exposure to 5-FC prodrug. In vivo, Toca 511 achieved significant tumor growth inhibition following 5-FC treatment in subcutaneous and orthotopic pleural dissemination models of lung cancer in both immunodeficient and immunocompetent hosts, resulting in significantly increased overall survival. This study demonstrates that RRV can serve as highly efficient vehicles for gene delivery to lung cancer, and indicates the translational potential of RRV-mediated prodrug activator gene therapy with Toca 511/5-FC as a novel therapeutic strategy for pulmonary malignancies.

Research Trends and Emerging Hotspots of Lung Cancer Surgery during 2012-2021: A 10-Year Bibliometric and Network Analysis

Background. Lung cancer remains the leading cause of death because of cancer globally in the past years. To inspire researchers with new targets and path-breaking directions for lung cancer research, this study is aimed at exploring the research trends and emerging hotspots in the lung cancer surgery literature in the recent decade.Methods. This cross-sectional study combined bibliometric and network analysis techniques to undertake a quantitative analysis of lung cancer surgery literature. Dimensions database was searched using keywords in a 10-year period (2012-2021). Publications were characterized by publication year, research countries, field citation ratio, cooperation status, research area, and emerging hotspots.Results. Overall, global scholarly outputs of lung cancer surgery had almost doubled during the recent decade, with China, Japan, and the United States leading the way, while Denmark and Belgium predominated in terms of scientific influence. Network analysis showed that international cooperation accounted for a relatively small portion in lung cancer surgery research, and the United States, China, and Europe were the prominent centers of international cooperation network. In the recent decade, research of lung cancer surgery majored in prevention, biomedical imaging, rehabilitation, and genetics, and the emerging research hotspots transformed into immunotherapy. Research on immunotherapy showed a considerable increase in scientific influence in the latest year.Conclusions. The study findings are expected to provide researchers and policymakers with interesting insights into the changing trends of lung cancer surgery research and further generate evidence to support decision-making in improving prognosis for patients with lung cancer.

Near-infrared fluorescence guided surgery: State of the evidence from a health technology assessment perspective

Different applications of near-infrared fluorescence-guided surgery are very promising, and techniques that help surgeons in intraoperative guidance have been developed, thereby bridging the gap between preoperative imaging and intraoperative visualization and palpation. Thus, these techniques are advantageous in terms of being faster, safer, less invasive, and cheaper. There are a few fluorescent dyes available, but the most commonly used dye is indocyanine green. It can be used in its natural form, but different nanocapsulated and targeted modifications are possible, making this dye more stable and specific. A new active tumor-targeting strategy is the conjugation of indocyanine green nanoparticles with antibodies, making this dye targeted and highly selective to various tumor proteins. In this mini-review, we discuss the application of near-infrared fluorescence-guided techniques in thoracic surgery. During lung surgery, it can help find small, non-palpable, or additional tumor nodules, it is also useful for finding the sentinel lymph node and identifying the proper intersegmental plane for segmentectomies. Furthermore, it can help visualize the thoracic duct, smaller bullae of the lung, phrenic nerve, or pleural nodules. We summarize current applications and provide a framework for future applications and development.

Preoperative CT-Guided Near-Infrared Dye Marking for Thoracoscopic Resection of Pulmonary Nodules: A Case Report

Localization of small-sized pulmonary nodules is challenging during video-assisted thoracoscopic surgery. Several preoperative strategies have been developed to mark these targets. We describe our localization strategy using a preoperative computed tomography-guided near-infrared dye marking.

A retrospective and prospective study to establish a preoperative difficulty predicting model for video-assisted thoracoscopic lobectomy and mediastinal lymph node dissection

Background

In previous studies, the difficulty of surgery has rarely been used as a research object. Our study aimed to develop a predictive model to enable preoperative prediction of the technical difficulty of video-assisted thoracoscopic lobectomy and mediastinal lymph node dissection using retrospective data and to validate our findings prospectively.

Methods

Collected data according to the designed data table and took the operation time as the outcome variable. A nomogram to predict the difficulty of surgery was established through Lasso logistic regression. The prospective datasets were analyzed and the outcome was the operation time.

Results

This retrospective study enrolled 351 patients and 85 patients were included in the prospective datasets. The variables in the retrospective research were selected by Lasso logistic regression (only used for modeling and not screening), and four significantly related influencing factors were obtained: FEV1/FVC (forced expiratory volume in the first second/forced vital capacity) (p < 0.001, OR, odds ratio = 0.89, 95% CI, confidence interval = 0.84–0.94), FEV1/pred FEV1 (forced expiratory volume in the first second/forced expiratory volume in the first second in predicted) (p = 0.076, OR = 0.98, 95% CI = 0.95–1.00), history of lung disease (p = 0.027, OR = 4.00, 95% CI = 1.27–15.64), and mediastinal lymph node enlargement or calcification (p < 0.001, OR = 9.78, 95% CI = 5.10–19.69). We used ROC (receiver operating characteristic) curves to evaluate the model. The training set AUC (area under curve) value was 0.877, the test set’s AUC was 0.789, and the model had a good calibration curve. In a prospective study, the data obtained in the research cohort were brought into the model again for verification, and the AUC value was 0.772.

Conclusion

Our retrospective study identified four preoperative variables that are correlated with a longer surgical time and can be presumed to reflect more difficult surgical procedures. Our prospective study verified that the variables in the prediction model (including prior lung disease, FEV1/pred FEV1, FEV1/FVC, mediastinal lymph node enlargement or calcification) were related to the difficulty.

Totally thoracoscopic versus standard VATS lobectomies: perioperative differences

BACKGROUND

Minimally invasive surgery is considered the gold standard approach for early stage lung cancer. Techniques range from a standard three-port approach to uniportal lobectomies, with no technique emerging as superior thus far. We retrospectively compared the pain outcomes of a standard approach using a utility incision with a totally thoracoscopic technique.

METHODS

Between January 2015 and December 2019, 168 patients received a VATS lobectomy in our centers. Two groups were created, Group A (82 patients, totally thoracoscopic approach) and Group B (86 patients, standard approach with utility incision). Perioperative outcomes, such as operative time, complications, length of stay, perioperative and chronic pain using visual analog scale (VAS), and rescue doses of painkillers were examined. A one-way analysis of covariance (ANCOVA) was conducted to investigate the impact of surgical time and days of drainage on VAS score.

RESULTS

Pain was less on postoperative day (POD) 1 and 2 (p = 0.025 and p = 0.020, respectively) in Group A. No differences were found in the baseline and perioperative characteristics of the two groups, in the mean VAS score at 1 month (p = 0.429), 1 year (p = 0.561), doses of NSAIDs (p = 0.609), and chronic pain (3vs7 patients, p = 0.220). The ANCOVA test showed no significant effect of surgical time and days of drainage on VAS score (p > 0.05).

CONCLUSIONS

In our experience, a totally thoracoscopic approach may improve acute postoperative pain without compromising the oncological results of the procedure and the safety of the patients.

Effects of Non-intubated Video-Assisted Thoracic Surgery on Patients With Pulmonary Dysfunction

Background: Non-intubated video-assisted thoracic surgery (NIVATS) can be safely performed in lung volume reduction surgery for patients with severe pulmonary dysfunction. However, there is still no cohort observation on the effects of NIVATS on patients with pulmonary dysfunction undergoing different types of thoracic procedures. This retrospective study aimed to observe the effects of NIVATS for this kind of patients.

Methods: Three hundred and twenty-eight patients with moderate to severe obstructive pulmonary dysfunction, who underwent video-assisted thoracic surgery (VATS), were retrospectively collected from June 1st, 2017 to September 30th, 2019. Patients in NIVATS were case-matched with those in intubated video-assisted thoracic surgery (IVATS) by a propensity score-matched analysis. The primary outcome was the comparison of perioperative values, the secondary outcome was the risk factors for postoperative clinical complications (PCP) which were identified by binary logistic regression analysis.

Results: After being matched, there were no differences in demographics and preoperative values of pulmonary function between NIVATS and IVATS groups. The duration of surgery and anesthesia had no difference (P = 0.091 and P = 0.467). As for the postoperative recovery, except for the mean intensive care unit (ICU) stay was longer in the IVATS group than in the NIVATS group (P = 0.015), the chest tube removal time and the postoperative hospital stay had no difference (P = 0.394 and P = 0.453), and the incidence of PCP also had no difference (P = 0.121). The binary logistic regression analysis revealed that the history of pulmonary disease, anesthesia method, and surgical location were risk factors of PCP.

Conclusion: For patients with pulmonary dysfunction when undergoing different types of thoracic procedures, the NIVATS can be performed as effectively and safely as the IVATS, and can reduce the ICU stay.

Incidence and risk factors of unplanned emergency department visits following thoracic surgery

Background

Unplanned visits for care following a surgical procedure can represent a lapse in quality of care. The purpose of this study was to define the proportion of patients undergoing thoracic surgery who return to the emergency department (ED) within 6 months after discharge and the reasons for the returns. In addition, the risk factors for ED visits after thoracic surgery were identified.

Methods

All adult patients undergoing thoracic surgery at the Leiden University Medical Center between January 1, 2016, and December 31, 2017, were reviewed. To identify potential risk factors for ED return visits, a multivariate regression analysis was performed. A subgroup analysis of patients who reported pain during the ED visit was performed to identify the risk factors for pain-related return to the ED.

Results

Of 277 patients who underwent thoracic surgery, 27.4% (n = 76) returned to the ED within 6 months after discharge. Among these patients, 41 (53.9%) presented with postoperative pain. Younger patients (odds ratio [OR], 0.98; P = .04), those who were operated on through a thoracotomy (OR, 2.92; P = .04), and those reporting a high pain score on the ward (OR, 1.98; P < .001) were at increased risk of returning to the ED.

Conclusions

The rate of patients returning to the ED after thoracic surgery was high. Pain was the most frequently reported reason for unplanned ED visits. The results of this study highlight the need to optimize the postoperative care and the follow-up of patients undergoing thoracic surgery.

Pneumonectomy for lung cancer in the elderly: lessons learned from a multicenter study

Background

60% of patients diagnosed with lung cancer are older than 65 years and are at risk for substandard treatment due to a reluctance to recommend surgery. Pneumonectomy remains a high risk procedure especially in elderly patients. Nevertheless, the impact of age and neoadjuvant treatment on outcomes after pneumonectomy is still not well described.

Methods

We performed a multicentric retrospective study, analyzing outcomes of patients older than 70 years who underwent pneumonectomy for central primary lung malignancy between January 2009 and June 2019 in 7 thoracic surgery departments: Lucerne and Bern (Switzerland), Hamilton (Canada), Alicante (Spain), Monza (Italy), London (UK), Leuven (Belgium). Survival was estimated with Kaplan-Meier, and differences in survival were determined by log-rank analysis. We investigated pre- and post-operative prognostic factors using Cox proportional hazards regression model; multivariable analysis was performed only with variables, which were statistically significant at the invariable analysis.

Results

A total of 136 patients were included in the study. Mean age was 73.8 years (SD 3.6). 24 patients (17.6%) had an induction treatment (chemotherapy alone in 15 patients and chemo-radiation in 9). Mean length of stay (LOS) was 12.6 days (SD 10.39) and 74 patients (54.4%) had experienced a post-operative complication: 29 (21.3%) had a pulmonary complication, 33 (24.3%) had a cardiac complication and in 12 cases (8.8%) patients experienced both cardiac and pulmonary complications. 16 patients were readmitted [median LOS 13.7 days (range, 2–39 days)] and of those 14 (10.3%) required redo surgery. Median overall survival (OS) of the entire cohort was 38 months (95% CI: 29.9–46.1 months); in-hospital mortality was 1.5%, 30-day mortality rate was 3.7%, while 90-day mortality was 8.8% accounting for 5 and 12 patients respectively. Patients receiving neo-adjuvant therapy did not experience a higher incidence of postoperative complications (P=0.633), did not have a longer postoperative course (P=0.588), nor did they have an increased mortality rate (P=0.863).

Conclusions

Age should not be considered an absolute contraindication for pneumonectomy in elderly patients even after neoadjuvant treatment. It has become apparent that especially in these patients, a patient-tailored approach with a careful selection should be used to define the risk-benefit balance.

Comparative Effectiveness of Surgical Approaches for Lung Cancer

BACKGROUND

The magnitude of association and quality of evidence comparing surgical approaches for lung cancer resection has not been analyzed. This has resulted in conflicting information regarding the relative superiority of the different approaches and disparate opinions on the optimal surgical treatment. We reviewed and systematically analyzed all published data comparing near- (30-d) and long-term mortality for minimally invasive to open surgical approaches for lung cancer.

METHODS

Comprehensive search of EMBASE, MEDLINE, and the Cochrane Library, from January 2009 to August 2019, was performed to identify the studies and those that passed bias assessment were included in the analysis utilizing propensity score matching techniques. Meta-analysis was performed using random-effects and fixed-effects models. Risk of bias was assessed via the Newcastle-Ottawa Scale and the ROBINS-I tool. The study was registered in PROSPERO (CRD42020150923) prior to analysis.

RESULTS

Overall, 1382 publications were identified but 19 studies were included encompassing 47,054 patients after matching. Minimally invasive techniques were found to be superior with respect to near-term mortality in early and advanced-stage lung cancer (risk ratio 0.45, 95% confidence interval [CI] 0.21-0.95, I2 = 0%) as well as for elderly patients (odds ratio 0.45, 95% CI 0.31-0.65, I2 = 30%), but did not demonstrate benefit for high-risk patients (odds ratio 0.74, 95% CI 0.06-8.73, I2 = 78%). However, no difference was found in long-term survival.

CONCLUSIONS

We performed the first systematic review and meta-analysis to compare surgical approaches for lung cancer which indicated that minimally invasive techniques may be superior to thoracotomy in near-term mortality, but there is no difference in long-term outcomes.

Application of Mimics Medical 21.0 software in thoracoscopic anatomical sublobectomy

BACKGROUND

The anatomical structure of pulmonary segments is complex, and there are many anatomical variations, making the operation more difficult, so we used Mimics Medical 21.0 software for three-dimensional computed tomography bronchography and angiography (3D-CTBA), carefully formulated the surgical plan and on this basis completed the video-assisted thoracoscopic anatomical sublobectomy.

METHODS

A total of 38 patients with pulmonary nodules were selected and received video-assisted thoracoscopic anatomical sublobectomy after using Mimics Medica 21.0 software for 3D-CTBA.

RESULTS

The mean operative duration was 158.42±20.21 minutes, and the operative hemorrhage was 97.66±22.37 mL. In pathological diagnoses, there were 5 benign cases (13.2%), 9 cases with atypical adenomatous hyperplasia (23.7%), 12 cases with adenocarcinoma in situ (31.6%), 11 cases with minimally invasive adenocarcinoma (28.9%) and 1 case with invasive adenocarcinoma (2.6%); 8.29±0.98 lymph nodes sampled had no metastasis. The chest tube drainage duration and postoperative hospitalstay were 2.47±0.73 days and 5.47±0.73 days, respectively.

CONCLUSIONS

Using Mimics Medical 21.0 software can quickly and accurately complete 3D-CTBA, which is beneficial to formulate a personalized anatomical sublobectomy surgical plan.

Video-assisted thoracoscopic surgery for primary lung cancer resections in patients with moderate to severe chronic obstructive pulmonary diseases

Background

Lung cancer patients with chronic obstructive pulmonary disease (COPD) are considered a high-risk population to receive radical surgical treatment due to the high incidence of cardiopulmonary complications. The aim of this study was to evaluate the clinical factors associated with postoperative complications in primary lung cancer patients with moderate to extremely severe grades of COPD.

Methods

From December 2015 to June 2020, 138 patients with moderate to extremely severe COPD who underwent video-assisted thoracoscopic surgery (VATS) lung cancer resection (lobectomy or sublobar resection) were retrospectively reviewed. Patients' postoperative complications were collected from clinical records. Clinical factors (such as COPD severity or surgical approaches, etc.) were evaluated to investigate the association with postoperative complications.

Results

Of the 138 patients included in the study, the mean age was 67 (63-74) years, the mean preoperative forced expiratory volume in one second (FEV1) was 1.33±0.39 L, the mean FEV1% was 51.23% (41.43-60.00%). 33% patients (46/138) had postoperative complications, and no mortality occurred. Univariate analysis revealed that incidence of overall complications (OCs) and respiratory complications (RCs) was markedly higher in extremely severe COPD patients compared to moderate (OCs, P=0.033; RCs, P=0.050) and severe (OCs, P=0.015; RCs, P=0.008) COPD patients, respectively. Multivariate analysis showed that COPD grade was an independent risk factor of RCs (P=0.024). Furthermore, the grades of COPD (moderate, P=0.029; severe, P=0.028; extremely severe, P=0.019) and the surgical procedure (lobectomy or sublobar resection, P=0.043) were independent risk factors for atelectasis, which was the most common postoperative complication.

Conclusions

The aggravation of COPD was accompanied by an increase in the incidence of respiratory system complications postoperatively, especially atelectasis. For patients with moderate to extremely severe grades of COPD, careful perioperative evaluation should be performed to identify the indicators that influence the surgical choice between lobectomy and sublobar resection.

Watershed analysis of the target pulmonary artery for real-time localization of non-palpable pulmonary nodules

Background

Some pulmonary nodules are not suitable for computed tomography-guided percutaneous localization. This study aimed to investigate the feasibility and safety of real-time localization for these non-palpable pulmonary nodules using watershed analysis of the target pulmonary artery during thoracoscopic wedge resection.

Methods

Watershed analysis is a novel technique that can be used to create a specific area on the lung surface for nodule localization. This analysis is performed by temporarily blocking the target pulmonary artery and using indocyanine green fluorescence during surgery. In our study, the surgery was simulated and evaluated preoperatively using a high-precision three-dimensional reconstruction model obtained by multidetector spiral computed tomography. The lung was observed using an infrared thoracoscopy system after an intravenous injection of indocyanine green (2.5 mg/mL), and the white-to-blue transitional zone was marked using electrocautery, after which a wedge resection was performed.

Results

A total of 25 out of 26 patients underwent successful wedge resection. The mean tumor size and depth based on computed tomography scans were 13.2±6.4 and 12.2±7.8 mm, respectively. The mean operation duration was 142.6±52.8 min. The mean bleeding volume during surgery was 12.9±9.7 mL. The mean drainage tube indwelling time was 35.6±20.0 h, and the median length of postoperative stay was 3 days (range, 2-6 days).

Conclusions

Our experience showed that the watershed analysis of the target pulmonary artery for nodule localization was safe and feasible. It may become an effective and attractive alternative method for localizing non-palpable pulmonary nodules in selected patients undergoing thoracoscopic wedge resection.

Postoperative outcomes, lymph node dissection and effects on costs among thoracotomy, video-assisted and robotic-assisted lobectomy for clinical stage I non-small cell lung cancer

BACKGROUND

Thoracotomy, video-assisted thoracoscopic surgery (VATS) and robotic assisted thoracoscopic surgery (RATS)-lobectomy are widely accepted procedures for the surgical treatment of clinical (c)stage I non- small cell lung cancer (NSCLC). In the current literature which procedure gives more benefits is still debated. We present a comparison between these three procedures in term of advantages and postoperative outcomes.

METHODS

A multicentric study about 259 lobectomies from 2013 to 2019: 128 patients underwent TL, 96 VATS and 35 RATS. Different variables were retrospectively analyzed among these three cohorts of patients with diagnosis of cStage I NSCLC.

RESULTS

Rate of major complications comparable in VATS, RATS and TL; Advantages for RATS in minor complications (TL 34.4% vs. VATS 18.75% vs. RATS 8.57%. P=0.0015), postoperative days in Intensive Care Unit, days to chest tube removal, length of postoperative hospitalization (P<0.0001) and number of lymph nodes dissected (P=0.0257). Operating times are shorter in VATS than RATS (P<0.05). Pain (NRS Scale) is comparable.

CONCLUSIONS

TL remains the conventional approach for stage II-IIIA(N2) NSCLC. RATS showed great advantages, but its higher operating time and costs, mostly, today don't justify its adoption as gold standard for the surgical treatment of cStage I NSCLC, instead of VATS.

Intraoperative conversion during video-assisted thoracoscopy resection for lung cancer does not alter survival

 

OBJECTIVES

The aim of this study was to assess the long-term outcomes of patients treated by anatomical pulmonary resection with the video-assisted thoracoscopic surgery (VATS) approach, VATS requiring intraoperative conversion to thoracotomy or an upfront open thoracotomy for lung cancer surgery.

METHODS

We performed a retrospective single-centre study that included consecutive patients between January 2011 and December 2018 treated either by VATS (with or without intraoperative conversion) or open thoracotomy for non-small-cell lung cancer (NSCLC). Patients treated for a benign or metastatic condition, stage IV disease, multiple primary lung cancer or by resection, such as pneumonectomies or angioplastic/bronchoplastic/chest wall resections, were excluded.

RESULTS

Among 1431 patients, 846 were included: 439 who underwent full-VATS, 94 who underwent VATS-conversion (21 emergent, 73 non-emergent) and 313 treated with upfront open thoracotomy. The median follow-up was 37 months. There were no statistical differences in stage-specific overall survival between the full-VATS, VATS-conversion, and open thoracotomy groups, with 5-year OS for stage I NSCLC of 76%, 72.3% and 69.4%, respectively (P = 0.47). There was a difference in disease-free survival for stage I NSCLC, with 71%, 60.2% and 53%, respectively at 5 years (P = 0.013). Fewer complications occurred in the full-VATS group (pneumonia, arrhythmia, length of stay), but complication rates were similar between the VATS-conversion and thoracotomy groups.

CONCLUSIONS

VATS resection for NSCLC with intraoperative conversion does not appear to alter the long-term oncological outcome relative to full-VATS or open upfront thoracotomy. Postoperative complications were higher than for full-VATS and comparable to those for thoracotomy. VATS should be favoured when possible.

Human corpse model for video-assisted thoracoscopic lobectomy simulation and training

OBJECTIVES

Minimally invasive surgery simulation is an integral part of surgical education and skills acquisition. Our goal was to present a new video-assisted thoracic surgery simulation model based on the human corpse as an alternative to animal models.

METHODS

Selective cannulation of the cadaver heart was used to fill the pulmonary vessels with a gel to improve the visibility and tactile feedback of the vessels and to simulate any bleeding complications. During surgical simulation, the tutor fills out a questionnaire designed to evaluate the duration of the procedure, the correct completion of the surgical steps and the occurrence of complications. At the end of the simulation session, in order to compare the simulation to clinical practice, all the participants were asked to answer 5 questions using a scale from 1 to 10.

RESULTS

We have performed 2 hands-on sessions using 2 human corpses for each session. Each surgeon performed 1 lobectomy using video-assisted thoracoscopic surgery (VATS) first as the operator and at least 1 lobectomy as an assistant. The median operative time was 83 min in favour of surgeons who had previously performed more than 30 video-assisted lobectomies (P = 0.03). All the surgeons were able to complete all the steps of the procedure; surgeons who had performed fewer than 10 lobectomies required more support by the tutors than the other surgeons. The median total score was 40.5 (interquartile range 39-44.8).

CONCLUSIONS

We believe that this model includes most of the features necessary to validate a surgical simulator and allows realistic training for performing a VATS lobectomy. This model could be an effective alternative to anaesthetized animals for VATS lobectomy training and simulation.

Efficacy of Automatic Retention Pressure of a Double-Lumen Tube Cuff: An Artificial Intubation Model

BACKGROUND

The movement of a double-lumen endotracheal tube (DLT) out of its appropriate position during thoracic surgery can result in the loss of one-lung ventilation (OLV), especially during pulmonary resection and node dissection. Our study aimed to validate the efficacy of automatic retention pressure control of the DLT bronchial cuff in maintaining OLV in an artificial intubation model.

MATERIALS AND METHODS

A 35-Fr left-sided DLT was intubated to the left main bronchus in an intubation simulator and connected to an anesthesia machine. The inspiratory volume, respiratory rate, and inspiratory-expiratory ratio were set at 500 mL, 12 times/min, and 1:2, respectively. A 1-kg right main bronchial traction in the lateral right was provided after OLV was established. SmartCuff (Smiths Medical, Minneapolis, Minnesota, USA) was used to maintain cuff pressure. The efficacy of retention pressure with SmartCuff (Group S) and without SmartCuff (Group WS) was compared. The primary outcome was the rate of tidal volume (TV) reduction following bronchial traction in the two groups.

RESULTS

The TVs were 289.8 ± 28.9 mL and 242.8 ± 31.9 mL in Group S and Group WS, respectively (P = 0.003). The rate of TV reduction after bronchial traction was significantly lower in Group S (29 ± 5%) than in Group WS (43 ± 6%) (P < 0.001).

CONCLUSIONS

Automatic retention pressure control of the DLT bronchial cuff improves the rate of TV reduction during right main bronchial traction in an artificial intubation model. Continuous retention cuff pressure may be useful in maintaining OLV during thoracic surgery.

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.

Impact of the integrated comprehensive care program post-thoracic surgery: A propensity score-matched study

OBJECTIVE

Thoracic surgery is associated with significant rates of postoperative morbidity and postdischarge return to the hospital or emergency department (ED). This study aims to assess the impact of a novel integrated patient-centered, hospital-based multidisciplinary community program (Integrated Comprehensive Care [ICC]) on postdischarge outcomes in patients undergoing thoracic surgery compared to routine care.

METHODS

This was a retrospective cohort study of patients who underwent surgical resection for lung malignancies at a tertiary care center from 2010 to 2014. Patients were divided into 2 cohorts based on their enrollment in the ICC program (intervention cohort; 2012-2014) or routine postoperative care (control cohort; 2010-2012). Propensity score matching was performed to match the 2 cohorts. The impact of the ICC program on postoperative length of stay (LOS), rate of ED visits, readmissions, and mortality within the first 60 days was assessed.

RESULTS

Of the 1288 patients included in this study, 658 (51.1%) were male patients with mean age of 64 years (standard deviation 14.1 years). After propensity score matching, 478 patients were enrolled in the ICC cohort and 592 were enrolled as controls. The ICC cohort had significantly shorter LOS (4 days, vs 5 days in controls, P = .001), lower rate of 60-day ED visits (9.8% vs 28.4% in controls, P < .001), and readmissions (6.9% vs 8.6% in controls, P < .001). The 60-day mortality was also significantly lower in the ICC cohort compared with the control group (0.6% vs 0.8% in controls, P < .001).

CONCLUSIONS

The ICC program is associated with shorter LOS, fewer ED visits and readmissions after discharge, and ultimately may decrease postoperative mortality.

Clinical Outcomes And Cost-Effectiveness Of Different Staplers For Lung Lobectomy With Video-Assisted Thoracic Surgery

Purpose

The aim of this study was to compare intra-operative adverse events (AE), post-operative outcomes, and costs of three different types of Echelon staplers (manual activated SC45A and electrical power-activated PSE45A & PSEE60A) used during video-assisted thoracic surgery (VATS) for lung lobectomy.

Patients and methods

We carried out a retrospective chart review of patients undergoing VATS lobectomies using one of three staplers (SC45A, PSE45A, or PSEE60A) during a 2-year period at our institution. We compared intra-operative AEs, post-operative outcomes (drainage volume, chest tube duration, prolonged air leaks [PALs]), endoscopic product costs [ECs], and hospitalization costs [HCs]) amongst the three stapler groups.

Results

In all 204 peripheral lung cancer patients were included in the study (95 in the SC45A group, 72 in the PSE45A group, and 37 in the PSEE60A group). We observed intra-operative AEs in 6 patients of the SC45A group, in 4 of the PSE45A group, and in 1 of the PSEE60A group (P>0.05). Drainage volumes among the three groups were similar. The mean chest tube duration was shorter]st in the PSE45A group followed by those in the PSEE60A and SC45A groups (P<0.05). PALs were lowest in the PSE45A group and highest in the SC45A group (P<0.05). The mean EC in the PSEE60A group was significantly higher than those in the other two groups (P<0.05). We found no statistically significant differences in terms of HCs among groups.

Conclusion

The three endoscopic staplers had similar incidences of intra-operative AEs when used for lobectomy with VATS. Use of the PSE45A stapler was associated with the shortest chest tube duration and least PALs, while use of the PSEE60A resulted in the highest EC rate.

VATS-US1: Thoracoscopic ultrasonography for the identification of nodules during lung metastasectomy

Open thoracotomy during pulmonary metastasectomy allows lung palpation and may discover unexpected further nodules. We assess the validity of intraoperative lung ultrasonography via thoracoscopy in identifying lung nodules. A first surgeon will perform an ultrasonographic investigation on the deflated lung by thoracoscopy. A second surgeon will then perform a manual exploration of the organ by thoracotomy. Data on number and localization of nodules will be matched and compared with final histology report. Sensitivity and specificity will be assessed. Concordance will be assessed with Cohen K test. Calculated sample size is 89 patients. This study might have an important role in shifting the surgical practice towards a less invasive approach, with consequent benefits for the patient. Protocol is registered on clinicaltrials.gov. Protocol registration number: NCT03864874.

Uniportal thoracoscopic pulmonary lobectomy in the treatment of Lung Cancer

OBJECTIVE

To investigate the clinical efficacy of uniportal thoracoscopic pulmonary lobectomy in the treatment of lung cancer.

METHODS

One hundred and ten patients with lung cancer who were admitted to our hospital from February 2017 to June 2018 were enrolled and they were divided into the control group (55 patients) and observation group (55 patients) according to the random number table method. The patients in the observation group received uniportal thoracoscopic pulmonary lobectomy, and patients in the control group underwent triportal thoracoscopic pulmonary lobectomy. The surgical condition, postoperative pulmonary functions, postoperative complication incidence, and postoperative quality of life were compared between the two groups.

RESULTS

The intraoperative blood loss and number of dissected lymph nodes of the observation group were (125.31±12.63) mL and (13.91±2.41) respectively, which were not significantly different with (127.54±13.60) mL and (13.96±2.69) of the control group (P>0.05). The incision length of the observation group was (4.22±0.31) cm, shorter than (6.97±0.42) cm of the control group, the postoperative pain score was (2.87±0.69) points, lower than (4.31±1.09) points of the control group, and the operation time was (195.21±19.42) minutes, longer than (162.68±18.52) min of the control group; the differences were significantly different (P<0.05). The postoperative forced vital capacity (FVC), Maximum Ventilatory Volume (MVV) and Forced Expiratory Volume in 1s (FEV1) in the observation group were (1.90±0.75) L, (54.59±16.03) L/minutes and (1.60±0.53) L respectively, larger than (1.06±0.28) L, (38.41±15.59) L/min and (1.02±0.15) L respectively (P<0.05). The scores of Short Form 36-item Health Survey (SF-36) of patients in the observation group was observed one month after surgery, significantly higher than those in the control group, and the difference was statistically significant (P<0.05). The incidence of complications of the postoperative complication of the observation group was 12.7%, which was not significantly different with 14.5% of the control group (P>0.05).

CONCLUSION

Patients who receive uniportal video-assisted thoracoscopic pulmonary lobectomy have milder trauma, which is beneficial to the lung functions and postoperative recovery. Moreover, the number of dissected lymph nodes in uniportal thoracoscopic pulmonary lobectomy is equivalent with that in triportal thoracoscopic pulmonary lobectomy. Hence it is worth clinical promotion.

Clinical study of video-assisted thoracoscopic surgery wedge resection in early-stage lung cancer by tumor mapping with indocyanine green

Aim

This study aimed to assess the clinical effectiveness of video-assisted thoracoscopic surgery (VATS) in early-stage lung cancer by indocyanine green (ICG) for tumor mapping.

Material and methods

Thirty patients with early-stage lung cancer with peripheral nodules smaller than 2 cm scheduled for computed tomography (CT)-guided microcoil placement followed by ICG tumor mapping by VATS wedge resection were enrolled. After microcoil deployment, 100 to 150 ml of diluted ICG was injected percutaneously near the nodule. The nodule initially was localized solely by using a near-infrared ray (NIR) thoracoscope to visualize ICG fluorescence. Thoracoscopic instruments were used to determine the staple line. Wedge resection was performed after confirmation of the location of the microcoil using fluoroscopy and pathology results.

Results

Thirty patients underwent VATS resection. The median tumor size was 1.3 cm by CT. The median depth from the pleural surface was 1.7 cm (range: 0.5–3.8 cm). The median CT-guided intervention time was 25 min, and VATS procedural time was 50 min. ICG fluorescence was clearly identified in 30 of 30 patients (100%). The surgical margins were all negative on final pathology in all included cases. The final diagnoses were 30 primary lung cancers; none needed additional resection.

Conclusions

CT-guided percutaneous ICG injection and intraoperative NIR localization of small nodules are safe and feasible. These offer surgeons the ease of localization through direct indocyanine green fluorescence imaging without the use of fluoroscopy and may be a complementary technique to preoperative microcoil placement for nonvisible, nonpalpable intrapulmonary nodules.

Video-assisted thoracoscopic surgery versus muscle-sparing thoracotomy for non-small cell lung cancer: a systematic review and meta-analysis

BACKGROUND

It has been widely accepted that video-assisted thoracoscopic surgery (VATS) lobectomy is superior to conventional open thoracotomy lobectomy in many aspects. However, the direct comparison between VATS and Muscle-sparing thoracotomy (MST) has not been widely conducted. We aimed to compare the perioperative outcomes in non-small cell lung cancer (NSCLC) patients following VATS and MST.

METHODS

PubMed, EMBASE, the Cochrane Library and Web of Science were searched for relevant studies. The retrieval time was up to April 24, 2019. Studies investigating the comparison of video-assisted thoracoscopy and muscle-sparing thoracotomy were included in our meta-analysis. Odds ratio and mean differences with 95% confidential interval were applied to determine the effectiveness of dichotomous or continuous variables respectively.

RESULTS

A total of 10 studies were included with 1514 patients. Compared with MST, the incidence of postoperative complications in VATS [OR = 0.54; 95%CI(0.4, 0.73); P < 0.001] and the hospital stay [MD = -1.5; 95%CI(- 2.28, - 0.73); P = 0.0001] decreased significantly, chest tube drainage time [MD = -0.71; 95%CI(- 1.18, - 0.24); P = 0.003] were shorter and the intraoperative blood loss [MD = - 43.87; 95%CI(- 73.66, - 14.08); P = 0.004] were less in VATS group. VATS also showed a relatively longer operative time [MD = 17.11; 95%CI(2.38, 31.85); P = 0.02]. However, no significant differences were observed in numbers of resected lymph nodes, postoperative mortality, postoperative pneumonia and postoperative bleeding.

CONCLUSION

Compared with MST, VATS was associated with lower incidence of postoperative complications, shorter length of hospital stay, less intraoperative blood loss and less chest tube drainage, which showed that VATS was a comparable method to MST. Meanwhile, these results should be further conformed by more randomized control trials.

Thoracotomy and VATS Surgery in Local Non-Small-Cell Lung Cancer: Differences in Long-Term Health-Related Quality Of Life

BACKGROUND

As a result of routine low-dose computed tomographic screening, lung cancer is more frequently diagnosed at earlier, operable stages of disease. In treating local non-small-cell lung cancer, video-assisted thoracoscopic surgery (VATS), a minimally invasive surgical approach, has replaced thoracotomy as the standard of care. While short-term quality-of-life outcomes favor the use of VATS, the impact of VATS on long-term health-related quality of life (HRQoL) is unknown.

PATIENTS AND METHODS

We studied patients who underwent lobectomy for the treatment of non-small-cell lung cancer from January 2006 to January 2013 at a single institution (n = 456). Patients who underwent segmentectomy (n = 27), who received neoadjuvant therapy (n = 13), or who were found to have clinical stage > T2 or > N0 disease (n = 45) were excluded from analysis. At time of HRQoL assessment, 199 patients were eligible for study and were mailed the generic HRQoL instrument 15D.

RESULTS

A total of 180 patients (90.5%) replied; 92 respondents underwent VATS while 88 underwent open thoracotomy. The VATS group more often had adenocarcinoma (P = .006), and lymph node stations were sampled to a lesser extent (P = .004); additionally, hospital length of stay was shorter among patients undergoing VATS (P = .001). No other clinical or pathologic differences were observed between the 2 groups. Surprisingly, patients who underwent VATS scored significantly lower on HRQoL on the dimensions of breathing, speaking, usual activities, mental function, and vitality, and they reported a lower total 15D score, which reflects overall quality of life (P < .05).

CONCLUSION

In contrast to earlier short-term reports, long-term quality-of-life measures are worse among patients who underwent VATS compared to thoracotomy.

Saving the split: the benefits of VATS thymectomy

Background

With the advent of minimally invasive techniques, the standard approaches to many surgeries have changed. We compared the financial costs and health care outcomes between standard thymectomy via sternotomy and video assisted thoracoscopic surgery (VATS).

Methods

A 3-year review [2010-2012] of the National Inpatient Sample (NIS) was performed. All patients undergoing thymectomy were included. Patients undergoing VATS thymectomy were identified. Outcomes measured were hospital length of stay (LOS), hospital charges, and mortality. Univariate and multivariate analyses were performed to control for demographics and comorbidities.

Results

The results of 2,065 patients who underwent thymectomy were analyzed, of which 373 (18.1%) had VATS thymectomy and 1,692 (81.9%) had standard thymectomy. Mean age was 52.8±16, 42.5% were male, and 65.5% were Caucasian. There was a significant interval increase in number of patients undergoing VATS thymectomy (10% in 2010 vs. 19.2% in 2012, P<0.001). Patients undergoing standard thymectomy had longer hospital LOS (6.8±6.6 vs. 3.3d±3.4 d, P<0.001), hospital charges $88,838±$120,892 vs. $57,251±$54,929) and hospital mortality (0.9% vs. 0%, P=0.01). In multivariate analysis, thymectomy via sternotomy was independently associated with increased hospital LOS B =1.6 d, P<0.001) and charges (B = $13,041, P=0.041).

Conclusions

Our study demonstrates decreased hospital length of stay and reduced hospital charges in patients undergoing VATS thymectomy compared to standard thymectomy. Our data demonstrates that the prevalence of VATS thymectomies is increasing, likely related to improved healthcare and financial outcomes.

Video-assisted thoracic surgery ultrasound (VATS-US) in the evaluation of subpleural disease: preliminary report of a systematic study

We provide a pictorial essay examining the preliminary data of an ongoing study whose primary aim is to assess the usefulness and safety of video-assisted thoracic surgery ultrasound (VATS-US) in the identification of different lung diseases. We studied 14 patients (five women and nine men with a mean age of 56.2 ± 8.4 SD years) with indication for VATS. All patients underwent pre-operative imaging of the chest using high-resolution computed-tomography, contrast-enhanced computed-tomography, and/or positron emission tomography and transthoracic ultrasound. VATS-US was performed under general anesthesia with single-lung ventilation through double-lumen endotracheal intubation in all patients, and the Esaote MyLab 25 laparoscope probe with flexible tip and a linear array transducer at frequencies 8.0-12.0 MHz was used. The final histological diagnoses in our cohort were cancer (three cases), usual interstitial pneumonia (five cases), nonspecific interstitial pneumonia (two cases), and hypersensitivity pneumonitis (one case). In patients with pulmonary fibrosis, the VATS-US showed a thick hyperechoic pleural line and no B-lines. Regarding cancer nodules, the VATS-US images showed a uniform hypoechogenic pattern with jagged margins. In patients with hamartochondroma and histocytosis X, VATS-US showed a mixed hyperechoic structure of the margins. In conclusion, we described the US semeiotics of various lung disorders assessed during VATS by reporting the preliminary data of the first study which applies the methodology systematically to all patients undergoing the surgery procedure. Final results from the study will further elucidate how the technique could be of use during the VATS procedure.