Trends and Outcomes of Thoracoscopic Lobectomy or Segmentectomy: A National Surgical Quality Improvement Project Analysis

Diffusion of Minimally Invasive Approach for Lung Cancer Surgery in France: A Nationwide, Population-Based Retrospective Cohort Study

BACKGROUND

The minimally invasive approach (MIA) has gained popularity thanks to its efficacy and safety. Our work consisted of evaluating the diffusion of the MIA in hospitals and the variability of this approach (within and between regions).

METHODS

All patients who underwent limited resection or lobectomy for lung cancer in France were included from the national hospital administrative database (2013-2020). We described between-hospital differences in the MIA rate over four periods (2013-2014, 2015-2016, 2017-2018, and 2019-2020). The potential influence of the hospital volume, hospital type, and period on the adjusted MIA rate was estimated by a multilevel linear regression.

RESULTS

From 2013 to 2020, 77,965 patients underwent a lobectomy or limited resection for lung cancer. The rate of the MIA increased significantly over the four periods (50% in 2019-2020). Variability decreased over time in 7/12 regions. The variables included in the multilevel model were significantly related to the adjusted rate of the MIA. Variability between regions was considerable since 18% of the variance was due to systematic differences between regions.

CONCLUSIONS

We confirm that the MIA is part of the surgical techniques used on a daily basis for the treatment of lung cancer. However, this technology is mostly used by surgeons in high volume institutions.

Lobectomías pulmonares en Colombia: una caracterización demográfica y clínico-patológica

Introducción. La lobectomía pulmonar es uno de los procedimientos más frecuentes en la cirugía torácica en Colombia y a nivel mundial. El objetivo de este estudio fue proporcionar información sobre el comportamiento clínico de los individuos sometidos a este tipo de cirugías. Métodos. Estudio observacional retrospectivo en un Hospital Universitario de Cali, Colombia, que incluyó todos los pacientes sometidos a lobectomía pulmonar, por causas benignas o malignas, entre los años 2010 y 2020. La información se extrajo del registro institucional de cirugía de tórax, obteniendo datos demográficos, clínicos y patológicos. Resultados. Se evaluaron los registros clínicos de 207 individuos. El 55,5 % eran mujeres, la edad promedio fue 58 años y el 41 % tuvieron antecedente de tabaquismo. En el 51,6 % de los casos se diagnosticaron neoplasias, de las cuales el 47,8 % eran primarias de pulmón, siendo el adenocarcinoma el subtipo más común. Las enfermedades benignas no tumorales representaron el 48,3 % de los casos y la causa más frecuente fueron las infecciones, dentro de las que se incluyeron 17 casos de tuberculosis pulmonar. La técnica más frecuente fue la cirugía toracoscópica video asistida (82,6 %). Presentaron un porcentaje de reintervención del 5,8 %, 10,6 % de complicaciones severas y una mortalidad hospitalaria del 4,3 %. Conclusión. La población evaluada muestra una carga alta de comorbilidades y riesgo operatorio elevado; de forma consecuente, al compararla con otras series internacionales, se encontró un porcentaje mayor de complicaciones perioperatorias y mortalidad.

Segmentectomy for clinical stage I non-small cell lung cancer: National benchmarks for nodal staging and outcomes by operative approach

BACKGROUND

Segmentectomy is increasingly used for parenchyma sparing anatomical resection for small stage I non-small cell lung cancer (NSCLC). This study characterizes the national outcomes for lymph node assessment and perioperative outcomes of segmentectomy for clinical stage I NSCLC by robotic-assisted surgery (RATS), video-assisted thoracoscopic surgery (VATS), and open thoracotomy approach.

METHODS

A retrospective cohort study was conducted of patients who underwent segmentectomy for clinical stage I NSCLC captured in the national Society of Thoracic Surgeons General Thoracic Surgery Database between years 2012 and 2018. Inverse probability of treatment weighting (IPTW) was used to balance baseline characteristics. Lymph node (LN) staging and 30-day outcomes were compared by approach.

RESULTS

A total of 3680 patients (VATS 61.9%, RATS 20%, open 18%) underwent segmentectomy. The IPTW adjusted rate of pathologic LN upstaging (pN1/pN2) was 6.2% (RATS 6.3%, VATS 5.6%, open 8.6%; P = .05). On multivariate analysis, there was no differences in pN1/N2 upstaging between RATS (odds ratio [OR], 0.81; 95% confidence interval [CI], 0.44-1.49) or VATS (OR, 0.96; 95% CI, 0.57-1.63) with open segmentectomy. The RATS and VATS approach was associated with fewer postoperative events (RATS 31.3%, VATS 28.8%, open 38.3%; P < .001) and shorter length of stay (RATS 4.3 days, VATS 4.4 days, open 5.2 days; P < .001) as compared with thoracotomy. RATS segmentectomy-specific complications included a higher rate of pneumothorax after chest tube removal and discharge with chest tube. Major complications were lower after RATS and VATS as compared with open segmentectomy (RATS 5.9%, VATS 4.5%, open 7.2%; P = .028).

CONCLUSIONS

Segmentectomy by VATS and robotic approach resulted in similar high rates of lymph node upstaging as a global marker of the quality of lymph node dissection and were associated with lower overall morbidity and shorter length of stay as compared with open thoracotomy. These national outcomes may serve as benchmarks for future comparative studies.

Minimizing postoperative pulmonary complications in thoracic surgery patients

PURPOSE OF REVIEW

Quantification and optimization of perioperative risk factors focusing on anesthesia-related strategies to reduce postoperative pulmonary complications (PPCs) after lung and esophageal surgery.

RECENT FINDINGS

There is an increasing amount of multimorbid patients undergoing thoracic surgery due to the demographic development and medical progress in perioperative medicine. Nevertheless, the rate of PPCs after thoracic surgery is still up to 30-50% with a significant influence on patients' outcome. PPCs are ranked first among the leading causes of early mortality after thoracic surgery. Although patients' risk factors are usually barely modifiable, current research focuses on procedural risk factors. From the surgical position, the minimal-invasive approach using video-assisted thoracoscopy and laparoscopy leads to a decreased rate of PPCs. The anesthesiological strategy to reduce the incidence of PPCs after thoracic surgery includes neuroaxial anesthesia, lung-protective ventilation, and goal-directed hemodynamic therapy.

SUMMARY

The main anesthesiological strategies to reduce PPCs after thoracic surgery include the use of epidural anesthesia, lung-protective ventilation: PEEP (positive end-expiratory pressure) of 5-8 mbar, tidal volume of 5 ml/kg BW (body weight) and goal-directed hemodynamics: CI (cardiac index) ≥ 2.5 l/min per m2, MAD (Mean arterial pressure) ≥ 70 mmHg, SVV (stroke volume variation) < 10% with a total amount of perioperative crystalloid fluids ≤ 6 ml/kg BW (body weight) per hour.

Spanish Video-Assisted Thoracic Surgery Group: Method, Auditing, and Initial Results From a National Prospective Cohort of Patients Receiving Anatomical Lung Resections

INTRODUCTION

Our study sought to know the current implementation of video-assisted thoracoscopic surgery (VATS) for anatomical lung resections in Spain. We present our initial results and describe the auditing systems developed by the Spanish VATS Group (GEVATS).

METHODS

We conducted a prospective multicentre cohort study that included patients receiving anatomical lung resections between 12/20/2016 and 03/20/2018. The main quality controls consisted of determining the recruitment rate of each centre and the accuracy of the perioperative data collected based on six key variables. The implications of a low recruitment rate were analysed for "90-day mortality" and "Grade IIIb-V complications".

RESULTS

The series was composed of 3533 cases (1917 VATS; 54.3%) across 33 departments. The centres' median recruitment rate was 99% (25-75th:76-100%), with an overall recruitment rate of 83% and a data accuracy of 98%. We were unable to demonstrate a significant association between the recruitment rate and the risk of morbidity/mortality, but a trend was found in the unadjusted analysis for those centres with recruitment rates lower than 80% (centres with 95-100% rates as reference): grade IIIb-V OR=0.61 (p=0.081), 90-day mortality OR=0.46 (p=0.051).

CONCLUSIONS

More than half of the anatomical lung resections in Spain are performed via VATS. According to our results, the centre's recruitment rate and its potential implications due to selection bias, should deserve further attention by the main voluntary multicentre studies of our speciality. The high representativeness as well as the reliability of the GEVATS data constitute a fundamental point of departure for this nationwide cohort.

A National Analysis of Minimally Invasive Vs Open Segmentectomy for Stage IA Non-Small-Cell Lung Cancer

The objective of this study was to compare long-term outcomes of open vs minimally invasive (MIS) segmentectomy for early stage non-small-cell lung cancer (NSCLC), which has not been previouslyevaluated using national studies. Outcomes of open vs MIS segmentectomy for clinical T1, N0, M0 NSCLC in the National Cancer Data Base (2010-2015) were evaluated using propensity score matching. Of the 39,351 patients who underwent surgery for stage IA NSCLC from 2010 to 2015, 770 underwent segmentectomy by thoracotomy and 1056 by MIS approach (876 thoracoscopic [VATS], 180 robotic). The MIS to open conversion rate was 6.7% (n = 71). After propensity score matching, all baseline characteristics were well-balanced between the open (n = 683) and MIS (n = 683) groups. When compared to the open group, the MIS group had shorter median length of stay (4 vs 5 days, P< 0.001) and lower 30-day mortality (0.6% vs 1.9%, P = 0.037). There were no significant differences between MIS and open groups with regard to 30-day readmission (5.0% vs 3.7%, P = 0.43), or upstaging from cN0 to pN1/N2/N3 (3.1% vs 3.6%, P = 0.89). The MIS approach was associated with similar long-term overall survival as the open approach (5-year survival: 62.3% vs 63.5%, P = 0.89; multivariable-adjusted hazard ratio: 0.99, 95% Confidence Intervial (CI): 0.82-1.21, P = 0.96). In this national analysis of open vs MIS segmentectomy for clinical stage IA NSCLC, MIS was associated with shorter length of stay and lower perioperative mortality, and similar nodal upstaging and 5-year survival when compared to segmentectomy via thoracotomy. MIS segmentectomy does not appear to compromise oncologic outcomes for clinical stage IA NSCLC.

Is less really more? Reexamining video-assisted thoracoscopic versus open lobectomy in the setting of an enhanced recovery protocol

OBJECTIVES

Video-assisted thoracoscopic surgery lobectomy has been associated with improved pain, length of stay, and outcomes compared with open lobectomy. However, enhanced recovery protocols improve outcomes after both procedures. We aimed to compare video-assisted thoracoscopic surgery and open lobectomy in the setting of a comprehensive enhanced recovery protocol.

METHODS

All patients undergoing lobectomy for lung cancer at a single institution since the adoption of an enhanced recovery protocol (May 2016 to December 2018) were stratified by video-assisted thoracoscopic surgery versus open status and compared. Demographics and outcomes, including length of stay, daily pain scores, and short-term operative complications, were compared using standard univariate statistics and multivariable models.

RESULTS

A total of 130 patients underwent lobectomy, including 71 (54.6%) undergoing video-assisted thoracoscopic surgery and 59 (45.4%) undergoing open surgery. Video-assisted thoracoscopic surgery versus open cases exhibited similar length of stay (median 4 days for both, P = .07), opioid requirement (33.2 vs 30.8 mg morphine equivalents, P = .86), and pain scores at 0, 1, 2, and 3 days after surgery (4.3 vs 2.8, P = .12; 4.4 vs 3.7, P = .27; 3.9 vs 3.5, P = .83; and 3.4 vs 3.5, P = .98, respectively). Patients undergoing video-assisted thoracoscopic surgery lobectomy exhibited lower rates of readmission (1.4% vs 17.0%, P < .01), postoperative transfusion requirement (0% vs 10.2%, P < .01), and pneumonia (1.4% vs 10.2%, P = .05). After risk adjustment, an open procedure (vs video-assisted thoracoscopic surgery status) did not significantly affect the length of stay (effect 0.18; P = .10) or overall complication rate (odds ratio, 1.9; P = .12).

CONCLUSIONS

In the setting of a comprehensive enhanced recovery protocol, patients undergoing video-assisted thoracoscopic surgery versus open lobectomy exhibited similar short-term outcomes. Surgical incision may have less impact on outcomes in the setting of a comprehensive thoracic enhanced recovery protocol.

Prospective, multicenter, international phase 2 trial evaluating ultrasonic energy for pulmonary artery branch sealing in video-assisted thoracoscopic surgery lobectomy

OBJECTIVES

The study objectives were to evaluate the immediate, short-, and medium-term efficacy and safety of pulmonary artery branch sealing using an ultrasonic vessel-sealing device in minimally invasive anatomic lung resection.

METHODS

This study consists of a prospective, phase 2, multicenter, international clinical trial (clinicaltrials.gov: NCT02719717) that enrolled patients planned for video-assisted thoracoscopic surgery/robotic anatomic lung resection in 7 centers (United States, Canada, United Kingdom). Pulmonary artery branches of 7 mm or less were sealed and divided with an ultrasonic energy vessel-sealing device. The remainder of the lobectomy was performed according to surgeon preference. Intraoperative, in-hospital, and 30-day postoperative bleeding and complications were prospectively recorded.

RESULTS

A total of 150 patients with a minimum of 1 pulmonary artery branch sealed with an ultrasonic vessel-sealing device were prospectively enrolled in the trial. Resections included 139 lobectomies and 11 segmentectomies. A total of 424 pulmonary artery branches were divided: 239 with the ultrasonic vessel-sealing device, 181 with endostaplers, and 4 with endoscopic clips. The mean and median pulmonary artery diameters were 4.7 mm/5.0 mm, 10.3 mm/10.0 mm, and 6.5 mm/6.5 mm for each method, respectively. Three of the pulmonary artery branches divided with the ultrasonic vessel-sealing device (1.3%) and 4 pulmonary artery branches divided with endostaplers (2.2%) bled intraoperatively. Among the patients with seal failures, 1 patient required conversion to thoracotomy. There was no postoperative bleeding from divided pulmonary artery branches with either sealing method. There was no mortality at 30 days.

CONCLUSIONS

Pulmonary artery branch sealing with ultrasonic energy during video-assisted thoracoscopic surgery lobectomy is safe for vessels 7 mm or less. The use of an ultrasonic device is a reasonable sealing method for pulmonary artery branches 7 mm or less.

Risk factors for post-operative pulmonary complications in lung cancer patients after video-assisted thoracoscopic lung resection: Results of the German Thorax Registry

OBJECTIVE

Post-operative pulmonary complications (PPCs) represent the most frequent complications after lung surgery. The aim of this study was to identify the modifiable risk factors for PPCs after video-assisted thoracoscopic surgery (VATS) in lung cancer patients.

METHODS

Data of this retrospective study were extracted from the German Thorax Registry, an interdisciplinary and multicenter database of the German Society of Anesthesiology and Intensive care medicine and the German Society of Thoracic Surgery. Univariate and multivariate stepwise logistic regression analysis of patient-specific and procedural risk factors for PPCs were conducted.

RESULTS

We analyzed 376 patients with lung cancer who underwent VATS bilobectomy (n = 2), lobectomy (n = 258) or segmentectomy (n = 116) in 2016 and 2017. One-hundred fourteen patients (114/376; 30%) developed PPCs. Two patients died within 30 days after surgery. In the univariate analysis, patients of the PPC group showed significantly more often a body mass index (BMI) ≤ 19 kg/m² ; a pre-operative forced expiratory volume in 1 second (FEV₁ ) ≤ 60%; a pre-operative arterial oxygen partial pressure (p_a O₂ ) ≤ 60 mm Hg; a higher rate of prolonged duration of surgery (≥2 hours [h]) and a higher frequency of intraoperative blood loss ≥500 mL. The multivariate stepwise logistic regression analysis revealed 4 independent risk factors: FEV₁ ≤ 60% (1.9[1.1-3.4] OR [95% CI], P = 0.029); p_a O₂ ≤ 60 mm Hg (4.6[1.7-12.8] OR [95% CI], P = 0.003; duration of surgery ≥2 hours (2.7[1.5-4.7] OR [95% CI], P = 0.001) and intraoperative crystalloids ≥6 mL/kg/h (2.9[1.2-7.5] OR [95% CI], P = 0.023).

CONCLUSION

Intraoperative amount of crystalloid fluids should be kept below 6 mL/kg/h and duration of surgery should be below 2 hours to avoid an increased risk for PPCs.

Clinical Application of Near-Infrared Thoracoscopy With Indocyanine Green in Video-Assisted Thoracoscopic Anatomical Segmentectomy

Background. To confirm the impact of near-infrared thoracoscopy with intravenous injection of indocyanine green (ICG) during video-assisted thoracic surgery (VATS)-based segmentectomy. Materials and Methods. We retrospectively screened the perioperative data in total 21 patients who underwent segmentectomy by VATS. The segmental arteries and bronchi were identified with the help of preoperative 3-dimensional computed tomography images. Among them, clinical effectiveness and postoperative complications were analyzed. VATS segmentectomy was performed using a 3-port approach with systemic intravenous injection of ICG. Results. A total of 21 patients underwent VATS-based segmentectomy with ICG injection. The mean operation time was 126.19 ± 15.32 minutes, and the mean bleeding volume was 158.10 ± 39.95 mL. In addition, the average drainage volume 1 day after surgery was 153.81 ± 32.19 mL, and mean duration of drainage was 1.62 ± 0.59 days. Complications occurred in 6 of the 21 patients. Two patients had pneumonia, 3 had arrhythmia, and 1 had prolonged air leak. There were no complications resulting from ICG angiography. Conclusions. Near-infrared thoracoscopy with intravenous injection of ICG is a safe, fast, simple, and highly accurate method that can be used to identify the intersegmental plane and facilitate the quality of VATS-based segmentectomy.

A prospective analysis of touch preparation cytology for intraoperative detection of mediastinal lymph node metastases

INTRODUCTION

Patients diagnosed with lung cancer may require immediate evaluation of mediastinal lymph nodes to determine treatment plan. Typically, frozen section (FS) analysis has been used, but this analysis can be time-consuming and uses more tissue than touch preparation (TP) cytologic analysis. TP accuracy has been studied in other organs, but no prospective studies comparing TP to FS have been performed on mediastinal lymph nodes in lung cancer. Our goal was to compare the accuracy of TP to FS in these cases.

MATERIALS AND METHODS

After obtaining institutional review board approval, all patients undergoing mediastinal lymph node evaluation for a diagnosis of lung cancer were asked to participate. If consent was given, TP and FS analyses were performed on all mediastinal lymph node stations in all patients and compared to permanent hematoxylin and eosin analysis. Data were collected prospectively.

RESULTS

Twenty patients were enrolled. Mean age was 67.7 years. Fifty-five percent (11 of 20) of patients were men. The mean number of lymph node stations sampled in each patient was 3.4. In predicting the stage of the patient, TP had a sensitivity and specificity of 95% and 100%, respectively. FS had a lower sensitivity, 85%, and a specificity of 100%. On permanent analysis, metastatic foci ranged in size from 0.15 mm to 1.5 mm.

CONCLUSIONS

TP was more sensitive than FS in detecting mediastinal lymph node metastases. The technical difficulty of obtaining full-thickness sections without creating significant artifact may contribute to the lower sensitivity of FS in detecting micrometastases.