European Society of Thoracic Surgeons expert consensus recommendations on technical standards of segmentectomy for primary lung cancer

A novel 3D image registration technique for augmented reality vision in minimally invasive thoracoscopic pulmonary segmentectomy

PURPOSE

In this feasibility study, we aimed to create a dedicated pulmonary augmented reality (AR) workflow to enable a semi-automated intraoperative overlay of the pulmonary anatomy during video-assisted thoracoscopic surgery (VATS) or robot-assisted thoracoscopic surgery (RATS).

METHODS

Initially, the stereoscopic cameras were calibrated to obtain the intrinsic camera parameters. Intraoperatively, stereoscopic images were recorded and a 3D point cloud was generated from these images. By manually selecting the bifurcation key points, the 3D segmentation (from the diagnostic CT scan) was registered onto the intraoperative 3D point cloud.

RESULTS

Image reprojection errors were 0.34 and 0.22 pixels for the VATS and RATS cameras, respectively. We created disparity maps and point clouds for all eight patients. Time for creation of the 3D AR overlay was 5 min. Validation of the point clouds was performed, resulting in a median absolute error of 0.20 mm [IQR 0.10-0.54]. We were able to visualize the AR overlay and identify the arterial bifurcations adequately for five patients. In addition to creating AR overlays of the visible or invisible structures intraoperatively, we successfully visualized branch labels and altered the transparency of the overlays.

CONCLUSION

An algorithm was developed transforming the operative field into a 3D point cloud surface. This allowed for an accurate registration and visualization of preoperative 3D models. Using this system, surgeons can navigate through the patient's anatomy intraoperatively, especially during crucial moments, by visualizing otherwise invisible structures. This proposed registration method lays the groundwork for automated intraoperative AR navigation during minimally invasive pulmonary resections.

Unforeseen nodal upstaging in patients undergoing segmentectomy without frozen section: a multicenter retrospective cohort study

OBJECTIVE

The study aimed to evaluate the risk of unforeseen nodal upstaging (pN+) after pulmonary segmentectomy without intraoperative frozen section.

METHODS

We conducted a retrospective analysis for consecutive patients who underwent segmentectomy for clinical stage IA1-2 non-small cell lung cancer (cIA1-2 NSCLC) in three centers between January 2017 and December 2022. A backward stepwise logistic regression analysis for variables with P < 0.1 in univariable analysis was performed to predict pN+. Kaplan-Meier analysis with log-rank test evaluated the discrepancy for overall (OS) and recurrence-free survivals (RFS).

RESULTS

Among 478 patients included in the final analysis, 19 (4.0%) had pN+, including 10 (2.1%) pN1, 6 (1.3%) pN2, and 3 (0.6%) pN1+2. With a median follow-up of 23.5 months (interquartile range 12.6-39.0), patients with pN+ had poorer OS compared to those with pN0 (3-year OS: 70.2% vs. 89.7%, P = 0.002). However, there was no significant difference in RFS and recurrence. The maximum standardized uptake value (SUVmax) of tumor in positron emission tomography scan ≥ 4.5 (versus < 4.5) was the only independent factor for pN + (odds ratio 3.5). Patients with a SUVmax ≥ 4.5 had 7.3% pN+, which was associated with poorer OS and similar RFS and recurrence compared to pN0. In contrast, those with a SUVmax < 4.5 had 2.2% pN+, which had comparable recurrence and survival to pN0.

CONCLUSION

Unforeseen nodal upstaging in segmentectomy for cIA1-2 NSCLC is low. Frozen section of lymph nodes may be necessary for lesions with high metabolic activity.

Planning thoracoscopic segmentectomies with 3-dimensional reconstruction software improves outcomes

OBJECTIVES

We investigated whether preoperatively generated models of the anatomy of the lung using 3-dimensional (3D) reconstruction software based on high-resolution computed tomography scans improve surgical and postoperative outcomes after video-assisted thoracoscopic surgery (VATS) segmentectomies.

METHODS

We retrospectively collected data from 100 consecutive patients who signed the general research consent form and underwent VATS segmentectomies between 2018 and 2023. The outcomes and complications of the operations planned with the 3D models were compared to the results of those performed without the models. We used propensity modelling and inverse probability of treatment weighting (IPTW) to analyse the data.

RESULTS

Thirty-seven of the 100 patients included underwent surgery planned using the 3D models. In the 3D group, complex segmentectomies were performed more frequently (89% vs 38%, P < 0.001), and there were markedly fewer conversions to thoracotomy (P = 0.003). The IPTW analysis showed fewer severe complications (Clavien-Dindo grade III or IV) [post-IPTW odds ratio 0.10 (95% confidence interval 0.01-0.87), P = 0.037], and no Clavien-Dindo grade V complications occurred. Additionally, operative planning using models generated from 3D reconstruction software may influence procedural and postoperative parameters, such as the number of segments removed (1.9 ± 1.0 vs 1.7 ± 0.8, P = 0.40), duration of chest tube placement (3.0 days, interquartile range 2.0-4.0 vs 2.0 days, interquartile range 1.0-3.0, P = 0.060), and stay in the intensive/intermediate care unit.

CONCLUSIONS

The planning of complex anatomical VATS segmentectomies using 3D models constructed from 3D reconstruction software significantly reduces the need for conversions to thoracotomy and postoperative complications rates. In addition, complex operations are thereby performed safely.

[Sublobar resection in early-stage NSCLC: towards a new therapeutic standard?]

Until now, the gold standard surgical treatment for early-stage non-small-cell lung cancer (NSCLC) has been pulmonary lobectomy with lymph node dissection. However, several cohort studies have suggested that infra-lobar resection may provide equivalent survival while better preserving quality of life and lung function. The results of two prospective randomized phase III studies comparing sublobar resection (segmentectomy or wedge resection) have recently been published. The JCOG 0802 trial focused on cT1a-b NSCLC and showed significantly better survival in the segmentectomy group, but a higher rate of local recurrence. The CALGB 140503 trial involving stage Ia NSCLC showed no difference in survival and recurrence rate between the two groups. Some questions remain unanswered in these studies, particularly in the CALGB 140503 trial where a majority of patients had an atypical resection. Pending clarification, the complexity of this new surgery calls for oncological rigor in terms of indications and technique, as well as compliance with quality criteria.

Video-Assisted vs. Robotic-Assisted Thoracoscopic Surgery in Lung Cancer: A Comprehensive Review of Techniques and Outcomes

Lung cancer is the primary cause of cancer-related mortality globally; hence, several medical and surgical approaches have been developed for its management. This can be easily recognized with the evolution from the traditional open thoracotomy toward minimally invasive procedures-in particular, video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracoscopic surgery (RATS)-in treating lung cancer. There has been a lot of controversy around the advantages and limitations of these procedures. VATS has been proven to be beneficial in treating early-stage lung cancer. Yet, the restricted mobility of its instruments, as well as the lack of a three-dimensional visualization of anatomical components, make the new RATS desired. RATS uses advanced technology, which has resulted in an exceptional high-definition, three-dimensional image of the working field. This has also led to fine dissection with great precision and accuracy, better lymph node removal, reduced postoperative recovery time, and better outcomes. Compared to VATS, there is less blood loss, shorter hospital stays, and less pleural effusion drainage. Despite its higher cost due to the expensive surgical systems, training and maintenance fees, and longer operative time, RATS has started to gain more use, potentially enhancing patient outcomes as experience and technological improvements progress.

Three-Dimensional Lung Reconstructions for Preoperative Planning of Uniportal Video-Assisted Thoracoscopic Segmentectomies Using Visible Patient Software

In this article, we present the use of 3-dimensional (3D) lung reconstructions performed by Visible Patient software and share our experience with the first 5 patients who were scheduled for a segmentectomy. These reconstructions provided useful insights into more accurate lung nodule locations, resulting in a preoperative change in the surgical plan in 3 of the 5 patients. In addition, surgeons were better prepared for surgery with the preoperative knowledge of anatomical variations identified in 4 patients. These findings highlight the critical role of preoperative 3D lung reconstructions in determining the appropriate surgical indication and refining the surgical plan when thoracoscopic segmentectomy is initially indicated.

Segmentectomy for non-peripheral and peripheral small-sized non-small-cell lung cancer

OBJECTIVES

To compare the oncological outcomes of segmentectomy for non-peripheral versus peripheral small-sized non-small-cell lung cancer (NSCLC).

METHODS

This retrospective observational study included patients with clinical stage IA1-A2 NSCLC who underwent segmentectomy. Patients were separated based on tumour distance index (DI, which was calculated as the ratio of the distance from the entrance of the segmental bronchus to the proximal tumour margin to the distance to the lobar pleura along the same line): non-peripheral group (DI ≤ 2/3) and peripheral group (DI > 2/3). Disease-free survival (DFS) and overall survival were compared with log-rank tests.

RESULTS

850 patients were included, comprising 274 in the non-peripheral group and 576 in the peripheral group. Recurrence occurred in 68 patients (24 in the peripheral group and 44 in the non-peripheral group), and 56 patients died (22 in the peripheral group and 34 in the non-peripheral group). Log-rank tests showed no statistical differences in 5-year DFS (92.2% vs 91.2%) and 5-year overall survival (96.3% vs 93.6%) between the two groups, but higher margin recurrence occurred in the non-peripheral group. Multivariable analysis revealed that age, tumour diameter, consolidation-to-tumour ratios, pathological subtype and pathologic stage were independent risk factors for DFS. Subgroup analysis indicated that patients with a non-peripheral solid NSCLC had a worse 5-year DFS (62.1% vs 76.3%) and a higher margin recurrence rate (13.2% vs 2.0%).

CONCLUSIONS

Segmentectomy for small-sized non-peripheral NSCLC could gain a comparable outcome to the peripheral, but worse DFS and higher margin recurrence occurred in the non-peripheral solid NSCLC.

Extended segmentectomy for intersegmental lesions with intraoperative surgical margin assessment by radiofrequency identification markers

Objective

We developed a technique to determine deep surgical margins using radiofrequency identification markers. This study assessed the feasibility of this technique during extended segmentectomy of intersegmental lesions.

Methods

A single-center, prospective, single-arm study was performed from 2020 to 2023. Small pulmonary lesions suspicious for malignancy locating the virtual intersegmental plane based on 3-dimensional imagery were included. Markers were placed in the vicinity of the lesions using electromagnetic navigation bronchoscopy. In addition to indocyanine green injection, surgeons used wireless signal strength to determine the best resection line without lung palpation to obtain surgical margins of 10 mm or the same size as the tumor.

Results

We analyzed 75 lesions in 75 patients. Median lesion size and depth from the pleura were 12.0 mm and 23.6 mm, respectively. Three-dimensional imagery identified lesions at a median distance of 7.0 mm from the virtual intersegmental plane. The median marker-lesion and marker-virtual intersegmental plane distances were 5.8 mm and 4.9 mm, respectively. Complex segmentectomy was performed in 64 of 75 patients (85.3%). The indocyanine green and preoperative simulated intersegmental lines agreed in 92.0% (69/75). In 6 cases (8.0%), the resection line was determined using radiofrequency identification markers to obtain adequate margins because the indocyanine green undyed area was smaller than the preoperatively simulated one. In 1 patient, planned segmentectomy was converted to lobectomy because of a misplaced radiofrequency identification marker (1.3%). The successful tumor resection rate was 98.7%. The median surgical margin was 16.0 mm.

Conclusions

Use of radiofrequency identification markers enabled precise extended segmentectomy with adequate surgical margins.

Performing High-Quality Sublobar Resections: Key Differences Between Wedge Resection and Segmentectomy

Lung cancer remains the leading cause of cancer-related deaths worldwide. The introduction of targeted treatments and immunotherapy in lung cancer has transformed patient care by offering "precision medicine" focused on the characteristics of the disease. The same concept has emerged in lung cancer surgery. This "precision surgery" aims to determine the best surgical approach based on the characteristics of the cancer, the patient's cardiorespiratory status, and technological advances in thoracic surgery. While lobectomy continues to be the gold standard for managing early-stage lung cancer, the implementation of screening programs has enabled the earlier detection of smaller tumors. In this context, sublobar resections, particularly segmentectomy, have emerged as valuable options in the treatment of early-stage lung cancer. Recent studies suggest that sublobar resections, including segmentectomy and wedge resection, provide a viable alternative to lobectomy. This review explores the various resection strategies available, tailored to patient and tumor characteristics, and highlights modern preoperative techniques aimed at advancing precision surgery.

Optimal planning and management strategies for minimally invasive lung segmentectomies: an international Delphi consensus report

OBJECTIVES

CALGB140503/JCOG0802 RCTs comparing lobectomy with sublobar resection in stage IA NSCLC have confirmed the non-inferiority of segmentectomy. Additional insight is needed to improve preoperative work-up and intraoperative strategies to increase safety and promote the dissemination of minimally invasive segmentectomy (MIS). A Delphi panel study assessed the level of consensus among surgeons for the planning and management of MIS.

METHODS

Twenty-one expert lung surgeons represented academic institutions, major teaching hospitals, and community hospitals from Europe, North America, and Asia. A 3-round Delphi methodology was used to analyse the answers of each panellist. Recognizing that questions with fewer response options have a higher consensus probability due to limited variability, weighted consensus thresholds were modified based on the number of response options.

RESULTS

The 21 panellists responded to all 3 rounds of questions. Based on the most robust consensus (94.4%), 3D chest CT reconstructions are recommended only when planning complex segmentectomies. Surgeons should perform 3D reconstructions chest CT scans (consensus = 83.3%). The most effective and safest technique is image-guided VATS in a hybrid operating room (consensus = 83.3%). Dyes with intravenous administration are the safest technique for identifying the intersegmental plane during MIS (consensus = 72.2%). Augmented/mixed reality will probably not immediately help reduce perioperative complications (consensus = 72.2%).

CONCLUSIONS

This Delphi consensus supports 3D reconstructions and preoperative pulmonary nodule localization before complex MIS. These recommendations should be considered when allocating resources to improve MIS's safety and oncologic efficacy for patients with small, early-stage lung cancers.

Robotic thoracic surgery: lessons learned from the first 1,000 procedures

Introduction

The aim of this study was to evaluate the impact of the thoracic robotic approach in a high-volume center regarding procedures and clinical outcomes after 1,000 procedures.

Methods

In a single-center subset of the Epithor® database, a prospective cohort database of French thoracic surgery, we analyzed procedural characteristics and clinical outcomes from February 2014 to April 2023. A surgical technique for lung surgery was conducted with a four-arm closed chest with the port access approach and vascular sewing and knotting were preferred over stapling. Statistical analysis was performed using the Chi-2 test for discontinuous variables and the Mann-Whitney-Wilcoxon test for continuous variables. Tests were considered significant for a p-value <0.05.

Results

Robotic thoracic surgery was used in anatomical lung resection in 85% of the cases. Over the study period, 1,067 patients underwent robotic surgery, of which 509 had lobectomies and 391 segmentectomies. In the segmentectomy group vs. lobectomy group we observed a shorter length of stay (9 ± 7 vs. 7 ± 5.6 days, p < 0.001), a shorter surgery time (99 ± 24 vs. 116 ± 38 min, p < 0.001) a lower conversion rate (n = 2 vs. n = 17, p = 0.004), and a lower complication rate (28% vs. 40%, p = 0.009, mainly Clavien-Dindo II, 18% and 28%, respectively). For cancer treatment surgery, we found more previous cancer in the segmentectomy group (48% vs. 26%, p < 0.001). We also observed a progressive change of lobectomy vs. segmentectomy from 80%/20% to 30%/70% over the 9 years.

Discussion

A robotic platform is an appropriate tool to perform anatomical lung resection and especially to develop a safe and systematic approach to lung-sparing sub-lobar resection.

Effect of transbronchial or intravenous administration of indocyanine green on resection margins during near-infrared-guided segmentectomy: a review

For early-stage non-small cell lung cancer, surgical resection remains the best treatment option. Currently, sublobar resection, including segmentectomy, is recommended in these cases, as it provides a better quality of life with the same oncological outcomes; however, is requires adequate resection margins. Accurate preoperative planning and proper identification of the intersegmental planes during thoracic surgery are crucial for ensuring precise surgical management and adequate resection margins. Three dimensional computed tomography reconstruction and near-infrared-guided intersegmental plane identification can greatly facilitate the surgical procedures. Three-dimensional computed tomography reconstruction can simulate both the resection and resection margins. Indocyanine green is one of the most frequently used and affordable fluorophores. There are two ways to identify the intersegmental planes using indocyanine green: intravenous and transbronchial administration. Intravenous application is simple; however, its effectiveness may be affected by underlying lung disease, and it requires the isolation of segmental structures before administration. Transbronchial use requires appropriate bronchoscopic skills and preoperative planning; however, it also allows for delineation deep in the parenchyma and can be used for complex segmentectomies. Both methods can be used to ensure adequate resection margins and, therefore, achieve the correct oncological radicality of the surgical procedure. Here, we summarise these applications and provide an overview of their different possibilities.

Feasibility and Safety of Uniportal Thoracoscopic Segmentectomy Using a Unidirectional Dissection Approach without Dissecting a Fissure

Background: Few original articles describe the perioperative outcomes of uniportal thoracoscopic segmentectomy using a unidirectional dissection approach. In this retrospective study, we evaluated the feasibility and safety of this procedure. Methods: This study included 119 patients who underwent uniportal thoracoscopic segmentectomy in our department between February 2019 and December 2022. The patients were divided into unidirectional (group U, n = 28) and conventional (group C, n = 91) dissection approach groups. While the dominant pulmonary vessels and bronchi were transected at the hilum without dissecting a fissure in the unidirectional (U) group, the dominant pulmonary artery was exposed and divided at a fissure in the conventional (C) group. Patient characteristics and perioperative outcomes were compared between groups U and C. Results: The proportions of simple and complex segmentectomies were statistically similar between the groups. The operating time was shorter (group U: 110 [interqurtile range: 90-140] min, group C: 135 [interqurtile range: 105-166] min, p = 0.012) and there was less blood loss (group U: 0 [interqurtile range: 0-0] g, group C: 0 [interqurtile range: 0-50] g, p = 0.003) in group U than in group C. However, there were no significant intergroup differences in other perioperative outcomes. Conclusions: The unidirectional dissection approach in uniportal thoracoscopic pulmonary segmentectomy is safe and feasible and enables a smoother operation.

Self-reported dyspnoea and shortness of breathing deterioration in long-term survivors after segmentectomy or lobectomy for early-stage lung cancer

OBJECTIVES

The aim of this study was to assess the self-reported current dyspnoea and perioperative changes of dyspnoea in long-term survivors after minimally invasive segmentectomy or lobectomy for early-stage lung cancer.

METHODS

Cross-sectional telephonic survey of patients alive and disease-free as of March 2023, with pathologic stage IA1-2, non-small-cell lung cancer, assessed 1-5 years after minimally invasive segmentectomy or lobectomy (performed from January 2018 to January 2022). Current dyspnoea level: Baseline Dyspnoea Index score <10. Perioperative changes of dyspnoea were assessed using the Transition Dyspnoea Index. A negative Transition Dyspnoea Index focal score indicates perioperative deterioration in dyspnoea. Mixed effect models were used to examine demographic, medical and health-related correlates of current dyspnoea and changes in dyspnoea level.

RESULTS

A total of 152 of 236 eligible patients consented or were available to respond to the telephonic interview(67% response rate): 90 lobectomies and 62 segmentectomies. The Baseline Dyspnoea Index score was lower (greater dyspnoea) in lobectomy patients (median 7, interquartile range 6-10) compared to segmentectomy (median 9, interquartile range 6-11), P = 0.034. 70% of lobectomy patients declared to have a current dyspnoea vs 53% after segmentectomy, P = 0.035. 82% of patients after lobectomy reported a perioperative deterioration in their dyspnoea compared to 57% after segmentectomy, P = 0.002. Mixed effect logistic regression analysis adjusting for patient-related factors and time elapsed from operation showed that segmentectomy was associated with a reduced risk of perioperative dyspnoea deterioration (as opposed to lobectomy) (Odds ratio (OR) 0.31, P = 0.004).

CONCLUSIONS

Our findings may be valuable to inform the shared decision-making process by complementing objective data on perioperative changes of pulmonary function.

Complete anatomic segmentectomy shows improved oncologic outcomes compared to incomplete anatomic segmentectomy

OBJECTIVES

To compare oncologic outcomes after segmentectomy with division of segmental bronchus, artery and vein (complete anatomic segmentectomy) versus segmentectomy with division of <3 segmental structures (incomplete anatomic segmentectomy).

METHODS

We conducted a single-centre, retrospective analysis of patients undergoing segmentectomy from March 2005 to May 2020. Operative reports were audited to classify procedures as complete or incomplete anatomic segmentectomy. Patients who underwent neoadjuvant therapy or pulmonary resection beyond indicated segments were excluded. Survival was estimated with Kaplan-Meier models and compared using log-rank tests. Cox proportional hazards models were used to estimate hazard ratios (HRs) for death. Cumulative incidence functions for loco-regional recurrence were compared with Gray's test, with death considered a competing event. Cox and Fine-Gray models were used to estimate cause-specific and subdistribution HRs, respectively, for loco-regional recurrence.

RESULTS

Of 390 cases, 266 (68.2%) were complete and 124 were incomplete anatomic segmentectomy. Demographics, pulmonary function, tumour size, stage and perioperative outcomes did not significantly differ between groups. Surgical margins were negative in all but 1 case. Complete anatomic segmentectomy was associated with improved lymph node dissection (5 vs 2 median nodes sampled; P < 0.001). Multivariable analysis revealed reduced incidence of loco-regional recurrence (cause-specific HR = 0.42; 95% confidence interval 0.22-0.80; subdistribution HR = 0.43; 95% confidence interval 0.23-0.81), and non-significant improvement in overall survival (HR = 0.66; 95% confidence interval: 0.43-1.00) after complete versus incomplete anatomic segmentectomy.

CONCLUSIONS

This single-centre experience suggests complete anatomic segmentectomy provides superior loco-regional control and may improve survival relative to incomplete anatomic segmentectomy. We recommend surgeons perform complete anatomic segmentectomy and lymph node dissection whenever possible.

Minimally invasive segmentectomy and lobectomy for peripheral stage IA1-2 non-small-cell lung cancer: a case-matched cohort study from a UK Centre

OBJECTIVES

The objective of this study is to compare in a real-world series the short- and long-term results of segmentectomy and lobectomy for peripheral clinical stage IA non-small-cell lung cancer (NSCLC).

METHODS

Single-centre cohort study including a series of consecutive patients undergoing minimally invasive segmentectomy or lobectomy for peripheral (outer third of the lung) clinical stage IA NSCLC (January 2017-August 2022). Propensity score case matching analysis generated 2 matched groups of patients undergoing segmentectomy or lobectomy. Short-term (morbidity and mortality) and long-term [overall survival and event-free survival (EFS)] outcomes were compared between the 2 matched groups. EFS was calculated by including death resulting from any cause and any recurrence as events.

RESULTS

Propensity score generated 118 pairs of patients undergoing minimally invasive segmentectomy or lobectomy. The median follow-up was 30 months (95% confidence limits (CL) 4-64). The median postoperative length of stay was 4 days in both groups. Ninety-day mortality was similar (segmentectomy 2.5% versus lobectomy 1.7%, P = 1). Three-year overall survival [segmentectomy 87% (76-93) versus lobectomy 81% (72-88), P = 0.73] and EFS [segmentectomy 82% (72-90) versus lobectomy 78% (68-84), P = 0.52] did not differ between the groups. Loco-regional recurrence rate [segmentectomy 4.2% (5/118) versus lobectomy 9.3% (11/118), P = 0.19] was similar despite a lower nodal upstaging [segmentectomy 3.4% (4/118) versus lobectomy 14% (17/118), P = 0.005]. The occurrence of compromised resection margins (pR1 or pR uncertain) was similar between the groups [segmentectomy 7.6% (9/118) versus lobectomy 9.3% (11/118), P = 0.81].

CONCLUSIONS

This observational series confirms the non-inferiority of segmentectomy compared to lobectomy in treating peripherally located stage IA NSCLC.

Three-Dimensional Imaging-Guided Lung Anatomic Segmentectomy: A Single-Center Preliminary Experiment

Background and objectives: VATS segmentectomy has been proven to be effective in the treatment of stage I NSCLC, but its technical complexity remains one of the most challenging aspects for thoracic surgeons. Furthermore, 3D-CT reconstruction images can help in planning and performing surgical procedures. In this paper, we present our personal experience of 11 VATS anatomical resections performed after accurate pre-operative planning with 3D reconstructions. Materials and methods: A 3D virtual model of the lungs, airways, and vasculature was obtained, starting from a 1.25 mm 3-phase contrast CT scan, and the original images were used for the semi-automatic segmentation of the lung parenchyma, airways, and tumor. Results: Six males and five females were included in this study. The median diameter of the pulmonary lesion at the pre-operative chest CT scan was 20 mm. The surgical indication was confirmed in seven patients: in three cases, a lobectomy, instead of a segmentectomy, was needed due to intraoperative findings of nodal metastasis. Meanwhile, only in one case, we performed a lobectomy because of inadequate surgical resection margins. Skin-to-skin operative average time was 142 (IQR 1-3 105-182.5) min. The median post-operative stay was 6 (IQR 1-3 3.5-7) days. The mean value of the closest surgical margin was 13.7 mm. Conclusion: Image-guided reconstructions are a useful tool for surgeons to perform complex resections in order to spare healthy parenchyma and to ensure disease-free margins. Nevertheless, human skill and surgeon experience still remain fundamental for the final decisions regarding the proper resection to perform.

Differences in selected postoperative outcomes between simple and complex segmentectomies for lung cancer: A systematic review and meta-analysis

BACKGROUND

This systematic review and meta-analysis aimed to synthesize the evidence on the preoperative characteristics, operative outcomes, and postoperative complications of simple and complex segmentectomy for lung cancer.

METHODS

A systematic review of EMBASE (through Ovid), MEDLINE (via PubMed), and Cochrane CENTRAL (January 1990 - January 2023) was done. We included studies to compare simple versus complex segmentectomies for lung cancer in terms of characteristics and operative and postoperative outcomes.

RESULTS

There was a statistically significant difference regarding higher operative time in favor of simple segmentectomies (Mean Difference, MD = 15.76, 95% Confidence Interval, CI: 2.46 - 29.07, p = 0.02). The incidence of postoperative complications did not change between the two groups (Risk Ratio, RR = 0.86, 95% CI: 0.66 - 1.13, p = 0.27). There were no significant differences regarding postoperative length of hospital stay between simple or complex segmentectomies (MD = -0.02, 95% CI: 0.56 - 0.51, p = 0.93).

CONCLUSIONS

Simple and complex segmentectomies have comparable postoperative outcomes; in particular, postoperative complication rates and length of hospital stay were similar. Complex segmentectomies were associated with a longer operative time.

Beyond the Frontline: A Triple-Line Approach of Thoracic Surgeons in Lung Cancer Management-State of the Art

Non-small cell lung cancer (NSCLC) is now described as an extremely heterogeneous disease in its clinical presentation, histology, molecular characteristics, and patient conditions. Over the past 20 years, the management of lung cancer has evolved with positive results. Immune checkpoint inhibitors have revolutionized the treatment landscape for NSCLC in both metastatic and locally advanced stages. The identification of molecular alterations in NSCLC has also allowed the development of targeted therapies, which provide better outcomes than chemotherapy in selected patients. However, patients usually develop acquired resistance to these treatments. On the other hand, thoracic surgery has progressed thanks to minimally invasive procedures, pre-habilitation and enhanced recovery after surgery. Moreover, within thoracic surgery, precision surgery considers the patient and his/her disease in their entirety to offer the best oncologic strategy. Surgeons support patients from pre-operative rehabilitation to surgery and beyond. They are involved in post-treatment follow-up and lung cancer recurrence. When conventional therapies are no longer effective, salvage surgery can be performed on selected patients.