Preoperative fractional exhaled nitric oxide is a risk and predictive factor of postoperative cough for early-stage non-small cell lung cancer patients: a longitudinal study

BACKGROUND

To determine whether preoperative fractional exhaled nitric oxide (FENO) level is a risk and predictive factor of postoperative cough by using the Leicester Cough Questionnaire in Mandarin-Chinese (LCQ-MC).

METHODS

292 early-stage non-small cell lung cancer (NSCLC) patients without preoperative cough were enrolled. 138 patients (47.2%) developed postoperative cough, univariate and multivariate logistic regression analysis were performed to identify the independent risk factors of postoperative cough. For an exploratory analysis, patients with cough were divided into low and high- FENO [≥ 31 parts per billion (ppb)] groups. The LCQ-CM was used to evaluate changes and recovery trajectory of postoperative cough over time between the two groups for 12 months after surgery.

RESULTS

The independent factors of postoperative cough included preoperative FENO level [odds ratio (OR) 1.106, 95% confidence interval (CI): 1.076-1.137, p < 0.001] and duration of anesthesia (OR 1.008, 95% CI: 1.002-1.013, p = 0.004). The low-FENO group reported significantly higher LCQ-MC scores at 1 month after surgery and returned to preoperative physical (28 vs. 91 days), psychological (28 vs. 60 days), social (28 vs. 80 days) and total (28 vs. 91 days) scores faster than the high-FENO group (all p < 0.05).

CONCLUSION

Higher preoperative FENO level and longer duration of anesthesia were independent risk factors related to postoperative cough. Additionally, patients with high preoperative FENO level had worse cough-related quality of life and slower recovery from postoperative cough.

TRIAL REGISTRATION

This study was approved by the Chinese Clinical Trial Registry (Clinicaltrials.gov number: ChiCTR1900023419) on 26 May 2019 and the first patient was enrolled after pre-registration.

[Management of adult bronchiectasis - Consensus-based Guidelines for the German Respiratory Society (DGP) e. V. (AWMF registration number 020-030)]

Bronchiectasis is an etiologically heterogeneous, chronic, and often progressive respiratory disease characterized by irreversible bronchial dilation. It is frequently associated with significant symptom burden, multiple complications, and reduced quality of life. For several years, there has been a marked global increase in the prevalence of bronchiectasis, which is linked to a substantial economic burden on healthcare systems. This consensus-based guideline is the first German-language guideline addressing the management of bronchiectasis in adults. The guideline emphasizes the importance of thoracic imaging using CT for diagnosis and differentiation of bronchiectasis and highlights the significance of etiology in determining treatment approaches. Both non-drug and drug treatments are comprehensively covered. Non-pharmacological measures include smoking cessation, physiotherapy, physical training, rehabilitation, non-invasive ventilation, thoracic surgery, and lung transplantation. Pharmacological treatments focus on the long-term use of mucolytics, bronchodilators, anti-inflammatory medications, and antibiotics. Additionally, the guideline covers the challenges and strategies for managing upper airway involvement, comorbidities, and exacerbations, as well as socio-medical aspects and disability rights. The importance of patient education and self-management is also emphasized. Finally, the guideline addresses special life stages such as transition, family planning, pregnancy and parenthood, and palliative care. The aim is to ensure comprehensive, consensus-based, and patient-centered care, taking into account individual risks and needs.

Mini-Invasive Thoracic Surgery for Early-Stage Lung Cancer: Which Is the Surgeon's Best Approach for Video-Assisted Thoracic Surgery?

Objectives: The choice of the best Video-Assisted Thoracic Surgery (VATS) surgical approach is still debated. Surgeons are often faced with the choice between innovation and self-confidence. The present study reports the experience of a high-volume single institute, comparing data of uni-portal, bi-portal and tri-portal VATS, to find out the safest and most effective mini-invasive approach, leading surgeon's choice. Methods: Between 2015 and 2022, a total of 210 matched patients underwent VATS lobectomy for early-stage cancer, using uni-portal (fifth intercostal space), bi-portal (seventh space for optic and the fifth), and tri-portal (seventh and the fifth/four) access. Patients were matched for age, BPCO, smoke, comorbidities, lesions (size and staging) to obtain three homogenous groups (A: uni-portal; B: bi-portal; C: tri-portal). The surgeons had comparable expertise. Data were retrospectively collected from institutional database and analyzed. Results: No differences were detected considering time of surgery, length of hospital stay, complications, conversion rate, specific survival, and days of chest tube length of stay. Better results on chest tube removal were described in group A (mean 1.1 days) compared to B (mean 2.6 days) and C (mean 4.7 days); nevertheless, they not statistically significant (p = 0.106). Conclusions: No significant differences among the groups were described, except for the reduction in chest tube permanence in group A. This allows to hypothesize an enhanced recovery after surgery in this group but the different approaches in this series seem to guarantee comparable safety and effectiveness. Considering no superiority of one method above the others, the best suggested approach should be the one for which the surgeon feels more confident.

Video-Assisted vs Robotic-Assisted Lung Lobectomies for Operating Room Resource Utilization and Patient Outcomes

Importance

With increased use of robots, there is an inadequate understanding of minimally invasive modalities' time costs. This study evaluates the operative durations of robotic-assisted vs video-assisted lung lobectomies.

Objective

To compare resource utilization, specifically operative time, between video-assisted and robotic-assisted thoracoscopic lung lobectomies.

Design, Setting, and Participants

This retrospective cohort study evaluated patients aged 18 to 90 years who underwent minimally invasive (robotic-assisted or video-assisted) lung lobectomy from January 1, 2020, to December 31, 2022, with 90 days' follow-up after surgery. The study included multicenter electronic health record data from 21 hospitals within an integrated health care system in Northern California. Thoracic surgery was regionalized to 4 centers with 14 board-certified general thoracic surgeons.

Exposures

Robotic-assisted or video-assisted lung lobectomy.

Main Outcomes and Measures

The primary outcome was operative duration (cut to close) in minutes. Secondary outcomes were length of stay, 30-day readmission, and 90-day mortality. Comparisons between video-assisted and robotic-assisted lobectomies were generated using the Wilcoxon rank sum test for continuous variables and the χ2 test for categorical variables. The average treatment effects were estimated with augmented inverse probability treatment weighting (AIPTW). Patient and surgeon covariates were adjusted for and included patient demographics, comorbidities, and case complexity (age, sex, race and ethnicity, neighborhood deprivation index, body mass index, Charlson Comorbidity Index score, nonelective hospitalizations, emergency department visits, a validated laboratory derangement score, a validated institutional comorbidity score, a surgeon-designated complexity indicator, and a procedural code count), and a primary surgeon-specific indicator.

Results

The study included 1088 patients (median age, 70.1 years [IQR, 63.3-75.8 years]; 704 [64.7%] female), of whom 446 (41.0%) underwent robotic-assisted and 642 (59.0%) underwent video-assisted lobectomy. The median unadjusted operative duration was 172.0 minutes (IQR, 128.0-226.0 minutes). After AIPTW, there was less than a 10% difference in all covariates between groups, and operative duration was a median 20.6 minutes (95% CI, 12.9-28.2 minutes; P < .001) longer for robotic-assisted compared with video-assisted lobectomies. There was no difference in adjusted secondary patient outcomes, specifically for length of stay (0.3 days; 95% CI, -0.3 to 0.8 days; P = .11) or risk of 30-day readmission (adjusted odds ratio, 1.29; 95% CI, 0.84-1.98; P = .13). The unadjusted 90-day mortality rate (1.3% [n = 14]) was too low for the AIPTW modeling process.

Conclusions and Relevance

In this cohort study, there was no difference in patient outcomes between modalities, but operative duration was longer in robotic-assisted compared with video-assisted lung lobectomy. Given that this elevated operative duration is additive when applied systematically, increased consideration of appropriate patient selection for robotic-assisted lung lobectomy is needed to improve resource utilization.

Learning curve of robotic surgery for lung cancer: analysis for two surgeons during the COVID-19 pandemic

OBJECTIVE

To describe and compare the RATS learning curve between two surgeons in one department for lung cancer surgery using the CUSUM method.

METHODS

Retrospective analysis using a prospective database on robotic-assisted lung resections performed by two different surgeons in one hospital. The CUSUM method was used to describe the learning curve.

RESULTS

366 consecutives cases were analysed (195 for the first surgeon and 171 for the second surgeon). A traditional 3-phase pattern learning curve was found with a diminution of the operating time throughout the different phases. For Surgeon 1, phase 1 was from case 1 to 59, phase 2 from case 60 to 99 and phase 3 started at case 100. For Surgeon 2, phase 1 was from 1 to 44, phase 2 from case 45 to 79 and phase 3 started at case 80.

CONCLUSION

This study described our first experience with the Da Vinci Robotic System in our department. The curves had a similar shape which shows the learning curve of robotic surgery using the CUSUM method is reproducible. Furthermore, our results showed that the learning curve may improve after the programme starts in the department when the different team elements are all trained.

Thoracoscopic Intercostal Nerve Block with Cocktail Analgesics for Pain Control After Video-Assisted Thoracoscopic Surgery: A Prospective Cohort Study

OBJECTIVE

To evaluate whether using a cocktail of intercostal nerve blocks (TINB) during thoracoscopic surgery results in better clinical outcomes than patient-controlled analgesia (PCIA).

METHODS

Patients in two medical groups undergoing video-assisted thoracoscopic surgery (VATS) for pulmonary nodules in West China Hospital of Sichuan University were collected consecutively between March 2022 and December 2022. The groups were divided into two subgroups based on their analgesic program, which were TINB group and PCIA group. The primary outcome was the visual analogue scale (VAS) of the two groups at different stage after surgery and after discharge. Any analgesic related adverse events (ARAEs) were also recorded.

RESULTS

A total of 230 patients who underwent VATS were enrolled, in which 113 patients (49.1%) received a cocktail TINB after surgery, and 117 patients (50.9%) received a PCIA. After PSM, 62 patients in each group were selected. The difference of resting VAS (RVAS) and active VAS (AVAS) at different stage during hospitalization was only related to the change of period (p < 0.05, p < 0.05), and the two groups showed no significant differences in RVAS or AVAS during hospitalization (p = 0.271, p = 0.915). However, the rates of dizziness (4.84% vs 25.81%, p = 0.002), nausea and vomiting (0 vs 22.58%, p < 0.05), fatigue (14.52% vs 34.87%, p = 0.012), and insomnia (0 vs 58.06%, p < 0.05) in TINB group were lower than that in PCIA group. Besides, AVAS and RVAS at 7, 14, and 30 days after discharge in TINB group were both significantly lower than that in PCIA group (p < 0.05, p < 0.05).

CONCLUSION

Cocktail TINB provided better analgesia after discharge and reduced the incidence of ARAEs in patients undergoing VATS.

Factors associated with overdiagnosis of benign pulmonary nodules as malignancy: a retrospective cohort study

OBJECTIVE

To establish a preoperative model for the differential diagnosis of benign and malignant pulmonary nodules (PNs), and to evaluate the related factors of overdiagnosis of benign PNs at the time of imaging assessments.

MATERIALS AND METHODS

In this retrospective study, 357 patients (median age, 52 years; interquartile range, 46-59 years) with 407 PNs were included, who underwent surgical histopathologic evaluation between January 2020 and December 2020. Patients were divided into a training set (n = 285) and a validation set (n = 122) to develop a preoperative model to identify benign PNs. CT scan features were reviewed by two chest radiologists, and imaging findings were categorized. The overdiagnosis rate of benign PNs was calculated, and bivariate and multivariable logistic regression analyses were used to evaluate factors associated with benign PNs that were over-diagnosed as malignant PNs.

RESULTS

The preoperative model identified features such as the absence of part-solid and non-solid nodules, absence of spiculation, absence of vascular convergence, larger lesion size, and CYFRA21-1 positivity as features for identifying benign PNs on imaging, with a high area under the receiver operating characteristic curve of 0.88 in the validation set. The overdiagnosis rate of benign PNs was found to be 50%. Independent risk factors for overdiagnosis included diagnosis as non-solid nodules, pleural retraction, vascular convergence, and larger lesion size at imaging.

CONCLUSION

We developed a preoperative model for identifying benign and malignant PNs and evaluating factors that led to the overdiagnosis of benign PNs. This preoperative model and result may help clinicians and imaging physicians reduce unnecessary surgery.

Spontaneous Ventilation Combined with Double-Lumen Tube Intubation during Thoracic Surgery: A New Anesthesiologic Method Based on 141 Cases over Three Years

BACKGROUND

Non-intubated thoracic surgery has not achieved widespread acceptance despite its potential to improve postoperative outcomes. To ensure airway safety, our institute has developed a technique combining spontaneous ventilation with double-lumen tube intubation (SVI). This study aimed to verify the feasibility and limitations of this SVI technique.

METHODS

For the SVI method, anesthesia induction involves fentanyl and propofol target-controlled infusion, with mivacurium administration. Bispectral index monitoring was used to ensure the optimal depth of anesthesia. Short-term muscle relaxation facilitated double-lumen tube intubation and early surgical steps. Chest opening preceded local infiltration, followed by a vagal nerve blockade to prevent the cough reflex and a paravertebral blockade for pain relief. Subsequently, the muscle relaxant was ceased. The patient underwent spontaneous breathing without coughing during surgical manipulation.

RESULTS

Between 10 March 2020 and 28 October 2022, 141 SVI surgeries were performed. Spontaneous respiration with positive end-expiratory pressure was sufficient in 65.96% (93/141) of cases, whereas 31.21% (44/141) required pressure support ventilation. Only 2.84% (4/141) of cases reversed to conventional anesthetic management, owing to technical or surgical difficulties. Results of the 141 cases: The mean maximal carbon dioxide pressure was 59.01 (34.4-92.9) mmHg, and the mean lowest oxygen saturation was 93.96% (81-100%). The mean one-lung, mechanical and spontaneous one-lung ventilation time was 74.88 (20-140), 17.55 (0-115) and 57.73 (0-130) min, respectively.

CONCLUSIONS

Spontaneous ventilation with double-lumen tube intubation is safe and feasible for thoracic surgery. The mechanical one-lung ventilation time was reduced by 76.5%, and the rate of anesthetic conversion to relaxation was low (2.8%).

Minimally invasive approaches for en-bloc anatomical lung and chest wall resection

Background

The aim of this study was to evaluate the feasibility of en-bloc anatomical lung and chest wall resection via minimally invasive surgery.

Methods

Between January 2013 and December 2021, a total of 22 patients (18 males, 4 females; mean age: 63±6.9 years; range, 48 to 78 years) who underwent anatomical lung and chest wall resection using minimally invasive surgery for non-small cell lung cancer were retrospectively analyzed. Demographic, clinical, intra- and postoperative data of the patients, recurrence, metastasis, mortality, and overall survival rates were recorded.

Results

The surgical technique was robot-assisted thoracic surgery in two, multiport video-assisted thoracoscopic surgery in 18, and uniport video-assisted thoracoscopic surgery in two patients. Upper lobectomy was performed in 17 (77.3%) patients, lower lobectomy in three (13.6%) patients, and upper lobe segmentectomy in two (9.1%) patients. Five different techniques were used for chest wall resection. Nine (40.9%) patients had one, eight (36.4%) patients had two, four (18.2%) patients had three, and one (4.5%) patient had four rib resections. Chest wall reconstruction was necessary for only one of the patients. The mean operation time was 114±36.8 min. Complete resection was achieved in all patients. Complications were observed in seven (31.8%) patients without mortality. The mean follow-up was 24.4±17.9 months. The five-year overall survival rate was 55.3%.

Conclusion

Segmentectomy/lobectomy and chest wall resection with minimally invasive surgery are safe and feasible in patients with nonsmall cell lung cancer. In addition, the localization of the area where chest wall resection would be performed should be considered the most crucial criterion in selecting the ideal technique.

Gastroparesis after video-assisted thoracic surgery: A case report

BACKGROUND

Video-assisted thoracic surgery (VATS) lobectomy is a common treatment for patients with early-stage lung cancer. Some patients can experience slight gastrointestinal discomfort after lobectomy for a moment. Gastroparesis is a gastrointestinal disorder that can be severe; it is associated with an increased risk of aspiration pneumonia and impaired postoperative recovery. Here, we report a rare case of gastroparesis after VATS lobectomy.

CASE SUMMARY

A 61-year-old man underwent VATS right lower lobectomy uneventfully but had an obstruction of the upper digestive tract 2 d after surgery. Acute gastroparesis was diagnosed after emergency computed tomography and oral iohexol X-ray imaging. After gastrointestinal decompression and administration of prokinetic drugs, the patient’s gastrointestinal symptoms improved. Since perioperative medication was applied according to the recommended dose and there was no evidence of electrolyte imbalance, intraoperative periesophageal vagal nerve injury was the most likely underlying cause of gastroparesis.

CONCLUSION

Although gastroparesis is a rare perioperative complication following VATS, clinicians should be on the alert when patients complain about gastrointestinal discomfort. When surgeons resect paraesophageal lymph nodes with electrocautery, excessive ambient heat and compression of paraesophageal hematoma might induce vagal nerve dysfunction.

Efficacy and safety of transcutaneous electrical acupoints stimulation for preoperative anxiety in thoracoscopic surgery: study protocol for a randomised controlled trial

INTRODUCTION

Preoperative anxiety occurs at a very high rate in patients undergoing video-assisted thoracoscopic surgery (VATS). Moreover, it will result in poor mental state, more analgesic consumptions, rehabilitation delay and extra hospitalisation costs. Transcutaneous electrical acupoints stimulation (TEAS) is a convenient intervention for pain control and anxiety reduction. Nevertheless, TEAS efficacy of preoperative anxiety in VATS is unknown.

METHODS AND ANALYSIS

This single-centre randomised sham-controlled trial will be conducted in cardiothoracic surgery department of the Yueyang Hospital of Integrated Traditional Chinese and Western Medicine in China. A total of 92 eligible participants with pulmonary nodules (size ≥8 mm) who are arranged for VATS will be randomly assigned to a TEAS group and a sham TEAS (STEAS) group in a 1:1 ratio. Daily TEAS/STEAS intervention will be administered starting on 3 days before the VATS and continued once per day for three consecutive days. The primary outcome will be the generalised anxiety disorder scale score change between the day before surgery with the baseline. The secondary outcomes will include serum concentrations of 5-hydroxytryptamine, norepinephrine and gamma-aminobutyric acid, intraoperative anaesthetic consumption, time to postoperative chest tube removal, postoperative pain, and length of postoperative hospital stay. The adverse events will be recorded for safety evaluation. All data in this trial will be analysed by the SPSS V.21.0 statistical software package.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Ethics Committee of the Yueyang Hospital of Integrated Traditional Chinese and Western Medicine affiliated to Shanghai University of Traditional Chinese Medicine (approval number: 2021-023). The results of this study will be distributed through peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04895852.

Ground glass opacity resection extent assessment trial : A study protocol of multi-institutional, prospective, open-label, randomized phase III trial of minimally invasive segmentectomy versus lobectomy for ground glass opacity (GGO)-containing early-stage invasive lung adenocarcinoma

Background

With widely use of computed tomography (CT) screening, an increasing number of early-stage lung cancers appearing as ground glass opacity (GGO) have been detected. Therefore, attempts have been made to investigate the feasibility of segmentectomy instead of lobectomy for those patients with GGO. However, the two recently released phase III trials failed to distinguish between GGO-containing lesions from pure solid nodules in the inclusion criteria, and the surgical methods did not distinguish between minimally invasive surgery and open thoracotomy. In addition, total lesion size≤ 2cm was taken as the inclusion criterion, instead of the solid part size recommended in the eighth edition of Union for International Cancer Control/International Association for the Study of Lung Cancer/American Joint Committee on Cancer (UICC/IASLC/AJCC) staging system. Hence, this present trial aims to figure out whether minimally invasive segmentectomy shows superiority in perioperative outcomes and non-inferiority in oncological prognosis over minimally invasive lobectomy among patients with GGO-containing clinical stage T1a-T1b lung invasive adenocarcinoma (IADC).

Methods/design

Sample sizes are 1024 patients, who will be randomized into minimally invasive segmentectomy and lobectomy groups . Patients will be collected from 19 hospitals in China. Patients with peripheral mixed ground glass opacity (mGGO) with 0.5cm

Discussions

If the primary endpoint shows at least non-inferiority in 5-year RFS of segmentectomy to lobectomy, minimally invasive segmentectomy can be recommended as an alternative to minimally invasive lobectomy. If second endpoints show non-inferior 5-year OS along with better perioperative outcomes and/or better pulmonary function preservation of segmentectomy compared with lobectomy after the primary endpoint has reached, minimally invasive segmentectomy may become a preferred procedure for patients with GGO-containing clinical stage T1a-T1b IADCs.

Trial registration

Chinese Clinical Trial Registry. Trial registration number: ChiCTR2000037065.

Clinical trial registration

https://www.chictr.org.cn/, identifier ChiCTR2000037065.

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Key Words

• early-stage invasive lung adenocarcinoma
• ground glass opacity
• lobectomy
• minimally invasive surgery
• segmentectomy

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MESH Headings Collapse

Grants

• Shanghai Shenkang Hospital Development Center

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Affiliation(s)

Hanyue Li
Yiyang Wang
Yang Chen
Chenxi Zhong
Wentao Fang Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China

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[Predictive model for additional intraoperative placement of chest drainage after thoracoscopic lobectomy]

OBJECTIVE

To create a prognostic model determining the risk of tension pneumothorax and the need for intraoperative installation of additional drainage after thoracoscopic lobectomy.

MATERIAL AND METHODS

A retrospective multiple-center study included patients who underwent thoracoscopic lobectomy for lung cancer between 2016 and 2022. One drainage tube was used after surgery in all cases. We synthesized data to expand patient selection using the Riley method and machine learning algorithm. In total, treatment outcomes in 1458 patients were analyzed. After identifying significant factors, we performed binary logistic regression analysis using backward stepwise inclusion of variables in accordance with the Akaike information criterion. After validating the model using the Bootstrap method (400 iterations) and original data set, we created a nomogram determining scoring characteristics, linear predictors and risk of postoperative tension pneumothorax.

RESULTS

The incidence of tension pneumothorax was 4.53% (n=66). The most significant variables associated with pneumothorax and the need for additional pleural drainage were adhesions, intraoperative lung suturing, unclear interlobar groove, enlarged intrapulmonary lymph nodes and chronic obstructive pulmonary disease (p<0.001). The model's C-index was 0.957, mean absolute calibration error - 0.6%, calibration curve slope - 0.959. A score of 26 indicated a 95% risk of postoperative pneumothorax.

CONCLUSION

We developed a prognostic model for tension pneumothorax after thoracoscopic lobectomy. Nomogram makes it possible to make a decision on intraoperative installation of additional pleural drainage tube and prevent complications associated with postoperative lung collapse.

Hemorrhagic shock caused by preoperative computed tomography-guided microcoil localization of lung nodules: a case report

Background

Video-assisted thoracoscopic surgery (VATS) is an emerging technology in minimally invasive surgery, which has become recognized as standard treatments for early-stage lung cancer. Microcoil localization is considered to be a safe and effective way of preoperative localization, and is essential to facilitate VATS wedge-resection for lung nodules.

Case presentation

Here we report a rare case of a 28-year-old female who developed hemorrhagic shock caused by delayed pneumothorax after preoperative computed tomography (CT)-guided microcoil localization. The thoracic CT revealed hydropneumothorax in the right thoracic cavity at 10 h after microcoil localization, and the patient later had significant decreased hemoglobin level (87 g/L). Emergency thoracoscopic exploration demonstrated that the hemorrhagic shock was induced by delayed pneumothorax, which led to the fracture of an adhesive pleura cord and an aberrant vessel. Electrocoagulation hemostasis was then performed for the fractured vessel and the patient gradually recovered from the hypovolemic shock.

Conclusions

Microcoil localization is a relatively safe and effective way of preoperative localization of lung nodules, however, hemorrhagic shock could be induced by rupture of pleural aberrant vessels subsequent to puncture related pneumothorax. Shorten the time interval between localization and thoracoscopic surgery, extend the monitoring time after localization might help to reduce the risk of these complications.

Outcomes of enhanced recovery after surgery in lung cancer: A systematic review and meta-analysis

Objective

Methods

Results

Conclusions

Bleeding during Learning Curve of Thoracoscopic Lobectomy: CUSUM Analysis Results

BACKGROUND

 The management of intraoperative bleeding during thoracoscopic lobectomy is challenging, especially for non-experienced surgeons. We evaluated intraoperative bleeding in relation to learning curve of thoracoscopic lobectomy, the strategies to face it, the outcomes, and the target case number for gaining the technical proficiency.

METHODS

 This was a retrospective single center study including consecutive patients undergoing thoracoscopic lobectomy for lung cancer. Based on cumulative sum analysis, patients were divided into early and late experience groups, and the differences on surgical outcomes, with particular focus on vascular injury, were statistically compared.

RESULTS

 Eight-three patients were evaluated. Cumulative sum charts showed a decreasing of operative time, blood loss, and hospital stay after the 49th, the 43th, and the 39th case, respectively. Early (n = 49) compared with late experience group (n = 34) was associated with higher conversion rate (p = 0.08), longer operative time (p <0.0001), greater blood loss (p <0.0001), higher transfusion rate (p = 0.01), higher postoperative air leak rate (p = 0.02), longer chest tube stay (p <0.0001), and hospitalization (p <0.0001). Six patients (7%) had intraoperative bleeding during early phase of learning curve, successfully treated by thoracoscopy in four cases. Patients with vascular injury (n = 6) compared with control group (n = 77) presented a longer operative time (p = 0.003), greater blood loss (p = 0.0001), and higher transfusion rate (p = 0.001); no significant differences were found regarding postoperative morbidity (p = 0.57), length of chest tube stay (p = 0.07), and hospitalization (p = 0.07).

CONCLUSION

 Technical proficiency was achieved after 50 procedures. All vascular injuries occurred in the early phase of learning curve; they were safely managed, without affecting surgical outcomes.

Better intraoperative cardiopulmonary stability and similar postoperative results of spontaneous ventilation combined with intubation than non-intubated thoracic surgery

OBJECTIVES

Non-intubated spontaneous ventilation video-assisted thoracic surgery lobectomy is a well-known procedure, but there are doubts regarding its safety. To solve this problem, we developed a safe procedure for spontaneous ventilation thoracic surgery (spontaneous ventilation with intubation). This study analyzed the intraoperative parameters and postoperative results of spontaneous ventilation with intubation.

METHODS

Between March 11, 2020 and March 26, 2021, 38 spontaneous ventilation with intubation video-assisted thoracic surgery lobectomies were performed. We chose the first 38 non-intubated spontaneous ventilation video-assisted thoracic surgery lobectomy cases with a laryngeal mask performed in 2017 for comparison.

RESULTS

There were no significant differences between the non-intubated spontaneous ventilation and spontaneous ventilation with intubation groups in postoperative surgical results (surgical time: 98,7 vs. 88,1 min (p = 0.067); drainage time: 3.5 vs. 2.7 days (p = 0.194); prolonged air leak 15.7% vs. 10.5% (p = 0.5); conversion rate to relaxation: 5.2% vs. 13.1% (p = 0.237); failure of the spontaneous ventilation rate: 10.5% vs. 13.1% (p = 0.724); and morbidity: 21% vs. 13.1% (p = 0.364)) and oncological outcomes. Significantly lower lowest systolic and diastolic blood pressure (systolic, 83.1 vs 132.3 mmHg, p = 0.001; diastolic 47.8 vs. 73.4 mmHg, p = 0.0001), lowest oxygen saturation (90.3% vs 94.9%, p = 0.026), and higher maximum pCO₂ level (62.5 vs 54.8 kPa, p = 0.009) were found in the non-intubated spontaneous ventilation group than in the spontaneous ventilation with intubation group.

CONCLUSIONS

Spontaneous ventilation with intubation is a more physiological procedure than non-intubated spontaneous ventilation in terms of intraoperative blood pressure stability and gas exchange. The surgical results were similar in the two groups.

Overview of the outcomes of robotic segmentectomy and lobectomy

Segmentectomy has gained popularity in the latest years as a valid alternative to lobectomy. Initially reserved to patient unfit for lobar lung resection, this procedure is now offered also in selected patient with <2 cm peripheral lung cancer confined to an anatomic segment with no nodal involvement on preoperative evaluation. The introduction of screening with low-dose CT chest scan allowed the identification of lung cancer at early stages, making possible to schedule a more conservative lung surgery. A major improvement came also from minimally invasive surgery (MIS), reducing complication rate with comparable survival rates when compared to open surgery. However, due to long learning curve and uncomfortable instruments handling of video-assisted thoracoscopy, many surgeons still prefer to perform segmentectomies through a thoracotomy and thus increasing perioperative morbidity and leading to post-thoracotomy syndrome due to rib-spreading. Robotic assisted thoracic surgery (RATS) can avoid this throwback, combining the handling of open surgery with lesser invasiveness of thoracoscopy. Although literature has given strong evidences in favour of robotic lobectomies, data are still limited regarding segmentectomies performed with this technique. Moreover, no results are still available from the two ongoing randomized controlled trials comparing segmentectomy to lobectomy and so the latter represent the oncologically proper procedure for lung cancer along with lymph-node dissection. In this review we analyse the literature currently available on outcomes of lobar and sublobar anatomical resection performed by RATS, with a brief mention of the existing surgical techniques of port positioning and the costs of this procedure.

A localization-independent approach for invisible and impalpable ground-glass opacity nodules detection in an in vitro lung specimen: two case reports

A growing number of ground-glass opacity (GGO) nodules are screened out in lungs. Small GGOs are frequently neither visible nor palpable, thus undetectable during operation. Various nodule localization techniques have been developed to facilitate the intraoperative detection of GGO nodules; however, general localization techniques are infeasible or inappropriate in some cases. The detection of small GGO is a great challenge, even within a surgical specimen in the absence of preoperative localization. A localization-independent approach for GGO detection is urgently needed. Herein, we report two cases with invisible and impalpable small GGO which were not appropriate for preoperative localization. The lesions were anatomically resected under the guidance of three-dimensional (3D) reconstruction and got an adequate margin distance. A vessel (artery, vein, or bronchus) which had advanced into or immediately adjacent to the nodule was assigned as a reference vessel. By dissecting and tracing the reference vessel from proximal to distal, the GGO lesions were successfully detected in the surgical specimens, to the eventual obtainment of an accurate pathological diagnosis. Via the two case reports, we introduced an easily handled approach, namely dissecting and tracing a reference vessel, for GGO detection. The novel approach was first described. Combined with precise anatomical segmentectomy guided by 3D reconstruction, it provides an alternative scheme for GGO resection with no need for preoperative localization.

Video-assisted thoracic surgery sleeve resection and bronchoplasty using 3D imaging system: its safety and efficacy

Background

Video-assisted thoracic surgery sleeve resection with bronchial anastomosis or bronchoplasty is a technically demanding procedure. Three-dimensional endoscopic surgery has been reported to be helpful in decreasing operation time and improving spatial perception with less surgical errors, but there have been rare reports about relatively difficult thoracoscopic procedures utilizing 3D thoracoscope. We performed this study to evaluate early clinical outcomes of thoracoscopic sleeve resection and bronchoplasty utilizing 3D thoracoscope.

Methods

Data from a total of 36 patients who underwent thoracoscopic sleeve lobectomy or bronchoplasty at our institution from December 2015 to October 2017 were retrospectively reviewed. Three-port approach with one utility incision was used with a 10 mm, 30° three-dimensional thoracoscope. Twenty-three patients (81%) were male, and mean age was 65.9 ± 9.4 years. Fourteen patients (38.9%) underwent sleeve resection with bronchial anastomosis, 22 (61.1%) underwent wedge or simple bronchoplasty, and one patient received concomitant PA procedure. Bronchial anastomosis sites were not covered with viable tissue flaps.

Results

There was no (0%) suture needle injury from spatial misperception during bronchoplasty or sleeve anastomosis. There was no (0%) operative mortality. The pathologic report revealed squamous cell carcinoma (63.9%), adenocarcinoma (19.4%), carcinoid (6.9%), adenosquamous carcinoma (3.4%), and sarcomatoid carcinoma (2.8%). One (2.8%) late mortality was due to systemic recurrence of sarcomatoid carcinoma. There was no (0.0%) anastomotic failure. The mean number of dissected lymph nodes were 27.4 ± 13.2, and mean operation time was 216.8 ± 60.0 min. Median postoperative 24-h drain amount was 315 mL. Median chest tube days and hospital days were 4 and 6, respectively. Two patients (5.6%) had complications greater than Clavien-Dindo grade II—one case of ARDS, and the other case of a delayed bronchopleural fistula.

Conclusions

Thoracoscopic sleeve resection and bronchoplasty utilizing HD 3D thoracoscope is a safe and effective procedure with excellent early clinical outcomes. Further investigation for long-term outcomes will be needed.

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

Background

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

Methods

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

Results

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

Conclusion

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

The robotic surgery learning curve of a surgeon experienced in video-assisted thoracoscopic surgery compared with his own video-assisted thoracoscopic surgery learning curve for anatomical lung resections

OBJECTIVES

Robotic surgery, although it shares some technical features with video-assisted thoracoscopic surgery (VATS), offers some advantages, such as ergonomic design and a 3-dimensional view. Thus, the learning curve for robotic lung resection could be expected to be shorter than that of VATS for surgeons who are proficient in VATS. The goal of this study was to analyse the robotic learning curve of a VATS experienced surgeon and to compare it to his own VATS learning curve for anatomical lung resections.

METHODS

We conducted a retrospective observational study based on the prospectively recorded data of the first 150 anatomical lung resections performed with VATS (75 cases) and with the robotic (75 cases) approach by the same surgeon in our centre. Learning curves were analysed using the cumulative sum method to assess the trends for total operating time and surgical failure (intraoperative complications, conversion, technical postoperative complications and reintervention) across case sequences. Subsequently, using adequate statistical tests, we compared the postoperative outcomes in both groups.

RESULTS

The median operating time was similar for both approaches (P = 0.401). Surgical failure rate was higher for the robotic cases (21.3% vs 12%; P = 0.125). Based on cumulative sum analyses, operating time decreased starting with case 34 in the VATS group and with case 32 in the robotic cohort. Surgical failure tended to decline starting with case 28 in the VATS group and with case 32 in the robotic group. Perioperative results were similar in both groups.

CONCLUSIONS

When we compared robotic and VATS learning curves for anatomical lung resection, we did not find any differences. Postoperative outcomes were also similar with both approaches.

Tracking the outcomes of surgical treatment of Stage 2 and 3 empyema: introduction and consolidation of minimally invasive approach

BACKGROUND

We described the results of surgical treatment of empyema, tracing outcomes throughout the passage from the open thoracotomy (OT) approach to video-assisted thoracoscopic surgery (VATS) in a single institute.

METHODS

We retrospectively analyzed the records of 88 consecutive patients treated for Stage 2 and 3 empyema (2010-2019). We divided the study period into three groups: OT period (2010-2013), early VATS (2014-2017, from the introduction of VATS program, until acme of learning curve), and late VATS (2018-2019). Groups were compared to investigate the outcomes evolution.

RESULTS

Most relevant findings of the study were significant variation in postoperative length of stay (median [interquartile range]: 9 days [7.5-10], 10 [7.5-17.5], and 7 [5-10] for OT period, early VATS, and late VATS, respectively, p = 0.005), hospital admission referral to thoracic surgery interval (7.5 days [4.5-11], 6.5 [3-9], and 2.5 [1.5-5.5], p = 0.003), chest tube duration (5.5 days [5-7.5], 6 [4-6], 4 [3-5], p = 0.003), and proportion of operation performed by residents (3 [15%], 6 [16.7%], 14 [43.6%], p = 0.01).

CONCLUSIONS

Our findings pictured the trajectory evolution of outcomes during introduction and consolidation of VATS treatment of empyema. During the early phase, we observed a decline in some indicators that improved significantly in the late VATS period. After a learning curve, all outcomes showed better results and we entered into a teaching phase.

Video-Assisted Thoracic Surgery Lobectomy

Video-assisted thoracoscopic surgery (VATS) has been established as the surgical approach of choice for lobectomy in patients with early-stage non-small cell lung cancer (NSCLC). Patients with clinical stage I NSCLC with no lymph node metastasis are considered candidates for VATS lobectomy. To rule out the presence of metastasis to lymph nodes or distant organs, patients should undergo meticulous clinical staging. Assessing patients' functional status is required to ensure that there are no medical contraindications, such as impaired pulmonary function or cardiac comorbidities. Although various combinations of the number, size, and location of ports are available, finding the best method of port placement for each surgeon is fundamental to maximize the efficiency of the surgical procedure. When conducting VATS lobectomy, it is always necessary to comply with the following oncological principles: (1) the vessels and bronchus of the target lobe should be individually divided, (2) systematic lymph node dissection is mandatory, and (3) touching the lymph node itself and rupturing the capsule of the lymph node should be minimized. Most surgeons conduct the procedure in the following sequence: (1) dissection along the hilar structure, (2) fissure division, (3) perivascular and peribronchial dissection, (4) individual division of the vessels and bronchus, (5) specimen retrieval, and (6) mediastinal lymph node dissection. Surgeons should obtain experience in enhancing the exposure of the dissection target and facilitating dissection. This review article provides the basic principles of the surgical techniques and practical maneuvers for performing VATS lobectomy easily, safely, and efficiently.

Nodal Upstaging Evaluation After Robotic-Assisted Lobectomy for Early-Stage Non-small Cell Lung Cancer Compared to Video-Assisted Thoracic Surgery and Thoracotomy: A Retrospective Single Center Analysis

Introduction: The standard surgical procedures for patients with early-stage NSCLC is lobectomy-associated radical lymphadenectomy performed by using the thoracotomy approach. In the last few years, minimally invasive techniques have increasingly strengthened their role in lung cancer treatment, especially in the early stage of the disease. Although the lobectomy technique has been accepted, controversy still surrounds lymph node dissection. In our study, we analyze the rate of upstaging early non-small cell lung cancer patients who underwent radical surgical treatment using the robotic and the VATS techniques compared to the standard thoracotomy approach.

Methods and Materials: We retrospectively reviewed patients who underwent a lobectomy and radical lymphadenectomy at our Institute between 2010 and 2019. We selected 505 patients who met the inclusion criteria of the study: 237 patients underwent robotic surgery, 158 patients had thoracotomy, and 110 patients were treated with VATS. We analyzed the demographic features between the groups as well as the nodal upstaging rate after pathological examination, the number of dissected lymph nodes and the ratio of dissected lymph nodes to metastatic lymph nodes of the three groups.

Results: The patients of the three groups were homogenous with respect to age, sex, and histology. The postoperative major morbidity rate was significantly higher in the thoracotomy group, and hospital stay was significantly longer. The percentage of the mediastinal nodal upstaging rate and the number of dissected lymph nodes was significantly higher in the robotic group compared with the VATS group. The ratio of dissected lymph nodes to metastatic lymph nodes was significantly lower compared with the VATS group and the thoracotomy group.

Discussion: The prognostic impact of the R(un) status is still highly debated. A surgical approach that allows better results in terms of resection has still not been defined. Our results show that robotic surgery is a safe and feasible approach especially regarding the accuracy of mediastinal lymphadenectomy. These findings can lead to defining a more precise pathological stage of the disease and, if necessary, to more accurate postoperative treatment.

Impact of pulmonary function on pulmonary complications after robotic-assisted thoracoscopic lobectomy

OBJECTIVES

Percentage-predicted forced expiratory volume in 1 s (FEV1) and diffusing capacity for carbon monoxide (DLCO), and their predicted postoperative (ppo) values are established prognostic factors for postoperative pulmonary complications after thoracotomy. However, their predictive value for minimally invasive pulmonary resections remains controversial. This study assessed the incidence of pulmonary complications after robotic lobectomy for primary lung cancer and analysed the predictive significance of FEV1 and DLCO.

METHODS

This was a retrospective analysis of patients who underwent robotic lobectomy from 4 institutions. Descriptive and comparative analyses were performed for patients who experienced pulmonary complications versus patients who did not, in relation to FEV1 and DLCO values. To identify thresholds for increased complications, patients were categorized into groups of 10% incremental increases in FEV1 and DLCO, and their ppo values.

RESULTS

From November 2002 to April 2018, 1088 patients underwent robotic lobectomy. Overall, 169 postoperative pulmonary complications occurred in 141 patients. Male gender and Eastern Cooperative Oncology Group grade ≥1 were associated with increased pulmonary complications on univariable analysis. Patients who experienced pulmonary complications had increased mortality (2.1% vs 0.2%, P = 0.017) and longer hospitalizations (9 vs 4 days, P < 0.001). Pulmonary complications were associated when FEV1 ≤60% and DLCO ≤50%, and when ppo FEV1 or DLCO was ≤50%; ppo FEV1 ≤50% (P < 0.001) and ppo DLCO ≤50% (P = 0.031) remained statistically significant on multivariable analysis.

CONCLUSIONS

Both FEV1 and DLCO were shown to be significant predictors of pulmonary complications. Furthermore, thresholds of percentage-predicted and ppo FEV1 and DLCO values were identified, below which pulmonary complications occurred significantly more frequently, suggesting their predictive values are particularly useful in patients with poorer pulmonary function.

Video-Assisted Thoracoscopic En Bloc Vertebrectomy for Spine Tumors: Technique and Outcomes in a Series of 33 Patients

BACKGROUND

In en bloc vertebrectomy, the posterior approach is associated with limited access to anterior structures (vertebral body, esophagus, aorta, azygos vein). Video-assisted thoracoscopic surgery (VATS) might prove to be advantageous during thoracic en bloc vertebrectomy by allowing a combined anterior-posterior access in the prone position. We describe the technique and review the outcomes of 33 cases of video-assisted thoracoscopic en bloc vertebrectomy.

METHODS

A retrospective, single-center cohort study included all cases of VATS with a minimum follow-up of 1 year. A team of thoracic and orthopaedic surgeons performed the surgical procedure with the patient in a single, prone position. Anterior release was carried out thoracoscopically, followed by posterior en bloc tumor removal.

RESULTS

From 2003 to 2019, 33 patients were included. Nine patients underwent total vertebrectomy (8 had single-level and 1 had 3-level), and 24 patients underwent partial vertebrectomy (1 had single-level, 8 had 2-level, 13 had 3-level, and 2 had 4-level). Ten patients had pulmonary resection. Histology revealed 18 cases (55%) of primary bone tumors, 6 cases (18%) of lung cancer invading the spine, 6 cases (18%) of solitary metastasis, and 3 other cases (9%). The margins were tumor-free in 28 cases (85%). The median operative time was 240 minutes (range, 150 to 510 minutes), with a median blood loss of 1,200 mL (range, 400 to 6,700 mL), and there were 2 cases of conversion to thoracotomy. A total of 33 complications occurred in 18 patients (55%), and these were predominantly pulmonary. One death was surgery-related (infection). One patient had a persistent monoplegia. At a median follow-up of 63 months (range, 12 to 156 months), there were 21 surviving patients (64%) with 2 local recurrences and 1 distant recurrence, and 2 patients (6%) were lost to follow-up. The survival rates were 94% at 1 year, 71% at 2 years, and 68% at 5 years.

CONCLUSIONS

VATS en bloc vertebrectomy may be indicated for T2-to-T11 spine tumors with the exception of massive tumors, substantial chest wall and/or mediastinal invasion, and lung cancer exceeding 7 cm. The technique yielded satisfactory surgical and oncologic outcomes.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Video-Assisted Thoracoscopic Surgery Lung Resection in United States Veterans: Trends and Outcomes versus Thoracotomy

BACKGROUND

 Video-assisted thoracoscopic surgery (VATS) offers reduced morbidity compared with open thoracotomy (OT) for pulmonary surgery. The use of VATS over time has increased, but at a modest rate in civilian populations. This study examines temporal trends in VATS use and compares outcomes between VATS and OT in the Veterans Health Administration (VHA).

METHODS

 Patients who underwent pulmonary surgery (wedge or segmental resection, lobectomy, or pneumonectomy) at Veterans Affairs centers from 2008 to 2018 were retrospectively identified using the Veterans Affairs Surgical Quality Improvement Project database. The cohort was divided into OT and VATS and propensity score matched, taking into account the type of pulmonary resection, preoperative diagnosis, and comorbidities. Thirty-day postoperative outcomes were compared. The prevalence of VATS use and respective complications over time was also analyzed.

RESULTS

 A total of 16,895 patients were identified, with 5,748 per group after propensity matching. VATS had significantly lower rates of morbidity and a 2-day reduction in hospital stay. Whereas 76% of lung resections were performed open in 2008, nearly 70% of procedures were performed using VATS in 2018. While VATS was associated with an 8% lower rate of major complications compared with thoracotomy in 2008, patients undergoing VATS lung resection in 2018 had a 58% lower rate of complications (p < 0.001).

CONCLUSIONS

 VATS utilization at VHA centers has become the predominant technique used for pulmonary surgeries over time. OT patients had more complications and longer hospital stays compared with VATS. Over the study period, VATS patients had increasingly lower complication rates compared with open surgery.

Learning curve in robotic-assisted lobectomy for non-small cell lung cancer is not steep after experience in video-assisted lobectomy; single-surgeon experience using cumulative sum analysis

BACKGROUND

Robotic assistance in lung lobectomy has been suggested to enhance the adoption of minimally invasive techniques among surgeons. However, little is known of learning curves in different minimally invasive techniques. We studied learning curves in robotic-assisted versus video- assisted lobectomies for lung cancer.

METHODS

A single surgeon performed his first 75 video-assisted thoracic surgery (VATS) lobectomies from April 2007 to November 2012, and his 75 first robotic-assisted thoracic surgery (RATS) lobectomies between August 2011 and May 2018. A retrospective chart review was done. Cumulative sum (CUSUM) analysis was used to identify the learning curve.

RESULTS

No operative deaths occurred for VATS patients or RATS patients. Conversion-to-open rate was significantly lower in the RATS group (2.7% vs. 13.3%, p = 0.016). Meanwhile, 90-day mortality (1.3% vs. 5.3%, p = 0.172), postoperative complications (24% vs. 24%, p = 0.999), re- operation rates (4% vs. 5.3%, p = 0.688), operation time (170±56 min vs. 178±66 min, p = 0.663) and length of stay (8.9 ± 7.9 days vs. 8.2 ± 5.8 days, p = 0.844) were similar between the two groups. Based on CUSUM analysis, learning curves were similar for both procedures, although slightly shorter for RATS (proficiency obtained with 53 VATS cases vs. 45 RATS cases, p = 0.198).

CONCLUSIONS

Robotic-assisted thoracoscopic lung lobectomy can be implemented safely and efficiently in an expert center with earlier experience in VATS lobectomies. However, there seems to be a learning curve of its own despite the surgeon's previous experience in conventional thoracoscopic surgery.

A comparison of non-intubated video-assisted thoracic surgery with spontaneous ventilation and intubated video-assisted thoracic surgery: a meta-analysis based on 14 randomized controlled trials

Background

Video-assisted thoracic surgery (VATS) generally involves endotracheal intubation under general anesthesia. However, inevitably, this may cause intubation-related complications and prolong the postoperative recovery process. Gradually, non-intubated video-assisted thoracic surgery (NIVATS) is increasingly being utilized. However, its safety and efficacy remain controversial.

Methods

Randomized controlled trials (RCTs) published up to August 2020 were selected from the Cochrane Library, Web of Science, PubMed, Embase, and ClinicalTrials.gov databases and included in this study according to the inclusion criteria. Two reviewers screened these RCTs and independently extracted the relevant data. After assessing the risk of bias in these RCTs, a meta-analysis was performed using Review Manager 5.3. Pooled data were meta-analyzed using a random-effects model.

Results

Meta-analysis data demonstrated that the mean difference (MD) in the length of hospital stay between non-intubated patients and intubated patients was −1.41 days, with a 95% confidence interval (CI) of −2.47 to −0.34 (P=0.01). The visual analogue scale (VAS) score between the two groups showed a MD of −0.34 (95% CI: −0.58 to −0.10; P=0.006). Patients who underwent NIVATS presented with lower rates of overall complications [odds ratio (OR) 0.41; 95% CI: 0.25 to 0.67; P=0.0004], air leak (OR 0.45; 95% CI: 0.24 to 0.87; P=0.02), pharyngeal discomfort (OR 0.08; 95% CI: 0.04 to 0.17; P<0.00001), hoarseness (OR 0.06; 95% CI: 0.02 to 0.21; P<0.00001), and gastrointestinal reactions (OR 0.23; 95% CI: 0.10 to 0.53; P=0.0005) compared to intubated patients. The anesthesia satisfaction scores in the NIVATS group were significantly higher than those of the VATS group (MD 0.50; 95% CI: 0.12 to 0.88; P=0.009). However, there were no statistically significant differences in the length of operation time (MD 0.90 hours; 95% CI: −0.23 to 2.03; P=0.12) and surgical field satisfaction (1 point) (OR 0.73; 95% CI: 0.34 to 1.59; P=0.43) between the two groups.

Conclusions

NIVATS is a safe and feasible form of intervention that can reduce the postoperative pain and complications of various systems and shorten hospital stay duration without prolonging the operation time.

Spontaneous ventilation combined with double-lumen tube intubation in thoracic surgery

OBJECTIVE

We present the combination of spontaneous ventilation and double-lumen tube intubation in thoracic surgery.

METHODS

At the beginning of the procedures, the patients with a body mass index of ≤ 30 were relaxed for a short time, and a double-lumen tube was inserted. After the utility incision or thoracotomy, the vagus nerve was blocked (in right side in the upper mediastinum; in left side in the aorto-pulmonary window) with 3-5 ml of 0.5% bupivacaine. The patients had a bispectral index of 40-60. After the short relaxation period, the patients were ventilating spontaneously without any cough during the manipulation.

RESULTS

Between March 10 and September 18. 2020, 26 spontaneous ventilation combined with intubation surgeries were performed: 19 uniportal video-assisted thoracic surgery (15 lobectomies, 1 segmentectomy, and 3 wedge resections) and 7 open (5 lobectomies and 1 sleeve segmentectomy, 1 wedge resection). The mean mechanical and spontaneous one-lung ventilation time was 25.5 (15-115) and 73.3 (45-100) minutes, respectively. In 2 cases conversion to relaxation were necessary (2/26; 7.7%). The mean maximal carbon dioxide pressure was 52.3 (38-66) Hgmm and the mean lowest oxygen saturation was 93.8 (86-99) %. Breathing frequency ranged between 10-25/minute. The mean surgical times was 83.3 (55-130) minutes.

CONCLUSIONS

Spontaneous ventilation combined with intubation in video-assisted thoracic surgery or open resections is a safe method in selected patients. It can reduce the mechanical one-lung ventilation period with 76.6% and give safe airway for spontaneous ventilation thoracic procedures.

The safety and feasibility of three-dimension single-port video-assisted thoracoscopic surgery for the treatment of early-stage lung cancer

Background

Video-assisted thoracoscopic surgery (VATS) has been widely used in the lung resections. Reports regarding three-dimension (3D) single-port VATS are very limited. The purpose of this study is to evaluate the perioperative outcomes of 3D single-port VATS in a single medical center.

Methods

Totally 523 clinical stage I lung cancer patients underwent surgical resection through VATS operation between September 2016 and October 2017 in our single institution were retrospectively collected and 374 were enrolled. The comparison between 3D single-port VATS and conventional VATS (c-VATS), single-port VATS was conducted focusing on intraoperative and postoperative outcomes. Continuous and categorical variables were analyzed through SPSS software.

Results

The 3D singe-port VATS demonstrated no significant difference neither on the intraoperative outcomes including the operative time and the intraoperative blood loss nor the postoperative outcomes including the length of drainage duration and postoperative complications when against c-VATS and single-port VATS. Besides, 3D singe-port VATS elucidated comparable ability of lymph node dissection with c-VATS in subgroup analysis (P=0.192), both of which were better than single-port VATS group (P<0.001). What’s more, the rate of conversion as well as hospital stays of 3D single-port group were also comparable. In subgroup analysis, 3D singe-port VATS also elucidated its safety and feasibility when dealing with routine thoracic surgeries including lobectomy and segmentectomy.

Conclusions

3D single-port VATS, integrating the advantages of single-port VATS and three-dimensional vision of 3D VATS, is a safe and feasible technique and is promising for next-generation thoracoscopic surgery.

Long-term survival of thoracoscopic surgery compared with open surgery for clinical N0 adenocarcinoma

Background

Early stage non-small cell lung cancer (NSCLC) is good candidate for video-assisted thoracoscopic surgery (VATS). Long-term outcome compared between VATS and open surgery remains unclear. The aim of this study was to assess the long-term outcome of VATS in early stage adenocarcinoma.

Methods

A retrospective study was performed in 546 patients which were operated between January 2006 and December 2010 in our institute and of those, 240 (220 lobectomies, and 20 segmentectomies) were clinical N0 adenocarcinoma. One hundred and thirty-five patients underwent VATS and 105 patients for open surgery. Long-term oncological outcomes were compared in both groups.

Results

There were significant differences in age, gender, Blinkman index, clinical T factor and tumor size between two groups. VATS group showed statistically longer operation time (P=0.01), less blood loss (P=0.005), shorter length of stay (P=0.001), and less dissected number of lymph nodes (P<0.001) compared with open surgery. Disease-free survival in VATS was significantly better than open surgery (5- and 10-year survival; VATS, 91.4%, 79.0%; open, 85.1%, 73.6%; respectively, P=0.04). Overall survival in VATS was not different from open (P=0.58). Propensity matched disease-free and overall survival was not significantly different between two groups. Multivariate Cox regression analysis showed that age [P=0.04, 95% confidence interval (CI): (1.02–6.81)] in overall and T factor [P=0.01, 95% CI: (1.41–17.3)] in disease-free survival was prognostic significant after propensity matching.

Conclusions

Our study demonstrated that long-term outcome in VATS for early stage adenocarcinoma was equivalent to open surgery. VATS may be a treatment of choice for promising long-term prognosis.

[Thoracic Surgery: The Era of Minimally Invasive Lobectomy]

The contingent of VATS (video assistend thoracic surgery) lobectomies will continue to increase in the time to come. Thoracic surgery departments that do not integrate this procedure into their routine spectrum will have to justify themselves to referrers and clinic administrations and will have problems with the recruitment of training assistants as well. The advantages of minimally invasive lobectomy are impressive and the long-term oncological results are equivalent to open lobectomy. VATS lobectomies in non-intubated patients will increase significantly in the next few years and further reduce the invasiveness of the operation. The number of clinics that offer RATS (roboter assistend thoracic surgery) lobectomies will also increase as more companies bring robot systems onto the market, making them significantly cheaper. Better screening programs for risk patients for lung cancer, rapid advances in thoracic oncology and further minimization of surgical trauma in lung resections will significantly improve the overall therapy and prognosis for lung cancer patients in the years to come.

Video-assisted thoracoscopic surgery using a three-dimensional thoracoscopic system as an educational tool for surgical trainees in general thoracic surgery

OBJECTIVE

The clinical practice of safe and efficient surgery and professional development of general thoracic surgical trainee are both important issues for mentors. We investigated the usefulness of a three-dimensional (3D) endoscopic system application for lung cancer treatment as a tool for training surgical trainees.

METHODS

Supervised by mentors, general thoracic surgical trainees were trained with video-assisted thoracoscopic surgery (VATS) for primary lung cancer using a 3D endoscopic system to enable them to become operators. Video clinics using 3D images were held weekly. The group using 3D endoscopic system (66 cases in the 3D-VATS group) was compared with the group using conventional two-dimensional (2D) thoracoscopic system (35 cases in the 2D-VATS group) to perform VATS lobectomies.

RESULTS

There was no significant difference in operative time between both groups. However, the 3D-VATS group comprised significantly less experience than the 2D-VATS group. The intraoperative blood loss was significantly reduced for the 3D group (34 mL in the 3D-VATS group vs. 76 mL in the 2D-VATS group, P = 0.0007). There were no cases of conversion from VATS to open thoracotomy and intraoperative transfusion in either group.

CONCLUSION

3D-VATS and video clinics using 3D videos are useful training tools for general thoracic surgical trainees with little experience in open thoracotomy.

Oncological advantage of nonintubated thoracic surgery: Better compliance of adjuvant treatment after lung lobectomy

BACKGROUND

Video-assisted thoracoscopic (VATS) surgery contributes to improved survival, adjuvant chemotherapy delivery and less postoperative complications. Nonintubated thoracic surgery (NITS) VATS procedures improves immunological responses in lung cancer patients; however, there is no data regarding adjuvant chemotherapy delivery effectiveness following NITS lobectomies. In this study, we aimed to compare protocol compliance and toxic complications during adjuvant chemotherapy after intubated and nonintubated VATS lobectomies in non-small cell lung cancer (NSCLC).

METHODS

We retrospectively reviewed the medical records of 66, stage IB-IIIB NSCLC patients who underwent intubated or nonintubated VATS lobectomy and received adjuvant chemotherapy.

RESULTS

A total of 38 patients (17 males, mean age 64 years) underwent conventional VATS and 28 (7 males; mean age 63 years) uniportal VATS NITS. Both groups had comparable demographic data, preoperative pulmonary function, and Eastern Cooperative Oncology Group (ECOG) status. Among the intubated and nonintubated patients, 82% and 75% were diagnosed with adenocarcinoma, respectively. The incidence of adenocarcinoma and squamous cell carcinoma cases were similar in both groups; however, the pathological staging showed significant differences, as 5 (18%) nonintubated patients had stage IB lung cancer, compared with the intubated group (P = 0.01). Further distribution of stages was similar between the groups. We observed significant differences in chest tube duration and operation time in the nonintubated group (P < 0.01). Among nonintubated patients, 92% completed the planned chemotherapy protocol, compared to 71% of the intubated group (P = 0.035). Grade 1/2 toxicity occurred significantly more often in the intubated group (16% vs. 0%, P = 0.03) and there was a lower incidence of grade 4 neutropenia in the nonintubated group (0% vs. 16%, P = 0.03).

CONCLUSIONS

Our results showed that the nonintubated procedure resulted in improved adjuvant chemotherapy compliance and lower toxicity rates after lobectomy.

KEY POINTS

SIGNIFICANT FINDINGS OF THE STUDY: Oncological advantage of the non-intubated thoracic surgery: better compliance with therapy protocol. What this study adds NITS lobectomies contribute to better administration of adjuvant chemotherapy with the planned cycle number and dosage.

Troubleshooting in thoracoscopic anatomical lung resection for lung cancer

Video-assisted thoracoscopic surgery (VATS) anatomical lung resection (ALR) has been gaining popularity in the treatment of lung cancer in line with remarkable advances in both equipment and technique. The development and refinement of its technique have allowed thoracic surgeons to perform a wide variety of challenging and complex procedures in a minimally invasive fashion. Careful and meticulous preparation may shift in the future with the increasing sophistication and capabilities of VATS ALR. Moreover, constant awareness and a structured plan of the procedure are imperative to reducing or preventing complications. Intraoperative major complications during VATS ALR are infrequent, but can have catastrophic consequences. The decision to continue with VATS should take into consideration the surgeon's skill level and ease with the approach and the relative potential benefit against the risk to the patient. We conducted this study to investigate the possible problems during VATS ALR and identify how to solve them based on the previous literature and our institutional data sampling.

Comparison of the Video-assisted Thoracoscopic Lobectomy versus Open Thoracotomy for Primary Non-Small Cell Lung Cancer: Single Cohort Study with 269 Cases

Objectives:

This study aims to compare the outcomes of video-assisted thoracoscopic surgery (VATS) lobectomy with open thoracotomy lobectomy in patients with non-small cell lung cancer (NSCLC).

Methods:

There were 269 cases with NSCLC who underwent lobectomy between 2017-2019; these cases were retrospectively studied. VATS lobectomy (VATS Group) and open thoracotomy lobectomy (Thoracotomy Group) patients’ results were compared according to the length of hospitalizations, early postoperative complications and tumor size and stages.

Results:

VATS lobectomy was performed in 89 (33%) of these patients, whereas 180 (67%) patients underwent lobectomy using open thoracotomy for NSCLC. The findings showed that the average length of hospitalization was shorter in the VATS Group compared to the Thoracotomy Group (4 vs. 5.5 days) (p<0.05). It was found that the mean size of the tumour was smaller in the VATS Group when compared to the Thoracotomy Group (2.66 cm vs 3.97 cm) (p<0.001). Early postoperative complications were lower in the VATS Group (n=15, 16.8% vs n=58, 32.2%; p<0.021).

Conclusion:

In VATS lobectomy cases, postoperative complications are less, and the length of hospitalization is shorter. VATS lobectomy is mostly preferred smaller than 3 cm tumor size.

Management of pulmonary ground-glass opacities: a position paper from a panel of experts of the Italian Society of Thoracic Surgery (SICT)

OBJECTIVES

A significant gap in our knowledge of how to manage pulmonary ground-glass opacities (GGOs) still exists. Accordingly, there is a lack of consensus among clinicians on this topic. The Italian Society of Thoracic Surgery (Società Italiana di Chirurgia Toracica, SICT) promoted a national expert meeting to provide insightful guidance for clinical practice. Our goal was to publish herein the final consensus document from this conference.

METHODS

The working panel of the PNR group (Pulmonary Nodules Recommendation Group, a branch of the SICT) together with 5 scientific supervisors (nominated by the SICT) identified a jury of expert thoracic surgeons who organized a multidisciplinary meeting to propose specific statements (n = 29); 73 participants discussed and voted on statements using a modified Delphi process (repeated iterations of anonymous voting over 2 rounds with electronic support) requiring 70% agreement to reach consensus on a statement.

RESULTS

Consensus was reached on several critical points in GGO management, in particular on the definition of GGO, radiological and radiometabolic evaluation, indications for a non-surgical biopsy, GGO management based on radiological characteristics, surgical strategies (extension of pulmonary resection and lymphadenectomy) and radiological surveillance. A list of 29 statements was finally approved.

CONCLUSIONS

The participants at this national expert meeting analysed this challenging topic and provided a list of suggestions for health institutions and physicians with practical indications for GGO management.

Comparison of the Short- and Long-term Outcomes of Video-assisted Thoracoscopic Surgery versus Open Thoracotomy Bronchial Sleeve Lobectomy for Central Lung Cancer: A Retrospective Propensity Score Matched Cohort Study

PURPOSE

The purpose of this study was to evaluate the short- and long-term outcomes of video-assisted thoracoscopic surgery (VATS) versus open thoracotomy bronchial sleeve lobectomy (BSL) for patients with central lung cancer.

METHODS

This is a retrospective cohort study. Perioperative outcomes and long-term survival of patients who underwent VATS versus open thoracotomy BSL for central lung cancer from June 2010 and June 2018 in the Western China Lung Cancer Database were compared using propensity score matching (PSM) between the two surgical approaches.

RESULTS

The retrospective study included 187 patients who divided into VATS group (n = 44) and open group (n = 143) according to surgical approach, and PSM resulted in 43 patients in each group, which were well matched by 11 potential prognostic factors. The VATS group was associated with lower overall incidence of postoperative complications (20.3% vs. 30.2%, P = 0.029), less postoperative drainage (875 ml [250-3960] vs. 1280 ml [100-4890], P = 0.039). The 5-year overall survival (OS) and disease-free survival (DFS) were comparable between the VATS and open groups (55.9% vs. 65.2% P = 0.836 and 54.1% vs. 60.2% P = 0.391, respectively) after matching. Multivariable adjusted analysis demonstrated that the surgical approach was not an independent favorable prognostic factor for OS (hazard ratio [HR] = 0.922; 95% confidence interval [CI], 0.427-1.993; P = 0.836) but just the pTNM stage (HR = 2.003; 95% CI 1.187-3.382; P = 0.009).

CONCLUSIONS

VATS BSL may achieve equivalent long-term outcomes for central lung cancer patients when comparing with open thoracotomy. Although slightly longer duration of surgery, VATS approach may be a feasible option for lung cancer patients requiring BSL.

Conversion method to manage surgical difficulties in non-intubated uniportal video-assisted thoracic surgery for major lung resection: simple thoracotomy without intubation

Background

The major limitations of widespread use of non-intubated thoracic surgery (NITS) is the fear of managing complications. Here we present our practice of converting from uniportal video-assisted thoracic surgery (VATS) NITS to open NITS in cases of surgical complications.

Methods

The study period was from January 26, 2017, to November 30, 2018. Total intravenous anesthesia was provided with propofol guided by bispectral index, and the airway was maintained with a laryngeal mask with spontaneous breathing. Local anesthesia with 2% lidocaine at the skin incision, and intercostal and vagus nerve blockades were induced using 0.5% bupivacaine. For conversion with surgical indications, a thoracotomy was performed at the incision without additional local or general anesthetics.

Results

In 160 complete NITS procedures, there were 145 VATS NITS and 15 open NITS (9 conversions to open NITS and 6 intended NITS thoracotomies). In the 15 open NITS cases (2 pneumonectomies, 1 bilobectomy, 1 sleeve lobectomy, 7 lobectomies, 3 sublobar resections, 1 exploration), the mean operative time was 146.7 (105–225) and 110 (75–190) minutes in the converted and intended open NITS groups, respectively. There were no significant differences between systolic blood pressure (P=0.316; 95% CI, −10.469 to 3.742), sat O2% (P=0.27; 95% CI, −1.902 to 0.593), or propofol concentration in the effect site (P=0.053; 95% CI, −0.307 to 0.002) but significant differences in pulse (P=0.007; 95% CI, −10.001 to −2.72), diastolic blood pressure (P=0.013; 95% CI, −9.489 to −1.420) and in end-tidal CO2 (P=0.016; 95% CI, −7.484 to −0.952) before versus after thoracotomy, but there was no clinical relevance of the differences.

Conclusions

For conversion with surgical indications during the VATS-NITS procedure, NITS thoracotomy can be performed safely at the site of the utility incision without the need for additional drugs, and the major lung resections can be performed through this approach.

The role of surgery for stage I non-small cell lung cancer in octogenarians in the era of stereotactic body radiotherapy in the Netherlands

OBJECTIVES

Resection is the standard treatment for stage I non-small cell lung cancer (NSCLC) in operable patients. Stereotactic body radiotherapy (SBRT) is recommended for inoperable patients. A shift from surgery to SBRT is expected in elderly patients due to increased frailty and competing risks. We assessed the current influence of age on treatment decision-making and overall survival (OS).

MATERIALS AND METHODS

We performed a retrospective cohort study using data from patients with clinical stage I NSCLC diagnosed in 2012-2016 and treated with lobectomy, segmentectomy, wedge resection, or SBRT, retrieved from the Netherlands Cancer Registry. Patient characteristics and OS were compared between SBRT and (sub)lobar resection for patients aged 18-79 and ≥80 years.

RESULTS AND CONCLUSION

8764 patients treated with lobectomy (n = 4648), segmentectomy (n = 122), wedge resection (n = 272), or SBRT (n = 3722) were included. In 2012-2016, SBRT was increasingly used for octogenarians and younger patients from 75.3% to 83.7% and from 30.8% to 43.2%, respectively. Five-year OS in the whole population was 70% after surgery versus 39% after SBRT and 50% versus 27% in octogenarians. After correction for age, gender, year of diagnosis, and clinical T-stage, OS was equal after lobectomy and SBRT in the first 2 years after diagnosis. However, after >2 years, OS was better after lobectomy than after SBRT. SBRT is the prevailing treatment in octogenarians with stage I NSCLC. While surgery is associated with better OS than SBRT, factors other than treatment modality (e.g. comorbidity) may have had a significant impact on survival. The wider application of SBRT in octogenarians likely reflects the frailty of this group. Registries and trials are required to identify key determinants of frailty in this specific population to improve patient selection for surgery or SBRT.