Perioperative Effect of Single-Port Thoracoscopic Segmentectomy and Three-Port Thoracoscopic Segmentectomy in the Treatment of Early Non-Small-Cell Lung Cancer

Background

Clinically, there were few reports on single-hole thoracoscopic segmental resection in non-small-cell lung cancer (NSCLC), and no report on the comparison of single-hole and three-hole thoracoscopic segmental resection. Hence, the purpose of the study was to explore the perioperative role of single-port thoracoscopic segmentectomy and three-port thoracoscopic segmentectomy for early-stage NSCLC.

Methods

The clinical data of 80 patients with early-stage NSCLC who were treated in our hospital from January 2021 to June 2022 were selected as the retrospective research subjects and divided into a comparison/research group with 40 cases in each group according to different surgical methods. Among them, the comparison group was received three-port thoracoscopic segmentectomy, and the research group was received single-port thoracoscopic segmentectomy. The surgical indicators, immune and tumor marker levels, as well as prognostic complications between two groups were compared.

Results

There was no remarkable diversity between the two groups in terms of operation time and the number of lymph nodes dissected during the operation (P > 0.05). The surgical blood loss in research group was lower than comparison group (P < 0.05). After treatment, the levels of CYFRA21-1, CA125, as well as VGEF in the research group were markedly lower than comparison group (P < 0.05). The differences in CD4+, CD3+, and CD4+/CD8+ after treatment were prominent, and the research group was higher than comparison group (P < 0.05). There was no statistical difference in postoperative complications between the two groups (P > 0.05).

Conclusions

Single-hole thoracoscopic lobectomy has obvious advantages in the treatment of NSCLC, which can reduce intraoperative bleeding, enhance the recovery of patients' immune function, and promote postoperative recovery.

Surgical Effectiveness of Uniportal-VATS Lobectomy Compared to Open Surgery in Early-Stage Lung Cancer

Background

Although the feasibility and safety of Uniportal-Video-Assisted thoracic surgery (U-VATS) has been proven, its surgical effectiveness is still debated. The aim of this study is to assess the equivalence of the U-VATS approach compared with an open technique in terms of surgical (nodal-upstaging, complications, and post-operative results) and short-term survival outcomes.

Methods

The clinical data of patients undergoing lobectomy for NSCLC at our center, from January 2014 to December 2019, were analyzed retrospectively. All patients undergoing open or U-VATS lobectomy with lymphadenectomy for early-stage lung cancer (cT1-T3N0, stages IA-IIB) were included in the study. Only 230 patients satisfied the inclusion criteria. Group bias was reduced through 1:1 propensity score matching, which resulted in 46 patients in each group (open surgery and U-VATS).

Results

The intra- and post-operative mortality were null in both groups. There was no difference in the post-operative complications (p: 1.00) between U-VATS and open lobectomy. There was also no recorded difference in the pathological nodal up-staging [11 (23.9%) after thoracotomy vs. 8 (17.4%) after U-VATS, p: 0.440). The chest tube duration was longer in the open group (p: 0.025), with a higher post-operative pain (p: 0.001). Additionally, the 3-year overall survival (OS) was 78% after U-VATS lobectomy vs. 74% after open lobectomy (p: 0.204), while 3-year disease-specific survival (DSS) was 97 vs. 89% (p: 0.371), respectively. The 3-year disease-free survival (DFS) was 62% in the U-VATS group and 66% in the thoracotomy group, respectively (p: 0.917).

Conclusions

Uniportal-VATS lobectomy for the treatment of early-stage lung cancer seems to be a safe and effective technique with similar surgical and short-term survival outcomes as open surgery, but with lower post-operative pain and shorter in-hospital stay.

Early surgical and oncological outcomes during adoption of a single port VATS lung resection in a tertiary cancer center: a retrospective analysis

Background

Video-assisted thoracoscopic surgery (VATS) is a safe and effective surgical approach for pulmonary resection. VATS can be accomplished with only a single incision, resulting in less postoperative pain and paresthesia, better cosmetic results, and greater patient satisfaction. Single-port VATS (spVATS) has become increasingly common for lung resection. We assess the early surgical and oncological outcomes after adopting this new technique at our tertiary cancer center as the first institution to do so in the country.

Method

Medical records for 257 patients in a tertiary cancer center, with a diagnosis of non-small cell lung cancer, pulmonary metastasis, or other chest-confined pathology, were accessed to obtain perioperative outcomes, pathologic results, post-operative follow-up data, and early surgical and oncological outcomes. All patients underwent spVATS for limited or major lung resection. Simple descriptive analysis was utilized.

Results

spVATS was either performed with curative intent (79.8%, N = 205), or as a diagnostic procedure (20.2%, N = 52). Resection types were subcategorized for curative intent group as limited (73.6%, N = 151), lobectomy (16.6%, N = 34), and complex (9.7%, N = 20). Resection with a negative margin (R0) rate was 100% for the primary lung cancer (PLC) patients and 97% for the pulmonary metastasectomy (PM) group. The complication rate was 5%. Three-year disease-free survival was 87% and 68.5% for PLC and PM group, respectively. The 3-year overall-survival was 91.3% for the PLC and 82.8% for PM. Operation duration showed a downtrend over the study period in each curative subcategory with a borderline difference in the limited resection (P value = 0.05).

Conclusion

All the spVATS procedures were successfully performed without perioperative severe complications or mortality, regardless of complexity. R0 resection was excellent. Middle- and long-term efficacies of spVATS for lung cancer require further follow-up. With proper training, appropriate indication and meticulous application, adopting spVATS is safe and feasible technique that does not compromise surgical and oncological outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-022-01777-y.

[Feasibility Investigation of Fluorescence Method in Uniport Thoracoscopic Anatomical Segmentectomy for Identifying the Intersegmental Boundary Line]

BACKGROUND

Segmentectomy has gradually become one of the standard surgical methods for small pulmonary nodules with early lung cancer on imaging. This study aimed to investigate the perioperative outcomes of patients who underwent uniport video-assisted thoracoscopic surgery (VATS) segmentectomy for identifying the intersegmental boundary line (IBL) by the near-infrared fluorescence imaging with intravenous indocyanine green (ICG) method or the modified inflation-deflation (MID) method and assess the feasibility and effectiveness of the ICG fluorescence (ICGF)-based method.

METHODS

We retrospectively analyzed the perioperative data in total 198 consecutive patients who underwent uniport VATS segmentectomy between February 2018 and August 2020. With the guidance of preoperative intelligent/interactive qualitative and quantitative analysis-three dimensional (IQQA-3D), the targeted segment structures could be precisely identified and dissected, and then the IBL was confirmed by ICGF-based method or MID method. Clinical effectiveness and postoperative complications of the two methods were evaluated.

RESULTS

An IBL was visible in 98% of patients by the ICGF-based group, even with the low-doses of ICG. The ICGF-based group was significantly associated with the shorter IBL clear presentation time [(23.59±4.47) s vs (1,026.80±318.34) s] (P<0.01) and operative time [(89.3±31.6) min vs (112.9±33.3) min] (P<0.01), compared to the MID group. The incidence of postoperative prolonged air leaks was higher in the MID group than in the ICGF-based group (8.0% vs 26.5%, P=0.025). There were no significant differences in bleeding volume, chest tube duration, postoperative hospital stays, surgical margin width and other postoperative complications (P>0.05).

CONCLUSIONS

The ICGF-based method could highly accurately identify the IBL and make anatomical segmentectomy easier and faster, and therefore has the potential to be a feasible and effective technique to facilitate the quality of uniport VATS segmentectomy.

Feasibility investigation of near-infrared fluorescence imaging with intravenous indocyanine green method in uniport video-assisted thoracoscopic anatomical segmentectomy for identifying the intersegmental boundary line

OBJECTIVES

To investigate the perioperative outcomes of patients who underwent uniport video-assisted thoracoscopic (VATS) segmentectomy for identifying the intersegmental boundary line (IBL) by the near-infrared fluorescence imaging with the intravenous indocyanine green (ICG) method or the modified inflation-deflation (MID) method and assess the feasibility and effectiveness of the ICG fluorescence (ICGF)-based method.

METHODS

We retrospectively analyzed the perioperative data in total 198 consecutive patients who underwent uniport VATS segmentectomy between February 2018 and August 2020. With the guidance of a preoperative imaging interpretation and analysis system (IQQA-3D), the targeted segment structures could be precisely identified and dissected, and then the IBL was confirmed by the ICGF-based method or the MID method. The clinical effectiveness and postoperative complications of the two methods were evaluated.

RESULTS

An IBL was visible in 98% of patients in the ICGF-based group, even with low doses of ICG. The ICGF-based group was significantly associated with a shorter IBL clear presentation time (23.6 ± 4.4 vs. 23.6 ± 4.4 s) (p < 0.01) and operative time (89.3 ± 31.6 vs. 112.9 ± 33.3 min) (p < 0.01) compared to the MID group. The incidence of postoperative prolonged air leaks was higher in the MID group than in the ICGF-based group (8/100, 8% vs. 26/98, 26.5%, p = 0.025). There were no significant differences in bleeding volume, chest tube duration, postoperative hospital stays, surgical margin width, and other postoperative complications.

CONCLUSION

The ICGF-based method could highly accurately identify the IBL and make anatomical segmentectomy easier and faster, and therefore has the potential to be a feasible and effective technique to facilitate the quality of uniport VATS segmentectomy.

Uniportal video-assisted thoracic surgery for the treatment of lung cancer: a consensus report from Chinese Society for Thoracic and Cardiovascular Surgery (CSTCVS) and Chinese Association of Thoracic Surgeons (CATS)

Uniportal video-assisted thoracoscopic surgery (UniVATS) has been widely adopted in China, where several ultra-high volume thoracic surgical and training centers are located. The objective of this consensus from Chinese experts was to summarize the current application and give reference for the future development of UniVATS in the treatment of lung cancer. A panel of 41 experts from 21 Chinese hospitals was invited to join this project. The Delphi method was used in this consensus consisting of two rounds of voting. The questionnaire was based on the current clinical evidence. Forty (97.6%) experts completed the 2 rounds of questionnaires. The experts’ experience was relatively similar. We defined the UniVATS as monitor-dependent surgery, no use of rib-spreading and single incision less than 4 cm. Tumor with stage of T1–T3 and N0–N2 is considered amenable to UniVATS. Other consensus was reached on several points outlining the safety and feasibility, surgical skills, learning curve, short-term and long-term outcomes for lung cancer, and current application of subxiphoid and nonintubated UniVATS approach. This consensus statement represents a collective agreement among Chinese experts to suggest that UniVATS is an effective alternative to multi-portal approach, although high-level evidence is expected in the future. Some agreements can be referred in the training of young surgeons.

Uniportal versus multiportal video-assisted thoracoscopic anatomical resection for NSCLC: a meta-analysis

Background

Uniportal video-assisted thoracoscopic surgery (U-VATS) has recently emerged as an alternative procedure for non-small cell lung cancer (NSCLC); however, whether U-VATS has advantages over multiportal VATS (M-VATS) remains unknown.

Methods

We performed a systematic review of two databases (Pubmed and Web of Science) to search comparative studies of U-VATS and M-VATS anatomical pulmonary resection for NSCLC. Operative time, blood loss, number of resected lymph nodes, drainage duration, length of postoperative stay, pain in postoperative day 1(POD1) and conversion rates were retrieved to estimate the comparison of outcomes. A subgroup analysis stratified by study type (propensity-matched analysis and randomized-controlled trial versus non-propensity matched analysis) was performed.

Result

A total of 20 studies with 4142 patients were included in this meta-analysis. U-VATS was performed on 1869 patients, whereas the other 2173 patients underwent M-VATS. This meta-analysis showed that there was no significant difference in operative time (U-VATS: 146.48 ± 55.07 min versus M-VATS: 171.70 ± 79.40 min, P = 0.81), blood loss (74.49 ± 109.03 mL versus 95.48 ± 133.67 mL, P = 0.18), resected lymph nodes (17.28 ± 9.46 versus 18.31 ± 10.17, P = 0.62), conversion rate (6.18% versus 4.34%, P = 0.14), drainage duration (3.90 ± 2.94 days versus 4.44 ± 3.12 days, p = 0.09), length of postoperative stay (6.16 ± 4.40 days versus 6.45 ± 4.80 days, P = 0.22), and pain in POD1 (3.94 ± 1.68 versus 3.59 ± 2.76, p = 0.07). Subgroup analysis showed the value of PSM and RCT group consistency with overall value.

Conclusion

This up-to-date meta-analysis shows that the perioperative outcomes of U-VATS and M-VATS anatomical pulmonary resection are equivalent. In addition, the differences in long-term outcomes of these two approaches are still unclear. Thoracic surgeons should pay more emphasize on providing high-quality and personalized surgical care for patients, to improve the survival ultimately.

Effectiveness and postoperative pain level of single-port versus two-port thoracoscopic lobectomy for lung cancer: a retrospective cohort study

Objectives

Single-port thoracoscopic lobectomy is a new therapeutic technique for patients with lung cancer; however, insufficient data are available regarding its clinical outcomes. We therefore compared the clinical outcomes of single-port and two-port thoracoscopic lobectomies for lung cancer.

Methods

We retrospectively analyzed and compared the data of 204 and 368 patients with lung cancer who underwent single-port or two-port thoracoscopic lobectomy, respectively, between October 2014 and October 2017 at our institution. Patients in both groups underwent 1:1 propensity score matching, and 400 patients (200 patients in each group) were included. Perioperative clinical indicators were analyzed, including operation time, lymph node dissection stations and numbers, incidence of postoperative complications, and pain scores at 24 h, 72 h, and 1 week after surgery.

Results

No perioperative deaths occurred in either group. The operation time, intraoperative blood loss, chest drainage duration, duration of postoperative hospital stay, lymph node dissection station and number, rate of conversion to open surgery, number of ruptured intraoperative pulmonary vessel, and incidence of postoperative complications were not significantly different between the groups (all P > 0.05). However, analysis of the 24-h (P = 0.005), 72-h (P = 0.011), and 1-week (P = 0.034) visual analog scale score after surgery revealed that the postoperative pain levels were significantly lower in the single-port than in the two-port group.

Conclusions

Single-port and two-port thoracoscopic lobectomies had similar perioperative outcomes, although the postoperative pain was lower after single-port than two-port thoracoscopic lobectomy. Hence, we concluded that single-port thoracoscopic lobectomy is an effective, minimally invasive, and promising surgical procedure.

Nodal Outcomes of Uniportal versus Multiportal Video-Assisted Thoracoscopic Surgery for Clinical Stage I Lung Cancer

Background

Accurate intraoperative assessment of mediastinal lymph nodes is a critical aspect of lung cancer surgery. The efficacy and potential for upstaging implicit in these dissections must therefore be revisited in the current era of uniportal video-assisted thoracoscopic surgery (VATS).

Methods

A retrospective study was conducted in which 544 patients with stage I (T1abc–T2a, N0, M0) primary lung cancer were analyzed. To assess risk factors for nodal upstaging and to limit any imbalance imposed by surgical choices, we constructed an inverse probability of treatment-weighted (IPTW) logistic regression model (in addition to non-weighted logistic models). We also evaluated risk factors for early locoregional recurrence using IPTW logistic regression analysis.

Results

In the comparison of uniportal and multiportal VATS, the resected lymph node count (14.03±8.02 vs. 14.41±7.41, respectively; p=0.48) and rate of nodal upstaging (6.5% vs. 8.7%, respectively; p=0.51) appeared similar. Predictors of nodal upstaging included tumor size (odds ratio [OR], 1.74; 95% confidence interval [CI], 1.12–2.70), carcinoembryonic antigen level (OR, 1.11; 95% CI, 1.04–1.18), and histologically confirmed pleural invasion (OR, 3.97; 95% CI, 1.89–8.34). The risk factors for locoregional recurrence within 1 year were found to be number of resected N2 nodes, age, and nodal upstaging.

Conclusion

Uniportal and multiportal VATS appear similar with regard to accuracy and thoroughness, showing no significant difference in the extent of nodal dissection.

Uniportal versus multiportal video-assisted thoracoscopic surgery in the treatment of lung cancer: a Canadian single-centre retrospective study

Background

Observational studies comparing uniportal and multiportal video-assisted thoracoscopic surgery (VATS) in the treatment of lung cancer have produced conflicting results. We present a Canadian study comparing clinical outcomes of uniportal and multiportal VATS in the treatment of lung cancer.

Methods

A retrospective study evaluating patients who underwent multiportal (2012–2014) or uniportal (2014–2016) VATS lobectomies, segmentectomies and wedge resections for lung cancer. Clinical outcomes measured included patient demographics, tumour factors, operative factors, length of hospital stay, postoperative complications, analgesic use, pain scores and mortality. Descriptive statistics were used to compare the 2 groups.

Results

Of 185 patients, 65 underwent uniportal and 63 underwent multiportal VATS resection. Patients were similar in terms of their baseline demographics, comorbidies and cancer characteristics. Median operative time was 184 and 185 minutes in the uniportal and multiportal groups, respectively. There were 5 conversions to thoracotomy in the uniportal group and 1 in the multiportal group. Similar lymph node retrieval (median 7 v. 5 nodes) and positive margin rates (6.2% v. 4.8%) were seen in the 2 groups. Median length of stay was 2 days (interquartile range [IQR] 1–3) and 3 days (IQR 2–4) in the uniportal and multiportal groups, respectively. Rates of postoperative complications were similar in the 2 groups (16.9% v. 19.0%, p = 0.76). Patient-controlled analgesia use and pain scores did not differ between the groups.

Conclusion

Adoption of uniportal VATS appears to be feasible and safe, without compromising oncologic principles or increasing intraoperative resource utilization. Larger, prospective studies can help confirm these findings.

Uniportal and three-portal video-assisted thoracic surgery lobectomy: analysis of the Italian video-assisted thoracic surgery group database

OBJECTIVES

This study compares the uniportal with the 3-portal video-assisted thoracic surgery (VATS) by examining the data collected in the Italian VATS Group Database. The primary end point was early postoperative pain; secondary end points were intraoperative and postoperative complications, surgical time, number of dissected lymph nodes and length of stay.

METHODS

This was an observational, retrospective, cohort, multicentre study on data collected by 49 Italian thoracic units. Inclusion criteria were clinical stage I-II non-small-cell lung cancer, uniportal or 3-portal VATS lobectomy and R0 resection. Exclusion criteria were cT3 disease, previous thoracic malignancy, induction therapy, significant comorbidities and conversion to other techniques. The pain parameter was dichotomized: the numeric rating scale ≤3 described mild pain, whereas the numeric rating scale score >3 described moderate/severe pain. The propensity score-adjusted generalized estimating equation was used to compare the uniportal with 3-portal lobectomy.

RESULTS

Among 4338 patients enrolled from January 2014 to July 2017, 1980 met the inclusion criteria; 1808 patients underwent 3-portal lobectomy and 172 uniportal surgery. The adjusted generalized estimating equation regression model using the propensity score showed that over time pain decreased in both groups (P < 0.001). There was a statistical difference on the second and third postoperative days; odds ratio (OR) 2.28 [95% confidence interval (CI) 1.62-3.21; P < 0.001] and OR 2.58 (95% CI 1.74-3.83; P < 0.001), respectively. The uniportal-VATS group had higher operative time (P < 0.001), shorter chest drain permanence (P < 0.001) and shorter length of stay (P < 0.001).

CONCLUSIONS

Data from the Italian VATS Group Database showed that in clinical practice uniportal lobectomy seems to entail a higher risk of moderate/severe pain on second and third postoperative days.

Uniportal versus multiportal video-assisted thoracic surgery for lung cancer

Background

Video-assisted thoracic surgery (VATS) lobectomy is the recommended surgical approach for patients with stage I lung cancer. Whether a multiportal or a uniportal approach is preferable remains unclear. The aim of this study was to evaluate the safety of implementing uniportal VATS lobectomy into the treatment program of lung cancer patients.

Methods

We used the national quality register for general thoracic surgery in Sweden and included all patients who underwent VATS lobectomy for lung cancer at the Karolinska University Hospital between 2016-2018. Early postoperative complications were compared in patients undergoing uniportal (n=122) and multiportal (n=211) VATS lobectomy for lung cancer. Inverse probability of treatment weighting and standardized mean differences were used to limit differences in baseline characteristics and to assess balance after weighting.

Results

The proportion of uniportal VATS lobectomies increased during the study period and the conversion rates declined significantly. Baseline characteristics were similar in the two groups with the exception of a higher percentage of patients without any comorbidity in the uniportal group (59.8% vs. 44.5%, P=0.010). After inverse probability of treatment weighting the groups were well balanced. Postoperative complications were rare regardless of surgical approach, 94% in both groups had no complications. The 30-day mortality and overall survival at 1 year was 0% and 97% in the uniportal group, and 0.5% and 98% in the multiportal group (P=0.71). Patients undergoing uniportal VATS lobectomy were discharged directly to home to a higher extent than multiportal VATS patients (76.2% vs. 62.1%, P=0.008).

Conclusions

We found that uniportal VATS lobectomy was feasible and safe, and might entail advantages in terms of a faster recovery after surgery as compared to multiportal VATS lobectomy in patients with lung cancer.

Learning curve for uniportal video-assisted thoracoscopic surgery lobectomy-results from 120 consecutive patients

Background

Uniportal video-assisted thoracoscopic surgery (VATS) is considered a technically demanding procedure. The learning curve, which directly influences the adoption of uniportal VATS, has not been described. In this study, we aimed to describe the learning curve for uniportal VATS lobectomy from our single center's experience.

Methods

Uniportal VATS lobectomy was started in October 2013 in Zhongshan Hospital, Fudan University. Since then, a total of 120 consecutive patients who underwent uniportal VATS lobectomy were retrospectively enrolled. Surgical videos were reviewed to determine the operation time, to which cumulative sum (CUMSUM) method was applied to evaluate the learning phases of the procedure. Accordingly, patients' clinical features in different phases were collected and compared to determine the learning curve for uniportal VATS lobectomy.

Results

Among the 120 consecutive patients reviewed from October 2013 to September 2014, the CUMSUM curve showed its inflection at patient number 44: the first 30 patients were in the ascending phase, the second 30 patients were in the plateau phase, and the remaining patients were in the descending phase. Comparable CUMSUM results were recorded both from upper and not-upper lobectomy. Intra-operatively, more repeated stapler attempts (73% versus 13% and 5%, P<0.001) and higher conversion rate (17% versus 7% and 2%, P=0.028) were recorded in ascending phase vs. the plateau phase and descending phase, respectively. Post-operatively, the morbidity, mortality and the length of hospital stay were similar before and after the learning curve cases.

Conclusions

In a center with conventional VATS experience, the learning period of uniportal VATS lobectomy was characterized by repeated stapler attempts, and the volume requirements would be approximately 30 cases to reach the performance plateau. Upper lobectomy seemed not more difficult to learn than lower or middle lobectomy in uniportal VATS.

Uniportal versus multiport video-assisted thoracoscopic surgery for anatomical lung resections: a glance at a dilemma

Introduction

As the number of operations performed by videothoracoscopy is increasing, there is also a tendency to decrease the number of port incisions. Apart from the reduced number of surgical incisions, there are a few reports and systematic reviews that demonstrate some potential advantages of the uniportal video-assisted thoracoscopic surgery, but the impact of the reduced incisions in the clinical setting still remains uncertain.

Aim

To compare uniportal video-assisted thoracoscopic surgery to multiport video-assisted thoracoscopic surgery for anatomical lung resections in patients with malignant and benign lung diseases.

Material and methods

From August 2010 to April 2016, a total of 102 patients with malignant and benign lung diseases underwent videothoracoscopic lobar and sublobar lung resections in our department. Comorbidities, tumor stage, tumor localization, mortality, operative time, pain visual analogue scale, length of hospital stay, perioperative blood loss, duration and amount of postoperative drainage and air leak, number of harvested lymph nodes and complication rates were analyzed.

Results

No significant difference was found in the duration of chest tube drainage, pain visual analogue scale score, length of hospital stay, perioperative blood loss, amount of postoperative drainage, number of harvested lymph nodes or complication rate. There was no surgical mortality in either of the two groups. However, operative time was shorter (189 min vs. 256 min, p < 0.005) in the multiport group than in the uniportal group.

Conclusions

Compared with the uniportal approach, the multiport approach is associated with a significantly shorter operative time in our study.

Minimally invasive thoracic surgery: beyond surgical access

Thoracic surgery has evolved throughout the decades. The difficulty of accessing the intrathoracic organs through the bony rib-cage has been a challenge for thoracic surgeons. In the past, large incisions stretching across the chest, such as posterolateral thoracotomies with rib spreading was the standard approach to access the lungs. These methods cause large amounts of trauma to the patient, with high rates of mortality and morbidity. However, with the advances in technology and the improvements in surgical technique, thoracic surgery has progressed to minimise trauma to the patient while still maintaining oncological and surgical principles. State-of-the-art technology, combined with wide variety of old and new surgical techniques give the thoracic surgeon a formidable armamentarium. Although there has been a focus on reducing the number and size of surgical wounds, considerations other than surgical approach can reduce the trauma suffered by the patient. Preservation of pulmonary function via organ preservation and anaesthetic techniques to further minimise the systemic inflammation such as non-intubated anaesthesia have also been shown to improve patient outcomes. This article aims to review the recent advances in minimally invasive thoracic surgery.

Lung cancer staging: a concise update

Diagnosis and clinical staging of lung cancer are fundamental to planning therapy. The techniques for clinical staging, i.e anatomic and metabolic imaging, endoscopies and minimally invasive surgical procedures, should be performed sequentially and with an increasing degree of invasiveness. Intraoperative staging, assessing the magnitude of the primary tumour, the involved structures, and the loco-regional lymphatic spread by means of systematic nodal dissection, is essential in order to achieve a complete resection. In resected tumours, pathological staging, with the systematic study of the resected specimens, is the strongest prognostic indicator and is essential to make further decisions on therapy. In the present decade, the guidelines on lung cancer staging of the American College of Chest Physicians and the European Society of Thoracic Surgeons are based on the best available evidence and are widely followed. Recent advances in the classification of the adenocarcinoma of the lung, with the definition of adenocarcinoma in situ, minimally invasive adenocarcinoma and lepidic predominant adenocarcinoma, and the publication of the eighth edition of the tumour, node and metastasis classification of lung cancer, have to be integrated into the staging process. The present review complements the latest guidelines on lung cancer staging by providing an update of all these issues.

Comparison of survival between lung cancer patients receiving single or multiple-incision thoracoscopic surgery

Background

The effect of single-incision thoracoscopic surgery for lung cancer on long-term survival is unknown and no studies have investigated whether there are differences in survival between single and multiple incision approaches. We aimed to compare long-term overall survival and disease-free survival of patients who underwent single-incision thoracoscopic surgery with those who received multiple-incision thoracoscopic surgery for lung cancer.

Methods

We retrospectively analyzed 532 patients with lung cancer who underwent either single-incision (n=150) or multiple-incision thoracoscopic resection (n=382) during the period January 2000 to December 2014. Patients were matched on propensity score at a 1:2 ratio to estimate the effect of treatment on long-term and disease-free survival. Overall survival and disease-free survival were assessed using the Kaplan-Meier method, the log-rank test and Cox proportional-hazards regression.

Results

Propensity matching resulted in 138 patients in the single-incision group and 276 patients in the multiple-incision group. The matched patients in the single-incision group had a significantly better 5-year overall survival than those in the multiple-incision group (P=0.027). Disease-free survival was similar between the two groups before and after matching. The number of chest wall incisions did not influence overall survival or disease-free survival.

Conclusions

The long-term outcomes of single-incision thoracoscopic surgery are comparable to those of multiple-incision thoracoscopic surgery for lung cancer.

Uniport versus multiport video-assisted thoracoscopic surgery in the perioperative treatment of patients with T1-3N0M0 non-small cell lung cancer: a systematic review and meta-analysis

Background

Uniport video-assisted thoracoscopic surgery (VATS) has emerged as a less invasive approach for the treatment of non-small cell lung cancer (NSCLC). However, whether uniport VATS has more potential advantages over multiport VATS remains controversial. This meta-analysis aimed to compare the perioperative efficacy of uniport and multiport VATS for T1-3N0M0 NSCLC.

Methods

An electronic and manual search of literature published before 1st October 2017 was conducted using PubMed, Embase, Web of Science, and the Wiley Online library. The effective values of dichotomous variables or continuous variables were estimated by odds ratios (OR) or by standardized mean differences (SMD) with 95% confidence intervals (CIs) respectively.

Results

Eleven relevant observational studies were included for meta-analysis. Results demonstrated that patients in the uniport group had a significant reduction in the duration of postoperative drainage (uniport: 4.39±2.48 vs. multiport: 4.99±3.24 days; P=0.003), bleeding volume (97.7±60.0 vs. 116.7±99.7 mL; P=0.006), length of hospital stay (6.3±2.4 vs. 7.0±3.6 days; P<0.001), VAS of postoperative pain (2.53±0.73 vs. 4.22±0.71, P=0.02) and in the overall rate of complications (14.5% vs. 17.5%; P=0.008). There were no significant differences between the two treatment groups with regards to mortality, operative time, the number of dissected lymph nodes or the conversion rate.

Conclusions

Uniport VATS might have represent a preferable option for the treatment of T1-3N0M0 NSCLC, due to its superior perioperative efficacy.

A glance at the history of uniportal video-assisted thoracic surgery

In the history of thoracic surgery, the advent of video-assisted thoracic surgery (VATS) had on effect equivalent to that provoked by a true revolution. VATS successfully allowed minor, major and complex procedures for various lung and mediastinal pathologies with small incision instead of the traditional accesses. These small incisions abolished ugly scars, generated less acute and chronic pain, reduced hospital stay and costs, allowed faster return to normal day life activities. Conventional VATS was initially performed through 3-4 ports and rapidly evolved to uniportal or single portal access [uniportal video-assisted thoracic surgery (uniVATS)]. First uniportal procedures were published in 2000. In 2010, uniportal technique for lobectomy was described. Focused experimental courses, live surgery events, the internet media favored the rapid diffusion of this technique over the world. Major and complex uniVATS lung resections involving segmentectomy, pneumonectomy, bronchoplasty and vascular reconstruction, redo VATS, en bloc chest wall resections have been accomplished with satisfactory outcomes. Interestingly, different uniportal approaches and techniques are emerging from a number of VATS centers particularly experienced in the mini-invasive thoracic surgery. As confidence grew, in 2014, the first uniVATS left upper lobectomy via the subxiphoid approach was reported. This novel technique is quite challenging but appropriate patient selection as well as availability of dedicated instruments allowed to perform procedures safely. The diffusion of uniVATS paralleled with the development of nonintubated awake anesthesia technique. In 2007 the first nonintubated lobectomy was described. In 2014 the first single port VATS lobectomy in a nonintubated patient with lung cancer of the right middle lobe was accomplished. The nonintubated uniVATS represents an intriguing technique, so that very experienced thoracoscopic surgeons may enroll to surgery elderly and high risk patients. Decreased postoperative pain and hospitalization, faster access to the radio-chemotherapy and diminished inflammatory response are important benefits of the modern approach to the thoracic pathologies. The history of uniVATS documented a constant and irresistible progress. This technique may further provide unthinkable surprises in next future.

A multi-center retrospective study of single-port versus multi-port video-assisted thoracoscopic lobectomy and anatomic segmentectomy

Background

To assess the feasibility and perioperative outcomes of single-port (SP) and multi-port (MP) approaches for video-assisted thoracoscopic surgery (VATS) lobectomy and anatomical segmentectomy.

Methods

Retrospective data from 458 patients who received VATS lobectomy or anatomical segmentectomy at Shanghai Chest Hospital, Korea University Guro Hospital, Affiliated Hospital of National Taiwan University, University of Hong Kong Queen Mary Hospital and Shenzhen Hospital were collected. Patients were divided into SP group and MP group according to the surgical approach. Perioperative factors such as operation time, blood loss during surgery, conversion rate, the number and stations of lymph nodes harvested, postoperative chest tube drainage time, postoperative hospitalization time, perioperative morbidity and mortality, and pain scores during the first 3 days after surgery were compared between the two groups.

Results

There were no differences in the number (P=0.278) and stations (P=0.564) of lymph nodes harvested, postoperative morbidity (P=0.414) or mortality(P=0.246), and pain score on the third day (P=0.630) after surgery between the two groups. The SP group had a longer operation time (P=0.042) and greater intraoperative blood loss (P<0.001), but the conversion rate was even higher in the MP group (P=0.018). Patients in the SP group had shorter chest tube removal time (P=0.012) and postoperative hospitalization time (P=0.005). Pain scores were lower on the first (P=0.014) and second (P=0.006) day after surgery in the SP group.

Conclusions

SP VATS lobectomy and anatomical segmentectomy is technologically more demanding than MP VATS. It can be safe and feasible in the hands of experienced surgeons, with comparable preoperative outcomes to MP VATS, but less pain in the early postoperative period.

Anterior fissureless uniport vs. posterior intra-fissure triple-port thoracoscopic right upper lobectomy: a propensity-matched study

Background

This study aimed to assess the efficiency of anterior fissureless uniport (AFU) thoracoscopic lobectomy for early stage right upper non-small cell lung cancer (NSCLC).

Methods

Between June 2014 and Dec 2016, 162 consecutive NSCLC patients who underwent thoracoscopic right upper lobectomy (RUL) by AFU approach (AFU group, n=65) or posterior intra-fissure triple-port dissection (PIFT group, n=97) were enrolled. A propensity-matched analysis was used to compare perioperative outcomes, safety and efficiency between the two groups.

Results

Propensity matching produced 40 pairs in this retrospective study. During the operation, lobectomy took less time in the AFU group compared with the PIFT group, while no statistical differences in mediastinal lymphadenectomy time, intraoperative blood loss, and total of lymph nodes harvested were found between the two groups. Postoperatively, length of hospital stay (LOS) and time of postoperative air leak were significantly reduced in AFU group than in PIFT group. However, the overall complication rate and volume of pleural effusion drainage within 48 h were similar. Compared with the PIFT group, visual analogue scale (VAS) of 3 postoperative days in AFU group was slighter.

Conclusions

In RUL, AFU thoracoscopic approach is safe, efficient and easily maneuverable, which would reduce the duration of lobectomy, LOS and time of postoperative air leak. Postoperative pain is also mild.

Advantages and disadvantages of single incision VATS in major anatomical resection for lung cancer

Safety and feasibility of lung resections by single incision thoracoscopy have been confirmed in large number of studies. As proponents claim its lesser invasive nature caused by lacking of additional intercostal port(s), opponents question the outcome measures of the approach especially in oncological manner. Since there is no major discussion regarding the superiority of video-assisted thoracoscopic surgery (VATS) on lung resections over the open technique in the surgical management of lung cancer today, advantage and disadvantage of single incision VATS lung resections was reviewed with the comparison of standard, multi-port VATS approach in this article. Overall, results of comparative studies confirm that single incision and multiportal thoracoscopy are similar, or single incision thoracoscopy has more advantages in the lung resection for lung cancer. Currently, the main disadvantage of single incision approach is the lacking of long-term oncological results.

From full thoracotomy to uniportal video-assisted thoracic surgery: lessons learned

Over the last two decades, conventional video-assisted thoracic surgery (VATS) has established itself as the preferred approach for almost all thoracic surgical procedures. The procedure provides a safe and easy approach with undisputed patient benefit at a cost acceptable to the healthcare system all over the world, in large hospitals as well as underprivileged rural areas. VATS has effectively addressed the patients' right to less scarring, trauma (both of access and intrathoracic manipulation), medication, pain, hospitalization, and early return home and work. These improvements have been further stressed by the introduction of uniportal VATS (uniVATS). Single port surgery is a very exciting new modality in the field of minimal access surgery which aims at further reducing scars of standard vats and towards an hypothetical prospective of scarless surgery.

Technological innovation in video-assisted thoracic surgery

The popularity of video-assisted thoracic surgery (VATS) which increased worldwide due to the recent innovations in thoracic surgical technics, equipment, electronic devices that carry light and vision and high definition monitors. Uniportal VATS (UVATS) is disseminated widely, creating a drive to develop new techniques and instruments, including new graspers and special staplers with more angulation capacities. During the history of VATS, the classical 10 mm 0° or 30° rigid rod lens system, has been replaced by new thoracoscopes providing a variable angle technology and allowing 0° and 120° range of vision. Besides, the tip of these novel thoracoscopes can be positioned away from the operating side minimize fencing with other thoracoscopic instruments. The curved-tip stapler technology, and better designed endostaplers helped better dissection, precision of control, more secure staple lines. UVATS also contributed to the development of embryonic natural orifice transluminal endoscopic surgery. Three-dimensional VATS systems facilitated faster and more accurate grasping, suturing, and dissection of the tissues by restoring natural 3D vision and the perception of depth. Another innovation in VATS is the energy-based coagulative and tissue fusion technology which may be an alternative to endostaplers.

From biportal to uniportal video-assisted thoracoscopic anatomical lung resection: A single-institute experience

Our study sought to review our experience from biportal to uniportal video-assisted thoracoscopic surgery (VATS) major lung resection. Lessons we learned from the evolution regarding technical aspects were also discussed.We retrospectively reviewed patients who underwent VATS lobectomy or segmentectomies in Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi, Taiwan, during January 2012 and December 2014. Patient clinical profiles, surgical indications and procedures, postoperative course, and oncological parameters were analyzed and compared between the biportal and uniportal groups.A total of 121 patients were enrolled in this study with median follow-up of 19.5 ± 11.6 months for all patients and 22.5 ± 11.5 months for primary lung cancer patients. Operation time (146.1 ± 31.9-158.7 ± 40.5 minutes; P = 0.077), chest drainage time (3.8 ± 3.3-4.4 ± 2.4 days; P = 0.309), conversion to thoracotomy rate (2.2%-2.6%; P = 0.889), and complication rate (15.6%-19.7%; P = 0.564) were equal between the groups, whereas blood loss (96.7 ± 193.2-263.6 ± 367; P = 0.006) was lower in the uniportal group. For lung cancer cases, there were no statistical differences in the histology, cancer staging, mediastinal lymph node dissection stations, numbers of dissected N1, N2, and overall lymph nodes between uniportal and biportal groups.Our preliminary data showed that uniportal VATS anatomical lung resection is as feasible, equally safe, and of comparative oncological clearance efficacy to biportal VATS.

Single-port video-assisted thoracic surgery in the treatment of non-small cell lung cancer: a propensity-matched comparative analysis

BACKGROUND

Video-assisted thoracic surgery (VATS)-assisted lobectomy is widely used to treat non-small cell lung carcinoma (NSCLC). There are no reports concerning the comparison between single-port VATS and two-port VATS in treating NSCLC. This study aimed to compare the perioperative and short-term follow-up results between these two methods for treating NSCLC.

METHODS

A retrospective surgical evaluation of patients undergoing either single-port VATS or two-port VATS for NSCLC between January 2013 and June 2015 was conducted. The propensity score (PS) matching method was used to reduce selection bias by creating two groups. After generating the PSs, 1:1 ratio and nearest-neighbor score matching was completed. The primary outcome measures were surgical time, blood loss, drainage time, length of hospital stay, postoperative pain score and patient satisfaction score. The data were analyzed statistically with P<0.05 defined as statistically significant.

RESULTS

Of the 143 patients who met the inclusion criteria, 66 (46.2%) were operated on using two-port VATS and 77 (53.8%) using single-port VATS. After 1-to-1 PS matching, 63 pairs were selected. Both groups were well balanced for age, gender, body mass index, pulmonary function, preoperative comorbidity, tumor size and tumor type. The single-port VATS group had less blood loss, less postoperative pain, and a higher satisfaction score than those in the two-port VATS group, with statistical significance. Postoperative complications occurred in 2 (2/63, 3.2%) patients in the single-port VATS group and 6 (6/63, 9.5%) patients in the two-port VATS group, not a significant difference. No deaths occurred during the follow-up period.

CONCLUSIONS

A single-port VATS-assisted lobectomy is suggested to be safe and feasible for treating NSCLC. Compared with two-port VATS, single-port VATS has many advantages, including reduced blood loss, less postoperative pain and a higher satisfaction score.

Systematic review and meta-analysis of uniportal versus multiportal video-assisted thoracoscopic lobectomy for lung cancer

BACKGROUND

Uniportal video-assisted thoracoscopic surgery (VATS) has emerged as a less invasive alternative to the conventional multiportal approach in the treatment of lung cancer. The benefits of this uniportal technique have not yet been characterized in patients undergoing VATS lobectomy. This meta-analysis aimed to compare the clinical outcomes of uniportal and multiportal VATS lobectomy for patients with lung cancer.

METHODS

A systematic review was conducted using seven electronic databases. Endpoints for analysis included perioperative mortality and morbidity, operative time, length of hospital stay, perioperative blood loss, duration of postoperative drainage and rates of conversion to open thoracotomy.

RESULTS

Eight relevant observational studies were identified and included for meta-analysis. Results demonstrated a statistically significant reduction in the overall rate of complications, length of hospital stay and duration of postoperative drainage for patients who underwent uniportal VATS lobectomy. There were no significant differences between the two treatment groups in regard to mortality, operative time, perioperative blood loss and rate of conversion to open thoracotomy.

CONCLUSIONS

The present meta-analysis demonstrated favourable outcomes for uniportal VATS lobectomy in the treatment of lung cancer compared to the conventional multiportal approach. However, long-term follow-up data is still needed to further characterize the benefits of the uniportal approach.

Single port VATS: recent developments in Asia

Single port video-assisted thoracic surgery (VATS) is the most recent evolution in minimally invasive thoracic surgery. With increasing global popularity, the single port VATS approach has been adopted by experienced thoracic surgeons in many Asian countries. From initial experience of single port VATS lobectomy to the more complex sleeve resection procedures now forming part of daily practice in some Asia institutes, the region has been the proving ground for single port VATS approaches' feasibility and safety. In addition, certain technical refinements in single port VATS lung resection and lymph node dissection have also sprung from Asia. Novel equipment designed to facilitate single port VATS allowing further reduce access trauma are being realized by the partnership between surgeons and the industries. Advanced thoracoscopes and staplers that are narrower and more maneuverable are particularly important in the smaller habitus of patients from Asia. These and similar new generation equipment are being applied to single port VATS in novel ways. As dedicated thoracic surgeons in the region continue to striving for excellence, innovative ideas in single incision access including subxiphoid and embryonic natural-orifice transluminal endoscopic surgery (e-NOTES) have been explored. Adjunct techniques and technology used in association with single port VATS such as non-intubated surgery, hybrid operating room image guidance and electromagnetic navigational bronchoscopy are all in rapid development in Asia.

Global development and current evidence of uniportal thoracoscopic surgery

In the era of video-assisted thoracoscopic surgery (VATS), uniportal and single incision thoracoscopic surgeries are gaining popularity. The spectrum of uniportal VATS indications is now almost equal to that of conventional VATS. For example, successful uniportal sleeve lobectomy, rib segmental resection, and management of intraoperative bleeding have all been reported. According to published data in the English-language literature, more than 9,545 uniportal VATS have been performed to date, including 1,293 lobectomies, 1,024 procedures for pneumothorax, and 6,845 sympathectomies. Of the 192 articles discussing this topic, 35 were conducted in Spain, and there were an increasing number of publications from China, Korea, and other Asian countries. There were 41 technical and review articles, all of which provided an excellent foundation of surgical concept and skill learning. The benefits of uniportal VATS include better surgical geometry and cosmetics. Regarding postoperative outcomes, thirteen out of the 15 articles reviewed showed that uniportal VATS has similar or superior outcomes to conventional VATS. Most studies demonstrated that uniportal VATS produced less postoperative pain and paresthesia. In conclusion, uniportal VATS can produce excellent operative outcome, which is becoming a mature surgical approach in thoracic disease, supported by fast-accumulating and abundant experience.

Reasons not to perform uniportal VATS lobectomy

The uniportal video assisted thoracic surgery (VATS) approach to lung lobectomy has generated phenomenal interest in recent years. It promises to offer patients less morbidity and faster recovery, even when compared to conventional multiportal VATS. However, critics of the uniportal VATS approach may raise concerns about whether this most minimally invasive surgical approach for lung surgery may compromise safety and treatment efficacy. This debate has great potential importance not only in determining how patients are operated on, but in understanding how 'success' is gauged in major pulmonary surgery. This article explores both sides of this debate, drawing on the experience of how clinical research in multiportal VATS evolved over the years. Systematic generation of clinical evidence with progressively increasing sophistication is required to fairly evaluate the uniportal VATS approach. A review of the current literature suggests that there remain many large gaps in the evidence surrounding uniportal VATS. Hence, at the present time, the reasons voiced by critics as to why uniportal VATS should not be performed should not be lightly dismissed. Instead, it behoves surgeons on both sides of the debate to continue to generate good clinical evidence to resolve it.

Why should we prefer the single port access thoracic surgery?

One of the greatest advances in Thoracic Surgery in our generation has been the advent of video assisted thoracic surgery (VATS). The more recent advance in VATS is the increasing use of Uniportal surgery. The development of single-port VATS has come a long way, from the beginning, when it was employed for performing simple procedures, to the last years with complex major lung resections. Nowadays, Uniportal VATS is not a Manichean law because there are several steps between open thoracotomy and Uniportal VATS. In thoracic surgery, a skilled surgeon alone cannot sustain new approaches or techniques; it is natural that minimally invasive thoracic surgery continues to evolve, since VATS is a never-ending story and Uniportal VATS is not the end of this history.

Comparing the postoperative outcomes of video-assisted thoracoscopic surgery (VATS) segmentectomy using a multi-port technique versus a single-port technique for primary lung cancer

BACKGROUND

Single-port video-assisted thoracoscopic surgery (VATS) has attracted much attention recently; however, it is still very challenging to perform especially on more technically demanding sublobar anatomic resection procedures such as segmentectomy. Therefore we conducted a retrospective study on the perioperative results of single-port segmentectomy using a propensity-matched method for comparison with multi-port segmentectomy in patients with primary lung cancer.

METHODS

For procedures of anatomic segmentectomy performed between May 2006 and March 2014, we retrieved data on patients' demographic information, medical history, cancer information, and postoperative outcomes from our surgical database of thoracoscopic lung cancer surgery. Outcome variables included the number of lymph nodes retrieved during the surgery, the amount of blood loss, the duration of hospitalization, the length of the wound, the operation duration in minutes, and incidence and types of complication. The t-test and Chi-squared test were used to compare demographic and clinical variables between single- and multi-port approaches.

RESULTS

A total of 98 consecutive patients who underwent VATS segmentectomy for lung cancer treatment were identified in our database: 52 (53.1%) underwent a single-port segmentectomy and 46 (46.9%) had a multi-port segmentectomy. After propensity score matching, the differences in patients' age, pulmonary function tests, tumor size, and operating surgeons were no longer significant between the two sample groups. The length of the wound was the only surgical outcome for which single-port segmentectomy had a significantly better outcome than multi-port segmentectomy (P value <0.001).

CONCLUSIONS

This study showed that single-port VATS segmentectomy yielded comparable surgical outcomes to multi-port segmentectomy despite technique difficulties and smaller wound in our setting.