Minimally Invasive Surgery in Non-Small Cell Lung Cancer: Where Do We Stand?

In the last two decades, robotic-assisted thoracoscopic surgery (RATS) has gained popularity as a minimally invasive surgical (MIS) alternative to multi- and uniportal video-assisted thoracoscopic surgery (VATS). With this approach, the surgeon obviates the known drawbacks of conventional MIS, such as the reduced in-depth perception, hand-eye coordination, and freedom of motion of the instruments. Previous studies have shown that a robotic approach for operable lung cancer has treatment outcomes comparable to other MIS techniques such as multi-and uniportal VATS, but with less blood loss, a lower conversion rate to open surgery, better lymph node dissection rates, and improved ergonomics for the surgeon. The thoracic surgeon of the future is expected to perform more complex procedures. More patients will enter a multimodal treatment scheme making surgery more difficult due to severe inflammation. Furthermore, due to lung cancer screening programs, the number of patients presenting with operable smaller lung nodules in the periphery of the lung will increase. This, combined with the fact that segmentectomy is becoming an increasingly popular treatment for small peripheral lung lesions, indicates that the future thoracic surgeons need to have profound knowledge of segmental resections. New imaging techniques will help them to locate these lesions and to achieve a complete oncologic resection. Current robotic techniques exist to help the thoracic surgeon overcome these challenges. In this review, an update of the latest MIS approaches and nodule detection techniques will be given.

Comparative early results of a robotics-assisted endoscope holder in single port thoracoscopic surgery in the era of COVID-19

Background

Innovations in surgical instruments have made single-port surgery more widely accepted and lead to a reduced demand for surgical assistants. As COVID-19 has ravaged the world, maintaining minimum medical staffing requirements and proper social distancing have become major topics of interest. We sought to evaluate the feasibility of applying the unisurgeon approach in single-port video-assisted thoracoscopic surgery aided by a robotic camera holder.

Methods

Operative time, blood loss, setup time, postoperative hospital stays, and the number of participating surgeons in single-port video-assisted thoracoscopic lung resections were gathered for investigation after the introduction of the ENDOFIX^exo robotic endoscope holder system. In this cohort, we collected 213 patients who underwent single port video thoracoscope surgery, including 57 patients underwent robotic endoscope arm assisted surgery and case-matched 52 patients in the robotic arm–assisted group with patients in the human-assisted group through propensity score–matched analysis.

Results

In wedge resection, a single surgeon was able to completely operate on all lobes of target lesions. However, for anatomical resections, namely segmentectomy, the success rate was 95%, and for lobectomy, the success rate was only 64%. No significant differences between setup times, blood loss, or operative times between the two groups were observed.

Conclusions

When an experienced uniport surgeon is assisted by a robotic endoscope holder, wedge resection is the most suitable procedure to be performed through unisurgeon single-port video-assisted thoracoscopic surgery without increasing setup time, operative time, or short-term complications. Verification of the technique’s applicability for use in anatomic resections requires further investigation.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-022-09054-8.

Conversion from video-assisted thoracic surgery (VATS) to thoracotomy during major lung resection: how does it affect perioperative outcomes?

OBJECTIVES

Since video-assisted thoracic surgery (VATS) was first performed in the early 1990s, there have been many developments, and the conversion rate has decreased over the years. This article highlights the specific outcomes of patients undergoing conversion to thoracotomy despite initially scheduled VATS lung resection.

METHODS

We retrospectively reviewed 501 patients who underwent thoracoscopic anatomic lung resection (i.e. lobectomy, segmentectomy or bilobectomy) between 1 January 2012 and 1 August 2017 at our institution. We explored the risk factors for surgical conversion and adverse events occurring in patients who underwent conversion to thoracotomy.

RESULTS

A total of 44/501 patients underwent conversion during the procedure (global rate: 8.8%). The main reasons for conversion were (i) anatomical variation, adhesions or unexpected tumour extension (37%), followed by (ii) vascular causes (30%) and (iii) unexpected lymph node invasion (20%). The least common reason for conversion was technical failure (13%). We could not identify any specific risk factors for conversion. The global complication rate was significantly higher in converted patients (40.9%) than in complete VATS patients (16.8%) (P = 0.001). Postoperative atrial fibrillation was a major complication in converted patients (18.2%) [odds ratio (OR) 5.09, 95% confidence interval (CI) 1.80-13.27; P = 0.001]. Perioperative mortality was higher in the conversion group (6.8%) than in the VATS group (0.2%) (OR 33.3, 95% CI 3.4-328; P = 0.003).

CONCLUSIONS

Through the years, the global conversion rate has dramatically decreased to <10%. Nevertheless, patients who undergo conversion represent a high-risk population in terms of complications (40.9% vs 16.8%) and perioperative mortality (6.8% vs 0.2%).

[Reasons for Conversion to Thoracotomy in 83 Cases during Video-assisted Thoracic Surgery Lobectomy: A Summary of 1,350 Consecutive Operations by A Single Surgical Team]

背景与目的

电视胸腔镜手术（video-assisted thoracic surgery, VATS）为肺癌治疗的主流术式，本研究旨在分析单手术组连续VATS肺叶切除术1, 350例中转开胸83例的中转原因，以期对常态下胸腔镜肺叶切除术中转开胸的规律有更深层次的认识，并更好地把握中转开胸的手术时机。

方法

回顾性分析2009年9月21日-2020年6月1日河北医科大学第四医院胸外科单手术组连续行胸腔镜肺叶切除术的1, 350例患者资料。其中男性773例，女性577例，年龄8岁-87岁，中位年龄61.3岁。全组良性疾病83例，肺转移瘤38例，原发性肺癌1, 229例，其中Ⅰ期: 676例，Ⅱ期: 323例，Ⅲa期: 230例。全组行左肺上叶切除术301例（22.30%），左肺下叶切除术231例（17.11%），右肺上叶切除术378例（28.00%），右肺中叶切除术119例（8.81%），右肺下叶切除术262例（19.41%），右肺中上叶切除术16例（1.19%），右肺中下叶切除术43例（3.19%）。

结果

单手术组连续1, 350例胸腔镜肺叶切除术患者中有83例（6.15%）因不同原因中转开胸。良性病变的中转开胸率高于恶性肿瘤（P < 0.05）；病理分期为Ⅲa期的中转开胸率明显高于Ⅰ期、Ⅱ期患者（P < 0.05）。联合肺叶切除术的中转开胸率明显高于单肺叶切除术（P=0.001）；左肺上叶切除术的中转开胸率显著高于其他单肺叶切除术（P < 0.001）；右肺中叶切除术的中转开胸率低于其他单肺叶切除术（P=0.049）。中转开胸主要原因为血管损伤（38.55%）、淋巴结干扰（26.51%）、胸腔致密粘连（16.87%）；中转开胸组总体手术时间为（236.99±66.50）min，总体失血量（395.85±306.38）mL。其中淋巴结干扰组患者手术时间（322.50±22.68）min，长于其他原因中转开胸组（P < 0.05）；血管损伤组术中出血量（560.94±361.84）mL，多于其他原因中转开胸组（P < 0.05）；随着时间的推移以及经验的积累，在手术前、中、后期血管损伤例数逐步下降（P < 0.05）。

结论

在胸腔镜手术中，肺部良性病变和较晚期恶性肿瘤有较高的手术难度和中转率。不同肺叶切除术中转开胸率不同，左肺上叶切除术中转率较高，而右肺中叶切除术中转率较低。血管损伤、淋巴结干扰、胸腔致密粘连仍是常态下胸腔镜肺叶切除术中转开胸的主要原因。中转开胸会导致手术时间延长和手术出血量增加。随着手术例数的增加，胸腔镜肺叶切除术中转开胸率有持续下降趋势，其主要原因是肺血管的处理更加成熟。

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

 

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Estimating the risk of conversion from video-assisted thoracoscopic lung surgery to thoracotomy-a systematic review and meta-analysis

Background

Understanding the risk of conversion from video-assisted thoracic surgery (VATS) to thoracotomy is important when considering patient selection and preoperative surgical risk assessment. This review aims to estimate the rate of intraoperative conversions to thoracotomy, predictive factors, and associated outcomes for VATS anatomic lung resections.

Methods

PubMed/MEDLINE and EMBASE were searched systematically in May of 2020. Observational studies examining conversions of VATS anatomic resections to thoracotomy were included. Conversion rates, causes, risk factors, and post-operative outcomes were reviewed and analyzed in aggregate.

Results

Twenty retrospective studies were reviewed, with a total of 72,932 patients undergoing VATS anatomic lung resection. The median conversion rate was 9.6% (95% CI: 6.6–13.9%). Nine studies reported a total of 114 emergency conversions, with a median incidence rate of 1.3% (95% CI: 0.6–2.8%). The most common reasons for thoracotomy were vascular injury/bleeding, difficulty lymph node dissection, and adhesions, accounting for 27.9%, 26.2% and 19% of conversions, respectively. Risk factors for conversion varied, but frequently included nodal disease, large tumors, and induction therapy. The risk of complications (OR 2.06; 95% CI: 1.77–2.40) and mortality (OR 4.11; 95% CI: 1.59–10.61) were significantly increased following conversions. There was also a significant increase in chest tube duration and length of stay following conversion.

Conclusions

The risk of conversion to thoracotomy may be as high as one in ten patients undergoing VATS anatomic lung resections, but may vary significantly based on patient selection. Although emergent conversions are rare, the need for thoracotomy may significantly increase postoperative morbidity and mortality.

Risk factors of conversion in robotic- and video-assisted pulmonary surgery for non-small cell lung cancer

BACKGROUND

This study aimed to investigate risk factors of conversion to thoracotomy for patients with non-small cell lung cancer (NSCLC) underwent robotic- (RATS) or video-assisted thoracoscopic surgery (VATS).

METHODS

A retrospective review was conducted to included consecutive participants from January 2016 to December 2018. Three groups [mini-invasive, conversion, and up-front open thoracotomy (OT) groups] and two series of comparison (conversion versus mini-invasive, and conversion versus OT) were generated. Propensity score-matched analysis (1:1) was conducted to verify outcomes of complications and perioperative factors. Multivariate binary logistic regression analysis was used to identify potential risk factors of conversion.

RESULTS

1177 patients (912 in mini-invasive group, 180 in conversion group, and 85 in OT group) were included. The overall conversion rate was 16.5%. Robotic approach resulted in dramatically lower conversion rate compared to VATS (2.4% vs 25.1%, p < 0.001). After propensity adjustment, no significant difference of complication rates was identified when comparing conversion group with mini-invasive and OT groups. Multivariate regression analyses shown that robotic approach (odd ratio (OR) = 0.037, 95% confidential interval (CI) 0.016-0.087), tumor size < 5 cm (OR = 0.274, 95% CI 0.152-0.493), no chief symptom(OR = 0.311, 95% CI 0.178-0.545), body mass index < 25 kg/m² (OR = 0.537, 95% CI 0.343-0.842), and lobectomy (OR = 0.079, 95% CI 0.017-0.370) were independent protectors of conversion.

CONCLUSIONS

Seven demographic factors might be recognized as independent predictors of conversion. For patients with highly risk of conversion, robotic approach is recommended to perform mini-invasive pulmonary surgery over VATS.

The Application of Uniportal Video-Assisted Thoracoscopic Anatomical Segmentectomy for Lung Resection: A Retrospective Clinical Study

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) is a new area of exploration and evolution in thoracic minimal invasive surgery. The uniportal VATS approach has become popular during lung resection for small nodules and ground glass lesions. Our objective is to investigate the efficacy, availability and safety of uniportal VATS anatomical segmentectomy compared with conventional VATS in patients for lung resection.

METHODS

Surgical patients of perioperative period who admitted and underwent uniportal, two-port and conventional three-port VATS segmentectomy were analyzed and compared retrospectively during the year 2017 to 2018.

RESULTS

During the research period, of 111 patients who had VATS anatomical segmentectomy, 38 underwent uniportal, 43 underwent two-port, and 30 underwent three-port VATS. Four patients underwent conversion to thoracotomy. There were no postoperative mortalities, and there were no significant differences among the three groups in surgical outcomes, including operative time, blood loss, conversions to thoracotomy, drainage time and volume, lymph node dissection, postoperative complications and hospital stay. The pain scores of visual analog scale (VAS) significantly decreased in uniportal group when operation is finished (P < 0.05).

CONCLUSION

This study demonstrates that uniportal VATS anatomical segmentectomy is a quite safe surgical technology, as well as feasible, which can cause reduced postoperative pain and less surgical trauma compared to conventional VATS. More experiences and observations of large samples are on the way.

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.

Early-Stage NSCLC: Advances in Thoracic Oncology 2018

2018 was a banner year for all thoracic oncology, but especially for early-stage NSCLC. Three seminal events occurred in the approximately 18 months from mid-2017 to the end of 2018: in June 2017 at the American Society of Clinical Oncology Annual Meeting a small, relatively unheralded study from Max Diehn's group at Stanford University reported on the use of a novel "cancer personalized profiling by deep sequencing" circulating tumor-DNA technology to identify minimal residual disease in patients after curative-intent radiation or surgery for NSCLC; in April 2018 at the American Association for Cancer Research Annual Meeting, Drew Pardoll presented a small pilot study of 21 patients who had received two doses of preoperative nivolumab; in September 2018, at the 19th World Conference on Lung Cancer, Harry J. De Koning presented the long-awaited results of the Dutch-Belgian Lung Cancer Screening Trial (NELSON). These three seminal studies, along with others which are reviewed in this paper, promise to accelerate our progress towards a world in which lung cancer is identified early, more patients undergo curative-intent treatment that achieves the promised cure, and those at risk for failure after treatment are identified early, when the cancer remains most vulnerable. The day is around the corner when lung cancer is defanged and no longer the worldwide terror it currently is. We herein present an overview of the most recent body of work that moves us inexorably towards that day.

Use of Minimally Invasive Surgery in the Diagnosis and Treatment of Cancer in Dogs and Cats

Surgical management of neoplastic disease is common in veterinary medicine. Minimally invasive surgery (MIS) has gained widespread acceptance by veterinary surgeons and is experiencing rapid growth and frequency of use. Many neoplastic diseases in the abdomen and thorax of dogs and cats can be treated as effectively with MIS as with traditional open surgery. Additionally, MIS allows for less invasive options for organ biopsy in cancer patients either for initial diagnosis or for staging to inform prognosis and treatment. Despite the recent increase in MIS, additional research is required to further characterize the benefits to oncology patients and to ensure that surgical oncologic principles and patient outcomes are not compromised by the use of MIS.