Standardizing eligibility and patient selection for Pressurized Intraperitoneal Aerosol Chemotherapy: A Delphi consensus statement

INTRODUCTION

Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) is a procedure for minimally invasive drug administration in patients with peritoneal metastasis. Previous studies have emphasized the importance of uniformity in treatment protocols and standardization of this practice. This study aimed to reach a consensus on eligibility, patient selection, and choice of chemotherapy for PIPAC.

METHODS

A three-round modified Delphi study was conducted. A steering group formulated a list of baseline statements, addressing the objectives. The steering group consisted of seven expert surgical and medical oncologists. Available evidence and published key opinions were critically reviewed. An international expert panel scored those statements on a 4-point Likert scale. The statements were submitted electronically and anonymously. Consensus was reached if the agreement rate was ≥75%. A minimum Cronbach's alpha of >0.8 was set.

RESULTS

Forty-five (45/58; 77.6%) experts participated and completed all rounds. Experts were digestive surgeons (n = 28), surgical oncologists (n = 7), gynecologists (n = 5), medical oncologists (n = 4), and one clinical researcher. Their assessment of 81 preliminary statements in the first round resulted in 41 consolidated statements. In round two, consensus was reached on 40 statements (40/41; 97.6%) with a consensus of ≥80% for each individual statement. In the third round, 40 statements were unanimously approved as definitive. The choice of first- and second-line chemotherapy remained controversial and could not reach consensus.

CONCLUSIONS

This International Delphi study provides practical guidance on eligibility and patient selection for PIPAC. Ongoing trial data and long-term results that could contribute to the further standardization of PIPAC are eagerly awaited.

Design Appropriate Incision Length for Uniportal Video-Assisted Thoracoscopic Lobectomy: Take into Account Safety and Minimal Invasiveness

BACKGROUND

 There is no criterion on the length of the uniportal video-assisted thoracoscopic surgery (UVATS) incision when performing lobectomy. We aimed to develop a nomogram to assist surgeons in designing incision length for different individuals.

METHODS

 A cohort consisting of 290 patients were enrolled for nomogram development. Univariate and multivariate logistic regression analyses were performed to identify candidate variables among perioperative characteristics. C-index and calibration curves were utilized for evaluating the performance of the nomogram. Short-term outcomes of nomogram-predicted high-risk patients were compared between long incision group and conventional incision group.

RESULTS

 Of 290 patients, 150 cases (51.7%) were performed incision extension during the surgery. Age, tumor size, and tumor location were identified as candidate variables related with intraoperative incision extension and were incorporated into the nomogram. C-index of the nomogram was 0.75 (95% confidence interval: 0.6961-0.8064), indicating the good predictive performance. Calibration curves presented good consistency between the nomogram prediction and actual observation. Of high-risk patients identified by the nomogram, the long incision group (n = 47) presented shorter duration of operation (p = 0.03), lower incidence of total complications (p = 0.01), and lower incidence of prolonged air leak (p = 0.03) compared with the conventional incision group (n = 55).

CONCLUSION

 We developed a novel nomogram for predicting the risk of intraoperative incision extension when performing uniportal video-assisted thoracoscopic lobectomy. This model has the potential to assist clinicians in designing the incision length preoperatively to ensure both safety and minimal invasiveness.

Get your 7-point golden medal for pain management in video-assisted thoracoscopic surgery

PURPOSE OF REVIEW

Thoracic surgery is evolving, necessitating an adaptation for perioperative anesthesia and analgesia. This review highlights the recent advancements in perioperative (multimodal) analgesia for minimally invasive thoracic surgery.

RECENT FINDINGS

Continuous advancements in surgical techniques have led to a reduction in surgical trauma. However, managing perioperative pain remains a major challenge, impeding postoperative recovery. The traditional neuraxial technique is now deemed outdated for minimally invasive thoracic surgery. Instead, newer regional techniques have emerged, and traditional approaches have undergone (re-)evaluation by experts and professional societies to establish guidelines and practices. Assessing the quality of recovery, evenafter discharge, has become a crucial factor in evaluating the effectiveness of these strategies, aiding clinicians in making informed decisions to improve perioperative care.

SUMMARY

In the realm of minimally invasive thoracic surgery, perioperative analgesia is typically administered through systemic and regional techniques. Nevertheless, collaboration between anesthesiologists and surgeons, utilizing surgically placed nerve blocks and an active chest drain management, has the potential to significantly improve overall patient care.

Are the Efficacy and Safety of Chest Tubes in Uniportal Video-Assisted Thoracic Surgery Related to the Level of Intercostal Space Insertion or to the Drain Type? A Prospective Multicenter Study

OBJECTIVES

The aim of this study is to evaluate if the efficacy and safety of chest tube placement are influenced by the level of intercostal space insertion (uniportal VATS vs. biportal VATS) or by the type of drain employed (standard vs. smart coaxial drain).

METHODS

Data on patients who underwent either uniportal or biportal VATS upper lobectomies with lymphadenectomy were prospectively collected in three European centers. The uniportal VATS group with a 28 Fr standard chest tube (U-VATS standard) was compared with the uniportal VATS group with a 28 Fr smart drain (U-VATS smart), and U-VATS smart was also compared with biportal VATS with a 28 Fr smart drain inserted in the VIII intercostal space (Bi-VATS smart).

RESULTS

When comparing the U-VATS standard group with the U-VATS smart, a higher fluid output was recorded in the U-VATS smart (p: 0.004) in the III post-operative day (p.o.) and overall (p: 0.027), with a lower 90-day re-admission in the U-VATS smart (p: 0.04). The Bi-VATS smart group compared to U-VATS smart showed a higher fluid output in the I p.o. (p < 0.001), with no difference in total fluid amount or hospitalization. The Bi-VATS smart recorded a lower incidence (p < 0.001) of residual pleural space or effusion (p: 0.004) at chest X-rays prior to drain removal but a higher level of pain and chronic intercostal neuralgia (p: 0.03).

CONCLUSIONS

Chest tube insertion through the same incision space in uniportal VATS seems to be safe and effective. Smart drains can improve the fluid output in uniportal VATS, as if the drainage were inserted in a lower space (i.e., biportal VATS), but with less discomfort.

Modifications to the video-assisted thoracoscopic surgery technique reduce 1-year mortality and postoperative complications in intrathoracic tumors

OBJECTIVE

The purpose of the study is to analyze the immediate outcomes and results of video-assisted thoracoscopic lobectomy and lung resection performed in the surgical department of the AOC between 2014 and 2018.

METHODS

For the period from 2014 to 2018, 118 patients with peripheral lung cancer were operated on in the surgical department of the AOC. The following operations were performed: lobectomy in 92 cases (78%), of which: upper lobectomy, 44 (47.8%); average lobectomy, 13 (14.1%); lower lobectomy, 32 (35%); bilobectomy, 3 (3.3%). All patients underwent extensive lymphadenectomy on the side of the operation. In 22 patients, for various reasons, preservation of thoracotomy was performed.

RESULTS

The absence of N0 lymph node damage was observed in 82 patients (70%), the first-order lymph node damage N1 in 13 (11%), N2 in 13 (11%), N3 in 5 (4%), and NX in 5 (4%). Histological examination revealed: squamous cell carcinoma - 35.1%, adenocarcinoma - 28.5%, undifferentiated carcinoma - 8.3%, NSCLC - 5.6%, NEO - 4.6%, sarcoma - 1.8%. At the same time, in 12.7% of patients, mts was detected - lung damage, and in 3.4%, malignant cells were not detected. Most patients were activated on the first day after surgery.

CONCLUSION

An analysis of the direct results of the study allows us to conclude that video-assisted thoracoscopic surgery is a highly effective, minimally invasive, safe method for treating peripheral lung cancer, which allows us to recommend it for wider use in oncological practice.

Pulmonary Lobectomy for Early-Stage Lung Cancer with Uniportal versus Three-Portal Video-Assisted Thoracic Surgery: Results from a Single-Centre Randomized Clinical Trial

Video-assisted thoracic surgery (VATS) is a consolidated approach; however, there is no consensus on the number of ports leading to less postoperative pain. We compared early postoperative pain after uniportal and three-portal VATS lobectomy for early-stage NSCLC. In this randomized clinical trial, patients undergoing VATS lobectomy were randomly assigned to receive uniportal (U-VATS Group) or three-portal (T-VATS Group) VATS. The inclusion criteria were age ≤ 80 years and ASA < 4. The exclusion criteria were clinical T3, previous thoracic surgery, induction therapy, chest radiotherapy, connective tissue or vascular diseases, major organ failure, and analgesics or corticosteroids use. The postoperative analgesia protocol was based on NRS. Pain was measured as analgesic consumption; the secondary endpoints were intra- and postoperative complications, conversion rate, surgical time, dissected lymph nodes, hospital stay, and respiratory function. Out of 302 eligible patients, 120 were included; demographics were distributed homogeneously. The mean cumulative morphine consumption (CMC) in the U-VATS Group after 7 days was lower than in the T-VATS Group (77.4 mg vs. 90.1 mg, p = 0.003). Intraoperative variables and postoperative complications were comparable. The 30-day intercostal neuralgia rate was lower in the U-VATS Group, without reaching statistical significance. Patients undergoing U-VATS showed a lower analgesic consumption compared with the T-VATS Group; analgesic consumption was moderate in both groups.

Comparison of robot-assisted thoracic surgery versus video-assisted thoracic surgery in the treatment of lung cancer: a systematic review and meta-analysis of prospective studies

Introduction

Previous studies have compared robot-assisted thoracic surgery(RATS) with video-assisted thoracic surgery (VATS) in the treatment of patients with lung cancer, but results were conflicting. The present meta-analysis aimed to compare the clinical outcomes of RATS with VATS in the treatment of patients with lung cancer.

Materials and methods

Web of Science, PubMed, Cochrane Library and Embase were comprehensively searched for randomized controlled trials or prospective cohort studies comparing the clinical outcomes of RATS and VATS from inception to 22 July 2023. The Cochrane Risk of Bias tool was used to assess risk of bias. Meta-analyses of length of hospital stay, postoperative duration of drainage, postoperative complications, operative time, conversion, estimated blood loss, the number of dissected lymph nodes and stations, 30-day readmission and 30-day mortality were performed.

Results

In total 5 studies were included in the meta-analysis. A total of 614 patients were included, of which 299 patients were treated by RATS and 315 patients treated by VATS. Blood loss was significantly less in RATS group than that in VATS (MD = -17.14, 95% CI -29.96 ~ -4.33, P = 0.009). More nodes stations were dissected in RATS group compared with VATS group(MD= 1.07, 95% CI 0.79 ~ 1.36, P < 0.001). No significant difference occurred between RATS and VATS in length of hospital stay(MD= -0.19, 95% CI -0.98~0.61), readmission(OR=0.74, 95%CI 0.36~1.51, P=0.41), operative time(MD=11.43 95% CI -8.41~31.26, P=0.26), conversion(OR=0.58, 95% CI 0.29~1.17, P=0.13), number of dissected lymph nodes(MD=0.98, 95% CI -0.02~1.97, P=0.05), upstaging rate(OR =0.67, 95% CI 0.38 ~ 1.18, P =0.16, I2 = 0%), time of chest tube drainage (MD= -0.34, 95%CI -0.84~0.15, P=0.17), post-operative complications(OR=0.76, 95% CI 0.52~ 1.11, P=0.16) and total cost(MD = 3103.48, 95% CI -575.78 ~ 6782.74, P=0.1, I2 = 99%).

Conclusion

RATS is a feasible and safe treatment that can achieve better surgical outcomes compared with VATS in terms of short-term outcomes. Except of higher total cost, RATS has obvious advantage in lymphadenectomy and control of intraoperative bleeding. However, large sample and long follow-up randomized clinical trials comparing RATS with VATS are still necessary to better demonstrate the advantages of RATS for lung cancer.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, Identifier CRD42023446653.

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 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.

Safety and feasibility of preferential manual bronchoplasty in 2-3 cm single-port video-assisted thoracoscopic lobectomy

BACKGROUND

This retrospective study aimed to compare preferential manual bronchoplasty (PMB) and mechanical stapler closure (MSC) of the bronchial stump after 2-3 cm single-port (SP) video-assisted thoracoscopic surgery (VATS) lobectomy in patients with pathological T1 (pT1) stage lung cancer.

METHODS

Between January 2019 and March 2022, patients with pulmonary neoplasms who underwent 2-3 cm SP VATS lobectomy were retrospectively screened. After propensity-matched analysis, we compared perioperative outcomes and analyzed the safety and feasibility of PMB and MSC of the bronchial stump while performing VATS lobectomy.

RESULTS

In this study, 280 and 832 patients were enrolled in the PMB and MSC groups, respectively. Propensity score matching produced 280 pairs. The operation time was shorter in the PMB group, whereas the average number of lymph nodes dissected was higher in the PMB group. The conversion rate was significantly lower in the PMB group. The following were similar between the PMB and MSC groups, respectively: average blood loss volume, postoperative hospital stay, and chest tube removal time. Postoperatively, the incidence of atelectasis was significantly higher in the MSC group. As per subgroup analyses, PMB was associated with a shorter operation time in left and right upper lobectomies. Particularly in left upper lobectomy, PMB had more lymph node dissections and less conversion to open and postoperative atelectasis.

CONCLUSIONS

In comparison with MSC of the bronchial stump, PMB showed better safety and feasibility in 2-3 cm SP VATS left and right superior lobectomies in patients with pT1 stage lung cancer.

Health-Related Quality of Life Following Robotic-Assisted or Video-Assisted Lobectomy in Patients With Non-Small Cell Lung Cancer: Results From the RVlob Randomized Clinical Trial

BACKGROUND

Robot-assisted lobectomy (RAL) is increasingly used as an alternative to video-assisted lobectomy (VAL) for resectable non-small cell lung cancer (NSCLC). However, there is little evidence of any difference in postoperative health-related quality of life (HRQoL) between these two approaches.

RESEARCH QUESTION

Is RAL superior to VAL in improving quality of life in patients with resectable NSCLC?

STUDY DESIGN AND METHODS

We performed a single-center, open-label randomized clinical trial from May 2017 to May 2020 with 320 enrolled patients undergoing RAL or VAL for resectable NSCLC (RVlob trial; NCT03134534). Postoperative pain was evaluated by visual analog score or numeric rating score on postoperative day 1 and at weeks 4, 24, and 48. The European Organization for Research and Treatment of Cancer (EORTC) Core Quality of Life Questionnaire (QLQ-C30), EORTC Quality of Life Questionnaire in Lung Cancer (QLQ-LC13), and the European Quality of Life 5 Dimensions (EQ-5D) questionnaire were also administered at weeks 4, 24, and 48 after surgery.

RESULTS

One hundred and fifty-seven patients underwent RAL and 163 underwent VAL. The mean pain score of patients after RAL was significantly lower at week 4 (2.097 ± 0.111 vs 2.431 ± 0.108; P = .032). QLQ-C30 and QLQ-LC13 summary scores (P > .05) were similar for both RAL and VAL during the first 48 weeks of follow-up. HRQoL scores assessed with the EQ-5D questionnaire were also comparable between the two groups (P > .05) during the whole study period.

INTERPRETATION

Both RAL and VAL showed satisfactory and comparable HRQoL and postoperative pain up to 48 weeks after surgery, despite some minor statistical differences at week 4.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov; No.: NCT03134534; URL: www.

CLINICALTRIALS

gov.

A Preclinical Feasibility Study of Single-Port Robotic Subcostal Anatomical Lung Resection and Subxiphoid Thymectomy Using the da Vinci® SP System

Despite the recent introduction of technologically advanced single-port (SP) robotic systems, their use in the field of thoracic surgery has been rarely explored. Here, we report our preclinical experience concerning SP robotic thoracic surgery using the da Vinci^® SP system. The da Vinci^® SP system was used to perform subcostal anatomical lung resection and subxiphoid thymectomy in three cadavers. The operative settings that best met the surgeon's requirements for each resection were also determined. Four subcostal anatomical lung resections and two subxiphoid thymectomies were completed. While both procedures did not require additional incisions, the use of an observation port in the intercostal spaces was strongly recommended to safely create subcostal access. Dissection of hilar structures and mediastinal lymph nodes was feasible. However, due to the current unavailability of a robotic stapler, a handheld stapling instrument was required to perform a transection of vital structures. When the stapling process proved to be difficult, the table surgeon temporarily removed a robotic arm to acquire the necessary space to complete the procedure. Our data represent a promising preclinical step in understanding the feasibility of using the da Vinci^® SP system to perform an SP subcostal anatomical lung resection and a subxiphoid thymectomy.

Uniportal VATS lobectomy versus thoracotomy lobectomy for NSCLC larger than 5 cm: A propensity score-matched study

BACKGROUND

The performance of uniportal VATS lobectomy (uVATS) for non-small cell lung cancer (NSCLC) larger than 5 cm is uncertain due to a lack of evidence. Here, we present a retrospective, propensity-score matched cohort study to evaluate the safety and effectiveness of uVATS for patients with locally advanced NSCLC.

METHODS

The data of patients with NSCLC larger than 5 cm diameter who underwent curative resection via uVATS or thoracotomy lobectomy between January 2015 and December 2020 was collected. Propensity-score matching was utilized to control the observable biases.

RESULTS

Seventy-two patients underwent uVATS lobectomy, while 38 received thoracotomy lobectomy. No conversion to open surgery or perioperative death occurred. uVATS lobectomy achieved similar total lymph node dissection counts compared to thoracotomy and even yielded a higher amount of lymph node dissection in pTNM stage II patients. The long-term overall and recurrence-free survival rates were also similar between the two groups. Results from the propensity-score matching generated cohort agreed with those from the full cohort.

CONCLUSIONS

uVATS lobectomy is feasible and effective for curative lobectomy for NSCLC larger than 5 cm in diameter in selected patients. Further validations from well-designed prospective studies are required for uVATS lobectomy for patients with locally advanced NSCLC.

Single-port robot-assisted retroperitoneal surgery: A feasible approach

INTRODUCTION

The concept of surgery through a single incision has been pursued in the field of minimal invasion for the treatment of different pathologies. This, added to a retroperitoneal approach, implies less aggression for the patient at different levels. We describe the first cases of single-port robot-assisted retroperitoneal surgery (SP-RARS) in our country using the da Vinci Xi® system.

MATERIAL AND METHODS

We present two cases of patients with right adrenal masses larger than 4 cm. The first case was a 55-year-old woman with an incidental diagnosis of angiomyolipoma, and the second case was a 62-year-old man with a non-functioning adrenal adenoma. Both cases were operated through a single 4-cm subcostal incision using the da Vinci Xi® system, annulling arm 4 without reallocating laterality on the surgeon's console.

RESULTS

Both surgeries were performed with console times of 75 and 150 min, respectively, with access and docking times below 30 min. Bleeding was less than 100 cc in both surgeries without the need to make accessory incisions or leave a drainage tube. The surgical specimens were removed through the same initial incision without the need for enlargement. Postoperative intravenous analgesia was not necessary in any case (VAS 0) and hospital stay was less than 24 h in both patients without reporting any complications.

CONCLUSIONS

SP-RARS is a feasible approach using the da Vinci Xi® system.

Easy Intra-Operative Localization of Pulmonary Nodules during Uniportal Video-Assisted Thoracoscopy: Experience with Hydrogel Plugs at Our Institution

Background: The diffusion of lung cancer screening programs has increased the detection of both solid and ground-glass opacity (GGO) sub-centimetric lesions, leading to the necessity for histological diagnoses. A percutaneous CT-guided biopsy may be challenging, thus making surgical excision a valid diagnostic alternative. CT-guided hydrogel plug deployment (BioSentry^®) was recently proposed to simplify intraoperative nodule localization. Here, we report our initial experience. Methods: We evaluated 62 patients with single, small, peripheral, non-subpleural pulmonary GGO that was suspicious for cancer. All lesions were preoperatively marked, using CT-guidance, with a hydrogel plug (BioSentry^®). Then, a uniportal video-assisted thoracoscopy (uniVATS) wedge resection was performed. If cancer was confirmed at the frozen section, a major lung resection was then performed. The study’s end points were the rates of intraoperative localization and of successful resection. Results: The hydrogel plug was correctly placed in 54 of the 62 cases, leading to an effective resection of the target lesion. In the remaining eight cases, the plug was displaced, and so the identification of pleural erosions due to the previous percutaneous procedure guided the resection. The uniVATS resection success rate was 98.3%. Conclusions: CT-guided hydrogel plug placement allowed for the successful detection of lung GGOs and resection with the uniVATS approach. This device allowed us to obtain lung cancer diagnoses and successfully treat 85.4% of cases.

Extensive open lobectomy experience is not a prerequisite for learning uniportal video-assisted thoracic surgery lobectomy

BACKGROUND AND OBJECTIVES

Uniportal video-assisted thoracoscopic surgery (U-VATS) lobectomy has been increasingly adopted to manage early stage lung cancer. However, little information is available on whether this technique can be taught to surgeons inexperienced in open lobectomy. This study aimed to investigate the learning curve for U-VATS lobectomy performed by a single surgeon with limited open lobectomy experience.

METHODS

From July 2018 to September 2020, 103 patients received U-VATS lobectomy for lung cancer by a single surgeon. The learning curve was assessed using three statistical methods: the moving average analysis, cumulative sum (CUSUM) analysis, and risk-adjusted CUSUM (RA-CUSUM) analysis.

RESULTS

The moving average analysis showed a continuous decrease in operative time throughout the study period. The CUSUM analysis demonstrated three well-differentiated learning phases: Phase 1 (the initial 34 cases) representing the initial learning, Phase 2 (the middle 33 cases) representing the improvement of competence, and Phase 3 (the final 36 cases) representing technical proficiency. RA-CUSUM analysis revealed that the maximized cumulative surgical failure, defined as the maximum cumulative difference between the observed and predicted surgical failures, was found in the 61st case.

CONCLUSIONS

U-VATS lobectomy is feasible for surgeons with limited open lobectomy experience. Multidimensional statistical analyses suggested that 61-67 cases were required to gain technical proficiency and ensure acceptable surgical outcomes.

Learning curve of uniportal video-assisted thoracoscopic lobectomy: an analysis of the proficiency of 538 cases from a single centre

OBJECTIVES

Uniportal video-assisted thoracoscopic surgery (UniVATS) is widely used as a minimally invasive thoracic operation. The goal of our study was to analyse the effect of long-term experience with the UniVATS lobectomy on the learning curve.

METHODS

The learning curves were quantitatively evaluated by the unadjusted cumulative sum, and they were segmented using joinpoint linear regression analysis. The variables were compared between subgroups using trend analysis, and linear regression analysis was applied to correlate clinical characteristics at different stages of the learning curve with the duration of the operation.

RESULTS

The learning curve for the UniVATS lobectomy can be divided into 3 phases of proficiency at ∼200-300 procedures, with a fourth phase as the number of procedures increases. The 1st-52nd, 52nd-156th, 156th-244th and 244th-538th procedures comprised the preliminary learning stage, preliminary proficiency stage, proficiency stage and advanced proficiency stage, respectively. Surgical outcomes and their variability between stages improved with increasing case numbers, with the most significant addition of an auxiliary operating port and conversions. In multivariable analysis, as stages progressed, influences other than surgical experience increased the operative time, with male and extensive pleural adhesions in the preliminary proficiency stage; male and incomplete pulmonary fissures in the proficiency stage; and male, extensive pleural adhesions and incomplete pulmonary fissures in the advanced proficiency stage.

CONCLUSIONS

As the number of procedures increases, there may be 4 different proficiency stages in the UniVATS lobectomy learning curve. The surgeon enters the fourth stage at approximately the 244th procedure. Moreover, at stage 4, the perioperative indicators tend to stabilize, and influences other than surgical experience become more significant.

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.

Non-intubated Thoracoscopic Surgery-Tips and Tricks From Anesthesiological Aspects: A Mini Review

Background

In the last few decades, surgical techniques have been developed in thoracic surgery, and minimally invasive strategies such as multi-and uniportal video-assisted thoracic surgery (VATS) have become more favorable even for major pulmonary resections. With this surgical evolution, the aesthetic approach has also changed, and a paradigm shift has occurred. The traditional conception of general anesthesia, muscle relaxation, and intubation has been re-evaluated, and spontaneous breathing plays a central role in our practice by performing non-intubated thoracoscopic surgeries (NITS-VATS).

Methods

We performed a computerized search of the medical literature (PubMed, Google Scholar, Scopus) to identify relevant articles in non-intubated thoracoscopic surgery using the following terms [(non-intubated) OR (non-intubated) OR (awake) OR (tubeless) OR (regional anesthesia)] AND [(VATS) OR (NIVATS)], as well as their Medical Subject Headings (MeSH) terms.

Results

Based on the outcomes of the reviewed literature and our practice, it seems that pathophysiological concerns can be overcome by proper surgical and anesthetic management. All risks are compensated by the advantageous physiological changes that result in better patient outcomes. With the maintenance of spontaneous breathing, the incidence of potential adverse effects of mechanical ventilation, such as ventilator-induced lung injury and consequent postoperative pulmonary complications, can be reduced. The avoidance of muscle relaxants also results in the maintenance of contraction of the dependent hemidiaphragm and lower airway pressure levels, which may lead to better ventilation-perfusion matching. These techniques can be challenging for surgeons as well as for anesthetists; hence, a good knowledge of physiological and pathophysiological changes, clear inclusion and exclusion and intraoperative conversion criteria, and good communication between team members are essential.

Conclusion

NITS-VATS seems to be a feasible and safe method in selected patients with evolving importance as a part of the minimally invasive surgical and anesthetic conception and has a role in reducing perioperative complications, which is crucial in the thoracic surgical patient population.

Suction Versus Nonsuction Drainage After Uniportal Video-Assisted Thoracoscopic Surgery: A Propensity Score-Matched Study

Background

Uniportal video-assisted thoracoscopic surgery (UniVATS) was utilized with a rapid growth. The evidence is sparse, however, on whether to add external suction to water-seal drainage for chest drainage after UniVATS. This retrospective propensity score-matched study aimed to identify the necessity of adding external suction to chest drainage after UniVATS.

Methods

Patients with lung cancer who underwent UniVATS were included from our prospectively maintained database. Patients were divided into two cohorts based on the addition of external suction to postoperative water-seal drainage or not. Propensity score-matched analysis was performed to identify the impact of suction on chest tube duration, incidence of persistent air leak, hospital stay, and hospitalization cost. Multivariable model with interaction terms was constructed to identify impact of covariables on effect of suction.

Results

The two cohorts matched well on baseline characteristics (nonsuction: 173; suction: 96). Compared with nonsuction group, suction group showed longer median chest tube duration (3 vs. 2 days, p = 0.003), higher incidences of persistent air leak (9.4% vs. 1.2%, p = 0.003), persistent drainage (16.8% vs. 5.8%, p = 0.007), and reduced drainage volume within first 3 postoperative days (386.90 vs. 504.78 ml, p = 0.011). Resection extent was identified to mediate the relationship between suction and chest tube drainage.

Conclusions

These findings discouraged adding external suction to water-seal drainage after UniVATS regarding longer chest tube duration and more persistent air leak. Patients undergoing lobectomy would benefit more from water-seal drainage without external suction compared with those doing sublobectomy.

Lung cancer

Lung cancer is one of the most frequently diagnosed cancers and the leading cause of cancer-related deaths worldwide with an estimated 2 million new cases and 1·76 million deaths per year. Substantial improvements in our understanding of disease biology, application of predictive biomarkers, and refinements in treatment have led to remarkable progress in the past two decades and transformed outcomes for many patients. This seminar provides an overview of advances in the screening, diagnosis, and treatment of non-small-cell lung cancer and small-cell lung cancer, with a particular focus on targeted therapies and immune checkpoint inhibitors.

Quality of life after partial lung resection with uniportal versus 3-port video-assisted thoracoscopic surgery: a prospective randomized controlled study

PURPOSE

The effect of uniportal video-assisted thoracoscopic surgery (uni-VATS) versus that of conventional VATS on postoperative quality of life (QOL) is unclear. This prospective randomized controlled study compared uni-VATS and conventional 3-port VATS in terms of QOL and patient satisfaction.

METHODS

The subjects of this study were 84 patients with pulmonary nodules or bullous formation, randomized to undergo uniportal or conventional 3-port video-assisted thoracoscopic partial lung resection. The primary endpoint was postoperative pain, assessed using a numeric rating scale on postoperative day (POD) 1.

RESULTS

No differences were found in the numeric rating scale on POD 1 after uni-VATS and conventional 3-port VATS. There were also no differences in blood loss, operative time, complication rate, surgical margin, analgesic requirement, vital capacity (VC), forced expiratory volume in 1 s (FEV1), the 6-min walk test (6MWT), C-reactive protein (CRP) levels, white blood cell count (WBC), or duration of chest tube drainage and hospital stay. Differences were found in the numeric rating scale on days 2, 3, 5, and 10 and in the patient satisfaction score on PODs 5 and 10.

CONCLUSIONS

Uni-VATS is associated with less chest pain and better patient satisfaction in the short term but without differences in complication rates or surgical margins from the lesions.

CLINICAL TRIAL REGISTRY NUMBER

University Hospital Medical Information Network Clinical Trial Registry (UMIN000015340 http://www.umin.ac.jp/english/ ).

The learning curve for uniportal video-assisted thoracoscopic anatomical segmentectomy

OBJECTIVES

The aim of this study is to evaluate the time course and caseload required to achieve proficiency by plotting the learning curve of uniportal thoracoscopic segmentectomy.

METHODS

We retrospectively analyzed the first 238 and 159 cases of uniportal thoracoscopic segmentectomy performed by two surgeons (A and B). The learning curves were assessed using cumulative sum analysis. Perioperative outcomes were evaluated as the learning curve developed. Two subtypes of this surgical approach, simple and complex segmentectomy, were separately analyzed.

RESULTS

Based on the learning curve, the inflection points occurred at 64 and 90 cases for surgeon A, 71 and 100 cases for surgeon B. Significantly longer operative time (p = .013), length of stay (p = .002), and drainage duration (p = .039) were observed between phase I and phase II compared to phase III for surgeon A. Operative times (p = .001) were significantly reduced for surgeon B. Furthermore, 26-28 and 52-56 cases were necessary to master the simple and complex segmentectomy, respectively.

CONCLUSIONS

A total 64-71 cases were required to master uniportal thoracoscopic segmentectomy and 90-100 cases were necessary to achieve proficiency.

Tailored anaesthesia for thoracoscopic surgery promoting enhanced recovery: The state of the art

PURPOSE OF THE REVIEW

The current review focuses on precise anaesthesia for video-assisted thoracoscopic surgery (VATS) with the goal of enhanced recovery. The main aim of an enhanced recovery program after thoracic surgery is to reduce postoperative stress response, protect from postoperative pulmonary complications, give hospitals a better financial option and improve overall patient outcome. This can ultimately reduce hospital stay and increase patient satisfaction. With advances in endoscopic, robotic and endovascular techniques, video-assisted thoracoscopic surgery (VATS) can be performed in a minimally invasive way in managing most pulmonary, pleural and mediastinal diseases. As a minimally invasive technique, video-assisted thoracoscopic surgery (VATS) represents an important element of enhanced recovery program in thoracic surgery as it can achieve most of its goals. Anaesthetic management during preoperative, intraoperative and postoperative period is essential for the establishment of a successful enhanced recovery program. In the era of enhanced recovery protocols, non-intubated thoracoscopic procedures present a step forward. This article focuses on the key anaesthetic elements of the enhanced recovery program during all phases of thoracoscopic surgery. Having reviewed recent literature, a systematic review of literature will highlight successful ERAS protocols published for thoracoscopic surgery.

Uniportal and three-portal video-assisted thoracic surgery pulmonary lobectomy for early-stage lung cancer (UNIT trial): study protocol of a single-center randomized trial

Background

Video-assisted thoracoscopic surgery (VATS) lobectomy is currently the recommended approach for treating early-stage non-small cell lung cancer (NSCLC). Different VATS approaches have been proposed so far, and the actual advantages of one technique over the other are still under debate. The aim of our study is to compare postoperative pain and analgesic drug consumption in uniportal VATS and triportal VATS for pulmonary lobectomy in early-stage lung cancer patients.

Methods

This study is a single-center, prospective, two-arm, parallel-group, randomized controlled trial. It is designed to compare uniportal video-assisted thoracic surgery (u-VATS) and three-port video-assisted thoracic surgery (t-VATS) in terms of postoperative pain. The trial will enroll 120 patients with a 1:1 randomization. The primary outcome is the assessment of analgesic drug consumption. Secondary outcomes are postoperative pain measurement, evaluation of postoperative pulmonary function, and metabolic recovery after pulmonary lobectomy.

Discussion

The choice of which VATS approach to adopt for treating patients undergoing pulmonary resection mostly depends on the surgeon’s preferences; therefore, it is hard to prove whether one VATS technique is superior to the other. Moreover, postoperative analgesic protocols vary consistently among different centers. To date, only a few studies have evaluated the effects of the most popular VATS techniques. There is no evidence about the difference between multiport VATS and u-VATS in terms of postoperative pain. We hope that the results of our trial will provide valuable information on the outcomes of these different surgical approaches.

Trial registration

ClinicalTrials.gov NCT03240250. Registered on 07 August 2017; retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05115-w.

Uniportal Versus Multiportal Video-Assisted Thoracoscopic Lobectomy for Lung Cancer: An Updated Meta-analysis

Objective

We reviewed the available literature on patients with lung cancer undergoing either uniportal (UVATS) or multiport video-assisted thoracoscopic surgery (MVATS).

Methods

Original research studies that evaluated perioperative and long-term outcomes of UVATS versus MVATS were identified, from January 1990 to April 2020. The perioperative, along with the oncologic and long-term survival outcomes, were calculated according to either a fixed or a random effect model, appropriately. The Q statistics and I² statistic were used to test for heterogeneity among the studies.

Results

Twenty studies were included, incorporating a total of 1,469 patients treated with UVATS and 3,231 treated with MVATS. The incidence of complications was lower in patients treated with UVATS [OR: 0.76 (95% CI 0.62, 0.93); p = 0.008]. The chest tube duration was significantly lower in the UVATS group (WMD: − 0.63 [95% CI − 1.03, − 0.23]; p = 0.002). Length of hospital stay (L.O.S.) was also lower in the UVATS patient group (WMD: − 0.54 [− 0.94, − 0.13]; p = 0.009), along with postoperative pain [WMD: − 0.57 (95% CI − 0.97, − 0.18); p = 0.004]. No significant differences were found regarding the mean operative time (M.O.T.), mean blood loss, the number of resected lymph nodes, the 30-day mortality, along with the survival at 1 and 3 years postoperatively.

Conclusions

The present meta-analysis indicates that UVATS is associated with enhanced outcomes in patients undergoing surgery for lung cancer. Well-designed, randomized studies, comparing UVATS to MVATS, are necessary to further assess their long-term clinical outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00408-020-00411-9.

Lung volume reduction surgery: from National Emphysema Treatment Trial to non-intubated awake video-assisted thoracoscopic surgery

Chronic obstructive pulmonary disease (COPD) is a major public health problem. Loss of elastic recoil, hyperinflation and obstruction of the expiratory airflow lead to an increased breathing work, which results in dyspnea during minimal physical activity of the patients. Reduction of the lung volume in these patients leads to improvement of dyspnea, physical activity and quality of life in these patients. Beside endoscopic lung volume reduction (ELVR), lung volume reduction surgery (LVRS) represents an important and valuable treatment option for patients with advanced lung emphysema. Since the National Emphysema Treatment Trial (NETT), thoracic surgery experienced a remarkable evolution of the surgical techniques enabling safe surgery and quick recovery in this critically ill patient cohort. A paradigm shift from open surgical approaches to most minimally invasive techniques accompanied by improvement of anesthesiologic management of these patients was evident. Moreover, indications for LVRS, which were originally described in the NETT, were extended to apply for further groups of patients with advanced lung emphysema, enabling significant clinical improvement in well-selected patients with a low perioperative morbidity and mortality. The current review will give an overview of the historical approaches for LVRS, highlight the indications for LVRS and discuss the development of the surgical approaches.

[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.

Single-Port vs Conventional Three-Port Video-Assisted Thoracoscopic Pulmonary Wedge Resection: Comparison of Postoperative Pain and Surgical Costs

PURPOSE

Single-port video-assisted thoracoscopic (VATS) pulmonary wedge resection was reported in 2004. We started using single-port VATS (SPVATS) pulmonary wedge resection in 2017 and compared results between conventional three-port VATS (VATS group) and SPVATS (SPVATS group).

METHODS

We identified 145 consecutive patients with VATS group and SPVATS group. Perioperative characteristics including pain and the number of stapler cartridges used were examined as the surgical outcomes, retrospectively.

RESULTS

In all, 66 cases of SPVATS group and 79 cases of VATS group pulmonary wedge resection were compared. The rate of epidural anesthesia (p <0.0001) was significantly higher and operative time (p <0.0001) was significantly longer with VATS group than with SPVATS group. The number of stapler cartridges used, duration of drain insertion, and rate of postoperative complications did not differ significantly between groups. Average numerical rating scale (NRS) score on postoperative day 1 and postoperative day 7 (p <0.0001 each), maximum NRS score on postoperative day 7 (p = 0.0082) and amount of 25 mg tramadol (p = 0.0062) were significantly lower in SPVAS group than in VATS group.

CONCLUSION

Our results suggest that SPVATS pulmonary wedge resection offers better pain control and cost-effectiveness than three-port VATS pulmonary wedge resection. These findings should contribute to the body of evidence for SPVATS.

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.

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.

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.

Developing training for uniportal video-assisted thoracic surgery: a commentary

OBJECTIVES

Today, thoracic surgeons have many possible pathways to advance their training in video-assisted thoracic surgery (VATS). For uniportal VATS (uVATS) in particular, what are the training options available and does regulating training matter?

METHODS

The relevant literature pertaining to uVATS training is reviewed.

RESULTS

Current options for surgeons looking to train in uVATS range from videos on the internet, through 'experts' demonstrating live surgery, to symposia and hands-on wet labs being held in all regions of the world. All have merits, and the aspiring VATS surgeon can choose from a range of preceptorship and proctorship modules to suit his/her own training needs. However, issues in the formalizing training in uVATS remains unresolved. Is there an ideal pathway through uVATS training? At what point can a trainee be considered to have 'graduated' to become an expert in uVATS? Who indeed trains the trainer, and certifies the competence of a training centre?

CONCLUSIONS

Although a plethora of training options exist, formulation of a robust training curriculum can further bolster the status of uVATS as a sustainable surgical approach that can be delivered with consistent quality.

Thoracic cancer surgery during the COVID-19 pandemic: a consensus statement from the Thoracic Domain of the Asian Society for Cardiovascular and Thoracic Surgery

OBJECTIVES

Healthcare resources have been mobilized to combat the COVID-19 pandemic of 2020. The Thoracic Domain of the Asian Society for Cardiovascular and Thoracic Surgery reports a consensus statement on the provision of thoracic cancer surgery during this pandemic.

METHODS

A Thoracic Experts Panel was convened by the Society. A consensus on the provision, safety, and setting of thoracic cancer surgery during the pandemic was obtained through a Delphi process.

RESULTS

Responses were received from 26 panel members (96% response rate) from 10 regions across Asia. The Society recommended that elective thoracic cancer surgery services may need to be reduced or postponed if medical resources were needed for COVID-19 patients, especially intensive care unit beds and ventilators. However, thoracic cancer surgery should proceed as normal for all solid tumors, without restrictions based on disease stage, availability of non-surgical treatment options, or patient condition (unless there is a high likelihood of postoperative intensive care unit stay). Aerosol-forming procedures should be avoided intra- and perioperatively. The surgical approach does not make a difference in terms of safety. Services for thoracic cancer patients should be offered only in hospitals that maintain isolation wards for patients with confirmed or suspected COVID-19.

CONCLUSIONS

Services for patients with thoracic cancer should be maintained during the COVID-19 pandemic. The position of the Society is that thoracic surgeons have a responsibility to perform good surgical management of thoracic cancer during the pandemic, to advocate for patients' rights to receive it, and to safeguard patients and staff from infection.

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 learning curve on uniportal video-assisted thoracic surgery: An analysis of proficiency

OBJECTIVES

Minimally invasive techniques for lung cancer surgery have revolutionized thoracic surgery, and single-port approaches are becoming increasingly used. We analyzed our experience with uniportal video-assisted thoracoscopic surgery for lobectomy to identify the number of procedures necessary to achieve proficiency according to clinical outcomes.

METHODS

We queried our institutional prospective database for all single-port lobectomies in patients with early-stage lung cancer performed by a single surgeon from 2014 to 2017; 274 patients met the inclusion criteria. Using cubic splines, we derived 3 distinct learning phases based on the length of the procedure. Blood loss, additional port insertion, and conversion to thoracotomy were also compared according to these learning phases.

RESULTS

The initial phase (procedures 1-60) had the longest procedure times and the most variability in procedure length (158.8 ± 52.2 minutes) compared with the transition phase (procedures 61-140; 145.9 ± 43.8 minutes) and the proficient phase (procedures 141-274; 117.9 ± 32.6 minutes, P < .001). Blood loss (156 mL vs 130.4 mL vs 64.9 mL, P = .003), conversion rate to thoracotomy (11.7% vs 3.8% vs 0.7%, P = .001), and need for a second incision (8.3% vs 5% vs 0.7%, P = .025) were all highest during the initial phase. In a multivariable model, there was a significant interaction between procedure number and learning phase (P = .003), indicating that the effect of each additional procedure on procedure length differed in each phase.

CONCLUSIONS

In this analysis, a distinct learning curve for uniportal video-assisted thoracoscopic surgery lobectomy was observed. Procedure time decreased sharply at approximately the 60th procedure, but 80 additional lobectomies were required to master the approach.

Uniportal VATS for non-small cell lung cancer

The video-assisted thoracic surgery (VATS) technique has evolved from its multiport origins to even less invasive approaches grounded in its proven benefits over open surgery for the treatment of early stage lung cancer. In this evolution process, the Uniportal VATS (UniVATS) strategy emerged. This technique is giving some evidence of benefits when compared to the multiport VATS and has been embraced by the surgical community spreading its geographical and surgical boundaries. Moreover, UniVATS has proven its feasibility for numerous and more complex procedures for lung cancer diagnosis and treatment, which are reviewed in this document as well as its current and future development.

Preoperative 3D-CT bronchography and angiography facilitates single-direction uniportal thoracoscopic anatomic lobectomy

Background

Competency in video-assisted thoracoscopic surgery (VATS) lobectomy is estimated to be reached after 50 cases. Preoperative identification of individualized pulmonary vascular drainage is essential for the safe and fluent performance of single-direction uniportal VATS (UVATS) anatomic lobectomy. Digital anatomy models established by three-dimensional computed tomography bronchography and angiography (3D-CTBA) is therefore utilized to accumulate variations of the right upper lobe (RUL) veins, as right upper lobectomy is considered to be the most complicated and challenging procedure. This study aims to investigate the perioperative outcomes and learning curve of single-direction UVATS RUL lobectomy assisted with 3D-CTBA.

Methods

The patients who underwent single-direction intercostal UVATS anatomic RUL lobectomy after 3D-CTBA simulation by the same surgeon at Xuzhou Central Hospital between January 2017 and April 2019 were retrospectively reviewed (3D-CTBA group), and consisted of 99 males and 54 females, with a mean age of 61.6 years, with the variations of the RUL vein being assessed preoperatively. They were further divided into group A (30 cases), B (30 cases), C (30 cases), and D (63 cases), in accordance with the order of surgery. Meanwhile, the first 35 cases of single-direction UVATS RUL lobectomy by another experienced surgeon (after the learning curve of this procedure) who did not use 3D-CTBA was enrolled as a control group. The operation time, intraoperative blood loss, stations and numbers of harvested lymph nodes, the incidence of conversion to multiport VATS or thoracotomy, thoracic tube retention for drainage, complications defined under the Clavien-Dindo system, pain score, and postoperative hospital stay were analyzed. The previous surgical experience of the two surgeons was also evaluated.

Results

A significant difference was evident among the 5 groups in terms of age, smoking history, the proportion of neoadjuvant chemotherapy, and T staging of the tumors (P<0.05, respectively). As for the 3D-CTBA group, a total of 29 cases (19.0%) of anomalous RUL posterior segmental pulmonary vein (PV) (V²) drainage were recorded, while the other 124 patients indicated the central type (V2a. Cent.). Of the uncommon RUL V², they could be further classified into 4 types [V2a. Post. (5/153, 3.3%), VX2a. Ant. (17/153, 11.1%), VXX2a. Ant. (3/153, 2.0%), and nonspecific complicated (4/153, 2.6%)]. Single-direction UVATS lobectomy was performed in every patient successfully. No perioperative mortality, major bleeding, conversion to thoracotomy, the addition of incisions, or 30-day unplanned readmission was recorded. One patient in group B reported an injury of a bronchial artery. All cases had an R0 resection. The operation time of group A (109.8±25.4 min) was significantly longer than that of group B (79.7±11.1 min), C (77.0±12.1 min), D (69.3±16.0 min), and the control (86.1±17.9 min, P<0.001 respectively). Moreover, the operation time of the patients in group B, C, and D was slightly shorter than the control, although without significance (P>0.05, respectively). Furthermore, the duration of chest tube drainage in group A (3.7±2.2 days) was noticeably longer than that in group B (3.0±0.9 days), C (2.7±1.6 days), D (2.6±0.8 days), and the control (2.7±1.6 days, P=0.004 among the groups). Similarly, postoperative hospital stay in group A (3.9±2.3 days) was noticeably longer than that in group B (3.0±1.0 days), C (2.8±1.8 days), D (2.6±0.8 days), and the control (2.8±1.8 days, P=0.002 among the groups). The 5 groups indicated comparable stations and numbers of the harvested lymph nodes, intraoperative blood loss, postoperative total chest drainage volume, incidence of complications, and pain scale on the 14^th day after surgery (P>0.05, respectively).

Conclusions

Preoperative 3D-CTBA digital anatomy facilitates the safe and fluent performance of single-direction UVATS anatomic right upper lobectomy, with a learning curve of 30 cases. High-quality trials for better evidence are called for to verify these findings.