The effect of postoperative change in bronchial angle on postoperative pulmonary function after upper lobectomy in lung cancer patients

Left Upper Division Segmentectomy Compared with Lobectomy for Lung Expansion and Bronchus Tortuosity

BACKGROUND

For patients with left upper lobe lesions, the functional benefit of left upper division segmentectomy over left upper lobectomy remains controversial. This study evaluated the clinical and functional outcomes after these two procedures.

METHODS

This retrospective study included 135 patients with left upper lobe lesions (left upper lobectomy, 110; left upper division segmentectomy, 25). Propensity score matching was used to compare the two groups. Spirometry and computed tomography volume assessments were performed to evaluate bronchus angle and tortuosity. Short-term clinical respiratory symptoms were assessed via medical record reviews.

RESULTS

Patients in both groups had similar preoperative characteristics, apart from tumor size (left upper division segmentectomy, 1.6 ± 0.9 cm; left upper lobectomy, 2.8 ± 1.7 cm; p = 0.002). After propensity score matching, both groups had similar preoperative spirometry and pathological results. The postoperative spirometry results were similar; however, the left upper division segmentectomy group had a significantly smaller decrease in left-side computed tomography lung volume compared with that in the left upper lobectomy group (left upper division segmentectomy, 323.6 ± 521.4 mL; left upper lobectomy, 690.7 ± 332.8 mL; p = 0.004). The left main bronchus-curvature index was higher in the left upper lobectomy group (left upper division segmentectomy, 1.074 ± 0.035; left upper lobectomy, 1.097 ± 0.036; p = 0.013), and more patients had persistent cough in the left upper lobectomy group (p = 0.001).

CONCLUSIONS

Left upper division segmentectomy may be a promising option for preventing marked bronchial angulation and decreasing postoperative persistent cough in patients with left upper lobe lung cancer.

The effect of lobar shifting following right upper lobectomy on postoperative pulmonary function

OBJECTIVES

Lobes occasionally displace after lobectomy, referred to as "lobar shifting". However, the benefits, especially in postoperative pulmonary function, remain controversial. This study aimed to measure the effect of lobar shifting on postoperative pulmonary function especially in the right upper lobe.

METHODS

This retrospective study includes 273 right upper lobectomy patients (lobectomy group) and 24 right upper segmentectomy patients (segmentectomy group) from 2012 to 2021. The lobectomy group was further subdivided based on their Synapse Vincent® image: with their postoperative middle lobe bronchus shifted toward the head (shift group: 176 cases) and without (non-shift group: 97 cases). Several factors were examined to determine the cause of lobar shifting. The rate of measured actual postoperative forced expiratory volume in 1 s (FEV1.0) to predicted postoperative FEV1.0 was analyzed and compared among the three groups.

RESULTS

Factors that correlated with lobar shifting included age (p < 0.001), a relatively small middle lobe volume (p = 0.03), no adhesions (p < 0.001), and good upper/middle and middle/lower lobulation (p = 0.04, p = 0.02). The rate of measured actual postoperative FEV1.0 to predicted postoperative FEV1 for the shift, non-shift, and segmentectomy groups were 112.5%, 107.9%, and 103.1% (shift vs non-shift: p = 0.04, shift vs segmentectomy: p = 0.02, non-shift vs segmentectomy: p = 0.19).

CONCLUSIONS

Lobar shifting after right upper lobectomy is influenced by morphological factors and may have a beneficial impact on postoperative pulmonary function.

Compensatory expansion of the right middle lobe: volumetric and functional analysis of the changes after right upper or lower lobectomy

The right middle lobe often poorly expands after right upper lobectomy. Postoperative pulmonary function may be inferior after right upper lobectomy than after right lower lobectomy due to poor expansion of the middle lobe. This study examined the difference in the postoperative right middle lobe expansion and pulmonary function between right upper and right lower lobectomy. Patients who underwent right upper or right lower lobectomy through video-assisted thoracic surgery (n = 82) were enrolled in this retrospective study. Pulmonary function tests and computed tomography were performed preoperatively and at 1 year postoperatively. Using three-dimensional computed tomography volumetry, the preoperative and postoperative lung volumes were measured, and the predicted postoperative forced expiratory volume in 1 s was calculated. Middle lobe volume ratio (i.e., ratio of the postoperative to the preoperative middle lobe volume) and the postoperative forced expiratory volume in 1 s ratio (i.e., ratio of the measured to the predicted postoperative forced expiratory volume in 1 s) were compared between right upper and right lower lobectomy. Compared with the patients who underwent right upper lobectomy (n = 50), those who underwent right lower lobectomy (n = 32) had significantly higher middle lobe volume ratio (1.15 ± 0.32 vs. 1.63 ± 0.52, p < 0.001) and postoperative forced expiratory volume in 1 s ratio (1.12 ± 0.12 vs. 1.19 ± 0.13, p = 0.010). The right middle lobe showed more expansion and better recovery of postoperative pulmonary function after right lower lobectomy than after right upper lobectomy.

Pulmonary Function Recovery and Displacement Patterns After Anatomic Segmentectomy vs Lobectomy

BACKGROUND

The functional benefit of segmentectomy compared with lobectomy remains controversial. This ambispective study characterizes the changes in pulmonary function as correlated to displacement patterns of residual lung after segmentectomies vs lobectomies.

METHODS

Patients with normal preoperative pulmonary function and undergoing segmentectomy or lobectomy between 2017 and 2021 were considered. Pulmonary function testing was scheduled preoperatively and at least 3 months postoperatively. Differences in the proportions of the median forced expiratory volume in 1 second (FEV1) reduction between segmentectomy and lobectomy were calculated. Covariance analysis was used to estimate the adjusted postoperative FEV1 (apoFEV1) and compare the difference value (DV) in apoFEV1 between segmentectomy and lobectomy.

RESULTS

The study enrolled 634 patients (334 lobectomies and 300 segmentectomies). Median difference in the proportions of the FEV1 reduction between segmentectomy and lobectomy was 4.58%, with maximal difference observed in right S6 (9.08%) and minimal difference in left S1+2+3 (2.80%). For resections involving the upper lobe, apoFEV1 was significantly higher after segmentectomy than after lobectomy (DV, 0.15-0.22 L), except for left S3 and S1+2+3 segmentectomies (DV, 0.08 L and 0.06 L, respectively). Compared with a lower lobe lobectomy, S6 segmentectomy conferred a higher apoFEV1, whereas S7+8 and S9+10 had a similar apoFEV1 (DV, 0.16-0.18 L, 0.07 L, and 0.00-0.06 L, respectively). Functional recovery after segmentectomy was associated with the number of intersegment planes (P < .01) and the presence of an adjacent nonoperated on lobe (P = .03).

CONCLUSIONS

Basilar and left S3 segmentectomies did not preserve more pulmonary function compared with their corresponding lobectomies, possibly due to the presence of multiple intersegmental resection planes.

Preservation vs. dissection of inferior pulmonary ligament for thoracoscopic upper lobectomy: a prospective randomized controlled trial

OBJECTIVES

The proper procedure for inferior pulmonary ligament (IPL) during upper lobectomy remains a topic of debate. To address this matter, we carried out a trial comparing the clinical outcomes of IPL preservation versus IPL dissection during thoracoscopic upper lobectomy (TUL).

METHODS

Patients undergoing thoracoscopic left/right upper lobectomy (TLUL/TRUL) were assigned to either the dissection group (Group D) or the preservation group (Group P). Our primary objective was to quantify and compare the alterations in postoperative residual bronchial angle and lung volume changes between the two groups. Our secondary objective encompassed the assessment of various other intraoperative and postoperative outcomes.

RESULTS

Following adherence to the inclusion and exclusion criteria, we enrolled 100 patients (41 left and 59 right) in Group P and 108 patients (41 left and 67 right) in Group D for the study. Our findings revealed that in TLUL, Group P was able to reduce the degree of postoperative residual bronchial angle change (P < 0.05). Conversely, the situation was distinct for TRUL. We found no notable disparity between the two groups (P > 0.05) with regard to alterations in lung volume or the occurrence of postoperative complications-except for the duration of postoperative hospital stay (P < 0.05).

CONCLUSIONS

Our study suggests IPL preservation especially for TLUL when compared to TRUL, which have important implications for the clinical management of patients undergoing upper lobectomy.

Changes in pulmonary function in lung cancer patients after segmentectomy or lobectomy: a retrospective, non-intervention, observation study

OBJECTIVES

Pulmonary segmentectomy (SE) became an increasingly popular method for resection of early-stage lung cancer. This study aims to compare the impact of single SE (SSE), multiple SE (MSE) and lobectomy (LE) on postoperative pulmonary function in patients with NSCLC.

METHODS

Medical records of a total of 1284 patients who underwent LE (n = 493), SSE (n = 558) and MSE (n = 233) at Shanghai Pulmonary Hospital from January 2013 to October, 2020 were retrospectively analysed. Pulmonary function tests (PFTs) were performed preoperatively and 12 months after surgery.

RESULTS

SSE was associated with a significantly smaller decline in the PFT values compared to MSE and LE. There was a poor consistency between the observed and expected (O/E) loss of pulmonary function in all study groups (P < 0.05). Both LE and SE resulted in similar O/E ratios of all PFT parameters (P > 0.05).

CONCLUSIONS

Overall loss of pulmonary function was much greater after LE than after both SSE and MSE. MSE was associated with higher postoperative pulmonary function decline compared to SSE but was still beneficial over LE. Both LE and SE groups had similar PFT loss per segment (P > 0.05).

A comparative analysis of segmentectomy-aswere medicated withinsociated factors influencing bronchial tortuosity in early-stage left upper lung cancer

BACKGROUND

Several studies of early-stage non-small cell lung cancer (NSCLC) have reported a notable therapeutic effect of segmentectomy. However, the secondary benefits of lung volume preservation remain unclear. This study aimed to investigate the potential benefits of segmentectomy, in terms of its impact on postoperative bronchial change.

METHODS

Patients who underwent left-sided upper lobectomy and upper division segmentectomy for pStage 0-IA2 NSCLC, were retrospectively analyzed. Degree of the left main bronchial deviation was measured by the curvature index (CI), determined using computed tomography. Variables, including CI value and postoperative rate of change in CI were compared for postoperative cough management the lobectomy and segmentectomy groups.

RESULTS

Sixty-seven patients were reviewed. Thirty-seven and 30 patients underwent lobectomy and segmentectomy, respectively, without any significant differences in baseline and surgical variables. The 5-year overall survival rates in the lobectomy and segmentectomy groups were 86.7 and 95.2%, respectively (p = 0.437). While there was no significant difference in postoperative complications, the rate of change in CI was significantly higher in the lobectomy group than in the segmentectomy group (113 vs. 106%, p = 0.005). In addition, the analysis based on postoperative cough reveals the rate of change in CI to be significantly higher in patients requiring medical treatment (p = 0.005). Conclusions Left upper division segmentectomy provides satisfactory treatment and relief of postoperative bronchial tortuosity. Our study suggests that there is a possibility the mitigation of environmental changes in the thoracic cavity may reduce symptoms, thus contributing to an improved quality of life.

A new strategy in lung/lobe isolation in patients with a lung abscess or a previous lung resection using double lumen tubes combined with bronchial blockers

The combined use of a double-lumen tube and a bronchial blocker can be very helpful in two different clinical scenarios: (1) in isolating not only the contralateral lung, but also the lobe/s of the same lung in which the infected lobe must be resected, (2) in preventing/treating hypoxemia because of the presence of a contralateral lobectomy. A cardiothoracic anesthesiologist must expertise this technique to avoid complications during surgery.

The impact of segmentectomy versus lobectomy on pulmonary function in patients with non-small-cell lung cancer: a meta-analysis

Objective

Segmentectomy has been reported as an alternative to lobectomy for small-sized NSCLC without detriment to survival. The long-term benefits of segmentectomy over lobectomy on pulmonary function have not been firmly established. This meta-analysis aims to compare postoperative changes in pulmonary function in NSCLC patients undergoing segmentectomy or lobectomy.

Methods

Medline, Embase, Web of Science and Scopus were searched through March 2021. Statistical comparisons were made when appropriate.

Results

Fourteen studies (2412 participants) out of 324 citations were included in this study. All selected studies were high quality, as indicated by the Newcastle–Ottawa scale for assessing the risk of bias. Clinical outcomes were compared between segmentectomy and lobectomy. ΔFEV1 [10 studies, P < 0.01, WMD = 0.40 (0.29, 0.51)], ΔFVC [4 studies, P < 0.01, WMD = 0.16 (0.07, 0.24)], ΔFVC% [4 studies, P < 0.01, WMD = 4.05 (2.32, 5.79)], ΔFEV1/FVC [2 studies, P < 0.01, WMD = 1.99 (0.90, 3.08)], and ΔDLCO [3 studies, P < 0.01, WMD = 1.30 (0.69, 1.90)] were significantly lower in the segmentectomy group than in the lobectomy group. Subgroup analysis showed that in stage IA patients, the ΔFEV1% [3 studies, P < 0.01, WMD = 0.26 (0.07, 0.46)] was significantly lower in the segmentectomy group. The ΔDLCO% and ΔMVV% were incomparable.

Conclusion

Segmentectomy preserves more lung function than lobectomy. There were significantly smaller decreases in FEV1, FVC, FVC%, FEV1/FVC and DLCO in the segmentectomy group than in the lobectomy group.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-022-01853-3.

Comparison of postoperative cough-related quality of life and recovery between sublobectomy and lobectomy for early-stage non-small cell lung cancer patients: a longitudinal study

Background

Cough is a common complication after pulmonary surgery. Previous studies lacked a standard measure to assess postoperative cough-related quality of life and recovery. The purpose of this study is to compare postoperative cough regarding changes in health-related quality of life (HRQOL) and recovery trajectory between video-assisted thoracic surgery (VATS) lobectomy and sublobectomy (segmentectomy or wedge resection) for early-stage non-small cell lung cancer (NSCLC) patients via the Leicester Cough Questionnaire in Mandarin Chinese (LCQ-MC).

Methods

Overall, 156 patients with NSCLC underwent either VATS lobectomy or VATS sublobectomy; LCQ-MC was used to report the impact of postoperative cough on HRQOL for 6 months after surgery. The total scores of LCQ-MC range from 3 to 21, with a higher score indicating better health. Recovery from postoperative cough was defined as LCQ-MC scores returning to preoperative levels. The sensitivity of LCQ-MC to changes in postoperative cough recovery over time was evaluated via its ability to distinguish between surgery types.

Results

The VATS sublobectomy group reported significantly higher mean LCQ-MC scores at 1 month after surgery, but no significant difference postoperatively at 3 and 6 months after surgery, and returned to preoperative physical (69 vs. 99 days), psychological (67 vs. 99 days), social (50 vs. 98 days) and total (69 vs. 99 days) scores faster than the VATS lobectomy group (all p < 0.05).

Conclusion

VATS sublobectomy had generally better HRQOL and faster recovery of postoperative cough than VATS lobectomy. In addition, the LCQ-MC performed satisfactorily in describing the longitudinal changes in postoperative cough.

Functional analysis of the airways after pulmonary lobectomy through computational fluid dynamics

Pulmonary lobectomy, which consists of the partial or complete resection of a lung lobe, is the gold standard intervention for lung cancer removal. The removal of functional tissue during the surgery and the re-adaptation of the remaining thoracic structures decrease the patient's post-operative pulmonary function. Residual functionality is evaluated through pulmonary function tests, which account for the number of resected segments without considering local structural alterations and provide an average at-the-mouth estimation. Computational Fluid Dynamics (CFD) has been demonstrated to provide patient-specific, quantitative, and local information about airways airflow dynamics. A CFD investigation was performed on image-based airway trees reconstructed before and after the surgery for twelve patients who underwent lobectomy at different lobes. The geometrical alterations and the variations in fluid dynamics parameters and in lobar ventilation between the pre and post-operative conditions were evaluated. The post-operative function was estimated and compared with current clinical algorithms and with actual clinical data. The post-operative configuration revealed a high intersubject variability: regardless of the lobectomy site, an increment of global velocity, wall pressure, and wall shear stress was observed. Local flow disturbances also emerged at, and downstream of, the resection site. The analysis of lobar ventilation showed severe variations in the volume flow rate distribution, highlighting the compensatory effects in the contralateral lung with an increment of inflow. The estimation of post-operative function through CFD was comparable with the current clinical algorithm and the actual spirometric measurements. The results confirmed that CFD could provide additional information to support the current clinical approaches both in the operability assessment and in the prescription of personalized respiratory rehabilitation.

Bronchial morphological changes are associated with postoperative intractable cough after right upper lobectomy in lung cancer patients

BACKGROUND

To date, postoperative intractable cough (PIC) has not received adequate attention, and the complex perioperative factors when performing pulmonary resection often prevent researchers from addressing this issue. This study aimed to investigate the clinicopathological and radiographic indicators related to PIC in lung cancer patients.

METHODS

In all, 112 patients who had had right upper lobectomy for primary lung cancer from January 2019 to December 2020 were retrospectively reviewed. We collected data via the electronic medical database of our department. Bronchial morphological features were investigated comprehensively via three-dimensional chest computer tomography reconstruction images.

RESULTS

During outpatient follow-up visits, 41 (36.6%) patients complained about persistent dry cough after surgery. Compared with the non-cough group, patients in the refractory cough group showed significant differences in smoking history, right upper lobe stump length, changes of right bronchus intermedius (RBI) diameter, changes of right lower lobe (RLL) basal bronchus diameter, changes of RBI/RLL bronchial angle, and bronchial kink. However, according to multivariable regression analysis, stump length, bronchial kink, and diameter change of the right lower lobe basal bronchus were independently associated with postoperative refractory cough. A nebulization drug was prescribed for the 41 patients diagnosed with PIC, and 33 (80.5%) patients had improved by the next visit.

CONCLUSIONS

After right upper lobectomy, the morphology of the remaining bronchial tree in the residual lung changed significantly. The bronchial morphological alterations were independent risk factors for PIC.

Comparison of Sleeve Lobectomy for Lung Cancer Using Mini-Thoracotomy and an Optimized Robot-Assisted Technique

Objective: To evaluate the clinical significance of an optimized approach to improve surgical field visualization and simplify anastomosis techniques using robotic-assisted sleeve lobectomy for lung or bronchial carcinoma. Method: A total of 26 consecutive patients who underwent sleeve lobectomy between January 2017 and April 2020 were enrolled in the study. The cohort included 11 cases of robotic-assisted surgery (RAS group) and 15 cases of mini-thoracotomy (MT group). RAS was performed via an exclusive optimized approach utilizing the "3 to 4-6 to 8/9" four-port technique. Retrieved demographical and clinical data included operation time, anastomosis time, blood loss, chest drainage time and volume, postoperative pain scores, complications, white blood cell (WBC) levels, and duration of hospital stay and follow-up. Results: No cases of perioperative death were recorded. Compared to MT group, the RAS group had a similar anastomosis time (30.82  ±  6.08 vs 33.20  ±  7.73 min, respectively, p > 0.05) and shorter operation time (189.73  ±  36.41 vs 225.33  ±  38.19 min, respectively, p < 0.05). The RAS group had lower pain scores (4.23  ±  0.26 vs 4.91  ±  0.51, p < 0.05), lower levels of WBC (p < 0.05), and no anastomotic complications postoperatively. The RAS and MT groups demonstrated a successful bronchus reconstruction with low risk of angulation (1/11 vs 1/15, p > 0.05) and satisfactory disease-free survival (eight cases, 72.73% and 12 cases, 80%, respectively). Conclusion: The optimized approach to RA sleeve lobectomy is convenient and efficient and provides satisfactory clinical outcomes. Further study with a large sample size and evaluation of long-term survival are warranted. Key points: (i) we present a novel, convenient, and efficient approach for robotic-assisted sleeve lobectomy, ie, "3 to 4-6 to 8/9" four-port technique. The optimized approach for RA sleeve lobectomy is convenient and efficient and provides satisfactory clinical outcomes; (ii) details for the "3 to 4-6 to 8/9" four-port method: the assistant port was located at the fourth intercostal space. The 1-cm camera port was inserted at the sixth intercostal space in the posterior axillary line. The 0.5-cm da Vinci ports of the instrument arms were placed at the third intercostal space in the anterior axillary line and the eighth or ninth intercostal space in the posterior axillary line. The patient cart was inserted from the back of the patient's head and shoulders at 75° to the longitudinal line.

The difference in postoperative pulmonary functional change between upper and lower thoracoscopic lobectomy

OBJECTIVES

Through 3-dimensional lung volumetric and morphological analyses, we aimed to evaluate the difference in postoperative functional changes between upper and lower thoracoscopic lobectomy.

METHODS

A total of 145 lung cancer patients who underwent thoracoscopic upper lobectomy (UL) were matched with 145 patients with lung cancer who underwent thoracoscopic lower lobectomy (LL) between April 2012 and December 2018, based on their sex, age, smoking history, operation side, and pulmonary function. Spirometry and computed tomography were performed before and 6 months after the operation. In addition, the postoperative pulmonary function, volume and morphological changes between the 2 groups were compared.

RESULTS

The rate of postoperative decreased and the ratio of actual to predicted postoperative forced expiratory volume in 1 s were significantly higher after LL than after UL (P < 0.001 for both). The tendency above was similar irrespective of the resected side. The postoperative actual volumes of the ipsilateral residual lobe and contralateral lung were larger than the preoperatively measured volumes in each side lobectomy. Moreover, the increased change was particularly remarkable in the middle lobe after right LL. The change in the D-value, representing the structural complexity of the lung, was better maintained in the left lung after LL than after UL (P = 0.042).

CONCLUSIONS

Pulmonary function after thoracoscopic LL was superior to that after UL because the upward displacement and the pulmonary reserves of the remaining lobe appeared more robust after LL.

The Value of Residual Volume/Total Lung Capacity as an Indicator for Predicting Postoperative Lung Function in Non-Small Lung Cancer

Chronic obstructive pulmonary disease (COPD) is one of the most frequently occurring concomitant diseases in patients with non-small cell lung cancer (NSCLC). It is characterized by small airways and the hyperinflation of the lung. Patients with hyperinflated lung tend to have more reserved lung function than conventionally predicted after lung cancer surgery. The aim of this study was to identify other indicators in predicting postoperative lung function after lung resection for lung cancer. Patients with NSCLC who underwent curative lobectomy with mediastinal lymph node dissection from 2017 to 2019 were included. Predicted postoperative FEV₁ (ppoFEV₁) was calculated using the formula: preoperative FEV₁ × (19 segments-the number of segments to be removed) ÷ 19. The difference between the measured postoperative FEV₁ and ppoFEV₁ was defined as an outcome. Patients were categorized into two groups: preserved FEV₁ if the difference was positive and non-preserved FEV₁, if otherwise. In total, 238 patients were included: 74 (31.1%) in the FEV₁ non-preserved group and 164 (68.9%) in the FEV₁ preserved group. The proportion of preoperative residual volume (RV)/total lung capacity (TLC) ≥ 40% in the FEV₁ non-preserved group (21.4%) was lower than in the preserved group (36.1%) (p = 0.03). In logistic regression analysis, preoperative RV/TLC ≥ 40% was related to postoperative FEV1 preservation. (adjusted OR, 2.02, p = 0.041). Linear regression analysis suggested that preoperative RV/TLC was positively correlated with a significant difference. (p = 0.004) Preoperative RV/TLC ≥ 40% was an independent predictor of preserved lung function in patients undergoing curative lobectomy with mediastinal lymph node dissection. Preoperative RV/TLC is positively correlated with postoperative lung function.

Biodegradable stent placement for airway kinking after bronchoscopic lung volume reduction treatment

Symptomatic airway kinking after bronchoscopic lung volume reduction with endobronchial valves is rare. Due to the development of the desired lobar atelectasis, the position of the airways of the non-treated lobe changes and this might lead to invalidating symptoms. We present a case of a patient with symptomatic airway kinking after treatment with endobronchial valves, who was successfully treated with a single placement of a biodegradable stent. Placement of a biodegradable stent can be considered in symptomatic patients with airway kinking.

Computational fluid dynamics of the airways after left-upper pulmonary lobectomy: A case study

Pulmonary lobectomy is the gold standard intervention for lung cancer removal and consists of the complete resection of the affected lung lobe, which, coupled with the re-adaptation of the remaining thoracic structures, decreases the postoperative pulmonary function of the patient. Current clinical practice, based on spirometry and cardiopulmonary exercise tests, does not consider local changes, providing an average at-the-mouth estimation of residual functionality. Computational Fluid Dynamics (CFD) has proved a valuable solution to obtain quantitative and local information about airways airflow dynamics. A CFD investigation was performed on the airway tree of a left-upper pulmonary lobectomy patient, to quantify the effects of the postoperative alterations. The patient-specific bronchial models were reconstructed from pre- and postoperative CT scans. A parametric laryngeal model was merged to the geometries to account for physiological-like inlet conditions. Numerical simulations were performed in Fluent. The postoperative configuration revealed fluid dynamic variations in terms of global velocity (+23%), wall pressure (+48%), and wall shear stress (+39%). Local flow disturbances emerged at the resection site: a high-velocity peak of 4.92 m/s was found at the left-lower lobe entrance, with a local increase of pressure at the suture zone (18 Pa). The magnitude of pressure and secondary flows increased in the trachea and flow dynamics variations were observed also in the contralateral lung, causing altered lobar ventilation. The results confirmed that CFD is a patient-specific approach for a quantitative evaluation of fluid dynamics parameters and local ventilation providing additional information with respect to current clinical approaches.

The Change Trend of Cause of Death in Patients With Stage I Non-Small Cell Lung Cancer After Surgery in US: A Long-Term Follow-Up Study Based on SEER Database

There are few studies on the cause of death in patients with stage I non-small cell lung cancer after surgery. Our aim is to study the trend of cause of death and risk factors affecting prognosis in the patients. We retrospectively reviewed patients in Surveillance, Epidemiology and End results database from 2004 to 2015. The change trend between cause of death and follow-up time was studied by calculating the proportion of cause of death at different periods and analyzing the cumulative risk. COX risk regression model was performed by univariate and multivariate analyses for survival analysis. Finally, 23,652 patients were enrolled. In the whole cohort, lung cancer accounted for 18.68% of deaths, followed by other causes (9.57%), heart disease (5.12%) and COPD (3.89%). With the increasing of follow-up time, the cumulative incidence of lung cancer was always the highest, but the growth rate in the late follow-up period was slower than that caused by heart disease and COPD. The proportion of death due to lung cancer decreased from 53.1%-73.1% in 0-30 months after follow-up to 7.8%-41.4% in 90 months after follow-up, while the proportion of deaths due to heart disease and COPD increased. Age was an independent risk factor for lung cancer-, heart disease- and COPD-specific survival, while lobectomy resection was a protective factor, even in patients older than 70 years old. In conclusion, during the follow-up period, lung cancer was still the main cause of death, but the proportion of patients died of heart disease and COPD increased gradually, especially in elderly. Furthermore, age was an important independent factor affecting prognosis, particularly for heart disease- and COPD-related mortality. The application of wedge resection in elderly patients needs further exploration.

Risk factors of middle lobe bronchus kinking following right upper lobectomy

Background

The incidence rate of kinking of the middle lobe bronchus following right upper lobectomy is higher compared to that with residual lung bronchus following other lobectomies. Bronchial kinking was presumed to be caused by the displacement of the residual lung lobes, but its etiology is unclear. Moreover, prevention methods and effective treatments have not yet been established. The purpose of this study was to investigate the risk factors and etiology of middle lobe bronchus kinking and discuss prevention methods.

Methods

Patients who underwent right upper lobectomy in our hospital were retrospectively evaluated. Patient clinical characteristics, lung function, and lung lobe volume, surgical procedure were analyzed in association with the incidence of middle lobe bronchus kinking. The association between the displacement of residual lung lobes after operation and the incidence of middle lobe bronchus kinking was analyzed to assess the etiology.

Results

A total of 175 patients were enrolled in the risk analysis. Middle lobe bronchus kinking was observed in 5 patients (2.9%). The low percentage of forced expiratory volume percentage in 1 second (P=0.021), the low volume ratio of the right middle lobe (RML) to the right thoracic cavity (RTC) (P=0.016), and the low volume ratio of RML to right upper lobe (RML/RUL) (P=0.006) were significant risk factors of middle lobe bronchus kinking. In the patients who underwent CT at 6 months after surgery, the degree of the cranial displacement of RML was associated with the incidence of middle lobe bronchus kinking (P=0.025).

Conclusions

The risk of middle lobe bronchus kinking could be assessed preoperatively by calculating the volume ratio of RML/RTC and RML/RUL. The displacement of RML could be associated with the incidence of middle lobe bronchus kinking.

Predictive factors of cough after uniportal video-assisted thoracoscopic pulmonary resection

Background

Cough is one of the shared complications after lung surgery. In this study, a prospective analysis was conducted for exploring the risk factors of persistent cough after uniportal video-assisted thoracoscopic pulmonary resection.

Methods

One hundred thirty-five patients with pulmonary nodules who underwent surgical treatment in the same surgical group from November 2019 to January 2020 were enrolled in this prospective study. The severity of cough and its impact on patients’ quality of life before and after surgery were assessed by the Mandarin Chinese version of the Leicester cough questionnaire (LCQ-MC), and postoperative cough was tested by the cough visual analog scale (VAS) and cough symptom score (CSS). Risk factors of cough after pulmonary resection (CAP) were determined by univariate and multivariate logistic regression analysis.

Results

The incidence of postoperative cough was 24.4% (33 of 135 patients). Univariate analysis showed that gender (female), the surgical site (upper right), the resection (lobectomy), subcarinal lymph node dissection, postoperative acid reflux, length of hospitalization contributed to the development of CAP resection. Multivariate logistic regression analysis showed that the resection (lobectomy) (OR 3.590, 95% CI: 0.637–20.300, P=0.017), subcarinal lymph node dissection (OR 4.420, 95% CI: 1.342–14.554, P=0.001), postoperative acid reflux (OR 13.55, 95% CI: 3.186–57.633, P<0.001) and duration of anesthesia (over 153 minutes, OR 0.987, 95% CI: 0.978–0.997, P=0.011) were independent risk factors for postoperative cough.

Conclusions

The application of uniportal video-assisted thoracoscopic techniques to several types of lung surgery are conducive to enhanced recovery after surgery (ERAS). Postoperative cough is related to an ocean of factors, the resection (lobectomy), subcarinal lymph node dissection, postoperative acid reflux, and duration of anesthesia (over 153 minutes) are independent high-risk factors for CAP resection.

Trial registration

This study was registered on ClinicalTrials.gov (NCT04204148).

Intermediate bronchial kinking after right upper lobectomy for lung cancer

BACKGROUND

Bronchial kinking after lung lobectomy is likely, whereas that of the intermediate bronchus after right upper lobectomy is often not recognized. The aim of this study was to examine the clinical implications of this condition.

METHODS

One-hundred cases of right upper lobectomy for primary lung cancer were reviewed. The cases were divided into groups with intermediate (group A) and non-intermediate (group B) bronchial kinking, and the patient characteristics and postoperative outcomes were compared. The remaining lower lobe deformation was also evaluated using the angle formed by the intrathoracic tracheal line and posterior fissure on reconstructed sagittal computed tomography.

RESULTS

There were 23 cases in group A which had a higher rate of bronchial calcification, older age, and female sex, whereas and smoking and pulmonary emphysema were less frequent. Three cases in group A had respiratory symptoms such as wheezing and respiratory noise, while only one case of middle lobe atelectasis was found in group B. In multivariate analysis, upper mediastinal lymph node dissection was an independent factor for non-intermediate bronchial kinking. The lower lobe was significantly more expanded in group A than in group B.

CONCLUSIONS

Intermediate bronchial kinking correlates with postoperative respiratory symptoms and was less likely after upper mediastinal lymph node dissection.

Thoracoscopic left S1 + 2 segmentectomy as a good resolution for preserving pulmonary function

OBJECTIVES

Segmentectomies such as S1 + 2, S1 + 2+3 and S4 + 5 segmentectomy are used to treat patients with non-small-cell lung cancer (NSCLC) in the left upper lobe. However, the preservable lung volume and changes after such segmentectomies remain unknown. We compared the residual pulmonary function after thoracoscopic segmentectomy or lobectomy in the left upper lobe and examined the efficacy of S1 + 2 segmentectomy regarding postoperative pulmonary function.

METHODS

Patients with left upper lobe NSCLC who underwent thoracoscopic segmentectomy or lobectomy were included. Spirometry and computed tomography were performed before and 6 months after resection, and the ipsilateral preserved lobe volume was calculated using 3-dimensional computer tomography. The percentage of postoperative/preoperative forced expiratory volume in 1 s and actual/predicted regional forced expiratory volume in 1 s (preservation rate) in the residual lobe were compared.

RESULTS

Eighty-eight patients underwent lobectomy and 70 patients underwent segmentectomy (23 S1 + 2, 35 S1 + 2+3 and 12 S4 + 5 segmentectomies). The percentage of postoperative/preoperative forced expiratory volume in 1 s was 97 in S1 + 2, 82 in S1 + 2+3, 86 in S4 + 5 segmentectomy and 73 in left upper lobectomy, indicating that segmentectomy could be a meaningful approach to preserve pulmonary function. The preservation rate was 83% in S1 + 2 and 62% in S1 + 2+3 segmentectomy and was significantly higher in S1 + 2 than in S1 + 2+3 segmentectomy (P < 0.001).

CONCLUSIONS

Postoperative pulmonary function and the preservable lung volume of the residual lobe after thoracoscopic S1 + 2 segmentectomy were well-preserved among other segmentectomies and lobectomy. Thoracoscopic S1 + 2 segmentectomy is a good alternative for preserving postoperative function.

Endobronchial valve therapy for severe emphysema: an overview of valve-related complications and its management

INTRODUCTION

Bronchoscopic lung volume reduction treatment with one-way valves is an effective guideline treatment option for patients with severe emphysema. However, important challenges and adverse reactions may occur after treatment.

AREAS COVERED

This review summarizes the complications after endobronchial and intrabronchial valve treatment that have been described by the currently published randomized controlled trials and other relevant papers regarding the complications and its management. In case there was no relevant literature regarding these subjects, recommendations are based on expert opinion. Complications include pneumothorax, post-obstruction pneumonia and hemoptysis. Also, the treatment may not be effective due to the presence of collateral ventilation or misplaced valves. Furthermore, an initial beneficial effect may vanish due to granulation tissue formation, valve dysfunction or valve migration. Careful follow-up after treatment with valves is important. Evaluation with a CT-scan and/or bronchoscopy is needed if there is no improvement after treatment, loss of benefit, or occurrence of important adverse events during follow-up.

EXPERT OPINION

Treating severe emphysema patients with one-way valves requires continuous dedication and expertise, especially to achieve an optimal outcome and elegantly deal with the various complications after treatment.

Postoperative complications of pulmonary resection

Thoracic surgery has seen a resurgence in recent years with increasing numbers of cases taken on since the mid-2000s. There has been a paradigm shift in how we manage lung cancer with more emphasis on surgical resection, and this has been aided by minimally invasive video-assisted thoracic surgery (VATS) techniques. As a result, the prevalence of postoperative findings and complications is also increasing, and it is increasingly important for the general radiologist to recognise and diagnose these conditions as thoracic surgical patients may present acutely to non-thoracic surgical institutions. This review will cover both the early and late complications following a variety of lung resection surgeries.

Lobectomy versus sublobar resection in patients with non-small cell lung cancer: a systematic review

Surgery is the gold standard treatment of lung cancer. The minimally invasive technique does not only concern access to the chest but also the limits of parenchymal resection. The study debates on the safety and oncological adequacy of sublobar resections in bronchogenic carcinoma patients. A systematic analysis of the data in the literature was carried out, comparing the outcomes of patients with resectable non-small lung cancer (NSCLC) who underwent lobectomy or sublobar resection. These last interventions include both segmentectomies and wedge resections taking into consideration the following parameters: complications, relapse rate and overall survival. The complication rate is higher in patients underwent lobectomy compared to sublobar resection, especially in presence of high comorbidity index or octogenarian patients (overall values respectively between 0 and 48% and 0 and 46.6%). Contrarily, the relapse rate (6.2% to 32% vs. 3.6% to 53.4%) and overall survival (50.2% to 93.8% vs. 38.6% to 100%) are more favorable in patients undergoing lobectomy. Sublobar resections are particularly indicated in elderly patients and in patients with high comorbidity index or reduced respiratory functional reserve. However, pulmonary lobectomy still remains the safest and oncologically correct method in patients with good performance status or higher risk of recurrence.

The choice of dissection or preservation of the inferior pulmonary ligament after an upper lobectomy: a systematic review and meta-analysis

BACKGROUND

The necessity of the inferior pulmonary ligament (IPL) dissection after an upper lobectomy remains controversial. This meta-analysis aimed to evaluate whether this accessional procedure could reduce the postoperative complications and improve outcomes.

METHODS

PubMed, Embase, Ovid, Cochrane Library, CBM, and CNKI databases were searched for the relevant studies which compared the dissection with preservation of IPL during the upper lobectomy. The Review Manager 5.3 software was used for this meta-analysis.

RESULTS

Three RCTs and five CCTs were included in this meta-analysis. These studies contained a total of 610 patients, in which 315 patients received a pulmonary ligament dissection (group D) after the upper lobectomy, while the other 295 patients preserved the pulmonary ligament (group P). No significant difference was demonstrated between the group D and group P in terms of drainage time after surgery (MD 0.14, 95%CI - 0.05 to 0.33, P = 0.15), rate of postoperative dead space (OR 1.33, 95%CI 0.72 to 2.46, P = 0.36), rate of postoperative complications (OR 1.20, 95%CI 0.66 to 2.19, P = 0.56). However, the pooled comparison revealed a greater change of the right main bronchial angle (MD 5.00, 95%CI 1.68 to 8.33, P = 0.003) in group D compared with group P, indicated that the dissection of IPL may lead to a greater distortion of bronchus.

CONCLUSIONS

This meta-analysis confirmed that the dissection of IPL do not effectively reduce the postoperative complications and improve the prognosis. Therefore, it is not necessary to dissect the IPL after an upper lobectomy.

Structural and functional alterations of the tracheobronchial tree after left upper pulmonary lobectomy for lung cancer

Background

Pulmonary lobectomy has been a well-established curative treatment method for localized lung cancer. After left upper pulmonary lobectomy, the upward displacement of remaining lower lobe causes the distortion or kink of bronchus, which is associated with intractable cough and breathless. However, the quantitative study on structural and functional alterations of the tracheobronchial tree after lobectomy has not been reported. We sought to investigate these alterations using CT imaging analysis and computational fluid dynamics (CFD) method.

Methods

Both preoperative and postoperative CT images of 18 patients who underwent left upper pulmonary lobectomy are collected. After the tracheobronchial tree models are extracted, the angles between trachea and bronchi, the surface area and volume of the tree, and the cross-sectional area of left lower lobar bronchus are investigated. CFD method is further used to describe the airflow characteristics by the wall pressure, airflow velocity, lobar flow rate, etc.

Results

It is found that the angle between the trachea and the right main bronchus increases after operation, but the angle with the left main bronchus decreases. No significant alteration is observed for the surface area or volume of the tree between pre-operation and post-operation. After left upper pulmonary lobectomy, the cross-sectional area of left lower lobar bronchus is reduced for most of the patients (15/18) by 15–75%, especially for 4 patients by more than 50%. The wall pressure, airflow velocity and pressure drop significantly increase after the operation. The flow rate to the right lung increases significantly by 2–30% (but there is no significant difference between each lobe), and the flow rate to the left lung drops accordingly. Many vortices are found in various places with severe distortions.

Conclusions

The favorable and unfavorable adaptive alterations of tracheobronchial tree will occur after left upper pulmonary lobectomy, and these alterations can be clarified through CT imaging and CFD analysis. The severe distortions at left lower lobar bronchus might exacerbate postoperative shortness of breath.

[Advances in the Study of the Effects of Video-assisted Thoracoscopic Segmentectomy on Pulmonary Function]

2018年美国国立综合癌症网络关于非小细胞肺癌（non-small cell lung cancer, NSCLC）指南指出，对于早期NSCLC，解剖性肺叶切除为首选方案。随着电视胸腔镜技术的发展，以胸腔镜为代表的胸外科微创手术在临床得到了广泛应用。胸腔镜肺段切除术已经成为早期NSCLC的治疗方案之一。临床研究发现相较于肺叶切除，亚肺叶切除在早期NSCLC治疗中也可取得相似的结果并保留更多的肺功能，但肺段切除术后患者肺功能的改变尚存争议。本文将重点对胸腔镜肺段切除术后患者肺功能改变的研究进展做一综述。

Evaluation of the Residual Lung Function After Thoracoscopic Segmentectomy Compared With Lobectomy

BACKGROUND

Segmentectomy has shown a beneficial effect on preserving lung function after resection. However, the preservable lung volume and changes after thoracoscopic segmentectomy remain unknown. We compared the residual lung function after thoracoscopic segmentectomy and lobectomy, using a novel three-dimensional computed tomography-based volumetric method.

METHODS

Seventy-four patients who received thoracoscopic segmentectomy were matched to the 74 patients who received thoracoscopic lobectomy. Spirometry and computed tomography were performed before and 6 months after resection, and the ipsilateral residual preserved and nonoperated lobe volume and the contralateral lung volume were calculated using three-dimensional computed tomography. The percentage of actual/predicted regional forced expiratory volume in 1 second (the preservation rate) in each lobe (measured by volumetry and spirometry) was compared with the extent of resection and procedural difficulty (typical or atypical segmentectomy).

RESULTS

The postoperative lung function was significantly more well preserved in segmentectomy than in lobectomy. After segmentectomy and lobectomy, the regional forced expiratory volume in 1 second of the ipsilateral unaffected lobe was increased in comparison with the preoperative value, whereas that of the residual lobe rescued by segmentectomy was decreased. The preservation rates of the residual and unaffected lobes were inversely and positively correlated, respectively, with the extent of the resected segment. The preservation rates of the residual lobe after typical or atypical segmentectomy were not significantly different.

CONCLUSIONS

Although the decrease in the actual lung function of the residual lobe was greater than predicted and increased with increasing extent of resection, segmentectomy preserved the whole lung function better than lobectomy.

[Postoperative complications after major lung resection]

INTRODUCTION

The advent of the minimally invasive techniques has allowed an expansion of the indications for thoracic surgery, particularly in older patients and those with more comorbidities. However, the rate of postoperative complications has remained stable.

STATE OF THE ART

Postoperative complications are defined as any variation from the normal course. They occur in 30% but majority of them are minor. The 30-day mortality rate for lung resection varies range between 2 % and 3% in the literature. Complications can be classified as: (1) early (occurring in the first 24hours) including both "generic" surgical complications (especially postoperative bleeding) and complications more specific to lung surgery (Acute respiratory syndrome, atelectasis); (2) in-hospital complications and those occurring during the first 3 months; these are dominated by infectious events in particular pneumonia but also bronchial (bronchopleural fistula), pleural (pneumothorax, hydrothorax) or cardiac complications; (3) late complications are dominated by chronic pain, affecting 60% of patients having a thoracotomy at three months. Lobectomy is the most common lung resection. Pneumonectomy is a distinct procedure requiring a specific peri- and postoperative management. Right pneumonectomy is associated with a higher risk with a treatment related-mortality ranging between 7 and 10%.

CONCLUSION

Major lung resection has benefited from minimally invasive approaches and fast track to surgery. However, it is important to note the occurrence of new and specific complications related to those news surgical access.

Postoperative Imaging After Lobectomy: Predicting the Displacement and Change in Orientation of Nonresected Lung Nodules

OBJECTIVES

The objective of this study was to determine the effect of a lobectomy to the location and orientation of nonresected lung nodule and its corresponding airway.

METHODS

We reviewed preoperative and postoperative computed tomography of patients who underwent lobectomies and have a separate nonresected nodule in the ipsilateral lung. Displacement of the nonresected nodule and angulation of its corresponding segmental bronchus were measured.

RESULTS

Fifty nodules from 40 patients (30 females, 10 male; mean ± SD age, 67 ± 7 years) were assessed. Nodules are displaced clockwise after right upper, right middle, and left lower lobectomies and counterclockwise after right lower and left upper lobectomies. Displacement of the remaining nodules was greater in the craniocaudal plane, followed by anteroposterior and transverses planes (mean, 3.7, 2.5, and 1.9 cm, respectively).

CONCLUSIONS

Remaining ipsilateral nodules and their associated segmental airways are displaced in a predictable fashion after lobectomy. This may help in the assessment of follow-up imaging.

Ventilation failure after lateral jackknife positioning for robot-assisted lung cancer surgery in a patient after lingula-sparing left upper lobectomy

BACKGROUND

Ventilation failure commonly occurs when a standard left-sided double-lumen tube is used in patients after left upper lobectomy having remarkable angulation of the left main bronchus. We present a female without remarkable angulation, in whom ventilation failure occurred after lateral jackknife positioning.

CASE PRESENTATION

A 73-year-old female after lingula-sparing left upper lobectomy without remarkable angulation was scheduled for robot-assisted right upper lobectomy. Ventilation failure with a standard left-sided double-lumen tube occurred when she was placed not in the lateral position but in the lateral jackknife position required for robotic surgery. After replacement by the Silbroncho® left-sided double-lumen tube, adequate one-lung ventilation became possible.

CONCLUSIONS

Ventilation failure with a standard tube may occur more easily when patients with bronchial angulation are placed in the lateral jackknife than lateral position due to posture-induced exacerbations of bronchial angulation. The Silbroncho® tube seems useful in such situations.

Analysis of middle- and long-term efficacy of thoracoscope-assisted segmental resection of the lung on non-small cell lung cancer in the early stage

We investigated the short- and long-term efficacy of thoracoscope-assisted segmental resection of lung of non-small cell lung cancer (NSCLC). We selected a total of 94 patients with lung cancer in the early stage who were admitted to The First People's Hospital of Xuzhou for treatment between March 2011 and February 2012. Patients were divided randomly into either the control group (n=47) or the observation group (n=47). In the observation group, patients received thoracoscope-assisted segmental resection of lung, while in the control group, the conventional thoracic surgery was performed for treatment. After surgeries, we observed the incidence rate of complications among the two groups, and enzyme-linked immunosorbent assay (ELISA) was adopted to detect levels of inflammatory factors. We also compared the cardiac and pulmonary functions, the levels of immunoglobulins and subgroups of T lymphocytes in the peripheral blood of the patients. In addition, all patients attended a 5-year follow-up to determine the recurrence and survival rate. Compared to the control group, patients in the observation group had significantly less intra-operative bleeding volume, a shorter duration of surgery, and suffered slighter pain after surgery (P<0.05). After surgery, the incidence rate of complications in the observation group was significantly lower than that in the control group (P<0.05). After surgeries, patients in both groups experienced a remarkable improvement in cardiac and pulmonary functions, and the improvement in the observation group was superior to that of the control group (P<0.05). During the 5-year follow-up, the survival rate of the observation group is significantly higher than that in thecontrol group, and patients in the observation group experienced a lower recurrence rate than those in the control group (P<0.05). Thus, thoracoscope-assisted segmental resection of lung is of great significance in clinical practice.

[Effects of VATS Lobectomy, VATS Anatomic Segmentectomy, and Open Thoracotomy on Pulmonary Function of Patients with Non-small Cell Lung Cancer]

背景与目的

肺癌是世界范围内发病率和死亡率最高的恶性肿瘤之一，手术仍然是早期非小细胞肺癌的首选治疗方法。本研究的目的是探讨术后极早期肺功能的恢复情况，并比较肺癌胸腔镜肺叶切除、胸腔镜肺段切除与开胸肺叶切除术后对肺功能影响。

方法

选取中国医学科学院肿瘤医院胸外科2015年9月-2016年2月间手术的肺癌患者，按术式不同分为胸腔镜肺段切除术组、胸腔镜肺叶切除术组、开胸肺叶切除术组，分别于术前、术后第3天和术后3个月检查测试肺功能。统计分析采用SPSS 20.0版本，应用单因素方差分析，比较组间差异。

结果

① 在术后第3天，对比胸腔镜肺叶切除术、胸腔镜肺段切除术、开胸肺叶切除术，三组患者的肺功能，用力肺活量（forced vital capacity, FVC）、FVC占预计值的百分比（FVC%）、一秒用力呼气容积（forced expiratory volume in one second, FEV1）、FEV1占预计值的百分比（FEV1%）、最大呼气流速峰值（peak expiratory?ow, PEF）、每分钟最大通气量（maximal voluntary ventilation, MVV）、肺一氧化碳弥散因子（transfer factor for carbon monoxide of lung, TLCO）、TLCO占预计值的百分比（TLCO%），组间差异具有统计学意义（P值分别为0.033、0.042、0.029、0.045、0.039、0.021、0.018、0.024）。②在术后3个月，对比胸腔镜肺叶切除术、胸腔镜肺段切除术、开胸肺叶切除术，三组患者的肺功能，组间比较发现FVC、FVC%、FEV1、FEV1%、PEF、MVV、TLCO、TLCO%差异显著（P值分别为0.019、0.024、0.044、0.021、0.037、0.029、0.045、0.017）。

结论

肺癌胸腔镜肺叶切除、胸腔镜肺段切除与开胸肺叶切除术后在术后极早期（术后第3天）与术后3个月，肺功能的恢复情况均为胸腔镜肺段切除优于胸腔镜肺叶切除，胸腔镜肺叶切除优于开胸肺叶切除。

Normal postoperative appearances of lung cancer

The major lung resections are the pneumonectomies and lobectomies. The sublobar resections are segmentectomies and wedge resections. These are performed either through open surgery through a thoracotomy or by video-assisted mini-invasive surgery for lobectomies and sublobar resections. Understanding the procedures involved allows the normal postoperative appearances to be interpreted and these normal anatomical changes to be distinguished from potential postoperative complications. Surgery results in a more or less extensive physiological adaptation of the chest cavity depending on the lung volume, which has been resected. This adaptation evolves during the initial months postoperatively. Chest radiography and computed tomography can show narrowing of the intercostal spaces, a rise of the diaphragm and shift of the mediastinum on the side concerned following major resections.

Pleural Hypercarbia After Lung Surgery Is Associated With Persistent Alveolopleural Fistulae

BACKGROUND

Persistent air leak (PAL) > 5 days due to alveolopleural fistulae is a leading cause of morbidity following surgical resection. Elevated CO2 levels reportedly inhibit alveolar epithelial cell proliferation and impair wound healing in vitro. Because the injured lung surface is in direct communication with the pleural cavity, we investigated whether the pleural gaseous milieu affected lung healing.

METHODS

Oxygen and CO2 levels in pleural gas were determined prospectively in consecutive patients (N = 116) undergoing lung resection by using an infrared spectroscopy-based analyzer. Poisson and logistic regression analyses were used to determine the relationship between time to resolution of air leaks and pleural oxygen and CO2. In addition, patients with pleural CO2 concentrations ? 6% on postoperative day 1 (n = 20) were alternatively treated with supplemental oxygen and extrapleural suction to reduce the pleural CO2 levels.

RESULTS

Poisson analyses revealed that every 1% increase in CO2 was associated with a delay in resolution of air leak by 9 h (95% CI, 7.1 to 10.8; P < .001). Linear regression showed that every 1% increase in CO2 increased the odds of PAL by 10-fold (95% CI, 2.2 to 47.8; P = .003). In patients with pleural CO2 ? 6%, a reduction in CO2 promoted resolution of air leak (6.0 ± 1.2 vs 3.4 ± 1.1 days; P < .001).

CONCLUSIONS

Pleural hypercarbia seems to be associated with persistent alveolopleural fistulae following lung resection. Analysis of pleural gases could allow for better chest tube management following lung resection. Patients with intrapleural hypercarbia seem to benefit from supplemental oxygen and suction, whereas patients who do not have hypercarbia can be maintained on water seal drainage.

Perioperative outcomes of upper lobectomy according to preservation or division of the inferior pulmonary ligament

BACKGROUND

The aim of this study was to investigate the relationship between inferior pulmonary ligament division and postoperative complications.

METHODS

Medical records of 72 non-small cell lung cancer (NSCLC) patients who underwent video-assisted thoracic surgery (VATS) upper lobectomy between March 2012 and November 2013 performed by a single thoracic surgeon at our center were reviewed retrospectively. Patients were categorized into two groups: the division group, who underwent division of the inferior pulmonary ligament, and the preservation group, who did not. The division group included 43 patients (27 right, 16 left), while the preservation group included 29 (11 right, 18 left). Postoperative outcomes such as the presence of pleural effusion, chest tube duration, and changes in the angle and diameter of remnant bronchus were compared; bronchial diameter and angle were measured on three-dimensional (3D) reconstruction chest CT images.

RESULTS

Chest tube duration, duration of chest tube drainage >200 mL, and the presence of pleural effusion on chest X-rays taken 1 month after surgery were not significantly different between the two groups (P=0.07, 0.33, and 1.00, respectively). There were also no significant differences between groups in the presence of apical dead space or in change in bronchial angle (P=0.22 and 0.74, respectively). In 3D reconstruction images, changes in the diameter of the right middle, right lower, and left lower lobar (LLL) bronchi were similar between groups (P=0.72, 0.12 and 0.29, respectively). Change in the angle between the right bronchus intermedius (RBI) and the right middle lobar (RML) bronchus and between the RBI and the right lower lobar (RLL) bronchus were significantly different between the division and preservation groups (P=0.02 and 0.05, respectively).

CONCLUSIONS

Inferior pulmonary ligament division had no clear benefits. Complications related to excessive dislocation of remnant bronchi might be associated with inferior pulmonary ligament division, but further research is needed to elucidate this relationship.

Dividing inferior pulmonary ligament may change the bronchial angle

BACKGROUND

Whether dissecting the inferior pulmonary ligaments (IPLs) during superior video-assisted thoracoscopic (VATS) lobectomy for early stage lung cancer remains controversial. This study aimed to evaluate the influence of dissecting the IPLs during VATS superior lobectomy on bronchial distortion and recovery of pulmonary function.

MATERIALS AND METHODS

This was a retrospective study of 72 patients with non-small cell lung cancer who underwent VATS superior lobectomy from March 2012-August 2013 at the First People's Hospital of Yunnan Province. Patients were grouped according to IPLs preservation (group P) or dissection (group D). The preoperative and postoperative pulmonary function and the postoperative complications were analyzed. The changes in bronchi angles and pulmonary capacity were measured using computed tomography.

RESULTS

There were no significant differences in the complication rate and volume of chest drainage between the two groups. The changes in bronchus angle in group P were significantly smaller than those in group D after left lung operation (P = 0.046 at 3 mo; P = 0.038 at 6 mo); in the right lung, the changes were not significant between the two groups (P = 0.057 at 3 mo; P = 0.541 at 6 mo). The forced expiratory volume of 2% and forced expiratory volume in 1 s (FEV1%) were significantly better in group P than those in group D at 3 and 6 mo (P < 0.05). The pulmonary capacity in group P was significantly larger than that in group D at 6 mo (P = 0.002).

CONCLUSIONS

Preservation of IPLs during VATS lobectomy might have an impact on the bronchus angle, lung function, and lung volume.

[Use of minimally invasive approaches for stage I non-small cell lung cancer: A surgeon's point of view]

Lobectomy with lymphadenectomy is the standard of care of patients with early stage non-small cell lung cancer, and the use of minimally invasive approaches is associated with reduced morbidity when compared with thoracotomy. Segmentectomy with lymphadenectomy seems to provide a curative effect equivalent to that of lobectomy for stage IA tumours of 2 cm or smaller, and for pure or predominant ground glass opacities. The combination of lung-sparing resections with minimally invasive approaches results in preserved pulmonary function, improved quality of life and very low morbidity. This benefit persists in so-called high-risk patients. Among patients with clinical stage IA managed with sublobar resections, more than 25% are proved to have a more advanced pathologic stage at surgery, suggesting that alternative ablative therapies would result in an incomplete resection in a similar proportion. Moreover, resection samples tumour tissue that is adequate in quantity and quality, and provides material for "research biopsies" to consolidate tissue availability for clinical trials, translational research, and in biobanks.

Changes in pulmonary function in lung cancer patients after video-assisted thoracic surgery

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) is widely performed in patients with resectable non-small cell lung cancer. However, it is unknown whether VATS sublobar resection has advantages compared with VATS lobectomy in preserving pulmonary function.

METHODS

Three hundred patients with non-small cell lung cancer who underwent VATS were enrolled. Pulmonary function tests were performed three times: preoperatively, and at 3 and 12 months postoperatively. Pulmonary function was compared between the VATS lobectomy group (n = 227) and the VATS sublobar resection group (n = 73).

RESULTS

The VATS sublobar resection group had greater preserved pulmonary function than the VATS lobectomy group at 3 and 12 months postoperatively (p < 0.001). However, a VATS lobectomy of the right upper or right middle lobe revealed no difference in forced vital capacity (-1.21% versus -1.45%; p = 0.88) or the diffusion capacity of carbon monoxide (-3.99% versus -2.45%; p = 0.61) compared with VATS sublobar resection after 12 months. In those who underwent VATS of the right lower lobe, forced expiratory volume in 1 second (-8.60% versus -3.69%; p = 0.12) was not different between the two groups after 12 months. Video-assisted thoracoscopic surgery lobectomy of the left upper or left lower lobe resulted in lower pulmonary function than VATS sublobar resection (p < 0.05).

CONCLUSIONS

Patients with non-small cell lung cancer who underwent VATS sublobar resection demonstrated greater pulmonary function than those who underwent VATS lobectomy. However, in right-side VATS lobectomy, some differences dissipated at 1 year.