Video-assisted thoracic surgery in lung cancer resection: a meta-analysis and systematic review of controlled trials

Modified surgical fusion: VATS and BABA approach for ectopic intrathoracic and cervical thyroidectomy

Ectopic goitre, presenting as an isolated thoracic mass without connection to the main thyroid gland enlargement, is a rare occurrence. We describe a case where a patient reported persistent dry cough and back pain for 1 year, along with throat discomfort unresponsive to medication. A 2×1 cm swelling was noted over the right anterior aspect of the neck. Extensive evaluation, including chest X-rays and contrast-enhanced CT of the thorax, revealed a mediastinal mass suggestive of an ectopic thyroid.This case presents a distinctive scenario involving the simultaneous presence of ectopic mediastinal and cervical thyroid lesions. Both were effectively managed using a minimally invasive approach, combining video-assisted thoracic surgery for the excision of the mediastinal mass and a bilateral axillo-breast approach for the cervical lesion in a single procedure. This approach yielded minimal morbidity, aesthetically pleasing outcomes and rapid recovery. Remarkably, such a case has not been previously documented in the available literature.

Effect of lung isolation with different airway devices on postoperative pneumonia in patients undergoing video-assisted thoracoscopic surgery: a propensity score-matched study

BACKGROUND

Postoperative pneumonia is one of the common complications after video-assisted thoracoscopic surgery. There is no related study on the effect of lung isolation with different airway devices on postoperative pneumonia. Therefore, in this study, the propensity score matching method was used to retrospectively explore the effects of different lung isolation methods on postoperative pneumonia in patients undergoing video-assisted thoracoscopic surgery.

METHODS

This is A single-center, retrospective, propensity score-matched study. The information of patients who underwent VATS in Weifang People 's Hospital from January 2020 to January 2021 was retrospectively included. The patients were divided into three groups according to the airway device used in thoracoscopic surgery: laryngeal mask combined with bronchial blocker group (LM + BB group), tracheal tube combined with bronchial blocker group (TT + BB group) and double-lumen endobronchial tube group (DLT group). The main outcome was the incidence of pneumonia within 7 days after surgery; the secondary outcome were hospitalization time and hospitalization expenses. Patients in the three groups were matched using propensity score matching (PSM) analysis.

RESULTS

After propensity score matching analysis, there was no significant difference in the incidence of postoperative pneumonia and hospitalization time among the three groups (P > 0.05), but there was significant difference in hospitalization expenses among the three groups (P < 0.05).

CONCLUSIONS

There was no significant difference in the effect of different intubation lung isolation methods on postoperative pneumonia in patients undergoing thoracoscopic surgery.

Bibliometric analysis of 40 most cited articles comparing video-assisted thoracic surgery and robotic-assisted thoracic surgery in lung cancer (1997-2021)

Background

In recent years, conventional thoracoscopic surgery has been accepted as the traditional treatment method in the non-small cell lung cancer (NSCLC). VATS and RATS, which are the techniques of this surgical method, have been increasing their effectiveness and applicability of late years. The aim of this bibliometric analysis is to evaluate the importance and efficiency of articles comparing VATS and RATS techniques.

Materials and methods

Studies comparing VATS and RATS published between 1997 and 2021 were identified in the Web of Science database (accessed on 31. 12. 2021). The 40 most cited studies were analyzed in terms of publication years, country of study, authors, institutions that the authors were affiliated with, journal, journal address and impact factor.

Results

While an article was cited a maximum of 187 times when the citations made by the authors were excluded from the analysis, it was observed that all publications were cited a total of 1946 times. It was seen that an average of 51. 30 ± 47. 73 (8-187) articles were cited. In the 25-year, the highest number of publications was reached in 2019, while eight articles were published this year. The Annals of Thoracic Surgery (n = 13, 32. 5 %) was the journal in which the articles in the list were published the most. Most of the articles in our study (n = 31, 77.5 %) were published in US journals. While many studies presented more than one topic and analysis, the topic of most interest in 19 (47.5 %) studies was postoperative complications.

Conclusion

This bibliometric analysis reflects important and qualified articles comparing VATS and RATS technique in thoracic surgery, but it can also be used to explain or explain the performance and results of these techniques, their positive and negative aspects, and their superiority over each other.

Effects of Press Needling combined with general anesthesia on postoperative analgesia in thoracoscopic pulmonary resection for lung cancer: A randomized, single-blind, controlled trial

OBJECTIVES

To investigate the effects of press needle therapy on postoperative analgesia and other relevant complications in patients undergoing thoracoscopic pulmonary resection.

DESIGN

randomized, single-blind, controlled trial SETTING: Teaching hospitals affiliated with universities.

INTERVENTIONS

Eighty-six patients were randomized into: the Acu group (press-needle group) and the control group MAIN OUTCOME MEASURES: Pain levels 24, 48, and three months after surgery were measured using the numeric rating scale (NRS). Perioperative hemodynamics, total and effective pressing numbers of patient-controlled intravenous analgesia (PCIA), and incidence of postoperative pulmonary complications were recorded. Peripheral blood samples were collected to measure the levels of inflammatory mediators RESULTS: Acu group had significantly lower NRS scores at 24 and 48 h after operation (NRS scores on movement at 24 h after surgery: Acu vs. Control, 3 (2,3) vs. 3 (3,5), Z = -3.393, P < 0.01 and NRS scores on movement at 48 h after surgery: 2 (1,3) vs. 3 (2,5), Z = -3.641, P < 0.01), lower number of PCIA attempts and effective rates (mean total pressing numbers: 4(2,8) vs. 6(3,19), Z = -1.994, P = 0.046 and mean effective pressing numbers: 3(2,8) vs. 6(3,16), Z = -2.116, P = 0.034). The Acu group had significantly reduced IL-1 (14.52 ± 3.84 vs. 16.36 ± 3.30, mean difference (MD): - 1.85, 95% confidence interval (CI): - 3.46, - 0.23, P = 0.026), HIF-1α (10.15 ± 1.71 vs. 10.96 ± 1.73, MD: -0.81, 95% CI: -1.59, -0.04, P = 0.040) and the incidence of pulmonary complications after surgery.

CONCLUSION

Press needles are a non-invasive and feasible adjunctive intervention for postoperative analgesic management in patients undergoing thoracoscopic pulmonary resection.

Laparoscopic Abdominal Surgery Under Thoracic Epidural Anesthesia in Patients with Interstitial Lung Disease: Retrospective Observational Cohort Study

BACKGROUND

Patients with interstitial lung disease who present with abdominal disease carry a perioperative risk of morbidity and mortality, including the risks of general anesthesia and postoperative pulmonary complications. We investigated the efficacy of laparoscopic surgery in such patients under epidural anesthesia.

MATERIALS AND METHODS

All patients with interstitial lung disease who underwent laparoscopic abdominal surgery were retrospectively studied. At 30 days, our primary end point was acute exacerbation of pulmonary complications. The second end point was nonpulmonary complications and 30-day hospital mortality.

RESULTS

Eighteen patients were enrolled in this study after reviewing their medical and surgical records. Our study revealed that none of the patients suffered from acute pulmonary exacerbations, and only 1 patient experienced a nonpulmonary event. There was no reported mortality. The conversion rate was low, with 1 patient necessitating conversion from laparoscopic to open surgery, which was conducted under epidural anesthesia. No conversions from epidural to general anesthesia were performed.

CONCLUSION

Epidural anesthesia is safe in a patient with interstitial lung disease, and laparoscopic surgery can be completed with low rate of conversion and, with minor complications.

Erector Spinae Plane Block versus Paravertebral Block after Thoracic Surgery for Lung Cancer: A Propensity Score Study

INTRODUCTION

The prevention of respiratory complications is a major issue after thoracic surgery for lung cancer, and requires adequate post-operative pain management. The erector spinae plane block (ESPB) may decrease post-operative pain. The objective of this study was to evaluate the impact of ESPB on pain after video or robot-assisted thoracic surgery (VATS or RATS).

METHODS

The main outcome of this retrospective study with a propensity score analysis (PSA) was to compare the post-operative pain at 24 h at rest and at cough between a group that received ESPB and a group that received paravertebral block (PVB). Post-operative morphine consumption at 24 h and complications were also assessed.

RESULTS

One hundred and seven patients were included: 54 in the ESPB group and 53 in the PVB group. The post-operative median pain score at rest and cough was lower in the ESPB group compared to the PVB group at 24 h (respectively, at rest 2 [1; 3.5] vs. 2 [0; 4], p = 0.0181, with PSA; ESPB -0.80 [-1.50; -0.10], p = 0.0255, and at cough (4 [3; 6] vs. 5 [4; 6], p = 0.0261, with PSA; ESPB -1.48 [-2.65; -0.31], p = 0.0135). There were no differences between groups concerning post-operative morphine consumption at 24 h and respiratory complications.

CONCLUSIONS

Our results suggest that ESPB is associated with less post-operative pain at 24 h than PVB after VATS or RATS for lung cancer. Furthermore, ESPB is an acceptable and safe alternative compared to PVB.

Uniportal VATS for Diagnosis and Staging in Non-Small Cell Lung Cancer (NSCLC)

Uniportal VATS has become an accepted approach in minimally invasive thoracic surgery since its first report for lobectomy in 2011. Since the initial restrictions in indications, it has been used in almost all procedures, from conventional lobectomies to sublobar resections, bronchial and vascular sleeve procedures and even tracheal and carinal resections. In addition to its use for treatment, it provides an excellent approach for suspicious solitary undiagnosed nodules after bronchoscopic or transthoracic image-guided biopsy. Uniportal VATS is also used as a surgical staging method in NSCLC due to its low invasiveness in terms of chest tube duration, hospital stay and postoperative pain. In this article, we review the evidence of uniportal VATS accuracy for NSCLC diagnosis and staging and provide technical details and recommendations for its safe performance for that purpose.

Sublobar resections for lung cancer: Finally, some answers and some more questions?

The Lung Cancer Study Group Trial, published in 1995, set the tone for lobectomy as the standard of care for early-stage nonsmall cell lung cancer. Twenty-seven years and two randomized trials later, does the thoracic oncology community have clarity regarding the choice type of resection, or more questions?

Thoracoscopic Versus Open Lobectomy After Induction Therapy for Nonsmall Cell Lung Cancer: New Study Results and Meta-analysis

INTRODUCTION

The use of video-assisted thoracoscopic surgery (VATS) lobectomy has become a mainstay of modern thoracic surgery practice and the technique of choice for resection of early-stage lung cancers. However, the benefits of VATS following induction therapy are yet to be clarified. This study aims to assess whether VATS lobectomy achieves similar perioperative and oncologic outcomes compared to thoracotomy for nonsmall cell lung cancer after induction therapy.

METHODS

We retrospectively reviewed the outcomes of 72 patients who underwent lung lobectomy after induction therapy in our institution from January 2017 to January 2020. Subsequently, we carried out a comprehensive literature search and pooled our results with available data from previously published studies to perform a meta-analysis.

RESULTS

VATS was associated with reduced intraoperative blood loss (P = 0.05) and less perioperative complications (P = 0.04) in our local institution. The meta-analysis comprised nine studies. A total of 943 patients underwent VATS and 2827 patients underwent open lobectomy. VATS was associated with significant shorter surgery duration (P < 0.0001), shorter chest-tube drainage duration (P < 0.0001), and shorter hospital stays (P < 0.0001). Furthermore, there was significantly less perioperative complications (P = 0.006) and less intraoperative blood loss (P = 0.036) in the VATS group. However, there were no significant differences in 3-y overall survival and 3-y disease-free survival rates.

CONCLUSIONS

In some selected patients undergoing induction therapy, VATS lobectomy could achieve equivalent perioperative outcomes to thoracotomy but evidence is lacking on oncologic outcomes. Further trials with a focus on oncologic outcomes and longer follow-up are required.

The efficacy and safety of acupuncture assisted anesthesia (AAA) for postoperative pain of thoracoscopy: A protocol for systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Enhanced recovery after surgery suggests the use of multimodal analgesia to optimize the perioperative pain management scheme. At present, studies have shown that the application of acupuncture combined anesthesia in thoracoscopy has achieved good curative effect. However, there is no relevant systematic evaluation. Our study is the first meta-analysis of the effectiveness and safety of acupuncture combined anesthesia in pain management after thoracoscopy, in order to provide strong evidence for clinical support.

METHODS

A comprehensive and systematic literature searching will mainly perform on 7 electronic databases (PubMed, the Cochrane Library, Embase, China National Knowledge Infrastructure, Chongqing VIP Information, and WanFang Data, Chinese Biomedical Database) from their inception up to November 30, 2021. We will also search for ongoing or unpublished studies from other websites (eg, PROSPERO, ClinicalTrials.gov, Chinese Clinical Trial Registry) and do manual retrieval for potential gray literature. Only the relevant randomized controlled trials published in English or Chinese were included. Two independent investigators will independently complete literature selection, assessment of risk bias, and data extraction, the disagreements will be discussed with the third party for final decisions. The primary outcome measures: visual analog scale, intraoperative anesthetic dosage, and the consumption of postoperative analgesics. The secondary outcome measures: Pittsburgh Sleep Quality Index, the total sleep time after operation, residence time in the anesthesia recovery room, the duration of hospitalization, and the incidence of adverse reactions and serious events. Assessment of bias risk will follow the Cochrane risk of bias tool. Data processing will be conducted by Stata 15.0 software.

RESULTS

We will evaluate the efficacy and safety of acupuncture assisted anesthesia for postoperative pain after thoracoscopy based on randomized controlled trials.

CONCLUSION

This study can provide more comprehensive and strong evidence whether acupuncture assisted anesthesia is efficacy and safe for postoperative pain in thoracoscopy.

REGISTRATION

The research has been registered and approved on the INPLASY website. The registration number is INPLASY 2021120129.

Video-assisted thoracoscopic lobectomy and bilobectomy versus open thoracotomy for non-small cell lung cancer: Mortality and survival

Background

In this study, we aimed to evaluate patients who had non-small cell lung cancer and underwent resection, to investigate our tendency to prefer video-assisted thoracic surgery or open thoracotomy, and to compare 30- and 90-day mortalities and survival rates.

Methods

Between January 2013 and January 2019, a total of 706 patients (577 males, 129 females; mean age: 61.9±8.6 years; range, 17 to 84 years) who underwent lobectomy or bilobectomy due to primary non-small cell lung cancer were retrospectively analyzed. The patients were divided into two groups as operated on through video-assisted thoracic surgery and through open thoracotomy. The 30- and 90-day mortality rates and survival rates were compared.

Results

Of the patients, 202 (28.6%) underwent video-assisted thoracic surgery and 504 (71.4%) underwent open thoracotomy. Lobectomy was performed in 632 patients (89.5%) and bilobectomy was performed in 74 patients (10.5%). Patients who were chosen for video-assisted thoracic surgery were statistically significantly older, did not require any procedure other than lobectomy, did not receive neoadjuvant therapy, had a small tumor, and did not have lymph node metastases. The 30- and 90-day mortality rates in the video-assisted thoracic surgery and open thoracotomy groups were 1.8% vs. 2% and 2.6% vs. 2.5%, respectively. The five-year survival rates of video-assisted thoracic surgery and open thoracotomy groups were 74.1% and 65.2%, respectively (p>0.05). The 30- and 90-day mortality and five-year survival rates were 2.1%, 2.6%, and 73.5% in the video-assisted thoracic surgery group and 2.1%, 2.1%, and 68.5% in the open thoracotomy group, respectively, indicating no statistically significant difference between the two groups.

Conclusion

Throughout the study period, video-assisted thoracic surgery was more preferred in patients with advanced age, in those who had a small tumor, who did not receive neoadjuvant therapy, did not have lymph node metastasis, and did not require any procedure other than lobectomy. In the video-assisted thoracic surgery and open thoracotomy groups, 30- and 90-day mortality and five-year survival rates were similar. Based on these findings, both procedures seem to be acceptable in this patient population.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Is video-assisted thoracoscopic lobectomy associated with higher overall costs compared with open surgery? Results of best evidence topic analysis

Thoracoscopic lobectomy has become the preferred approach for surgical management of early stage lung cancer, but the potential higher operative costs limit its widespread use. Theoretically, higher direct costs may be significantly counterbalanced by lower indirect costs, resulting in lower overall costs for thoracoscopic than for open lobectomy. To support this hypothesis, we reviewed the literature until May 2020, analyzing all papers comparing the cost of thoracoscopic versus open lobectomy.A total of 20 studies provided the most applicable evidence to evaluate this issue. In all the studies apart from one, thoracoscopic lobectomy was associated with higher operative costs due to the increased use of disposable instruments, and prolonged operative time. By contrast, in 17 studies the increased operative costs were significantly offset by indirect costs which were lower in thoracoscopic than in open lobectomy due to fewer postoperative complications, faster recovery, and lower readmission rates. It translated into lower overall costs for thoracoscopic than for open lobectomy in 10 studies, similar costs in seven, and higher in three, despite the lower hospitalization costs. The low bed fees and high prices of disposable instruments in these three studies may explain the discordance. The careful use of disposable instruments, and the minimizing hospitalization costs can reduce the total costs of thoracoscopic lobectomy to levels similar or to below those of open lobectomy. The worry that video‐assisted thoracoscopic surgery lobectomy (VATSL) might be associated with an increased overal cost is thus not warranted, and should not be used as an excuse against the use of VATS in surgery for early stage lung cancers.

Short-Term Impact of Video-Assisted Thoracoscopic Surgery on Lung Function, Physical Function, and Quality of Life

Background: Video-assisted thoracoscopic surgery (VATS) has been increasingly used as an approach for lung lobectomy. However, the recovery of respiratory and physical function may be insufficient at discharge because the average length of hospital stay is decreasing after surgery. In this study, we investigated the changes in physical function, lung function, and quality of life (QOL) of lung cancer patients after VATS, and factors for QOL were also evaluated. Methods: The subjects of this study were 41 consecutive patients who underwent video-assisted lung lobectomy for lung cancer. Rehabilitation was performed both before and after surgery. Lung function testing, physical function testing (timed up and go test (TUG) and the 30-s chair-stand test (CS-30)), and QOL (EORTC QLQ-C30) were measured before and 1 week after surgery. Results: Postoperative VC recovered to 76.3% ± 15.6% 1 week after surgery. TUG, CS-30, and QOL were significantly worse after surgery (p < 0.05). Lung function and physical function were found to affect QOL. Postoperative complications included pneumonia in 1 patient. There were no patients who discontinued rehabilitation. Conclusion: Our rehabilitation program was safe and useful for patients after VATS.

Uptake and survival effects of minimally invasive surgery for lung cancer: A population-based study

INTRODUCTION

Despite growing evidence supporting the safety of minimally invasive surgery (MIS) in the treatment of lung cancer, its uptake is still variable and its outcomes debated. This study examines the factors associated with MIS uptake and its effects on survival in patients with non-small cell lung cancer (NSCLC).

METHODS

All patients in the Canadian province of Ontario with early stage NSCLC (stage I/II) from 2007 to 2017 were included. A logistic regression identified the predictors of MIS uptake, and a flexible parametric model was used to estimate survival rates based on MIS versus open resection.

RESULTS

In total, 8,988 patients underwent surgical resection; 53.6% had MIS. Year of diagnosis was associated with MIS uptake (OR = 1.33, p < 0.001); patients in later years were more likely to receive MIS. Rurality was a significant predictor of MIS, though distance from nearest regional cancer center did not predict MIS utilization. Patients with stage II disease were less likely to receive MIS compared to those with stage I disease (OR = 0.44, p < 0.001). MIS had a significantly higher 5-year survival compared to open resection for stage I and II disease. Patients >70 years had the greatest 5-year survival benefit from MIS.

CONCLUSIONS

We observed a substantial long-term survival benefit in patients undergoing MIS for early stage NSCLC. This difference was most pronounced in the oldest age group. These findings support the use of MIS in the treatment of lung cancer and challenge the notion that MIS compromises oncologic outcomes.

Thoracoscopic Vs Open Surgery Following Neoadjuvant Chemoradiation for Clinical N2 Lung Cancer

We evaluated the feasibility of video-assisted thoracoscopic surgery (VATS) following neoadjuvant concurrent chemoradiotherapy (nCCRT) for N2 non-small-cell lung cancer (NSCLC). We retrospectively reviewed patients with clinical N2 NSCLC who underwent lobectomy and lymph node dissection after nCCRT. The patients were matched using a propensity score based on age, sex, pulmonary function test, histologic type, clinical T factor, and method of N-staging. A total of 385 patients were enrolled between June 2012 and July 2017 (35 VATS, 350 open). After propensity matching (31 VATS, 112 open), the VATS group showed a significantly lower major complication rate (≥ grade II Clavien-Dindo classification; 9.7% vs 30.4%, P = 0.036). No significant differences were found between 2 group of 5-year survival rates (77.1% for the VATS group, 59.9% for the open group; P = 0.276) and recurrence-free survival rates (66.3% for the VATS group, 54.6% for the open group; P = 0.354). In multivariable analysis, VATS did not affect overall survival and recurrence-free survival. VATS was comparable to open thoracotomy in patients with clinical N2 NSCLC after nCCRT without compromising oncologic efficacy.

Community Size and Lung Cancer Resection Outcomes: Studying The Society of Thoracic Surgeons Database

BACKGROUND

Socioeconomic factors play key roles in surgical outcomes. Socioeconomic data within The Society of Thoracic Surgeons (STS) General Thoracic Surgery Database (GTSD) are limited. Therefore, we utilized community size as a surrogate to understand socioeconomic differences in lung cancer resection outcomes.

METHODS

We retrospectively reviewed all lung cancer resections from January 2012 to January 2017 in the STS GTSD. This captured 68,722 patients from 286 centers nationwide. We then linked patient zip codes with 2013 Rural-Urban Continuum Codes to understand the association between community size and postoperative outcomes. Demographic and clinical variables were evaluated for relationships with 30-day mortality, major morbidity, and readmission.

RESULTS

Zip codes were included in 47.2% of patients. Zip-coded patients were older, were more comorbid, had less advanced disease, and were more commonly treated with minimally invasive approaches than were those without zip code classification. For geocoded patients, multivariable analyses demonstrated that sex, insurance payor, and hospital region were associated with all 3 major endpoints. Community size, based on Rural-Urban Continuum Codes coding, was not associated with any primary endpoint. Invasive mediastinal staging was related to morbidity, greater pathological stage predicted mortality, and worsened clinical stage was associated with readmission. More invasive surgery and greater extent of lung resection were associated with all primary endpoints.

CONCLUSIONS

Incomplete data capture can promote selection bias within the STS GTSD and skew outcomes reporting. Moreover, community size is an insufficient surrogate, compared with sex, insurance payor, hospital region, for understanding socioeconomic differences in lung cancer resection outcomes.

Does the length of uniportal video-assisted thoracoscopic lobectomy affect postoperative pain? Results of a randomized controlled trial

BACKGROUND

Uniportal video-assisted thoracoscopic surgery (VATS) lobectomy has become a common approach for the treatment of early stage lung cancer. Here, we aimed to establish whether the length of uniportal incision could affect postoperative pain and surgical outcomes in consecutive patients undergoing uniportal VATS lobectomy for early stage lung cancer.

METHODS

This was a unicenter Randomized Control Trial (NCT03218098). Consecutive patients undergoing uniportal VATS lobectomy for Stage I lung cancer were randomly assigned to a Small Incision group or Long Incision group in 1:1 ratio based on whether patients received a 4 cm or 8 cm incision. The endpoints were to compare the intergroup difference regarding (i) postoperative pain measured by brief pain inventory (BPI) questionnaire (first endpoint); (ii) operative time; (iii) length of chest drainage; (iv) length of hospital stay; (v) postoperative complications; and (vi) pulmonary functional status (secondary endpoints).

RESULTS

A total of 48 patients were eligible for the study. Four patients were excluded; the study population included 44 patients: 23 within the Small Incision group, and 21 within the Long Incision group. The 11 BPI scores between the two groups showed no significant difference. Small Incision group presented higher operative time than Long Incision group (138.69 vs. 112.14 minutes; P = 0.0001) while no significant differences were found regarding length of hospital stay (P = 0.95); respiratory complications (P = 0.92); FEV1% (P = 0.63), and 6-Minute Walking Test (P = 0.77).

CONCLUSIONS

A larger incision for uniportal VATS lobectomy significantly reduced the operative time due to better exposure of the anatomical structures without increasing postoperative pain or affecting the surgical outcome.

KEY POINTS

A larger incision for uniportal VATS lobectomy significantly reduced the operative time due to better exposure of the anatomical structures without increasing postoperative pain or affecting the surgical outcome. To perform a larger incision could be a valuable strategy, particularly in nonexpert hands or when the patient's anatomy or tumor size make exposure of anatomic structures through smaller incisions difficult.

Laparoscopic surgery in patients with interstitial lung disease: A single-center retrospective observational cohort study

INTRODUCTION

Laparoscopic surgery requiring longer operative times and artificial pneumoperitoneum may affect pulmonary function; its feasibility in patients with interstitial lung disease remains unknown. Therefore, we examined the feasibility of laparoscopic surgery in patients with interstitial lung disease.

METHODS

We conducted a retrospective observational cohort study and examined the clinical data of patients with interstitial lung disease who had undergone abdominal surgery under general anesthesia. The primary end-point was the incidence of pulmonary complications. The secondary end-points were non-pulmonary complications and in-hospital mortality.

RESULTS

Twenty-nine patients who had undergone abdominal surgery were diagnosed with interstitial lung disease after a review of their clinical and imaging records. Laparoscopic surgery and open surgery were performed in 11 and 18 patients, respectively. Acute exacerbation occurred in one (9%) patient in the laparoscopic group and three patients (17%) in the open group; all had undergone emergency surgery. Postoperative pneumonia did not occur in any patients. Non-pulmonary complications occurred in one patient (9%) in the laparoscopic group and two patients (11%) in the open group. One patient in each group died of acute exacerbation during hospitalization.

CONCLUSION

Neither acute exacerbation nor pulmonary complications occurred after elective laparoscopic or open surgery in patients with interstitial lung disease. The risk of acute exacerbation after elective laparoscopic surgery may not be as high as that after elective thoracic surgery.

Dimensionality and Measurement Invariance of the Italian Version of the EORTC QLQ-C30 in Postoperative Lung Cancer Patients

Background

This study aims to validate and evaluate the psychometric properties and measurement invariance of the Italian version of the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire-Core 30 (QLQ-C30), which is a measure of quality of life (QoL) for lung cancer patients after surgery.

Methods

A total of 167 lung cancer patients completed the Italian version of the EORTC QLQ-C30 questionnaire at 30 days after they received a lobectomy. The factor structure of this scale was assessed by performing confirmatory factor analysis (CFA). Measurement invariance was evaluated by considering differential item functioning (DIF) due to age, gender, and type of surgery (i.e., robot- or not robot-assisted).

Results

The CFA demonstrated the validity of the factor structure of the EORTC QLQ-C30 in assessing overall health and eight distinct subscales of adverse events and functioning. Moreover, the results highlighted a minimal DIF with only trivial consequences on measurement invariance. Specifically, the DIF did not affect the mean differences of latent scores of QoL between patients undergoing robot-assisted surgery or traditional surgery.

Conclusion

These findings supported the validity and suitability of the EORTC QLQ-C30 for the assessment of QoL in lung cancer patients of diverse ages and genders undergoing lobectomy with or without robot-assisted surgery.

Video-Assisted Thoracic Surgery for Lung Cancer Resection

Objective

The purpose of this consensus conference was to determine whether video-assisted thoracic surgery (VATS) improves clinical and resource outcomes compared with conventional thoracotomy (OPEN) in adults undergoing lobectomy for lung cancer, and to outline evidence-based recommendations for the use of VATS in performing lobectomy for lung cancer.

Methods

Before the consensus conference, the best available evidence was reviewed in that systematic reviews, randomized trials, and nonrandomized trials were considered in descending order of validity and importance. At the consensus conference, evidence-based statements were created, and consensus processes were used to determine the ensuing recommendations. The American Heart Association/American College of Cardiology system was used to label the level of evidence and class of recommendation.

Results and Recommendations

The consensus panel agreed upon the following statements and recommendations in patients with clinical stage I nonsmall cell lung cancer undergoing lung lobectomy: 1. VATS can be recommended to reduce overall postoperative complications (class IIa, level A evidence). 2. VATS can be recommended to reduce pain and overall functionality over the short term (class IIa, level B evidence). 3. VATS can be recommended to improve delivery of adjuvant chemotherapy delivery (class IIa, level B evidence). 4. VATS can be recommended for lobectomy in clinical stage I and II non-small cell lung cancer patients, with no proven difference in stage-specific 5-year survival compared with open thoracotomy (class IIb, level B evidence).

Comparative study of anatomic lung resection by robotic vs. video-assisted thoracoscopic surgery

Background

Comparative studies of robotic lung resection are limited. Our study aims to compare short-term and long-term outcomes of anatomic lung resection by robotic or video-assisted thoracoscopic surgery (VATS) from a single surgeon experienced in both approaches.

Methods

A retrospective analysis of consecutive anatomic lung resections by robot or VATS was performed to compare perioperative characteristics and long-term survival.

Results

From December 2010 to June 2015, 61 patients underwent robotic surgery, and 105 patients underwent VATS. Patient demographics were similar except that the VATS group had higher percentage of diabetic patients (robotic 14.75% vs. VATS 30.48%, P=0.0258) and a slightly lower percentage of patients with previous cancer history (robotic 57.38% vs. VATS 40.95%, P=0.0409). The robotic group had a higher rate of prolonged air leak ≥7 d (robotic 14.75% vs. VATS 3.81%; P=0.0161), and a modestly longer length of hospital stay (robotic median of 4.0 days vs. VATS median of 3.0 days, P=0.0123). Other postoperative complications, mortality, nodal upstaging and conversion rate were similar. Disease-free survival was not different. The robotic group appeared to have slightly better overall survival, however, this observation was confounded by a lower percentage of diabetic patients in this group. Further analysis has demonstrated that in non-diabetic patients who underwent either surgery, the overall survival remained similar. The same observation was also made in diabetic patients.

Conclusions

Robotic anatomic lung resection appears to be associated with a higher rate of prolonged air leak (≥7 d), and resulting slightly longer length of hospital stay than VATS. Within the same follow-up period, both the disease-free survival and the overall survival are similar.

Perioperative outcomes of thoracoscopic lung resection requiring a long operative time

OBJECTIVES

Difficult thoracoscopic surgery sometimes requires a long operative time. It is unclear whether patients benefit from such thoracoscopic surgeries. We investigated whether thoracoscopic surgery for difficult cases contributed to improvements in perioperative outcomes.

METHODS

We retrospectively reviewed cases of anatomical lung resection with thoracoscopic surgery, including conversion to thoracotomy, between January 2006 and December 2016 and compared patient demographics and perioperative outcomes of the long (≥360 min) and the normal operative time groups (<360 min).

RESULTS

One hundred and seventy-six patients were in the long operative time group and 655 patients were in the normal operative time group. The long operative time group had more male patients, more progressive clinical stages, bilobectomy or pneumonectomy, conversion to thoracotomy and more blood loss than the normal operative time group. The long operative time group had higher rates of postoperative complications and longer hospital stay (30% vs 16%, P < 0.001 and 9 ± 9 days vs 7 ± 8 days, P < 0.001; respectively). Multivariate analysis showed that in the first half of the operative period, chronic obstructive pulmonary disease and bilobectomy or pneumonectomy were independent predictive factors for postoperative complications. The long operative time as a factor was close to statistical significance (odds ratio 1.689, P = 0.079) unlike the elective conversion to thoracotomy (odds ratio 0.784, P = 0.667) and emergency conversion to thoracotomy (odds ratio 0.938, P = 0.924).

CONCLUSIONS

In conclusion, when difficult cases are encountered, conversion to thoracotomy should be considered by surgeons if continuation of thoracoscopic surgery increases the operative time.

Transcutaneous Electrical Acupoint Stimulation Improves Immunological Function During the Perioperative Period in Patients With Non-Small Cell Lung Cancer Undergoing Video-Assisted Thoracic Surgical Lobectomy

The immunological function of patients with malignant tumors may be suppressed during the perioperative period. However, details on the effects of transcutaneous electrical acupoint stimulation (TEAS) on immunological function are relatively lacking. We designed this study to examine the effects of TEAS on the immunological function of patients with non-small cell lung cancer (NSCLC) during the perioperative period. Participants (n = 144) were enrolled and randomly assigned into group TEAS or group sham TEAS. TEAS on bilateral Feishu (BL13), Hegu (L14), and Zusanli (ST36) was performed continuously throughout the procedure. The primary outcome was the quantities of natural killer (NK) cells at 30 minutes before induction (T₀), 5 minutes after intubation (T₁), at the beginning of the operation (T₂), at the beginning of the lobectomy (T₃), at the beginning of the lymphadenectomy (T₄), and immediately after extubation (T₅). The secondary outcomes were the serum levels of tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6) at T₀ to T₅, the mean arterial pressure (MAP) and heart rate (HR), the intraoperative consumption of propofol and remifentanil, the incidence of hypoxemia, postoperative nausea and vomiting (PONV), and the length of hospital stay. The quantities of NK cells were decreased in group sham TEAS after intubation compared to that in group TEAS, while the quantities of NK cells in group TEAS were similar at T₀ to T₅. Meanwhile, the quantities of NK cells in group sham TEAS at T₁ (P = .012), T₂ (P < .001), T₃ (P = .027), T₄ (P = .045), and T₅ (P = .021) were lower than those in group TEAS. In group TEAS, the serum levels of TNF-α were lower at T₁ to T₅, while the levels of IL-6 were lower at T₂ to T₅. Furthermore, the intraoperative MAP and HR were more stable, the total propofol and remifentanil consumptions were lower, and the length of hospital stay was shorter than those in group sham TEAS. The application of TEAS can effectively reverse the decrease in NK cells, decrease the serum levels of TNF-α and IL-6, maintain hemodynamic stability during the perioperative period, decrease the consumption of propofol and remifentanil, and shorten the length of the hospital stay.

Hospital cost and clinical effectiveness of robotic-assisted versus video-assisted thoracoscopic and open lobectomy: A propensity score-weighted comparison

OBJECTIVE

To compare cost and perioperative outcomes of robotic, video-assisted thoracoscopic surgery (VATS), and open surgical approaches to pulmonary lobectomy.

METHODS

Patients who underwent pulmonary lobectomy between 2012 and 2017 at a single tertiary referral center were reviewed. Propensity score adjustment by inverse probability of treatment weighting (IPTW) was used to balance baseline patient characteristics. The primary outcomes of the study were direct hospital cost and perioperative outcomes, including operative time, complications rates, and length of stay. Indirect cost and charges were secondary financial outcomes.

RESULTS

A total of 697 patients underwent pulmonary lobectomy by robotic (n = 296), VATS (n = 161), and open thoracotomy (n = 240). In the IPTW-adjusted analysis, open thoracotomy had the shortest mean operating room time (robotic 278 minutes vs VATS 298 minutes vs open 265 minutes, P = .05), and lowest operating room costs (robotic $9,912 vs VATS $9491 vs open $8698, P = .001). Length of stay was significantly shorter after robotic and VATS lobectomy (robotic 3.8 days vs VATS 3.8 days vs open 5.4 days, P < .001), with significantly fewer events of atelectasis and pneumonia as compared with the open group. In sum, no significant differences were seen in IPTW-adjusted direct cost (robotic $17,223 vs VATS $17,260 vs open $18,075, P = .48), indirect cost, or charges for the total hospital stay.

CONCLUSIONS

Robotic and VATS lobectomy were associated with similar cost and improved clinical effectiveness as compared with the open thoracotomy approach. Increased procedural cost of minimally invasive lobectomy can be recovered by postoperative costs reductions, associated with improved postoperative outcomes and shorter hospital stay.

Robotic versus Video-Assisted Thoracoscopic Surgery Pulmonary Segmentectomy

Objective

Pulmonary segmentectomy using robotic assistance is often perceived as being more expensive than segmentectomy using video-assisted thoracic surgery. The robotic technique allows for meticulous dissection during segmentectomy, potentially leading to fewer parenchymal injuries, fewer air leaks, and shorter length of stay. This study compared pulmonary segmentectomy costs using video-assisted thoracic surgery versus robotic with manual staplers versus robotic with robotic staplers.

Methods

Retrospective analyses were performed evaluating our early experience with robotic pulmonary segmentectomy for 30 months compared with the video-assisted thoracic surgery approach. All 50 anatomical segmentectomies performed since introduction of robotic technique in the practice were included. Twenty-eight procedures were robotic-assisted and 22 were video-assisted thoracic surgery. Procedure-specific evaluation of direct costs was performed, including cost of robotic instruments, staplers, and average length of stay in the hospital.

Results

The mean ± SD age was 70 ± 10 years (range = 43–91 years). There were 12 males in the robotic group and eight in the video-assisted thoracic surgery group ( P = 0.642). The mean age was 69 years in the robotic group and 71 years in the video-assisted thoracic surgery group ( P = 0.367). The median length of stay was 2 (2–4) days in the robotic group (range = 1–9) and 4 (2–5) days in the video-assisted thoracic surgery group (range = 1–20, P = 0.089). The cost of robotic segmentectomy with manual staplers was less than that with robotic staplers. Both robotic techniques cost less than video-assisted thoracic surgery.

Conclusions

In this small series, cost and outcomes in our early experience with robotic-assisted segmentectomy were comparable with our video-assisted thoracic surgery approach with trends toward shorter length of stay and fewer complications. Larger series are needed to validate these results.

[Thoracoscopic pulmonary resection for metastatic lesion without pleural drainage: initial experience]

AIM

To analyze the possibility of thoracoscopic pulmonary resection for metastatic lesion without pleural drainage.

MATERIAL AND METHODS

There were 10 patients aged 53.8 years. Most of patients had solitary lung injury within 3 cm from the visceral pleura on the average. Surgical treatment was performed in standard fashion: hardware atypical pulmonary resection within healthy tissues. Pleural cavity was drained with 24 Fr tube. After that lung was inflated under visual control. Since wounds were closured residual air was evacuated by active aspiration and drainage tube was removed. Control chest X-ray was performed in 2 hours and 1 day after surgery.

RESULTS

The technique was successful in all patients. Mean surgery time was 52 minutes. There was no blood loss in all patients. Pneumo- and/or hydrothorax were absent according to control chest X-ray in postoperative period. Mean length of postoperative hospital-stay was 3 days (median 2 days). There were no cases of repeated hospitalization.

Oncologic Equivalence of Minimally Invasive Lobectomy: The Scientific and Practical Arguments

BACKGROUND

Despite the slow adoption of minimally invasive lobectomy (MIL), it is now a preferred approach for early lung cancer. Nevertheless, ongoing concerns about MIL oncologic effectiveness has led to calls for prospective, randomized trials.

METHODS

Retrospective analysis of on-line databases, collected readings, and other scholarly experiences of the experienced authors were used to construct this review. All available reports that contained long-term survival comparisons for open versus MIL were tabulated.

RESULTS

The preponderance of limited randomized and numerous large propensity-matched database analyses indicate equivalent or improved long-term MIL survival for early-stage disease. MIL lymph node dissection quality has been challenged; however, this was attributed to MIL avoidance of central tumors in early reports. Although technical inadequacies for MIL should be amplified for advanced cancer resections, early reports show no such concern. In fact, for special populations such as older, frail patients, evidence is much stronger that MIL confers a survival advantage.

CONCLUSIONS

MIL is an oncologically equivalent operation with substantially less morbidity, especially in frail populations. It is reasonable to suggest that MIL should be the technique of choice, even a quality indicator, for lobectomy.

Predictors of conversion to thoracotomy during video-assisted thoracoscopic surgery lobectomy in lung cancer: additional predictive value of FDG-PET/CT in a tuberculosis endemic region

BACKGROUND

To evaluate the added clinical value of ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) scans to chest CT imaging in predicting the conversion to thoracotomy during video-assisted thoracoscopic surgery (VATS) lobectomy in patients with lung cancer.

METHODS

This is a retrospective study of 235 consecutive patients who underwent planned VATS lobectomy for primary lung cancer between 2011 and 2015. CT images were interpreted in terms of the presence and the attenuation of peribronchial lymph nodes (PLN) and peribronchial cuffs of soft (PCS) tissue, pleural calcification, and parenchymal calcified nodule. On FDG PET/CT images, anthracofibrotic lymph node was considered present when high FDG uptake (SUVmax >3.5) was observed on PET/CT images corresponded to PLN or PCS on chest CT.

RESULTS

Among the 235 patients undergoing attempted VATS lobectomy, 55 (23.4%) underwent conversion to thoracotomy. Multivariate logistic regression analysis revealed that the attenuation of PLN or PCS on chest CT (OR, 2.57; 95% CI, 1.328-4.380, 0.005) was an only independent predictor of conversion. The ROC curve showed that combined FDG PET/CT and chest CT reading [areas under curve (AUC), 0.847 (95% CI, 0.795-0.891)] was significantly better than that of chest CT scans alone [AUC, 0.655 (95% CI, 0.50-0.751)] in predicting conversion (P=0.024).

CONCLUSIONS

The addition of FDG PET/CT scanning to chest CT imaging provides better performance for predicting conversion to thoracotomy during VATS lobectomy in lung cancer patients. Therefore, in lung cancer patients undergoing surgical resection, FDG PET/CT can provide additional reliable information in selecting the appropriate surgical approach for a lobectomy.

Cost and effectiveness of lung lobectomy by video-assisted thoracic surgery for lung cancer

BACKGROUND

Video-assisted thoracic surgery (VATS) emerged as a minimally invasive surgery for diseases in the field of thoracic surgery. We herein reviewed our experience on thoracoscopic lobectomy for early lung cancer and evaluated Health System use.

METHODS

A cost-effectiveness study was performed comparing VATS vs. open thoracic surgery (OPEN) for lung cancer patients. Demographic data, tumor localization, dynamic pulmonary function tests [forced vital capacity (FVC), forced expiratory volume in one second (FEV1), diffusion capacity (DLCO) and maximal oxygen uptake (VO2max)], surgical approach, postoperative details, and complications were recorded and analyzed.

RESULTS

One hundred seventeen patients underwent lung resection by VATS (n=42, 36%; age: 63±9 years old, 57% males) or OPEN (n=75, 64%; age: 61±11 years old, 73% males). Pulmonary function tests decreased just after surgery with a parallel increasing tendency during first 12 months. VATS group tended to recover FEV1 and FVC quicker with significantly less clinical and post-surgical complications (31% vs. 53%, P=0.015). Costs including surgery and associated hospital stay, complications and costs in the 12 months after surgery were significantly lower for VATS (P<0.05).

CONCLUSIONS

The VATS approach surgery allowed earlier recovery at a lower cost than OPEN with a better cost-effectiveness profile.

Perioperative outcomes of robotic surgery for the treatment of lung cancer compared to a conventional video-assisted thoracoscopic surgery (VATS) technique

Aim

To conduct a meta-analysis to determine the relative merits between robotic video-assisted thoracoscopic surgery (R-VATS) and conventional video-assisted thoracoscopic surgery (VATS) for lung cancer.

Results

Fifteen studies matched the selection criterion, which reported 8827 subjects, of whom 1704 underwent R-VATS and 7123 underwent VATS. Compared the perioperative outcomes with VATS, reports of R-VATS indicated unfavorable outcomes considering the operative time (SMD = 0.48, 95% CI 0.15 to 0.81). Meanwhile, the number of dissected lymph nodes (SMD = 0.12, 95% CI -0.27 to 0.51) and hospital stay following surgery (SMD = -0.1; 95% CI -0.27 to 0.07), conversion (RR = 0.68; 95% CI 0.42 to 1.11), morbidity (RR = 0.99, 95% CI 0.92 to 1.07) and mortality (RR = 0.33, 95% CI 0.1 to 1.09) were similar for both procedures.

Materials and Methods

A literature search was performed to identify comparative studies reporting perioperative outcomes for R-VATS and VATS for lung cancer. Pooled risk ratio (RR) and standardized mean differences (SMDs) with 95% confidence intervals (95% CIs) were calculated using either the fixed effects model or the random effects model.

Conclusions

There is no difference in terms of perioperative outcomes between R-VATS and VATS except for the operative time which is significantly high for R-VATS. Further studies are required to confirm these results.

[Current knowledge on perioperative treatments of non-small cell lung carcinomas]

Surgery is still the main treatment in early-stage of non-small cell lung cancer with 5-year survival of stage IA patients exceeding 80%, but 5-year survival of stage II patients rapidly decreasing with tumor size, N status, and visceral pleura invasion. The major metastatic risk in such patients has supported clinical research assessing systemic or loco-regional perioperative treatments. Modern phase 3 trials clearly validated adjuvant or neo-adjuvant platinum-based chemotherapy in resected stage I-III patients as a standard treatment of which value has been reassessed several independent meta-analyses, showing a 5% benefit in 5y-survival, and a decrease of the relative risk for death around from 12 to 25%. Conversely perioperative treatments were not validated for stage IA and IB patients. In more advanced stage patients, neo-adjuvant radio-chemotherapy has not been validated either. Adjuvant radiotherapy for N2 patients is currently tested in the large international phase 3 trial Lung-ART/IFCT-0503. The development of video-assisted thoracic surgery (VATS) has helped adjuvant chemotherapies for elderly patients. Perioperative targeted treatments in NSCLC with EGFR or ALK molecular alterations is currently assessed in the U.S. ALCHEMIST prospective trial. Finally, the role of immune check-points inhibitors is currently evaluated in a large international phase 3 trial testing adjuvant anti-PD-L1 monoclonal antibody, the BR31/IFCT-1401 trial, while a proof-of principle neo-adjuvant trial IONESCO/IFCT-1601, has just begun by the end of the 2016 year, with survival results of both trials expected in 5 to 7 years.

Evaluation of a novel multi-articulated endoscope: proof of concept through a virtual simulation

PURPOSE

In endoscopic surgery such as video-assisted thoracoscopic surgery and laparoscopic surgery, providing the surgeon a good view of the target is important. Rigid endoscope has for years been the go-to tool for this purpose, but it has certain limitations like the inability to work around obstacles. To improve on current tools, a novel multi-articulated endoscope (MAE) is currently under development. To investigate its feasibility and possible value, we performed a user test using virtual prototype of the MAE with the intent to show that it outperforms the conventional endoscope while bringing minimal additional burden to the operator.

METHODS

To evaluate the prototype, we built a virtual model of the MAE and a rigid oblique-viewing endoscope. Through a comparative user study we evaluate the ability of each device to visualize certain targets placed inside the virtual chest cavity by the angle between the visual axis of the scope and the normal of the plane of the target, while accounting for the usability of each endoscope by recording the time taken for each task. In addition, we collected a questionnaire from each participant to obtain feedback.

RESULTS

The angles obtained using the MAE were smaller on average ([Formula: see text]), indicating that better visualization can be achieved through the proposed method. A nonsignificant difference in mean time taken for each task in favor of the rigid endoscope was also found ([Formula: see text]).

CONCLUSIONS

We have demonstrated that better visualization for endoscopic surgery can be achieved through our novel MAE. The scope may bring about a paradigm shift in the field of minimally invasive surgery by providing more freedom in viewpoint selection, enabling surgeons to perform more elaborate procedures in minimally invasive settings.

Overall Survival Following Thoracoscopic vs Open Lobectomy for Early-stage Non-small Cell Lung Cancer: A Meta-analysis

A majority of observational studies on overall survival following thoracoscopic vs open lobectomy for early-stage non-small cell lung cancer did not demonstrate a significant difference, whereas several meta-analyses on this topic showed a significant difference. The PubMed, Scopus, and Web of Science databases were queried for studies published in the English language. We searched for meta-analyses and original studies comparing overall survival between thoracoscopic and open lobectomy for early-stage non-small cell lung cancer. Our meta-analysis, using random effect models and with a hazard ratio as a measure of effect, was performed on original studies. Publication bias was evaluated with funnel plots of precision and the Egger test. Seven meta-analyses on this topic were found and all of them have shown that thoracoscopic lobectomy is associated with significantly more favorable overall survival than open lobectomy, using odds ratio, risk ratio, or risk difference as measures of effect. Our meta-analysis of 11 observational studies demonstrated no significant difference in overall survival between thoracoscopic (n = 2386) and open lobectomy (n = 3494) for early-stage non-small cell lung cancer (pooled hazard ratio: 0.91, 95% confidence interval: 0.76-1.09, P = 0.30). Neither funnel plots of precision nor the Egger test suggested a publication bias. Our meta-analysis, using a hazard ratio as a measure of effect for a time-to-event outcome, did not demonstrate a significant difference in overall survival between thoracoscopic and open lobectomy with the current dataset available in the literature, as opposed to previous meta-analyses.

Video-assisted thoracic surgery and open chest surgery in lung cancer treatment: present and future

Surgical resection remains the most effective treatment of early stage lung cancer. The surgical approach has evolved, and now consists primarily of video-assisted thoracic surgery (VATS) and more limited incisions even with open techniques. Both approaches have their place. Many factors contribute to deciding whether one or the other is better for a particular tumor, patient and in a particular setting and region. Video assisted surgery, where appropriate, is associated with fewer complications and a shorter hospital stay, and similar long term survival. But modern open surgery is also associated with good results. This article reviews the data and discusses considerations to weigh in finding the right balance between the video-assisted and the open approaches.

Comparative study of three-dimensional versus two-dimensional video-assisted thoracoscopic two-port lobectomy

Background

The advantages and disadvantages of three‐dimensional (3D) and two‐dimensional (2D) two‐port video‐assisted thoracoscopic surgery (VATS) lobectomy and systematic dissection of mediastinal lymph nodes for lung cancer were investigated.

Methods

Between December 2013 and July 2015 at Beijing Hospital, 191 patients underwent lobectomy and systematic dissection of mediastinal lymph nodes for lung cancer. After applying the study criteria, a total of 165 patients were included and allocated to 3D (n = 76) and 2D (n = 89) groups. Variables of the study design, including duration of surgery, volume of intraoperative bleeding, numbers and groups of lymph nodes dissected, drainage volume after surgery, duration of drainage tube insertion, hospitalization time after surgery, hospitalization costs, and complications, were recorded and analyzed. Intergroup differences for all data were compared and statistically analyzed.

Results

No statistical difference was found between the two groups with respect to duration of surgery, volume of intraoperative bleeding, drainage volume after surgery, duration of drainage tube insertion, hospitalization time after surgery, hospitalization costs, and complications (P > 0.05). Additionally, there was no significant difference in the numbers and groups of all lymph nodes or N₂ lymph nodes resected (P > 0.05).

Conclusion

Lobectomy with systematic lymph node dissection can be undertaken with two ports using a 3D thoracoscope, and presents similar results to the use of a traditional 2D thoracoscope, at no greater hospitalization cost but with better operational perception and sensitivity during surgery. Two‐port lobectomy with systematic lymph node dissection using a 3D thoracoscope is a safe and effective surgical process for lung cancer treatment.

Thoracoscopic Lobectomy Produces Long-Term Survival Similar to That with Open Lobectomy in Cases of Non-Small Cell Lung Carcinoma: A Propensity-Matched Analysis Using a Population-Based Cancer Registry

BACKGROUND

There is a lack of large, prospective, randomized studies comparing thoracoscopic and open lobectomy in terms of long-term survival in the setting of NSCLC. Additionally, large case series evaluating the issue are limited. Until now, whether thoracoscopic lobectomy entails a long-term survival benefit compared with open lobectomy not been determined.

METHODS

Data were obtained from the National Health Insurance Research Database published in Taiwan. We included patients treated with open lobectomy or thoracoscopic lobectomy. In this retrospective review, the clinicopathologic characteristics of 5222 patients with lung cancer during the period 2004-2010 were analyzed. Patients were stratified according to clinical stage. Overall survival (OS) was compared between patients treated with open and those treated with thoracoscopic lobectomy and was also compared between patients in the three different clinical stages. Propensity-matching analysis and multivariate analysis were performed.

RESULTS

Open lobectomy was performed on 3058 patients (58.6%) and thoracoscopic lobectomy on 2164 (41.4%). Propensity matching produced 1848 patients in each group. The 1-year, 3-year, and 5-year OS rates for propensity-matched patients treated with open lobectomy were 93.4%, 79.3%, and 65.5%, respectively. The 1-year, 3-year, and 5-year OS rates for propensity-matched patients treated with thoracoscopic lobectomy were 94.1%, 80.9%, and 68.7%, respectively. The difference was not statistically significant. In multivariate analysis, surgical resection (open versus thoracoscopic) was not an independent prognostic factor.

CONCLUSIONS

This propensity-matched study suggests that open and thoracoscopic lobectomy are associated with similar long-term survival in the setting of lung cancer. Thoracoscopic lobectomy is an acceptable surgical treatment of lung cancer.

Hospital-Based HTA and Know4Go at MEDICI in London, Ontario, Canada

The majority of healthcare in Canada is universally provided and publicly funded through the provincial government.

Single-port video-assisted thoracic surgery for early lung cancer: initial experience in Japan

BACKGROUND

Single-port video-assisted thoracic surgery (SPVATS) emerged several years ago as a new, minimally invasive surgery for diseases in the field of respiratory surgery, and is increasingly becoming a subject of interest for some thoracic surgeons in Europe and Asia. However, the adoption rate of this procedure in the United States and Japan remains low. We herein reviewed our experience of SPVATS for early lung cancer in our center, and evaluated the safety and minimal invasiveness of this technique.

METHODS

We retrospectively analyzed patients who had undergone SPVATS for pathological stage I lung cancer in Nippon Medical School Chiba Hokusoh Hospital between September 2012 and October 2015. In SPVATS, an approximately 4-cm incision was made at the 4(th) or 5(th) intercostal space between the anterior and posterior axillary lines. A rib spreader was not used at the incision site, and surgical manipulation was performed very carefully in order to avoid contact between surgical instruments and the intercostal nerves. The same surgeon performed surgery on all patients, and analyzed laboratory data before and after surgery.

RESULTS

Eighty-four patients underwent anatomical lung resection for postoperative pathological stage I lung cancer. The mean wound length was 4.2 cm. Eighty-four patients underwent lobectomy and segmentectomy, respectively. The mean preoperative forced expiratory volume in 1 second (FEV1%) was 1.85%±0.36%. Our patients consisted of 49 men (58.3%) and 35 women (41.7%), with 64, 18, 1, and 1 having adenocarcinoma, squamous cell carcinoma, adenosquamous carcinoma, and small-cell lung cancer, respectively. The mean operative time was 175±21 min, operative blood loss 92±18 mL, and duration of drain placement 1.9±0.6 days. The duration of the postoperative hospital stay was 7.1±1.7 days, numeric rating scale (NRS) 1 week after surgery 2.8±0.6, and occurrence rate of allodynia 1 month after surgery 10.7%. No patient developed serious complications, and no deaths occurred within 30 days of surgery. Two patients (2.4%) were converted to open thoracotomy.

CONCLUSIONS

SPVATS is a safe and feasible technique, and is promising for next-generation thoracoscopic surgery. It may also reduce postoperative wound pain and contribute to improvements in the activities of daily living of patients.

A Population-Based Cost Analysis of Thoracoscopic Versus Open Lobectomy in Primary Lung Cancer

Background

Thoracoscopic lobectomy for primary lung cancer has become increasingly popular worldwide due to several advantages over open lobectomy including reduced pain, reduced length of hospital stay, and comparable oncologic outcomes. The costs of thoracoscopic versus conventional open lobectomy have been compared in several studies with variable results. We compared the costs of thoracoscopic versus open lobectomy in lung cancer patients in Taiwan.

Methods

Patients who underwent lobectomy for primary lung cancer from the Taiwan National Health Insurance Research Database (NHIRD) between 2004 and 2010 were identified. Patient characteristics, operative data, and costs for each part of the hospitalization for surgery and 30 days of care after discharge were analyzed.

Results

A total of 5366 patients with complete clinical data who underwent either conventional open lobectomy (n = 3166, 59 %) or thoracoscopic lobectomy (n = 2200, 41 %) for primary lung cancer were identified from the database. Compared with open lobectomy, thoracoscopic lobectomy was associated with younger age, less comorbidity, shorter anesthesia times, and reduced lengths of hospital stay. Total hospital costs, operative costs, and other costs were significantly higher in the thoracoscopic group. The 30-day after discharge costs were significantly lower in the thoracoscopic group.

Conclusions

Thoracoscopic lobectomy for primary lung cancer in Taiwan was associated with higher total hospital costs but lower 30 days after discharge costs than open lobectomy. These differences may have resulted from higher operative and instrument costs in the thoracoscopic group.

Perioperative outcomes of video- and robot-assisted segmentectomies

OBJECTIVE

Video-assisted thoracic surgery appears to be technically difficult for segmentectomy. Conversely, robotic surgery could facilitate the performance of segmentectomy. The aim of this study was to compare the early results of video- and robot-assisted segmentectomies.

METHODS

Data were collected prospectively on videothoracoscopy from 2010 and on robotic procedures from 2013. Fifty-one patients who were candidates for minimally invasive segmentectomy were included in the study. Perioperative outcomes of video-assisted and robotic segmentectomies were compared.

RESULTS

The minimally invasive segmentectomies included 32 video- and 16 robot-assisted procedures; 3 segmentectomies (2 video-assisted and 1 robot-assisted) were converted to lobectomies. Four conversions to thoracotomy were necessary for anatomical reason or arterial injury, with no uncontrolled bleeding in the robotic arm. There were 7 benign or infectious lesions, 9 pre-invasive lesions, 25 lung cancers, and 10 metastatic diseases. Patient characteristics, type of segment, conversion to thoracotomy, conversion to lobectomy, operative time, postoperative complications, chest tube duration, postoperative stay, and histology were similar in the video and robot groups. Estimated blood loss was significantly higher in the video group (100 vs. 50 mL, p = 0.028).

CONCLUSIONS

The morbidity rate of minimally invasive segmentectomy was low. The short-term results of video-assisted and robot-assisted segmentectomies were similar, and more data are required to show any advantages between the two techniques. Long-term oncologic outcomes are necessary to evaluate these new surgical practices.

[Video-assisted thoracoscopic anatomic lung resection: experience of 246 operations]

AIM

To present one of the largest materials of video-assisted thoracoscopic (VATS) anatomic lung resections in Russia.

MATERIAL AND METHODS

It is a retrospective analysis of treatment of 246 patients who underwent VATS anatomic lung resection for the period from 2010 to 2014 at the Center for Thoracic Surgery of St. Petersburg Clinical Hospital №122. One surgical team has operated 125 men and 121 women aged from 20 to 85 years (58.8±13.4 years). There were 216 (87.8%) lobectomies, 4 (1.6%) bilobectomies, 9 (3.7%) pneumonectomies, 10 (4.1%) segmentectomies and 7 (2.8%) trisegmentectomies. Upper right-side lobectomy was the most frequent in this group (87 (40.3%)). Most of operations was performed via 2 approaches (119 patients). Average length of the longest incision was 4.3±0.93 cm (range 2-6 cm). All patients were examined according to a single plan. FEV1 less than 70% was observed in 26% of patients; comorbidity index was 5 scores or more in 24% of cases; 23.2% of patients were older than 70 years.

RESULTS

Non-small cell lung cancer (NSCLC) was diagnosed in 168 patients (68.3%), pulmonary tuberculosis - in 27 (11%), chronic suppurative lung disease - in 27 (11%) cases. Furthermore there were 9 cases of pulmonary metastases, 11 cases of carcinoid, 1 - MALT-lymphoma, 1 - leiomyoma, 2 - small cell lung cancer, as well as one case of IgG-associated pseudotumor. Among 168 cases of NSCLC operations were performed in 87 (51.8%) cases for cancer stage I, in 46 (27.3%) patients for stage II, in 27 patients for stage III (including 16 cases of stage IIIA and 11 cases of stage IIIB). 8 patients (4.7%) with lung cancer stage IV have been operated in radical surgery for solitary metastasis. Mean duration of surgery was 202.1±58.2 minutes (range 100-380). On the average 12.8±5.6 (range 9-32) mediastinal lymph nodes were excised during lymph node dissection in cancer patients. Mean number of nodes groups was 4.1±1.1. In 11 (4.5%) patients conversion to open surgery was made due to intraoperative bleeding (3 cases) and technical difficulties (8 cases). Mean duration of postoperative pleural drainage and hospital-stay were 5.1±4.3 (median - 3 days) and 7.9±4.7 days (median - 6 days) respectively. Complications which were not associated with perioperative deaths were observed in 66 patients (26.8%). Prolonged air vent was the most common complication.

CONCLUSION

VATS anatomical lung resections are safe and effective in most of pulmonary surgical diseases. Such interventions may be recommended for wider introduction at the Thoracic Departments of Russia because of small number of complications and rapid rehabilitation. Bleeding or its risk associated with fibrotic changes in pulmonary root are the most frequent causes of conversion to open access.

Out-of-plane ultrasound-guided paravertebral blocks improve analgesic outcomes in patients undergoing video-assisted thoracoscopic surgery

Purpose

Paravertebral blocks (PVBs) are a method of limiting postoperative pain for patients undergoing video-assisted thoracoscopic surgery (VATS). We began providing ultrasound-guided PVBs for patients undergoing VATS in the spring of 2011, using an out-of-plane approach. The aim of this study was to evaluate this practice change.

Methods

Following institutional review board approval, we reviewed the charts of 114 patients undergoing VATS by one surgeon at our institution between January 2011 and July 2012. Of the 78 eligible patients, 49 patients received a PVB prior to surgery. We evaluated opioids administered in the perioperative period, pain scores, and side effects from pain medications.

Results

Patients who received a preoperative PVB required fewer narcotics intraoperatively and during their hospital stay (P=0.001 and 0.011, respectively). Pain scores on initial assessment and in recovery were lower in patients who received a PVB (P=0.005), as were dynamic and resting pain scores at 24 hours after surgery (P=0.003 and P<0.001, respectively). Patients receiving a PVB had fewer episodes of treated nausea both in the postanesthesia care unit (P=0.004) and for the first 24 hours after surgery (P=0.001). These patients also spent less time in recovery (P=0.025) than the patients who did not receive a block.

Conclusion

The current study suggests improved outcomes in patients who underwent VATS with a preoperative PVB. All variables showed a trend toward improved results in patients who obtained a preoperative PVB.