Video-Assisted Thoracoscopic Surgery vs Thoracotomy for Non-Small Cell Lung Cancer Greater Than 5 cm: Is VATS a feasible approach for large tumors?

Lung Cancer-Epidemiology, Pathogenesis, Treatment and Molecular Aspect (Review of Literature)

Lung cancer is one of the most common malignant cancers in most countries and is the leading cause of death among cancer diseases worldwide. Despite constant progress in diagnosis and therapy, survival rates of patients diagnosed with lung cancer remain unsatisfactory. Numerous epidemiological and experimental studies conducted as early as the 1970s confirm that the most important risk factor for the development of lung cancer is long-term smoking, which remains valid to this day. In the paper, the authors present the latest data on the epidemiology, pathogenesis, treatment and molecular aspects of this cancer. In the last decade, many molecular alterations that are effective in the development of lung cancer have been discovered. In adenocarcinoma, tyrosine kinase inhibitors were developed for EGFR mutations and ALK and ROS1 translocations and were approved for use in the treatment of advanced stage adenocarcinomas. In the case of squamous cell carcinoma, the evaluation of these mutations is not yet being used in clinical practice. In addition, there are ongoing studies concerning many potential therapeutic molecular targets, such as ROS, MET, FGFR, DDR-2 and RET. Constant progress in diagnostic and therapeutic methods gives rise to hopes for an improved prognosis in patients with lung cancer.

Preoperative Diaphragm Muscle Atrophy Increases the Likelihood of Postoperative Pulmonary Complications After Lung Cancer Resection: A Pilot Study

Background/Objectives: Various conditions contribute to the development of postoperative pulmonary complications (PPCs) following thoracic surgery. In this study, the aim was to investigate whether preoperative diaphragm dysfunction is associated with an increased risk of PPCs after lung cancer resection. Methods: We prospectively examined 45 patients scheduled for video-assisted thoracoscopic surgery (VATS) lobectomy or open thoracotomy. Relevant clinical data were retrieved from hospital database records, while diaphragm muscles were assessed using ultrasound. Results: Our results demonstrated that preoperative diaphragm muscle atrophy was significantly associated with a higher risk of developing PPCs compared to patients with normal diaphragm thickness. Diaphragm atrophy was also linked to prolonged hospital stays. Additionally, we observed a moderate correlation between expiratory diaphragm thickness and the number of PPCs. Conclusions: Low diaphragm expiratory thickness is associated with postoperative pulmonary complications after lobectomy for lung cancer. Importantly, unlike other predictive factors such as age, COPD, or smoking, diaphragmatic atrophy is a modifiable risk factor that can potentially be addressed through early therapeutic intervention.

Risk Factors and Postoperative Complications of Lobectomy for Non-Small Cell Lung Cancer: An Exploratory Analysis of Premedication and Clinical Variables

Background and Objectives: Postoperative pneumonia and complications significantly impact outcomes in thoracic surgery, particularly for patients undergoing lobectomy for non-small cell lung cancer (NSCLC). This study evaluates whether preoperative premedication influences the risk of postoperative pneumonia and overall complications. Materials and Methods: This retrospective study included 346 patients who underwent lobectomy for NSCLC at the University Hospital Ostrava between 2015 and 2021. Data on demographic variables, tumour staging, surgical approach, and premedication (anticholinergics, benzodiazepines, antihistamines, and analgesics) were analysed. Postoperative outcomes included pneumonia and complications classified by the modified Clavien-Dindo system. Results: Premedication was not significantly associated with postoperative pneumonia (10.7%) or overall complications (26.0%). Tumour size was the only factor significantly associated with complications, with larger tumours increasing the odds (OR: 1.16, p = 0.032). Other factors, including age, ASA classification, BMI, and surgical approach, did not demonstrate significant associations with postoperative outcomes. Conclusions: Premedication does not appear to significantly influence the risk of postoperative pneumonia or overall complications in patients undergoing lobectomy for NSCLC. Similarly, other clinical variables, such as age, ASA classification, BMI, and surgical approach, also did not show significant associations with these outcomes. These findings suggest that premedication can be individualised without increasing postoperative risks. However, tumour size emerged as a significant factor associated with complications, highlighting the need for careful preoperative assessment and planning, particularly in patients with larger tumours.

Evaluation of myocardial work changes after lung resection-the significance of surgical approach: an echocardiographic comparison between VATS and thoracotomy

OBJECTIVE

Considering the controversial benefits of video-assisted thoracoscopic surgery (VATS), we intended to evaluate the impact of surgical approach on cardiac function after lung resection using myocardial work analysis.

METHODS

Echocardiographic data of 48 patients (25 thoracotomy vs. 23 VATS) were retrospectively analyzed. All patients underwent transthoracic echocardiography (TTE) within 2 weeks before and after surgery, including two-dimensional speckle tracking and tissue Doppler imaging.

RESULTS

No notable changes in left ventricular (LV) function, assessed mainly using the LV global longitudinal strain (GLS), global myocardial work index (GMWI), and global work efficiency (GWE), were observed. Right ventricular (RV) TTE values, including tricuspid annular plane systolic excursion (TAPSE), tricuspid annular systolic velocity (TASV), right ventricular global longitudinal strain (RVGLS), and RV free-wall GLS (RVFWGLS), indicated greater RV function impairment in the thoracotomy group than in the VATS group [TAPSE(mm) 17.90 ± 3.80 vs. 21.00 ± 3.48, p = 0.006; d = 0.84; TASV(cm/s): 12.40 ± 2.90 vs. 14.70 ± 2.40, p = 0.004, d = 0.86; RVGLS(%): - 16.00 ± 4.50 vs. - 19.40 ± 2.30, p = 0.012, d = 0.20; RVFWGLS(%): - 11.50 ± 8.50 vs. - 18.31 ± 5.40, p = 0.009, d = 0.59; respectively].

CONCLUSIONS

Unlike RV function, LV function remained preserved after lung resection. The thoracotomy group exhibited greater RV function impairment than did the VATS group. Further studies should evaluate the long-term impact of surgical approach on cardiac function.

Perioperative Challenges: Analysis of Surgical Complications in Screening Lung Carcinoma Patient

Introduction In September 2020, the Institute for Pulmonary Diseases of Vojvodina (IPBV) started a lung cancer screening program using low-dose computed tomography (LDCT). Video-assisted thoracic surgery (VATS) lobectomy is the most effective treatment for early-stage lung cancer. However, the frequency of postoperative complications in VATS anatomical lung resections among patients enrolled in the screening program has not been adequately studied. This study aims to compare the frequency of surgical complications and length of hospital stay between patients enrolled in the screening program and a control group. Methods Retrospective, observational, monocentric, non-randomized study was conducted at the IPBV in Sremska Kamenica. The study included patients with a confirmed diagnosis of lung cancer who underwent anatomic pulmonary resection with mediastinal lymphadenectomy for therapeutic purposes. The patients were divided into two groups: the first group consisted of 34 patients who participated in the lung carcinoma screening program, while the second control group consisted of 102 patients. Over the past three years, all patients identified with nodules suspicious of malignancy during the screening program were sequentially enrolled in the screening group. For the control group, patients were selected based on a matching process to ensure valid statistical comparisons with the screening group. They were matched in a 3:1 ratio with patients from the screening group based on criteria including gender, disease stage, pathohistological type of cancer, tumor, node, and metastasis (TNM) stage of the disease, and degree of surgical resection. Patients were monitored for demographic parameters, smoking status, presence of comorbidities and prior oncological diseases, pulmonary function parameters, level of pre-operational risk, the number of lymph nodes removed by biopsies, spread through alveolar spaces (STAS), and the occurrence of complications after surgery (infection, bleeding, air leak, presence of adhesions), re-drainage, and length of hospital stay. Results The patients in the screening group had a higher incidence of infections, bleeding, prolonged air leak, and required re-drainage after surgery compared to the control group. Patients from the screening program with a high operative risk, prolonged air leak, and pleural adhesions had a statistically significant higher hospital stay longer than the control group. Conclusions This research emphasizes the importance of screening programs for detecting lung cancer in the early stages. However, it also highlights the need for further research to reduce surgical complications and improve therapeutic interventions for patients in the screening program.

Operation room nursing based on humanized nursing mode combined with nitric oxide on rehabilitation effect after lung surgery

BACKGROUND

With advancements in the diagnosis and treatment of lung diseases, lung segment surgery has become increasingly common. Postoperative rehabilitation is critical for patient recovery, yet challenges such as complications and adverse outcomes persist. Incorporating humanized nursing modes and novel treatments like nitric oxide inhalation may enhance recovery and reduce postoperative complications.

AIM

To evaluate the effects of a humanized nursing mode combined with nitric oxide inhalation on the rehabilitation outcomes of patients undergoing lung surgery, focusing on pulmonary function, recovery speed, and overall treatment costs.

METHODS

A total of 79 patients who underwent lung surgery at a tertiary hospital from March 2021 to December 2021 were divided into a control group (n = 39) receiving a routine nursing program and an experimental group (n = 40) receiving additional humanized nursing interventions and atomized inhalation of nitric oxide. Key indicators were compared between the two groups alongside an analysis of treatment costs.

RESULTS

The experimental group demonstrated significant improvements in pulmonary function, reduced average recovery time, and lower total treatment costs compared to the control group. Moreover, the quality of life in the experimental group was significantly better in the 3 months post-surgery, indicating a more effective rehabilitation process.

CONCLUSION

The combination of humanized nursing mode and nitric oxide inhalation in postoperative care for lung surgery patients significantly enhances pulmonary rehabilitation outcomes, accelerates recovery, and reduces economic burden. This approach offers a promising reference for improving patient care and rehabilitation efficiency following lung surgery.

Comparison of Early Postoperative Diaphragm Muscle Function after Lobectomy via VATS and Open Thoracotomy: A Sonographic Study

Although a growing body of evidence emphasizes the superiority of VATS over conventional thoracotomy, little is still known about early postoperative diaphragm muscle function after lobectomy via these two approaches. To fill the gap in existing literature, we conducted a comparative study between VATS and conventional thoracotomy in terms of postoperative diaphragm muscle function, assessing its contractility, strength, the magnitude of effort and potential risk of dysfunction such as atrophy and paralysis. A total of 59 patients (30 after VATS), who underwent anatomical pulmonary resection at our institution, were enrolled in this study. The control group consisted of 28 health subjects without medical conditions that could contribute to diaphragm dysfunction. Diaphragm muscle was assessed before and after surgery using ultrasonography. We found that both surgical approaches were associated with postoperative impairment of diaphragm muscle function-compared to baseline data. Postoperative reduction in diaphragm contraction was demonstrated in most of the 59 patients. In the case of the control group, the differences between measurements were not observed. We noted that lobectomy via thoracotomy was linked with a greater percentage of patients with diaphragm paralysis and/or atrophy than VATS. Similar findings were observed in referring to diaphragm magnitude effort, as well as diaphragm contraction strength, where minimally invasive surgery was associated with better diaphragm function parameters-in comparison to thoracotomy. Disturbance of diaphragm work was reported both at the operated and non-operated side. Upper-right and left lobectomy were connected with greater diaphragm function impairment than other segments. In conclusion, the VATS technique seems to be less invasive than conventional thoracotomy providing a better postoperative function of the main respiratory muscle.

A successful shift from thoracotomy to video-assisted thoracoscopic lobectomy for non-small cell lung cancer in a low-volume center

OBJECTIVES

Although video-assisted thoracoscopic surgery (VATS) lobectomy has become the gold standard for pulmonary resections of non-small-cell lung cancer (NSCLC), lobectomy is still performed via thoracotomy in many European and North American centres. VATS lobectomy was implemented overnight from thoracotomy in our low-volume centre in early 2019, after 1 senior surgeon undertook observership VATS-training overseas, and immediately became the mainstay of surgical treatment for NSCLC in Iceland. We aimed to investigate our short-term outcomes of VATS lobectomy.

METHODS

This was a retrospective study on all pulmonary resections for NSCLC in Iceland 2019-2022, especially focusing on VATS lobectomies, all at cTNM stage I or II. Data were retrieved from hospital charts, including information on perioperative complications, mortality, length of stay and operation time.

RESULTS

Out of 204 pulmonary resections, mostly performed by a single senior cardiothoracic surgeon, 169 were lobectomies (82.9%) with 147 out of 169 (87.0%) being VATS lobectomies. Anterolateral thoracotomy was used in 34 cases (16.7%), including 22 lobectomies (64.7%), and 5 (3.4%) conversions from VATS lobectomy. The median postoperative stay for VATS lobectomy was 4 days and the average operating time decreased from 155 to 124 min between the first and last year of the study (P < 0.001). The rate of major and minor complications was 2.7% and 15.6% respectively. One year survival was 95.6% and all patients survived 30 days postoperatively.

CONCLUSIONS

The implementation of VATS lobectomy has been successful in our small geographically isolated centre, serving a population of 390 000. Although technically challenging, VATS lobectomy was implemented fast for most NSCLC cases, with short-term outcomes that are comparable to larger high-volume centres.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

External validation of risk prediction scores in patients undergoing anatomic video-assisted thoracoscopic resection

Background

EuroLung Risk scores were established to predict postoperative morbidity and mortality in patients undergoing anatomic lung resections. We aimed to perform an external validation of the EuroLung scores, which were calculated from data of the European Society of Thoracic Surgeons database, in our video-assisted thoracoscopic surgery cohort.

Methods

All available EuroLung scores were calculated for 718 patients scheduled for anatomic video-assisted thoracoscopic surgery resections between 2009 and 2019. Morbidity and mortality according to the definitions of the EuroLung scores were analyzed in a prospectively maintained database.

Results

Overall observed complication rate was 10.45%. Scores showed weak individual correlation (η = 0.155–0.174). The EuroLung1 app score showed the biggest area under the receiver operative characteristic (ROC) curve with 0.660. Binary logistic regression analysis showed that predicted postoperative forced expiratory volume in 1 s was associated with increased complications in both EuroLung1 and parsimonious EuroLung1 scores. Thirty-day mortality was 0.7% (predicted 1.10–1.40%) and was associated with predicted postoperative forced expiratory volume in 1 s for both EuroLung2 and parsimonious EuroLung2 scores. The EuroLung2 (2016) showed the biggest area under the ROC curve with 0.673. Only a very weak eta correlation between predicted and observed mortality was found for both aggregate EuroLung2, EuroLung2 (2016), EuroLung2 (2019), and parsimonious EuroLung2 (2016) (η = 0.025/0.015/0.011/0.009).

Conclusion

EuroLung scores help to estimate postoperative morbidity. However, even with the highest aggregate EuroLung scores possible only 50% suffer from postoperative morbidity. Although calibration of the scores was acceptable, discrimination between predicted and observed events was poor. Therefore, individual correlation between predicted and observed events is weak. Therefore, EuroLung scores may be best used to compare institutional quality of care to the European Society of Thoracic Surgeons database but should not be used to preclude patients from surgical treatment.

Thoracic surgery may alter body static balance via diaphragm dysfunction

Many diseases and conditions can alter an ability to maintain body balance. The aim of the present study was to investigate whether thoracic surgery may elicit diaphragm dysfunction thereby impairing postural stability. 40 patients qualified to video-assisted thoracoscopy (VATS) lobectomy or lobectomy via thoracotomy due to pulmonary carcinoma were examined two times: a day before lung resection and 3–5 days after surgical procedure. Diaphragm assessment was performed using ultrasonography, while postural sways were evaluated by Zebris FDM-S stabilometric platform. Thoracic surgery was associated with decrease of diaphragm thickness and movement, as well as, with deterioration of static body balance maintenance. Upper lobe resection was linked with greater diaphragm excursion restriction and worse body sway parameters than middle and lower lobe resection. VATS lobectomy was associated with better postoperative diaphragm function and better postural sway parameters than lobectomy via thoracotomy. Patients after lobectomy via thoracotomy had significantly more load on lower limb on the operated side than patients after VATS lobectomy. Impairment of diaphragm function is closely associated with equilibrium impairment after pulmonary resection. VATS lobectomy was less invasive than lobectomy via thoracotomy in terms of primary respiratory muscle function and body balance maintenance parameters.

Perioperative Inflammatory Response and Cancer Recurrence in Lung Cancer Surgery: A Narrative Review

While surgical resection is the gold standard treatment for solid tumors, cancer recurrence after surgery is common. Immunosurveillance of remnant tumor cells is an important protective mechanism. Therefore, maintenance of anti-tumor cell activity and proper levels of inflammatory mediators is crucial. An increasing body of evidence suggests that surgery itself and perioperative interventions could affect these pathophysiological responses. Various factors, such as the extent of tissue injury, perioperative medications such as anesthetics and analgesics, and perioperative management including transfusions and methods of mechanical ventilation, modulate the inflammatory response in lung cancer surgery. This narrative review summarizes the pathophysiological mechanisms involved in cancer recurrence after surgery and perioperative management related to cancer recurrence after lung cancer surgery.

Post-thoracotomy Pain Syndrome

PURPOSE OF REVIEW

This article reviews PTPS demographics, diagnosis, pathophysiology, surgical and anesthetic techniques, and their role in preventing PTPS along with updated treatment options.

RECENT FINDINGS

Post-thoracotomy pain syndrome (PTPS) can be incapacitating. The neuropathic type pain of PTPS is along the incision site and persists at least 2 months postoperatively. There is a wide reported range of prevalence of PTPS. There are several risk factors that have been identified including surgical technique and younger age. Several surgical and anesthetic techniques have been trialed to reduce pain after thoracotomy. Multimodal pain control is the suggested long-term treatment plan for patients with PTPS. There are several factors that can be modified to reduce pain and incidence of PTPS during the perioperative period and the use of multimodal analgesia is suggested for the treatment of PTPS.

Complete Video-Assisted Thoracoscopic Surgery and Traditional Open Surgery for Elderly Patients With NSCLC

Objective:

To observe the efficacy of complete video-assisted thoracoscopic surgery (CVATS) and traditional open surgery (TOS) in the treatment of elderly patients with non-small cell lung cancer (NSCLC) and their influence on cardiopulmonary function.

Methods

A total of 120 elderly patients with primary NSCLC who were treated surgically in our hospital from January 2018 to January 2021 were selected and divided into the study group and the control group according to the different surgical procedures, 60 patients in each group. CVATS was used in the observation group and TOS in the control group. The surgical indexes and cardiopulmonary function indexes were observed and compared between the two groups. The serum C-reactive protein (CRP) level and visual analog scale's (VAS) score of the patients at different time points were detected. The incidence of postoperative complications was compared between the two groups.

Results

The perioperative indexes such as operation time were significantly different between the two groups (p < 0.05), but the number of lymph node dissection was not significantly different (p > 0.05). The serum CRP level and VAS score of the observation group were significantly lower than those of the control group on the 1st, 3rd, and 7th postoperative days (p < 0.05). There were significant differences in cardiopulmonary function between the two groups on the 7th postoperative day (p < 0.05). The incidence of adverse reactions in the observation group was significantly lower than that in the control group (p > 0.05).

Conclusion

CVATS is effective in the treatment of NSCLC. Compared with TOS therapy, CVATS has less damage to cardiopulmonary function and fewer complications, which is conducive to the rehabilitation of elderly patients. It is a safe and reliable scheme for the treatment of elderly patients with NSCLC.

Effect and feasibility of uniportal thoracoscopic surgery in the treatment of early-stage lung cancer in a primary hospital

BACKGROUND

Thoracoscopic radical lobectomy is a routine procedure for radical surgery of lung cancer. Meanwhile, thoracoscopic surgery has been gradually transformed from assisted small incision and multiport thoracoscopic radical surgery to uniportal thoracoscopic surgery for treatment of early-stage lung cancers. However, there are still controversies regarding the efficacy and feasibility of 2 surgical methods. The purpose of this study is to investigate the effect and feasibility of uniportal thoracoscopic surgery for treatment of early-stage lung cancer in a primary hospital.

METHODS

Clinical data of 142 patients with early-stage lung cancer were retrospectively chosen in the period from September 2019 to March 2021 in our hospital and divided into 2 groups: a control group (66 patients) with 3-port thoracoscopic radical surgery and an experimental group (76 patients) with uniportal thoracoscopic radical surgery. The baseline clinical data, perioperative clinical data, and lymph node dissection of 2 groups were compared.

RESULTS

There was no significant difference in baseline general clinical data between 2 groups (P>0.05), and no significant difference in the incidence of postoperative complications, conversion rate, or operation time between 2 groups (P>0.05). The intraoperative blood loss volume, postoperative chest drainage volume, postoperative hospitalization time, and postoperative catheter time of experimental group were significantly lower than those of control group (P<0.05). There was no significant difference in the total number of lymph node dissection stations and lymph node dissections, the number of N2 lymph node dissection stations, or N2 lymph node dissections between 2 groups (P>0.05). There was also no significant difference in the number of left and right lymph node dissection stations between 2 groups (P>0.05).

CONCLUSIONS

Compared with 3-port thoracoscopic radical surgery, uniportal thoracoscopic radical surgery in the treatment of patients with early-stage lung cancer provides the same effect of lymph node dissection and has advantages in reducing surgical trauma and accelerating postoperative rehabilitation, popularizing for use in primary hospitals.