Hybrid surgical approach of video-assisted minithoracotomy for lung cancer: significance of direct visualization on quality of surgery

Comparative outcomes video-assisted thoracic surgery versus open thoracic surgery in pulmonary echinococcosis: a systematic review and meta-analysis

AIM

This meta-analysis aimed to evaluate and compare the outcomes of video-assisted thoracic surgery (VATS) and open thoracic surgery (OT) in the management of pulmonary echinococcosis.

METHODS

We conducted a comprehensive search of PubMed, Embase, and Cochrane databases for studies comparing VATS and OT. Odds ratios (ORs) for binary outcomes and mean differences (MDs) for continuous variables were calculated with 95% confidence intervals (CIs) using the DerSimonian and Laird random-effects model. Heterogeneity was assessed using I2 statistics.

RESULTS

Seven studies involving 2292 patients were included. VATS demonstrated significant advantages over OT, with reductions in intraoperative blood loss (MD - 81.65 mL, 95% CI - 129.90 to - 33.40), duration of thoracic drainage (MD - 2.29 days, 95% CI - 3.61 to - 0.98), operative time (MD - 45.73 min, 95% CI - 68.41 to - 23.05), narcotic use (MD -3.98 days, 95% CI - 6.21 to - 1.75), length of hospital stay (MD - 3.66 days, 95% CI - 5.66 to - 1.67), postoperative drainage volume (MD - 124.77 mL, 95% CI - 206.27 to - 43.27), and visual analogic score pain at 24 h after surgery (MD - 2.05 points, 95% CI - 2.40 to - 1.70). However, VATS was associated with a higher incidence of atelectasis (OR 3.27, 95% CI 1.03-10.35). No significant differences were observed in other complications, such as bronchopulmonary fistula, surgical wound infection, prolonged air leak, or failure of lung expansion.

CONCLUSIONS

VATS was associated with perioperative benefits, including reduced recovery times and resource utilization. Nonetheless, the higher risk of atelectasis suggests OT may remain favorable in complex cases requiring broader surgical access. Tailoring the surgical approach to the patient's needs remains crucial.

TRIAL REGISTRY

International Prospective Register of Systematic Reviews; Nº: CRD42025630187; URL: https://www.crd.york.ac.uk/prospero/ .

A prospective multi-institutional study to verify the non-inferiority of postoperative pain in robot-assisted thoracic surgery in comparison with video-assisted thoracoscopic surgery for lung cancer: The Japanese RATS interest group 01 (J-RATSIG 01)

OBJECTIVES

We sought to compare the latest data on postoperative pain between robot-assisted thoracic surgery (RATS) and video-assisted thoracoscopic surgery (VATS), and to clarify the relationship between the number or placement of ports and postoperative pain in patients with lung cancer.

METHODS

Patients who underwent anatomical lung resection by RATS or VATS and whose chest tube was removed within 7 days were enrolled. The primary endpoint was the percentage of patients with a numeric rating scale (NRS) score ≤ 3 on postoperative day 30 (POD30). The target sample size was 400 patients.

RESULTS

Four hundred five patients (RATS, n = 196; VATS, n = 209) managed at 12 institutions were included. Ninety-nine patients in the VATS group underwent a uniport procedure. Significant differences were observed between the RATS and VATS groups in the mean number of inserted ports (5.0 vs. 2.2), number of injured intercostal sites (2.9 vs. 1.9), largest wound size (3.4 vs. 3.7 cm), operation time (202 vs. 165 min), and use of epidural anesthesia or continuous nerve block (45 vs. 31 %). In the RATS and VATS groups, the rates of NRS≤3 on POD30 were 82.0 % and 94.7 % (95 %CI: -19.0 to -6.6 %), respectively, which could not prove noninferiority. However, in a multivariable analysis, the RATS approach was not proven to be a significant risk factor.

CONCLUSION

In the current status of minimally invasive thoracic surgery in Japan, RATS involves a greater number of ports, longer operation time, and higher frequency of local anesthesia than VATS and may be inferior in terms of postoperative pain.

Significance of the Goddard Score in Predicting Complications Related to Air Leak After Lobectomy

BACKGROUND

Postoperative air leakage is a frequent complication after lung resection, and emphysema is a risk factor. However, no study has investigated the relationship between emphysema severity and postoperative complications related to air leak by the Goddard score (GS), a visual evaluation method of radiologic emphysema using computed tomography.

METHODS

This study included patients who underwent lobectomy for non-small cell lung cancer between April 2009 and March 2022. The utility of GS in predicting complications related to air leak (air leak prolonged for ≥5 days, pleurodesis, and reoperation for air leak) was investigated by receiver operating characteristic curve analysis and multivariable analysis with a logistic regression model.

RESULTS

This study included 477 patients. The GS was a significant predictor of complications related to air leak (area under the curve, 0.696; P < .001). Based on the receiver operating characteristic curve analysis, GS of 6 points was used as the cutoff point for multivariable analysis. In the multivariable analysis, GS of ≥6 points was a significant predictor of complications related to air leak (odds ratio, 2.719; P = .007). In the subgroup analysis of patients with emphysema, GS of ≥6 points was a significant predictor of complications related to air leak (P = .014).

CONCLUSIONS

The GS was useful in predicting complications related to air leak. Patients with radiologic findings of emphysema with GS of ≥6 points should be recognized as a high-risk group for complications related to air leak.

Innovations in Hybrid Laparoscopic Surgery: Integrating Advanced Technologies for Multidisciplinary Cases

Combining conventional laparoscopic techniques with cutting-edge technologies, such as robotics, improved imaging, and flexible equipment, hybrid laparoscopic techniques represent a revolutionary advancement in minimally invasive surgery. These methods have several benefits, such as increased accuracy, quicker healing periods, and fewer complications, which makes them especially useful in complicated multidisciplinary situations. The historical evolution, uses, benefits, and drawbacks of hybrid laparoscopic procedures are examined in this narrative review, which also covers urological, gastrointestinal, cardiothoracic, and gynecological surgery. The review focuses on how these methods promote interdisciplinary cooperation and creativity by enabling more accurate and successful surgical operations. It also discusses the equipment needs, integration difficulties, and technical difficulties that need to be resolved to reach the full potential of hybrid laparoscopic surgery. For hybrid laparoscopic procedures to become more widely used and effective in the future, there is a need for specialized training programs, interdisciplinary research collaborations, and ongoing technological advancements.

Tumor distance from the mediastinum predicts N2 upstaging in clinical stage I lower-lobe non-small cell lung cancer

OBJECTIVE

Pulmonary lymphatic drainage of the lower lobe into the mediastinal lymph nodes includes not only the pathway via the hilar lymph nodes but also the pathway directly into the mediastinum via the pulmonary ligament. This study aimed to determine the association between the distance from the mediastinum to the tumor and the frequency of occult mediastinal nodal metastasis (OMNM) in patients with clinical stage I lower-lobe non-small cell lung cancer (NSCLC).

METHODS

Between April 2007 and March 2022, data of patients who underwent anatomical pulmonary resection and mediastinal lymph node dissection for clinical stage I radiological pure-solid lower-lobe NSCLC were retrospectively reviewed. In computed tomography axial sections, the ratio of the distance from the inner edge of the lung to the inner margin of the tumor within the lung width of the affected lung was defined as the inner margin ratio. Patients were divided into 2 groups based on whether the inner margin ratio was ≤0.50 (inner-type) or >0.50 (outer-type), and the association between inner margin ratio status and clinicopathological findings was assessed.

RESULTS

In total, 200 patients were enrolled in the study. OMNM frequency was 8.5%. More inner-type than outer-type patients had OMNM (13.2% vs 3.2%; P = .012) and skip N2 metastasis (7.5% vs 1.1%; P = .038). Multivariable analysis revealed that the inner margin ratio was the only independent preoperative predictor of OMNM (odds ratio, 4.72; 95% CI, 1.31-17.07; P = .018).

CONCLUSIONS

Tumor distance from the mediastinum was the most important preoperative predictor of OMNM in patients with lower-lobe NSCLC.

Complete thoracoscopic lobectomy versus hybrid video-assisted thoracoscopic lobectomy for non-small cell lung cancer

OBJECTIVE

Video-assisted thoracoscopic surgery (VATS) is the standard approach to lobectomy for early-stage non-small cell lung cancer (NSCLC). However, there are many different types. One of its approaches is complete thoracoscopic surgery (CTS), which may be less invasive because of low chest wall stress. This study compared the treatment outcomes of CTS and hybrid VATS lobectomy for NSCLC.

METHODS

In total, 442 eligible patients with clinical N0 NSCLC underwent lobectomy between 2007 and 2016. Patients were classified into a group of patients who underwent CTS and a group of those who underwent hybrid VATS. Propensity score matching was performed between the two groups.

RESULTS

There were 175 patients after matching. The median follow-up period in the CTS and hybrid VATS groups was 60 and 63 months, respectively. The CTS group showed less blood loss (CTS, 50 mL vs. 100 mL, p = 0.005), fewer complications (CTS, 25.7% vs. 36.6%, p = 0.037), and shorter postoperative hospital stays (CTS, 8 days vs. 12 days, p < 0.001). There was no significant difference in the postoperative 30-day mortality rates. Between the patients who underwent CTS and hybrid VATS groups, the 5-year overall survival rates were 85.4% and 86.0% (p = 0.701), the relapse-free survival rates were 76.5% and 74.9% (p = 0.435), and the lung cancer-specific survival rates were 91.5% and 91.7% (p = 0.90), respectively.

CONCLUSIONS

CTS is less invasive and has superior short-term outcomes as an approach to lobectomy for early-stage NSCLC.

Comparison of the Outcomes between Systematic Lymph Node Dissection and Lobe-Specific Lymph Node Dissection for Stage I Non-small Cell Lung Cancer

BACKGROUND

This study compares the surgical and long-term outcomes, including disease-free survival (DFS), overall survival (OS), and cancer-specific survival (CSS), between lobe-specific lymph node dissection (L-SND) and systematic lymph node dissection (SND) among patients with stage I non-small cell lung cancer (NSCLC).

METHODS

In this retrospective study, 107 patients diagnosed with clinical stage I NSCLC undergoing video-assisted thoracic surgery lobectomy (exclusion of the right middle lobe) from January 2011 to December 2018 were enrolled. The patients were assigned to the L-SND (n = 28) and SND (n = 79) groups according to the procedure performed on them. Demographics, perioperative data, and surgical and long-term oncological outcomes were collected and compared between the L-SND and SND groups.

RESULTS

The mean follow-duration was 60.6 months. The demographic data and surgical outcomes and long-term oncological outcomes were not significantly different between the two groups. The 5-year OS of the L-SND and SND groups was 82% and 84%, respectively. The 5-year DFS of the L-SND and SND groups was 70% and 65%, respectively. The 5-year CSS of the L-SND and SND groups was 80% and 86%, respectively. All the surgical and long-term outcomes were not statistically different between the two groups.

CONCLUSION

L-SND showed comparable surgical and oncologic outcomes with SND for clinical stage I NSCLC. L-SND could be a treatment choice for stage I NSCLC.

Tumour location predicts occult N1 nodal metastasis in clinical stage I non-small-cell lung cancer

OBJECTIVES

Pathological lymph node metastases are often observed in patients with clinical N0 lung cancer. Identifying preoperative predictors of occult hilar nodal metastasis (OHNM) is important in determining the surgical procedure in patients with clinical stage I non-small-cell lung cancer. This study aimed to determine the frequency and predictors of OHNM by tumour location in these patients.

METHODS

Between April 2007 and May 2019, data of patients who underwent lobectomy or segmentectomy for clinical stage I pure-solid non-small-cell lung cancer were retrospectively reviewed. The ratio of the distance from the pulmonary hilum to the proximal side of the tumour to the distance from the pulmonary hilum to the visceral pleural surface through the centre of the tumour, named 'distance ratio (DR)', was calculated. The relationship of the DR with clinicopathological findings and prognosis was discussed.

RESULTS

A total of 357 patients were enrolled. OHNM frequency was 14.6%. Patients were divided into 2 groups based on whether the DR was ≤0.67 (central type) or >0.67 (peripheral type). The frequency of OHNM was significantly higher in the DR ≤0.67 group (21.5% vs 7.4%; P < 0.001). Multivariable analysis revealed that DR was the only independent preoperative predictor of OHNM (odds ratio, 3.63; 95% confidence interval, 1.83-7.18; P < 0.001).

CONCLUSIONS

The frequency of OHNM was significantly lower in peripheral-type lung cancer; therefore, tumour location was the most important preoperative predictor of OHNM.

Segmentectomy versus wedge resection for radiological solid predominant and low metabolic non-small cell lung cancer

OBJECTIVES

The prognosis of segmentectomy and wedge resection for solid predominant early-stage non-small cell lung cancer with low metabolic activity is unclear.

METHODS

This study aimed to assess patients who underwent segmentectomy or wedge resection with curative intent for clinically node-negative non-small cell lung cancer presenting as a solid predominant tumour (consolidation tumour ratio >50%) with a whole size ≤3 cm and [18F]-fluoro-2-deoxy-D-glucose accumulation weaker than that of the mediastinum tissue (Deauville score, 1 or 2) on positron emission tomography/computed tomography. The cumulative incidence of recurrence (CIR) was compared using the Gray method, and the predictive factor of CIR was analysed using the Fine and Gray method.

RESULTS

Of 140 patients included in this study, 93 (66.4%) underwent segmentectomy and 47 (33.6%) underwent wedge resection. No significant difference in the clinical stage was found between the 2 groups. The CIR was higher with wedge resection than with segmentectomy (P = 0.004). Recurrence after wedge resection was noted in 4 (8.5%) patients, 2 of whom had a recurrent site containing lung parenchyma of the preserved lobe and hilum lymph node, which would have been resected if segmentectomy had been performed. In the multivariable analysis for CIR using inverse probability of treatment weighting and the procedure, wedge resection was a significantly worse predictive factor (hazard ratio, 12.280; P = 0.025).

CONCLUSIONS

Segmentectomy rather than wedge resection should be considered for solid predominant, small-size non-small cell lung cancer even if [18F]-fluoro-2-deoxy-D-glucose accumulation is low.

Segmentectomy versus lobectomy for solid predominant cN0 lung cancer: analysis using visual evaluation of positron emission tomography

OBJECTIVES

Prognosis after segmentectomy for early-stage non-small cell lung cancer (NSCLC) with a high consolidation tumour ratio (CTR) and [18F]-fluoro-2-deoxy-D-glucose (FDG) accumulation on positron emission tomography/computed tomography is unclear.

METHODS

Participants of this study were 465 patients who underwent lobectomy or segmentectomy for clinical N0 NSCLC presenting solid component predominant tumour (CTR >50%) with a whole size ≤3 cm. Accumulations of FDG on positron emission tomography/computed tomography scans were scored according to the Deauville criteria, a 5-point visual evaluating method (Deauville score). The correlations between Deauville score, prognosis, and procedures were analysed.

RESULTS

Characteristics of pathological invasiveness, such as lymphatic invasion (P < 0.001), vascular invasion (P < 0.001) and pleural invasion (P < 0.001), and non-adenocarcinoma histologies (P < 0.001) were more common in patients with Deauville scores of 3-5. The cumulative incidence of recurrence (CIR) was higher in patients with Deauville scores of 3-5 (P < 0.001). The CIR after lobectomy and segmentectomy did not differ significantly among patients with Deauville scores of 1 or 2 (P = 0.598) or those with Deauville scores of 3-5 (P = 0.322). In the analysis of propensity score matched cohort, the CIR after lobectomy and segmentectomy did not differ significantly between patients with Deauville scores of 1 or 2 and Deauville scores of 3-5.

CONCLUSIONS

Segmentectomy may be feasible for NSCLC with high CTR (>50%) and accumulation of FDG. This finding should be confirmed in larger prospective studies.

Minimally invasive open surgery (MIOS) for clinical stage I lung cancer: diversity in minimally invasive procedures

BACKGROUND

Many thoracic surgeons have tried to make lung cancer surgery less invasive. Among the minimally invasive approaches that are currently available, it is controversial which is optimal. Minimally invasive open surgery, i.e. hybrid video-assisted thoracic surgery, has been adopted for lung cancer surgery at our institute. The objective of this study was to evaluate minimally invasive open surgery in terms of perioperative outcomes over the most recent 5 years.

METHODS

Between 2015 and 2019, 2738 patients underwent pulmonary resection for lung cancer at National Cancer Center Hospital, Japan. Among them, 2174 patients with clinical stage I lung cancer who underwent minimally invasive open surgery were included. Several perioperative parameters were evaluated.

RESULTS

The patients consisted of 1092 men (50.2%) and 1082 women (49.8%). Lobectomy was performed in 1255 patients (57.7%), segmentectomy in 603 (27.7%) and wide wedge resection in 316 (14.5%). Median blood loss was 30 ml (interquartile range: 15-57 ml) for lobectomy, 17 ml (interquartile range: 10-31 ml) for segmentectomy and 5 ml (interquartile range: 2-10 ml) for wide wedge resection. Median operative time was 120 min (interquartile range: 104-139 min) for lobectomy, 109 min (interquartile range: 98-123 min) for segmentectomy and 59 min (interquartile range: 48-76 min) for wide wedge resection. Median length of postoperative hospital stay was 4 days (interquartile range: 3-5 days). The 30-day mortality rate was 0.08% for lobectomy, 0.17% for segmentectomy and 0.00% for wide wedge resection.

CONCLUSIONS

Minimally invasive open surgery for clinical stage I lung cancer is a feasible approach with a low mortality and a short hospital stay. Oncological outcomes need to be investigated.

Postoperative Pulmonary Function After Complex Segmentectomy

BACKGROUND

Segmentectomy has been increasingly used for lung cancer treatment, however there are very limited data evaluating the postoperative pulmonary function of patients treated with complex segmentectomy. We evaluated the postoperative pulmonary function of patients who underwent complex segmentectomy compared with simple segmentectomy, wedge resection, and lobectomy.

METHODS

We retrospectively analyzed data from 580 patients who underwent surgical resection. The patients were divided into four groups: complex segmentectomy (n = 135), simple segmentectomy (n = 83), wedge resection (n = 89), and lobectomy (n = 273). Functional testing included forced vital capacity (FVC), forced expiratory volume in 1 s (FEV₁), and predicted diffusing capacity of the lung for carbon monoxide (%DLCO) measured preoperatively and at 12 months after surgery.

RESULTS

During the postoperative course, the complex segmentectomy and simple segmentectomy groups showed a comparable course of pulmonary function. The complex segmentectomy group significantly preserved pulmonary function compared with the lobectomy group (FVC, p = 0.017; FEV₁, p = 0.010; %DLCO, p = 0.0043). A similar trend was observed even when restricted to lung diseases in the right upper lobe. On the other hand, when comparing complex segmentectomy with wedge resection, complex segmentectomy showed a trend that was more disadvantageous than wedge resection, but this difference was not significant (FVC, p = 0.19; FEV₁, p = 0.40; %DLCO, p = 0.96).

CONCLUSIONS

Complex segmentectomy showed comparable postoperative pulmonary functions as simple segmentectomy. Complex segmentectomy could preserve pulmonary function significantly compared with lobectomy and did not result in significant loss compared with wedge resection.

Clinical Behavior of Combined Versus Pure High-Grade Neuroendocrine Carcinoma

BACKGROUND

The aim of this study was to investigate and compare the clinical behaviors of combined and pure high-grade neuroendocrine carcinoma (large-cell neuroendocrine carcinoma [LCNEC] and small-cell lung carcinoma [SCLC]).

PATIENTS AND METHODS

Data of 132 patients who underwent complete resection for combined or pure high-grade neuroendocrine carcinoma (combined group, 67; pure group, 65) between January 2001 and December 2015 were retrospectively reviewed. The clinicopathological features were analyzed and compared, and the prognoses were assessed by performing the Kaplan-Meier method and Cox regression analysis.

RESULTS

The combined and pure groups had nearly equivalent clinicopathological characteristics, specifically, older males with smoking history, almost the same percentage of pleural/lymphatic/vascular invasion, and nearly the same recurrence rates and relapse patterns. The combined group had prognosis equivalent to that of the pure group (5-year overall survival [OS] rates: 61.8% vs. 52.2%, respectively; P = .82 and 5-year recurrence-free survival [RFS] rates: 42.4% vs. 43.9%, respectively; P = .96), and this trend was identified in sub-analyses only for patients with LCNEC, SCLC, and the same pathological stage. Multivariable Cox regression analysis in patients with high-grade neuroendocrine carcinoma revealed that vascular invasion and pathological stage were independent prognostic factors for OS; more importantly, combined and pure histologies were proven to have nearly equivalent associations with prognosis (hazard ratio, 0.96; 95% confidence interval, 0.22to 1.66; P = .96).

RESULTS

Combined high-grade neuroendocrine carcinoma had clinical behavior equivalent to those of pure high-grade neuroendocrine carcinoma, with similar clinicopathological characteristics.

Technical Advances in Segmentectomy for Lung Cancer: A Minimally Invasive Strategy for Deep, Small, and Impalpable Tumors

With the increased detection of early-stage lung cancer and the technical advancement of minimally invasive surgery (MIS) in the field of thoracic surgery, lung segmentectomy using MIS, including video- and robot-assisted thoracic surgery, has been widely adopted. However, lung segmentectomy can be technically challenging for thoracic surgeons due to (1) complex segmental and subsegmental anatomy with frequent anomalies, and (2) difficulty in localizing deep, small, and impalpable tumors, leading to difficulty in obtaining adequate margins. In this review, we summarize the published evidence and discuss key issues related to MIS segmentectomy, focusing on preoperative planning/simulation and intraoperative tumor localization. We also demonstrate two of our techniques: (1) three-dimensional computed tomography (3DCT)-based resection planning using a novel 3DCT processing software, and (2) tumor localization using a novel radiofrequency identification technology.

Complex segmentectomy in the treatment of stage IA non-small-cell lung cancer

OBJECTIVES

Although segmentectomy for lung cancer has been widely accepted, complex segmentectomy, which creates several, intricate intersegmental planes, remains controversial. Potential arguments include risk of incurability and 'failure of cancer control'. We compared the outcomes of complex segmentectomy versus lobectomy and evaluated its use in lung cancer treatment.

METHODS

We retrospectively reviewed clinical stage IA lung cancer patients who underwent complex segmentectomy (n = 99) or location-adjusted lobectomy (n = 94) between April 2009 and December 2017. Clinicopathological and postoperative results were compared. Factors affecting survival were assessed by the Kaplan-Meier method and the Cox regression analysis.

RESULTS

No significant differences were detected in 30-day mortality (0% vs 0%), overall complications (26.3% vs 21.3%) and prolonged air leakage (11.1% vs 9.6%) rates between the 2 groups, respectively. Comparable results were obtained for 5-year overall (93.5% vs 96.4%, respectively; P = 0.21) or recurrence-free (92.3% vs 88.5%, respectively; P = 0.82) survivals after complex segmentectomy or lobectomy. There were 2 (2.0%) recurrences after complex segmentectomy and 7 (7.5%) after lobectomy (P = 0.094), with 0 (0%) margin relapses in each group. Multivariable Cox regression analysis revealed that complex segmentectomy and lobectomy had a numerically similar impact on recurrence-free survival (hazard ratio 0.93, 95% confidence interval 0.32-2.69; P = 0.90).

CONCLUSIONS

Complex segmentectomy can provide acceptable short- and long-term outcomes in lung cancer treatment.

Serum S100 calcium-binding protein A4 as a novel predictive marker of acute exacerbation of interstitial pneumonia after surgery for lung cancer

BACKGROUND

Acute exacerbation (AE) of interstitial pneumonia (IP) is the most fatal complication after lung resection for lung cancer. To improve the prognosis of lung cancer with IP, the risk factors of AE of IP after lung resection should be assessed. S100 calcium-binding protein A4 (S100A4) is a member of the S100 family of proteins and is a known marker of tissue fibrosis. We examined the usefulness of S100A4 in predicting AE of IP after lung resection for lung cancer.

METHODS

This study included 162 patients with IP findings on preoperative high-resolution computed tomography scan who underwent curative-intent lung resection for primary lung cancer between April 2007 and March 2019. Serum samples were collected preoperatively. Resected lung tissue from 76 patients exhibited usual IP (UIP) pattern in resected lung were performed immunohistochemistry (IHC). Relationship between S100A4 and the incidence of AE of IP and short-term mortality was analyzed.

RESULTS

The receiver operating characteristic area under the curve for serum S100A4 to predict postoperative AE of IP was 0.871 (95% confidence interval [CI], 0.799-0.943; P < 0.001), with a sensitivity of 93.8% and a specificity of 75.3% at the cutoff value of 17.13 ng/mL. Multivariable analysis revealed that a high serum S100A4 level (> 17.13 ng/mL) was a significant risk factor for AE of IP (odds ratio, 42.28; 95% CI, 3.98-449.29; P = 0.002). A 1-year overall survival (OS) was significantly shorter in patients with high serum levels of S100A4 (75.3%) than in those with low serum levels (92.3%; P = 0.003). IHC staining revealed that fibroblasts, lymphocytes, and macrophages expressed S100A4 in the UIP area, and the stroma and fibrosis in the primary tumor expressed S100A4, whereas tumor cells did not.

CONCLUSIONS

Serum S100A4 had a high predictive value for postoperative AE of IP and short-term mortality after lung resection.

Complex Segmentectomy for Hypermetabolic Clinical Stage IA Non-Small Cell Lung Cancer

BACKGROUND

Due to its invasiveness, the indications for "complex segmentectomy" for radiologically hypermetabolic (high maximum standard uptake value [SUV max]) non-small cell lung cancer (NSCLC) remains controversial. This study compared the outcomes after complex segmentectomy and lobectomy in these patients.

METHODS

We retrospectively reviewed 717 patients with radiologically hypermetabolic (SUV max ≥ 2.5), clinical Stage IA NSCLC who underwent complex segmentectomy (n = 61) or "location-adjusted" lobectomy (n = 656) at three institutions from 2010 to 2019. Postoperative outcomes were analyzed for all patients and their propensity score-matched pairs. Factors affecting oncologic outcomes were assessed by Kaplan-Meier estimates and Cox proportional hazards regression analyses.

RESULTS

The prognosis of patients undergoing complex segmentectomy was not significantly different from that of patients undergoing lobectomy [5-year cancer specific survival (CSS) rate, 89.9% vs. 91.1%, P = 0.98 and 5-year recurrence-free interval (RFI) rates, 83.0% vs. 77.5%, P = 0.62] in non-adjusted cohort. In 55 propensity score-matched pairs, oncologic outcomes were not significantly different between patients undergoing complex segmentectomy (5-year CSS, 89.9%; 5-year RFI, 83.0%) and lobectomy (5-year CSS, 83.6%; 5-year RFI, 82.5%). Multivariable Cox regression analysis for RFI revealed no significant differences between oncologic outcomes associated with complex segmentectomy and lobectomy (hazard ratio, 0.84; 95% confidence interval, 0.25-2.14; P = 0.74).

CONCLUSIONS

Oncologic outcomes of complex segmentectomy and lobectomy were not significantly different in those with radiologically hypermetabolic, clinical Stage IA NSCLC patients. Complex segmentectomy can treat high SUV max, clinical Stage IA lung cancers without compromising oncologic results.

Impact of postoperative pleurodesis on pulmonary function after lung segmentectomy

Objective

Pleurodesis is among several treatment strategies for postoperative alveolo-pleural fistula (APF) after lung resection. Accordingly, the present study aimed to determine the influence of pleurodesis on postoperative pulmonary function.

Methods

Patients who underwent anatomical segmentectomy between January 2009 and March 2020 and pulmonary function tests 6 and 12 months after initial surgery were included in this study. Differences in pulmonary function decline between patients who did and did not undergo pleurodesis were compared.

Results

Among the 319 patients included, 39 (12.2%) underwent pleurodesis. Among patients who did not receive pleurodesis, there were no difference in decline of vital capacity at 6 months (−13.7% ± 1.1% vs −11.2% ± 0.7%; P = .063) and 12 months (−10.7% ± 1.3% vs −9.5% ± 0.7%; P = .391) after surgery between patients who had APF on postoperative day 2 and those who did not. Patients who received pleurodesis had a significantly larger decline in vital capacity at 6 months (−19.4% ± 2.4% vs −13.7% ± 1.1%; P = .015) and 12 months (−16.2% ± 1.6% vs −10.7% ± 1.3%; P = .010) after surgery compared with those who had APF on postoperative day 2 and did not receive pleurodesis. There were no significant differences in decline of forced expiratory volume in 1 second.

Conclusions

Pleurodesis negatively influenced postoperative vital capacity after lung segmentectomy. Although the clinical influence of this is unknown, careful consideration is needed before performing pleurodesis given its potential influence on postoperative pulmonary function.

Surgical Procedure Selection for Stage I Lung Cancer: Complex Segmentectomy versus Wedge Resection

BACKGROUND

Although sublobar resection has become widely used for lung cancer treatment, very limited data comparing outcomes following complex segmentectomy or wedge resection have been available. Questions remain regarding mortality, morbidity, surgical margin, lymph node dissection, and long-term survival outcomes. This study compares operative and postoperative outcomes of complex segmentectomy and wedge resection.

PATIENTS AND METHODS

A total of 216 patients with clinical stage I lung cancer who underwent complex segmentectomy (n = 110) or wedge resection (n = 106) between April 2007 and March 2017 were retrospectively reviewed, and 61 propensity score-matched pairs were analyzed. Operative and postoperative results were compared. Factors affecting survival were assessed using the Kaplan-Meier method.

RESULTS

Although the complex segmentectomy group tended to have higher overall complications (26.2% vs. 16.4%; P = .27) and prolonged air leakage (11.5% vs. 6.6%; P = .53) rates than the wedge resection group, major complications (≥grade IIIa) (0% vs. 3.3%; P = .50) and 30-day mortality (0% vs. 0%; P = 1.00) rates were comparable between both groups. Complex segmentectomy provided better median surgical margin distance (15.0 vs. 10.0 mm; P = .052) and number of dissected lymph nodes (6.0 vs. 0.0 nodes; P = .0002) than wedge resection. The complex segmentectomy group tended to have better prognosis than the wedge resection group (5-year overall survival rates, 94.7% vs. 79.4% and 5-year recurrence-free survival rates, 94.0% vs. 76.5%, respectively).

CONCLUSIONS

Complex segmentectomy could provide better oncological and survival outcomes with acceptable perioperative safety compared with wedge resection.

Segmentectomy vs Lobectomy for Clinical Stage IA Lung Adenocarcinoma With Spread Through Air Spaces

BACKGROUND

This study aimed to investigate the prognosis after segmentectomy as compared with lobectomy for small-sized lung adenocarcinoma with spread through air spaces (STAS).

METHODS

This retrospective study included 609 patients who underwent lobectomy or segmentectomy with lymph node dissection for clinical stage IA lung adenocarcinoma between April 2011 and March 2020 at Hiroshima University Hospital. Patient characteristics and prognosis after segmentectomy and lobectomy were investigated.

RESULTS

STAS was detected in 293 patients (48.1%). The recurrence-free survival (RFS) rate was significantly worse with STAS-positive adenocarcinoma than with STAS-negative adenocarcinoma both in patients who underwent lobectomy (5-year RFS, 68.2% vs 90.2%; P < .001) and in patients who underwent segmentectomy (5-year RFS, 81.3% vs 93.0%; P = .003). Among the patients with STAS, there was no significant difference in RFS between patients who underwent lobectomy (5-year RFS, 68.2%) and those who underwent segmentectomy (5-year RFS, 81.3%; P = .225). In a multivariable analysis using propensity score to adjust clinical patient characteristics, segmentectomy was not found to be an independent prognostic factor of RFS (hazard ratio 0.732, P = .326) among patients with STAS. Among the patients with STAS, only 1 patient (1%) with insufficient resection margin (0.5 mm) had local recurrence and 1 patient (1%) with invasive mucinous adenocarcinoma had recurrence in preserved lobe after segmentectomy.

CONCLUSIONS

Spread through air spaces was a poor prognostic factor in patients with clinical stage IA lung adenocarcinoma. Prognosis after segmentectomy was comparable with that of lobectomy in lung adenocarcinoma with STAS without increasing locoregional recurrence.

Prediction of Acute Exacerbation of Interstitial Pneumonia Using Visual Evaluation of PET

BACKGROUND

Acute exacerbation (AE) of interstitial pneumonia (IP) is a fatal complication after lung resection. We aimed to investigate whether the visual accumulation of [18F]-fluoro-2-deoxy-D-glucose (FDG) in the field of IP on preoperative FDG-positron emission tomography-computed tomography is useful for predicting AE of IP.

METHODS

This study included 193 patients with IP findings on preoperative computed tomography who underwent curative intent lung resection for primary lung cancer at Hiroshima University Hospital between April 2007 and March 2019. If the uptake of IP area was higher than the background normal lung, the patients were considered to have positive FDG accumulation. The relationship of the accumulation of FDG in the IP area and the incidence of AE of IP and short-term mortality was analyzed.

RESULTS

Among the included patients, accumulation of FDG in the IP area was detected in 130 (67.4%) patients. The incidence of AE of IP was significantly different between patients with (10.0%) and without (0%) FDG accumulation in the IP area (P = .001). The 90-day mortality rate was also significantly different between patients with (6.9%) and without (0%) accumulation of FDG in the IP area (P = .007). In the multivariable analysis, the accumulation of FDG in the IP area was a significant risk factor of AE of IP (P = .005).

CONCLUSIONS

The visual evaluation of accumulation of FDG in the IP area was useful to predict the AE of IP and short-term mortality after lung resection.

Patient Selection of Sublobar Resection Using Visual Evaluation of Positron-Emission Tomography (PET) for Early-Stage Lung Adenocarcinoma

BACKGROUND

This study aimed to investigate the efficacy of the Deauville criteria (a 5-point visual scale criteria) in assessing the accumulation of [18F]-fluoro-2-deoxy-D-glucose (FDG) on positron-emission tomography (PET)/computed tomography (CT) for predicting prognosis of early-stage lung adenocarcinoma and selecting candidates for sublobar resection.

METHODS

This retrospective study included 648 patients undergoing curative resection for clinical N0 lung adenocarcinoma with a whole tumor size of 3 cm or smaller between April 2007 and March 2019. Accumulations of the FDG on PET/CT scans were scored using the Deauville criteria (Deauville score), and correlations between the Deauville score and prognosis were analyzed.

RESULTS

The recurrence-free survival (RFS) was significantly better for the patients with a Deauville score of 1 or 2 (n = 415, 5-year RFS, 92.6%) than for those with a score of 3 (n = 82, 5-year RFS, 72.7%; P < 0.001) or a score of 4 or 5 (n = 151, RFS, 70.8%; P < 0.001). The RFS did not differ significantly among the patients with Deauville scores of 1 and 2 who underwent wedge resection (n = 102, 5-year RFS, 90.5%), segmentectomy (n = 188, RFS, 95.1%; P = 0.355), and lobectomy (n = 125, RFS, 91.1%; P = 0.462).

CONCLUSION

The 5-point-scale evaluation of FDG accumulation on PET/CT was useful in predicting the prognosis for patients with early-stage lung adenocarcinoma. Lung adenocarcinoma patients with a whole tumor size of 3 cm or smaller and a Deauville score of 1 or 2 can be candidates for sublobar resection.

Initial experience of robotic anatomical segmentectomy for non-small cell lung cancer

OBJECTIVE

Anatomical segmentectomy has the potential to replace lobectomy as the standard procedure for early stage non-small cell lung cancer. We investigated the safety and feasibility of robotic anatomical segmentectomy for non-small cell lung cancer.

METHODS

Overall 20 patients underwent robotic anatomical segmentectomy at Hiroshima University Hospital between January 2014 and January 2018. The clinicopathological characteristics, surgical outcomes, complications and prognosis were analyzed.

RESULTS

The median age was 68 (range 42-86) years, and 15 patients were female. Six patients were non-smokers. The most common clinical stage was IA1 (nine patients). Complex segmentectomies were performed in four patients (one right S3 segmentectomy, two right S8 segmentectomies and one left S8 + S9 segmentectomy). The median operation time was 163.5 (range, 114-314) minutes, and the median console time was 104 (range, 60-246) minutes. The median blood loss was 26.5 (range, 5-247) ml. The median resection margin and number of dissected lymph node were 15 (range, 2-60) mm and 5 (range, 1-15), respectively. Although five (25.0%) patients had grade IIIa complications (pleurodesis for prolonged air leakage) and one (5.0%) had a grade IIIb complication (reoperation for prolonged air leakage), no post-operative deaths occurred. The surgical outcomes were comparable with those of anatomical segmentectomy performed under hybrid video-assisted thoracoscopic surgery during the same period.

CONCLUSION

In our initial experience of robotic anatomical segmentectomy for early stage non-small cell lung cancer, the procedure seems to be safe and feasible.

Oncological results of full thoracoscopic major pulmonary resections for clinical Stage I non-small-cell lung cancer

OBJECTIVES

The full thoracoscopic approach to major pulmonary resections is considered challenging and controversial as it might compromise oncological outcomes. The aim of this work was to analyse the results of a full thoracoscopic technique in terms of nodal upstaging and survival in patients with non-small-cell lung carcinoma (NSCLC).

METHODS

All patients who underwent a full thoracoscopic major pulmonary resection for NSCLC between 2007 and August 2016 were analysed from an 'intent-to-treat' prospective database. Overall survival and disease-free survival were estimated using the Kaplan-Meier curves and comparisons in survival using the log-rank test.

RESULTS

A total of 648 patients met the inclusion criteria, of whom 621 patients had clinical Stage I and 27 had higher stages (16 oligometastatic patients were excluded from the analysis, 11 cT3 or cT4). The mean follow-up was 34.5 months. There were 40 conversions to thoracotomy (6.3%). Thirty-day or in-hospital mortality was 0.95%. Complications occurred in 29.3% of patients. On pathological examination, 22.5% of clinical Stage I patients were upstaged. Nodal upstaging to N1 or N2 was observed in 15.8% of clinical Stage I patients. Five-year overall survival of the whole cohort was 75% and was significantly different between clinical Stages IA (76%) and IB (70.9%). For tumours <2 cm, no significant difference in overall survival was found for the segmentectomy group compared to the lobectomy group: 74% versus 78.9% (P = 0.634).

CONCLUSIONS

Long-term survival is not compromised by a full thoracoscopic approach. Our results compared favourably with those of video-assisted techniques.

Video-assisted thoracic surgery anatomical lobectomy for a primary lung tumor in a dog

A female Bernese Mountain Dog was diagnosed with a right middle lung lobe mass. The dog was positioned in a left lateral recumbency and one-lung ventilation was used under general anesthesia. Video-assisted thoracic surgery anatomical lobectomy was performed with 4 cm small thoracotomy and two 6-mm ports. Pulmonary vessels and bronchus were dissected and isolated individually at the hilum of the right middle lung lobe. Pulmonary vessels were ligated and were coagulated and transected using a vessel sealing device. The bronchus was ligated and transected. The mass in the right middle lung lobe was removed with a clean margin and without complications. Video-assisted thoracic surgery anatomical lobectomy was used to successfully remove a primary lung tumor in a dog.

Minimally Invasive Anterior Thoracotomy for Routine Lung Cancer Resection

Objectives

A 7-year experience with a minimally invasive approach to routine lung cancer resection is compared with standard lateral open thoracotomy.

Methods

All patients undergoing lung resection with curative intent for primary lung cancer between July 1998 and November 2005 by a single surgical team were registered. Surgical access was obtained through a mini 5- to 6-cm anterior thoracotomy with video assistance; direct visualization was also used extensively.

Results

Patients (n = 167) underwent major pulmonary resection for primary lung cancer. The minimally invasive group (MI), 137 patients, included 12 fully endoscopic or robotic approaches. The open lateral (OL) approach included 30 patients (18%). Both groups included pneumonectomies (8 MI, 3 OL), sleeve resections (3 MI, 2 OL), chest wall resections (2 MI, 5 OL), and pancoasts (3 MI, 0 OL) and had full lymph node resections. The Kaplan-Meier estimated overall mean survival was 64.5 months (95% CL, 58 to 71 months). Mean estimate survivals were stage 1a, 66%; stage 1b, 65%; stage 2a, 61%; stage 2b, 55%; stage 3a, 52%; stage 3b, 45%. Mean survival in the MI group was 64.3 months versus 59.3 with standard open access (OL) (X2 = 0.003 Mantel-Cox; significance, 0.959). In-hospital mortality rate was 2.2%; conversion from a mini to open procedure was 1.5%. Avoidance of rib spreading (soft tissue retractor) and small incisions appeared to have reduced pain and improved early recovery.

Conclusions

Kaplan-Meier survival for routine unselected lung cancer resection through a minimal access approach was not significantly different from the open approach and reflects published survival curves.

Updates on Minimally Invasive Surgery in Non-Small Cell Lung Cancer

OPINION STATEMENT

Video-assisted thoracic surgery (VATS) has become widely used since the 1990s and has become a standard treatment approach mainly for early-stage non-small cell lung cancer. The few randomized controlled trials providing evidence of the effectiveness of VATS lobectomy at present are supported by a large number of propensity-matched studies, several high-quality meta-analyses, and outcome studies. These studies provide comprehensive data demonstrating the lower morbidity, shorter chest tube duration, and shorter hospital stay of VATS than thoracotomy during the postoperative course. Moreover, VATS shows equivalent oncological outcome as thoracotomy and therefore should be performed for lobectomy as much as possible. Importantly, VATS has recently been applied to advanced cases and previously contraindicated complex procedures such as bronchoplasty and chest wall resection. Attention has also been paid to reduced port surgery performed by frontier surgeons. Thus, the indications of VATS have seen a significant expansion. This major development logically negates any hesitation to change to the VATS technique as any doubt will likely constrain its wider applications. Preparation of scientific learning environments is necessary and should be actively pursued to adopt new skills instead of debating between the choice of "VATS or open."

Thoracoscopic segmentectomy: hybrid approach for clinical stage I non-small cell lung cancer

Background

Recently, minimally invasive surgical approaches have been developed, typified by video-assisted thoracic surgery (VATS). A meticulous surgical procedure to prevent local recurrence is required during segmentectomy for clinical stage I non-small-cell primary lung cancer. In this article, we demonstrated the validity of hybrid VATS segmentectomy.

Methods

Of these 125 patients, 62 (49.6%) underwent intensively radical segmentectomy (RS). The remaining 63 (50.4%) patients underwent palliative segmentectomy (PS). We used two 2-cm ports and performed a muscle-sparing mini-thoracotomy in which a partially open metal retractor allowed direct, thoracoscopic visualization as hybrid VATS segmentectomy in 63.2% of our cases.

Results

The consolidation/tumor ratio obtained with thin-sliced computed tomography was significantly lower in RS cases than in PS cases (P=0.001). The proportion of pathological stage IA cases was significantly higher in RS cases (95.2%) than in PS cases (66.7%; P<0.01). Five-year overall survival (OS) for clinical stage I was 100.0% in RS cases and 73.5% in PS cases (log-rank P<0.001). Five-year disease-free survival (DFS) was 95.5% and 55.7%, respectively (log-rank P<0.001).

Conclusions

During segmentectomy, the most critical consideration is establishment of sufficient surgical margins around the cancer. Our hybrid approach that includes meticulous surgical manipulations may produce sufficient surgical margins.

VATS segmentectomy: past, present, and future

Video-assisted thoracoscopic surgery (VATS) has gradually been implemented in thoracic surgery, and the VATS approach has now been extended to technically challenging procedures, such as segmentectomy. The definition of VATS segmentectomy is changing over time, and the repertoire of segmentectomy is getting wider with increasing reports on atypical segmentectomy. VATS segmentectomy bears surgical, oncological, and technical advantages; however, there are still areas of controversy, particularly regarding oncological outcomes. The indication of VATS segmentectomy is diverse and is used for treating lung cancer, metastatic lung tumors, or a variety of nonmalignant diseases. It is particularly valuable for the lung-sparing resection of deeply located small nodules or repeated surgery for multiple lung lesions. VATS segmentectomy requires a thorough analysis of segmental anatomy and a tailored preoperative planning with the assessment of surgical margins. Technical challenges include intraoperative navigation, methods to identify and dissect the intersegmental plane, and the prevention of air leakage. This review will discuss the present state of VATS segmentectomy, with a focus on past studies, current indications and techniques, and future view.

Nodal upstaging: effects of instrumentation and three-dimensional view in clinical stage I lung cancer

Nodal upstaging after surgical intervention for non-small cell lung cancer (NSCLC) is defined as the presence of unsuspected pathologic hilar (pN1) or mediastinal (pN2) disease detected during the final histopathologic evaluation of surgical specimens. The prevalence of pathologic nodal upstaging is used as a quality measure for the definition of the completeness of the nodal dissection. Risk factors for nodal upstaging may be patient-related (history of tuberculosis, rheumatoid arthritis, and diabetes mellitus), or tumor-related (central tumor, higher T stage, higher SUVmax value, or adenocarcinoma). Actually, the theorical superiority of a minimally invasive resections is the lymph node dissection. Studies may suggest that, expert video-assisted thoracoscopic surgery (VATS) surgeon could do similar lymph node dissection as it is done in open. Robotic surgeons may replicate the results of lymph node dissection in the open techniques. The possible reason for this is the instrumental superiority provided by the higher technology.

Clinical Prognosis of Superior Versus Basal Segment Stage I Non-Small Cell Lung Cancer

BACKGROUND

Despite its extensive size, variations in the clinicopathologic features of tumors in the lower lobe have been little studied. The present study investigated the prognostic differences in tumors originating from the superior and basal segments of the lower lobe in patients with non-small cell lung cancer.

METHODS

Data of 134 patients who underwent lobectomy or segmentectomy with systematic nodal dissection for clinical stage I, radiologically solid-dominant, non-small cell lung cancer in the superior segment (n = 60) or basal segment (n = 74) between April 2007 and December 2015 were retrospectively reviewed. Factors affecting survival were assessed by the Kaplan-Meier method and Cox regression analyses.

RESULTS

Prognosis in the superior segment group was worse than that in the basal segment group (5-year overall survival rates 62.6% versus 89.9%, p = 0.0072; and 5-year recurrence-free survival rates 54.4% versus 75.7%, p = 0.032). In multivariable Cox regression analysis, a superior segment tumor was an independent factor for poor overall survival (hazard ratio 3.33, 95% confidence interval: 1.22 to 13.5, p = 0.010) and recurrence-free survival (hazard ratio 2.90, 95% confidence interval: 1.20 to 7.00, p = 0.008). The superior segment group tended to have more pathologic mediastinal lymph node metastases than the basal segment group (15.0% versus 5.4%, p = 0.080).

CONCLUSIONS

Tumor location was a prognostic factor for clinical stage I non-small cell lung cancer in the lower lobe. Patients with superior segment tumors had worse prognosis than patients with basal segment tumors, with more metastases in mediastinal lymph nodes.

Anatomical Segmentectomy with a Hybrid VATS Approach in a Patient with Intralobar Pulmonary Sequestration after Severe Pneumonia: A Case Report

Anatomical segmentectomy is an advantageous procedure because it spares healthy lung that has potential to show compensatory growth after lung resection and decreases the risk of air leak and residual resection, which becomes a problem in wedge resection. However, anatomical segmentectomy has not become a common procedure in pediatrics because it requires more complicated procedure than lobectomy or wedge resection, especially in patients with a history of pulmonary infection. In this case report, anatomical basal segmentectomy was safely performed with magnified vision by a hybrid video-assisted thoracic surgery (VATS) approach in a 6-year-old girl with intralobar pulmonary sequestration after severe pneumonia. The result suggests that the indications for hybrid VATS segmentectomy can expand further to include segmental lesions in children.

Multiportal video-assisted thoracic surgery, uniportal video-assisted thoracic surgery and minimally invasive open chest surgery-selection criteria

Thoracic surgery started the path to minimally invasive surgery over a hundred years ago, with the first thoracoscopic procedure performed by Jacobeus in 1910. Interestingly, these first procedures were performed using a single port approach and were used for diagnostic and minor procedures only. For a long period of time, the progress for minimally invasive thoracic surgery was considerably slow until the early 90s, when video assisted thoracic surgery started to be used for major pulmonary resections. Since then, video-assisted thoracic surgery (VATS) had a widespread use around the world and an ongoing search for a less invasive procedures evolved into uniportal VATS. Now, thoracic surgeons have a variety of choices for minimally invasive thoracic surgery and must be trained in these approaches to keep up with the evolution of the specialty and be up to date with the recommended treatments for diseases needing surgical intervention. The approach chosen by each surgeon is a matter of preference, while keeping in mind certain characteristics specific to the pathology and patient to be treated, the level of training of the surgeon, and the healthcare resources available. As more evidence is collected, the choice for video-assisted procedures, which have currently been proven safe, effective, less invasive and, in general, show good results, will prevail.

Troubleshooting for bleeding in thoracoscopic anatomic pulmonary resection

Introduction The objective of this study was to evaluate intraoperative vessel injury and assess troubleshooting during thoracoscopic anatomic pulmonary resection. Methods Between April 2012 and March 2016, 240 patients underwent thoracoscopic anatomic lung resection, 26 of whom were identified as having massive bleeding intraoperatively. We analyzed the injured vessel and the hemostatic procedure employed, then compared the perioperative outcomes in patients with ( n = 26) and without ( n = 214) vessel injury. In addition, we compared perioperative results based on the period when surgery was performed: early period: April 2012 to March 2014 ( n = 93) or late period: April 2014 to March 2016 ( n = 146). Results The surgical procedures included 20 lobectomies and 6 segmentectomies. One of the 26 patients had vessel injury at 2 points, giving a total of 27 points of injury. Hemostasis was mostly achieved by application of thrombostatic sealant (63.0%). There were no significant differences in the length postoperative hospitalization ( p = 0.67) or morbidity rate ( p = 0.43) between the vessel injury and the no-vessel injury groups. There were no significant differences in the incidence of significant intraoperative bleeding ( p = 0.13) and total blood loss ( p = 0.13) between the early and late periods. Conclusions Application of thrombostatic sealant is one of the useful methods to achieve hemostasis during thoracoscopic anatomic pulmonary resection. Vascular hazards are inherent to a thoracoscopic approach. Therefore, thoracic surgeons should always be concerned about significant intraoperative bleeding and treat it appropriately.

Therapeutic strategy for small-sized lung cancer

Minimizing the volume of lung resection without diminishing curability has recently become an important issue in primary lung cancer. In this review, we will discuss the current state of the feasibility of sublobar resection and specific issues for a segmentectomy procedure. A previous randomized controlled trial showed that lobectomy must still be considered the standard surgical procedure compared with sublobar resection for T1N0 non-small cell lung cancer with a tumor less than 3 cm in size. Since then, supporting studies for segmentectomy of lung cancer with a tumor less than 2 cm in size were reported. In addition, segmentectomy seems to be feasible for clinical stage I adenocarcinoma less than 2 cm in size, in women younger than 70 years old, with a low tumor 18F-fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) standardized uptake value (SUV) from propensity-matching studies. In a meta-analysis of sublobar resection vs. lobectomy, intentionally performed sublobar resection showed equivalent outcomes to lobectomy. In the near future, two ongoing prospective, randomized trials will report results. As specific issues for the surgical procedure of segmentectomy, achieving a sufficient surgical margin is an important issue for preventing loco-regional recurrence. More studies regarding the regional lymph node dissection area for segmentectomy are needed. Sublobar resection has the potential to become the standard procedure for peripheral small-sized lung cancer less than 2 cm. However, more information is needed about the characteristics of this cancer and the surgical procedure, including nodal dissection.

Hybrid video-assisted thoracoscopic surgery lobectomy of fissureless congenital cystic adenomatoid malformation: a case report

INTRODUCTION

Thoracoscopic lobectomy for congenital pulmonary airway malformation has been indicated from the neonatal period to adolescence. However, it is difficult to approach the pulmonary artery for lobectomy in congenital lung malformations with incomplete or absent interlobar fissures. Multidetector computed tomographic images and computed tomography pulmonary angiography gave us helpful information before the operation. We performed thoracoscopic lobectomy for congenital pulmonary airway malformations with absent interlobar fissures and adhesions in accordance with information from multidetector computed tomographic images.

CASE PRESENTATION

A 14-year-old Japanese girl received a diagnosis of congenital pulmonary airway malformation when she presented with pneumonia. Using multidetector computed tomography and three-dimensional reconstruction provides meticulous characterization of the anatomy in pediatric patients. We confirmed that her left A4+5 artery arose from her left pulmonary artery medial to A6. Her left pulmonary artery was divided just proximal to the A6 origin before the lobes were separated safely. We took advantage of using a stapler to divide the fissureless thick parenchyma. Perioperative diagnosis was congenital cystic adenomatoid malformation.

CONCLUSIONS

We used preoperative multidetector computed tomography to outline the bronchovascular anatomy and guide hybrid video-assisted thoracoscopic surgery for a congenital cystic adenomatoid malformation in a fissureless left lung.

Video-assisted thoracoscopic surgery and thoracotomy during lobectomy for clinical stage I non-small-cell lung cancer have equivalent oncological outcomes: A single-center experience of 212 consecutive resections

The aim of the present study was to compare the oncological outcomes following lobectomy using either video-assisted thoracoscopic surgery (VATS) or thoracotomy in clinical stage I non-small cell lung cancer (NSCLC) patients. Short- and long-term data from 212 consecutive patients who underwent lobectomy for clinical stage I NSCLC via VATS or thoracotomy between February 2003 and July 2013 were retrospectively reviewed. The primary endpoints were mediastinal lymph node staging, disease-free survival time and overall survival time. A total of 212 lobectomies for clinical stage I NSCLC were performed, 123 by VATS and 89 by thoracotomy. Patients’ demographic data, pathological stage and residual tumor were similar in the two groups. Reduced blood loss, less post-operative analgesia required and earlier hospital discharge were recorded for the VATS group, as compared with the thoracotomy group. The overall morbidity was similar in the two groups. However, the rate of major complications was higher following thoracotomy than following VATS. No 30-day mortality occurred subsequent to either thoracotomy or VATS lobectomy. The overall survival and disease-free survival times were comparable between the two groups. In the univariate analysis, the treatment approach was not associated with the overall five-year survival or the disease-free survival times. Multivariate Cox regression analysis of survival times revealed that significant predictors of shorter survival times were advanced pathological T3 stage, pathological N1 or N2 disease and poor cancer differentiation. In conclusion, it is reasonable to conclude from the present study that VATS lobectomy performed by specialist thoracic surgeons is safe and may achieve similar long-term survival times to the open surgery approach. However, further prospective randomized multi-center trials are warranted prior to incorporating VATS into clinical routine.

Advances in the use of video-assisted thoracoscopic lobectomy in lung cancer: sleeve bronchoplasty and arterioplasty

SUMMARY 

This article focuses on the technical strategies for performing sleeve bronchoplasty and pulmonary arterioplasty as advances in the application of video-assisted thoracoscopic surgery (VATS) as lobectomy with bronchovascular reconstruction is a favorable alternative to pneumonectomy in terms of the pulmonary function. When performing VATS sleeve bronchoplasty or arterioplasty, several technical issues should be discussed, including how to reduce the anastomotic tension of the airway, perform bronchial anastomosis, and clamp the pulmonary artery and select the type of vascular clamp. The traction device technique and continuous suture technique are thought to help surgeons perform VATS sleeve bronchoplasty, while cross-clamping of the pulmonary artery using thoracoscopic instruments aids in carrying out VATS arterioplasty.

Video-assisted minithoracotomy for pulmonary laceration with a massive hemothorax

Severe intrathoracic hemorrhage from pulmonary parenchyma is the most serious complication of pulmonary laceration after blunt trauma requiring immediate surgical hemostasis through open thoracotomy. The safety and efficacy of video-assisted thoracoscopic surgery (VATS) techniques for this life-threatening condition have not been fully evaluated yet. We report a case of pulmonary laceration with a massive hemothorax after blunt trauma successfully treated using a combination of muscle-sparing minithoracotomy with VATS techniques (video-assisted minithoracotomy). A 22-year-old man was transferred to our department after a falling accident. A diagnosis of right-sided pneumothorax was made on physical examination and urgent chest decompression was performed with a tube thoracostomy. Chest computed tomographic scan revealed pulmonary laceration with hematoma in the right lung. The pulmonary hematoma extending along segmental pulmonary artery in the helium of the middle lobe ruptured suddenly into the thoracic cavity, resulting in hemorrhagic shock on the fourth day after admission. Emergency right middle lobectomy was performed through video-assisted minithoracotomy. We used two cotton dissectors as a chopstick for achieving compression hemostasis during surgery. The patient recovered satisfactorily. Video-assisted minithoracotomy can be an alternative approach for the treatment of pulmonary lacerations with a massive hemothorax in hemodynamically unstable patients.

Techniques to define segmental anatomy during segmentectomy

Pulmonary segmentectomy is generally acknowledged to be more technically complex than lobectomy. Three-dimensional computed tomography (3D CT) angiography is useful for understanding the pulmonary arterial and venous branching, as well as planning the surgery to secure adequate surgical margins. Comprehension of the intersegmental and intrasegmental veins makes the parenchymal dissection easier. To visualize the segmental border, creation of an inflation-deflation line by using a method of inflating the affected segment has become the standard in small-sized lung cancer surgery. Various modifications to create the segmental demarcation line have been devised to accurately perform the segmentectomy procedure.