No-waiting segmentectomy: an optimized approach for segmentectomy

Partial pressure of oxygen control versus modified inflation-deflation method in identifying intersegmental plane during anatomical sublobectomy: a prospective, randomized, controlled trial

Background

With increasing early-stage non-small cell lung cancer (NSCLC) diagnoses, sublobar resections including segmentectomy and wedge resection have become commonly used in clinical settings. The success of lung segment surgery hinges on the accurate identification of intersegmental planes (ISPs), which is typically achieved by the modified inflation-deflation method; however, this technique is associated with a prolonged duration for identifying ISP. The "partial pressure of oxygen control method" represents an optimization of the inflation-deflation technique, designed to facilitate rapid identification of ISP during surgical procedures. The present study was designed to assess the safety and effectiveness of the partial pressure of oxygen (PaO2) control method for ISP identification in thoracoscopic anatomical sublobectomy, in comparison to the modified inflation-deflation method.

Methods

A total of 60 patients scheduled for thoracoscopic anatomical sublobectomy were randomly allocated into two groups: the intervention group (using the PaO2 control method; n=30) and the control group (using the modified inflation-deflation method; n=30). The time to ISP appearance (TISP) was compared between these two groups. Arterial blood gas (ABG) levels were recorded at the following time points: prior to entry to operating room, during one-lung ventilation (OLV), upon completion of lung inflation, 3 minutes post-lung inflation, and 6 minutes post-lung inflation. Statistical analyses were conducted to evaluate the differences in operative time, intraoperative blood loss, incidence of postoperative complications, and average postoperative hospital stay.

Results

The TISP was significantly shorter in the intervention group than in the control group (307.0±108.3 vs. 496.7±154.0 seconds; P<0.001). Furthermore, the PaO2 in the intervention group was significantly lower compared to the control group at 3 minutes following 100% oxygen administration (156.6±76.5 vs. 114.1±47.5 mmHg; P=0.01).

Conclusions

The PaO2 control method facilitates more rapid acquisition of ISP compared to the modified inflation-deflation method, and it is deemed a safe and effective technique in thoracoscopic anatomical sublobectomy.

Trial Registration

ClinicalTrials.gov NCT06644066.

Delineation of intersegmental plane: application of blood flow blocking method in pulmonary segmentectomy

BACKGROUND

The Modified Inflation-Deflation Method (MIDM) is widely used in China in pulmonary segmentectomies. We optimized the procedure, which was named as Blood Flow Blocking Method (BFBM), also known as "No-Waiting Segmentectomy". This method has produced commendable clinical outcomes in segmentectomies. The aim of this research is to confirm whether the intersegmental planes formed by MIDM and BFBM techniques during segmentectomies have high degree of concordance.

METHODS

We utilized the Open Sequential Test design in our study. Using both MIDM and BFBM techniques, intersegmental planes were created in the same patient, one after the other. The degree of alignment between the planes formed by the two techniques was assessed by two experienced chief surgeons. Based on the results obtained in each case, a test line was plotted until it intersected the effective or ineffective line.

RESULTS

In every case studied, the intersegmental planes created by the MIDM and BFBM displayed high congruity. The test line crossed the effective line during the 12th case. When comparing the time taken to form the intersegmental plane using either MIDM or BFBM technique, no significant difference was observed. However, the application of the BFBM technique resulted in an average time savings of 13.8 min.

CONCLUSIONS

In segmentectomies, the intersegmental planes formed by MIDM and BFBM techniques exhibit high concordance. However, given that BFBM affords a time-saving advantage, we propose that BFBM could potentially replace MIDM in performing lung segmentectomies.

Natural Sequential Collapse Method: A Common Technique to Identify the Intersegmental Plane

The natural sequential collapse method (NSCM) can be employed during surgery to reduce the duration of segmentectomy. This method avoids inflating the lung by rapidly blocking vessels within the tumor basin. It is important to note that the color of the lungs should be used to determine the surgical procedure. The NSCM is efficient and straightforward in revealing the intersegmental plane.

Enhancing surgical precision in early-stage non-small cell lung cancer: A novel approach through temporary pulmonary vascular occlusion

BACKGROUND

To evaluate a novel intraoperative localization technique utilizing temporary pulmonary arteriovenous occlusion for enhancing the precision of sublobar resections in early-stage NSCLC.

METHODS

Conducted from January to November 2023, this study involved 140 patients. During the surgery, key pulmonary vessels were identified using preoperative three-dimensional (3D) imaging and temporarily occluded with noninvasive clamps to isolate the target lung segment. Following vascular occlusion, indocyanine green (ICG) was administered intravenously to precisely delineate the resection margins. After visually confirming the marked areas, the clamps were released, and a targeted partial resection was performed on the delineated segment. Surgical data, including operation times, surgical margins, and hospitalization costs, were collected and compared with those from a historical control group of 110 patients who underwent traditional pulmonary wedge resections.

RESULTS

In the study group, the median surgical margin achieved was 16 mm, which was statistically significant compared to 15 mm in the control group (p < 0.05). Operation times were reduced to an average of 58.43 ± 12.962 min, showing a decrease from the control group's average of 69.50 ± 17.544 min (p < 0.05). Hospitalization costs were also lower, averaging $4772.98 ± 624.339 for the study group versus $5161.34 ± 856.336 for the control group (p < 0.05). Patient safety was maintained with no increase in surgical complications.

CONCLUSION

The technique, leveraging temporary pulmonary arteriovenous occlusion, offered a significant advancement in the surgical treatment of peripheral early-stage NSCLC. It reduced operation time and lowered overall surgical costs. This method represented a promising alternative to traditional surgical approaches.

Identifying the intersegmental plane for segmentectomy using the open insufflation technique

Accurate identification of the intersegmental plane is the key to successful segmentectomy. This case series included 41 patients who underwent uniportal thoracoscopic segmentectomy using the open insufflation method to identify the intersegmental plane for pulmonary nodules. The median age of the patients was 58 (range 35-73) years, and 63.4% were female. Malignant pulmonary nodules accounted for 80.5% of cases and were staged as 0-IA2. Seventeen patients underwent a single subsegmentectomy or single segmentectomy, and 24 underwent combined subsegmentectomy or subsegmentectomy combined with segmentectomy. There was no conversion to multiportal video-assisted thoracoscopic surgery, open surgery, or lobectomy. The median operative time was 84 (range 45-194) min, and the median blood loss was 50 (range 10-150) ml. The median chest tube duration and postoperative hospital stay were 2 (range 1 - 7) days. One (2.4%) developed an air leak for >5 days. No deaths occurred within 30 days after surgery.

Application of three-dimensional computed tomography bronchography and angiography in thoracoscopic anatomical segmentectomy of the right upper lobe: A cohort study

Objective

Three-dimensional computed tomography bronchography and angiography (3D-CTBA) can provide detailed imaging information for pulmonary segmentectomy. This study aimed to investigate the safety and effectiveness of 3D-CTBA guidance of anatomical segmentectomy of the right upper lobe (RUL).

Methods

This was a retrospective analysis of anatomical segmentectomy of the RUL at the Thoracic Surgery Department of the Fourth Hospital of Hebei Medical University from December 9, 2013, to June 2, 2021. Preoperatively, all patients underwent contrast-enhanced CT of the chest (to determine the size of the pulmonary nodule) and a lung function test. 3D-CTBA has been performed since 2018; patients with vs. without 3D-CTBA were compared. Segmentectomy was performed according to nodule location.

Results

Of 139 patients (46 males and 93 females, aged 21–81 years), 93 (66.9%) completed single segmentectomy, 3 (2.2%) completed single subsegmentectomy, 29 had combined subsegmentectomy, 7 had segmentectomy combined with subsegmentectomy, and 6 had combined resection of two segments. Eighty-five (61.2%) patients underwent 3D-CTBA. 3D-CTBA cases had decreased intraoperative blood loss (67.4 ± 17.6 vs. 73.1 ± 11.0, P = 0.021) and shorter operation time (143.0 ± 10.8 vs. 133.4 ± 20.9, P = 0.001). 3D-CTBA (Beta = −7.594, 95% CI: −12.877 to −2.311, P = 0.005) and surgical procedure (Beta = 9.352, 95% CI: 3.551–15.153, P = 0.002) were independently associated with intraoperative blood loss. 3D-CTBA (Beta = −13.027, 95% CI: −18.632 to 17.422, P < 0.001) and surgical procedure (Beta = 7.072, 95% CI: 0.864–13.280, P = 0.026) were also independent factors affecting the operation time.

Conclusion

Preoperative use of 3D-CTBA to evaluate the pulmonary vessels and bronchial branch patterns of the RUL decreased blood loss and procedure time and so would be expected to improve the safety and effectiveness of thoracoscopic segmentectomy.

Functional Preserving Sublobectomy: A Novel Method for Sublobectomy

We introduce a new method for sublobectomy. It utilizes the easiness and rapidity of wedge resection, and the accuracy and functional preserving of anatomical segmentectomy. It can preserve lung function with less sacrifice of lung parenchyma.