Estimating the risk of conversion from video-assisted thoracoscopic lung surgery to thoracotomy-a systematic review and meta-analysis

Development of a Risk Scoring Model to Predict Unexpected Conversion to Thoracotomy during Video-Assisted Thoracoscopic Surgery for Lung Cancer

Background

Unexpected conversion to thoracotomy during planned video-assisted thoracoscopic surgery (VATS) can lead to poor outcomes and comparatively high morbidity. This study was conducted to assess preoperative risk factors associated with unexpected thoracotomy conversion and to develop a risk scoring model for preoperative use, aimed at identifying patients with an elevated risk of conversion.

Methods

A retrospective analysis was conducted of 1,506 patients who underwent surgical resection for non-small cell lung cancer. To evaluate the risk factors, univariate analysis and logistic regression were performed. A risk scoring model was established to predict unexpected thoracotomy conversion during VATS of the lung, based on preoperative factors. To validate the model, an additional cohort of 878 patients was analyzed.

Results

Among the potentially significant clinical variables, male sex, previous ipsilateral lung surgery, preoperative detection of calcified lymph nodes, and clinical T stage were identified as independent risk factors for unplanned conversion to thoracotomy. A 6-point risk scoring model was developed to predict conversion based on the assessed risk, with patients categorized into 4 groups. The results indicated an area under the receiver operating characteristic curve of 0.747, with a sensitivity of 80.5%, specificity of 56.4%, positive predictive value of 1.8%, and negative predictive value of 91.0%. When applied to the validation cohort, the model exhibited good predictive accuracy.

Conclusion

We successfully developed and validated a risk scoring model for preoperative use that can predict the likelihood of unplanned conversion to thoracotomy during VATS of the lung.

N1-positive non-small cell lung cancer: surgeons' perspective before undertaking a major resection

Among various reasons for a rise in surgical referrals for locally advanced non-small cell lung cancer, few are improved clinical-pathological staging, better understanding of oncological driver mutation, and aggressive neoadjuvant treatment options. These cases with positive ipsilateral bronchopulmonary lymph nodes are intriguing subset where multiple treatment options have been explored to improve disease-free survival. Targeted neoadjuvant therapy followed by surgical resection is becoming a new norm and surgeons are referred these complex cases. This narrative review is highlighting the importance of proper preoperative staging, contemporary practices in surgical decision-making, and procedural aspect of hilar node dissection.

Spontaneous Ventilation Combined with Double-Lumen Tube Intubation during Thoracic Surgery: A New Anesthesiologic Method Based on 141 Cases over Three Years

BACKGROUND

Non-intubated thoracic surgery has not achieved widespread acceptance despite its potential to improve postoperative outcomes. To ensure airway safety, our institute has developed a technique combining spontaneous ventilation with double-lumen tube intubation (SVI). This study aimed to verify the feasibility and limitations of this SVI technique.

METHODS

For the SVI method, anesthesia induction involves fentanyl and propofol target-controlled infusion, with mivacurium administration. Bispectral index monitoring was used to ensure the optimal depth of anesthesia. Short-term muscle relaxation facilitated double-lumen tube intubation and early surgical steps. Chest opening preceded local infiltration, followed by a vagal nerve blockade to prevent the cough reflex and a paravertebral blockade for pain relief. Subsequently, the muscle relaxant was ceased. The patient underwent spontaneous breathing without coughing during surgical manipulation.

RESULTS

Between 10 March 2020 and 28 October 2022, 141 SVI surgeries were performed. Spontaneous respiration with positive end-expiratory pressure was sufficient in 65.96% (93/141) of cases, whereas 31.21% (44/141) required pressure support ventilation. Only 2.84% (4/141) of cases reversed to conventional anesthetic management, owing to technical or surgical difficulties. Results of the 141 cases: The mean maximal carbon dioxide pressure was 59.01 (34.4-92.9) mmHg, and the mean lowest oxygen saturation was 93.96% (81-100%). The mean one-lung, mechanical and spontaneous one-lung ventilation time was 74.88 (20-140), 17.55 (0-115) and 57.73 (0-130) min, respectively.

CONCLUSIONS

Spontaneous ventilation with double-lumen tube intubation is safe and feasible for thoracic surgery. The mechanical one-lung ventilation time was reduced by 76.5%, and the rate of anesthetic conversion to relaxation was low (2.8%).

The detailed classification of the interlobar artery and the artery crossing intersegmental planes in the right upper lobe

Background

With the prevalence of three-dimensional computed tomography bronchography and angiography (3D-CTBA) and the development of anatomical segmentectomy, several studies have analyzed the branching patterns of peripheral segmental arteries in the right upper lobe (RUL). Nevertheless, the detailed classification of the branching patterns of the interlobar artery and the artery crossing intersegmental planes remains unknown. Thus, we conducted a retrospective study to analyze the variations of the interlobar artery and the artery crossing intersegmental planes in the RUL using 3D-CTBA.

Materials and methods

A total of 600 patients with ground-glass opacity (GGO) who had undergone 3D-CTBA preoperatively at Hebei General Hospital between September 2020 and September 2022 were used for the retrospective study. We reviewed the anatomical variations of the RUL arteries in these patients using 3D-CTBA images.

Results

The branching patterns of the RUL artery were classified into the following four categories: trunk superior (Tr. sup), Tr. sup + interlobar artery, Tr. sup + trunk inferior (Tr. inf), and Tr. sup + Tr. inf + interlobar artery. The branching patterns of the interlobar artery were subclassified into four subtypes: posterior ascending artery (A. pos), anterior ascending artery (A. ant), A. pos + A. ant, and ascending artery (A. asc). The artery crossing intersegmental planes contains two types: type A, anterior subsegmental artery crossing intersegmental planes (AX¹b); type B, recurrent artery crossing intersegmental planes (AX. rec).

Conclusion

The variation types of blood vessels in the RUL are complex. This study explored the detailed classification of the interlobar artery and the artery crossing intersegmental planes. It can help thoracic surgeons understand the anatomy variations, accurately locate lesions before surgery, and effectively plan surgeries.

The Impact of Surgical Experience in VATS Lobectomy on Conversion and Patient Quality of Life: Results from a Comprehensive National Video-Assisted Thoracic Surgical Database

OBJECTIVES

Although unexpected conversion during Video-Assisted Thoracic Surgery (VATS) lobectomy is up to 23%, the effects on postoperative outcomes remain debatable. This retrospective study aimed: (i) to identify potential preoperative risk factors of VATS conversion to standard thoracotomy; (ii) to assess the impact of surgical experience in VATS lobectomy on conversion rate and patient health-related quality of life.

METHODS

We extracted detailed information on VATS lobectomy procedures performed consecutively (2014-2019). Predictors of conversion were assessed with univariable and multivariable logistic regressions. To assess the impact of VATS lobectomy experience, observations were divided according to surgeons' experiences with VATS lobectomy. The impact of VATS lobectomy experience on conversion and occurrence of postoperative complications was evaluated using logistic regressions. The impact of VATS lobectomy experience on EuroQoL-5D (EQ-5D) scores at discharge was assessed using Tobit regressions.

RESULTS

A total of 11,772 patients underwent planned VATS for non-small-cell lung cancer (NSCLC), with 1074 (9.1%) requiring conversion to thoracotomy. The independent predictors at multivariable analysis were: FEV1% (OR = 0.99; 95% CI: 0.98-0.99, p = 0.007), clinical nodal involvement (OR = 1.43; 95% CI: 1.08-1.90, p = 0.014). Experienced surgeons performed 4079 (34.7%) interventions. Experience in VATS lobectomy did not show a relevant impact on the risk of open surgery conversion (p = 0.13) and postoperative complications (p = 0.10), whereas it showed a significant positive impact (p = 0.012) on EQ-5D scores at discharge.

CONCLUSIONS

Clinical nodal involvement was confirmed as the most critical predictor of conversion. Greater experience in VATS lobectomy did not decrease conversion rate and postoperative complications but was positively associated with postoperative patient quality of life.

Impact of center volume on conversion to thoracotomy during minimally invasive pulmonary lobectomy

BACKGROUND

Conversion to open is a potentially serious intraoperative event associated with minimally invasive pulmonary lobectomy. However, the impact of institutional expertise on conversion to open has not been studied on a large scale. We used a nationally representative database to evaluate the association between hospital pulmonary lobectomy caseload and rates of conversion to open.

METHODS

All adults who underwent minimally invasive pulmonary lobectomy were identified from the 2017 to 2019 Nationwide Readmissions Database. Annual institutional caseloads of open and minimally invasive lobectomy were independently tabulated. Restricted cubic splines were used to parametrize the relationship between conversion to open and hospital volumes. Furthermore, multivariable regression was used to examine the association of conversion to open with in-hospital mortality, length of stay, and hospitalization costs.

RESULTS

Of an estimated 52,886 patients who met study criteria, 4.9% required conversion to open. Compared to others, conversion to open patients were slightly younger (66 vs 67 years) and more commonly male (52.2 vs 42.3%, P < .001). After adjustment, male sex (adjusted odds ratio 1.42), history of tobacco use (adjusted odds ratio 1.35), and prior radiation therapy (adjusted odds ratio 1.35, P < .001) were associated with increased odds of conversion to open. Increasing minimally invasive lobectomy volume was linked to lower risk-adjusted rates of conversion to open, whereas greater open lobectomy caseload was associated with higher rates. Despite no impact on mortality (adjusted odds ratio 1.11, P = .73), conversion to open was associated with a 1.2-day increment in length of stay and $5,600 in attributable costs.

CONCLUSION

The present study found institutional minimally invasive pulmonary lobectomy caseload to be associated with decreased rates of conversion to thoracotomy, emphasizing the relevance of minimally invasive training among surgeons and perioperative staff.

Application of Continuous Positive Airway Pressure During Video-Assisted Thoracoscopic Surgery

Purpose of Review

Video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracoscopic surgery (RATS) are used for anatomic resection of early stage cancer. These surgical techniques require the use of one-lung ventilation (OLV). During OLV, an obligatory intrapulmonary shunt may produce hypoxemia. One method to correct hypoxemia is with the use of continuous positive airway pressure (CPAP). This review focuses on 1) the lung physiology of OLV; 2) application of CPAP in VATS or RATS during supine and lateral position; and 3) the application of CPAP in COVID-19 patients during OLV.

Recent Findings

Studies have shown the beneficial effects of CPAP to improve oxygenation during OLV while the patient is in the lateral decubitus position. In contrast, studies have shown no benefit on improving oxygenation with CPAP in patients undergoing OLV in supine position.

Summary

The application of CPAP to the non-dependent lung is one of the options to treat hypoxemia during VATS or RATS.