Modified bronchial anastomosis in video-assisted thoracoscopic sleeve lobectomy: a report of 32 cases

Single-port video-assisted thoracoscopic sleeve lobectomy after neoadjuvant immunochemotherapy: a case report

Background

The morbidity and mortality of lung cancer have always ranked first among malignant tumors (MTs). Previous studies have shown that neoadjuvant chemotherapy can improve the 5-year survival rate of patients with non-small cell lung cancer (NSCLC), but the benefit is limited. Studies have proven that neoadjuvant immunotherapy combined with chemotherapy has unique advantages in prolonging patient survival, reducing distant recurrence, and inducing antitumor immunity. However, its impact remains to be more comprehensively investigated.

Case Description

A 59-year-old male who was admitted to the hospital with a primary complaint of repeated cough and expectoration for 6 months. Preoperative assessment showed right upper lung squamous cell carcinoma with multiple hilar and mediastinal lymph node metastasis, and the clinical stage was cT2aN2M0 stage (IIIA). After three cycles of pembrolizumab + carboplatin + paclitaxel therapy were administered, the reexamination of the tumor was evaluated as partial response (PR), and a sleeve lobectomy of the right upper lung was performed under single-port thoracoscopic surgery. The operation proceeded smoothly without conversion to thoracotomy, and R0 resection was successfully achieved. Postoperative pathological stage was ypT1bN0M0 stage IA, and postoperative pathological remission was evaluated as major pathological response (MPR). After the operation, three cycles of immunotherapy combined with chemotherapy were completed, which was followed by maintenance therapy with pembrolizumab monotherapy for 1 year, and no signs of tumor recurrence and metastasis have been found in follow-up thus far.

Conclusions

Through this case, we believe that for locally advanced NSCLC sleeve lobectomy after neoadjuvant therapy may be a safe and feasible treatment option, can avoid pneumonectomy, protect the lung function of patients, and still ensure the R0 resection rate. Moreover, it may does not significantly increase the difficulty of surgical operation or reduce safety. However, further research is needed to confirm our conclusion. And then, neoadjuvant therapy in the perioperative period may induce a series of side effects or adverse reactions, and thus greater attention should be paid to its timely management.

Video-assisted thoracoscopic versus open sleeve lobectomy for non-small cell lung cancer: A systematic review and meta-analysis from six comparative studies

BACKGROUND

Lung sleeve resection is indicated for centrally located lung tumors, especially for patients who cannot tolerate pneumonectomy. With video-assisted thoracoscopic surgery (VATS) being increasingly implemented for a wide variety of thoracic pathologies, this study aims to compare the intraoperative, postoperative, and long-term outcomes of VATS and open bronchial sleeve lobectomy for non-small cell lung cancer (NSCLC).

METHODS

The MEDLINE (via PubMed), Cochrane Library, and Scopus databases were searched. Original clinical studies, comparing VATS and open sleeve lobectomy for NSCLC were included. Evidence was synthesized as odds ratios for categorical and weighted mean difference (WMD) for continuous variables.

RESULTS

Our analysis included six studies with non-overlapping populations reporting on 655 patients undergoing bronchial sleeve lobectomy for NSCLC (229 VATS and 426 open). VATS sleeve lobectomy was associated with significantly longer operative time ((WMD): 45.85 min, 95% confidence interval (CI): 12.06 to 79.65, p  =  0.01) but less intraoperative blood loss ((WMD): -34.57 mL, 95%CI: -58.35 to -10.78, p < 0.001). No significant difference was found between VATS and open bronchial sleeve lobectomy in margin-negative resection rate, number of lymph nodes resected, postoperative outcomes (drainage duration, length of hospital stay, 30-day mortality), postoperative complications (pneumonia, bronchopleural fistula/empyema, prolonged air leakage, chylothorax, pulmonary embolism, and arrhythmia), and long-term outcomes (overall survival, recurrence-free survival).

CONCLUSIONS

The limitation of our study arises mainly due to the heterogeneity of the included studies. Nevertheless, VATS bronchial sleeve lung resection constitutes a feasible and safe alternative to the open sleeve lung resection surgery for the management of centrally located lung tumors.

Video-assisted thoracic surgery sleeve resection and bronchoplasty using 3D imaging system: its safety and efficacy

Background

Video-assisted thoracic surgery sleeve resection with bronchial anastomosis or bronchoplasty is a technically demanding procedure. Three-dimensional endoscopic surgery has been reported to be helpful in decreasing operation time and improving spatial perception with less surgical errors, but there have been rare reports about relatively difficult thoracoscopic procedures utilizing 3D thoracoscope. We performed this study to evaluate early clinical outcomes of thoracoscopic sleeve resection and bronchoplasty utilizing 3D thoracoscope.

Methods

Data from a total of 36 patients who underwent thoracoscopic sleeve lobectomy or bronchoplasty at our institution from December 2015 to October 2017 were retrospectively reviewed. Three-port approach with one utility incision was used with a 10 mm, 30° three-dimensional thoracoscope. Twenty-three patients (81%) were male, and mean age was 65.9 ± 9.4 years. Fourteen patients (38.9%) underwent sleeve resection with bronchial anastomosis, 22 (61.1%) underwent wedge or simple bronchoplasty, and one patient received concomitant PA procedure. Bronchial anastomosis sites were not covered with viable tissue flaps.

Results

There was no (0%) suture needle injury from spatial misperception during bronchoplasty or sleeve anastomosis. There was no (0%) operative mortality. The pathologic report revealed squamous cell carcinoma (63.9%), adenocarcinoma (19.4%), carcinoid (6.9%), adenosquamous carcinoma (3.4%), and sarcomatoid carcinoma (2.8%). One (2.8%) late mortality was due to systemic recurrence of sarcomatoid carcinoma. There was no (0.0%) anastomotic failure. The mean number of dissected lymph nodes were 27.4 ± 13.2, and mean operation time was 216.8 ± 60.0 min. Median postoperative 24-h drain amount was 315 mL. Median chest tube days and hospital days were 4 and 6, respectively. Two patients (5.6%) had complications greater than Clavien-Dindo grade II—one case of ARDS, and the other case of a delayed bronchopleural fistula.

Conclusions

Thoracoscopic sleeve resection and bronchoplasty utilizing HD 3D thoracoscope is a safe and effective procedure with excellent early clinical outcomes. Further investigation for long-term outcomes will be needed.

Endobronchial Carcinoids: Surgical Outcome in 100 Consecutive Patients and Factors Affecting Lung Preservation

Bronchial carcinoids are slow-growing tumours of the neuroendocrine family. Most of them have a benign course with excellent outcome after complete resection. Due to their location in the primary bronchi, adequate resection with lung preservation requires considerable technical expertise. In this paper we present our surgical experience with endobronchial carcinoids and analyse the factors that predict possibility of lung preservation surgery. Retrospective analysis of a prospectively maintained database of patients operated for endobronchial carcinoids for the period March 2012 to September 2019 was carried out. Demographic factors and peri-operative variables were recorded and analysed. Factors that influence surgical outcome and possibility of lung preservation surgery were analysed. A total of 137 patients underwent surgery for resection of carcinoid tumours, out of which 100 had endobronchial carcinoids whereas 37 had peripheral carcinoids. The surgical procedure in 100 patients with endobronchial carcinoids included 14 left main bronchus sleeve resections, 13 pneumonectomies (7 right sided and 6 left sided), 10 right lower and middle bi-lobectomies, 10 lobectomies (4 left upper, 2 left lower and 4 right upper), and 53 sleeve lobectomies (18 left upper lobe sleeves, 8 left lower lobe sleeves, 20 right upper lobe sleeves, 5 right middle lobe sleeves and 2 right lower lobe sleeve lobectomies). There was no operative mortality. Median tumour size was 3.9 cm (range 5-130 mm). On univariate analysis, longer duration of symptoms was associated with poor surgical outcomes. On multivariate analysis, tumour in the main bronchus, duration of disease < 3 months (p = 0.006), left-sided disease (p = 0.03), and presence of healthy distal lung parenchyma (p < 0.001) were associated with successful lung preservation. Majority of endobronchial carcinoid tumours can be managed with lung-sparing procedures with minimal morbidity and mortality and excellent immediate and short-term outcomes. Early referral and experience of team performing these complex procedures are the key to success.

Perioperative Outcomes and 5-year Survival After Open versus Thoracoscopic Sleeve Resection for Lung Cancer

The objective of this study was to evaluate the impact of a video-assisted thoracoscopic (VATS) approach on outcomes in patients who underwent sleeve lobectomy for non-small-cell lung cancer (NSCLC). Outcomes of patients with cT1-T3, N0-N2, M0 NSCLC who underwent sleeve lobectomy in the National Cancer Data Base (NCDB) from 2010-2015 were assessed using Kaplan-Meier, propensity score-matching, and Cox proportional hazards analyses. An "intent-to-treat" analysis was performed. In the NCDB, 210 sleeve lobectomy patients met inclusion criteria (VATS 44 [21%], thoracotomy 166 [79%]). Nine (20%) of the VATS cases were converted to open. Compared to an open approach, VATS was associated with no significant differences in lymph nodes examined (median 9.5 vs 9.0; p = 0.72), length of stay (median 6 days vs 6 days; p = 0.36), 30-day mortality (4.5% vs 1.8%; p = 0.28), and 90-day mortality (6.8% vs 4.8%; p = 0.70). There were no significant differences in 5-year survival between the VATS and open groups in both the entire cohort (VATS [85%] vs open [79%]; log-rank p = 0.91) and in a propensity score-matched analysis of 86 patients (log-rank p = 0.75). Furthermore, a VATS approach was also not associated with worse survival in multivariable analysis (HR = 0.64; 95% CI [0.23-1.78]; p = 0.39). In this national analysis, a VATS approach for sleeve lobectomy for NSCLC was not associated with worse short-term or long-term outcomes when compared to an open approach.

The Initial Experience on Thoracoscopic Sleeve Lobectomy: Continuous Suturing Technique of the Bronchial Anastomosis in 12 Cases

BACKGROUND

Sleeve resection is a widely performed type of operation in the surgical treatment of non-small cell lung cancer. Video-assisted thoracoscopic surgery (VATS) is now used even in central tumor surgeries of the lung with the increasing technology and experience. Sleeve resection cases performed through VATS in our clinic in recent years were presented with demographic, surgical, pathologic, and survey characteristics.

MATERIALS AND METHODS

Twelve patients who underwent sleeve resection with VATS in our clinic between November 2015 and August 2019 were included in the study. Operative, pathologic, and postoperative characteristics of the patients were examined.

RESULTS

A total of 12 patients, 3 female and 9 male individuals, were included in the study. The mean age of the patients was 61.7±12.9 years. According to the localization of the tumors, left upper lobectomy was performed in 4 patients and 8 patients underwent right upper lobectomy. During the sleeve anastomosis of the patients, 3/0 prolene sutures were used in 5 patients (36%) and 4/0 prolene sutures in 4 patients (36%), whereas 3/0 polydioxanone suture (PDS) was used in 3 patients (28%). The mean operation time was 288.2±77.1 (205 to 460) minutes and the mean anastomosis time was 70±18.5 (55 to 110) minutes. In the postoperative period, 1 patient who had acute myocardial infarction died on the fourth postoperative day. The mean postoperative drainage duration of the patients was 5.5±1.9 (3 to 10) days and the mean length of hospital stay was 6.4±1.9 (4 to 11) days. When the pathologic features were examined, the mean tumor diameter was found to be 2.5±1.2 (1 to 5.5) cm. The mean follow-up period was calculated as 26.1±15.6 months (2 to 47). Other than 1 patient who died, the follow-up of 11 patients still proceeds.

CONCLUSIONS

VATS approach of sleeve resections, which is performed cautiously even by thoracotomy, is becoming more common. These operations, which could be performed in experienced centers, offer a postoperative period of less morbidity to the patients with the advantage of reduced postoperative pain, drainage time, and hospital stay.

PREOPERATIVE ENDOBRONCHIAL SANITATION AS PREPARATION FOR THORACIC INTERVENTIONS

The aim – to study the effectiveness of endoscopic photodynamic therapy as a preoperative preparation of the tracheobronchial tree in patients with lung cancer. Materials and methods. The study included 181 patients with II-III stage of lung’s cancer. Diagnose of lung’s cancer was confirmed with a morphologically and concomitant endobronchitis. During the preoperative preparation, we used a technique developed by us introducing into the tracheobronchial tree an aqueous solution of brilliant green at concentration of 0.04 %, followed by irradiation of this solution with laser radiation with the wavelength of 0.63 μm (AFL-2 helium-neon laser) in an independent form and in combination with traditional anti-inflammatory therapy. Endoscopic endobronchial sanitation therapy was carried out by low-intensity radiation of the red part of the spectrum (λ=0.63–0.66 μm) in a pulsed mode, with a power of 12 mW. Results. After 3–5 days of the start preoperative preparation and 1–2 sessions of endoscopic bronchosanation, the general state of patients was improved, the amount of sputum decreased and was changing from mucopurulent to mucous. To completely stop the clinical phenomena of endobronchitis, it was necessary to conduct 5-6 sessions of endoscopic photodynamic therapy according to our methodology, with the introduction of our method. In patients without pronounced clinical symptoms of concomitant chronic bronchitis, it was enough to complete only 3 sessions of bronchosanation. Conclusion. Endoscopic photodynamic bronchosanation in the preoperative period in patients for correcting accompanying endobronchitis can significantly reduce or completely stop the clinical manifestations of endobronchitis in the shortest time and leads to a significant decrease in the number of endobronchial complications in surgical and combined treatment of lung cancer.

Right upper sleeve lobectomy by video-assisted thoracic surgery

With accumulation of experiences in video-assisted thoracic surgery (VATS) lobectomy, complete VATS sleeve lobectomy (SL) has been carried out in more and more medical centers. We here presented a procedure of sleeve right upper lobectomy by complete VATS for a 62-year-old male patient with central squamous cell carcinoma. Traditional three incisions VATS technique was applied and the utility incision located on anterior axillary line of the 4th intercostal space. Continuous sutures were chosen for bronchial anastomosis using 3-0 prolene sutures. The chest drainage was removed on the postoperative fourth day.

Application of the "continuous suture dividing and equal suture tightening" method in video-assisted thoracoscopic surgery sleeve lobectomy

Background

The primary focus of video-assisted thoracoscopic surgery (VATS) sleeve lobectomy is bronchial anastomosis. Both interrupted suture and continuous suture cannot overcome entanglement of the suture threads. The present study used the "continuous suture dividing and equal suture tightening" method in VATS sleeve lobectomy for bronchial anastomosis and discussed the feasibility of this approach.

Methods

A total of 17 patients underwent VATS sleeve lobectomy with bronchial anastomosis using the "continuous suture dividing and equal suture tightening" method. Four incisions were utilized in the operation as follows: (I) the pulmonary arteries and veins were cut-off using an endoscopic linear stapler. Systematic hilar and mediastinal lymph node dissection was performed; (II) the surgeon used a surgical knife for incision into the thoracic cavity and to cut the lung lobe and main bronchi. Intraoperative pathological analysis revealed negative bronchial margins; (III) the "continuous suture dividing and equal suture tightening" method was performed for anastomosis; (IV) the integrity of the anastomosis was assessed by intraoperative bronchoscopy. Computed tomography (CT), three-dimensional (3D) reconstruction and bronchoscopy assessed the anastomosis 1-week postoperatively. A follow-up was conducted using a 3-month bronchoscopy, and CT scans monitored the recurrence and stenosis of the anastomosis.

Results

The method was successfully completed for VATS sleeve lobectomy with bronchial anastomosis in 17 cases. Although various histological profiles were observed, the 1-week postoperative CT and bronchoscopy showed adequate healing of the anastomotic stoma as well as the absence of postoperative mortality and bronchial pleural fistula. All patients were alive and followed up for 31-49 months postoperatively; local recurrence and anastomotic stenosis were not detected.

Conclusions

The continuous suture dividing and equal suture tightening method is convenient, feasible, and safe for bronchial anastomosis in VATS sleeve lobectomy. It can effectively avoid the entanglement of the suture threads, thereby enabling the widespread adoption of VATS sleeve lobectomy.

Robotic sleeve resection for pulmonary disease

Background

Few studies have described robotic sleeve resection with pulmonary resection. Here, we report the successful implementation of a completely portal robotic sleeve resection with or without pulmonary resection using a modified suture mode.

Methods

In total, 339 patients underwent curative robotic pulmonary surgery at Ruijin Hospital between May 2015 and September 2017. Three of these patients underwent robotic sleeve resection (right upper lobe, one; left upper lobe, one; and lingular segmental bronchus, one). Five port incisions were utilized, and a simple continuous running suture combined with two interrupted sutures of the membranous and cartilaginous junction portion was preferred for the anastomosis.

Results

The postoperative course was uneventful for two patients with squamous cell carcinoma. The lingular segmental bronchus patient without pulmonary resection (a salivary gland tumor) underwent short-term atelectasis. The median operation time was 155 (range 132–230) minutes. The median anastomosis time was 25 (range 23–32) minutes. The median length of postoperative hospital stay was 7 (range 6–10) days. There was no mortality or conversion to thoracotomy for any of the patients. All patients were followed for 3–6 months, and there is no tumour recurrence.

Conclusions

Our limited experience suggested that robotic sleeve resection for pulmonary disease with or without pulmonary resection may be safe and effective. The anastomosis time can be shortened with more robotic surgery experiences and the modified suture mode.

Video-assisted thoracoscopic surgery bronchial sleeve lobectomy

A sleeve lobectomy (SL) is considered a valid option instead of a pneumonectomy in patients affected by central non-small cell lung cancer (NSCLC). In the last few years, the improvement of video-assisted thoracoscopic surgery (VATS) has allowed experienced surgeons to carry out this challenging operation by a minimally invasive approach. A full pre-operative assessment enclosing a flexible fiber-optic bronchoscopy evaluation and a multidisciplinary team discussion of the clinical case must be accomplished. There is no strictly an indication for the number of thoracoscopic ports: VATS SL is reported from 1 to 3-4 incisions. A significant variability in the technique of the anastomosis is documented and depends on the personal use and ability of the surgeon. However the operational principles are the same of an open SL: free bronchial margins at the frozen section examination, tension-free anastomosis, avoid luminal disparity and en-bloc resection. Due to the extent of the tumour, VATS SL can be associated to other complex resections like arterioplasty, or double sleeve (bronchial and artery) mainly on the left side. A patient underwent a VATS SL must be enrolled in an enhanced recovery pathway (ERP): physiological rehabilitation is a key point to achieve good outcomes and avoid complications.