Concepts and techniques: how to determine and identify the appropriate target segment in anatomical pulmonary segmentectomy?

Predictors of prolonged hospital stay after segmentectomy

OBJECTIVE

Segmentectomy is becoming the standard of care for small, peripheral non-small cell lung cancer. To improve perioperative management in this population, this study aims to identify factors influencing hospital length of stay after segmentectomy.

METHODS

Patients who underwent segmentectomy for any indication between January 2018 and May 2023 were identified using a prospectively maintained institutional database. Multivariable logistic regression models were used to estimate associations between clinical features and prolonged (≥3 days) hospital stay. A nomogram was designed to understand better and possibly calculate the individual risk of prolonged hospital stays.

RESULTS

In total, 533 cases were included; 337 (63%) were female. Median age was 66 years (interquartile range [IQR], 63-75). The median size of resected lesions was 1.6 cm (IQR, 1.3-2.1 cm). Median hospital stay was 3 days (IQR, 2-4 days). Major adverse events occurred in 31 (5.8%) cases. The 30-day readmission rate was 5.8% (n = 31). There was no 30-day mortality; 90-day mortality was <1%. Patients older than 75 years (odds ratio [OR], 2.01, 95% confidence interval [CI], 1.15-3.57, P = .02), those with forced expiratory volume in 1 second <88% predicted (OR, 1.99; 95% CI, 1.38-2.89, P < .001), or positive smoking history (OR, 1.72; 95% CI, 1.15-2.60, P = .01) were more likely to have prolonged hospital stays after segmentectomy. A nomogram accounting for age, sex, forced expiratory volume in 1 second, body mass index, smoking history, and comorbidities was created to predict the probability of prolonged hospital stay with an area under the receiver operating characteristic curve of 0.66.

CONCLUSIONS

Older patients, those with reduced pulmonary function, and current and past smokers have elevated risk for prolonged hospital stays after segmentectomy. Validation of our nomogram could improve perioperative risk stratification in patients who undergo segmentectomy.

BCNet: Bronchus Classification via Structure Guided Representation Learning

CT-based bronchial tree analysis is a key step for the diagnosis of lung and airway diseases. However, the topology of bronchial trees varies across individuals, which presents a challenge to the automatic bronchus classification. To solve this issue, we propose the Bronchus Classification Network (BCNet), a structure-guided framework that exploits the segment-level topological information using point clouds to learn the voxel-level features. BCNet has two branches, a Point-Voxel Graph Neural Network (PV-GNN) for segment classification, and a Convolutional Neural Network (CNN) for voxel labeling. The two branches are simultaneously trained to learn topology-aware features for their shared backbone while it is feasible to run only the CNN branch for the inference. Therefore, BCNet maintains the same inference efficiency as its CNN baseline. Experimental results show that BCNet significantly exceeds the state-of-the-art methods by over 8.0% both on F1-score for classifying bronchus. Furthermore, we contribute BronAtlas: an open-access benchmark of bronchus imaging analysis with high-quality voxel-wise annotations of both anatomical and abnormal bronchial segments. The benchmark is available at https://osf.io/pskr9/?viewonly=94fa3d87274b4095ac9a4b88cc9a1341.

Novel locally nebulized indocyanine green for simultaneous identification of tumor margin and intersegmental plane

BACKGROUND

Segmentectomy, recommended for early-stage lung cancer or compromised lung function, demands precise tumor detection and intersegmental plane identification. While indocyanine green (ICG) commonly aids in these aspects using near-infrared imaging, its separate administrations through different routes and times can lead to complications and patient anxiety. This study aims to develop a lung-specific delivery method by nebulizing low-dose ICG to targeted lung segments, allowing simultaneous detection of lung tumors and intersegmental planes across diverse animal models.

METHODS

To optimizing the dose of ICG for lung tumor and interlobar fissure detection, different doses of ICG (0.25, 0.1, and 0.05 mg/kg) were nebulized to rabbit lung tumor models. The distribution of locally nebulized ICG in targeted segments was studied to evaluate the feasibility of detecting lung tumor and intersegmental planes in canine lung pseudotumor models.

RESULTS

Near-infrared fluorescence imaging demonstrated clear visualization of lung tumor margin and interlobar fissure using local nebulization of 0.1 mg/kg ICG for only 4 min during surgery in the rabbit models. In the canine model, the local nebulization of 0.05 mg/kg of ICG into the target segment enabled clear visualization of pseudotumor and intersegmental planes for 30 min.

CONCLUSIONS

This innovative approach achieves a reduction in ICG dose and prolonged the visualization time of the intersegmental plane and effectively eliminates the need for the hurried marking of tumors and intersegmental planes. The authors anticipate that lung-specific delivery of ICG will prove valuable for image-guided limited resection of lung tumors in clinical practice.

Precise and safe pulmonary segmentectomy enabled by visualizing cancer margins with dual-channel near-infrared fluorescence

BACKGROUND

Segmentectomy is a type of limited resection surgery indicated for patients with very early-stage lung cancer or compromised function because it can improve quality of life with minimal removal of normal tissue. For segmentectomy, an accurate detection of the tumor with simultaneous identification of the lung intersegment plane is critical. However, it is not easy to identify both during surgery. Here, the authors report dual-channel image-guided lung cancer surgery using renally clearable and physiochemically stable targeted fluorophores to visualize the tumor and intersegmental plane distinctly with different colors; cRGD-ZW800 (800 nm channel) targets tumors specifically, and ZW700 (700 nm channel) simultaneously helps discriminate segmental planes.

METHODS

The near-infrared (NIR) fluorophores with 700 nm and with 800 nm channels were developed and evaluated the feasibility of dual-channel fluorescence imaging of lung tumors and intersegmental lines simultaneously in mouse, rabbit, and canine animal models. Expression levels of integrin αvβ3, which is targeted by cRGD-ZW800-PEG, were retrospectively studied in the lung tissue of 61 patients who underwent lung cancer surgery.

RESULTS

cRGD-ZW800-PEG has clinically useful optical properties and outperforms the FDA-approved NIR fluorophore indocyanine green and serum unstable cRGD-ZW800-1 in multiple animal models of lung cancer. Combined with the blood-pooling agent ZW700-1C, cRGD-ZW800-PEG permits dual-channel NIR fluorescence imaging for intraoperative identification of lung segment lines and tumor margins with different colors simultaneously and accurately.

CONCLUSION

This dual-channel image-guided surgery enables complete tumor resection with adequate negative margins that can reduce the recurrence rate and increase the survival rate of lung cancer patients.

The use of intravenous indocyanine green in minimally invasive segmental lung resections: a systematic review

Background

To identify intersegmental planes (ISPs) in video/robot-assisted thoracoscopic segmentectomies, indocyanine green (ICG) is commonly used. The aim of this systematic review is to evaluate the efficacy of intravenous ICG in the identification of ISP.

Methods

A systematic search was performed. Studies evaluating patients who underwent a video/robot-assisted thoracoscopic segmentectomy using intravenous ICG were included. The primary outcome measure was the frequency and percentage of patients in whom the ISP was adequately visualized. Secondary outcomes encompassed the ICG dose, time to visualization, time to maximum ICG visualization, time to disappearance of ICG effect and adverse reactions to ICG.

Results

Eighteen studies were included for systematic review, enrolling a total of 1,090 patients. Irrespective of the injected dose, intravenous ICG identified the ISP in 94% of the cases (range, 30-100%). Overall, there was a considerable amount of heterogeneity regarding the injected dose of ICG (range, 5-25 mg or 0.05-0.5 mg/kg). The mean time before first effect of ICG was visible ranged from 10 to 40 seconds. The mean total time of ICG visibility ranged from 90 to 140 seconds after a bolus injection and was 170 seconds after continuous infusion. No adverse reactions were reported.

Conclusions

After administration of intravenous ICG, visualization of the ISP is successful in up to 94% of cases, even after administration of a low dose (0.05 mg/kg) of ICG. The use of intravenous ICG is safe with no reported adverse effects in the immediate peri-operative period.

[Indocyanine green fluorescence in thoracoscopic segmentectomy: indications and benefits]

OBJECTIVE

To determine the role of ICG fluorescence in segmentectomies.

MATERIAL AND METHODS

One surgical team performed 178 thoracoscopic anatomical segmentectomies in two hospitals between 2017 and 2023. Of these, 93 (52.2%) patients underwent ICG fluorescence perfusion tests. This study was retrospective and consecutive. Intraoperative and early postoperative results were analyzed. Patients were divided into 3 equal periods. Ventilation and perfusion methods were used to navigate the intersegmental planes in the first period. In the second one, only ventilation methods were used due to the absence of ICG. In the third period, the choice of navigation method was determined by «surgical complexity of segment».

RESULTS

In 74% of patients, surgeries were performed for primary or metastatic lung tumors. The scheduled procedure was performed in all patients. However, 2 ones required lobectomy for total resection. Uneventful postoperative period was observed in 69.7% of patients. Other ones had complications grade I-IIIA. No reoperations or mortality were recorded.

CONCLUSION

ICG perfusion is not inferior to ventilation methods in identification of intersegmental planes. This method is also more convenient for thoracoscopy. ICG fluorescence thoracoscopy is the only method in patients with COPD scheduled for thoracoscopic segmentectomy with two or more intersegmental planes.

Asia expert consensus on segmentectomy in non-small cell lung cancer: A modified Delphi study

Objective

Segmentectomy as a parenchymal-sparing surgical approach has been recommended over lobectomy in select patients with early-stage non-small cell lung cancer. This study aimed to address 3 aspects of segmentectomy ("patient indication"; "segmentectomy approaches"; "lymph node assessment") where there is limited clinical guidance.

Methods

A modified Delphi approach comprising 3 anonymous surveys and 2 expert discussions was used to establish consensus on the aforementioned topics among 15 thoracic surgeons (2 Steering Committee; 2 Task Force; 11 Voting Experts) from Asia who have extensive segmentectomy experience. Statements were developed by the Steering Committee and Task Force based on their clinical experience, published literature (rounds 1-3), and comments received from Voting Experts through surveys (rounds 2-3). Voting Experts indicated their agreement with each statement on a 5-point Likert scale. Consensus was defined as ≥70% of Voting Experts selecting either "Agree"/"Strongly Agree" or "Disagree"/"Strongly Disagree."

Results

Consensus from the 11 Voting Experts was reached on 36 statements (11 "patient indication" statements; 19 "segmentation approaches" statements; 6 "lymph node assessment" statements). In rounds 1, 2, and 3, consensus was reached on 48%, 81%, and 100% of drafted statements, respectively.

Conclusions

A recent phase 3 trial reported significantly improved 5-year overall survival rates for segmentectomy compared with lobectomy, proposing thoracic surgeons to consider segmentectomy as a surgical option in suitable patients. This consensus serves as a guidance to thoracic surgeons considering segmentectomy in patients with early non-small cell lung cancer, outlining key principles that surgeons should consider in surgical decision-making.

Left Upper Lobe Multi-Segmentectomy Vs Lobectomy for Early-Stage Lung Cancer: A Meta-Analysis

INTRODUCTION

The left upper lobe (LUL) has unique hilar anatomy, and LUL multi-segmentectomy (apical trisegmentectomy and lingulectomy) may result in different outcomes than both single anatomical segmentectomy and left upper lobectomy in the management of early-stage primary lung cancer; however no meta-analyses have been performed. The aim of this meta-analysis is to determine if LUL multi-segmentectomy is non-inferior to left upper lobectomy for long-term survival outcomes, or superior for in-hospital outcomes.

METHODS

Electronic databases searches were performed on PubMed, Embase, and the Cochrane Library to identify studies comparing outcomes in LUL multi-segmentectomy vs left upper lobectomy in early-stage lung cancer (clinical stage T2 N0 or less). Long-term postoperative overall and disease-free survival were assessed via reconstruction of Kaplan-Meier survival curves. In-hospital complications and length of stay, as well as long term recurrence were analysed via random effects models.

RESULTS

Five relevant studies were identified, including 1,196 patients. Overall survival did not differ at 5 years (multi-segmentectomy 92.6% vs lobectomy 89.3%, P=0.188), but patients undergoing LUL multi-segmentectomy had better disease-free survival at 5 years (93.1% vs 88.4%, P=0.041). Patients undergoing LUL multi-segmentectomy had a shorter mean length of hospital stay (mean difference -0.26 days, 95% CI; -0.39 to 0.14, P<0.01, I²=0.00%). There was no difference in combined in-hospital complications (P=0.14), local recurrence (P=0.35), distant recurrence (P=0.23), or overall recurrence (P=0.39).

CONCLUSION

LUL multi-segmentectomy is associated with reduced hospital length of stay, but no difference in long-term overall survival compared with left upper lobectomy in the management of early-stage primary lung cancer.

Usefulness of near-infrared fluorescence for identifying the segmental bronchus in minimally invasive segmentectomy

Minimally invasive anatomical sublobar resections have gained relevance in recent years mainly due to advances in imaging techniques, screening programs and the increase in second neoplasms. Accurate identification of the segmental or subsegmental bronchus is vital to guarantee optimal results in segmentectomies and subsegmentectomies. Given the complexity and the possibility of anatomical variations, several authors have published different methods to identify the target bronchus. However, these methods have certain limitations. This article describes a new rapid and effective technique, with a low risk of complications and without additional cost, for the identification of segmental bronchi in minimally invasive segmentectomies.

Size Measurement and Segmentectomy Resection Margin of Early-Stage Lung Adenocarcinoma Manifesting on Virtual 3D Imagery and Pathology: A Pilot Correlation Study

Background: The objective of our study was to assess if 3D reconstructed images could be extrapolated to reflect pathologies, as evaluated by early-stage lung adenocarcinoma tumor size and simulated segmentectomy resection margin. Methods: Retrospectively selected patients (n = 18) who underwent segmentectomy at Changhua Christian Hospital between 2012 and 2018 and then had pulmonary 3D reconstruction using Ziostation2 were included in our study. Tumor size and simulated segmentectomy resection distance on a 3D model were measure and compared to pathology. Results: Both tumor size and segmentectomy resection margin showed positive correlations between 3D image measurements and pathological measurements. The resection margin showed a stronger correlation and was beneficial in pre-operative planning. Conclusions: A 3D reconstructed model aided understanding of pulmonary anatomy, prompting confidence in surgical approaches and ensured segmentectomy outcome success. Regardless of age and pulmonary function, 3D simulation can accurately mimic segmentectomy, making it a simple, effective and feasible pre-operative planning tool.

Analysis of anatomical variations of the lingular artery of the left upper lobe using 3D computed tomography angiography and bronchography

Background

Thoracic surgeons must be familiar with the anatomy of the pulmonary artery during segmentectomy and segmentectomy. But pulmonary arteries have numerous variations and aberrant branching patterns. The purpose of the present study was to analyze the anatomical variations and frequencies of the lingular artery of the left upper lobe (LUL) using 3D computed tomography angiography and bronchography (3D-CTAB).

Methods

We retrospectively studied 166 patients having undergone lobectomy or segmentectomy from January to December 2020 at Fujian Medical University Cancer Hospital's Department of Thoracic Surgery. All patients underwent 3D reconstruction using 3D-CTAB before surgery.

Results

The lingular segment was supplied by 1 artery in 45.18% of cases, 2 arteries in 46.39% of cases, and 3 arteries in 8.43% of cases. The branching patterns of the lingular artery included 119 (71.68%) cases with interlobar origin, 35 (21.08%) cases with interlobar and mediastinal origin, and 13 (7.83%) cases with mediastinal origin. The interlobar lingular artery include superior lingular artery (A4) and inferior lingular artery (A5). The interlobar lingular artery type was A4a, A4b, A5 in 7.23% of cases; A4 and A4b+5 in 3.01% of cases; and A4b and A4a+5 in 4.82% of cases. The mediastinal lingular artery was divided into the following 5 types: 'A4', 'A4b', 'A4b+5', 'A4b+5a', and 'A4+5'. The most common type was A4 (12.05%, 20/166) in 166 patients. The interlobar lingular artery had the following 5 patterns of variation: 'A4+5', 'A4, A5', 'A4a, A4b, A5', 'A4a, A4b+5', and 'A4b, A4a+5'. The single interlobar lingular artery (A4+5) was the most common type in 38.55% of cases. In 24.10% of cases, A5 came from A8 or A8+9. Besides In 8.43% of cases, the origin of A5 was close to A8 or A8+9.

Conclusions

We identified the left various lingular artery branching patterns with 3D-CTAB in patients and defined the frequency of anatomic variations. 3D-CTAB is useful for finding these variations.

The role of virtual-assisted lung mapping 2.0 combining microcoils and dye marks in deep lung resection

OBJECTIVES

Virtual-assisted lung mapping 2.0 is a novel preoperative bronchoscopic lung mapping technique combining the multiple dye marks of conventional virtual-assisted lung mapping with intrabronchial microcoils to navigate thoracoscopic deep lung resection. This study's purpose was to evaluate the feasibility of virtual-assisted lung mapping 2.0 in resecting deeply located pulmonary nodules with adequate margins.

METHODS

A multicenter, prospective single-arm study was performed from 2019 to 2020 in 8 institutions. The selection criteria were barely identifiable nodules requiring sublobar lung resections, nodules requiring resection lines reaching the inner 2/3 of the pulmonary lobe on computed tomography images in wedge resection, or the nodule center located in the inner 2/3 of the pulmonary lobe in wedge resection or segmentectomy. Resection margins larger than 2 cm or the nodule diameter were considered successful resection. Bronchoscopic placement of multiple dye marks and microcoil(s) was conducted 0 to 2 days before surgery.

RESULTS

We analyzed 65 lesions in 64 patients. The diameter and depth of the targeted nodules and the minimum required resection depth reported as median (interquartile range) were 9 (7-13) mm, 11 (5-15) mm, and 30 (25-35) mm, respectively. Among 60 wedge resections and 5 segmentectomies, successful resection was achieved in 64 of 65 resections (98.5%; 95% confidence interval, 91.7-100). Among 75 microcoils placed, 3 showed major displacement after bronchoscopic placement. There were no severe adverse events associated with the virtual-assisted lung mapping procedure.

CONCLUSIONS

This study demonstrated that virtual-assisted lung mapping 2.0 can facilitate successful resections for deep pulmonary nodules, overcoming the limitations of conventional virtual-assisted lung mapping.

Electromagnetic navigational bronchoscopy-guided dye marking to identify the subsegmental bronchus in thoracoscopic anatomic subsegmentectomy

Video‐assisted thoracoscopic surgery (VATS) subsegmentectomy has been widely used to resect small‐sized lung lesions in clinical practice. Precise identification of the subsegmental bronchus is one of the essential steps in performing thoracoscopic anatomic subsegmentectomy. Here, we report a thoracoscopic right S²a segmentectomy with preoperative electromagnetic navigational bronchoscopy (ENB)‐guided injection of methylene blue to identify the subsegmental bronchus in a 51‐year‐old male. We successfully performed complicated surgery using this method. This ENB‐guided dye marking method may accurately distinguish the subsegmental bronchus to effectively guide surgery.

Video-Assisted Thoracic Surgery Segmentectomy

Although lobectomy remains the gold-standard surgical treatment for non-small-cell lung cancer, the frequency of thoracoscopic segmentectomy is increasing. Multiple factors must be considered in the choice of the procedure, ranging from adequate surgical planning or simulation, tumor localization, and identification of the intersegmental plane to severing the intersegmental plane to achieve an oncologically safe surgical margin with no or minimal manual palpation and different landmarks. In this article, we present an overview of methods for each procedural step of thoracoscopic segmentectomy, from preoperative planning to division of the intersegmental plane.

Predictors of failure of intersegmental line creation using bronchoscopic jet ventilation for thoracoscopic pulmonary segmentectomy

BACKGROUND

During pulmonary segmentectomy, identification of the target segment is essential. We used bronchoscopic jet ventilation (BJV) to delineate the intersegmental plane by selectively sending air into the target segment. The purpose of this study was to investigate the factors associated with BJV failure.

METHODS

Data were retrospectively collected from 48 patients who underwent pulmonary segmentectomy with BJV between March 2014 and May 2019 at a single center. Data were compared between BJV succeeded cases and failed cases.

RESULTS

In 13 cases (27%), BJV were unsuccessful. The Brinkman index was significantly higher in failed cases (962 ± 965 failed vs. 395 ± 415 successful, P = 0.0067). The success rate was significantly lower when BJV was applied to the posterior basal segmental bronchus (B10) (B10: 1/5 (20%) vs others: 34/43 (79%), P = 0.015).

CONCLUSION

Long-term smoking and the bronchus corresponding to the posterior basal segment might make successful performance of BJV difficult.

Managing screening-detected subsolid nodules-the Asian perspective

The broad application of low-dose computed tomography (CT) screening has resulted in the detection of many small pulmonary nodules. In Asia, a large number of these detected nodules with a radiological ground glass pattern are reported as lung adenocarcinomas or premalignant lesions, especially among female non-smokers. In this review article, we discuss controversial issues and conditions involving these subsolid pulmonary nodules that we often face in Asia, including a lack or insufficiency of current guidelines; the roles of preoperative biopsy and imaging; the location of lesions; appropriate selection of localization techniques; the roles of dissection and sampling of frozen sections and lymph nodes; multifocal lesions; and the roles of non-surgical treatment modalities. For these complex issues, we have tried to present up-to-date evidence and our own opinions regarding the management of subsolid nodules. It is our hope that this article helps surgeons and physicians to manage the complex issues involving ground glass nodules (GGNs) in a balanced manner in their daily practice and provokes further discussion towards better guidelines and/or algorithms.

Combination of nitrous oxide and the modified inflation-deflation method for identifying the intersegmental plane in segmentectomy: A randomized controlled trial

Background

During thoracoscopic segmentectomy, accurately and rapidly identifying the intersegmental plane (ISP) is of great importance. This study aimed to investigate the effect and safety of a nitrous oxide (N₂O)/oxygen (O₂) inspired mixture on the appearance time of the ISP (T_ISP) via the modified inflation‐deflation method.

Methods

A total of 65 participants who underwent segmentectomy were randomized into three groups: 75% N₂O (n = 24), 50% N₂O (n = 23) or 0% N₂O (n = 18). The 75% N₂O group received a gas mixture of N₂O/O₂ (Fio₂ = 0.25), the 50% N₂O group received N₂O/O₂ (Fio₂ = 0.5), and the 0% N₂O group received 100% oxygen during lung expansion. The appearance time of satisfactory and ideal planes was recorded. Furthermore, arterial blood gas at breathing room air, one‐lung ventilation (OLV) before lung expansion, 5 and 15 min after lung expansion were also recorded.

Results

T_ISP was significantly shorter in the 75% N₂O group (320.2 ± 65.9 s) compared with that of the 50% N₂O group (552.4 ± 88.9 s, p < 0.001) and the 0% N₂O group (968.3 ± 85.5 s, p < 0.001), while the 50% N₂O group was shorter than that of the 0% N₂O group (p < 0.001). Arterial oxygenation was significantly improved in the 0% N₂O group only after lung expansion, before which there were no differences in mean PaO₂ values among groups.

Conclusions

The use of N₂O in the inspired gas mixture during lung expansion is an applicable strategy to rapidly identify the ISP via the modified inflation‐deflation method without any adverse effect on OLV related arterial oxygenation during segmentectomy.

Augmented Reality and 3-Dimensional Printing Technologies for Guiding Complex Thoracoscopic Surgery

BACKGROUND

Virtual 3-dimentional models of the lungs have been used for guiding thoracoscopic procedures including segmentectomy and subsegmentectomy. However, the virtual models displayed on the screen were not tangible. A printed model with assistance of augmented reality (AR) might add value to guide surgical performance. We wanted to investigate whether the combined technology with patient-specific printed models and the AR display could offer better surgical outcomes than the on-screen models in complex thoracoscopic surgery.

METHODS

A total of 142 patients with early lung cancers undertaking thoracoscopic segmentectomy or subsegmentectomy. The 3-dimentional lung models were either displayed on screen (n = 87) or printed out and displayed using AR (n = 55) in the operating room. A propensity score-matching analysis was used to compare the surgical outcomes between the 2 groups.

RESULTS

The surgical outcomes data before and after propensity score matching showed 3-dimensional printing with AR had a shorter operating time (P = .001 and .001, respectively), less intraoperative blood loss (P = .024 and .006, respectively), and shorter length of hospital stay (P = .001 and .001, respectively) than the on-screen group. The complications and operating success rate (P = .846 and >.999, respectively) and (P = .567 and >.999, respectively) were not significantly different. Surgeons gave a higher score in the tangible group than in the on-screen group (P = .001 vs .001, respectively).

CONCLUSIONS

The printed 3-dimentional models enabled surgeons to see and touch interior structures of the lung. The AR provided instant guidance to the surgery in the operating room. The combination of these technologies produced positive values in guiding laparoscopic lung surgery.

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

With improvements in detection technology, increasing numbers of patients with non-small cell lung cancer (NSCLC) are being diagnosed at an early stage. In order to treat the illness with minimal invasion and preserve lung function to the greatest possible extent, there has been an increasing tendency towards treating early-stage NSCLC by segmentectomy. However, questions remain regarding whether patients may benefit from this procedure considering the surgical and oncological outcomes. Whether adequate margin distance and lymph node dissection may be achieved is one of the most important issues associated with this procedure. The present study reviews the prognosis of segmentectomy in the treatment of stage IA NSCLC.

Prevalence and risk factors for lung involvement on low-dose chest CT (LDCT) in a paucisymptomatic population of 247 patients affected by COVID-19

BACKGROUND

Low-dose chest CT (LDCT) showed high sensitivity and ability to quantify lung involvement of COVID-19 pneumopathy. The aim of this study was to describe the prevalence and risk factors for lung involvement in 247 patients with a visual score and assess the prevalence of incidental findings.

METHODS

For 12 days in March 2020, 250 patients with RT-PCR positive tests and who underwent LDCT were prospectively included. Clinical and imaging findings were recorded. The extent of lung involvement was quantified using a score ranging from 0 to 40. A logistic regression model was used to explore factors associated with a score ≥ 10.

RESULTS

A total of 247 patients were analyzed; 138 (54%) showed lung involvement. The mean score was 4.5 ± 6.5, and the mean score for patients with lung involvement was 8.1 ± 6.8 [1-31]. The mean age was 43 ± 15 years, with 121 males (48%) and 17 asymptomatic patients (7%). Multivariate analysis showed that age > 54 years (odds ratio 4.4[2.0-9.6] p < 0.001) and diabetes (4.7[1.0-22.1] p = 0.049) were risk factors for a score ≥ 10. Multivariate analysis including symptoms showed that only age > 54 years (4.1[1.7-10.0] p = 0.002) was a risk factor for a score ≥ 10. Rhinitis (0.3[0.1-0.7] p = 0.005) and anosmia (0.3[0.1-0.9] p = 0.043) were protective against lung involvement. Incidental imaging findings were found in 19% of patients, with a need for follow-up in 0.6%.

CONCLUSION

The prevalence of lung involvement was 54% in a predominantly paucisymptomatic population. Age ≥ 55 years and diabetes were risk factors for significant parenchymal lung involvement. Rhinitis and anosmia were protective against LDCT abnormalities.

Hybrid technique of virtual-assisted lung mapping and systemic indocyanine green injection for extended segmentectomy

BACKGROUND

Various approaches have been used to assist and facilitate segmentectomy with favorable oncological outcomes. We describe a hybrid approach comprising virtual-assisted lung mapping (VAL-MAP), which is a preoperative bronchoscopic dye-marking technique, combined with systemic indocyanine green (ICG) injection.

CLINICAL PRESENTATION

An asymptomatic 64-year-old man was referred to our department because of a lung nodule detected during his annual medical checkup. The chest computed-tomography image revealed a 16-mm, partly solid, ground-glass nodule in the left segment 4. Because the nodule was hardly palpable and deeply located between the left upper division segment and the left lingular segment, we performed VAL-MAP to facilitate extended left lingulectomy. Five dye markings were undertaken preoperatively. Surgery to remove the nodule was then conducted via complete three-port video-assisted thoracic surgery. The VAL-MAP markings were easily identified intraoperatively and helped locate the nodule. The intersegmental plane was identified by the ICG injection. The resection line was determined based on the intersegmental plane identified by the ICG injection and the site of the nodule suggested by the VAL-MAP markings. Following the resection line, we thoracoscopically achieved extended lingulectomy with sufficient surgical margins. The patient was discharged with no complications. The pathological diagnosis was adenocarcinoma in situ.

CONCLUSION

The hybrid technique of VAL-MAP and systemic ICG injection can be useful for accomplishing successful extended segmentectomy.

Multicenter, prospective, observational study of a novel technique for preoperative pulmonary nodule localization

OBJECTIVES

Minimally invasive surgery provides an ideal method for pathologic diagnosis and curative intent of small pulmonary nodules (SPNs); however, the main problem with thoracoscopic resection is the difficulty in locating the nodules. The goal of this study was to determine the safety and feasibility of a new localization technique tailored for SPNs.

METHODS

A computed tomography (CT)-guided technique, which has a tri-colored suture and claw with 4 fishhook-shaped hooks, was designed to localize SPN preoperatively. Then a multicenter, prospective study was conducted to evaluate the safety and feasibility of this device. The primary endpoints included safety (asymptomatic/symptomatic pneumothorax or parenchymal hemorrhage, and unanticipated adverse effects) and success rate (precise placement and device fracture, displacement, or dislodgement). The secondary endpoints included feasibility (duration of the localization procedure and device fracture or fault) and patient comfort (pain).

RESULTS

A total of 90 SPNs were localized from 80 patients. Overall, no symptomatic complications requiring medical intervention, with the exception of asymptomatic pneumothorax (n = 7 [7.8%]) and lung hemorrhages (n = 5 [5.6%]), were observed. The device was successfully placed without dislodgment or movement in 87 of 90 lesions (96.7%). The median nodule size was 0.70 cm (range, 0.30-1.0 cm). The median duration of the procedure was 15 minutes (range, 7-36 minutes). No patient complained of notable pain during or after the procedure.

CONCLUSIONS

This new device for SPNs is safe, and has a high success rate, feasibility and good tolerance.

Simple method for distinguishing the intersegmental plane in thoracoscopic lung segmentectomy

Here, we introduce a simple method for delineating the intersegmental border in thoracoscopic pulmonary segmentectomy which can be widely reproduced because it is less time‐consuming, fault‐tolerant, and does not require any special chemical reagents or equipment. This method provides clear and accurate demarcation lines between the inflated and deflated lung parenchyma.

Key points

A method with an effective and simple application which can be popularized. This modified targeted bronchus inflation method provides a clear and accurate intersegmental plane.

The powered vascular staple (PVS) versus conventional powered linier cutter (PLC) for the application of bronchial transection in thoracoscopic anatomic segmentectomy

Background

Recent studies indicated that thoracoscopic anatomical segmentectomy (TAS) is widely adopted in early non-small cell lung cancer. Considering the slender segmental bronchi and the narrow space around segmental bronchi, it is easier to treat segmental bronchi with powered vascular stapler (PVS), which was designed to have a narrower anvil and a beak like tip. However, the safety and feasibility of PVS in stapling segmental bronchi are not yet clear.

Methods

We retrospectively compared the perioperative features of segmental bronchial closure treated with PVS and powered linier cutter (PLC) in thoracoscopic anatomic segmentectomy performed by a single surgeon and evaluated the safety and feasibility of PVS for the segmental or subsegmental bronchus.

Results

Between April 2018 and April 2019, a total of 162 patients who underwent anatomic segmentectomy were analyzed (PVS n=75 and PLC n=87). No bronchopleural fistula (BPF) occurred in 162 patients. Intraoperative blood loss in PVS group (15.2±8.91 mL) was significantly lower than that in PLC group (25.29±24.06 mL) (P<0.05). The operative time of PVS group was similar to the PLC group (P>0.05). There was no significant difference between the two groups in postoperative drainage and chest tube duration (all P>0.05). In terms of postoperative complications, the incidence of hemoptysis in PVS group was similar to PLC group (P>0.05). Two cases of subcutaneous emphysema occurred in PVS group, one case of pulmonary air leakage (>3 days) and one case of subcutaneous emphysema occurred in PLC group. Besides, all the surgeons (100%) slight agree or strongly agree that PVS is easier to pass through the segmental bronchus.

Conclusions

PVS is a smoother and easier instrument and has the same effectiveness and security as PLC. It leads to reduced operation difficulty and potential intraoperative complications.