A novel technique for identification of the segments based on pulmonary artery plane combined with oxygen diffusing discrepancy

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.

Indocyanine green fluorescence identification of the intersegmental plane by the target segmental vein-first single-blocking during thoracoscopic segmentectomy

BACKGROUND

Innovative attempt to explore the feasibility and accuracy of using indocyanine green fluorescence (ICGF) to identify the intersegmental plane by the target segmental veins preferential ligation during thoracoscopic segmentectomy.

METHODS

A retrospective analysis was conducted on clinical data of 32 consecutive patients who underwent thoracoscopic segmentectomy with intersegmental plane identification using both ICGF and inflation-deflation method after target segmental veins prioritized blocking at Nanjing Chest Hospital from December 2022 to June 2023. Preoperative three-dimensional reconstruction was used to identify the target segment and the anatomical structure of the arteries, veins, and bronchi. After ligating the target segmental veins during surgery, the first intersegmental plane was immediately identified and marked with an electrocoagulation device using an inflation-deflation method. Subsequently, the second intersegmental plane was determined using the ICGF method. Finally, the consistency of the two intersegmental planes was evaluated.

RESULTS

All the 32 patients successfully completed thoracoscopic segmentectomy without ICG-related complications and perioperative death. The average operation time was (98.59 ± 20.72) min, the average intraoperative blood loss was (45.31 ± 35.65) ml, and the average postoperative chest tube removal time was (3.5 ± 1.16) days. The average postoperative hospital stay was (4.66 ± 1.29) days, and the average tumor margin width was (26.96 ± 5.86) mm. The intersegmental plane determined by ICGF method was basically consistent with inflation-deflation method in all patients.

CONCLUSION

The ICGF can safely and accurately identify the intersegmental plane by target segmental veins preferential ligation during thoracoscopic segmentectomy, which is a beneficial exploration and important supplement to the simplified thoracoscopic anatomical segmentectomy.

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.

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.

No-waiting segmentectomy: an optimized approach for segmentectomy

Background

Currently, modified inflation–deflation is considered the easiest way to identify the intersegmental plane during pulmonary segmentectomy. However, this approach requires a wait of about 10–20 min during the operative procedure. Therefore, we optimized the procedure, which we call no-waiting segmentectomy. In this study, we compared no-waiting segmentectomy with the modified inflation–deflation method.

Methods

We studied 123 consecutive patients with pulmonary ground-glass nodules who underwent segmentectomy by uniportal video-assisted thoracoscopic surgery in a single medical group from January 2019 to April 2020. Forty-five patients underwent the modified inflation–deflation method and 78 patients underwent the no-waiting method. The no-waiting procedure involved severing of the target segmental pulmonary artery, inflating the lung with atmospheric air, dissecting the hilum, and dividing the target segmental bronchus. The entire procedure could be performed at a stretch and no pause was needed. We compared the two methods for surgery time, bleeding volume, drainage time, and postoperative hospital stay. Propensity-score matching was used to adjust the baseline characteristics.

Results

Thirty-three pairs of 123 patients were successfully matched. Before propensity-score matching, there was no difference between the two methods in terms of surgery time, bleeding volume, drainage time, and postoperative hospital stay. After propensity-score matching, the surgery time in the no-waiting group was significantly shorter than that in the modified inflation–deflation method group (80.12±35.53 vs. 102.97±48.07 min, P=0.03). There was no difference between the two methods in terms of bleeding volume, drainage time, and postoperative hospital stay.

Conclusions

No-waiting segmentectomy was associated with a reduced surgery time, compared to that associated with modified inflation–deflation segmentectomy. Furthermore, no-waiting segmentectomy did not increase bleeding volume, drainage time, and postoperative hospital stay. Thus, no-waiting segmentectomy is an optional optimized approach for segmentectomy.

Efficacy of thoracoscopic anatomical segmentectomy for small pulmonary nodules

BACKGROUND

Small pulmonary nodules are tissue shadows and thoracoscopic segmentectomy in China is still at the exploratory stage with limited application.

AIM

To evaluate the efficacy of thoracoscopic anatomical segmentectomy for small pulmonary nodules.

METHODS

Medical records of 86 patients with small pulmonary nodules treated at our hospital between August 2016 and October 2019 were retrospectively analyzed; 40 cases who underwent thoracoscopic lobectomy were set as a reference group, and 46 cases who underwent thoracoscopic anatomical segmentectomy were set as an observation group. Preoperative and postoperative parameters were measured in both groups, including the percentage of forced expiratory volume in the first second (FEV₁%), the percentage of forced vital capacity (FVC%), and the FEV₁/FVC ratio (FEV₁/FVC). Patients with positive pathological diagnosis received tests for neuron-specific enolase, carbohydrate antigen 125 (CA125), CA19-9, and squamous cell carcinoma antigen. Intraoperative bleeding volume, drainage volume, the number of dissected lymph nodes, drainage time, hospital stay, treatment cost, postoperative complications, and postoperative pain condition were compared between the two groups.

RESULTS

No significant difference was observed in the results of four serum tumor marker (CA125, CA19-9, squamous cell carcinoma antigen, and neuron-specific enolase), the number of dissected lymph nodes, treatment cost, or preoperative pulmonary ventilation index between the two groups. Intraoperative bleeding volume, drainage volume, drainage time, hospital stay, and visual analogue scale score were significantly lower in the observation group (P < 0.05). The results of FEV₁%, FVC%, and FEV₁/FVC were significantly higher in the observation group (P < 0.05).

CONCLUSION

The efficacy of thoracoscopic anatomical segmentectomy and lobectomy for small pulmonary nodules shows no significant difference in terms of lesion removal, but anatomical segmentectomy is less invasive with fewer postoperative complications and less influence on lung function.