Electrocautery vs. Stapler in Comparing Safety for Segmentectomy of Lung Cancer: A Meta-Analysis

Long-term pulmonary repair in rat lungs after sublobar resection: electrocautery versus stapler methods

OBJECTIVE

We investigated and compared the long-term (6-month) histologic changes in a rat model of sublobar resection created using electrocautery or stapler techniques.

METHODS

Nine-week-old male rats were anesthetized and intubated; thoracotomy with sublobar resection was performed in the right middle lobe using electrocautery or stapler techniques. Histological examination was performed at 2, 4, 8, 12, and 24 weeks post-surgery to assess long-term effects on lung tissue repair and morphologic changes. Lung expansion and alveolar epithelial cell proliferation were evaluated by measuring the mean linear intercept and counting the number of alveolar type I and II cells.

RESULTS

The electrocautery group showed signs of lung self-repair at the resected area over time, with inflammatory cell infiltration followed by growth of vessels and bronchioles. Mesothelial cells covered the resected area by 2 weeks; elastic fibers gradually connected from both sides by 24 weeks. Lung expansion, measured by mean linear intercept, was initially small below the electrocautery resection area at 2 weeks but recovered from 4 to 24 weeks. The stapler group showed persistently small mean linear intercept over time. In the electrocautery group, the number of alveolar type II cells was higher just below the resection than in other areas from 2 to 24 weeks, followed by alveolar type I cells (4 to 24 weeks). The stapler group showed a transient alveolar type II cell increase at 2 weeks.

CONCLUSIONS

Compared to the stapler technique, electrocautery may provide advantages for postoperative lung repair by promoting lung expansion and alveolar epithelial cell proliferation.

Application of microwave surgical instrument to lung segmentectomy for small-sized lung cancer

Objectives

For lung segmentectomy of small lung cancers, we used a microwave surgical instrument for lung parenchymal dissection mainly at the pulmonary hilum, which is difficult to handle with surgical staplers. This technique facilitated the insertion of staples.

Methods

In total, 116 patients with cStage 0-1A3 non-small cell lung cancer who underwent lung segmentectomy were included in this study. We compared the perioperative factors of the group in which a microwave surgical instrument was used for dissection procedures, including lung parenchymal dissection at the pulmonary hilum, and peripheral intersegmental dissection was performed with surgical staplers (group M+S: N = 69), with those of the group in which parenchymal dissection was performed mainly with surgical staplers without using the microwave surgical instrument (group S: N = 47).

Results

Although more complex segmentectomies were performed in the M+S group (P = .001), the number of staple cartridges (7 staple cartridges vs 8 staple cartridges, P = .005), the surgical times (179 vs 221 minutes, P < .0001), and the blood loss (5 mL vs 30 mL, P = .012) were significantly lower in the M+S group. The duration of chest tube placement was significantly shorter in the M+S group (P = .019), and postoperative complications of grade 2 or greater were significantly lower in the M+S group (P = .049).

Conclusions

The effective use of the microwave surgical instrument combined with surgical staplers can simplify pulmonary hilar and intersegmental plane dissections not only for simple segmentectomy but also for complex segmentectomy, leading to favorable intraoperative and postoperative outcomes.

The role of new staplers in reducing the incidence of air leak

Surgical staplers play an important role in the contemporary minimally invasive thoracic surgery including resection of lung tissue. However, staple line failure resulting in postoperative air leaks is a common complication after lung surgery, that if persist more than five days are defined as prolonged air leaks (PALs). PALs are associated with increased length of stay, patient morbidity and mortality, and hospital costs. To reduce the incidence of PALs, stapler devices underwent in the last years ongoing development aimed at improving device-to-tissue interaction. This clinical practice review explores the most important aspects of the evolution of surgical staplers, based on the review of the available literature. Modern staple cartridges entail small bumps to engage tissue and minimize tissue movement during compression and firing. Staplers with graduated staple heights are advocated to generate less stress on tissue during compression and clamping, thus affording greater perfusion into the staple line. However, air leaks may occur from an appropriate staple line with complete pleural coverage and perfusion due to enlarged staple canals after lung inflation, particularly in case of emphysema. To buttress staple line, thus prevent air leaks in high-risk patients, several types of tissue coverage (bovine pericardium, polytetrafluoroethylene, knitted calcium alginate, bioabsorbable polyglycolic acid) have been successfully developed in the last years. Finally, the most advanced stapler technology is represented by the new energy powered staplers, able to eliminate the manual firing force, monitor tissue compression during firing, and making automatic adjustments to optimize the staple line.

Division of the intersegmental demarcation using the "modified hand-tearing method" is safe and feasible in thoracoscopic anatomical segmentectomy

BACKGROUND

The accurate and safe division of the intersegmental demarcation (ISD) is critical and challenging during thoracoscopic anatomical segmentectomy. Here, we provide an improved technique which emphasizes the application of an electric hook and blunt division of ISD. The technique is termed as the "modified hand-tearing method" (MHT method) with combined application of an electric hook and staplers. The study aimed to review the outcomes of patients who underwent thoracoscopic anatomical segmentectomy, with or without the MHT method in our institute and assess its feasibility and safety. In addition, we compared the feasibility between video-assisted thoracoscopic surgery (VATS) and robot-assisted thoracoscopic surgery (RATS) using the MHT method.

METHODS

From 2018 July to 2021 June, we retrospectively analyzed 701 patients who underwent segmentectomy. Using propensity score matching, data of two well-matched pairs of 276 cases in the MHT method and non-MHT method groups, and two well-matched pairs of 40 cases in the VATS and RATS subgroups were obtained. The clinical and perioperative characteristics of patients were compared between groups.

RESULTS

Compared with the non-MHT method group, the MHT method group had shorter operation time and shorter postoperative hospital stay. Period of chest tube drainage and postoperative total drainage and postoperative complications had no between-group difference. Compared with VATS, the RATS subgroup had less intraoperative bleeding and shorter postoperative hospital stay.

CONCLUSION

Division of ISD using the MHT method has advantages in precision and ease of operation, so it has the potential to become a feasible and effective method for thoracoscopic anatomical segmentectomy.