Application of three-dimensional (3D) reconstruction in the treatment of video-assisted thoracoscopic complex segmentectomy of the lower lung lobe: A retrospective study

Perioperative comparison of uniportal versus multiportal video-assisted thoracoscopic surgery for complex segmentectomy of the lower lung lobe

BACKGROUND

Resection of basal segmentectomy through uniportal video-assisted thoracoscopic surgery (U-VATS) is technically challenging for thoracic surgeons. Compared with multiportal VATS (M-VATS), the safety and feasibility of U-VATS for complex segmentectomy of lower lung lobe need further validation. In this study, we aimed to compare the perioperative outcomes of U-VATS with M-VATS in the treatment of complex segmentectomy of lower lung lobe for stage IA lung cancer.

METHODS

We conducted a retrospective cohort study of 168 patients (116 U-VATS and 52 M-VATS) undergoing complex lower lobe segmentectomy for stage IA NSCLC from January 2021 to May 2023. The demographics of the enrolled patients were collected and propensity score matching (PSM) was used to reduce the heterogeneity of baseline characteristics. Perioperative outcomes were compared between the two groups.

RESULTS

After matching, 50 cases were yielded in each group. There was no 30-day postoperative mortality and conversion to open in both groups. The U-VATS exhibited shorter postoperative hospital stays (P = 0.034) and a trend toward reduced postoperative drainage (P = 0.081) compared to the M-VATS group. Pain score on postoperative day 2 in the U-VATS group was lower than M-VATS group (P = 0.004). There were no significant differences in resection margins, operation time and postoperative complications between the two groups.

CONCLUSIONS

U-VATS provides comparable perioperative safety and efficacy to M-VATS for complex lower lobe segmentectomy, with advantages in accelerated recovery and reduced postoperative pain. U-VATS complex segmentectomy of lower lung lobe is a safe and feasible technique for experienced thoracic surgeons, which deserves support and popularity.

Artificial intelligence driven 3D reconstruction for enhanced lung surgery planning

The increasing complexity of lung surgeries necessitates the need for enhanced imaging support to improve the precision and efficiency of preoperative planning. Despite the promise of 3D reconstruction, clinical adoption remains limited due to time constraints and insufficient validation. To address this, we evaluate an artificial intelligence-driven 3D reconstruction system for pulmonary vessels and bronchi in a retrospective, multi-center multi-reader multi-case study. Using a two-stage crossover design, ten thoracic surgeons assess 140 cases with and without the system's assistance. The system significantly improves the accuracy of anatomical variant identification by 8% (p < 0.01), reducing errors by 41%. Improvements in secondary endpoints are also observed. Operation procedure selection accuracy is improved by 8%, with a 35% decrease in errors. Preoperative planning time is decreased by 25%, and user satisfaction is high at 99%. These benefits are consistent across surgeons of varying experience. In conclusion, the artificial intelligence-driven 3D reconstruction system significantly improves the identification of anatomical variants, addressing a critical need in preoperative planning for thoracic surgery.

Rare complex anatomical variation of right pulmonary vessels and bronchi: a case report

Background

The patterns of bronchopulmonary vascular bifurcation within the lung exhibit considerable diversity. To perform safe and accurate anatomical pulmonary resections, an understanding of the anatomy of the pulmonary vessels and bronchi, including variations, is of utmost importance to general thoracic surgeons.

Case Description

We performed a 3-dimensional (3D) computed tomography (CT) reconstruction of the pulmonary vessels and bronchi for a 66-year-old female patient. From the 3D reconstruction, we were able to observe clearly that this patient had complex variations in the right pulmonary artery, vein, and bronchus. Not only the bronchi and vessels of the right upper lobe, but also the vessels and bronchi of the middle and lower lobes are also variable. Due to this, we performed video-assisted right upper lobectomy and mediastinal lymph node dissection for her without misjudgment of the pulmonary vessels and bronchi. The patient recovered well and was discharged after 3 days.

Conclusions

We first report a very rare case involving complex variations in the right pulmonary artery, vein, and bronchus in a single patient using 3D reconstruction technology. We hope this article can remind all thoracic surgeons to evaluate the variations of pulmonary blood vessels and bronchi thoroughly and comprehensively before surgery and formulate appropriate surgical plans to ensure the successful implementation of the surgery.

Lobar or sublobar resection of peripheral stage I non-small cell lung cancer

PURPOSE OF REVIEW

We aim to highlight two recent clinical trials that have altered the approach of the management of stage I nonsmall cell lung cancer.

RECENT FINDINGS

The JCOG 0802 and CALGB 140503 trials demonstrated that sublobar resection is noninferior to lobectomy for overall and disease-free survival in patients with stage I nonsmall cell lung cancer.

SUMMARY

Since 1962, lobectomy has been deemed the gold standard treatment for operable lung cancer. However, two recent clinical trials have demonstrated that, for select patients, sublobar resection is oncologically noninferior; results, which are leading us into a new era for the surgical management of lung cancer. Notwithstanding the progress made by these studies and the opportunities that have been put forth, questions remain. This review aims at reviewing the results of both trials and to discuss future perspectives for the surgical treatment of lung cancer.

Evolution of Three-Dimensional Computed Tomography Imaging in Thoracic Surgery

Radiologic reconstruction technology allows the wide use of three-dimensional (3D) computed tomography (CT) images in thoracic surgery. A minimally invasive surgery has become one of the standard therapies in thoracic surgery, and therefore, the need for preoperative and intraoperative simulations has increased. Three-dimensional CT images have been extensively used, and various types of software have been developed to reconstruct 3D-CT images for surgical simulation worldwide. Several software types have been commercialized and widely used by not only radiologists and technicians, but also thoracic surgeons. Three-dimensional CT images are helpful surgical guides; however, in almost all cases, they provide only static images, different from the intraoperative views. Lungs are soft and variable organs that can easily change shape by intraoperative inflation/deflation and surgical procedures. To address this issue, we have developed a novel software called the Resection Process Map (RPM), which creates variable virtual 3D images. Herein, we introduce the RPM and its development by tracking the history of 3D CT imaging in thoracic surgery. The RPM could help develop a real-time and accurate surgical navigation system for thoracic surgery.

Evaluating the use of three-dimensional reconstruction visualization technology for precise laparoscopic resection in gastroesophageal junction cancer

BACKGROUND

Laparoscopic gastrectomy for esophagogastric junction (EGJ) carcinoma enables the removal of the carcinoma at the junction between the stomach and esophagus while preserving the gastric function, thereby providing patients with better treatment outcomes and quality of life. Nonetheless, this surgical technique also presents some challenges and limitations. Therefore, three-dimensional reconstruction visualization technology (3D RVT) has been introduced into the procedure, providing doctors with more comprehensive and intuitive anatomical information that helps with surgical planning, navigation, and outcome evaluation.

AIM

To discuss the application and advantages of 3D RVT in precise laparoscopic resection of EGJ carcinomas.

METHODS

Data were obtained from the electronic or paper-based medical records at The First Affiliated Hospital of Hebei North University from January 2020 to June 2022. A total of 120 patients diagnosed with EGJ carcinoma were included in the study. Of these, 68 underwent laparoscopic resection after computed tomography (CT)-enhanced scanning and were categorized into the 2D group, whereas 52 underwent laparoscopic resection after CT-enhanced scanning and 3D RVT and were categorized into the 3D group. This study had two outcome measures: the deviation between tumor-related factors (such as maximum tumor diameter and infiltration length) in 3D RVT and clinical reality, and surgical outcome indicators (such as operative time, intraoperative blood loss, number of lymph node dissections, R0 resection rate, postoperative hospital stay, postoperative gas discharge time, drainage tube removal time, and related complications) between the 2D and 3D groups.

RESULTS

Among patients included in the 3D group, 27 had a maximum tumor diameter of less than 3 cm, whereas 25 had a diameter of 3 cm or more. In actual surgical observations, 24 had a diameter of less than 3 cm, whereas 28 had a diameter of 3 cm or more. The findings were consistent between the two methods (χ2 = 0.346, P = 0.556), with a kappa consistency coefficient of 0.808. With respect to infiltration length, in the 3D group, 23 patients had a length of less than 5 cm, whereas 29 had a length of 5 cm or more. In actual surgical observations, 20 cases had a length of less than 5 cm, whereas 32 had a length of 5 cm or more. The findings were consistent between the two methods (χ2 = 0.357, P = 0.550), with a kappa consistency coefficient of 0.486. Pearson correlation analysis showed that the maximum tumor diameter and infiltration length measured using 3D RVT were positively correlated with clinical observations during surgery (r = 0.814 and 0.490, both P < 0.05). The 3D group had a shorter operative time (157.02 ± 8.38 vs 183.16 ± 23.87), less intraoperative blood loss (83.65 ± 14.22 vs 110.94 ± 22.05), and higher number of lymph node dissections (28.98 ± 2.82 vs 23.56 ± 2.77) and R0 resection rate (80.77% vs 61.64%) than the 2D group. Furthermore, the 3D group had shorter hospital stay [8 (8, 9) vs 13 (14, 16)], time to gas passage [3 (3, 4) vs 4 (5, 5)], and drainage tube removal time [4 (4, 5) vs 6 (6, 7)] than the 2D group. The complication rate was lower in the 3D group (11.54%) than in the 2D group (26.47%) (χ2 = 4.106, P < 0.05).

CONCLUSION

Using 3D RVT, doctors can gain a more comprehensive and intuitive understanding of the anatomy and related lesions of EGJ carcinomas, thus enabling more accurate surgical planning.

Different anatomical variations in the anterior segment of the right upper lung

During a routine physical examination three years ago, a 47-year-old woman received a diagnosis of a nodule in her right upper lung. Since then, she has been regularly attending outpatient clinic appointments for follow-up. Over time, the nodule has shown gradual growth, leading to a suspicion of lung cancer. Through the use of enhanced CT imaging, a three-dimensional reconstruction was performed to examine the bronchi and blood vessels in the patient's chest. This reconstruction revealed several variations in the anatomy of the anterior segment of the right upper lobe. Specifically, the anterior segmental bronchus (B3) was found to have originated from the right middle lung bronchus. Additionally, the medial subsegmental artery of the anterior segmental artery (A3b) and the medial segmental artery (A5) were observed to share a common trunk. As for the lateral subsegmental artery of the anterior segmental artery (A3a), it was found to have originated from the right inferior pulmonary trunk. Furthermore, the apical subsegmental artery of the apical segmental artery (A1a) and the posterior segmental artery (A2) were found to have a shared trunk.

Resectability versus Operability in Early-Stage Non-Small Cell Lung Cancer

PURPOSE OF REVIEW

With increased detection of early-stage non-small cell lung cancer (NSCLC) owing to screening, determining optimal management increasingly hinges on assessing resectability and operability. Resectability refers to the feasibility of achieving microscopically negative margins based on tumour size, location and degree of local invasion and achieving an anatomical lobar resection. Operability reflects the patient's tolerance for resection based on comorbidities, cardiopulmonary reserve and frailty. Standardized criteria help guide these assessments, but application variability contributes to practice inconsistencies. This review synthesizes a strategic approach to evaluating resectability and operability in contemporary practice. Standardization promises reduced care variability and optimized patient selection to maximize curative outcomes in this new era of early detection.

RECENT FINDINGS

Recent pivotal trials demonstrate equivalency of sublobar resection to lobectomy for small, peripheral, node-negative NSCLC, expanding options for parenchymal preservation in borderline surgical candidates. Furthermore, recent phase 3 trials have highlighted the benefit of chemoimmunotherapy as a neoadjuvant treatment with an excellent pathological response and a down staging of the tumour, improving the resectability of the early-stage NSCLC. A good assessment of the operability and resectability is paramount in order to offer the best course of treatment for our patients. European and American societies have issued recommendations to help clinicians assess the cardiopulmonary function and predict the extension of pulmonary resection that could afford the patient. This operability assessment is closely linked with the evaluated tumour resectability which will determine the extension of pulmonary resection that is needed for the patient in order to achieve a good oncological outcome. Some major progresses have been done recently to improve the operability and resectability of patients. For instance, prehabilitation program allows better postoperative morbidity. Some studies have shown a potential good oncological outcome with sublobar resection expending access to surgery for patient with reduced lung function. Some others have identified the neoadjuvant immunochemotherapy as a potential solution for downstaging tumours. Work-up of early-stage NSCLC is a key moment and has to be done thoroughly and in full knowledge of the recent findings in order to propose the most appropriate treatment for the patient.

Three-Dimensional Imaging-Guided Lung Anatomic Segmentectomy: A Single-Center Preliminary Experiment

Background and objectives: VATS segmentectomy has been proven to be effective in the treatment of stage I NSCLC, but its technical complexity remains one of the most challenging aspects for thoracic surgeons. Furthermore, 3D-CT reconstruction images can help in planning and performing surgical procedures. In this paper, we present our personal experience of 11 VATS anatomical resections performed after accurate pre-operative planning with 3D reconstructions. Materials and methods: A 3D virtual model of the lungs, airways, and vasculature was obtained, starting from a 1.25 mm 3-phase contrast CT scan, and the original images were used for the semi-automatic segmentation of the lung parenchyma, airways, and tumor. Results: Six males and five females were included in this study. The median diameter of the pulmonary lesion at the pre-operative chest CT scan was 20 mm. The surgical indication was confirmed in seven patients: in three cases, a lobectomy, instead of a segmentectomy, was needed due to intraoperative findings of nodal metastasis. Meanwhile, only in one case, we performed a lobectomy because of inadequate surgical resection margins. Skin-to-skin operative average time was 142 (IQR 1-3 105-182.5) min. The median post-operative stay was 6 (IQR 1-3 3.5-7) days. The mean value of the closest surgical margin was 13.7 mm. Conclusion: Image-guided reconstructions are a useful tool for surgeons to perform complex resections in order to spare healthy parenchyma and to ensure disease-free margins. Nevertheless, human skill and surgeon experience still remain fundamental for the final decisions regarding the proper resection to perform.

Harnessing 3D-CT Simulation and Planning for Enhanced Precision Surgery: A Review of Applications and Advancements in Lung Cancer Treatment

The clinical application of three-dimensional computed tomography (3D-CT) technology has rapidly expanded in the last decade and has been applied to lung cancer surgery. Two consecutive reports of large-scale prospective clinical trials from Japan and the United States have brought a paradigm shift in lung cancer surgery and may have led to a rapid increase in sublobar lung resections. Sublobar resection, especially segmentectomy, requires a more precise understanding of the anatomy than lobectomy, and preoperative 3D simulation and intraoperative navigation support it. The latest 3D simulation software packages are user-friendly. Therefore, in this narrative review, we focus on recent attempts to apply 3D imaging technologies, particularly in the sublobar resection of the lung, and review respective research and outcomes. Improvements in CT accuracy and the use of 3D technology have advanced lung segmental anatomy. Clinical applications have enabled the safe execution of complex sublobar resection through a minimally invasive approach, such as video-assisted thoracoscopic surgery and robotic surgery. However, currently, many facilities still render 3D images on two-dimensional monitors for usage. In the future, it will be challenging to further spread and advance intraoperative navigation through the application of 3D output technologies such as extended reality.

What's new in minimally invasive thoracic surgery? Clinical application of augmented reality and learning opportunities in surgical simulation

Lung cancer represents the most lethal cancer worldwide. Surgery is the treatment of choice for early-stage non-small cell lung cancer, with an overall survival that can reach 90% at 5 years, but its detection is difficult to achieve due to the lack of symptoms. Screening programs are crucial to identify small cancer. Minimally invasive surgery has modified the therapeutical approach of these tumors, becoming the standard of care, with an important clinical yield in terms of reduction of postoperative pain and length of hospital stay. The aim of this mini-review is to explore and describe two important and innovative aspects in the context of "growing opportunities in minimally invasive thoracic surgery": the clinical application of augmented reality and its advantages for patient and surgeon, and the pedagogical issue through simulation-based training.

A comparison of the short-term outcomes of simple and complex segmentectomy via uniportal video-assisted thoracoscopic surgery

Background

Performing complex segmentectomy via uniportal video-assisted thoracoscopic surgery (VATS) is a more demanding and intricate procedure than simple segmentectomy or lobectomy. Thus, the aim of our study is to evaluate the safety and feasibility of uniportal VATS complex segmentectomy compared to uniportal VATS simple segmentectomy by investigating surgical outcomes of patients undergoing those procedures.

Methods

We conducted a review of medical records for all patients who underwent uniportal VATS segmentectomy for lung cancer from May 2019 to February 2023. The characteristics of the patients and tumors, as well as the operative and postoperative outcomes, were compared between the group of patients who underwent simple segmentectomy and the group who underwent complex segmentectomy.

Results

Among 199 patients, 67 underwent simple segmentectomy through uniportal VATS, while 132 patients received complex segmentectomy through the same technique. There were no significant differences between the two groups regarding patient and tumor characteristics, operative outcomes, and postoperative outcomes, except for the surgical margin distances. Uniportal VATS complex segmentectomy resulted in shorter duration of postoperative stay (6 vs. 7 days, P=0.0116) but a closer surgical margin distance (20 vs. 22 mm, P=0.0175).

Conclusions

Our study supports the use of uniportal VATS complex segmentectomy as a safe and feasible treatment option compared to uniportal VATS simple segmentectomy for patients with clinical stage 1A non-small-cell lung cancer (NSCLC). However, it is important to note that a short resection margin is probable in complex segmentectomy cases. Therefore, the location of the tumor should be thoroughly evaluated when performing uniportal VATS complex segmentectomy.

Prospective randomized study on the efficacy of three-dimensional reconstructions of bronchovascular structures on preoperative chest CT scan in patients who are candidates for pulmonary segmentectomy surgery: the PATCHES (Prospective rAndomized sTudy efficaCy of tHree-dimensional rEconstructions Segmentecomy) study protocol

INTRODUCTION

Pulmonary segmentectomy, when combined with hilar and mediastinal lymphadenectomy, is currently considered the gold standard treatment for early-stage lung tumors (NSCLC) smaller than 2 cm in diameter. The preoperative planning for segmentectomies usually includes a contrast-enhanced CT with 2D reconstructions (axial, coronary, and sagittal). Recent technological advances allow 3D (volume rendering) reconstructions of preoperative CT scans, intended to improve the surgeon's understanding of the segmental anatomy. The study aims to investigate the added value of 3D reconstruction in enhancing the surgeon's understanding of anatomical structures, thus facilitating surgical planning and improving oncological outcomes.

METHODS AND ANALYSIS

This is a prospective, randomized, controlled study. Patients will be randomized into two groups: 1. Group 2D: the preoperative workup for these patients will consist of a contrast-enhanced chest CT with two-dimensional (2D) reconstructions (axial, coronary, and sagittal); 2. Group 3D: the preoperative workup for these patients will consist of a contrast-enhanced chest CT with two-dimensional (2D) reconstructions (axial, coronary, and sagittal) and a 3D reconstruction (volume rendering) of the same chest CT employing dedicated software. The primary endpoints will be negative margin (R0) resection rate, resection margin (staple line-to-tumor distance), and thoracotomy conversions. We will use Fisher's exact test for binary outcomes and Mann-Whitney U test for continuous outcomes. For subgroup analyses, we will use regression. Multivariable analyses will be based on logistic regression for binary outcomes and linear regression for continuous outcomes.

ETHICS AND DISSEMINATION

The protocol and the model informed consent forms have been reviewed and approved by the ethics committee (N.: 1-2023) concerning scientific content and compliance with applicable research and human subject regulations. A Subcommittee on Publications was established to review all publications and report its recommendations to the steering committee. The anonymized participant-level dataset and statistical code for generating the results will not be publicly available.

TRIAL REGISTRATION

The protocol was registered at ClinicalTrials.gov (ID: NCT05716815; Prospective rAndomized sTudy efficaCy tHree-dimensional rEconstructions Segmentectomy - Full-Text View - ClinicalTrials.gov). Jan 19, 2023.

Application of three-dimensional computed tomography imaging and reconstructive techniques in lung surgery: A mini-review

Background

Pulmonary surgery is an innovative discipline with increasing demands for minimally invasive techniques in complicated anatomical resections, warranting adequate preoperative imaging of relevant surgical anatomy to ensure safe and radical resection of target lesions. Over the recent years, the emergence of imaging techniques enabling three-dimensional reconstruction has exerted promising influence on pulmonary surgery, facilitating optimal surgical planning and easier identification of the spatial relationship between bronchovascular structures in the individual patient and aiding the safe resection of target pulmonary lesions. The goal of this mini-review is to provide an overview of three-dimensional computed tomography imaging within pulmonary surgery.

Methods

The authors performed a targeted qualitative review of the literature to identify current trends and to provide better understanding of three-dimensional reconstruction within the boundaries of pulmonary surgery.

Results

Three-dimensional reconstructive techniques can be used for resectability assessment, identification of surgically relevant interindividual anatomic variance and may improve perioperative outcomes.

Discussion

Three-dimensional reconstruction using computed tomography imaging improves surgical planning and there is evidence that it results in shorter operative times, less intraoperative blood loss and lower rates of surgical conversion, as it can be applied both pre- and intraoperatively.