Analysis of variation in bronchovascular pattern of the right middle and lower lobes of the lung using three-dimensional CT angiography and bronchography

Objectives

General thoracic surgeons must be familiar with anatomical variation in the pulmonary vessels and bronchi. Here, we analyzed the bronchovascular pattern of the right middle lobe (RML) and right lower lobe (RLL) of the lung using three-dimensional CT angiography and bronchography (3DCTAB).

Methods

We reviewed the anatomical patterns of the pulmonary vessels and bronchi in 270 patients using 3DCTAB images.

Results

The branching patterns of vessels and bronchi of RML and S⁶ were classified according to the number of stems. The single-stem type was the most common, except in the artery of the RML, for which the two-stem type was the most common. The artery and bronchus of S*, which is an independent segment between S⁶ and S¹⁰, were observed in 20.4% of cases. The branching pattern of A⁷ (B⁷) was classified into four types. The A⁷a (B⁷a) type was observed in 74.8% of cases, and was the most common. The branching pattern of the artery and bronchus of S⁸⁻¹⁰ was classified into five and three types, respectively. The A⁸ and A⁹ + A¹⁰ type, and the B⁸ and B⁹ + B¹⁰ type, were observed in 68.1 and 80.4% of cases, respectively, and were the most common types. The branching pattern of V⁸⁻¹⁰ was more complex than that of A⁸⁻¹⁰ and B⁸⁻¹⁰.

Conclusion

We explored the bronchovascular patterns of RML and RLL and their frequencies using a large number of 3DCTAB images. Our data can be used by thoracic surgeons to perform safe and precise lung resections.

Electronic supplementary material

The online version of this article (doi:10.1007/s11748-017-0754-4) contains supplementary material, which is available to authorized users.

Tips and tricks to decrease the duration of operation in robotic surgery for lung cancer

Minimally invasive surgery (MIS) for lung cancer has been associated with decreased perioperative morbidity while maintaining similar long-term survival when compared to open thoracotomy. Robotic thoracic surgery constitutes an evolutionary step in this field, beckoning dramatic advancements both in visualization as well as surgical instrument range of motion and ergonomics. As such, robotic thoracic surgery is growing in adoption worldwide. One of its oft-cited disadvantages, however, is increased operative time, especially for less-experienced surgeons. We describe an assortment of tips and tricks that we conclude can safely reduce robotic operative duration.

A Novel Neoadjuvant Therapy for Operable Locally Invasive Non-Small-Cell Lung Cancer. Phase I Study of Neoadjuvant Stereotactic Body Radiotherapy. LINNEARRE I (NCT02433574)

BACKGROUND

Despite improved staging and surgical techniques, the rate of incomplete resection (R1) of non-small-cell lung cancer (NSCLC) has not significantly decreased. Patients with R1 resection have worse survival compared with those with complete resection (R0). Stereotactic body radiotherapy (SBRT) is a rapid and convenient radiotherapy treatment that delivers high-dose radiotherapy to tumors with high precision while sparing normal organs. Although its efficacy in treating small lung tumors is documented, its use as neoadjuvant therapy for locally advanced (LA) NSCLC has not been examined. We hypothesized that a short course of preoperative SBRT is feasible and can be delivered safely as a neoadjuvant therapy in patients at risk for incomplete resection.

METHODS

In this phase I study, 20 patients with cT3 to 4, N0 to 1, M0 NSCLC at risk for incomplete resection will be treated with neoadjuvant SBRT followed by surgery and adjuvant chemotherapy. Four groups of 5 patients will be treated with escalating doses (35, 40, 45, and 50 Gy) in 10 daily fractions. The primary outcome is feasibility (ie, the ability to complete SBRT and surgery as planned; within 7 weeks). Secondary outcomes include acute and late adverse events; R0, R1, and R2 rates; and secondary surrogates of feasibility and safety.

RELEVANCE

This study is an important first step in introducing a new therapeutic modality to patients with LA NSCLC that could improve surgical outcomes in the future. If neoadjuvant SBRT is found to be feasible and safe for LA NSCLC, its effect in achieving R0 resection could be investigated in randomized trials.

Lymph node ratio as a prognostic factor in patients with pathological N2 non-small cell lung cancer

BACKGROUND

The aim of this study was to investigate whether the lymph node ratio (LNR) was associated with the prognosis of patients, who underwent surgery for pathological N2 non-small cell lung cancer (NSCLC).

METHODS

A total of 182 patients were diagnosed with pathological N2 disease and underwent complete resection surgeries with systematic lymphadenectomies. We counted the number of positives and removed lymph nodes to calculate a ratio between them (LNR). We also investigated the association between skip mediastinal lymph node metastasis and survival.

RESULTS

Univariate analysis of survival in patients with N2 NSCLC showed that the T factor, clinical N factor, and LNR were significant prognostic factors. Multivariate analyses showed that the clinical N stage and LNR were significant independent prognostic factors for patients with pathological N2 NSCLC. Patients with a clinical lymph node status of 0 (cN0) and LNR ≤0.22 showed a significantly higher survival rate than patients with a cN1-2 and LNR ≥0.22 and 5-year survival rates were 47.1 and 10.3%, respectively (p < 0.0001).

CONCLUSIONS

LNR is an important prognostic factor for poor outcome following surgery in patients with N2 disease. The combination of the LNR and cN status provides a valuable prognostic tool.

Supplement CT-Guided Microcoil Placement for Localising Ground-glass Opacity (GGO) Lesions at "Blind Areas" of the Conventional Hook-Wire Technique

BACKGROUND

In the conventional hook-wire technique of pulmonary nodular localisations there are several "blind areas", including the mediastinum-vicinity region, interlobar fissure-neighbouring areas and scapulae-shadowed areas. The present study aims to summarise the experiences of CT-guided microcoil placement as an alternative method for localising pulmonary ground-glass opacity (GGO) lesions before thoracoscopic wedge resections.

METHODS

Sixteen GGO lesions at "blind areas" in 16 patients were localised with platinum-fibered microcoils under CT assistance before undergoing video-assisted thoracoscopic surgical resections. Information regarding coil placement, operations and complications was recorded.

RESULTS

Of all lesions, 1 was in the mediastinum-vicinity region, 8 were covered by the scapulae, and 7 were close to interlobar fissures (3 horizontal fissures, 4 oblique fissures). All 16 (100%) lesions had been successfully marked with microcoils. No major complications of the puncture procedure occurred; there were only minor pneumothorax (n=2) and haemoptysis (n=1) complications, which required no intervention before operations. All GGO lesions and microcoils were successfully removed by initial wedge resections. Of the 16 lesions in "blind areas", 8 were adenocarcinoma in situ (AIS), 4 were minimally invasive adenocarcinoma (MIA), 3 were atypical adenomatous hyperplasia (AAH), and 1 was interstitial fibrous tissue proliferation. No major complications occurred postoperatively.

CONCLUSIONS

For the "blind areas" of the hook-wire technique, CT-guided microcoil placement is an effective method of marking GGO lesions that makes thoracoscopic wedge resection easier.

Choriocarcinoma syndrome after resection of primary pulmonary choriocarcinoma: report of a case

Background

Choriocarcinoma syndrome is known as a lethal complication from tumoral hemorrhage, which frequently occurs at the site of tumor metastasis.

Case presentation

A 59-year-old man with 60-pack-year smoking history was referred to our hospital because of hemoptysis. Chest computed tomography (CT) showed a 28 × 18 mm spiculated nodule with a cavity infiltrating the left upper lobe. A transbronchial lung biopsy was performed, and histopathological examinations revealed adenocarcinoma. No distant or regional metastasis was observed, and therefore, the patient underwent a left upper lobectomy with lymphadenectomy. Histological examinations showed that the tumor consisted of poorly differentiated adenocarcinoma cells and a choriocarcinomatous component; no multiple pulmonary metastases and mediastinal lymph node metastasis were observed. Immunohistochemical analysis showed a positive immunoreaction for human chorionic gonadotropin in the syncytiotrophoblastic cells of the choriocarcinoma. One month after the operation, the patient developed massive hemoptysis. CT showed diffuse alveolar infiltration in both the lungs. A bronchoscopic examination showed bleeding from the right upper bronchus. Aspiration cytology showed carcinoma. Despite blood transfusion and management in the intensive care unit, the patient died one and a half month after diagnosis.

Conclusions

We herein report a case of a man who developed choriocarcinoma syndrome 1 month after resection for combined choriocarcinoma and adenocarcinoma of the lung. Choriocarcinoma syndrome is a rare and life-threatening complication which may occur in patients with primary pulmonary choriocarcinoma. However, we need to consider the risk of this syndrome while dealing with patients who have massive hemoptysis.

Pulmonary artery reconstruction with a tailor-made bovine pericardial conduit following sleeve resection of a long segmental pulmonary artery for the treatment of lung cancer: technical details of the dog-ear method for adjusting diameter during vascular anastomosis

Sleeve resection of the pulmonary artery (PA) is always required for lung-sparing operations in which half or more of the vessel circumference is infiltrated by the primary tumor or metastatic hilar nodes. Following sleeve resection, conduit reconstruction may be indicated if there is excessive distance between the two vascular stumps, because there is a high degree of tension when repaired by direct anastomosis. We herein present a case of PA reconstruction using a tailor-made bovine pericardial conduit after sleeve resection of PA during lung cancer surgery. The length of resection was longer than 3 cm, and the difference in diameter between the conduit and peripheral PA stump was larger than 0.5 cm. We describe the surgical and oncological merits of a bovine pericardial conduit, and provide details of our reconstruction technique, focusing on adjustment of diameter between the conduit and peripheral PA (dog-ear method).

Lobectomy and limited resection in small-sized peripheral non-small cell lung cancer

BACKGROUND

Although lobectomy is the standard surgical procedure for non-small cell lung cancer (NSCLC), recent studies show favorable outcomes after limited resection in patients with small-sized peripheral tumors. We conducted a randomized controlled trial of such patients to estimate postoperative outcomes and pulmonary function following these surgical techniques.

METHODS

Between 2005 and 2008, eligible patients with tumors of 2 cm or less were randomly assigned 1:1 to undergo lobectomy or limited resection; 32 and 33 NSCLC patients in each group, respectively, were analyzed. The primary end points were 5-year overall survival (OS) and disease-free survival (DFS), while the secondary end points were postoperative pulmonary function including forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV₁).

RESULTS

The 5-year OS rates were 93.8% and 90.9% in the lobectomy and limited resection groups, respectively (P=0.921). The 5-year DFS rates were 93.8% and 90.9% in the lobectomy and limited resection groups, respectively (P=0.714). These rates did not differ significantly between the two resection groups. The median postoperative/preoperative FVC ratios were 84.1% and 90.0% in the lobectomy and limited resection groups, respectively, while the median postoperative/preoperative FEV₁ ratios were 81.9% and 89.1%, respectively. Both ratios were significantly higher in the limited resection group (P=0.032 and P=0.005 for FVC and FEV₁ ratios, respectively).

CONCLUSIONS

A similar outcome, with more preserved postoperative pulmonary function, was observed in patients who underwent limited resection compared to those who underwent lobectomy. Ongoing large-scale multi-institutional prospective randomized trials of lobar versus sublobar resection in patients with small peripheral NSCLCs will hopefully provide definitive information about intentional limited resection of small peripheral tumors.

Two-port approached thoracoscopic carina reconstruction using natural bronchial bifurcation

Background

Carina resection and reconstruction is a challenging procedure for thoracic surgeons. We describe a novel technique of thoracoscopic carina reconstruction using the natural bifurcation, following pulmonary resection of the lung neoplasm. To our knowledge, it is the first report of this kind.

Case presentation

A 71-year-old male diagnosed of squamous cell lung cancer received two-port approached video-assisted thoracoscopic right bilobectomy with carina resection after 2 cycles of neoadjuvant therapy. After the removal of right lower lobe and middle lobe, the 7 station lymph nodes were resected with the invaded carina and bronchial walls in an en-bloc fashion. The neocarina was reconstructed by the natural bifurcation between the right upper bronchus and the bronchus intermedius. Intraoperative blood loss was about 220 mL, and operative time was about 225 min. The postoperative course was uneventful. The pathological TNM stage was pT3N2M0, IIIA. Adjuvant chemotherapy using gemcitabine and cisplatin was administered for 4 cycles. Follow-up 6 months after surgery confirmed no stenosis and no signs of local recurrence by bronchoscopy and CT scan.

Conclusions

We consider that the surgical procedure described here is a new alternative strategy for carina resection and reconstruction in the similar situation. The minimally invasive method is safe and effective for this challenging operation.

Electronic supplementary material

The online version of this article (doi:10.1186/s13019-016-0541-9) contains supplementary material, which is available to authorized users.

Lobectomy for a mediastinal basal pulmonary artery

Anatomical variations of the pulmonary artery increase the risks for vessel injury and critical mistakes during pulmonary artery resection. The mediastinal basal pulmonary artery is a rare branch abnormality and is the first branch of the pulmonary artery to flow into the basal segment. We report a patient who underwent video-assisted thoracic surgery (VATS) right lower lobectomy for lung cancer with a mediastinal basal pulmonary artery. The mediastinal basal pulmonary artery was detected preoperatively by computed tomography. During VATS, this artery was found with careful dissection by dividing the lung parenchyma within the fissure, and right lower lobectomy was safely performed.

Risk Stratification in Lung Resection

PURPOSE OF REVIEW

Surgery is considered the best treatment option for patients with early stage lung cancer. Nevertheless, lung resection may cause a variable functional impairment that could influence the whole cardio-respiratory system with potential life-threatening complications. The aim of the present study is to review the most relevant evidences about the evaluation of surgical risk before lung resection, in order to define a practical approach for the preoperative functional assessment in lung cancer patients.

RECENT FINDINGS

The first step in the preoperative functional evaluation of a lung resection candidate is a cardiac risk assessment. The predicted postoperative values of forced expiratory volume in one second and carbon monoxide lung diffusion capacity should be estimated next. If both values are greater than 60 % of the predicted values, the patients are regarded to be at low surgical risk. If either or both of them result in values lower than 60 %, then a cardiopulmonary exercise test is recommended. Patients with VO2max >20 mL/kg/min are regarded to be at low risk, while those with VO2max <10 mL/kg/min at high risk. Values of VO2max between 10 and 20 mL/kg/min require further risk stratification by the VE/VCO2 slope. A VE/VCO2 <35 indicates an intermediate-low risk, while values above 35 an intermediate-high risk.

SUMMARY

The recent scientific evidence confirms that the cardiologic evaluation, the pulmonary function test with DLCO measurement, and the cardiopulmonary exercise test are the cornerstones of the preoperative functional evaluation before lung resection. We present a simplified functional algorithm for the surgical risk stratification in lung resection candidates.

Spread through air spaces is a predictive factor of recurrence and a prognostic factor in stage I lung adenocarcinoma

OBJECTIVES

Spread through air spaces (STAS) is considered a prognosticator related to local recurrence. We assessed the prognostic impact of spread through air spaces and local recurrence in stage I lung adenocarcinoma.

METHODS

From July 2004 to November 2014, 877 lung cancer patients underwent surgery, of whom 318 with pathological stage I adenocarcinoma were reviewed. We investigated the characteristics of spread through air spaces and analysed the relationship between spread through air spaces and prognosis.

RESULTS

The median follow-up was 30 months. Of the 318 patients, 47 (14.8%) had spread through air spaces. The patients with spread through air spaces were associated with male sex (P < 0.001), smoking (P < 0.001), solid nodules (P < 0.001), stage IB disease (P = 0.006), epidermal growth factor receptor mutation negativity (P < 0.001), and lymphovascular (P < 0.001) and pleural invasion (P = 0.001). Among the preoperative findings, spread through air spaces was significantly related to solid nodules on computed tomography. Local recurrence occurred in 11 of 47 (23.4%) cases with spread through air spaces and 10 of 271 (3.7%) cases without spread through air spaces (P < 0.01). Univariate analysis showed that the overall 5-year survival rates were 62.7 and 91.1% in cases with and without spread through air spaces, respectively (P < 0.01), and the recurrence-free 5-year survival rates were 54.4 and 87.8% in cases with and without spread through air spaces, respectively (P < 0.01). Multivariate analysis confirmed spread through air spaces as a significant prognosticator for overall survival and a predictive factor for recurrence after surgery.

CONCLUSIONS

Among stage I lung adenocarcinoma patients, spread through air spaces was found frequently in the invasive cases and was closely related to poor prognosis and recurrence.

Predicting exercise capacity after lobectomy by single photon emission computed tomography and computed tomography

OBJECTIVES

This study compared the prediction of postoperative exercise capacity by employing lung perfusion scintigraphy images obtained with single photon emission computed tomography together with computed tomography (SPECT/CT) versus the common method of counting subsegments (SC method).

METHODS

In 18 patients scheduled for lobectomy, predicted postoperative maximum oxygen uptake per kilogram body weight ([Formula: see text]) was calculated by the SPECT/CT and SC methods. Correlations were examined between the [Formula: see text] predicted by SPECT/CT or the SC method, and the actual [Formula: see text] measured at 2 weeks (mean 15.4 ± 1.5 days) and 1 month (mean 29.1 ± 0.75 days) after surgery to determine whether SPECT/CT was more accurate than SC for predicting postoperative exercise capacity.

RESULTS

There was a significant positive correlation between the [Formula: see text] predicted by SPECT/CT and the actual value at 2 weeks (r = 0.802, p < 0.0001) or 1 month (r = 0.770, p < 0.0001). There was also a significant positive correlation between the [Formula: see text] predicted by SC and the actual value at 2 weeks (r = 0.785, p < 0.0001) or 1 month (r = 0.784, p < 0.0001).

CONCLUSIONS

This study showed that both SPECT/CT and the SC method were useful for predicting postoperative [Formula: see text] in the clinical setting.

Inadvertently transected left superior pulmonary vein during thoracoscopic left lower lobectomy

Background

There are several anatomical variations of the pulmonary vein which can cause serious complications in pulmonary lobectomy.

Case presentation

We inadvertently divided the left superior pulmonary vein during thoracoscopic left lower lobectomy in a lung cancer patient. Retrospective review of the preoperative computed tomography showed extra-pericardial common trunk of the left pulmonary venous system. Left superior pulmonary vein was reimplanted into stump of divided common trunk via thoracotomy.

Conclusions

Awareness of vascular anomalies will help thoracic surgeons to prevent potential morbidity and mortality from complications.

Translocation of left inferior lobe pulmonary artery to the pulmonary artery trunk for central type non-small cell lung cancers

BACKGROUND

The purpose of this study was to report on a technique for translocation of the left inferior lobar pulmonary artery (PA) to the PA trunk associated with bronchial sleeve resection of the left superior lobe in the treatment of bronchogenic cancer.

METHODS

The clinical data of four non-small-cell lung cancer (NSCLC) patients with translocation of the left inferior lobar PA to the PA trunk associated with bronchial sleeve resection of the left superior lobe was retrospectively reviewed between June 13, 2014 and June 8, 2015. A reconstruction of the left pulmonary arteries was performed by translocating the left inferior lobar PA to the PA trunk with end-to-side anastomosis, sleeve resection of bronchus, and systemic lymphadenectomy.

RESULTS

Histology confirmed squamous carcinoma in these four cases. Stage pT3N2M0-IIIA was confirmed in 2 cases, pT3N1M0-IIIA in 1 case, and pT3N0M0-IIB in 1 case. No perioperative deaths or complications were observed. Four patients underwent postoperative chemotherapies, and the end of follow-ups date was Oct. 21, 2015.

CONCLUSIONS

Translocation of the left inferior lobar PA to the PA trunk is practicable as a lung-sparing procedure, despite being technically challenging.

Left lower lobe sleeve lobectomy for lung cancer using the Da Vinci surgical system

BACKGROUND

Despite the robotic surgery is widely applied, sleeve lobectomy for lung cancer using the Da Vinci surgical system is still less performed. We described a sleeve lobectomy for adenocarcinoma located at the left lower lobe using the Da Vinci surgical system.

CASE PRESENTATION

A case of 57-year old female referred to our hospital. Computed tomography scan showed an occupation located at the left lower lobe and adenocarcinoma project from the lobe bronchus was diagnosed by bronchoscope examination. A sleeve lobectomy was performed using the Da Vinci surgical system and the postoperative recovery was uneventful.

CONCLUSIONS

Robotic thoracic surgery is feasible to perform sleeve lobectomy inspite of inadequate experience.

Outpatient air leak management after lobectomy: a CMS cost analysis

BACKGROUND

Air leaks after lobectomy are associated with increased length of stay (LOS) and protracted resource utilization. Portable drainage systems (PDS) allow for outpatient management of air leaks in patients otherwise meeting discharge criteria. We evaluated the safety and cost efficiency of a protocol for outpatient management of air leaks with a PDS.

METHODS

We retrospectively assessed patients who underwent lobectomy for non-small-cell lung cancer at our institution between 2004 and 2014. All patients discharged with a PDS for air leak were included in the analysis. The study group was compared to an internally matched cohort of patients undergoing lobectomy for non-small-cell lung cancer managed without the need for outpatient PDS. Study end points included resource utilization, postoperative complications, and readmission.

RESULTS

A total of 739 lobectomies were performed during the study period, 73 (10%) patients with air leaks were discharged with a PDS after fulfilling postoperative milestones. Shorter LOS was observed in the study group (3.88 ± 2.4 versus 5.68 ± 5.7 d, P = 0.014) without significant differences in 30-d readmission (11.7% versus 9.0%, P = 0.615). PDS-related complications occurred in 6.8% of study patients (5/73), and 2.7% (2/73) required overnight readmission. PDSs were used for 8.30 ± 4.5 outpatient days. A CMS-based cost analysis predicted an overall savings of $686.72/patient (4.9% of Medicare reimbursement for a major thoracic procedure), associated with significantly fewer hospital days and resources used.

CONCLUSIONS

In patients otherwise meeting discharge criteria, outpatient management of air leaks is safe and effective. This strategy is associated with improved efficiency of postoperative care and a modest reduction in hospital costs. This model may be applicable to other thoracic procedures associated with protracted LOS.

Prognostic analysis of the bronchoplastic and broncho-arterioplastic lobectomy of non-small cell lung cancers-10-year experiences of 161 patients

BACKGROUND

Bronchoplastic and broncho-arterioplastic lobectomy is technically demanding. Present study performed a prognostic analysis of lobectomy patient based on 10-year data in a high-volume center.

METHODS

Overall, 161 non-small cell lung cancer (NSCLC) cases underwent bronchoplastic and broncho-arterioplastic lobectomy between January 2004 and November 2013. Follow-up information was obtained for 88.8% patients. Prognostic analysis was performed with the Cox proportional hazards model.

RESULTS

There were 133 bronchoplastic and 28 broncho-arterioplastic procedures. In detail, 97 sleeve and 64 wedge broncho-resection and reconstructions were conducted; pulmonary artery sleeve reconstructions were performed in 26 cases and tangential resection in 135 cases. 90-day post-operative mortality was 3.1% (5/161), and 24.8% (40/161) patients had post-operative complications. 5-year overall survival was 53.4% and 5-year disease-free survival (DFS) was 48.2% for the entire case series; these survival rates were 67.7% and 55.7% for stage I (n=31), 64.4% and 58.9% for stage II (n=62), and 36.9% and 31.9% for stage III disease, respectively. Univariate analysis revealed that age >65 and higher grade of pN were associated with worse overall survival while right side tumor, non-squamous histology type, and higher grade of pT and pN were associated with worse DFS. Multivariate analysis revealed that pN is the only independent factor of worse outcome.

CONCLUSIONS

Bronchoplastic and broncho-arterioplastic lobectomy are safe procedures for indicated NSCLC patients associated with a low rate of post-operative complications but favorable long-term survival. Recognition of prognostic factors helps improve outcomes for these patients.

A lobe-specific lymphadenectomy protocol for solitary pulmonary nodules in non-small cell lung cancer

BACKGROUND

We want to establish a lobe-specific mediastinal lymphadenectomy protocol for solitary pulmonary nodules (SPNs) in non-small cell lung cancer (NSCLC).

METHODS

We retrospectively analyzed 401 patients with pathological diagnoses of NSCLC who underwent lobectomy, bilobectomy, or pneumonectomy with systematic lymphadenectomy from March 2004 to June 2011 in our hospital. All of the patients enrolled had a SPN preoperatively. Information about the primary tumor location, lymph node metastasis, and other baseline data were collected. Stepwise logistic regression was used to identify the key factors indicating non-regional mediastinal lymph node metastases (NRM).

RESULTS

Of the primary tumors, 117, 39, 74, 104, and 67 were in the right upper lung (RUL), right middle lung (RML), right lower lung (RLL), left upper lung (LUL), and left lower lung (LLL), respectively. Stepwise regression showed that #2,4, #10,11, and #10,11 as well as #7 was the key lymph node station for RUL, LUL, and lower lobes: #2,4 [odds ratio (OR)=28.000, 95% confidence interval (CI): 2.917-268.790, P=0.004] for RUL, #10,11 (OR=31.667, 95% CI: 2.502-400.833, P=0.008) for LUL, #10,11 (OR=19.540, 95% CI: 4.217-90.541, P<0.001) and #7 (OR=7.395, 95% CI: 1.586-34.484, P=0.011) for lower lobes, respectively. Patients with tumors >2 cm rarely had NRM without primary regional mediastinal involvement.

CONCLUSIONS

With rigid consideration, a lobe-specific lymphadenectomy is feasible in practice. This protocol can be used when the lobe-specific key nodes are negative in intraoperative frozen sections, especially for NSCLC diagnosed as SPN <2 cm preoperatively.

Nodal Upstaging Is More Common with Thoracotomy than with VATS During Lobectomy for Early-Stage Lung Cancer: An Analysis from the National Cancer Data Base

INTRODUCTION

Questions remain regarding differences in nodal evaluation and upstaging between thoracotomy (open) and video-assisted thoracic surgery (VATS) approaches to lobectomy for early-stage lung cancer. Potential differences in nodal staging based on operative approach remain the final significant barrier to widespread adoption of VATS lobectomy. The current study examines differences in nodal staging between open and VATS lobectomy.

METHODS

The National Cancer Data Base was queried for patients with clinical stage T2N0M0 or lower lung cancer who underwent lobectomy in 2010-2011. Propensity score matching was performed to compare the rate of nodal upstaging in VATS with that in open approaches. Additional subgroup analysis was performed to assess whether rates of upstaging differed by specific clinical setting.

RESULTS

A total of 16,983 lobectomies were analyzed; 4935 (29.1%) were performed using VATS. Nodal upstaging was more frequent in the open group (12.8% versus 10.3%; p < 0.001). In 4437 matched pairs, nodal upstaging remained more common for open approaches. For a subgroup of patients who had seven lymph or more nodes examined, propensity matching revealed that nodal upstaging remained more common after an open approach than after VATS (14.0% versus 12.1%; p = 0.03). For patients who were treated in an academic/research facility, however, the difference in nodal upstaging between an open and VATS approach was no longer significant (12.2% versus 10.5%, p = 0.08).

CONCLUSIONS

For early-stage lung cancer, nodal upstaging was observed more frequently with thoracotomy than with VATS. However, nodal upstaging appears to be affected by facility type, which may be a surrogate for expertise in minimally invasive surgical procedures.

Safety of thoracoscopic surgery for lung cancer without interruption of anti-platelet agents

BACKGROUND

Perioperative bleeding concerns have led to the general recommendation that antiplatelet agents (APAs) be discontinued 7-10 days preoperatively, but this could increase the risk of perioperative cardiovascular events. This retrospective study aimed to evaluate the safety of APA continuation during thoracoscopic surgery for lung cancer.

METHODS

Between January 2009 and February 2015, 164 patients taking APAs underwent curative resection. Comparisons were conducted between two groups: preoperatively interrupted APA administration (group I, n=106) and continued APA administration (group N, n=58).

RESULTS

Group N had a significantly higher revised cardiac risk index (rCRI) (P=0.001). Lobectomy was performed in the majority of patients [95 (89.6%) in group I; 52 (89.7%) in group N]. There were no significant differences in intraoperative outcomes, such as the thoracotomy conversion rate, operating time, intraoperative transfusion, and amount of blood loss during the operation, or postoperative outcomes, such as postoperative bleeding and thrombotic complications, postoperative transfusions, and operative mortality. Within group N, the patients taking aspirin + clopidogrel (n=11) had significantly greater postoperative bleeding (P=0.005), and more postoperative transfusions (P=0.003) and chest tube drainage over a 3-day period (P=0.049) compared with other antiplatelet regimens.

CONCLUSIONS

Continued use of APAs during thoracoscopic surgery for lung cancer could be safely done in patients at high risk of cardiac or thrombotic events. However, in patients administered aspirin + clopidogrel, it may be the best to continue aspirin only because of an increased risk of postoperative bleeding and transfusion requirements.

Middle lobe preserving right lower lobectomy with a serratus anterior hammock flap in a patient with previous right upper lobectomy

Increasingly, many patients are diagnosed with a second lung cancer after curative thoracotomy. It is very difficult to manage such patients surgically due to the significant loss of pulmonary function. Especially on the right side, avoiding a completion pneumonectomy may contribute to reducing postoperative functional loss and surgical complications as well as the morbidity of post-pneumonectomy syndrome. A technique is needed to prevent torsion of the preserved middle lobe. Following recently published cases utilizing a latissimus dorsi muscle flap, in this case report, we describe the use of the serratus anterior muscle flap as an alternative.

Residual disease at the bronchial stump is positively associated with the risk of bronchoplerual fistula in patients undergoing lung cancer surgery: a meta-analysis

OBJECTIVES

Residual disease at the bronchial stump (RDBS) is regarded as an important factor possibly resulting in bronchopleural fistula (BPF) after lung cancer surgery, but this has not been confirmed. We conducted this meta-analysis to evaluate the effects of RDBS on BPF formation in patients undergoing lung cancer surgery.

METHODS

PubMed and EMBASE databases were searched for full-text articles that met our eligibility criteria. Odds ratios (ORs) with 95% confidence interval (95% CI) served as the summarized outcomes. Q-test and I(2) statistic were used to evaluate the level of heterogeneity, determining the fixed-effect model or random-effect model for quantitative synthesis. Sensitivity analysis was conducted to identify the possible origins of heterogeneity. The publication bias was assessed by Begg's test.

RESULTS

A total of eight retrospective observational studies were included in our meta-analysis. In overall analysis, the pooled outcomes indicated that RDBS was significantly associated with BPF formation after lung cancer surgery (OR: 3.12; 95% CI: 1.72-5.64; P < 0.001). In subgroup analysis, the pooled outcomes revealed a significantly increased risk of post-pneumonectomy BPF in patients with RDBS (OR: 2.78; 95% CI: 1.06-7.28; P = 0.037). The subgroup analysis assessing the effects of RDBS on post-lobectomy BPF was given up due to the scarcity of available data. No heterogeneity was revealed within this meta-analysis. No evidence for publication bias was detected by Begg's test.

CONCLUSIONS

Our meta-analysis indicates that RDBS is positively associated with the increased risk of BPF in patients undergoing lung cancer surgery. The further analysis also reveals an increased risk of post-pneumonectomy BPF in patients with RDBS. More accurate and comprehensive evidence should be collected and summarized in updated meta-analyses.

Intraoperative bronchial stump air leak control by Progel® application after pulmonary lobectomy

Diffuse tracheobronchial calcification is a physiological condition associated with advanced age, especially in women. A calcified bronchus can be fractured during major lung resections (lobectomy, bilobectomy, and pneumonectomy), exposing patients to intraoperative air leakage and broncho-pleural fistula (BPF) occurrence. We retrospectively evaluated the use of Progel® application on the suture line of bronchial stump after pulmonary lobectomy analysing the intraoperative air leak and BPF occurrence. Between January 2014 and December 2014, Progel® was applied in 11 patients who presented intraoperative bronchial fractures after suture resection by mechanical staplers and air leak from bronchial stump, in order to treat air leakage. Patients were 7 men and 4 women, aged between 56 and 81 years (mean age 71.2 ± 12.1 years). Surgical procedures included 6 upper lobectomies (4 right, 2 left), 1 bilobectomy and 4 lower lobectomies (3 right, 1 left). Mean hospital stay was 4.5 ± 2.6 days (2-8 days). None of the patients had postoperative air leakage. No Progel® application-related complications occurred. No other major complications occurred. No mortality occurred. Progel® proved to be useful in treating intraoperative air leakage during major lung resections, particularly those occurring as a result of fracture of the bronchus from a mechanical stapler.