Surgery for early-stage non-small cell lung cancer: a systematic review of the video-assisted thoracoscopic surgery versus thoracotomy approaches to lobectomy

Simultaneous thoracoscopic surgery in patients with atrial fibrillation and early-stage lung cancer

OBJECTIVES

Atrial fibrillation (AF) and early-stage lung cancer can both be treated under thoracoscopy. This study aims to evaluate the feasibility and safety of simultaneous thoracoscopic surgery for atrial fibrillation and early-stage lung cancer.

METHODS

This was a single-center, retrospective study of 865 patients with paroxysmal or non-paroxysmal AF who underwent surgical ablation between October 2014 and December 2021. Patients were divided into two groups according to whether they have undergone simultaneous thoracoscopic early-stage lung cancer surgery and resulting in 24 pairs of patients.

RESULTS

In total, 48 patients (24 matched pairs) were analyzed. The age was 63.71 ± 8.43 years. Procedure time and postoperative mechanical ventilation time were significantly lower in the group AF than group AFLC (Atrial fibrillation and lung cancer) (140.38 ± 27.53 vs. 230.79 ± 59.06 min, P<0.001; 5 vs 6.5 h, P = 0.002). There was no significant difference between the groups in terms of operative bleeding volume (90.00 ± 29.78 vs 85.83 ± 53.56 ml, P = 0.741), total postoperative drainage volume (1020.83 ± 516.5 vs 1406.25 ± 840.33 ml, P = 0.067), ICU (intensive care unit) length of stay (LOS) (43.5 vs 44 h, P = 0.33), hospitalization LOS (9.29 ± 1.92 vs 8.58 ± 1.98 days, P = 0.214) and incidence of freedom from AF or complications.

CONCLUSIONS

Simultaneous thoracoscopic surgical AF ablation and early-stage lung cancer is safe and feasible. It can be used as an alternative method for coexisting atrial fibrillation and lung cancer with acceptable operative risks.

Germline Polymorphisms Associated with Overall Survival in Lung Adenocarcinoma: Genome-Wide Analysis

BACKGROUND/OBJECTIVES

Lung cancer remains a global health concern, with substantial variation in patient survival. Despite advances in detection and treatment, the genetic basis for the divergent outcomes is not understood. We investigated germline polymorphisms that modulate overall survival in 1464 surgically resected lung adenocarcinoma patients.

METHODS

A multivariable Cox proportional hazard model was used to assess the association of more than seven million polymorphisms with overall survival at the 60-month follow-up, considering age, sex, pathological stage, decade of surgery and principal components as covariates. Genes in which variants were identified were studied in silico to investigate functional roles.

RESULTS

Six germline variants passed the genome-wide significance threshold. These single nucleotide polymorphisms were mapped to non-coding (intronic) regions on chromosomes 2, 3, and 5. The minor alleles of rs13000315, rs151212827, and rs190923216 (chr. 2, 3 and 5, respectively) were found to be independent negative prognostic factors. All six variants have been reported to regulate the expression of nine genes, seven of which are protein-coding, in different tissues. Survival-associated variants on chromosomes 2 and 3 were already reported to regulate the expression of NT5DC2 and NAGK, with high expression associated with the minor alleles. High NT5DC2 and NAGK expression in lung adenocarcinoma tissue was already shown to correlate with poor overall survival.

CONCLUSIONS

This study highlights a potential regulatory role of the identified polymorphisms in influencing outcome and suggests a mechanistic link between these variants, gene expression regulation, and lung adenocarcinoma prognosis. Validation and functional studies are warranted to elucidate the mechanisms underlying these associations.

The Surgical Renaissance: Advancements in Video-Assisted Thoracoscopic Surgery and Robotic-Assisted Thoracic Surgery and Their Impact on Patient Outcomes

Minimally invasive thoracic surgery has advanced the treatment of lung cancer since its introduction in the 1990s. Video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracic surgery (RATS) offer the advantage of smaller incisions without compromising patient outcomes. These techniques have been shown to be safe and effective in standard pulmonary resections (lobectomy and sub-lobar resection) and in complex pulmonary resections (sleeve resection and pneumonectomy). Furthermore, several studies show these techniques enhance patient outcomes from early recovery to improved quality of life (QoL) and excellent oncologic results. The rise of RATS has yielded further operative benefits compared to thoracoscopic surgery. The wristed instruments, neutralization of tremor, dexterity, and magnification allow for more precise and delicate dissection of tissues and vessels. This review summarizes of the advancements in minimally invasive thoracic surgery and the positive impact on patient outcomes.

Modified surgical fusion: VATS and BABA approach for ectopic intrathoracic and cervical thyroidectomy

Ectopic goitre, presenting as an isolated thoracic mass without connection to the main thyroid gland enlargement, is a rare occurrence. We describe a case where a patient reported persistent dry cough and back pain for 1 year, along with throat discomfort unresponsive to medication. A 2×1 cm swelling was noted over the right anterior aspect of the neck. Extensive evaluation, including chest X-rays and contrast-enhanced CT of the thorax, revealed a mediastinal mass suggestive of an ectopic thyroid.This case presents a distinctive scenario involving the simultaneous presence of ectopic mediastinal and cervical thyroid lesions. Both were effectively managed using a minimally invasive approach, combining video-assisted thoracic surgery for the excision of the mediastinal mass and a bilateral axillo-breast approach for the cervical lesion in a single procedure. This approach yielded minimal morbidity, aesthetically pleasing outcomes and rapid recovery. Remarkably, such a case has not been previously documented in the available literature.

An injectable fluorescent and iodinated hydrogel for preoperative localization and dual image-guided surgery of pulmonary nodules

The widespread use of video-assisted thoracoscopic surgery (VATS) has triggered the rapid expansion in the field of computed tomography (CT)-guided preoperative localization and near-infrared (NIR) fluorescence image-guided surgery. However, its broader application has been hindered by the absence of ideal imaging contrasts that are biocompatible, minimally invasive, highly resolvable, and perfectly localized within the diseased tissue. To achieve this goal, we synthesize a dextran-based fluorescent and iodinated hydrogel, which can be injected into the tissue and imaged with both CT and NIR fluorescence modalities. By finely tuning the physical parameters such as gelation time and composition of iodinated oil (X-ray contrast agent) and indocyanine green (ICG, NIR fluorescence dye), we optimize the hydrogel for prolonged localization at the injected site without losing the dual-imaging capability. We validate the effectiveness of the developed injectable dual-imaging platform by performing image-guided resection of pulmonary nodules on tumor-bearing rabbits, which are preoperatively localized with the hydrogel. The injectable dual-imaging marker, therefore, can emerge as a powerful tool for surgical guidance.

Development of a Risk Scoring Model to Predict Unexpected Conversion to Thoracotomy during Video-Assisted Thoracoscopic Surgery for Lung Cancer

Background

Unexpected conversion to thoracotomy during planned video-assisted thoracoscopic surgery (VATS) can lead to poor outcomes and comparatively high morbidity. This study was conducted to assess preoperative risk factors associated with unexpected thoracotomy conversion and to develop a risk scoring model for preoperative use, aimed at identifying patients with an elevated risk of conversion.

Methods

A retrospective analysis was conducted of 1,506 patients who underwent surgical resection for non-small cell lung cancer. To evaluate the risk factors, univariate analysis and logistic regression were performed. A risk scoring model was established to predict unexpected thoracotomy conversion during VATS of the lung, based on preoperative factors. To validate the model, an additional cohort of 878 patients was analyzed.

Results

Among the potentially significant clinical variables, male sex, previous ipsilateral lung surgery, preoperative detection of calcified lymph nodes, and clinical T stage were identified as independent risk factors for unplanned conversion to thoracotomy. A 6-point risk scoring model was developed to predict conversion based on the assessed risk, with patients categorized into 4 groups. The results indicated an area under the receiver operating characteristic curve of 0.747, with a sensitivity of 80.5%, specificity of 56.4%, positive predictive value of 1.8%, and negative predictive value of 91.0%. When applied to the validation cohort, the model exhibited good predictive accuracy.

Conclusion

We successfully developed and validated a risk scoring model for preoperative use that can predict the likelihood of unplanned conversion to thoracotomy during VATS of the lung.

Resectable non-stage IV nonsmall cell lung cancer: the surgical perspective

Surgery remains an essential element of the multimodality radical treatment of patients with early-stage nonsmall cell lung cancer. In addition, thoracic surgery is one of the key specialties involved in the lung cancer tumour board. The importance of the surgeon in the setting of a multidisciplinary panel is ever-increasing in light of the crucial concept of resectability, which is at the base of patient selection for neoadjuvant/adjuvant treatments within trials and in real-world practice. This review covers some of the topics which are relevant in the daily practice of a thoracic oncological surgeon and should also be known by the nonsurgical members of the tumour board. It covers the following topics: the pre-operative selection of the surgical candidate in terms of fitness in light of the ever-improving nonsurgical treatment alternatives unfit patients may benefit from; the definition of resectability, which is so important to include patients into trials and to select the most appropriate radical treatment; the impact of surgical access and surgical extension with the evolving role of minimally invasive surgery, sublobar resections and parenchymal-sparing sleeve resections to avoid pneumonectomy.

Extracervical Approaches to Substernal Thyroid Goiter Resection: A Systematic Review and Meta-Analysis

Objective

To evaluate the prevalence of extracervical approaches (ECAs) for substernal goiter (SSG) excision.

Data Sources

Search strategies created in collaboration with a medical librarian were implemented using PubMed, Cochrane, Scopus, Web of Science, and Google Scholar from inception to July 2021.

Review Methods

Participants included adults ages >18 years undergoing SSG excision. The primary outcome was rate of ECA via sternotomy or thoracotomy. Studies were categorized into the 3 most common distinct definitions: goiter descending below the plane of the thoracic inlet (definition 1), ≥50% of thyroid mass extending below the sternal notch (definition 2), and goiter extending ≥3 cm below the suprasternal notch when the neck is hyperextended (definition 3). Two reviewers independently extracted data for analysis and performed a quality assessment using the Methodological Index for Non-Randomized Studies criteria.

Results

Of the 551 studies identified, 69 studies were included for analysis. Definition 1 included 3441 patients from 31 studies; definition 2 included 2957 patients from 26 studies; and definition 3 included 2921 patients from 12 studies. A random-effect model estimating the pooled prevalence of ECA using definition 1 resulted in prevalence of 6.12% (95% confidence interval: 3.48-9.34, I 2 = 90.72%).

Conclusion

Extension below the thoracic inlet is the most widely used definition of SSG. Approximately 6% of patients with a SSG undergo an ECA. Patients with SSG undergoing surgery should be counseled on the prevalence, risks, and morbidity of an ECA in the rare occurrence it is needed.

Results of video-assisted thoracoscopic surgery versus thoracotomy for lung cancer in a mixed practice medium-volume hospital: a propensity-matched study

OBJECTIVES

The aim of this study was to compare the short- and long-term results of video-assisted thoracoscopic surgery (VATS) and thoracotomy for non-small-cell lung cancer in a medium-volume centre, where cardiothoracic surgeons perform both cardiac and general thoracic surgery. The primary outcome of interest was 5-year overall survival and disease-specific survival. Secondary outcomes were short-term postoperative complications, length of hospital stay and lymph node yield.

METHODS

This was a retrospective cohort study including 670 lung cancer patients undergoing VATS (n = 207) or open surgery (n = 463) with a curative intent in Oulu University Hospital between the years 2000-2020. Propensity score matching was implemented with surgical technique as the dependent and age, sex, Charlson comorbidity index, pulmonary function, pathological stage, histological type and the year of the operation as covariates resulting in 127 pairs.

RESULTS

In the propensity-matched cohort, 5-year overall survival was 64.3% after VATS and 63.2% after thoracotomy (P = 0.969). Five-year disease-specific survival was 71.6% vs 76.2% (P = 0.559). There were no differences in overall (34.6% vs 44.9%, p = 0.096) or major postoperative complications (8.7% vs 14.2%, P = 0.167) between the study groups. The average length of hospital stay was shorter (5.8 vs 6.6 days, P = 0.012) and the median lymph node yield was lower (4.0 vs 7.0, P < 0.001) in the VATS group compared to the thoracotomy group.

CONCLUSIONS

According to this study, the long-term results of lung cancer surgery in a mixed practice are comparable between VATS and open surgery.

Effectiveness of Surgeon-Performed Paravertebral Block Analgesia for Minimally Invasive Thoracic Surgery: A Randomized Clinical Trial

Importance

In minimally invasive thoracic surgery, paravertebral block (PVB) using ultrasound (US)-guided technique is an efficient postoperative analgesia. However, it is an operator-dependent process depending on experience and local resources. Because pain-control failure is highly detrimental, surgeons may consider other locoregional analgesic options.

Objective

To demonstrate the noninferiority of PVB performed by surgeons under video-assisted thoracoscopic surgery (VATS), hereafter referred to as PVB-VATS, as the experimental group compared with PVB performed by anesthesiologists using US-guided technique (PVB-US) as the control group.

Design, Setting, and Participants

In this single-center, noninferiority, patient-blinded, randomized clinical trial conducted from September 8, 2020, to December 8, 2021, patients older than 18 years who were undergoing a scheduled minimally invasive thoracic surgery with lung resection including video-assisted or robotic approaches were included. Exclusion criteria included scheduled open surgery, any antalgic World Health Organization level greater than 2 before surgery, or a medical history of homolateral thoracic surgery. Patients were randomly assigned (1:1) to an intervention group after general anesthesia. They received single-injection PVB before the first incision was made in the control group (PVB-US) or after 1 incision was made under thoracoscopic vision in the experimental group (PVB-VATS).

Interventions

PVB-VATS or PVB-US.

Main Outcomes and Measures

The primary end point was mean 48-hour post-PVB opioid consumption considering a noninferiority range of less than 7.5 mg of opioid consumption between groups. Secondary outcomes included time of anesthesia, surgery, and operating room occupancy; 48-hour pain visual analog scale score at rest and while coughing; and 30-day postoperative complications.

Results

A total of 196 patients were randomly assigned to intervention groups: 98 in the PVB-VATS group (mean [SD] age, 64.6 [9.5] years; 53 female [54.1%]) and 98 in the PVB-US group (mean [SD] age, 65.8 [11.5] years; 62 male [63.3%]). The mean (SD) of 48-hour opioid consumption in the PVB-VATS group (33.9 [19.8] mg; 95% CI, 30.0-37.9 mg) was noninferior to that measured in the PVB-US group (28.5 [18.2] mg; 95% CI, 24.8-32.2 mg; difference: -5.4 mg; 95% CI, -∞ to -0.93; noninferiority Welsh test, P ≤ .001). Pain score at rest and while coughing after surgery, overall time, and postoperative complications did not differ between groups.

Conclusions and Relevance

PVB placed by a surgeon during thoracoscopy was noninferior to PVB placed by an anesthesiologist using ultrasonography before incision in terms of opioid consumption during the first 48 hours.

Trial Registration

ClinicalTrials.gov Identifier: NCT04579276.

Sublobar resection versus lobectomy for stage IA non-small-cell lung cancer: A systematic review and meta-analysis of randomized controlled trials

Surgical resection is the first-line treatment for early-stage lung cancer, with lobectomy being the standard choice since the 1960s. Nevertheless, recent studies have shown controversies about whether sublobar resection or lobectomy is the optimal surgical approach today. In this sense, this meta-analysis aims to compare these techniques. PubMed, EMBASE, and Cochrane databases were searched for randomized controlled trials (RCTs) comparing sublobar resection with lobectomy for stage IA non-small-cell lung cancer (NSCLC) and reporting any of the following outcomes: (1) Overall survival (OS); (2) disease-free survival (DFS); and (3) total disease recurrences. Sublobar resection encompassed wedge resection and segmentectomy techniques. A total of 1975 patients from four studies were included, of whom 978 (49.5%) underwent sublobar resection and 973 (49.3%) were male. All tumors were smaller than 2 cm. Follow-up ranged from 5 to 7.3 years. Mean age was 62.8 ± 37.0 years, and 1353 (68.5%) patients had a known smoking history. OS (HR 0.79; 95% CI 0.60-1.05; p = 0.11) and DFS (HR 1.02; 95% CI 0.86-1.22; p = 0.80) did not significantly differ between the sublobar resection and lobectomy groups. Similarly, no significant statistical difference was observed in total disease recurrences (RR 1.17; 95% CI 0.93-1.46; p = 0.17). Subgroup and isolated sublobar resection techniques analyses were not possible due to the lack of data. Sublobar resection and lobectomy have similar OS, DFS, and disease recurrence rates for stage IA NSCLC. These findings underline the need for new RCTs investigating these outcomes in specific patient subgroups and isolated sublobar resection techniques.

Comparing Thoracoscopic and Robotic Lobectomy Using a Nationally Representative Database

BACKGROUND

Studies of robotic lobectomy (Robot-L) have been performed using data from high-volume, specialty centers which may not be generalizable. The purpose of this study was to compare mortality, length of stay (LOS), and cost between Robot-L and thoracoscopic lobectomy (VATS-L) using a nationally representative database hypothesizing they would be similar.

METHODS

The Premier Healthcare Database was used to identify patients receiving elective lobectomy for lung cancer from 2009 to 2019. Patients were categorized as receiving Robot-L or VATS-L using ICD-9/10 codes. Survey methodology and patient level weighting were used to correct for sampling error and estimation of a nationally representative sample. A propensity match analysis was performed to reduce bias between the groups. Primary outcome of interest was in-hospital mortality. Secondary outcomes were LOS and patient charges.

RESULTS

Among 62 698 patients, 19 506 (31.1%) underwent Robot-L and 43 192 (68.9%) underwent VATS-L. Differences between the groups included age, race, comorbidities, and insurance type. A propensity matched cohort demonstrated similar in-hospital mortality for Robot-L and VATS-L (.9% vs .9%, respectively, P = .91). Patients who underwent Robot-L had a shorter LOS (4 vs 5d, respectively, P < .001) but higher patient charges (90 593.0 vs 72 733.3 USD, respectively, P < .001).

CONCLUSIONS

In a nationally representative database, Robot-L and VATS-L had similar mortality. Although Robot-L was associated with shorter hospitalization, it was also associated with excess charges of almost $20,000. As Robot-L is now the most common approach for lobectomy in the U.S., further study into the cost and benefit of robotic surgery is warranted.

Paravertebral vs Epidural Anesthesia for Video-assisted Thoracoscopic Surgery: A Randomized Trial

BACKGROUND

The choice of postoperative pain management for patients who experience moderate to severe acute pain after thoracoscopic surgery is debatable. This study aimed to determine whether paravertebral block (PVB) provides more benefits than thoracic epidural analgesia (TEA) for thoracoscopic surgery.

METHODS

From February 2020 to April 2022, patients without chronic pain who were scheduled to undergo thoracoscopic surgery were randomly assigned to the PVB group or the TEA group. The visual analogue scale score was used to measure the degree of pain when the patients were at rest or coughing.

RESULTS

In total, 176 eligible patients were enrolled in this study. No significant difference in the visual analogue scale score was found between the 2 groups at rest (P = .395) or with coughing (P = .157). Additionally, there was no significant difference in the average pain score between these 2 states (P = .221). The median time for catheter placement in the PVB group was 5 minutes, which was shorter than that (14 minutes) in the TEA group (P < .001). Moreover, the catheter placement failure rate in the PVB group was lower than that in the TEA group (P = .038). The incidence of hypotension (P = .016) and urinary retention (P = .006) in the PVB group was lower than that in the TEA group.

CONCLUSIONS

PVB can provide pain relief that is similar to that of TEA but with no additional puncture pain, a shorter catheter placement time, and fewer side effects in patients undergoing video-assisted thoracoscopic surgery.

Clinical, Microbiological and Treatment Characteristics of Severe Postoperative Respiratory Infections: An Observational Cohort Study

Respiratory infections are frequent and life-threatening complications of surgery. This study aimed to evaluate the clinical, microbiological and treatment characteristics of severe postoperative pneumonia (POP) and tracheobronchitis (POT) in a large series of patients. This single-center, prospective observational cohort study included patients with POP or POT requiring intensive care unit admission in the past 10 years. We recorded demographic, clinical, microbiological and therapeutic data. A total of 207 patients were included, and 152 (73%) were men. The mean (SD) age was 70 (13) years and the mean (SD) ARISCAT score was 46 (19). Ventilator-associated pneumonia was reported in 21 patients (10%), hospital-acquired pneumonia was reported in 132 (64%) and tracheobronchitis was reported in 54 (26%). The mean (SD) number of days from surgery to POP/POT diagnosis was 6 (4). The mean (SD) SOFA score was 5 (3). Respiratory microbiological sampling was performed in 201 patients (97%). A total of 177 organisms were cultured in 130 (63%) patients, with a high proportion of Gram-negative and multi-drug resistant (MDR) bacteria (20%). The most common empirical antibiotic therapy was a triple-drug regimen covering MDR Gram-negative bacteria and MRSA. In conclusion, surgical patients are a high-risk population with a high proportion of early onset severe POP/POT and nosocomial bacteria isolation.

A look ahead to promote the early detection of lung cancer: technical and cost implications of a confirmed diagnosis before surgery

OBJECTIVE

To compare the costs and length of hospital stay among patients with a confirmed diagnosis of lung cancer (LC) prior to surgery versus those without confirmation.

METHODS

This retrospective, single-center study was conducted in patients who underwent a surgical procedure for LC, with or without a pathologically confirmed LC diagnosis prior to surgery, between March 2017 and December 2019. The main outcomes were costs and length of hospital stay (LOS).

RESULTS

Among the 269 patients who underwent surgery for lung cancer between March 2017 and December 2019, 203 (75.5%) patients underwent surgery due to a histopathological diagnosis, and 66 (24.5%) because of a Multidisciplinary Cancer Committee indication. The unadjusted mean cost was significantly lower in Group II (patients with surgery based on Multidisciplinary Cancer Committee criteria) (Є2,581.80 ± Є1,002.50) than in Group I (patients with histopathological diagnosis) (Є4,244.60 ± Є2,008.80), P < 0.0001. Once adjusted for covariables, there was a mean difference of -Є1,437.20 in the costs of Group II, P < 0.0001. Unadjusted mean hospital stay was significantly longer in Group I (5.6 days) than in Group II (3.5 days).

CONCLUSIONS

The results suggest that indicating surgical resection of lung cancer based on Multidisciplinary Cancer Committee criteria, rather than performing CT-guided percutaneous lung biopsy, may result in a significant decrease in cost and length of hospital stay.

Safety and feasibility of a novel chest tube placement in uniportal video-assisted thoracoscopic surgery for non-small cell lung cancer

BACKGROUND

The type and placement of chest tube for patients undergoing uniportal video-assisted thoracoscopic lobectomy remains controversial. The aim of this study was to assess the efficacy and safety of a novel technique in which a pigtail catheter was used alone as the chest tube and placed near the incision for chest drainage after uniportal video-assisted thoracoscopic lobectomy and extended lymphadenectomy.

METHODS

A total of 217 patients undergoing uniportal video-assisted thoracoscopic lobectomy were retrospectively reviewed and divided into two groups. In group A, a 12-Fr pigtail catheter with several side ports was placed next to the uniportal wound. In group B, a conventional 20-Fr chest tube was placed through the uniportal wound itself. Postoperative complications related to chest tube placement and patients' subjective satisfaction were compared between the two groups. Postoperative pain management effect and other clinical outcomes such as duration of chest drainage and postoperative stay were also compared.

RESULTS

There were 112 patients in group A and 105 patients in group B. A significantly lower incidence of wound complications was found in group A postoperatively (p = 0.034). The pain score on coughing in group A was significantly lower than that in group B on postoperative day two (POD2) (p = 0.021). There was no significant difference of other clinical outcomes such as duration of chest drainage and postoperative stay as well as major complications between the two groups.

CONCLUSION

Placing a 12-Fr pigtail catheter alone next to the uniportal wound for chest drainage might be effective and safe after uniportal video-assisted thoracoscopic lobectomy and extended lymphadenectomy.

Bleeding-related re-exploration following pulmonary resection: a report of a single-center experience

PURPOSE

Postoperative bleeding is a potentially fatal complication after lung surgery and usually requires re-operation. The aim of this study was to analyze the characteristics of bleeding-related re-exploration following pulmonary resection and reduce the incidence of this complication.

METHODS

From January 2016 to December 2020, 14,104 patients underwent pulmonary resection for lung cancer or pulmonary nodule at Fudan University Shanghai Cancer Center, China. We evaluated cases with bleeding-related re-exploration, and analyzed the relationship between postoperative bleeding and clinical characteristics. We further developed a protocol to reduce the proportion of bleeding-related re-exploration in our center.

RESULTS

Bleeding-related re-exploration occurred in 85 (0.60%) out of 14,104 patients. The sources of postoperative bleeding included surgical incision (20, 23.53%), parietal pleura (20, 23.53%), bronchial artery (14, 16.47%), lung parenchyma (13, 15.29%), pulmonary vessel (5, 5.88%) and rare source of bleeding. There were various patterns of postoperative bleeding. Open thoracotomy had a significantly higher bleeding rate than video-assisted thoracoscopic surgery (VATS) (1.27% vs 0.34%, p < 0.0001). The bleeding rate of pneumonectomy, lobectomy, segmentectomy and wedge resection was significantly different (1.78%, 0.88%, 0.46% vs 0.28%, p < 0.0001). All patients were discharged successfully except for one patient died of respiratory failure. A protocol based on these findings was developed to reduce the proportion of bleeding-related re-exploration in our center.

CONCLUSION

Our findings revealed that the source of bleeding, surgical approach and procedure affected the pattern of postoperative bleeding. Postoperative bleeding could be managed properly on the timely decision of re-exploration considering its origin, severity, onset and risk factors.

Uniportal video-assisted anatomical segmentectomy: an analysis of the learning curve

BACKGROUND

This study aimed to demonstrate the learning curve of anatomical segmentectomy performed by uniportal video-assisted thoracoscopic surgery (U-VATS).

METHOD

We conducted a retrospective study of U-VATS segmentectomies performed by the same surgeon between September 2019 and August 2022. The learning curve was demonstrated using risk-adjusted cumulative sum (RA-CUSUM) analysis in terms of perioperative complications, which reflected surgical quality and technique proficiency. The surgical outcomes were also compared between different phases.

RESULT

The complication-based learning curve of U-VATS segmentectomy could be divided into two phases based on RA-CUSUM analysis: phase I, the initial learning phase (cases 1-50) and phase II, the proficiency phase (cases 51-141). Significantly higher complication rates (24.0 vs. 8.8%, p=0.013), longer surgical times (119.8±31.9 vs. 106.2±23.8 min, p=0.005), and more blood loss (20 [IQR, 20-30] vs. 20 [IQR, 10-20] ml, p=0.003) were observed in phase I than in phase II.

CONCLUSION

The learning curve of U-VATS segmentectomy consists of two phases, and at least 50 cases were required to gain technique proficiency and achieve high-quality surgical outcomes.

Optimization of Indocyanine Green for Intraoperative Fluorescent Image-Guided Localization of Lung Cancer; Analysis Based on Solid Component of Lung Nodule

ICG fluorescence imaging has been used to detect lung cancer; however, there is no consensus regarding the optimization of the indocyanine green (ICG) injection method. The aim of this study was to determine the optimal dose and timing of ICG for lung cancer detection using animal models and to evaluate the feasibility of ICG fluorescence in lung cancer patients. In a preclinical study, twenty C57BL/6 mice with footpad cancer and thirty-three rabbits with VX2 lung cancer were used. These animals received an intravenous injection of ICG at 0.5, 1, 2, or 5 mg/kg, and the cancers were detected using a fluorescent imaging system after 3, 6, 12, and 24 h. In a clinical study, fifty-one patients diagnosed with lung cancer and scheduled to undergo surgery were included. Fluorescent images of lung cancer were obtained, and the fluorescent signal was quantified. Based on a preclinical study, the optimal injection method for lung cancer detection was 2 mg/kg ICG 12 h before surgery. Among the 51 patients, ICG successfully detected 37 of 39 cases with a consolidation-to-tumor (C/T) ratio of >50% (TNR: 3.3 ± 1.2), while it failed in 12 cases with a C/T ratio ≤ 50% and 2 cases with anthracosis. ICG injection at 2 mg/kg, 12 h before surgery was optimal for lung cancer detection. Lung cancers with the C/T ratio > 50% were successfully detected using ICG with a detection rate of 95%, but not with the C/T ratio ≤ 50%. Therefore, further research is needed to develop fluorescent agents targeting lung cancer.

Pulmonary Open, Robotic, and Thoracoscopic Lobectomy (PORTaL) Study: Survival Analysis of 6646 Cases

OBJECTIVE

The aim of this study was to analyze overall survival (OS) of robotic-assisted lobectomy (RL), video-assisted thoracoscopic lobectomy (VATS), and open lobectomy (OL) performed by experienced thoracic surgeons across multiple institutions.

SUMMARY BACKGROUND DATA

Surgeons have increasingly adopted RL for resection of early-stage lung cancer. Comparative survival data following these approaches is largely from single-institution case series or administrative data sets.

METHODS

Retrospective data was collected from 21 institutions from 2013 to 2019. Consecutive cases performed for clinical stage IA-IIIA lung cancer were included. Induction therapy patients were excluded. The propensity-score method of inverse-probability of treatment weighting was used to balance baseline characteristics. OS was estimated using the Kaplan-Meier method. Multivariable Cox proportional hazard models were used to evaluate association among OS and relevant risk factors.

RESULTS

A total of 2789 RL, 2661 VATS, and 1196 OL cases were included. The unadjusted 5-year OS rate was highest for OL (84%) followed by RL (81%) and VATS (74%); P =0.008. Similar trends were also observed after inverse-probability of treatment weighting adjustment (RL 81%; VATS 73%, OL 85%, P =0.001). Multivariable Cox regression analyses revealed that OL and RL were associated with significantly higher OS compared with VATS (OL vs. VATS: hazard ratio=0.64, P <0.001 and RL vs. VATS: hazard ratio=0.79; P =0.007).

CONCLUSIONS

Our finding from this large multicenter study suggests that patients undergoing RL and OL have statistically similar OS, while the VATS group was associated with shorter OS. Further studies with longer follow-up are necessary to help evaluate these observations.

Long-term Functional Outcomes Among Older Adults Undergoing Video-assisted Versus Open Surgery for Lung Cancer: A Population-based Cohort Study

OBJECTIVE

To examine the long-term healthcare dependency outcomes of older adults undergoing VATS compared to open lung cancer resection.

SUMMARY OF BACKGROUND DATA

Although the benefits of VATS for lung cancer resection have been reported, there is a knowledge gap related to long-term functional outcomes central to decision-making for older adults.

METHODS

We conducted a population-based retrospective comparative cohort study of patients ≥70 years old undergoing lung cancer resection between 2010 and 2017 using linked administrative health databases. VATS was compared to open surgery for lung cancer resection. Outcomes were receipt of homecare and high time-at-home, defined as <14 institution-days within 1 year, in 5 years after surgery. We used time-to-event analyses. Homecare was analyzed as recurrent dichotomous outcome with Andersen-Gill multivariable models, and high time-at-home with Cox multivariable models.

RESULTS

Of 4974 patients, 2951 had VATS (59.3%). In the first three months postoperatively, homecare use ranged from 17.5% to 34.4% for VATS and 23.0% to 36.6% for open surgery. VATS was independently associated with lower need for postoperative homecare over 5 years (hazard ratio 0.82, 95% confidence interval 0.74-0.92). 1- and 5-year probability of high "time-at-home" were superior for VATS (74.4% vs 66.7% and 55.6% vs 45.4%, p < 0.001). VATS was independently associated with higher probability of high "time-at-home" (hazard ratio 0.81, 95% confidence interval 0.74-0.89) compared to open surgery.

CONCLUSIONS

Compared to open surgery, VATS was associated with lower homecare needs and higher probability of high "time-at-home," indicating reduced long-term functional dependence. Those important patient-centered endpoints reflect the overall long-term treatment burden on mortality and morbidity that can inform surgical decision-making.

Perioperative outcomes of robotic-assisted versus video-assisted thoracoscopic lobectomy: A propensity score matched analysis

BACKGROUND

The existing literature on perioperative outcomes of robotic-assisted thoracoscopic surgery (RATS) versus video-assisted thoracoscopic surgery (VATS) for lung lobectomy is inconclusive.

METHODS

We conducted a retrospective cohort analysis of VATS and RATS lobectomy procedures for patients with non-small cell lung cancer to compare the short-term perioperative outcomes by propensity score matching (PSM) analysis.

RESULTS

A total of 418 patients were enrolled in this study. After PSM, 71 patients each received VATS and RATS lobectomy for further analysis. RATS lobectomy was associated with a lower rate of conversion to thoracotomy (0% vs. 5.63%, p = 0.006), a lower rate of postoperative prolonged air leak (1.14% vs. 19.72%, p = 0.001) and a shorter duration of postoperative chest tube drainage (3 days interquartile range [IQR: 3, 4] vs. 4 days IQR [3-5], p = 0.027). Subgroup analysis indicated that after acquiring proficiency in the RATS procedure, its disadvantages diminished while its advantages were enhanced. In terms of rate of conversion to thoracotomy, length of hospital stays, and duration of postoperative chest tube drainage, RATS was comparable to uniportal VATS and superior to triportal VATS.

CONCLUSION

RATS has advantages over VATS in terms of early chest tube removal, early discharge, lower thoracotomy rate, less postoperative air leak, and a potential trend of more lymph node dissection numbers. These advantages are more pronounced after acquiring proficiency in RATS.

Pulmonary Open, Robotic, and Thoracoscopic Lobectomy (PORTaL) Study: An Analysis of 5721 Cases

OBJECTIVE

The aim of this study was to analyze outcomes of open lobectomy (OL), VATS, and robotic-assisted lobectomy (RL).

SUMMARY BACKGROUND DATA

Robotic-assisted lobectomy has seen increasing adoption for treatment of early-stage lung cancer. Comparative data regarding these approaches is largely from single-institution case series or administrative datasets.

METHODS

Retrospective data was collected from 21 institutions from 2013 to 2019. All consecutive cases performed for clinical stage IA-IIIA lung cancer were included. Neoadjuvant cases were excluded. Propensity-score matching (1:1) was based on age, sex, race, smoking-status, FEV1%, Zubrod score, American Society of Anesthesiologists score, tumor size, and clinical T and N stage.

RESULTS

A total of 2391 RL, 2174 VATS, and 1156 OL cases were included. After propensity-score matching there were 885 pairs of RL vs OL, 1,711 pairs of RL vs VATS, and 952 pairs of VATS vs OL. Operative time for RL was shorter than VATS ( P < 0.0001) and OL ( P = 0.0004). Compared to OL, RL and VATS had less overall postoperative complications, shorter hospital stay (LOS), and lower transfusion rates (all P <0.02). Compared to VATS, RL had lower conversion rate ( P <0.0001), shorter hospital stay ( P <0.0001) and a lower postoperative transfusion rate ( P =0.01). RL and VATS cohorts had comparable postoperative complication rates. In-hospital mortality was comparable between all groups.

CONCLUSIONS

RL and VATS approaches were associated with favorable perioperative outcomes compared to OL. Robotic-assisted lobectomy was also associated with a reduced length of stay and decreased conversion rate when compared to VATS.

Salvage surgery in lung cancer following definitive therapies

Salvage surgery refers to operative resection of persistent or recurrent disease in patients initially treated with intention-to-cure nonoperative management. In non-small-cell lung cancer, salvage surgery may be effective in treating selected patients with locally progressive tumors, recurrent local or locoregional disease, or local complications after nonoperative therapy. Importantly, those patients who may be candidates for salvage surgery are evolving, in terms of disease stage as well as the types of attempted definitive therapy received.

Sublobar resections for lung cancer: Finally, some answers and some more questions?

The Lung Cancer Study Group Trial, published in 1995, set the tone for lobectomy as the standard of care for early-stage nonsmall cell lung cancer. Twenty-seven years and two randomized trials later, does the thoracic oncology community have clarity regarding the choice type of resection, or more questions?

Navigating patient journey in early diagnosis of lung cancer in India

Lung cancer (LC) is one of the leading causes of cancer deaths worldwide. In India, the incidence of LC is increasing rapidly, and a majority of the patients are diagnosed at advanced stages of the disease when treatment is less likely to be effective. Recent therapeutic developments have significantly improved survival outcomes in patients with LC. Prompt specialist referral remains critical for early diagnosis for improved patient survival. In the Indian scenario, distinguishing LC from benign and endemic medical conditions such as tuberculosis can pose a challenge. Hence, awareness regarding the red flags-signs and symptoms that warrant further investigations and referral-is vital. This review is an effort toward encouraging general physicians to maintain a high index of clinical suspicion for those at risk of developing LC and assisting them in refering patients with concerning symptoms to specialists or multidisciplinary teams as early as possible.

Improvements in perioperative outcomes for non-small cell lung cancer: a decade-long analysis

BACKGROUND

Video-assisted thoracic surgery (VATS) procedures for non-small cell lung cancer (NSCLC) have steadily increased and have become the gold standard, but their prognostic advantage compared with thoracotomy has not been elucidated. This study retrospectively evaluated perioperative characteristics of VATS for NSCLC over time.

METHODS

We collected the clinical data of 760 patients with NSCLC who underwent pulmonary resection over the past decade, classifying patients into early (2011-2015) and late (2016-2020) periods. Changes in NSCLC patient characteristics, surgical approaches, perioperative factors, postoperative morbidities, and prognoses were analyzed.

RESULTS

Patients in the late period were older (p = 0.01), had more comorbidities (p = 0.01), and had earlier-stage cancer (p < 0.01) than those in the early period. The late period had significantly fewer surgical procedures for lobectomy or extended resection beyond lobectomy (p < 0.01), open thoracotomies (p < 0.01), postoperative (p = 0.02) and severe morbidities (p < 0.01), and a significantly shorter postoperative hospital stay than the early period. Surgical procedures of lobectomy or extended resection beyond lobectomy (p < 0.01) were significant risk factors for postoperative morbidity, and being in the early period (p < 0.01) and surgical procedures of lobectomy or extended resection beyond lobectomy (p < 0.01) were significant risk factors for severe postoperative morbidities. The overall survival prognosis significantly differed between the groups (p = 0.02) but progression-free survival did not (p = 0.89).

CONCLUSIONS

The incidence of postoperative morbidities decreased over time in older patients and patients with more comorbidities. The prognosis of patients with NSCLC did not change with increasing VATS or sublobar resection.

Perioperative outcomes of robotic lobectomy for early-stage non-small cell lung cancer in elderly patients

Introduction

Minimally invasive surgery has become the standard for the early-stage non-small cell lung cancer (NSCLC). The appropriateness of the kind of lung resection for the elderly patients is still debated.

Methods

We retrospectively reviewed patients with older than 75 years who underwent robotic lobectomy between May 2016 to June 2022. We selected 103 patients who met the inclusion criteria of the study. The preoperative cardiorespiratory functional evaluations were collected, and the risk of postoperative complications was calculated according to the Charlson Comorbidity Index, the American College of Surgery surgical risk calculator (ACS-NSQIP), EVAD score, and American Society of Anesthesiology (ASA) score. The patients were divided in two groups according to the presence of postoperative complications.

Results

Forty-three patients were female, and 72.8% of the total population were former or active smokers. Thirty-five patients reported postoperative complications. The analysis of the two groups showed that the predicted postoperative forced expiratory volumes in the first second (FEV1) and forced vital capacity (FVC) were significantly lower in patients presenting postoperative complications (p=0.04). Moreover, the upstaging rate and the unexpected nodal metastases were higher in the postoperative complication groups.

Conclusion

Robotic-assisted lobectomy for early-stage lung cancer is a safe and feasible approach in selected elderly patients. The factors that could predict the complication rate was the predicted postoperative FEV1 and the nodal disease.

Is there a role for lung surgery in initially unresectable non-small cell lung cancer after tyrosine kinase inhibitor treatment?

BACKGROUND

The role of lung surgery in initially unresectable non-small cell lung cancer (NSCLC) after tyrosine kinase inhibitor (TKI) treatment remains unclear. We aimed to assess the survival benefits of patients who underwent surgery for regressed or regrown tumors after receiving TKI treatment.

METHODS

The details of patients diagnosed with unresectable NSCLC treated with TKI followed by lung resection from 2010 to 2020 were retrieved from our database. The primary endpoint was 3-year overall survival (OS), whereas the secondary endpoints were a 2-year progression-free survival (PFS), feasibility, and the safety of pulmonary resection. The statistical tests used were Fisher's exact test, Kruskal Wallis test, Kaplan-Meier method, Cox proportional hazards model, and Firth correction.

RESULTS

Nineteen out of thirty-two patients were selected for the study. The patients underwent lung surgery after confirmed tumor regression (17 [89.5%]) and regrowth (two [10.5%]). All surgeries were performed via video-assisted thoracoscopic surgery: 14 (73.7%) lobectomies and five (26.3%) sublobar resections after a median duration of 5 months of TKI. Two (10.5%) postoperative complications and no 30-day postoperative mortality were observed. The median postoperative follow-up was 22 months. The 2-year PFS and 3-year OS rates were 43.9% and 61.5%, respectively. Patients who underwent surgery for regressed disease showed a significantly better OS than for regrowth disease (HR=0.086, 95% CI 0.008-0.957, p=0.046). TKI-adjuvant demonstrated a better PFS than non-TKI adjuvant (HR=0.146, 95% CI 0.027-0.782, p=0.025).

CONCLUSION

Lung surgery after TKI treatment is feasible and safe and prolongs survival via local control and directed consequential therapy. Lung surgery should be adopted in multimodality therapy for initially unresectable NSCLC.

Mortality and lung function decline in patients who develop chronic pulmonary aspergillosis after lung cancer surgery

BACKGROUND

Lung cancer surgery is reported as a risk factor for chronic pulmonary aspergillosis (CPA). However, limited data are available on its clinical impact. We aimed to determine the effect of developed CPA after lung cancer surgery on mortality and lung function decline.

METHODS

We retrospectively identified the development of CPA after lung cancer surgery between 2010 and 2016. The effect of CPA on mortality was evaluated using multivariable Cox proportional hazard analyses. The effect of CPA on lung function decline was evaluated using multiple linear regression analyses.

RESULTS

During a median follow-up duration of 5.01 (IQR, 3.41-6.70) years in 6777 patients, 93 developed CPA at a median of 3.01 (IQR, 1.60-4.64) years. The development of CPA did not affect mortality in multivariable analysis. However, the decline in forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV₁) were greater in patients with CPA than in those without (FVC, - 71.0 [- 272.9 to - 19.4] vs. - 10.9 [- 82.6 to 57.9] mL/year, p < 0.001; FEV₁, - 52.9 [- 192.2 to 3.9] vs. - 20.0 [- 72.6 to 28.6] mL/year, p = 0.010). After adjusting for confounding factors, patients with CPA had greater FVC decline (β coefficient, - 103.6; 95% CI - 179.2 to - 27.9; p = 0.007) than those without CPA. However, the FEV₁ decline (β coefficient, - 14.4; 95% CI - 72.1 to 43.4; p = 0.626) was not significantly different.

CONCLUSION

Although the development of CPA after lung cancer surgery did not increase mortality, the impact on restrictive lung function deterioration was profound.

Evaluation of pulmonary artery bleeding during thoracoscopic pulmonary resection for lung cancer

BACKGROUND

Bleeding from the pulmonary artery (PA) can be fatal in video-assisted thoracoscopic surgery (VATS) for lung cancer. We evaluated intraoperative PA injury and assessed precautions for thoracoscopic anatomic pulmonary resection.

METHODS

We retrospectively analyzed a total of 1098 patients who underwent radical surgery for lung cancer utilizing complete VATS from January 2010 to December 2021.

RESULTS

A total of 16 patients (1.5%) had PA injury during VATS, while hemostasis was performed by conversion to thoracotomy in eight patients (50.0%). Although there was a significantly greater operation time and blood loss for patients in the PA injury group (318.4 vs. 264.9 min, p = 0.001; 550.3 vs. 60.5 g, p ≤ 0.001, respectively), there was no significant different for the chest tube insertion duration and length of postoperative hospital stay (4.9 vs. 7.8 days, p = 0.157; 10.6 vs. 9.9 days, p = 0.136, respectively). There was a significant difference observed for the surgical procedure related to the left upper lobectomy in the PA injury group (43.8 vs. 18.8%, p = 0.012), with the primary causative PA determined to be the left anterior segmental PA (A³ ) (31.3%).

CONCLUSIONS

VATS is both feasible and safe for lung cancer treatment provided the surgeon performs appropriate hemostasis, although fatal vascular injury could potentially occur during VATS. Surgeons need to be aware of the pitfalls regarding PA dissection management.

Lung Cancer Management in Low and Middle-Income Countries

Lung cancer is an increasing problem in the developing world due to rising trends in smoking, high incidence of air pollution, lack of awareness and screening, delayed presentation, and diagnosis at the advanced stage. Even after diagnosis, there are disparities in access to health care facilities and inequitable distribution of resources and treatment options. In addition, the shortage of trained personnel and infrastructure adds to the challenges faced by patients with lung cancer in these regions. A multi-pronged effort targeting tobacco cessation, health promotion and awareness, capacity building, and value-based care are the need of the hour.

Prognostic implication of isolated pulmonary nodules in patients with a history of breast cancer

BACKGROUND

Isolated malignant pulmonary nodules were frequently seen in patients with breast cancer. These were metastasis from the breast cancer or new primary lung cancer. The role of surgery for such pulmonary nodules remains unclear.

METHODS

A total of 90 patients who underwent surgery for solitary malignant pulmonary nodules between January 2010 and April 2018 after curative operation for breast cancer were reviewed.

RESULTS

The pathologic diagnoses revealed 63 patients with primary lung cancer (PLC) and 27 patients with pulmonary metastatic breast cancer (MBC), which were divided into two groups. All patients were female with a mean age of 55.08 ± 9.84 years (range 31-75). Age differences between the two groups were insignificant. Of the 63 patients with PLC, 55(87%) had a lobectomy with lymphadenctomy and 8(13%) had a limited resection, while the majority of patients (78%) with MBC had a limited resection. All nodules were adenocarcinomas and their mean diameter was 1.63 ± 0.57 cm. 7/55 of patients with PLC had N1 disease while 3/6 of those with MBC had involvement of N1 nodes. For all patients, the overall survival (OS) was 86.1% at 5 years and the disease-free survival (DFS) was 86.0% at 5 years. Patients with PLC had the better surgical outcomes including OS and DFS than those with MBC did (94.2% vs. 72.8%, p = 0.017; 93.6% vs. 63.9%, p = 0.002).

CONCLUSIONS

Surgical outcomes of isolated malignant pulmonary nodules in breast cancer patients were favorable. Surgery should be considered as an option for breast cancer patients with isolated pulmonary nodules.

Effect of an Antiracism Intervention on Racial Disparities in Time to Lung Cancer Surgery

PURPOSE

Timely lung cancer surgery is a metric of high-quality cancer care and improves survival for early-stage non-small-cell lung cancer. Historically, Black patients experience longer delays to surgery than White patients and have lower survival rates. Antiracism interventions have shown benefits in reducing racial disparities in lung cancer treatment.

METHODS

We conducted a secondary analysis of Accountability for Cancer Care through Undoing Racism and Equity, an antiracism prospective pragmatic trial, at five cancer centers to assess the impact on overall timeliness of lung cancer surgery and racial disparities in timely surgery. The intervention consisted of (1) a real-time warning system to identify unmet care milestones, (2) race-specific feedback on lung cancer treatment rates, and (3) patient navigation. The primary outcome was surgery within 8 weeks of diagnosis. Risk ratios (RRs) and 95% CIs were estimated using log-binomial regression and adjusted for clinical and demographic factors.

RESULTS

A total of 2,363 patients with stage I and II non-small-cell lung cancer were included in the analyses: intervention (n = 263), retrospective control (n = 1,798), and concurrent control (n = 302). 87.1% of Black patients and 85.4% of White patients in the intervention group (P = .13) received surgery within 8 weeks of diagnosis compared with 58.7% of Black patients and 75.0% of White patients in the retrospective group (P < .01) and 64.9% of Black patients and 73.2% of White patients (P = .29) in the concurrent group. Black patients in the intervention group were more likely to receive timely surgery than Black patients in the retrospective group (RR 1.43; 95% CI, 1.26 to 1.64). White patients in the intervention group also had timelier surgery than White patients in the retrospective group (RR 1.10; 95% CI, 1.02 to 1.18).

CONCLUSION

Accountability for Cancer Care through Undoing Racism and Equity is associated with timelier lung cancer surgery and reduction of the racial gap in timely surgery.

Conversion to Thoracotomy in Non-Small Cell Lung Cancer: Risk Factors and Perioperative Outcomes

Objective: We aimed to identify predictors of conversion to thoracotomy and test the hypothesis that conversion is associated with inferior perioperative outcomes in non-small cell lung cancer (NSCLC). Methods: We queried the National Cancer Database for patients with stage I to III NSCLC undergoing minimally invasive surgery (MIS) during 2010 to 2016. We compared clinicopathologic factors between patients undergoing MIS with and without conversion. We fitted multivariable regression models to identify independent predictors of conversion and compare perioperative outcomes between the 2 groups. Results: A rising trend in the use of MIS was accompanied by a declining trend in the rate of conversion to thoracotomy. A total of 11.3% of the 83,219 cases were converted. Conversion was associated with a higher Charlson-Deyo score, squamous histology, nodal involvement, high tumor grade, tumor size ≥5 cm, and a higher T stage ( P < 0.05). Successful MIS without conversion was predicted by advanced age, sublobar resection, robotic approach, and treatment at an academic high-volume facility ( P < 0.05). Conversion was linked to longer hospital stays, higher 30-day and 90-day mortality, and unplanned readmission ( P < 0.05), irrespective of the type of MIS approach. Conclusions: Conversion rates for video-assisted and robot-assisted thoracoscopic surgery have seen a decline in recent years. Irrespective of the type of MIS approach, conversion was associated with inferior perioperative outcomes. The robotic approach and treatment at an academic high-volume facility were associated with a lower likelihood of conversion. Early recognition of the individual risk factors for conversion may help to counsel patients about the likelihood of, and detriments associated with, conversion and ultimately reduce conversion rates.

Early outcomes of lung resections in non-small cell lung cancer after COVID-19 pneumonia

Objective

There is limited literature on patients with a history of COVID-19 pneumonia who underwent anatomical lung resection for non-small cell lung cancer (NSCLC). This study was aimed to share the early postoperative outcomes in patients who underwent lung resection after COVID-19 pneumonia.

Materials and methods

We retrospectively evaluated 30 patients who underwent lobectomy with thoracotomy and systematic mediastinal lymph node dissection due to NSCLC in a single center between November 2018 and September 2021. The patients were divided into two groups regarding COVID-19 pneumonia history; the COVID-19 group consisted of 14 patients (46.7%) and the non-COVID-19 group 16 (53.3%) patients. The patients’ age, gender, comorbidity, Charlson Comorbidity Index (CCI) score, forced expiratory volume in 1 s (FEV1) value, tumor type and size, resection type, postoperative air leak duration, total drainage volume, drain removal time, postoperative complications, and length of stay (LOS) were recorded.

Results

9 (30%) patients were female, and 21 (70%) were male. The mean age was 62.1 ± 8.91 years. Our comparison of postoperative air leak duration, total drainage volume, time to drain removal, postoperative complications, and LOS between the COVID-19 and non-COVID-19 groups revealed no statistically significant difference.

Conclusion

Anatomical lung resection can be performed safely in NSCLC patients with a history of COVID-19 pneumonia without significant difference in early postoperative morbidity and mortality.

Risk Factors for the Development of Nontuberculous Mycobacteria Pulmonary Disease during Long-Term Follow-Up after Lung Cancer Surgery

The aim of this study is to determine the cumulative incidence of, and the risk factors for, the development of nontuberculous mycobacteria pulmonary disease (NTM-PD) following lung cancer surgery. We retrospectively analyzed patients with non-small cell lung cancer who underwent surgical resection between 2010 and 2016. Patients who met all the diagnostic criteria in the NTM guidelines were defined as having NTM-PD. Additionally, we classified participants as NTM-positive when NTM were cultured in respiratory specimens, regardless of the diagnostic criteria. We followed 6503 patients for a median of 4.89 years, and NTM-PD and NTM-positive diagnoses occurred in 59 and 156 patients, respectively. The cumulative incidence rates of NTM-PD and NTM-positive were 2.8% and 5.9% at 10 years, respectively. Mycobacterium avium complex was the most commonly identified pathogen, and half of the NTM-PD patients had cavitary lesions. Several host-related factors (age > 65 years, body mass index ≤ 18.5 kg/m2, interstitial lung disease, bronchiectasis, and bronchiolitis) and treatment-related factors (postoperative pulmonary complications and neoadjuvant/adjuvant treatments) were identified as risk factors for developing NTM-PD and/or being NTM-positive after lung cancer surgery. The incidences of NTM-PD and NTM-positive diagnoses after lung cancer surgery were not low, and half of the NTM-PD patients had cavitary lesions, which are known to progress rapidly and often require treatment. Therefore, it is necessary to raise awareness of NTM-PD development after lung cancer surgery.

Video-assisted thoracoscopic lobectomy versus open lobectomy in the treatment of large lung cancer: propensity-score matched analysis

Background

There are several concerns on thoracoscopic surgery for large tumors because of the increased risk of tumor cell spillage. This study aimed to compare perioperative outcomes and oncological validity between video-assisted thoracoscopic surgery (VATS) and open lobectomy for non-small cell lung cancer (NSCLC) with tumor size > 5 cm.

Methods

We retrospectively reviewed 355 patients who underwent lobectomy with clinical N0 NSCLC with solid tumor component diameter > 5 cm between January 2009 and December 2016. Patients with tumor invading adjacent structures were excluded. The patients were divided into the VATS group (n = 132) and thoracotomy group (n = 223). Propensity score matching (1:1) was applied.

Results

After propensity score matching, 204 patients were matched, and clinical characteristics of the two groups were well balanced. The VATS group was associated with a shorter length of hospital stay (6 days vs. 7 days; P < 0.001) than the thoracotomy group. There were no significant differences in the 5-year overall survival (71.5% in VATS vs. 64.4% in thoracotomy, P = 0.390) and 5-year recurrence-free survival (60.1% in VATS vs. 51.5% in thoracotomy, P = 0.210) between the two groups. The cumulative incidence of ipsilateral pleural recurrence was not significantly different between the two groups (12.0% in VATS vs. 7.9% in thoracotomy; P = 0.582).

Conclusions

In clinical N0 NSCLC larger than 5 cm, VATS lobectomy resulted in shorter hospital stay and similar survival outcome compared to open lobectomy. Based on these results, VATS lobectomy is a valuable option in this subset of patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-021-01749-8.

Video-assisted thoracoscopic lobectomy and bilobectomy versus open thoracotomy for non-small cell lung cancer: Mortality and survival

Background

In this study, we aimed to evaluate patients who had non-small cell lung cancer and underwent resection, to investigate our tendency to prefer video-assisted thoracic surgery or open thoracotomy, and to compare 30- and 90-day mortalities and survival rates.

Methods

Between January 2013 and January 2019, a total of 706 patients (577 males, 129 females; mean age: 61.9±8.6 years; range, 17 to 84 years) who underwent lobectomy or bilobectomy due to primary non-small cell lung cancer were retrospectively analyzed. The patients were divided into two groups as operated on through video-assisted thoracic surgery and through open thoracotomy. The 30- and 90-day mortality rates and survival rates were compared.

Results

Of the patients, 202 (28.6%) underwent video-assisted thoracic surgery and 504 (71.4%) underwent open thoracotomy. Lobectomy was performed in 632 patients (89.5%) and bilobectomy was performed in 74 patients (10.5%). Patients who were chosen for video-assisted thoracic surgery were statistically significantly older, did not require any procedure other than lobectomy, did not receive neoadjuvant therapy, had a small tumor, and did not have lymph node metastases. The 30- and 90-day mortality rates in the video-assisted thoracic surgery and open thoracotomy groups were 1.8% vs. 2% and 2.6% vs. 2.5%, respectively. The five-year survival rates of video-assisted thoracic surgery and open thoracotomy groups were 74.1% and 65.2%, respectively (p>0.05). The 30- and 90-day mortality and five-year survival rates were 2.1%, 2.6%, and 73.5% in the video-assisted thoracic surgery group and 2.1%, 2.1%, and 68.5% in the open thoracotomy group, respectively, indicating no statistically significant difference between the two groups.

Conclusion

Throughout the study period, video-assisted thoracic surgery was more preferred in patients with advanced age, in those who had a small tumor, who did not receive neoadjuvant therapy, did not have lymph node metastasis, and did not require any procedure other than lobectomy. In the video-assisted thoracic surgery and open thoracotomy groups, 30- and 90-day mortality and five-year survival rates were similar. Based on these findings, both procedures seem to be acceptable in this patient population.

The effects of erector spinae plane block on perioperative opioid consumption and rehabilitation in video assisted thoracic surgery

BACKGROUND

This study aimed to determine whether ultrasound-guided continuous erector spinae plane block (ESPB) had an effect on opioid consumption and postoperative rehabilitation in patients undergoing video-assisted thoracic surgery (VATS).

METHODS

In this prospective study, 120 patients aged 20-70 years who underwent elective VATS were randomly allocated to one of three groups: group C (general anesthesia with patient-controlled intravenous analgesia [PCIA]), group T (general anesthesia with patient-controlled epidural analgesia [PCEA]), or group E (general anesthesia with continuous ESPB and PCIA). Perioperative opioid consumption, visual analog scale (VAS) scores, preoperative and postoperative Quality of Recovery-15 scores, and postoperative opioid-related adverse events were all assessed.

RESULTS

Intraoperative sufentanil consumption in groups T and E was significantly lower than that in group C (both P < 0.001), and the postoperative sufentanil consumption in group E was also significantly lower than that in group C (P = 0.001). Compared with group C, the VAS scores at rest or during coughing immediately out of the post-anesthesia care unit at 6 h, 12 h, and 24 h postoperatively were significantly lower in group T (P < 0.05). However, the VAS scores at rest at 6 h and 12 h postoperatively in group E were lower than those of group C (P < 0.05), but were significantly higher than those of group T at all study times (P < 0.05).

CONCLUSION

Ultrasound-guided continuous ESPB significantly reduced perioperative opioid consumption during VATS and improved postoperative rehabilitation. However, these effects were inferior to those of thoracic epidural anesthesia.

TRIAL REGISTRATION

The present study was prospectively registered at http://www.chictr.org/cn /(registration number: ChiCTR1900023050 ); registration date: May 82,019.

Positive bag lavage cytology during thoracoscopic surgery for lung cancer is a significant predictor of locoregional recurrence

OBJECTIVES

Advances in thoracoscopic surgery have made skin incisions smaller, but there are concerns about cancer cell contamination during sample extraction. We performed retrieval bag lavage cytology (BLC) during thoracoscopic surgery to evaluate the risk of cancer dissemination and the prognostic influence of BLC status.

METHODS

BLC was investigated in 893 patients who underwent thoracoscopic lobectomy or segmentectomy for lung cancer between 2013 and 2018. The clinicopathological features and prognosis were compared between the BLC-positive and BLC-negative groups.

RESULTS

Forty-nine patients (5.5%) were positive for BLC. BLC correlated with pleural invasion (49.0% vs. 12.9%, P < 0.001); however, BLC was positive in 3.3% of cases without pleural invasion. Multivariate analysis revealed that tumor size, lymph node metastasis, lymphatic and pleural invasion were predictive factors for positive BLC. Prognosis was poorer in the BLC-positive group than in the BLC-negative group (5-year overall survival, 73.6% vs. 90.2%, P < 0.001); nevertheless, positive BLC was not an independent prognostic factor. The locoregional recurrence rate was higher among BLC-positive patients than among BLC-negative patients, whereas there was no significant difference in the distant recurrence rate. Positive BLC was associated with locoregional recurrence (hazard ratio 1.87, P = 0.044) and the correlation was stronger in stage I lung cancer. There were no cases of extraction bag breakage or port-site recurrence.

CONCLUSIONS

BLC positivity was correlated with the risk of locoregional recurrence in patients with surgically resected lung cancer, although it was not an independent prognostic factor. Careful manipulation is essential for extracting specimens from the thoracic cavity.

Video-assisted thoracic surgery sleeve resection and bronchoplasty using 3D imaging system: its safety and efficacy

Background

Video-assisted thoracic surgery sleeve resection with bronchial anastomosis or bronchoplasty is a technically demanding procedure. Three-dimensional endoscopic surgery has been reported to be helpful in decreasing operation time and improving spatial perception with less surgical errors, but there have been rare reports about relatively difficult thoracoscopic procedures utilizing 3D thoracoscope. We performed this study to evaluate early clinical outcomes of thoracoscopic sleeve resection and bronchoplasty utilizing 3D thoracoscope.

Methods

Data from a total of 36 patients who underwent thoracoscopic sleeve lobectomy or bronchoplasty at our institution from December 2015 to October 2017 were retrospectively reviewed. Three-port approach with one utility incision was used with a 10 mm, 30° three-dimensional thoracoscope. Twenty-three patients (81%) were male, and mean age was 65.9 ± 9.4 years. Fourteen patients (38.9%) underwent sleeve resection with bronchial anastomosis, 22 (61.1%) underwent wedge or simple bronchoplasty, and one patient received concomitant PA procedure. Bronchial anastomosis sites were not covered with viable tissue flaps.

Results

There was no (0%) suture needle injury from spatial misperception during bronchoplasty or sleeve anastomosis. There was no (0%) operative mortality. The pathologic report revealed squamous cell carcinoma (63.9%), adenocarcinoma (19.4%), carcinoid (6.9%), adenosquamous carcinoma (3.4%), and sarcomatoid carcinoma (2.8%). One (2.8%) late mortality was due to systemic recurrence of sarcomatoid carcinoma. There was no (0.0%) anastomotic failure. The mean number of dissected lymph nodes were 27.4 ± 13.2, and mean operation time was 216.8 ± 60.0 min. Median postoperative 24-h drain amount was 315 mL. Median chest tube days and hospital days were 4 and 6, respectively. Two patients (5.6%) had complications greater than Clavien-Dindo grade II—one case of ARDS, and the other case of a delayed bronchopleural fistula.

Conclusions

Thoracoscopic sleeve resection and bronchoplasty utilizing HD 3D thoracoscope is a safe and effective procedure with excellent early clinical outcomes. Further investigation for long-term outcomes will be needed.

Coagulation Status and Surgical Approach as Predictors of Postoperative Anemia in Patients Undergoing Thoracic Surgery: A Retrospective Study

Objective: Postoperative anemia is a common complication after a major surgery. Our study aims to identify factors that are associated with higher risk of developing postoperative anemia after thoracic surgery.

Methods: We conducted a retrospective study of 465 patients who underwent pulmonary surgery in 2017 in Shanghai Pulmonary Hospital, China. Of them, 191 patients underwent standard open thoracotomy (OT), and 274 patients underwent video-assisted thoracic surgery (VATS). A total of 350 patients were diagnosed with postoperative anemia, and 115 patients did not have anemia. Multiple logistic regression was used to compute odds ratios for predicting preoperative anemia.

Results: Postoperative anemia was associated with significantly lower weight (p < 0.001) and height (p = 0.022) of the patients, as well as higher prothrombin time (PT), and international normalized ratio (INR) (p = 0.012). Open thoracotomy resulted in a 1.2-fold increase in the incidence of postoperative anemia compared to VATS (p = 0.002). Multiple logistic regression analysis identified INR [OR (95% CI) 24.46 (2.05–292.27; p = 0.012] and surgical approach [OR (95% CI) 0.48 (0.31–0.74); p < 0.001] as predictors of postoperative anemia and postoperative drop in hemoglobin (Hb).

Conclusion: Postoperative coagulation status and surgical approach are statistically significant predictors of postoperative anemia in patients undergoing thoracic surgery. International normalized ratio and surgical approach are specifically associated with Hb drop immediately after the surgery.

Left Upper Lobectomy for Lung Cancer as a Risk Factor for Cerebral Infarction: A Systematic Review and Meta-Analysis

BACKGROUND

There is limited evidence on the role of the type of lobectomy after primary lung cancer with postoperative cerebral infarction (CI). The purpose of this review was to evaluate the role of left upper lobectomy (LUL) in pulmonary vein thrombosis (PVT) and eventual CI.

METHODS

A search was performed on MEDLINE, Embase, and Web of Science from inception to January 2021. Prospective and retrospective cohort studies investigating the association between types of lobectomies for primary lung cancer with PVT and/or CI were included. Newcastle-Ottawa Scale (NOS) was used to assess the risk of bias. A random-effect model meta-analysis was utilized if significant heterogeneity was observed.

RESULTS

Twelve studies, including 5266 patients were included. The majority of studies were having a low risk of bias. LUL was associated with higher likelihood of CI (OR_fixed 6.27, 95% Confidence Interval (CI) 3.12-12.56; p < 0.00001) and PVT (OR_fixed 13.46, 95% CI 5.97-30.33; p < 0.00001) as compared to other lobectomies. Sensitivity analysis showed an independent role of LUL without underlying PVT in CI (OR_fixed 2.44, 95% CI 1.25-4.74; p = 0.009). Male and diabetic patients were at a higher risk, while Video-Assisted Thoracoscopic Surgery (VATS) was protective from CI.

CONCLUSION

The results of this review indicate that LUL after lung cancer is an independent risk factor for developing CI without underlying PVT. In addition, the risk of CI increases significantly when PVT develops after LUL. LUL is also a risk factor for PVT. A more frequent follow-up may be beneficial in lung cancer patients after LUL, especially in those with diabetes or undergoing adjuvant systemic therapy.