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

Post-operative hypercoagulable whole blood profiles in patients undergoing open thoracotomy vs video-assisted thoracoscopic surgery

BACKGROUND

Patients undergoing video-assisted thoracoscopic surgery (VATS) have a lower risk of thrombosis compared to those undergoing open thoracotomy (OT) which may be due to several post-operative factors such as early mobilisation, shorter hospital stays, lower transfusion rates and lower risk of infections. Whether the higher thrombotic risk after OT is also linked to a peri-operative hypercoagulable state is a matter of debate. We therefore conducted a case-control study to compare peri-operative coagulation profiles in patients with primary lung cancer undergoing VATS vs OT.

MATERIALS AND METHODS

All consecutive patients undergoing VATS or OT for primary lung cancer at the Department of Thoracic Surgery of Padua University Hospital, Italy, between February and June 2018 were enrolled. Each patient provided a venous blood sample at least 30 min prior to surgical incision (T0) and 4±1 days after surgery (T1). Peri-operative coagulation profiles were assessed via traditional, viscoelastic whole blood (ROTEM^® [Instrumentation Laboratory-Werfen]) and impedance aggregometry (Multiplate^® Analyser [Roche Diagnostics]) tests.

RESULTS

We enrolled 65 patients (males 43, females 22; mean age 65±13 years) of whom 35 (54%) underwent VATS and 30 (46%) underwent OT. Compared to healthy controls, the surgical group (VATS and OT patients) had a significantly shorter clot formation time and higher alpha angle and maximum clot firmness values, as well as increased mean platelet function. In the post-operative period, patients who underwent OT had a significantly shorter clot formation time, higher alpha angle and maximum clot firmness values and higher mean platelet function vs VATS patients.

DISCUSSION

Whole blood ROTEM^® profiles and Multiplate^® aggregometry identified a more hypercoagulable post-operative state in patients who underwent OT than in those who underwent VATS. Larger studies are warranted to confirm our results and ascertain whether the observed hypercoagulability might promote post-operative thrombosis.

Feasibility analysis for the development of a video-assisted thoracoscopic (VATS) lobectomy 23-hour recovery pathway

Background

Video-assisted thoracoscopic (VATS) lobectomy has been demonstrated to offer several benefits over open surgery. The purpose of this study was to assess the feasibility and safety of an ultra-fast-track 23-hour recovery pathway for VATS lobectomy.

Methods

A prospectively maintained institutional database was queried for patients who underwent VATS lobectomy from 2006 to 2016 at the McGill University Health Centre in Montreal, Quebec, and data were supplemented with focused chart review. Patients discharged with a length of stay (LOS) of 23 hours or less were compared with those with an LOS of 2 days or more. Logistic regression was performed to identify predictors of LOS of 23 hours or less.

Results

Two hundred and five patients were included in the study. Perioperative 30-day mortality for our cohort was 0% and the major complication rate was 8.3%. The median LOS was 3 days (interquartile range [IQR] 2-4 d). Thirty-four patients were discharged within 23 hours and none of them required readmission; 171 patients were discharged on postoperative day 2 or later and 9 of them (5.3%) required readmission (p = 0.36). The proportion of patients discharged within 23 hours increased in 2016 compared with previous years (25.8% v. 12.0%, p = 0.05). Patients discharged within 23 hours had shorter chest tube duration (odds ratio [OR] 0.20, 95% confidence interval [CI] 0.09-0.46, p < 0.001), lower clinical stage disease (stages II-III v. stage I OR 0.07, 95% CI 0.01-0.52, p = 0.011), lower pathologic stage lesions (stages II-III v. stage I OR 0.26, 95% CI 0.07-0.91, p = 0.035), fewer surgical complications (OR 0.04, 95% CI 0.01-0.30, p = 0.002) and shorter operative time (surgery duration > 120 min OR 0.42, 95% CI 0.18-0.95, p = 0.04). Our exploratory prediction modelling showed that chest tube duration, clinical stage and surgeon were the most influential predictors of discharge within 23 hours.

Conclusion

The only preoperative factors that predicted shorter LOS in our cohort were clinical stage and surgeon. A significant proportion of patients can be discharged safely by adopting a VATS lobectomy 23-hour enhanced recovery pathway.

Video-assisted thoracoscopic surgery as the gold standard for lung cancer surgery

Surgical resection remains the only effective means of cure in the vast majority of patients with early-stage lung cancer. It can be performed via a traditional open approach (particularly thoracotomy) or a minimally invasive approach. VATS is 'keyhole' surgery in the chest, and was first used for lung cancer resection in the early 1990s. Since then, a large volume of evolving clinical evidence has confirmed that VATS lung cancer resection offered proven safety and feasibility, better patient-reported post-operative outcomes, less surgical trauma as quantified by objective outcome measures and equivalent or better survival than open surgery. This has firmly established VATS as the surgical approach of choice for early-stage lung cancer today. Although impressive new non-surgical lung cancer therapies have emerged in recent years, VATS is also being constantly rejuvenated by the development of 'next generation' VATS techniques, the refinement of VATS sublobar resection for selected patients, the utilization of bespoke post-operative recovery programmes for VATS and the synthesis of VATS into multi-modality lung cancer therapy. There is little doubt that VATS will remain as the gold standard for lung cancer surgery for the foreseeable future.

Early Adoption of Robotic Pulmonary Lobectomy: Feasibility and Initial Outcomes

Despite the published benefits of minimally invasive video-assisted thoracoscopic surgery (VATS) for lobectomy, the majority of lobectomies in the United States continue to be performed through a thoracotomy. The low adoption rate of VATS has been attributed to its technical challenges and ergonomic inefficiencies. Robotic surgery has been proposed as an alternative minimally invasive technique that allows the replication of open lobectomy with wristed instruments and three-dimensional vision. Our aim was to analyze the transition from open to robotic lobectomy at our hospital where there had been no significant VATS lobectomy experience. We analyzed 88 open and 43 robotic lobectomies that met criteria for inclusion. Operative times were significantly longer with the robotic group but decreased with experience. The resection time of the latter half of the robotic cases decreased to within 20 minutes of the open cases. There were no conversions in the robotic cases to either VATS or open. Robotic lobectomy was associated with faster postoperative recovery with a 60 per cent decrease in length of stay. Complications were uncommon and there were no deaths in the robotic group. We conclude that the transition from open to robotic lobectomy can be achieved safely with excellent postoperative outcomes. This new technique is a viable alternative to VATS lobectomy.

New Surgical Approaches in the Treatment of Non-Small Cell Lung Cancer

Surgery for non-small cell lung cancer has undergone repeated innovations over time. Although medical thoracoscopy has been available for centuries, it was not incorporated into the standard approach until the 1990s, when successful video-assisted thoracoscopic surgery (VATS) techniques were widely reported. Progressive efforts to offer minimally invasive approaches while maintaining oncologic surgical quality led to the development of robotic-assisted thoracic surgery and uniportal VATS, which offer improved pain control, shorter hospital stays, and more patients able to receive adjuvant therapy. Innovations in interventional bronchoscopy, localization methods, and 3D printing have improved the safety, efficacy, and precision of surgery.

Robotic segmentectomy: indication and technique

Use of low-dose CT scan allows detection of lung cancer at early stages, enabling a more conservative surgery and a better long-term survival in those patients. In this scenario, intentional anatomical segmentectomy is gaining consent over standard lobectomy among surgeons. A minimally invasive approach such as VATS reduced invasiveness and complication rate compared to open surgery, but this technique comes also with some disadvantages in terms of dexterity and intuitiveness. Robotic surgery allows to overcome those limitations, making segmentectomies easier and safer to perform. In addition, it offers the possibility to utilize intravenous indocyanine green to define the intersegmental plane, allowing a more precise surgery. We reviewed the literature and describe the technique of the robot assisted segmentectomy with a focus on the new technologies available nowadays.

Ergonomical Assessment of Three-Dimensional Versus Two-Dimensional Thoracoscopic Lobectomy

In this study. we compared ergonomical domains characteristics of three-dimensional (3D) versus two-dimensional (2D) video-systems in thoracoscopic lobectomy using a scoring-scale-based assessment. Seventy patients (mean age, 69 ± 6.9 years, 43 males and 27 females) with early stage lung cancer were randomized to undergo thoracoscopic lobectomy by either 3D (N = 35) or 2D (N = 35) video-systems. All operations were divided into 5 standardized surgical steps (vein, artery, bronchus, fissure, and lymph nodes), which were evaluated by 4 thoracic surgeons using a scoring scale (score range from 1, unsatisfactory to 3,excellent) entailing assessment of 3 ergonomical domains: exposure, instrumentation and maneuvering. Primary outcome was a difference ≥10% in the maneuvering domain steps. At intergroup comparisons, there was no difference in demographics. The 3D system results were better for maneuvering domain total score and particularly for the artery and bronchus steps scores (score ≥10%, P ≤ 0.006). Other significant differences included exposure of the vein, artery and bronchus (P ≤ 0.03). Results favoring the 2D system included maneuvering, exposure and instrumentation of the fissure (P = 0.001). Inter-rater concordance of ergonomics scoring was satisfactory (Cronbach's α range, 0.85-0.88). Operative time was significantly shorter in the 3D group (127 ± 19 min vs 143±18 min, P = 0.001) whereas there was no difference in hospital stay (3.4 ± 1.2 vs 4.1 ± 1.6 days, P = 0.07). In this study comparison of ergonomic domains scoring in 3D versus 2D thoracoscopic lobectomy favored the 3D system for the maneuvering total score, which proved inversely correlated with operative times possibly due to a better perception of depth and more precise surgical maneuvering.

Does the length of uniportal video-assisted thoracoscopic lobectomy affect postoperative pain? Results of a randomized controlled trial

BACKGROUND

Uniportal video-assisted thoracoscopic surgery (VATS) lobectomy has become a common approach for the treatment of early stage lung cancer. Here, we aimed to establish whether the length of uniportal incision could affect postoperative pain and surgical outcomes in consecutive patients undergoing uniportal VATS lobectomy for early stage lung cancer.

METHODS

This was a unicenter Randomized Control Trial (NCT03218098). Consecutive patients undergoing uniportal VATS lobectomy for Stage I lung cancer were randomly assigned to a Small Incision group or Long Incision group in 1:1 ratio based on whether patients received a 4 cm or 8 cm incision. The endpoints were to compare the intergroup difference regarding (i) postoperative pain measured by brief pain inventory (BPI) questionnaire (first endpoint); (ii) operative time; (iii) length of chest drainage; (iv) length of hospital stay; (v) postoperative complications; and (vi) pulmonary functional status (secondary endpoints).

RESULTS

A total of 48 patients were eligible for the study. Four patients were excluded; the study population included 44 patients: 23 within the Small Incision group, and 21 within the Long Incision group. The 11 BPI scores between the two groups showed no significant difference. Small Incision group presented higher operative time than Long Incision group (138.69 vs. 112.14 minutes; P = 0.0001) while no significant differences were found regarding length of hospital stay (P = 0.95); respiratory complications (P = 0.92); FEV1% (P = 0.63), and 6-Minute Walking Test (P = 0.77).

CONCLUSIONS

A larger incision for uniportal VATS lobectomy significantly reduced the operative time due to better exposure of the anatomical structures without increasing postoperative pain or affecting the surgical outcome.

KEY POINTS

A larger incision for uniportal VATS lobectomy significantly reduced the operative time due to better exposure of the anatomical structures without increasing postoperative pain or affecting the surgical outcome. To perform a larger incision could be a valuable strategy, particularly in nonexpert hands or when the patient's anatomy or tumor size make exposure of anatomic structures through smaller incisions difficult.

Initial experience with uniportal video-assisted thoracoscopic surgery for the treatment of lung cancer performed by a surgeon who did not have previous experience performing multiportal thoracoscopic surgery: a single center retrospective study

Background

The purpose of this study was to evaluate the surgical outcome of uniportal video-assisted thoracoscopic surgery (VATS) for the treatment of non-small cell lung cancer performed by a surgeon who did not have previous experience performing open thoracotomy and multiportal VATS.

Methods

From January 2017 to December 2018, 85 patients underwent uniportal VATS anatomical pulmonary resection performed by one surgeon. The remaining 269 patients underwent multiportal VATS performed by other experienced surgeons. Clinicopathological characteristics and surgical outcomes of the uniportal VATS and multiportal VATS groups were compared.

Results

The uniportal VATS procedures included 7 segmentectomies, 66 lobectomies, 1 bilobectomy, and 1 pneumonectomy. There was no conversion to multiportal VATS or open thoracotomy. Patients who underwent multiportal VATS surgery were older, more often men, and more often smokers than those who underwent uniportal VATS. Other clinicopathological characteristics were not statistically different between the two groups. The number of dissected lymph nodes was higher in uniportal VATS than in multiportal VATS (16.8 vs. 14.6, P=0.030). Anesthetic time and operative time were shorter in uniportal VATS than in multiportal VATS (both P<0.001). Intraoperative blood loss was also less in the uniportal VATS group than in the multiportal VATS group (P<0.001). There were no statistical between-group differences in chest tube drainage period, hospital stay, postoperative complication rate, and operative mortality rate.

Conclusions

Uniportal VATS for pulmonary anatomical resection of non-small cell lung cancer performed by a surgeon without previous multiportal VATS experience yielded acceptable surgical outcomes.

Postoperative Elevations of Neutrophil-to-lymphocyte and Platelet-to-lymphocyte Ratios Predict Postoperative Pulmonary Complications in Non-small Cell Lung Cancer Patients: A Retrospective Cohort Study

The neutrophil-to-lymphocyte ratio (NLR) and the platelet-to-lymphocyte ratio (PLR) are found to increase in patients who develop postoperative complications (PCs). The aim of the present study was to explore the association of the perioperative changes of NLR (ΔNLR) and PLR (ΔPLR) with PCs in non-small cell lung cancer (NSCLC). Clinical data of 509 patients, who were diagnosed with NSCLC and underwent thoracoscopic radical resection between January 1, 2014 and July 31, 2016 at the Department of Thoracic Surgery, West China Hospital, were reviewed. Patients were divided into PC and non-PC groups, and clinical characteristics including ΔNLR and ΔPLR were compared between them. The optimal cut-off values of ΔNLR and ΔPLR were determined by receiver operating characteristics (ROC) curves and patients were assigned to high ΔNLR/ΔPLR and low ΔNLR/ΔPLR groups in terms of the cut-off values. Clinicopathologic characteristics and the incidence of different PCs were compared between the dichotomized groups. Univariate and multivariate logistic regression analyses were performed to identify the independent risk factors for PCs. The results showed that the ΔNLR and ΔPLR in the PC group were signifcantly higher than those in the non-PC group (P<0.001 for both). The optimal cutoff values of ΔNLR and ΔPLR were 6.6 and 49, respectively. Patients with ΔNLR>6.6 or ΔPLR>49 were more likely to experience postoperative pulmonary complications (PPCs) (P<0.001 for both). Multivariate logistic regression analysis demonstrated that smoking [odds ratio (OR): 2.450, 95% confdence interval (95% CI): 1.084-5.535, P=0.031)], tumor size (OR: 1.225, 95% CI: 1.047-1.433, P=0.011), ΔNLR>6.6 (OR: 2.453, 95% CI: 1.224-4.914, P=0.011) and ΔPLR>49 (OR: 2.231, 95% CI: 1.182-4.212, P=0.013) were predictive of PPCs. In conclusion, the ΔNLR and ΔPLR may act as novel predictors for PPCs in NSCLC patients undergoing thoracoscopic radical lung resection, and patients with ΔNLR>6.6 or ΔPLR>49 should be treated more actively to prevent or reduce PPCs.

Completion pneumonectomy is safe and effective in select patients with recurrent non-small cell lung cancer

Background

Locoregional recurrence rates for non-small cell lung cancer (NSCLC) remain high, even following curative surgical resection. While national guidelines advocate surgical resection for locoregional recurrence, it is rarely offered when resection would require completion pneumonectomy, which available literature associates with a 12–36% perioperative mortality and 40–80% morbidity. Additionally, survival advantages to radical surgery in this scenario are largely unknown, particularly because available series often include patients undergoing completion pneumonectomy for benign indications or metastatic disease from other primary sites, making extrapolation to primary lung cancer patients challenging. As systemic therapy options continue to evolve, particularly as it relates to immunotherapy, we expect that there will be more and more opportunities for locoregional surgical control. The aim of this study was to evaluate outcomes following completion pneumonectomy for recurrent NSCLC.

Methods

We retrospectively reviewed all patients who underwent completion pneumonectomy for recurrent NSCLC at our institution between 2000 and 2015. Factors affecting perioperative morbidity and mortality, as well as overall survival, were analyzed.

Results

Between 2000 and 2015, 28 patients underwent completion pneumonectomy for recurrent lung cancer (14 female, 14 male). The median age was 64.2 years (range, 36.7–84.0). There were 11 left-sided and 17 right-sided operations. Fourteen patients (50.0%) underwent chemotherapy or chemoradiotherapy prior to surgery. Perioperative morbidity was seen in 13 of 28 (46.4%) patients, and atrial fibrillation was the most common complication. Mortality at 30- and 90-day intervals was 3.6%, and 14.3% respectively. Five-year overall survival was 43.1% and was not associated with preoperative chemotherapy or chemoradiotherapy use. Patients over 70 years old (n=5) experienced a statistically higher rate of postoperative complications (100.0% vs. 34.8%, P=0.013), and this translated into a higher mortality rate at 60 and 90 days. Left-sided resections were associated with increased risk of recurrent laryngeal nerve injury (RLN) compared to right-sided resections (36.4% vs. 0%, P=0.016), and those patients with RLN injury were more likely to be reintubated (50.0% vs. 4.2%, P=0.04). Bronchopleural fistula occurred in 1 patient (3.6%).

Conclusions

Completion pneumonectomy is a viable treatment option for patients with recurrent NSCLC. We attribute our low risks of major morbidity, such as bronchopleural fistula, to careful patient selection and technique. In patients over 70 years, morbidity is higher which should inform discussion regarding surgical options.

Clinical and economic comparative effectiveness of robotic-assisted, video-assisted thoracoscopic, and open lobectomy

Background

We sought to evaluate trends and clinical and economic outcomes between robotic-assisted lobectomy (RL), video-assisted thoracoscopic lobectomy (VL), and open pulmonary lobectomy (OL).

Methods

Patients who underwent a lobectomy for malignancy from January 1, 2008, to September 30, 2015, were identified in the Premier Healthcare Database. Propensity score matched (PSM) comparisons were performed between RL versus VL and RL versus OL. Patient characteristics were applied to generate propensity scores. In-hospital and perioperative 30-day outcomes and costs were compared within matched cohorts.

Results

From 2008 to 2015, there was a marked decline for OL (71% to 43%, P<0.0001) with a significant increase in RL (1% to 17%, P<0.0001) and VL (28% to 41%, P<0.0001). In the early period (January 2008 to December 2012), total operating room time was longer (P<0.0001) and admission to ICU was more common for RL compared to VL or OL (P<0.0001) although the total length of ICU stay was shorter for RL compared to VL or OL (P<0.0001). In the late period (January 2013 to September 2015), RL was associated with significantly lower rates of complications (P<0.05), conversions, and shorter length of stay than VL and OL. When hospital volume was not considered, costs were higher for RL than VL and OL. In hospitals where >25 lobectomies were performed annually, the total cost of RL was comparable to VL (P=0.09) and OL (P=0.11).

Conclusions

During the study period, the utilization of RL increased substantially and was associated with improved perioperative outcomes compared with VL and OL. When annual hospital volume was >25 cases, these clinical advantages persisted and there was no significant cost difference between RL, VL, or OL. RL is an effective and cost-comparable approach for lobectomy in patients with lung malignancy.

Unusual complication of endostapler use in video-assisted thoracoscopic surgery

Video-assisted thoracoscopic surgery is becoming more popular in thoracic surgery practice. Use of endostaplers is mandatory for anatomical video-assisted thoracoscopic surgery resections. In this article, we present an unusual complication related to use of endostapler, which, to our knowledge, may be the first reported in the literature.

TIMs, TAMs, and PS- antibody targeting: implications for cancer immunotherapy

Immunotherapy for cancer is making impressive strides at improving survival of a subset of cancer patients. To increase the breadth of patients that benefit from immunotherapy, new strategies that combat the immunosuppressive microenvironment of tumors are needed. Phosphatidylserine (PS) signaling is exploited by tumors to enhance tumor immune evasion and thus strategies to inhibit PS-mediated immune suppression have potential to increase the efficacy of immunotherapy. PS is a membrane lipid that flips to the outer surface of the cell membrane during apoptosis and/or cell stress. Externalized PS can drive efferocytosis or engage PS receptors (PSRs) to promote local immune suppression. In the tumor microenvironment (TME) PS-mediated immune suppression is often termed apoptotic mimicry. Monoclonal antibodies (mAbs) targeting PS or PSRs have been developed and are in preclinical and clinical testing. The TIM (T-cell/transmembrane, immunoglobulin, and mucin) and TAM (Tyro3, AXL, and MerTK) family of receptors are PSRs that have been shown to drive PS-mediated immune suppression in tumors. This review will highlight the development of mAbs targeting PS, TIM-3 and the TAM receptors.

Dynamics of coagulation factor XIII activity after video-assisted thoracoscopic lobectomy for non-small cell lung cancer

Background

The present study was performed to investigate the perioperative dynamics of coagulation factor XIII (FXIII) in patients with non-small cell lung cancer undergoing video-assisted thoracoscopic surgery (VATS) lobectomy compared with open lobectomy.

Methods

Perioperative coagulation factors including FXIII were analyzed in 30 patients who underwent VATS lobectomy and 10 patients who underwent open lobectomy at Teikyo University Hospital from December 2017 to April 2019.

Results

Patients in the VATS lobectomy group showed higher FXIII activity on postoperative day (POD) 5 than patients in the open lobectomy group (P=0.028). The FXIII activity was significantly lower on POD3, POD5, and POD7 than that in the preoperative period and on POD1, even in patients who had undergone VATS lobectomy (P<0.001). No factors were found to affect the maintenance of FXIII in the VATS lobectomy group.

Conclusion

The postoperative decrease of FXIII activity differed between patients who underwent VATS lobectomy and those who underwent open lobectomy. Based on the characteristics of FXIII, the FXIII activity may be a good marker of the invasiveness of VATS lobectomy versus open lobectomy.

Definitive Management of Presumed Synchronous Early Stage Non-Small Cell Lung Cancers: Outcomes and Utility of Stereotactic Ablative Radiation Therapy

PURPOSE

Management of synchronous early-stage non-small cell lung cancer (NSCLC) remains controversial because resection is not always feasible. This study evaluates efficacy and patterns of failure after SABR for synchronous early-stage NSCLC.

METHODS AND MATERIALS

From 2005 to 2015, patients presenting with ≥2 synchronous NSCLC tumors (T1a-T2b) and receiving SABR to ≥1 lesion were reviewed. The most common prescriptions were 50 Gy in 4 or 70 Gy in 10 fractions. Patients underwent multidisciplinary management with workup including chest computed tomography and positron emission tomography/computed tomography, plus brain imaging and endoscopic bronchial ultrasound for most patients to rule out mediastinal and distant disease. Synchronous lesions were defined as multiple ipsilateral or contralateral intrapulmonary lesions diagnosed within 6 months.

RESULTS

Of 912 patients treated with SABR for early-stage NSCLC at our institution, 82 (9%) presented with synchronous disease, with a total of 169 lesions. SABR was delivered to 142 lesions (84%), with 57 patients (69.5%) receiving SABR for all sites. Median overall survival (OS) and progression-free survival (PFS) were 5.1 and 2.7 years, respectively. At a median follow-up of 58 months, OS was 67% and 52% at 3 and 5 years, and corresponding PFS was 47% and 29%. Thirty-nine patients (48%) had progression, with 21 (26%) experiencing distant failure, and intralobar recurrence was among the first failure for 15 patients (18%). Of the 142 SABR-treated sites, these included 6 in-field (4%) and 4 marginal (3%) recurrences. There were no grade ≥3 adverse events. Among patients receiving SABR for all sites, there were no differences in OS (P = .946), PFS (P = .980), local control (P = .683), regional and distant control (P = .656), or toxicity (P = .791). On multivariable analysis, ipsilateral synchronous disease was associated with greater regional and distant failure (hazard ratio, 2.691; P = .025).

CONCLUSIONS

Synchronous NSCLC can be managed with definitive local therapy. With high control rates and favorable outcomes, SABR is an effective and feasible treatment for synchronous early-stage NSCLC.

Is less really more? Reexamining video-assisted thoracoscopic versus open lobectomy in the setting of an enhanced recovery protocol

OBJECTIVES

Video-assisted thoracoscopic surgery lobectomy has been associated with improved pain, length of stay, and outcomes compared with open lobectomy. However, enhanced recovery protocols improve outcomes after both procedures. We aimed to compare video-assisted thoracoscopic surgery and open lobectomy in the setting of a comprehensive enhanced recovery protocol.

METHODS

All patients undergoing lobectomy for lung cancer at a single institution since the adoption of an enhanced recovery protocol (May 2016 to December 2018) were stratified by video-assisted thoracoscopic surgery versus open status and compared. Demographics and outcomes, including length of stay, daily pain scores, and short-term operative complications, were compared using standard univariate statistics and multivariable models.

RESULTS

A total of 130 patients underwent lobectomy, including 71 (54.6%) undergoing video-assisted thoracoscopic surgery and 59 (45.4%) undergoing open surgery. Video-assisted thoracoscopic surgery versus open cases exhibited similar length of stay (median 4 days for both, P = .07), opioid requirement (33.2 vs 30.8 mg morphine equivalents, P = .86), and pain scores at 0, 1, 2, and 3 days after surgery (4.3 vs 2.8, P = .12; 4.4 vs 3.7, P = .27; 3.9 vs 3.5, P = .83; and 3.4 vs 3.5, P = .98, respectively). Patients undergoing video-assisted thoracoscopic surgery lobectomy exhibited lower rates of readmission (1.4% vs 17.0%, P < .01), postoperative transfusion requirement (0% vs 10.2%, P < .01), and pneumonia (1.4% vs 10.2%, P = .05). After risk adjustment, an open procedure (vs video-assisted thoracoscopic surgery status) did not significantly affect the length of stay (effect 0.18; P = .10) or overall complication rate (odds ratio, 1.9; P = .12).

CONCLUSIONS

In the setting of a comprehensive enhanced recovery protocol, patients undergoing video-assisted thoracoscopic surgery versus open lobectomy exhibited similar short-term outcomes. Surgical incision may have less impact on outcomes in the setting of a comprehensive thoracic enhanced recovery protocol.

Point of Care Ultrasound to Identify Diaphragmatic Dysfunction after Thoracic Surgery

BACKGROUND

Postoperative diaphragmatic dysfunction after thoracic surgery is underestimated due to the lack of reproducible bedside diagnostic methods. We used point of care ultrasound to assess diaphragmatic function bedside in patients undergoing video-assisted thoracoscopic or thoracotomic lung resection. Our main hypothesis was that the thoracoscopic approach may be associated with lower incidence of postoperative diaphragm dysfunction as compared to thoracotomy. Furthermore, we assessed the association between postoperative diaphragmatic dysfunction and postoperative pulmonary complications.

METHODS

This was a prospective observational cohort study. Two cohorts of patients were evaluated: those undergoing video-assisted thoracoscopic surgery versus those undergoing thoracotomy. Diaphragmatic dysfunction was defined as a diaphragmatic excursion less than 10 mm. The ultrasound evaluations were carried out before (preoperative) and after (i.e., 2 h and 24 h postoperatively) surgery. The occurrence of postoperative pulmonary complications was assessed up to 7 days after surgery.

RESULTS

Among the 75 patients enrolled, the incidence of postoperative diaphragmatic dysfunction at 24 h was higher in the thoracotomy group as compared to video-assisted thoracoscopic surgery group (29 of 35, 83% vs. 22 of 40, 55%, respectively; odds ratio = 3.95 [95% CI, 1.5 to 10.3]; P = 0.005). Patients with diaphragmatic dysfunction on the first day after surgery had higher percentage of postoperative pulmonary complications (odds ratio = 5.5 [95% CI, 1.9 to 16.3]; P = 0.001). Radiologically assessed atelectasis was 46% (16 of 35) in the thoracotomy group versus 13% (5 of 40) in the video-assisted thoracoscopic surgery group (P = 0.040). Univariate logistic regression analysis indicated postoperative diaphragmatic dysfunction as a risk factor for postoperative pulmonary complications (odds ratio = 5.5 [95% CI, 1.9 to 16.3]; P = 0.002).

CONCLUSIONS

Point of care ultrasound can be used to evaluate postoperative diaphragmatic function. On the first postoperative day, diaphragmatic dysfunction was less common after video-assisted than after the thoracotomic surgery and is associated with postoperative pulmonary complications.

Comparative Effectiveness of Robotic-Assisted Surgery for Resectable Lung Cancer in Older Patients

BACKGROUND

Robotic-assisted surgery (RAS) is a novel surgical approach increasingly used for patients with non-small cell lung cancer (NSCLC). However, data comparing the effectiveness and costs of RAS vs open thoracotomy and video-assisted thoracoscopic surgery (VATS) for NSCLC are limited.

METHODS

Patients > 65 years old with stage I to IIIA NSCLC treated with RAS, VATS, or open thoracotomy were identified from the Surveillance, Epidemiology, and End Results-Medicare database and matched according to age, sex, stage, and extent of resection. Propensity score methods were used to compare adjusted rates of postoperative complications, adequate lymph node staging, survival, and treatment-related costs.

RESULTS

In this matched study cohort of 2,766 patients with resected NSCLC, RAS was associated with lower complication rates (OR, 0.57; 95% CI, 0.42-0.79) compared with open thoracotomy, and similar complication rates (OR, 1.02; 95% CI, 0.76-1.37) compared with VATS. Patients undergoing RAS were as likely to have adequate lymph node sampling as those undergoing open thoracotomy (OR, 1.28; 95% CI, 0.94-1.74) or VATS (OR, 0.88; 95% CI, 0.66-1.18). There was no significant difference in overall survival after RAS vs open thoracotomy (hazard ratio, 0.81; 95% CI, 0.63-1.04) or VATS (hazard ratio, 0.91; 95% CI, 0.70-1.18). Costs were similar for RAS ($54,702) vs open thoracotomy ($57,104; P = .08), and higher compared with VATS ($48,729; P = .02).

CONCLUSIONS

RAS led to improved operative outcomes compared with open thoracotomy but may not offer an advantage over VATS. The comparative effectiveness of RAS should be further evaluated prior to widespread adoption.

Ivor Lewis esophagectomy patients are particularly vulnerable to respiratory impairment - a comparison to major lung resection

Pulmonary complications and a poor clinical outcome are common in response to transthoracic esophagectomy, but their etiology is not well understood. Clinical observation suggests that patients undergoing pulmonary resection, a surgical intervention with similarities to the thoracic part of esophagectomy, fare much better, but this has not been investigated in detail. A retrospective single-center analysis of 181 consecutive patients after right-sided thoracotomy for either Ivor Lewis esophagectomy (n = 83) or major pulmonary resection (n = 98) was performed. An oxygenation index <300 mm Hg was used to indicate respiratory impairment. When starting surgery, respiratory impairment was seen more frequently in patients undergoing major pulmonary resection compared to esophagectomy patients (p = 0.009). On postoperative days one to ten, however, esophagectomy caused higher rates of respiratory impairment (p < 0.05) resulting in a higher cumulative incidence of postoperative respiratory impairment for patients after esophagectomy (p < 0.001). Accordingly, esophagectomy patients were characterized by longer ventilation times (p < 0.0001), intensive care unit and total postoperative hospital stays (both p < 0.0001). In conclusion, the postoperative clinical course including respiratory impairment after Ivor Lewis esophagectomy is significantly worse than that after major pulmonary resection. A detailed investigation of the underlying causes is required to improve the outcome of esophagectomy.

Perioperative Management May Improve Long-term Survival in Patients After Lung Cancer Surgery: A Retrospective Cohort Study

BACKGROUND:

Surgical resection is the main treatment for patients with non–small-cell lung cancer (NSCLC), but patients’ long-term outcome is still challenging. The purpose of this study was to identify predictors of long-term survival in patients after lung cancer surgery.

METHODS:

Patients who underwent surgery for NSCLC from January 1, 2006, to December 31, 2009, were enrolled into this retrospective cohort study. The primary outcome was the survival length after surgery. Predictors of long-term survival were screened with the multivariable Cox proportional hazard model.

RESULTS:

Postoperative follow-up was completed in 588 patients with a median follow-up duration of 5.2 years (interquartile range, 2.0–6.8). Two hundred ninety-one patients (49.5%) survived at the end of follow-up with median survival duration of 64.3 months (interquartile range, 28.5–81.6). The overall survival rates were 90.8%, 70.0%, and 57.1% at the end of the first, third, and fifth year after surgery, respectively. Limited resection (hazard ratio [HR], 1.46; 95% confidence interval [CI], 1.08–1.98; P = .013) and large tumor size (HR, 1.29; 95% CI, 1.17–1.42; P < .001) were associated with short survival; whereas high body mass index grade (HR, 0.82; 95% CI, 0.69–0.97; P = .021), highly differentiated tumor (HR, 0.59; 95% CI, 0.37–0.93; P = .024), dissection of mediastinal lymph node during surgery (HR, 0.45; 95% CI, 0.30–0.67; P < .001), and perioperative use of dexamethasone (HR, 0.70; 95% CI, 0.54–0.90; P = .006) were associated with long survival. No association was found between perioperative use of flurbiprofen axetil and long survival (HR, 0.80; 95% CI, 0.62–1.03; P = .086). However, combined administration of dexamethasone and flurbiprofen axetil was associated with longer survival (compared to no use of both: adjusted HR, 0.57; 95% CI, 0.38–0.84; P = .005).

CONCLUSIONS:

Certain factors in particular perioperative dexamethasone and flurbiprofen axetil therapy may improve patients’ long-term survival after surgery for NSCLC. Given the small sample size, these findings should be interpreted with caution, and randomized clinical trials are needed for further clarification.

Systematic mediastinal lymph node dissection outcomes and conversion rates of uniportal video-assisted thoracoscopic lobectomy for lung cancer

BACKGROUND

To evaluate the systematic mediastinal lymph node (LN) dissection outcomes and conversion rates of uniportal video-assisted thoracoscopic surgery (UVATS).

METHODS

Patients with non-small-cell lung cancer who underwent video-assisted thoracoscopic surgery (VATS) and systematic mediastinal LN dissection between January 2015 and January 2017 were retrospectively reviewed. We categorized the patients into two groups according to the different surgical approaches. Patients' clinical data were collected and compared. The index of estimated benefit from LN dissection was used to evaluate the therapeutic value of LN dissection for each station.

RESULTS

A total of 453 patients underwent VATS, including 197 patients in the UVATS group and 256 patients in the triportal VATS (TVATS) group. There were no significant differences in the 1-, 2- and 3-year survival rates of these two groups (P > 0.05). There were no statistically significant differences in the operative time, numbers and stations of LNs, numbers and stations of N2 LNs, conversion rate or postoperative complications. The UVATS group had less intraoperative blood loss, a shorter duration of hospital stay, less chest tube drainage and a shorter duration of chest tube drainage than the TVATS group (P < 0.05). The conversion rates in the UVATS and TVATS groups were 5.1% and 4.3%, respectively, and the difference was not significant. The same degree of LN sampling was achieved in both groups.

CONCLUSION

UVATS permits the same degree of LN sampling as TVATS without a difference in the conversion rate.

Is incentive spirometry beneficial for patients with lung cancer receiving video-assisted thoracic surgery?

Background

The effectiveness of Incentive spirometry (IS) in patients undergoing video-assisted thoracic surgery (VATS) remains lacking. We conducted a population-based study to investigate the effectiveness of IS on patients with lung cancers following VATS.

Methods

We identified patients newly diagnosed with lung cancer who underwent surgical resection by VATS or thoracotomy from the years 2000 to 2008 in the Longitudinal Health Insurance Database. Exposure variable was the use of IS during admission for surgical resection by VATS or thoracotomy. Primary outcomes included hospitalization cost, incidence of pneumonia, and length of hospital stay. Secondary outcomes included the frequency of emergency department (ED) visits and hospitalizations at 3-month, 6-month, and 12-month follow-ups after thoracic surgery.

Results

We analyzed 7549 patients with lung cancer undergoing surgical resection by VATS and thoracotomy. The proportion of patients who were subjected to IS was significantly higher in those who underwent thoracotomy than in those who underwent VATS (68.4% vs. 53.1%, P < 0.0001). After we controlled for potential covariates, the IS group significantly reduced hospitalization costs (− 524.5 USD, 95% confidence interval [CI] = − 982.6 USD – -66.4 USD) and the risk of pneumonia (odds ratio = 0.55, 95% CI = 0.32–0.95) compared to the non-IS group following VATS. No difference in ED visit frequency and hospitalization frequency at 3-month, 6-month, and 1-year follow-up was noted between the IS and the non-IS groups following VATS.

Conclusions

The use of IS in patients with lung cancers undergoing VATS may reduce hospitalization cost and the risk of pneumonia.

Long-term oncological outcome after thoracoscopic lobectomy for non-small cell lung cancer patients

BACKGROUND

Thoracoscopic surgery (TS) has been used more commonly as a less invasive procedure for early-stage non-small cell lung cancer (NSCLC) than conventional thoracotomy (TH) in Japan. However, limited evidential data are available to compare the treatment efficacy of TS and TH. The purpose of this study was to retrospectively investigate the difference in the long-term outcome and invasiveness of TS and TH.

METHODS

Total 1,166 NSCLC patients who underwent surgery between 2005 and 2013 were enrolled. Of these, 844 patients underwent surgery via TH and 322 via TS. We compared several clinicopathological factors and the long-term outcome between the two groups. We performed propensity score matching analysis to minimize differences in the patient background and tumor states.

RESULTS

The TS group included more women, non-smokers or light smokers, and healthy patients. In the TS group, the disease states were significantly less aggressive. The TS group had a much better 5-year overall survival (OS) rate of 92.6% as compared to 76.7% in the TH group (P<0.0001). Using propensity score matching, we extracted 190 patients each from the two groups. No statistical differences were present in the OS rates of the two matched groups (P=0.2223), indicating the achievement of adequate balance. For a balanced cohort, intraoperative blood loss was significantly less, and the duration of postoperative drainage was shorter in the TS group.

CONCLUSIONS

We observed excellent long-term oncological outcomes in NSCLC patients after TS, with comparable treatment outcomes and less-invasiveness than TH.

Association of tumor location with economic outcomes and air leak complications in thoracic lobectomies: results from a national hospital billing dataset

Purpose: To assess whether tumor location during thoracic lobectomies affects economic outcomes or air leak complications.

Patients and methods: Retrospective, observational study using Premier Healthcare Database. The study included patients aged ≥18 years who underwent elective inpatient thoracic lobectomy for lung cancer between 2012 and 2014 (first qualifying=index admission). Three mutually exclusive tumor location groups were formed: upper lobe, middle lobe, and lower lobe. Primary outcomes were index admission’s length of stay (LOS), total hospital costs, and operating room time; in-hospital air leak complications (composite of air leak/pneumothorax) served as an exploratory outcome. Multivariable models were used to examine the association between tumor location and the study outcomes, accounting for covariates and hospital-level clustering.

Results: 8,750 thoracic lobectomies were identified: upper lobe (n=5,284), middle lobe (n=512), and lower lobe (n=2,954). Compared with the upper lobe, the middle and lower lobe groups had statistically significant (p<0.05): shorter adjusted LOS (7.0 days upper vs 5.8 days middle, 6.6 days lower), lower adjusted mean total hospital costs ($26,177 upper vs $23,109 middle, $24,557 lower), and lower adjusted odds of air leak complications (odds ratio middle vs upper=0.81, 95% CI=0.74–0.89; odds ratio lower vs upper=0.60, 95% CI=0.46–0.78). Findings were similar but varied in statistical significance when stratified by open and video-assisted thoracoscopic surgery approach.

Conclusion: Among patients undergoing elective thoracic lobectomy for lung cancer in real-world clinical practice, upper lobe tumors were significantly associated with increased in-hospital resource use and air leak complications as compared with lower or middle lobe tumors.

Electromagnetic Transthoracic Nodule Localization for Minimally Invasive Pulmonary Resection

BACKGROUND

Increased use of chest computed tomography and the institution of lung cancer screening have increased the detection of ground-glass and small pulmonary nodules. Intraoperative localization of these lesions via a minimally invasive thoracoscopic approach can be challenging. We present the feasibility of perioperative transthoracic percutaneous nodule localization using a novel electromagnetic navigation platform.

METHODS

This is a multicenter retrospective analysis of a prospectively collected database of patients who underwent perioperative electromagnetic transthoracic nodule localization before attempted minimally invasive resection between July 2016 and March 2018. Localization was performed using methylene blue or a mixture of methylene blue and the patient's blood (1:1 ratio). Patient, nodule, and procedure characteristics were collected and reported.

RESULTS

Thirty-one nodules were resected from 30 patients. Twenty-nine of 31 nodules (94%) were successfully localized. Minimally invasive resection was successful in 93% of patients (28/30); 7% (2/30) required conversion to thoracotomy. The median nodule size was 13 mm (interquartile range 25%-75%, 9.5-15.5), and the median depth from the surface of the visceral pleura to the nodule was 10 mm (interquartile range 25%-75%, 5.0-15.9). Seventy-one percent (22/31) of nodules were malignant. No complications associated with nodule localization were reported.

CONCLUSIONS

The use of intraoperative electromagnetic transthoracic nodule localization before thoracoscopic resection of small and/or difficult to palpate lung nodules is safe and effective, potentially eliminating the need for direct nodule palpation. Use of this technique aids in minimally invasive localization and resection of small, deep, and/or ground-glass lung nodules.

Patient-reported Outcomes After the Treatment of Early Stage Non-small-cell Lung Cancer With Stereotactic Body Radiotherapy Compared With Surgery

INTRODUCTION

As there is increasing evidence for comparable survival after either stereotactic body radiotherapy (SBRT) or surgery for patients with stage I non-small-cell lung cancer (NSCLC), treatment impact on the quality of life (QoL) is essential for well-informed decision-making. Our previous work evaluated health utility between surgery and SBRT in stage I NSCLC. The aim of this secondary analysis is to directly compare QoL in the first year after SBRT and surgery.

MATERIALS AND METHODS

QoL was assessed at baseline and 3, 6, and 12 months after treatment. Two prospectively collected databases of patients with clinically proven stage I NSCLC, from 2 large hospitals in the Netherlands, were pooled (n = 306; 265 patients were treated with SBRT and 41 patients with surgery). To correct for confounding, propensity scores were calculated, to be selected for surgical treatment. A mixed model analysis was used to study differences in QoL between the 2 treatments.

RESULTS

The 41 surgical patients were matched to 41 SBRT patients on propensity score with a 1:1 ratio. At baseline, patients in the surgery group report a lower QoL compared with patients in the SBRT group. However, during the first year after treatment, no clinical meaningful differences were observed, except for role functioning, between patients treated using either modality.

CONCLUSION

This study comparing a matched cohort revealed no clinically significant differences in QoL following either SBRT or surgery for early stage NSCLC. These results support the hypothesis that surgery and SBRT are comparable treatments.

Changes in the Risk of Mortality and Morbidity After Lung Resection in the Last 20 Years

INTRODUCTION

The aim of this study is to evaluate changes in the risk of cardiorespiratory mortality and morbidity calculated by Eurolung risk models 1 and 2 in the last 20 years, and to identify variations in patient selection or surgical practice that might have altered the risk of death and complications after anatomical lung resections.

METHOD

This was a retrospective analysis of a series of 2,435 consecutive patients who underwent anatomical lung resection. The population was divided into three time periods: 1994-2006 (976 cases), 2007-2015 (945 cases), and 2016-2017 (420 cases). Eurolung models 1 and 2 were applied to the series, and the individual probability of adverse effects was calculated. We compared this mean probability, and the prevalence or means of each of the variables included in the models in each period and plotted the evolution of the risk.

RESULTS

A progressive decrease was observed in both adverse effects over time. The prevalence of the binary variables, except for coronary heart disease, was higher in the last period. The percentage of pneumonectomies and extended resections fell in the last two periods and the number of cases treated with VATS increased substantially in 2016-2017.

CONCLUSIONS

The decline in the number of pneumonectomies and the increase in the rate of minimally invasive procedures appear to be the variables most closely associated with decreased risk. Other changes in the clinical characteristics of the patients do not seem to have influenced the outcomes.

Understanding patients' values and preferences regarding early stage lung cancer treatment decision making

INTRODUCTION

With advances in treatments among patients with lung cancer, it is increasingly important to understand patients' values and preferences to facilitate shared decision making.

METHODS

Prospective, multicenter study of patients with treated stage I lung cancer. At the time of study participation, participants were 4-6 months posttreatment. Value clarification and discrete choice methods were used to elicit participants' values and treatment preferences regarding stereotactic body radiation therapy (SBRT) and surgical resection using only treatment attributes.

RESULTS

Among 114 participants, mean age was 70 years (Standard Deviation = 7.9), 65% were male, 68 (60%) received SBRT and 46 (40%) received surgery. More participants valued independence and quality of life (QOL) as "most important" compared to survival or cancer recurrence. Most participants (83%) were willing to accept lung cancer treatment with a 2% chance of periprocedural death for only one additional year of life. Participants also valued independence more than additional years of life as most (86%) were unwilling to accept either permanent placement in a nursing home or being limited to a bed/chair for four additional years of life. Surprisingly, treatment discordance was common as 49% of participants preferred the alternative lung cancer treatment than what they received.

CONCLUSIONS

Among participants with early stage lung cancer, maintaining independence and QOL were more highly valued than survival or cancer recurrence. Participants were willing to accept high periprocedural mortality, but not severe deficits affecting QOL when considering treatment. Treatment discordance was common among participants who received SBRT or surgery. Understanding patients' values and preferences regarding treatment decisions is essential to foster shared decision making and ensure treatment plans are consistent with patients' goals. Clinicians need more resources to engage in high quality communication during lung cancer treatment discussions.

Outcomes after Video-assisted Thoracoscopic Lobectomy versus Open Lobectomy for Early-Stage Lung Cancer in Older Adults

RATIONALE

Video-assisted thoracoscopic surgery (VATS) and open lobectomy are both standard of care for the treatment of early-stage non-small cell lung cancer (NSCLC) because of equivalent long-term survival.

OBJECTIVES

To evaluate whether the improved perioperative outcomes associated with VATS lobectomy are explained by surgeon characteristics, including case volume and specialty training.

METHODS

We analyzed the Surveillance, Epidemiology, and End Results-Medicare-linked registry to identify stage I-II NSCLC in patients above 65 years of age. We used a propensity score model to adjust for differences in patient characteristics undergoing VATS versus open lobectomy. Perioperative complications, extended length of stay, and perioperative mortality among patients were compared after adjustment for surgeon's volume and specialty using linear mixed models. We compared survival using a Cox model with robust standard errors.

RESULTS

We identified 9,508 patients in the registry who underwent lobectomy for early-stage NSCLC. VATS lobectomies were more commonly performed by high-volume surgeons (P < 0.001) and thoracic surgeons (P = 0.01). VATS lobectomy was associated with decreased adjusted odds of cardiovascular complications (odds ratio [OR] = 0.65; 95% confidence interval [CI] = 0.47-0.90), thromboembolic complications (OR = 0.47; 95% CI = 0.38-0.58), extrapulmonary infections (OR = 0.75; 95% CI = 0.61-0.94), extended length of stay (OR = 0.47; 95% CI = 0.40-0.56), and perioperative mortality (OR = 0.33; 95% CI = 0.23-0.48) even after controlling for differences in surgeon volume and specialty. Long-term survival was equivalent for VATS and open lobectomy (hazard ratio = 0.95; 95% CI = 0.85-1.08) after controlling for patient and tumor characteristics, surgeon volume, and specialization.

CONCLUSIONS

VATS lobectomy for NSCLC is associated with better postoperative outcomes, but similar long-term survival, compared with open lobectomy among older adults, even after controlling for surgeon experience.

Videothoracoscopic lobectomy training in non-small cell lung cancer

Background

This study aims to evaluate the outcomes of video-assisted thoracoscopic surgery lobectomies performed by a training consultant or an experienced consultant.

Methods

The study included 103 patients (81 males, 22 females; mean age 59.6±9.5 years; range, 32 to 84 years) who underwent video-assisted thoracoscopic surgery lobectomy due to non-small cell lung cancer. The training consultant assisted on the same side with the experienced consultant during the operations of the experienced consultant. The experienced consultant observed in the operating room and provided advice from a distance during the first five operations of the training consultant. Comorbidities, postoperative complications, and mortality were evaluated.

Results

Patients" demographic characteristics, comorbidities, and postoperative complications were similar between the two surgeons (p>0.05). Operative time, incidence of prolonged air leak, and length of hospital stay were higher in procedures performed by the training consultant (p<0.05). There were no significant differences in rates of life-threatening complications or mortality.

Conclusion

Video-assisted thoracoscopic surgery lobectomy can be performed safely by surgeons in training. Effective training programs may produce outcomes comparable to those of experienced surgeons.

Comparative study of anatomic lung resection by robotic vs. video-assisted thoracoscopic surgery

Background

Comparative studies of robotic lung resection are limited. Our study aims to compare short-term and long-term outcomes of anatomic lung resection by robotic or video-assisted thoracoscopic surgery (VATS) from a single surgeon experienced in both approaches.

Methods

A retrospective analysis of consecutive anatomic lung resections by robot or VATS was performed to compare perioperative characteristics and long-term survival.

Results

From December 2010 to June 2015, 61 patients underwent robotic surgery, and 105 patients underwent VATS. Patient demographics were similar except that the VATS group had higher percentage of diabetic patients (robotic 14.75% vs. VATS 30.48%, P=0.0258) and a slightly lower percentage of patients with previous cancer history (robotic 57.38% vs. VATS 40.95%, P=0.0409). The robotic group had a higher rate of prolonged air leak ≥7 d (robotic 14.75% vs. VATS 3.81%; P=0.0161), and a modestly longer length of hospital stay (robotic median of 4.0 days vs. VATS median of 3.0 days, P=0.0123). Other postoperative complications, mortality, nodal upstaging and conversion rate were similar. Disease-free survival was not different. The robotic group appeared to have slightly better overall survival, however, this observation was confounded by a lower percentage of diabetic patients in this group. Further analysis has demonstrated that in non-diabetic patients who underwent either surgery, the overall survival remained similar. The same observation was also made in diabetic patients.

Conclusions

Robotic anatomic lung resection appears to be associated with a higher rate of prolonged air leak (≥7 d), and resulting slightly longer length of hospital stay than VATS. Within the same follow-up period, both the disease-free survival and the overall survival are similar.

Stereotactic Body Radiotherapy for Centrally Located Primary Non-Small-Cell Lung Cancer: A Meta-Analysis

BACKGROUND

The purpose of the study was to evaluate the efficacy and safety of stereotactic body radiotherapy (SBRT) for centrally located, primary non-small-cell lung cancer (NSCLC).

MATERIALS AND METHODS

Systematic search of 4 databases (PubMed, MEDLINE, EMBASE, and Cochrane Library) was performed for literature published until May 9, 2018. Primary (overall survival [OS] and local control [LC] rates) and secondary (Grade ≥3 toxicity) endpoints were reported.

RESULTS

Thirteen studies encompassing 599 patients with central NSCLCs were included. Median values of T1 tumor proportion, tumor size, and median survival were 55.3% (range, 0%-75%), 3.3 (range, 2.1-4.1) cm, and 26 (range, 14-68.9) months, respectively. Pooled rates of 1-, 2-, and 3-year OS rates were 84.3% (95% confidence interval [CI], 75.7-90.3), 64.0% (95% CI, 52.9-72.2), and 50.5% (95% CI, 39.4-61.5), respectively. Pooled rates of 1-, 2-, and 3-year LC rates were 89.4% (95% CI, 80.8-94.4), 82.2% (95% CI, 71.7-89.4), and 72.2% (95% CI, 55.0-84.7), respectively. Pooled rate of Grade ≥3 complication was 12.0% (95% CI, 7.3-19.0). Meta-regression analyses showed significant positive relationships between biologically equivalent dose using an α/β of 10 Gy in the linear quadratic model (BED_10Gy) and 1- and 2-year LC rates (P < .001 and P < .001), and 1- and 2-year OS rates (P = .0178 and P = .032), and Grade ≥3 complication rate (P = .0029). In subgroup comparisons between BED_10Gy <100 Gy versus ≥100 Gy, 1- and 2-year LC rates were significantly different but not for OS and Grade ≥3 complication rates.

CONCLUSION

Our results suggests that SBRT is potent for tumor control in central NSCLC, although complications should be further minimized through optimization of dose-fractionation scheme and accurate planning. Using BED_10Gy ≥100 Gy yielded higher LC rates, and dose escalation was related to OS, LC, and complications.

Understanding the financial cost of robotic lobectomy: calculating the value of innovation?

Background

The advantages of a minimally-invasive surgical approach compared to conventional open thoracotomy for lung resection have been previously described. While robot-assisted thoracoscopic surgery (RATS) has shown comparable clinical outcomes for lobectomy as compared with video-assisted thoracic surgery (VATS), the cost and inherent value associated with the robotic technology remains a main concern.

Methods

We conducted a systematic review of the literature on the cost of RATS lobectomy using studies published prior to December 2017 on MEDLINE and EMBASE.

Results

Six observational studies met our inclusion criteria. Median cost of RATS lobectomy ranged from $15,440 to $22,582. Operating room (OR) cost was a major contributing factor to overall cost. The lowest per-procedure cost was reported by the highest volume center. Cost definitions were highly variable among studies. The total cost of RATS was similar or lower to open lobectomy, and higher than that of VATS, with cost difference ranging from $2,901 to $4,708.

Conclusions

Assessment of cost for RATS lobectomy varies significantly. High OR costs may be offset by improved outcomes as compared with open lobectomy, but currently the costs exceed that of VATS lobectomy. Further work is needed to define the cost and actual value parameters for RATS lobectomy.

Perioperative outcomes of thoracoscopic lung resection requiring a long operative time

OBJECTIVES

Difficult thoracoscopic surgery sometimes requires a long operative time. It is unclear whether patients benefit from such thoracoscopic surgeries. We investigated whether thoracoscopic surgery for difficult cases contributed to improvements in perioperative outcomes.

METHODS

We retrospectively reviewed cases of anatomical lung resection with thoracoscopic surgery, including conversion to thoracotomy, between January 2006 and December 2016 and compared patient demographics and perioperative outcomes of the long (≥360 min) and the normal operative time groups (<360 min).

RESULTS

One hundred and seventy-six patients were in the long operative time group and 655 patients were in the normal operative time group. The long operative time group had more male patients, more progressive clinical stages, bilobectomy or pneumonectomy, conversion to thoracotomy and more blood loss than the normal operative time group. The long operative time group had higher rates of postoperative complications and longer hospital stay (30% vs 16%, P < 0.001 and 9 ± 9 days vs 7 ± 8 days, P < 0.001; respectively). Multivariate analysis showed that in the first half of the operative period, chronic obstructive pulmonary disease and bilobectomy or pneumonectomy were independent predictive factors for postoperative complications. The long operative time as a factor was close to statistical significance (odds ratio 1.689, P = 0.079) unlike the elective conversion to thoracotomy (odds ratio 0.784, P = 0.667) and emergency conversion to thoracotomy (odds ratio 0.938, P = 0.924).

CONCLUSIONS

In conclusion, when difficult cases are encountered, conversion to thoracotomy should be considered by surgeons if continuation of thoracoscopic surgery increases the operative time.

Updates on Minimally Invasive Surgery in Non-Small Cell Lung Cancer

OPINION STATEMENT

Video-assisted thoracic surgery (VATS) has become widely used since the 1990s and has become a standard treatment approach mainly for early-stage non-small cell lung cancer. The few randomized controlled trials providing evidence of the effectiveness of VATS lobectomy at present are supported by a large number of propensity-matched studies, several high-quality meta-analyses, and outcome studies. These studies provide comprehensive data demonstrating the lower morbidity, shorter chest tube duration, and shorter hospital stay of VATS than thoracotomy during the postoperative course. Moreover, VATS shows equivalent oncological outcome as thoracotomy and therefore should be performed for lobectomy as much as possible. Importantly, VATS has recently been applied to advanced cases and previously contraindicated complex procedures such as bronchoplasty and chest wall resection. Attention has also been paid to reduced port surgery performed by frontier surgeons. Thus, the indications of VATS have seen a significant expansion. This major development logically negates any hesitation to change to the VATS technique as any doubt will likely constrain its wider applications. Preparation of scientific learning environments is necessary and should be actively pursued to adopt new skills instead of debating between the choice of "VATS or open."

Impact of Postoperative Pneumonia Developing After Discharge on Long-Term Follow-up for Resected Lung Cancer

BACKGROUND

Postoperative nosocomial pneumonia is a common immediate complication following lung resection. However, the incidence and mortality of pneumonia developing after discharge (PDAD) for lung-resected patients during long-term observation remain unclear. The aim of this study was to investigate the clinical features of PDAD in patients with resected lung cancer.

METHODS

We conducted a retrospective cohort study of 357 consecutive patients with lung cancer who had undergone lung resection at a single institution, between April 2007 and December 2016. The clinical characteristics, pathological features, and overall survival were analyzed. Propensity score matched analysis was used for the evaluation of overall survival between PDAD and non-PDAD groups with adjusted relevant confounding factors.

RESULTS

PDAD was observed in 66 patients (18.5%). The cumulative incidence of PDAD was 14.9% at 3 years and 21.6% at 5 years. Mortality of PDAD was 30.3%. Multivariate analysis demonstrated that the risk factors for PDAD were age (OR 1.07; P = 0.005), oral steroid use (OR 5.62; P = 0.046), and lower-lobe resection (OR 1.87; P = 0.034). After propensity score matching, 52 patients with PDAD and 52 patients without it were compared. The incidence of PDAD resulted in a worse 5-year overall survival (56.1 vs. 69.3%; P = 0.024). The Cox proportional hazards model indicated that PDAD was associated with poor overall survival (HR 1.99, P = 0.027).

CONCLUSIONS

Our findings revealed a high incidence and mortality of PDAD among patients who had undergone lung resection with long-term follow-up. Therefore, PDAD could be associated with poorer overall survival.