Limax Nd:YAG laser-assisted thoracoscopic resection of pulmonary metastases; a single centre's initial experience

New Prognostic Score (Essen Score) to Predict Postoperative Morbidity after Resection of Lung Metastases

BACKGROUND

Pulmonary metastasectomy (PM) is a widely accepted surgical procedure. This study aims to investigate postoperative morbidity and mortality after PM and develop a score to predict high-risk patients.

METHODS

We retrospectively investigated all patients undergoing a PM in our institution from November 2012 to January 2023. Complications were defined as the diagnosis of any new disease after the PM up to 30 days after the operation.

RESULTS

1284 patients were identified. At least one complication occurred in 145 patients (11.29%). Only one patient died during the hospital stay. Preoperative cardiovascular comorbidities (OR: 2.99, 95% CI: 1.412-3.744, p = 0.01), major lung resections (OR: 2.727, 95% CI: 1.678-4.431, p < 0.01), repeated pulmonary metastasectomy (OR: 1.759, 95% CI: 1.040-2.976, p = 0.03) and open thoracotomy (OR: 0.621, 95% CI: 0.415-0.930, p = 0.02) were identified as independent factors for postoperative complications. Based on the above independent factors for postoperative morbidity, the Essen score was developed (overall correct classification: 94.6%, ROC-Analysis: 0.828, 95% CI: 0.795-0.903).

CONCLUSION

PM is a safe surgical procedure with acceptable morbidity and low mortality. The aim of the Essen score is to identify patients that are associated with risk for postoperative complications after PM.

The Management of Oligometastatic Disease in Colorectal Cancer: Present Strategies and Future Perspectives

Oligometastatic disease has been described as an intermediate clinical state between localized cancer and systemically metastasized disease. Recent clinical studies have shown prolonged survival when aggressive locoregional approaches are added to systemic therapies in patients with oligometastases. The aim of this review is to outline the newest options to treat oligometastatic colorectal cancer (CRC), also considering its molecular patterns. We present an overview of the available local treatment strategies, including surgical procedures, stereotactic body radiation therapy (SBRT), thermal ablation, as well as trans-arterial chemoembolization (TACE) and selective internal radiotherapy (SIRT). Moreover, since imaging methods provide crucial information for the early diagnosis and management of oligometastatic CRC, we discuss the role of modern radiologic techniques in selecting patients that are amenable to potentially curative locoregional treatments.

Lung Metastatectomy: Can Laser-Assisted Surgery Make a Difference?

BACKGROUND

Resection of lung metastases with curative intention in selected patients is associated with prolonged survival. Laser-assisted resection of lung metastases results in complete resection of a high number of lung metastases, while preserving lung parenchyma. However, data concerning laser lung resections are scarce and contradictory. The aim of this study was to conduct a systematic review to evaluate the utility of laser-assisted pulmonary metastasectomy.

METHODS

An electronic search in MEDLINE (via PubMed), complemented by manual searches in article references, was conducted to identify eligible studies.

RESULTS

Fourteen studies with a total of 1196 patients were included in this metanalysis. Laser-assisted surgery (LAS) for lung metastases is a safe procedure with a postoperative morbidity up to 24.2% and almost zero mortality. LAS resulted in the resection of a high number of lung metastases with reduction of the lung parenchyma loss in comparison with conventional resection methods. Survival was similar between LAS and conventional resections.

CONCLUSION

LAS allows radical lung-parenchyma saving resection of a high number of lung metastases with similar survival to conventional methods.

Initial Airtightness of the Lung Parenchyma After Transection of the Interlobar Fissure - Monopolar Cutter, Stapler Versus Nd: YAG Laser

INTRODUCTION

Every lobectomy requires the transection of the interlobar fissure. Resection surfaces must be airtight in order to avoid leakage and infection. Using an ex vivo model based on porcine lung, we compared three techniques with respect to initial airtightness at different inspiratory pressures.

MATERIALS AND METHODS

In the first technique (group 1), we transected the interlobar fissure with a monopolar cutter and overstitched the edges of the resection area with a monofilament thread. In the second technique (group 2), the interlobar fissure was cut with a stapling device. In the third technique (group 3), the interlobar fissure was cut using a laser fibre connected to an Nd: YAG laser. The resection areas were not overstitched; 15 transections were performed in each group.

RESULTS

In group 1, three parenchymatous bridges leaked starting at a pressure of 25 mbar. In the other two groups, all preparations were airtight at this pressure. If the ventilation pressure was increased up to 40 mbar, all seams in group 1 were leaky at a pressure of 35 mbar. Four staple seams were airtight at a pressure of 40 mbar. In group 3, 11 preparations (73.3 %) were airtight up to a pressure of 40 mbar.

CONCLUSIONS

Based on our results, the use of an Nd: YAG laser is suitable for the transection of the interlobar fissure. In effect, this technique compares well with the other techniques examined.

Local Effects of a 1940 nm Thulium-Doped Fiber Laser and a 1470 nm Diode Laser on the Pulmonary Parenchyma: An Experimental Study in a Pig Model

The lungs are a common site of metastases from malignant tumors. Their removal with a minimal but safe tissue margin is essential for the long-term survival of patients. The aim of this study was to evaluate the usefulness of a 1940 nm thulium-doped fiber laser (TDFL) and a 1470 nm diode laser (DL) in a pig model of lung surgery that involved the incision and excision of lung tissue. Histopathological analysis was performed on days 0 and 7 after surgery. Neither TDFL nor DL caused significant perioperative or postoperative bleeding. Histological analysis revealed the presence of carbonized necrotic tissue, mixed fibrin-cellular exudate in the superficial zone of thermal damage and bands of deeper thermal changes. The mean total width of thermal damage on day 0 was 499.46 ± 61.44 and 937.39 ± 109.65 µm for TDFL and DL, respectively. On day 7, cell activation and repair processes were visible. The total width of thermal damage was 2615.74 ± 487.17 µm for TDFL vs. 6500.34 ±1118.02 µm for DL. The superficial zone of thermal damage was narrower for TDFL on both days 0 and 7. The results confirm the effectiveness of both types of laser in cutting and providing hemostasis in the lungs. TDFL caused less thermal damage to the lung parenchyma than DL.

Is laser-assisted resection preferable to lobectomy for pulmonary metastasectomy?

The aim of this study was to investigate if laser-assisted resection is appropriate for large and/or central lung metastases, when stapler wedge resection is not feasible, to determine whether this technique can be an alternative to lobectomy. All patients who underwent laser-assisted resection for large and/or central metastases were selected for the study. For comparison, patients who underwent lobectomy for metastases between 2005 and 2017 were reviewed. All resections were performed with a 1318-nm Nd:YAG laser. Perioperative features and long-term oncological outcomes were investigated. Some aspects and drawbacks of laser resection were also investigated. Among 89 patients, 42 (47%) underwent laser resection and 47 underwent lobectomy. Complete resection was achieved in 91% of laser resections and in 98% of lobectomies. The operative time, postoperative drainage time, and length of stay were significantly shorter in patients who underwent laser resection than in those who underwent lobectomy. Severe postoperative complications tended to be more frequent after lobectomy. The 5-year survival was 66% and 54% after laser resection and lobectomy respectively; the 5-year disease-free survival was 35% and 32% after laser resection and lobectomy respectively. No differences were found in long-term outcomes between the two techniques. Our experience showed that laser resection, when performed for large/central metastases, resulted in comparable survival and obtained better perioperative outcomes with respect to lobectomy. We believe that laser resection can be proposed as a reliable and advantageous lung-sparing technique, as an alternative to lobectomy for metastasectomy, when stapler wedge resection is not feasible.