Is video-assisted thoracic surgery lobectomy better? Quality of life considerations

Surgeon experience does not influence nodal upstaging during vats lobectomy: Results from a large prospective national database

BACKGROUND

Despite recent improvement in preoperative staging, nodal and mediastinal upstaging occur in about 5% to 15% of cN0 patients. Different clinical and tumor characteristics are associated with upstaging, whereas the role of the surgeon's experience is not well evaluated. This study aimed to investigate if operator experience might influence nodal upstaging during video-assisted thoracic surgery anatomical lung resection.

METHODS

Clinical and pathological data from the prospective video-assisted thoracic surgery Italian nationwide registry were reviewed and analyzed. Patients with incomplete data about tumor and surgical characteristics, ground glass opacities tumors, cN2 to 3, and M+ were excluded. Clinical data, tumor characteristics, and surgeon experience were correlated to nodal and mediastinal (N2) upstaging using Pearson's χ2 statistic or Fisher exact test for categorical variables and Mann-Whitney U and t tests for quantitative variables. A multivariable model was built using logistic regression analysis. Surgeon experience was categorized considering the number of video-assisted thoracic surgery major anatomical resections and years after residency.

RESULTS

Final analysis was conducted on 3,319 cN0 patients for nodal upstaging and 3,471 cN0N1 patients for N2 upstaging. Clinical tumor-nodes-metastasis stage was stage I in 2,846 (81.9%) patients, stage II in 533 (15.3%), and stage III (cT3N1) in 92 (2.8%). Nodal upstaging occurred in 489 (13.1%) patients, whereas N2 upstaging occurred in 229 (6.1%) patients. Years after residency (P = .60 for nodal, P = .13 for N2 upstaging) and a number of video-assisted thoracic surgery procedures(P = .49 for nodal, P = .72 for nodal upstaging) did not correlate with upstaging. Multivariable analysis confirmed cT-dimension (P = .001), solid nodules (P < .001), clinical tumor-nodes-metastasis (P < .001) and maximum standardized uptake values (P < .001) as factors independently correlated to nodal upstaging, whereas cT-dimension (P = .005), clinical tumor-nodes-metastasis (P < .001) and maximum standardized uptake values (P = .028) resulted independently correlated to N2 upstaging.

CONCLUSION

Our study showed that surgeon experience did not influence nodal and mediastinal upstaging during -assisted thoracic surgery anatomical resection, whereas cT-dimension, clinical tumor-nodes-metastasis, and maximum standardized uptake values resulted independently correlated to nodal and mediastinal upstaging.

Comparison of Early Postoperative Diaphragm Muscle Function after Lobectomy via VATS and Open Thoracotomy: A Sonographic Study

Although a growing body of evidence emphasizes the superiority of VATS over conventional thoracotomy, little is still known about early postoperative diaphragm muscle function after lobectomy via these two approaches. To fill the gap in existing literature, we conducted a comparative study between VATS and conventional thoracotomy in terms of postoperative diaphragm muscle function, assessing its contractility, strength, the magnitude of effort and potential risk of dysfunction such as atrophy and paralysis. A total of 59 patients (30 after VATS), who underwent anatomical pulmonary resection at our institution, were enrolled in this study. The control group consisted of 28 health subjects without medical conditions that could contribute to diaphragm dysfunction. Diaphragm muscle was assessed before and after surgery using ultrasonography. We found that both surgical approaches were associated with postoperative impairment of diaphragm muscle function-compared to baseline data. Postoperative reduction in diaphragm contraction was demonstrated in most of the 59 patients. In the case of the control group, the differences between measurements were not observed. We noted that lobectomy via thoracotomy was linked with a greater percentage of patients with diaphragm paralysis and/or atrophy than VATS. Similar findings were observed in referring to diaphragm magnitude effort, as well as diaphragm contraction strength, where minimally invasive surgery was associated with better diaphragm function parameters-in comparison to thoracotomy. Disturbance of diaphragm work was reported both at the operated and non-operated side. Upper-right and left lobectomy were connected with greater diaphragm function impairment than other segments. In conclusion, the VATS technique seems to be less invasive than conventional thoracotomy providing a better postoperative function of the main respiratory muscle.

Efficacy of postoperative analgesia with intravenous paracetamol and mannitol injection, combined with thoracic paravertebral nerve block in post video-assisted thoracoscopic surgery pain: a prospective, randomized, double-blind controlled trial

BACKGROUND

Although video-assisted thoracoscopic surgery (VATS) has advantages of reduced injury and faster healing, patients still endure moderate and severe postoperative pain. Paracetamol and mannitol injection, the first acetaminophen injection in China, has the advantages of convenient administration, rapid onset of action, and no first-pass effect. This aim of this study was to investigate the efficacy of postoperative analgesia with paracetamol and mannitol injection, combined with thoracic paravertebral nerve block (TPVB) in post VATS pain.

METHODS

This study was a single-center, prospective, randomized, double-blind controlled clinical trial. Patients scheduled for VATS were randomly divided into three groups, general anesthesia group (Group C), TPVB group (Group T) and TPVB + paracetamol and mannitol injection group (Group TP). In this study, the primary outcome was determined as visual analog scale (VAS) scores at rest and coughing, the secondary observation outcomes were the first time to use analgesic pump, the total consumption of oxycodone in the analgesic pump, number of effective and total analgesic pump compressions at first 48 h postoperatively, the perioperative consumption of sufentanil, time to extubation, hospital length of stay, urine volume, and the incidence of adverse events.

RESULTS

In a state of rest and cough, patients in the Group TP showed significantly lower VAS pain scores at 1, 12, 24, and 48 postoperative-hour compared with Group C and Group T. Intraoperative sufentanil and postoperative oxycodone consumption, the first time to press analgesic pump, the times of effective and total compressions of patient- controlled analgesia (PCA) were lower than those of the Group C and Group T. Interestingly, urine output was higher in Group TP. There were no differences between the three groups in terms of extubation time, length of hospital stay and adverse effects, indicating that intravenous paracetamol and mannitol injection is an effective and safe perioperative analgesia method.

CONCLUSIONS

Paracetamol and mannitol injection, combined with TPVB may provide important beneficial effects on acute pain control and reduce the consumption of opioid in patients undergoing VATS.

TRIAL REGISTRATION

The trial was registered on Jun 19, 2023 in the Chinese Clinical Trial Registry ( https://www.chictr.org.cn/showproj.html?proj=199315 ), registration number ChiCTR2300072623 (19/06/2023).

Non-intubated versus intubated video-assisted thoracoscopic lobectomy for lung cancer patients

INTRODUCTION

Video-assisted thoracoscopic surgery (VATS) lobectomy has been shown to be a standard treatment for lung cancer patient due to less pain, post-operative complication and faster recovery. In recent years, Non-intubated video-assisted thoracoscopic surgery (NIVATS) is become an alternative approach for various types of thoracic surgery with a benefit on fewer complication from mechanical ventilation. Out study is aimed to study outcome compare between NIVATS lobectomy and to general anesthetic video assisted thoracoscopic surgery (GAVATS) lobectomy.

METHODS

This is a retrospective cohort study conduct in Vajira hospital, Navamindradhiraj University, Bangkok, Thailand between January 2019 to September 2022.152 lung cancer patients underwent lobectomy. However, lung cancer patients whom needed to convert to GAVATS, open thoracotomy or emergency surgery were excluded from this study. In this study, we compare lung patients whom underwent NIVATS lobectomy and those whom underwent GAVATS lobectomy. These two groups are compared in term of pre-, intra- and post-operative outcomes. The inverse-probability weighting propensity score is used to identify the treatment effects of NIVATS.

RESULTS

In total, there are 132 cases patients including in this analysis. There are 54 and 78 patients in the NIVATS and GAVATS respectively. Intra-operative outcome, induction and operative time are lower in the NIVATS lobectomy group (25 vs 30 min, p < 0.001 and 90 vs 120 min, p = 0.003). There is no difference regarding number of node resection, station of lymph node dissection, arrhythmia, postoperative complications, and pain visual analogue score (VAS) in both groups. Postoperative outcome, length of hospital stay is shorter in NIVATS lobectomy group (4 vs 5 days, p < 0.001). There is no patient which needed to convert from NIVATS to GAVATS. The treatment-effect analyzed by using inverse-probability weighting propensity score has shown benefits of NIVATS in terms of shorter hospital stays (coefficient -2.31, 95%CI -3.65 to -0.97, p = 0.001), and shorter chest tube duration (coefficient -1.59, 95%CI -2.93 to -0.26, p = 0.019).

CONCLUSION

NIVATS lobectomy could be an alternative approach for lung cancer patients with benefits of lesser in hospital stays and duration of chest tube.

Minimally invasive sleeve lobectomy for centrally located lung cancer: A real-world study with propensity-score matching

Background

The safety, feasibility, and prognosis of sleeve lobectomy by minimally invasive surgery (MIS) remain to be validated. The purpose of this study was to investigate outcomes in real-world patients receiving minimally invasive sleeve lobectomy in a balanced large cohort.

Methods

Between January 2013 and December 2018, 578 consecutive patients undergoing sleeve resection at a high-volume center were retrospectively analyzed. Surgical and oncologic outcomes were compared between MIS and thoracotomy patients after propensity-score matching (PSM).

Results

MIS sleeve lobectomy was increasingly used as a time-trend in real-world. Before PSM, the MIS group had smaller tumor size, more T2-stage cases, and more right upper lobe sleeve lobectomies compared to the Open group. After 1:4 PSM by patient demographics and tumoral characteristics, 100 cases of MIS and 338 cases of Open sleeve lobectomy were further analyzed. Although median operation time was longer in the MIS group than in the Open group (170.5 minutes vs.149.5 minutes, P < 0.001), patients in MIS group had significantly less estimated intraoperative blood loss (100 ml vs. 200 ml, P = 0.003), shorter drainage duration (5 days vs. 6 days, P = 0.027) and less amount of drainage (1280 ml vs. 1640 ml, P < 0.001) after surgery. Complete resection rate, combined angioplasty, number of dissected lymph nodes, post-operative length of stay, postoperative morbidity and mortality rate, and application of adjuvant therapy were similar between the two matched groups. Conversion to open thoracotomy was necessary in 13.6% patients, but with similar perioperative outcomes compared to Open cases except for longer operation time. More lower lobe sleeve lobectomies were accomplished via robot-assisted thoracoscopic surgery than via video-assisted thoracoscopic surgery (40.0% vs. 12.0%, P = 0.017) in MIS patients. Five-year overall survivals (MIS vs. Open: 72.7% vs. 64.4%, P = 0.156) and five-year progression-free survivals (MIS vs. Open: 49.2% vs. 50.5%, P = 0.605) were similar between the two matched groups.

Conclusions

MIS sleeve lobectomy is associated with similar or even better perioperative results and oncologic outcomes to open thoracotomy. Conversion to thoracotomy does not compromise perioperative outcomes. Robot surgery may be preferable for more complex sleeve resections.

The ARISCAT Risk Index as a Predictor of Pulmonary Complications After Thoracic Surgeries, Almoosa Specialist Hospital, Saudi Arabia

Background

Pulmonary complications after thoracic surgery are common and are associated with prolonged hospital stay, higher costs, and increased mortality. This study aimed to evaluate the value of The Assess Respiratory risk in Surgical Patients in Catalonia (ARISCAT) risk index in predicting pulmonary complications after thoracic surgery.

Methods

This retrospective study was conducted at Almoosa Specialist Hospital, Saudi Arabia, from August 2016 to August 2019 and included 108 patients who underwent thoracic surgery during the study period. Demographic data, ARISCAT risk index score, length of hospital stay, time of chest tube removal, postoperative complications, and time of discharge were recorded.

Results

The study involved 108 patients who met the inclusion criteria. Their mean age was 42.5 ± 18.9 years, and most of them were men (67.6%). Comorbid diseases were present in 53.7%, including mainly type 2 diabetes mellitus and hypertension. FEV1% was measured in 58 patients, with a mean of 71.1 ± 7.3%. The mean ARISCAT score was 39.3 ± 12.4 and ranged from 24 to 76, with more than one-third (35.2%) having a high score grade. The most common surgical procedures were thoracotomy in 47.2%, video-assisted thoracoscopic surgery (VATS) in 28.7%, and mediastinoscopy in 17.6%. Postoperative pulmonary complications (PPCs) occurred in 22 patients (20.4%), mainly pneumonia and atelectasis (9.2%). PPCs occurred most frequently during thoracotomy (68.2%), followed by VATS (13.6%), and mediastinoscopy (9.1%). Multinomial logistic regression of significant risk factors showed that lower FEV1% (OR = 0.88 [0.79-0.98]; p=0.017), longer ICU length of stay (OR = 1.53 [1.04-2.25]; p=0.033), a higher ARISCAT score (OR = 1.22 [1.02-1.47]; p=0.040), and a high ARISCAT grade (OR = 2.77 [1.06-7.21]; p=0.037) were significant predictors of the occurrence of postoperative complications.

Conclusion

ARISCAT scoring system, lower FEV1% score, and longer ICU stay were significant predictors of postoperative complications. In addition, thoracotomy was also found to be associated with PPCs.

Thoracic surgery may alter body static balance via diaphragm dysfunction

Many diseases and conditions can alter an ability to maintain body balance. The aim of the present study was to investigate whether thoracic surgery may elicit diaphragm dysfunction thereby impairing postural stability. 40 patients qualified to video-assisted thoracoscopy (VATS) lobectomy or lobectomy via thoracotomy due to pulmonary carcinoma were examined two times: a day before lung resection and 3–5 days after surgical procedure. Diaphragm assessment was performed using ultrasonography, while postural sways were evaluated by Zebris FDM-S stabilometric platform. Thoracic surgery was associated with decrease of diaphragm thickness and movement, as well as, with deterioration of static body balance maintenance. Upper lobe resection was linked with greater diaphragm excursion restriction and worse body sway parameters than middle and lower lobe resection. VATS lobectomy was associated with better postoperative diaphragm function and better postural sway parameters than lobectomy via thoracotomy. Patients after lobectomy via thoracotomy had significantly more load on lower limb on the operated side than patients after VATS lobectomy. Impairment of diaphragm function is closely associated with equilibrium impairment after pulmonary resection. VATS lobectomy was less invasive than lobectomy via thoracotomy in terms of primary respiratory muscle function and body balance maintenance parameters.

Comparison of single-port, multi-port video-assisted thoracoscopic and open lobectomy for children: a single-center experience

PURPOSE

The feasibility of single-port video-assisted thoracic surgery (SPVATS) for pediatric lobectomy has not been clearly established. We compared the feasibilities of single-port (SP), multi-port (MP) VATS and open lobectomy (OL) for surgical treatment of children with lung disease.

METHODS

In this study, we retrospectively analyzed and compared data for 22,19 and 30 pediatric lung disease patients who had been subjected to SP, MP and OL, respectively. These procedures were performed between March, 2012 and August, 2020 at the Second Affiliated Hospital of Wenzhou Medical University. Perioperative clinical indicators were analyzed.

RESULTS

Compared to OL, SP was associated with lower intraoperative blood loss (p = 0.008), lower postoperative thoracic drainage volume (p = 0.041), shorter chest drainage duration (p = 0.002) and hospital stay (p = 0.001). Operation time (p = 0.437), volume of estimated blood loss (p = 0.979), conversion rate to thoracotomy (p = 0.861), total thoracic drainage volume (p = 0.824), duration of chest tube drainage (p = 0.543), length of hospital stay (p = 0.812) and incidences of postoperative complications were comparable in MP and SP groups.

CONCLUSION

SPVATS is a safe and feasible approach for lobectomy in pediatrics, with comparable postoperative clinical outcomes to MPVATS and better outcomes relative to OL. However, studies with large sample sizes in multicenter should be performed to verify our findings.

Overview of the outcomes of robotic segmentectomy and lobectomy

Segmentectomy has gained popularity in the latest years as a valid alternative to lobectomy. Initially reserved to patient unfit for lobar lung resection, this procedure is now offered also in selected patient with <2 cm peripheral lung cancer confined to an anatomic segment with no nodal involvement on preoperative evaluation. The introduction of screening with low-dose CT chest scan allowed the identification of lung cancer at early stages, making possible to schedule a more conservative lung surgery. A major improvement came also from minimally invasive surgery (MIS), reducing complication rate with comparable survival rates when compared to open surgery. However, due to long learning curve and uncomfortable instruments handling of video-assisted thoracoscopy, many surgeons still prefer to perform segmentectomies through a thoracotomy and thus increasing perioperative morbidity and leading to post-thoracotomy syndrome due to rib-spreading. Robotic assisted thoracic surgery (RATS) can avoid this throwback, combining the handling of open surgery with lesser invasiveness of thoracoscopy. Although literature has given strong evidences in favour of robotic lobectomies, data are still limited regarding segmentectomies performed with this technique. Moreover, no results are still available from the two ongoing randomized controlled trials comparing segmentectomy to lobectomy and so the latter represent the oncologically proper procedure for lung cancer along with lymph-node dissection. In this review we analyse the literature currently available on outcomes of lobar and sublobar anatomical resection performed by RATS, with a brief mention of the existing surgical techniques of port positioning and the costs of this procedure.

Retrospective case-control study on the outcomes of early minimally invasive pleural lavage for pleural empyema in oncology patients

BACKGROUND

Oncology patients carry a substantial risk of developing pleural empyema. Here, we report the preliminary results of our early video-assisted thoracoscopic surgery (VATS) lavage strategy in cases of empyema occurring in patients undergoing (radio-) chemotherapy.

METHODS

This was a retrospective case-control study comparing early VATS lavage (test group, current therapy since January 2018, n = 46) versus VATS pleurectomy (historical control; before January 2018, n = 46).

RESULTS

Five patients in the control group and one in the test group developed recurrence of empyema within 30 days. Complications were more severe and more frequently observed in the historical control group than in the test group (30/46 vs. 12/46 CI: 5%-95%, p = < 0.05). Early VATS lavage saved operating time, allowed a shorter ICU stay (2.6 days CI: 5%-95% vs. 5.1 days CI: 5%-95%, p = ns) and an earlier hospital discharge (6.1 days CI: 5%-95% vs. 13.5 days CI: 5%-95%, p < 0.05). Moreover, radio and/or chemotherapy could be reinitiated earlier (15 ± 20.5 days CI: 5%-95% vs. 40 ± 12 days CI: 5%-95%, p < 0.05).

CONCLUSIONS

In this retrospective cohort study, early VATS lavage was found to have a beneficial effect especially on hospital stay and enabling an earlier restart of radio- and/or chemotherapy.

Nontuberculous Mycobacteria

Nontuberculous mycobacteria (NTM) are ubiquitous in the environment and 193 species of NTM have been discovered thus far. NTM species vary in virulence from benign environmental organisms to difficult-to-treat human pathogens. Pulmonary infections remain the most common manifestation of NTM disease in humans and bronchiectasis continues to be a major risk factor for NTM pulmonary disease (NTM PD). This article will provide a useful introduction and framework for clinicians involved in the management of bronchiectasis and NTM. It includes an overview of the epidemiology, pathogenesis, diagnosis, and management of NTM PD. We will address the challenges faced in the diagnosis of NTM PD and the importance of subspeciation in guiding treatment and follow-up, especially in Mycobacterium abscessus infections. The treatment of both Mycobacterium avium complex and M. abscessus, the two most common NTM species known to cause disease, will be discussed in detail. Elements of the recent ATS/ERS/ESCMID/IDSA NTM guidelines published in 2020 will also be reviewed.

Oncological outcomes after lobe-specific mediastinal lymph node dissection via multiport video-assisted thoracoscopic surgery

OBJECTIVES

We retrospectively investigated oncological outcomes after video-assisted thoracoscopic surgery (VATS) lobectomy with lobe-specific mediastinal lymph node dissection (MLND).

METHODS

Between April 2008 and December 2016, a total of 660 patients underwent VATS lobectomy with lobe-specific MLND for clinical T1-3N0M0 non-small-cell lung cancer, of which 54 (8.2%) patients had pathological node-positive disease (18 N1 and 36 N2). We evaluated their oncological outcomes.

RESULTS

The predominant histological type was adenocarcinoma (87%). Six (33%) patients in the pN1 and 11 (31%) patients in the pN2 received adjuvant chemotherapy. The median follow-up period was 51.6 months. Postoperative recurrence was observed in 5 (28%) pN1 and 22 (61%) pN2 patients. One (6%) pN1 and 12 (33%) pN2 patients experienced locoregional recurrence. None of the pN1 patient experienced local recurrence at the dissected zone, whereas 11 (31%) pN2 patients had lymph node recurrence, including four at the dissected area and three in the area omitted from dissection in the lobe-specific MLND. The 5-year overall survival rates were 88.1% in the pN1 patients and 80.0% in the pN2 patients; the 5-year recurrence-free survival rates were 63.9% in the pN1 patients and 34.8% in the pN2 patients. In pN2 patients, pathological T classification was a prognostic factor for overall survival (P < 0.001) and recurrence-free survival (P = 0.034), and single-station N2 disease was also prognostic factor for overall survival (P = 0.023).

CONCLUSIONS

Recurrence at the omitted zone is an issue for this type of MLND. For pN1 patients, adequate MLND is an important factor for curative treatment. However, for pN2 patients, systemic treatment after recurrence may also contribute to survival.

The Impact of Expedited Discharge on 30-Day Readmission Following Lung Resection: A National Study

BACKGROUND

Expedited discharge (within 24 hours) following lung resection has received scrutiny due to concerns for higher readmissions and paradoxically increased costs. The present study examined the impact of expedited discharge on hospitalization costs and unplanned readmissions using a nationally-representative sample. In addition, we sought to determine inter-hospital practice variation.

METHODS

Adults undergoing elective lobar or sublobar resection were identified using the 2016-2018 Nationwide Readmissions Database, while those with postoperative duration of hospitalization >5 days or experienced any perioperative complication, were excluded. Patients were classified as Expedited if postoperative hospitalization was 0 or 1 day and otherwise as Routine. Inverse probability of treatment weighing was utilized to adjust for intergroup differences. Hospitals were ranked according to risk-adjusted early discharge rates. Multivariable regression models were developed to assess the association of expedited discharge on nonelective 30-day readmissions as well as associated mortality and costs.

RESULTS

Of an estimated 84,152 patients, 13,834 (16.4%) comprised the Expedited group. Compared to Routine, Expedited were younger, less likely to have chronic obstructive pulmonary disease and undergo open procedures. Following adjustment, early discharge was associated with lower incremental costs (β coefficient: -$3.6K, 95%CI: -4.4 - -2.8) as well as similar readmissions (odds ratio: 0.89, 95%CI: 0.70 - 1.13) and related-mortality. Nearly half (48.1%) of all hospitals performed zero early discharges.

CONCLUSIONS

Expedited discharge following lung resection is a feasible management strategy and is associated with decreased costs and similar readmission risk compared to the norm. Select individuals should be strongly considered for expedited discharge following lung resection.

Failure to rescue after surgical re-exploration in lung resection

BACKGROUND

Surgical re-exploration after lung resection remains poorly characterized, although institutional series have previously reported its association with greater mortality and complications. The present study sought to examine the impact of institutional lung-resection volume on the incidence of and short-term outcomes after surgical re-exploration.

METHODS

The 2007 to 2018 National Inpatient Sample was used to identify all adults who underwent lobectomy or pneumonectomy. Hospitals were divided into tertiles based on institutional lung-resection caseload. Multivariable regressions were used to identify associations between independent covariates on clinical outcomes.

RESULTS

Of an estimated 329,273 patients, 3,592 (1.09%) were re-explored with decreasing incidence over time. Open and minimal access pneumonectomy among other factors were associated with greater odds of reoperation. Those re-explored had greater odds of mortality and complications as well as increased duration of stay and adjusted costs. Although risk of re-exploration was similar across hospital tertiles, reoperative mortality was significantly lower at high-volume hospitals.

CONCLUSION

Re-exploration after lung resection is uncommon; however, when occurring, it is associated with worse clinical outcomes. After re-exploration, high-volume center status was associated with reduced odds of mortality relative to low volume. Failure to rescue at lower-volume centers suggests the need for optimization of perioperative factors to decrease incidence of reoperation.

Short-Term Impact of Video-Assisted Thoracoscopic Surgery on Lung Function, Physical Function, and Quality of Life

Background: Video-assisted thoracoscopic surgery (VATS) has been increasingly used as an approach for lung lobectomy. However, the recovery of respiratory and physical function may be insufficient at discharge because the average length of hospital stay is decreasing after surgery. In this study, we investigated the changes in physical function, lung function, and quality of life (QOL) of lung cancer patients after VATS, and factors for QOL were also evaluated. Methods: The subjects of this study were 41 consecutive patients who underwent video-assisted lung lobectomy for lung cancer. Rehabilitation was performed both before and after surgery. Lung function testing, physical function testing (timed up and go test (TUG) and the 30-s chair-stand test (CS-30)), and QOL (EORTC QLQ-C30) were measured before and 1 week after surgery. Results: Postoperative VC recovered to 76.3% ± 15.6% 1 week after surgery. TUG, CS-30, and QOL were significantly worse after surgery (p < 0.05). Lung function and physical function were found to affect QOL. Postoperative complications included pneumonia in 1 patient. There were no patients who discontinued rehabilitation. Conclusion: Our rehabilitation program was safe and useful for patients after VATS.

Video-assisted thoracoscopic surgery versus open thoracotomy in the management of empyema: A comparative study

Introduction:

With a rise in the incidence of thoracic empyema, surgical interventions also have evolved from the traditional open decortication to the current minimally invasive video-assisted thoracoscopic surgery (VATS). In this study, we determine the feasibility of VATS and also put the superiority of VATS over open thoracotomy (OT) to test.

Subjects and Methods:

Prospective single-centre comparative analysis of clinical outcome in 60 patients undergoing either VATS or OT for thoracic empyema was done between 1^st September, 2014, and 1^st November, 2018. Furthermore, another group of patients, who were converted intraoperatively from VATS to OT, was studied descriptively.

Results:

Nearly 75% of the patients were male with a mean age of 45.16 years. Every second patient had associated tuberculosis (TB), attributed to the endemicity of TB in India. When compared with OT, VATS had a shorter duration of surgery (268.15 vs. 178.33 min), chest tube drainage (11.70 vs. 6.13 days), post-operative hospital stay (13.56 vs. 7.42 days) and time to return to work (26.96 vs. 12.57 days). Post-operative pain and analgesic requirement were also significantly reduced in the VATS group (P < 0.0001). Conversion rate observed was 14.2%, the most common reason being the presence of dense adhesions.

Conclusion:

We conclude that VATS, a minimally invasive procedure with its substantial advantages over thoracotomy and better functional outcome, should be preferred whenever feasible to do so. Also if needed, conversion of VATS to the conventional open procedure, rather than a failure, is a wise surgical judgement.

Lifestyle behaviors and intervention preferences of early-stage lung cancer survivors and their family caregivers

PURPOSE

Lung cancer (LC) is a highly prevalent disease with more survivors diagnosed and treated at earlier stages. There is a need to understand psychological and lifestyle behavior needs to design interventions for this population. Furthermore, understanding the needs and role of family caregivers, especially given the risks associated with second-hand smoke, is needed.

METHODS

Thirty-one early-stage (stages I or IIA) LC survivors of (52% men) and 22 (50% women) caregivers (N = 53 total) completed surveys after surgery (baseline) and at 3- and 6-month follow-ups. Participants reported on psychological functioning, smoking, and physical activity (PA) as well as intervention preferences.

RESULTS

Survivors reported low levels of psychological distress and 3% were current smokers during the study. Approximately 79% were sedentary and not meeting national PA guidelines. Caregivers also reported minimal psychological distress and were sedentary (62% not meeting guidelines), but a larger proportion continued to smoke following the survivor's cancer diagnosis (14%). Both survivors and caregivers expressed interest in home-based PA interventions but differed regarding preferred format for delivery. Most (64%) caregivers preferred a dyadic format, where survivors and caregivers participate in the intervention together. However, most survivors preferred an individual or group format (57%) for intervention delivery.

CONCLUSION

Both LC survivors and family caregivers could benefit from PA interventions, and flexible, dyadic interventions could additionally support smoking cessation for family caregivers.

Video-assisted Thoracoscopic Surgery versus Thoracotomy for Non-Small Cell Lung Cancer: A Meta-Analysis

BACKGROUND

Patients undergoing surgery for non-small cell lung cancer (NSCLC) are often elderly and have co-morbidity conditions and decreased performance status. Compared with open thoracotomy, video-assisted thoracoscopic lobectomy is associated with fewer postoperative complications. Despite encouraging results for patients with NSCLC who underwent VATS, the procedure is still not widely accepted, and large retrospective studies have yielded conflicting results.

OBJECTIVES

In video-assisted lobectomy for NSCLC, it has remained controversial whether mediastinal lymphadenectomy can be performed as effectively as an open procedure via thoracotomy. To deal with inherent biases in any non-randomized comparison, we analyzed propensity-matched studies and randomized controlled trials. The aim of this study was to evaluate the treatment outcomes of VATS and open thoracotomy for NSCLC patients.

METHODS

We collected publications on comparison of VATS versus open thoracotomy for NSCLC patients from 2007 to 2017. All trials analyzed the summary Hazard Ratios (HRs) of the endpoints of interest, including perioperative mortality and morbidity, and individual postoperative complications. Revman 5.3 software was used to analyze the combined pooled HRs using fixed- or random-effects models according to heterogeneity.

RESULTS

A systematic literature search was conducted including 15 studies. The results indicated that VATS was associated with lower postoperative morbidity and mortality, and significantly lower rates of prolonged pneumonia, atrial arrhythmias and renal failure.

CONCLUSIONS

Compared with lobectomy by thoracotomy, thoracoscopic lobectomy is associated with a lower incidence of major complications, including lower rates of prolonged pneumonia, atrial arrhythmias and renal failure. Lobectomy via VATs may be the preferred strategy for appropriately selected NSCLC patients. The determinants of this advantage should be analyzed to improve the safety and outcomes of other thoracic procedures.

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.

Anesthesia and enhanced recovery in subxiphoid video-assisted thoracoscopic surgery

Subxiphoid video-assisted thoracoscopic surgery (VATS) is a surgical approach in minimally invasive thoracic surgery that aims to aid enhanced recovery by reducing postoperative pain by avoiding instrumentation of the intercostal spaces. Access through a subxiphoid port presents challenges for both the surgeon and anaesthetist. Particularly for left sided procedures, the heart can be compressed resulting in arrhythmia and haemodynamic compromise. The anaesthetic team play an important role in ensuring the success of subxiphoid VATS procedures. The key is continuous and comprehensive monitoring for circulatory disturbance and arrhythmia intraoperatively. Should arrhythmia develop it is important that it is managed rapidly and effectively in such a manner to minimize haemodynamic disturbance. In this article, important considerations for anaesthesia in subxiphoid VATS procedures is presented and solutions presented.

Uniportal thoracoscopic treatment in bronchiectasis patients: preliminary experience

Introduction

Bronchiectasis is defined as a permanent and abnormal dilation of the bronchi due to destruction of the bronchial wall. The thoracoscopic approach is represented in the literature by a few reports, and multiple port incisions are observed in these studies.

Aim

To investigate the effectiveness and outcomes of the single port video-assisted thoracoscopic surgery (VATS) method in the surgical treatment of bronchiectasis. To our knowledge, this is the first study reporting surgical treatment of bronchiectasis via the uniportal thoracoscopic approach.

Material and methods

The medical records of 15 patients undergoing surgery for bronchiectasis between 2013 and 2017 were reviewed. The patients were evaluated with regard to age, gender, duration of symptoms, localization, types and duration of the surgery, presence of pleural adhesion, intraoperative complications, amount of intraoperative bleeding, conversion to open surgery, postoperative drainage amount, chest tube removal time, length of hospital stay, mortality and morbidity, follow-up period, duration of narcotic analgesic usage, pain according to visual analog scale evaluation and satisfaction score.

Results

A total of 15 patients initially underwent single port thoracoscopic resection and 14 procedures were completed thoracoscopically. In terms of anatomic resections, 6 patients underwent left lower lobectomy, 4 right lower lobectomy, 1 right upper lobectomy, 1 left lower lobectomy + lingulectomy, 1 right basal segmentectomy and 1 patient underwent lingulectomy. The mean operative time was 137.1 ±24.5 min and the mean length of hospital stay was 4.78 ±1.52 days. The mean postoperative analgesic requirement was 2.85 ±0.66 days.

Conclusions

We believe that uniportal VATS is a safe, feasible, and effective technique for selected bronchiectasis patients.

Lung decortication in phase III pleural empyema by video-assisted thoracoscopic surgery (VATS)-results of a learning curve study

Background

Pleural empyema (PE) is a devastating disease with a high morbidity and mortality. According to the American Thoracic Society it is graduated into three phases and surgery is indicated in intermediate phase II and organized phase III. In the latter, open decortication of the lung via thoracotomy is the gold standard whereas the evidence for feasibility and safety of a minimally-invasive video-assisted thoracoscopic approach is still poor.

Methods

Retrospective single-center analysis of patients undergoing surgery for phase III PE from 02/2011 to 03/2015 [n=138, including n=130 VATS approach (n=3 of them with bilateral disease) and n=8 open approach]. The learning curve was assessed by grouping those 127 patients with unilateral disease who underwent a video-assisted thoracoscopic approach into two groups: VATS-1 (03/2011 to 06/2012, n=43) and VATS-2 (06/2012 to 03/2015, n=84).

Results

ASA-scores (P=0.0279) and rate of pre-operative drainage therapy (P=0.0534) were higher in VATS-2 patients. Operating times were longer in VATS-1 (P=0.0308), intra-operative complication as well as conversion to open surgery rates did both not differ. Rates of post-operative vasoconstrictive therapy (P=0.0191) and prolonged mechanical ventilation (P=0.0560) were both higher in VATS-2, however, post-operative length of stay (LOS) at intensive care unit, overall post-operative LOS and post-operative complication rate were similar in both groups.

Conclusions

Video-assisted thoracoscopic surgery is feasible for evacuation and decortication in late phase III PE. A learning curve of approximately 40 cases is sufficient to gain procedure-specific surgical skills and thus reduce the operating times sufficiently.

The Feasibility of Thoracoscopic Resection in Bronchiectasis

INTRODUCTION

Minimally invasive surgery is the treatment of choice in early-stage lung cancer. However, experience in infectious lung disease, primarily bronchiectasis, is limited probably because of the presence of dense pleural adhesions, multiple lymph nodes, and spiral bronchial arteries. The present study shows our experience of video-assisted thoracoscopic surgery (VATS) lobectomy and segmentectomy in the treatment of bronchiectasis.

MATERIALS AND METHODS

Patients who underwent VATS lobectomy or segmentectomy in our clinic between April 2008 and 2015 were retrospectively evaluated. Surgery was indicated in patients with radiologic localized bronchiectasis who also had a history of recurrent lower respiratory tract infection or expectorating mucopurulent secretion. The patients were analyzed in terms of age, sex, thoracotomy conversion rate, postoperative drainage amount, chest tube removal time, length of hospital stay, morbidity, and mortality.

RESULTS

A total of 44 patients initially underwent VATS pulmonary anatomic resection and 41 procedures were completed on 40 patients. One patient had bilateral resection. Fifteen patients were male individuals and 26 were female individuals. The average age was 31.4 (15 to 57) years. Forty lobectomies and 1 segmentectomy were performed. The conversion rate was 6.8%. VATS was performed on 28 patients by 3 ports, 8 patients by 2 ports, and 5 patients by a single port. In terms of anatomic resections, 18 patients underwent left lower lobectomy, 8 right lower lobectomy, 8 middle lobectomy, 6 right upper lobectomy, and 1 patient underwent lingular segmentectomy. No major postoperative complication or mortality was observed. Prolonged air leak was observed in 2 patients and subcutaneous emphysema occurred in 2 patients. The average postoperative drainage amount, chest tube removal time, and length of hospital stay were 320 mL, 3.1 (1 to 11) days, and 4.6 (2 to 11) days, respectively.

CONCLUSIONS

VATS pulmonary resection is a safe, feasible, and effective treatment in the surgery of bronchiectasis with low morbidity and mortality rates. Moreover, because of cosmetic results, patients with benign diseases such as bronchiectasis could be initiated by minimally invasive surgery options just like patients with malignancies.

A comprehensive protocol for physiokinesis therapy and enhanced recovery after surgery in patients undergoing video-assisted thoracoscopic surgery lobectomy

Background

Video-assisted thoracoscopic surgery (VATS) lobectomy has recently been adopted as the gold standard surgical option for the treatment of early stage non-small cell lung cancer. Enhanced recovery after surgery (ERAS) is being progressively adopted in thoracic surgery to improve the postoperative outcomes. Even if the benefits of ERAS are universally accepted, to date a standardized and uniform approach has not been described in the medical literature. The Italian VATS group has recently proposed to include in the VATS lobectomy database a structured protocol for ERAS.

Methods

The ERAS section of the Italian VATS group is proposing a comprehensive ERAS protocol within the VATS lobectomy database, allowing the prospective collection of a dedicated set of data. Separate sections of the protocol are dedicated to different topics of ERAS. This study is specifically dedicated to the section of physiokinesis therapy. The medical literature will be extensively reviewed and a physiotherapy (PT) protocol of ERAS will be presented and discussed. A seta of structured clinical pathways will also be suggested for adoption in the VATS Group database.

Discussion

Pre- and post-operative adoption of an ERAS protocol in patients undergoing VATS lobectomy may promote an improved post-operative course, a shorter hospital stay and an overall more comfortable patients' experience. The mainstays of a physiokinesis therapy ERAS protocol are patients' education, constant physical and respiratory therapy sessions, and adoption of adequate devices. Although many studies have investigated the usefulness of physical and respiratory physiokinesis therapy, a comprehensive ERAS protocol for VATS lobectomy patients has not yet been described. The proposed ERAS platform, adopted by the VATS Group database, will contribute to a prospective data collection and allow a scientific analysis of the results.

Decrease in pulmonary function and oxygenation after lung resection

Respiratory deficits are common following curative intent lung cancer surgery and may reduce the patient's ability to be physically active. We evaluated the influence of surgery on pulmonary function, respiratory muscle strength and physical performance after lung resection.

Pulmonary function, respiratory muscle strength (maximal inspiratory/expiratory pressure) and 6-min walk test (6MWT) were assessed pre-operatively, 2 weeks post-operatively and 6 months post-operatively in 80 patients (age 68±9 years).

Video-assisted thoracoscopic surgery was performed in 58% of cases. Two weeks post-operatively, we found a significant decline in pulmonary function (forced vital capacity −0.6±0.6 L and forced expiratory volume in 1 s −0.43±0.4 L; both p<0.0001), 6MWT (−37.6±74.8 m; p<0.0001) and oxygenation (−2.9±4.7 units; p<0.001), while maximal inspiratory and maximal expiratory pressure were unaffected. At 6 months post-operatively, pulmonary function and oxygenation remained significantly decreased (p<0.001), whereas 6MWT was recovered.

We conclude that lung resection has a significant short- and long-term impact on pulmonary function and oxygenation, but not on respiratory muscle strength. Future research should focus on mechanisms negatively influencing post-operative pulmonary function other than impaired respiratory muscle strength.

Lung resection has a significant short- and long-term impact on pulmonary function and oxygenation, but not on respiratory muscle strengthhttp://ow.ly/WTqc30h6j4i

A multi-center retrospective study of single-port versus multi-port video-assisted thoracoscopic lobectomy and anatomic segmentectomy

Background

To assess the feasibility and perioperative outcomes of single-port (SP) and multi-port (MP) approaches for video-assisted thoracoscopic surgery (VATS) lobectomy and anatomical segmentectomy.

Methods

Retrospective data from 458 patients who received VATS lobectomy or anatomical segmentectomy at Shanghai Chest Hospital, Korea University Guro Hospital, Affiliated Hospital of National Taiwan University, University of Hong Kong Queen Mary Hospital and Shenzhen Hospital were collected. Patients were divided into SP group and MP group according to the surgical approach. Perioperative factors such as operation time, blood loss during surgery, conversion rate, the number and stations of lymph nodes harvested, postoperative chest tube drainage time, postoperative hospitalization time, perioperative morbidity and mortality, and pain scores during the first 3 days after surgery were compared between the two groups.

Results

There were no differences in the number (P=0.278) and stations (P=0.564) of lymph nodes harvested, postoperative morbidity (P=0.414) or mortality(P=0.246), and pain score on the third day (P=0.630) after surgery between the two groups. The SP group had a longer operation time (P=0.042) and greater intraoperative blood loss (P<0.001), but the conversion rate was even higher in the MP group (P=0.018). Patients in the SP group had shorter chest tube removal time (P=0.012) and postoperative hospitalization time (P=0.005). Pain scores were lower on the first (P=0.014) and second (P=0.006) day after surgery in the SP group.

Conclusions

SP VATS lobectomy and anatomical segmentectomy is technologically more demanding than MP VATS. It can be safe and feasible in the hands of experienced surgeons, with comparable preoperative outcomes to MP VATS, but less pain in the early postoperative period.

All grades of severity of postoperative adverse events are associated with prolonged length of stay after lung cancer resection

OBJECTIVE

To determine whether all grades of severity of postoperative adverse events are associated with prolonged length of stay in patients undergoing pulmonary cancer resection.

METHODS

This was a retrospective cohort study of all patients who underwent pulmonary resection with curative intent for malignancy at The Ottawa Hospital, Division of Thoracic Surgery (January 2008 to July 2015). Postoperative adverse events were collected prospectively with the Thoracic Morbidity & Mortality System, based on the Clavien-Dindo severity classification. Patient demographics, comorbidities, preoperative investigations, cardiopulmonary assessment, pathologic staging, operative characteristics, and length of stay were retrospectively reviewed. Prolonged hospital stay was defined as >75th percentile for each procedure performed (wedge resection 6 days, segmentectomy 6 days, lobectomy 7 days, extended lobectomy 8 days, pneumonectomy 10 days). Univariable and multivariable logistic regression analyses were conducted to identify factors associated with prolonged hospital stay.

RESULTS

Of 1041 patients, 579 (55.6%) were female, 610 (58.1%) were >65 years old, 232 (22.3%) experienced prolonged hospital stay, and 416 (40.0%) patients had ≥1 postoperative adverse event. Multivariable analyses identified significant (P < .05) factors associated with prolonged hospital stay to be (odds ratio; 95% confidence interval): lower diffusion capacity of the lung for carbon monoxide (0.99; 0.98-0.99), surgical approach: open thoracotomy (1.8; 1.3-2.5), and presence of any postoperative adverse event: Grade I (5.8; 3.3-10.2), Grade II (6.0; 4.0-8.9), Grade III (11.4; 7.0-18.7), and Grade IV (19.40; 7.1-55.18).

CONCLUSIONS

Lower diffusion capacity of the lung for carbon monoxide, open thoracotomy approach, and the development of any postoperative adverse event, including minor events that required no additional therapy, were factors associated with prolonged hospital stay.

Patient reported outcomes following video assisted thoracoscopic (VATS) resection or stereotactic ablative body radiotherapy (SABR) for treatment of non-small cell lung cancer: protocol for an observational pilot study (LiLAC)

BACKGROUND

Lung cancer is increasingly a disease of the elderly and frail population with a median age of 70 years at diagnosis. Therefore, consideration of the impact of interventions on health-related quality of life (HRQOL) and not only absolute survival is especially important. For non-small cell lung cancer (NSCLC), video-assisted thoracoscopic surgery (VATS) has been gaining popularity over the last few decades, replacing traditional open lobectomies. For high-risk patients who are not deemed suitable for surgery, stereotactic ablative body radiotherapy (SABR) provides a potentially curative alternative. However, little is known about how VATS and SABR affect HRQOL measured using patient reported outcome measures (PROMs). The LiLAC study (Life after Lung Cancer) aims to explore HRQOL following intervention with VATS or SABR using validated PROMs and to pilot the use of an online questionnaire system (QTool) in this setting. We hope the results will aid both patients and clinicians in decision making and improve the management of post-intervention problems.

METHODS

In total, 300 patients (150 VATS and 150 SABR) patients will be recruited over the study period. Patients will be approached prior to intervention and asked to complete baseline HRQOL questionnaires. They will be given access to the QTool online system and then in the 12 months following intervention will be asked to complete questionnaires (paper or online) at 4-time points. Answers will available for patients and clinicians to view throughout the study period. Clinical information (age, gender, co-morbidity, current medications and smoking status along with treatment-specific information) will also be collected. Primary outcome will be to detect changes of PROs (HRQOL and patient satisfaction) after VATS lung resections or SABR in early stage lung cancer patients. Secondary outcomes include correlation of patient's clinical data with HRQOL results to identify predictors of poor outcomes and exploration of patient and clinician views on the usefulness of QOL measurements.

DISCUSSION

(I) This first study will primarily compare multiple patients reported outcomes for 12 months after VATS lobectomy and SABR in early stages NSCLC patients. We will explore the acceptability of an online assessment of the HRQOL in NSCLC patients. (II) The study is also focused on the patients' opinion during the shared decision-making process, which has rarely been investigated in surgical lung cancer patients. (III) This is not a randomised trial. As a consequence, inherent cohort selection bias and unknown or unaccounted confounders correlated with the outcome of interest may influence the results of the comparison between the treatment groups. (IV) LILAC is not looking at a direct comparison, but to depict the trajectory of recovery post-treatments and preservation or improvement of the HRQOL. This study has received ethical approval from NRES Yorkshire and the Humber- Leeds East Research Ethics Committee (REC Ref: 16/YH/0407). Results of this study will be shared with participating hospitals and made available to the academic community through submission for publication in international peer-reviewed journals and presentation at relevant national and international conferences.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02882750.

Surgery versus percutaneous transcatheter embolization for pulmonary arteriovenous malformation: Analysis of a national inpatient database in Japan

OBJECTIVE

Although the treatment options for pulmonary arteriovenous malformation are surgery and percutaneous transcatheter embolization, no study has compared the outcomes between these 2 treatments.

METHODS

From the Japanese Diagnosis Procedure Combination database, the medical records of 996 patients who received treatment for pulmonary arteriovenous malformation between 2010 and 2015 were retrospectively reviewed. We created balanced groups for surgery or percutaneous transcatheter embolization using propensity scoring. The primary outcome was the rate of reintervention for pulmonary arteriovenous malformation, and the secondary outcomes were composite complications and postoperative length of stay. Patients who had any 1 of the complications during hospitalization were considered to have experienced a composite complication.

RESULTS

Of the total sample, 211 patients underwent surgery and 785 patients underwent percutaneous transcatheter embolization. By using 1-to-1 propensity score matching, 202 pairs were selected. Compared with percutaneous transcatheter embolization, surgery was associated with a significantly higher proportion of composite complications (6.9% vs 2.0%, P = .027) and longer postoperative length of hospital stay (median, 6 vs 2 days, P < .01). However, surgery resulted in a significantly lower rate of reintervention for pulmonary arteriovenous malformation (2.1% vs 8.3% at 2 years; P < .01).

CONCLUSIONS

Percutaneous transcatheter embolization had the advantage in composite complications and shorter postoperative length of stay compared with surgery, but surgery had higher curability than percutaneous transcatheter embolization. Surgery may be considered as a therapeutic option for patients with lesions that can be completely resected and are difficult to treat with percutaneous transcatheter embolization.

Amplatzer vascular plug in occlusion of a pulmonary arteriovenous malformation

Pulmonary arteriovenous malformation is a rare condition with abnormal communication of the pulmonary artery with the pulmonary vein. It is associated with significant morbidity and mortality when patients develop complications. Patients with symptomatic pulmonary arteriovenous malformation should be considered for intervention. We describe the case of a 54-year-old woman with a large right pulmonary arteriovenous malformation who presented with right chest pain due to hemothorax. She underwent successful embolotherapy with an Amplatzer plug.

Efficacy of lymph node dissection during robotic-assisted lobectomy for non-small cell lung cancer: retrospective review of 159 consecutive cases

BACKGROUND

We investigated whether robotic-assisted surgery improves mediastinal lymph node dissection (MLND).

METHODS

We analyzed patients (pts) who underwent robotic-assisted video-assisted thoracoscopic surgery (R-VATS) lobectomy for non-small cell lung cancer (NSCLC) over 36 months. Perioperative outcomes, tumor histology, numbers, locations, and status of all lymph nodes (LNs), and TNM (tumor, nodal, and metastasis) stage changes were analyzed.

RESULTS

One hundred fifty-nine pts had mean tumor size 3.3±0.2 cm, most commonly being adenocarcinoma. Assessment of ≥3 N2 stations occurred in 156 (98.1%) pts, with 141 (88.7%) pts having >3 N2 stations reported. Mean total N1 + N2 stations assessed was 5.6±0.1 stations, including mean 4.1±0.1 N2 stations assessed. Mean N2 LNs reported was 7.2±0.3 LNs, and mean total N1 + N2 LNs reported was 13.4±0.4 LNs. There were 118 (74.2%) clinical stage-I pts versus 96 (60.4%) pathologic stage-I pts. Overall, 48 (30.2%) pts were upstaged, including 13 pts with cN0-pN1, 13 pts with cN0-pN2, 4 pts with cN1-pN2, and 18 pts with changes in T.

CONCLUSIONS

R-VATS lobectomy is safe and results in perioperative outcomes comparable to those reported for conventional VATS. R-VATS MLND is effective at detecting occult metastatic disease during lobectomy for NSCLC.

Anatomic lung resections for benign pulmonary diseases by video-assisted thoracoscopic surgery (VATS)

PURPOSE

Based on increasing evidence of its benefits regarding perioperative and oncologic outcome, video-assisted thoracoscopic surgery (VATS) has gained increasing acceptance in the surgical treatment of early stage non-small cell lung cancer (NSCLC). However, the evidence for a VATS approach in anatomic lung resection for benign pulmonary diseases is still limited.

METHODS

Between March 2011 and May 2014, data from 33 and 63 patients who received VATS anatomic lung resection for benign diseases (VATS-B) and early stage NSCLC (VATS-N), respectively, were analyzed retrospectively. For subgroup analyses, VATS-B was subdivided by operation time and underlying diseases. Subgroups were compared to VATS-N.

RESULTS

Three patients from VATS-B and four from VATS-N experienced conversion to open surgery. Causes of conversion in VATS-B were intraoperative complications, whereas conversions in VATS-N were elective for oncological concerns (p < 0.05). Operation time and duration of postoperative mechanical ventilation were longer by tendency; postoperative stay on intensive care unit and chest tube duration were significantly longer in VATS-B. Subgroup analyses showed a longer operation time as a predictor for worse perioperative outcome regarding postoperative mechanical ventilation, postoperative stay on intensive care unit, chest tube duration, and length of hospital stay. Patients with longer operation time suffered from more postoperative complications. Differences in perioperative outcome data were not significantly dependent on the underlying benign diseases compared to VATS-N.

CONCLUSIONS

VATS is feasible and safe in anatomic lung resection for benign pulmonary diseases. Not the underlying disease, but a longer operation time is a factor for worse postoperative outcome.

A method to expose the posterior or superior mediastinum in video-assisted thoracoscopic surgery

A method of exposing the posterior and superior mediastinum in video-assisted thoracoscopic surgery (VATS) will be introduced. In the study, all cases underwent two-port VATS as follows: two or three pieces of suture were stitched on the invagination between the visceral and parietal pleura of the posterior or superior mediastinum; the suture was drawn out of the operating port and fixed, so that the lung could be depressed and posterior or superior mediastinum could be exposed very well. This method was performed in 215 cases; there were no operative deaths and all cases recovered. This stitching method to expose the posterior or superior mediastinum can reduce the wound size and decrease the operation time. Additionally, it is simple, practicable and safe.

Video-assisted thoracoscopic surgery for complex mediastinal mass resections

Minimally invasive surgery has changed the way operative procedures are performed in many specialties. As surgeons have become progressively facile with these techniques, the opportunities to use them have expanded. In thoracic surgery, many surgeons now use minimally invasive techniques to resect small, uncomplicated pathologies of the mediastinum as well as to perform thymectomy for myasthenia gravis. Experience with these techniques has allowed new knowledge to be gained and expansion of the use of these techniques for more complicated mediastinal pathology. This keynote address will outline the instrumentation and techniques that we have adopted over a decade of using these techniques for more complicated mediastinal pathology.

Thoracoscopic lobectomy in a lung cancer patient with severe hemophilia: A case report

Hemophilia is a hereditary disease with impaired blood coagulation due to a genetic deficiency of blood coagulation factors. Hemophilia often causes spontaneous life-threatening bleeding, so patients with hemophilia are often not suitable for any surgery that may cause iatrogenic bleeding and threaten the life of the patient. Therefore, surgery in lung cancer patients with hemophilia is extremely rare. The present study reported the case of a lung cancer patient with hemophilia who presented with a persistent cough. A mass was revealed by computed tomography and the patient underwent a successful thoracoscopic right lower lobectomy. The study discusses the patient's diagnosis and treatment options for hemophilia A and lung cancer, including indications for thoracoscopic lobectomy, pre-operative preparation and post-operative care, and other treatment options are discussed. The literature is also reviewed on this subject.

Management of a solitary pulmonary arteriovenous malformation by video-assisted thoracoscopic surgery and anatomic lingula resection: video and review

BACKGROUND

Pulmonary arteriovenous malformations are abnormal communications between the pulmonary arterial and venous vasculature leading to a right-to-left blood shunt. Based on possible complications, including hypoxemia, hemorrhage, infection and paradoxical embolism, deactivation of the malformation from the circulation is the treatment option of choice, either by interventional embolization or by surgery. Embolization is less invasive and has widely replaced surgery, but bears the risk of revascularization, recanalization and downstream migration of the device with paradoxical embolism.

METHODS

We report on the case of a 76-year-old male patient suffering from a complex, plexiform pulmonary arteriovenous malformation in the lingula, which was treated by video-assisted thoracoscopic surgery and anatomic lingula resection. Patient's medical history, clinical examination and imaging studies did not reveal any evidence of hereditary hemorrhagic telangiectasia.

RESULTS

Left-sided anterior three-port video-assisted thoracoscopic surgery (VATS) approach was used. Instead of only wedge resecting the very peripherally located pulmonary arteriovenous malformation, the lingular vessels were controlled centrally and an anatomic lingula resection was performed in order to prevent a more central re-malformation. To prevent rupture of the aneurysm sac through pressure overload, the feeding arteries were controlled before the draining vein. Duration of the total procedure was 151 min, the single chest tube was removed on the postoperative day 3, and the patient was discharged on the postoperative day 6.

CONCLUSION

Although interventional embolism of the feeding artery of a pulmonary arteriovenous malformation is the current therapeutic gold standard, minimally invasive anatomic lung resection by video-assisted thoracoscopic surgery can be considered, especially for the treatment of solitary large arteriovenous malformations. By anatomic lung resection, the risk of recanalization, collateralization and peri-interventional paradoxical embolism may be reduced.

A standardized technique of systematic mediastinal lymph node dissection by video-assisted thoracoscopic surgery (VATS) leads to a high rate of nodal upstaging in early-stage non-small cell lung cancer

BACKGROUND

A substantial part of the oncologic surgical procedure in non-small cell lung cancer (NSCLC) is systematic lymph node dissection (sLND). However, controversies still exist regarding the quality of minimally invasive (video-assisted thoracoscopic surgery, VATS) sLND in oncologic resections. The rate of stage migration from clinical to pathological N-status has been discussed as one parameter for the quality of sLND.

METHODS

Between March 2011 and May 2014, seventy-seven patients (62 male, 15 female) were scheduled for anatomical lung resection and sLND by VATS for clinical stage I (UICC 7th edition) NSCLC. Preoperative staging was performed by [18F]-fluorodesoxyglucose positron emission tomography with computed tomography (FDG-PET/CT). Patient data were retrospectively analyzed with regard to divergence in clinical and pathological N-factor. FDG-PET/CTs of patients with lymph node (LN) upstaging after VATS resections were blindly re-evaluated by an experienced radiologist.

RESULTS

In FDG-PET/CT, preoperative tumor stage was cT1N0M0 in 41 (53.2%) and cT2aN0M0 in 28 (36.4%) patients. In six (7.8%) patients the primary tumor was not suspicious for malignancy, and in two (2.6%) patients the tumor was not evaluable due to prior wedge resection before FDG-PET/CT. Thirty-one (40.3%) left-sided and 46 (59.7%) right-sided pulmonary resections with sLND were performed; 19.57 ± 0.99 LNs were dissected. In 13 (16.9%) patients a nodal stage migration from preoperative clinical to postoperative pathological N-stage was observed [cN0 to pN1 in 9 (11.7%) and cN0 to pN2 in 4 (5.2%) cases]. In correlation to the clinical T-factor, the rate of N-factor upstaging for cT1 was 12.2% and for cT2a was 28.6%, respectively. In 50% of the patients with postoperative nodal staging shift, no changes were observed on re-evaluation of the preoperative FDG-PET/CT.

CONCLUSION

In this series of clinical stage I NSCLC patients, the rate of nodal stage migration after sLND by VATS is higher than previously reported. Prospective randomized controlled trials are needed to prove the oncologic quality of a sLND by VATS versus standard open approach.

Hospital readmission after pulmonary lobectomy is not affected by surgical approach

BACKGROUND

The aim of this study is to identify the predictors of hospital readmission or early unplanned return to clinic within 30 days of discharge after pulmonary lobectomy.

METHODS

The medical records of patients undergoing lobectomy by the thoracic surgery service between January 2009 and July 2012 were reviewed. All lobectomies were included irrespective of the etiology of disease. Multivariate logistic regression methods were used to identify predictors of readmission and or early unplanned return to clinic.

RESULTS

Two hundred thirteen patients underwent a pulmonary lobectomy during the study period (median age, 67 years). Pathologic diagnosis was malignant in 94% of the patients and benign in 6%. Minimally invasive approaches were used in 69% of the patients, whereas open thoracotomy was used in 31%. Median hospital length of stay was 4 days, and postoperative mortality occurred in 1 patient (0.5%). The Charlson comorbidity index was 1 ± 1. Predicted postoperative forced expiratory volume in 1 second and diffusing capacity of the lung for carbon monoxide were 68% ± 18% and 64% ± 17%, respectively. Postoperative complications occurred in 31% of patients; 13% required readmission to the hospital within 30 days of discharge or early unplanned return to clinic. Predictors of readmission or early unplanned return to clinic were unplanned transfer to the intensive care unit (odds ratio, 10.4; 95% confidence interval, 1.1 to 103.5; p = 0.04) and Charlson comorbidity index greater than 0 (odds ratio, 1.5; 95% confidence interval, 1.04 to 2.03; p = 0.03). Readmission or early unplanned return to clinic was independent of surgical approach (p = 0.32).

CONCLUSIONS

Patients who require a postoperative transfer to the intensive care unit or with higher Charlson comorbidity index are at higher risk for hospital readmission after pulmonary lobectomy. Readmission was not affected by the surgical approach. Whether a different strategy to follow-up for these high-risk patients can prevent readmission remains to be determined.

VATS lobectomy has better perioperative outcomes than open lobectomy: CALGB 31001, an ancillary analysis of CALGB 140202 (Alliance)

BACKGROUND

The short-term superiority of video-assisted thoracoscopic surgery lobectomy compared with open lobectomy for early-stage lung cancer has been suggested by single-institution studies. Lack of equipoise limits the feasibility of a randomized study to confirm this. The hypothesis of this study (CALGB 31001) was that VATS lobectomy results in shorter length of hospital stay and fewer complications compared with open lobectomy in stages I and II non-small cell lung cancer in a multi-institutional setting.

METHODS

Five hundred nineteen patients whose tumors had been collected as part of CALGB 140202 (lung cancer tissue bank) were eligible. Propensity-scoring using age, race, sex, performance status, comorbidities, histology, tumor stage, and size as independent variables was used to create a 1:1 matched group of 175 pairs of patients. McNemar's test for binary variables and Wilcoxon signed-rank test for continuous variables were used to assess differences in length of hospital stay, complications, and discharge dispositions between the groups. Comparison of disease-free and overall survival between the two approaches was done using the log-rank test. Probability values of less than 0.05 were considered significant.

RESULTS

The matched data on length of hospital stay, complications, and discharge dispositions significantly favored the video-assisted thoracoscopic surgery group. There was no statistically significant difference in survival between the two approaches.

CONCLUSIONS

This multi-institutional study supports the assertion that thoracoscopic lobectomy results in shorter hospital length of stay, fewer perioperative complications, and greater likelihood of independent home discharge compared with open lobectomy for early-stage lung cancer. Survival was comparable between the two groups.

Total video-assisted thoracoscopic (VATS) resection of a left-sided sulcus superior tumor after induction radiochemotherapy: video and review

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) has gained increasing acceptance for surgical therapy of early stage non small cell lung cancer (NSCLC). Even for extended pulmonary resections in advanced tumor stages, increasing evidence suggests feasibility and safety of the VATS approach. However, so far very little experience has been reported on VATS management of sulcus superior tumors.

METHODS

We report on a 56-year-old female patient with a left-sided anterior sulcus superior adenocarcinoma (cT3 cN1 cM0), which was completely resected by VATS after induction radiochemotherapy.

RESULTS

The surgical procedure was performed completely minimally invasively via a three-incision anterior thoracoscopic approach. The total operating time was 285 min (composed of 116 min for hilar lobectomy, 103 min for sulcus superior preparation and chest wall resection, and 26 min for systematic en-bloc lymph node dissection). The single chest tube was removed on postoperative day two and the patient was discharged on postoperative day six. No intraoperative and no postoperative complications were observed. Histopathology confirmed a complete (R0) resection of an ypT2aN0M0 bronchogenic adenocarcinoma.

CONCLUSION

With increasing experience even extended pulmonary resections are safe and feasible by a video-assisted thoracoscopic approach. We propose that in sulcus superior tumors without tumor invasion of vascular structures VATS can be considered.

Pain and recovery are comparable after either uniportal or multiport video-assisted thoracoscopic lobectomy: an observation study

OBJECTIVES

Uniportal approaches to video-assisted thoracoscopic surgery (VATS) lobectomy have been described in significant series. Few comparison studies between the two techniques exist. The aim was to determine whether the uniportal technique had more favourable postoperative outcomes than the multiport technique.

METHODS

All VATS lobectomies undertaken at a single university hospital during August 2012 to December 2013 were studied. Patients with preoperative opiate use or chronic pain were excluded. Patients were divided into those with uniportal and multiport approaches for analysis. All continuous data were assessed for normality, and analysed with the Mann-Whitney U-tests or t-tests as appropriate. Categorical data were analysed by Fisher's exact or χ(2) test for trend as appropriate.

RESULTS

One hundred and twenty-nine VATS lobectomies were completed. Six were excluded and data were incomplete for 13, leaving 110 (15 uniportal, 95 multiport) for analysis. The demographics of the two groups were similar. There was no significant difference in the Thoracoscore or American Society of Anesthesiologists grades. The median morphine use in the first 24 postoperative hours was 19 mg in the uniportal group and 23 mg in the multiport group, P = 0.84. The median visual analogue pain score in the first 24 h was 0 in the uniportal group and 0 in the multiport group, P = 0.65. There was no difference in the duration of patient-controlled analgesia (P = 0.97), chest drain duration (P = 0.67) or hospital length of stay (P = 0.54). There was no inpatient mortality and no unplanned admission to critical care in either group.

CONCLUSIONS

Uniportal VATS lobectomy is safe, and there is no appreciable negative impact on the hospital stay or morbidity. Patient-reported pain and morphine use in the first 24 h was low with either technique. Larger prospective studies are needed to quantify any benefit to a particular approach for VATS lobectomy.