Evolution to video-assisted thoracic surgery lobectomy after training: initial results of the first 30 patients

Decreased In-Hospital Mortality after Lobectomy Using Video-assisted Thoracoscopic Surgery Compared with Open Thoracotomy

RATIONALE

There is a paucity of data regarding the optimal surgical approach for lung lobectomy. Lobectomy performed by video-assisted thoracoscopic surgery (VATS) has been associated with lower morbidity as compared with lobectomy performed by thoracotomy. However, no multicenter studies have shown improved mortality with VATS lobectomy compared with open surgical lobectomy.

OBJECTIVES

We used data from the United States Healthcare Cost and Utilization Project Nationwide Inpatient Sample database from 2009 to 2012 to compare VATS with open lobectomy for in-hospital mortality and other short-term outcomes.

METHODS

We used International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes to identify the patients undergoing lobectomy. We used 1:1 ratio propensity matching with the nearest neighbor method without replacement to generate matched pairs.

MEASUREMENTS AND MAIN RESULTS

Over the 4-year period, 27,451 patients underwent lobectomy. The majority of these procedures were performed by thoracotomy (65%) as compared with VATS (35%). A total of 9,393 matched pairs were created. VATS lobectomy was associated with significantly lower in-hospital mortality when compared with thoracotomy (1.3% vs. 2.5%, P < 0.001). A shorter length of hospital stay was observed for those undergoing VATS lobectomy (6.21 vs. 8.75 d, P < 0.001). The overall rate of perioperative complications was low, with those undergoing VATS being less likely to have any perioperative morbidity.

CONCLUSIONS

In recent years, the use of VATS for lobectomy has increased relative to thoracotomy. This trend has coincided with increased survival and shorter length of stay for VATS lobectomy compared with thoracotomy. Further studies are needed to identify comorbidities that identify ideal candidates for VATS lobectomy.

[Troubleshooting Common Unexpected Situations during Thoracoscopic Anatomical Pulmonary Resection]

The history of modern thoracoscopic pulmonary surgery could date back to the 1990s, and the related surgical technique has been matured after 20 years' development. Meanwhile, large amount of clinical data has been collected. Minimally invasive thoracic surgery represented by the thoracoscopic approach has been universally accepted as the preferred choice for the surgical treatment of early-staged non-small cell lung cancer and pulmonary benign diseases, and for the diagnosis of pulmonary diseases. With the generalization of thoracoscopic anatomical pulmonary resection, some unexpected situations during clinical practice has been reported in literatures, with issues involving anatomical variation, pathological factors, and surgical techniques. However, the systemic summary of the unexpected situations during thoracoscopic anatomical pulmonary resection is lacking until now. The present review, therefore, aims to summarize accidental issues and troubleshooting these unexpected situations on the basis of our own clinical practice and literature reports.

Lobectomy by Video-Assisted Thoracic Surgery vs Muscle-Sparing Thoracotomy for Stage I Lung Cancer: A Critical Evaluation of Short- and Long-Term Outcomes

BACKGROUND

Propensity-matched studies have shown lobectomy by VATS to be superior to thoracotomy. However, these studies do not control for institution or surgeon expertise and do not compare VATS strictly with muscle-sparing thoracotomy (MST).

STUDY DESIGN

From a single surgeon experienced in both VATS and MST, patients undergoing lobectomy for clinical stage I non-small cell cancer were evaluated. Video-assisted thoracic surgery was chosen if the patient requested this approach, otherwise MST was used. Short-term and long-term outcomes were compared.

RESULTS

From 2007 to 2012, two hundred and ninety-eight patients were evaluated, 74 (25%) VATS and 224 (75%) MST. There were no statistically significant differences in demographics, chest tube days, and postoperative complications between the 2 surgical groups. Operative time was longer for VATS (median 130 minutes for VATS vs 90 minutes for MST; p<0.001). Hospital length of stay was longer for MST (median 4.5 days for VATS vs 5 days for MST; p=0.007). There was no difference in disease-free survival (5-year: 76% for VATS vs 78% for MST; p=0.446) and overall survival (5-year: 80% for VATS vs 79% for MST; p=0.840) for clinical stage I disease. Results were unchanged using propensity score matching of 60 VATS and 60 MST patients for postoperative complications, disease-free survival, and overall survival between the 2 matched groups.

CONCLUSIONS

Our current comparison of VATS vs MST, from a single surgeon experienced with both approaches, found operative time (favoring MST) and hospital days (favoring VATS) to be the only difference between the 2 groups; and major outcomes, such as postoperative complications, disease-free survival, and overall survival, were not different. A multi-institution randomized trial should be considered before deeming any one approach to be superior.

Adopting a standardized anterior approach significantly increases video-assisted thoracoscopic surgery lobectomy rates

OBJECTIVES

Video-assisted thoracoscopic surgery (VATS) lobectomy is associated with improved short-term outcomes compared with thoracotomy. Definition of the hilar structures is crucial to safe VATS lobectomy. Several VATS approaches have been described. We report the effect of three surgeons in our institution undertaking standardized anterior approach (SAA) training on the proportion of isolated lobectomies subsequently completed by VATS. Predictors of successful VATS lobectomy were analysed.

METHODS

Three consultant surgeons undertook SAA training at two different time points. Two were performing VATS lobectomy prior to SAA training. Training involved a 2-day visit to an established SAA unit. Lobectomies performed by these surgeons between April 2011 and December 2012 (20 months), before and after training, were recorded prospectively. Bilobectomies, sleeve resections, pneumonectomies and chest wall resections were excluded. VATS lobectomy proportions before and after training were compared. Independent predictors of completion by VATS rather than thoracotomy were identified by multivariable logistic regression.

RESULTS

One hundred and sixty-three isolated lobectomies were performed, 97 of these by VATS (59.5%). The mean age was 68.8 (± 10.5) years. Pathology was lung cancer in 137 (84.0%), other primary malignancy in 10 (6.1%), pulmonary metastases in 8 (4.9%) and benign in 8 (4.9%). The VATS lobectomy rate rose from 22.2% before SAA training to 77.3% after, P < 0.001. The effect was significant for both existing and adopting VATS lobectomy surgeons, P = 0.002 to <0.001. The median hospital stay was 4 days after VATS and 5 after thoracotomy, P < 0.001. There were 5 in-hospital deaths after thoracotomy and none after VATS lobectomy, unadjusted P = 0.01. In the final logistic regression model, SAA training was the strongest predictor of successful VATS lobectomy (odds ratio 15.16; 95% confidence interval 6.39, 35.96).

CONCLUSIONS

Formal training and adoption of the SAA approach were associated with a more than 3-fold increase in our VATS lobectomy rate. The effect was immediate and sustained. This may reflect easier identification of the major structures from the anterior view. In addition, standardization of surgical techniques and perioperative protocols may facilitate efficient team working. VATS lobectomy was associated with a shorter median hospital stay. Units seeking to increase their VATS lobectomy rate should consider group adoption of the SAA approach.

Teaching video-assisted thoracic surgery (VATS) lobectomy

Video-assisted thoracic surgery (VATS) lobectomy has become the standard of care for early stage lung cancer throughout the world. Teaching this complex procedure requires adequate case volume, adequate instrumentation, a committed operating room team and baseline experience with open lobectomy. We outline what key maneuvers and steps are required to teach and learn VATS lobectomy. This is most easily performed as part of a thoracic surgery training program, but with adequate commitment and proctoring, there is no reason experienced open surgeons cannot become proficient VATS surgeons. We provide videos showing the key portions of a subcarinal lymph node dissection, posterior hilar dissection of the right upper lobe, fissureless right middle lobectomy, and fissureless left lower lobectomy. These videos highlight what we feel are important principals in VATS lobectomy, i.e., N2 and N1 lymph node dissection, fissureless techniques, and progressive responsibility of the learner. Current literature in simulation of VATS lobectomy is also outlined as this will be the future of teaching in VATS lobectomy.

A randomized comparison of different ventilator strategies during thoracotomy for pulmonary resection

OBJECTIVE

Protective lung ventilation is reported to benefit patients with acute respiratory distress syndrome. It is not known whether protective lung ventilation is also beneficial to patients undergoing single-lung ventilation for elective pulmonary resection.

METHODS

In an institutional review board-approved prospective randomized trial, 34 patients undergoing elective pulmonary resection requiring single-lung ventilation were enrolled. Informed consent was obtained. Patients were randomized to 1 of 2 groups: (1) high tidal volume (Hi-TV) of 10 mL/kg, rate of 7 breaths/min, and zero positive end-expiratory pressure or (2) low tidal volume (Lo-TV) of 5 mL/kg, rate of 14 breaths/min, and 5 cmH2O positive end-expiratory pressure. Ventilator settings were continued during both double- and single-lung ventilation. Pulmonary functions, hemodynamics, and postoperative outcomes were recorded.

RESULTS

Patient demographics, operative characteristics, intraoperative hemodynamics, and postoperative pain and sedation scores were similar between the 2 groups. During most time periods, airway pressures (peak and plateau) were significantly higher in the Hi-TV group; however, plateau pressures remained less than 30 cmH2O at all times for all patients. The Hi-TV group had significantly lower arterial carbon dioxide tension, less arterial carbon dioxide tension-end-tidal carbon dioxide gradient, lower alveolar dead space ratio, and higher dynamic pulmonary compliance. There were no differences in postoperative morbidity and hospital days between the 2 groups, but atelectasis scores on postoperative days 1 and 2 were lower in the Hi-TV group.

CONCLUSIONS

The use of Hi-TV during single-lung ventilation for pulmonary resection resulted in no increase in morbidity and was associated with less hypercarbia, less dead space ventilation, better dynamic compliance, and less postoperative atelectasis.

Surgeons' volume-outcome relationship for lobectomies and wedge resections for cancer using video-assisted thoracoscopic techniques

This study examined the effect of surgeons' volume on outcomes in lung surgery: lobectomies and wedge resections. Additionally, the effect of video-assisted thoracoscopic surgery (VATS) on cost, utilization, and adverse events was analyzed. The Premier Hospital Database was the data source for this analysis. Eligible patients were those of any age undergoing lobectomy or wedge resection using VATS for cancer treatment. Volume was represented by the aggregate experience level of the surgeon in a six-month window before each surgery. A positive volume-outcome relationship was found with some notable features. The relationship is stronger for cost and utilization outcomes than for adverse events; for thoracic surgeons as opposed to other surgeons; for VATS lobectomies rather than VATS wedge resections. While there was a reduction in cost and resource utilization with greater experience in VATS, these outcomes were not associated with greater experience in open procedures.

A novel method for troubleshooting vascular injury during anatomic thoracoscopic pulmonary resection without conversion to thoracotomy

Background

Massive bleeding caused by vascular injury is considered the most troublesome and dangerous complication during video-assisted thoracoscopic surgery (VATS) pulmonary resection and is an important reason for emergency conversion to thoracotomy. The purpose of this paper was to show the suction-compressing angiorrhaphy technique (SCAT) for troubleshooting this problem without conversion.

Methods

A total of 414 consecutive VATS anatomic pulmonary resections were performed between May 2006 and July 2011, among which 17 operations (4.11 %) encountered unexpected vascular injury. The procedure for troubleshooting vascular injury included bleeding control and angiorrhaphy. Bleeding was first controlled through side compression of the injured site with an endoscopic suction. Angiorrhaphy was then performed with running 5-0 Prolene suture using different procedures according to the size and location of the injuries, including direct suture upon suction compression, suture after substituting suction compression with clamping of the injured site, or suture after attaining proximal cross-clamping of the main pulmonary artery. Detailed information of these patients was carefully reviewed. The reasons for conversion to thoracotomy also were revealed.

Results

Fifteen cases (15/17, 88.24 %) were successfully managed without conversion. Two cases of left main pulmonary artery injury were converted to thoracotomy due to difficulties in proximal cross-clamping of the injured vessel. Blood loss of the 17 patients ranged from 60–935 (median, 350) ml. Two patients were administered with allogeneic blood. The postoperative chest CT scan showed normal blood flow on the injured vessels. The total conversion rate was 2.66 % (11/414). The most common reason for conversion was hilar lymphadenopathy.

Conclusions

The SCAT is an effective procedure for managing vascular injury during VATS anatomic pulmonary resection. In most cases, bleeding control and angiorrhaphy could be achieved using this method with acceptable blood loss, thereby avoiding emergency conversion to thoracotomy.

Is thoracoscopic pneumonectomy safe?

BACKGROUND

While thoracoscopic surgical lobectomy is an established operation, the safety of thoracoscopic pneumonectomy (TP) is uncertain.

METHODS

From January 1, 2002, to September 30, 2008 at a comprehensive cancer center, 70 patients underwent pneumonectomy. Three patients were excluded for emergent operations. Thoracoscopic pneumonectomy was completed successfully in 24 patients and attempted in 8 others (25% conversion rate). Analysis was done on an intention-to-treat basis.

RESULTS

By 2008, 75% of pneumonectomy cases were planned as TP while there were no conversions to thoracotomy. There was no difference in median blood loss between patients undergoing TP versus thoracotomy (325 vs 300 mL, p = 0.52), but operations were longer (286 vs 228 minutes, p < 0.01). Median intensive care unit stay was 2 days in both groups and median hospital stay was 5.0 days in the TP group versus 6.0 days in the thoracotomy group (p = 0.28). Major complications were similar between groups. The TP reoperations were for bleeding (2), bronchopleural fistula (2), empyema (1), and chylothorax (1). The only TP death occurred in an 83-year-old patient from respiratory failure. Neither the use of adjuvant therapy nor the time between surgery and commencement of adjuvant therapy was different between groups. Conversions alone compared with patients undergoing thoracotomy were associated with a moderate increase in blood loss and intensive care unit stay, but not in any major complications.

CONCLUSIONS

Thoracoscopic pneumonectomy can be done safely. The availability of this option is important especially in an era of multimodality therapy as more debilitated patients present for surgical therapy.