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Minamikawa K, Okumura A, Kokudo N, Kono K. Regulation on introducing process of the highly difficult new medical technologies: A survey on the current status of practice guidelines in Japan and overseas. Biosci Trends 2019; 12:560-568. [PMID: 30606978 DOI: 10.5582/bst.2018.01226] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Since serious problematic cases regarding the technical safety of technically demanding operations were reported in Japan, the Ministry of Health, Labor and Welfare issued new regulations on June 10, 2016 requiring each hospital to check the status of informed consent, skill of surgery team and governance system of the surgical unit, when the highly difficult new medical technologies were introduced to a hospital. In order to firmly establish this new system for highly difficult new medical technologies, it is very important and informative to survey the current situation for guidelines and consensus regarding introduction of medical technology with special skills in Japan and overseas. Based on the survey of questionnaires, document retrieval, and expert interviews, we found that documentation related to the introduction process of highly difficult medical technologies is very rare, and the regulations were mainly issued by academic societies. Moreover, even if such documentation existed, the quality of the regulations is poor and not sufficient enough to perform surgical practice safely. Therefore, for medical practitioners, comprehensive and concrete regulations should be issued by the government or ministry to legally follow in regard to technically demanding operations. A new practice guideline was proposed by our special research group to regulate the introduction process of highly difficult new medical technologies in hospitals in Japan. This guideline, gained understanding from relevant academic societies, provided a comprehensive view on the interpretation of "high difficulty new medical technology" prescribed by the law and show the basic idea at a preliminary examination from the viewpoints of "Surgeon's requirement", "Guidance system", "Medical safety" , and "Informed consent". These efforts will contribute to the improvement of the quality of guidelines regarding "highly difficult new medical technology".
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Affiliation(s)
- Kazuo Minamikawa
- Departments of Gastrointestinal Tract Surgery, Fukushima Medical University.,Medical Research Center, Fukushima Medical University.,Special Research Group on Evaluation and Improvement of Clinical Guidelines for Introduction Process of Highly Difficult New Medical Technologies
| | - Akiko Okumura
- Special Research Group on Evaluation and Improvement of Clinical Guidelines for Introduction Process of Highly Difficult New Medical Technologies.,Department of EBM and Guidelines, Japan Council for Quality Health Care
| | - Norihiro Kokudo
- Special Research Group on Evaluation and Improvement of Clinical Guidelines for Introduction Process of Highly Difficult New Medical Technologies.,Department of Surgery, University of Tokyo
| | - Koji Kono
- Departments of Gastrointestinal Tract Surgery, Fukushima Medical University.,Special Research Group on Evaluation and Improvement of Clinical Guidelines for Introduction Process of Highly Difficult New Medical Technologies
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Mafé JJ, Planelles B, Asensio S, Cerezal J, Inda MDM, Lacueva J, Esteban MD, Hernández L, Martín C, Baschwitz B, Peiró AM. Cost and effectiveness of lung lobectomy by video-assisted thoracic surgery for lung cancer. J Thorac Dis 2017; 9:2534-2543. [PMID: 28932560 DOI: 10.21037/jtd.2017.07.51] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Video-assisted thoracic surgery (VATS) emerged as a minimally invasive surgery for diseases in the field of thoracic surgery. We herein reviewed our experience on thoracoscopic lobectomy for early lung cancer and evaluated Health System use. METHODS A cost-effectiveness study was performed comparing VATS vs. open thoracic surgery (OPEN) for lung cancer patients. Demographic data, tumor localization, dynamic pulmonary function tests [forced vital capacity (FVC), forced expiratory volume in one second (FEV1), diffusion capacity (DLCO) and maximal oxygen uptake (VO2max)], surgical approach, postoperative details, and complications were recorded and analyzed. RESULTS One hundred seventeen patients underwent lung resection by VATS (n=42, 36%; age: 63±9 years old, 57% males) or OPEN (n=75, 64%; age: 61±11 years old, 73% males). Pulmonary function tests decreased just after surgery with a parallel increasing tendency during first 12 months. VATS group tended to recover FEV1 and FVC quicker with significantly less clinical and post-surgical complications (31% vs. 53%, P=0.015). Costs including surgery and associated hospital stay, complications and costs in the 12 months after surgery were significantly lower for VATS (P<0.05). CONCLUSIONS The VATS approach surgery allowed earlier recovery at a lower cost than OPEN with a better cost-effectiveness profile.
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Affiliation(s)
- Juan J Mafé
- Department of Thoracic Surgery, Department of Health of Alicante-General Hospital, Alicante, Spain
| | - Beatriz Planelles
- Neuropharmacology on Pain (NED), Research Unit, Department of Health of Alicante-General Hospital, ISABIAL, Spain
| | - Santos Asensio
- Department of Pneumology, Department of Health of Alicante-General Hospital, Alicante, Spain
| | - Jorge Cerezal
- Department of Thoracic Surgery, Department of Health of Alicante-General Hospital, Alicante, Spain
| | - María-Del-Mar Inda
- Neuropharmacology on Pain (NED), Research Unit, Department of Health of Alicante-General Hospital, ISABIAL, Spain
| | - Javier Lacueva
- Department of Thoracic Surgery, Department of Health of Alicante-General Hospital, Alicante, Spain
| | | | - Luis Hernández
- Department of Pneumology, Department of Health of Alicante-General Hospital, Alicante, Spain
| | - Concepción Martín
- Department of Pneumology, Department of Health of Alicante-General Hospital, Alicante, Spain
| | - Benno Baschwitz
- Department of Thoracic Surgery, Department of Health of Alicante-General Hospital, Alicante, Spain
| | - Ana M Peiró
- Neuropharmacology on Pain (NED), Research Unit, Department of Health of Alicante-General Hospital, ISABIAL, Spain.,Clinical Pharmacology Unit, Department of Health of Alicante-General Hospital, Alicante, Spain
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Czarnecka-Kujawa K, Rochau U, Siebert U, Atenafu E, Darling G, Waddell TK, Pierre A, De Perrot M, Cypel M, Keshavjee S, Yasufuku K. Cost-effectiveness of mediastinal lymph node staging in non–small cell lung cancer. J Thorac Cardiovasc Surg 2017; 153:1567-1578. [DOI: 10.1016/j.jtcvs.2016.12.048] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 12/07/2016] [Accepted: 12/17/2016] [Indexed: 12/25/2022]
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Passera E, Rocco G. From full thoracotomy to uniportal video-assisted thoracic surgery: lessons learned. J Vis Surg 2017; 3:36. [PMID: 29078599 PMCID: PMC5637876 DOI: 10.21037/jovs.2017.01.14] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 12/10/2016] [Indexed: 11/06/2022]
Abstract
Over the last two decades, conventional video-assisted thoracic surgery (VATS) has established itself as the preferred approach for almost all thoracic surgical procedures. The procedure provides a safe and easy approach with undisputed patient benefit at a cost acceptable to the healthcare system all over the world, in large hospitals as well as underprivileged rural areas. VATS has effectively addressed the patients' right to less scarring, trauma (both of access and intrathoracic manipulation), medication, pain, hospitalization, and early return home and work. These improvements have been further stressed by the introduction of uniportal VATS (uniVATS). Single port surgery is a very exciting new modality in the field of minimal access surgery which aims at further reducing scars of standard vats and towards an hypothetical prospective of scarless surgery.
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Affiliation(s)
- Eliseo Passera
- Department of Thoracic Surgery, Humanitas Gavazzeni Institute, Bergamo, Italy
| | - Gaetano Rocco
- Department of Thoracic Surgery and Oncology, Division of Thoracic Surgery, Istituto Nazionale Tumori, IRCCS, Pascale Foundation, Naples, Italy
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Hirji SA, Balderson SS, D'Amico TA. Troubleshooting hilar and interlobar lymphadenopathy during thoracoscopic lobectomy for benign disease-case report. J Vis Surg 2016; 2:1. [PMID: 29078429 DOI: 10.3978/j.issn.2221-2965.2015.12.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 12/24/2015] [Indexed: 11/14/2022]
Abstract
The completion of thoracoscopic lobectomy can be more difficult in the setting of clinically positive lymph nodes, which may be found in the setting of a proximal tumor causing bronchial obstruction or a larger tumor which may create an inflammatory state, both of which cause benign significant enlargement of hilar lymph nodes. Knowledge of the typical locations of these enlarged nodes facilitates the conduct of the operation. For all video-assisted thoracoscopic surgery (VATS) lobectomies, it is prudent to remove all visible lymph nodes prior to arterial and bronchial dissection. Moreover, in cases of significant hilar adenopathy, this strategy becomes more important and effective. For left upper lobectomy, the removal of level 11 lymph node anteriorly improves visualization of both bronchi, the interlobar pulmonary artery, the arterial aspect of the fissure, and the lingular artery. Subsequent dissection of the level 10 lymph node superior to the upper lobe bronchus exposes the main pulmonary artery and the truncal branches. For right upper lobectomy, dissection of the level 11 lymph node posteriorly not only exposes the upper lobe bronchus, but also the adjacent posterior ascending pulmonary artery. Dissection of the level 10 lymph node at the superior hilum facilitates exposure of the right pulmonary artery.
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Affiliation(s)
- Sameer A Hirji
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Thomas A D'Amico
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
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Pishchik VG, Zinchenko EI, Obornev AD, Kovalenko AI. [Video-assisted thoracoscopic anatomic lung resection: experience of 246 operations]. Khirurgiia (Mosk) 2016:10-15. [PMID: 26977763 DOI: 10.17116/hirurgia20161210-15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
AIM To present one of the largest materials of video-assisted thoracoscopic (VATS) anatomic lung resections in Russia. MATERIAL AND METHODS It is a retrospective analysis of treatment of 246 patients who underwent VATS anatomic lung resection for the period from 2010 to 2014 at the Center for Thoracic Surgery of St. Petersburg Clinical Hospital №122. One surgical team has operated 125 men and 121 women aged from 20 to 85 years (58.8±13.4 years). There were 216 (87.8%) lobectomies, 4 (1.6%) bilobectomies, 9 (3.7%) pneumonectomies, 10 (4.1%) segmentectomies and 7 (2.8%) trisegmentectomies. Upper right-side lobectomy was the most frequent in this group (87 (40.3%)). Most of operations was performed via 2 approaches (119 patients). Average length of the longest incision was 4.3±0.93 cm (range 2-6 cm). All patients were examined according to a single plan. FEV1 less than 70% was observed in 26% of patients; comorbidity index was 5 scores or more in 24% of cases; 23.2% of patients were older than 70 years. RESULTS Non-small cell lung cancer (NSCLC) was diagnosed in 168 patients (68.3%), pulmonary tuberculosis - in 27 (11%), chronic suppurative lung disease - in 27 (11%) cases. Furthermore there were 9 cases of pulmonary metastases, 11 cases of carcinoid, 1 - MALT-lymphoma, 1 - leiomyoma, 2 - small cell lung cancer, as well as one case of IgG-associated pseudotumor. Among 168 cases of NSCLC operations were performed in 87 (51.8%) cases for cancer stage I, in 46 (27.3%) patients for stage II, in 27 patients for stage III (including 16 cases of stage IIIA and 11 cases of stage IIIB). 8 patients (4.7%) with lung cancer stage IV have been operated in radical surgery for solitary metastasis. Mean duration of surgery was 202.1±58.2 minutes (range 100-380). On the average 12.8±5.6 (range 9-32) mediastinal lymph nodes were excised during lymph node dissection in cancer patients. Mean number of nodes groups was 4.1±1.1. In 11 (4.5%) patients conversion to open surgery was made due to intraoperative bleeding (3 cases) and technical difficulties (8 cases). Mean duration of postoperative pleural drainage and hospital-stay were 5.1±4.3 (median - 3 days) and 7.9±4.7 days (median - 6 days) respectively. Complications which were not associated with perioperative deaths were observed in 66 patients (26.8%). Prolonged air vent was the most common complication. CONCLUSION VATS anatomical lung resections are safe and effective in most of pulmonary surgical diseases. Such interventions may be recommended for wider introduction at the Thoracic Departments of Russia because of small number of complications and rapid rehabilitation. Bleeding or its risk associated with fibrotic changes in pulmonary root are the most frequent causes of conversion to open access.
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Affiliation(s)
- V G Pishchik
- L.G. Sokolov Clinical Hospital #122, FMBA of Russia, St. Petersburg, Russia; Medical Faculty of St. Petersburg State University, St. Petersburg, Russia
| | - E I Zinchenko
- L.G. Sokolov Clinical Hospital #122, FMBA of Russia, St. Petersburg, Russia; Medical Faculty of St. Petersburg State University, St. Petersburg, Russia
| | - A D Obornev
- L.G. Sokolov Clinical Hospital #122, FMBA of Russia, St. Petersburg, Russia; Medical Faculty of St. Petersburg State University, St. Petersburg, Russia
| | - A I Kovalenko
- Medical Faculty of St. Petersburg State University, St. Petersburg, Russia
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Hirji SA, Balderson SS, Berry MF, D'Amico TA. Troubleshooting thoracoscopic anterior mediastinal surgery: lessons learned from thoracoscopic lobectomy. Ann Cardiothorac Surg 2015; 4:545-9. [PMID: 26693151 DOI: 10.3978/j.issn.2225-319x.2015.07.04] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Video-assisted thoracoscopic surgery (VATS) lobectomy is safe, oncologically effective, and increasingly utilized for lung cancer resection. Lessons from VATS lobectomy experience can guide the use of a VATS approach to resect mediastinal masses. Exposure and dissection when using VATS to resect anterior mediastinal masses has unique challenges. Several maneuvers acquired from experience with VATS lobectomy can reduce the technical difficulty and often prevent conversion to an open approach. In this troubleshooting guide, we offer 'tips' to both avoid and manage numerous intra-operative technical difficulties that commonly arise during VATS anterior mediastinal procedures. Avoiding an open approach may improve outcomes, although conversion for safety or complete resection can be necessary. Techniques and experiences derived from VATS lobectomy can facilitate VATS resection of mediastinal masses.
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Affiliation(s)
- Sameer A Hirji
- 1 Department of Surgery, Division of Thoracic Surgery, Duke University Medical Center, Durham, NC, USA ; 2 Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Scott S Balderson
- 1 Department of Surgery, Division of Thoracic Surgery, Duke University Medical Center, Durham, NC, USA ; 2 Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Mark F Berry
- 1 Department of Surgery, Division of Thoracic Surgery, Duke University Medical Center, Durham, NC, USA ; 2 Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Thomas A D'Amico
- 1 Department of Surgery, Division of Thoracic Surgery, Duke University Medical Center, Durham, NC, USA ; 2 Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, USA
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Pischik VG. Technical difficulties and extending the indications for VATS lobectomy. J Thorac Dis 2014; 6:S623-30. [PMID: 25379200 DOI: 10.3978/j.issn.2072-1439.2014.10.11] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Accepted: 09/02/2014] [Indexed: 11/14/2022]
Abstract
BACKGROUND Data on advantages of video-assisted thoracoscopic surgery (VATS) lobectomies has been accumulated during the last 10 years then number of thoracoscopic anatomic pulmonary resections rapidly increased. But still there is no agreement about limitations of the method. The most popular "technical contraindications" for VATS anatomic pulmonary resections are: dense pleural adhesions, incompleteness of interlobar fissure, previous chemo- or/and radiotherapy, perivascular or/and peribronchial fibrosis, tumor larger than 5 cm, chest wall involvement, centrally located tumor, severe comorbidity, advanced age, severe COPD and emphysema. Extending of indications for the VATS anatomic pulmonary resection and its influence on the immediate outcomes was investigated. METHODS Ninety two consecutive cases of VATS anatomic pulmonary resection performed by the single surgeon from January 2012 till December 2013 at the Federal University Hospital #122 in Saint Petersburg, Russia were retrospectively analyzed. Forty three males and 49 females at the age from 21 to 87 years old (mean age 59±7.2). The most of the cases were comprised by lung cancer of I-III stage together with bronchiectasis and tuberculomas. Conversion rate was 3.2% mostly due to perivascular calcification and/or fibrosis. There were no cases of 30-days mortality and readmission. All those patients retrospectively divided into two groups: with standard and extended indications for the VATS lobectomy. Inclusion in "extended" group was made if patients had one or more technical challenges among following: size of the lesion 5 cm and more; strong pleural adhesions and/or "bad fissure"; adjacent structures involvement; hilar or mediastinal lymph nodes enlargement or involvement; centrally located tumors; previous chemo- or chemoradiotherapy or previous thoracic surgery. RESULTS According to these criteria, 45 standard (S) and 47 extended (E) patients were pair-matched with no statistically significant differences between the groups in common patients' characteristics. Postoperative comparison of "standard" and "expanded" groups revealed some differences in average operation time (152 vs. 189 min), in number of resected mediastinal lymph nodes (10.2 vs. 13.1), and in the mean time before removal of the chest tube (3.9 vs. 5.2 days). But the blood loss, morbidity and the length of hospital stay were almost the same in the two groups. CONCLUSIONS Extension of indications to VATS lobectomy does not compromise the short-term results. Incompleteness of interlobar fissures, pleural adhesions, preoperative chemotherapy, big size of lesion, and some cases of centrally located tumors are not supposed to be the contraindications for VATS lobectomy. Peribronchial and perivascular lymph node calcification may complicate and even preclude lobectomy by VATS.
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Affiliation(s)
- Vadim G Pischik
- Thoracic Surgery Department, Federal Hospital #122, Saint Petersburg, Russia ; Faculty of Medicine, Saint Petersburg State University, Saint Petersburg, Russia
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Blackmon SH. Minimally Invasive Resections for Lung Cancer. Lung Cancer 2014. [DOI: 10.1002/9781118468791.ch14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Lacin T, Swanson S. Current costs of video-assisted thoracic surgery (VATS) lobectomy. J Thorac Dis 2013; 5 Suppl 3:S190-3. [PMID: 24040522 DOI: 10.3978/j.issn.2072-1439.2013.07.13] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Accepted: 07/07/2013] [Indexed: 11/14/2022]
Abstract
Video-assisted thoracoscopic lobectomy has many benefits over open surgery such as smaller incisions, less pain, less blood loss, faster postoperative recovery, shortened hospital stay, similar or superior survival rates. In contrast video-assisted thoracic surgery (VATS) has higher equipment costs, increased operating room times, at least initially, and a learning curve for the team. However when an experienced surgeon performs the surgery, significant hospital savings combined with better outcomes are achieved by video-assisted thoracoscopic lobectomy.
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Affiliation(s)
- Tunc Lacin
- Department of Thoracic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Wang H, D'Amico TA. Efficacy of mediastinal lymph node dissection during thoracoscopic lobectomy. Ann Cardiothorac Surg 2013; 1:27-32. [PMID: 23977461 DOI: 10.3978/j.issn.2225-319x.2012.04.02] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Accepted: 04/23/2012] [Indexed: 11/14/2022]
Affiliation(s)
- Hanghang Wang
- Division of Thoracic Surgery, Duke University Medical Center, Durham, North Carolina 27705, USA
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Rath T. [Minimally invasive surgery for the treatment of lung cancer--indications]. MMW Fortschr Med 2013; 155:38-40. [PMID: 23964505 DOI: 10.1007/s15006-013-1138-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Thomas Rath
- Klinikum Heidenheim, Kliniken Landkreis Heidenheim gGmbH, Schlosshausstrasse 100, D-89522 Heidenheim.
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Jheon S, Yang HC, Cho S. Video-assisted thoracic surgery for lung cancer. Gen Thorac Cardiovasc Surg 2012; 60:255-60. [PMID: 22453533 DOI: 10.1007/s11748-011-0898-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2011] [Indexed: 02/08/2023]
Abstract
Video-assisted thoracic surgery (VATS) lobectomy is currently accepted as an appropriate procedure for selected patients with early-stage non-small-cell lung cancer (NSCLC). Evidence has demonstrated that VATS lobectomy is not only a safe and feasible technique, it provides better functional recovery and oncological efficacy similar to that achieved with conventional thoracotomy. However, there are still ongoing issues concerning VATS in terms of terminology, oncological efficacy, functional recovery, benefit of screening detected lung cancer, and its role in limited resection. As the number of VATS procedures are increasing and VATS is becoming a dominant procedural choice, it would be wise to collect evidence and come to a consensus to justify the expansion of surgical indications for VATS.
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Affiliation(s)
- Sanghoon Jheon
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, 166 Gumiro, Bundang, Seungnam, Gyeonggi, 463-707, Korea.
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Efficacy of Mediastinal Lymph Node Dissection During Lobectomy for Lung Cancer by Thoracoscopy and Thoracotomy. Ann Thorac Surg 2011; 92:226-31; discussion 231-2. [DOI: 10.1016/j.athoracsur.2011.03.134] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2011] [Revised: 03/16/2011] [Accepted: 03/21/2011] [Indexed: 11/23/2022]
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Surgical techniques to avoid parenchymal injury during lung resection (fissureless lobectomy). Thorac Surg Clin 2010; 20:365-9. [PMID: 20619227 DOI: 10.1016/j.thorsurg.2010.04.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Thoracoscopic lobectomy has become an accepted, safe, and oncologically sound procedure compared with open lobectomy. Several studies have reported that it reduces the length of stay, postoperative pain, and postoperative complications, including air leaks. Although there are specific technical considerations that must be taken into account, it is increasingly becoming the preferred method of anatomic lobectomy. Surgeons should be encouraged to embrace the minimally invasive strategy, which may be learned in courses using novel simulation techniques. Future directions suggest that this technique will be expanded to address even the most challenging thoracic procedures.
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Augustin F, Schmid T, Lucciarini P, Bieck S, Bodner J. Minimally invasive lung lobectomy: indication, patient selection, surgical technique and outcome. Eur Surg 2010. [DOI: 10.1007/s10353-010-0558-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Comparison of costs for video-assisted thoracic surgery lobectomy and open lobectomy for non-small cell lung cancer. Surg Endosc 2010; 25:1054-61. [DOI: 10.1007/s00464-010-1315-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2009] [Accepted: 07/26/2010] [Indexed: 12/25/2022]
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Initial experience with robotic lung lobectomy: report of two different approaches. Surg Endosc 2010; 25:108-13. [DOI: 10.1007/s00464-010-1138-3] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2009] [Accepted: 04/20/2010] [Indexed: 10/19/2022]
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Hartwig MG, D'Amico TA. Thoracoscopic lobectomy: the gold standard for early-stage lung cancer? Ann Thorac Surg 2010; 89:S2098-101. [PMID: 20493989 DOI: 10.1016/j.athoracsur.2010.02.102] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2009] [Revised: 02/07/2010] [Accepted: 02/12/2010] [Indexed: 10/19/2022]
Abstract
Primary lung cancers remain the most lethal of all the malignancies, predicted to account for nearly 160,000 deaths and 220,000 new diagnoses in 2009. The cornerstone of therapy for early-stage lung cancer is surgical resection by lobectomy with concomitant removal of the draining nodal basin. Minimally invasive lobectomy with the use of a thoracoscope has been established as an alternative to standard thoracotomy approaches. Thoracoscopic lobectomy provides advantages over a traditional thoracotomy, including less pain, shorter hospitalization, decreased overall costs, superior chemotherapy compliance, and fewer overall complications. In light of these advantages and with evidence of oncologic equivalence, thoracoscopic lobectomy should be considered the gold standard for the treatment of early-stage lung cancer. This article details the technical strategies for performing thoracoscopic lobectomy and highlights the published evidence demonstrating its advantages over a traditional thoracotomy approach.
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Affiliation(s)
- Matthew G Hartwig
- Department of Surgery, Duke University Medical Center, Durham, North Carolina 27710, USA
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Paul S, Altorki NK, Sheng S, Lee PC, Harpole DH, Onaitis MW, Stiles BM, Port JL, D'Amico TA. Thoracoscopic lobectomy is associated with lower morbidity than open lobectomy: A propensity-matched analysis from the STS database. J Thorac Cardiovasc Surg 2010; 139:366-78. [DOI: 10.1016/j.jtcvs.2009.08.026] [Citation(s) in RCA: 503] [Impact Index Per Article: 35.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2009] [Revised: 08/11/2009] [Accepted: 08/16/2009] [Indexed: 10/19/2022]
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Belgers EH, Siebenga J, Bosch AM, van Haren EH, Bollen EC. Complete video-assisted thoracoscopic surgery lobectomy and its learning curve. A single center study introducing the technique in The Netherlands. Interact Cardiovasc Thorac Surg 2010; 10:176-80. [DOI: 10.1510/icvts.2009.212878] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Berry MF, Hanna J, Tong BC, Burfeind WR, Harpole DH, D'Amico TA, Onaitis MW. Risk factors for morbidity after lobectomy for lung cancer in elderly patients. Ann Thorac Surg 2009; 88:1093-9. [PMID: 19766786 DOI: 10.1016/j.athoracsur.2009.06.012] [Citation(s) in RCA: 105] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2009] [Revised: 05/31/2009] [Accepted: 06/04/2009] [Indexed: 01/18/2023]
Abstract
BACKGROUND Studies evaluating risk factors for complications after lobectomy in elderly patients have not adequately analyzed the effect of using minimally invasive approaches. METHODS A model for morbidity including published preoperative risk factors and surgical approach was developed by multivariable logistic regression. All patients aged 70 years or older who underwent lobectomy for primary lung cancer without chest wall resection or airway procedure between December 1999 and October 2007 at a single institution were reviewed. Preoperative, histopathologic, perioperative, and outcome variables were assessed using standard descriptive statistics. Morbidity was measured as a patient having any perioperative complication. The impact of bias in the selection of surgical approach was assessed using propensity scoring. RESULTS During the study period, 338 patients older than 70 years (mean age, 75.7 +/- 0.2) underwent lobectomy (219 thoracoscopy, 119 thoracotomy). Operative mortality was 3.8% (13 patients) and morbidity was 47% (159 patients). Patients with at least one complication had increased length of stay (8.3 +/- 0.6 versus 3.8 +/- 0.1 days; p < 0.0001) and mortality (6.9% [11 of 159] versus 1.1% [2 of 179]; p = 0.008). Significant predictors of morbidity by multivariable analysis included age (odds ratio, 1.09 per year; p = 0.01) and thoracotomy as surgical approach (odds ratio, 2.21; p = 0.004). Thoracotomy remained a significant predictor of morbidity when the propensity to undergo thoracoscopy was considered (odds ratio, 4.9; p= 0.002). CONCLUSIONS Patients older than 70 years of age can undergo lobectomy for lung cancer with low morbidity and mortality. Advanced age and the use of a thoracotomy increased the risk of complications in this patient population.
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Affiliation(s)
- Mark F Berry
- Department of Surgery, Division of Thoracic Surgery, Duke University Medical Center, Durham, North Carolina 27710, USA
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Villamizar NR, Darrabie MD, Burfeind WR, Petersen RP, Onaitis MW, Toloza E, Harpole DH, D'Amico TA. Thoracoscopic lobectomy is associated with lower morbidity compared with thoracotomy. J Thorac Cardiovasc Surg 2009; 138:419-25. [PMID: 19619789 DOI: 10.1016/j.jtcvs.2009.04.026] [Citation(s) in RCA: 273] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2008] [Revised: 04/07/2009] [Accepted: 04/24/2009] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Advantages of thoracoscopic lobectomy include less postoperative pain, shorter hospitalization, and improved delivery of adjuvant chemotherapy. The incidence of postoperative complications has not been thoroughly assessed. This study analyzes morbidity after lobectomy to compare the thoracoscopic approach and thoracotomy. METHODS By using a prospective database, the outcomes of patients who underwent lobectomy from 1999-2009 were analyzed with respect to postoperative complications. Propensity-matched groups were analyzed based on preoperative variables and stage. RESULTS Of the 1079 patients in the study, 697 underwent thoracoscopic lobectomy, and 382 underwent lobectomy by means of thoracotomy. In the overall analysis thoracoscopic lobectomy was associated with a lower incidence of atrial fibrillation (P = .01), atelectasis (P = .0001), prolonged air leak (P = .0004), transfusion (P = .0001), pneumonia (P = .001), sepsis (P = .008), renal failure (P = .003), and death (P = .003). In the propensity-matched analysis based on preoperative variables, when comparing 284 patients in each group, 196 (69%) patients who underwent thoracoscopic lobectomy had no complications versus 144 (51%) patients who underwent thoracotomy (P = .0001). In addition, thoracoscopic lobectomy was associated with a lower incidence of atrial fibrillation (13% vs 21%, P = .01), less atelectasis (5% vs 12%, P = .006), fewer prolonged air leaks (13% vs 19%, P = .05), fewer transfusions (4% vs 13%, P = .002), less pneumonia (5% vs 10%, P = .05), less renal failure (1.4% vs 5%, P = .02), shorter chest tube duration (median of 3 vs 4 days, P < .0001), and shorter length of hospital stay (median of 4 vs 5 days, P < .0001). CONCLUSIONS Thoracoscopic lobectomy is associated with a lower incidence of major complications, including atrial fibrillation, compared with lobectomy by means of thoracotomy. The underlying factors responsible for this advantage should be analyzed to improve the safety and outcomes of other thoracic procedures.
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Affiliation(s)
- Nestor R Villamizar
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
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