Pulmonary segmentectomy: results and complications

Traumatic Chylothorax Following Pulmonary Segmentectomy: A Case Report and Review of Postoperative Investigation and Management

The incidence of iatrogenic traumatic chylothorax is on the rise secondary to the preferred use of minimally invasive thoracic surgery over thoracotomy. Most reported causes of chylothorax occur following pneumonectomy or lobectomy. There have been no reported cases of traumatic chylothorax following segmentectomy according to our literature review. Complications following lung resection typically include pneumonia, atelectasis, or prolonged air leak. Here, we present a rare case of postoperative chylothorax following minimally invasive segmentectomy to diagnose an enlarging singular pulmonary nodule. This condition was diagnosed with fluid analysis after CT imaging revealed a postoperative unilateral pleural effusion. Interestingly, the patient had a loculated pleural effusion that mimicked a pericardial effusion and empyema. Our patient was managed conservatively with a low-fat diet and short-term pleural drainage without the need for repeat surgical intervention. The importance of imaging interpretation following lung resection along with a working differential diagnosis, appropriate examination, and testing can assist with the diagnosis of this known, but rare, postoperative complication.

Utility of Functional Pneumonectomy by Using Intrabronchial Valves: First Case Series and Single Center Experience

BACKGROUND

Intrabronchial valves are approved for bronchoscopic lung volume reduction in chronic obstructive pulmonary disease patients and used for prolonged air leak. There is no data on bronchoscopic functional pneumonectomy (BFP) when treating patients with persistent air leak (PAL) or for lung volume reduction purposes.

METHODS

In this observational study, 10 consecutive patients who failed to improve with traditional therapies were assessed after they underwent BFP for PAL or lung volume reduction.

RESULTS

Ten patients underwent 17 valve placement procedures; 82 valves were placed (median: 8; range: 5 to 12). BFP was performed in 1 single lung transplant patient with hyperinflation of native lung compromising lung function. The rest of the patients had prolonged air leak because of various reasons; spontaneous (n=7) and postoperative (n=2). Pneumonia was the only procedure-related complication seen in 1 patient. Of patients with prolonged air leak with chest tubes (n=9), all had successful chest tube removal (median of 7 days; range: 3 to 21 d). The valves were removed within 6 weeks of chest tube removal in 6 patients. Prebronchoscopic and post-BFP actual forced expiratory volume in first second values in 2 transplant patients.

CONCLUSION

PAL usually occurs in patients with severe underlying lung condition or after surgery. Management of PAL can be challenging despite pleurodesis (medical or surgical). BFP offers a minimally invasive management option.

The role of three-dimensional reconstructions in understanding the intersegmental plane: an anatomical study of segment 6

OBJECTIVES

The identification of the intersegmental plane during lung segmentectomies remains a practical difficulty, notably with minimally invasive approaches. The intraoperative techniques are based on demarcating either the bronchial or the vascular territories. The goal of this study was to evaluate the use of 3-dimensional reconstructions in understanding the intersegmental plane of segment 6.

METHODS

Between March and September 2018, Synapse 3-dimensional programme was used to carry out bilateral venous, arterial and bronchial segmentations of segment 6. All computed tomography (CT) scans were contrast-enhanced and of a high resolution (0.6 mm slices). The patients had normal results on respiratory function tests. The volumes obtained from each of the 3 modalities were then compared. The results are presented as mean and standard deviation and as median and interquartile ranges for lung volume measurements.

RESULTS

During the aforementioned period, 15 high-resolution chest CT scans were selected (8 men and 7 women). The median age was 70 years. In all of the studied segments (N = 30, 15 right S6 and 15 left S6), the segmental volume of the vein was greater than the segmental volumes of the bronchus and the artery. A significant difference was found between the segmental volumes obtained from the 3 modalities (P = 0.001). The segmental volume of the vein was significantly higher than the segmental volume of the bronchus (P < 0.001) and the segmental volume of the artery (P < 0.001). On the other hand, the segmental volume of the artery was significantly higher than the segmental volume of the bronchus (P = 0.01).

CONCLUSIONS

Within the limits of this study, the segmental venous volume of S6 was greater than the volumes of the segmental bronchial and arterial volumes. Thus, depending solely on bronchial techniques might lead to leaving a border zone in venous congestion.

Demarcation of arteriopulmonary segments: a novel and effective method for the identification of pulmonary segments

Objective

Each pulmonary segment is an anatomical and functional unit. However, it is fundamentally difficult to precisely distinguish every pulmonary segment using the conventional pulmonary intersegmental planes from computed tomography images. Building arteriopulmonary segments is likely to be an effective way to identify pulmonary segments.

Methods

The thoracic computed tomography images of 40 patients were collected. The anatomic structures of interest were extracted in the transverse, sagittal, and coronal planes using the semi-automated segmentation tools provided by Amira software. The intrapulmonary vessels were subsequently segmented and reconstructed. The distributions of the pulmonary arteries, veins, and bronchi were observed. In patients with pulmonary masses, the mass was also reconstructed.

Results

The three-dimensional reconstructed images showed the branches of the pulmonary artery ramified up to their eighth order covering the entire lung as well as evident intersegmental gaps without pulmonary arteries. The segmental artery was closely accompanied by the segmental bronchi in 486 pulmonary segments (90% of total number of segments). The size and spatial location of the pulmonary mass within a pulmonary segment were also clearly visible.

Conclusions

Demarcation of arteriopulmonary segments can be used to precisely distinguish every pulmonary segment and provide its detailed anatomical structure before pulmonary segmentectomy.

Postsurgical residual lung complications following left upper trisegmentectomy

OBJECTIVES

Segmentectomy has become an increasingly popular surgical procedure for small-sized lung lesions. Left upper trisegmentectomy (LUTS) is one of the most common segmentectomies performed because of its relative ease and simplicity; however, limited information is currently available on the specific postoperative complications associated with this procedure.

METHODS

Among 2060 surgically resected cases in our institute between 2009 and 2016, 129 (6.2%) underwent LUTS. Postoperative chest X-rays and/or thoracic computed tomography (CT) scans were retrospectively assessed for all cases to assess postsurgical residual lung complications following LUTS. We categorized cases into 4 groups: type A (atelectasis of the lingular segment), type B (lung torsion of the lingular segment), type C (necrosis of the 'isolated segment') and type D (haematoma along stapling lines).

RESULTS

Postsurgical lung complications following LUTS were observed in 17 (13.1%) patients (type A: n = 7, type B: n = 1, type C: n = 4 and type D: n = 5). Three patients (2.3%) required surgical intervention because of type B (n = 1) and type C (n = 2), namely, decreased permeability and remaining ground glass opacities in the residual lung, showing an exacerbated systemic inflammatory response. In contrast, type A and D cases were successfully observed by chest CT without any surgical intervention, and patients recovered within a few months of surgery.

CONCLUSIONS

We identified several postoperative residual lung complications following LUTS. Lung torsion or necrosis of the residual segment may require intensive care, including reoperation. Potentially serious complications always need to be ruled out after LUTS when radiological consolidation is detected postoperatively.

Conversion to thoracotomy during VATS segmentectomy for treatment of symptomatic endobronchial hamartoma

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Endobronchial hamartomas are rare benign tumors.

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Surgical resection is recommended in patients with end stage lung injury or extra bronchial spread lesion.

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In presence of extra bronchial spread lesion, surgical team should keep in mind the possibility of potential vascular injury.

Introduction

Most hamartomas are located peripherally in the lung parenchyma and are rarely identified as an endobronchial lesion. Clinically patients with an endobronchial hamartoma are often symptomatic and may present with various symptoms including: fever, wheezing, hemoptysis and obstructive pneumonia.

Case presentation

A 68-year-old man presented with complaints of fever and cough for 1 month. Chest X-ray revealed a right infrahilar density, which on chest CT was found to be a lesion obstructing the superior segmental bronchus of the right lower lobe and extending outside of the bronchus. A round rubbery mass obstructing the same segmental bronchus was noticed during bronchoscopy and endoscopic biopsy yielded a pathological diagnosis of hamartoma.

Discussion

Bronchoscopy is most helpful in diagnosis and management of endobronchial hamartomas but if the lung distal to the obstruction is irreversibly damaged or imaging studies suggest that tumor extends outside of the bronchus, pulmonary segmentectomy, lobar resection or even pneumonectomy may be indicated.

Conclusion

When a benign tumor of the lung, as endobronchial hamartoma, is located in a segmental bronchus and presents extrabronchial spread, we recommend to perform a parenchymal-sparing surgical resection. In this case surgical team, however, should keep in mind, due to difficult individual dissection of the segmental bronchovascular elements, the possibility of conversion from VATS (video-assisted thoracic surgery) to open thoracotomy.

Uniportal Video-Assisted Thoracoscopic Surgery Segmentectomy

This article addresses technical details of uniportal VATS segmentectomy by lung segments, suggesting available techniques for lesion localization and identification of the intersegmental plane. Long-term results and superiority have not yet been characterized in standard VATS for lung malignancy. Indications include almost all thoracic procedures currently performed by conventional multiport VATS. We review our experience and published literature on the feasibility of uniportal VATS segmentectomy.

Endobronchial one-way valves for treatment of persistent air leaks: a systematic review

Persistent air leak (PAL) is associated with significant morbidity and mortality, prolonged hospitalization and increased health-care costs. It can arise from a number of conditions, including pneumothorax, necrotizing infection, trauma, malignancies, procedural interventions and complications after thoracic surgery. Numerous therapeutic options, including noninvasive and invasive techniques, are available to treat PALs. Recently, endobronchial one-way valves have been used to treat PAL. We conducted a systematic review based on studies retrieved from PubMed, EMbase and Cochrane library. We also did a hand-search in the bibliographies of relevant articles for additional studies. 34 case reports and 10 case series comprising 208 patients were included in our review. Only 4 patients were children, most of the patients were males. The most common underlying disease was COPD, emphysema and cancer. The most remarkable cause was pneumothorax. The upper lobes were the most frequent locations of air leaks. Complete resolution was gained within less than 24 h in majority of patients. Complications were migration or expectoration of valves, moderate oxygen desaturation and infection of related lung. No death related to endobronchial one-way valves implantation has been found. The use of endobronchial one-way valve adds to the armamentarium for non-invasive treatments of challenging PAL, especially those with difficulties of anesthesia, poor condition and high morbidity. Nevertheless, prospective randomized control trials with large sample should be needed to further evaluate the effects and safety of endobronchial one-way valve implantation in the treatment of PAL.

Management of Prolonged Pulmonary Air Leaks With Endobronchial Valve Placement

Background:

Prolonged pulmonary air leaks (PALs) are associated with increased morbidity and extended hospital stay. We sought to investigate the role of bronchoscopic placement of 1-way valves in treating this condition.

Methods:

We queried a prospectively maintained database of patients with PAL lasting more than 7 days at a tertiary medical center. Main outcome measures included duration of chest tube placement and hospital stay before and after valve deployment.

Results:

Sixteen patients were eligible to be enrolled from September 2012 through December 2014. One patient refused to give consent, and in 4 patients, the source of air leak could not be identified with bronchoscopic balloon occlusion. Eleven patients (9 men; mean age, 65 ± 15 years) underwent bronchoscopic valve deployment. Eight patients had postoperative PAL and 3 had a secondary spontaneous pneumothorax. The mean duration of air leak before valve deployment was 16 ± 12 days, and the mean number of implanted valves was 1.9 (median, 2). Mean duration of hospital stay before and after valve deployment was 18 and 9 days, respectively (P = .03). Patients who had more than a 50% decrease in air leak on digital monitoring had the thoracostomy tube removed within 3–6 days. There were no procedural complications related to deployment or removal of the valves.

Conclusions:

Bronchoscopic placement of 1-way valves is a safe procedure that could help manage patients with prolonged PAL. A prospective randomized trial with cost-efficiency analysis is necessary to better define the role of this bronchoscopic intervention and demonstrate its effect on air leak duration.

Completion lobectomy after radical segmentectomy for pulmonary malignancies

OBJECTIVE

Completion lobectomy after radical segmentectomy is relatively rare, with no systematic evaluation of this challenging procedure. We aimed to clarify the details of this operation performed in 3 Japanese institutions.

METHODS

Completion lobectomy after segmentectomy in the same lobe was performed in 11 patients (9 lung cancers and 2 metastatic lung tumors) between 2007 and 2013. Surgical outcomes were analyzed retrospectively.

RESULTS

The 11 patients accounted for 1.37% of the 805 segmentectomies performed in the 3 institutions. The reasons for completion lobectomy were postoperative complications in the remaining lobe (n = 3), positive pathological lymph node metastasis found by permanent section (n = 3), and malignancy in the remaining lobe (n = 5). The patients were divided into two groups according the interval between segmentectomy and completion lobectomy: group A (3-35 days, n = 5) and group B (56-1470 days, n = 6). There was a tendency for more severe adhesions around the hilum (p = 0.061) in group B, resulting in increased operative bleeding (p = 0.055), more usage of fibrin glue (p = 0.080), and significantly longer operative time (p = 0.036). Injury to the pulmonary arteries was experienced only in group B (3/6 cases). There was no operation-related mortality.

CONCLUSIONS

Completion lobectomy may become more difficult approximately 5 weeks after segmentectomy, due to severe adhesions, but it can be performed safely with careful manipulation.

Techniques of stapler-based navigational thoracoscopic segmentectomy using virtual assisted lung mapping (VAL-MAP)

Anatomical segmentectomies play an important role in oncological lung resection, particularly for ground-glass types of primary lung cancers. This operation can also be applied to metastatic lung tumors deep in the lung. Virtual assisted lung mapping (VAL-MAP) is a novel technique that allows for bronchoscopic multi-spot dye markings to provide "geometric information" to the lung surface, using three-dimensional virtual images. In addition to wedge resections, VAL-MAP has been found to be useful in thoracoscopic segmentectomies, particularly complex segmentectomies, such as combined subsegmentectomies or extended segmentectomies. There are five steps in VAL-MAP-assisted segmentectomies: (I) "standing" stitches along the resection lines; (II) cleaning hilar anatomy; (III) confirming hilar anatomy; (IV) going 1 cm deeper; (V) step-by-step stapling technique. Depending on the anatomy, segmentectomies can be classified into linear (lingular, S6, S2), V- or U-shaped (right S1, left S3, S2b + S3a), and three dimensional (S7, S8, S9, S10) segmentectomies. Particularly three dimensional segmentectomies are challenging in the complexity of stapling techniques. This review focuses on how VAL-MAP can be utilized in segmentectomy, and how this technique can assist the stapling process in even the most challenging ones.

Single-port video-assisted thoracoscopic pulmonary segmentectomy: a report on 30 cases†

OBJECTIVES

This study aimed to evaluate the feasibility of a single-port video-assisted thoracoscopic surgery for pulmonary segmentectomy in patients with malignant or benign lung diseases.

METHODS

Thirty patients (17 women; mean age, 61.7 ± 10.9 years) who underwent a single-port thoracoscopic segmentectomy were consecutively included in this study. A 2- to 4-cm incision was made at the fifth intercostal space on the anterior or posterior axillary line, depending on the tumour location. We investigated the postoperative outcomes according to the size of the incision (2 vs 3-4 cm) or the location of segmentectomy.

RESULTS

Fifteen primary lung cancers, 5 metastatic lung cancers, 1 pulmonary sarcoma, 7 cases of inflammatory lung disease and 2 benign lung tumours were diagnosed. A 3- to 4-cm incision was used in 16 patients (53.3%), and a 2-cm incision in 14 patients. The most frequent segment removed was the left upper division (9 patients, 30%). A single-port thoracoscopic segmentectomy was completed in all of the patients except one (96.7%). This 1 patient underwent lobectomy instead because the lesion was not found in the initial segment removed. The mean operation time was 159 ± 56 min, and no significant difference in the size of incision was observed (P = 0.651). The right middle and superior segments tended to require shorter operation times (97.1 ± 44.9 min) than the other segments (p < 0.001). One patient died (3.3%) because of septic shock. The chest tube drain was removed 4.6 ± 1.6 days after the operation.

CONCLUSIONS

This study results suggest that a single-port thoracoscopic surgery might be a feasible option for pulmonary segmentectomy with acceptable postoperative outcomes in the early stages of lung cancer or for benign lung disease.

Congenital lung lesions: Postnatal management and outcome

Antenatal diagnosis of lung lesion has become more accurate resulting in dilemma and controversies of its antenatal and postnatal management. Majority of antenatally diagnosed congenital lung lesions are asymptomatic in the neonatal age group. Large lung lesions cause respiratory compromise and inevitably require urgent investigations and surgery. The congenital lung lesion presenting with hydrops requires careful postnatal management of lung hypoplasia and persistent pulmonary hypertension. Preoperative stabilization with gentle ventilation with permissive hypercapnia and delayed surgery similar to congenital diaphragmatic hernia management has been shown to result in good outcome. The diagnostic investigations and surgical management of the asymptomatic lung lesions remain controversial. Postnatal management and outcome of congenital cystic lung lesions are discussed.

Development of a New Magnetometer for Sentinel Lymph Node Mapping Designed for Video-Assisted Thoracic Surgery in Non-Small Cell Lung Cancer

BACKGROUND

We previously developed a method for sentinel lymph node (SLN) mapping in non-small cell lung cancer (NSCLC), based on the magnetic force produced by a magnetite tracer already approved for use as a contrast material for magnetic resonance imaging. However, it is difficult to use that technique with video-assisted thoracic surgery (VATS) because the sensing element of the magnetometer is large and thick. The purpose of the present study was to develop a smaller, thinner VATS-compatible magnetometer.

METHODS

The tracer employed was Ferucarbotran, a colloidal solution of superparamagnetic iron oxide coated with carbodextran. Fifteen patients with clinical stage I NSCLC were enrolled, and each received 1.6 mL of Ferucarbotran, injected intraoperatively at 5 points around the tumor. The magnetic force within the sampling lymph nodes was measured using the new VATS-compatible magnetometer.

RESULTS

SLNs were detected in 11 (73.3%) of the 15 patients using the VATS-compatible magnetometer. The average number of SLNs identified per patient was 1.8 (range 0-4). No complications related to the SLN detection method were observed.

CONCLUSIONS

The new VATS-compatible magnetometer appears to have substantial advantages over techniques using a radioisotope and our earlier magnetometer, as it can be inserted through the small VATS port site.

Indication for VATS sublobar resections in early lung cancer

When dealing with early non-small cell lung cancer (NSCLC) sublobar resections still remain part of the surgical armamentarium. In selected patients with lung cancer, the combination of the potential benefits of parenchyma sparing procedures to the limited trauma provided by Video Assisted Thoracic Surgery (VATS) techniques can become very appealing. Two main groups are included: non-anatomical (wedges) and anatomical (segmentectomies) excisions. We describe the techniques, results and potential indications of both of these techniques.

The efficacy of 320-detector row computed tomography for the assessment of preoperative pulmonary vasculature of candidates for pulmonary segmentectomy

OBJECTIVES

The purpose of this study was to compare the efficacy of 320-detector row computed tomography (CT) with that of 64-detector row CT for three-dimensional assessment of pulmonary vasculature of candidates for pulmonary segmentectomy.

METHODS

We included 32 patients who underwent both 320- and 64-detector CT before pulmonary segmentectomy, which was performed by cutting the pulmonary artery and bronchi of the affected segment followed by dissection of the intersegmental plane along the intersegmental vein. Before the operation, three-dimensional pulmonary vasculature images were obtained for each patient, and the arteries and intersegmental veins of the affected segments were identified. Two thoracic surgeons independently assessed the vessels with visual scoring systems, and kappa analysis was used to determine interobserver agreement. The Wilcoxon signed-rank test was used to compare the visual scores for the assessment of the visualization capabilities of the two methods. In addition, the final determination of pulmonary vasculature at a given site was made by consensus from thoracic surgeons during operation, and receiver operating characteristic analysis was performed to compare their efficacy of pulmonary vasculature assessment. Sensitivity, specificity and accuracy of either method were also compared by means of McNemar's test.

RESULTS

Of the 32 cases, there were no operative complications, but 1 patient died of postoperative idiopathic interstitial pneumonia. Visualization scores for the pulmonary vessels were significantly higher for 320- than those for 64-detector CT (P < 0.0001 for the affected arteries and P < 0.0001 for the intersegmental veins). As for pulmonary vasculature assessment, the areas under the curve showed no statistically significant differences in between the two methods, while the specificity and accuracy of intersegemental vein assessment were significantly better for 320- than those for 64-detector row CT (P < 0.05). Interobserver agreement for the assessment yielded by either method was almost perfect for all cases.

CONCLUSIONS

Three hundred and twenty-detector row CT is more useful than conventional 64-detector row CT for preoperative three-dimensional assessment of pulmonary vasculature, especially when we identify the intersegmental veins, in candidates for pulmonary segmentectomy.

Predictive factors for complications of anatomical pulmonary segmentectomies

OBJECTIVES

The role of anatomical pulmonary segmentectomy is increasing, but there are few data about its complication rate. We have analysed the postoperative morbidity, mortality and risk factors in a consecutive series of 228 segmentectomies performed in our department.

METHODS

Between January 2007 and December 2011, 221 patients underwent 228 segmentectomies. There were 99 women (45%) and 122 men (55%). The mean age was 61 years (range 18-86 years). The mean forced expiratory volume in 1 s (FEV1) was 87%, and 30 patients had an FEV1 of ≤60%. Fifty-seven patients had a previous history of pulmonary resection. Indications for segmentectomy were: primary lung cancer (111 cases), metastases (71 cases), benign non-infectious (25 cases) and benign infectious diseases (21 cases). The approach was a posterolateral thoracotomy (Group PLT) in 146 patients (64%) and a thoracoscopy (Group TS) in 82 (36%). The two groups were homogenous in terms of age, gender, indications of surgery and type of segmentectomy.

RESULTS

The mortality rate at 3 months was 1.3% (3 patients). The overall complication rate was 34%. Ten patients were reoperated for the following reasons: haemothorax (4 cases), ischaemia of the remaining segment (3 cases), active bleeding (1 case), prolonged air leak (1 case) and dehiscence of thoracotomy (1 case). The average duration of drainage was 5 days (range 1-34 days) and the average length of stay was 9 days (range 3-126 days). On univariate analysis, FEV1, male gender and thoracotomy were statistically significant risk factors for complications. On multivariate analysis, the same three predictive factors of complications independently of age were found statistically significant: preoperative FEV1 < 60% [odds ratio (OR) = 5.9, 95% CI (2.5-13.7), P < 0.001] male gender [OR = 2.04, 95% CI (1.2-3.6), P < 0.013] and thoracotomy [OR = 2.14, 95% CI (1.33-3.46), P = 0.001].

CONCLUSIONS

Pulmonary anatomical segmentectomies have an acceptable morbidity rate. Postoperative complications are more likely to develop in male gender patients, with FEV1 ≤ 60% and operated by open surgery.

Segmentectomy as a safe and equally effective surgical option under complete video-assisted thoracic surgery for patients of stage I non-small cell lung cancer

BACKGROUND

While video-assisted thoracic surgery lobectomy has been widely accepted for the treatment of non-small cell lung cancer, the debate over video-assisted thoracic surgery segmentectomy still remains. This study compared the clinical outcomes using the two procedures for stage I non-small cell lung cancer patients.

METHODS

Retrospective review was conducted on patients who underwent video-assisted thoracic surgery segmentectomy or lobectomy for clinical stage I non-small cell lung cancer at Shanghai Chest Hospital between November 2009 and May 2012. Video-assisted thoracic surgery segmentectomy was performed on 36 patients and video-assisted thoracic surgery lobectomy on 138 patients. Comparisons between the 2 groups were performed in patient demographic and clinical characteristics, intraoperative parameters and oncology outcomes.

RESULTS

Mean volume of chest tube drainage after operation was smaller for segmentectomy than for lobectomy (1021 ml vs. 1328 ml, P=0.036). Other parameters analysis including blood loss, operation time, chest tube duration and length of hospital stay favors the segmentectomy group numerically without significance. There was no significant difference in distributions in both intra and post operative complications. There was one peri-operative mortality from segmentectomy group and all other patients are alive with a median follow up of 327 days. There were 1 (2.8%) locoregional recurrence after segmentectomy and 6 recurrences (4.4%) after lobectomy (P=1.00). Multivariate survival analysis revealed no significant difference in recurrence-free survivals between the two groups. Two patients successfully underwent bilateral segmentectomies and are free of disease.

CONCLUSIONS

For patients with stage I non-small cell lung cancer, video-assisted thoracic surgery segmentectomy offers a safe and equally effective option and can be applied to complicated operation such as bilateral segmentectomy.

Butterfly-needle video-assisted thoracoscopic segmentectomy: a retrospective review and technique in detail

OBJECTIVE

: A pulmonary segmentectomy is requires the identification of the segmental planes, making it technically more difficult than a lobectomy. Therefore, we present a new method that uses a butterfly needle to distinguish the intersegmental plane under video-assisted thoracoscopic surgery (VATS).

METHODS

: From May 2005 to August 2008, 15 patients underwent anatomic segmentectomy using VATS. In this approach, a working port 4 to 7 cm in length was made in the fifth intercostal space. Additional 1.2-cm thoracic ports were made in the seventh intercostal space on the anterior axillary line and the ninth intercostal space on the posterior axillary line. Each segment was selectively isolated, and the targeted bronchovascular pedicle was divided. For the segmentectomy, the lung was deflated, and the pulmonary artery and vein to the involved segment were divided. The segmental bronchus was divided using a stapling device. Using a butterfly needle, oxygen/air (1-2 L) was used to inflate the involved segment, and the involved segment was severed and removed using electrocautery or a stapling device. The raw surface was covered with an absorbable sealing material such as polyglycolic acid to prevent air leaks.

RESULTS

: Using this method, apical segment of the right upper lobe (S1), apical posterior segment of the left upper lobe (S1 + 2), upper division, and posterior segment of the right upper lobe (S2), superior segment of the right or left lower lobe (S6), and basal segmentectomies could be performed with VATS. However, the technique did not work in one patient with severe emphysematous changes, because the plane was not readily identifiable.

CONCLUSIONS

: Butterfly-needle video-assisted segmentectomy is a useful technique. Selective segmental inflation allows the intersegmental plane to be identified completely under the surgeon's control, eliminating the need for an anesthesiologist to pass a bronchoscope or insufflate the lung in a particular manner.

Thoracoscopic segmentectomy for T1 classification of non-small cell lung cancer: a single center experience

OBJECTIVES

Segmentectomy is one of the treatment options for small-sized non-small cell lung cancer (NSCLC). Although growing results support the feasibility and efficacy, it still remains unclear in segmentectomy. The International Association for the Study of Lung Cancer recommended a revised classification of TNM staging in 2009 (the seventh edition) and multidisciplinary classification of adenocarcinoma. We report here the outcome of totally thoracoscopic segmentectomy and lobectomy for T factor and adenocarcinoma.

METHODS

Ninety patients with Stage IA NSCLC underwent thoracoscopic segmentectomy between September 2003 and June 2011. A total of 124 patients were referred as a control group to compare the peri-operative outcome, local recurrence rate and survival. These survivals were analysed using the Kaplan-Meier method with the log-rank test and propensity score analyses.

RESULTS

The peri-operative outcome, including operative time, blood loss, duration of chest tube drainage and length of hospital stay, was not significantly different between groups. The number of dissected lymph nodes with segmentectomy was less than that with lobectomy. Morbidity and mortality were not significantly different between groups. Seven patients relapsed in each group and propensity score analysis in disease-free and overall survivals showed no differences between two groups in Stage IA. Subclass analyses revealed that disease-free and overall survivals in T1a and T1b were not significantly different between the two groups.

CONCLUSIONS

Our study demonstrated that thoracoscopic segmentectomy was feasible with regard to peri-operative and oncological outcomes for Stage IA NSCLC, especially T1a and carefully selected T1b descriptor.

Radical hybrid video-assisted thoracic segmentectomy: long-term results of minimally invasive anatomical sublobar resection for treating lung cancer

We analysed the results of radical segmentectomy achieved through a hybrid video-assisted thoracic surgery (VATS) approach that used both direct vision and television monitor visualization at a median follow-up of over 5 years. Between April 2004 and October 2010, 102 consecutive patients able to tolerate lobectomy to treat clinical T1N0M0 non-small cell lung cancer (NSCLC) underwent hybrid VATS segmentectomy in which we used electrocautery without a stapler to divide the intersegmental plane detected by selective jet ventilation in addition to the path of the intersegmental veins. Curative resection was achieved in all patients. The median surgical duration and blood loss during the surgery were 129 min (range, 60-275 min) and 50 ml (range, 10-350 ml), respectively. The complication rate was 9.8% (10/102) with the most frequent being prolonged air leak, and there was no case of in-hospital death or 30-day mortality post procedure. Five and seven patients developed locoregional and distant recurrences, respectively. The overall and disease-free 5-year survival rates were 89.8% and 84.7%, respectively. Radical hybrid VATS segmentectomy including atypical resection of (sub)segments is a useful option for clinical stage-I NSCLC. The exact identification of anatomical intersegmental plane followed by dissection using electrocautery is critical from oncological and functional perspectives.

Thoracoscopic segmentectomy with intraoperative evaluation of sentinel nodes for stage I non-small cell lung cancer

OBJECTIVES

Segmentectomy is the treatment of choice for small-sized non-small cell lung cancer (NSCLC); however, it is difficult to decide the surgical procedure because accurate evaluation of hilar lymph node metastasis remains unclear. We here report the outcome of video-assisted thoracic surgery (VATS) segmentectomy with and without the assessment of sentinel nodes.

MATERIALS AND METHODS

Eighty-three patients with stage IA NSCLC underwent VATS segmentectomy between January 2003 and December 2010. Twenty patients underwent indocyanine green fluorescence imaging for sentinel node biopsy (SNB) and 63 did not. Intraoperative real-time quantitative RT-PCR to determine the expression of CK-19 was used for evaluation of metastasis. Perioperative outcome, local recurrence rates and survival were compared in both groups.

RESULTS

Sentinel lymph nodes were identified in 16 of 20 patients (80%) with segmentectomy in the SNB group. The false negative rate was 0%. By RT-PCR for CK-19 expression, only one of these patients showed positive sentinel nodes, which indicated isolated tumor cells; however, segmentectomy was not converted to lobectomy. Seven of 63 patients with VATS segementectomy without SNB and none of the SNB group relapsed. In the relapsed patients without SNB, 4 (6.3%) were local recurrences and 3 (4.7%) were distant metastases. Recurrence-free survival rates in both groups were not significantly different because of the short follow-up period of the SNB group.

CONCLUSIONS

Our study demonstrated that VATS segmentectomy with SNB was useful for deciding intraoperatively to perform segmentectomy with an accurate lymph node status.

Superselective segmentectomy for deep and small pulmonary nodules under the guidance of three-dimensional reconstructed computed tomographic angiography

BACKGROUND

Three-dimensional computed tomographic angiography (3D-CT angio) allows selective access to peripheral segments. Superselective segmentectomy (SSS) was applied to the surgical management of indeterminate small and deep pulmonary nodules.

METHODS

Thirty patients with indeterminate pulmonary nodules less than 25 mm in diameter and located deeper than 20 mm from the pleural surface were enrolled in this study between 2002 and 2009. All patients underwent exploratory thoracotomy. The SSS with a surgical margin from the nodule larger than the nodule diameter or 20 mm was directed toward the target pulmonary arteries by 3D-CT angio using a multidetector-row CT scanner. The SSS was evaluated for resected area, surgical margin, regional lymph nodes, morbidity, lung function, and survival rate.

RESULTS

Three patients received SSS at the daughter segment, 23 patients that at the subsegment, and the remaining four underwent miscellaneous SSS without major complications. Twenty patients exhibited early lung cancer, one patient stage IIA lung cancer, and the remaining nine patients had metastatic or benign tumors. Five patients with primary cancer subsequently underwent standard lobectomy. The remaining 16 patients with early lung cancer did not undergo lobectomy because of their major comorbidities or refusal of a second thoracotomy. The surgical margins were free of disease in all patients. The actual and disease-free five-year survival rates were 100% for the lung cancer patients, excluding those who subsequently underwent lobectomy. The lung function after SSS was well preserved.

CONCLUSIONS

Superselective segmentectomy is an applicable optional strategy for the surgical management of indeterminate small and deep pulmonary nodules.

Thoracoscopic segmentectomy compares favorably with thoracoscopic lobectomy for patients with small stage I lung cancer

OBJECTIVE

As thoracoscopic lobectomy becomes widely applied for treatment of non-small cell lung cancer, thoracoscopic segmentectomy remains controversial for patients with small stage I lung cancers. Questions remain regarding safety, morbidity, mortality, and recurrence rate. This study compared outcomes between thoracoscopic segmentectomy and lobectomy.

METHODS

Retrospective review was undertaken of patients who underwent thoracoscopic segmentectomy or lobectomy for clinical stage I non-small cell lung cancer between January 2002 and February 2008. Indications for segmentectomy were tumor smaller than 3 cm, limited pulmonary reserve, comorbidities, and peripheral tumor location.

RESULTS

Thirty-one patients underwent segmentectomy and 113 underwent lobectomy. Patients after segmentectomy had worse mean forced expiratory volume in 1 second than after lobectomy (83% vs 92%, P = .04). There were no differences in mean number of nodes (10) and nodal stations (5) resected. Segmentectomy and lobectomy groups had similar median chest tube durations (2 vs 3 days, P = .18), stays (both 4 days), total complications, recurrence rates, and survivals at mean follow-ups of 22 and 21 months, respectively. Lobectomy group had 1 30-day death; segmentectomy group had none. There were 5 (17.2%) recurrences after segmentectomy and 23 (20.4%) after lobectomy (P = .71), with locoregional recurrence rates of 3.5% and 3.6%, respectively.

CONCLUSION

Thoracoscopic segmentectomy is a safe option for experienced thoracoscopic surgeons treating patients with small stage I lung cancers. No significant difference in oncologic outcome was seen between thoracoscopic segmentectomy and thoracoscopic lobectomy. Lymph node dissection could be performed as effectively during segmentectomy as lobectomy.

A follow-up report on a new method of segmental resection for small-sized early lung cancer

We previously reported a new method of segmentectomy, pulmonary artery-guided segmentectomy as a surgical alternative for small-sized early lung cancer with favorable results, but the follow-up time was too short for definitive conclusion. To examine the efficacy of the segmentectomy, and to determine the appropriate surgical procedure for early lung cancer, we conducted a retrospective follow-up study, and examined the influences of tumor size and preoperative serum tumor marker levels on the prognosis. We reviewed the records of 91 patients who underwent the segmentectomy for pathological T1N0M0 non-small cell lung cancer from 1993 to 2002. In 85 patients, carcinoembryonic antigen, squamous cell carcinoma-related antigen, and a fragment of cytokeratin were measured preoperatively. The overall 5-year survival rate was 83%. Indication (intentional, n=47; compromised, n=44) and tumor size (20mm or less, n=68; 21 to 30 mm, n=23) had no significant impact on survival. The 5-year survival rate for 49 patients with normal tumor marker levels was 93%, and significantly higher than 36 patients with at least one elevated tumor marker level (68%, p<0.01). Median follow-up time of 72.0 months revealed 11 locoregional recurrences. The incidence of locoregional recurrence was significantly higher in the patients with tumors of 21-30 mm, and elevated tumor marker (p<0.01). The follow-up study demonstrated that the segmentectomy could be an acceptable surgical treatment for early lung cancer patients with tumors of 20mm or smaller and normal tumor marker levels.

Pulmonary segmentectomy by thoracotomy or thoracoscopy: reduced hospital length of stay with a minimally-invasive approach

BACKGROUND

Previous studies have discouraged limited pulmonary resection for primary lung cancer, but pulmonary segmentectomy has advantages for some patients. Furthermore, while thoracoscopic lobectomy has been increasingly applied with well-demonstrated advantages compared with thoracotomy, few data exist regarding thoracoscopic approaches to pulmonary segmentectomy. This study compares thoracoscopic segmentectomy (TS) with open segmentectomy (OS).

METHODS

This is a retrospective review of prospectively collected data for 77 consecutive segmentectomy patients treated between 2000 and 2006 at a single center. Preoperative, intraoperative, and postoperative variables for patients undergoing TS (n = 48) were compared with those undergoing OS (n = 29). Student's t tests were used for continuous data and Fisher's exact tests for dichotomous data.

RESULTS

Baseline demographics were similar between groups. Indications for pulmonary resection included non-small cell lung cancer (n = 39), metastatic disease (n = 30), and other diagnoses (n = 8). All common segmentectomies were represented. No thoracoscopic cases required conversion to open procedures. Operative times, estimated blood loss, and chest tube duration were similar between groups. Outcomes were similar except that hospital length of stay was significantly less among TS patients (length of stay 6.8 +/- 6 days OS versus 4.3 +/- 3 days TS; p = 0.03). Thirty-day mortality was 6.9% (2 of 29) for the OS group compared with 0% for the TS group. Long-term survival rates were significantly better in the TS group (p = 0.0007).

CONCLUSIONS

Thoracoscopic segmentectomy is a safe and feasible procedure, comparing favorably with OS by reducing hospital length of stay. For experienced thoracoscopic surgeons, TS appears to be a sound option for lung-sparing, anatomic pulmonary resections.

Role of Sublobar Resection (Segmentectomy and Wedge Resection) in the Surgical Management of Non–Small Cell Lung Cancer

Segmentectomy demands a thorough knowledge of the three-dimensional bronchovascular anatomy of the lung. This anatomic detail makes segmentectomy significantly more challenging than lobectomy. Several principles must be applied when performing segmental lung resection: (1) the surgeon should avoid dissection in a poorly developed fissure, (2) use the transected bronchus as the base of the segmental resection during the division of the lung parenchymal in the intersegmental plane, (3) consider the use of endostapler division of the pulmonary parenchyma to reduce the air leak complications related to "finger fracture" dissection of the intersegmental plane, and (4) consider the use of adjuvant iodine 125 brachytherapy as a means of reducing local recurrence following sublobar resection. Increasing evidence supports the use of anatomic segmentectomy in the treatment of primary lung cancer for appropriately selected patients. This resection approach seems most appropriate in the management of the small (<2 cm in diameter) peripheral stage I NSCLC in which a generous margin of resection can be obtained. Accurate intraoperative nodal staging is important to estimate the relative use of these approaches compared with more aggressive resection and to determine the need for adjuvant systemic therapy if metastatic lymphadenopathy is identified. Future investigations comparing the results of sublobar resection with lobectomy will more clearly define the role of segmentectomy among good-risk patients with clinical stage I NSCLC. At the present time, it seems that sublobar resection is an appropriate therapy for the management of stage I NSCLC identified in the elderly patient, those individuals with significant cardiopulmonary dysfunction, and for the management of peripheral solitary metastatic disease to the lung. Because the primary disadvantage of sublobar resection is that of local recurrence, intraoperative adjuvant iodine 125 brachytherapy may be considered to minimize this local recurrence risk.

A novel video-assisted anatomic segmentectomy technique: selective segmental inflation via bronchofiberoptic jet followed by cautery cutting

OBJECTIVE

Segmentectomy is an anatomic parenchyma-sparing resection that is recently being performed for small-sized lung carcinoma and constitutes a useful procedure in a thoracic surgeon's armamentarium. We have generated a new technique that improves the identification of the intersegmental border and whose clinical utility we evaluate in this study.

METHODS

Under bronchofiberscopy, jet ventilation is selectively applied to the burdened bronchus to develop an anatomic plane between the inflated segment to be resected and the deflated area to be preserved. From April 2004 to June 2006, 52 consecutive patients with a clinical T1 N0 M0 peripheral cancer 2 cm or smaller underwent video-assisted segmental resection called hybrid VATS segmentectomy in which electrocautery with no stapler was used to divide the intersegmental plane detected by selective jet ventilation.

RESULTS

Complete resection was achieved in all patients. The median operative time and bleeding during the operation were 155 minutes (range 85-225 minutes) and 60 mL (range 10-210 mL), respectively. The complication rate was 13.5% (7/52), and the most common was concerning air leak. The median duration of postoperative air leak and chest tube drainage was 1 day and 3 days, respectively. There were no in-hospital deaths. There was one case of mediastinal lymph node recurrence and another of metastasis to the brain although there was no case of local recurrence in the surgical margin area.

CONCLUSIONS

A novel video-assisted segmentectomy technique for lung cancer is clinically useful. Selective segmental inflation provides an obvious intersegmental plane quickly and easily, allowing a real margin distance in the ventilated segment. Despite the minimally invasive approach, since only the segment to be resected and not the entire lobe is expanded, an appropriate surgical view is possible.

Radical sublobar resection for small-sized non–small cell lung cancer: A multicenter study

OBJECTIVE

At present, even when early-stage, small-sized non-small cell lung cancers are being increasingly detected, lesser resection has not become the treatment of choice. We sought to compare sublobar resection (segmentectomy or wedge resection) with lobar resection to test which one is the appropriate procedure for such lesions.

METHODS

From 1992 to 2001, a nonrandomized study was performed in 3 institutes for patients with a peripheral cT1N0M0 non-small cell lung cancer of 2 cm or less who were able to tolerate a lobectomy. The results of the sublobar resection group enrolled preoperatively (n = 305) were compared with those of the lobar resection group (n = 262).

RESULTS

Except for distribution of tumor location, there were no significant differences in any variable, patient characteristics, curability, pathologic stage, morbidity, or recurrence rate. Median follow-up was more than 5 years. Disease-free and overall survivals were similar in both groups with 5-year survivals of 85.9% and 89.6% for the sublobar resection group and 83.4% and 89.1% for the lobar resection group, respectively. Multivariate analysis confirmed that the recurrence rate and prognosis associated with sublobar resection were not inferior to those obtained with lobar resection. Postoperative lung function was significantly better in patients who underwent sublobar resection.

CONCLUSIONS

Sublobar resection should be considered as an alternative for stage IA non-small cell lung cancers 2 cm or less, even in low-risk patients. These results could lay the foundation for starting randomized controlled trials anew, which would bring great changes of lung cancer surgery in this era of early detection of lung cancer.

Postoperative Pneumonia after Major Lung Resection

BACKGROUND

Postoperative pneumonia (POP) is a life-threatening complication of lung resection. The incidence, causative bacteria, predisposing factors, and outcome are poorly understood.

DESIGN

Prospective observational study.

METHODS

A prospective study of all patients undergoing major lung resections for noninfectious disease was performed over a 6-mo period. Culture of intraoperative bronchial aspirates was systematically performed. All patients with suspicion of pneumonia underwent bronchoscopic sampling and culture before antibiotherapy.

RESULTS

One hundred and sixty-eight patients were included in the study. Bronchial colonization was identified in 31 of 136 patients (22.8%) on analysis of intraoperative samples. The incidence of POP was 25% (42 of 168). Microbiologically documented and nondocumented pneumonias were recorded in 24 and 18 cases, respectively. Haemophilus species, Streptococcus species, and, to a much lesser extent, Pseudomonas and Serratia species were the most frequently identified pathogens. Among colonized and noncolonized patients, POP occurred in 15 of 31 and 20 of 105 cases, respectively (p = 0.0010; relative risk, 2.54). Death occurred in 8 of 42 patients who developed POP and in 3 of 126 of patients who did not (p = 0.0012). Patients with POP required noninvasive ventilation or reintubation more frequently than patients who did not develop POP (p < 0.0000001 and p = 0.00075, respectively). POP was associated with longer intensive care unit and hospital stay (p < 0.0000001 and p = 0.0000005, respectively). Multivariate analysis showed that chronic obstructive pulmonary disease, extent of resection, presence of intraoperative bronchial colonization, and male sex were independent risk factors for POP.

CONCLUSIONS

Pneumonia acquired in-hospital represents a relatively frequent complication of lung resections, associated with an important percentage of postoperative morbidity and mortality.

Effect of tumor size on prognosis in patients with non-small cell lung cancer: the role of segmentectomy as a type of lesser resection

OBJECTIVE

As a result of increasing discovery of small-sized lung cancer in clinical practice, tumor size has come to be considered an important variable affecting planning of treatment. Nevertheless, there have been no reports including large numbers of patients and focusing on tumor size, and controversy remains concerning the surgical management of small-sized tumors. Therefore, we investigated the relationships between tumor dimension and clinical and follow-up data, as well as surgical procedure in particular.

METHODS

We reviewed the records of 1272 consecutive patients who underwent complete resection for non-small cell carcinoma of the lung.

RESULTS

Fifty patients had tumors of 10 mm or less, 273 had tumors of 11 to 20 mm, 368 had tumors of 21 to 30 mm, and 581 had tumors of greater than 30 mm in diameter. The cancer-specific 5-year survivals of patients in these 4 groups were 100%, 83.5%, 76.5%, and 57.9%, respectively. For patients with pathologic stage I disease, they were 100%, 92.6%, 84.1%, and 76.4%, respectively. Multivariate analysis demonstrated that male sex, older age, larger tumor, and advanced pathologic stage adversely affected survival. Lesser resection was performed in 167 (52%) of 323 patients with a tumor of 20 mm or less in diameter but in 156 (16%) of 949 patients with a tumor of greater than 20 mm in diameter. The percentages of lesser resection among all procedures performed were 79%, 56%, 30%, and 15% in patients with pathologic stage I disease with a tumor of 10 mm or less, 11 to 20 mm, 21 to 30 mm, and greater than 30 mm in diameter, respectively. The 5-year cancer-specific survivals of patients with pathologic stage I disease with tumors of 20 mm or less and 21 to 30 mm in diameter were 92.4% and 87.4% after lobectomy, 96.7% and 84.6% after segmentectomy, and 85.7% and 39.4% after wedge resection, respectively. On the other hand, with a tumor of greater than 30 mm in diameter, survivals were 81.3% after lobectomy, 62.9% after segmentectomy, and 0% after wedge resection, respectively.

CONCLUSIONS

Tumor size is an independent and significant prognostic factor and important for planning of surgical treatment. Although lobectomy should be chosen for patients with a tumor of greater than 30 mm in diameter, further investigation is required for tumors of 21 to 30 mm in diameter. Segmentectomy should, as a lesser anatomic resection, be distinguished from wedge resection and might be acceptable for patients with a tumor of 20 mm or less in diameter without nodal involvement.