Thoracoscopic pulmonary lobectomy

[Modern individualized diagnostics and treatment of non-small cell lung cancer]

Approximately one half of patients with non-small cell lung cancer (NSCLC) are diagnosed at resectable tumor stages (I-IIIA), which can potentially be curatively treated. In the early tumor stages (tumor diameter ≤2 cm) sublobar resection (segmentectomy or atypical wedge resection) leads to a 5‑year long-term survival comparable to lobectomy. The use of immunotherapy, especially within the framework of neoadjuvant treatment, is anticipated to change the surgical treatment of NSCLC in the future. With the introduction of lung cancer screening for certain risk groups in Germany planned for 2024, lung tumors can be expected to be diagnosed at earlier stages and more frequently curatively treated. This article provides an overview of the potential impact of lung cancer screening, modern minimally invasive surgical techniques and neoadjuvant treatment concepts for the surgical treatment of NSCLC.

Evaluation of the efficacy and safety of robot-assisted and video assisted thoracic surgery for early non-small cell lung cancer: A meta-analysis

BACKGROUND

Radical resection of lung cancer and chemotherapy are the main methods for the treatment of early lung cancer, but surgical treatment is still the key and preferred method.

OBJECTIVE

To evaluate the efficacy and safety of robotic-assisted thoracic surgery (RATS) and video assisted thoracic surgery (VATS) for non-small cell lung cancer (NSCLC).

METHODS

The clinical cohort studies on the comparison of the effects of RATS and VATS in the treatment of NSCLC published in Web of Science, PubMed, The National Library of Medicine (NLM), China National Knowledge Infrastructure (CNKI) and Wanfang database from January 1, 2015 to December 31, 2022 were searched. Two researchers independently screened the literature, extracted the data, such as operation time, intraoperative conversion rate, intraoperative blood loss, number of lymph nodes dissected, and evaluated the quality of the included literature based on the Newcastle-Ottawa Scale (NOS). RevMan 5.3 software was used for Meat analysis.

RESULTS

A total of 18 articles and 21,802 subjects were included. The results of the meta-analysis showed that the intraoperative blood loss of RATS was significantly less than that of VAS, and the difference was statistically significant [MD =-38.43 (95% CI: -57.71, -19.15, P< 0.001)]. Compared with VATS, the number of lymph nodes dissected in RATS was significantly higher [MD = 2.61 (95% CI: 0.47, 4.76, P= 0.02)]. The rate of conversion to thoracotomy in RATS was lower, and the difference was statistically significant [OR = 0.59 (95% CI: 0.50, 0.70, P< 0.001)]. There was no significant difference between RATS and VATS in operation time [MD =-9.34 (95% CI: -28.72, 10.04, P= 0.34)], postoperative thoracic drainage time [MD =-0.08 (95% CI: -0.42, 0.26, P= 0.64)], postoperative hospital stay [MD =-0.05 (95% CI: -0.19, 0.08, P= 0.42)], postoperative mortality [OR = 0.88 (95% CI: 0.56, 1.36, P= 0.56)] and postoperative complications [OR = 1.03 (95% CI: 0.93, 1.13, P= 0.57)].

CONCLUSION

Compared with VATS, the number of lymph nodes dissected in RATS was significantly more, and the removal of lesions and lymph nodes was more thorough and accurate. More flexible and precise operation avoids the injury of important blood vessels during operation, effectively reduces the amount of blood loss during operation, shortens the indwelling time of thoracic drainage tube, and is conducive to postoperative rehabilitation of patients.

Bibliometric analysis of 40 most cited articles comparing video-assisted thoracic surgery and robotic-assisted thoracic surgery in lung cancer (1997-2021)

Background

In recent years, conventional thoracoscopic surgery has been accepted as the traditional treatment method in the non-small cell lung cancer (NSCLC). VATS and RATS, which are the techniques of this surgical method, have been increasing their effectiveness and applicability of late years. The aim of this bibliometric analysis is to evaluate the importance and efficiency of articles comparing VATS and RATS techniques.

Materials and methods

Studies comparing VATS and RATS published between 1997 and 2021 were identified in the Web of Science database (accessed on 31. 12. 2021). The 40 most cited studies were analyzed in terms of publication years, country of study, authors, institutions that the authors were affiliated with, journal, journal address and impact factor.

Results

While an article was cited a maximum of 187 times when the citations made by the authors were excluded from the analysis, it was observed that all publications were cited a total of 1946 times. It was seen that an average of 51. 30 ± 47. 73 (8-187) articles were cited. In the 25-year, the highest number of publications was reached in 2019, while eight articles were published this year. The Annals of Thoracic Surgery (n = 13, 32. 5 %) was the journal in which the articles in the list were published the most. Most of the articles in our study (n = 31, 77.5 %) were published in US journals. While many studies presented more than one topic and analysis, the topic of most interest in 19 (47.5 %) studies was postoperative complications.

Conclusion

This bibliometric analysis reflects important and qualified articles comparing VATS and RATS technique in thoracic surgery, but it can also be used to explain or explain the performance and results of these techniques, their positive and negative aspects, and their superiority over each other.

Robot-assisted thoracic surgery versus video-assisted thoracic surgery for lung lobectomy or segmentectomy in patients with non-small cell lung cancer: a meta-analysis

Background

It remains no clear conclusion about which is better between robot-assisted thoracic surgery (RATS) and video-assisted thoracic surgery (VATS) for the treatment of patients with non-small cell lung cancer (NSCLC). Therefore, this meta-analysis aimed to compare the short-term and long-term efficacy between RATS and VATS for NSCLC.

Methods

Pubmed, Cochrane Library, Embase, China National Knowledge Infrastructure (CNKI), Medline, and Web of Science databases were comprehensively searched for studies published before December 2020. The quality of the articles was evaluated using the Newcastle-Ottawa Scale (NOS) and the data analyzed using the Review Manager 5.3 software. Fixed or random effect models were applied according to heterogeneity. Subgroup analysis and sensitivity analysis were conducted.

Results

A total of 18 studies including 11,247 patients were included in the meta-analyses, of which 5114 patients were in the RATS group and 6133 in the VATS group. Compared with VATS, RATS was associated with less blood loss (WMD = − 50.40, 95% CI -90.32 ~ − 10.48, P = 0.010), lower conversion rate (OR = 0.50, 95% CI 0.43 ~ 0.60, P < 0.001), more harvested lymph nodes (WMD = 1.72, 95% CI 0.63 ~ 2.81, P = 0.002) and stations (WMD = 0.51, 95% CI 0.15 ~ 0.86, P = 0.005), shorter duration of postoperative chest tube drainage (WMD = − 0.61, 95% CI -0.78 ~ − 0.44, P < 0.001) and hospital stay (WMD = − 1.12, 95% CI -1.58 ~ − 0.66, P < 0.001), lower overall complication rate (OR = 0.90, 95% CI 0.83 ~ 0.99, P = 0.020), lower recurrence rate (OR = 0.51, 95% CI 0.36 ~ 0.72, P < 0.001), and higher cost (WMD = 3909.87 USD, 95% CI 3706.90 ~ 4112.84, P < 0.001). There was no significant difference between RATS and VATS in operative time, mortality, overall survival (OS), and disease-free survival (DFS). Sensitivity analysis showed that no significant differences were found between the two techniques in conversion rate, number of harvested lymph nodes and stations, and overall complication.

Conclusions

The results revealed that RATS is a feasible and safe technique compared with VATS in terms of short-term and long-term outcomes. Moreover, more randomized controlled trials comparing the two techniques with rigorous study designs are still essential to evaluate the value of robotic surgery for NSCLC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08241-5.

Uptake and survival effects of minimally invasive surgery for lung cancer: A population-based study

INTRODUCTION

Despite growing evidence supporting the safety of minimally invasive surgery (MIS) in the treatment of lung cancer, its uptake is still variable and its outcomes debated. This study examines the factors associated with MIS uptake and its effects on survival in patients with non-small cell lung cancer (NSCLC).

METHODS

All patients in the Canadian province of Ontario with early stage NSCLC (stage I/II) from 2007 to 2017 were included. A logistic regression identified the predictors of MIS uptake, and a flexible parametric model was used to estimate survival rates based on MIS versus open resection.

RESULTS

In total, 8,988 patients underwent surgical resection; 53.6% had MIS. Year of diagnosis was associated with MIS uptake (OR = 1.33, p < 0.001); patients in later years were more likely to receive MIS. Rurality was a significant predictor of MIS, though distance from nearest regional cancer center did not predict MIS utilization. Patients with stage II disease were less likely to receive MIS compared to those with stage I disease (OR = 0.44, p < 0.001). MIS had a significantly higher 5-year survival compared to open resection for stage I and II disease. Patients >70 years had the greatest 5-year survival benefit from MIS.

CONCLUSIONS

We observed a substantial long-term survival benefit in patients undergoing MIS for early stage NSCLC. This difference was most pronounced in the oldest age group. These findings support the use of MIS in the treatment of lung cancer and challenge the notion that MIS compromises oncologic outcomes.

Early Adoption of Robotic Pulmonary Lobectomy: Feasibility and Initial Outcomes

Despite the published benefits of minimally invasive video-assisted thoracoscopic surgery (VATS) for lobectomy, the majority of lobectomies in the United States continue to be performed through a thoracotomy. The low adoption rate of VATS has been attributed to its technical challenges and ergonomic inefficiencies. Robotic surgery has been proposed as an alternative minimally invasive technique that allows the replication of open lobectomy with wristed instruments and three-dimensional vision. Our aim was to analyze the transition from open to robotic lobectomy at our hospital where there had been no significant VATS lobectomy experience. We analyzed 88 open and 43 robotic lobectomies that met criteria for inclusion. Operative times were significantly longer with the robotic group but decreased with experience. The resection time of the latter half of the robotic cases decreased to within 20 minutes of the open cases. There were no conversions in the robotic cases to either VATS or open. Robotic lobectomy was associated with faster postoperative recovery with a 60 per cent decrease in length of stay. Complications were uncommon and there were no deaths in the robotic group. We conclude that the transition from open to robotic lobectomy can be achieved safely with excellent postoperative outcomes. This new technique is a viable alternative to VATS lobectomy.

Efficacy and Safety of Robot-assisted Thoracic Surgery (RATS) Compare with Video-assisted Thoracoscopic Surgery (VATS) for Lung Lobectomy in Patients with Non-small Cell Lung Cancer

BACKGROUND

In the past decade, many researchers focused on Robotic- Assisted Thoracoscopic Surgery (RATS), which has been introduced as an alternative minimally invasive approach, versus Video- Assisted Thoracoscopic Surgery (VATS) for lung lobectomy in patients with non-small cell lung cancer. However, the advantage of RVATS compared to VATS is still under investigation. The results are unclear.

AIM

The aim of this study is to compare the efficacy and safety of Robot-assisted Thoracic Surgery (RATS) lobectomy versus Video-assisted Thoracic Surgery (VATS) for lobectomy in patients with Non- Small Cell Lung Cancer (NSCLC).

METHODS

A systematic electronic search of online electronic databases: Pubmed, Embase, Cochrane library updated in June 2017. The meta-analysis was performed including the studies are designed as randomized or non- randomized controlled.

RESULTS

Twenty retrospective cohort studies met our inclusion criteria. The pooled analysis of mortality showed that RATS lobectomy significantly reduced the mortality rate when compared with VATS lobectomy (RR =0.53, 95% CI 0.37 - 0.76; P = 0.0005). With the pooled result of duration of surgery indicated that RATS has a tendency towards longer surgery time (SMD= 0.52, 95% CI 0.23- 0.81; P < 0.0004=). However, the meta-analysis on the median length of hospital stay (MD =0.00, 95% CI -0.03 - 0.03; P = 0.91), number of dissected lymph nodes station (SMD =0.39, 95% CI -0.60 - 1.38; P = 0.44), the number of removed lymph nodes (SMD =0.98, 95% CI -0.61 - 2.56; P = 0.23), mean duration of drainage (SMD =0.29, 95% CI -0.15 - 0.73; P = 0.20), prolonged air leak (RR =1.01, 95% CI 0.84 - 1.21; P = 0.93), arrhythmia (RR =1.06, 95% CI 0.88 - 1.26; P = 0.54) (P= 0.54), pneumonia (RR =0.89, 95% CI 0.69 - 1.13; P = 0.33), the incidence of conversion (RR =0.82, 95% CI 0.54 - 1.26; P = 0.37) and morbidity (RR =1.05, 95% CI 0.90 - 1.23; P = 0.055) all showed no significant differences between RATS and VATS lobectomy.

CONCLUSIONS

RATS result in better mortality as compared with VATS. However, robotics seems to have longer operative time and higher hospital costs, without superior advantages in morbidity rates and oncologic efficiency. Since the advantages of RATS has been performed in some area, the continuation of a comparative investigation with VATS may be necessary. And some efforts need to be taken into consideration to reduce the operative time and cost.

Compare the prognosis of Da Vinci robot-assisted thoracic surgery (RATS) with video-assisted thoracic surgery (VATS) for non-small cell lung cancer: A Meta-analysis

To determine if there are advantages to transitioning to Da Vinci robotics by a surgeon compared to the video-assisted thoracic surgical lobectomy.A systematic electronic search of online electronic databases: PubMed, Embase, and Cochrane library updated on December 2017. Publications on comparison Da Vinci-robot-assisted thoracic surgery (RATS) and video-assisted thoracic surgery (VATS) for non-small cell lung cancer were collected. Meta-analysis RevMan 5.3 software (The Cochrane collaboration, Oxford, UK) was used to analyze the combined pooled HRs using fixed or random-effects models according to the heterogeneity.Fourteen retrospective cohort studies were included. No statistical difference was found between the 2 groups with respect to conversion to open, dissected lymph nodes number, hospitalization time after surgery, duration of surgery, drainage volume after surgery, prolonged air leak, and morbidity (P > .05).Da Vinci-RATS lobectomy is a feasible and safe technique and can achieve an equivalent surgical efficacy when compared with VATS. There does not seem to be a significant advantage for an established VATS lobectomy surgeon to transition to robotics based on clinical outcomes.

Feasibility and safety of reduced-port video-assisted thoracoscopic surgery using a needle scope for pulmonary lobectomy- retrospective study

Background

This study aimed to determine the usefulness and limitations of videoassisted thoracoscopic (VATS) lobectomy using one-window and puncture method (1WPM).

Methods

This study involved 14 patients who underwent lobectomy using the 1WPM at our institute from 2008 to 2017.

Results

The study patients comprised of 3 men and 11 women with a median age of 10.5 years (range, 0-72 years). There were eight cases in children younger than 18 years old and the youngest patient was 9 days old. The diagnoses were congenital pulmonary cystic disease (n = 7), primary lung cancer (n = 4), metastatic lung tumor (n = 1), and others (n = 2). The 1WPM was successful in 9 of 14 patients (64.3%) and, in 5 cases (35.7%), needed conversion to either two-window method (TWM) using additional port (n = 3) or open thoracotomy (n = 2). The causes for conversion were need for additional bronchoplasty or lymph node dissection (n = 3), failure of one-lung ventilation (n = 1), and presence of a small thoracic cavity that made the procedure extremely difficult (n = 1). In the group that was successfully treated with 1WPM, the median values were as follows: operation time, 193 min (range, 112-480 min); blood loss, 0 ml (range, 0-90 ml); drainage duration, 1 day (range, 1-4 days); and postoperative hospital stay, 7 days (range, 4-13 days).

Conclusions

Lobectomy by 1WPM can be safely performed and has good postoperative course and this procedure can be applicable and effective in small infants.

•

This study describes the novel VATS lobectomy method: the one-window and puncture method (1WPM).

•

1WPM is performed using 2–3 cm single incisions and a needle scope for intrathoracic access from other points.

•

This retrospective study involved 14 patients who underwent lobectomy using the 1WPM.

•

VATS lobectomy using 1WPM can be safely applied from adult cases to new born cases.

Postoperative pain after lobectomy: robot-assisted, video-assisted and open thoracic surgery

Surgical resection is the optimal procedure for early stage non-small cell lung cancer (NSCLC). Open thoracotomy, video-assisted thoracic surgery (VATS) and robot-assisted thoracic surgery (RATS) are different surgical modalities with possible different outcomes. The aim of this study was to analyze differences in outcome with a focus on postoperative pain. Patients undergoing lobectomy at the Maasstad Hospital in 2015 and 2016 were included. Postoperative pain was scored according to the Numerical Rating Scale (NRS). Additionally, duration of chest tube drainage and thoracic epidural analgesia (TEA), hospital length of stay and type of surgery were assessed. Lobectomy was performed in 57 patients. There was no significant difference in type of surgery, age, gender, right-sided surgery, postoperative NRS scores, duration of chest tube drainage and epidural anesthesia, and hospital length of stay (p > 0.05). Operative time for RATS was significantly longer (p = 0.002). Postoperative pain scores and other outcomes did not differ between the three different modalities in surgery for NSCLC. In the future, more minimally invasive surgery will be used in pulmonary surgery with thoracotomy as a safe alternative in selected cases. Future studies have to demonstrate if RATS will overcome the differences concerning cost-effectiveness over VATS.

[Video-assisted thoracic surgery : A global development]

More than 200 years ago the first attempts at thoracoscopy were made but only after its introduction 25 years ago has video-assisted thoracoscopic surgery (VATS) experienced rapid progress. Due to worldwide cooperation and international networking tremendous progress of the technique was made by thoracic surgeons on all continents developing the technique into a less invasive operating procedure on the thorax. For patients this meant improvement in the quality of life and ultimately better survival rates following lung cancer surgery. The VATS procedures are nowadays the preferred method unless the size and extent of the tumor prohibits a minimally invasive procedure. New trends in VATS are ambulatory, drainless or uniportal VATS, the latter being possible because insufflation of carbon dioxide is not necessary, allowing manipulation with multiple instruments through one small incision. The other trend is robotic-assisted thoracic surgery. The benefits of the robotics are higher degrees of freedom for movement of the instruments. The development of VATS is nowadays a global one with North America and Asian countries being the most active protagonists, but European countries also play an important role in shaping the future of minimally invasive surgery. Modern media help to further promote the technique.

Lung Cancer Screening and Its Impact on Surgical Volume

Lung cancer screening has demonstrated a reduction in lung cancer mortality by 20%. Annual low-dose computed tomography examination in high-risk individuals is now recommended by multiple national health care organizations and is covered under Medicare and Medicaid services. The impact of this public health intervention is projected to increase the case load for the thoracic surgery workforce.

Robotic versus thoracoscopic lung resection: A systematic review and meta-analysis

BACKGROUND

Robotic video-assisted surgery (RVATS) has been reported to be equally effective to video-assisted surgery (VATS) in lung resection (pneumonectomy, lobectomy, and segmentectomy). Operation time, mortality, drainage duration, and length of hospitalization of patients undergoing either RVATS or VATS are compared in this meta-analysis.

METHODS

A systematic research for articles meeting our inclusion criteria was performed using the PubMed database. Articles published from January 2011 to January 2016 were included. We used results of reported mortality, operation time, drainage duration, and hospitalization length for performing this meta-analysis. Mean difference and logarithmic odds ratio were used as summary statistics.

RESULTS

Ten studies eligible were included into this analysis (5 studies for operation time, 3 studies for chest in tube days, 4 studies for length of hospitalization, and 6 studies for mortality). We were able to include 3375 subjects for RVATS and 58,683 subjects for VATS. Patients were mainly treated for lung cancer, metastatic foci, and benign lesions. We could not detect any difference between operation time; however, we found 2 trends showing that drainage duration and length of hospitalization are shorter for following RVATS than for following VATS. Mortality also is lower in patients undergoing RVATS.

CONCLUSIONS

Therefore, we conclude that RVATS is a suitable minimal-invasive procedure for lung resection and suitable alternative to VATS. RVATS is as time-efficient as VATS and shows a trend to reduced hospital stay and drainage duration. More and better studies are required to provide reliable, unbiased evidence regarding the relative benefits of both methods.

Microlobectomy: A Novel Form of Endoscopic Lobectomy

Objective

Microlobectomy is a novel form of videoscopic-assisted thoracic surgery lobectomy. Strict inclusion criteria consist of the following: no intercostal incisions greater than 5 mm, 12 mm subxiphoid port, subxiphoid removal of the specimen, total endoscopic technique with CO2 insufflation, vision through a 5-mm camera, stapling via the subxiphoid port, or with 5-mm stapling devices.

Methods

The combined early experiences of six hospitals from three countries were combined from September 2014 to May 2016. During that time, the study represents a consecutive cohort study of this technique.

Results

Seventy-two patients underwent microlobectomy. The median (range) age was 66 (27–82). Half of the patients were female. There were 48 right-sided resections and 24 on the left. There were four segmental resections and there was one right pneumonectomy. Four operations were performed robotically (with 8-mm intercostal incisions). The median (range) operative time was 180 (94–285) minutes and the blood loss was 118 (5–800) mL. There were three conversions to thoracotomy and two conversions to videoscopic-assisted thoracic surgery by means of an intercostal utility incision to complete the operation. The median (range)length of stay was 3(1–44) days and 30 patients (42%) when home by day 2 and 16 patients (22%) were discharged on day 1. There were no deaths. Five patients (7%) had a prolonged airleak. There were no wound infections and there was one incisional hernia.

Conclusions

We believe that microlobectomy is an interesting novel form of videoscopic-assisted thoracic surgery lobectomy and has several theoretical advantages. We have presented our early results and hope that this will stimulate others to investigate this type of videoscopic-assisted thoracic surgery lobectomy further.

Feasibility and safety of robot-assisted thoracic surgery for lung lobectomy in patients with non-small cell lung cancer: a systematic review and meta-analysis

Background

The aim of this study is to evaluate the feasibility and safety of robot-assisted thoracic surgery (RATS) lobectomy versus video-assisted thoracic surgery (VATS) for lobectomy in patients with non-small cell lung cancer (NSCLC).

Methods

An electronic search of six electronic databases was performed to identify relevant comparative studies. Meta-analysis was performed by pooling the results of reported incidence of overall morbidity, mortality, prolonged air leak, arrhythmia, and pneumonia between RATS and VATS lobectomy. Subgroup analysis was also conducted based on matched and unmatched cohort studies, if possible. Relative risks (RR) with their 95% confidence intervals (CI) were calculated by means of Revman version 5.3.

Results

Twelve retrospective cohort studies were included, with a total of 60,959 patients. RATS lobectomy significantly reduced the mortality rate when compared with VATS lobectomy (RR = 0.54, 95% CI 0.38–0.77; P = 0.0006), but this was not consistent with the pooled result of six matched studies (RR = 0.12, 95% CI 0.01–1.07; P = 0.06). There was no significant difference in morbidity between the two approaches (RR = 0.97, 95% CI 0.85–1.12; P = 0.70).

Conclusions

RATS lobectomy is a feasible and safe technique and can achieve an equivalent short-term surgical efficacy when compared with VATS, but its cost effectiveness also should be taken into consideration.

Is VATS lobectomy standard of care for operable non-small cell lung cancer?

Video-Assisted Thoracic Surgery (VATS) for treatment of lung cancer is being increasingly applied worldwide in the last few years. Since its introduction, many publications have been providing strong evidences that this minimally invasive approach is feasible, safe and oncologically efficient; offering to patients several advantages over traditional open thoracotomy, particularly for early-stage disease (I and II). The application of VATS for locally advanced disease treatment has also been largely described, but probably requires a further level of experience, which is more likely to be found in reference centers, with skilled experts. Although a large multi-institutional prospective randomized-controlled trial is the best way to confirm the superiority of one technique over another, such study comparing VATS versus open lobectomy for lung cancer is unlikely to ever come out. And in this scenario, retrospective data remains as the most reliable source of scientific information. Based on a literature review, the main objective of this article is to discuss to what extent VATS lobectomy can be considered the gold standard in the surgical treatment of lung cancer, taking into account the most important comparison aspects between the minimally invasive approach and open thoracotomy technique. This review addresses questions regarding lymph node dissection, oncologic efficacy, extended resections beyond standard lobectomy, post-operative complications/pain/quality of life, survival rates and the present limits of indication (and contraindication) for VATS, in order to define the real role of this technique on the surgical treatment of lung cancer in a minimally invasive, but safe and effective manner.

[Video-assisted thoracoscopic anatomic lung resection: experience of 246 operations]

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.

Robotic video-assisted thoracoscopic lung resection for lung tumors: a community tertiary care center experience over four years

INTRODUCTION/BACKGROUND

After its initial description in 1990, video-assisted thoracoscopic surgery (VATS) has emerged as the minimally invasive approach for lung resection in early lung cancer.

METHODS

A retrospective review of prospectively collected data on patients who underwent robotic pulmonary resection for cancer by a single surgeon, between years 2009 and 2013, was performed. Age, gender, type and duration of surgery, length of stay, estimated blood loss, early and late complications, follow-up time, and local recurrence were reviewed and analyzed descriptively.

RESULTS

Three hundred and thirty-one patients underwent the procedure for pulmonary neoplasm. Two hundred and fifty-nine (79%) patients underwent anatomic lobectomies, 56 (17%) patients had wedge resection, while five (1.5%) patients underwent pneumonectomy. In 11 patients, no pulmonary resection was performed for different reasons. Most common neoplasm was adenocarcinoma (185, 56%). All procedures involved a systematic mediastinal and hilar lymph node exploration and removal of suspicious nodes. Twenty-six (6.9%) procedures were converted to open thoracotomy. Mean duration of surgery was 185.63 min. Mean length of hospital stay was 5.52 days. Mean estimated blood loss (EBL) was 47.85 ml. Mean follow-up was 249.41 days (20-1550 days), and five (1.5%) patients developed local recurrence. Early complications were seen in 29 patients (8.8%), most commonly cardiac arrhythmias (20, 6%).

CONCLUSION

Robotic video-assisted thoracoscopic surgery is feasible in lung lesions, with all the advantages of VATS in terms of decreased length of stay and decreased blood loss with local recurrence rate and complication rate comparable to open procedures. There is a clear need for more studies comparing the apparent advantages of robotic-assisted surgery with increased cost of technology.

Is surgical morbidity decreased with minimally invasive lobectomy?

Non-small cell lung cancer remains one of the leading causes of cancer-related mortality worldwide. Despite recent advances in molecular characterization and targeted and adjuvant therapies, surgical resection remains the mainstay of curative treatment. Minimally invasive video-assisted thoracic surgery techniques, in particular video-assisted thoracic surgery lobectomy, are being increasingly utilized and championed over traditional thoracotomy approaches in the treatment of localized non-small cell lung cancer for the reported benefits of lower operative morbidity, accelerated postoperative recovery, and oncological equivalence. This article reviews the available literature comparing surgical outcomes of minimally invasive versus traditional open lobectomy with an emphasis on differences in surgical morbidity.

Systematic review and meta-analysis of randomized and nonrandomized trials on safety and efficacy of video-assisted thoracic surgery lobectomy for early-stage non-small-cell lung cancer

PURPOSE

The current randomized trials comparing video-assisted thoracic surgery (VATS) lobectomy with open lobectomy for patients with early-stage non-small-cell lung cancer (NSCLC) have been of small size. We performed the present meta-analysis of the randomized and nonrandomized comparative studies in an attempt to assess the safety and efficacy of VATS lobectomy.

METHODS

Electronic searches identified 21 eligible comparative studies (two randomized and 19 nonrandomized) for inclusion. Two reviewers independently appraised each study. Meta-analysis was performed by combining the results of reported incidence of morbidity and mortality, recurrence, and 5-year mortality rates. The relative risk (RR) was used as a summary statistic.

RESULTS

There were no significant statistical differences between VATS and open lobectomy in terms of postoperative prolonged air leak (P = .71), arrhythmia (P = .86), pneumonia (P = .09), and mortality (P = .49). VATS did not demonstrate any significant difference in locoregional recurrence (P = .24), as compared with the open lobectomy arm, but the data suggested a reduced systemic recurrence rate (P = .03) and an improved 5-year mortality rate of VATS (P = .04). There was no evidence to suggest heterogeneity of trial results. Fourteen studies reported VATS to open lobectomy conversion rate ranging from 0% to 15.7% (median = 8.1%).

CONCLUSION

Both randomized and nonrandomized trials suggest that VATS lobectomy is an appropriate procedure for selected patients with early-stage NSCLC when compared with open surgery.

Video-assisted thoracic surgery (VATS) for resection of metastatic adenocarcinoma as an acceptable alternative

BACKGROUND

Adenocarcinomas commonly metastasize to the lungs and can be resected using open thoracotomy or video-assisted thoracic surgery (VATS). This study reviews metastatic resections in primary adenocarcinoma patients, using both thoracotomy and VATS. We aim to compare long-term prognoses to test the efficacy and viability of VATS.

METHODS

A retrospective review of primary adenocarcinoma patients who underwent resection of pulmonary metastases from 1990 to 2006 was carried out. Information was obtained by chart review. Endpoints analyzed were disease-free interval (DFI), survival time, and recurrence-free survival (RFS).

RESULTS

In a total of 42 (16 male, 26 female; median age 58.5 years) primary adenocarcinoma patients, 21 patients underwent first pulmonary metastatic resection using VATS (7 male, 14 female; median age 57 years) and 21 using thoracotomy (9 male, 12 female; median age 59 years). Primary adenocarcinomas were mainly 27 colorectal (64%) and 11 breast (26%). Two VATS (10%) and three open patients (14%) had local recurrences of the original cancer. Median postoperative follow was 13.3 months [interquartile range (IQR) 4.5-32.8 months] for VATS and 36.9 months (IQR 19.3-48.6 months) after thoracotomy. Median DFI-1 was 22.3 months (IQR 13.5-40.6 months) for VATS patients and 35.6 months (IQR 26.7-61.3 months) for open patients. Second thoracic occurrences were noted in six VATS patients (median DFI-2 9.2 months), and in seven open patients (median DFI-2 21.5 months). Third thoracic occurrences were noted in one VATS patient (DFI-3 18.7 months) and in one thoracotomy patient (DFI-3 21.8 months). Odds ratio of recurrence showed 12.5% less chance of developing recurrence in VATS patients. Five-year RFS was 53% in VATS and 57% in thoracotomy patients.

CONCLUSIONS

VATS has become a viable alternative to open thoracotomy for resection of pulmonary metastases. In cases of primary adenocarcinoma, VATS showed no increase in number of thoracic recurrences, and comparable RFS. Short-term follow-up is encouraging; long-term follow-up will be needed to confirm these results.

VATS lobectomy is better than open thoracotomy: what is the evidence for short-term outcomes?

VATS lobectomy is an acceptable alternative to open lobectomy for treating early-stage NSCLC. Although no large randomized control trial has compared these procedures, recent large series and case-control studies provide strong evidence that patients undergoing VATS lobectomy have less pain, fewer perioperative complications, shorter chest-tube duration, and decreased length of stay. Increasing evidence supports improved quality of life up to 1 year, less inflammation, and greater safety profile in high-risk patients. More data are needed to better show an improvement in the economic efficacy, ability to more effectively administer adjuvant therapies, and benefit of robotic assistance in VATS lobectomy.

Robot-assisted endoscopic airway reconstruction in rabbits, with the aim to perform robot-assisted thoracoscopic bronchoplasty in human subjects

OBJECTIVE

Robotic telemanipulation systems have been introduced recently to enhance the surgeon's dexterity and visualization in endoscopic surgery and thus facilitate refined dissection, suturing, and knot tying. This study examined the technical feasibility of performing safe and efficient robot-assisted, hand-sewn endoscopic airway reconstruction in a rabbit model.

METHODS

A total of 18 tracheal anastomoses were performed in rabbits, with 6 anastomoses performed endoscopically using the da Vinci Surgical system (Robot group), 6 anastomoses performed using traditional thoracoscopic surgical instruments (VATS group), and 6 anastomoses performed using open surgical instruments (Open group). Anastomosis time and complications were recorded. The effectiveness of anastomoses was evaluated by postoperative observation of all rabbits for 8 weeks and measurement of anastomotic stricture and pathologic findings. These parameters and anastomosis time were compared between groups.

RESULTS

In all cases in the Robot group, the procedure was completed endoscopically. No perioperative or postoperative complications were encountered. Mean procedure time of the Robot group was 14.1 +/- 2.6 minutes (mean +/- standard deviation). Anastomosis time in the Robot group was significantly shorter than in the VATS group (33.5 +/- 5.2 minutes, P = .0039) and was not significantly different in the Open group (11.4 +/- 2.3 minutes, P = .1282). All anastomoses in the Robot group remained mechanically intact, and all parameters were comparable with those of the open surgery group.

CONCLUSIONS

The technical feasibility of performing safe and efficient robot-assisted endoscopic airway reconstruction was repeatedly demonstrated in a rabbit model. Robotic assistance significantly improved the time associated with and the quality of endoscopic airway reconstruction.

Video-assisted thoracic surgery does not reduce the incidence of postoperative atrial fibrillation after pulmonary lobectomy

OBJECTIVE

The objective was to define the incidence of atrial fibrillation after video-assisted thoracic surgery lobectomy and determine whether video-assisted thoracic surgery reduces atrial fibrillation rate compared with thoracotomy.

METHODS

With the use of a single-institution database of patients who underwent lobectomy for clinical stage I non-small cell lung cancer, 389 patients were identified who were in sinus rhythm preoperatively and received no prophylactic antiarrhythmics. Patients undergoing video-assisted thoracic surgery were age and gender matched with those undergoing thoracotomy.

RESULTS

After matching, 122 patients undergoing video-assisted thoracic surgery and 122 patients undergoing thoracotomy were eligible for analysis. Patients undergoing video-assisted thoracic surgery had a higher preoperative diffusion capacity (92% +/- 28% vs 80% +/- 18% predicted, P = .001) and a lower rate of induction chemotherapy (5/122, 4% vs 11/122, 11%, P = .05) than patients undergoing thoracotomy. Atrial fibrillation occurred in 12% of patients (15/122) undergoing video-assisted thoracic surgery and 16% of patients (20/122) undergoing thoracotomy (P = .36). Overall, complications were lower in the video-assisted thoracic surgery group (17.2% vs 27.9%, P = .046). Patients with atrial fibrillation were older in both video-assisted thoracic surgery (73 +/- 7 years vs 66 +/- 9 years, P = .002) and thoracotomy groups (72 +/- 7 years vs 66 +/- 10 years, P = .005). Length of stay for patients with atrial fibrillation was greater in both video-assisted thoracic surgery (6.0 +/- 1.5 days vs 4.7 +/- 2.5 days, P = .01) and thoracotomy groups (9.2 +/- 4.3 days vs 6.8 +/- 3.6 days, P = .03).

CONCLUSIONS

Regardless of surgical approach, atrial fibrillation after lobectomy occurred with equal frequency. This supports the theory that autonomic denervation and stress-mediated neurohumoral mechanisms are responsible for the pathogenesis of postoperative atrial fibrillation. Prophylaxis regimens against atrial fibrillation should be the same for either operative approach.

Robotic assistance for video-assisted thoracic surgical lobectomy: technique and initial results

OBJECTIVES

There is little experience with telerobotic assistance for video-assisted thoracic surgical lobectomy. We developed a technique for robotic assistance during video-assisted thoracic surgical lobectomy and report our initial results.

METHODS

Video-assisted thoracic surgical lobectomy with the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, Calif) was attempted in 34 patients (median age, 69.0 years; age range, 12-85 years). Robotic instruments were used for individual dissection of the hilar structures through 2 thoracoscopic ports and a 4-cm utility incision without rib spreading. Data on patient characteristics and perioperative results were collected prospectively.

RESULTS

Robot-assisted video-assisted thoracic surgical lobectomy was accomplished in 30 patients (19 female and 11 male patients). Every type of lobectomy was performed. Four (4/34 [12%]) patients required conversion to thoracotomy. The majority of patients had non-small cell lung cancer (32/34 [94%]), and 1 patient each had a typical carcinoid tumor and an extranodal B-cell lymphoma. Every patient underwent an R0 resection. The median number of lymph node stations dissected with robotic assistance was 4 (range, 2-7). Operative mortality was 0%, with no in-hospital or perioperative deaths. Nine (26%) patients experienced National Cancer Institute Common Toxicity Criteria for Adverse Events version 3.0 grade 2 or 3 complications. The median chest tube duration was 3.0 days (range, 2-12 days), and the median length of stay was 4.5 days (range, 2-14 days). The median operative time was 218 minutes (range, 155-350 minutes).

CONCLUSIONS

Robot assistance for video-assisted thoracic surgical lobectomy is feasible and safe. The utility and advantages of robotic assistance for video-assisted thoracic surgical lobectomy require further refinement and study of the technique.

Video-assisted thoracic surgery (VATS) resection for lung cancer

VATS is a relatively new technology that has become the standard of care for basic procedures such as drainage of pleural effusion and blebectomy. VATS anatomic lung resection is more controversial. Published studies demonstrate several advantages of VATS over a standard posterolateral thoracotomy. A minimally invasive approach causes less inflammatory reaction. Acute and chronic pain are diminished. As a result, the length of hospitalization is shorter. Early and late shoulder dysfunction is less and return to work time is shorter. Taken together, these factors suggest a better overall outcome using a VATS approach. From an oncologic standpoint, lymph node dissection can be accomplished and locoregional recurrence is low. The validity of VATS for lung cancer will be determined by long-term data. A phase III national (intergroup) protocol is being drafted and will help to answer these questions.

Full thoracoscopic approach for surgical management of invasive pulmonary aspergillosis

BACKGROUND

Invasive pulmonary aspergillosis (IPA) is a frequent and serious infection occurring in patients with hematologic malignancies and allogenic stem cell transplant (SCT) recipients, causing a high mortality rate. We report the use of full thoracoscopic management in 19 patients.

METHODS

Nineteen patients (mean age 27 years) with diagnosed or probable IPA were operated on. Seventeen had an hematologic malignancy and 2 had a refractory aplastic anemia. Nine patients had undergone an allogenic SCT that was complicated by a graft-versus-host disease in 5 patients. In 3 patients, SCT was pending. All patients had preoperative systemic antifungal therapy for at least 2 weeks. Fifteen patients had only one lesion, whereas 4 had two lesions. Eight patients had an absolute neutrophil count less than 3,000 and 2 less than 1,000, and 9 were thrombopenic (platelet count <60,000) at the day of surgery. Wedge resections were performed in 7 patients and lobectomies were performed for the other 12. For the latter, an open approach via posterolateral thoracotomy was decided upon in only 1 patient. For the other 11 lobectomies, a mini-thoracotomy was needed in 3 cases for intraoperative difficulties. Conversion to conventional thoracotomy was necessary for 2 of these patients. In total, out of the 19 patients, 15 had a total endoscopic approach, 3 had a thoracotomy, and 1 had a video-assisted approach.

RESULTS

There was no intraoperative mortality. In the group of wedge resections, no intraoperative or postoperative complication occurred. In the lobectomy group, three hemorrhages occurred during dissection of the pulmonary artery in the fissure, leading to conversion to a mini-thoracotomy in 2 patients and to a classic posterolateral thoracotomy in 1 patient. There were two minor complications: one pneumothorax and one mild pleural effusion.

CONCLUSIONS

In these debilitated and immunocompromised patients, a full thoracoscopic resection of fungal infection is feasible, even for lobectomies. It allows a simpler postoperative course and minimizes sequelae.

Thoracoscopic lobectomy for benign disease--a single centre study on 64 cases

OBJECTIVE

Chronic lung infection is the main indication for lobectomy in benign pulmonary disease and may be technically demanding due to inflammatory changes such as adhesions, lymph node enlargement and neovascularization. The role of the thoracoscopic operation in these indications is yet ill-defined.

METHODS

We retrospectively analyzed the results of patients who underwent thoracoscopic lobectomy (TL) between 1992 and June 1999 and compared this study group with patients who underwent open lobectomy (OL), all for benign disease. Data were not normally distributed, therefore, the median and range is given and nonparametric statistical analysis was applied.

RESULTS

A total of 117 lobectomies for benign disease (64 TL) were analyzed. Indications included bronchiectasis (36 TL; 18 OL), chronic infections (13 TL; eight OL), tuberculosis (five TL; 15 OL), emphysema (five TL; one OL), AV-malformations (two TL; one OL), severe haemoptysis (four OL), and others (three TL; six OL). Twelve conversions to thoracotomy were necessary due to severe adhesions. One patient in the open lobectomy group died within 30 days postoperative. Drainage time was 5.0 (1-32) days in TL and 6.0 (3-21) days in OL, hospital stay was 8.5 (4-41) days and 10.0 (5-52) days, respectively. Blood loss was 0 (0-2000) ml in TL and 300 (0-6000) ml in OL. Operation time for thoracoscopic lobectomies significantly decreased from 2.5 (1-6) h for cases between 1992 and 1997 (n=49) to 1.5 (0.5-2.5) h for recent cases (n=15) (P<0.01). In addition, a trend towards less blood loss was noted (100 (0-2000) ml vs. 0 (0-400) ml; P=0.06). Drainage time and hospital stay did not differ significantly.

CONCLUSIONS

Thoracoscopic lobectomy in chronic inflammatory disease can be performed safely in selected patients, especially with bronchiectasis. Conversion rate to thoracotomy is low. Operation time with this approach declined significantly over time.

Lymphocyte responses following open and minimally invasive thoracic surgery

BACKGROUND

Immunosuppression associated with surgery may predispose to increased tumour growth or recurrence. Lymphocytes are central components of the immune network, signalling specific and non-specific responses in tumour immunosurveillance. This study was therefore designed to compare the effects of minimally invasive and conventional approaches to major thoracic surgery on lymphocyte populations and oxidative activity.

PATIENTS AND METHODS

The effects of conventional and minimally invasive video-assisted thoracic surgery (VATS) on the numbers and types of circulating lymphocytes and on lymphocyte oxidation were compared in a prospective randomized study of 41 patients undergoing lobectomy for peripheral bronchogenic carcinoma. Blood taken pre-operatively and on days 2 and 7 post-operatively was analysed for T (CD4, CD8), B (CD19) and natural killer (NK) (CD56, CD16) cell counts and for lymphocyte oxidative activity. Leucocyte numbers were compared with pre-surgical values and oxidative rate with healthy donor controls.

RESULTS

Lymphocyte counts fell after surgery; VATS was associated with less effect on circulating T (CD4) cells at 2 days and on NK lymphocytes at 7 days post-surgery. Lymphocyte oxidation was less suppressed in the VATS group 2 days after surgery. In general, post-surgical changes in key cells of cellular immunity were smaller in the VATS group, and recovery to normal levels was more rapid.

CONCLUSION

The degree of invasiveness of thoracic surgery may influence the extent of immunosuppression in patients undergoing pulmonary lobectomy for pulmonary neoplasm.