Is complete systematic nodal dissection by thoracoscopic surgery possible? A prospective trial of video-assisted lobectomy for cancer of the right lung

Anatomic pulmonary resection via video-assisted thoracic surgery: analysis of 117 cases at a referral center in Brazil

Objective:

To describe our experience with video-assisted thoracic surgery (VATS) for anatomic pulmonary resection at a referral center for thoracic surgery in Brazil.

Methods:

All patients who underwent anatomic pulmonary resection by VATS between 2010 and 2015 were included. Clinical and pathological data, as well as postoperative complications, were analyzed.

Results:

A total of 117 pulmonary resections by VATS were performed, of which 98 were lobectomies and 19 were anatomic segmentectomies. The mean age of the patients was 63.6 years (range, 15-86 years). Females predominated (n = 69; 59%). The mean time to chest tube removal was 2.47 days, and the mean length of ICU stay was 1.88 days. The mean length of hospital stay was 4.48 days. Bleeding ≥ 400 mL occurred in 15 patients. Conversion to thoracotomy was required in 4 patients.

Conclusions:

Our results are similar to those published in major international studies, indicating that VATS is an important strategy for pulmonary resection. They also show that VATS can be safely performed with adequate training. This technique should be used more often for the treatment of lung diseases in Brazil.

Thoracoscopic lobectomy versus open lobectomy in stage I non-small cell lung cancer: a meta-analysis

The objective of the present meta-analysis was to evaluate the survival, recurrence rate, and complications in patients with stage I non-small cell lung cancer (NSCLC) who received video-assisted thoracoscopic surgery (VATS) or open lobectomy. A literature search was conducted on June 31, 2012 using combinations of the search terms video-assisted thoracic surgery, open thoracotomy, lobectomy, and non-small-cell lung cancer (NSCLC). Inclusion criteria were: 1) Compared video-assisted thoracic surgery (VATS) lobectomy with open lobectomy. 2) Stage I NSCLC. 2) No previous treatment for lung cancer. 4) Outcome data included 5-year survival rate, complication, and recurrence rate. Tests of heterogeneity, sensitivity, and publication bias were performed. A total of 23 studies (21 retrospective and 2 prospective) met the inclusion criteria. VATS was associated with a longer 5-year survival (odds ratio [OR] = 1.622, 95% confidence interval [CI] 1.272 to 2.069; P<0.001), higher local recurrence rate (OR = 2.152, 95% CI 1.349 to 3.434; P = 0.001), similar distant recurrence rate (OR = 0.91, 95% CI 0.33 to 2.48; P = 0.8560), and lower total complication rate (OR = 0.45, 95% CI 0.24 to 0.84; P = 0.013) compared to open lobectomy. VATS was also associated with lower rates arrhythmias, prolonged air leakage, and pneumonia but it did not show any statistical significance. Patients with stage I NSCLC undergoing VATS lobectomy had longer survival and fewer complications than those who received open lobectomy.

Current costs of video-assisted thoracic surgery (VATS) lobectomy

Video-assisted thoracoscopic lobectomy has many benefits over open surgery such as smaller incisions, less pain, less blood loss, faster postoperative recovery, shortened hospital stay, similar or superior survival rates. In contrast video-assisted thoracic surgery (VATS) has higher equipment costs, increased operating room times, at least initially, and a learning curve for the team. However when an experienced surgeon performs the surgery, significant hospital savings combined with better outcomes are achieved by video-assisted thoracoscopic lobectomy.

Minimally invasive pulmonary surgery for lung cancer, up to date

Recently, the minimally invasive surgical approach is an important issue in the pulmonary surgery. In this review, we present the current fashion of video-assisted thoracic surgery (VATS) and new approach including robotic lobectomy. There is no clear definition or standard for this surgical procedure regarding VATS lobectomy. Therefore, no randomized controlled trial of VATS and conventional lobectomy can be set up. Although the definition of VATS lobectomy is not straightforward, VATS lobectomy showed the technical feasibility of conventional lobectomy in mortality and postoperative complication as well as lymph node dissection. VATS procedure for advanced lung cancer is unclear whether such observations can be developed into a standardized approach. There are no reports to evaluate the advantages of robotic lobectomy in terms of treatment outcomes for lung cancer compared with VATS lobectomy. However, we believe that robotic lobectomy has clear potential to improve the quality of minimally invasive surgery.

Video-assisted thoracoscopic lobectomy: an unavoidable trend? A retrospective single-institution series of 410 cases

OBJECTIVES

Evaluation of the feasibility, safety and oncological validity of video-assisted thoracic lobectomy (VATS). The VATS study exclusion criteria included T3 or T4 tumours, central hilar tumours, tumours visible on bronchoscopy requiring sleeve resection, hilar lymphadenopathy, N2 disease, history of neoadjuvant chemotherapy or radiation, previous thoracic surgery or pleurodesis.

METHODS

A retrospective study of 410 patients (143 women, mean age 61.5 ± 13.1 years (84-15) treated by VATS lobectomy between 1996 and 2011 was performed at our institution. VATS lobectomy was performed for lung cancer (n = 364, 88.9%), pulmonary metastasis (n = 25, 5.8%) and non-neoplastic diseases (n = 21, 5.1%). In lung cancer, a systematic radical lymph node dissection was performed.

RESULTS

There was no intraoperative death. The conversion rate was 6.1% (n = 25): bleeding (n = 4), extended pleural adhesion (n = 6, 1.4%), technical difficulty (n = 6, 1.4%), tumour extension to the fissure or mediastinum or adenopathy (n = 7, 1.7%) and intolerance to one-lung ventilation (n = 2, 0.4%). The postoperative mortality rate was 1.2% (n = 5). Major complications occurred in 21 patients (5.1%). The mean number of mediastinal nodes removed was 14.6 (5-44) and 42 patients (10.2%) presented N2 disease at the definitive staging. The mean operating time was 152 (85-315) min. The mean drainage duration was 3.2 days (1-15). Mean postoperative length of hospital stay before return at home was 6.8 days (3-75) and 5.5 days in patients without major complications. There was no port site recurrence. Kaplan-Meier 3-year survival rates were 76.5% for Stage I and 87.3% for Stage IA, 58% for Stage II and 61% for Stage III.

CONCLUSIONS

VATS lobectomy is an acceptable alternative and seems equivalent to open lobectomy in terms of complications and oncological value. Our experience prompts us to consider VATS lobectomy for early stage NSCLC as the first surgical approach in view of the improvement in outcome, provided that the procedure is performed by a surgeon with adequate experience with this approach.

Mediastinal lymph nodes: ignore? sample? dissect? The role of mediastinal node dissection in the surgical management of primary lung cancer

The role of mediastinal lymph node dissection (MLND) during the resection of non-small-cell lung cancer is still unclear although most surgeons agree that a minimum of hilar and mediastinal nodes must be examined for appropriate pathological staging. Current surgical practices vary from visual inspection of the mediastinum with biopsy of only abnormal looking nodes to systematic mediastinal node sampling which is to the biopsy of lymph nodes from multiple levels whether they appear abnormal or not to MLND which involves the systematic removal of all lymph node bearing tissue from multiple sites unilaterally or bilaterally within the mediastinum. This review article looks at the evidence and arguments in favour of lymphadenectomy, including improved pathological staging, better locoregional control, and ultimately longer disease-free survival and those against which are longer operating time, increased operative morbidity, and lack of evidence for survival benefit.

Video-assisted thoracic surgery for lung cancer

Video-assisted thoracic surgery (VATS) lobectomy is currently accepted as an appropriate procedure for selected patients with early-stage non-small-cell lung cancer (NSCLC). Evidence has demonstrated that VATS lobectomy is not only a safe and feasible technique, it provides better functional recovery and oncological efficacy similar to that achieved with conventional thoracotomy. However, there are still ongoing issues concerning VATS in terms of terminology, oncological efficacy, functional recovery, benefit of screening detected lung cancer, and its role in limited resection. As the number of VATS procedures are increasing and VATS is becoming a dominant procedural choice, it would be wise to collect evidence and come to a consensus to justify the expansion of surgical indications for VATS.

Complete versus assisted thoracoscopic approach: a prospective randomized trial comparing a variety of video-assisted thoracoscopic lobectomy techniques

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) lobectomy does not represent a unified approach, but rather a spectrum of operative techniques ranging from a complete endoscopic thoracotomy to a minithoracotomy. A prospective randomized trial was conducted to compare the differences in these techniques and their results to determine the best of VATS lobectomy for lung cancer.

METHODS

This study randomized 39 consecutive patients with clinical stage I lung cancer to undergo either a complete (C-VATS, n = 20) or an assisted (A-VATS, n = 19) VATS approach for pulmonary lobectomy.

RESULTS

The operating time was longer (p = 0.002) and blood loss was less (p = 0.004) with C-VATS than with A-VATS. Although there was no significant difference in analgesic use or duration of thoracic drainage between the groups, a shorter hospitalization was observed after C-VATS. Serum peak levels of postoperative inflammatory markers (white blood cell count, C-reactive protein, creatine phosphokinase) were lower with C-VATS and an earlier return to normalization than with A-VATS.

CONCLUSION

Various differences exist among the VATS lobectomy techniques, and complete VATS lobectomy as a purely endoscopic surgery may be technically feasible and a satisfactory alternative to the conventional procedure for stage I lung cancer.

[Video-assisted lobectomy through the auscultatory triangle for the surgical treatment of bronchopulmonary carcinoma. Preliminary experience]

OBJECTIVE

To describe a technique for video-assisted lobectomy through the auscultatory triangle (VALAT) and to assess early and medium-term outcome of the procedure in patients with non-small cell bronchopulmonary carcinoma in stage I.

PATIENTS AND METHOD

Between April 1999 and May 2002 we performed 25 VALAT procedures (24 lobectomies and 1 bilobectomy) in 25 patients with a mean age of 63.6 years (range 39-80).

RESULTS

No deaths occurred during or after surgery. Conversion to conventional thoracotomy was necessary in two cases. One patient was re-operated to resolve hemothorax and one developed a bronchopleural fistula that was treated by pleural drainage. The mean hospital stay was 6.3 days. Twenty-three patients have been disease-free throughout a mean follow-up period of 11.5 months (range 1-36). The two-year actuarial survival rate (Kaplan-Meier) was 93% 7%.

CONCLUSIONS

VALAT is a safe procedure that nevertheless requires specific training. The rate of complications was low in our patient series and mortality was nil. The outcome for patients with stage I bronchogenic carcinoma over a two-year follow-up period has been comparable to results obtained with conventional thoracotomy.

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.

A prospective trial of systematic nodal dissection for lung cancer by video-assisted thoracic surgery: can it be perfect?

BACKGROUND

There have been no reports evaluating the completeness of systematic nodal dissection with video-assisted thoracic surgery (VATS). In order to elucidate the completeness of the dissection, we have conducted a prospective trial with patients having primary lung cancer.

METHODS

Patients with clinical stage I lung cancer were the candidates for this study. Thoracotomy was performed with a small skin incision of 7 cm to 8 cm in length. Through these small wounds and two trocars, pulmonary resection was performed and then hilar and mediastinal lymph nodes were dissected. After that, a standard thoracotomy was carried out by another surgeon to complete systematic nodal dissection.

RESULTS

Video-assisted thoracic surgery lobectomy with lymph node dissection was accomplished in 17 right lung cancer patients and 12 left lung cancer patients. On the right side, the average numbers of resected lymph nodes by VATS and remnant lymph nodes were 40.3 and 1.2, respectively. The average weights of dissected tissues by VATS and remnant tissues were 10.0 g and 0.2 g, respectively. On the left side, there were 37.1 and 1.2 lymph nodes and 8.3 g and 0.2 g of weight of dissected tissues. No nodal involvement was observed in the remnant lymph nodes.

CONCLUSIONS

The lymph node dissection with VATS was technically feasible and the remnant ("missed" by VATS) lymph nodes and tissues were 2% to 3%, which seems acceptable for clinical stage I lung cancer.