Indocyanine green fluorescence identification of the intersegmental plane by the target segmental vein-first single-blocking during thoracoscopic segmentectomy

BACKGROUND

Innovative attempt to explore the feasibility and accuracy of using indocyanine green fluorescence (ICGF) to identify the intersegmental plane by the target segmental veins preferential ligation during thoracoscopic segmentectomy.

METHODS

A retrospective analysis was conducted on clinical data of 32 consecutive patients who underwent thoracoscopic segmentectomy with intersegmental plane identification using both ICGF and inflation-deflation method after target segmental veins prioritized blocking at Nanjing Chest Hospital from December 2022 to June 2023. Preoperative three-dimensional reconstruction was used to identify the target segment and the anatomical structure of the arteries, veins, and bronchi. After ligating the target segmental veins during surgery, the first intersegmental plane was immediately identified and marked with an electrocoagulation device using an inflation-deflation method. Subsequently, the second intersegmental plane was determined using the ICGF method. Finally, the consistency of the two intersegmental planes was evaluated.

RESULTS

All the 32 patients successfully completed thoracoscopic segmentectomy without ICG-related complications and perioperative death. The average operation time was (98.59 ± 20.72) min, the average intraoperative blood loss was (45.31 ± 35.65) ml, and the average postoperative chest tube removal time was (3.5 ± 1.16) days. The average postoperative hospital stay was (4.66 ± 1.29) days, and the average tumor margin width was (26.96 ± 5.86) mm. The intersegmental plane determined by ICGF method was basically consistent with inflation-deflation method in all patients.

CONCLUSION

The ICGF can safely and accurately identify the intersegmental plane by target segmental veins preferential ligation during thoracoscopic segmentectomy, which is a beneficial exploration and important supplement to the simplified thoracoscopic anatomical segmentectomy.

Effect of Resected Lung Volume on Pulmonary Function and Residual Lung Volume in Patients Undergoing Segmentectomy: A Retrospective Study

PURPOSE

We elucidated the effects of planned resection volume on postoperative pulmonary function and changes in residual lung volume during segmentectomy.

METHODS

This study included patients who underwent thoracoscopic segmentectomy between January 2017 and December 2022 and met eligibility criteria. Pre- and post-resection spirometry and computed tomography were performed. Three-dimensional reconstructions were performed by using computed tomography images to calculate the volumes of the resected, remaining, and nonoperative side regions. Based on the resected region volume, patients were divided into the higher and lower volume segmentectomy groups. Changes in lung volume and pulmonary function before and after the surgery were comparatively analyzed.

RESULTS

The median percentage of resected lung volume was 10.9%, forming the basis for categorizing patients into the two groups. Postoperative forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC) ratios to preoperative measurements in both groups did not differ significantly (FEV1, p = 0.254; FVC, p = 0.777). Postoperative FEV1 and FVC ratios to their predicted postoperative values were significantly higher in the higher volume segmentectomy group than in the lower volume segmentectomy group (FEV1, p = 0003; FVC, p < 0.001). The higher volume segmentectomy group showed significantly greater post-to-preoperative lung volume ratio in overall, contralateral, ipsilateral, residual lobe and residual segment than the lower volume segmentectomy group.

CONCLUSIONS

Postoperative respiratory function did not differ significantly between the higher- and lower-volume segmentectomy groups, indicating improved respiratory function because of substantial postoperative residual lung expansion. Our findings would aid in determining the extent of resection during segmentectomy.

Left Upper Lobectomy vs Trisegmentectomy for Lung Cancer: A Propensity Score-Matched Comparison

BACKGROUND

The left upper division (segments I-III) and the lingula (segments IV and V) are analogous to the right upper and middle lobes, respectively. Whereas bilobectomy for right upper lobe tumors is rare, left upper division tumors are often resected by left upper lobectomy (LUL) rather than by left upper trisegmentectomy (LU3S). To assess safety and oncologic efficacy of LUL vs LU3S, we compared short- and long-term outcomes after both procedures.

METHODS

Patients undergoing LUL or LU3S for clinical stage IA-IIA non-small cell lung cancer in the left upper division from January 2006 to December 2020 were identified from an institutional database. Propensity score matching was used to control for clinical differences.

RESULTS

We identified 229 cases meeting inclusion criteria: 131 (57.2%) LUL, 98 LU3S. After matching, 83 cases were included in each group. Median clinical tumor size was similar for LUL vs LU3S (2.2 cm [interquartile range, 1.6-3.0 cm] vs 2.1 cm [interquartile range, 1.7-2.9 cm]; P = .80). Total lymph nodes sampled did not differ between LUL and LU3S (median, 7 vs 6; P = .36), nor did patterns of N2 sampling (P = .11). Odds of postoperative complications did not differ after LUL vs LU3S (odds ratio, 0.75; 95% CI, 0.39-1.46). No 30-day death was observed. Median follow-up was 72 months. There was no statistically significant difference in 5-year overall survival (75.9% vs 82.1%; P = .28) or locoregional recurrence-free survival (73.7% vs 80.0%; P = .23) after LUL vs LU3S.

CONCLUSIONS

Our findings suggest that LU3S and LUL have equivalent short- and long-term outcomes in patients with clinical stage IA-IIA non-small cell lung cancer in the left upper division.

Pulmonary Function Recovery and Displacement Patterns After Anatomic Segmentectomy vs Lobectomy

BACKGROUND

The functional benefit of segmentectomy compared with lobectomy remains controversial. This ambispective study characterizes the changes in pulmonary function as correlated to displacement patterns of residual lung after segmentectomies vs lobectomies.

METHODS

Patients with normal preoperative pulmonary function and undergoing segmentectomy or lobectomy between 2017 and 2021 were considered. Pulmonary function testing was scheduled preoperatively and at least 3 months postoperatively. Differences in the proportions of the median forced expiratory volume in 1 second (FEV1) reduction between segmentectomy and lobectomy were calculated. Covariance analysis was used to estimate the adjusted postoperative FEV1 (apoFEV1) and compare the difference value (DV) in apoFEV1 between segmentectomy and lobectomy.

RESULTS

The study enrolled 634 patients (334 lobectomies and 300 segmentectomies). Median difference in the proportions of the FEV1 reduction between segmentectomy and lobectomy was 4.58%, with maximal difference observed in right S6 (9.08%) and minimal difference in left S1+2+3 (2.80%). For resections involving the upper lobe, apoFEV1 was significantly higher after segmentectomy than after lobectomy (DV, 0.15-0.22 L), except for left S3 and S1+2+3 segmentectomies (DV, 0.08 L and 0.06 L, respectively). Compared with a lower lobe lobectomy, S6 segmentectomy conferred a higher apoFEV1, whereas S7+8 and S9+10 had a similar apoFEV1 (DV, 0.16-0.18 L, 0.07 L, and 0.00-0.06 L, respectively). Functional recovery after segmentectomy was associated with the number of intersegment planes (P < .01) and the presence of an adjacent nonoperated on lobe (P = .03).

CONCLUSIONS

Basilar and left S3 segmentectomies did not preserve more pulmonary function compared with their corresponding lobectomies, possibly due to the presence of multiple intersegmental resection planes.

Sublobar Resection of Non-Small-Cell Lung Cancer: Wedge Resection vs. Segmentectomy

Lung cancer is the most common cause of cancer death. The mainstay treatment for non-small-cell lung cancer (NSCLC), particularly in the early stages, is surgical resection. Traditionally, lobectomy has been considered the gold-standard technique. Sublobar resection includes segmentectomy and wedge resection. Compared to lobectomy, these procedures have been viewed as a compromise procedure, reserved for those with poor cardiopulmonary function or who are poor surgical candidates for other reasons. However, with the advances in imaging and surgical techniques, the subject of sublobar resection as a curative treatment is being revisited. Many studies have now shown segmentectomy to be equivalent to lobectomy in patients with small (<2.0 cm), peripheral NSCLC. However, there is a mix of evidence when it comes to wedge resection and its suitability as a curative procedure. At this time, until more data can be found, segmentectomy should be considered before wedge resection for patients with early-stage NSCLC.

Differential efficacy of segmentectomy and wedge resection in sublobar resection compared to lobectomy for solid-dominant stage IA lung cancer: a systematic review and meta-analysis

BACKGROUND

Currently, the impact of sublobar resection versus lobectomy on the prognosis of solid-dominant stage IA lung cancer is contradictory in different studies, which requires further exploration.

METHODS

The authors analyzed 26 studies, including one randomized controlled trial and retrospective cohort studies. Pooled hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using fixed-effects or random-effects models based on heterogeneity levels.

RESULTS

The analysis included 12 667 patients, with 3488 undergoing sublobar resections and 9179 receiving lobectomies. The overall analysis revealed no statistically significant difference in overall survival (OS) (HR=1.28, 95% CI: 0.98-1.69) between sublobar resection and lobectomy, but lobectomy was associated with better recurrence-free survival (RFS) (HR=1.39, 95% CI: 1.10-1.75). Subgroup analyses revealed that, for tumors with a diameter ≤2 cm, sublobar resection versus lobectomy showed no significant difference in OS but sublobar resection had lower RFS. For 2-3 cm tumors, both OS and RFS were significantly lower in the sublobar resection group. When consolidation-to-tumor ratio (CTR) ranged from 0.5 to <1, OS did not differ significantly, but RFS was significantly lower in sublobar resection. Lung cancers with CTR=1 showed significantly lower OS and RFS in the sublobar resection group. Segmentectomy provided similar OS and RFS compared to lobectomy, while wedge resection had a detrimental effect on patient prognosis. However, wedge resection may have provided comparable outcomes for patients aged 75 years or older.

CONCLUSION

Our findings suggest that segmentectomy and lobectomy yield similar oncological outcomes. However, compared to lobectomy, wedge resection is associated with a poorer prognosis. Nevertheless, for elderly patients, wedge resection is also a reasonable surgical option.

Robot-assisted segmentectomy with improved modified inflation-deflation combined with the intravenous indocyanine green method

To investigate the perioperative outcomes of patients who underwent robot-assisted thoracoscopic (RATS) segmentectomy for identifying the intersegmental plane (ISP) by improved modified inflation-deflation (MID) combined with near-infrared fluorescence imaging with the intravenous indocyanine green (ICG) method and to assess the feasibility of this method in a large-scale cohort according to the type of segmentectomy performed. We retrospectively analysed the perioperative data of a total of 155 consecutive patients who underwent RATS segmentectomy between April 2020 and December 2021. Data from the operation, including the demarcation status of the intersegmental plane, were analysed retrospectively. The mean operative time and estimated blood loss were 125.56 ± 36.32 min and 41.81 ± 49.18 mL, respectively. Good demarcation of the intersegmental plane was observed in 150 (96.77%) patients, with no correlation with the type of resected segments or the surgical method. Postoperative complications of Clavien-Dindo classification grade 3 or more were observed in 4 patients (2.58%), and no ICG-related adverse events were noted. Demarcation of the intersegmental plane by improved MID combined with ICG is feasible regardless of the type of segmentectomy and can be commonly applied in robot-assisted segmentectomy.

Predictive factors inhibiting recovery of the respiratory function after anatomical pulmonary resection

PURPOSE

Some patients have worse actual observed postoperative (apo) respiratory function values than predicted postoperative (ppo) values. The present study therefore clarified the predictive factors that hinder the recovery of the postoperative respiratory function.

METHODS

This study enrolled 255 patients who underwent anatomical pulmonary resection for lung cancer. A pulmonary function test (PFT) was carried out before surgery and at one, three, and six months after surgery. In each surgical procedures, the forced expiratory volume in 1 s (FEV1) ratio was calculated as the apo value divided by the ppo value. In addition, we investigated the predictive factors that inhibited postoperative respiratory function improvement in patients with an FEV1 ratio < 1.0 at 6 months after surgery.

RESULTS

The FEV1 ratio gradually improved over time in all surgical procedures. However, 49 of 196 patients who underwent a PFT at 6 months after surgery had an FEV1 ratio < 1.0. In a multivariate analysis, right side, upper lobe, segmentectomy and pleurodesis for prolonged air leakage were independent significant predictors of a decreased FEV1 ratio (p = 0.003, 0.006, 0.001, and 0.009, respectively).

CONCLUSION

Pleurodesis was the only controllable factor that might help preserve the postoperative respiratory function. Thus, the intraoperative management of air leakage is important.

[Robot-assisted Lung Surgery: Techniques, Evidence and Data on Anatomical Resections]

Thanks to improved visualisation and instruments with an endowrist function, robot-assisted thoracic surgery has led to technical progress in thoracic surgery. This makes it easier to carry out complex thoracic surgical interventions, e.g. with an intrathoracic suture. As a result, this technology is increasingly being adopted and implemented in therapeutic use. Worldwide, the number of thoracotomies for lung cancer has decreased, while the number of minimally invasive surgical thoracic resections has increased. The aim of this work is to give an up-to-date overview of robotic operations on bronchial carcinoma.

Analysis of bronchovascular patterns in the left superior division segment to explore the relationship between the descending bronchus and the artery crossing intersegmental planes

Background

A comprehensive understanding of the anatomical variations in the pulmonary bronchi and arteries is particularly essential to the implementation of safe and precise left superior division segment (LSDS) segmentectomy. However, no report shows the relationship between the descending bronchus and the artery crossing intersegmental planes. Thus, the purpose of the present study was to analyze the branching pattern of the pulmonary artery and bronchus in LSDS using three-dimensional computed tomography bronchography and angiography (3D-CTBA) and to explore the associated pulmonary anatomical features of the artery crossing intersegmental planes.

Materials and methods

The 3D-CTBA images of 540 cases were retrospectively analyzed. We reviewed the anatomical variations of the LSDS bronchus and artery and assorted them according to different classifications.

Results

Among all 540 cases of 3D-CTBA, there were 16 cases (44.4%) with lateral subsegmental artery crossing intersegmental planes (AX³a), 20 cases (55.6%) Without AX³a in the descending B³a or B³ type, and 53 cases (10.5%) with AX³a, 451 cases (89.5%) Without AX³a in the Without the descending B³a or B³ type. This illustrated that the AX³a was more common in the descending B³a or B³ type (P < 0.005). Similarly, there were 69 cases (36.1%) with horizontal subsegmental artery crossing intersegmental planes (AX^{1 + 2}c), 122 cases (63.9%) Without AX^{1 + 2}c in the descending B^{1 + 2}c type, and 33 cases (9.5%) with AX^{1 + 2}c, 316 cases (90.5%) Without AX^{1 + 2}c in the Without the descending B^{1 + 2}c type. Combinations of the branching patterns of the AX^{1 + 2}c and the descending B^{1 + 2}c type were significantly dependent (p < 0.005). The combinations of the branching patterns of the AX^{1 + 2}c and the descending B^{1 + 2}c type were frequently observed.

Conclusions

This is the first report to explore the relationship between the descending bronchus and the artery crossing intersegmental planes. In patients with the descending B³a or B³ type, the incidence of the AX³a was increased. Similarly, the incidence of the AX^{1 + 2}c was increased in patients with the descending B^{1 + 2}c type. These findings should be carefully identified when performing an accurate LSDS segmentectomy.

The detailed classification of the interlobar artery and the artery crossing intersegmental planes in the right upper lobe

Background

With the prevalence of three-dimensional computed tomography bronchography and angiography (3D-CTBA) and the development of anatomical segmentectomy, several studies have analyzed the branching patterns of peripheral segmental arteries in the right upper lobe (RUL). Nevertheless, the detailed classification of the branching patterns of the interlobar artery and the artery crossing intersegmental planes remains unknown. Thus, we conducted a retrospective study to analyze the variations of the interlobar artery and the artery crossing intersegmental planes in the RUL using 3D-CTBA.

Materials and methods

A total of 600 patients with ground-glass opacity (GGO) who had undergone 3D-CTBA preoperatively at Hebei General Hospital between September 2020 and September 2022 were used for the retrospective study. We reviewed the anatomical variations of the RUL arteries in these patients using 3D-CTBA images.

Results

The branching patterns of the RUL artery were classified into the following four categories: trunk superior (Tr. sup), Tr. sup + interlobar artery, Tr. sup + trunk inferior (Tr. inf), and Tr. sup + Tr. inf + interlobar artery. The branching patterns of the interlobar artery were subclassified into four subtypes: posterior ascending artery (A. pos), anterior ascending artery (A. ant), A. pos + A. ant, and ascending artery (A. asc). The artery crossing intersegmental planes contains two types: type A, anterior subsegmental artery crossing intersegmental planes (AX¹b); type B, recurrent artery crossing intersegmental planes (AX. rec).

Conclusion

The variation types of blood vessels in the RUL are complex. This study explored the detailed classification of the interlobar artery and the artery crossing intersegmental planes. It can help thoracic surgeons understand the anatomy variations, accurately locate lesions before surgery, and effectively plan surgeries.

Patterns of Postoperative Changes in Lung Volume and Perfusion Assessed by Dual-Energy CT: Comparison of Lobectomy and Limited Resection

BACKGROUND. Pulmonary function tests (PFTs) and perfusion scintigraphy have limited utility for evaluating postoperative changes in regional pulmonary function after lung cancer resection surgery. OBJECTIVE. The purpose of this study is to compare postoperative changes in lung volume and perfusion, as assessed by dual-energy CT (DECT), between patients undergoing surgical resection of lung cancer by lobectomy versus limited resection as well as to assess associations between such changes and the lobar location of the resected tumor. METHODS. This study entailed a retrospective post hoc analysis of a prospective study that enrolled patients awaiting lung cancer resection surgery between March 2019 and February 2020. Eighty-one patients (38 men and 43 women; mean age, 60.5 ± 8.9 [SD] years), 43 of whom underwent lobectomy and 38 of whom underwent limited resection, were included. Patients underwent thoracic DECT and PFT evaluation preoperatively and at 6 months postoperatively. Pulmonary lobes were segmented. Lobar lung volume and lung perfusion ratios (both relative to whole-lung values) were computed. Perfusion measures reflected DECT-derived iodine content. Patients completed 6-month postoperative quality-of-life (QOL) questionnaires. RESULTS. Patients undergoing lobectomy, compared with those undergoing limited resection, had greater increases in the lung volume ratio of the ipsilateral nonresected lobe(s) (mean, 42.3% ± 24.2% [SD] vs 22.9% ± 13.2%, p < .001) and the contralateral lung (mean, 14.6% ± 14.0% vs 6.4% ± 6.9%, p = .002) as well as greater increases in the lung perfusion ratio of the ipsilateral nonresected lobe(s) (mean, 39.9% ± 20.7% [SD] vs 22.8% ± 17.8%, p < .001) and the contralateral lung (mean, 20.9% ± 9.4% vs 4.3% ± 5.6%, p < .001). In patients with right lower lobe tumors, the largest postoperative increases in the lung volume ratio were in the right middle lobe in those undergoing lobectomy (mean, 44.1% ± 21.0%) and limited resection (mean, 24.6% ± 14.5%), whereas the largest postoperative increase in the lung perfusion ratio was in the left lower lobe in those undergoing lobectomy (mean, 53.9% ± 8.6%) and in the right middle lobe in those undergoing limited resection (mean, 32.5% ± 24.1%). Otherwise, the largest increases in lung volume and perfusion ratios occurred in the ipsilateral nonresected lobes (vs the contra-lateral lobes), regardless of the operative approach used and the lobar location. Changes in the lung volume and perfusion ratios in the ipsilateral lobe(s) and the contralateral lung showed weak correlations with certain QOL scores (e.g., for role functioning: ρ = 0.234-0.279 [volume] and -0.233 to -0.284 [perfusion]). CONCLUSION. DECT depicts patterns of lung volume and perfusion changes after lung cancer surgery, depending on the surgical approach (lobectomy vs limited resection) used and the lobar location of the tumor. CLINICAL IMPACT. DECT-derived metrics can help understand variable physiologic impacts of lung cancer resection surgeries.

What is the correlation between the defective and splitting posterior segmental bronchus and recurrent artery crossing intersegmental planes in the right upper lobe?

Background

With the prevalence of three-dimensional computed tomography bronchography and angiography (3D-CTBA) and the development of anatomical segmentectomy, studies have confirmed the increased incidence of anomalous veins in patients with tracheobronchial abnormalities. Nevertheless, the characteristic anatomical correlation between bronchus and artery variation remains unknown. Thus, we conducted a retrospective study to investigate recurrent artery crossing intersegmental planes and their associated pulmonary anatomical features by analyzing the incidence and types of the right upper lobe (RUL) bronchus and the artery composition of the posterior segment.

Materials and Methods

A total of 600 patients with ground-glass opacity who had undergone 3D-CTBA preoperatively at Hebei General Hospital between September 2020 and September 2022 were included. We reviewed the anatomical variations of the RUL bronchus and artery in these patients using 3D-CTBA images.

Results

Among all 600 cases, the defective and splitting B2 contained four types of the RUL bronchial structure: B1 + BX2a, B2b, B3 (11/600, 1.8%); B1, B2a, BX2b + B3 (3/600, 0.5%); B1 + BX2a, B3 + BX2b (18/600, 3%); B1, B2a, B2b, B3 type (29/600, 4.8%). The incidence of recurrent artery crossing intersegmental planes was 12.7% (70/600). The incidence of recurrent artery crossing intersegmental planes with and without the defective and splitting B2 was 26.2% (16/61) and 10.0% (54/539), respectively (p < 0.005).

Conclusions

In patients with defective and splitting B2, the incidence of recurrent artery crossing intersegmental planes was increased. Our study provides certain references that surgeons can use to plan and perform RUL segmentectomy.

Comparison between functional lung volume measurement and segment counting for predicting postoperative pulmonary function after pulmonary resection in lung cancer patients

BACKGROUND

Functional lung volume (FLV) obtained from computed tomography images was a breakthrough for lung imaging and functional assessment. We compared the accuracy of the FLV measurement method and the segment-counting (SC) method in predicting postoperative pulmonary function.

METHODS

A total of 113 patients who underwent two thoracoscopic surgeries were enrolled in our study. We predicted postoperative pulmonary function by the FLV measurement method and the SC method. Novel formulas based on the FLV measurement method were established using linear regression equations between the factors affecting pulmonary function and the measured values.

RESULTS

The predicted postoperative forced vital capacity (ppoFVC) and forced expiratory volume in 1 s (ppoFEV1) measured by the 2 methods showed high concordance between the actual postoperative forced vital capacity (postFVC) and the forced expiratory volume in 1 s (postFEV1) [r = 0.762, P < 0.001 (FLV method) and r = 0.759, P < 0.001 (SC method) for FVC; r = 0.790, P < 0.001 (FLV method) and r = 0.795, P < 0.001 (SC method) for FEV1]. Regression analysis showed that the measured preoperative pulmonary function parameters (FVC, FEV1) and the ratio of reduced FLV to preoperative FLV were significantly associated with the actual postoperative values and could predict these parameters (all P < 0.001). The feasibility of using these equations [postFVC = 0.8 × FVC - 0.784 × ΔFLV/FLV + 0.283 (R² = 0.677, RSD = 0.338), postFEV1 = 0.766 × FEV1 - 0.694 × ΔFLV/FLV + 0.22 (R² = 0.743, RSD = 0.265)] to predict the pulmonary function parameters after wedge resection was also verified.

CONCLUSIONS

The new FLV measurement method is valuable for predicting postoperative pulmonary function in patients undergoing lung resection surgery, with accuracy and consistency similar to those of the conventional SC method.

Analysis of variations in the bronchovascular pattern of the lingular segment to explore the correlations between the lingular segment artery and left superior division veins

Background

With the development of anatomical segmentectomy, the thoracic surgeons must master the anatomical variations of the pulmonary bronchi and vessels. However, there are only a few reports showing anatomic variations of the lingular segment (LS) using three-dimensional computed tomography bronchography and angiography (3D-CTBA). Thus, the present study aimed to analyze the bronchovascular patterns of the LS and explore the correlation between the lingular segment artery (LSA) and left superior division veins (LSDV).

Materials and methods

The 3D-CTBA data of the left upper lobe (LUL) were collected from patients who had undergone lobectomy or segmentectomy at Hebei General Hospital between October 2020 and October 2022. We reviewed the clinical characteristics and variations in bronchi and pulmonary vessels and grouped them according to different classifications.

Results

Among all 540 cases of 3D-CTBA, the branching patterns of LSA included 369 (68.3%) cases with the interlobar origin, 126 (23.3%) cases with the interlobar and mediastinal origin, and 45 (8.3%) cases with the mediastinal origin. The branching pattern of LSDV could be classified into three forms: Semi-central vein type (345/540, 63.9%), Non-central vein type (76/540, 14.1%), and Central vein type (119/540, 22.0%). There were 51 cases (9.4%) with Non-central vein type, 50 cases (9.3%) with Central vein type, 268 cases (49.6%) with Semi-central vein type in the interlobar type, and 7 cases (1.3%) with Non-central vein type, 9 cases (1.7%) with Central vein type, 29 cases (5.4%) with Semi-central vein type in the mediastinal type. Moreover, the Non-central vein type, the Central vein type, and the Semi-central vein type accounted for 18 (3.3%), 60 (11.1%), and 48 (8.9%) in the interlobar and mediastinal type. Combinations of the branching patterns of the LSA and LSDV were significantly dependent (p < 0.005). The combinations of the interlobar and mediastinal type with the Central vein type, and the interlobar type and the mediastinal type with the Semi-central vein type were frequently observed.

Conclusions

This study found the relationship between the LSA and LSDV and clarified the bifurcation patterns of the bronchovascular in the LS. Our data can be used by thoracic surgeons to perform safe and precise LS segmentectomy.

Application of three-dimensional computed tomography imaging and reconstructive techniques in lung surgery: A mini-review

Background

Pulmonary surgery is an innovative discipline with increasing demands for minimally invasive techniques in complicated anatomical resections, warranting adequate preoperative imaging of relevant surgical anatomy to ensure safe and radical resection of target lesions. Over the recent years, the emergence of imaging techniques enabling three-dimensional reconstruction has exerted promising influence on pulmonary surgery, facilitating optimal surgical planning and easier identification of the spatial relationship between bronchovascular structures in the individual patient and aiding the safe resection of target pulmonary lesions. The goal of this mini-review is to provide an overview of three-dimensional computed tomography imaging within pulmonary surgery.

Methods

The authors performed a targeted qualitative review of the literature to identify current trends and to provide better understanding of three-dimensional reconstruction within the boundaries of pulmonary surgery.

Results

Three-dimensional reconstructive techniques can be used for resectability assessment, identification of surgically relevant interindividual anatomic variance and may improve perioperative outcomes.

Discussion

Three-dimensional reconstruction using computed tomography imaging improves surgical planning and there is evidence that it results in shorter operative times, less intraoperative blood loss and lower rates of surgical conversion, as it can be applied both pre- and intraoperatively.

Identification of the intersegmental plane by arterial ligation method during thoracoscopic segmentectomy

Background

Thoracoscopic segmentectomy is a common surgical procedure in thoracic surgery today. However, identifying the intersegmental plane is difficult in the surgical process. Therefore, we evaluated the feasibility of the arterial ligation method for determining the intersegmental plane and compared the demarcation status with the intravenous indocyanine green (ICG).

Methods

We retrospectively reviewed the records of 35 patients with peripheral small lung nodules who underwent thoracoscopic segmentectomy between May and December 2020. First, the preoperative three-dimensional reconstruction was performed to distinguish the location of lung nodules and the anatomical structures of targeted segmental arteries, veins, and bronchi. Second, the targeted segmental arteries were ligated, and the intersegmental plane was determined by the inflation-deflation technique. The waiting time for the appearance of the inflation-deflation line was recorded. Thirdly, the intersegmental plane was identified again using the ICG fluorescence method. Finally, the consistency of the two intersegmental planes was evaluated.

Results

The intersegmental planes were successfully observed in all patients using the arterial ligation method. Thirty-four patients underwent segmentectomy as planned, and one patient finally underwent lobectomy due to insufficient surgical margin. The waiting time for the appearance of the intersegmental plane by arterial ligation method was 13.7 ± 3.2 min (6–19 min). The intersegmental planes determined by the arterial ligation method and the ICG fluorescence method were comparable, with a maximum distance of no more than 5 mm between the two planes. The mean operative duration was 119.1 ± 34.9 min, and the mean blood loss was 76.9 ± 70.3 ml. No evident air leakage was found during the operation. Only one patient experienced a prolonged air leak (≥ 5 days) during the postoperative recovery. No atelectasis occurred in all cases. The chest tube duration was 3.1 ± 0.9 days.

Conclusion

The arterial ligation method can efficiently and accurately identify the intersegmental plane, comparable to the ICG fluorescence method.

Characteristics of High-Volume Lung Segmentectomy Hospitals: A Propensity Score-Matched Analysis

BACKGROUND

Segmental resection continues to gain favor in the treatment of early-stage non-small cell lung cancer, but there is limited data on outcomes as related to facility volume. The purpose of this study is to better define the relationship between segmentectomy outcomes, survival, and facility volume.

METHODS

A retrospective cohort analysis was completed using the National Cancer Database. Patients with stage I disease undergoing segmentectomy 2004 to 2015 were included. Facility volume was determined per year; facilities performing higher than the median number of segmental resections were deemed high-volume and retained that classification for the remainder of the study. Propensity-score matching was used to compare 5-year survival and outcomes.

RESULTS

Six hundred eighty-one centers performing 2481 segmentectomies were included. High-volume centers had higher utilization of minimally invasive approaches and lower conversion rates. There was no difference in readmission or 30-day mortality, but 90-day mortality differed between groups (1.2% vs. 2.6%, P = .03). High-volume centers were more likely to sample lymph nodes (88.5% vs. 80.7%, P < .01), and patients were less likely to have positives margins (1.3% vs. 2.7%, P = .03). Patients were no more likely to be upstaged based on facility volume (4.6% vs. 3.3%, P = .21). Overall, 5-year survival was better for patients treated at high-volume centers in the full cohort (69.5% vs. 66.4%, P = .014) but in propensity score-matched analysis this survival difference became non-significant (68.0% vs. 67.9% (P = .172).

CONCLUSION

Segmentectomy performed at high-volume centers is associated with more frequent use of minimally invasive approach, more frequent negative margins, and improved 90-day survival.

Expert consensus on indocyanine green fluorescence imaging for thoracoscopic lung resection (The Version 2022)

The use of the white-light thoracoscopy is hampered by the low contrast between oncologic margins and surrounding normal parenchyma. As a result, many patients with in situ or micro-infiltrating adenocarcinoma have to undergo lobectomy due to a lack of tactile and visual feedback in the resection of solitary pulmonary nodules. Near-infrared (NIR) guided indocyanine green (ICG) fluorescence imaging technique has been widely investigated due to its unique capability in addressing the current challenges; however, there is no special consensus on the evidence and recommendations for its preoperative and intraoperative applications. This manuscript will describe the development process of a consensus on ICG fluorescence-guided thoracoscopic resection of pulmonary lesions and make recommendations that can be applied in a greater number of centers. Specifically, an expert panel of thoracic surgeons and radiographers was formed. Based on the quality of evidence and strength of recommendations, the consensus was developed in conjunction with the Chinese Guidelines on Video-assisted Thoracoscopy, and the National Comprehensive Cancer Network (NCCN) guidelines on the management of pulmonary lesions. Each of the statements was discussed and agreed upon with a unanimous consensus amongst the panel. A total of 6 consensus statements were developed. Fluorescence-guided thoracoscopy has unique advantages in the visualization of pulmonary nodules, and recognition and resection of the anterior plane of the pulmonary segment. The expert panel agrees that fluorescence-guided thoracoscopic surgery has the potential to become a routine operation for the treatment of pulmonary lesions.

Three Weeks of Pulmonary Rehabilitation Do Not Influence Oscillometry Parameters in Postoperative Lung Cancer Patients

Background: Thoracic surgery is a recommended treatment option for non-small cell lung cancer patients. An important part of a patient’s therapy, which helps to prevent postoperative complications and improve quality of life, is pulmonary rehabilitation (PR). The aim of this study was to assess whether the implementation of physical activity has an influence on forced oscillation technique (FOT) values in patients after thoracic surgery due to lung cancer. Methods: In this observational study, we enrolled 54 patients after thoracic surgery due to lung cancer, 49 patients with idiopathic interstitial fibrosis (IPF), and 54 patients with chronic obstructive pulmonary disease/asthma−COPD overlap (COPD/ACO). All patients were subjected to three weeks of in-hospital PR and assessed at the baseline as well as after completing PR by FOT, spirometry, grip strength measurement, and the 6-min walk test (6MWT). Results: We observed differences between FOT values under the influence of physical activity in studied groups, mostly between patients after thoracic surgery and COPD/ACO patients; however, no significant improvement after completing PR among FOT parameters was noticed in any group of patients. Improvements in the 6MWT distance, left hand strength, and right hand strength after PR were noticed (p < 0.001, 0.002, and 0.012, respectively). Conclusions: Three weeks of pulmonary rehabilitation had no impact on FOT values in patients after thoracic surgery due to lung cancer. Instead, we observed improvements in the 6MWT distance and the strength of both hands. Similarly, no FOT changes were observed in IPF and COPD/ACO patients after completing PR.

Clinical application of bronchial high-frequency ventilation in 2-port thoracoscopic segmentectomy

To evaluate the safety and clinical application of a computer-aided surgery system (CAS) combined with high-frequency bronchial ventilation in 2-port thoracoscopic anatomical segmentectomy. A total of 301 patients who underwent 2-port thoracoscopic segmentectomy between January 1, 2019 and March 1, 2022 in the 960th Hospital of the People's Liberation Army and the Department of Thoracic Surgery of Zibo Municipal Hospital were retrospectively analyzed. The experimental and control groups were created according to the different methods of appearing the intersegmental plane of the lung. The experimental group comprised 152 patients who underwent CAS reconstruction combined with high-frequency ventilation, and the control group comprised 149 patients who underwent CAS reconstruction combined with expansion collapse. The characteristics of the patients, including age, sex, smoking history, forced expiratory volume in 1 second/forced vital capacity, Maximal ventilation, diameter of pulmonary nodules, intraoperative blood loss, postoperative drainage volume, drainage tube removal time, length of hospital stay after extubation, postoperative complication rate, operation time and appearance time of the intersegmental plane, were compared between the 2 groups. All patients completed the operation between high-frequency bronchial ventilation and expansion collapse group. There was no significant difference in Forced expiratory volume in 1 second/Forced vital capacity [(101.05 ± 11.86) vs (101.86 ± 11.61)], maximum expiratory volume [(86.36 ± 17.59 L) vs (85.28 ± 17.68 L)], the diameter of lung nodules [(13.61 ± 3.51 cm) vs (13.21 ± 3.41 cm)], intraoperative blood loss [(47.50 ± 45.90 mL) vs (48.49 ± 34.65 mL)], postoperative drainage volume [(425.16 ± 221.61 mL) vs (444.70 ± 243.72 mL)], drainage tube removal time [(3.88 ± 1.85 days) vs (3.43 ± 1.81 days)], or postoperative hospital stay [(6.07 ± 2.14 days) vs (5.82 ± 1.88 days) between the experimental group and the control group (P > .05)]. There were significant differences in operation time [(95.05 ± 26.85 min) vs (117.85 ± 31.70 min), P = .017] and intersegmental plane appearance time [(2.37 ± 1.03 min) vs (14.20 ± 3.23 min), P < .001]. High-frequency bronchial ventilation is safe and feasible when used in quickly and accurately identifying the intersegmental plane and is worthy of clinical application in 2-port thoracoscopic segmentectomy.

Pulmonary function changes after uniportal video-assisted thoracoscopic anatomical lung resection

OBJECTIVE

The superiority of segmentectomy over lobectomy with regard to preservation of pulmonary function is controversial. This study aimed to examine changes in pulmonary function after uniportal video-assisted thoracoscopic surgery (VATS) according to the number of resected segments.

METHODS

We retrospectively reviewed 135 consecutive patients who underwent anatomical lung resection via uniportal VATS from April 2015 to December 2020. Pulmonary function loss was evaluated using forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV1). Patients were grouped according to number of resected segments: one-segment (n = 33), two segments (n = 22), three segments (n = 40), four segments (n = 15), and five segments (n = 25).

RESULTS

Clinical characteristics did not significantly differ between groups, except for tumor size. Mean follow-up was 8.96 ± 3.16 months. FVC loss was significantly greater in five-segment resection (10.8%) than one-segment (0.97%, p = 0.008) and two-segment resections (2.44%, p = 0.040). FEV1 loss was significantly greater in five-segment resection (15.02%) than one-segment (3.83%, p < 0.001), two-segment (4.63%, p = 0.001), and three-segment resections (7.63%, p = 0.007). Mean FVC loss and FEV1 loss increased linearly from one-segment resection to five-segment resection. Mean loss in FVC and FEV1 per segment resected was 2.16% and 3.00%, respectively.

CONCLUSIONS

Anatomical lung resection of fewer segments was associated with better preservation of pulmonary function in patients undergoing uniportal VATS, and function loss was approximately 2%-3% per segment resected with linear relationship.

Division of the intersegmental demarcation using the "modified hand-tearing method" is safe and feasible in thoracoscopic anatomical segmentectomy

BACKGROUND

The accurate and safe division of the intersegmental demarcation (ISD) is critical and challenging during thoracoscopic anatomical segmentectomy. Here, we provide an improved technique which emphasizes the application of an electric hook and blunt division of ISD. The technique is termed as the "modified hand-tearing method" (MHT method) with combined application of an electric hook and staplers. The study aimed to review the outcomes of patients who underwent thoracoscopic anatomical segmentectomy, with or without the MHT method in our institute and assess its feasibility and safety. In addition, we compared the feasibility between video-assisted thoracoscopic surgery (VATS) and robot-assisted thoracoscopic surgery (RATS) using the MHT method.

METHODS

From 2018 July to 2021 June, we retrospectively analyzed 701 patients who underwent segmentectomy. Using propensity score matching, data of two well-matched pairs of 276 cases in the MHT method and non-MHT method groups, and two well-matched pairs of 40 cases in the VATS and RATS subgroups were obtained. The clinical and perioperative characteristics of patients were compared between groups.

RESULTS

Compared with the non-MHT method group, the MHT method group had shorter operation time and shorter postoperative hospital stay. Period of chest tube drainage and postoperative total drainage and postoperative complications had no between-group difference. Compared with VATS, the RATS subgroup had less intraoperative bleeding and shorter postoperative hospital stay.

CONCLUSION

Division of ISD using the MHT method has advantages in precision and ease of operation, so it has the potential to become a feasible and effective method for thoracoscopic anatomical segmentectomy.

A guide for managing patients with stage I NSCLC: deciding between lobectomy, segmentectomy, wedge, SBRT and ablation-part 2: systematic review of evidence regarding resection extent in generally healthy patients

Background

Clinical decision-making for patients with stage I lung cancer is complex. It involves multiple options (lobectomy, segmentectomy, wedge, stereotactic body radiotherapy, thermal ablation), weighing multiple outcomes (e.g., short-, intermediate-, long-term) and multiple aspects of each (e.g., magnitude of a difference, the degree of confidence in the evidence, and the applicability to the patient and setting at hand). A structure is needed to summarize the relevant evidence for an individual patient and to identify which outcomes have the greatest impact on the decision-making.

Methods

A PubMed systematic review from 2000-2021 of outcomes after lobectomy, segmentectomy and wedge resection in generally healthy patients is the focus of this paper. Evidence was abstracted from randomized trials and non-randomized comparisons with at least some adjustment for confounders. The analysis involved careful assessment, including characteristics of patients, settings, residual confounding etc. to expose degrees of uncertainty and applicability to individual patients. Evidence is summarized that provides an at-a-glance overall impression as well as the ability to delve into layers of details of the patients, settings and treatments involved.

Results

In healthy patients there is no short-term benefit to sublobar resection vs. lobectomy in randomized and non-randomized comparisons. A detriment in long-term outcomes is demonstrated by adjusted non-randomized comparisons, more marked for wedge than segmentectomy. Quality-of-life data is confounded by the use of video-assisted approaches; evidence suggests the approach has more impact than the resection extent. Differences in pulmonary function tests by resection extent are not clinically meaningful in healthy patients, especially for multi-segmentectomy vs. lobectomy. The margin distance is associated with the risk of recurrence.

Conclusions

A systematic, comprehensive summary of evidence regarding resection extent in healthy patients with attention to aspects of applicability, uncertainty and effect modifiers provides a foundation on which to build a framework for individualized clinical decision-making.

A Method to Identify Intersegmental Planes for Robotic-assisted Anatomic Segmentectomy Without Waiting

Identifying intersegmental planes is considered the key step during segmentectomy. Several techniques, including modified inflation-deflation techniques, target-segment jet ventilation, and infrared-fluorescence-enhanced methods, have been reported for the identification of intersegmental planes. However, limitations of these methods have also been reported. Here, we described an improved collateral ventilation method to identify the inflation-deflation line without waiting and without any auxiliary materials needed during robotic-assisted anatomic segmentectomy. We present this handy technique of identifying the intersegmental planes and comment on its advantages, including decreased operative time and improved clarity of the inflation-deflation line.

Real-time image-guided indocyanine green fluorescence dual-visualization technique to measure the intraoperative resection margin during thoracoscopic segmentectomy

AIMS

The primary goal of thoracoscopic segmentectomy is the complete resection of early pulmonary carcinoma while sparing as much of the normal pulmonary parenchyma as possible, but an obvious trade-off exists between the pulmonary parenchymal preservation and an adequate resection margin. In this clinical trial, we explored a real-time image-guided indocyanine green (ICG) fluorescence dual-visualization technique to confirm the resection margin by improving the intraoperative localization of the pulmonary nodule and identification of the intersegmental boundary line (IBL).

METHODS

This study was utilized in 35 patients with a screening-detected lung nodule <2 cm to complete thoracoscopic segmentectomy from December 2020 to June 2021. Computed tomography-guided localization of the pulmonary nodule with ICG solution was performed on the day of surgery. During the surgery, after dissecting the targeted pulmonary segmental arteries, ICG at 5 mg/body was injected into the systemic vein.

RESULTS

We observed no toxicity. The dual-visualization technique was successfully implemented in all 35 patients to achieve a negative resection margin, which was more than 2 (mean 2.71 ± 0.59) cm, or the size of the tumor based on the final pathological examinations. No intraoperative complications occurred and only one patient had postoperative prolonged air leaks, which was ceased 8 days later after conservative management without reoperation.

CONCLUSIONS

This method is a safe and feasible alternative to ensure a negative resection margin without removing an unreasonable amount of pulmonary parenchyma during pulmonary segmentectomy. Future studies will be needed to compare this method to alternative techniques in a clinical trial.

The impact of segmentectomy versus lobectomy on pulmonary function in patients with non-small-cell lung cancer: a meta-analysis

Objective

Segmentectomy has been reported as an alternative to lobectomy for small-sized NSCLC without detriment to survival. The long-term benefits of segmentectomy over lobectomy on pulmonary function have not been firmly established. This meta-analysis aims to compare postoperative changes in pulmonary function in NSCLC patients undergoing segmentectomy or lobectomy.

Methods

Medline, Embase, Web of Science and Scopus were searched through March 2021. Statistical comparisons were made when appropriate.

Results

Fourteen studies (2412 participants) out of 324 citations were included in this study. All selected studies were high quality, as indicated by the Newcastle–Ottawa scale for assessing the risk of bias. Clinical outcomes were compared between segmentectomy and lobectomy. ΔFEV1 [10 studies, P < 0.01, WMD = 0.40 (0.29, 0.51)], ΔFVC [4 studies, P < 0.01, WMD = 0.16 (0.07, 0.24)], ΔFVC% [4 studies, P < 0.01, WMD = 4.05 (2.32, 5.79)], ΔFEV1/FVC [2 studies, P < 0.01, WMD = 1.99 (0.90, 3.08)], and ΔDLCO [3 studies, P < 0.01, WMD = 1.30 (0.69, 1.90)] were significantly lower in the segmentectomy group than in the lobectomy group. Subgroup analysis showed that in stage IA patients, the ΔFEV1% [3 studies, P < 0.01, WMD = 0.26 (0.07, 0.46)] was significantly lower in the segmentectomy group. The ΔDLCO% and ΔMVV% were incomparable.

Conclusion

Segmentectomy preserves more lung function than lobectomy. There were significantly smaller decreases in FEV1, FVC, FVC%, FEV1/FVC and DLCO in the segmentectomy group than in the lobectomy group.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-022-01853-3.

Comparison of extended segmentectomy with traditional segmentectomy for stage I lung cancer

BACKGROUND

For stage I non-small cell lung cancer (NSCLC), lobectomy and segmentectomy are still controversial operations. Extended segmentectomy was proposed to make larger safe margins than segmentectomy. Image-guided video-assisted thoracoscopic surgery (iVATS) is useful to accomplish extended segmentectomy. We aimed to compare the effects of iVATS extended segmentectomy to the effects of traditional segmentectomy for stage I NSCLC.

METHODS

This study is a retrospective analysis in a single institute. Patients with stage I NSCLC who received segmentectomy between January 2017 and September 2020 were included. Patients were distributed to iVATS extended segmentectomy (group A), and traditional segmentectomy (group B). The impacts of the different surgical methods on resection margin were assessed.

RESULTS

There were 116 patients enrolled in this study. Sixty-two patients distributed in group A, and the other 54 patients in group B. The resection margin to a staple line was 17.94 mm in group A versus 14.15 mm in group B, p = 0.037. The margin/tumor diameter ratio was 2.08 in group A versus 1.39 in group B, p = 0.003. The enough margin rate was 75.81% and 57.41%, respectively, for group A and group B. The subgroup analysis of iVATS extended segmentectomy showed that T1a lesions had larger margin distances than did T1b lesions (19.85 mm vs. 14.83 mm, p = 0.026).

CONCLUSIONS

The iVATS extended segmentectomy can provide more resection margin than traditional segmentectomy. Segmentectomy is more suitable to perform when the nodule's diameter is less than 10 mm.

[Correlation Analysis of the Lung Volume Reduction and the Lung Function Loss after the Thoracoscopic Lobectomy]

BACKGROUND

To investigate the correlation between the reduction of lung volume and the degree of lung function damage after lobectomy.

METHODS

A total of 131 patients (72 males and 59 females) who underwent thoracoscopic lobectomy in the First Affiliated Hospital of Suzhou University from January 2019 to July 2020 (including thoracoscopic resection of left upper lobe, left lower lobe, right upper lobe, right middle lobe and right lower lobe). In order to compare the difference between postoperative pulmonary function and preoperative pulmonary function, the pulmonary function measurements were recorded at 7 days before operation, and 3 months, 6 months and 1 year after operation. Forced expiratory volume in 1 second (FEV1) was used as the main evaluation parameter of pulmonary function. The original lung volume and the remaining lung volume at each stage were calculated by Mimics Research 19.0 software. The correlation between lung volume and lung function was analyzed.

RESULTS

FEV1 in postoperative patients was lower than that before operation, and the degree of decline was positively correlated with the resection volume of lung lobes (the maximum value was shown in the left lower lobe group). Significantly, there was no significant difference in the degree of pulmonary function reduction between 3 months, 6 months and 1 year after operation.

CONCLUSIONS

The decrease of lung tissue volume after lobectomy is the main reason for the decrease of lung function, especially in the left lower lobe. And 3 months after lobectomy can be selected as the evaluation node of residual lung function.

Comparison of stapler and electrocautery for division of the intersegmental plane in lung segmentectomy

Background

We retrospectively compared the use of a stapler and electrocautery for division of the intersegmental plane during pulmonary segmentectomy.

Methods

We enrolled 156 patients who underwent pulmonary segmentectomy in our department between March 2006 and August 2020. The patients were divided into electrocautery (n=62) and stapler (n=94) groups based on the device used to divide the intersegmental plane. Patient characteristics, perioperative outcomes, and ratios of actual (calculated using software) to predicted (calculated by counting the resected segments) lung volumes were compared between the two groups. Additionally, we used multivariate analysis to identify the factors that contributed to the incidence of postoperative air leakage after cut-off value was set by receiver operating characteristic (ROC) curve analysis. Moreover, a subset analysis was performed based on the type of segmentectomy (common or uncommon). Common segmentectomies included resection of the basilar or superior segment of the lower lobe, or lingular or upper division of the left upper lobe; all other segmentectomies were classified as uncommon.

Results

Compared to the electrocautery group, the stapler group had shorter operative times (P=0.0027), duration of postoperative drainage (P=0.00037), and duration of postoperative hospitalization (P=0.0021). Moreover, incidence of postoperative ≥3 days drainage was significantly reduced in the stapler group (P=0.003). There were no significant differences between the stapler and electrocautery groups in the actual:predicted lung volumes at 6 months (1.01 and 1.04, respectively; P=0.28) or 12 months (1.06 and 1.07, respectively; P=0.68) after surgery. Preoperative lung volume was significantly correlated with preoperative vital capacity (VC) (γ=0.69; P<0.001) and forced expiratory volume in 1 second (FEV₁) (γ=0.48; P<0.001). The multivariate analysis indicated that the use of stapler for division of intersegmental plane was the only factor that contributed to reducing the incidence of postoperative ≥3 days drainage (P=0.0027, odds ratio: 0.23, 95% CI: 0.086–0.597). In a subset analysis of uncommon segmentectomy, there were no significant differences among the groups in most perioperative results.

Conclusions

Compared to electrocautery, the use of a stapler for division of the intersegmental plane was associated with better perioperative outcomes, especially reduction of postoperative drainage time, and similar postoperative remnant lung volumes and function.

Lobectomy versus segmentectomy: a propensity score-matched comparison of postoperative complications, pulmonary function and prognosis

OBJECTIVES

To demonstrate the differences in clinical outcomes between lobectomy and segmentectomy for non-small cell lung cancer using propensity score matching.

METHODS

A single-centre, retrospective, matched cohort study was conducted in clinical T1N0M0 non-small cell lung cancer patients treated by surgery between 2012 and 2019. Differences in freedom from recurrence, overall survival, postoperative complications, chest drainage and preservation of pulmonary function between lobectomy and segmentectomy were evaluated using the propensity score model. Matched variables of patients were age, sex, comorbidity index and pulmonary function. Matched variables of tumours were tumour size, T-stage, fluorodeoxyglucose uptake on positron emission tomography, histopathology, lobe site and tumour distance ratio from the hilum.

RESULTS

Of the 112 patients treated by lobectomy and 233 patients treated by segmentectomy, 93 patients each from both groups were selected after the matching. The median tumour distance ratio from hilum was 0.7 in lobectomy and 0.8 in segmentectomy group (P = 0.59), i.e. almost outer third tumour location. There were no significant differences in freedom from recurrence (P = 0.38), overall survival (P = 0.51), postoperative complications (P = 0.94), drainage period (P = 0.53) and prolonged air leakage (P = 0.82) between the two. Median preservation of pulmonary function was 93.2% after segmentectomy, which was significantly higher than 85.9% after lobectomy (P < 0.001).

CONCLUSIONS

Freedom from recurrence, overall survival, postoperative complications and chest drainage were similar between segmentectomy and lobectomy. Segmentectomy could be one of the options for clinical T1N0M0 non-small cell lung cancer located outer third as well as being able to preserve pulmonary function better than lobectomy.

CLINICAL TRIAL REGISTRATION

[Feasibility Investigation of Fluorescence Method in Uniport Thoracoscopic Anatomical Segmentectomy for Identifying the Intersegmental Boundary Line]

BACKGROUND

Segmentectomy has gradually become one of the standard surgical methods for small pulmonary nodules with early lung cancer on imaging. This study aimed to investigate the perioperative outcomes of patients who underwent uniport video-assisted thoracoscopic surgery (VATS) segmentectomy for identifying the intersegmental boundary line (IBL) by the near-infrared fluorescence imaging with intravenous indocyanine green (ICG) method or the modified inflation-deflation (MID) method and assess the feasibility and effectiveness of the ICG fluorescence (ICGF)-based method.

METHODS

We retrospectively analyzed the perioperative data in total 198 consecutive patients who underwent uniport VATS segmentectomy between February 2018 and August 2020. With the guidance of preoperative intelligent/interactive qualitative and quantitative analysis-three dimensional (IQQA-3D), the targeted segment structures could be precisely identified and dissected, and then the IBL was confirmed by ICGF-based method or MID method. Clinical effectiveness and postoperative complications of the two methods were evaluated.

RESULTS

An IBL was visible in 98% of patients by the ICGF-based group, even with the low-doses of ICG. The ICGF-based group was significantly associated with the shorter IBL clear presentation time [(23.59±4.47) s vs (1,026.80±318.34) s] (P<0.01) and operative time [(89.3±31.6) min vs (112.9±33.3) min] (P<0.01), compared to the MID group. The incidence of postoperative prolonged air leaks was higher in the MID group than in the ICGF-based group (8.0% vs 26.5%, P=0.025). There were no significant differences in bleeding volume, chest tube duration, postoperative hospital stays, surgical margin width and other postoperative complications (P>0.05).

CONCLUSIONS

The ICGF-based method could highly accurately identify the IBL and make anatomical segmentectomy easier and faster, and therefore has the potential to be a feasible and effective technique to facilitate the quality of uniport VATS segmentectomy.

Pulmonary function changes after thoracoscopic lobectomy versus intentional thoracoscopic segmentectomy for early-stage non-small cell lung cancer

BACKGROUND

Thoracoscopic segmentectomy is increasingly used in the surgical treatment of early-stage non-small cell lung cancer. However, it remains unclear whether pulmonary function loss after thoracoscopic lung resection is in direct proportion to the number of resected segments, and thus intentional thoracoscopic segmentectomy has the function-preserving advantage over thoracoscopic lobectomy.

METHODS

In this prospective observational study, spirometry tests were performed preoperatively and 6 months postoperatively. The observed functional loss was compared with the expected loss estimated by the segment counting method. Resection extent index was introduced as the number of resected segments to total number of segments in the corresponding lobe. Spirometry changes after thoracoscopic lobectomy and intentional thoracoscopic segmentectomy were compared using propensity score matching.

RESULTS

There were 338 thoracoscopic lobectomies and 321 thoracoscopic segmentectomies. Overall, the observed pulmonary function loss after segmentectomy was significantly less than after lobectomy. But the observed functional loss was significantly greater than the expected loss after segmentectomy. And pulmonary function loss per segment resected was almost doubled after segmentectomy comparing to lobectomy. For segmentectomies with a resection extent index less than 0.5, especially single segmentectomies, pulmonary function loss was significantly less than after corresponding lobectomies. Otherwise, no significant differences in spirometry changes between lobectomies and segmentectomies were detected.

CONCLUSIONS

Pulmonary function loss after thoracoscopic lung resection cannot be accurately evaluated by the number of resected segments. According to the resection extent index, intentional thoracoscopic segmentectomy may help preserve more pulmonary function than thoracoscopic lobectomy only when less than half of the corresponding lobe are resected.

Efficacy of the Segment-Counting Method in Predicting Lung Function and Volume Following Stapler-Based Thoracoscopic Segmentectomy

Purpose: To investigate the accuracy of a segment-counting method in predicting lung function and volume after stapler-based thoracoscopic segmentectomy in comparison with lobectomy.

Methods: Between 2014 and 2018, patients who underwent these procedures were retrospectively reviewed. Thoracic computed tomography and spirometry data before and 1 year after the surgery were assessed. We evaluated the differences between the predicted values using a segment-counting method and the actual postoperative values for lung function and volume in each group. Sub-analyses were also performed to assess the impact of the number of staples and resected segments in predicting patient outcomes.

Results: We included 116 patients (segmentectomy, 69; lobectomy, 47). Actual postoperative lung function and volume values matched the predicted values in the stapler-based segmentectomy group, and significantly exceeded the predictions in the lobectomy group (P <0.01). Sub-analyses revealed lower postoperative lung function values than predicted existed after single segmentectomy, with an odds ratio of 3.29 (95% confidence interval: 1.02–10.70, P = 0.04) in a multivariable analysis. The degree of predicted error regarding lung function was negligible.

Conclusions: The segment-counting method was useful in predicting lung function after stapler-based thoracoscopic segmentectomy. Segmentectomy rarely yielded lower- than-predicted lung function and volume values.

Pulmonary function after segmentectomy versus lobectomy in patients with early-stage non-small-cell lung cancer: a meta-analysis

Objective

Segmentectomy is widely performed for early-stage lung cancer. However, the effects of segmentectomy versus lobectomy on pulmonary function remain unclear. We performed a meta-analysis with the aim of comparing segmentectomy and lobectomy in terms of preservation of pulmonary function in patients with early-stage non-small-cell lung cancer (NSCLC).

Methods

We conducted a literature search of PubMed using the terms ‘pulmonary function’ AND ‘segmentectomy’ AND ‘lobectomy’. The primary outcomes of interest were the forced expiratory volume in 1 second (FEV1), FEV1 as percent of predicted (%FEV1), change in FEV1 (Δ%FEV1), and the ratio of postoperative to preoperative FEV1.

Results

Thirteen studies comprising 2027 patients met the inclusion and exclusion criteria and were included for analysis, including 787 patients in the segmentectomy group and 1240 patients in the lobectomy group. Patients in the segmentectomy group showed significantly better preservation of FEV1 and %FEV1 compared with the lobectomy group. The reduction in FEV1 after surgery was significantly less in the segmentectomy group compared with the lobectomy group, and Δ%FEV1 was significantly higher in the segmentectomy group than in the lobectomy group.

Conclusion

Segmentectomy results in better preservation of pulmonary function compared with lobectomy in patients with early-stage NSCLC.

Thoracoscopic complex basilar segmentectomies: an analysis of 63 procedures

Background

Thoracoscopic complex basilar segmentectomies are technically demanding and challenging. We review our experience to check whether this complexity can lead to specific surgical issues or increased post-operative morbidity.

Methods

Complex basilar segmentectomies were defined as the anatomical resection of at least one segment composing the basilar pyramid, excluding S⁶. Data of patients who had an intention-to-treat thoracoscopic complex basilar segmentectomy were retrospectively collected from 2007 to 2019: indications, preoperative assessment, clinical features, operative technical aspects and early post-operative outcome.

Results

Sixty-three patients, 26 men (41%) and 37 women (59%) with a median age of 66 years and a median body mass index (BMI) of 26 kg/m2 were included. Interventions performed were mostly S⁹⁺¹⁰ (n=32) and S⁸ (n=12) segmentectomies. Forty-five planned operations (71%) were completed. Extension to a larger resection was necessary in 17 patients (27%) and 4 patients underwent conversion to open surgery (6%). Median operative time was 168 minutes with a median intraoperative bleeding of 30 mL. Complications occurred in 11 patients (17%). There was no mortality. Median length of pleural drainage was 2 days (range, 1–2 days) and median hospital stay 4 days.

Conclusions

The extension rate of complex basilar segmentectomy is higher than that of other sublobar resections but their post-operative morbidity is identical.

Segmentectomy or lobectomy for early-stage non-small-cell lung cancer: a systematic review and meta-analysis

OBJECTIVES

The role of segmentectomy in early-stage non-small-cell lung cancer (NSCLC) remains a matter of debate. We performed a meta-analysis to evaluate the oncological outcomes following segmentectomy versus lobectomy for stage I, stage IA only and stage IA <2 cm only.

METHODS

We systematically searched the literature for articles reporting on overall survival (OS), cancer-specific survival (CSS) or recurrence-free survival (RFS). The hazard ratios (HRs) were retrieved and pooled using an inverse variance-weighted approach.

RESULTS

Twenty-eight studies were included in the analysis. In stage I, segmentectomy was found to be inferior to lobectomy for all 3 outcomes with HR: 1.25 (P = 0.01) for OS, 1.59 (P = 0.02) for CSS and 1.40 (P < 0.001) for RFS. In stage IA, the differences were significant for OS and CSS, though not for RFS with HR: 1.31 (P = 0.04), 1.56 (P = 0.02) and 1.22 (P = 0.11), respectively. In stage IA <2 cm, no significant differences were found between segmentectomy and lobectomy with HR: 1.13 (P = 0.37) for OS, 1.02 (P = 0.95) for CSS and 1.24 (P = 0.11) for RFS.

CONCLUSIONS

For stages I and IA, lobectomy showed superior results whereas for tumours <2 cm, our study did not find significant differences in oncological outcomes between both groups. These results suggest that segmentectomy might be a valuable alternative to lobectomy for NSCLC in tumours <2 cm.

Feasibility investigation of near-infrared fluorescence imaging with intravenous indocyanine green method in uniport video-assisted thoracoscopic anatomical segmentectomy for identifying the intersegmental boundary line

OBJECTIVES

To investigate the perioperative outcomes of patients who underwent uniport video-assisted thoracoscopic (VATS) segmentectomy for identifying the intersegmental boundary line (IBL) by the near-infrared fluorescence imaging with the intravenous indocyanine green (ICG) method or the modified inflation-deflation (MID) method and assess the feasibility and effectiveness of the ICG fluorescence (ICGF)-based method.

METHODS

We retrospectively analyzed the perioperative data in total 198 consecutive patients who underwent uniport VATS segmentectomy between February 2018 and August 2020. With the guidance of a preoperative imaging interpretation and analysis system (IQQA-3D), the targeted segment structures could be precisely identified and dissected, and then the IBL was confirmed by the ICGF-based method or the MID method. The clinical effectiveness and postoperative complications of the two methods were evaluated.

RESULTS

An IBL was visible in 98% of patients in the ICGF-based group, even with low doses of ICG. The ICGF-based group was significantly associated with a shorter IBL clear presentation time (23.6 ± 4.4 vs. 23.6 ± 4.4 s) (p < 0.01) and operative time (89.3 ± 31.6 vs. 112.9 ± 33.3 min) (p < 0.01) compared to the MID group. The incidence of postoperative prolonged air leaks was higher in the MID group than in the ICGF-based group (8/100, 8% vs. 26/98, 26.5%, p = 0.025). There were no significant differences in bleeding volume, chest tube duration, postoperative hospital stays, surgical margin width, and other postoperative complications.

CONCLUSION

The ICGF-based method could highly accurately identify the IBL and make anatomical segmentectomy easier and faster, and therefore has the potential to be a feasible and effective technique to facilitate the quality of uniport VATS segmentectomy.

[Assessment of the Accuracy of Modified Inflation-deflation Methods for Distinguishing the Intersegmental Border]

背景与目的

对于早期肺癌，肺段切除术可以获得和肺叶切除术相同的肿瘤学疗效。肺段间交界面的精准界定是肺段手术的关键。本研究采用“改良膨胀萎陷法”行扩大肺段、亚段切除术治疗肺段间、亚段间磨玻璃结节（ground-glass nodules, GGN），评价“改良膨胀萎陷法”界定肺段交界面的精确性，和对扩大切除确保安全切缘宽度的有效性。

方法

回顾性分析本中心采用扩大肺段、亚段切除术治疗的患者83例。术前三维CT支气管血管成像（three-dimensional computed tomography bronchography and angiography, 3D-CTBA）显示结节累及段间静脉。根据三维重建设计手术，扩大切除结节所属的优势肺段或亚段，无法确定优势肺段、亚段时，选择较为简单的肺段、亚段切除方式。术中切断靶段血管、支气管后采用“改良膨胀萎陷法”确定肺段间或亚段间交界面，应用切割缝合器距离膨胀萎陷交界线2 cm-3 cm扩大切除部分相邻肺段或亚段肺组织。观察标本中膨胀萎陷交界线与结节的关系，测量切缘宽度，收集围术期临床资料。

结果

实施扩大肺段切除术56例，扩大肺亚段切除术27例，肺结节平均直径（0.9±0.3）cm。出现清晰可辨膨胀萎陷交界线79例，交界线形成时间（13.6±6.5）min。解剖标本观察发现，结节累及膨胀萎陷交界线55例，其余24例结节距交界线的最小距离（0.6±0.3）cm，平均切缘宽度（2.1±0.3）cm。无术后30 d死亡和重大并发症。

结论

改良膨胀萎陷法可有效界定肺段间、亚段间交界面，以此为标准可确保扩大肺段、亚段切除术治疗段间、亚段间小肺癌的安全切缘。

Combination of nitrous oxide and the modified inflation-deflation method for identifying the intersegmental plane in segmentectomy: A randomized controlled trial

Background

During thoracoscopic segmentectomy, accurately and rapidly identifying the intersegmental plane (ISP) is of great importance. This study aimed to investigate the effect and safety of a nitrous oxide (N₂O)/oxygen (O₂) inspired mixture on the appearance time of the ISP (T_ISP) via the modified inflation‐deflation method.

Methods

A total of 65 participants who underwent segmentectomy were randomized into three groups: 75% N₂O (n = 24), 50% N₂O (n = 23) or 0% N₂O (n = 18). The 75% N₂O group received a gas mixture of N₂O/O₂ (Fio₂ = 0.25), the 50% N₂O group received N₂O/O₂ (Fio₂ = 0.5), and the 0% N₂O group received 100% oxygen during lung expansion. The appearance time of satisfactory and ideal planes was recorded. Furthermore, arterial blood gas at breathing room air, one‐lung ventilation (OLV) before lung expansion, 5 and 15 min after lung expansion were also recorded.

Results

T_ISP was significantly shorter in the 75% N₂O group (320.2 ± 65.9 s) compared with that of the 50% N₂O group (552.4 ± 88.9 s, p < 0.001) and the 0% N₂O group (968.3 ± 85.5 s, p < 0.001), while the 50% N₂O group was shorter than that of the 0% N₂O group (p < 0.001). Arterial oxygenation was significantly improved in the 0% N₂O group only after lung expansion, before which there were no differences in mean PaO₂ values among groups.

Conclusions

The use of N₂O in the inspired gas mixture during lung expansion is an applicable strategy to rapidly identify the ISP via the modified inflation‐deflation method without any adverse effect on OLV related arterial oxygenation during segmentectomy.

Clinical significance of intrapulmonary lymph node dissection in pathological stage IA non-small cell lung cancer: A propensity score matching analysis

Background

This study aimed to investigate the prognostic impact of intrapulmonary lymph node (ILN, stations 13–14) dissection on disease‐free survival (DFS) in stage IA non‐small cell lung cancer (NSCLC) patients in order to facilitate a more suitable determination of surgical strategies for early‐stage cases.

Methods

We retrospectively analyzed 416 patients with pathological stage IA NSCLC from February 2016 to November 2019. The patients were divided into a group with ILN dissection (ILN^D+ group) and a group without ILN dissection (ILN^D‐ group). DFS was compared using the Kaplan–Meier method and compared statistically using the log‐rank test before and after propensity score matching (PSM). Subgroup analysis of DFS stratified based on tumor size was also calculated.

Results

Both before and after PSM, the four‐year DFS of the ILN^D+ group was greatly increased compared to that of ILN^D‐ group (90.1% vs. 79.7%, p = 0.003; 95.5% vs. 80.6%, p = 0.003, respectively) and multivariable cox regression analysis revealed ILN dissection was an independent factor favoring DFS in stage IA NSCLC (p = 0.016 and p = 0.015, respectively). Subgroup analysis revealed the four‐year DFS was comparable between the ILN ^D+ and ILN^D‐ groups with regard to tumor size ≤1.5 cm (90.6% vs. 92.7%, p = 0.715). However, the ILN ^D+ group was found to have a better oncological outcome compared with the ILN^D‐ group with regard to tumor size >1.5 cm (90.0% vs. 73.8%, p = 0.003).

Conclusions

The prognostic impact of ILN dissection on patients with stage IA NSCLC appears to be significantly influenced by tumor size, and this should be taken into account when choosing the most appropriate therapeutic modality.

Clinical features and prognosis of patients with COVID-19 after lung surgery: A retrospective clinical study

AIM

To evaluate whether the history of lung surgery in patients was associated with poor prognosis of coronavirus disease 2019 (COVID-19).

METHODS

Clinical data of patients with COVID-19 in a single-center were retrospectively analyzed. Patients with and without lung surgery were matched in 1:4 ratio to compare the differences in clinical characteristics, laboratory results, computed tomography findings, treatment regimens, and prognosis between them.

RESULTS

Four patients had a history of lung surgery. The time from surgery to COVID-19 onset ranged from 3 to 10 days, with a median of 6.75 days. The mortality rate in the surgical group was higher than that in the nonsurgical group (25.0% vs. 6.3%).

CONCLUSION

Patients contracting COVID-19 after lung surgery presented a higher death rate; hence, it is necessary to omit lung surgery in patients with active COVID-19 infection.

Subsegmental resection preserves regional pulmonary function: A focus on thoracoscopy

Background

The aim of this study was to evaluate regional postoperative preserved pulmonary function (PPPF) and three‐dimensional (3D) volumetric changes according to the number of resected subsegments and investigate the factors that most affected pre‐/post PPPF.

Methods

Patients who underwent thoracoscopic lobectomy (n = 73), and segmentectomy (n = 87) were eligible for inclusion in the study. They were classified according to the number of resected subsegments which ranged from 1 to 10. The percentage of pre‐/postoperative forced expiratory volume in 1 s (FEV1) was used for comparison. Furthermore, lung volumetric changes were calculated using 3D computed tomography (CT) volumetry.

Results

The percentage of pre‐/postoperative EFV1 between 4 and 5–7 and between 5–7 and 10 were significant (p = 0.03 and p < 0.01, respectively), but not between 1–2 to 4 (p = 0.99). The difference between volumetric changes in the left lower lobe of patients with a number of resected subsegments was significant (p < 0.01). On univariate and multivariate analyses, chronic inflammation was significant for decrease in recovery percentages. When the PPPF was compared among resected subsegments, it gradually decreased with an increase in the number of patients without a postoperative procrastination of inflammation (p < 0.01).

Conclusions

Segmentectomy is feasible and useful for PPPF. Even a relatively large‐volume resection procedure where 5–7 subsegments are resected can preserve pulmonary function. Chronic inflammation was statistically identified as a risk factor for postoperative preserved pulmonary function.

Key points

 

Positron Emission Tomography in Segmentectomy for cT1N0M0 Nonsmall Cell Lung Cancer

BACKGROUND

This study was aimed to examine the significance of fluorodeoxyglucose positron emission tomography in predicting prognosis after segmentectomy in lung cancer.

METHODS

This was a retrospective cohort study, including 227 patients with cT1N0M0 nonsmall cell lung cancer who underwent positron emission tomography followed by segmentectomy between 2012 and 2019. Significance of tumor histology, T-stage, tumor size, and standardized uptake value on positron emission tomography in relation to recurrence-free survival were examined using Cox's proportional hazard analysis. Median follow-up period was 56 months (range: 1-95 months).

RESULTS

Tumor stages were Tis in 25 patients, T1mi/T1a in 51, T1b in 98, and T1c in 53. Twenty-six patients (11%) experienced recurrences, including local (n = 8) and distant (n = 18). Multivariate analysis showed that the significant variables for recurrence-free survival were T-stage and standardized uptake value (p = 0.002 and 0.015, respectively), whereas tumor histology and tumor size were not significant (p = 0.28 and 0.44, respectively). When tumor size was divided into ≤2 cm and >2 cm for analysis, it was not significant again (p = 0.49), whereas standardized uptake value remained significant (p = 0.008). While standardized uptake value of tumors with recurrences was significantly higher than those without (4.9-2.8 and 2.6-2.5, respectively, p < 0.001), there was no significant difference between local and distant recurrences (p = 0.32). Cut-off value of standardized uptake value for recurrences was 3.2. Five-year recurrence-free survival rates in tumors with standardized uptake value <3.2 and ≥3.2 were 86 and 65%, respectively (p < 0.001).

CONCLUSION

Positron emission tomography could predict the prognosis after segmentectomy better than tumor size.

Thoracoscopic Pulmonary Segmentectomy With Collateral Ventilation Method

BACKGROUND

Despite its popularity in recent years, segmentectomy still faces a challenge: the accurate delineation of the intersegmental plane, especially in complex segmentectomy. In this study, we describe a method using collateral ventilation to create an inflation-deflation line for video-assisted thoracoscopic surgery (VATS) segmentectomy and evaluated its efficacy in complex segmentectomy by comparing it with simple segmentectomy.

METHODS

Enrolled in the study were 264 patients who underwent VATS segmentectomy from January 2017 to September 2018. We classified the clarity of the inflation-deflation line into 4 grades, and the procedures of grade 3 or 4 were considered successful. Meanwhile, we performed a propensity score matching analysis to compare complex and simple segmentectomy.

RESULTS

Complete resection with free margins was achieved in all patients. In inflation-deflation line clarity evaluation, 245 patients were classified as grade 4 (92.8%), 10 as grade 3 (3.8%), 8 as grade 2 (3.0%), and 1 as grade 1 (0.4%). Procedural success (grade 3 or 4) was achieved in 255 patients (96.6%). Prolonged air leak (>5 days) was observed in 11 patients (4.2%). Propensity matching generated 83 pairs of well-matched patients. The proportion of procedural success and the incidence of prolonged air leak (>5 days) were similar in both groups. However, compared with simple segmentectomy, complex segmentectomy was associated with a longer median operative time (159 versus 135 minutes; P < .001).

CONCLUSIONS

Collateral ventilation method is simple, safe, and effective in VATS segmentectomy to identify the intersegmental plane, and also well-adapted for complex segmentectomy.

Anatomical segmentectomy versus pulmonary lobectomy for stage I non-small-cell lung cancer: patients selection and outcomes from the European Society of Thoracic Surgeons database analysis

OBJECTIVES

The aims of this study were to describe the potential selection criteria for patients scheduled for lobectomy versus segmentectomy for stage I non-small-cell lung cancer and to compare the 2 procedures in terms of intraoperative variables and postoperative outcomes using the European Society of Thoracic Surgeons (ESTS) Registry.

METHODS

This observational multicentre retrospective cross-sectional study was based on data collected from the ESTS database. The following were set as inclusion criteria: pulmonary lobectomy or segmentectomy for stage I primary lung cancer (according to 8th TNM edition), no previous lung surgery and no induction chemotherapy or radiotherapy. Statistical significance was examined using Mann-Whitney or 2 proportions Z tests.

RESULTS

Among 63 542 patients enrolled in the ESTS database (2007-2018), 17 692 met the inclusion criteria: 15 845 patients received lobectomy and 1847 segmentectomy. Video-assisted thoracic surgery (VATS) lobectomy and VATS segmentectomy were the 27.8% and 31.9% of the procedures, respectively. Lobectomy group was significantly younger and had a lower American Society of Anaesthesiology (ASA) score, lower comorbidities prevalence and better respiratory function. The segmentectomy group had lower complications rate (25.6% vs 33.8%). When considering only the last 5 years, ASA score was similar between the 2 groups, although pulmonary function remained significantly lower in the segmentectomy group.

CONCLUSIONS

According to the ESTS database, segmentectomy was preferably offered to 'compromised' patients, with limited respiratory function, higher ASA score and relevant comorbidities. Nevertheless, the procedure showed lower complications rate and similar short-term outcomes compared to lobectomy. During the last 5 years, segmentectomy appeared to be regarded as a valid alternative, even for selected patients who could tolerate both procedures.

Extent of Segmentectomy That Achieves Greater Lung Preservation Than Lobectomy

BACKGROUND

This study sought to clarify the extent of segmentectomy that achieves greater lung preservation than lobectomy.

METHODS

This was a single-center retrospective cohort study involving 374 patients with lung cancer who were treated with either lobectomy or segmentectomy between 2013 and 2018. The percentage of preserved pulmonary function (%PPF) after surgery was compared among patients who underwent lobectomy (n = 164), segmentectomy of 2 or more segments (Seg ≥2S; n = 42), and segmentectomy of less than 2 segments (Seg <2S; n = 168). Using perfusion scintigraphy, forced expiratory volume in 1 second of the preserved target lobe was measured to examine its effect on the %PPF. The number of resected subsegments (SSs) in segmentectomy that made the %PPF higher than that observed with lobectomy was also examined.

RESULTS

Mean %PPF was lowest in those patients who underwent lobectomy (86%), followed by Seg ≥2S (89%) and Seg <2S (95%) (P < .001), but the difference between the lobectomy and Seg ≥2S was not significant (P = .21). The forced expiratory volume in 1 second of the preserved target lobe was significantly lower in the Seg ≥2S group than in the Seg <2S group (P < .001). The number of resected SSs was 6 to 12 in lobectomy, 4 to 7 in Seg ≥2S, and 1 to 4 in Seg <2S. Although the %PPF after segmentectomy of less than 5 SSs (Seg <5SS) was significantly higher than that after lobectomy (P < .001), the %PPF after segmentectomy of 5 or more SSs (Seg ≥5SS) was not significantly different from that after lobectomy (P = .68).

CONCLUSIONS

Both the Seg ≥2S and Seg ≥5SS groups did not differ from lobectomy in %PPF because of the low function of preserved target lobe.

Postoperative Short-term Outcomes Between Sublobar Resection and Lobectomy in Patients with Lung Adenocarcinoma

Background

To investigate postoperative temporary consequences of the enrolled patients with lung adenocarcinoma.

Patients and Methods

We analyzed the clinical data of patients with lung adenocarcinoma admitted by the same surgical team of Peking Union Medical College Hospital (PUMCH) from July 2019 to December 2019. Statistical methods including propensity score matching (PSM) analysis was used to analyze the differences among them.

Results

A total of 108 patients were enrolled, including 50 patients with sublobar resection and 58 patients with lobectomy. Before PSM, there were statistically significant differences in age (p=0.015), hospitalization costs (p=0.042), lymphadenectomy (p=0.000), pathological staging (p=0.000), number of lymph nodes removed (p=0.000), number of positive lymph nodes (p=0.034), chest drainage duration (p=0.000), total chest drainage (p=0.000), length of postoperative hospital stays (p=0.000), postoperative D-dimer level (p=0.030) and perioperative lymphocyte margin (LM) (p=0.003) between sublobar resection and lobectomy. After PSM, there were statistical differences in number of lymph nodes removed (p=0.000), chest drainage duration (p=0.031) and total chest drainage (p=0.002) between sublobar resection and lobectomy. Whether with PSM analysis or not, there were no significant differences in other blood test results, such as inflammation indicators, postoperative neutrophil-lymphocyte ratio (NLR), albumin level, perioperative activity of daily living (ADL) scale scoring margin, complications, postoperative admission to intensive care unit (ICU) and readmission within 30 days. NLR was associated with total chest drainage (p=0.000), length of postoperative hospital stays (p=0.000), postoperative D-dimer level (p=0.050) and ADL scale scoring margin (p=0.003) between sublobar resection and lobectomy.

Conclusion

Sublobar resection, including wedge resection and segmentectomy, was as safe and feasible as lobectomy in our study, and they shared similar short-term outcomes. Postoperative NLR could be used to detect the clinical outcomes of patients. Secondary resectability of pulmonary function (SRPF) should be the main purpose of sublobar resection.

Perioperative outcomes of segmentectomies versus lobectomies in high-risk patients: an ESTS database analysis

OBJECTIVES

We queried the European Society of Thoracic Surgeons (ESTS) database with the aim to assess cardiopulmonary morbidity and 30-day mortality of segmentectomies and lobectomies in patients with a Eurolung-predicted mortality above the upper interquartile and classified as high risk.

METHODS

A total of 61 492 patients registered in the ESTS database (2007-2018) and submitted to lobectomy (55 353) or segmentectomy (6139) were divided into high risk or low risk according to a Eurolung-predicted mortality cut-off of 2.5% (corresponding in our population to the upper interquartile). Predicted versus observed mortalities were compared within each type of operation by using binomial test of proportion. Observed morbidity and mortality rates were compared between the 2 procedures using the χ2 test.

RESULTS

A total of 14 007 lobectomies and 1251 segmentectomies were classified as high risk. In the high-risk group, the cardiopulmonary morbidity and 30-day mortality rates observed in segmentectomies were lower than in lobectomies (morbidity: 12% vs 17%, P < 0.0001; mortality: 2.4% vs 3.7%, P = 0.018). In segmentectomy patients, the observed mortality rate was lower than the Eurolung-predicted one (2.4% vs 3.8%, P = 0.009), while in the lobectomy patients, there was no difference between observed and predicted mortality (3.7% vs 3.8%, P = 0.9). In the low-risk group, the cardiopulmonary morbidity and 30-day mortality rates observed in segmentectomies were lower than in lobectomies (morbidity: 4.5% vs 7.8%, P < 0.0001; mortality: 0.6% vs 1.0%, P = 0.01). In segmentectomy patients, the observed mortality rate was lower than the Eurolung-predicted one (0.6% vs 1.0%, P = 0.0003), while in the lobectomy patients, there was no difference between observed and predicted mortality (1.0% vs 1.1%, P = 0.06).

CONCLUSIONS

Segmentectomy was found associated with a 0.65 relative risk of mortality rate compared to lobectomy in patients deemed at higher surgical risk.