Technique and outcomes of 79 consecutive uniportal video-assisted sleeve lobectomies

Effect of preoperative three-dimensional modeling on uniportal video-assisted thoracoscopic bronchial sleeve resection and early postoperative outcomes

Background

The aim of this study was to evaluate the effects of preoperative three-dimensional (3D) modeling on the performance of uniportal video-assisted thoracoscopic bronchial sleeve resection and early postoperative outcomes.

Methods

A total of 10 patients (5 males, 5 females; mean age: 53.8±16.9 years; range, 18 to 75 years) who underwent uniportal video-assisted thoracoscopic bronchial sleeve resection with preoperative 3D modeling between April 2021 and November 2023 were retrospectively analyzed. Preoperative 3D modeling was prepared using computed tomography with an open-source 3D software program. Demographic, clinical, intraoperative, and postoperative data of the patients were recorded. Anatomical landmarks identified by preoperative 3D modeling were compared with intraoperative findings.

Results

The anatomical landmarks created with the 3D model were in 100% agreement with the intraoperative findings. The procedures performed were three left lower lobes, three right upper lobes, one middle lobe, one right lower lobe, and one parenchyma-sparing intermediate bronchial sleeve resection. Bronchial sleeve resection was completed using uniportal video-assisted thoracoscopic technique in 90% of patients, with only one patient requiring conversion to open thoracotomy. The mean resection time was 264.2±40.5 min, and the mean anastomosis time was 86.0±20.3 min. Anastomosis times decreased with increasing experience (p=0.008). Postoperative atelectasis was observed in two patients, and there was no mortality. The mean follow-up duration was 12.2±11.8 months.

Conclusion

Preoperative 3D modeling significantly contributed to the successful implementation of uniportal video-assisted thoracoscopic bronchial sleeve resection surgery. In the future, with advancements in simulation programs, patient-specific 3D modeling is expected to benefit the identification of anatomical landmarks for bronchial sleeve resections.

VATS sleeve resections

Sleeve resections in central tumors is a surgical method preferred over pneumonectomy owing to its parenchymasparing features. With the increasing surgical experience and developing technology in recent years, sleeve resections can be performed using the video-assisted thoracoscopic surgery method. However, these resections are technically challenging and require significant experience. In this review, we discuss sleeve resections with video-assisted thoracoscopic surgery in the light of the literature.

Video-assisted thoracoscopic versus open sleeve lobectomy for non-small cell lung cancer: A systematic review and meta-analysis from six comparative studies

BACKGROUND

Lung sleeve resection is indicated for centrally located lung tumors, especially for patients who cannot tolerate pneumonectomy. With video-assisted thoracoscopic surgery (VATS) being increasingly implemented for a wide variety of thoracic pathologies, this study aims to compare the intraoperative, postoperative, and long-term outcomes of VATS and open bronchial sleeve lobectomy for non-small cell lung cancer (NSCLC).

METHODS

The MEDLINE (via PubMed), Cochrane Library, and Scopus databases were searched. Original clinical studies, comparing VATS and open sleeve lobectomy for NSCLC were included. Evidence was synthesized as odds ratios for categorical and weighted mean difference (WMD) for continuous variables.

RESULTS

Our analysis included six studies with non-overlapping populations reporting on 655 patients undergoing bronchial sleeve lobectomy for NSCLC (229 VATS and 426 open). VATS sleeve lobectomy was associated with significantly longer operative time ((WMD): 45.85 min, 95% confidence interval (CI): 12.06 to 79.65, p  =  0.01) but less intraoperative blood loss ((WMD): -34.57 mL, 95%CI: -58.35 to -10.78, p < 0.001). No significant difference was found between VATS and open bronchial sleeve lobectomy in margin-negative resection rate, number of lymph nodes resected, postoperative outcomes (drainage duration, length of hospital stay, 30-day mortality), postoperative complications (pneumonia, bronchopleural fistula/empyema, prolonged air leakage, chylothorax, pulmonary embolism, and arrhythmia), and long-term outcomes (overall survival, recurrence-free survival).

CONCLUSIONS

The limitation of our study arises mainly due to the heterogeneity of the included studies. Nevertheless, VATS bronchial sleeve lung resection constitutes a feasible and safe alternative to the open sleeve lung resection surgery for the management of centrally located lung tumors.

Lung cancer

Lung cancer is one of the most frequently diagnosed cancers and the leading cause of cancer-related deaths worldwide with an estimated 2 million new cases and 1·76 million deaths per year. Substantial improvements in our understanding of disease biology, application of predictive biomarkers, and refinements in treatment have led to remarkable progress in the past two decades and transformed outcomes for many patients. This seminar provides an overview of advances in the screening, diagnosis, and treatment of non-small-cell lung cancer and small-cell lung cancer, with a particular focus on targeted therapies and immune checkpoint inhibitors.

Extended Pulmonary Resection by Sleeve Lobectomy and Carinal Pneumonectomy: Selection and Technique

Minimally invasive surgical approaches for extended pulmonary resections are becoming increasingly common as more surgeons gain experience in thoracoscopic and robotic technique. Outcome studies demonstrate improved decreased morbidity as compared with an open surgery.

Technical aspects of uniportal video-assisted thoracoscopic double sleeve bronchovascular resections

Double sleeve, bronchial and vascular reconstructions are challenging procedures indicated for centrally located tumours to avoid pneumonectomy. Traditionally, these resections have been performed by thoracotomy, but thanks to advances in imaging systems, better surgical instruments and the gained experience in video-assisted thoracic surgery (VATS), the scenario now is different. During the last decade, we have seen a rapid evolution of the uniportal VATS technique from simple lobectomies to advanced double sleeve bronchovascular procedures and carinal resections. The advantages of VATS over open surgery for major lung resections in terms of postoperative pain and morbidity, length of hospital stay and quality of life have prompted experienced surgeons to adopt uniportal VATS for cases requiring a sleeve resection. However, when a double bronchial and vascular sleeve resection is required, the adoption rate of minimally invasive surgery is still very low even for very experienced VATS surgeons. The difficulty of tumour mobilization, complexity of the suturing technique and the concern about possible uncontrolled massive bleeding during VATS are the main reasons for this low rate of adoption. In this article, we describe the technical aspects and tricks of this procedure when it is done by the uniportal VATS approach.

Uniportal video-assisted versus open pneumonectomy: a propensity score-matched comparative analysis with short-term outcomes

OBJECTIVES

Uniportal (U-VATS) pneumonectomy in lung cancer patients remains disputed in terms of oncological outcomes, and has not been compared to open approaches previously. We evaluated U-VATS versus open pneumonectomy at a high-volume centre.

METHODS

Patients undergoing pneumonectomy for lung cancer between 2014 and 2018 were retrospectively reviewed and divided into two groups based on surgical approach. Propensity-score matching was performed (1:1), and intention-to-treat analysis applied. Overall survival, operative time, intraoperative blood loss, hospital-stay and readmission, pain, time to adjuvant therapy, morbidity and mortality were tested. Statistical analysis was performed using SAS version 9.4 (SAS Institute Inc. NC) RESULTS: 341 patients underwent pneumonectomy; 23 patients with small-cell lung cancer were excluded, thus 318 patients were submitted to surgery by either U-VATS (n = 54) or open (n = 264). After matching, 52 patients were selected from each group. Five patients (9.2%) in the uniportal group required conversion. There was no significant difference in intraoperative outcomes, complication rates, readmission rates or mortality. The U-VATS group experienced significantly shorter hospital stay (mean ± SD; 6.7 ± 2.7 vs 9.1 ± 2.3 days, p < 0.001) and reported less pain postoperatively (p < 0.0001). Adjuvant chemotherapy was initiated sooner after U-VATS (38.1 ± 8.4 vs 50.8 ± 11.5 days, p < 0.0001). Overall survival appeared to be superior in U-VATS when pathology stage was aligned (p = 0.001).

CONCLUSIONS

Uniportal VATS is a safe and effective alternative approach to open surgery for pneumonectomy in lung cancer. Complications and oncologic outcomes were comparatively similar. U-VATS showed lower postoperative pain, shorter hospital stay and superior overall survival. The study is a preliminary analysis.

Surgical techniques and outcome analysis of uniportal video-assisted thoracic surgery complex sleeve lung resection: a 20 case-series study

Background

Our study aims to explore the feasibility of uniportal video-assisted complex sleeve lung resection and summarize the surgical techniques and clinical outcomes.

Methods

From June 2016 to April 2020, a total of 20 complex sleeve pulmonary and distal tracheal resections were performed by the single surgical team at the Thoracic Surgery Department of the Shanghai Pulmonary Hospital. We defined cases as complex sleeve pulmonary resections if they required pulmonary segment sleeve resection, extended sleeve resection (lobectomy plus segmentectomy of the remaining lobe), sleeve pneumonectomy, lobectomy plus carinoplasty or neo-carina construction, pulmonary-sparing main bronchus resection plus carina reconstruction, and distal trachea resection with end to end anastomosis.

Results

The 20 cases comprised lung squamous cell carcinoma (n=11), lung adenocarcinoma (n=2), hamartoma (n=3), adenoid cystic carcinoma (n=2), carcinoid tumor (n=1), and pleomorphic carcinoma (n=1). The average blood loss during the operation was 250±126.17 mL (50–800 mL). The average operation time was 192.0±61.1 minutes. The average number of lymph node stations removed was 5.82±1.33, including station seven in all cases, and the median number of lymph nodes removed was 4.18±5.89. On the day of surgery, the drainage volume was 266±192.01 mL. The mean postoperative hospital stay was 5.37±1.86 days. Twelve of the 16 patients diagnosed with malignancy received postoperative chemotherapy. Granuloma formation at the anastomosis level led to stenosis in one case, and tumor recurrence occurred in one case. Broncho-esophageal fistula occurred in one patient after radiochemotherapy. The postoperative follow-up time was 15.6±10.7 months. The 30-day mortality was zero, and at one-year follow-up, only one patient had died of metastatic disease after the operation.

Conclusions

Uniportal video-assisted complex sleeve pulmonary resections are feasible when conducted by experienced teams.

Endobronchial Carcinoids: Surgical Outcome in 100 Consecutive Patients and Factors Affecting Lung Preservation

Bronchial carcinoids are slow-growing tumours of the neuroendocrine family. Most of them have a benign course with excellent outcome after complete resection. Due to their location in the primary bronchi, adequate resection with lung preservation requires considerable technical expertise. In this paper we present our surgical experience with endobronchial carcinoids and analyse the factors that predict possibility of lung preservation surgery. Retrospective analysis of a prospectively maintained database of patients operated for endobronchial carcinoids for the period March 2012 to September 2019 was carried out. Demographic factors and peri-operative variables were recorded and analysed. Factors that influence surgical outcome and possibility of lung preservation surgery were analysed. A total of 137 patients underwent surgery for resection of carcinoid tumours, out of which 100 had endobronchial carcinoids whereas 37 had peripheral carcinoids. The surgical procedure in 100 patients with endobronchial carcinoids included 14 left main bronchus sleeve resections, 13 pneumonectomies (7 right sided and 6 left sided), 10 right lower and middle bi-lobectomies, 10 lobectomies (4 left upper, 2 left lower and 4 right upper), and 53 sleeve lobectomies (18 left upper lobe sleeves, 8 left lower lobe sleeves, 20 right upper lobe sleeves, 5 right middle lobe sleeves and 2 right lower lobe sleeve lobectomies). There was no operative mortality. Median tumour size was 3.9 cm (range 5-130 mm). On univariate analysis, longer duration of symptoms was associated with poor surgical outcomes. On multivariate analysis, tumour in the main bronchus, duration of disease < 3 months (p = 0.006), left-sided disease (p = 0.03), and presence of healthy distal lung parenchyma (p < 0.001) were associated with successful lung preservation. Majority of endobronchial carcinoid tumours can be managed with lung-sparing procedures with minimal morbidity and mortality and excellent immediate and short-term outcomes. Early referral and experience of team performing these complex procedures are the key to success.

Prophylaxis and management of postoperative complications after tracheobronchial surgery

Prevention of bronchial complications after airway surgery must be our primary goal. Understanding bronchial and anastomotic healing is the first step to success. This can be improved by standardizing operating technique (bronchial closure and end-to-end anastomosis) as well as postoperative care. Bronchopleural fistula after pneumonectomy still remains a feared complication with a high mortality rate. Especially after sleeve resection interpretation of endobronchial healing and postoperative measures of care with the help of an algorithm, may avoid anastomotic insufficiency and therefore reduced the secondary pneumonectomy rate.

Uniportal Thoracoscopic Decortication for Stage III Tuberculous Empyema With Severe Rib Crowding

BACKGROUND

This study explored the safety and feasibility of uniportal video-assisted thoracoscopic (VATS) decortication in patients presenting with stage III tuberculous empyema with severe rib crowding.

METHODS

From August 2017 to January /2019, 33 patients with stage III tuberculous empyema and severe rib crowding underwent uniportal VATS decortication with partial rib resection and the use of a customized periosteal stripper. Preoperative and postoperative chest computed tomography (CT) imaging and pulmonary function testing were analyzed to evaluate the clinical significance of certain imaging findings and surgical efficacy.

RESULTS

There was 1 conversion to open thoracotomy. Median operative time was 3.5 hours (range, 2.1-4.5 hours) and the median blood loss was 500 mL (range, 250-1000 mL). There were no perioperative mortalities. The incidence of prolonged air leaks (>5 days) was 81.8%. Median postoperative hospital stay was 4 days (range, 4-5 days). All patients were discharged with 2 chest tubes, and median duration drainage was 39 days (range, 30-60 days). The presence of a low-density line between the parietal fibrous pleural rind and chest wall was demonstrated on chest CT in 13 patients. Intraoperative blood loss was considerably lower in these patients compared with those without this imaging finding. Follow-up was complete in all patients over a median of 8 months (range, 6-11.5 months). All patients recovered well and achieved notable improvement in pulmonary function.

CONCLUSIONS

Uniportal VATS decortication is safe and effective. Patients presenting with a low-density line around the thickened fibrous pleural rind on preoperative chest CT scan may be good candidates.

Uniportal video-assisted thoracoscopic lung sparing tracheo-bronchial and carinal sleeve resections

Pathology arising from the intrathoracic portion of the trachea (distal trachea), the carina and the main bronchi is usually neoplastic and is mainly treated with surgery. Resection of the intrathoracic portion of the trachea, the carina and the main bronchi for neoplastic lesions does not necessitate lung resection and is traditionally being conducted via open surgery. Video-assisted thoracic surgery (VATS) is witnessing an exponential growth and is the treatment of choice for early-stage non-small cell lung cancer (NSCLC). The experience accumulated over the past two decades along with the introduction of reliable and ergonomic technology, has led to the expansion of its indications. In this article we provide a detailed description of lung sparing distal tracheal, carinal and main bronchi resection for primary neoplasms of the airway, without involvement of the lung, with the uniportal video-assisted technique. The chest is entered through the fourth intercostal space, mid-axillary line. Dissection of the paratracheal space anteriorly, the tracheoesophageal groove posteriorly and the subcarinal space and division of the azygos arch are essential to mobilize the distal trachea and carina. Lateral dissection should be avoided beyond the points of division of the airway, as it may hinder the blood supply to the anastomosis. Any tension to the anastomosis should be relieved by release maneuvers. Ventilation is achieved through an endobronchial catheter, inserted into the left main bronchus through which a high-frequency jet ventilation catheter can be also inserted through it. The rationale of applying a minimally invasive technique for the conduction of tracheal and carinal resections, is to exploit its advantages, namely less pain, earlier mobilization and lower morbidity. Uniportal video-assisted resections of the distal trachea, carina and the main bronchi, are safe when conducted by experienced surgical and anesthetic teams.

Perioperative Outcomes and 5-year Survival After Open versus Thoracoscopic Sleeve Resection for Lung Cancer

The objective of this study was to evaluate the impact of a video-assisted thoracoscopic (VATS) approach on outcomes in patients who underwent sleeve lobectomy for non-small-cell lung cancer (NSCLC). Outcomes of patients with cT1-T3, N0-N2, M0 NSCLC who underwent sleeve lobectomy in the National Cancer Data Base (NCDB) from 2010-2015 were assessed using Kaplan-Meier, propensity score-matching, and Cox proportional hazards analyses. An "intent-to-treat" analysis was performed. In the NCDB, 210 sleeve lobectomy patients met inclusion criteria (VATS 44 [21%], thoracotomy 166 [79%]). Nine (20%) of the VATS cases were converted to open. Compared to an open approach, VATS was associated with no significant differences in lymph nodes examined (median 9.5 vs 9.0; p = 0.72), length of stay (median 6 days vs 6 days; p = 0.36), 30-day mortality (4.5% vs 1.8%; p = 0.28), and 90-day mortality (6.8% vs 4.8%; p = 0.70). There were no significant differences in 5-year survival between the VATS and open groups in both the entire cohort (VATS [85%] vs open [79%]; log-rank p = 0.91) and in a propensity score-matched analysis of 86 patients (log-rank p = 0.75). Furthermore, a VATS approach was also not associated with worse survival in multivariable analysis (HR = 0.64; 95% CI [0.23-1.78]; p = 0.39). In this national analysis, a VATS approach for sleeve lobectomy for NSCLC was not associated with worse short-term or long-term outcomes when compared to an open approach.

[Efficacy of Lung Autotransplantation for Central Non-small Cell Lung Cancer]

BACKGROUND

Pneumonectomy and sleeve resection are routine operations for the treatment of central non-small cell lung cancer (NSCLC), but some patients suffered of central NSCLC, whose pulmonary function is too poor to tolerate pneumonectomy, or the tumor involves the bronchus and pulmonary artery extensively,it is hard to perform bronchovascular sleeve lobectomy. The aim of this study is to assess the feasibility of lung autotransplantation in the treatment of central NSCLC.

METHODS

The clinical data of 3 cases with central NSCLC treated by lung autotransplantation was reviewed from December 2016 to December 2018. One patient underwent double sleeve resection of left upper lobe with end-to-end anastomosis of the bronchus. Because the resection of the pulmonary artery was too long to perfrom a tension-free anastomosis, the inferior pulmonary vein was cut off, then the left lower lobe was moved up for an anastomosis of the inferior pulmonary vein and the stump of the superior pulmonary vein. In the other 2 cases, left pneumonectomy was performed directly, and the upper left lobe was excised in vitro. The lower left lobe was reset to the chest after trimming and flushing and then the bronchus, pulmonary artery and pulmonary vein were anastomosed in turn.

RESULTS

The average operation time was 333 min, the average time of vascular occlusion was 86 min, the average blood loss was 450 mL, and the average hospital stay was 18.7 d; Perioperative complications included a case of bronchial obstruction, which improved after sputum aspiration through bronchofibroscope. The average follow-up period was 20 mon; One case died of cancer, one case had recurrence of anastomotic stoma and brain metastasis, one case had 4R lymph node metastasis (stable condition after chemotherapy), and one case survived without recurrence.

CONCLUSIONS

For patients with central NSCLC with extensive tumor invasion, thus inability to tolerate sleeve resection or pneumonectomy, autologous lung transplantation can preserve lung function to the greatest extent with a complete tumor resection and improve postoperative quality of life.

The Initial Experience on Thoracoscopic Sleeve Lobectomy: Continuous Suturing Technique of the Bronchial Anastomosis in 12 Cases

BACKGROUND

Sleeve resection is a widely performed type of operation in the surgical treatment of non-small cell lung cancer. Video-assisted thoracoscopic surgery (VATS) is now used even in central tumor surgeries of the lung with the increasing technology and experience. Sleeve resection cases performed through VATS in our clinic in recent years were presented with demographic, surgical, pathologic, and survey characteristics.

MATERIALS AND METHODS

Twelve patients who underwent sleeve resection with VATS in our clinic between November 2015 and August 2019 were included in the study. Operative, pathologic, and postoperative characteristics of the patients were examined.

RESULTS

A total of 12 patients, 3 female and 9 male individuals, were included in the study. The mean age of the patients was 61.7±12.9 years. According to the localization of the tumors, left upper lobectomy was performed in 4 patients and 8 patients underwent right upper lobectomy. During the sleeve anastomosis of the patients, 3/0 prolene sutures were used in 5 patients (36%) and 4/0 prolene sutures in 4 patients (36%), whereas 3/0 polydioxanone suture (PDS) was used in 3 patients (28%). The mean operation time was 288.2±77.1 (205 to 460) minutes and the mean anastomosis time was 70±18.5 (55 to 110) minutes. In the postoperative period, 1 patient who had acute myocardial infarction died on the fourth postoperative day. The mean postoperative drainage duration of the patients was 5.5±1.9 (3 to 10) days and the mean length of hospital stay was 6.4±1.9 (4 to 11) days. When the pathologic features were examined, the mean tumor diameter was found to be 2.5±1.2 (1 to 5.5) cm. The mean follow-up period was calculated as 26.1±15.6 months (2 to 47). Other than 1 patient who died, the follow-up of 11 patients still proceeds.

CONCLUSIONS

VATS approach of sleeve resections, which is performed cautiously even by thoracotomy, is becoming more common. These operations, which could be performed in experienced centers, offer a postoperative period of less morbidity to the patients with the advantage of reduced postoperative pain, drainage time, and hospital stay.

Uniportal VATS for non-small cell lung cancer

The video-assisted thoracic surgery (VATS) technique has evolved from its multiport origins to even less invasive approaches grounded in its proven benefits over open surgery for the treatment of early stage lung cancer. In this evolution process, the Uniportal VATS (UniVATS) strategy emerged. This technique is giving some evidence of benefits when compared to the multiport VATS and has been embraced by the surgical community spreading its geographical and surgical boundaries. Moreover, UniVATS has proven its feasibility for numerous and more complex procedures for lung cancer diagnosis and treatment, which are reviewed in this document as well as its current and future development.