Video-assisted thoracoscopic surgery versus open thoracotomy for pulmonary metastasectomy: a systematic review

Could video-assisted thoracoscopic surgery be feasible for blunt trauma patients with massive haemothorax?

INTRODUCTION

The study reviewed the experience of video-assisted thoracoscopic surgery (VATS) for the treatment of massive haemothorax (MHT).

MATERIALS AND METHODS

All adult patients who sustained blunt trauma with a diagnosis of traumatic haemothorax or pneumothorax (ICD9 860; ICD10 S27.0-2), injury to the heart and lungs (ICD9 861; ICD10 S26, S27.3-9), and injury to the blood vessels of the thorax (ICD9 901; ICD10 S25) were queried from the trauma registry between 2014 and 2018. Patients who had chest tube drainage amounts meeting the criteria for MHT and who underwent subsequent operations were eligible for analyses. The patients were divided into VATS or thoracotomy groups based on the surgical modalities. Descriptions and analyses of the two groups were made.

RESULTS

Thirty-eight patients were enroled in the study, including 8 females (21%) and 30 males. The median age was 47.0 (first quartile (Q1) 25.5 and third quartile (Q3) 59.3) years. Twenty-three patients were in the VATS group, six (26%) of whom were converted to thoracotomy. There were no obvious differences in age, sex, pulse rate, or systolic pressure on arrival to the ED or after resuscitation between the two groups. The laboratory data were worse amongst the thoracotomy group, especially the arterial blood gas analysis (ABG) results: pH 7.2 (7.1, 7.3) vs. 7.4 (7.2, 7.4); HCO₃ 14.6 (12.4, 18.7) vs. 19.7 (16.1, 23.9) mEq/L; base excess (BE) -12.6 (-15.8, -7.8) vs. -5.2 (-11.1, -0.9) mEq/L. The PaO₂/FiO₂ ratio was lower in the thoracotomy group (91.4 (68.5, 193.3) vs. 245.3 (95.7, 398.0) mmHg). The thoracotomy group had coagulopathy (INR 1.6 (1.2, 1.9) vs. 1.3 (1.1, 1.4)) and required more blood transfusions (WB and PRBC 36.0 (16.0, 48.0) vs. 12.0 (4.0, 24.0) units; FFP 20.0 (6.0, 50.0) vs. 6.0 (2.0, 20.0) unit). No factors associated with VATS conversion to thoracotomy could be identified.

CONCLUSIONS

VATS could be applied to selected blunt trauma patients with MHT. The major differences between the VATS and thoracotomy groups were coagulopathy, acidosis, PaO₂/FiO₂ ratio < 200 mmHg, or a persistent need for blood transfusion.

Correlation between preoperative CT scan and lung metastases according to surgical approach in patients with colorectal cancer

INTRODUCTION

The number of lung metastases (M1) of colorectal carcinoma (CRC) in relation to the findings of computed tomography (CT) is the object of study.

METHODS

Prospective and multicenter study of the Spanish Group for Surgery of CRC lung metastases (GECMP-CCR). The role of CT in the detection of pulmonary M1 is evaluated in 522 patients who underwent a pulmonary metastasectomy for CRC. We define M1/CT as the ratio between metastatic nodules and those found on preoperative CT. Disease-specific survival (DSS), disease-free survival (DFS), and surgical approach were analyzed using the Kaplan-Meier method.

RESULTS

93 patients were performed by video-assisted surgery (VATS) and 429 by thoracotomy. In 90%, the M1/CT ratio was ≤1, with no differences between VATS and thoracotomy (94.1% vs 89.7%, p=0.874). In the remaining 10% there were more M1s than those predicted by CT (M1/CT>1), with no differences between approaches (8.6% vs 10%, p=0.874). 51 patients with M1/CT>1, showed a lower median DSS (35.4 months vs 55.8; p=0.002) and DFS (14.2 months vs 29.3; p=0.025) compared to 470 with M1/CT≤1. No differences were observed in DSS and DFS according to VATS or thoracotomy.

CONCLUSIONS

Our study shows equivalent oncological results in the resection of M1 of CRC using VATS or thoracotomy approach. The group of patients with an M1/CT ratio >1 have a worse DSS and DFS, which may mean a more advanced disease than predicted preoperatively.

Correlation between preoperative CT scan and lung metastases according to surgical approach in patients with colorectal cancer

INTRODUCTION

The number of lung metastases (M1) of colorectal carcinoma (CRC) in relation to the findings of computed tomography (CT) is the object of study.

METHODS

Prospective and multicenter study of the Spanish Group for Surgery of CRC lung metastases (GECMP-CCR). The role of CT in the detection of pulmonary M1 is evaluated in 522 patients who underwent a pulmonary metastasectomy for CRC. We define M1/CT as the ratio between metastatic nodules and those found on preoperative CT. Disease-specific survival (DSS), disease-free survival (DFS), and surgical approach were analyzed using the Kaplan-Meier method.

RESULTS

93 patients were performed by video-assisted surgery (VATS) and 429 by thoracotomy. In 90%, the M1/CT ratio was ≤1, with no differences between VATS and thoracotomy (94.1% vs 89.7%, p=0.874). In the remaining 10% there were more M1s than those predicted by CT (M1/CT>1), with no differences between approaches (8.6% vs 10%, p=0.874). 51 patients with M1/CT>1, showed a lower median DSS (35.4 months vs 55.8; p=0.002) and DFS (14.2 months vs 29.3; p=0.025) compared to 470 with M1/CT≤1. No differences were observed in DSS and DFS according to VATS or thoracotomy.

CONCLUSIONS

Our study shows equivalent oncological results in the resection of M1 of CRC using VATS or thoracotomy approach. The group of patients with an M1/CT ratio >1 have a worse DSS and DFS, which may mean a more advanced disease than predicted preoperatively.

Thoracoscopy vs thoracotomy for the management of metastatic osteosarcoma: A Pediatric Surgical Oncology Research Collaborative Study

Complete surgical resection of pulmonary metastatic disease in patients with osteosarcoma is crucial to long-term survival. Open thoracotomy allows palpation of nodules not identified on imaging but the impact on survival is unknown. The objective of this study was to compare overall survival (OS) and pulmonary disease-free survival (DFS) in children who underwent thoracotomy vs thoracoscopic surgery for pulmonary metastasectomy. A multi-institutional collaborative group retrospectively reviewed 202 pediatric patients with osteosarcoma who underwent pulmonary metastasectomy by thoracotomy (n = 154) or thoracoscopy (n = 48). Results were analyzed by Kaplan-Meier survival estimates and multivariate Cox proportional hazard regression models. With median follow-up of 45 months, 135 (67.5%) patients had a pulmonary relapse and 95 (47%) patients were deceased. Kaplan-Meier analysis showed no significant difference in 5-year pulmonary DFS (25% vs 38%; P = .18) or OS (49% vs 42%, P = .37) between the surgical approaches of thoracotomy and thoracoscopy. In Cox regression analysis controlling for other factors impacting outcome, there was a significantly increased risk of mortality (HR 2.11; P = .027; 95% CI 1.09-4.09) but not pulmonary recurrence (HR 0.96; P = .90; 95% CI 0.52-1.79) with a thoracoscopic approach. However, in the subset analysis limited to patients with oligometastatic disease, thoracoscopy had no increased risk of mortality (HR 1.16; P = .62; 0.64-2.11). In conclusion, patients with metastatic osteosarcoma and limited pulmonary disease burden demonstrate comparable outcomes after thoracotomy and thoracoscopy for metastasectomy. While significant selection bias in these surgical cohorts limits the generalizability of the conclusions, clinical equipoise for a randomized clinical trial in patients with oligometastatic disease is supported.

Surgical management of colorectal lung metastases

Pulmonary metastasectomy for colorectal cancer is an established means of treatment for select patients. This article will highlight the recent evidence published in the literature related to current practices for the surgical management of colorectal lung metastases and propose a diagnostic algorithm for use in clinical practice. It will also discuss controversies related to pulmonary metastasectomy, including the optimal timing of surgery, the extent of lymph node sampling/dissection, and the extent of surgical resection.

Near-infrared intraoperative imaging for minimally invasive pulmonary metastasectomy for sarcomas

BACKGROUND

Complete pulmonary metastasectomy for sarcoma metastases provides patients an opportunity for long-term survival and possible cure. Intraoperative localization of preoperatively identified metastases and identification of occult lesions can be challenging. In this trial, we evaluated the efficacy of near-infrared (NIR) intraoperative imaging using second window indocyanine green during metastasectomy to identify known metastases and to detect occult nodules.

METHODS

Thirty patients with pulmonary nodules suspicious for sarcoma metastases were enrolled in an open-label, feasibility study (NCT02280954). All patients received intravenous indocyanine green (5 mg/kg) 24 hours before metastasectomy. Patients 1 through 10 (cohort 1) underwent metastasectomy via thoracotomy to assess fluorescence patterns of nodules detected by traditional methods (preoperative imaging and intraoperative visualization/bimanual palpation). After confirming reliability within cohort 1, patients 11 through 30 (cohort 2) underwent video-assisted thoracic surgery metastasectomy with NIR imaging.

RESULTS

In cohort 1, 14 out of 16 preoperatively identified pulmonary metastases (87.5%) displayed tumor fluorescence. Nonfluorescent metastases were deeper than fluorescent metastases (2.1 cm vs 1.3 cm; P = .03). Five out of 5 metastases identified during thoracotomy displayed fluorescence. NIR imaging identified 3 additional occult lesions in this cohort. In cohort 2, 33 out of 37 known pulmonary metastases (89.1%) displayed fluorescence. Nonfluorescent tumors were deeper than 2.0 cm (P = .007). NIR imaging identified 24 additional occult lesions. Of 24 occult lesions, 21 (87.5%) were confirmed metastases and the remaining 3 nodules were lymphoid aggregates.

CONCLUSIONS

NIR intraoperative imaging with indocyanine green (5 mg/kg and 24 hours before surgery) localizes known sarcoma pulmonary metastases and identifies otherwise occult lesions. This approach may be a useful intraoperative adjunct to improve metastasectomy.

Management of Sarcoma Metastases to the Lung

For decades, surgical resection of pulmonary metastases has been performed; despite limited randomized data, surgery is increasingly accepted as an integral part in the management of metastatic disease. Long-term results indicate resection is potentially curative with significantly improved survival following complete resection. Recurrence, however, is not uncommon with many patients undergoing repeat resection. With advancing surgical technique and adjuvant therapies, patients with high or recurrent tumor burden are increasingly afforded disease control and potential cure. In this review, the prognostic characteristics of pulmonary metastases from sarcoma, preoperative evaluation, operative technique, long-term outcomes, and management of complex patients are highlighted.