Expert Consensus Statement on Optimal Approach to Lobectomy for Non-Small Cell Lung Cancer

Overview of the outcomes of robotic segmentectomy and lobectomy

Segmentectomy has gained popularity in the latest years as a valid alternative to lobectomy. Initially reserved to patient unfit for lobar lung resection, this procedure is now offered also in selected patient with <2 cm peripheral lung cancer confined to an anatomic segment with no nodal involvement on preoperative evaluation. The introduction of screening with low-dose CT chest scan allowed the identification of lung cancer at early stages, making possible to schedule a more conservative lung surgery. A major improvement came also from minimally invasive surgery (MIS), reducing complication rate with comparable survival rates when compared to open surgery. However, due to long learning curve and uncomfortable instruments handling of video-assisted thoracoscopy, many surgeons still prefer to perform segmentectomies through a thoracotomy and thus increasing perioperative morbidity and leading to post-thoracotomy syndrome due to rib-spreading. Robotic assisted thoracic surgery (RATS) can avoid this throwback, combining the handling of open surgery with lesser invasiveness of thoracoscopy. Although literature has given strong evidences in favour of robotic lobectomies, data are still limited regarding segmentectomies performed with this technique. Moreover, no results are still available from the two ongoing randomized controlled trials comparing segmentectomy to lobectomy and so the latter represent the oncologically proper procedure for lung cancer along with lymph-node dissection. In this review we analyse the literature currently available on outcomes of lobar and sublobar anatomical resection performed by RATS, with a brief mention of the existing surgical techniques of port positioning and the costs of this procedure.

Application of Continuous Positive Airway Pressure During Video-Assisted Thoracoscopic Surgery

Purpose of Review

Video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracoscopic surgery (RATS) are used for anatomic resection of early stage cancer. These surgical techniques require the use of one-lung ventilation (OLV). During OLV, an obligatory intrapulmonary shunt may produce hypoxemia. One method to correct hypoxemia is with the use of continuous positive airway pressure (CPAP). This review focuses on 1) the lung physiology of OLV; 2) application of CPAP in VATS or RATS during supine and lateral position; and 3) the application of CPAP in COVID-19 patients during OLV.

Recent Findings

Studies have shown the beneficial effects of CPAP to improve oxygenation during OLV while the patient is in the lateral decubitus position. In contrast, studies have shown no benefit on improving oxygenation with CPAP in patients undergoing OLV in supine position.

Summary

The application of CPAP to the non-dependent lung is one of the options to treat hypoxemia during VATS or RATS.

Uniportal and three-portal video-assisted thoracic surgery pulmonary lobectomy for early-stage lung cancer (UNIT trial): study protocol of a single-center randomized trial

Background

Video-assisted thoracoscopic surgery (VATS) lobectomy is currently the recommended approach for treating early-stage non-small cell lung cancer (NSCLC). Different VATS approaches have been proposed so far, and the actual advantages of one technique over the other are still under debate. The aim of our study is to compare postoperative pain and analgesic drug consumption in uniportal VATS and triportal VATS for pulmonary lobectomy in early-stage lung cancer patients.

Methods

This study is a single-center, prospective, two-arm, parallel-group, randomized controlled trial. It is designed to compare uniportal video-assisted thoracic surgery (u-VATS) and three-port video-assisted thoracic surgery (t-VATS) in terms of postoperative pain. The trial will enroll 120 patients with a 1:1 randomization. The primary outcome is the assessment of analgesic drug consumption. Secondary outcomes are postoperative pain measurement, evaluation of postoperative pulmonary function, and metabolic recovery after pulmonary lobectomy.

Discussion

The choice of which VATS approach to adopt for treating patients undergoing pulmonary resection mostly depends on the surgeon’s preferences; therefore, it is hard to prove whether one VATS technique is superior to the other. Moreover, postoperative analgesic protocols vary consistently among different centers. To date, only a few studies have evaluated the effects of the most popular VATS techniques. There is no evidence about the difference between multiport VATS and u-VATS in terms of postoperative pain. We hope that the results of our trial will provide valuable information on the outcomes of these different surgical approaches.

Trial registration

ClinicalTrials.gov NCT03240250. Registered on 07 August 2017; retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05115-w.

Estimating the risk of conversion from video-assisted thoracoscopic lung surgery to thoracotomy-a systematic review and meta-analysis

Background

Understanding the risk of conversion from video-assisted thoracic surgery (VATS) to thoracotomy is important when considering patient selection and preoperative surgical risk assessment. This review aims to estimate the rate of intraoperative conversions to thoracotomy, predictive factors, and associated outcomes for VATS anatomic lung resections.

Methods

PubMed/MEDLINE and EMBASE were searched systematically in May of 2020. Observational studies examining conversions of VATS anatomic resections to thoracotomy were included. Conversion rates, causes, risk factors, and post-operative outcomes were reviewed and analyzed in aggregate.

Results

Twenty retrospective studies were reviewed, with a total of 72,932 patients undergoing VATS anatomic lung resection. The median conversion rate was 9.6% (95% CI: 6.6–13.9%). Nine studies reported a total of 114 emergency conversions, with a median incidence rate of 1.3% (95% CI: 0.6–2.8%). The most common reasons for thoracotomy were vascular injury/bleeding, difficulty lymph node dissection, and adhesions, accounting for 27.9%, 26.2% and 19% of conversions, respectively. Risk factors for conversion varied, but frequently included nodal disease, large tumors, and induction therapy. The risk of complications (OR 2.06; 95% CI: 1.77–2.40) and mortality (OR 4.11; 95% CI: 1.59–10.61) were significantly increased following conversions. There was also a significant increase in chest tube duration and length of stay following conversion.

Conclusions

The risk of conversion to thoracotomy may be as high as one in ten patients undergoing VATS anatomic lung resections, but may vary significantly based on patient selection. Although emergent conversions are rare, the need for thoracotomy may significantly increase postoperative morbidity and mortality.