Feasibility and safety of robot-assisted thoracic surgery for lung lobectomy in patients with non-small cell lung cancer: a systematic review and meta-analysis

Comparison of early postoperative patient-reported outcomes after multiportal robotic-assisted thoracoscopic surgery and uniportal video-assisted thoracoscopic surgery for non-small cell lung cancer

INTRODUCTION

We aimed to compare early postoperative patient-reported outcomes between multiportal robotic-assisted thoracoscopic surgery (M-RATS) and uniportal video-assisted thoracoscopic surgery (U-VATS) for non-small-cell lung cancer (NSCLC).

MATERIALS AND METHODS

Symptom severity and functional status were measured using the Perioperative Symptom Assessment for Lung Surgery at pre-surgery, during postoperative hospitalisation, and within 4 weeks of discharge. A propensity score-matched (PSM) analysis of patients with NSCLC who were treated with M-RATS and U-VATS was performed. The symptom severity and daily functional status presented as proportion of moderate-to-severe scores on a 0-10-point scale, were compared using a generalised estimation equation model.

RESULTS

We enrolled 762 patients with NSCLC from a prospective cohort (CN-PRO-Lung 3), including 151 and 611 who underwent M-RATS and U-VATS, respectively, before PSM analysis. After 1:1 PSM, two groups of 148 patients each were created. Pain severity (P = 0.019) and activity limitation (P = 0.001) during hospitalisation were higher in the M-RATS group. However, no significant differences existed post-discharge in pain (P = 0.383), cough (P = 0.677), shortness of breath (P = 0.526), disturbed sleep (P = 0.525), drowsiness (P = 0.304), fatigue (P = 0.153), distress (P = 0.893), walking difficulty (P = 0.242), or activity limitation (P = 0.513). M-RATS caused less intraoperative blood loss (P = 0.013), more stations of dissected lymph nodes (P = 0.001), more numbers of dissected lymph nodes (P = 0.001), and less tube drainage on the first postoperative day (P = 0.003) than U-VATS.

CONCLUSION

M-RATS and U-VATS achieved comparable symptom burden and functional impairment after discharge. However, compared to U-VATS, M-RATS was associated with more severe pain and activity limitation in the short postoperative period.

TRIAL REGISTRATION NUMBER

ChiCTR2000033016.

Video-Assisted vs Robotic-Assisted Lung Lobectomies for Operating Room Resource Utilization and Patient Outcomes

Importance

With increased use of robots, there is an inadequate understanding of minimally invasive modalities' time costs. This study evaluates the operative durations of robotic-assisted vs video-assisted lung lobectomies.

Objective

To compare resource utilization, specifically operative time, between video-assisted and robotic-assisted thoracoscopic lung lobectomies.

Design, Setting, and Participants

This retrospective cohort study evaluated patients aged 18 to 90 years who underwent minimally invasive (robotic-assisted or video-assisted) lung lobectomy from January 1, 2020, to December 31, 2022, with 90 days' follow-up after surgery. The study included multicenter electronic health record data from 21 hospitals within an integrated health care system in Northern California. Thoracic surgery was regionalized to 4 centers with 14 board-certified general thoracic surgeons.

Exposures

Robotic-assisted or video-assisted lung lobectomy.

Main Outcomes and Measures

The primary outcome was operative duration (cut to close) in minutes. Secondary outcomes were length of stay, 30-day readmission, and 90-day mortality. Comparisons between video-assisted and robotic-assisted lobectomies were generated using the Wilcoxon rank sum test for continuous variables and the χ2 test for categorical variables. The average treatment effects were estimated with augmented inverse probability treatment weighting (AIPTW). Patient and surgeon covariates were adjusted for and included patient demographics, comorbidities, and case complexity (age, sex, race and ethnicity, neighborhood deprivation index, body mass index, Charlson Comorbidity Index score, nonelective hospitalizations, emergency department visits, a validated laboratory derangement score, a validated institutional comorbidity score, a surgeon-designated complexity indicator, and a procedural code count), and a primary surgeon-specific indicator.

Results

The study included 1088 patients (median age, 70.1 years [IQR, 63.3-75.8 years]; 704 [64.7%] female), of whom 446 (41.0%) underwent robotic-assisted and 642 (59.0%) underwent video-assisted lobectomy. The median unadjusted operative duration was 172.0 minutes (IQR, 128.0-226.0 minutes). After AIPTW, there was less than a 10% difference in all covariates between groups, and operative duration was a median 20.6 minutes (95% CI, 12.9-28.2 minutes; P < .001) longer for robotic-assisted compared with video-assisted lobectomies. There was no difference in adjusted secondary patient outcomes, specifically for length of stay (0.3 days; 95% CI, -0.3 to 0.8 days; P = .11) or risk of 30-day readmission (adjusted odds ratio, 1.29; 95% CI, 0.84-1.98; P = .13). The unadjusted 90-day mortality rate (1.3% [n = 14]) was too low for the AIPTW modeling process.

Conclusions and Relevance

In this cohort study, there was no difference in patient outcomes between modalities, but operative duration was longer in robotic-assisted compared with video-assisted lung lobectomy. Given that this elevated operative duration is additive when applied systematically, increased consideration of appropriate patient selection for robotic-assisted lung lobectomy is needed to improve resource utilization.

[ERAS Implementation in Thoracic Surgery]

This manuscript provides an overview of the principles and requirements for implementing the ERAS program in thoracic surgery.The ERAS program optimises perioperative management of elective lung resection procedures and is based on the ERAS Guidelines for Thoracic Surgery of the ERAS Society. The clinical measures are described as in the current literature, with a focus on postoperative outcome. There are currently 45 enhanced recovery items covering four perioperative phases: from the prehospital admission phase (patient education, screening and treatment of potential risk factors such as anaemia, malnutrition, cessation of nicotine or alcohol abuse, prehabilitation, carbohydrate loading) to the immediate preoperative phase (shortened fasting period, non-sedating premedication, prophylaxis of PONV and thromboembolic complications), the intraoperative measures (antibiotic prophylaxis, standardised anaesthesia, normothermia, targeted fluid therapy, minimally invasive surgery, avoidance of catheters and probes) through to the postoperative measures (early mobilisation, early nutrition, removal of a urinary catheter, hyperglycaemia control). Most of these measures are based on scientific studies, with a high level of evidence and aim to reduce general postoperative complications.The ERAS program is an optimised perioperative treatment approach aiming to improve the postoperative recovery in patients after elective lung resection by reducing the overall complication rates and overall morbidity.

Comparison of clinical efficacy of da Vinci robot-assisted lung cancer surgery with two-, three- and four-hole approaches

Orifice reduction strategies for da Vinci robotic surgery have been a hot topic of research in recent years. We retrospectively analyzed the perioperative outcomes of robotic-assisted thoracoscopic surgery (RATS) with two, three, and four-hole approaches in radical lung cancer surgery. Our results revealed that the two-hole group has advantages in terms of operative time, postoperative 3-day drainage, postoperative drainage time, postoperative hospital stay and postoperative day 3 visual analogue scale (VAS) pain scores. There were no significant differences between the three groups in terms of intraoperative bleeding, number of lymph nodes dissected, VAS pain scores on postoperative days 1 and 2, and postoperative complications. In addition, the two-hole group was superior to the three-hole and four-hole groups in terms of C-reactive protein (CRP), procalcitonin (PCT) and interleukin 10 (IL-10). In summary, the RATS two-hole approach has advantages in operation time, rapid recovery after operation and some postoperative inflammatory indicators, and is worth promoting in hospitals that are skilled in three-hole and four-hole da Vinci robot surgery and have conditions.

Operative outcomes and middle-term survival of robotic-assisted lung resection for clinical stage IA lung cancer compared with video-assisted thoracoscopic surgery

BACKGROUND

Despite limited published evidence, robotic-assisted thoracoscopic surgery (RATS) for anatomic lung resection in early-stage lung cancer continues growing. The aim of this study is to evaluate its safety and oncologic efficacy compared to video-assisted thoracoscopic surgery (VATS).

METHODS

Single-centre retrospective study of all patients with resected clinical stage IA NSCLC who underwent RATS or VATS anatomic lung resection from June 2018 to January 2022. RATS and VATS cases were matched by propensity scoring (PSM) according to age, sex, histology, and type of resection. Short-term outcomes were compared, and the Kaplan-Meier method and log-rank test were used to evaluate the overall survival (OS) and disease-free survival (DFS).

RESULTS

321 patients (94 RATS and 227 VATS cases) were included. After PSM, 94 VATS and 94 RATS cases were compared. Demographics, pulmonary function, and comorbidity were similar in both groups. Overall postoperative morbidity was comparable for RATS and VATS cases (20.2% vs 25.5%, P = 0.385, respectively). Pathological nodal upstaging was similar in both groups (10.6% in RATS and 12.8% in VATS). During the 3.5-year follow-up period (median: 29 months; IQR: 18-39), recurrence rate was 6.4% in RATS group and 18.1% in the VATS group (P = 0.014). OS and DFS were similar in RATS and VATS groups (log rank P = 0.848 and P = 0.117, respectively).

CONCLUSION

RATS can be performed safely in patients with early-stage NSCLC. For clinical stage IA disease, robotic anatomic lung resection offers better oncologic outcomes in terms of recurrence, although there are no differences in OS and DFS compared with VATS.

[Recent Advances in Diagnosis and Treatment Strategies for Multiple Primary Lung Cancer]

As the utilization of computed tomography in lung cancer screening becomes more prevalent in the post-pandemic era, the incidence of multiple primary lung cancer (MPLC) has surged in various countries and regions. Despite the continued application of advanced histologic and sequencing technologies in this research field, the differentiation between MPLC and intrapulmonary metastasis (IM) remains challenging. In recent years, the specific mechanisms of genetic and environmental factors in MPLC have gradually come to light. Lobectomy still predominates in the treatment of MPLC, but the observation that tumor-specific sublobar resection has not detrimentally impacted survival appears to be a viable option. With the evolution of paradigms, the amalgamated treatment, primarily surgical, is an emerging trend. Among these, stereotactic ablative radiotherapy (SABR) and lung ablation techniques have emerged as efficacious treatments for early unresectable tumors and control of residual lesions. Furthermore, targeted therapies for driver-positive mutations and immunotherapy have demonstrated promising outcomes in the postoperative adjuvant phase. In this manuscript, we intend to provide an overview of the management of MPLC based on the latest discoveries.
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Place of robotic surgery in completion lobectomy after anatomical segmentectomy

OBJECTIVES

Although segmentectomy is steadily increasing in early-stage non-small-cell lung cancer, recurrence in the ipsilateral lobe is also increasing. Completion lobectomy (CL) is a challenging procedure that has already been described in a few studies using video-assisted thoracic surgery or thoracotomy. In this study, we aimed to show the feasibility and safety of robot-assisted thoracic surgery in cases of CL.

METHODS

Among 2073 major resections performed between January 2018 and september 2022 in the Department of Thoracic Surgery at Nancy University Regional Hospital, we retrospectively included patients who underwent CL by robot-assisted thoracic surgery after previous segmentectomy for non-small-cell lung cancer. Data and perioperative results were described and analysed.

RESULTS

Seventeen patients underwent CL with a median recurrence time after previous segmentectomy of 18 months [interquartile range (IQR): 12]. Four patients (23.5%) had a pulmonary artery injury that was controlled, and no conversion to open thoracotomy was needed. The operative time was 150 min (IQR: 20), and blood loss was 300 ml (IQR: 150). The median postoperative chest tube duration was 2 days (IQR: 1), and the length of hospital stay was 3 days (IQR: 3), with no postoperative deaths.

CONCLUSIONS

Completion lobectomy is a challenging procedure due to severe adhesions surrounding vessels, which potentially could cause higher rate of PA bleeding than conventional surgeries. With experienced team and surgeons, CL with robotic surgery may be reported as a safe and feasible procedure.

Outcomes Comparison of Robot-Assisted and Video-Assisted Thoracoscopic Cardiac Sympathetic Denervation

OBJECTIVE

Cardiac sympathetic denervation (CSD) is a surgical antiadrenergic procedure that can reduce sustained ventricular tachyarrhythmia (VT). Video-assisted thoracoscopic surgery (VATS) is currently the standard approach used in CSD, and the practicality for robot-assisted thoracoscopic surgery (RATS) has yet to be investigated.

METHODS

We conducted a single-center retrospective study of all adult patients (N = 67) who underwent CSD from 2015 to 2021. We compared short-term outcomes of those treated with RATS versus VATS thoracic sympathectomy. For patients with VT, we examined the effectiveness of a RATS approach in reducing implantable cardioverter defibrillator (ICD) shock burden.

RESULTS

A total of 34 patients underwent RATS cardiac denervation, and 33 underwent VATS cardiac denervation. Those undergoing RATS denervation had a significantly shorter procedure duration with a median of 129 min (P = 0.008). Patients receiving the VATS approach were significantly more complicated by pneumothorax (P = 0.004) and overall complications (P = 0.01) when compared with the RATS approach. At 1 year after surgery, both groups had significant reductions in ICD shocks compared with before surgery, both decreasing from a median of 4 to 0 shocks (P < 0.001). In addition, at 1 year after surgery, the percentage of patients with persistent ICD shocks and the median of ICD shocks were similar between the groups.

CONCLUSIONS

The RATS approach to cardiac denervation has similar 1-year follow-up outcomes in reducing recurrent VT as the VATS approach. However, patients undergoing RATS denervation experienced better perioperative outcomes. This shows promise for robotic CSD to be an effective and safe therapeutic option for patients with malignant arrhythmias.

Minimally invasive thoracic surgery: robot-assisted versus video-assisted thoracoscopic surgery

Minimally invasive techniques have been widely applied in general thoracic surgery. Compared with video-assisted thoracoscopic surgery (VATS), due to its theoretic superiority, robotic surgery is challenging the traditional position of VATS. With its unique advantages, including 3D vision and a high-freedom endowrist, it leads to easier lymph node dissection, more convenient blood vessel dissection, a shorter learning curve and competence for the completion of complex surgery. However, as a new surgical technology, the safety and efficacy of robotic-assisted thoracoscopic surgery (RATS) still need to be further verified. Thus, in this article, we review and summarize the application of RATS versus VATS in general thoracic surgery.

Paediatric robotic surgery: a narrative review

The benefits of minimally invasive surgery (MIS) compared with traditional open surgery, including reduced postoperative pain and a reduced length of stay, are well recognised. A significant barrier for MIS in paediatric populations has been the technical challenge posed by laparoscopic surgery in small working spaces, where rigid instruments and restrictive working angles act as barriers to safe dissection. Thus, open surgery remains commonplace in paediatrics, particularly for complex major surgery and for surgical oncology. Robotic surgical platforms have been designed to overcome the limitations of laparoscopic surgery by offering a stable 3-dimensional view, improved ergonomics and greater range of motion. Such advantages may be particularly beneficial in paediatric surgery by empowering the surgeon to perform MIS in the smaller working spaces found in children, particularly in cases that may demand intracorporeal suturing and anastomosis. However, some reservations have been raised regarding the utilisation of robotic platforms in children, including elevated cost, an increased operative time and a lack of dedicated paediatric equipment. This article aims to review the current role of robotics within the field of paediatric surgery.

Short-term outcomes of robot-assisted versus video-assisted thoracoscopic surgery for non-small cell lung cancer patients with neoadjuvant immunochemotherapy: a single-center retrospective study

Background

Neoadjuvant immunochemotherapy has been increasingly applied to treat non-small cell lung cancer (NSCLC). However, the comparison between robotic-assisted thoracoscopic surgery (RATS) and video-assisted thoracoscopic surgery (VATS) in the feasibility and oncological efficacy following neoadjuvant immunochemotherapy is scarce. This study aims to assess the superiorities of RATS over (VATS) concerning short-term outcomes in treating NSCLC patients with neoadjuvant immunochemotherapy.

Methods

NSCLC patients receiving RATS or VATS lobectomy following neoadjuvant immunochemotherapy at Shanghai Chest Hospital from 2019 to 2022 were retrospectively identified. Baseline clinical characteristics, perioperative outcomes, and survival profiles were analyzed.

Results

Forty-six NSCLC patients with neoadjuvant immunochemotherapy were included and divided into the RATS (n=15) and VATS (n=31) groups. The baseline clinical characteristics and induction-related adverse events were comparable between the two groups (all p>0.050). The 30-day mortality in the RATS and VATS groups were 0% and 3.23%, respectively (p=1.000). Patients undergoing RATS were associated with reduced surgical-related intensive unit care (ICU) stay than those receiving VATS (0.0 [0.0-0.0] vs. 0.0 [0.0-1.0] days, p=0.026). Moreover, RATS assessed more N1 LNs (6.27 ± 1.94 vs 4.90 ± 1.92, p=0.042) and LN stations (3.07 ± 1.03 vs 2.52 ± 0.57, p=0.038) compared with VATS. By comparison, no difference was found in surgical outcomes, pathological results, and postoperative complications between the RATS and VATS groups (all p>0.050). Finally, RATS and VATS achieved comparable one-year recurrence-free survival (82.96% vs. 85.23%, p=0.821) and the timing of central nervous system, LN, and bone recurrences (all p>0.050).

Conclusion

RATS is safe and feasible for NSCLC patients with neoadjuvant immunochemotherapy, reducing surgical-related ICU stay, assessing increased N1 LNs and stations, and achieving similar survival profiles to VATS.

Diffusion of Minimally Invasive Approach for Lung Cancer Surgery in France: A Nationwide, Population-Based Retrospective Cohort Study

BACKGROUND

The minimally invasive approach (MIA) has gained popularity thanks to its efficacy and safety. Our work consisted of evaluating the diffusion of the MIA in hospitals and the variability of this approach (within and between regions).

METHODS

All patients who underwent limited resection or lobectomy for lung cancer in France were included from the national hospital administrative database (2013-2020). We described between-hospital differences in the MIA rate over four periods (2013-2014, 2015-2016, 2017-2018, and 2019-2020). The potential influence of the hospital volume, hospital type, and period on the adjusted MIA rate was estimated by a multilevel linear regression.

RESULTS

From 2013 to 2020, 77,965 patients underwent a lobectomy or limited resection for lung cancer. The rate of the MIA increased significantly over the four periods (50% in 2019-2020). Variability decreased over time in 7/12 regions. The variables included in the multilevel model were significantly related to the adjusted rate of the MIA. Variability between regions was considerable since 18% of the variance was due to systematic differences between regions.

CONCLUSIONS

We confirm that the MIA is part of the surgical techniques used on a daily basis for the treatment of lung cancer. However, this technology is mostly used by surgeons in high volume institutions.

Impact of robotic access on outcomes after lung cancer surgery in France: Analysis from the Epithor database

Introduction

We aimed to compare postoperative outcomes after pulmonary resection for lung cancer after open thoracotomy (OT), video-assisted (VATS), and robotic-assisted (RA) thoracic surgery using a propensity score analysis.

Methods

From 2010 to 2020, 38,423 patients underwent resection for lung cancer. In total, 58.05% (n = 22,306) were operated by thoracotomy, 35.35% (n = 13,581) by VATS, and 6.6% (n = 2536) by RA. A propensity score was used to create balanced groups with weighting. End points were in-hospital mortality, postoperative complications, and length of hospital stay, reported by odds ratios (ORs) and 95% confidence intervals (CIs).

Results

VATS decreased in-hospital mortality compared with OT (OR, 0.64; 95% CI, 0.58-0.79; P < .0001) but not compared with RA (OR, 1.09; 95% CI, 0.77-1.52; P = .61). VATS reduced major postoperative complications compared with OT (OR, 0.83; 95% CI, 0.76-0.92; P < .0001) but not RA (OR, 1.01; 95% CI, 0.84-1.21; P = .17). VATS reduced prolonged air leaks rate compared with OT (OR, 0.9; 95% CI, 0.84-0.98; P = .015) but not RA (OR, 1.02; 95% CI, 0.88-1.18; P = .77). As compared with OT, VATS and RA decreased the incidence of atelectasis (respectively: OR, 0.57; 95% CI, 0.50-0.65; P < .0001 and OR, 0.75; 95% CI, 0.60-0.95; P = .016); the incidence of pneumonia (OR, 0.75; 95% CI, 0.67-0.83; P < .0001 and OR, 0.62; 95% CI, 0.50-0.78; P < .0001); and the number of postoperative arrhythmias (OR, 0.69; 95% CI, 0.61-0.78; P < .0001 and OR, 0.75; 95% CI, 0.59-0.96; P = .024). Both VATS and RA resulted in shorter hospital stays (-1.91 days [-2.24; -1.58]; P < .0001 and -2.73 days [-3.1; -2.36]; P < .0001, respectively).

Conclusions

RA appeared to decrease postoperative pulmonary complications as well as VATS compared with OT. VATS decreased postoperative mortality as compared with RA and OT.

Perioperative outcomes of robotic-assisted versus video-assisted thoracoscopic lobectomy: A propensity score matched analysis

BACKGROUND

The existing literature on perioperative outcomes of robotic-assisted thoracoscopic surgery (RATS) versus video-assisted thoracoscopic surgery (VATS) for lung lobectomy is inconclusive.

METHODS

We conducted a retrospective cohort analysis of VATS and RATS lobectomy procedures for patients with non-small cell lung cancer to compare the short-term perioperative outcomes by propensity score matching (PSM) analysis.

RESULTS

A total of 418 patients were enrolled in this study. After PSM, 71 patients each received VATS and RATS lobectomy for further analysis. RATS lobectomy was associated with a lower rate of conversion to thoracotomy (0% vs. 5.63%, p = 0.006), a lower rate of postoperative prolonged air leak (1.14% vs. 19.72%, p = 0.001) and a shorter duration of postoperative chest tube drainage (3 days interquartile range [IQR: 3, 4] vs. 4 days IQR [3-5], p = 0.027). Subgroup analysis indicated that after acquiring proficiency in the RATS procedure, its disadvantages diminished while its advantages were enhanced. In terms of rate of conversion to thoracotomy, length of hospital stays, and duration of postoperative chest tube drainage, RATS was comparable to uniportal VATS and superior to triportal VATS.

CONCLUSION

RATS has advantages over VATS in terms of early chest tube removal, early discharge, lower thoracotomy rate, less postoperative air leak, and a potential trend of more lymph node dissection numbers. These advantages are more pronounced after acquiring proficiency in RATS.

Causes and management of intraoperative complications in robot-assisted anatomical pulmonary resection for lung cancer

Background

To perform safe robot-assisted anatomical lung resections, the details of intraoperative complications need to be shared among thoracic surgeons. However, only limited data are available.

Methods

This retrospective, single-institutional study evaluated 134 patients who underwent robot-assisted anatomical lung resection. We examined the causes, management, and outcomes of all intraoperative complications.

Results

Of the 134 eligible patients, 118 (88%) underwent lobectomy and 16 (12%) underwent segmentectomy. Intraoperative complications occurred in 17 (12.7%) patients. These complications included pulmonary artery (PA) injuries in seven patients, pulmonary vein (PV) injuries in three, azygos vein (AV) injury in one, superior vena cava (SVC) injury in one, bronchial injuries in three, and lung injuries in four. Most PA injuries were at a distal side and controlled by pressure, fibrin sealant, or stapling of the proximal side. In the three PV injuries, right upper PV was sandwiched by robotic instruments, V6 was punctured by the tip of the Maryland bipolar forceps, and the distal side of V2t was injured during tunneling of a minor interlobar fissure. These were controlled the same way as the PA injuries. The AV injury occurred during hilar lymph node (LN) dissection and was controlled by suturing. The SVC injury was caused by interference of the robotic forceps and the suction tube outside the field of view during upper mediastinal LN dissection. The injury was controlled by continuous pressure while layering polyglycolic acid sheets and fibrin glue. In the three bronchial injuries, B10 was injured during subcarinal LN dissection, right main bronchus was injured during upper bronchus dissection and the stapling failure of the bronchus occurred by strong traction. They were all repaired by suturing. All lung parenchymal injuries were caused by manipulation of robotic instruments outside the field of view. The lung injuries were repaired by suturing with pledgets. No cases were converted to thoracotomy. The 30-day mortality rate was 0.7%. The cause of mortality was pneumonia.

Conclusions

In robot-assisted anatomical pulmonary resection for lung cancer, most major intraoperative complications can be safely managed robotically without conversion to thoracotomy.

Clinical Efficacy of Thoracoscopic Surgery with the da Vinci Surgical System versus Video-Assisted Thoracoscopic Surgery for Lung Cancer

Objective

To assess the clinical efficacy of thoracoscopic surgery with the da Vinci surgical system versus video-assisted thoracoscopic surgery (VATS) for lung cancer.

Methods

From August 2019 to December 2020, 193 patients with lung cancer assessed for eligibility scheduled for surgery in our hospital were recruited and assigned at a ratio of 1 : 1 to receive VATS (control group) or thoracoscopic surgery with the da Vinci surgical system (research group). The primary measurement is the clinical efficacy of the two surgical modalities.

Results

The baseline features of the research group were comparable with those of the control group (P > 0.05). Besides, the two groups showed similar tumor types, tumor locations, and clinicopathological staging (P > 0.05). Da Vinci surgical system-assisted thoracoscopic surgery had short operative time, less intraoperative blood loss, better lymph node dissection, and lower intraoperative conversion rates compared to VATS. Compared with the control group, the research group had significantly higher postoperative forced expiratory volume in one second (FEV1), forced vital capacity (FVC), maximal voluntary ventilation (MVV), the functional assessment of cancer therapy-general module (FACT-G) of the FACT-lung (FACT-L) Chinese version V4.0, lung cancer-specific module scores, and total scores (P < 0.05). The research group showed better postoperative drainage volume, shorter intubation duration, and length of hospital stay and a lower incidence of complications versus the control group (P < 0.05). The da Vinci surgical system reduced the probability of intraoperative mistakes and better ensured a safe and satisfactory surgery.

Conclusion

The thoracoscopic surgery with the da Vinci surgical system better reduces intraoperative and postoperative bleeding, shortens drainage and intubation duration, enhances the lung function and survival quality of patients, and lowers the risk of surgical mistakes to ensure surgical safety versus VATS.

[Comparison of robot-assisted and conventional endoscopic surgeries in the Russian Federation. (A systematic review and meta-analysis)]

OBJECTIVE

Comparative assessment of immediate and long-term results of robot-assisted and conventional endoscopic technologies in the Russian Federation.

MATERIAL AND METHODS

Searching for primary trials devoted to robot-assisted (RAE) and traditional video endoscopic (TVE) surgeries in the Russian Federation was carried out in the e-library and CENTRAL Cochrane databases. We used the recommendations of the Center for Expertise and Quality Control of Medical Care (2017, 2019) and the current version of the Cochrane Community Guidelines (2021). These guidelines define the features of meta-analysis of non-randomized comparative studies. Review Manager 5.4 software was used for statistical analysis.

RESULTS

We enrolled 26 Russian-language primary sources (3111 patients) including 1174 (38%) ones in the RAE group and 1937 (62%) patients in the TVE group. There were no randomized controlled trials in the Russian Federation, and all primary studies were non-randomized. We found no significant between-group differences in surgery time, incidence of intraoperative complications, intraoperative blood loss in thoracic surgery, urology and gynecology, conversion rate, postoperative hospital-stay, postoperative morbidity (in abdominal surgery, urology and gynecology), postoperative mortality. We observed slightly lower intraoperative blood loss for RAE in abdominal surgery and lower incidence of postoperative complications in robot-assisted thoracic surgery. These results can be compromised by methodological quality of comparative studies, significant heterogeneity and systematic errors.

CONCLUSION

Currently, we cannot confirm the benefits of robot-assisted technologies, since this approach does not worsen or improve treatment outcomes. Further high-quality studies are needed.

Long-Term Survival Following Minimally Invasive Lung Cancer Surgery: Comparing Robotic-Assisted and Video-Assisted Surgery

Simple Summary

Video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracoscopic surgery (RATS) are known to be safe and efficient surgical procedures to treat lung cancer. Both VATS and RATS allow anatomical resection associated with radical lymph node dissection. However, RATS, unlike VATS, allows the thoracic surgeon to mimic an open approach and to perform lung resection. We hypothesized that the technical advantages of RATS, compared with VATS, would allow more precise resection, with “better lymph node dissection” which could increase survival compared to VATS. Nevertheless, VATS, and RATS nodal up-staging are still debated, with conflicting results and in our study, as well as in the medical literature, RATS failed to show its superiority over VATS in resectable non-small cell lung cancer.

Abstract

Background: Nowadays, video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracoscopic surgery (RATS) are known to be safe and efficient surgical procedures to treat early-stage non-small cell lung cancer (NSCLC). We assessed whether RATS increased disease-free survival (DFS) compared with VATS for lobectomy and segmentectomy. Methods: This retrospective cohort study included patients treated for resectable NSCLC performed by RATS or VATS, in our tertiary care center from 2012 to 2019. Patients’ data were prospectively recorded and reviewed in the French EPITHOR database. Primary outcomes were 5-year DFS for lobectomy and 3-year DFS for segmentectomy, compared by propensity-score adjusted difference of Kaplan–Meier estimates. Results: Among 844 lung resections, 436 VATS and 234 RATS lobectomies and 46 VATS and 128 RATS segmentectomies were performed. For lobectomy, the adjusted 5-year DFS was 60.9% (95% confidence interval (CI) 52.9–68.8%) for VATS and 52.7% (95%CI 41.7–63.7%) for RATS, with a difference estimated at −8.3% (−22.2–+4.9%, p = 0.24). For segmentectomy, the adjusted 3-year DFS was 84.6% (95%CI 69.8–99.0%) for VATS and 72.9% (95%CI 50.6–92.4%) for RATS, with a difference estimated at −11.7% (−38.7–+7.8%, p = 0.21). Conclusions: RATS failed to show its superiority over VATS for resectable NSCLC.

Role of STAT3 Expression in Thyroid Cancer: A Meta-Analysis and Systematic Review Based on the Chinese Population

Background

Signal transduction and activator of transcription 3 (STAT3) is an oncogene with transcriptional activity. In recent years, there have been several studies concerning the clinicopathological significance of the expression of the STAT3 protein in thyroid cancer. However, the results are still inconsistent. In this study, we conducted a meta-analysis to evaluate the relationship between the expression of STAT3 protein and thyroid cancer susceptibility and its clinicopathological characteristics.

Methods

We searched the China National Knowledge Infrastructure (CNKI) database, Chinese Biomedical Literature Database (CBM), Chinese Scientific and Journal Database (VIP), Wanfang, PubMed, and EMBASE. The time frame of the publication search was from the establishment of each of the databases until December 2021. We performed a meta-analysis to quantitatively evaluate the relationship between the expression of the STAT3 protein in thyroid cancer and its clinicopathological characteristics.

Results

A total of eight articles were included in the meta-analysis, covering 448 thyroid cancer patients and 227 controls. Results indicated that the expression of STAT3 protein in thyroid cancer tissue is highly expressed (OR = 14.41, 95% CI (6.94, 29.91), p < 0.001). Besides, we also discovered that STAT3 protein is negatively correlated with thyroid cancer tumor diameter and TNM stage (OR = 0.13, 95% CI (0.05, 0.33), p < 0.001; OR = 0.40, 95% CI (0.24, 0.67), p < 0.001) and positively correlated with lymph node metastasis (OR = 2.83, 95% CI (1.08, 7.46), p = 0.035). However, STAT3 expression is not related to gender (OR = 0.88, 95% CI (0.54, 1.44), p = 0.609), age (OR = 0.54, 95% CI (0.21, 1.36), p = 0.191), capsular invasion (OR = 2.98, 95% CI (0.23, 38.29), p = 0.403), or tumor multiplicity (OR = 0.25, 95% CI (0.003, 19.28), p = 0.533).

Conclusions

This study reveals that STAT3 protein expression is significantly related to the susceptibility and clinicopathological characteristics of thyroid cancer. It also suggests that STAT3 may be a potential predictor of the clinical progression of thyroid cancer.

Photodynamic therapy for peripheral lung cancer

Photodynamic therapy (PDT) is an internationally approved ablation technique for endo-bronchial lung cancer. The majority of reported outcomes are for central and obstructing lesions where excellent long term control is possible. With the current trend of screening high risk for lung cancer populations, a larger cohort of patients are now diagnosed with earlier stage disease. When these early tumors are located in the lung periphery the current therapeutic options include surgery or radiation therapy. Still, many patients may not be candidates or amenable for these procedures. As PDT is a well tolerated non-thermal outpatient therapy to treat lung cancer and as newer bronchoscopy techniques allow for treatment of peripheral lesions, PDT may be an option. We report a case of a primary non-small cell lung cancer treated by interstitial PDT through placement of the diffusing fiber via magnetic navigational bronchoscopy. Forty eight hours post 2 mg/kg intravenous (IV) injection of Photofrin®, a single 500 second illumination of 200 J/cm at 630 nm was directed to the solitary peripheral lesion without complication. On day 30, as a part of planned therapy, lobectomy was undertaken. Pathology reported necrosis and no viable remaining tumor. At 90 days follow up, the patient remains well,with no evidence of disease. Additional details follow in the report.

Robotic and Video-Assisted Thoracic Surgery for Early-Stage Lung Cancer: Comparison of Long-Term Pain at a Single Centre

Backgrounds: Since the application of mini-invasive surgery to pulmonary lobectomy, various studies confirmed the feasibility and the safety of the technique, with equivalent oncological standards. However, there are no studies that compare long-term postoperative pain in minimally invasive thoracic surgery. Methods: Between 1 January 2019 and 28 February 2020, we analysed pain scores at 2 weeks, 3 months, 6 months, and 1 year after the operation, where 50 patients underwent a VATS lobectomy and 50 underwent a RATS lobectomy. Pain scores are obtained through a telephone questionnaire, according to a Numerical Rating Scale (NRS). Results: The medias of the NRS scores, at 2 weeks, 3 months, 6 months, and 1 year after the operation were similar in both groups. Group I was composed of 50 patients who underwent a video-assisted lobectomy, while Group II was composed of 50 patients who underwent a robotic-assisted lobectomy. Two weeks after surgery Group I had a NRS value of 2.96 and in Group II it was 2.86; three months after in Group I the value was 2.16 and in Group II it was 2.06; six months after Group I ‘s value was 1.62 and Group II’s was 1.56; one year after in Group I the value was 1.30 and in the Group II was 1.24. For each time interval, no statistically significant differences were found (p > 0.05). Conclusions: In our analysis, RATS and VATS did not have significant differences in post-operative and long-term pain.

Robotic and video-assisted lobectomy/segmentectomy for non-small cell lung cancer have similar perioperative outcomes: a systematic review and meta-analysis

Background

At present, the clinical conclusion that robotic-assisted thoracic surgery (RATS) and video-assisted thoracic surgery (VATS), which is better for patients with non-small cell lung cancer (NSCLC) is not clear. Therefore, this meta-analysis aimed to compare the perioperative outcomes between RATS and VATS for NSCLC.

Methods

The Population, Interventions, Comparators, Outcomes, and Study design (PICOS) framework was employed to develop the search strategy, and the findings was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. We searched EMbase, The Cochrane Library, PubMed, Web of Science, CNKI, and Wan Fang Data to collect clinical studies about RATS vs. VATS for patients with NSCLC from inception to October 2019. The following outcomes were measured: rate of conversion to thoracotomy, postoperative complications, postoperative hospital mortality, lymph node dissection, hospitalization time, operating time, and postoperative drainage days. Estimation of potential publication bias was conducted by Begg’s test and Egger’s test. The Standardized Mean Difference (SMD) and Odds Ratio (OR) with 95% confidence intervals (CI) were pooled using Stata 15.0 software.

Results

A total of 18 studies involving 60,349 patients were included. Among them, 8,726 cases were in the RATS group, and 51,623 were in the VATS group. The results of meta-analysis showed that the operation time of RATS group was longer than that of VATS group (SMD=0.532, 95% CI: 0.391–0.674, P=0.000). And the further meta-analysis suggested that the incidence of postoperative complications was lower in patients who underwent RATS after 2015 (OR=0.848, 95% CI: 0.748–0.962, P=0.010). Meanwhile, there was no significant difference between both groups in postoperative hospitalization time (SMD=0.003, 95% CI: −0.104–0.110, P=0.957). In addition, more lymph nodes were retrieved in RATS group than VATS (SMD=0.308, 95% CI: 0.131–0.486, P=0.001). However, the conversion rate, retrieved lymph node station, days to tube removal and in-hospital mortality rate have no significant differences between both groups.

Discussion

The current meta-analysis indicates that the perioperative outcomes of RATS and VATS for NSCLC are equivalence. Due to the limited quantity and quality of included studies, the above conclusions still need to be verified by more high-quality studies.

Robotic vs. Thoracoscopic Anatomic Lung Resection in Obese Patients: A Propensity Adjusted Analysis

BACKGROUND

Minimally-invasive lung resections can be particularly challenging in obese patients. We hypothesized robotic surgery (RTS) is associated with less conversion to thoracotomy than thoracoscopic surgery (VATS) in obese populations.

METHODS

The STS GTSD, Epithor French National Database, and McMaster University Database were queried for obese (BMI≥30 kg/m²) patients who underwent VATS or RTS lobectomy or segmentectomy for clinical T1-2, N0-1 NSCLC between 2015-2019. Propensity score adjusted logistic regression analysis was used to compare the rate of conversion to thoracotomy between the VATS and RTS cohorts.

RESULTS

Overall, 8,108 patients (STS GTSD: n=7,473; Epithor: n=572; McMaster: n=63) met inclusion criteria with a mean age of 66.6 years (SD 9 years) and BMI of 34.7 kg/m² (SD 4.5 kg/m²). After propensity score adjusted multivariable analysis, patients who underwent VATS were over 5 times more likely to experience conversion to thoracotomy than those who underwent RTS (OR=5.33; 95% CI 4.14, 6.81, p<0.001). There was a linear association between degree of obesity and odds ratio of VATS conversion to thoracotomy compared to RTS. The VATS cohort had a longer mean length of stay (5.0 vs. 4.3 days, p<0.001), higher rate of respiratory failure (2.8% [168/5975] vs. 1.8% [39/2133], p=0.026), and were less likely to be discharged to their home (92.5% [5,525/5,975] vs. 94.3% [2,012/2,133]; p=0.013) compared to RTS patients.

CONCLUSIONS

In obese patients, RTS anatomic lung resection is associated with a lower rate of conversion to thoracotomy than VATS.

Perioperative Outcome of Robotic Approach Versus Manual Videothoracoscopic Major Resection in Patients Affected by Early Lung Cancer: Results of a Randomized Multicentric Study (ROMAN Study)

Introduction

We report the results of the first prospective international randomized control trial to compare the perioperative outcome and surgical radicality of the robotic approach with those of traditional video-assisted surgery in the treatment of early-stage lung cancer.

Methods

Patients with clinical stage T1–T2, N0–N1 non-small cell lung cancer (NSCLC) were randomly assigned to robotic-assisted thoracoscopic surgery (RATS) or video-assisted thoracic surgery (VATS) resection arms. The primary objective was the incidence of adverse events including complications and conversion to thoracotomy. The secondary objectives included extent of lymph node (LN) dissection and other indicators.

Results

This trial was closed at 83 cases as the probability of concluding in favor of the robot arm for the primary outcome was null according to the observed trend. In this study, we report the results of the analysis conducted on the patients enrolled until trial suspension. Thirty-nine cases were randomized in the VATS arm and 38 in the robotic arm. Six patients were excluded from analysis. Despite finding no difference between the two arms in perioperative complications, conversions, duration of surgery, or duration of postoperative stay, a significantly greater degree of LN assessment by the robotic technique was observed in regards to the median number of sampled LN stations [6, interquartile range (IQR) 4–6 vs. 4, IQR 3–5; p = 0.0002], hilar LNs (7, IQR 5–10 vs. 4, IQR 2–7; p = 0.0003), and mediastinal LNs (7, IQR 5–10 vs. 5, IQR 3–7; p = 0.0001).

Conclusions

The results of this trial demonstrated that RATS was not superior to VATS considering the perioperative outcome for early-stage NSCLC, but the robotic approach allowed an improvement of LN dissection. Further studies are suggested to validate the results of this trial.

Clinical Trial Registration

clinicaltrials.gov, identifier NCT02804893.

Robotic-Assisted Minimally Invasive Surgery in Children

Currently, minimally invasive surgery (MIS) includes conventional laparo-thoracoscopic surgery and robot-assisted surgery (RAS) or robotic surgery. Robotic surgery is performed with robotic devices, for example the Da Vinci system from Intuitive Surgical, which has a miniaturized camera capable of image magnification, a three-dimensional image of the surgical field, and the instruments are articulated with 7 degrees of freedom of movement, and the surgeon operates in a sitting position at a surgical console near the patient. Robotic surgery has gained an enormous surge in use on adults, but it has been slowly accepted for children, although it offers important advantages in complex surgeries. The areas of application of robotic surgery in the pediatric population include urological, general surgery, thoracic, oncological, and otorhinolaryngology, the largest application has been in urological surgery. There is evidence that robotic surgery in children is safe and it is important to offer its benefits. Intraoperative complications are rare, and the frequency of postoperative complications ranges from 0–15%. Recommendations for the implementation of a pediatric robotic surgery program are included. The future will be fascinating with upcoming advancements in robotic surgical systems, the use of artificial intelligence, and digital surgery.

Mobile health applications for the detection of atrial fibrillation: a systematic review

AIMS

Atrial fibrillation (AF) is the most common sustained arrhythmia and an important risk factor for stroke and heart failure. We aimed to conduct a systematic review of the literature and summarize the performance of mobile health (mHealth) devices in diagnosing and screening for AF.

METHODS AND RESULTS

We conducted a systematic search of MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials. Forty-three studies met the inclusion criteria and were divided into two groups: 28 studies aimed at validating smart devices for AF diagnosis, and 15 studies used smart devices to screen for AF. Evaluated technologies included smartphones, with photoplethysmographic (PPG) pulse waveform measurement or accelerometer sensors, smartbands, external electrodes that can provide a smartphone single-lead electrocardiogram (iECG), such as AliveCor, Zenicor and MyDiagnostick, and earlobe monitor. The accuracy of these devices depended on the technology and the population, AliveCor and smartphone PPG sensors being the most frequent systems analysed. The iECG provided by AliveCor demonstrated a sensitivity and specificity between 66.7% and 98.5% and 99.4% and 99.0%, respectively. The PPG sensors detected AF with a sensitivity of 85.0-100% and a specificity of 93.5-99.0%. The incidence of newly diagnosed arrhythmia ranged from 0.12% in a healthy population to 8% among hospitalized patients.

CONCLUSION

Although the evidence for clinical effectiveness is limited, these devices may be useful in detecting AF. While mHealth is growing in popularity, its clinical, economic, and policy implications merit further investigation. More head-to-head comparisons between mHealth and medical devices are needed to establish their comparative effectiveness.

The Role of Surgery in Lung Cancer Treatment: Present Indications and Future Perspectives-State of the Art

Non-small cell lung cancers (NSCLC) are different today, due to the increased use of screening programs and of innovative systemic therapies, leading to the diagnosis of earlier and pre-invasive tumors, and of more advanced and controlled metastatic tumors. Surgery for NSCLC remains the cornerstone treatment when it can be performed. The role of surgery and surgeons has also evolved because surgeons not only perform the initial curative lung cancer resection but they also accompany and follow-up patients from pre-operative rehabilitation, to treatment for recurrences. Surgery is personalized, according to cancer characteristics, including cancer extensions, from pre-invasive and local tumors to locally advanced, metastatic disease, or residual disease after medical treatment, anticipating recurrences, and patients' characteristics. Surgical management is constantly evolving to offer the best oncologic resection adapted to each NSCLC stage. Today, NSCLC can be considered as a chronic disease and surgery is a valuable tool for the diagnosis and treatment of recurrences, and in palliative conditions to relieve dyspnea and improve patients' comfort.

Robot-assisted thoracic surgery versus video-assisted thoracic surgery for lung lobectomy or segmentectomy in patients with non-small cell lung cancer: a meta-analysis

Background

It remains no clear conclusion about which is better between robot-assisted thoracic surgery (RATS) and video-assisted thoracic surgery (VATS) for the treatment of patients with non-small cell lung cancer (NSCLC). Therefore, this meta-analysis aimed to compare the short-term and long-term efficacy between RATS and VATS for NSCLC.

Methods

Pubmed, Cochrane Library, Embase, China National Knowledge Infrastructure (CNKI), Medline, and Web of Science databases were comprehensively searched for studies published before December 2020. The quality of the articles was evaluated using the Newcastle-Ottawa Scale (NOS) and the data analyzed using the Review Manager 5.3 software. Fixed or random effect models were applied according to heterogeneity. Subgroup analysis and sensitivity analysis were conducted.

Results

A total of 18 studies including 11,247 patients were included in the meta-analyses, of which 5114 patients were in the RATS group and 6133 in the VATS group. Compared with VATS, RATS was associated with less blood loss (WMD = − 50.40, 95% CI -90.32 ~ − 10.48, P = 0.010), lower conversion rate (OR = 0.50, 95% CI 0.43 ~ 0.60, P < 0.001), more harvested lymph nodes (WMD = 1.72, 95% CI 0.63 ~ 2.81, P = 0.002) and stations (WMD = 0.51, 95% CI 0.15 ~ 0.86, P = 0.005), shorter duration of postoperative chest tube drainage (WMD = − 0.61, 95% CI -0.78 ~ − 0.44, P < 0.001) and hospital stay (WMD = − 1.12, 95% CI -1.58 ~ − 0.66, P < 0.001), lower overall complication rate (OR = 0.90, 95% CI 0.83 ~ 0.99, P = 0.020), lower recurrence rate (OR = 0.51, 95% CI 0.36 ~ 0.72, P < 0.001), and higher cost (WMD = 3909.87 USD, 95% CI 3706.90 ~ 4112.84, P < 0.001). There was no significant difference between RATS and VATS in operative time, mortality, overall survival (OS), and disease-free survival (DFS). Sensitivity analysis showed that no significant differences were found between the two techniques in conversion rate, number of harvested lymph nodes and stations, and overall complication.

Conclusions

The results revealed that RATS is a feasible and safe technique compared with VATS in terms of short-term and long-term outcomes. Moreover, more randomized controlled trials comparing the two techniques with rigorous study designs are still essential to evaluate the value of robotic surgery for NSCLC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08241-5.

Robotic-Assisted versus Video-Assisted Thoracoscopic Lobectomy: Short-Term Results of a Randomized Clinical Trial (RVlob Trial)

OBJECTIVE

To determine whether robotic-assisted lobectomy (RAL) affects perioperative outcomes and long-term efficacy in non-small cell lung cancer (NSCLC) patients, compared with traditional video-assisted lobectomy (VAL).

SUMMARY BACKGROUND DATA

RAL is a promising treatment for NSCLC. However, its efficacy has not been fully evaluated.

METHODS

A single-center, open-labeled prospective randomized clinical trial was launched in May 2017 to compare the efficacy of RAL and VAL. By May 2020, 320 patients were enrolled. The perioperative results of RAL and VAL were compared.

RESULTS

The 320 enrolled patients were randomly assigned to the RAL group (n = 157) and the VAL group (n = 163). Perioperative outcomes were comparable between the two groups, including the length of hospital stay (P = 0.76) and the rate of postoperative complications (P = 0.45). No perioperative mortality occurred in either group. The total amount of chest tube drainage (830 ml [IQR, 550-1130 ml] vs. 685 ml [IQR, 367.5-1160 ml], P = 0.007) and hospitalization costs ($12821 [IQR, $12145-$13924] vs. $8009 [IQR, $7014-$9003], P < 0.001) were significantly higher in the RAL group. RAL group had a significantly higher number of lymph nodes (LNs) harvested (11 [IQR, 8-15] vs. 10 [IQR, 8-13], P = 0.02), higher number of N1 LNs (6 [IQR, 4-8] vs. 5 [IQR, 3-7], P = 0.005), and more LN stations examined (6 [IQR, 5-7] vs. 5 [IQR, 4-6], P < 0.001).

CONCLUSIONS

Both RAL and VAL are safe and feasible for the treatment of NSCLC. RAL achieved similar perioperative outcomes, together with higher LN yield. Further follow-up investigations are required to evaluate the long-term efficacy of RAL. (ClinicalTrials.gov identifier: NCT03134534).

[A Prospective Study of Da Vinci Surgical Robotic System with Chest Wall External Nursing Interventions]

背景与目的

微创与快速康复是肺癌外科治疗的趋势，而达芬奇机器人在肺癌的治疗及快速康复中起到重要作用。本研究探索在其基础上结合胸壁外敷的护理干预措施，对减少术后胸腔引流量、促进患者快速康复的作用。

方法

对我院2017年11月1日-2018年4月2日行达芬奇机器人肺癌根治术的患者进行随机分组，对照组常规行达芬奇机器人肺癌根治术，术后胸部缠绕腹带。实验组行达芬奇机器人肺癌根治术，术后辅助胸壁局部外敷芒硝进行护理干预。统计相关数据并分析。

结果

实验组的术后总引流量、日均引流量均少于对照组，术后拔管时间短于对照组，住院时间较对照组缩短，但无明显统计学差异。术后第2天疼痛评分上，实验组略高于对照组，无明显统计学差异。对于胸壁厚度≤4 cm的患者，胸壁外敷的护理干预可显著减少术后日均及总引流量，但在拔管时间、住院时间上无明显差异。

结论

胸壁外敷护理干预有利于达芬奇机器人肺癌手术患者的术后恢复，尤其对于胸壁厚度较小的患者，能够减少术后引流量，缩短留管时间，加快出院。进一步改良后有望达到更好的临床效果。

[Robot-Assisted Lung Surgery]

Anatomical lung resection is the standard treatment for patients with early-stage lung cancer. The conventional surgical techniques are thoracotomy and video-assisted thoracic surgery, but new methods have been added as technology has developed. The latest technological development is the robot-assisted anatomical lung resection. In this technique, a robot is used to perform an anatomical lobectomy or segmentectomy as well as lymph node dissection, as determined by oncological criteria. Comparison between the robot-assisted and video-assisted thoracic surgery is still of the greatest interest, since both minimally invasive approaches have their advantages and disadvantages. The aim of this work is to describe the development and performance of robot-assisted thoracic surgery, as well as the comparison with other surgical methods.

Extended Robotic Pulmonary Resections

While lung cancer remains the most common cause of cancer-related mortality in the United States, surgery for curative intent continues to be a mainstay of therapy. The robotic platform for pulmonary resection for non-small cell lung cancer (NSCLC) has been utilized for more than a decade now. With respect to more localized resections, such as wedge resection or lobectomy, considerable data exist demonstrating shorter length of stay, decreased postoperative pain, improved lymph node dissection, and overall lower complication rate. There are a multitude of technical advantages the robotic approach offers, such as improved optics, natural movement of the operator's hands to control the instruments, and precise identification of tissue planes leading to a more ergonomic and safe dissection. Due to the advantages, the scope of robotic resections is expanding. In this review, we will look at the existing data on extended robotic pulmonary resections, specifically post-induction therapy resection, sleeve lobectomy, and pneumonectomy. Additionally, this review will examine the indications for these more complex resections, as well as review the data and outcomes from other institutions' experience with performing them. Lastly, we will share the strategy and outlook of our own institution with respect to these three types of extended pulmonary resections. Though some controversy remains regarding the use and safety of robotic surgery in these complex pulmonary resections, we hope to shed some light on the existing evidence and evaluate the efficacy and safety for patients with NSCLC.

Guidelines on enhanced recovery after pulmonary lobectomy

OBJECTIVE

To establish recommendations for optimisation of the management of patients undergoing pulmonary lobectomy, particularly Enhanced Recovery After Surgery (ERAS).

DESIGN

A consensus committee of 13 experts from the French Society of Anaesthesia and Intensive Care Medicine (Soci,t, franOaise d'anesth,sie et de r,animation, SFAR) and the French Society of Thoracic and Cardiovascular Surgery (Soci,t, franOaise de chirurgie thoracique et cardiovasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence.

METHODS

Five domains were defined: 1) patient pathway and patient information; 2) preoperative management and rehabilitation; 3) anaesthesia and analgesia for lobectomy; 4) surgical strategy for lobectomy; and 5) enhanced recovery after surgery. For each domain, the objective of the recommendations was to address a number of questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). An extensive literature search on these questions was carried out and analysed using the GRADE® methodology. Recommendations were formulated according to the GRADE® methodology, and were then voted by all experts according to the GRADE grid method.

RESULTS

The SFAR/SFCTCV guideline panel provided 32 recommendations on the management of patients undergoing pulmonary lobectomy. After two voting rounds and several amendments, a strong consensus was reached for 31 of the 32 recommendations and a moderate consensus was reached for the last recommendation. Seven of these recommendations present a high level of evidence (GRADE 1+), 23 have a moderate level of evidence (18 GRADE 2+ and 5 GRADE 2-), and 2 correspond to expert opinions. Finally, no recommendation was provided for 2 of the questions.

CONCLUSIONS

A strong consensus was expressed by the experts to provide recommendations to optimise the whole perioperative management of patients undergoing pulmonary lobectomy.

Intrathoracic gastric volvulus complicating a robotic left upper lobectomy: A case report and review of literature

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Intrathoracic gastric volvulus.

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Robotic Lobectomy unusual complication.

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Para esophageal hernias a cause for concern during robotic thoracic procedures.

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Gastric Ischemia.

•

Etiology of gastric volvulus.

Unrecognized intrathoracic gastric volvulus can be a life-threatening condition, especially in elderly individuals undergoing major surgical procedures. We herein report the first case of a gastric volvulus after a robot-assisted left upper lobectomy for non-small-cell lung cancer in a patient with a known paraesophageal hernia. The operative procedure was performed by Dr Jacques Fontaine a senior thoracic surgeon at Moffitt Cancer Center in Tampa Florida a major academic institution. This operation was complicated by a large type-III hiatal hernia, with most of the stomach having herniated into the left pleural cavity and demonstrating organo-axial torsion one day after the indexed operation for the lung cancer. The patient required emergency surgery due to gastric ischemia. The patient underwent exploratory laparotomy with reduction of the volvulus and closure of the esophageal hiatus at that time. The patient was taken back to the operating room for a planned relook 24 h after the exploratory laparotomy to assess viability of the stomach. Unfortunately, the second look revealed necrotic areas of the stomach, which required to be resected. Given her age and poor nutritional status, we elected to place a feeding jejunostomy tube. Her postoperative course was marred by an abdominal wound infection treated with a wound vacuum-assisted closure device. Ultimately she was discharged home on POD#19 tolerating a regular diet. This case report highlights that in the elderly patients undergoing left lung resection with a known large hiatal hernia, the index of suspicion for herniation must be high and prompt recognition can avert mortality or morbidity.

Mid-term results of completely portal robotic lobectomy for stage I & II non-small cell lung cancer

Background

Minimally invasive robotic-assisted thoracic surgery is an increasingly popular platform for oncological thoracic resection. The aim of this study is to evaluate the feasibility of completely portal robotic lobectomy for patients with early non-small cell lung cancer (NSCLC), analysing the perioperative and mid-term results.

Methods

This is a single-institution retrospective cohort study of consecutive patients who underwent completely portal robotic lobectomy for early stage NSCLC over a 53-month period.

Results

A total of 59 consecutive patients were included in this study. Median operative time was 155 min (range, 80–313 min). Conversion rate was 13.6%. Median intensive care/high dependency unit stay, chest tube duration and length of hospital stay were 1 day (range, 0–4 days), 2 days (range, 1–20 days) and 4 days (range, 2–30 days) respectively; 98.2% of patients achieved R0 resection. Overall, 23.7% had minor complications. There was no perioperative (30-day) mortality in this study. Final pathological staging distribution was 55.9% stage 1A, 23.7% stage 1B, 10.2% stage 2A and 10.2% stage 2B; 23% were upstaged after pathological staging. Median follow-up was 33 months (range, 3–70 months). The 3-year overall survival and recurrence-free survival were 86.2% (95% CI, 72.0–96.8) and 69% (95% CI, 56.1–81.9) respectively. The 3-year overall survival and recurrence free survival for stage 1 patients were 88.4% (95% CI, 77.4–99.4) and 75.6% (95% CI, 62.3–88.9) respectively.

Conclusions

By clearly defining completely portal robotic lobectomy, it is possible to delivery promising perioperative and mid-term results for early stage primary lung cancer, even in a geographical location that has yet to assimilate this technology.

Effect of phenotypic detection of circulating tumor cells marked by epithelial-mesenchymal transformation on the prognosis of lung cancer: A protocol for systematic review and meta-analysis

BACKGROUND

To explore the significance of phenotype detection of circulating tumor cells (CTCs) based on epithelial-mesenchymal transition (EMT) labeling to evaluate the prognosis of lung cancer.

METHODS

Database was retrieved from China National Knowledge Infrastructure (CNKI), Chinese Biomedical literature Database (CBM), Chinese Scientific and Journal Database (VIP), Wan Fang database, PubMed, and EMBASE. Based on EMT on overall survival (OS) and disease-free survival (DFS), hazard ratios (HRs) and its 95% of confidence intervals (CIs) were applied to assess the prognostic effect of CTCs. RevMan 5.3 and STATA 16.0 software were adopted to perform the meta-analysis.

RESULTS

Based on EMT in terms of the prognosis of patients suffering from lung cancer, this study comprehensively reviewed and evaluated the available evidence of phenotype detection of CTCs.

CONCLUSION

Based on EMT in the prognosis of patients who developed with lung cancer, our findings proved the effect of phenotype detection of CTCs. Such studies may reveal a new prognostic marker for lung cancer patients and help clinicians and health professionals make clinical decisions.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/E7KAZ.

European Cancer Organisation Essential Requirements for Quality Cancer Care (ERQCC): Lung cancer

European Cancer Organisation Essential Requirements for Quality Cancer Care (ERQCC) are written by experts representing all disciplines involved in cancer care in Europe. They give patients, health professionals, managers and policymakers a guide to essential care throughout the patient journey. Lung cancer is the leading cause of cancer mortality and has a wide variation in treatment and outcomes in Europe. It is a major healthcare burden and has complex diagnosis and treatment challenges. Care must only be carried out in lung cancer units or centres that have a core multidisciplinary team (MDT) and an extended team of health professionals detailed here. Such units are far from universal in European countries. To meet European aspirations for comprehensive cancer control, healthcare organisations must consider the requirements in this paper, paying particular attention to multidisciplinarity and patient-centred pathways from diagnosis, to treatment, to survivorship.

Intraoperative complications and troubles in robot-assisted anatomical pulmonary resection

OBJECTIVE

Regarding intraoperative complications and troubles during robot-assisted thoracic surgery, few data are available especially in Japan. This study was aimed to elucidate intraoperative complications and troubles in robotic anatomical lung resection, and to present managements and outcomes of those.

METHODS

This was a retrospective singe-institutional study. The first 192 consecutive patients who underwent robot-assisted anatomical lung resection between January 2017 and August 2019 were evaluated. We examined the frequency, management and outcomes of intraoperative complications and troubles.

RESULTS

Of the 192 eligible patients who underwent robotic anatomical lung resection, lobectomy was performed for 156 (81.2%), and segmentectomy for 36 (18.8%). Three (1.5%) required conversion to open thoracotomy. Of these, bleeding from the pulmonary artery was the cause in two patients (1.0%) and inflammatory adhesion of hilar lymph nodes in 1 (0.5%). Other intraoperative complications and troubles included bronchial injuries in 3 patients (1.5%), lung injury by assistant in one patient (0.5%) and horizontal movement limitation of da Vinci arm in one patient (0.5%). Regarding bronchial injuries, two of three were stump injuries related to stapling, the remaining was to dissection of the bronchial tissues. All bronchial repairs were completed without conversion, and postoperative complications related to bronchial injury were not observed. The 30-day and 90-day mortality rates were both 0%.

CONCLUSIONS

The frequency of intraoperative complications and troubles in robot-assisted thoracic surgery was low in our first series. All conversions were related to bleeding and impending bleeding, and no conversion was required for bronchial injury.

Perioperative outcomes of robot-assisted vs video-assisted and traditional open thoracic surgery for lung cancer: A systematic review and network meta-analysis

BACKGROUND

The superiority of robot-assisted thoracic surgery (RATS) over video-assisted thoracic surgery (VATS) and thoracotomy remains controversial for lung cancer.

METHODS

A network meta-analysis (NMA) and pairwise meta-analysis (PMA) were performed to evaluate the perioperative outcomes using five databases.

RESULTS

Thirty-two studies involving 6593 patients were included for analysis. The NMA showed that RATS had similar operative time, conversion rate to thoracotomy, number of lymph node, postoperative morbidity, and length of hospital stay with VATS, except for lower 30-day mortality. Compared with thoracotomy, longer operative time and shorter hospital stay were observed in RATS, but no significant difference was observed in number of lymph node, postoperative morbidity, and 30-day mortality in both NMA and PMA. In lobectomy/segmentectomy subgroup, all outcomes, except for operative time of RATS vs VATS and number of lymph node, were similar with overall analyses.

CONCLUSIONS

RATS had comparable perioperative outcomes with VATS and open surgery.

A clinical study of efficacy of polyglycolic acid patch in surgery for pneumothorax:a systematic review and meta-analysis

Objectives

A polyglycolic acid (PGA) patch is often used in pulmonary bullae resection, but consensus has not been reached on its effect on patient recovery. The aim of the study is to conduct a systematic review and meta-analysis of studies of polyglycolic acid for bullectomy.

Methods

A comprehensive literature search was performed using ScienceDirect, EMBASE, Ovid MEDLINE, PubMed, The Cochrane Library, Scopus, and Google Scholar. Clinical trials that compared PGA versus non-PGA for bullectomy were selected. The clinical endpoints included postoperative recurrence, average postoperative air leakage, prolonged air leaks, drainage tube removal time, and postoperative hospital stay.

Results

A total of eight articles (1095 patients) were included. Compared to the non-PGA approach, the PGA approach was associated with lower rates of postoperative recurrence (95% confidence interval [CI]: 0.16 to 0.39, p < 0.00001),) and of prolonged air leaks (95% CI: 0.29 to 0.72, p = 0.0007); a shorter time of drainage tube removal (95% CI: − 1.36 to − 0.13, p = 0.02); The time of average postoperative air leakage, postoperative hospital stay and operative time did not show a significant difference between the two groups.

Conclusions

These results suggest that the use of PGA patch might can prevent the postoperative recurrence of spontaneous pneumothorax and decrease the rates of prolonged air leaks. More large-scale, high-quality randomized controlled trials are required to confirm our finding.

Mortality for Robotic- vs Video-Assisted Lobectomy-Treated Stage I Non-Small Cell Lung Cancer Patients

Background

To address the US Food and Drug Administration’s recent safety concern on robotic surgery procedures, we compared short- and long-term mortality for stage I non-small cell lung cancer (NSCLC) patients treated by robotic-assisted thoracoscopic surgical lobectomy (RATS-L) vs video-assisted thoracoscopic surgical lobectomy (VATS-L).

Methods

From the National Cancer Database, we identified 18 908 stage I NSCLC patients who underwent RATS-L or VATS-L as the primary operation from 2010 to 2014. Cox proportional hazards models were used to estimate hazard ratios (HRs) for short- and long-term mortality using unmatched and propensity score–matched analyses. All statistical tests were 2-sided.

Results

Patients treated by RATS-L had higher 90-day mortality than those with VATS-L (6.6% vs 3.8%, P = .03) if conversion to open thoracotomy occurred. After excluding first-year observation, multiple regression analyses showed RATS-L was associated with increased long-term mortality, compared with VATS-L, in cases with tumor size 20 mm or less: hazard ratio (HR) = 1.33 (95% confidence interval [CI] = 1.15 to 1.55), HR = 1.36 (95% CI = 1.17 to 1.58), and HR = 1.33 (95% CI = 1.11 to 1.61) for unmatched, N:1 matched, and 1:1 matched analyses, respectively, in the intention-to-treat analysis. Among patients without conversion to an open thoracotomy, the respective hazard ratios were 1.19 (95% CI = 1.10 to 1.29), 1.19 (95% CI = 1.10 to 1.29), and 1.17 (95% CI = 1.06 to 1.29). Similar associations were observed when follow-up time started 18 or 24 months postsurgery. No statistically significant mortality difference was found for patients with tumor size of greater than 20 mm. These associations were not related to case volume of VATS-L or RATS-L performed at treatment institutes.

Conclusions

Patients with small (≤20 mm) stage I NSCLC treated with RATS-L had statistically significantly higher long-term mortality risk than VATS-L after 1 year postsurgery.

Simultaneous Vs Sequential Retroperitoneal, Thoracic and Cervical Resection of Post Chemotherapy Residual Masses in Patients With Metastatic Nonseminomatous Germ Cell Tumors of the Testis

OBJECTIVE

To compare a simultaneous vs sequential approach to residual post chemotherapy mass resections in metastatic testis cancer.

METHODS

A retrospective review was performed of patients who underwent retroperitoneal and thoracic/cervical resection of post chemotherapy residual masses between 2002 and 2018. Group 1: "Simultaneous" (Combined Retroperitoneal and Thoracic/Cervical resections on the same date); Group 2: "Sequential" (Retroperitoneal and Thoracic/Cervical resections at separate dates).

RESULTS

During the study period, 35 simultaneous and 17 sequential resections were performed. The median age at surgery was 28 years (Range 16-61). The median follow-up from last surgical procedure was 62.7 months (Range 0.4-194). Histology revealed teratoma in 38 (73.1%) patients, necrosis in 8 (15.4%) and viable tumor in 6 (11.5%). Discordant pathology findings between thoracic/cervical and abdominal resections were noted in 16 (30.8%) patients. No differences were observed between the simultaneous vs sequential groups in median operating time (585 minutes vs 545 minutes, P = .64), blood loss (1300 vs 1300 mls, P = .42), or length of stay (9 vs 11 days, P = .14). There was no difference between the 5-year (65.7% vs 68.6%) relapse-free survival between the 2 groups (P = .84) or the 5-year (88.6% vs 100%) overall and disease-specific survival (P = .25).

CONCLUSION

Simultaneous resection of retroperitoneal and thoracic/cervical post chemotherapy metastases is a feasible in some patients. It requires multidisciplinary collaboration and a longer primary procedure.

[Robot-assisted Lobectomy under Port-only Mode with Artificial Pneumothorax]

背景与目的

达芬奇机器人手术操作系统目前在胸外科得到了广泛的应用，国内不同中心采用的建立通道方式及操作流程，不同辅助操作孔多采用小切口的方式。

方法

基于大量临床实践的基础上，我们在实践中总结国内、外经验，并结合国人体型特点，对机器人辅助肺叶切除术的切口及操作流程进行了改进并实践出一套更加简化易行的手术方法。

结果

全孔道（port-only）人工气胸下机器人辅助肺叶切除术在术中解剖安全性，止血效果和伤口美观性方面，都有进一步的提升。

结论

本研究对全孔道人工气胸机器人辅助肺叶切除的流程加以优化，以期为肺癌患者更好地服务。

[Application of artificial intelligence in thoracic surgery]

BACKGROUND

The application of artificial intelligence is a relatively new option to enable improved patient treatment in modern medicine and is therefore currently the focus of many research projects. In the clinical practice the application of artificial intelligence so far seems to be confined to the analysis of medical imaging.

OBJECTIVE

In which form is the use of artificial intelligence possible in routine daily work in thoracic surgery and is already being practiced?

MATERIAL AND METHODS

A search of the currently available literature was performed.

RESULTS

Under current conditions artificial intelligence can best be used as part of diagnostics and treatment planning; however, in order to enable a comprehensive use standardization and evaluation of the centralized data collection are necessary.

CONCLUSION

At the present time promising study results are available but the implementation into the surgical routine has so far been very difficult.

A systematic review and meta-analysis of robotic versus open and video-assisted thoracoscopic surgery approaches for lobectomy

OBJECTIVES

A number of meta-analytical and database studies have sought to compare open, video-assisted thoracoscopic surgery (VATS) and robotic operative approaches to lobectomy, often with conflicting results. Our objective was to perform a comprehensive review of these meta-analytical and database studies published to date.

METHODS

A systematic review was conducted in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines using the PubMed and Scopus databases. Primary outcome was short-term mortality, and secondary outcomes were operative time, blood loss or transfusion rate, hospital stay, conversions, lymph node yield and complications. Meta-analyses of the primary and secondary outcomes were performed.

RESULTS

Robotic lobectomy is a valid alternative to the VATS approach and is superior to the open approach with respect to complications [OR 0.67, 95% CI 0.58-0.76, P  < 0.00001] and duration of hospital stay (WMD -1.4, 95% CI -1.96-0.85, P < 0.00001). It is inferior to both VATS and open with respect to operative duration (robotic vs. VATS; WMD 4.98, 95% CI 2.61-7.36, P < 0.001, robotic vs. open WMD 65.56, 95% CI 53.66-77.46, P < 0.00001). Robotic approach is superior with respect to 30-day mortality compared to VATS (OR 0.61, 95% CI 0.45-0.83, P = 0.001 and open approaches (OR 0.53, 95% CI 0.33-0.85, P = 0.008).

CONCLUSIONS

This is the largest published systematic review and meta-analysis to date qualifying the robotic lobectomy as a reasonable alternative to VATS and open surgery. Short-term survival is superior in the robotic cohorts. No definitive conclusions on long-term outcomes can be drawn until a randomized controlled trial comparing approaches is conducted.

Current status and evolution of robotic-assisted thoracic surgery in Germany-results from a nationwide survey

Background

Robot-assisted surgery has made a significant entry into surgical practice within Germany, including thoracic surgery. As no published data exists regarding robotic-assisted thoracic surgery (RATS), we conducted a survey to investigate its current status.

Methods

We performed a nationwide survey of all centers active in RATS, using a standardized questionnaire. The annual number of operations, mean duration of surgery, docking time, length of hospital stay(s), conversions, chest tube duration, the RATS program start date, robot system used, operating room capacity, and staplers and instruments used were recorded.

Results

Of the 22 centers contacted, 14 responded. In total, 786 RATS interventions were recorded. Most were anatomical lung resections, comprising 372 (bi-) lobectomies and 80 segmentectomies. During the study period, eight bronchoplastic procedures were performed robotically. There were 93 wedge lung resections, 148 thymectomies, 26 sympathectomies, and 59 other RATS procedures, and a single-center series of around 1,000 RATS thymectomies (excluded from statistical analysis). The average incision-suture time of the RATS lobectomy was 245 (range, 80-419) minutes, average residence time seven days. The conversion rate was 6.7% across all interventions, with significant inter-intervention differences. All surveyed centers plan to further expand RATS, with OR capacity being a frequent impediment. Five RATS interventions were performed in Germany in 2013, versus 320 in 2018.

Conclusions

Overall, RATS is becoming more established in everyday clinical practice in Germany. The number of operations, active centers, and trained RATS surgeons has increased steadily since 2013. A German-speaking operation course for entry into RATS already exists. Even extended resections can be carried out safely, and RATS has become standard procedure in some centers.