Thoracoscopic-assisted lobectomy. Preliminary experience and results

Minimally invasive surgery vs. open thoracotomy for non-small-cell lung cancer with N2 disease: a systematic review and meta-analysis

Background

This meta-analysis aimed to investigate the effectiveness and safety of minimally invasive surgery [MIS, including robotic-assisted thoracoscopic surgery (RATS) and video-assisted thoracoscopic surgery (VATS)] and open thoracotomy (OT) for non-small cell lung cancer (NSCLC) patients with N2 disease.

Methods

We searched online databases and studies from the creation of the database to August 2022, comparing the MIS group to the OT group for NSCLC with N2 disease. Study endpoints included intraoperative outcomes [e.g., conversion, estimated blood loss (EBL), surgery time (ST), total lymph nodes (TLN), and R0 resection], postoperative outcomes [e.g., length of stay (LOS) and complication], and survival outcomes [e.g., 30-day mortality, overall survival (OS), and disease-free survival (DFS)]. We estimated outcomes using random effects meta-analysis to account for studies with high heterogeneity (I² > 50 or p < 0.05). Otherwise, we used a fixed-effect model. We calculated odds ratios (ORs) for binary outcomes and standard mean differences (SMDs) for continuous outcomes. Treatment effects on OS and DFS were described by hazard ratio (HR).

Results

This systematic review and meta-analysis of 15 studies on MIS vs. OT for NSCLC with N2 disease included 8,374 patients. Compared to OT, patients that underwent MIS had less estimated blood loss (EBL) (SMD = - 64.82, p < 0.01), shorter length of stay (LOS) (SMD = -0.15, p < 0.01), higher R0 resection rate (OR = 1.22, p = 0.049), lower 30-day mortality (OR = 0.67, p = 0.03), and longer overall survival (OS) (HR = 0.61, P < 0.01). The results showed no statistically significant differences in surgical time (ST), total lymph nodes (TLN), complications, and disease-free survival (DFS) between the two groups.

Conclusion

Current data suggest that minimally invasive surgery may provide satisfying outcomes, a higher R0 resection rate, and better short-term and long-term survival than open thoracotomy.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42022355712.

Asian perspectives in thoracic surgery: clinical innovation in Taiwan

The development of minimally-invasive surgery of the thorax began in the 1990s, but not until the recent decade did we see dramatic improvements in patient care and refinement of technique. The current generation has witnessed the evolution from traditional thoracotomy, to a single-port, non-intubated thoracoscopic approach. The investigation of subxiphoid single-port, transumbilical approach, and natural orifice transluminal endoscopic surgery (NOTES) in animal model are also undergoing. In Taiwan, several talented young surgeons have vigorously devoted their ideas and innovations to this field, making the Taiwan surgical society vivid and prosperous. The desire to improve, and willingness to change are the foundation of those surgeons. Providing better patient care is their impetus to strive for improvement. This article provides an account of how minimally-invasive thoracic surgery has evolved in recent years, and what clinical innovations have been developed by the Taiwan surgical society.

Changes in pulmonary function in lung cancer patients after video-assisted thoracic surgery

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) is widely performed in patients with resectable non-small cell lung cancer. However, it is unknown whether VATS sublobar resection has advantages compared with VATS lobectomy in preserving pulmonary function.

METHODS

Three hundred patients with non-small cell lung cancer who underwent VATS were enrolled. Pulmonary function tests were performed three times: preoperatively, and at 3 and 12 months postoperatively. Pulmonary function was compared between the VATS lobectomy group (n = 227) and the VATS sublobar resection group (n = 73).

RESULTS

The VATS sublobar resection group had greater preserved pulmonary function than the VATS lobectomy group at 3 and 12 months postoperatively (p < 0.001). However, a VATS lobectomy of the right upper or right middle lobe revealed no difference in forced vital capacity (-1.21% versus -1.45%; p = 0.88) or the diffusion capacity of carbon monoxide (-3.99% versus -2.45%; p = 0.61) compared with VATS sublobar resection after 12 months. In those who underwent VATS of the right lower lobe, forced expiratory volume in 1 second (-8.60% versus -3.69%; p = 0.12) was not different between the two groups after 12 months. Video-assisted thoracoscopic surgery lobectomy of the left upper or left lower lobe resulted in lower pulmonary function than VATS sublobar resection (p < 0.05).

CONCLUSIONS

Patients with non-small cell lung cancer who underwent VATS sublobar resection demonstrated greater pulmonary function than those who underwent VATS lobectomy. However, in right-side VATS lobectomy, some differences dissipated at 1 year.

Video-assisted thoracoscopic pulmonary resections - The Melbourne experience

BACKGROUND

Despite its privileged economic and educational place in the world, Melbourne was relatively slow to embrace video-assisted thoracic surgery (VATS) for lobectomy. The initial driver of this was Professor C Peter Clarke at the Austin Hospital at the beginning of the new millennium. His legacy was carried on by his apprentice, but at St Vincent's Hospital. After a period of slow development, it became the procedure of choice from 2005, and began to filter sporadically to other hospitals from 2010.

METHODS

This paper details the historical development, techniques and results of 343 VATS pulmonary resections (including lobectomies, sub-lobar anatomical resections, sleeve resections, bi-lobectomies and pneumonectomies).

RESULTS

In-hospital and 30-day mortality was 2.0% and 5-year survival for all stages of NSCLC was 70%. Over 36% of patients were stage II-III using the new 7(th) revision TNM staging system. The conversion to thoracotomy rate was 4.7%. The estimated learning curve for this experience VATS lobectomy appears to be in the range of 15-20 cases. In this series, the same lymph node dissection or sampling was attempted and usually achieved as would have occurred at thoracotomy.

CONCLUSIONS

The results confirm the findings of other large case series that the benefits of a minimally invasive approach are achieved without compromising the long-term survival.

Thoracoscopic-assisted lung lobectomy in the dog: report of two cases

The benefits and application of thoracoscopy with selective ventilation, as an adjunct to thoracotomy, in facilitating pleural exploration and lung lobectomy in two dogs are presented. Similar thoracoscopic-assisted procedures are commonly used in human patients because there is better exposure and they are technically less demanding than thoracoscopy alone, while causing less postoperative morbidity than conventional thoracotomy. There are no previous reports of thoracoscopic-assisted surgery in the veterinary literature. In the cases described, thoracoscopic-assisted mini-thoracotomy was an effective, minimally-invasive approach for ipsilateral hemithorax exploration and lung lobectomy.

Video-assisted thoracic surgery (VATS) resection for lung cancer

VATS is a relatively new technology that has become the standard of care for basic procedures such as drainage of pleural effusion and blebectomy. VATS anatomic lung resection is more controversial. Published studies demonstrate several advantages of VATS over a standard posterolateral thoracotomy. A minimally invasive approach causes less inflammatory reaction. Acute and chronic pain are diminished. As a result, the length of hospitalization is shorter. Early and late shoulder dysfunction is less and return to work time is shorter. Taken together, these factors suggest a better overall outcome using a VATS approach. From an oncologic standpoint, lymph node dissection can be accomplished and locoregional recurrence is low. The validity of VATS for lung cancer will be determined by long-term data. A phase III national (intergroup) protocol is being drafted and will help to answer these questions.

Changes in right ventricular performance in elderly patients who underwent lobectomy using video-assisted thoracic surgery for primary lung cancer

OBJECTIVE

Even though lobectomy using video-assisted thoracic surgery for primary lung cancer has been reported to be beneficial in terms of the perioperative outcome, changes in the right ventricular performance have not yet been reported. The aim of this study was to determine whether lobectomy by video-assisted thoracic surgery is also advantageous with respect to the right ventricular performance in elderly patients who are 70 years old or older.

SUBJECTS AND METHODS

Thirteen patients (mean age: 76 years) who underwent lobectomy using video-assisted thoracic surgery (Video-assisted Thoracic Surgery Group), and 10 patients (mean age: 76 years) who underwent lobectomy using a standard thoracotomy as a historical control group (Standard Thoracotomy Group) were studied. The hemodynamics and right ventricular ejection fraction were evaluated preoperatively, and at 6, 12, 24, and at 48 hours postoperatively.

RESULTS

Postoperative values were expressed as a percentage of the preoperative values. The systemic vascular resistance index decreased to a greater extent in the Video-assisted Thoracic Surgery Group than in the Standard Thoracotomy Group. The pulmonary arteriolar resistance index at 24 hours postoperation tended to be higher in the Standard Thoracotomy Group than in the Video-assisted Thoracic Surgery Group. The stroke index, cardiac index, and right ventricular ejection fraction at 24 hours postoperation were each significantly higher in the Video-assisted Thoracic Surgery Group than in the Standard Thoracotomy Group.

CONCLUSION

Lobectomy using video-assisted thoracic surgery for elderly patients offers not only beneficial effects in the right ventricular afterload but also acceleration in the expected compensatory hyperdynamics during the acute postoperative phase.

Pulmonary function after lobectomy: video-assisted thoracic surgery versus thoracotomy

BACKGROUND

Whether video-assisted thoracic surgery (VATS) improves postoperative pulmonary function is still controversial. We compared postoperative pulmonary function after VATS lobectomy and standard lobectomy.

METHODS

Eleven patients who had undergone standard lobectomy and 10 patients who had undergone VATS lobectomy were studied. Arterial blood gas analyses were performed on the 4th, 7th, and 14th postoperative days. Pulmonary function, including forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1.0), and peak flow rate (PFR) were measured on the 7th and 14th postoperative days (early phase), and approximately 1 year after surgery (late phase).

RESULTS

Pulmonary function, as assessed with arterial oxygen partial pressure (PaO2) (p = 0.054), arterial oxygen saturation (O2SAT) (p = 0.063), FVC (p = 0.10), and FEV1.0 (p = 0.08), was better after VATS lobectomy than after thoracotomy on the 7th postoperative day. PFR was significantly better after VATS on both the 7th and 14th postoperative days (p = 0.008 and p = 0.03, respectively).

CONCLUSIONS

VATS lobectomy had advantages on early postoperative pulmonary function. We conclude that VATS lobectomy is a beneficial alternative to standard thoracotomy, especially for patients with poor pulmonary reserve.

Thoracoscopic major lung resections: an Asian perspective

The application of video-assisted thoracic surgery (VATS) for major lung resection is controversial. We review our combined experience from three centers in Asia. From June 1993 through June 1997, 214 patients underwent VATS major resections (2 segmentectomies, 203 lobectomies, 6 bilobectomies, 3 pneumonectomies), mostly for primary malignancy. Stringent selection criteria were used to choose patients for this approach. We prefer a technique of not spreading ribs, using conventional thoracic instrument for dissection and routine use of wound protector for specimen retrieval. There was one postoperative surgical death and 47 non-fatal complications, which compare favorably with published series on open technique. Of the primary lung cancer patients, 93% are still alive after a mean follow-up of 26 months. We conclude that VATS major lung resection is technically feasible in selected patients and associated with favorable intermediate-term results.

Lobectomy: video-assisted thoracic surgery versus posterolateral thoracotomy

BACKGROUND

Video-assisted lobectomy has been adopted by many thoracic surgeons, because it is a less invasive approach to small peripheral lung cancers. However, some authors disagree that video-assisted lobectomy is less invasive than traditional thoracotomy and lobectomy. The purpose of this study was to evaluate the advantages of video-assisted lobectomy over posterolateral thoracotomy and lobectomy in terms of pain-related morbidity.

METHODS

A total of 70 patients with clinical T1N0M0 non-small-cell lung carcinomas underwent lobectomy with complete mediastinal lymphadenectomy. Of these 35 underwent posterolateral thoracotomy (between April 1994 and December 1995; open group), and 35 underwent video-assisted thoracic surgery (VATS) (between January and December 1996; VATS group).

RESULTS

Although the operative time was significantly longer in the VATS group (p = 0.04), the intraoperative blood loss was significantly less (p = 0.03). No significant differences were found for the two groups with respect to the total number of mediastinal lymph nodes dissected or duration of chest tube drainage. Postoperative pain was less severe as determined by the number of doses of analgesics required between postoperative days 0 and 7 (p < 0.0001), and the length of postoperative hospitalization was shorter in the VATS group (p < 0.0001).

CONCLUSION

Video-assisted lobectomy is associated with decreased postoperative pain and shortened length of postoperative hospitalization, when compared with posterolateral thoracotomy and lobectomy.

Therapeutic thoracoscopy

Thoracoscopy provides a minimally invasive window to the pleural space, lung, and mediastinum. Further advances prompted by improvements of specifically designed endoscopic instruments and procedural techniques are expected. There is no doubt that thoracoscopy has a place among therapeutic procedures in the chest. The time-proven principles of thoracic surgical intervention, particularly in regard to patients with cancer, however, must not be neglected. A beckoning window always offers new opportunities, but the open door of classic surgical techniques should not be ignored.

Thoracoscopic loop ligation of parenchymal blebs and bullae: is it effective and safe?

Surgeons who have gained experience and confidence with video-assisted thoracic surgery are now routinely applying the minimally invasive approach to treat patients with spontaneous pneumothorax. Although the endoscopic stapling device may be a preferred method for resection of parenchymal blebs or bullae, the stapling device is not inexpensive. In an effort to contain costs since we started performing the video-assisted thoracoscopic procedure in chest surgical diseases, we have used a self-made endoscopic loop as an alternative method. It has assisted us in performing bulla ablation in a cost-effective manner. Over a 4-year period (1992 to 1996), we assessed the efficacy of ligating parenchymal blebs and bullae with a self-made endoscopic loop by video-assisted techniques. A total of 263 ligations were performed in 250 patients. Surgical indications included recurrence (n = 146), bilaterality of the disease (n = 13), hemopneumothorax (n = 7), radiologically demonstrated large bulla (n = 9), persistent air leak (n = 52), and nonexpansion of the lung (n = 23). There were no operative deaths. Early postoperative complications included a dislodged endoscopic loop necessitating reexploration in one patient and postoperative minor wound infections in 13. The average postoperative hospitalization was 4.5 days. Two hundred seventeen patients (86.8% of all patients) were followed up for a median of 28 months (1 to 46 months) after the operation. There have been no recurrences to date. Our results showed that thoracoscopic loop ligation is safe and effective in managing blebs and parenchymal bullae, with a lower cost, fewer complications, and a lower recurrence rate than provided by standard surgical techniques. On the basis of our results, we advocate the use of the self-made endoscopic loop for ligation of parenchymal blebs and bulla in patients with spontaneous pneumothorax to achieve a truly cost-effective and minimally invasive thoracoscopic procedure.

Complications and failures of video-assisted thoracic surgery: experience from two centers in Asia

BACKGROUND

There have been few specific reports on negative outcomes after video-assisted thoracic surgery. We report our combined experience from two centers in Asia.

METHODS

From September 1992 to April 1995, 1,337 patients were operated on with the video-assisted thoracic surgical approach. All the patients were prospectively studied.

RESULTS

There was one death (mortality rate, 0.07%) and 56 nonfatal complications: persistent air leaks (21), bleeding (6), wound infection (13), empyema (2), cerebrovascular accident (1), reexpansion pulmonary edema (2), deep vein thrombosis (1), prolonged ventilatory support (4), intercostal neuralgia (5), and port-site recurrence (1), giving rise to an overall nonfatal complication rate of 4.26%. Procedure failures consisted of 7 recurrences of spontaneous pneumothorax (of 407 cases or 1.7%); 2 recurrences of malignant pleural effusion (of 39 cases or 5.1%), and 2 local recurrences after resections for stage I lung cancers (of 41 cases or 4.9%).

CONCLUSIONS

We conclude that video-assisted thoracic surgery is safe and effective for a wide range of procedures. A learning curve is present, and careful patient selection and attention to details are essential in optimizing surgical results.