Surgical Outcomes of Video-Assisted versus Open Pneumonectomy for Lung Cancer: A Real-World Study

BACKGROUND

The safety, feasibility and potential benefits of Video-assisted thoracoscopic surgery (VATS) pneumonectomy remain to be investigated.

METHODS

Patients receiving VATS or Open pneumonectomy during the study period were included to compare surgical outcomes. Propensity-score matched (PSM) analysis was performed to eliminate potential biases.

RESULTS

From 2013 to 2020, 583 consecutive patients receiving either VATS (105, 18%) or Open (478, 82%) pneumonectomy were included. Conversion from VATS to open was found in 20 patients (19.0%). The conversion patients had similar rates of major complications and perioperative mortality compared with the Open group. After PSM, 203 patients were included. No significant differences were observed in major complications and perioperative mortality between the two groups. For patients with stage pT2 tumors, the major complication rate in the VATS group was significantly lower than in the Open group (7.6% vs. 20.6%, p = 0.042). Compared with left pneumonectomy, the incidence of bronchopleural fistula (BPF) was significantly higher in right pneumonectomy for both VATS (0 vs. 16.7%, p = 0.005) and Open (0.7% vs. 6.5%, p = 0.002) approaches.

CONCLUSIONS

Perioperative results of VATS pneumonectomy are non-inferior to those of the Open approach. Conversion to open surgery does not compromise perioperative outcomes. Patients with lower pT stage tumors who need pneumonectomy may benefit from VATS.

Clinical characteristics and survival outcomes of patients with pneumonectomies: A population-based study

Background

Prognostic factors in a pneumonectomy (PN) are not yet fully defined. This study sought to analyze and evaluate long-term survival after pneumonectomies (PNs) for patients with non-small cell lung cancer (NSCLC).

Methods

We obtained data from the Surveillance, Epidemiology, and End Results (SEER) database for patients who underwent PNs between 2004 and 2015. Propensity score matching (PSM) analysis and Kaplan–Meier curves were used to estimate overall survival (OS), while univariate and multivariable Cox proportional hazards regression analyses were applied to create a forest plot.

Results

In total, 1,376 patients were grouped according to right/left PNs. Before matching, OS was worse after a right PN [hazard ratio (HR): 1.459; 95% CI 1.254–1.697; P < 0.001] and after matching, survival differences between groups were not significant (HR: 1.060; 95% CI 0.906–1.240; P = 0.465). Regression analysis revealed that age, gender, grade, lymph node dissection, N-stage, and chemotherapy were independent predictors of OS (P < 0.05). Chemotherapy was associated with improved OS (P < 0.001).

Conclusions

Laterality was not a significant prognostic factor for long-term survival after a PN for NSCLC. Chemotherapy was a significant independent predictor of improved OS. Long-term survival and outcomes analyses should be conducted on larger numbers of patients.

Subxiphoid, Nonintubated, Opioid-Free, Video-Assisted Pneumonectomy: A New Frontier in Thoracic Surgery

Surgical approaches to major pulmonary resections have evolved from thoracotomy to multiportal video-assisted thoracoscopy (VATS) and subsequently uniportal VATS. The efficacy of this progress has been validated in a multitude of publications demonstrating reductions in complications, patient perception of pain, and postoperative length of stay. More recent advances include subxiphoid extrathoracic access and nonintubated, opioid-free anesthesia. Early publications have demonstrated promising results with respect to safety, technical feasibility, and enhanced recovery. However, there remains a paucity of literature relating to hybrid approaches comprising both subxiphoid and nonintubated, opioid-free anesthesia in the context of pneumonectomy. The current report is the case of a patient undergoing pneumonectomy. Both subxiphoid and nonintubated, opioid-free techniques were utilized. The authors describe preoperative workup, surgical and anesthesia-related caveats, and postoperative recovery. In conclusion, this approach is technically feasible, safe, and may be associated with enhanced recovery.

UniPortal thoracoscopic pneumonectomy does not compromise perioperative and long-term survival in patients with NSCLC: A retrospective, multicenter, and propensity score matching study

OBJECTIVES

To compare the perioperative and oncologic outcomes following pneumonectomy performed by uniportal video-assisted thoracoscopic surgery (U-VATS) and thoracotomy in patients with centrally located non-small cell lung cancer (NSCLC).

MATERIALS AND METHODS

Patients with NSCLC who underwent pneumonectomy at the Shanghai Pulmonary Hospital (SPH) and Sun Yat-sen University Cancer Center (SYUCC) with the U-VATS approach or open approach between 2011 and 2016 were selected. Propensity score matching (1:3) was performed to balance the baseline covariates. Overall survival (OS) rates and recurrence-free survival (RFS) rates were estimated and compared using the Kaplan-Meier method, respectively.

RESULTS

The enrollees in the study were 579 patients in the SPH cohort, with 501 (86.5%) in the open group and 48 (13.5%) in the U-VATS group, and 271 patients in the SYUCC cohort, with 245 (90.4%) in the open group and 26 (9.6%) in the U-VATS group. After propensity score matching, morbidity rates and 30-day mortality rates were found to be similar between the U-VATS group and open group in both the SPH and SYUCC cohorts. The long-term OS rate of patients who underwent U-VATS pneumonectomy did not significantly differ compared with the patients who underwent open pneumonectomy in both cohorts (SPH, p = .900; SYUCC, p = .240). Cox regression analysis revealed that the surgical option was not a risk factor for the OS rate (SPH: hazard ratio [HR], 0.925; 95% confidence interval [CI], 0.555 to 1.542; SYUCC: HR, 1.524; 95% CI, 0.752 to 3.087).

CONCLUSION

U-VATS can be used to safely perform pneumonectomy in patients with centrally located NSCLC without compromising the perioperative and oncologic outcomes compared with an open approach.

Minimally invasive surgery versus thoracotomy for resectable stage II and III non-small-cell lung cancers: a systematic review and meta-analysis

OBJECTIVES

The study aimed to compare the long-term oncological efficacy and perioperative outcomes of patients with locally advanced non-small-cell lung cancers who underwent minimally invasive surgery (MIS) or thoracotomy.

METHODS

Cochrane Library, PubMed and EMBASE databases, ClinicalTrials.gov and reference lists were searched for relevant studies. Two reviewers independently assessed the quality of the studies. Recurrence-free survival (RFS) and overall survival (OS) and perioperative outcomes were synthesized. Random-effects models were used to summarize hazard ratios (HRs), relative risks and standardized mean differences (SMDs) with 95% confidence intervals (CIs).

RESULTS

Twenty-three retrospective cohort studies were reviewed with a total of 3281 patients, of whom 1376 (41.9%) received MIS and 1905 (58.1%) received thoracotomy. Meta-analysis showed no significant differences in both RFS (HR, 1.02; 95% CI, 0.89-1.17; P = 0.78) and OS (HR, 0.91; 95% CI, 0.80-1.03; P = 0.15) between MIS versus thoracotomy approaches. Similar results were observed in propensity score matched studies (RFS, HR, 0.94; 95% CI, 0.73-1.20; P = 0.62; OS, HR, 0.96; 95% CI, 0.72-1.30; P = 0.81). No significant difference was found in lymph node clearance and margin positivity. As for perioperative outcomes, MIS was associated with a significant reduction in postoperative complications (relative risk, 0.83; P = 0.01), intraoperative blood loss (standardized mean difference, -0.68; P = 0.007), chest tube drainage (standardized mean difference, -0.38; P = 0.03) and length of hospital stay (standardized mean difference, -0.79; P = 0.002) when compared with thoracotomy.

CONCLUSIONS

The use of MIS for resectable stage II and III non-small-cell lung cancers is an eligible alternative to conventional thoracotomy without compromising the long-term survival and short-term outcomes.

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

OBJECTIVES

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

METHODS

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

CONCLUSIONS

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

Short- and long-term outcomes of thoracoscopic pneumonectomy - single center experience

Introduction

The video-assisted thoracic surgery (VATS) approach is widely used for pulmonary lobectomy, but its application for pneumonectomy is much less common and outcomes are ambiguous.

Aim

To evaluate the feasibility and outcomes of VATS pneumonectomy.

Material and methods

This retrospective study included 19 patients with the mean age of 62.6 ±5.5 years who were qualified for VATS pneumonectomy between September 1, 2010, and January 31, 2020. Indications and technical aspects were analyzed. Moreover, short- and long-term outcomes were assessed.

Results

There were no intraoperative deaths. Conversion to thoracotomy was necessary in 2 (10.5%) patients, because of bleeding in 1 patient and technical reasons in another. One patient died during the in-hospital period due to multi-organ failure as a result of bronchopleural fistula. Five other subjects developed postoperative complications, most often atrial fibrillation (n = 3). One patient was readmitted for empyema of the postpneumonectomy space without bronchopleural fistula. Histopathological examination revealed that the resection was complete (R0) in all cases and the most common type of cancer was squamous cell carcinoma (79%). Seven patients died during the follow-up: 1 because of surgical complications, 4 as a result of cancer progression, and 2 for non-cancer related reasons. Median survival was 47 months. One- and five-year probability of survival estimated by means of the Kaplan-Meier method was 0.88 ±0.07 and 0.43 ±0.15, respectively.

Conclusions

VATS pneumonectomy can be performed safely, without increased risk of intraoperative and postoperative complications. It enables a complete lung cancer resection and is likely to provide good short- and long-term outcomes.

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.

Robotic Pneumonectomy for Lung Cancer: Perioperative Outcomes and Factors Leading to Conversion to Thoracotomy

OBJECTIVE

In the tide of robot-assisted minimally invasive surgery, few cases of robot-assisted pneumonectomy exist in the literature. This study evaluates the perioperative outcomes and risk factors for conversion to thoracotomy with an initial robotic approach to pneumonectomy for lung cancer.

METHODS

This study is a single-center retrospective review of all pneumonectomies for lung cancer with an initial robotic approach between 2015 and 2019. Patients were divided into 2 groups: surgeries completed robotically and surgeries converted to thoracotomy. Patient demographics, preoperative clinical data, surgical pathology, and perioperative outcomes were compared for meaningful differences between the groups.

RESULTS

Thirteen total patients underwent robotic pneumonectomy with 8 of them completed robotically and 5 converted to thoracotomy. There were no significant differences in patient characteristics between the groups. The Robotic group had a shorter operative time (P < 0.01) and less estimated blood loss (P = 0.02). There were more lymph nodes harvested in the Robotic group (P = 0.08) but without statistical significance. There were 2 major complications in the Robotic group and none in the Conversion group. Neither tumor size nor stage were predictive of conversion to thoracotomy. Conversions decreased over time with a majority occurring in the first 2 years. There were no conversions for bleeding and no mortalities.

CONCLUSIONS

Robotic pneumonectomy for lung cancer is a safe procedure and a reasonable alternative to thoracotomy. With meticulous technique, major bleeding can be avoided and most procedures can be completed robotically. Larger studies are needed to elucidate any advantages of a robotic versus open approach.

Uniportal video-assisted thoracoscopic left pneumonectomy: Retrospective analysis of eighteen consecutive patients from a single center

Background

Uniportal video‐assisted thoracoscopic surgery (VATS) is being more widely used in lung cancer, yet reports on its application in pneumonectomies are limited. This study aimed to evaluate the safety and feasibility of uniportal video‐assisted thoracoscopic left pneumonectomy for lung cancer.

Methods

A series of 18 lung cancer patients who had received uniportal video‐assisted thoracoscopic left pneumonectomies were included in the study. Their clinical, pathological, and surgical features, as well as postoperative recovery, were analyzed.

Results

The majority of the patients were male and smokers and their average age was 62.0 ± 8.9 years. All had primary lung cancer, while three (16.7%) had received neoadjuvant therapy. A total of 16 (88.9%) patients had stage II–III disease, with an average tumor size of 3.6 ± 1.5 cm. The average surgery time was 137.4 ± 47.0 minutes, with a 16.7% (3/18) conversion rate. The mean blood loss was 37.5 ± 59.4 mL and no patients needed blood transfusion during, or after, surgery. There was no perioperative death and the overall complication rate was 22.2% (4/18). Two (11.1%) patients needed to stay in the intensive care unit after surgery, and the average length of hospital stay after surgery was 6.3 ± 1.1 days (range 4–7 days).

Conclusions

Uniportal video‐assisted thoracoscopic left pneumonectomy is a safe and feasible procedure for selected lung cancer patients. The use of uniportal VATS in right pneumonectomies and the effect of uniportal video‐assisted thoracoscopic pneumonectomy on the survival of patients merits further study.

Patients receiving uniportal VATS pneumonectomies had standard surgical results and recovery. Uniportal VATS pneumonectomy is safe for properly selected lung cancer patients.

Key points

Significant findings of the study: • Patients receiving uniportal VATS left pneumonectomies had standard surgical results and recovery.

What this study adds: • Uniportal VATS left pneumonectomy is safe for properly selected lung cancer patients.

Conversion from thoracoscopic to open pneumonectomy is not associated with short- or long-term mortality

BACKGROUND

Thoracoscopic pneumonectomy commonly requires conversion to thoracotomy. We hypothesize that conversion would lead to worse short- and long-term outcomes compared with operations completed thoracoscopically.

METHODS

The National Cancer Database identified patients who underwent a pneumonectomy from 2010 to 2016. Trends in conversion were described using linear regression. Multivariable regression of factors associated with conversion was performed. Short-term outcomes included duration of stay, number of lymph nodes harvested, margin status, readmission, and 90-day mortality. Long-term outcome was evaluated as overall survival.

RESULTS

A total of 8,037 patients underwent a pneumonectomy. The rate of attempted thoracoscopic pneumonectomies increased from 11% to 22% (P < .001) and the rate of conversion decreased from 39% to 33% (P = .011). On multivariable analysis, a greater patient comorbidity index and pathologic nodal-stage 2 disease were associated with an increased rate of conversion. The mean number of lymph nodes evaluated was greater as was the duration of stay in the conversion group, but conversion to open thoracotomy was not associated with positive surgical margins, readmission rate, 90-day mortality, or survival.

CONCLUSION

Thoracoscopic pneumonectomy is performed with increasing frequency and decreasing conversion rate. Conversion is associated with a greater duration of stay but other short- and long-term outcomes are similar. This observation suggests minimal harm in conversion from minimally invasive to open pneumonectomy.

Uniportal VATS for non-small cell lung cancer

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

Multiportal subxiphoid thoracoscopic major pulmonary resections

Background

New subxiphoid video-assisted thoracoscopic surgery (SVATS) approaches are emerging for major pulmonary resection. The underlying concept is to reduce invasiveness and morbidity, by minimising intercostal nerve trauma, without any concession on safety and carcinologic issues. This study describes and evaluates our initial experience in multiportal SVATS, compared to conventional VATS (CVATS).

Methods

Between June 2016 and October 2017, 75 consecutive patients underwent major pulmonary resection with an original multiportal SVATS approach developed through a single or double access under the costal arch, unsystematically associated with intercostal ports for 5-mm instruments only. We retrospectively compared results of this SVATS group (n=75) against an historic CVATS group (n=75).

Results

Fifty-one lobectomies, 20 segmentectomies and 4 pneumonectomies were achieved through multiportal SVATS. Sixty-eight malignant lesions and 7 benign lesions were noted. All patients with primary lung cancer underwent R0 resection and complete lymphadenectomy, with 11% of clinical N0 upstaging. When compared, the SVATS and CVATS groups were similar in terms of demographics and pathology. No statistical differences were observed in terms of conversion (9% vs. 12%), mean operative time (157 vs. 155 min), morbidity (24% vs. 32%) and 30-day mortality (0% vs. 1.3%). The SVATS group had a significantly shorter length of drainage (median: 1 vs. 3 days, P<0.001), and a shorter postoperative length of stay (median: 2 vs. 4 days, P<0.001). Comfortable pain relief on postoperative day 1 (Numeric Rating Scale ≤3) was equally achieved (96% vs. 93%) with a significantly simplified SVATS analgesic protocol (local block and opioid-free oral analgesia) compared to the CVATS analgesic protocol (paravertebral catheter and opioid-free oral analgesia). SVATS group presented significantly less patients with persistent morphine use at day 7 (4% vs. 15%, P=0.04).

Conclusions

Multiportal SVATS is a safe, carcinologic and reproducible approach for major pulmonary resection. By avoiding intercostal strains, it enables a high compliance to opioid-free analgesic protocol, contributing to significantly shorter hospitalisation and better recovery, compared to CVATS.

Risk and benefit of neoadjuvant therapy among patients undergoing resection for non-small-cell lung cancer

OBJECTIVES

Neoadjuvant therapy has emerged as a favoured treatment paradigm for patients with clinical N2 disease undergoing surgical resection for non-small-cell lung cancer. It is unclear whether such a treatment paradigm affects perioperative outcomes. We sought to examine the National Cancer Database (NCDB) to assess the impact of neoadjuvant therapy on perioperative outcomes and long-term survival in these patients.

METHODS

All patients with a history of non-small-cell lung cancer undergoing anatomical resection between 2004 and 2014 were included. Thirty-day and 90-day mortality of all patients having neoadjuvant therapy versus those who did not were compared. In addition, the impact of neoadjuvant therapy on the overall survival of patients with clinical N2 disease was examined.

RESULTS

Of the 134 428 selected patients, 9896 (7.4%) patients had neoadjuvant chemotherapy. Patients undergoing neoadjuvant therapy had a higher 30-day (3% vs 2.6%; P < 0.01) and 90-day mortality (6.5% vs 4.9%; P < 0.01). This association remained after adjusting for covariates. Among patients with clinical N2 disease (n = 10 139), 42.3%, 35.3% and 22.4% of patients had neoadjuvant, adjuvant and no chemotherapy, respectively. Univariable, multivariable and propensity score-weighted analyses indicated no difference in survival between patients receiving neoadjuvant and adjuvant chemotherapy.

CONCLUSIONS

Neoadjuvant therapy may adversely affect perioperative outcomes without providing a survival advantage compared with adjuvant therapy in clinical N2 stage patients. Randomized controlled trials need to be conducted to examine this issue further.

The role of thoracoscopic pneumonectomy in the management of non-small cell lung cancer: A multicenter study

OBJECTIVE

The objective of this study was to evaluate the impact of the video-assisted thoracoscopic (VATS) approach on the outcomes of patients who underwent pneumonectomy.

METHODS

The effect of the surgical approach on perioperative complications and survival in patients who underwent pneumonectomy for nonmetastatic non-small cell lung cancer across 3 institutions (2000-2016) was assessed using multivariable logistic regression, Cox proportional hazards analysis, and propensity-score matching. Completion pneumonectomies were excluded from this study, and an "intent-to-treat" analysis was performed.

RESULTS

During the study period, 359 patients met inclusion criteria and underwent pneumonectomy for nonmetastatic non-small cell lung cancer; 124 (35%) underwent pneumonectomy via VATS and 235 (65%) via thoracotomy. Perioperative mortality (VATS, 7% [n = 9] vs open, 8% [n = 19]; P = .75) and morbidity (VATS, 28% [n = 35] vs open, 28% [n = 65]; P = .91) were similar between the groups, even after multivariable adjustment. VATS showed similar 5-year survival when compared with thoracotomy in unadjusted analysis (47% [95% confidence interval (CI), 36-56] vs 33% [95% CI, 27-40]; P = .19), even after multivariable adjustment (hazard ratio, 0.76 [95% CI, 0.50-1.18]; P = .23). In a propensity score-matched analysis that balanced patient characteristics, there were no significant differences found in overall survival between the 2 groups (P = .69).

CONCLUSIONS

Although the role of VATS pneumonectomy will likely become clearer as more surgeons report results, this multicenter study suggests that the VATS approach for pneumonectomy can be performed safely, with at least equivalent oncologic outcomes when compared with thoracotomy.

Single incision video-assisted thoracic surgery pneumonectomy for centrally located lung cancer

Increasing experience in single-incision video-assisted thoracoscopic (SIVATS) lung resections for lung cancer has made some sophisticated lung resections such as bronchial or vascular sleeve resections, chest wall resections and pneumonectomy possible. There are some case series published in medical literature about the feasibility and safety of multiportal video-assisted thoracic surgery pneumonectomy. However, in this prepubertal period of its evolution the literature data are still immature, and limited only to rare case reports or video presentations for SIVATS pneumonectomy for lung cancer. This article aims to discuss the technique, feasibility and place of SIVATS pneumonectomy in the management of non-small-cell lung cancer.

Enhanced recovery for thoracic surgery in the elderly

PURPOSE OF REVIEW

Both surgical workload and the age of those patients being considered for radial pulmonary resection are increasing. Enhanced recovery programmes are now well established in most surgical disciplines and are increasingly reported in thoracic procedures. This review will discuss the relevant principles of these programmes as applied to an increasing elderly population.

RECENT FINDINGS

Elderly patients undergoing less radial surgical resections without lymphadenectomy have comparable outcomes to those undergoing classical curative treatment. Patients require careful assessment and self-reported quality of life metrics or function may be a better marker of outcome than static measures such as lung function. Hypotension, low values for bispectral index and low anaesthetic gas mean alveolar concentration values are common and independent predictors of mortality in the elderly. Paravertebral blockade is preferred to epidural anaesthesia because of a more favourable side-effect profile and comparable efficacy. As yet no robust work has examined the efficacy of an integrated enhanced recovery programme in thoracic surgery.

SUMMARY

Elderly patients are suitable for enhanced recovery programmes but these must be tailored to individual circumstance. Further work is required to comprehensively assess their value in a modern healthcare setting.

Technique of video-assisted thoracoscopic left pneumonectomy

Video-assisted thoracoscopic surgery (VATS) approaches to lobectomy for treatment of early stage non-small cell lung cancer (NSCLC) have generally been accepted to be beneficial. Experience and results for more extensive resections, including thoracoscopic pneumonectomy are limited. Here we report a case with attached videos describing key technical aspects of performing a thoracoscopic left pneumonectomy. This demonstrates the adoption of VATS for tumor pathology requiring pneumonectomy is feasible and can be done safely. Further study is needed to clarify potential advantages or drawbacks to approaching more complex tumor pathology by VATS.

Clinical outcomes of video-assisted thoracic surgery and stereotactic body radiation therapy for early-stage non-small cell lung cancer: A meta-analysis

Background

We compared video‐assisted thoracoscopic surgery (VATS) lobectomy and stereotactic body radiation therapy (SABR) to explore clinical outcomes in the treatment of patients with early stage NSCLC.

Methods

Major medical databases were systematically searched to identify studies on VATS and SBRT published between January 2010 and October 2015. English publications of stage I and II NSCLC with adequate patients and SBRT doses were included. A multivariate random effects model was used to perform meta‐analysis to compare overall survival (OS) and disease‐free survival (DFS) between VATS and SBRT, adjusting for median age and operable patient numbers.

Results

Thirteen VATS (3436 patients) and 24 SBRT (4433) studies were eligible. The median age and follow‐up duration was 68 years and 42 months for VATS and 74 years and 29.4 months for SBRT patients. After adjusting for the proportion of operable patients and median age, the estimated OS rates at one, two, three, and five years with VATS were 94%, 89%, 84%, and 69% compared with 96%, 94%, 89%, and 82% for SBRT. The estimated DFS rates at one, two, three, and five years with VATS were 97%, 93%, 87%, and 77% compared with 86%, 80%, 73%, and 58% for SBRT.

Conclusion

Before adjustment, patients treated with SBRT had poorer clinical outcomes compared to those treated with VATS. A substantial difference between median age and operability exists between patients treated with SBRT and VATS. After adjusting for these differences, OS and DFS did not differ significantly between the two techniques.

Single-incision thoracoscopic right pneumonectomy with primary division of the pulmonary artery

In recent years video-assisted thoracoscopic surgery (VATS) techniques have gained popularity also for major lung resections. Furthermore, especially in experienced VATS centers, single-incision thoracoscopic surgery is more and more adapted due to its even lesser invasiveness. Most thoracic surgeons still prefer an open approach to perform pneumonectomy, although reports of VATS and even single-incision VATS pneumonectomy are increasing. Unlike other authors we prefer to divide the pulmonary artery (PA) as one of the first steps of the procedure in order to obtain a clear field of vision on one hand and to obtain optimal control of bleeding and total blood loss on the other hand. Herein we describe our technique for single incision thoracoscopic right pneumonectomy and mediastinal lymphadenectomy without rib-spreading and with division of the PA as a first step. Furthermore we prefer to routinely cover the bronchial stump (BS) with an in situ azygos vein (AV) flap during right pneumonectomy.

Pulmonary Artery Bleeding During Video-Assisted Thoracoscopic Surgery: Intraoperative Bleeding and Control

With appropriate planning and operative technique, the risk of pulmonary artery injury and bleeding during video-assisted thoracoscopic surgery (VATS) lobectomy can be minimized. However, the risk cannot be completely eliminated; surgeons should always ensure that they are prepared to manage this situation if it occurs. Although pulmonary artery bleeding can potentially lead to intraoperative disasters, appropriate judgment, management, and control via VATS or conversion to thoracotomy can avoid any impact on either short-term or long-term patient outcomes.

The Latest in Surgical Management of Stage IIIA Non-Small Cell Lung Cancer: Video-Assisted Thoracic Surgery and Tumor Molecular Profiling

Stage IIIA non-small cell lung cancer (NSCLC) remains a treatment challenge and requires a multidisciplinary care team to optimize survival outcomes. Thoracic surgeons play an important role in selecting operative candidates and assisting with pathologic mediastinal staging via cervical mediastinoscopy, endobronchial ultrasound, or esophageal ultrasound with fine needle aspiration. The majority of patients with stage IIIA disease will receive induction therapy followed by repeat staging before undergoing lobectomy or pneumonectomy; occasionally, a patient with an incidentally found, single-station microscopic IIIA tumor will undergo resection as the primary initial therapy. Multiple large clinical trials, including SWOG-8805, EORTC-8941, INT-0139, and ANITA, have shown 5-year overall survival rates of up to 30% to 40% using triple-modality treatments, and the best outcomes repeatedly are seen among patients who respond to induction treatment or who have tumors amenable to lobectomy instead of pneumonectomy. The need for a pneumonectomy is not a reason to deny patients an operation, because current operative mortality and morbidity rates are acceptably low at 5% and 30%, respectively. In select patients with stage IIIA disease, video-assisted thoracic surgery and open resections have been shown to have comparable rates of local recurrence and long-term survival. New developments in genetic profiling and personalized medicine are exciting areas of research, and early data suggest that molecular profiling of stage IIIA NSCLC tumors can accurately stratify patients by risk within this stage and predict survival outcomes. Future advances in treating stage IIIA disease will involve developing better systemic therapies and customizing treatment plans on the basis of an individual tumor's genetic profile.