Video-assisted thoracoscopic versus open sleeve lobectomy for non-small cell lung cancer: A systematic review and meta-analysis from six comparative studies

BACKGROUND

Lung sleeve resection is indicated for centrally located lung tumors, especially for patients who cannot tolerate pneumonectomy. With video-assisted thoracoscopic surgery (VATS) being increasingly implemented for a wide variety of thoracic pathologies, this study aims to compare the intraoperative, postoperative, and long-term outcomes of VATS and open bronchial sleeve lobectomy for non-small cell lung cancer (NSCLC).

METHODS

The MEDLINE (via PubMed), Cochrane Library, and Scopus databases were searched. Original clinical studies, comparing VATS and open sleeve lobectomy for NSCLC were included. Evidence was synthesized as odds ratios for categorical and weighted mean difference (WMD) for continuous variables.

RESULTS

Our analysis included six studies with non-overlapping populations reporting on 655 patients undergoing bronchial sleeve lobectomy for NSCLC (229 VATS and 426 open). VATS sleeve lobectomy was associated with significantly longer operative time ((WMD): 45.85 min, 95% confidence interval (CI): 12.06 to 79.65, p  =  0.01) but less intraoperative blood loss ((WMD): -34.57 mL, 95%CI: -58.35 to -10.78, p < 0.001). No significant difference was found between VATS and open bronchial sleeve lobectomy in margin-negative resection rate, number of lymph nodes resected, postoperative outcomes (drainage duration, length of hospital stay, 30-day mortality), postoperative complications (pneumonia, bronchopleural fistula/empyema, prolonged air leakage, chylothorax, pulmonary embolism, and arrhythmia), and long-term outcomes (overall survival, recurrence-free survival).

CONCLUSIONS

The limitation of our study arises mainly due to the heterogeneity of the included studies. Nevertheless, VATS bronchial sleeve lung resection constitutes a feasible and safe alternative to the open sleeve lung resection surgery for the management of centrally located lung tumors.

VATS right upper lobe bronchial sleeve resection

BACKGROUND

The aim of this study is to discuss video-assisted thoracic surgery (VATS) sleeve bronchial lobectomy when handling the locally advanced central lung cancer (involving the trachea and/or main bronchus).

METHODS

A 2.5 cm × 1.0 cm mass was found in the right upper lobe. Bronchoscopy demonstrated the tumor obstructing the right upper lobe bronchus and involved the right main bronchus and bronchus intermedius. Interrupted sutures were chosen for bronchial anastomosis. Bronchial membrane was sutured first, and then circumference end-to-end anastomoses were carried out using 3-0 absorbable sutures.

RESULTS

There were no complications and the patient was discharged 8 days postoperatively.

CONCLUSIONS

The third intercostal space of the anterior axillary line was suggested for right upper lobe bronchial sleeve resection. This incision can reduce the distance and angle between the anastomosis to the incision, and facilitate anastomosis. This approach can also prevent operator from fatigue for keeping one posture for a long time. Clearance of the mediastinal lymph nodes before cutting the bronchus was helpful for exposing the right main bronchus, the upper lobe bronchus and bronchus intermedius satisfied. And this option would avoid pulling bronchial anastomosis during mediastinal lymph nodes clearance. Interrupted suture was safe and effective for VATS bronchial anastomosis.

Thoracoscopic tracheal reconstruction without surgical field intubation

A cross‐filed endotracheal intubation is usually applied to maintain single lung ventilation during both open and thoracoscopic tracheal resection and reconstruction. Herein, we report a case of thoracoscopic tracheal resection and reconstruction with interrupted ventilation via transoral endotracheal intubation in a patient with thoracic tracheal adenocarcinoma. Tracheal anastomosis was accomplished using a running suture with a 3‐0 Prolene stitch.

Complete video-assisted thoracoscopic surgery (VATS) bronchial sleeve lobectomy

BACKGROUND

To explore the effectiveness of video-assisted thoracoscopic surgery (VATS) bronchial sleeve resection and reconstruction.

METHODS

The clinical data of patients who had received VATS bronchial sleeve lobectomy in our center from January 2008 to February 2015 were retrospectively analyzed.

RESULTS

Totally 118 patients (105 men and 13 women) received the VATS bronchial sleeve lobectomy. The procedures included sleeve resection of right upper lobe (n=59), right middle lobe (n=7), right lower lobe (n=8), left upper lobe (n=34), and left lower lobe (n=10). The lesions were confirmed to be squamous cell carcinoma (n=68), adenocarcinoma (n=16), mucoepidermoid carcinoma (n=8), adenosquamous carcinoma (n=7), large cell carcinoma (n=1), carcinoids (n=5), and others (n=13; including small cell carcinoma, pleomorphic carcinoma, and inflammatory myofibroblastic tumor). Operations lasted 118-223 min [mean ± standard deviations (SD): 124.00±31.75 min]. The length of removed bronchus was 1.50-2.00 cm (mean ± SD: 1.75±0.26 cm). The duration of bronchial anastomosis (from the first puncture to the completion of knotting) was 15-42 min (mean ± SD: 30.20±7.97 min). The number of dissected lymph node stations (at least three mediastinal lymph node stations, including station 7) was 5-9 stations (mean ± SD: 6.50±1.18 min). The number of dissected lymph nodes was 10-46 (mean ± SD: 26.00±10.48). The intraoperative blood loss was 20-400 mL (mean ± SD: 71.00±43.95 mL), and no blood transfusion was performed. All patients were observed in intensive care unit (ICU) for 1 day. Postoperative drainage was performed for 3-8 days (mean ± SD: 5.00±1.49 days). Postoperative hospital stay was 3-8 days (mean ± SD: 5.10±2.07 days).

CONCLUSIONS

VATS bronchial sleeve resection and reconstruction is a safe and feasible technique.

Video-assisted thoracic surgery right upper lobe bronchial sleeve resection

BACKGROUND

Video-assisted thoracic surgery (VATS) is a new technology for nearly 30 years in the field of thoracic surgery most watched. However, there are still some controversy concerning the technical difficulties, operation duration, the extent of lymph node dissection and perioperative complications for VATS sleeve bronchial lobectomy when handling the locally advanced central lung cancer (involving the trachea and/or main bronchus).

METHODS

A 66 years old man was admitted for coughing for 2 months. He had smoked for 30 years, 20 packs a day. Chest computed tomography (CT) revealed a 2.5 cm × 4.5 cm mass in the right upper lobe. Bronchoscopy demonstrated the tumor obstructing the right upper lobe bronchus and involved the right main bronchus and bronchus intermedius. Pathology was squamous cell carcinoma. His pulmonary function result was forced expiratory volume in 1 second (FEV1): 1.91 L (64.7% predicted), forced vital capacity (FVC): 4.36 L. He received general anesthesia with double-lumen endotracheal intubation and left lung ventilation. Left lateral decubitus position was chosen. The first 1.5 cm incision was selected in the eighth intercostal space in the midaxillary line, and was used for the camera. A 4 cm long incision was made in the 3rd intercostal space in the preaxillary line. A third 1.5 cm incision was performed in the 9th intercostal space in the postaxillary line for assistant. Pulmonary ligament and the entire right hilum were mobilized. Pulmonary vein is the most forward hilar structure, sometimes immediately prior pulmonary trunk. The right upper lobe vein was transected with a vascular stapler. Truncus and posterior ascending pulmonary artery were then divided and transected with a vascular stapler. Major and minor fissures were stapled by 60 mm green linear stapler. Following clearance of the mediastinal lymph nodes of level 7, 4R and 2R, the bronchial sleeve resection and reconstruction began. The distal right main bronchus and bronchus intermedius were fully mobilized to ensure adequate surgical exposure. Traction sutures were routinely placed on the lateral walls and to reduce tension. Interrupted sutures were chosen for bronchial anastomosis. Bronchial membrane was sutured first, and then circumference end-to-end anastomoses were carried out using 3-0 absorbable sutures.

RESULTS

There were no complications and the patient was discharged 8 days postoperatively.

CONCLUSIONS

The 3rd intercostal space of the anterior axillary line was suggested for right upper lobe bronchial sleeve resection. This incision can reduce the distance and angle between the anastomosis to the incision, providing convenient conditions for easy anastomosis. And avoid the operator fatigue for keeping the posture for a long time. Clearance of the mediastinal lymph nodes before cutting the bronchus was helpful for satisfied explosion of the right main bronchus, the upper lobe bronchus and bronchus intermedius. And this would avoid pulling bronchial anastomosis for mediastinal lymph nodes clearance. Interrupted suture was safe and effective for VATS bronchial anastomosis.

Sleeve lobectomy by video-assisted thoracic surgery versus thoracotomy for non-small cell lung cancer

BACKGROUND

Both video-assisted thoracic surgery (VATS) and thoracotomy are used for sleeve lobectomy for patients with non-small cell lung cancer (NSCLC). This retrospective study aimed to assess the safety and efficacy of VATS sleeve lobectomy for NSCLC patients.

METHODS

Between May 2009 and May 2013, 51 sleeve lobectomies (10 by VATS and 41 by thoracotomy) were performed for patients with NSCLC. Operative characteristics and postoperative course were compared between two groups.

RESULTS

Patient demographics were similar between the two groups. Thoracotomy patients had larger tumors compared with VATS patients (p = 0.02). VATS patients had a longer operating time (p < 0.001) but a shorter length of postoperative hospital stay (p = 0.009). The two groups did not differ in pathologic stage, histologic results, blood loss, ICU stay, amount of chest drainage, duration of chest drainage, numbers and distributions of dissected lymph nodes and the occurrence of complications. There were no perioperative deaths in the VATS group, whereas there was one death (2.4 %) in the thoracotomy group. There were no conversions to thoracotomy in the VATS group. The overall median survival between the two groups was similar (3.2 years VATS versus 3.2 years thoracotomy, log-rank p = 0.58).

CONCLUSIONS

VATS sleeve lobectomy for the treatment of NSCLC is technically feasible and safe and is associated with comparable complication rates and survival compared with thoracotomy approach, but it deserves further investigation in large series.

Challenging cases: thoracoscopic lobectomy with chest wall resection and sleeve lobectomy-Duke experience

Video-assisted thoracoscopic surgery (VATS) had recent advances in both equipment and technique so has been applied to more complex conditions in some thoracic surgery centers. We have adopted our VATS lobectomy experience for patients with chest wall invasion and endobronchial localized tumor requiring bronchial sleeve resection. We are describing our decision-making and surgical methods for these patients which we believe will be decreasing the number of contraindications for VATS and offering this surgical method for more patients.

Precise and fast video assisted thoracoscopic bronchial sleeve resection

Surgical management for lung cancer is basically a destructive one. The lung parenchyma removed is in the balance between the purpose of curative resection and the preservation of patient's lung function. Bronchial sleeve has been alternatively developed to achieve the same purpose, but through a different way-to save back healthy lung tissue through reconstruction of the central airway. Sleeve resection had been done with open technique for years, and just like the other thoracic operations, has continuously evolved into the era of minimally invasive surgery in spite of its difficulty. With rapid advancement and availability in technology-high resolution 3-D dynamic chest computed tomography (CT), PET-CT, and endobronchial ultrasound (EBUS), these tools are very helpful for us to have more precise tumor staging, and suitable for preoperative surgical planning. Under magnified 3-D endoscopic view and modified endoscopic suturing method, re-anastomosis of the airway could be easier and quicker, which would facilitate this innovative operation to accumulate experience in the not too distant future.

Modified application of a wound retractor for surgery in chest trauma

Wound retraction is useful for chest wall surgery involving surgical rib fixation in patients with rib fractures. However, blunt chest trauma with rib fractures frequently involves lung injury, requiring simultaneous pulmonary repairs. In intrapleural surgery for chest trauma involving rib fractures, a rib spreader could cause additional rib fractures. Therefore, we describe the modified application of a second wound retractor for surgery in the thorax and chest wall, and discuss its advantages and disadvantages. We call this method double-wound retraction.

Video-assisted thoracic bronchial sleeve lobectomy with bronchoplasty for treatment of lung cancer confined to a single lung lobe: a case series of Chinese patients

Background

The outcomes of video-assisted thoracic bronchial sleeve lobectomy (VABSL), a minimally invasive video-assisted thoracoscopic (VATS) lobectomy, are mostly unknown in Chinese patients.

Objectives

To investigate operative and postoperative outcomes of VABSL in a cases series of Chinese patients with lung cancer.

Methods

Retrospective study of 9 patients (male:female 8:1; mean age 59.4 ± 17.6 years, ranging 21–79 years) diagnosed with lung cancer of a single lobe, treated with VABSL between March 2009 and November 2011, and followed up for at least 2 months (mean follow-up: 14.17 ± 12.91 months). Operative outcomes (tumor size, operation time, estimated blood loss and blood transfusion), postoperative outcomes (intensive care unit [ICU] stay, hospitalization length and pathological tumor stage), death, tumor recurrence and safety were assessed.

Results

Patients were diagnosed with carcinoid cancer (11.1%), squamous carcinoma (66.7%) or small cell carcinoma (22.2%), affecting the right (77.8%) or left (22.2%) lung lobes in the upper (55.6%), middle (11.1%) or lower (33.3%) regions. TNM stages were T2 (88.9%) or T3 (11.1%); N0 (66.7%), N1 (11.1%) or N2 (22.2%); and M0 (100%). No patient required conversion to thoracotomy. Mean tumor size, operation time and blood loss were 2.50 ± 0.75 cm, 203 ± 20 min and 390 ± 206 ml, respectively. Patients were treated in the ICU for 18.7 ± 0.7 hours, and overall hospitalization duration was 20.8 ± 2.0 days. No deaths, recurrences or severe complications were reported.

Conclusions

VABSL surgery is safe and effective for treatment of lung cancer by experienced physicians, warranting wider implementation of VABSL and VATS training in China.

Thoracoscopic half carina resection and bronchial sleeve resection for central lung cancer

BACKGROUND

The objectives of this study were to report the surgical techniques and clinical outcome of thoracoscopic half carina resection and thoracoscopic bronchial sleeve resection for central lung cancer.

METHODS

Between January 2011 and November 2012, 675 patients with lung cancer underwent radical surgery by thoracoscopy, and 49 (7.3%) underwent bronchial sleeve resection. Among 49 patients, 20 (41%) received thoracoscopic bronchial sleeve lobectomy. Perioperative variables and postoperative outcomes of these cases were analyzed to evaluate the technical feasibility and safety of this operation.

RESULTS

In one patient, right upper lung sleeve resection was combined with half-carinal resection and reconstruction. In another, right medial lung sleeve resection was combined with lower right dorsal segment resection. The average time of surgery was 239 ± 51 minutes (range = 142-330 minutes), and the average time of airway reconstruction was 44 ± 17 minutes (range = 22-75 minutes). The intraoperative blood loss averaged 207 ± 96 mL (range = 80-550 mL). The median postoperative hospital stay was 10 days (interquartile range = 8-12 days). Postoperatively, extubation was achieved in the recovery room without further need for mechanical ventilation. None of the patients developed anastomotic leak. Perioperative mortality was not observed.

CONCLUSION

Thoracoscopic bronchial sleeve resection can be considered a feasible and safe operation for selected patients with central lung cancer. The complicated anastomosis technique of half carina resection was feasible.

Initial experience with video-assisted thoracoscopic bronchoplasty

OBJECTIVES

Bronchial-origin involvement by endobronchial tumours or direct invasion by tumour or metastatic lymph nodes is a relative contraindication for video-assisted thoracoscopic (VATS) lobectomy. However, selected cases can be resected by VATS bronchoplasty.

METHODS

Between 2006 and 2009, 21 of 231 (9.1%) VATS lobectomy cases underwent VATS bronchoplasty. Cases with endobronchial involvement and limited non-bulky invasion of bronchus by tumour or metastatic nodes without major vascular invasion were selected for bronchoplasty by preoperative bronchosocpy and CT scan thorax. Patients underwent a simple/wedge bronchoplasty (bronchus divided at origin and closed flush or transversely), sleeve bronchoplasty or others (bronchoplasty combined with other extended resections). All bronchoplasties were done totally endoscopically by directly watching a TV monitor. Bronchial margins were all subjected to intraoperative pathological analysis. Anastomosis was done with interrupted sutures. Integrity of anastomosis was checked by intraoperative bronchoscopy. The follow-up was done by 6-monthly CT scans and bronchoscopy.

RESULTS

Eleven patients were females. Mean age was 64.9 years (range, 47-83 years). Indications were endobronchial tumours in 3, direct invasion in 6 and metastatic nodes in 12. In 4 cases, invasion was detected at the time of surgery. Mean hospital stay was 5.2 days (range, 3-8 days). Mean duration of surgery was 287 min (range, 135-540 min). Nine had simple/wedge bronchoplasty, 8, sleeve bronchoplasty and 4, extended bronchoplasties. Histology was non-small-cell carcinoma (NSCLC) in 19, carcinoid in 1 and colonic metastasis in 1. In the NSCLC, 5 patients were in stage IB, 5 in stage IIA, 2 in stage IIB and 7 were in IIIA. All bronchial margins were negative for malignancy. The mean follow-up was 26.2 months (range, 6-32 months). There was no operative mortality, but 1 patient developed bronchopleural fistula. To date, there have been no local tumour recurrences.

CONCLUSIONS

Selected endobronchial and non bulky tumours with limited invasion at bronchial origin can be resected by VATS bronchoplasty.

Complex thoracoscopic pulmonary resections for the treatment of lung cancer-a review

Minimally invasive surgery is increasingly being used in cancer resections. Benefits attributed to minimally invasive surgery include improved functional and oncological outcomes. In keeping with this trend, thoracoscopic lung resections are gaining acceptance amongst thoracic oncologic surgeons. As surgeons become more comfortable with these approaches, more complex resections are being performed through these techniques. This review article summarizes the current state of the art with respect to complex thoracoscopic resections.

A new application of a wound retractor for chest wall surgery

Use of a wound retraction (WR) is useful for lung resection by video-assisted thoracic surgery via a mini-thoracotomy. We have employed a WR for chest wall surgery involving surgical rib fixation in a patient with rib fractures, and obtained successful results in terms of a good surgical view and lack of postoperative wound infection. On the basis of our experience, we consider that a WR is useful even for chest wall surgery.

Unanticipated troubles in video-assisted thoracic surgery: a proposal for the classification of troubleshooting

INTRODUCTION

Most thoracic surgeons encounter atypical cases or unexpected situations that usually lead them to convert minimally invasive surgery to open thoracotomy. But are there other options besides open surgery? The purpose of this study was to suggest a video-assisted thoracic surgery (VATS) classification system and present tips for the application of VATS to atypical cases or unexpected situations. We have categorized VATS procedures for atypical cases or unexpected situations into two groups: the modification of techniques/instruments and the creation of additional access incisions.

METHODS

We retrospectively reviewed VATS with optional additional techniques. We used direct visualization or monitoring as the situation demanded, switching back and forth between the monitor and direct vision.

RESULTS

Of the 33 cases we reviewed, 27 patients had malignant lung disease and 6 had benign lung disease. All patients underwent lobectomies including one or more of the following: bronchoplasty (n = 12), control of the main pulmonary artery (n = 9), total adhesiotomy (n = 7), combined resection with the diaphragm (n = 3), and separation of totally fused fissures (n = 2). The mean length of the skin incision was 8 cm, the mean total operating time was 208 min, and the mean blood loss was 173 mL No operative or hospital deaths occurred.

CONCLUSIONS

Veteran surgeons can instinctively deal with intraoperative variance, but we frequently see inexperienced surgeons panic and change the course of their procedures. A VATS classification system may have educational benefits for newer surgeons. We believe that the creation of a categorized coping plan will help inexperienced surgeons deal with unanticipated problems.