Robotic pulmonary lobectomy for lung cancer treatment: program implementation and initial experience

Global status of the robotic thoracic surgery

Robotics has taken its place in thoracic surgery since the end of the 20th century. Since then, it has been developed worldwide with many different applications, such as the treatment of mediastinal tumors and lung cancer. Although, the contradictory results comparing this new technology to other minimally invasive techniques may raise some skepticism, the high quality of the instrument and images provided by the robot brings a whole new perspective for the thoracic surgeon, since the robotic platform can ally the ease of movement obtained with open technique with the advantages of the minimally invasive surgery. When it comes to the implementation of a robotic program the costs of RATS are an important issue. However, it is necessary to take into account not only the cost of the robotic platform itself but also the maintenance expenses, disposable tools, and training programs. Nevertheless, the cost of the robotic surgery is expected to decrease in the coming years and like the instrumentation, virtual reality will see improvements. Many different countries around the world have contributed with original articles for the development of the robotic thoracic surgery and in this paper, we aim at describing the global status of the robotic thoracic surgery.

Robotic thoracic surgery for inflammatory and infectious lung disease: initial experience in Brazil

OBJECTIVE

in Latin America, especially Brazil, the use of a robotic platform for thoracic surgery is gradually increasing in recent years. However, despite tuberculosis and inflammatory pulmonary diseases are endemic in our country, there is a lack of studies describing the results of robotic surgical treatment of bronchiectasis. This study aims to evaluate the surgical outcomes of robotic surgery for inflammatory and infective diseases by determining the extent of resection, postoperative complications, operative time, and length of hospital stay.

METHODS

retrospective study from a database involving patients diagnosed with bronchiectasis and undergoing robotic thoracic surgery at three hospitals in Brazil between January of 2017 and January of 2020.

RESULTS

a total of 7 patients were included. The mean age was 47 + 18.3 years (range, 18-70 years). Most patients had non-cystic fibrosis bronchiectasis (n=5), followed by tuberculosis bronchiectasis (n=1) and lung abscess (n=1). The performed surgeries were lobectomy (n=3), anatomic segmentectomy (n=3), and bilobectomy (n=1). The median console time was 147 minutes (range 61-288 min.) and there was no need for conversion to open thoracotomy. There were no major complications. Postoperative complications occurred in one patient and it was a case of constipation with the need for an intestinal lavage. The median for chest tube time and hospital stay, in days, was 1 (range, 1-6 days) and 5 (range, 2-14 days) respectively.

CONCLUSIONS

robotic thoracic surgery for inflammatory and infective diseases is a feasible and safe procedure, with a low risk of complications and morbidity.

Evolution of the surgical treatment of lung cancer at a tertiary referral center in Brazil, 2011-2018

Objective:

To evaluate the evolution of clinical and epidemiological data, as well as data related to diagnosis, staging, treatment, and survival, among patients undergoing curative surgery for lung cancer at a tertiary referral center in the city of São Paulo, Brazil.

Methods:

This was a retrospective study of cases in the International Association for the Study of Lung Cancer database. We selected only cases of patients undergoing curative surgery between January of 2011 and April of 2018. We determined overall and disease-free survival at 36 months and compared the data between two periods (2011-2014 and 2015-2018).

Results:

Comparing the two periods (N = 437 cases), we observed trends toward increases in the number of female patients, as well as in the proportions of former smokers (44.09% vs. 53.59%), of patients diagnosed with adenocarcinoma (52.21% vs. 59.72%), and of patients diagnosed at an earlier pathological stage, together with a decrease in 30-day mortality (4.05% vs. 2.39%). There were significant increases in the proportions of cases diagnosed at an earlier clinical stage (p = 0.002) or incidentally (p = 0.003). Although lobectomy was the main surgical technique employed, there was a proportional increase in segmentectomies (2.67% vs. 7.11%; p = 0.026). Overall and disease-free survival rates were 79.4% (95% CI: 74.0-83.9%) and 75.1% (95% CI: 69.1-80.1%), respectively. The difference in overall survival between the periods lost statistical significance when adjusted for pathological stage, the only factor that affected survival (log-rank: p = 0.038 to p = 0.079).

Conclusions:

The clinical and epidemiological evolution presented in this study corroborates global trends. The decrease in 30-day mortality was probably due to better patient selection and improved surgical techniques.

Robot-assisted lobectomy versus completely portal robotic lobectomy: What is the difference?

Background

This study aims to compare robot-assisted lobectomy versus completely portal robotic lobectomy.

Methods

Between January 2014 and December 2019, a total of 41 patients (10 males, 31 females; median age 62 years; range, 50 to 68 years) underwent robotic anatomical pulmonary resection in our institution were retrospectively analyzed. The patients were consecutively divided into two groups: the first 20 (48.8%) patients underwent pulmonary resection by robot-assisted lobectomy technique, while the next 21 (51.2%) patients underwent pulmonary resection by completely portal robotic lobectomy with four arms. Data including age, sex, diagnosis, surgery type and duration, rate of conversion to open surgery, and length of stay of the patients were recorded. The operation time, docking time, console time, and closure duration for each patient were also noted.

Results

There was no statistically significant difference in age, sex, comorbidities, complications, length of hospital stay, adequate lymph node staging, or tumor size and side between the two groups (p>0.05). However, the mean console and operation times were statistically significantly shorter in the patients receiving completely portal robotic lobectomy with four arms (p=0.001).

Conclusion

The advantage of completely portal robotic lobectomy with four arms is relative, although it significantly shortens the operation time. Based on our experiences, this technique may be preferred in case of inadequate lung deflation, as carbon dioxide insufflation allows sufficient workspace for robotic lung resection.

Robotic thoracic surgery for resection of thymoma and tumors of the thymus: technical development and initial experience

Objective:

To evaluate the results of resection of tumors of the thymus by robotic thoracic surgery, analyzing the extent of resection, postoperative complications, time of surgery, and length of stay.

Methods:

Retrospective study from a database involving patients diagnosed with a tumor of the thymus and undergoing robotic thoracic surgery at one of seven hospitals in Brazil between October of 2015 and June of 2018.

Results:

During the study period, there were 18 cases of resection of tumors of the thymus: thymoma, in 12; carcinoma, in 2; and carcinoid tumor, in 1; high-grade sarcoma, in 1; teratoma, in 1; and thymolipoma, in 1. The mean lesion size was 60.1 ± 32.0 mm. Tumors of the thymus were resected with tumor-free margins in 17 cases. The median (interquartile range) for pleural drain time and hospital stay, in days, was 1 (1-3) and 2 (2-4), respectively. There was no need for surgical conversion, and there were no major complications.

Conclusions:

Robotic thoracic surgery for resection of tumors of the thymus has been shown to be feasible and safe, with a low risk of complications and with postoperative outcomes comparable to those of other techniques.

Robotic thoracic surgery for non-small cell lung cancer: initial experience in Brazil

Objective:

To describe the morbidity, mortality, and rate of complete resection associated with robotic surgery for the treatment of non-small cell lung cancer in Brazil, as well as to report the rates of overall survival and disease-free survival in patients so treated.

Methods:

This was a retrospective study of patients diagnosed with non-small cell lung carcinoma and undergoing resection by robotic surgery at one of six hospitals in Brazil between February of 2015 and July of 2018. Data were collected retrospectively from the electronic medical records.

Results:

A total of 154 patients were included. The mean age was 65 ± 9.5 years (range, 30-85 years). The main histological diagnosis was adenocarcinoma, which was identified in 128 patients (81.5%), followed by epidermoid carcinoma, identified in 14 (9.0%). Lobectomy was performed in 133 patients (86.3%), and segmentectomy was performed in 21 (13.7%). The mean operative time was 209 ± 80 min. Postoperative complications occurred in 32 patients (20.4%). The main complication was air leak, which occurred in 15 patients (9.5%). The median (interquartile range) values for hospital stay and drainage time were 4 days (3-6 days) and 2 days (2-4 days), respectively. There was one death in the immediate postoperative period (30-day mortality rate, 0.5%). The mean follow-up period was 326 ± 274 days (range, 3-1,110 days). Complete resection was achieved in 97.4% of the cases. Overall mortality was 1.5% (3 deaths), and overall survival was 97.5%.

Conclusions:

Robotic pulmonary resection proved to be a safe treatment for lung cancer. Longer follow-up periods are required in order to assess long-term survival.

Building a Large Robotic Thoracic Surgery Program in an Emerging Country: Experience in Brazil

BACKGROUND

In the last decade, robotic video-assisted thoracic surgery (R-VATS) has grown significantly and consolidated as an alternative to video-assisted thoracic surgery. The objective of this study is to present the implementation as well as the experience with R-VATS accumulated by 2 Brazilian groups. We also compared the outcomes of procedures performed during the learning curve and after a more mature experience.

METHODS

Retrospective cohort study included all R-VATS procedures performed since April 2015 until April 2018. We describe the process of implantation of robotic surgery, highlighting the peculiarities and difficulties found in a developing country. Moreover, we reported our descriptive results and compared the first 60 patients to the subsequent cases.

RESULTS

Two hundred and five patients included 101 females/104 males. Mean age was 61.7 years. There were hundred and sixty-four pulmonary resections, 39 resections of mediastinal lesions, 1 diaphragmatic plication, and 1 resection of a hilar tumor. Median operative times were 205 min for lung resections and 129 min for mediastinal. There was no conversion to VATS or thoracotomy or major intraoperative complications. Median length of stay was 3 days for pulmonary resections and 1 day for mediastinal. Postoperative complications occurred in 35 cases (17.0%)-prolonged air leak was the most common (17 cases). One fatality occurred in an elderly patient with pneumonia and sepsis (0.4%). Comparison of the first 60 patients (learning curve) with subsequent 145 patients (consolidated experience) showed significant differences in surgical and ICU time, both favoring consolidated experience.

CONCLUSIONS

Our results were comparable to the literature. Robotic thoracic surgery can be safely and successfully implemented in tertiary hospitals in emerging countries provided that all stakeholders are involved and compromised with the implementation process.

Robot-assisted thoracic surgery in Colombia: a multi-institutional initial experience

Background

Robotic assisted videothoracoscopic surgery (RVATS) adoption has increased worldwide from 3.4% in 2010 to 17.5% in 2015. However, in Latin America, the literature is limited to a report of a series of 10 patients who underwent RVATS lobectomy and one case report of an RVATS thymectomy from Brazil.

Methods

This is a retrospective review of all RVATS performed in Bogotá Colombia since 2012. A single thoracic surgeon (RB) performed all the operations at three institutions: Clínica de Marly, Fundación Clínica Shaio and Instituto Nacional de Cancerología. Preoperative, intraoperative, postoperative and pathology report variables were included. Patients were analyzed in three groups: robotic RVATS pulmonary resections, RVATS mediastinal surgeries and other RVATS procedures. Descriptive statistics were used to report the median and interquartile range (IQR) of the continuous variables, and number and percentage were used to describe categorical variables. The association between total operative time and the year the surgery was analyzed using a linear regression model.

Results

Forty-seven patients underwent RVATS pulmonary resections; 72.3% (n=34) of these patients underwent a RVATS lobectomy. The median total operative time was 220 (IQR: 200 to 250) minutes, 6.4% (n=3) had intraoperative complications, and the most frequent histologic diagnosis was adenocarcinoma (n=24, 51.1%). Of 18 patients who underwent RVATS mediastinal surgeries, 50.0% (n=9) had RVATS thymectomy, the median total operative time was 195.5 (IQR: 131 to 221) minutes and two patients (11.1%) had intraoperative complications. The linear regression model of the association between total operative time and the year the surgery showed a 10.3 minute reduction per year (P=0.006).

Conclusions

This is the second series of RVATS published in Latin America and the first published in Colombia, with comparable perioperative results to other reports.

Segmentectomia pulmonar anatômica robótica: aspectos técnicos e desfechos

RESUMO Objetivo: relatar nossa experiência inicial com a segmentectomia robótica, descrevendo a técnica operatória, a colocação preferencial dos portais, os resultados iniciais e desfechos. Métodos: dados clínicos de pacientes submetidos à segmentectomia robótica, entre janeiro de 2017 e dezembro de 2018, foram obtidos de um banco de dados prospectivo de cirurgia robótica. Todos os pacientes tinham câncer de pulmão, primário ou secundário, ou doenças benignas, e foram operados usando o sistema Da Vinci com a técnica de três portais mais uma incisão utilitária de 3cm. As estruturas hilares foram dissecadas individualmente e as ligaduras dos ramos arteriais e venosos, dos brônquios segmentares, assim como, a transecção do parênquima, realizadas com grampeadores endoscópicos. Dissecção sistemática dos linfonodos mediastinais foi realizada para os casos de câncer de pulmão não de pequenas células (CPNPC). Resultados: quarenta e nove pacientes, dos quais 33 mulheres, foram submetidos à segmentectomia robótica. A média de idade foi de 68 anos. A maioria dos pacientes tinha CPNPC (n=34), seguido de doença metastática (n=11) e doenças benignas (n=4). Não houve conversão para cirurgia aberta ou vídeo, ou conversão para lobectomia. A mediana do tempo operatório total foi de 160 minutos e do tempo de console foi de 117 minutos. Complicações pós-operatórias ocorreram em nove pacientes (18,3%), dos quais sete (14,2%) tiveram internação prolongada (>7 dias) devido à fístula aérea persistente (n=4; 8,1%) ou complicações abdominais (n=2; 4%). Conclusão: a segmentectomia robótica é um procedimento seguro e viável, oferecendo curto período de internação e baixa morbidade.

Thymic minimally invasive surgery: state of the art across the world: Central-South America

Literature suggests that, for thymectomy in myasthenia or resection of thymic tumors, minimally invasive surgery is equivalent to open surgery with regard to long-term outcomes. However, it could bring some benefits in the immediate results as complication rate or length-of-stay. There are doubts about the worldwide adoption of the method, though. In Latin America, the implementation of video-assisted thoracic surgery (VATS) started in the 1990s, but it progressed slowly. The main barriers were associated costs and training. Thymic surgery poses a bigger challenge due to its rarity, so just a few reports mention the use of the method in the region. Nonetheless, in recent years we observe a faster dissemination of the method both in number and in complexity of the procedures performed. Confirming this fact, half of the patients registered in the Brazilian Society of Thoracic Surgery database in the last 2 years as undergoing resection of thymic tumors, underwent a minimally invasive procedure. Although promising, robotic surgery is still in its early days in Latin America.