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Chen T, Chan EG, Huang B, Bertolaccini L, Fernando HC, Tasoudis PT, Motas N, Pennathur A, Fang W, Zhang J. Outcomes following minimally invasive approaches vs. open extended lobectomy for non-small cell lung cancer: a propensity-matched analysis of the National Cancer Database. Transl Lung Cancer Res 2024; 13:334-344. [PMID: 38496690 PMCID: PMC10938095 DOI: 10.21037/tlcr-24-37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 02/18/2024] [Indexed: 03/19/2024]
Abstract
Background Traditional thoracotomy, an invasive surgical procedure, has been the standard approach for extended lobectomy in treating non-small cell lung cancer (NSCLC). However, minimally invasive surgery (MIS) has gained traction with advancements in surgical techniques. Despite this, the outcomes of extended lobectomy via a minimally invasive approach remain largely uncharted. Using the comprehensive National Cancer Database (NCDB), our research aimed to clarify the safety, feasibility, and efficacy of minimally invasive extended lobectomy in patients diagnosed with NSCLC. Methods Our study encompassed a selection of patients with NSCLC who underwent extended lobectomy (defined as lobectomy or bilobectomy with chest wall, diaphragm or pericardial resection) between 2010 and 2014. Through propensity score matching (PSM), we ensured a balanced comparison between patients who underwent MIS and those who opted for the traditional open extended lobectomy. Both univariate and multivariate analyses were employed to discern whether the surgical approach had any significant impact on the prognosis of patients undergoing this specific procedure. Results Before PSM, our dataset included 3,934 patients. After 1:2 PSM, the MIS group included 683 cases, while the open group included 1,317 cases. One notable finding was the reduced average postoperative hospital stay for the MIS group at 7.15 days compared to the open group at 8.40 days (P<0.001). Furthermore, the 5-year survival rate was similar, with the MIS group at 53.1% and the open group at 51.3% (P=0.683). Conclusions The results of our study suggest that MIS for extended lobectomy not only is safe and feasible but also is oncologically effective. However, it is imperative to note that these encouraging findings necessitate further validation through prospective studies to ascertain the full scope of benefits and potential risks associated with MIS.
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Affiliation(s)
- Tangbing Chen
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ernest G. Chan
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Binhao Huang
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Gastric Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Luca Bertolaccini
- Department of Thoracic Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Hiran C. Fernando
- Department of Cardiothoracic Surgery, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Panagiotis T. Tasoudis
- Division of Cardiothoracic Surgery, Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Natalia Motas
- Department of Thoracic Surgery, Institute of Oncology Bucharest, Bucharest, Romania
- Clinic of Thoracic Surgery, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Department of Thoracic Surgery, Memorial Hospital, Bucharest, Romania
| | - Arjun Pennathur
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Wentao Fang
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jie Zhang
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
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Kahya Y, Yüksel C. Pulmonary sleeve resection complications and management. TURK GOGUS KALP DAMAR CERRAHISI DERGISI 2023; 31:S54-S61. [PMID: 38344123 PMCID: PMC10852210 DOI: 10.5606/tgkdc.dergisi.2023.24898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 04/03/2023] [Indexed: 02/21/2024]
Abstract
In tumors involving the central airway or vascular structures, achieving local control and preserving pulmonary function can be possible with a pulmonary sleeve resection. In this section, complications and management of pulmonary sleeve resections are discussed.
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Affiliation(s)
- Yusuf Kahya
- Department of Thoracic Surgery, Ankara University Faculty of Medicine, Ankara, Türkiye
| | - Cabir Yüksel
- Department of Thoracic Surgery, Ankara University Faculty of Medicine, Ankara, Türkiye
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Sun D, Hu J, Li X, He J, Xu L, Fu X, Liu Y, Liu D, Chen P, Zhang X, Liu L. Real-world surgical treatment patterns and clinical outcomes in patients with stages IA-IIIA non-small cell lung cancer: a retrospective multicentric observational study involving 11,958 patients. J Cancer Res Clin Oncol 2023:10.1007/s00432-023-04729-8. [PMID: 37062036 DOI: 10.1007/s00432-023-04729-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 03/28/2023] [Indexed: 04/17/2023]
Abstract
PURPOSE Surgical resection is cornerstone treatment for early-stage non-small cell lung cancer (NSCLC) and offers a chance for cure. This study was conducted to determine current surgical treatment patterns and outcomes of Chinese patients with NSCLC. METHODS Data of patients with histologically confirmed NSCLC of stages IA-IIIA and who underwent surgery between July 2014 and July 2020 were retrospectively collected from 9 tertiary hospitals in China. Cox model was used for multivariate analyses. RESULTS This study included 11,958 patients, among whom 59.1%, 19.2%, and 21.7% were in stages I, II, and IIIA, respectively. Lobectomy was the most common operation method (78.4%), followed by wedge resection (8.2%), segmentectomy (5.4%), pneumonectomy (5.2%), and bronchial sleeve lobectomy (2.8%). Among patients who underwent wedge resection and segmentectomy, majority had stage I NSCLC (87.2% and 93.3%, respectively), and sublobectomy accounted for 20.7% of stage I operations. With a median follow-up time of 30.2 months, disease-free survival (DFS) and overall survival (OS) rates of entire population were 88.9% and 96.1% at 1 year, 75.2% and 85.1% at 3 years, and 65.3% and 77.0% at 5 years, respectively. The 5-year OS rates for stages IA, IB, IIA, IIB, and IIIA disease were 93.2%, 82.7%, 70.3%, 67.0%, and 52.1%, respectively. CONCLUSION This is the largest real-world cohort study of patients with NSCLC who underwent surgery in China, where we described characteristics of surgical treatment and survival outcomes. The results of our study provide insights into real-world surgical treatment status for surgeons and clinicians.
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Affiliation(s)
- Daqiang Sun
- Department of Thoracic Surgery, Tianjin Chest Hospital, Tianjin, 300051, China
| | - Jian Hu
- Department of Thoracic Surgery, The First Hospital Affiliated to Medical College of Zhejiang University, Hangzhou, 310003, China
| | - Xiaofei Li
- Department of Thoracic Surgery, Tangdu Hospital, Air Force Military Medical University, Xi'an, 710038, China
| | - Jianxing He
- Department of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, China
| | - Lin Xu
- Department of Thoracic Surgery, Jiangsu Cancer Hospital, Nanjing, 210009, China
| | - Xiangning Fu
- Department of Thoracic Surgery, Tongji Hospital Affiliated to Tongji Medical College of Huazhong University of Science & Technology, Wuhan, 430030, China
| | - Yang Liu
- Department of Thoracic Surgery, Chinese People's Liberation Army General Hospital, Beijing, 100853, China
| | - Deruo Liu
- Department of Thoracic Surgery, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Pingyan Chen
- Department of Biostatistics, Southern Medical University, Hainan Institute of Real World Data, Guangzhou, 510515, China
| | - Xun Zhang
- Department of Thoracic Surgery, Tianjin Chest Hospital, Tianjin, 300051, China
| | - Lunxu Liu
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China.
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The Surgical Management of Lung Neuroendocrine Neoplasms. Cancers (Basel) 2023; 15:cancers15061695. [PMID: 36980581 PMCID: PMC10046489 DOI: 10.3390/cancers15061695] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 03/06/2023] [Indexed: 03/12/2023] Open
Abstract
This review summarizes key recent developments relevant to the surgical management of lung neuroendocrine neoplasms (L-NENs), including typical and atypical carcinoids, large cell neuroendocrine carcinoma, and small cell lung carcinoma. This review includes recent insights into the classification, clinical presentation, diagnostic workup, treatment options, and follow-up. Highlighted topics include general principles of surgery in localized or locally advanced or metastatic L-NENs, lung-sparing surgery for small, peripheral typical carcinoids, adjuvant and systemic therapies for typical and atypical carcinoids, and surgery and adjuvant therapies for large cell neuroendocrine carcinoma and small cell lung carcinoma.
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Amirkhosravi F, Kim MP. Complex Robotic Lung Resection. Thorac Surg Clin 2023; 33:51-60. [DOI: 10.1016/j.thorsurg.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Chriqui LE, Forster C, Lovis A, Bouchaab H, Krueger T, Perentes JY, Gonzalez M. Is sleeve lobectomy safe after induction therapy?-a systematic review and meta-analysis. J Thorac Dis 2021; 13:5887-5898. [PMID: 34795937 PMCID: PMC8575812 DOI: 10.21037/jtd-21-939] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 08/06/2021] [Indexed: 11/06/2022]
Abstract
Background Sleeve lobectomy (SL) is a lung-sparing procedure, which is accepted as a valid operation for centrally-located advanced tumors. These tumors often require induction treatment by chemotherapy and/or radiotherapy to downstage the disease and thus facilitate subsequent surgery. However, induction therapy may potentially increase the risk of bronchial anastomotic complications and related morbidity. This meta-analysis aims to determine the impact of induction therapy on the outcomes of pulmonary SL. Methods We compared studies of patients undergoing SL or bilobectomy for non-small cell lung cancer (NSCLC) with and without induction therapy. Outcomes of interest were in-hospital mortality, morbidity, anastomosis complication and 5-year survival. Odds ratio (OR) were computed following the Mantel-Haenszel method. Results Ten studies were included for a total of 1,204 patients. There was no statistical difference for between patients who underwent induction therapy followed by surgery and patients who underwent surgery alone in term of post-operative mortality (OR: 1.80, 95% confidence interval (CI): 0.76-4.25, P value =0.19) and morbidity (OR: 1.17, 95% CI: 0.90-1.52, P value =0.237). Anastomosis related complications rate were 5.2% and appears increased after induction therapy with a statistical difference close to the significance (OR: 1.65, 95% CI: 0.97-2.83, P value =0.06). Patients undergoing surgery alone showed better survival at 5 years (OR: 1.52, 95% CI: 1.15-2.00, P value =0.003). Conclusions SL following induction therapy can be safely performed with no increase of mortality and morbidity. However, the need for induction therapy before surgery is associated with increased anastomotic complications and poorer survival prognosis at 5 years.
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Affiliation(s)
- Louis-Emmanuel Chriqui
- Service of Thoracic Surgery. University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Céline Forster
- Service of Thoracic Surgery. University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Alban Lovis
- Service of Pneumology. University Hospital of Lausanne (CHUV), Lausanne, Switzerland.,University of Lausanne, Lausanne, Switzerland
| | - Hasna Bouchaab
- Service of Oncology University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Thorsten Krueger
- Service of Thoracic Surgery. University Hospital of Lausanne (CHUV), Lausanne, Switzerland.,University of Lausanne, Lausanne, Switzerland
| | - Jean Yannis Perentes
- Service of Thoracic Surgery. University Hospital of Lausanne (CHUV), Lausanne, Switzerland.,University of Lausanne, Lausanne, Switzerland
| | - Michel Gonzalez
- Service of Thoracic Surgery. University Hospital of Lausanne (CHUV), Lausanne, Switzerland.,University of Lausanne, Lausanne, Switzerland
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Shaolin T, Yonggeng F, Poming K, Longyong M, Cheng S, Chunshu F, Licheng W, Qunyou T, Bo D. Comparison of Sleeve Lobectomy for Lung Cancer Using Mini-Thoracotomy and an Optimized Robot-Assisted Technique. Technol Cancer Res Treat 2021; 20:15330338211051547. [PMID: 34736363 PMCID: PMC8573479 DOI: 10.1177/15330338211051547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective: To evaluate the clinical significance of an optimized approach to improve surgical field visualization and simplify anastomosis techniques using robotic-assisted sleeve lobectomy for lung or bronchial carcinoma. Method: A total of 26 consecutive patients who underwent sleeve lobectomy between January 2017 and April 2020 were enrolled in the study. The cohort included 11 cases of robotic-assisted surgery (RAS group) and 15 cases of mini-thoracotomy (MT group). RAS was performed via an exclusive optimized approach utilizing the "3 to 4-6 to 8/9" four-port technique. Retrieved demographical and clinical data included operation time, anastomosis time, blood loss, chest drainage time and volume, postoperative pain scores, complications, white blood cell (WBC) levels, and duration of hospital stay and follow-up. Results: No cases of perioperative death were recorded. Compared to MT group, the RAS group had a similar anastomosis time (30.82 ± 6.08 vs 33.20 ± 7.73 min, respectively, p > 0.05) and shorter operation time (189.73 ± 36.41 vs 225.33 ± 38.19 min, respectively, p < 0.05). The RAS group had lower pain scores (4.23 ± 0.26 vs 4.91 ± 0.51, p < 0.05), lower levels of WBC (p < 0.05), and no anastomotic complications postoperatively. The RAS and MT groups demonstrated a successful bronchus reconstruction with low risk of angulation (1/11 vs 1/15, p > 0.05) and satisfactory disease-free survival (eight cases, 72.73% and 12 cases, 80%, respectively). Conclusion: The optimized approach to RA sleeve lobectomy is convenient and efficient and provides satisfactory clinical outcomes. Further study with a large sample size and evaluation of long-term survival are warranted. Key points: (i) we present a novel, convenient, and efficient approach for robotic-assisted sleeve lobectomy, ie, "3 to 4-6 to 8/9" four-port technique. The optimized approach for RA sleeve lobectomy is convenient and efficient and provides satisfactory clinical outcomes; (ii) details for the "3 to 4-6 to 8/9" four-port method: the assistant port was located at the fourth intercostal space. The 1-cm camera port was inserted at the sixth intercostal space in the posterior axillary line. The 0.5-cm da Vinci ports of the instrument arms were placed at the third intercostal space in the anterior axillary line and the eighth or ninth intercostal space in the posterior axillary line. The patient cart was inserted from the back of the patient's head and shoulders at 75° to the longitudinal line.
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Affiliation(s)
- Tao Shaolin
- Department of Thoracic Surgery, Institute of Surgery Research, Daping Hospital, 12525Army Medical University, Chongqing 400042, China
| | - Feng Yonggeng
- Department of Thoracic Surgery, Institute of Surgery Research, Daping Hospital, 12525Army Medical University, Chongqing 400042, China
| | - Kang Poming
- Department of Thoracic Surgery, Institute of Surgery Research, Daping Hospital, 12525Army Medical University, Chongqing 400042, China
| | - Mei Longyong
- Department of Thoracic Surgery, Institute of Surgery Research, Daping Hospital, 12525Army Medical University, Chongqing 400042, China
| | - Shen Cheng
- Department of Thoracic Surgery, Institute of Surgery Research, Daping Hospital, 12525Army Medical University, Chongqing 400042, China
| | - Fang Chunshu
- Department of Thoracic Surgery, Institute of Surgery Research, Daping Hospital, 12525Army Medical University, Chongqing 400042, China
| | - Wu Licheng
- Department of Thoracic Surgery, Institute of Surgery Research, Daping Hospital, 12525Army Medical University, Chongqing 400042, China
| | - Tan Qunyou
- Department of Thoracic Surgery, Institute of Surgery Research, Daping Hospital, 12525Army Medical University, Chongqing 400042, China
| | - Deng Bo
- Department of Thoracic Surgery, Institute of Surgery Research, Daping Hospital, 12525Army Medical University, Chongqing 400042, China
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Costantino CL, Wright CD. Extended Pulmonary Resection by Sleeve Lobectomy and Carinal Pneumonectomy: Selection and Technique. Thorac Surg Clin 2021; 31:273-281. [PMID: 34304835 DOI: 10.1016/j.thorsurg.2021.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Minimally invasive surgical approaches for extended pulmonary resections are becoming increasingly common as more surgeons gain experience in thoracoscopic and robotic technique. Outcome studies demonstrate improved decreased morbidity as compared with an open surgery.
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Affiliation(s)
- Christina L Costantino
- Department of Thoracic Surgery, Massachusetts General Hospital, GRB 4-425, Boston, MA 02114, USA
| | - Cameron D Wright
- Department of Thoracic Surgery, Massachusetts General Hospital, Founders House, FND-7, Boston, MA 02114, USA.
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Soldath P, Binderup T, Kjær A, Federspiel B, Langer SW, Knigge U, Petersen RH. Long-term survival and recurrence after resection of bronchopulmonary carcinoids: A single-center cohort study of 236 patients. Lung Cancer 2021; 156:109-116. [PMID: 33940543 DOI: 10.1016/j.lungcan.2021.04.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 03/30/2021] [Accepted: 04/09/2021] [Indexed: 02/01/2023]
Abstract
OBJECTIVE The aim of this study was to determine overall survival and recurrence-free survival after resection of bronchopulmonary carcinoids by means of predominantly minimally invasive surgery and lung-sparing resections. In addition, we aimed to identify prognostic factors for overall survival. MATERIALS AND METHODS Retrospective review of consecutive patients operated for bronchopulmonary carcinoids between January 2009 and October 2020 identified from a prospectively collected database. RESULTS A total of 236 patients representing 240 cases of bronchopulmonary carcinoids were included. Of these, 212 (88.3 %) were typical carcinoids, while 28 (11.7 %) were atypical carcinoids. A Video-Assisted Thoracoscopic Surgery (VATS) approach was used in 75 % of cases. There was no 30-day mortality. The median follow-up was 5.6 years for overall survival and 4.7 years for recurrence-free survival. 5- and 10-year overall survival rates were 89 % and 71 %, while 5- and 10-year recurrence-free survival rates were 84 % and 71 %. Patients with atypical carcinoids had significantly reduced overall survival and recurrence-free survival rates (HR 3.4; 95 % CI 1.5-7.6; p = 0.003 and HR 5.4; 95 % CI 2.6-11.4; p < 0.001). Independent predictors of overall survival included atypical carcinoid (HR 2.7; 95 % CI 1.2-6.0; p = 0.018) and age > 60 years (HR 2.9; 95 % CI 1.2-7.3; p = 0.021). CONCLUSION Surgery for bronchopulmonary carcinoids by means of predominantly VATS and lung-sparing resections provides favorable long-term survival. Atypical carcinoids and age > 60 years are independent predictors of poor overall survival.
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Affiliation(s)
- Patrick Soldath
- Department of Cardiothoracic Surgery, Rigshospitalet, Copenhagen, Denmark; ENETS Neuroendocrine Tumor Centre of Excellence Rigshospitalet, University of Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
| | - Tina Binderup
- Department of Clinical Physiology, Nuclear Medicine & PET and Cluster for Molecular Imaging, Rigshospitalet and University of Copenhagen, Denmark; ENETS Neuroendocrine Tumor Centre of Excellence Rigshospitalet, University of Copenhagen, Denmark.
| | - Andreas Kjær
- Department of Clinical Physiology, Nuclear Medicine & PET and Cluster for Molecular Imaging, Rigshospitalet and University of Copenhagen, Denmark; ENETS Neuroendocrine Tumor Centre of Excellence Rigshospitalet, University of Copenhagen, Denmark.
| | - Birgitte Federspiel
- Department of Pathology, Rigshospitalet, Copenhagen, Denmark; ENETS Neuroendocrine Tumor Centre of Excellence Rigshospitalet, University of Copenhagen, Denmark.
| | - Seppo W Langer
- Department of Oncology, Rigshospitalet, Copenhagen, Denmark; ENETS Neuroendocrine Tumor Centre of Excellence Rigshospitalet, University of Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
| | - Ulrich Knigge
- Department of Gastrointestinal Surgery, Rigshospitalet, Copenhagen, Denmark; Department of Endocrinology, Rigshospitalet, Copenhagen, Denmark; ENETS Neuroendocrine Tumor Centre of Excellence Rigshospitalet, University of Copenhagen, Denmark.
| | - René Horsleben Petersen
- Department of Cardiothoracic Surgery, Rigshospitalet, Copenhagen, Denmark; ENETS Neuroendocrine Tumor Centre of Excellence Rigshospitalet, University of Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
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Li J, Xue Q, Gao Y, Mao Y, Zhao J, Gao S. Uniportal video-assisted thoracoscopic left pneumonectomy: Retrospective analysis of eighteen consecutive patients from a single center. Thorac Cancer 2021; 12:324-328. [PMID: 33410290 PMCID: PMC7862792 DOI: 10.1111/1759-7714.13728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 10/15/2020] [Accepted: 10/16/2020] [Indexed: 12/09/2022] Open
Abstract
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.
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Affiliation(s)
- Jiagen Li
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qi Xue
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yushun Gao
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yousheng Mao
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun Zhao
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shugeng Gao
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Deng HY, Qiu XM, Zhu DX, Tang X, Zhou Q. Video-Assisted Thoracoscopic Sleeve Lobectomy for Centrally Located Non-small Cell Lung Cancer: A Meta-analysis. World J Surg 2020; 45:897-906. [PMID: 33230587 DOI: 10.1007/s00268-020-05877-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Whether video-assisted thoracoscopic surgery (VATS) sleeve lobectomy could be an alternative to traditional thoracotomy sleeve lobectomy in treating centrally located non-small cell lung cancer (NSCLC) remains unclear. Therefore, we conducted the first meta-analysis to compare the effects of VATS sleeve lobectomy with thoracotomy sleeve lobectomy. METHODS We systematically searched relevant studies from Pubmed, Embase, and Web of Science on May 12, 2020. Data for analysis included short-term outcomes (blood loss, lymph node dissected, operation time, hospital stay, complications) and long-term outcomes (3-year overall survival (OS) and progression-free survival (PFS) rates). We calculated the weighted mean differences (WMDs) for continuous data and risk ratio (RR) for pooling categorical data. RESULTS We finally included 5 retrospective cohort study consisting of 436 patients. VATS sleeve lobectomy yielded significantly less blood loss (WMD = -37.83; 95% confidence intervals (CIs) = [-58.56, -17.11]; P < 0.001) than thoracotomy sleeve lobectomy and comparable total number of dissected lymph node to thoracotomy sleeve lobectomy (WMD = - 0.07; 95%CI = [-1.14, 0.99]; P = 0.89). However, VATS sleeve lobectomy consumed significantly more operation time than thoracotomy sleeve lobectomy (WMD = 49.00; 95%CI = [14.67, 83.34]; P = 0.005). VATS sleeve lobectomy yielded significantly less postoperative hospital stay time than thoracotomy sleeve lobectomy (WMD = -1.68; 95%CI = [-2.98, -0.39]; P = 0.011) and comparable postoperative complication rate to thoracotomy sleeve lobectomy (RR = 0.84; 95%CI = [0.49, 1.44]; P = 0.52). Moreover, VATS sleeve lobectomy yielded comparable 3-year OS (RR = 1.08; 95%CI = [0.95, 1.22]; P = 0.23) and PFS (RR = 1.15; 95%CI = [0.96, 1.37]; P = 0.13) rates to thoracotomy sleeve lobectomy. No significant heterogeneities were observed. CONCLUSIONS VATS sleeve lobectomy yielded less surgical trauma than thoracotomy sleeve lobectomy and improved postoperative recovery without compromising oncological prognosis. Even though VATS sleeve lobectomy may consume more operation time, it could be recommended as an alternative to thoracotomy sleeve lobectomy for treating centrally located NSCLC in carefully selected cases.
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Affiliation(s)
- Han-Yu Deng
- Lung Cancer Center, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041, Sichuan, People's Republic of China
| | - Xiao-Ming Qiu
- Lung Cancer Center, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041, Sichuan, People's Republic of China
| | - Da-Xing Zhu
- Lung Cancer Center, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041, Sichuan, People's Republic of China
| | - Xiaojun Tang
- Lung Cancer Center, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041, Sichuan, People's Republic of China.
| | - Qinghua Zhou
- Lung Cancer Center, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041, Sichuan, People's Republic of China
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Abstract
Robotic technology is positioned to transform the approach to tracheobronchial surgery. With its magnified 3D view, intuitive controls, wristed-instruments, high-fidelity simulation platforms, and the steady implementation of new technical improvement, the robot is well-suited to manage the careful dissection and delicate handling of the airway in tracheobronchial surgery. This innovative technology has the potential to promote the widespread adoption of minimally invasive techniques for this complex thoracic surgery.
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Affiliation(s)
- Brian D Cohen
- General Surgery Residency Program, MedStar Georgetown/Washington Hospital Center, Washington DC, USA
| | - M Blair Marshall
- Division of Thoracic Surgery, Brigham and Women's Hospital, Faculty, Harvard Medical School, Boston, MA, USA
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13
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Mayne NR, Darling AJ, Raman V, Balderson S, Berry MF, Harpole DH, D'Amico TA, Yang CFJ. Perioperative Outcomes and 5-year Survival After Open versus Thoracoscopic Sleeve Resection for Lung Cancer. Semin Thorac Cardiovasc Surg 2020; 33:522-530. [PMID: 32858216 DOI: 10.1053/j.semtcvs.2020.08.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 08/21/2020] [Indexed: 01/09/2023]
Abstract
The objective of this study was to evaluate the impact of a video-assisted thoracoscopic (VATS) approach on outcomes in patients who underwent sleeve lobectomy for non-small-cell lung cancer (NSCLC). Outcomes of patients with cT1-T3, N0-N2, M0 NSCLC who underwent sleeve lobectomy in the National Cancer Data Base (NCDB) from 2010-2015 were assessed using Kaplan-Meier, propensity score-matching, and Cox proportional hazards analyses. An "intent-to-treat" analysis was performed. In the NCDB, 210 sleeve lobectomy patients met inclusion criteria (VATS 44 [21%], thoracotomy 166 [79%]). Nine (20%) of the VATS cases were converted to open. Compared to an open approach, VATS was associated with no significant differences in lymph nodes examined (median 9.5 vs 9.0; p = 0.72), length of stay (median 6 days vs 6 days; p = 0.36), 30-day mortality (4.5% vs 1.8%; p = 0.28), and 90-day mortality (6.8% vs 4.8%; p = 0.70). There were no significant differences in 5-year survival between the VATS and open groups in both the entire cohort (VATS [85%] vs open [79%]; log-rank p = 0.91) and in a propensity score-matched analysis of 86 patients (log-rank p = 0.75). Furthermore, a VATS approach was also not associated with worse survival in multivariable analysis (HR = 0.64; 95% CI [0.23-1.78]; p = 0.39). In this national analysis, a VATS approach for sleeve lobectomy for NSCLC was not associated with worse short-term or long-term outcomes when compared to an open approach.
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Affiliation(s)
- Nicholas R Mayne
- Department of Surgery, Division of Thoracic Surgery, Duke University Medical Center, Durham, NC.
| | - Alice J Darling
- Department of Surgery, Division of Thoracic Surgery, Duke University Medical Center, Durham, NC
| | - Vignesh Raman
- Department of Surgery, Division of Thoracic Surgery, Duke University Medical Center, Durham, NC
| | - Scott Balderson
- Department of Surgery, Division of Thoracic Surgery, Duke University Medical Center, Durham, NC
| | - Mark F Berry
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, CA; VA Palo Alto Health Care System, Palo Alto, CA
| | - David H Harpole
- Department of Surgery, Division of Thoracic Surgery, Duke University Medical Center, Durham, NC
| | - Thomas A D'Amico
- Department of Surgery, Division of Thoracic Surgery, Duke University Medical Center, Durham, NC
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14
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Imai T, Weksler B. Commentary: Open or VATS? Roll up your sleeve. J Thorac Cardiovasc Surg 2020; 161:414-415. [PMID: 32475499 DOI: 10.1016/j.jtcvs.2020.03.109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 03/14/2020] [Accepted: 03/16/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Taryne Imai
- Division of Thoracic Surgery, Department of Surgery, Cedar Sinai Medical Center, Los Angeles, Calif
| | - Benny Weksler
- Division of Thoracic and Esophageal Surgery, Department of Thoracic and Cardiovascular Surgery, Allegheny General Hospital, Pittsburgh, Pa.
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15
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Gao S, Barello S, Chen L, Chen C, Che G, Cai K, Crisci R, D'Andrilli A, Droghetti A, Fu X, Ferrari PA, Fernando HC, Ge D, Graffigna G, Huang Y, Hu J, Jiao W, Jiang G, Li X, Li H, Li S, Liu L, Ma H, Ma D, Martinez G, Maurizi G, Phan K, Qiao K, Refai M, Rendina EA, Shao G, Shen J, Tian H, Voltolini L, Vannucci J, Vanni C, Wu Q, Xu S, Yu F, Zhao S, Zhang P, Zhang L, Zhi X, Zhu C, Ng C, Sihoe ADL, Ho AMH. Clinical guidelines on perioperative management strategies for enhanced recovery after lung surgery. Transl Lung Cancer Res 2019; 8:1174-1187. [PMID: 32010595 DOI: 10.21037/tlcr.2019.12.25] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Shugeng Gao
- Department of Thoracic Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Serena Barello
- Department of Psychology, EngageMinds Hub Research Center, Università Cattolica del Sacro Cuore, Milan, Italy
| | - Liang Chen
- Department of Thoracic Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing 211166, China
| | - Chun Chen
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou 350122, China
| | - Guowei Che
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610065, China
| | - Kaican Cai
- Department of Thoracic Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Roberto Crisci
- Division of Thoracic Surgery, University of L'Aquila, Mazzini Hospital, Teramo, Italy
| | - Antonio D'Andrilli
- Department of Thoracic Surgery, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Andrea Droghetti
- Division of Thoracic Surgery, Carlo Poma Hospital, Mantova, Italy
| | - Xiangning Fu
- Department of Thoracic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Paolo Albino Ferrari
- Division of Thoracic Surgery, A. Businco Cancer Center, Azienda Ospedaliera Brotzu, Cagliari, Italy
| | - Hiran C Fernando
- Inova Cardiac and Thoracic Surgery, Department of Surgery, Inova Fairfax Medical Campus, Falls Church, Virginia, USA
| | - Di Ge
- Department of Thoracic Surgery, Zhongshan Hospital of Fudan University, Shanghai 200032, China
| | - Guendalina Graffigna
- Department of Psychology, EngageMinds Hub Research Center, Università Cattolica del Sacro Cuore, Milan, Italy
| | - Yunchao Huang
- Department of Thoracic Surgery, Cancer Research Institute of Yunnan Province, The Third Affiliated Hospital of Kunming Medical University (Yunnan Cancer Hospital), Kunming 650106, China
| | - Jian Hu
- Department of Thoracic Surgery, The First Affiliated Hospital, Zhejiang University, Hangzhou 310003, China
| | - Wenjie Jiao
- Division of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao 266555, China
| | - Gening Jiang
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University, Shanghai 200433, China
| | - Xiaofei Li
- Department of Thoracic Surgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an 710038, China
| | - Hui Li
- Department of Thoracic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Shanqing Li
- Department of Thoracic Surgery, Peking Union Medical College Hospital, CAMS & PUMC, Beijing 100032, China
| | - Lunxu Liu
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610065, China
| | - Haitao Ma
- Department of Thoracic Surgery, The First Affiliated Hospital of Soochow University, Soochow 215006, China
| | - Dongchun Ma
- Department of Cardiothoracic Surgery, Anhui Chest Hospital, Hefei 230022, China
| | - Guillermo Martinez
- Department of Anesthesia and Intensive Care, Papworth Hospital, Cambridge, UK
| | - Giulio Maurizi
- Department of Thoracic Surgery, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Kevin Phan
- Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Kun Qiao
- Department of Thoracic Surgery, The Third People's Hospital of Shenzhen, Shenzhen 518034, China
| | - Majed Refai
- Division of Thoracic Surgery, AOU Ospedali Riuniti, Ancona, Italy
| | - Erino A Rendina
- Department of Thoracic Surgery, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Guoguang Shao
- Department of Thoracic Surgery, The First Hospital of Jilin University, Changchun 130021, China
| | - Jianfei Shen
- Department of Thoracic Surgery, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, Wenzhou 325035, China
| | - Hui Tian
- Department of Thoracic Surgery, The Qilu Hospital of Shandong University, Jinan 250012, China
| | - Luca Voltolini
- Thoracic Surgery Unit, Careggi University Hospital, Florence, Italy
| | - Jacopo Vannucci
- Department of Thoracic Surgery, University of Rome Sapienza, Policlinico Umberto I, Rome, Italy
| | - Camilla Vanni
- Department of Thoracic Surgery, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Qingchen Wu
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400042, China
| | - Shidong Xu
- Department of Thoracic Surgery, Harbin Medical University Cancer Hospital, Harbin 150081, China
| | - Fenglei Yu
- Department of Thoracic Surgery, The Second Xiangya Hospital of Central South University, Changsha 410011, China
| | - Song Zhao
- Department of Thoracic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China
| | - Peng Zhang
- Department of Cardiothoracic Surgery, Tianjing General Hospital of Tianjing Medical University, Tianjing 300052, China
| | - Lanjun Zhang
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou 510060, China
| | - Xiuyi Zhi
- Department of Thoracic Surgery, Xuanwu Hospital of Capital Medical University, Beijing 100053, China
| | - Chengchu Zhu
- Department of Thoracic Surgery, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, Wenzhou 325035, China
| | - Calvin Ng
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
| | | | - Anthony M H Ho
- Department of Anesthesiology and Perioperative Medicine, Queen's University Kingston, Ontario, Canada
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16
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Reddy RM. Robotic sleeve lobectomy-technically possible but is it being overused? J Thorac Dis 2019; 11:S1211-S1212. [PMID: 31245088 DOI: 10.21037/jtd.2019.03.46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Rishindra M Reddy
- Section of Thoracic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
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17
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Decaluwé H, Van Raemdonck D, De Leyn P. A plea for conservatism: minimally invasive sleeve resections. J Thorac Dis 2019; 11:S1349-S1350. [PMID: 31245130 DOI: 10.21037/jtd.2019.03.97] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Herbert Decaluwé
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Dirk Van Raemdonck
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Paul De Leyn
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
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18
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Kosaka T, Shimizu K, Nakazawa S, Obayashi K, Ohtaki Y, Kawatani N, Ibe T, Yajima T, Mogi A, Shirabe K. Will minimally invasive sleeve resection become the future trend for treatment of advanced lung cancer? J Thorac Dis 2019; 11:1085-1087. [PMID: 31179046 DOI: 10.21037/jtd.2019.02.95] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Takayuki Kosaka
- Division of General Thoracic Surgery, Integrative Center of General Surgery, Gunma University Hospital, Gunma, Japan
| | - Kimihiro Shimizu
- Division of General Thoracic Surgery, Integrative Center of General Surgery, Gunma University Hospital, Gunma, Japan
| | - Seshiru Nakazawa
- Division of General Thoracic Surgery, Integrative Center of General Surgery, Gunma University Hospital, Gunma, Japan
| | - Kai Obayashi
- Division of General Thoracic Surgery, Integrative Center of General Surgery, Gunma University Hospital, Gunma, Japan
| | - Yoichi Ohtaki
- Division of General Thoracic Surgery, Integrative Center of General Surgery, Gunma University Hospital, Gunma, Japan
| | - Natsuko Kawatani
- Division of General Thoracic Surgery, Integrative Center of General Surgery, Gunma University Hospital, Gunma, Japan
| | - Takashi Ibe
- Division of General Thoracic Surgery, Integrative Center of General Surgery, Gunma University Hospital, Gunma, Japan
| | - Toshiki Yajima
- Division of General Thoracic Surgery, Integrative Center of General Surgery, Gunma University Hospital, Gunma, Japan
| | - Akira Mogi
- Division of General Thoracic Surgery, Integrative Center of General Surgery, Gunma University Hospital, Gunma, Japan
| | - Ken Shirabe
- Division of General Thoracic Surgery, Integrative Center of General Surgery, Gunma University Hospital, Gunma, Japan
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19
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Molina JC, Liberman M. Commentary: Pulling an entire lung out of a small incision-Video-assisted thoracoscopic surgical pneumonectomy, the final frontier in minimally invasive thoracic surgery. J Thorac Cardiovasc Surg 2019; 158:267-268. [PMID: 31103205 DOI: 10.1016/j.jtcvs.2019.03.110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 03/26/2019] [Indexed: 11/24/2022]
Affiliation(s)
- Juan Carlos Molina
- Division of Thoracic Surgery, Department of Surgery, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Moishe Liberman
- C.E.T.O.C. (CHUM Endoscopic Tracheobronchial and Oesophageal Center), Montréal, Québec, Canada.
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20
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Bölükbas S, Baldes N, Eberlein M. Minimally invasive bronchial and bronchovascular sleeve resections. J Thorac Dis 2019; 11:S1177-S1179. [PMID: 31245077 DOI: 10.21037/jtd.2019.03.94] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Servet Bölükbas
- Department of Thoracic Surgery, Evangelische Kliniken Essen-Mitte, Essen, Germany
| | - Natalie Baldes
- Department of Thoracic Surgery, Evangelische Kliniken Essen-Mitte, Essen, Germany
| | - Michael Eberlein
- Division of Pulmonary, Critical Care and Occupational Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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21
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Affiliation(s)
- Gregor J Kocher
- Division of General Thoracic Surgery, Inselspital, Bern University Hospital, University of Bern, Switzerland
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