Lobectomy in octogenarians: real world outcomes for robotic-assisted, video-assisted thoracoscopic, and open approaches

Protecting the non-operative lobe/s of the operative lung can reduce the pneumonia incidence after thoracoscopic lobectomy: a randomised controlled trial

Lung isolation usually refers to the isolation of the operative from the non-operative lung without isolating the non-operative lobe(s) of the operative lung. We aimed to evaluate whether protecting the non-operative lobe of the operative lung using a double-bronchial blocker (DBB) with continuous positive airway pressure (CPAP) could reduce the incidence of postoperative pneumonia. Eighty patients were randomly divided into two groups (n = 40 each): the DBB with CPAP (Group DBB) and routine bronchial blocker (Group BB) groups. In Group DBB, a 7-Fr BB was placed in the middle bronchus of the right lung for right lung surgery and in the inferior lobar bronchus of the left lung for left lung surgery. Further, a 9-Fr BB was placed in the main bronchus of the operative lung. In Group BB, routine BB placement was performed on the main bronchus on the surgical side. The primary endpoint was the postoperative pneumonia incidence. Compared with Group BB, Group DBB had a significantly lower postoperative pneumonia incidence in the operative (27.5% vs 5%, P = 0.013) and non-operative lung (40% vs 15%) on postoperative day 1. Compared with routine BB use for thoracoscopic lobectomy, using the DBB technique to isolate the operative lobe from the non-operative lobe(s) of the operative lung and providing CPAP to the non-operative lobe(s) through a BB can reduce the incidence of postoperative pneumonia in the operative and non-operative lungs.

Energy devices versus electrocoagulation in video-assisted thoracoscopic lobectomy: a propensity-match cohort study

BACKGROUND

The aim of the study was to compare the effect on perioperative outcome of intraoperative use of different devices for tissue dissection (electrocoagulation [EC] or energy devices [ED]) in patients who underwent video-assisted thoracoscopic surgery (VATS) lobectomy for lung cancer.

METHODS

We retrospectively reviewed 191 consecutive patients who underwent VATS lobectomy, divided into two cohorts: ED (117 patients), and EC (74 patients); after propensity score matching, 148 patients were extracted, 74 for each cohort. The primary endpoints considered were complication rate and 30-day mortality rate. The secondary endpoints considered were length of stay (LOS) and the number of lymph nodes harvested.

RESULTS

The complication rate did not differ between the two cohorts (16.22% EC group, 19.66% ED group, P=0.549), before and after propensity matching (16.22% for both EC and ED group, P=1.000). The 30-day mortality rate was 1 in the overall population. Median LOS was 5 days for both groups, before and after propensity match, with the same interquartile range, (IQR: 4-8). ED group had a significantly higher median number of lymph nodes harvested (ED median: 18, IQR: 12-24; EC median: 10, IQR: 5-19; P=0.0002). The difference was confirmed after the propensity score matching (ED median: 17, IQR: 13-23; EC median: 10, IQR: 5-19; P=0.0008).

CONCLUSIONS

ED dissection during VATS lobectomy did not lead to different complication rates, mortality rates, and LOS compared to EC tissue dissection. ED use led to a significantly higher number of intraoperative lymph nodes harvested compared to EC use.

Impact of robotic access on outcomes after lung cancer surgery in France: Analysis from the Epithor database

Introduction

We aimed to compare postoperative outcomes after pulmonary resection for lung cancer after open thoracotomy (OT), video-assisted (VATS), and robotic-assisted (RA) thoracic surgery using a propensity score analysis.

Methods

From 2010 to 2020, 38,423 patients underwent resection for lung cancer. In total, 58.05% (n = 22,306) were operated by thoracotomy, 35.35% (n = 13,581) by VATS, and 6.6% (n = 2536) by RA. A propensity score was used to create balanced groups with weighting. End points were in-hospital mortality, postoperative complications, and length of hospital stay, reported by odds ratios (ORs) and 95% confidence intervals (CIs).

Results

VATS decreased in-hospital mortality compared with OT (OR, 0.64; 95% CI, 0.58-0.79; P < .0001) but not compared with RA (OR, 1.09; 95% CI, 0.77-1.52; P = .61). VATS reduced major postoperative complications compared with OT (OR, 0.83; 95% CI, 0.76-0.92; P < .0001) but not RA (OR, 1.01; 95% CI, 0.84-1.21; P = .17). VATS reduced prolonged air leaks rate compared with OT (OR, 0.9; 95% CI, 0.84-0.98; P = .015) but not RA (OR, 1.02; 95% CI, 0.88-1.18; P = .77). As compared with OT, VATS and RA decreased the incidence of atelectasis (respectively: OR, 0.57; 95% CI, 0.50-0.65; P < .0001 and OR, 0.75; 95% CI, 0.60-0.95; P = .016); the incidence of pneumonia (OR, 0.75; 95% CI, 0.67-0.83; P < .0001 and OR, 0.62; 95% CI, 0.50-0.78; P < .0001); and the number of postoperative arrhythmias (OR, 0.69; 95% CI, 0.61-0.78; P < .0001 and OR, 0.75; 95% CI, 0.59-0.96; P = .024). Both VATS and RA resulted in shorter hospital stays (-1.91 days [-2.24; -1.58]; P < .0001 and -2.73 days [-3.1; -2.36]; P < .0001, respectively).

Conclusions

RA appeared to decrease postoperative pulmonary complications as well as VATS compared with OT. VATS decreased postoperative mortality as compared with RA and OT.

[Surgery of old people-Thoracic surgery]

Background

The incidence of a large number of diseases relevant to thoracic surgery increases with age; however, old age is still frequently considered a contraindication per se for curative interventions and extensive surgical procedures.

Objective

Overview of the current relevant literature, derivation of recommendations for patient selection as well as preoperative, perioperative and postoperative optimization.

Material and methods

Analysis of the current study situation.

Results

Recent data show that for most thoracic diseases, age alone is not a reason to withhold surgical treatment. Much more important for the selection are comorbidities, frailty, malnutrition and cognitive impairment. A lobectomy or segmentectomy for stage I non-small cell lung cancer (NSCLC) in carefully selected octogenarians can provide acceptable to even comparably good short-term and long-term results as in younger patients. Selected > 75-year-old patients with stages II-IIIA NSCLC even benefit from adjuvant chemotherapy. With appropriate selection high-risk interventions, such as pneumonectomy in > 70-year-old patients and pulmonary endarterectomy in > 80-year-old patients can be performed without an increase in mortality rates. Even lung transplantation can lead to good long-term results in carefully selected > 70-year-old patients. Minimally invasive surgical techniques and nonintubated anesthesia contribute to risk reduction in marginal patients.

Discussion

In thoracic surgery the biological age rather than the chronological age is decisive. In view of the increasingly older population, further studies are urgently needed to optimize patient selection, type of intervention, preoperative planning and postoperative treatment as well as the quality of life.

[Surgery of old people-Thoracic surgery]

BACKGROUND

The incidence of a large number of diseases relevant to thoracic surgery increases with age; however, old age is still frequently considered a contraindication per se for curative interventions and extensive surgical procedures.

OBJECTIVE

Overview of the current relevant literature, derivation of recommendations for patient selection as well as preoperative, perioperative and postoperative optimization.

MATERIAL AND METHODS

Analysis of the current study situation.

RESULTS

Recent data show that for most thoracic diseases, age alone is not a reason to withhold surgical treatment. Much more important for the selection are comorbidities, frailty, malnutrition and cognitive impairment. A lobectomy or segmentectomy for stage I non-small cell lung cancer (NSCLC) in carefully selected octogenarians can provide acceptable to even comparably good short-term and long-term results as in younger patients. Selected > 75-year-old patients with stages II-IIIA NSCLC even benefit from adjuvant chemotherapy. With appropriate selection high-risk interventions, such as pneumonectomy in > 70-year-old patients and pulmonary endarterectomy in > 80-year-old patients can be performed without an increase in mortality rates. Even lung transplantation can lead to good long-term results in carefully selected > 70-year-old patients. Minimally invasive surgical techniques and nonintubated anesthesia contribute to risk reduction in marginal patients.

DISCUSSION

In thoracic surgery the biological age rather than the chronological age is decisive. In view of the increasingly older population, further studies are urgently needed to optimize patient selection, type of intervention, preoperative planning and postoperative treatment as well as the quality of life.

Robotic approach for pediatric pulmonary resection: preliminary investigation and comparative study with thoracoscopic approach

BACKGROUND

Minimal invasive pulmonary resection in children is challenging, irrespective of whether it is conducted using a robot or a thoracoscope. This study presents the preliminary results of pediatric robotic pulmonary resection (RPR) and comparison outcomes with conventional thoracoscopic pulmonary resection (TPR).

METHODS

This is a retrospective study conducted in patients underwent RPR (RPR group; n=30) and TPR (TPR group; n=44). The clinical data, including operative time, post-operative body temperature, surgical complications, surgeon's workload (by NASA-TLX), postoperative hospital stay, and scar score (using the SCAR scale), of both the RPR and TPR groups were collected and compared.

RESULTS

Both groups had similar age and weight. The youngest patient belonged to the RPR group and was 6 months old and weighed 8 kg. One case in the RPR group and two in the TPR group were converted to thoracotomy. RPR had a longer total operative time (148.3±36.8 min), but a shorter pure operative time (103.9±28.5 min) than those of the TPR group [118.3±22.5 (P<0.001) and 111.4±18.3 min (P=0.045), respectively]. Compared to the TPR group, fewer patients in the RPR group reported fever postoperatively (2/29 vs. 11/42, P=0.039). The workload of the surgeons was also lower in the RPR group (55.2±4.7 vs. 62.9±6.0, P<0.01). No significant difference was observed in perioperative complications, drainage length, postoperative hospital stays, and scar score of the two groups.

CONCLUSIONS

The safety and effectiveness of the robotic approach are similar to those of the thoracoscopic surgery for pediatric pulmonary resection in children heavier than 8 kg. In addition, the robotic approach shows improved operative dissection efficiency and accuracy for patients and reduced workload for surgeons. Hence, it is beneficial to both surgeons and patients.

Select octogenarians with stage IIIa non–small cell lung cancer can benefit from trimodality therapy

Objectives

Currently, more than 36% of patients diagnosed with lung cancer are 75 years of age or older. Management of stage IIIA cancer is variable, especially for octogenarians who might not be offered surgery because of questionable benefit. In this study we investigated the outcomes of definitive chemoradiotherapy (CR) and trimodality therapy (TM) management (CR and surgery) for clinical stage IIIA non–small cell lung cancer (NSCLC) in patients 80 years of age or older.

Methods

The National Cancer Data Base was queried for stage IIIA NSCLC in patients 80 years of age or older between 2004 and 2015. Patients were divided according to treatment type: definitive CR and TM. Patient demographic characteristics, facility type, Charlson–Deyo score, final tumor pathology, and survival data were extracted. Univariate analysis was performed, followed by 3:1 propensity matching to analyze overall survival differences. Unadjusted and adjusted Kaplan–Meier survival analyses were performed.

Results

From the database, 6048 CR and 190 TM octogenarians were identified. Patients in the TM group were younger (82 years old [TM] vs 83 years old [CR]; P < .0001), more likely to be treated at an academic/research institution (36% [TM] vs 26% [CR]; P = .003), had greater proportion of adenocarcinoma (52% [TM] vs 34% [CR]; P < .001), and a smaller tumor size (38 mm [TM] vs 33 mm [CR]; P = .025). After 3:1 matching, the 5-year overall survival for the TM group was 29% (95% CI, 22%-38%) versus 15% (95% CI, 11%-20%) for the CR group.

Conclusions

Selected elderly patients with stage IIIa NSCLC can benefit from an aggressive TM approach.

Computerized Tomography Image Features under the Reconstruction Algorithm in the Evaluation of the Effect of Ropivacaine Combined with Dexamethasone and Dexmedetomidine on Assisted Thoracoscopic Lobectomy

This research was aimed to study CT image features based on the backprojection filtering reconstruction algorithm and evaluate the effect of ropivacaine combined with dexamethasone and dexmedetomidine on assisted thoracoscopic lobectomy to provide reference for clinical diagnosis. A total of 110 patients undergoing laparoscopic resection were selected as the study subjects. Anesthesia induction and nerve block were performed with ropivacaine combined with dexamethasone and dexmedetomidine before surgery, and chest CT scan was performed. The backprojection image reconstruction algorithm was constructed and applied to patient CT images for reconstruction processing. The results showed that when the overlapping step size was 16 and the block size was 32 × 32, the running time of the algorithm was the shortest. The resolution and sharpness of reconstructed images were better than the Fourier transform analytical method and iterative reconstruction algorithm. The detection rates of lung nodules smaller than 6 mm and 6–30 mm (92.35% and 95.44%) were significantly higher than those of the Fourier transform analytical method and iterative reconstruction algorithm (90.98% and 87.53%; 88.32% and 90.87%) (P < 0.05). After anesthesia induction and lobectomy with ropivacaine combined with dexamethasone and dexmedetomidine, the visual analogue scale (VAS) decreased with postoperative time. The VAS score decreased to a lower level (1.76 ± 0.54) after five days. In summary, ropivacaine combined with dexamethasone and dexmedetomidine had better sedation and analgesia effects in patients with thoracoscopic lobectomy. CT images based on backprojection reconstruction algorithm had a high recognition accuracy for lung lesions.

[Thoracic Surgery: The Era of Minimally Invasive Lobectomy]

The contingent of VATS (video assistend thoracic surgery) lobectomies will continue to increase in the time to come. Thoracic surgery departments that do not integrate this procedure into their routine spectrum will have to justify themselves to referrers and clinic administrations and will have problems with the recruitment of training assistants as well. The advantages of minimally invasive lobectomy are impressive and the long-term oncological results are equivalent to open lobectomy. VATS lobectomies in non-intubated patients will increase significantly in the next few years and further reduce the invasiveness of the operation. The number of clinics that offer RATS (roboter assistend thoracic surgery) lobectomies will also increase as more companies bring robot systems onto the market, making them significantly cheaper. Better screening programs for risk patients for lung cancer, rapid advances in thoracic oncology and further minimization of surgical trauma in lung resections will significantly improve the overall therapy and prognosis for lung cancer patients in the years to come.

Lobectomy Versus Stereotactic Body Radiotherapy in Healthy Octogenarians With Stage I Lung Cancer

BACKGROUND

Stereotactic body radiation therapy (SBRT) is increasingly being offered for early stage non-small cell lung cancer (NSCLC). We sought to evaluate long-term survival outcomes after lobectomy and SBRT in patients aged 80 years or more with stage I NSCLC.

METHODS

The National Cancer Database was queried for patients with clinical stage IA and IB (size 40 mm or smaller) NSCLC who underwent SBRT or lobectomy. Only patients with no comorbidities were selected. Number of lymph nodes (LN) examined was used to stratify lobectomy patients into 0 LN, 1 to 6 LN, and 7 or more LN. Propensity score analysis was used to adjust treatment groups. Kaplan-Meier and multivariate Cox regression analysis were used for survival analysis.

RESULTS

A total of 8964 patients with stage I NSCLC treated with lobectomy were compared with 286 patients who received SBRT. Using propensity matched pairs, lobectomy (7 LN or more) had significantly improved survival as compared with SBRT (median 74 vs 53.2 months, P < .05); however, no survival differences were observed when 0 LN were sampled (median 53.8 vs 52.3 months, P = .88). In multivariate analysis, lobectomy was associated with significantly improved survival (hazard ratio 0.726; 95% confidence interval; 0.580 to 0.910; P = .005). In addition, age, sex, high grade, and tumor size were independent predictors of survival.

CONCLUSIONS

Among healthy octogenarians with clinical stage I NSCLC who are good surgical candidates, lobectomy offers better survival than SBRT. Adequate LN dissection allows true nodal staging and opportunity for adjuvant treatment when unsuspected nodal metastases are found.