Indication for VATS sublobar resections in early lung cancer

Comparison Between Wedge Resection and Lobectomy/Segmentectomy for Early-Stage Non-small Cell Lung Cancer: A Bayesian Meta-analysis and Systematic Review

BACKGROUND

Surgery has become an accepted method for the treatment of early-stage non-small cell lung cancer (NSCLC). The purpose of this Bayesian meta-analysis was to compare the overall survival (OS), disease-free survival (DFS), and relapse-free survival (RFS) between wedge resection and lobectomy/segmentectomy for treatment of early-stage NSCLC.

METHODS

Eligible studies were retrieved from Web of Science, PubMed, MEDLINE, Cochrane Library, EMBASE, CNKI, and WanFang up to July 2021 and screened based on established selection criteria. The Bayesian meta-analysis was performed with the combination of the reported survival outcomes of the individual studies using a random-effect model. The OS, DFS, and RFS of the wedge resection group was compared with the lobectomy/segmentectomy group. The hazard ratio (HR) and standard error were extracted or calculated for each study using the Kaplan-Meier method.

RESULTS

This study was registered with PROSPERO (INPLASY202080090).The pooled OS hazard ratio between segmentectomy and lobectomy was 1.1 [95% confidence interval (CI) 0.92-1.4], the pooled HR between lobectomy and wedge resection was 0.71 [95% CI 0.52-0.96], and the pooled HR between segmentectomy and wedge was 0.80 [95% CI 0.56-1.10]. The pooled HR of DFS or RFS was not statistically significant among the three surgical approaches.

CONCLUSIONS

Patients with early-stage NSCLC received lobectomy had the lowest hazard ratio of OS than patients received wedge resection, indicating that the overall survival of patients received lobectomy was higher than patients received wedge resection. However, regarding DFS and RFS, the three surgical approaches showed no significant difference.

Surgical procedure of segmentectomy as a possible cause of postoperative cerebral embolism: a case report

Background

Cerebral embolism after lobectomy is a life-threatening complication during the early postoperative period. However, it is unclear if cerebral embolism can develop after segmentectomy.

Case presentation

We experienced a case of a 37-year-old man who demonstrated early symptom of acute ischemic stroke in early postoperative period after right upper posterior segmentectomy and performed intra-arterial mechanical thrombectomy (IAMT) successfully.

Conclusions

Long and irregular pulmonary vein stump (PVS) and endothelial injury caused by surgical procedure may lead to cerebral embolism after segmentectomy. We believe that doing preoperative pulmonary vascular assessment and using appropriate surgical procedure may reduce the rate of cerebral embolism.

Powered articulation by the SigniaTM stapling system for stapling position adjustments: optimizing safe surgical margins in thoracoscopic sublobar resection

Accumulation of experience and advances in techniques and instruments have enabled surgeons to perform video-assisted thoracic surgery (VATS) safely for sublobar resection, including segmentectomy and wedge resection. A key to successful VATS sublobar resection is to have adequate resection margins and the appropriate use of articulated surgical staplers is essential for this purpose. The Signia^TM stapling system (Covidien Japan, Tokyo) has been used extensively in the fields of thoracic surgery. Its features include high maneuverability with fully powered articulation, rotation, clamping, and firing, which the surgeon can control with one hand. We introduce the "sliding technique" using the Signia^TM system, which allows for adjustment of the resection lines of the pulmonary parenchyma to optimize safe surgical margins with minimal stapler movement, and without repetitively moving the stapler in and out of the pleural cavity, during VATS sublobar resection.

Short-term outcomes of typical versus atypical lung segmentectomy by minimally invasive surgeries

Background

Segmentectomy is increasingly used to resect lung nodules. Robotic‐assisted thoracic surgery (RATS) is considered a safe and practical method for segmentectomy. Few studies have compared robotic surgery and video‐assisted thoracic surgery (VATS) for lung segmentectomy.

Method

We retrospectively examined 215 consecutive patients who underwent typical (88 patients) or atypical (128 patients) segmentectomy by either robotic surgery or VATS. The postoperative characteristics including operation time, blood loss, pneumonia, tumor size, lymph nodes harvested, chest tube duration, prolonged air leak, atrial fibrillation, and postoperative hospital stay were recorded.

Results

A total of 88 patients underwent typical segmentectomy, while 127 patients underwent atypical segmentectomy. A greater number of lymph nodes were resected via RATS than by VATS (13.24 ± 4.84 vs. 11.71 ± 3.89; P = 0.018). The operation time for typical segmentectomy was shorter than that for atypical segmentectomy (115.69 ± 22.32 vs. 131.68 ± 22.52; P = 0). No significant differences were found between RATS and VATS in terms of chest drainage duration and postoperative hospital stay. The incidence of postoperative complications including prolonged air leak and atrial fibrillation was not significantly different between typical segmentectomy and atypical segmentectomy.

Conclusion

Atypical segmentectomy is more complicated than typical segmentectomy, which may lead to increases in complications and operation time. Robotic surgery was safe and practical for segmentectomy compared to VATS and more lymph nodes could be dissected by RATS without increasing the risk of postoperative complications.

Cerebral Thromboembolism after Lobectomy for Lung Cancer: Pathological Diagnosis and Mechanism of Thrombus Formation

Lung cancer is the leading cause of cancer-related deaths worldwide. Although molecular therapies have emerged as efficacious strategies for the treatment of lung cancer, surgical resection is still recommended as a radical therapeutic option. Currently, lobectomy is regarded as the most reliable radical treatment of primary lung cancer. Among the various complications after lobectomy, cerebral thromboembolism requires attention as a life-threatening complication during the early postoperative period. It occurs in 0.2–1.2% of surgical cases of lung cancer and typically develops following left upper lobectomy with a long pulmonary vein stump (PVS). PVS-associated thrombosis is known to cause cerebral thromboembolism after such procedures; however, distinguishing this specific complication from that caused by postoperative atrial fibrillation is challenging. We summarize herein the diagnostic pathology of thrombus formation in accordance with its thrombogenic mechanism. We focus on the potential utility of the pathological assessment of thrombectomy specimens. The morphological information obtained from these specimens enables the presumption of thrombogenic etiology and provides useful clues to both select an appropriate pharmacotherapy and determine a follow-up treatment for cerebral thromboembolism.

Perioperative outcome after open and thoracoscopic segmentectomy for the treatment of malignant and benign pulmonary lesions: a propensity-matched analysis

Background

The aim of this study was to compare the perioperative outcome of patients receiving anatomic segmentectomy either by open surgery or video-assisted thoracoscopic surgery (VATS). To assess the short-term morbidity of the procedure itself, lung cancer patients in all stages as well as patients with pulmonary metastases and benign lesions scheduled for segmental resection were enrolled in this study.

Methods

A retrospective analysis of prospectively collected data on 445 consecutive patients that underwent segmentectomy either by VATS (n=233) or thoracotomy (n=212) was performed. A propensity-matched analysis was conducted based on age, gender, smoking history, histology, tumor size, forced expiratory volume in 1 second (FEV1) and history of previous pulmonary resections. The matched sample included two groups of 140 patients each.

Results

Both study groups were comparable with respect to age, gender, smoking history, diagnosis, tumor size, pulmonary function and history of previous pulmonary resections. VATS segmentectomy was associated with decreased length of stay (7.4 vs. 9.5 days, P<0.001), drainage treatment time (4.7 vs. 5.9 days, P=0.012) and severe postoperative complications (1.4% vs. 7.1%, P=0.018).

Conclusions

VATS segmentectomy is safe and effective for the treatment of benign and malignant pulmonary lesions. Compared with open thoracotomy, it is associated with shorter hospitalization time and decreased number of severe complications. The preservation of functional lung tissue, combined with a minimally invasive approach, make VATS segmentectomy highly suitable for patients with reduced pulmonary function or severe comorbidities.

Uniportal video-assisted thoracoscopic anatomic segmentectomy for small-sized lung cancer

Increasing evidences prove video-assisted thoracic surgery (VATS) segmentectomy is accepted as a valid alternative to lobectomy esp. a greater number of small lung nodules have been detected. Uniportal VATS segmentectomy for small-sized lung cancer is more challenging not only for technical issues in simple or complex uniportal segmentectomy, but also considering oncological efficacy in terms of localization, safe margin, the extent of lymph node dissection and pathological analysis. In this work, we evaluated our evolving uniportal experience, the surgical technique and decision-making of uniportal VATS segmentectomy for small-sized lung cancer.

Single-incision video-assisted thoracoscopic surgery left-lower lobe anterior segmentectomy (S8)

Unusual anatomical segmentectomies are technically demanding procedures that require a deep knowledge of intralobar anatomy and surgical skill. In the other hand, these procedures preserve more normal lung parenchyma for lesions located in specific anatomical segments, and are indicated for benign lesions, metastasis and also early stage adenocarcinomas without nodal involvement. A 32-year-old woman was diagnosed of a benign pneumocytoma in the anterior segment of the left-lower lobe (S8, LLL), so we performed a single-incision video-assisted thoracoscopic surgery (SI-VATS) anatomical S8 segmentectomy in 140 minutes under intercostal block. There were no intraoperative neither postoperative complications, the chest tube was removed at 24 hours and the patient discharged at 5^th postoperative day with low pain on the visual analogue scale (VAS). Final pathologic exam reported a benign sclerosant pneumocytoma with free margins. The patient has recovered her normal activities at 3 months completely with radiological normal controls at 1 and 3 months.

"Old people suffer the ravages of the years": changes of treatments in elderly patients with early stage non-small cell lung cancer

The increase in life expectancy and the spreading of lung cancer screening led to a further rise of newly detected non-small cell lung cancer (NSCLC) cases. Age, per se, should not be considered a contraindication for treatments in fit patients. Early stage NSCLC is more and more treated with minimally invasive surgery. Stereotactic ablative radiation therapy (SABR) has been developed as an innovative therapy for stage I NSCLC and is now considered a standard treatment option for medically inoperable patients or for patient who refuse operation. Preoperative careful functional evaluations either respiratory or cardiovascular, as well as preoperative staging, are mandatory to pose indication for surgery in elderly. On the other hand, all elderly patients with lung cancer should have some form of assessment of physiologic age. As minimally invasive thoracic surgery has reduced the postoperative morbidity and has led to a decrease in the length of hospital stay, lobectomy remains the treatment of choice for early stage NSCLC in elderly patients. Discussion by experienced multidisciplinary team is the best approach to evaluate the advantages/disadvantages of each treatment modality in elderly patients with early-stage NSCLC.