Anatomical Segmentectomy Research Articles

Phrenic nerve infiltration: a good practice to combine pulmonary expansion and pain control in patients with high-risk of prolonged air leak.

ObjectiveProlonged air leak (PAL) due to residual air space after lung resection is a main challenge. To date, few surgical options have been described to prevent this complication. The aim of this study is to investigate the safety and the efficacy of intra-operative phrenic nerve infiltration with long-acting anaesthetics in producing transient hemidiaphragm paralysis in patients at high risk for PAL, thus improving pulmonary expansion after surgery, and reducing air leaks, while controlling post-operative pain. MethodsBetween January 2021-2023, 65 consecutive patients at risk for PAL (defined in accordance with “2019 Society of Thoracic Surgery score-criteria of PAL”) who underwent lung resection (lobectomy or anatomical segmentectomy) for malignancy were prospectively included in the study. They have been randomly (1:2 ratio) assigned to receive (group A, 22 patients) intra-operative phrenic nerve infiltration with Ropivacaine 10 mg/ml in the peri-neurotic fat on the pericardium or not to receive intra-operative phrenic nerve infiltration (group B, 43 patients). Five patients of Group B have been excluded because they did not undergo anatomical resection. Data on pulmonary re-expansion, prolonged air leaks, pain at 24- and 72-hours post-surgery, referred shoulder pain, length of hospital stay, length of chest tube permanence, were collected and compared. ResultsHemidiaphragm elevation (p=0.006) and pulmonary expansion (p=0.000) were significantly higher in Group A. Patients in Group A showed lower pain at 24 and 72 hours compared to Group B (p=0.004). Shoulder pain (0.001) and prolonged air leak (0.000) were higher in Group B. Length of chest tube was longer in group B. No difference in hospital stay length was observed. ConclusionThis is the first study to investigate two combined effects of phrenic nerve anaesthetic infiltration (hemidiaphragm elevation and pain control), with potential enhancement of patient’s recovery after surgery. Intraoperative phrenic nerve infiltration in patients with risk for PAL appears a safe and effective clinical practice to improve pulmonary expansion in this set of patients, reducing post-operative air leak. This result is associated with an additional improvement in pain control, especially for shoulder pain.

Early outcomes of robotic versus video-thoracoscopic anatomical segmentectomy: a propensity score-matched real-world study.

Minimally invasive anatomic segmentectomy for the resection of pulmonary nodules has significantly increased in the last years. Nevertheless, there is limited evidence on the safety and feasibility of robotic segmentectomy compared to video-assisted thoracic surgery. This study aimed to compare the real-world early outcomes of robotic and video-thoracoscopic in anatomic segmentectomy. Single centre cohort study including all consecutive patients undergoing segmentectomy by either robotic or video-thoracoscopic from June 2018 to November 2023. Propensity score case matching analysis generated two matched groups undergoing robotic or video-thoracoscopic segmentectomy. Short-term outcomes were analysed and compared between groups. 204 patients (75 robotic and 129 video-thoracoscopic patients) were included. After matching, 146 patients (73 cases in each group) were compared. One 30-day death was observed in the robotic group (P = 1). Two conversions to thoracotomy occurred in the robotic, and none in the video-thoracoscopic group (P = 0.5). Surgical time was longer in the robotic group (P = 0.091). There were no significant differences between robotic and video-thoracoscopic groups in postoperative complications (13.7% vs 15.1%, P = 1), cardiopulmonary complications (6.8% vs 6.8%, P = 1), major complications (4.1% vs 4.1%, P = 1), prolonged air leak (4.1% vs 5.5%, P = 1), arrythmia (1.4% vs 0%, P = 1) and reoperation (2.7% vs 2.7%, P = 1). Median length of stay was 3 days (IQR, 2-3 days) in the robotic group vs 3 days (IQR, 2.5-4 days) in the video-thoracoscopic group (P = 0.212). Robotic segmentectomy is a safe and feasible alternative to video-thoracoscopy, as no significant differences in early postoperative outcomes were found between the two techniques.

Indocyanine green fluorescence identification of the intersegmental plane by the target segmental vein-first single-blocking during thoracoscopic segmentectomy

BackgroundInnovative attempt to explore the feasibility and accuracy of using indocyanine green fluorescence (ICGF) to identify the intersegmental plane by the target segmental veins preferential ligation during thoracoscopic segmentectomy.MethodsA retrospective analysis was conducted on clinical data of 32 consecutive patients who underwent thoracoscopic segmentectomy with intersegmental plane identification using both ICGF and inflation-deflation method after target segmental veins prioritized blocking at Nanjing Chest Hospital from December 2022 to June 2023. Preoperative three-dimensional reconstruction was used to identify the target segment and the anatomical structure of the arteries, veins, and bronchi. After ligating the target segmental veins during surgery, the first intersegmental plane was immediately identified and marked with an electrocoagulation device using an inflation-deflation method. Subsequently, the second intersegmental plane was determined using the ICGF method. Finally, the consistency of the two intersegmental planes was evaluated.ResultsAll the 32 patients successfully completed thoracoscopic segmentectomy without ICG-related complications and perioperative death. The average operation time was (98.59 ± 20.72) min, the average intraoperative blood loss was (45.31 ± 35.65) ml, and the average postoperative chest tube removal time was (3.5 ± 1.16) days. The average postoperative hospital stay was (4.66 ± 1.29) days, and the average tumor margin width was (26.96 ± 5.86) mm. The intersegmental plane determined by ICGF method was basically consistent with inflation-deflation method in all patients.ConclusionThe ICGF can safely and accurately identify the intersegmental plane by target segmental veins preferential ligation during thoracoscopic segmentectomy, which is a beneficial exploration and important supplement to the simplified thoracoscopic anatomical segmentectomy.

Therapeutic effects of single-port thoracoscopic anatomical segmentectomy on early-stage non-small-cell lung cancer.

We aimed to assess the therapeutic effects of single-port thoracoscopic anatomical segmentectomy on early-stage non-small-cell lung cancer (NSCLC). Sixty patients with early-stage NSCLC admitted from December 2022 to July 2023 were selected and divided into a lobectomy group (n = 30) and a segmentectomy group (n = 30) according to the different procedures. Their perioperative indicators, pre-operative and post-operative pulmonary function indicators, pain degree 24 h, 48 h, 72 h and 7 day after operation, the incidence of post-operative complications and recurrence, survival and mortality rates 1 year after operation were compared. The segmentectomy group had significantly smaller intraoperative blood loss, shorter length of drainage and length of hospital stay and longer operation time than those of the lobectomy group (P < 0.05). The pulmonary function decreased significantly in both groups 1 week, 1 month and 3 months after operation. Compared with the lobectomy group, the forced expiratory volume in 1 s per cent, forced-vital capacity per cent and maximal voluntary ventilation of the segmentectomy group significantly increased at each time point after operation (P < 0.05). The Visual Analogue Scale scores 24 h, 48 h, 72 h and 7 days after operation were significantly lower in the segmentectomy group than those in the lobectomy group (P < 0.05). There were no significant differences in the incidence of post-operative complications and recurrence, survival and mortality rates 1 year after operation between the two groups (P > 0.05). Single-port thoracoscopic anatomical segmentectomy has obvious therapeutic effects on early-stage NSCLC, characterised by smaller surgical trauma, milder post-operative pain and less impact on pulmonary function.

Contribution of fluorescence imaging to thoracoscopic anatomical segmentectomy: a multicenter propensity matching analysis.

Thoracoscopic anatomical segmentectomy is increasingly recognized for managing early-stage lung cancer. However accurately identifying intersegmental planes (ISPs), especially in complex lung segments, remains challenging. In comparison to conventional methods, fluorescence imaging represents a novel solution. This study aimed to examine the potential benefits of fluorescence imaging in single-port thoracoscopic anatomical segmentectomy. A multicenter (three regional hospitals), retrospective, comparative analysis was conducted using data from 402 consecutive patients who underwent single-port thoracoscopic anatomical segmentectomy from June 2020 to December 2022. The cohort included 191 patients treated with the fluorescence method and 211 patients treated with the modified inflation-deflation method. Among the cohort, 130 patients were placed in the simple segmentectomy group and 272 in the complex segmentectomy group. Propensity score matching (PSM) was used to adjust for baseline differences between the fluorescence and modified inflation-deflation subgroups in the complex segmentectomy group. Perioperative outcomes were compared between the groups. In the simple segmentectomy group, no significant differences were observed between the fluorescence and modified inflation-deflation methods regarding segmental resection time, intraoperative blood loss, postoperative chest tube drainage and duration, postoperative pain, length of hospital stay, complication rate, or hospital costs. In the complex segmentectomy group, however, fluorescence imaging significantly shortened segmental resection time (69.37±28.22 vs. 78.80±34.66 min; P=0.03), while reducing intraoperative blood loss (P=0.046); and improving visual analogue scale (VAS) pain scores on the first postoperative day (P=0.006). Both methods demonstrated comparable safety and oncologic effectiveness. Fluorescence-guided single-port thoracoscopic anatomical segmentectomy demonstrated comparable perioperative safety and effectiveness to the modified inflation-deflation technique while offering advantages, such as shorter segmental resection time, for complex segmentectomies.

Indocyanine Green Fluorescence-Guided Laparoscopic Anatomical Segmentectomy of Liver Segment 6: Surgical Strategy and Technical Details.

Because of the complex anatomy of the right posterior hepatic pedicle, there have been few reports on standardized laparoscopic portal territory staining-guided anatomical resection of liver segment 6 (LPTAR-S6). This study aimed to elucidate the indocyanine green (ICG) fluorescence staining methods for LPTAR-S6. LPTAR-S6 can be performed using positive and negative fluorescence staining approaches. We implemented these two approaches for patients with hepatocellular carcinoma. Descriptions of the surgical strategy and technical details are presented. Two patients safely underwent LPTAR-S6 using a preoperative three-dimensional reconstruction plan. The intraoperative ICG fluorescence staining effect was satisfactory, and the anatomical landmarks were fully exposed. A detailed preoperative three-dimensional reconstruction plan, complete intraoperative application of real-time laparoscopic ultrasound guidance, and ICG fluorescence staining can result in accurate transection of the liver parenchyma during LPTAR-S6.

3D printing in anatomical lung segmentectomies: A randomized pilot trial

ObjectiveThis pilot study evaluated the impact of using a 3D printed model of the patient's bronchovascular lung anatomy on the mental workload and fatigue of surgeons during full thoracoscopic segmentectomy. DesignWe performed a feasibility pilot study of a prospective randomized controlled trial with 2 parallel arms. All included patients underwent digital 3D visual reconstruction of their bronchovascular anatomy and were randomized into the following two groups: Digital arm (only a virtual 3D model was available) and Digital + Object arm (both virtual and printed 3D models were available). The primary end-point was the surgeons’ mental workload measured using the National Aeronautics and Space Administration-Task Load Index (NASA-TLX) score. SettingBetween October 28, 2020 and October 05, 2021, we successively investigated all anatomic segmentectomies performed via thoracoscopy in the Thoracic Department of the Montsouris Mutualiste Institute, except for S6 segmentectomies and S4+5 left bi-segmentectomies. ParticipantsWe assessed 102 patients for anatomical segmentectomy. Among the, 40 were randomly assigned, and 34 were deemed analysable, with 17 patients included in each arm. ResultsComparison of the two groups, each comprising 17 patients, revealed no statistically significant difference in primary or secondary end-points. The consultation of the visual digital model was significantly less frequent when a 3D printed model was available (6 versus 54 consultations, p = 0.001). Notably, both arms exhibited high NASA-TLX scores, particularly in terms of mental demand, temporal demand, and effort scores. ConclusionIn our pilot study, 3D printed models and digital 3D reconstructions for pre-operative planning had an equivalent effect on thoracoscopic anatomic segmentectomy for experienced surgeons. The originality of this study lies in its focus on the impact of 3D printing of bronchovascular anatomy on surgeons, rather than solely on the surgical procedure.

Risk Factors for Prolonged Air Leakage after Uniportal Anatomical Segmentectomy

Abstract Background As the population ages and comorbidities increase, minimal invasive anatomical segmentectomies are increasingly being performed. Complications are to be considered in this vulnerable population. Aims Our aim was to investigate the incidence and risk factors for prolonged air leak in patients undergoing minimally invasive single-port pulmonary segmentectomy at our institution. Methods Retrospective analysis of all patients undergoing uniportal segmentectomy in our department from March 2015 to August 2023. Prolonged air leak (PAL) was defined as an air leak that lasted longer than 5 days. Results 575 segmentectomies were performed using uniportal video-assisted thoracoscopic surgery (uVATS). 374 complex segmentectomies (65.0%) and 405 (70.4%) single segmentectomies were performed. Prolonged air leak occurred in 88 patients (15.3%). Length of stay and duration of drainage were 8.6 (±4.86) and 10.6 (±8.12) days in the PAL subgroup, whereas they wer 3.6 (±2.25) and 2.0 (±1.3) days in the non-PAL group, both statistically significant. Patients with COPD GOLD II/III were significantly more common in the PAL group. Using machine learning, two models were developed that predicted the occurrence of PAL with an accuracy of 70 %. The first model detected the following parameters as significant: removal of segment 2 or 8, diabetes, inhalers, squamous cell carcinoma. The second model recognized DLCO (%), pack-years, FEV1 (%) and operation time as parameters. Furthermore, we used recursive partitioning to develop a decision tree that stratified PAL risk by answering 1-3 yes/no questions. Patients with &amp;gt;28 pack-years and DLCO &amp;lt; 71% had a 77% probability of developing prolonged air leak. Conclusion Severe COPD, low DLCO and FEV1, increased pack-years, inhalers, diabetes, and segment 2 or 8 surgery were identified as risk factors for prolonged air leak. These findings may help in the planning of surgery and the use of sealants at the end of surgery in high-risk patients.

Thoracoscopic segmentectomy for trans-fissure ground-glass opacity.

The trans-fissure ground-glass opacity (GGO) is a special category of lesions, with a diameter always exceeding 2 cm. It is located on a fused fissure, 'seizing' 2 neighbouring lobes simultaneously. The segmentectomy for the trans-fissure GGO is never reported. Between August 2016 and December 2022, patients operated with a trans-fissure GGO were included. The patients' backgrounds and surgical data were summarized. All procedures were performed with the help of preoperative three-dimensional computed tomography bronchography and angiography. A total of 84 patients were included. The selection criteria included a consolidation tumour ratio <50% and a lesion size >2 and ≤3 cm. Thirty-six patients were operated with lobectomy + wedge (the traditional method group) and 48 patients were operated with anatomical segmentectomy + function-preserving sublobectomy (the new method group). The median operative time was 87 min in the traditional group and 98 min in the new method group, and the median blood loss was 60 ml in the traditional group and 70 ml in the new method group. The median duration of hospital stays was 4 days in the traditional group and 2 days in the new method group. In the traditional method group, there was 1 case of postoperative air leakage and 5 cases of haemoptysis. In the new method group, 2 cases of postoperative air leakage were identified. The median size of the tumour in the resected segment was 2.6 cm in the traditional group and 2.5 cm in the new method group. The median margin was 2.5 cm in the traditional group and 3.3 cm in the new method group. The trans-fissure GGO could be safely resected en bloc by segmentectomy with a well-designed surgical procedure and appropriate preoperative planning.

Safety and efficacy of delayed completion lobectomy following wedge resection vs. segmentectomy-a retrospective cohort study.

Data regarding the safety and efficacy of delayed completion lobectomy (CL) following sublobar resections remain scant. We evaluated the technical difficulty and short-term outcomes of CL occurring at least 3 months following the anatomical segmentectomy or wedge resection. Consecutive non-small cell lung cancer (NSCLC) patients who underwent a second resection within the same lobe at least 3 months after their initial resection from January 2013 to December 2019 at the Shanghai Pulmonary Hospital were retrospectively included. The patients were divided into a segmentectomy group (SG group) and a wedge resection group (WR group) based on their initial resection strategy. Baseline characteristics and short-term outcomes after CL between the two groups were compared. Twenty-five patients undergoing CL were included, nine in the SG group and 16 in the WR group. No deaths occurred within 30 days postoperatively, and the rate of overall postoperative complications was 28.0% (7/25). Statistically significant differences were found in rates of postoperative complications between the two groups (SG: 55.6% vs. WR: 12.5%, P=0.03) and in the use of bronchoplasty or angioplasty during the CL (SG: 33.3% vs. WR: 0.0%, P=0.04). After CL, no significant differences were found in 5-year recurrence-free survival (RFS) (WR: 66.7% vs. SG: 61.0%, P=0.31) or overall survival (OS) (WR: 93.8% vs. SG: 66.7%, P=0.06) between two groups. Delayed CL occurring over 3 months after sublobar resection is a safe and effective procedure, with no deaths occurring within 30 days postoperatively. As compared to a segmentectomy at the time of the index operation, a wedge resection may portend less morbidity, with a decreased risk of needing adjunctive bronchoplasty or angioplasty procedures during CL. After CL, 5-year RFS and OS were comparable between WR and SG groups.

Modern approaches to the treatment of primary multiple unilateral synchronous lung tumors (literature review)

The review article focuses on recent approaches to the treatment of primary multiple unilateral synchronous and metachronous lung tumors. Unilateral primary multiple lung cancer is diagnosed relatively rare. The introduction of modern computed tomography into clinical practice made it possible to diagnose a peripheral tumor at the initial stages. The second synchronous, usually central lung cancer is more often detected during surgery or during bronchoscopy. Despite the established criteria, differential diagnosis of primary tumor and intrapulmonary metastasis in synchronous PMRL remains a difficult task. Often histological signs do not allow differentiating the primary tumor from metastasis. The use of next generation genomic sequencing (NGS) makes it possible to distinguish a primary tumor from a metastasis. To date, there are no unambiguous recommendations for staging primary multiple unilateral lung cancer. There is no clear understanding of what criteria and classification to use to determine the stage of primary multiple cancer, and the type of surgical intervention depends on it. Based on the 8th classification of staging according to the TNM system, patients with primary multiple lung cancer often need to undergo extensive surgical interventions, up to pneumonectomy. Staging each tumor separately allows us to expand the indications for anatomical segmentectomies and reconstructive plastic surgery. For the treatment of PMLC, the main type of surgery is an operative manual with lobectomy. Reconstructive plastic surgeries and anatomical segmentectomies have little effect on increase in frequency of local relapses, on worsening of survival rates. However, the methods are a reasonable alternative for some types of tumors and poor functional indicators. Stereotactic radiation therapy is the standard of treatment for patients who refuse surgery or in patients with functional limitations with early stage primary multiple lung cancer. Moreover, systemic therapies such as targeted therapy in patients with driver mutations and immunotherapy have shown outstanding results.

Uniportal Video-Assisted Thoracoscopic Surgery Completion Lobectomy Long after Wedge Resection or Segmentectomy in the Same Lobe: A Bicenter Study.

Completion lobectomy (CL) following a prior resection in the same lobe may be complicated by severe pleural or hilar adhesions. The role of uniportal video-assisted thoracoscopic surgery (U-VATS) has never been evaluated in this setting. Data were collected from two Italian centers. Between 2015 and 2022, 122 patients (60 men and 62 women, median age 67.7 ± 8.913) underwent U-VATS CL at least 4 weeks after previous lung surgery. Twenty-eight (22.9%) patients were affected by chronic obstructive pulmonary disease (COPD) and twenty-five (20.4%) were active smokers. Among the cohort, the initial surgery was performed using U-VATS in 103 (84.4%) patients, triportal-VATS in 8 (6.6%), and thoracotomy in 11 (9.0%). Anatomical segmentectomy was the initial surgery in 46 (37.7%) patients, while hilar lymphadenectomy was performed in 16 (13.1%) cases. CL was performed on 110 (90.2%) patients, segmentectomy on 10 (8.2%), and completion pneumonectomy on 2 (1.6%). Upon reoperation, moderate pleural adhesions were observed in 38 (31.1%) patients, with 2 (1.6%) exhibiting strong adhesions. Moderate hilar adhesions were found in 18 (14.8%) patients and strong adhesions in 11 (9.0%). The median operative time was 203.93 ± 74.4 min. In four (3.3%) patients, PA taping was performed. One patient experienced intraoperative bleeding that did not require conversion to thoracotomy. Conversion to thoracotomy was necessary in three (2.5%) patients. The median postoperative drainage stay and postoperative hospital stay were 5.67 ± 4.44 and 5.52 ± 2.66 days, respectively. Postoperative complications occurred in 34 (27.9%) patients. Thirty-day mortality was null. Histology was the only factor found to negatively influence intraoperative outcomes (p = 0.000). Factors identified as negatively impacting postoperative outcomes at univariate analyses were male sex (p = 0.003), age > 60 years (p = 0.003), COPD (p = 0.014), previous thoracotomy (p = 0.000), previous S2 segmentectomy (p = 0.001), previous S8 segmentectomy (p = 0.008), and interval between operations > 5 weeks (p= 0.005). In multivariate analysis, only COPD confirmed its role as an independent risk factor for postoperative complications (HR: 5.12, 95% CI (1.07-24.50), p = 0.04). U-VATS CL seems feasible and safe after wedge resection and anatomical segmentectomy.

ICG-Enhanced Compression Anatomical Segment 7 Segmentectomy in Laparoscopic and Robotic Approach.

Minimally invasive anatomical resection (AR) for posterosuperior lesions is technically challenging.1,2 The Glissonean approach or puncture technique is generally selected.3,4 The tumor-feeding portal pedicle compression AR (C-AR) is an established procedure in open surgery.5 This technique has benefited from the association with indocyanine green (ICG) fluorescence, used to enhance the anatomical area to be resected.6 Recently, C-AR via the minimal access approach has been reported.7 Herein, we report the first cases of laparoscopic and robotic segment 7 (S7) segmentectomy using the ICG-enhanced compression technique. Two cases of CHILD-class A hepatocellular carcinoma (HCC) in segment 7 with a liver stiffness less than 7 kPa treated by laparoscopic and robotic anatomical S7 segmentectomies were reported. Using the intraoperative ultrasound (IOUS), the tumor-bearing portal pedicle and the level targeted for compression were identified. The right hemiliver was adequately mobilized to allow handling of the organ during dissection. Using the grasper and the probe itself, the S7 Glissonean pedicle was transparenchymally compressed under real-time IOUS control. To further enhance the visibility of the discolored S7, ICG was administered intravenously, obtaining the compressed area to be resected as a non-stained one. Dissection was performed under intermittent Pringle maneuver up to exposing the right hepatic vein, dividing the Glissonean pedicle to segment 7 and then completing the resection. Pathologic findings demonstrated a 4.9 cm and 7.3 cm HCC with a R0-resection margin (> 1 cm in both). Postoperative complications were nil. The patients were discharged 6 days after surgery. This preliminary experience shows that the C-AR is a feasible and reliable technique in laparoscopic and robotic approach for posterosuperior lesions. Further studies are needed to investigate its applicability and standardization.

Impact of indocyanine green on prolonged air leak in minimally invasive segmentectomy.

Video-assisted thoracoscopic segmentectomies have become the gold standard for the treatment of early-stage non-small cell lung cancer less than two centimeters. The main difficulty is the identification of intersegmental boundary lines which dictate postoperative morbidities. We conducted a retrospective study to compare the perioperative outcomes of patients who underwent minimally invasive segmentectomy using the traditional deflation-inflation method or the novel indocyanine green (ICG) technique. Using a prospectively maintained database, we performed a retrospective analysis of 197 consecutive anatomical segmentectomies, from 2020 to 2023. Clinical effectiveness, postoperative complications, and histological data were compared. A total of 73 (37%) patients had the inflation-deflation method and 124 (63%) had the intravenous ICG method. There were no significant differences in chest tube duration, prolonged air leak, postoperative complications, and postoperative hospital stays. Surgical margin width was also similar between the two groups. The multivariable analysis confirmed these results. Lastly, intravenous ICG brought no additional value in complex segmentectomies. This monocentric and retrospective analysis found no added value of the intravenous ICG on the perioperative results of minimally invasive segmentectomies. The place of this novel technique in the surgical armamentarium remains to be defined. Specific indications such as complex segmentectomy or patients with chronic pulmonary disease require further study.

Advantages of laparoscopic segmentectomy of the liver using ICG fluorescent navigation by the negative staining method: A comparison with open procedure.

Laparoscopic segmentectomy (LS) using indocyanine green (ICG) fluorescence navigation with negative staining method has potential for performing accurate and safe anatomical excision. This study aimed to evaluate the significance of LS using ICG fluorescence navigation compared with open segmentectomy (OS). Eighty-seven patients who underwent anatomical segmentectomies were evaluated for OS (n = 44) and LS (n = 43). The Glissonean pedicle approach was performed using either extra- or intrahepatic method, depending on the location of segment in LS. After clamping pedicle, negative staining method was performed. Liver transection was done along intersegmental plane visualizing by overlay mode of ICG camera. Surgical outcomes were compared between two groups. Correlation between predicted resecting liver volume (PRLV) calculated using volumetry and actual resected liver volume (ARLV) was assessed in two groups. Patients who underwent LS showed better outcomes in operative time, blood loss, and length of hospital stay. There were significantly fewer Grade II and Grade III or higher postoperative complications in LS group. Both values of AST (p < 0.001) and ALT (p < 0.001) on postoperative day 1 were significantly lower in LS group than in OS group. PRLV and ARLV were more strongly correlated in LS (r = 0.896) than in OS (r = 0.773). The difference between PRLV and ARLV was significantly lower in LS group than in OS group (p = 0.022), and this trend was particularly noticeable in posterosuperior segment (p = 0.008) than in anterolateral segment (p = 0.811). LS using ICG navigation allows precise resection and may contribute to safer short-term outcomes than OS, particularly in posterosuperior segment.

Complete anatomic segmentectomy shows improved oncologic outcomes compared to incomplete anatomic segmentectomy.

To compare oncologic outcomes after segmentectomy with division of segmental bronchus, artery and vein (complete anatomic segmentectomy) versus segmentectomy with division of <3 segmental structures (incomplete anatomic segmentectomy). We conducted a single-centre, retrospective analysis of patients undergoing segmentectomy from March 2005 to May 2020. Operative reports were audited to classify procedures as complete or incomplete anatomic segmentectomy. Patients who underwent neoadjuvant therapy or pulmonary resection beyond indicated segments were excluded. Survival was estimated with Kaplan-Meier models and compared using log-rank tests. Cox proportional hazards models were used to estimate hazard ratios (HRs) for death. Cumulative incidence functions for loco-regional recurrence were compared with Gray's test, with death considered a competing event. Cox and Fine-Gray models were used to estimate cause-specific and subdistribution HRs, respectively, for loco-regional recurrence. Of 390 cases, 266 (68.2%) were complete and 124 were incomplete anatomic segmentectomy. Demographics, pulmonary function, tumour size, stage and perioperative outcomes did not significantly differ between groups. Surgical margins were negative in all but 1 case. Complete anatomic segmentectomy was associated with improved lymph node dissection (5 vs 2 median nodes sampled; P < 0.001). Multivariable analysis revealed reduced incidence of loco-regional recurrence (cause-specific HR = 0.42; 95% confidence interval 0.22-0.80; subdistribution HR = 0.43; 95% confidence interval 0.23-0.81), and non-significant improvement in overall survival (HR = 0.66; 95% confidence interval: 0.43-1.00) after complete versus incomplete anatomic segmentectomy. This single-centre experience suggests complete anatomic segmentectomy provides superior loco-regional control and may improve survival relative to incomplete anatomic segmentectomy. We recommend surgeons perform complete anatomic segmentectomy and lymph node dissection whenever possible.

Impact of intrapulmonary tumour location of non-small-cell lung cancer on surgical outcomes for segmentectomy.

While segmentectomy is considered a viable option for small peripheral non-small-cell lung cancer, its efficacy for central lesions remains uncertain. This study aimed to assess the oncological outcomes of segmentectomy for central lesions compared to peripheral ones. We retrospectively examined 338 clinical stage IA non-small-cell lung cancer patients who underwent thoracoscopic anatomical segmentectomy at our institution from January 2013 to December 2021. Patients were divided into 2 groups based on intrapulmonary tumour location: inner two-thirds (central group, n = 82) and outer one-third (peripheral group, n = 256). The gender, body mass index, performance score, smoking, comorbidities and preoperative pulmonary function were similar in both groups. On computed tomography images, tumour diameter and consolidation-to-tumour ratio were comparable between the groups. The central group had significantly greater tumour-to-pleura distances [mm, 23 (18-27) vs 11 (8-14); P < 0.001], shorter margin distances [mm, 20 (15-20) vs 20 (20-20); P < 0.001] and larger resected lung volumes based on subsegment count [4 (3-6) vs 3 (3-5); P = 0.004] than the peripheral group. Surgery duration, bleeding, hospitalization or drainage period, mortality, readmission and pathological stage were equivalent between the groups. The central group showed significantly more postoperative pleural effusions (5% vs 1%; P = 0.03) than the peripheral group, with no adverse impact on postoperative pulmonary functions. During the follow-up period, local-only recurrence rates were 0% and 8% in the respective groups (Gray test P = 0.07), and total recurrence rates were 6% and 11% (Gray test P = 0.70), with no significant differences. Moreover, no significant inter-group difference in overall survival rates was observed (82% vs 93%; P = 0.15). Segmentectomy may be a promising therapeutic option for early-stage non-small-cell lung cancer located in the inner two-thirds of the parenchyma.

Pulmonary Function Recovery and Displacement Patterns After Anatomic Segmentectomy vs Lobectomy

BackgroundThe functional benefit of segmentectomy compared with lobectomy remains controversial. This ambispective study characterizes the changes in pulmonary function as correlated to displacement patterns of residual lung after segmentectomies vs lobectomies. MethodsPatients with normal preoperative pulmonary function and undergoing segmentectomy or lobectomy between 2017 and 2021 were considered. Pulmonary function testing was scheduled preoperatively and at least 3 months postoperatively. Differences in the proportions of the median forced expiratory volume in 1 second (FEV1) reduction between segmentectomy and lobectomy were calculated. Covariance analysis was used to estimate the adjusted postoperative FEV1 (apoFEV1) and compare the difference value (DV) in apoFEV1 between segmentectomy and lobectomy. ResultsThe study enrolled 634 patients (334 lobectomies and 300 segmentectomies). Median difference in the proportions of the FEV1 reduction between segmentectomy and lobectomy was 4.58%, with maximal difference observed in right S6 (9.08%) and minimal difference in left S1+2+3 (2.80%). For resections involving the upper lobe, apoFEV1 was significantly higher after segmentectomy than after lobectomy (DV, 0.15-0.22 L), except for left S3 and S1+2+3 segmentectomies (DV, 0.08 L and 0.06 L, respectively). Compared with a lower lobe lobectomy, S6 segmentectomy conferred a higher apoFEV1, whereas S7+8 and S9+10 had a similar apoFEV1 (DV, 0.16-0.18 L, 0.07 L, and 0.00-0.06 L, respectively). Functional recovery after segmentectomy was associated with the number of intersegment planes (P < .01) and the presence of an adjacent nonoperated on lobe (P = .03). ConclusionsBasilar and left S3 segmentectomies did not preserve more pulmonary function compared with their corresponding lobectomies, possibly due to the presence of multiple intersegmental resection planes.

A Multi-Institutional, Randomized, Phase III Trial Comparing Anatomical Segmentectomy and Lobectomy for Clinical Stage IA3 Pure-Solid Non–Small-Cell Lung Cancer: West Japan Oncology Group Study WJOG16923L (STEP UP Trial)

IntroductionAlthough the standard treatment for patients with resectable early-stage non–small-cell lung cancer (NSCLC) is pulmonary lobectomy, recent clinical trials have demonstrated the efficacy of anatomical segmentectomy for small-sized early-stage NSCLC measuring ≤2 cm. Segmentectomy is gaining attention as an alternative procedure to lobectomy for early-stage NSCLC. Patients and MethodsIn January 2024, we have initiated a randomized phase III trial in Japan to confirm the noninferiority of anatomical segmentectomy to lobectomy in patients with peripheral clinical stage IA3 pure-solid NSCLC (tumor measuring >2 cm and ≤3 cm; consolidation-to-tumor ratio = 1.0). We plan to enroll 520 patients from 61 institutions over a period of 5 years. The primary endpoint is overall survival, and the secondary endpoints include relapse-free survival, postoperative respiratory function, proportion of patients with respiratory failure and cerebrovascular disease, cumulative incidence of death from other diseases, cumulative incidence of local recurrence, proportion of patients who undergo segmentectomy, number of resected segments, operative time, blood loss, and adverse events. This trial has been registered in the UMIN Clinical Trials Registry under the code UMIN000052064. ConclusionsThis trial will help establish a novel treatment strategy for patients with peripheral clinical stage IA3 pure-solid NSCLC.

Impact of Minimally Invasive Surgery on Anatomic Liver Segmentectomy Using the Extrahepatic Glissonean Approach.

Accurate minimally invasive anatomic liver (sub)segmentectomy (MIAS) is technically demanding and not yet standardized, and its surgical outcomes are undefined. To study the impact of the minimally invasive approach on perioperative outcomes of anatomic liver (sub)segmentectomy (AS), we retrospectively studied and compared perioperative outcomes of 99 open AS (OAS) and 112 MIAS (laparoscopic 77, robotic 35) cases using the extrahepatic Glissonean approach, based on the 1:1 propensity score matched analyses. After matching (71:71), MIAS was superior to OAS in terms of blood loss (p < 0.0001), maximum postoperative serum total bilirubin (p < 0.0001), C-reactive protein (p = 0.034) levels, R0 resection rate (p = 0.021), bile leak (p = 0.049), and length of hospital stay (p < 0.0001). The matched robotic and laparoscopic AS groups (30:30) had comparable outcomes in terms of operative time, blood loss, transfusion, open conversion, postoperative morbidity and mortality, R0 resection, and hospital stay, although the rate of Pringle maneuver application (p = 0.0002) and the postoperative aspartate aminotransferase level (p = 0.002) were higher in the robotic group. Comparing the matched posterosuperior (sub)segmentectomy cases or unmatched repeat hepatectomy cases between MIAS and OAS, we observed significantly less blood loss and shorter hospital stays in MIAS. Robotic AS yielded comparable outcomes with laparoscopic AS in the posterosuperior (sub)segmentectomy and repeat hepatectomy settings, despite the worse tumor and procedural backgrounds in robotic AS. In conclusion, various types of MIAS standardized by the extrahepatic Glissonean approach were feasible and safe with more favorable perioperative outcomes than those of OAS. Although robotic AS had almost comparable outcomes with laparoscopic AS, robotics may serve to decrease the surgical difficulty of MIAS in selected patients undergoing posterosuperior (sub)segmentectomy and repeat hepatectomy.