Open Lobectomy Research Articles

Insulin-like growth factor-1 deficiency caused by hepatocellular adenoma leads to growth arrest, primary amenorrhea and metabolic syndrome: a case report and 4 years follow up

BackgroundHepatocellular adenoma (HCA) is a rare benign neoplasm, seldom ascribed as the cause of endocrine and metabolic derangement. We herein report a case of primary amenorrhea, growth arrest and metabolic syndrome. En bloc resection of the tumor normalized all the disturbances.Case presentationA 16-year-old girl complained of primary amenorrhea and growth arrest for the past 2 years. Her height and weight were at the 3rd percentile, whereas waist circumference was at the 90th percentile for chronological age. She was hypertensive on admission. Plasma cholesterol, triglyceride and uric acid were elevated. Evaluation of GH/IGF-1 axis showed extremely low IGF-1 concentration, which was unresponsive to hGH stimulation. Computer tomography identified a huge liver mass (18.2 cm×13.7 cm×21 cm). The patient underwent an uneventful open right hepatic lobectomy. The tumor was en bloc resected. Immunohistochemistry indicated an unclassified HCA, which was confirmed by genetic screening. IGF-1 concentration, blood pressure, lipid profile and ovarian function were all normalized after surgery, and the girl had reduction in waist circumference and gain in height during the follow up.ConclusionWe provide evidence that liver-derived IGF-1 has a direct effect on skeletal and pubertal development, blood pressure, visceral adiposity and dyslipidemia independent of insulin resistance and obesity in the circumstance of undernutrition. Though rare, we propose the need to look into HCA cases for the existence of IGF-1 deficiency and its impact on metabolic derangement.

Operative Timing for Elective Thoracoscopic Lobectomy for CPAM and Sequestration: A NSQIP-Pediatric Analysis 2017–2021

BackgroundThere is limited literature on optimal timing for elective thoracoscopic lobectomy for congenital pulmonary airway malformations (CPAM) and sequestration. Using NSQIP-P, we aim to assess optimal operative timing for elective thoracoscopic lobectomy for CPAM and sequestration. MethodsData from the NSQIP-Pediatric registry was used to evaluate elective thoracoscopic lobectomy patients from 2017 to 2021 diagnosed with congenital pulmonary airway malformation or sequestration. Open lobectomy, ventilator dependent, oxygen dependent, and patients <1 month old were excluded. Clinical characteristics and outcomes were compared for age cohorts (in months): 1–3, 3–6, 6–9, 9–12, 12–24, and 24+. ResultsThere were 717 patients identified. Operative time significantly increased with age from 1 to 3 months to the 24+ month cohort (164.9 min–221.7 min, p = 0.014). Rates of conversion to open were 7.4% vs 21.8%, p = 0.181 in these age groups, respectively. Though not statistically significant, 14.8% of patients at 1–3 months had transfusion events reported compared to 6.4% at 3–6 months and 1.3% at 24+ months (p = 0.067). There were no significant differences between age groups for 30-day unplanned readmission, reoperation, non-transfusion complications, all complications, or mortality. ConclusionOptimal surgical timing for thoracoscopic lobectomy for CPAM and sequestration is complex. Surgery at younger ages is associated with significantly shorter operative times; however, a greater powered study is needed to further assess the conversion to open rate in patients >3 months and the bleeding/transfusion rate in patients <3 months of age. Level of Evidence (I-V)Level III.

Weekly Afatinib in the Treatment of Advanced Non-small Cell Lung Cancer with EGFR-G719C Mutation Followed by Lobectomy: A Case Report

Introduction: Lung cancer stands as the leading cause of cancer-related deaths worldwide. Over the past three decades, the advent of tyrosine kinase inhibitors (TKIs) has marked a significant turning point in the treatment of non-small cell lung cancer (NSCLC) harboring EGFR mutations. Notably, high response rates have been observed in cases with exon 19 deletions (Del19) and Exon 21 substitution L858R mutations. Conversely, the G719X mutation on exon 18 is less prevalent, with variable sensitivity across different generations of TKIs. Afatinib, a second-generation inhibitor, gained FDA approval for the initial treatment of EGFR-mutant metastatic NSCLC in 2013, though its role remains incompletely understood within a multidisciplinary treatment framework, particularly in combination with surgery. However, the standard daily dose of 40mg Afatinib has demonstrated poor tolerability, often resulting in adverse events such as diarrhea and skin toxicity, leading to treatment discontinuation. A recent strategy involving a weekly dose of 280mg Afatinib has shown promising outcomes and a reduced risk of adverse events. Case Presentation: This case report highlights a 50 - year-old female diagnosed with stage IVa right lung adenocarcinoma metastasizing to the left lung (cT3N0M1a), revealing the rare EGFR-G719C (exon18) mutation. Following this diagnosis, the patient underwent open lobectomy. Nine months post-surgery, a treatment approach involving 280mg weekly Afatinib was initiated. Subsequently, the patient was closely monitored for 16 months with no signs of recurrence. Conclusions: EGFR G719C exhibits sensitivity to Afatinib, endorsing the use of Afatinib with fewer adverse events compared to the traditional daily dosage. Our case further advocates for collaborative strategies between medical oncologists and surgeons in the management of advanced-stage NSCLC.

Video-Assisted Thoracoscopic Surgery Versus Thoracotomy Following Neoadjuvant Immunochemotherapy in Resectable Stage III Non-Small Cell Lung Cancer Among Chinese Populations: A Multi-Center Retrospective Cohort Study

BackgroundImmune checkpoint inhibitors have revolutionized non-small cell lung cancer (NSCLC) treatment but may pose greater technical challenges for surgery. This study aims to assess the feasibility and oncological effectiveness of video-assisted thoracoscopic surgery (VATS) for resectable stage III NSCLC after neoadjuvant immunochemotherapy. MethodsInitial stage IIIA-IIIB NSCLC patients with neoadjuvant immunochemotherapy undergoing either VATS or open lobectomy at 6 medical centers during 2019-2023 were retrospectively identified. Perioperative outcomes and 2-year survival was analyzed. Propensity-score matching (PSM) was employed to balance patient baseline characteristics. ResultsAmong the total 143 patients, PSM yielded 62 cases each for VATS and OPEN groups. Induction-related adverse events were comparable between the 2 groups. VATS showed a 14.5% conversion rate. Notably, VATS decreased numeric rating scales for postoperative pain, shortened chest tube duration (5[4-7] vs. 6[5-8] days, P = .021), reduced postoperative comorbidities (21.0% vs. 37.1%, P = .048), and dissected less N1 lymph nodes (5[4-6] vs. 7[5-9], P = .005) compared with thoracotomy. Even when converted, VATS achieves perioperative outcomes equivalent to thoracotomy. Additionally, over a median follow-up of 29.5 months, VATS and thoracotomy demonstrated comparable 2-year recurrence-free survival (77.20% vs. 73.73%, P = .640), overall survival (87.22% vs. 88.00%, P = .738), cumulative incidences of cancer-related death, and recurrence patterns. Subsequent subgroup comparisons and multivariate Cox analysis likewise revealed no statistical difference between VATS and thoracotomy. ConclusionVATS is a viable and effective option for resectable stage III NSCLC patients following neoadjuvant immunochemotherapy, leading to decreased surgical-related pain, earlier chest tube removal, reduced postoperative complications, and similar survival outcomes compared to thoracotomy.

Institutional Experience With Robotic Lobectomy After Neoadjuvant Immunotherapy and Chemotherapy

BackgroundThe real-world safety of robotic resections after neoadjuvant chemoimmunotherapy remains poorly defined in patients with non-small cell lung cancer. Due to reported increased operative challenges after neoadjuvant immunotherapy, we aim to describe our early institutional experience and outcomes after robotic resection in this clinical context. MethodsWe performed a retrospective chart review of patients with non-small cell lung cancer who underwent a robotic lobectomy, comparing patients from June 1, 2022, through October 31, 2023, who were treated with neoadjuvant chemoimmunotherapy consistent with the Checkmate-816 protocol and a control group with upfront resection. ResultsA total of 21 patients underwent neoadjuvant chemoimmunotherapy and robotic lobectomy in our cohort, and 64 patients were in the control group. Compared with control, the median tumor size was 3.2 cm vs 2.0 cm (P = .001). The most common clinical stage was IIIA (11 patients, 52%) in the neoadjuvant chemoimmunotherapy group and IA2 in the control group (26 patients, 45%) (P < .001). Operative time was greater in the neoadjuvant chemoimmunotherapy group (224 vs 177 minutes, P = .011). The median quantity of lymph nodes resected in the neoadjuvant chemoimmunotherapy group was greater (21 vs 16.5, P = .042). A R0 resection was achieved in all cases and no conversions to an open lobectomy occurred. Postoperative length of stay was 2 days in both groups (P = .92), and there were similar rates of postoperative air leak (33% vs 48%, P = .23) and acute post-hemorrhagic anemia (19% vs 14%, P = .58). ConclusionsIn our cohort, robotic-assisted lobectomy was safe and of comparable quality in the setting of neoadjuvant chemoimmunotherapy.

Comparison of Postoperative Respiratory Function Between Patients After Thoracoscopic and Open Lobectomy.

Purpose: This study aimed to compare respiratory functions of patients after thoracoscopic lobectomy (TS) with those after thoracotomy (TR). Methods: This retrospective study was conducted in two centers, one of which adapted TS as a standard procedure in 2009 and the other performs it via TR. Data on patients who underwent lobectomy for congenital lung disease between 2009 and 2021 and underwent pulmonary function test (spirometry) were collected. Results: Ten patients underwent TS and 36 underwent TR. Distribution based on sex, prenatal diagnosis, pathological diagnosis, and resected lobe were similar between the two groups. The median [interquartile range] age at procedure in the TR group was significantly smaller than that in the TS group (13 [11-18] months versus 38 [13-79] months, P = .03). The procedure duration in the TR group was significantly shorter than that in the TS group (230 [171-264] minutes versus 264 [226-420] minutes, P = .02). Pulmonary function test was conducted at the age of eight in both groups, but the interval between the procedure, and the test was significantly shorter in the TS group (TR: 7 [5-8] years versus TS: 5 [2-7] years, P = .03). The ratio of forced vital capacity compared to predicted one (TR: 86.6 [76.6-95.3] versus TS: 88.7 [86.8-89.1], P = .58) and the ratio of forced expiratory volume in 1 second against that predicted (TR: 84.0 [80.5-88.7] versus TS: 88.7 [86.8-89.1], P = .08) were not significantly different between the two groups. Conclusions: Although TR was performed earlier than TS, respiratory function was similar between the two groups.

Outcomes following minimally invasive approaches vs. open extended lobectomy for non-small cell lung cancer: a propensity-matched analysis of the National Cancer Database.

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. 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. 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). 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.

Intravenous infusion of lidocaine as a component of opioid-free anesthesia in thoracic surgery: prospective randomized single-center observational study

BACKGROUND: The possibility of reducing doses of narcotic analgesics during the perioperative period is widely discussed in modern scientific literature. This direction is called opioid-free anesthesia and is used in abdominal surgery, oncology, gynecology, and other areas. Publications on the use of opioid-free anesthesia in thoracic surgery are scarce.&#x0D; OBJECTIVE: To evaluate the analgesic effectiveness of intravenous lidocaine infusion as a component of anesthesia in thoracic surgery.&#x0D; MATERIALS AND METHODS: Ninety patients who underwent open lobectomy or pneumonectomy were examined. Depending on the analgesic component, patients were divided into three groups: group 1 (n=30) received intravenous infusion of lidocaine, group 2 (n=30) received epidural block, and group 3 (n=30) had fentanyl infusion. Blood pressure, heart rate, cortisol, and blood serum glycemia levels were measured. The intensity of postoperative pain syndrome and the need for promedol, tramadol, and sanitation fibrobronchoscopy were assessed. Arterial hypotension and frequency of postoperative nausea and vomiting were recorded. The length of stay of the patients in the intensive care unit and hospital was recorded.&#x0D; RESULTS: Cortisol levels did not differ between groups (p=0.26). The glucose level in the epidural block group was significantly lower than that in other groups (p=0.011). A significant increase in mean blood pressure and heart rate was observed in the opioid analgesia group (p 0.001). The lowest severity of pain 6 h after surgery was observed in the epidural blockade and lidocaine groups (p 0.001). Perioperative hypotension was more common in the epidural analgesia group (p=0.045). The incidence of postoperative nausea and vomiting was higher in the opioid anesthesia group (p=0.004). In the fentanyl infusion group, sanitary fibrobronchoscopy was more often required to eliminate atelectasis (p=0.039). The number of bed days spent in the ICU was significantly higher in the opioid analgesic group (p=0.002); however, no significant differences were noted between the groups regarding the number of days spent in the hospital (p=0.228).&#x0D; CONCLUSION: Opioid-free anesthesia based on intravenous lidocaine infusion, as a component of anesthetic management in thoracic surgery, provides sufficient perioperative stability of hemodynamic and neuroendocrine status, has a pronounced analgesic effect, with less opioid consumption on the first day after surgery, and helps reduce the length of stay in the intensive care unit and hospital.

Vats lobectomy for lung cancer. What has been the evolution over the time?

Video assisted thoracic surgery (VATS) lobectomy is the treatment of choice for early-stage lung cancer. It is safe and effective compared to open surgery, as demonstrated by a large body of scientific evidence over the last few decades. VATS lobectomy's evolution was driven by the need to decrease post-operative pain by reducing the extent of surgical accesses, maintaining the same oncological efficacy of open lobectomy with less invasiveness. VATS lobectomy just turned 30 years old, evolving and changing significantly from its origins. The aim of this mini review is to retrace the history, starting from a multiport approach to a single port approach. At the end of this mini review, we will discuss the advanced and the future challenges of the technique that has revolutionized thoracic surgery.

Clinical effectiveness of robotic-assisted compared to open or video-assisted lobectomy in Germany: a real-world data analysis.

Despite robotic-assisted thoracic surgery (RATS) lobectomy being on the rise in Europe, the majority of lobectomies in Germany are still performed with an open or thoracoscopic [video-assisted thoracic surgery (VATS)] approach. Empirical evidence in favour of RATS lobectomy is inconsistent. This retrospective cohort study investigates the impact of RATS lobectomy compared with open thoracic surgery (OPEN) and VATS lobectomy on short-term outcomes in Germany using multicentre real-world data. Anonymized routine data from Germany from 2018 to 2020 were retrospectively analysed. These data were provided by 61 German hospitals. Propensity score matching with subsequent generalized linear models was performed for statistical analysis. Additionally, in order to test the robustness of the results, multivariable regression analyses with cluster-robust standard errors were used. A total of 2498 patients with lobectomy were identified: in 1345 patients OPEN, in 983 VATS and 170 a RATS lobectomy was performed. RATS-compared to OPEN and VATS-reduced length of stay (LOS) by 28% or 4.2 days [confidence interval: 2.9; 5.4] and by 13% or 1.6 days [confidence interval: 0.2; 3.0], respectively. The risk of pneumonia was reduced by 5.3 percentage points in the RATS group compared to both OPEN and VATS (P = 0.07/0.01). RATS-compared to an open approach-reduces the risk of blood transfusions by 8.8 percentage points (P < 0.001) and LOS on the intensive care unit (P < 0.001). This study provides strong support that RATS lobectomy outperforms OPEN or VATS lobectomy in terms of hospital LOS, and short-term in-hospital postoperative complications in the real-world scenario in Germany.

Comparison between use of a pleural drainage system with flutter valve and a conventional water-seal drainage system after lung resection: a randomized prospective study.

There is still a debate regarding the most appropriate pleural collector model to ensure a short hospital stay and minimum complications. To study aimed to compare the time of air leak, time to drain removal, and length of hospital stay between a standard water-seal drainage system and a pleural collector system with a unidirectional flutter valve and rigid chamber. A randomized prospective clinical trial was conducted at a high-complexity hospital in São Paulo, Brazil. Sixty-three patients who underwent open or video-assisted thoracoscopic lung wedge resection or lobectomy were randomized into two groups, according to the drainage system used: the control group (WS), which used a conventional water-seal pleural collector, and the study group (V), which used a flutter valve device (Sinapi® Model XL1000®). Variables related to the drainage system, time of air leak, time to drain removal, and time spent in hospital were compared between the groups. Most patients (63%) had lung cancer. No differences were observed between the groups in the time of air leak or time spent hospitalized. The time to drain removal was slightly shorter in the V group; however, the difference was not statistically significant. Seven patients presented with surgery-related complications: five and two in the WS and V groups, respectively. Air leak, time to drain removal, and time spent in the hospital were similar between the groups. The system used in the V group resulted in no adverse events and was safe. RBR-85qq6jc (https://ensaiosclinicos.gov.br/rg/RBR-85qq6jc).

Comparison of Robotic and Open Lobectomy for Lung Cancer in Marginal Pulmonary Function Patients: A Single-Centre Retrospective Study.

The treatment of non-small-cell lung cancer (NSCLC) patients with reduced respiratory function represents a challenge for thoracic surgeons. Minimally invasive surgery seems to be beneficial for these patients because it reduces tissue trauma and its impact on respiratory mechanics. Application of the robotic technique, the use of CO2 insufflation and longer surgical time are factors that could influence the outcomes of marginal pulmonary function patients. The objective of this study was to evaluate the impact of the robotic technique on the postoperative outcomes of patients with poor lung function. We retrospectively collected and analyzed data from consecutive marginal respiratory function patients who underwent robotic or open lobectomy for NSCLC. Data regarding clinical, operative and postoperative details were compared between the open and robotic approaches. The outcomes of 100 patients with reduced respiratory function were evaluated, of whom 59 underwent open lobectomies and 41 underwent robotic lobectomies. Robotic lobectomy was characterized by a longer operative time, a reduced hospital stay and a lower incidence of postoperative complications (22% vs. 33.9%), when compared to the open approach. Robotic lobectomy is a safe and feasible procedure for patients with marginal pulmonary function.

Postoperative Complications and Outcome for all Stages with Non-Small Cell Lung Cancer after Video-Assisted Thoracoscopic Lobectomy and Open Lobectomy: A Propensity-Score Matched Analysis

Postoperative Complications and Outcome for all Stages with Non-Small Cell Lung Cancer after Video-Assisted Thoracoscopic Lobectomy and Open Lobectomy: A Propensity-Score Matched Analysis

Pediatric thoracoscopic lung resections: a comprehensive analysis of congenital lesion cases

Background Congenital lung lesions in pediatric patients may be managed conservatively or by video assisted thoracoscopic surgery (VATS). This study aimed to determine the complications after VATS for congenital lung lesions in children. Methods All children undergoing a lung resection between January 2009 and June 2022 were retrospectively identified. Children undergoing a primary open lobectomy or a resection other than a congenital lung lesion were excluded. Both early (<30 days) and late postoperative pulmonary complications were determined. The primary endpoint was postoperative complications within 30 days. Results In total, 56 patients were included, with a median age of 13 months (IQR 9-37). A VATS lobectomy were performed in 46 patients (82%), an extralobar sequestration in 8 patients (14%), an wedge resection in 1 patient and a segment resection in 1 patient. During the COVID pandemic, fewer resections were performed with an increase in symptomatic patients. A conversion to open occurred in 6 patients (11%), of which a preoperative lung infection was associated with an increased risk thereof(p = 0.004). The median follow-up was 22 months (IQR 7-57) and all patients were alive. A postoperative complication (Clavien Dindo ≥3) occurred in 9 patients and complications without the need of intervention in 6 patients. During follow-up a pneumonia occurred in 11 patients. Conclusion There seems to be a shift towards delayed surgery with an increase in symptomatic congenital lung malformations, which might lead to an increase in postoperative complications

The Clinical Outcomes of Thoracoscopic Versus Open Lobectomy for Non–Small-Cell Lung Cancer After Neoadjuvant Therapy: A Multi-Center Retrospective Cohort Study

BackgroundThe safety and efficacy of video-assisted thoracic surgical (VATS) versus open lobectomy for non–small-cell lung cancer (NSCLC) following neoadjuvant therapy remained controversial. The aim of this study was to compare the outcomes of VATS with those of open lobectomy for NSCLC after neoadjuvant therapy. MethodsPatients who had undergone VATS or open lobectomy for NSCLC following neoadjuvant therapy in nine hospitals in China from July 2014 to July 2020 were retrospectively reviewed. The clinical characteristics and overall survival (OS) of patients were analyzed using Cox regression models and propensity score matching. ResultsWe identified 685 patients, 436 (63.6%) who had undergone VATS lobectomy and 249 (36.4%) who had undergone open lobectomy. Patients who had undergone VATS lobectomy tended to have had fewer nodes removed than those who had undergone open lobectomy. However, compared with open group, the VATS group had a better perioperative outcome, such as smaller blood loss volumes and shorter postoperative stays. The groups had a similar operation durations and postoperative complications, and there was a nonsignificant difference between their 30-day mortality rates. After propensity score matching, there was no significant different between the OS of the groups, and only postoperative adjuvant therapy was associated with worse OS. ConclusionThis multi-center analysis of patients with NSCLC who had undergone surgery subsequent to neoadjuvant therapy reveals that VATS lobectomy tended to have a better perioperative outcome, and have a similar OS compared to open lobectomy. These findings suggest that VATS lobectomy is appropriate for NSCLC following neoadjuvant therapy.

Management and Outcomes of Patients With High-Risk (Congenital Lung Malformation Volume Ratio≥ 1.6) Congenital Lung Malformations

IntroductionCongenital lung malformations (CLMs) have a variable natural history. Larger lesions with CLM volume ratio (CVR) ≥ 1.6 are associated with hydrops and fetal mortality. The purpose of this study is to describe the management and outcomes of high-risk (CVR ≥ 1.6) CLM patients. MethodsA retrospective cohort study was performed for all fetuses evaluated between May 2015 and May 2022. Demographics, prenatal imaging factors, prenatal and postnatal treatment, and outcomes were collected. Descriptive statistics were used to compare the cohorts. ResultsOf 149 fetal CLM patients referred to our fetal center, 21/149 (14%) had CVR ≥ 1.6. One CLM patient had intrauterine fetal demise, and 2 patients were lost to follow-up. Of the remaining 18 patients, 11/18 (67%) received maternal steroids. Seven out of 18 patients (39%) underwent resection at the time of delivery with 1/7 (14%) undergoing exutero intrapartum treatment (EXIT)-to-resection, 5/7 (71%) undergoing EXIT-to-exteriorization-to-resection, and 1/7 (14%) undergoing a coordinated delivery to resection; among those undergoing resection, there were 2 fatalities (28.5%). Seven out of 18 (39%) patients required urgent neonatal open lobectomies, and the remaining 4/18 (22%) patients underwent elective thoracoscopic lobectomies with no mortality. ConclusionsThe natural history and outcomes of severe CLM patients remain highly variable. The EXIT-to-exteriorization-to-resection procedure may be a safe and effective approach for a subset of CLM patients with persistent symptoms of mass effect and severe mediastinal shift due to the observed decreased operative time requiring placental support observed in our study.

Risk Factors for Chronic Atrial Fibrillation Following Lung Lobectomy

IntroductionPostoperative atrial fibrillation (POAF) is a common complication following lung lobectomy and is associated with increased risk of stroke, mortality, and prolonged hospital length of stay. The purpose of this study was to define the risk factors for POAF after lobectomy, hypothesizing that operative approach would be associated with risk of chronic POAF. MethodsThe TriNetX database was used to identify adult patients with no history of arrythmia receiving elective lung lobectomy for cancer from 7/6/2003-7/6/2023. Patients were categorized by approach: video-assisted thoracoscopic surgery (VATS) or open. The outcome of interest was the presence of POAF occurring at 1-3 months (“early”) and 12-24 months postop (“chronic”). Propensity matching was performed to reduce bias between cohorts. ResultsWe identified 22,998 patients: 8472 (36.8%) who received open and 14,526 (63.2%) VATS lobectomy. The rate of early POAF was 3.7% of VATS and 5.3% of open patients. The rate of chronic POAF was 5.5 % of VATS patients and 6.2% of open lobectomy patients. Propensity matching decreased bias between the approach groups, creating 7942 pairs for analysis. After matching, the risk of early POAF was greater in the open approach (5.5% open vs 3.4% VATS, risk ratio 1.607 (95% confidence interval 1.385-1.865), P < 0.001). Chronic POAF was (also) higher in the open approach (6.3% open vs 5.2% VATS, Risk Ratio 1.211 (95%CI 1.067-1.374), P = 0.003). ConclusionsPostoperative atrial fibrillation (POAF) occurs more commonly after open lobectomy, both acutely and chronically. Providers should counsel patients about the risk of chronic arrythmia after lung resection.

Cardiac patient for lung surgery: Walking the tightrope

A patient with poor cardiac function undergoing any surgery under any form of anaesthesia is at high risk for perioperative morbidity and mortality. Both open thoracic surgery and emergency laparotomy in these patients are associated with high incidence of postoperative pulmonary and cardiac complications. Perioperative assessment and multidisciplinary approach are key to managing such cases. Having a clear plan for induction, invasive monitoring, intraoperative fluid management and post-operative analgesia is important for a positive outcome. We present a case of an elective open pulmonary lobectomy and emergency laparotomy conducted within an interval of 7 days in a patient with adenocarcinoma lung and ischemic heart disease with ejection fraction of 10-15%, highlighting the perioperative challenges and management.

Video-assisted thoracic surgery or thoracotomy for lung cancer surgery in obese patients? An analysis of the European Society of Thoracic Surgeons database.

There is a lack of evidence on whether perioperative outcomes differ in obese patients after video-assisted thoracic surgery (VATS) or open lobectomy. We queried the European Society of Thoracic Surgeons database to assess morbidity and postoperative length of hospital stay in obese patients submitted to VATS and open pulmonary lobectomy for non-small-cell lung cancer. We collected all consecutive patients from 2007 to 2021 submitted to lobectomy through VATS or thoracotomy with a body mass index greater than or equal to 30. An intention-to-treat analysis was carried out. Primary outcomes were morbidity rate, mortality and postoperative length of stay (LOS). Differences in outcomes were assessed through univariable, multivariable-adjusted and propensity score-matched analysis. Out of a total of 78018 patients submitted to lung lobectomy, 13999 cases (17.9%) were considered in the analysis, including 5562 VATS lobectomies and 8437 thoracotomy lobectomies. The VATS group showed a lower complication rate (23.2% vs 30.2%, P < 0.001), mortality (0.8% vs 1.5%, P < 0.001) and postoperative LOS (median 5 vs 7 days, P < 0.001). After propensity score matching, the VATS approach confirmed a lower complication rate (24.7% vs 29.7%, P = 0.002) and postoperative LOS (median 5 vs 7 days, P < 0.001). Moreover, these results were consistently observed when analyzing the severe obese subgroup (body mass index 35-39.9) and morbid obese subgroup (body mass index ≥40). In obese patients with non-small cell lung cancer, VATS lobectomy was found to be associated with improved postoperative outcomes than open lobectomy. Consequently, it should be considered the approach of choice for the Obese population.

Elevated respiratory complications following robotic-assisted lobectomy: A national cohort analysis of 26,140 cases.

Robotic-assisted lobectomy (RL) is increasingly used nationally, but little comparative data exist on its safety compared with open lobectomy (OL) or video-assisted lobectomy (VL). This study aimed to estimate the risk of perioperative complications for RL, VL, or OL. Admissions were identified from the hospital administrative data collected between 2015 and 2019. Propensity score matching and inverse probabilistic weighting were used to account for selection bias. Logistic and quantile regression models were applied to determine perioperative outcome differences. We identified 26,140 cases of which 5337 (20.4%), 12,680 (48.5%), and 8123 (31.1%) underwent RL, VL, and OL. RL and VL were associated with lower complication rates, shorter lengths of stay, and fewer mortality risks. RL was associated with significantly elevated risks for perioperative respiratory complications (adjusted odds ratio 1.10, p=0.010). Relatively low rates of perioperative complications for VL and RL, and higher respiratory complication rates in RL are concerning.