Thoracic Surgery For Lung Cancer Research Articles

Robotic versus Video-Assisted Thoracic Surgery for Lung Cancer: Short-Term Outcomes of a Propensity Matched Analysis.

Robot-assisted thoracic surgery (RATS) has gained popularity for the treatment of lung cancer, but its quality outcome measures are still being evaluated. The purpose of this study was to compare the perioperative outcomes of lung cancer resection using RATS versus video-assisted thoracic surgery (VATS). To achieve this aim, we conducted a retrospective analysis of consecutive patients who underwent lung cancer surgery between July 2015 and December 2020. A propensity-matched analysis was performed based on patients' performance status, forced expiratory volume in 1 s% of predicted, diffusing capacity of the lungs for carbon monoxide% of predicted, and surgical procedure (lobectomy or segmentectomy). Following propensity matching, a total of 613 patients were included in the analysis, of which 328 underwent RATS, and 285 underwent VATS, with satisfactory performance indicators. The results of the analysis indicated that RATS had a significantly longer operating time than VATS (132.4 ± 37.3 versus 122.4 ± 27.7 min; mean difference of 10 min 95% CI [confidence interval], 4.2 to 15.9 min; p = 0.001). On the other hand, VATS had a significantly higher estimated blood loss compared to RATS (169.7 ± 237.2 versus 82.2 ± 195.4 mL; mean difference of 87.5 mL; 95% CI, 48.1 to 126.8 mL; p < 0.001). However, there were no significant differences between the groups in terms of the duration of chest tubes, length of hospital stay, low- and high-grade complications, as well as readmissions and mortality within 30 days after surgery. Moreover, the number of dissected lymph-node stations was significantly higher with VATS than RATS (5.9 ± 1.5 versus 4.8 ± 2.2; mean difference of 1.2; 95% CI, 0.8 to 1.5; p = 0.001). Nonetheless, the percentage of patients who were upstaged after histopathological analysis of the resected lymph nodes was similar between the two groups. In conclusion, RATS and VATS yielded comparable results for most of the short-term outcomes assessed. Further research is needed to validate the implementation of RATS and identify its potential benefits over VATS.

Erector Spinae Plane Block versus Paravertebral Block after Thoracic Surgery for Lung Cancer: A Propensity Score Study.

The prevention of respiratory complications is a major issue after thoracic surgery for lung cancer, and requires adequate post-operative pain management. The erector spinae plane block (ESPB) may decrease post-operative pain. The objective of this study was to evaluate the impact of ESPB on pain after video or robot-assisted thoracic surgery (VATS or RATS). The main outcome of this retrospective study with a propensity score analysis (PSA) was to compare the post-operative pain at 24 h at rest and at cough between a group that received ESPB and a group that received paravertebral block (PVB). Post-operative morphine consumption at 24 h and complications were also assessed. One hundred and seven patients were included: 54 in the ESPB group and 53 in the PVB group. The post-operative median pain score at rest and cough was lower in the ESPB group compared to the PVB group at 24 h (respectively, at rest 2 [1; 3.5] vs. 2 [0; 4], p = 0.0181, with PSA; ESPB -0.80 [-1.50; -0.10], p = 0.0255, and at cough (4 [3; 6] vs. 5 [4; 6], p = 0.0261, with PSA; ESPB -1.48 [-2.65; -0.31], p = 0.0135). There were no differences between groups concerning post-operative morphine consumption at 24 h and respiratory complications. Our results suggest that ESPB is associated with less post-operative pain at 24 h than PVB after VATS or RATS for lung cancer. Furthermore, ESPB is an acceptable and safe alternative compared to PVB.

Is there variation between hospitals within each region in postoperative mortality for lung cancer surgery in France? A nationwide study from 2013 to 2020.

The practice of thoracic surgery for lung cancer is subject to authorization in France. We evaluated the performance of hospitals using 30-day post-operative mortality as a quality indicator, estimating its distribution within each region and measuring its variability between regions. All data for patients who underwent pulmonary resection for lung cancer in France (2013-2020) were collected from the national hospital administrative database. Thirty-day mortality was defined as any patient who died in hospital (including transferred patients) within the first 30 days after the operation and those who died later during the initial hospitalization. The Standardized Mortality ratio (SMR) was the smoothed, adjusted, hospital-specific mortality rate divided by the expected mortality. To describe the variation in hospital mortality between hospitals in each region, we used different commonly used indicators of variation such as coefficients of variation (CV), interquartile interval or range (IQR), extreme ratio, and systematic component of variance (SCV). In 2013-2020, 87,232 patients underwent lung resection for cancer in France. The number of deaths was 2,537, a rate of 2.91%. The median SMR of 199 hospitals was 0.99 with an IQR of 0.86 to 1.18 and a CV of 0.25. Among the regions that had the most hospitals performing lung resections for cancer, the extreme ratio was >2, which means that the maximum value is twice as high as the minimum value. The SCV between hospitals was >10 for two of these regions, which is considered indicative of very high variation. For the other regions (with few hospitals performing lung resections for cancer), the variation between hospitals was lower. Globally, the variability between regions concerning the SMR was moderate, 6% of the variance was due to differences across regions. On the contrary, the hospital volume was significantly related to the SMR (p = 0.003) with a negative linear trend, whatever the region. This work shows significant differences in the practices of the various hospitals within regions. However, overall, the variability in the 30-day mortality rate between regions was moderate. Our findings raises questions regarding the regionalization of major surgical procedures in France.

Procedural Aspects of Epidural Catheter Placement: A Prospective Observational Study of 173 Epidural Catheter Insertions

The risks and benefits of epidural analgesia have been studied extensively, but information regarding many other aspects of epidural catheter insertion is limited. The authors aimed to add information regarding procedural pain, procedure duration, failure rates, and the effect of experience to the ongoing discussion on this procedure. A prospective observational study. A Danish tertiary hospital. Patients scheduled to undergo video-assisted thoracic surgery. Epidural catheter insertion in 173 patients undergoing video-assisted thoracic surgery for lung cancer. The authors recorded the time required for the epidural insertion procedure, the attempts used, insertion level, access use, patient position, placement technique used, and the designation of the physician placing the catheter. Furthermore, the authors asked the patients to evaluate the expected procedural pain, and after the procedure the authors asked them to evaluate the actual level of pain experienced. Six and 24 months after discharge, the authors examined persistent sequelae by using questionnaire assessments. The median procedure duration was 13 minutes, with 75% of the catheters placed within 22 minutes. Actual procedure-related pain (mean score [M]=3.5, SD=2.0) was significantly (p < 0.0001) less than that expected before the procedure (M=4.9, SD=2.0). The patients' expected pain, attempts required for successful catheter placement, and approach used to access the epidural space significantly affected the actual procedure-related pain (p=0.001, p ≤ 0.003, and p=0.023, respectively). Persistent pain and sensory disturbances were observed in 11% and 4% of the patients, respectively, after 6 months and in 6% and 4% of the patients, respectively, after 2 years. In this study, the authors examined several lesser-known aspects of epidural procedures. The use of epidural analgesia as part of the pain management plan after surgery requires a more complex evaluation instead of merely discussing the possibility of procedural infections, hematomas, or neurologic injuries. The procedure time, patients' expected and experienced pain related to the procedure, and the potential long-term side effects should be a part of the decision-making process.

How effective is indocyanine green (ICG) in localization of malignant pulmonary nodules? A systematic review and meta-analysis.

BackgroundVideo-Assisted and Robotic-Assisted techniques become constantly more prominent practice in thoracic surgery for lung cancer. Furthermore, the increased frequency in detection of small lung cancers makes the intra-operative identification of these cancers even more challenging. Indocyanine Green (ICG) is one of the most commonly used dyes that assists surgeons identify small lung cancers intra-operatively. Our study aimed to evaluate the effectiveness and safety of ICG in lung cancer detection.MethodsWe performed a systematic review of the literature by screening the databases of MEDLINE, EMBASE, CENTRAL and Scopus until 30th April 2022 and the first 300 articles of Google Scholar for any suitable grey literature. We included any study that investigated the effectiveness of ICG in lung cancer detection. We excluded studies that explored the use of ICG only in identification of intersegmental planes, lymph node mapping, case reports and non-English articles. We aimed to perform a meta-analysis on test accuracy studies using hierarchical summary receiver operating characteristic (HSROC) and the bivariate random-effects models. In cases where the data for a localization technique was not sufficient for that analysis, it was presented with tables with narrative purposes. Each study was assessed for Risk of Bias (RoB) and Applicability using the QUADAS-2 tool.ResultsWe found 30 eligible studies that included a total of 1,776 patients who underwent ICG localization of pulmonary nodules. We identified three ICG localization techniques: CT-guided, endobronchial and intravenous. From the 30 studies, 13 investigated CT-guided localization, 12 explored an endobronchial method while 8 studies administered ICG intravenously the median reported success rate was 94.3% (IQR: 91.4%–100%) and 98.3% (IQR: 94%–100%) for the first two techniques respectively. Intravenous ICG lung cancer localization showed Sensitivity of 88% (95% CI: 59%–0.97%) and Specificity of 25% (95% CI: 0.04%–0.74%). There were 15.2% (150/989) patients who experienced complications from CT guided ICG localization. No ICG-related complications were reported in endobronchial or intravenous techniques.ConclusionOur study provides a comprehensive review of the literature on ICG localization techniques for lung cancer. Current evidence suggests that ICG is boh effective and safe. Further prospective research with standardized protocols across multiple thoracic units is required in order to accurately validate these findings.

Ultrasound-guided paravertebral nerve block anesthesia on the stress response and hemodynamics among lung cancer patients.

BACKGROUNDThoracic surgery for radical resection of lung tumor requires deep anesthesia which can lead to an adverse inflammatory response, loss of hemodynamic stability, and decreased immune function. Herein, we evaluated the feasibility and benefits of ultrasound-guided paravertebral nerve block anesthesia, in combination with general anesthesia, for thoracic surgery for lung cancer. The block was performed by diffusion of anesthetic drugs along the paravertebral space to achieve unilateral multi-segment intercostal nerve and dorsal branch nerve block. AIMTo evaluate the application of ultrasound-guided paravertebral nerve block anesthesia for lung cancer surgery to inform practice. METHODSThe analysis was based on 140 patients who underwent thoracic surgery for lung cancer at our hospital between January 2018 and May 2020. Patients were randomly allocated to the peripheral + general anesthesia (observation) group (n = 74) or to the general anesthesia (control) group (n = 66). Patients in the observation group received ultrasound-guided paravertebral nerve block anesthesia combined with general anesthesia, with those in the control group receiving an epidural block combined with general anesthesia. Measured outcomes included the operative and anesthesia times, as well as the mean arterial pressure (MAP), heart rate (HR), and blood oxygen saturation (SpO2) measured before surgery, 15 min after anesthesia (T1), after intubation, 5 min after skin incision, and before extubation (T4).RESULTSThe dose of intra-operative use of remifentanil and propofol and the postoperative use of sufentanil was lower in the observation group (1.48 ± 0.43 mg, 760.50 ± 92.28 mg, and 72.50 ± 16.62 mg, respectively) than control group (P < 0.05). At the four time points of measurement (T1 through T4), MAP and HR values were higher in the observation than control group (MAP, 90.20 ± 9.15 mmHg, 85.50 ± 7.22 mmHg, 88.59 ± 8.15 mmHg, and 90.02 ± 10.02 mmHg, respectively; and HR, 72.39 ± 8.22 beats/min, 69.03 ± 9.03 beats/min, 70.12 ± 8.11 beats/min, and 71.24 ± 9.01 beats/min, respectively; P < 0.05). There was no difference in SpO2 between the two groups (P > 0.05). Postoperative levels of epinephrine, norepinephrine, and dopamine used were significantly lower in the observation than control group (210.20 ± 40.41 pg/mL, 230.30 ± 65.58 pg/mL, and 54.49 ± 13.32 pg/mL, respectively; P < 0.05). Similarly, the postoperative tumor necrosis factor-α and interleukin-6 levels were lower in the observation (2.43 ± 0.44 pg/mL and 170.03 ± 35.54 pg/mL, respectively) than control group (P < 0.05). There was no significant difference in the incidence of adverse reactions between the two groups (P > 0.05).CONCLUSIONUltrasound-guided paravertebral nerve block anesthesia improved the stress and hemodynamic response in patients undergoing thoracic surgery for lung cancer, with no increase in the rate of adverse events.

Population-Based Analysis of Sex-Dependent Risk Factors for Mortality in Thoracic Surgery for Lung Cancer

Objective: Sex is an important predictor for lung cancer survival and a favorable prognostic indicator for women compared to men. Specific surgery-related sex differences of patients with lung cancer remain unclear. The aim of this study is to analyze sex-specific differences after lung cancer resections to identify factors for an unfavorable prognosis. Methods: This is a retrospective analysis of a German nationwide discharge register of every adult inpatient undergoing pulmonary resection for lung cancer from 2014 until 2017. DRG data and OPS procedures were analyzed with the help of the Federal Statistical Office using remote controlled data. A multivariable regression model was established in a stepwise process to evaluate the effect of sex on inpatient mortality. Results: A total of 38,806 patients underwent surgical resection for lung cancer between January 2014 and December 2017 in Germany. Women were significantly younger at admission than men (mean 64.7 years [SD 10.1] vs. 66.6 years [SD 9.5]; p < 0.0001). They had fewer unreferred admissions (risk ratio 0.83 [0.77, 0.90], p < 0.0001) and were significantly less likely to have recorded comorbidities. Raw in-hospital mortality was 1.8% for women and 4.1% for men. In the multivariable analysis of in-hospital mortality, the likelihood of death for women compared to men was 21% reduced (OR 0.79 [CI: 0.66, 0.93, p = 0.005]). The risk of postoperative complications such as ventilation >48 h, ARDS, tracheotomy, or pneumonia was significantly lower for women. Conclusions: Women undergoing lung cancer surgery were younger and had less comorbidities than men in Germany. Female sex was associated with lower mortality and less postoperative complications.

Preoperative CT Findings for Predicting Acute Exacerbation of Interstitial Pneumonia After Lung Cancer Surgery: A Multicenter Case-Control Study.

BACKGROUND. Acute exacerbation (AE) is a life-threatening complication of inter-stitial pneumonia (IP). Thoracic surgery may trigger AE. OBJECTIVE. The purpose of this study is to explore the role of preoperative CT findings in predicting postoperative AE in patients with IP and lung cancer. METHODS. This retrospective case-control study included patients from 22 institutions who had IP and underwent thoracic surgery for lung cancer. AE was diagnosed on the basis of symptoms and imaging findings noted within 30 days after surgery and the absence of alternate causes. For each patient with AE, two control patients without AE were identified. After exclusions, the study included 92 patients (78 men and 14 women; 31 with AE [the AE group] and 61 without AE [the no-AE group]; mean age, 72 years). Two radiologists independently reviewed preoperative thin-slice CT examinations for pulmonary findings and resolved differences by consensus. The AE and no-AE groups were compared using the Fisher exact and Mann-Whitney U tests. Multivariable logistic regression was performed. Interreader agreement was assessed by kappa coefficients. RESULTS. A total of 94% of patients in the AE group underwent segmentectomy or other surgery that was more extensive than wedge resection versus 75% in the no-AE group (p = .046). The usual IP pattern was present in 58% of the AE group versus 74% of the no-AE group (p = .16). According to subjective visual scoring, the mean (± SD) ground-glass opacity (GGO) extent was 6.3 ± 5.4 in the AE group versus 3.9 ± 3.8 in the no-AE group (p = .03), and the mean consolidation extent was 0.5 ± 1.2 in the AE group versus 0.1 ± 0.3 in the no-AE group (p = .009). Mean pulmonary trunk diameter was 28 ± 4 mm in the AE group versus 26 ± 3 mm in the no-AE group (p = .02). In a model of CT features only, independent predictors of AE (p < .05) were GGO extent (odds ratio [OR], 2.8), consolidation extent (OR, 9.4), and pulmonary trunk diameter (OR, 4.2); this model achieved an AUC of 0.75, a PPV of 71%, and an NPV of 77% for AE. When CT and clinical variables were combined, undergoing segmentectomy or more extensive surgery also independently predicted AE (OR, 8.2; p = .02). CONCLUSION. The presence of GGO, consolidation, and pulmonary trunk enlargement on preoperative CT predicts AE in patients with IP who are undergoing lung cancer surgery. CLINICAL IMPACT. Patients with IP and lung cancer should be carefully managed when predictive CT features are present. Wedge resection, if possible, may help reduce the risk of AE in these patients. TRIAL REGISTRATION. University Hospital Medical Information Clinical Trial Registry UMIN000029661.

Atrial Fibrillation after Lung Cancer Surgery: Prediction, Prevention and Anticoagulation Management.

Simple SummaryAtrial fibrillation that occurs after surgery raises further questions with respect to spontaneous atrial fibrillation, being an event unquestionably related to the surgical act itself and always quite self-limiting. The purpose of this review is to present the knowledge gained so far, including the most recent findings, regarding this peculiar form of arrhythmia. Its prognostic impact and the possibility of predicting and preventing it were the subject of our analysis, as well as the similarities and differences with spontaneous atrial fibrillation in relation to anticoagulation. Where possible, the search for evidence has focused on studies involving lung cancer patients undergoing thoracic surgery, highlighting any differences with cardiac surgery.Atrial fibrillation (AF) is a common complication of the early postoperative period of various types of surgery, including that for lung cancer. Although induced by the homeostatic alterations related to surgery, there is evidence that it is not a mere stand-alone transitory event, but it represents a relevant complication of surgery, bearing considerable prognostic consequences. Different methods have therefore been explored to predict the occurrence of postoperative atrial fibrillation (POAF) and prevent it. In particular, the age among clinical factors, and N-terminal prohormone of brain natriuretic peptide (NT-proBNP), as a marker, have proven to be good predictors, and the use of beta-blockers or amiodarone in primary prevention seems to reduce its incidence significantly. There is growing evidence that POAF significantly increases the risk of stroke and global mortality in the long term; therefore, it should be managed in the same way as spontaneous atrial fibrillation. In this review, we will present the strongest evidence found so far and the most recent findings regarding the management of POAF, with a special focus on patients undergoing thoracic surgery for lung cancer.

Contralateral tension pneumothorax during video-assisted thoracic surgery for lung cancer in a patient with obesity and rib fractures: a case report and review of the literature

BackgroundIntraoperative contralateral pneumothorax during one-lung ventilation is a rare but life-threatening complication. Although the exact incidence is unknown, only 14 cases with this complication have been reported until now.Case presentationA 67-year-old Japanese man with a weight of 80 kg, height of 162.2 cm, and body mass index of 30.4 kg/m2 underwent three-port video-assisted thoracic surgery for lung cancer with one-lung ventilation. He had suffered from traumatic right rib fractures 6 weeks before the referral. Fifteen minutes before the end of the surgery, the systolic blood pressure suddenly dropped to about 50 mmHg, which was immediately recovered by intravenous injection of phenylephrine. This episode occurred during chest closure after the completion of the left upper lobectomy, and one-lung ventilation was soon switched to two-lung ventilation. Contralateral tension pneumothorax was noted by the postoperative chest x-ray. As the patient was complicated with obesity and a past history of rib fractures, increased airway pressure during one-lung ventilation related to obesity together with the persistent compression of the visceral pleura by the fractured ends of the ribs was considered to be the factors responsible for this critical complication.ConclusionsPatient backgrounds such as obesity and past history of rib fractures should be noted carefully as risk factors for intraoperative contralateral pneumothorax during one-lung ventilation. We present the clinical course and discuss the mechanism of development of this potentially life-threatening complication in the present case with a review of the literature.

Perioperative outcomes of robot-assisted vs video-assisted and traditional open thoracic surgery for lung cancer: A systematic review and network meta-analysis.

The superiority of robot-assisted thoracic surgery (RATS) over video-assisted thoracic surgery (VATS) and thoracotomy remains controversial for lung cancer. A network meta-analysis (NMA) and pairwise meta-analysis (PMA) were performed to evaluate the perioperative outcomes using five databases. Thirty-two studies involving 6593 patients were included for analysis. The NMA showed that RATS had similar operative time, conversion rate to thoracotomy, number of lymph node, postoperative morbidity, and length of hospital stay with VATS, except for lower 30-day mortality. Compared with thoracotomy, longer operative time and shorter hospital stay were observed in RATS, but no significant difference was observed in number of lymph node, postoperative morbidity, and 30-day mortality in both NMA and PMA. In lobectomy/segmentectomy subgroup, all outcomes, except for operative time of RATS vs VATS and number of lymph node, were similar with overall analyses. RATS had comparable perioperative outcomes with VATS and open surgery.

Long-term incidence of chronic postsurgical pain after thoracic surgery for lung cancer: a 10-year single-center retrospective study

BackgroundThe long-term incidence of chronic postsurgical pain (CPSP) after thoracic surgery has not yet been reported.MethodsWe retrospectively reviewed the electronic medical records of 4218 consecutive patients who underwent thoracic surgery...

Cost in video-assisted thoracic surgery versus robotic-assisted thoracic surgery for lung cancer: should we focus on other metrics?

Historically, pulmonary resections for lung cancer have been done in an open fashion. With the adoption of VATS, incisions became smaller but challenges such as cost, safety, and quality of resection became the center of the discussion. However, now we have extensive evidence of the benefit of minimally invasive approaches. With the introduction of robotic-assisted thoracic surgery (RATS), the discussion has gone back to cost as the main driver. This increased robotic cost has been evaluated by multiple studies without a general consensus, given the varying definitions of cost. Medical institutions and health systems will never share the details of what those technologies cost, which makes comparisons not truly significant. In this article, we analyzed the pros and cons of RATS versus VATS and tried to answer if cost is the adequate metric when comparing both techniques.

179 - Mobilisation in the post anaesthetic care unit following video-assisted thoracic surgery for lung cancer: a future study involving the specialist nurse role

179 - Mobilisation in the post anaesthetic care unit following video-assisted thoracic surgery for lung cancer: a future study involving the specialist nurse role

Uniportal versus multiportal video-assisted thoracic surgery for lung cancer.

Video-assisted thoracic surgery (VATS) lobectomy is the recommended surgical approach for patients with stage I lung cancer. Whether a multiportal or a uniportal approach is preferable remains unclear. The aim of this study was to evaluate the safety of implementing uniportal VATS lobectomy into the treatment program of lung cancer patients. We used the national quality register for general thoracic surgery in Sweden and included all patients who underwent VATS lobectomy for lung cancer at the Karolinska University Hospital between 2016-2018. Early postoperative complications were compared in patients undergoing uniportal (n=122) and multiportal (n=211) VATS lobectomy for lung cancer. Inverse probability of treatment weighting and standardized mean differences were used to limit differences in baseline characteristics and to assess balance after weighting. The proportion of uniportal VATS lobectomies increased during the study period and the conversion rates declined significantly. Baseline characteristics were similar in the two groups with the exception of a higher percentage of patients without any comorbidity in the uniportal group (59.8% vs. 44.5%, P=0.010). After inverse probability of treatment weighting the groups were well balanced. Postoperative complications were rare regardless of surgical approach, 94% in both groups had no complications. The 30-day mortality and overall survival at 1 year was 0% and 97% in the uniportal group, and 0.5% and 98% in the multiportal group (P=0.71). Patients undergoing uniportal VATS lobectomy were discharged directly to home to a higher extent than multiportal VATS patients (76.2% vs. 62.1%, P=0.008). We found that uniportal VATS lobectomy was feasible and safe, and might entail advantages in terms of a faster recovery after surgery as compared to multiportal VATS lobectomy in patients with lung cancer.

Application Value of the Screening Questionnaires to Predict OSA-Related Complications Following Thoracic Surgery for Lung Cancer

Application Value of the Screening Questionnaires to Predict OSA-Related Complications Following Thoracic Surgery for Lung Cancer

Computer-aided Quantification of Pulmonary Fibrosis in Patients with Lung Cancer: Relationship to Disease-free Survival.

Background Interstitial lung abnormalities (ILAs) are present at CT in about 10% of individuals undergoing lung cancer screening. The relationship between histologic findings of ILAs and their influence on patient prognosis remains unknown. Purpose To evaluate the percentage of ILAs at preoperative CT, as measured by radiologists and a computer-aided detection (CAD) software, as a predictor of disease-free survival in patients with lung cancer. Materials and Methods This retrospective study evaluated 217 consecutive patients who underwent complete resection of lung cancer from April 2010 to December 2015. Two radiologists, blinded to the patients' clinical information, scored percentage fibrosis extent and determined whether ILAs and the usual interstitial pneumonia (UIP) pattern were present. They assessed ILA progression at follow-up CT. Two pathologists determined the presence of an UIP pattern. Percentage fibrosis extent was also measured by using CAD. Binary logistic regression analysis was performed to determine whether the CAD percentage fibrosis extent was associated with ILA at CT. Multivariable Cox regression analysis was used to evaluate the significance of CAD percentage fibrosis extent as a predictor of prognosis. Results The radiologists classified 47 patients with ILAs and 24 patients with a UIP pattern at chest CT. The pathologists detected a UIP pattern in 25 patients. CT abnormalities showed progression over a 2-year period in all patients with histologic evidence of UIP. After adjustment for age, sex, and smoking index, the CAD percentage fibrosis extent was independently associated with ILA (odds ratio: 3.1; 95% confidence interval [CI]: 2.1, 4.7; P < .001). After adjustment for age, forced expiratory volume in 1 second (percentage predicted) radiologist-assessed percentage fibrosis extent, and pathologic stage, CAD percentage fibrosis extent was independently associated with worse disease-free survival (hazard ratio: 1.3; 95% CI: 1.1, 1.6; P < .001). Conclusion Greater computer-aided detection percentage fibrosis extent at preoperative CT independently predicted worse disease-free survival in patients with lung cancer. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Goo in this issue.

Thoracic surgery for lung cancer: current practice and future directions.

Thoracic surgery for lung cancer: current practice and future directions.

Post-thoracotomy pain syndrome as a risk factor for the development of nosocomial pneumonia

Background. Pain syndrome is the most common complication of thoracotomy. It is the main reason of discomfort in postoperative period and could impair respiratory function. The aim of the study. The aim of our study was to analyze the effect of PTPS on pulmonary function and postoperative pneumonia rate in patients underwent open surgery on the lung cancer. Methods. 300 patients were included in the study operated on in our clinic for lung cancer via thoracotomy approach. All patients were randomly assigned to 3 comparable groups according to the method of anesthesia: thoracic epidural analgesia (HEA), n = 100; paravertebral block (PVB), n = 100; intercostal block (IRB), n = 100. On the 3rd day after the operation, the intensity of the pain syndrome was evaluated by VAS and spirometry was performed. Results. Analysis of the intensity of postoperative pain syndrome showed the superiority of epidural analgesia over other techniques. In patients with pain syndrome with an intensity of more than 30 mm VAS, the FEV1, VC, and chest excursions were significantly lower than in patients with pain up to 30 mm VAS. The development of pain syndrome of more than 70 mm of VAS led to a significant deterioration in VC rate and chest excursion if compare to patients with AHD 31–70 mm of VAS, which increases the risk of infectious complications. Conclusion. An optimal antinociceptive protection in the perioperative period improves respiratory function and helps to reduce pulmonary complications rate. The method of choice in open thoracic surgery for lung cancer is a combined general anesthesia with a high thoracic epidural block.

Surgical Management of Lung Cancer: History, Evolution, and Modern Advances

Although surgery for lung cancer was not common before the early twentieth century, it has enjoyed remarkable progress since then both in type of resection and technical approach. This has been coupled with significant technological advances. Here, we will review the history and evolution of this relatively new field of surgery. The gold standard of the extent of resection for lung cancer evolved from pneumonectomy to lobectomy to even sublobar resection for select situations. In addition, major advances have occurred in the technical aspect of the surgical procedure. The incisional approach has evolved from rib spreading thoracotomy to thoracoscopic surgery with the latter showing significant improvement in short-term outcomes over open thoracotomy. However, standard video-assisted thoracoscopic surgery or VATS is associated with visual and mechanical limitations, including lack of depth perception and rigid straight instruments. This makes it appropriate only for early-stage peripheral and small tumors. Most of the limitations of VATS can be overcome with the more recently introduced robotic-assisted thoracic surgery (RATS). RATS utilizes wristed instruments that are introduced in the chest through 8-mm ports and can mimic the movements of the human hand. In addition, magnified, three-dimensional and high definition imaging gives the surgeon an image of the lung unlike any other modality. This has allowed surgeons to perform advanced resections such as pneumonectomy or sleeve resection in a minimally invasive fashion. In addition, RATS has become a platform for the addition of other technical enhancements such as incorporating a near infra-red light source into the camera allowing identification of autoflourescent agents, such as indocyanin green. This has allowed localization of small nodules for resection and identification of tissue planes for sublobar resection. However, new technologies also require investments in time and money. Thoracic surgery for lung cancer has evolved to include advanced minimally invasive techniques including video-assisted and robotic-assisted thoracoscopy. RATS in particular may enable surgeons to perform more advanced procedures in a minimally invasive fashion. It is hoped that the higher costs of new surgical technology may be offset by the potential for improved patient outcomes and resultant socioeconomic benefits.