Thoracoscopic Anatomic Pulmonary Resection Research Articles

CT-Derived Sarcopenia and Outcomes after Thoracoscopic Pulmonary Resection for Non-Small Cell Lung Cancer.

We aimed to evaluate whether computed tomography (CT)-derived preoperative sarcopenia measures were associated with postoperative outcomes and survival after video-assisted thoracoscopic (VATS) anatomical pulmonary resection in patients with early-stage non-small cell lung cancer (NSCLC). We retrospectively reviewed all consecutive patients that underwent VATS anatomical pulmonary resection for NSCLC between 2012 and 2019. Skeletal muscle mass was measured at L3 vertebral level on preoperative CT or PET/CT scans to identify sarcopenic patients according to established threshold values. We compared postoperative outcomes and survival of sarcopenic vs. non-sarcopenic patients. A total of 401 patients underwent VATS anatomical pulmonary resection for NSCLC. Sarcopenia was identified in 92 patients (23%). Sarcopenic patients were predominantly males (75% vs. 25%; p < 0.001) and had a lower BMI (21.4 vs. 26.5 kg/m2; p < 0.001). The overall postoperative complication rate was significantly higher (53.2% vs. 39.2%; p = 0.017) in sarcopenic patients and the length of hospital stay was prolonged (8 vs. 6 days; p = 0.032). Two factors were associated with postoperative morbidity in multivariate analysis: BMI and American Society of Anesthesiologists score >2. Median overall survival was comparable between groups (41 vs. 46 months; p = 0.240). CT-derived sarcopenia appeared to have a small impact on early postoperative clinical outcomes, but no effect on overall survival after VATS anatomical lung resection for NSCLC.

Evaluation of pulmonary artery bleeding during thoracoscopic pulmonary resection for lung cancer.

Bleeding from the pulmonary artery (PA) can be fatal in video-assisted thoracoscopic surgery (VATS) for lung cancer. We evaluated intraoperative PA injury and assessed precautions for thoracoscopic anatomic pulmonary resection. We retrospectively analyzed a total of 1098 patients who underwent radical surgery for lung cancer utilizing complete VATS from January 2010 to December 2021. A total of 16 patients (1.5%) had PA injury during VATS, while hemostasis was performed by conversion to thoracotomy in eight patients (50.0%). Although there was a significantly greater operation time and blood loss for patients in the PA injury group (318.4 vs. 264.9min, p= 0.001; 550.3 vs. 60.5g, p≤ 0.001, respectively), there was no significant different for the chest tube insertion duration and length of postoperative hospital stay (4.9 vs. 7.8 days, p= 0.157; 10.6 vs. 9.9 days, p= 0.136, respectively). There was a significant difference observed for the surgical procedure related to the left upper lobectomy in the PA injury group (43.8 vs. 18.8%, p= 0.012), with the primary causative PA determined to be the left anterior segmental PA (A3 ) (31.3%). VATS is both feasible and safe for lung cancer treatment provided the surgeon performs appropriate hemostasis, although fatal vascular injury could potentially occur during VATS. Surgeons need to be aware of the pitfalls regarding PA dissection management.

Pulmonary vessels and bronchus anatomy of the left upper lobe.

The bronchopulmonary vascular bifurcation patterns in the upper lobe of the left lung are diverse. Therefore, it is important for general thoracic surgeons to understand the detailed anatomy of the pulmonary segments when performing thoracoscopic anatomical pulmonary resection. This study aimed to analyze the bronchovascular patterns of the left upper lobe and summarize the anatomical information associated with pulmonary anatomical pulmonary resection. We reviewed the anatomical patterns of pulmonary vessels and the left lung bronchus of 539 patients using computed tomography imaging data including those obtained using three-dimensional computed tomography. We herein report the anatomic structure in the left upper lobe. Regarding the superior division bronchi, a pattern of trifurcation into B1+2, B3, lingular division bronchus was observed in nine patients (1.7%). A pattern of proximal bifurcation of B4 was found in eight patients (1.5%). Regarding the lingular veins (LV), patterns of LV drainage into the left lower pulmonary vein were observed in 22 patients (4.1%). Regarding the pulmonary artery, mediastinal lingular arteries (MLA) were found in 161 patients (29.9%). The bifurcation patterns of the bronchovascular region in the upper lobe of the left lung were clarified. These results should be carefully noted when performing anatomical pulmonary resection.

Early discharge after thoracoscopic anatomical pulmonary resection for non-small-cell lung cancer.

Although video-assisted thoracic surgery (VATS) has shortened hospitalization duration for non-small-cell lung cancer (NSCLC) patients, the factors associated with early discharge remain unclear. This study aimed to identify patients eligible for a 72-h stay after VATS anatomical resection. Monocentric retrospective study including all consecutive patients undergoing VATS anatomical resection for NSCLC between February 2010 and December 2019. Two groups were defined according to the discharge: 'early discharge' (within 72 postoperative hours) and 'routine discharge' (at >72 postoperative hours). A total of 660 patients with a median age of 66.5 years (interquartile range 60-73 years) (female/male: 321/339) underwent VATS anatomical pulmonary resection for NSCLC [segmentectomy in 169 (25.6%), lobectomy in 481 (72.9%), bilobectomy in 8 (1.2%) and pneumonectomy in 2 (0.3%) patients]. The cardiopulmonary and Clavien-Dindo III-IV postoperative complication rates were 32.6% and 7.7%, respectively. The median postoperative length of stay was 6 days (interquartile range 4-10 days). In total, 119 patients (18%) could be discharged within 72 h of surgery. On multivariable analysis, the factors significantly associated with an increased likelihood of early discharge were: body mass index >20 kg/m2 [odds ratio (OR) 2.37], absence of prior cardiopathy (OR 2), diffusing capacity of the lung for carbon monoxide >60% (OR 1.82), inclusion in an enhanced recovery after surgery protocol (OR 2.23), use of a single chest tube (OR 5.73) and postoperative transfer to the ward (OR 4.84). Factors significantly associated with a decreased likelihood of early discharge were: age >60 years (OR 0.53), American Society of Anaesthesiologists score >2 (OR 0.46) and use of an epidural catheter (OR 0.41). Readmission rates were not statistically different between both groups (5.9% vs 3.1%; P = 0.17). Age, pulmonary functions and comorbidities may influence discharge after VATS anatomical resection. The early discharge does not increase readmission rates.

Four Hours Postoperative Mobilization is Feasible After Thoracoscopic Anatomical Pulmonary Resection.

We aimed to analyze the feasibility and risk factors associated with early mobilization (EM) within 4h after thoracoscopic lobectomy and segmentectomy. This study retrospectively evaluated 214 consecutive patients who underwent thoracoscopic anatomical pulmonary resection using our EM protocol between October 2017 and February 2019. We compared the correlations of the patients' characteristics including the total number of drugs and perioperative parameters such as air leak, and orthostatic hypotension (OH) between the EM (E group) and failed EM (F group) groups. Second, we evaluated risk factors for OH, which often causes critical complications. A total of 198 patients (92.5%: E group) completed the EM protocol, whereas 16 patients did not (7.5%: F group). The primary causes of failure were severe pain, air leak, postoperative nausea and vomiting, and OH (n = 1, 3, 8, and 4). Upon univariate analysis, air leakage, OH, and non-hypertension were identified as risk factors for failed EM (all p <0.05). EM was associated with a shortened chest tube drainage period (p <0.01). Thirty patients (14%) experienced OH, and 20% of them failed EM. A total number of drugs ≥5 (p = 0.015) was an independent risk factor for OH. Operative and anesthetic variables were not associated with EM or OH. The EM protocol was safe and useful for tubeless management. Surgeons should be advised to actively prevent air leak. Our EM protocol achieved a low frequency of OH in mobilization. Due to its versatility, our mobilization protocol may be promising, especially in patients without severe comorbidities. Clinical registration number: The study protocol was approved by the Review Board of Aichi Cancer Center (approval number: 2020-1-067).

Comparison of robotic and video-assisted thoracic surgery for lung cancer: a propensity-matched analysis.

Reports of comparison between robotic and thoracoscopic surgery for lung cancer are limited, we aimed to compare the perioperative outcomes of robotic and thoracoscopic anatomic pulmonary resection for lung cancer. A total of 184 patients with lung cancer underwent anatomic pulmonary resection by robotics or thoracoscopy. A propensity-matched analysis with incorporated preoperative variables was used to compare the perioperative outcomes between the two procedures. Overall, 71 patients underwent robotic pulmonary resection, including 64 lobectomies and 7 segmentectomies, while 113 patients underwent thoracoscopic lobectomy and segmentectomy. Propensity match produced 69 pairs. The mean length of postoperative stay (7.6±4.6 vs. 6.4±2.6 d, P=0.078), chest tube duration (5.3±3.7 vs. 4.4±1.7 d, P=0.056), number of lymph nodes retrieved (17.9±6.9 vs. 17.4±7.0, P=0.660), stations of lymph nodes resected (7.4±1.6 vs. 7.6±1.7, P=0.563), operative blood loss (53.9±29.3 vs. 50.3±37.9 mL, P=0.531), morbidity rates (42.0% vs. 30.4%, P=0.157) were similar between the robotics and thoracoscopy. However, robotics was associated with higher cost ($12,067±1,610 vs. $8,328±1,004, P<0.001), and longer operative time (136±40 vs. 111±28 min, P<0.001). Robotics seems to have higher hospital costs and longer operative time, without superior advantages in morbidity rates and oncologic efficiency. Further prospective randomized clinical trials were needed to validate both of its short- and long-term oncologic efficiency.

Troubleshooting Common Unexpected Situations during Thoracoscopic Anatomical Pulmonary Resection

现代意义上的胸腔镜肺外科始于20世纪90年代初，经过20余年发展，手术技术已臻成熟，同时也有了丰富的临床数据积累。以胸腔镜为代表的微创技术在早期非小细胞肺癌及肺部良性疾病的外科治疗、肺部疾病诊断等方面的应用均已得到公认，也是上述情况的首选手术方法。随着胸腔镜解剖性肺切除手术的普及，文献中也逐渐有了一些临床实践中意外情形的报道，涉及解剖异常、病变自身相关因素、手术操作及技术等多方面，但目前少有对胸腔镜解剖性肺切除手术中意外情形的系统梳理，本文拟结合自身临床实践及文献报道，对这方面内容进行总结，为临床工作提供参考。

Transition from multiple port to single port video-assisted thoracoscopic anatomic pulmonary resection: early experience and comparison of perioperative outcomes.

Single port thoracoscopy is an approach aimed at minimizing trauma to the chest wall during lung resection. The objectives of this study were to describe early experience in the transition from multiple port video-assisted thoracic surgery (VATS) to single port surgery (S-VATS) and to compare perioperative outcomes between approaches. Consecutive anatomic lung resections using S-VATS were reviewed and compared to a historical, prospective cohort of multiple port VATS cases. Outcomes analysis was focused on the use of operating room resources and postoperative recovery. Over 12 months, 50 S-VATS procedures were completed by one surgeon and compared to an equal number of VATS patients. The groups were similar in age, gender, BMI, comorbidity, tumor size and pulmonary function. There was no statistically significant difference in operative time. All tumors were completely resected (R0) and the median number of lymph nodes evaluated pathologically was equivalent {S-VATS=7 [4-10]; VATS=7 [4-10]; P=0.92}. There was no significant difference in conversion rate {S-VATS=2 (4%); VATS=1 (2%); P=0.56}. The median length of stay was similar in both groups {S-VATS=4 [3-7]; VATS=4 [3-7]; P=0.99}. There was no mortality and no significant difference in the rate of major complications {S-VATS=10/50 [20%]; VATS=5/50 [10%]; P=0.26}. There was no difference in patient reported pain as measured by a visual analog scale at 24 hours {S-VATS=4 [2-5]; VATS=4 [3-5]; P=0.63}. Early experience in the transition from multiple port VATS to S-VATS lung resection indicates that safety, efficiency and surgical quality are preserved. More long-term data are required. Alternative approaches to perform thoracoscopic lung resection should be carefully evaluated and compared to established minimally invasive techniques.

Invited Commentary

This paper by Nakanishi and coworkers [1Nakanishi R. Fujino Y. Yamashita T. Shinohara S. Oyama T. Thoracoscopic anatomic pulmonary resection for locally advanced non-small cell lung cancer.Ann Thorac Surg. 2014; 97: 980-986Google Scholar] represents the continuing evolution of thoracoscopic anatomic resection. There are several laudable aspects of the article. The first is a formal grading of the complications using the National Cancer Institute's common terminology criteria for adverse event reporting system. Such rigorous objective reporting should serve as a model for other clinical papers. The second is the low conversion rate of 2.6%. That depicts the expertise of the surgical team and their motivation to complete the resection thoracoscopically—both are required elements of maturing a team's thoracoscopic experience. The third is a reasonably low mortality and morbidity. A 2.6% mortality rate for this group of patients is very respectable. Of note, the researchers report a 1.3% incidence of pneumonia, a remarkably low rate. One wonders if this is a result of good patient selection or aggressive pulmonary rehabilitation. Indications of increasing experience include decreasing operating time and blood loss, and a decreasing pneumonectomy rate coupled with increasing bronchoplasty rate. The experience at our institution is quite similar to that of Nakanishi and colleagues [1Nakanishi R. Fujino Y. Yamashita T. Shinohara S. Oyama T. Thoracoscopic anatomic pulmonary resection for locally advanced non-small cell lung cancer.Ann Thorac Surg. 2014; 97: 980-986Google Scholar] in the feasibility of performing resections for locally advanced lung cancers. Although we have a higher incidence of conversion to open thoracotomy, a thoracoscopic approach is attempted for almost every patient. However, some differences do exist in our approach. The major difference is our increasing reliance on transcervical extended mediastinal lymphadenectomy for lymph node clearance. Also, unlike Nakanishi and colleagues [1Nakanishi R. Fujino Y. Yamashita T. Shinohara S. Oyama T. Thoracoscopic anatomic pulmonary resection for locally advanced non-small cell lung cancer.Ann Thorac Surg. 2014; 97: 980-986Google Scholar], we continue to use interrupted sutures for bronchial anastomoses. Another small difference in our experience is that we have never needed to break up a specimen in the bag to extract it. An important aspect of thoracoscopic resection of locally advanced lung cancer is the reliance of the surgeon on haptic sensation as well as visualization during dissection. With increasing adoption of robotic surgery, it remains to be seen if such resections can be safely performed in the absence of haptic feedback. Overall, this superb report highlights the ability of video-assisted thoracoscopic surgery to resect locally advanced lung cancer with acceptable oncologic results. Although a randomized controlled trial would be ideal to prove oncologic equivalence to open surgical resection, it is unlikely that it will ever be done. Therefore, retrospective evidence of the kind presented here will help shape surgical opinion. Thoracoscopic Anatomic Pulmonary Resection for Locally Advanced Non-Small Cell Lung CancerThe Annals of Thoracic SurgeryVol. 97Issue 3PreviewThe safety and feasibility of thoracoscopic lobectomy for locally advanced lung cancer remain controversial. Full-Text PDF

Thoracoscopic Anatomic Pulmonary Resection for Locally Advanced Non-Small Cell Lung Cancer

The safety and feasibility of thoracoscopic lobectomy for locally advanced lung cancer remain controversial. Between April 2002 and April 2011, we retrospectively reviewed 100 consecutive patients who underwent anatomic pulmonary resection for preoperative stage II or greater non-small cell lung cancer at a single institution. After excluding 16 patients undergoing planned thoracotomy and 8 patients with preoperative stage IV disease, the remaining 76 patients who underwent thoracoscopic surgery were divided chronologically into three groups and analyzed. Thoracoscopic anatomic pulmonary resection was successfully performed in 74 patients (97.4%). There were 32 complications in 27 patients (35.5%), and 2 patients (2.6%) had grade 3 or higher complications. The operative, perioperative (30-day), and hospital mortality were 0%, 0%, and 2.6%, respectively. A significantly decreased operation time, a lower amount of blood loss, and increased numbers of bronchoplasty and bronchial coverage were seen, although there were no significant differences in the patient characteristics or other outcomes among the three groups. At a mean follow-up time of 40 months, the overall 3-year survival rates for pathologic stages I (n = 12), II (n = 27), III (n = 33), and IV (n = 4) were 100%, 64.2%, 36.2%, and 25.0%, respectively. Thoracoscopic anatomic pulmonary resection is feasible, with acceptable morbidity and mortality rates, as well as favorable oncologic outcomes, in selected patients with locally advanced non-small cell lung cancer. The learning curve for this procedure appears to be overcome after 25 consecutive patients.