Video-assisted Thoracic Surgery Group Research Articles

Comparison of efficacy between video-assisted thoracoscopic surgery and thoracotomy in children with mediastinal tumors: 6-year experience

Video-assisted thoracic surgery (VATS) has been increasingly used in pediatric patients. We evaluated the outcomes of VATS and thoracotomy for pediatric mediastinal tumors. A total of 137 patients who underwent surgery for mediastinal tumors at our department from March 2012 to September 2018 were recruited in this retrospective study. Forty-three patients were treated by VATS and ninety-four underwent thoracotomy (two patients who underwent open surgery were excluded from the study because they were lost to follow-up). Data including demographic information, tumor characteristics, operative time, conversion of surgery, blood transfusion, postoperative hospital stay, mortality and recurrence were collected and compared between the two groups. No significant difference was found in gender, age, weight and tumor distribution between the two groups. The number of patients with malignant tumors who underwent thoracotomy was significantly higher than those who received VATS (78.0% vs. 22.0%, P=0.04). Patients received thoracotomy had significantly larger mean tumor diameter than those who underwent VATS (7.6±3.8 vs. 4.4±1.7 cm, P<0.001). The intraoperative transfusion rate in the thoracotomy group was significantly higher than that in the VATS group (67.4% vs. 14.0%, P<0.001), so was the amount of blood transfusion (148.1±150.7 vs. 23.3±61.1 mL, P<0.001). The VATS group had significantly shorter operative time as compared with the thoracotomy group (94.3±40.9 vs. 133.5±72.1 min, P=0.002). During follow-up, local recurrence was found in 8 (8.7%) patients who underwent thoracotomy, and no significant difference was found in local recurrence rate between the two groups. Four patients who underwent thoracotomy died, and no significant difference was found in mortality between two groups. Due to less blood transfusion, shorter operative time and postoperative hospital stay, VATS is a safer surgical treatment for pediatric mediastinal tumors than thoracotomy.

Corrigendum to: Uniportal and three-portal video-assisted thoracic surgery lobectomy: analysis of the Italian video-assisted thoracic surgery group database [Interact CardioVasc Thorac Surg 2019;29:714–21

Corrigendum to: Uniportal and three-portal video-assisted thoracic surgery lobectomy: analysis of the Italian video-assisted thoracic surgery group database [Interact CardioVasc Thorac Surg 2019;29:714–21

Comparison between thoracoscopic and open approaches in thymoma resection.

To investigate the feasibility and indications of video-assisted thoracic surgery (VATS) in thymoma resection. The clinical data of 103 patients undergoing thymoma resection via different approaches [including conventional lateral thoracotomy approach (LTA) in 41 cases, median sternotomy approach (MSA) in 40 cases, and right-sided VATS in 22 cases] were analyzed. Among them, 59, 13, 25, and 6 patients were in Masaoka stage I, II, III, and IV, respectively. Myasthenia gravis (MG) was also found in 54 cases. The patients were followed up for postoperative survival and the improvement in MG. The prognostic indicators of patients undergoing thymoma resection via different surgical approaches (i.e., LTA, MSA, and VATS) were statistically analyzed. Eight of 103 patients died. Six patients underwent unilateral sacral nerve resection, among whom 4 patients developed respiratory dysfunction, and 3 died. Two patients died of MG after surgery, 1 patient died of tumor recurrence and metastasis, 1 patient died of heart disease, and the cause of death was unknown in the remaining patient. The drainage time was shorter in VATS group than in open groups, along with smaller tumor size. The VATS group also had shorter hospital stay in the whole series and the subgroup without accompanying MG. The improvement in MG showed no significant difference among the three surgical groups. Both 5- and 10-year survival rates were 91% in the entire cohort. VATS is like a conventional surgeries for improving MG in thymoma patients with accompanying MG. VATS resection can still be considered for thymoma that only invades the mediastinal pleura. For thymomas that have intact capsules and have not invaded mediastinal pleura, MSA surgery shall be performed to ensure patient safety if the anteroposterior diameters of the tumors are large and the masses have produced severe compression of the innominate vein, even if the tumors are still in the Masaoka stage II. For thymomas with large left-to-right diameters and with most parts of the tumors located in the left thoracic cavity, a left-sided approach (either VATS or an open approach) may be used in the absence of MG; if MG accompanies the condition, an MT approach or a bilateral VATS may be considered. In patients with unilateral pericardial phrenic nerve and/or local pericardial involvement, right-sided VATS thymectomy may be considered for thymomas located at the right side and bilateral VATS surgery can be performed for tumors located at the left side. In summary, VATS is feasible for the treatment of thymoma complicated by MG. VATS can be performed in patients with Masaoka stage I, II and (a certain portion of) III thymoma; for some patients with Masaoka stage II thymoma, especially those with compression of the innominate vein, the use of VATS should be cautious.

Uniportal and three-portal video-assisted thoracic surgery lobectomy: analysis of the Italian video-assisted thoracic surgery group database

This study compares the uniportal with the 3-portal video-assisted thoracic surgery (VATS) by examining the data collected in the Italian VATS Group Database. The primary end point was early postoperative pain; secondary end points were intraoperative and postoperative complications, surgical time, number of dissected lymph nodes and length of stay. This was an observational, retrospective, cohort, multicentre study on data collected by 49 Italian thoracic units. Inclusion criteria were clinical stage I-II non-small-cell lung cancer, uniportal or 3-portal VATS lobectomy and R0 resection. Exclusion criteria were cT3 disease, previous thoracic malignancy, induction therapy, significant comorbidities and conversion to other techniques. The pain parameter was dichotomized: the numeric rating scale ≤3 described mild pain, whereas the numeric rating scale score >3 described moderate/severe pain. The propensity score-adjusted generalized estimating equation was used to compare the uniportal with 3-portal lobectomy. Among 4338 patients enrolled from January 2014 to July 2017, 1980 met the inclusion criteria; 1808 patients underwent 3-portal lobectomy and 172 uniportal surgery. The adjusted generalized estimating equation regression model using the propensity score showed that over time pain decreased in both groups (P < 0.001). There was a statistical difference on the second and third postoperative days; odds ratio (OR) 2.28 [95% confidence interval (CI) 1.62-3.21; P < 0.001] and OR 2.58 (95% CI 1.74-3.83; P < 0.001), respectively. The uniportal-VATS group had higher operative time (P < 0.001), shorter chest drain permanence (P < 0.001) and shorter length of stay (P < 0.001). Data from the Italian VATS Group Database showed that in clinical practice uniportal lobectomy seems to entail a higher risk of moderate/severe pain on second and third postoperative days.

Video-Assisted Vs Thoracotomy Sleeve Lobectomy for Lung Cancer: A Propensity Matched Analysis

In this retrospective study, we evaluated the safety and efficacy of video-assisted thoracic surgery (VATS) sleeve lobectomy for patients with centrally located non-small cell lung cancer. All consecutive patients who received VATS sleeve lobectomy (n= 54) and thoracotomy sleeve lobectomy (n= 94) were analyzed retrospectively; after propensity score matching, 78 paired cases were selected for further statistical analysis. Among all patients, the VATS group showed significantly better recurrence-free survival and overall survival than the thoracotomy group (P= .025 and P= .026, respectively) with smaller total tumor size and earlier pathological tumor-node-metastasis (TNM) stage. Nevertheless, after matching, the recurrence-free survival (50.9% vs 48.7%; P= .445) and overall survival (79.5% vs 66.7%; P= .198) were not significantly different. There was significantly less blood loss (228 vs 246 mL; P= .022), shorter thoracic drainage stay (4.6 vs 6.8 days; P < .001), and postoperative hospital stay (9.2 vs 11.3 days; P= .033) in the VATS group. Multivariate Cox analyses demonstrated that the surgical procedure was not an independent prognostic factor for recurrence-free survival, not only for patients with an invasive component size of 3 cm or less and negative lymphatic invasion, but for locally advanced patients with an invasive tumor size >3 cm (hazard ratio: 0.94; 95% confidence interval: 0.36-2.45; P= .55) or positive lymphatic invasion (hazard ratio: 0.91; 95% confidence interval: 0.35-2.39; P= .41). VATS sleeve lobectomy is a safe and effective procedure associated with better postoperative recovery and equivalent oncological results, even for locally advanced non-small cell lung cancer patients with an invasive tumor size larger than 3 cm or accompanying lymphatic invasion.

Long-term survival outcomes of video-assisted thoracic surgery lobectomy for stage I-II non-small cell lung cancer are more favorable than thoracotomy: a propensity score-matched analysis from a high-volume center in China.

Video-assisted thoracic surgery (VATS) has been considered as the better choice for the surgical treatment of resectable non-small cell lung cancer (NSCLC). This study aimed to evaluate the short- and long-term outcomes of VATS versus open thoracotomy lobectomy for patients with pathological stage (p-stage) I-II NSCLC in one of the high-volume center in China. Perioperative outcomes and long-term survival of patients who underwent VATS versus open lobectomies for p-stage I-II NSCLC from May 2006 to June 2013 in the Western China Lung Cancer Database (WCLCD) were studied using propensity score matching (PSM). The VATS lobectomy was mainly carried out using the single-direction technique. Of the 3,678 patients who underwent surgery for lung malignancies, 1,485 patients with stage I-II NSCLC were enrolled for the study, including 737 cases of VATS lobectomies and 748 cases of open lobectomies. PSM resulted in 464 cases of VATS lobectomies and 464 cases of open lobectomies who were well matched by ten potential prognostic factors including tumor size, T- and N-stage. VATS lobectomy was associated with less blood loss than open surgery (median: 60 vs. 100 mL, P=0.000), as well as fewer postoperative complications (15.1% vs. 20.3%, P=0.039). In addition, the VATS approach removed more lymph node stations (4.9±1.5 vs. 4.2±1.8, P=0.000). The postoperative hospital stay was shorter in the VATS group (7.7±3.8 vs. 8.3±4.3, P=0.019), but the total hospital costs were more expensive (48.4±11.3 vs. 35.5±9.4 kRMB, P=0.000). The matched cohorts revealed that VATS lobectomy for stage I-II NSCLC had improved 5-year overall survival (OS) than the open approach (71.1% vs. 65.4%, P=0.045). The VATS lobectomy is associated with less blood loss, fewer postoperative complications, and shorter postoperative hospital stay when comparing with the open approach for stage I-II NSCLC. Despite more hospital costs, VATS lobectomy offer improved 5-year OS than the open approach. It is reasonable to recommend the VATS approach as the preferred option for the surgical treatment of stage I-II NSCLC.

Cost-utility analysis of minimally invasive surgery for lung cancer: a randomized controlled trial.

Minimally invasive video-assisted thoracic surgery (VATS) was first introduced in the early 1990s. For decades, numerous non-randomized studies demonstrated advantages of VATS over thoracotomy with lower morbidity and shorter hospital stay, but only recently did a randomized trial document that VATS results in lower pain scores and better quality of life. Opposing arguments for VATS have always been increased costs and concerns about oncological adequacy. In this paper, we aim to investigate the cost-effectiveness of VATS. The study was designed as a cost-utility analysis of the first 12 months following surgery and was performed together with a clinical randomized controlled trial of VATS versus thoracotomy for lobectomy of stage 1 lung cancer during a 6-year period (2008-2014). All health-related expenses were retrieved from a national database (Statistics Denmark) including hospital readmissions, outpatient clinic visits, prescription medication costs, consultations with general practitioners, specialists, physiotherapists, psychologists and chiropractors. One hundred and three VATS patients and 103 thoracotomy patients were randomized. Mean costs per patient operated by VATS were 103108 Danish Kroner (Dkr) (€13818) and 134945 Dkr (€18085) by thoracotomy, making the costs for VATS 31837 Dkr (€4267) lower than thoracotomy (P < 0.001). The difference in quality-adjusted life years gained over 52 weeks of follow-up was 0.021 (P = 0.048, 95% confidence interval -0.04 to -0.00015) in favour of VATS. The median duration of the surgical procedure was shorter after thoracotomy (79 vs 100 min; P < 0.001). The mean length of hospitalization was shorter following VATS (4.8 vs 6.7 days; P = 0.027). The use of other resources was not significantly different between groups. The costs of resources were lower in the VATS group. This difference was primarily due to reduced costs of readmissions (VATS 29247 Dkr vs thoracotomy 51734 Dkr; P < 0.001) and costs of outpatient visits (VATS 51412 Dkr vs thoracotomy 61575 Dkr; P = 0.012). VATS is a cost-effective alternative to thoracotomy following lobectomy for stage 1 lung cancer. Economical outcomes as measured by quality-adjusted life years were significantly better and overall costs were lower for VATS. NCT01278888.

Robotic lobectomy for lung cancer: initial experience of a single institution in Korea

Robotic surgery is known to have several advantages including magnified three-dimensional vision and angulation of the surgical instruments. To evaluate the feasibility and efficiency of robotic lobectomy in the treatment of lung cancer, we analyzed the outcomes of our initial experiences with robotic lobectomy at a single institution in Korea. Eighty-seven patients with lung cancer underwent robotic lobectomy (robotic group: 34 patients) and video-assisted thoracic surgery (VATS) lobectomy (VATS group: 53 patients) between 2011 and 2016 at our hospital. The medical records of these patients were retrospectively analyzed. The operation times of the two groups were significantly different (robotic group, 293±74 min; VATS group, 201±62 min; P<0.01). Intraoperative blood loss occurred more in the robotic group than in the VATS group (robotic group, 403±197 mL; VATS group, 298±188 mL; P=0.018). The numbers of lymph nodes dissected in the two groups were significantly different (robotic group, 22±12; VATS group, 14±7; P<0.01). There was no intraoperative mortality in both groups. Despite the initial difficulties, robotic lobectomy for lung cancer was a safe and feasible procedure with no operative mortality. If operation time and intraoperative blood loss improve as the learning curve progresses, robotic surgery may overcome the limitations of VATS in lung cancer surgery.

Conversion due to vascular injury during video-assisted thoracic surgery lobectomy: A multicentre retrospective analysis from the Italian video-assisted thoracic surgery group registry

ObjectivesVascular injuries are among the most severe causes of unplanned conversion during VATS lobectomies. The study aimed to analyse the incidence of vascular injuries and their risk factors during VATS lobectomy. MethodsThe Italian VATS lobectomy Registry was used to collect data from 66 Thoracic Surgery Units. From 2013 to October 2016 (out of more than 3,700 patients enrolled) only information from Units with an enrollment >100 VATS lobectomies were retrospectively analysed. Logistic regression analysis was performed on selected variables of the univariate analysis. ResultsTen institutions contributed a total of 1,679 patients. Vascular injuries leading to conversion occurred in 44 (2.6%) patients. Years of experiences were inversely related to the risk of vascular injuries. Univariate analysis showed age, gender, surgical activity, Charlson Index Score and number of resected lymph nodes like significantly associated variables. Multivariate analysis revealed that number of resected lymph nodes, VATS experience ratio (number of VATS lobectomies/total lobectomies performed in the same year at same centre), and surgical activity of the centre were significantly associated with the risk of conversion. Unplanned thoracotomy was correlated with postoperative morbidity. ConclusionVascular injuries in VATS lobectomies represented a rare complication which could directly affect the postoperative outcomes. The predictive factors for conversion were multifactorial and depended on characteristics of centres and surgeons’ seniority. Minimally invasive VATS lobectomy approaches did not influence the risk of vascular damages.

Video assisted thoracic surgery vs. thoracotomy for locally advanced lung squamous cell carcinoma after neoadjuvant chemotherapy

BackgroundSurgery is an important part of multidisciplinary treatment strategy for locally advanced lung squamous cell carcinoma (LSCC), but insufficient evidence supports the feasibility and safety of video assisted thoracic surgery (VATS) following neoadjuvant chemotherapy for locally advanced LSCC. This study aims to compare perioperative data and long-term survival of locally advanced LSCC patients between VATS and thoracotomy after neoadjuvant chemotherapy.MethodsWe retrospectively collected the clinical and pathological information of patients with locally advanced LSCC who underwent surgical resection after neoadjuvant chemotherapy from October 2013 to October 2017. All patients were divided into two groups (thoracotomy and VATS) and were compared the differences in perioperative, oncological and survival outcomes.ResultsA total of 81 patients were analyzed in this study (67 thoracotomy and 14 VATS). VATS provided less postoperative pain (P = 0.005) and produced less volume of chest drainage (P = 0.019) than thoracotomy, but the number of resected lymph nodes was less in VATS group (P = 0.011). However, there was no significant difference in the number of resected lymph node stations and the rate of nodal upstaging between two groups. The mean disease free survival (DFS) was 32.7 ± 2.7 months for the thoracotomy group and 31.8 ± 3.0 months for the VATS group (P = 0.335); the corresponding overall survival (OS) was 41.7 ± 2.2 months and 36.4 ± 4.1 months (P = 0.925).ConclusionIn selected patients with locally advanced LSCC, VATS played a positive role in postoperative recovery and associated similar survival outcome compared with thoracotomy after neoadjuvant chemotherapy.

Survival Analysis of Stage I Non-small Cell Lung Cancer Patients Treated with Da Vinci Robot-assisted Thoracic Surgery

背景与目的达芬奇机器人手术系统在胸外科的应用日益广泛，本研究旨在探讨经达芬奇机器人手术治疗Ⅰ期非小细胞肺癌（non-small cell lung cancer, NSCLC）患者的疗效。方法回顾2012年1月-2017年12月于我科行手术治疗的Ⅰ期NSCLC患者347例，依据手术方式分为机器人（robot-assisted thoracic surgery, RATS）组134例及腔镜（video-assisted thoracic surgery, VATS）组213例。比较两组患者围术期一般指标（术中出血量、术后引流量、术后带管时间、术后住院时间、淋巴结清扫状况），分析患者生存状况（overall survival, OS）、无进展生存状况（disease free survival, DFS）及相关影响因子。结果机器人组与腔镜组术中出血量[(49±39) mL vs (202±239) mL]、术后引流量[Day 1: (248±123) mL vs (350±213) mL; Day 2: (288±189) mL vs (338±189) mL]比较，机器人组均少于腔镜组（P < 0.05）；术后带管时间[(10±5) d vs (11±8) d]及住院时间[(13±6) d vs (14±9) d]两组患者无明显差异（P > 0.05）。机器人组与腔镜组的淋巴结清扫组数[（5±2）组vs（4±2）组]及淋巴清扫数量[（18±9）枚vs（11±8）枚]比较，机器人组均优于腔镜组（P < 0.05）。机器人组与腔镜组生存状况比较[1年生存率：97.3% vs 96%、3年生存率：89.8% vs 83.1%、5年生存率：87.5 % vs 70.3%，平均生存时间（month）：61 vs 59]，两组无统计学差异（P > 0.05）。无进展生存状况：机器人组与腔镜组比较[1年无进展生存率：93.7% vs 91.3%、3年无进展生存率：87.7% vs 68.4%、5年无进展生存率：87.7% vs 52.5%，平均无进展生存时间（month）：61 vs 50]，机器人组明显优于腔镜组（P < 0.05）。单因素分析显示，淋巴结清扫数量是患者生存状况的影响因子；肿瘤直径、手术方式、淋巴结清扫组数、淋巴结清扫数量为患者无进展生存状况的影响因子。多因素分析显示生存状况无独立影响因子，肿瘤直径及手术方式为无进展生存状况的独立影响因子。结论达芬奇机器人Ⅰ期非小细胞肺癌患者术后生存状况与腔镜手术无差异，但无进展生存状况优于腔镜手术；达芬奇机器人手术淋巴结清扫更彻底，同时术中出血量更少。

Solitary fibrous tumors of the pleura: A single center experience at National Cancer Center, China.

BackgroundThis study explored the clinicopathological features, predictive factors of malignancy, effectiveness of video assisted thoracic surgery (VATS), and prognosis of solitary fibrous tumor of the pleura (SFTP).MethodsA single‐center retrospective study of the data of 82 patients with SFTP who were surgically treated in our department between January 2003 and December 2015 was conducted.ResultsA total of 82 SFTPs (70 benign, 12 malignant) were included and all patients underwent complete en bloc resection. SFTPs originated from the visceral pleura in 47 (57%) and the parietal pleura in 35 (43%) patients. In our cohort, malignant tumors were often symptomatically large, and the patients with malignant SFTPs (mSFTPs) often had a family history of neoplasms. Patients in the VATS group (n = 22) had tumors with significantly smaller diameters, required a shorter surgical duration and shorter hospital stay, and experienced less intraoperative blood loss and less postoperative chest tube drainage compared to the thoracotomy group (n = 60). No tumor recurrence was found in benign SFTP (bSFTP) patients. The long term survival and disease‐free survival rates of mSFTP patients were 76% and 53%, respectively.ConclusionLarger tumor diameter and a family history of neoplasm may be predictive factors for mSFTP; however, this conclusion needs to be verified in large cohort. VATS is safe and reliable for treating selected SFTP patients. Local recurrence is associated with mSFTP patient death, thus close follow‐up of such patients is crucial.

The feasibility and efficacy of two micro-portal video-assisted thoracic surgery in pulmonary lobectomy for lung cancer.

Conventional three-port video-assisted thoracic surgery (VATS) is well established internationally. Meanwhile, uniportal VATS technique has been become more and more popular in the past two decades. However, both methods have their merits and drawbacks. The purpose of this paper is to compare the surgical outcome of patients with lung cancer between traditional three-port VATS and our new two micro-portal VATS technique in an attempt to validate the safety, feasibility and efficacy of the latter procedure. We retrospectively analyzed the perioperative data of two hundred and eight patients with primary lung cancer who underwent successful VATS lobectomy between September 2016 and December 2017 at our unit. Comparing to conventional three-port VATS group, the numeral analogue scale (NAS) pain scores were significantly lower in the two micro-portal VATS group. There were no surgery related mortality and no significant differences in operative time, blood loss, number of lymph nodes dissected, chest tube duration, length of stay or postoperative complications between the two group. The two micro-portal VATS procedure is a safe and effective strategy for patients with lung cancer, which is associated with decreased surgical trauma and less postoperative pain. This emerging technology may benefit patients by enhancing comfort during their postoperative hospitalization.

Robotic Versus Video-Assisted Thoracoscopic Surgery Pulmonary Segmentectomy: A Cost Analysis.

Pulmonary segmentectomy using robotic assistance is often perceived as being more expensive than segmentectomy using video-assisted thoracic surgery. The robotic technique allows for meticulous dissection during segmentectomy, potentially leading to fewer parenchymal injuries, fewer air leaks, and shorter length of stay. This study compared pulmonary segmentectomy costs using video-assisted thoracic surgery versus robotic with manual staplers versus robotic with robotic staplers. Retrospective analyses were performed evaluating our early experience with robotic pulmonary segmentectomy for 30 months compared with the video-assisted thoracic surgery approach. All 50 anatomical segmentectomies performed since introduction of robotic technique in the practice were included. Twenty-eight procedures were robotic-assisted and 22 were video-assisted thoracic surgery. Procedure-specific evaluation of direct costs was performed, including cost of robotic instruments, staplers, and average length of stay in the hospital. The mean ± SD age was 70 ± 10 years (range = 43-91 years). There were 12 males in the robotic group and eight in the video-assisted thoracic surgery group (P = 0.642). The mean age was 69 years in the robotic group and 71 years in the video-assisted thoracic surgery group (P = 0.367). The median length of stay was 2 (2-4) days in the robotic group (range = 1-9) and 4 (2-5) days in the video-assisted thoracic surgery group (range = 1-20, P = 0.089). The cost of robotic segmentectomy with manual staplers was less than that with robotic staplers. Both robotic techniques cost less than video-assisted thoracic surgery. In this small series, cost and outcomes in our early experience with robotic-assisted segmentectomy were comparable with our video-assisted thoracic surgery approach with trends toward shorter length of stay and fewer complications. Larger series are needed to validate these results.

Video-assisted thoracic surgery is an optimal alternative to conventional thoracotomy for reoperations for ipsilateral pulmonary lesions.

BackgroundIpsilateral pulmonary reoperation is empirically considered a contraindication of video‐assisted thoracic surgery (VATS) because of intrapleural adhesion and the destruction of anatomical structures caused by previous surgery. The purpose of this study was to present our experience of the use of VATS for ipsilateral reoperations.MethodsThe medical records of patients who underwent VATS reoperation or re‐thoracotomy between January 2006 and March 2017 were retrospectively reviewed. Data were compared to assess the feasibility and safety of VATS for ipsilateral reoperations.ResultsThe study enrolled 64 patients, including 36 patients who underwent attempted ipsilateral VATS reoperations (VATS group) and 28 who underwent conventional re‐thoracotomy as a control with clinicopathological characteristics similar to those in the VATS group. Intrapleural severe adhesions were detected in 28 (77.8%) and 22 (78.6%) patients in the VATS and re‐thoracotomy groups, respectively (P = 0.906), and their dissection required a longer period in the VATS group (P = 0.014). VATS reoperations were converted to re‐thoracotomy or video‐assisted mini re‐thoracotomy in three patients because of bleeding or difficulty in dissecting hilar structures. There were no significant differences in resection methods, time to reoperation, intraoperative blood loss, or drainage time between the two groups. However, patients in the VATS group had a shorter hospital stay (P < 0.01) and fewer complications (P = 0.042).ConclusionVATS is an optimal alternative to re‐thoracotomy for ipsilateral pulmonary lesions, regardless of intrapleural adhesions and the destruction of anatomical structures caused by former operations in selected patients.

Surgical wound-site inflammation: video-assisted thoracic surgery versus thoracotomy.

Mechanical trauma occurring during pulmonary resection through both video-assisted thoracic surgery (VATS) or thoracotomy causes profound alterations in cytokines and the cellular network. The aim of this study was to analyse biological changes occurring in both the microenvironment (wound site) and macroenvironment (systemic circulation) following pulmonary lobectomy via the VATS or thoracotomic approach. From October 2016 to July 2017, 30 patients with clinical Stage I lung cancer were recruited. In 12 cases (the VATS group), surgery was performed through a video-assisted thoracoscopic approach and in 15 cases (the thoracotomy group) through a muscle-sparing minithoracotomy. Following the skin incision, the wound was irrigated with a saline solution (20 ml) and then collected. After the pulmonary resection, the surgical incision was re-irrigated. The number of polymorphonuclears, granulocytes and lymphocytes in the fluids was determined by the fluorescence activated cell sorting (FACS) analysis. Cytokine profiles of interleukin (IL)-6, tumour necrosis factor (TNF)-α, IL-1 and IL-8 from sera and fluids were detected by the enzyme linked immunosorbent assay (ELISA) assay. Functional results were evaluated through spirometry, and pain was assessed using the visual analogue scale. In the postoperative fluids of the VATS group, fewer polymorphonuclears were seen compared to the thoracotomy group (P = 0.001), as well as a decreased percentage of granulocytes (P = 0.01) and a parallel increased lymphocytes fraction (P = 0.001). Only the systemic IL-1β levels were significantly lower in postoperative sera of the VATS group (P = 0.038). No differences were observed regarding other cytokines. The local microenvironment during VATS differs from that of thoracotomy by not producing the same inflammatory phenotype. The clinical efficacy of a less invasive surgical approach is confirmed by a reduced inflammation of the systemic and local districts.

Short-term and long-term survival in sleeve lobectomy by video-assisted thoracic surgery versus thoracotomy basing on the propensity score matching

Objective: To evaluate the safety and efficacy of patients with centrally located lung cancer in sleeve lobectomy by video-assisted thoracic surgery (VATS). Methods: A retrospective analysis was performed on consecutive patients with centrally located lung cancer who underwent sleeve lobectomy admitted in the Affiliated Hospital of Qingdao University from January 2010 to September 2014. Propensity score matching analysis was performed to compare patients for thoracoscopic surgery and open surgery. Twenty-one pairs (42 cases) patients were included for analysis. The t-test, χ(2) test or Fisher's exact probabilities was adopted, if appropriate, to compare demographics and outcomes between the 2 groups. The Kaplan-Meier method and the Log-rank test were used for the distributions of disease free survival (DFS) and overall survival (OS) and their comparisons. Results: After propensity score-matched analysis, the VATS group had a longer operative time ((296.9±73.6) minutes vs. (218.1±59.2) minutes, t=3.82, P=0.00), but shorter postoperative drainage time ((3.3±1.5) days vs. (2.0±3.0) days, t=-0.93, P=0.01) and hospitalization time((6.7±2.8) days vs. (12.1±8.7)days, t=-1.72, P=0.01) than that of the thoracotomy group. Perioperative complications, 1-year and 3-year disease-free and overall survival rates were not statistically different between the two groups. Conclusion: For suitable patients, sleeve lobectomy by VATS is an acceptable safe and effective surgical procedure for patients with central lung cancer.

Enhanced recovery after thoracic surgery: patient information and care-plans.

Many studies have confirmed that the implementation of enhanced recovery after surgery (ERAS) protocols has the advantages of reducing the potential complications after thoracic surgery and the length of hospital stay. The ERAS program involves a multidisciplinary team, aimed at integrating evidence-based knowledge into clinical practice in order to reduce the patient's stress response to the surgical procedure and improve the response to stress, guaranteeing a combination of better outcomes and cost savings. All this would not be possible without the improvement of minimally invasive surgical techniques, progression of anesthesia, pain control, and careful patient preparation. In this setting, a preoperative personal counselling may play a key role to reduce stress, fear or anxiety and improve the morbidity of patients, enabling them to achieve functional and psychological compensatory mechanisms more quickly. Preoperative patient counselling, performed using verbal, written or multimedia materials, is crucial in order to achieve the goal of the ERAS project: making the patient a potentially active participant and the main character of his recovery, able to positively impact himself throughout the surgical and healing process. This report is aimed at evaluating patient information and care-plans in thoracic surgery, reviewing the available evidence on ERAS pathways, and demonstrating our ideal program as discussed and shared among the Italian Thoracic Surgery Units accredited in the video-assisted thoracic surgery (VATS) group.

Enhanced recovery pathways in thoracic surgery from Italian VATS Group: preoperative optimisation

Preoperative patient optimisation is a key point of enhanced recovery after thoracic surgery pathways. This could be particularly advantageous when considering video-assisted thoracic surgery (VATS) lobectomy, because reduced trauma related to minimally invasive techniques is one of the main factors favouring improved postoperative outcome. Main specific interventions for clinical optimisation before major lung resection include assessment and treatment of comorbidities, minimizing preoperative hospitalization, optimisation of pharmacological prophylaxis (antibiotic and thromboembolic) and minimizing preoperative fasting. Literature data and clinical evidences in this setting are reported and discussed.

Robotic surgery, video-assisted thoracic surgery, and open surgery for early stage lung cancer: comparison of costs and outcomes at a single institute.

Robotic surgery is increasingly used to resect lung cancer. However costs are high. We compared costs and outcomes for robotic surgery, video-assisted thoracic surgery (VATS), and open surgery, to treat non-small cell lung cancer (NSCLC). We retrospectively assessed 103 consecutive patients given lobectomy or segmentectomy for clinical stage I or II NSCLC. Three surgeons could choose VATS or open, the fourth could choose between all three techniques. Between-group differences were assessed by Fisher's exact, two-way analysis of variance (ANOVA), and Wilcoxon-Mann-Whitney test. P values <0.05 were considered significant. Twenty-three patients were treated by robot, 41 by VATS, and 39 by open surgery. Age, physical status, pulmonary function, comorbidities, stage, and perioperative complications did not differ between the groups. Pathological tumor size was greater in the open than VATS and robotic groups (P=0.025). Duration of surgery was 150, 191 and 116 minutes, by robotic, VATS and open approaches, respectively (P<0.001). Significantly more lymph node stations were removed (P<0.001), and median length of stay was shorter (4, 5 and 6 days, respectively; P<0.001) in the robotic than VATS and open groups. Estimated costs were 82%, 68% and 69%, respectively, of the regional health service reimbursement for robotic, VATS and open approaches. Robotic surgery for early lung cancer was associated with shorter stay and more extensive lymph node dissection than VATS and open surgery. Duration of surgery was shorter for robotic than VATS. Although the cost of robotic thoracic surgery is high, the hospital makes a profit.