Video-assisted Thoracic Surgical Lobectomy Research Articles

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.

Erector Spinae Plane Block compared to Paravertebral Block in the post-operative pain management of patients undergoing elective Video-Assisted Thoracic Surgical lobectomy for lung cancer: a randomized, non-inferiority clinical trial protocol.

Background and aim: Erector spinae plane (ESP) block is a regional anesthesia technique recently described, that has gained growing interest because of its relative safety, versatility and simplicity, when compared to other approaches, including paravertebral block (PVB). In the context of thoracic surgery, clinical trials are needed to evaluate the potential efficacy of this new technique. This clinical trial aims to test the non-inferiority of ESP block compared to PVB, in patients with early-stage lung cancer admitted to a tertiary referral center for elective pulmonary lobectomy, under video-assisted thoracic surgery (VATS). Design: Randomized, controlled, single-blinded, non-inferiority clinical trial. Participants: Patients aging between 18 and 85 years old, diagnosed of early-stage non-small cell lung cancer, and admitted for elective VATS lobectomy. Measurements and procedures: All participants will be blinded to the intervention. After undergoing general anesthesia, they will receive either ESP block or PVB, according to their randomized allocation. The primary outcome will be pain intensity at 30 minutes after the operation, which will be measured by an 11-point (0 to 10) Visual Analogue Scale (VAS). Secondary outcomes will include VAS score at 30 min and at 6, 12 and 24 hours after arrival to the recovery area, morphine consumption at 24 hours, time of performance of the block, and complications related to the procedure. Ethical aspects: For the development of this protocol, all ethical principles outlined in the last version of the Declaration of Helsinki (Fortaleza, Brazil, 2013) have been followed. Approval from local ethical committee and written informed consent from all participants will be obtained. Keywords: Thoracic surgery video-assisted, non-small-cell lung carcinoma, anesthesia recovery period, pain management. Abbreviations: ANOVA Analysis of Variance, DMC Data Monitoring Committee, ESP Erector Spinae Plane, MAR Missing At Random, MCAR Missing Completely At random, PVB Paravertebral Block, PCA Patient-controlled Analgesia, TEA Thoracic Epidural Analgesia, VAS Visual Analogue Scale, VATS Video-Assisted Thoracic Surgery.

Transcutaneous Electrical Acupoint Stimulation Improves Immunological Function During the Perioperative Period in Patients With Non-Small Cell Lung Cancer Undergoing Video-Assisted Thoracic Surgical Lobectomy.

The immunological function of patients with malignant tumors may be suppressed during the perioperative period. However, details on the effects of transcutaneous electrical acupoint stimulation (TEAS) on immunological function are relatively lacking. We designed this study to examine the effects of TEAS on the immunological function of patients with non-small cell lung cancer (NSCLC) during the perioperative period. Participants (n = 144) were enrolled and randomly assigned into group TEAS or group sham TEAS. TEAS on bilateral Feishu (BL13), Hegu (L14), and Zusanli (ST36) was performed continuously throughout the procedure. The primary outcome was the quantities of natural killer (NK) cells at 30 minutes before induction (T0), 5 minutes after intubation (T1), at the beginning of the operation (T2), at the beginning of the lobectomy (T3), at the beginning of the lymphadenectomy (T4), and immediately after extubation (T5). The secondary outcomes were the serum levels of tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6) at T0 to T5, the mean arterial pressure (MAP) and heart rate (HR), the intraoperative consumption of propofol and remifentanil, the incidence of hypoxemia, postoperative nausea and vomiting (PONV), and the length of hospital stay. The quantities of NK cells were decreased in group sham TEAS after intubation compared to that in group TEAS, while the quantities of NK cells in group TEAS were similar at T0 to T5. Meanwhile, the quantities of NK cells in group sham TEAS at T1 (P = .012), T2 (P < .001), T3 (P = .027), T4 (P = .045), and T5 (P = .021) were lower than those in group TEAS. In group TEAS, the serum levels of TNF-α were lower at T1 to T5, while the levels of IL-6 were lower at T2 to T5. Furthermore, the intraoperative MAP and HR were more stable, the total propofol and remifentanil consumptions were lower, and the length of hospital stay was shorter than those in group sham TEAS. The application of TEAS can effectively reverse the decrease in NK cells, decrease the serum levels of TNF-α and IL-6, maintain hemodynamic stability during the perioperative period, decrease the consumption of propofol and remifentanil, and shorten the length of the hospital stay.

Video-Assisted Thoracic Surgical Right Upper Lobectomy with Bronchus-First and Simultaneous Vessel Stapling Technique.

A method of video-assisted thoracic surgical (VATS) right upper lobectomy with bronchus-first and simultaneous vessel stapling will be introduced. In this study, all cases underwent two-port VATS as follows: first, the right upper lobe bronchus was identified and stapled; then, all right upper lobe vessels were stapled simultaneously. This method was performed in 50 cases. There was no surgical mortality, hemorrhage, vascular injuries, or conversion. This technique can reduce wound size and operative time and make the operation safer and easier to accomplish.

Video-Assisted Thoracic Surgical Lobectomy for Lung Cancer: Description of a Learning Curve.

Video-assisted thoracic surgical (VATS) lobectomy is gaining popularity in the treatment of lung cancer. The aim of this study is to investigate the learning curve of VATS lobectomy by using multidimensional methods and to compare the learning curve groups with respect to perioperative clinical outcomes. We retrospectively reviewed a prospective database to identify 67 consecutive patients who underwent VATS lobectomy for lung cancer by a single surgeon. The learning curve was analyzed by using moving average and the cumulative sum (CUSUM) method. With the moving average and CUSUM analyses for the operation time, patients were stratified into two groups, with chronological order defining early and late experiences. Perioperative clinical outcomes were compared between the two learning curve groups. According to the moving average method, the peak point for operation time occurred at the 26th case. The CUSUM method also showed the operation time peak point at the 26th case. When results were compared between early- and late-experience periods, the operation time, duration of chest drainage, and postoperative hospital stay were significantly longer in the early-experience group (cases 1 to 26). The intraoperative estimated blood loss was significantly less in the late-experience group (cases 27 to 67). CUSUM charts showed a decreasing duration of chest drainage after the 36th case and shortening postoperative hospital stay after the 37th case. Multidimensional statistical analyses suggested that the learning curve for VATS lobectomy for lung cancer required ∼26 cases. Favorable intraoperative and postoperative care parameters for VATS lobectomy were observed in the late-experience group.

Robotic Lobectomy: Left Lower Lobectomy by Surgery

According to National Comprehensive Cancer Network guidelines concerning non–small cell lung cancer, robotic lobectomy is considered an advisable oncologic procedure for patients with lung cancer, with no anatomic or surgical contraindications. At present, da Vinci is the only available robotic system (Intuitive Surgical, Inc., Sunnyvale, CA), with 2 platforms (da Vinci SI and da Vinci XI) requiring different port-mapping and cart positioning. Robotic left lower lobectomy can be considered one of the most technically simple of all lobectomies. We describe our endoscopic technique, with 4 surgical ports, using CO2 insufflation.

Effects of transcutaneous electrical acupoint stimulation at different frequencies on perioperative anesthetic dosage, recovery, complications, and prognosis in video-assisted thoracic surgical lobectomy: a randomized, double-blinded, placebo-controlled trial.

Transcutaneous electrical acupoint stimulation (TEAS), a non-invasive and non-pharmacological adjunctive intervention for perioperative analgesia, may also reduce the incidence of postoperative pulmonary complications. The effect of TEAS on video-assisted thoracic surgical (VATS) patients is still unknown, however. The purpose of this study was to investigate the effects of TEAS of different frequency on perioperative anesthetic dosage, recovery, complications, and prognosis for patients undergoing VATS lobectomy. Eighty VATS lobectomy patients with no previous experience of TEAS or acupuncture were randomly assigned to four groups: control (con), 2/100, 2, and 100Hz. The last three experimental groups received TEAS at the indicated frequencies for 30min before induction, during the operation, and for another 30min 24 and 48h after surgery. 2/100Hz is a type of alternating frequency which goes between 2 and 100Hz every 3s. TEAS was administered over acupoints Neiguan, Hegu, Lieque, and Quchi on the sick lateral. Electrodes were applied to the patients in the control group, but no TEAS was used. Anesthetic dosage, blood gas analysis results, lung function indexes FEV1 and FVC, post-anesthesia care unit (PACU) status, postoperative complications, and quality of life scores were recorded and analyzed statistically. Intraoperative opioid consumption was lowest in the 2/100Hz group, with statistical significance (con, P≤0.001; 2Hz, P≤0.001; 100Hz, P=0.026). Compared with preoperative FEV1 and FVC, postoperative FEV1 and FVC were significantly lower in all groups; during one-lung ventilation, arterial oxygen partial pressure (PaO2) decreased more slowly in the 2/100Hz group than in the con group (P=0.042). Moreover, in the 2/100Hz group extubation time was shorter (P=0.038), visual analgesia scale score lower (P=0.047), and duration of PACU stay shorter (P=0.043) than in the con group. In the 100Hz group incidence of postoperative nausea and vomiting (PONV) was lower than the con group (P=0.044). In all groups mean postoperative physical component scores were significantly lower than mean preoperative scores. TEAS is a safe noninvasive adjunctive intervention for anesthesia management among patients undergoing VATS lobectomy. TEAS at 2/100Hz can reduce intraoperative opioid dosage and slow the decrease of PaO2 during one-lung ventilation. It can also effectively reduce pain score, extubation time, and PACU stay immediately after surgery. Further, 100Hz TEAS can reduce PONV morbidity.

A comparative cost analysis study of lobectomy performed via video-assisted thoracic surgery versus thoracotomy in Turkey.

IntroductionCost analysis studies performed in western countries report that the overall cost of lobectomies performed via video-assisted thoracic surgery is similar to or less than those performed via thoracotomy. The situation may be different in a developing country.AimWe evaluated the cost differences of these two surgical methods.Material and methodsWe retrospectively reviewed the hospital records of 81 patients who underwent lobectomy either via video-assisted thoracic surgery (n = 32) or via thoracotomy (n = 49). Patient characteristics, pathology, perioperative complications, additional surgical procedures, length of hospital and intensive care unit stay, and outcomes of both groups were recorded. Detailed cost data for medications, anesthesia, laboratory, surgical instruments, disposable instruments and surgery cost itself were also documented. Statistical analyses were performed to compare the groups.ResultsThe two groups were homogeneous in regard to age, sex, pathology and perioperative morbidity. The mean duration of hospitalization in the video-assisted thoracic surgery group was significantly shorter than that of the thoracotomy group (7.78 ±5.11 days vs. 10.65 ±6.57 days, p < 0.05). Overall final mean cost in the video-assisted thoracic surgery group was significantly higher than that of the thoracotomy group ($3970 ±1873 vs. $3083 ±1013, p = 0.002). This significant difference relies mostly on the cost of disposable surgical instruments, which were used much more in the video-assisted thoracic surgery group than the thoracotomy group ($2252 ±1856 vs. $427 ±47, p < 0.05).ConclusionsIn contrast to western countries, a video-assisted thoracic surgical lobectomy may cost more than a lobectomy via thoracotomy in a developing country. More expensive disposable surgical instruments and cheaper hospital stay charges lead to higher overall costs in video-assisted thoracic surgical lobectomy patients.

Transitioning from video-assisted thoracic surgical lobectomy to robotics for lung cancer: Are there outcomes advantages?

To determine if there are advantages to transitioning to robotics by a surgeon who is already proficient in performing video-assisted thoracic surgical (VATS) lobectomy. A single surgeon proficient in VATS lobectomy initiated a robotic lobectomy program, and a retrospective review was conducted of his patients undergoing minimally invasive lobectomy (robotics or VATS) for lung cancer between 2011 and 2012. Data collected included patient/tumor characteristics, morbidity, mortality, operative times, and length of hospital stay. Over a 24-month period, a total of 69 patients underwent minimally invasive lobectomy (35 robotic, 34 VATS). Patients in each group were similar in age and clinical stage. Robotic upper lobectomy operative times were longer than VATS (172 vs 134 minutes; P = .001), with no significant difference in lower lobectomies noted (140 vs 123 minutes; P = .1). Median length of stay was 3 days in both groups, and the median number of lymph nodes harvested was 18 (robotic) versus 16 (VATS; P = .42). Morbidity and mortality for robotic versus VATS were 11% versus 18% (P = .46) and 0% versus 3% (P = .49), respectively. There does not seem to be a significant advantage for an established VATS lobectomy surgeon to transition to robotics based on clinical outcomes. The learning curve for robotic upper lobectomies seems to be more significant than that for lower lobectomies.

Comparing robot-assisted thoracic surgical lobectomy with conventional video-assisted thoracic surgical lobectomy and wedge resection: Results from a multihospital database (Premier)

Video-assisted thoracic surgical (VATS) lobectomies and wedge resections result in less morbidity and shorter length of stay than resections via thoracotomy. The impact of robot-assisted thoracic surgical (RATS) lobectomy on clinical and economic outcomes has not been examined. This study compared hospital costs and clinical outcomes for VATS lobectomies and wedge resections versus RATS. Using the Premier hospital database, patients aged ≥18 years with a record of thoracoscopic lobectomy, segmental resection, or excision of a lesion or tissue from the lung between 2009 and 2011 were identified. Procedures using robotic technology were identified if 1 of 2 conditions were met: (1) a robotic International Classification of Diseases, Ninth Revision procedure code or (2) the text fields in the hospital record indicated that the robot was used. Using a propensity score and based on severity and comorbidities, certain demographics and hospital characteristics were matched. The association between VATS or RATS and adverse events, hospital costs, surgery time, and length of stay was examined. Of 15,502 patient records analyzed, 96% (n=14,837) were performed without robotic assistance. Using robotic assistance was associated with higher average hospital costs per patient. The average cost of inpatient procedures with RATS was $25,040.70 versus $20,476.60 for VATS (P=.0001) for lobectomies and $19,592.40 versus $16,600.10 (P=.0001) for wedge resections, respectively. Inpatient operating times were longer for RATS lobectomy than VATS lobectomy (4.49 hours vs 4.23 hours; P=.0959) and wedge resection (3.26 vs 2.86 hours; P=.0003). Length of stay was similar with no differences in adverse events. RATS lobectomy and wedge resection seem to have higher hospital costs and longer operating times, without any differences in adverse events.

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A video-assisted thoracic surgical lobectomy for a lung tumour with a rare anomalous pulmonary artery

A detailed knowledge of anomalies of the anatomical course of the pulmonary vessels is extremely important for video-assisted thoracic surgery (VATS). Inadvertent vascular ligation and dissection are catastrophic for patients undergoing lobectomy. We describe a case with a rare anomaly of the left pulmonary artery and highlight the importance of identifying the courses of pulmonary vessels for VATS lobectomy.

Disparities in Access to Video-Assisted Thoracic Surgical Lobectomy for Treatment of Early-Stage Lung Cancer

Video-assisted thoracic surgical (VATS) lobectomy was originally described in 1992 and has slowly gained increasing acceptance. This study documents current utilization and outcomes for VATS versus open lobectomy in three Mid-Atlantic states. Inpatient discharge claims data were queried for all lobectomies performed for cancer in the Mid-Atlantic United States (New Jersey, New York, and Pennsylvania) between October 2007 and December 2008. Associations between sociodemographic factors and likelihood of undergoing VATS were tested with multiple logistic regressions. Outcomes were compared using two-sample t tests. There were 5489 lobectomies included. Forty-seven percent of patients were men, and 62% were ≥65 years old. Thirty-two percent (1741 of 5489) were VATS lobectomies. Men were less likely to undergo VATS (odds ratio 0.86, P=.004); those ≥65 years old were more likely to undergo VATS (odds ratio 1.34, P=.009). Uninsured patients underwent VATS less often (odds ratio 0.46, P=.01). Patients from rural areas were less likely to undergo VATS (odds ratio 0.67, P=.001), although travel distances for both groups were similar. A total of 44% of these hospitals (125 of 284) performed only open lobectomies. Patients without private insurance or Medicare were less likely to undergo a VATS lobectomy (P=0.01). In general, the likelihood of VATS lobectomy increased as hospital lobectomy volume increased. VATS patients had a shorter median length of stay (5 versus 6 days, P<.001) and a higher rate of discharge to home (92.5% versus 89.5%, P<.001). Mean total hospital costs were less for VATS patients ($49,948 versus $56,280, P<.001). In-hospital mortality was less for VATS patients (1.2% versus 2.1%, P=.013). For the period studied, patients in rural areas, in low-volume hospitals, who had Medicaid, or with lower median incomes underwent VATS lobectomy less often.

PSU11 Comparing Robot-Assisted to Conventional Video-Assisted Thoracic Surgical (VATS)Lobectomy and Wedge Resection: Results from a Multi-Hospital (Premier) Database

PSU11 Comparing Robot-Assisted to Conventional Video-Assisted Thoracic Surgical (VATS)Lobectomy and Wedge Resection: Results from a Multi-Hospital (Premier) Database

A new technique for partial removal of the pulmonary artery in video-assisted thoracic surgical lobectomy

A new technique for partial removal of the pulmonary artery in video-assisted thoracic surgical lobectomy

Off-the-job training for VATS employing anatomically correct lung models

We evaluated our simulated major lung resection employing anatomically correct lung models as "off-the-job training" for video-assisted thoracic surgery trainees. A total of 76 surgeons voluntarily participated in our study. They performed video-assisted thoracic surgical lobectomy employing anatomically correct lung models, which are made of sponges so that vessels and bronchi can be cut using usual surgical techniques with typical forceps. After the simulation surgery, participants answered questionnaires on a visual analogue scale, in terms of their level of interest and the reality of our training method as off-the-job training for trainees. We considered that the closer a score was to 10, the more useful our method would be for training new surgeons. Regarding the appeal or level of interest in this simulation surgery, the mean score was 8.3 of 10, and regarding reality, it was 7.0. The participants could feel some of the real sensations of the surgery and seemed to be satisfied to perform the simulation lobectomy. Our training method is considered to be suitable as an appropriate type of surgical off-the-job training.

A comparison of perioperative outcomes of Video-Assisted Thoracic Surgical (VATS) Lobectomy with open thoracotomy and lobectomy: Results of an analysis using propensity score based weighting

BackgroundRandomized trials comparing VATS lobectomy to open lobectomy are of small size. We analyzed a case-control series using propensity score-weighting to adjust for important covariates in order to compare the clinical outcomes of the two techniques.MethodsWe compared patients undergoing lobectomy for clinical stage I lung cancer (NSCLC) by either VATS or open (THOR) methods. Inverse probability of treatment weighted estimators, with weights derived from propensity scores, were used to adjust cohorts for determinants of perioperative morbidity and mortality including age, gender, preop FEV1, ASA class, and Charlson Comorbidity Index (CCI). Bootstrap methods provided standard errors. Endpoints were postoperative stay (LOS), chest tube duration, complications, and lymph node retrieval.ResultsWe analyzed 136 consecutive lobectomy patients. Operative mortality was 1/62 (1.6%) for THOR and 1/74 (1.4%) for VATS, P = 1.00. 5/74 (6.7%) VATS were converted to open procedures. Adjusted median LOS was 7 days (THOR) versus 4 days (VATS), P < 0.0001, HR = 0.33. Adjusted median chest tube duration (days) was 5 (THOR) versus 3 (VATS), P < 0.0001, HR = 0.42. Complication rates were 39% (THOR) versus 34% (VATS), P = 0.61. Adjusted mean number of lymph nodes dissected per patient was 18.1 (THOR) versus 14.8 (VATS), p = 0.17.ConclusionsAfter balancing covariates that affect morbidity, mortality and LOS in this case-control series using propensity-weighting, the results confirm that VATS lobectomy is associated with a statistically significant shorter LOS, similar mortality and complication rates and similar rates of lymph node removal in patients with clinical stage I NSCLC.

Is Intravenous Patient Controlled Analgesia Enough for Pain Control in Patients Who Underwent Thoracoscopy?

This prospective randomized study was conducted to evaluate the efficacy of two common analgesic techniques, thoracic epidural patient-controlled analgesia (Epidural PCA), and intravenous patient-controlled analgesia (IV PCA), in patients undergoing lobectomy by the video-assisted thoracic surgical (VATS) approach. Fifty-two patients scheduled for VATS lobectomy were randomly allocated into two groups: an Epidural PCA group receiving an epidural infusion of ropivacaine 0.2%+fentanyl 5 µg/mL combination at a rate of 4 mL/hr, and an IV PCA group receiving an intravenous infusion of ketorolac 0.2 mg/kg+fentanyl 15 µg/mL combination at a rate of 1 mL/hr. Pain scores were then recorded using the visual analogue scale at rest and during motion (VAS-R and VAS-M, 0-10) for five days following surgery. In addition, we measured the daily morphine consumption, forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), satisfaction score, and the incidence of side effects. Thirty-seven patients out of 52 completed the study (18 in the Epidural PCA group, 19 in the IV PCA group). There were no differences in the pain scores, analgesic requirements, pulmonary function, satisfaction score, and the incidence of side effects between groups. This indicates that IV PCA and Epidural PCA are equally effective to control the postoperative pain after VATS lobectomy, which suggests that IV PCA may be used instead of Epidural PCA.

Novel Retractor for Lymph Node Dissection by Video-Assisted Thoracic Surgery

In nonrandomized studies, the video-assisted thoracic surgical (VATS) lobectomy seems to be a safe and effective procedure for treatment of lung cancer. However, there are some difficulties in VATS complete mediastinal lymph node dissection. The presence of the lymph node deep in the mediastinal space necessitates retraction of the surrounding organs. Therefore, we developed a retractor to create enough working space during the VATS procedure. To dissect lymph nodes, we use endoscopic bipolar forceps. These instruments are connected to a special electrosurgical generator to apply bipolar soft coagulation, which enables simultaneous dissection and sealing. Thus, "en bloc" lymph node dissection can be performed during the VATS procedure.

Robotic assistance for video-assisted thoracic surgical lobectomy: Technique and initial results

Robotic assistance for video-assisted thoracic surgical lobectomy: Technique and initial results