Video-assisted Thoracoscopic Surgery Pulmonary Resection Research Articles

Early Clinical Outcomes of Thoracoscopic Major Pulmonary Resection and Thymectomy Using Novel Articulating Endoscopic Forceps.

Video-assisted thoracoscopic surgery (VATS) is recognized as a safe and effective treatment modality for early-stage lung cancer and anterior mediastinal masses. Recently, novel articulating instruments have been developed and introduced to endoscopic surgery. Here, we share our early experiences with VATS major pulmonary resection and thymectomy performed using ArtiSential articulating instruments. At the Seoul Metropolitan Government-Seoul National University Boramae Medical Center, 500 patients underwent VATS pulmonary resection between July 2020 and April 2023, while 43 patients underwent VATS thymectomy between January 2020 and April 2023. After exclusion, 224 patients were enrolled for VATS major pulmonary resection, and 38 were enrolled for VATS thymectomy. ArtiSential forceps were utilized in 35 of the 224 patients undergoing pulmonary resection and in 12 of the 38 individuals undergoing thymectomy. Early clinical outcomes were retrospectively analyzed. No significant differences were observed in sex, age, surgical approach, operation time, histological diagnosis, or additional procedures between the patients who underwent surgery using novel articulating instruments and the group treated with conventional endoscopic instruments for both VATS major pulmonary resection and thymectomy. However, the use of the novel articulating endoscopic forceps was associated with a significantly larger number of dissected lymph nodes (p=0.028) and lower estimated blood loss (p=0.009) in VATS major pulmonary resection. Major pulmonary resection and thymectomy via VATS using ArtiSential forceps were found to be safe and effective, with early clinical outcomes comparable to established methods. Further research into long-term clinical outcomes and cost-effectiveness is warranted.

Ameliorated chest drain wound closure in patients undergoing uniportal thoracoscopic pulmonary resection.

Although uniportal video-assisted thoracoscopic surgery (VATS) has been performed for a wide array of thoracic diseases, unsightliness and poor wound healing often occur, particularly when a chest drain is placed postoperatively. Different chest drain wound closure (CWC) methods have been introduced with the benefits of cosmesis and patient satisfaction. We aimed to describe our improved CWC technique in this setting and assess its efficacy. A total of consecutive 334 patients undergoing uniportal VATS pulmonary resection with single chest drain placement were investigated from 2016 to 2021. The techniques for CWC were classified into the conventional method (35 patients, group A), continuous suture with removal-free stitches (122 patients, group B), and continuous suture with removal-free barbed suture plus topical skin adhesives (177 patients, group C). Perioperative data and complications related to CWC were analyzed. Group C had a significantly shorter operative time, postoperative hospital stay, and chest tube days than groups A and B (all p < 0.01). In terms of chest tube-related complications, there were no statistically significant differences in post-removal pneumothorax, subcutaneous emphysema, incisional effusion leakage, wound dehiscence, or infection. Overall, significant differences in scar scale scores were observed between the groups, where the ameliorated group C was superior to the conventional group A (p < 0.01). The improved CWC technique using continuous sutures with removal-free barbed sutures and topical skin adhesives is simple, safe, and effective. This may be a favorable CWC strategy when performing uniportal VATS, with enhanced patient satisfaction.

Comparison between costotransverse foramen block and thoracic paravertebral block for VATS pulmonary resection: A randomized noninferiority trial

Study objectiveThe present study assessed whether costotransverse foramen block (CTFB) is noninferior to thoracic paravertebral block (TPVB) for postoperative analgesia in video-assisted thoracoscopic surgery (VATS) pulmonary resection. DesignSingle-center, double-blinded, randomized, non-inferiority trial. SettingOperating room and intensive care unit or ward in a tertiary hospital. PatientsPatients aged 20 to 80 years with American Society of Anesthesiology physical status 1 to 3 scheduled for elective VATS pulmonary resection. InterventionsSixty patients were randomly allocated 1:1 to receive CTFB or TPVB using 15 mL aliquots of 0.5% ropivacaine at the T4–5 and T6–7 intercostal levels immediately after the induction of general anesthesia. MeasurementsThe primary outcome was the area under the curve (AUC) of numeric rating scale (NRS, 0 to 10) during 24 h postoperatively (noninferiority limit was 24; NRS 1 per hour). The secondary outcomes included postoperative opioid consumption, rescue analgesic use, postoperative nausea and vomiting, pulmonary function, dermatomal spread of the blockade, and quality of recovery. Main resultsForty-seven patients were included for final analysis. The difference between the mean 24-h AUCs of NRS in the CTFB (34.25 ± 16.30, n = 24) and TPVB (39.52 ± 17.13, n = 23) groups was −5.27 (95% confidence interval [CI], −15.09 to 4.55), with the upper limit of 95% CI being far below the predefined noninferiority margin of 24. There was no significant difference in the dermatomal spread of the blockades between the groups, as both reached the upper and lower most levels of T3 and T7 (median). Additionally, there were no significant differences in other secondary outcomes between the two groups. ConclusionsThe analgesic effect of CTFB was noninferior to that of TPVB during 24 h postoperatively in VATS pulmonary resection. Moreover, CTFB may offer potential safety benefits by keeping the tip of the needle far from the pleura and vascular structure.

Chest tube-free video-assisted thoracoscopic surgery secured by quantitative air leak monitoring: a case series.

Although chest tube-omitted video-assisted thoracoscopic surgery (VATS) has been proven to be safe and efficacious, its universal application is precluded by a varying morbidity rate due to a lack of standardization. Since digital chest drainage has already shown improved accuracy and consistency in the management of postoperative air leak, we incorporated it in the strategy of intraoperative chest tube withdrawal, aiming to achieve better results. We collected the clinical data of 114 consecutive patients who underwent elective uniportal VATS pulmonary wedge resection at the Shanghai Pulmonary Hospital from May 2021 to February 2022. Their chest tubes were withdrawn intraoperatively after an air-tightness test facilitated by digital drainage: the end flow rate had to be kept ≤30 mL/min for >15 s at the setting of -8 cmH2O suctioning. The recordings and patterns of the air suctioning process were documented and analyzed as potential standards of chest tube withdrawal. The mean age of the patients was 49.7±11.7 years. The mean size of the nodules was 1.0±0.2 cm. The location of the nodules encompassed all lobes, and 90 (78.9%) patients received preoperative localization. The postoperative morbidity and mortality rates were 7.0% and 0%, respectively. Six patients had clinically overt pneumothorax and two patients had postoperative bleeding that required intervention. All of the patients recovered on conservative treatment except for one case of pneumothorax that required additional tube thoracostomy. The median length of postoperative stay was 2 days; and the median time of suctioning, peak flow rate, and end flow rate were 126 s, 210 mL/min, and 0 mL/min, respectively. The median numeric rating scale for pain was 1 on postoperative day (POD) 1 and 0 on the day of discharge. Chest tube-free VATS assisted by digital drainage is feasible with minimal morbidity. Its strength of quantitative air leak monitoring produces important measurements for the prediction of postoperative pneumothorax and future standardization of the procedure.

Intramuscular stimulation as a new modality to control postthoracotomy pain: A randomized clinical trial

ObjectivePostoperative pain after thoracic surgery primarily hinders patients’ mobility, decreasing the quality of life. To date, various modalities have been suggested to improve postoperative pain. However, pain alleviation still remains a challenge, resulting in continued reliance on opioids. To tackle this problem, this study introduces a needle electrical twitch obtaining intramuscular stimulation (NETOIMS) as a new effective treatment modality for postoperative pain after thoracoscopic surgery. MethodsThis randomized clinical trial analyzed patients receiving video-assisted thoracoscopic surgery pulmonary resection between March 2018 and June 2020 at a single institution. A total of 77 patients (NETOIMS, 36; intravenous patient-controlled analgesia, 41) were included. NETOIMS was conducted on the retracted intercostal muscle immediately following the main procedure, just before skin closure. Postoperative pain (numeric rating scale) and oral opioid morphine milligram equivalent were assessed daily until postoperative day 5. ResultsThe NETOIMS group had a significantly lower numeric rating scale score on postoperative day (POD) 0 (P < .01), POD2 (P < .001), POD4 (P < .001), and POD5 (P = .01). The predicted time to complete pain resolution was 6.15 days in the NETOIMS group and 20.7 days in the intravenous patient-controlled analgesia group. The oral opioid morphine milligram equivalent was significantly lower in the NETOIMS group on POD0 (P < .001) and POD1 (P < .001). ConclusionsNETOIMS appears to be an effective modality in alleviating postoperative pain after thoracoscopic surgery, thereby reducing the reliance on opioid use.

Management of Complications During Video-Assisted Thoracic Surgery Lung Resection and Lymph Node Dissection.

Intraoperative events can occur during video-assisted thoracoscopic surgery (VATS) lobectomy due to unfavorable surgical anatomy, such as dense adhesions or calcifications around the pulmonary arteries. Troubleshooting intraoperative complications is essential for performing safe and successful VATS pulmonary resection and lymph node dissection. If continuous bleeding occurs or VATS does not proceed despite all measures, conversion to open thoracotomy should not be delayed.

Effectiveness of scheduled intravenous acetaminophen in the postoperative pain management of video-assisted thoracic surgery.

The scheduled administration of intravenous acetaminophen (scheduled-IV-AcA) is one of the more effective multimodal analgesic approaches for postoperative pain in abdominal/orthopedic surgeries. However, there is little evidence concerning scheduled-IV-AcA after general thoracic surgery, especially when limited to video-assisted thoracoscopic surgery (VATS). We investigated the efficacy of scheduled-IV-AcA administration in patients after undergoing VATS. Ninety-nine patients who underwent VATS lobectomy or segmentectomy via an 8-cm access window and 1 camera port were retrospectively reviewed by categorizing them into groups either with scheduled-IV-AcA (Group AcA: n = 29) or without it (Group non-AcA: n = 70). Group AcA received 1g of IV-AcA every 6h from the end of the operation until the end of POD2. Postoperative pain was measured using a numeric rating scale (NRS) three times per day until discharge. NRS scores were significantly lower in Group AcA with motion (on POD1 to the first point of POD2) than in Group non-AcA. Group non-AcA was also more likely to use additional analgesics than Group AcA (39% vs. 17%, p = 0.058). Scheduled-IV-AcA administration is a safe and effective multimodal analgesic approach in patients undergoing VATS pulmonary resection via an 8-cm access window.

Patients\u2019 confidence in treatment decisions for early stage non-small cell lung cancer (NSCLC)

BackgroundIn early-stage Non-Small Cell Lung Cancer (NSCLC) patients, little is known about how to measure patient participation in Shared-Decision Making (SDM). We examined the psychometric properties and clinical acceptability of the Decision Self-Efficacy scale (DSE) in a cohort of patients undergoing to Stereotactic Ablative Radiotherapy (SABR) or Video-assisted Thoracoscopic Surgery (VATS) to capture patient involvement in treatment decisions.MethodsIn the context of a prospective longitudinal study (Life after Lung Cancer-LiLAC) involving 244 patients with early-stage NSCLC, 158 (64.7%) patients completed the DSE either on paper or electronically online prior to treatment with SABR or VATS pulmonary resection. DSE psychometric properties were examined using: principal components analysis of item properties and internal structure, and internal construct validity; we also performed a sensitivity analysis according to Eastern Cooperative Oncology Group Performance Status (ECOG PS), gender, age and treatment received (VATS or SABR) difference.ResultsExploratory factor analysis using polychoric correlations substantiated that the 11 item DSE is one scale accounting for 81% of the variance. We calculated a value of 0.96 for Cronbach’s alpha for the total DSE score.DSE scores did not differ by gender (p = 0.37), between the two treatment groups (p = 0.09) and between younger and older patients (p = 0.4). However, patients with an ECOG PS > 1 have a DSE mean of 73.8 (SD 26) compared to patients with a PS 0–1 who have a DSE mean of 85.8 (SD 20.3 p = 0.002).ConclusionFindings provide preliminary evidence for the reliability and validity of the DSE questionnaire in this population. However, future studies are warranted to identify the most appropriate SDM tool for clinical practice in the lung cancer treatment field.

Prognostic value of the advanced lung cancer inflammation index in early-stage non-small cell lung cancer patients undergoing video-assisted thoracoscopic pulmonary resection.

The aim of this study was to assess the prognostic value of the preoperative advanced lung cancer inflammation index (ALI) in early stage non-small lung cancer (NSCLC) patients who received videoassisted thoracoscopic surgery (VATS) pulmonary surgery as their only therapy. We retrospectively reviewed the medical records of patients who were diagnosed with earlystage NSCLC and received a VATS pulmonary resection from January 2014 to June 2016 in the Department of Thoracic Surgery, West China Hospital. A receiver operating characteristic (ROC) curve analysis was conducted to determine the optimal cut-off values, and patients were divided into low and high ALI groups. The Kaplan-Meier method and Cox proportional hazards model were used to evaluate potential predictors of overall survival (OS) and disease-free survival (DFS). A total of 292 patients were enrolled in our analysis. Then, 155 and 137 patients were assigned to the low ALI (ALI <50) and high (ALI >50) groups, respectively. The multivariate analyses revealed that preoperative ALI <50 was an independent prognostic factor for both OS [hazard ratio (HR) = 2.603, 95% confidence interval (95% CI): 1.128-6.006, P=0.025] and DFS (HR =2.372, 95% CI: 1.141-4.935, P=0.021), and patients with a low preoperative ALI had worse OS (P<0.001) and DFS (P<0.001) compared with those with a high preoperative ALI. A low preoperative ALI was significantly correlated with poor survival, and the ALI might serve as a promising marker of prognosis in early-stage NSCLC patients who received a VATS pulmonary resection as their only therapy.

Surgery performed at night by continuously working surgeons contributes to a higher incidence of intraoperative complications in video-assisted thoracoscopic pulmonary resection: a large monocentric retrospective study.

Our goal was to assess the influence of working hours and working at night on intraoperative complications on surgeons conducting video-assisted pulmonary resections. We identified all patients who underwent video-assisted thoracoscopic surgery (VATS) in Shanghai Chest Hospital from January 2015 to April 2017. Univariable and multivariable logistic analyses were used to analyse independent risk factors for intraoperative complications. A 1:4 propensity score matching analysis was conducted to verify those results. A total of 15767 patients who underwent VATS pulmonary resection were included in this study. Among them, 15280 patients (96.1%) were operated on during daytime working hours and 487 (3.1%) at night. A total of 203 (1.3%) intraoperative complications occurred. Vascular injury was the main cause of intraoperative complications, accounting for 92.1% (187/203). Multivariable logistic regression indicated that age [odds ratio (OR) = 1.68, 95% confidence interval (CI) 1.43-1.98; P < 0.001], gender (OR = 1.71, 95% CI 1.26-2.32; P = 0.001), surgical experience (OR = 2.07, 95% CI 1.56-2.75; P < 0.001), type of surgery (OR = 0.31, 95% CI 0.20-0.49; P < 0.001) and operative periods (OR = 2.69, 95% CI 1.61-4.86; P < 0.001) were independent predictors for intraoperative complications. The incidence of intraoperative complications during night-time surgery was significantly higher than that during daytime working hours. A 1:4 propensity score matching-based results verification showed that night-time surgery was still an independent risk factor after propensity score matching (OR = 2.76, 95% CI 1.47-5.15; P = 0.002). The incidence of intraoperative complications from VATS pulmonary resection performed during night hours was significantly higher than that performed during working hours. In the present labour environment, thoracic surgeons should avoid night-time surgery whenever possible.

Feasibility and surgical outcomes of video-assisted thoracoscopic pulmonary resection in patients with advanced-stage lung cancer after neoadjuvant chemoradiotherapy.

Video‐assisted thoracoscopic surgery (VATS) is regarded as the standard treatment for lung cancer. However, the feasibility and safety of VATS for lung cancer after neoadjuvant chemoradiotherapy (CRT) is unclear. This study evaluated the feasibility and safety of VATS in patients who had received neoadjuvant CRT.MethodsBetween January 2008 and December 2017, 85 patients who were administered neoadjuvant CRT and underwent anatomic lung resection were enrolled. Fifty‐nine patients underwent open thoracotomy and 26 patients underwent VATS. The clinical characteristics and perioperative outcomes were reviewed.ResultsIn six of the initial 32 patients who underwent VATS, the procedure was converted to thoracotomy. Adjacent structural invasion (33.9% vs. 11.5%; P = 0.037) and combined resection (16.9% vs. 0%; P = 0.025) were higher in the open group than in the VATS group. Surgical duration was higher in the open group than in the VATS group (203.86 ± 65.97 vs. 173.27 ± 59.87 minutes; P = 0.046). With regard to postoperative outcomes, the length of the hospital stay was longer in the open group compared to the VATS group (14.46 ± 16.94 vs. 8.62 ± 4.72 days; P = 0.017). There was no significant difference in the three‐year disease‐free survival (69.3% vs. 67.9%; P = 0.879) or overall survival rates (76.6% vs. 61.9%; P = 0.516).ConclusionIn selected patients, VATS pulmonary resection after neoadjuvant CRT showed results comparable to that of thoracotomy in terms of postoperative outcomes, operative morbidities, and survival rate.

Nonintubated Uniportal Video-Assisted Thoracoscopic Surgery: A Single-Center Experience.

BackgroundWe report our surgical technique for nonintubated uniportal video-assisted thoracoscopic surgery (VATS) pulmonary resection and early postoperative outcomes at a single center.MethodsBetween January and July 2017, 40 consecutive patients underwent nonintubated uniportal VATS pulmonary resection. Multilevel intercostal nerve block was performed using local anesthesia in all patients, and an intrathoracic vagal blockade was performed in 35 patients (87.5%).ResultsTwenty-nine procedures (72.5%) were performed in patients with lung cancer (21 lobectomies, 6 segmentectomies, and 2 wedge resections), and 11 (27.5%) in patients with pulmonary metastases, benign lung disease, or pleural disease. The mean anesthesia time was 166.8 minutes, and the mean operative duration was 125.9 minutes. The mean postoperative chest tube duration was 3.2 days, and the mean hospital stay was 5.8 days. There were 3 conversions (7.5%) to intubation due to intraoperative hypoxemia and 1 conversion (2.5%) to multiportal VATS due to injury of the segmental artery. There were 7 complications (17.5%), including 3 cases of prolonged air leak, 2 cases of chylothorax, 1 case of pleural effusion, and 1 case of pneumonia. There was no in-hospital mortality.ConclusionNonintubated uniportal VATS appears to be a feasible and valid surgical option, depending on the surgeon’s experience, for appropriately selected patients.

AB004. Choices of minimally invasive thoracic incisions: the experience from Shanghai Renji Hospital

: Numerous incisions are used in thoracic surgery. The change of thoracic incisions from thoracotomy, conventional multi-port video-assisted thoracoscopic surgery (VATS) to the recent uniportal VATS and subxiphoid surgery shows the evolution of minimally invasive thoracic surgical approach. The selection of the surgical incision is the responsibility of the surgeon who needs the best possible exposure to complete the proposed operation. Indeed, a poorly planned incision is likely to lead to a difficult and frustrating operation, increasing the chances of technical misadventures. Careful consideration of the goals of the operation and individual patient characteristics must be kept in mind before laying scalpel to skin. Nowadays, minimally invasive thoracic incisions become lesser and smaller. More and more surgeons are interesting in how to develop their incisions. Therefore, a clear understanding of the choices of incisions is important if one is to achieve maximum use of the incision. In this paper, we introduce our experience and some tips and tricks in choosing minimally invasive thoracic incisions. Currently, the minimally invasive thoracic incision must firstly be acceptable to the patient, who will have postoperative pain or may suffer from long-term muscular, neurologic, or even cosmetic disabilities. In order to achieve the aesthetic appearance of the incision and reduce the influence of postoperative quality of life, every thoracic surgeon must understand the direction of skeletal muscle in the chest wall and the distribution of intercostal nerve, so as to avoid the damage as possible. Meticulous surgical technique will minimize local wound problems (wound infection, hemorrhage of incision, implantation metastasis of incisions, lung herniation, etc.). We think appropriate minimally invasive thoracic incisions should facilitate the surgery with both surgical vision and technique maneuver. In the case of uniportal VATS pulmonary resection, for instance, the locations of incisions vary according to surgeon preference. Whereas, incisions must be accurately positioned to allow for the best possible exposure to the necessary area, and to facilitate technically challenging parts of the operation. The selected incision should not only meet the anatomy of the hilar structure, but also facilitate lymph node dissection. Moreover, preoperative imaging studies may always help direct the location of the incision. Indeed, the selection of the surgical incision also is based on the surgeon’s experience and familiarity with the exposure that a particular incision provides. Here, we firstly introduce the evolution of minimally invasive thoracic incisions at our department. Then, the characteristic of various incisions and our unique experience will be described. At last, we will discuss a few potential improvements of minimally invasive thoracic incisions and give a glimpse into the future.

AB007. Needlescopic-assisted uniportal thoracoscopic pulmonary anatomical resection

Background: Pulmonary anatomical resection can be standard treatment for small non-small cell lung cancer. Uniportal video-assisted thoracoscopic surgery (VATS) has recently showed favorable surgical outcomes, but remains technical demanding, especially in a complex procedure like anatomic segmentectomy. This manuscript demonstrates the surgical techniques for uniportal VATS pulmonary anatomical resection with the assistance of additional needlescopic instruments.

Is it still necessary to leave a chest tube after video-assisted pulmonary wedge resection?

The controversy whether or not leaving a chest tube in the pleural cavity after pulmonary resection has been under debate. A chest tube could negatively influence the postoperative course and diminish the possible benefits of video-assisted thoracoscopic surgery (VATS). The aim of this study was to evaluate our protocol of omitting a chest tube in the pleural cavity after pulmonary wedge resection in a selected group of patients. Between September 2011 and November 2014, 49 pulmonary wedge resections by VATS without conversion were performed. A chest tube was omitted if there was no air leak after performing the air leak test and patients did not have bullous/emphysematous lesions or dense pleural adhesions. If patients did not meet these criteria, a chest tube was placed. Primary outcome was postoperative morbidity and the secondary outcome was hospital stay. We omitted a chest tube in 28 patients and left a chest tube in the pleural cavity in 21 patients after VATS pulmonary wedge resection. Three reinterventions were necessary postoperatively because of pneumothorax or hematopneumothorax, all in the group without a chest tube. Hospital stay was 1 day shorter in the group without chest tube placement. Omitting a chest tube can decrease hospital stay but we have to be vigilant regarding postoperative complications. Quick removal of the chest tube in the recovery room could be a good alternative to prevent unnecessary reinterventions and to play it real safe.

Evaluation of acute and chronic pain outcomes after robotic, video-assisted thoracoscopic surgery, or open anatomic pulmonary resection

ObjectivesAlthough robotic-assisted thoracic surgery (RATS) provides improved dexterity, the effect of RATS on pain compared with video-assisted thoracoscopic surgery (VATS) or open lobectomy is poorly understood. This study evaluated acute and chronic pain following RATS, VATS, and open anatomic pulmonary resection. MethodsA retrospective review of 498 patients (502 procedures) who underwent RATS (74), VATS (227), and open (201) anatomic pulmonary resection including lobectomy and segmentectomy from 2010 to 2014 was performed to identify factors related to acute and chronic pain. Acute pain scores were analyzed over the first 9 postoperative days. Chronic pain was assessed using the validated PainDETECT survey. ResultsThere were no significant differences in acute or chronic pain between RATS and VATS. There was a significant decrease in acute pain for patients with minimally invasive surgery (P = .0004). Chronic numbness was significantly higher after open resection (25.5% vs 11.6%; P = .0269) but with no difference in other symptoms of chronic pain. Despite no significant difference in pain scores, 69.2% of patients who received RATS felt the approach affected pain versus 44.2% VATS (P = .0330). On multivariable analysis, younger age (P < .0001), female gender (P = .0364), and baseline narcotic use (P = .0142) were associated with acute pain, whereas younger age (P = .0021) and major complications (P = .0003) were associated with chronic numbness in patients who received MIS. ConclusionsAlthough minimally invasive approaches resulted in less acute pain and chronic numbness, there were no significant differences between RATS and VATS. In contrast, more RATS patients believed the approach affected their pain, suggesting a difference between reality and perception.

A propensity matched comparison of effects between video assisted thoracoscopic single-port, two-port and three-port pulmonary resection on lung cancer.

To summarize our experiences of single-port, two-port vs. three-port VATS pulmonary resection for lung cancer patients. Data of consecutive 1,553 patients who underwent video assisted thoracoscopic surgery (VATS) pulmonary resection for lung cancer in the Department of Thoracic Surgery of Cancer Hospital of Chinese Academy of Medical Sciences and Peking Union Medical College between November 2014 and January 2016 were prospectively collected and analyzed. A propensity-matched analysis was used to compare the short-term outcomes of lung cancer patients who received VATS single-port, two-port and three-port pulmonary resection. There were 716 males and 837 females. The mean age was 58.90 years (range, 25-82 years) and the conversion rate was 2.7% (42/1,553) in this cohort. After propensity score matching, there were 207 patients in single-port and two-port group, and 680 patients in three-port group. Propensity-matched analysis demonstrated that there were no significant differences in duration of operation (129 vs. 131 min, P=0.689), intra-operative blood loss (63 vs. 70 mL, P=0.175), number of dissected lymph nodes (12 vs. 13, P=0.074), total hospital expense (﹩9,928 vs. ﹩9,956, P=0.884) and cost of operation (﹩536 vs. ﹩535, P=0.879) between VATS single-port, two-port and conventional three-port pulmonary resection groups. There was no significant difference in the complication rate between two groups (5.3% vs. 4.7%, P=0.220). However, compared with three-port group, patients who underwent single port and two-port experienced shorter postoperative length of stay (6.24 vs. 5.61 d, P=0.033), shorter duration of chest tube (4.92 vs. 4.25 d, P=0.008), and decreased volume of drainage (926 vs. 791 d, P=0.003). The short term outcomes between VATS single-port, two-port and conventional three-port groups for the surgical treatment of lung cancer were comparable. However, compared with three-port VATS pulmonary resection, single-port and two-port were associated with shorter postoperative length of stay, shorter duration of chest tube, and decreased volume of drainage.

Physiologic assessment before video thoracoscopic resection for lung cancer in patients with abnormal pulmonary function.

Impaired respiratory function may prevent curative surgery for patients with non-small cell lung cancer (NSCLC). Video-assisted thoracoscopic surgery (VATS) reduces postoperative morbility-mortality and could change preoperative assessment practices and therapeutic decisions. We evaluated the relation between preoperative pulmonary function tests and the occurrence of postoperative complications after VATS pulmonary resection in patients with abnormal pulmonary function. We included 106 consecutive patients with ≤80% predicted value of presurgical expiratory volume in one second (FEV1) and/or diffusing capacity of carbon monoxide (DLCO) and who underwent VATS pulmonary resection for NSCLC from a prospective surgical database. Patients (64±9.5 years) had lobectomy (n=91), segmentectomy (n=7), bilobectomy (n=4), or pneumonectomy (n=4). FEV1 and DLCO preoperative averages were 68%±21% and 60%±18%. Operative mortality was 1.89%. Only FEV1 was predictive of postoperative complications [odds ratio (OR), 0.96; 95% confidence interval (CI), 0.926-0.991, P=0.016], but there was no determinable threshold. Twenty-five patients underwent incremental exercise testing. Desaturations during exercise (OR, 0.462; 95% CI, 0.191-0.878, P=0.039) and heart rate (HR) response (OR, 0.953; 95% CI, 0.895-0.993, P=0.05) were associated with postoperative complications. FEV1 but not DLCO was a significant predictor of pulmonary complications after VATS pulmonary resection despite a low rate of severe morbidity. Incremental exercise testing seems more discriminating. Further investigation is required in a larger patient population to change current pre-operative threshold in a new era of minimally invasive surgery.

Minimally invasive rib-sparing video-assisted thoracoscopic surgery resections with high-dose-rate intraoperative brachytherapy for selected chest wall tumors

BackgroundBy avoiding chest wall resection, iridium-192 (Ir-192) high-dose-rate (HDR) intraoperative brachytherapy (IOBT) and video-assisted thoracoscopic surgery (VATS) might improve outcomes for high-risk patients requiring surgical resection for pulmonary malignancy with limited pleura and/or chest wall involvement. Methods and materialsSeven patients with non-small cell lung cancer involving the pleura or chest wall underwent VATS pulmonary resections combined with HDR IOBT. After tumor extraction, an Ir-192 source was delivered via a Freiburg applicator to intrathoracic sites with potential for R1-positive surgical margins. The number of catheters, dwell position along each catheter, prescription depth, and dose were customized based on clinical needs. ResultsSix patients had pT3N0M0 non-small cell lung cancers. A seventh case was a recurrent sarcomatoid carcinoma. One case required conversion to open thoracotomy for pneumonectomy with en bloc chest wall resection. There were no intraoperative complications and average operative time was 5.8 hours. Five of seven patients without transmural chest wall involvement underwent rib-sparing resection. Four of the 6 patients treated with VATS and IORT remain alive in follow-up without evidence of local recurrence (median follow-up, 25 months). Noted toxicities were recurrent postoperative pneumothorax, pleural effusion with persistent chest wall pain, avid fibrosis at 2 years of follow-up, and a late traumatic rib fracture. ConclusionsHDR IOBT with Ir-192 via VATS is technically feasible and safe for intrathoracic disease with pleural and/or limited chest wall involvement. Short-term morbidity associated with chest wall resection may be reduced. Additional study is required to define long-term benefits.

Robotics - The answer to the Achilles' heel of VATS pulmonary resection.

During the past decade, robotic surgical systems have been increasingly utilized to perform highly complex surgical procedures. In fact, the robotic-assisted approach to the treatment of many gynecological and urological surgical procedures has become the standard-of-care. The use of robotic surgical system in thoracic surgery is in its early development. Video-assisted thoracoscopic surgery (VATS) was propelled forward in the early 1990’s without full appreciation for long-term consequences, increased cost or therapeutic benefit. The trend in robotic-assisted thoracic surgery is projected to surpass the adoption of VATS and to mirror that of other robotic surgical subspecialties.