Video-assisted Thoracoscopic Surgery Lobectomy Research Articles

Effect of da Vinci robot versus thoracoscopic surgery on lung function and oxidative stress levels in NSCLC patients: a propensity score-matched study.

To evaluate the short-term efficacy, lung function, and oxidative stress levels between the robotic-assisted thoracoscopic surgery (RATS) and video-assisted thoracoscopic surgery group (VATS) for non-small cell lung cancer (NSCLC). We conducted a retrospective cohort study, selecting 248 NSCLC patients who underwent minimally invasive lobectomy at the Department of Thoracic Surgery, Gansu Provincial People's Hospital, from August 2019 to February 2023. There were 105 patients in the RATS group and 143 patients in the VATS group. The patients in the two groups were subjected to 1:1 propensity score matching analysis (PSM), and the perioperative indicators were recorded. The levels of oxidative stress factors (superoxide dismutase, SOD; malondialdehyde, MDA) and inflammatory factors were measured 1day before surgery and 3days after surgery, respectively. Pulmonary function and patient quality of life were measured at 1day preoperatively and 3months postoperatively. There are 93 patients in each group after PSM. Compared to the VATS group, the RATS group had shorter operation time, less intraoperative blood loss, greater number and groups of lymph nodes cleared, and shorter postoperative hospital stay. The SOD level in the RATS group was higher and the MDA level was lower than that in the VATS group after surgery. Postoperative inflammatory cytokine levels were less elevated in the RATS group than in the VATS group. At 3months postoperatively, FVC%, FEV1%, and GQOLI-74 scores were higher in the RATS group than in the VATS group. Compared to VATS lobectomy, RATS lobectomy has the advantages of shorter operative time, lesser bleeding, more lymph node dissection, faster postoperative recovery, and lesser impact on postoperative lung function. It is also capable of reducing the postoperative oxidative stress and inflammatory response, which can improve patients' quality of life.

Pulmonary Lobectomy for Early-Stage Lung Cancer with Uniportal versus Three-Portal Video-Assisted Thoracic Surgery: Results from a Single-Centre Randomized Clinical Trial.

Video-assisted thoracic surgery (VATS) is a consolidated approach; however, there is no consensus on the number of ports leading to less postoperative pain. We compared early postoperative pain after uniportal and three-portal VATS lobectomy for early-stage NSCLC. In this randomized clinical trial, patients undergoing VATS lobectomy were randomly assigned to receive uniportal (U-VATS Group) or three-portal (T-VATS Group) VATS. The inclusion criteria were age ≤ 80 years and ASA < 4. The exclusion criteria were clinical T3, previous thoracic surgery, induction therapy, chest radiotherapy, connective tissue or vascular diseases, major organ failure, and analgesics or corticosteroids use. The postoperative analgesia protocol was based on NRS. Pain was measured as analgesic consumption; the secondary endpoints were intra- and postoperative complications, conversion rate, surgical time, dissected lymph nodes, hospital stay, and respiratory function. Out of 302 eligible patients, 120 were included; demographics were distributed homogeneously. The mean cumulative morphine consumption (CMC) in the U-VATS Group after 7 days was lower than in the T-VATS Group (77.4 mg vs. 90.1 mg, p = 0.003). Intraoperative variables and postoperative complications were comparable. The 30-day intercostal neuralgia rate was lower in the U-VATS Group, without reaching statistical significance. Patients undergoing U-VATS showed a lower analgesic consumption compared with the T-VATS Group; analgesic consumption was moderate in both groups.

Video-assisted thoracic surgery or thoracotomy for lung cancer surgery in obese patients? An analysis of the European Society of Thoracic Surgeons database.

There is a lack of evidence on whether perioperative outcomes differ in obese patients after video-assisted thoracic surgery (VATS) or open lobectomy. We queried the European Society of Thoracic Surgeons database to assess morbidity and postoperative length of hospital stay in obese patients submitted to VATS and open pulmonary lobectomy for non-small-cell lung cancer. We collected all consecutive patients from 2007 to 2021 submitted to lobectomy through VATS or thoracotomy with a body mass index greater than or equal to 30. An intention-to-treat analysis was carried out. Primary outcomes were morbidity rate, mortality and postoperative length of stay (LOS). Differences in outcomes were assessed through univariable, multivariable-adjusted and propensity score-matched analysis. Out of a total of 78018 patients submitted to lung lobectomy, 13999 cases (17.9%) were considered in the analysis, including 5562 VATS lobectomies and 8437 thoracotomy lobectomies. The VATS group showed a lower complication rate (23.2% vs 30.2%, P < 0.001), mortality (0.8% vs 1.5%, P < 0.001) and postoperative LOS (median 5 vs 7 days, P < 0.001). After propensity score matching, the VATS approach confirmed a lower complication rate (24.7% vs 29.7%, P = 0.002) and postoperative LOS (median 5 vs 7 days, P < 0.001). Moreover, these results were consistently observed when analyzing the severe obese subgroup (body mass index 35-39.9) and morbid obese subgroup (body mass index ≥40). In obese patients with non-small cell lung cancer, VATS lobectomy was found to be associated with improved postoperative outcomes than open lobectomy. Consequently, it should be considered the approach of choice for the Obese population.

EP07.03-15 Nodal Upstaging in Uniportal VATS Lobectomy for Early-Stage Lung Cancer: Is It Fair?

EP07.03-15 Nodal Upstaging in Uniportal VATS Lobectomy for Early-Stage Lung Cancer: Is It Fair?

MA01.10 A Smartphone App Assisting Rehabilitation and Symptom Management after VATS lobectomy of Lung Cancer: A Prospective Randomized Controlled Trial

MA01.10 A Smartphone App Assisting Rehabilitation and Symptom Management after VATS lobectomy of Lung Cancer: A Prospective Randomized Controlled Trial

Efficacy and safety of thoracoscopic-guided multiple paravertebral block for video-assisted thoracoscopic lobectomy surgery: a randomized blinded controlled study

BackgroundParavertebral block (PVB) has been increasingly popular for postoperative analgesia. However, few studies estimated the efficacy and safety of multiple PVB using thoracoscope-assisted technique for intraoperative analgesia and postoperative pain management for video-assisted thoracoscopic lobectomy (VATS LOBECTOMY).MethodsA total of 120 patients scheduled to undergo VATS LOBECTOMY were randomly assigned into two groups: a placebo group and a PVB group in a ratio of 1:2. Thoracoscopic-guided multi-point PVB was carried out with 0.5% ropivacaine (PVB group) or 0.9% NaCl (placebo group) at the beginning and the end of surgery. The primary endpoint was consumption of intraoperative opioid.ResultsConsumption rate of intraoperative opioids was significantly lower in the PVB group (878.14 ± 98.37 vs. 1,432.20 ± 383.53 for remifentanil; 123.83 ± 17.98 vs. 266.42 ± 41.97 for fentanyl). Postoperatively, significantly longer duration of using patient-controlled intravenous analgesia for the first time, reduced times of analgesic pump pressing, and less rescue analgetic consumption were observed in the PVB group. Visual analog scale scores at rest and during exercising were significantly lower in the PVB group at all time points within the first 48 h after surgery. The PVB group was also associated with significantly higher total QoR-40 scores and lower incidence of analgesia-related adverse events.ConclusionsThoracoscopic-guided multiple PVB was a simple and effective technique in controlling pain both intra- and postoperatively for VATS LOBECTOMY. It was also associated with the absence of detrimental effects attributed to opioid overuse and benefits of the early resumption of activity and physical function recovery. Therefore, this regional anesthesia technique should be advocated as part of a multimodal analgesia protocol for VATS LOBECTOMY.

Long-Term Oncologic Outcomes in Robot-Assisted and Video-Assisted Lobectomies for Non-Small Cell Lung Cancer.

This study compares long-term outcomes in patients undergoing video-assisted thoracic surgery (VATS) and robotic-assisted thoracic surgery (RATS) lobectomy for non-small cell lung cancer (NSCLC); all consecutive patients who underwent RATS or VATS lobectomy for NSCLC between July 2015 and December 2021 in our center were enrolled in a single-center prospective study. The primary outcomes were overall survival (OS), disease-free survival (DFS), and recurrence rate. The secondary outcomes were complication rate, length of hospitalization (LOS), duration of chest tubes (LOD), and number of lymph node stations harvested. A total of 619 patients treated with RATS (n = 403) or VATS (n = 216) were included in the study. There was no significant difference in OS between the RATS and VATS groups (3-year OS: 75.9% vs. 82.3%; 5-year OS: 70.5% vs. 68.5%; p = 0.637). There was a statistically significant difference in DFS between the RATS and VATS groups (3-year DFS: 92.4% vs. 81.2%; 5-year DFS: 90.3% vs. 77.6%; p < 0.001). Subgroup analysis according to the pathological stage also demonstrated a significant difference between RATS and VATS groups in DFS in stage I (3-year DFS: 94.4% vs. 88.9%; 5-year DFS: 91.8% vs. 85.2%; p = 0.037) and stage III disease (3-year DFS: 82.4% vs. 51.1%; 5-year DFS: 82.4% vs. 37.7%; p = 0.024). Moreover, in multivariable Cox regression analysis, the surgical approach was significantly associated with DFS, with an HR of 0.46 (95% CI 0.27-0.78, p = 0.004) for RATS compared to VATS. VATS lobectomy was associated with a significantly higher recurrence rate compared to RATS (21.8% vs. 6.2%; p < 0.001). LOS and LOD, as well as complication rate and in-hospital and 30-day mortality, were similar among the groups. RATS lobectomy was associated with a higher number of lymph node stations harvested compared to VATS (7 [IQR:2] vs. 5 [IQR:2]; p < 0.001). In conclusion, in our series, RATS lobectomy for lung cancer led to a significantly higher DFS and significantly lower recurrence rate compared to the VATS approach. RATS may allow more extensive nodal dissection, and this could translate into reduced recurrence.

Safety and economic analysis of the EasyEndo disposable endoscopic cutting and stapling device for VATS lobectomy or segmentectomy in lung cancer patients: a retrospective study.

The aim of this retrospective study was to investigate the safety and economic aspects of using the EasyEndo disposable endoscopic cutting and stapling device for video-assisted thoracoscopic surgery (VATS) lobectomy or segmentectomy in patients with lung cancer. The choice between the two staplers was influenced by changes in our hospital's procurement policy; Johnson EC45A was used before January 2022 and was then replaced by the EasyEndo stapler. We reviewed and analyzed consecutive patients with lung cancer who underwent VATS segmentectomy from March 2021 to December 2022. Inclusion criteria included patients with suspected non-small cell lung cancer (NSCLC) who were eligible for surgical resection. The surgical procedures were performed using either the EasyEndo or Johnson EC45A staplers. Intraoperative variables, postoperative outcomes, and cost analysis were compared between the two groups. A total of 1556 patients were included in the study, with 775 patients in the Control group and 781 patients in the EasyEndo group. There were no significant differences in patient characteristics between the two groups. Intraoperative variables, including blood loss, blood transfusion, and operation time, showed no significant differences between the groups. Postoperative outcomes, such as hospital stay, drainage tube placement time, and incidence of complications, were also comparable between the two groups. However, there was a significant difference in the cost of stapler usage, with the EasyEndo group showing a lower cost compared to the Control group. The EasyEndo disposable endoscopic cutting and stapling device demonstrated comparable safety and effectiveness to the Johnson EC45A stapler in VATS segmentectomy for lung cancer patients. Moreover, the use of the EasyEndo stapler resulted in cost savings, indicating its potential economic benefits for healthcare institutions.

What’s Going on in the Hospital?: A Qualitative Study Investigating Patient Experiences of Prolonged Hospitalization After Video-assisted Thoracoscopic Surgery

Background: Patients with lung cancer in “enhanced recovery after surgery” programs are offered the prospect of early hospital discharge before undergoing surgery. Little is known about what patients experience when hospitalization lasts longer than expected. Objective: To explore patient experiences of prolonged hospitalization in an “enhanced recovery after surgery” program following video-assisted thoracoscopic surgery lobectomy. Methods: Fifteen face-to-face, nonstructured interviews were conducted with patients who had undergone surgery and were hospitalized for 7 days or more. Results: Six themes emerged regarding experiences and coping strategies: lacking information, drawing boundaries, coping with boredom, time for existential thoughts, relying on other patients for reflection, and sufficient time to worry about the aftermath. The analysis was based on Gadamer’s philosophical hermeneutical approach and Antonovsky’s theory of sense of coherence (SOC). Conclusions: Patients had various strategies for coping with their situation when hospitalized for a prolonged period in an “enhanced recovery after surgery” program. Health care professionals had an important role in supporting patients’ individual coping strategies to help patients maintain a SOC. Implications for Practice: The findings can be used to understand how patients experience hospitalization when their trajectory deviates from standardized programs. Need for an individual approach to patients is recommended. Foundational: The results indicate an important role for nursing care in “enhanced recovery after surgery” programs and underscore that an individualized approach to patients can bolster coping strategies and thus a SOC.

Association of mechanical power during one-lung ventilation and post-operative pulmonary complications among patients undergoing lobectomy: a protocol for a prospective cohort study.

The association of intra-operative mechanical power (MP) with post-operative pulmonary complications (PPCs) has been described before, but it is uncertain whether the potential inherent bias can limit the use of this parameter, particularly in the context of one-lung ventilation. This single-center study aims to investigate the effect of MP during one-lung ventilation (OLV), and the risks of PPCs in patients undergoing thoracoscopic lobectomy. This prospective observational study is being conducted in an academic tertiary hospital in mainland China. Participants diagnosed with lung cancer, and aged 50 to 80years are eligible. Video-assisted thoracoscopic surgery (VATS) lobectomy is performed for all patients. The primary outcome is the occurrence of PPCs over 5 consecutive days after the surgery, or until discharge from the hospital. Secondary outcomes include the composite conditions of PPCs, in-hospital stay, systematic inflammation tested by blood samples, and changes in aeration compartments in the ventilated lung as assessed by CT scans. We aim to evaluate the association of mean MP and the temporal patterns in the trend of MP during OLV with the occurrence of PPCs. A total of 120 patients will be enrolled in this study. The study protocol has received approval from the Ethics Committee of the affiliated hospital of Southwest Medical University, China (Reference number: KY2022162). The findings will be made available to the funder and researchers via scientific conferences and peer-reviewed publications. This controlledtrialwasapprovedbytheEthicsCommitteeofSouthwest Medical University(ChiCTR2200062173),andregisteredintheChineseClinicalTrialRegisterwebsite( http://www.chictr.org.cn/edit.aspx?pid=172533&htm=4 ,ChiCTR2200062173).Awrittenconsentwasobtainedfromeachpatient.

The effectiveness of surgical treatment of lung cancer in Polish academic and nonacademic centers.

The theoretical advantage of academic hospitals over nonacademic are: more qualified surgeons, adequate diagnostic facilities and infrastructure, including intensive care units. The aim of the study was to compare the effectiveness of surgical lung cancer treatment in academic (ACA) and nonacademic (non-ACA) centers. This was a retrospective analysis of data from 31,777 patients surgically-treated for lung cancer during the period from 2007 to 2020 in 9 ACA and 21 non-ACA centers. The analysis considered the clinical data of patients, the effectiveness of preoperative diagnostics, the type of procedures performed, the complications, the postoperative mortality and the long-term survival. The median number of anatomical lung resection procedures was 1,218 for ACA and 550 for non-ACA centers. In the ACA group, resection using the video-assisted thoracic surgery (VATS) technique was performed significantly more often than in the non-ACA group (23.6% vs. 14.2%, P<0.001). The pN feature analysis showed significantly lower proportions of pNX (9.2%) in the ACA group than those in the non-ACA group (17.1%) (P<0.001). The rates of postoperative complications in the ACA and non-ACA groups were 30.7% and 33.8%, respectively (P<0.001). There were no significant differences in 5-year survival between the ACA and non-ACA groups (56% and 56%, respectively) (P=0.2). The present study showed that ACA centers are characterized by better preoperative diagnostics, a higher percentage of VATS lobectomies, a lower percentage of postoperative complications and a shorter hospitalization period than non-ACA centers, but there was no impact on 5-year survival.

Optimal ropivacaine concentration for ultrasound-guided erector spinae plane block in patients who underwent video-assisted thoracoscopic lobectomy surgery.

An ultrasound-guided erector spinae plane block (ESPB) has emerged as an effective way to control postoperative pain and may be a good alternative way to an epidural block. However, relevant research on the appropriate concentration of local anesthetics for an ESPB remains scarce. This study aimed to investigate the optimal concentration of ropivacaine for an ESPB in patients undergoing video-assisted thoracoscopic surgery (VATS). A total of 68 patients who underwent a VATS lobectomy were enrolled. An ipsilateral ultrasound-guided ESPB was performed with three different ropivacaine concentrations as a local anesthetic: 0.189% (G1), 0.375% (G2), and 0.556% (G3). The total amount of perioperative remifentanil administered, patient-controlled analgesia (PCA) applied, and rescue drugs for postoperative analgesia during the 24 h after surgery were acquired, and numeric rating scale (NRS) scores were obtained. The total amount of intraoperative remifentanil administered was 7.20 ± 3.04 mcg/kg, 5.32 ± 2.70 mcg/kg, and 4.60 ± 1.75 in the G1, G2, and G3 groups, respectively. G2 and G3 had significantly lower amounts of remifentanil administered than the G1 group (P = 0.02 vs. G2; P = 0.003 vs. G3). The G3 group needed more inotropes than the G1 and G2 groups in the perioperative period (P = 0.045). The NRS scores, PCA, and rescue drug were not significantly different in the three groups. The optimal concentration of ropivacaine recommended for an ESPB was 0.375%, which was effective in controlling pain and reducing the intraoperative opioid requirements with minimal adverse reactions such as hypotension.

Safety and feasibility of preferential manual bronchoplasty in 2-3 cm single-port video-assisted thoracoscopic lobectomy.

This retrospective study aimed to compare preferential manual bronchoplasty (PMB) and mechanical stapler closure (MSC) of the bronchial stump after 2-3 cm single-port (SP) video-assisted thoracoscopic surgery (VATS) lobectomy in patients with pathological T1 (pT1) stage lung cancer. Between January 2019 and March 2022, patients with pulmonary neoplasms who underwent 2-3 cm SP VATS lobectomy were retrospectively screened. After propensity-matched analysis, we compared perioperative outcomes and analyzed the safety and feasibility of PMB and MSC of the bronchial stump while performing VATS lobectomy. In this study, 280 and 832 patients were enrolled in the PMB and MSC groups, respectively. Propensity score matching produced 280 pairs. The operation time was shorter in the PMB group, whereas the average number of lymph nodes dissected was higher in the PMB group. The conversion rate was significantly lower in the PMB group. The following were similar between the PMB and MSC groups, respectively: average blood loss volume, postoperative hospital stay, and chest tube removal time. Postoperatively, the incidence of atelectasis was significantly higher in the MSC group. As per subgroup analyses, PMB was associated with a shorter operation time in left and right upper lobectomies. Particularly in left upper lobectomy, PMB had more lymph node dissections and less conversion to open and postoperative atelectasis. In comparison with MSC of the bronchial stump, PMB showed better safety and feasibility in 2-3 cm SP VATS left and right superior lobectomies in patients with pT1 stage lung cancer.

Short-term outcomes of robot-assisted versus video-assisted thoracoscopic surgery for non-small cell lung cancer patients with neoadjuvant immunochemotherapy: a single-center retrospective study.

Neoadjuvant immunochemotherapy has been increasingly applied to treat non-small cell lung cancer (NSCLC). However, the comparison between robotic-assisted thoracoscopic surgery (RATS) and video-assisted thoracoscopic surgery (VATS) in the feasibility and oncological efficacy following neoadjuvant immunochemotherapy is scarce. This study aims to assess the superiorities of RATS over (VATS) concerning short-term outcomes in treating NSCLC patients with neoadjuvant immunochemotherapy. NSCLC patients receiving RATS or VATS lobectomy following neoadjuvant immunochemotherapy at Shanghai Chest Hospital from 2019 to 2022 were retrospectively identified. Baseline clinical characteristics, perioperative outcomes, and survival profiles were analyzed. Forty-six NSCLC patients with neoadjuvant immunochemotherapy were included and divided into the RATS (n=15) and VATS (n=31) groups. The baseline clinical characteristics and induction-related adverse events were comparable between the two groups (all p>0.050). The 30-day mortality in the RATS and VATS groups were 0% and 3.23%, respectively (p=1.000). Patients undergoing RATS were associated with reduced surgical-related intensive unit care (ICU) stay than those receiving VATS (0.0 [0.0-0.0] vs. 0.0 [0.0-1.0] days, p=0.026). Moreover, RATS assessed more N1 LNs (6.27 ± 1.94 vs 4.90 ± 1.92, p=0.042) and LN stations (3.07 ± 1.03 vs 2.52 ± 0.57, p=0.038) compared with VATS. By comparison, no difference was found in surgical outcomes, pathological results, and postoperative complications between the RATS and VATS groups (all p>0.050). Finally, RATS and VATS achieved comparable one-year recurrence-free survival (82.96% vs. 85.23%, p=0.821) and the timing of central nervous system, LN, and bone recurrences (all p>0.050). RATS is safe and feasible for NSCLC patients with neoadjuvant immunochemotherapy, reducing surgical-related ICU stay, assessing increased N1 LNs and stations, and achieving similar survival profiles to VATS.

The efficacy of three-ball breathing apparatus exercise based on the concept of pulmonary rehabilitation in patients after lung cancer surgery

BackgroundPostoperative patients with lung cancer mostly experience different degrees of dyspnea and decreased activity tolerance, and these symptoms all significantly affect postoperative quality of life. The concept of pulmonary rehabilitation applicable to patients with chronic respiratory diseases is also applicable to patients with postoperative lung cancer. The current application of postoperative pulmonary rehabilitation for lung cancer is inconsistent, and reliable guidelines are lacking. The purpose of this study was to further verify the efficacy and feasibility of postoperative pulmonary rehabilitation for lung cancer patients, and to find a suitable local pulmonary rehabilitation program for postoperative patients with lung cancer that is clinically promoted in our department through this study.MethodsWe collected the clinical data of patients undergoing video-assisted thoracoscopic surgery (VATS) wedge resection or lobectomy. The patients were divided into rehabilitation group (using three-ball breathing apparatus after discharge) and control group (routine follow-up after discharge) according to whether the patients were trained with three-ball breathing apparatus after operation. The detailed method using three-ball apparatus is as follows. To begin with, patients are required to put themselves in a comfortable position. Then, after the three-ball breathing apparatus put on the same plane of their eyes, patients hold the tube in their mouth closely and control their breath slowly. When patients inhale to their largest extent, the balls will rise up accordingly. Then they exhale. The evaluation results of pulmonary function, activity tolerance, anxiety scores and others were collected. All data was gathered at the First Affiliated Hospital of Soochow University. The effects of pulmonary rehabilitation training on wedge resection and lobectomy were compared.ResultsA total of 210 patients were included in this study, including 126 patients with VATS wedge resection and 84 patients with VATS lobectomies. No discrepancy was noticed when FEV1 loss between two groups were compared in the wedge resection patients, and the same results were also shown in patients undergoing lobectomy (12.8% ± 2.0% vs. 12.7% ± 1.9%, P = 0.84, wedge resection; 12.6% ± 2.9% vs. 12.1% ± 1.8%, P = 0.37, lobectomy). The loss of FVC in the control group was greater than that in the rehabilitation group for patients undergoing lobectomy (11.7% ± 5.2%, vs. 17.1% ± 5.6%, P < 0.001, lobectomy). No difference was found in the wedge resection patients between the control and rehabilitation groups (6.6% ± 2.8%, vs. 6.4% ± 3.2%, P = 0.76, lobectomy). Moreover, all patients showed no significant difference in 6MWD regardless of surgical procedure and with or without breathing exercises at T3 (392.6 ± 50.6 m, rehabilitation group vs. 394.0 ± 46.6 m, control group. P = 0.87, wedge resection; 381.3 ± 38.9 m, rehabilitation group vs. 369.1 ± 49.3 m, control group. P = 0.21, lobectomy).ConclusionsFor patients after thoracoscopic pulmonary wedge resection, the use of three-ball apparatus did not significantly improve postoperative pulmonary function and activity tolerance, dyspnea, and anxiety symptoms. In patients after thoracoscopic lobectomy, respiratory trainers were able to improve postoperative lung function but were unable to significantly improve dyspnea and anxiety symptoms. There was a significant benefit for the use of three-ball apparatus in patients after thoracoscopic lobectomy, whereas there was no significant benefit for the use of respiratory trainers after wedge resection.Registry: Medical Ethics Committee of the First Affiliated Hospital of Soochow University. Registration number: no. 2022455.

Variation in Treatment Charges and Reimbursement Among Individual Thoracic Surgeons

BackgroundHealth care use and costs have undergone an increase in public scrutiny. Other specialties have evaluated practice patterns of their most highly reimbursed surgeons and found unique billing and procedure overuse. In this study, we evaluate Medicare payments to general thoracic surgeons and evaluate those with the highest reimbursements. MethodsThe 2018 Medicare Provider Utilization Data were queried to identify thoracic surgeons. Services were grouped into common categories: Evaluation and Management, Lung/Pleura, Foregut, Chest Wall, Airway, Diaphragm, Mediastinum, Endoscopy, and Transplant. Payment data were analyzed for surgeons receiving the top 1% of Medicare payments and the remainder of the workforce. ResultsIn 2018, 2000 unique self-identified thoracic surgeons received a total of $54,734,736 in payments from Medicare for thoracic-related services. The top 1% of thoracic surgeons (n = 20) received $4,607,561, or 8.4% of total payments. Inpatient Evaluation and Management was the leading payment category for the top 1% (48.5% of payments), whereas Outpatient Evaluation and Management led for the remaining workforce (43.5% of payments). Whereas the surgical procedure code with overall highest reimbursement for both groups was Current Procedural Terminology (American Medical Association) 32663 (video-assisted thoracic surgery lobectomy), there was a difference with an increased use of high relative value unit unbundled Current Procedural Terminology codes in the highest earners. ConclusionsA disproportionate amount of Medicare reimbursement went to top 1%. The highest earners appeared to earn the most from inpatient treatment codes and also used unbundled codes more often. Because billing code use is not regulated and often subjective, a deeper evaluation by the major surgical societies may be warranted.

Comparison of the efficacy of high-flow oxygen insufflations and continuous positive airway pressure during one-lung ventilation undergoing video-assisted thoracoscopic surgery

Isolation of one-lung leads to ventilation-perfusion mismatch and increases intrapulmonary shunt, which in some cases may lead to clinically significant hypoxemia.The objective was to compare the efficacy of hypoxemia correction and the convenience of surgical work during one-lung ventilation with the use of high-flow oxygen insufflation (HFI) and continuous positive airway pressure (CPAP) in the non-ventilated lung during video-assisted thoracoscopic surgery (VATS).Materials and methods. The study included 60 patients who underwent surgical intervention in the form of VATS lobectomy. All studied patients were randomly divided into two groups: group 1 included patients who received HFI into non-ventilated lung to correct hypoxemia, and group 2 – CPAP into non-ventilated lung. The study was divided into four stages. Stage I – two-lung ventilation. Stage II – one-lung ventilation. At stage III, HFI of 60 L/min (FiO2 = 0,5) into non-ventilated lung was used to correct hypoxemia in group 1, and CPAP of 5 cm H2O into non-ventilated lung was used in group 2. At stage IV, HFI of 30 L/min (FiO2 = 0,5) into non-ventilated lung was used to correct hypoxemia in group 1, and CPAP of 2 cm H2O into non-ventilated lung was used in group 2. The following parameters were recorded during the stages of the study: PaO2, PaCO2, SpO2, Qs/Qt, and surgical team satisfaction with lung collapse by 10-point visual analogue scale (VAS).Results. At stages I and II, there was no statistically significant difference between groups in such parameters as PaO2, PaCO2, SaO2, and SpO2 (p &gt; 0.05). Starting from stage III, a statistically significant difference between the two groups was found for a parameter PaO2 (U 26.0; Z = –6.27; p &lt; 0.001). For group 1, it was equal to 134.5 (126.0; 141.75) and for group 2 – 108.5 (104.0; 114.5) correspondingly. At stage IV, the values of PaO2 were higher in group 1: 118.5 (113.0; 122.25) vs 92.5 (89.0; 98.25) in group 2 (U 0.0; Z = –6.66; p &lt; 0.001). When comparing PaCO2 between the two groups, there were no statistically significant differences at all stages (p &gt; 0.35). When comparing SaO2 at stages I (U 450.0; Z = 0.0; p = 1.0), II (U 422.5; Z = –0.4; p = 0.69), III (U 339.0; Z = –1.8; p = 0.69), no statistically significant differences were indicated between the two groups. However, at stage IV, the value of SaO2 was higher (97 (96; 97)) in group 1 than in group 2 (94 (94; 95)), U 69.5; Z = –5.75; p &lt; 0.001. When comparing SpO2 between the two groups, there was no statistical difference at all stages (p &gt; 0.69). Comparing the two groups by such indicator as Qs/Qt, no statistically significant differences were found at the first three stages (p &gt; 0.4). A comparison of Qs/Qt at stage IV revealed statistically significant differences (U 69.0; Z = –5.6; p &lt; 0.001). This parameter was equal to 10.7% (9.5; 15.7) in group 1 and 21.3% (18.4; 23.9) in group 2 correspondingly. When assessing surgical team satisfaction levels with surgical field visualization by VAS, there were statistically significant differences between group 1 and group 2 at stage III (p &lt; 0.001) and stage IV (p &lt; 0.001). The satisfaction level was significantly higher in group 1.Conclusions. The usage of high-flow oxygen insufflation during one-lung ventilation undergoing VATS allows to effectively correcting hypoxemia similar to the CPAP method, but as opposed to CPAP, it can provide comfortable conditions for carrying out the surgical procedures.

Thoracoscopic segmentectomy in children with congenital lung malformation

Congenital lung malformations (CLM) are most commonly treated with a pulmonary lobectomy. However, due to technological advancement, video-assisted thoracoscopic surgery (VATS) segmentectomy is becoming an attractive alternative to VATS lobectomy. This study aimed to evaluate the safety, feasibility, and efficacy of VATS segmentectomy as a lung parenchyma-saving strategy in children with CLM. A retrospective analysis was performed on 85 children, for whom VATS segmentectomy was tried for CLM between January 2010 and July 2020. We compared the surgical outcomes of VATS segmentectomy with the outcomes of 465 patients who underwent VATS lobectomy. Eighty-four patients received VATS segmentectomy and thoracotomy conversion was necessary for one patient for CLM. The mean age was 3.2 ± 2.5 (range 1.2–11.6) years. The mean operative time was 91.4 ± 35.6 (range 40–200) minutes. The median duration of chest tube drainage was 1 (range 1–21) day, and the median length of postoperative hospital stay was 4 (range 3–23) days. There were no postoperative mortality and postoperative complications developed in 7 patients (8.2%), including persistent air leakage in 6 patients (7.1%) and postoperative pneumonia in 1 patient (1.2%). The median follow-up period was 33.5 (interquartile range 31–57) months and there were no patients requiring re-intervention or reoperation during the follow-up period. In the VATS segmentectomy group, the persistent air leakage rate was higher than in the VATS lobectomy group (7.1 vs. 1.1%, p = 0.003). Otherwise, postoperative outcomes were comparable between the two groups. VATS segmentectomy in children with CLM is a technically feasible alternative to VATS lobectomy with acceptable early and mid-term outcomes. However, the persistent air-leakage rate was higher in VATS segmentectomy.

Complete thoracoscopic lobectomy versus hybrid video-assisted thoracoscopic lobectomy for non-small cell lung cancer.

Video-assisted thoracoscopic surgery (VATS) is the standard approach to lobectomy for early-stage non-small cell lung cancer (NSCLC). However, there are many different types. One of its approaches is complete thoracoscopic surgery (CTS), which may be less invasive because of low chest wall stress. This study compared the treatment outcomes of CTS and hybrid VATS lobectomy for NSCLC. In total, 442 eligible patients with clinical N0 NSCLC underwent lobectomy between 2007 and 2016. Patients were classified into a group of patients who underwent CTS and a group of those who underwent hybrid VATS. Propensity score matching was performed between the two groups. There were 175 patients after matching. The median follow-up period in the CTS and hybrid VATS groups was 60 and 63months, respectively. The CTS group showed less blood loss (CTS, 50mL vs. 100mL, p = 0.005), fewer complications (CTS, 25.7% vs. 36.6%, p = 0.037), and shorter postoperative hospital stays (CTS, 8days vs. 12days, p < 0.001). There was no significant difference in the postoperative 30-day mortality rates. Between the patients who underwent CTS and hybrid VATS groups, the 5-year overall survival rates were 85.4% and 86.0% (p = 0.701), the relapse-free survival rates were 76.5% and 74.9% (p = 0.435), and the lung cancer-specific survival rates were 91.5% and 91.7% (p = 0.90), respectively. CTS is less invasive and has superior short-term outcomes as an approach to lobectomy for early-stage NSCLC.

Right Middle Lobe Torsion Post-VATS Right-Sided Lobectomy

The reported incidence of postoperative right middle lobe torsion following right-sided VATS (video-assisted thoracoscopic surgery) lobectomy is very low. However, this study presents four cases of post-VATS right middle lobe torsion that occurred in the space of 12 months at this institution. These cases were reviewed to try to ascertain the aetiology of the pathology and hence determine ways to prevent similar situations occurring in the future.