Worse outcomes after conversion of thoracoscopic lobectomy for lung cancer

OBJECTIVESConversion of thoracoscopic lobectomy for lung cancer to thoracotomy can adversely affect short-term outcomes, but the impact on long-term outcomes is unknown. This study aimed to identify the risk factors for conversion and to determine the influence of conversion on the outcomes of lung cancer treatment. Open in a separate windowMETHODSThis retrospective study included 1002 consecutive patients with lung cancer who underwent thoracoscopic lobectomy between 7 June 1999 and 17 July 2018. The groups of patients with and without conversion were compared in terms of possible risk factors and the short- and long-term outcomes. The survival of patients was analysed by the Kaplan–Meier method.RESULTSConversion was done in 105 patients (10.5%). On multivariable logistic regression analysis, the independent risk factors for conversion were pleural adhesions (P < 0.001) and mediastinal lymph node metastases (P < 0.001). Compared with the non-conversion group, the conversion group had longer chest drainage time (4 vs 3 days, P < 0.001) and hospital stay (8 vs 6 days, P < 0.001); more frequent complications (38.1% vs 27.1%, P = 0.018), including red blood cell transfusion (10.5% vs 2%, P < 0.001) and supraventricular arrhythmia (13.3% vs 7.5%, P = 0.037); and lower 5-year survival rate in patients with stage I lung cancer (70% vs 87%, P = 0.014). Conversion did not increase in-hospital mortality.CONCLUSIONSPleural adhesions and lymph node metastases increased the probability of conversion to thoracotomy. Conversion adversely affected the short-term outcomes of thoracoscopic lobectomy. Long-term outcomes of treatment of non-small-cell lung cancer could be worse in patients after conversion, but definitive conclusions cannot be made in this regard because of the absence of control of selection bias.     

Very long-term outcomes of video-assisted thoracoscopic surgery for lung cancer

Background  The most critical parameter in the evaluation of the feasibility of video-assisted thoracoscopic surgery (VATS) lobectomy for lung cancer is long-term outcome. In this study, patients in whom more than 5 years had elapsed since they had undergone VATS lobectomy for lung cancer were identified, and the 5-year survival rate and frequency of recurrence were evaluated as the long-term outcomes; in addition, the frequency of perioperative complications were also evaluated as the short-term outcomes. Methods  The stage, histology, perioperative complications, recurrence, and survival data were carefully reviewed in 198 patients who underwent VATS lobectomy for lung cancer between 1998 and 2002. Results  Median postoperative follow-up period was 72.1 months. Of the 198 patients, 138 and 30 were diagnosed as having p-stage IA and IB disease, respectively, while the remaining 30 patients had more advanced disease. Perioperative complications were observed in 20 patients (10.1%), however, there were no perioperative mortalities. Recurrence was observed in 26 patients (13.1%): of these, 11 patients showed local recurrence, including malignant pleural effusion and mediastinal lymph node recurrence, and 16 patients showed distant metastasis, the lung being the commonest site of metastasis; six patients had both local recurrence and distant metastasis. During the study period, there were 26 deaths (13.1%), of which 17 were due to lung cancer and 9 were due to other causes. The 5-year overall survival rates of the patients with p-stage IA and IB disease were 93.5% and 81.6%, respectively. Conclusion  VATS lobectomy for the treatment of lung cancer is as feasible and safe as open lobectomy in terms of both very long- and short-term outcomes.     

电视胸腔镜手术在肺癌治疗中的应用

电视胸腔镜手术（video-assisted thoracoscopic surgery，VATS）是一种微创、安全、可行的技术。随着手术器械和技巧的日趋改进，电视胸腔镜在临床的应用越来越广泛。本文就电视胸腔镜手术在肺癌治疗中的应用作一综述。     

Comparison between robot-assisted thoracoscopic surgery and video-assisted thoracoscopic surgery for mediastinal and hilar lymph node dissection in lung cancer surgery

 Open in a separate windowOBJECTIVESLymph node dissection (LND) with robot-assisted thoracoscopic surgery (RATS) in lung cancer surgery has not been fully evaluated. The aim of this study was to compare LND surgical results between video-assisted thoracoscopic surgery (VATS) and RATS.METHODSWe retrospectively compared perioperative parameters, including the incidence of LND-associated complications (chylothorax, recurrent and/or phrenic nerve paralysis and bronchopleural fistula), lymph node (LN) counts and postoperative locoregional recurrence, among 390 patients with primary lung cancer who underwent lobectomy and mediastinal LND by RATS (n = 104) or VATS (n = 286) at our institution.RESULTSThe median total dissected LN numbers significantly differed between the RATS and the VATS groups (RATS: 18, VATS: 15; P < 0.001). They also significantly differed in right upper zone and hilar (#2R + #4R + #10L) (RATS: 12, VATS: 10; P = 0.002), left lower paratracheal and hilar (#4L + #10L) (RATS: 4, VATS: 3; P = 0.019), aortopulmonary zone (#5 + #6) (RATS: 3, VATS: 2; P = 0.001) and interlobar and lobar (#11 + #12) LNs (RATS: 7, VATS: 6; P = 0.041). The groups did not significantly differ in overall nodal upstaging (P = 0.64), total blood loss (P = 0.69) or incidence of LND-associated complications (P = 0.77).CONCLUSIONSIn this comparison, it was suggested that more LNs could be dissected using RATS than VATS, especially in bilateral superior mediastinum and hilar regions. Accumulation of more cases and longer observation periods are needed to verify whether RATS can provide the acceptable quality of LND and local control of lung cancer.     

小切口电视胸腔镜辅助与传统开胸肺癌根治术的比较

目的探讨小切口电视胸腔镜辅助肺癌根治术的临床价值。方法2005年1月～2006年6月收治49例I、Ⅱ期非小细胞肺癌,22例在小切口(腋前线肋间6～8cm)辅助电视胸腔镜下行肺叶切除术及肺门纵隔淋巴结清扫(VATS组),27例在常规开胸手术下完成肺叶切除术及淋巴结清扫(传统开胸组),比较2种术式肺功能和C反应蛋白(C reactiveprotein,CRP)的变化。结果胸腔镜组2例为方便安全地处理肺门血管将小切口扩大至12～15cm。2组患者术后血清CRP浓度明显升高,第1天达到峰值,胸腔镜组CRP术后1d(56.1±10.9)mg/L,显著低于传统开胸组(73.8±15.1)mg/L(t=-4.603,P=0.000)。2组术后肺功能每分钟通气量相对值(minute ventilation volume,MV)、1秒用力呼气容积相对值(forced expiratory volume in one second,FEV1)下降,术后1周时胸腔镜组MV为(95.6±16.4)L,显著高于传统开胸组(81.9±12.7)L(t=3.296,P=0.002),胸腔镜组FEV1为(57.1±5.7)%,显著高于传统开胸组(51.4±6.9)%(t=3.105,P=0.003)。结论与常规开胸肺癌根治术相比,小切口电视胸腔镜辅助肺叶切除术适合于早中期肺癌,疗效确切,可明显减少病人的手术创伤,可以作为非小细胞型肺癌的一种常规的治疗手段。     

胸腔镜肺叶切除术治疗早期肺癌的学习曲线

目的 通过评估胸腔镜肺叶切除术治疗早期肺癌不同阶段的手术效果,探讨胸腔镜肺叶切除术的学习曲线.方法 回顾性分析2006年9月至2008年6月由同一手术组连续完成的60例全胸腔镜下肺叶切除加纵隔淋巴结清扫术治疗早期肺癌的病例资料.按手术先后依次分为4组(A、B、C、D),每组15例,比较各组手术时间、术中出血量、纵隔淋巴结清扫站数及个数、中转开胸率、术后并发症、术后胸管引流时间以及术后住院天数,分析不同阶段的手术效果.结果 各组病例在年龄、性别、肿瘤大小、病理分期以及手术方式等方面差异无统计学意义(P>0.05).A组手术时间(228.0±55.6)min明显长于C组(155.0±33.6)min或D组(152.7±27.4)min(P<0.001),B组手术时间(200.3±67.1)min亦明显长于C组或D组(P<0.05),而C、D两组之间差异无统计学意义(P=0.896);在术中出血量方面,A组(283.3±111.2)ml明显多于C组(156.7±86.3)ml或D组(143.3±67.8)ml(P<0.01),B组(286.7±188.4)ml亦明显多于C组或D组(P<0.01),C、D两组之间差异无统计学意义(P=0.767);各组淋巴结清扫数量、中转开胸率、术后并发症、术后胸管引流时间以及术后住院天数比较,差异均无统计学意义(P>0.05).结论 胸腔镜肺叶切除术的学习曲线大约为30例.     

电视胸腔镜手术与开胸手术治疗肺癌的创伤程度比较

目的：比较电视胸腔镜手术与开胸手术治疗肺癌的创伤程度。方法将本院2010年2月~2013年6月本院收治的70例肺癌患者分为对照组和观察组,每组各35例,对照组患者给予开胸手术治疗,观察组患者给予电视胸腔镜手术治疗,比较两组患者血清、胸水中IL-6、α1-AT的变化。结果观察组患者术后1、3d时,血清、胸水的IL-6、α1-AT均低于对照组,差异有统计学意义（P＜0.05）。结论电视胸腔镜手术治疗肺癌校开胸手术对患者的创伤程度小。     

肺部疾病中胸腔镜手术的应用研究

目的探讨胸腔镜手术在肺部疾病中的疗效。方法回顾性分析两年来电视胸腔镜手术治疗的15例患者的临床资料,并与同期的25例传统开胸手术作比较。结果经比较,VATS组手术时间、失血量、术后胸腔引流管放置时间和住院时间均明显短于传统开胸手术组,手术效果满意,无并发症发生。结论电视胸腔镜手术具有创伤小、出血少、手术时间短、康复快、风险小、疗效可靠及术后并发症少等优点,是值得临床推广、安全有效的治疗方法。     

达芬奇机器人与电视胸腔镜治疗纵隔神经源性肿瘤的对比研究

目的探讨和比较达芬奇机器人手术(robot-assisted thoracoscopic surgery,RATS)、电视胸腔镜手术(video-assisted thoracoscopic surgery,VATS)治疗纵隔神经源性肿瘤的临床结果。 方法回顾性分析2015年7月至2019年12月期间,解放军总医院微创手术治疗的95例MNT患者临床病理资料,比较RATS、VATS的临床治疗结果。 结果RATS组31例,VATS组64例,均实现R0切除,两组基线资料差异无统计学意义(P>0.05);术中出血量、术后引流量、术后并发症发生率方面,差异无统计学意义(P>0.05)。RATS组手术时间长于VATS组,但术后引流管留置时间、术后住院时间显著低于VATS组,差异有统计学意义(P<0.05)。 结论RATS是治疗MNT安全、可行的手术方式,相比于VATS,患者术后恢复更快。     

全电视胸腔镜下肺叶切除术

目的总结探讨全电视胸腔镜肺叶切除的安全手术方法。方法在自2008年7月至2010年3月以来共完成全电胸腔镜下肺叶切除57例,男34例,女23例,年龄45～78岁。临床诊断支气管扩张症3例,肺曲菌球病2例,肺硬化性血管瘤2例,慢性肺部炎症1例,肺癌49例。腋中线第7或第8肋间作镜孔（1.5～2cm）,肩胛下角线第7或第8肋间作操作孔（1.5～2cm）,腋前线与锁骨中线间第4肋间（上中叶切除）或第5肋间（下叶切除）作一长约4～6cm辅助切口,便于游离肺门血管和取出被切肺叶。术中应用血管切割缝合器处理血管、支气管。结果切除左肺上叶12例,左肺下叶13例,右肺上叶11例,右肺中叶5例,右肺下叶16例。术后平均胸管引流量50～150ml/d。平均住院时间10.5d。全组无死亡病例。结论全电视胸腔镜肺叶切除具有出血少、疼痛小、住院时间短和病程恢复快等优点。胸外科医师经过相关训练完全能掌握这项微创技术进行安全手术。     

Learning curve for two-port video-assisted thoracoscopic surgery lung segmentectomy

 Open in a separate windowOBJECTIVESWhen lung cancer evolves from a large, centrally located mass to small, peripherally located pulmonary nodules, such as ground glass nodules, segmentectomy offers a reasonable method by which to save lung parenchyma without eliciting compromising oncological effects. To master these techniques, it is important to analyse the learning curve of surgeons. Therefore, the aim of the present study was to analyse the learning curve for two-port video-assisted thoracoscopic surgery (VATS) segmentectomy in our institution.METHODSWe retrospectively collected data from 86 consecutive patients who underwent two-port VATS segmentectomy between June 2019 and November 2019. The operative time (OT) and estimated blood loss and other complications were analysed. The learning curve was evaluated using the OT and the cumulative sum (CUSUM) value of OTs across all cases.RESULTSWe generated a graph of the CUSUM of OTs and found that the learning curve could be differentiated into 3 phases: phase 1, the initial learning phase (1st to 27th operation); phase 2, the increased competence phase (28th to 54th operation); and phase 3, the experienced phase (55th to 86th operation). The CUSUM value inflected at patient number 47. There were significant reductions in the OT and bleeding in phase 3 relative to phases 1 and 2. There were also significant differences in OT and estimated blood loss between the simple and complex segmentectomy procedures.CONCLUSIONSIn conclusion, the 3 phases identified using CUSUM analysis of the OT represented characteristic stages of the learning curve for two-port VATS segmentectomy. The data indicate that, in our institution, the inflection point for the learning curve was achieved after operating on 47 cases.     

Single-incision versus multiport video-assisted thoracoscopic surgery in the treatment of lung cancer: a systematic review and meta-analysis

Objectives: Recent studies compared single-incision thoracoscopic surgery (SITS) with more widely used conventional multiport video-assisted thoracoscopic surgery in the treatment of lung cancer. To establish the safety and feasible of SITS in the treatment of lung cancer, we conducted this systematic review and meta-analysis.

Methods: Eleven studies were identified from the databases of PubMed, Cochrane Library, SpringerLink, and ScienceDirect. The randomized controlled trials (RCTs) and non-randomized studies evaluated the outcomes of SITS compared with multiport video-assisted thoracoscopic surgery in the treatment of lung cancer were included for analysis. Odds ratio (OR, used to compare dichotomous variables) and weight mean difference (WMD, used to compare continuous variables) were calculated with 95% confidence intervals (CIs) based on intention-to-treat analysis.

Results: Eleven studies including 1314 patients were included for analysis. Our analysis showed that the operative time, blood loss amount, mean duration of chest tube, lymph nodes retrieved were similar between two approaches, the SITS pulmonary resection might be associated with shorter hospital stay (p?=?.008) and lower complication rate (p?=?.009) when compared with conventional multiport video-assisted thoracoscopic surgery approaches.

Conclusions: In selected patients SITS is safe, feasible and may be considered an alternative to multiport VATS.     

Evaluation of video-assisted thoracoscopic surgery lobectomy requiring emergency conversion to thoracotomy

Objective: Video-assisted thoracoscopic surgery (VATS) lobectomy has been employed for the treatment of lung cancer. Many investigators have reported that the outcomes of VATS lobectomy for lung cancer are comparable to those of thoracotomy; however, several controversial issues remain. One of the critical concerns is the safety. VATS lobectomy often requires an emergency conversion to thoracotomy, for example, in the event of massive bleeding. In this study, cases in which VATS lobectomy for lung cancer was converted to thoracotomy intra-operatively (converted VATS lobectomy) were identified. The safety of the converted VATS lobectomy was evaluated. Methods: Between 2003 and 2007, VATS lobectomy was converted to thoracotomy in 24 out of 492 cases. Information regarding the patients’ characteristics, reasons for the conversion and perioperative complications as well as the recurrence and survival data were carefully reviewed. The reasons for the conversion were classified into two groups: (1) problems related to the VATS procedure (VATS-related problems) and (2) problems not related to the VATS procedure (non-VATS-related problems). Results: Of the 24 converted cases, 19 (79%) had a history of smoking. Nine patients (38%) had a history of lung disease. Left upper lobectomy was the most frequently associated with conversion (11/24, 46%), followed by right lower lobectomy and right upper lobectomy. The most frequent reasons for the conversion were hilar lymphadenopathy and bleeding (seven patients each), followed by fused fissure. Eight of the conversions were considered to be attributable to VATS-related problems. Perioperative complications were observed in four patients, consisting of prolonged air leak in three patients and transient recurrent laryngeal nerve palsy in one patient. However, there were no life-threatening complications. The median follow-up period was 26 months. Recurrence occurred in two patients: pleural dissemination in one and bone metastasis in the other. Two deaths were observed during the follow-up period: one related to lung cancer and another related to other type of cancer. Conclusions: The safety of the conversion was acceptable. Our findings suggest that VATS lobectomy for lung cancer is feasible from the viewpoint of safety, even after taking into account the potential need for conversion to thoracotomy in some patients.     

Evaluation of video-assisted thoracoscopic surgery for pulmonary metastases: 11-years of experience

Background  Although video-assisted thoracoscopic surgery (VATS) has been applied to pulmonary resection for pulmonary metastases, the clinical validity of this approach remains controversial. The purpose of this study was to evaluate the validity and problems of VATS for pulmonary metastasectomy. Methods  From January 1993 to December 2003, VATS for pulmonary metastasectomy was performed in 53 resections for 48 patients at our institution. The medical records of these patients were retrospectively reviewed. Results  The primary tumor was colorectal cancer in 23 patients, renal cell carcinoma in 6, breast cancer in 6, germ cell tumor in 5, head and neck cancer in 2, and others in 6. Thirty-six cases had a solitary lesion, 8 had unilateral multiple lesions, and 9 had bilateral multiple lesions. The following procedures were performed: 7 lobectomies, 5 segmentectomies, and 41 wedge resections. There was no major postoperative morbidity related to VATS. At a median follow-up period of 29.0 months, 13 patients were alive without recurrences. The 3-year overall survival rate and the 3-year intrathoracic disease-free survival rate were 59.8% and 33.4%, respectively. Five cases had recurrence at the surgical stump or at the port sites, but these recurrences have not been found in the recent period since June 1997. Intrathoracic recurrences within 3 months after VATS occurred in four. Conclusion  VATS for pulmonary metastases is not superior to the conventional open thoracotomy and is not recommended as a standard procedure. Further studies with a larger number of cases performed by skilled surgeons familiar with VATS are needed.     

Simultaneous three-port thoracoscopic surgery for bilateral lung cancers with a pulmonary vein anomaly: A case report

IntroductionSimultaneous resection of bilateral lung cancers is technically challenging but may be preferable to a staged procedure in patients with a partial anomalous pulmonary venous connection (PAPVC) in an affected lobe. We performed single-stage resection of bilateral lung cancers in a patient with a PAPVC.Presentation of caseA 73-year-old man was diagnosed as having bilateral lung cancers (right, cT3N1M0, stage IIIA and left, cT2aN0M0, stage IB). Left upper trisegmentectomy was performed, followed by right upper lobectomy with deep wedge bronchoplasty. A PAPVC was found incidentally in the affected right upper lobe and successfully divided. The postoperative course was uneventful and he commenced chemoradiotherapy.DiscussionResection of the PAPVC, which was located in the same lobe as the lung cancer, would have mitigated load increase in the right heart and may have alleviated the adverse effects of bilateral lung resection. Moreover, the single-stage procedure likely shortened the overall duration of treatment.ConclusionSingle-stage bilateral thoracoscopic resection may have advantages over staged procedures in some patients with PAPVCs.     

Minimally invasive resection of synchronous triple primary tumors of the esophagus,lung, and thymus: A case report

IntroductionReports of synchronous multiple primary tumors are very rare. We report a case of synchronous esophagus and lung cancer combined with thymoma treated with a minimally invasive approach.Presentation of caseIn a 63-year-old patient, cT2 esophageal squamous cell carcinoma was found. Chest computed tomography revealed a lesion in the right upper lobe combined with an antero-superior mediastinal mass. She was treated with one-stage bilateral video-assisted thoracoscopic + laparoscopic esophagectomy with lymph node dissection and lobectomy with complete lymphadenectomy followed by thymomectomy and demonstrated a favorable response at early follow-up, without severe adverse surgical complications and evidence of local recurrence or distant metastasis. But the long-term follow-up is still needed for the evaluation of therapeutic effects of surgery.DiscussionIn the diagnostic procedure we excluded the probability of esophageal carcinoma metastasizing to the lung. Considering the patient's physical condition permit, we performed a minimally invasive surgery for three tumors. Besides, suitable operative incisions are important for the success of surgery.ConclusionTo our knowledge, this is the first case report in which simultaneous minimally invasive resection of esophagus and lung cancer combined with thymoma.     

Video-assisted thoracic surgery (VATS) lobectomy: the evidence base.

BACKGROUND: Video-assisted thoracic surgery (VATS) lobectomy provides a minimally invasive alternative for management of early stage non-small cell lung cancer, but is still only performed in a few specialized centers around the world. Questions about the safety of the surgery and its adequacy as a cancer operation remain hurdles for many surgeons. METHODS: We performed a systematic review of the literature on VATS lobectomy to assess these questions. The MEDLINE database was queried and the papers analyzed. RESULTS: Four randomized control trials, 11 case-control series, and 10 case series were reviewed. A variety of VATS techniques are used, making generalization of results difficult. The weight of this evidence suggests that VATS lobectomy can be safely performed and is an adequate cancer operation for early stage non-small cell lung cancer. There is also evidence that patients experience less pain with VATS, but that length of hospital stay is similar. CONCLUSION: In expert hands, VATS lobectomy appears to be a safe procedure. However, the published evidence is thin and ongoing study is required, preferably with standardization of VATS techniques.     

早期拔除胸腔引流管在胸腔镜肺部手术后的应用

目的探讨胸腔镜肺部手术后早期拔除胸腔引流管的可行性和安全性,探索胸腔引流管的拔除指征。 方法选择2019年11月至2020年4月在南京大学医学院附属鼓楼医院行胸腔镜肺部手术,并于术后早期(48 h内)拔除胸腔引流管患者117例作为观察组;另外选择2018年11月至2019年4月在南京大学医学院附属鼓楼医院行胸腔镜肺部手术,但术后非早期拔除胸腔引流管患者114例作为对照组。两组在年龄(P＝0.476)、性别(P＝0.216)、术式(P＝0.715)、是否行纵隔淋巴结清扫或采样(P＝0.200)、目标肺叶(P＝0.925)、病变性质(P＝0.957)方面均差异无统计学意义。回顾性分析两组患者术后临床结果、拔除引流管后并发症及再次行胸腔引流情况。 结果观察组和对照组拔管前24 h引流量[(245.7±98.1)ml比(120.8±46.8)ml,P<0.001]、术后引流时间[(43.9±2.6)h比(84.5±10.5)h,P<0.001]、术后住院时间[(2.2±0.4)d比(4.2±1.1)d,P<0.001]、住院费用[(5.3±0.4)万元比(5.6±0.3)万元,P<0.001]、拔管后疼痛视觉模拟评分(visionl analogue scale, VAS) [(4.4±1.2)分比(3.3±1.2)分,P<0.001]、拔管后总体并发症发生率(20.5%比10.5%,P＝0.036)差异有统计学意义,观察组拔管前后VAS [(5.9±0.8)分比(4.4±1.2)分,P<0.001]和对照组拔管前后VAS [(6.0±0.9)分比(3.3±1.2)分,P<0.001]差异有统计学意义。观察组和对照组拔管前VAS [(5.9±0.8)分比(6.0±0.9)分,P＝0.464]、拔管后气胸(1.7%比0.9%,P>0.999)、胸腔积液(12.8%比6.1%,P＝0.084)、皮下气肿(2.6%比1.8%,P>0.999)、发热(3.4%比1.8%,P＝0.703)、再次行胸腔引流(2.6%比1.8%,P>0.999)发生率差异无统计学意义。 结论虽然术后早期拔除引流管可能会增加拔除引流管后胸腔积液的发生率,但早期拔除引流管可以明显减轻患者术后疼痛,并且不会增加气胸、皮下气肿、发热的发生率,也不会增加再次行胸腔引流的风险。因此,胸腔镜肺部手术后早期拔除胸腔引流管是安全、可行的,有利于减轻患者经济负担,缩短住院时间,促进患者加速康复。     

《单孔胸腔镜手术治疗肺癌中国专家共识》解读

单孔胸腔镜手术是肺癌微创治疗的重要方式.2010年,单孔胸腔镜手术首次应用于肺癌治疗;2019年、2020年,欧洲共识和中国共识相继发表.最新发表的中国共识分别从单孔胸腔镜手术的定义、用于肺癌治疗的适应证、安全性及可行性、手术技巧、学习曲线、短期及长期结果等方面为单孔胸腔镜手术标准化提供建议,对提高手术质量及减少相关并...