Benedetta Bedetti

Segmentectomy versus lobectomy for stage I non-small cell lung cancer: a systematic review and meta-analysis

BACKGROUND In recent years, many factors have revamped the interest in segmentectomies as preferred procedure for stage I non-small cell lung cancer (NSCLC). The aim of this systematic review and meta-analysis is to compare the outcomes of segmentectomy versus lobectomy regarding overall survival (OS) in the surgical treatment of stage I NSCLC, as stated in the conclusions of the largest studies conducted in this field and reported to date. METHODS The searching strategy was developed in EMBASE, MEDLINE and Cochrane CENTRAL from 1990 until December 2016. The meta-analysis was performed with the combination of the reported survival outcomes of the individual studies using a random effect model. The OS of the lobectomy group was compared with the segmentectomy group alone. The hazard ratio (HR) and standard error were extracted or calculated for each study using the Kaplan-Meier method. RESULTS Regarding the results, most of these studies were based on the retrospective data. The size of the cohorts varied from 17 to 11,520, with a total number of 24,542 patients. The pooled HR was 1.04 [95% confidence interval (CI), 0.92-1.18; P=0.50]. CONCLUSIONS The survival in the segmentectomy group was not inferior to patients treated with lobectomy. In conclusion, the current meta-analysis disclosed that segmentectomies produce similar survival compared to lobectomy for patients with stage I NSCLC. To establish the role of segmentectomy in early NSCLC, more evidence is needed, in particular, a large numbered, prospective, randomised trials, which should dissolve the uncertainties and the questions raised by retrospective data.

Learning curve and established phase for uniportal VATS lobectomies: the Papworth experience

BACKGROUND Uniportal video-assisted thoracoscopy (VATS) has increasingly gained importance in the thoracic surgery scenario. The use of this technique can reduce postoperative pain and length of stay and gives the surgeon the same operative perspective as open surgery. METHODS We retrospectively analysed the data of 73 patients who underwent uniportal VATS lobectomies from November 2014 to December 2015 in our institution. We divided the patients in two groups (group 1: first 30 patients vs. group 2: established phase, 43 patients) to compare and evaluate the data regarding the learning curve. To explore evolution of learning curve, data were plotted to calculate Spearmans Rank-Order Correlation. R (version 3.2.3) was used for statistical analysis. RESULTS The median age was 69.9 (group 1) and 68.8 (group 2) years. Mean operative time was 84.9±33.0 (group 1) and 84.8±31.5 (group 2) minutes. The conversion rate was 13.3% in group 1 vs. 9.3% in group 2, showing a significant learning reduction (rho=0.590). Overall morbidity rate was 15.1%. The most common complication consisted in prolonged air leak. Interpolation line of complications showed a significant decrease due to learning curve (rho=0.676). The median length of stay was 4 days in group 1 vs. 3 days in group 2. The 30-day mortality was 3.3% in group 1 and 0% in group 2. CONCLUSIONS The comparison between the groups showed that the median length of stay, operative time, conversion rate and 30-day mortality statistically significantly improved in the established phase. Also, complications like prolonged air leak were decreasing in the established phase. In conclusion, the uniportal VATS lobectomy technique can be performed safely from experienced surgeons without major complications and with an acceptable mortality rate.

Non-intubated awake uniportal VATS: how to start?

The history of thoracoscopic surgery started more than 100 years ago when Hans Christian Jacobaeus, a Swedish internist, performed and described in 1910 a procedure to treat pleural adhesions and tuberculosis. After the 1950s with the success of the medical treatment against tuberculosis, the “Jacobaeus operation” was gradually abandoned until the 1970s when some pulmonologists became the reference persons for the thoracoscopy, especially in Continental Europe.

Pros-cons debate about the role and evolution of uniportal video-assisted thoracic surgery (VATS)

Uniportal video-assisted thoracic surgery (VATS) is the latest advancement in minimally invasive surgery, combining the advantages of triportal thoracoscopic surgery, such as less pain or paresthesia and faster recovery, with optimal cosmetic outcomes. The uniportal access was first described by Marcello Migliore and Gaetano Rocco for minor thoracic procedures like wedge resection (1,2) and nowadays, thanks to the gained experience in the past years, more complex cases are performed hence expanding the indications for single-incision thoracoscopic surgery.

Uniportal non-intubated thoracic surgery

Uniportal video-assisted thoracoscopic surgery (VATS) is the most advanced evolution of the minimally invasive technique, which allows often the possibility to include patients in enhanced recovery programs in order to optimize the therapeutic pathway, shorten the length of stay and reduce hospital costs. Non-intubated VATS procedures allow the performance of surgeries with minimal sedation without general anesthesia, maintaining throughout the operation spontaneous breathing. The principle is to create an iatrogenic spontaneous pneumothorax, which can provide a good lung isolation without the need of a double lumen tube. A survey between the members of the European Society of Thoracic Surgery (ESTS) showed that non-intubated VATS procedures are already performed by a large number of ESTS members for minor procedures. With the publication of new data and the spreading of uniportal VATS in many centers worldwide in the last decades, the application of the non-intubated technique in major procedure like anatomic resections is expected to grow. This technique can potentially be beneficial for high-risk patients but also could be used for the routine procedures as well, but more data are needed to establish the real benefit for these groups of patients.

Management of Intraoperative Difficulties During Uniportal Video-Assisted Thoracoscopic Surgery

The learning curve of the uniportal video-assisted thoracoscopic surgery (VATS) approach is linked to a larger rate of intraoperative complications, which can lead to an emergency conversion to thoracotomy. Despite technical advancements and the large number of surgical videos posted on specialized websites, live surgery events and experimental courses have significantly contributed to accelerate the learning and evolution of minimally invasive thoracic surgery. Bleeding and other complications are the most dreaded event for many VATS surgeons. This article analyzes possible major intraoperative complications during uniportal VATS and explains how to manage them effectively and safely.

Left sided lobectomies

Lobectomies can be performed in case of both malignant and non-malignant lung diseases. Preoperative assessment is fundamental and should always include lung function tests, as the patients should have an adequate pulmonary reserve in order to tolerate the resection. Video-assisted thoracoscopic (VATS) lobectomies are increasingly performed as standard for early stage lung cancer, so the indication for open approaches are evolving and often depends on the surgeon’s experience with VATS techniques. In the paper is described the technique for left sided lobectomies step by step.

Uniportal video-thoracoscopic mediastinal lymphadenectomy

Systemic mediastinal lymphadenectomy has a key role in lung cancer surgery, as it permits to define the pathological staging and therefore the treatment and the prognosis of the patients. Currently the video-assisted thoracoscopic approach is the most common technique to remove these tumours, if technically feasible. Particularly the uniportal approach provides with the best anatomic instrumentation and a direct view. In this paper, we describe our technique to perform a safe an effective radical mediastinal lymphadenectomy.

Technical steps in single port video-assisted thoracoscopic surgery lobectomy

Video-assisted thoracoscopic surgery (VATS) has transformed the way of treating patients with lung diseases over the past two decades and this is particularly true referred to patients with lung carcinoma. The indication for surgical treatment could be extended to those patients that were functionally unable to receive a thoracotomy and overall this approach shortened the length of stay in hospital and improved the quality of life of these patients postoperatively. The best VATS technique for lobectomy has not been well defined yet. The VATS approach to lobectomy can be performed via 1-4 incisions without rib spreading with similar outcomes. Over the last few years the single port VATS approach has generated a growing interest in the scientific thoracic surgery community as less invasive for the patients and comfortable for the performing surgeon. The aim of this video-article is to show the different steps of this technique and to provide some tips and tricks to improve and facilitate the execution of the uniportal VATS lobectomy.

Commentary on the article “Radioguided video-assisted resection of non-palpable solitary pulmonary nodule/ground glass opacity: how to do it”

The article describes the radioguided localization technique of small lesions (maximum nodule diameter 99m technetium macro-aggregate albumin diluted with iodized contrast medium. This allows the stability of the radiotracer in the lung for up to 18 hours for an optimal planning of the surgical resection. A CT scan was performed to confirm the precise staining. Then a VATS with three ports was performed and the gamma detector was inserted inside the chest to localize the tracer and the parenchyma was grasped in its correspondence. After a double check of the tracer’s position with the gamma detector, the resection was performed and the sample was sent for histologic examination (frozen section). In case of diagnosis of lung cancer, a VATS lobectomy was performed.