Chunyu Ji

Pulmonary function changes after different extent of pulmonary resection under video-assisted thoracic surgery

BackgroundnLimited resections for early stage lung cancer have been of increasing interests recently. However, it is still unclear to what extent a limited resection could preserve pulmonary function comparing to standard lobectomy, especially in the context of minimally invasive surgery. The purpose of this study was to evaluate postoperative changes of spirometry in patients undergoing video-assisted thoracic surgery (VATS) lobectomy or limited resections.nnnMethodsnSpirometry tests were obtained prospectively before and 6 months after 75 VATS lobectomy, 34 VATS segmentectomy, 15 VATS wedge resection. Eleven VATS mediastinal procedures without lung resection were taken as a control group. Results were compared between groups of different resection extent.nnnResultsnDemographic characteristics and preoperative pulmonary function showed no differences among the four groups. Forced vital capacity (FVC) loss after lobectomy was significantly greater than after segmentectomy (P=0.048), and much significantly greater than after wedge resection (P<0.001). Forced expiratory volume in 1 second (FEV1) loss after lobectomy was similar to segmentectomy (P=0.273), both significantly greater than after wedge resection (P<0.01). Diffusing capacity of the lungs for carbon monoxide (DLCO) loss was similar among these three groups (P=0.293). There was no significant difference in any spirometry index between wedge resection and mediastinal procedures (FVC: P=0.856; FEV1: P=0.671; DLCO: P=0.057). When compared by average value per segment resected, pulmonary function loss was significantly less after lobectomy than after segmentectomy in all spirometry indexes (P<0.001). On average, pulmonary function loss was around 5% per segment for VATS lobectomy and 10% per segment for VATS segmentectomy.nnnConclusionsnIn minimal invasive surgery, wedge resection best preserves pulmonary function with similar spirometry change with VATS mediastinal procedures without lung resection. Compared with VATS lobectomy, VATS segmentectomy may help minimize loss of FVC but not FEV1 or DLCO. Pulmonary function loss per segment resected is doubled after VATS segmentectomy than after lobectomy. These results should be taken into account when deciding the extent of resection for patients with early stage lung cancer.

A multi-center retrospective study of single-port versus multi-port video-assisted thoracoscopic lobectomy and anatomic segmentectomy

BackgroundnTo assess the feasibility and perioperative outcomes of single-port (SP) and multi-port (MP) approaches for video-assisted thoracoscopic surgery (VATS) lobectomy and anatomical segmentectomy.nnnMethodsnRetrospective data from 458 patients who received VATS lobectomy or anatomical segmentectomy at Shanghai Chest Hospital, Korea University Guro Hospital, Affiliated Hospital of National Taiwan University, University of Hong Kong Queen Mary Hospital and Shenzhen Hospital were collected. Patients were divided into SP group and MP group according to the surgical approach. Perioperative factors such as operation time, blood loss during surgery, conversion rate, the number and stations of lymph nodes harvested, postoperative chest tube drainage time, postoperative hospitalization time, perioperative morbidity and mortality, and pain scores during the first 3 days after surgery were compared between the two groups.nnnResultsnThere were no differences in the number (P=0.278) and stations (P=0.564) of lymph nodes harvested, postoperative morbidity (P=0.414) or mortality(P=0.246), and pain score on the third day (P=0.630) after surgery between the two groups. The SP group had a longer operation time (P=0.042) and greater intraoperative blood loss (P<0.001), but the conversion rate was even higher in the MP group (P=0.018). Patients in the SP group had shorter chest tube removal time (P=0.012) and postoperative hospitalization time (P=0.005). Pain scores were lower on the first (P=0.014) and second (P=0.006) day after surgery in the SP group.nnnConclusionsnSP VATS lobectomy and anatomical segmentectomy is technologically more demanding than MP VATS. It can be safe and feasible in the hands of experienced surgeons, with comparable preoperative outcomes to MP VATS, but less pain in the early postoperative period.

Minimally invasive thymectomy for locally advanced recurrent thymoma

BACKGROUNDnMinimally invasive thymectomy for early stage thymoma patients has been shown to yield similar oncological results while being helpful in reducing surgical trauma, improving postoperative recovery, and diminishing incisional pain. However, patients with locally advanced tumors, preoperative induction therapies, or prior history of mediastinal surgery have been considered as not suitable for video-assisted thoracoscopic surgery (VATS). This video aims to show that VATS thymectomy may also be feasible in reoperation for recurrent invasive thymoma in selected cases.nnnMETHODSnA 45-year-old female patient had recurrent type B2 thymoma in the anterior mediastinum 10 years after tumor resection through left thoracotomy. The lesion was in rcStage III. Reoperation was carried out via left approach VATS. The tumor was resected completely together with remnant thymus, pericardium, the left phrenic nerve, and the left innominate vein.nnnRESULTSnThe patient recovered uneventfully and was discharged on postoperative day 4. Pathologic study revealed an rpStage III type B tumor, invading the left phrenic nerve and the left innominate vein.nnnCONCLUSIONSnVATS thymectomy may also be feasible in locally advanced thymic tumors or recurrent diseases. In selected cases, VATS should at least be tried so that this subgroup of patients may also benefit from minimally invasive surgery.

Minimally invasive esophagectomy and thoraco-abdominal two-field lymph node dissection for thoracic esophageal squamous cell carcinoma—antegrade dissection of the thoracic esophagus

BACKGROUNDnMinimally invasive esophagectomy has been gaining increasing interest in management of early stage esophageal cancers. Similar oncological principles including radical removal of the tumor as well as systemic lymph node dissection should be observed, regardless of the surgical approach. Improvement in surgical techniques would help achieve comparable oncological outcomes while help patients benefit from the minimally invasive approach. This video introduces an antegrade dissection which is an alternative to the traditional retrograde esophagectomy for squamous cell carcinoma of the thoracic esophagus.nnnMETHODSnA 54-year-old male patient had a cT1bN0M0 (stage I) squamous cell carcinoma in the middle thoracic esophagus. The surgery selected was thoracoscopic-laparoscopic three-hole esophagectomy with thoraco-abdominal two-field lymph-adenectomy. In the chest part of the procedure, dissection was carried out in an antegrade fashion, from the apex of the chest downwards to the diaphragm. The thoracic esophagus and the tumor was resected en-bloc with surrounding connective tissue. Thorough lymph node dissection was carefully completed, with special attention paid to those along the bilateral recurrent laryngeal nerves.nnnRESULTSnThe patient recovered uneventfully and was discharged on postoperative day 6. Pathologic study revealed a pT1bN1M0 (stage IIb) tumor, with lymphatic involvement detected in a right recurrent nerve node.nnnCONCLUSIONSnWith the help of minimally invasive approach, rapid recovery from the extensive esophagectomy could be expected. However, it is critically important to make sure that the same oncological principles including a radical resection margin and a thorough lymph node dissection should also be observed. For the thoracic part of the procedure, an antegrade dissection could help achieve this goal, while making surgical maneuver simpler and safer.