Norihiko Ikeda

Cine MRI enables better therapeutic planning than CT in cases of possible lung cancer chest wall invasion

THE OBJECTIVEnTo evaluate the hypothesis that lung cancer treatment planning (whether or not to use induction therapy) can be improved if respiratory dynamic cine magnetic resonance imaging (RD MR) is used.nnnMETHODnWe studied 100 lung cancer patients, 76 men and 21 women, scheduled for thoracotomies between May 1997 and December 2006 wherein it was unclear preoperatively whether chest wall invasion would be found. We evaluated the accuracy of RD MR as compared with the findings at operation and postoperative pathology. The accuracy of RD MRI for evaluating chest wall invasion was compared with the efficacy of CT and MRI within our own group of patients and with data from the studies of other investigators.nnnRESULTSnConcerning the evaluation of chest wall invasion, conventional computed tomography (CT) had 43.9% specificity, 60.0% sensitivity and 47.1% accuracy, while RD MR had 68.5% specificity, 100.0% sensitivity and 77.0% accuracy. RD MRI was particularly useful in the evaluation of cancers around 5 cm in diameter that were located adjacent to the diaphragm. Postoperative evaluation of superior sulcus tumor cases that had received induction therapy also showed that the RD MR procedure enabled an accurate decision in 87.5% of cases, and there were no false negative cases.nnnCONCLUSIONSnRD MR is more useful than CT or standard MRI for evaluating thoracic wall invasion. This noninvasive method enhances the reliability of deciding whether induction therapy should be employed.

High-quality 3-dimensional image simulation for pulmonary lobectomy and segmentectomy: results of preoperative assessment of pulmonary vessels and short-term surgical outcomes in consecutive patients undergoing video-assisted thoracic surgery

OBJECTIVESnThe aim of this study was to evaluate the effectiveness of 3-dimensional computed tomography (3D-CT) software in short-term surgical outcomes and the assessment of variations of pulmonary vessel branching patterns on performing video-assisted thoracic surgery (VATS).nnnMETHODSnThe study included 179 consecutive patients who had undergone VATS anatomical lung resection, of which 172 were lobectomies (96%) and 7 were segmentectomies (4%), from May 2011 through January 2013. There were 124 patients (69%) in whom 3D-CT was performed and 55 patients (31%) who had not undergone 3D-CT. Observed actual pulmonary vessel branching patterns by intraoperative findings or footage were compared with the 3D image findings. Various surgical outcomes, including the occurrence of postoperative complications, in this study defined as those of Grade 2 or above under the Clavien-Dindo classification system, and total operative time, were retrieved from available clinical records.nnnRESULTSnAmong the 124 patients with preoperative 3D imaging, there were 5 (4%) conversions from VATS to thoracotomy. The incidence rate of patients with postoperative complications was 8% (n = 10), and there were no 30-day or 90-day mortalities. Pulmonary artery (PA) branches were precisely identified for 97.8% (309 of 316) of branches on 3D images, and the sizes of the seven undetected branches (five in the right upper lobe, two in the left upper lobe) ranged from 1 to 2 mm. The 3D images accurately revealed 15 cases (12%) of anomalous or unusual PA branches and 5 cases (4%) of variant pulmonary veins. Multivariate logistic regression analysis of the association with postoperative complications and operative time in 165 lung cancer patients demonstrated that male gender was the only statistically significant independent predictor of complications (risk ratio: 5.432, P = 0.013), and patients without 3D imaging tended to have operative complications (risk ratio: 2.852, P = 0.074), whereas conducting the 3D-CT (risk ratio: 2.282, P = 0.021) as well as intraoperative bleeding amount (risk ratio: 1.005, P = 0.005) had significant association with operative time.nnnCONCLUSIONSnHigh-quality 3D-CT images clearly revealed the anatomies of pulmonary vessels, which could play important roles in safe and efficient VATS anatomical resection.

Extended indications for robotic surgery for posterior mediastinal tumors

Previously, we evaluated use of the da Vinci Surgical System for anterior and middle mediastinal tumors in clinical cases, focusing on feasibility, safety, and appropriate settings. In this study, we evaluated extending the indications for robotic surgical treatment of posterior mediastinal tumors to include those located adjacent to the upper vertebrae or aorta. Three patients with mediastinal tumors located immediately adjacent to the vertebrae or aorta, underwent resection with the da Vinci Surgical System. All resected tumors were benign histologically. Robotic surgery enabled treatment of tumors located in the posterior mediastinum, which are very difficult to reach, making resection with the conventional video-assisted thoracoscopic surgery technique extremely difficult. All procedures were performed safely, smoothly, and extremely precisely. Crucial to the success of these operations were the appropriate placement and angle of the special da Vinci surgical ports in relation to the target and the patient’s position, which varied according to the tumor location.

Appropriate set-up of the da Vinci® Surgical System in relation to the location of anterior and middle mediastinal tumors

The da Vinci® Surgical System (dV) and its later version [da Vinci S® Surgical System (dVS)] have been used only in very few cases in selected thoracic surgical areas in Japan. Recently, we used the dV and dVS for various types of anterior and middle mediastinal tumors in clinical practice. We report our experience, and review the settings which depended on tumor location. Six patients gave written informed consent to undergo robotic surgery using the dV or dVS. We evaluated the feasibility, safety and appropriate settings of this system for the surgical treatment of mediastinal tumors. Tumor dissection was performed by two specialists in thoracic surgery certified to use the dV and dVS, and another specialist who acted as an assistant. We were able to access difficult-to-reach areas like the mediastinum. All the resected tumors were classified as benign tumors histologically. Crucial to the success of these operations was the set-up of the dV, which varied according to the location of mediastinal tumors. Robotic surgery enables various types of mediastinal tumor dissection more safely and easily than conventional video-assisted thoracoscopic surgery (VATS). The dV requires the appropriate set-up configuration, which varies according to the location of the mediastinal tumor.

Virtual segmentectomy based on high-quality three-dimensional lung modelling from computed tomography images

OBJECTIVESnThe aim of this study was to demonstrate the feasibility and efficacy of a novel simulation software called, virtual segmentectomy.nnnMETHODSnWe developed the segmentectomy simulation system, which was programmed to analyse the detailed 3D bronchovascular structure and to predict the appropriate segmental surface and surgical margin, based on lung modelling from CT images.nnnRESULTSnWe have attempted this novel technique for 3 cases of pulmonary metastases and 1 case of multiple lung cancer. For validation, the predicted resection margin was compared with the actual resected specimen. The surgical surface, as estimated by the simulation, was compared with the surface of the specimen and a surgical video. To test its feasibility, the operation time, blood loss, durations of chest tube placement and hospitalization as well as pathological findings were assessed.nnnCONCLUSIONSnPreoperative simulation and intraoperative guidance by virtual segmentectomy could contribute significantly to determining the most appropriate anatomical segmentectomy and curative resection.

High-Speed 3-Dimensional Imaging in Robot-Assisted Thoracic Surgical Procedures

We used a high-speed 3-dimensional (3D) image analysis system (SYNAPSE VINCENT, Fujifilm Corp, Tokyo, Japan) to determine the best positioning of robotic arms and instruments preoperatively. The da Vinci S (Intuitive Surgical Inc, Sunnyvale, CA) was easily set up accurately and rapidly for this operation. Preoperative simulation and intraoperative navigation using the SYNAPSE VINCENT for robot-assisted thoracic operations enabled efficient planning of the operation settings. The SYNAPSE VINCENT can detect the tumor location and depictxa0surrounding tissues quickly, accurately, and safely. This system is also excellent for navigational and educational use.

Cost-Benefit Performance of Robotic Surgery Compared with Video-Assisted Thoracoscopic Surgery under the Japanese National Health Insurance System

BACKGROUNDnMedical economics have significant impact on the entire country. The explosion in surgical techniques has been accompanied by questions regarding actual improvements in outcome and cost-effectiveness, such as the da Vinci(®) Surgical System (dVS) compared with conventional video-assisted thoracic surgery (VATS).nnnOBJECTIVEnTo establish a medical fee system for robot-assisted thoracic surgery (RATS), which is a system not yet firmly established in Japan.nnnMETHODSnThis study examines the cost benefit performance (CBP) based on medical fees compared with VATS and RATS under the Japanese National Health Insurance System (JNHIS) introduced in 2012.nnnRESULTSnThe projected (but as yet undecided) price in the JNHIS would be insufficient if institutions have less than even 200 dVS cases per year. Only institutions which perform more than 300 dVS operations per year would obtain a positive CBP with the projected JNHIS reimbursement.nnnCONCLUSIONnThus, under the present conditions, it is necessary to perform at least 300 dVS operations per year in each institution with a dVS system to avoid financial deficit with current robotic surgical management. This may hopefully encourage a downward price revision of the dVS equipment by the manufacture which would result in a decrease in the cost per procedure.

Interventional management for benign airway tumors in relation to location, size, character and morphology

OBJECTIVEnTo select minimally stressful methods for patients with benign bronchial tumors, and evaluate interventional strategies in relation to location, size, character and morphology.nnnMETHODSnWe reviewed the indications and efficacy of various interventional bronchology techniques at our institution, including individual or combined laser resection, electrocautery, argon plasma coagulation and high radiofrequency snaring for the treatment of various types of benign bronchial tumors.nnnRESULTSnIt is essential to treat endoscopically that the tumor is visible and has a stalk and not invade beyond bronchial wall. By using combined techniques, no complications or recurrences were encountered.nnnCONCLUSIONSnInterventional bronchology techniques for benign bronchial tumors can be simple and safe, and therapeutic strategies should be designed in relation to location, size, character and morphology of tumors.

Three-dimensional multidetector computed tomography may aid preoperative planning of the transmanubrial osteomuscular-sparing approach to completely resect superior sulcus tumor.

The anterior transcervical-thoracic approach clearly exposes the subclavian vessels and brachial plexus. We believe that this approach is optimal when a superior sulcus tumor (SST) invades the anterior part of the thoracic inlet. However, this approach is not yet widely applied because anatomical relationships in this procedure are difficult to visualize. Three-dimensional tomography can considerably improve preoperative planning, enhance the surgeon’s skill and simplify the approach to complex surgical procedures. We applied preoperative 3-dimensional multidetector computed tomography to a case where an SST had invaded the anterior part of the thoracic inlet including the clavicle, sternoclavicular joint, first rib, subclavian vessels and brachial plexus. After the patient underwent induction chemotherapy, we performed the transmanubrial osteomuscular-sparing approach and added a third anterolateral thoracotomy with a hemi-clamshell incision and completely resected the tumor.

Maximizing Use of Robot-Arm No. 3 in Da Vinci–Assisted Thoracic Surgery

We have previously reported on the importance of appropriate robot-arm settings and replacement of instrument ports in robot-assisted thoracic surgery, because the thoracic cavity requires a large space to access all lesions in various areas of the thoracic cavity from the apex to the diaphragm and mediastinum and the chest wall. (1 - 3) Moreover, it can be difficult to manipulate the da Vinci Surgical System using only arms No. 1 and No. 2 depending on the tumor location. However, arm No. 3 is usually positioned on the same side as arm No. 2, and sometimes it is only used as an assisting-arm to avoid conflict with other arms ( Fig. 1 ). In this report, we show how robot-arm No. 3 can be used with maximum effectiveness in da Vinci-assisted thoracic surgery. [Figure: see text].