Ze-Rui Zhao

Comparison of Segmentectomy and Lobectomy in Stage IA Adenocarcinomas

Introduction: Recent studies have suggested that segmentectomy may be an acceptable alternative treatment to lobectomy for surgical management of smaller lung adenocarcinomas. The objective of this study was to compare survival after lobectomy and segmentectomy among patients with pathological stage IA adenocarcinoma categorized as stage T1b (>0 to ≤20 mm) according to the new eighth edition of the TNM system. Methods: In total, 7989 patients were identified from the Surveillance, Epidemiology, and End Results registry. Propensity scores generated from logistic regression on preoperative characteristics were used to balance the selection bias of undergoing segmentectomy. Overall and lung cancer–specific survival rates of patients undergoing segmentectomy and lobectomy were compared in propensity score–matched groups. Results: Overall, 564 patients (7.1%) underwent segmentectomy. Lobectomy led to better overall and lung cancer–specific survival than segmentectomy for the entire cohort (log‐rank p < 0.01). After 1:2 propensity score matching, segmentectomy (n = 552) was no longer associated with significantly worse overall survival (5‐year survival = 74.45% versus 76.67%, hazard ratio = 1.09, 95% confidence interval: 0.90–1.33) or lung cancer–specific survival (5‐year survival = 83.89% versus 86.11%, hazard ratio = 1.12, 95% confidence interval: 0.86–1.46) compared with lobectomy (n = 1085) after adjustment for age, sex, lymph node quantity, and histological subtype. Similar negative findings were identified when patients were stratified according to sex, age, histological subtype, and number of evaluated lymph nodes. Conclusions: Patients who underwent segmentectomy may have survival outcomes no different than those of some patients who received lobectomy for pathological stage IA adenocarcinomas at least 10 but no larger than 20 mm in size. These results should be further confirmed through prospective randomized trials.

Image-guided localization of small lung nodules in video-assisted thoracic surgery

The advancement of imaging technology has recently facilitated single port minimally-invasive thoracic surgery techniques. Cone-beam computed tomography (CBCT) shows promising results in visualizing the target lesion and its surrounding critical anatomy, with an error of less than 2 mm. The integration of CBCT with the operating room (OR) to form the hybrid OR, provides unparalleled real-time imaging of the patient, which can be used with electromagnetic navigation bronchoscopy to confirm successful navigation and increase procedural accuracy particularly for small peripheral pulmonary targets. Furthermore, implantation of hookwires or microcoils that are widely used to localize the lesion can take place in the hybrid suite, eliminating the common complications and discomfort associated with the conventional workflow carried out in the radiology suite. Displacement leading to localization failure can be also reduced, and sublobar resection will be performed without resecting a larger area of parenchyma than desired. This one-stop, paradigm-shifting concept for simultaneously diagnosing and managing small pulmonary lesions in the hybrid OR can lead to reduced invasiveness and improved patient care.

Recent clinical innovations in thoracic surgery in Hong Kong

The concept of personalized medicine, which aims to provide patients with targeted therapies while greatly reducing surgical trauma, is gaining popularity among Asian clinicians. Single port video-assisted thoracic surgery (VATS) has rapidly gained popularity in Hong Kong for major lung resections, despite bringing new challenges such as interference between surgical instruments and insertion of the optical source through a single incision. Novel types of endocutters and thoracoscopes can help reduce the difficulties commonly encountered during single-port VATS. Our region has been the testing ground and has led the development of many of these innovations. Performing VATS, in particular single-port VATS in hybrid operating theatre helps to localise small pulmonary lesions with real-time images, thus increasing surgical accuracy and pushes the boundaries in treating subcentimeter diseases. Such approach may be assisted by use of electromagnetic navigational bronchoscopy in the same setting. In addition, sublobar resection can also be more individualised according to pathologic tumour subtype that require rapid intraoperative diagnostic test to guide appropriate surgical therapy. A focus on technology and innovation for large tumours that require chest wall resection and reconstructions have also been on going, with new materials and prostheses that may be tailored to each individual needs. The current paper reviews the literature pertaining to the above topics and discusses recent related innovations in Hong Kong, highlighting the study results and future perspectives.

Hybrid Theater and Uniportal Video-Assisted Thoracic Surgery: The Perfect Match for Lung Nodule Localization

Cone-beam computed tomography provides unparalleled real-time imaging of the patient within the hybrid theater, which can be used for simultaneously diagnosing and localizing small pulmonary lesions for resection. Hybrid theater can guide more precise placement of electromagnetic navigation bronchoscopy tools, thereby increasing the diagnostic yield in biopsy procedures while reducing diffusion artifact in dye marking for nodule localization. Furthermore, hook-wires implantation that is widely used to assist in lesion localization for uniportal thoracoscopic surgery can take place in the hybrid suite, eliminating the common complications and discomfort associated with the conventional workflow carried out in the radiology suite.

Multi-dimensional printing in thoracic surgery: current and future applications

Three-dimensional (3D) printing has been gaining much attention in the medical field in recent years. At present, 3D printing most commonly contributes in pre-operative surgical planning of complicated surgery. It is also utilized for producing personalized prosthesis, well demonstrated by the customized rib cage, vertebral body models and customized airway splints. With on-going research and development, it will likely play an increasingly important role across the surgical fields. This article reviews current application of 3D printing in thoracic surgery and also provides a brief overview on the extended and updated use of 3D printing in bioprinting and 4D printing.

Anaesthesiology for uniportal VATS: double lumen, single lumen and tubeless

The advent of one-lung ventilation (OLV) technique provides immobilized surgical field which is fundamental in minimally invasive thoracic surgery. Mainstem methods of achieving lung separation are either via a double-lumen endotracheal tube or placing a bronchial blocker (BB) through a single-lumen endotracheal tube. More recently, the use of non-intubated thoracic surgery (NITS) has been investigated intensively, attempting to minimise the complications that follow general anaesthesia. The aim of this review is to describe the mechanism of these techniques briefly and outlines the advantages and drawbacks of them with the comparison.

Laser resection of pulmonary nodule via uniportal thoracoscopic surgery

Uniportal video-assisted thoracic surgery (VATS) lung wedge resection usually requires three devices, thoracoscope, lung retracting instrument and an endo-stapler cutter to perform the procedure. With advances in miniaturization of the thoracoscope and lung retracting instruments, a major limitation to operating through a smaller uniportal incision has become the endo-stapler. We describe the surgical technique for uniportal VATS laser lung resection which uses a much narrower laser catheter device to replace the endo-stapler for resection. The new approach to limited lung resection can potentially reduce instrument fencing and the uniportal incision wound size, while achieving satisfactory hemostasis and pneumostasis.

Catheter-based alternative treatment for early-stage lung cancer with a high-risk for morbidity

The mainstream treatment modality for early stage non-small cell lung cancer (NSCLC) is surgery; however, many patients are deemed inoperable and warrant alternative therapeutic options. Several minimally invasive catheter-based therapies are emerging as viable alternatives. In this review, we evaluate the outcomes from radiofrequency ablation (RFA), microwave ablation (MWA), cryoablation (CRA) and photodynamic therapy (PDT) for early-stage lung cancer. Novel technical developments have allowed for endobronchial thermal ablation to be conducted in a hybrid theatre setting, which may optimize treatment outcomes and minimise treatment-related complications.

Tri-modality treatment in N2 stage IIIa non-small cell lung cancer: proper sequence remains unknown

Pathologic stage IIIA non-small cell lung cancer (NSCLC) is a challenging disease to treat and the role of postoperative radiotherapy (PORT) in patients following resection remains controversial.

Robotic lobectomy: an essential addition to the minimally invasive armory

As the only robotic system approved by the United States Food and Drug Administration for lung surgery, the Da Vinci System (Intuitive Surgical, Sunnyvale, CA, USA) is gaining popularity worldwide as an important alternative to the conventional minimally invasive surgical approach of video-assisted thoracic surgery (VATS). The robotic system is considered a significant evolution in the development of surgical tools, allowing the surgeon to view the surgical site in three dimensions and perform the operation via a console located near the operating table. The endo-wrist instruments attached to the robotic arms provide a wide range of precision movements with greater dexterity. Moreover, the hand tremor of the surgeon can be filtered out by using a 6-Hz motion filter, which guarantees precise micro-movement around vital structures.