Surgical techniques and outcome analysis of uniportal video-assisted thoracic surgery complex sleeve lung resection: a 20 case-series study.

BACKGROUND: Our study aims to explore the feasibility of uniportal video-assisted complex sleeve lung resection and summarize the surgical techniques and clinical outcomes. METHODS: From June 2016 to April 2020, a total of 20 complex sleeve pulmonary and distal tracheal resections were performed by the single surgical team at the Thoracic Surgery Department of the Shanghai Pulmonary Hospital. We defined cases as complex sleeve pulmonary resections if they required pulmonary segment sleeve resection, extended sleeve resection (lobectomy plus segmentectomy of the remaining lobe), sleeve pneumonectomy, lobectomy plus carinoplasty or neo-carina construction, pulmonary-sparing main bronchus resection plus carina reconstruction, and distal trachea resection with end to end anastomosis. RESULTS: The 20 cases comprised lung squamous cell carcinoma (n=11), lung adenocarcinoma (n=2), hamartoma (n=3), adenoid cystic carcinoma (n=2), carcinoid tumor (n=1), and pleomorphic carcinoma (n=1). The average blood loss during the operation was 250±126.17 mL (50-800 mL). The average operation time was 192.0±61.1 minutes. The average number of lymph node stations removed was 5.82±1.33, including station seven in all cases, and the median number of lymph nodes removed was 4.18±5.89. On the day of surgery, the drainage volume was 266±192.01 mL. The mean postoperative hospital stay was 5.37±1.86 days. Twelve of the 16 patients diagnosed with malignancy received postoperative chemotherapy. Granuloma formation at the anastomosis level led to stenosis in one case, and tumor recurrence occurred in one case. Broncho-esophageal fistula occurred in one patient after radiochemotherapy. The postoperative follow-up time was 15.6±10.7 months. The 30-day mortality was zero, and at one-year follow-up, only one patient had died of metastatic disease after the operation. CONCLUSIONS: Uniportal video-assisted complex sleeve pulmonary resections are feasible when conducted by experienced teams.

Outcomes of sleeve lobectomy versus pneumonectomy: A propensity score-matched study.

OBJECTIVES: To compare short- and long-term outcomes between sleeve lobectomy and pneumonectomy for lung cancer in a single center during a 15-year period. METHODS: One thousand nine hundred eighty-one patients who underwent either a sleeve lobectomy (n = 964; 48.7%) or a pneumonectomy (n = 1017; 51.3%) from January 2003 to December 2017 at the Shanghai Pulmonary Hospital, were matched according to a propensity score to produce 2 groups of 665 patients each. The study period was divided into 3 5-year subperiods. RESULTS: Sleeve lobectomy was associated with a lower 30- and 90-day mortality (0.60% and 0.90% vs 1.5% and 3.91%; P = .177 and P = .001, respectively, after matching), lower morbidity (4.36% vs 8.16%; P = .005 before matching, 3.61% vs 8.72%; P < .001 after matching), improved 5-year survival (62.7% vs 43.1%; P < .001 before matching and 61% vs 44.7%; P < .001 after matching), and 5-year disease-free survival after matching (56.6% vs 46.2%; P < .001). The sleeve lobectomy to pneumonectomy ratio increased by 78%, whereas 90-day mortality decreased by 66.81% between the first and the last subperiods. CONCLUSIONS: Sleeve lobectomy is associated with improved short- and long-term outcomes and should be the resection of choice for centrally located lung cancers, when feasible.

Uniportal video-assisted thoracoscopic lung sparing tracheo-bronchial and carinal sleeve resections.

Pathology arising from the intrathoracic portion of the trachea (distal trachea), the carina and the main bronchi is usually neoplastic and is mainly treated with surgery. Resection of the intrathoracic portion of the trachea, the carina and the main bronchi for neoplastic lesions does not necessitate lung resection and is traditionally being conducted via open surgery. Video-assisted thoracic surgery (VATS) is witnessing an exponential growth and is the treatment of choice for early-stage non-small cell lung cancer (NSCLC). The experience accumulated over the past two decades along with the introduction of reliable and ergonomic technology, has led to the expansion of its indications. In this article we provide a detailed description of lung sparing distal tracheal, carinal and main bronchi resection for primary neoplasms of the airway, without involvement of the lung, with the uniportal video-assisted technique. The chest is entered through the fourth intercostal space, mid-axillary line. Dissection of the paratracheal space anteriorly, the tracheoesophageal groove posteriorly and the subcarinal space and division of the azygos arch are essential to mobilize the distal trachea and carina. Lateral dissection should be avoided beyond the points of division of the airway, as it may hinder the blood supply to the anastomosis. Any tension to the anastomosis should be relieved by release maneuvers. Ventilation is achieved through an endobronchial catheter, inserted into the left main bronchus through which a high-frequency jet ventilation catheter can be also inserted through it. The rationale of applying a minimally invasive technique for the conduction of tracheal and carinal resections, is to exploit its advantages, namely less pain, earlier mobilization and lower morbidity. Uniportal video-assisted resections of the distal trachea, carina and the main bronchi, are safe when conducted by experienced surgical and anesthetic teams.

Devising the guidelines: the concept of uniportal video-assisted thoracoscopic surgery-incisions and anesthetic management.

Uniportal video-assisted thoracoscopic surgery (VATS) is an already established minimally invasive technique in the field of thoracic surgery. The feasibility, safety and efficacy of the technique are already well documented. Comparative studies and meta-analyses have shown a clear advantage over open surgery and other minimally invasive techniques in terms of pain, length of stay (LOS), chest drain duration and morbidity. It covers a broad spectrum of indications for both malignant and benign diseases, including pulmonary and mediastinal tumor resections, diaphragm procedures (plication), esophageal surgery and airway surgery (bronchial resections, carinal resections). Its swift and wide adoption has resulted into many variations, all of whom are common in the fact they utilize a single incision to enter the chest and conduct the planned procedure. With this article, we attempt to standardize the technique as to the incision and the anesthetic management.

Technique and outcomes of 79 consecutive uniportal video-assisted sleeve lobectomies.

OBJECTIVES: Uniportal video-assisted thoracic surgery (VATS) is well accepted by surgeons for anatomical major lung resections. However, large series evaluating the results, safety and efficacy of the technique for sleeve resections are still lacking. The aim of this study was to examine our experience with the use of uniportal VATS for sleeve resections. METHODS: From September 2014 to January 2018, a total of 79 consecutive patients were offered uniportal VATS sleeve resection for centrally located tumours invading the orifice of the lobar bronchus or extending into the main stem bronchus by a single surgical team of the Thoracic Surgery Department of the Shanghai Pulmonary Hospital. Perioperative data were collected and analysed. Survival data were collected via telephone calls. RESULTS: Sixty-six of the 79 patients had a diagnosis of non-small-cell lung cancer, 47 of whom had squamous cell carcinoma. Twenty-one of the group with non-small-cell carcinoma were already at an advanced stage (III, IV) when operated on. The mean number of lymph node stations dissected was 5.5 ± 0.97 (4-8) and that of lymph nodes harvested was 13.7 ± 3.7 (5-23). A right upper lobectomy was the most common and time-consuming procedure. There was 1 conversion to a thoracotomy due to bleeding. No anastomotic-related complications were noted. The mean length of stay was 5.14 ± 1.56 (2-11) days. The 1- and 2-year survival rates were 98% and 80%, respectively. CONCLUSIONS: Uniportal VATS sleeve resection is a safe and efficient procedure for the treatment of centrally located tumours otherwise requiring a pneumonectomy.