Quality of lymph node dissection and early recurrence in robotic versus thoracoscopic lobectomy for stage N1-2 non-small cell lung cancer: Eleven-year real-world data from a high-volume center.

BACKGROUND: The efficacy of lymph node dissection (LND) and oncological outcomes of robot-assisted (RL) versus video-assisted thoracoscopic lobectomy (VL) for non-small cell lung cancer (NSCLC) with nodal involvement remains controversial. This study aims to compare LND quality and early recurrence (ER) rate between RL and VL for stage N1-2 NSCLC patients based on eleven-year real-world data from a high-volume center. METHODS: Pathologic stage IIB-IIIB (T1-3N1-2) NSCLC patients undergoing RL or VL in Shanghai Chest Hospital from 2010 to 2021 were retrospectively reviewed from a prospectively maintained database. Propensity-score matching (PSM, 1:4 RL versus VL) was performed to mitigate baseline differences. LND quality was evaluated by adequate (≥16) LND and nodal upstaging rates. ER was defined as recurrence occurring within 24 months post-surgery. RESULTS: Out of 1578 cases reviewed, PSM yielded 200 RL and 800 VL cases. Without compromising perioperative outcomes, RL assessed more N1 and N2 LNs and N1 stations, and led to higher incidences of adequate LND (58.5 % vs. 42.0 %, p < 0.001) and nodal upstaging (p = 0.026), compared to VL. Notably, RL improved perioperative outcomes for patients undergoing adequate LND than VL. Finally, RL notably reduced ER rate (22.0 % vs. 29.6 %, p = 0.032), especially LN ER rate (15.0 % vs. 21.5 %, p = 0.041), and prolonged disease-free survival (DFS; hazard ratio = 0.837, p = 0.040) compared with VL. Further subgroup analysis of ER and DFS within the cN1-2-stage cohort verified this survival benefit. CONCLUSIONS: RL surpasses VL in enhancing LND quality, reducing ER rates, and improving perioperative outcomes when adequate LND is performed for stage N1-2 NSCLC patients.

Neoadjuvant therapy bridging percutaneous coronary intervention (PCI) and video-assisted thoracoscopic (VATS) lobectomy: a retrospective study.

Background: Currently, there is no unified standard for the treatment of coronary artery disease (CAD) in non-small cell lung cancer (NSCLC), and the treatments have their own advantages and disadvantages. Thus, this study aimed to analyze the safety and feasibility of neoadjuvant therapy during the dual antiplatelet therapy (DAPT) period before surgery in patients with NSCLC coexisting with CAD after percutaneous coronary intervention (PCI) treatment. Methods: We retrospectively included 13 patients with T2aN0M0 (stage IB) NSCLC who also had concomitant CAD. After PCI treatment, neoadjuvant targeted or immunotherapy was administered based on the type of lung cancer, and the effects on treatment and impact on surgery were observed. Results: The objective response rate (ORR) after neoadjuvant treatment in 13 patients was 53.8% [95% confidence interval (CI): 25.1-80.8%], and the disease control rate (DCR) reached 100%. Ten patients (76.9%) experienced adverse events (AEs) ≤ grade 2. All patients underwent standard VATS lobectomy with lymph node dissection. One case (7.7%) required conversion to open thoracotomy, and all cases achieved R0 resection. The median operative time was 150 [interquartile range (IQR) 125-250] minutes, median intraoperative blood loss was 180 (IQR 150-235) mL, median postoperative drainage tube placement time was 4 (IQR 3-5) days, median total drainage volume was 1,310 (IQR 780-1,705) mL, and the median postoperative hospitalization was 7 (IQR 7-8) days. One patient (7.7%) experienced rapid atrial fibrillation. No deaths occurred. Postoperative pathological evaluation in three cases achieved major pathological response (MPR) (23.1%, 95% CI: 5-53.8%), with two cases achieving pathological complete response (pCR) (15.4%, 95% CI: 1.9-45.4%). Conclusions: The study presents initial evidence suggesting for the safety and feasibility of performing PCI treatment followed by neoadjuvant therapy during the DAPT period for patients with T2aN0M0 (IB) stage NSCLC coexisting with CAD. This approach presents a potential treatment option to control the disease while eliminating concerns about tumor progression and metastasis.

Development and validation of an intraoperative hypothermia nomograph model for patients undergoing video-assisted thoracoscopic lobectomy: a retrospective study.

This study aimed to develop and internally validate a nomogram model for assessing the risk of intraoperative hypothermia in patients undergoing video-assisted thoracoscopic (VATS) lobectomy. This study is a retrospective study. A total of 530 patients who undergoing VATS lobectomy from January 2022 to December 2023 in a tertiary hospital in Wuhan were selected. Patients were divided into hypothermia group (n = 346) and non-hypothermia group (n = 184) according to whether hypothermia occurred during the operation. Lasso regression was used to screen the independent variables. Logistic regression was used to analyze the risk factors of hypothermia during operation, and a nomogram model was established. Bootstrap method was used to internally verify the nomogram model. Receiver operating characteristic (ROC) curve was used to evaluate the discrimination of the model. Calibration curve and Hosmer Lemeshow test were used to evaluate the accuracy of the model. Decision curve analysis (DCA) was used to evaluate the clinical utility of the model. Intraoperative hypothermia occurred in 346 of 530 patients undergoing VATS lobectomy (65.28%). Logistic regression analysis showed that age, serum total bilirubin, inhaled desflurane, anesthesia duration, intraoperative infusion volume, intraoperative blood loss and body mass index were risk factors for intraoperative hypothermia in patients undergoing VATS lobectomy (P < 0.05). The area under ROC curve was 0.757, 95% CI (0.714-0.799). The optimal cutoff value was 0.635, the sensitivity was 0.717, and the specificity was 0.658. These results suggested that the model was well discriminated. Calibration curve has shown that the actual values are generally in agreement with the predicted values. Hosmer-Lemeshow test showed that χ2 = 5.588, P = 0.693, indicating that the model has a good accuracy. The DCA results confirmed that the model had high clinical utility. The nomogram model constructed in this study showed good discrimination, accuracy and clinical utility in predicting patients with intraoperative hypothermia, which can provide reference for medical staff to screen high-risk of intraoperative hypothermia in patients undergoing VATS lobectomy.

Optimizing patient outcomes: the impact of multimodal preemptive analgesia in video-assisted thoracoscopic lobectomy.

OBJECTIVES: The aim of this study was to evaluate the efficacy of a multimodal preemptive analgesia management approach, specifically incorporating ultrasound-guided thoracic paravertebral block (UG-TPVB) in conjunction with intravenous analgesia, after video-assisted thoracoscopic (VATS) lobectomy under the guidance of enhanced recovery after surgery. METHODS: A total of 690 patients who underwent VATS lobectomy between October 2021 and March 2022 were divided into the UG-TPVB group (group T, n = 345) and the control group (group C, n = 345). Patients in group T received UG-TPVB prior to the induction of general anaesthesia, while group C did not undergo nerve block. A comparison was conducted between the 2 groups regarding various indicators, including postoperative sedation, static/dynamic numeric rating scale scores, intraoperative fentanyl consumption, duration of mechanical ventilation/anaesthesia recovery/hospitalization, postoperative complications and other relevant factors. RESULTS: The static/dynamic numeric rating scale scores of group T were lower than those of group C after surgery. Intraoperative fentanyl consumption in group T (0.384 ± 0.095 mg) was lower than that in group C (0.465 ± 0.053 mg). The duration of mechanical ventilation, anaesthesia recovery and hospitalization were significantly shorter in group T compared to group C. Patient satisfaction rate in group T (70.1%) was higher than that in group C (53.6%). All differences were statistically significant (P < 0.05). CONCLUSIONS: The multimodal preemptive analgesia management strategy effectively reduces postoperative pain, decreases opioid consumption and promotes faster recovery in patients undergoing VATS lobectomy.

Efficacy of Transcutaneous Electrical Acupoint Stimulation on Chronic Postsurgical Pain After Video-Assisted Thoracoscopic Lobectomy: Study Protocol for a Prospective Randomized Controlled Trial.

INTRODUCTION: Patients undergoing video-assisted thoracoscopic lobectomy (VATL) often experience chronic postsurgical pain (CPSP). Postoperative pain can affect the recovery of postoperative lung function, prolong postoperative recovery time, and increase patient hospitalization expenses. Transcutaneous electrical acupoint stimulation (TEAS) is an alternative therapy based on acupuncture that has shown promise in postoperative recovery and pain management across various medical fields. However, research specifically focused on the improvement of CPSP after VATL is currently lacking. The purpose of this study is to evaluate whether TEAS can effectively reduce the severity and occurrence of chronic postsurgical pain in patients undergoing VATL. By investigating the potential benefits of TEAS in mitigating CPSP after VATL, this study aims to provide valuable clinical evidence to support the integration of TEAS into postoperative care protocols for patients undergoing VATL. METHODS: This study is a prospective, single-center, double-blinded, randomized controlled trial to be conducted at the 920th Hospital of Joint Logistics Support Force. Eighty patients undergoing VATL will be randomly divided into an experimental group (TEAS group) and a control group (sham group). The experimental group will receive TEAS at bilateral PC6, LI4, LR3, LU5, TE5, and LI11. The control group will not receive TEAS at the same acupoints. Both groups will receive TEAS or no TEAS before anesthesia induction and 1-7 days after surgery, with each session lasting 30 min. PLANNED OUTCOMES: The primary outcome will be the incidence of CPSP at 3 months after surgery. Secondary outcomes will include the incidence of CPSP at 6 months after surgery, the numerical rating scale (NRS) scores at 3 and 6 months after surgery, as well as the NRS scores at 24, 48, and 72 h after surgery, remifentanil consumption during general anesthesia, demand for rescue analgesics, number and duration of indwelling chest tubes, incidence of postoperative nausea and vomiting, and changes of norepinephrine (NE), cortisol (Cor), tumor necrosis factor (TNF- α), and interleukin 6 (IL-6) in serum. TRIAL REGISTRATION: ChiCTR2300069458. Registered on March 16, 2023.

Efficacy and safety of thoracoscopic-guided multiple paravertebral block for video-assisted thoracoscopic lobectomy surgery: a randomized blinded controlled study.

Background: Paravertebral block (PVB) has been increasingly popular for postoperative analgesia. However, few studies estimated the efficacy and safety of multiple PVB using thoracoscope-assisted technique for intraoperative analgesia and postoperative pain management for video-assisted thoracoscopic lobectomy (VATS LOBECTOMY). Methods: A total of 120 patients scheduled to undergo VATS LOBECTOMY were randomly assigned into two groups: a placebo group and a PVB group in a ratio of 1:2. Thoracoscopic-guided multi-point PVB was carried out with 0.5% ropivacaine (PVB group) or 0.9% NaCl (placebo group) at the beginning and the end of surgery. The primary endpoint was consumption of intraoperative opioid. Results: Consumption rate of intraoperative opioids was significantly lower in the PVB group (878.14 ± 98.37 vs. 1,432.20 ± 383.53 for remifentanil; 123.83 ± 17.98 vs. 266.42 ± 41.97 for fentanyl). Postoperatively, significantly longer duration of using patient-controlled intravenous analgesia for the first time, reduced times of analgesic pump pressing, and less rescue analgetic consumption were observed in the PVB group. Visual analog scale scores at rest and during exercising were significantly lower in the PVB group at all time points within the first 48 h after surgery. The PVB group was also associated with significantly higher total QoR-40 scores and lower incidence of analgesia-related adverse events. Conclusions: Thoracoscopic-guided multiple PVB was a simple and effective technique in controlling pain both intra- and postoperatively for VATS LOBECTOMY. It was also associated with the absence of detrimental effects attributed to opioid overuse and benefits of the early resumption of activity and physical function recovery. Therefore, this regional anesthesia technique should be advocated as part of a multimodal analgesia protocol for VATS LOBECTOMY.

Comparative retrospective review of perioperative analgesia using ultrasound-guided programmed intermittent erector spinae plane block for video-assisted thoracoscopic lobectomy.

BACKGROUND: The retrospective cohort study was conducted to estimate the opioid-sparing anesthesia and limited side-effects with ultrasound (US)-guided ESPB using programmed intermittent bolus (PIB) or continuous infusion (CI) and standard opioid-based anesthesia in patients undergoing video-assisted thoracoscopic lobectomy (VATS). METHODS: Patients underwent VATS were stratified into either control group or one of the two ESPB groups in a 1:2:2 ratio depending on whether PIB was implemented or not. The primary endpoint was intra- and post-operative opioids consumption over the first 48 h following surgery. RESULTS: A total of 180 cases were included in the analysis. Cumulative perioperative opioid administration was found to be significantly different between PIB, CI and control group (both p < 0.001), and between PIB and CI group (p = 0.028). More specifically, the mean was 305.30 ± 51.35 mg, 339.68 ± 56.07 mg and 468.91 ± 79.84 mg in PIB, CI and control group. NRS scores at rest across all postoperative times were comparable in two ESPB groups, while significantly lower than control group, however, scores during exercising at postoperative 3, 6, 12 h were significantly lower in PIB group as compared to CI group. A wider anesthetized dermatomes with PIB was observed at 6, 24 and 48 h as opposed to the CI. The mean of levobupivacaine plasma concentration was significantly lower for PIB at postoperative 0.5, 12, 24 and 48 h after initiation than CI. However, local anesthetic toxicity was not observed in any of the two ESPB groups. CONCLUSIONS: When US-guided ESPB using PIB was performed preoperatively, it contributed to the minimization of intra- and post-operative opioid consumption due to better analgesia with a wider anesthetic dermatome opposed to conventional CI, whereas, it was also associated with lower risk of local anesthetic toxicity because of lower plasma concentration of levobupivacaine.

Safety and feasibility of preferential manual bronchoplasty in 2-3 cm single-port video-assisted thoracoscopic lobectomy.

BACKGROUND: This retrospective study aimed to compare preferential manual bronchoplasty (PMB) and mechanical stapler closure (MSC) of the bronchial stump after 2-3 cm single-port (SP) video-assisted thoracoscopic surgery (VATS) lobectomy in patients with pathological T1 (pT1) stage lung cancer. METHODS: Between January 2019 and March 2022, patients with pulmonary neoplasms who underwent 2-3 cm SP VATS lobectomy were retrospectively screened. After propensity-matched analysis, we compared perioperative outcomes and analyzed the safety and feasibility of PMB and MSC of the bronchial stump while performing VATS lobectomy. RESULTS: In this study, 280 and 832 patients were enrolled in the PMB and MSC groups, respectively. Propensity score matching produced 280 pairs. The operation time was shorter in the PMB group, whereas the average number of lymph nodes dissected was higher in the PMB group. The conversion rate was significantly lower in the PMB group. The following were similar between the PMB and MSC groups, respectively: average blood loss volume, postoperative hospital stay, and chest tube removal time. Postoperatively, the incidence of atelectasis was significantly higher in the MSC group. As per subgroup analyses, PMB was associated with a shorter operation time in left and right upper lobectomies. Particularly in left upper lobectomy, PMB had more lymph node dissections and less conversion to open and postoperative atelectasis. CONCLUSIONS: In comparison with MSC of the bronchial stump, PMB showed better safety and feasibility in 2-3 cm SP VATS left and right superior lobectomies in patients with pT1 stage lung cancer.

The learning curve on uniportal video-assisted thoracoscopic lobectomy with the help of postoperative review of videos.

Objectives: Video-assisted thoracoscopic lobectomy has become the preferred surgical approach in experienced centers, and uniportal approaches are becoming increasingly used. But the uniportal approach is still not widely applied presumably due to the learning difficulties of this complex procedure. The use of surgical videos may be helpful to accelerate the learning of this new techniques as in other fields. In this study, we aimed to analyze the learning curve of uniportal video-assisted thoracoscopic lobectomy with the help of postoperative review of videos. Methods: 114 patients with early-stage lung cancer who underwent uniportal video-assisted thoracoscopic lobectomy performed from 2020 to 2021 were reviewed in this study. We recorded the operation video for each patient and reviewed all the videos after surgery. The learning curves were assessed using cumulative sum analysis and the collected data of perioperative outcomes were assessed. Results: The CUMSUM curve showed its inflection points were around case 38 and 53. It was less compared with previous studies, which about 57-140 cases are needed to attain the proficient phase. The perioperative outcomes were similar in each phase, which included intraoperative blood loss (79.00 ± 26.70 vs 70.67 ± 26.64 vs 70.56 ± 27.23, p=0.0119), the length of hospital stay (3.60 ± 1.52 days vs. 3.23 ± 0.90 days vs. 3.06 ± 0.88 days, p=0.053), the rate of prolonged air leak and conversion to open thoracotomy. There was also no significant difference in the numbers and station of lymph node dissection among the three phases. Conclusions: Uniportal video-assisted thoracoscopic lobectomy is a safe and reliable approach. Recording and reviewing the operation video could help the surgeon to improve deficiencies and refine the procedure.

Systemic inflammation influences the prognosis of patients with radically resected non-small cell lung cancer and correlates with the immunosuppressive microenvironment.

The impact of host condition on prognosis of non-small cell lung cancer (NSCLC) and the interaction between host and NSCLC remain unclear. This study investigated the association between systemic inflammation and prognosis and characteristics of radically resected NSCLC. This study consisted of a cohort study and an exploratory study of institutional prospective databases. All participants underwent video-assisted thoracoscopic lobectomy as the primary treatment. Systemic inflammation was assessed before surgery using the advanced lung cancer inflammation index and the systemic inflammation response index. Next-generation sequencing and multiplex immunofluorescence analysis were conducted to delineate tumor characteristics. In the cohort study including 1507 participants, high inflammation was associated with poor disease-free survival and overall survival before and after propensity score matching and in multivariable analysis. Systemic inflammation showed good prognostic value for stage IA-IB NSCLC, and the prognostic value diminished with upstaging of NSCLC. In the exploratory study including 217 adenocarcinomas, tumor microenvironment of high inflammation group showed a greater abundance of PDL1+ tumor cells and immune cells, which were independent from driver gene mutations and clinicopathological characteristics. Spatial analysis demonstrated a higher frequency of immune-suppressed cellular neighborhood, increased avoidance between immune cells and PDL1- tumor cells and compromised immune killing and presentation in tumor microenvironment of high inflammation group. Systemic inflammation showed limited association with genomic mutations. Systemic inflammation may influence the prognosis of NSCLC at both the systematic level and the local immune response. The correlation between high inflammation and immunosuppressive microenvironment indicates a novel thread for anticancer treatment.

Effect of general anesthesia with thoracic paravertebral block on postoperative delirium in elderly patients undergoing thoracoscopic lobectomy: a randomized-controlled trial.

BACKGROUND: Postoperative delirium (POD) is characterized by acute brain dysfunction, especially in elderly patients. Postoperative pain is an important factor in the development of delirium, and effective pain management can reduce the risk of POD. Thoracic paravertebral block (TPVB) can effectively relieve postoperative pain and inhibit the perioperative stress and inflammatory response. We investigated whether the combination of TPVB with general anesthesia reduced the occurrence of POD following thoracoscopic lobectomy. METHODS: A total of 338 elderly patients, aged 65-80 years, who underwent elective surgery for video-assisted thoracoscopic lobectomy (VATS) were randomly assigned to either a patient-controlled intravenous analgesia group (PIA) or a patient-controlled paravertebral-block analgesia group (PBA). POD was evaluated using the 3-min diagnostic confusion assessment method (3D-CAM). The postoperative quality of recovery (QoR) was assessed with Chinese version of QoR-40 scale. Pain intensity was measured using the visual analog scale (VAS) score. Tumor necrosis factor-α (TNF-α) and neurofilament light (NFL) levels were determined using enzyme-linked immunosorbent assay (ELISA) kits. RESULTS: Delirium occurred in 47 (28%) of 168 cases in the PIA group and 28 (16.5%) of 170 cases in the PBA group (RR 1.7, p = 0.03). PBA was also associated with a higher rate of overall recovery quality at day 7 after surgery (27.1% vs. 17.3%, P = 0.013) compared with PIA. The incremental change in surgery-induced TNF-α and NFL was greater in the PIA group than PBA group (p < 0.05). CONCLUSION: Thoracic paravertebral block analgesia is associated with lower incidence of postoperative delirium, probably due to its anti-neuroinflammatory effects. Furthermore, as a component of multimodal analgesia, TPVB provides not only superior analgesic but also opioid-sparing effects. TRIAL REGISTRATION: The study was registered on the Chinese Clinical Trial Registry Center ( www.chictr.org.cn ; registration number: ChiCTR 2,000,033,238 ) on 25/05/2018.

Paravertebral block with modified catheter under surgeon's direct vision after video-assisted thoracoscopic lobectomy.

BACKGROUND: Paravertebral block (PVB) conducted by epidural catheter is a prevalent pain management for patients undergoing video-assisted thoracoscopic surgery (VATS) lobectomy. The aim of this study was to assess the efficacy and safety of paravertebral block with a modified PVB (MPVB) catheter under surgeon's direct vision after video-assisted thoracoscopic lobectomy. METHODS: Three hundred fifty-six patients undergoing VATS lobectomy were retrospectively reviewed and divided into two groups consecutively according to the catheter applied in PVB procedure (PVB group and MPVB group). In the MPVB group, a modified catheter with a flexible forepart and more apertures distributing along the forepart than the conventional epidural catheter was introduced. An infusion pump containing of 150 mL mixture was connected to the catheter to provide sustained regional analgesia. Intramuscular dezocine 10 mg was administered as a rescue medication when necessary. Postoperative pain management effect was assessed by visual analog scale (VAS) at rest and on coughing. Spirometry values and blood gas analysis were monitored and recorded for the first 3 postoperative days (PODs). Analgesia-related adverse events, characteristics of PVB procedure and postoperative major complication were also compared between the two groups. RESULTS: There were 172 patients who received PVB with conventional epidural catheter in the PVB group, and 184 patients were performed PVB with modified paravertebral catheter in the MPVB group. Significantly lower pain score at rest was found in MPVB group at 24 h postoperatively (P=0.006). The pain score on coughing in MPVB group was significantly lower than that in PVB group at 12 and 24 h postoperatively (P=0.037 and P<0.001, respectively). Patients needing for rescue medication was significantly lower in the MPVB group (P=0.028). The incidence of pleural perforation was lower in the MPVB group (P=0.020). Postoperative spirometry values revealed comparable pulmonary function between the two groups, and arterial blood gas analysis showed a normal range of pH and PaCO2 in both groups. There was no significant difference of analgesia-related adverse events as well as major complications between the two groups. CONCLUSIONS: PVB with modified catheter under surgeon's direct vision was effective and safe after video-assisted thoracoscopic lobectomy.

Switching from Thoracoscopic to Robotic Platform for Lobectomy: Report of Learning Curve and Outcome.

OBJECTIVE: The optimal minimally invasive surgical management for patients with non-small-cell lung cancer (NSCLC) is unclear. For experienced video-assisted thoracoscopic surgery (VATS) surgeons, the increased costs and learning curve are strong barriers for adoption of robotics. We examined the learning curve and outcome of an experienced VATS lobectomy surgeon switching to a robotic platform. METHODS: We conducted a retrospective review to identify patients who underwent a robotic or VATS lobectomy for NSCLC from 2016 to 2018. Analysis of patient demographics, perioperative data, pathological upstaging rates, and robotic approach (RA) learning curve was performed. RESULTS: This study evaluated 167 lobectomies in total, 118 by RA and 49 by VATS. Patient and tumor characteristics were similar. RA had significantly more lymph node harvested (14 versus 10; P = 0.004), more nodal stations sampled (5 versus 4; P < 0.001), and more N1 nodes (8 versus 6; P = 0.010) and N2 nodes (6 versus 4; P = 0.017) resected. With RA, 22 patients were upstaged (18.6%) compared to 5 patients (10.2%) with VATS (P = 0.26). No differences were found in perioperative outcome. Operative time decreased significantly with a learning curve of 20 cases, along with a steady increase in lymph node yield. CONCLUSIONS: RA can be adopted safely by experienced VATS surgeons. Learning curve is 20 cases, with RA resulting in superior lymph node clearance compared to VATS. The potential improvement in upstaging and oncologic resection for NSCLC may justify the associated investments of robotics even for experienced VATS surgeons.

Effects of ultrasound-guided paravertebral block on MMP-9 and postoperative pain in patients undergoing VATS lobectomy: a randomized, controlled clinical trial.

BACKGROUND: Local anesthesia can reduce the response to surgical stress and decrease the consumption of opioids, which may reduce immunosuppression and potentially delay postoperative tumor recurrence. We compared paravertebral block (PVB) combined with general anesthesia (GA) and general anesthesia regarding their effects on postoperative pain and matrix metalloproteinase-9 (MMP-9) after video-assisted thoracoscopic surgery (VATS) lobectomy. METHODS: 54 patients undergoing elective VATS lobectomy at a single tertiary care, teaching hospital located in Qingdao between May 2, 2018 and Sep 28, 2018 were randomised by computer to either paravertebral block combined with general anesthesia or general anesthesia. The primary outcomes were pain scores at rest and on cough at 1, 4, 24, and 48 h after surgery. The secondary outcome were plasma concentrations of MMP-9, complications, and length of postoperative hospital stay. RESULTS: 75 were enrolled to the study, of whom 21 were excluded before surgery. We analyzed lobectomy patients undergoing paravertebral block combined with general anesthesia (n = 25) or general anesthesia (n = 24). Both groups were similar regarding baseline characteristics. Pain scores at rest at 4 h and 24 h, on cough at 4 h were lower in PVB/GA group, compared with GA group (P < 0.05). There were no difference in pain scores at rest at 1 h, 48 h and on cough at 1 h, 24 h, and 48 h between groups. Patients in the PVB/GA group showed a greater decrease in plasma MMP-9 level at T1 and T2 after VATS lobectomy (P < 0.05). Postoperative complications and length of stay did not differ by anesthetic technique. CONCLUSIONS: The paravertebral block/general anesthesia can provide statistically better pain relief and attenuate MMP-9 response to surgery and after VATS lobectomy. This technique may be beneficial for patients to recover rapidly after lung surgery and reduce postoperative tumor recurrence. TRIAL REGISTRATION: Chinese Clinical Trial registration number ChiCTR1800016379. Registered 28 May 2018.

Incidence and risk factors for 90-day hospital readmission following video-assisted thoracoscopic anatomical lung resection†.

OBJECTIVES: The objective of this study was to identify risk factors for 90-day hospital readmission after video-assisted thoracoscopic surgery (VATS) anatomical lung resections. METHODS: This study is a retrospective analysis of data collected from 481 patients discharged after VATS lobectomy or segmentectomy (January 2012-February 2016). Univariable and stepwise logistic regression analyses were used to identify risk factors for hospital readmission. RESULTS: Hospital readmissions occurred in 59 patients (12.3%). Twenty-three (39%) of them were readmitted after the first 30 days following operation. A short hospital stay (<3 days) was associated with only 3.6% readmission, while 21% of patients with a hospital stay longer than 7 days were readmitted. The most frequent cause of readmission was pneumonia in 17 patients accounting for 26% of all readmissions. Eighteen patients were readmitted for problems related to prolonged chest drain management. Readmission for chest pain occurred in six patients in this VATS population. One hundred and one patients experienced prolonged air leak. Their readmission rate was 21% vs 11% in patients without prolonged air leak (P < 0.0001). The 90-day mortality rate after the initial discharge was similar in readmitted and non-readmitted patients (0 vs 1.2%, Fisher's exact test, P = 1). Stepwise logistic regression analysis showed that the only patient-related factor independently associated with readmission was low body mass index (<18.5 kg/m2) (P < 0.0001). CONCLUSIONS: Readmissions after VATS anatomical lung resections are not uncommon. More than one-third of readmissions occur between 30 days and 90 days from the index operation. Patients should be counselled about the risk of readmission to set realistic expectations of the surgical procedure.

Salvage Pulmonary Operations Following Stereotactic Body Radiotherapy for Small Primary and Metastatic Lung Tumors: Evaluation of the Operative Procedures.

Stereotactic body radiotherapy is an alternative treatment option for small-sized, primary lung cancers and pulmonary metastatic diseases. In the case of local relapse after stereotactic body radiotherapy, salvage pulmonary resection is considered cautiously. However, no study has described the difficulty of the salvage operations. This study aimed to assess the difficulty associated with salvage operative procedures. Eight patients who developed local relapse after stereotactic body radiotherapy and had undergone salvage pulmonary operations were enrolled in this study (stereotactic body radiotherapy group). Additionally, 439 patients who underwent video-assisted thoracoscopic lobectomy without previous stereotactic body radiotherapy were enrolled as the standard operative control group (non-stereotactic body radiotherapy group). In the stereotactic body radiotherapy group, 1 of the 8 patients had undergone lobectomy with composite resection of the third and fourth ribs. Of the 8 patients, 6 had undergone video-assisted thoracoscopic lobectomy and 1 had been inoperable because of rapid tumor progression. The operation time and the incision length of the utility port were apt to be longer in the stereotactic body radiotherapy group than in the non-stereotactic body radiotherapy group. On the contrary, the duration of drain placement and the length of hospital stay after the operation were not different. Thus, the salvage pulmonary operations were performed in the usual video-assisted thoracoscopic lobectomy approach, but slightly complicated than the standard video-assisted thoracoscopic lobectomy. Although to decide the indication of salvage operation might be difficult, it could be a feasible treatment option in local relapse after stereotactic body radiotherapy.

Pulmonary Lobectomy: What are the Benefits of Video-assisted Thoracoscopy?

Introduction: Despite the increasing use of video-assisted thoracoscopic lobectomy, this surgical approach is still controversial in certain aspects. The purpose of this study is to compare the surgical results of video-assisted thoracoscopic pulmonary lobectomy to pulmonary lobectomy via thoracotomy. Materials and Methods: Between 2008 and 2017, 153 patients (n = 89 males) had surgery at the Hospital Universitario Fundación Favaloro. Results: 39/89 patients underwent video-assisted thoracoscopic lobectomy. Patients who had video-assisted thoracoscopy and were diagnosed with lung cancer mostly had stage I tumors (25/39 patients). Postoperative complications and mortality rates were similar in both groups. Video-assisted thoracoscopy patients had a significantly shorter pleural drainage time (4 vs. 3 days, p = 0.004) and a shorter length of hospital stay (6 vs. 4 days of stay, p = 0.03). The number of lymph node stations sampled during surgery was higher in the patients operated via thoracotomy (4 vs. 3.5 lymph node stations, p < 0.001). Conclusion: Video-assisted thoracoscopic lobectomy was at least equivalent to surgery by means of thoracotomy in terms of postoperative complications. The main benefits of the video-assisted thoracoscopy approach were shorter pleural drainage time and length of hospital stay. Special attention should be paid to nodal sampling when the surgery is performed via video-assisted thoracoscopy.

Improvement of recovery parameters using patient-controlled epidural analgesia for video-assisted thoracoscopic surgery lobectomy in enhanced recovery after surgery: A prospective, randomized single center study.

BACKGROUND: We compared the effects of thoracic epidural analgesia (TEA) to conventional patient-controlled analgesia (PCA) on several postoperative parameters of recovery after elective video-assisted thoracoscopic (VATS) lobectomy. METHODS: Ninety-eight patients undergoing elective VATS lobectomy were enrolled. The primary endpoint was pain score. Recovery of bowel function, length of stay in the postanesthesia care unit (PACU), duration of postoperative hospital stay, and complications were assessed. Continuous variables were expressed and compared between groups using either a two-tailed Student's t or Mann-Whitney U test. Recovery of bowel function was compared using the log-rank test. RESULTS: Baseline characteristics between the groups were similar. Dynamic pain scores on postoperative days (PODs) 0-2 were significantly lower in the TEA group, as were resting pain scores on PODs 1 and 2 (P < 0.05). The mean duration to first flatus (16 ± 0.7 vs. 26 ± 0.7 hours; P < 0.001) and the mean length of stay in the PACU (34 vs. 67 minutes; P = 0.027) were shorter in the TEA compared to the PCA group, respectively. The only difference in postoperative complications was regarding confusion (5 TEA vs. 18 PCA patients; P = 0.002). No difference in overall length of stay was noted. CONCLUSIONS: Compared to PCA, TEA provided better postoperative pain control after VATS lobectomy and facilitated postoperative recovery of bowel function without increasing the length of hospital stay. This beneficial effect of TEA might be attributed to the attenuation of sympathetic hyperactivation, improved analgesia, and reduced opioid use.