The surgical outcome of standard lobectomy versus sleeve lobectomy in patients with non-small cell lung cancer: propensity score matching.

OBJECTIVES: The goal of this study was to compare the patients who underwent standard or sleeve lobectomy for non-small cell lung cancer in terms of postoperative outcomes, prognostic factors and overall survival. METHODS: Between January 2002 and January 2020, the patients with squamous cell carcinoma or adenocarcinoma who underwent standard lobectomy or sleeve lobectomy by thoracotomy in our clinic were analysed retrospectively. Standard and sleeve groups were compared after propensity score matching in terms of age, comorbidity, T status, N status and pathological stage. Primary outcomes were morbidity and mortality; the secondary outcome was overall survival. RESULTS: The study included 476 patients, and sleeve lobectomy was performed in 196 (41.1%) patients. Multivariable analysis revealed that age over 61 years (P = 0.003 and P = 0.005, respectively), forced expiratory volume in 1 s (FEV1) below 84% (P = 0.013 and P = 0.205, respectively) and the presence of perineural invasion (P = 0.052 and P = 0.001, respectively) were poor prognostic factors in the standard lobectomy and the sleeve groups. The propensity matching analysis included 276 patients (138 sleeve lobectomy and 138 standard lobectomy). Complications occurred in 96 (69.6%) and 92 (66.7%) patients in the standard and sleeve groups, respectively (P = 0.605). Three (2.2%) patients in the standard group and 5 (3.6%) patients in the sleeve group died within 90 days postoperatively (P = 0.723). CONCLUSIONS: Bronchial sleeve lobectomy is a safe procedure that can be applied in oncologically suitable cases without causing higher mortality than a standard lobectomy.

Right uniportal video-assisted thoracoscopic surgery lung-sparing sleeve resection of the bronchus intermedius

Complete surgical resection has been the main treatment modality for pulmonary neoplasms without locoregional or distant spread of the disease. Sleeve resections were developed to minimize unnecessary loss of pulmonary parenchyma mainly in the case of centrally located tumours. Experience with sleeve resections and recent technological advancements made minimally invasive resection possible for selected patients. We present a case report of the totally thoracoscopic uniportal sleeve resection of the bronchus intermedius without any resection of pulmonary parenchyma. The operation was performed successfully, and the patient did not experience any postoperative complications. In this case report, we describe our surgical approach and short-term results.

Effect of preoperative three-dimensional modeling on uniportal video-assisted thoracoscopic bronchial sleeve resection and early postoperative outcomes.

Background: The aim of this study was to evaluate the effects of preoperative three-dimensional (3D) modeling on the performance of uniportal video-assisted thoracoscopic bronchial sleeve resection and early postoperative outcomes. Methods: A total of 10 patients (5 males, 5 females; mean age: 53.8±16.9 years; range, 18 to 75 years) who underwent uniportal video-assisted thoracoscopic bronchial sleeve resection with preoperative 3D modeling between April 2021 and November 2023 were retrospectively analyzed. Preoperative 3D modeling was prepared using computed tomography with an open-source 3D software program. Demographic, clinical, intraoperative, and postoperative data of the patients were recorded. Anatomical landmarks identified by preoperative 3D modeling were compared with intraoperative findings. Results: The anatomical landmarks created with the 3D model were in 100% agreement with the intraoperative findings. The procedures performed were three left lower lobes, three right upper lobes, one middle lobe, one right lower lobe, and one parenchyma-sparing intermediate bronchial sleeve resection. Bronchial sleeve resection was completed using uniportal video-assisted thoracoscopic technique in 90% of patients, with only one patient requiring conversion to open thoracotomy. The mean resection time was 264.2±40.5 min, and the mean anastomosis time was 86.0±20.3 min. Anastomosis times decreased with increasing experience (p=0.008). Postoperative atelectasis was observed in two patients, and there was no mortality. The mean follow-up duration was 12.2±11.8 months. Conclusion: Preoperative 3D modeling significantly contributed to the successful implementation of uniportal video-assisted thoracoscopic bronchial sleeve resection surgery. In the future, with advancements in simulation programs, patient-specific 3D modeling is expected to benefit the identification of anatomical landmarks for bronchial sleeve resections.

Generalizability of Randomized Clinical Trial Outcomes for Diabetes Control Resulting From Bariatric Surgery.

Objective: To assess the external validity of randomized controlled trials (RCTs) of bariatric surgical treatment on diabetes control. Background: Multisite RCTs provide the strongest evidence supporting clinical treatments and have the greatest internal validity. However, characteristics of trial participants may not be representative of patients receiving treatment in the real world. There is a need to assess how the results of RCTs generalize to all contemporary patient populations undergoing treatments. Methods: All patients undergoing sleeve gastrectomy at University of California Los Angeles (UCLA) between January 8, 2018 and May 19, 2023 had their baseline characteristics, weight change, and diabetes control compared with those enrolled in the surgical treatment and medications potentially eradicate diabetes efficiently (STAMPEDE) and diabetes surgery study (DSS) RCTs of bariatric surgery's effect on diabetes control. Weight loss and diabetes control were compared between UCLA patients who did and did not fit the entry criteria for these RCTs. Results: Only 65 (17%) of 387 patients with diabetes fulfilled the eligibility criteria for STAMPEDE, and 29 (7.5%) fulfilled the criteria for DSS due to being older, having higher body mass index, and lower HbA1c. UCLA patients experienced slightly less weight loss than patients in the RCTs but had similar diabetes control. The 313 (81%) patients not eligible for study entry into either RCT had similar long-term diabetes control as those who were eligible for the RCTs. Conclusions: Even though only a very small proportion of patients undergoing bariatric surgery met the eligibility criteria for the 2 major RCTs, most patients in this contemporary cohort had similar outcomes. Diabetes outcomes from STAMPEDE and DSS generalize to most patients undergoing bariatric surgery for diabetes control.

A middle lobe sparing sleeve resection versus bilobectomy for right lower central non-small cell lung cancer: a retrospective propensity score matched cohort study.

OBJECTIVES: The right lower sleeve lobectomy is a rarely performed major lung resection.This study aims to evaluate the safety and effectiveness of this procedure by comparing to right lower bilobectomy in non-small cell lung cancer patients. METHODS: We retrospectively reviewed a prospective database of non-small cell lung cancer patients who underwent right lower sleeve lobectomy (group S) or right lower bilobectomy (group B) from January 2014 to January 2020 in Shanghai Pulmonary Hospital. Propensity score matching method was applied to balance confounders between the two groups, resulting in 41 matched pairs.The analysis was performed to compare perioperative outcomes, long-term survival, and postoperative pulmonary volume between the two groups. RESULTS: No significant differences in the characteristics were observed between the two matched groups.Major postoperative complications developed in 31.7% of the patients in group B and 12.1% of the patients in group S (P = 0.032).Intervention rate for surgical residual cavity in group B is significantly higher than those patients in group S(21.9%vs7.3%,p = 0.037).The postoperative right lateral and overall lung volume in group S were both significantly larger than that in group B (P = 0.026,P = 0.001,respectively). CONCLUSIONS: Compared to bi-lobectomy, a middle lobe sparing sleeve resection obtains a less prevalence of major complications, smaller postoperative residual air space and similar long-term survival for selected central right lower NSCLC patients.

Case Report: Uniportal robot-assisted thoracoscopic double-sleeve lobectomy after neoadjuvant immunotherapy.

Minimally invasive thoracic surgery, including video-assisted thoracoscopic surgery and robot-assisted thoracoscopic surgery, has been proven to have an advantage over open thoracotomy with less pain, fewer postoperative complications, faster discharge, and better tolerance among elderly patients. We introduce a uniportal robot-assisted thoracoscopic double-sleeve lobectomy performed on a patient following neoadjuvant immunotherapy. Specialized instruments like customized trocars with a reduced diameter, bulldog clamps, and double-needle sutures were utilized to facilitate the maneuverability through the single incision. This technique integrates the merits of multiport robot-assisted thoracic surgery with uniportal video-assisted thoracoscopic surgery.

Robotic-assisted thoracic surgery: left upper lobe sleeve lobectomy for an endobronchial tumour.

Pulmonary sleeve resection is a technically challenging procedure entailing expertise to perform via a minimally invasive approach. Robotic thoracic surgery with its three-dimensional high-definition imaging and true depth perception enables clarity of anatomical structures and, in conjunction with its articulated instruments, provides greater dexterity compared with video-assisted thoracoscopic surgery, allowing complex manoeuvres in limited spaces. We present the case of a 22-year-old woman who presented with recurrent chest infections, dyspnoea on exertion, cough, loss of appetite and weight loss. On investigation, she was diagnosed with an endobronchial neuroendocrine tumour. She underwent a robotic-assisted left upper lobe sleeve lobectomy and mediastinal lymph node dissection. The patient made a good recovery with no perioperative or postoperative complications. This case serves as an educational tool and includes instructions for excellent results.

Surgical strategy for patients with papillary thyroid carcinoma invading the trachea: a comparison of tracheal sleeve resection with end-to-end anastomosis and window resection with tracheocutaneous fistula.

Background: Sleeve resection with end-to-end anastomosis (Procedure A) and window resection with a tracheocutaneous fistula (Procedure B) are the major surgical procedures for patients with papillary thyroid carcinoma (PTC) exhibiting transluminal tracheal invasion. For each procedure, the indications, postoperative course, and treatment results were examined retrospectively. Methods: Of 1,456 patients with PTC (maximum tumor diameter >1 cm) who received initial treatment between 1993 and 2013, we reviewed 51 patients. Of these 51 cases, 45 showed full-layer tracheal invasion, and 6 did not reach the tracheal mucosa, but required full-layer tracheal resection. Twenty-four patients underwent Procedure A, and 27 patients underwent Procedure B. Results: Regarding surgical procedure selection, Procedure B was selected significantly more frequently than Procedure A for cases with preoperative recurrent laryngeal nerve (RLN) palsy, tumor invasion of the esophagus, clinical lymph node metastasis, or a large number of resected tracheal rings. Postoperative airway-related complications were not significantly different between the procedures, but decreased with the use of intraoperative neuromonitoring (IONM). The postoperative hospital stay was significantly longer for Procedure B than for Procedure A. In addition, the rate of a permanent postoperative tracheostoma was higher with Procedure B than with Procedure A. Local recurrence-free survival (LRFS) and cause-specific survival (CSS) did not differ significantly between the two procedures. Conclusions: Certain patients may benefit from Procedure A with IONM in terms of a shorter hospital stay and avoiding the need for a permanent tracheostoma. Although Procedure B was indicated for patients with more advanced disease than Procedure A, treatment outcomes were similar.

Intraoperative Determination of Bronchus Stump and Anastomosis Perfusion with Hyperspectral Imaging.

BACKGROUND: The intraoperative evaluation of bronchus perfusion is limited. Hyperspectral Imaging (HSI) is a newly established intraoperative imaging technique that enables a non-invasive, real-time perfusion analysis. Therefore, the purpose of this study was to determine the intraoperative perfusion of bronchus stump and anastomosis during pulmonary resections with HSI. METHODS: In this prospective, IDEAL Stage 2a study (Clinicaltrials.gov: NCT04784884) HSI measurements were carried out before bronchial dissection and after bronchial stump formation or bronchial anastomosis, respectively. Tissue oxygenation (StO2; upper tissue perfusion), organ hemoglobin index (OHI), near-infrared index (NIR; deeper tissue perfusion) and tissue water index (TWI) were calculated. RESULTS: Bronchus stumps showed a reduced NIR (77.82 ± 10.27 vs 68.01 ± 8.95; P = 0,02158) and OHI (48.60 ± 1.39 vs 38.15 ± 9.74; P = <.0001), although the perfusion of the upper tissue layers was equivalent before and after resection (67.42% ± 12.53 vs 65.91% ± 10.40). In the sleeve resection group, we found both a significant decrease in StO 2 and NIR between central bronchus and anastomosis region (StO2: 65.09% ± 12.57 vs 49.45 ± 9.94; P = .044; NIR: 83.73 ± 10.92 vs 58.62 ± 3.01; P = .0063). Additionally, NIR was decreased in the re-anastomosed bronchus compared to central bronchus region (83.73 ± 10.92 vs 55.15 ± 17.56; P = .0029). CONCLUSIONS: Although both bronchus stumps and anastomosis show an intraoperative reduction of tissue perfusion, there is no difference of tissue hemoglobin level in bronchus anastomosis.

Complex Robotic Lung Resection.

Performing robotic thoracic lung resection is becoming an option for patients with complex thoracic disease. The robotic-assisted approach has similar survival with decreased postoperative pain, morbidity, and hospital length of stay compared with the open approach in pneumonectomy, bronchoplasty, and arterioplasty. Appropriate patient selection based on medical and surgical history combined with surgeon experience is imperative for an excellent outcome. This article will discuss the use of the robot in pneumonectomy, arterioplasty, and bronchoplasty to provide information about the technical approach and postoperative management.

Effect of da Vinci robot-assisted versus traditional thoracoscopic bronchial sleeve lobectomy.

OBJECTIVE: To analyze the short-term effect of Da Vinci robot-assisted thoracoscopic (RATS) bronchial sleeve lobectomy, so as to summarize its safety and effectiveness. METHODS: It was a retrospective single-center study with the inclusion of 22 cases receiving RATS lobectomy and 49 cases of traditional thoracoscopic surgery. Further comparison was performed focusing on the baseline characteristics and perioperative performance of the two groups. RESULTS: Compared with the traditional thoracoscopic surgery group, RATS group had more advantages in the number of lymph nodes dissected (P = 0.003), shorter postoperative length of stay in the hospital (P = 0.040), shorter drainage time (P = 0.022), reduced drainage volume (P = 0.001). Moreover, this study found for the first time that there was a shortening in the operation of sleeve lobectomy by using Da Vinci robot-assisted surgical system (P = 0.001). The operation cost of RATS group is more expensive (96000 ± 9100.782 vs 63000 ± 5102.563 yuan; P＜0.001). CONCLUSION: Compared with the traditional thoracoscopic bronchial sleeve lobectomy, RATS lobectomy shows advantages of higher operating sensitivity, shorter operation time, faster postoperative recovery, and more lymph nodes dissected. Collectively, RATS bronchial sleeve lobectomy is safe and effective in operation.

Overview of indications for pulmonary sleeve resection.

Pulmonary sleeve resection is a complex lung resection and reconstruction surgery mostly performed in patients with centrally located locally invasive lung cancers which often penetrate into central airways and vasculature. This approach was initially used for patients unable to tolerate pneumonectomies, while it is currently also being preferred in patients whose tumors are anatomically suited. Today, thoracic sleeve resections include a wide range of procedures ranging from bronchial and tracheal sleeve resections to carinal sleeve pneumonectomies. In this review, we discuss indications for various types of sleeve resection in the light of current literature.

Bronchial sleeve resections.

Although bronchial sleeve resections were previously defined as an alternative technique to pneumonectomy for patients with limited pulmonary reserve, currently these resections are applied as a standard even in patients having normal pulmonary capacity. Pneumonectomy, itself, is a disease, and sleeve lobectomies can be performed without compromising oncological principles and without causing significant morbidity and mortality. In parallel with the developments in surgical techniques, bronchial sleeve resections can be performed by videothoracoscopic and robotic surgeries. Major complications in sleeve lobectomies are bronchial dehiscence, bronchopleural fistulas, and broncho-arterial fistulas. Late complications are bronchial stenosis and tumor recurrence.

Pulmonary sleeve resection complications and management.

In tumors involving the central airway or vascular structures, achieving local control and preserving pulmonary function can be possible with a pulmonary sleeve resection. In this section, complications and management of pulmonary sleeve resections are discussed.

VATS sleeve resections.

Sleeve resections in central tumors is a surgical method preferred over pneumonectomy owing to its parenchymasparing features. With the increasing surgical experience and developing technology in recent years, sleeve resections can be performed using the video-assisted thoracoscopic surgery method. However, these resections are technically challenging and require significant experience. In this review, we discuss sleeve resections with video-assisted thoracoscopic surgery in the light of the literature.

Sleeve resection with end-to-end anastomosis in the reconstruction of tracheal defects exceeding six rings: a clinical feasibility study and safety assessment.

Objectives: Reconstruction is always required for tracheal defects and sleeve resection with end-to-end anastomosis is the most common used. The aim of the study was to present surgical techniques and evaluate the outcomes of sleeve resection with end-to-end anastomosis in the reconstruction of tracheal defects exceeding six rings. Methods: The study included patients with primary or secondary malignancies and tracheal stenosis from 2014 to 2019, who were treated with sleeve resection exceeding six tracheal rings, and reconstructed with end-to-end anastomosis. Airway status and patient outcomes were the principal follow-up measures. Results: A total of 16 patients were enrolled in the study including three primary tracheal malignancies, 12 invasive thyroid carcinomas and one with tracheal stenosis. The extent of tracheal resection ranged from seven to nine rings, and the primary end-to-end anastomosis was performed in all 16 patients. Performance of tracheostomy or cricothyroidotomy was done in 6 patients with decannulation at a median of 42 days (range, 28-56). No anastomotic dehiscence, infection or bleeding occurred postoperatively, and all 16 patients maintained an unobstructed airway through the end of follow-up. Conclusions: Sleeve resection reconstructed with end-to-end anastomosis can serve as an appropriate therapeutic strategy for the tracheal defects even exceeding six rings. Adequate laryngeal release is the key to surgical success.

Oblique supine one-piece posterior laparoscopic total nephroureterectomy plus cystic sleeve resection in the treatment of 24 cases of upper urinary tract uroepithelial carcinoma / 现代泌尿外科杂志

【Objective】 To explore the safety and efficacy of a modified one-piece posterior laparoscopic total nephroureterectomy with cystic sleeve resection in the treatment of upper urinary tract uroepithelial carcinoma (UTUC). 【Methods】 A total of 24 patients treated during Jan. and Jun. 2022 were involved, including 16 males and 8 females, aged 62 to 90 (average 73) years. The UTUC was in the left side in 15 cases, and in the right side in 9 cases. There were 10 cases of renal pelvis tumor, 6 cases of upper ureteral tumor and 8 cases of lower ureteral tumor. 【Results】 All operations were successful without conversion to open surgery. The operation time ranged from 60 to 100 minutes, average (71.25±9.80) minutes. The intraoperative bleeding volume was 20 to 200 mL, average (30.03±8.13) mL. No significant intraoperative or postoperative complications occurred. The postoperative hospital stay was 4 to 7 days, average (5.83±1.44) days. Bladder perfusion chemotherapy was performed after surgery. 【Conclusion】 The modified one-piece posterior laparoscopic total nephroureterectomy plus cystic sleeve resection for UTUC is an effective and feasible procedure with satisfactory tumor control, which is worth further promotion in clinical practice.

Parenchymal Sparing Surgery for Lung Cancer: Focus on Pulmonary Artery Reconstruction.

Reconstruction of the pulmonary artery (PA) associated with lobectomy for the radical resection of lung cancer has been progressively gaining diffusion in lung cancer surgery as a safe and effective therapeutic option that may allow radical resection when lobectomy is not technically feasible, avoiding pneumonectomy. There are some controversial aspects concerning the intraoperative and perioperative management of a sleeve resection with PA reconstruction that may influence the outcome. In the present article, the authors have analyzed some of the main technical and oncological aspects to take stock of what they have learned from their lung-sparing operations experience over time. PA reconstruction may require prosthetic materials including different options with variable cost. A main concern in vascular reconstructive procedures is avoiding tension on the anastomosis. When PA reconstruction is required, appropriate anticoagulation management is crucial. Results from the main literature data confirm the reliability of lobectomy associated with PA reconstruction in terms of perioperative morbidity and long-term survival. Sleeve lobectomy and PA reconstruction can be performed safely and effectively even after induction therapy.

Video-assisted thoracoscopic versus open sleeve lobectomy for non-small cell lung cancer: A systematic review and meta-analysis from six comparative studies.

BACKGROUND: Lung sleeve resection is indicated for centrally located lung tumors, especially for patients who cannot tolerate pneumonectomy. With video-assisted thoracoscopic surgery (VATS) being increasingly implemented for a wide variety of thoracic pathologies, this study aims to compare the intraoperative, postoperative, and long-term outcomes of VATS and open bronchial sleeve lobectomy for non-small cell lung cancer (NSCLC). METHODS: The MEDLINE (via PubMed), Cochrane Library, and Scopus databases were searched. Original clinical studies, comparing VATS and open sleeve lobectomy for NSCLC were included. Evidence was synthesized as odds ratios for categorical and weighted mean difference (WMD) for continuous variables. RESULTS: Our analysis included six studies with non-overlapping populations reporting on 655 patients undergoing bronchial sleeve lobectomy for NSCLC (229 VATS and 426 open). VATS sleeve lobectomy was associated with significantly longer operative time ((WMD): 45.85 min, 95% confidence interval (CI): 12.06 to 79.65, p = 0.01) but less intraoperative blood loss ((WMD): -34.57 mL, 95%CI: -58.35 to -10.78, p < 0.001). No significant difference was found between VATS and open bronchial sleeve lobectomy in margin-negative resection rate, number of lymph nodes resected, postoperative outcomes (drainage duration, length of hospital stay, 30-day mortality), postoperative complications (pneumonia, bronchopleural fistula/empyema, prolonged air leakage, chylothorax, pulmonary embolism, and arrhythmia), and long-term outcomes (overall survival, recurrence-free survival). CONCLUSIONS: The limitation of our study arises mainly due to the heterogeneity of the included studies. Nevertheless, VATS bronchial sleeve lung resection constitutes a feasible and safe alternative to the open sleeve lung resection surgery for the management of centrally located lung tumors.

Double-Staged Sleeve Resection of Laryngotracheal Tumor of Papillary and Follicular Thyroid Carcinoma.

Advanced thyroid carcinoma involving the upper aerodigestive tract confers a poor prognosis mainly due to airway complications. The management of thyroid carcinoma with infiltration to the aerodigestive tract has been widely discussed with no consensus regarding the best surgical technique. Complete surgical resection is the aim of the surgery. However, it has high morbidity if the postsurgical care is compromised, which will lead to airway obstruction, bleeding, infection, and anastomotic dehiscence. In our center, complete resection was achieved through cricotracheal window resection with partial closure and tracheostomy tube insertion. This procedure was chosen due to the time-sensitive nature of surgery in these patients with airway compromise and postoperative limitation of intensive care unit (ICU) bed availability. In our case series, we present six cases of papillary and follicular thyroid carcinoma complicated with intraluminal laryngotracheal infiltration and discuss its management and outcome.