Comparison of 5-Year Survival and Disease Recurrence After Trisegmentectomy or Left Upper Lobectomy: A Propensity Score Analysis of the National GEVATS Database.

INTRODUCTION: Trisegmentectomy, or resection of the upper subdivision of the left upper lobe with preservation of the lingula, is considered by some authors to be equivalent to right upper lobectomy with middle lobe preservation. Our objective was to compare survival and recurrence after trisegmentectomy versus left upper lobectomy procedures registered in the Spanish Video-Assisted Thoracic Surgery group (GEVATS) database. METHODS: We compared mortality, survival and recurrence in patients with left upper lobectomy or trisegmentectomy after propensity score matching for the following variables: age, smoking habit, tumor size, histologic type, radiological density of tumor, surgical access, forced expiratory volume in one second, diffusing capacity of the lungs for carbon monoxide, hypertension, chronic heart failure, ischemic heart disease, arrhythmia, stroke, peripheral vascular disease, diabetes and pre-surgery nodal status by positron emission tomography/computed tomography. RESULTS: A total of 540 left upper lobectomies and 83 trisegmentectomies were registered in the GEVATS database. After propensity score matching, 134 left upper lobectomies and 67 trisegmentectomies were selected. Survival outcomes were similar, but differences were found for recurrence (21.5% for trisegmentectomies vs. 35.4% for left upper lobectomies, p=0.05). Moreover, the recurrence patterns differed, with the lobectomy group showing a greater tendency to distant dissemination. CONCLUSIONS: Trisegmentectomy and left upper lobectomy show similar 5-year survival rates. In our database, recurrence after trisegmentectomy was lower than after left upper lobectomy, while the recurrence pattern differed among the 2 surgical approaches, with a greater tendency to distant metastasis after left upper lobectomy.

Proximal ligation technique prevents thrombus formation in the pulmonary vein stump after lobectomy.

PURPOSE: To assess the risk factors for thrombosis in the pulmonary vein stump (PVT) and the efficacy of proximal ligation in preventing PVT after lobectomy. METHODS: In total, 649 surgical patients with lung cancer were retrospectively reviewed. To compare the clinical effectiveness of PV proximal ligation, the simple stapler group (290 patients) and the proximal ligation group (359 patients who underwent thread ligation at the pericardial reflection with/without a stapler) were analyzed. RESULTS: In the simple stapler group, 12 of 290 patients (4.1%) developed PVT. Among these, 9 of 58 underwent left upper lobectomy (LUL). In contrast, 5 of the 359 patients (1.4%) in the proximal ligation group developed PVT. All five patients received LUL. The incidence of PVT in the proximal ligation group was significantly lower than that in the simple stapler group (p = 0.0295) as well as in the analysis by LUL alone (p = 0.0263). A logistic regression analysis indicated that higher BMI and LUL were associated with the development of PVT (p = 0.0031, p < 0.0001), and PV proximal ligation reduced PVT (p = 0.0055). CONCLUSION: Proximal ligation of the PV has the potential to prevent PVT, especially after LUL.

Cardiac herniation post left upper lobectomy and thymectomy: a case report.

BACKGROUND: Cardiac herniation occurs when there is a residual pericardial defect post thoracic surgery and is recognised as a rare but fatal complication. It confers a high mortality and requires immediate surgical correction upon recognition. We present a case of cardiac herniation occurring post thymectomy and left upper lobectomy. CASE PRESENTATION: Initial presentation: A 48-year-old male, hypertensive smoker presented with progressive breathlessness and was found to have a left upper zone mass confirmed on CT biopsy as carcinoid of unclear origin. PET-CT revealed avidity in a left anterior mediastinal area, left upper lobe (LUL) lung mass, mediastinal lymph nodes, and a right thymic satellite nodule. Intraoperatively: Access via left thoracotomy and sternotomy. The LUL tumour involved the left thymic lobe (LTL), left superior pulmonary vein (LSPV), left phrenic nerve and intervening mediastinal fat and pericardium, which were resected en-masse. The satellite nodule in the right thymic lobe (RTL) was adjacent to the junction between the left innominate vein and superior vena cava (SVC). The pericardium was resected from the SVC to the left atrial appendage. Clinical deterioration: Initially the patient was doing well clinically on day 1, however there was sudden bradycardia, hypotension, clamminess, and oligoanuria, with raised central venous pressures and troponins. ECG: no capture in leads V1-2, but positive deflections seen on posterior leads. Echo: no acoustic windows, but good windows seen posteriorly. CXR: left mediastinal shift. Redo operation: After initial resuscitation and stabilisation on the intensive care unit, on day 2 a redo-sternotomy revealed cardiac herniation into the left thoracic cavity with the left ventricular apex pointing towards the spine, and inferior caval kinking. After reduction and repair of the pericardial defect with a fenestrated GoreTex patch, the patient recovered well with complete resolution of the ECG and CXR. CONCLUSION: Cardiac herniation can even occur following sub-pneumonectomy lung resections and should be considered as a differential when faced with a sudden clinical deterioration, warranting early surgical correction.

The learning curve of a bronchus-first method in bi-port video-assisted thoracoscopic surgery for left upper lobe lung cancer.

Video-assisted thoracic surgery (VATS) has been widely used in lung cancer treatment. However, VATS left upper lobectomy (LUL) is complex due to the intricate branching pattern of the left pulmonary artery (PA). Nevertheless, VATS right upper lobectomy can be simplified through a bronchus-first and simultaneous vessel stapling technique. In this study, the learning curve was obtained while ensuring favorable oncological outcomes using bronchus-first method for VATS LUL. First, retrospective data of 148 consecutive patients who underwent VATS LUL (bronchus-first method) for non-small cell lung cancer (NSCLC) from March 2018 to October 2020 were analyzed. The learning curve was then assessed via cumulative sum (CUSUM) analysis. Moreover, data at different stages of the learning curve, including operation time, blood loss, postoperative hospital stay, lymph node harvested, thoracotomy conversion, postoperative complications, endoscopic stapler consumptions, and 3 year overall survival, were recorded. The learning curve was best modeled as the equation: y = - 7.78 + 2.05x-2.23 × 10-2x2 + 6.43 × 10-5x3, with a good-to-fit test R2 = 0.97. The surgeon entered the proficient stage (59th case-148th case) after consecutive operations of 58 cases (learning stage, 1st case-58th case). Notably, more lymph nodes were harvested in the proficient stage than in the learning stage (17.69 ± 1.47 vs. 15.53 ± 1.43, P < 0.01). Compared with the learning stage, the proficient stage was associated with shorter operation time (114.28 ± 8.56 min vs. 126.81 ± 7.30 min, P < 0.01), fewer blood loss (44.22 ± 7.75 mL vs. 57.41 ± 22.98 mL, P < 0.01), shorter postoperative hospital stay (6.02 ± 0.99 d vs. 7.22 ± 1.34 d, P < 0.01), and fewer endoscopic stapler consumptions (5.89 ± 0.64 vs. 6.53 ± 0.50, P < 0.01). However, thoracotomy conversion (4/90 vs. 5/58, P = 0.32), postoperative complications (10/90 vs. 11/58, P = 0.23) and 3 year overall survival (62.2% vs. 50.8%, log-rank test, P = 0.11) showed no significant difference between the two stages. The surgeon with former single-direction VATS lobectomy experience can master bronchus-first VATS LUL after attending to 58 cases.

Left Upper Division Segmentectomy Compared with Lobectomy for Lung Expansion and Bronchus Tortuosity.

BACKGROUND: For patients with left upper lobe lesions, the functional benefit of left upper division segmentectomy over left upper lobectomy remains controversial. This study evaluated the clinical and functional outcomes after these two procedures. METHODS: This retrospective study included 135 patients with left upper lobe lesions (left upper lobectomy, 110; left upper division segmentectomy, 25). Propensity score matching was used to compare the two groups. Spirometry and computed tomography volume assessments were performed to evaluate bronchus angle and tortuosity. Short-term clinical respiratory symptoms were assessed via medical record reviews. RESULTS: Patients in both groups had similar preoperative characteristics, apart from tumor size (left upper division segmentectomy, 1.6 ± 0.9 cm; left upper lobectomy, 2.8 ± 1.7 cm; p = 0.002). After propensity score matching, both groups had similar preoperative spirometry and pathological results. The postoperative spirometry results were similar; however, the left upper division segmentectomy group had a significantly smaller decrease in left-side computed tomography lung volume compared with that in the left upper lobectomy group (left upper division segmentectomy, 323.6 ± 521.4 mL; left upper lobectomy, 690.7 ± 332.8 mL; p = 0.004). The left main bronchus-curvature index was higher in the left upper lobectomy group (left upper division segmentectomy, 1.074 ± 0.035; left upper lobectomy, 1.097 ± 0.036; p = 0.013), and more patients had persistent cough in the left upper lobectomy group (p = 0.001). CONCLUSIONS: Left upper division segmentectomy may be a promising option for preventing marked bronchial angulation and decreasing postoperative persistent cough in patients with left upper lobe lung cancer.

Mechanical Thrombectomy Using Double Stent Retriever Technique for Acute Ischemic Stroke Following Embolism From the Pulmonary Vein Stump After Left Upper Lobectomy: A Case Report.

Acute ischemic stroke (AIS) following pulmonary lobectomy, which is traditionally attributed to air embolism and atrial fibrillation (AF), may occur after thrombus formation in the pulmonary vein stump (PVS). Herein, we document the mechanical thrombectomy (MT) of a carotid bifurcation occlusion post-left upper lobectomy (LUL) to manage AIS. A 76-year-old male with a history of diabetes, dyslipidemia, and a treated dural arteriovenous fistula at the transverse sigmoid junction, with no history of AF, successfully underwent LUL for a pulmonary tumor. The patient independently walked on postoperative day 1. He developed right hemiparesis and total aphasia on the morning of the second day after surgery, which was discovered by the nursing staff. A magnetic resonance imaging (MRI) confirmed an occlusion of the left common carotid artery (CCA). Tissue plasminogen activator (t-PA) was not administered owing to recent surgery. An urgent MT using multiple MT techniques carried out 90 minutes after the discovery of symptoms only achieved partial recanalization. Subsequently, a double stent retriever technique (DSRT) addressed the occlusion in the common and cervical internal carotid artery (ICA). Following this, a T occlusion was encountered, which was addressed with a combined approach using a single stent retriever (SR), achieving a thrombolysis in cerebral infarction (TICI) grade 2b result. However, postoperative aphasia and severe right hemiparesis remained. Postoperative imaging showed a significant left cerebral hemisphere infarction and a thrombus in the PVS. Oral edoxaban was administered, and PVS thrombosis did not recur. The patient was transferred to a rehabilitation facility 190 days post-embolization with a modified Rankin Scale score of 4. In this report, we demonstrate the challenging case of the DSRT in addressing AIS after LUL, which led to the formation of a massive thrombus and occlusion of the carotid artery, as revealed by the PVS. This case emphasizes the importance of collaborative efforts between thoracic surgeons and all staff involved in stroke care in managing such complex scenarios.

Perioperative outcomes of robot-assisted versus video-assisted left upper lobectomy in non-small cell lung cancer: A retrospective cohort study / 中国胸心血管外科临床杂志

@#Objective    To summarize the efficacy of robot-assisted thoracic surgery (RATS) and video-assisted thoracoscopic surgery (VATS) in the treatment of left upper lobectomy for non-small cell lung cancer. Methods    The clinical data of patients with non-small cell lung cancer who underwent left upper lobectomy with RATS or VATS in our center from January 2019 to October 2021 were retrospectively analyzed. The patients were divided into two groups according to surgical methods: a RATS group and a VATS group. The baseline clinical data and results were compared between the two groups. Results    A total of 145 patients were included. There were 78 males and 67 females with a mean age of 59.9 years. There were 63 patients in the RATS group and 82 patients in the VATS group. There was no death within 30 days after operation in both groups. In the RATS group, the drainage volume on the second postoperative day (233.49±83.94 mL vs. 284.88±120.21 mL, P=0.003), total operative time (126.94±29.50 min vs. 181.59±61.51 min, P=0.000), intraoperative resection time of the left upper lobe (76.48±27.52 min vs. 107.23±47.84 min, P=0.000), intraoperative blood loss (P=0.000), and conversion rate to thoracotomy (P=0.018) were significantly better than those in the VATS group. The group (5.41±0.94 groups vs. 4.83±1.31 groups, P=0.002) and number (18.27±7.39 vs. 12.76±6.54, P=0.000) of dissected lymph nodes in the RATS group were significantly more than those in the VATS group. The differences in the drainage volume on the first day after operation, postoperative intubation time, postoperative hospital stay or postoperative complications between the two groups were not statistically significant (P>0.05). Conclusion    The application of RATS in the left upper lobectomy for non-small cell lung cancer is safe and feasible, and has obvious advantages over VATS.

Clinical analysis for the short-term outcome of Da Vinci robotic-assisted left upper lobectomy for lung cancer / 中国胸心血管外科临床杂志

@#Objective    To summarize the clinical experience of Da Vinci robotic-assisted left upper lobectomy for treating lung cancer. Methods    We retrospectively analyzed the perioperative data of 33 patients with primary lung cancer who underwent Da Vinci robotic-assisted left upper lobectomy between December 2016 and December 2018 in our hospital. Meanwhile, the perioperative data of 41 patients with lung cancer who underwent video-assisted thoracoscopic left upper lobectomy during the same period by the same surgeon were studied as a control group. The resection was followed by the principle of "from back down to front up" way. Systemic lymph node dissection including No.4-9 was performed for all patients. Results    All patients received successful surgery with no case of conversion to thoracotomy and perioperative death. Comparing to video-assisted thoracoscopic surgery, the Da Vinci robotic-assisted left upper lobectomy had longer operating time (191.21±61.77 min vs. 154.51±38.81 min, P=0.003), more cost (82 307.75±11 859.03 yuan vs. 58 966.57±5 640.07 yuan, P=0.000), shorter chest tube duration (4.58±1.77 d vs. 5.41±1.52 d, P=0.031) and postoperative hospital stay (6.48±1.82 d vs. 7.66±2.12 d, P=0.014). However, there was no significant difference between the two groups regarding to blood loss, lymph node dissection, postoperative pain score, total chest drainage volume, chest drainage volume per day and the rate of pulmonary complications. Conclusion    The Da Vinci robotic-assisted left upper lobectomy for treating lung cancer is safe and more minimally invasive, but more expensive.