Split-lobe resections versus lobectomy for lung carcinoma of the left upper lobe: a pair-matched case-control study of clinical and oncological outcomes.

OBJECTIVES: To compare left upper split-lobe procedures, being upper trisegmentectomy and resection of the lingula, with left upper lobectomy for surgical treatment of lung carcinoma originating from the left upper lobe. METHODS: A pair-matched control study comparing the clinical and oncological outcomes of 22 consecutive patients after left upper split-lobe resections with those of 44 pair-matched controls that received left upper lobectomy for non-small-cell lung carcinomas. The control group was matched 1:2 for tumour diameter, histology, nodal status and patient age. In both groups, diagnosis and surgical treatment adhered to the principles of tissue-based preoperative mediastinal staging, intraoperative systematic nodal dissection, and gross surgical margins equal to the tumour diameter or at least 2 cm, a sufficient preoperative pulmonary function given. RESULTS: As intended by the study design, the split-lobe and lobectomy groups had similar median tumour diameters of 22.5 (range, 11-63) and 25 (range, 7-68) mm, respectively (P = 0.98), identical histologies (45.5% adenocarcinoma, 4.5% adenocarcinoma in situ, 45.5% squamous cell carcinoma and 4.5% neuroendocrine carcinoma) and identical pN stages (pN0 77.3%, pN1 9.1%, pN2 9.1% and ypN0 4.5%). In the split-lobe group, a lower preOP forced expiratory volume in one second (median 2.0 vs 2.3 l), a higher comorbidity (median Charlton score of 3 vs 2) and a preponderance of video-assisted thoracoscopy procedures (63.6 vs 27.3%) were prevalent (all P < 0.05). There were no significant outcome differences detected, neither with regard to the postoperative clinical course assessed by intra- and postoperative complications, operation time, tissue margins, duration of drainage and hospital stay and 30-day mortality, nor with regard to 5-year overall (0.89 vs 0.81, P = 0.90). CONCLUSIONS: Left upper lobectomy might be an overtreatment for selected cases of lung carcinoma whose resection by a split-lobe procedure produces adequate margins and a complete lymphadenectomy. Tumour diameters exceeding 2 cm, nodal involvement and previous neoadjuvant treatment do not necessarily exclude this option for selected patients under the condition of a meticulous nodal dissection. In this context, we would like to suggest a translational research of the split-lobe concept to other large pulmonary lobes.

Extended cervical mediastinoscopy revisited.

OBJECTIVES: To describe the diagnostic value of selective extended cervical mediastinoscopy (ECM) in combination with video-assisted mediastinoscopic lymphadenectomy (VAMLA) in mediastinal staging of potentially resectable left-sided lung carcinoma. METHODS: Institutional report on 110 ECM procedures indicated for enlarged lymph nodes within the aorto-pulmonary (AP) zone on computed tomography. Staging sensitivity, negative predictive value (NPV) and specificity of ECM, combined VAMLA and ECM, VAMLA alone and systematic dissection for lung resection via left-sided video-assisted thoracoscopic surgery (VATS) or thoracotomy were calculated from a subset of 92 patients with left-sided lung carcinoma. RESULTS: Selective ECM was performed in 12.6% of all video-mediastinoscopic procedures, and added, except for one vascular complication, there was no morbidity. ECM had an impact on mediastinal staging in 78.0% of the lung cancer cases. Sensitivity, NPV and specificity were 0.94, 0.96 and 1 for ECM to detect nodal involvement within the AP zone. Sensitivity, NPV and specificity to detect any mediastinal diseases were 0.94, 0.96 and 1 for the combination of ECM and VAMLA; 0.64, 0.80 and 1 for VAMLA alone and 0.76, 0.84 and 1 for systematic mediastinal dissection via left-sided VATS or thoracotomy approach. CONCLUSIONS: ECM complements VAMLA in comprehensive mediastinal dissection. Selective ECM is a valuable addendum to mediastinoscopic staging procedures for left-sided tumours, as it enhances sensitivity and NPV. Precaution and experience are required to circumvent the rare risk of potentially fatal vascular accidents.

Cotton-derived oxidized cellulose in minimally invasive thoracic surgery: a clinicopathological study.

OBJECTIVE: The aim of this study was to identify resorption, clinical performance, and safety of cotton-derived oxidized cellulose gauze applied as a hemostat in minimally invasive oncologic thoracic surgery. METHODS: This is a pilot prospective noncomparative observational human in vivo study. A piece of cotton-derived oxidized cellulose gauze measuring 5 × 20 cm was inserted into the subcarinal space of patients with potentially resectable lung carcinoma at the time of video-assisted mediastinoscopic lymphadenectomy and reexamined several days later for macroscopic and histologic evaluation at the time of subsequent lung resection. The primary endpoint was the local situation at the implantation site described by cellulose remnants, fluid collections, and adhesions. The secondary endpoint was safety, described by the number of adverse events and surgical reinterventions. RESULTS: Twenty-five consecutive eligible patients with potentially resectable lung carcinoma were included. The desired hemostatic effect was achieved in all cases. No adverse events were observed. At re-exploration 10.5 (5-28) days later, the cellulose gauze was found to lose its solid structure from the fifth day on. Remnants were last detected 14 days after insertion. The implantation site exhibited no inflammatory changes and a remarkable small amount of fluid collections and adhesions. CONCLUSIONS: Mediastinal application of cotton-derived oxidized cellulose is safe and effective. A piece of gauze measuring 5 × 20 cm seems to be absorbed completely within 15 days, thus precluding any interference with oncologic restaging and follow-up. The absence of relevant adhesions facilitates further surgical procedures. Larger comparative confirmatory studies are required. For large-scale resorption studies, our clinical model should be translated into a porcine model.

Complete video-assisted thoracoscopic surgery anatomic segmentectomy for clinical stage I lung carcinoma - technique and feasibility.

This paper describes a prospective, observational, single-centre study of 20 consecutive patients with clinical stage I lung carcinoma undergoing anatomical sublobar resections using complete video-assisted thoracoscopic surgery (cVATS). Thirteen male and seven female patients with a median age of 68 (range 57-84) years and a median of four (range 0-9) relevant comorbid conditions presented with five right-sided and 15 left-sided tumours, with a median diameter of 2.3 (range 1.0-5.2) cm. Thirteen segmentectomies, three bisegmentectomies and four trisegmentectomies with lymphadenectomy of the N1 stations and the mediastinum were performed, with a median duration of 212 (range 91-397) min, a conversion rate to open surgery of 20% and conversion to lobectomy of 10%. In five patients, we noted 10 postoperative adverse events but no transfusions, no readmissions and zero mortality. Median drainage time was six days, with a median hospital stay of 8.5 days. According to the pTNM classification, 10, three, one, and six patients were staged as Ia, Ib, IIb and IIIa, respectively. The distance between the tumour and the parenchymal stapling line exceeded the tumour diameter in 56%, 0% and 0% of T1a, T1b and T2 tumours, respectively. To conclude, cVATS anatomical sublobar resections are technically feasible. We observed a favourable postoperative course in 20 multimorbid or aged patients. In patients fit for lobectomy, the tumour diameter should not exceed 2 cm.

Combined videothoracoscopic and videomediastinoscopic approach improves radicality of minimally invasive mediastinal lymphadenectomy for early stage lung carcinoma.

OBJECTIVES: To assess the feasibility and radicality of a combined thoracoscopic and mediastinoscopic approach to mediastinal lymphadenectomy compared to thoracoscopy only for minimally invasive management of early stage lung carcinoma. METHODS: Prospective observational study of patients undergoing anatomical thoracoscopic lung resection for lung carcinoma in our department in 2007. Mediastinal lymphadenectomy was performed either thoracoscopically (VATS group) or by a combination of video-assisted mediastinoscopic lymphadenectomy (VAMLA) and thoracoscopy (VAMLA+VATS group). Inclusion criteria for the study were: stage Ia on CT scan, no central tumor at bronchoscopy, and no contraindications against lobectomy or segmentectomy. RESULTS: Eighteen VAMLA+VATS and fourteen VATS patients were studied. For histology, pTNM stage, type of resection, semiquantitative assessment of the fissure and vascular dissection plane, conversions, blood loss, operation time, adverse events and drainage time, no differences between the two groups were observed. In the VATS group, there was a slight preponderance of women, and right-sided tumors. In the VAMLA+VATS group, both the number of dissected mediastinal lymph node stations (mean, 6.4 stations vs 3.6 stations) and the weight of the mediastinal specimen (median, 11.2 groups vs 5.5 groups), were significantly higher than in the VATS group (p<0.05). CONCLUSIONS: A combined approach by VATS and VAMLA improves radicality of minimally invasive mediastinal lymphadenectomy without increase in operation time, morbidity, and drainage time.