Re-appraisal of bronchus-first right upper lobectomy as an alternative routine procedure.

OBJECTIVES: Postoperative air leakage is a major complication of lung resection, particularly right upper lobectomy. However, various surgical procedures can reduce postoperative complications and shorten the drainage period. The current study aimed to analyse the utility of bronchus-first right upper lobectomy as an alternative routine procedure. METHODS: We retrospectively analysed the data of 225 (53.7%) patients who underwent bronchus-first right upper lobectomy and 194 (46.3%) patients who underwent the conventional bronchus-last right upper lobectomy at our institution from 2015 to 2022. In patients with incomplete fissures who underwent bronchus-first right upper lobectomy, the bronchus was dissected 1st, followed by the pulmonary artery and vein, and then, the interlobar fissure was divided. We compared the outcomes of 2 procedures and analysed the surgical utility of bronchus-first right upper lobectomy. RESULTS: The surgical outcomes and postoperative morbidity comparing bronchus-first and bronchus-last procedure were as follows: median operation time (min) 103/126 (P < 0.001), median bleeding amount (ml) 28/55 (P = 0.003), incomplete lobulation rate (%) 35.1/24.2 (P = 0.02), incidence of prolonged air leakage (%) 2.2/3.1 (P = 0.76) and rate of fellow surgeon's operation (%) 28.0/4.6 (P < 0.001). The procedure was associated with a decreased incidence of prolonged air leakage. The 4-year overall survival rates did not significantly differ between the 2 groups (P = 0.24). CONCLUSIONS: Bronchus-first right upper lobectomy can prevent postoperative air leakage in patients with incomplete fissure. Additionally, as an alternative routine procedure, it is associated with a shorter surgical duration and a lower volume of blood loss regardless of interlobar fissure and operator's experience.

Mortality index is more accurate than volume in predicting outcome and failure to rescue in Medicare beneficiaries undergoing robotic right upper lobectomy.

Background: Surgical volume is known to influence failure to rescue (FTR), defined as death following a complication. Robotic lung surgery continues to expand and there is variability in outcomes among hospitals. We sought to estimate the contribution of hospital-based factors on outcomes and FTR following robotic right upper lobectomy (RRUL). Methods: Using the Centers for Medicare and Medicaid Services inpatient claims database, we evaluated all patients age ≥65 years with a diagnosis of lung cancer who underwent RRUL between January 2018 and December 2020. We excluded patients who had undergone segmentectomy, sublobar, wedge, or bronchoplastic resection; had metastatic or nonmalignant disease; or had a history of neoadjuvant chemotherapy. Primary outcomes included FTR rate, length of stay (LOS), readmissions, conversion to open surgery, complications, and costs. We analyzed hospitals by tertiles of volume and Medicare Mortality Index (MMI). Defined as the institutional number of deaths per number of survivors, MMI is a marker of overall hospital performance and quality. Propensity score models were adjusted for confounding using goodness of fit. Results: Data for 4317 patients who underwent robotic right upper lobectomy were analyzed. Hospitals were categorized by volume of cases (low, <9; medium, 9-20; high, >20) and MMI (low, <0.04; medium, 0.04-0.13; high, >0.13). After propensity score balancing, patients from tertiles of lowest volume and highest MMI had higher costs ($34,222 vs $30,316; P = .006), as well as higher mortality (odds ratio, 7.46; 95% confidence interval, 2.67-28.2; P < .001). Compared to high-volume centers, low-volume centers had higher rates of conversion to open surgery, respiratory failure, hemorrhagic anemia, and death; longer LOS; and greater cost (P < .001 for all). The C-statistic for volume as a predictor of overall mortality was 0.6, and the FTR was 0.8. Hospitals in the highest tertile of MMI had the highest rates of conversion to open surgery (P = .01), pneumothorax (P = .02), and respiratory failure (P < .001). They also had the highest mortality and rate of readmission, longest LOS, and greatest costs (P < .001 for all) and the shortest survival (P < .001). The C-statistic for MMI as a predictor of overall mortality was 0.8, and FTR was 0.9. Conclusions: The MMI incorporates hospital-based factors in the adjudication of outcomes and is a more sensitive predictor of FTR rates than volume alone. Combining MMI and volume may provide a metric that can guide quality improvement and cost-effectiveness measures in hospitals seeking to implement robotic lung surgery programs.

The effect of lobar shifting following right upper lobectomy on postoperative pulmonary function.

OBJECTIVES: Lobes occasionally displace after lobectomy, referred to as "lobar shifting". However, the benefits, especially in postoperative pulmonary function, remain controversial. This study aimed to measure the effect of lobar shifting on postoperative pulmonary function especially in the right upper lobe. METHODS: This retrospective study includes 273 right upper lobectomy patients (lobectomy group) and 24 right upper segmentectomy patients (segmentectomy group) from 2012 to 2021. The lobectomy group was further subdivided based on their Synapse Vincent® image: with their postoperative middle lobe bronchus shifted toward the head (shift group: 176 cases) and without (non-shift group: 97 cases). Several factors were examined to determine the cause of lobar shifting. The rate of measured actual postoperative forced expiratory volume in 1 s (FEV1.0) to predicted postoperative FEV1.0 was analyzed and compared among the three groups. RESULTS: Factors that correlated with lobar shifting included age (p < 0.001), a relatively small middle lobe volume (p = 0.03), no adhesions (p < 0.001), and good upper/middle and middle/lower lobulation (p = 0.04, p = 0.02). The rate of measured actual postoperative FEV1.0 to predicted postoperative FEV1 for the shift, non-shift, and segmentectomy groups were 112.5%, 107.9%, and 103.1% (shift vs non-shift: p = 0.04, shift vs segmentectomy: p = 0.02, non-shift vs segmentectomy: p = 0.19). CONCLUSIONS: Lobar shifting after right upper lobectomy is influenced by morphological factors and may have a beneficial impact on postoperative pulmonary function.

Middle lobe suffering due to malposition and 180° tilt of the 2 remaining lobes after right upper lobectomy.

Middle lobe (ML) suffering after right upper lobectomy (RUL) is rare but represents a major complication usually due to lobar torsion. We report 3 atypical consecutive cases of ML suffering due to malposition of the 2 remaining right lobes with a 180° tilt. All 3 female patients had surgery for non-small-cell carcinoma including RUL associated with radical hilar and mediastinal lymph node removal. Postoperative chest X-ray abnormalities appeared at days 1-3 respectively. The diagnosis of malposition of the 2 lobes was done on contrast-enhanced chest CT scan at days 7, 7 and 6, respectively. A reoperation for suspected ML torsion was required in all patients. Three repositionings of the 2 lobes and 1 middle lobectomy were performed. The postoperative courses were then uneventful, and the 3 patients were alive at a mean follow-up of 12 months. Before thoracic approach closure after RUL, systematic check of good positioning of the 2 reinflated remaining lobes is indispensable. It may prevent ML suffering secondary to 180° lobar tilt leading to whole pulmonary malposition.

The three steps method for uniportal video-assisted thoracoscopic right upper lobectomy.

BACKGROUND: The uniportal video-assisted thoracoscopic right upper lobectomy (UVATRUL), as a common procedure for thoracic surgeons, is difficult to manipulate and has some inherent challenges. To solve both of problems, we summarized a series of techniques as the three steps method and investigated its feasibility on the patients of right upper lung cancer. METHODS: Forty-eight patients with right upper lobe lung cancer who underwent the three steps method UVATRUL in our hospital from January 2020 to May 2022 were selected as the three steps method group. Forty-seven patients who underwent the traditional UVATRUL were selected as the traditional method group. The intraoperative condition and postoperative condition of the two groups were retrospectively analysed. Multiple linear regression analysis was carried out to analyze the relationship between positive results and surgical method. RESULTS: All patients had successfully completed their surgeries. There was no significant difference between the two groups in respect of intraoperative blood loss, rate of conversion, day one thoracic drainage volume, chest tube indwelling time, incidence of postoperative complications, number of lymph node, and postoperative hospital stay (P > 0.05). Operative time of the three steps method group was significantly shorter than the traditional method group (P < 0.001), and number of reloads used was also significantly less than the traditional method group (P = 0.014). Multiple linear regression analysis showed that operative time (ß = - 0.470, P < 0.001), and number of reloads (ß = - 0.254, P = 0.007) correlated with surgical method. CONCLUSION: Compared with the traditional UVATRUL, the three steps method trims the surgery procedures, shortens the operative time, and reduces the use of reloads which makes it an effective procedure for UVATRUL.

Multi-center experience in an optimized right upper lobectomy surgical procedure in China.

BACKGROUND: This multi-center study was aimed at retrospectively evaluating the feasibility, safety, clinical outcomes, and surgical learning curve of an optimized procedure for right upper lobectomy (RUL), which is challenging because of the anatomical structures and features of this lobe. METHODS: This study included 45 RUL cases of robot-assisted thoracoscopy (RATS) in a pilot cohort and 187 RUL cases of video-assisted thoracoscopy (VATS) in three cohorts. A total of 121 and 111 patients underwent traditional and optimized RUL, respectively. The optimized surgical procedure was performed to consecutively transect the superior arterial trunk and bronchus, and finally disconnect the pulmonary vein and posterior ascending artery with interlobar fissures. Clinical and radiological data were reviewed retrospectively. RESULTS: Optimized RUL can be performed successfully by RATS or VATS. The optimized procedure yielded better clinical outcomes than the traditional procedure, including shorter operation times, less blood loss, fewer complications, shorter hospital times, lower costs, and a lower likelihood of postoperative intermedius bronchial kinking. Additionally, for calcified interlobar lymph nodes, the optimized VATS group was less likely to be converted to thoracotomy than the traditional group. The skills required to perform optimized VATS RUL can be gained by surgeons after 12 to 15 cases. The two RUL procedures in the pilot cohort showed similar disease-free survival. CONCLUSIONS: The optimized RUL was safe, economical, and feasible, with a short learning curve and satisfactory disease-free survival.

Infrared thoracoscopic extended lobectomy (right upper lobe and S6) with intravenous indocyanine green administration using preoperative simulation to ensure safe surgical margin.

Although it is crucial to ensure a sufficient surgical margin for a malignant neoplasm, we sometimes struggle to achieve this goal using a minimally invasive approach because it is difficult to palpate the tumor adequately via the small skin incision. To overcome this issue, we adopted a preoperative simulation method for a patient undergoing a right upper lobe and a posterior segmentectomy of the lower lobe (extended lobectomy) and obtained successful results. The discrepancy between the virtual and the actual surgical margins was 5 mm.

Bronchial morphological changes are associated with postoperative intractable cough after right upper lobectomy in lung cancer patients.

BACKGROUND: To date, postoperative intractable cough (PIC) has not received adequate attention, and the complex perioperative factors when performing pulmonary resection often prevent researchers from addressing this issue. This study aimed to investigate the clinicopathological and radiographic indicators related to PIC in lung cancer patients. METHODS: In all, 112 patients who had had right upper lobectomy for primary lung cancer from January 2019 to December 2020 were retrospectively reviewed. We collected data via the electronic medical database of our department. Bronchial morphological features were investigated comprehensively via three-dimensional chest computer tomography reconstruction images. RESULTS: During outpatient follow-up visits, 41 (36.6%) patients complained about persistent dry cough after surgery. Compared with the non-cough group, patients in the refractory cough group showed significant differences in smoking history, right upper lobe stump length, changes of right bronchus intermedius (RBI) diameter, changes of right lower lobe (RLL) basal bronchus diameter, changes of RBI/RLL bronchial angle, and bronchial kink. However, according to multivariable regression analysis, stump length, bronchial kink, and diameter change of the right lower lobe basal bronchus were independently associated with postoperative refractory cough. A nebulization drug was prescribed for the 41 patients diagnosed with PIC, and 33 (80.5%) patients had improved by the next visit. CONCLUSIONS: After right upper lobectomy, the morphology of the remaining bronchial tree in the residual lung changed significantly. The bronchial morphological alterations were independent risk factors for PIC.

Impact of counterclockwise rotation of the right middle lobe following right upper lobectomy.

OBJECTIVES: Following right upper lobectomy, the right middle lobe may shift towards the apex and rotate in a counterclockwise direction with respect to the hilum. This study aimed to investigate the incidence and clinical impact of middle lobe rotation in patients undergoing right upper lobectomy. METHODS: From January 2014 to November 2018, 82 patients underwent right upper lobectomy at our institution for lung cancer using a surgical stapler to divide the minor fissure. Postoperative computed tomography scans evaluated the counterclockwise rotation of the middle lobe, in which the staple lines placed on the minor fissure were in contact with the major fissure of the right lower lobe (120° counterclockwise rotation). Clinicoradiological factors were evaluated and compared between patients with and without middle lobe rotation. We also reviewed surgical videos in patients with middle lobe rotation to evaluate the position of the middle lobe at the end of surgery. RESULTS: Nine patients had a middle lobe rotation (11%), where 1 patient required surgical derotation. Patients with middle lobe rotation were significantly associated with more frequent right middle lobe atelectasis and severe postoperative complications compared with those without rotation. A surgical video review detected potential middle lobe rotation at the end of the surgery. CONCLUSIONS: Middle lobe rotation without torsion following right upper lobectomy is not rare, and it is associated with adverse postoperative courses. Careful positioning of the right middle lobe at the end of surgery is warranted to improve postoperative outcomes.

Risk factors for atelectasis of the middle lobe after right upper lobectomy: preoperative bronchial diameter and stapling of the fissure.

BACKGROUND: Atelectasis of the middle lobe after right upper lobectomy is often seen. However, the risk factors for atelectasis are uncertain. Therefore, we assessed cases in our institution and investigated risk factors for atelectasis of the middle lobe following right upper lobectomy. METHODS: We identified 354 cases in which right upper lobectomy had been performed in our institution between January 2009 and December 2018, and 342 were included in this retrospective analysis. We divided patients into two groups according to the presence of postoperative atelectasis of the middle lobe, and then preoperative clinical variables and perioperative variables were compared between the two groups. Multivariable analyses for postoperative atelectasis of the middle lobe were performed using the logistic regression model. RESULTS: Middle lobe atelectasis was detected in 59 cases (17.3%). Multivariable analysis demonstrated that the preoperative diameter of the middle lobe bronchus [P=0.012; confidence interval (CI), 0.525-0.930] and stapling of the fissure between the upper and middle lobes (P=0.004; CI, 1.997-37.050) were independent risk factors for postoperative atelectasis of the middle lobe. CONCLUSIONS: A small preoperative diameter of the middle lobe bronchus and stapling of the fissure between the upper and middle lobes are risk factors for middle lobe atelectasis following right upper lobectomy.

How to optimize your set-up for a VATS right upper lobectomy.

A 77-year-old woman with multiple ground-glass opacities, the largest of which measured 21 mm, has a biopsy-proven primary lung adenocarcinoma in her right upper lobe. We performed a 3-port right-sided VATS using the Copenhagen approach. There was no pleural effusion or evidence of pleural metastatic spread. A tumor was identified in the upper lobe. The surrounding lung tissue appeared normal.  We performed a multilevel intercostal block using 0.25% levobupivacaine. The inferior pulmonary ligament was divided. The superior pulmonary vein and 2 branches of the pulmonary artery to the right upper lobe were dissected, encircled, and divided using tan reloads of the Endo GIA stapler. The right upper lobe bronchus was dissected, encircled, and divided in a similar fashion using a purple reload of the Endo GIA stapler following a successful test inflation of the lower and middle lobes. The horizontal fissure was completed with further firings of the stapler. Lymph nodes from stations 2, 4, 7, 8, 9, 10, and 11 were sampled and sent separately for histological analysis. There was no parenchymal or stump leak to 20 cm H20 on the test inflation. Hemostasis and pneumostasis were checked and ensured. A single 24 Fr drain was placed in the apex. Hemostasis was complete. The incision was closed in layers.

Intermediate bronchial kinking after right upper lobectomy for lung cancer.

BACKGROUND: Bronchial kinking after lung lobectomy is likely, whereas that of the intermediate bronchus after right upper lobectomy is often not recognized. The aim of this study was to examine the clinical implications of this condition. METHODS: One-hundred cases of right upper lobectomy for primary lung cancer were reviewed. The cases were divided into groups with intermediate (group A) and non-intermediate (group B) bronchial kinking, and the patient characteristics and postoperative outcomes were compared. The remaining lower lobe deformation was also evaluated using the angle formed by the intrathoracic tracheal line and posterior fissure on reconstructed sagittal computed tomography. RESULTS: There were 23 cases in group A which had a higher rate of bronchial calcification, older age, and female sex, whereas and smoking and pulmonary emphysema were less frequent. Three cases in group A had respiratory symptoms such as wheezing and respiratory noise, while only one case of middle lobe atelectasis was found in group B. In multivariate analysis, upper mediastinal lymph node dissection was an independent factor for non-intermediate bronchial kinking. The lower lobe was significantly more expanded in group A than in group B. CONCLUSIONS: Intermediate bronchial kinking correlates with postoperative respiratory symptoms and was less likely after upper mediastinal lymph node dissection.

Successful video-assisted thoracoscopic management of the right middle lobe torsion: A rare complication of right upper lobectomy - A report of two cases.

Middle lobe torsion is an uncommon complication after right upper lobectomy. Clinical features are non-specific. CECT chest and diagnostic bronchoscopy are the essential investigations for the diagnosis. The treatment of choice is urgent re-exploration with either lobectomy or de-rotation with pneumopexy through thoracotomy or video assisted thoracoscopic approach based on the viability of lobe. Strong clinical suspiscion and early surgical intervention are the key points for success. This report highlights the role of video assisted thoracoscopic approach in the management of this rare complication.

Transposition of pulmonary veins for mobilization of residual right middle and lower lobes after carinal right upper lobectomy: a unique pulmonary hilar mobilization technique for safe tension-free airway anastomosis.

Unique right hilar mobilization was performed by pulmonary venous transposition of the right middle and lower lobe veins to the opening of the right upper pulmonary vein to achieve tension-free airway anastomosis after carinal right upper lobectomy for a patient with adenoid cystic carcinoma. The right middle and lower lobes were reconstructed safely thereafter by side-to-end anastomosis between the side of the lower trachea and intermediate bronchus with acceptable suturing tension.

Perioperative outcomes of robot-assisted versus video-assisted right 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 perioperative outcome of patients undergoing robot-assisted thoracic surgery (RATS) or four-port single-direction video-assisted thoracic surgery (VATS) right upper lobectomy (RUL), and to discuss the safety and the essentials of the surgery. Methods    The clinical data of 579 patients with non-small cell lung cancer (NSCLC) undergoing minimally invasive RUL in Dr. Luo Qingquan’s team of our center from 2015 to 2018 were retrospectively analyzed. There were 246 males and 333 females aged 33-78 years. The 579 patients were divided into a RATS group (n=283) and a VATS group (n=296) according to surgical methods. Baseline characteristics and perioperative outcomes including dissected lymph nodes, postoperative duration of drainage, postoperative hospital stay, postoperative complications and surgery cost were compared between the two groups. Results    There was no significant difference in baseline data between the two groups (P>0.05), and no postoperative 30 d mortality or intraoperative blood transfusion was observed. Compared with VATS, RATS had shorter operation time (90.22±12.16 min vs. 92.68±12.26 min, P=0.016), postoperative hospital stay (4.67±1.43 d vs. 5.31±1.59 d, P<0.001) and time of drainage (3.55±1.38 d vs. 4.16±1.58 d, P<0.001). No significant difference was observed between the two groups in the lymph nodes dissection, blood loss volume, conversion rate or complications. The cost of RATS was much higher than that of VATS (93 275.46±13 276.69 yuan vs. 67 082.58±12 978.17 yuan, P<0.001). Conclusion    The safety and effectiveness of robot-assisted and video-assisted RUL are satisfactory, and they have similar perioperative outcomes. However, RATS costs relatively shorter operation time and postoperative hospital stay.

Subxiphoid approach for a combined right upper lobectomy and thymectomy through a single incision.

The subxiphoid uniportal video assisted thoracoscopic surgery (VATS) is a new interesting approach for the resection of anterior mediastinal masses and lung resections. For this reason in cases with both pathologies is an ideal approach to perform both procedures at the same time without multiple incisions. The evolution in the surgery of thymoma is getting less invasive, from the transsternal thymectomy to the minimally invasive Thoracic surgery improving the recovery of the patients and with satisfactory postoperative results, otherwise the anatomical view of the main structures and the recognition of the vascular anatomy, and his variants is feasible. In those cases with synchronic masses, the Subxiphoid approach is an ideal option in hands of experienced surgeons. In this video, we present the case of a right upper lobectomy and a thymectomy by subxiphoid approach in which the anatomical variations of the thymic artery are well recognized, and both procedures were completed without complications.

Uniportal video-assisted thoracoscopic right upper lobectomy with systematic lymphadenectomy.

Over the past decade, uniportal video-assisted thoracic surgery (VATS) has been reported to be a promising, less invasive alternative with potentially better cosmesis and less postoperative pain and paraesthesia. Although uniportal VATS has now evolved into a sophisticated technique capable of performing some of the most complex thoracic procedures, this approach to lobectomy is not standardized, and the surgical procedure still varies between surgeons. Here, we describe our uniportal VATS procedure during right upper lobectomy in a patient with a nodule in the right upper lobe. Subsequent mediastinal lymphadenectomy was performed to remove lymph nodes from the 2(nd), 3(rd), 4(th), 7(th), 8(th), and 9(th) groups. Although there are some details that are different compared to the conventional VATS approach, as experience with uniportal VATS has grown, this approach is a viable alternative approach for lobectomy in selected patients.

Right upper lobectomy performed as dividing posterior ascending artery-bronchus-pulmonary vessels is alternative to primary indolent scar carcinomas.

We describe a case of pulmonary indolent malignancy requiring a strategic surgery and introduce an alternative technique of right upper lobectomy via video-assisted thoracic surgery (VATS) for primary lung cancer patients. A 42-year-old male non-smoker was referred to the hospital following the detection of an opacity with a cystic airspace in the right upper lobe during a routine physical examination. During a regular follow-up over 3.5 years, the solid component enlarged and the cystic wall thickened. Based on a suspicion of indolent scar carcinoma, a right upper lobectomy was performed using VATS. The preoperative diagnosis was clinical T1bN0M0, stage Ia primary lung cancer. Our surgical procedure, posterior single-direction aBVA, consists of dividing the posterior ascending artery branch and then the right upper bronchus, followed by the right upper pulmonary vessels. By efficiently reducing the operation time and blood loss, our method is potentially superior to conventional right upper lobectomy.

A case report: right upper lobectomy with middle lobe preservation after right lower lobectomy.

Few reports have described right upper and lower lobectomy with preservation of the middle lobe because of the risk of middle lobe torsion or emphysematous change. Herein we describe a successful result following lobectomy with preservation of the middle lobe for metachronous pulmonary metastasis originating from colon cancer in the right upper lobe after initial right lower lobectomy. A 69-year-old man who had undergone right lower lobectomy for pulmonary metastasis originating from colon cancer 3 years earlier was diagnosed as having suspected metachronous pulmonary metastasis in the right upper lobe. Because preoperative computed tomography (CT) indicated that the distance between the tumor and the entrance of the upper bronchus was 20 mm, it was considered difficult to achieve complete resection by a wedge resection or segmentectomy. Furthermore, preoperative CT demonstrated compensatory hypertrophy of the middle lobe and elevation of the right diaphragm, thus reducing the size of the thorax. Therefore, right upper lobectomy with middle lobe preservation was planned. The operation was performed using a totally thoracoscopic approach. Adhesion of the upper lobe to the chest wall was easily detached. As the middle lobe adhered to the chest wall, this served to prevent middle lobe torsion. The fissure between the upper and middle lobes had fused because of adhesion resulting from the initial lower lobectomy. Therefore, an 'anterior fissureless approach' was adopted to avoid any postoperative air leakage. There were no intraoperative problems, and the postoperative course was uneventful. The patient was discharged on postoperative day 6. Pathological examination of the specimen confirmed that the tumor was a metachronous pulmonary metastasis originating from the colon cancer. Four months after the operation, he had no requirement for additional oxygen support, and postoperative CT demonstrated a sufficiently expanded residual middle lobe without emphysematous change.

VATS right upper lobectomy.

A 56-year-old male patient was admitted due to one small pulmonary nodule in the apicoposterior segment of the right upper lobe, which was found on his health screening one month ago. Preoperative examinations showed no distant metastasis, and his heart and lung functions could tolerate the lobectomy. Chest computed tomography (CT) showed one small pulmonary nodules on the apicoposterior segment of the right upper lobe, which was considered to be malignant lesions. No remarkably swollen lymph node was visible in the mediastinum. Therefore, VATS right upper lobectomy was performed and intraoperative frozen section confirmed the diagnosis of adenocarcinoma.