Objectives The functional impact of thoracoscopic basal segmentectomy in comparison with lower lobectomy has not been investigated in-depth and the aim of this study was to clarify this topic. Material and Methods We retrospectively analyzed a cohort of patients who underwent surgery between 2015 and 2019 for NSCLC, peripherally located lung nodules, far enough from both the apical segment and the lobar hilum to allow an oncologically safe thoracoscopic lower lobectomy or basal segmentectomy. Pulmonary function tests (PFTs) including spirometry and plethysmography were performed one month after surgery and Forced Expiratory Volume in 1 second (FEV1), Forced Vital Capacity (FVC) and Diffusing capacity for CO (DLCO) were collected; the difference, the loss and the recovery rate of pulmonary function were calculated and compared with Wilkoxon-Mann-Whitney test. Results During the study period, n = 45 and n = 16 patients for VATS - Lower Lobectomy (VATS-LL) and for VATS - Basal Segmentectomy (VATS-BS) respectively completed the study protocol: the two groups were homogeneous as to pre-operative variables and PFTs values. Post-operative outcomes were similar and PFTs revealed significant differences between post-operative FEV1%, FVC%, ΔFVC, ΔFVC%. The loss percentage of FVC%, DLCO% and the recovery rate were better for FVC and DLCO in the VATS - BS group. Conclusion Thoracoscopic basal segmentectomy seems to be associated with a more preserved lung function, maintaining more FVC and DLCO levels than lower lobectomy and could be performed in selected cases ensuring also adequate oncological margins.
IntroductionAwake minimally invasive Uniportal Video Assisted Thoracic Surgery (U-VATS) represents the last challenge in thoracic surgery that could change the future scenario for high comorbidity patients with early-stage non-small cell lung cancer (NSCLC). We report a single center preliminary experience of awake thoracoscopic uni-portal anatomic and non-anatomic sub-lobar resections in this setting.MethodsWe retrospectively analyzed data collected on a prospective database of patients undergoing U-VATS awake sub-lobar lung resections for NSCLC between September 2021 and September 2022. Inclusion criteria were clinical stage I disease; contraindication to standard lobectomy due to high respiratory function impairment; general anesthesia considered at high risk based on the American Society of Anesthesiologist score and on the Charlson Comorbidity Index. All patients underwent a standardized awake non-intubated anesthesia protocol approved by our institutional board.ResultsThey were n = 10 patients: n = 8 wedge resections; n = 2 segmentectomies. We had n = 1 (10%) conversion to standard general anesthesia and n = 1 laryngeal mask support but maintaining spontaneous breathing. N = 5 patients (50%) needed an Intensive Care Unit recovery (mean time = 17.20 h). Mean chest tube duration and Hospital stay were 2.0 and 3.5 days respectively. We did not register 30- days postoperative mortality.ConclusionAwake thoracic surgery is a feasible technique, and it could be performed also in high comorbidities’ patients without a high rate of complications and allows to operate patients that so far were considered borderline for surgery.
Current guidelines recommend surgery for early-stage non-small cell lung cancer (NSCLC). The standard treatment for patients with cT1N0 NSCLC has been lobectomy with lymph-node dissection, with sublobar resection used only in patients with inadequate cardio-respiratory reserve, with poor performance status, or who are elderly. In 1995, the Lung Cancer Study Group published the results of a randomized, prospective trial demonstrating the superiority of lobectomy compared with sublobar resection. From then on, wedge resection and segmentectomy were reserved exclusively for patients with poor functional reserve who could not tolerate lobectomy. Therefore, the exact role of segmentectomy has been controversial over the past 20 years. Recently, the randomized controlled trial JCOG0802/WJOG4607L demonstrated that segmentectomy was superior to lobectomy in patients with stage IA NSCLC (<2 cm and CTR < 0.5) in terms of both overall-survival and post-operative lung function. Based on these results, segmentectomy should be considered the standard surgical procedure for this patient group. In 2023, the randomized phase III CALGB 140503 (Alliance) trial demonstrated the efficacy and non-inferiority of sublobar resection, including wedge resection, for clinical stage IA NSCLC with tumor diameter of < 2 cm. This article is a narrative review of the current role of segmentectomy in lung cancer treatment and summarizes the most relevant studies in this context.
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