Neoplasms

Respiratory Tract (Lung and Bronchial) Diseases

All Conditions

Lung Neoplasms

Respiratory Tract Neoplasms

Thoracic Neoplasms

Lung Diseases

Respiratory Tract Diseases

VATS lobectomy is undertaken through one to four keyhole incisions without rib spreading. The use of 'rib spreading' is prohibited as this is the key intra-operative manoeuvre which disrupts tissues and causes pain (and is used in open surgery). The procedure is performed with videoscopic visualisation without direct vision. The hilar structures are dissected, stapled and divided. Endoscopic ligation of pulmonary arterial branches may be performed. The fissure is completed and the lobe of lung resected. Lymph node management is the same as described for open surgery. The incisions are closed in layers and may involve muscle, fat and skin layers. This definition of VATS lobectomy is a modification of CALGB 39802.

Conventional open surgery is undertaken through a single incision +/- rib resection and with rib spreading. The operation is performed under direct vision with isolation of the hilar structures (vein, artery and bronchus) which are dissected, ligated and divided in sequence and the lobe of lung resected. The procedures may be undertaken using ligatures, over sewing or with staplers. Lymph node management is undertaken in accordance with the International Association of the Study of Lung Cancer (IASLC) recommendations where a minimal of 6 nodes / stations are removed, of which 3 are from the mediastinum that includes the subcarinal station. The thoracotomy is closed in layers starting from pericostal sutures over the ribs, muscle, fat and skin layers.

Open Surgery

Video Assisted Thoracoscopic Surgery (VATS)

Chris Rogers

Eric Lim

Lung cancer is the leading cause of cancer death worldwide and survival in the United Kingdom (UK) remains amongst the lowest in Europe. Surgery is the main method of managing early stage disease and is traditionally undertaken via conventional open surgery. However, over the last decade there has been a surge in the number of minimal access resections performed using Video-assisted thoracoscopic surgery (VATS). However, there remains a need for well-designed and conducted randomised controlled trial (RCT) to provide the evidence base for the wide spread uptake and delivery of this surgical approach.

The uptake of surgery for lung cancer in the UK is low and minimal access surgery may be regarded as a more acceptable intervention (compared to open surgery) by patients, referring respiratory physicians and oncologists. However, a large multi-centre RCT is essential to inform patient and clinician decision making and influence surgical practice in the UK.

The VIOLET study will compare the effectiveness, cost-effectiveness and acceptability of VATS lobectomy versus open surgery for treatment of lung cancer and will test the hypothesis that VATS surgery is superior to open surgery with respect to self-reported physical function five weeks after randomisation (approx. one month after surgery).

Specific objectives are to estimate:

A. The difference between groups in the average self-reported physical function at five weeks.

B. The difference between groups with respect to a range of secondary outcomes including assessment of efficacy (hospital stay, pain, proportion and time to uptake of chemotherapy), measures of safety (adverse health events), oncological outcomes (proportion of patients upstaged to pN2 disease and disease free survival) and overall survival.

C. The cost effectiveness of VATs and open surgery.

VIdeo Assisted Thoracoscopic Lobectomy Versus Conventional Open LobEcTomy for Lung Cancer

VIdeo Assisted Thoracoscopic Lobectomy Versus Conventional Open LobEcTomy for Lung Cancer, a Multi-centre Randomised Controlled Trial With an Internal Pilot

Physical functioning scale, ranges between 0 and 100. High score indicates high level of physical functioning.

3 types of scales. Functioning scales which include physical functioning, role functioning, emotional function, cognitive functioning and social functioning. Symptom scales which include fatigue, nausea and vomiting, pain, dysponea, insomnia, appetite loss, constipation, diarrhoea, financial difficulties.

An overall global health status/QoL All scales range between 0 and 100. For functioning scales, a high score indicates a high level of functioning. Similarly, a high global health status/QoL score indicates a high quality of life. For symptom scales, a high score indicates a high level of symptoms.

Symptoms scales which include Dyspnoea, Couging, Haemoptysis, Sore mouth, Dysphagia, Peripheral neuropathy, Alopecia, Pain in chest, Pain in arm or shoulder, Pain in other parts, and Pain medication. For these scales, a high score indicates a high level of symptoms, as with the QLQ-C30.

Scales range between 0 and 100.

Subscales: mobility, self-care, usual activities, pain/discomfort, anxiety/depression. These range from 1-5.

subscales mobility, self-care, usual activities, pain/discomfort, anxiety/depression are combined to calculate an overall index score which ranges from -0.59 to 1.

A higher score indicates better quality of life

Resource use to 1-year (measured for the duration of post-operative hospital stay until discharge, and at 5 weeks, 3 months, 6 months and 1-year post randomisation)

Royal Brompton & Harefield NHS Foundation Trust

University of Oxford

University of Bristol

Pulmonary artery Energy Sealing with HARMONIC ACE+ Shears (HS) ex-vivo

We plan to evaluate the efficacy of the HS for the sealing of PAs in an ex-vivo human model. Efficacy will be measured and compared using the bursting pressure point following vascular energy sealing. Energy sealing may be superior to stapling devices as it eliminates the need for excessive tissue dissection around the pulmonary vessels, which in turn decrease the incidence of vascular injuries during VATS anatomical lung resection. All vessels will be sealed ex-vivo using the HARMONIC ACE®+ Shears (Ethicon, Cincinnati, Ohio, USA).

HARMONIC ACE®+ Shears (HS)

Moishe Liberman, MD, PhD

VATS anatomical lung resection provides an effective minimally invasive treatment strategy for stage I and II lung cancer. VATS lobectomy is associated with significantly less postoperative atrial fibrillation, blood transfusion, renal failure, and other complications when compared with lobectomy via thoracotomy.

Although VATS lobectomy has been proven to be effective and safe in experienced hands, it is not devoid of risk. Intra-operative surgical complications can be at times catastrophic.

Currently, in spite of being a safe and effective technique in experienced hands, a minority of anatomical pulmonary resections are being performed by VATS. The technical difficulty and increased actual and perceived danger of VATS lobectomy is related to PA branch manipulation and this is the main limitation for many thoracic surgeons regarding the adoption of VATS lobectomy into their practise. Furthermore, the majority of VATS lobectomies are being performed in high volume, academic medical centers with a resultant disparity in socioeconomic status between those that undergo VATS versus open lobectomy. If we can find a way to decrease the manipulation required by the surgeon on the PA branches, these procedures will be safer, less stressful for the surgeon and therefore more prevalent for anatomical pulmonary resections.

The intraoperative techniques will not differ from standard resection techniques and blood vessel ligation will be performed according to standard operative procedures either using endostaplers or direct ligation of the pulmonary vessels.

After resection and removal of the resected specimen, the specimen will be examined ex-vivo, out of the operative field in a non-sterile field in the operative room. The lobar PA and its main segmental branches will be sharply dissected. Cannulation of a major segmental PA branch will be performed using our pressurization and monitoring device. The cannulation will be secured with a 2-0 silk suture. The vascular pressurization and recording device has been described in section E and is outlined in Figures 4 and 5. All pressure measurements will be recorded and graphed related to time from initial vascular pressurization to PA bursting pressure.

All distal segmental branches of the PA will be ligated to maintain the pressure throughout the catheterized segmental branch. An initial pressure of 25 mmHg will be obtained by inflating the vessel with normal saline. The lobar PA and the main segmental branches' diameters will be measured from vascular adventitia to adventitia. The lobar PA and the main segmental arteries will be sealed using the Harmonic Scalpel Ace+. The sealing will be performed with an intravascular pressure of 25 mmHg in order to simulate normal human PA pressures.

Following division of the PA, normal saline solution will be injected through the controlled pressure syringe pump in order to achieve an intralumenal vascular pressure until the bursting pressure is reached. Intralumenal pressure will be recorded at a frequency of 10 times per second. The bursting pressure will be recorded. Ex-vivo experimentation will take approximately 20 to 30 minutes. Burst pressure of the in-vivo endo-stapled (Endopath® ETS, 35mm, 2.5mm staples, white cartridge; Ethicon, Cincinnati, Ohio, USA) main lobar PA branches will be evaluated and recorded ex-vivo on the same specimens.

Endo-stapled vessels will be utilized as the size-matched control for energy sealed vessels in a 1:2 ratio. Allotment into the stapled or energy sealed group will be based on vascular size measurement prior to sealing. Attempts will be made to use the in-vivo staple line as the control vessel in all possible cases (size permitting) in order to increase the sample size of the energy sealed vessels.

Following vascular sealing, experimentation and recordings, the specimen will be sent for pathological evaluation of the resected lesion. All specimen manipulations will be strictly performed on the proximal main PA branches, away from the resected tumour. Care will be taken to not affect the pathological integrity of the resected lesion and its surrounding tissue and lymph nodes. Experimentation will be performed under the direct supervision of the attending thoracic surgeon in order to assure integrity of the specimen for pathological analysis.

Analysis will consist of between group comparisons of the efficacies and bursting pressure of both the energy sealed vessels (experimental group) and the endostapler-sealed vessels (control group). Vessels will be stratified by luminal diameter by millimeter. Primary outcome for analysis will be the intergroup comparisons of mean PA burst pressure by size of vessel. Intergroup differences will be compared with the student's t-test with bursting pressures entered as a continuous variable. Statistical testing for normality of data will be performed and when data is non-normal, non-parametric methods (ex: Wilcoxon Rank Sum Test...) will be used. Multivariable linear regression models will be employed in order to compare burst pressures between groups controlling for potential confounders (disease state, size of vessel sealed, age of patient, sex, pulmonary lobe, laterality, immunosupression, diabetes, vascular disease...).

Pulmonary Artery Sealing Using the HARMONIC ACE+ Shears(HS) for VATS Lobectomy

Ex-Vivo Evaluation of the Effectiveness of Pulmonary Artery Sealing Using the HARMONIC ACE + Shears (HS) for VATS Lobectomy

Intergroup differences will be compared with the student's t-test with bursting pressures entered as a continuous variable. Statistical testing for normality of data will be performed and when data is non-normal, non-parametric methods (ex: Wilcoxon Rank Sum Test...) will be used. Multivariable linear regression models will be employed in order to compare burst pressures between groups controlling for potential confounders (disease state, size of vessel sealed, age of patient, sex, pulmonary lobe, laterality, immunosupression, diabetes, vascular disease...).

Study title	NCT ID	Conditions	Interventions	Eligibility	Organization	Link
VIdeo Assisted Thoracoscopic Lobectomy Versus Conventional Open LobEcTomy for Lung Cancer	NCT03521375	Lung Neoplasms	Open Surgery Video Assisted ...	16 Years -	University of Bristol
Pulmonary Artery Sealing Using the HARMONIC ACE+ Shears(HS) for VATS Lobectomy	NCT01975623	Lung Cancer	HARMONIC ACE®+ ...	18 Years -	Centre hospitalier de l'Université de Montréal (CHUM)

Spots Global Cancer Trial Database for video assisted thoracoscopic surgery (vats)