Sleeve resection after neoadjuvant treatment via minimally invasive approaches for lung cancer

摘要

To the Editor: Sleeve resection, which is a procedure to resect and reconstruct bronchial and/or pulmonary arteries, is considered a valid therapeutic approach for centrally located lung cancer. With the establishment and development of the comprehensive treatment concept, applying neoadjuvant treatment such as neoadjuvant immunotherapy against centrally located lung cancer with locally advanced staging is effective. Neoadjuvant treatment might reduce the tumor size to increase the chances of complete resection and achieve parenchyma-sparing procedures of sleeve resection. Generally, sleeve resection improves postoperative respiratory function and quality of life, and achieves lower postoperative morbidity and mortality with similar oncological outcomes to pneumonectomy after neoadjuvant treatment. Sleeve resection is traditionally performed by thoracotomy. In the recent two decades, minimally invasive surgery has gradually become an alternative to thoracotomy owing to the development of instruments and surgical techniques. However, minimally invasive sleeve resection via video-assisted thoracoscopic surgery (VATS) or robot-assisted thoracoscopic surgery (RATS) is still technically challenging, with major concerns regarding the safety and feasibility in terms of perioperative and oncological outcomes. Additionally, the safety and efficacy of minimally invasive sleeve resection after neoadjuvant treatment are still controversial. Sleeve resection is most commonly indicated for centrally located lung cancer or metastatic N1 lymph node infiltrating the origin of the lobar bronchus and/or pulmonary arterial lobar branches. In addition, sleeve resection can also be used to achieve radical resection when frozen sections confirm microscopic residual disease on the bronchial or arterial margin after standard lobectomy. In the application of the minimally invasive approach in sleeve resection, the continuous improvement and optimization of technical strategies have gradually made it feasible. In 2002, Santambrogio et al[1] reported the first case of left lower sleeve lobectomy via VATS. Thereafter, the hybrid VATS (mini-thoracotomy with VATS) and complete VATS approaches were successively used for sleeve lobectomy. Because of an association of less chest pain with fewer ports, multiple portal VATS sleeve lobectomy with four or three ports gradually evolved into biportal or uniportal VATS. In the RATS procedure, the first case of sleeve lobectomy using a combined robotic and thoracoscopic approach was reported by Schmid et al[2] in 2011 who suggested the application potential of RATS in sleeve resection. In 2019, a landmark study published by Jiao et al[3] established the technological maturity of RATS for sleeve resections. This large series with 67 patients showed excellent clinical outcomes, indicating the safety and feasibility of RATS in complex and extended lung resections represented by bronchial sleeve lobectomies. In 2020, Qiu et al[4] reported the evolution of surgical approaches from thoracotomy to VATS and then to RATS for sleeve resections including single and double sleeve lobectomies. Additionally, RATS with fewer ports (biportal and uniportal RATS) and suture adjustment (v-loc sutures) strategies is useful application in sleeve resections. These applications should be further explored. With increased surgical experience and cases, clinically acceptable perioperative outcomes from a series of studies indicated the safety of minimally invasive sleeve resection. We reviewed the relevant studies published to date [Supplementary Table 1, https://links.lww.com/CM9/B802] and found the following. In minimally invasive sleeve resection, the conversion rate to thoracotomy ranged from 0 to 21.1%, R0 resection rate ranged from 84.5% to 100%, postoperative morbidity rate ranged from 0 to 44.4%, 30-day mortality rate ranged from 0 to 6.8%, and 90-day mortality rate ranged from 0 to 6.8%. In the balanced population, the perioperative o