Uniportal Video-Assisted Thoracoscopic Surgery Completion Lobectomy Long after Wedge Resection or Segmentectomy in the Same Lobe: A Bicenter Study

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Congratulations to you on your successful uniportal VATS completion lobectomy. The entire manuscript was well written with acceptable language and layout. The topic is of novelty.

There is without doubt that uniportal VATS is a safe procedure for even a re-operation. The main difficulty of the operation is the severe adhesions.  The cases you studied were those at least five weeks after the previous resections. I suggested should you divide the population into three groups, which are five , ten and fifteen weeks or longer after the first operation, to see if there were any differences in terms of operation time, blood loss, drainage period, hospital stay, medical expenditure and complications ?

Author Response

 

 

Dear Reviewer 1 ,

Thank you so much for your comments.

Following your suggestions, we evaluated the postoperative outcome according to the different time interval ( 5 weeks, >5 and<15 weeks, >15 weeks). We found no differences in terms of operative time ( p=0.27), blood loss ( p=0.68) and p.o. drainage stay ( p= 0.123).

We found a significant difference in (p: 0,015) in terms of postoperative  hospital stay, in particular evaluating the difference in terms of  median p.o stay between  the Group <5 weeks  (3,75 +/- 1,39 days)  vs Group >15 weeks ( 6,80 +/- 4,02 days).

 

 

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for the opportunity to analyze your interesting article dealing with a modern management of “redo surgery”.      

 

In this article, authors have retrospectively analyzed the cohort of patients operated by uniportal-VATS (u-VATS) to perform a completion lobectomy (CL). 

 

            Concerning the Introduction:

            The introduction is well written, highlighting major questions dealing with minimally invasive surgery, single port VATS procedures and “redo surgery” with a special focus on CL. 

 

            Concerning the Methodology:

            Population:

            No major concerns about the population.

            Do you have an ERAS program now? Was it implemented during the covered period 2015 to 2022?  

 

            Surgery:  

            How many surgeons are involved in your U-VATS program in the 2 centers? 

            Can you give more information about the “systematic lymphadenectomy” you used to perform? 

            

Post-operative management:

What kind of drainage device do you use? Digital one? 

 

Criteria:

90-day mortality is better than 30-day, can you give this data? 

 

Statistical analysis conducted: 

            No major concerns about it. 

 

Concerning the Results

            Results are well reported and clearly presented in tables and in the article, but still have some comments:

-       A flow-chart of the U-VATS approach would be interesting to identify the proportion of this approach in your daily practice. Can you give this information? 

-       Concerning the lymphadenectomy can you also give the number of area harvested ? More informative the number of lymph nodes. 

-       You confirm that everyone had a lymphadenectomy during the CL ?

-       What are per operative complications and outcomes? Conversion and bleeding? Other things you mean?  Can you precise this idea ?  

-       Can you report PO complications with the Clavian Dindo Classification? 

-       Can you give the 90-day mortality rather than the 30-day?

-       Concerning patients operated first by thoracotomy, do you have any supp data about the indication of this approach? And why now “it’s possible” to perform a U-VATS ? 

             

            Concerning the Discussion:

It’s a well written discussion well documented with good references.

Post operative pleural adhesions are well discussed. But, maybe one idea is missing, the use of CO2 during the first procedure. Do you have any date about this? It’s reported that capnothorax can reduce PO adherences. But I agree that it’s only for closed VATS procedure of robotic procedure.  

Major bleeding in minimally invasive procedure is still a fear. Concerning per opeative bleedings, no conversions were indicated to control and to manage it, what was your tips and tricks? What kind of hemostatic devices are you using? 

Concerning air leaks, do you use some sealant or mesh? 

 

Concerning the Conclusion:

It’s an interesting article highlighting a challenging approach for redo surgery. 

 

It’s a well written, easy reading and interesting article, but some precisions will be welcome.

And  maybe a short surgical movie with some dissection of hilar, mediastinal structures can be interesting also. 

 

            Congratulations to authors for this work. 

Author Response

Dear Reviewer 2,

thank you so much for your comments.

 

Question 1  Do you have an ERAS program now? Was it implemented during the covered period 2015 to 2022?: Since 2015 we improved our ERAS program introducing early mobilization and early iniziation of oral intake of the patient  8  hours after surgery. An  early FKT improved program has been introduced since 2019 .  

 

Question 2:  How many surgeons are involved in your U-VATS program in the 2 centers?  All the staff is involved in the U-VATS program in the two centers, but CL have been performed only by surgeon very skilled in the field.

Question 3:             Can you give more information about the “systematic lymphadenectomy” you used to perform? We follow the classic definition of systematic lymphadenectomy, that comprise the removal of lymph nodes in predefined and organized manner .

Question 4: What kind of drainage device do you use? Digital one?  In our clinical setting we use the  Redax  Drentech simple ( compact) system.  We use digital system only in selected cases.

Question 5: 90-day mortality is better than 30-day, can you give this data? We didn’t include in our DB 90-day mortality, because this paper analyzed intra and early p.o outcomes, but we will take into account this indicator in our next paper evaluating long term results.

Question 6: A flow-chart of the U-VATS approach would be interesting to identify the proportion of this approach in your daily practice. Can you give this information?  Our proportion of patients operated by U-VATS is about 85 % of total lung procedures.

Question 6:   Concerning the lymphadenectomy can you also give the number of area harvested ? More informative the number of lymph nodes. The specific stations includes: 2,4,7,8,9,10 depending on the location of the tumor . Obviously, during CL, especially in case of previous Lymph node dissection performed in the first operation, the extension of lymphadenectomy might be reduced by the dense adhesions that sometimes we found in the mediastinal area.

Question 7:        You confirm that everyone had a lymphadenectomy during the CL ? Lymphadenectomy is integrative part of surgical operation. Of course, in case of dense adhesions that can make dangerous the systematic lymphadenectomy, the extension of the nodal dissection might be reduced, but every patient undergo, at least, nodal sampling.

Question 8:   What are per operative complications and outcomes? Conversion and bleeding? Other things you mean?  Can you precise this idea?  We described our results extensively in the paper. We don’t consider conversion to thoracotomy as a complication.

Question 9:  Can you report PO complications with the Clavian Dindo Classification? We reported p.o complications  comprised between grade I and IIIb according to Clavien-Dindo Classification.

 

Question 10:Can you give the 90-day mortality rather than the 30-day? Already answered

Question 11: Concerning patients operated first by thoracotomy, do you have any supp data about the indication of this approach? And why now “it’s possible” to perform a U-VATS ? 

This paper evaluate patients operated during a long time interval. Some patients have been operated for the first time before the introduction of U-VATS in the two centers, or for deep nodules before the introduction of localization technique, so, this population of patients has been selected to be approached by U-VATS at CL.

Question 12: Post operative pleural adhesions are well discussed. But, maybe one idea is missing, the use of CO2 during the first procedure. Do you have any date about this? It’s reported that capnothorax can reduce PO adherences. But I agree that it’s only for closed VATS procedure of robotic procedure.

Thank you so much for this comment. I agree with you. In totally robotic procedures it’s possible to make a capnothorax, but during U-VATS procedurs the use of CO2 is non indicated because there is a wide communication between the intra and extrathoracic compartments, so a capnothorax is not reliable. Unfortunately I don’t have any data regarding the topic.

 

  

Major bleeding in minimally invasive procedure is still a fear. Concerning per opeative bleedings, no conversions were indicated to control and to manage it, what was your tips and tricks? What kind of hemostatic devices are you using? 

The most used hemostatic device used is Flo-seal that is really efficient in bleeding control. During procedure we make wide use of bipolar forceps that warranty a great control of bleeding also during realease of adhesions.

 

 

Concerning air leaks, do you use some sealant or mesh? 

Sometimes , at the end of operations, we apply Tabo-tamp on the operative field.

 

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Please incorporate you answer into your Discussion.

Author Response

Thank you so much. I reported the results in the text.