Special series: VATS segmentectomy

In 1995, the Lung Cancer Study Group published a prospective randomized controlled study comparing lobectomy patients with those undergoing a sub-lobar resection (1). This study reported a lower local recurrence rate and a better long-term survival in the lobectomy group compared to sub-lobar resections. Ever since then, pulmonary lobectomy has been considered the standard surgical procedure for early stage lung cancer, and sub-lobar resections have remained indicated for unfit patients only. This last decade has been marked on the one hand by the launch of lung cancer screening programs with early detection of small nodules or ground glass opacities, and on the other hand by the adoption of minimally invasive techniques for anatomical resections. Both aspects revived the controversy on whether segmentectomies are indicated as intentional resections for patients with early-stage lung cancer rather than for patients with limited lung functions only. Since the historical presentation of JCOG0802 trial by Professor Asamura during the AATS 2021 (2), which reported on the first phase III trial and demonstrated the benefits of segmentectomies in terms of survival for patients with lung tumors of less than 2 cm, no doubt is permitted: segmentectomy will become the standard surgical procedure for early stage lung cancer. However, he also reported increased local recurrence rates in the segmentectomy group (12.1% vs. 7.9%; P=0.021) in comparison with the lobectomy group. In spite of the clear foundations afforded by his study, not all questions could be answered: pulmonary segmentectomy is a technically more difficult procedure than lobectomy, with more frequent anatomical variations, requiring deeper hilar vascular and bronchial dissection and the division of two or more intersegmental planes. This may lead to potential complications or to insufficient margins, perhaps explaining the increased rate of local recurrences.

Lack of standardization remains in terms of surgical approaches, extent of lymph node dissection, identification of intersegmental planes, identification of the tumor and oncological surgical margins to decrease local recurrence rates. In this special series, we have asked various recognized international experts in this field how they manage and perform simple or complex segmentectomies in order to simplify this surgical intervention. Of course, this will not replace learning from a mentor or visiting high volume centers, but this series will give some advice on how to safely perform VATS segmentectomies.

I would like to thank all authors for their valuable contributions to this special series and the editorial office of the Journal of Visualized Surgery for their support. I really believe that this special series reflects a considerable effort from numerous international colleagues, so I hope you will find it interesting and useful!

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Visualized Surgery for the series “VATS Segmentectomy”. The article did not undergo external peer review.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://jovs.amegroups.com/article/view/10.21037/jovs-21-27/coif). The series “VATS Segmentectomy” was commissioned by the editorial office without any funding or sponsorship. The author served as the unpaid Guest Editor of the series. The author has no other conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Ginsberg RJ, Rubinstein LV. Randomized trial of lobectomy versus limited resection for T1 N0 non-small cell lung cancer. Lung Cancer Study Group. Ann Thorac Surg 1995;60:615-22; discussion 622-3. [Crossref] [PubMed]
2. Asamura H, Okada M, Saji H, et al. Randomized Trial of Segmentectomy Compared to Lobectomy in Small-Sized Peripheral Non-Small Cell Lung Cancer (JCOG0802/WJOG4607L). In: 101st Annual Meeting of the American Association for Thoracic Surgery. 2021.

Michel Gonzalez