title: High-quality 3-dimensional image simulation for pulmonary lobectomy and segmentectomy: results of preoperative assessment of pulmonary vessels and short-term surgical outcomes in consecutive patients undergoing video-assisted thoracic surgery†.
abstract: OBJECTIVE
  The aim of this study was to evaluate the effectiveness of 3-dimensional computed tomography (3D-CT) software in short-term surgical outcomes and the assessment of variations of pulmonary vessel branching patterns on performing video-assisted thoracic surgery (VATS).
  
  
  METHODS
  The study included 179 consecutive patients who had undergone VATS anatomical lung resection, of which 172 were lobectomies (96%) and 7 were segmentectomies (4%), from May 2011 through January 2013. There were 124 patients (69%) in whom 3D-CT was performed and 55 patients (31%) who had not undergone 3D-CT. Observed actual pulmonary vessel branching patterns by intraoperative findings or footage were compared with the 3D image findings. Various surgical outcomes, including the occurrence of postoperative complications, in this study defined as those of Grade 2 or above under the Clavien-Dindo classification system, and total operative time, were retrieved from available clinical records.
  
  
  RESULTS
  Among the 124 patients with preoperative 3D imaging, there were 5 (4%) conversions from VATS to thoracotomy. The incidence rate of patients with postoperative complications was 8% (n = 10), and there were no 30-day or 90-day mortalities. Pulmonary artery (PA) branches were precisely identified for 97.8% (309 of 316) of branches on 3D images, and the sizes of the seven undetected branches (five in the right upper lobe, two in the left upper lobe) ranged from 1 to 2 mm. The 3D images accurately revealed 15 cases (12%) of anomalous or unusual PA branches and 5 cases (4%) of variant pulmonary veins. Multivariate logistic regression analysis of the association with postoperative complications and operative time in 165 lung cancer patients demonstrated that male gender was the only statistically significant independent predictor of complications (risk ratio: 5.432, P = 0.013), and patients without 3D imaging tended to have operative complications (risk ratio: 2.852, P = 0.074), whereas conducting the 3D-CT (risk ratio: 2.282, P = 0.021) as well as intraoperative bleeding amount (risk ratio: 1.005, P = 0.005) had significant association with operative time.
  
  
  CONCLUSIONS
  High-quality 3D-CT images clearly revealed the anatomies of pulmonary vessels, which could play important roles in safe and efficient VATS anatomical resection.
authors.affiliation: First Department of Surgery, Tokyo Medical University Hospital, Tokyo, Japan.
authors.forename: Masaru
authors.initials: M
authors.lastname: Hagiwara
authors.affiliation: First Department of Surgery, Tokyo Medical University Hospital, Tokyo, Japan zenkyu@za3.so-net.ne.jp.
authors.forename: Yoshihisa
authors.initials: Y
authors.lastname: Shimada
authors.affiliation: First Department of Surgery, Tokyo Medical University Hospital, Tokyo, Japan.
authors.forename: Yasufumi
authors.initials: Y
authors.lastname: Kato
authors.affiliation: First Department of Surgery, Tokyo Medical University Hospital, Tokyo, Japan.
authors.forename: Kimitoshi
authors.initials: K
authors.lastname: Nawa
authors.affiliation: First Department of Surgery, Tokyo Medical University Hospital, Tokyo, Japan.
authors.forename: Yojiro
authors.initials: Y
authors.lastname: Makino
authors.affiliation: First Department of Surgery, Tokyo Medical University Hospital, Tokyo, Japan.
authors.forename: Hideyuki
authors.initials: H
authors.lastname: Furumoto
authors.affiliation: Department of Radiology, Tokyo Medical University Hospital, Tokyo, Japan.
authors.forename: Soichi
authors.initials: S
authors.lastname: Akata
authors.affiliation: First Department of Surgery, Tokyo Medical University Hospital, Tokyo, Japan.
authors.forename: Masatoshi
authors.initials: M
authors.lastname: Kakihana
authors.affiliation: First Department of Surgery, Tokyo Medical University Hospital, Tokyo, Japan.
authors.forename: Naohiro
authors.initials: N
authors.lastname: Kajiwara
authors.affiliation: First Department of Surgery, Tokyo Medical University Hospital, Tokyo, Japan.
authors.forename: Tatsuo
authors.initials: T
authors.lastname: Ohira
authors.affiliation: Department of Chest Surgery, St. Marianna University School of Medicine, Yokohama, Japan.
authors.forename: Hisashi
authors.initials: H
authors.lastname: Saji
authors.affiliation: First Department of Surgery, Tokyo Medical University Hospital, Tokyo, Japan.
authors.forename: Norihiko
authors.initials: N
authors.lastname: Ikeda
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D021621:Imaging, Three-Dimensional / Q000379:methods*; D008297:Male; D008875:Middle Aged; D011013:Pneumonectomy / Q000379:methods*; D011651:Pulmonary Artery / Q000000981:diagnostic imaging*; D011667:Pulmonary Veins / Q000000981:diagnostic imaging*; D012189:Retrospective Studies; D020775:Thoracic Surgery, Video-Assisted / Q000379:methods*; D014057:Tomography, X-Ray Computed / Q000379:methods*; D016896:Treatment Outcome
keywords: 3-Dimensional computed tomography; Lobectomy; Pulmonary vessels; Simulation; Video-assisted thoracic surgery