title: Fissure-last video-assisted thoracoscopic lobectomy for 'non-upper' lobes.
abstract: BACKGROUND
  Surgical approach into the fissural parenchyma may be an important and modifiable factor for the prevention of air leak after anatomical lung resections. Fissureless fissure-last technique has been described as useful technique to reduce air leak, yet in video-assisted thoracoscopic surgery (VATS) data are limited and mostly on the upper lobes. The purpose of this study is to evaluate the safety and feasibility of fissureless fissure-last VATS 'non-upper' lobectomies and the impact of it on the immediate outcome, especially relating to air leak.
  
  
  METHODS
  This study is a monocentric single-surgeon retrospective analysis on prospectively collected data. During 24 months, 46 patients underwent VATS 'non-upper' lobectomy or lower bilobectomy, with conventional (VATS-c) technique in 20 and fissureless fissure-last (VATS-f) technique in 26 patients. Results were evaluated according to preoperative, perioperative and postoperative parameters.
  
  
  RESULTS
  There were no differences between VATS-c and VATS-f groups in any characteristics or peri- and postoperative variables, except the number of staplers, where it was significantly higher in VATS-c group (MVATS-c = 5.7; MVATS-f = 7.7; P = 0.001). Operation time did not differ between the groups, but showed gender-related difference, being longer in males (MVATS-c = 188; MVATS-f = 157; P = 0.04). Prevalence of air leak was 20%; prolonged air leak (PAL) (>5 days) being 11% and PAL (>7 days) 0%. Patients with air leak were older by tendency (MVATS-c = 74.9; MVATS-f = 66.5; P = 0.08), had more complications (P = 0.025; relative risk = 2.65) and stayed longer at hospital (MVATS-c = 10.8; MVATS-f = 7.7; P = 0.02). Postoperative complications were present in 24% of patients.
  
  
  CONCLUSIONS
  VATS-f lobectomy is safe and feasible not only for 'upper' but also for 'non-upper' lobes. When applied to properly selected patients, it may reduce air leak and PAL and thus may potentially reduce the rate of complications.
authors.affiliation: Department of Thoracic Surgery, St. Vincentius Kliniken, Karlsruhe, Germany.
authors.forename: Davor
authors.initials: D
authors.lastname: Stamenovic
authors.affiliation: Department of Thoracic Surgery, Faculty of Medicine, Marmara University, Istanbul, Turkey.
authors.forename: Korkut
authors.initials: K
authors.lastname: Bostanci
authors.affiliation: Department of Thoracic Surgery, St. Vincentius Kliniken, Karlsruhe, Germany.
authors.forename: Antje
authors.initials: A
authors.lastname: Messerschmidt
authors.affiliation: Department of Thoracic Surgery, St. Vincentius Kliniken, Karlsruhe, Germany.
authors.forename: Jahn
authors.initials: J
authors.lastname: Tillmann
authors.affiliation: Clinic for Thoracic Surgery, Clinical Center of Serbia, Belgrade, Serbia.
authors.forename: Marko
authors.initials: M
authors.lastname: Kostic
authors.affiliation: Department of Thoracic Surgery, St. Vincentius Kliniken, Karlsruhe, Germany.
authors.forename: Thomas
authors.initials: T
authors.lastname: Schneider
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005240:Feasibility Studies; D005260:Female; D005402:Fistula / Q000601:surgery*; D006801:Humans; D008168:Lung / Q000473:pathology* / Q000503:physiopathology; D008175:Lung Neoplasms / Q000601:surgery; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D000072356:Parenchymal Tissue / Q000473:pathology*; D011013:Pneumonectomy / Q000009:adverse effects / Q000379:methods*; D011183:Postoperative Complications / Q000453:epidemiology; D012189:Retrospective Studies; D017792:Surgical Stapling / Q000379:methods; D020775:Thoracic Surgery, Video-Assisted / Q000379:methods* / Q000639:trends; D000267:Tissue Adhesions / Q000209:etiology
keywords: VATS; lobectomy; parenchymal fistula; pleural air leak