Post-operative and oncological outcomes of minimally-invasive simple and complex segmentectomy: a narrative review

Background and Objective: The recent two randomized controlled trials (RCTs) (JCOG0802/ WJOG4607L and CALBG/Alliance 140503) have definitively removed the belief that segmentectomy is the surgical treatment of patients not able to tolerate lobectomy, but some arguments remained without a clear answer such as the adequacy of the minimally invasive approach, the effectiveness in the treatment of cIA (< 2 cm) non-small cell lung cancer (NSCLC) and also the long-term functional impact of segmentectomy. The purpose of this narrative review is to clarify the role of sublobar resection by presenting the most important scientific papers on this topic, focusing on the minimally-invasive approach. Methods: PubMed, Embase and Scopus were searched for "lung segmentectomy", "minimally-invasive lung segmentectomy", "Video Assisted Thoracic Surgery (VATS) segmentectomy", and "Robot Assisted Thoracic Surgery (RATS) segmentectomy" in January 2023. Key Content and Findings: Four RCT studies, five systematic reviews and meta-analyses, one prospective and 12 retrospective studies published from 1995 to 2023 that compared the oncological and functional outcomes of lobectomy and segmentectomy were included. Seven retrospective papers compared the results of minimally-invasive simple or complex segmentectomy. The two recent large RCT (JCOG0802/ WJOG4607L and CALBG/Alliance 140503) demonstrate the non-inferiority of segmentectomy on the overall survival (OS) and disease-free survival (DFS) and partial functional advantage 6 months after surgery. The oncological adequacy of segmentectomy was demonstrated also by several retrospective studies in which the functional impact of segmentectomy was more evident. The retrospective studies on simple and complex segmentectomy showed that these procedures are feasible, associated with an increased risk of post-operative prolonged air leak, but complex segmentectomy considered oncologically sound option for clinical stage IA NSCLC. Conclusions: Segmentectomy could become the standard surgical approach for small and peripheral clinical IA NSCLC guaranteeing adequate oncological outcomes and a more preserved lung function.