Single anesthetic bronchoscopy and resection (SABR): keeping up with the changing times

Technology is advancing quickly: apps at our fingertips provide rapid access to any information as well as anything from clothes, groceries, and food. In the same way, improvements in both the diagnosis and intervention for lung cancer have progressed in an exponential manner.

Despite these advancements, lung cancer remains the leading cause of cancer-related deaths in the United States (1). Developing new strategies to enhance diagnosis and reduce the time to treatment could greatly benefit patients. Given that early-stage lung cancer usually shows no symptoms, early detection and treatment are difficult. Delay from diagnosis to treatment of early-stage lung cancer negatively affects survival. Due to variable wait times for different biopsy modalities, diagnostic wedge resection (WR) is often required at the time of planned oncologic resection. With a benign resection rate of 20–25%, these operations can be viewed as potentially unnecessary surgeries (2).

One of the latest techniques to assist doctors in diagnosing pulmonary lesions is robotic-assisted bronchoscopy (3).

The PRECISION-1, BENEFIT, and PRECIsE (4-6) trials were pivotal in confirming its role in the diagnosis of lung lesions as well as contemporaneous mediastinal staging.

After establishing itself as a safe and reliable method of diagnosis, its addition to concomitant resection has been entertained by various institutions.

The single anesthetic bronchoscopy and resection (SABR) technique has been developed to allow for real-time diagnosis via robotic navigational bronchoscopy (RNB) with biopsy, followed by immediate formal oncologic resection as indicated.

At Cedars-Sinai Medical Center, this technique is undertaken with the patient in the lateral decubitus position. The hindrance of not being able to perform a standard registration and relying on the “Preview Path mode” is balanced by the lack of need for tube exchange and patient position change. After placement of a right-sided double lumen tube for all left-sided lesions and viceversa, the shape-sensing robotic-assisted bronchoscopy (ssRAB) is used in concomitance to fluoroscopy and radial EBUS to identify the target lesion. Biopsies are performed using either a 19-, 21-, or 23-gauge needle, typically with eight needle passes using suction and then four cryoprobe biopsies. Rapid on-site evaluation (ROSE) is then obtained for pathological confirmation. Marking for subsequent anatomic lung resection (lobectomy, segmentectomy) is undertaken at this time if needed with a mixture 0.5 cc of indocyanine green (ICG) and 0.5 cc of methylene blue.

In one of our recent manuscripts, 65 patients underwent SABR compared to 75 patients that were subject to a traditional surgical WR for diagnosis, followed by anatomic resection if indicated. There were no differences in clinical characteristics or nodule location between the two groups. The mean time from clinic to definitive treatment was 30±21 days in the SABR group and 32±23 days in the WR group (P=0.545). Mean nodule size was larger (2.0±0.9 vs. 1.7±0.7, P=0.006) and mean operating room (OR) time was longer (218±76 vs. 113±43 minutes, P<0.001) in the SABR group. There were no differences in post-operative complications or 90-day readmission between groups. Eleven SABRs were stopped at biopsy alone due to a diagnosis precluding surgical resection. Benign resection rate of 7.6% in the SABR group was significantly lower than the rate of 21.9% in the WR group (P=0.037).

Overall complication rate comparison including air leaks, pneumonias, and atrial fibrillation were not statistically significant.

Furthermore, based on a financial analysis at Cedars-Sinai Medical Center, SABR seems to have an overall cost per case that is lower compared to robotic bronchoscopy and subsequent resection. Median total cost was $70,591 (range, $62,515–77,080) and $81,025 (range, $67,136–91,307) for the SABR and staggered groups, respectively (P=0.002) (7). This seems to be comparable to other studies and presentations (8).

In the context of stage I non-small cell lung cancer (NSCLC), Wolf et al. also reported shorter times between identification of a pulmonary nodule and intervention compared to controls (65 vs. 116 days). The SABR cases also had a lower complication rate and shorter length of stay (9).

Wong et al. reported improved diagnostic rates at 93% compared to prior studies at 80–83% for nodules less than 2 cm (10).

The feasibility and expeditious nature of this technique could have implications in minimizing the time between cancer diagnosis and definitive surgical treatment; this could have significant implications for clinical perioperative outcomes, patient satisfaction, and length of hospital stay. The aforementioned benefits could theoretically be extended not only to large academic centers but also to non-specialized centers where a prolonged wait time for radiographic biopsies and/or the extensive travel time could be mitigated.

Although it is undeniable that further research is necessary to determine how this reduction in time will translate into significant improvements in clinical outcomes, this new technique may simply be keeping up with the times by realizing your needs or your goals with minimal delays and optimal efficiency.

Acknowledgments

None

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Shanghai Chest. The article has undergone external peer review.

Peer Review File: Available at https://shc.amegroups.com/article/view/10.21037/shc-24-28/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://shc.amegroups.com/article/view/10.21037/shc-24-28/coif). The authors have no conflicts of interest to declare.

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