Quality of life (QoL) after pulmonary resections is an important consideration while deciding whether to proceed with surgery or not. For years, as the thoracic surgery community, we have paid a great effort to achieve better QoL with the help of emerging technology and perioperative care protocols such as enhanced recovery after surgery (ERAS).

I would like to congratulate Cansever et al.[1] for their recent publication comparing the short-term QoL of patients undergoing video-assisted thoracoscopic surgery (VATS) versus thoracotomy. They successfully validated the impact of VATS resections on better short-term QoL in the post-resection period. In this context, I aim to focus on further steps that need to be taken to ensure even better QoL after pulmonary resections. My primary emphasis will be on the impact of the extent of resection on QoL, as the number of the elderly and patients with underlying multiple comorbidities who need pulmonary resection has been increasing and technological improvements allow achieving comparable oncological results with limited resections.

I believe that there is enough evidence in the literature showing that VATS is associated with less QoL impairment. However, the impact of sublobar resection is still unclear. There are very limited studies most of which are confounded by varying use of VATS. In a randomized-controlled trial, global QoL significantly decreased at discharge, six weeks, and return to baseline within three months, without a significant difference between the treatment arms (lobectomy vs. segmentectomy). However, VATS was used for 43% of lobectomies, for 23% of segmentectomies, and 44% of segmentectomies were "lobe-like". Pain outcomes were similar for lobectomy and segmentectomy. Dyspnea was greater than baseline throughout the follow-up year which was worse after lobectomy than segmentectomy.[2] It can be speculated that most symptoms following lung resections are incision-related and, thus, largely driven by the approach (VATS vs. open). Thus, resection extent seems to be the main factor affecting the degree of postoperative dyspnea. Another potential factor to be considered is the type of segmentectomy. A multivariate analysis of a prospective study observed more Grade ≥2 pulmonary complications following complex versus simple segmentectomy.[3]

In conclusion, there are limited data to conclude on the impact of the extent of resection on QoL. We need to conduct more studies and interpret the literature further in this context. I believe that the era of limited resections is the future of thoracic surgery practice.

Declaration of conflicting interests
The author declared no conflicts of interest with respect to the authorship and/or publication of this article.

Funding
The author received no financial support for the research and/or authorship of this article.

REFERENCES
1. Cansever L, Sezen CL, Yaran OV, Bedirhan MA. Comparison of short-term quality of life in patients undergoing videoassisted thoracoscopic surgery versus thoracotomy. Turk Gogus Kalp Dama 2020;28:292-293.

2. Stamatis G, Leschber G, Schwarz B, Brintrup DL, Ose C, Weinreich G, et al. Perioperative course and quality of life in a prospective randomized multicenter phase III trial, comparing standard lobectomy versus anatomical segmentectomy in patients with non-small cell lung cancer up to 2 cm, stage IA (7th edition of TNM staging system). Lung Cancer 2019;138:19-26.

3. Suzuki K, Saji H, Aokage K, Watanabe SI, Okada M, Mizusawa J, et al. Comparison of pulmonary segmentectomy and lobectomy: Safety results of a randomized trial. J Thorac Cardiovasc Surg 2019;158:895-907.

Author Reply
Dear Editor,

First of all, I would like to thank valuable comments of the author. The main problem is that we do not have screening programs in lung cancers. Therefore, we mostly find T1c or highergrade tumors in our clinical practice. In our article, we excluded our segmentectomies, as the sample size is extremely low and to prevent heterogeneity in our study. Early surgical outcomes of complex segmental resections are identical to simple segmentectomies in retrospective studies. On the other hand, long-term results of complex segmental resections are still controversial.

Correspondence: Levent Cansever, MD. Sağlık Bilimleri Üniversitesi, Yedikule Göğüs Hastalıkları ve Göğüs Cerrahisi Eğitim ve Araştırma Hastanesi, Göğüs Cerrahisi Kliniği, 34020 Zeytinburnu, İstanbul, Türkiye.

Tel: +90 532 - 277 08 88 e-mail: lcansever@yahoo.com