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Interact CardioVasc Thorac Surg 2009;9:618-622. doi:10.1510/icvts.2009.210310 © 2009 European Association of Cardio-Thoracic Surgery
Video-assisted thoracic surgery major pulmonary resection requiring control of the main pulmonary arteryDepartment of Thoracic Surgery, Shin-Kokura Hospital, Federation of National Public Service Personnel Mutual Aid Associations, 1-3-1 Kanada, Kokurakita-ku, Kitakyusyu 803-8505, Japan Received 22 April 2009; received in revised form 22 June 2009; accepted 23 June 2009
*Corresponding author. Tel.: +81-93-571-1031; fax: +81-93-591-0553.
The purpose of this study is to examine the feasibility and safety of thoracoscopic major pulmonary resection requiring the cross-clamping of the main pulmonary artery (PA), in comparison to an open thoracotomy performed in patients with lung cancer. A retrospective database of 27 consecutive lung cancer patients, who underwent either video-assisted thoracic surgery (VATS) (n=13) or open thoracotomy (n=14) for a major pulmonary resection using these procedures, was analyzed regarding the demographic, perioperative, histopathologic, and outcome variables. The thoracoscopic procedures were successfully performed in 12 of 13 patients (92.3%). Two groups showed no differences in the demographic, perioperative, histopathologic and staging variables. Both groups presented with no mortality. The VATS group showed better results regarding the length of epidural anesthesia (P=0.0066), additional analgesic requirements (P=0.0009), and morbidity (P=0.0213) than the open thoracotomy group. Despite the short follow-up time, the two groups were comparable regarding both the recurrence and survival rates. The results indicate that VATS is feasible and safe for selected lung cancer patients requiring the cross-clamping of the main PA, with acceptable perioperative results in comparison to an open thoracotomy.
Key Words: Lung cancer; Pulmonary artery; Complications; Lobectomy; Pneumonectomy; Video-assisted thoracic surgery (VATS)
Surgical procedures requiring the cross-clamping of the main pulmonary artery (PA), such as lobectomy with a partial PA resection, completion pneumonectomy, and pneumonectomy, are still risky procedures in video-assisted thoracic surgery (VATS) [1, 2]. Such procedures done through open thoracotomy have shown a high morbidity and mortality [3–8]. On the other hand, VATS major pulmonary resection is reported to result in lower morbidity than that associated with thoracotomy [9]. If the equivalent operation can be achieved with VATS, some of the morbidity associated with thoracotomy may be avoided. With this background, we retrospectively analyzed the technical feasibility and safety of VATS major pulmonary resection requiring the cross-clamping of the main PA and compared the results of VATS with those of open thoracotomy.
Between April 2000 and January 2007, 27 consecutive patients underwent either VATS (n=13) or open thoracotomy (n=14) major pulmonary resection requiring the cross-clamping of the main PA, including lobectomy with a partial resection of the affected PA, completion pneumonectomy, and pneumonectomy. The open thoracotomy major pulmonary resection was performed between April 2000 and March 2002. We changed the surgical approach for such procedures to a minimally invasive approach from April 2002. The indications for a VATS lobectomy were based on the standard criteria for an open thoracotomy, including tumors up to 6 cm in diameter. To avoid a pneumonectomy, a lobectomy including a partial PA resection and a primary closure performed totally using VATS procedures was indicated for direct tumor invasion of less than one-fourth of the external wall of the PA (Fig. 1) [10]. A VATS completion pneumonectomy was indicated to obtain a cure in patients with second primary lung cancer [11]. Patients with involvement of mainstem bronchi or secondary carinae in configurations that preclude sleeve bronchial resections or isolated tumors extending into multiple lobes were candidates for a VATS pneumonectomy. A chest wall resection and a complete obliteration of the pleural space were excluded from the indications for the VATS procedures.
The patients included those with histologically confirmed primary lung cancer invading the PA. The preoperative staging included a chest roentgenogram, computed tomography (CT) scan of the body with intravenous contrast, bronchoscopy, brain magnetic resonance, and bone scintigraphy. T4 and/or N3 diseases were excluded from this study. All patients radiologically suspected of limited single-station N2 disease were eligible for this study while multiple-station and/or bulky (looking clearly on plain chest X-ray) N2 diseases were excluded. In patients with preoperative stage IV, only treatable brain metastasis was included. This series included four patients who underwent induction chemotherapy whereas others with advanced disease declined the chemotherapy. The Institutional Review Board of Clinical Research of the hospital ethically approved this study, and informed consent for this study was obtained from all patients. 2.1.1. VATS Through a 7-cm utility incision and three additional trocar ports, all VATS procedures were performed without the use of a rib spreader while viewing a video monitor, as previously reported [10–12]. After each surgical procedure for the pulmonary vessels, the bronchi were divided. The bronchial stump with additional sutures at both ends was not reinforced with any viable tissue. An extensive dissection of the mediastinal lymph nodes was then performed. No patients received any segmental rib resection.
2.1.2. Open thoracotomy The details of a partial resection of the PA and of completion pneumonectomy using VATS procedures have been described in our previous reports [10, 11]. 2.2. Postoperative pain control A continuous epidural infusion of 0.125% bupivacaine or of 0.2% ropivacaine (4 ml/h) was used postoperatively. An indometacin suppository was predominantly used in addition to the epidural anesthesia. The intramuscular administration of pentazocine was used when the pain was uncontrollable by suppositories.2.3. Data acquisition and follow-up The demographic, perioperative, histopathologic, and outcome variables, including recurrence and survival, were analyzed. The operative mortality included all patients who died within the first 30 days after surgery or during the hospitalization. The postoperative morbidity included all patients who suffered complications during the hospitalization and after discharge from the hospital. All complications were graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events version 3.0 (http://ctep.cancer.gov/reporting/ctc.html). The complete follow-up data were obtained from the records of the post-discharge visits, from the regular radiographic follow-up, and from telephone interviews. CT-scans of the body were obtained in most patients at 6 and 12 months postoperatively and thereafter, at yearly intervals. Standard descriptive statistics and Kaplan–Meier survival analyses were used. Either the 2 or Fisher's exact test was used to clarify whether any relationships existed between the nominal variables. The continuous variables were analyzed by the Mann–Whitney U-test. Comparisons of the survival were made using the log-rank test. A P<0.05 was considered to be statistically significant.
3.1. Demographic data The 13 patients of the VATS group accounted for 6.7% of the patients undergoing a VATS major pulmonary resection at this hospital. The VATS procedures were successfully performed in 12 of 13 patients (92.3%). One patient was converted to an open thoracotomy because of an inability to tolerate single-lung ventilation caused by frequent dislocations of the endotracheal tube in the course of thoracoscopic angioplasty of the PA. Although the VATS group tended to contain the more patients with obstructive disorders than the open thoracotomy group, there were no significant differences between the two groups in the demographic data (Table 1).
3.2. Operative data The anatomic distribution of the pulmonary resections showed no differences between the groups (Table 2). Four patients who underwent induction chemotherapy showed a partial response and their surgery resulted in a complete resection in both groups (VATS, 1 lobectomy with PA angioplasty and 2 pneumonectomies; open, 1 pneumonectomy).
3.3. Histopathologic and staging data The preoperative stages were as follows: IB in 4 patients, IIA in 1, IIB in 10, IIIA in 9, and IV in 3. All patients with stage IB had a large hilar tumor while all patients with stage IV had brain metastasis treated by a gamma knife. Three patients with small cell lung cancer underwent surgeries for the purpose of adjuvant treatment after intensive chemotherapy. Stage IIIA disease was identified as parietal pleural invasion (T3) in one patient of open group and N2 disease in nine patients (VATS, n=7; open, n=2). N2 disease had single-station metastasis in seven patients (VATS, n=5; open, n=2) and multiple-station metastases in two patients in the VATS group. Four patients with postoperative stage IV included a patient with lung metastasis in addition to three patients with brain metastasis. There were no significant differences in the distributions of pathologic cell types and of the postoperative stages between the groups (Table 2). All patients in the VATS group achieved complete resections, while one patient in the open group underwent an incomplete resection because of a microscopic remnant tumor in the PA margin. No significant differences were detected between the two groups in the ratio of complete resection, the number of dissected mediastinal nodes, the operating time, the blood loss, and the length of chest tube drainage. No patients required a blood transfusion during the surgery or the postoperative course in the VATS group, whereas transfusions were needed in two patients (14.3%) in the open group. Regarding postoperative pain, the VATS group showed significantly better results than the open group (Table 3).
3.5. Morbidity and mortality All complications in the VATS group showed grade 2 (moderate) while grade 3 (severe) complications occurred in four patients in the open group. In each procedure, complications were seen in 7 of 9 patients undergoing a partial PA resection [VATS, n=3 (75.0%) vs. open, n=4 (80%), P>0.9999], in 1 of 3 patients undergoing a completion pneumonectomy [VATS, 0% vs. open, n=1 (50%), P>0.9999], and in 7 of 15 patients undergoing a pneumonectomy [VATS, n=1 (12.5%) vs. open, n=6 (85.7%), P=0.0101]. A significant difference (VATS, 30.8% vs. open, 71.4%, P=0.0213) was detected in the morbidity between the groups (Table 4), although no intraoperative or in-hospital deaths were observed in either group.
3.6. Recurrence and survival No patients were lost to the follow-up. At a mean follow-up time of 21 months (range, 2–79 months) in the VATS group, the cause of death included a recurrence of lung cancer in eight patients and pneumonia in one patient. Recurrence included distant organ metastases in five patients, supraclavicular lymphadenopathy in two patients and malignant pericardial effusion in one patient. There was no instance of wound implantation. On the other hand, at a mean follow-up time of 33 months (range, 2–91 months) in the open thoracotomy group, 10 patients died of a recurrence of lung cancer (n=7), other cancer (n=2), and pneumonia (n=1). Recurrence included distant organ metastases (n=5), mediastinal (n=1) and supraclavicular (n=1) lymphadenopathy. There were no differences between the groups regarding the number of patients with recurrence (8 vs. 7, P=0.7036) and actuarial survival (Fig. 2).
Essentially, major pulmonary resections requiring the cross-clamping of the main PA should be discussed individually. However, the study of such procedures by VATS remains to be thoroughly investigated due to numerous issues, such as a small patient population, few specialized centers, and the surgeon's skill. Therefore, these procedures were grouped together under the themes of dealing with the cross-clamping of the PA and then were assessed. Such a difficult operation should continue to be performed in order to expand the capability of VATS. Under the open thoracotomy, previous reports of a lobectomy with a partial PA resection showed the morbidity of 12.4–31.0% and the mortality of 0–17.2% [13, 14]. Likewise in the completion pneumonectomy, the morbidity and mortality ranged from 47.0 to 63.7% and from 7.6 to 57.0%, respectively [5, 6]. After an open pneumonectomy, the incidence of morbidity and mortality varied from 15.0 to 60.0% and from 1.5 to 30.0%, respectively [7, 8]. The surgery for the PA associated with a lobectomy tends to show less morbidity and mortality than a pneumonectomy because of the preserved pulmonary function. In this series, however, the PA surgery showed a higher morbidity rate than the pneumonectomy. This is probably due to the complete fused fissure and/or preoperative pulmonary comorbidity including the chronic obstructive pulmonary disease. The results of the open thoracotomy showed neither fatal complications nor mortality despite an unfavorable morbidity ratio. This morbidity ratio may be closely associated with the increased postoperative pain. However, it should be noted that the VATS yielded safer results, associated with a lower grade complication in each procedure and a lower ratio morbidity. Nwogu and associates reported that complications were recognized in four of seven patients (57.1%) who underwent a VATS pneumonectomy [15]. Especially regarding a VATS pneumonectomy, our results (morbidity, 12.5%) seem to be favorable results and showed the lack of major morbidity. The VATS group showed significantly lower analgesic requirements and less postoperative complications than the open group, whereas the two groups were comparable in the recurrence and survival rates. Such results support the notion that VATS is a safe and reliable procedure for lung cancer patients requiring the cross-clamping of the main PA. The main limitations of this study are its retrospective nature, small cohort, and compilation of various surgical procedures. Further investigation is, therefore, needed to confirm our findings.
In conclusion, this study suggests that the VATS major pulmonary resection requiring the cross-clamping of the main PA is a feasible and safe surgical procedure in selected patients with lung cancer
The authors would like to thank Professor Masamitsu Kido, Department of Respiratory Medicine, University of Occupational and Environmental Health, Japan, for his advice.
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Abstract
1. Introduction
20–30 cm long was made. All muscles were divided except for the serratus anterior muscle. A thoracotomy with controlled rib fracture was performed using a large rib spreader. 
6 cm in size.