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Ann Thorac Surg 1996;61:202-204
© 1996 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Resection of Pulmonary Nodules Using Video-Assisted Thoracic Surgery

Clinique Chirurgicale Universitaire, Hôpital du Bocage, Dijon, France

Accepted for publication September 12, 1995.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. The aim of this study was to assess the experience with video-assisted thoracic surgery for the resection of pulmonary nodules.

Methods. This voluntary registry (20 centers) included 388 patients with either benign (n = 171) or malignant (n = 217) pulmonary nodules. Pulmonary nodules were located using computed tomography scan-guided injection of methylene blue (59 patients) and hook wire technique (17 patients).

Results. Video-assisted thoracic surgery was converted into thoracotomy in 67 patients (17%) because of technical emergency in 4, inability to complete resection in 33, and the need to perform lobectomy for cancer through thoracotomy in 30. In other patients, video-assisted thoracic surgery allowed wedge resection in 300 cases and lobectomy in 21 cases. No intraoperative and two postoperative deaths (0.56%) occurred. The complication rate was 8% (n = 31). Mean durations of chest tube placement and hospital stay were 3.3 days (range, 1 to 20 days) and 6 days (range, 1 to 25 days), respectively. Video-assisted thoracic surgery was judged by the surgeon to be a diagnostic procedure 226 times (58%) and a therapeutic procedure 162 times (42%).

Conclusion. Video-assisted thoracic surgery appears to be safe and remains mainly a diagnostic procedure for malignant tumors.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
See also page 204.

Pulmonary nodules are defined using radiologic procedures. Such lesions develop in one lung without atelectasis or hilar enlargement, and can be round or oval with a diameter of less than 4 cm in greatest axis [1]. We took interest in peripheral nodules located at a maximum of 3 cm from the visceral pleura. This type of lesion presents a problem for diagnosis. Bronchoscopy allows diagnosis in 10% of nodules with a diameter less than 2 cm and in 40% to 50% of those with a diameter greater than 2 cm [1, 2]. Transthoracic needle aspiration biopsy has an accuracy of 43% to 97% for peripheral nodules [1, 2], and is more effective for the diagnosis of malignant than for benign lesions [1]. This technique can induce complications such as pneumothorax in 15% to 30% of cases [1]. Because of the lack of formal etiologic proof, thoracotomy has been necessary for diagnosis but causes substantial morbidity [1, 2].

During recent years, video-assisted thoracic surgery (VATS) has been described for resection of pulmonary nodules. Theoretically, this technique lacks the drawbacks of thoracotomy, as there is no muscular section and all the faces of the lung are accessible. The French Thorax Group performed a multicenter study to determine the technique development level among thoracic surgeons who have various experience with the technique. The aim of this study is to evaluate the failures, accidents, and complications of the new technique and to evaluate its interest for the diagnosis and treatment of peripheral pulmonary nodules.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
The voluntary registry was sent to 29 French surgeons, 18 practicing in a public institution and 11 in a private one. Twenty centers answered the questions (69%) (14 public and six private). From May 1991 to February 1994, 388 patients were included (average, 18 patients per center; range, 1 to 66). The mean age of the patients (275 men, 113 women) was 54 years (range, 17 to 85 years). Mean forced expiratory volume was 2.55 L (range, 0.8 to 4.5 L), and mean vital capacity was 3.57 L (range, 1.1 to 5.6 L).

All operations were performed under general anesthesia using a double-lumen endotracheal tube. The patient was turned in the lateral decubitus position as for a thoracotomy. In all cases, three trocars were set up in triangulation. Equipped with its camera, the optic was most often inserted between the fifth and seventh intercostal spaces, either behind the scapula or on an axillary middle line. The optic position depended on the location of the nodule to be resected. The optic allowed exploration of the pleural cavity to help with positioning of the other trocars. Most teams set up the two other trocars on both sides of the optic. According to the nodule location, the different positions ranged from the fourth to eighth intercostal spaces. To resect the parenchyma where the nodule was located, we used a prehension forceps and an endoscopic stapler inserted through the trocar. Rarely, a fourth trocar was used for insertion of an additional instrument to facilitate the resection. Most surgeons used an endoscopic stapler, and only one team resorted to YAG laser for pulmonary resection.

A preoperative computed tomographic scan was used to locate the nodule in all patients. Six teams used preoperative methylene blue injection combined with computed tomographic scan or hook wire technique; two teams used both methylene blue and hook wire techniques. All together, methylene blue and hook wire technique were used in 59 patients (15%) and in 17 patients (4.5%), respectively. Preoperative localization techniques were necessary when the diameter of the nodule was less than 2 cm or the nodule was situated more than 1 cm from the visceral pleura. For other patients, the surgeon resorted to finger or instrumental palpation to locate the nodule.

The lesion was extracted in a bag in 121 patients (31%). For a large piece, the surgeon used a minithoracotomy (n = 130, 33%). An anatomicopathologic examination was systematically practiced. A lobectomy was performed in the same procedure when the nodule was malignant, according to the pulmonary function. One chest tube was placed in 88 patients (27%) and two chest tubes in 228 patients (72%).

Chi-square tests were used for categoric data and Student's t tests for continuous variables.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
The failure rate of the methylene blue localization technique was 13% (n = 8) and was explained by either too large a quantity of injected liquid or an error in nodule localization. The failure rate of the hook wire technique was 47% (n = 8), due to removal of the hook wire, an error in nodule localization, or subpleural hematoma.

Conversion to thoracotomy was necessary for 67 patients (17%), with large variations in the rate from one team to another (0% to 50%). The conversion rate was 28% for the teams that included 10 patients or fewer, 22% for the teams with 11 to 20 patients, 39% for the teams with 21 to 30 patients, and 8.5% for the teams with 30 patients or more (p < 0.0001). Thoracotomy was needed because of a perioperative accident in 4 patients (1%) (bleeding in 3 and air leak in 1). Nodule localization was impossible in 29 patients (7.5%). In 30 patients, the surgeon converted the procedure into thoracotomy because of concern for carcinoma (8%). Other causes for conversion were a dense adhesion in a pleural space (2 patients), a lack of pulmonary exclusion (1), and poor tolerance of pulmonary exclusion (1). The conversion rate for the teams that used the localization techniques was 23%, compared with 17.5% for the other teams (p = 0.32).

There were no perioperative deaths. The type of resection using VATS alone was a wedge resection in 300 cases and a lobectomy in 21 cases. Two postoperative deaths were reported (0.56%). The complication rate was 8% (n = 31) and included air leak (11 patients), pneumonia (12), lack of pulmonary reexpansion (2), hemothorax (2), and miscellaneous complications (4). The mean duration of chest tube placement was 3.3 days (range, 1 to 20 days), and the mean hospital stay was 6 days (range, 1 to 25 days).

The mean diameter of the resected nodules was 1.9 cm (range, 0.5 to 4 cm). The mean diameter of the benign lesions was 1.7 cm (range, 0.5 to 4 cm), compared with 2.7 cm (range, 1 to 4 cm) for the malignant lesions (p = 0.01). The rate of malignancy in nodules measuring 1 cm or less was 3.5%. The rate of benignancy in nodules of 1 cm or less was 24%. For 171 patients (44%), the nodule was a benign lesion; for 217 patients (56%), it was a malignant lesion. Benign lesions included hamartoma in 60 patients, tuberculoma in 35, pneumonitis in 28, pulmonary infarction in 8, bronchogenic cyst in 8, sarcoid nodule in 6, granuloma in 6, fibroma in 6, histoplasmoma in 4, rheumatoid nodule in 2, anthrosilicolis in 2, wegener's granulomatosis in 2, aspergillosis in 1, echinococcus in 1, pneumocystis in 1, and sequestration in 1. Malignant lesions included metastatic lesion in 104 patients, primary lung cancer in 93, bronchioloalveolar in 9, carcinoid in 7, and lymphoma in 4.

According to the opinion of the surgeon, VATS was used as a diagnostic procedure in 226 cases (58%) and a therapeutic procedure in 162 cases (42%). Among the 226 diagnostic procedures, the nodule was a benign lesion in 29% of the cases, a primary lung cancer in 30%, and a metastatic lesion in 41%. A thoracotomy with lobectomy was performed in 30 patients with primary lung cancer. Resection was impossible in other cases because the tumor was metastatic. Among the 162 therapeutic procedures, the nodule was a benign lesion in 65% of cases, a primary lung cancer in 25%, and a metastatic lesion in 7%. For primary lung cancer, 21 lobectomies were performed using VATS and 24 wedge resections were done for patients with poor pulmonary reserve.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
The VATS technique is safe, as the perioperative accident rate was low but dependent on the surgeon's experience. The lack of perioperative deaths reported during the survey could be explained by the fact that the surgeons did not hesitate to perform a thoracotomy. The main cause for conversion was a failure of nodule localization [3–5]. The observed conversion rate (17%) is comparable to that in previous reports, which varied from 24% to 28% [4, 5]. The visceral pleura tattoo with methylene blue can help to locate the nodule preoperatively, but the quantity of liquid must be very low, approximately 0.1 mL [6], and the injection must be done at a maximum of 2 hours before the operation [6, 7]. However, it is not always easy to send the patient for a computed tomography scan immediately before the operation. In our study, the hook wire technique for nodule localization was not used as often as methylene blue. The rate of failure of hook wire localization was more important, especially that due to hook wire removal [6–8]. Failures can be explained by the lack of experience of the teams. In contrast to methylene blue, a hook wire can be set the day before the operation [7, 8]. For the small-diameter nodules (less than 2 cm) [6–8], a preoperative localization method is indispensable. Another cause of failure is the bad position of different trocars.

In our study, the conversion rate to thoracotomy was related to surgical experience. To carry out the resection using VATS [3–5], it is critical to obtain a good collapse of the ipsilateral lung. The rate of postoperative death was low and similar to that in the literature, which has ranged from 0% to 2.5% [3–5]. Any death was directly caused by the technique. The VATS technique can be applied to fragile patients. Our rate of morbidity is comparable to that in the literature [3–5]. Air leak is one of the major complications, most often due to bad parenchyma quality [4]. The endoscopic stapler is not always adapted to the parenchyma thickness. With instrument improvement, this complication should decrease. The mean hospital stay has ranged from 2.5 to 6 days according to various studies [3–5, 9, 10]. The hospital stay after VATS is shorter than that after thoracotomy [9, 10], despite being used for fragile patients. Air leak is responsible for the longer hospital stays.

Video-assisted thoracic surgery can be applied only for a nodule less than 3 cm from the visceral pleura. According to most surgeons, the technique is primarily a diagnostic procedure. One can use VATS if the noninvasive diagnostic methods (bronchoscopy, computed tomography) have not allowed nodule diagnosis [1, 2]. Video-assisted thoracic surgery can become a therapeutic procedure for benign lesions, allowing lesion resection at the price of a small prejudice for the patient [3, 5]. For metastatic lesions, VATS is a diagnostic method because the small metastasis can easily be neglected. In such a situation, thoracotomy or stenotomy remains the best treatment [11, 12]. Studies concerning resection of metastasis using VATS are still too recent and too limited to draw conclusions about its potential interest [13].

The treatment for peripheral and small primary lung cancer is lobectomy. Lobectomy by thoracotomy remains the preferred technique; lobectomy performed using VATS requires further study [4]. For patients with poor pulmonary reserve, a wedge resection using VATS can be proposed [14, 15], provided that the mediastinal lymph nodes have been checked [14, 15].

We conclude that VATS is a reliable technique but that nodule localization can cause technical problems. The surgical principles of primary lung cancer treatment must remain unchanged. Video-assisted thoracic surgery has been established primarily as a diagnostic procedure, and occasionally as a therapeutic procedure.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Address reprint requests to Dr Bernard, Clinique Chirurgicale Universitaire, Hôpital du Bocage, 2 Bd Maréchal de Lattre De Tassigny, BP 1542, 21034, Dijon Cedex, France.

^* The Thorax Group includes the following: Jacques Azorin (Bobigny), François Bellenot (Argenteuil), Alain Bernard (Dijon), Pierre Bonnette (Paris), Pierre-Yves Brichon (Grenoble), Paul Brutus (Limoges), Alain Chapelier (Le Plessis-Robinson), Roland Charpentier (Crest), Marcel Dahan (Toulouse), Antoine Dujon (Rouen), Georges Escande (Clermont-Ferrand), Jean-Marie Faillon (Lille), Roger Giudicelli (Marseille), Gilles Grosdidier (Nancy), Dominique Grunenwald (Paris), René Jancovici (Paris), André Joyeux (Nimes), Serge Meriot (Bordeaux), Michel Monteau (Reims), Jean-Luc Moreau (Annemasse), Patrick Moreau (Angers), Jérome Mouroux (Nice), Emmanuel Pouliquen (Ploemeur), Yvonnick Raut (Brest), Jean-François Regnard (Le Plessis Robinson), Marc Riquet (Paris), Jean-Pierre Valverde (Orléans), Jean-François Velly (Bordeaux), and Jean-Marie Wilhm (Strasbourg).

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Alain Bernard Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Bernard, A. Search for Related Content PubMed PubMed Citation Articles by Bernard, A. Related Collections Related Article