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Ann Thorac Surg 1999;68:194-200
© 1999 The Society of Thoracic Surgeons
a Division of Cardiothoracic Surgery, University of Missouri, Columbia, Missouri, USA
Address reprint requests to Dr Demmy, Division of Cardiothoracic Surgery, University of Missouri, #1 Hospital Dr, MA 312, Columbia, MO 65212
e-mail: demmyt{at}health.missouri.edu
Presented at the Forty-fifth Annual Meeting of the Southern Thoracic Surgical Association, Orlando, FL, Nov 12–14, 1998.
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Abstract |
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Methods. A thoracotomy case was paired to each of 19 VATS cases by age, sex, lobe, side, and forced expiratory volume in 1 second. Eleven VATS and 5 thoracotomy patients with severe activity impairments or reduced forced expiratory volume in 1 second (< 1.5 L or 50% predicted) were classified as higher risk than the others.
Results. Despite more high-risk cases, VATS yielded shorter hospitalizations (5.3 ± 3.7 versus 12.2 ± 11.1 days, p = 0.02), chest tube durations (4.0 ± 2.8 versus 8.3 ± 8.9 days, p = 0.06), and earlier returns to full preoperative activities (2.2 ± 1.0 versus 3.6 ± 1.0 months, p < 0.01). The VATS operations had no intraoperative complications and lasted 229 ± 59 minutes. Pain 3 weeks later was dramatically better for the VATS group (none or mild, 63% versus 6%; severe, 6% versus 63%; p < 0.01). Six complications or deaths occurred in each group and were related to forced expiratory volume in 1 second, steroid usage, age, active smoking, and upper lobe resection (p < 0.01). Three VATS deaths occurred only in elderly, performance status 3 patients, with two caused by gastrointestinal-related problems masked by steroid use.
Conclusions. A VATS lobectomy is less painful and may offer faster recovery for the frail or high-risk patient. Further study, particularly of its safety in severely activity-impaired patients, is warranted.
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Introduction |
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Early reports of VATS lobectomy described relatively good operative risk patients whose favorable anatomy allowed surgeons to provide operations that appeared equivalent to open thoracotomy [2–4]. These studies have established safety and shown some benefits for VATS over standard thoracotomy, but a randomized study failed to show many long-term benefits in these patients who could tolerate thoracotomy well [5].
We began our experience with VATS lobectomy by directing it toward those at high risk for having an unfavorable outcome if they underwent a thoracotomy. We anticipated that the reduced operative trauma and recovery time associated with VATS would be optimal for fragile patients. Because of their impairment, these patients were unlikely to be offered adjuvant therapy and, therefore, less adversely affected by possible problems like incomplete lymph node staging.
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Material and methods |
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Matches for the 19 successful VATS cases were selected from 98 standard lobectomies. The subject with the forced expiratory volume in a second (FEV1) nearest to the VATS patient was selected as a match from a subgroup of patients of identical sex, lobe resected, and age within 5 years. Because right middle lobectomies are uncommon, a control patient with an age of 77 was selected for a 66-year-old VATS patient. One surgeon (T.L.D.) directed all the operations in the study either as the primary surgeon or by instructing a resident physician. The same postoperative care guidelines were used on all patients, and only 4 patients in the control group had their operations 1 to 3 years earlier than the first VATS patient. Performance status matching was limited by the lack of severely activity-impaired patients in the thoracotomy group. Because this bias would improve the characteristics of the control group, any favorable comparisons of VATS with the control group would still be valid. Mediastinoscopy was used routinely except for patients who had both no preoperative diagnosis and no enlarged nodes by computed tomographic scanning. A VATS lobectomy was limited to patients with clinical stage I tumors without bronchoscopic endobronchial involvement and a tumor size small enough to allow delivery through the access thoracotomy.
Operative techniques: incisions and closure
Both techniques used general anesthesia and double-lumen endotracheal intubation to provide optimal selective ventilation during the operation. The patients were positioned in the lateral decubitus position with the bed flexed to increase intercostal spacing.
Video-assisted thoracic surgery
A camera port incision was placed in the midaxillary line near the eighth intercostal space. A 0-degrees rigid thoracoscope was then inserted, and the ipsilateral thoracic exploration performed. Using the scope, the optimal intercostal space was then selected for performing a 5- to 8-cm access thoracotomy with muscle division. This was made over the major fissure to facilitate dissection of the pulmonary artery and incomplete fissures. A schematic diagram is provided in the report by Kirby and associates [4], but we often prefer a more anterior access incision placement allowing wider exposure and some direct vision of the superior pulmonary vein and anterior pulmonary artery segments. This is especially useful for upper lobectomies, whereas a more lateral placement is satisfactory for lower lobectomies. A retractor was used to push the intercostal and overlying muscles firmly against the rib edges already widened by lateral flexing, but active spreading was avoided. This results in just enough room for direct dissection with standard scissors and forceps. Usually this retractor had to be removed to provide extra room for the specimen to be extracted in its sac. After some hilar dissection, the optimal angle for placement of the vascular stapler was determined. This angle was achieved with another port placed at the same level as the camera port, but more anterior to and in line with the major fissure. Mimicking a standard thoracotomy, these two port sites served as exit holes for 28F silicone-elastomer chest tubes positioned anteriorly and posteriorly. Bupivicaine (0.25%) was infiltrated in the posterior intercostal spaces supplying the innervation to the wound sites. The access thoracotomy was closed by approximating only the divided muscle and skin with no pericostal sutures.
Thoracotomy
A fifth-interspace posterolateral thoracotomy was used. In 12 patients who had normal or underdeveloped chest muscles and in whom adequate exposure was anticipated, the serratus and latissimus muscles were spared by raising skin flaps and using an abdominal wall retractor to retract the muscles. To prevent rib fracture in 7 patients, a segment of the posterior sixth rib was excised to facilitate rib spreading, and the corresponding intercostal nerve was divided to prevent traction-related neuralgia. The ribs were approximated with interrupted number 1 polyglycolic suture, and the remainder of the wound was closed with polyglycolic suture. Suction drains were placed beneath the skin flaps for those patients in whom muscle-sparing techniques were used. Epidural anesthesia was used routinely for thoracotomy patients for the first 3 postoperative days.
Common operative techniques: lobectomy
The lobectomy technique was similar for both the VATS and standard operations. First the hilar pleura of the desired lobe was dissected to expose the pulmonary artery and vein. Generally the pulmonary artery branches were divided first; however, division of the superior pulmonary vein was occasionally useful for exposure of the remaining pulmonary artery branches. Pulmonary artery branches were divided in continuity with silk sutures for the open technique, and an endoscopic vascular stapler was used for the VATS cases. The vein was always divided using a vascular stapler, and the incomplete fissures were separated using a single load of a standard gastrointestinal anastomosis stapler for open cases or multiple fires of an endoscopic gastrointestinal anastomosis stapler for VATS. Finally, the bronchus was always divided using a standard TA-30 4.8-mm stapler (United States Surgical Corporation, Norwalk, CT) introduced through the standard or the access thoracotomy. The remaining lobes were test inflated before firing the stapler, and the bronchial stump was checked for pneumostasis. The inferior pulmonary ligament was always divided, and its lymph nodes as well as the ipsilateral lymph node stations not biopsied during mediastinoscopy were sampled.
Operative techniques: special video-assisted thoracic surgery considerations
By swapping camera and instruments using the angles afforded by the three access sites (two ports and the access thoracotomy), all visualization and most of the dissection techniques practiced in open techniques can be duplicated. The surgeon has the advantage of the three-dimensional view provided by the access incision (the preferred working portal), as well as the television monitor that the assistants use. A 30-degree telescope is frequently useful to provide better exposure. The use of an articulating vascular stapler greatly facilitates the division of vascular branches, especially for upper lobectomies. A red rubber catheter with its flange cut so that it is just long enough to cover the tip of the endoscopic gastrointestinal anastomosis stapler anvil is occasionally passed around the vessel and then used to guide the stapler into place. Vessel branches too small for division with the stapler can be controlled by hemoclips or sutures. Hemorrhage is uncommon but can be controlled by direct compression using a peanut dissector or other instrument until the appropriate method of hemostasis is ready. The lobe is extracted using a sturdy sealed nylon sac (Cook Lap Sac, Cook OB-GYN, Indianapolis, IN) such as those used for laparoscopic colectomies.
Data collection, classifications, and analyses
Demographic, operative, pathologic, and outcome data were entered into an electronic database either retrospectively or concurrently. Poor pulmonary function tests (PFTs) were defined as an FEV1 less than 1.5 L (the exclusion value for the large randomized trial) or less than 50% of predicted [5]. Poor functional status was defined as an Eastern Cooperative Oncology Group performance status of 2 or worse [6]. This value generally excludes involvement in most clinical trial studies of chemotherapy or radiation therapy and was documented in this study routinely preoperatively. Patients were classified as higher risk than the others on the basis of poor PFTs, poor function, or both. For the other patients, unfavorable comorbidities that led to the recommendation for VATS lobectomy were documented. Poor nutrition was defined by one of the following: unintentional weight loss of at least 4.5 kg (10 pounds) within 2 months, lymphopenia (< 1500/mm3), or hypoalbuminemia (< 3.5 mg/dL). Computer enhancements to documentation occurred midway through this study allowing for retrospective separation of the lobectomy portion from the overall operative time. Patients were discharged from the hospital with a limited analgesic prescription. Pain complaints were reassessed at the 3 to 4-week postoperative clinic visit, and the least potent but effective analgesic was prescribed and documented. If the patient remained hospitalized, then the pain medication usage at the 21st postoperative day was recorded. The patients’ pain was graded as follows: none, no complaints, no pain medication usage; mild, minimal complaints, controlled by nonsteroidal analgesics like ibuprofen; moderate, some pain, controlled by narcotics like acetaminophen with codeine; severe, frequent or severe pain requiring schedule II narcotics like oxycodone. Long-term survival was assessed by records of clinic visits to the surgery clinic and other physicians in the university network.
Data were analyzed using BMDP statistical software (Berkeley, CA) and summarized as mean ± standard deviation. Continuous variables were analyzed by t tests, and categorical variables were tested using 
2 analyses (BMDP 3D and 4F). Independent predictors of outcome were determined using stepwise logistic regression (BMDP LR).
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Results |
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Four patients had PFTs that showed marginal capacity to withstand a lobectomy. These patients had favorable split lung function and exercise tests that showed peak oxygen consumption values ranging from 12 to 20 mL O2 · kg-1 · min-1.
The lobes resected in each group were left lower (7), left upper (6), right upper (3), right lower (2), and right middle (1). Additional procedures as well as the operation times are listed in Table 2. Unfortunately, it was not possible to separate the times for the other procedures from 7 of the VATS cases and 15 of the control cases. However, the associated time bias of these procedures is less than 1 hour, and the available data for isolated lobectomies were also similar (thoracotomy 185 ± 56 versus VATS 204 ± 53 minutes, p = not significant). Although not used as matching criteria, pathologic classification and staging were remarkably similar between groups.
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Three VATS and 5 control surviving patients suffered major, primarily respiratory, complications that prolonged their hospitalization. These complications were multiple in 3 patients and included exacerbation of emphysema (3), prolonged air leak (3), pneumonia (2), atelectasis (2), and ileus. Another control patient experienced an unrelated complication from a vascular operation performed during the same hospitalization. There were 3 late deaths for the VATS group and 5 for the control group (not significant). Causes of late mortality were metastatic disease (3), myocardial infarction, sudden death, pneumonia, pulmonary failure, and unknown. Of the late survivors, 4 patients had protracted pain and 2 had metastatic disease. These late complications or deaths were evenly distributed except for protracted pain, which occurred only in the thoracotomy group (p = 0.03) For the whole study, 6 patients were lost after completing an average follow-up of 13.2 months.
The hospital stay and follow-up data for the survivors are shown in Table 2. The 13 patients who underwent uncomplicated VATS lobectomy were dismissed even earlier (3.8 ± 1.4 versus 6.5 ± 2.6 days, p < 0.003) than the 12 who underwent uncomplicated thoracotomy. Also, if the higher risk VATS cases and their matches are considered alone, the results still favor VATS. This is demonstrated in Figure 1, which shows the hospital stays for all patients. Six of the higher risk VATS survivors were dismissed before day 7 as opposed to none of the higher risk thoracotomy patients. Excluding the complicated outlier hospitalizations (>14 days) that skew the data in both group, VATS discharges were earlier (4.9 ± 1.7 versus 8.1 ± 3.3 days, p = 0.03).
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Comment |
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TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
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There is some controversy regarding the indications, advantages, safety, and oncologic validity of VATS lobectomy [1]. Like other investigators, we have found that VATS lobectomy is applied best to relatively thin patients with few intrathoracic adhesions, fissures that are easy to divide, no chest wall invasion, and a tumor small enough not to hamper dissection or specimen extraction [2, 8]. Safety issues such as uncontrollable hemorrhage or tumor spillage caused by faulty dissection have been reported rarely other than to emphasize the need for this technique to be performed by a well-trained surgeon [12]. In fact, local recurrences from tumor spillage may occur more often with the relatively well-established technique of VATS nodulectomy [13]. It has been our experience that a deep excisional lung nodule biopsy may be more difficult to perform by VATS than the lobectomy. This is because the endoscopic stapler can compress smaller hilar structures better than a deep purchase of lung. This problem has expanded our indication for preoperative computed tomography-directed needle biopsies for those patients with deep nodules in whom a VATS lobectomy is contemplated and the diagnosis is uncertain.
Regarding efficacy, two studies reported no significant difference between this technique and limited or muscle-sparing thoracotomy with respect to PFTs and complications; however, mild to moderate rib spreading was used [3, 10]. A randomized trial comparing VATS with standard techniques for low-risk patients showed few sustained differences between groups except for fewer complications in the VATS group [5]. Whether the complications would have been as well tolerated in a high-risk population is unknown.
Oncologic validity is more difficult to establish and relates to the quality of the lobectomy and the adequacy of additional procedures like the mediastinal lymph node dissection. In our series, the dissection quality and final specimens appeared to be the same as those obtained by open thoracotomy. We were able to access all superficial ipsilateral stations, but subcarinal and deeper mediastinal dissections were more difficult. McKenna [14] was able to obtain 9 to 21 lymph nodes per case, a range similar to our study. It is controversial what advantages deeper lymph node dissections add over cervical mediastinoscopy, particularly for the high-risk patient whose impaired function limits adjuvant therapy. However, there is some evidence that certain isolated N2 nodes (eg, subaortic nodes) removed during a complete resection may confer a survival advantage [15]. This region is very accessible by VATS. Also, patients with small squamous cell carcinomas so rarely have lymph node metastases that the necessity of lymph node dissection is uncertain [16]. The reduced operative trauma of a VATS procedure may not be an oncologic advantage; however, better cancer pain therapy has survival benefits [17, 18]. Accordingly, although we anticipate oncologic equivalence in the long-term results after VATS lobectomy, it is possible that survival benefits will be realized for certain patients prone to pain.
The higher operative cost of this procedure is unquestioned. Average time in the operating room is not decreased. Vessel divisions require the use of the endoscopic stapler [3]. Generally six or more stapler reloads are needed for each case, plus any other endoscopic disposables. There is hope that stapling technology will become less costly. In the meantime, shorter hospitalizations, earlier return to work, easier convalescence, and avoidance of chronic pain disability offset the extra expense [7, 19].
We are concerned about two deaths because of gastrointestinal-related complications in older patients who suffered acute activity impairments and were receiving steroids. For these patients, additional prophylactic measures and perhaps avoidance of any major operation seem warranted. Because the intestinal complications were potentially avoidable, it is not clear that VATS lobectomy should be proscribed in patients with isolated activity impairment or steroid use. Such patients may benefit most from this procedure, as prolonged convalescence from a thoracotomy could significantly reduce the amount of remaining satisfactory life in chronically ill patients. Another investigator stated that VATS lobectomy was "beneficial for aged patients, especially in those with restricted physical conditions" [20]. Similarly, we favor this approach for the occasional attempt at cure for the patient with a clinical stage I lung cancer with a resectable, isolated brain metastasis. Lastly, logistic regression analyses in this study did not show reduced activity levels to be an independent risk factor.
Although an attempt was made to match the patients well, this study had activity bias favoring the control group that makes the observations more interesting. Alternatively, the VATS group was favored by a highly selected study population with three minimal-risk patients, all of whom had anatomy simple enough to allow a VATS resection. Despite some heterogeneity of the study group’s risk levels, it is interesting to see the tight grouping of the recovery times apart from those patients who sustained a complication (Fig 1). The retrospective nature of this study accounts for the lack of the visual analog instrument used by others to definitively establish less pain with VATS lobectomy [9]. Although crude, the remarkably higher rate of pain denial and marked reduction in analgesic medication usage at home are suggestive enough to support our conclusions regarding pain. Also, this study had insufficient power to reliably exclude the relevance of criteria not achieving statistical significance.
From this preliminary experience of VATS lobectomy in relatively high-risk groups, short-term results warrant its continued study for carefully selected patients. Because of the marginal reserve of our patients who died, one cannot yet say that this procedure extends operability to those too ill for thoracotomy. The surgeon should observe the same level of technical excellence for VATS as for open lobectomy and be wary of older, activity-impaired patients, particularly those on steroids.
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Footnotes |
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