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Ann Thorac Surg 2000;70:938-941
© 2000 The Society of Thoracic Surgeons

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Original articles: general thoracic

Pulmonary function after lobectomy: video-assisted thoracic surgery versus thoracotomy

^a Clinical Research, Department of Surgery, National Shikoku Cancer Center Hospital, Matsuyama, Japan

Address reprint requests to Dr Nakata, Department of Surgery, National Shikoku Cancer Center Hospital, Horinouchi 13, Matsuyama, Ehime, 790-0007, Japan
e-mail: mnakata{at}shikoku-cc.go.jp

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. Whether video-assisted thoracic surgery (VATS) improves postoperative pulmonary function is still controversial. We compared postoperative pulmonary function after VATS lobectomy and standard lobectomy.

Methods. Eleven patients who had undergone standard lobectomy and 10 patients who had undergone VATS lobectomy were studied. Arterial blood gas analyses were performed on the 4th, 7th, and 14th postoperative days. Pulmonary function, including forced vital capacity (FVC), forced expiratory volume in 1 second (FEV_1.0), and peak flow rate (PFR) were measured on the 7th and 14th postoperative days (early phase), and approximately 1 year after surgery (late phase).

Results. Pulmonary function, as assessed with arterial oxygen partial pressure (PaO₂) (p = 0.054), arterial oxygen saturation (O_2SAT) (p = 0.063), FVC (p = 0.10), and FEV_1.0 (p = 0.08), was better after VATS lobectomy than after thoracotomy on the 7th postoperative day. PFR was significantly better after VATS on both the 7th and 14th postoperative days (p = 0.008 and p = 0.03, respectively).

Conclusions. VATS lobectomy had advantages on early postoperative pulmonary function. We conclude that VATS lobectomy is a beneficial alternative to standard thoracotomy, especially for patients with poor pulmonary reserve.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Lobectomy with systematic mediastinal lymphadenectomy is the standard treatment for patients with stage I or II non-small cell lung cancer. The most common surgical approach for lobectomy has been posterolateral thoracotomy. This approach provides the wide exposure of intrathoracic structures. However, because both the latissimus dorsi and trapezius muscles are divided and one or two ribs are resected, postoperative pain and decreased compliance of the thoracic wall may persist.

Video-assisted thoracic surgery (VATS) is a new approach for thoracic surgery. This technique has been used for several diagnostic procedures and resection of small peripheral lung nodules. Recently, VATS has been applied for more complex therapeutic procedures, such as lobectomy for peripheral small lung cancers. Because VATS lobectomy can be performed through a small access thoracotomy incision and two or three port incisions, it results in less postoperative pain, better shoulder function, and faster recovery [1–3]. However, whether VATS lobectomy has some advantages on postoperative pulmonary function remains unclear.

In this study, we compared postoperative pulmonary function after VATS lobectomy and posterolateral thoracotomy in order to evaluate the benefits of this new approach.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
Patients
From November 1996 through August 1997, 31 consecutive patients with primary lung cancer underwent lobectomy at our institution. Twenty-one patients underwent lobectomy by posterolateral thoracotomy and 10 patients underwent VATS lobectomy. Of these 31 patients, 3 patients with hilar lung cancer were excluded from this study because preoperative pulmonary function was thought to be impaired by obstructed or narrowed bronchi. An additional 7 patients who underwent thoracotomy were excluded because of postoperative complications in 3 patients (pulmonary embolism, persistent air leakage, and delirium), and combined resection of neighboring structures in 2 patients (chest wall and adjacent pulmonary segment), and previous operations for head-and-neck cancer in 2 patients. Therefore, 11 patients who underwent thoracotomy (thoracotomy group) and 10 patients who underwent VATS lobectomy (VATS group) were studied.

Operative procedure
In posterolateral thoracotomy, both the latissimus dorsi and serratus anterior muscles were divided. Thoracotomy was performed through the 4th or 5th intercostal space, and two ribs were usually divided. Complete mediastinal lymph node dissection was routinely performed. Continuous epidural anesthesia with morphine was employed for about 10 days after thoracotomy.

VATS lobectomy was performed through three incisions. Two incisions were for thoracoscopic ports (12 mm in diameter), and the other incision was an access thoracotomy incision (6 to 10 cm in length) placed anteriorly in the 4th or 5th intercostal space. The latissimus dorsi was not divided. A small rib spreader was usually used to widen the intercostal space. Hilar lymph nodes were dissected and the mediastinal lymph nodes were sampled.

The surgical approach was chosen on the basis of tumor size, patient age, and pulmonary function. In general, patients with tumors 2 cm or less in diameter, patients older than 75 years, and patients with poor pulmonary function were assigned to VATS lobectomy after they had given informed consent. All operations were performed by two thoracic surgeons (M.N., H.S.).

Pulmonary function tests
Arterial blood gases on room air were analyzed on the 4th, 7th, and 14th postoperative days. Pulmonary function studies including forced vital capacity (FVC), forced expiratory volume in 1 second (FEV_1.0), and peak flow rate (PFR) were performed at early postoperative phase (the 4th, 7th, and 14th postoperative days) and late postoperative phase (approximately 1 year after surgery).

Statistical analysis
Data were analyzed with the unpaired Student’s t test. All values are expressed as mean ± standard error of the mean. Differences with a p value less than 0.05 were considered to be statistically significant.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
The patient characteristics are shown in Table 1. The two groups did not differ significantly with respect to age, tumor size, preoperative arterial oxygen partial pressure (PaO₂), arterial carbon dioxide partial pressure (PaCO₂), arterial oxygen saturation (O_2SAT), and FEV_1.0%. The percentage of the predicted vital capacity (%VC) was significantly better in the thoracotomy group (p = 0.002). However, the mean value in the VATS group (92.9 ± 12.1%) was sufficiently high for lobectomy. The resected lobes were: the right upper lobe in 3 patients, the right lower lobe in 4 patients, the left upper lobe in 2 patients, and the left lower lobe in 1 patient in the VATS group; and the right upper lobe in 2 patients, the right lower lobe in 1 patient, the left upper lobe in 6 patients, and the left lower lobe in 2 patients in the thoracotomy group.

View larger version (15K): [in this window] [in a new window]   Fig 1. Changes in arterial oxygen partial pressure (PaO2) during the perioperative period. PaO2 in the video-assisted thoracic surgery (VATS) group was higher than that in the thoracotomy group on the 7th postoperative day (POD) (p = 0.054).

View larger version (15K): [in this window] [in a new window]   Fig 2. Changes in arterial oxygen saturation (O2SAT) during the perioperative period. O2SAT in the video-assisted thoracic surgery (VATS) group was higher than that in the thoracotomy group on the 7th postoperative day (POD) (p = 0.063).

View larger version (14K): [in this window] [in a new window]   Fig 3. Changes in arterial carbon dioxide pressure (PaCO2) during the perioperative period. There were no differences between the thoracotomy group and the video-assisted thoracic surgery (VATS) group. (POD = postoperative day.)

View larger version (18K): [in this window] [in a new window]   Fig 4. Postoperative changes in forced vital capacity (FVC). Values are expressed as percentages of predicted postoperative values. On the 7th and 14th postoperative days, FVCs in the video-assisted thoracic surgery (VATS) group were slightly better than those in the thoracotomy group. In the late phase, there were no differences between the two groups. (POD = postoperative day.)

View larger version (18K): [in this window] [in a new window]   Fig 5. Postoperative changes in forced expiratory volume in 1 s (FEV1.0). Values are expressed as percentages of predicted postoperative values. On the 7th and 14th postoperative days, FEV1.0 in the video-assisted thoracic surgery (VATS) group were better, although not significant, than those in the thoracotomy group. In the late phase, there were no differences between the 2 groups. (POD = postoperative day.)

View larger version (18K): [in this window] [in a new window]   Fig 6. Postoperative changes in peak flow rate (PFR). Values are expressed as percentages of preoperative values. PFRs in the video-assisted thoracic surgery (VATS) group were significantly higher than those in the thoracotomy group in the early postoperative period. (POD = postoperative day.)

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
VATS is a new approach for thoracic surgery. Several previous studies have already demonstrated the benefit of this new approach [1–3, 5, 6]. Landreneau and coworkers [1, 2] found that the patients who underwent VATS had less pain, less shoulder dysfunction, and decreased morbidity. Tschernko and colleagues [6] found that the plasma epinephrine levels 3 and 15 hours after VATS were significantly lower than those after axillary thoracotomy. According to these results, VATS is considered "minimally invasive surgery."

However, whether VATS benefits postoperative pulmonary function is still controversial. Giudicelli and colleagues [5] did not find significant differences in postoperative FVC and FEV_1.0 between VATS and muscle-sparing thoracotomy for lobectomy. In contrast, Nomori and associates [7] showed significantly better respiratory muscle strength after VATS than after posterolateral thoracotomy. However, the object of their study was pulmonary wedge resection, which is not an appropriate procedure for lung cancer. In Japan, the standard surgical approach for lobectomy is posterolateral thoracotomy. Therefore, in order to evaluate whether VATS has some advantages on postoperative pulmonary function in lung cancer patients, we compared VATS lobectomy with lobectomy by posterolateral thoracotomy.

The procedure of VATS lobectomy is different with each surgeon. In a strict sense, VATS lobectomy might mean lobectomy performed through only several port incisions without a rib spreader. However, for patients with lung cancer, mini-thoracotomy is necessary in order to dissect mediastinal lymph nodes.

Because our patients were not randomized, preoperative pulmonary function in patients undergoing VATS tended to be worse than that in patients undergoing thoracotomy. However, the differences were not significant except for %VC. Besides, %VC in the VATS group were sufficient for lobectomy. Therefore, we believe that the comparisons of these groups were appropriate for evaluating the benefit of VATS for lung cancer patients.

PaO₂ and O_2SAT were higher on the 7th postoperative day after VATS than after thoracotomy (p = 0.054 and 0.063, respectively). Tschernko and colleagues [6] have also shown higher PaO₂ during the first 3 days after VATS than after thoracotomy. They concluded that the postoperative pain after thoracotomy impaired breathing, which prevented oxygenation. In our study, the differences between VATS and thoracotomy did not reach statistical significance, possibly because continuous epidural anesthesia was routinely administered to patients who had undergone thoracotomy. However, some improvements in oxygenation were suggested in the VATS group.

Pulmonary function tests also demonstrated some benefits of VATS. Postoperative PFR was exceedingly higher in patients undergoing VATS on the 7th postoperative day. It continued until the 2nd postoperative week at least. Postoperative FVC and FEV_1.0 were also better after VATS than after thoracotomy during the early postoperative period, although the differences were not significant. Postoperative decreases in FVC, FEV_1.0, and PFR are derived from restrictive damage of the thoracic wall and reduced muscular activity of the diaphragm. VATS require neither the division of muscles nor ribs. These differences in the destruction of the thoracic wall would result in the improved pulmonary function as well as less pain. We thought our current study demonstrated less invasiveness of VATS in terms of early postoperative pulmonary function even when compared to thoracotomy with epidural anesthesia.

On the other hand, about 1 year after surgery, we could not find any differences in pulmonary function between the two approaches. These approaches differ only in the destructive damage to the thoracic wall. Therefore, it stands to reason that advantages of VATS on pulmonary function were found only in the acute postoperative phase, and not detected after the recovery of the damage.

Good preservation of postoperative pulmonary function is a great benefit for patients with lung cancer, because these patients are often elderly, and with poor pulmonary reserve. The improved PFR and FEV_1.0 were reported to be correlated with the ability to expectorate retained bronchial secretions [8]. Therefore, we believe that good pulmonary function could reduce postoperative complications and help faster recovery especially for these high-risk patients. The surgical approach for primary lung cancer must be determined on the basis of its radicality. However, pulmonary reserve should be considered as well. Our current study, in spite of a small number of patients, showed that VATS was advantageous for postoperative pulmonary function which concerned most critically high-risk patients. Several reports have already demonstrated fast recovery and decreased mobidity after VATS. We believe that these advantages are confirmed by the improved postoperative pulmonary function after this less-invasive approach. Therefore, we conclude that VATS lobectomy is a beneficial alternative to standard thoracotomy for patients with poor pulmonary reserve.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

1. Landreneau R.J., Hazelrigg S.R., Mack M.J., et al. Postoperative pain-related morbidity. Ann Thorac Surg 1993;56:1285-1289.[Abstract]
2. Landreneau R.J., Mack M.J., Hazelrigg S.R., et al. Prevalence of chronic pain after pulmonary resection by thoracotomy or video-assisted thoracic surgery. J Thorac Cardiovasc Surg 1994;107:1079-1086.[Abstract/Free Full Text]
3. Liu H.P., Chang C.H., Lin P.J., Chang J.P., Hsieh M.J. Thoracoscopic-assisted lobectomy, preliminary experience and results. Chest 1995;107:853-855.[Abstract/Free Full Text]
4. Nakahara K., Monden Y., Ohno K., Miyoshi S., Maeda H., Kawashima Y. A method for predicting postoperative lung function and its relation to postoperative complications in patients with lung cancer. Ann Thorac Surg 1985;39:260-265.[Abstract]
5. Giudicelli R., Thomas P., Lonjon T., et al. Video-assisted minithoracotomy versus muscle-sparing thoracotomy for performing lobectomy. Ann Thorac Surg 1994;58:712-718.[Abstract]
6. Tschernko E.M., Hofer S., Bieglmayer C., Wisser W., Haider W. Early postoperative stress. Chest 1996;109:1636-1642.[Abstract/Free Full Text]
7. Nomori H., Horio H., Fuyuno G., Kobayashi R., Yashima H. Respiratory muscle strength after lung resection with special reference to age and procedures of thoracotomy. Eur J Cardiothorac Surg 1996;10:352-358.[Abstract]
8. Takizawa T. Assessment of mechanical efficiency of coughing in pre- and post-operative lung cancer patients. Nippon Kyobu Geka Gakkai Zasshi 1993;41:2319-2324.[Medline]

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