Ann Thorac Surg 2000;70:1181-1184
© 2000 The Society of Thoracic Surgeons
Original articles: general thoracic
Evaluation of ultracision in lung metastatic surgery
Uwe Eichfeld, MD, PhDa,
Andrea Tannapfel, MDb,
Matthias Steinert, MDa,
Thomas Friedrich, MDa
a Department of Surgery I, General Surgery, Surgical Oncology and Thoracic Surgery, Leipzig, Germany
b Institute of Pathology, University of Leipzig, Leipzig, Germany
Address reprint requests to Dr Eichfeld, Department of Surgery I, General Surgery, Surgical Oncology and Thoracic Surgery, Liebigstrasse 20a, 04103 Leipzig, Germany
e-mail: eichu{at}medizin.uni-leipzig.de
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Abstract
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Background. There are very few studies on the histological outcome of lung metastatic surgery using the Ultracision particularly in deeper areas of the lung.
Methods. In a prospective study, we resected 24 lung metastases from 18 patients using the Ultrasonic scalpel (Ethicon Endo-Surgery, Norderstedt, Germany). We analyzed the risk of bleeding and air leakage as well as the histopathological features of the resection area.
Results. There was no intraoperative bleeding and, in 72%, no intraoperative air leakage. The resection surface was closed with a suture. In 8 cases, the metastases were located deeply, near the hilus of the lobe which did not necessitate a lobectomy. Histologically, occluded blood vessels as well as occluded small bronchioli under 0.1 cm were observed. There was no evidence of deep tissue destruction. No postoperative complications occurred.
Conclusions. Ultracision in metastatic lung surgery is an appropriate method of treatment with minimum risk of bleeding or air leakage. This procedural approach allows for adequate resection of lung metastases while sparing a generous amount of healthy lung tissue.
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Introduction
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Ultracision has proven its usefulness in various surgical procedures. The main indications include laparoscopic surgery and open surgery of the spleen, liver [1, 2], gall bladder [3, 4], kidneys [5, 6], and uterus and ovaries [7]. The established methods for excising lung parenchyma are laser surgery, staplers, manual mechanical dissection, and, in some cases, the use of electrocauterization. We found only two clinical publications [8, 9] and one animal study [10] on the use of Ultracision in lung parenchyma resection. This encouraged us to analyze our current use of Ultracision in a prospective study to evaluate its general usefulness in the excision of lung metastases. We further analyzed the histologic changes seen with this procedure. Our overall goal was to prove that with Ultracision there is a substantial amount of lung parenchyma salvaged, especially in deeply located lesions.
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Material and methods
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Patients
From January 1998 until August 1999, we performed 18 operations using the Ultracision (7 women of 42 to 67 years, average 55.5 years, and 11 men of 52 to 70 years, average 61.6 years) resecting a total of 24 unilaterally located lung metastases. The primary lesions were renal cell carcinoma (5 cases), colorectal carcinoma (5 cases), esophageal carcinoma (2 cases), breast cancer (2 cases), one soft tissue sarcoma, one malignant melanoma, one urothelial cell carcinoma, and one laryngeal carcinoma.
Patients were included in the study who had three or less lung metastases and only those patients with no recurrence at the region of the primary carcinoma for an appropriate disease-free time interval. Only patients with slowly progressing esophageal cancer were included in the study.
Procedure
After intubation with a double-lumen tube and closing ventilation on the operated side, the thorax was opened unilaterally by dorsolateral thoracotomy. The lung was inspected and palpated to identify the location and extent of the metastatic areas. The initial incision of the visceral pleura was performed using the electrocautery over the site of the metastatic lesion. Allowing for a 1 to 1.5-cm border of tissue around the metastasis, the Ultrasonic dissector (Fig 1) was used to excise the metastasis from the lung parenchyma. The Harmonic scalpel (HS-2 blade) as well as the Laparosonic Coagulating Shear (LCS) with a sharp and flat surface (all instruments manufactured by Ethicon Endo-Surgery, Norderstedt, Germany) were used to perform this procedure. The major bronchial structures were located and occluded with titanium clips or ligations. Following resection and control of local bleeding, the thorax was filled with 0.9% NaCl solution at a respiratory pressure of 15 cm H2O and we were then able to control airtightness. The wound was closed with an absorbable suture.
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Fig. 1. Metastasectomy by Ultracision using the Laparosonic Coagulating Shear and a blade with the flat surface.
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Our initial criteria for analysis were number of metastases, character of tumor, the localization of resected metastases, airtightness of lung parenchyma before suturing, visually controlled bleeding, and the number of surplus clips or ligations needed. Chest roentgenograms were taken immediately following surgery and 7 days postoperatively. Other postoperative complications, eg, persisting air leaks, were controlled carefully and the duration of thoracic drain usage was monitored.
The resected metastases were analyzed pathohistologically. In unfixed condition, the distance of the tumor from the cutting edge was checked macroscopically (Fig 2). Then the tissue was formalin fixed, paraffin embedded, and evaluated microscopically after cutting in serial sections.
To rule out the possibility of a primary lung carcinoma, the histology of each patient’s primary carcinoma was compared to the excised lung specimen. Each specimen was compared to the patient’s primary carcinoma as to tumor differention including tumor grade. For both cases of esophageal cancer, the specimens were found to have identical histological patterns and types of keratinization. For the 2 cases of primary breast carcinoma, immunohistochemical analysis of estrogen and progesterone receptors was performed on the lung tumors.
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Results
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The operation time for all thoracotomies was 60 to 140 minutes (average 107 minutes). Sixteen metastases were located in the periphery with a median volume of 1.5 cubic cm (0.3 to 2.0 cubic cm); eight were located near the lobar hilus with a median volume of 3.1 cubic cm (1.3 to 8.0 cubic cm). Solitary metastases near the hilus were found in 8 patients, 7 patients had metastases in the periphery, 3 patients had three peripherally spread metastases which we were able to resect by Ultracision. Ultracision allowed us to operate on the eight deeply located lesions near the hilus and thus allowed us to save healthy lung parenchyma.
We achieved airtightness of the resection site in 72% of the cases (13 of 18 patients) before proceeding with the parenchyma closure with suture using on average 3.4 clips or ligations. After the parenchyma was sutured, airtightness reached nearly 100%.
There was no bleeding in all cases. The thorax drains were removed between postoperative day 2 and 10 with an average drainage time of 4 days. The chest x-rays showed normal postoperative findings in all cases (Fig 3). There were no postoperative complications locally or systemically.
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Fig 3. Postoperative x-ray film 2 days after operation: there are no radiographic signs of pneumothorax or air leakage. Resected area (arrow) is visible.
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Histological analysis
In all cases, serial cuts of the resection rim showed lung tissue with grouped fibrinoid necroses paralleling the edge. Bordering the necroses, there was approximately 0.3 cm of blood-suffused, vital lung tissue with intraalveolar erythrocytes, as well as undamaged normal lung parenchyma. Blood vessels near the cutting edge showed thrombosis, occluding the lumen partially or totally until a distance of about 0.5 cm from the cutting edge. Fibrinoid necroses were also found in the terminal bronchioli which are bronchi with a diameter less than 0.1 cm. Their inner layer of respiratory epithelium was suffused with blood to a great extent and infiltrated by granulocytes. The lumens were filled with fibrin thromboses. Bronchial structures distant to the necrotic zone did not show, histologically evident of thermal damage.
Small and medium-sized bronchi were mostly unaffected, but had a slight and unspecific peribronchial inflammatory infiltration. The cartilagineous and glandular structures in the bronchial wall were thermically undamaged. Extended necroses or inflammatory infiltration were not found. There was no atelectasis found. Intraalveolar tumor cells in the sense of tumor cell dissemination or mechanical spreading were not observed (Fig 4).
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Fig 4. Histological examination of the cutting edge after using Laparosonic Coagulating Shear (hematoxylin and eosin stain, original magnification x60). We found a strip of fibrinous necrosis (N) and followed by regular blood coagula (B), sealing the edge with a thickness of 2 to 3 mm, followed by regular lung parenchyma (LP). A terminal bronchiolus is occluded with thromboembolic and fibrinous material (OB).
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In only 2 cases, the resection margin was not examinable due to extensive thermal damage.
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Comment
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Ultracision is a method mainly used in laparoscopic surgery, but is now gaining importance in open surgery. Up to now, little has been studied about Ultracision in lung surgery [8–10]. Thus, we tested the possibilities of Ultracision and its morphological aspects in lung tissue with the intention of parenchyma-saving resection of lung metastases.
Countless publications, especially the first worldwide study by Pastorino and colleagues [11] (5,206 cases) show that surgery of lung metastases is safely established and a potentially curative method. The resection of solitary or multiple metastases as well as reoperation in cases of tumor recurrence are prognostically beneficial for the patient [12–14]. The reasoning for the complete resection of the metastases is with the intention of curative measures of the metastatic carcinoma, as well as saving as much lung parenchyma as possible and, therefore, retaining the maximal respiratory surface. The problems arise with metastases which are located deeply in lung tissue, near vulnerable structures. Through a radical operation such as lobectomy, it is often difficult to save parenchyma, in which case laser- or electrothermic resection are beneficial [15].
What value does Ultracision, being well established in other disciplines, have for surgery of deeply located pulmonary lesions? Can it be applied to lung parenchyma? Ultracision is a technological advancement for cutting and coagulating tissue. It was developed especially for abdominal and laparoscopic surgery [3, 16, 17]. Ultracision works by liberating energy at the tip of the instrument as an ultrasonic wave with a frequency of 55.5 kHz. The longitudinal waves coagulate by denaturizing proteins. Tissue is separated by forming steam bubbles with a temperature not exceeding 100°C. The penetration of the applied heat is better controlled in comparison to high-frequency surgery. Further assets include reduced lateral spreading of heat, which allows operating near vulnerable structures, and minimal smoke production compared with the usual electric scalpel. Velocity of tissue separation can be controlled very well by variation of manual pressure [16–18], which we were able to demonstrate in our intraoperative experiences.
The coagulative and cautering effect on tissue was verified by the excellent control of bleeding and, moreover, histomorphologically by fibrinoid necrotic zones and obstructed blood vessels in the resection zone. Our observations of minimal tissue damage and optimal coagulatory properties are confirmed by the work of Hayashi and coworkers [10], who used Ultracision in lung parenchyma of animals. The hemostatic effect of Ultracision on large blood vessels was proven by Ohtsuka and associates [18], using a resected and coagulated branch of the internal mammary artery, and by Aoki and Kaseda [8] in a study about Ultracision under VATS conditions. Due to these hemostatic properties, Ultracision is superior to laser surgery and electrocautery, which do not stop bleeding from medium-sized blood vessels [8]. Prolonged airleaks were seen by these authors in only a few cases and by Tajiri and colleagues [9], who saw only one airleak in 20 cases during a time interval of 10 days. This correlates well with our own findings of immediate airtightness in 72% of our cases. We explain this fact by our diligent operating technique with additional clipping and ligation, and microscopically with results of small terminal bronchioli occluded by fibrin thromboses. The additional clips and ligations were used mainly out of a need for security. They are justified by the predescribed clinical observations and our histological findings and, therefore, are absolutely necessary for the occlusion of major bronchioli.
Minimal thermal damage to the surrounding tissue in comparison to the use of electrocauters or lasers which have the possibility of more thermal damage [8] was verified in our own histological observations, as well as in the studies of Hayashi and associates [10]. However, we had 2 cases in which the resection rim was so badly damaged by heat that it was impossible to analyze. These cases were the first we performed using the Ultracision. We feel that, in our initial technique, we were too close to the tumor. Our conclusion is that it is extremely important to allow a safe distance from the metastasis while cutting through the surrounding tissue.
Due to the risk of postoperative bleeding and the development of atelectases, a lobectomy is necessary in most cases of metastases near the lobe hilus [15, 19], resulting in the need for lobe-saving complete resection techniques such as laser- or electric surgery [15, 20]. All of the eight deeply located metastases were resected without complications, leaving a safe border and avoiding the greater parenchyma-loss of a cutter or the possibility of anatomical resection. In some of the cases, we were able to operate directly beside the lobar blood vessels and the lobar bronchus, without seeing any intra- or postoperative complications.
This procedure was justified because of the already described reduced lateral spreading of heat [8, 10] and reduced deep tissue damage. This was also verified in our microscopic observations and in the experimental and clinical studies of Hayashi and colleagues [10], who describe Ultracision as a method to be used near greater blood vessels of the lung. Due to the variability of the analyzed patients, a direct comparison of the duration of the operations, between operations using Ultracision and operations using other methods, is not possible.
Our method is even more justified by the complication-free postoperative phase, ie, no morbidity, no mortality that we saw in all our patients, consistent with the results of Aoki and Kaseda [8]. Experimental studies of dispersion and concentration of aerosol particles during ultrasonic surgery show a significant rise of blood and tissue particles in the aerosol, which can be avoided by the use of an evacuation system [21].
Another study reports on the quantitative assembly of tumor-cell debridement in lung tissue, but not of spreading of vital tumor cells [22], which means spreading is possible but not very probable. This is confirmed by our observations of the lung parenchyma at the resection rim, never showing any intraalveolar vital tumor cells. Nevertheless, when resecting malignancies, safe distances around the tumor border should be respected.
In conclusion, we are able to say that using Ultracision in lung tissue is characterized by good tissue-separating properties, very good hemostatic properties, and even the ability to achieve substantial airtightness. Through histomorphologically proven reduced thermal tissue damage, Ultracision is a method that can be used directly beside big central blood vessels, creating the possibility for a parenchyma-sparing resection. The dissemination of tumor cells by Ultracision was histologically not observed.
All in all, with other authors [8, 10], we can say that using Ultracision in lung parenchyma resection is a method which is as effective as it is beneficial. Further studies are mandatory, especially to compare the thermal damage in deeper tissue areas. This effect should be directly compared with standard resection methods such as laser, electrocauterization, and stapling. Prospective studies are needed to evaluate the cost-benefit ratio and also the possibility of tumor cell dissemination.
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Acknowledgments
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We thank especially our colleagues of the Department of Anesthesiology and Intensive Care Medicine for their good cooperation during operations and their diligent postoperative supervision, and the colleagues of the Department of Radiology for their willingness to evaluate the radiological controls.
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Accepted for publication April 24, 2000.
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Abstract
Introduction
