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Ann Thorac Surg 2000;70:1644-1646
© 2000 The Society of Thoracic Surgeons

Original articles: general thoracic

Better pulmonary function and prognosis with video-assisted thoracic surgery than with thoracotomy

Shizuka Kaseda, MDa,b, Teruhiro Aoki, MDa,b, Nanae Hangai, MDa,b, Kunihiko Shimizu, MDa,b

a Department of Thoracic Surgery Yokohama 221-8601, Japan
b Department of Internal Medicine, Saiseikai Kanagawa-ken Hospital, Yokohama 221-8601, Japan

Address reprint requests to Dr Kaseda, Department of Thoracic Surgery, Saiseikai Kanagawa-ken Hospital, 6-6 Tomiya-cho, Kanagawa-ku, Yokohama 221-8601, Japan
e-mail: kaseda{at}ra2.so-net.ne.jp


   Abstract
Top
 Abstract
Introduction
 Patients and methods
 Results
 Comment
 References
 
Background. Data regarding pulmonary function and prognosis after video-assisted thoracic surgery lobectomy are limited.

Methods. From September 1992 to April 2000, 204 video-assisted thoracic surgery lobectomies were performed, and their preoperative and postoperative pulmonary function test results and prognoses were evaluated.

Results. The postoperative to preoperative ratio of pulmonary function tests (vital capacity and forced expiratory volume in 1 s) were better in video-assisted thoracic surgery lobectomy than in open thoracotomy (p < 0.0001). Furthermore, the 5-year survival rate of pathologic stage I lung cancers after video-assisted thoracic surgery was 97.0%, whereas that after open thoracotomy was 78.5% (p = 0.0173; Mantel-Cox).

Conclusions. Pulmonary function and prognosis were far better after video-assisted thoracic surgery lobectomy than after open thoracotomy.


   Introduction
Top
 Abstract
 Introduction
Patients and methods
 Results
 Comment
 References
 
Since the beginning of the 1990s, thoracoscopic surgery has acquired widespread favor with the rapid development of associated techniques and instrumentation [1–3]. We first experienced video-assisted thoracic surgery (VATS) lobectomy in September 1992, and started extended lymph node dissection as well in November 1993. We have performed a total of 204 VATS lobectomies as of April 2000 [4, 5].

Thoracoscopic surgery has made it possible to remove a contracted lobe through a small opening, 5 to 8 cm, which is far smaller compared with that of open thoracotomy. It is presumed that this causes less postoperative deformity of the thorax, and fewer adhesions between the thoracic wall and the remaining lung around the wound, yielding smaller pulmonary function loss after major lung resection. Furthermore, better prognosis has already been reported with VATS lobectomy than with open thoracotomy [5–7].

We report on our results with VATS lobectomy, focusing on the changes of pulmonary function as well as patients’ prognoses based on our 8 years’ experience.


   Patients and methods
Top
 Abstract
 Introduction
 Patients and methods
Results
 Comment
 References
 
From September 1992 through April 2000, we performed 204 major lung resections under VATS: 13 segmentectomies, 187 lobectomies, and 4 pneumonectomies. There were 120 male and 84 female patients with an average age of 64 years (range, 28 to 87 years). The patients consisted of 159 cases with lung cancer, 13 with bronchiectasis, 9 with granulomas, 8 with metastatic tumors, and 15 with miscellaneous diseases. After intubation with a double-lumen endotracheal tube (Broncho-Cath, Mallinckrodt Medical, St. Louis, MO) or an endobronchial tube with a movable blocker for one lung anesthesia (Univent, Fuji Medical, Tokyo, Japan), the patient was fully flexed in the lateral decubitus position. A thoracoscope was introduced through the seventh intercostal space at the midaxillary line. An anterolateral minithoracotomy (5 to 8 cm) was placed in the fourth intercostal space for an upper lobectomy, and in the fifth intercostal space for a middle or lower lobectomy. The extent of the incision was determined based on the size of the tumor or the volume of lung tissue to be removed. One or two 5- to 10-mm incisions were made additionally at the posteroaxillary line to handle a variety of instruments (Fig 1).



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  		Fig 1. Positions of access thoracotomy and additional incisions to facilitate lymph node dissection as well as lobectomy. (Reprinted from Kaseda S, Aoki T, Hangai N. Video-assisted thoracic surgery (VATS) lobectomy. The Japanese experience. Semin Thorac Cardiovasc Surg 1998;10:300–4 with the permission of W.B. Saunders Company.)

 
During lobectomy, pulmonary arteries and veins exceeding 10 mm in diameter were transected with a vascular endostapler, whereas smaller vessels were ligated with silk threads and dissected. The bronchus was closed with a Roticulator 30-3.5 stapler (U.S. Surgical Corporation, Norwalk, CT) or with an endostapler simply to reduce the cost of the procedure [5]. Patients younger than 75 years and without any major complications have undergone extended lymph node dissection as well since November 1993.

Pulmonary function testing was performed routinely 1 week before operation using Chestac-25 Part II EX (Chest Corporation, Tokyo, Japan) [8, 9]. Of the 204 patients undergoing VATS lobectomy, 42 who complained of dyspnea gave consent to undergoing pulmonary function testing 3 months postoperatively, and the data were compared with those gathered preoperatively. These data were evaluated in comparison with those patients undergoing open thoracotomy in which a 30- to 40-cm posterolateral incision was made (Table 1). For each group, the change of variables over time from 1 week before the operation to 3 months after it was analyzed by the paired Student’s t test. The probability of survival was calculated using the Kaplan-Meier method [10], and the significance of the difference between pairs of Kaplan-Meier curves was calculated using the log-rank test. For each group, an analysis was performed using StatView for Macintosh Version 5.0 (SAS Institute, Inc, Cary, NC).


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  		Table 1. Characteristics of Study Groups

 

   Results
Top
 Abstract
 Introduction
 Patients and methods
 Results
Comment
 References
 
Among spirometry variables, the data of vital capacity and forced expiratory volume in 1 s are presented in Table 2. A comparison of postoperative and preoperative values was made between the VATS lobectomy and open thoracotomy groups; the average postoperative vital capacity was divided by the average preoperative value in both the VATS lobectomy and open thoracotomy groups. The resulting quotients were 0.849 and 0.668, respectively (Fig 2). A comparison of another spirometry variable, forced expiratory volume in 1 second, was made in both groups; the resulting quotient in the VATS lobectomy group was 0.848, and in the open thoracotomy group, 0.712 (Fig 3).


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  		Table 2. Preoperative and Postoperative Pulmonary Function Test Resultsa

 


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  		Fig 2. Ratio of postoperative to preoperative vital capacity.

 


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  		Fig 3. Ratio of postoperative to preoperative forced expiratory volume in 1 second.

 
Among the 50 patients with N0 (pathologic stage I) in whom long-term follow-up was possible, 1 developed generalized bone metastasis and died 20 months after the operation. However, no recurrence has been noted in the remaining 49 patients during a 1- to 69-month follow-up (median, 30 months), and the 5-year survival rate for the pathologic stage I cancer cases was 97.0%. This survival rate was far better than that of patients undergoing open thoracotomy with a posterolateral incision from 1976 to 1990 (78.5%, p = 0.0173; Fig 4).



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  		Fig 4. Survival of patients with stage I lung cancer undergoing video-assisted thoracic surgery lobectomy and open thoracotomy.

 

   Comment
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
References
 
Although open thoracotomy has long been adopted as a standard approach in lung resection, it contributes to morbidity, mortality, and prolonged, painful recovery of the patient. All these things are believed to come from the extent of the incision. On the other hand, the less destructive nature of VATS lobectomy is associated with low mortality and morbidity, early recovery, less deformity of the thorax, and better survival than open thoracotomy. Although medical insurance allowed only patients complaining of dyspnea to undergo pulmonary function testing, our study showed that VATS lobectomy leads to only a 15% loss in vital capacity and forced expiratory volume in 1 second, whereas open thoracotomy leads to losses of 23% and 29%, respectively. Furthermore, the 5-year survival rate after VATS lobectomy combined with extended lymph node dissection for pathologic stage I cancer was 97.0%, which is far better than that (78.5%) after open thoracotomy (Fig 4).

It is believed that metastases occur most frequently during the perioperative period, when injury and repair are most prominent and stress can elaborate various humoral substances that potentiate the growth of carcinomas [6, 11]. Thus, Lewis proposed that minimally invasive surgical procedures with the small incisions required for VATS could account for improved long-term survival after a VATS lobectomy. Such operations would provide a less favorable environment for malignant cell growth; furthermore, in VATS, fewer malignant cells would be disseminated and passed into the blood vessels or lymphatics, which could occur from the extensive mechanical stress through palpation and compression common to the open technique [7].

Although some surgeons insist that a randomized study should be performed among many institutions to determine the superiority of a new surgical procedure, until recently there was no institution in Japan that could perform the present procedure: VATS lobectomy accompanied by extended lymph node dissection. For this reason, we could not find a partner with which to make a randomized study to compare VATS with open thoracotomy. However, our initial results with VATS lobectomy and extended lymph node dissection encouraged us to continue performing these new procedures for clinical stage I lung cancer.

From the results in the present study as well, it is clear that VATS lobectomy with lymph node dissection has already gone well beyond the stage of an experimental technique and is on the way to becoming a standard procedure for stage I lung cancer.


   References
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
 References
 

  1. Lewis R., Caccavale R.J., Sisler G.E., Mackenzie J.W. One hundred consecutive patients undergoing video-assisted thoracic operations. Ann Thorac Surg 1992;54:421-426.[Abstract]
  2. Kirby T.J., Rice T.W. Thoracoscopic lobectomy. Ann Thorac Surg 1993;56:784-786.[Abstract]
  3. Roviaro G., Rebuffat C., Varoli F., Vergani C., Mariani C., Maciocco M. Videoendoscopic pulmonary lobectomy for cancer. Surg Laparosc Endosc 1992;2:244-247.[Medline]
  4. Kaseda S., Hangai N., Yamamoto S., Kitano M. Lobectomy with extended lymph node dissection by video-assisted thoracic surgery for lung cancer. Surg Endosc 1997;11:703-706.[Medline]
  5. Kaseda S., Aoki T., Hangai N. Video-assisted thoracic surgery (VATS) lobectomy. Semin Thorac Cardiovasc Surg 1998;10:300-304.[Medline]
  6. Walker W.S. Video-assisted thoracic surgery (VATS) lobectomy. Semin Thorac Cardiovasc Surg 1998;10:291-299.[Medline]
  7. Lewis R.J., Caccavale R.J. Video-assisted thoracic surgical non-rib spreading simultaneously stapled lobectomy (VATS(n)SSL). Semin Thorac Cardiovasc Surg 1998;10:332-339.[Medline]
  8. Gardner R.M., Hankinson J.L., West B.J. Standardization of spirometry. J Occup Med 1988;30:272-273.[Medline]
  9. Morris J.F., Koski A., Johnson L.C. Spirometric standards for healthy nonsmoking adults. Am Rev Respir Dis 1971;103:57-67.[Medline]
  10. Kaplan E., Meier P. Nonparametric estimation from incomplete observation. J Am Stat Assoc 1958;53:457-481.
  11. Reid S.E., Kaufman M.W., Murthy S., Scanlon E.F. Perioperative stimulation of residual cancer cells promotes local and distant recurrence of breast cancer. J Am Coll Surg 1997;185:290-306.[Medline]
Accepted for publication April 17, 2000.




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