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Ann Thorac Surg 2001;72:879-884
© 2001 The Society of Thoracic Surgeons

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Original article: general thoracic

What is the advantage of a thoracoscopic lobectomy over a limited thoracotomy procedure for lung cancer surgery?

^a Department of Thoracic Surgery, Saiseikai Central Hospital, Tokyo, Japan

Accepted for publication May 17, 2001.

Address reprint requests to Dr Nomori, Department of Thoracic Surgery, Saiseikai Central Hospital, 1-4-17 Mita, Minato-ku, Tokyo 108-0073, Japan
e-mail: hnomori{at}qk9.so-net.ne.jp

	Abstract

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Background. To clarify any advantages of video-assisted thoracoscopic surgery (VATS) over anterior limited thoracotomy (ALT) for lobectomy in lung cancer, we compared the two procedures in a retrospective analysis.

Methods. Sex- and age-matched (± 5 years) lung cancer patients in clinical stage I who underwent lobectomy by means of VATS (n = 33) or ALT (n = 33) were compared in terms of the number of resected lymph nodes, operating time, intraoperative blood loss, duration of postoperative chest tube drainage, and chest pain. Pain was evaluated using a visual analog scale and analgesic requirements. Vital capacity (VC), respiratory muscle strength, and results of a 6-minute walking (6 MW) test were also compared preoperatively and 1 and 2 weeks postoperatively.

Results. Compared with the ALT group, the VATS group experienced less pain between postoperative day (POD) 1 and POD 7 (p < 0.05 to 0.001) and had lower analgesic requirements up to POD 7 (p < 0.001). However, there were no significant differences in pain on POD 14. There were also no significant differences in intraoperative factors or in the postoperative impairment of VC, respiratory muscle strength, and 6 MW test results.

Conclusions. Although VATS lobectomy reduces chest pain during the first week after surgery compared with ALT, this advantage is lost within 2 weeks. Both techniques result in similar impairments of pulmonary function, respiratory muscle strength and walking capacity. Therefore, if curative resection of lung cancer by VATS would be technically difficult for any reason, including the surgeon’s skill and experience, a limited open thoracotomy would be preferable from the standpoints of safety and the patient’s prognosis.

	Introduction

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Although video-assisted thoracoscopic surgery (VATS) is gaining popularity as a technique for performing lobectomy in lung cancer, other minimally invasive types of thoracotomy, such as limited or muscle-sparing thoracotomies, are also widely used [1–5]. However, although the VATS approach is less invasive than a posterolateral thoracotomy, its advantages over a limited or muscle-sparing thoracotomy for lung cancer surgery are still a matter of controversy [4, 5].

Between January 1997 and July 1999 we conducted a study to investigate the usefulness of anterior limited thoracotomy (ALT) for lung cancer surgery; we reported that it had advantages over posterolateral thoracotomy in both reducing chest pain and diminishing the impairment of pulmonary function between 1 week and 6 months after surgery [1]. Since August 1999 we have been using VATS lobectomy with mediastinal lymph node dissection for clinical stage I lung cancer. To determine any advantages of VATS lobectomy over ALT we compared the two procedures in terms of intraoperative factors (number of resected lymph nodes, operating time, and blood loss) and postoperative recovery (duration of chest tube drainage, chest pain, length of hospital stay, impairment of pulmonary function, respiratory muscle strength, and results of a 6-minute walking [6 MW] test).

	Material and methods

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Study groups
Between August 1999 and December 2000 a total of 63 patients with primary lung cancer underwent surgical treatment at our hospital. For all 38 patients in clinical stage I we attempted VATS lobectomy and mediastinal lymph node dissection. Five of these patients were converted to an open thoracotomy procedure during surgery (because of perinodal invasion of lymph node metastasis in 3 patients, the need for a bronchoplasty in 1 patient, and bleeding in another). As a result, 33 patients successfully underwent VATS lobectomy and lymph node dissection. In the present study we investigated intraoperative factors (the number of resected lymph nodes, operating time, and blood loss during surgery) and postoperative recovery (the duration of chest tube drainage, chest pain, pulmonary function, respiratory muscle strength, and the outcome of a 6 MW test) in these 33 patients. As a control group we used the 33 most recent patients with clinical stage I lung cancer who had undergone lobectomy by means of ALT between April 1998 and July 1999 and who could be matched with the VATS lobectomy group for sex and age (± 5 years), as shown in Table 1. No significant differences were observed between the VATS and ALT groups in terms of preoperative pulmonary function, respiratory muscle strength, the distance covered during the 6 MW test (6 MWD), lobectomy site, tumor size, or pathologic tumor stage. All patients underwent general anesthesia and intubation with a double-lumen endotracheal tube to allow selective contralateral ventilation.

View larger version (11K): [in this window] [in a new window]   Fig 1. Skin incisions for lobectomy by means of video-assisted thoracoscopic surgery. Area with oblique lines indicates opening in thorax.

View larger version (19K): [in this window] [in a new window]   Fig 2. Illustration of anterior limited thoracotomy. The chest is entered through the fourth intercostal space with anterior cartilage junction disconnected. Two retractors are used, one for the intercostal space and the other for the posterior site. Area with oblique lines indicates opening in the thorax. (IV = the fourth rib; V = the fifth rib.)

Postoperative chest tube drainage
The chest tube was generally removed on the morning after surgery if the drainage volume was less than 400 mL per day and no air leakage was observed.

Evaluation of postoperative pain
Postoperative pain was assessed from POD 1 to 14 using the visual analog scale described by Hazelrigg and colleagues [3]. This involved patients marking a pain score from 0 mm (no pain) to 100 mm (most severe pain imaginable) on a 100-mm line drawing. The visual analog scale was explained to the patients preoperatively and was administered by the nursing staff three times a day during hospitalization. The pain experienced on each day was calculated as the mean of the three measurements. To ensure that there were no obvious psychological differences in pain perception between the groups, a pain reference was determined preoperatively for each patient by using the visual analog scale to assess the degree of pain experienced during a skin puncture to draw blood, as described by Giudicelli and colleagues [4]. Analgesic requirements from POD 1 to 7 were also examined.

Pulmonary function tests
We measured vital capacity (VC), forced vital capacity and forced expiratory volume in 1 second (FEV₁) with the subjects seated, using a dry rolling-seal spirometer (Fudac-50, Fukuda Co, Tokyo, Japan). Predicted normal VC volumes were determined by sex, height and age, using the formulae of Baldwin and colleagues [6]. Pulmonary function measurements were obtained less than 2 days before surgery and repeated 1 and 2 weeks after surgery. The percentage change in the postoperative VC compared with the preoperative volume was evaluated as follows: VC (% of preoperative level) = postoperative VC / preoperative VC x 100 (%).

Measurements of respiratory muscle strength
Maximum inspiratory pressure (MIP) and maximum expiratory pressure (MEP) were measured as before [7, 8], according to the method described by Black and Hyatt [9]. Briefly, an obstructive mouthpiece (2.5 cm in diameter, 6.5 cm long) with a small air leak was used to measure mouth pressure during MIP and MEP at functional residual capacity (FRC), and these values were used as an index of inspiratory and expiratory muscle strength, respectively. The mouthpiece was connected to a pressure transducer (TP-604T, Nihon Kohden Co, Tokyo, Japan) and measurements were made with the subjects seated and wearing a nose clip. Each subject performed a series of maximal inspiratory and expiratory maneuvers, which were repeated until at least three readings were sustained for 2 to 3 s with a variation of less than 10%. The highest value was used in the analysis. The MIP and MEP measurements were obtained less than 2 days before surgery and repeated 1 and 2 weeks after surgery. The percentage changes in postoperative MIP and MEP compared with the preoperative values were evaluated as follows: MIP (% of preoperative level) = postoperative MIP / preoperative MIP x 100 (%); and MEP (% of preoperative level) = postoperative MEP / preoperative MEP x 100 (%).

Six-minute walking test
The 6 MW test was conducted by physiotherapists according to a standardized protocol [10]. Patients were instructed to walk from one end of a 90-m hallway to the other at their own pace, attempting to go as far as possible in the allotted 6 minutes. They were allowed to rest during the test, but were instructed to resume walking as soon as they were able to do so. The total distance covered during the 6 MW test was measured. Oxygen saturation (SpO₂) and the pulse rate were measured during the test using a finger oxymeter (ONYX 9500, Nonin Medical Inc, Plymouth, MN), and values were assessed at the start and end of the test. The initial 6 MW test was conducted less than 2 days before the operation, with a postoperative test 1 week after operation. The percentage change in the postoperative 6 MWD compared with the preoperative value was evaluated as follows: 6 MWD (% of preoperative level) = postoperative 6 MWD / preoperative 6 MWD x 100 (%).

Discharge from hospital
Because the 6 MW and pulmonary function tests were performed on POD 7, most of the patients were discharged from the hospital on or after POD 7. The pulmonary function tests 2 weeks after surgery were generally conducted in the outpatient department.

Statistical analysis
All data are expressed as means ± standard deviation. All data were analyzed using the two-tailed Student’s t test. Between-group differences with p less than 0.05 were regarded as significant.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
Intraoperative data, postoperative chest tube drainage, and hospital stay
Data on the intraoperative factors and postoperative chest tube drainage are summarized in Table 2. There were no significant differences in either the operating time or the intraoperative blood loss between the VATS and ALT groups. The mean number of resected hilar and mediastinal lymph nodes on both sides of the lung was similar in both groups. The duration of chest tube drainage was somewhat shorter in the VATS group than in the ALT (p = 0.06) but the difference was not statistically significant. The length of hospital stay after operation was 7.3 ± 1.3 days in the VATS group and 7.9 ± 1.3 days in the ALT (difference not significant).

Postoperative chest pain
Chest pain data are summarized in Table 3. Preoperative pain reference values were similar in both the VATS and ALT groups. The mean postoperative pain scores from POD 1 to POD 7 were significantly lower in the VATS group than in the ALT group (p < 0.05 to 0.001), and the mean number of occasions on which analgesics were required during this period was significantly lower in the VATS group (p < 0.001). However, on POD 14 there was no significant difference in mean pain scores between the two groups (p = 0.09).

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
In the present study, the only advantage of VATS over ALT was a decrease in chest pain during the first week after surgery; by 2 weeks, however, this advantage was no longer apparent. We found no significant differences in the operating time, intraoperative blood loss, postoperative chest tube drainage, or in impairment of postoperative pulmonary function, respiratory muscle strength, and 6 MW test results between the two groups.

With regard to chest pain, we previously reported that pain scores between 1 week and 6 months after surgery were significantly lower after ALT than after posterolateral thoracotomy [1]. In the present study we demonstrated that VATS resulted in a further lowering of the pain score for 1 week after surgery. It therefore appears that the more limited the thoracic wound, the less the postoperative pain. We could not find any difference in the length of hospital stay after surgery between the two groups. Most of the patients were discharged from the hospital after 6 MW and pulmonary function tests on POD 7.

Several investigators have demonstrated the advantages of VATS or limited thoracotomy over posterolateral thoracotomy in improving postoperative pulmonary function [11, 12]. Because thoracotomy injures the respiratory muscles of the chest wall and reduces total chest compliance regardless of whether lung resection is performed [8, 13, 14], postoperative pulmonary function, respiratory muscle strength, and 6 MWD would be expected to be influenced by alterations in thoracotomy procedures. However, in the present study we could not detect any differences in these factors between VATS and ALT. These findings are in line with those of Giudicelli and colleagues [4], who found no significant differences in postoperative pulmonary function between VATS and latissimus dorsi muscle-sparing lateral thoracotomy. In addition, we previously reported that ALT produced less impairment of postoperative pulmonary function than did posterolateral thoracotomy, but that there was no significant difference between ALT and latissimus dorsi muscle-sparing anteroaxillary thoracotomy [1]. We therefore believe that preserving the latissimus dorsi muscle is one of the most important factors in maintaining adequate pulmonary function after surgery.

Although we could not demonstrate any significant advantages of VATS over ALT in terms of the postoperative recovery of pulmonary function, respiratory muscle strength, and walking capacity, the recovery of MEP and 6 MWD was somewhat better in the VATS group than in the ALT group at 1 week after surgery and these differences almost reached significance. We consider that the improvements in the postoperative impairment of MEP and 6 MWD seen in the VATS group could be due to the significant decrease in pain associated with VATS. Because patients usually experience chest pain more severely during active expiration (such as coughing) than during active inspiration, postoperative MEP values could be more significantly affected by ALT than by VATS because of chest pain. In addition, although the 6 MWD is well known to be reduced by cardiopulmonary dysfunction [10, 15], its impairment after lung surgery could be partially due to chest pain, because patients experiencing pain would not be able to walk as far after the operation as before surgery. Therefore, the relative improvement of 6 MWD in the VATS group compared with the ALT group at 1 week after surgery could be due to the decrease in chest pain associated with the former procedure. An adequate MEP value is important in allowing coughing to expectorate sputum, which in turn lowers the risk of postoperative pulmonary complications such as atelectasis and pneumonia. Early improvements in 6 MWD could also help patient mobility in the early period after surgery, which is associated with a decreased risk of postoperative pulmonary complications. Although the between-group differences in the postoperative recoveries of both MEP and 6 MWD did not reach significance, VATS lobectomy could have a beneficial impact on the risk of postoperative pulmonary complications, especially in elderly or poor-risk patients, because of the earlier recovery of expiratory muscle strength and walking capacity after the decrease in chest pain associated with this technique.

Although VATS lobectomy decreased chest pain after surgery, the most important feature of lung cancer surgery is its ability to cure the tumor, thereby ensuring a good prognosis. Because lung cancers (except for locally advanced ones) can be completely resected by means of a limited or muscle-sparing thoracotomy, it should be kept in mind that if curative resection of a lung cancer would be difficult to perform by means of a VATS procedure for any reason, including the skill and experience of the surgeon, a limited or muscle-sparing thoracotomy would be preferable from the standpoints of safety and ensuring complete resection of the tumor. In conclusion, VATS lobectomy could be accepted as a legitimate surgical option in the treatment of early-stage lung cancer for reducing early postoperative pain.

	References

Top Abstract Introduction Material and methods Results Comment References

 

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This Article Abstract Full Text (PDF) 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): Tsuguo Naruke Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Nomori, H. Articles by Suemasu, K. Search for Related Content PubMed PubMed Citation Articles by Nomori, H. Articles by Suemasu, K. Related Collections