Video-assisted thoracic surgery (VATS) lobectomy: 13 years experience

Transcription

1 DOI /s z Video-assisted thoracic surgery (VATS) lobectomy: 13 years experience Miguel Congregado Æ Rafael Jimenez Merchan Æ Gregorio Gallardo Æ Javier Ayarra Æ Jesus Loscertales Received: 28 April 2007 / Accepted: 2 November 2007 Ó Springer Science+Business Media, LLC 2007 Abstract Background Major lung resection by video-assisted thoracic surgery (VATS) has been proven to be both safe and technically feasible, but is not routinely performed in most hospitals. The aim of this paper is to show our technique for VATS lobectomy and our experience and outcomes obtained. Methods We have performed a retrospective review included all patients undergoing major pulmonary resection by VATS at the General and Thoracic Surgery Unit, Virgen Macarena University Hospital, Seville (Spain) since The clinical records of all patients were drawn from the hospital archive and data for the following variables were recorded for analysis: age, sex, clinical diagnosis, clinical status, date of surgery, type of surgery, inoperability, conversion to conventional surgery and reasons, duration of surgery and intraoperative complications, postoperative and long-term complications, postoperative stay, diagnosis, definitive status, and mortality. We also describe our surgical technique for each lobectomy. Results A total of 237 major pulmonary resections were performed, on 203 males and 34 males, with a mean age of years (non-small-cell bronchogenic carcinoma: 204, benign processes: 24, carcinoid tumors: 4, and lobectomy due to metastases: 5). The overall conversion rate was 14.01%. Mean duration of lobectomy was 153 min, with a median of 98 min, and mean postoperative stay was M. Congregado (&) R. J. Merchan G. Gallardo J. Ayarra J. Loscertales Department of General and Thoracic Surgery, Hospital Universitario Virgen Macarena, Avda. Dr. Fedriani 1, Seville, Spain miguelcongregado@wanadoo.es 4.2 days. The morbidity rate was 15.18%, mostly involving minor complications. Perioperative mortality was 3.7%. The actuarial 5-year survival rate was 77.7%. Conclusions VATS lobectomy is a viable safe procedure that meets oncological criteria for lung cancer surgery. In our experience, VATS is currently to be considered ideally indicated for certain benign processes and for T1-T2 N0 M0 bronchogenic carcinomas. Keywords VATS Lung lobectomy Thoracoscopy Lung cancer Minimally invasive surgery Over the last 10 years, major pulmonary resection by video-assisted thoracic surgery (VATS) has been shown to be both safe and technically feasible, and to offer a number of advantages over conventional surgery [1 4]. Nevertheless, its adoption as a standard technique is proving slow; VATS is not routinely performed in most hospitals, and tends to be used mainly in highly specialized centers. Recently published papers review the results obtained in very large patient series [5], and underline the importance of training surgeons in this complex technique [6]. This unit, part of a teaching hospital in southern Spain, with a catchment population of around 500,000 people, has been performing major pulmonary resections by VATS since 1993, making it one of the pioneer groups in Europe. The unit is directly involved in the advanced thoracoscopic-surgery training program run every year by the minimally invasive surgery unit at Cáceres, Spain. Available data suggest that the proportion of lobectomies performed using VATS in Spain is still very small, even below the European average [6], although widespread interest has been expressed in the adoption of this technique in the country s leading hospitals.

2 The present paper reports on the VATS lobectomy technique in use at this institution (developed over the last 13 years), and on the surgeons experience and outcomes obtained. Materials and methods This descriptive, retrospective review included all patients undergoing major pulmonary resection by VATS at the General and Thoracic Surgery Unit of the Virgen Macarena University Hospital, Seville (Spain) since The clinical records of all patients, drawn from the hospital archive, were entered into the unit database (Microsoft Ò Office Access) for analysis. Selection criteria At this unit, VATS lobectomy has become the gold standard for the treatment of early-stage non-small-cell bronchogenic carcinoma (NSCBC) and of a number of benign processes. Since March 1993, a number of indications have been modified, and more importantly the number of contraindications has been reduced. The current indications for VATS lobectomy are: 1. Tumor size \4 cm. The authors have removed tumors of up to 6 cm, but only in exceptional cases. 2. Peripheral location, i.e., over 1 cm from the fissure and over 3 cm from the lobar carina. 3. Stage I, i.e., cn0, although this is not a completely exclusive criterion; swollen intrapulmonary or mediastinal lymph nodes detected intraoperatively do not necessarily contraindicate resection, although they may hinder it. 4. Open fissures, although for certain lobectomies (e.g., right upper), this is not absolutely essential. Surgical technique The patient was placed in the lateral decubitus position, and selective intubation was used in all cases. Three entryport incisions were made to introduce 12-mm trocars: one in the seventh or eighth intercostal space (depending on the patient s thorax configuration) in the midaxillary line, for the camera; a second just below the scapular vertex in the sixth or seventh intercostal space; and the third in the third or fourth intercostal space in the anterior axillary line. Having confirmed the viability of the technique, an anterior minithoracotomy approximately 4 5 cm long was placed over the fifth intercostal space (Fig. 1), without rib Fig. 1 Thoracic ports and minithoracotomy spreading, for the insertion of surgical instruments and dissection of vessels and bronchi. As reported elsewhere [7], exploratory videothoracoscopy was performed to rule out any unforeseen causes of inoperability (e.g., pleural carcinomatosis with no pleural effusion), to check tumor size and absence of fissure invasion, and to confirm the viability of VATS. The presence of removable pleural adhesions or small hilar lymphnode swellings was not considered a contraindication for VATS resection. The surgeon stood facing the patient, with the principal assistant beside him. Two assistants were placed behind the patient; the more caudally located of the two operated the camera. A 10-mm 0 thoracoscope was used. Although the lower entry port was earlier described as the camera port, the entry port should be changed to achieve a good front view; the upper anterior port provides a better view for artery dissection in upper lobectomies, while the minithoracotomy can also be used for the camera in order to enable insertion of the endostapler through the lower port. Although details of the VATS lobectomy technique used at our institution have been provided previously [7], a brief description of each operation follows. Right upper lobectomy After retracting the lobe backwards using the subscapular port, the hilum was exposed using endoscopic scissors with an electrocautery attachment or an ultrasound scalpel. First, the pulmonary vein was dissected, sutured, and divided to enhance visualization of the pulmonary artery. The thoracoscope was then inserted through the anterosuperior port and dissection was performed to separate the

3 Medial lobectomy This is the simplest lobectomy, and required the fewest switches of entry port for the camera. The procedure differed from that for upper lobectomy in terms of the order in which the structures were transected: middle lobe vein followed by middle lobe bronchus, middle lobe artery, and finally the minor fissure. Right lower lobectomy Fig. 2 View and dissection of the apical artery branch for the upper right lobe with the video-thoracoscope inserted through the anterosuperior port artery branch from the apical segments (Fig. 2); moving along the pulmonary artery, a varying number of other segmental branches to the upper lobe were dissected, ligated, and divided. Vessels were sutured using an endoscopic cutting stapler with a vascular load cartridge, clips or ligatures, depending on vessel size and ease of access. Next, the right upper lobe bronchus was transected using an endoscopic stapler with 4.8-mm staples. Fissures were then divided, if fused, using an endoscopic cutting stapler with 3.5-mm staples, together with bioabsorbable sleeves (Gore Seamguard Ò ) to avoid or minimize air leakage during the postoperative period (Fig. 3). The resected lobe was placed in a plastic retrieval bag and extracted through the minithoracotomy; finally, mediastinal lymphadenectomy was routinely performed as in conventional surgery. The inferior pulmonary ligament was transected as far as the caudal edge of the lower pulmonary vein, and any level 9 lymph nodes were removed. The lower pulmonary vein was then transected with an Endogia 30 universal stapler (Fig. 4). Next, the lower lobe artery was transected at the fissure, although in some cases it was deemed preferable, for technical reasons, to transect separately the artery trunk for the basal segments and the artery branch for the sixth segment. Prior division of the anterior aspect of the fissure proved useful for this purpose. The lower lobe bronchus was then transected, followed by the major fissure, using an Endogia 45 or 60 universal stapler with 3.5-mm staples and bioabsorbable polyglycol-acid sleeves. Lower bilobectomy The first step in lower bilobectomy was transection of the lower pulmonary vein and the middle lobe vein as described above. Arteries were also transected as already described; the only major difference was that the middle lobe bronchus was first transected to obtain clear visualization of the intermediate bronchus, which was transected Fig. 3 Fissure suture using Endogia with 3.5-mm staples with bioabsorbable sleeve (Gore Seamguard) Fig. 4 Lower pulmonary vein transection

4 just below the edge of the upper lobe bronchus using an Endogia 45 universal stapler with 4.8-mm staples. Left upper lobectomy This was perhaps the most complex lobectomy, due to the number of artery branches to that lobe, and to their positioning posterior to the bronchus. Following dissection and transection of the upper pulmonary vein, the thoracoscope was inserted through the anterosuperior port throughout virtually the entire procedure to enable closer control when transecting all the segmental arteries to the upper lobe; however, better visualization of the lingular artery was obtained from the lower port, and occasionally required transection of the posterior aspect of the fissure (using EndogiaÒ Seamguard Ò in all cases). After transection of all artery branches, transection of the upper lobe bronchus presented few if any technical difficulties. Finally, the fissure was divided, the resected lobe placed in a plastic retrieval bag, and any mediastinal lymph nodes removed. Left lower lobectomy This technique was similar to that employed for right lower lobectomy. First, the triangular ligament was dissected free using scissors or a harmonic scalpel, to facilitate transection of the lower pulmonary vein using an endoscopic cutting stapler with a vascular load. A sharp incision was made into the visceral pleura at the fissure, and the artery was then dissected free, taking care to maintain hemostasis. In some cases, as also reported for left upper lobectomy, transection of the posterior aspect of the fissure was required to ensure good access to the artery. The artery to the lower lobe was transected, sparing the lingular artery to the upper lobe. Finally, the lower lobe bronchus was transected, the fissure divided, and any mediastinal lymph nodes removed. Data The following patient variables were recorded: age, sex, clinical diagnosis, clinical status, date of surgery, type of surgery, inoperability, conversion to conventional surgery and reasons, duration of surgery and intraoperative complications. Data were also recorded for postoperative and long-term complications, postoperative stay, diagnosis, definitive status, and mortality. Results A total of 237 major pulmonary resections were performed at this institution from March 1993 to June The ratio of male to female patients was 6:1 (203:34). Mean age was years (range years; median 63 years; mode 61 years). A total of 204 cases were diagnosed as non-small-cell bronchogenic carcinoma (clinical and pathological stages shown in Table 2), 24 as benign processes (e.g., pulmonary sequestration, cystic adenomatoid malformation, bronchiectasis), 4 patients had carcinoid tumors, and 5 patients required lobectomy due to metastases that ruled out wedge resection. The number of patients undergoing each type of lobectomy or pneumonectomy is shown in Table 1; right upper lobectomy was by far the most common type. Conversion was more frequent in the early, learning years. The overall conversion rate was 14.01% (n = 22), due to heavy bleeding in 10 cases, technical difficulties in 11 cases, and invasion of pulmonary artery in 1 case (confirmed after vein transection). Mean duration of lobectomy was 153 min, but the median time was 98 min, since the procedure took much longer at first than later, once the technique was more thoroughly mastered. The mean postoperative stay was 4.2 days. The morbidity rate was 15.18%, mostly involving minor complications which were readily solved; the most frequent was air leakage lasting longer than four days. Postoperative complications are listed in Table 3. Perioperative mortality (i.e., up to 30 days post-surgery) was 1.69% (two cases of sepsis, one acute myocardial infarct, and one congestive heart failure not detected in preoperative tests), but when referred about lobectomy (n =3; 1.39%) or pneumonectomy (n = 1; 4.5%) we noted that Table 1 Major lung resections performed by VATS ( ) Right (n = 146) Left (n = 91) Pneumonectomy: 13 Pneumonectomy: 9 Right upper lobectomy: 68 Left upper lobectomy: 44 Medial lobectomy: 8 Left lower lobectomy: 38 Right lower lobectomy: 39 Upper bilobectomy: 9 Lower bilobectomy: 7 VATS: video-assisted thoracic surgery Table 2 Preoperative and pathological stages of resected lung cancers by video-assisted thoracic surgery Stage Clinical Pathological IA 88 (43.2%) 81 (39.7%) IB 103 (50.5%) 92 (45.1%) IIA 2 (0.98%) 6 (2.9%) IIB 5 (2.45%) 13 (6.4%) IIIA 6 (2.9%) 12 (5.9%)

5 Table 3 Morbidity after video-assisted major lung resections Complication Atelectasis 6 Apical air space 6 Pulmonary thromboembolism 2 Cardiorespiratory failure 3 Wound infection 1 Hemothorax 2 Pneumonia 3 Atrial fibrillation 3 Prolonged air leakage 10 Total 36 pneumonectomy had a higher risk than lobectomy, as usual. The actuarial 5-year survival rate was 77.7%. During follow-up, there were three cases of mediastinal recurrence (despite removal of mediastinal lymph nodes from all patients); one patient developed one brain and one costal metastasis three months after surgery; two patients developed metachronic tumors, 23 and 48 months, respectively, post-surgery; recurrence was detected in the same lung in three patients. There were seven cases of multiple metastases. Discussion Current bibliographical searches show that VATS is increasingly being used for major pulmonary resection worldwide [8 14]. Even so, it is still not used as widely as might be expected. The authors would advocate the keeping of a national, or even international, register in order to determine the actual proportion of VATS lobectomies performed and chart their development over time. This is why the publication of surgeons experience of this type of operation is felt to be of particular value. The scientific literature suggests that VATS lobectomy has certain advantages over conventional thoracotomy [15 20]; critics, however, argue that VATS major lung resection is risky, does not meet oncological criteria for lung cancer surgery and, in short, offers no advantage over conventional thoracotomy. Although no prospective randomized studies have been performed to compare the two techniques, published data suggest that VATS lobectomy is safe, and is associated with less pain, a better immune response, and a shorter hospital stay. Morbidity and mortality are no greater in VATS resections than in conventional surgery [21]; here, postoperative mortality in the 237 VATS major lung resections performed over 13 years was very low, especially for lobectomies (1.39%) and if we exclude pneumonectomies n (interventions performed only at the start of this series; nowadays we do not perform VATS pneumonectomies), while morbidity rates were even lower than for conventional surgery. Although the learning curve has, to an extent, rightly been blamed for increased morbidity and, especially, greater mortality in this type of surgery [6], this should no longer happen, since the technique is becoming increasingly standardized and detailed, and can be taught and practised at specialist training centers until thorough mastery is achieved. Similarly, as a result of training and practice, operating time occasionally criticized as overlong with VATS is reduced to that of conventional surgery. Although the mean duration of a lobectomy in this series was 153 min, most later operations took no longer than 90 min; the process of opening and closing the thoracotomy particularly lengthy for posterolateral thoracotomy is obviated, thus saving time. The most serious of the potential intraoperative accidents is perhaps heavy bleeding due to the rupture of a blood vessel, and this should not entail any more serious consequences than in open surgery. As always, it is imperative to remain calm and, rather than rushing immediately to open surgery, attempt hemostasis by VATS, or at least insert a clamp or other instrument to compress the site of bleeding, proceeding to thoracotomy if necessary. Only ten instances of heavy bleeding occurred in the 237 cases examined here; none of them had serious repercussions, and all were controlled by VATS. As McKenna et al. [5] report, VATS lobectomy is an advanced video-thoracoscopic procedure, and not all surgeons have the technical skill required to dissect pulmonary vessels using a television monitor for visualization. The risk of bleeding would seem to be low for surgeons experienced in endoscopic surgery [22]. Another potential cause of morbidity is air leakage; the water-seal test should always be performed to check that the bronchial suture is watertight, and reinforcement can be used where necessary. In our opinion, adoption of Gore- Tex Ò polyglycol-acid sleeves could minimize this complication, but further studies are necessary to confirm this impression. However, the key datum in assessing the validity of this type of surgery in lung cancer is long-term patient survival. Published reports quote survival rates similar to, and sometimes better than, those achieved with conventional surgery (although these results should be viewed with caution, due to a possible implicit bias at patient selection): Sugi et al. [23] report 5-year survival rates of 90% for VATS lobectomy and 85% for conventional lobectomy. Here, the survival rate was 77.7%, i.e., similar to that reported by Walker et al. [24]. The authors firmly believe that, if VATS surgery is properly performed, with resection of mediastinal lymph nodes [25], and meets oncological

6 criteria for lung cancer surgery, long-term survival should not be affected by the choice of surgical approach. Conclusion Our experience suggests that, given appropriate patient selection and expert surgeons, VATS major pulmonary resection is a viable, safe procedure that meets oncological criteria for lung cancer surgery, since as in conventional surgery mediastinal lymphadenectomy can be performed simultaneously. The authors own results, together with those reported in the literature [26], suggest that morbidity and mortality may both be lower than in conventional surgery, with faster postoperative recovery, and, most importantly, a long-term survival rate similar to that achieved with open surgery. VATS is currently to be considered ideally indicated for certain benign processes and for T1-T2 N0 M0 bronchogenic carcinomas. References 1. Roviaro G, Varoli F, Vergani C, Maciocco M (2002) State of the art in the thoracoscopic surgery: a personal experience of 2000 videothoracoscopic procedures and an overview of the literature. Surg Endosc 16: Gharagozloo F, Tempesta B, Margolis M, Alexander EP (2003) Video-assisted thoracic surgery lobectomy for stage I lung cancer. Ann Thorac Surg 76: Solaini L, Prusciano F, Bagioni P, Di Francesco F, Basilio Poddie D (2001) Video-assisted thoracic surgery major pulmonary resections. Present experience. Eur J Cardiothorac Surg 20: Shiraishi T, Shirakusa T, Miyosi T, Hiratsuka M, Yamamoto S, Iwasaki A (2006) A completely thoracoscopic lobectomy/segmentectomy for primary lung cancer- technique, feasibility, and advantages. Thorac Cardiovasc Surg 54: McKenna RJ Jr, Houck W, Fuller C B (2006) Video-Assisted thoracic surgery lobectomy: Experience with 1100 cases. Ann Thorac Surg 81: Ferguson J, Walker W (2006) Developing a VATS lobectomy programme can VATS lobectomy be taught? Eur J Cardiothorac Surg 29: Congregado M, Jimenez R, Loscertales J (2006) Resezioni polmonary Maggiore In: Lavini C, Ruggiero C, Morandi U (eds) Chirurgia toracica videoassistita. Springer-Verlag, Milano (Italia) pp Weissberg D, Schachner A (2000) Video-assisted thoracic surgery-state of the art. Ann Ital Chir 71: Hermansson U, Konstantinov IE, Aren C (1998) Video-assisted thoracic surgery (VATS) lobectomy: the initial Swedish experience. Semin Thorac Cardiovasc Surg 10: Rothenberg SS (2003) Experience with thoracoscopic lobectomy in infants and children. J Pediatric Surg 38: Koren JP, Bocage JP, Geis WP, Caccavale RJ (2003) Major thoracic surgery in octogenarians: the video-assisted thoracic surgery (VATS) approach. Surg Endosc 17: Cano I, Anton-Pacheco JL, Garcia A, Rothenberg S (2006) Video-assisted thoracoscopic lobectomy in infants. Eur J Cardiovasc Surg 29: Walker WS (1998) Video-assisted thoracic surgery (VATS) lobectomy: Edinburgh experience. Semin Thorac Cardiovasc Surg 10: Kaseda S, Aoki T, Hangai N, Shimizu K (2000) Better pulmonary function and prognosis with video-asissted thoracic surgery than with thoracotomy. Ann Thorac Surg 70: Nomori H, Ohtsuka T, Horio H, Naruke T, Suemasu K (2003) Difference in the impairment of vital capacity and 6-minute walking after a lobectomy performed by thoracoscopic surgery, an anterior limited thoracotomy, an anteroaxillary thoracotomy, and a posterolateral thoracotomy. Surg Today 33: Nagahiro I, Andou A, Aoe M, Sano Y, Date H, Shimizu N (2001) Pulmonary function, postoperative pain, and serum cytokine level after lobectomy: a comparison of VATS and conventional procedure. Ann Thorac Surg 72: Stammberger U, Steinacher C, Hillinger S, Schmid RA, Kinsbergen T, Weder W (2000) Early and long-term complaints following video-assisted thoracoscopic surgery: evaluation in 173 patients. Eur J Cardiothorac Surg 18: Yim AP, Wan S, Lee TW, Arifi AA (2000) VATS lobectomy reduces cytokine responses compared with conventional surgery. Ann Thorac Surg 70: Craig SR, Leaver HA, Yap PL, Pugh GC, Walker WS (2001) Acute phase responses following minimal access and conventional thoracic surgery. Eur J Cardiothorac Surg 20: Tschernko EM, Hofer S, Bieglmayer C, Wisser W, Haider W (1996) Early postoperative stress: video-assisted wedge resection/ lobectomy vs conventional axillarythoracotomy. Chest 109: Sollitto F, De Palma A, Lopez C, Loizzi M (2003) Minimally invasive thoracic surgery versus standard surgery. Ann Ital Chir 74: Roviaro G, Varoli F, Vergani C, Nucca O, Maciocco M, Grignani F (2004) Long-term survival after videothoracoscopic lobectomy for stage I lung cancer. Chest 126: Sugi K, Kaneda Y, Esato K (2000) Video-assisted thoracoscopic lobectomy achieves a satisfactory long-term prognosis in patients with clinical stage IA lung cancer. World J Surg 24: Walker WS, Cadispoti M, Soon SY, Stamenkovic S, Carnochan F, Pugh G (2003) Long-term outcomes following VATS lobectomy for non-small cell bronchogenic carcinoma. Eur J Cardiothorac Surg 23: Sagawa M, Sato M, Sakurada A, Matsumura Y, Endo C, Handa M, Kondo T (2002) A prospective trial of systematic nodal dissection for lung cancer by video-assisted thoracic surgery: can it be perfect? Ann Thorac Surg 73: Iwasaki A. Shirakusa T, Shiraishi T, Yamamoto S (2004) Results of video-assisted thoracic surgery for stage I/II non-small cell lung cancer. Eur J Cardiothorac Surg 26: