Bronchiectasis, one of the primary diseases of bronchi

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1 Video-Assisted Thoracic Surgery for Bronchiectasis Peng Zhang, MD, PhD, Fujun Zhang, MD, Siming Jiang, MD, Gening Jiang, MD, Xiao Zhou, MD, Jiaan Ding, MD, and Wen Gao, MD Department of Thoracic Surgery, Shanghai Pulmonary Hospital of Tongji University School of Medicine, Shanghai; and Department of Thoracic Surgery, Rizhao Hospital of Chinese Medicine, Shandong, China Background. Bronchiectasis is one of the common diseases diagnosed in the world. No major improvement for the treatment approaches and limited efficacy promote a big challenge for management of this disease. Videoassisted thoracoscopic surgery () offers a new choice for the treatment of bronchiectasis. The purpose of this study was to present our experience of for bronchiectasis and to compare this with thoracotomy in our institution. Methods. We reviewed the medical records of patients who underwent lobectomy and general lobectomy for bronchiectasis between January 2005 and December Results. A total of 279 patients underwent thoracotomy, 52 patients underwent attempted lobectomy. Fifty-two patients from 279 patients for thoracotomy were selected and compared with the group. Pleural adhesion was observed in 15 patients (28.8%) in. The lobectomy was converted to open thoracotomy in 7 patients. There was no difference in the blood loss and median operative time between the two groups, but the patients with had shorter length of stay in hospital (p 0.045), fewer complications (p 0.039) than those with thoracotomy. Forty-nine (94%) and 46 (88%) patients fully recovered after operation by and thoracotomy, respectively. Conclusions. Video-assisted thoracoscopic lobectomy in localized bronchiectasis is a safe and more efficient procedure in selected patients with better recovery. (Ann Thorac Surg 2011;91:239 43) 2011 by The Society of Thoracic Surgeons Bronchiectasis, one of the primary diseases of bronchi and bronchioles involved in a vicious circle of transmutable infection and inflammation with mediator release [1], is diagnosed with increasing frequency in North America and around the world [2]. Surgery is the only option for potential cure for bronchiectasis. Although improvement of the outcome for nonsurgical treatment has been shown due to the development of more effective antibiotics and conservative therapeutics, less invasive surgery still provides substantial benefits in some selected patients with bronchiectasis [3, 4]. Thanks to the development of surgical techniques, video-assisted thoracoscopic surgery () for major lung resection has become a more frequent procedure in recent years with promising outcome [5]. Video-assisted thoracoscopic surgery may become a potentially new surgical choice for the treatment of bronchiectasis. Here we analyzed total thoracoscopic lobectomy for patients with localized bronchiectasis and compared it with patients who underwent thoracotomy lobectomy in our hospital. For the sake of description, we define lobectomy as a videoassisted, minimal access technique in which the entire procedure is performed by a surgeon, with the help of observing a television monitor, and rib spreading is not needed [6]. Accepted for publication Aug 17, Address correspondence to Dr Gening Jiang, Department of Thoracic Surgery, Shanghai Pulmonary Hospital of Tongji University School of Medicine, Shanghai, , China; jgnwp@yahoo.com.cn. Patients and Methods This study was approved by the Medical College Review Board of Tongji University, Shanghai, China. Informed consent was not required for this retrospective study. We reviewed the medical records of consecutive patients who underwent lobectomy for bronchiectasis between January 2005 and December 2008 at the Department of Thoracic Surgery of Shanghai Pulmonary Hospital, affiliated with Tongji University, China. Patients were chosen as candidates for surgical treatment or thoracotomy according to the following criteria: localized bronchiectasis documented by high-resolution computed tomography; adequate cardiopulmonary reserve; and obvious symptom failure of medical treatment. Medical therapy constituted the judicious use of systemic antibiotics based on current sputum or bronchoscopic lavage cultures, mucolytic agents, nonirritant expectorants, postural drainage, humidification, antiinflammatory agents, and bronchodilators. Failure of medical treatment was defined as frequent exacerbation interfering with normal professional or social life or requiring multiple hospitalizations. The selection of was based mainly on the judgment of surgeons. The following patients were considered to be the candidates for procedure: young patients with aesthetic demands; there was no severe parenchymal and (or) pleural scarring and no calcified lymph nodes near pulmonary arteries and veins shown on computed tomographic scan; the symptom of puru by The Society of Thoracic Surgeons /$36.00 Published by Elsevier Inc doi: /j.athoracsur

2 240 ZHANG ET AL Ann Thorac Surg FOR BRONCHIECTASIS 2011;91: lent sputum usually lasted less than 5 years; and patients with evidence for severe parenchymal and (or) pleural scarring on computed tomographic scan often underwent thoracotomy. Briefly, patients were placed in the lateral decubitus position and one-lung ventilation was established through a double-lumen endotracheal tube. For, two entry-port 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, and the second just below the scapular vertex in the sixth or seventh intercostal space. Having confirmed the viability of the technique, an anterior (approximately 4 to 5 cm long) incision was placed over the third or fourth intercostal space without rib spreading. The first operative step was to undertake a inspection of the pleural cavity in order to exclude unexpected causes of irresistibility by. Having confirmed operability, the pulmonary artery was identified at the base of the major fissure and the sheath of the artery entered. In general, the hilar structures were divided according to the most convenient manner determined at surgery, usually with division of the arteries prior to the vein in order to avoid congestion of the lobe. Thoracotomy lobectomy was performed through a posterolateral thoracotomy incision that spared the stratus anterior muscle. The chest was entered through the fifth intercostals space and a Finochietto retractor (G U Manufacturing Co. Ltd, London, UK) was used to gain exposure. All specimens had pathologic confirmation of bronchiectasis. All patients received epidural administration of 0.125% bupivacaine during the operations. Continuous epidural infusion of 0.125% bupivacaine (4 ml/hour) was used postoperatively until chest drainage tubes were removed. Diclofenac suppositories were predominantly used for postoperative pain control in addition to the epidural anesthesia, and intramuscular administration of pentazocine was used if uncontrollable pain was observed.pain was quantitated by an 11-point pain scale (0 no pain, 10 maximal imaginable pain) on postoperative days 0, 1, 2, 3, 7, and 14 [15]. The outcome of surgery was evaluated according to the following criteria: excellent (complete absence of preoperative symptoms that led to surgery); good (marked reduction in preoperative symptoms but needing antibiotic therapy occasionally); no change (no reduction in preoperative symptoms, and no decrease in hospital admissions or medical therapy requirements); and worse (frequent exacerbations of disease requiring hospitalization). Statistical Analysis Patient data were reported as either median and range for quantitative variables or absolute and relative frequencies for qualitative variables. Patient characteristics and preoperative data were compared using the Student t, Pearson 2, and Fisher exact tests. A p value less than 0.05 was considered significant. We chose to match and thoracotomy patients in a one-to-one fashion by using all available clinical data. This was performed by constructing propensity scores [16] using all preoperative variables that might have an effect on the result of the surgical treatment of bronchiectasis (shown by Table 1). Pairwise matches were based on the nearest propensity scores. Results Between January 2005 and December 2009, 331 patients with bronchiectasis were diagnosed in our department. Among them, 279 patients underwent thoracotomy and 52 patients underwent attempted lobotomy. Fiftytwo patients from the 279 patients for thoracotomy were selected and were compared with the group. Patient characteristics are shown in Table 1. In the group, the presenting symptoms included productive cough in 32 patients (62%), hemoptysis in 25 patients (48%), fetid sputum in 2 patients (4%), and no symptoms in 2 patients (4%). No patients were found for emergency (eg, massive hemorrhage) in either group. In the group there were 12 patients who had a positive microorganism that was obtained from preoperative sputum cultures, compared with 16 patients who had a positive sputum culture in the thoracotomy group. Pleural adhesion was observed in 15 patients (28.8%) in the group. Note that 7 patients were failed for a lobectomy and were finally switched to open thoracotomy due to bleeding (n 3), fused fissure (n 3), and hilar lymphadenopathy (n 1). Intraoperative and (or) postoperative transfusions were not needed. There was no difference in the blood loss and median operative time between the two groups; however, the patients in the group had a shorter length of stay in the hospital (p 0.045) (as shown in Table 2) and less complications (p 0.039) as compared with those in the thoracotomy group (as shown in Table 3). The group patients also had significantly less pain than those in thoracotomy group after procedure (Fig 1). There were no intraoperative or postoperative deaths. In, postoperative complications were found in Table 1. Characteristics for and Thoracotomy Patients in Propensity-Matched Group Characteristics Thoracotomy p Value Age, years (mean) Male/sex Duration of symptoms (m) FEV 1 (%) predicted Comorbidities Chronic obstructive pulmonary disease Hypertension Chronic renal insufficiency TB history Sputum culture/positive FEV 1 forced expiratory volume in the first second of expiration; tuberculosis; video-assisted thoracoscopic surgery. TB

3 Ann Thorac Surg ZHANG ET AL 2011;91: FOR BRONCHIECTASIS 241 Table 2. Perioperative Data for and Thoracotomy Patients for Bronchiectasis in Shanghai Pulmonary Hospital of Tongji University Variables Thoracotomy p Value Surgical procedure Lobectomy Bilobectomy 1 5 Lobectomy segmentectomy 4 7 segmentectomy 2 0 Blood loss (ml) Median operation time (hours) Length of stay in hospital (days) Perioperative death 0 0 Cost (10 5 RMB) RMB Renminbi; video-assisted thoracoscopic surgery. eight patients (Table 3). Postoperative lung torsion was observed in a 43-year-old male patient who had undergone a left upper lobectomy and wedge resection of the inferior lobe for bronchiectasis with. A completion pneumonectomy was needed for this patient. Empyema was observed in one patient (2%). The other six patients experienced minor complications, which were cured by conservative therapy. Seven patients converted to thoracotomy recovered well except one patient who experienced postoperative atelectasis. In thoracotomy, more patients (total 14) experienced postoperative complications as compared with those in the group. Follow-up was completed in all patients (100%) with a mean of 42.6 months (range, 12 to 64 months). In the group, 49 (94%) patients were excellent after operation, good in 2 (4%), and no change or worse in 1 (2%). In the thoracotomy group, 46 (88%) patients were excellent after operation, good in 4 (8%), and no change or worse in 2 (4%) (Table 4). The surgical outcome of appeared to be better than thoracotomy, but there was no statistical difference between the two groups. Table 3. Postoperative Complications of Versus Thoracotomy for Bronchiectasis in Shanghai Pulmonary Hospital of Tongji University Complications Thoracotomy p Value Atelectasis 2 4 Persistent air leak more than weeks Pneumonia 1 3 Cardiac arrhythmia 2 4 Empyema 1 2 Lung torsion 1 0 Total video-assisted thoracoscopic surgery. Fig 1. Postoperative pain measured by 11-point pain scale of the two groups. Data are shown as mean standard deviation of the mean. ( thoracotomy; ; PODs postoperative days; video-assisted thoracic surgery.) Comment Brochiectasis refers to the permanent abnormal dilatation of the center and medium sized bronchi because of a vicious cycle of transmutable infection and inflammation with mediator release. The prevalence of bronchiectasis is still unknown [7]. In our hospital, most of operated patients for bronchiectasis who preferred the lung resection were young and middle aged. Bronchiectasis was considered the best lung benign disease suitable for lobectomy [6]. The pulmonary resection has become an established alternative approach to conventional open surgery for selected patients. The major resection has demonstrated to be a safe procedure when performed by experienced physicians. Postoperative pain after is uncommon as compared with open surgery. Other documented advantages include better preservation of pulmonary function in the early postoperative period, earlier return to full activities, and better quality of life after recovery. Older and severe sick patients were recommended for surgery [6]. One report [8] showed that there were three major differences between anatomic lung resections of benign versus malignant diseases by. First, adequacy of tumor clearance was not relevant in the benign diseases though it is very important for malignant diseases such Table 4. Results of and Thoracotomy Results Thoractomy p Value Excellent Good 2 4 No change or worse 1 2 video-assisted thoracoscopic surgery.

4 242 ZHANG ET AL Ann Thorac Surg FOR BRONCHIECTASIS 2011;91: as systematic mediastinal lymphadenectomy. Second, inflammatory changes might render dissection more difficult in certain diseases such as tuberculosis, especially when accompanied by inflammation of the pleura. Third, while the port site where malignant tumor recurrence and tumor seeding were found by, wound infection was also a concern in resections for an infectious cause. Another study [9] demonstrated that all benign pulmonary disease could be explored thoracoscopically; however, the feasibility of resection depended on the local anatomic situation, especially adhesions. The severity of adhesions to the chest wall, the hilum, and especially in the fissure, typically seen in inflammatory disease, was the key limiting factor for a safe lobectomy [5]. Adhesions need to be dissected to explore the relevant anatomy. If there were dense adhesions (such as destroyed lobes mainly after tuberculosis with or without aspergillosis) or enlarged lymph nodes, especially calcified, open operations were required. Video-assisted thoracoscopic surgery represents a new approach; the indications for major resection remain the same as for conventional resection. But not all the patients with bronchiectasis who needed operations were suitable for lobectomy; severe scarring and adhesions on computed tomographic scan should be considered [5]. One major advantage of resection is that it allows recruitment of older and sicker patients with multiple comorbidities who would otherwise not be candidates for resection through a conventional thoracotomy approach [10, 11]. In China there were patients with benign disease who would rather choose conservative therapy when those patients were severely ill or older. Compared with the right bronchus, the left one has the narrower diameter, longer mediastinal course, and limited peribronchial space when passing through the subaortic tunnel. These features might make the left bronchus more vulnerable to obstruction than the right. The lower lobes are more likely to be affected and the left lung seems to be more vulnerable to bronchiectasis than the right lung [12]. Fortunately, left and lower lobectomies seemed easier in the technology. We also have the same experience in the group. One study reported that prolonged air leaks were the major morbidity after both as well as open lobectomy for inflammatory disease [5]. However, in our case only one patient in the group had experienced prolonged air leak. We preferred to suture the lung wounds by 5-0 prolene thread by. This procedure could effectively prevent air leak. The resection of infected or purulent lesions through minimal access may predispose to contamination of the pleural cavity and wound, leading to empyema and wound infection. In our patients, one patient who suffered from postoperative empyema was cured by chest tube insertion and pleural lavage. There was no wound contamination in our patients. In our experience of, before closing around 3000 ml neomycin sulfate solution was used to clean the cavity and the incision, and the lung resected was stored in a specimen bag and then taken out from the cavity to prevent the incision from being infected. Note that this is a routine procedure of surgery for bronchiectasis in our department. In our study, the patients with had a shorter length of stay in the hospital, fewer complications, and less pain in the postoperative period than those with thoracotomies. It is reasonable to recommend for some selected patients with bronchiectasis. Some authors pointed out that by choosing the right patients for this technique, as well as relying on ligation and suturing, the consumable costs could be minimized [13]. A study from Japan [14] comparing versus open resections for cancer showed that the overall hospital charges were lower for the approach. However, in this study, the whole cost of was significantly higher than those in the open one. We think that the high cost of the consumables is a serious concern and represents a major deterrent to adopt in China, especially for patients from the rural areas. We hope that medical insurance would cover this area and more patients would benefit from it in China. In short, video-assisted thoracoscopic lobectomy in bronchiectasis can be performed safely in selected patients with a better satisfactory outcome. References 1. Zhang P, Jiang G, Ding J, Zhou X, Gao W. Surgical treatment of bronchiectasis: a retrospective analysis of 790 patients. Ann Thorac Surg 2010;90: O Donnell AE. Bronchiectasis. Chest 2008;134: Fujimoto T, Hillejan L, Stamatis G. Current strategy for surgical management of bronchiectasis. Ann Thorac Surg 2001;72: Schneiter D, Meyer N, Lardinois D, Korom S, Kestenholz P, Weder W. Surgery for non-localized bronchiectasis. Br J Surg 2005;92: Weber A, Stammberger U, Inci I, Schmid RA, Dutly A, Weder W. Thoracoscopic lobectomy for benign disease a single centre study on 64 cases. Eur J Cardiothorac Surg 2001;20: Yim AP. major pulmonary resection revisited controversies, techniques, and results. Ann Thorac Surg 2002;74: ten Hacken NH, Wijkstra PJ, Kerstjens HA. Treatment of bronchiectasis in adults. BMJ 2007;335: Yim AP, Ko KM, Ma CC, Chau WS, Kyaw K. Thoracoscopic lobectomy for benign diseases. Chest 1996;109: Roviaro G, Varoli F, Rebuffat C, et al. Major pulmonary resections: pneumonectomies and lobectomies. Ann Thorac Surg 1993;56: Farjah F, Wood DE, Mulligan MS, et al. Safety and efficacy of video-assisted versus conventional lung resection for lung cancer. J Thorac Cardiovasc Surg 2009;137: Gonzalez-Aragoneses F, Moreno-Mata N, Simon-Adiego C, Peñalver-Pascual R, Gonzalez-Casaurran G, Perea LA. Lung cancer surgery in the elderly. Crit Rev Oncol Hematol 2009;71: Ashour M, Al-Kattan K, Rafay MA, Saja KF, Hajjar W, Al-Fraye AR. Current surgical therapy for bronchiectasis. World J Surg 1999;23: Yim AP, Ho JK. Malfunctioning of vascular staple cutter during thoracoscopic lobectomy. J Thorac Cardiovasc Surg 1995;109: Nakajima J, Takamoto S, Kohno T, Ohtsuka T. Costs of video thoracoscopic surgery versus open resection for

5 Ann Thorac Surg ZHANG ET AL 2011;91: FOR BRONCHIECTASIS 243 patients with lung carcinoma. Cancer 2000;89 (11 Suppl): Nagahiro I, Andou A, Aoe M, Sano Y, Date H, Shimizu N. Pulmonary function, postoperative pain, and serum cytokine level after lobectomy: a comparison of and conventional procedure. Ann Thorac Surg 2001;72: Maxwell AE. Comparing the classification of subjects by two independent judges. Br J Psychiatry 1970;116: INVITED COMMENTARY Zhang and colleagues [1] retrospectively analyzed a single institutional experience on lobectomy for bronchiectasis. The authors compared 52 patients who underwent the video-assisted thoracoscopic surgical () approach with a matched cohort of 52 patients (selected from 279 patients) who underwent the conventional open approach during the same 5-year period. They concluded that the approach gave superior results in shorter hospital stay and less perioperative complications. The authors are to be congratulated for sharing with us their large experience on an important topic that is underreported. Although they tried to avoid using the approach on patients whose thoracic computed tomography showed marked pleural reaction, computed tomography alone is not a reliable guide to technical difficulty. Surgeons who would like to pursue the approach for these patients must be prepared to face the technical challenges. In my own experience, I have found it useful to excise a small segment of rib subperiosteally underneath the utility thoracotomy wound to enhance instrument maneuvering [2]. This increases the safety margin in the event of unexpected technical mishaps. With the segmental rib resection, thin patients may experience a small cough impulse postoperatively, but this will improve with time. Surgical experience is gained through small increments. Resident surgeons in training are advised to use a slightly bigger incision at the beginning while keeping the scope for visualization until more experience is gained. Surgical resection for localized bronchiectasis is now an established option in the overall treatment strategy for this condition. If the patients come to us early, often wedge resection would be sufficient, and hilar dissection (with the associated risks) may be avoided. Surgical resection is important not only for symptomatic relief but also for accurate microbiologic and histologic diagnosis to exclude a coexisting pathology such as lung cancer or tuberculosis. In experienced hands, is a safe alternative to open procedures in the management of bronchiectasis. As surgeons, it is our duty to update our pulmonology and family physician colleagues so that we may be able to see these patients at an earlier stage when wedge pulmonary resection would be both adequate and optimal. Anthony P. C. Yim, MD Minimally Invasive Thoracic Surgery Centre Ste 607 Central Building, 1-3 Pedder St, Central Hong Kong, China yimap@cuhk.edu.hk References 1. Zhang P, Zhang F, Jiang S, et al. Video-assisted thoracic surgery for bronchiectasis. Ann Thorac Surg 2011;91: Shigemura N, Hsin M, Yim APC. Segmental rib resection for difficult cases. J Thorac Cardiovasc Surg 2006;132: by The Society of Thoracic Surgeons /$36.00 Published by Elsevier Inc doi: /j.athoracsur