Thoracoscopic lobectomy and segmentectomy have become

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1 Thoracoscopic Lobectomy and Segmentectomy for Infectious Lung Disease John D. Mitchell, MD, Jessica A. Yu, MD, Amy Bishop, BA, Michael J. Weyant, MD, and Marvin Pomerantz, MD Section of General Thoracic Surgery and Center for the Surgical Treatment of Lung Infections, Division of Cardiothoracic Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado Background. The potential benefits of thoracoscopic lobectomy and segmentectomy for early stage non small cell lung cancer have been well documented in the literature. However, little is known about the use of these techniques in patients requiring resection for infectious or inflammatory lung disease. Methods. Using a prospectively collected database, we performed a retrospective review of consecutive operations from July 2004 to June All patients who underwent elective thoracoscopic lobectomy or segmentectomy for focal bronchiectasis or cavitary lung disease associated with active pulmonary infection were included. Results. In all, 212 resections were performed in 171 patients. The average age was 59 years (range, 26 to 82 years). Patients were predominately white (93%) and female (93%). Indications for surgery included recurrent active infection, hemoptysis, or antibiotic intolerance associated with focal bronchiectasis (86%), cavitary disease (7%), or both (7%). Operations included 126 lobectomies, 73 segmentectomies, 10 lobe plus segmental resections, and 3 bilobectomies. Conversion to thoracotomy occurred in 10 patients. The operative mortality rate was zero. Complications occurred in 9%, consisting largely of prolonged air leak and atrial fibrillation. The mean hospital length of stay was 3.7 days. Conclusions. Thoracoscopic lobectomy and segmentectomy for individuals with infectious lung disease can be accomplished safely with minimal morbidity and mortality. These techniques may provide the optimal surgical approach for patients with focal bronchiectasis or cavitary lung disease requiring resection. (Ann Thorac Surg 2012;93: ) 2012 by The Society of Thoracic Surgeons Thoracoscopic lobectomy and segmentectomy have become established surgical techniques for the treatment of early stage lung cancer [1]. Numerous reports have documented the safety and efficacy of a thoracoscopic approach, with equivalent oncologic outcomes compared with open thoracotomy [2 4]. Less morbidity [5, 6], better functional status, and the improved ability to deliver subsequent medical therapy [7, 8] have all been reported with minimally invasive procedures. In addition, shorter hospital stays [5, 9] and possible cost savings [10] have also been associated with thoracoscopic techniques. Despite these advantages, much less is known about the use of these techniques in the setting of benign lung disease, and specifically infectious lung disease. In theory, patients with focal bronchiectasis or cavitary infectious lung disease that meet indications for surgical resection would be excellent candidates for a minimally invasive approach. In this report, we describe our experience with thoracoscopic lobectomy and segmentectomy Accepted for publication Jan 6, Presented at the Forty-seventh Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 31 Feb 2, Address correspondence to Dr Mitchell, Division of Cardiothoracic Surgery, C-310, University of Colorado Anschutz Medical Campus, Academic Office 1, Room 6607, E 17th Ave, Aurora, CO 80045; john. mitchell@ucdenver.edu. for patients with chronic focal bronchiectasis and cavitary lung disease. Patients and Methods We reviewed the hospital records of 171 consecutive patients who underwent thoracoscopic lobectomy or segmentectomy for localized bronchiectasis with or without cavitary lung disease at our institution between July 2004 and June Forty-one patients with bilateral disease had a planned second thoracoscopic resection. All patients had a history of active or recurrent pulmonary infection. The study was approved with the need for patient consent waived by the University of Colorado Hospital s Institutional Review Board. Preoperative Evaluation Patients initially underwent an extensive assessment at National Jewish Health in Denver, Colorado, including sputum analysis and radiologic and physiologic testing. High-resolution computed tomography of the chest was performed to assess the extent of the parenchymal lung disease. Adequate pulmonary reserve was assured through the use of pulmonary function testing, with occasional use of perfusion scanning and exercise testing when appropriate. Bronchoscopy was performed when appropriate, primarily for diagnostic purposes and to rule out concomitant endobronchial disease. In the setting of active hemopty by The Society of Thoracic Surgeons /$36.00 Published by Elsevier Inc doi: /j.athoracsur

2 1034 MITCHELL ET AL Ann Thorac Surg THORACOSCOPIC LOBECTOMY FOR BRONCHIECTASIS 2012;93: sis, bronchoscopy was used to localize the source within the bronchial tree to the segmental or even subsegmental level. Collection of sputum and bronchoalveolar lavage specimens allowed identification of the likely microbial pathogens. Confirmation of the presence of nontuberculous mycobacterial disease was made in accordance with the guidelines published by the American Thoracic Society [11]. Evaluation of culture results included in vitro susceptibility testing appropriate for the cultured organism. Patients were then typically initiated on three- or four-drug oral antimicrobial therapy, often combined with intravenous antibiotics as indicated. Revisions to the planned therapy were occasionally made as a result of intolerance of the initial regimen. The duration of the preoperative antibiotic therapy varied, but typically lasted 1 to 2 weeks for bacterial infections, to 8 to 12 weeks for nontuberculous mycobacterial infections. The goal with the preoperative therapy is to achieve a nadir in the bacterial counts before surgical resection, which we believe limits complications in the perioperative period. A complete nutritional assessment was made at the time of initial presentation, and dietary supplementation was initiated when indicated. Feeding tubes were generally believed to be unnecessary in these patients with limited, focal parenchymal disease. In addition, all patients were evaluated for the presence of significant gastroesophageal reflux. If present and believed to be a contributing factor to the patient s chronic pulmonary disease, recommendations were made for possible antireflux surgery with or soon after pulmonary resection. Surgery for bronchiectasis and cavitary lung disease is used only as part of a multimodality treatment approach, and patients appropriate for surgical therapy were discussed at a weekly multidisciplinary conference attended by surgeons, pulmonologists, and infectious disease clinicians with specialization in respiratory infectious disease. All patients in this study had focal, persistent lung damage (bronchiectasis, cavitation, consolidation) amenable to complete anatomic resection after initiation of appropriate antimicrobial therapy. Indications for surgery included the presence of focal parenchymal disease associated with recurrent pulmonary infections or hemoptysis, usually in the setting of failure or intolerance of medical therapy. After the planned duration of preoperative antibiotic therapy, patients returned for repeat clinical and radiologic evaluation before surgery. Computed tomography scanning again confirmed the presence of focal disease amenable to surgical resection. Assessment of pulmonary function was made to ensure adequate postoperative pulmonary reserve in view of the planned resection. Nutritional status was again evaluated, and consultation with nutritional specialists was obtained as indicated. Careful attention was paid to other known or potential comorbidities in this patient population and addressed as needed. Surgical Technique Epidural catheters were available to all patients undergoing a thoracoscopic procedure, but were typically not used. Surgical resection was performed with the patient under general anesthesia using a double-lumen endotracheal tube, or rarely a standard endotracheal tube with a bronchial blocker. All operations used two 1-cm trocar sites and a single 4-cm to 5-cm utility incision. The trocar sites were located in the seventh or eighth intercostal space in the anterior axillary line and a single intercostal space caudad to the scapular tip. Once the feasibility of a thoracoscopic approach was confirmed, the utility incision was made in the anterior axillary line over the anterior hilum or major fissure, depending on the planned resection. The latissimus dorsi muscle was routinely spared, and the serratus anterior opened parallel to its fibers. No rib spreading was used. The soft tissues at the utility incision were retracted and protected from contamination with the use of a small Alexis wound retractor (Applied Medical Co, Rancho Santa Margarita, CA). Adhesions were often encountered throughout the hemithorax, particularly involving the diseased lung segment(s). These adhesions were divided with cautery or blunt dissection, taking care to identify and preserve vital structures. The planned anatomic resection was then carried out using standard techniques. Much of the dissection within the pulmonary hilum was completed using blunt dissection along natural tissue planes or the cautery, given the hypertrophied bronchial circulation in these patients with chronic lung infection. Individual bronchial arteries of significant size were controlled with clips. The pulmonary vessels were ligated with an Endo- GIA vascular stapling device (Auto Suture Company, United States Surgical Corp, Norwalk, CT). The bronchi were closed with an Endo-GIA stapler, minimizing endobronchial spillage within the thoracic cavity. The bronchial stumps were not routinely buttressed with autologous tissue. The fissures and lines of parenchymal division for segmentectomy were completed using the Endo-GIA stapler, erring a bit to the side of uninvolved lung. We believe this latter point is an important technical feature that ensures complete excision of the infected, diseased lung tissue. Lobectomy specimens were placed in an EndoCatch (Auto Suture Company, United States Surgical Corp) for removal, although smaller segments could be occasionally removed directly through the protected utility incision. The removed specimens were double cultured, with samples sent to two separate microbiology laboratories to minimize sampling error. Multilevel intercostal blocks using 0.25% bupivacaine were placed from within the thoracic cavity using a mediastinoscopy aspiration needle and syringe. After irrigation of the thoracic cavity and placement of a single chest drain through the lowest trocar site, routine techniques were used to close the remaining trocar site and utility incision. Postoperative Care Intravenous cefazolin (vancomycin in the setting of significant penicillin or cephalosporin allergy) was given at the time of the procedure and continued for 24 hours. The antibiotic regimen prescribed for the pulmonary infection was continued throughout the postoperative course. After evaluation in the postanesthesia care unit,

3 Ann Thorac Surg MITCHELL ET AL 2012;93: THORACOSCOPIC LOBECTOMY FOR BRONCHIECTASIS Table 1. Presenting Symptoms in 171 Patients With Bronchiectasis or Cavitary Lung Disease Symptom n % Cough 52 (30.4%) Hemoptysis 39 (22.8%) Dyspnea 21 (12.3%) Recurrent pneumonias 21 (12.3%) Antibiotic intolerance 8 (4.7%) Fatigue 7 (4.1%) Chest pain 7 (4.1%) Excess sputum production 6 (3.5%) Fever 3 (1.8%) Wheeze 3 (1.8%) Weight loss 2 (1.2%) None 28 (16.4%) patients were admitted directly to the standard thoracic ward for convalescence. Routine postoperative care was used, with emphasis on pulmonary toilet, pain control, and early patient mobilization. Ongoing nutritional supplementation to standard oral intake was given when indicated. After discharge, patients received follow-up both by our service and at National Jewish Health. Interpretation of intraoperative tissue culture results allowed for further tailoring of antimicrobial therapy, including some assessment regarding duration of treatment. Patients who presented with bilateral disease underwent staged procedures, with the second procedure usually planned for 3 to 8 weeks later. Results During a 6-year period from July 2004 to June 2010, 171 patients underwent 212 consecutive thoracoscopic lobectomies or segmentectomies for infectious lung disease at our institution. Forty-one patients had two (bilateral, staged) procedures. The mean age was 59 years (range, 26 to 82 years). The patient cohort was predominately female (93%) and white (93%). A history of previous thoracic surgery was noted in 17 patients (10%). These patients had been treated for an average of 61 months (range, 4 to 354 months) before referral for surgical intervention, and typically had been managed with rotating antibiotic regimens in addition to dependent drainage and percussive therapy techniques. During the same 6-year period, 42 patients had a planned open lobectomy, segmentectomy, bilobectomy, or lobe plus segmental resection through a lateral thoracotomy incision. The presenting symptoms are detailed in Table 1. Most of the symptoms were indicative of chronic pulmonary infection, including cough, dyspnea, excess sputum production, and recurrent pneumonias. Almost a quarter of the patient cohort described a history of recurrent hemoptysis. Seven patients (4.1%) reported intolerance, or severe side effects, attributed to the chronic antibiotic suppression used in their care. Finally, 28 patients (16.4%) reported no symptoms associated with their chronic pulmonary disease. The preoperative culture data is listed in Table 2. Mycobacterium avium complex disease was seen in 147 patients (86%), followed by Mycobacterium abscessus or Mycobacterium chelonae (36 patients, 21%), Pseudomonas aeruginosa (18 patients, 11%), and fungi such as Aspergillus and Scedosporium species (16 patients, 9%). Fifty-six patients (33%) had a mixed infection in which two or more pathogenic organisms were thought to be present. Despite months of targeted antimicrobial therapy, only 51% were tissue culture negative at operation. The most common pattern of focal parenchymal lung disease was bronchiectasis (Fig 1), seen in 86% of patients. Cavitary lung disease (Fig 2) was noted in 7%, and a mixed pattern was seen in 7%. Forty-one patients (41 of 171, 24%) had bilateral disease, most commonly right middle lobe and lingular bronchiectasis. Significant volume loss often accompanied the affected bronchiectatic lobe or segment (Fig 3). The mean forced expiratory volume in 1 second in the patient cohort was 77% of predicted (range, 39% to 115%). In 13 patients, continual dependent drainage from an original area of bronchiectasis appeared to produce a secondary focus of parenchymal disease (Fig 4). In these situations, a bilobectomy or lobe plus ipsilateral segment resection was performed. The operations performed are listed in Table 3. All patients underwent anatomic lung resection for their infectious lung disease. One hundred twenty-six lobectomies, 73 segmentectomies, and 13 mixed procedures were performed. One patient with situs inversus underwent left middle lobectomy and right lingulectomy. Thirteen patients, in addition to a lobar or segmental resection, had a wedge resection of an ipsilateral lobe, typically for a small isolated nodule or cavity related to the infectious process. One patient with concomitant severe gastroesophageal reflux disease underwent a laparoscopic Nissen fundoplication in addition to lobectomy, and 1 patient required a primary bronchial repair after an injury was sustained to the right lower lobe bronchus during lobectomy. The mean operating time was 124 minutes, and the estimated blood loss averaged 101 ml (range, 5 to 1500 ml; median, 75 ml). Conversion to open thoracotomy was required in 10 cases (4.7%), in all cases as a result of dense adhesions other than the Table 2. Microbiology in 171 Patients With Chronic Bronchiectasis or Cavitary Lung Disease Organism n % Mycobacterium avium complex (MAC) 147 (86%) Mycobacterium abscessus 36 (21%) Mycobacterium fortuitum 3 (2%) Mycobacterium simiae 2 (1%) Mycobacterium kansasii 1 (0.6%) Pseudomonas aeruginosa 18 (11%) Aspergillus/Scedosporium 16 (9%) Haemophilus influenzae 4 (2%) MRSA 2 (1.2%) MRSA methicillin-resistant Staphylococcus aureus. 1035

4 1036 MITCHELL ET AL Ann Thorac Surg THORACOSCOPIC LOBECTOMY FOR BRONCHIECTASIS 2012;93: Fig 1. A patient with classic, cylindrical bronchiectasis of the left lower lobe, depicted in the (A) transverse and (B) coronal planes. bronchial injury case noted above. No autologous tissue buttressing of the bronchial stump was performed. The observed postoperative complications are detailed in Table 4. There was no operative mortality. Complications occurred in 19 cases (8.9%). The most common complication was prolonged air leak, defined as an air leak beyond the fifth postoperative day, which in 3 patients presented (or became apparent) after initial hospital discharge. Atrial fibrillation occurred in 3 patients (1.4%). There was one wound infection, and 1 patient had pneumonia after the procedure, requiring readmission. In these latter 2 patients, the causative organism differed from the original cultured lung pathogens. Despite the lack of autologous tissue buttressing of the bronchial stump(s), no postoperative bronchopleural fistulae were noted in this group of patients. The average length of hospital stay was 3.7 days (range, 1 to 23 days; median, 3 days). Comment In this report we describe our experience with the use of thoracoscopic lobectomy and segmentectomy for localized bronchiectasis or cavitary lung disease. Patients underwent targeted anatomic resection to remove diseased, damaged lung parenchyma as part of a multimodality treatment program. In 212 cases, we observed no operative mortality, a low morbidity rate, and an average hospital stay of 3.7 days. These results suggest that in selected cases, the use of thoracoscopic techniques is safe Fig 2. Cavitary infectious lung disease of the right upper lobe. Fig 3. In this sagittal image of right middle lobe bronchiectasis, severe consolidation and volume loss of the affected lobe are seen.

5 Ann Thorac Surg MITCHELL ET AL 2012;93: THORACOSCOPIC LOBECTOMY FOR BRONCHIECTASIS 1037 Fig 4. In patients with chronic bronchiectasis, dependent drainage of purulent secretions can secondarily involve another area, as shown in (A) coronal and (B) sagittal images in this patient with right middle lobe and right lower lobe superior segmental disease. and feasible in patients with infectious lung disease amenable to resection. Bronchiectasis represents an abnormal dilation of the bronchi and bronchioles, attributable to repeated cycles of airway inflammation and infection. Once thought to be in decline, the diagnosis of bronchiectasis (non cystic fibrosis related) is now made with increasing frequency in North America and throughout the world [12]. Traditional treatment paradigms have included repeated cycles or schedules of antibiotic therapy along with maneuvers designed to aid in airway clearance of purulent secretions. Surgery has usually been reserved for patients with focal disease who have failed or become intolerant to medical therapy, have recurrent episodes of hemoptysis, or both. When surgery is advised, it is Table 3. Extent of Thoracoscopic Resection for Bronchiectasis or Cavitary Lung Disease Procedure Lobectomy 126 Right upper lobe 13 Right middle lobe 101 Right lower lobe 4 Left upper lobe 4 Left middle lobe 1 Left lower lobe 3 Segmentectomy 73 Lingulectomy 72 Left lower lobe basilar segments 1 Mixed Procedures 13 Right upper and middle lobe 3 RML, RLL superior segment 5 RML, RUL posterior segment 3 RML, RUL anterior segment 2 Total Cases 212 RLL right lower lobe; RML right middle lobe; RUL right upper lobe. n usually performed through an open thoracotomy approach, described by some authors as a necessity to ensure complete resection [13]. Several large series of patients undergoing resection for bronchiectasis have been published within the last decade [14 18]. All report low mortality rates of 0% to 1.7% and acceptable morbidity rates of 9% to 23%, and emphasize the need for complete resection of disease. Our findings in the present study are comparable with these results, and suggest that a thoracoscopic approach for lobectomy and segmentectomy is feasible in patients with focal bronchiectasis. There have been two series in the last decade that have also examined a thoracoscopic approach to patients with bronchiectasis. Weber and colleagues [19] described a five-trocar technique with subsequent minithoracotomy for thoracoscopic lobectomy in 76 patients with benign lung disease, 49 of which had bronchiectasis or chronic lung infection. The mortality rate was 0%, the morbidity rate was 18.7%, and conversion to thoracotomy occurred in 12 cases (15.3%). Compared with patients undergoing an open thoracotomy for similar indications during the same period, they noted less morbidity, less blood loss, and a shorter hospital stay in the thoracoscopic group. More recently, Zhang and coworkers [20] reported 52 Table 4. Morbidity and Mortality After Thoracoscopic Lobectomy or Segmentectomy Complication n % Operative mortality 0 (0%) Operative morbidity 19 (8.9%) Prolonged air leak 12 (5.6%) Atrial fibrillation 3 (1.4%) Bronchial injury 1 (0.5%) Pneumonia 1 (0.5%) Wound infection 1 (0.5%) Atelectasis 1 (0.5%) Pleural effusion 1 (0.5%)

6 1038 MITCHELL ET AL Ann Thorac Surg THORACOSCOPIC LOBECTOMY FOR BRONCHIECTASIS 2012;93: patients who underwent thoracoscopic lobectomy using a technique similar to ours with two 12-mm trocar ports and a 4- to 5-cm incision. They noted no operative mortality, a morbidity rate of 15.4%, and a conversion to thoracotomy rate of 13.5%. Again, compared with a matched group of open lobectomies during the same period, the thoracoscopic group had less morbidity and a shorter hospital stay than the thoracotomy cohort. We have previously emphasized the importance of a multidisciplinary approach to the surgical treatment of patients with infectious lung disease [21]. Careful consultation with pulmonologists and infectious disease specialists with a dedicated interest in lung infection is essential, and surgery should be considered as part of a multimodality therapy program. Although the antibiotic therapy remains the mainstay of treatment for those with focal bronchiectasis, the goal of adding surgery to the treatment regimen is to remove these areas of permanently damaged lung parenchyma that can serve as a reservoir or nidus for recurrent infection. Adequate pretreatment with a targeted antimicrobial regimen minimizes perioperative complications, and we believe this leads to optimal outcomes. Thoracoscopic lobectomy or segmentectomy for bronchiectasis or cavitary lung disease poses several technical challenges when compared with a similar procedure for thoracic malignancy. Pleural adhesions are almost always present to some degree, and in some cases can be extensive and vascular in nature. They typically involve the affected segment(s) of lung, but can also be scattered throughout the hemithorax. In cavitary upper lobe disease, the adhesions to the overlying parietal pleura can be significant. The preoperative high-resolution computed tomography will usually predict the presence of dense adhesions, but frequently underestimates the amount of pleural symphysis. In almost all cases, the adhesions can be divided through a minimally invasive approach, often with improved visibility compared with thoracotomy. Indications to convert to an open approach would include the perceived need for an extrapleural dissection or because of concern regarding underlying vital structures. The bronchial circulation in patients with bronchiectasis or cavitary lung disease is almost always hypertrophied, and in most cases should be directly ligated with clips to minimize bleeding. Similarly, considerable lymphadenopathy may be present within the ipsilateral hilum. Although a nodal dissection is clearly not required, the lymphadenopathy in the setting of chronic pulmonary granulomatous disease can make dissection of the hilar vessels difficult. When developing a fissure with a stapling device, we tend to err toward the uninvolved lobe to aid in complete resection. Beyond this, the diseased tissue is thickened and tends to compress poorly, thus making it a poor substrate for staple closure. Lobes with cavitary disease often have concomitant, adjacent pleural symphysis, and care must be taken during lung mobilization to avoid spillage of infected debris within the pleural space. After segmentectomy or smaller lobar resections, a significant residual space is typically not an issue given the degree of parenchymal collapse or consolidation usually seen. This should be assessed on a case by case basis as the residual ipsilateral lung can be poorly compliant (especially for nontuberculous mycobacterial patients) and may contribute to a space problem. In larger resections or if a significant space is anticipated, we have now found it possible to transpose the latissimus dorsi by means of the original thoracoscopic incisions, although this latter technique was not used in this study. As mentioned previously, we do not routinely buttress the bronchial stump closure in this group of patients, and did not note any bronchopleural fistula postoperatively. Situations in which buttressing of the bronchial stump might be considered would be in the presence of a multidrug-resistant organism, or in the setting of poorly controlled infection before surgery. It is our bias to perform anatomic lung resection in the setting of focal bronchiectasis or cavitary lung disease associated with recurrent lung infection, believing this approach removes all of the bronchiectasis and damaged lung parenchyma that might lead to later recurrence of disease. However, an isolated nodule or small cavity may occasionally be addressed with nonanatomic (wedge) resection in combination with anatomic resection of a more heavily diseased area of lung, as was done in 6% of our cases. In this setting, the target for nonanatomic resection should be small, peripheral, amenable to complete resection, and not associated with visible bronchiectasis on the highresolution computed tomography. Finally, it should be emphasized that this report describes a selected series of patients, as an additional 42 lobar or segmental resections were performed during the same period through a planned open approach. The operating surgeon should carefully consider the preoperative imaging studies in light of the planned resection. Indications for thoracotomy primarily include evidence of significant pleural obliteration on the high-resolution computed tomography (often associated with a greater degree of lung destruction), often with the perceived need for concomitant thoracoplasty or muscle transposition. Although 83% (212 of 254) of the lobar and segmental resections were attempted thoracoscopically, we believe careful assessment and allocation of the most difficult cases to an open approach contributes significantly to optimal outcomes. In cases in which the best approach is unclear, initial evaluation by means of thoracoscopy can determine the feasibility of a minimally invasive approach. In summary, thoracoscopic lobectomy and segmentectomy for focal bronchiectasis or cavitary lung disease is safe and effective, and can be accomplished with acceptable morbidity and mortality. Proper patient selection and a multidisciplinary approach are key factors to success. In the future, minimally invasive techniques may perhaps allow for earlier referral for surgical resection in bronchiectasis and related disorders.

7 Ann Thorac Surg MITCHELL ET AL 2012;93: THORACOSCOPIC LOBECTOMY FOR BRONCHIECTASIS References Hartwig MG, D Amico TA. Thoracoscopic lobectomy: the gold standard for early-stage lung cancer? Ann Thorac Surg 2010;89(Suppl):S Leshnower BG, Miller DL, Fernandez FG, Pickens A, Force SD. Video-assisted thoracoscopic surgery segmentectomy: a safe and effective procedure. Ann Thorac Surg 2010;89: McKenna RJ Jr, Houck W, Fuller CB. Video-assisted thoracic surgery lobectomy: experience with 1,100 cases. Ann Thorac Surg 2006;81: Onaitis M, Petersen R, Balderson S, et al. Thoracoscopic lobectomy is a safe and versatile procedure: experience with 500 cases. Ann Surg 2006;244: Paul S, Altorki NK, Sheng S, et al. Thoracoscopic lobectomy is associated with lower morbidity than open lobectomy: a propensity-matched analysis from the STS database. J Thorac Cardiovasc Surg 2010;139: Villamizar NR, Darrabie MD, Burfeind WR, et al. Thoracoscopic lobectomy is associated with lower morbidity compared with thoracotomy. J Thorac Cardiovasc Surg 2009;138: Lee JG, Cho BC, Bae MK, et al. Thoracoscopic lobectomy is associated with superior compliance with adjuvant chemotherapy in lung cancer. Ann Thorac Surg 2011;91: Petersen RP, Pham D, Burfeind WR, et al. Thoracoscopic lobectomy facilitates the delivery of chemotherapy after resection for lung cancer. Ann Thorac Surg 2007;83: Atkins BZ, Harpole DH Jr, Mangum JH, Toloza EM, D Amico TA, Burfeind WR Jr. Pulmonary segmentectomy by thoracotomy or thoracoscopy: reduced hospital length of stay with a minimally-invasive approach. Ann Thorac Surg 2007;84: Burfeind WR Jr, Jaik NP, Villamizar N, Toloza EM, Harpole DH Jr, D Amico TA. A cost-minimisation analysis of lobectomy: thoracoscopic versus posterolateral thoracotomy. Eur J Cardiothorac Surg 2010;37: Griffith DE, Aksamit T, Brown-Elliott BA, et al. An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. Am J Respir Crit Care Med 2007;175: O Donnell AE. Bronchiectasis. Chest 2008;134: Watanabe M, Hasegawa N, Ishizaka A, et al. Early pulmonary resection for Mycobacterium avium complex lung disease treated with macrolides and quinolones. Ann Thorac Surg 2006;81: Balkanli K, Genç O, Dakak M, et al. Surgical management of bronchiectasis: analysis and short-term results in 238 patients. Eur J Cardiothorac Surg 2003;24: Eren S, Esme H, Avci A. Risk factors affecting outcome and morbidity in the surgical management of bronchiectasis. J Thorac Cardiovasc Surg 2007;134: Fujimoto T, Hillejan L, Stamatis G. Current strategy for surgical management of bronchiectasis. Ann Thorac Surg 2001;72: Prieto D, Bernardo J, Matos MJ, Eugénio L, Antunes M. Surgery for bronchiectasis. Eur J Cardiothorac Surg 2001;20: 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: 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: Zhang P, Zhang F, Jiang S, et al. Video-assisted thoracic surgery for bronchiectasis. Ann Thorac Surg 2011;91: Mitchell JD, Bishop A, Cafaro A, Weyant MJ, Pomerantz M. Anatomic lung resection for nontuberculous mycobacterial disease. Ann Thorac Surg 2008;85: DISCUSSION DR ROYCE F. CALHOUN (Sacramento, CA): John, that was impressive. I don t think we see as much of that as you do, but I ve certainly tackled many patients with bad mycetomas and bronchiectasis and whatnot and the anatomy can be quite challenging. You said that there was a subset that right up front you decided you weren t going to do thoracoscopically. Can you tell us what the features of those patients were that you did not go thoracoscopic? DR MITCHELL: Thanks, Royce. Certainly some of the people that were included in the open group were going to have planned thoracoplasty or muscle transposition, which would knock them out of the box from the beginning. But for the rest of the patients, it was the characteristics of the CT (computed tomography) scan that led us to just go straight to an open approach. Typically, if you see individuals with obvious pleural symphysis and a thickened rind where you re almost certain an extrapleural approach is going to be needed, we would usually go straight to thoracotomy. You know, often there is no downside to putting in a thoracoscope and assessing the situation as well at the beginning of a case. I think there are a small number of patients in whom it s obvious you re going to need an open approach, there are many patients for whom a thoracoscopic approach is certainly feasible, and then there s a small gray area in between. DR DANIEL MILLER (Atlanta, GA): John, that was an outstanding series. I think the most important issue in deciding on doing these patients is the amount of pleural disease, because if you have total pleural symphysis or a very thickened pleura, you re not going to be able to get in. Can you tell us your approach technically? Do you start off anteriorly? Do you ever use CO 2? We ve used CO 2 a number of times and it has really helped out. The second question, I m still very surprised that you re not reinforcing the bronchus, especially with pan-resistant Pseudomonas or Aspergillus. You say you ve had no bronchopleural fistulas, which I believe you, but those are the ones that usually develop a BPF (bronchopleural fistula). I just want to know why you ve become that strict with no buttress material for your bronchial stumps. DR MITCHELL: We have not used insufflation, Dan, and that might be a good approach. I have never tried that. Typically when you see patients with bronchiectasis, the adhesions are moderate in nature and really not something that s really going to slow you down too much. The ones that have the worst adhesions are those with upper lobe cavitary disease, and I think that can be the toughest to take down thoracoscopically, and we have spent an hour or two in select cases doing so. I ll continue to do that, unless I don t think it s safe for the patient, in which case we would convert to open. Other than perseverance, I don t know if there are a lot of specific technical keys I could give you. DR MICHAEL LANUTI (Boston, MA): John, very nice presentation. What struck me was that the mean duration of time of antimycobacterial or antituberculosis treatment was 5 years in your study. It really speaks to the skewed referral pattern that your institution experiences. In Boston for example, we typically

8 1040 MITCHELL ET AL Ann Thorac Surg THORACOSCOPIC LOBECTOMY FOR BRONCHIECTASIS 2012;93: consult on patients for pulmonary resection who have undergone 12 to 24 months of therapy as opposed to 5 years. Would you recommend a thoracoscopic approach versus an open approach for thin-walled cavitary disease that harbored resistant mycobacterial disease, ie, resistant MAI (Mycobacterium avium-intracellulare) orm. abscessus? DR MITCHELL: Thank you. As you know, Mike, in patients with nontuberculous mycobacterial disease, we feel that surgery is an important adjunct to their overall treatment regimen. Patients with persistent cavitary disease after adequate treatment would typically be considered a candidate for operation. Those individuals with thin-walled cavities are typically the ones which will often close with proper antimicrobial therapy, particularly amikacin, or some other injectable. As for the duration of therapy, I think that just speaks to the reluctance of pulmonologists to refer patients for resectional therapy for what s clearly focal disease. DR THOMAS A. D AMICO (Durham, NC): John, first of all, it s a great series, and I really have to congratulate you on having no conversions for bleeding. Obviously that speaks to your patience and attention to detail. I have two questions. In the same time period did you do any open pneumonectomies, and would you consider thoracoscopic pneumonectomy for the very few patients who are candidates for resection? And if you did, would you then be more aggressive at utilizing tissue and muscle buttresses? The second question: when you do segmentectomies, do you divide the parenchyma with a stapler, like most people do, or do you just use the combination of blunt and sharp dissection to develop the natural segmental plane? DR MITCHELL: Thank you, Tommy. When we do segmentectomies we typically use a stapler, but I think that is a device that has not yet been perfected for patients with infectious lung disease. When stapling you try to get beyond the extent of the disease but in those with chronic mycobacterial disease, even if they don t have bronchiectasis, their whole lung is involved. The parenchyma is thicker, it s more restricted, it doesn t expand as well, and the staplers don t compress it as well. So I think that s something that could be improved upon. With respect to the pneumonectomy, I have just done one thoracoscopic pneumonectomy. It was an infectious case. It went fine. I think the indications to do that are very few and far between. DR D AMICO: I would agree. DR JEAN DESLAURIERS (Quebec City, Quebec, Canada): I have only one item of discussion regarding Dr Miller s comments about bronchopleural fistula in patients who undergo pulmonary resection for bronchiectasis. In my opinion, these patients almost never have a bronchopleural fistula because of the tremendous bronchial vascular supply due to bronchial artery hyperplasia. Indeed you could leave the bronchus wide open and it would still heal. DR MITCHELL: We haven t tried that. DR DESLAURIERS: I would not advise that; also, in bronchiectasis patients with active tuberculosis where incidence of bronchopleural fistula is very high and you have to reinforce the bronchial stump.