minimally invasive techniques Video-Assisted Thoracoscopic Surgery Using Single-Lumen Endotracheal Tube Anesthesia*

minimally invasive techniques Video-Assisted Thoracoscopic Surgery Using Single-Lumen Endotracheal Tube Anesthesia* Robert James Cerfolio, MD, FCCP; Ayesha S. Bryant, MSPH; Todd M. Sheils, MD; Cynthia S. Bass, RN, MSN, CNRP; and Alfred A. Bartolucci, PhD Background: Most general thoracic surgeons use double-lumen endotracheal tube (DLET) anesthesia for all video-assisted thoracoscopic surgery (VATS). We evaluated a single-lumen endotracheal tube (SLET) for VATS for drainage of pleural effusions and pleural biopsies. Methods: A consecutive series of patients with recurrent pleural effusions underwent VATS using an SLET and only one incision. Operations were accomplished via one 2-cm incision using a 5-mm rigid thoracoscope and mediastinoscopic biopsy forceps for directed pleural biopsies. A working area was accomplished with low tidal volumes. Results: There were 376 patients (191 women). The indications for VATS were a nondiagnosed or benign pleural effusion in 294 patients, and a malignant effusion in 82 patients. Two hundred eight patients underwent biopsy of the parietal pleura, and mean operative time was 17 min. Adequate visibility was obtained in all. When compared to preoperative cytology, VATS was more sensitive (45% compared to 99%, p < 0.001), had a higher negative predictive value (56% compared to 99%, p < 0.001), and was more accurate (67% compared to 99%, p < 0.001). Forty-seven percent of patients with a history of cancer had false-negative preoperative cytology results. Complications occurred in seven patients (2%), and there were three operative deaths (none related to the operative procedure). Conclusion: VATS using SLET and only one incision is possible, and it affords excellent visualization of the pleural space, allowing pleural biopsies and talc insufflation. It avoids the risk, time, and cost of a DLET. It is significantly more sensitive and accurate than preoperative cytology, and it should be considered as the diagnostic and therapeutic procedure of choice in patients with recurrent pleural effusions. (CHEST 2004; 126:281 285) Key words: cytology; pleural biopsy; pleural effusion; single-lumen endotracheal tube; video-assisted thoracoscopic surgery Abbreviations: DLET double-lumen endotracheal tube; SLET single-lumen endotracheal tube; VATS videoassisted thoracoscopic surgery *From the Section of Thoracic Surgery (Dr. Cerfolio and Ms. Bass), and Department of Orthopedic Surgery (Dr. Sheils), University of Alabama, Birmingham; and Departments of Epidemiology (Ms. Bryant) and Biostatistics (Dr. Bartolucci), University of Alabama, School of Public Health, Birmingham, AL. Manuscript received October 23, 2003; revision accepted January 26, 2004. Video-assisted thoracoscopic surgery (VATS) is the procedure of choice for the diagnosis and management of diseases of the pleura, nondiagnosed small peripheral pulmonary nodules, and interstitial lung disease. 1 Most thoracic surgeons use a doublelumen endotracheal tube (DLET) when performing VATS. Placement of a DLET is usually safe, and it provides superb visualization and an excellent working field for procedures of the pleura, lung, and Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (e-mail: permissions@chestnet.org). Correspondence to: Robert J. Cerfolio, MD, FCCP, Associate Professor of Surgery, Chief of Thoracic Surgery, Division of Cardiothoracic Surgery, University of Alabama at Birmingham, 1900 University Blvd, THT 712, Birmingham, AL 35294; e-mail: Robert.cerfolio@ccc.uab.edu www.chestjournal.org CHEST / 126 / 1/ JULY, 2004 281

mediastinum. However, a DLET has complications and cost. It requires fiberoptic bronchoscopy to be positioned. 2 6 This increases the time and cost to what is an otherwise very short and simple operation. On occasion, we have performed VATS with DLET and have had to inflate the lung because of decreasing oxygen saturations, or because the lung remained expanded due to a migrated or incorrectly positioned DLET. During these instances, we were impressed with the working field that one could obtain just by using low tidal volumes while both lungs are being ventilated. We found it relatively easy to perform simple VATS procedures such as pleural biopsies and talc pleurodesis. We therefore decided to evaluate the role of VATS with single-lumen endotracheal tube (SLET) anesthesia for the management of malignant and nondiagnosed, recurrent pleural effusions. We also wanted to evaluate the accuracy of the preoperative cytology and to compare it to the biopsy specimens and cytology obtained during VATS. Patients and Methods Over a 5-year period, one surgeon (R.J.C.) performed VATS 376 consecutive times using an SLET on patients with a recurrent, persistent, nondiagnosed or malignant effusion. Patients who had an indeterminate nodule and an effusion were excluded from this study. The primary outcomes of this study were the ability to adequately see and sample the entire pleura, and the time it took to complete the operation. The secondary outcomes were operative morbidity and mortality, sensitivity, specificity, positive predictive value, negative positive value, accuracy of the pleural biopsy, postoperative cytology, and the preoperative cytology. The prospective database used to collect this information and this study were both approved by the University of Alabama Institutional Review Board. Patients with a malignant pleural effusion were given the option of VATS with intraoperative talc pleurodesis or bedside chest tube placement with subsequent bedside talc slurry pleurodesis. Patients with benign, recurrent pleural effusion were recommended to undergo VATS with pleural biopsies and intraoperative talc pleurodesis if the biopsy samples were positive for malignancy on frozen pathologic examination. Only those patients who were at least ambulatory and otherwise able to safely undergo a general anesthesia were offered VATS. Patients underwent general anesthesia and were placed in the lateral decubitus position. After prepping and draping, one small, 2- to 3-cm incision is made anterior to the superior iliac crest (so the patient does not lie on his or her chest tube postoperatively). It is made in the inferior aspect of the chest, over the ninth or tenth rib. The muscle is incised, and the chest is entered bluntly. Prior to entering the chest, a short period of apnea is used to prevent injury to the underlying lung. A sucker is carefully placed into the chest, and the effusion is drained and sent for cytology, culture, and triglyceride content if indicated. The tidal volume is reduced to about 150 to 250 ml, and the ventilatory rate increased. A trocar is then inserted, and a 5-mm rigid thoracoscope with a 0 lens is placed through it. The trocar is then slid over the scope. This move allows one to easily place other instruments alongside the camera so only one incision is needed, and avoids undue pressure on the intercostal nerve. First, a sucker is placed alongside the scope through the only incision, and the remaining effusion is completely drained under direct vision. Biopsies of the pleura are then performed in any patient who had a nondiagnosed recurrent pleural effusion with a suspicious lesion seen on the pleural, diaphragmatic, or pericardial surface. Pleural biopsies were also performed in any patient with a known malignancy if the oncologist requested tissue to help direct subsequent treatment. Biopsies were accomplished by sliding a standard mediastinoscopic biopsy forceps alongside the camera. The camera and the biopsy forceps can be maneuvered in tandem to obtain directed biopsy samples. If greater visibility is needed for apical biopsies, occasional short periods of apnea can be used. End-tidal carbon dioxide is monitored. In patients with metastatic cancer, a history of positive preoperative cytology or intraoperative findings of metastatic disease based on frozen-section analysis, 2.5 g of talc were insufflated with an atomizer. The talc was evenly distributed throughout the pleural space, with special emphasis on the apex and diaphragm. A 28F right-angle chest tube was positioned posterior to inferior through the only incision. Adequate visibility of the pleural space was defined as the ability of the surgeon to both view and to sample the entire surface of the pleura, pericardium, and diaphragm that is not normal obstructed by structures (ie, the heart, pericardial fat, etc) The records of these 376 patients were reviewed for age, gender, preoperative history, operative findings, hospital course, and follow-up visits. Operative mortality was defined as any death within 30 days from the procedure or during the hospitalization. Patients who had benign cytology and pathology findings after VATS using SLET were followed up for a minimum of 9 months to ensure their cytology and pathology results were not falsenegative. If they died during this time frame without another reasonable explanation for their death or without an autopsy, the biopsy results were considered false-negative. A false-positive pleural biopsy and/or cytology result was defined as not having radiographs or a clinical course consistent with progression of disease over a 9-month period after VATS. Chest tubes were removed the day after talc pleurodesis in all patients irrespective of the amount of drainage, unless the patient was being kept in the hospital by another service. All data are reported as medians. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were calculated for the preoperative thoracentesis and VATS cytology using a multivariable reference standard that included postoperative pathology, postoperative cytology, and patient clinical course if the VATS finding was negative. The binomial test was used to test for a significant difference between the two groups. A two-sided p value 0.05 was considered significant. Results The median age of these 376 patients was 58 years (range, 39 to 72 years). Baseline characteristics of the patients are shown in Table 1. The indications for VATS were a nondiagnosed or benign pleural effusion in 294 patients. Ninety-one patients (24%) did not undergo preoperative cytology because the referring service did not believe one was needed prior to the operation. The remaining 203 patients had benign cytology preoperatively. Eight-two patients (22%) had a known malignant effusion by cytology prior to surgery. All procedures were accomplished through one incision, except in one patient who had two incisions. 282 Minimally Invasive Techniques

Table 1 Patient Demographics* Data Mean age, yr 58 Gender Female 191 (51) Male 185 (49) Race Black 37 (10) White 332 (88) Other 7 (2) History of cancer 199 (53) Site of primary cancer, No. Breast 72 Lung 39 Renal 10 Bone 7 Cervical/ovarian 7 Colorectal/anal 7 Other 36 *Data are presented as No. (%) unless otherwise indicated; n 376. The median amount of fluid drainage was 1,200 ml (range, 90 to 5,500 ml). All VATS procedures were performed with adequate visualization as defined above, and no patient required a DLET or thoracotomy in order to adequately see and sample the pleura. In 54 patients, we used periods of apnea that lasted approximately 30 s in order to aid our visualization of the apex of the chest. There was no difficulty in maintaining adequate oxygen saturation or preventing hypercapnia in any patient. No patient had a urinary catheter or arterial line placed. The median time for placement, positioning, and securing of an SLET at our institution averages 3 min, compared to 14 min for a DLET. The median operative time was 17 min (range, 12 to 37 min). Of the 294 patients who had benign or nondiagnosed pleural effusions, 182 patients (62%) had suspicious lesions on the pleural, diaphragm, or pericardium, and therefore underwent a biopsy. Of the 82 patients with malignant pleural effusions, 26 patients (32%) underwent a pleural biopsy. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for these values when compared to the reference standards are shown in Table 2. When calculating these values, only those patients who underwent preoperative cytology, and VATS cytology and biopsy were included. This table shows that VATS with SLET using pleural biopsies and cytology is more sensitive, specific, has a higher positive predictive value, a higher negative predictive value, and a better accuracy then preoperative cytology (p 0.004 for all). As shown, however, VATS was not correct in all patients. Two patients had false-negative VATS findings with biopsy. These two patients both died with evidence of systemic metastatic disease despite having had a negative pleural biopsy findings and negative VATS cytology results. In addition, there was one patient who had a false-positive biopsy result. His preoperative cytology and VATS cytology findings were negative, but the pleural biopsy was eventually called metastatic cancer. However, this patient is alive and well 16 months after VATS with no evidence of cancer anywhere. Table 2 also shows that VATS cytology alone is more accurate than preoperative cytology. Of the 203 patients with benign, recurrent pleural effusions, 83 patients (41%) had parietal pleura biopsy findings that were positive for malignancy. Of these 83 patients, 84% had a history of cancer. However, in patients with a history of cancer who presented with a pleural effusion, only 54% had metastatic cancer in the chest. In the 199 patients with a history of cancer, the most common sites of the primary cancer were breast in 72 patients and lung in 39 patients. Chest tubes were removed on median postoperative day 1 (range, 1 to 9 days). Complications occurred in seven patients, as shown in Table 3. Fever, which occurred in 64% of the patients who had talc, was attributed to the talc and not reported as a complication. There were three operative deaths. All three deaths occurred in patients with do-not-resuscitate orders, who had widely metastatic cancer, and had prolonged hospitaliza- Table 2 Values Comparing Preoperative Cytology and VATS Cytology Findings With Pleural Biopsy to Reference Standard* Preoperative Cytology, % VATS Cytology Alone, % VATS Cytology With Biopsy, % p Value, Preoperative Cytology vs VATS Cytology With Biopsy Sensitivity 45 68 99 0.001 Specificity 95 92 99 0.004 PPV 93 90 99 0.002 NPV 56 72 99 0.001 Accuracy 67 80 99 0.001 *PPV positive predictive value; NPV negative predictive value. www.chestjournal.org CHEST / 126 / 1/ JULY, 2004 283

Table 3 Outcomes tions both before and after VATS. Their shortness of breath was improved with the operation, and all died from metastatic disease on postoperative days 27, 31, and 47. Discussion Data Median amount of fluid drained, ml (range) 1,200 (30 5,500) Median operative time, min (range) 17 (12 37) Postoperative complications, No. (%) 7 (1)* Mortality, No. (%) 3 ( 1) *Renal failure, prolonged drainage, re-intubation, air leak, urinary retention, atrial fibrillation. VATS is a commonly used procedure in thoracic surgery, and its frequency continues to increase. It offers a minimally invasive approach to a variety of thoracic pathologies that previously required thoracotomy. 7 Recently, even more complicated procedures such as lobectomy are being performed via VATS. DLET is almost always used for VATS, and we still prefer it for complicated or targeted VATS procedures such as wedge resection of a small indeterminate nodule or one that is deep. However, as seen in this study, VATS when used for simple procedures such as pleural disease does not require a DLET. Placement of a DLET has risks and takes time, 6,8 10 and is more expensive than an SLET. At our institution, the cost of an SLET and placing it is $50, as compared to the cost of a placing a DLET, which is $375. As one might expect, and as shown in this article, it also takes longer to place a DLET even in very experienced hands. This risk and expense can therefore be avoided by using an SLET. When we first noticed that we were able to perform VATS with both lungs inflated, we were initially hesitant to try an SLET for fear that we might have to roll the patient over in the middle of an operation to place a DLET. But we tested it several times. We placed a DLET but inflated both lungs and used low tidal volumes, and had almost the same visibility with a DLET. After doing this in several patients with no problems, this consecutive series was started. This study shows that SLET using low tidal volumes was able to offer more than enough space to adequately visualize and sample the entire pleura (especially the lower hemithorax) and perform talc pleurodesis. We now prefer and exclusively use an SLET in these patients, who are often sick and debilitated. Recurrent effusions are often troublesome and lead to recurrent hospitalizations because of shortness of breath. Repeated thoracentesis for malignant effusion removes only part of the effusion and is not useful. Therefore, most recommend pleurodesis either via VATS or by bedside talc slurry. 11 Moreover, recurrent benign pleural effusions are a diagnostic dilemma when they cannot be attributed to renal, heart, or liver failure, or any other identifiable cause. VATS can therefore be both diagnostic, for benign effusions, and therapeutic, for malignant effusions. It can be performed on one day, and radiation or chemotherapy can be performed the next day if needed. It can also provide large pieces of tissue to help confirm the diagnosis of cancer or to perform further pathologic tests if needed to help guide subsequent treatment. We found that when patients had benign preoperative cytology findings and a history of a previous cancer, the preoperative cytology result might be false-negative. Fifty-four percent of patients who had a history of cancer and presented with a new pleural effusion had metastatic cancer to the pleural space. Therefore, we strongly recommend VATS with biopsy and talc to diagnosis the recurrent cancer and to palliate the pleural space. It is interesting to note that VATS cytology was more accurate than the preoperative cytology findings. Although we cannot fully explain this finding, possible reasons are that VATS drains the fluid with large suckers and thus causes less cellular destruction. Second, it removes all the pleural effusion, and thus there is more volume for the cytologist to examine. When one adds magnified visualization of the pleura and biopsies of suspicious pleural areas, VATS is much more accurate than preoperative cytology alone. These findings are consistent with other studies 12 16 that show cytology findings under optimal conditions are diagnostic in only 60 to 80% of patients with metastatic disease. Similarly, another study 17 has shown that the sensitivity of VATS for diagnosing malignant pleural effusions is 95%, and is superior to cytology or the 44% for needle biopsy. Because of these results, we now recommend VATS using SLET in this group of patients. VATS can also be performed on patients who are awake under local anesthesia. Rusch and Mountain 18 reported a series of 52 patients who underwent VATS while awake. We have attempted it in nine patients, all with severe hypercapnea and loculated, complex pneumothoraces. We used VATS to help lyse adhesions and to guide chest tubes into the apex of the chest. Our experience was mixed, and in a few patients it was very difficult to see because of tachypnea, anxiety, and poor analgesia. Finally, VATS using SLET can also be used for wedge resection of the lung when needed for interstitial 284 Minimally Invasive Techniques

lung disease. However, when a directed biopsy of a small nodule is needed and careful lung palpation is required, we use a DLET. We conclude that VATS using an SLET and only one small incision is possible. It is the treatment of choice for the evaluation and treatment of pleural disease. It affords excellent visualization of the chest and allows directed biopsies of the pleura, diaphragm, and pericardium for diagnosis, as well as talc pleurodesis for treatment. Patients with recurrent, benign pleural effusions and a history of cancer have a high probability of having false-negative cytology results and should undergo VATS with VATS cytology and pleural biopsy. VATS is more sensitive, specific, and accurate than preoperative cytology. In patients with recurrent malignant pleural effusion or effusions of unknown cause, we recommend VATS for both therapeutic and diagnostic purposes and an SLET may be used. References 1 Miller JI. The present role and future considerations of video-assisted thoracoscopy in general thoracic surgery. Ann Thorac Surg 1993; 56:804 806 2 McGahren ED, Kern JA, Rodgers BM. Anesthetic techniques for pediatric thoracoscopy. Ann Thorac Surg 1995; 60:927 930 3 Horswell JL. Anesthetic techniques for thoracoscopy. Ann Thorac Surg 1993; 56:624 629 4 Smith G, Hirsch N, Ehrenwerth J. Placement of doublelumen endotracheal tubes: correlation between clinical impression and bronchoscopic findings. Br J Anaesth 1986; 58:1317 1320 5 Benumof J, Partridge B, Salvatiena C, et al. Margin of safety in positioning modern double-lumen endotracheal tubes. Anesthesiology 1987; 67:729 738 6 Walker T, Bensky KP. Thorascopy: anesthetic considerations. AANA J 1995; 63:217 224 7 Landrenau RJ. Role of thorascopy in thoracic surgical practice. West J Med 1997; 166:59 60 8 Conrady PA, Goodman LR, Lainge F, et al. Alteration of endotracheal tube position. Crit Care Med 1976; 4:8 12 9 Torda TA, McCulloch CH, Obrien HD, et al. Pulmonary venous admixture during one-lung anesthesia. Anaesthesia 1974; 29:272 279 10 Katz JA, Laverne RG, Fairley HB, et al. Pulmonary oxygen exchange during endobronchial anesthesia: effect of tidal volume and PEEP. Anesthesiology 1982; 56:164 171 11 Hausheer FH, Yarbro JW. Diagnosis and treatment of malignant pleural effusion. Semin Oncol 1985; 12:54 75 12 Moores DWO. Management of the malignant pleural effusion. Chest Clin North Am 1994; 4:481 495 13 Dines DE, Pienne RV, Frazen SJ. The value of cells in the pleural fluid in the differential diagnosis [abstract]. Mayo Clin Proc 1975; 50:571 14 Light RW. Pleural diseases. 1st ed. Philadelphia, PA: Lea and Febiger, 1990; 241 244 15 Salyer WR, Englesten JC, Erozen YS. Efficacy of pleural needle biopsy and pleural fluid cytopathology in the diagnosis of malignant neoplasm involving the pleura. Chest 1975; 67:536 539 16 Scerbo J, Keltz H, Stone DJ. A prospective study of closed pleural biopsies [abstract]. JAMA 1971; 218:377 17 Loddenkemper R, Grosser H, Mai J. Prospective evaluation of biopsy methods in the diagnosis of malignant pleural effusions: intrapatient comparison between pleural fluid cytology, blind needle biopsy, and thoracoscopy [abstract]. Am Rev Respir Dis 1983; 127:114 18 Rusch VW, Mountain C. Thoracoscopy under regional anesthesia for the diagnosis and management of pleural disease. Am J Surg 1987; 154:274 278 www.chestjournal.org CHEST / 126 / 1/ JULY, 2004 285