JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol 10 - A p r / 2 0 1 5
Assessment on early the results of thoracoscopic lobec- tomy for non-small cell lung cancer
Tran Trong Kiem, Le Hai Son 108 Military Central Hospital
Summary
Objective: Advantages of thoracoscopic lobectomy for early stage non-small cell lung cancer (NSCLC) include less postoperative pain, earlier pulmonary rehabilitation and shorter length of hospitali- zation. We assess the results of thoracoscopic lobectomy for non-small cell lung cancer in stage 1,11. Sub- ject and method: A prospective database of 47 consecutive patients who underwent thoracoscopic lo- bectomy between March 2010 and December 2013 was queried. Demographic, histopathologic, pe- rioperative and outcome variables were assessed using standard descriptive statistics and Kaplan-Meier survival analyses. Result: Of the 47 patients undergoing planed thoracoscopic lobectomy, 40 patients (85.1%) had a completed thoracoscopic lobectomy, 6 patients (12,8%) had a video- assisted thoraco- scopic lobectomy and 1 patient (2.1%) underwent conversion to thoracotomy. Among the 47 patients with NSCLC, pathologic analysis demonstrated stage I in 34 patients (72.3%), stage 11 in 13 patients (27.7%). The operative and perioperative (30-day) mortality was 0%, similarly. Postoperative pulmonary function was normal in all patients. The overall 34-month survival rate for the entire cohort was 78.1%, and the 36-month overall survival rates for stage 1 NSCLC, stage II NSCLC were 96.9%, 66.7%, respec- tively. Conclusion: Thoracoscopic lobectomy is applicable to early stage non-small cell lung cancer and is associated with a low perioperative morbidity and mortality rate,
/keywords: Thoracoscopic lobectomy, lung cancer.
1 . Background Selection criteria
Kirby performed thoracoscopic lobectomy in ^ ^ ^ ^ ^ ^ performed thoracoscopic lobectomy 1993 [4]. He is said t o be t h e first surgeon w h o per- for all cases w h o have all presented:
formed this technique. After that, thoracoscopic lo- _ p^^-^^^^^^^ ^^^ _ ^ ^ g l l cell lung cancer stage bectomy was developed widespread and rapidly all
over t h e w o r l d . Most research has shown that this 11 of 5cm or less in diameter.
- Never underwent ipsilateralthoracotomy.
technique has many advantages in comparison w i t h ^^^^^^ ^^ 1^^^, ^.^^ obstruction pulmonary open lung lobectomy, function test.
2. Subject a n d m e t h o d Exclusion criteria
, . r „-, . . - . , . -Small cell lung cancer.
We used prospective analysis for 47 patients _ ^^^^^ ^^^^^ ^^ ^^ ^^ ^^^^^ ^^ ^^^^ 5 ^ ^ .^ ^,_
w h o u n d e r w e n t thoracoscopic lobectomy between March 2010 and December 2013. Demographic, his- topathologic, perioperative and outcome variables including overall survival were analyzed.
a meter
- Post mediastinoscopy -Discouragement Pre-operative assessment
Correspondence to: Tran Trong Kiem-Department of yy^ perform contrast-enhanced computed tomo- Thoracic Surgery, 108 Military Central Hospital ^ ^ ^H ^,^^^5 ^ft^r thaL anatomy pathology Email: [email protected]
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was defined with bronchoscopy or CT - guided trans- thoracic core biopsy. All non-small cell lung cancers, which haven't got N3, N3 lymphnodes, were chosen for thoracoscopic lobectomy. If a patient has N2, N3 lym- phnodes, mediastinoscopy or positron emission tomo- graphy - CT will be tested for staging. If the result is pos- itive, radiation therapy or chemotherapy will be chosen for treatment. If the result is negative, surgical therapy will be chosen for treatment.
Operative technique Anaesthesia and position
We use double lumen endotracheal techniqu^
t o anaesthetise. Then t h e patient Is positioned In t h ^ ' lateral decubitus position. The hands are placed iij t h e prayer position in front of t h e face, and the 00 eratlng table is bended t o extend t h e intercostll;
space. When t h e double lumen endotracheal t u b e l ' confirmed t o be in t h e correct position, ventilationl^
switched t o t h e contralateral lung to optimise defla- t i o n . If t h e lung doesn't collapse readily, suction is occasionally used.
Instruments
Thoracoscopic lobectomy instruments include:
a zero degree 10 mm high definiton video thoraco- scope, forceps, peanut, hook, dissector and thoraco- scopic stapler.
There are t w o kinds of thoracoscopic stapler. A 45/60 mm length - 3.5mm thickness blue/violet stapler is used for panchyema. A 30/45 mm length - 2,5 m m thickness white/bronze stapler is used for vascular.
Incisions
Three access ports are used.
On the nght side: A 1 cm incision is made in the 8*'' intercostal space between middle axillary line and posterior axillary line for camera. The second 1 cm incision is made in the 6 * intercostal space at t h e anterior axillary line. A 2 -3 cm utility incision is made in t h e 4"' intercostal just in front of anterior border of the latisslmusdorsi muscle.
Figure 1 . Position [Our study]
On t h e left side: A 1 cm incision Is made in the 7"" intercostal space between middle axillary line and anterior axillary line for camera. The second 1 cm incision is made in t h e 6"' intercostal space at the posterior axillary line. A 2 -3 cm utility incision is made in t h e 4''^ intercostal just in the outer border of t h e pectoralis major muscle.
Technique
The first step is t o identify t h e t u m o r character, establish resectability and exclude unanticipated factor that m i g h t preclude resection.
The second step is lobectomy. Dissection of the pulmonary vessels and bronchi is performed in the same manner as in o p e n surgery. Endoscopic sta- plers are used for vessel and bronchial control. One the lobe is completely resected, it is placed in a spe cimen bag and taken o u t of thorax for avoiding im- plantation of t u m o r cell into t h e chest wall.
JOURNAL Or 108 - CLINICAL MEDICINE AND PHARMACY VollO-Apr/2015
Figure 2. Vessel (A) and bronchi (B) resection [Our study]
- Length of utility incision (cm) were measured after closure.
- Degree of pain is measured w i t h Visual Analog Scale (VAS)
iCSCAU
lufpir f MX - MO r j t a SCALE The t h i r d step is l y m p h node dissection. For
both right and left side, remove all of l y m p h node from station 7 t o 11. A n d :
- For right - sided t u m o r , removal of all lym- phatic tissues b o u n d e d by t h e right upper bronchus, the right subclavian artery, t h e superior vena cava and the trachea (station 2R and 4R).
- For left - sided t u m o r , removal of all lymphatic tissues b o u n d e d by t h e phrenic nerve, t h e vagus nerve and t h e t o p o f t h e aortic arch (station 5 and 6).
Assessment
- Baseline characteristics include: age, sex, tobacco
history, median follow - up, pulmonary function test. ^'9""'^ 3. Visual Analog Scale [5]
3. Result
Demographic information is presented in table 1.
Table 1 . Baseline characteristics of Thoracoscopic lobectomy patients (n=47) characteristic
Age (yr) (mean ± SD) Sex
Tobacco history
Male Female Yes (pack-year) No Median f o l l o w - u p (months) FEV,
57.3 + 9.1 30
17 37 10
63.8%
36 2%
21.3 ±8.6
21.6 ± 1 . 4 75,8 ± 4,3
Sexual distribution was 30 men (63.8%) and 17 was 21.6 ± 1.4 months. The mean preoperative FEV, w o m e n (36.2%). Mean age was 57.3 ± 9.1 years. Ac- was 75.8 ± 4.3%.
tive s m o k i n g history was 78.7%. Median f o l l o w - up
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY VollO-Apr/2015*
Thoracoscopic lobectomy was successfully per- formed In 40 of the 47 patients. Conversion rate was 2.1%. Of the conversions, 1 was for hemorrhage com- plication. Anatomic resections Included all lobes. Tho- racoscope pneumonectomy and thoracoscopic sleeve lobectomy were not performed (table 2).
Table 4 . Degree of pain
Table 2 . Anatomic resection (n = Anatomic resection
Right upper lobectomy Right midle lobectomy Right iower lobectomy Left upper lobectomy Left lower lobectomy
Total
n 7 7 17 6 10 47
= 47)
%
14.9 14.9 36.2 12.7 21.3 TOO
Pathologic analysis included. They are d e m o n - strated stage I in 33 patients (70.2%), stage 11 in 14 patients (29.8%), There were not stage ill and stage IV. The histopathologic distribution is also d e m o n - strated in table 3.
Table 3. Pathology
stage
Stage 1 Stage II Stage III Stage IV Total
Pathology Adenocarcinoma
28 10 0 0 38
Squamous cell 5 4 0 0
'
Total
33 14 0 0 47
The mean operative time was 170,5 ± 23.9 m i n - utes. The median chest tube duration was 48.1 ± 6.4 hours. The median time of hospitalization was 6,9 ± 3.7 days (range 6 - 1 8 days). Length of utility incision was 3.8 ± 0.6 cm. The operative and perioperative mortality were 0%. Postoperative complications in- cluded prolonged air leak (4.2%), hemothorax (2.1%).
Postoperative pain was described in Table 4
Degree of pain Degree 0 Degree 1 Degree 2 Degree 3 Degree 4 Degree 5 Total
n 0 0 18 25 4 0 22
%
0 0 38.3 53.2 8.5 0 100
The overall 36 - m o n t h sun/ival rate for entire cohort was 87.2%, for stage I was 93.9%, for stage 11 was 71.4%.
Survival Function
4, Discussion
There are many advantages of thoracoscopic lobectomy for non - small cell lung cancer: for ex- ample decreased blood loss, decreased pain, shorter hospitalization, more rapid return t o preoperative and working activity, preserved postoperative pul- monary function. These benefits are achieved with equivalent oncologic effectiveness [2], [7], [13).
Safety of thoracoscopic lobectomy has been addressed in many studies. In our study, no patient died intraoperatively. In Angellllo's study, including 1578 thoracoscopic lobectomies, only 1 patient died intraoperatively, secondary t o a myocardial infarc- t i o n . Conversion t o open lobectomy occurred in 1 patient (2.1%) In t h e study, which is consistent with t h e conversion rate of 1 % t o 1 1 % reported in most
100
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large series. Perioperative mortality in these series was 0%. These results indicate that thoracoscopic lobectomy is safe and efficacious, w i t h results c o m - parable t o t h o r a c o t o m y [1 ], [8].
Table 5. Literature Review Author
McKenna et al [8]
Yim e t a l [161 Roviaro et al [9]
Walker et al [15]
Keseda et al [6]
Swansonetal [14]
Daniels et al [3]
S o l a i n i e t a l [ l l ] Sugietal[12]
Present
n 1100
214 171 159 130 128 l i e 105 50 47
Conversion rate (%) 2.5 0.9 5.3 11.2 1.5 13 1.8 5.7 4.0 2.1
We used b o t h completed thoracoscopic lobec- t o m y (85.1%) and video assisted thoracoscopic lo- bectomy (12,8%) in our study. As proposed by Shi- gemura et al. totally endoscopic technique (or c o m - pleted thoracoscopic lobectomy) is defined as: (1) no use of rib expander; (2) if a small access w i n d o w is made, no work performed t h r o u g h t it; (3) perform- ing all operative work under thoracoscopy; (4) using no other instruments than those specialized for en- doscopic surgery [10].
Incision length is not an important factor de- termining t h e outcome of treatment. However, w i t h t h e same therapeutic effect, small incision is t h e more aesthetical and psychological for t h e patient t h a n large incision. Average incision length in our study was 3.8 ± 0.6 cm, much shorter than conven- tional open incision (8-12cm). Therefore, there are better postoperative rehabilitations and less pain than open lobectomy.
5. Conclusion
Figure 4. Thoracoscopy (A) and c o n v e n t i o n (B) incision [Our study]
Thoracoscopic lobectomy is applicable to early stage non-small cell lung cancer and is associated with a low perioperative morbidity and mortality rate.
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