|Year : 2014 | Volume
| Issue : 6 | Page : 37-41
Short term curative effect of video assisted thoracoscopic lobectomy for early-stage lung cancer
HB Cai, YX Li, Z Li
Department of Thoracic Surgery, Jining No.1 People's Hospital, Jining 272011, China
|Date of Web Publication||24-Feb-2015|
Dr. Y X Li
Department of Thoracic Surgery, Jining No.1 People's Hospital, Jining 272011
Source of Support: None, Conflict of Interest: None
Objective: To investigate the feasibility, safety and short term efficacy of video assisted thoracoscopic (VATS) lobectomy for patients with early-stage lung cancer. Methods: We reviewed clinical data of 138 consecutive patients with early stage lung cancer who underwent lobectomy in the First People's Hospital of Jining during the January 2010 to May 2012. Of them, 71 cases were performed complete VATS, male 39 cases, female 32 cases, age (57.9 ± 10.6) years old; 67 cases were performed thoracotomy, male 36 cases, female 31 cases, age (60.3 ± 8.2) years old. Clinical features were collected and compared. Results: Operations of two groups were successfully finished. Compared with thoracotomy group, the differences in intraoperative blood loss (147 ± 113 ml vs. 146 ± 91 ml), number of lymph node dissection group (3.1 ± 1.3 vs. 3.4 ± 1.3), the number of lymph node dissection (9.9 ± 3.6 vs. 10.0 ± 3.6), and vision analog score (VAS) of postoperative 1st and 3rd day in VATS group were not statistically significant (P > 0.05). Statistical differences were observed in operation time (119 ± 27 min vs. 135 ± 29 min), the thoracic drainage tube time (3.0 ± 0.9 d vs. 3.8 ± 1.2 d), postoperative hospital stay (8.0 ± 2.1 d vs. 10.2 ± 5.4 d), postoperative VAS of 30th day (2.6 ± 0.7 vs. 3.2 ± 1.1), and postoperative complications (8.5% vs. 19.4%) between the two groups (P < 0.05). Conclusion: Video assisted thoracoscopic lobectomy for early lung cancer is safe and effective, with fewer traumas, fewer complications, faster postoperative recovery, milder chronic chest pain, and other advantages. At the same time, the lymph node dissection of VATS lobectomy is similar to that of thoracotomy.
Keywords: Lobectomy, lung cancer, lymph node dissection, video assisted thoracoscopic surgery
|How to cite this article:|
Cai H B, Li Y X, Li Z. Short term curative effect of video assisted thoracoscopic lobectomy for early-stage lung cancer. Indian J Cancer 2014;51, Suppl S2:37-41
|How to cite this URL:|
Cai H B, Li Y X, Li Z. Short term curative effect of video assisted thoracoscopic lobectomy for early-stage lung cancer. Indian J Cancer [serial online] 2014 [cited 2021 Dec 1];51, Suppl S2:37-41. Available from: https://www.indianjcancer.com/text.asp?2014/51/6/37/151993
| » Introduction|| |
At present, lung cancer has become the most common cancer in men worldwide, accounting for 17% of new cancer cases and 23% of the death cases.  The morbidity and mortality increased sharply in the developing world, especially in female patient. , In China, lung cancer becomes the most common cancer and the leading cancer death both in urban and rural areas. , Although there are many methods for treating lung cancer at present, the recognized option of choice for the treatment of early-stage and mid-stage nonsmall cell lung cancer (NSCLC) is surgical excision and the standard surgical approach is lobectomy combined with systematic lymph node dissection. The past decade has seen an increase in the use of video assisted thoracoscopic (VATS) for early stage lung cancer. With the accumulation of experience and widespread use of technological innovation worldwide, VATS lobectomy has been developing rapidly since the 1990s. ,, Many published studies had demonstrated encouraging outcomes of this procedure when compared with conventional thoracotomy, including reduced incidence of arrhythmias, pneumonia, pain and lower levels of inflammatory markers, shorter length of hospital stay, milder pain, less intraoperative blood loss, more rapid return to normal activities, earlier ability to receive adjuvant therapy, and higher postoperative quality of life. ,,,,,, In 2006, minimally invasive surgical treatment of lung cancer was written in NSCLC clinical practice guidelines of National Comprehensive Cancer Network (NCCN).  The 2013 version of the NCCN guidelines recommended that VATS is a reasonable and acceptable approach for patients with no anatomic or surgical contraindications, as long as there is no compromise of standard oncologic dissection principles of thoracic surgery.  Despite encouraging results were achieved for patients with NSCLC who underwent VATS, there are many doubts regarding the role of VATS in lobectomy for the treatment of lung cancer. ,
Video assisted thoracoscopic lobectomy for NSCLC was implemented in March 2007 in our unit, and the procedure is performed skilled. The objective of this study is to further confirm the superiority of VATS lobectomy for NSCLC to thoracotomy.
| » Materials and Methods|| |
Clinical data and grouping
This study was approved by the institutional review board of the First People's Hospital of Jining. Written informed consent was obtained from each patient.
In this retrospective study, we reviewed clinical data of 207 consecutive patients with early stage lung cancer who underwent lobectomy in the First People's Hospital of Jining during the January 2010 to May 2012. Patient's characteristics and clinical data were collected from individual patient records and then analyzed in an electronic database anonymously. The majority of patients without obvious clinical symptoms and the lesions were found mainly by means of the medical examination. All the operations were performed by 3 surgeons and 1 of them conducted VATS operations. Of these 207 patients, patients received neoadjuvant therapy, bi-lobectomy or pneumonectomy and patients with tumor >5 cm in diameter were excluded. Eventually, 138 patients with clinical stage I and stage II NSCLC, who underwent lobectomy, were included to this retrospective observational study. Of them, 71 cases received VATS, and 67 cases received thoracotomy.
Pathologic evidence of lung cancer was obtained in all patients by transbronchial biopsy, sputum cytology, or transcutaneous lung biopsy under computed tomography (CT) guidance. If no prior preoperative pathologic diagnosis was established, intraoperative frozen section specimens confirmed the pathologic diagnosis. All patients underwent CT scan of the lung and upper abdomen, bone scintigraphy scan and magnetic resonance imaging of the brain to rule out the extrathoracic metastasis of the disease prior to surgery. Tumor staging was according to the 7 th edition of the TNM (UICC) classification. Various factors including age, sex, pathological type, location, operative duration, blood loss, lymph node dissection, TNM stage, time of drainage, duration of hospitalization and complications were compared between two groups. The Clinical features are shown in [Table 1].
All patients underwent general anesthesia with double lumen endotracheal intubation and single lung ventilation. The patient was placed in the lateral decubitus position. The surgeon stood at the ventral position of the patient, and the whole operation procedure was implemented according to thoracoscopic display. Thoracoscopic lobectomy was performed through three or four incisions. We placed thoracoscope in the 7 th or 8 th intercostal space in the middle or anterior axillary line. The main operating port incision was located at the anterior axillary line in the 4 th or 5 th intercostal space, and the length was about 3 cm, and the port just facing hilus of the lung was best. The 1.5 cm auxiliary operating port was placed in the triangle of auscultation. If necessary, we added second auxiliary operating port at the posterior axillary line in the 8 th or 9 th intercostal space. Ribs were not retracted. The lung and the pleural space were carefully inspected for the presence of unexpected metastatic disease. According to the different situations of fissures, the management sequence of pulmonary arteries, veins and bronchial was different. Pulmonary artery, vein, bronchus, and fissure were divided using an Endoscopic Linear Cutters. The pulmonary artery with smaller diameter (<7 cm) was ligated using Hem-o-lok. Systematic lymph node dissection was performed conventionally. The sequence of conventional thoracotomy lobectomy was basically similar to that of lobectomy performed via thoracoscopy.
Operation time, intraoperative blood loss, number of lymph node dissection group, the number of lymph node dissection, the thoracic drainage tube time, postoperative hospital stay, vision analogue score (VAS) of postoperative 1 rd , 3 rd , 30 th day, and postoperative complications were assessed for each patient. Perioperative data of the two groups are shown in [Table 2] and [Table 3].
Early postoperative ambulation was performed in two groups. The pleural cavity was irrigated with Iodophor disinfection solution for patients with poor quality of lung and postoperative pulmonary air leakage time lasting >7 days. Drainage volume <150 ml, drainage liquid with shallow color, no air leakage, and a good pulmonary inflation by chest X-ray were the decannulation indication of thoracic drainage tube.
All patients underwent follow-up after surgery. The death, tumor recurrence or other adverse events were recorded.
The SPSS 17.0 software (SPSS Inc., USA) was used for the statistical analysis. Variables were compared between the VATS and the thoracotomy groups. Student t-test and Chi-square or Fisher's exact test were applied for analysis of continuous variables and categorical data respectively. A possibility value of 0.05 or less was considered statistically significant.
| » Results|| |
The characteristics of the two groups are shown in [Table 1]. There was no significant difference in gender, age, location of the tumor, histologic type and pTNM stage between the two groups. Among 138 patients with NSCLC, 71 cases were performed VATS, male 39 cases, female 32 cases, age (57.9 ± 10.6) years old; 67 cases were performed thoracotomy, male 36 cases, female 31 cases, age (60.3 ± 8.2) years old. In VATS group, 2 cases were converted to thoracotomy for lymph node and left truncus anterior artery tight adhesion. Surgical procedures were performed successfully in both groups. The main postoperative complications included pulmonary infection, arrhythmia (atrial fibrillation), poor lung reexpansion, and persistent air leakage (lasting ≥7 days). There were 1 case chylothorax and 1 case bronchopleural fistula in VATS and thoracotomy group respectively, cured by conservative therapy. Perioperative death occurred in one case in the thoracotomy group, caused by acute respiratory distress syndrome.
Compared with thoracotomy group, VATS group intraoperative blood loss (147 ± 113 ml vs. 146 ± 91 ml), number of lymph node dissection group (3.1 ± 1.3 vs. 3.4 ± 1.3), the number of lymph node dissection (9.9 ± 3.6 vs. 10.0 ± 3.6), and VAS of postoperative 1 rd and 3 rd day were not statistically significant (P > 0.05). There were statistical differences in operation time (119 ± 27 min vs. 135 ± 29 min), the thoracic drainage tube time (3.0 ± 0.9 d vs. 3.8 ± 1.2 d), postoperative hospital stay (8.0 ± 2.1 d vs. 10.2 ± 5.4 d), VAS of postoperative 30 th day (2.6 ± 0.7 vs. 3.2 ± 1.1), and postoperative complications (8.5% vs. 19.4%) between the two groups (P < 0.05).
Totally, 59 cases were followed-up in VATS group, the rate of follow-up was 83.1%, and the median postoperative follow-up period was 8 months (range, 3-17 months). There were 1 case brain metastasis and 1 case hepatic metastasis, and the remaining patients were found no abnormality by imaging examination. In thoracotomy group, 58 cases were followed-up, the rate of follow-up was 86.6%, and the median postoperative follow-up period was 9 months (range, 2-18 months). 1 case mediastinal lymph nodes enlargement in and 2 cases bone metastasis were diagnosed in the group. There was no death in two groups.
| » Discussion|| |
With people's health awareness growing and improvement in imaging technology, more and more early-stage lung cancer was diagnosed.  So, we must choose an optimal procedure for the treatment of lung cancer to reduce the mortality rate. According to evidence-based medicine, there is no significant difference between curative effect of thoracoscopic lobectomy and thoracotomy lobectomy for stage I NSCLC. ,,,,,, However, adopting VATS or thoracotomy for the treatment of early stage lung cancer has been controversial, and conflicting evidence exists in the form of large retrospective studies that failed to show any significant benefit from VATS.  Its adoption has been variable, likely due to perceived technical challenges when compared to an open approach and a concern for intraoperative complications, especially whether VATS is radical or not.  Complete mediastinal lymphadenectomy is the core component of the multidisciplinary therapy in resectable NSCLC. Murthy et al. reported that in patients with early-stage lung cancer, thorough lymphadenectomy might confer an important survival benefit even if sampled lymph nodes were found to be negative.  Whether VATS allows thorough mediastinal lymph node dissection and can achieve comparable effects to thoracotomy have been controversial. At present, compared with thoracotomy, the results varied in different reported studies on the use of VATS for lobectomy combined with lymphadenectomy of resectable NSCLC. ,,,,, In this study, the range of lymphadenectomy met the NCCN Clinical Practice Guidelines in both groups.  And the number of lymph node dissection station and the number of lymph node dissection were 3.1 ± 1.3 and 9.9 ± 3.6 respectively in VATS group, while it were 3.4 ± 1.3 and 10.0 ± 3.6 respectively in thoracotomy group. There was no significant differences between the two groups (P > 0.05), which is consistent with previous reports. ,, VATS can provide a good surgical field, and the mediastinal structures can be more clearly identified and exposed. In this way, we are able to clean out more mediastinal lymph node, reducing the incidence of residual lymph nodes.
The safety of VATS lobectomy in combination with systematic lymphadenectomy for esectable NSCLC is another concern. Compared with thoracotomy group, VATS group intraoperative blood loss (119 ± 27 min vs. 135 ± 29 min), the thoracic drainage tube time (3.0 ± 0.9 d vs. 3.8 ± 1.2 d), postoperative hospital stay (8.0 ± 2.1 d vs. 10.2 ± 5.4 d), and postoperative complications (8.5% vs. 19.4%) were statistically significant (P < 0.05), which is consistent with previous studies. ,,, The reasons for this result are that VATS incision is obviously smaller than that in thoracotomy, not affecting the most of chest muscles, not cutting and shoving off the rib, and avoiding intercostal nerve damage. And accurate dissection without damaging small blood vessels and lymph nodes, reduces lymphatic drainage and the occurrence of postoperative chylothorax, allowing earlier postoperative extubation and shorter postoperative hospital stays. And VATS shortens the thoracic open and close time, reduces the bleeding and oozing caused by large incision, accelerates postoperative recovery too, compared with the traditional thoracotomy.
In VATS group, chylothorax occurred in 1 case with right upper lung lobe cancer and the postoperative thoracic drainage around 500 ml every day, cured by conservative therapy. The reason may be the thoracic duct branch was injured when we performed lymph node dissection at 2R and 4R group. A total of 6 patients experienced postoperative pulmonary air leakage lasting time >7 days in two groups. The patients were cured by the Iodophor disinfectant pleural lavage, and chest drainage tubes were removed within 10 days. The specific mechanism and effect of Iodophor disinfection solution for the treatment of postoperative pulmonary air leakage need further verification. In VATS group, the rate of conversion to thoracotomy was low, which might benefit from the rational selection of patients and skilled operation.
Compared with thoracotomy group, VAS of postoperative 1 st , 3 rd , and 30 th day had the advantage in VATS group (P < 0.05), as seen similarly in other studies. , The main reason might be the intercostal nerve, which was crushed by careless operation and compressed by postoperative drainage tube. The large trauma of thoracotomy made patients can't cough hard enough to clear the airways and have late ambulation. Which placed them at higher risk for complications including increased incidence of arrhythmias, pneumonia, atelectasis. 
In our clinical work, we summarize some experiences, and we must emphasize that this procedure should be performed only by experienced thoracic surgeons for a selective indication in clinical practice. Our experience is as follows: (1) The quality and precision of thoracoscopic dissection is superior to thoracotomy. With the help of the advantage, operation should be performed step by step, controlling hemorrhage and staxis, keeping the operative field and vision clean. (2) The pulmonary artery should be dissected sufficient length, to avoid damage to the branch of targeted pulmonary artery, which supplies blood for nontargeted lung lobe. Nail pulmonary artery processed by Endoscopic Linear Cutters, sometimes may cause hemorrhage because of twist and pull. We can choose the vascular clamp or Hem-o-lok or silk ligature. (3) Conversion from video-assisted thoracoscopic lobectomy to thoracotomy or video-assisted minithoracotomy should be promptly performed in case of tumor invasion, lymph node calcification on the targeted pulmonary vessels, or intraoperative hemorrhage, etc. (4) The damage to the branch of thoracic duct should be found and treated in time, when we implement dissection of 4R group lymph node; the left recurrent laryngeal nerve should arouse our attention to avoid the nerve injury when we clean the 4 L group lymph nodes; In the left chest operation, dissection of 7 th group of lymph node should be performed before lobectomy because carinal exposure is difficult and tissue stretch easily leads to rupture of blood vessels and bronchial stump injury; we should pay attention to the interspace of lymph nodes and esophagus, to avoid injury of esophagus in both sides of 7 th group lymphadenectomy. (5) Compared to thoracotomy, extensive pleural adhesion released by thoracoscopy has the advantage of having full view.
| » Conclusion|| |
The results of the current study demonstrate that completely thoracoscopic lobectomy is safe, feasible and effective for the treatment of early lung cancer, with smaller trauma, fewer complications, faster postoperative recovery and slighter chronic chest pain. We believe that with the development of clinical skills and thoracoscopic techniques, minimally invasive operation will gradually become the first choice for treatment of lung cancer.
Some limitations in the present study need to be acknowledged. First, the limitations of this study include the retrospective analysis, selection bias, and single institutional study. Second, the sample size was small and follow-up period was relative short. Longer follow-up and more patients' number in both groups may make the results more convincing.
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[Table 1], [Table 2], [Table 3]