Bilateral staged uniportal VATS for synchronous lung cancers
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《血管的通路杂志》
Unit of Thoracic Surgery, ‘Umberto I’ Regional Hospital, Ancona, Italy
Abstract
We report a case of bilateral staged uniportal video-assisted thoracic surgery (VATS) pulmonary resections for synchronous early stage squamous cell carcinoma in a patient with limited respiratory reserve. Wide wedge resections and lymph nodes sampling were performed. Postoperative respiratory function and pain scores were unaffected by the bilateral operations. Uniportal VATS proved to be a feasible alternative to more traditional procedures (three portal VATS or minithoracotomy) in case lesser resections are required for compromised respiratory function and may contribute to increase operability in high-risk patients.
Key Words: Thoracoscopy/VATS; Minimally invasive surgery; Lung cancer surgery; Pulmonary function testing; Pain
1. Introduction
Uniportal VATS has been shown to be an effective technique for the treatment and diagnosis of many intrathoracic conditions. It allows a wide exposure of the lung, pleura and mediastinum and, compared to the traditional tri-portal access, may reduce postoperative chest pain and shorten the hospital stay [1–3].
Uniportal VATS wedge resection has been described for the diagnosis of interstitial lung disease, solitary pulmonary nodules or for treatment of spontaneous primary pneumothoraces [1–3]. The minimal invasiveness of this technique makes it suitable in those patients with lung cancer and marginal respiratory function, in whom thoracotomy may represent per se a major risk factor due to impaired respiratory mechanics.
In this regard, we describe a case of staged bilateral uniportal VATS wedge resections for synchronous early stage squamous cell carcinoma in a patient with airflow limitation, in whom bilateral thoracotomies and major lung resections were deemed at prohibitive risk for his compromised respiratory reserve.
2. Clinical summary
A 72-year-old patient was referred to our center for bilateral pulmonary nodules: one in the left lower lobe and the other in the right upper lobe. At the time of presentation, the patient was asymptomatic with the exception of exertional dyspnea. Fig. 1 depicts his preoperative CT scan of the chest. The left lower lobe nodule underwent trans-parietal biopsy which revealed a squamous cell carcinoma. A trans-parietal biopsy of the right upper lobe nodule was attempted but resulted non-diagnostic. Nevertheless, both nodules were positive on PET scan. Evaluation for metastatic disease was negative and CT scan showed no enlarged mediastinal lymph nodes.
The nodules were considered as synchronous clinical stage I lung cancers. Due to his preoperative pulmonary function (Table 1), the patient was deemed unsuitable for bilateral thoracotomies and lobectomies. Therefore, in order to minimize the trauma to the chest wall and for the clinical early stages of both lung neoplasms, we planned a bilateral staged uniportal VATS approach. We firstly operated on the left side. The uniportal VATS technique has been described in detail elsewhere [1–3].
Briefly, a 2.5-cm incision was performed on the left side in the fifth intercostal space along the posterior axillary line, and a 5-mm videothoracoscope (30°) and roticulating instruments (Endo-GIA Universal and Roticulator Endograsp, Tyco Healthcare) were introduced through the same port. We performed a wedge resection (total staple line length 315 mm, margins were free of disease at frozen section) in the left lower lobe and sub-carinal lymph nodes sampling. The patient was discharged after 3 days without any complications.
After 5 weeks (the patient refused to be operated on early), we operated on the right side by using a similar incision and the same technique. In this case a wedge resection was performed in the posterior segment of the right upper lobe (total staple line length 285 mm, margins were free of disease at frozen section) along with right paratracheal lymph nodes sampling. Even in this case, the patient was discharged after 3 days without any complication.
Histology revealed, on the left side, a squamous cell carcinoma with a diameter of 1.8 cm and on the right side, a squamous cell carcinoma with mixed areas of clear cell carcinoma with a diameter of 2 cm. No mediastinal lymph nodes metastases were found. Therefore, both lesions were staged as pT1N0.
As shown in Table 1, postoperative pulmonary functions were unaffected by both operations as evaluated at one month postoperatively. Moreover, pain scores and maximal inspiratory and expiratory pressures measured at the mouth of the patient confirmed the minimal invasiveness of this bilateral uniportal approach on chest wall mechanics.
3. Discussion
We showed that uniportal VATS may be a valuable and feasible technique even in those circumstances in which cardio-respiratory function would preclude more invasive bilateral approaches, such as in the case herein presented. Uniportal access allowed us to perform wedge resections and mediastinal lymph nodes sampling bilaterally.
Wedge resections constitute a large part of the common surgical practice in Europe and in the USA for the treatment of compromised patients with non-small cell lung cancer (NSCLC), ranging from 15.6 to 26.4% [4,5] of all lung resections. In addition, these lung-sparing procedures are not without risk, and their mortality rate may even reach 5% in some circumstances [5]. Therefore, we think that whenever a compromised resection is required for severe co-morbidities in patients with NSCLC, the less invasive approach as possible should be selected. In this regard, uniportal VATS, whenever technically feasible, is in our view a valuable alternative for the treatment of high-risk lung resection candidates, which may contribute to increase their operability.
References
Rocco G, Martin-Ucar A, Passera E. Uniportal VATS wedge pulmonary resection. Ann Thorac Surg 2004; 77:726–728.
Rocco G, Khalil M, Jutley R. Uniportal video-assisted thoracoscopic surgery wedge lung biopsy in the diagnosis of interstitial lung diseases. J Thorac Cardiovasc Surg 2005; 129:947–948.
Jutley RS, Khalil MW, Rocco G. Uniportal vs. Three port VATS technique for spontaneous pneumothorax: comparison of postoperative pain and residual paraesthesia. Eur J Cardiothorac Surg 2005; 28:43–46.
Berrisford R, Brunelli A, Rocco G, Treasure T, Utley M. On behalf of the audit and guidelines committee of the European Association for Cardiothoracic Surgery and the European Society of Thoracic Surgeons. The European Thoracic Surgery Database Project: modelling the risk of in-hospital death following lung resection. Eur J Cardiothorac Surg 2005; 28:306–311.
Little AG, Rush VW, Bonner JA, Gaspar LE, Green ME, Webb WR, Stewart AK. Patterns of surgical care of lung cancer patients. Ann Thorac Surg 2005; 80:2051–2056.(Alessandro Brunelli, Fran)
Abstract
We report a case of bilateral staged uniportal video-assisted thoracic surgery (VATS) pulmonary resections for synchronous early stage squamous cell carcinoma in a patient with limited respiratory reserve. Wide wedge resections and lymph nodes sampling were performed. Postoperative respiratory function and pain scores were unaffected by the bilateral operations. Uniportal VATS proved to be a feasible alternative to more traditional procedures (three portal VATS or minithoracotomy) in case lesser resections are required for compromised respiratory function and may contribute to increase operability in high-risk patients.
Key Words: Thoracoscopy/VATS; Minimally invasive surgery; Lung cancer surgery; Pulmonary function testing; Pain
1. Introduction
Uniportal VATS has been shown to be an effective technique for the treatment and diagnosis of many intrathoracic conditions. It allows a wide exposure of the lung, pleura and mediastinum and, compared to the traditional tri-portal access, may reduce postoperative chest pain and shorten the hospital stay [1–3].
Uniportal VATS wedge resection has been described for the diagnosis of interstitial lung disease, solitary pulmonary nodules or for treatment of spontaneous primary pneumothoraces [1–3]. The minimal invasiveness of this technique makes it suitable in those patients with lung cancer and marginal respiratory function, in whom thoracotomy may represent per se a major risk factor due to impaired respiratory mechanics.
In this regard, we describe a case of staged bilateral uniportal VATS wedge resections for synchronous early stage squamous cell carcinoma in a patient with airflow limitation, in whom bilateral thoracotomies and major lung resections were deemed at prohibitive risk for his compromised respiratory reserve.
2. Clinical summary
A 72-year-old patient was referred to our center for bilateral pulmonary nodules: one in the left lower lobe and the other in the right upper lobe. At the time of presentation, the patient was asymptomatic with the exception of exertional dyspnea. Fig. 1 depicts his preoperative CT scan of the chest. The left lower lobe nodule underwent trans-parietal biopsy which revealed a squamous cell carcinoma. A trans-parietal biopsy of the right upper lobe nodule was attempted but resulted non-diagnostic. Nevertheless, both nodules were positive on PET scan. Evaluation for metastatic disease was negative and CT scan showed no enlarged mediastinal lymph nodes.
The nodules were considered as synchronous clinical stage I lung cancers. Due to his preoperative pulmonary function (Table 1), the patient was deemed unsuitable for bilateral thoracotomies and lobectomies. Therefore, in order to minimize the trauma to the chest wall and for the clinical early stages of both lung neoplasms, we planned a bilateral staged uniportal VATS approach. We firstly operated on the left side. The uniportal VATS technique has been described in detail elsewhere [1–3].
Briefly, a 2.5-cm incision was performed on the left side in the fifth intercostal space along the posterior axillary line, and a 5-mm videothoracoscope (30°) and roticulating instruments (Endo-GIA Universal and Roticulator Endograsp, Tyco Healthcare) were introduced through the same port. We performed a wedge resection (total staple line length 315 mm, margins were free of disease at frozen section) in the left lower lobe and sub-carinal lymph nodes sampling. The patient was discharged after 3 days without any complications.
After 5 weeks (the patient refused to be operated on early), we operated on the right side by using a similar incision and the same technique. In this case a wedge resection was performed in the posterior segment of the right upper lobe (total staple line length 285 mm, margins were free of disease at frozen section) along with right paratracheal lymph nodes sampling. Even in this case, the patient was discharged after 3 days without any complication.
Histology revealed, on the left side, a squamous cell carcinoma with a diameter of 1.8 cm and on the right side, a squamous cell carcinoma with mixed areas of clear cell carcinoma with a diameter of 2 cm. No mediastinal lymph nodes metastases were found. Therefore, both lesions were staged as pT1N0.
As shown in Table 1, postoperative pulmonary functions were unaffected by both operations as evaluated at one month postoperatively. Moreover, pain scores and maximal inspiratory and expiratory pressures measured at the mouth of the patient confirmed the minimal invasiveness of this bilateral uniportal approach on chest wall mechanics.
3. Discussion
We showed that uniportal VATS may be a valuable and feasible technique even in those circumstances in which cardio-respiratory function would preclude more invasive bilateral approaches, such as in the case herein presented. Uniportal access allowed us to perform wedge resections and mediastinal lymph nodes sampling bilaterally.
Wedge resections constitute a large part of the common surgical practice in Europe and in the USA for the treatment of compromised patients with non-small cell lung cancer (NSCLC), ranging from 15.6 to 26.4% [4,5] of all lung resections. In addition, these lung-sparing procedures are not without risk, and their mortality rate may even reach 5% in some circumstances [5]. Therefore, we think that whenever a compromised resection is required for severe co-morbidities in patients with NSCLC, the less invasive approach as possible should be selected. In this regard, uniportal VATS, whenever technically feasible, is in our view a valuable alternative for the treatment of high-risk lung resection candidates, which may contribute to increase their operability.
References
Rocco G, Martin-Ucar A, Passera E. Uniportal VATS wedge pulmonary resection. Ann Thorac Surg 2004; 77:726–728.
Rocco G, Khalil M, Jutley R. Uniportal video-assisted thoracoscopic surgery wedge lung biopsy in the diagnosis of interstitial lung diseases. J Thorac Cardiovasc Surg 2005; 129:947–948.
Jutley RS, Khalil MW, Rocco G. Uniportal vs. Three port VATS technique for spontaneous pneumothorax: comparison of postoperative pain and residual paraesthesia. Eur J Cardiothorac Surg 2005; 28:43–46.
Berrisford R, Brunelli A, Rocco G, Treasure T, Utley M. On behalf of the audit and guidelines committee of the European Association for Cardiothoracic Surgery and the European Society of Thoracic Surgeons. The European Thoracic Surgery Database Project: modelling the risk of in-hospital death following lung resection. Eur J Cardiothorac Surg 2005; 28:306–311.
Little AG, Rush VW, Bonner JA, Gaspar LE, Green ME, Webb WR, Stewart AK. Patterns of surgical care of lung cancer patients. Ann Thorac Surg 2005; 80:2051–2056.(Alessandro Brunelli, Fran)