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Ann Thorac Surg 1997;64:1869-1871
© 1997 The Society of Thoracic Surgeons
185 Livingston Ave, New Brunswick, Nj 08901
To the Editor:
We read Dr Kirby's Invited Commentary on our article, "One Hundred Video-Assisted Thoracic Surgical Simultaneously Stapled Lobectomies Without Rib Spreading" [1] with bewilderment. We believe every criticism he raised was answered in our article, so readdressing each of them at this time would be redundant and inappropriate.
His Invited Commentary is directed more at video-assisted thoracic surgery (VATS) in general than at VATS simultaneously stapled lobectomy without rib spreading [VATS(n)SSL]; nevertheless, two topics do deserve clarification: the use of VATS lobectomy for benign disease and its application for resection of mediastinal lymph nodes.
Regarding the first topic, Dr Kirby stated, "It is unusual that a lobectomy is required for benign disease" and focused on the inadequacy of VATS lobectomy, not specifically VATS(n)SSL, for the diagnosis and treatment of benign disease. He requested roentgenograms of all 8 patients in our series with benign disease, and these were sent to him with X-ray reports and clinical summaries. Four of these 8 patients had a known diagnosis of benign disease preoperatively, and each underwent a planned VATS(n)SSL successfully for their benign disease, ie, giant bulla replacing the entire right upper lobe, 10-cm infected intraparenchymal bronchogenic cyst, intralobar sequestration, and a large hamartoma deep within the pulmonary parenchyma. Lobectomy for each of these 4 patients was definitely indicated regardless of the surgical technique used. The other 4 patients had lesions suspected of being carcinoma.
In his criticism of VATS lobectomy for benign disease, Dr Kirby had more than adequate information for each patient, yet he chose not to discuss them as a group. Instead, he inexplicably decided to concentrate on a single, specific patient with an apparent peripheral lesion that was supposed to epitomize all of the intrathoracic pathology. He selected a single mediastinal window from the computed tomographic scan for this particular patient, and this roentgenogram was published along with his Invited Commentary as a true, unbiased representation of the lesion. According to our radiologists, mediastinal windows are unreliable and inaccurate for diagnosis or demonstration of pulmonary parenchymal disease. Of interest, the cut of that particular mediastinal window revealed only a portion of the true lesion. Actually, the pulmonary windows, which were given to Dr Kirby but not published, revealed a larger lesion that was surrounded by diffuse pulmonary infiltrates. At operation, the lobe in question was diffusely erythematous and edematous. Although a peripheral lesion measuring 2.5 cm could be identified on the computed tomographic scan, it was irregular in shape and resided in "boggy" pulmonary parenchyma on the large, ovoid surface of the lobe. It was easily identified at VATS exploration, but it was our opinion, during the operation, that a limited resection could carry a high risk because sutures or staples would cut through this diseased lung. Technically, a wedge resection could have been performed very easily, but it would have been the wrong operation. Postoperative pathologic evaluation revealed histoplasma organisms diffusely involving the inflamed pulmonary tissue. In this case, VATS did not limit our options, but instead allowed a complete and curative resection with an excellent recovery and discharge from the hospital on the fourth postoperative day. This patient was a noncompliant heroin addict with suspected acquired immunodeficiency syndrome. Postoperatively, he refused any further studies or treatments. Nevertheless, he made a complete, uneventful recovery because he had an appropriate operation.
It is our conclusion, after retrospective analysis, that each of these 8 patients with benign disease deserved a lobectomy and that a lobectomy would have been performed by us even if an open thoracotomy had been used for access to the pulmonary pathology instead of VATS. Figures 1A and 1B
are representative of our patients with benign disease undergoing a VATS(n)SSL.
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Video-assisted lobectomy for benign disease in only 8 of 100 patients, in whom 4 were known to have benign disease preoperatively, is better than most statistics found in the literature for lobectomy by open thoracotomy. Of course, during this period of time, we had numerous other patients with benign disease who had only a VATS wedge resection, and many of these patients were discharged on the same day of their operation. We would never knowingly perform a lobectomy for benign disease if a lesser resection would be sufficient; however, if malignancy is suspected and a lesser resection would compromise the function of the lobe, then we believe lobectomy is indicated. All of the remaining patients in this series had a malignancy, and according to the Lung Cancer Study Group each deserved a lobectomy [5].
The second topic for clarification is Dr Kirby's criticism of our low incidence of resected N2 disease. Again, he does not refer to VATS(n)SSL specifically but rather implies that VATS, in general, is not a suitable technique for staging pulmonary malignancies or for evaluating mediastinal lymph nodes. Obviously, this is not a valid supposition because numerous articles advocate VATS for staging and lymph node evaluation [6]. In fact, in each patient with a proven or suspected malignancy, we carefully evaluate every ipsilateral station and resect all nodes present for frozen section examination, when indicated, before performing a lobectomy.
We will not knowingly or intentionally perform a lobectomy when N2 disease is diagnosed because we cannot justify the very poor outcomes that result from this type of radical operation. Many surgeons, including ourselves, have known a few patients with N2 disease who have had good outcomes after resection and adjuvant therapy. We maintain that these purportedly good outcomes had little to do with the specific type of resection and adjuvant therapy but, more likely, were related to a favorable tumor biology. We make every effort to avoid this type of unnecessary resection by carefully evaluating all patients preoperatively for incurable disease before proceeding with lobectomy, using computed tomographic scan, cervical or parasternal mediastinoscopy, percutaneous fine-needle biopsy of mediastinal nodes, and VATS exploration for lymph nodes. If N2 disease is confirmed, we do not resect. Doctor Kirby criticized us because only 2 patients in our series had positive N2 disease. In reality, we failed in these 2 cases because each had a lobectomy when metastases were already present. Because these patients had very small, freely mobile, benign-appearing lymph nodes at operation, frozen section was not obtained. Malignant, microscopic deposits were diagnosed and confirmed only after review of the permanent slides. When positive N2 nodes are diagnosed during VATS exploration, it is our current policy not to perform a lobectomy for these incurable patients.
In fact, we agree with Goldstraw and associates' [7] statement that "the discovery of unexpected N2 disease at thoracotomy by routine nodal dissection carries serious implications," and "the surgeon must weigh the increased perioperative mortality against the severely reduced prospects for long-term survival." They add, "we believe resection is justified in these patients, who have already necessarily incurred the morbidity and mortality of thoracotomy" [7]. Because VATS exploration with lymph node resection does not incur the morbidity and mortality of a thoracotomy, we do not feel obligated to perform an unnecessary traumatic resection when incurable (N2) disease is present. Actually our VATS patients who undergo only lymph node staging and confirmation of N2 disease recover expeditiously, and most of them can be discharged on the same day or on the first postoperative day.
Rather than rebutting Dr Kirby's ingemination of the traditionalists' party line on VATS, which we have heard for several years, we will simply say that the thoracic surgeons on the University Thoracic Surgical Service, with an extensive combined experience with thousands of open, isolation-ligation lobectomies, have successfully and uneventfully performed 225 VATS(n)SSLs over a 5-year period for all patients meeting the criteria outlined in our article. We presented only our first 100 consecutive patients, when we were still on the learning curve, because we wanted an adequate period of follow-up for our cancer patients. Our second group of 100 consecutive patients has done even better, and their results will be published when follow-up for our cancer patients averages at least 3 years. For each case, in the entire group of 225 patients, there has been:
A review of surgical history informs us that many new surgical techniques, when first proposed, encountered harsh, unscientific criticism and rejection, eg, mitral valvulotomy, lobectomy for tuberculosis or carcinoma, cardiac bypass, pacemakers, and lumpectomy for breast carcinoma. We are not surprised or even dismayed that traditionalists harbor similar attitudes towards VATS and VATS(n)SSL. Video-assisted thoracic surgery is not for everyone because it requires different skills, different abilities, and different attitudes from those of traditional surgery.
In his last paragraph, Dr Kirby recommends that we read Forbidden Knowledge because we "have another example of acquiring new knowledge (VATS) but not yet the wisdom that should guide its application." We invite every surgeon who has ever performed lung volume reduction surgery to join with us in reading this book.
Finally, Mr William Walker of Edinburgh, Scotland, who was an early pioneer of VATS lobectomy and who has one of the largest series in the world, and his associates recently wrote, "as data continues to accumulate, we believe that it will become increasingly difficult to justify open thoracotomy for patients with Stage I bronchogenic carcinoma or benign lung lesions" [8]. We emphatically agree with them.
References
This article has been cited by other articles:
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  N. Durrleman and G. Massard Thoracic incisions - general considerations MMCTS, August 10, 2006; 2006(0810): 1420. [Abstract] [Full Text] [PDF]
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 M. F. Szwerc, R. J. Landreneau, R. S. Santos, R. J. Keenan, and G. F. Murray Minithoracotomy combined with mechanically stapled bronchial and vascular ligation for anatomical lung resection Ann. Thorac. Surg., June 1, 2004; 77(6): 1904 - 1910. [Abstract] [Full Text] [PDF]
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