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Ann Thorac Surg 2002;73:904
© 2002 The Society of Thoracic Surgeons
a Department of Surgery, Virginia Mason Clinic, 1100 Ninth Ave, Seattle, WA 98111-0900 USA
e-mail: gtsdel{at}vmmc.org
There are an increasing number of publications documenting the technical feasibility of video-assisted or thoracoscopic lobectomy. Typically these reports involve highly selected patients and originate in centers with significant experience in general thoracic and video-assisted surgery. Analysis of the collective publications on video assisted thoracic surgery (VATS) lobectomy indicate mortality rates of 0% to 2%, conversion rates of 0% to 25%, complications of 10% to 30%, and reports of "lymph node dissection" in up to 50% of cases.
Early outcome assessments of video-assisted lobectomy have suggested improved levels of pain, pulmonary function, and cytokine production, as well as suggesting potential benefits in cost and patient satisfaction. Retrospective comparisons have also indicated similar survival rates in patients with early stage lung cancer. On the other hand, there are separate reports, which have raised concerns regarding the increased propensity of tumor seeding both locally in the chest wall and systemically. There have also been indications that improvements in pain and pulmonary function may only be seen within the first one to two weeks and may not affect outcome.
The theme that dominates the current published data on VATS lobectomy is the fact that they are non-randomized, sometimes non-consecutive reports of a very highly selected subset of patients with lung cancer. Granting the early indications that VATS lobectomy can be done effectively and safely in selected patients, there remains the reality that in spite of current regimented and invasive methods, patients with pathologic early lung cancer can be singled out within the major cancer groups as the most likely to be understaged. The question that remains is not whether a VATS lobectomy is feasible, but whether it is a good cancer operation.
The article by Sagawa and colleagues confronts this issue in a way which is far more valid and interpretable than the majority of previous publications where lymph node staging is not mentioned, or reported simply as number of lymph nodes removed without evidence indicating the adequacy of dissection. Sagawa has reported a very high yield of lymph nodes with VATS lobectomy (mean yield, 40.3 nodes right lobectomy, 37.1 nodes, left lobectomy). In addition, they have taken the process one step further by following the VATS lobectomy and lymph node dissection with a standard thoracotomy with lymph node dissection by a different surgeon, which yielded a mean of less than 2 additional nodes missed with VATS dissection in each patient.
More importantly, both dissections involved removing nodes from all 13 stations (American Thoracic Society) and N1 or N2 disease was discovered in 9 of 29 (31%) of patients following VATS nodal dissection with no additional positive nodes discovered following open thoracotomy. This report provides the first real objective indication of the ability to maintain good cancer principles with VATS lobectomy.
However, did the authors carry out what would currently be considered a standard VATS lobectomy? They describe a 7 cm–8 cm (mini-thoracotomy) using a "retractor" which I assume was a rib spreader. They describe doing 50% of the resection under "direct vision" and ligated and transected pulmonary artery branches through the "small thoracotomy." The stated advantages of thoracoscopic and video assisted surgery is to limit rib and muscle incision and retraction to facilitate a straightforward recovery. Since all the patients in this series went on to thoracotomy, no meaningful assessment of pain or other quality of life parameters could be made.
In addition, even though the adequacy of VATS nodal dissection appears excellent, hilar nodes were missed in three patients (10%), and in spite of careful preoperative patient selection six patients (17%) required conversion to thoracotomy prior to lobectomy and lymph node dissection. The majority of these conversions (4 of 6) were for oncologic reasons related to the inability to carry out the required procedure with VATS technique alone.
The article by Sagawa and associates is a unique substantiation in humans that video-assisted thoracic surgical techniques can in appropriate hands be utilized not only for pulmonary resection, but appropriate lymph node staging. The authors note that the study was done with IRB approval and full informed consent. However, I believe this study would be at best difficult, and more likely impossible, to replicate in North America.
As indicated by the authors, the true assessment of the place of video-assisted techniques in patients with lung cancer awaits prospective controlled randomized trials comparing outcomes and survival parameters with up-to-date open techniques.
Related Article
Ann. Thorac. Surg. 2002 73: 900-904.
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