Ann Thorac Surg 2003;76:2079-2080
© 2003 The Society of Thoracic Surgeons
Case report
Combined video-assisted thoracoscopic lung volume reduction surgery and lobectomy in a high-risk patient
James W. Klena, MDa*,
Arthur F. Saari, MD, FCCPb,
David O. Peterson, MDc,
Christianne Collins, CNPa,
Joel A. Johnson, MD, FACSa
a Department of Cardiothoracic Surgery, Marquette General Hospital, Marquette, Michigan, USA
b Department of Pulmonary Medicine, Marquette General Hospital, Marquette, Michigan, USA
c Department of Anesthesia, Marquette General Hospital, Marquette, Michigan, USA
Accepted for publication April 8, 2003.
* Address reprint requests to Dr Klena, 528 Bishop Woods Road, Marquette, MI 49855, USA
e-mail: jwklena{at}yahoo.com
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Abstract
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Nonsmall cell lung cancer often occurs in patients with severe emphysema. Lobectomy in these patients is often contraindicated due to extensive parenchymal destruction and subsequent pulmonary insufficiency. Video-assisted thoracoscopic lobectomy has been described as a less morbid procedure in high-risk patients. Lung volume reduction surgery has been shown to improve pulmonary function in selected patients with emphysema. We describe the successful combination of lobectomy and lung volume reduction surgery (LVRS) with a video-assisted thoracoscopic (VATS) approach in a high-risk patient with Stage I nonsmall cell lung cancer.
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Introduction
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Video-assisted thoracoscopic surgery (VATS) has been successfully used to perform minimally invasive lobectomy in high-risk patients with nonsmall cell lung cancer [1]. Video-assisted thoracoscopic surgery has also been utilized for the unilateral or bilateral treatment of emphysema with lung volume reduction surgery (LVRS) [2]. Poor pulmonary function tests due to extensive tissue destruction from emphysema are a common reason for a patient to be classified as high risk and thus not be considered a candidate for standard lobectomy through a posterolateral thoracotomy [3]. Video-assisted thoracoscopic surgery provides a means by which lobectomy for an early stage nonsmall cell lung cancer can be combined with resection of emphysematous lung parenchyma in a minimally invasive fashion. The combined procedure offers the patient a chance for cure from their neoplastic process as well as providing the possibility of a paradoxical improvement in their respiratory function. We present the case of a 76-year-old male with severe emphysema and a Stage I nonsmall cell lung cancer successfully treated with combined video-assisted thoracoscopic lobectomy and unilateral lung volume reduction surgery.
A 76-year-old male with an 80-pack-year smoking history was referred to our service after a computed tomography guided biopsy of a right lower lobe mass revealed nonsmall cell lung cancer. The patient also had a long history of emphysema and was dependent upon 2 L/min of oxygen for most of his activities. His preoperative computed tomography scan revealed a bilateral heterogeneous pattern of emphysema as well as a 3-cm nodular lesion in the right lower lobe (Fig 1).
An arterial blood gas was obtained which revealed a pH of 7.37, a PCO2 of 62 mm Hg, a HCO3 of 36 mm Hg, a PO2 of 83 mm Hg, and an O2 saturation of 95% on 2 L of oxygen. After review of the arterial blood gas results and the initial pulmonary function tests (Table 1)
it was initially decided to deny the patient surgical resection. It was noted, however, that the patient had quit smoking two and one half years earlier and participated in a weekly lung disease support group; because of his high degree of motivation, a lung perfusion study was obtained to help determine resectability.
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Fig 1. Computed tomography scan of the chest revealing heterogeneous pattern of emphysema and superior pole of right lower lobe mass (arrow).
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Although the results of the preoperative pulmonary function tests were poor, the lung perfusion study revealed the contribution of the patient's tumor containing right lower lobe to be only 8% of his overall lung perfusion. This finding, and the heterogeneous pattern of emphysema that the patient demonstrated, prompted the consideration of performing a combined right lower lobectomy and unilateral stapled lung volume reduction surgery in an attempt to resect the patient's lung cancer. Because of his poor pulmonary function, a VATS procedure was planned in the hope that it would lessen perioperative morbidity and optimize his recovery [4].
A right bronchial blocker was used for selective ventilation of the left lung. The patient was placed in a left lateral decubitus position and a 0-degree thoracoscope was introduced through the eighth intercostal space in the midaxillary line. Several areas of thin adhesions were taken down with cautery and the right pleural space was explored. An 8-cm utility incision was then made in the fifth intercostal space centered over the major fissure with aid from the thoracoscope to facilitate dissection of the pulmonary artery. Control and division of the right inferior pulmonary vein, the lower lobe branches of the right pulmonary artery, and the right lower lobe bronchus, as well as dissection of the hilum and fissures, were all done via the utility incision and two additional port sites as described elsewhere [1]. A 45-mm articulating endothoracic linear cutting device (Endopath ETS Flex 45, Ethicon, Cincinnati, Ohio) with 2.5-mm and 4.8-mm staples was used for division of the vascular and bronchial structures, respectively. The same device with 3.5-mm staples was used during the dissection of the fissures as well as the subsequent volume reduction surgery.
Following successful completion of the right lower lobectomy, an additional 30 gm of right middle and upper lobe lung parenchyma was resected. Resection was based on preoperative localization of the most severe bullous disease by both computed tomography and lung perfusion scan as well as intraoperative identification of the bullae.
The patient's chest tubes were discontinued on postoperative day 5 and he was discharged to home on postoperative day 7. His final pathology was a Stage IA high-grade adenocarcinoma. He remains well six months postresection. He subjectively states his breathing is improved. His postoperative pulmonary function studies, obtained ten weeks after his operation, reveal moderate improvement despite complete resection of his right lower lobe (Table 1). He experienced an absolute increase in his prebronchodilator FEV1 of 9% predicted and an absolute increase in his postbronchodilator FEV1 of 12% predicted.
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Comment
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Video-assisted thoracoscopic lobectomy has extended the chance for cure from nonsmall cell lung cancer to high-risk patients who otherwise could not undergo surgical resection. High-risk patients include those with a preoperative FEV1 of less than 1.5 L, an FEV1 of less than 50% predicted, and unfavorable comorbidities such as poor nutrition and heart failure [1]. Several studies have demonstrated that VATS lobectomy is less painful and may speed recovery [1, 4]. There is also evidence that VATS lobectomy may be superior to open lobectomy with respect to the immunologic response experienced by the patient with nonsmall cell lung cancer after surgery [5].
Lung volume reduction surgery has been shown to improve pulmonary function, reduce oxygen and steroid dependence, and improve subjective dyspnea [2]. Thoracoscopic volume reduction surgery offers equivalent functional outcome with the potential to decrease morbidity and mortality as compared to open resection via median sternotomy [6]. Although unilateral thoracoscopic LVRS has been shown as efficacious, bilateral LVRS has been shown to have better results without increased morbidity [2, 3].
The patient successfully underwent a combined VATS lobectomy and unilateral lung volume reduction. His pulmonary function studies reflect an objective improvement in his respiratory function. Although right lower lobectomy unquestionably allowed expansion of the right upper and middle lobes it was felt that the addition of the right volume reduction surgery added little morbidity to the procedure. A unilateral procedure was done because it was felt that the most important aspect of the operation was safe removal of the patient's malignancy. Contralateral thoracoscopic LVRS has been discussed with the patient as the second part of a staged procedure and this will be done should he regress to his previous symptoms. This case demonstrates that a combined procedure with the VATS approach can be safely undertaken in specific patients with a heterogeneous pattern of emphysema and an early stage nonsmall cell lung cancer previously thought to be unresectable due to poor pulmonary reserve.
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Acknowledgments
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The authors wish to thank Paula Fraley, Burnett Banton, Chuck Reynolds, and all operating room staff who contribute to the improvement of thoracoscopic surgery.
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References
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- Demmy T.L., Curtis J.J. Minimally invasive lobectomy directed toward frail and high-risk patients: A case-control study. Ann Thorac Surg 1999;68:194-200.[Abstract/Free Full Text]
- McKenna R.J., Brenner M., Fischel R.J., Gelb A.F. Should lung volume reduction for emphysema be unilateral or bilateral?. J Thorac Cardiovasc Surg 1996;112:1331-1339.[Abstract/Free Full Text]
- McKenna R.J., Fischel R.J., Brenner M., Gelb A.F. Combined operations for lung volume reduction surgery and lung cancer. Chest 1996;110:885-888.[Abstract/Free Full Text]
- Nakata M., Saeki H., Yokoyama N., et al. Pulmonary function after lobectomy: video-assisted thoracic surgery versus thoracotomy. Ann Thorac Surg 2000;70:938-941.[Abstract/Free Full Text]
- Walker W.S., Leaver H.A., Craig S.R., Yap P.L. The immune response to surgery: Conventional and VATS lobectomy. In: Yim A.P.C., Hazelrigg S.R., Izzat M.B., Landreneau R.J., Mack M.J., Naunheim K.S., eds. Minimal access cardiothoracic surgery. Philadelphia: W. B. Saunders Company, 2000:127-134.
- Roberts J.R., Bavaria J.E., Wahl P., Wurster A., Friedberg J.S., Kaiser L.R. Comparison of open and thoracoscopic bilateral volume reduction surgery: Complication analysis. Ann Thorac Surg 1998;66:1759-1765.[Abstract/Free Full Text]
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Abstract
Introduction
