Ann Thorac Surg 2009;87:990. doi:10.1016/j.athoracsur.2008.10.059
© 2009 The Society of Thoracic Surgeons
Correspondence
Reply
Dominique Gossot, MD
Thoracic Department, Institut Mutualiste Montsouris, 42, Boulevard Jourdan, Paris, F-75014 France
(Email: dominique.gossot{at}imm.fr).
To the Editor:
The criticism from Drs Kamiyoshihara and Ibe [1] on my article [2] is based on a prejudice, that is, that totally endoscopic or complete video-assisted thoracoscopic surgical lobectomies are not equal to conventional video-assisted thoracoscopic surgery (VATS) or open lobectomies. I suggest that the authors consider another hypothesis: In some indications, could a complete VATS be equivalent or even superior? This is a question we still cannot answer, but we should at least stay open minded, considering the fact that the history of VATS lobectomies is both recent and multiform. I wish to answer some of these doctors' remarks as follows:
- 1 "What if nodes are identified as positive during or after the operation?" In which way is this issue different during an open procedure? Our indications are limited to clinical N0 cancers so far. We perform a radical lymphadenectomy, which is as satisfactory as those done by a mini-incision, whose location rarely fits all lymph node stations. Some of our patients are then upstaged to pN1 or even pN2, as they would also be after an open approach. If a nondissectable lymph node were encountered, a thoracotomy could be performed, and as recently shown in this journal by Jones and colleagues [3], a conversion does not impact the outcome of these patients.
- 2 "We should not pursue a procedure that is applied to limited stage only." Why should we stay stuck to not using a unique approach? Digestive surgeons find it natural to use a laparoscopic approach for limited stage cancer and a laparotomy for advanced or complex cases. It seems better both for patients and for surgeons to master a wider range of techniques.
- 3 "There is no need to focus on whether the procedure is complete or assisted VATS." Again, this is an assertion that is not grounded on evidence. Based on our limited experience of 120 patients, we certainly can not assert that our technique is superior to another one, but there are some indications that patients operated on by a totally endoscopic technique have less blood loss, shorter hospitalization, and faster recovery with similar survival [4].
With the development of VATS lobectomies for lung cancer, whatever the names and technical variations may be, we are facing a debate that occurred 10 years ago in laparoscopy and that is now partly solved. I would thus suggest observing various techniques without prejudice, studying their benefits and limitations, and let time and trials make way for the sorting.
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References
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- Kamiyoshihara M, Ibe T. The blurred border between thoracoscopic surgery and thoracotomy(letter) Ann Thorac Surg 2009;87:989-990.[Free Full Text]
- Gossot D. Technical tricks to facilitate totally endoscopic major pulmonary resections Ann Thorac Surg 2008;86:323-326.[Abstract/Free Full Text]
- Jones RO, Casali G, Walker WS. Does failed video-assisted lobectomy for lung cancer prejudice immediate and long-term outcome? Ann Thorac Surg 2008;86:235-239.[Abstract/Free Full Text]
- Shigemura N, Akashi A, Funaki S, et al. Long-term outcomes after a variety of video-assisted thoracoscopic lobectomy approaches for clinical stage IA lung cancer: a multi-institutional study J Thorac Cardiovasc Surg 2006;132:507-512.[Abstract/Free Full Text]
Related Article
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The Blurred Border Between Thoracoscopic Surgery and Thoracotomy
- Mitsuhiro Kamiyoshihara and Takashi Ibe
Ann. Thorac. Surg. 2009 87: 989-990.
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