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Ann Thorac Surg 1997;63:1421-1422
© 1997 The Society of Thoracic Surgeons

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Invited Commentary

Invited Commentary

Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195

See also page 1415.

Lewis and associates report their experience with 100 "consecutive" simultaneously stapled (SS) lobectomies. The term consecutive is somewhat misleading because these cases were obviously selected preoperatively from a larger group of patients undergoing standard thoracotomy and lobectomy. Therefore the implied suggestion that one can indiscriminately apply SS lobectomy is without basis.

The rationale used to develop SS lobectomy was that individual isolation, ligation, and transection of the bronchovascular structures using a video-assisted thoracic surgical (VATS) approach to lobectomy was "awkward, cumbersome, and at times dangerous." In my experience and that of others in more than 200 cases of VATS and anatomic lobectomy this has not proved to be the case [1, 2]. Also Lewis and associates could not predict when developing this technique whether SS lobectomy might have carried even more risks than the traditional technique. There was no reported work in an animal model to verify the technique's safety before commencing a human series. Certainly the complications associated with mass ligation in the early history of thoracic surgery were significant. Fortunately, at present, there has been no significant morbidity or mortality associated with SS lobectomy.

It is unusual that a lobectomy is required for benign disease. Eight of the patients in this series underwent SS lobectomy for benign disease, which included a histoplasmoma, bronchogenic cyst, giant bulla, two granulomas, bronchiolitis obliterans, hamartoma, and a sequestration. The stated reason for SS lobectomy in these cases was that "none of these benign lesions could be completely removed by a lesser resection." Figure 1, reproduced from a computed tomographic scan provided by Lewis and associates, is one such example. I doubt that the majority of thoracic surgeons would concur with this assessment. In a separate letter (personal communication, 1996) Lewis stated that in some cases the results of frozen section analysis were questioned and an SS lobectomy performed to ensure complete removal of a potential underlying malignancy. At the time of thoracotomy, when a benign solitary pulmonary nodule is completely excised, what is the rationale for resecting the remaining lobe?

View larger version (37K): [in this window] [in a new window]   Fig 1.. Histoplasmoma of left lower lobe.

Finally the article does not substantiate claims that SS lobectomy is superior to thoracotomy by reason of decreased pain, cost, and length of stay. No data are giventhat compare the two procedures in this manner. Reference 27 is used to bolster claims of the cost-effectiveness of SS lobectomy, but this article is flawed by a lack of specificity and inclusion of generalized statements [5]. A trial of 100 patients randomized to either SS lobectomy or muscle-sparing thoracotomy and lobectomy would clarify many issues. It would also allow Lewis and associates to omit the vague and imprecise language that permeates their discussion, such as "could," "seems," "appear to be similar," and "impression." Perhaps significant benefits to SS lobectomy will emerge in terms of cost, length of stay, and pain control. Thoracic surgeons will then have to balance these benefits to the disadvantages of SS lobectomy for benign disease, and against the possibility that SS lobectomy may encourage compromised or inappropriate resections for cancer.

Finally, I would recommend a book to Lewis and associates called Forbidden Knowledge by Dr Roger Shattuck [6]. Doctor Shattuck explores the interesting idea that occasionally our acquisition of knowledge precedes our wisdom to wisely apply this knowledge (eg, the Tree of Knowledge of Good and Evil, the atom bomb). Lewis and associates have reintroduced a form of "mass ligation" of the hilum to allow a VATS lobectomy to be performed. There was little information supporting the safety of the technique and, as discussed, there are major drawbacks including ill-advised lobectomy for benign disease. This leads me to the conclusion we have another example of acquiring new knowledge (VATS) but not yet the wisdom that should guide its application.

References

1. Kirby TJ, Mack MJ, Landreneau RJ, et al. Lobectomy-VATS vs muscle sparing thoracotomy: a randomized trial. J Thorac Cardiovasc Surg 1995;109:997–1002.[Abstract]
2. McKenna RJ. Lobectomy by video-assisted thoracic surgery with mediastinal node sampling for lung cancer. J Thorac Cardiovasc Surg 1994;107:879–81.[Abstract/Free Full Text]
3. The Canadian Lung Oncology Group. Investigation for mediastinal disease in patients with apparently operable lung cancer. Ann Thorac Surg 1995;60:1382–9.[Abstract/Free Full Text]
4. Takizawa T, Terashima M, Koike T, et al. Mediastinal lymph node metastasis in patients with clinical stage I peripheral non-small cell cancer. J Thorac Cardiovasc Surg 1997;11:248–52.
5. Lewis RJ, Caccavale RJ, Sisler GE, et al. Is video-assisted thoracic surgery cost-effective for major pulmonary resections? NJ Med (in press).
6. Shattuck R. Forbidden knowledge. New York: St. Martin's, 1996.

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This Article Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Thomas J. Kirby Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kirby, T. J. Search for Related Content PubMed Articles by Kirby, T. J. Related Collections Related Article