| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Ann Thorac Surg 2000;70:247
© 2000 The Society of Thoracic Surgeons
a Department of Thoracic Surgery, Royal Infirmary of Edinburgh, Lauriston Pl, Edinburgh, Scotland EH3 9YW, United Kingdom
e-mail: wsw{at}holyrood.ed.ac.uk
Major pulmonary resection using video-assisted thoracic surgery (VATS) techniques has been an option available to thoracic surgeons for some years but take up has been modest. This probably reflects a combination of different concerns related to technical difficulty, perioperative risk and, perhaps most importantly, long term outcome in cancer cases. These concerns are perfectly reasonable and it makes good sense to observe the evolution of a new operative strategy before opting to change from established practice and known outcomes.
Gradually, the evidence supporting VATS major pulmonary resection is increasing. Early fears regarding perioperative safety have proved groundless as many authors report low surgical morbidity and mortality and there seems little doubt that immediate and late postoperative pain are reduced. The most important data, however, will be that provided for outcomes following resection of lung cancer. The available mid term evidence supports the view that these are at least as good as those obtained with conventional surgery. Wound recurrence is rare and there does not seem to be an excess of locoregional recurrences such as would be expected with inadequate local resection. Reported survival data indicate that the results with Stage I nonsmall cell lung cancer (NSCLC)–the intended target of most VATS lobectomy practitioners–are consistently within the upper range of values reported following equivalently staged conventional resection. Further follow up and randomized trials are required to confirm or refute this effect.
While the excellent survival in Stage I NSCLC could reflect good surgery and case selection, it is also possible that the enhanced survival in these cases relates to the minimally invasive approach. We have postulated that the reduced trauma inherent in a minimally invasive resection might create an immunologically more favourable environment for the resection of early cancer–possibly by enhanced preservation of the integrity of cellular immune mechanisms in the perioperative period. Recent data points to the high incidence of pre–operative occult metastases in bone marrow even with no lesions. It is tempting to suppose that all or most NSCLC cases are metastatic at presentation and that the probability of cure following resection of early lesions may depend in part on maintenance of host immune competence following resection.
In this paper Yim and colleagues demonstrate reduced levels of circulating IL-6 and IL-8 cytokines following VATS lobectomy compared with open lobectomy cases. The present study is open to criticism on the grounds that the patients were not randomised and, therefore, the more technically favourable cases undergoing VATS resection may have required less surgical intervention and had less ongoing inflammation. Nonetheless, the results reported in this study are consistent with studies of cytokine activation and white cell function following laparoscopic surgery and with data reported from other randomised series comparing open and VATS lobectomy. The present study, therefore, adds important additional weight to the argument that VATS surgery is less traumatic than an open procedure.
Progress in the care of cancer patients is likely to be made up from small additive increments. There will doubtless be survival gains obtained with neoadjuvant chemotherapy regimens and, probably, with currently unknown substances or treatments. Altering the trauma of surgery may improve survival by a valuable few percent and is obtainable with currently available techniques. Resection of early stage disease is our best opportunity to cure the patient with lung cancer and one which may become more frequent if the evidence of recent screening data is put into clinical practice. In contrast to the present situation, the question for such patients may ultimately become: "on what basis can you justify not undertaking a VATS resection?".
Related Article
Ann. Thorac. Surg. 2000 70: 243-247.
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
