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K.N. Han et al. / Interactive CardioVascular and Thoracic Surgery
time. In addition, the one-stage approach to bilateral disease by VATS is not yet a routine procedure and has not been widely adopted because of the potential for an intraoperative event, such as adverse hypotensive conditions and cardiac arrhythmia during the procedure [21]. However, we did not experience any adverse events during the procedure and surgeons may more readily adopt a one-stage VATS-based approach to bilateral disease if they are sufficiently familiar with the conventional VATS approach. In summary, despite the limitations of this study, a VATS approach to bilateral disease should be considered as a feasible option because it can result in reduced hospital stays, low perioperative morbidity and acceptable long-term outcomes. Potentially, the one-stage approach could replace the routine use of staged bilateral open surgery in patients with small-sized and few bilateral metastatic nodules. Conflict of interest: none declared.
[15] Cerfolio RJ, Bryant AS, McCarty TP, Minnich DJ. A prospective study to determine the incidence of non-imaged malignant pulmonary nodules in patients who undergo metastasectomy by thoracotomy with lung palpation. Ann Thorac Surg 2011;91:1696–700. [16] Greenwood A, West D. Is a thoracotomy rather than thoracoscopic resection associated with improved survival after pulmonary metastasectomy? Interact CardioVasc Thorac Surg 2013;7:720–4. [17] Nichols FC. Pulmonary metastasectomy. Thorac Surg Clin 2012;22:91–9. [18] Lee J, Aronchick JM, Alavi A. Accuracy of f-18 fluorodeoxyglucose positron emission tomography for the evaluation of malignancy in patients presenting with new lung abnormalities: a retrospective review. Chest 2001; 120:1791–7. [19] Mutsaerts EL, Zoetmulder FA, Meijer S, Baas P, Hart AA, Rutgers EJ. Long term survival of thoracoscopic metastasectomy vs metastasectomy by thoracotomy in patients with a solitary pulmonary lesion. Eur J Surg Oncol 2002;28:864–8. [20] Welter S, Cheufou D, Sommerwerck U, Maletzki F, Stamatis G. Changes in lung function parameters after wedge resections: a prospective evaluation of patients undergoing metastasectomy. Chest 2012;141:1482–9. [21] Mineo TC, Ambrogi V, Mineo D, Pompeo E. Transxiphoid hand-assisted videothoracoscopic surgery. Ann Thorac Surg 2007;83:1978–84.
REFERENCES [1] Internullo E, Cassivi SD, Van Raemdonck D, Friedel G, Treasure T, ESTS Pulmonary Metastasectomy Working Group. Pulmonary metastasectomy: a survey of current practice amongst members of the European Society of Thoracic Surgeons. J Thorac Oncol 2008;3:1257–66. [2] Hornbech K, Ravn J, Steinbruchel DA. Current status of pulmonary metastasectomy. Eur J Cardiothorac Surg 2011;39:955–62. [3] Long-term results of lung metastasectomy: prognostic analyses based on 5206 cases. The International Registry of Lung Metastases. J Thorac Cardiovasc Surg 1997;113:37–49. [4] Eckardt J, Licht PB. Thoracoscopic versus open pulmonary metastasectomy: a prospective, sequentially controlled study. Chest 2012;142:1598–602. [5] Saisho S, Nakata M, Sawada S, Yamashita M, Saeki H, Kurita A et al. Evaluation of video-assisted thoracoscopic surgery for pulmonary metastases: 11-years of experience. Surg Endosc 2009;23:55–61. [6] Kang MC, Kang CH, Lee HJ, Goo JM, Kim YT, Kim JH. Accuracy of 16-channel multi-detector row chest computed tomography with thin sections in the detection of metastatic pulmonary nodules. Eur J Cardiothorac Surg 2008;33:473–79. [7] Younes RN, Gross JL, Deheinzelin D. Surgical resection of unilateral lung metastases: is bilateral thoracotomy necessary? World J Surg 2002;26: 1112–6. [8] Tsai J, Mattei P. Median sternotomy for bilateral pulmonary metastasectomy in children. J Pediatr Surg 2012;47:1345–8. [9] Seely AJ, Ivanovic J, Threader J, Al-Hussaini A, Al-Shehab D, Ramsay T et al. Systematic classification of morbidity and mortality after thoracic surgery. Ann Thorac Surg 2010;90:936–42. [10] Molnar TF, Gebitekin C, Turna A. What are the considerations in the surgical approach in pulmonary metastasectomy? J Thorac Oncol 2010;5: S140–4. [11] Yamamura Y, Hida Y, Kaga K, Kawada M, Niizeki H, Ichinokawa M et al. Simultaneous resection of bilateral intralobar and extralobar pulmonary sequestrations with video-assisted thoracoscopic surgery. Ann Thorac Surg 2009;87:1939–41. [12] Bains MS, Ginsberg RJ, Jones WG II, McCormack PM, Rusch VW, Burt ME et al. The clamshell incision: an improved approach to bilateral pulmonary and mediastinal tumor. Ann Thorac Surg 1994;58:30–2. [13] Detterbeck FC, Grodzki T, Gleeson F, Robert JH. Imaging requirements in the practice of pulmonary metastasectomy. J Thorac Oncol 2010;5: S134–9. [14] Cerfolio RJ, McCarty T, Bryant AS. Non-imaged pulmonary nodules discovered during thoracotomy for metastasectomy by lung palpation. Eur J Cardiothorac Surg 2009;35:786–91.
eComment. Thoracoscopic approach to bilateral pulmonary metastasis: is it justified? Authors: Dimitrios Paliouras, Fotios Chatzinikolaou, Apostolos Gogakos and Nikolaos Barbetakis Department of Thoracic Surgery, Theagenio Cancer Hospital,Thessaloniki Greece doi: 10.1093/icvts/ivu046 © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. We have read the article by Han et al. [1] with great interest. We think that videoassisted thoracoscopic surgery (VATS) procedures have many benefits for patients, especially for those suffering from malignancies and requiring further treatment immediately after surgery. For metastasectomies, in order to detect non-imaged nodules, palpation of the lung during surgery seems to be the gold standard according to the international literature. On the basis of our findings during surgery for pulmonary metastatic disease, and although some surgeons suggest that they can palpate major parts of the lung parenchyma through the utility incision [2,3], we believe that VATS is not recommended if curative resection is intended, due to insufficient palpation of the deflated lung. One stage bilateral metastasectomy should be performed in selected patients, bearing in mind the morbidity, the mortality, and the overall cost of hospitalization [4]. We think that a thoracic surgeon should decide on the type of surgery depending on the age and the performance status of the patients. Conflict of interest: none declared. References [1] Han KN, Kang CH, Park IK, Kim YT. Thoracoscopic approach to bilateral pulmonary metastasis: is it justified? Interact CardioVasc Thorac Surg 2014;18:615–20. [2] Carballo M, Maish MS, Jaroszewski DE, Holmes CE. Video-assisted thoracic surgery cohort study. J Cardiothorac Surg 2009;4:13. [3] Barbetakis N, Samanidis G, Paliouras D, Tsilikas C. Surgery for pulmonary metastases of renal cell carcinoma. Video-assisted thoracoscopic or open procedure? Interact CardioVasc Thorac Surg 2008;7:828. [4] Mizuno Y, Iwata H, Shirahashi K, Takemura H. One-stage bilateral pulmonary resections for pulmonary metastases. Gen Thorac Cardiovasc Surg 2014; 62:53–7.
K.N. Han et al. / Interactive CardioVascular and Thoracic Surgery
time. In addition, the one-stage approach to bilateral disease by VATS is not yet a routine procedure and has not been widely adopted because of the potential for an intraoperative event, such as adverse hypotensive conditions and cardiac arrhythmia during the procedure [21]. However, we did not experience any adverse events during the procedure and surgeons may more readily adopt a one-stage VATS-based approach to bilateral disease if they are sufficiently familiar with the conventional VATS approach. In summary, despite the limitations of this study, a VATS approach to bilateral disease should be considered as a feasible option because it can result in reduced hospital stays, low perioperative morbidity and acceptable long-term outcomes. Potentially, the one-stage approach could replace the routine use of staged bilateral open surgery in patients with small-sized and few bilateral metastatic nodules. Conflict of interest: none declared.
[15] Cerfolio RJ, Bryant AS, McCarty TP, Minnich DJ. A prospective study to determine the incidence of non-imaged malignant pulmonary nodules in patients who undergo metastasectomy by thoracotomy with lung palpation. Ann Thorac Surg 2011;91:1696–700. [16] Greenwood A, West D. Is a thoracotomy rather than thoracoscopic resection associated with improved survival after pulmonary metastasectomy? Interact CardioVasc Thorac Surg 2013;7:720–4. [17] Nichols FC. Pulmonary metastasectomy. Thorac Surg Clin 2012;22:91–9. [18] Lee J, Aronchick JM, Alavi A. Accuracy of f-18 fluorodeoxyglucose positron emission tomography for the evaluation of malignancy in patients presenting with new lung abnormalities: a retrospective review. Chest 2001; 120:1791–7. [19] Mutsaerts EL, Zoetmulder FA, Meijer S, Baas P, Hart AA, Rutgers EJ. Long term survival of thoracoscopic metastasectomy vs metastasectomy by thoracotomy in patients with a solitary pulmonary lesion. Eur J Surg Oncol 2002;28:864–8. [20] Welter S, Cheufou D, Sommerwerck U, Maletzki F, Stamatis G. Changes in lung function parameters after wedge resections: a prospective evaluation of patients undergoing metastasectomy. Chest 2012;141:1482–9. [21] Mineo TC, Ambrogi V, Mineo D, Pompeo E. Transxiphoid hand-assisted videothoracoscopic surgery. Ann Thorac Surg 2007;83:1978–84.
REFERENCES [1] Internullo E, Cassivi SD, Van Raemdonck D, Friedel G, Treasure T, ESTS Pulmonary Metastasectomy Working Group. Pulmonary metastasectomy: a survey of current practice amongst members of the European Society of Thoracic Surgeons. J Thorac Oncol 2008;3:1257–66. [2] Hornbech K, Ravn J, Steinbruchel DA. Current status of pulmonary metastasectomy. Eur J Cardiothorac Surg 2011;39:955–62. [3] Long-term results of lung metastasectomy: prognostic analyses based on 5206 cases. The International Registry of Lung Metastases. J Thorac Cardiovasc Surg 1997;113:37–49. [4] Eckardt J, Licht PB. Thoracoscopic versus open pulmonary metastasectomy: a prospective, sequentially controlled study. Chest 2012;142:1598–602. [5] Saisho S, Nakata M, Sawada S, Yamashita M, Saeki H, Kurita A et al. Evaluation of video-assisted thoracoscopic surgery for pulmonary metastases: 11-years of experience. Surg Endosc 2009;23:55–61. [6] Kang MC, Kang CH, Lee HJ, Goo JM, Kim YT, Kim JH. Accuracy of 16-channel multi-detector row chest computed tomography with thin sections in the detection of metastatic pulmonary nodules. Eur J Cardiothorac Surg 2008;33:473–79. [7] Younes RN, Gross JL, Deheinzelin D. Surgical resection of unilateral lung metastases: is bilateral thoracotomy necessary? World J Surg 2002;26: 1112–6. [8] Tsai J, Mattei P. Median sternotomy for bilateral pulmonary metastasectomy in children. J Pediatr Surg 2012;47:1345–8. [9] Seely AJ, Ivanovic J, Threader J, Al-Hussaini A, Al-Shehab D, Ramsay T et al. Systematic classification of morbidity and mortality after thoracic surgery. Ann Thorac Surg 2010;90:936–42. [10] Molnar TF, Gebitekin C, Turna A. What are the considerations in the surgical approach in pulmonary metastasectomy? J Thorac Oncol 2010;5: S140–4. [11] Yamamura Y, Hida Y, Kaga K, Kawada M, Niizeki H, Ichinokawa M et al. Simultaneous resection of bilateral intralobar and extralobar pulmonary sequestrations with video-assisted thoracoscopic surgery. Ann Thorac Surg 2009;87:1939–41. [12] Bains MS, Ginsberg RJ, Jones WG II, McCormack PM, Rusch VW, Burt ME et al. The clamshell incision: an improved approach to bilateral pulmonary and mediastinal tumor. Ann Thorac Surg 1994;58:30–2. [13] Detterbeck FC, Grodzki T, Gleeson F, Robert JH. Imaging requirements in the practice of pulmonary metastasectomy. J Thorac Oncol 2010;5: S134–9. [14] Cerfolio RJ, McCarty T, Bryant AS. Non-imaged pulmonary nodules discovered during thoracotomy for metastasectomy by lung palpation. Eur J Cardiothorac Surg 2009;35:786–91.
eComment. Thoracoscopic approach to bilateral pulmonary metastasis: is it justified? Authors: Dimitrios Paliouras, Fotios Chatzinikolaou, Apostolos Gogakos and Nikolaos Barbetakis Department of Thoracic Surgery, Theagenio Cancer Hospital,Thessaloniki Greece doi: 10.1093/icvts/ivu046 © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. We have read the article by Han et al. [1] with great interest. We think that videoassisted thoracoscopic surgery (VATS) procedures have many benefits for patients, especially for those suffering from malignancies and requiring further treatment immediately after surgery. For metastasectomies, in order to detect non-imaged nodules, palpation of the lung during surgery seems to be the gold standard according to the international literature. On the basis of our findings during surgery for pulmonary metastatic disease, and although some surgeons suggest that they can palpate major parts of the lung parenchyma through the utility incision [2,3], we believe that VATS is not recommended if curative resection is intended, due to insufficient palpation of the deflated lung. One stage bilateral metastasectomy should be performed in selected patients, bearing in mind the morbidity, the mortality, and the overall cost of hospitalization [4]. We think that a thoracic surgeon should decide on the type of surgery depending on the age and the performance status of the patients. Conflict of interest: none declared. References [1] Han KN, Kang CH, Park IK, Kim YT. Thoracoscopic approach to bilateral pulmonary metastasis: is it justified? Interact CardioVasc Thorac Surg 2014;18:615–20. [2] Carballo M, Maish MS, Jaroszewski DE, Holmes CE. Video-assisted thoracic surgery cohort study. J Cardiothorac Surg 2009;4:13. [3] Barbetakis N, Samanidis G, Paliouras D, Tsilikas C. Surgery for pulmonary metastases of renal cell carcinoma. Video-assisted thoracoscopic or open procedure? Interact CardioVasc Thorac Surg 2008;7:828. [4] Mizuno Y, Iwata H, Shirahashi K, Takemura H. One-stage bilateral pulmonary resections for pulmonary metastases. Gen Thorac Cardiovasc Surg 2014; 62:53–7.
