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and extensive smoking histories that can be associated with impaired pulmonary function. In our experience these patients tend to derive the most benefit from thoracoscopic surgery [7, 10, 19]. However, the study group is relatively small, although we could not find a larger series in the literature that examined outcomes of thoracoscopic LUL in patients with LIMA grafts. Another limitation is that there may have been patients who had LIMA grafts and were eligible, but not offered, lobectomy. We were not able to capture these patients from our database. The patients in our study were likely carefully selected as appropriate operative candidates and we advocate very careful preoperative assessment when considering LUL in patients who have had a LIMA graft. This careful assessment is necessary whether considering a minimally invasive approach or a thoracotomy. In conclusion, thoracoscopic LUL can be performed safely in patients with LIMA bypass grafts. Leaving lung parenchyma on the graft avoids inadvertent injury and cardiac ischemic events. Dr Berry has received support from the National Institutes of Health funded Cardiothoracic Surgical Trials Network, NHLBI Clinical Research Scholar, NIH Grant 5U01HL088953-05 (Principal Investigator Peter K. Smith, MD). We also wish to thank the Duke Tumor Registry for their support in this study.
References 1. Ettinger DS, Akerly W, Bepler G, et al. Non-small cell lung cancer. J Natl Compr Canc Netw 2010;8:740–801. 2. Ceppa DP, Kosinski AS, Berry MF, et al. Thoracoscopic lobectomy has increasing benefit in patients with poor pulmonary function: a Society of Thoracic Surgeons Database analysis. Ann Surg 2012;256:487–93. 3. Scott WJ, Allen MS, Darling G, et al. Video-assisted thoracic surgery versus open lobectomy for lung cancer: a secondary analysis of data from the American College of Surgeons Oncology Group Z0030 randomized clinical trial. J Thorac Cardiovasc Surg 2010;139:976–81. 4. Paul S, Altorki NK, Sheng S, et al. Thoracoscopic lobectomy is associated with lower morbidity than open lobectomy: a propensity-matched analysis from the STS database. J Thorac Cardiovasc Surg 2010;139:366–78.
Ann Thorac Surg 2014;98:1207–13
5. Villamizar NR, Darrabie MD, Burfeind WR, et al. Thoracoscopic lobectomy is associated with lower morbidity compared with thoracotomy. J Thorac Cardiovasc Surg 2009;138:419–25. 6. Berry MF, Onaitis MW, Tong BC, Balderson SS, Harpole DH, D’Amico TA. Feasibility of hybrid thoracoscopic lobectomy and en-bloc chest wall resection. Eur J Cardiothorac Surg 2012;41:888–92. 7. Berry MF, Hanna J, Tong BC, et al. Risk factors for morbidity after lobectomy for lung cancer in elderly patients. Ann Thorac Surg 2009;88:1093–9. 8. Port JL, Mirza FM, Lee PC, Paul S, Stiles BM, Altorki NK. Lobectomy in octogenarians with non-small cell lung cancer: ramifications of increasing life expectancy and the benefits of minimally invasive surgery. Ann Thorac Surg 2011;92:1951–7. 9. Mahtabifard A, Fuller CB, McKenna RJ Jr. Video-assisted thoracic surgery sleeve lobectomy: a case series. Ann Thorac Surg 2008;85:S729–32. 10. Berry MF, Villamizar-Ortiz NR, Tong BC, et al. Pulmonary function tests do not predict pulmonary complications after thoracoscopic lobectomy. Ann Thorac Surg 2010;89:1044–52. 11. Shapiro M, Swanson SJ, Wright CD, et al. Predictors of major morbidity and mortality after pneumonectomy utilizing The Society for Thoracic Surgeons General Thoracic Surgery database. Ann Thorac Surg 2010;90:927–35. 12. Wright CD, Gaissert HA, Grab JD, O’Brien SM, Peterson ED, Allen MS. Predictors of prolonged length of stay after lobectomy for lung cancer: a Society of Thoracic Surgeons General Thoracic Surgery Database risk-adjustment model. Ann Thorac Surg 2008;85:1857–65. 13. Funaki S, Inoue M, Shigemura N, Okumura M. Thoracoscopic lobectomy for lung cancer after coronary artery bypass grafting using internal thoracic artery. Interact Cardiovasc Thorac Surg 2012;15:928–9. 14. D’Amico TA. Operative techniques in early-stage lung cancer. J Natl Compr Canc Netw 2010;8:807–13. 15. Singhatanadgige S, Sindhvanada W, Kittayarak C. Left upper lobectomy after CABG with the left internal mammary artery graft. J Med Assoc Thai 2006;89:887–9. 16. Flores RM, Ihekweazu U, Dycoco J, et al. Video-assisted thoracoscopic surgery (VATS) lobectomy: catastrophic intraoperative complications. J Thorac Cardiovasc Surg 2011;142:1412–7. 17. Ikeda N, Saji H, Hagiwara M, Ohira T, Usuda J, Kajiwara N. Recent advances in video-assisted thoracoscopic surgery for lung cancer. Asian J Endosc Surg 2013;6:9–13. 18. Demmy TL, Curtis JJ. Minimally invasive lobectomy directed toward frail and high-risk patients: a case-control study. Ann Thorac Surg 1999;68:194–200. 19. Berry MF, Onaitis MW, Tong BC, Harpole DH, D’Amico TA. A model for morbidity after lung resection in octogenarians. Eur J Cardiothorac Surg 2011;39:989–94.
INVITED COMMENTARY Shah and colleagues [1] have written a provocative essay about managing the critically important, but vulnerable, internal mammary conduit during video-assisted thoracic surgery (VATS) lobectomy. This is an important issue as many patients survive revascularization of their smoking-related coronary atherosclerotic occlusive disease and now live long enough to develop lung cancer. Before addressing appropriateness, it is important to emphasize several themes. First, the authors used careful judgment and planning. They reviewed operative reports considering internal mammary artery (IMA) orientation, pleural opening, preparation (skeletonized or pedicle), Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier
sequencing, and conduit age. Catheterization or computed tomographic angiography showed relative branch coronary artery importance and its dependence on the IMA graft. Injury strategies were planned with collaborative cardiac teams. Intraoperative transesophageal echocardiography, cardiac anesthesiology, and detecting and managing perioperative cardiac events were important. During surgery, their high VATS reliability experience facilitated dealing with hostile pleural spaces. Initiating safe dissection planes between the lung hilum and pericardium remote from the graft and stapling lung to leave a remnant on the sternotomy or IMA were useful 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.06.006
strategies. Both improved exposure and reduced parenchymal bleeding so tissue remnants could be observed or debrided appropriately. Supplemental thoracoscopic viewpoints may have helped. Finally, by VATS emulation of open vascular control methods they could perform safe conversions, if required. Currently, our specialty actively debates the merits of VATS for any lung cancer, not just these advanced cases. We generally trust master open thoracic surgeons to venture into more advanced frontiers by leveraging their aggregated skills and judgment. Perhaps it is time to extend the same provisional acceptance to our minimally invasive colleagues. On a personal note, I perform IMA cases such as these based on an advanced VATS practice that followed an earlier career emphasizing cardiac surgery. However, performing advanced cases like these without the aggregate experience or backup teams probably is unwise. Physically frail or advanced chronic obstructive pulmonary disease patients might be good cases to avoid thoracotomy; alternatively, those with good ventricular function tolerate thoracotomy if their grafts are protected. Importantly, not every successful VATS or robotic program exists within a cardiac center of excellence.
SHAH ET AL VATS LOBECTOMY AFTER MAMMARY GRAFT
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Thus, a frank discussion of the above issues or contingency plans should be communicated with all parties. Should a frail patient chance an IMA injury at a high VATS reliability, noncardiac hospital, or go to a heart center for likely thoracotomy? Such questions remain imponderable until others have replicated these authors’ excellent but modest experience. Until then, we must disclose all reasonable options to patients including those of thoughtful surgeons who consider VATS approaches unproven or undesirable. Todd L. Demmy, MD Roswell Park Cancer Institute Elm and Carlton Sts Buffalo, NY 14263 e-mail: [email protected]
Reference 1. Shah AA, Worni M, Onaitis MW, et al. Thoracoscopic left upper lobectomy in patients with internal mammary artery coronary bypass grafts. Ann Thorac Surg 2014;98: 1207–13.
GENERAL THORACIC
Ann Thorac Surg 2014;98:1207–13
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SHAH ET AL VATS LOBECTOMY AFTER MAMMARY GRAFT
and extensive smoking histories that can be associated with impaired pulmonary function. In our experience these patients tend to derive the most benefit from thoracoscopic surgery [7, 10, 19]. However, the study group is relatively small, although we could not find a larger series in the literature that examined outcomes of thoracoscopic LUL in patients with LIMA grafts. Another limitation is that there may have been patients who had LIMA grafts and were eligible, but not offered, lobectomy. We were not able to capture these patients from our database. The patients in our study were likely carefully selected as appropriate operative candidates and we advocate very careful preoperative assessment when considering LUL in patients who have had a LIMA graft. This careful assessment is necessary whether considering a minimally invasive approach or a thoracotomy. In conclusion, thoracoscopic LUL can be performed safely in patients with LIMA bypass grafts. Leaving lung parenchyma on the graft avoids inadvertent injury and cardiac ischemic events. Dr Berry has received support from the National Institutes of Health funded Cardiothoracic Surgical Trials Network, NHLBI Clinical Research Scholar, NIH Grant 5U01HL088953-05 (Principal Investigator Peter K. Smith, MD). We also wish to thank the Duke Tumor Registry for their support in this study.
References 1. Ettinger DS, Akerly W, Bepler G, et al. Non-small cell lung cancer. J Natl Compr Canc Netw 2010;8:740–801. 2. Ceppa DP, Kosinski AS, Berry MF, et al. Thoracoscopic lobectomy has increasing benefit in patients with poor pulmonary function: a Society of Thoracic Surgeons Database analysis. Ann Surg 2012;256:487–93. 3. Scott WJ, Allen MS, Darling G, et al. Video-assisted thoracic surgery versus open lobectomy for lung cancer: a secondary analysis of data from the American College of Surgeons Oncology Group Z0030 randomized clinical trial. J Thorac Cardiovasc Surg 2010;139:976–81. 4. Paul S, Altorki NK, Sheng S, et al. Thoracoscopic lobectomy is associated with lower morbidity than open lobectomy: a propensity-matched analysis from the STS database. J Thorac Cardiovasc Surg 2010;139:366–78.
Ann Thorac Surg 2014;98:1207–13
5. Villamizar NR, Darrabie MD, Burfeind WR, et al. Thoracoscopic lobectomy is associated with lower morbidity compared with thoracotomy. J Thorac Cardiovasc Surg 2009;138:419–25. 6. Berry MF, Onaitis MW, Tong BC, Balderson SS, Harpole DH, D’Amico TA. Feasibility of hybrid thoracoscopic lobectomy and en-bloc chest wall resection. Eur J Cardiothorac Surg 2012;41:888–92. 7. Berry MF, Hanna J, Tong BC, et al. Risk factors for morbidity after lobectomy for lung cancer in elderly patients. Ann Thorac Surg 2009;88:1093–9. 8. Port JL, Mirza FM, Lee PC, Paul S, Stiles BM, Altorki NK. Lobectomy in octogenarians with non-small cell lung cancer: ramifications of increasing life expectancy and the benefits of minimally invasive surgery. Ann Thorac Surg 2011;92:1951–7. 9. Mahtabifard A, Fuller CB, McKenna RJ Jr. Video-assisted thoracic surgery sleeve lobectomy: a case series. Ann Thorac Surg 2008;85:S729–32. 10. Berry MF, Villamizar-Ortiz NR, Tong BC, et al. Pulmonary function tests do not predict pulmonary complications after thoracoscopic lobectomy. Ann Thorac Surg 2010;89:1044–52. 11. Shapiro M, Swanson SJ, Wright CD, et al. Predictors of major morbidity and mortality after pneumonectomy utilizing The Society for Thoracic Surgeons General Thoracic Surgery database. Ann Thorac Surg 2010;90:927–35. 12. Wright CD, Gaissert HA, Grab JD, O’Brien SM, Peterson ED, Allen MS. Predictors of prolonged length of stay after lobectomy for lung cancer: a Society of Thoracic Surgeons General Thoracic Surgery Database risk-adjustment model. Ann Thorac Surg 2008;85:1857–65. 13. Funaki S, Inoue M, Shigemura N, Okumura M. Thoracoscopic lobectomy for lung cancer after coronary artery bypass grafting using internal thoracic artery. Interact Cardiovasc Thorac Surg 2012;15:928–9. 14. D’Amico TA. Operative techniques in early-stage lung cancer. J Natl Compr Canc Netw 2010;8:807–13. 15. Singhatanadgige S, Sindhvanada W, Kittayarak C. Left upper lobectomy after CABG with the left internal mammary artery graft. J Med Assoc Thai 2006;89:887–9. 16. Flores RM, Ihekweazu U, Dycoco J, et al. Video-assisted thoracoscopic surgery (VATS) lobectomy: catastrophic intraoperative complications. J Thorac Cardiovasc Surg 2011;142:1412–7. 17. Ikeda N, Saji H, Hagiwara M, Ohira T, Usuda J, Kajiwara N. Recent advances in video-assisted thoracoscopic surgery for lung cancer. Asian J Endosc Surg 2013;6:9–13. 18. Demmy TL, Curtis JJ. Minimally invasive lobectomy directed toward frail and high-risk patients: a case-control study. Ann Thorac Surg 1999;68:194–200. 19. Berry MF, Onaitis MW, Tong BC, Harpole DH, D’Amico TA. A model for morbidity after lung resection in octogenarians. Eur J Cardiothorac Surg 2011;39:989–94.
INVITED COMMENTARY Shah and colleagues [1] have written a provocative essay about managing the critically important, but vulnerable, internal mammary conduit during video-assisted thoracic surgery (VATS) lobectomy. This is an important issue as many patients survive revascularization of their smoking-related coronary atherosclerotic occlusive disease and now live long enough to develop lung cancer. Before addressing appropriateness, it is important to emphasize several themes. First, the authors used careful judgment and planning. They reviewed operative reports considering internal mammary artery (IMA) orientation, pleural opening, preparation (skeletonized or pedicle), Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier
sequencing, and conduit age. Catheterization or computed tomographic angiography showed relative branch coronary artery importance and its dependence on the IMA graft. Injury strategies were planned with collaborative cardiac teams. Intraoperative transesophageal echocardiography, cardiac anesthesiology, and detecting and managing perioperative cardiac events were important. During surgery, their high VATS reliability experience facilitated dealing with hostile pleural spaces. Initiating safe dissection planes between the lung hilum and pericardium remote from the graft and stapling lung to leave a remnant on the sternotomy or IMA were useful 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.06.006
strategies. Both improved exposure and reduced parenchymal bleeding so tissue remnants could be observed or debrided appropriately. Supplemental thoracoscopic viewpoints may have helped. Finally, by VATS emulation of open vascular control methods they could perform safe conversions, if required. Currently, our specialty actively debates the merits of VATS for any lung cancer, not just these advanced cases. We generally trust master open thoracic surgeons to venture into more advanced frontiers by leveraging their aggregated skills and judgment. Perhaps it is time to extend the same provisional acceptance to our minimally invasive colleagues. On a personal note, I perform IMA cases such as these based on an advanced VATS practice that followed an earlier career emphasizing cardiac surgery. However, performing advanced cases like these without the aggregate experience or backup teams probably is unwise. Physically frail or advanced chronic obstructive pulmonary disease patients might be good cases to avoid thoracotomy; alternatively, those with good ventricular function tolerate thoracotomy if their grafts are protected. Importantly, not every successful VATS or robotic program exists within a cardiac center of excellence.
SHAH ET AL VATS LOBECTOMY AFTER MAMMARY GRAFT
1213
Thus, a frank discussion of the above issues or contingency plans should be communicated with all parties. Should a frail patient chance an IMA injury at a high VATS reliability, noncardiac hospital, or go to a heart center for likely thoracotomy? Such questions remain imponderable until others have replicated these authors’ excellent but modest experience. Until then, we must disclose all reasonable options to patients including those of thoughtful surgeons who consider VATS approaches unproven or undesirable. Todd L. Demmy, MD Roswell Park Cancer Institute Elm and Carlton Sts Buffalo, NY 14263 e-mail: [email protected]
Reference 1. Shah AA, Worni M, Onaitis MW, et al. Thoracoscopic left upper lobectomy in patients with internal mammary artery coronary bypass grafts. Ann Thorac Surg 2014;98: 1207–13.
GENERAL THORACIC
Ann Thorac Surg 2014;98:1207–13
