Original Article
Prior thoracoscopic surgery may improve reoperative pulmonary resection
Asian Cardiovascular & Thoracic Annals 2014, Vol. 22(6) 700–705 ß The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492313515252 aan.sagepub.com
Masatsugu Hamaji, Stephen D Cassivi, K Robert Shen, Mark S Allen, Francis C Nichols, Claude Deschamps and Dennis A Wigle
Abstract Objectives: although video-assisted thoracoscopic surgery for pulmonary resection appears to be associated with more favorable postoperative outcomes than thoracotomy, no reports have discussed its benefit at subsequent reoperative pulmonary resection. Methods: between January 2000 and December 2009, 144 patients underwent reoperative pulmonary resections for benign and malignant nodules at the Mayo Clinic, Rochester. Their data were evaluated retrospectively. Twenty-three (16%) patients had prior video-assisted thoracoscopic surgery, and 121 (84%) had undergone a prior open thoracotomy. Intraoperative and short-term postoperative outcomes were analyzed and compared between the two groups, using the chi-square test or Mann-Whitney test. Results: overall reoperative mortality was 1.38% and morbidity was 49.3%. Intraoperative factor analysis showed that the prior video-assisted thoracoscopic surgery group more often underwent anatomical resection (p ¼ 0.0011) and showed a tendency towards a lower conversion rate from video-assisted thoracoscopic surgery to thoracotomy at reoperative pulmonary resection (p ¼ 0.051). Short-term postoperative outcomes showed that the prior video-assisted thoracoscopic surgery group had a significantly lower morbidity rate (p ¼ 0.013), significantly shorter hospital stay (p ¼ 0.002), and a tendency for a shorter duration of chest tube drainage (p ¼ 0.09). Conclusion: our results suggest that prior video-assisted thoracoscopic surgery may lead to improved postoperative outcomes at subsequent reoperative pulmonary resection. Video-assisted thoracoscopic surgery may be favored for future potential reoperative pulmonary resections.
Keywords Lung Neoplasms, Pneumonectomy, Reoperation, Thoracic surgery, video-assisted, Thoracotomy
Introduction As shown in animal experiments, a prior thoracotomy appears to be associated with significant pleural adhesions making reoperative pulmonary resection potentially challenging.1,2 However, video-assisted thoracoscopic surgery (VATS), which was shown to lead to improved postoperative outcomes, may result in fewer adhesions due to its minimal invasiveness.3–5 Also, while many thoracic surgeons consider prior chest surgery, either by VATS or open thoracotomy, a relative contraindication to the use of VATS at reoperative pulmonary resection, prior VATS may be more likely enable a complete VATS approach at reoperative pulmonary resection. Hence the aim of our study was to
investigate any benefit of prior VATS in subsequent reoperative pulmonary resection.
Patients and methods This study was approved by the institutional review board at the Mayo Clinic. The requirement for patient
Division of General Thoracic Surgery, Mayo Clinic, Rochester, MN, USA Corresponding author: Dennis A Wigle, MD, PhD, Division of General Thoracic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MMN 55905, USA. Email: [email protected]
Downloaded from aan.sagepub.com at UNIV OF NORTH DAKOTA on June 4, 2015
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consent was waived. A retrospective chart review was performed. Between January 2000 and December 2009, 144 patients underwent reoperative pulmonary resections for benign and malignant nodules, which were performed on thoraces with previous general thoracic surgery at the Mayo Clinic, Rochester. Completion pneumonectomy patients, those with a prior contralateral pneumonectomy, and pneumothorax patients were excluded from our analysis due to the extreme extent of pulmonary resection. Patients who underwent pulmonary resection via a sternotomy were excluded. Cases in which the interval between the two procedures was less than one month were also excluded because of presumably minimal adhesions. Preoperative, intraoperative, and postoperative data were collected by a review of medical records. Preoperative patient characteristics are summarized in Table 1 for prior VATS patients and prior thoracotomy patients. Prior mediastinal procedures were defined as procedures including opening of the ipsilateral mediastinal pleura, such as intrathoracic gastric fundoplication, esophageal procedures, mediastinal tumor resection, or mediastinal lymph node dissection at first operations, either by open thoracotomy or VATS. Prior pulmonary anatomical resections were defined as pulmonary resections including dissecting
hilar vessels at first operations by open thoracotomy or VATS. All prior (first-time) or reoperative procedures in this study were performed under general anesthesia with selective one-lung ventilation using a doublelumen endotracheal tube. In reoperative VATS cases, the previous camera port site was typically used, otherwise, the camera port was placed on the anterior axillary line in the 6th or 7th intercostal space. Thereafter, the other 2 incisions were made sequentially, depending on the location of intrapleural adhesions. In reoperative thoracotomy cases, the previous incision site was typically used, or a new posterolateral incision, sparing the anterior serratus muscles, was made. In taking down adhesions between the lung and chest wall, electrocautery or sharp dissection was typically used. Adhesions between the lung and mediastinum were taken down by sharp dissection, electrocautery, or blunt dissection. Postoperative mortality and morbidity were recorded within 30 days of the reoperative procedure or during the same hospital stay. Prolonged air leak was defined as an air leak of 5 or more days with or without the need for a chest tube and Heimlich valve at discharge. Postoperative respiratory failure
Table 1. Preoperative patient characteristics in prior VATS and prior thoracotomy patients. Variable Median age (years) [range] Female sex Right laterality Diagnosis at initial surgery Primary lung cancer Pulmonary metastasis Benign lung nodule Others Diagnosis at reoperation Primary lung cancer Pulmonary metastasis Benign lung nodule Others Prior pulmonary resection Prior mediastinal procedure Prior pulmonary anatomical resection Preoperative % of predicted FEV1 Median interval between procedures (months) [range]
Prior VATS (n ¼ 23)
Prior thoracotomy (n ¼ 121)
72 [52–88] 8 (34.8%) 13 (56.5%)
69 [19–86] 56 (46.3%) 81 (66.9%)
0.51 0.39 0.48
18 2 2 1
92 8 10 11
0.81 0.72 0.94
21 2 0 0 19 (82.6%) 7 (30.4%)
104 8 9 0 112 (92.5%) 84 (69.4%)
0.47 0.72 0.2 0.16
Prior thoracoscopic surgery may improve reoperative pulmonary resection
Asian Cardiovascular & Thoracic Annals 2014, Vol. 22(6) 700–705 ß The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492313515252 aan.sagepub.com
Masatsugu Hamaji, Stephen D Cassivi, K Robert Shen, Mark S Allen, Francis C Nichols, Claude Deschamps and Dennis A Wigle
Abstract Objectives: although video-assisted thoracoscopic surgery for pulmonary resection appears to be associated with more favorable postoperative outcomes than thoracotomy, no reports have discussed its benefit at subsequent reoperative pulmonary resection. Methods: between January 2000 and December 2009, 144 patients underwent reoperative pulmonary resections for benign and malignant nodules at the Mayo Clinic, Rochester. Their data were evaluated retrospectively. Twenty-three (16%) patients had prior video-assisted thoracoscopic surgery, and 121 (84%) had undergone a prior open thoracotomy. Intraoperative and short-term postoperative outcomes were analyzed and compared between the two groups, using the chi-square test or Mann-Whitney test. Results: overall reoperative mortality was 1.38% and morbidity was 49.3%. Intraoperative factor analysis showed that the prior video-assisted thoracoscopic surgery group more often underwent anatomical resection (p ¼ 0.0011) and showed a tendency towards a lower conversion rate from video-assisted thoracoscopic surgery to thoracotomy at reoperative pulmonary resection (p ¼ 0.051). Short-term postoperative outcomes showed that the prior video-assisted thoracoscopic surgery group had a significantly lower morbidity rate (p ¼ 0.013), significantly shorter hospital stay (p ¼ 0.002), and a tendency for a shorter duration of chest tube drainage (p ¼ 0.09). Conclusion: our results suggest that prior video-assisted thoracoscopic surgery may lead to improved postoperative outcomes at subsequent reoperative pulmonary resection. Video-assisted thoracoscopic surgery may be favored for future potential reoperative pulmonary resections.
Keywords Lung Neoplasms, Pneumonectomy, Reoperation, Thoracic surgery, video-assisted, Thoracotomy
Introduction As shown in animal experiments, a prior thoracotomy appears to be associated with significant pleural adhesions making reoperative pulmonary resection potentially challenging.1,2 However, video-assisted thoracoscopic surgery (VATS), which was shown to lead to improved postoperative outcomes, may result in fewer adhesions due to its minimal invasiveness.3–5 Also, while many thoracic surgeons consider prior chest surgery, either by VATS or open thoracotomy, a relative contraindication to the use of VATS at reoperative pulmonary resection, prior VATS may be more likely enable a complete VATS approach at reoperative pulmonary resection. Hence the aim of our study was to
investigate any benefit of prior VATS in subsequent reoperative pulmonary resection.
Patients and methods This study was approved by the institutional review board at the Mayo Clinic. The requirement for patient
Division of General Thoracic Surgery, Mayo Clinic, Rochester, MN, USA Corresponding author: Dennis A Wigle, MD, PhD, Division of General Thoracic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MMN 55905, USA. Email: [email protected]
Downloaded from aan.sagepub.com at UNIV OF NORTH DAKOTA on June 4, 2015
Hamaji et al.
701
consent was waived. A retrospective chart review was performed. Between January 2000 and December 2009, 144 patients underwent reoperative pulmonary resections for benign and malignant nodules, which were performed on thoraces with previous general thoracic surgery at the Mayo Clinic, Rochester. Completion pneumonectomy patients, those with a prior contralateral pneumonectomy, and pneumothorax patients were excluded from our analysis due to the extreme extent of pulmonary resection. Patients who underwent pulmonary resection via a sternotomy were excluded. Cases in which the interval between the two procedures was less than one month were also excluded because of presumably minimal adhesions. Preoperative, intraoperative, and postoperative data were collected by a review of medical records. Preoperative patient characteristics are summarized in Table 1 for prior VATS patients and prior thoracotomy patients. Prior mediastinal procedures were defined as procedures including opening of the ipsilateral mediastinal pleura, such as intrathoracic gastric fundoplication, esophageal procedures, mediastinal tumor resection, or mediastinal lymph node dissection at first operations, either by open thoracotomy or VATS. Prior pulmonary anatomical resections were defined as pulmonary resections including dissecting
hilar vessels at first operations by open thoracotomy or VATS. All prior (first-time) or reoperative procedures in this study were performed under general anesthesia with selective one-lung ventilation using a doublelumen endotracheal tube. In reoperative VATS cases, the previous camera port site was typically used, otherwise, the camera port was placed on the anterior axillary line in the 6th or 7th intercostal space. Thereafter, the other 2 incisions were made sequentially, depending on the location of intrapleural adhesions. In reoperative thoracotomy cases, the previous incision site was typically used, or a new posterolateral incision, sparing the anterior serratus muscles, was made. In taking down adhesions between the lung and chest wall, electrocautery or sharp dissection was typically used. Adhesions between the lung and mediastinum were taken down by sharp dissection, electrocautery, or blunt dissection. Postoperative mortality and morbidity were recorded within 30 days of the reoperative procedure or during the same hospital stay. Prolonged air leak was defined as an air leak of 5 or more days with or without the need for a chest tube and Heimlich valve at discharge. Postoperative respiratory failure
Table 1. Preoperative patient characteristics in prior VATS and prior thoracotomy patients. Variable Median age (years) [range] Female sex Right laterality Diagnosis at initial surgery Primary lung cancer Pulmonary metastasis Benign lung nodule Others Diagnosis at reoperation Primary lung cancer Pulmonary metastasis Benign lung nodule Others Prior pulmonary resection Prior mediastinal procedure Prior pulmonary anatomical resection Preoperative % of predicted FEV1 Median interval between procedures (months) [range]
Prior VATS (n ¼ 23)
Prior thoracotomy (n ¼ 121)
72 [52–88] 8 (34.8%) 13 (56.5%)
69 [19–86] 56 (46.3%) 81 (66.9%)
0.51 0.39 0.48
18 2 2 1
92 8 10 11
0.81 0.72 0.94
21 2 0 0 19 (82.6%) 7 (30.4%)
104 8 9 0 112 (92.5%) 84 (69.4%)
0.47 0.72 0.2 0.16
