509728
research-article2013
SRIXXX10.1177/1553350613509728Surgical InnovationXu et al
Procedural Innovation
Thoracoscopic Half Carina Resection and Bronchial Sleeve Resection for Central Lung Cancer
Surgical Innovation 2014, Vol. 21(5) 481–486 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1553350613509728 sri.sagepub.com
Xin Xu, MD, PhD1,2, Hanzhang Chen, MD1,2, Weiqiang Yin, MD1,2, Wenlong Shao, MD, PhD1,2, Xinguo Xiong, MD1,2, Jun Huang, MD, PhD1,2, and Jianxing He, MD, PhD, FACS1,2
Abstract Background. The objectives of this study were to report the surgical techniques and clinical outcome of thoracoscopic half carina resection and thoracoscopic bronchial sleeve resection for central lung cancer. Methods. Between January 2011 and November 2012, 675 patients with lung cancer underwent radical surgery by thoracoscopy, and 49 (7.3%) underwent bronchial sleeve resection. Among 49 patients, 20 (41%) received thoracoscopic bronchial sleeve lobectomy. Perioperative variables and postoperative outcomes of these cases were analyzed to evaluate the technical feasibility and safety of this operation. Results. In one patient, right upper lung sleeve resection was combined with half-carinal resection and reconstruction. In another, right medial lung sleeve resection was combined with lower right dorsal segment resection. The average time of surgery was 239 ± 51 minutes (range = 142-330 minutes), and the average time of airway reconstruction was 44 ± 17 minutes (range = 22-75 minutes). The intraoperative blood loss averaged 207 ± 96 mL (range = 80-550 mL). The median postoperative hospital stay was 10 days (interquartile range = 8-12 days). Postoperatively, extubation was achieved in the recovery room without further need for mechanical ventilation. None of the patients developed anastomotic leak. Perioperative mortality was not observed. Conclusion. Thoracoscopic bronchial sleeve resection can be considered a feasible and safe operation for selected patients with central lung cancer. The complicated anastomosis technique of half carina resection was feasible. Keywords lung cancer, video-assisted thoracoscopic surgery (VATS), sleeve lobectomy
Introduction Lung cancer is one of the leading causes of death around the world.1 In 1947, Thomas conducted the first sleeve resection of the right upper lobe.2 Since then, bronchial sleeve resection has developed into one of the standard techniques for treatment of lung cancer. Long-term survival and outcomes for lung cancer patients after sleeve lobectomy are comparable to pneumonectomy. However, sleeve lobectomy is less damaging to the lung function and thus reduces operative mortality and improves quality of life. This approach is therefore used even if the patient can tolerate total pneumonectomy.3 In 1992, Lewis et al4 demonstrated the technical feasibility of thoracoscopic lobectomy; however, it was still controversial as to whether thoracoscopy was a suitable approach for lung cancer surgery. McKenna et al5 widely applied the combination of thoracoscopic lobectomy and lymph node dissection to surgical treatment of lung cancer, and demonstrated its efficacy and safety by achieving
a complete removal of the tumor. The thoracoscopic techniques have advantages (eg, smaller incision, shorter hospital stay, reduced postoperative pain and bleeding, and less damage to the lung function).6-8 The utilization of bronchial sleeve resection is not rare (4.9% to 8.7%) in traditional lung cancer surgery.9,10 However, a thoracoscopic approach is most commonly used for peripheral lesions11,12; therefore, thoracoscopic bronchial sleeve resection for lung cancer has only been reported in limited studies.13-16 1
The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China 2 Guangzhou Institute of Respiratory Disease & China State Key Laboratory of Respiratory Disease, Guangzhou, China Corresponding Author: Jianxing He, Department of Cardiothoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, No. 151, Yanjiang Road, Guangzhou 510120, Guangdong Province, PR China. Email: [email protected]
Downloaded from sri.sagepub.com at UNIV CALIFORNIA SANTA BARBARA on July 13, 2015
482
Surgical Innovation 21(5)
We have previously successfully performed bronchial sleeve resection with video-assisted mini-thoracotomy in patients with lung cancer.17 In light of the satisfying outcomes, we have conducted thoracoscopic bronchial sleeve resection for an additional 20 patients with lung cancer. The objectives of this study were to report the surgical techniques and clinical outcome of thoracoscopic half carina resection and thoracoscopic bronchial sleeve resection for central lung cancer.
Materials and Methods Operative Procedure For thoracoscopic bronchial sleeve lobectomy patient selection, we used similar inclusion criteria reported by Nakanishi.13 However, a tumor diameter of less than 5 cm was not strictly required because of difficulty in accurate measurement. Combined intravenous anesthesia was achieved using double-lumen tube intubation. A bronchoscope was used to ensure proper positioning of the endobronchial tubes in order to assure proper lung ventilation. Patients were positioned on the contralateral side with their waist elevated to allow for maximum width of the intercostal spaces. Overall, 3 incisions were made. The 1.2-cm long camera incision was placed in the sixth or seventh intercostal space at the middle auxiliary line. The 1.2-cm long auxiliary incision was located in the same intercostal space at the posterior auxiliary line to minimize damage to the intercostal nerves. The main incision, 4 to 6 cm in length, was located in the fourth or fifth intercostal space between the anterior and posterior auxiliary line, and retracted with a soft protector (Figure 1). The lobar veins and arteries were first freed and dissected using Endo cutter (Ethicon Endo-Surgery Inc, Blue Ash, OH). The pulmonary arteries were fully separated to accommodate a vessel occlusion clamp, in the event of an accidental rupture of the pulmonary artery this would allow for rapid hemostasis. The bronchus was divided, the proximal and distal lengths for sleeve resection were designed according to the degree of tumor invasion, and the corresponding segments were resected. The main bronchus and lower lobe bronchi were fully divided to reduce anastomotic tension. The bronchus was cut at both the proximal and distal ends with 0.5 to 1 cm margins from the tumor. The resected lobe was then extracted with a bag. Next, hilar and mediastinal lymph node dissection was conducted. After a negative margins confirmed by the frozen pathological diagnosis, airway reconstruction was immediately initiated. Modified interrupted suture was used for anatasmosis in our initial 8 cases (8/20). The membranous posterior wall of the bronchus was closed using continuous (4-0 polypropylene) suture; the cartilage part of the anterior wall was then closed with alternating
Figure 1. The incisions distribution for thoracoscopic bronchial sleeve resection and the incision protectors for soft distraction.
Figure 2. Interrupted and alternate anastomosis for the cartilage part of the anterior wall by figure-of-eight suturing and mattress suturing.
figure-of-eight and mattress suture with 4-0 single-strand absorbable suture (Figure 2). For the remaining 12 cases (12/20), continuous suture was used, during which the membranous posterior and the cartilage wall were anastomosed with single 3-0 or 4-0 prolene suture (Figure 3). A knot pusher was used to tie the suture knots following the anastomosis. Coverage of anastomosis was not needed. Once the chest was washed with saline, the lung was inflated at the pressure of 30 cm H2O to identify potential air leakage from the anastomosis suture line. In one case, the tumor was located from the right upper to the lower segment of trachea, right upper sleeve lobectomy in combination with half-carinal reconstruction was performed (Figure 4). To facilitate the operations, a single-lumen endotracheal tube was directly intubated into left main bronchus for single lateral ventilation so that the procedure of suture for half-carinal reconstruction will be easier because of the thinner tube
Downloaded from sri.sagepub.com at UNIV CALIFORNIA SANTA BARBARA on July 13, 2015
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Xu et al
Figure 3. Continuous anastomosis for both the membarnous posterior wall and the cartilage of the anterior wall then anastomosed.
compared with the double- lumen endotracheal tube generally used in thoracoscopic lobectomy. The side of the lower segment of trachea was sutured first to narrow the rim of proximal trachea to better match the distal right intermediate bronchus. The entirety of the operation, including anastomosis, was completed only by observation via monitor. All incisions were maintained by the incision protectors. Conventional surgical instruments including needle holders were used for the anastomosis.
Intraoperative and Postoperative Management In lower lobectomy a 28 Fr chest tube was placed through the observation incision after the main procedure, with the tip above the costophrenic angle. In the case of an upper lobectomy, an additional 28 Fr chest tube was placed through the auxiliary operation incision, with the tip at the apex. The drainage tubes were removed once no air leak was observed when coughing, and the 24-hour drainage volume was less than 150 mL. Before removal of the drainage tube, chest radiography was performed to confirm proper lung expansion. Fiber-optic bronchoscopy was performed prior to discharge to verify proper healing of anastomosis.17
Statistical Analysis Normally distributed continuous variables are presented as mean ± standard deviation, while significantly skewed variables are presented as median with interquartile range. SPSS software version 11.0 (SPSS, Chicago, IL) was used for statistical calculations.
Results From January 2011 to November 2012, 675 patients with lung cancer underwent radical lobectomy in our department.
Forty-nine (7.3%) patients underwent bronchial sleeve resection, including 20 patients (41%) who received thoracoscopic bronchial sleeve resection (17 men, 3 women; median age 60 years, range 26-78 years). The details of the characteristics are listed in Table 1. Of the 20 patients, 1 had small cell lung cancer, and the remaining 19 had non–small cell lung cancer. In one case, right upper lung sleeve resection was combined with half-carinal resection and reconstruction; in another, the patient underwent right medial lung sleeve resection in combination with lower right dorsal segment resection. The average time of surgery was 239 ± 51 minutes (range = 142-330 minutes), and the average time of airway reconstruction was 44 ± 17 minutes (range = 22-75 minutes). For the first 8 cases with interrupted suture, the average time of airway reconstruction was 54 minutes; the average of the remaining 12 with continuous suture was 37 minutes (Table 2). The intraoperative blood loss averaged 207 ± 96 mL (range 80-550 mL). The median postoperative hospital stay was 10 days (interquartile range, 8-12 days). Postoperative extubation was achieved in the recovery room for all patients. None of the patients required intubation and mechanical ventilation afterward. Anastomotic leak did not occur in any of the patients. Perioperative mortality was not observed.
Discussion Although there are a number of patients with operable lung cancer in need of bronchial sleeve resection accounting for 4.9% to 8.7% of cases,9,10 most thoracic surgeons will select cases with peripheral lung cancer for thoracoscopic approach without considering bronchial sleeve resection, as there is higher level of difficulty for bronchial sleeve resection, compared with peripheral lung cancer surgery under thoracoscopy. Airway reconstruction needed for thoracoscopic bronchial sleeve resection has a prolonged learning curve and requires an extended training period. Surgeons, therefore, often chose traditional thoracotomy or video-assisted mini-thoracotomy over thoracoscopy for operations involving airway reconstruction. In our clinical practice, we performed bronchial sleeve resection under thoracoscopy alone in selected cases. We performed bronchial sleeve resection using only 3 incisions. We found that this method was efficient enough to allow the surgeon easily access at the main incision. In addition, we have made a smaller incision (range 4-6 cm) compared with the more widely applied mini thoractomy. The entirety of the operation was completed via monitor. Thoracoscopic lymph node dissection was performed while waiting for the frozen pathological diagnosis. In this situation, the pulmonary lobe had been removed and the bronchus had been dissected, the subcarinal space
Downloaded from sri.sagepub.com at UNIV CALIFORNIA SANTA BARBARA on July 13, 2015
484
Surgical Innovation 21(5)
Figure 4. Mosaic pictures of right upper sleeve lobectomy in combination with half-carinal reconstruction. (1) Computed tomography scan of the tumor. (2) Right upper lobe and a part of the carina and trachea were removed. (3) The side wall of the lower segment of trachea was continuously sutured first. (4) The distal right intermediate bronchus and the narrowed proximal trachea were continuously anastomosed. (5) The anastomosis was to be finished. (6) The finished anastomosis. White arrow, the lower segment of trachea and carina; red arrow, the tumor was located from the right upper to the lower segment of trachea. A, trachea; B, left main bronchus; C, right intermediate bronchus; D, single-lumen endotracheal tube. Table 1. Patient Characteristics. Characteristic Age (years)
research-article2013
SRIXXX10.1177/1553350613509728Surgical InnovationXu et al
Procedural Innovation
Thoracoscopic Half Carina Resection and Bronchial Sleeve Resection for Central Lung Cancer
Surgical Innovation 2014, Vol. 21(5) 481–486 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1553350613509728 sri.sagepub.com
Xin Xu, MD, PhD1,2, Hanzhang Chen, MD1,2, Weiqiang Yin, MD1,2, Wenlong Shao, MD, PhD1,2, Xinguo Xiong, MD1,2, Jun Huang, MD, PhD1,2, and Jianxing He, MD, PhD, FACS1,2
Abstract Background. The objectives of this study were to report the surgical techniques and clinical outcome of thoracoscopic half carina resection and thoracoscopic bronchial sleeve resection for central lung cancer. Methods. Between January 2011 and November 2012, 675 patients with lung cancer underwent radical surgery by thoracoscopy, and 49 (7.3%) underwent bronchial sleeve resection. Among 49 patients, 20 (41%) received thoracoscopic bronchial sleeve lobectomy. Perioperative variables and postoperative outcomes of these cases were analyzed to evaluate the technical feasibility and safety of this operation. Results. In one patient, right upper lung sleeve resection was combined with half-carinal resection and reconstruction. In another, right medial lung sleeve resection was combined with lower right dorsal segment resection. The average time of surgery was 239 ± 51 minutes (range = 142-330 minutes), and the average time of airway reconstruction was 44 ± 17 minutes (range = 22-75 minutes). The intraoperative blood loss averaged 207 ± 96 mL (range = 80-550 mL). The median postoperative hospital stay was 10 days (interquartile range = 8-12 days). Postoperatively, extubation was achieved in the recovery room without further need for mechanical ventilation. None of the patients developed anastomotic leak. Perioperative mortality was not observed. Conclusion. Thoracoscopic bronchial sleeve resection can be considered a feasible and safe operation for selected patients with central lung cancer. The complicated anastomosis technique of half carina resection was feasible. Keywords lung cancer, video-assisted thoracoscopic surgery (VATS), sleeve lobectomy
Introduction Lung cancer is one of the leading causes of death around the world.1 In 1947, Thomas conducted the first sleeve resection of the right upper lobe.2 Since then, bronchial sleeve resection has developed into one of the standard techniques for treatment of lung cancer. Long-term survival and outcomes for lung cancer patients after sleeve lobectomy are comparable to pneumonectomy. However, sleeve lobectomy is less damaging to the lung function and thus reduces operative mortality and improves quality of life. This approach is therefore used even if the patient can tolerate total pneumonectomy.3 In 1992, Lewis et al4 demonstrated the technical feasibility of thoracoscopic lobectomy; however, it was still controversial as to whether thoracoscopy was a suitable approach for lung cancer surgery. McKenna et al5 widely applied the combination of thoracoscopic lobectomy and lymph node dissection to surgical treatment of lung cancer, and demonstrated its efficacy and safety by achieving
a complete removal of the tumor. The thoracoscopic techniques have advantages (eg, smaller incision, shorter hospital stay, reduced postoperative pain and bleeding, and less damage to the lung function).6-8 The utilization of bronchial sleeve resection is not rare (4.9% to 8.7%) in traditional lung cancer surgery.9,10 However, a thoracoscopic approach is most commonly used for peripheral lesions11,12; therefore, thoracoscopic bronchial sleeve resection for lung cancer has only been reported in limited studies.13-16 1
The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China 2 Guangzhou Institute of Respiratory Disease & China State Key Laboratory of Respiratory Disease, Guangzhou, China Corresponding Author: Jianxing He, Department of Cardiothoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, No. 151, Yanjiang Road, Guangzhou 510120, Guangdong Province, PR China. Email: [email protected]
Downloaded from sri.sagepub.com at UNIV CALIFORNIA SANTA BARBARA on July 13, 2015
482
Surgical Innovation 21(5)
We have previously successfully performed bronchial sleeve resection with video-assisted mini-thoracotomy in patients with lung cancer.17 In light of the satisfying outcomes, we have conducted thoracoscopic bronchial sleeve resection for an additional 20 patients with lung cancer. The objectives of this study were to report the surgical techniques and clinical outcome of thoracoscopic half carina resection and thoracoscopic bronchial sleeve resection for central lung cancer.
Materials and Methods Operative Procedure For thoracoscopic bronchial sleeve lobectomy patient selection, we used similar inclusion criteria reported by Nakanishi.13 However, a tumor diameter of less than 5 cm was not strictly required because of difficulty in accurate measurement. Combined intravenous anesthesia was achieved using double-lumen tube intubation. A bronchoscope was used to ensure proper positioning of the endobronchial tubes in order to assure proper lung ventilation. Patients were positioned on the contralateral side with their waist elevated to allow for maximum width of the intercostal spaces. Overall, 3 incisions were made. The 1.2-cm long camera incision was placed in the sixth or seventh intercostal space at the middle auxiliary line. The 1.2-cm long auxiliary incision was located in the same intercostal space at the posterior auxiliary line to minimize damage to the intercostal nerves. The main incision, 4 to 6 cm in length, was located in the fourth or fifth intercostal space between the anterior and posterior auxiliary line, and retracted with a soft protector (Figure 1). The lobar veins and arteries were first freed and dissected using Endo cutter (Ethicon Endo-Surgery Inc, Blue Ash, OH). The pulmonary arteries were fully separated to accommodate a vessel occlusion clamp, in the event of an accidental rupture of the pulmonary artery this would allow for rapid hemostasis. The bronchus was divided, the proximal and distal lengths for sleeve resection were designed according to the degree of tumor invasion, and the corresponding segments were resected. The main bronchus and lower lobe bronchi were fully divided to reduce anastomotic tension. The bronchus was cut at both the proximal and distal ends with 0.5 to 1 cm margins from the tumor. The resected lobe was then extracted with a bag. Next, hilar and mediastinal lymph node dissection was conducted. After a negative margins confirmed by the frozen pathological diagnosis, airway reconstruction was immediately initiated. Modified interrupted suture was used for anatasmosis in our initial 8 cases (8/20). The membranous posterior wall of the bronchus was closed using continuous (4-0 polypropylene) suture; the cartilage part of the anterior wall was then closed with alternating
Figure 1. The incisions distribution for thoracoscopic bronchial sleeve resection and the incision protectors for soft distraction.
Figure 2. Interrupted and alternate anastomosis for the cartilage part of the anterior wall by figure-of-eight suturing and mattress suturing.
figure-of-eight and mattress suture with 4-0 single-strand absorbable suture (Figure 2). For the remaining 12 cases (12/20), continuous suture was used, during which the membranous posterior and the cartilage wall were anastomosed with single 3-0 or 4-0 prolene suture (Figure 3). A knot pusher was used to tie the suture knots following the anastomosis. Coverage of anastomosis was not needed. Once the chest was washed with saline, the lung was inflated at the pressure of 30 cm H2O to identify potential air leakage from the anastomosis suture line. In one case, the tumor was located from the right upper to the lower segment of trachea, right upper sleeve lobectomy in combination with half-carinal reconstruction was performed (Figure 4). To facilitate the operations, a single-lumen endotracheal tube was directly intubated into left main bronchus for single lateral ventilation so that the procedure of suture for half-carinal reconstruction will be easier because of the thinner tube
Downloaded from sri.sagepub.com at UNIV CALIFORNIA SANTA BARBARA on July 13, 2015
483
Xu et al
Figure 3. Continuous anastomosis for both the membarnous posterior wall and the cartilage of the anterior wall then anastomosed.
compared with the double- lumen endotracheal tube generally used in thoracoscopic lobectomy. The side of the lower segment of trachea was sutured first to narrow the rim of proximal trachea to better match the distal right intermediate bronchus. The entirety of the operation, including anastomosis, was completed only by observation via monitor. All incisions were maintained by the incision protectors. Conventional surgical instruments including needle holders were used for the anastomosis.
Intraoperative and Postoperative Management In lower lobectomy a 28 Fr chest tube was placed through the observation incision after the main procedure, with the tip above the costophrenic angle. In the case of an upper lobectomy, an additional 28 Fr chest tube was placed through the auxiliary operation incision, with the tip at the apex. The drainage tubes were removed once no air leak was observed when coughing, and the 24-hour drainage volume was less than 150 mL. Before removal of the drainage tube, chest radiography was performed to confirm proper lung expansion. Fiber-optic bronchoscopy was performed prior to discharge to verify proper healing of anastomosis.17
Statistical Analysis Normally distributed continuous variables are presented as mean ± standard deviation, while significantly skewed variables are presented as median with interquartile range. SPSS software version 11.0 (SPSS, Chicago, IL) was used for statistical calculations.
Results From January 2011 to November 2012, 675 patients with lung cancer underwent radical lobectomy in our department.
Forty-nine (7.3%) patients underwent bronchial sleeve resection, including 20 patients (41%) who received thoracoscopic bronchial sleeve resection (17 men, 3 women; median age 60 years, range 26-78 years). The details of the characteristics are listed in Table 1. Of the 20 patients, 1 had small cell lung cancer, and the remaining 19 had non–small cell lung cancer. In one case, right upper lung sleeve resection was combined with half-carinal resection and reconstruction; in another, the patient underwent right medial lung sleeve resection in combination with lower right dorsal segment resection. The average time of surgery was 239 ± 51 minutes (range = 142-330 minutes), and the average time of airway reconstruction was 44 ± 17 minutes (range = 22-75 minutes). For the first 8 cases with interrupted suture, the average time of airway reconstruction was 54 minutes; the average of the remaining 12 with continuous suture was 37 minutes (Table 2). The intraoperative blood loss averaged 207 ± 96 mL (range 80-550 mL). The median postoperative hospital stay was 10 days (interquartile range, 8-12 days). Postoperative extubation was achieved in the recovery room for all patients. None of the patients required intubation and mechanical ventilation afterward. Anastomotic leak did not occur in any of the patients. Perioperative mortality was not observed.
Discussion Although there are a number of patients with operable lung cancer in need of bronchial sleeve resection accounting for 4.9% to 8.7% of cases,9,10 most thoracic surgeons will select cases with peripheral lung cancer for thoracoscopic approach without considering bronchial sleeve resection, as there is higher level of difficulty for bronchial sleeve resection, compared with peripheral lung cancer surgery under thoracoscopy. Airway reconstruction needed for thoracoscopic bronchial sleeve resection has a prolonged learning curve and requires an extended training period. Surgeons, therefore, often chose traditional thoracotomy or video-assisted mini-thoracotomy over thoracoscopy for operations involving airway reconstruction. In our clinical practice, we performed bronchial sleeve resection under thoracoscopy alone in selected cases. We performed bronchial sleeve resection using only 3 incisions. We found that this method was efficient enough to allow the surgeon easily access at the main incision. In addition, we have made a smaller incision (range 4-6 cm) compared with the more widely applied mini thoractomy. The entirety of the operation was completed via monitor. Thoracoscopic lymph node dissection was performed while waiting for the frozen pathological diagnosis. In this situation, the pulmonary lobe had been removed and the bronchus had been dissected, the subcarinal space
Downloaded from sri.sagepub.com at UNIV CALIFORNIA SANTA BARBARA on July 13, 2015
484
Surgical Innovation 21(5)
Figure 4. Mosaic pictures of right upper sleeve lobectomy in combination with half-carinal reconstruction. (1) Computed tomography scan of the tumor. (2) Right upper lobe and a part of the carina and trachea were removed. (3) The side wall of the lower segment of trachea was continuously sutured first. (4) The distal right intermediate bronchus and the narrowed proximal trachea were continuously anastomosed. (5) The anastomosis was to be finished. (6) The finished anastomosis. White arrow, the lower segment of trachea and carina; red arrow, the tumor was located from the right upper to the lower segment of trachea. A, trachea; B, left main bronchus; C, right intermediate bronchus; D, single-lumen endotracheal tube. Table 1. Patient Characteristics. Characteristic Age (years)
