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Video-Assisted Thoracoscopic Surgery for Treatment of Early-Stage Non-Small Cell Lung Cancer

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Video-Assisted Thoracoscopic Surgery for Treatment of Early-Stage Non-Small Cell Lung Cancer DOI:http://dx.doi.org/10.7314/APJCP.2013.14.5.2871 Video-assisted Thoracoscopic Surgery for Early-stage Non-small Cell Lung Cancer RESEARCH ARTICLE Video-assisted Thoracoscopic Surgery for Treatment of Early- stage Non-small Cell Lung Cancer Xing-Long Fan1,2, Yu-Xia Liu2, Hui Tian1* Abstract Objectives: To evaluate the safety, efficacy, and invasiveness of lobectomy by video-assisted thoracoscopic surgery (VATS) in the treatment of stage I/II non-small cell lung cancer (NSCLC). Methods: A total of 148 patients presenting with Stage I or II NSCLC were enrolled into our study, comprising 71 who underwent VATS and 77 patients undergoing conventional thoracotomic lobectomy, in combination with systematic lymph node resection. Results: It was found that VATS was superior to conventional thoracotomy in terms of the duration of surgery, intraoperative blood loss, frequency of the need to administer postoperative analgesia, thoracic intubation indwelling time, post-operative hospital stay, and survival rate (P<0.05). We saw no obvious difference in the number of resected lymph nodes with either approach. Conclusions: VATS lobectomy is a safe and reliable surgical approach for the treatment of Stage I/II NSCLC, characterized by significantly minimal invasiveness, rapid post-operative recovery, and markedly lower loss of blood. Keywords: Video-assisted thoracscopic surgery - lung cancer - lobectomy - lymph node dissection - prognosis Asian Pacific J Cancer Prev, 14 (5), 2871-2877 Introduction et al., 2006; Mahtabifard et al., 2007; Swanson et al., 2012). Prior to 2003, the rate of annual VATS lobectomy Traditionally, thoracotomy was the most common in lung cancer was shown to be less than 5% but rose to thoracic surgical approach before the advent of minimally approximately 10% by 2006. Experts in the field have invasive devices. The malignant lesions can be fully estimated that approximately 60% of lung cancer surgeries exposed and resected, however, there are major concerns could be performed by adopting VATS in the US over the associated with post-operative and severe pulmonary next several years. complications and prolonged wound healing. This is Application of VATS in surgical medicine was first largely due to massive surgical trauma and intraoperative elaborated in the Guidelines of Clinical Oncology of the loss of blood loss, all of which have been major concerns National Comprehensive Cancer Network (NCCN) in for both the surgeon and the patient. The initial clinical 2006. VATS lobectomy is now considered the standard report on thoracoscopic surgery was published in the approach in the treatment of early stage NSCLC by 1990s (Lee, 2010). Thereafter, thoracoscopic techniques the NCCN guidelines of 2007. However, in China, have become an important surgical approach for thoracic safety concerns in regard VATS lobectomy have limited surgery, especially following the advent of video-assisted application of this approach and it is only performed in thoracoscopic surgery (VATS). developed regions. Surveying the published literature The advantage of VATS over thoracotomy is that informs us that the major approach for tharocscopy- the incision to the patient’s chest is relatively minor, assisted lobectomy is by direct visualization and does not which leads to reductions in post-operative infection and rely solely on the use of a fiber optic thoracoscope in VATS wound dehiscence. This permits the prompt return of the lobectomy. Therefore, we conducted a comprehensive patient to full activity. Therefore, thoracoscopic surgery assessment of VATS lobectomy in the treatment of early was gradually adopted for the diagnosis and treatment stage NSCLC to elucidate the safety and efficacy of of lung malignancies complementing the application of this approach as compared with that of conventional endoscopic gastrointestinal anastomat (Endo-GIA). In thoracotomy. addition, lobectomy and mediastinal lymph node resection using thoracoscopic devices (Flores, 2010) enables VATS Materials and Methods to be one of the most feasible alternatives for early stage lung cancer treatment, an approach which has been widely Patients adopted in developed countries(Yim et al., 1996; Ohbuchi We recruited 148 study subjects to this study et al., 1998; Roviaro et al., 1998; McKenna, 2006; Onaitis who presented with NSCLC at stage I or II, without 1Department of Thoracic, QiLu Hospital, Shandong University, Jinan, 2Department of Thoracic, Qingdao Municipal Hospital, Qingdao, Shangdong, China *For correspondence: [email protected] Asian Pacific Journal of Cancer Prevention, Vol 14, 2013 2871 Xing-Long Fan et al radiotherapy or chemotherapy between January 2005 made at the anterior axillary line, at the 4th intercostal and December 2010. Surgical treatment of the recruited space for the resection of the superior and middle lobes, subjects was considered as a first line therapeutic strategy. and at the 5th intercostal space for the resection of the Thus, 71 study subjects underwent VATS (VATS group) inferior lobe respectively, according to the location of the and 77 study subjects (Thoracotomy group) underwent tumor. The incision location was in accordance with that conventional thoracotomic lobectomy respectively. Chest reported in the literature (Yim et al., 1996; Demmy and X-ray examination, bronchoscopy, arterial blood/gas Nwogu, 2008; Kim et al., 2010; Swanson et al., 2012). analysis, and pulmonary function tests were performed We suggest that in the first instance massive pleural prior to surgery. Inspection of chest CT scans revealed an adhesions should be disassociated in order to retain absence of enlarged mediastinal lymph nodes (defined as a acceptable mobility of the lobes. Conventional thoracic lymph node having a diameter larger than 1.0 cm) in all of surgery devices were used to detach the pulmonary veins the recruited subjects. In addition, the size of the tumors in and artery if the interlobar fissure could be completely the study subjects was less than 6.0 cm in diameter. This differentiated. An additional suture needed to be placed study was conducted in accordance with the declaration of across the large vessel (with a diameter greater than 1.0 Helsinki. This study was conducted with approval from the cm) using forceps or endoscopic equipment, and served Ethics Committee of QiLu Hospital, Shandon University. as a traction tool under situations when the vessel was Written informed consent was obtained from each subject dissected. Endo-GIA or conventional suture ligation of the before participation in the study. dissected vessel was used according to the intraoperative We found that the clinical data from both groups were or the financial condition of the subject. By contrast, comparable. In addition, the inclusion criteria for VATS Endo-GIA was used for bronchial treatment in all study surgery included a requirement that the study subjects subjects. During this procedure, forced lung inflation was presented with Stage I or II NSCLC and that it was usually conducted prior to bronchial dissection in order to technologically feasible to perform VATS lobectomy. For confirm involvement of the targeted bronchi in the lesions. example, such requirements as an absence of enlarged Thorough mediastinal lymph node resection should also be lung hilum, enlarged mediastinal lymph nodes, absence performed following lobectomy. The resection strategies of extensive pleural thickness and calcification, and a used in VATS and conventional thoracotomy were similar tumor diameter of less than 5 cm needed to be satisfied. in that R2, R4, the 7th, and 9th lymph nodes on the right Following signed informed consent by the study subjects side, and the 5th, 6th, 7th, and 9th lymph nodes on the left and their families, VAST lobectomy was initiated (Table side were routinely resected (D’Amico, 2006). Surgical 1). specimens were removed from the functional incision and placed into a home made specimen bag. Rinsing of Surgical approach the thoracic cavity with pre-warmed distilled water and Surgery was performed under general anesthesia. In an air leakage test were conducted before closure of the addition, for some subjects, continuous high epidural incision. anesthesia was supplemented so that the amount of inhalation anesthetic drugs could be reduced, and Thoracotomic lobectomy thus facilitate recovery of the study subjects from The standard posterolateral thoracotomic incision was anesthesia, and reduce postoperative pain. It was noted adopted for all study subjects. The incision was made that continuous epidural anesthesia was not necessary in between 15 and 20 cm in length and at the 4th or 5th successfully performingVATS lobectomy. In our surgical intercostal space according to the location of the lesion. approaches, left lateral double- lumen endotracheal The thoracic cavity was opened layer-by-layer, and the intubation, unilateral lobar ventilation. ribs were distracted by use of a thoracic retractor. The VATS lobectomy adhesions were first disassociated, following which the Two 1.5 cm incisions were made at the 8th intercostal Endo-GIA or the conventional ligation approach was used axillary line or at the 7th or 8th intercostal subscapular for treatment of the interlobar fissures, depending on the line, to enable access ports for observation and operating economic condition of the study subjects. The pulmonary devices, respectively. In addition, one 4.0 cm incision was arteries and veins were detached from the surrounding Table 1. The Comparison of Baseline Data of
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