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nitial Results of the First 30 Patients

homas Ng, MD, FACS, Beth A Ryder, MD

BACKGROUND: In early-stage lung cancer, evidence is accumulating for the benefits of lobectomy by video-assisted thoracic surgery (VATS) over open lobectomy. Few thoracic training programs offersufficient experience in this technically demanding procedure. This article describes the evolu-tion of a new graduate’s practice from open thoracotomy to VATS lobectomy.

STUDY DESIGN: Our model involves a transition in technique from posterolateral thoracotomy to muscle-sparing thoracotomy and, ultimately, to VATS lobectomy. This approach was evaluated byexamining outcomes of open thoracotomy patients before VATS lobectomy and outcomes ofthe initial 30 VATS patients. Data were collected prospectively.

RESULTS: Before undertaking VATS lobectomy, 94 major pulmonary resections were performed by tho-racotomy. Mortality was 1.2% for lobectomy and 0% for pneumonectomy. Use of the muscle-sparing thoracotomy increased from 17% of patients in the first half to 70% in the latter half ofthis group. For the first 30 VATS lobectomy patients, the mean operative time was 168 minutes.Median blood loss was 200 mL. Conversion rate to open thoracotomy was 13.3%. Mortalitywas 3.3% and morbidity was 26.7%. After short-term followup (mean followup 16 months),overall survival for stage I lung cancer was 96%.

CONCLUSIONS: With our approach, new graduates of thoracic surgery programs can safely transition to VATSlobectomy. Gaining experience with the lateral muscle-sparing thoracotomy is an importantstep in the transition, as it offers similar operative exposure. Longterm disease-free and overallsurvival data are needed to evaluate our oncologic efficacy with this approach. (J Am Coll Surg

2006;203:551–557. © 2006 by the American College of Surgeons)

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inimally invasive techniques have afforded new op-ions for surgical management of early-stage lung cancer.

ultiple publications have demonstrated the safety andncologic efficacy of video-assisted thoracic surgeryVATS) lobectomy.1-13 Advantages reported for thisechnique include fewer prolonged air leaks,14,15 shorterospital stay,15,16 decreased postoperative pain,15-23 im-roved postoperative pulmonary function,13,23,24 im-roved shoulder function,20-22 more rapid resumption oformal daily activities,21,25 and a reduction in cytokineroduction and associated inflammation.17,23,26-29 Forhese reasons, VATS lobectomy might be more suit-

ompeting Interests Declared: None.

eceived February 28, 2006; Revised June 3, 2006; Accepted June 5, 2006.rom the Department of Surgery, Brown Medical School, Providence, RI.orrespondence address: Thomas Ng, MD, FACS, Department of Surgery,rown Medical School, 2 Dudley St, Ste 470, Providence, RI 02905. email:

fng@usasurg.org

5512006 by the American College of Surgeons

ublished by Elsevier Inc.

ble for older and higher-risk patients than openobectomy.30-32

Despite increasing evidence for the superiority ofATS over open lobectomy for stage I lung cancer, few

horacic surgeons perform this procedure and few fel-owship graduates receive adequate training in this tech-ically demanding procedure.11 In addition, there is lit-le available literature outlining a safe approach for theransition from open thoracotomy to VATS lobectomy.n this article, we describe and evaluate our model usedn this evolution. The model involves a shift from openobectomy through posterolateral thoracotomy, to openobectomy through lateral muscle-sparing incision, andltimately to VATS lobectomy for early-stage lung can-er. We examine the outcomes of our open thoracotomyatients before VATS and our first 30 VATS lobectomyatients, demonstrating that a step-wise evolution to-ard a VATS approach can help ensure safe and success-

ul short-term outcomes.

ISSN 1072-7515/06/$32.00doi:10.1016/j.jamcollsurg.2006.06.003

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552 Ng and Ryder Video-Assisted Lobectomy after Training J Am Coll Surg

ETHODSata were derived from a prospective database of a

ingle new graduate surgeon (TN) whose training wasomprised of 5 years of general surgery followed by 3ears of thoracic surgery. The surgeon did not havexperience with VATS lobectomy during training bute was familiar with VATS as a technique for nonana-omic pulmonary resection. In preparation for VATSobectomy, he attended postgraduate courses andommunicated with surgeons who had experienceith the VATS procedure.The open thoracotomy experience for major pulmo-

ary resections before performing the first VATS lobec-omy was examined. Two approaches were used in thispen group. The posterolateral thoracotomy involvedivision of the latissimus dorsi with preservation of theerratus anterior muscle. The lateral muscle-sparing tho-acotomy involved posterior retraction of the latissimusorsi and splitting of the serratus anterior along the di-ection of its muscle fibers. The decision about whichpproach to use was determined at the discretion of theurgeon. Characteristics that mandated a posterolateralpproach included: tumor size �5 cm, suspected dia-hragm or chest-wall involvement, central tumors pos-ibly requiring sleeve resection, and use of preoperativeadiation.

Outcomes for the first 30 VATS lobectomy patientsere also prospectively recorded. VATS lobectomyas performed in the lateral decubitus position afterouble-lumen endotracheal intubation for lung isola-ion. Two monitors were placed at the head of theable on either side of the patient, with the surgeontanding anterior to the patient. A 5-cm utility tho-acotomy and three additional port sites (two 10 mm,ne 5 mm) were used. Utility thoracotomy was annterolateral incision with splitting of the serratusnterior along the direction of its muscle fibers, butithout rib spreading. A 30-degree thoracoscope wassed for visualization. Lobectomy was performed in aashion similar to that of open operation, with indi-idual ligation and division of the pulmonary vein,rtery, and bronchus using endoscopic stapling de-ices (Endo GIA Universal; United States Surgicalorporation). The specimen was retrieved with an

ndoscopic bag. Mediastinal lymph node samplingas then performed. A single chest tube was placed

nder direct vision through 1 of the 10-mm port sites. p

Exclusion criteria for VATS lobectomy included:umor size �3 cm, suspected chest-wall or diaphragmnvolvement, centrally located tumor possibly requir-ng sleeve resection, any suspected nodal diseasestage �I), and tumors managed with neoadjuvanthemotherapy or radiotherapy. Incomplete fissureas not a contraindication to VATS. Patients were notffered resection if postoperative predicted forced ex-iratory volume in 1 second and postoperative pre-icted maximum oxygen consumption were �40%nd 10 mL/kg/minute, respectively, or if presence ofevere medical comorbidities precluded operation. All

able 1. Patient Demographics

haracteristics

Open thoracotomyprior to VATS

(n � 94)VATS lobectomy (n

� 30)

ale-to-female ratio 51:43 12:18ean age, y (range) 66 (42�85) 70 (44�86)ean FEV1 (range) 1.95 L (0.76�4.04) 1.88 L (0.95�2.76)ean % FEV1(range) 76 (28�132) 79 (46�108)ean % DLCO (range) 79 (38�134) 75 (30�115)

urgical approach, n (%)Total

Muscle-sparing 41 (44)Posterolateral 53 (56)

Initial half *Muscle-sparing 8 (17)Posterolateral 39 (83)

Latter half *Muscle-sparing 33 (70)Posterolateral 14 (30)

xtent of resection,n (%)

Lobectomy 82 (87)Pneumonectomy 9 (10)Segmentectomy 2 (2)Completion

pneumonectomy 1 (1)edian length of stay,

d (range)Lobectomy 8 (3�105) 6 (3�14)Pneumonectomy 7 (5�44)

athology, n (%)Non-small cell 82 (87) 27 (90)Carcinoid 1 (1) 2 (7)Colon metastasis 3 (3)Benign 8 (9) 1 (3)

Increased use of muscle-sparing incision, p � 0.001 by chi-square test.LCO, diffusion capacity of lung for carbon monoxide; FEV1, forced expi-

atory volume in 1 second; VATS, video-assisted thoracic surgery.

atients underwent computerized tomography of the

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553Vol. 203, No. 4, October 2006 Ng and Ryder Video-Assisted Lobectomy after Training

hest and upper abdomen. The mediastinum was furthervaluated with positron emission tomography, mediasti-oscopy, or both, before pulmonary resection.Mortality was defined as death within 30 days of op-

ration or death during the inpatient admission for op-ration. Morbidity was defined as any complicationequiring intervention or prolonging hospital stay.ategorical variables were compared using chi-square

est; p values �0.05 were considered statisticallyignificant.

ESULTSfter completion of thoracic surgery training, 94 majorulmonary resections were performed by open thoracot-my in a 13-month period before performing the firstATS lobectomy. Table 1 shows the patient demograph-

cs, pulmonary function parameters, extent of resection,ength of hospital stay, and pathology of this open group.he 82 lobectomy patients included 8 who underwentilobectomy, four en-bloc chest-wall resections, and twoleeve resections. One bilobectomy patient also requiredn en-bloc diaphragm resection. Median blood loss was00 mL (range 50 to 2,000 mL). Twenty-six patients27.7%) required blood transfusion. Use of muscle-paring lateral thoracotomy significantly increased (p �.001 by chi-square test) from 17% in the initial half to0% in the latter half of this group (Table 1). No pa-ients with the muscle-sparing incision required conver-ion to posterolateral thoracotomy.

We analyzed our outcomes for pneumonectomy (n �), lobectomy (n � 82, combining lobectomy, bilobec-omy, and sleeve resection), and all patients (n � 94) and

able 2. Mortality: Open Thoracotomy prior to VATS Compa

irst author nPneumonectomy

(%)

agasaki33 961 5.6insberg34 2,220 6.2omano35 12,439 11.6eslauriers36 783 —amhuis37 1,577 5.7uque38 605 13.4ada39 7,099 3.2

ombined results — 8.6urrent series 94 0

p � 0.358

By chi-square test.ATS, video-assisted thoracic surgery.

ompared them with large reported series. There was no p

ifference in mortality (Table 2). One of two deathsesulted from pneumonia after lobectomy. The othereath occurred after completion pneumonectomy fromulmonary edema. Table 3 compares morbidity rates.here was no difference in morbidity for pneumonec-

omy, but lobectomy morbidity and overall morbidityates were higher in our patients.

Patient demographics, pulmonary function parame-ers, length of hospital stay, and pathology for the first 30ATS patients are also shown in Table 1. Pulmonary

esections in the VATS group included 12 right upperobectomies, 2 right middle lobectomies, 1 right uppernd middle lobectomy (bilobectomy), 9 left upper lo-ectomies, and 6 left lower lobectomies. Disease stageor non-small cell lung cancer in the VATS group was1N0 for 21 patients, T2N0 for 5 patients, and T2N1

or 1 patient. No patient who underwent VATS wasound to have pleural disease or chest wall invasion athoracoscopy.

Outcomes for the 30 VATS patients are detailed inable 4. The single death from pneumonia was in aatient who underwent bilobectomy without intraoper-tive event. Seven patients (23.3%) required bloodransfusion. Four patients were converted to lateraluscle-sparing thoracotomy because of bleeding from

he pulmonary artery (two left upper lobectomy, oneight upper lobectomy, one left lower lobectomy). Bloodoss for each of these patients was 500, 800, 1,500, and,700 mL (mean 1,125 mL). With these patients ex-luded, mean blood loss for the remaining 26 patientsas 298 mL, with a median of 200 mL. Two of the fouratients who underwent conversion experienced com-

ith Large Published Serieslity Lobectomy mortality

(%)Overall mortality

(%)

1.6 2.12.9 3.74.2 5.0

— 3.81.8 3.14.4 6.61.2 1.32.8 3.6

1.2p � 0.389*

1.2p � 0.437*

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lications. One had an episode of self-limited atrial fi-

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554 Ng and Ryder Video-Assisted Lobectomy after Training J Am Coll Surg

rillation. The other had atelectasis requiring bronchos-opy for reexpansion. All arrhythmias in the VATSroup were self-limited, without need for electric cardio-ersion or anticoagulation. One patient had two com-lications after VATS left lower lobectomy, ie, a smalletained hemothorax drained by thoracoscopy (to ruleut empyema) and a symptomatic peptic ulcer found onpper endoscopy. Table 5 compares our VATS lobec-omy outcomes with those from large published series.here was no significant difference in conversion, mor-idity, and mortality rates.Twenty-six patients in the VATS group had stage I

on-small cell lung cancer (T1N0 and T2N0). Includ-ng 1 postoperative death, overall survival for pathologictage I has been 96% (25 of 26) after mean followup of6 months. No recurrent disease has been identifieduring this time.

ISCUSSIONhe data currently available shows VATS lobectomy

o be similar, if not preferable, to open thoracotomy

able 3. Morbidity: Open Thoracotomy prior to VATS Compa

orbidity Deslauriers3

verall morbidity (%) 26.9obectomy morbidity (%) 28.2neumonectomy morbidity (%) 31.9verall specific complication (%)Arrhythmia (supraventricular) 4.7Prolonged air leak (�7 days) —Atelectasis 5.1Pneumonia 6.4Respiratory failure/intubation 2.4Return for bleeding —Alcohol withdrawal —Chylothorax —Empyema 5.0Pulmonary embolism 5.4Clostridium difficile —Bronchopleural fistula 5.1Wound infection 2.4Congestive heart failure 2.4Cerebral vascular accident 1.9Pneumothorax —Cardiac herniation 1.7Myocardial infarction —

By chi-square test.ATS, video-assisted thoracic surgery.

n terms of morbidity, mortality, and survival in stage r

non-small cell lung cancer. McKenna and col-eagues,11 who recently updated their series to 1,100atients, continue to show the same excellent out-omes after VATS lobectomy, as seen in their earliereries of 298 patients.1 Armed with such outcomesata, patients are likely to request minimally invasive

obectomy, especially if randomized controlled trialsonfirm these findings. For these reasons, it is impor-ant for thoracic surgeons, especially new graduates,o be proficient in VATS lobectomy.

Because of the technical demands of the procedure,he potential for uncontrolled pulmonary artery hem-rrhage, and concerns about oncologic compromise,e believe a careful step-wise approach should be fol-

owed before adopting VATS lobectomy into practice.ecause new graduates lack experience at the staff

urgeon level, we believed it was important to docu-ent acceptable outcomes for open procedures before

ttempting transition to VATS. Table 2 shows similarortality rates for our open thoracotomy patients be-

ore VATS, when compared with large published se-

with Large Published Seriesirst author

Duque38 Current series

32.4 41.5 (p � 0.013)*33.3 41.5 (p � 0.040)*40.1 44.4 (p � 0.625)*

6.8 19.1 (p � 0.001)*6.8 9.6 (p � 0.327)*3.6 7.4 (p � 0.184)*5.3 4.35.1 3.22.5 2.1

— 2.1— 2.14.4 1.10.4 1.1

— 1.14.4 —2.5 —

— —0.2 —1.9 —

— —0.3 —

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ies. To compare morbidity (Table 3), we selected the

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555Vol. 203, No. 4, October 2006 Ng and Ryder Video-Assisted Lobectomy after Training

eries from Deslauriers and colleagues36 and Duquend colleagues38 because their data, like ours, werecquired prospectively. Unlike our series, these tworticles also included data from wedge resections.orbidity rate for pneumonectomy was similar. The

obectomy and overall morbidity rates were consider-bly higher in our patients than was observed in thether two series. When examining specific complica-ions, Table 3 shows only the incidence of arrhythmiao be increased, as the rates of all other complicationsere similar. We routinely use cardiac monitoring for

he first 5 postoperative days, so the majority of re-orted arrhythmias were asymptomatic. All arrhyth-ias were self-limited, without need for electric car-

ioversion or anticoagulation.Our model for transitioning to the VATS approach

nvolves switching from the posterolateral thoracot-my to the lateral muscle-sparing incision. McKennand colleagues1 described how the lateral muscle-paring thoracotomy is a natural transition to theATS approach, as the 5-cm utility thoracotomy used

n VATS lobectomy is in the same position as thencision for the lateral muscle-sparing thoracotomy. Itiffers only in length (the VATS incision is shorter)nd in width, because the VATS incision does notnvolve any rib spreading. Hilar dissection for bothpproaches is from the anterior aspect. In this data set,nce experience with posterolateral thoracotomy wasbtained, open resections were performed throughhe more limited lateral muscle-sparing incision whenlinically indicated. Use of the lateral muscle-sparing

able 4. Results of First 30 VATS Lobectomy Cases

utcomesVATS lobectomy

(n � 30)

perative time (min), mean (range) 168 (87�292)lood loss (mL), median (range) 200 (50�1,700)onversion to open, n (%) 4 (13.3)orbidity, n (%) 8 (26.7)ortality, n (%) 1 (3.3)

pecific complicationArrhythmia (supraventricular), n (%) 3 (10)Prolonged air leak (�7 d), n (%) 0 (0)Atelectasis, n (%) 2 (6.7)Pneumonia, n (%) 1 (3.3)Retained hemothorax, n (%) 1 (3.3)Peptic ulcer, n (%) 1 (3.3)

ATS, video-assisted thoracic surgery.

ncision increased significantly from 17% to 70% (p

0.001) when the first and latter halves of our openesection experience are compared, showing a transi-ion in technique in preparation for VATS lobectomy.

There are a wide variety of techniques for VATSobectomy described in the literature. We believe thathe utility thoracotomy should be limited to approx-mately 5 cm and should be performed without ribpreading to retain the recovery advantages of theATS approach. We agree with Ginsberg40 that theATS operative technique should closely approxi-ate the open technique to ensure equivalent onco-

ogic efficacy. This includes individual ligation of theulmonary artery, vein, and bronchus, along with me-iastinal lymph node sampling or dissection. Theumber of port sites used for VATS resection variesetween different publications. In this series, threeorts are used in addition to the utility thoracotomy.ith experience, we have begun to use only two

orts. To minimize costs, we use standard open in-truments for dissection, reusable trocars, and a reus-ble suction catheter.

With this step-wise approach, we have shown accept-ble outcomes for our first 30 VATS lobectomy patientshen compared with large reported series (Table 5).here were no intraoperative deaths or deaths directly

ttributable to the VATS technique. There was a non-tatistically significant trend toward higher morbidity inur series. This might be a result of the difference inefining and reporting specific complications, includingsymptomatic arrhythmias, as seen with our open data.n addition, we included patients requiring conversiono open in our data analysis, although the other pub-ished series in Table 5, with the exception of Daniels,5

id not.Bleeding from the pulmonary artery remains a con-

ern early in our VATS experience. This required con-ersion to open thoracotomy in four patients. As sug-ested by McKenna,11 bleeding from the pulmonaryrtery was quickly controlled with a sponge stick, asould be done during open thoracotomy. Extending

he 5-cm utility incision and placing a rib spreader forxposure easily accomplished conversion to lateraluscle-sparing thoracotomy for successful control of

he pulmonary artery. None of these patients experi-nced hemodynamic instability. Minor complicationsatelectasis, self-limited arrhythmia) developed in twof the four patients.

Currently, open thoracotomy for pulmonary resec-

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556 Ng and Ryder Video-Assisted Lobectomy after Training J Am Coll Surg

ion in early-stage lung cancer remains the standardpproach for most surgeons. No guidelines existbout when a thoracic surgeon without VATS lobec-omy experience should begin performing this com-lex procedure. Reviewing the literature and attend-

ng lectures and workshops are important initial steps.deally, this would be followed by intraoperative proc-oring by an experienced surgeon. Because few tho-acic surgeons routinely perform VATS lobectomy,roctoring becomes challenging to arrange. We pro-ose that our model offers a more practical approach.e have shown that using this model, a safe and

uccessful transition can be made from posterolateralhoracotomy to muscle-sparing thoracotomy and ul-imately to VATS lobectomy. Finally, careful monitor-ng of the surgeon’s initial VATS lobectomy outcomess necessary before adopting this procedure into rou-ine practice. Data from other new graduates usinghis model and longterm disease-free and overall sur-ival outcomes from this series are needed to confirmhe success of our approach to VATS lobectomy.

uthor Contributionstudy conception and design: Ng, Rydercquisition of data: Ng, Rydernalysis and interpretation of data: Ng, Ryderrafting of manuscript: Ng, Ryder

able 5. Outcomes of VATS Lobectomy Compared with Larg

irst author nMean operative

time (min)Conversion

(%)

cKenna1 298 — 6.0im2 214 132 18.0aseda3 128 — 11.7olaini4 112 — 10.4aniels5 110 — 1.8

wanson6 97 130† 12.6alker7 159 130† 11.2

oviaro8 193 — 22.8htsuka9 95 264 10.4

wasaki10 140 — 2.1ombined results — — 11.6urrent series 30 168 13.3

p � 0.774*

By chi-square test.Median rather than mean values.EV1, forced expiratory volume in 1 second; VATS, video-assisted thoracic s

ritical revision: Ng, Ryder 1

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Morbidity(%)

Mean hospitalstay (d) Survival stage I

0.3 12.4 5.1 70% at 48 mo0.5 21.9 6.8 —0.8 — — 94% at 48 mo0 11.6 6.2 90% at 36 mo3.6 19.1 3† —2.1 8.2 — —1.8 — 6† 78% at 60 mo1.0 — — 64% at 60 mo1.1 9.5 7.6 97% at 36 mo0 — — 81% at 60 mo1.0 14.7 — —3.30.201*

26.7p � 0.071*

6.4 96% meanfollowup 16 mo

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