Uniportal VATS for mediastinal nodal diagnosis and staging
http://www.100md.com
《交互式心脏血管和胸部手术》
a Division of Thoracic Surgery, National Cancer Institute, Pascale Foundation, Via M Semmola, 81 80131, Naples, Italy
b Section of Thoracic Surgery, Umberto I Regional Hospital, Ancona, Italy
c The Price Thomas Thoracic Unit, Northern General Hospital, Sheffield Teaching Hospitals, Sheffield, UK
Abstract
The objective of the present study was to assess feasibility of single port (uniportal) VATS in the diagnosis and staging of mediastinal nodal enlargements. To this purpose, between January 2002 and October 2005, 13 patients (8 males and 5 females; mean age 54 years) have undergone uniportal VATS sampling of mediastinal nodes either as part of a diagnostic pathway or as a staging procedure for primary lung cancer when either nodal stations were inaccessible to standard mediastinoscopy or in the event of redo nodal biopsy. Sampled stations were the aortopulmonary window (6), subcarinal (1), right paratracheal (5), and, paraesophageal (1) ones. In all cases, sufficient samples were made available for pathological diagnosis. Postoperatively, neither morbidity nor mortality was observed. The median length of stay in the hospital was 1 day. In conclusion we showed that uniportal VATS can be effectively used to achieve diagnosis and staging of mediastinal nodal stations.
Key Words: VATS; Staging; Lung cancer; Mediastinum
1. Introduction
Some mediastinal nodal stations are difficult to assess by standard surgical diagnostic procedures such as cervical mediastinoscopy and anterior mediastinotomy [1–3]. In addition, there are some circumstances when the above- mentioned options may not be safe, i.e. after complicated neck surgery or sternotomy, following radiotherapy or due to anatomic abnormalities. As a consequence, VATS becomes a viable alternative when diagnosis and staging need to be achieved [1–3]. Uniportal VATS has recently been proposed as a method of performing pleural and pulmonary biopsies [4–6]: its role in the diagnosis of enlarged mediastinal nodes is hereafter investigated.
2. Materials and methods
Between January 2002 and September 2005, 13 patients (8 males and 5 females; mean age 54 years) with undiagnosed mediastinal adenopathy have been selected to undergo uniportal VATS. Sampled stations were the aortopulmonary window (6), subcarinal (1), right paratracheal (5), and, paraesophageal (1) ones. Indeed, cervical mediastinoscopy was not an option due to the location of the enlarged lymph nodes or to previous mediastinoscopy in 7 cases (5 in the aortopulmonary window, 1 in the subcarinal, and 1 in the paraesophageal area). In one of the remaining patients, the right paratracheal stations were sampled along with a diagnostic wedge resection of a right upper lobe pulmonary nodule (non-small cell lung cancer at frozen section in a case with insufficient pulmonary reserve to tolerate a standard lobectomy). More recently, uniportal VATS was preferred for sampling the right paratracheal lymph node station (4 patients) as it became our preferred mediastinal diagnostic approach. In 4 patients, pleural biopsies were also obtained while in another patient a pericardial window was performed through the same port [7].
2.1. Surgical technique
The patient is in the lateral decubitus position. Only one incision (2–2.5 cm) is placed in the fifth intercostal space, slightly posterior to the scapular line. Either a 0° or a 30° 5-mm videothoracoscope and 5-mm endoscopic instruments were used. The targeted nodal station is approached by lifting upward the mediastinal pleural overlying it with a roticulating grasper. The pleura is opened by endoscissors and the mediastinal fat is swept aside with an endopeanut (Fig. 1). The nodes are sampled with a biopsy forceps, in a fashion similar to the traditional mediastinoscopic procedures (Fig. 2), and hemostasis is obtained with oxidized cellulose (Fig. 3). Alternatively, the same endograsper is used to suspend cranially the entire lymph node while an endoclip is fired at the base of the vascular pedicle. This maneuver is repeated by sequentially introducing the endoclip applier and the endoscissors to complete nodal dissection and ensure adequate hemostasis. The same principles are followed for nodal biopsies in the anterior mediastinal compartment with the only exceptions being the patient in the supine position and the port placement along the posterior axillary line with the operated side elevated (45°) by an axillary roll.
3. Results
In all instances, enough material for pathologic analysis was obtained, showing sarcoidosis in 2 patients, metastasis from NSCLC in 6 and non Hodgkin's lymphoma in 5. Table 1 shows the distribution of the side, site of biopsy and the corresponding diagnosis for each patient. During the period under analysis, no conversion to open thoracotomy or mediastinoscopy was needed. Neither morbidity nor mortality was observed. The median hospital stay was 1 day after surgery (range 1–3).
4. Discussion
The potential benefits of a widespread utilization of uniportal VATS in the diagnosis and treatment of intrathoracic conditions have already been described [4–6]. The diagnostic pathway of such diseases often demands surgical procedures, which represent a considerable fraction of the routine workload of a general thoracic unit (www.ctsnet.org/file/NationalSummary2001To2002.xls).
Compared to more traditional mediastinal staging procedures (mediastinoscopy or anterior mediastinotomy), the uniportal VATS allows for a wider surgical exposure with minimal operative trauma. A thorough exploration of the chest cavity is facilitated, thus enabling the surgeon to accurately assess the T and the N factors. In this setting, nodal stations traditionally inaccessible to mediastinoscopy, i.e. in the paraesophageal and in the pulmonary ligament areas, are easily reached. Like with mediastinoscopy, uniportal VATS performed in patients with lung cancer do not contraindicate to proceed to lung resection in the same operative session, in case frozen sections show negative nodal status. In a fashion similar to standard, three-port VATS, any size lymph node can be either sampled or totally removed by uniportal VATS. This technical detail is of extreme importance when specimens of significant size are requested, as for the pathological diagnosis of lymphomas, and when a concomitant evaluation and, possibly, biopsy of the pleura or lung parenchyma [5] are indicated. However, mediastinoscopy should be preferred in case of lung cancer with suspected N3 disease, as it allows bilateral mediastinal sampling.
Uniportal VATS has been shown to cause less discomfort compared to traditional three-port VATS [6]. In addition, the increasing costs initially attributed to uniportal VATS due to the need for roticulating instruments are currently being offset by their routine use during three-port VATS and the curtailed hospital stay. In the future, with the increasing use of loco-regional anesthesia, uniportal VATS nodal biopsy will be performed in an outpatient facility with the attendant positive impact on the hospital resource distribution.
As with three-port VATS, the main contraindications to uniportal VATS include the absence of a pleural space (i.e. previous thoracotomy) and the inability to establish one-lung ventilation. In these instances, mediastinoscopy or open mini-thoracotomy are recommended. These are the reasons why this procedure should be considered a useful adjunct to the conventional mediastinal surgical techniques in order to facilitate diagnosis and staging of mediastinal nodal disease.
References
Porte H, Roumilhac D, Eraldi L, Cordonnier C, Puech P, Wurtz A. The role of mediastinoscopy in the diagnosis of mediastinal lymphadenopathy. Eur J Cardiothorac Surg 1998; 13:196–199.
Rendina EA, Venuta F, De Giacomo T, Ciriaco PP, Pescarmona EO, Francioni F, Pulsoni A, Malagnino F, Ricci C. Comparative merits of thoracoscopy, mediastinoscopy, and mediastinotomy for mediastinal biopsy. Ann Thorac Surg 1994; 57:992–995.
Landreneau RJ, Hazelrigg SR, Mack MJ, Fitzgibbon LD, Dowling LD, Acuff TE, Keenan RJ, Ferson PF. Thoracoscopic mediastinal lymph node sampling: useful for mediastinal lymph node stations inaccessible by cervical mediastinoscopy. J Thorac Cardiovasc Surg 1993; 106:554–564.
Rocco G. VATS lung biopsy: the uniportal technique. MMCTS January 21, 2005; 10.1510/mmcts.2004.000356.
Rocco G, Martin-Ucar A, Passera E. Uniportal VATS wedge pulmonary resections. Ann Thorac Surg 2004; 77:726–728.
Jutley RS, Khalil MW, Rocco G. Uniportal vs standard three-port VATS technique for spontaneous pneumothorax: comparison of post-operative pain and residual paraesthesia. Eur J Cardiothorac Surg 2005; 28:43–46.
Rocco G, La Rocca A, La Manna C, Scognamiglio F, D'Aiuto M, Jutley R, Martucci N. Uniportal VATS pericardial window. J Thorac Cardiovasc Surg (in press).(Gaetano Roccoa, Alessandr)
b Section of Thoracic Surgery, Umberto I Regional Hospital, Ancona, Italy
c The Price Thomas Thoracic Unit, Northern General Hospital, Sheffield Teaching Hospitals, Sheffield, UK
Abstract
The objective of the present study was to assess feasibility of single port (uniportal) VATS in the diagnosis and staging of mediastinal nodal enlargements. To this purpose, between January 2002 and October 2005, 13 patients (8 males and 5 females; mean age 54 years) have undergone uniportal VATS sampling of mediastinal nodes either as part of a diagnostic pathway or as a staging procedure for primary lung cancer when either nodal stations were inaccessible to standard mediastinoscopy or in the event of redo nodal biopsy. Sampled stations were the aortopulmonary window (6), subcarinal (1), right paratracheal (5), and, paraesophageal (1) ones. In all cases, sufficient samples were made available for pathological diagnosis. Postoperatively, neither morbidity nor mortality was observed. The median length of stay in the hospital was 1 day. In conclusion we showed that uniportal VATS can be effectively used to achieve diagnosis and staging of mediastinal nodal stations.
Key Words: VATS; Staging; Lung cancer; Mediastinum
1. Introduction
Some mediastinal nodal stations are difficult to assess by standard surgical diagnostic procedures such as cervical mediastinoscopy and anterior mediastinotomy [1–3]. In addition, there are some circumstances when the above- mentioned options may not be safe, i.e. after complicated neck surgery or sternotomy, following radiotherapy or due to anatomic abnormalities. As a consequence, VATS becomes a viable alternative when diagnosis and staging need to be achieved [1–3]. Uniportal VATS has recently been proposed as a method of performing pleural and pulmonary biopsies [4–6]: its role in the diagnosis of enlarged mediastinal nodes is hereafter investigated.
2. Materials and methods
Between January 2002 and September 2005, 13 patients (8 males and 5 females; mean age 54 years) with undiagnosed mediastinal adenopathy have been selected to undergo uniportal VATS. Sampled stations were the aortopulmonary window (6), subcarinal (1), right paratracheal (5), and, paraesophageal (1) ones. Indeed, cervical mediastinoscopy was not an option due to the location of the enlarged lymph nodes or to previous mediastinoscopy in 7 cases (5 in the aortopulmonary window, 1 in the subcarinal, and 1 in the paraesophageal area). In one of the remaining patients, the right paratracheal stations were sampled along with a diagnostic wedge resection of a right upper lobe pulmonary nodule (non-small cell lung cancer at frozen section in a case with insufficient pulmonary reserve to tolerate a standard lobectomy). More recently, uniportal VATS was preferred for sampling the right paratracheal lymph node station (4 patients) as it became our preferred mediastinal diagnostic approach. In 4 patients, pleural biopsies were also obtained while in another patient a pericardial window was performed through the same port [7].
2.1. Surgical technique
The patient is in the lateral decubitus position. Only one incision (2–2.5 cm) is placed in the fifth intercostal space, slightly posterior to the scapular line. Either a 0° or a 30° 5-mm videothoracoscope and 5-mm endoscopic instruments were used. The targeted nodal station is approached by lifting upward the mediastinal pleural overlying it with a roticulating grasper. The pleura is opened by endoscissors and the mediastinal fat is swept aside with an endopeanut (Fig. 1). The nodes are sampled with a biopsy forceps, in a fashion similar to the traditional mediastinoscopic procedures (Fig. 2), and hemostasis is obtained with oxidized cellulose (Fig. 3). Alternatively, the same endograsper is used to suspend cranially the entire lymph node while an endoclip is fired at the base of the vascular pedicle. This maneuver is repeated by sequentially introducing the endoclip applier and the endoscissors to complete nodal dissection and ensure adequate hemostasis. The same principles are followed for nodal biopsies in the anterior mediastinal compartment with the only exceptions being the patient in the supine position and the port placement along the posterior axillary line with the operated side elevated (45°) by an axillary roll.
3. Results
In all instances, enough material for pathologic analysis was obtained, showing sarcoidosis in 2 patients, metastasis from NSCLC in 6 and non Hodgkin's lymphoma in 5. Table 1 shows the distribution of the side, site of biopsy and the corresponding diagnosis for each patient. During the period under analysis, no conversion to open thoracotomy or mediastinoscopy was needed. Neither morbidity nor mortality was observed. The median hospital stay was 1 day after surgery (range 1–3).
4. Discussion
The potential benefits of a widespread utilization of uniportal VATS in the diagnosis and treatment of intrathoracic conditions have already been described [4–6]. The diagnostic pathway of such diseases often demands surgical procedures, which represent a considerable fraction of the routine workload of a general thoracic unit (www.ctsnet.org/file/NationalSummary2001To2002.xls).
Compared to more traditional mediastinal staging procedures (mediastinoscopy or anterior mediastinotomy), the uniportal VATS allows for a wider surgical exposure with minimal operative trauma. A thorough exploration of the chest cavity is facilitated, thus enabling the surgeon to accurately assess the T and the N factors. In this setting, nodal stations traditionally inaccessible to mediastinoscopy, i.e. in the paraesophageal and in the pulmonary ligament areas, are easily reached. Like with mediastinoscopy, uniportal VATS performed in patients with lung cancer do not contraindicate to proceed to lung resection in the same operative session, in case frozen sections show negative nodal status. In a fashion similar to standard, three-port VATS, any size lymph node can be either sampled or totally removed by uniportal VATS. This technical detail is of extreme importance when specimens of significant size are requested, as for the pathological diagnosis of lymphomas, and when a concomitant evaluation and, possibly, biopsy of the pleura or lung parenchyma [5] are indicated. However, mediastinoscopy should be preferred in case of lung cancer with suspected N3 disease, as it allows bilateral mediastinal sampling.
Uniportal VATS has been shown to cause less discomfort compared to traditional three-port VATS [6]. In addition, the increasing costs initially attributed to uniportal VATS due to the need for roticulating instruments are currently being offset by their routine use during three-port VATS and the curtailed hospital stay. In the future, with the increasing use of loco-regional anesthesia, uniportal VATS nodal biopsy will be performed in an outpatient facility with the attendant positive impact on the hospital resource distribution.
As with three-port VATS, the main contraindications to uniportal VATS include the absence of a pleural space (i.e. previous thoracotomy) and the inability to establish one-lung ventilation. In these instances, mediastinoscopy or open mini-thoracotomy are recommended. These are the reasons why this procedure should be considered a useful adjunct to the conventional mediastinal surgical techniques in order to facilitate diagnosis and staging of mediastinal nodal disease.
References
Porte H, Roumilhac D, Eraldi L, Cordonnier C, Puech P, Wurtz A. The role of mediastinoscopy in the diagnosis of mediastinal lymphadenopathy. Eur J Cardiothorac Surg 1998; 13:196–199.
Rendina EA, Venuta F, De Giacomo T, Ciriaco PP, Pescarmona EO, Francioni F, Pulsoni A, Malagnino F, Ricci C. Comparative merits of thoracoscopy, mediastinoscopy, and mediastinotomy for mediastinal biopsy. Ann Thorac Surg 1994; 57:992–995.
Landreneau RJ, Hazelrigg SR, Mack MJ, Fitzgibbon LD, Dowling LD, Acuff TE, Keenan RJ, Ferson PF. Thoracoscopic mediastinal lymph node sampling: useful for mediastinal lymph node stations inaccessible by cervical mediastinoscopy. J Thorac Cardiovasc Surg 1993; 106:554–564.
Rocco G. VATS lung biopsy: the uniportal technique. MMCTS January 21, 2005; 10.1510/mmcts.2004.000356.
Rocco G, Martin-Ucar A, Passera E. Uniportal VATS wedge pulmonary resections. Ann Thorac Surg 2004; 77:726–728.
Jutley RS, Khalil MW, Rocco G. Uniportal vs standard three-port VATS technique for spontaneous pneumothorax: comparison of post-operative pain and residual paraesthesia. Eur J Cardiothorac Surg 2005; 28:43–46.
Rocco G, La Rocca A, La Manna C, Scognamiglio F, D'Aiuto M, Jutley R, Martucci N. Uniportal VATS pericardial window. J Thorac Cardiovasc Surg (in press).(Gaetano Roccoa, Alessandr)