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Bilateral staged versus bilateral simultaneous thoracotomy in the pediatric population
Journal of Pediatric Surgery (2006) 41, 647 – 651
www.elsevier.com/locate/jpedsurg
Bilateral staged versus bilateral simultaneous thoracotomy in the pediatric population Abdalla E. Zarrouga, Chad E. Hamnera, Tuan H. Phama, Scott G. Houghtona Penny Stavloa, Christopher R. Moira, David A. Rodebergb,* a
Department of Surgery, Mayo Clinic College of Medicine, Rochester, MN 55905, USA Department of Surgery, Children’s Hospital of Pittsburgh, Pittsburgh, PA 15213, USA
b
Index words: Bilateral; Staged; Simultaneous; Thoracotomy
Abstract Aim: The aim of the study was to evaluate the safety and outcomes of simultaneous bilateral thoracotomy in pediatric patients compared with traditional bilateral staged thoracotomy. Methods: This is a retrospective review of 30 consecutive patients 18 years or younger undergoing either bilateral staged or bilateral simultaneous thoracotomy between March 1994 and July 2004. Follow-up (mean, 47 months) was available for all patients. Results: Thirty patients (17 boys, 13 girls; average age, 12 years) underwent bilateral staged or bilateral simultaneous thoracotomy. Eighteen patients underwent staged thoracotomy, 9 patients underwent simultaneous thoracotomy, and 3 patients underwent both procedures. Diagnosis included sarcoma (n = 21), Wilms tumor (n = 4), indeterminate pulmonary nodules (n = 3), and germ cell tumor (n = 2). When we compared outcomes for patients undergoing simultaneous versus staged bilateral thoracotomy, mean hospital stay (5.2 vs 10.6 days; P b .002), intensive care unit stay (1 vs 2 nights; P b .0001), days with tube thoracostomy (4 vs 8 days; P b .0005), and time to initiation of adjuvant chemotherapy (13 vs 30 days; P b .05) were all significantly less for patients undergoing bilateral simultaneous thoracotomy. In addition, postoperative complications were less frequent in patients undergoing simultaneous versus staged thoracotomy (0 vs 3 events; P = .25). Conclusions: In selected patients, bilateral simultaneous thoracotomy is safe and may lessen morbidity and hospital stay while avoiding delay in initiation of adjuvant chemotherapy. D 2006 Elsevier Inc. All rights reserved.
Complete resection of pulmonary metastasis has been shown to increase survival in select pediatric patients [1-3]. The traditional accepted management of bilateral metastasis in both pediatric [4,5] and adult literature [6] consisted of Presented at the 57th Annual Meeting of the Section on Surgery of the American Academy of Pediatrics, Washington, DC, October 7-9, 2005. * Corresponding author. Tel.: +1 412 251 2173; fax: +1 412 692 6069. E-mail address: [email protected] (D.A. Rodeberg). 0022-3468/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2005.12.003
staged thoracotomy or median sternotomy. Both approaches have been proven safe and effective; yet, certain disadvantages, including 2 anesthetics, a second hospitalization, and a delay in chemotherapy with staged procedures and inadequate exposure of both lungs with median sternotomy, exist. Recent adult studies suggest that bilateral simultaneous thoracotomy is an equally safe and effective alternative to staged bilateral thoracotomy [7,8] and avoids the disadvantages of staged procedures. Although simultaneous bilateral
648 thoracotomy has been reported in pediatric literature [9], the safety of this approach is not known. In addition, direct comparison, comparing morbidity, hospital stay, and outcomes, with staged bilateral thoracotomy in children has not been reported. The aim of this study is to review our institution’s experience with simultaneous bilateral thoracotomy in pediatric surgical patients. Specifically, we wanted to compare the safety, postoperative course, hospital utilization, and surgical outcomes between traditional bilateral staged thoracotomy and simultaneous thoracotomy. We hypothesized that simultaneous bilateral thoracotomy is as safe as staged bilateral thoracotomy, results in equivalent outcomes, and decreases hospitalization.
1. Methods and materials Institutional review board approval was obtained for all aspects of this study. We retrospectively reviewed the medical records of 30 consecutive patients 18 years or younger who underwent either bilateral staged thoracotomy or bilateral simultaneous thoracotomy between March 1994 and July 2004 at the Mayo Clinic Rochester, Minn. Children were excluded if they underwent thorascopic resections. Children were also excluded if they underwent multiple unilateral thoracotomies, but they were included if, after unilateral thoracotomy, they underwent a second contralateral thoracotomy for the same disease process within 3 months. Separate hospitalizations for staged procedures were treated as a single admission for comparison purposes. The 2 procedures were performed over the same period, with all bilateral staged procedures occurring from 1994 to 2004 and all bilateral simultaneous procedures occurring from 1994 to 2003. Primary end points included the length of hospital stay, days spent in the intensive care unit (ICU), number of days with a tube thoracostomy in place, time from initial procedure to initiation of adjuvant chemotherapy, incidence of postoperative complications, and number of deaths. Secondary study end points included operative times and also the differences between the number of pulmonary nodules detected during operative exploration and pathological examination versus those detected by preoperative computed tomography (CT). If chest CT reports did not specifically mention the number of nodules, then an independent member of the radiology department (blinded to the study) counted the number of nodules on CT scans. Data were analyzed using the JMP statistical package (Cary, NC). Statistical differences between groups for the end-point variables were analyzed using the Student t test, and P values b .05 were considered statistically significant. Data in the text are presented as mean values F SEM.
A.E. Zarroug et al.
2. Results 2.1. Patient demographics Thirty patients (17 boys, 13 girls) with an average age of 12 years (range, 1-17 years) underwent either bilateral staged or bilateral simultaneous thoracotomy. The average age at the time of the initial primary diagnosis was 11 years, whereas the average age of both the diagnosis and treatment for metastatic thoracic disease was 12 years; no differences in age between staged and simultaneous thoracotomy were noted ( P N .05). Initial diagnoses included sarcoma (n = 21), Wilms tumor (n = 4), indeterminate pulmonary nodules (n = 3), and germ cell tumor (n = 2). Indications for operation included curative resection for oncological disease (n = 27) and diagnosis for indeterminate disease (n = 3). Overall, patients had minimal medical comorbidities: 2 patients had gastroesophageal reflux disease, and 1 patient underwent orchidopexy as an infant.
2.2. Operations Eighteen patients underwent staged procedures only, 9 patients underwent simultaneous thoracotomy only, and 3 patients underwent multiple staged and/or simultaneous procedures for recurrent disease. Therefore, a total of 22 bilateral staged and 13 bilateral simultaneous thoracotomy procedures were performed on the 30 patients studied. Of the 3 patients who underwent multiple procedures, 2 children underwent both staged and simultaneous thoracotomy; the third patient underwent 2 staged thoracotomies and 2 simultaneous thoracotomies. The 2 procedures (staged and simultaneous) were performed contemporaneously from 1993 to 2004.
2.3. Outcomes When we compared primary end points (mean hospital stay, ICU stay, days with a tube thoracostomy, and time until initiation of adjuvant chemotherapy) for patients undergoing bilateral simultaneous thoracotomy versus staged thoracotomy, all outcomes were significantly improved for patients undergoing bilateral simultaneous thoracotomy (Table 1). Neoadjuvant and adjuvant chemotherapy was administered to 24 of 27 patients with an oncological diagnosis. The Table 1 Comparison of simultaneous versus staged bilateral thoracotomy Primary end points
Simultaneous*
Staged*
P
Hospital stay (d) ICU stay (d) Tube thoracostomy (d) Time until initiation of adjuvant chemotherapy (d) No. of complications
5.2 F 0.4 1F0 4 F1
10.6 F 1.1 2F1 8F1
b.002 b.0001 b.0005
13 F 2
30 F 8
* Mean F SEM.
0
3
b.05
.25
Bilateral staged versus bilateral simultaneous thoracotomy 3 patients who did not receive neoadjuvant therapy were not the same 3 patients who did not receive adjuvant therapy (all of whose parents declined adjuvant treatment). Postoperative complications occurred in no patients who had bilateral simultaneous thoracotomy versus 3 complications in patients who underwent staged thoracotomy ( P = .25); complications included 2 patients with a prolonged air leak from a tube thoracostomy and 1 patient with pneumonia. No perioperative deaths (b30 days) or intraoperative complications occurred. Regarding secondary end points, although the average operative time for each thoracotomy during bilateral staged procedures was 164 F 14 minutes, the combined average operative time for bilateral staged procedures was 328 F 30 minutes. The average operative time for bilateral simultaneous procedures was 280 F 19 minutes ( P = .18). Chest CT scans significantly underestimated the average number of nodules reported on each side (n = 3 F 1) when compared with the average number of nodules palpated at operation (n = 6 F 1; P b .0001). The average number of diseased nodules noted by pathological examination was similar to nodules palpated at operation (n = 6 F 1). No differences in the average number of nodules found either on CT or at operation were noted between patients who had bilateral staged or simultaneous procedures.
2.4. Follow-up Follow-up was available for all 30 patients (complete in 100% of patients) at a mean of 47 months (range, 3-132 months; SEM, F7). The average disease-free interval from pulmonary recurrence or any extrapulmonary recurrence for staged and simultaneous bilateral thoracotomy was 38 and 37 months, respectively ( P N .05). Eighteen of the 30 patients are currently alive. The causes of death included overwhelming pneumonia in the setting of recurrent pulmonary disease (n = 7), complications related to adjuvant chemotherapy (n = 4), and unknown causes (n = 1). All 3 patients who had a diagnosis of indeterminate nodules had benign pathological diseases diagnosed, and all 3 patients underwent bilateral staged thoracotomy only.
3. Discussion Pulmonary metastasectomy has been shown to improve survival in pediatric patients with various types of malignancies, including sarcoma, Wilms tumor, neuroendocrine tumors, and germ cell tumors [1,2,4,5]. The traditional approach for bilateral pulmonary metastasectomy has been bilateral staged thoracotomy with typically a 14- to 30-day interval between procedures. The rationale for staging separate procedures is a potential for lower operative risk related to bleeding and length of anesthesia and for fewer postoperative pulmonary complications [6]. More recently, the approach at our institution has been to perform bilateral simultaneous thoracotomy in select patients based on reports from adult studies that suggest
649 bilateral simultaneous thoracotomy as an acceptable alternative to staged bilateral thoracotomy [7,8]. Potential advantages of a simultaneous thoracotomy approach include lower overall anesthetic risks, faster overall postoperative recovery, and shorter delay until initiation of adjuvant chemotherapy. However, evidence supporting bilateral simultaneous thoracotomy in pediatric patients is less clear with only one published report demonstrating better outcomes for pulmonary hydatid disease [9]. Pediatric patients under consideration for bilateral simultaneous thoracotomy should have a thorough preoperative evaluation and careful assessment of anticipated postoperative pulmonary function. Patients with poor preoperative pulmonary function or who are anticipated to have inadequate postoperative pulmonary function secondary to major resections (lobectomy) may be better approached with a staged procedure, where pulmonary rehabilitation may improve residual lung function after initial resection [10]. In low-risk patients, however, we demonstrated that bilateral simultaneous thoracotomy is a safe alternative to a traditional 2-stage approach. Specifically, we found a statistically and clinically significant difference in (1) faster overall postoperative recovery with a lower length of stay in the hospital, (2) lower overall morbidity with less time for tube thoracostomy requirement and less time in an intensive care setting, and (3) less time to initiation of adjuvant chemotherapy. In addition, the morbidity rate for bilateral simultaneous thoracotomy was less than the staged approach, although this may be because patients who underwent simultaneous thoracotomy were judged preoperatively to better tolerate simultaneous procedure; thus, there may be a selection bias toward preoperatively healthier patients in the simultaneous group. Moreover, an earlier postoperative recovery course facilitated the initiation of adjuvant chemotherapy. Thus, simultaneous bilateral thoracotomy may be preferable for select children who require bilateral pulmonary metastasectomy. This study has limitations. First, we address neither the surgical techniques involved nor the different surgical incisions that can be implemented for these operations. Specifically, we excluded all patients who underwent thorascopic/laparoscopic procedures. Moreover, no patients underwent median sternotomy or bilateral thoracotomy via the clam shell approach for simultaneous procedures [7], and therefore, we cannot make recommendations for or against these approaches. Our practice bias has been to perform standard posterolateral or anterolateral thoracotomy for all our procedures whether staged or simultaneous, primarily because we have concerns about the ability to adequately explore, using other surgical approaches, the posterior side of the lungs (median sternotomy) and increasing morbidity (clam shell). Second, this study does not address the indications for bilateral thoracotomy for benign or malignant disease; however, it does begin to help clinicians define a role for simultaneous bilateral thoracotomy. Finally, this is a retrospective review open to selection bias, and our results should be interpreted in an appropriate
650
A.E. Zarroug et al.
clinical context; that is, simultaneous bilateral thoracotomy does not appear to increase postoperative morbidity or mortality over staged thoracotomy, and it may also have certain benefits.
4. Conclusion Our institution’s recent experience supports bilateral simultaneous thoracotomy as a safe and viable alternative to traditional staged bilateral thoracotomy for pulmonary metastasectomy in select pediatric patients. The main benefit of this approach appears to be that it avoids delay between surgical resection and initiation of adjuvant chemotherapy. In addition, our results indicate that bilateral simultaneous thoracotomy is well tolerated with a more rapid global recovery and disposition from hospital without significantly increasing perioperative morbidity or mortality. Future prospective studies may help definitively substantiate these results and better elucidate the characteristics of those patients who would best benefit from simultaneous or staged procedures.
References [1] Abel RM, Brown J, Moreland B, et al. Pulmonary metastasectomy for pediatric solid tumors. Pediatr Surg Int 2004;20(8):630 - 2. [2] Temeck BK, Wexler LH, Steinberg SM, et al. Metastasectomy for sarcomatous pediatric histologies: results and prognostic factors. Ann Thorac Surg 1995;59(6):1385 - 90. [3] Heij HA, Vos A, de Kraker J, et al. Prognostic factors in surgery for pulmonary metastases in children. Surgery 1994;115(6):687 - 93. [4] Todd TR. The surgical treatment of pulmonary metastases. Chest 1997;112(4 Suppl):287S - 90S. [5] Anonymous. Long-term results of lung metastasectomy: prognostic analyses based on 5206 cases. The International Registry of Lung Metastases. J Thorac Cardiovasc Surg 1997;113(1):37 - 49. [6] Margaritora S, Cesario A, Galetta D, et al. Staged axillary thoracotomy for bilateral lung metastases: an effective and minimally invasive approach. Eur J Cardiothorac Surg 1999;16(Suppl):S37 - 9. [7] Rusch VW. Surgical techniques for pulmonary metastasectomy. Semin Thorac Cardiovasc Surg 2002;14(1):4 - 9. [8] Pastorino U. History of the surgical management of pulmonary metastases and development of the International Registry. Semin Thorac Cardiovasc Surg 2002;14(1):18 - 28. [9] Ceran S, Sunam GS, Gormus N, et al. Cost-effective and time-saving surgical treatment of pulmonary hydatid cysts with multiple localization. Surg Today 2002;32(7):573 - 6. [10] Boysen PG. Perioperative management of the thoracotomy patient. Clin Chest Med 1993;14(2):321 - 33.
Discussion Dr Andrew Davidoff (Memphis, TN): Do you not consider median sternotomy for approaching both lungs to be an option? Chad Hamner, MD (response): We have not used median sternotomy, at least in the last 10 years. It was used early
on mostly by our thoracic surgeons when they were referred these cases. Because of limitations in examining posterior and apical lung segments, we would not recommend this approach. This is especially true because we found a significant discrepancy between the number of nodules detected on preoperative CT scan and those we actually found intraoperatively. We have a great concern that we might leave disease behind if we use a median sternotomy. Dr Minniati (Houston, TX): One of the concerns about doing bilateral thoracotomies might be the postoperative pain management and impaired mobilization. I just wondered if you could comment on your postoperative pain regimen. Chad Hamner, MD (response): We typically use patientcontrolled analgesia for these patients and then quickly convert over to oral analgesia as soon as diet is resumed. Infrequently, epidurals are performed by our anesthesia colleagues in older children, but that has not been our standard of practice. Dr Raffensperg (Chicago, IL): Were all these just lumpectomies, or were you doing lobectomies, and did you have any special way of relieving postoperative pain such as nerve infiltration to reduce the amount of narcotics afterward? Chad Hamner, MD (response): To answer the first question, most of these patients underwent multiple wedge resections. There were 2 patients who had a combination of wedge resections and a single lobectomy. As for your second question, we do not routinely use intercostal nerve blocks as part of the pain regimen. Dr Donna Caniano (Columbus, OH): Would there be any patient who would not fall into the group who safely should undergo the simultaneous procedure, and who should have a staged procedure? Chad Hamner, MD (response): Because of the low number of patients, we really were not able to identify any preoperative factors that would absolutely contraindicate simultaneous procedures in our patients. Relative contraindications may include profound pulmonary function abnormalities or any clinical condition that would severely limit pulmonary function postoperatively. Also, staged procedures may be best for those with extensive pulmonary metastasis in whom you might anticipate that the amount of resection from both lungs may significantly alter pulmonary mechanics. Dr Larry Hill (Baltimore, MD): A question about detecting small nodules—you made a statement that you did not always find those nodules that you expected from the
Bilateral staged versus bilateral simultaneous thoracotomy reports and your reviews. In lieu of the popularity of thoracoscopy with biopsy and excision, could you comment on how many of your patients had other lesions that were not in evidence, particularly when you had diagnostic radiological fields to find them? Chad Hamner, MD (response): When we reviewed our preoperative imaging and compared it to operative and pathological examination, we noted a significant difference
651 in the number of nodules seen on CT and those found at operation. CT, on average, detected only half the number of nodules that were palpable at operation. Pathological assessment coincided almost exactly with our operative findings. Therefore, a thorough evaluation of all lung segments is pivotal to remove even occult disease. For this reason, if metastasis is highly suspected as the underlying etiology, then we do not use thoracoscopy.
www.elsevier.com/locate/jpedsurg
Bilateral staged versus bilateral simultaneous thoracotomy in the pediatric population Abdalla E. Zarrouga, Chad E. Hamnera, Tuan H. Phama, Scott G. Houghtona Penny Stavloa, Christopher R. Moira, David A. Rodebergb,* a
Department of Surgery, Mayo Clinic College of Medicine, Rochester, MN 55905, USA Department of Surgery, Children’s Hospital of Pittsburgh, Pittsburgh, PA 15213, USA
b
Index words: Bilateral; Staged; Simultaneous; Thoracotomy
Abstract Aim: The aim of the study was to evaluate the safety and outcomes of simultaneous bilateral thoracotomy in pediatric patients compared with traditional bilateral staged thoracotomy. Methods: This is a retrospective review of 30 consecutive patients 18 years or younger undergoing either bilateral staged or bilateral simultaneous thoracotomy between March 1994 and July 2004. Follow-up (mean, 47 months) was available for all patients. Results: Thirty patients (17 boys, 13 girls; average age, 12 years) underwent bilateral staged or bilateral simultaneous thoracotomy. Eighteen patients underwent staged thoracotomy, 9 patients underwent simultaneous thoracotomy, and 3 patients underwent both procedures. Diagnosis included sarcoma (n = 21), Wilms tumor (n = 4), indeterminate pulmonary nodules (n = 3), and germ cell tumor (n = 2). When we compared outcomes for patients undergoing simultaneous versus staged bilateral thoracotomy, mean hospital stay (5.2 vs 10.6 days; P b .002), intensive care unit stay (1 vs 2 nights; P b .0001), days with tube thoracostomy (4 vs 8 days; P b .0005), and time to initiation of adjuvant chemotherapy (13 vs 30 days; P b .05) were all significantly less for patients undergoing bilateral simultaneous thoracotomy. In addition, postoperative complications were less frequent in patients undergoing simultaneous versus staged thoracotomy (0 vs 3 events; P = .25). Conclusions: In selected patients, bilateral simultaneous thoracotomy is safe and may lessen morbidity and hospital stay while avoiding delay in initiation of adjuvant chemotherapy. D 2006 Elsevier Inc. All rights reserved.
Complete resection of pulmonary metastasis has been shown to increase survival in select pediatric patients [1-3]. The traditional accepted management of bilateral metastasis in both pediatric [4,5] and adult literature [6] consisted of Presented at the 57th Annual Meeting of the Section on Surgery of the American Academy of Pediatrics, Washington, DC, October 7-9, 2005. * Corresponding author. Tel.: +1 412 251 2173; fax: +1 412 692 6069. E-mail address: [email protected] (D.A. Rodeberg). 0022-3468/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2005.12.003
staged thoracotomy or median sternotomy. Both approaches have been proven safe and effective; yet, certain disadvantages, including 2 anesthetics, a second hospitalization, and a delay in chemotherapy with staged procedures and inadequate exposure of both lungs with median sternotomy, exist. Recent adult studies suggest that bilateral simultaneous thoracotomy is an equally safe and effective alternative to staged bilateral thoracotomy [7,8] and avoids the disadvantages of staged procedures. Although simultaneous bilateral
648 thoracotomy has been reported in pediatric literature [9], the safety of this approach is not known. In addition, direct comparison, comparing morbidity, hospital stay, and outcomes, with staged bilateral thoracotomy in children has not been reported. The aim of this study is to review our institution’s experience with simultaneous bilateral thoracotomy in pediatric surgical patients. Specifically, we wanted to compare the safety, postoperative course, hospital utilization, and surgical outcomes between traditional bilateral staged thoracotomy and simultaneous thoracotomy. We hypothesized that simultaneous bilateral thoracotomy is as safe as staged bilateral thoracotomy, results in equivalent outcomes, and decreases hospitalization.
1. Methods and materials Institutional review board approval was obtained for all aspects of this study. We retrospectively reviewed the medical records of 30 consecutive patients 18 years or younger who underwent either bilateral staged thoracotomy or bilateral simultaneous thoracotomy between March 1994 and July 2004 at the Mayo Clinic Rochester, Minn. Children were excluded if they underwent thorascopic resections. Children were also excluded if they underwent multiple unilateral thoracotomies, but they were included if, after unilateral thoracotomy, they underwent a second contralateral thoracotomy for the same disease process within 3 months. Separate hospitalizations for staged procedures were treated as a single admission for comparison purposes. The 2 procedures were performed over the same period, with all bilateral staged procedures occurring from 1994 to 2004 and all bilateral simultaneous procedures occurring from 1994 to 2003. Primary end points included the length of hospital stay, days spent in the intensive care unit (ICU), number of days with a tube thoracostomy in place, time from initial procedure to initiation of adjuvant chemotherapy, incidence of postoperative complications, and number of deaths. Secondary study end points included operative times and also the differences between the number of pulmonary nodules detected during operative exploration and pathological examination versus those detected by preoperative computed tomography (CT). If chest CT reports did not specifically mention the number of nodules, then an independent member of the radiology department (blinded to the study) counted the number of nodules on CT scans. Data were analyzed using the JMP statistical package (Cary, NC). Statistical differences between groups for the end-point variables were analyzed using the Student t test, and P values b .05 were considered statistically significant. Data in the text are presented as mean values F SEM.
A.E. Zarroug et al.
2. Results 2.1. Patient demographics Thirty patients (17 boys, 13 girls) with an average age of 12 years (range, 1-17 years) underwent either bilateral staged or bilateral simultaneous thoracotomy. The average age at the time of the initial primary diagnosis was 11 years, whereas the average age of both the diagnosis and treatment for metastatic thoracic disease was 12 years; no differences in age between staged and simultaneous thoracotomy were noted ( P N .05). Initial diagnoses included sarcoma (n = 21), Wilms tumor (n = 4), indeterminate pulmonary nodules (n = 3), and germ cell tumor (n = 2). Indications for operation included curative resection for oncological disease (n = 27) and diagnosis for indeterminate disease (n = 3). Overall, patients had minimal medical comorbidities: 2 patients had gastroesophageal reflux disease, and 1 patient underwent orchidopexy as an infant.
2.2. Operations Eighteen patients underwent staged procedures only, 9 patients underwent simultaneous thoracotomy only, and 3 patients underwent multiple staged and/or simultaneous procedures for recurrent disease. Therefore, a total of 22 bilateral staged and 13 bilateral simultaneous thoracotomy procedures were performed on the 30 patients studied. Of the 3 patients who underwent multiple procedures, 2 children underwent both staged and simultaneous thoracotomy; the third patient underwent 2 staged thoracotomies and 2 simultaneous thoracotomies. The 2 procedures (staged and simultaneous) were performed contemporaneously from 1993 to 2004.
2.3. Outcomes When we compared primary end points (mean hospital stay, ICU stay, days with a tube thoracostomy, and time until initiation of adjuvant chemotherapy) for patients undergoing bilateral simultaneous thoracotomy versus staged thoracotomy, all outcomes were significantly improved for patients undergoing bilateral simultaneous thoracotomy (Table 1). Neoadjuvant and adjuvant chemotherapy was administered to 24 of 27 patients with an oncological diagnosis. The Table 1 Comparison of simultaneous versus staged bilateral thoracotomy Primary end points
Simultaneous*
Staged*
P
Hospital stay (d) ICU stay (d) Tube thoracostomy (d) Time until initiation of adjuvant chemotherapy (d) No. of complications
5.2 F 0.4 1F0 4 F1
10.6 F 1.1 2F1 8F1
b.002 b.0001 b.0005
13 F 2
30 F 8
* Mean F SEM.
0
3
b.05
.25
Bilateral staged versus bilateral simultaneous thoracotomy 3 patients who did not receive neoadjuvant therapy were not the same 3 patients who did not receive adjuvant therapy (all of whose parents declined adjuvant treatment). Postoperative complications occurred in no patients who had bilateral simultaneous thoracotomy versus 3 complications in patients who underwent staged thoracotomy ( P = .25); complications included 2 patients with a prolonged air leak from a tube thoracostomy and 1 patient with pneumonia. No perioperative deaths (b30 days) or intraoperative complications occurred. Regarding secondary end points, although the average operative time for each thoracotomy during bilateral staged procedures was 164 F 14 minutes, the combined average operative time for bilateral staged procedures was 328 F 30 minutes. The average operative time for bilateral simultaneous procedures was 280 F 19 minutes ( P = .18). Chest CT scans significantly underestimated the average number of nodules reported on each side (n = 3 F 1) when compared with the average number of nodules palpated at operation (n = 6 F 1; P b .0001). The average number of diseased nodules noted by pathological examination was similar to nodules palpated at operation (n = 6 F 1). No differences in the average number of nodules found either on CT or at operation were noted between patients who had bilateral staged or simultaneous procedures.
2.4. Follow-up Follow-up was available for all 30 patients (complete in 100% of patients) at a mean of 47 months (range, 3-132 months; SEM, F7). The average disease-free interval from pulmonary recurrence or any extrapulmonary recurrence for staged and simultaneous bilateral thoracotomy was 38 and 37 months, respectively ( P N .05). Eighteen of the 30 patients are currently alive. The causes of death included overwhelming pneumonia in the setting of recurrent pulmonary disease (n = 7), complications related to adjuvant chemotherapy (n = 4), and unknown causes (n = 1). All 3 patients who had a diagnosis of indeterminate nodules had benign pathological diseases diagnosed, and all 3 patients underwent bilateral staged thoracotomy only.
3. Discussion Pulmonary metastasectomy has been shown to improve survival in pediatric patients with various types of malignancies, including sarcoma, Wilms tumor, neuroendocrine tumors, and germ cell tumors [1,2,4,5]. The traditional approach for bilateral pulmonary metastasectomy has been bilateral staged thoracotomy with typically a 14- to 30-day interval between procedures. The rationale for staging separate procedures is a potential for lower operative risk related to bleeding and length of anesthesia and for fewer postoperative pulmonary complications [6]. More recently, the approach at our institution has been to perform bilateral simultaneous thoracotomy in select patients based on reports from adult studies that suggest
649 bilateral simultaneous thoracotomy as an acceptable alternative to staged bilateral thoracotomy [7,8]. Potential advantages of a simultaneous thoracotomy approach include lower overall anesthetic risks, faster overall postoperative recovery, and shorter delay until initiation of adjuvant chemotherapy. However, evidence supporting bilateral simultaneous thoracotomy in pediatric patients is less clear with only one published report demonstrating better outcomes for pulmonary hydatid disease [9]. Pediatric patients under consideration for bilateral simultaneous thoracotomy should have a thorough preoperative evaluation and careful assessment of anticipated postoperative pulmonary function. Patients with poor preoperative pulmonary function or who are anticipated to have inadequate postoperative pulmonary function secondary to major resections (lobectomy) may be better approached with a staged procedure, where pulmonary rehabilitation may improve residual lung function after initial resection [10]. In low-risk patients, however, we demonstrated that bilateral simultaneous thoracotomy is a safe alternative to a traditional 2-stage approach. Specifically, we found a statistically and clinically significant difference in (1) faster overall postoperative recovery with a lower length of stay in the hospital, (2) lower overall morbidity with less time for tube thoracostomy requirement and less time in an intensive care setting, and (3) less time to initiation of adjuvant chemotherapy. In addition, the morbidity rate for bilateral simultaneous thoracotomy was less than the staged approach, although this may be because patients who underwent simultaneous thoracotomy were judged preoperatively to better tolerate simultaneous procedure; thus, there may be a selection bias toward preoperatively healthier patients in the simultaneous group. Moreover, an earlier postoperative recovery course facilitated the initiation of adjuvant chemotherapy. Thus, simultaneous bilateral thoracotomy may be preferable for select children who require bilateral pulmonary metastasectomy. This study has limitations. First, we address neither the surgical techniques involved nor the different surgical incisions that can be implemented for these operations. Specifically, we excluded all patients who underwent thorascopic/laparoscopic procedures. Moreover, no patients underwent median sternotomy or bilateral thoracotomy via the clam shell approach for simultaneous procedures [7], and therefore, we cannot make recommendations for or against these approaches. Our practice bias has been to perform standard posterolateral or anterolateral thoracotomy for all our procedures whether staged or simultaneous, primarily because we have concerns about the ability to adequately explore, using other surgical approaches, the posterior side of the lungs (median sternotomy) and increasing morbidity (clam shell). Second, this study does not address the indications for bilateral thoracotomy for benign or malignant disease; however, it does begin to help clinicians define a role for simultaneous bilateral thoracotomy. Finally, this is a retrospective review open to selection bias, and our results should be interpreted in an appropriate
650
A.E. Zarroug et al.
clinical context; that is, simultaneous bilateral thoracotomy does not appear to increase postoperative morbidity or mortality over staged thoracotomy, and it may also have certain benefits.
4. Conclusion Our institution’s recent experience supports bilateral simultaneous thoracotomy as a safe and viable alternative to traditional staged bilateral thoracotomy for pulmonary metastasectomy in select pediatric patients. The main benefit of this approach appears to be that it avoids delay between surgical resection and initiation of adjuvant chemotherapy. In addition, our results indicate that bilateral simultaneous thoracotomy is well tolerated with a more rapid global recovery and disposition from hospital without significantly increasing perioperative morbidity or mortality. Future prospective studies may help definitively substantiate these results and better elucidate the characteristics of those patients who would best benefit from simultaneous or staged procedures.
References [1] Abel RM, Brown J, Moreland B, et al. Pulmonary metastasectomy for pediatric solid tumors. Pediatr Surg Int 2004;20(8):630 - 2. [2] Temeck BK, Wexler LH, Steinberg SM, et al. Metastasectomy for sarcomatous pediatric histologies: results and prognostic factors. Ann Thorac Surg 1995;59(6):1385 - 90. [3] Heij HA, Vos A, de Kraker J, et al. Prognostic factors in surgery for pulmonary metastases in children. Surgery 1994;115(6):687 - 93. [4] Todd TR. The surgical treatment of pulmonary metastases. Chest 1997;112(4 Suppl):287S - 90S. [5] Anonymous. Long-term results of lung metastasectomy: prognostic analyses based on 5206 cases. The International Registry of Lung Metastases. J Thorac Cardiovasc Surg 1997;113(1):37 - 49. [6] Margaritora S, Cesario A, Galetta D, et al. Staged axillary thoracotomy for bilateral lung metastases: an effective and minimally invasive approach. Eur J Cardiothorac Surg 1999;16(Suppl):S37 - 9. [7] Rusch VW. Surgical techniques for pulmonary metastasectomy. Semin Thorac Cardiovasc Surg 2002;14(1):4 - 9. [8] Pastorino U. History of the surgical management of pulmonary metastases and development of the International Registry. Semin Thorac Cardiovasc Surg 2002;14(1):18 - 28. [9] Ceran S, Sunam GS, Gormus N, et al. Cost-effective and time-saving surgical treatment of pulmonary hydatid cysts with multiple localization. Surg Today 2002;32(7):573 - 6. [10] Boysen PG. Perioperative management of the thoracotomy patient. Clin Chest Med 1993;14(2):321 - 33.
Discussion Dr Andrew Davidoff (Memphis, TN): Do you not consider median sternotomy for approaching both lungs to be an option? Chad Hamner, MD (response): We have not used median sternotomy, at least in the last 10 years. It was used early
on mostly by our thoracic surgeons when they were referred these cases. Because of limitations in examining posterior and apical lung segments, we would not recommend this approach. This is especially true because we found a significant discrepancy between the number of nodules detected on preoperative CT scan and those we actually found intraoperatively. We have a great concern that we might leave disease behind if we use a median sternotomy. Dr Minniati (Houston, TX): One of the concerns about doing bilateral thoracotomies might be the postoperative pain management and impaired mobilization. I just wondered if you could comment on your postoperative pain regimen. Chad Hamner, MD (response): We typically use patientcontrolled analgesia for these patients and then quickly convert over to oral analgesia as soon as diet is resumed. Infrequently, epidurals are performed by our anesthesia colleagues in older children, but that has not been our standard of practice. Dr Raffensperg (Chicago, IL): Were all these just lumpectomies, or were you doing lobectomies, and did you have any special way of relieving postoperative pain such as nerve infiltration to reduce the amount of narcotics afterward? Chad Hamner, MD (response): To answer the first question, most of these patients underwent multiple wedge resections. There were 2 patients who had a combination of wedge resections and a single lobectomy. As for your second question, we do not routinely use intercostal nerve blocks as part of the pain regimen. Dr Donna Caniano (Columbus, OH): Would there be any patient who would not fall into the group who safely should undergo the simultaneous procedure, and who should have a staged procedure? Chad Hamner, MD (response): Because of the low number of patients, we really were not able to identify any preoperative factors that would absolutely contraindicate simultaneous procedures in our patients. Relative contraindications may include profound pulmonary function abnormalities or any clinical condition that would severely limit pulmonary function postoperatively. Also, staged procedures may be best for those with extensive pulmonary metastasis in whom you might anticipate that the amount of resection from both lungs may significantly alter pulmonary mechanics. Dr Larry Hill (Baltimore, MD): A question about detecting small nodules—you made a statement that you did not always find those nodules that you expected from the
Bilateral staged versus bilateral simultaneous thoracotomy reports and your reviews. In lieu of the popularity of thoracoscopy with biopsy and excision, could you comment on how many of your patients had other lesions that were not in evidence, particularly when you had diagnostic radiological fields to find them? Chad Hamner, MD (response): When we reviewed our preoperative imaging and compared it to operative and pathological examination, we noted a significant difference
651 in the number of nodules seen on CT and those found at operation. CT, on average, detected only half the number of nodules that were palpable at operation. Pathological assessment coincided almost exactly with our operative findings. Therefore, a thorough evaluation of all lung segments is pivotal to remove even occult disease. For this reason, if metastasis is highly suspected as the underlying etiology, then we do not use thoracoscopy.