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Bilateral Thoracoscopy and Limited Thoracotomy
minimally invasive techniques Bilateral Thoracoscopy and Limited Thoracotomy* A Combined Approach for the Resection of Metastatic Fibrosarcoma W. Sherman Turnage, M .D., F.C.C.P.; Carrie Gill-Murdoch, M.D .; Peter P. McKeown, M.D ., F.C.C.P.; and Patricia Conant, M.S .
(Chest 1994; 106:935-86) Key words: Bilateral thoracoscopy; bilateral thoracotomy ; pulmonary metastatic fibrosarcoma ; metastatic disease; thoracic anesthesia
pulmonary metastases are a well-known complication of fibrosarcomatous tumors , and it is common for these lesions to occur bilaterally. In the past, the difficulty in managing patients with bilateral metastatic disease has been the nature and timing of resection of the lesions from each lung. Video-assisted thoracoscopic surgery provides a minimally invasive means of obtaining lung tissue for biopsy and for performing limited resection of metastatic lesions. The benefits of this procedure are smaller incisions and a potentially shortened postoperative stay. We recently cared for a patient who presented with bilateral lung lesions evidenced on a routine follow-up CT scan of the chest after hemipelvectomy for malignant fibrous histiocytoma. This report describes a unique approach to bilateral lung resection and compares it with previously described methods. CASE REPORT
A 24-year-old woman presented with bilateral pulmonary nodules shown on a chest roentgenogram and CT scan 7 months after resection of a malignant fibrous histiocytoma of the left pelvis. At age 12 years, a Ewing's variant tumor was resected from the left iliac crest, and she received extensive postoperative radiation and chemotherapy to the left hip region. She remained disease-free until the appearance of the malignant fibrous histiocytoma at 23 years of age. She was treated with preoperative chemotherapy and underwent a radical internal hemipelvectomy with ischiofemoral arthrodesis followed by postoperative chemotherapy. The disease appeared well controlled until the discovery of the bilateral pulmonary nodules. They were 12 em in diameter. Three were present in the left upper lobe, two in the left lower lobe, and two in the right middle lobe. There was no evidence of local recurrence, and the decision was made to attempt resection of these lesions. *From the Departments of Anesthesiology and Surgery, University of South Florida College of Medicine, Tampa. Reprint requests: Dr. Turnage, Dept. of Anesthesiology, USF College of Medicine , 12901 Bruce B. Downs Blvd, MDC 59, Tampa 33612
Before surgery, a peripheral intravenous cannula and routine monitors were placed. After the induction of general anesthesia with sodium thiopental, fentanyl, and vecuronium, an intraarterial cannula and 37F Robert-Shaw endobronchial tube were inserted. The patient was then turned to the right lateral decubitus position, an epidural catheter was placed in the L2.3 interspace, and 4 mg of morphine sulfate was administered via the catheter. General anesthesia was then maintained with isoflurane in a mixture of oxygen and nitrous oxide, and muscle relaxation was maintained with vecuronium. The left lung was deflated, and a 12-mm thoracoport was placed in the eighth intercostal space. A straight (0°) thoracoscope was inserted into the left hemithorax. Visualization of the left lung and pleura allowed the surgeon to localize a 2-cm lesion in the left upper lobe and guide a small (10 em), muscle-sparing thoracotomy incision at that level. Combining standard thoracotomy and thoracoscopic instruments, the lesion was excised. Frozen section was positive for spindle cells consistent with a metastatic sarcoma. The ability to palpate the lung through this small incision led to the discovery of four smaller metastases not seen radiographically or via the thoracoscope alone. These lesions were resected. A chest tube was placed and the incision was closed in the usual manner. The patient was then repositioned, prepared and draped for a right thoracotomy. The left chest tube was appropriately padded to prevent kinking or obstruction, and the chest drainage system was placed within view of the anesthesiologist to provide for monitoring of air drainage from the left hemithorax. The patient tolerated collapse of the right lung, and the thoracoscope was inserted at the eighth intercostal space. Identification of the specific location of the right lung lesions enabled excision of two right middle lobe metastases through a 10-cm thoracotomy incision. After excision of these lesions, achest tube was placed in the right sixth intercostal space and the incision was closed. All specimens were confirmed to be metastatic sarcoma. At the conclusion of the procedure, a permanent intravenous port for chemotherapy was placed via the right subclavian vein. The patient emerged from general anesthesia and was uneventfully extubated. Postoperatively, she had excellent pain relief from morphine administered by epidural route. The limited thoracotomy incisions allowed discontinuation of epidural analgesia on the first postoperative day and conversion to oral analgesics. The patient had a persistent bilateral air leak as a result of the multiple excisions, but she was discharged from the hospital on postoperative day 20 without other complications. DISCUSSION
This is a report of bilateral thoracoscopy and limited thoracotomy being performed during one operative procedure. Previous reports have described eiCHEST I 106 I 3 I SEPTEMBER, 1994
935
ther two separate "staged" posterolateral thoracotomies for the diagnosis and resection of pulmonary nodules, 1 an operative diagnosis of bilateral pulmonary lesions via a median sternotomy, 2 or transsternal thoracotomy.3 Recently , Dowling et al 4 reported a series of patients who underwent unilateral thoracoscopic resection of peripheral pulmonary nodules for diagnosis. They reported excellent results in their series of 15 patients and fewer days of hospitalization. We believe video-assisted thoracoscopic examination of both lungs facilitated the management of this patient in several ways. First, it allowed visualization of the primary nodule, confirming the diagnosis of metastatic disease. Second , by localizing the lesion with the thoracoscope, it guided the muscle-sparing limited thoracotomy incision. Final! y, this smaller incision had less respiratory muscle involvement, thus leading to a rapid recovery of pulmonary function. This approach was less painful than standard bilateral posterolateral thoracotomy incisions. It should be emphasized that thoracoscopy alone may have limited application in metastatic disease because of the inability to palpate the lung, which may introduce the possibility of missing lesions. In this patient, at least four of the lesions were not detected by CT and may have been missed by thoracoscopy alone. Similar findings are supported by McCormack et al, 5 who question the role of thoracoscopy alone in metastectomy, advocating that an incomplete resection is more likely without the use of tactile palpation . By combining thoracoscopy and mini-thoracotomy, however, one is able to use the advantages of each to obtain (1) extensive visualization , including the chest wall and diaphragm and (2) manipulation and palpation of the lung. These two techniques, thoracoscopy and mini-thoracotomy, should be considered complementary and not mutually exclusive. An alternative use of combined thoracoscopy with surgical incision was reported by Hazelrigg et al 6 These authors report combining median sternotomy with left hemithorax thoracoscopy to guide exploration of the left chest without the need for retraction of the heart. This approach allows exploration and resection of lesions in both lungs, and it may provide some advantages in avoiding the need to turn the patient and prepare the opposite side for a surgical incision, thus saving operative time. This case shows that a bilateral thoracic approach to metastatic disease during a single operation is now feasible by combining thoracoscopy with mini-thoracotomies. In performing bilateral thoracoscopy, there is a potential for pneumothorax on the initial operative side, and the anesthesiologist needs to be alert for evidence of an air leak, obstruction of the chest tube, and hemodynamic compromise. The an936
esthesiologist also should pay particular attention to airway pressure and continually monitor ventilation by auscultation via an esophageal stethoscope to detect early signs of a tension pneumothorax while observing for appropriate fluctuations of the water column in the chest drainage system with positive pressure ventilation. It is conceivable that an air leak of sufficient magnitude could develop in the initial operative side and prohibit effective alveolar ventilation of the dependent lung during one lung ventilation. Further operative intervention may then not be possible; however, it seems unlikely that a significant air leak would develop when the prior operated lung is dependent and the resistance to airflow is increased by the weight of the mediastinum compressing the lung against the chest wall. In our opinion, the persistent air leaks were related to the resection of the multiple metastases that left raw surfaces of lung parenchyma. Similar results would have been obtained if the resections had been performed via standard thoracotomy incisions. We can only speculate that using a laser instrument for the resections might have improved the sealing of the lung surfaces and reduced the period of postoperative air leak. In summary, bilateral thoracoscopy and mini-thoracotomies offer a unique approach in selected patients with metastatic pulmonary disease. In our patient, this combined approach for the diagnosis and excision of metastatic malignant fibrous histiocytoma proved to be safe and cost-effective. We suggest this approach can be used in similar patients, but caution that appropriate monitoring of ventilation and of the chest drainage system is essential to detect the incipient development of tension pneumothorax in the initially operated hemithorax. A close working relationship between the anesthesiologist and thoracic surgeon is essential for a successful outcome in this complex operative procedure. REFERENCES
2 3 4 5
6
Levinsky L, Lewinski U, de Vries A, Levy M. Bilateral thoracotomy for Hodgkin's disease involving the hilar nodes. Chest 1971; 59:446-48 Takita H, Merrin C, Didolkar M, Douglass H, Edgerton F. The surgical management of multiple lung metastases. Ann Thorac Surg 1977; 24:359-65 Shimizu N, Ando A, Matsutani T, Maruyama S, Teramoto S. Transsternal thoracotomy for bilateral pulmonary metastasis. J Surg Oncol1992; 50:105-09 Dowling R, Ferson P, Landreneau R. Thoracoscopic resection of pulmonary metastases. Chest 1992; 102:1450-54 McCormack P, Ginsberg K, Bains M, Burt M, Martini N, Rusch V, et al. Accuracy of lung imaging in metastases with implications for the role of thoracoscopy. Ann Thorac Surg 1993; 56:863-66 Hazelrigg SR, Naunheim K, Auer JE, Seifert PE. Combined median sternotomy and video-assisted thoracoscopic resection of pulmonary metastases. Chest 1993; 104:956-58 Resection of Metastatic Fibrosarcoma (Turnage et alj
(Chest 1994; 106:935-86) Key words: Bilateral thoracoscopy; bilateral thoracotomy ; pulmonary metastatic fibrosarcoma ; metastatic disease; thoracic anesthesia
pulmonary metastases are a well-known complication of fibrosarcomatous tumors , and it is common for these lesions to occur bilaterally. In the past, the difficulty in managing patients with bilateral metastatic disease has been the nature and timing of resection of the lesions from each lung. Video-assisted thoracoscopic surgery provides a minimally invasive means of obtaining lung tissue for biopsy and for performing limited resection of metastatic lesions. The benefits of this procedure are smaller incisions and a potentially shortened postoperative stay. We recently cared for a patient who presented with bilateral lung lesions evidenced on a routine follow-up CT scan of the chest after hemipelvectomy for malignant fibrous histiocytoma. This report describes a unique approach to bilateral lung resection and compares it with previously described methods. CASE REPORT
A 24-year-old woman presented with bilateral pulmonary nodules shown on a chest roentgenogram and CT scan 7 months after resection of a malignant fibrous histiocytoma of the left pelvis. At age 12 years, a Ewing's variant tumor was resected from the left iliac crest, and she received extensive postoperative radiation and chemotherapy to the left hip region. She remained disease-free until the appearance of the malignant fibrous histiocytoma at 23 years of age. She was treated with preoperative chemotherapy and underwent a radical internal hemipelvectomy with ischiofemoral arthrodesis followed by postoperative chemotherapy. The disease appeared well controlled until the discovery of the bilateral pulmonary nodules. They were 12 em in diameter. Three were present in the left upper lobe, two in the left lower lobe, and two in the right middle lobe. There was no evidence of local recurrence, and the decision was made to attempt resection of these lesions. *From the Departments of Anesthesiology and Surgery, University of South Florida College of Medicine, Tampa. Reprint requests: Dr. Turnage, Dept. of Anesthesiology, USF College of Medicine , 12901 Bruce B. Downs Blvd, MDC 59, Tampa 33612
Before surgery, a peripheral intravenous cannula and routine monitors were placed. After the induction of general anesthesia with sodium thiopental, fentanyl, and vecuronium, an intraarterial cannula and 37F Robert-Shaw endobronchial tube were inserted. The patient was then turned to the right lateral decubitus position, an epidural catheter was placed in the L2.3 interspace, and 4 mg of morphine sulfate was administered via the catheter. General anesthesia was then maintained with isoflurane in a mixture of oxygen and nitrous oxide, and muscle relaxation was maintained with vecuronium. The left lung was deflated, and a 12-mm thoracoport was placed in the eighth intercostal space. A straight (0°) thoracoscope was inserted into the left hemithorax. Visualization of the left lung and pleura allowed the surgeon to localize a 2-cm lesion in the left upper lobe and guide a small (10 em), muscle-sparing thoracotomy incision at that level. Combining standard thoracotomy and thoracoscopic instruments, the lesion was excised. Frozen section was positive for spindle cells consistent with a metastatic sarcoma. The ability to palpate the lung through this small incision led to the discovery of four smaller metastases not seen radiographically or via the thoracoscope alone. These lesions were resected. A chest tube was placed and the incision was closed in the usual manner. The patient was then repositioned, prepared and draped for a right thoracotomy. The left chest tube was appropriately padded to prevent kinking or obstruction, and the chest drainage system was placed within view of the anesthesiologist to provide for monitoring of air drainage from the left hemithorax. The patient tolerated collapse of the right lung, and the thoracoscope was inserted at the eighth intercostal space. Identification of the specific location of the right lung lesions enabled excision of two right middle lobe metastases through a 10-cm thoracotomy incision. After excision of these lesions, achest tube was placed in the right sixth intercostal space and the incision was closed. All specimens were confirmed to be metastatic sarcoma. At the conclusion of the procedure, a permanent intravenous port for chemotherapy was placed via the right subclavian vein. The patient emerged from general anesthesia and was uneventfully extubated. Postoperatively, she had excellent pain relief from morphine administered by epidural route. The limited thoracotomy incisions allowed discontinuation of epidural analgesia on the first postoperative day and conversion to oral analgesics. The patient had a persistent bilateral air leak as a result of the multiple excisions, but she was discharged from the hospital on postoperative day 20 without other complications. DISCUSSION
This is a report of bilateral thoracoscopy and limited thoracotomy being performed during one operative procedure. Previous reports have described eiCHEST I 106 I 3 I SEPTEMBER, 1994
935
ther two separate "staged" posterolateral thoracotomies for the diagnosis and resection of pulmonary nodules, 1 an operative diagnosis of bilateral pulmonary lesions via a median sternotomy, 2 or transsternal thoracotomy.3 Recently , Dowling et al 4 reported a series of patients who underwent unilateral thoracoscopic resection of peripheral pulmonary nodules for diagnosis. They reported excellent results in their series of 15 patients and fewer days of hospitalization. We believe video-assisted thoracoscopic examination of both lungs facilitated the management of this patient in several ways. First, it allowed visualization of the primary nodule, confirming the diagnosis of metastatic disease. Second , by localizing the lesion with the thoracoscope, it guided the muscle-sparing limited thoracotomy incision. Final! y, this smaller incision had less respiratory muscle involvement, thus leading to a rapid recovery of pulmonary function. This approach was less painful than standard bilateral posterolateral thoracotomy incisions. It should be emphasized that thoracoscopy alone may have limited application in metastatic disease because of the inability to palpate the lung, which may introduce the possibility of missing lesions. In this patient, at least four of the lesions were not detected by CT and may have been missed by thoracoscopy alone. Similar findings are supported by McCormack et al, 5 who question the role of thoracoscopy alone in metastectomy, advocating that an incomplete resection is more likely without the use of tactile palpation . By combining thoracoscopy and mini-thoracotomy, however, one is able to use the advantages of each to obtain (1) extensive visualization , including the chest wall and diaphragm and (2) manipulation and palpation of the lung. These two techniques, thoracoscopy and mini-thoracotomy, should be considered complementary and not mutually exclusive. An alternative use of combined thoracoscopy with surgical incision was reported by Hazelrigg et al 6 These authors report combining median sternotomy with left hemithorax thoracoscopy to guide exploration of the left chest without the need for retraction of the heart. This approach allows exploration and resection of lesions in both lungs, and it may provide some advantages in avoiding the need to turn the patient and prepare the opposite side for a surgical incision, thus saving operative time. This case shows that a bilateral thoracic approach to metastatic disease during a single operation is now feasible by combining thoracoscopy with mini-thoracotomies. In performing bilateral thoracoscopy, there is a potential for pneumothorax on the initial operative side, and the anesthesiologist needs to be alert for evidence of an air leak, obstruction of the chest tube, and hemodynamic compromise. The an936
esthesiologist also should pay particular attention to airway pressure and continually monitor ventilation by auscultation via an esophageal stethoscope to detect early signs of a tension pneumothorax while observing for appropriate fluctuations of the water column in the chest drainage system with positive pressure ventilation. It is conceivable that an air leak of sufficient magnitude could develop in the initial operative side and prohibit effective alveolar ventilation of the dependent lung during one lung ventilation. Further operative intervention may then not be possible; however, it seems unlikely that a significant air leak would develop when the prior operated lung is dependent and the resistance to airflow is increased by the weight of the mediastinum compressing the lung against the chest wall. In our opinion, the persistent air leaks were related to the resection of the multiple metastases that left raw surfaces of lung parenchyma. Similar results would have been obtained if the resections had been performed via standard thoracotomy incisions. We can only speculate that using a laser instrument for the resections might have improved the sealing of the lung surfaces and reduced the period of postoperative air leak. In summary, bilateral thoracoscopy and mini-thoracotomies offer a unique approach in selected patients with metastatic pulmonary disease. In our patient, this combined approach for the diagnosis and excision of metastatic malignant fibrous histiocytoma proved to be safe and cost-effective. We suggest this approach can be used in similar patients, but caution that appropriate monitoring of ventilation and of the chest drainage system is essential to detect the incipient development of tension pneumothorax in the initially operated hemithorax. A close working relationship between the anesthesiologist and thoracic surgeon is essential for a successful outcome in this complex operative procedure. REFERENCES
2 3 4 5
6
Levinsky L, Lewinski U, de Vries A, Levy M. Bilateral thoracotomy for Hodgkin's disease involving the hilar nodes. Chest 1971; 59:446-48 Takita H, Merrin C, Didolkar M, Douglass H, Edgerton F. The surgical management of multiple lung metastases. Ann Thorac Surg 1977; 24:359-65 Shimizu N, Ando A, Matsutani T, Maruyama S, Teramoto S. Transsternal thoracotomy for bilateral pulmonary metastasis. J Surg Oncol1992; 50:105-09 Dowling R, Ferson P, Landreneau R. Thoracoscopic resection of pulmonary metastases. Chest 1992; 102:1450-54 McCormack P, Ginsberg K, Bains M, Burt M, Martini N, Rusch V, et al. Accuracy of lung imaging in metastases with implications for the role of thoracoscopy. Ann Thorac Surg 1993; 56:863-66 Hazelrigg SR, Naunheim K, Auer JE, Seifert PE. Combined median sternotomy and video-assisted thoracoscopic resection of pulmonary metastases. Chest 1993; 104:956-58 Resection of Metastatic Fibrosarcoma (Turnage et alj