Department of Cardiothoracic Surgery, Odense University Hospital, Odense, Denmark.
Department of Cardiothoracic Surgery, Odense University Hospital, Odense, Denmark.
Chest. 2012 Dec;142(6):1598-1602. doi: 10.1378/chest.12-0249.
Patients with limited metastatic disease in the lung may benefit from metastasectomy. Thoracotomy is considered the gold standard, and video-assisted thoracoscopic surgery (VATS) is controversial because nonimaged nodules may be missed when bimanual palpation is restricted. Against guideline recommendations, metastasectomy with therapeutic intent is now performed by VATS by 40% of thoracic surgeons surveyed. The evidence base for optimal surgical approach is limited to case series and registries, and no comparative surgical studies were observer blinded.
Patients considered eligible for pulmonary metastasectomy by VATS prospectively underwent high-definition VATS by one surgical team, followed by immediate thoracotomy with bimanual palpation and resection of all palpable nodules by a second surgical team during the same anesthesia. Both surgical teams were blinded during preoperative evaluation of CT scans and during surgery. Primary end points were number and histology of nodules detected.
During a 12-month period, 37 patients were included. Both surgical teams observed exactly 55 nodules suspicious of metastases on CT scans. Of these, 51 nodules were palpable during VATS (92%), and during subsequent thoracotomy 29 additional nodules were resected: Six (21%) were metastases, 19 (66%) were benign lesions, three (10%) were subpleural lymph nodes and one was a primary lung cancer.
Modern VATS technology is increasingly used for pulmonary metastasectomy with therapeutic intent, but several nonimaged, and therefore unexpected, nodules are frequently found during subsequent observer-blinded thoracotomy. A substantial proportion of these nodules are malignant, and, despite modern imaging and surgical technology, they would have been missed if VATS was used exclusively for metastasectomy with therapeutic intent.
肺部局限性转移疾病的患者可能受益于转移灶切除术。开胸手术被认为是金标准，而电视辅助胸腔镜手术（VATS）存在争议，因为当限制双手触诊时，可能会错过非影像学结节。尽管有指南建议，但仍有 40%接受调查的胸外科医生出于治疗目的而采用 VATS 进行转移灶切除术。最佳手术方法的证据基础仅限于病例系列和登记处，并且没有比较性手术研究是观察者盲法的。
前瞻性地对符合 VATS 适应证的患者由同一手术团队进行高清 VATS，然后由第二手术团队在同一麻醉下立即进行开胸手术，进行双手触诊并切除所有触诊到的结节。在术前评估 CT 扫描和手术过程中，两个手术团队都处于盲法状态。主要终点是检测到的结节数量和组织学。
在 12 个月的时间里，共纳入了 37 名患者。两个手术团队在 CT 扫描上均观察到 55 个可疑转移的结节。其中，51 个结节在 VATS 中可触及（92%），随后在开胸手术中又切除了 29 个额外的结节：6 个（21%）为转移灶，19 个（66%）为良性病变，3 个（10%）为胸膜下淋巴结，1 个为原发性肺癌。
现代 VATS 技术越来越多地用于有治疗目的的肺转移灶切除术，但在随后的观察者盲法开胸手术中经常会发现多个非影像学、因此意外的结节。这些结节中有相当一部分是恶性的，如果仅使用 VATS 进行有治疗目的的转移灶切除术，尽管有现代成像和手术技术，这些结节也会被遗漏。
