| BackgroundSurgeons always continue to seek to minimally invasive surgery, and endoscopic technique is an important part of minimally invasive technology. In1986, Cuschieri started to conduct an experiment of laparoscopic cholecystectomy on animals, and then began to put it into clinical application in February1989. The successful laparoscopic cholecystectomy achieved in patient marked the advent of authenticminimally invasive technology. In1991Xun Zuwu completed the first case of laparoscopic cholecystectomy in China. After laparoscopic surgery, thoracic surgeons began to set off a study of therapeutic thoracoscopic surgery with the emergence of high-tech devices at the end of the1980s. With the zoom function of thoracoscope to operative field, surgeons can complete sophisticated operation within a smaller incision. But throughout the1990s, the progress of thoracoscopic surgery was relatively slow, and during this period it was mainly used for spontaneous pneumothorax, intrathoracic biopsy, and excision of benign tumor in the chest cavity more than excision of lung cancer. In1992, Lewis and Roviaro successively reported lobectomy for treatment of patient with non-small cell lung cancer (NSCLC) by video-assisted thoracic surgery (VATS). Over the past decade, due to the pursuit of thoracic surgeons on the concept of minimally invasive technology, accumulation of surgical experience, improvement of surgical techniques and ceaseless emergence of excellent endoscopic instruments, the VATS has been exceptionally rapidly developed and promoted, and the technique has been put into use in the world’s major medical centers. The VATS has cosmetic effect and less postoperative pain favoured by patients, and the preference is one of reasons that promote it to be developed. Accordingly, indications of the VATS are gradually expanded to the lobectomy for patient with NSCLC. from stage I NSCLC to stage Ⅱ NSCLC, and from VATS lobectomy to complete video-assisted thoracoscopy (c-VATS) lobectomy. As early as1993, Mentzer et al come up with bronchial sleeve lobectomy and pulmonary segmental resection to be performed by VATS, and Japanese scholar Nakinishi et al even successfully performed thoracoscopic lobectomy for patient with a single lung. Garzon et al pointed out that the VATS indications were still expanding. Some scholars have already applied the VATS for patients with some type of esophageal cancer, or mediastinal tumor, and for valve replacement or harvesting internal mammary artery for coronary artery bypass. Currently, however, VATS technique is most widely applied for the organ-lung. According to statistics, VATS lung surgery accounted for2/3of the total VATS cases over the same period.For lung cancer patients with advanced age, hypertension, old chronic bronchitis, or debilitation, VATS lobectomy has its obvious advantages demonstrated. In2006,The U.S. National Comprehensive Cancer Network (NCCN) put minimally invasive surgical treatment by VATS for lung cancer into their clinical guidelines, and recommended that the elderly, debilitating patient or cosmetic requirement patient with lung cancer could be treated with thoracoscopic minimally invasive surgery. However, on lobectomy by VATS especially c-VATS for patient with NSCLC, there is still a big controversy. The focus of the controversy is that how much the c-VATS lobectomy influences patient during perioperation-whether it is really safe, complete for lymph node dissection and minimally invasive or not. Many medical centers, especially smaller medical centers and grassroots medical centers have not yet applied VATS for lobectomy because of not only objective constraints of technique and equipment, but also people’s suspicious attitudes to its safety, thoroughness of lymph node dissection and minimally invasive effect. In fact, VATS lobectomy applied by some medical centers often leads to that the incidence of complications is higher, lymph node dissection is not more complete, operating and anesthetic time is longer, and bleeding volume is greater because of the surgeon’s technique, experience and so on. Moreover, a small skin incision with a length of subcutaneous sneak distance to cut muscles and a rib tractor are employed to facilitate exposure and operation in pursuit of smaller incision and cosmetic effect, which means not so safe and minimally invasive to the patients.Therefore, to perform VATS technique requires good anesthesia, experienced surgeons that experienced conventional thoracotomy(CT), the close cooperation of doctors and excellent endoscopic instruments. In this study, the c-VATS means that throughout the procedure, the surgeons always orient the thoracoscopic monitor-vision to perform lobectomy by thoracoscopic instruments without rib tractor. As Li Jianfeng, Rocco and Lewis indicate:the c-VATS lobectomy is a method that surgeons completely abandoned employing rib tractor and a large range of chest muscles incision, and that surgical instruments are put into the thoracic cavity through soft tissues and natural width of the intercostal space, which is different from the small incision VATS lobectomy with thoracoscope for illumination; the surgeons operate under the monitor-vision instead of direct vision from first to last, which requires excellent technique and rich experience. It should be noted that, whether we run after any form of minimal invasion, we must keep to the cancer therapeutic principles followed for CT under the existing technical conditions and perform systematic hilar and mediastinal lymphadenectomy (the4th,5th,6th,7th,8th,9th and10th groups of lymphadenectomies for left lobectomy, the2nd,3rd,4th,7th,8th,9th and10th groups of lymphadenectomies for right lobectomy),and we should not just pursue unilaterally minimal invasion regardless of surgical quality and at the expense of long term quality of life in patients.The existing literatures mainly focus on the comparison of the macroscopic clinical data such as perioperative incision size, bleeding volume, complications and so on, which indicate that c-VATS lobectomy for patient with NSCLC is superior to CT. Researches are relatively rare about that whether the perioperative effects of thoracoscopic surgery on patients reflect in perioperative changes of the microscopic data such as the body’s blood, biochemistry and so on, and whether the changes of the macro are consistent with the changes of the micro.ObjectiveThe objective of the research was to compare perioperative changes of lobectomy by c-VATS and CT on pre-op and post-op day1,2,3,5and7white blood cell count (WBC-C) and high-sensitive C-reactive protein(hs-CRP) concentration, while monitoring clinical data, to objectively judge perioperative period effect of the two surgical methods on stage I and stage II apart from T3N0M0NSCLC patients-whether c-VATS is really safe, complete for lymph node dissection and minimally invasive or not.Methods and materialsIn our department,34stage Ⅰ and stage Ⅱ apart from T3N0M0NSCLC patients who meeted admission criteria for lobectomy were consecutively selected into c-VATS group from December2010to November2011. In order to reduce selection bias, a propensity matching method was adopted to make pre-op baseline data similar between both groups:33cases who meeted admission criteria were selected into control group(CT group) from248corresponding period NSCLC surgery cases who did not undergo c-VATS.1.Operative methods and main equipmentsTwo groups of patients who were placed in the full left or right lateral decubitus position,with double-lumen endotracheal tube intubation for one-lung ventilation, were performed for lobectomy by the same team of surgeons who are very skilled in lobectomy technique and had conventional thoracotomy lobectomy experience for years; disposable staplers and bronchial stump closure devices made in Johnson&Johnson medical(Shanghai) Ltd were used for dealing with lung fissures, pulmonary vessels and bronchia respectively; a high frequency electric knife, an electric electrocautery hook and an ultrosonic scalpel were used in two groups; some drugs such as ulinastatin, dexamethasone, etc which influence hs-CRP plasma concentration could not be used. In c-VATS group, Stryker1088i30°video-assisted thoracoscope (Stryker corperation of United States) was used; an observation port incision was about1.5cm at the7th or8th intercostal space in the middle axillary line; a main operating port (4～8cm) was located at the4th (for upper lobe or middle lobe) or5th intercostal space (for lower lobe) in the anterior axillary line with the vertical incision through the thoracic cavity rather than sneakly cutting the muscles beneath the subcutaneous tissue, and the ribs were not spreaded but an elastic soft trocar was used to protect the operating port incision; an auxiliary port was about2cm, and located at the7th intercostal space in the posterior axillary line or in the subscapular line. The order of operation was as follows:the thoracoscope was placed into the thoracic cavity to explore situation of adhesion and location of tumor, then thoracoscopic instruments were placed into the thoracic cavity through the main operating port to separate the adhesion and reveal hilar structures; disposal staplers were applied for handling pulmonary vessels, bronchia, lung fissure; pulmonary vessels were dealed as far as possible from artery to vein in order to prevent pulmonary congestion which led to be difficult to remove the specimen and increased blood loss volume,but in the process of the actual operation, the order above could be ajusted flexibly for following the principle of safe operation; a specimen bag was placed into thoracic cavity to contain the specimen and then pulled out; after systematic lymph node dissection,we began to stop bleeding, inflate lung, check for leak, freeze intercostal nerves, lavage the thoracic cavity, and put into a single drainage chest tube through the observation port in sequence; while lobectomy for upper lobe, we conventionally put into another drainage chest tube at the2nd intercostal space in the midclavicular line to exhaust air and to have lung inflated; tissues of the chest wall were sutured layer by layer, and the skin layer was cosmetically sutured with absorbable suture; anesthesiologist inflating the lung to exhaust air was asked before closing the thoracic cavity. However, in the CT group, the incision which was20to30cm in length was located at posterolateral position of the fifth or sixth intercostal space; after getting into the thoracic cavity, with rib retractor for exposure, the surgical procedures of the CT group were the same as those of the c-VATS group; a drainage chest tube was placed at the the7th or8th intercostal space in the middle axillary line and another one was placed at the2nd intercostal space in the midclavicular line if there was a lobectomy for upper lobe.2.Collecting, testing of specimens of laboratory data and clinical dataRespectively, before operation and at post-op day1,2,3,5and7, two tubes of patient’s fasting peripheral venous blood drew, each tube of blood4ml, were used to detect WBC-C and hs-CRP concentration. EDTA anticoagulant tube and ordinary non-anticoagulant tube respectively was used for detecting WBC-C and hs-CRP concentration, and the specimens were sent to test within1h. ABX120five-classification automatic hematology analyzer(French ABX company) was used to detect WBC-C, and Siemens BN prospec automatic specific protein analyzer and reagents (German Siemens Company) were used to test plasma hs-CRP concentration with immune scattering turbidimetry principle. Clinical data included: volume of blood loss during operation, operative time, groups and numbers of lymphnodectomy, drainage volume, chest tube drainage days, days of first getting out of bed, hospital stay, complications, postoperative pain score(adopting the average value of numerical pain rating scales on the first3postoperative days)and postoperative pathological staging of tumor.3. Statistical analysisSPSS software version13.0was used for statistical analysis. Two independent samples t-test was used to test measurement data between two groups; preoperative WBC-C and hs-CRP concentration between two groups were compared with two independent samples t-test, and the WBC-C and hs-CRP concentration between two groups and at each time point were compared with repeated measurement data analysis of variance; R×C table data Chi-square test (χ2-test) or fourfold table data χ2-test were used to test enumeration data. Significance was defined as a P-value of <0.05.Results1.The laboratory data of two groups:before operation, the WBC-C as well as hs-CRP concentration in two groups was no significant difference (P>0.05); both the WBC-C and the hs-CRP concentration before operation were less than those at each postoperative time point in two groups and the differences were statistically significant (P<0.01); the WBC-C reached its highest value in two groups on the first post-operative day, then gradually decreased and dropped to the normal range on the third postoperative day; the hs-CRP concentration reached its highest value on the third postoperative day, then gradually decreased and dropped to the normal range on the7th postoperative day; both the WBC-C and the hs-CRP concentration in c-VATS group were significantly lower than those in the CT group and the differences were statistically significant (P<0.01).2.The perioperative clinical data in two groups: two of the cases scheduled for c-VATS lobectomy were converted to open thoracotomy during the study (not included in the study, the last entry into the study was34cases in c-VATS group); there were no death, serious complications and reoperations in two groups; in c-VATS group, blood loss volume during operation, days of first getting out of bed and postoperative pain score were significantly lower than those in CT group(P<0.01); there was no significant difference in operative time, groups and numbers of lymphnodectomy, drainage volume, the chest tube drainage days, hospital stay, complications (P>0.05); postoperative pathological staging of tumor tended to upgrade by and large and there was a little more advanced stage Ⅲ; in c-VATS group, stage1upgraded to stage Ⅱ,Ⅲ2cases, respectively, and the Phase Ⅱ upgraded to stage Ⅲ4cases; in CT group, stage Ⅰ upgraded to stage Ⅱ,Ⅲ3and4cases, respectively, and the stage Ⅱ upgraded to stage Ⅲ4cases, however.stageⅡ degraded to stage Ⅰ lcase.ConclusionOn the condition of following the principles of cancer treatment, c-VATS lobectomy with systematic hilar and niediastinal lyniphadenectomy has not only the same results as the CT for stage I and partial stage Ⅱ patients with NSCLC but also has a smaller effect on the patient during the perioperative period-reducing trauma to the body,the acute phase response and patient’s pain. So it is safe, minimally invasive and complete in lymph node dissection.The c-VATS is worth popularizing and can take the place of the CT for seclected cases. |
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