以單孔方式進行再次胸腔鏡手術做主要肺切除的可行性 The Feasibility of Major Lung Resection in Repeated Video-Assisted Thoracoscopic Surgery (VATS) by Single-Port Approach Ying-Yuan Chen (陳盈元), Yau-Lin Tseng (曾堯麟) Division of Thoracic Surgery National Cheng Kung University Hospital, Tainan 2017/03/18

Introduction A growing number of repeated pulmonary surgery has been adopted in metachronous or recurrent lung cancer, and pulmonary metastases, especially in thoracoscopic era Adhesion makes repeated pulmonary surgery difficult for the surgeon and hazardous for the patients Parenchymal hemorrhage, vascular injury, prolonged air-leak Although VATS resulted in less adhesion to the chest wall than thoracotomy (54 vs. 100%), but there was no difference in mediastinal or interlobar adhesion. Tanaka K, et al. (2010)

Introduction Single-port VATS (SP-VATS) major lung resection is an established techniques No article discussing about single-port approach in dealing with repeated VATS major lung resection. To investigate the feasibility of single-port approach in repeated VATS major lung resection

Case 55 M Cholangiocarcinoma with pulmonary metastases s/p 3-port VATS RUL lobectomy + RLL wedge resection on 2014/12/15

Case Chest CT (2017/01/12) 2 new nodules LUL: 0.85cm, peripheral RLL: 3.1cm, central

Operation Single-port VATS RLL basal segmentectomy + LUL wedge resection Via previous 3rd ICS incision, 4cm Operation time: 4 h 20m (total) Blood loss: 300mL

Patients SP-VATS anatomical pulmonary resection in NCKUH Prospective data collection since starting the SP-VATS Lobectomy, segmentectomy March 30th, 2015 to Feb 28th, 2017 290 operations 276 primary surgery, 14 repeated surgery

Repeated SP-VATS group Suspect metastasis: 13/14 (93%) 1st operation: wedge:12(86%), segmentectomy: 1, lobectomy: 1 2nd operation: segmentectomy: 9 (64%), lobectomy: 5 OP time: 2h 56m (1h – 5h 5m) Blood loss: 150mL (0 – 750mL) Significant adhesion: 7/14 (50%)

Patients SP-VATS anatomical resection in NCKUH (2015.04 – 2017.02) Infectious disease, N=47 Double anatomical resection, N=11 Primary SP-VATS N=222 Repeated SP-VATS N=14

Repeated vs. Primary - Demographic characteristics Table. Comparison between patients with repeated and primary VATS major lung resection Repeated SP-VATS (n=14) Primary SP-VATS (n=222) p-value Age (years) 57.3 ± 13.2 (26 – 76) 62.3 ± 10.6 (21 - 86) 0.089 Gender (male, %) 7 (50) 92 (41.4) 0.583 Bilateral surgery (n, %) 1 (7.1) 4 (1.8) 0.265 Combined procedure (n, %) 1 2 5 (35.7) 2 (14.3) 20 (9) 175 (78.8) 27 (12.2) 0.000 Diagnosis (n, %) Primary lung cancer Metastasis Benign nodule 10 (71.4) 192 (86.5) 12 (5.4) 18 (8.1) Resection (n, %) Lobectomy Simple segmentectomy Complicated segmentectomy 3 (21.4) 6 (42.9) 102 (45.9) 33 (14.9) 87 (39.2) 0.697

Repeated vs. Primary – Peri-operative factors Table. Comparison between patients with repeated and primary VATS major lung resection Repeated SP-VATS (n=14) Primary SP-VATS (n=222) p-value Operation time, mean (minutes) 177 ± 72 (60 – 305) 177 ± 58 (77 - 445) 0.957 Estimated blood loss, mean (mL) 150 ± 211 (0 - 750) 115 ± 228 (0 - 2300) 0.575 Fissure adhesion/fusion (n, %) 7 (50.0) 48 (21.6) 0.023 Pleural adhesion (n, %) 5 (35.7) 18 (8.1) 0.006 Intra-operative complication (n, %) 2 (14.3) 20 (9) 0.626 Conversion (n, %) 2 (0.9) 1.000 Post-operative complication (n, %) 24 (10.8) 0.657 Chest tube drainage, median (days) 2 (2 – 25) 2 (1 - 31) 0.789 Postoperative stay, median (days) 3.5 (3 – 26) 4 (2 - 33) 0.665 30-day mortality (n, %) 1 (0.5)

Results Higher proportion of significant adhesion/fussion in the fissure (50 vs.21.6%) and in the pleural space (35.7% vs. 8.1%) in repeated SP-VATS group No increased in intra-operative vascular injury, conversion or post-operative complication rate No difference in duration of pleural drainage and post-op hospital stay

Limitation Retrospective study Small size in repeated VATS group Prospective data collection Small size in repeated VATS group Heterogeneity in operation Selection bias Single institute Different operator, different experience

Conclusion VATS pulmonary resection causes significant fissure and pleural adhesion when redoing the VATS lung resection Careful management of such adhesion to complete major lung resection by single-port VATS approach yields comparable perioperative outcomes Single-port VATS approach is a feasible method for major lung resection in repeated VATS lung resection.

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