Objectives: to evaluate the use of thoracoscopy in the management of solitary pulmonary nodules.
Patients and methods: From June 2005 to March 2010, 40 had single pulmonary nodule larger than 1 cm and located within 3 cm of the visceral pleura. Those patients were reviewed retrogradelly. Patients divided into 2 groups: group A (15 patients) in which thoracoscopy was done and group B (25 patients) in which thoracotomy was done. Chest x-rays was done for every patient and pulmonary nodule was detected. CT chest with contrast was also done for all patients to confirm the diagnosis.
Results: The mean age of our patients was 49.2±6.5 years in group A and 50.76±7.3 years in group B with non-significant difference. Females were dominant than males in both groups. Patients had cough, hemoptysis, dyspnea, asthenia and fever more in group (B) than group (A) but with insignificant difference. The pulmonary nodules in group (A) were present in right upper lobe in 40% of patients, right lower lobe in 27%, left upper lobe in 13%, left lower lobe in 20%. While it was presented in group (B) in right upper lobe in 37% of patients, right lower lobe in 20%, right middle lobe in 8%, left upper lobe in 12%, left lower lobe in 24%. The mean size of the pulmonary nodule was 24.1±6.9 mm in group (A) while it was 23.4±5.3 mm in group (B) with insignificant differences. Bronchoscopy was done preoperatively in 29 patients (73%) in both groups; 11 patients (73%) in group A and in 18 patients (72%) in group B with insignificant difference. All reports of the bronchoscopy were within normal and not definitive in the diagnosis. Fine needle aspiration cytology (FNAC) was done in 21 patients in both groups; 5 cases (33%) in group A and in 16 cases (64%) in group B with insignificant difference. Results of the FNAC were positive for malignancy in 8 patients (38%), benign in 4 patients (19%) and nondiagnostic in 9 patients (43%). Diagnostic accuracy was 57%. Wedge resection was the main procedure done during thoracoscopy while lobectomy was the main procedure done during thoracotomy. Wedge resection was done in 9 cases (60%) in group (A) but not done in group (B) with highly significant difference. Biopsy was taken in 3 cases (20%) in group (A) while it was taken in 7 cases (28%) in group (B) without significant difference. Hilar lymph node resection was done in 2 cases (13%) only in group (A) while it was resected in 9 cases (36%) in group (B) with insignificant difference. Segmentectomy was not done in group (A) and was done in 4 cases (16%) in group (B) with significant difference. Lobectomy was not done in group (A) and was done in 14 cases (56%) in group (B) with highly significant difference. Four cases (27%) in group (A) were converted to thoracotomy: 2 cases (50%) due to inability to localize the nodule, one (25%) due to malignancy by frozen section and one (25%) due to adhesion and difficult of access. The postoperative histopathological results showed malignancy in 4 patients (36%) in group (A) and in 18 patients (62%) in group (B) with insignificant difference. While results showed that the nodules were benign in 7 patients (64%) in group (A) and in 11 patients (38%) in group (B) with insignificant difference. Postoperative bleeding occurred in 1 patient (9%) in group (A) and in 2 patients (7%) in group (B) with insignificant difference. All those patients were treated with blood transfusion. Air leak was detected for more than 7 days in one patient (9%) in group (A) and in 2 patients (7%) in group (B) with insignificant difference. Those patients were reoperated. Postoperative infection was developed in 3 patients (10%) of group (B) and not developed in patients in group (A) with insignificant difference. Postoperative dead space was developed in one patient (3%) in group (B) and not developed in group (A) with insignificant difference. Reoperation was done in one patient (3%) in both groups due to persistent of air leak. The operative time was 96.4±12.8 min in group (A) and 147.12±39.4 min in group (B) with highly significant difference. Chest tube duration was 6.8±2.6 days in group (A) and 11.8±3.5 days in group (B) with highly significant difference. The postoperative stay was 8.8±2.7 days and 13.8±3.4 days in group (B) with highly significant difference. The total hospital stay was 11.6±2.4 days and 16.4±3.0 days in group (B) with highly significant difference.
Conclusions: Video-assisted thoracoscopic surgery is a safe and effective tool for the management of patients with pulmonary nodules. It is easy and quick procedure when the nodule is larger than 10mm and nearer than 10mm of the visceral pleura. Localization in that case can be done with instrumental palpation. Preoperative marking may be needed if the nodule is smaller than 10mm and deeper than 10mm. Wedge resection can be done by thoracoscopy safely and easily for resection of the nodule. With more training, conversion to thoracotomy may be decreased and lobectomy can be done also safely.
|
