Invited Commentary

Abstract

This paper by Nakanishi and coworkers [1Nakanishi R. Fujino Y. Yamashita T. Shinohara S. Oyama T. Thoracoscopic anatomic pulmonary resection for locally advanced non-small cell lung cancer.Ann Thorac Surg. 2014; 97: 980-986Google Scholar] represents the continuing evolution of thoracoscopic anatomic resection. There are several laudable aspects of the article. The first is a formal grading of the complications using the National Cancer Institute's common terminology criteria for adverse event reporting system. Such rigorous objective reporting should serve as a model for other clinical papers. The second is the low conversion rate of 2.6%. That depicts the expertise of the surgical team and their motivation to complete the resection thoracoscopically—both are required elements of maturing a team's thoracoscopic experience. The third is a reasonably low mortality and morbidity. A 2.6% mortality rate for this group of patients is very respectable. Of note, the researchers report a 1.3% incidence of pneumonia, a remarkably low rate. One wonders if this is a result of good patient selection or aggressive pulmonary rehabilitation. Indications of increasing experience include decreasing operating time and blood loss, and a decreasing pneumonectomy rate coupled with increasing bronchoplasty rate. The experience at our institution is quite similar to that of Nakanishi and colleagues [1Nakanishi R. Fujino Y. Yamashita T. Shinohara S. Oyama T. Thoracoscopic anatomic pulmonary resection for locally advanced non-small cell lung cancer.Ann Thorac Surg. 2014; 97: 980-986Google Scholar] in the feasibility of performing resections for locally advanced lung cancers. Although we have a higher incidence of conversion to open thoracotomy, a thoracoscopic approach is attempted for almost every patient. However, some differences do exist in our approach. The major difference is our increasing reliance on transcervical extended mediastinal lymphadenectomy for lymph node clearance. Also, unlike Nakanishi and colleagues [1Nakanishi R. Fujino Y. Yamashita T. Shinohara S. Oyama T. Thoracoscopic anatomic pulmonary resection for locally advanced non-small cell lung cancer.Ann Thorac Surg. 2014; 97: 980-986Google Scholar], we continue to use interrupted sutures for bronchial anastomoses. Another small difference in our experience is that we have never needed to break up a specimen in the bag to extract it. An important aspect of thoracoscopic resection of locally advanced lung cancer is the reliance of the surgeon on haptic sensation as well as visualization during dissection. With increasing adoption of robotic surgery, it remains to be seen if such resections can be safely performed in the absence of haptic feedback. Overall, this superb report highlights the ability of video-assisted thoracoscopic surgery to resect locally advanced lung cancer with acceptable oncologic results. Although a randomized controlled trial would be ideal to prove oncologic equivalence to open surgical resection, it is unlikely that it will ever be done. Therefore, retrospective evidence of the kind presented here will help shape surgical opinion. Thoracoscopic Anatomic Pulmonary Resection for Locally Advanced Non-Small Cell Lung CancerThe Annals of Thoracic SurgeryVol. 97Issue 3PreviewThe safety and feasibility of thoracoscopic lobectomy for locally advanced lung cancer remain controversial. Full-Text PDF