Open Access
Open Peer Review

This article has Open Peer Review reports available.

How does Open Peer Review work?

Dissection of lung parenchyma using electrocautery is a safe and acceptable method for anatomical sublobar resection

  • Takashi Ohtsuka1Email author,
  • Taichiro Goto1,
  • Masaki Anraku1,
  • Mitsutomo Kohno1,
  • Yotaro Izumi1,
  • Hirohisa Horinouchi1 and
  • Hiroaki Nomori1
Journal of Cardiothoracic Surgery20127:42

https://doi.org/10.1186/1749-8090-7-42

Received: 10 December 2011

Accepted: 3 May 2012

Published: 3 May 2012

Abstract

Background

Anatomic sublobar resection is being assessed as a substitute to lobectomy for primary lung cancers. However, persistent air leak after anatomic sublobar resection is prevalent and increasing surgical morbidity and costs. The use of electrocautery is being popularized recently in anatomic sublobar resection. We have retrospectively evaluated the safety and efficacy of intersegmental plane dissection using electrocautery.

Methods

Between April 2009 to September 2010, 47 patients were treated with segmentectomy for clinical T1N0M0 non-small cell lung cancers. The intersegmental plane was dissected using electrocautery alone or in combination with staplers. We evaluated the methods of dividing intersegmental plane (electrocautery alone or combination with electrocautery and staplers), intraoperative blood loss, duration of chest tube placement, duration of surgery, preoperative FEV1.0 %, incidence of prolonged air leak, length of postoperative hospital stay, postoperative pulmonary function at 6 months after surgery and the cost for sealing intersegmental plane.

Results

Among the 47 patients, 22 patients underwent intersegmental plane dissection with electrocautery alone and 25 patients did in combination with electrocautery and staplers. The mean number of stapler cartridges used was only 1.3 in electrocautery and staplers group. Mean age, gender, number of patients whose FEV1% < 70 % were similar between two groups. There was no statistical difference between electrocautery alone and combination with electrocautery and staplers group in duration of surgery (282 vs. 290 minutes), intraoperative blood loss (203 vs.151 ml), duration of chest tube placement (3.2 vs. 3.1 days), postoperative hospital stay (11.0 vs.10.0 days), postoperative loss of FEV1.0 (13 vs.8 %), loss of FVC (11 vs. 6 %) or incidence of minor postoperative complications [9 % (2/22) vs. 16 % (4/25), p = 0.30)]. However, incidence of prolonged air leak was higher in electrocautery alone group than in combination with electrocautery and staplers group [14 % (3/22) vs. 4 % (1/25), p = 0.025)]. The cost of materials for sealing air leaks amounted to €964 per patient in the electrocautery alone group and €1594 per patient in combination with electrocautery and staplers group.

Conclusions

The number of patients with prolonged air leak was higher in the electrocautery alone group. The use of staplers in addition to electrocautery may lead to reduced prolonged air leak. However, the use of electrocautery for intersegmental plane dissection appeared to be safe with acceptable postoperative complications and effective in reducing costs.

Keywords

Pulmonary segmentectomy Lung tissue sealing Stapling devices

Background

Segmentectomy is now going to be recognized as an acceptable procedure for early stage lung cancer [1]. However, persistent air leaks and intraoperative bleeding in the dissecting plane are common dilemmas for thoracic surgeons performing segmentectomy. Surgical staplers are widely used to dissect intersegmental plane for segmentectomy [2, 3]. However, lung resection with staplers could result in lesser postoperative pulmonary function compared with resection without stapling devices, because of shrinkage of the preserved segment [4, 5].

In this study, we retrospectively evaluated the feasibility and safety of intersegmental plane dissection using electrocautery.

Patients and methods

This study protocol was approved by Keio University institutional review board (approval ID: 20-174). Written informed consent was obtained from each participant in accordance with the Declaration of Helsinki. Between April 2009 to September 2010, 47 patients were treated with segmentectomy with open thoracotomy for clinical T1N0M0 biopsy proven non-small cell lung cancers (NSCLC). All patients were operated by one of five surgeons specialized in thoracic surgery, and they were managed by the same team. Patients’ data was obtained included age, gender, smoking habits, site of resection and spirometry variables. The patients’ characteristics are summarized in Table 1. During segmentectomy, the intersegmental plane was identified with the procedure reported by Tsubota [6]. In summary, after the segmental bronchus was isolated, the whole lung was temporarily inflated. The segmental bronchus was first ligated to retain the air inside the segment and then divided at the point of proximal to the ligation. Single lung ventilation was initiated, producing the inflated – deflated line between the resecting segments and preserving ones. The intersegmental plane was then dissected along the inflated – deflated line using mainly electrocautery alone. Surgeons were allowed to use the staplers in dissecting thick lung parenchyma, but were enforced to use as little as possible. Electrocautery output was set for 60 watts. During the procedure, the surgeon retracted the segment to be removed with one hand, and used electrocautery with the other hand. The decision of using staplers in addition to electrocautery was made by the surgeon. After the dissection of intersegmental plane, the plane was covered with a fibrin sealant, composed of fibrinogen and thrombin and an absorbable polyglycolic acid felt (Neoveil; Japan Medical Planning Co, Kyoto, Japan). Afterward, all patients received single chest tube drainage (28Fr) and were connected to Chest Drainage Vac (Sumitomo Bakelite, Tokyo, Japan). Chest tubes were placed to water seal after surgery. To remove the tube, the volume of drained fluids was required to be less than 200 mL during the preceding 24-hour period and all the leaks resolved. We evaluated the methods of dividing intersegmental plane (electrocautery alone or combination with electrocautery and staplers), intraoperative blood loss, interval between surgery and chest tube removal, duration of surgery, preoperative FEV1.0 %, number of patients with prolonged air leak more than 7 days, length of postoperative hospital stay, pneumothorax after the chest tube removal and the cost of materials for sealing air leaks.
Table 1

Characteristics of patients

  

Electrocautery

Electrocautery and staplers

Number

 

22

25

Gender

Male

9

13

 

Female

13

12

Age

 

62 ± 10

66 ± 11

Smoking history

Yes

14

14

 

No

8

11

Statistical analysis

The unpaired Student’s t test was used to test relationships between discrete variables and continuous variables. The χ -square test was used to compare discrete variables.

Results

Among the 47 patients, 22 patients underwent intersegmental plane dissection with electrocautery alone and 25 patients underwent intersegmental plane dissection in combination with electrocautery and staplers. The two groups were absolutely similar when sex, age, and smoke exposure were compared. There were no intraoperative complications and no perioperative deaths. Table 2 shows the locations of burdened segments. The comparisons of the two groups are shown in Table 3. There was no difference in two groups in number of patients whose FEV1% < 70 %. Duration of surgery was 282 ± 71 min in electrocautery alone group, and 290 ± 64 min in combination with electrocautery and staplers group ( p = 0.695) . Number of staplers used was1.3 ± 0.7 (range1-4) in combination with electrocautery and staplers group. Duration of chest tube placement was 3.2 days in electrocautery alone group and 3.1 days in combination with electrocautery and staplers group (p = 0.957). There was no difference in two groups in occurrence of pneumothorax after chest tube removal, and hospital stay. However, the number of patients with prolonged air leak more than 7 days was higher in the electrocautery alone group than that in combination with electrocautery and staplers group (3 and 1, respectively, p = 0.025). Postoperative complications developed in 2 patients (9 %) in electrocautery alone group and 4 patients (16 %) in combination with electrocautery and staplers group (p = 0.31) (Table 4.). There was no perioperative death. The postoperative loss of FVC and FEV1.0 was 11 % and 13 % in electrocautery alone group and 6 % and 8 % in combination with electrocautery and staplers group (p = 0.48 and 0.30, respectively) (Table 5). The mean cost of materials for sealing air leaks including the cost of staplers amounted to €964 per patient in the electrocautery alone group and €1594 (range 1495 to 2421) per patient in the electrocautery and staplers group (p < 0.01).
Table 2

Location of burdened lung

  

Electrocautery

Electrocautery and staplers

Lobe

   
 

Right upper

3

11

 

Right lower

5

5

 

Left upper

8

7

 

Left lower

6

2

Resected segment(s)

   

Right

S1a + 2

2

 
 

S2 + 3a

1

 
 

S2b + 3a

 

1

 

S2

 

3

 

S1b + S3

 

1

 

S1

 

4

 

S1 + 2

 

1

 

S3

 

1

 

S8

 

3

 

S6

4

2

 

S8 + 9

1

 

Left

S1 + 2

5

1

 

S1 + 2 + 3

2

4

 

S4 + 5

1

2

 

S6

2

1

 

S8

1

 
 

S8 + 9

1

 
 

S9 + 10

2

1

a, posterior subsegment; b, anterior subsegment; S1, apical; S2, posterior; S3, anterior; S4, superior; S5, inferior; S6, superior; S8, anterior basal; S9, lateral basal; S10, posteiror basal.

Table 3

Comparison of patients

 

Electrocautery

Electrocautery and stapler

p value

Number of patients whose FEV1% < 70 %

8

10

0.495

Duration of surgery (min)

282 ± 71

290 ± 64

0.695

Duration of chest tube drainage (days)

3.2 ± 3.0

3.1 ± 4.0

0.957

Duration of hospital stay after surgery (days)

11.0 ± 4.6

10.0 ± 4.7

0.450

Number of patients with prolonged air leak more than 7 days

3

1

0.025

Number of patients with pneumothorax after chest tube removal

1

3

0.240

Intraoperative bleeding (ml)

203 ± 214

151 ± 116

0.305

Table 4

Postoperative complications

 

Electrocautery (n = 22)

Electrocautery and staplers ( n = 25)

Atelectasis

0

2

Pneumonia

1

1

Arrhythmia

1

1

Total

2

4

Table 5

Postoperative pulmonary function change

 

Electrocautery

Electrocautery and stapler

p value

Postoperative FVC / Preoperative FVC

0.89 ± 0.20

0.94 ± 0.21

0.48

Postoperative FEV1.0 / Preoperative FEV1.0

0.87 ± 0.14

0.92 ± 0.18

0.30

FVC, forced vital capacity; FEV1.0, forced expiratory volume in 1 second.

Discussion

In recent years and there is growing evidence to suggest that segmentectomy can yield results equivalent to lobectomy in patients with early stage peripheral lung cancers [1, 7]. Moreover, several studies showed segmentectomy offers significantly better functional preservation compared with lobectomy [8, 9]. Indications of segmentectomy as a treatment option for early stage lung cancer are spreading. Staplers are widely used for intersegmental dissection because of reliable hemostasis and easiness in use. However, intersegmental plane dissection with staplers could cause shrinkage of the preserved segment. Asakura et al. showed staplers interfere the expansion of preserved lung in comparison to scissors in swine lung segmentectomy model [5]. Additionally, staplers divide the intersegmental plane without recognizing the intersegmental veins, which are important for the drainage of the preserved segment. Sacrificing the pulmonary vein could cause an impairment of gas exchange leading to decrease in pulmonary function. Although intersegmental dissection with electrocautery has been thought to increase the incidence of postoperative air leaks and intraoperative bleeding, our results demonstrated 14 % of prolonged air leaks and 203 ml of intraoperative bleeding in the electrocautery alone group, which were similar to the incidence reported by others performed segmentectomy using staplers [2, 3]. In addition, the combination use of staplers with electrocautery showed acceptable morbidity and minimum postoperative loss of respiratory function.

Drogehetti et al. showed that the use of electrocautery and collagen patches reduced the incidence of air leaks, duration of air leaks, and procedure costs compared with the use of staplers in dissecting interlober fissures [10]. However, there have been few reports evaluating intersegmental plane dissection with electrocautery. Our report here is the first article evaluating the usefulness of intersegmental plane dissection with electrocautery.

Our study has several limitations including its retrospective nature and small number of patients. In addition, the use of fibrin sealant and absorbable polyglycolic acid felt can make the comparison of the dissecting method unclear. However, we believe the results of this retrospective analysis of intersegmental dissection using electrocautery confirm that this technique can be performed with acceptable morbidity.

Declarations

Authors’ Affiliations

(1)
Department of Surgery, Section of General Thoracic Surgery, School of Medicine, Keio University

References

  1. Okada M, Koike T, Higashiyama M, Yamato Y, Kodama K, Tsubota N: Radical sublobar resection for small-sized non-small cell lung cancer: a multicenter study. J Thorac Cardiovasc Surg. 2006, 132: 769-775. 10.1016/j.jtcvs.2006.02.063.View ArticlePubMedGoogle Scholar
  2. Atkins BZ, Harpole DH, Mangum JH, Toloza EM, D’Amico TA, Burfeind WR: Pulmonary segmentectomy by thoracotomy or thoracoscopy: reduced hospital length of stay with a minimally-invasive approach. Ann Thorac Surg. 2007, 84: 1107-1112. 10.1016/j.athoracsur.2007.05.013. discussion 1112–1103View ArticlePubMedGoogle Scholar
  3. Leshnower BG, Miller DL, Fernandez FG, Pickens A, Force SD: Video-assisted thoracoscopic surgery segmentectomy: a safe and effective procedure. Ann Thorac Surg. 2010, 89: 1571-1576. 10.1016/j.athoracsur.2010.01.061.View ArticlePubMedGoogle Scholar
  4. Yoshimoto K, Nomori H, Mori T, Ohba Y, Shiraishi K, Ikeda K: Combined subsegmentectomy: postoperative pulmonary function compared to multiple segmental resection. J Cardiothorac Surg. 2011, 6: 17-10.1186/1749-8090-6-17.View ArticlePubMedPubMed CentralGoogle Scholar
  5. Asakura K, Izumi Y, Kohno M, Ohtsuka T, Okui M, Hashimoto K, Nakayama T, Nomori H: Effect of cutting technique at the intersegmental plane during segmentectomy on expansion of the preserved segment: comparison between staplers and scissors in ex vivo pig lung. Eur J Cardiothorac Surg. 2011, 40: 34-38. 10.1016/j.ejcts.2011.02.021.View ArticleGoogle Scholar
  6. Tsubota N: An improved method for distinguishing the intersegmental plane of the lung. Surg Today. 2000, 30: 963-964. 10.1007/s005950070056.View ArticlePubMedGoogle Scholar
  7. Nakamura H, Kawasaki N, Taguchi M, Kabasawa K: Survival following lobectomy vs limited resection for stage I lung cancer: a meta-analysis. Br J Cancer. 2005, 92: 1033-1037. 10.1038/sj.bjc.6602414.View ArticlePubMedPubMed CentralGoogle Scholar
  8. Yoshimoto K, Nomori H, Mori T, Kobayashi H, Ohba Y, Shibata H, Tashiro K, Shiraishi S, Kobayashi T: Quantification of the impact of segmentectomy on pulmonary function by perfusion single-photon-emission computed tomography and multidetector computed tomography. J Thorac Cardiovasc Surg. 2009, 137: 1200-1205. 10.1016/j.jtcvs.2008.10.028.View ArticlePubMedGoogle Scholar
  9. Harada H, Okada M, Sakamoto T, Matsuoka H, Tsubota N: Functional advantage after radical segmentectomy versus lobectomy for lung cancer. Ann Thorac Surg. 2005, 80: 2041-2045. 10.1016/j.athoracsur.2005.06.010.View ArticlePubMedGoogle Scholar
  10. Droghetti A, Schiavini A, Muriana P, Folloni A, Picarone M, Bonadiman C, Sturani C, Paladini R, Muriana G: A prospective randomized trial comparing completion technique of fissures for lobectomy: stapler versus precision dissection and sealant. J Thorac Cardiovasc Surg. 2008, 136: 383-391. 10.1016/j.jtcvs.2008.04.014.View ArticlePubMedGoogle Scholar

Copyright

© Ohtsuka et al.; licensee BioMed Central Ltd. 2012

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Advertisement