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Asian J Endosc Surg ISSN 1758-5902
S H O RT R E P O RT
Simultaneous laparoscopic colorectal resection and pulmonary resection by minithoracotomy: Report of four cases Tetsuo Tsukahara,1 Seiichiro Yamamoto,1 Taihei Oshiro,1 Shin Fujita,1 Hiroyuki Sakurai2 & Shun-ichi Watanabe2 1 Division of Colorectal Surgery, National Cancer Center Hospital, Tokyo, Japan 2 Division of Thoracic Surgery, National Cancer Center Hospital, Tokyo, Japan
Keywords Laparoscopic colorectal resection; pulmonary resection; simultaneous resection Correspondence Seiichiro Yamamoto, Division of Colorectal Surgery, National Cancer Center Hospital, 5-1-1, Tsukiji, Chuo-ku, Tokyo 104-0045, Japan. Tel: +81 3 3542 2511 Fax: +81 3 3542 3815 Email: [email protected]
Abstract The aim of the present study was to determine the feasibility of simultaneous resection of colorectal cancer by laparoscopy and a pulmonary lesion through minithoracotomy. Four patients underwent laparoscopic resection of colorectal cancer followed by pulmonary resection. The mean operative duration was 390 min and the mean blood loss was 133 mL. The postoperative course was uneventful. The indication for simultaneous resection of colorectal cancer by the laparoscopic approach and a pulmonary lesion is controversial. This method is safe and feasible in selected patients, but whether colorectal resection or pulmonary surgery is performed first should be determined on a case-by-case basis.
Received: 23 August 2013; revised 19 November 2013; accepted 27 November 2013 DOI:10.1111/ases.12082
Introduction The technical and oncological safety of laparoscopic surgery for colorectal cancer has been examined in several randomized control trials, and the indication for laparoscopic surgery has been expanded (1–5). Recently, the number of cancers detected simultaneously with colorectal cancer has increased. This has occurred in part due to the development of new diagnostic techniques, the increased rate of health examinations, and the aging of society. There have been many reports of patients with multiple diseases being treated with simultaneous laparoscopic surgery for colorectal cancer and another malignant abdominal tumor (6–11). For example, colon cancer and hepatic metastasis were removed simultaneously by laparoscopy (7–9). However, to the best of our knowledge, there has been no report of laparoscopic colorectal resection performed simultaneously with a minithoracotomy for resection of a pulmonary tumor detected with colorectal cancer. To determine the feasibility of simultaneous resection of colorectal cancer by laparoscopy and a
160
pulmonary lesion, we report our experience of four cases with a literature review.
Case Presentation From June 2001 to April 2012, 1210 patients with colorectal cancer, excluding familial adenomatous polyposis, underwent laparoscopic surgery at our institution (National Cancer Center Hospital, Tokyo, Japan). These patients included four patients who received simultaneous laparoscopic colorectal resection and pulmonary resection. Radical resection of colorectal cancer was considered necessary regardless of the pulmonary lesion in these four patients. Radical resection of a primary or metastatic pulmonary lesion was also indicated. The general condition of the patients was judged to be able to tolerate simultaneous resections. The anesthesiologist agreed to do these two resections simultaneously. The patients agreed to have both procedures performed.
Asian J Endosc Surg 7 (2014) 160–164 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Stage IIA
Inflammatory granulation tissue (1.7 cm) Stage IV pT3N0M0 None 8 1 Not inserted 3 1 142 (82/60)
LUL, left upper lobe; POD, postoperative day; RLL, right lower lobe; RUL, right upper lobe.
400 (250/117) Wedge resection Transverse colectomy Primary LUL 72 4
Transverse colon
53 3
Rectosigmoid
RUL
Primary
High anterior resection
Lobectomy
432 (246/158)
200 (26/174)
1
3
5
2
8
None
pT3N1M1
pT1aN0M0 Stage IA Metastasis (1.4 cm)
74 2
Stage IIIB
Stage IV pT3N1M0 Atelectasis 8 2 Not inserted 3 1 93 (75/18) 400 (215/170) Segmentectomy Right hemicolectomy Primary LUL
59 1
Ascending colon
Metastasis (2.1 cm) pT4N0M1 Atelectasis 7 1
Chest Abdominal
Not inserted 3 1 98 (87/11) 327 (242/49) Wedge resection Right hemicolectomy Metastatic
Operative procedure for pulmonary lesion Laparoscopic procedure for colorectal cancer Location of the pulmonary lesion Location of the colorectal tumor
RLL
Oral intake (POD)
Liquid meal intake (POD)
Removal of drainage tube (POD)
Total blood loss (colorectal/ pulmonary) (mL) Total operative duration (colorectal/ pulmonary) (min) Preoperative diagnosis of the pulmonary lesion
Asian J Endosc Surg 7 (2014) 160–164 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Case
Traditionally, abdominal surgery performed simultaneously with thoracotomy has been thought to have an
Age (years)
Discussion
Table 1 Clinical characteristics and outcomes
Patient demographics and outcomes are summarized in Table 1. There were four male patients with a mean age of 65 years and a mean BMI of 27.8, and all the patients were classified as ASA II. Preoperative cardiac function was within the normal range, although one patient had a mild obstructive lung disturbance. All patients underwent laparoscopic colorectal resection followed by pulmonary resection, and all colorectal resections were completed laparoscopically. The second patient underwent segmentectomy for pulmonary cancer because of clinical stage IA lung adenocarcinoma and advanced colorectal cancer (stage IIIB). The third patient underwent upper lobectomy for metastasis of the colorectal cancer because the tumor was located near the pulmonary hilum. The mean operative time was 390 min (range, 327– 432 min) and the mean estimated blood loss during surgery was 133 mL (range, 93–200 mL); no patient required an intraoperative transfusion. Postoperatively, liquid and solid foods were started on postoperative days 1 and 3, respectively, and all patients were discharged within 8 days postoperatively. Two patients had postoperative complications; they both had mild atelectasis, which was treated conservatively. The final pathological diagnosis of the pulmonary lesion was metastatic colorectal cancer in two patients, primary lung cancer in one, and inflammatory granulation tissue in one. The mean follow-up period was 44 months (range, 23–61 months). Two of the four patients, the patients with primary lung cancer and inflammatory granulation tissue, are alive and well without evidence of tumor recurrence at 61 and 23 months after the operation, respectively. In contrast, the two patients with pulmonary metastasis developed recurrence. One patient died because of liver and lung metastases 61 months after surgery, and the other remains alive 30 months after surgery, though he has lung and brain metastases.
Discharge (POD)
Results
Ascending colon
Postoperative complications
TNM stage of the colorectal cancer
Pathological diagnosis (size) or TNM stage of pulmonary lesion
The surgical procedures were performed with the patients under general anesthesia with an epidural block. After intubation with a double lumen airway tube, laparoscopic colorectal resection was performed with the patient in the supine or lithotomy position. After removal of the colorectal cancer, the patient was placed in a lateral position, and video-assisted pulmonary resection with an 8–10-cm minithoracotomy was performed.
Primary (1.6 cm)
Simultaneous colon and lung resection
T Tsukahara et al.
161
Simultaneous colon and lung resection
T Tsukahara et al.
increased risk of adverse events because of excessive physical stress on the patient. Therefore, simultaneous surgeries have rarely been performed except for radical surgery for esophageal cancer. Recently, the demonstrated technical and oncological safety of laparoscopic surgery for colorectal cancer has allowed this procedure to be applied to more advanced surgeries (1–5). Additionally, the feasibility of simultaneous laparoscopic resection of a synchronous abdominal tumor or hepatic metastasis with surgery for colorectal cancer has been reported (6–11). However, simultaneous resection of a pulmonary tumor with surgical treatment for colorectal cancer is particularly rare (12), and simultaneous resection of colorectal cancer by a laparoscopic approach and a pulmonary lesion has not been reported previously. In the present study, we describe the favorable outcomes of four patients in which minithoracotomy for pulmonary resection was performed after laparoscopic surgery for colorectal cancer. The simultaneous approach may have helped decrease physical stress on the patients. Compared to open abdominal surgery, laparoscopic surgery is less invasive, has better cosmesis, and enables faster recovery and discharge from hospital; laparoscopic surgery also offers improved postoperative quality of life (13–15). In open abdominal surgery with a medial incision, respiratory function decreases to approximately 50% immediately after surgery, and a week or longer is required to recover full respiratory function. In contrast, forced vital capacity, forced expiratory volume in 1 second, and arterial oxygen saturation are significantly higher after laparoscopic colorectal resection, reducing the onset of pulmonary complications (16). Therefore, it may be feasible and reasonable to perform laparoscopic surgery simultaneously with mini-thoracotomy to reduce patient physical strain. Otherwise, patients must undergo abdominal surgery and thoracotomy separately. In the present study, two of the four patients developed mild atelectasis, which was diagnosed based on postoperative chest X-ray. The patients required no further treatments and their postoperative courses were uneventful. Wilcox et al. described the atelectasis score on the basis of daily chest radiographs: a score of 0 = no atelectasis, 1 = subsegmental atelectasis, 2 = mild lobar atelectasis, 3 = moderate lobar atelectasis, and 4 = complete lobar atelectasis (17). In a study of protective lung ventilation for elective pulmonary resection, Maslow et al. indicated that atelectasis scores on postoperative days 1 and 2 were significantly lower in the high tidal volume (10 mL/kg) group than in the low tidal volume (5 mL/kg) group (0.81 vs 1.25 on postoperative day 1, P = 0.05; 0.87 vs 1.37 on postoperative day 2, P = 0.04) (18). The atelectasis score in the present series on postoperative day 1 was 0.5 because two patients had
162
subsegmental atelectasis, but it was still lower than the scores in the study by Maslow et al. It is necessary to pay attention to postoperative atelectasis because simultaneous abdominal surgery may affect postoperative atelectasis. The indication for simultaneous surgery should be carefully determined and requires further discussion. It is not easy to determine before surgery whether a pulmonary lesion detected simultaneously with colorectal cancer is a primary lesion or metastasis or if it is benign or malignant, even with sophisticated imaging techniques (19). It has been suggested that when qualitative differential diagnosis is difficult by bronchoscopy, biopsy, and cytotechnology, the priority should be placed on resection of colorectal cancer; the surgical indication for the pulmonary lesion should be determined by a CT scan performed several months after the colorectal surgery (20,21). However, in our institution, when malignant pulmonary disease is strongly suspected based on imaging findings, we do not make a histological diagnosis before surgery. Instead, an excisional biopsy is performed immediately after the thoracotomy to determine the surgical procedure based on the pathological diagnosis of a frozen section of the principal tumor. The characteristics of the principal tumor (primary, metastasis, or inflammatory) then determine whether additional lymph node dissection is indicated (22). Also, tumor size and site are used to determine whether wedge resection, segmentectomy, or lobectomy is indicated. Because the technical and oncological safety of the thoracoscopic approach for lung cancer patients in all stages has not been established, minimal thoracotomy is indicated for almost all patients in our institution (23). The benefits of simultaneous surgeries for colorectal cancer and pulmonary lesion include a shortened hospital stay and decreased psychological burden. All patients were treated with early mobilization, early oral intake according to the clinical pathway for colorectal cancer, and respiratory physiotherapy according to that for pulmonary surgery. In our institution, nearly 97% of patients after laparoscopic colorectal resection can be discharged within 8 days postoperatively, and fortunately, no problematic adverse events have occurred in our patients who underwent simultaneous resections. In addition, primary lung cancer may be treated earlier. Despite the benefits, simultaneous surgeries do involve an increased surgical risk compared to each surgery alone, even if the two surgeries are of low invasiveness. In contrast, the benefits of two-stage surgery include low surgical risks in individual operations. Also, during the waiting period between the two surgeries, extremely small metastases that were not detected on initial imaging may become large enough, enabling re-evaluation of the
Asian J Endosc Surg 7 (2014) 160–164 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Simultaneous colon and lung resection
T Tsukahara et al.
therapeutic strategy. At the same, this may have a negative impact, as this possibly delays the commencement of treatment for primary lung cancer and secondary metastasis of lung cancer. Similarly, when adverse events occur in the first surgery, the second surgery may be delayed or the planned therapeutic strategy may need to be changed. It is important to recognize that the effects of treating one disease may influence the treatment of another. This can make decisions about which treatment should be started first controversial. Usually, the priority should be the treatment of the more malignant and advanced disease. For the treatment of synchronous colon cancer and pulmonary tumor, pulmonary resection followed by laparoscopic colon resection could present some problems because the anesthesiologist may encounter ventilation problems, as CO2 used for insufflation of the abdominal cavity affects the residual lung. Therefore, if pulmonary surgery needs to be performed first, a twostage operation is preferable; otherwise, a simultaneous operation with colorectal resection followed by pulmonary resection may be a choice for consideration. Whether colorectal resection or pulmonary surgery is performed first should be determined on a case-by-case basis. In conclusion, the clinical course was favorable in four patients who underwent simultaneous pulmonary resection and laparoscopic colorectal resection. As this is the first report of simultaneous colorectal and pulmonary resection, the safety of this procedure requires confirmation through the accumulation of more patients prospectively, and further discussion of the surgical indication and procedures. However, such simultaneous surgeries appear to be a treatment choice in selected patients.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Acknowledgment The authors have no conflicts of interest or financial ties to disclose.
References 1. Abraham NS, Young JM, Solomon MJ. Meta-analysis of short-term outcomes after laparoscopic resection for colorectal cancer. Br J Surg 2004; 91: 1111–1124. 2. Kuhry E, Schwenk W, Gaupset R et al. Long-term outcome of laparoscopic surgery for colorectal cancer: A cochrane systematic review of randomised controlled trials. Cancer Treat Rev 2008; 34: 498–504. 3. Ma Y, Yang Z, Qin H et al. A meta-analysis of laparoscopy compared with open colorectal resection for colorectal cancer. Med Oncol 2011; 28: 925–933. 4. Ohtani H, Tamamori Y, Arimoto Y et al. A meta-analysis of the short- and long-term results of randomized controlled
14.
15.
16.
17.
18.
trials that compared laparoscopy-assisted and conventional open surgery for colorectal cancer. J Cancer 2011; 2: 425– 434. Ohtani H, Tamamori Y, Azuma T et al. A meta-analysis of the short- and long-term results of randomized controlled trials that compared laparoscopy-assisted and conventional open surgery for rectal cancer. J Gastrointest Surg 2011; 15: 1375– 1385. Nishiyama N, Yamamoto S, Matsuoka N et al. Simultaneous laparoscopic descending colectomy and nephroureterectomy for descending colon carcinoma and left ureteral carcinoma: Report of a case. Surg Today 2009; 39: 728–732. Akiyoshi T, Kuroyanagi H, Saiura A et al. Simultaneous resection of colorectal cancer and synchronous liver metastases: Initial experience of laparoscopy for colorectal cancer resection. Dig Surg 2009; 26: 471–475. Lee JS, Hong HT, Kim JH et al. Simultaneous laparoscopic resection of primary colorectal cancer and metastatic liver tumor: Initial experience of single institute. J Laparoendosc Adv Surg Tech A 2010; 20: 683–687. Tranchart H, Diop PS, Lainas P et al. Laparoscopic major hepatectomy can be safely performed with colorectal surgery for synchronous colorectal liver metastasis. HPB (Oxford) 2011; 13: 46–50. Matsui H, Okamoto Y, Ishii A et al. Laparoscopy-assisted combined resection for synchronous gastric and colorectal cancer: Report of three cases. Surg Today 2009; 39: 434– 439. Tokunaga M, Hiki N, Fukunaga T et al. Laparoscopic surgery for synchronous gastric and colorectal cancer: A preliminary experience. Langenbecks Arch Surg 2010; 395: 207–210. Peng YF & Gu J. Synchronous colorectal and lung cancer: Report of three cases. World J Gastroenterol 2008; 14: 969– 973. Braga M, Vignali A, Gianotti L et al. Laparoscopic versus open colorectal surgery: A randomized trial on short-term outcome. Ann Surg 2002; 236: 759–766. Weeks JC, Nelson H, Gelber S et al. Short-term quality-oflife outcomes following laparoscopic-assisted colectomy vs open colectomy for colon cancer: A randomized trial. JAMA 2002; 287: 321–328. Raymond TM, Kumar S, Dastur JK et al. Case controlled study of the hospital stay and return to full activity following laparoscopic and open colorectal surgery before and after the introduction of an enhanced recovery programme. Colorectal Dis 2010; 12: 1001–1006. Schwenk W, Bohm B, Witt C et al. Pulmonary function following laparoscopic or conventional colorectal resection: A randomized controlled evaluation. Arch Surg 1999; 134: 6–12. Wilcox P, Baile EM, Hards J et al. Phrenic nerve function and its relationship to atelectasis after coronary artery bypass surgery. Chest 1988; 93: 693–698. Maslow AD, Stafford TS, Davignon KR et al. A randomized comparison of different ventilator strategies during
Asian J Endosc Surg 7 (2014) 160–164 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
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Simultaneous colon and lung resection
T Tsukahara et al.
thoracotomy for pulmonary resection. J Thorac Cardiovasc Surg 2013; 146: 38–44. 19. Nishiyama N, Iwata T, Nagano K et al. Lung metastases from various malignancies combined with primary lung cancer. Gen Thorac Cardiovasc Surg 2010; 58: 538–541. 20. Brent A, Talbot R, Coyne J et al. Should indeterminate lung lesions reported on staging CT scans influence the management of patients with colorectal cancer. Colorectal Dis 2007; 9: 816–818.
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21. Shin JW, Lee SI, Moon HY. Significance of Follow-up in Detection of Pulmonary Metastasis of Colorectal Cancer. J Korean Soc Coloproctol 2010; 26: 293–297. 22. Morcos SK & Anderson PB. Percutaneous needle-aspiration lung biopsy: Is it really necessary in all patients with a focal lung opacity. Radiology 1999; 211: 590–592. 23. Asamura H. Minimally invasive open surgery approach for the surgical resection of thoracic malignancies. Thorac Surg Clin 2008; 18: 269–273.
Asian J Endosc Surg 7 (2014) 160–164 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Asian J Endosc Surg ISSN 1758-5902
S H O RT R E P O RT
Simultaneous laparoscopic colorectal resection and pulmonary resection by minithoracotomy: Report of four cases Tetsuo Tsukahara,1 Seiichiro Yamamoto,1 Taihei Oshiro,1 Shin Fujita,1 Hiroyuki Sakurai2 & Shun-ichi Watanabe2 1 Division of Colorectal Surgery, National Cancer Center Hospital, Tokyo, Japan 2 Division of Thoracic Surgery, National Cancer Center Hospital, Tokyo, Japan
Keywords Laparoscopic colorectal resection; pulmonary resection; simultaneous resection Correspondence Seiichiro Yamamoto, Division of Colorectal Surgery, National Cancer Center Hospital, 5-1-1, Tsukiji, Chuo-ku, Tokyo 104-0045, Japan. Tel: +81 3 3542 2511 Fax: +81 3 3542 3815 Email: [email protected]
Abstract The aim of the present study was to determine the feasibility of simultaneous resection of colorectal cancer by laparoscopy and a pulmonary lesion through minithoracotomy. Four patients underwent laparoscopic resection of colorectal cancer followed by pulmonary resection. The mean operative duration was 390 min and the mean blood loss was 133 mL. The postoperative course was uneventful. The indication for simultaneous resection of colorectal cancer by the laparoscopic approach and a pulmonary lesion is controversial. This method is safe and feasible in selected patients, but whether colorectal resection or pulmonary surgery is performed first should be determined on a case-by-case basis.
Received: 23 August 2013; revised 19 November 2013; accepted 27 November 2013 DOI:10.1111/ases.12082
Introduction The technical and oncological safety of laparoscopic surgery for colorectal cancer has been examined in several randomized control trials, and the indication for laparoscopic surgery has been expanded (1–5). Recently, the number of cancers detected simultaneously with colorectal cancer has increased. This has occurred in part due to the development of new diagnostic techniques, the increased rate of health examinations, and the aging of society. There have been many reports of patients with multiple diseases being treated with simultaneous laparoscopic surgery for colorectal cancer and another malignant abdominal tumor (6–11). For example, colon cancer and hepatic metastasis were removed simultaneously by laparoscopy (7–9). However, to the best of our knowledge, there has been no report of laparoscopic colorectal resection performed simultaneously with a minithoracotomy for resection of a pulmonary tumor detected with colorectal cancer. To determine the feasibility of simultaneous resection of colorectal cancer by laparoscopy and a
160
pulmonary lesion, we report our experience of four cases with a literature review.
Case Presentation From June 2001 to April 2012, 1210 patients with colorectal cancer, excluding familial adenomatous polyposis, underwent laparoscopic surgery at our institution (National Cancer Center Hospital, Tokyo, Japan). These patients included four patients who received simultaneous laparoscopic colorectal resection and pulmonary resection. Radical resection of colorectal cancer was considered necessary regardless of the pulmonary lesion in these four patients. Radical resection of a primary or metastatic pulmonary lesion was also indicated. The general condition of the patients was judged to be able to tolerate simultaneous resections. The anesthesiologist agreed to do these two resections simultaneously. The patients agreed to have both procedures performed.
Asian J Endosc Surg 7 (2014) 160–164 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Stage IIA
Inflammatory granulation tissue (1.7 cm) Stage IV pT3N0M0 None 8 1 Not inserted 3 1 142 (82/60)
LUL, left upper lobe; POD, postoperative day; RLL, right lower lobe; RUL, right upper lobe.
400 (250/117) Wedge resection Transverse colectomy Primary LUL 72 4
Transverse colon
53 3
Rectosigmoid
RUL
Primary
High anterior resection
Lobectomy
432 (246/158)
200 (26/174)
1
3
5
2
8
None
pT3N1M1
pT1aN0M0 Stage IA Metastasis (1.4 cm)
74 2
Stage IIIB
Stage IV pT3N1M0 Atelectasis 8 2 Not inserted 3 1 93 (75/18) 400 (215/170) Segmentectomy Right hemicolectomy Primary LUL
59 1
Ascending colon
Metastasis (2.1 cm) pT4N0M1 Atelectasis 7 1
Chest Abdominal
Not inserted 3 1 98 (87/11) 327 (242/49) Wedge resection Right hemicolectomy Metastatic
Operative procedure for pulmonary lesion Laparoscopic procedure for colorectal cancer Location of the pulmonary lesion Location of the colorectal tumor
RLL
Oral intake (POD)
Liquid meal intake (POD)
Removal of drainage tube (POD)
Total blood loss (colorectal/ pulmonary) (mL) Total operative duration (colorectal/ pulmonary) (min) Preoperative diagnosis of the pulmonary lesion
Asian J Endosc Surg 7 (2014) 160–164 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Case
Traditionally, abdominal surgery performed simultaneously with thoracotomy has been thought to have an
Age (years)
Discussion
Table 1 Clinical characteristics and outcomes
Patient demographics and outcomes are summarized in Table 1. There were four male patients with a mean age of 65 years and a mean BMI of 27.8, and all the patients were classified as ASA II. Preoperative cardiac function was within the normal range, although one patient had a mild obstructive lung disturbance. All patients underwent laparoscopic colorectal resection followed by pulmonary resection, and all colorectal resections were completed laparoscopically. The second patient underwent segmentectomy for pulmonary cancer because of clinical stage IA lung adenocarcinoma and advanced colorectal cancer (stage IIIB). The third patient underwent upper lobectomy for metastasis of the colorectal cancer because the tumor was located near the pulmonary hilum. The mean operative time was 390 min (range, 327– 432 min) and the mean estimated blood loss during surgery was 133 mL (range, 93–200 mL); no patient required an intraoperative transfusion. Postoperatively, liquid and solid foods were started on postoperative days 1 and 3, respectively, and all patients were discharged within 8 days postoperatively. Two patients had postoperative complications; they both had mild atelectasis, which was treated conservatively. The final pathological diagnosis of the pulmonary lesion was metastatic colorectal cancer in two patients, primary lung cancer in one, and inflammatory granulation tissue in one. The mean follow-up period was 44 months (range, 23–61 months). Two of the four patients, the patients with primary lung cancer and inflammatory granulation tissue, are alive and well without evidence of tumor recurrence at 61 and 23 months after the operation, respectively. In contrast, the two patients with pulmonary metastasis developed recurrence. One patient died because of liver and lung metastases 61 months after surgery, and the other remains alive 30 months after surgery, though he has lung and brain metastases.
Discharge (POD)
Results
Ascending colon
Postoperative complications
TNM stage of the colorectal cancer
Pathological diagnosis (size) or TNM stage of pulmonary lesion
The surgical procedures were performed with the patients under general anesthesia with an epidural block. After intubation with a double lumen airway tube, laparoscopic colorectal resection was performed with the patient in the supine or lithotomy position. After removal of the colorectal cancer, the patient was placed in a lateral position, and video-assisted pulmonary resection with an 8–10-cm minithoracotomy was performed.
Primary (1.6 cm)
Simultaneous colon and lung resection
T Tsukahara et al.
161
Simultaneous colon and lung resection
T Tsukahara et al.
increased risk of adverse events because of excessive physical stress on the patient. Therefore, simultaneous surgeries have rarely been performed except for radical surgery for esophageal cancer. Recently, the demonstrated technical and oncological safety of laparoscopic surgery for colorectal cancer has allowed this procedure to be applied to more advanced surgeries (1–5). Additionally, the feasibility of simultaneous laparoscopic resection of a synchronous abdominal tumor or hepatic metastasis with surgery for colorectal cancer has been reported (6–11). However, simultaneous resection of a pulmonary tumor with surgical treatment for colorectal cancer is particularly rare (12), and simultaneous resection of colorectal cancer by a laparoscopic approach and a pulmonary lesion has not been reported previously. In the present study, we describe the favorable outcomes of four patients in which minithoracotomy for pulmonary resection was performed after laparoscopic surgery for colorectal cancer. The simultaneous approach may have helped decrease physical stress on the patients. Compared to open abdominal surgery, laparoscopic surgery is less invasive, has better cosmesis, and enables faster recovery and discharge from hospital; laparoscopic surgery also offers improved postoperative quality of life (13–15). In open abdominal surgery with a medial incision, respiratory function decreases to approximately 50% immediately after surgery, and a week or longer is required to recover full respiratory function. In contrast, forced vital capacity, forced expiratory volume in 1 second, and arterial oxygen saturation are significantly higher after laparoscopic colorectal resection, reducing the onset of pulmonary complications (16). Therefore, it may be feasible and reasonable to perform laparoscopic surgery simultaneously with mini-thoracotomy to reduce patient physical strain. Otherwise, patients must undergo abdominal surgery and thoracotomy separately. In the present study, two of the four patients developed mild atelectasis, which was diagnosed based on postoperative chest X-ray. The patients required no further treatments and their postoperative courses were uneventful. Wilcox et al. described the atelectasis score on the basis of daily chest radiographs: a score of 0 = no atelectasis, 1 = subsegmental atelectasis, 2 = mild lobar atelectasis, 3 = moderate lobar atelectasis, and 4 = complete lobar atelectasis (17). In a study of protective lung ventilation for elective pulmonary resection, Maslow et al. indicated that atelectasis scores on postoperative days 1 and 2 were significantly lower in the high tidal volume (10 mL/kg) group than in the low tidal volume (5 mL/kg) group (0.81 vs 1.25 on postoperative day 1, P = 0.05; 0.87 vs 1.37 on postoperative day 2, P = 0.04) (18). The atelectasis score in the present series on postoperative day 1 was 0.5 because two patients had
162
subsegmental atelectasis, but it was still lower than the scores in the study by Maslow et al. It is necessary to pay attention to postoperative atelectasis because simultaneous abdominal surgery may affect postoperative atelectasis. The indication for simultaneous surgery should be carefully determined and requires further discussion. It is not easy to determine before surgery whether a pulmonary lesion detected simultaneously with colorectal cancer is a primary lesion or metastasis or if it is benign or malignant, even with sophisticated imaging techniques (19). It has been suggested that when qualitative differential diagnosis is difficult by bronchoscopy, biopsy, and cytotechnology, the priority should be placed on resection of colorectal cancer; the surgical indication for the pulmonary lesion should be determined by a CT scan performed several months after the colorectal surgery (20,21). However, in our institution, when malignant pulmonary disease is strongly suspected based on imaging findings, we do not make a histological diagnosis before surgery. Instead, an excisional biopsy is performed immediately after the thoracotomy to determine the surgical procedure based on the pathological diagnosis of a frozen section of the principal tumor. The characteristics of the principal tumor (primary, metastasis, or inflammatory) then determine whether additional lymph node dissection is indicated (22). Also, tumor size and site are used to determine whether wedge resection, segmentectomy, or lobectomy is indicated. Because the technical and oncological safety of the thoracoscopic approach for lung cancer patients in all stages has not been established, minimal thoracotomy is indicated for almost all patients in our institution (23). The benefits of simultaneous surgeries for colorectal cancer and pulmonary lesion include a shortened hospital stay and decreased psychological burden. All patients were treated with early mobilization, early oral intake according to the clinical pathway for colorectal cancer, and respiratory physiotherapy according to that for pulmonary surgery. In our institution, nearly 97% of patients after laparoscopic colorectal resection can be discharged within 8 days postoperatively, and fortunately, no problematic adverse events have occurred in our patients who underwent simultaneous resections. In addition, primary lung cancer may be treated earlier. Despite the benefits, simultaneous surgeries do involve an increased surgical risk compared to each surgery alone, even if the two surgeries are of low invasiveness. In contrast, the benefits of two-stage surgery include low surgical risks in individual operations. Also, during the waiting period between the two surgeries, extremely small metastases that were not detected on initial imaging may become large enough, enabling re-evaluation of the
Asian J Endosc Surg 7 (2014) 160–164 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Simultaneous colon and lung resection
T Tsukahara et al.
therapeutic strategy. At the same, this may have a negative impact, as this possibly delays the commencement of treatment for primary lung cancer and secondary metastasis of lung cancer. Similarly, when adverse events occur in the first surgery, the second surgery may be delayed or the planned therapeutic strategy may need to be changed. It is important to recognize that the effects of treating one disease may influence the treatment of another. This can make decisions about which treatment should be started first controversial. Usually, the priority should be the treatment of the more malignant and advanced disease. For the treatment of synchronous colon cancer and pulmonary tumor, pulmonary resection followed by laparoscopic colon resection could present some problems because the anesthesiologist may encounter ventilation problems, as CO2 used for insufflation of the abdominal cavity affects the residual lung. Therefore, if pulmonary surgery needs to be performed first, a twostage operation is preferable; otherwise, a simultaneous operation with colorectal resection followed by pulmonary resection may be a choice for consideration. Whether colorectal resection or pulmonary surgery is performed first should be determined on a case-by-case basis. In conclusion, the clinical course was favorable in four patients who underwent simultaneous pulmonary resection and laparoscopic colorectal resection. As this is the first report of simultaneous colorectal and pulmonary resection, the safety of this procedure requires confirmation through the accumulation of more patients prospectively, and further discussion of the surgical indication and procedures. However, such simultaneous surgeries appear to be a treatment choice in selected patients.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Acknowledgment The authors have no conflicts of interest or financial ties to disclose.
References 1. Abraham NS, Young JM, Solomon MJ. Meta-analysis of short-term outcomes after laparoscopic resection for colorectal cancer. Br J Surg 2004; 91: 1111–1124. 2. Kuhry E, Schwenk W, Gaupset R et al. Long-term outcome of laparoscopic surgery for colorectal cancer: A cochrane systematic review of randomised controlled trials. Cancer Treat Rev 2008; 34: 498–504. 3. Ma Y, Yang Z, Qin H et al. A meta-analysis of laparoscopy compared with open colorectal resection for colorectal cancer. Med Oncol 2011; 28: 925–933. 4. Ohtani H, Tamamori Y, Arimoto Y et al. A meta-analysis of the short- and long-term results of randomized controlled
14.
15.
16.
17.
18.
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