THE LUNG PROJECT
SURGERY
EXTENT OF SURGERY
Surgery is the main treatment option for early stage lung cancer (Stage IA-IIB) and selected stage IIIA patients who are in good physical condition and have adequate lung capacity. In more advanced stages, surgery alone may not sufficient to achieve long term survival and combination treatments of surgery with chemotherapy and/or radiation may be required. The goal of surgery is to remove the main tumor with a surrounding area of normal lung tissue (called a margin), while preserving as much lung as possible. This is best accomplished in most cases with a lobectomy, which is the removal of the pulmonary lobe or piece that contains the tumor. Removal of the entire lobe as opposed to a piece of the lobe (called a wedge) is preferable if possible since it allows the surgeon to remove all the draining lymph nodes and get a larger margin. A study by Ginsberg and colleagues in 1995 comparing lobectomy to a lesser surgery found that lobectomy had a better result in terms of less lung cancer recurrence (6% vs 18%) with a trend towards better survival rates (Lung Cancer Study Group 1995). In some cases, a lesser resection is preferable for a very small tumor, advanced age and in patients with more serious medical problems or limited lung function.
APPROACHES FOR SURGERY
ILung cancer surgery can be performed with either a traditional open technique called a thoracotomy or a less invasive option called thoracoscopy (VATS or video assisted thoracic surgery). Robotic assisted lung surgery uses similar small access incisions like VTAS but adds robotic technology and instruments to facilitate the operation. Open surgery or thoracotomy involves an open incision on the side or back between the ribs, where retractor spreads the ribs and the surgery can be performed under direct vision. This is a well established technique and is the most common approach in the US. The surgeon has excellent access and visualization and facilitates more complex surgeries. The disadvantage is pain, a slower recovery ad more risks of pulmonary complications such as difficulty breathing and pneumonia in up to 10% of patients.
MINIMALLY INVASIVE SURGERY OPTIONS
for most patients facing lung cancer surgery, there is a less invasive surgical option called thoracoscopy or VATS (video assisted thoracic surgery). Robotic assisted or Da Vinci lobectomy is another similar approach to VATS but uses robotic assistance and robotic instruments to perform the surgery via small incisions called robotic lobectomy. Robotic surgery gives the surgeon improved visualization and more versatile instruments which is preferred by some surgeons. The advantage of this minimally invasive surgery (MIS) VATS and robotic approach is less pain, less blood loss and a shorter hospital say and recovery. Most centers offer a less invasive approach for most patients, and almost all patients with early stage lung cancers are candidates for this technique. (images or video VATS robotic). In most experienced centers, most early stage lung cancers (more than 75%) are performed using a minimally invasive approach (VATS or robotic).
SURGERY RECOVERY AND RESULTS
a.lung cancer surgery is performed under general anesthesia; surgery takes approximately 2-3 hours. After completion of surgery, the breathing tubes and anesthesia devices are removed and the patient is observed in recovery room for 2 hours the transferred to a monitored room for recovery. The next morning a diet is started, and patients start walking and becoming independently mobile. Drainage tubes are removed when appropriate starting the day after surgery. Typically, patients leave the hospital after 2-4 days and more than 95% are discharged to home without the need of rehabilitation. At home, pain is controlled with pain pills. Ambulation and breathing exercises are encouraged. Most patients need minimal assistance at home and full recovery (driving, exercise, travel) can be achieved after 3-4 weeks. Few patients need oxygen supplementation after surgery and this depends on their baseline lung function. If needed, most patients only need oxygen therapy temporarily and pulmonary rehabilitation can help wean from needing oxygen.
OUTCOMES
a.hospital outcomes after lung cancer surgery are good and lung resection have become a very safe operation. The outcome will depend on several factors including the amount of lung removed (riskier with complete lung removal or pneumonectomy), the patient condition and breathing function and the volume or experience of the hospital. The mortality for lung cancer surgery is lass than 2% (meaning that 2 out of 100 patients having this surgery does not survive the 30-day recovery period), and complications occur in 20-30% of patients which range from minor to more life threatening. Common complications are heart problem such as arrhythmias, breathing problems such as delayed lung healing and infections such as urinary infections and pneumonias. Most complications are resolved without surgery and by the time of hospital discharge.
SURVIVAL
a.Survival or cancer cure rates after lung cancer surgery depends on several factors including the tumor stage, the patient condition and the addition of additional treatments such as chemotherapy. In general, survival is reported as 5-year survival rates, which means hoe many patients are alive at a certain time point since their surgery and is grouped by stage. For example, a patient with a stage IA lung cancer who had surgery, is estimated to have a 5-year survival of approximately 70% or more, which means that 70% of patients with stage IA lung cancer should be alive without disease 5 years after surgery and live beyond that point, essentially becoming a cancer survivor after 5 years from surgery. Another way to look at it is that 30% of patients with stage IA lung cancer who have surgery will die within 5 years from surgery often from disease relapse but the cause of death at times could be non cancer related.
