A new technique against a formidable disease in lung cancer

A less invasive, safer surgical approach for lobectomy combines video-assisted thoracoscopic surgery (VATS) with an ultrasonic energy device for pulmonary artery sealing—a technological combination that reduces the risk of postoperative bleeding, complications, and pain among patients with lung cancer, according to the results of a large international clinical trial presented at the 99th Annual Meeting of the American Association for Thoracic Surgery.

“Thanks to this clinical trial conducted in Canadian, American and British hospitals, we have shown that it is possible to safely seal pulmonary blood vessels through ultrasonic sealing and effectively control possible bleeding during a VATS procedure,” noted lead author Moishe Liberman, MD, PhD, thoracic surgeon and associate professor, Department of Surgery, Université de Montréal, Quebec, Canada.

Reducing invasiveness

In this year alone, more than 228,000 US individuals will receive diagnoses of lung cancer, with a new diagnosis occurring every 2.3 minutes. Although lung cancer accounts for 13% of all new cancer diagnoses, it is responsible for 24% of all cancer deaths. Indeed, lung cancer is the leading cause of cancer-related deaths, and claims more lives than colorectal, breast, and prostate cancers combined.

If delivering this type of diagnosis, with its grim statistics, is not intimidating enough, physicians are often burdened with delivering more bad news if the patient qualifies for a lobectomy. This procedure is highly invasive, prone to risks, and has an extended and painful recovery time.

Traditionally, lobectomy is performed via thoracotomy—an incision made in the chest wall that permits access to the organs behind the ribcage. This incision is typically 25 cm in length and involves cutting the ribs. Because of the strain involved in the procedure, patients commonly experience tenderness, itching, pain, and difficulty breathing as part of their postoperative recovery, which can take weeks to months.

But, what if a safer and less invasive technique could be used for patients requiring this type of surgery? This very question led Dr. Liberman and colleagues to investigate other approaches, specifically the use of the VATS to offset some of the complexity and subsequent adverse outcomes of the traditional methods. Unlike the large incision in traditional thoracotomy, the VATS procedure is less invasive, requiring 3-4 small incisions as opposed to single large cut. A small video camera is then inserted through one of the incisions, which allows surgeons to maneuver and observe the lungs while other surgical tools are inserted in the other incisions to perform the necessary work.

In some studies, researchers have demonstrated the efficacy of lobectomy by VATS vs thoracotomy. While the 5-year survival is similar in both approaches, the VATS procedure resulted in fewer complications and shorter lengths of hospital stay. In fact, patients undergoing VATS procedures typically demonstrated shorter lengths of stay by 2 days, further demonstrating the shorter recovery time.

Addressing bleeding risk

While this methodology is in many ways superior, both traditional thoracotomy and VATS possess an increased risk of bleeding. This is due to the fact that the pulmonary artery is very thin and delicate. Its direct attachment to the heart makes the procedure even more risky.

To combat this bleeding risk, Dr. Liberman and fellow researchers investigated the use of an ultrasonic energy device—a pistol-like technology allows surgeons to seal blood vessels by delivering ultrasonic energy—to seal the pulmonary artery in conjunction with thoracoscopic lobectomy. In this prospective, phase 2, multi-institutional, international clinical trial, the investigators assessed the immediate, short- and medium-term safety and efficacy of pulmonary artery branch sealing via using the ultrasonic vessel-sealing device in minimally invasive lung resection. The study sample consisted of 150 patients planned for VATS/robotic anatomical lung resection in seven centers across the United States, Canada, and the United Kingdom.

In all, 424 pulmonary artery branches were sealed during lobectomy/segmentectomy procedures: 181 were sealed using surgical staplers, 4 with endoscopic clips, and 239 with the ultrasonic vessel-sealing device (Ethicon’s HARMONIC ACE^® +7 Shears). The mean and median pulmonary artery diameters were 4.7 mm/5 mm, 10.3 mm /10 mm, and 6.5 mm/6.5 mm for each method, respectively. The researchers noted that there was no postoperative bleeding from divided pulmonary artery branches with any sealing method, and there was no mortality at 30 days following surgery.

Furthermore, pulmonary artery branches sealed using the ultrasound device were able to withstand higher intraluminal pressures and burst at mean bursting pressures equal to or greater than the gold-standard vascular endostapler method, according to the study findings.

Overall, Dr. Liberman and colleagues concluded that: “[Pulmonary artery] branch sealing with ultrasonic energy during VATS lobectomy is safe for vessels of 7 mm or less. With appropriate training, the use of an ultrasonic vessel-sealing device is a reasonable alternative for vascular sealing in [pulmonary artery] branches of 7 mm or less.”

This dual approach using the VATS procedure alongside the ultrasonic sealer is expected to revolutionize the way surgeons perform lobectomies in patients with lung cancer. Current estimates indicate that only 15% of lobectomies worldwide are performed by VATS. This has been largely attributed to the fear of major bleeding events previously ascribed to pulmonary artery sealing, a major complication of the procedure. This new technique however, has shown promise in mitigating these risks.

“I truly hope that the results of our clinical trial will reassure surgeons about the technical feasibility and safety of this operation and will encourage them to adopt it. A large number of patients could benefit from it and would be on their feet faster, with less pain,” noted Dr. Liberman.