Video-Assisted Thoracic Surgery for Bronchiectasis
Peng Zhang, MD, PhD, Fujun Zhang, MD, Siming Jiang, MD, Gening Jiang, MD,
Xiao Zhou, MD, Jiaan Ding, MD, and Wen Gao, MD
Department of Thoracic Surgery, Shanghai Pulmonary Hospital of Tongji University School of Medicine, Shanghai; and
Department of Thoracic Surgery, Rizhao Hospital of Chinese Medicine, Shandong, China
Background. Bronchiectasis is one of the common dis-
eases diagnosed in the world. No major improvement for
the treatment approaches and limited efficacy promote a
big challenge for management of this disease. Video-
assisted thoracoscopic surgery (VATS) offers a new
choice for the treatment of bronchiectasis. The purpose of
this study was to present our experience of VATS for
bronchiectasis and to compare this with thoracotomy in
our institution.
Methods. We reviewed the medical records of patients
who underwent VATS lobectomy and general lobectomy
for bronchiectasis between January 2005 and December
2009.
Results. A total of 279 patients underwent thoracot-
omy, 52 patients underwent attempted VATS lobectomy.
Fifty-two patients from 279 patients for thoracotomy
B ronchiectasis, one of the primary diseases of bronchi
and bronchioles involved in a vicious circle of trans-
mutable infection and inflammation with mediator re-
lease [1], is diagnosed with increasing frequency in North
America and around the world [2]. Surgery is the only
option for potential cure for bronchiectasis. Although
improvement of the outcome for nonsurgical treatment
has been shown due to the development of more effective
antibiotics and conservative therapeutics, less invasive
surgery still provides substantial benefits in some se-
lected patients with bronchiectasis [3, 4]. Thanks to the
development of surgical techniques, video-assisted tho-
racoscopic surgery (VATS) for major lung resection has
become a more frequent procedure in recent years with
promising outcome [5]. Video-assisted thoracoscopic sur-
gery may become a potentially new surgical choice for
the treatment of bronchiectasis. Here we analyzed total
thoracoscopic lobectomy for patients with localized bron-
chiectasis and compared it with patients who underwent
thoracotomy lobectomy in our hospital. For the sake of
description, we define VATS lobectomy as a video-
assisted, minimal access technique in which the entire
procedure is performed by a surgeon, with the help of
observing a television monitor, and rib spreading is not
needed [6].
Accepted for publication Aug 17, 2010.
Address correspondence to Dr Gening Jiang, Department of Thoracic
Surgery, Shanghai Pulmonary Hospital of Tongji University School of
Medicine, Shanghai, 200433, China; e-mail: jgnwp@yahoo.com.cn.
2011 by The Society of Thoracic Surgeons
Published by Elsevier Inc
were selected and compared with the VATS group.
Pleural adhesion was observed in 15 patients (28.8%) in
GENERAL THORACIC
VATS. The VATS lobectomy was converted to open
thoracotomy in 7 patients. There was no difference in the
blood loss and median operative time between the two
groups, but the patients with VATS had shorter length of
stay in hospital (p 0.045), fewer complications (p 0.039)
than those with thoracotomy. Forty-nine (94%) and 46 (88%)
patients fully recovered after operation by VATS and
thoracotomy, respectively.
Conclusions. Video-assisted thoracoscopic lobectomy
in localized bronchiectasis is a safe and more efficient
procedure in selected patients with better recovery.
(Ann Thorac Surg 2011;91:239 43)
2011 by The Society of Thoracic Surgeons
Patients and Methods
This study was approved by the Medical College
Review Board of Tongji University, Shanghai, China.
Informed consent was not required for this retrospec-
tive study. We reviewed the medical records of con-
secutive patients who underwent lobectomy for bron-
chiectasis between January 2005 and December 2008 at
the Department of Thoracic Surgery of Shanghai Pul-
monary Hospital, affiliated with Tongji University,
China. Patients were chosen as candidates for VATS
surgical treatment or thoracotomy according to the
following criteria: localized bronchiectasis docu-
mented by high-resolution computed tomography; ad-
equate cardiopulmonary reserve; and obvious symp-
tom failure of medical treatment. Medical therapy
constituted the judicious use of systemic antibiotics
based on current sputum or bronchoscopic lavage
cultures, mucolytic agents, nonirritant expectorants,
postural drainage, humidification, antiinflammatory
agents, and bronchodilators. Failure of medical treat-
ment was defined as frequent exacerbation interfering
with normal professional or social life or requiring
multiple hospitalizations.
The selection of VATS was based mainly on the judg-
ment of surgeons. The following patients were consid-
ered to be the candidates for VATS procedure: young
patients with aesthetic demands; there was no severe
parenchymal and (or) pleural scarring and no calcified
lymph nodes near pulmonary arteries and veins shown
on computed tomographic scan; the symptom of puru-
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 240 ZHANG ET AL Ann Thorac Surg
VATS FOR BRONCHIECTASIS 2011;91:239 43

lent sputum usually lasted less than 5 years; and patients
with evidence for severe parenchymal and (or) pleural
scarring on computed tomographic scan often under-
went thoracotomy.
Briefly, patients were placed in the lateral decubitus
position and one-lung ventilation was established
through a double-lumen endotracheal tube. For VATS,
two entry-port incisions were made to introduce 12-mm
trocars; one in the seventh or eighth intercostal space
(depending on the patients thorax configuration) in the
midaxillary line, and the second just below the scapular
vertex in the sixth or seventh intercostal space. Having
GENERAL THORACIC
This was performed by constructing propensity scores
[16] using all preoperative variables that might have an
effect on the result of the surgical treatment of bronchi-
ectasis (shown by Table 1). Pairwise matches were based
on the nearest propensity scores.
Results
Between January 2005 and December 2009, 331 patients
with bronchiectasis were diagnosed in our department.
Among them, 279 patients underwent thoracotomy and
52 patients underwent attempted VATS lobotomy. Fifty-

confirmed the viability of the technique, an anterior two patients from the 279 patients for thoracotomy were
(approximately 4 to 5 cm long) incision was placed over selected and were compared with the VATS group.
the third or fourth intercostal space without rib spread- Patient characteristics are shown in Table 1. In the VATS
ing. The first operative step was to undertake a VATS group, the presenting symptoms included productive
inspection of the pleural cavity in order to exclude cough in 32 patients (62%), hemoptysis in 25 patients
unexpected causes of irresistibility by VATS. Having (48%), fetid sputum in 2 patients (4%), and no symptoms
confirmed operability, the pulmonary artery was identi- in 2 patients (4%). No patients were found for emergency
fied at the base of the major fissure and the sheath of the (eg, massive hemorrhage) in either group. In the VATS
artery entered. In general, the hilar structures were group there were 12 patients who had a positive micro-
divided according to the most convenient manner deter- organism that was obtained from preoperative sputum
mined at surgery, usually with division of the arteries cultures, compared with 16 patients who had a positive
prior to the vein in order to avoid congestion of the lobe. sputum culture in the thoracotomy group. Pleural adhe-
Thoracotomy lobectomy was performed through a pos- sion was observed in 15 patients (28.8%) in the VATS
terolateral thoracotomy incision that spared the stratus group. Note that 7 patients were failed for a VATS
anterior muscle. The chest was entered through the fifth lobectomy and were finally switched to open thoracot-
intercostals space and a Finochietto retractor (G U Man- omy due to bleeding (n 3), fused fissure (n 3), and
ufacturing Co. Ltd, London, UK) was used to gain expo- hilar lymphadenopathy (n 1). Intraoperative and (or)
sure. All specimens had pathologic confirmation of postoperative transfusions were not needed.
bronchiectasis. There was no difference in the blood loss and median
All patients received epidural administration of 0.125% operative time between the two groups; however, the
bupivacaine during the operations. Continuous epidural patients in the VATS group had a shorter length of stay in
infusion of 0.125% bupivacaine (4 mL/hour) was used the hospital (p 0.045) (as shown in Table 2) and less
postoperatively until chest drainage tubes were removed. complications (p 0.039) as compared with those in the
Diclofenac suppositories were predominantly used for thoracotomy group (as shown in Table 3). The VATS
postoperative pain control in addition to the epidural group patients also had significantly less pain than those
anesthesia, and intramuscular administration of penta- in thoracotomy group after procedure (Fig 1).
zocine was used if uncontrollable pain was observed.Pain There were no intraoperative or postoperative deaths.
was quantitated by an 11-point pain scale (0 no pain, 10 In VATS, postoperative complications were found in
maximal imaginable pain) on postoperative days 0, 1, 2, 3,
7, and 14 [15].
The outcome of surgery was evaluated according to the Table 1. Characteristics for VATS and Thoracotomy Patients
following criteria: excellent (complete absence of preoper- in Propensity-Matched Group
ative symptoms that led to surgery); good (marked reduc- VATS Thoracotomy p
tion in preoperative symptoms but needing antibiotic ther- Characteristics (n 52) (n 52) Value
apy occasionally); no change (no reduction in preoperative
Age, years (mean) 41.0 6.5 41.0 7.2 0.818
symptoms, and no decrease in hospital admissions or
Male/sex 21 23 0.691
medical therapy requirements); and worse (frequent exac-
Duration of symptoms (m) 25.8 8.2 30.2 6.5 0.06
erbations of disease requiring hospitalization).
FEV1 (%) predicted 85 16 80 25 0.055
Statistical Analysis Comorbidities
Patient data were reported as either median and range Chronic obstructive 9 12 0.464
pulmonary disease
for quantitative variables or absolute and relative fre-
Hypertension 4 6 0.506
quencies for qualitative variables. Patient characteristics
Chronic renal insufficiency 2 3 0.647
and preoperative data were compared using the Student
TB history 6 8 0.566
t, Pearson 2, and Fisher exact tests. A p value less than
0.05 was considered significant. Sputum culture/positive 12 16 0.377
We chose to match VATS and thoracotomy patients in FEV1 forced expiratory volume in the first second of expiration; TB
a one-to-one fashion by using all available clinical data. tuberculosis; VATS video-assisted thoracoscopic surgery.
Ann Thorac Surg ZHANG ET AL 241
2011;91:239 43 VATS FOR BRONCHIECTASIS

Table 2. Perioperative Data for VATS and Thoracotomy

Patients for Bronchiectasis in Shanghai Pulmonary Hospital
of Tongji University
VATS Thoracotomy p
Variables (n 52) (n 52) Value

Surgical procedure
Lobectomy 45 40 0.101
Bilobectomy 1 5
Lobectomysegmentectomy 4 7
segmentectomy 2 0
Blood loss (mL) 126 70 130 54 0.06

GENERAL THORACIC
Median operation time 143.5 82 156 95 0.056
(hours)
Length of stay in hospital 11 6.5 14 12 0.045
(days)
Perioperative death 0 0
Cost (105 RMB) 5.4 1.2 4.6 0.7 0.001

RMB Renminbi; VATS video-assisted thoracoscopic surgery.
eight patients (Table 3). Postoperative lung torsion was
observed in a 43-year-old male patient who had under-
gone a left upper lobectomy and wedge resection of the
inferior lobe for bronchiectasis with VATS. A completion
pneumonectomy was needed for this patient. Empyema
was observed in one patient (2%). The other six patients
experienced minor complications, which were cured by
conservative therapy. Seven patients converted to thora-
cotomy recovered well except one patient who experi-
enced postoperative atelectasis. In thoracotomy, more
patients (total 14) experienced postoperative complica-
tions as compared with those in the VATS group.
Follow-up was completed in all patients (100%) with a
mean of 42.6 months (range, 12 to 64 months). In the
VATS group, 49 (94%) patients were excellent after
operation, good in 2 (4%), and no change or worse in
1 (2%). In the thoracotomy group, 46 (88%) patients were
excellent after operation, good in 4 (8%), and no
change or worse in 2 (4%) (Table 4). The surgical
outcome of VATS appeared to be better than thoracot-
omy, but there was no statistical difference between the
two groups.
Table 3. Postoperative Complications of VATS Versus
Thoracotomy for Bronchiectasis in Shanghai Pulmonary
Hospital of Tongji University
Complications VATS Thoracotomy
Atelectasis 2 4
Persistent air leak more than 1 1
2 weeks
Pneumonia 1 3
Cardiac arrhythmia 2 4
Empyema 1 2
Lung torsion 1 0
Total 8 14
Fig 1. Postoperative pain measured by 11-point pain scale of the
two groups. Data are shown as mean standard deviation of the
mean. ( thoracotomy; VATS; PODs postoperative days;
VATS video-assisted thoracic surgery.)
Comment
Brochiectasis refers to the permanent abnormal dilata-
tion of the center and medium sized bronchi because of
a vicious cycle of transmutable infection and inflamma-
tion with mediator release. The prevalence of bronchiec-
tasis is still unknown [7]. In our hospital, most of oper-
ated patients for bronchiectasis who preferred the VATS
lung resection were young and middle aged. Bronchiec-
tasis was considered the best lung benign disease suit-
able for VATS lobectomy [6].
The VATS pulmonary resection has become an estab-
lished alternative approach to conventional open surgery
for selected patients. The VATS major resection has
demonstrated to be a safe procedure when performed by
experienced physicians. Postoperative pain after VATS is
uncommon as compared with open surgery. Other doc-
umented advantages include better preservation of pul-
monary function in the early postoperative period, earlier
return to full activities, and better quality of life after
recovery. Older and severe sick patients were recom-
mended for surgery [6].
One report [8] showed that there were three major
differences between anatomic lung resections of benign
versus malignant diseases by VATS. First, adequacy of
tumor clearance was not relevant in the benign diseases
p Value though it is very important for malignant diseases such
Table 4. Results of VATS and Thoracotomy
VATS Thoractomy
Results (n 52) (n 52) p Value
Excellent 49 46 0.573
Good 2 4
0.039 No change or worse 1 2

VATS video-assisted thoracoscopic surgery. VATS video-assisted thoracoscopic surgery.

 242 ZHANG ET AL
VATS FOR BRONCHIECTASIS
as systematic mediastinal lymphadenectomy. Second,
inflammatory changes might render dissection more dif-
ficult in certain diseases such as tuberculosis, especially
when accompanied by inflammation of the pleura. Third,
while the port site where malignant tumor recurrence
and tumor seeding were found by VATS, wound infec-
tion was also a concern in resections for an infectious
cause. Another study [9] demonstrated that all benign
pulmonary disease could be explored thoracoscopically;
however, the feasibility of resection depended on the
local anatomic situation, especially adhesions. The sever-
ity of adhesions to the chest wall, the hilum, and especially
GENERAL THORACIC
in the fissure, typically seen in inflammatory disease, was
the key limiting factor for a safe VATS lobectomy [5].
Adhesions need to be dissected to explore the relevant
anatomy. If there were dense adhesions (such as destroyed
lobes mainly after tuberculosis with or without aspergillo-
sis) or enlarged lymph nodes, especially calcified, open
operations were required. Video-assisted thoracoscopic
surgery represents a new approach; the indications for
VATS major resection remain the same as for conventional
resection. But not all the patients with bronchiectasis who
needed operations were suitable for VATS lobectomy; se-
vere scarring and adhesions on computed tomographic
scan should be considered [5].
One major advantage of VATS resection is that it
allows recruitment of older and sicker patients with
multiple comorbidities who would otherwise not be
candidates for resection through a conventional thora-
cotomy approach [10, 11]. In China there were patients
with benign disease who would rather choose conser-
vative therapy when those patients were severely ill or
older.
Compared with the right bronchus, the left one has the
narrower diameter, longer mediastinal course, and lim-
ited peribronchial space when passing through the sub-
aortic tunnel. These features might make the left bron-
chus more vulnerable to obstruction than the right. The
lower lobes are more likely to be affected and the left
lung seems to be more vulnerable to bronchiectasis than
the right lung [12].
Fortunately, left and lower lobectomies seemed easier
in the technology. We also have the same experience in
the VATS group. One study reported that prolonged air
leaks were the major morbidity after both VATS as well
as open lobectomy for inflammatory disease [5]. How-
ever, in our case only one patient in the VATS group had
experienced prolonged air leak. We preferred to suture
the lung wounds by 5-0 prolene thread by VATS. This
procedure could effectively prevent air leak.
The resection of infected or purulent lesions through
minimal access may predispose to contamination of the
pleural cavity and wound, leading to empyema and
wound infection. In our patients, one patient who suf-
fered from postoperative empyema was cured by chest
tube insertion and pleural lavage. There was no wound
contamination in our patients. In our experience of
VATS, before closing around 3000 mL neomycin sulfate
solution was used to clean the cavity and the incision,
and the lung resected was stored in a specimen bag and
Ann Thorac Surg
2011;91:239 43
then taken out from the cavity to prevent the incision
from being infected. Note that this is a routine procedure
of surgery for bronchiectasis in our department.
In our study, the patients with VATS had a shorter
length of stay in the hospital, fewer complications, and
less pain in the postoperative period than those with
thoracotomies. It is reasonable to recommend VATS for
some selected patients with bronchiectasis.
Some authors pointed out that by choosing the right
patients for this technique, as well as relying on ligation
and suturing, the consumable costs could be minimized
[13]. A study from Japan [14] comparing VATS versus
open resections for cancer showed that the overall hos-
pital charges were lower for the VATS approach. How-
ever, in this study, the whole cost of VATS was signifi-
cantly higher than those in the open one. We think that
the high cost of the consumables is a serious concern and
represents a major deterrent to adopt VATS in China,
especially for patients from the rural areas. We hope that
medical insurance would cover this area and more pa-
tients would benefit from it in China.
In short, video-assisted thoracoscopic lobectomy in
bronchiectasis can be performed safely in selected pa-
tients with a better satisfactory outcome.
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INVITED COMMENTARY
Zhang and colleagues [1] retrospectively analyzed a sin-
gle institutional experience on lobectomy for bronchiec-
tasis. The authors compared 52 patients who underwent
the video-assisted thoracoscopic surgical (VATS) ap-
proach with a matched cohort of 52 patients (selected
from 279 patients) who underwent the conventional open
approach during the same 5-year period. They concluded
that the VATS approach gave superior results in shorter
hospital stay and less perioperative complications.
The authors are to be congratulated for sharing with us
their large experience on an important topic that is
underreported. Although they tried to avoid using the
VATS approach on patients whose thoracic computed
tomography showed marked pleural reaction, computed
tomography alone is not a reliable guide to technical
difficulty. Surgeons who would like to pursue the VATS
approach for these patients must be prepared to face the
technical challenges.
In my own experience, I have found it useful to excise
a small segment of rib subperiosteally underneath the
utility thoracotomy wound to enhance instrument ma-
neuvering [2]. This increases the safety margin in the
event of unexpected technical mishaps. With the seg-
mental rib resection, thin patients may experience a
small cough impulse postoperatively, but this will im-
prove with time. Surgical experience is gained through
small increments. Resident surgeons in training are ad-
vised to use a slightly bigger incision at the beginning
while keeping the scope for visualization until more
experience is gained.
2011 by The Society of Thoracic Surgeons
Published by Elsevier Inc
ZHANG ET AL 243
VATS FOR BRONCHIECTASIS
kine level after lobectomy: a comparison of VATS and
conventional procedure. Ann Thorac Surg 2001;72:3625.
16. Maxwell AE. Comparing the classification of subjects by two
independent judges. Br J Psychiatry 1970;116:6515.
Surgical resection for localized bronchiectasis is now
an established option in the overall treatment strategy for
this condition. If the patients come to us early, often
wedge resection would be sufficient, and hilar dissection
(with the associated risks) may be avoided. Surgical
GENERAL THORACIC
resection is important not only for symptomatic relief but
also for accurate microbiologic and histologic diagnosis
to exclude a coexisting pathology such as lung cancer or
tuberculosis.
In experienced hands, VATS is a safe alternative to
open procedures in the management of bronchiectasis.
As surgeons, it is our duty to update our pulmonology
and family physician colleagues so that we may be able
to see these patients at an earlier stage when wedge
pulmonary resection would be both adequate and
optimal.
Anthony P. C. Yim, MD
Minimally Invasive Thoracic Surgery Centre
Ste 607 Central Building, 1-3 Pedder St, Central
Hong Kong, China
e-mail: yimap@cuhk.edu.hk
References
1. Zhang P, Zhang F, Jiang S, et al. Video-assisted thoracic
surgery for bronchiectasis. Ann Thorac Surg 2011;91:239 43.
2. Shigemura N, Hsin M, Yim APC. Segmental rib resection for
difficult VATS cases. J Thorac Cardiovasc Surg 2006;132:7012.
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