Complete versus assisted thoracoscopic approach: a prospective randomized trial comparing a variety of video-assisted thoracoscopic lobectomy techniques

A comparison of perioperative outcomes of video-assisted thoracic surgical (VATS) lobectomy with open thoracotomy and lobectomy: results of an analysis using propensity score based weighting

Background

Randomized trials comparing VATS lobectomy to open lobectomy are of small size. We analyzed a case-control series using propensity score-weighting to adjust for important covariates in order to compare the clinical outcomes of the two techniques.

Methods

We compared patients undergoing lobectomy for clinical stage I lung cancer (NSCLC) by either VATS or open (THOR) methods. Inverse probability of treatment weighted estimators, with weights derived from propensity scores, were used to adjust cohorts for determinants of perioperative morbidity and mortality including age, gender, preop FEV1, ASA class, and Charlson Comorbidity Index (CCI). Bootstrap methods provided standard errors. Endpoints were postoperative stay (LOS), chest tube duration, complications, and lymph node retrieval.

Results

We analyzed 136 consecutive lobectomy patients. Operative mortality was 1/62 (1.6%) for THOR and 1/74 (1.4%) for VATS, P = 1.00. 5/74 (6.7%) VATS were converted to open procedures. Adjusted median LOS was 7 days (THOR) versus 4 days (VATS), P < 0.0001, HR = 0.33. Adjusted median chest tube duration (days) was 5 (THOR) versus 3 (VATS), P < 0.0001, HR = 0.42. Complication rates were 39% (THOR) versus 34% (VATS), P = 0.61. Adjusted mean number of lymph nodes dissected per patient was 18.1 (THOR) versus 14.8 (VATS), p = 0.17.

Conclusions

After balancing covariates that affect morbidity, mortality and LOS in this case-control series using propensity-weighting, the results confirm that VATS lobectomy is associated with a statistically significant shorter LOS, similar mortality and complication rates and similar rates of lymph node removal in patients with clinical stage I NSCLC.

Subcarinal lymph node in upper lobe non-small cell lung cancer patients: is selective lymph node dissection valid?

Little is known about selective lymph node dissection in non-small cell lung cancer (NSCLC) patients. We sought to gain insight into subcarinal node involvement for its frequency and impact on outcome to evaluate whether it is valid to omit subcarinal lymph node dissection in upper lobe NSCLC patients. We reviewed node metastases distribution according to node region, tumor location, and histology among 1099 patients with upper lobe NSCLC. We paid special attention to subcarinal metastases patients without superior mediastinal node metastases, because their pathological stages would have been underdiagnosed if subcarinal node dissection had been omitted. We also assessed the outcome and the pattern of failure among subcarinal metastases patients. To identify subcarinal node involvement predictors, we analyzed 7 clinical factors. Subcarinal node metastases were found in 20 patients and were least frequent among squamous cell carcinoma patients (0.5%). Two of them were free from superior mediastinal metastases but died of the disease at 1 month and due to an unknown cause at 18 months, respectively. Seventeen of the 20 patients developed multi-site recurrence within 37 months. The 5-year survival rate of the 20 patients with subcarinal metastases was 9.0%, which was significantly lower than 32.0% of patients with only superior mediastinal metastases. Clinical diagnosis of node metastases was significantly predictive of subcarinal metastases. Subcarinal node metastases from upper lobe NSCLC were rare and predicted an extremely poor outcome. It appears valid to omit subcarinal node dissection in upper lobe NSCLC patients, especially in clinical N0 squamous cell carcinoma patients.

Video-assisted surgery for lung cancer. State of the art and personal experience

This paper reviews the role of videothoracoscopy in lung cancer, highlighting its utility in definitive staging, diagnosis, and treatment. We show exploratory videothoracoscopy to be the perfect technique for last-minute staging, looking for tumor invasion, especially parietal T3 and vascular T4 (due to videopericardioscopy), management of solitary pulmonary nodules, and the possibility of radical treatment with video-assisted thoracoscopic lobectomy. We perform an overview of the literature and analyze our experience of 1,381 patients with lung cancer. In 1,277 of them, the final decision on resectability was made by exploratory videothoracoscopy, including 91 by videopericardioscopy (only 30 were considered non-resectable on videopericardioscopy). Solitary pulmonary nodules were diagnosed in 382 cases (190 were cancer), and we performed 260 major lung resections by video-assisted thoracoscopic surgery (22 pneumonectomies, 238 lobectomies/bilobectomies).

Lobectomy by video-assisted thoracic surgery (VATS) versus thoracotomy for lung cancer

BACKGROUND

The optimal surgical technique for lobectomy in lung cancer is not well defined. Proponents of video-assisted thoracic surgery (VATS) hypothesize that less trauma leads to quicker recovery, whereas those who advocate thoracotomy claim it as an oncologically superior procedure. However, a well-balanced comparison of the two procedures is lacking in the literature.

METHODS

All patients who underwent lobectomy for clinical stage 1A lung cancer by computed tomographic and positron emission tomographic scan were identified from a prospective database. Patient characteristics were compared by the Student t test, Pearson chi(2), and Fisher exact test. A propensity score-matched analysis was performed. Survival was assessed by Kaplan-Meier and Cox proportional hazards analysis. Complications were assessed by a multivariate logistic regression model evaluating age, sex, comorbidities, pulmonary function, tumor size, nodal status, surgeon, and histologic characteristics.

RESULTS

From May 2002 to August 2007, 398 patients underwent an attempt at VATS lobectomy and 343 underwent thoracotomy. An "intent-to-treat" analysis was performed. There was 1 postoperative death in each group. Survival by Cox model was no different for VATS versus thoracotomy (hazard ratio 0.72; P = .12), whereas age (hazard ratio 1.03; P < .001), larger tumor size (hazard ratio 1.34; P < .001), and higher nodal stage (hazard ratio 1.92; P < .001) were associated with worse survival. Logistic regression demonstrated fewer complications for VATS lobectomy (odds ratio 0.73; P = .06), whereas age (odds ratio 1.04; P < .001) and tumor size (odds ratio 1.2; P < .020) correlated with a greater number of complications. Patients undergoing VATS lobectomy demonstrated a 2-day shorter length of stay than patients undergoing thoracotomy (P < .001). Propensity score-matched analysis supported these findings.

CONCLUSIONS

VATS lobectomy and thoracotomy demonstrated similar 5-year survivals. However, VATS lobectomy was associated with fewer complications and shorter length of hospital stay.

Systematic review and meta-analysis of randomized and nonrandomized trials on safety and efficacy of video-assisted thoracic surgery lobectomy for early-stage non-small-cell lung cancer

PURPOSE

The current randomized trials comparing video-assisted thoracic surgery (VATS) lobectomy with open lobectomy for patients with early-stage non-small-cell lung cancer (NSCLC) have been of small size. We performed the present meta-analysis of the randomized and nonrandomized comparative studies in an attempt to assess the safety and efficacy of VATS lobectomy.

METHODS

Electronic searches identified 21 eligible comparative studies (two randomized and 19 nonrandomized) for inclusion. Two reviewers independently appraised each study. Meta-analysis was performed by combining the results of reported incidence of morbidity and mortality, recurrence, and 5-year mortality rates. The relative risk (RR) was used as a summary statistic.

RESULTS

There were no significant statistical differences between VATS and open lobectomy in terms of postoperative prolonged air leak (P = .71), arrhythmia (P = .86), pneumonia (P = .09), and mortality (P = .49). VATS did not demonstrate any significant difference in locoregional recurrence (P = .24), as compared with the open lobectomy arm, but the data suggested a reduced systemic recurrence rate (P = .03) and an improved 5-year mortality rate of VATS (P = .04). There was no evidence to suggest heterogeneity of trial results. Fourteen studies reported VATS to open lobectomy conversion rate ranging from 0% to 15.7% (median = 8.1%).

CONCLUSION

Both randomized and nonrandomized trials suggest that VATS lobectomy is an appropriate procedure for selected patients with early-stage NSCLC when compared with open surgery.

Video-assisted thoracic surgery lobectomy (VATS), open thoracotomy, and the robot for lung cancer

Video-assisted thoracic surgery (VATS) lobectomy provides a minimally invasive approach for the management of early-stage lung cancer. Questions about the safety of VATS lobectomy and its adequacy as a cancer operation compared with open thoracotomy have hindered its universal acceptance among thoracic surgeons. Evidence suggests that VATS lobectomy can be safely performed and is an adequate cancer operation for early-stage non-small cell lung cancer. However, adequately powered well-balanced studies comparing VATS with open thoracotomy for lobectomy are lacking in the literature.

[Lobectomy performed through a video-assisted mini thoracotomy, as a new technique in our clinical practice]

In this retrospective study, we present our experiences and results with lobectomy performed through video-assisted mini thoracotomy (VAMT), a technique that we have been using since 2006.

METHOD AND PATIENTS

In the first half of 2006 10 video-assisted lobectomies were performed in our department. There were eight women and two men; the mean age was 61.4 (47-68) years. The indications for surgery were the following: benign lesions in three cases, T1N0 squamous lung cancers proved by cytology in six patients, and another case, when the CT suggested - but cytologically not proved - T1N0 lung cancer. After a double lumen endotracheal tube intubation and videothoracoscopic exploration, a 6-8 cm mini thoracotomy was performed. Manual palpation of the lung parenchyma, resection with mediastinal block dissection (in cases of malignancy) was carried out through a 2 cm wide rib spread, without rib resection. Five lower, four upper lobe lobectomies and one upper bilobectomy were performed. There was no perioperative mortality or serious morbidity detected. The mean operative time was 130 (80-200) minutes. The three benign lesions were hamartochondromas. The final histology revealed four T1N0 and two T2N2 stage squamous cell lung cancers, while one T1N2 small cell lung cancer was also found. Lobectomy performed through a video-assisted mini thoracotomy is a safe procedure. The manual palpation, parenchyma resection and mediastinal block dissection can be performed similarly to open procedures.

Totally endoscopic anatomic pulmonary segmentectomies

Although some series of video-assisted major pulmonary resections have been reported, very few series of totally endoscopic lobectomies have been published and - to our knowledge - none of totally endoscopic anatomic segmentectomies. We have recently performed five anatomic segmentectomies using this approach. The video demonstrates the main steps of the procedure, based on the recordings of three different operations: a lingulectomy, a left basilar segmentectomy and a resection of the right lower lobe superior segment.

Variation in the Approach to VATS Lobectomy: Effect on the Evaluation of Surgical Morbidity Following VATS Lobectomy for the Treatment of Stage I Non–Small Cell Lung Cancer

Recent advances in imaging, chemical pathology, and target therapy have made it necessary to redefine the role of surgery in the therapeutic algorithm in the management of lung cancer. Although video-assisted thoracic surgery lobectomy with hilar and mediastinal lymph node dissection was proposed over a decade ago to treat early lung cancer, this technique is currently not widely practiced, despite many documented advantages. This article examines the role of video-assisted thoracic surgery lobectomy in the treatment of early lung cancer and, in particular, variations in the approach and published results.

Long-term outcomes after a variety of video-assisted thoracoscopic lobectomy approaches for clinical stage IA lung cancer: a multi-institutional study

BACKGROUND

Although video-assisted thoracic surgery (VATS) has been in use for more than a decade, its application to major lung resection for lung cancer is still not widely practiced. The success of a cancer operation is judged by the long-term survival of the treated patients. Therefore, the goal of the present study was to evaluate long-term outcomes associated with various video-assisted lobectomy techniques and conventional surgery in patients with peripheral non-small cell lung cancer less than or equal to 2 cm in diameter (stage IA).

METHODS

A multi-institutional, retrospective review was performed in 145 consecutive patients. Patients with clinical stage IA disease, with tumor size less than or equal to 2 cm in diameter, from three institutions underwent a complete VATS (c-VATS, n = 56), an assisted VATS (a-VATS, n = 34), or a conventional open (open, n = 55) approach for pulmonary lobectomy and lymph node dissection.

RESULTS

Patients undergoing lobectomy and lymph node dissection with c-VATS had less blood loss, faster recovery, shorter hospitalization, and longer operating times than did patients undergoing the lobectomy with the a-VATS and open approaches. At a mean follow-up of 38.8 months, Kaplan-Meier probabilities of survival at 5 years were as follows: c-VATS, 96.7%; a-VATS, 95.2%; open, 97.2%. There was no significant difference in the rate of recurrence among the 3 different procedures.

CONCLUSION

VATS lobectomy, a safe procedure with earlier return to normal activities, can be regarded as an acceptable cancer operation for the patients with peripheral non-small cell lung cancer less than or equal to 2 cm in diameter (clinical stage IA) with the same long-term survivals as open surgery.