| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
J Thorac Cardiovasc Surg 2009;138:11-18
© 2009 The American Association for Thoracic Surgery
General Thoracic Surgery |
Thoracic Service, Department of Surgery, Memorial Sloan–Kettering Cancer Center, New York, NY
Received for publication May 9, 2008; revisions received January 27, 2009; accepted for publication March 7, 2009. * Address for reprints: Raja M. Flores, MD, Thoracic Service, Department of Surgery, Memorial Sloan–Kettering Cancer Center, 1275 York Ave, Room C-879, New York, NY 10021. (Email: floresr{at}mskcc.org).
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsResultsDiscussionReferences |
|---|
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 
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.
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
 Earn CME credits at http://cme.ctsnetjournals.org
|
The role of VATS wedge resection for the diagnosis of lung cancer is well established whereas the role of VATS lobectomy for treatment is not well defined. Many case series have demonstrated the feasibility of VATS lobectomy since it was first described in the early 1990s; however, surgeons have been reticent to use the technique because of intraoperative safety and long-term oncologic concerns.1
The Society of Thoracic Surgeons database demonstrates that only 16% of lobectomies reported in the United States are performed by the VATS method.2
Data from well-designed comparative studies in the literature are scarce. The majority of data is low on the evidence-based scale and the studies are often underpowered.3 Recently, the demand in our practice for VATS lobectomy appears to be driven by patients and to a lesser extent by resident trainees. The obvious arguments in favor of VATS lobectomy include cosmesis, less postoperative pain, shorter length of stay, and lower overall cost, but there is a paucity of evidence-based data to support these assumptions. At present, no well-balanced comparative studies of sufficient power exist to adequately compare VATS lobectomy with thoracotomy lobectomy.
Therefore, we undertook this study to evaluate whether VATS lobectomy could be performed by a uniform technique among different surgeons with acceptable short- and long-term outcomes when compared with standard thoracotomy on a homogeneous well-balanced large population from a single institution.
|
Methods |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Variables recorded included age, sex, comorbidities, pulmonary function, tumor size, nodal status, and histologic characteristics. Comorbidities included coronary artery disease, valvular heart disease, dysrhythmia, hypertension, chronic obstructive pulmonary disease, asthma, renal insufficiency, and diabetes mellitus. Smoking history was defined as current (any amount), former (>100 cigarettes in a lifetime), and never (0–100 cigarettes in a lifetime) smokers.
All complications were graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events version 3.0 (http://ctep.cancer.gov/reporting/ctc.html). Survival was recorded from day of the operation until date of death or last follow-up. Deaths were verified by the Social Security Death Index. Perioperative mortality was defined as death within 30 days of the operation or within the same hospital admission.
Operative Technique
The decision to perform either procedure was made by the individual surgeon. Four surgeons (R.F., V.R., B.P., and N.R.) perform VATS lobectomy for patients with early-stage disease whereas two surgeons (R.D. and M.B.) exclusively perform thoracotomy lobectomy for such patients.
All patients underwent standard anesthesia care with the use of double-lumen endotracheal tubes and perioperative fluid restriction. Postoperative pain relief was provided by continuous epidural administration of fentanyl and bupivacaine and/or intravenous opioid administration.
VATS lobectomy was performed via a 4-cm utility incision at the anterior axillary line at the third or fourth intercostal space by using standard thoracic instruments without rib spreading, a 2-cm anterior thoracostomy port at the eighth intercostal space at the anterior axillary line for the camera, and a 2-cm posterior port for retraction and stapler insertion. The operation was performed entirely with thoracoscopic visualization. The hilar structures were individually ligated by endovascular staplers, and mediastinal nodal dissection or sampling was performed. The camera port was subsequently used as a thoracostomy tube site. Our technique has been described previously.4,5 In VATS cases in which the robot was used for assistance in dissection, the same three VATS incisions were used as described in an earlier report.6
Thoracotomy lobectomy was performed via a posterolateral thoracotomy incision that spared the serratus anterior muscle. The chest was entered via the fifth intercostal space and a Finochietto retractor was used to gain exposure. Endoscopic staplers were routinely used for the transection of vessels and the completion of the fissures. In all patients an ipsilateral mediastinal dissection or sampling was performed.
Statistical Methods
Patient characteristics and perioperative data were compared by the Student t test, Pearson 2, and Fisher's exact test. Survival was assessed by Kaplan–Meier and Cox proportional hazards analysis. Conversions from VATS to thoracotomy were analyzed in the VATS cohort by the "intent-to-treat" method. Complications were assessed by a multivariate logistic regression model evaluating age, sex, comorbidities, pulmonary function, tumor size, nodal status, surgeon, and histologic characteristics; nonsignificant variables were excluded in a stepwise fashion to obtain the final model. STATA 10 software (Stata Corporation, College Station, TX) was used to perform statistical analyses.
A propensity score–matched analysis was performed. Propensity scores were generated for all patients eligible to undergo either VATS or thoracotomy lobectomy. VATS versus thoracotomy was the treatment indicator (dependent variable) and the covariates were age, sex, comorbidities, forced expiratory volume in 1 second (FEV1), diffusing capacity for carbon monoxide (DLCO), smoking history, stage, histologic characteristics, tumor size, and nodal status. Nearest neighbor matching method was used without replacement. VATS and thoracotomy group covariates were compared by standardized differences. Patients were stratified by propensity score groupings to evaluate survival, complications, and length of stay among the VATS and thoracotomy groups. Cox and logistic regression models were constructed to evaluate the influence of VATS on survival and complications, respectively, adjusting for propensity score. STATA 10/ PSMATCH2 (Leuven and Sianesi) was used to perform statistical analyses.
|
Results |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
, respectively.
|
|
).
|
|
|
|
|
|
The two groups were well balanced with regard to stage. This was the main reason for performing the analysis by the intent-to-treat method. We wanted patients with more complicated disease, and (theoretically) a greater tendency for complications and longer lengths of hospital stay, to be included in the VATS lobectomy group. However, the conversion group demonstrated a similar stage distribution when compared with the VATS and thoracotomy groups: stage IA, 47 patients; stage IB, 8 patients; stage IIA, 2 patients; stage IIB, 3 patients; stage IIIA, 8 patients; and stage IIIB, 2 patients.
A propensity score–matched analysis was performed. Propensity scores were generated for 677 patients; 64 of 741 patients did not receive a propensity score owing to missing variables. After propensity score matching, 51 unmatched patients were excluded, yielding a total of 313 patients in each of the VATS and thoracotomy groups. Covariates were compared by standardized differences (Table 6 ). Patients were then grouped by propensity scores, which demonstrated similar survival between the VATS and thoracotomy groups but fewer complications and a shorter length of stay for the VATS group (Table 7 ). Propensity scores were then multiplied by 10 to present hazard ratios in terms of a 10% change in propensity score. A Cox proportional hazards model demonstrated a hazard ratio of 0.8 for the VATS group when adjusted for propensity score (Table 8A ). A logistic regression model with complication as the dependent variable demonstrated an odds ratio of 0.67 for the VATS group when adjusted for propensity score (Table 8B ).
|
|
|
|
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
However, these large series tend to favor VATS lobectomy inasmuch as they do not provide adequate thoracotomy comparison groups and may inadvertently exclude conversions of VATS to thoracotomy. A major problem in comparing VATS lobectomy from one study with thoracotomy survival from other studies is that populations may differ significantly with regard to patient tumor histologic types, sex, and stage. Such factors influence survival results and can mask any differences related to surgical technique. The theoretical advantages of decreased pain, shorter length of stay, better pulmonary function, and preservation of host immunity should lead to improved short- and long-term outcomes. However, VATS lobectomy must be supported by solid data if it is to gain greater acceptance in mainstream thoracic surgery practice.
Current published data comparing VATS with thoracotomy consist of a few underpowered randomized controlled trials. The quality and sample size of these studies do not permit statistically valid conclusions.11-14 One of the largest retrospective comparative studies from Watanabe and associates,15 which included more than 100 patients in each group, was imbalanced because of a greater number of T2 lesions in the thoracotomy patient group.
In addition, the vast majority of comparative studies fail to adhere to the intention-to-treat principle, a major design flaw that would inherently bias results in favor of VATS lobectomy. Indeed, many comparative studies demonstrate a survival benefit in favor of VATS lobectomy that is frequently attributed to better outcome from less chest wall trauma.16-18 However, it is more likely that the thoracotomy group includes converted cases that are likely to be higher stage and more technically difficult then those performed by VATS.
Published conversion rates from VATS to thoracotomy range from 1.6% to 19%.1,3,8,9 These results may be inaccurate because of retrospective data acquisition. Our study benefits from routine prospective data collections performed weekly by our group with review by the involved surgical attending staff. Indications for VATS lobectomy as well as thresholds for conversions vary among surgeons, and these factors change over time as the surgeon gains more experience with the procedure.
Our cohort of patients was well balanced in all categories between the thoracotomy and VATS lobectomy groups, therefore minimizing bias from known confounders. Preoperative comorbidities were similar. Although more patients were labeled as having chronic obstructive pulmonary disease in the thoracotomy group, smoking history was similar and preoperative FEV1 and DLCO differed between the two groups by only 4% and 6%, respectively. The thoracotomy group had a mean of one extranodal station sampled; however, there were no significant differences in stage distribution or overall survival. Nodal evaluation is dependent on effort and surgeon and is not due to any technical limitation of VATS. For example, when operating on upper lobe tumors by VATS, we rarely take down the inferior pulmonary ligament and dissect out the level 9 nodes, thus reducing the total number of nodal stations sampled by one. However, the value of such additional sampling is debatable inasmuch as level 9 nodal metastases are rare for upper lobe tumors.
The propensity score–matched analysis supported the results of the raw data. Survival among the different propensity score groupings demonstrated similar survival between VATS and thoracotomy groups and fewer complications and shorter length of stay for the VATS group.
This study also demonstrates that thoracotomy for lung cancer can be performed with an excellent outcome. Interestingly, conversion from VATS to thoracotomy does not appear to pose an increased risk of complications other than those associated with thoracotomy alone. Conversion in the regression model is an interaction term because only patients undergoing VATS can be converted. The regression coefficient of VATS (–0.3) was equal and opposite in sign to that of patients converted from VATS to thoracotomy (0.3), indicating that complications from the conversion of VATS to thoracotomy were the same as for primary thoracotomy. The small difference in complication rate and low operative mortality underscores the effectiveness of lobectomy by thoracotomy even after conversion; therefore, any VATS case in which oncologic principles may be compromised should be converted to thoracotomy.
Limitations of the Study
Every study has limitations. Our data lack narcotic information, a validated pain scale, and an objective measurement of postoperative pulmonary function. Although the data in this study were gathered prospectively, the analysis was performed retrospectively; therefore, unknown confounding variables and inherent selection biases could exist. The comparisons in this study are inextricably confounded with systematic surgeon selection bias: 100% of the VATS lobectomies are performed by four surgeons whereas two of the surgeons only perform thoracotomy. Thus, complications may be based on unrecorded surgeon-related factors that cannot be separated from those intrinsic to the approach. However, given the experience and the expertise of the two surgeons performing thoracotomy, we believe this is unlikely.
A randomized controlled trial is considered to be the gold standard to demonstrate superiority of one procedure over another, but it may not be feasible in many situations. However, an adequately powered randomized controlled trial on this topic is unlikely because many VATS surgeons are unwilling to randomize patients and many patients tend to seek out surgeons who are willing to perform this procedure.
On the basis of the presented data, VATS lobectomy and thoracotomy are both acceptable procedures for the treatment of lung cancer and are associated with similar long-term survivals. However, VATS lobectomy is associated with fewer complications and a significantly decreased length of hospital stay. Nevertheless, the performance of an oncologically sound operation must take priority over a suboptimal VATS lobectomy, and conversion to thoracotomy should be performed in situations in which the extent of disease mandates an open procedure for complete resection.
|
Acknowledgments |
|---|
|
Footnotes |
|---|
|
References |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
This article has been cited by other articles:
|
|
 |
|
  H. Launer, D. V. Nguyen, and D. T. Cooke National perioperative outcomes of pulmonary lobectomy for cancer in the obese patient: A propensity score matched analysis J. Thorac. Cardiovasc. Surg., May 1, 2013; 145(5): 1312 - 1318. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. Khanbhai, J. Dunning, K. H. Yap, and K. S. Rammohan Dissection of the pulmonary ligament during upper lobectomy: is it necessary? Interact CardioVasc Thorac Surg, April 28, 2013; (2013) ivt144v1. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C.-H. Marty-Ane, L. Canaud, L. Solovei, P. Alric, and J.-P. Berthet Video-assisted thoracoscopic lobectomy: an unavoidable trend? A retrospective single-institution series of 410 cases Interact CardioVasc Thorac Surg, April 16, 2013; (2013) ivt146v1. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. Paul, A. Sedrakyan, Y.-l. Chiu, A. Nasar, J. L. Port, P. C. Lee, B. M. Stiles, and N. K. Altorki Outcomes after lobectomy using thoracoscopy vs thoracotomy: a comparative effectiveness analysis utilizing the Nationwide Inpatient Sample database Eur J Cardiothorac Surg, April 1, 2013; 43(4): 813 - 817. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T. Crabtree, V. Puri, R. Timmerman, H. Fernando, J. Bradley, P. A. Decker, R. Paulus, J. B. Putnum Jr., D. E. Dupuy, and B. Meyers Treatment of stage I lung cancer in high-risk and inoperable patients: Comparison of prospective clinical trials using stereotactic body radiotherapy (RTOG 0236), sublobar resection (ACOSOG Z4032), and radiofrequency ablation (ACOSOG Z4033) J. Thorac. Cardiovasc. Surg., March 1, 2013; 145(3): 692 - 699. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. Cao, C. Manganas, S. C. Ang, S. Peeceeyen, and T. D. Yan Video-assisted thoracic surgery versus open thoracotomy for non-small cell lung cancer: a meta-analysis of propensity score-matched patients Interact CardioVasc Thorac Surg, March 1, 2013; 16(3): 244 - 249. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
E. Taioli, D.-S. Lee, M. Lesser, and R. Flores Long-term survival in video-assisted thoracoscopic lobectomy vs open lobectomy in lung-cancer patients: a meta-analysis Eur J Cardiothorac Surg, February 14, 2013; (2013) ezt051v1. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
Z. Zhang, Y. Zhang, H. Feng, Z. Yao, J. Teng, D. Wei, and D. Liu Is video-assisted thoracic surgery lobectomy better than thoracotomy for early-stage non-small-cell lung cancer? A systematic review and meta-analysis Eur J Cardiothorac Surg, January 30, 2013; (2013) ezt015v1. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
N. M. Rueth, H. M. Parsons, E. B. Habermann, S. S. Groth, B. A. Virnig, T. M. Tuttle, R. S. Andrade, M. A. Maddaus, and J. D'Cunha Surgical treatment of lung cancer: Predicting postoperative morbidity in the elderly population J. Thorac. Cardiovasc. Surg., June 1, 2012; 143(6): 1314 - 1323. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. F. Berry, M. W. Onaitis, B. C. Tong, S. S. Balderson, D. H. Harpole, and T. A. D'Amico Feasibility of hybrid thoracoscopic lobectomy and en-bloc chest wall resection Eur J Cardiothorac Surg, April 1, 2012; 41(4): 888 - 892. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 H. S. Park, F. C. Detterbeck, D. J. Boffa, and A. W. Kim Impact of Hospital Volume of Thoracoscopic Lobectomy on Primary Lung Cancer Outcomes Ann. Thorac. Surg., February 1, 2012; 93(2): 372 - 379. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
B. J. Park, F. Melfi, A. Mussi, P. Maisonneuve, L. Spaggiari, R. K. C. Da Silva, and G. Veronesi Robotic lobectomy for non-small cell lung cancer (NSCLC): Long-term oncologic results J. Thorac. Cardiovasc. Surg., February 1, 2012; 143(2): 383 - 389. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. M. Flores, U. Ihekweazu, J. Dycoco, N. P. Rizk, V. W. Rusch, M. S. Bains, R. J. Downey, D. Finley, P. Adusumilli, I. Sarkaria, et al. Video-assisted thoracoscopic surgery (VATS) lobectomy: Catastrophic intraoperative complications J. Thorac. Cardiovasc. Surg., December 1, 2011; 142(6): 1412 - 1417. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. Takagi, M. Matsui, and T. Umemoto Long-Term Survival of VATS Versus Open Lobectomy Ann. Thorac. Surg., July 1, 2011; 92(1): 408 - 409. [Full Text] [PDF]
|
|
|
|
|
|
D. Gonzalez, M. de la Torre, M. Paradela, R. Fernandez, M. Delgado, J. Garcia, E. Fieira, and L. Mendez Video-assisted thoracic surgery lobectomy: 3-year initial experience with 200 cases Eur J Cardiothorac Surg, July 1, 2011; 40(1): e21 - e28. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. M. Flores, U. N. Ihekweazu, N. Rizk, J. Dycoco, M. S. Bains, R. J. Downey, P. Adusumilli, D. J. Finley, J. Huang, V. W. Rusch, et al. Patterns of recurrence and incidence of second primary tumors after lobectomy by means of video-assisted thoracoscopic surgery (VATS) versus thoracotomy for lung cancer J. Thorac. Cardiovasc. Surg., January 1, 2011; 141(1): 59 - 64. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. K. Kim, Y. S. Choi, J. Kim, Y. M. Shim, and K. Kim Outcomes of unexpected pathologic N1 and N2 disease after video-assisted thoracic surgery lobectomy for clinical stage I non-small cell lung cancer J. Thorac. Cardiovasc. Surg., December 1, 2010; 140(6): 1288 - 1293. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Ninan and M. R. Dylewski Total port-access robot-assisted pulmonary lobectomy without utility thoracotomy Eur J Cardiothorac Surg, August 1, 2010; 38(2): 231 - 232. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
K. K. W. Lau, A. E. Martin-Ucar, A. Nakas, and D. A. Waller Lung cancer surgery in the breathless patient -- the benefits of avoiding the gold standard Eur J Cardiothorac Surg, July 1, 2010; 38(1): 6 - 13. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
N. M. Rueth and R. S. Andrade Is VATS Lobectomy Better: Perioperatively, Biologically and Oncologically? Ann. Thorac. Surg., June 1, 2010; 89(6): S2107 - S2111. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 L. Crino, W. Weder, J. van Meerbeeck, E. Felip, and On behalf of the ESMO Guidelines Working Group Early stage and locally advanced (non-metastatic) non-small-cell lung cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up Ann. Onc., May 1, 2010; 21(suppl_5): v103 - v115. [Full Text] [PDF]
|
|
|
|
 |
|
 J. P. Sculier, T. Berghmans, and A. P. Meert Update in Lung Cancer and Mesothelioma 2009 , April 15, 2010; 181(8): 773 - 781. [Full Text] [PDF]
|
|
|
|
|
|
S. Paul, N. K. Altorki, S. Sheng, P. C. Lee, D. H. Harpole, M. W. Onaitis, B. M. Stiles, J. L. Port, and T. A. D'Amico Thoracoscopic lobectomy is associated with lower morbidity than open lobectomy: A propensity-matched analysis from the STS database J. Thorac. Cardiovasc. Surg., February 1, 2010; 139(2): 366 - 378. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. Scarci, J. Pilling, K. Harrison-Phipps, C. Tennyson, and T. Routledge Right upper video-assisted thoracoscopic lobectomy for early stage lung cancer MMCTS, January 1, 2010; 2010(0416): mmcts.2009.004333 - mmcts.2009.004333. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
