Review Article
Is Video-Assisted Thoracic Surgery Lobectomy the Best Choice for the Treatment of Lung Cancer?
Giulio Maurizi1*, Mohsen Ibrahim1, Antonio D’Andrilli1, Anna Maria Ciccone1, Claudio Andreetti1, Camilla Poggi1, Camilla Vanni1, Federico Venuta2,3 and Erino Angelo Rendina1,3
1Division of Thoracic Surgery, Sapienza University of Rome, Italy
2Division of Thoracic Surgery, Sapienza University of Rome, Italy
3Lorillard Spencer Cenci Foundation, Italy
*Corresponding author: Giulio Maurizi, Department of Thoracic Surgery, Sapienza University of Rome– “Sant’Andrea” Hospital, Via di Grottarossa, 1035, 00189 Rome, Italy
Published: 23 Sep, 2016
Cite this article as: Maurizi G, Ibrahim M, D’Andrilli A,
Ciccone AM, Andreetti C, Poggi C, et
al. Is Video-Assisted Thoracic Surgery
Lobectomy the Best Choice for the
Treatment of Lung Cancer?. Clin Surg.
2016; 1: 1137.
Abstract
Video-assisted lobectomy has proved to be safe and effective since it was initially reported in 1994.
Over time, many comparative studies have shown that video-assisted thoracic surgery (VATS)
lobectomy is better than open lobectomy in terms of postoperative complications and length of
hospital stay (LOS). There is also evidence suggesting that acute and chronic postoperative pain
rates are lower after VATS lobectomy than after open lobectomy.
An accurate lymphadenectomy can be performed easily and safely during VATS lobectomy;
however its completeness is still being debated, particularly in terms of peribronchial and hilar
lymph node evaluation.
Previous data have shown that VATS lobectomy is indicated for the treatment of early stage lung
cancer. Long-term oncologic results in patients with early stage non-small cell lung cancer (NSCLC)
appear to be comparable between VATS and open lobectomy.
Published experiences showing have shown good results after VATS lobectomy for advanced stage
lung cancer and after VATS lobectomy associated with bronchoplasty and/or angioplasty have
appeared.
More recently, cost analysis studies have reported that the overall cost of VATS is similar or
less than open lobectomy because of its association with shorter LOS, faster recovery, and fewer
adverse events. Moreover, the economic impact of the VATS approach is magnified with increased
experience of the surgeon.
Nevertheless, to the best of our knowledge, a large prospective and randomized multi-institutional
study comparing results of patients undergoing VATS lobectomy with those of patients undergoing
open lobectomy has never been conducted. Therefore, a large clinical trial is needed in order to
validate the results shown in previous studies and clarify some controversial aspects.
Keywords: VATS lobectomy; Open lobectomy; NSCLC
Introduction
Since it was initially reported in 1994, lobectomy performed using a video-assisted approach has
proved to be safe and effective [1 and 2]. Published experiences since then suggest that video-assisted
thoracic surgery (VATS) lobectomy is indicated for the treatment of early-stage lung cancer.
Although no large prospective, randomized, controlled trial has compared VATS lobectomy with
lobectomy performed via open thoracotomy, over time many well designed retrospective studies
have consistently shown that VATS has comparable oncologic outcomes and is associated with fewer
complications, reduced length of hospital stay, improvement in patient quality of life, and superior
tolerance of adjuvant therapies [3 and 4]. Moreover, some authors have suggested the possibility of a
potential survival benefit after VATS lobectomy due to the resulting decreased release of cytokines
which would reduce the level of postoperative immunosuppression [5,6].
Recent reports have examined the feasibility of bronchial and/or vascular sleeve lobectomy
performed by VATS rather than by standard thoracotomy approaches. Other investigations
examined acute and chronic postoperative pain and quality of life evaluation after VATS lobectomy.
Cost analyses of VATS lobectomy and lymphadenectomy during VATS lobectomy are two
crucial areas that need to be evaluated. The latter main aspects will be
the object of the present literature data review.
Early stage lung cancer: results of surgery
The current indication for VATS lobectomy is the treatment of
early stage lung cancer.
Since the initial reports of McKenna and Roviaro, other published
experiences have confirmed this indication and showed comparable
results with those of patients undergoing open lobectomy. [Table 1]
[7-15].
A systematic review from Whitson et al. [16] including 39
studies with an aggregate number of 3,256 thoracotomy lobectomy
patients and 3,114 VATS lobectomy patients, demonstrated that
VATS lobectomy, when compared to thoracotomy, was associated
with significantly shorter chest tube insertion duration, shorter LOS,
and improved survival (4 years after pulmonary resection). Their
data analysis concluded that compared to lobectomy performed by
thoracotomy, VATS lobectomy for patients with early-stage nonsmall
cell lung cancer (NSCLC) had lower morbidity and improved
survival rates.
In 2006, McKenna et al. [17] reported short term and long term
results on more than 1,000 VATS lobectomies. The patients included
in this series experienced a median LOS of 3 days, a mortality rate
of 0.8%, and a postoperative complication rate of 15.3%. Five year
survival rates based on the pathological stage were comparable than
those of other published series, including open lobectomy patients.
In 2009, Flores et al. [12] compared long-term outcomes of 398
patients who had undergone triportal VATS lobectomy with those
of 343 patients who had undergone posterolateral thoracotomy
lobectomy for NSCLC. They found significant differences in terms
of complications and 5-year survival rates (VATS group 79% vs.
thoracotomy group 75%, p=0.08). They also reported a statistically
significant difference between the VATS group and open thoracotomy
group in terms of LOS; VATS lobectomy patient LOS was 2 days
shorter than thoracotomy patients (p=0.0001).
Although literature data suggested comparable survival rates
between the two surgical approaches to lobectomy, published series
showed overall better short term results after VATS lobectomy. In
2010, data from 752 patients of the American College of Surgeons
Oncology Group Z0030 randomized clinical trial [18] were used to
construct propensity scores for VATS versus open lobectomy. The
median operative time was shorter for VATS lobectomy (VATS 117.5
min vs. 171.5 min, p< 0.001). Patients undergoing VATS lobectomy
had fewer chest tube placement lasting longer than 7 days (1.5%
vs. 10.8%, p=0.29) and shorter median LOS (5 days vs. 7 days). No
difference in operative mortality was observed between the two
groups.
Another propensity-matched analysis of outcome comparing
VATS versus open lobectomy for primary lung cancer was published
by Falcoz et al. [15] in 2015 using data from the European Society
of Thoracic Surgeons database. Results of two matched groups of
2,721 patients who underwent surgery between 2007 and 2009 were
compared. They reported the VATS group had significantly lower
rates of postoperative complications (29.1% vs. 31.7%, p=0.03); 2 days
shorter LOS (7.8 days vs. 9.8 days, p=0.0003); and lower mortality
rates (1% vs. 1.9%, p=0.02).
In 2013, CAI et al. [19] published a meta-analysis of VATS
versus open lobectomy. A total of 23 studies that included only
Stage I NSCLC patients were evaluated; 21 were retrospective and
2 prospective. According to their analysis, VATS was associated
with increased 5-year survival (p≤ 0.001), higher local recurrence
rate (p=0.001), similar distant recurrence rate (p=0.8), and lower
complication rate (p=0.013) compared to open lobectomy.
Tumors infiltrating the bronchus and/or the pulmonary artery
Some authors have reported single case or small case-series of
patients undergoing sleeve lobectomy by VATS; the latter authors
reported good short and medium term results [20,21]. Gonzalez-
Rivas et al. [22-23] also examined on the uniportal VATS “y” sleeve
lobectomy and uniportal VATS double sleeve lobectomy and showed
encouraging results. A recent retrospective study from Zhou et al.
[24] compared results of 10 patients who underwent VATS sleeve
resections with patients who underwent open sleeve lobectomy. No
significant differences were found in terms of complications (p=0.57)
and 3 and 4 year survival rates (VATS: 73% and 40% vs. open: 63%
and 56%, p=0.58); while significant differences were observed in favor
of VATS patients in terms of shorter LOS (p=0.009) and in favor of
open patients in terms of operating time (p=0.001).
Lymphadenectomy
One of the chief concerns of VATS lobectomy is that lymph node
dissection may be inadequate. However, these concerns seem to be
unjustified, as studies have indicated that a standard lobectomy with
lymph node dissection can be performed via VATS [25-26].
A comparative study from Sugi et al. [5] (including 48 VATS
lobectomy and 52 open lobectomy cases) reported an overall mean
number of 8 hilar and 13 mediastinal lymph nodes removed, with no
significant differences between VATS and open lobectomy. Five-year
survival rates were 90% and 85% after VATS and open lobectomy,
respectively (p=ns); while reported locoregional recurrence rates
were 10% after VATS and 19% after open lobectomy. Sagawa et al
[27] reported a series that included 35 patients who underwent
VATS lobectomy for stage-I lung cancer and sequential lymph node
stations re-exploration by minithoracotomy to assess the adequacy
of lymph node evaluation during VATS. They showed a 2-3% rate
of resectable nodes underestimated by VATS, with a mean number
of 40.3 lymph nodes removed on the right side and 37.1 on the left
side. Data from the ACOSOG Z0030 clinical trial showed that the
median total number of lymph nodes retrieved was similar between
VATS and open lobectomy (VATS group: 15 nodes vs. open group:
19 nodes, p=0.14) [18].
Conversely, an important comparative study between VATS and
open lobectomy patients showed that the open approach provided
a significantly higher number of lymph node stations removed than
VATS [Table 2] [12].
Whitson et al. [10] reported an overall significant higher (mean)
number of lymph nodes retrieved after open lobectomy. Interestingly,
this paper also reported that the number of lymph nodes collected
for the last 10 patients in each approach was similar, with a mean of
14 nodes for thoracotomy and 10 nodes for VATS (p=0.2551), thus
indicating that the number of lymph nodes collected over time in (all
59) VATS patients increased.
In a 2010 paper, Kim et al. [28] reported that patients with
pathological N1 and N2 tumors after VATS lobectomy had a 3-year
survival rate of 98% and 89%, respectively, with no differences in
comparison to open lobectomy. These data suggest that even if lymph
node involvement is found during VATS operations for clinical
stage-I disease, conversion to an open procedure is not necessary.
Pain and quality of life
The efficacy of VATS lobectomy has been validated in terms of
postoperative morbidity including pain and quality of life [29-30],
with an extremely low rate of complications [31]. However, many
other studies have compared the minimally invasive technique with
the standard posterolateral thoracotomy. A recent study from the
current authors that compared lobectomy executed through VATS
versus an open muscle-sparing mini-thoracotomy [32].
The above mentioned study demonstrated that the incidence
of severe intraoperative complication during VATS lobectomy
was low and similar to open lobectomy. The severe intraoperative
complications during VATS lobectomy are manageable, and the
surgeons need to take proper caution in performing VATS lobectomy.
The conversion rate to open surgery in our experience is very low
(3 patients, 4.00%). The authors found in patients who underwent
VATS lobectomy lower pain scores. The differences between mean
postoperative pain values were significant at 1, 12, 24 and 48 h (6.24
vs. 8.74, 5.16 vs. 7.66, 4.19 vs. 6.89, 2.23 vs. 5.33; P=0.000). Reduced
hospital stay (median: 4.00 vs. 6.00) was not normally distributed and
it did not significantly different (p=0.088). Quality of life functional
results showed significant differences, as FEV1 and 6MWT values
(FEV1: p=0.028; 6MWT: p=0.000; comparisons: p=0.000) were better
in the VATS group [32].
Cost analysis
One of the main issues that has limited the wide acceptance of
VATS lobectomy has been the presumed increased cost of VATS.
Although VATS lobectomy offers advantages with regard to pain,
respiratory function, and mobility, concern is often expressed
regarding the costs of stapling devices and increased operative time.
Casali and Walker [33] compared the costs of VATS and open
lobectomy in order to assess the overall economic sustainability of a
VATS program. More recently, a cost analysis study reported that the
overall cost of VATS is similar to or less than that of open lobectomy
due to its association with shorter LOS, faster recovery, and fewer
adverse events [34].
In a retrospective multi-institutional North American database
analysis [35] where a total of 3,961 patients underwent lobectomy
(open: 2,907, VATS: 1,054), hospital costs were higher for open
versus VATS. However, adjustment for the surgeon’s experience with
VATS over the 6 months prior to each operation showed a significant
association between surgeon experience and cost; indicating that the
economic impact of the VATS approach is magnified with increasing
surgeon’s experience.
Recently, a multi-institutional taskforce assessed a risk-adjusted
financial model to estimate the cost of a video-assisted thoracoscopic
surgery [36].
Table 1
Table 2
Conclusion
The shared conclusions of the main published experiences of the
use of VATS have shown that it has become the standard approach for
the surgical resection of early-stage lung cancer and provides excellent
results that are better than those of open lobectomy. In recent years,
some limited experiences have demonstrated the feasibility of VATS
even for complex lung sparing bronchovascular operations.
Lymph node dissection appears to be adequate during VATS
lobectomy and cost analyses performed up to now have shown
comparable or even better performance in favor of VATS.
Nevertheless, to the best of our knowledge, a large prospective and
randomized multi-institutional study comparing results of patients
undergoing VATS lobectomy with those of patients undergoing open
lobectomy has never been conducted. Therefore, a large clinical trial
is needed in order to validate the results that arise from published
series and to clarify some controversial aspects that are still under
debate.
Acknowledgment
We wish to thank Dr. Marta Silvi for data management and editorial work.
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