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Ann Thorac Surg 2007;83:1965-1970
© 2007 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Video-Assisted Thoracoscopic Surgery is More Favorable Than Thoracotomy for Resection of Clinical Stage I Non-Small Cell Lung Cancer

^a Department of Surgery, Section of Thoracic and Foregut Surgery, University of Minnesota Medical Center, Minneapolis, Minnesota
^b Department of Medicine, Division of Hematology, Oncology, and Transplantation, University of Minnesota Medical Center, Minneapolis, Minnesota

Accepted for publication January 23, 2007.

^_* Address correspondence to Dr Whitson, University of Minnesota Department of Surgery, MMC 207, 420 Delaware St SE, Minneapolis, MN 55455 (Email: bwhit{at}umn.edu).

	Abstract

Top Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Background: Lobectomy for patients with clinical stage I non-small cell lung cancer (NSCLC) can be performed by thoracotomy or by video-assisted thoracoscopic surgery (VATS). We compared the operative characteristics and postoperative course for patients with clinical stage I NSCLC who underwent lobectomy by VATS or thoracotomy.

Methods: We retrospectively reviewed the charts of all patients undergoing lobectomy for clinical stage I NSCLC from January 1, 1998, through June 30, 2005.

Results: We performed 147 lobectomies (88 thoracotomy, 59 VATS) in 147 patients with clinical stage I NSCLC. Patient demographics were similar between groups; however, VATS patients had more hypertension (p = 0.0114), chronic renal insufficiency (p = 0.0479), and previous malignancies (p = 0.0086). The two groups did not differ in pathologic stage, tumor size, histologic results, or number of positive nodes. More total nodes were identified in thoracotomy patients (p = 0.0001), and they had a shorter intensive care unit stay (p = 0.0224). VATS patients had significantly less postoperative pneumonia (p = 0.0023). VATS patients trended toward fewer chest tube days and a shorter hospital length of stay. The two groups did not differ in operative time, blood loss, atrial fibrillation, or number of ventilator days. Median survival between the cohorts was similar (>7.9 years thoracotomy versus >4.6 years VATS, log-rank p = 0.6939).

Conclusions: Patients undergoing VATS lobectomy for clinical stage I NSCLC, despite having more comorbidities, had fewer postoperative complications. The approaches are equivalent in operative time, blood loss, length of stay, and survival rate. Compared with thoracotomy, VATS lobectomy for patients with clinical stage I NSCLC appears to be a less morbid operation.

	Introduction

Top Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Early-stage non-small cell lung cancer (NSCLC) is primarily treated through surgical resection. For clinical stage I NSCLC, the procedure consists of a pulmonary lobectomy, which is typically performed with the intent of definitive cure. These lobectomies have traditionally been performed through a large thoracotomy incision; however, as instrumentation has become more refined and as visualization has improved, a minimally invasive approach to lobectomy with video-assisted thoracoscopic surgery (VATS) has developed. In a relatively short period, VATS lobectomies have become more frequent for resection of early-stage NSCLC.

Although VATS is now more frequent, objective comparisons of VATS versus thoracotomy patients’ outcomes and morbidity are not prevalent in the literature. The purported benefits of VATS over thoracotomy have been reported in series using only one surgical approach, in isolated case reports, or in anecdotes. Minimal data are available for directly comparing the two surgical approaches. The aim of our single-institution study was to directly compare the operative characteristics and postoperative courses for patients with clinical stage I NSCLC who underwent VATS versus thoracotomy.

	Material and Methods

Top Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Data Collection
The Institutional Review Board at the University of Minnesota approved this retrospective study (#0412E66312) with waiver of the need for individual consent. We reviewed the charts of all patients who underwent a single lobectomy for clinical stage I NSCLC from January 1, 1998, through June 30, 2005. These operations were performed on the Thoracic and Foregut Surgery Service at the University of Minnesota Medical Center. We gathered information on patient characteristics and their preoperative comorbidities, on operative details, on the hospital course, any 30-day complications, and overall survival. We grouped patients by the operation completed: thoracotomy or VATS.

Preoperative comorbidities examined were a history of tobacco use, hypertension, coronary artery disease, chronic obstructive pulmonary disease (COPD), diabetes mellitus, chronic renal insufficiency (baseline serum creatinine >1.5 mg/dL), and previous malignancy. Postoperative complications examined were reoperation, myocardial infarction, atrial fibrillation, a prolonged air leak (an air leak present on postoperative day [41]), and pneumonia as defined by the Centers for Disease Control (CDC) and Prevention guidelines [2–4]. The modified CDC guidelines used for a clinically defined pneumonia consisted of two or more chest roentgenograms where a new or worsening persistent infiltrate, consolidation, or cavitation was seen. In addition to the radiographic findings, the patient must have had either a fever (>38°C) with no other source, leucopenia, leucocytosis, or mental status changes with no other cause in someone aged older than 70 years. There must be two of the following: a change in the quality or quantity of the sputum; dyspnea, tachypnea or change in cough; rales or rhonchi; or a worsening of gas exchange [2–4].

Statistical Analysis
For statistical analyses, we used JMP 4.0.4 (SAS Institute Inc, Cary, NC) for Windows (Microsoft, Redmond WA). Unless otherwise noted, results are reported as means with associated p values. Ordinal and nominal data were analyzed with the ² test. Continuous data were analyzed with the independent sample t test. Kaplan-Meier actuarial survival curves were calculated and compared using the log-rank test. Survival time was defined as the time from surgery to death or last follow-up as recorded in the University of Minnesota Cancer Center Registry. A value of p < 0.05 was considered significant.

Surgical Technique
Thoracotomy and VATS were both performed with the patient in the lateral decubitus position. For VATS patients, we used three or four 1-cm incisions for trocar introduction, and an access incision of 4 to 6 cm for specimen retrieval in an endobag. The typical configuration used (Fig 1) consisted of a 10-mm camera port placed in the eighth intercostal space (ICS) at the anterior axillary line, a 10-mm accessory port placed in the ninth ICS as the mid-scapular line, and a 5-mm accessory port at the tip of the scapula. The access incision was placed in the third, fourth, or fifth ICS and centered on the anterior axillary line. Rib resection or rib spreading was not used in the VATS approach. Except for changes in lymph node resection (commented on below), there were no major variations in the parenchymal resections.

View larger version (70K): [in this window] [in a new window]   Fig 1. Typical setup for a left-sided video-assisted thoracoscopic lobectomy. Depending on which lobe is to be resected, the access incision and port intercostal level may be adjusted accordingly. (Reproduced from Whitson BA, et al, Operative Techniques in Thoracic and Cardiovascular Surgery, in Press, with permission from Elsevier, Inc.)

	Results

Top Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Patient Characteristics
We performed 147 single pulmonary lobectomies for patients with clinical stage I NSCLC during our study period. No VATS lobectomies were performed (Table 1) for the first 3 years of the study. In 2001 we began using VATS for lobectomy in clinical stage I NSCLC. Of the 147 lobectomies performed, thoracotomy was done in 88 and VATS in 59. The mean age was 64.9 years for the thoracotomy group and 67.1 years for the VATS group (p = 0.2841). The thoracotomy group consisted of 51.1% women and 48.9% men; the VATS group, 50.9% and 49.1% (p = 0.9726). There were 11 conversions, and these patients were analyzed as the operation completed (ie, thoracotomy). At the time of operation, mediastinoscopy was performed in 65.9% of the thoracotomy group and in 59.3% of the VATS group (p = 0.4177).

No significant differences were found in the preoperative pulmonary function in the subset of patients in whom pneumonia developed compared with those patients who did not develop pneumonia. The mean FEV₁ for those patients who developed pneumonia was 2.05 L compared with 2.03 L for those who did not develop pneumonia (p = 0.9279). The mean FVC for those patients who developed pneumonia was 3.21 L compared with 3.17 L for those who did not develop pneumonia (p = 0.9229).

Operative Details
We found no differences in operative time or estimated blood loss between the two groups (Table 3). No significant difference was found between groups in the location of the resected lesion or in the number of ventilator days. The median number of ventilator days for both groups was 0 days. The VATS group had a small, but significant, increase in the number of intensive care unit (ICU) days compared with the thoracotomy group; however, the median number of ICU days for both groups was 0 days. The VATS group had, on average, one less day with a chest tube; however, this difference was not significant (p = 0.0887). Similarly, the average hospital length of stay for the VATS group was 1.3 days shorter than for the thoracotomy group; again, this difference was not significant (p = 0.0772).

View larger version (9K): [in this window] [in a new window]   Fig 2. The number of lymph nodes collected is plotted as function of time of operation for the video-assisted thoracoscopic (VATS; filled boxes, solid trend line) and the thoracotomy approach (clear diamonds, dashed trend line). Each point displayed is the average of five consecutive cases, except for the final thoracotomy point, which contains three cases, and the final VATS, which contains 4 cases.

View larger version (16K): [in this window] [in a new window]   Fig 3. Kaplan-Meier curve for overall survival by video-assisted thoracoscopic (VATS; black line) and thoracotomy (gray line). The number of patients at risk is listed below the abscissa.

	Comment

Top Abstract Introduction Material and Methods Results Comment Acknowledgments References

Pneumonia
VATS is less painful than thoracotomy according to measurements at the time of surgery and also results in less sputum production [15]. This combination of less postoperative inflammation, less pain, and fewer secretions may have contributed to the beneficial effect of VATS on postoperative pneumonia in our series.

The rates of postthoracotomy pneumonia have been reported at 6.4% to 16% [16–18]. These series have been heterogeneous, consisting predominantly of series containing approximately 60% lobectomies and 20% wedge or segmental resections. When authors have specifically investigated patients undergoing lobectomy by thoracotomy, pneumonia rates are reported at 9% to 16.3% [19–21]. Large series of VATS lobectomies have demonstrated postoperative pneumonia rates of 1.2% to 5.6% [22–24]. A similar effect of minimally invasive surgery on pulmonary complication rates has been seen in esophagectomy patients. In their series of open transthoracic and transhiatal esophagectomies, Hulscher and colleagues [25] reported pulmonary complications in 42.3%, whereas the minimally invasive series by Luketich and colleagues [26] reported pneumonia in only 7.7%. Our series, which specifically evaluated lobectomy in patients with a defined disease process (ie, clinical stage I NSCLC) over a concurrent time period, demonstrated VATS to have significantly less postoperative pneumonia than thoracotomy. We believe this is the key finding of this directly comparative, retrospective study in lung cancer patients.

Length of Stay
In our series, we noted a trend among VATS patients toward a shorter length of hospital stay and fewer chest tube days. This effect was also shown by other researchers to be an advantage of VATS compared with thoracotomy [27]. In a large series of 1100 VATS lobectomies reported by McKenna [28], the mean length of hospital stay was 4.78 days. The VATS length of stay in our series is similar to McKenna [28].

Tube Thoracostomy Management
Throughout the study period, the management of tube thoracostomies evolved. Initially, in addition to a lack of an air leak, chest tube output needed to be less than a couple of hundred milliliters in a 24-hour period before tubes were removed. Our current chest tube management protocol is in line with that advocated by Cerfolio [1].

There is increased vigilance with patients at higher risk for a prolonged air leak. Such factors are steroid use, male gender, a large leak, a pneumothorax, or having undergone a lobectomy (our patient cohort) [29]. Initially, chest tubes are attached to –20 cm H₂O suction overnight, and then if there is no air leak, a small air leak, or small pneumothorax (if one is present at all) the patient is switched to water seal on morning rounds [30]. Typically, if there is drainage of less than 400 mL on postoperative day 2, one tube is removed. If there continues to be less than 400 mL and no air leak on postoperative day 3, the second tube is removed and the patient is discharged on postoperative day [41]. This management style has the potential for patients leaving the hospital earlier than has been traditionally held. This evolution over the study period may account for the trend toward less chest tube days in the VATS group.

Survival
Poor FEV₁ and poor pulmonary function are associated with worse postoperative survival [31], a fact that is increasingly accepted in the surgical community. In a small nonrandomized series, VATS patients have had better conservation of pulmonary function postoperatively and better survival rates compared with thoracotomy [9]. These trends may continue beyond the perioperative period.

Single-approach series of VATS patients showed 5-year survival rates of 63.6% to 97% [5, 7, 9, 32], and 3-year survival rates were about 80% [7]. One study that looked at the VATS approach for patients with clinical stage I disease found a 3-year survival rate of 79%, which improved to 89% for patients with pathologic stage I disease [33]. Patients with T1 lesions did better than those with T2 lesions, and those younger than 70 years did better than those aged older than 70 years [7]. In a series that compared a contemporary VATS series of 44 patients with a historical thoracotomy series of 77 patients, the overall 5-year survival rate for those with pathologic stage I disease was 97% for VATS versus 78.5% for thoracotomy [9]. This trend is encouraging, although the size of the lesions was not reported and the eras were distinct.

Morbidity
The VATS patients in our series, which had clinical stage I NSCLC, had more comorbidities, including significantly more hypertension, chronic renal insufficiency, and previous malignancies. They also tended to be older and to have more coronary artery disease. The thoracotomy group had a shorter ICU stays and more total nodes identified. The VATS group tended to have fewer chest tube days and a shorter length of hospital stay. Despite having more comorbidities, our VATS patients had less postoperative pneumonia and tended to have fewer reoperations with no difference in survival. A patient’s level of satisfaction with a procedure and the incidence of postoperative complications are related; the fewer the complications, the better the satisfaction [34].

Lymph Node Evaluation
In this series, the approach to the management of mediastinal lymph nodes in those patients undergoing thoracotomy was one of a complete mediastinal lymph node dissection. Those patients undergoing thoracotomy did not undergo a lymph node sampling, and this approach did not change throughout the study. The initial technique in the patients who underwent the VATS approach was one of mediastinal lymph node sampling; however, this approach evolved over a relatively short period to one of a lymph node dissection. This evolution was due to an improvement in our thoracoscopic operative skills and to a shift in our belief, based on published data, that better staging and patient outcomes are achieved with lymph node dissection compared with lymph node sampling. We currently routinely perform lymph node dissections in patients undergoing lobectomy for NSCLC by the VATS approach.

Future Implications
Larger, multiinstitutional prospective studies should be performed to more definitively evaluate the advantages of VATS over thoracotomy. One such trial is the Cancer and Leukemia Group B trial (CALGB Study 140501). This prospective registry trial aims to investigate outcome differences for patients with stage I NSCLC who undergo open thoracotomy and VATS. Specifically, it will evaluate quality of life, functional status, pain, medication use, and survival rates.

Conclusion
Our retrospective series demonstrated that compared with thoracotomy, VATS lobectomy for patients with clinical stage I NSCLC appears to be a less morbid operation, with an equivalent survival rate. A note of caution should be made because there can be a learning curve associated with performing VATS mediastinal lymph node dissections. Despite more comorbidities, the marked decrease in incidence of postoperative pneumonia in the VATS group makes a strong argument for further cultivation of this approach.

	Acknowledgments

Top Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
We would like to acknowledge Mary Knatterud, PhD, for her editorial assistance with this manuscript.

	References

Top Abstract Introduction Material and Methods Results Comment Acknowledgments References

 

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