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Ann Thorac Surg 2008;85:231-236. doi:10.1016/j.athoracsur.2007.07.080
© 2008 The Society of Thoracic Surgeons
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Right arrow Lung - cancer

Original Articles: General Thoracic

Use of Video-Assisted Thoracic Surgery for Lobectomy in the Elderly Results in Fewer Complications

Stephen M. Cattaneo, MDa, Bernard J. Park, MDa,*, Andrew S. Wilton, MSb, Venkatraman E. Seshan, PhDb, Manjit S. Bains, MDa, Robert J. Downey, MDa, Raja M. Flores, MDa, Nabil Rizk, MDa, Valerie W. Rusch, MDa

a Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
b Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, New York

Accepted for publication July 24, 2007.

* Address correspondence to Dr Park, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, Room C-867, New York, NY 10021 (Email: parkb{at}mskcc.org).

Presented at the Forty-third Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 29–31, 2007. Winner of the Geriatric Patient Care Award.


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 Discussion
 References
 
Background: The purpose of this study was to determine if the utilization of video-assisted thoracic surgery (VATS) for lobectomy for clinical stage I non-small cell lung cancer in elderly patients results in decreased complications compared with lobectomy by thoracotomy (THOR).

Methods: A retrospective, matched case-control study was performed evaluating the perioperative outcomes after lobectomy by VATS versus THOR performed in elderly patients (age ≥70 years) at a single institution. 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).

Results: Between May 1, 2002 and December 31, 2005 333 patients (245 THOR, 88 VATS) 70 years old or greater underwent lobectomy for clinical stage I non-small cell lung cancer. After matching based on age, gender, presence of comorbid conditions, and preoperative clinical stage, there were 82 patients in each group. Patients had similar preoperative characteristics. A VATS approach resulted in a significantly lower rate of complications compared with THOR (28% vs 45%, p = 0.04) and a shorter median length of stay (5 days, range 2 to 20 vs 6 days, range 2 to 27, p < 0.001). No patients undergoing VATS lobectomy had higher than grade 2 complications, whereas 7% of complications in the THOR group were grade 3 or higher. There were no perioperative deaths in the VATS patients compared with an in-hospital mortality rate of 3.6% (3 of 82) for THOR patients.

Conclusions: A VATS approach to lobectomy for clinical stage I non-small cell lung cancer in the elderly was associated with fewer and overall reduced severity of complications as well as a shorter hospital stay compared with thoracotomy.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 Discussion
 References
 
Lung cancer remains the leading cause of cancer-related mortality among men and women in the United States with an estimated 213,380 new cases and 160,390 deaths in 2007 [1]. Non-small cell lung cancer (NSCLC) accounts for roughly 80% of all lung cancer cases, and more than 50% of NSCLC patients are older than 65 years while over 30% are at least 70 years old at diagnosis [2, 3]. This, combined with the fact that the proportion of individuals over 65 years of age in the U.S. is rising, suggests that number of elderly lung cancer patients will only grow [4]. Large modern series analyzing postoperative mortality rates for lung cancer resections have demonstrated that extent of resection and increasing age are major determinants of surgical mortality [5, 6]. As a result, elderly patients traditionally have lower rates of pneumonectomy and higher rates of sublobar resections than younger patients, despite the fact that sublobar resections can have up to a threefold higher risk of local recurrence [7].

The technique of video-assisted thoracic surgery (VATS) pulmonary lobectomy for NSCLC, when employed with a non-rib spreading technique, has been shown to be associated with shorter hospital stay and decreased acute postoperative pain [8, 9]. Because of this and indications that the procedure is safe and oncologically acceptable in patients with clinical stage I disease, utilization of VATS lobectomy for primary surgical therapy of early stage NSCLC has been slowly increasing [10–14]. There is also a belief that use of a minimally invasive VATS technique may result in superior rates of postoperative morbidity when compared with thoracotomy, especially in elderly or high risk populations [15, 16].

However, relatively few studies have analyzed in detail whether the morbidity rate after VATS lobectomy is decreased in these patients when compared with those undergoing traditional thoracotomy. We decided to perform a case-control study analyzing the rate and types of postoperative morbidity in elderly patients undergoing lobectomy in order to determine if there is an advantage afforded by the minimally invasive VATS approach in this high-risk group.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 Discussion
 References
 
Approval for the study was obtained and the need for individual patient consent was waived by the Institutional Review Board. A prospectively maintained database of all patients undergoing thoracic surgery for lung cancer at a single institution, approved by the Institutional Review Board, was used to identify those patients greater than or equal to 70 years of age who underwent elective pulmonary lobectomy for clinical stage I NSCLC. Excluded were patients who underwent a lesser resection (exploration, wedge, or segmentectomy) or those who had a more extensive operation (bilobectomy, pneumonectomy, chest wall resection, or major vascular resection). Additionally, patients who received preoperative therapy in the form of systemic cytotoxic chemotherapy, radiation, or both were excluded from consideration.

Standard anesthesia induction and maintenance regimens, as well as intraoperative fluid restriction, were used for all patients. Postoperative pain relief was provided by continuous administration of epidural (usually fentanyl with bupivacaine 0.05%) or intravenous opioid administration. In all patients anatomic pulmonary lobectomy and ipsilateral mediastinal lymph node dissection were performed either by VATS or standard posterolateral thoracotomy under single lung ventilation. The VATS lobectomy was defined as anatomic pulmonary lobectomy using a video thoracoscope and three non-rib spreading incisions, the largest of which was a 3 to 4 cm utility incision. The detailed technique of VATS lobectomy employed at our institution has been previously described elsewhere [17]. Posterolateral thoracotomy was performed with division of the latissimus dorsi muscle and sparing of the serratus anterior muscle. The decision to employ either a VATS or thoracotomy approach was made by the surgeon. Four of the authors (BP, RF, NR, and VR) utilize VATS for early stage patients, whereas the other two authors (RD and MB) exclusively perform thoracotomy for such patients. Patients converted from VATS to thoracotomy were considered in the thoracotomy group. All patients remained overnight in the postanesthesia care unit on continuous telemetry and were then discharged to a dedicated thoracic surgical ward on the first postoperative day. Data on patient characteristics, operative details, and postoperative recovery were collected in a prospective database approved by the Institutional Review Board and analyzed retrospectively. 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).

Statistics
Cases were defined as patients undergoing VATS lobectomy, while controls were those patients having thoracotomy and lobectomy. Patients were matched based on age, gender, and presence of comorbid conditions. Only patients classified as preoperative clinical stage I were considered in this analysis. The data are summarized using frequency counts for categoric variables such as chronic obstructive pulmonary disease (COPD) and as median and range for continuous variables such as forced expiratory volume in 1 minute (FEV1). Differences between the VATS and thoracotomy groups were assessed using the Wilcoxon rank sum test for continuous variables and the {chi}2 or Fisher exact tests for categoric variables and a p value less than 0.05 was considered significant. Statistical analyses were performed using the R statistical software [18].


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 Discussion
 References
 
Review of the prospective database of thoracic surgical cases performed from May 2002 through December 2005 identified 333 patients who were greater than or equal to 70 years old at the time of surgery and underwent elective lobectomy for clinical stage I NSCLC. Of these 245 ultimately underwent thoracotomy, and 88 had a successful VATS approach. After matching for age, gender, number of comorbidities, and clinical stage, there were 164 patients eligible for analysis, 82 in each group. There were 3 patients in the thoracotomy group who initially underwent VATS but required conversion for bleeding. None of these individuals suffered significant complications or required transfusion at any time during the hospital stay. The patients in each group were well-matched with respect to preoperative characteristics (Table 1). The median age of patients was 76 years, and there were a higher proportion of women (60%). Most had one or fewer comorbid conditions with patients in the VATS group having a higher incidence of diabetes, but otherwise similar rates of COPD and cardiac disease. Preoperative lung function was excellent in both groups. The preoperative clinical stage was IA in the majority of individuals with only a few patients receiving any preoperative therapy. None received induction cytotoxic chemotherapy or radiotherapy.


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  		Table 1 Patient Characteristics
 
The perioperative results are demonstrated in Table 2. Patients in both the thoracotomy and VATS groups had similar median tumor size and histologies. There was no statistically significant difference in the distribution of pathologic stages with the majority of patients being stage I. Patients undergoing VATS lobectomy had a shorter length of stay compared with those having thoracotomy (median 5 days, range 2 to 20 days versus median 6 days, range 2 to 27 days, p < 0.001). In addition, the VATS group had a significantly lower overall rate of complications compared with the thoracotomy group (23 of 82 [28%] vs 37 of 82 [45%], p = 0.04). There were no perioperative deaths among patients undergoing VATS lobectomy, whereas there were 3 deaths (3.6% mortality) in the thoracotomy group although this difference was not statistically significant. All 3 deaths were the result of postoperative acute lung injury or acute respiratory distress syndrome.


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  		Table 2 Perioperative Data
 
When the number and grades of complications were analyzed further, a number of interesting trends were noted (Table 3). The majority patients in both groups had two or fewer complications. However, no VATS patients with complications had more than two, whereas 6 patients (7%) in the thoracotomy group had three or more. Similarly, most patients in each group had grade 1 or 2 complications, but grade 3 and higher complications were only seen in the thoracotomy group. This included 3 patients that died postoperatively of respiratory failure. Table 4 details the types of complications in each group. As expected, pulmonary and cardiac complications (predominantly arrhythmia) were the most common in both groups. There were, however, a higher proportion of patients in the thoracotomy group that developed postoperative pulmonary problems. The rate of postoperative atrial fibrillation was similar between groups.


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  		Table 3 Severity of Complications
 

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  		Table 4 Complication Profile
 

   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
Discussion
 References
 
The main finding of the present study is that postoperative complications after pulmonary lobectomy in an elderly patient population occurs with a lower frequency with a minimally invasive VATS approach compared with a traditional, rib-spreading thoracotomy. The overall morbidity rate was 28% in the VATS patients versus 45% in those undergoing thoracotomy. This is an important finding because it is well-established that operative morbidity and mortality rates for pulmonary resections rise with advancing patient age. Ginsberg and colleagues for the Lung Cancer Study Group [5] observed a 7.1% 30-day operative mortality rate in patients greater than or equal to 70 years (n = 453) versus 1.3% for patients younger than 60 years and 3.7% overall for 2,200 patients undergoing lung resection. Similarly, Damhuis and Schutte [6] noted from a series of 1,577 lung cancer patients undergoing resection that age and extent of resection were the major determinants of operative risk. Operative mortality in that series was 4.0% for patients age 70 years and older (n = 521) versus 1.4% for patients younger than 60 years.

Chronologic age, however, is not an absolute risk factor for morbidity and mortality after lung cancer resection. It is clear from a number of studies that in carefully selected elderly patients, lung cancer resection can be performed safely with operative mortality rates similar to that seen in their younger counterparts [19–24]. Cerfolio and Bryant [24] reported no difference in overall morbidity or mortality between elderly (≥70 years, n = 363) and controls (<70 years, n = 363) matched in a nested case-control study of patients undergoing anatomic pulmonary resection for NSCLC. Postoperative morbidity in most of these series ranged from 20% to 58%, reflecting that the potential for complications in the elderly population is significant.

Proponents of VATS for anatomic lung resection emphasize the benefits of decreased acute postoperative pain, shorter chest tube duration, and consequently, shorter hospital stays. In the present study we observed that the VATS group had a shorter median length of stay compared with the thoracotomy group by 1 day. In addition, some authors have attempted to show that a less invasive approach to lung resection results in fewer postoperative complications in high-risk patients, such as the elderly, that might not otherwise tolerate thoracotomy [15, 16]. Only a few studies have reviewed outcomes of VATS lobectomy in older patients, primarily in octogenarians [25–27]. All demonstrated acceptable results employing minimally invasive techniques. In particular, McVay and colleagues [27] reported an overall complication rate of only 18% and operative mortality of 1.8% in 159 consecutive octogenarians undergoing VATS lobectomy. Koizumi and colleagues [25] published the only study attempting to compare elderly patients undergoing VATS versus those having standard thoracotomy, but failed to show any difference in morbidity or mortality in part because of low patient numbers (17 VATS, 15 thoracotomy).

In contrast the present study achieved matching a sufficient number of patients in each group in order to show not only a lower complication rate associated with VATS, but a lower proportion of patients with one or more complications. Moreover, VATS patients tended to have lower grades of complications compared with patients undergoing thoracotomy. The exact mechanisms by which complications are reduced are not known; however, we also observed that the rate of pulmonary complications in the thoracotomy group was slightly higher that in the VATS group. This suggests that perhaps limiting chest wall trauma by employing VATS may help reduce pulmonary morbidity, which in turn reduces the overall rate of operative complications. This notion is supported by a previous study by Kaseda and colleagues [11] showing that the use of VATS resulted in improved immediate postoperative pulmonary function compared with a thoracotomy approach.

Strengths and Limitations
There are several strengths of this study. First, we evaluated an important and timely issue: whether a minimally invasive VATS approach is associated with lower postoperative morbidity after anatomic lung resection compared with standard rib-spreading thoracotomy in an ever increasing elderly population of lung cancer patients. Second, the recording and grading of complications were done uniformly and consistently employing the National Cancer Institute’s Common Terminology Criteria for Adverse Events version 3.0. Third, by matching patients we have attempted to eliminate selection bias as rigorously as possible outside of the setting of a randomized, prospective study.

However, there are also several limitations to our study. First, we did not exclude patients from analysis if they had an initial VATS that was converted to thoracotomy, choosing to include them in the thoracotomy group. While it did not appear that this subset of the thoracotomy patients had significant complications and therefore did not bias the results in favor of the VATS group, bias may have been introduced. Second, despite matching, this is still a retrospective analysis, and there may be inequalities between groups both known (higher rate of diabetes in the VATS patients) and unknown (what proportion of thoracotomy patients could have had VATS). Lastly, while the results suggest that the operative approach is associated with a lower rate of postoperative complications, the data do not conclusively indicate the precise mechanism by which VATS reduces postoperative complications.

Conclusions and Clinical Implications
Postoperative complications in older patients undergoing anatomic pulmonary resection are common and contribute to prolonged hospitalization and associated healthcare costs. Compared with standard thoracotomy, successful utilization of a minimally invasive, non-rib spreading VATS approach for resection of early stage bronchogenic carcinoma is associated with reduced incidence and severity of postoperative complications in the elderly. A thoracoscopic approach to anatomic resection of early stage lung cancer may be preferred in these and possibly other high-risk patients. This issue warrants additional investigation.


   Discussion
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Discussion
References
 
DR ROBERT J. CERFOLIO (Birmingham, AL): Excellent presentation and great data. Let me just ask you a question. This is the second or third paper that I’ve heard presented at this meeting that has concluded that there is a lower incidence of air leak with a VATS lobectomy when compared to an open lobectomy. And I purport to you you’re doing your open lobectomy wrong. Are you doing a fissure-less technique when you do the open lobectomy, or is it being performed differently by surgeons who are digging in the fissure? I suspect your older surgeons do it the "the old way" and the younger surgeons do the "new way." It is not the VATS, it is how the fissure is being handled. I suggest we should all do lung cancer surgery that allows for bimanual palpation of the lung but performed fissure-less surgery. Do you have any data on that?

DR CATTANEO: One-half of the group performs lobectomy exclusively by thoracotomy, whereas the other half will utilize a VATS approach for early stage disease. I don’t have specific data on whether during thoracotomy the fissure is routinely explored first, but our study is retrospective and therefore limited by not controlling for differences in surgical technique. In addition, there was no difference in rate of air leak between groups, thus I do not believe this contributed to our results.

DR CERFOLIO: I would say the way to do this, is to get a surgeon who does both—now, I may do a VATS lobectomy rarely but only for benign disease, but I do not for cancer—and there is no difference, but get a surgeon who does VATS and open lobes frequently and then see if there is a difference, and I don’t think you’ll find one.

DR CATTANEO: That would be potentially interesting but would introduce bias between groups because of inherent surgeon selection biases as to those patients offered a VATS versus an open lobectomy.

DR THOMAS A. D’AMICO: I enjoyed your paper, your presentation, and congratulations on winning the Geriatric Patient Care Award.

DR CATTANEO: Thank you.

DR D’AMICO: I have a couple of questions regarding the geriatric issues. Did you look at the incidence of confusion or delirium, the neurologic complications? Since you have a prospective database, you might have that. And secondly, what is the rate of discharge to a nonhome facility, and does a thoracoscopic lobectomy improve that as well?

DR CATTANEO: There were very few neurologic complications. One patient in the thoracotomy group suffered a debilitating stroke, and three patients in the VATS group suffered minor delirium. The numbers were too small, however, to show a meaningful difference.

DR D’AMICO: Does your database capture postoperative confusion as a complication?

DR CATTANEO: Yes, it does. To answer your second question, we don’t capture, in our database, whether the patients go home directly or whether they temporarily go to a rehab facility. However, the majority of patients, particularly those not suffering complications, are discharged to home in the care of a family member or spouse.

DR G. ALEXANDER PATTERSON (St. Louis, MO): Can I just make a comment. For those of you who are gathering data prospectively and entering into databases, it’s my own view that delirium is vastly underreported. We just looked at our own data in our group and delirium is right up there with air leaks. And it’s not just because people in Missouri are crazy. It’s a huge, huge problem. And the hospitals, nationally, they’re being measured by what they’re doing about common problems—deep venous thrombosis, postoperative heparin-induced thrombocytopenia—and this is another one, delirium. Hospitals are paying close attention to that, and we need to be doing so as well.

DR CATTANEO: To continue with that thought, I think part of the reason that our rates of delirium were so low is that the vast majority of the patients had epidural analgesia. Especially in this elderly group of patients, I think that’s an important component of postoperative management.

DR MICHAEL S. MULLIGAN (Seattle, WA): I want to caution you about that. And I suspect that that’s one of the reasons that your length of stay differential wasn’t that great, because you were using epidural analgesia in the VATS population probably a little bit too liberally. Most of us who do VATS pretty aggressively are pretty conservative of who gets an epidural, because they are treated on protocol by the pain service and that typically adds a day to two to the hospital stay. So I don’t think it’s necessary in most of these folks, and I suspect your length-of-stay data would have been even better had you not used it so aggressively.

DR CATTANEO: Yes.

DR CERFOLIO: Well, I think that’s a good point. But I wanted to address your point about the epidural. And I think it’s an outstanding point, that as surgeons we lose control of the patient. And so although I hate to use a chronologic cutoff, I do not use epidurals in patients that undergo open lobectomy thoracotomy. We don’t use an epidural if they’re 73 or 74 and older, for exactly the points that you relate. They all get confused, they all get delirium. And maybe they’ve got the same problem in Alabama that you have in the Midwest, maybe they come in that way, but I think by avoiding the epidural you’re actually able to have a conversation with your patient on postoperative day 1 and 2 instead of asking them, Who is the president?

DR HYUN-SUNG LEE (Goyang, Korea): Thank you for your nice presentation. I have a question regarding the method of statistical analysis. Your data were analyzed with a matched case-control study. I think you did patient selection. Did you perform the risk factor analysis between many variables and the complications that you mentioned in 333 patients? Through another statistical analysis, the conclusion that VATS lobectomy in the elderly leads fewer complications is constant?

DR CATTANEO: No, we did not. Within the limitations of a retrospective analysis, we attempted to match the two groups as best we could. And so we chose four factors, matched the patients, and then did our analysis of the complications subsequent to that. It would be interesting to go back and take a look; however, I suspect the populations are going to differ a fair bit without matching, and I’m not sure what conclusions we would be able to draw.

DR MULLIGAN: I have one favor to ask, and that is, I know you didn’t present it, you probably have this data somewhere because your registry is so good, but I’d like to know, of those patients, based on stage, postresection stage, some of these folks got chemotherapy after they were done, and I’d like to know whether or not you can define a difference in tolerance to chemotherapy between your VATS and open group? We tend to track short-term outcomes, but I’d like to know whether or not physiologically you have patients who were tolerating chemotherapy better with VATS or open, or if there is absolutely no difference?

DR D’AMICO: If I could just address Dr Mulligan’s question. We presented that at the Southern Thoracic this year, our experience with adjuvant therapy, and we demonstrated that patients after a thoracoscopic lobectomy had fewer missed doses and greater total compliance in terms of percent of planned therapy.

DR MULLIGAN: I think that’s going to turn out to be one of the greatest benefits of VATS lobectomy. I think that’s what’s going to stem the tide. Thank you very much, Dr D’Amico, for making that comment.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Discussion
 References
 

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Safety and efficacy of video-assisted versus conventional lung resection for lung cancer.
J. Thorac. Cardiovasc. Surg., June 1, 2009; 137(6): 1415 - 1421.
[Abstract] [Full Text] [PDF]

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 Mayo Clin Proc.Home page
S. C. Tomaszek, S. D. Cassivi, K. R. Shen, M. S. Allen, F. C. Nichols III, C. Deschamps, and D. A. Wigle
Clinical Outcomes of Video-Assisted Thoracoscopic Lobectomy
Mayo Clin. Proc., June 1, 2009; 84(6): 509 - 513.
[Abstract] [Full Text] [PDF]

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 Ann. Thorac. Surg.Home page
F. Farjah, D. R. Flum, T. K. Varghese Jr, R. G. Symons, and D. E. Wood
Surgeon Specialty and Long-Term Survival After Pulmonary Resection for Lung Cancer
Ann. Thorac. Surg., April 1, 2009; 87(4): 995 - 1006.
[Abstract] [Full Text] [PDF]

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