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Ann Thorac Surg 2008;85:S705-S709. doi:10.1016/j.athoracsur.2007.11.048
© 2008 The Society of Thoracic Surgeons
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Supplement: The Minimally Invasive Thoracic Surgery Summit

Video-Assisted Thoracoscopic Lobectomy: State of the Art and Future Directions

Jason P. Shaw, MDa, Francine R. Dembitzer, MDb,c, Juan P. Wisnivesky, MD, MPHb, Virginia R. Litle, MDa, Todd S. Weiser, MDa, Jaime Yun, MDa, Cynthia Chin, MDa, Scott J. Swanson, MDa,*

a Department of Thoracic Surgery, The Mount Sinai Medical Center, New York, New York
b Departments of Medicine, The Mount Sinai Medical Center, New York, New York
c Department of Pathology, The Mount Sinai Medical Center, New York, New York

* Address correspondence to Dr Swanson, The Mount Sinai Medical Center, 1190 Fifth Ave, New York, NY 10029 (Email: scott.swanson{at}mountsinai.org).

Presented at the Minimally Invasive Thoracic Surgery Summit, New York, NY, June 8–9, 2007.


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
Background: Thoracoscopic lobectomy is performed with increasing frequency for early-stage lung cancer. Several published reports suggest thoracoscopic resection is safe, with the potential advantage of shorter hospital stay, quicker recovery, and comparable oncologic results.

Methods: Data on 180 video-assisted thoracoscopic surgery (VATS) patients who underwent thoracoscopic lobectomy or sublobar anatomic resection at our institution between January 2002 and December 2006 were reviewed. The conversion rate to thoracotomy, complications, length of stay, and duration of chest tube drainage were determined. Similar variables were evaluated for patients aged older than 80 years, those with a forced expiratory volume in 1 second (FEV1) that was less than 50% predicted, those who had undergone preoperative neoadjuvant therapy, and those who had undergone lung-sparing anatomic resections.

Results: Thoracoscopic anatomic lung resection was performed successfully in 166 patients. One of 180 patients (0.6%) died, and 14 patients (9.2%) underwent conversions. Overall median length of stay was 4 days (range, 1 to 98; interquartile range [IQR], 3), and median duration of chest tube drainage was 3 days (range, 0 to 35 days; IQR, 2). The median length of hospital stay and median chest tube duration for the group aged 80 years and older was 5 and 3 days; for the segmental resection group, 4 and 3 days; for the chemotherapy or radiotherapy induction group, 3.5 and 3 days; and for the FEV1 less than 50% group, 5.5 and 4 days, respectively. No patients died in any of these groups.

Conclusions: Thoracoscopic lung resection can be performed safely in selected patients aged 80 years and older, in those with marginal pulmonary function, and in those with pathologic response to neoadjuvant therapy.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 References
 
In the past decade, video-assisted thoracoscopic (VATS) lobectomy has been performed with increasing frequency for early-stage lung cancer. In 1992, the first published report of VATS lobectomy by Lewis and colleagues [1] described 40 patients; in 3 of these patients, the simultaneous individual stapling technique was used for the lobectomy. Subsequently, Hazelrigg and colleagues [2] reported results from 40 institutions and 1820 patients, 38 of whom underwent lobectomy, with an average length of stay of 6.3 days.

Although these and other early reports helped to establish the safety and feasibility of VATS lobectomy and suggested a potential advantage of shorter hospital stay and decreased postoperative pain, most studies were small and techniques variable. Furthermore, an early randomized trial that compared VATS lobectomy with muscle-sparing thoracotomy enrolled 55 patients and did not show a significant benefit favoring the VATS approach over open thoracotomy, other than fewer air leaks [3].

However, with technical advances and more widespread use of VATS lobectomy worldwide, new studies emerged that evaluated the use of a standardized VATS procedure and clinical outcomes. We analyzed data from 180 patients at Mount Sinai Medical Center to determine safety and feasibility of VATS lobectomy. We also examined our database to identify patient populations most likely to benefit from the minimally invasive approach. In addition to overall results, we focused on outcomes in four special patient groups: those who underwent segmental resections, patients at least 80 years old, those with poor pulmonary reserve, and patients who underwent induction chemotherapy or radiotherapy, or both, for advanced disease before undergoing surgical resection.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 References
 
We collected data from a cohort of 180 consecutive patients who underwent attempted thoracoscopic anatomic resection at Mount Sinai Hospital between January 2002 and December 2006 for presumed early-stage non-small cell lung cancer (NSCLC). Institutional Review Board approval was obtained and individual consent for the study was waived. Perioperative outcomes, including complications, length of stay and duration of chest tube drainage were obtained through chart review. We compared our results to VATS series published in the literature. Major complications were considered mortality, respiratory failure, empyema, and atrial fibrillation requiring cardioversion or anticoagulation. Minor complications were considered prolonged air-leak (chest tube drainage for longer than 1 week), atrial fibrillation not requiring cardioversion and anticoagulation, pneumonia without respiratory failure, and deep vein thrombosis. In addition, we evaluated the same variables in patients aged 80 years and older, those with poor pulmonary function (forced expiratory volume in 1 second [FEV1] < 50% predicted), patients who had received neoadjuvant chemotherapy or radiotherapy, or both, before thoracoscopic resection, and those who underwent lung-sparing or sublobar resections, such as segmentectomy.

Anatomic resections included lobectomy, bilobectomy, and segmentectomy. Candidates for thoracoscopic anatomic resection included those with known or suspected lung cancer, tumor amenable to anatomic resection, tumor size 6 cm or smaller, and anticipated ability to tolerate single-lung ventilation as determined by a preoperative pulmonary evaluation.

Patients who had undergone previous thoracotomy were considered candidates for thoracoscopic resection. Patients with T3 tumors were not considered for this approach. Although most candidates considered for thoracoscopic resection were at clinical stage I or II, selective patients with stage IIIA disease and proven pathologic response to neoadjuvant treatment were also considered candidates for the VATS approach. Generally, these stage III patients would have had successful induction therapy (ie, the absence of microscopic disease in the N2 lymph nodes). Thoracoscopic lung resection was performed using two ports, an access incision 5 to 8 cm in length, individual hilar ligation, and lymph node dissection without rib-spreading. Segmentectomy was performed with individual ligation of the segmental bronchus, artery, and vein.

All 180 patients underwent mediastinal lymph node dissection. For right-sided tumors, lymph nodes 2, 4, 7, 8, 9, 10 to 12 (or hilar) were dissected; for left-sided tumors, lymph node stations 5, 6, 7, 8, 9, 10 to 12 were dissected; and on cervical mediastinoscopies, 4R, 4L, and 7 were dissected. Typically, for peripheral T1 tumors, we did not perform mediastinoscopy unless the preoperative CT scan demonstrated lymphadenopathy of more than 1 cm or a positron emission tomography (PET) scan was positive in the mediastinum. We routinely performed mediastinoscopies in patients with PET-positive mediastinal adenopathy (standardized uptake value >3) or T2 or greater sized tumors.


   Results
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 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
Between January 2002 and December 2006, 180 patients with suspected or histologically documented clinical stage I NSCLC with solitary peripheral tumors sized 6 cm or smaller underwent attempted VATS lobectomy. The median age was 66.3 (SD, 11.3) years. There were 12 major complications (6.7%) and one perioperative death (0.6%). The most common complications were atrial fibrillation in 18 (10%) and prolonged air leak exceeding 7 days in 13 (7.2%). Most patients with atrial fibrillation were successfully treated with amiodarone; however, 2 patients underwent electrical cardioversion and 2 patients required anticoagulation. A summary of postsurgical complications is found in Table 1.


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  		Table 1 Complications After Video-Assisted Thoracoscopic Surgery in 180 Patients
 
Conversion to thoracotomy or minithoracotomy occurred in 14 patients (9.2%) because of bleeding of a pulmonary artery branch in 5 patients, hilar structures involved with tumor in 6, and other anatomic considerations in 3.

The median length of the hospital stay was 4 days (range, 1 to 98 days; interquartile range [IQR], 3). The median length of the chest tube duration was 3 days (range, 0 to 35 days; IQR, 2). Median follow-up for 106 patients with stage I NSCLC of 14 months yielded disease-free survival rates of 97% at 1 year, 86% at 2 years, and 72% at 3 years.

Thoracoscopic, anatomic sublobar resections were done in 24 patients, including superior segmentectomy in 7, lingulectomy in 2, lingula-sparing left upper lobectomy in 13, or basilar segmentectomy (ie, lower lobectomy sparing the superior segment) in 2. Mean age was 67 (SD, 10) years. Median chest tube duration was 3 days (IQR, 3), and median length of stay was 4 days (IQR, 4). No patients died. Five complications (21%) occurred, which were atrial arrhythmias in 2, pneumonia in 1, and prolonged air leaks in 2.

Thoracoscopic resection was successful in 25 patients aged 80 years or older. The median age was 83 (SD, 2) years. Median chest tube duration was 3 days (IQR, 4 days), and median length of stay was 5 days (IQR, 4.5 days). No patients died. Complications included pneumonia in 2, atrial arrhythmias in 5, prolonged air leak in 2, reintubation in 1, and bleeding requiring transfusion in 2.

Ten patients with both clinical and pathologic stage III underwent thoracoscopic resection after induction therapy. All patients underwent concurrent chemotherapy with a platinum-based regimen and radiation. Mean age was 68 (SD, 10) years. No patients died. Complications included vocal cord paralysis in 1 and atrial arrhythmias in 2. Median chest tube duration was 3 days (IQR, 3) and mean length of stay was 3.5 days (IQR, 4).

Eight patients with FEV1 less than 50% of predicted underwent thoracoscopic lobectomy. Mean age was 68 (SD, 10) years. Complications included pneumonia in 1 and prolonged air leak in 2. Median chest tube duration was 4 days (IQR, 5), and median length of stay was 5.5 days (IQR, 3.5).


   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
The most recent and relevant VATS lobectomy series is listed in Table 2 [3–17]. These studies show that VATS lobectomy and anatomic resection can be performed safely. In the multiinstitution prospective trial Cancer and Leukemia Group B (CALGB) 39802, which was designed to evaluate success rate, morbidity, mortality, cancer recurrence, and survival, VATS lobectomy was defined more rigorously to include node sampling or dissection, individual hilar dissection, and access incision of less than 8 cm without rib-spreading [11]. The study excluded patients with tumors larger than 3 cm or N2 disease. Results demonstrated feasibility and showed low perioperative morbidity and chest tube duration.


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  		Table 2 Summary of Studies of Video-Assisted Thoracoscopic Procedures and Overall Results
 
The few, small randomized trials of VATS resections vs conventional thoracotomy have generally shown no difference in postoperative survival or complications. In fact, Kirby found a lower incidence of air leaks among patients undergoing VATS lobectomy compared with those undergoing thoracotomy [18], and a randomized trial from Germany found the complication rate to be significantly lower using the VATS approach (14% vs 50%) [19]. Although similar concerns have been raised about the risk for blood loss during a VATS lung resection, studies suggest that blood loss is significantly decreased during VATS procedures compared with thoracotomy [20]. In the largest series, which had 1100 patients, only 7 patients were converted to thoracotomy to control bleeding, and the rates for mortality rate (less than 1%) and complications were both remarkably low [4].

The preponderance of literature suggests that VATS lung resection is associated with decreased postoperative pain compared with conventional thoracotomy [9, 21–23]. One randomized trial of VATS sublobar resection vs thoracotomy showed reduced postoperative pain scores and analgesic requirements in the VATS group [24]. Sugiura and colleagues [22] found a reduced duration of epidural catheter use, less narcotic use, decreased frequency of analgesic administration, and possibly a lower incidence of postthoracotomy pain syndrome in patients undergoing VATS compared with those undergoing thoracotomy.

There is also some evidence to suggest that postoperative pulmonary function is better preserved after VATS resection than after thoracotomy [25]. Nakata and colleagues [26] found that measures of oxygenation, peak flow rates, FEV1, and forced vital capacity were higher among patients at 1 week and 2 weeks after VATS lobectomy than after thoracotomy. Similar results were found for the 6-minute walk test [23]. Video-assisted thoracoscopic lobectomy may also be associated with lower cytokine response [27].

Several studies suggest that the VATS approach reduces length of stay and duration of chest tube drainage [28], allowing for earlier return to full activities. Among 1100 patients reported by McKenna and colleagues [4], median length of stay was, in fact, just under 3 days.

Finally, some surgeons have raised questions whether VATS resections yield the same oncologic outcomes as resections performed through a conventional thoracotomy. Studies to date have shown comparable long-term survival for VATS resections of 75% to 90% (Table 2), comparable with historical controls. Of interest is that there may, in fact, be an oncologic benefit in favor of the VATS approach: a recent study suggested that VATS lobectomy may confer a greater likelihood of delivery of planned postresection adjuvant therapy [29]. In this observational study, 61% of VATS lobectomy patients received 75% or more of their planned adjuvant regimen without delay or reduction in dosage compared with 40% of patients in the thoracotomy group. Our data are consistent with the reported studies. Of the 26 patients in our series of 153 who received chemotherapy, 19 (73%) received their full planned dose of chemotherapy on schedule, and only 3 (12%) experienced a delay in one or more cycles [30].

The future expansion of indications for VATS resection for lung cancer includes those patients who are at high risk, for example, older age and low pulmonary function. Results at our center support the findings of Demmy and Curtis [28] and Garzon and colleagues [31] that suggest that VATS lobectomy can be performed safely in these patients.

Furthermore, it is possible to use the VATS approach for more technically demanding surgery. Our early experience with segmental resections and lobectomy after induction therapy suggests that these procedures are feasible and safe, offering the potential for cure in patients unable to tolerate a more extensive resection or in those patients who have had prior chemotherapy or radiotherapy or both. Long-term follow-up for local recurrence is needed to determine whether our limited resections do indeed afford patients equivalent oncologic outcomes. Video-assisted thorascopic lobectomy after induction therapy should be done in selected patients and by surgeons who have extensive lobectomy experience to achieve the best results possible.

Video-assisted thorascopic lobectomy for early stage lung cancer should be the standard of care given the improvement in outcomes seen in these patients by those surgeons who have adequate experience with this approach. With the potential for less perioperative pain, preservation of pulmonary function, and quicker recovery, VATS lobectomy may become the procedure of choice in high-risk patients, such as the elderly and those with poor pulmonary function. Technically demanding surgical procedures such as segmental resection and lobectomy after induction therapy appear to be feasible using a VATS approach and in selected patients may confer the same benefits that are enjoyed by patients who have a VATS lobectomy for other more standard indications. These small series will need to be verified in larger series and, ideally, through prospective multi-institution protocols.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

  1. Lewis RJ, Caccavale RJ, Sisler GE, Mackenzie JW. Video-assisted thoracic surgical resection of malignant lung tumors J Thorac Cardiovasc Surg 1992;104:1679-1685.[Abstract]
  2. Hazelrigg SR, Nunchuck SK, LoCicero 3rd J. Video Assisted Thoracic Surgery Study Group data Ann Thorac Surg 1993;56:1039-1043.[Abstract]
  3. Kirby TJ, Mack MJ, Landreneau RJ, Rice TW. Lobectomy–video-assisted thoracic surgery versus muscle-sparing thoracotomyA randomized trial. J Thorac Cardiovasc Surg 1995;109:997-1001.[Abstract]
  4. McKenna Jr RJ, Houck W, Fuller CB. Video-assisted thoracic surgery lobectomy: experience with 1,100 cases Ann Thorac Surg 2006;81:421-425discussion 425–6.[Abstract/Free Full Text]
  5. Onaitis MW, Petersen RP, Balderson SS, et al. Thoracoscopic lobectomy is a safe and versatile procedure: experience with 500 consecutive patients Ann Surg 2006;244:420-425.[Medline]
  6. Yim AP, Liu HP. Thoracoscopic major lung resection–indications, technique, and early results: experience from two centers in Asia Surg Laparosc Endosc 1997;7:241-244.[Medline]
  7. Kaseda S, Aoki T, Hangai N, Shimizu K. Better pulmonary function and prognosis with video-assisted thoracic surgery than with thoracotomy Ann Thorac Surg 2000;70:1644-1646.[Abstract/Free Full Text]
  8. Roviaro G, Varoli F, Vergani C, Nucca O, Maciocco M, Grignani F. Long-term survival after videothoracoscopic lobectomy for stage I lung cancer Chest 2004;126:725-732.[Medline]
  9. Walker WS, Codispoti M, Soon SY, Stamenkovic S, Carnochan F, Pugh G. Long-term outcomes following VATS lobectomy for non-small cell bronchogenic carcinoma Eur J Cardiothorac Surg 2003;23:397-402.[Abstract/Free Full Text]
  10. Iwasaki A, Shirakusa T, Shiraishi T, Yamamoto S. Results of video-assisted thoracic surgery for stage I/II non-small cell lung cancer Eur J Cardiothorac Surg 2004;26:158-164.[Abstract/Free Full Text]
  11. Swanson SJ, Herndon J, D’Amico A, et al. Results of CALGB 39802: feasibility of video assisted thoracic surgery (VATS) lobectomy for early stage lung cancer Proc ASCO 2002;21:290a.
  12. Daniels LJ, Balderson SS, Onaitis MW, D’Amico TA. Thoracoscopic lobectomy: a safe and effective strategy for patients with stage I lung cancer Ann Thorac Surg 2002;74:860-864.[Abstract/Free Full Text]
  13. Ohtsuka T, Nomori H, Horio H, Naruke T, Suemasu K. Is major pulmonary resection by video-assisted thoracic surgery an adequate procedure in clinical stage I lung cancer? Chest 2004;125:1742-1746.[Medline]
  14. Solaini L, Prusciano F, Bagioni P, Di Francesco F, Basilio Poddie D. Video-assisted thoracic surgery major pulmonary resectionsPresent experience. Eur J Cardiothorac Surg 2001;20:437-442.[Abstract/Free Full Text]
  15. Sugi K, Kaneda Y, Esato K. Video-assisted thoracoscopic lobectomy achieves a satisfactory long-term prognosis in patients with clinical stage IA lung cancer World J Surg 2000;24:27-30discussion 30–1.[Medline]
  16. Shiraishi T, Shirakusa T, Hiratsuka M, Yamamoto S, Iwasaki A. Video-assisted thoracoscopic surgery lobectomy for c-T1N0M0 primary lung cancer: its impact on locoregional control Ann Thorac Surg 2006;82:1021-1026.[Abstract/Free Full Text]
  17. Whitson BA, Andrade RS, Boettcher A, et al. Video-assisted thoracoscopic surgery is more favorable than thoracotomy for resection of clinical stage I non-small cell lung cancer Ann Thorac Surg 2007;83:1965-1970.[Abstract/Free Full Text]
  18. Kirby TJ, Rice TW. Thoracoscopic lobectomy Ann Thorac Surg 1993;56:784-786.[Abstract]
  19. Hoksch B, Ablassmaier B, Walter M, Muller JM. Complication rate after thoracoscopic and conventional lobectomy Zentralbl Chir 2003;128:106-110.[Medline]
  20. Shigemura N, Akashi A, Funaki S, et al. Long-term outcomes after a variety of video-assisted thoracoscopic lobectomy approaches for clinical stage IA lung cancer: a multi-institutional study J Thorac Cardiovasc Surg 2006;132:507-512Erratum in: J ThoracCardiovasc Surg 2007;133:189.[Abstract/Free Full Text]
  21. Giudicelli R, Thomas P, Lonjon T, et al. Major pulmonary resection by video assisted mini-thoracotomyInitial experience in 35 patients. Eur J Cardiothorac Surg 1994;8:254-258.[Abstract]
  22. Sugiura H, Morikawa T, Kaji M, et al. Long-term benefits for the quality of life after video-assisted thoracoscopic lobectomy in patients with lung cancer Surg Laparosc Endosc Percutan Tech 1999;9:403-408.[Medline]
  23. Nomori H, Horio H, Naruke T, Suemasu K. What is the advantage of a thoracoscopic lobectomy over a limited thoracotomy procedure for lung cancer surgery? Ann Thorac Surg 2001;72:879-884.[Abstract/Free Full Text]
  24. Santambrogio L, Nosotti M, Bellaviti N, Mezzetti M. Videothoracoscopy versus thoracotomy for the diagnosis of the indeterminate solitary pulmonary nodule Ann Thorac Surg 1995;59:868-870discussion 870–1.[Abstract/Free Full Text]
  25. Nagahiro I, Andou A, Aoe M, Sano Y, Date H, Shimizu N. Pulmonary function, postoperative pain, and serum cytokine level after lobectomy: a comparison of VATS and conventional procedure Ann Thorac Surg 2001;72:362-365.[Abstract/Free Full Text]
  26. Nakata M, Saeki H, Yokoyama N, Kurita A, Takiyama W, Takashima S. Pulmonary function after lobectomy: video-assisted thoracic surgery versus thoracotomyBetter pulmonary function and prognosis with video-assisted thoracic surgery than with thoracotomy. Ann Thorac Surg 2000;70:938-941.[Abstract/Free Full Text]
  27. Yim AP, Wan S, Lee TW, Arifi AA. VATS lobectomy reduces cytokine responses compared with conventional surgery Ann Thorac Surg 2000;70:243-247.[Abstract/Free Full Text]
  28. Demmy TL, Curtis JJ. Minimally invasive lobectomy directed toward frail and high-risk patients: a case-control study Ann Thorac Surg 1999;68:194-200.[Abstract/Free Full Text]
  29. Petersen RP, Pham D, Burfeind WR, et al. Thoracoscopic lobectomy facilitates the delivery of chemotherapy after resection for lung cancer Ann Thorac Surg 2007;83:1245-1249discussion 1250.[Abstract/Free Full Text]
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