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Ann Thorac Surg 2008;85:S719-S728. doi:10.1016/j.athoracsur.2007.09.056
© 2008 The Society of Thoracic Surgeons
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Right arrow Minimally invasive surgery

Supplement: The Minimally Invasive Thoracic Surgery Summit

Is Video-Assisted Thoracic Surgery Lobectomy Better? Quality of Life Considerations

Todd L. Demmy, MD*, Chukwumere Nwogu, MD

Department of Thoracic Surgery, Roswell Park Cancer Institute, Buffalo, New York

* Address correspondence to Dr Demmy, Department of Thoracic Surgery, Roswell Park Cancer Institute, Elm and Carlton Str, Buffalo, NY 14263 (Email: todd.demmy{at}roswellpark.org).

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


   Abstract
Top
 Abstract
Introduction
 Methods
 Definitions of Video-Assisted...
 Survival After Video-Assisted...
 Quality of Life Instruments
 Subjective Measures of Quality...
 Objective Measurements or...
 Special Populations
 References
 
Video-assisted thoracic surgery lobectomy has controversial advantages over traditional open surgical approaches. Subjective concerns such as pain, dyspnea, physical functioning, and overall satisfaction generally favor VATS but vary depending on survey timing. Independence, a major quality of life component, favors video-assisted thoracic surgery because fewer objective hospital and discharge resources are needed because pulmonary function, activity level, muscle strength, and walking capacity are better. Video-assisted thoracic surgery often hastens return to work and facilitates adjuvant chemotherapy or subsequent urgent surgical procedures. Video-assisted thoracic surgery–related quality of life benefits are amplified by advanced age (or other frailties) and reduced by advanced cancer stage or comorbid illness.


   Introduction
Top
 Abstract
 Introduction
Methods
 Definitions of Video-Assisted...
 Survival After Video-Assisted...
 Quality of Life Instruments
 Subjective Measures of Quality...
 Objective Measurements or...
 Special Populations
 References
 
Whether thoracoscopic lobectomy is better for quality of life (QOL) is controversial. Some factors that confound this analysis are lack of a standard definition for thoracoscopic or video-assisted thoracic surgery (VATS) lobectomy, variability in subjective satisfaction and QOL instruments used, different time intervals sampled, bias in patient selection, controversial objective surrogates for QOL, and the inclusion of select populations. Accordingly, this article will explore how these factors affect the relative QOL value of VATS lobectomy.


   Methods
Top
 Abstract
 Introduction
 Methods
Definitions of Video-Assisted...
 Survival After Video-Assisted...
 Quality of Life Instruments
 Subjective Measures of Quality...
 Objective Measurements or...
 Special Populations
 References
 
Reference Manager software (Thomson ResearchSoft, Stamford, CT) was used to search PubMed and compile references found on related electronic sources. More than 300 citations were found by using the terms quality, life, VATS, thoracoscopy, lung surgery, and thoracotomy. Reprints were obtained from this set, related searches, and citations from high quality articles for a systematic review, and an annotated bibliography was created from 97 source documents. Outcomes that were studied related to survival, complications, hospital resources, QOL scales of pain and function, and numerous objective surrogate indicators of QOL that enable activity and independence. The strength of the evidence is rated A (derived from multiple randomized clinical trials), B (derived from a single randomized trial or from nonrandomized trials) or C (consensus expert opinion). Most of the evidence in this review is category B.

Recommendations are classified as:

• Level 1—evidence or general agreement, or both, that a given procedure is useful and effective;
• Level 2—conflicting evidence or a divergence of opinion, or both, about the usefulness/efficacy of a procedure where (2A) it favors usefulness/efficacy and (2B) the support is weaker.

A total of 200 consecutive discharge dispositions from an Investigational Review Board–approved (2003) retrospective, nonpatient-consent-required, quality assurance data review of thoracic surgery service at Roswell Park Cancer Institute from 2001 to 2002 were categorized by age to produce one original explanatory figure.


   Definitions of Video-Assisted Thoracic Surgery Lobectomy
Top
 Abstract
 Introduction
 Methods
 Definitions of Video-Assisted...
Survival After Video-Assisted...
 Quality of Life Instruments
 Subjective Measures of Quality...
 Objective Measurements or...
 Special Populations
 References
 
Some surgeons prefer the term "thoracoscopic lobectomy" to define an operation done entirely with ports and camera visualization, with no rib-spreading, using a small access incision (4 to 6 cm). Other reports of VATS lobectomy describe more invasive elements such as rib-spreading retractors, hand-assistance, or larger incisions to allow occasional direct viewing [1]. This has been categorized as "assisted VATS" vs "completely VATS" (all thoracoscopic) vs conventional open thoracotomy [2, 3]. Surgeons can also introduce variability by choosing different anatomic hilar or nodal dissections [4,5].

Invasive VATS lobectomy techniques can limit favorable effects on perioperative pain and recovery. This was demonstrated in a multi-institutional study where the assisted VATS patients had longer hospital day and impaired results compared with those with the complete thoracoscopic procedure [2]. Although terms like "thoracoscopic," "VATS," and "minimally invasive" will be used interchangeably in this article, the reader should understand that such approaches are not uniform and can yield different QOL outcomes.


   Survival After Video-Assisted Thoracic Surgery Lobectomy and Physiologic Factors that May Improve Quality of Life
Top
 Abstract
 Introduction
 Methods
 Definitions of Video-Assisted...
 Survival After Video-Assisted...
Quality of Life Instruments
 Subjective Measures of Quality...
 Objective Measurements or...
 Special Populations
 References
 
Available evidence (mostly category B) shows that thoracoscopic lobectomy provides equivalent (level 1) and possibly superior (level 2b) outcomes with regards to complications and survival (Table 1) [2, 4, 6–19]. If equivalent, QOL investigations are needed to select the optimal procedure. Unfortunately, most investigators do not believe that patients would currently accept randomization to arms of different invasiveness to test a question of survival or QOL superiority. More than a decade ago, Kirby and colleagues [20] managed to do so and showed fewer complications with VATS. They concluded, however, that VATS was not that much better from the perspective of QOL because many of the patients were of retirement age, thereby reducing the return to work advantage. That study was limited in its power (n = 25 in the VATS arm), the relative invasiveness of the procedures, and in that no QOL instruments or pain scales were used.


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  		Table 1 Survival in Video-Assisted Thoracic Surgery Lobectomy Investigations
 
Regarding the possibility that less invasive lung resections could have a better oncologic result, an excellent review by Coffey and colleagues [21] makes the general argument for this hypothesis. It is interesting that certain biochemical factors may be in play that could also translate into improved QOL. For instance, there is a less of an acute-phase response documented by minimal access thoracic surgery [22]. Despite a report of greater tumor cell dissemination during VATS lobectomy, favorable cytokine release and better preservation of immune functions may prevail [23].


   Quality of Life Instruments
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 Abstract
 Introduction
 Methods
 Definitions of Video-Assisted...
 Survival After Video-Assisted...
 Quality of Life Instruments
Subjective Measures of Quality...
 Objective Measurements or...
 Special Populations
 References
 
Many different QOL tools exist for evaluating the multiple dimensions needed to adequately characterize patient mood and life functions. Some of those tested in lung cancer patients and cross-validated are summarized in Table 2 [24–37]. Many others exist, but there has been some standardization toward forms like the Medical Outcomes Study Short Form 36 (SF-36) Health Survey and European Organization for Research and Treatment of Cancer (EORTC) QOL instruments. In addition, the results of these forms are frequently correlated to objective surrogates for QOL such as pulmonary function and activity measurements [29, 36]. Two comprehensive reviews of these instruments have been authored by Montazeri and colleagues [38] (50 scales described), and Li and colleagues [30] (good overall review).


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  		Table 2 Assortment of Quality of Life Tools Used for Lung Cancer Patients
 
Some consensus exists in form selection, but the timing of data acquisition is variable [39]. The forms have many data elements, and frequent surveys, although optimal, can impair compliance, particularly as patients are transitioning back into their regular lives after a hospital stay. Although frail patients might benefit most from VATS lobectomy, their reduced functional reserves could make them even less likely to participate in a voluntary survey. This inherent bias can be reduced by active data collection by a third party, particularly during early convalescence where the differences between open and VATS cases are most striking.


   Subjective Measures of Quality of Life After Video-Assisted Thoracic Surgery
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 Abstract
 Introduction
 Methods
 Definitions of Video-Assisted...
 Survival After Video-Assisted...
 Quality of Life Instruments
 Subjective Measures of Quality...
Objective Measurements or...
 Special Populations
 References
 
The subjective QOL measurements of lung cancer patients can be considered after the surgical procedure in general sense and then in specific comparisons of VATS vs open thoracotomy patients. In general, the preoperative health of potential lung resection patients is significantly impaired, and this reduction is compounded by additional pain complaints that can last for 6 months after the operation [36]. One of the greatest contributors of lower QOL scores is dyspnea from impaired pulmonary function [25, 34], which is why larger resections like pneumonectomy have worse long-term QOL [31, 35]. Additional therapies, such as postoperative chemotherapy, are associated with worse QOL [34].

A depressed mood is very common and exists in about 29% of lung resection patients [27]. This is the primary predictor of low scores in the mental component of QOL metrics and also adversely influences the physical component scores along with problems like advanced age and comorbid diseases [28]. After operation, the tension-anxiety component of depression improves, but the fatigue component worsens [40].

Video-assisted thoracic surgery has the potential to affect favorably many of the subjective QOL concerns that have been presented, and reports proving the same are listed in Table 3 [1, 3, 30, 31, 41–46]. Improved pain control seems to be the most commonly demonstrated benefit (category A, level 1), and this probably drives secondary enhancements of QOL scores of performance and symptom control (level 2a). Although some disagreement may exist about the duration of these benefits, the results in the literature supporting the benefits of VATS in reduced pain and perceived functional recovery are consistent and reproducible.


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  		Table 3 Subjective Quality of Life Measurements Favoring Video-Assisted Thoracic Surgery Lobectomy
 

   Objective Measurements or Surrogates of Quality of Life
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 Abstract
 Introduction
 Methods
 Definitions of Video-Assisted...
 Survival After Video-Assisted...
 Quality of Life Instruments
 Subjective Measures of Quality...
 Objective Measurements or...
Special Populations
 References
 
Because of the problems already stated with the measurement and collection of subjective QOL data, many investigators prefer to use objective criteria. Some are validated by investigations using subjective QOL survey forms in concert with the objective measurements. Some examples of the validated objective values that predict thoracic operation complications are reduced pulmonary function tests, such as diffusion capacity of the lung for carbon monoxide and forced vital capacity, and greater extent of resection (level 1) [31, 35, 36, 47]. It is important to note that symptom burden affects QOL more than pulmonary function tests performed at rest [25]. Functional tests like the 6-minute walk and exercise tests are better predictors (level 1) [35, 47].

Again, many studies have shown objective measurements to suggest that QOL is improved for VATS (Table 4) [2–4, 9, 41–46, 48–60]. Some effects are immediate, and others are more prolonged. Most of the literature (category B) has documented a substantial reduction in pain control measures and better physical recovery documented by faster returns to work or other equivalents of preoperative functioning (level 1). Infection, which adversely affects QOL, is less with nonanatomic VATS lung resections, although large cohorts are needed to detect differences in clean procedures [60].


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  		Table 4 Objective or Surrogate Measures of Quality of Life Favoring Video-Assisted Thoracic Surgery Lobectomy
 
It is important to note that many criteria are measured best several weeks after the operation rather than during the hospitalization. This is because the presence of the chest tube limits patient activity and accounts for a lot of the initial postoperative pain after thoracic operations. Patients are generally discharged shortly after chest tube removal and go home much more independently (Fig 1). Independence is a strong component of QOL scales and is sensitive to changes over time like other important metrics [24]. Pain at 2 to 3 weeks after VATS lobectomy is generally absent to mild for most patients (Fig 2) [49, 61]. Accordingly, they can return to work or their other lifestyle activities sooner (level 2a). Reduced hospital costs ($2300 to $4500) and faster return to work for VATS can reduce the economic hardship some patients face [41, 53, 56].


Figure 1
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  		Fig 1. Discharge independence after thoracoscopic lobectomy. The bar graphs demonstrate a much lower need for home health services in the video-assisted thoracic surgery (VATS) group. The types of services needed for each procedure type are displayed as well. (OT = occupational therapy; other = other miscellaneous care needs; PT = physical therapy.) Adapted from Demmy TL, et al. Discharge independence with minimally invasive lobectomy. Am J Surg 2004;188:698–702.

 

Figure 2
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  		Fig 2. Pain control at 3 weeks after video assisted thoracic surgery (VATS) lobectomy. The pie charts show that VATS patients have significantly (p < 0.01) less pain as measured by the most potent analgesic still required: severe—–schedule 2 narcotic; moderate—schedule 3 or lower; mild–nonsteroidal anti-inflammatory drugs or acetaminophen. These data represent an updated series of high-risk reported previously [49, 61].

 

   Special Populations
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 Introduction
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 Definitions of Video-Assisted...
 Survival After Video-Assisted...
 Quality of Life Instruments
 Subjective Measures of Quality...
 Objective Measurements or...
 Special Populations
References
 
The use of VATS lobectomy in special populations requires special comment. Regional estimates and data from the Society of Thoracic Surgeons General Thoracic Surgery Database indicate that only about 20% of the lung cancer resections performed in the United States are by VATS [62]. At many centers, the VATS lobectomy population is limited to patients with smaller, more peripheral tumors. Patients with underlying lung disease may be more difficult cases to perform by VATS because of adhesions, inflammation, and difficulty with single-lung ventilation. Thus, many of the study populations where QOL has been evaluated are themselves special because they are enriched with better-risk patients who can tolerate alternative aggressive therapies well. This is demonstrated by the work of Li and colleagues [30], where 136 potential patients were winnowed to 51 better-risk patients because of such associated disease characteristics. This may have accounted for the lack of statistical significance of their QOL data that trended in favor of VATS.

Alternatively, investigators applying VATS lobectomy in cases where open operations are high risk have noted more dramatic differences [49, 63]. Quality of life studies show a strong, bidirectional interplay between physical performance, respiratory symptoms and function, and thoracic pain, all of which are perturbed less by VATS. Patients with severe chronic obstructive pulmonary disease have chronic chest wall pain that lasts for months [64]. Thus, a prolonged cycle of QOL impairment after thoracoscopic resection is less likely to develop in patients who have preoperative difficulty in one or more of these areas.

Elderly patients frequently have these problems, and VATS has shown better performance preservation in this group (level 2a) [39, 59, 65–67]. This is demonstrated nicely in an exploratory set of discharge requirements for open thoracotomy patients that shows an abrupt increase in postdischarge support requirement for patients older than 70 (Fig 3). This exploration immediately preceded the establishment of preferred VATS lobectomy at one center and the resultant research summarized in Figure 1 [19]. The same age-range cutoff yielding worse outcomes was reproduced by Nomori and colleagues [55]. The associated sequelae and complications evidenced by need for home health support not only are costly (about $2000 per case estimate) but may hasten geriatric decompensation. In fact, in an extreme population of 32 octogenarian or nonagenarian patients, 56% of early stage VATS cases survived 5 years compared with 0% of open cases [68].


Figure 3
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  		Fig 3. Outpatient support, including home health care, rehabilitation, nursing home care, or death, required for 200 consecutive thoracic surgery patients by age group at Roswell Park Cancer Institute preceding the video-assisted thoracic surgery (VATS) lobectomy preference era. This bar graph shows the abrupt increase in outpatient support required after patients reach the eighth decade of life.

 
Table 5 lists medical conditions that increase the frailty of patients so that a VATS resection is expected to provide a much better QOL result. Besides age, severe emphysema causes frailty and has been addressed by surgical thoracoscopic lung reduction to improve QOL [64]. This technique also improves QOL when combined with VATS lobectomy [64]. Other patients who are frail in an economic sense can return to work faster after VATS lobectomy to avoid financial hardship.


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  		Table 5 Special Populations for which Video-Assisted Thoracic Surgery Lobectomy May Be Preferable
 
For many patients with advanced lung cancer, operation offers a less certain benefit. Stage III patients, who are offered preoperative chemotherapy, and node-negative stage IV patients with isolated brain or adrenal metastases, occasionally undergo resection with intent to cure. It is known that most patients in these special categories will die of metastatic disease within a short time and have relatively little remaining favorable quality lifetime remaining to invest in extended postoperative convalescence. A VATS lobectomy provides a safer option in terms of faster recovery in these cases and can be done safely (level 2b) [61, 69–70]. Using the same logic, metastatic tumors that require lobectomy for extirpation can be addressed selectively with VATS because most of these patients will die of their progressive disease (level 2b) and because surgeons often prefer open thoracotomy to palpate lung metastases missed by computed tomography imaging [71].

When adjuvant chemotherapy is required after lobectomy to enhance the chance for cure, VATS patients tolerate it better than their open lobectomy counterparts, demonstrating the superior reserves in performance status afforded by less invasive surgery (level 2a) [50]. Alternatively, VATS lobectomy has been applied selectively in patients with benign disease or low-grade tumors where the oncologic validity of the operation is less of a concern [72, 73].

In summary, there is sufficient objective evidence to reassure patients and physicians that VATS lobectomy is noninferior in terms of long-term cancer survival and superior in terms of certain dimensions of QOL. The degree and duration of QOL superiority is amplified or dampened depending on the functional reserves of the population in which it is applied.


   References
Top
 Abstract
 Introduction
 Methods
 Definitions of Video-Assisted...
 Survival After Video-Assisted...
 Quality of Life Instruments
 Subjective Measures of Quality...
 Objective Measurements or...
 Special Populations
 References
 

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