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Ann Thorac Surg 2008;86:235-239. doi:10.1016/j.athoracsur.2008.03.080
© 2008 The Society of Thoracic Surgeons
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Original Articles: General Thoracic

Does Failed Video-Assisted Lobectomy for Lung Cancer Prejudice Immediate and Long-Term Outcomes?

Richard O. Jones, MB, ChB*, Gianluca Casali, FRCS, William S. Walker, FRCS

Department of Cardiothoracic Surgery, The Royal Infirmary of Edinburgh, Edinburgh, United Kingdom

Accepted for publication March 28, 2008.

* Address correspondence to Dr Jones, Department of Cardiothoracic Surgery, The Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Rd, Edinburgh, EH16 4SA, United Kingdom (Email: richard.o.jones{at}blueyonder.co.uk).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
Background: Lobectomy for lung cancer by video-assisted thorascopic surgery (VATS) remains an infrequently performed operation despite numerous publications showing the benefits of successful VATS compared with an open thoracotomy approach. However, concern remains regarding patient safety, notably the need for emergency intraoperative conversion to open thoracotomy leading to potential adverse consequences. We therefore compared the outcomes of converted VATS patients with open thoracotomy controls.

Methods: Between May 1992 and April 2006, 30 of 286 VATS lobectomies for lung cancer required intraoperative conversion to open thoracotomy. Four patients were of advanced stage and excluded from the study. The remaining patients were matched 2:1 with open thoracotomy controls by age, sex, cancer stage, year, and type of operation. Postoperative complications and pathology were determined from the hospital discharge summary and pathology report. Long-term survival information was obtained from the family doctor or central registry.

Results: There were no statistically significant differences in postoperative complications between the two groups (p = 0.093). There were no in-hospital deaths in the converted VATS group. Kaplan-Meier survival analysis for cancer-related or unassociated death demonstrated no statistically significant difference (log-rank p = 0.1627).

Conclusions: Conversion during attempted VATS resection does not prejudice short-term or long-term surgical outcomes. We therefore suggest that VATS lobectomy should be the treatment strategy of choice for stage I and II non-small cell lung cancer in view of the well-established short-term benefits and equivalent survival associated with successful VATS resection.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 References
 
Lobectomy for bronchogenic carcinoma using video assisted thorascopic surgery (VATS) was first described 16 years ago [1–4]. The benefits conferred compared with open thoracotomy stem primarily from the less traumatic approach and include reduced postoperative pain, impairment in respiratory muscle and pulmonary function, cytokine production and improved immunosurveillance [5–10]. Various authors have shown this to be a safe procedure with good long-term survival [11, 12]. However, the advantages of VATS compared with open thoracotomy, shown in several studies, have not been fully evaluated in a large randomized prospective study. Indeed, VATS lobectomy is still not practiced widely, accounting for approximately 5% of lobectomies performed annually in the United States [12] and 2% to 3% of lobectomies in the United Kingdom [11]. This may be partly related to concern amongst some thoracic surgeons about its safety, notably the possibility of uncontrolled hemorrhage or incomplete cancer clearance.

Intraoperative conversion rates to open thoracotomy range up to 13% in published series [11–14]. It is unknown whether intraoperative conversion leads to an adverse short-term or long-term disadvantage compared with patients whose initial planned operation was through an open thoracotomy. One can postulate whether emergency conversion leads to unintended disruption of cancer cells and dissemination of malignancy or increased postoperative complications such as infection. We therefore conducted a retrospective case-controlled study to specifically compare converted VATS cases with open thoracotomy controls.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 References
 
Study Groups
This study was a retrospective audit of outcome within the United Kingdom and did not require formal ethical approval or institutional review. This distinction is discussed in the NHS National Patient Safety Agency, National Research Ethics Service publication Defining Research: Issue 3 [15].

Between May 1992 and April 2006, 1291 patients underwent isolated pulmonary lobectomy/bilobectomy for non-small cell lung cancer (NSCLC) in Edinburgh. One consultant cardiothoracic surgeon was undertaking VATS lobectomy in this period. Of the 1291 operations, 286 were attempted using a VATS procedure and 30 required conversion to open thoracotomy (conversion rate, 10.5%). Four of these converted patients had advanced disease (≥IIIB) and were therefore excluded from the study. The 26 remaining cases were matched 2:1 with open thoracotomy controls. These were drawn at random from the open thoracotomy group searching by year of operation (±1 year), type of operation, cancer stage, age (±10 years), and sex. Two controls were selected in accordance with published guidance on case-controlled studies [16]. A number of the control patients were not an exact T N match by the tumor, node, metastasis (TNM) classification owing to the difficulty of identifying suitable controls using the matching criteria. In these instances the most suitable control of the same cancer stage was selected.

The VATS patients who required conversion and reasons for conversion had been entered into a prospective computer database. Control patients were selected from hospital discharge summaries in accordance with the specified criteria. Long-term outcomes were determined from the patient's family doctor. Where patients were no longer registered with the last known family doctor, death or registration with a new doctor was confirmed by reference to a central registry. If a patient had died before 60 months postoperatively, the cause of death was ascertained from the General Register Office for Scotland, Vital Events Demography Branch. Survival to 60 months was adopted for this study on the basis that recurrence is most likely within 2 to 3 years of operation and that 60-month data are frequently reported and used to describe survival after resection for lung cancer.

Selection for Operation
Patients were selected for resection according to a local protocol that was intended to target clinical stage I or II bronchogenic carcinoma cases in suitable operative candidates. Noninvasive staging was undertaken using thoracic and upper abdominal computed tomography (CT) imaging to exclude multiple pulmonary lesions and hepatic or adrenal metastases. Further imaging with hepatic ultrasound, bone scintigraphic, and brain CT scans were ordered where clinically indicated.

All patients underwent routine cervical mediastinoscopy with systematic investigation and biopsy of station 7, ipsilateral stations 2 and 4, and contralateral station 4. Negative mediastinoscopy was a prerequisite for operation. A tumor size criterion of 5 cm was used as the upper limit for VATS resection on the premise that lesions larger than this could not be extracted between the anterior ribs without the use of a mechanical retractor.

Fitness criteria were similar for intended VATS and intended open thoracotomy, but as confidence in the reduced trauma of a VATS procedure developed, less fit patients were accepted, including those with a preoperative ratio of actual vs predicted forced expiratory volume in 1 second (FEV1) of 30% to 35%. Patients with obvious complete obliteration of the pleural cavity on preoperative chest films were excluded.

VATS Lobectomy Technique
Details of the surgical techniques used in this series have been presented elsewhere [17]. Essentially, the surgeon used an endoscopic hilar dissection technique under single-lung anesthesia. A 5-cm incision was then created in the lateral submammary area as a utility port for the passage of large instruments and staplers. This allowed prompt lung collapse and the identification of the most appropriate location for a posterior videothoracoscope port. We have found that this provides an excellent view of the thoracic cavity and major fissure similar to the aspect presented to the surgeon at a conventional thoracotomy. In the early part of the series, two inferior ports were created for additional instrument access, which were then used at the end of the procedure for apical and basal pleural drains. In recent years, a single inferior port and single chest drain were used. Conversion to open thoracotomy was effected by linking the posterior videothoracoscope port and submammary incision, which created a virtually identical thoracotomy to that used in our standard open technique.

Open Thoracotomy Technique
Access was gained through a limited lateral thoracotomy. This involved division of the latissimus dorsi and posterior elements of the serratus muscle.

Statistical Analysis
Routine summary statistics were obtained, and Kaplan-Meier survival curves were generated using StatView 5 software (SAS Institute Inc, Cary, NC). Survival calculations were based on freedom from death either due to or in the presence of NSCLC. Death from noncancer-related causes, when recurrent disease was known to be present, was therefore classed as a cancer-related death.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
During the study period, 22.2% of the lobectomy/bilobectomy caseload was undertaken using a VATS approach and was performed by one consultant cardiothoracic surgeon in the department. A total of 286 VATS lobectomies were undertaken for NSC bronchogenic carcinoma. Of these, 30 (10.5%) required intraoperative conversion to open thoracotomy, mainly for bleeding, location/local extent of tumor, and adhesions (Table 1). As noted previously, 4 patients were at an advanced stage (IIIB, IV) and were excluded from this study.


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  		Table 1 Reasons for Intraoperative Conversion from Video-Assisted Thorascopic Surgery Lobectomy to Open Thoracotomy
 
The final pathologic TN staging and histology are summarized in Tables 2 and 3, Go respectively. Table 2 also reports the mean age and sex breakdown for each cancer stage to confirm matching according to the criteria previously specified. Although difficulty was found matching patients to an exact TN stage, notably more T2 N0 patients than T1 N0 in the control group, no statistical difference was found by {chi}2 analysis (p = 0.55).


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  		Table 2 Final Tumor Node Stage and Demography of Converted Video-Assisted Thorascopic Surgery Cases Compared With Thoracotomy Controls a
 

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  		Table 3 Final Histological Diagnosis of Converted Video-Assisted Thorascopic Surgery Patients Compared with Open Thoracotomy Controls a
 
The actual operation undergone by the VATS conversion cases compared with their open controls is presented in Table 4. Lobectomy/bilobectomy patients were matched in addition to patients who unexpectedly required pneumonectomy at the time of operation or subsequently proceeded to completion pneumonectomy.


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  		Table 4 Specific Operations Undergone by Converted Video-Assisted Thorascopic Surgery Patients Compared With Open Thoracotomy Controls
 
Outcomes
No in-hospital deaths occurred in the VATS conversion group, but one patient in the control group died after pneumonia, type II respiratory failure, and failure to wean from the ventilator.

Postoperative complications are summarized in Table 5. No postoperative complications were available for one VATS conversion. Overall, no statistically significant differences were noted in the complication rate between the two groups ({chi}2 p = 0.093). The major complication in the converted VATS group was a bronchopleural fistula. The major complications of the control group included bleeding requiring reexploration, stroke, and empyema. Minor complications common to both groups included chest infection requiring antibiotics with or without physiotherapy/minitracheostomy, atelectasis, sputum retention, pneumothorax, prolonged air leak, surgical emphysema, delirium, neuropathic pain, supraventricular tachycardia, urinary retention, urinary tract infection, hematemesis, wound infection, and vasovagal episode.


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  		Table 5 A Comparison of Complications in the Converted Video-Assisted Thorascopic Surgery Patients vs Open Thoracotomy Controls a
 
Overall, mean postoperative stay was 8.35 days (converted VATS group, 8.37 days; open control group, 9.36) and not statistically different between the groups (Mann-Whitney U, p = 0.3).

One patient in the converted VATS group was lost to follow-up. Kaplan-Meier cancer-related or associated death for all cancer stages is shown in Figure 1. This generated an overall probability of survival to 60 months for the converted VATS group of 65.6% (95% confidence interval [CI], 44.5% to 86.8%) vs 43.9% (95% CI, 27.7% to 60.0%) for the open control group (log rank p = 0.1627). Figure 2 details survival by individual cancer stage between the two groups and Table 6 details the number of patients at risk according to each cancer stage. The small numbers in each cancer stage render meaningful statistical comparison difficult.


Figure 1
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  		Fig 1. Kaplan-Meier curves show overall survival after converted video-assisted thorascopic surgery (VATS) lobectomy (dashed line) vs open thoracotomy control (solid line) for non-small cell bronchogenic carcinoma.

 

Figure 2
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  		Fig 2. Survival of video-assisted thorascopic surgery (VATS) conversion (dashed lines) and open control patients (solid lines) according to stage of non-small cell carcinoma. (Ivc = stage 1 VATS conversion; Io = stage 1 open control; IIvc = stage II VATS conversion; IIo = stage II open control; IIIvc = stage III VATS conversion; IIIo = stage III open control.)

 

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  		Table 6 Number of Video-Assisted Thorascopic Surgery Conversion and Open Control Patients at Risk for Each Cancer Stage
 

   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
VATS lobectomy for lung cancer remains an infrequently performed operation accounting for less than 5% of all lobectomies. The procedure remains controversial, partly because of concerns about its safety. A proportion of VATS patients will require intraoperative conversion to open thoracotomy, in some cases emergently to control hemorrhage, and concern remains regarding adequate cancer clearance with a minimally invasive approach. Although no large randomized prospective series has compared the two approaches, several studies have shown benefits to patients with a VATS lobectomy [5–10] and at least equivalent morbidity and mortality in both the short term and long term [11, 12]. Previous published series have commented that converted patients have no increase in perioperative morbidity and mortality compared with patients who had a successful VATS procedure[11, 12]. This current retrospective case-controlled study focused on VATS cases converted intraoperatively to open thoracotomy comparing the short-term and long-term outcomes with open thoracotomy controls and found no statistically significant differences between the two groups.

The conversion rate to open thoracotomy in the current study was 10.5%, and most conversions occurred in the earlier phase of operative experience. Conversion rates in the published literature vary but range up to 13% [11–14]. Part of the apparent discrepancy in conversion rates may relate to the definition used for conversion. For example, if on initial inspection/trial dissection a case is not considered suitable for VATS lobectomy this may not be captured in some series.

We found the most common reasons for conversion to be bleeding and location/extent of tumor, which is similar to other studies [11,12]. No conversion in our center resulted in an in-hospital death. This confirms other published data on the safety of a VATS lobectomy.

The long-term survival for stage I NSC bronchogenic carcinoma in this study is comparable to published survival figures of 67% for surgical-pathologic stage IA and 57% of surgical-pathologic stage IB tumors [18]. Stage II and III lung cancer provided less favorable outcomes, as expected.

This case-controlled study may be criticized in a number of respects. It is inevitable that small numbers of patients are involved, which may have led to a type II statistical error. Indeed, the small number of converted cases would make it difficult to demonstrate an adverse statistical effect with VATS conversion were that to be apparent from the survival curves.

Although no statistically significant difference was found in survival between the two groups, the survival curve of the converted VATS patients may appear more favorable than that of the open thoracotomy controls. This counterintuitive finding may be explained by the larger number of stage 1a patients in the converted group compared with Ib. It should also be noted, however, that more patients in the control group had squamous cell carcinomas, which may confer a small survival advantage, although equally, no patients in the converted group had bronchoalveolar carcinoma [19].

It may be argued that the variation in size of T2 tumors led to smaller T2 tumors being selected for attempted VATS, although this was found not to be the case. Mean T2 tumor size was 4.7 (SD, 1.45) cm in the control group compared with to 4.4 (SD, 1.28) cm in the VATS conversion group, for which there was no statistically significant difference (unpaired t test, p = 0.049).

Finally, the statistical methodology could be criticized because propensity score matching would offer a more rigorous approach. Against that it must be observed that the fundamental requirement for individuals to be sorted into different treatments as if randomly assigned clearly cannot apply when the VATS patients were specifically identified preoperatively as being potentially suitable for that treatment. Also, the comparatively small size of the study group may not allow the propensity method to function at best advantage. Thus, the comparison offered is in many respects a qualitative attempt to determine whether any noticeable detriment resulted from an initial attempt at a VATS approach. This was not evident, but we recognize the inherent limitations of the study, as noted.

This retrospective case-controlled study has shown that even when a patient is converted from VATS to open thoracotomy, there is no apparent detrimental effect on perioperative outcomes or long-term mortality compared with patients whose planned cancer intervention was through a traditional thoracotomy. We therefore conclude that VATS lobectomy should be the treatment strategy of choice for stage I and II NSCLC in view of the well-established short-term benefits and equivalent survival associated with successful VATS resection.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

  1. Roviaro G, Rebuffat C, Varoli FC, Mariani C, Maciocco M. Videoendoscopic pulmonary lobectomy for cancer Surg Laparosc Endosc Percutan Tech 1992;2:244-247.
  2. Landreneau RJ, Hazelrigg SR, Ferson PF. Thoroscopic resection of 85 pulmonary lesions Ann Thorac Surg 1992;54:415-419.[Abstract]
  3. Stantley DG. Thorascopic lobectomy Tenn Med 1992;85:463-464.
  4. Lewis RJ, Sisler GE, Caccavale RJ. Imaged thoracic lobectomy: should it be done? Ann Thorac Surg 1992;54:80-83.[Abstract]
  5. Walker WS. Video-assisted thoracic surgery (VATS) lobectomy: the Edinburgh experience Semin Thorac Cardiovasc Surg 1998;10:291-299.[Medline]
  6. Sugiura H, Morikawa T, Kaji M, Sasamura Y, Kondo S, Katoh H. Long-term benefits for the quality of life after video-assisted thorascopic lobectomy in patients with lung cancer Surg Laparosc Endosc Percutan Tech 1999;9:403-408.[Medline]
  7. Giudicelli R, Thomas P, Lonjon T, et al. Video-assisted minithoracotomy versus muscle-sparing thoracotomy for performing lobectomy Ann Thorac Surg 1994;58:712-718.[Abstract]
  8. 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]
  9. Craig SR, Leaver HA, Yap PL, Pugh GC, Walker WS. Acute phase responses following minimal access and conventional thoracic surgery Eur J Cardiothoracic Surg 2001;20:455-463.[Abstract/Free Full Text]
  10. Leaver HA, Craig SR, Yap PL, Walker WS. Lymphocyte responses following open and minimally invasive thoracic surgery Eur J Clin Invest 2000;30:230-238.[Medline]
  11. Walker WS, Codispoti M, Soon S-Y, Stamenkovic S, Carnochan F, Pugh G. Long-term outcomes following VATS lobectomy for non-small cell bronchogenic carcinoma Eur J Cardthorac Surg 2003;23:397-402.
  12. McKenna RJ, Houck W, Fuller CB. Video-assisted thoracic surgery lobectomy: experience with 1,100 cases Ann Thorac Surg 2006;81:421-426.[Abstract/Free Full Text]
  13. Gharagozloo F, Tempesta B, Margolis M, Alexander EP. Video-assisted thoracic surgery lobectomy for stage I lung cancer Ann Thorac Surg 2003;76:1009-1015.[Abstract/Free Full Text]
  14. Nomori H, Horio H, Naruke T, Suemasu K. What is the advantage of a thorascopic lobectomy over a limited thoracotomy procedure for lung cancer surgery? Ann Thorac Surg 2001;72:879-884.[Abstract/Free Full Text]
  15. The NHS Confederation NHS Research Ethics: a guide to the new serviceDecember 2006. Issue 03:1–4http://www.rdu.mmu.ac.uk/ethics/docs/NHSresethicsnewservicefeb07_000.pdf 2001Accessed Mar 25, 2008.
  16. Coggon D, Rose G, Barker DJP, eds. Case control and cross-sectional studies. In: Epidemiology for the uninitiated. 4th ed. BMJ 1997. http://bmj.bmjjournals.com/epidem/epid.html. Accessed Mar 25, 2008.
  17. Walker WS. Major pulmonary resectionIn: Walker WS, editor. Video assisted thoracic surgery. Oxford, UK: Isis (now Martin Dunitz); 1999. pp. 135-164.
  18. Mountain CF. Revisions in the international system for staging lung cancer Chest 1997;111:1710-1717.[Medline]
  19. Khan OA, Fitzgerald JJ, Field ML, et al. Histological determinants of survival in completely resected T1–2N1M0 non-small cell cancer of the lung Ann Thorac Surg 2004;77:1173-1178.[Abstract/Free Full Text]



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