Background Several single-institution series have demonstrated that compared with open thoracotomy, video-assisted thoracoscopic lobectomy may be associated with fewer postoperative complications. In ...the absence of randomized trials, we queried the Society of Thoracic Surgeons database to compare postoperative mortality and morbidity following open and video-assisted thoracoscopic lobectomy. A propensity-matched analysis using a large national database may enable a more comprehensive comparison of postoperative outcomes. Methods All patients having lobectomy as the primary procedure via thoracoscopy or thoracotomy were identified in the Society of Thoracic Surgeons database from 2002 to 2007. After exclusions, 6323 patients were identified: 5042 having thoracotomy, 1281 having thoracoscopy. A propensity analysis was performed, incorporating preoperative variables, and the incidence of postoperative complications was compared. Results Matching based on propensity scores produced 1281 patients in each group for analysis of postoperative outcomes. After video-assisted thoracoscopic lobectomy, 945 patients (73.8%) had no complications, compared with 847 patients (65.3%) who had lobectomy via thoracotomy ( P < .0001). Compared with open lobectomy, video-assisted thoracoscopic lobectomy was associated with a lower incidence of arrhythmias n = 93 (7.3%) vs 147 (11.5%); P = .0004, reintubation n = 18 (1.4%) vs 40 (3.1%); P = .0046, and blood transfusion n = 31 (2.4%) vs n = 60 (4.7%); P = .0028, as well as a shorter length of stay (4.0 vs 6.0 days; P < .0001) and chest tube duration (3.0 vs 4.0 days; P < .0001). There was no difference in operative mortality between the 2 groups. Conclusions Video-assisted thoracoscopic lobectomy is associated with a lower incidence of complications compared with lobectomy via thoracotomy. For appropriate candidates, video-assisted thoracoscopic lobectomy may be the preferred strategy for appropriately selected patients with lung cancer.
Background Unsuspected lymph node metastases are found in the surgical specimens of 10% to 25% clinical stage I lung cancers. Video-assisted thoracic surgery (VATS) is a minimally invasive ...alternative to thoracotomy. Because detection of clinically occult metastases is dependent on the completeness of surgical lymph node dissection, the influence of surgical approach on nodal evaluation is of interest. We determined the frequency of nodal metastases identified in clinically node-negative tumors by thoracotomy (“open”) and VATS approaches to approximate the completeness of surgical nodal dissections. Methods The Society of Thoracic Surgery database was queried for lobectomies and segmentectomies from 2001 to 2010. Results A total of 11,531 (7,137 open and 4,394 VATS) clinical stage I primary lung cancers were resected. Nodal upstaging was seen in 14.3% (1,024) in the open group and 11.6% (508) in the VATS group ( p < 0.001). Upstaging from N0 to N1 was more common in the open group (9.3% versus 6.7%; p < 0.001); however, upstaging from N0 to N2 was similar (5.0% open and 4.9% VATS; p = 0.52). Among 2,745 propensity-matched pairs, N0 to N1 upstaging remained less common with VATS (6.8% versus 9%; p = 0.002). Conclusions During lobectomy or segmentectomy for clinical N0 lung cancer, mediastinal nodal evaluation by VATS and thoracotomy results in equivalent upstaging. In contrast, lower rates of N1 upstaging in the VATS group may indicate variability in the completeness of the peribronchial and hilar lymph node evaluation. Systematic hilar dissection is encouraged, particularly as more surgeons adopt the VATS approach.
Objectives Anatomic resection is currently the standard of care for clinical stage I lung cancer, yet clinicians increasingly pursue nonsurgical, ablative therapies to avoid the morbidity of ...thoracotomy. The video-assisted thoracic surgery (VATS) approach is a minimally invasive alternative to thoracotomy yet the effect of VATS on the morbidity of patients undergoing lung cancer resection is not fully characterized. We evaluated complications following anatomic resection of clinical stage I lung cancer by VATS and thoracotomy to clarify the effect of the minimally invasive approach. Methods The Society of Thoracic Surgeons database was queried for lobectomies and segmentectomies performed between 2001 and 2010 for clinical stage I primary cancer. Results A total of 11,531 (7137 open and 4394 VATS) patients with clinical stage I primary lung cancers underwent resection. Propensity scoring was used to match cases into 2745 well-balanced pairs. Overall complications were significantly more likely in the thoracotomy group (36%) than in the VATS cohort (30%; P < .001). Patients undergoing thoracotomy experienced significantly more pulmonary complications (21% vs 18%), atrial arrhythmias (13% vs 10%), and were more likely to undergo transfusion (6% vs 4%). Operative mortality was similar (thoracotomy 1.8%, VATS 1.3%; P = .13). Conclusions Anatomic resection of early stage lung cancer is performed with a low mortality rate, according to data from the Society of Thoracic Surgeons database. Perioperative complications are significantly less likely to occur when patients with stage I lung cancers undergo resection using the VATS approach. Further study is warranted to determine long-term effects of these differences in perioperative outcomes.
Abstract BACKGROUND: Robotic-assisted lobectomy is being offered increasingly to patients. However, little is known about its safety, complication profile, or effectiveness. METHODS: Patients ...undergoing lobectomy in in the United States from 2008 to 2011 were identified in the Nationwide Inpatient Sample. In-hospital mortality, complications, length of stay, and cost for patients undergoing robotic-assisted lobectomy were compared with those for patients undergoing thoracoscopic lobectomy. RESULTS: We identified 2,498 robotic-assisted and 37,595 thoracoscopic lobectomies performed from 2008 to 2011. The unadjusted rate for any complication was higher for those undergoing robotic-assisted lobectomy than for those undergoing thoracoscopic lobectomy (50.1% vs 45.2%, P < .05). Specific complications that were higher included cardiovascular complications (23.3% vs 20.0%, P < .05) and iatrogenic bleeding complications (5.0% vs 2.0%, P < .05). The higher risk of iatrogenic bleeding complications persisted in multivariable analyses (adjusted OR, 2.64; 95% CI, 1.58-4.43). Robotic-assisted lobectomy costs significantly more than thoracoscopic lobectomy ($22,582 vs $17,874, P < .05). CONCLUSIONS: In this early experience with robotic surgery, robotic-assisted lobectomy was associated with a higher rate of intraoperative injury and bleeding than was thoracoscopic lobectomy, at a significantly higher cost.
Background Video-assisted thoracic surgery (VATS) lobectomy for non-small cell lung cancer (NSCLC) is increasingly popular. However, the oncologic soundness of VATS for patients with NSCLC as ...measured by long-term survival has not been proven. The objective here is to determine the overall survival (OS) and disease-free survival (DFS) in two well-matched groups of patients with NSCLC resected by VATS or thoracotomy. Methods We conducted a retrospective review of a prospective database to identify patients who had a lobectomy for NSCLC. A propensity score-matched analysis was done with variables of age, sex, smoking history, Charlson comorbidity index, forced expiratory volume in 1 second, lung diffusing capacity for carbon monoxide, histology, and clinical T and N status. Medical records were reviewed and survival was analyzed. Results After matching, there were 208 patients in each group. Patient and tumor characteristics were similar. The VATS group had a shorter length of stay. More nodes (14.3 versus 11.3; p = 0.001) and more nodal stations (3.8 versus 3.1; p < 0.001) were removed by thoracotomy. No differences were seen in OS and DFS. Median follow-up was 36 months. More than 90% of patients had clinical stage I disease, with 3- and 5-year OS of 87.4% and 76.5%, respectively, for VATS, and 81.6% and 77.5%, respectively, for thoracotomy ( p = 0.672). Both the incidence and distribution of recurrence were similar. Multivariate Cox regression analyses of OS and DFS confirmed the noninferiority of VATS. Conclusions For patients with clinical stage I NSCLC, VATS lobectomy offered similar OS and DFS compared with thoracotomy. Thoracotomy offers a more thorough lymph node evaluation, and may be appropriate for patients with more advanced clinical disease.
Background There is rising interest among thoracic surgeons in anatomical segmental resection for early-stage non-small cell lung cancer (NSCLC). In the current study we compared video-assisted ...thoracoscopic surgery (VATS) and thoracotomy approaches for segmentectomy to explore the safety and oncologic efficacy of VATS for stage I NSCLC. Methods We retrospectively analyzed all patients who underwent segmentectomy for clinical stage I NSCLC from 2000 to 2013. Perioperative and oncologic outcomes were evaluated. The probabilities of disease-free survival (DFS) and overall survival (OS) were estimated with the Kaplan-Meier method and multivariate Cox regression analysis. Results We identified 193 segmentectomies, including 91 (47%) performed by VATS and 102 (53%) performed by thoracotomy. Patients who underwent VATS, although older (median age 72 versus 68 years; p = 0.016), had similar sex distribution (63% versus 61% women; p = 0.792) and similar clinical stages as the thoracotomy group (stage IA: VATS, 93.4% versus thoracotomy 87.3%; p = 0.152). No significant differences were found in the final pathologic stages ( p = 0.439), total number of lymph nodes (LNs) sampled (7 versus 8; p = 0.104), or median number of mediastinal LN stations sampled (2 versus 2; p = 0.234). VATS was associated with decreased length of stay (4 versus 5 days; p = 0.001) and decreased pulmonary complications (13.2% versus 26.5%; p = 0.022). Five-year DFS and OS favored VATS over thoracotomy (58% versus 47%; p = 0.013 and 75% versus 62%; p = 0.017, respectively). By multivariable analysis, the only predictor of poor DFS or OS was larger tumor size. Conclusions VATS segmentectomy is a safe and oncologically effective technique for the treatment of stage I NSCLC. Patients who underwent VATS had a shorter length of stay, fewer pulmonary complications, equivalent lymphadenectomy results, and similar oncologic outcomes compared with patients undergoing thoracotomy.
Background As the population ages, clinicians are increasingly confronted with octogenarians with resectable non-small cell lung cancer (NSCLC). We reviewed the outcomes of octogenarians who ...underwent lobectomy for NSCLC by video-assisted thoracic surgery (VATS) versus open thoracotomy, to determine if there was a benefit to the VATS approach in this group. Methods We conducted a retrospective single-institution review of patients age 80 years or greater who underwent a lobectomy for NSCLC from 1998 to 2009. Outcomes including complication rates, length of stay, disposition, and long-term survival were analyzed. Results One hundred twenty-one octogenarians underwent lobectomy: 40 VATS and 81 through open thoracotomy. Compared with thoracotomy, VATS patients had fewer complications (35.0% vs 63.0%, p = 0.004), shorter length of stay (5 vs 6 days, p = 0.001), and were less likely to require admission to the intensive care unit (2.5% vs 14.8%, p = 0.038) or rehabilitation after discharge (5% vs 22.5%, p = 0.015). In multivariate analysis, VATS was an independent predictor of reduced complications (odds ratio, 0.35; 95% confidence interval, 0.15 to 0.84; p = 0.019). Survival comparisons demonstrated no significant difference between the two techniques, either in univariate analysis of stage I patients (5-year VATS, 76.0%; thoracotomy, 65.3%; p = 0.111) or multivariate analysis of the entire cohort (adjusted hazard ratio, 0.59; 95% confidence interval, 0.27 to 1.28; p = 0.183). Conclusions Octogenarians with NSCLC can undergo resection with low mortality and survival among stage I patients, which is comparable with the general lung cancer population. The VATS approach to resection reduces morbidity in this age demographic, resulting in shorter, less intensive hospitalization, and less frequent need for postoperative rehabilitation.
Background Patients who present with early stage non-small cell lung cancer and are poor candidates for lobar resection may be offered sublobar resection (commonly wedge) or stereotactic body ...radiotherapy (SBRT). However, comparing the relative effectiveness of these techniques is difficult because of differences in patient selection. We performed a propensity-matched analysis to compare the different treatment modalities. We compared the overall recurrence, overall survival, disease-free survival, and recurrence-free survival between treatment groups. Methods A prospectively collected database was reviewed for patients who underwent a wedge resection, a wedge plus brachytherapy, or SBRT for clinical stage IA non-small cell lung cancer from 2001 to 2012. Patients who underwent SBRT were further assessed to confirm operability. Univariate and Cox regression multivariate analysis were performed for predictors of a composite end point of recurrence and mortality. Results There were 164 patients identified, from which 99 were matched by age, sex, and histology. There were 61 women (62%) and 38 men (38%) with a median age of 73 years. Thirty-eight patients underwent a wedge resection only, 38 patients underwent a wedge with brachytherapy, and 23 patients had SBRT. Median follow-up was 35 months. Overall recurrence (local and distant) was significantly higher after SBRT (wedge, 9%; SBRT, 30%; p = 0.016). Although recurrence-free 3 -year survival was significantly better after wedge resection (88% versus 72%; p = 0.001), there was no difference between the two groups in disease-free 3-year survival (77% versus 59%; p = 0.066). Multivariate regression analysis identified male sex and SBRT as significant predictors for mortality and recurrence. Conclusions Patients with clinical stage IA non-small cell lung cancer treated by SBRT appear to have higher overall disease recurrence than those treated by wedge resection. However, there was no significant difference in disease-free survival. A randomized trial is needed to define the role of SBRT in the potentially operable patient.
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