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. 2009 Aug 3:6:Doc04.
doi: 10.3205/tss000018.

Thoracoscopic versus open lobectomy debate: the pro argument

Frank Detterbeck  1
Affiliations

Thoracoscopic versus open lobectomy debate: the pro argument

Frank Detterbeck. Thorac Surg Sci. .

Abstract
in English, German

Introduction: Controversy persists about the role of VATS lobectomy for patients with lung cancer. This is particularly true in Europe, where VATS (video assisted thoracic surgery) lobectomy is performed for lung cancer less often than in the USA or Japan. This article reviews existing data comparing the results of VATS vs. open lobectomy for the treatment of lung cancer in order to provide a scientific basis for a rational assessment of this issue.

Methods: The review of the data presented here draws heavily from a 2007 metaanalysis by Cheng et al. [1] published in 2007, as it employed rigorous methodology in performing a systematic review and metaanalysis, and involved a detailed analysis of many major and minor endpoints on an intent to treat basis. This included 36 trials, three of them randomized, and 3589 patients, reported between 1995 and 2007. Summary results for individual endpoints are shown as a mean value with 95% confidence intervals (CI). These values are taken from the summary results of the Forrest plots in the source article. Dichotomized variables are expressed as an Odds Ratio, with values <1 being in favor of VATS lobectomy. Continuous variables are reported as weighted mean differences.

Results: The operative time for a VATS lobectomy was statistically longer, but only by 16 minutes. The conversion rate from VATS to open was 6%. There was no significant difference in the rates of major bleeding, blood transfusion or re-operation. VATS lobectomy was associated with a significantly lower rate of complications in general and pulmonary complications in particular. Postoperative pain was reduced, functional outcome was better, whereas overall quality of life was not. Mediastinal staging was equal with regard to the number of nodes or the number of nodal stations sampled. The ability of patients to receive adjuvant chemotherapy was improved following VATS. There was no difference in survival at 1 and 3 years for lung cancer (all stages combined). There was no difference in survival at 5 years for each tumor stage, and no difference in the rate of deaths at maximal follow-up.

Conclusion: The data suggests that VATS lobectomy for NSCLC is safe, results in fewer complications, less pain, and more rapid return of normal functioning. There appears to be either no difference or a slight benefit in long term survival after VATS lobectomy. These conclusions are demonstrated by a comprehensive, rigorous metaanalysis of the controlled clinical trials, but are weakened by the fact that most of the studies were not randomized. However, because a large randomized trial is not likely to ever be conducted, this represents the best assessment of the value of VATS lobectomy that is available.

Einführung: An der thorakoskopischen Lobektomie scheiden sich die Geister, ganz besonders, wenn es um die Therapie des Bronchialkarzinoms geht. Diese Kontroverse ist in Europa, wo wesentllich weniger onkologische VATS (videoassistierte Thorakoskopie)-Lobektomien durchgeführt werden als in den USA oder Japan, besonders ausgeprägt. Der vorliegende Artikel möchte eine rationale Bewertung erleichtern, indem er die Ergebnisse der offenen und thorakoskopischen Lobektomie bei Bronchialkarzinom anhand der aktuellen Datenlage gegenüberstellt.

Methoden: Die hier vorgestellte Übersicht lehnt sich an eine 2007 von Cheng et al. [1] publizierte Metaanalyse an, die sich durch ihre rigorose Methodik, die genaue Analyse aller relevanten Endpunkte und die eingeschlossene Anzahl von 36 Studien, darunter drei randomisierte, und 3589 Patienten auszeichnet. Zur übersichtlichen Darstellung einzelner Endpunkte wurde der Mittelwert mit einem 95% Konfidenzinterval (CI) gewählt; die Werte wurde den Forrest Plots der Quellenartikel entnommen. Kategorielle Daten wurden durch Odds Ratios abgebildet, wobei eine Odds Ratio <1 einen Vorteil für die VATS Lobektomie ausdrückt. Quantitative Daten wurden als gewichtete Mittelwerte dargestellt.

Ergebnisse: Thorakoskopische Lobektomien dauerten statistisch gesehen 16 Minuten länger als offene. Die Konversionsrate betrug 6%. Hinsichtlich der Häufigkeit von Blutungskomplikationen, Transfusionen und Revisionseingriffen gab es keine signifikanten Unterschiede. Die Häufigkeit allgemeiner und pulmonaler Komplikationen war beim thorakoskopischen Vorgehen signifikant geringer. Weitere signifikante Vorteile zeigte das thorakoskopische Vorgehen bei postoperativen Schmerzen und funktionellem Ergebnis, allerdings ohne Niederschlag in Lebensqualitätsanalysen. Das intraoperative mediastinale Lymphknotensampling zeigte hinsichtlich Anzahl untersuchter Lymphknoten und Lymphknotenstationen keinen signifikanten Unterschied. Adjuvante Chemotherapien sind nach thorakoskopischer Lobektomie besser durchführbar. Überleben nach einem und drei Jahren (alle Tumorstadien) sowie stadienspezifisches Überleben nach 5 Jahren und maximaler Beobachtungszeit waren nicht signifikant verschieden.

Schlussfolgerung: Die bisher umfassendste Metaanalyse kontrollierter klinischer Studien lässt folgende Schlüsse zu: Die thorakoskopische Lobektomie zur Behandlung geeigneter Stadien des Bronchialkarzinoms ist sicher durchführbar und verursacht im Vergleich zum offenen Vorgehen weniger Komplikationen, weniger Schmerzen und weniger Funktionseinschränkungen. Das Langzeitüberleben ist der offenen Lobektomie zumindest gleichwertig. Einerseits darf nicht übersehen werden, daß in diese Analyse lediglich drei randomisierte Studie eingeschlossen werden konnten. Andererseits ist die Durchführung einer großen randomisierten Studie sehr unwahrscheinlich, so daß es vernünftig erscheint, die Ergebnisse der Metaanalyse im Moment als bestmögliche Bewertung der thorakoskopischen Lobektomie zu akzeptieren.

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Figures

Table 1
Table 1. Baseline characteristics of patients in controlled trials
Figure 1
Figure 1. Intraoperative outcomes of VATS vs. open lobectomy
Bl, blood; CI, confidence interval; Op duratn, operative duration; Re-op, re-operation
Figure 2
Figure 2. Peri-operative complications of VATS vs. open lobectomy
Card, cardiac; CI, confidence interval; Compl, complications; d, days; Hosp. LOS, hospital length of stay; Periop, peri-operative; Pulm, pulmonary; Resp dysfunctn, respiratory dysfunction
Figure 3
Figure 3. Post-operative pain with VATS vs. open lobectomy
CI, confidence interval; Incid, incidence; Duratn Analg, duration analgesic medication needed; freq, frequency; mo, months; VAS, Visual Analog Scale pain score; yr, year
Figure 4
Figure 4. Quality of life and functional outcomes of VATS vs. open lobectomy
CI, confidence interval; FEV1, forced expiratory volume in 1 second (post-operative as compared with pre-operative results as % of normal); FVC, forced vital capacity (post-operative as compared with pre-operative results as % of normal); Indepen func, independent functioning; Limitatn, limitation; m, months; min, minute; Phys func, physical functioning; QOL, Quality of Life; wk, week; yr, year; Δ, change (between pre-operative and post-operative results)
Figure 5
Figure 5. Oncologic aspects of VATS vs. open lobectomy
Adj, adjuvant; Bx’d, biopsied; Chemo, chemotherapy; CI, confidence interval; No., number; reductn, reduction
Figure 6
Figure 6. Long-term outcomes of VATS vs. open lobectomy
CI, confidence interval; max f/u, maximal follow-up; rand, randomized studies; S, survival; Surv, survival; yr, year
Figure 7
Figure 7. Overall survival after VATS lobectomy for lung cancer in 1100 patients
Reproduced with permission from McKenna et al. [5]
Figure 8
Figure 8. Overall survival after VATS vs. open lobectomy in clinical stage Ia patients
Reproduced with permission from Sakuraba et al. [21]
Figure 9
Figure 9. Rib-spreading vs. non-rib-spreading VATS approaches
a-VATS, assisted VATS (rib-spreading, with dissection done by direct vision through an incision as well as on a video monitor); CI, confidence interval; c-VATS, complete VATS (no rib-spreading, dissection done entirely by viewing structures on a video monitor); Hosp. LOS, hospital length of stay; OR, operating room; VAS/Analg d, Visual Analog Scale pain scores or analgesic days
See this image and copyright information in PMC

References

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