A meta-analysis of unmatched and matched patients comparing video-assisted thoracoscopic lobectomy and conventional open lobectomy

Abstract

Background: Video-assisted thoracic surgery (VATS) for patients with early-stage non-small cell lung cancer (NSCLC) has been established as a safe and feasible alternative to open thoracotomy. This meta-analysis aims to assess the potential difference between unmatched and propensity score-matched cohorts who underwent VATS versus open thoracotomy in the current literature.

Methods: Three relevant studies with unmatched and propensity score-matched patients were identified from six electronic databases to examine perioperative outcomes after VATS lobectomy versus open thoracotomy for patients with early-stage NSCLC. Endpoints included perioperative mortality and morbidity, individual postoperative complications and duration of hospitalization.

Results: Results indicate that perioperative mortality was significantly lower for VATS compared to open thoracotomy in unmatched patients but no significant difference was detected amongst propensity score-matched patients. Similarly, the incidences of prolonged air leak and sepsis were significantly lower for VATS in the unmatched cohort, but not identified in the propensity score-matched cohort. In both the unmatched and matched groups, patients who underwent VATS were found to have a significantly lower overall perioperative morbidity rate, incidences of pneumonia and atrial arrhythmias, and a shorter duration of hospitalization in comparison to patients who underwent open thoracotomy.

Conclusions: The present meta-analysis indicates that VATS lobectomy has superior perioperative outcomes compared to open thoracotomy in both matched and unmatched cohorts. However, the extent of the superiority may have been overestimated in the unmatched patients when compared to propensity score-matched patients. Due to the limited number of studies with available data included in the present meta-analysis, these results are only of observational interest and should be interpreted with caution.

Keywords: Video-assisted thoracic surgery; meta-analysis; non-small cell lung cancer; propensity score analysis; thoracotomy.

Figure 1

Forest plots of the relative risk (RR) of all-cause perioperative mortality after video-assisted thoracic surgery (VATS) versus open thoracotomy for patients with non-small cell lung cancer (NSCLC) in unmatched (A) and propensity score-matched (B) patients. The estimate of the RR of each trial corresponds to the middle of the squares, and the horizontal line shows the 95% confidence interval (CI). On each line, the numbers of events as a fraction of the total number randomized are shown for both treatment groups. For each subgroup, the sum of the statistics, along with the summary RR, is represented by the middle of the solid diamonds. A test of heterogeneity between the trials within a subgroup is given below the summary statistics

Figure 2

Forest plots of the relative risk (RR) of perioperative morbidity after video-assisted thoracic surgery (VATS) versus open thoracotomy for patients with non-small cell lung cancer (NSCLC) in unmatched (A) and propensity score-matched (B) patients. The estimate of the RR of each trial corresponds to the middle of the squares, and the horizontal line shows the 95% confidence interval (CI). On each line, the numbers of events as a fraction of the total number randomized are shown for both treatment groups. For each subgroup, the sum of the statistics, along with the summary RR, is represented by the middle of the solid diamonds. A test of heterogeneity between the trials within a subgroup is given below the summary statistics

Figure 3

Forest plots of the relative risk (RR) of prolonged air leak after video-assisted thoracic surgery (VATS) versus open thoracotomy for patients with non-small cell lung cancer (NSCLC) in unmatched (A) and propensity score-matched (B) patients. The estimate of the RR of each trial corresponds to the middle of the squares, and the horizontal line shows the 95% confidence interval (CI). On each line, the numbers of events as a fraction of the total number randomized are shown for both treatment groups. For each subgroup, the sum of the statistics, along with the summary RR, is represented by the middle of the solid diamonds. A test of heterogeneity between the trials within a subgroup is given below the summary statistics

Figure 4

Forest plots of the relative risk (RR) of sepsis after video-assisted thoracic surgery (VATS) versus open thoracotomy for patients with non-small cell lung cancer (NSCLC) in unmatched (A) and propensity score-matched (B) patients. The estimate of the RR of each trial corresponds to the middle of the squares, and the horizontal line shows the 95% confidence interval (CI). On each line, the numbers of events as a fraction of the total number randomized are shown for both treatment groups. For each subgroup, the sum of the statistics, along with the summary RR, is represented by the middle of the solid diamonds. A test of heterogeneity between the trials within a subgroup is given below the summary statistics

Figure 5

Forest plots of the standardized mean difference (SMD) of duration of hospitalization after video-assisted thoracic surgery (VATS) versus open thoracotomy for patients with non-small cell lung cancer (NSCLC) in unmatched (A) and propensity score-matched (B) patients. The estimate of the SMD of each trial corresponds to the middle of the squares, and the horizontal line shows the 95% confidence interval (CI). For each subgroup, the sum of the statistics, along with the summary SMD, is represented by the middle of the solid diamonds. A test of heterogeneity between the trials within a subgroup is given below the summary statistics