VATS in Lung Cancer Shortens Hospital Stay, Decreases Complications

By Roxanne Nelson
Medscape Medical News

November 5, 2008 (Philadelphia, Pennsylvania) — Video-assisted thoracic surgery (VATS), a recently developed and minimally invasive procedure, appears to be beneficial to lung cancer patients. A preliminary study, presented here at CHEST 2008, the American College of Chest Physicians 74th Annual Scientific Assembly, showed that length of hospital stay is significantly shorter and perioperative morbidity lower with VATS than with open thoracotomy and lobectomy, in patients with stage?1 non-small-cell lung cancer (NSCLC).

"There was a trend toward fewer respiratory complications with VATS, but it wasn't significant," explained lead author Walter Scott, MD, a thoracic surgeon at Fox Chase Cancer Center, in Philadelphia, Pennsylvania. "But patients were able to ambulate much sooner."

VATS lobectomy appears to be an acceptable, even preferable, surgical treatment for patients with stage?1 NSCLC, according to Dr. Scott. "But because we are using smaller incisions and we are not spreading the ribs, that does somewhat limit the size of the tumor that we can remove with VATS. The procedure is primarily done with clinical stage?1 tumors that are less than 3 cm in size."

In an interview, Dr. Scott also pointed out that there are limited data showing that elderly patients and those with low pulmonary function might actually benefit the most from this procedure. "There is less of an impact on the chest wall," he said. "They can breathe easier and they have less pain."

The use of VATS has expanded over the past decade, allowing surgeons to perform complex procedures that previously required a thoracotomy. The use of VATS in the management of lung cancer continues to evolve, although it still tends to be performed primarily at academic centers.

In this study, Dr. Scott and colleagues compared patients with clinical stage?1 NSCLC who underwent VATS lobectomy and patients who underwent thoracotomy and lobectomy. The researchers analyzed the records of 140 lobectomy patients: 74 who underwent VATS and 66 who underwent open surgery. Of the 74 scheduled VATS procedures, 5 were converted to open surgeries.

The operative mortality rate was the same for both groups: 1.5% (1 of 66 patients) for open surgery and 1.5% (1 of 74 patients) for VATS. The researchers also observed that the median length of hospital stay was only 4 days for VATS patients, compared with 7 days for those who had undergone an open procedure. The VATS patients also had their postoperative chest tube removed sooner than patients with open surgery (adjusted median chest tube duration was 5 days for open surgery and 4 days for VATS; P?< .0001).

The rate of complications was lower for VATS than for open surgery (35% vs 42%, respectively). Lymph node retrieval was similar between the 2 groups (4.2 for VATS vs. 4.6 for open surgery).

In a related presentation, Dr. Scott and his team conducted a literature search to grade the clinical evidence and determine the strength of the recommendations for the use of VATS lobectomy.

Lack of Supporting Published Literature

There is a lack of strong evidence supporting the use of VATS lobectomy, Dr. Scott explained, with few published randomized trials. Their literature search yielded only 4 randomized controlled trials, 12 case–control series, and 11 cases series. Two of the randomized trials were excluded from their analysis because they did not have clinical end points; the 2 that were included were both small, with 60 and 100 patients.

A similar rate of lymph node removal was reported by the 2 randomized controlled trials and 2 case–control series for VATS and open thoracotomy. A decreased length of hospital stay was only reported in 3 case–control series, as was improved quality of life with VATS lobectomy.

The recommendations for using VATS to treat NSCLC patients with clinical stage?1 disease are generally based on moderate or low-grade evidence. Some data show that VATS is safe and survival is similar to open surgery, said Dr. Scott. "But even though there is not a lot of published evidence supporting it, people have come to believe that VATS is better for most patients."

Although a larger multicenter randomized trial comparing the 2 approaches would provide stronger support for the procedure, Dr. Scott is doubtful that such a study will ever take place. "Patients are unwilling to participate in that kind of trial," he said. "And surgeons who perform the procedure see good results with VATS and don't want to randomize patients."

The authors have disclosed no relevant financial relationships.

CHEST 2008: American College of Chest Physicians 74th Annual Scientific Assembly: Abstracts AP2269 and AS2242. Both presented October 28, 2008.