肺癌之VATS縮短了住院天數與減少併發症


  November 5, 2008(賓州費城) — 影像輔助胸腔手術(Video-assisted thoracic surgery,VATS)這個最近發展出來的微創手術,對於肺癌病患有所助益。這項於CHEST 2008美國胸腔外科第74屆年會中發表的研究顯示,對於第一期非小細胞肺癌(NSCLC)病患而言,相較於開放式胸廓切開術與肺葉切除術,VATS的住院天數明顯縮短且手術前後的發病率降低。
  
  主要作者、Fox Chase癌症中心胸腔外科的Walter Scott醫師表示,VATS傾向有較少的呼吸道併發症,但並不顯著。不過,病患可以比較早下床走動。
  
  Scott醫師表示,對於第一期NSCLC病患,VATS肺葉切除看似是可以接受,甚至是更好的手術;但因為我們使用較小的切口且不會進入肋間,藉由VATS切除的腫瘤大小受到限制;此手術主要用於臨床第一期腫瘤且小於三公分者。
  
  在訪問中,Scott醫師也指出,年長病患和肺功能低的病患從此一手術獲利的實際資料有限;他表示,對胸壁的影響較少,病患可以比較容易呼吸且疼痛較少。
  
  在過去10年間,VATS的使用漸增,讓醫師可以進行之前需要開胸的複雜手術;使用VATS於肺癌則持續演進,不過傾向於醫學教學中心進行。在此研究中,Scott醫師等人比較接受VATS和接受開放式胸廓切開術與肺葉切除術的臨床第一期NSCLC病患;研究者分析140名肺葉切除病患的資料:74 人接受 VATS,66 名接受開放式手術。在這74名接受VATS手術的病患中,有5人轉為開放式手術。
  
  兩組的手術死亡率相似:開放式手術為1.5% (66人中有1人死亡),VATS組為1.5% (74人中有1人死亡)。研究者也觀察發現,VATS病患的平均住院天數只有4天,開放式手術者為7 天。VATS病患術後移除胸管天數也比開放式手術病患快(開放手術的平均胸管留置天數為5天,VATS為4天; P< .0001)。
  
  VATS病患的併發症比率也比開放式手術低(分別是35% vs. 42%)。兩組的淋巴結恢復(Lymph node retrieval)相似 (VATS組為4.2、開放式手術為4.6)。
  
  Scott 醫師等人在相關發表中,進行一個文獻搜尋。區分臨床證據等級,確認使用VATS肺葉切除建議的強度。
  
  【缺乏已發表的文獻支持】
  Scott 醫師解釋,缺乏使用VATS肺葉切除的強力證據支持,很少已經發表的隨機試驗。他們的文獻搜尋僅獲得四篇隨機控制試驗,12 篇案例控制系列研究,11篇案例系列研究。他們的分析排除其中兩個隨機試驗,因為這兩篇沒有臨床終點;納入的兩篇都是小型研究,分別只有 60名和100名病患。
  
  VATS和開放式胸廓切開術的兩篇隨機控制試驗和兩篇案例控制系列研究中,淋巴結移除比率相似。僅有三篇控制控制系列研究提到VATS肺葉切除術的住院天數縮短和生活品質獲得改善。
  
  一般是根據中到低度的證據建議使用VATS治療臨床第一期NSCLC病患;Scott 醫師表示,有些資料顯示,VATS是安全的,且存活和開放式手術相似。即使沒有許多已發表的證據支持,一般相信VATS對大多數病患是比較好的。
  
  雖然比較這兩種方式的大型多中心隨機試驗可以提供更有利的支持,但Scott醫師對是否會進行這種研究有所疑慮;他表示,病患不願意參加這種試驗。進行手術的醫師看到VATS有好的結果,因而不願意隨機篩選病患。
  
  作者宣稱沒有相關資金上的往來。
  
  CHEST 2008: 美國胸腔外科第74屆年會:摘要AP2269與AS2242。兩篇都發表於2008年10月28日。

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.

    
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