New Approaches to the Minimally Invasive Treatment of Lung Cancer

Robert J McKenna, Jr; Ward V Houck

Disclosures

Curr Opin Pulm Med. 2005;11(4):282-286. 

In This Article

Video-Assisted Thoracoscopic Surgery Versus Thoracotomy

The evidence is mounting that a VATS lobectomy may have advantages over a lobectomy by thoracotomy. Opponents believe that a VATS lobectomy is unsafe, an incomplete cancer operation, and offers no advantage over a thoracotomy for lobectomy. Proponents believe that VATS lobectomy is a safe and effective treatment for lung cancer.[14] There is now enough experience with VATS lobectomy and enough data to address these issues, although there is very little data from randomized, prospective studies to compare the two approaches.

Intraoperative Comparison

Intraoperatively, VATS appears to be the same or better than a thoracotomy. In a nonrandomized comparison, Sugiura et al.[16] found no significant difference in the average operative time for VATS (227 ± 47 min) and thoracotomy (196 ± 64 min) for lobectomy; however, the mean blood loss was less for the VATS group (150 ± 126 mL vs 300 ± 192 mL; P = 0.0089). Demmy and Curtis[17] also found VATS lobectomy is associated with significant less blood loss than thoracotomy. There were no intraoperative deaths or major complications in the series.

Hospitalization

The postoperative course and cost appear to be the same or better for the VATS approach. Demmy and Curtis[17] compared VATS lobectomy patients with historic control subjects who underwent thoracotomies for lobectomies. Despite more high-risk cases, VATS patients had shorter hospitalizations (5.3 ± 3.7 days vs 12.2 ± 11.1 days; P = 0.02) and chest tube durations (4.0 ± 2.8 days vs 8.3 ± 8.9 days; P = 0.06).

In a randomized trial from Germany, there were fewer complications after VATS (14.2%) than thoracotomy (50%).[18] Comparing the mortality and morbidity, Sugiura et al.[16] found no operation-related mortality was experienced in either the VATS or the thoracotomy groups. Six patients (27.3%) in both groups experienced nonfatal postoperative complications. Prolonged air leak (longer than 7 days) occurred in two patients from the VATS group and in three from the thoracotomy group. The other complications included pyothorax in two VATS patients and one thoracotomy patient, pneumonia in two VATS patients, lymphorrhea in one thoracotomy patient, and chylothorax in one thoracotomy patient. On postoperative day 14, one VATS patient required reoperation for prolonged air leak.

Costs, as measured by anesthesia charges, lab charges, and hospital charges, are reportedly less with the VATS approach.[19]

Postoperative Pain

Postoperative pain is generally reported to be less after VATS. In a randomized, prospective study, patients had significantly less pain after a VATS approach than a muscle-sparing thoracotomy.[20] In contrast, a randomized trial by Kirby et al.[21] showed no decrease in postthoracotomy pain. Several nonrandomized series also reported reduced postoperative pain after VATS.[7,8,9,10,11,12,13,14,15,16,17,18] Sugiura et al.[16] reported a shorter need for an epidural catheter after VATS than thoracotomy (3 ± 2 days vs 7 ± 4 days; P = 0.0001). The amount of postoperative analgesic for VATS patients (P = 0.0439) was less than that for thoracotomy patients.[16] In another series, the postoperative visual pain scale, total dose of narcotic, need for additional narcotic, need for intercostal blocks, and sleep disturbances were less after VATS.[22] Long-term follow-up showed that the number of patients who still required narcotic medication for chest pain in the thoracotomy group (n = 4) was significantly higher (P = 0.014) than in the VATS group (n = 0), although the mean follow-up period of the thoracotomy group was significantly longer than that of the VATS group.[16] Pain 3 weeks postoperatively was dramatically better for the VATS group (none or mild, 63% vs 6%; severe, 6% vs 63%; P < 0.01).[17] Demmy and Curtis ([17] concluded that VATS lobectomy is less painful and may offer faster recovery, especially for the frail or high-risk patient.

Postoperative Pulmonary Function

VATS patients have less impairment of pulmonary function and a better 6-min walk test than thoracotomy patients.[23] In a nonrandomized comparison of patients who had a lobectomy by a thoracotomy or VATS, postoperative PaO2, O2 saturation, peak flow rates, FEV 1, and FVC on both postoperative days 7 and 14 were better for the patients who had undergone the VATS procedure.[24]

Quality of Life

The postoperative recovery appears to be better for the VATS approach than a thoracotomy. Demmy and Curtis[17] showed earlier returns to full preoperative activities (2.2 ± 1.0 months vs 3.6 ± 1.0 months; P < 0.01). Suguira et al.[16] compared the short-term and long-term quality of life after VATS lobectomy (n = 22 patients) or thoracotomy approach (n = 22 patients). The time until return to preoperative activity was 2.5 ± 1.7 months (range, 0.5 to 6.0 months) in the VATS group, which was significantly shorter (P = 0.0267) than the 7.8 ± 8.6 months (range, 0.5 to 32.6 months) for the thoracotomy group. At last follow-up, four thoracotomy patients still required narcotic medication for chest pain, compared with none for the VATS group (P = 0.014). In addition, the VATS patients were more satisfied than the thoracotomy patients with regard to scar size (P = 0.0011) and the overall impression of the operation (P = 0.0261). Numbness in or around the incision and limitations in the use of the arm or shoulder were similar in the two groups. VATS lobectomy significantly decreases the incidence of shoulder dysfunction compared with open thoracotomy.[25,26]

Effect on Inflammatory Response

Yim et al.[27] compared the inflammatory reaction, as measured by cytokine response, in patients who underwent lobectomy by VATS or thoracotomy. VATS patients also had reduced postoperative release of both proinflammatory and antiinflammatory cytokines. Although the postoperative release of tumor necrosis factor-a and interleukin (IL)-1β were minimal for both groups, the levels of IL-6, IL-8, and IL-10 were higher in the open group.[28] The clinical significance of these findings remains to be fully elucidated.

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