Limited operation of lung cancer: the role of video-assisted thoracic surgery for lung cancer

Lobectomy with systemic nodal dissection is recognized as a standard operation for lung cancer. Partial resection and segmental resection are classified as limited resections for lung cancer to preserve pulmonary function. Minor complications occur more frequently with limited resection than with lobectomy. Partial resection of the lung and simple lobectomy can be performed as video-assisted thoracic surgery (VATS). Systemic hilar and mediastinal lymph node dissection is not yet standardized using VATS. On the other hand, VATS preserves chest wall muscles. The difference between standard thoracotomy and VATS is a difference of approach to the thoracic cavity. It is most important for lung cancer surgery to be performed in the thoracic cavity with the minimum burden on patients.     

How much skill should we need for a VATS lobectomy in stage I lung cancer? An evaluation of surgeon groups

Although there has been progress in video-assisted thoracic surgery (VATS), there have been no reports about the skill needed to perform this surgery for patients with stage I lung cancer. We reviewed a randomized series of surgeons in a single institution and attempted to identify the quality of skill needed in this surgery. Cases of surgery on clinical stage I non-small cell lung cancer (NSCLC) involving 103 patients (56 VATS and 47 conventional approach) from January 2000 to April 2006 were assessed for eligibility. We reviewed these patients and placed them in random order into three surgeon groups (groups A, B, and C) that were based on surgeons who had performed 50 lobectomies through thoracotomy. Three patients were converted to a thoracotomy. Of the remaining 53 patients, 17 were in group A, 15 were in group B, and 21 were in group C. There were no significant differences between the three surgeon groups regarding technical factors such as blood loss and operation time. After a short initial learning period, two of the three surgeon groups significantly decreased total blood loss. Morbidity and recurrence did not differ between the groups, and there was no mortality in our sample. The volume of VATS operations performed by individual surgeons who have had good training in open lobectomy may not make for a positive impact on clinical outcomes. The decision for a VATS lobectomy in cases of stage I NSCLC should not be limited only by a surgeon's thoracoscopic experience.     

The role of video-assisted thoracic surgery for the treatment of lung cancer: lung lobectomy by thoracoscopy versus the standard thoracotomy approach

Our objective was to evaluate the usefulness, safety, validity and benefits of video-assisted thoracoscopic surgery (VATS) for performing pulmonary lobectomy in 24 patients with clinical NO stage I primary non-small-cell lung cancer compared with 30 patients who underwent a conventional thoracotomy. There were no significant differences in the intra-operative blood loss, duration of operation, or duration of chest tube drainage between the VATS group and the standard lobectomy group, but in this VATS' experience, patients had less postoperative pain. Numbers and distributions of dissected lymph-nodes were similar in patients whether undergoing standard thoracotomy or VATS lobectomy. We can confirm that the safety and validity of VATS are virtually identical to those of the standard thoracotomy approach in the lobectomy. However, the former technique causes less discomfort to patients and requires a shorter recovery period of laboratory data and IL-6 concentrations in thoracic drainage fluid. We conclude that VATS major lung resection is technically feasible. Stringent patient selection is important and special training is needed.     

Video-assisted thoracic surgery lobectomy (VATS), open thoracotomy, and the robot for lung cancer

Video-assisted thoracic surgery (VATS) lobectomy provides a minimally invasive approach for the management of early-stage lung cancer. Questions about the safety of VATS lobectomy and its adequacy as a cancer operation compared with open thoracotomy have hindered its universal acceptance among thoracic surgeons. Evidence suggests that VATS lobectomy can be safely performed and is an adequate cancer operation for early-stage non-small cell lung cancer. However, adequately powered well-balanced studies comparing VATS with open thoracotomy for lobectomy are lacking in the literature.     

Is lobectomy by video-assisted thoracic surgery an adequate cancer operation?

Background. Although the public perceives video-assisted thoracic surgery (VATS) as advantageous because it is less invasive than a thoracotomy, the medical community has questioned the safety of VATS lobectomy and its adequacy as a cancer operation. Reported series have not been able to address these issues because follow-up has been only short-term.

Methods. A multiinstitutional, retrospective review was performed in 298 consecutive patients who underwent VATS for a standard anatomic lobectomy with lymph node dissection for lung cancer. Pathologic staging was I in 233 (78%), II in 27 (9%), and IIIA in 38 (13%) patients. Kaplan Meier survival analysis was performed.

Results. The conversion rate from VATS lobectomy to thoracotomy was 6%, but none were for massive intraoperative bleeding. The only death (0.3%) was because of mesenteric venous thrombosis. Forty minor complications occurred in 38 patients (12.8%) undergoing VATS. The mean and median lengths of stay were 5 ± 3.39 and 4 days, respectively. Recurrence in an incision occurred in 1 patient (0.3%). The Kaplan Meier 4-year survival for stage I was 70% ± 5%.

Conclusion. The VATS lobectomy for bronchogenic carcinoma appears to be a safe operation, with the same survival as expected for a lobectomy done by thoracotomy.     

Thoracotomy is associated with significantly more profound suppression in lymphocytes and natural killer cells than video-assisted thoracic surgery following major lung resections for cancer.

Major surgery is immunosuppressive, and this could have an impact on postoperative tumor immunosurveillance and, therefore, long-term survival in cancer patients. Video-assisted thoracic surgery (VATS) lung resection is a new alternative surgical approach to thoracotomy for patients with early lung cancer. This is a pilot study to examine the postoperative changes in leukocytes, lymphocyte subsets, B cells, T cells, and natural killer (NK) cells in non-small-cell lung cancer (NSCLC) patients undergoing lung resection with VATS versus thoracotomy approaches. Twenty-one consecutive patients with resectable primary NSCLC were assigned to VATS or thoracotomy approach over a 3-month period. Blood samples were collected preoperatively and at postoperative days (POD) 1, 3, and 7 for flow cytometry determination of total leucocytes, B cells, NK cells, lymphocytes, total T cells, and T4 and T8 cell numbers. There were no demographic differences between the two groups. Compared with the preoperative values, significantly increased total white cell numbers were detected at POD 1, 3, and 7 in all patients. At POD 1, although T8 cells and NK cells were reduced in both groups, total T cell, T4 cell, and lymphocyte numbers were significantly reduced only in the thoracotomy group. At POD 7, NK cell numbers were significantly lower in the thoracotomy group than that in the VATS group. No significant intra- or intergroup differences were seen with B cells. No significant differences in survival or disease-free survival were found between the two groups. Thus, VATS major lung resection for NSCLC is associated with less, as well as quicker recovery from, postoperative immunosuppression compared with the thoracotomy approach. The clinical relevance of better preserved cellular immunity in the early postoperative period warrants confirmation from large randomized trials.     

Video-assisted thoracoscopic surgery for lung cancer: current indications

Recently, video-assisted thoracoscopic surgery (VATS) has been widely applied in lung cancer surgery in Japan, although there is no consensus on the definition of VATS and its standard techniques. VATS lobectomy may result in long-term survival rates as high as after standard thoracotomy and is becoming an optional treatment for stage IA lung cancer. It is still not a standard treatment because of the problems of safety and oncologic radicality. However, as long as the safety and radicality are ensured by the tumor type, patient risk factors, and the expertise of the surgeon, less-invasive techniques like VATS should be performed.     

Surgical Outcome of Video-Assisted Thoracoscopic Surgery vs. Thoracotomy for Primary Lung Cancer >5 cm in Diameter

Objectives: The indications for video-assisted thoracoscopic surgery (VATS) for advanced-stage lung cancer are expanding, but the criteria vary among institutions. This study compared the minimal invasiveness and oncologic validity of VATS lobectomy and thoracotomy lobectomy for the treatment of large-diameter primary lung cancer.Methods: We retrospectively reviewed clinical features and surgical outcomes of 68 patients who underwent anatomical pulmonary resection for primary lung cancer of >5-cm diameter from July 2006 to March 2013. The patients were divided into a VATS group (Group V, n = 35) and a thoracotomy group (Group T, n = 33).Results: Group V exhibited less intraoperative bleeding (p = 0.012) and had a shorter length of postoperative hospital stay (p = 0.024). The 1- and 5-year overall survival rates were 91.3% and 39.3% in Group V and 84.8% and 56.9% in Group T, respectively (p = 0.48). Multivariate analysis showed that limited lymph node dissection contributed to local recurrence. The extraction bag lavage cytology in Group V revealed that the positivity rate was 35.7%.Conclusions: VATS for primary lung cancer of >5-cm diameter is similar to thoracotomy in terms of surgical outcomes. Large tumors must be carefully maneuvered during VATS to prevent cancer cell spillage.     

Pleurectomy in primary pneumothorax: is extensive pleurectomy necessary?

BACKGROUND: The aim of the study was to evaluate the results of parietal pleurectomy in patients with primary spontaneous pneumothorax comparing extensive pleurectomy performed by thoracotomy versus more limited pleurectomy performed by VATS. METHODS: Records of the patients operated on for primary pneumothorax at Royal Brompton Hospital from January 1994 to April 1997 were retrospectively reviewed. A follow-up questionnaire was sent to patients asking about further pneumothorax and the presence of long-term chest problems on the operated side. A statistical uni- and multivariate analysis was performed searching predictors for postoperative complications, recurrence and chronic chest problems. RESULTS: Thirty-six patients underwent extensive pleurectomy through a limited postero-lateral thoracotomy (40%, group A), 54 patients had a limited pleurectomy (60%, group B), 50 by VATS and 4 by axillary thoracotomy. Overall, 11 patients had postoperative complications (12.2%). In group A, 4 patients (11.1%) had complications (2 reoperation, 2 air leak >7 days). In group B, 7 patients (12.9%) had complications (1 reoperation, air leak >7 days, 1 wound infection). Two patients experienced recurrent ipsilateral pneumothorax after surgery, both belonging to group B (overall recurrence rate 2.5%, group B 4.1%). Thirteen patients in both groups (respectively 41.9% in group A and 27% in group B) admitted chest problems on the operated side. From statistical analysis, "indication" resulted a predictor of complications (p=0.03) and "thoracotomy" a predictor of long-term chest problems (p=0.03). CONCLUSIONS: Many theoretical advantages of limited VATS pleurectomy have still to be confirmed and it is reasonable to use it in uncomplicated primary pneumothorax. The superb exposure obtained with thoracotomy and the superiority of extensive pleurectomy in terms of recurrence indicate this approach in case of complicated pneumothorax or when long-term security is of paramount importance.     

Video-assisted thoracic surgical lobectomy in conjunction with lymphadenectomy for lung cancer

Video-assisted thoracic surgery (VATS) has been in widespread use since the beginning of the 1990s. The initial indications for VATS were benign lesions of the lung, pneumothorax, benign tumors, etc. However, its application was extended to resection of lung cancer. We first gained experience with VATS lobectomy in September 1992, and also started performing lymphadenectomy using VATS in November 1993 after developing instruments for this meticulous operation. The 8-year survival rate of final stage IA lung cancers following VATS is 97.2%; this survival rate is significantly better than that with open thoracotomy. Here we report on our 10-year experience with VATS lobectomy, focusing on stage I lung cancer.     

Chancen der endoskopischen Thoraxchirurgie und ihre Grenzen

Mediastinoscopy and mediastinotomy are used primarily in the staging of lung cancer; they are also of value in biopsying mediastinal masses and lymph nodes to establish diagnoses such as sarcoidosis,lymphoma, and mediastinal tumors. Video-assisted thoracic surgery (VATS) was introduced in 1990 and has now replaced open thoracotomy in the evaluation of many pleuropulmonary disorders. Specific advantages of VATS over open thoracotomy include the use of smaller incisions, reduced operative morbidity, and optimal visualization of the entire lung and pleural space. In many centers it has become the procedure of choice for the biopsy of interstitial disease, indeterminate lung nodules, or pleural lesions. The role of VATS for staging of lung cancer patients is still under debate.VATS procedures have also been adopted for the treatment of a wide range of thoracic disorders. With increasing experience surgeons have become more skilled with this limited access technique and meanwhile lobectomies can be performed safely.The role of VATS in the management of lung metastases or lung cancer is still being investigated. It is a concern that there is a temptation to do less when a minimal access operation is performed that does not allow for palpation of the lung. In addition, lymph node dissection cannot be performed adequately and there continue to be reports of local recurrences in port sites. If the VATS approach is to be used, surgeons should always respect the oncological principles that have been developed over the past decades.     

Assessment of node dissection for clinical stage I primary lung cancer by VATS.

OBJECTIVE: The feasibility of systematic node dissection (SND) for stage I primary lung cancer by video-assisted thoracic surgery (VATS) remains controversial. The aim of this study was to assess the feasibility of SND by VATS. METHODS: Four hundred and eleven patients with clinical stage I primary lung cancer were enrolled in this study. Two hundred and twenty-one patients, VATS group, underwent a major pulmonary resection with SND by VATS through a minithoracotomy (30-70mm) and two access ports; 190 patients, open thoracotomy (OT) group, did so through anterolateral thoracotomy. The two groups were compared regarding clinical data including number of dissected nodes in each nodal station for evaluating the feasibility of SND by VATS. RESULTS: In the right side, the total number (N) of nodes dissected (VATS 31 vs OT 31, P=0.899), N of mediastinal nodes dissected (20 vs 21, P=0.553), and N of dissected nodes in each nodal station were similar between the two groups. In the left side, total N of nodes dissected (28 vs 27, P=0.714), N of mediastinal nodes dissected (16 vs 17, P=0.333), and N of dissected nodes in each nodal station were similar between the two groups. There were three (1.4%) and five (2.6%) operation related deaths in the VATS group and OT group, respectively (P=0.48). Chest tube duration was shorter in the VATS group than the OT group (5.8 vs 7.6 days, P=0.001). The incidences of chylothorax, recurrent laryngeal nerve injury and pleural effusion requiring thoracentesis after surgery were similar between the two groups (3 vs 4, P=0.709; 5 vs 3, P=0.480, 3 vs 8, P=0.122). The 5-year actuarial recurrence-free survival rate and cumulative survival rate of pathological stage IA cases were similar between the two groups (88.6 vs 92.4%, P=0.698; 92.9 vs 86.5%, P=0.358). CONCLUSIONS: The SND by VATS was as technically feasible as SND through OT regarding number of dissected nodes and morbidity. It seems acceptable as an oncological treatment for clinical stage I lung cancer.     

Complications and learning curves for video-assisted thoracic surgery lobectomy

Surgery remains the mainstay for the treatment of lung cancer. While pulmonary resection has been safe for years, there is a trend toward minimally invasive (VATS) pulmonary resections. Studies have now shown that standard complete cancer operations performed via VATS offer patients a shorter hospital stay and quicker recovery without compromising the cure rate for an operation performed via a thoracotomy.     

A prospective trial of systematic nodal dissection for lung cancer by video-assisted thoracic surgery: can it be perfect?

BACKGROUND: There have been no reports evaluating the completeness of systematic nodal dissection with video-assisted thoracic surgery (VATS). In order to elucidate the completeness of the dissection, we have conducted a prospective trial with patients having primary lung cancer. METHODS: Patients with clinical stage I lung cancer were the candidates for this study. Thoracotomy was performed with a small skin incision of 7 cm to 8 cm in length. Through these small wounds and two trocars, pulmonary resection was performed and then hilar and mediastinal lymph nodes were dissected. After that, a standard thoracotomy was carried out by another surgeon to complete systematic nodal dissection. RESULTS: Video-assisted thoracic surgery lobectomy with lymph node dissection was accomplished in 17 right lung cancer patients and 12 left lung cancer patients. On the right side, the average numbers of resected lymph nodes by VATS and remnant lymph nodes were 40.3 and 1.2, respectively. The average weights of dissected tissues by VATS and remnant tissues were 10.0 g and 0.2 g, respectively. On the left side, there were 37.1 and 1.2 lymph nodes and 8.3 g and 0.2 g of weight of dissected tissues. No nodal involvement was observed in the remnant lymph nodes. CONCLUSIONS: The lymph node dissection with VATS was technically feasible and the remnant ("missed" by VATS) lymph nodes and tissues were 2% to 3%, which seems acceptable for clinical stage I lung cancer.     

Video-assisted thoracic surgery for lung cancer

Video-assisted thoracic surgery (VATS) lobectomy is currently accepted as an appropriate procedure for selected patients with early-stage non-small-cell lung cancer (NSCLC). Evidence has demonstrated that VATS lobectomy is not only a safe and feasible technique, it provides better functional recovery and oncological efficacy similar to that achieved with conventional thoracotomy. However, there are still ongoing issues concerning VATS in terms of terminology, oncological efficacy, functional recovery, benefit of screening detected lung cancer, and its role in limited resection. As the number of VATS procedures are increasing and VATS is becoming a dominant procedural choice, it would be wise to collect evidence and come to a consensus to justify the expansion of surgical indications for VATS.     

Usefulness of video-assisted thoracic surgery (Two Windows Method) in the treatment of lung cancer for elderly patients

BACKGROUND: We have been performing it less invasively by making just two, small skin incisions (Two Windows Method) for lung cancer surgery. We assess the usefulness of VATS by the Two Windows Method in elderly patients. METHODS: The subjects were 32 of the 75-year-old or older patients with primary lung cancer in our department. We assessed cases in which thoracotomy was performed and the cases in which VATS by Two Windows Method was performed, and compared postoperative complications, hospital deaths, and postoperative length of stay. RESULTS: Operations by video-assisted thoracic surgery (VATS) by the Two Windows Method were completed in 20 of the 32 patients, and a conversion to thoracotomy was done in two patients (rate 9%). Ultimately, thoracotomy was performed in a total of 12 cases, including these two. In the thoracotomy patients, the most common postoperative complication was pneumonia/atelectasis (4 cases) secondary to poor sputum expectoration. There were 2 hospital deaths due to septicemia, and there was 1 due to pulmonary artery embolism. In the VATS patients, the rate of occurrence of postoperative complications was 30%, and clearly lower than the 67% among the thoracotomy patients (p<0.05). No hospital death occurred among the VATS patients. The postoperative hospital stay of the VATS patients (21 days) was shorter than that of the thoracotomy patients (31 days), (p<0.05). CONCLUSIONS: VATS by the Two Windows Method is safer than thoracotomy, and it should be considered first for lung cancer surgery in the aged.     

Lobectomy with extended lymph node dissection by video-assisted thoracic surgery for lung cancer

Background: Between September 1992 and September 1996, we performed 88 VATS (video-assisted thoracic surgery) lobectomies and two VATS pneumonectomies. Methods: The indications for surgery were 68 cases of lung cancer, nine cases of bronchiectasis, six cases of tuberculosis, and seven cases of benign lesions. Of the 68 cases of lung cancer, 36 were treated by VATS lobectomy with extended lymph node dissection for clinical stage I lung cancer, making full use of recently developed devices for thoracoscopic surgery, such as roticulating endoscissors, miniretractors, endoclips, and harmonic scalpels. Results: Twenty-four lymph nodes were resected on average (range, 10 to 51) by VATS. This number was comparable to lymph nodes resected in open thoracotomy during the same period. Among the 36 patients who underwent extended lymph node dissection, 20 showed no lymph node metastasis postoperatively (stage I), while 16 had N1 or N2 cancer. All patients with stage I cancer have survived 4 to 36 months (median: 17 months) with no signs of recurrence. Conclusions: This survival of stage I lung cancer after VATS is comparable to that of open thoracotomy. We thus believe that VATS lobectomy with extended lymph node dissection can be an alternative to standard posterolateral thoracotomy for stage I lung cancer. Received: 10 May 1996/Accepted: 19 November 1996     

Video-Assisted Thoracoscopic Surgery for Recurrent Spontaneous Pneumothorax: The Long-term Benefit

Background Management of recurrent primary spontaneous pneumothorax by open surgery was considered the treatment of choice until recently. The major drawbacks of this management are the prolonged postoperative pain and cosmetic results. In the last decade, video-assisted thoracoscopic surgery (VATS) has replaced the routine use of open surgery. Most papers that compared limited open surgery to VATS addressed the early postoperative results, and studies that assessed the long-term results focused primarily on the rate of recurrence and pulmonary function tests. The aim of this study was to compare the outcome of minithoracotomy and VATS with emphasis on patients’ long-term, subjective perspective and satisfaction. Methods Medical records of patients with recurrent primary spontaneous pneumothorax were retrospectively reviewed. Patients who underwent surgical treatment by limited thoracotomy (63 patients) or VATS (58 patients) more than 3 years ago were enrolled. Hospital medical charts were used to compare the early postoperative results. Outpatient clinic records and a telephone questionnaire were employed to evaluate long-term results. Results There was no mortality or major morbidity in either group, and hospitalization time was similar. Patients in the thoracotomy group needed significantly higher doses of narcotic analgesia for a longer period. There were two cases of recurrence in the VATS group (3%). Seventy-eight percent of patients in the VATS and 21% in the thoracotomy group classified their pain as insignificant a month following the operation (P < 0.05). Three years following surgery, 97% of the VATS group patients considered themselves completely recovered from the operation compared with only 79% in the thoracotomy group (P < 0.05). Nineteen percent of the thoracotomy group and 3% of the VATS group suffered from chronic or intermittent pain necessitating use of analgesics more than once a month. Thirteen percent of patients from the open procedure group required services from the pain clinic. Patients in the VATS group were, in general, much more satisfied with their operation and with the surgical scars compared with patients from the thoracotomy group. Conclusion We recommend video-assisted surgery as the first-line surgical treatment for patients with recurrent primary spontaneous pneumothorax. This recommendation is based on its somewhat favorable early postoperative course, the superior long-term outcome, and patient satisfaction.