Elsevier

The Annals of Thoracic Surgery

Volume 86, Issue 6, December 2008, Pages 2008-2018
The Annals of Thoracic Surgery

Review
Surgery for Early-Stage Non-Small Cell Lung Cancer: A Systematic Review of the Video-Assisted Thoracoscopic Surgery Versus Thoracotomy Approaches to Lobectomy

Presented at the Forty-fourth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28–30, 2008.
https://doi.org/10.1016/j.athoracsur.2008.07.009Get rights and content

Video-assisted thoracoscopic surgery (VATS) for lobectomy has been touted to provide superior outcomes, compared with thoracotomy, for patients with early-stage non-small-cell lung cancer (NSCLC). However, supporting data are limited to case series and small observational studies. We hypothesized that a systematic review of the literature would enable a more objective evaluation of the evidence in order to determine the potential superiority of the VATS approach, compared with thoracotomy, in terms of short-term morbidity and long-term survival. To identify relevant articles for inclusion in our analysis, we performed a systematic review of the MEDLINE database. We looked for randomized controlled trials, observational studies, and case series that reported outcomes after VATS or thoracotomy lobectomy for NSCLC. For statistical testing, we used a two-sided approach (α = 0.05) under the hypothesis that VATS lobectomy is superior to thoracotomy lobectomy. We screened 17,923 studies. After independent review of the abstracts by 2 reviewers, we included 39 studies (only one randomized controlled trial) in our analysis. In aggregate, these 39 studies involved 3256 thoracotomy and 3114 VATS patients. The characteristics of the two groups were not significantly different. Compared with thoracotomy, VATS lobectomy was associated with shorter chest tube duration, shorter length of hospital stay, and improved survival (at 4 years after resection), all statistically significant. Compared with lobectomy performed by thoracotomy, VATS lobectomy for patients with early-stage NSCLC is appears to favor lower morbidity and improved survival rates.

Section snippets

Data Collection

To identify relevant articles for inclusion in our analysis, we performed a structured literature retrieval of the MEDLINE database. We looked for randomized controlled, trials, observational studies, and case series that reported outcomes after either VATS or thoracotomy lobectomy for NSCLC. Our MEDLINE search algorithm (Fig 1) began by querying for non-small cell lung carcinoma (medical subject heading) and for non-small cell lung cancer (mapping term). This query yielded article abstracts

Study Characteristics

Of the 39 articles included in our analysis, 22 provided data on the VATS approach and 27 on thoracotomy. Twenty-nine manuscripts provided data on a single approach, 10 on both approaches. In aggregate, the studies involved 3256 thoracotomy lobectomy patients and 3114 VATS lobectomy patients. The two groups were not significantly different with regards to patient characteristics or tumor histology (Table 1) [4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27

Systematic Review Analysis

Level I data directly comparing VATS with thoracotomy lobectomy for the treatment of early-stage (I or II) NSCLC are not available. Rather, the literature is limited to case series and small retrospective cohort studies. Previous attempts at performing multi-institution trials to compare the outcomes of thoracotomy vs VATS lobectomy were impaired by poor accrual rates.

Speculation about one of the reasons for poor accrual was a lag in the dissemination of the technical skills necessary to

References (55)

  • S. Kaseda et al.

    Video-assisted thoracic surgery (VATS) lobectomy: the Japanese experience

    Semin Thorac Cardiovasc Surg

    (1998)
  • W.S. Walker

    Video-assisted thoracic surgery (VATS) lobectomy: the Edinburgh experience

    Semin Thorac Cardiovasc Surg

    (1998)
  • A.P. Yim et al.

    Thoracoscopic major lung resections: an Asian perspective

    Semin Thorac Cardiovasc Surg

    (1998)
  • T. Ohtsuka et al.

    Is major pulmonary resection by video-assisted thoracic surgery an adequate procedure in clinical stage I lung cancer?

    Chest

    (2004)
  • G. Roviaro et al.

    Long-term survival after videothoracoscopic lobectomy for stage I lung cancer

    Chest

    (2004)
  • R.N. Younes et al.

    When to remove a chest tube?A randomized study with subsequent prospective consecutive validation

    J Am Coll Surg

    (2002)
  • R.J. Cerfolio et al.

    Results of a prospective algorithm to remove chest tubes after pulmonary resection with high output

    J Thorac Cardiovasc Surg

    (2008)
  • R.J. Cerfolio et al.

    Fast-tracking pulmonary resections

    J Thorac Cardiovasc Surg

    (2001)
  • B.A. Whitson et al.

    Surgical assessment and intraoperative management of mediastinal lymph nodes in non-small cell lung cancer

    Ann Thorac Surg

    (2007)
  • M.S. Ludwig et al.

    Postoperative survival and the number of lymph nodes sampled during resection of node-negative non-small cell lung cancer

    Chest

    (2005)
  • A. Watanabe et al.

    Systematic node dissection by VATS is not inferior to that through an open thoracotomy: A comparative clinicopathologic retrospective study

    Surgery

    (2005)
  • B.A. Whitson et al.

    Minimally invasive cancer surgery improves patient survival rates through less perioperative immunosuppression

    Med Hypotheses

    (2007)
  • J.P. Higgins et al.

    Measuring inconsistency in meta-analyses

    BMJ

    (2003)
  • R.J. McKenna

    New approaches to the minimally invasive treatment of lung cancer

    Cancer J

    (2005)
  • N. Martini et al.

    Survival after resection of stage II non-small cell lung cancer

    Ann Thorac Surg

    (1992)
  • W.H. Warren et al.

    Segmentectomy versus lobectomy in patients with stage I pulmonary carcinomaFive-year survival and patterns of intrathoracic recurrence

    J Thorac Cardiovasc Surg

    (1994)
  • R.J. Ginsberg et al.

    Randomized trial of lobectomy versus limited resection for T1 N0 non-small cell lung cancerLung Cancer Study Group

    Ann Thorac Surg

    (1995)
  • Cited by (551)

    View all citing articles on Scopus
    View full text