Invited Commentary

Abstract

Dr Wolf and colleagues [1Wolf A. Liu B. Leoncini E. et al.Outcomes for thoracoscopy versus thoracotomy not just technique dependent: a study of 9,787 patients.Ann Thorac Surg. 2018; 105: 886-892Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar] add to an ever growing body of literature that compares outcomes between thoracotomy and a video-assisted thoracoscopic surgical (VATS) approach to lobar and sublobar resection. They hypothesized that there would be no relationship between VATS and outcomes after adequately controlling for selection bias. With the use of a New York State administrative database, they adjusted for potential confounding from patient, surgeon, and hospital factors and found that VATS was associated with lower rates of morbidity and mortality. Nearly a decade ago, our research team conducted a similar analysis with the use of the Surveillance, End-Results, and Epidemiology (SEER)-Medicare database and adjusted for patient, cancer, management, surgeon, and hospital factors. We found no relationship between VATS and operative mortality or long-term survival, except among low-volume surgeons whereby there was a trend toward lower long-term survival rates with VATS. Although our study findings are inconsistent, both research teams emphasize the importance of mitigating confounding bias arising from patient, cancer, surgeon, and hospital/health system factors. Our teams are also united in the view that randomization is the best way to mitigate known and unknown confounding, but there must be equipoise to conduct a randomized trial. Most retrospective and single-institution studies show an association between VATS and better short-term outcomes. However, Wolf and colleagues [1Wolf A. Liu B. Leoncini E. et al.Outcomes for thoracoscopy versus thoracotomy not just technique dependent: a study of 9,787 patients.Ann Thorac Surg. 2018; 105: 886-892Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar] provide citations for studies in which there is no association between VATS and short-term outcomes. In addition, a recent prospective study from Memorial Sloan-Kettering showed no evidence of a relationship between VATS and patient-reported health-related quality-of-life or pain scores at 12 months. Findings from a noninferiority randomized trial conducted in China—presented as a late-breaking abstract at The Society of Thoracic Surgeons 2017 annual meeting—showed no effect of VATS on length-of-stay or rate of morbidity or mortality. An objective view of the literature reveals uncertainty (ie, equipoise) about the purported benefits of VATS. Nonetheless, there is considerable belief that VATS is a superior incisional approach compared with thoracotomy. Yet, proof—rather than belief—will advance our field. If VATS is superior, then we should take steps to limit the care of early-stage lung cancer patients to only surgeons who competently perform VATS. If VATS is equivalent to a thoracotomy, then we can be liberated from the pressure to perform a minimally invasive operation—pressure that may arise from patients, surgical colleagues, referring physicians, market forces or a combination. VATS advocates may say it is impossible to randomly assign patients to VATS versus thoracotomy because the benefits are self-evident, but saying so may in fact be a self-fulfilling prophecy. Our colleagues in colorectal surgery have conducted several such studies published in high-profile journals (all which demonstrated equivalence). Thoracic surgeons should consider conducting a multicenter, noninferiority, pragmatic randomized trial of VATS versus thoracotomy among patients with suspected or confirmed clinical stage I lung cancer. Doing so would likely lay to rest recurring questions about VATS versus thoracotomy. Outcomes for Thoracoscopy Versus Thoracotomy Not Just Technique Dependent: A Study of 9,787 PatientsThe Annals of Thoracic SurgeryVol. 105Issue 3PreviewStudies reporting the benefits of video-assisted thoracoscopic surgery (VATS) lung cancer resection over thoracotomy have been subject to selection bias. We evaluated patient and hospital characteristics associated with type of surgery and the independent effect of VATS on outcomes. Full-Text PDF