Video-assisted Thoracoscopic Surgery Lobectomy For Lung Cancer Research Articles

Video-assisted thoracoscopic versus open lobectomy in patients with early-stage lung cancer: One-year results from a randomized controlled trial (VIOLET).

8504 Background: Video assisted thoracoscopic surgery (VATS) is a popular access for lung cancer resection. However, there is limited information from RCTs from in-hospital to one-year clinical efficacy, safety and oncologic outcomes of a minimal access approach. Methods: VIOLET is a parallel group multi-center RCT conducted in 9 centers in the United Kingdom that recruited participants with known or suspected (cT1-3, N0-1 and M0) lung cancer (ISRCTN13472721). Trial protocol: https://bmjopen.bmj.com/content/9/10/e029507.info. Results: From July 2015 to February 2019, 503 participants were randomized to VATS (n=247) or open (n=256) lobectomy. Patients allocated to VATS had less pain with a mean difference (MD) in visual analogue score of -0.54 (95%CI -0.99 to -0.10) despite less analgesic consumption (mean ratio 0.90, 95%CI 0.80 to 1.01). After discharge pain was consistent on multiple sub-scales including overall pain (MD -7.19, -10.59 to -3.80), chest pain (MD -4.66, -7.96 to -1.36) and an 18% relative risk (RR) reduction in incision pain (RR 0.82; 0.72 to 0.94) up to one-year. Better functional recovery continued in VATS arm after discharge with better physical function (primary outcome) with MD of 4.65 (1.69 to 7.61; P=0.002) at 5 weeks and overall improvement in global health status with a MD of 4.21 (1.62 to 6.79; P=0.001). In hospital, VATS arm had fewer complications (RR 0.74, 0.66 to 0.84; P<0.001) with no difference in serious adverse events (RR 0.98, 0.59 to 1.63; P=0.948). Median hospital stay was one day shorter in the VATS arm (4 vs 5 days) corresponding to hazard ratio (HR) for discharge of 1.34, 95%CI 1.09 to 1.65; P=0.006). After discharge VATS arm had 19% less serious adverse events (RR 0.81, 0.66 to 1.00; p=0.053) and lower readmission rates (29.0% vs. 35.9% respectively) to one-year. Of those with lymph node disease, 50.9% in the VATS and 45.9% in open arms received adjuvant treatment. There was no difference in the time to uptake of adjuvant chemotherapy (HR 1.12, 0.62 to 2.02; p=0.716). Recurrence with clinical follow up and CT at one-year was similar with 7.7% versus 8.1% in the VATS and open groups respectively. Progression-free survival (HR 0.74, 0.43 to 1.27; p=0.27) and overall survival HR 0.67, 0.32 to 1.40; p=0.282) was not significantly different. Conclusions: VATS lobectomy for lung cancer is associated with less pain, fewer in-hospital complications and shorter hospital stay, achieved without any compromise to early oncologic outcomes nor serious adverse events. Superior functional recovery continues in the post-operative period with improved physical function, lower re-admission rates and no difference in disease-free and overall survival up to one-year. Clinical trial information: ISRCTN13472721.

Poor preoperative quality of life predicts prolonged hospital stay after VATS lobectomy for lung cancer.

The aim of this study was to assess whether quality of life (QoL) scales are associated with postoperative length of stay (LoS) following video-assisted thoracoscopic surgery (VATS) lobectomy for lung cancer. This is a single-centre retrospective analysis on 250 consecutive patients submitted to VATS lobectomies (233) or segmentectomies (17) over a period of 3 years. QoL was assessed in all patients by the self-administration of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30 questionnaire. The individual QoL scales were tested for possible association with LoS along with other objective baseline and surgical parameters using univariable and multivariable analyses. Thirty-day cardiopulmonary and mortality rates were 22% and 2.4%. The median LoS was 4 days [interquartile range (IQR) 3-7]. Fifty-one (20%) patients remained in hospital longer than 7 days after surgery (upper quartile). General health [global health score (GHS)] (P = 0.019), physical function (P = 0.014) and role functioning (P = 0.016) scales were significantly worse in patients with prolonged stay. They were highly correlated between each other and tested separately in different logistic regression analyses. The best model resulted the one containing GHS (P = 0.032) along with age, low force expiratory volume in 1 s and carbon monoxide lung diffusion capacity and history of cerebrovascular disease. Fifty-nine patients had GHS <58 (lower interquartile value). Thirty-one percent of them experienced prolonged hospital stay (vs 17% of those with higher GHS, P = 0.027). Preoperative patient-reported QoL was associated with prolonged postoperative hospital stay. Baseline QoL status should be taken into consideration to implement psychosocial supportive programmes in the context of enhanced recovery after surgery.

THE BENEFIT OF VATS ON THE IMPACT OF SMOKING AND RECENT CESSATION ON 30-DAY OUTCOMES IN LOBECTOMY FOR CANCER IN VETERANS

SESSION TITLE: Cardiothoracic Surgery Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Recent research has shown that smoking cessation as soon as two weeks prior to lobectomy for lung cancer results in lower odds of pulmonary complications relative to active smoking at the time of surgery. The increasing use of video-assisted thoracoscopic surgery (VATS) has reduced postoperative complications, but the effect of VATS on active smokers and recent quitters has not been investigated. The purpose of this study was to determine whether the use of VATS mitigates the negative effects of tobacco use on 30-day postoperative outcomes. METHODS: Patients who underwent VATS lobectomy for lung cancer at Veterans Health Administration (VHA) centers from 2012-2018 were retrospectively identified in the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. The sample was stratified into 3 groups: smokers within 2 weeks of surgery (“active smokers”), those who quit between 2 weeks to 3 months prior to surgery (“recent quitters”), and those who had not smoked in 1 year or longer (“non-smokers”). Multivariable analysis was used to compare groups after adjusting for covariates. RESULTS: Of 2,814 patients who met inclusion criteria, 1,351 were non-smokers, 395 were recent quitters, and 1,068 were active smokers. Compared to recent quitters, active smokers were significantly more likely to be reintubated (adjusted odds ratio (aOR) of 2.53, 95% confidence interval (CI) 1.05 – 6.06, p=0.04); however, there was no difference when pulmonary composite (including prolonged intubation, pneumonia, and reintubation) and complication rates of other organ systems were compared. Compared to non-smokers, active smokers were more likely to suffer pulmonary complications (aOR=1.58, CI 1.12 – 2.23, p=0.01), overall complications (aOR=1.43, CI 1.06 – 1.92, p=0.02), renal complications (aOR=3.91, CI 1.10 – 13.98, p=0.04) and infectious complications (aOR=2.07, CI 1.12 – 3.83, p=0.02). There were no differences in morbidity between recent quitters and non-smokers. CONCLUSIONS: In spite of previous evidence that smoking cessation has a significant impact on pulmonary complications after lung resection, this analysis demonstrates that the use of VATS technique appears to mitigate the difference in risk of morbidity between patients who are active smokers at the time of surgery compared to recent quitters. This distinction may be the result of the established benefits of minimally invasive techniques for lobectomy. Despite the demonstrated advantages of VATS, the likelihood of suffering from complications – both pulmonary and otherwise – is still significantly higher in active smokers compared to non-smokers. CLINICAL IMPLICATIONS: In addition to the other recognized benefits of VATS for lobectomy in lung cancer, this approach may lessen the adverse effects of smoking on postoperative outcomes. Despite improved operative techniques, smoking cessation is still imperative in reducing pulmonary complications. DISCLOSURES: No relevant relationships by Jared Antevil, source=Web Response No relevant relationships by Michael Napolitano, source=Web Response No relevant relationships by Ethan Rosenfeld, source=Web Response No relevant relationships by Andrew Sparks, source=Web Response No relevant relationships by Gregory Trachiotis, source=Web Response

Two-Week Multimodal Prehabilitation Program Improves Perioperative Functional Capability in Patients Undergoing Thoracoscopic Lobectomy for Lung Cancer: A Randomized Controlled Trial.

Patients with lung cancer often experience reduced functional capacity and quality of life after surgery. The current study investigated the impact of a short-term, home-based, multimodal prehabilitation program on perioperative functional capacity in patients undergoing video-assisted thoracoscopic surgery (VATS) lobectomy for nonsmall cell lung cancer (NSCLC). A randomized controlled trial was conducted with 73 patients. Patients in the prehabilitation group (n = 37) received a 2-week multimodal intervention program before surgery, including aerobic and resistance exercises, respiratory training, nutrition counseling with whey protein supplementation, and psychological guidance. Patients in the control group (n = 36) received the usual clinical care. The assessors were blinded to the patient allocation. The primary outcome was perioperative functional capacity measured as the 6-minute walk distance (6MWD), which was assessed at 1 day before and 30 days after surgery. A linear mixed-effects model was built to analyze the perioperative 6MWD. Other outcomes included lung function, disability and psychometric evaluations, length of stay (LOS), short-term recovery quality, postoperative complications, and mortality. The median duration of prehabilitation was 15 days. The average 6MWD was 60.9 m higher perioperatively in the prehabilitation group compared to the control group (95% confidence interval [CI], 32.4-89.5; P < .001). There were no differences in lung function, disability and psychological assessment, LOS, short-term recovery quality, postoperative complications, and mortality, except for forced vital capacity (FVC; 0.35 L higher in the prehabilitation group, 95% CI, 0.05-0.66; P = .021). A 2-week, home-based, multimodal prehabilitation program could produce clinically relevant improvements in perioperative functional capacity in patients undergoing VATS lobectomy for lung cancer.

Risk factors and short-term outcomes of postoperative pulmonary complications after VATS lobectomy

BackgroundPostoperative pulmonary complications (PPCs) are associated with poor outcomes following thoracotomy and lung resection. Video-assisted thoracoscopic surgery (VATS) for lobectomy is now frequently utilised as an alternative to thoracotomy, however patients remain at risk for development of PPC. There is little known of the short-term outcome associated with PPC following VATS lobectomy and if there are any potential risk factors that could be modified to prevent PPC development; our study aimed to investigate this.MethodsA prospective observational study of consecutive patients undergoing VATS lobectomy for lung cancer over a 4-year period in a regional centre was performed (2012–2016). Exclusion criteria included re-do VATS or surgery for pulmonary infection. All patients received physiotherapy as necessary from postoperative day 1 (POD1) and PPC was determined using the Melbourne Group Scale. Outcomes included hospital LOS, intensive therapy unit (ITU) admission and hospital mortality.ResultsOf the 285 patients included in the study, 137 were male (48.1%), the median (IQR) age was 69 (13) years and the mean (±SD) FEV1% predicted was 87% (±19). Patients that developed a PPC (n = 21; 7.4%) had a significantly longer hospital LOS (4 vs. 3 days), higher frequency of ITU admission (23.8% vs. 0.5%) and higher hospital mortality (14.3% vs. 0%) (p < 0.001). PPC patients also required more physiotherapy contacts/time, emergency call-outs and specific pulmonary therapy (p < 0.05). Current smoking and COPD diagnosis were significantly associated with development of PPC on univariate analysis (p < 0.05), however only current smoking was a significant independent risk factor on multivariate analysis (p = 0.015).ConclusionsPatients undergoing VATS lobectomy remain at risk of developing a PPC, which is associated with an increase in physiotherapy requirements and a worse short-term morbidity and mortality. Current smoking is the only independent risk factor for PPC after VATS lobectomy, thus vigorous addressing of preoperative smoking cessation is urgently needed.

Making a decision of conversation is always difficult, but should be done in a timely manner

Levi et al. introduced video-assisted thoracoscopic surgery (VATS) in 1990 (1). VATS has become an alternative technique, especially for benign diseases (2,3). After the accumulation of surgical experience for benign diseases, VATS technique has been gradually applied for lung cancer surgery. Roviaro et al. first reported the VATS lobectomy for lung cancer. Since then, many investigators have evaluated and reported the efficacy of VATS for lung cancer (4). VATS is considered to be superior to a thoracotomy in terms of perioperative pain and cosmesis. However, several issues needed to be confirmed, the most important of which are the adequacy of VATS for cancer operations and its safety.

Major morbidity after video-assisted thoracic surgery lung resections: a comparison between the European Society of Thoracic Surgeons definition and the Thoracic Morbidity and Mortality system.

The thoracic morbidity and mortality (TM&M) classification system univocally encodes the postoperative adverse events by their management complexity. This study aims to compare the distribution of the severity of complications according to the TM&M system versus the distribution according to the classification proposed by European Society of Thoracic Surgeons (ESTS) Database in a population of patients submitted to video assisted thoracoscopic surgery (VATS) lung resection. A total of 227 consecutive patients submitted to VATS lobectomy for lung cancer were analyzed. Any complication developed postoperatively was graded from I to V according to the TM&M system, reflecting the increasing severity of its management. We verified the distribution of the different grades of complications and analyzed their frequency among those defined as "major cardiopulmonary complications" by the ESTS Database. Following the ESTS definitions, 20 were the major cardiopulmonary complications [atrial fibrillation (AF): 10, 50%; adult respiratory distress syndrome (ARDS): 1, 5%; pulmonary embolism: 2, 10%; mechanical ventilation >24 h: 1, 5%; pneumonia: 3, 15%; myocardial infarct: 1, 5%; atelectasis requiring bronchoscopy: 2, 10%] of which 9 (45%) were reclassified as minor complications (grade II) by the TM&M classification system. According to the TM&M system, 10/34 (29.4%) of all complications were considered minor (grade I or II) while 21/34 (71.4%) as major (IIIa: 8, 23.5%; IIIb: 4, 11.7%; IVa: 8, 23.5%; IVb: 1, 2.9%; V: 3, 8.8%). Other 14 surgical complications occurred and were classified as major complications according to the TM&M system. The distribution of postoperative complications differs between the two classification systems. The TM&M grading system questions the traditional classification of major complications following VATS lung resection and may be used as an additional endpoint for outcome analyses.

VATS anatomic lung resections-the European experience.

Video-assisted thoracoscopic surgery (VATS) has undergone significant evolution over several decades. Although endoscopic instruments continued to improve, it was not until 1992 that the first VATS lobectomy for lung cancer was performed. Despite significant seeding of such procedure in several thoracic units globally, the uptake was slow and frustrating. Many surgeons considered it complex and unsafe being skeptic about its oncological validity. The last decade has witnessed significant change of practice in many thoracic units with a new generation of VATS thoracic surgeons. Additionally the technique has been refined, standardized and proved its validity and superiority in lung cancer treatment.

Preoperative computed tomography of the chest in lung cancer patients: the predictive value of calcified lymph nodes for the perioperative outcomes of video-assisted thoracoscopic surgery lobectomy

To determine the predictive value of identifying calcified lymph nodes (LNs) for the perioperative outcomes of video-assisted thoracoscopic surgery (VATS). Fifty-six consecutive patients who underwent VATS lobectomy for lung cancer were included. We evaluated the number and location of calcified LNs on computed tomography (CT). We investigated clinical parameters, including percentage forced expiratory volume in 1 s (FEV1%), surgery duration, chest tube indwelling duration, and length of hospital stay. We performed linear regression analysis and multiple comparisons of perioperative outcomes. Mean number of calcified LNs per patient was 0.9 (range, 0-6), mostly located in the hilar-interlobar zone (43.8 %). For surgery duration (mean, 5.0 h), FEV1% and emphysema severity were independent predictors (P = 0.010 and 0.003, respectively). The number of calcified LNs was an independent predictor for chest tube indwelling duration (P = 0.030) and length of hospital stay (P = 0.046). Mean duration of chest tube indwelling and hospital stay was 8.8 days and 12.7 days in no calcified LN group; 9.2 and 13.2 in 1 calcified LN group; 12.8 and 19.7 in ≥2 calcified LNs group, respectively. The presence of calcified LNs on CT can help predict more complicated perioperative course following VATS lobectomy.

Long-term patient outcome 10 years after video-assisted thoracoscopic surgery lobectomy for non-small-cell lung cancer

Introduction: Although there have been many reports associating video-assisted thoracoscopic surgery (VATS) with improved survival rates in early lung cancer, almost all of the reports have involved short median follow-ups and been presented at a 5-year point. Here, we establish the pattern and frequency of recurrences, as well as the long-term survival rates of patients who have undergone VATS more than 10 years ago. Methods: We retrospectively studied 41 patients who underwent VATS lobectomy for clinical stage I non-small-cell lung cancer at Fukuoka University Hospital between November 1994 and December 1999. All patients underwent lobectomy, including a dissection of hilar and mediastinal lymph nodes. Follow-up consisted of clinical and radiological examinations every 3 months for the first 2 years after the surgery and then once a year thereafter. Results: Of the 41 patients, 31 were diagnosed to be at pathologic stage IA and six at stage IB, while the remaining four were more advanced cases. During the follow-up period, recurrences were found in five cases (12.2%). Four patients with recurrence died of lung cancer and an additional two died from cancers of other organs. There were other non-cancer related deaths, largely from respiratory failures. Overall, the 5- and 10-year survival rates after the operation were 79.8% and 68.8%, respectively. Conclusion: Long-term survival and recurrence rates after a classic VATS lobectomy for lung cancer are favorable compared to the conventional approach.

Evaluation of video-assisted thoracoscopic surgery lobectomy requiring emergency conversion to thoracotomy

Video-assisted thoracoscopic surgery (VATS) lobectomy has been employed for the treatment of lung cancer. Many investigators have reported that the outcomes of VATS lobectomy for lung cancer are comparable to those of thoracotomy; however, several controversial issues remain. One of the critical concerns is the safety. VATS lobectomy often requires an emergency conversion to thoracotomy, for example, in the event of massive bleeding. In this study, cases in which VATS lobectomy for lung cancer was converted to thoracotomy intra-operatively (converted VATS lobectomy) were identified. The safety of the converted VATS lobectomy was evaluated. Between 2003 and 2007, VATS lobectomy was converted to thoracotomy in 24 out of 492 cases. Information regarding the patients' characteristics, reasons for the conversion and perioperative complications as well as the recurrence and survival data were carefully reviewed. The reasons for the conversion were classified into two groups: (1) problems related to the VATS procedure (VATS-related problems) and (2) problems not related to the VATS procedure (non-VATS-related problems). Of the 24 converted cases, 19 (79%) had a history of smoking. Nine patients (38%) had a history of lung disease. Left upper lobectomy was the most frequently associated with conversion (11/24, 46%), followed by right lower lobectomy and right upper lobectomy. The most frequent reasons for the conversion were hilar lymphadenopathy and bleeding (seven patients each), followed by fused fissure. Eight of the conversions were considered to be attributable to VATS-related problems. Perioperative complications were observed in four patients, consisting of prolonged air leak in three patients and transient recurrent laryngeal nerve palsy in one patient. However, there were no life-threatening complications. The median follow-up period was 26 months. Recurrence occurred in two patients: pleural dissemination in one and bone metastasis in the other. Two deaths were observed during the follow-up period: one related to lung cancer and another related to other type of cancer. The safety of the conversion was acceptable. Our findings suggest that VATS lobectomy for lung cancer is feasible from the viewpoint of safety, even after taking into account the potential need for conversion to thoracotomy in some patients.

Very long-term outcomes of video-assisted thoracoscopic surgery for lung cancer

The most critical parameter in the evaluation of the feasibility of video-assisted thoracoscopic surgery (VATS) lobectomy for lung cancer is long-term outcome. In this study, patients in whom more than 5 years had elapsed since they had undergone VATS lobectomy for lung cancer were identified, and the 5-year survival rate and frequency of recurrence were evaluated as the long-term outcomes; in addition, the frequency of perioperative complications were also evaluated as the short-term outcomes. The stage, histology, perioperative complications, recurrence, and survival data were carefully reviewed in 198 patients who underwent VATS lobectomy for lung cancer between 1998 and 2002. Median postoperative follow-up period was 72.1 months. Of the 198 patients, 138 and 30 were diagnosed as having p-stage IA and IB disease, respectively, while the remaining 30 patients had more advanced disease. Perioperative complications were observed in 20 patients (10.1%), however, there were no perioperative mortalities. Recurrence was observed in 26 patients (13.1%): of these, 11 patients showed local recurrence, including malignant pleural effusion and mediastinal lymph node recurrence, and 16 patients showed distant metastasis, the lung being the commonest site of metastasis; six patients had both local recurrence and distant metastasis. During the study period, there were 26 deaths (13.1%), of which 17 were due to lung cancer and 9 were due to other causes. The 5-year overall survival rates of the patients with p-stage IA and IB disease were 93.5% and 81.6%, respectively. VATS lobectomy for the treatment of lung cancer is as feasible and safe as open lobectomy in terms of both very long- and short-term outcomes.

Complete versus assisted thoracoscopic approach: a prospective randomized trial comparing a variety of video-assisted thoracoscopic lobectomy techniques

Video-assisted thoracoscopic surgery (VATS) lobectomy does not represent a unified approach, but rather a spectrum of operative techniques ranging from a complete endoscopic thoracotomy to a minithoracotomy. A prospective randomized trial was conducted to compare the differences in these techniques and their results to determine the best of VATS lobectomy for lung cancer. This study randomized 39 consecutive patients with clinical stage I lung cancer to undergo either a complete (C-VATS, n = 20) or an assisted (A-VATS, n = 19) VATS approach for pulmonary lobectomy. The operating time was longer (p = 0.002) and blood loss was less (p = 0.004) with C-VATS than with A-VATS. Although there was no significant difference in analgesic use or duration of thoracic drainage between the groups, a shorter hospitalization was observed after C-VATS. Serum peak levels of postoperative inflammatory markers (white blood cell count, C-reactive protein, creatine phosphokinase) were lower with C-VATS and an earlier return to normalization than with A-VATS. Various differences exist among the VATS lobectomy techniques, and complete VATS lobectomy as a purely endoscopic surgery may be technically feasible and a satisfactory alternative to the conventional procedure for stage I lung cancer.