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Lobectomy for Non–Small Cell Lung Cancer: Differences in Morbidity and Mortality Between Thoracotomy and Thoracoscopy

Papiashvilli, Michael MD*; Stav, David MD; Cyjon, Arnold MD; Haitov, Zoya MD§; Gofman, Vladislav MD§; Bar, Ilan MD*

Innovations:Technology and Techniques in Cardiothoracic and Vascular Surgery: January/February 2012 - Volume 7 - Issue 1 - p 15–22
doi: 10.1097/IMI.0b013e3182566221
Original Articles

Objective Until the last decade, lobectomy by thoracotomy (TL) was the “gold standard” for treatment of patients with operable lung carcinoma. Today, video-assisted thoracic surgery lobectomy (VATS-L) has become accepted as a safe and effective procedure to treat early-stage lung cancer. We analyzed and compared postoperative complications, hospital stay, morbidity, and mortality after TL and VATS-L in patients with non–small cell lung carcinoma (NSCLC).

Methods Between February 1998 and December 2007, we performed 326 TLs in patients with NSCLC. From December 2007, VATS-L was preferentially performed, and 63 cases of NSCLC patients underwent surgery using this method. Comorbidities were scaled according to the Charlson Comorbidity Index, and propensity scores between the TL and VATS-L patients were compared.

Results Postoperative complications occurred in 142 TL patients (43.6%) and 17 VATS-L patients (27%), with 3.6% and 1.6% intrahospital mortality, respectively. There were no significant differences between the TL and VATS-L patients in Charlson Comorbidity Index or propensity scores, which led us to compare complications between TL and VATS-L groups and discovered that VATS-L patients had a shorter median length of stay (P < 0.001) and VATS-L was associated with a reduction in the occurrence of atrial fibrillation (P = 0.011) and offered benefits for patients with more significant comorbidities, for example, congestive heart failure patients (P = 0.042).

Conclusions Our clinical impression is that VATS-L offers advantages over TL in terms of lower morbidity, fewer and less serious complications, shorter hospital stays, and the possibility to operate on patients with more comorbidities.

From the Departments of *General Thoracic Surgery, †Pulmonology, ‡Oncology,and §Anesthesiology, Assaf Harofeh Medical Center, Zerifin, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Ramat Aviv, Israel.

Accepted for publication March 15, 2012.

Presented at the Annual Scientific Meeting of the International Society for Minimally Invasive Cardiothoracic Surgery, June 8–11, 2011, Washington, DC USA.

Disclosure: The authors declare no conflict of interest.

Address correspondence and reprint requests to Ilan Bar, MD, Department of General Thoracic Surgery, Assaf Harofeh Medical Center, Zerifin 70300, Israel. E-mail:

Lobectomy by thoracotomy (TL) has been the standard of care for early-stage non–small cell lung cancer (NSCLC) that achieves the highest long-term survival compared with other treatment options.1 Video-assisted thoracic surgery lobectomy (VATS-L) has also been reported to be a safe and effective procedure for resectable NSCLC with fewer complication rates, shorter hospital stays, and faster recovery, without compromising the oncologic aspects of lung cancer surgery, when compared with TL.2–4 The recent meta-analysis studies that compared VATS-L with TL suggested that VATS-L is an appropriate procedure for selected patients with early-stage NSCLC5 and that there may be some short-term, and possibly even long-term, advantages to performing lung resections with VATS techniques rather than via conventional thoracotomy.6

We aimed to compare postoperative complications, hospital stay, morbidity, and mortality after we performed TL and VATS-L and investigate factors that could have an impact on these conditions, such as comorbidity, the incidence of which is rising with the increasing age of the population diagnosed with NSCLC. Several scoring systems based on different comorbidities have previously been used to stratify patients according to risk of complications, and the Charlson Comorbidity Index (CCI) was found to predict postoperative outcome more accurately than the individual comorbidities of each patient.7 We used the CCI and propensity scores for comparison of TL and VATS-L patients to find possible advantages of each of these surgical methods.

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We performed a retrospective chart review of all patients undergoing TL for NSCLC at our institution from February 1998 to December 2007 and VATS-L for NSCLC from December 2007 to January 2010 (during which time period VATS-L was preferentially performed in patients with NSCLC). This study was approved by the investigational review board at our institution.

The inclusion criterion for the study was patients with operable NSCLC who underwent lobectomy or bilobectomy. Patients who underwent wedge resection, segmentectomy, sleeve resection, lobectomy, or bilobectomy with chest wall resection or salvage lobectomy were excluded from the study.

Early hospital mortality was defined as death occurring within 30 days of surgery or any later death during the postoperative hospitalization period. Late mortality was defined as death occurring within 3 to 6 months of surgery.

In all patients, the preoperative diagnostic workup included a complete medical history and a physical examination. Preoperative chest radiography and computed tomography (CT) scan (scanned at 5-mm intervals; Phillips MX800 CT Scanner (Philips, Amsterdam, Netherlands) until 2005; Philips Brilliance CT 64-Channel Scanner (Philips) from 2005) of the chest and upper abdomen including the liver and adrenal glands were performed in all cases, and surgery took place within 60 days of the CT scan. In symptomatic patients and in patients considered to be at high risk for metastases, brain CT and bone scans were performed. From 2004, when positron emission tomography–CT (PET-CT) was introduced in Israel, we performed PET-CT scans for lung cancer patients for more precise staging. Electrocardiography and routine biochemical tests were performed in all cases. All patients were evaluated by fiberoptic bronchoscopy. Before surgery, all the patients underwent pulmonary functions tests, preoperative respiratory preparation, and in high-risk patients, cardiorespiratory exercise testing. Congestive heart failure was defined as a reduced ejection fraction of less than 45%–50% and chronic renal failure was defined as an elevated creatinine level greater than 1.5 mg/dL. Chronic obstructive pulmonary disease (COPD) was defined as a forced expiratory volume in 1 second/forced vital capacity ratio of less than 70%. Each patient was retrospectively assessed for preoperative CCI,7 which is a composite score of comorbid conditions that has been validated in cohorts of men and women with both malignant and nonmalignant disease (Table 1). This index can be divided into four comorbidity grades: 0, 1, 2, or 3 (Table 1).



There was no clinical evidence of metastatic disease in either patient population (TL/VATS-L patients), and the patients only had pulmonary lesions that were eligible for complete resection by means of lobectomy or bilobectomy. Those with mediastinal lymphadenopathy on CT scan (>1.0 cm in diameter) underwent prethoracotomy mediastinoscopy. Patients with metastatic lymph nodes on mediastinoscopy underwent neoadjuvant chemoradiation. Patients downstaged after neoadjuvant chemoradiation therapy were also included in the study (21 patients in the TL group and 1 patient in the VATS-L group).The clinical, pathologic, and operative records of the 389 patients (326 after TL and 63 after VATS-L) were retrospectively reviewed, and the tumors were classified and staged preoperatively and postoperatively according to the Union for International Cancer Control TNM classification of tumors (Table 2). The Naruke map was used to indicate lymph node locations during TL and VATS-L. Lymph nodes at stations 1 through 9 were considered to be mediastinal nodes, and nodes at stations 10 through 13 were regarded as hilar/pulmonary lymph nodes. During TL/VATS-L, generally whole hilar/mediastinal lymph nodes were dissected, and during mediastinoscopy, we generally performed lymphadenectomy, but fragments of nodes were also accepted. The following clinical and pathologic parameters were studied in each case: sex, side and type of surgery, histological type, vascular invasion, and tumor size (T1, <3 cm; and T2, >3 cm) (Table 3). The number of stations and lymph nodes dissected were also calculated (Table 4). Lymph nodes dissected during TL/VATS-L were counted separately from lymph nodes/fragments dissected during mediastinoscopy.







Lobectomy by thoracotomy was performed using the standard serratus-sparing posterolateral thoracotomy incision.8 Video-assisted thoracic surgery lobectomy was performed through three or four incisions without rib spreading: first, a 1.0-cm incision in the eighth intercostal space in the mid/post axillary line for the 0 grade thoracoscope; second, a 1.0-cm utility incision in the sixth intercostal space in the midclavicle line; third, a 3.0- to 4.0-cm working incision in the fourth/fifth intercostal space just anterior to the latissimus muscle; and fourth, a 1.0-cm incision beneath the tip of the scapula for thoracoscopic upper lobectomies.9 The learning curve for VATS-L was defined as the first 20 cases (approximately four to lobectomies for each lobe). Two chest drains were generally inserted after TL and VATS-L, and in the last 13 VATS-L patients, only one chest tube was inserted.

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Data Analysis

Analysis of data was carried out using SPSS 11.0 statistical analysis software (SPSS Inc, Chicago, IL USA). For continuous variables such as age, descriptive statistics were calculated and reported as mean ± SD. Distributions of continuous variables were assessed for normality using the Kolmogorov-Smirnov test (cutoff at P = 0.01). Categorical variables such as sex, surgical method, and the presence of comorbidities/complications were described using frequency distributions and are presented as frequency (%). Continuous variables were compared by surgical method using the t test for independent samples. Categorical variables were compared by surgical method using the χ2 test (exact as needed). Logistic regression analysis was used to develop propensity scores for the entire study population.

Variables presumed to influence odds of having any versus no complication included age, gender, obesity, smoking, coronary artery disease, COPD, and non-insulin-dependent diabetes mellitus. Propensity scores were then compared by surgical method and were found to be similar, suggesting that subjects in both surgical groups had similar surgical risk profiles.

We analyzed the background information that we had on our subjects before treatments were assigned: age, gender, obesity, smoking, coronary artery disease, COPD, and non–insulin-dependent diabetes and built a model to predict the probability that they would not have complications (both groups together). The propensity scores were calculated based on the entire sample.

Subjects with similar propensity scores could then be expected to have similar values of all of the background information. We then analyzed the results of comparing the mean propensity score of the two groups (TL and VATS-L) and found no differences (P = 0.126). This result enabled us to further compare the groups by the outcomes.

All tests are two sided and considered significant at P < 0.05.

Because of the skewed distribution of the patient populations when using the CCI, it was better to represent the populations using medians (min-max) and to compare them using the Mann Whitney U test rather than the t test. This comparison indicated that the CCI did not differ significantly between the two surgical methods.

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Of the 389 NSCLC patients presenting for curative lung resection, 326 (83.8%) with a median age of 65.7 years underwent TL (234 men [median age, 65.8 years; range, 46–86 years]; 92 women [median age, 65.2 years; range, 47–83 years]; 19 [5.8%] >80 years old) and 63 (16.2%) with a median age of 66.4 years underwent VATS-L (43 men [median age, 67.4 years]; 20 women [median age, 64.6 years; range, 37–83 years]; 8 [12.7%] >80 years old). Of 84 NSCLC patients presenting for curative lobectomy/bilobectomy from December 2007 to January 2010, 21 patients (25%) were not considered suitable for VATS-L for various reasons (more central tumors, thoracotomy or pleurodesis in the past, hilar lymphadenopathy complicating thoracoscopic dissection, and post neoadjuvant chemoradiation treatment) and underwent TL and only 63 patients (75%), with more peripheral lung lesions, underwent VATS-L.

The comorbidities in the two groups can be seen in Table 1. The data on the comorbidities were calculated from the medical history of the patients. All the patients were staged preoperatively by CT scans of the chest and upper abdomen and/or PET-CT and postoperatively according to the final pathologic examination (Table 2), and 53 (16.3%) patients in the TL group and 26 (41.3%) patients in the VATS-L group underwent PET-CT scanning preoperatively.

Thirty-two patients with mediastinal lymphadenopathy on CT scan (>1.0 cm in diameter) underwent prethoracotomy mediastinoscopy (31 patients [9.5%] without mediastinal lymph node metastasis in the TL group and 1 patient [1.6%] in the VATS-L group).

In the TL group, of 157 patients preoperatively staged as T1N0M0, 10 patients were upstaged (postoperatively) to T2N0 and 3 patients to T2N1 because of visceral pleural invasion and nodal disease, 2 patients to T3N0 because of parietal pleural invasion, 16 patients to T1N1 and 9 patients to T1N2 because of nodal disease, and 3 patients to M1 disease. Of 134 patients preoperatively staged as T2N0M0, 3 patients were upstaged (postoperatively) to T4N0 because of additional satellite lesions in the removed lobe (not identified on preoperative CT scan), 9 patients to T3N0-2 because of parietal pleural invasion with/without nodal disease, 8 patients to T3N0-2 because of mediastinal pleural/pericardial/diaphragmatic invasion with/without nodal disease, 24 to T2N1 and 13 to T2N2 because of nodal disease, and 1 to M1. Of 24 patients staged as T4N0M0, 14 patients were staged as T4N0 preoperatively because of two satellite lesions in the same lobe. Nine of them upstaged to T4N1-2 because of nodal disease and one to M1.

Twenty-one patients downstaged after neoadjuvant chemoradiation and, according to pretreatment staging (7 staged as T2N2M0, 10 as T4N0M0, and 4 as T4N2M0), underwent surgery. From these patients, nine were postoperatively found to be without residual disease, three were downstaged to T1N0, three to T2N0, four to T1N2, one to T2N1, and one toT4N0 (Table 2).

In the VATS-L group, of 44 patients staged as T1N0 preoperatively, 5 were upstaged postoperatively to T2N0/T1N1/2 because of visceral pleural invasion or nodal disease. Of 14 patients preoperatively staged as T2N0M0, 2 were upstaged to T2N1 postoperatively because of nodal disease and 1 to T4N2 because of an additional satellite lesion in the removed lobe and nodal disease. Four patients were staged as T4N0M0 preoperatively because of two satellite lesions in the same lobe. One patient staged as T2N2 before neoadjuvant chemoradiation treatment was downstaged postoperatively to T1N0 (Table 2).

The median number of lymph nodes dissected during the procedure was slightly higher in the TL group than the VATS-L group (Table 4).

We compared the mean propensity scores, which were calculated for the entire sample by analyzing the background information, between the groups and found them to be similar: predicted probability for not having complications was 0.60 ± 0.22 and 0.55 ± 0.25 (P = 0.126) for the LT and VATS-L groups, respectively. Therefore, we were able to compare the complications between the two groups. The CCI also did not show a significant difference between the two groups.

Early (hospital) and late (3-, and 6-month) mortality occurred in 3.6% (14 patients), 3.1% (10 patients), and 3.4% (11 patients), respectively, in the TL group and 1.6% (1 patient), 0%, and 1.6% (1 patient), respectively, in the VATS-L group (not significant [NS]; Table 5). Rethoracotomy due to postoperative bleeding occurred in four (1.2%) TL patients. Conversion from VATS-L to an anterior thoracotomy approach occurred in four (6.3%) VATS-L patients, mainly because of severe adhesions or bleeding. Median hospital stay was statistically significantly higher in the TL patients compared with the VATS-L patients (8 days [range, 3–102 days] and 5 days [range, 3–14 days]; P < 0.001).



The most common postoperative complication encountered in the TL group was atrial fibrillation (AF; 49 patients, 15.0%), which occurred less frequently in the VATS-L patients (2 [3.2%] patients; P = 0.011, significant). Lobar atelectasis was seen in 35 patients (10.7%) after TL (right upper lobe, 3 cases; right lower lobe, 6 six cases; right middle lobe, 8 cases; right bilobectomy, 6 cases; left upper lobe, 4 cases; left lower lobe, 8 cases) and in 6 patients (9.5%) after VATS-L (right lower lobe, 2 cases; left lower lobe, 2 cases; right middle lobe, 2 cases) (NS). All cases of atelectasis were treated by immediate bronchoscopy. A prolonged air leak (for >7 days) occurred in 7 patients (11.1%) in the VATS-L group compared with 30 patients (9.2%) in the TL group (NS). Serious complications seen in the TL group, such as prolonged mechanical ventilation in 15 patients (4.6%), tracheostomy in 12 patients (3.7%), sepsis in 14 patients (4.3%), prolonged fluid excretion (for >10 days) in 12 patients (3.7%), deep vein thrombosis in 3 patients (0.9%) (2 subclavian), cerebrovascular accident in 10 patients (3.1%), and pneumonia in 36 patients (11.0%), were generally not seen in the VATS-L group. Other complications like empyema, acute respiratory distress syndrome, renal failure, rethoracotomy, myocardial infarction, paralytic ileus, pulmonary or ischemic emboli, bronchopleural fistula, wound infection, and recurrent laryngeal and phrenic nerve palsy also occurred more frequently in the TL group (Table 5).

In 184 (56.4%) TL and 46 (73.0%) VATS-L patients, there were no postoperative complications (P = 0.014, significant). An investigation of the subgroup of patients older than 80 years (19 patients [5.8%] after TL and 8 patients [12.7%] after VATS-L) revealed that all 8 VATS-L patients had 0% mortality and 1.6% (1 patient) morbidity, and of the 19 patients who underwent TL, 3 (0.9%) died postoperatively and 12 (3.7%) had significant morbidities. Of 21 patients in the TL group who were post neoadjuvant therapy, there were 2 cases of perioperative mortality and 4 cases of significant morbidity (0.6% and 1.2% of 326 patients, respectively). It is true that after the introduction of VATS-L at our institution in December 2007, TL was generally performed in the more difficult and locally advanced lung cancer patients, and we are now carrying out a comparative study.

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The Thoracic Surgery Department at our Medical Center was opened in February 1998. The process of developing the department included the building of guidelines for the treatment and preparation of patients before, during, and after surgery and the professional preparation of anesthesiology teams, emergency department teams, and surgical and department nurses. Special attention was paid to the preparation of young surgeons, which included not only improving surgical skills but also becoming well acquainted with all the medical equipment. All these had a great influence on patient outcome. Despite this, a comparison of the morbidity and mortality results of our postoperative TL patients with those of postoperative VATS-L patients reported in the literature2–6,9 led us to fly far from our small Middle Eastern country to Los Angeles in search of new surgical techniques. From the end of 2007, after we had been performing TL for nearly 10 years, we started to carry out VATS-L. After a learning curve of 20 cases, we achieved results that are, in our opinion, comparable with those reported in the literature, and our clinical impression is that the department has completely changed over the last 2 years in comparison with the 10 years before this period.

The main goal of our study was to compare the clinical outcome of patients undergoing TL and VATS-L lobectomy during these two time periods. Before reviewing the findings of our study, we examined the morbidity/mortality in TL/VATS-L reported in recent literature.

Wada et al10 reported a 1.2% operative mortality for TL. The mortality by age was 0.4% for patients younger than 60 years, 1.3% for those aged 60 to 69 years, 2.0% for those aged 70 to 79 years, and 2.2% for those 80 years or older. Pneumonia and respiratory failure caused most deaths (51.6%). Martin et al11 reported a total mortality of 11.3% after lobectomies via thoracotomy in post neoadjuvant chemotherapy patients. Harpole et al12 reported a 30-day mortality of 4.0% (119/2949 patients) and a 30-day morbidity of 23.8% (703/2949 patients) for lobectomy. The authors also found that independent preoperative predictors of 30-day morbidity for TL were age, weight loss greater than 10% in the 6 months before surgery, history of COPD, transfusion of more than 4 units of blood, albumin level, hemiplegia, smoking, and dyspnea.12 Schneider et al13 reported an overall mortality rate after TL of 1.4% (21/1505 patients) and age-related mortality of 0.9% (8/919) in patients younger than 65 years, 1.9% (9/486) in patients aged 65 to 75 years, and 4.0% in patients older than 75 years, mainly because of pulmonary problems. Berry et al14 found that age and TL as the surgical approach were significant predictors of morbidity.

Other factors, such as comorbidity and extent of resection, have also been proven to predict outcome after NSCLC surgery.15–18 Moreover, Birim et al19,20 found that the CCI predicted postoperative outcome more accurately than the individual comorbid conditions did. Kates et al21 found that patients with multiple comorbidities had an increased 30-day postoperative mortality rate, with 14% of those who died having a CCI score greater than 4. They also found that greater age, male sex, tumor size, stage, and squamous histology were associated with a higher risk of 30-day postoperative mortality (P < 0.001 in all instances).

The important advantages of VATS-L reported in the literature include smaller incisions with better postoperative mechanics and less postoperative pain, a lower incidence of postoperative atrial arrhythmias, fewer respiratory complications, earlier chest tube removal, shorter length of hospital stay, and others.22,23 Sugi et al24 reported a similar overall 5-year survival rate when comparing VATS-L and TL, which supports the opinion that VATS-L preserves the oncologic principles of open lung cancer surgery, certainly in terms of the ability to achieve a complete (R0) resection and adequate dissection of lymph nodes. It is interesting that in their study, Kirby et al25 demonstrated no clear advantages of VATS-L because patients experienced similar length of stay and perioperative morbidity. Sakuraba et al26 also reported no significant difference in the overall survival rate between VATS-L and TL groups of patients (72% 5-year survival rate after TL and 82% after VATS-L in patients with stage IA NSCLC).

The main finding of our retrospective study was that patients who underwent VATS-L had a significantly shorter median length of stay (5 days) compared with TL patients (8 days) (P < 0.001). This finding is also supported by the article written by Whitson et al.27 No significant difference was found in the rate of occurrence of an air leak lasting more than 7 days in the VATS-L group compared with the TL group (11.1% vs 9.2%) and recurrence of postoperative atelectasis requiring bronchoscopy (10.7% in the TL group vs 9.5% in the VATS-L group). As mentioned by Scott et al,22 the fact that there is a reduced occurrence of alectasis after VATS-L may be related to the combination of decreased pain and inflammation and better mobilization of secretions because of improved postoperative chest wall function in the VATS-L patients. A very significant finding deduced from our comparison of comorbidities in TL and VATS-L patients (Table 1) is that patients with serious comorbidities, such as congestive heart failure or alcohol/drug abuse, may benefit from VATS-L (P = 0.042 and P = 0.022, respectively).

Another significant benefit of VATS-L is a decrease in postoperative complications. Serious respiratory complications such as prolonged mechanical ventilation, pneumonia, and tracheostomy and other critical complications such as sepsis, empyema, cerebrovascular accident, deep vein thrombosis, and others occurred more frequently in the TL patients, but without statistical significance (Table 5). A decrease in postoperative complications after VATS-L in comparison with TL was also reported in others studies,4,14,22 especially in the elder population,4,13 but a reduction in cases of AF after VATS-L in comparison with TL (15.0% vs 3.2%), a finding not supported by some studies28 and yet in accordance with others,22,23,29 proved to be statistically significant (P = 0.011) (Table 5) in our study.

The median number of lymph nodes dissected was higher in the TL group than the VATS-L group (6.9 vs 5.6 nodes) (Table 4). These data differ from those in other reports, which stated that the total number of mediastinal lymph nodes dissected was similar for VATS-L and TL.30 In the article of Ludwig et al,31 patient survival after resection of NSCLC was associated with the number of lymph nodes dissected during surgery, with a statistically significant increase in survival when more than five (five to eight) lymph nodes were dissected, with the highest survival in patients after dissection of more than 10 to 11 lymph nodes. The article by Ou and Zell32 also demonstrated that the number of lymph nodes removed at lobectomy in stage IA NSCLC is an important prognostic factor for survival. It appears that we did not remove sufficient lymph nodes, and we consider the lower number of lymph nodes dissected during TL/VATS-L (generally from stations 7, L6, and R8 during VATS-L) to be a limitation of our study. We are presently investigating the issue of overall survival and disease-free survival in patients after TL and VATS-L.

Of 326 patients who underwent TL, 184 (56.4%) had no complications, and the other 142 (43.6%) patients had 263 complications (1.8 complications per patient). Of the 63 patients who underwent VATS-L, 46 (73.0%) patients had no complications, whereas the other 17 (27.0%) had 26 complications (0.4 complications per patient). This finding also proved to be statistically significant (P = 0.014) (Table 5). Moreover, in our opinion, morbidity and hospital stay were directly influenced by the fact that complications in the VATS-L group were significantly less serious and less dramatic than those in the TL group (Table 5) and also probably by the fact that in the TL group, there were more post neoadjuvant patients than in the VATS-L group (6.4% vs 1.6%, respectively), more bilobectomies were performed, there were fewer T1 tumors and more T2 tumors, there were fewer adenocarcinomas, and there were fewer smokers. We consider these findings to be limitations of our study.

Our statistical analysis shows that the new method (VATS-L) is associated with a significant reduction in the occurrence of AF (P = 0.011) and a significant increase in patients with no complications after surgery (P = 0.014) (Table 5). This, together with a reduction in median hospital stay (P < 0.001) (Table 5), demonstrates the main success of our study, with statistically proven advantages of the VATS-L method compared with the TL method. When all individual comorbidities were compared, patients with a history of congestive heart failure and alcohol and drug abuse had fewer complications after VATS-L than after TL (P = 0.042 and P = 0.012, respectively).

The identification of patients with a low postoperative mortality risk could increase the use of surgery for older individuals, whereas the identification of high-risk patients could help in the decision-making process and enable the selection of suitable candidates for targeted interventions to reduce postoperative mortality.21 The predictive models for perioperative morbidity can be used for the purpose of a preliminary evaluation to assess the probability of survival of an individual patient and identify patients with a poor prognosis.21,22 In terms of morbidity, it was significantly proven that the newer VATS-L method is superior to the older TL surgical method in patients with early-stage NSCLC.33

Our retrospective analysis also shows that VATS-L may offer advantages in terms of fewer overall and serious (dramatic) complications and significantly less morbidity and, in our opinion, may be considered as the treatment of choice for early-stage lung cancer. The results of our study are comparable with those published in the recent literature.2,4–6,8 Long-term follow-up data are needed to check overall survival and local recurrence when comparing TL and VATS-L.

In conclusion, first, we managed to change our operative technique from TL to VATS-L without causing any harm to the patients and also succeeded in improving the postoperative outcome. Second, our experience enabled us to build protocols for those interested in making the same change, which we have done. Third, knowledge of the VATS-L technique enables us to perform open surgery more easily and more anatomically, which, in our opinion, is the biggest achievement when teaching young thoracic surgeons. We are still improving our VATS-L technique with hilar/mediastinal lymph node dissection with each new case and are satisfied with the intraoperative/postoperative results. Moreover, we are extending the policy of using VATS-L in more locally advanced lung cancer cases by scrupulous selection of the type of surgery (TL or VATS-L) before rather than during surgery.

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The authors thank Robert J. McKenna, Jr, MD, Los Angeles, CA USA for allowing us to observe him and learn his operative technique, and Ms Fredrica Gendler, for her meticulous secretarial assistance in the preparation of this article.

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There are two particularly unique aspects about this article. The first is that it comes from a relatively new Middle Eastern thoracic service. The team coordinated with the hospital administration to develop a minimally invasive program that started in 2007. They obtained outside consultation from an experienced minimally invasive surgical team and then coordinated their efforts to carefully collect the details of patient care. In their efforts to improve quality, they compared the first 10 years of their program with their minimally invasive approach. For this new program, in comparison with other published reports, the rate of complications and surgical outcomes were similar.

The second important aspect of this publication is that they attempted to remove bias in their retrospective evaluation by propensity matching, that is, identifying risk factors for poor outcomes and selecting patients in both groups who appeared to be similar for those risk factors. This technique has not been commonly performed in comparing the minimally invasive methods to the standard open thoracotomy. Using this technique, the authors found that the minimally invasive approach seemed to have a lower morbidity and, when complications occurred, seemed to be less drastic, and as a result, there was a shorter length of stay.


Video-assisted thoracic surgery; Minimally invasive; Complications; Lung cancer; Thoracotomy; Lobectomy; Morbidity

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