Thoracoscopic versus open lobectomy debate: the pro argument

INTRODUCTION Controversy persists about the role of VATS lobectomy for patients with lung cancer. This is particularly true in Europe, where VATS (video assisted thoracic surgery) lobectomy is performed for lung cancer less often than in the USA or Japan. This article reviews existing data comparing the results of VATS vs. open lobectomy for the treatment of lung cancer in order to provide a scientific basis for a rational assessment of this issue. METHODS The review of the data presented here draws heavily from a 2007 metaanalysis by Cheng et al. [1] published in 2007, as it employed rigorous methodology in performing a systematic review and metaanalysis, and involved a detailed analysis of many major and minor endpoints on an intent to treat basis. This included 36 trials, three of them randomized, and 3589 patients, reported between 1995 and 2007. Summary results for individual endpoints are shown as a mean value with 95% confidence intervals (CI). These values are taken from the summary results of the Forrest plots in the source article. Dichotomized variables are expressed as an Odds Ratio, with values <1 being in favor of VATS lobectomy. Continuous variables are reported as weighted mean differences. RESULTS The operative time for a VATS lobectomy was statistically longer, but only by 16 minutes. The conversion rate from VATS to open was 6%. There was no significant difference in the rates of major bleeding, blood transfusion or re-operation. VATS lobectomy was associated with a significantly lower rate of complications in general and pulmonary complications in particular. Postoperative pain was reduced, functional outcome was better, whereas overall quality of life was not. Mediastinal staging was equal with regard to the number of nodes or the number of nodal stations sampled. The ability of patients to receive adjuvant chemotherapy was improved following VATS. There was no difference in survival at 1 and 3 years for lung cancer (all stages combined). There was no difference in survival at 5 years for each tumor stage, and no difference in the rate of deaths at maximal follow-up. CONCLUSION The data suggests that VATS lobectomy for NSCLC is safe, results in fewer complications, less pain, and more rapid return of normal functioning. There appears to be either no difference or a slight benefit in long term survival after VATS lobectomy. These conclusions are demonstrated by a comprehensive, rigorous metaanalysis of the controlled clinical trials, but are weakened by the fact that most of the studies were not randomized. However, because a large randomized trial is not likely to ever be conducted, this represents the best assessment of the value of VATS lobectomy that is available.