PerspectiveIn the Journals

Video-assisted thoracoscopic surgery for NSCLC reduces pain, improves quality of life

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June 28, 2016

Patients with stage I non–small cell lung cancer who underwent video-assisted thoracoscopic surgery experienced less postoperative pain and better quality of life than those who underwent thoracotomy, according to results of a randomized controlled trial.

Complete surgical resection with thoracotomy is standard treatment for early-stage NSCLC; however, video-assisted thoracoscopic surgery (VATS) has become a minimally invasive alternative for advanced resections.

Nonrandomized studies suggested VATS may result in less postoperative pain, less perioperative bleeding, shorter hospital stays and an earlier return to activities compared with thoracotomy.

Peter B. Licht, MD, PhD, of the department of cardiothoracic surgery at Odense University Hospital in Denmark, and colleagues compared postoperative pain and quality of life among patients randomly assigned 1:1 to lobectomy via VATS (n = 102; mean age, 66 years) or open surgery (n = 99; mean age, 65 years) for stage I NSCLC.

The primary endpoints included postoperative pain — measured using the numeric rating scale — and quality of life, assessed with the EuroQol 5 Dimensions and European Organization for Research and Treatment of Cancer 30 item Quality of Life (EORTC QLQ-C30) questionnaires. All assessments were taken during patients’ hospital stays, as well as at 2, 4, 8, 12, 26 and 52 weeks.

Perioperative blood loss, length of surgical procedures, chest tube durations, postoperative complications and length of hospital stays served as secondary endpoints.

More patients assigned thoracotomy reported moderate to severe pain — defined as a numeric rating scale of 3 or more —during the 52-week follow-up (P < .001).

Patients assigned VATS were significantly less likely than those assigned thoracotomy to report moderate to severe pain in the first 24 hours after surgery (38% vs. 63%; P = .001).

The researchers observed better self-reported EuroQol 5 Dimensions scores in the VATS group than the thoracotomy group throughout follow-up (P = .014). However, no significant differences existed in quality of life, according to QLQ-C30 scores.

Patients in both groups reported similar postoperative complications, including prolonged air leakage over 4 days, reoperation for bleeding, twisted middle lobe, prolonged air leakage over 7 days, arrhythmia and neurological events.

Three patients in the VATS group and six patients in the thoracotomy group died during follow-up.

Post-hoc analysis showed a shorter median duration of surgery with thoracotomy group (79 minutes vs. 100 minutes; P < .0001). Results showed less median perioperative blood loss (50 mL vs. 100 mL; P = .028), shorter median chest tube duration (2 days vs. 3 days; P = .068) and shorter median lengths of hospital stays (4 days vs. 5 days; P = .027) with VATS.

The researchers acknowledged the study was limited by its single-center design, the small number of patients and strict exclusion criteria.

“Other relevant questions to investigate include the role of VATS for patients on chronic pain medication, comparison of VATS with posterolateral thoracotomy, specific investigation of whether VATS is more beneficial when done with fewer portholes, and eventual investigation of the effect of VATS on survival as a study endpoint,” Licht and colleagues wrote.

It is important to remember that VATS is an approach and not a new surgical technique, Francesco Petrella, MD, and Lorenzo Spaggiari, MD, PhD, of the department of thoracic surgery at University of Milan, wrote in an accompanying editorial.

“The future challenge for the minimally invasive philosophy is to show that it is worth applying not just in terms of immediate pain relief and postoperative quality of life, but more importantly in terms of long-term oncological outcome, which still needs to be demonstrated,” Petrella and Spaggiari wrote.

VATS does appear feasible and safe for early-stage lung cancers, they wrote.

“Nonetheless, respect for the oncological criteria of safety and radicality must remain the key consideration in surgical lung cancer therapy, irrespective of how this result is achieved,” Petrella and Spaggiari wrote. “Surgeons and oncologists should not lose sight of this goal of offering patients the best chance for cure and survival.” – by Kristie L. Kahl

Disclosure: Licht reports a speaker’s honorarium from Ethicon, a subsidiary of Johnson & Johnson. The other researchers report no relevant financial disclosures.

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Daniel Raymond

Daniel Raymond

One of the major obstacles to lung surgery is postoperative pain, which impairs a patients ability to breathe. Video-assisted thoracoscopic surgery (VATS) is a relatively new technique for performing lung resection without large incisions in the chest wall and placement of rib-spreading devices. There have been numerous nonrandomized studies that demonstrate a benefit of VATS with respect to reduction in pain, perioperative complications and hospital stay, as well as a more rapid return to work. The current study is a rigorously conducted randomized trial that provides the strongest evidence to date demonstrating the early benefits of VATS over thoracotomy for resection of early-stage lung cancer.

It is important to remember the original intent of this surgery, which is to cure cancer. Although this study provides strong support for VATS surgery, survival data are essential before concluding that VATS is the preferred approach. This would require 5 years of close patient follow-up, which is understandably difficult to perform. An alternative would be to assess the quality of the cancer operation with surrogate markers, such as the number of lymph nodes removed, number of lymph node stations assessed and margin length. I routinely tell patients with lung cancer that I will perform a VATS resection as long as I do not compromise their safety or the quality of their cancer operation. I am hopeful that the authors are ultimately able to provide us with the 5-year survival data from this cohort of data and demonstrate an equivalency in the quality of the cancer operation along with the shorter-term benefits, including diminished pain and more rapid recovery.

Daniel Raymond, MD
Cleveland Clinic

Disclosure: Raymond reports no relevant financial disclosures.