IASLC World Conference on Lung Cancer
IASLC World Conference on Lung Cancer
September 20, 2019
3 min read

Video-assisted thoracic surgery linked to fewer complications in early lung cancer

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BARCELONA — Lobectomy performed through video-assisted thoracic surgery resulted in significantly fewer in-hospital complications and a shorter hospital stay compared with open lobectomy among patients with early-stage lung cancer, according to results from the randomized VIOLET trial presented at International Associated for the Study of Lung Cancer World Conference on Lung Cancer.

“If you have early-stage lung cancer, many of your doctors will refer you to see a surgeon. The operation can be done two ways: through small incisions, projected on a TV screen and using telescopes and instruments, or via a big cut in the chest, with the ribs spread open,” Eric Lim, MD, professor of thoracic surgery at Royal Brompton Hospital in the U.K., said during a press conference. “We think that keyhole surgery may be less painful and [result in] a better recovery, because we don’t put pressure on the nerves when we’re opening the chest. The question is, how can a surgeon who can’t use his eyes and can’t actually feel the cancer be able to get as good a cancer removal just using instruments and a TV screen?”

Lim noted that very little is known about potential negative outcomes of the minimally invasive video-assisted thoracic surgery (VATS) technique vs. open surgery for lobectomy among patients with lung cancer. The randomized, multicenter VIOLET trial compared the clinical efficacy and cost-effectiveness of the surgeries among 503 patients (mean age, 69 years; 49.5% men) with known or suspected primary lung cancer at nine surgery centers in the U.K.

Researchers randomly assigned patients in a 1:1 ratio to VATS (n = 247) — performed through one to four keyhole incisions (21% one; 9% two; 58% three; 7% four) — or open surgery (n = 256) through a single thoracotomy incision with rib spreading. Surgeons harvested lymph nodes according to International Association for the Study of Lung Cancer recommendations and used standardized pain management regimens for both groups. Opaque dressings concealed the incision type from patients and research nurses.

Among patients assigned to VATS, 221 underwent lobectomy compared with 232 of those assigned to open surgery.

Lim noted the low rates of benign resection (1.2%), in-hospital mortality (1.4%) and conversion from VATS to open surgery (5.7%). Pleural adhesions (n = 4) and bleeding (n = 4) were the main reasons for conversion.

On day 1 after surgery, both groups had a median visual analogue scale pain score of 4 (interquartile range [IQR], 2-5); on day 2, the median pain score declined to 3 (IQR, 0-5) for the VATS group and remained at 4 (IQR, 2-5) for the open surgery group. Researchers adjusted the analyses for operating surgeon, center, and each intraoperative/postoperative painkiller used.


The groups demonstrated similar rates of complete resection (97.8% with VATS vs. 97.4% with open surgery) and median number of lymph nodes harvested (n = 5; IQR, 4-6).

The rate of lymph node upstaging from cN0/1 to pN2 was 6.2% in the VATS group and 4.8% in the open surgery group.

“To our surprise, we found that keyhole surgery picked up even more lymph node disease than open surgery,” Lim said. “All previous studies, which were mostly not randomized, showed a big difference in lymph node staging in favor of open surgery. But when we used the surgeon as his or her own internal control, we found that access didn’t make any difference.”

A smaller proportion of patients in the VATS group experienced overall in-hospital complications than the open surgery group (32.8% vs. 44.3%; P < .001), but the groups demonstrated similar rates of serious adverse events (8.1% vs. 7.8%). VATS particularly reduced kidney and infection complications, Lim noted.

Further, patients in the VATS group had a shorter median hospital stay than those in the open surgery group (4 days vs. 5 days; HR = 1.34; 95% CI, 1.09-1.65).

“Keyhole surgery is less painful and has less complications, leading to a shorter length of stay in hospital for our patients,” Lim said. “This was achieved without any compromise to cancer clearance or the cancer operation, and without any compromise to any serious adverse events compared [with] open surgery for lung cancer.” – by Jennifer Byrne


Lim E, et al. Abstract PL02.06. Presented at: International Association for the Study of Lung Cancer World Conference on Lung Cancer; Sept. 7-10, 2019; Barcelona.

Disclosures: Lim reports no relevant financial disclosures. Please see the abstract for all other authors’ relevant financial disclosures.