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1.  A meta-analysis of unmatched and matched patients comparing video-assisted thoracoscopic lobectomy and conventional open lobectomy 
Video-assisted thoracic surgery (VATS) for patients with early-stage non-small cell lung cancer (NSCLC) has been established as a safe and feasible alternative to open thoracotomy. This meta-analysis aims to assess the potential difference between unmatched and propensity score-matched cohorts who underwent VATS versus open thoracotomy in the current literature.
Three relevant studies with unmatched and propensity score-matched patients were identified from six electronic databases to examine perioperative outcomes after VATS lobectomy versus open thoracotomy for patients with early-stage NSCLC. Endpoints included perioperative mortality and morbidity, individual postoperative complications and duration of hospitalization.
Results indicate that perioperative mortality was significantly lower for VATS compared to open thoracotomy in unmatched patients but no significant difference was detected amongst propensity score-matched patients. Similarly, the incidences of prolonged air leak and sepsis were significantly lower for VATS in the unmatched cohort, but not identified in the propensity score-matched cohort. In both the unmatched and matched groups, patients who underwent VATS were found to have a significantly lower overall perioperative morbidity rate, incidences of pneumonia and atrial arrhythmias, and a shorter duration of hospitalization in comparison to patients who underwent open thoracotomy.
The present meta-analysis indicates that VATS lobectomy has superior perioperative outcomes compared to open thoracotomy in both matched and unmatched cohorts. However, the extent of the superiority may have been overestimated in the unmatched patients when compared to propensity score-matched patients. Due to the limited number of studies with available data included in the present meta-analysis, these results are only of observational interest and should be interpreted with caution.
PMCID: PMC3741727  PMID: 23977459
Video-assisted thoracic surgery; thoracotomy; non-small cell lung cancer; propensity score analysis; meta-analysis
2.  Technical difficulties and extending the indications for VATS lobectomy 
Journal of Thoracic Disease  2014;6(Suppl 6):S623-S630.
Data on advantages of video-assisted thoracoscopic surgery (VATS) lobectomies has been accumulated during the last 10 years then number of thoracoscopic anatomic pulmonary resections rapidly increased. But still there is no agreement about limitations of the method. The most popular “technical contraindications” for VATS anatomic pulmonary resections are: dense pleural adhesions, incompleteness of interlobar fissure, previous chemo- or/and radiotherapy, perivascular or/and peribronchial fibrosis, tumor larger than 5 cm, chest wall involvement, centrally located tumor, severe comorbidity, advanced age, severe COPD and emphysema. Extending of indications for the VATS anatomic pulmonary resection and its influence on the immediate outcomes was investigated.
Ninety two consecutive cases of VATS anatomic pulmonary resection performed by the single surgeon from January 2012 till December 2013 at the Federal University Hospital #122 in Saint Petersburg, Russia were retrospectively analyzed. Forty three males and 49 females at the age from 21 to 87 years old (mean age 59±7.2). The most of the cases were comprised by lung cancer of I-III stage together with bronchiectasis and tuberculomas. Conversion rate was 3.2% mostly due to perivascular calcification and/or fibrosis. There were no cases of 30-days mortality and readmission. All those patients retrospectively divided into two groups: with standard and extended indications for the VATS lobectomy. Inclusion in “extended” group was made if patients had one or more technical challenges among following: size of the lesion 5 cm and more; strong pleural adhesions and/or “bad fissure”; adjacent structures involvement; hilar or mediastinal lymph nodes enlargement or involvement; centrally located tumors; previous chemo- or chemoradiotherapy or previous thoracic surgery.
According to these criteria, 45 standard (S) and 47 extended (E) patients were pair-matched with no statistically significant differences between the groups in common patients’ characteristics. Postoperative comparison of “standard” and “expanded” groups revealed some differences in average operation time (152 vs. 189 min), in number of resected mediastinal lymph nodes (10.2 vs. 13.1), and in the mean time before removal of the chest tube (3.9 vs. 5.2 days). But the blood loss, morbidity and the length of hospital stay were almost the same in the two groups.
Extension of indications to VATS lobectomy does not compromise the short-term results. Incompleteness of interlobar fissures, pleural adhesions, preoperative chemotherapy, big size of lesion, and some cases of centrally located tumors are not supposed to be the contraindications for VATS lobectomy. Peribronchial and perivascular lymph node calcification may complicate and even preclude lobectomy by VATS.
PMCID: PMC4221338  PMID: 25379200
Video-assisted thoracoscopic surgery (VATS); lobectomy; indications; contraindications; matched-pair comparison
3.  Video-assisted thoracoscopic surgery and thoracotomy during lobectomy for clinical stage I non-small-cell lung cancer have equivalent oncological outcomes: A single-center experience of 212 consecutive resections 
Oncology Letters  2014;9(3):1364-1372.
The aim of the present study was to compare the oncological outcomes following lobectomy using either video-assisted thoracoscopic surgery (VATS) or thoracotomy in clinical stage I non-small cell lung cancer (NSCLC) patients. Short- and long-term data from 212 consecutive patients who underwent lobectomy for clinical stage I NSCLC via VATS or thoracotomy between February 2003 and July 2013 were retrospectively reviewed. The primary endpoints were mediastinal lymph node staging, disease-free survival time and overall survival time. A total of 212 lobectomies for clinical stage I NSCLC were performed, 123 by VATS and 89 by thoracotomy. Patients’ demographic data, pathological stage and residual tumor were similar in the two groups. Reduced blood loss, less post-operative analgesia required and earlier hospital discharge were recorded for the VATS group, as compared with the thoracotomy group. The overall morbidity was similar in the two groups. However, the rate of major complications was higher following thoracotomy than following VATS. No 30-day mortality occurred subsequent to either thoracotomy or VATS lobectomy. The overall survival and disease-free survival times were comparable between the two groups. In the univariate analysis, the treatment approach was not associated with the overall five-year survival or the disease-free survival times. Multivariate Cox regression analysis of survival times revealed that significant predictors of shorter survival times were advanced pathological T3 stage, pathological N1 or N2 disease and poor cancer differentiation. In conclusion, it is reasonable to conclude from the present study that VATS lobectomy performed by specialist thoracic surgeons is safe and may achieve similar long-term survival times to the open surgery approach. However, further prospective randomized multi-center trials are warranted prior to incorporating VATS into clinical routine.
PMCID: PMC4315067  PMID: 25663914
video-assisted thoracoscopic surgery; thoracotomy; non-small cell lung cancer; mediastinal lymph node; disease-free survival; overall survival
4.  Uniportal video assisted thoracoscopic lobectomy: primary experience from an Eastern center 
Journal of Thoracic Disease  2014;6(12):1751-1756.
Uniportal video-assisted thoracoscopic surgery (VATS) lobectomy is an emerging technique for the surgical resection of non-small cell lung cancer (NSCLC). Besides its wide debates on safety and efficacy throughout the world, there were few report on uniportal VATS from the Eastern countries. In this article, we summarized our primary experience on uniportal VATS lobectomy in an Eastern center.
From October 2013 till February 2014, 54 consecutive uniportal VATS lobectomy were performed in the Department of Thoracic Surgery, Zhongshan Hospital of Fudan University. Patients’ clinical features and operative details were recorded. Post-operatively, the morbidity and mortality were recorded to analyze the safety and efficacy of uniportal VATS lobectomy for NSCLCs.
Among the 54 planned uniportal VATS lobectomy, there was one conversion to mini-thoracotomy due to lymph node sticking. Extra ports were required in two patients. The uniportal VATS lobectomy was achieved in 51 out of 54 patients (94.4%). The average operation duration was 122.2±37.5 min (90-160 min). The average volume of estimated blood loss during the operation was 88.8±47.1 mL (50-200 mL). The mean chest tube duration and hospital stay were 3.2±1.9 days and 4.6±2.0 days, respectively. There was no postoperative mortality in this study. Two patients suffered from prolonged air leakage (5 and 7 days), and one atrial fibrillation was observed in this cohort.
Based on our primary experience, uniportal VATS lobectomy is a safe and effective procedure for the surgical resection of NSCLCs. The surgical refinements and instrumental improvements would facilitate the technique. Further studies based on larger population are required to determine its benefits towards patients with NSCLCs.
PMCID: PMC4283325  PMID: 25589969
Lobectomy; minimally invasive surgery; non-small-cell-lung carcinoma (NSCLC)
5.  High costs as a slow down factor of thoracoscopic lobectomy development in Poland – an institutional experience 
Thoracoscopic (VATS) lobectomy after a decade of criticism is nowadays considered as a technically feasible, safe and oncologically proper operation. This approach has some advantages over conventional thoracotomy like: less postoperative pain, shorter hospitalization, fewer postoperative complications, better tolerance of adjuvant chemotherapy with comparable long-term survival rate. The VATS lobectomy is now generally accepted as an important alternative to open lobectomy in early-stage lung cancer.
In the study we analyzed all aspects of introducing video-assisted thoracoscopic surgery (VATS) lobectomy in our institution with special consideration of the costs of the procedure as a potential limiting factor of its widespread development.
Material and methods
The data of 212 consecutive patients with early stage lung cancer operated on during 2008-2011 were selected and analyzed. One hundred and eight patients underwent VATS lobectomy (VATS group) and 104 patients antero-lateral thoracotomy (thoracotomy group). Perioperative outcomes including operating time, blood loss during surgery, postoperative complication rate, length of hospital stay, and duration of chest tube drainage were assessed. The cost evaluation included: all direct theater costs, daily hospital costs, intensive care costs, pharmacy and disposable costs with special consideration of stapling device costs.
The mean hospital stay after VATS lobectomy was significantly shorter than after thoracotomy, mean 7 days vs. 10 days (p < 0.0012). The complication rate and ICU admission rate were almost twice as high after thoracotomy than after VATS and were 46% vs. 23% (p < 0.0006) and 42% vs. 22% (p < 0.0027) respectively. Cost analysis showed significantly higher total costs of VATS lobectomy than after thoracotomy (median €2445 vs. €2047). Considerably higher theater costs for VATS compared to thoracotomy, median €1395 vs. €479, were caused mainly by endostapler costs, median €1069 vs. €161. Significantly higher hospital costs and ICU costs after thoracotomy did not compensate high theater costs of VATS lobectomy.
In Polish financial reality and potentially in other middle-income countries significantly higher costs of the procedure can limit widespread introduction of VATS lobectomy in clinical practice.
PMCID: PMC3908642  PMID: 24501604
lobectomy; lung cancer; minimally invasive surgery; video-assisted thoracoscopic surgery; health economics
6.  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.
PMCID: PMC3011293  PMID: 21289905
7.  Application of video-assisted thoracic surgery in the standard operation for thoracic tumors 
Cancer Biology & Medicine  2013;10(1):28-35.
To evaluate the short-term outcomes of video-assisted thoracic surgery (VATS) for thoracic tumors.
The data of 1,790 consecutive patients were retrospectively reviewed. These patients underwent VATS pulmonary resections, VATS esophagectomies, and VATS resections of mediastinal tumors or biopsies at the Cancer Institute & Hospital, Chinese Academy of Medical Sciences between January 2009 and January 2012.
There were 33 patients converted to open thoracotomy (OT, 1.84%). The overall morbidity and mortality rate was 2.79% (50/1790) and 0.28% (5/1790), respectively. The overall hospitalization and chest tube duration were shorter in the VATS lobectomy group (n=949) than in the open thoracotomy (OT) lobectomy group (n=753). There were no significant differences in morbidity rate, mortality rate and operation time between the two groups. In the esophageal cancer patients, no significant difference was found in the number of nodal dissection, chest tube duration, morbidity rate, mortality rate, and hospital length of stay between the VATS esophagectomy group (n=81) and open esophagectomy group (n=81). However, the operation time was longer in the VATS esophagectomy group. In the thymoma patients, there was no significant difference in the chest tube duration, morbidity rate, mortality rate, and hospital length of stay between the VATS thymectomy group (n=41) and open thymectomy group (n=41). However, the operation time was longer in the VATS group. The median tumor size in the VATS thymectomy group was comparable with that in the OT group.
In early-stage (I/II) non-small cell lung cancer patients who underwent lobectomies, VATS is comparable with the OT approach with similar short-term outcomes. In patients with resectable esophageal cancer, VATS esophagectomy is comparable with OT esophagectomy with similar morbidity and mortality. VATS thymectomy for Masaoka stage I and II thymoma is feasible and safe, and tumor size is not contraindicated. Longer follow-ups are needed to determine the oncologic equivalency of VATS lobectomy, esophagectomy, and thymectomy for thymoma vs. OT.
PMCID: PMC3643687  PMID: 23691442
Video-assisted thoracic surgery (VATS); non-small cell lung cancer (NSCLC); esophageal cancer; thymoma
8.  Video-Assisted Thoracic Surgery (VATS) Lobectomy for Pathologic Stage I Non-Small Cell Lung Cancer: A Comparative Study with Thoracotomy Lobectomy 
Surgical treatment of stage I non-small cell lung cancer (NSCLC) can be performed either by thoracotomy or by employing video-assisted thoracic surgery (VATS). The aim of this study was to evaluate the feasibility of VATS lobectomy for pathologic stage I NSCLC.
Material and Methods
Between December 2003 and December 2007, 529 patients with pathologic stage I NSCLC underwent lobectomies (373 thoracotomy, 156 VATS). Patients in both groups were selected after being matched by age, gender and pathologic stage using propensity score method, to create two comparable groups: thoracotomy and VATS groups, and the overall survival, recurrence-free survival, complication and length of hospitalization were compared between these two groups.
After the patients were matched by age, gender and pathologic stage, 272 patients remained eligible for analysis, 136 in each group (mean age of 59.5 years; 70 men, 66 women; 80 stage IA, 56 stage IB). There was no statistical difference in other preoperative clinical characteristics between the two groups. No hospital mortality was observed in both groups. Overall 3-year survival rate was 97.4% in thoracotomy group and 96.6% in VATS groups (p=0.76). During the follow-up, 20 patients (14.7%) developed recurrence in thoracotomy group, including loco- regional recurrence in 7, distant metastasis in 13. In VATS group, 13 patients (9.6%) developed recurrence, including loco-regional recurrence in 4, distant metastasis in 9. Three-year recurrence-free survival rate was 81.8% in thoracotomy group and 85.3% in VATS groups (p=0.43). There was no significant difference in postoperative complications between thoracotomy and VATS groups (30 cases in 22 patients vs. 19 cases in 17 patients, p=0.65, odds ratio=1.19). The mean hospital stay of VATS group was 2 days shorter than that of thoracotomy group (8.8±6.5 days vs. 6.3±3.3 days, p<0.05).
VATS lobectomy for pathologic stage I lung cancer is a feasible operation with shorter hospitalization, while surgical outcome is comparable to thoracotomy lobectomy.
PMCID: PMC3249270  PMID: 22263121
Video-assisted thoracic surgery; Lobectomy; Lung neoplasms; Neoplasm staging
9.  Video-assisted thoracoscopic lobectomy: an unavoidable trend? A retrospective single-institution series of 410 cases  
Evaluation of the feasibility, safety and oncological validity of video-assisted thoracic lobectomy (VATS). The VATS study exclusion criteria included T3 or T4 tumours, central hilar tumours, tumours visible on bronchoscopy requiring sleeve resection, hilar lymphadenopathy, N2 disease, history of neoadjuvant chemotherapy or radiation, previous thoracic surgery or pleurodesis.
A retrospective study of 410 patients (143 women, mean age 61.5 ± 13.1 years (84–15) treated by VATS lobectomy between 1996 and 2011 was performed at our institution. VATS lobectomy was performed for lung cancer (n = 364, 88.9%), pulmonary metastasis (n = 25, 5.8%) and non-neoplastic diseases (n = 21, 5.1%). In lung cancer, a systematic radical lymph node dissection was performed.
There was no intraoperative death. The conversion rate was 6.1% (n = 25): bleeding (n = 4), extended pleural adhesion (n = 6, 1.4%), technical difficulty (n = 6, 1.4%), tumour extension to the fissure or mediastinum or adenopathy (n = 7, 1.7%) and intolerance to one-lung ventilation (n = 2, 0.4%). The postoperative mortality rate was 1.2% (n = 5). Major complications occurred in 21 patients (5.1%). The mean number of mediastinal nodes removed was 14.6 (5–44) and 42 patients (10.2%) presented N2 disease at the definitive staging. The mean operating time was 152 (85–315) min. The mean drainage duration was 3.2 days (1–15). Mean postoperative length of hospital stay before return at home was 6.8 days (3–75) and 5.5 days in patients without major complications. There was no port site recurrence. Kaplan–Meier 3-year survival rates were 76.5% for Stage I and 87.3% for Stage IA, 58% for Stage II and 61% for Stage III.
VATS lobectomy is an acceptable alternative and seems equivalent to open lobectomy in terms of complications and oncological value. Our experience prompts us to consider VATS lobectomy for early stage NSCLC as the first surgical approach in view of the improvement in outcome, provided that the procedure is performed by a surgeon with adequate experience with this approach.
PMCID: PMC3686401  PMID: 23592725
Lung cancer; Video-assisted thoracic lobectomy
10.  The feasibility of a Two-incision video-assisted thoracoscopic lobectomy 
This study is to evaluate the feasibility and safety of video-assisted thoracoscopic (VATS) lobectomy with two incisions.
A total of 73 patients (male 47, female 26; mean age 61.2 ± 12.00 years old) who underwent major pulmonary resection, through VATS, using two incisions were included in this study. The thoracoscopy port was placed at the 7th or the 8th intercostal space in the mid-axillary line, and the working port, 3~5 cm long, at the 5th intercostal space, on the operator’s side.
The preoperative diagnosis was benign lung disease in 8 patients (11.0%) and malignant lung disease in 65 (89.0%). Two patients (3.1%) needed a third port during surgery due to severe pleural adhesion, and conversion to thoracotomy was needed in 5 (6.8%), due to bleeding at pulmonary arterial branch (n = 3), anthracofibrotic lymph nodes around pulmonary artery (n = 1), and severe pleural adhesion (n = 1). The mean duration of the operation in the 66 patients, completed by a two-incision VATS lobectomy, was 163.4 ± 30.40 minutes. In 56 cases, which were completed by a two-incision VATS lobectomy for primary lung cancer, a total number of dissected lymph nodes per patient were 20.2 ± 11.2. The chest tube was removed on postoperative day 5.4 ± 2.8, and there was no occurrence of major perioperative morbidity and mortality.
Two-incision VATS lobectomy is applicable in the selected cases, and may obtain similar results with the conventional VATS lobectomy, through a certain period of learning curve.
PMCID: PMC3660169  PMID: 23587171
Thoracosocopy/VATS; Lobectomy
11.  Analysis of clinical application of thoracoscopic lobectomy for lung cancer 
VATS has been extensively considered as a standard method of pulmonary diagnosis and treatment of benign lung diseases. This study aimed to investigate the safety, efficacy, and feasibility of video-assisted thoracoscopic surgery (VATS) lobectomy compared with conventional lobectomy via open thoracotomy in patients with clinical early stage lung cancer.
A total of 120 patients with lung cancer underwent VATS lobectomy; another 120 patients with lung cancer underwent conventional lobectomy. The clinical outcomes from these two groups were retrospectively analyzed and compared.
The numbers of patients who underwent lobectomy in the left upper lobe, left lower lobe, right upper lobe, right middle lobe, and right lower lobe were 24, 28, 40, 4, and 24 in the VATS group and 38, 20, 30, 7, and 25 in the conventional group, respectively. No statistical differences were observed between the two groups. Likewise, no statistical differences were observed in terms of duration of operation, time for postoperative extubation, complications, length of hospital stay, and number of dissected lymph nodes (VATS group: left, 5.12 ± 1.45, right, 6.84 ± 1.33; conventional group: left, 4.96 ± 1.39 mm, right, 6.91 ± 1.27; P >0.05).
Anatomical lobectomy was successfully completed by VATS lobectomy for lung cancer; the standard lymph node dissection was also achieved. This procedure also showed advantages in terms of surgical bleeding, duration, postoperative complications, indwelling time of chest tube, and short-term recurrence rate without significant differences from conventional lobectomy.
PMCID: PMC4061527  PMID: 24886331
Video-assisted thoracoscopic surgery (VATS); Clinical early stage lung cancer; Lobectomy; Complication; Short-term recurrence rate
12.  Is uniportal thoracoscopic surgery a feasible approach for advanced stages of non-small cell lung cancer? 
Journal of Thoracic Disease  2014;6(6):641-648.
Conventional video-assisted thoracoscopic (VATS) lobectomy for advanced lung cancer is a feasible and safe surgery in experienced centers. The aim of this study is to assess the feasibility of uniportal VATS approach in the treatment of advanced non-small cell lung cancer (NSCLC) and compare the perioperative outcomes and survival with those in early-stage tumors operated through the uniportal approach.
From June 2010 to December 2012, we performed 163 uniportal VATS major pulmonary resections. Only NSCLC cases were included in this study (130 cases). Patients were divided into two groups: (A) early stage and (B) advanced cases (>5 cm, T3 or T4, or tumors requiring neoadjuvant treatment). A descriptive and retrospective study was performed, comparing perioperative outcomes and survival obtained in both groups. A survival analysis was performed with Kaplan-Meier curves and the log-rank test was used to compare survival between patients with early and advanced stages.
A total of 130 cases were included in the study: 87 (A) vs. 43 (B) patients (conversion rate 1.1 vs. 6.5%, P=0.119). Mean global age was 64.9 years and 73.8% were men. The patient demographic data was similar in both groups. Upper lobectomies (A, 52 vs. B, 21 patients) and anatomic segmentectomies (A, 4 vs. B, 0) were more frequent in group A while pneumonectomy was more frequent in B (A, 1 vs. B, 6 patients). Surgical time was longer (144.9±41.3 vs. 183.2±48.9, P<0.001), and median number of lymph nodes (14 vs. 16, P=0.004) were statistically higher in advanced cases. Median number of nodal stations (5 vs. 5, P=0.165), days of chest tube (2 vs. 2, P=0.098), HOS (3 vs. 3, P=0.072), and rate of complications (17.2% vs. 14%, P=0.075) were similar in both groups. One patient died on the 58th postoperative day. The 30-month survival rate was 90% for the early stage group and 74% for advanced cases
Uniportal VATS lobectomy for advanced cases of NSCLC is a safe and reliable procedure that provides perioperative outcomes similar to those obtained in early stage tumours operated through this same technique. Further long term survival analyses are ongoing on a large number of patients.
PMCID: PMC4073401  PMID: 24976985
Advanced lung cancer; uniportal; thoracoscopy; video-assisted thoracoscopic(VATS) lobectomy; minimally invasive surgery; non-small cell lung cancer (NSCLC)
13.  Video-Assisted Thoracic Surgery Lobectomy: Results in Lung Cancer 
Journal of Thoracic Disease  2010;2(1):29-35.
The application of video-assisted thoracic surgery (VATS) in major pulmonary resections is still far from routine in most hospitals, even though the safety and technical feasibility of the procedure have by now been amply demonstrated. This paper reports on the surgical technique used by the authors for VATS lobectomy, on their experience of the procedure and on the results obtained.
A retrospective study was performed of all patients undergoing VATS lobectomy at the our Thoracic Surgery Department ,between 1993 and 2009.The clinical records of all patients were reviewed, and the following variables were noted for purposes of analysis: patient age and sex; clinical diagnosis; staging; date of surgery; type of surgery; conversion to conventional surgery and grounds for conversion; duration of surgery; intraoperative, postoperative and long-term complications; postoperative stay, final diagnosis and staging; and death rates.
A total of 349 VATS lobectomies were performed over the study period (292 men, 57 women; mean age 59.7) The aetiology was non-small-cell lung carcinoma (NSCLC) in 313 patients and benign processes in 26;four patients had carcinoid tumours, and a further six required lobectomy due to metastases. The overall conversion rate was 9.4%. Mean duration of lobectomy was 148 minutes, and median duration 92 minutes. Mean postoperative was 3.9 days. The morbidity rate was 12.89 %, mostly involving minor complications. Perioperative mortality was 1.43%. There were no intraoperative deaths. The overall five-year survival rate for patients with NSCLC was 80.1%.
VATS lobectomy is a safe and technically-viable procedure that meets oncological criteria for lung-cancer surgery. Major pulmonary resection using VATS should be considered the procedure of choice for a number of benign processes and for early-stage bronchogenic carcinoma (T1-T2 N0 M0).
PMCID: PMC3256439  PMID: 22263014
Video-assisted thoracic surgery; VATS; lung cancer; thoracoscopy; minimally invasive surgical procedures; lobectomy
14.  Comparative study of systematic thoracoscopic lymphadenectomy and conventional thoracotomy in resectable non-small cell lung cancer 
Journal of Thoracic Disease  2014;6(1):45-51.
To assess the feasibility and safety of the video-assisted thoracoscopy surgery (VATS) systematic lymph node dissection in resectable non-small cell lung cancer (NSCLC).
The clinical data of patients with NSCLC who underwent VATS or thoracotomy combined with lobectomy and systematic lymphadenectomy from January 2001 to January 2008 were retrospectively analyzed to identify their demographic parameters, number of dissected lymph nodes and postoperative complications.
A total of 5,620 patients were enrolled in this study, with 2,703 in the VATS group, including 1,742 men (64.4%), and 961 women (35.6%), aged 59.5±10.9 years; and 2,917 in the thoracotomy group, including 2,163 men (74.2%), and 754 women (25.8%), aged 58.5±10.4 years. Comparing the VATS with the thoracotomy groups, the mean operative time was 146 vs. 157 min, with a significant difference (P<0.001); and the average blood loss was 162 vs. 267 mL, with a significant difference (P<0.001). Comparing the two groups of patients data, the number of lymph node dissection: 18.03 in the VATS group and 15.07 in the thoracotomy group on average, with a significant difference (P<0.001); postoperative drainage time: 4.5 days in the VATS group and 6.37 days in the thoracotomy group on average, with a significant difference (P<0.001); postoperative hospital stay: 6.5 days in the VATS group and 8.37 days in the thoracotomy group on average, with a significant difference (P<0.001); proportion of postoperative chylothorax: 0.2% (4/2,579) in the VATS group and 0.4% (10/2,799) in the thoracotomy group, without significant difference (P>0.05).
For patients with resectable NSCLC, VATS systematic lymph node dissection is safe and effective with fewer postoperative complications, and significantly faster postoperative recovery compared with traditional open chest surgery.
PMCID: PMC3895592  PMID: 24455175
Non-small cell lung cancer (NSCLC); video-assisted thoracoscopy surgery (VATS); systematic lymph node dissection
15.  Feasibility and long-term efficacy of video-assisted thoracic surgery for unexpected pathologic N2 disease in non-small cell lung cancer 
Annals of Thoracic Medicine  2013;8(3):170-175.
This study compares early and late outcomes for treatment by video-assisted thoracic surgery (VATS) versus treatment by thoracotomy for clinical N0, but post-operatively unexpected, pathologic N2 disease (cN0-pN2).
Clinical records of patients with unexpected N2 non-small cell lung cancer (NSCLC) who underwent VATS were retrospectively reviewed, and their early and late outcomes were compared to those of patients undergoing conventional thoracotomy during the same period.
VATS lobectomy took a longer time than thoracotomy (P < 0.001), but removal of thoracic drainage and patient discharge were earlier for patients in the VATS group (P < 0.001). There was no difference in lymph node dissection, mortality and morbidity between the two groups (P > 0.05). The median follow-up time for 287 patients (89.7%) was 37.0 months (range: 7.0-69.0). The VATS group had a longer survival time than for the thoracotomy group (median 49.0 months vs. 31.7 months, P < 0.001). The increased survival time of the VATS group was due to patients with a single station of N2 metastasis (P = 0.001), rather than to patients with multiple stations of N2 metastasis (P = 0.225).
It is both feasible and safe to perform VATS lobectomy on patients with unexpected N2 NSCLC. VATS provides better survival rates for those patients with just one station of metastatic mediastinal lymph nodes.
PMCID: PMC3731860  PMID: 23922613
Non-small cell lung cancer; outcomes; staging; surgery
16.  Severe intraoperative complications during VATS Lobectomy compared with thoracotomy lobectomy for early stage non-small cell lung cancer 
Journal of Thoracic Disease  2013;5(4):513-517.
Video-assisted thoracic surgery (VATS) lobectomy has been proved to have shorter hospital stay, less perioperative complications and less pain compared with lobectomy by thoracotomy, but severe intraoperative complications during VATS lobectomy is rare reported. We compared intraoperative safety between VATS lobectomy and lobectomy by thoracotomy.
659 patients with postoperative stage I and IIa non-small cell lung cancer (NSCLC) who underwent lobectomy in China-Japan Friendship Hospital from February 2008 to June 2012 were analyzed retrospectively, in which 277 were performed by thoracotomy, 357 performed by VATS, and 25 performed by VATS converted to open. Outcomes were analyzed to compare the incidence of significant bleeding, with conversion cases were included into VATS group.
Ten severe intraoperative complications were identified in 10 patients (6 in VATS, 4 in open), with no intraoperative deaths. The incidence of severe intraoperative complications was similar between VATS group and thoracotomy group [1.57% (6/382) vs. 1.44% (4/277), P=1.0]. Most severe intraoperative complications were related to the injury of major pulmonary vessels (9/10), and most of these complications occurred during upper lobectomy (8/10). There was no statistically significant difference in blood loss (242.85±220.47 vs. 240.43±144.36, P=0.865), and operative time (198.00±75.24 vs. 208.05±61.97, P=0.061) between the open and VATS groups, respectively, but blood loss and operative time are significant different after elimination of conversion cases (214.34±151.85 vs. 240.43±144.36, P<0.01; 193.24±72.64 vs. 208.05±61.97, P<0.01).
Our preliminary study demonstrated that the incidence of severe intraoperative complication during VATS lobectomy was low and similar to open lobectomy. The severe intraoperative complications during VATS lobectomy are manageable and the surgeons need to take proper caution in performing VATS lobectomy.
PMCID: PMC3755690  PMID: 23991310
Lung cancer surgery; lobectomy; bleeding; surgery complications
17.  Video-assisted thoracic surgery versus open thoracotomy for non-small cell lung cancer: a meta-analysis of propensity score-matched patients 
This meta-analysis aimed to compare the perioperative outcomes of video-assisted thoracic surgery (VATS) with open thoracotomy for propensity score-matched patients with early-stage non-small cell lung cancer (NSCLC).
Four relevant studies with propensity score-matched patients were identified from six electronic databases. Endpoints included perioperative mortality and morbidity, individual postoperative complications and duration of hospitalization.
Results indicate that all-cause perioperative mortality was similar between VATS and open thoracotomy. However, patients who underwent VATS were found to have significantly fewer overall complications, and significantly lower rates of prolonged air leak, pneumonia, atrial arrhythmias and renal failure. In addition, patients who underwent VATS had a significantly shorter length of hospitalization compared with those who underwent open thoracotomy.
In view of a paucity of high-level clinical evidence in the form of large, well-designed randomized controlled trials, propensity score matching may provide the highest level of evidence to compare VATS with open thoracotomy for patients with NSCLC. The present meta-analysis demonstrated superior perioperative outcomes for patients who underwent VATS, including overall complication rates and duration of hospitalization.
PMCID: PMC3568798  PMID: 23169877
Video-assisted thoracic surgery; Thoracotomy; Non-small cell lung cancer; Propensity score analysis; Meta-analysis
18.  Outcomes of a hybrid technique for video-assisted thoracoscopic surgery (VATS) pulmonary resection in a community setting 
Journal of Thoracic Disease  2010;2(4):210-214.
Video-assisted thoracoscopic surgery (VATS) for pulmonary resection was first described 18 years ago; however, it has yet to gain widespread acceptance in community hospitals in the United States. The majority of surgeons who routinely perform VATS resections work in academic or government institutions. There is little data reporting outcomes of VATS pulmonary resections by community-based surgeons. This article reports the outcomes of a hybrid technique for VATS pulmonary resection in a single-surgeon, community-based practice.
A retrospective study was performed on all VATS pulmonary resections performed from January 2000 to March 2008 by a community-based, solo-practice surgeon using a hybrid VATS technique, which utilizes dual access through a thoracoscopy port and a utility incision.
A total of 1170 VATS pulmonary resections were performed over the study period, which is the largest single-surgeon series on VATS pulmonary resection to our knowledge. Among them, 746 cases were for malignant disease. Mean operative time was 52 minutes (median 48 minutes). Mean length of stay was 7 days (median 4 days). Mean length of ICU stay was 1.4 days, with 83% of patients having no days spent in the ICU. Mean length of chest tube duration was 4.5 days. The morbidity rate was 21.1 %, with neuropraxia as the most frequent complication. Perioperative mortality was 4.3% and overall mortality was 16.4%, with a mean follow-up of 425 days.
This series shows that our hybrid VATS approach to pulmonary resection is safe and feasible at community hospital-based practices.
PMCID: PMC3256472  PMID: 22263049
VATS; video-assisted thoracoscopy; pulmonary resection; minimally invasive; community-based; lung cancer
19.  Clinical Outcomes of Video-Assisted Thoracoscopic Lobectomy 
Mayo Clinic Proceedings  2009;84(6):509-513.
OBJECTIVE: To review our experience with video-assisted thoracoscopic (VATS) lobectomy with respect to morbidity, mortality, and short-term outcome.
PATIENTS AND METHODS: VATS lobectomies were performed in 56 patients between July 6, 2006, and February 26, 2008. Two patients declined consent for research participation and were excluded. Clinical data for 54 patients were collected from medical records and analyzed retrospectively.
RESULTS: The studied cohort included 19 men (35%) and 35 women (65%) with a median age of 67.5 years (minimum-maximum, 21-87 years; interquartile range [IQR], 59-74 years). Median duration of operation for VATS lobectomy was 139 minutes (minimum-maximum, 78-275 minutes; IQR, 121-182 minutes). Two cases (4%) required conversion to open lobectomy. Median time to chest tube removal was 2 days (minimum-maximum, 1-12 days; IQR, 1.3-3.8 days). Median length of stay was 4 days (minimum-maximum, 1-12 days; IQR, 4-7 days). There was no operative mortality.
CONCLUSION: VATS lobectomy is safe and feasible for pulmonary resection. This minimally invasive approach may allow patients to benefit from lobectomy with shorter recovery times and hospital stays compared with conventional open thoracotomy.
The authors reviewed their experience with video-assisted thoracoscopic lobectomy with respect to morbidity, mortality, and short-term outcome and found that this procedure is safe and feasible for pulmonary resection. This minimally invasive approach may allow patients to benefit from lobectomy with shorter recovery times and hospital stays compared with conventional open thoracotomy.
PMCID: PMC2688624  PMID: 19483167
20.  Trainees Can Safely Learn Video-Assisted Thoracic Surgery Lobectomy despite Limited Experience in Open Lobectomy 
The aim of this study was to establish whether pulmonary lobectomy using video-assisted thoracic surgery (VATS) can be safely performed by trainees with limited experience with open lobectomy.
Data were retrospectively collected from 251 patients who underwent VATS lobectomy at a single institution between October 2007 and April 2011. The surgical outcomes of the procedures that were performed by three trainee surgeons were compared to the outcomes of procedures performed by a surgeon who had performed more than 150 VATS lobectomies. The cumulative failure graph of each trainee was used for quality assessment and learning curve analysis.
The surgery time, estimated blood loss, final pathologic stage, thoracotomy conversion rate, chest tube duration, duration of hospital stay, complication rate, and mortality rate were comparable between the expert surgeon and each trainee. Cumulative failure graphs showed that the performance of each trainee was acceptable and that all trainees reached proficiency in performing VATS lobectomy after 40 cases.
This study shows that trainees with limited experience with open lobectomy can safely learn to perform VATS lobectomy for the treatment of lung cancer under expert supervision without compromising outcomes.
PMCID: PMC4398157  PMID: 25883893
Education; Lobectomy; Lung neoplasms; Minimal invasive surgery; Thoracic surgery, video-assisted
21.  Safety and feasibility of video-assisted thoracoscopic surgery for stage IIIA lung cancer 
The current study was prospectively designed to explore the application of video-assisted thoracoscopic surgery (VATS) radical treatment for patients with stage IIIA lung cancer, with the primary endpoints being the safety and feasibility of this operation and the second endpoints being the survival and complications after the surgery.
A total of 51 patients with radiologically or mediastinoscopically confirmed stage IIIA lung cancer underwent VATS radical treatment, during which the standard pulmonary lobectomy and mediastinal lymph node dissection were performed after pre-operative assessment. The operative time, intraoperative blood loss/complications, postoperative recovery, postoperative complications, and lymph node dissection were recorded and analyzed. This study was regarded as successful if the surgical success rate reached 90% or higher.
A total of 51 patients with non-small cell lung cancer (NSCLC) were enrolled in this study from March 2009 to February 2010. The median post-operative follow-up duration was 50.5 months. Of these 51 patients, 41 (80.4%) had N2 lymph node metastases. All patients underwent the thoracoscopic surgeries, among whom 50 (98%) received pulmonary lobectomy and mediastinal lymph node dissection completely under the thoracoscope, 6 had their incisions extended to about 6 cm due to larger tumor sizes, and 1 had his surgery performed using a 12 cm small incision for handling the adhesions between lymph nodes and blood vessels. No patient was converted to conventional open thoracotomy. No perioperative death was noted. One patient received a second surgery on the second post-operative day due to large drainage (>1,000 mL), and the postoperative recovery was satisfactory. Up to 45 patients (88.2%) did not suffer from any perioperative complication, and 6 (11.8%) experienced one or more complications.
VATS radical treatment is a safe and feasible treatment for stage IIIA lung cancer.
PMCID: PMC4153931  PMID: 25232214
Lung cancer; video-assisted thoracoscopic surgery (VATS); systematic node dissection (SND)
22.  Video-Assisted versus Open Lobectomy in Patients with Compromised Lung Function: A Literature Review and Meta-Analysis 
PLoS ONE  2015;10(7):e0124512.
It has been suggested that video-assisted (VATS) lobectomy is safer than open lobectomy in patients with compromised lung function, but data regarding this are limited. We assessed acute outcomes of VATS compared to open lobectomy in these high-risk patients using a systematic literature review and meta-analysis of data.
The databases PubMed and Scopus were searched for studies published between 2000 and 2013 that reported mortality and morbidity of VATS in high-risk lung cancer patients defined as having compromised pulmonary or cardiopulmonary function. Study selection, data collection and critical assessment of the included studies were performed according to the recommendations of the Cochrane Collaboration.
Three case-control studies and three case series that included 330 VATS and 257 open patients were identified for inclusion. Operative mortality, overall morbidity and pulmonary morbidity were 2.5%, 39.3%, 26.2% in VATS patients and 7.8%, 57.5%, 45.5% in open lobectomy group, respectively. VATS lobectomy patients experienced significantly lower pulmonary morbidity (RR = 0.45; 95% CI, 0.30 to 0.67; p = 0.0001), somewhat reduced operative mortality (RR = 0.51; 95% CI, 0.24 to 1.06; p = 0.07), but no significant difference in overall morbidity (RR = 0.68; 95% CI, 0.41 to 1.14; p = 0.14).
The existing data suggest that VATS lobectomy is associated with lower risk for pulmonary morbidity compared with open lobectomy in lung cancer patients with compromised lung function.
PMCID: PMC4493021  PMID: 26146827
23.  Comparative study of video-assisted thoracic surgery versus open thymectomy for thymoma in one single center 
Journal of Thoracic Disease  2014;6(6):726-733.
Due to the popularity of video-assisted thoracic surgery (VATS) techniques in clinical, thymoma patients via VATS thymectomy are increasing rapidly. However, compared with open thymectomy, the potential superiorities and defects of VATS thymectomy remain controversial.
A number of 129 patients who underwent thymectomy of early stage thymoma (Masaoka stage I and stage II) in one single center from January 2007 to September 2013 were selected in this retrospective study. Of those patients, 38 thymoma patients underwent VATS thymectomy (VATS group) and 91 underwent open thymectomy (open group) via either transsternal [44] or transthoracic approach [47] in the same period. The postoperative variables, which included postoperative hospital length of stay (LOS), the intensive care unit (ICU) LOS, the entire resection ratio, the number of thoracic drainage tubes, the quantity of output and duration of drainage, were analyzed. Meanwhile, the operation time and blood loss were considered as intraoperative variables.
All thymoma patients in the analysis included 19 thymoma patients with myasthenia gravis, among which five patients via VATS thymectomy and 14 patients via open thymectomy respectively. There was no death or morbidity due to the surgical procedures perioperatively. The ICU LOS, operation time, entire resection ratio, and the number of chest tubes were not significantly different in two groups. The postoperative hospital LOS of VATS thymectomy was shorter than that of open thymectomy (5.26 versus 8.32 days, P<0.001). The blood loss of VATS thymectomy was less than open thymectomy (114.74 versus 194.51 mL, P=0.002). Postoperatively, the quantity of chest tubes output in VATS group was less than that in open thymectomy group (617.86 versus 850.08 mL, P=0.007) and duration of drainage in VATS group was shorter than that in open thymectomy group (3.87 versus 5.22 days, P<0.001).
VATS thymectomy is a safe and practicable treatment for early-stage thymoma patients. Thymoma according with Masaoka staging I-II without evident invading seems to be performed through VATS approach appropriately, which has shorter postoperative hospital LOS, less blood loss and less restrictions to activities, hence patients will recover sooner.
PMCID: PMC4073414  PMID: 24976996
Thymoma; thymectomy; video-assisted thoracic surgery (VATS); open surgery
24.  Long-term outcomes after video-assisted thoracic surgery (VATS) lobectomy versus lobectomy via open thoracotomy for clinical stage IA non-small cell lung cancer 
Video-assisted thoracic surgery (VATS) lobectomy is a standard treatment for lung cancer. This study retrospectively compared long-term outcomes after VATS lobectomy versus lobectomy via open thoracotomy for clinical stage IA non-small cell lung cancer (NSCLC).
From July 2002 to June 2012, 160 patients were diagnosed with clinical stage IA NSCLC and underwent lobectomy. Of these, 114 underwent VATS lobectomy and 46 underwent lobectomy via open thoracotomy.
The 5-year disease-free survival (DFS) rate was 88.0% in the VATS group and 77.1% in the thoracotomy group for clinical stage IA NSCLC (p = 0.1504), and 91.5% in the VATS group and 93.8% in the thoracotomy group for pathological stage IA NSCLC (p = 0.2662). The 5-year overall survival (OS) rate was 94.1% in the VATS group and 81.8% in the thoracotomy group for clinical stage IA NSCLC (p = 0.0268), and 94.8% in the VATS group and 96.2% in the thoracotomy group for pathological stage IA NSCLC (p = 0.5545). The rate of accurate preoperative staging was 71.9% in the VATS group and 56.5% in the thoracotomy group (p = 0.2611). Inconsistencies between the clinical and pathological stages were mainly related to tumor size, nodal status, and pleural invasion. Local recurrence occurred for one lesion in the VATS group and six lesions (five patients) in the thoracotomy group (p = 0.0495).
The DFS and OS were not inferior after VATS compared with thoracotomy. Local control was significantly better after VATS than after thoracotomy. Preoperative staging lacked sufficient accuracy.
PMCID: PMC4058716  PMID: 24886655
Clinical stage IA; Lobectomy; Open thoracotomy; Prognosis; Video-assisted thoracic surgery (VATS)
25.  Analysis of 1,067 Cases of Video-Assisted Thoracic Surgery Lobectomy 
Video-assisted thoracic surgery (VATS) lobectomy has been performed with increasing frequency over the last decade. However, there is still controversy as to its indications, safety, and feasibility. Especially regarding lung cancer surgery, it is not certain whether it can reduce local recurrences and improve overall survival.
Materials and Methods
We retrospectively reviewed 1,067 cases of VATS lobectomy performed between 2003 and 2009, including the indications, postoperative morbidity, mortality, recurrence, and survival rate.
One thousand and sixty seven patients underwent VATS lobectomy for the following indications: non-small cell lung cancer (NSCLC) (n=832), carcinoid tumors (n=12), metastatic lung cancer (n=48), and benign or other diseases (n=175). There were 63 cases (5.9%) of conversion to open thoracotomy during VATS lobectomy. One hundred thirty one (15.7%) of the 832 NSCLC patients experienced pathologic upstaging postoperatively. The hospital mortality rate was 0.84% (9 patients), and all of them died of acute respiratory distress syndrome. One hundred forty-nine patients (14.0%) experienced postoperative complications. The median follow-up was 22.9 months for patients with NSCLC. During follow-up, 120 patients had a recurrence and 55 patients died. For patients with pathologic stage I, the overall survival rate and disease-free survival rate at 3 years was 92.2±1.5% and 86.2±1.9%, respectively. For patients with pathologic stage II disease, the overall survival rate and disease-free survival rate at 3 years was 79.2±6.5% and 61.9±6.6%, respectively.
Our results suggest that VATS lobectomy is a technically feasible and safe operation, which can be applied to various lung diseases. In patients with early-stage lung cancer, excellent survival can be also achieved.
PMCID: PMC3249295  PMID: 22263146
Video-assisted thoracic surgery; Lobectomy; Lung neoplasm

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