Research in context
Evidence before this study
We searched PubMed for randomised trials that compared video-assisted thoracoscopic surgery (VATS) with thoracotomy for resection of early stage lung cancer. VATS is used increasingly as an alternative to thoracotomy for surgical treatment of early stage non-small-cell lung cancer. VATS was introduced more than 20 years ago, but the approach remains controversial and worldwide adoption rates are low. We used the search terms “thoracoscopy”, “VATS”, “lung cancer”, and “randomised” to identify reports published up to Dec 14, 2015. We found three randomised controlled trails in the English scientific literature, but none investigated postoperative pain or quality of life. One trial from the USA showed fewer surgical complications after VATS, a trial from Scotland showed smaller cytokine response after VATS, and a trial from Japan showed no difference in 5-year overall survival between VATS and thoracotomy. Additionally, we identified two Chinese papers that seem to study the same cohort of patients. The results of these studies showed significantly less postoperative pain and better quality of life after VATS than after thoracotomy, but neither has been cited in the English literature.
Added value of this study
Our results are the first from a randomised trial reported in the English scientific literaure to suggest that VATS was more beneficial for patients than thoracotomy for the surgical treatment of early stage non-small cell-lung cancer. Compared with patients who underwent thoracotomy, patients who underwent VATS lobectomy had less postoperative pain and better quality of life during the following 12 months, at least on EQ5D.
Implications of all evidence
From the growing body of non-randomised studies, VATS is generally assumed to be less traumatic than thoracotomy, with reduced postoperative pain, perioperative bleeding, length of hospital stay, and faster return to normal activities. Our results support this assumption in terms of postoperative pain and quality of life. Future trials should compare VATS with thoracotomy in a multicentre setting that includes both high-volume and low-volume surgical centres. In particular, future studies should investigate whether VATS is more beneficial when performed with fewer portholes, and survival should eventually be a included as a study endpoint.