Elsevier

The Lancet Oncology

Volume 17, Issue 6, June 2016, Pages 836-844
The Lancet Oncology

Articles
Postoperative pain and quality of life after lobectomy via video-assisted thoracoscopic surgery or anterolateral thoracotomy for early stage lung cancer: a randomised controlled trial

https://doi.org/10.1016/S1470-2045(16)00173-XGet rights and content

Summary

Background

Video-assisted thoracoscopic surgery (VATS) is used increasingly as an alternative to thoracotomy for lobectomy in the treatment of early-stage non-small-cell lung cancer, but remains controversial and worldwide adoption rates are low. Non-randomised studies have suggested that VATS reduces postoperative morbidity, but there is little high-quality evidence to show its superiority over open surgery. We aimed to investigate postoperative pain and quality of life in a randomised trial of patients with early-stage non-small-cell lung cancer undergoing VATS versus open surgery.

Methods

We did a randomised controlled patient and observer blinded trial at a public university-based cardiothoracic surgery department in Denmark. We enrolled patients who were scheduled for lobectomy for stage I non-small-cell lung cancer. By use of a web-based randomisation system, we assigned patients (1:1) to lobectomy via four-port VATS or anterolateral thoracotomy. After surgery, we applied identical surgical dressings to ensure masking of patients and staff. Postoperative pain was measured with a numeric rating scale (NRS) six times per day during hospital stay and once at 2, 4, 8, 12, 26, and 52 weeks, and self-reported quality of life was assessed with the EuroQol 5 Dimensions (EQ5D) and the European Organisation for Research and Treatment of Cancer (EORTC) 30 item Quality of Life Questionnaire (QLQ-C30) during hospital stay and 2, 4, 8, 12, 26, and 52 weeks after discharge. The primary outcomes were the proportion of patients with clinically relevant moderate-to-severe pain (NRS ≥3) and mean quality of life scores. These outcomes were assessed longitudinally by logistic regression across all timepoints. Data for the primary analysis were analysed by modified intention to treat (ie, all randomised patients with pathologically confirmed non-small-cell lung cancer). This trial is registered with ClinicalTrials.gov, number NCT01278888.

Findings

Between Oct 1, 2008, and Aug 20, 2014, we screened 772 patients, of whom 361 were eligible for inclusion and 206 were enrolled. We randomly assigned 103 patients to VATS and 103 to anterolateral thoracotomy. 102 patients in the VATS group and 99 in the thoracotomy group were included in the final analysis. The proportion of patients with clinically relevant pain (NRS ≥3) was significantly lower during the first 24 h after VATS than after anterolateral thoracotomy (VATS 38%, 95% CI 0·28–0·48 vs thoracotomy 63%, 95% CI 0·52–0·72, p=0·0012). During 52 weeks of follow-up, episodes of moderate-to-severe pain were significantly less frequent after VATS than after anterolateral thoracotomy (p<0·0001) and self-reported quality of life according to EQ5D was significantly better after VATS (p=0·014). By contrast, for the whole study period, quality of life according to QLQ-C30 was not significantly different between groups (p=0·13). Postoperative surgical complications (grade 3–4 adverse events) were similar between the two groups, consisting of prolonged air leakage over 4 days (14 patients in the VATS group vs nine patients in the thoracotomy group), re-operation for bleeding (two vs none), twisted middle lobe (one vs three) or prolonged air leakage over 7 days (five vs six), arrhythmia (one vs one), or neurological events (one vs two). Nine (4%) patients died during the follow-up period (three in the VATS group and six in the thoracotomy group).

Interpretation

VATS is associated with less postoperative pain and better quality of life than is anterolateral thoracotomy for the first year after surgery, suggesting that VATS should be the preferred surgical approach for lobectomy in stage I non-small-cell lung cancer.

Funding

Simon Fougner Hartmanns Familiefond, Guldsmed AL & D Rasmussens Mindefond, Karen S Jensens legat, The University of Southern Denmark, The Research Council at Odense University Hospital, and Department of Cardiothoracic Surgery, Odense University Hospital.

Introduction

Complete surgical resection remains the gold standard for curative treatment of early stage non-small-cell lung cancer in patients who are physiologically fit. Traditionally, resection is done via a thoracotomy, but during the past two decades, video-assisted thoracoscopic surgery (VATS) has emerged as a minimally invasive alternative for advanced resections, including lobectomy. Although adoption rates remain low, VATS lobectomy is used increasingly worldwide.1, 2 A general assumption among the surgical community is that lobectomy via VATS is superior to lobectomy via thoracotomy, but the quality of evidence for this assumption is low. Results from many non-randomised studies have suggested that VATS is less traumatic than thoracotomy, resulting in less postoperative pain, less perioperative bleeding, shorter hospital stays, and earlier return to normal activities.3, 4 However, all of these studies suffer from potential selection biases, and they often differ substantially with respect to stages of disease or different surgeons and time periods of follow-up. Only three small randomised controlled trials5, 6, 7 have been published in English. In a US study,5 significantly more complications occurred in the thoracotomy group (mainly prolonged air leaks) than in the VATS group, but pain or length of hospital stay did not differ between surgical techniques. Results from a Japanese study suggested no difference in 5-year overall survival between thoracotomy and VATS, but the study did not investigate pain.6 Furthermore, researchers in Scotland reported significantly lower post-surgery cytokine concentrations after VATS than after thoracotomy, which could be interpreted as a reduced surgical stress response, but pain was again not investigated. Additionally, findings from two studies from China,8, 9 which both seem to describe the same patients, showed that patients who underwent VATS had significantly less postoperative pain and better quality of life than those who underwent thoracotomy. However, these studies8, 9 have not been cited in the English scientific literature. Finally, in another Japanese study,10 patients were randomly assigned to different variations of VATS, but the study did not compare VATS with thoracotomy.

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.

In view of the gaps in the scientific literature, we did a trial to compare postoperative pain and quality of life between VATS and thoracotomy in patients undergoing lobectomy for early stage non-small-cell lung cancer.

Section snippets

Study design and participants

We did our patient and observer blinded randomised controlled trial at a public university-based cardiothoracic surgery department in Denmark (Odense University Hospital, Odense, Denmark). This trial was approved by the Ethics Committee of Southern Denmark (S-20080085).

We recruited patients who were scheduled for lobectomy for stage I non-small-cell lung cancer with curative intent. We offered any patients at the hospital undergoing this procedure the chance to participate. We diagnosed and

Results

Between Oct 1, 2008, and Aug 20, 2014, we screened 772 patients with proven or suspected stage I non-small-cell lung cancer who were scheduled for lobectomy (figure 1). We excluded 411 patients in accordance with our inclusion criteria and identified 361 patients eligible for inclusion. Of these patients, 69 were not willing to participate in the trial and 86 patients were eligible, but for unknown reasons were not asked to participate. Of the 206 enrolled patients, 103 were randomly assigned

Discussion

For patients who undergo lobectomy, the most common surgical procedure for operable stage I lung cancer, our findings show that, compared with anterolateral thoracotomy, VATS leads to a small but significant reduction in moderate-to-severe postoperative pain, and significantly better self-reported quality of life during the first 52 weeks after surgery.

We used peak values of pain to discriminate between mild, moderate, or severe pain, which is generally accepted,17 and we divided pain scores

References (30)

  • TJ Kirby et al.

    Lobectomy—video-assisted thoracic surgery versus muscle-sparing thoracotomy. A randomized trial

    J Thorac Cardiovasc Surg

    (1995)
  • K Sugi et al.

    Video-assisted thoracoscopic lobectomy achieves a satisfactory long-term prognosis in patients with clinical stage IA lung cancer

    World J Surg

    (2000)
  • SR Craig et al.

    Acute phase responses following minimal access and conventional thoracic surgery

    Eur J Cardiothorac Surg

    (2001)
  • H Long et al.

    Quality of life after lobectomy for early stage non-small cell lung cancer—video-assisted thoracoscopic surgery versus minimal incision thoracotomy

    Ai Zheng

    (2007)
  • H Long et al.

    Cytokine responses after lobectomy: a prospective randomized comparison of video-assisted thoracoscopic surgery and minimal incision thoracotomy

    Ai Zheng

    (2007)
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