Video assisted thoracic surgery for treatment of pneumothorax and lung resections: systematic review of randomised clinical trials

Introduction

Thoracoscopy by direct vision (crouching and peering through an inadequate instrument) has been possible for many years but two developments opened the way to its wider application in the diagnosis and treatment of lung disease: the development of television cameras that displayed on large television screens a brilliantly lit and magnified view of the inside of the chest and the manufacture of a range of stapling and cutting devices for operating through ports of a centimetre or less in diameter. The newly developed term of video assisted thoracic surgery (VATS) was rapidly popularised. It was assumed that if patients could be managed with “keyhole” surgery rather than thoracotomy they would experience less pain and shorter hospital stays.1 Lung biopsies for parenchymal lung disease or excision biopsies at the lung edge can readily be performed for diagnostic purposes. Virtually all operations for pneumothorax can be performed by video assisted thoracic surgery, and clinical experience is that it makes inspection and biopsy of the pleura easier. Formal anatomical lobectomy for the resection of lung cancer is more challenging.

The relative advantages compared with open surgery through thoracotomy have not been assessed in a systematic review of the evidence from randomised trials. Without this evidence it is not possible to make recommendations for best practice or to provide guidance for its wider application. We carried out a systematic review of randomised clinical trials to determine if video assisted thoracic surgery is associated with better clinical outcomes than thoracotomy for three common thoracic procedures: surgery for pneumothorax, minor resections (wedge and segmental resections), and lobectomy.

Methods

We included only randomised clinical trials that compared video assisted thoracic surgery with conventional surgery. Our inclusion criteria were random allocation of patients, enrolment of general thoracic surgery patients, and no concurrent use of another experimental medication or device. We included in the review any trial of video assisted thoracic surgery applicable to our topics of interest.

Randomised trials were identified by searching Medline, Embase, Cochrane database of systematic reviews, and the Cochrane controlled trials register from 1980 to 2003. Only studies in humans were considered, and no language restrictions were applied. We used MeSH terms “thoracic surgery, video assisted” “thoracoscopy” and various combinations of text words that might be related to this specific procedure. A standard randomised controlled trial filter designed by the Cochrane collaboration for identifying trials was used for Medline and Embase (adapted from Scottish Intercollegiate Guideline Network (www.sign.ac.uk/methodology/filters.html)). We also searched the reference lists of randomised trials and reviews to look for additional studies.

We identified 142 unique abstracts. Independent review of these abstracts identified 12 unique studies meeting all inclusion criteria (figure). For each trial, we abstracted data on the number of patients randomised and the frequency of the events in the intervention (video assisted thoracic surgery) and control groups. One of the authors (AS) abstracted the data and another (JL) independently confirmed the counts of events and number of patients randomised to treatment groups. All authors participated in adjudication of any discrepancies.

Selection of papers for inclusion

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For each trial, we collected data on outcomes such as recurrence of disease or failure (for pneumothorax surgery only), surgery time, measurement of pain and medication for pain, complications (any major), length of hospital stay, and costs. We also collected information on age, sex, and malignancy. We could not carry out meta-analysis because of the qualitative diversity of the outcomes and reported estimates.

We evaluated methodological quality of included studies using modified Jadad criteria,2 which were based on study description, randomisation procedure, concealment of allocation, and dropouts and intention to treat analysis. Blinding was not applicable.

Results

Pneumothorax surgery—Six trials compared video assisted thoracic surgery with conventional methods in 327 patients. In four studies video assisted thoracic surgery was compared with conventional thoracotomy and in two studies with pleural drainage. In the trials that reported this information the average age of participants was 34 years and 27% were women (table 1). Three trials reported the method of randomisation, and one study had a significant imbalance in the number of patients assigned in each group.3 All studies reported a reduced need for pain medication and three studies4^–6 reported significantly shorter hospital stays in patients in the intervention group (table 2). While Waller et al7 and Ayed et al6 reported more recurrences of pneumothorax in patients in the video assisted thoracic surgery group compared with thoracotomy group (6 ν 2 and 3 ν 0), Sekine et al reported three more cases of lung atelectasis (5 ν 2) for patients in the thoracotomy group compared with patients in the video assisted thoracic surgery group.8 Two studies that compared video assisted thoracic surgery with pleural drainage reported substantially fewer recurrences of pneumothorax in the intervention group (0 ν 8 in Abdala et al5 and 1 ν 10 in Tschopp et al3).

Minor resection—Three randomised studies that compared video assisted thoracic surgery with conventional thoracotomy enrolled 147 patients.9^–11 The average age was 50 years (in three trials) and 61% were women (in two trials). All three trials reported information about the method of randomisation, and two received the highest quality score.9 11 In two studies video assisted thoracic surgery was associated with reduced need for pain medication, shorter surgery time, and shorter length of stay.9 10 In the third study there were no differences with regard to all outcomes of interest, and video assisted thoracic surgery was associated with higher costs (over $C1000 (£431, $774, €632) more) (table 2).11

Lobectomy—Three trials looked at video assisted lobectomy and conventional lobectomy in 196 patients. The average age of patients in these studies was 63 years and 49% were women. None of the studies reported information on method of randomisation, and in two studies analysis was not based on intention to treat.12 13 Sugi et al found no difference in survival after video assisted thoracic surgery versus conventional surgery for lung cancer (90% ν 93% at three years and 90% ν 85% at five years).12 Two other studies13 14 reported information on outcomes of interest and found no substantial differences between the groups except for fewer air leaks found in the study by Kirby et al13 (table 2).

Discussion