Video assisted thoracic surgery for treatment of pneumothorax and lung resections: systematic review of randomised clinical trials
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《英国医生杂志》
1 Health Services Research Unit, Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London WC1E 7HT, 2 Cardiothoracic Unit, Guy's Hospital, London SE1 9RT
Correspondence to: T Treasure Tom.Treasure@ukgateway.net
Abstract
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
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 2 and 3 0), Sekine et al reported three more cases of lung atelectasis (5 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 8 in Abdala et al5 and 1 10 in Tschopp et al3).
Table 1 Characteristics of the randomised trials of video assisted thoracic surgery and conventional strategy
Table 2 Outcomes reported in the randomised trials of video assisted thoracic surgery (VATS) and conventional strategy
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% 93% at three years and 90% 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
Wakabayashi A. Expanded applications of diagnostic and therapeutic thoracoscopy. J Thorac Cardiovasc Surg 1991;102: 721-3.
Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 1996;17: 1-12.
Tschopp JM, Boutin C, Astoul P, Janssen JP, Grandin S, Bolliger CT, et al. Talcage by medical thoracoscopy for primary spontaneous pneumothorax is more cost-effective than drainage: a randomised study. Eur Respir J 2002;20: 1003-9.
Gebhard FT, Becker HP, Gerngross H, Bruckner UB. Reduced inflammatory response in minimal invasive surgery of pneumothorax. Arch Surg 1996;131: 1079-82.
Abdala OA, Levy RR, Bibiloni RH, Viso HD, De Souza M, Satler VH. . Medicina (B Aires) 2001;61: 157-60.
Ayed AK, Al-Din HJ. Video-assisted thoracoscopy versus thoracotomy for primary spontaneous pneumothorax: a randomized controlled trial. Med Principles Pract 2000;9: 113-8.
Waller DA, Forty J, Morritt GN. Video-assisted thoracoscopic surgery versus thoracotomy for spontaneous pneumothorax. Ann Thorac Surg 1994;58: 372-7.
Sekine Y, Miyata Y, Yamada K, Yamada H, Yasukawa T, Saitoh Y, et al. Video-assisted thoracoscopic surgery does not deteriorate postoperative pulmonary gas exchange in spontaneous pneumothorax patients. Eur J Cardiothorac Surg 1999;16: 48-53.
Santambrogio L, Nosotti M, Bellaviti N, Mezzetti M. Videothoracoscopy versus thoracotomy for the diagnosis of the indeterminate solitary pulmonary nodule. Ann Thorac Surg 1995;59: 868-71.
Ayed AK, Raghunathan R. Thoracoscopy versus open lung biopsy in the diagnosis of interstitial lung disease: a randomised controlled trial. J R Coll Surg Edinb 2000;45: 159-63.
Miller JD, Urschel JD, Cox G, Olak J, Young JE, Kay JM, et al. A randomized, controlled trial comparing thoracoscopy and limited thoracotomy for lung biopsy in interstitial lung disease. Ann Thorac Surg 2000;70: 1647-50.
Sugi K, Kaneda Y, Esato K. Video-assisted thoracoscopic lobectomy achieves a satisfactory long-term prognosis in patients with clinical stage IA lung cancer. World J Surg 2000;24: 27-31.
Kirby TJ, Mack MJ, Landreneau RJ, Rice TW. Lobectomy—video-assisted thoracic surgery versus muscle-sparing thoracotomy. A randomized trial. J Thorac Cardiovasc Surg 1995;109: 997-1002.
Craig SR, Leaver HA, Yap PL, Pugh GC, Walker WS. Acute phase responses following minimal access and conventional thoracic surgery. Eur J Cardiothorac Surg 2001;20: 455-63.
Rivas De Andres JJ, Freixinet Gilart J, Rodriguez De Castro F. . Arch Bronconeumol 2002;38: 60-3.
Margolis M, Gharagozloo F, Tempesta B, Trachiotis GD, Katz NM, Alexander EP. Video-assisted thoracic surgical treatment of initial spontaneous pneumothorax in young patients. Ann Thorac Surg 2003;76: 1661-4.
Hatz R, Kaps M, Meimarakis G, Loehe F, Muller C, Furst H. Long-term results after video-assisted thoracoscopic surgery for first-time and recurrent spontaneous pneumothorax. Ann Thorac Surg 2000;70: 253-7.
Cardillo G, Regal M, Sera F, Di Martino M, Carbone L, Facciolo F, et al. Videothoracoscopic management of the solitary pulmonary nodule: a single-institution study on 429 cases. Ann Thorac Surg 2003;75: 1607-12.
Jimenez MF. Prospective study on video-assisted thoracoscopic surgery in the resection of pulmonary nodules: 209 cases from the Spanish Video-Assisted Thoracic Surgery Study Group. Eur J Cardiothorac Surg 2001;19: 562-5.
Walker WS, Codispoti M, Soon SY, Stamenkovic S, Carnochan F, Pugh G. Long-term outcomes following VATS lobectomy for non-small cell bronchogenic carcinoma. Eur J Cardiothorac Surg 2003;23: 397-402.
Gharagozloo F, Tempesta B, Margolis M, Alexander EP. Video-assisted thoracic surgery lobectomy for stage I lung cancer. Ann Thorac Surg 2003;76: 1009-14.
Hazelrigg SR, Nunchuck SK, Landreneau RJ, Mack MJ, Naunheim KS, Seifert PE, et al. Cost analysis for thoracoscopy: thoracoscopic wedge resection. Ann Thorac Surg 1993;56: 633-5.(Artyom Sedrakyan, honorar)
Correspondence to: T Treasure Tom.Treasure@ukgateway.net
Abstract
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
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 2 and 3 0), Sekine et al reported three more cases of lung atelectasis (5 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 8 in Abdala et al5 and 1 10 in Tschopp et al3).
Table 1 Characteristics of the randomised trials of video assisted thoracic surgery and conventional strategy
Table 2 Outcomes reported in the randomised trials of video assisted thoracic surgery (VATS) and conventional strategy
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% 93% at three years and 90% 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
Wakabayashi A. Expanded applications of diagnostic and therapeutic thoracoscopy. J Thorac Cardiovasc Surg 1991;102: 721-3.
Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 1996;17: 1-12.
Tschopp JM, Boutin C, Astoul P, Janssen JP, Grandin S, Bolliger CT, et al. Talcage by medical thoracoscopy for primary spontaneous pneumothorax is more cost-effective than drainage: a randomised study. Eur Respir J 2002;20: 1003-9.
Gebhard FT, Becker HP, Gerngross H, Bruckner UB. Reduced inflammatory response in minimal invasive surgery of pneumothorax. Arch Surg 1996;131: 1079-82.
Abdala OA, Levy RR, Bibiloni RH, Viso HD, De Souza M, Satler VH. . Medicina (B Aires) 2001;61: 157-60.
Ayed AK, Al-Din HJ. Video-assisted thoracoscopy versus thoracotomy for primary spontaneous pneumothorax: a randomized controlled trial. Med Principles Pract 2000;9: 113-8.
Waller DA, Forty J, Morritt GN. Video-assisted thoracoscopic surgery versus thoracotomy for spontaneous pneumothorax. Ann Thorac Surg 1994;58: 372-7.
Sekine Y, Miyata Y, Yamada K, Yamada H, Yasukawa T, Saitoh Y, et al. Video-assisted thoracoscopic surgery does not deteriorate postoperative pulmonary gas exchange in spontaneous pneumothorax patients. Eur J Cardiothorac Surg 1999;16: 48-53.
Santambrogio L, Nosotti M, Bellaviti N, Mezzetti M. Videothoracoscopy versus thoracotomy for the diagnosis of the indeterminate solitary pulmonary nodule. Ann Thorac Surg 1995;59: 868-71.
Ayed AK, Raghunathan R. Thoracoscopy versus open lung biopsy in the diagnosis of interstitial lung disease: a randomised controlled trial. J R Coll Surg Edinb 2000;45: 159-63.
Miller JD, Urschel JD, Cox G, Olak J, Young JE, Kay JM, et al. A randomized, controlled trial comparing thoracoscopy and limited thoracotomy for lung biopsy in interstitial lung disease. Ann Thorac Surg 2000;70: 1647-50.
Sugi K, Kaneda Y, Esato K. Video-assisted thoracoscopic lobectomy achieves a satisfactory long-term prognosis in patients with clinical stage IA lung cancer. World J Surg 2000;24: 27-31.
Kirby TJ, Mack MJ, Landreneau RJ, Rice TW. Lobectomy—video-assisted thoracic surgery versus muscle-sparing thoracotomy. A randomized trial. J Thorac Cardiovasc Surg 1995;109: 997-1002.
Craig SR, Leaver HA, Yap PL, Pugh GC, Walker WS. Acute phase responses following minimal access and conventional thoracic surgery. Eur J Cardiothorac Surg 2001;20: 455-63.
Rivas De Andres JJ, Freixinet Gilart J, Rodriguez De Castro F. . Arch Bronconeumol 2002;38: 60-3.
Margolis M, Gharagozloo F, Tempesta B, Trachiotis GD, Katz NM, Alexander EP. Video-assisted thoracic surgical treatment of initial spontaneous pneumothorax in young patients. Ann Thorac Surg 2003;76: 1661-4.
Hatz R, Kaps M, Meimarakis G, Loehe F, Muller C, Furst H. Long-term results after video-assisted thoracoscopic surgery for first-time and recurrent spontaneous pneumothorax. Ann Thorac Surg 2000;70: 253-7.
Cardillo G, Regal M, Sera F, Di Martino M, Carbone L, Facciolo F, et al. Videothoracoscopic management of the solitary pulmonary nodule: a single-institution study on 429 cases. Ann Thorac Surg 2003;75: 1607-12.
Jimenez MF. Prospective study on video-assisted thoracoscopic surgery in the resection of pulmonary nodules: 209 cases from the Spanish Video-Assisted Thoracic Surgery Study Group. Eur J Cardiothorac Surg 2001;19: 562-5.
Walker WS, Codispoti M, Soon SY, Stamenkovic S, Carnochan F, Pugh G. Long-term outcomes following VATS lobectomy for non-small cell bronchogenic carcinoma. Eur J Cardiothorac Surg 2003;23: 397-402.
Gharagozloo F, Tempesta B, Margolis M, Alexander EP. Video-assisted thoracic surgery lobectomy for stage I lung cancer. Ann Thorac Surg 2003;76: 1009-14.
Hazelrigg SR, Nunchuck SK, Landreneau RJ, Mack MJ, Naunheim KS, Seifert PE, et al. Cost analysis for thoracoscopy: thoracoscopic wedge resection. Ann Thorac Surg 1993;56: 633-5.(Artyom Sedrakyan, honorar)