M. Hennon1,2, J. Xiao2, M. Huang1, E. Dexter1,2, A. Picone1,2, S. Yendamuri1,2, C. Nwogu1,2, W. Tan3, T. Demmy5 1Roswell Park Cancer Institute,Thoracic Surgery,Buffalo, NY, USA 2State University Of New York At Buffalo,Surgery,Buffalo, NY, USA 3Roswell Park Cancer Institute,Biostatistics,Buffalo, NY, USA 5Rutgers Cancer Institute Of New Jersey,Cardiothoracic Surgery,New Brunswick, NJ, USA
Introduction: Outcomes for thoracoscopic (VATS) lobectomy at the institutional level can be affected by numerous variables, including selection bias. The total percentage of cases completed by VATS for locally advanced nonsmall cell lung carcinoma may be an important component of individual program quality.
Methods: Over 11 years (from January 2002 to March 2013), 1289 consecutive lobectomies were performed, of which 300 were for patients with locally advanced NSCLC (tumors greater than 4cm, T3, T4, or patients who underwent induction chemotherapy). Patients requiring chest wall resection, sleeve lobectomy, or pneumonectomy were excluded. Cases were divided into three sequential groups of 100 patients for comparison. Reliability is defined as the total number of cases completed thoracoscopically (VATS) divided by all cases (VATS + Conversion+ Open). Conversion rates, percentage of cases completed by VATS, along with preoperative, perioperative and outcome variables were compared and analyzed by Mann-Whitney-Wilcoxon and Fisher’s exact tests. Estimated overall survival and disease free survival distributions were obtained using the Kaplan-Meier method.
Results: Of 300 cases during the study period, 219 were completed by VATS. VATS reliability increased from 62% (early), to 77% (middle), and 80% (late). Reliability increased due to a steady decrease in planned thoracotomy from 17%, to 9% and 2.1% respectively. A higher percentage of patients in the late group had more preoperative comorbidities (CAD/MI 27% vs. 19% vs. 42.6%, p = 0.0016). Median operative time increased over the study period from 225 min. [96-574] vs. 328 min. [115-687] vs. 340 min. [140-810], presumably due to approaching more complex tumor pathology. Median operative blood loss was the same for all groups at 200 mL (10-2200). Median postoperative ICU stay was 1 day (0-92) for all groups. Higher neoadjuvant therapy rates (16% vs. 54% vs. 50%, p <0.0001) were achieved in the middle/late groups. Fewer postoperative complications occurred in the middle and late time groups (any major complication was 38% vs. 13% vs. 16%, p < 0.0001; bleeding 23% vs. 4% vs. 6%, p < 0.0001; air leak 16% vs. 13% vs. 3%, p = 0.0037). Number of lymph nodes harvested during surgery (10.2 vs. 12.5 vs. 22.8, p <0.0001) improved significantly.
Conclusion: In our experience, VATS reliability increased over time with favorable perioperative and postoperative outcomes due to fewer cases being approached by planned thoracotomy. Since there were associations with factors like lymph node harvest, VATS reliability deserves additional study as an indicator of individual program achievement and as a tool to explain differences between VATS and open surgeries reported in large, cooperative databases.