VATS-Lobectomy: Ready for Routine Use in Stage 1 and 2 Non-Small Cell Lung Cancer?

Objective: Video-assisted thoracic lobe resections (VATS-Lobectomy) has been criticized for the therapy of stage 1 and 2 non-small cell lung cancer (NSCLC), especially in Germany. The main concerns are that VATS-Lobectomy presents a highly specialized procedure often performed by individual thoracic surgeons with long learning curves, extended operating times and missing oncological accuracy leading to omission of mediastinal stage 2 lymph node (N2) dissections. The aim of the study is to systematically analyze these concerns in our patient population.

Methods: In this multicenter retrospective study, we systematically analyzed 197 VATS-Lobectomies performed by 5 different surgeons in 3 centers (Dessau, Halle and Jena) during a period of 3 years (2013–2015). All operations were performed in the same standardized tri-portal VATS technique. The analysis focused on the impact of the learning curve, the different surgeons, the operating times and the accuracy of lymph node dissection.

Results: Patients presented with typical baseline characteristics regarding age (66.4 ± 9.8 years), gender (male: 73,6%), number of co-morbidities (3.1 ± 1.6) and lung function (FEV1 2,34l, min-max: 0,85–4,23l) for patients with NSCLC. In hospital mortality was 0%. There were 4 (2,0%) conversions to open resection, due to intraoperative bleeding (1) or pleural adhesions (3). Postoperative complications occurred in 11,2% (n = 22) of the cases requiring a reexploration mainly for lung fistula (n = 14) or hematothorax (n = 6). Operating time was 166 ± 51 minutes without major differences between the individual surgeons. In all cases, lymph node dissection was performed according the ESTS guidelines. An average of 16,2 ± 6,3 lymph nodes were dissected, therefrom 4.1 ± 1.8 stage 2 lymph nodes (N2). Station 7 was dissected in 89,8%. Inter-surgeon comparison showed similar results for lymph node dissection and complication rates. In the course of the observation period, complication rates declined, suggesting a learning curve influence.

Conclusion: VATS-Lobectomy represents a safe and oncologically accurate procedure for the therapy of stage 1 and 2 NSCLC. The operative technique is reproducible by several surgeons. Influence of a slight learning curve is visible. We suggest that VATS-Lobectomy may be considered a routine operative strategy for the treatment of stage 1 and 2 NSCLC.