Outcomes With Video-Assisted vs Open Surgery in Lung Cancer

Video-assisted thoracic surgery (VATS) results in fewer in-hospital complications and a shorter length of stay compared with open surgery in patients with early-stage lung cancer, according to study results presented at the International Association for the Study of Lung Cancer (IASLC) 2019 World Conference on Lung Cancer (WCLC) held in Barcelona.

“The VIOLET Trial is the largest randomized trial conducted to date to compare clinical efficacy, safety and oncologic outcomes of VATS versus open surgery for lung cancer,” said lead study author Eric Lim, MD, of Royal Brompton Hospital in London. “The study achieved its positive results without any compromise to early oncologic outcomes-pathologic complete resection and upstaging of mediastinal lymph nodes.”

After screening more than 2,000 patients, the investigators randomized 503 patients (mean age, 69 years; 50.5% women) to receive either VATS or open surgery at nine surgery centers in the United Kingdom. Patients who had VATS demonstrated a lower number of overall in-hospital complications than those who underwent open surgery (32.8% vs 44.3%). Moreover, VATS patients had a decreased length of stay, with 1 fewer day spent in the hospital.

VATS is a minimally invasive approach that can be used to diagnose and treat chest and lung disease by means of small incisions (eg, keyholes). With VATS, a small camera transmits images from inside the chest to a video monitor, which guides the surgeon. Open surgery (eg, thoracotomy), on the other hand, involves a long incision to the chest, with the ribs spread open to allow full visualization. Lobectomy, which entails the removal of a lung lobe, can be done on either lung using either technique.

Compared with open lobectomy, VATS is less painful and can be done without compromise to early oncologic outcomes (eg, upstaging of mediastinal nodes, lymph node dissection, and complete resection), and it causes more limited adverse events.

In the trial, lymph node harvesting was performed as recommended by IASCLC, and pain management was standardized in both groups. Patients and nurses were blinded to which surgical approach was taken by means of opaque dressings that covered the thoracotomy incisions. Lim noted that only 50% of patients could guess which type of surgery they had, which is the same as chance.

Lim described the additional benefits of VATS observed in the trial at the conference.

“We had very good surgical quality, we had a very low mortality rate, and a very low benign resection rate. Keyhole surgery was performed through three keyholes in the majority [of patients] and one keyhole in about 20% of patients,” Lim said.

“We had a very low conversion from keyhole to open surgery, and that’s a marker of the maturity of the keyhole technique. If the conversion rate was very high, then we would have concerns that keyhole surgeons weren’t that good. But in our study, our conversion rates were relatively low,” said Lim.