Twenty years of video‐assisted thoracoscopic surgery: The past, present, and future

摘要

This November, the pioneers of video-assisted thoracoscopic surgery (VATS) gathered in Edinburgh at the 3rd International VATS lobectomy meeting to celebrate the 20th anniversary of VATS pulmonary resection. Experts in the field from the United States, China, and Europe shared their experiences and discussed the innovations and technologies that would see the technique prosper in the 21st century. The first VATS lobectomy was reported in Italy in 1991.1 Several other centers were quick to implement the technique and report successful early operative experience.2, 3 The overall uptake worldwide was modest over the following decade. In 2006, the STS database reported that 32% of lobectomies were performed via VATS,4 whilst here in the UK, acceptance of the technique was slower with only 13% of lobectomies being performed by VATS in 2011.5 Despite obvious potential advantages, adoption of the technique has been slow, which is attributed to several factors. Understandably, there were early concerns from surgeons regarding immediate and long-term outcomes, with oncological efficacy being an initial focus of interest. Furthermore, the technique itself is challenging and is considered to have a demanding learning curve. For others, issues of safety have been paramount and the risks of managing complications, such as massive hemorrhage, have been a source of deterrence. In light of what has now become an overwhelming body of evidence in support of the VATS approach, the above arguments have begun to lose credibility. At the time of writing, VATS has become a well-established technique for the treatment of early stage non-small cell lung cancer (NSCLC).6-9 There are many potential benefits of VATS resection, compared with a traditional muscle-splitting thoracotomy. Established examples include reduced length of hospital stay, decreased blood loss, decreased pain, improved cosmesis, earlier return to normal activities, and improved tolerance of chemotherapy.10-13 Additionally, a reduced level of inflammatory response and preserved immune function has been demonstrated following VATS resections.14, 15 Pulmonary function testing, at one and two weeks post-operatively, has demonstrated accelerated recovery of FEV1 and FVC in VATS lobectomy, compared to the open approach.16 Of even greater significance were the results from a recent systematic review and meta-analysis, of both randomized and non-randomized trials, demonstrating improved outcomes for VATS in relation to systemic recurrence and overall five-year survival when compared with open thoracotomy.17 Despite a multitude of retrospective comparative studies in support of the VATS approach, an ongoing hurdle has been the lack of a large randomized controlled trial (RCT) comparing VATS with open thoracotomy. Critics of the VATS approach have suggested that selection bias in the non-randomized retrospective studies may create a false positive finding of superior outcomes in support of VATS, as a result of patients who are considered more “favorable” being selected in the study group. To date, there exists two small RCT's in which the authors compared patients with NSCLC undergoing VATS lobectomy with resection via open thoracotomy.18, 19 One of the studies demonstrated a significant reduction in overall complications in the VATS group, while the other reported no significant differences in recurrence and survival rates. In addition to small patient numbers, it is noteworthy that rib spreading was performed in the VATS group of both studies, which does not conform to the current “gold standard” definition of VATS as reported in the CALGB study.20 Accordingly, these studies have not satisfied the demand for a large RCT and opinion is currently divided as to whether one is necessary. It also remains uncertain as to whether such a study remains feasible and, indeed, ethical. Recruiting VATS enthusiasts to participate in such a study and subject patients to what they believe to be an inferior