Minimally invasive lobectomy directed toward frail and high-risk patients: a case-control study

Background. To compare minimally invasive video-assisted thoracic surgery (VATS) with thoracotomy, cases were matched from a pool of pulmonary lobectomies performed by one surgeon who offered VATS for patients with unfavorable risk factors. Methods. A thoracotomy case was paired to each of 19 VATS cases by age, sex, lobe, side, and forced expiratory volume in 1 second. Eleven VATS and 5 thoracotomy patients with severe activity impairments or reduced forced expiratory volume in 1 second (< 1.5 L or 50% predicted) were classified as higher risk than the others. Results. Despite more high-risk cases, VATS yielded shorter hospitalizations (5.3 ± 3.7 versus 12.2 ± 11.1 days, p = 0.02), chest tube durations (4.0 ± 2.8 versus 8.3 ± 8.9 days, p = 0.06), and earlier returns to full preoperative activities (2.2 ± 1.0 versus 3.6 ± 1.0 months, p< 0.01). The VATS operations had no intraoperative complications and lasted 229 ± 59 minutes. Pain 3 weeks later was dramatically better for the VATS group (none or mild, 63% versus 6%; severe, 6% versus 63%; p< 0.01). Six complications or deaths occurred in each group and were related to forced expiratory volume in 1 second, steroid usage, age, active smoking, and upper lobe resection (p< 0.01). Three VATS deaths occurred only in elderly, performance status 3 patients, with two caused by gastrointestinal-related problems masked by steroid use. Conclusions. A VATS lobectomy is less painful and may offer faster recovery for the frail or high-risk patient. Further study, particularly of its safety in severely activity-impaired patients, is warranted.