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.
Division of Cardiothoracic Surgery, University of Missouri, Columbia 65212, USA. demmyt@health.missouri.edu
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D000368:Aged; D016022:Case-Control Studies; D004724:Endoscopy; D005260:Female; D005541:Forced Expiratory Volume; D006801:Humans; D007431:Intraoperative Complications; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures; D011013:Pneumonectomy / Q000379:methods; D011183:Postoperative Complications; D012189:Retrospective Studies; D012307:Risk Factors; D013908:Thoracotomy; D014741:Video Recording