Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York.
Department of Population Health Science and Policy, Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, New York.
Ann Thorac Surg. 2018 Mar;105(3):886-891. doi: 10.1016/j.athoracsur.2017.09.059. Epub 2018 Feb 1.
Studies reporting the benefits of video-assisted thoracoscopic surgery (VATS) lung cancer resection over thoracotomy have been subject to selection bias. We evaluated patient and hospital characteristics associated with type of surgery and the independent effect of VATS on outcomes.
The Statewide Planning and Research Cooperative System of New York State database was queried to identify all lung cancer patients undergoing lobectomy or sublobar resection between 2007 and 2012. Multivariable logistic regression was performed to identify patient (age, sex, race, comorbidities, year, and insurance) and hospital (urban, teaching, and total lung surgery volume) cofactors associated with surgical technique and propensity scores were used to evaluate whether technique was independently associated with complications or in-hospital mortality.
There were 5,505 lobectomy and 4,282 sublobar resection patients, with 2,318 (42%) and 2,416 (56%) undergoing VATS, respectively. For lobectomy, VATS was associated with being female, lower comorbidity index, private insurance, older age, surgery in recent year, nonteaching hospital, and higher annual lung surgery volume. For sublobar resection, VATS was associated with black race, lower comorbidity index, Medicaid or other insurance, surgery in recent year, rural hospital, and higher annual lung surgery volume. Complication rate was significantly lower for VATS lobectomy and not sublobar resection, whereas in-hospital mortality was lower for VATS in both resection groups.
Numerous patient- and hospital-related variables that affect morbidity and mortality also affect whether a patient undergoes VATS or open lung resection. Studies evaluating VATS must account more accurately for selection bias and adjust for these confounders.
报道胸腔镜辅助（VATS）肺癌切除术优于开胸手术的益处的研究受到选择偏倚的影响。我们评估了与手术类型相关的患者和医院特征以及 VATS 对结果的独立影响。
纽约州全州规划和研究合作系统数据库被查询以确定在 2007 年至 2012 年间接受肺叶切除术或亚肺叶切除术的所有肺癌患者。多变量逻辑回归用于确定与手术技术相关的患者（年龄、性别、种族、合并症、年份和保险）和医院（城市、教学和总肺手术量）协变量，并使用倾向评分来评估技术是否与并发症或住院死亡率独立相关。
有 5505 例肺叶切除术和 4282 例亚肺叶切除术患者，分别有 2318 例（42%）和 2416 例（56%）接受了 VATS。对于肺叶切除术，VATS 与女性、较低的合并症指数、私人保险、年龄较大、近年手术、非教学医院和更高的年肺手术量相关。对于亚肺叶切除术，VATS 与黑人、较低的合并症指数、医疗补助或其他保险、近年手术、农村医院和更高的年肺手术量相关。VATS 肺叶切除术的并发症发生率显著低于非亚肺叶切除术，而 VATS 在两组肺切除术患者中的住院死亡率较低。
影响发病率和死亡率的众多患者和医院相关变量也影响患者是否接受 VATS 或开胸肺切除术。评估 VATS 的研究必须更准确地考虑选择偏倚，并调整这些混杂因素。
