Ng Calvin S H, MacDonald John K, Gilbert Sebastien, Khan Ali Z, Kim Young T, Louie Brian E, Blair Marshall M, Santos Ricardo S, Scarci Marco, Shargal Yaron, Fernando Hiran C
1 The Chinese University of Hong Kong, Shatin, China.
2 Western University, London, ON, Canada.
Innovations (Phila). 2019 Apr;14(2):90-116. doi: 10.1177/1556984519837027.
Video-assisted thoracic surgery (VATS) lobectomy was introduced over 25 years ago. More recently, the technique has been modified from a multiport video-assisted thoracic surgery (mVATS) to uniportal (uVATS) and robotic (rVATS), with proponents for each approach. Additionally most lobectomies are still performed using an open approach. We sought to provide evidence-based recommendations to help define the optimal surgical approach to lobectomy for early stage non-small cell lung cancer.
Systematic review and meta-analysis of articles searched without limits from January 2000 to January 2018 comparing open, mVATS, uVATS, and rVATS using sources Medline, Embase, and Cochrane Library were considered for inclusion. Articles were individually scrutinized by ISMICS consensus conference members, and evidence-based statements were created and consensus processes were used to determine the ensuing recommendations. The ACC/AHA Clinical Practice Guideline Recommendation Classification system was used to assess the overall quality of evidence and the strength of recommendations.
One hundred and forty-five studies met the predefined inclusion criteria and were included in the meta-analysis. Comparisons were analyzed between VATS and open, and between different VATS approaches looking at oncological outcomes (survival, recurrence, lymph node evaluation), safety (adverse events), function (pain, quality of life, pulmonary function), and cost-effectiveness. Fifteen statements addressing these areas achieved consensus. The highest level of evidence suggested that mVATS is preferable to open lobectomy with lower adverse events (36% versus 42%; 88,460 patients) and less pain (IIa recommendation). Our meta-analysis suggested that overall survival was better (IIb) with mVATS compared with open (71.5% versus 66.7% 5-years; 16,200 patients). Different VATS approaches were similar for most outcomes, although uVATS may be associated with less pain and analgesic requirements (IIb).
This meta-analysis supports the role of VATS lobectomy for non-small cell lung cancer. Apart from potentially less pain and analgesic requirement with uVATS, different minimally invasive surgical approaches appear to have similar outcomes.
电视辅助胸腔镜手术（VATS）肺叶切除术于25年多前问世。最近，该技术已从多端口电视辅助胸腔镜手术（mVATS）改进为单孔（uVATS）和机器人辅助（rVATS），每种方法都有其支持者。此外，大多数肺叶切除术仍采用开放手术方式。我们试图提供基于证据的建议，以帮助确定早期非小细胞肺癌肺叶切除术的最佳手术方法。
对2000年1月至2018年1月期间检索到的无限制文章进行系统评价和荟萃分析，比较开放手术、mVATS、uVATS和rVATS，纳入来源为Medline、Embase和Cochrane图书馆。文章由ISMICS共识会议成员逐一审查，并制定基于证据的陈述，通过共识过程确定后续建议。采用ACC/AHA临床实践指南推荐分类系统评估证据的总体质量和建议的强度。
145项研究符合预定义的纳入标准并纳入荟萃分析。分析了VATS与开放手术之间以及不同VATS方法之间在肿瘤学结局（生存、复发、淋巴结评估）、安全性（不良事件）、功能（疼痛、生活质量、肺功能）和成本效益方面的比较。针对这些领域的15项陈述达成了共识。最高级别的证据表明，mVATS优于开放肺叶切除术，不良事件发生率更低（36%对42%；88460例患者），疼痛更轻（IIa类推荐）。我们的荟萃分析表明，与开放手术相比，mVATS的总生存率更高（IIb类）（5年生存率71.5%对66.7%；16200例患者）。对于大多数结局，不同的VATS方法相似，尽管uVATS可能与更少的疼痛和镇痛需求相关（IIb类）。
这项荟萃分析支持VATS肺叶切除术在非小细胞肺癌治疗中的作用。除了uVATS可能疼痛和镇痛需求更少外，不同的微创手术方法似乎具有相似的结局。
