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Do We Still Need a Randomized Prospective Trial Comparing VATS to Open Lobectomy?
Thomas J. van Brakel, Ad F. Verhagen.
Radboud University Nijmegen Medical Center, Nijmegen, Netherlands.

OBJECTIVE: Lobectomy by video-assisted thoracic surgery (VATS) has become a widely adopted treatment for early stage non-small cell lung cancer. However, the percentage of VATS over OPEN lobectomies remains less than 40%, with a considerable variation between centers. Furthermore, a guideline indicating a preferential procedure is still lacking. The objective of this study was to evaluate the evidence comparing VATS to OPEN lobectomy and to investigate the need for a randomized controlled trial (RCT).
METHODS: We performed a systematic review of the available literature from 1994 to present. All studies comparing VATS lobectomy with OPEN surgery (thoracotomy) for non-small cell lung cancer (stage I/IIa) with data on oncologic completeness of resection, hospital length of stay (LOS), postoperative complications and quality of life, were included. 880 references were identified and after systematic exclusion of irrelevant studies, 190 were abstracted by two independent reviewers. Two RCTs and 48 observational studies were selected for data extraction.
RESULTS: 33 of 48 were retrospective studies without case matching (69%). In 14 studies a historical control group was used (29%). Conversion to thoracotomy was reported in 11 studies (22%) and 45 out of 50 studies (including both RCTs) did not follow an intention to treat principle. Both RCTs (1995, n=61 and 2013, n=66) reported no differences on primary endpoints (LOS/complications and number of lymphnodes/stations respectively). Ten studies (20%) reported on number of dissected lymph nodes/stations or completeness of resection. Only 3 studies reported data on functional outcome or quality of life. Overall (50 studies), VATS compared to open lobectomy was associated with a shorter median LOS (5.1 versus 7 days). Postoperative complication rate as composite endpoint was lower for VATS compared to open lobectomy (median 27 versus 39%).
CONCLUSIONS: Although VATS lobectomy has become a common procedure in many centers, the available evidence is based on comparative non randomized cohort- and patient control studies, resulting in imbalanced patient groups. To recommend VATS lobectomy as a standard of care, randomized controlled trials are necessary both with regard to functional- and oncologic outcome. Currently we conduct a multi-centre RCT (SCOPE trial, NCT01933828) comparing VATS to OPEN lobectomy.

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