WCLC 2019 – The use of video-assisted lung surgery reduces the complications of lobectomy

  • Elena Riboldi — Agenzia Zoe
  • Univadis
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  • Lobectomy by video-assisted thoracoscopic surgery (VATS) is associated with less pain, significantly lower in-hospital complications and a shorter length of stay compared to lobectomy by thoracotomy.
  • The use of keyhole surgery does not affect early oncologic outcomes (lymph node dissection, upstaging of mediastinal nodes, complete resection).


Why this matters

  • There is limited information from high quality randomised controlled trials on clinical efficacy, safety, and oncologic outcomes of VATS for lung cancer.


Study design

  • The VIOLET trial enrolled 503 patients with known/suspected lung cancer within cT1-3 cN0-1 M0 (TNM8).
  • Patients were allocated (1:1 ratio; stratification by operator) to VATS (1-4 ports) or open surgery; patients were blinded to allocation.
  • Lymph node dissection and pain management were standardised.
  • The primary outcome was physical function at 5 weeks.
  • Pain was assessed on day 1-2 through Visual Analogue Scale; the pain score was adjusted for amounts of analgesics.


Key results

  • Rates of benign resection, in-hospital mortality, and conversion to open surgery were 1.2%, 1.4%, and 6.4%, respectively.
  • Compared to patients in the open surgery arm, patients in the VATS arm had a lower pain score on day 2 (difference -0.49;  P=0.044).
  • Patients in the VATS arm experienced less in-hospital adverse events (32.8% vs 44.3%; RR 0.74; P
  • Intra-operative bleeding occurred in 6.2% of patients undergoing VATS and in 3.9% of patients undergoing open surgery.
  • The median length of stay was 4 days with VATS and 5 days with open surgery (HR for discharge 1.34; P=0.006).
  • Rates of complete resection were similar (97.4% with open surgery, 97.8% with VATS).
  • The number of lymph node stations harvested was identical (median 5; IQR 4-6).
  • Nodal upstaging from cN0/1 to pN2 disease was observed in 6.2% patients in the VATS arm and 4.8% patients in the open surgery arm (P=0.503).


  • UK National Institute for Health Research.

Expert commentary

“I think this is a well-designed and well-executed multi-institutional prospective trial. They clearly show that VATS is associated with fewer complications and decreased pain, while maintaining equivalent oncologic outcomes. I think that going forward we cannot accept thoracotomy as a standard of care for early-stage lung cancer.” Jessica S. Donington, MD, University of Chicago Medicine, USA.