| BACKGROUNDThe malignant tumor which is originated from the lung & bronchial epithelium is called lung cancer. In recent years, the incidence and mortality of lung cancer has been increasing obviously. The latest analysis of the data from Surveillance, Epidemiology, and End Results (SEER) program indicated that the incidence of lung cancer during 2008 and 2012 in male is 76.7/100,000, the second place next to prostate cancer in all male cancers, as well as 54.1/100,000, the second one after breast cancer in female cancers. Meanwhile, the mortality is 59.8/100,000 in male and 37.8/100,000 in female, which are both the most common one. Therefore, lung cancer has been the one of the most serious threat to human in all the cancers all around the world.Currently, surgery predominant comprehensive therapy is the only potential therapy to cure lung cancer. Since 1933, when Dr. Evarts Graham firstly performed left pneumonectomy to cure a patient with left lung cacner, after more than 80 years development, lobectomy with hilar and mediastinal lymph node dissection has been the standard procedure. However, the surgical approaches have been improved radically.The original approach was open surgery, which was underwent through posterolateral thoracotomy. The length was about 30cm, with the Latissimus dorsi and the Serratus anterior be both dissected. Despite that the good operative visual field could be obtained, as well as operative time be short, invasiveness is huge, resulting in severe postoperative pain or upper extremity disorders. With the long-term accumulation of experience on lobectomy using traditional thoracotomy, in 1980s, muscle sparing thoracotomy became fashionable for a time. The approach didn’t spilt the Latissimus dorsi, the length of incision be shorter. However, operative visual field would be not as good as the posterolateral thoracotomy. Despite that, the muscle sparing thoracotomy could be regarded as the eve of minimally invasive thoracic surgery. Until the early of 1990s, the use of thoracoscopy truly opened the era of minimally invasive thoracic surgery. The original use of thoracoscopy is mainly as the intrathoracic lighting, or as an assisted tool to help hand the chest top and costophrenic angle. From that time, the term Video-assisted Thoracoscopic Surgery (VATS) is used. After that, the approach was evolved to assisted VATS, which meaning shorter length of incisions and more visualization of video screen. In fact, it is the primary development stage of VATS lobectomy in the world. In 2006, professor Mckenna and his colleagues reported more than 1,200 cased of successful multiport complete VATS lobectomy, which directly leading to that the NCCN guide adept the complete VATS lobectomy as the radical surgery approach for early-stage NSCLC lung cancer in 2006. Until now, the multiport VATS lobectomy remains to be the most commonly used approach. Nevertheless, from 2012, the uniportal VATS approach which was reported by Gonzalez-Rivas stimulates academic research boom all around the world now again.Because of that the uniportal VATS lobectomy is a latest technique, the published research findings now are limited. Firstly, the comparisons of uniportal VATS with other approaches in perioperative results were limited, as well as the controversial conclusions be obtained. Secondly, the medical model is transferring from the biomedical model to the socio-psycho-biological model. Nowadays, the psychology of patients is gradually emphasized by people. Moreover, published studies indicated that the longer long-term survival rate is correlated to better postoperative quality of life. Quality of life scales are the tools to system evaluate the quality of life of patients. In the field of surgical therapy of lung cancer, the major of the comparison of QOL is focused on open surgery and VATS approach. There is no study about the QOL after uniportal VATS lobectomy up to now.OBJECTIVETo evaluate the difference of postoperative pain, short-term recovery, and quality of life after assist video assisted thoracoscopic surgery, complete video assisted thoracoscopic surgery and uniportal video assisted thoracoscopic surgery in patients with early stage Non-small Cell Lung Cancer.METHODSProspective and retrospective analysis of the NSCLC patients who underwent VATS lobectomy with hilar and mediastinal lymph node dissection in our department during October,2014 to October,2015 were performed. According to the VATS approaches received, patients were divided into 3 groups:Assisted VATS, Multiport complete VATS, and Uniportal VATS.In part 1, Preoperative general situation and operation time, intraoperative blood loss, postoperative drainage time, total volume of postoperative drainage, postoperative hospital stay, VAS pain score of preoperative 1st day and postoperative 3rd day,7th day and 1 month, the white blood count (WBC) and the c-reactive protein (CRP) of preoperative and postoperative 1st,3rd,5th,7th days were all recorded and analyzed.Data were expressed as mean values±standard error. One-way factorial ANOVA and multiple comparison tests were employed to test the statistical significance of differences between mean values among the three groups when data presented as normally distributed. Non-normal data were compared with the Kruskal-Wallis test. Categorical data were analyzed with Fisher’s exact test, or the x2 test for trend where appropriate.In part 2, we used the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Lung Cancer 43, Chinese Version (EORTC QLQ-LC43-CN) to evaluate the QOL of patients in preoperative 1st day,1 month postoperatively and 3 month postoperatively.The QOL scores were presented as a mean. The preoperative QOL is the baseline. Student t test is used to o test the statistical significance of differences between 1 month postoperatively and baseline, as well as 3 month postoperatively. A Student’s t-test was used to compare parametric QoL data between groups. The Man-Whitney U-test is performed to compare non-parametric QoL data between groups. One-way factorial ANOVA and multiple comparison tests were employed to test the statistical significance of differences between mean values among the three groups when data presented as normally distributed. Categorical data were analyzed with the x2 test.A two-tailed p<0.05 was considered statistically significant. Data analysis was performed using the Statistical Package for the Social Science software (version 21.0; SPSS Inc, Chicago, IL).RESULTSPart 1A total of 180 patients with lung cancer received VATS lobectomy at our unit. Six patients were excluded because of conversion to open surgery. Nine patients were excluded for the reason of suffered from preoperative pain. According to the surgical approaches, the remaining eligible 165 patients were divided into a-VATS (n=58), c-VATS (n=56), and u-VATS (n=51) group.Age, gender, pathological type, operation time, postoperative drainage time, total volume of postoperative drainage, postoperative hospital stays were all no significant difference among 3 groups. Intraoperative blood loss is significant difference among 3 groups. A-VATS group is more than c-VATS group, while c-VATS group is more than u-VATS group (p=0.002).The VAS assessments of three groups are all low. It is significant lower in u-VATS group than a-VATS group at 3 days,1 week, and 1 month postoperatively (all p<0.01). At 1 week postoperatively, VAS score was higher in a-VATS group than c-VATS group, while c-VATS group is higher than u-VATS group (both p<0.05). Dezocine used during hospitalization is the largest in a-VATS compared with the other 2 groups (p<0.05). There are 6 patients need additional Pethidine in a-VATS group (mean dose,0.075g). Meanwhile, the number of pethidine used in c-VATS (mean dose,0.05g) and u-VATS (mean dose,0.05g) groups is 1 and 1, respectively.The peak of serum inflammatory marker the white blood count (WBC) is at 1 day postoperatively in all 3 groups. Meanwhile, the peak of the C-reaction protein (CRP) is at 3 day postoperatively in all 3 groups. WBC in the a-VATS group is significant higher than in the u-VATS group at 1, and 3 days postoperatively (p<0.05). CRP in a-VATS group is significant higher than in c-VATS group and u-VATS group (p<0.01), while CRP in c-VATS group is significant higher than u-VATS group at 1 day postoperatively (p<0.01). The same situation is observed at 3 day postoperatively. Meanwhile, CRP in a-VATS group is significantly higher than in u-VATS group at 5 day postoperatively (p<0.01).Part 2138 eligible patients with NSCLC were enrolled in this part. According to the practical VATS approaches received, patients were divided into 3 groups:Assisted VATS (n=44), Multiport complete VATS (n=42), and Uniportal VATS (n=50).The Quality of Life at preoperative 1st day among 3 groups showed no significant difference. The QoL at 1 month,3 month postoperatively showed no significant differences, too.Assisted VATS group:44 eligible questionnaires were received on the preoperative 1st day.40 eligible questionnaires were received on the 1 month postoperatively (follow up rate:90.9%).36 eligible questionnaires were received on the 3 month postoperatively (follow up rate:81.8%). At the 1st month postoperatively, physical function (p=0.000), role function (p=0.000), social function (p=0.036) were all damaged. Patients-reported global QoL was decreased (p=0.000). Economic difficulties was increased (p=0.001). Meanwhile, patients would be suffered from more pain in general (p=0.000), dyspnea (p=0.000), chest pain (p=0.001), and cough (p=0.005). At 3rd month postoperatively, social function and cough have been recovered. The remaining domains were physical function (p=0.001), role function (p=0.009), global QoL (p=0.001), economic difficulties (p=0.020), pain in general (p=0.000), dyspnea (p=0.010), chest pain (p=0.027).Three ports complete VATS group:42 eligible questionnaires were received on the preoperative 1st day.38 eligible questionnaires were received on the 1 month postoperatively (follow up rate:90.5%).36 eligible questionnaires were received on the 3 month postoperatively (follow up rate:85.7%). At the 1st month postoperatively, physical function (p=0.003), role function (p=0.000) were both damaged. Patients-reported global QoL was decreased (p=0.001). Economic difficulties was increased (p=0.00). Meanwhile, patients would be suffered from more pain in general (p=0.000), dyspnea (p=0.022), chest pain (p=0.000), and cough (p=0.030). At 3rd month postoperatively, physical function and role function have been recovered. The remaining domains were global QoL (p=0.022), economic difficulties (p=0.011), pain in general (p=0.048), dyspnea (p=0.037), chest pain (p=0.005).Uniportal VATS group:50 eligible questionnaires were received on the preoperative 1st day.48 eligible questionnaires were received on the 1 month postoperatively (follow up rate:96.0%).41 eligible questionnaires were received on the 3 month postoperatively (follow up rate:82.0%). At the 1st month postoperatively, physical function (p=0.000), role function (p=0.000) were both damaged. Patients-reported global QoL was decreased (p=0.000). Economic difficulties was increased (p=0.000). Meanwhile, patients would be suffered from more pain in general (p=0.000), dyspnea (p=0.001). At 3rd month postoperatively, global QoL, physical function and role function have been recovered. The remaining domains were economic difficulties (p=0.000), pain in general (p=0.032), dyspnea (p=0.010), chest pain (p=0.024).CONCULSIONS1. Postoperative pain in uniportal VATS was less than assisted VATS, as well as be similarity to three ports complete VATS. However, there is a trend that uniportal VATS may be better than three ports complete VATS in pain.2. The invasiveness of assisted VATS, three ports VATS, and uniportal VATS was decreased.3. The Quality of Life was damaged similarity in all three VATS approaches. However, the recovery of QoL is faster in uniportal VATS than the other 2 groups.In conclusion, uniportal VATS lobectomy is a safe and feasible approach. It has large advantage when compared to assisted VATS, as well as a certain advantage when compared to three ports complete VATS. Nevertheless, Large and randomized prospective trials are needed to clarify any of the differences between the three ports complete VATS and uniportal VATS approach in the future. |
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