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Thoracoscopic Lobectomy is Associated with Lower Morbidity than Open Lobectomy: A Propensity-Matched Analysis from the STS Database
Subroto Paul1, Nasser K. Altorki1, Shubin Sheng2, Paul C. Lee1, David H. Harpole2, Mark W. Onaitis2, Brendon M. Stiles1, Jeffrey L. Port1, Thomas A. D'Amico2; 1Cardiothoracic Surgery, New York Presbyterian-Weill Cornell Medical Center, New York, NY; 2Duke University Medical Center, Durham, NC
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Objective: Thoracoscopic lobectomy, compared to thoracotomy, may be associated with fewer overall postoperative complications based on several single institution series. Propensity matching using a large national database may enable a more powerful and comprehensive analysis of postoperative outcomes.
Methods: All patients undergoing lobectomy as the primary procedure via thoracoscopy or thoracotomy were identified in the Society of Thoracic Surgeons (STS) prospective database from 2002-2007. After excluding patients with prior thoracic surgery, 6434 patients were identified (5134 thoracotomy, 1300 thoracoscopy). A propensity analysis was performed, incorporating preoperative variables using a greedy matching algorithm.
Results: Propensity scores were calculated based on age, sex, body mass index, functional status, medical co-morbidities, smoking status, pulmonary function tests, and preoperative therapy. Matching based on propensity scores produced 1281 patients in each group for analysis of postoperative outcomes. After thoracoscopic lobectomy, 73.8% (n=945) had no complications, compared to only 65.3% (n=847) after thoracotomy (p<0.0001). Compared to thoracotomy, thoracoscopic lobectomy was associated with a lower incidence of arrhythmias [93 (7.3%) v 147 (11.5%); p=0.0004], reintubation [18 (1.4%) v 40 (3.1%); p=0.0046], and blood transfusion [31 (2.4%) v 60 (4.68%); p=0.0028], as well as a shorter length of stay (4.00 v 6.00 days; p<0.0001) and chest tube duration (3.00 v 4.00 days; p<0.0001; Table). Thoracoscopic lobectomy required longer operative time (173 v. 143 minutes; p<0.05). There was no difference in operative mortality between the 2 groups.
Conclusion: Thoracoscopic lobectomy is associated with a lower incidence of many complications compared to thoracotomy. For appropriate candidates, thoracoscopic lobectomy may be the preferred strategy for patients with lung cancer.

TABLE
Postoperative Complications Thoracotomy (n=1281) Thoracoscopy (n=1281) p Value*
Atrial Arrhythmia, n (%) 147 (11.48) 93 (7.26) 0.0004
Reintubation, n (%) 40 (3.12) 18 (1.41) 0.0046
Blood Transfusion, n (%) 60 (4.68) 31 (2.42) 0.0028
No complications 847 (65.3) 945 (73.8) <0.0001
Air Leak >5 Days, n (%) 111 (8.67) 97 (7.57) 0.3531
Pneumonia, n (%) 56 (4.37) 38 (2.97) 0.0758
Atelectasis, n (%) 42 (3.28) 27 (2.11) 0.0722
Bleeding, n (%) 7 (0.55) 16 (1.25) 0.0931
DVT, n (%) 4 (0.31) 2 (0.16) 0.6875
Pulmonary Embolus, n (%) 3 (.23) 3 (.23) 1.000
Myocardial Infarct, n (%) 1 (0.08)1 (0.08) 1.000
Operative mortality n(%) 12 (0.94) 12 (1.01) 1.000
LOS (median), days 6.00 4.00 <0.0001
Chest Tube Duration (median), days 4.00 3.00 <0.0001
OR Time (median), minutes 143.00 173.00 <0.0001

* p-values are based on McNemar tests for categorical outcomes and Wilcoxon signed rank tests for continuous outcomes.
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