HEA 3102 Research Methods: VATS vs Thoracotomy Lobectomy

This research report critically appraises published studies comparing video-assisted thoracic surgery (VATS) and thoracotomy for lobectomy in lung cancer patients. It investigates risk factors, cost-effectiveness, and early postoperative complications, including quality of life. While VATS is often limited to stage 1A non-small cell lung cancer (NSCLC) with limited lymph node dissection, existing literature suggests it is associated with fewer postoperative complications and shorter hospital stays compared to thoracotomy. The report aims to establish a standardized, evidence-based approach to lobectomy, potentially benefiting patients. It reviews studies from 2014-2019, highlighting the benefits and risks of both approaches, including reduced morbidity and mortality rates with VATS. The report also acknowledges limitations, such as selection bias and the need for more randomized trials, while considering the implications for UK NHS trust hospitals.

Video-Assisted Thoracic Surgery versus Open Thoracotomy for lobectomy for lung cancer:
- Is standardizing minimal access surgery beneficial for patients?
Introduction: -
The aim of this research proposal is to compare video-assisted thoracic surgery (VATS) and
thoracotomy, the best surgical resection technique for lobectomy for lung cancer. VATs
lobectomy and thoracotomy lobectomy operations are commonly done around the world, but
still carry significant risks (Falk & Williams, 2009). In this research proposal assignment, the
author will critically appraise published research studies and will investigate risk factors
during surgery, cost-effectiveness, an early postoperative complication such as quality of life
following VATs lobectomy compared to thoracotomy (open) lobectomy (Chunhua et al
2015). Despite the fact that VATS is restricted for patients with stage 1A non- small cell lung
cancer (NSCLC) and limited lymph node dissection as compared to thoracotomy lobectomy,
the literature findings analyze that VATs lobectomy is associated with less postoperative
complications, and shorter hospital stay compared to thoracotomy (open) lobectomy (Higuchi
et al, 2014., Rachel et al, 2015).
The purpose of this research proposal is to gain a better understanding of the best surgical
procedure for lobectomy between VATS and thoracotomy. VATS lobectomy is believed to
have fewer post-operative complications results, require a shorter hospital stay and cause less
pain for patients as there are no ribs spreading. However, there is no standard approach for
lobectomy and it mainly depends on the surgeon's preference whether to choose VATs or
thoracotomy approach.
1 Sadaf Naveed

In this research proposal, the author is aiming to set a standardized approach and evidence-
based practice from which patients can benefit the most. The objective is to compare the
overall survival and disease-free survival between two well-matched groups of patients who
had lobectomy for NSCLC by VATs or thoracotomy.
Background: -
The Code (NMC, 2016), suggests that the nurses should stay up to date with their knowledge
and skills to maintain a safe and effective practice and be in a position of delivering high
standard and evidence-based care. The research will help the nurses advance in their field
and stay updated thus enabling them to deliver quality nursing healthcare services to their
patients. Although, nursing profession is a consumer of nursing research, in order to have
knowledge of evidence-based practice and skills (hands-on experience) will allow the nurse
to theorize, hypothesize, structure studies and collect evidence that can take crucial part in
improving patient care and implement the best surgical approach for patients who are to
undergo lobectomy.
Literature review
2 Sadaf Naveed

Definition of terms
“Cancer is defined as an abnormal growth of cells which tend to divide and grow in an
uncontrolled way and in some cases, to metastasize (spread to other organs)” (Falk and
Williams, 2009). Lung cancer is the most common cause of cancer in the UK and worldwide
and it is the most common cause of death (Leary, 2012).
Lobectomy (lobe resection), is the most common surgery for lung cancer which provides long
term survival for early-stage cancer (Higuchi et al, 2014) and can be performed using VATs
or thoracotomy approach (Ondrejicka and Goldstein, 2014).
A VATs lobectomy is a minimal invasive thoracic surgical procedure where one of the lung
lobes is removed using 10mm 30-degree thoracoscopic instrument and a straight endoscopic
instrument.
A thoracotomy lobectomy is an open surgical procedure in which surgeons make a surgical
incision into the chest wall by making a cut between the ribs and gain access to the thoracic
organs including lungs. The lung’s lobe can then be removed (Chunhua et al 2015).
3 Sadaf Naveed

Literature review
Discover more and Athens were searched for articles published between 2014 and 2019. In
order to include articles for literature review based on VATS lobectomy versus thoracotomy
lobectomy for NSCLC. For selection and screening details refer to appendix table 1 & 2.
Lung cancer resection is the best treatment for NSCLC (Leary, 2012). However, the best
approach for lobectomy is still debated. The purpose of critical research articles will enable
the author to stay up to date with evidence-based practice and to provide regular and high
standard quality care (Hoe & Hoare, 2012). This review is to increase the author's knowledge
and understanding of the chosen topic as she is new to thoracic surgery. Also, to critically
evaluate some of the studies that have previously been done ending up identifying the
benefits and risks of post-operative VATS lobectomy and thoracotomy lobectomy. Video-
assisted thoracoscopic surgery (VATs) has been performed since the early 1990s but its
adoption has been slow, despite its advantages (Paul, 2014). Several previous studies/ articles
of qualitative and quantitative have compared the effectiveness of both VATS lobectomy and
thoracotomy lobectomy. For effective critical appraisal research articles, the author will be
using CASP (critical appraisal skill program, 2018).
Higuchi (2014), studied patients who had lobectomy via VATs and thoracotomy. This was a
retrospective quantitative study for the patients who suffered from Stage 1A Non- Small Cell
Lung Cancer and had lobectomy through either approach VATs or thoracotomy between
2002- 2012. Patients age was between 60- >70 years old. “In this study 160 patients
participated, from which 114 patients underwent lobectomy by VATs approach and 46
patients underwent thoracotomy” (Higuchi, 2014: pp 88).
4 Sadaf Naveed

This quantitative study showed 5 years of disease-free survival, “VATs was 88.0% and
thoracotomy was 77.1%. 5 years overall survival showed 94.1% for VATs and 81.8% for
thoracotomy” (Higuchi, 2014: pp 88). Following this research material Higuchi (2014),
concluded that video-assisted thoracoscopic surgery (VATS), is feasible and safe without
perioperative chemotherapy or radiotherapy in stage 1A NSCLC.
Moreover, quantitative research developed over the past two decades has stated that VATS
has reduced morbidity and mortality rates and mainly short- term advantages compared to
thoracotomy lobectomy. These advantages include fewer complications, decreased post-
operative pain, improved lung function, shorter recovery periods i.e. shorter hospital stay
which leads to reduced cost. VATS is specifically beneficial in elderly patient >70 years.
Early administration of adjuvant therapy such as chemotherapy or radiotherapy is beneficial
for patients (Higuchi, 2014, Rachel et at, 2016, Tcherveniakov et al., 2017 & Augustin et al.,
2016).
However, some studies are still uncertain about long term efficacy for both approaches
(Rachel et al, 2016). It has also been stated that there has been selection bias during this study
when diagnosing patients who suffer from clinical stage 1A NSCLC. For example, female
patients who suffer from small adenocarcinomas are preferably considered for VATs
lobectomy than male patients who suffer from squamous cell carcinoma due to the patient
might emphysematous lungs and could have non- specific lymph node enlargement in a
patient who is a heavy smoker. These reasons may increase complications during VATs
surgery (Higuchi, 2014 & Rachel et al, 2015).
.
5 Sadaf Naveed

Even though the number of lymph node dissection for both the two groups in the research has
not been evaluated for its stated that nodal upstaging was more common in thoracotomy
lobectomy compare to VATs lobectomy patients with clinical stage 1A NSCLC.
Rachel et al, 2016. Stated in her research article that, survival for node-negative lung cancer
post-operatively depends on the numbers of lymph node evaluated. Higher numbers of lymph
nodes resected provide more complete staging and reduce the likelihood of metastasis of the
lymph nodes. Based on multiple centers in USA research findings, nodal staging is
commonly done in thoracotomy lobectomy and lymph nodes dissection. It lacked enough
accuracy in VATS lobectomy compared to an open approach. Additionally, unplanned 30
days readmission was also higher in VATS lobectomy than thoracotomy lobectomy. Hence
there is no difference in survival rate for both approaches.
There were 39 studies which were reviewed by Whilston et al (2008) and found that after
comparing patient’s who underwent VATS lobectomy and thoracotomy lobectomy there 5
years survival rates were similar. Although Yan et al, (2009), disagreed with this after
performing a systematic review and found that 5 years survival rates were significantly
higher in a patient who underwent VATS lobectomy compared to open approach.
The SEER-Medicare database analyses long term survival for VATs lobectomy versus
thoracotomy lobectomy from 2007 to 2009. According to this propensity-matched analysis
overall, cancer-specific and disease-free survival are similar in VATs lobectomy compared to
thoracotomy lobectomy (Paul et al, 2014).
6 Sadaf Naveed

In another research article, Zhang and Ferguson, (2015), analyzed a systematic literature
review and meta-analysis of data in San Francisco which stated that patients who suffer high
risks of having compromised pulmonary and cardiopulmonary functions can benefit from
minimally invasive surgery. The database was gathered from PubMed and Scopus which was
published between 2000- 2013. There were 3 case-control studies and 3 case series which
were included. A total number of 620 patients who suffer from clinical stage 1A NSCLC, 330
patients underwent VATs and 257 patients had lobectomy via thoracotomy. A literature
review and meta-analysis showed that operative mortality from VATs “2.5% and open 7.8%,
overall morbidity 39.3% and open 57.5% and pulmonary morbidity 26.2% and 45.5 %”
(Zhang and Ferguson, 2015: pp 1). Thoracoscopic lobectomy patients post- operatively
experienced lower pulmonary morbidity and it reduces operative mortality, but there are no
significant differences in overall morbidity. Its also stated that older patients can benefit more
from VATs (Zhang and Ferguson, 2015).
Additionally, Augustin et al. (2015), analyzed in his research article the causes, predictors,
and consequences of thoracotomy conversion from VATs due to complications, such as
bleeding adhesion due to pleuritis, patients who had radiotherapy for other tumors and limited
space, etc. The reason for conversion rate was due to patient age, lymph node staging, body
mass index and due to patients suffering from chronic obstructive pulmonary disease, lung
function or benign disease. From VATs to thoracotomy conversion significantly increase
patient's hospital stay. However, the overall postoperative complication rate, chest drain
duration, and in-hospital mortality were not affected. Another small randomized evaluated no
difference in lymph node staging with VATs compared to thoracotomy (Ellis, 2014).
7 Sadaf Naveed

Even though VATs resection surgery has been done since 1990s and some thoracic surgeons
considered this technique as ‘gold standard’ for the management of early-stage cancer
disease, the adoption it has been adopted slowly by the thoracic surgeons. This could be due
to intraoperative safety, long- term oncological concerns and a lack of agreement on how this
procedure should be added into a training program.
The Leeds Teaching Hospital NHS Trust, UK organized a training program for 2 thoracic
assistant registrars for 6 months period. The assistant operating surgeon played a vital role in
the VATs procedures and provided a wider view of the field by holding a camera and
anticipated requirements of the surgeon. There were 22 VATs lobectomies which were
performed for stage 1A NSCLC. The outcome of this study was good. There was no post-
operative mortality and no conversion to thoracotomy. However, 4 patients suffered from
atrial fibrillation and 3 patient had prolonged air leak.
Limitation of literature review
The literature analysis has several limitations and several outstanding questions that not been
answered by the literature review. The implication of VATs approach is challenging and
unfavorable by surgeons. However, there are some articles highlighted that some thoracic
surgeons like VATs approach for lobectomy for early-stage cancer to be ‘gold standards.
There is also a lack of randomized and recent trail. The non- randomized trials reliability is a
question as there is a risk for errors the effect the outcomes of the trial (Hoe & Hoare, 2012).
Most research has taken place outside the UK which might not apply in UK NHS trust
hospitals. The reason could be long surgery time and cost-effectiveness which is affected
8 Sadaf Naveed

when VATs needs to be converted to thoracotomy due to complications. More use of
equipment longer theatre time, prolonged hospital stays. There has been apparent bias when
propensity selection in most literature. The decision to perform thoracotomy lobectomy and
VATS lobectomy would be based on surgeon’s preference or institution experience i.e.
training program and may not apply to a less experienced surgeon. Some generalized research
findings may not be appropriate for the hospital in which the author working at present or for
the wider population and it is limited in their application (Tcherniakov, et, al. 2017, Rachel,
et, al. 2016, and Paul, et al. 2014).
As there is not enough literature and local research some of the questions remained
unanswered and needs strong evidence to promote either approach to recommend VATs
lobectomy as the standard of care for patients with early-stage NSCLC compared to
thoracotomy. Although the world-based literature supports VATs lobectomy and it seems to
be a safe alternative to thoracotomy lobectomy for patients managed by well-trained
surgeons. For strong evidence-based practice, it is important to do research in local thoracic
theatres.
Pilot study
Research question: -
What are the thoracic surgeon’s perceptions and experiences providing differences in
outcomes between VATs lobectomy and thoracotomy lobectomy?
What are the protocols for selecting patients for either VATS lobectomy or thoracotomy
lobectomy? How do surgeons make this decision?
What is the surgeon's opinion on trainee surgeons training? How can this be improved?
9 Sadaf Naveed

It was witnessed by the scrub nurse in thoracic surgery is that most experienced surgeons’
preference is thoracotomy lobectomy compare to VATs lobectomy, but most research support
VATs lobectomy for early-stage cancer. It could be due to ritualism in healthcare practice.
This research will, therefore, enable the researcher to fulfill the needs to validate what is the
clinical procedure of the two and to remove outdated rituals.
Methodology
To achieve getting answers for the proposed questions it is imported to choose the most
suited method for research and the kind of information to answer the hypotheses this was
according to Parahoo, (2006) and Meadows, (2003). The researcher has chosen qualitative
methods to answer purposed research questions for a pilot study in the hope to explore
surgeons’ perceptions and experiences of surgical aspects and outcomes about VATS
lobectomy and Thoracotomy lobectomy. In this study, a qualitative approach will be chosen
in the form of questionnaires. The questionnaire will be about how and why thoracic
surgeons make their decision about approach, their experience and their opinions for the best
approach for overall surgical outcomes. To explore the factors that influence their choice of
approach such as cost and demands on resources. This pilot study will help in generating
ideas and hypotheses, which later will be addressed in main quantitative research (Polit and
Hungler1995, and Meadows, 2003). The author implicated pilot study because the analysis is
lacking in rigors in prior research articles and there is further research needed.
10 Sadaf Naveed

In order to develop more understanding and learn from experts, the author will implement the
pilot study in which the chosen participants will be the small group of surgeons in thoracic
operating theatres, this will help the author to carry out main research more effectively.
The researcher/ author will be using internal questionnaire for pilot study as it is an easy
option to take for data collection. It gives the surgeons freedom as they can also fill the
questionnaires at their own time. However, before issuing of the questionnaires the author or
the researcher has to build a rapport with the surgeons whom will be involved in filling in
them, she will, therefore, notify them in advance and will explain the purpose for this
research to them.
Main Research Study
Pre and post -operative data: -
Which is the common surgical procedure preferred by the surgeons for lobectomy
during stage 1A NSCLC? VATS or Thoracotomy?
What are the long- term post-operative outcomes for VATS and thoracotomy in the
department where the researcher works as a scrub nurse?
Of the two surgical procedures, which approach causes more blood loss risks and
restricted lymph node sampling?
Which approach is more time-consuming?
Which approach has more demand for resources?
11 Sadaf Naveed

Which surgical approach leads to more post- operative complications such as pain,
length of hospital stays, 5 years disease-free survival and overall survival?
Which approach is more cost-effective? Do the benefits outweigh the cost?
Are there some risks when the surgeons need to convert VATS into thoracotomy?
What are the reasons for the conversion?
Methodology
Patients data will be collected by cohort retrospectively studies from 2009- 2014 from the
patient who underwent VATs lobectomy and thoracotomy for clinical stage 1A NSCLC.
To determine the effectiveness of both treatment systematic reviews, randomized controlled
trials and meta-analysis will be used. To avoid bias and random errors, participants will be
randomly allocated from a group and treatments will be given under controlled conditions
effectively. The data will be collected pre- operative and 5 years post- operative to evaluate
the differences in the survival outcomes between the patients who went through the VATS
lobectomy and thoracotomy lobectomy.
The participants of interest will be patients who suffer from lung cancer and who underwent
lung resection through VATs or thoracotomy. This will also include high-risk patients but
evaluation for high risk and low risk will be done separately for the reliability and validity of
the research. It is essential for the validity and reliability of research to audit prospective data
relating to both groups of patients went through lobectomy for clinical stage 1A NSCLC. To
collect information the statistical analysis will be carried out.
12 Sadaf Naveed