VOLUME 25 䡠 NUMBER 31 䡠 NOVEMBER 1 2007

JOURNAL OF CLINICAL ONCOLOGY O R I G I N A L R E P O R T

Video-Assisted Thoracic Surgery Lobectomy: Report

of CALGB 39802—A Prospective, Multi-Institution
Feasibility Study
Scott J. Swanson, James E. Herndon II, Thomas A. D’Amico, Todd L. Demmy, Robert J. McKenna Jr,
Mark R. Green, and David J. Sugarbaker
From the Surgery Committee of the
Cancer and Leukemia Group B
A B S T R A C T
(CALGB), Statistics Office of CALGB,
and Respiratory Committee of CALGB, Purpose
Chicago, IL. To evaluate the technical feasibility and safety of video-assisted thoracic surgery (VATS) lobectomy
Submitted May 22, 2007; accepted
for small lung cancers.
August 8, 2007. Patients and Methods
Supported by the National Cancer Insti- The Cancer and Leukemia Group B 39802 trial was a prospective, multi-institutional study
tute Grants No. UO1 CA65170 and U10 designed to elucidate the technical feasibility of VATS in early non–small-cell lung cancer (NSCLC)
CA59594. using a standard definition for VATS lobectomy (one 4- to 8-cm access and two 0.5-cm port
Presented at the 38th Annual Meeting incisions) that mandated videoscopic guidance and a traditional hilar dissection without rib
of the American Society of Clinical spreading. Between 1998 and 2001, 128 patients with peripheral lung nodules ⱕ 3 cm in size with
Oncology, May 18-21, 2002, Orlando suspected NSCLC were prospectively registered for VATS lobectomy.
FL.

Authors’ disclosures of potential con-

Results
flicts of interest and author contribu-
One hundred twenty-seven patients (66 males and 61 females; median age, 66 years; range, 37
tions are found at the end of this to 86 years), with a performance status of 0 (74%) or 1 (26%), underwent surgery. Patients with
article. lymph nodes more than 1 cm by computed tomography scan underwent mediastinal lymph node
Address reprint requests to Scott J.
sampling to rule out N2 disease. One hundred eleven patients (87%) had stage I lung cancer, and
Swanson, MD, Division of Thoracic 96 (86.5%) of these 111 patients underwent successful VATS lobectomies. The median procedure
Surgery, Mt Sinai Medical Center, 1190 length was 130 minutes (range, 47 to 428 minutes), and median chest tube duration was 3 days
5th Ave, New York, NY 10029; e-mail: (range, 1 to 14 days). Fifty-eight (60%) of 97 patients underwent diagnostic biopsy at lobectomy.
[email protected]. Within 30 days, three (2.7%) of 111 patient deaths occurred, none of which were directly related
© 2007 by American Society of Clinical to VATS technique; seven (7.4%) of 95 patients had grade 3 or greater complications, with only
Oncology one case of bleeding.
0732-183X/07/2531-4993/$20.00
Conclusion
DOI: 10.1200/JCO.2007.12.6649 A standardized approach to VATS lobectomy as specifically defined with avoidance of rib spreading
is feasible.

J Clin Oncol 25:4993-4997. © 2007 by American Society of Clinical Oncology

refer to a range of operations including a standard

INTRODUCTION
thoracotomy and lobectomy via a small skin inci-
Minimally invasive surgery has improved the treat- sion or a giant wedge resection. We prefer to stan-
ment of surgical patients. These surgical techniques dardize the definition of a VATS lobectomy to
minimize trauma and optimize patient recovery encompass a true anatomic lobectomy with individ-
without compromising the surgical outcome. Lapa- ual ligation of lobar vessels and bronchus as well as
roscopic cholecystectomy is a prime example of a hilar lymph node dissection or sampling using the
minimally invasive surgical procedure that has be- video screen for guidance, two or three ports, and no
come the standard of care for the surgical treatment retractor use or rib spreading.1-3
of gallbladder disease. With respect to thoracic sur- To date, to our knowledge, there are no pro-
gery, video-assisted thoracic surgery (VATS) is pre- spective studies that use a standardized definition to
ferred by most thoracic surgeons for procedures examine the utility of a VATS lobectomy. The onco-
such as pleural biopsy, wedge resection, blebectomy, logic efficacy of the VATS approach, which is of
and lung biopsy. However, VATS anatomic lung critical importance, has been questioned by some
resection for cancer is controversial. The definition thoracic surgeons.4 Others have reported similar and
of VATS lobectomy has been variable. The term can improved survival relative to historical controls.5-7

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With this background, the Cancer and Leukemia Group B as the time between surgery and death. The Kaplan-Meier product-limit
(CALGB) 39802 prospective, multi-institutional study was designed estimator was used to graphically describe FFS and overall survival.
to elucidate the technical feasibility and safety of VATS in early non– A VATS lobectomy procedure form was required for each participant.
The VATS procedure was defined as successfully completed, converted to a
small-cell lung cancer (NSCLC) using a standardized definition for thoracotomy, or aborted because of an inability to perform either VATS or
VATS lobectomy that mandated videoscopic guidance and a tradi- thoracotomy for the following specified reasons: bleeding, tumor larger than
tional hilar dissection without rib spreading. appreciated, tumor more central than appreciated, vascular anatomy not
We were primarily interested in the feasibility of performing amenable to VATS, pleural adhesions, positive N2 nodes, tumors other than
VATS lobectomy in patients with peripheral NSCLC ⱕ 3 cm in size. NSCLC, difficulty with one-lung ventilation, other anesthesia problems, or
Feasibility was defined as the ability to successfully perform a lobec- other technical or anatomic considerations.
tomy via a VATS approach without significant morbidity or periop-
erative mortality (death within 30 days of the VATS procedure). RESULTS
Significant morbidity included bleeding that required greater than
two transfusion units, pneumonia that required antibiotic treatment,
One hundred twenty-eight patients were accrued to the study at six
cardiac arrhythmias that required treatment, supraventricular ar-
centers by 11 surgeons between 1998 and 2001. One patient who was
rhythmia that required cardioversion, deep vein thrombosis, pulmo-
registered to the study after undergoing surgical resection was ex-
nary embolus, myocardial infarction, wound infection that required
cluded from the analyses. Another two patients who underwent suc-
either antibiotic therapy or wound opening, empyema, bronchopleu-
cessful surgery were included even though both had at least one lesion
ral fistula, and prolonged air leak. If, despite the various retrospective
more than 3 cm on prestudy computed tomography scans. Therefore,
reports, VATS lobectomy, as carefully defined, was not feasible (ie, analyses are based on 127 patients with a median age of 66 years
successful and safe), then there would be little point in further exam- (range, 37 to 86 years). Patient characteristics are listed in Table 1. One
ining this technically advanced approach to lobectomy for early-stage hundred eleven of the remaining 127 patients had stage T1N0 (1 to 3
lung cancer. cm) NSCLC. VATS lobectomy was performed successfully in 96 of
111 patients, for a success rate of 86.5%. The median length of the
successfully completed procedures was 130 minutes (range, 47 to 428
PATIENTS AND METHODS
minutes). The median length of chest tube duration was 3 days (range,
1 to 14 days). Additional operative data are listed in Table 2. Ninety-
Between 1998 and 2001, 128 patients with suspected or histologically docu-
mented clinical stage I NSCLC with solitary peripheral tumors ⱕ 3 cm were one of 111 patients who had stage I NSCLC underwent lymph node
registered. Preresectional biopsy was not required, but patients with enlarged sampling. The mean number of lymph nodes stations dissected was
(⬎ 1 cm) mediastinal lymph nodes by computed tomography scan were 4.2 (standard deviation, 2.2 stations). The lymph node distribution for
required to undergo mediastinoscopy. All other patients underwent ipsilateral lymph node stations is shown in Table 3.
thoracoscopic mediastinal lymph node sampling or dissection for adequate There were three perioperative deaths (2.7%). Patient deaths
staging. Patients with metastatic disease or a diagnosis of NSCLC or small-cell were attributed to mesenteric ischemia (one patient, day 19), sudden
lung cancer within the past 5 years were also excluded. Patients who were cardiopulmonary arrest (one patient, day 7), and pulmonary embolus
included had an Eastern Cooperative Oncology Group performance status of
0 to 2.
(one patient, day 7). None of these three patients had a complicated
Participating surgeons were required to undergo a rigorous credentialing VATS lobectomy operation. Adverse events were evaluated for 95 of
protocol that included registration in a course to review technique, submission 96 patients who had successful VATS resection; no data were available
of an unedited videotape, operative and pathology reports from a VATS for one patient. Nine severe or life-threatening complications oc-
lobectomy for central review, and participation in an animal laboratory. Sur- curred in seven patients (Table 4). There were five episodes of arrhyth-
geons were required to perform at least five VATS lobectomies before being mias (supraventricular tachycardia or atrial fibrillation), one episode
credentialed. The technique was carefully outlined in the appendix of the of hypotension, one episode of bleeding, one prolonged air leak, and
protocol and mandated no rib spreading; a maximum length of 8 cm of the
one pleural effusion.
access incision for removal of the lobectomy specimen; individual dissection of
the vein, arteries, and airway for the lobe in question; and standard node
sampling or dissection (identical to an open thoracotomy). All specimens were
placed in an impermeable bag and removed through the access incision.
The two primary end points, technical feasibility and safety, were the Table 1. Patient Characteristics
bases for the study accrual goal. The study’s sample size goal was chosen with
No. of Patients
the following issues in mind: the study was designed to have 80% power to Characteristic (N ⫽ 127) %
differentiate between a 75% and 85% success rate for a test conducted at the
0.05 level of significance, where success was defined as a patient who can be Sex
completely resected using VATS without conversion to a thoracotomy; the Male 66 52
study was designed to have 80% power to differentiate between an 80% and Female 61 48
90% morbidity/complication rate, with safety defined as the in-house morbid- Age, years
ity and 30-day or in-house mortality, whichever was longer; and approxi- Median 66
mately 20% of patients would not have stage T1N0 disease. The study’s accrual Range 37-86
goal was 135 patients, including 107 patients with T1N0 disease. 70⫹ 44 35
Performance status
The length of time of the surgical procedures, duration of chest tube, and
0; normal activity 94 74
other complications were recorded. Secondary end points included failure-
1; fully ambulatory 33 26
free survival (FFS) and survival. FFS was defined as the time between surgery
and initial failure (death, disease progression, or relapse); survival was defined

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 VATS Lobectomy in Early-Stage Lung Cancer

in question (n ⫽ 1), and camera technology inadequate for visualiza-

Table 2. Operative Data (N ⫽ 127)
tion (n ⫽ 1). Among the 111 patients determined to have T1N0
Operative Characteristic Value NSCLC, the probability of FFS is 91% (95% CI, 85.9% to 96.9%) at 1
Stage I NSCLC year and 78% (95% CI, 70% to 86%) at 2 years at a median follow-up
No. of patients 111 time of 36 months (Fig 1).
% 87
Successful VATS lobectomy
No. of patients/total 96/111 DISCUSSION
% 86.5
95% CI, % 80% to 93%
Lobe resected, No. of patients The use of minimally invasive surgical techniques in thoracic surgery
RUL 23 is now routine for biopsies and basic procedures such as drainage of
RML 2 pleural effusion and blebectomy. Although its use is still controversial,
RLL 17 VATS lobectomy has been performed for the surgical treatment of
LUL 35
lung cancer for more than 14 years by a limited number of surgeons.8
LLL 12
Single-institution retrospective series have reported favorable mor-
Unknown/other 7
Operative time, minutes
bidity, mortality, and survival data.4-7,9,10 However, a standardized
Median 130 definition for VATS lobectomy has not been established, and a multi-
Range 47-428 institution study has not been conducted, so the benefits have not been
Chest tube duration, days well characterized.
Median 3 Like the proponents of laparoscopic cholecystectomy, advocates
Range 1-14 of VATS lobectomy have suggested that the advantages to patients are
Abbreviations: NSCLC, non–small-cell lung cancer; VATS, video-assisted obvious. However, it is important to be certain that this technique
thoracic surgery; RUL, right upper lobe; RML, right middle lobe; RLL, right preserves oncologic principles and, because it is technically more de-
lower lobe; LUL, left upper lobe; LLL, left lower lobe.
manding, that it is beneficial to patients. To this end, the CALGB
specifically defines VATS lobectomy as the same procedure per-
formed via a thoracotomy but without the chest wall muscle division
or rib spreading that are the key sources of postoperative pain and
Twelve of 111 patients underwent conversion to open thoracot- limitation of function.
omy. The reasons for the conversions included bleeding (n ⫽ 2), dense Eleven surgeons at six centers underwent credentialing to assure
lymphadenopathy (n ⫽ 1), calcified node adherent to pulmonary uniformity of procedure. The success rate, morbidity, and mortality of
artery and bronchus (n ⫽ 1), history of tuberculosis with adhesions the procedure achieved or surpassed previous levels.1,11 Notably, more
of pulmonary vein and artery with anthracotic adenopathy (n ⫽ 1), than one third of the patients in this study were older than 70 years of
inability to tolerate single-lung ventilation (n ⫽ 1), near fusion of ribs age, suggesting to investigators that VATS is better tolerated in the
rendering it difficult to pass instruments through a small space elderly than thoracotomy.12 Our results are in contrast to a recent
(n ⫽ 1), unsatisfactory orientation that did not permit stapler to be series of patients older than age 70 years who underwent open thora-
passed around the superior pulmonary vein (n ⫽ 1), abnormal bron- cotomy for slightly more advanced-stage disease, in whom reported
chial anatomy (n ⫽ 1), pathology frozen section nondiagnostic for operative morbidity was 40% to 50%.13 Another study reported hos-
tumor (n ⫽ 2), need to fully palpate lungs to identify pathologic area pital mortality rates of 12.8% in patients older than 70 years compared
with 4.7% in patients younger than 70 years.14 Also of interest is the
finding that certain complications, such as arrhythmias and pro-
longed air leak, were observed at a lower frequency (5.6% and ⬍ 1%,
Table 3. Distribution of the Lymph Node Stations Sampled Among respectively) with VATS procedures compared with lobectomy per-
111 Patients
formed via a thoracotomy. The American College of Surgeons Oncol-
No. of Lymph
Nodes No. of Cumulative No.
ogy Group Z0030 trial reported atrial arrhythmias in 15% and
Sampled Patients % of Patients Cumulative % prolonged air leak in 8% of patients who underwent open lobecto-
NR 10 9.01 10 9.01 my.13 These findings may be related to reduced trauma and less direct
NLNS 6 5.41 16 14.41 manipulation of the lung and hilum. Various inflammatory mediators
1 4 3.60 20 18.02 and cytokines, such as C-reactive protein, interleukin-6, and polymor-
2 2 1.80 22 19.82 phonuclear elastase, are less perturbed in VATS patients than in pa-
3 16 14.41 38 34.23 tients who undergo thoracotomy and may, in part, explain these
4 19 17.12 57 51.35 observations.15-17 The length of chest tube duration and arrhythmia
5 17 15.32 74 66.67
incidence observed in this study were noticeably lower than the 12%
6 13 11.71 87 78.38
7 14 12.61 101 90.99
and 15% rates, respectively, reported in thoracotomy patients12,13 and
8 8 7.21 109 98.20 should result in shorter hospital stays with consequent cost savings, as
9 1 0.90 110 99.10 suggested by other authors,18 particularly because the average VATS
10 1 0.90 111 100.00 operation in our study took just longer than 2 hours including a
Abbreviations: NR, no records of lymph node sampling data information; confirmational wedge biopsy.
NLNS, no lymph nodes sampled. The secondary study end points were recurrence and survival.
The finding of 78% FFS at 36 months for patients with stage I

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 Swanson et al

Table 4. Complications Among Patients Who Underwent Successful Resection With Video-Assisted Thoracic Surgery
Grade of Complications
Grade 4: Life
Grade 3: Severe Threatening Grade 5: Lethal
Total No. of
No. of No. of No. of Patients
Complication Patients % Patients % Patients % Evaluated
Cardiovascular: arrhythmia
Arrhythmia, other 3 3 1 1 0 0 95
Supraventricular arrhythmias 1 1 0 0 0 0 95
Cardiovascular: general
Hypotension 1 1 0 0 0 0 95
Cardiac ischemia/infarction 0 0 0 0 0 0 95
Thrombosis/embolism 0 0 0 0 0 0 95
Operative injury of vein/artery 0 0 0 0 0 0 95
Dermatology/skin
Wound infection 0 0 0 0 0 0 95
Hemorrhage
Hemorrhage/bleeding associated 0 0 1 1 0 0 95
Infection/febrile neutropenia
Infection without neutropenia 0 0 0 0 0 0 95
Catheter-related infection 0 0 0 0 0 0 95
Infection/other 0 0 0 0 0 0 95
Pulmonary
Pleural effusion 1 1 0 0 0 0 95
Adult respiratory distress syndrome 0 0 0 0 0 0 95
Pneumothorax 0 0 0 0 0 0 95
Pulmonary, other 0 0 1 1 0 0 95
Summary
Maximum toxicity 4 4 3 3 0 0 95

NSCLC suggests that the VATS operation yields results equal to with respect to postsurgical pulmonary function, pain, activity param-
those observed using a thoracotomy approach. Given that VATS eters, and overall well-being.20-27 Finally, the credentialing method
was defined as a procedure identical to that performed by thora- used in this study may serve as a standard to facilitate the safe use of
cotomy, the equivalent survival data are not surprising. In addi- new technology in a surgical practice.
tion, lymph node clearance is quite effective using a VATS CALGB 39802 is the first prospective, multi-institution study
technique.19 Whether minimizing trauma will lead to improved to examine a standardized, truly videoscopic, minimally invasive
survival, perhaps via improved immune surveillance, as noted in VATS lobectomy for early-stage lung cancer. The results demon-
some reports,5-7,15,17 remains to be investigated. strate that a VATS lobectomy as defined herein (ie, a lobectomy
Ideally, the benefits of the VATS operation to the patient will be performed with videoscopic guidance and anatomic hilar vascular,
based on quality-of-life measures that currently are difficult to dem- bronchial, and lymphatic dissection using two or three ports and
onstrate. The existing data are sparse but favor the VATS approach without rib spreading) is feasible. The low complication rate and
short chest tube duration suggest there may be a benefit to the
patient; furthermore, at early follow-up, the secondary survival
end point compares favorably to open series. A follow-up cooper-
1.0 ative cancer group study to compare the outcome of a VATS
approach with a thoracotomy for early-stage lung cancer has been
0.8 proposed to further define the potential patient benefit.
Probability

0.6
AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS
0.4
OF INTEREST

Although all authors completed the disclosure declaration, the following

0.2 author(s) indicated a financial or other interest that is relevant to the subject
matter under consideration in this article. Certain relationships marked
with a “U” are those for which no compensation was received; those
0 10 20 30 40 50 60 relationships marked with a “C” were compensated. For a detailed
Time from Surgery (months) description of the disclosure categories, or for more information about
ASCO’s conflict of interest policy, please refer to the Author Disclosure
Fig 1. Probability of failure-free survival among patients who underwent Declaration and the Disclosures of Potential Conflicts of Interest section in
complete resection. Information for Contributors.

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 VATS Lobectomy in Early-Stage Lung Cancer

Employment or Leadership Position: None Consultant or Advisory Administrative support: David J. Sugarbaker
Role: Scott J. Swanson, Ethicon (C); Todd L. Demmy, US Surgical (U); Provision of study materials or patients: Todd L. Demmy, Robert J.
Robert J. McKenna Jr, Ethicon (C) Stock Ownership: Mark R. Green, McKenna Jr
Johnson & Johnson Honoraria: Thomas A. D’Amico, US Surgical; Todd Collection and assembly of data: James E. Herndon II
L. Demmy, US Surgical; Robert J. McKenna Jr, Ethicon Research Data analysis and interpretation: Scott J. Swanson, James E. Herndon II,
Funding: None Expert Testimony: None Other Remuneration: Todd L. Mark R. Green
Demmy, US Surgical Manuscript writing: Scott J. Swanson, James E. Herndon II, Thomas A.
D’Amico, Todd L. Demmy, Robert J. McKenna Jr, David J. Sugarbaker
AUTHOR CONTRIBUTIONS Final approval of manuscript: Scott J. Swanson, James E. Herndon II,
Todd L. Demmy, Robert J. McKenna Jr, Mark R. Green, David J.
Conception and design: Scott J. Swanson, James E. Herndon II, Thomas Sugarbaker
A. D’Amico, Todd L. Demmy, Robert J. McKenna Jr, Mark R. Green,
David J. Sugarbaker

long-term prognosis in patients with clinical stage IA lung cancer by video-assisted thoracic surgery: Can
REFERENCES lung cancer. World J Surg 24:27-31, 2000 it be perfect? Ann Thorac Surg 73:900-904, 2002
10. Daniels LJ, Balderson SS, Onaitis MW, et al: 20. Nagahiro I, Andou A, Aoe M, et al: Pulmonary
1. Swanson SJ, Batirel HF: Video-assisted tho- Thoracoscopic lobectomy: A safe and effective function, postoperative pain, and serum cytokine
racic surgery (VATS) resection for lung cancer, in strategy for patients with stage I lung cancer. Ann level after lobectomy: A comparison of VATS and
Ferguson MK (ed): The Surgical Clinics of North Thorac Surg 74:860-864, 2002 conventional procedure. Ann Thorac Surg 72:362-
America, General Thoracic Surgery, Part I. Philadel- 11. Walker WS: Video-assisted thoracic surgery 365, 2001
phia, PA, WB Saunders, 2002, pp 541-559 (VATS) lobectomy: The Edinburgh experience. Se- 21. Nomori H, Ohtsuka T, Horio H, et al: Differ-
2. Lewis RJ, Caccavale RJ, Bocage JP, et al: min Thorac Cardiovasc Surg 10:291-299, 1998 ence in the impairment of vital capacity and
Video-assisted thoracic surgical non-rib spreading 12. Demmy T, Curtis J: Minimally invasive lobec- 6-minute walking after a lobectomy performed by
simultaneously stapled lobectomy. Chest 116:1119- tomy directed toward frail and high-risk patients: A thoracoscopic surgery, an anterior limited thoracot-
1124, 1999 case-control study. Ann Thorac Surg 68:194-200, 1999 omy, an anteroaxillary thoracotomy and a postero-
3. Kirby TJ, Mack MJ, Landreneau RJ, et al: 13. Allen MS, Darling GE, Pechet TTV, et al: lateral thoracotomy. Surg Today 33:7-12, 2003
Lobectomy-video-assisted thoracic surgery versus Morbidity and mortality of major pulmonary resec- 22. Landreneau RJ, Hazelrigg SR, Mack MJ, et al:
muscle-sparing thoracotomy: A randomized trial. tions in patients with early-stage lung cancer: Initial Postoperative pain-related morbidity: Video-assisted
J Thorac Cardiovasc Surg 109:997-1002, 1995 results of the randomized, prospective ACOSOG thoracic surgery versus thoracotomy. Ann Thorac
4. McKenna RJ Jr, Wolf RK, Brenner M, et al: Is Z0030 trial. Ann Thorac Surg 81:1013-1020, 2006 Surg 56:1285-1289, 1993
lobectomy by video-assisted thoracic surgery an 14. Thomas P, Sielezneff I, Ragni J, et al: Is lung 23. Giudicelli R, Thomas P, Lonjon T, et al: Video-
adequate cancer operation? Ann Thorac Surg 66: cancer resection justified in patients aged over 70 assisted minithoracotomy versus muscle-sparing
years? Eur J Cardiothorac Surg 7:246-251, 1993 thoracotomy for performing lobectomy. Ann Thorac
1903-1908, 1998
15. Craig SR, Leaver HA, Yap PL, et al: Acute Surg 58:712-718, 1994
5. Walker WS, Codispoti M, Soon SY, et al:
phase responses following minimal access and con- 24. Nakata M, Saeki H, Yokoyama N, et al: Pul-
Long-term outcomes following VATS lobectomy for
ventional thoracic surgery. Eur J Cardiothorac Surg monary function after lobectomy: Video-assisted
non-small cell bronchogenic carcinoma. Eur J Car-
20:455-463, 2001 thoracic surgery versus thoracotomy. Ann Thorac
diothorac Surg 23:397-402, 2003
16. Yim APC, Wan S, Lee TW, et al: VATS lobec- Surg 70:938-941, 2000
6. Solaini L, Prusciano F, Bagioni P, et al: Video-
tomy reduces cytokine responses compared with 25. Sugiura H, Morikawa T, Kaji M, et al: Long-
assisted thoracic surgery major pulmonary resec-
conventional surgery. Ann Thorac Surg 70:243-247, term benefits for the quality of life after video-
tions: Present experience. Eur J Cardiothorac Surg 2000 assisted thoracoscopic lobectomy in patients with
20:437-442, 2003 17. Leaver HA, Craig SR, Yap PL, et al: Lympho- lung cancer. Surg Laparosc Endosc Percutan Tech
7. Kaseda S, Aoki T, Hangai N, et al: Better cyte responses following open and minimally inva- 9:403-408, 1999
pulmonary function and prognosis with video- sive thoracic surgery. Eur J Clin Invest 30:230-238, 26. Landreneau RJ, Mack MJ, Hazelrigg SR, et al:
assisted thoracic surgery than with thoracotomy. 2000 Prevalence of chronic pain after pulmonary resec-
Ann Thorac Surg 70:1644-1646, 2000 18. Nakajima J, Takamoto S, Kohno T, et al: Costs tion by thoracotomy or video-assisted thoracic sur-
8. Roviaro G, Rebuffat C, Varoli FC, et al: Video- of videothoracoscopic surgery versus open resec- gery. J Thorac Cardiovasc Surg 107:1079-1086,
endoscopic pulmonary lobectomy for cancer. Surg tion for patients with lung carcinoma. Cancer 89: 1994
Laparosc Endosc Percutan Tech 2:244-247, 1992 2497-2501, 2000 27. Demmy TL, Plante AJ, Nwogu CE, et al:
9. Sugi K, Kaneda Y, Esato K: Video-assisted 19. Sagawa M, Sato M, Sakurada A, et al: A Discharge independence with minimally invasive
thoracoscopic lobectomy achieves a satisfactory prospective trial of systematic nodal dissection for lobectomy. Am J Surg 188:698-702, 2004

■ ■ ■

Acknowledgment
We thank Francine R. Dembitzer, MD, for assistance with this article.

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