Observational Study Medicine ®

OPEN

Uniport video assisted thoracoscopic surgery (U-

VATS) exhibits increased feasibility, non-inferior
tolerance, and equal efficiency compared with
multiport VATS and open thoracotomy in the
elderly non-small cell lung cancer patients at
early stage
∗
Ruixing Zhao, MMa, Zhihua Shi, MMb, Siqiang Cheng, MBa,

Abstract
This study aimed to compare the feasibility, efficacy and safety among uniport video assisted thoracoscopic surgery (U-VATS),
multiport VATS (M-TATS), and open thoracotomy in elderly non-small cell lung cancer (NSCLC) patients at early stage.
One hundred ninety-one elderly NSCLC patients at early stage underwent U-VATS (N = 73), M-VATS (N = 56) or open thoracotomy
(N = 62) were included. Perioperative parameters, short-term outcomes, postoperative complications, and overall survival (OS) were
assessed.
Three-group analysis disclosed that operational duration, blood loss, drainage duration, hospital stay, pain score on the first day
(D1) and D3, patients’ global assessment (PGA), lasing air leak, infection, arrhythmia, and cardio-cerebrovascular events incidences
were different among U-VATS, M-VATS, and open thoracotomy groups. Subsequently, 2-group analysis revealed that:
1. Pain score on D1 and D3 and PGA score were decreased in U-VATS group compared with M-VATS group;
2. The operational duration was longer, blood loss, drainage duration, hospital stay, pain score on D1 and D3, PGA score, lasing air
leak, infection, arrhythmia, and cardio-cerebrovascular events were decreased in U-VATS group than open thoracotomy group;
3. The operational duration was longer, blood loss, drainage duration, hospital stay, pain score on D1 and D3, lasing air leak,
infection, and arrhythmia were reduced in M-VATS group than open thoracotomy group.

In addition, there was no difference of OS among 3 groups, nor between any of the 2 groups.
U-VATS presents with elevated feasibility, non-inferior tolerance, and similar efficacy compared with M-VATS and open
thoracotomy in the elderly NSCLC patients at early stage.
Abbreviations: COPD = chronic obstructive pulmonary disease, CXR = chest X-ray, DM = diabetes mellitus, FEV1 = forced
expiratory volume in 1 second, M-VATS = more feasible than multiport VATS, NSCLC = non-small cell lung cancer, OS = overall
survival, PGA = patient global assessment, U-VATS = uniport VATS, VAS = visual analogy scale, VATS = video assisted
thoracoscopic surgery.
Keywords: efficacy, elderly, feasibility, non-small cell lung cancer (NSCLC), open thoracotomy, safety

1. Introduction
Editor: Min Lu.
The authors have no funding and conflicts of interest to disclose. Lung cancer, the dominant cause of cancer deaths worldwide and
Supplemental Digital Content is available for this article.
the most common and fatal cancer in China, has a prevalence of
a 44.7/100, 000 in developed area and 30.0/100, 000 in less
Department of Thoracic Surgery, The Second People’s Hospital of Liaocheng,
Liaocheng, Shandong, b Department of Thoracic Surgery, The Fourth Hospital of developed areas in the world.[1,2] Non-small cell lung cancer
Hebei Medical University, Shijiazhuang, Hebei, China. (NSCLC) is the most frequently diagnosed lung cancer, which
∗
Correspondence: Siqiang Cheng, Department of Thoracic Surgery, The Second mainly contains squamous-cell carcinoma, large cell carcinoma
People’s Hospital of Liaocheng, 306 Jiankang Road, Liaocheng 252600, China and adenocarcinoma.[3] The early stage NSCLC patients account
(e-mail: dijiepanom@163.com). for approximately 35% of all NSCLC cases, and the elderly is the
Copyright © 2019 the Author(s). Published by Wolters Kluwer Health, Inc. major population of early stage NSCLC patients, for whom
This is an open access article distributed under the terms of the Creative thoracotomy is the first choice of treatment if the patient is
Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-
ND), where it is permissible to download and share the work provided it is
clinically operable.[4,5]
properly cited. The work cannot be changed in any way or used commercially Performing thoracotomy on the elderly NSCLC patients at
without permission from the journal. early stage is rather complex due to that the surgeons have to
Medicine (2019) 98:28(e16137) consider more factors before operation, such as reduced
Received: 25 October 2018 / Received in final form: 19 February 2019 / performance status, inadequate liver or renal function, higher
Accepted: 30 May 2019 incidence of surgical complications and more comorbidities of the
http://dx.doi.org/10.1097/MD.0000000000016137 elderlies.[6,7] Open thoracotomy, broadly applied but presents

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with many complications in NSCLC patients, requires a more ventilation using double lumen endotracheal intubation, and the
complete physical functions, which limited its applications in the operator and thoracoscopic assistant stood at the anterior side of
elderly patients. Video assisted thoracoscopic surgery (VATS) has the patient during all steps of the procedure.
been established by mounting clinical trials and cohort studies on
1. U-VATS: A 3 to 5 cm incision was performed in the fifth
its practicability, tolerance and efficacy in early stage NSCLC
intercostal space in the anterior axillary line area without rib
patients, moreover, uniport VATS (U-VATS) has been reported
spreading, and a plastic wound protector was used for the
to be more feasible than multiport VATS (M-VATS), including
operation port incision to avoid surgical site infection and
less blood loss, less postoperative drainage time and so on.[8–10]
tumor spread. Then a 30-degree, 10-mm high definition
Nonetheless, despite that there are various advantages of VATS
camera thoracoscope was introduced into the pleural cavity
treatments, including U-VATS, and M-VATS, compared with
and maintained in the posterior part of the incision. The main
open thoracotomy in early stage NSCLC patients, they have
procedures of lobectomy were as follows: firstly, adhesions
rarely been compared in the elderly NSCLC patients.
were separated, inferior pulmonary ligament was dissociated,
Herein, the aim of this study was to compare the feasibility,
and the pleura of pulmonary hilar was opened, then the
efficacy, and safety among U-VATS, M-VATS, and open
pulmonary vein, pulmonary artery, and bronchus were ligated
thoracotomy in treating elderly NSCLC patients at early stage.
and cut with an endoscopic stapler. Subsequently, a complete
lymphadenectomy was carried out, which included stations
2. Materials and methods 4L, 5, 6, 7, and 9 for left side cancers and stations 2R, 4R, 7, 8,
and 9 for right side cancers. After resection, all specimens were
2.1. Patients
placed in an endoscopic plastic bag under thoracoscopic
From Jan 2013 to Dec 2015, 191 elderly patients with early stage assistance and removed through the operational incision.
NSCLC who underwent U-VATS, M-VATS, or open thoracoto- Finally, the chest was rinsed using normal saline, and the
my were included in this retrospective cohort study. The inclusion bleeding was examined. Single lung ventilation was changed to
criteria were: double lung ventilation, and expansion of lung lobe and
leakage were checked. A closed thoracic drainage tube was
1. postoperative pathological diagnosis of NSCLC;
inserted through the posterior border of the incision, which
2. with TNM stage Ia or Ib;
was removed depending on the drainage. The muscular layer
3. age ≥60 years old;
and subcutaneous tissue around the drainage tube were
4. underwent U-VATS, M-VATS, or open thoracotomy;
carefully stitched.
5. clinical data, surgical information, short-term outcomes, and
2. M-VATS: The operative incision consisted of 3 parts:
records of adverse events were complete and accessible.
operation port, observation port, and auxiliary operation
The exclusion criteria included: port. A 4 to 5 cm incision was made in the fourth intercostal
space in the anterior axillary line area and used as the utility
(1) patients with TNM stage II-IV;
port, and another two 1 to 2 cm incisions used as observation
(2) had a history of malignancies other than NSCLC;
port and auxiliary operation port were made between the
(3) without follow-up data or follow-up duration less than 1
seventh and eighth intercostal space in the midaxillary line and
year.
posterior axillary line, respectively. A 10 mm thoracoscope
This study was approved by the Ethics Committee of The was inserted into the observation port to perform intrathoracic
Second People’s Hospital of Liaocheng. All patients or their exploration. During the operation, the latissimus dorsi was not
guardians provided the written informed consents. cut off, and the serratus anterior was split along the muscle
fibers without rib spreading. The procedures of lobectomy and
lymphadenectomy were as same as U-VATS. All resected
2.2. Baseline characteristics collection
tumor specimens were removed from the chest using a retrieval
Patients’ baseline characteristics were collected from medical bag. After operation, the thoracic cavity was cleaned up using
records, which included: normal saline, bleeding and leakage were examined, and a
closed thoracic drainage tube was inserted through the
(1) demographics: age, gender, and BMI;
observation port, reaching the apex of the thorax. Finally,
(2) smoke status and complications: smoke, hypertension,
the muscular layer and subcutaneous tissue were stitched.
diabetes mellitus (DM), chronic obstructive pulmonary
3. Open thoracotomy: Double lumen tracheal intubation,
disease (COPD), and cardiac disease;
intravenous, and respiratory combined general anesthesia,
(3) tumor features: tumor location, histological type, tumor size,
single lung ventilation on the healthy side and routine
and TNM stage;
disinfection were performed before operation. A traditional
(4) preoperative evaluation of pulmonary function: forced
posterolateral incision about 15 to 30 cm in the chest was
expiratory volume in 1 second (FEV1) and predicted FEV1.
made, and the tumor size and invasion were identified. After
dissociating the blood vessels (about 1–2 cm), the pulmonary
vein, pulmonary artery and bronchus were ligated and cut off
2.3. Grouping and procedures
with an endoscopic stapler, and the underdeveloped pulmo-
Patients were assigned to U-VATS group (N = 73), M-VATS nary fissure was cut by the linear stapler. Lymphadenectomy
group (N = 56), or open thoracotomy group (N = 62), respective- was performed as same as U-VATS. Normal saline cleaning,
ly, according to the surgery they received. As for the U-VATS and bleeding and leakage examination were conducted after
M-VATS, all patients underwent intravenous combined general operation. A closed thoracic drainage tube was inserted at
anesthesia in the lateral decubitus position with single lung operated side between the seventh and eighth intercostal space

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in the midaxillary line, and for the patients who underwent incomplete data required for inclusion (N = 110), TNM stage II-
radical resection of upper pulmonary carcinoma, another IV (N = 67), follow-up duration <1 year (N = 32), history of
thoracic drainage tube was inserted at operated side in the malignancies other than NSCLC (N = 9) (Fig. 1). Therefore, the
second intercostal space in midline of clavicle. remaining 223 patients who received U-VATS, M-VATS, or open
thoracotomy were eligible for our study, among whom 32
patients were excluded (28 could not be reached to get informed
2.4. Postoperative management consents and 4 were reluctant to provide the written informed
The postoperative pain was treated by intravenously administer- consents). And then the remaining 191 patients who received
ing 150 mL normal saline (0.9%), 50 mg sufentanil, 150 mg U-VATS, M-VATS, or open thoracotomy were included in the
dezocine and 8 mg ondansetron hydrochloride for 48 hours analysis, who were divided into U-VATS group (N = 73), M-
according to pain visual analogy scale (VAS) score. Chest X-ray VATS group (N = 56) and open thoracotomy group (N = 62)
(CXR) was performed on the day of operation, on the first day accordingly.
after operation and after thoracic drainage tube removal before
discharge. Thoracic drainage tube removal occurred with normal 3.2. Baseline characteristics
CXR findings, no air leak and secretions of less than 250 cc in 24
hours. Mean values of age were 67.5 ± 4.6 years, 67.3 ± 5.3 years, and
65.8 ± 3.5 years in U-VATS group, M-VATS group, and open
thoracotomy group, respectively (Table 1). And the male/female
2.5. Operational and short-term assessments was 59/14 in U-VATS group, 47/9 in M-VATS group and 44/18
Assessments of operations included operational duration (from in open thoracotomy group. There was no difference among 3
incision to suturing the skin), blood loss, drainage duration (from groups in regard to all the baseline characteristics, including age
the day of surgery to the day of drainage tube removal) and (P = .058), gender (P = .192), BMI (P = .304), current smoke
hospital stay; the short-term assessments included pain VAS score (P = .804), concomitant diseases (hypertension (P = .452), DM
on the first day and third day after operation and patient global (P = .098), COPD (P = .822), cardiac disease (P = .261)), tumor
assessment (PGA) score on last day of hospitalization. location (P = .421), histological type (P = .257), tumor size
(P = .760), TNM stage (P = .435), FEV1 (P = .319) and predicted
FEV1 (P = .521). In addition, we observed that the mean value of
2.6. Safety and survival assessments
age in open thoracotomy group was numerically reduced than
Postoperative complications were used to assess safeties of the those in U-VATS group and M-VATS group. The other clinical
operations, which included air leak, atrial fibrillation, atelectasis, characteristics at baseline were displayed in Table 1.
bleeding, infection, arrhythmia, cardiovascular, and cerebrovas-
cular events. After operation, patients were followed up
regularly, and median follow-up duration was 33.0 months 3.3. Comparisons of perioperative parameters and short-
(range: 1.0–55.0 months). The overall survival (OS) was used to term outcomes among 3 groups
evaluate long-term outcome, which was defined as the duration Perioperative parameters and short-term outcomes were com-
from the time of operation to the time of patients’ death. pared among three groups, which disclosed that all the
perioperative parameters and short-term outcomes were different
2.7. Statistical analysis among the three groups (all P < .05) (Table 2). Subsequently,
further 2-group comparisons disclosed that:
SPSS 22.0 software (IBM, USA) was applied for statistical
analysis and graph making. Normal distributed continuous 1. the pain VAS score on the first day after operation (P < .001),
variables were presented as mean ± standard deviation, and pain VAS score on the third day after operation (P = .025) and
comparison among three groups was determined by one-way PGA score on the last day of hospitalization (P < .001) were
ANOVA followed by Bonferroni test. Skewed distributed declined in U-VATS group compared with M-VATS group;
continuous variables were presented as median (25th–75th 2. the operational duration was elevated (P = .019), while blood
quantiles), comparison was determined by Kruskal–Wallis H loss (P < .001), drainage duration (P < .001), hospital stay
rank sum test (among 3 groups) or Wilcoxon rank sum test (P < .001), pain VAS score on the first day after operation
(between 2 groups). Categorized variables were presented as (P < .001), pain VAS score on the third day after operation
count (percentage), and comparison was determined by Chi- (P < .001) and PGA score on the last day of hospitalization
square test, Yates corrected Chi-square test or Fisher exact test. (P < .001) were decreased in U-VATS group compared with
Kaplan–Meier curve was used to show the survival profiles, and open thoracotomy group;
log-rank test was applied for comparison of OS among 3 groups. 3. the operational duration was more prolonged (P = .005),
P value <.05 was considered as significant. however, blood loss (P < .001), drainage duration (P < .001),
hospital stay (P < .001), pain VAS score on the first day after
3. Results operation (P < .001) and pain VAS score on the third day after
operation (P < .001) were reduced in M-VATS group than
3.1. Study flow those in open thoracotomy group.
At the beginning of our study, 563 NSCLC patients who These results indicated that U-VATS and M-VATS were both
underwent U-VATS, M-VATS, or open thoracotomy were better than open thoracotomy concerning feasibility, and
screened for eligibility, after which 340 patients were excluded U-VATS was superior to M-VATS in regard to postoperative
because of the following reasons: age <60 years old (N = 122), pain and PGA score in the elderly NSCLC patients at early stage.

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Figure 1. OS comparison among 3 groups. There was no difference of OS in the elderly NSCLC patients at early stage among U-VATS group, M-VATS group, and
open thoracotomy group, nor between any of the 2 groups. Kaplan–Meier curve was used to show the survival profiles, and log-rank test was applied for
comparison of OS among 3 groups. P < .05 was considered significant. M-VATS = multiport video assisted thoracoscopic surgery, NSCLC = non-small cell lung
cancer, OS = overall survival, U-VATS = uniport video assisted thoracoscopic surgery.

3.4. Comparisons of postoperative complications among both caused less postoperative complications compared with
the three groups open thoracotomy.
There were no difference in the incidences of atrial fibrillation
(P = .945), atelectasis (P = .982) and bleeding (P = .362) among 3.5. Comparison of OS among three groups
three groups, while the incidences of air leak lasted for 6 days or Kaplan–Meier curve and log-rank test were applied for OS
above (P = .006), infection (P = .001), arrhythmia (P = .007) and comparison, which exhibited that there was no difference of OS
cardiovascular and cerebrovascular events (P = .008) were among three groups (P = .327) (Fig. 2). Additionally, there was no
distinct among 3 groups (Table 3). Furthermore, the subsequent difference of OS between U-VATS group and open thoracotomy
2-group comparisons were performed, which displayed that: group (P = .150), M-VATS group and open thoracotomy group
(P = .525) or U-VATS group and M-VATS group (P = .327),
1. there were no differences of all the postoperative complica-
either, which indicated that the survival profile of patients
tions incidences between U-VATS group and M-VATS group
receiving U-VATS and M-VATS were not inferior to that of
(all P > .05);
patients treated by open thoracotomy.
2. the air leak lasted for 6 days or above (P = .018), infection
(P = .001), arrhythmia (P = .020) and cardiovascular, and
cerebrovascular events (P = .021) were less in U-VATS group 3.6. Comparison of cause of deaths among 3 groups
than open thoracotomy group;
There was no difference of number of deaths (P = .666) or the
3. the air leak lasted for 6 days or above (P = .005), infection
cause of deaths, which included cancer progression (P = .930),
(P = .013) and arrhythmia (P = .004) were also reduced in M-
infection (P = .320), complications (P = .982), and unknown
VATS group compared with open thoracotomy group.
reason (P = .366), among the U-VATS, M-VATS and open
And those results suggested that U-VATS was as tolerable as thoracotomy groups (Supplementary Table 1, http://links.lww.
M-VATS in the elderly NSCLC patients at early stage, while they com/MD/D102).

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Table 1
Baseline characteristics of NSCLC patients in U-VATS group, M-VATS group, and open thoracotomy group.
U-VATS group M-VATS group Open thoracotomy group
Parameters (N = 73) (N = 56) (N = 62) P value
Age (years) 67.5 ± 4.6 67.3 ± 5.3 65.8 ± 3.5 .058
Gender (male/female) 59/14 47/9 44/18 .192
BMI (kg/m2) 22.2 ± 2.5 21.8 ± 2.6 22.5 ± 2.5 .304
Smoke (n/%) 25 (34.2) 22 (39.3) 24 (38.7) .804
Hypertension (n/%) 14 (19.2) 16 (28.6) 14 (22.6) .452
DM (n/%) 4 (5.5) 1 (1.8) 7 (11.3) .098
COPD (n/%) 6 (8.2) 5 (8.9) 7 (11.3) .822
Cardiac disease (n/%) 6 (8.2) 10 (17.9) 8 (12.9) .261
Tumor location (n/%) .421
Left lung 26 (35.6) 23 (41.1) 29 (46.8)
Right lung 47 (64.4) 33 (58.9) 33 (53.2)
Histological type (n/%) .257
Adenocarcinoma 46 (63.0) 40 (71.4) 47 (75.8)
Squamous cell carcinoma 27 (37.0) 16 (28.6) 15 (24.2)
Tumor size (cm) 2.9 ± 0.8 2.9 ± 0.9 2.8 ± 0.7 .760
TNM stage (n/%) .435
Ia 42 (57.5) 37 (66.1) 34 (54.8)
Ib 31 (42.5) 19 (33.9) 28 (45.2)
FEV1 2.0 ± 0.4 2.0 ± 0.4 1.9 ± 0.4 .319
Predicted FEV1 (%) 86.0 ± 8.9 86.0 ± 9.5 84.4 ± 9.4 .521
Data were presented as mean value ± standard deviation, count (percentage) or median (25th–75th quantiles). Comparison was determined by one-way ANOVA, Chi-square test or Kruskal–Wallis H rank sum
test. P value < .05 was considered significant.
BMI = body mass index, COPD = chronic obstructive pulmonary disease, DM = diabetes mellitus, FEV1 = forced expiratory volume in 1 second, M-VATS = multiportal video-assisted thoracoscopic surgery,
NSCLC = non-small cell lung cancer, U-VATS = uniportal video-assisted thoracoscopic surgery.

Table 2
Comparison of perioperative parameters and short-term outcomes among 3 groups.
U-VATS group M-VATS group Open thoracotomy group
∗
Parameters (N = 73) (N = 56) (N = 62) P value P value†
Operational duration (minutes) 164.3 ± 33.7 168.5 ± 37.6 146.2 ± 42.7 .003 U vs M 1.000
U vs O .019
M vs O .005
Blood loss (mL) 130.0 ± 39.8 158.9 ± 62.0 300.0 ± 111.2 <.001 U vs M .112
U vs O <.001
M vs O <.001
Drainage duration (days) 4.2 ± 1.4 4.1 ± 1.1 6.5 ± 1.5 <.001 U vs M 1.000
U vs O <.001
M vs O <.001
Hospital stay (days) 8.2 ± 2.2 8.1 ± 2.3 12.9 ± 3.2 <.001 U vs M 1.000
U vs O <.001
M vs O <.001
Pain VAS score on the first day after operation 3.8 ± 1.0 5.0 ± 1.0 6.3 ± 2.0 <.001 U vs M <.001
U vs O <.001
M vs O <.001
Pain VAS score on the third day after operation 2.2 ± 0.7 2.7 ± 0.8 3.5 ± 1.3 <.001 U vs M .025
U vs O <.001
M vs O <.001
PGA score on the last day of hospitalization 2.8 ± 1.2 3.8 ± 1.4 4.3 ± 1.4 <.001 U vs M <.001
U vs O <.001
M vs O .108
Data were presented as mean value ± standard deviation. Comparison was determined by one-way ANOVA followed by Bonferroni test. P value <.05 was considered significant (in bold).
∗
Comparison among 3 groups.
†
Comparison between 2 groups.
M = multiportal video-assisted thoracoscopic surgery, M-VATS = multiportal video-assisted thoracoscopic surgery, O = open thoracotomy, PGA = patient global assessment, U = uniportal video-assisted
thoracoscopic surgery, U-VATS = uniportal video-assisted thoracoscopic surgery, VAS = visual analogue scale.

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4. Discussion
In this study, we discovered that:
1. U-VATS presented with the best feasibility among the three
thoracotomies;
2. no difference concerning safety between U-VATS and M-
VATS was observed, while both of them were more tolerable
than open thoracotomy;
3. there was no difference of efficacy among U-VATS, M-VATS,
and open thoracotomy, nor between any of the 2 thoracoto-
mies.
Perioperative parameters and short-term outcomes are crucial
for feasibility assessment of thoracotomy in the elderly NSCLC
patients, specifically for fragile elderly patients, however, the
feasibility of VATS compared with open thoracotomy in the
elderly NSCLC patients at early stage is still quite insufficient, and
most of the studies are focusing on total NSCLC patients. For
instance, a case control study with propensity score weighting-
based analysis validates that NSCLC patients who receive VATS
show notably shorter duration of hospital stay post operation
compared with those receiving open thoracotomy.[11] And
Figure 2. OS in patients receiving U-VATS, M-VATS, and open thoracotomy.
another study conducted illuminates that intraoperative blood
No difference was observed among 3 groups or between any of the 2 groups. loss and chest tube duration are less in NSCLC patients treated
Kaplan–Meier curve was drawn to present the survival profiles, and log-rank with VATS than those in patients treated by open thoracoto-
test was utilized for comparison of OS among three groups or between 2 my.[12] And an earlier retrospective cohort study reports a much
groups. P < .05 was considered significant. M-VATS = multiport-video assisted
less blood loss in NSCLC patients receiving VATS compared with
thoracoscopic surgery, OS = overall survival, U-VATS = uniport-video assisted
thoracoscopic surgery. patients treated by open thoracotomy.[13] In our study, we found
that except for operational duration, U-VATS and M-VATS were
superior to open thoracotomy concerning blood loss, drainage
duration, hospital stay, pain VAS score on the first and third day
post operation, and the PGA score on the last day of
hospitalization was also higher in patients treated by U-VATS

Table 3
Comparison of postoperative complications among 3 groups.
U-VATS group M-VATS group Open thoracotomy group
∗
Parameters (N = 73) (N = 56) (N = 62) P value P value†
Air leak lasted for 6 days or above (n/%) 11 (15.1) 6 (10.7) 20 (32.3) .006 U vs M .469
U vs O .018
M vs O .005
Atrial fibrillation (n/%) 3 (4.1) 3 (5.4) 3 (4.8) .945 U vs M 1.000
U vs O 1.000
M vs O 1.000
Atelectasis (n/%) 1 (1.4) 1 (1.8) 1 (1.6) .982 U vs M 1.000
U vs O 1.000
M vs O 1.000
Bleeding (n/%) 2 (2.7) 4 (7.1) 5 (8.1) .362 U vs M .450
U vs O .317
M vs O 1.000
Infection (n/%) 2 (2.7) 3 (5.4) 13 (21.0) .001 U vs M .762
U vs O .001
M vs O .013
Arrhythmia (n/%) 16 (21.9) 9 (16.1) 25 (40.3) .007 U vs M .405
U vs O .020
M vs O .004
Cardiovascular and cerebrovascular events (n/%) 0 (0.0) 1 (1.8) 6 (9.7) .008 U vs M .434
U vs O .021
M vs O .155
Data were presented as count (percentage). Comparison was determined by Chi-square test, Yates corrected Chi-square test or Fisher exact test. P value <.05 was considered significant (in bold).
∗
Comparison among 3 groups.
†
Comparison between 2 groups.
M = multiportal video-assisted thoracoscopic surgery, M-VATS = multiportal video-assisted thoracoscopic surgery, O = open thoracotomy, U = uniportal video-assisted thoracoscopic surgery, U-VATS = uniportal
video-assisted thoracoscopic surgery.

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than that in patients receiving open thoracotomy. Here are some A study that analyzes patients undergoing lung resection elucidates
possible explanations for these results: that after propensity score matching, the major cardiopulmonary
complication rate and overall complication rate in patients
1. the operational duration were longer in U-VATS and M-VATS
receiving VATS are reduced compared with patients who receive
groups compared with that in open thoracotomy group, which
open thoracotomy.[17] A retrospective cohort study reports that
may be derived from 2 reasons, firstly, U-VATS and M-VATS
the in-hospital mortality rate is markedly declined in patients with
required more instruments and more complicated operation
various lung diseases treated by VATS compared with that in
technique, which needed more time; secondly, open thoracot-
patients treated by open thoracotomy.[18] These prior studies
omy provided a broader view of the upper thoracic region
suggest that VATS may be more tolerable in patients with lung
anatomical structure, and surgeons were usually more skilled
diseases including lung cancer than open thoracotomy. In our
in the procedure of open thoracotomy, which largely reduced
study, we found that incidence of air leak lasted for 6 days or
the operation time;
above, infection or arrhythmia was decreased in the elderly
2. technically, U-VATS and M-VATS were minimally invasive
NSCLC patients receiving U-VATS and M-VATS compared with
surgical operations, which caused smaller incision and
patients treated by open thoracotomy, and less cardiovascular and
diminished damage to the chest anatomical structure, while
cerebrovascular events were found in patients treated by U-VATS
open thoracotomy needed a large incision and more damage to
than that in patients receiving open thoracotomy, suggesting that
thorax, thereby U-VATS and M-VATS caused less blood
U-VATS and M-VATS were more tolerable than open thoracoto-
vessel injury, smaller volume of intrathoracic liquid and gas,
my in the elderly NSCLC patients. The possible explanations
less need of post-operative care and less pain compared with
might consist of:
open thoracotomy, which subsequently led to less blood loss,
(1) air leak and infection were closely related to destruction of
drainage duration, hospital stay and lower pain VAS score on
thoracic anatomic structure, which was much milder in U-VATS
the first and third day after operation;
and M-VATS than that in open thoracotomy;
3. because of shorter drainage duration, hospital stay and less
(2) arrhythmia was usually caused by hypovolemia, cardiac
pain after operation, the elderly patients may experience less
damage, decrease in lung compliance and so on.[19] The
unsatisfactory after U-VATS and M-VATS compared with
hypovolemia might be the main reason for arrhythmia in the
open thoracotomy, contributing to a higher PGA score on the
elderly NSCLC patients receiving thoracotomies in our study,
last day of hospitalization.
and there was less blood loss of patients in U-VATS and M-VATS
VATS is initially designed as a single port thoracotomy, groups compared with open thoracotomy group, causing less
however, is firstly applied in a multiport way in clinical practice, hypovolemia and subsequently less cases with arrhythmia.
namely the M-VATS. Nonetheless, due to that complications (3) Cardiovascular and cerebrovascular events: blood loss
such as chest paresthesia are reported in NSCLC patients post M- during operation, long time of lay in bed, pain and tension during
VATS, the U-VATS is re-introduced in clinical practice to and post operation may result in myocardial and cerebral
minimize the complications.[14] Since U-VATS was developed, ischemia, venous thrombus, increase of blood pressure and heart
there are various benefits of this surgery have been reported. A rate elevation, which were more severe in the open thoracotomy
retrospective cohort study reveals that NSCLC patients present group compared with U-VATS group in our study. Therefore, the
with less blood loss, reduced pain, and elevated VAS score of patients in the open thoracotomy group presented with more
satisfaction after treatment by U-VATS than M-VATS.[15] And cardiovascular and cerebrovascular events than patients in the U-
another study finds that the Numeric Rating scale (NRS) pain VATS group.
score is decreased in early stage NSCLC patients treated with U- Studies that assess the survival profile of the elderly NSCLC
VATS compared with M-VATS.[16] Partially in accordance with patients who receive VATS and open thoracotomy are rare, and
the previous studies, we found that the pain VAS score on the first most of the reported studies are performed in total NSCLC
and third day after operation as well as PGA score on the last day patients, which display rather controversial results.[9,20–22] For
of hospitalization were lower in U-VATS group compared with example, a retrospective cohort study finds that NSCLC patients
M-VATS group. The probable explanations of these results are: have better OS after VATS compared with open thoracotomy,
and a similar 3-year survival rate while a higher 5-year survival
1. pain post operation was related to the injury of intercostal
rate are found in patients receiving VATS than patients treated by
nerves, which was less in U-VATS compared with M-VATS
open thoracotomy as well.[20] And a study which analyze the data
because of that the incision located at mid-axillary and
from an institutional registry including the profile between 2002
posterior axillary line in M-VATS but not in U-VATS,
and 2012 validates that the 5-year survival rate and OS are better
furthermore, the pressure in intercostal nerve was also milder
in patients with or suspected of lung cancer who are treated with
in U-VATS compared with M-VATS;
VATS compared with open thoracotomy.[23] Another study that
2. comprehensively, U-VATS presented with less drainage
is conducted on stage Ia NSCLC patients reveals that the disease-
duration, hospital stay and pain in the elderly NSCLC
free survival (DFS) and 5-year OS rate display no difference
patients, moreover, the U-VATS resulted in very limited
between patients treated with VATS and patients treated by open
cosmetic appearance loss compared with M-VATS. Therefore,
thoracotomy, which is in line with our study.[24] We found that
the elderly NSCLC patients presented with better global
there was no difference of OS among U-VATS, M-VATS, and
satisfaction after U-VATS than M-VATS.
open thoracotomy group, or between any of the 2 groups,
The elderly NSCLC patients, although at early stage, often suggesting that these different types of thoracotomies may be
present with inadequate physical condition, therefore the elderly even in view of the survival in the elderly NSCLC patients at early
NSCLC patients more easily to develop complications after stage. As for the explanations, it was probably because of the
operation, thus, surgeons have to be very cautious before decision follow up time in our study was not long enough, or the sample
making and in dealing with the perioperative complications.[5] size was relatively small.

7
Zhao et al. Medicine (2019) 98:28 Medicine

In addition, there were several limitations in this study. First, [9] Swanson SJ, Herndon JE2nd, D’Amico TA, et al. Video-assisted thoracic
surgery lobectomy: report of CALGB 39802–a prospective, multi-
the follow up time may be too short to observe the long-term
institution feasibility study. J Clin Oncol 2007;25:4993–7.
efficacy, with the median follow up duration being only 33.0 [10] Yang X, Li M, Yang X, et al. Uniport versus multiport video-assisted
months (range: 1.0–55.0 months). Second, VATS is a relatively thoracoscopic surgery in the perioperative treatment of patients with T1-
complicated thoracotomy that demands the surgeon to be more 3N0M0 non-small cell lung cancer: a systematic review and meta-
skilled and familiar to the surgery process, thus the surgeons’ skill analysis. J Thorac Dis 2018;10:2186–95.
[11] Scott WJ, Matteotti RS, Egleston BL, et al. A comparison of perioperative
level might cause bias of our results. Third, the sample size was outcomes of video-assisted thoracic surgical (VATS) lobectomy with
relatively small, which reduced the statistical power to some open thoracotomy and lobectomy: results of an analysis using propensity
extent. Forth, as an observational study, there might be several score based weighting. Ann Surg Innov Res 2010;4:1.
baseline characteristics that are confounding factors in this study. [12] Muraoka M, Oka T, Akamine S, et al. Video-assisted thoracic surgery
lobectomy reduces the morbidity after surgery for stage I non-small cell
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lung cancer. Jpn J Thorac Cardiovasc Surg 2006;54:49–55.
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and open thoracotomy in the elderly NSCLC patients at early thoracic surgery for stage I/II non-small cell lung cancer. Eur J
stage. Cardiothorac Surg 2004;26:158–64.
[14] Sihoe AD, Au SS, Cheung ML, et al. Incidence of chest wall paresthesia
after video-assisted thoracic surgery for primary spontaneous pneumo-
Author contributions thorax. Eur J Cardiothorac Surg 2004;25:1054–8.
[15] Dai F, Meng S, Mei L, et al. Single-port video-assisted thoracic surgery in
Conceptualization: Siqiang Cheng. the treatment of non-small cell lung cancer: a propensity-matched
Formal analysis: Ruixing Zhao. comparative analysis. J Thorac Dis 2016;8:2872–8.
Methodology: Ruixing Zhao. [16] Hirai K, Takeuchi S, Usuda J. Single-incision thoracoscopic surgery and
conventional video-assisted thoracoscopic surgery: a retrospective
Supervision: Zhihua Shi. comparative study of perioperative clinical outcomesdagger. Eur J
Validation: Zhihua Shi. Cardiothorac Surg 2016;49 Suppl 1:i37–41.
Writing – original draft: Ruixing Zhao. [17] Tsukazan MTR, Terra RM, Vigo A, et al. Video-assisted thoracoscopic
Writing – review & editing: Siqiang Cheng. surgery yields better outcomes than thoracotomy for anatomical lung
resection in Brazil: a propensity score-matching analysis using the
Siqiang Cheng orcid: 0000-0002-5902-2285.
Brazilian Society of Thoracic Surgery database. Eur J Cardiothorac Surg
2018;53:993–8.
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