Comparison of patient-reported outcomes after uniportal versus multiportal video-assisted thoracoscopic sub-lobar resection

Introduction

Video-assisted thoracoscopic surgery (VATS) has become the standard approach in lung resection, providing superior clinical outcomes compared to thoracotomy (1-3). Multiportal VATS (M-VATS) required 3 or 4 incisions. While uniportal VATS (U-VATS) required only one incision, further minimizing incision size and reducing surgical trauma (4,5). Studies indicated that U-VATS was associated with improved clinical outcomes, including shorter length of hospital stay (LOS), reduced postoperative complications, and decreased duration of chest tube placement (1,6-8). Moreover, U-VATS achieved similar oncological outcomes compared with M-VATS in previous studies, demonstrating its safety and feasibility (9,10). However, high-level evidence based on randomized clinical trials is still lacking.

Previous studies mainly focused on conventional clinical outcomes, overlooking patients’ subjective experiences, which may lead to an incomplete evaluation of different surgical approaches (4-10). In this study, we employed patient-reported outcomes (PROs). PROs are quality metrics that provide subjective information directly from patients, offering fresh insights for clinical decision-making (11-13). Studies have reported a significantly higher symptom burden with M-VATS compared to U-VATS (4,14-16). However, most of these studies only focused on pain, ignoring other important symptoms (17-20). Additionally, previous studies measured symptoms over short periods with relatively low frequency and longitudinal studies monitoring symptoms both during hospitalization and after discharge are scarce (6-8). Currently, sub-lobar resection has become an important approach for patients with early-stage lung cancer, as survival outcomes were similar compared with lobectomy (21-23). However, none of the existing studies investigate symptom burden after uniportal or multiportal segmentectomy or wedge resection (6-10,16).

To address this gap, our study assessed prevalent symptoms after lung resection through longitudinal and frequent measurements, aiming to comprehensively evaluate the differences in postoperative PROs between U-VATS and M-VATS among patients who underwent sub-lobar resections. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1816/rc).

Methods

Study design

This prospective cohort study was conducted between March 2021 and July 2024 at Guangdong Province People’s Hospital. Patients who underwent U-VATS or M-VATS wedge resection, sub-segmentectomy, or segmentectomy and completed at least 2 symptom assessments during hospitalization and 3 after discharge were included. The exclusion criteria were (I) patients who received neoadjuvant treatment, including neoadjuvant chemotherapy, immunotherapy, radiotherapy, and targeted therapy; (II) patients who required conversion to open surgery; (III) patients who underwent pleurectomy, mediastinal tumor resection, and other thoracic procedures; (IV) patients with a history of thoracic surgery. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by ethics committee of Guangdong Province People’s Hospital (No. KY-Q-2021-170-03) and informed consent was obtained before operation via the electronic symptom monitoring platform.

Surgical procedures and postoperative care

At our center, 2 surgeons routinely performed U-VATS, and the earliest U-VATS was performed in 2011. Three surgeons performed both U-VATS and M-VATS, while 1 surgeon only performed M-VATS. The surgical approaches were determined by the surgeon’s preference and the patient’s condition. All procedures were conducted with single-lung ventilation. U-VATS involved a single incision within 4 cm at the fourth or fifth intercostal space, while M-VATS involved 2 to 4 incisions ranging from 0.5 to 4 cm. The robotic-assisted surgery was not included. Lymph node dissection or sampling was performed after surgery. Chest tubes were routinely placed at the end of surgery. A silicone chest tube (20–30 F) or no more than 2 ultrafine chest tubes (i.e., pigtail catheter 10–12 F) were placed at the end of surgery. The silicone tube was placed through the original incision, while ultrafine tubes were inserted either through the original incisions or additional puncture sites. All patients received standardized postoperative care, including pain management, routine X-rays, respiratory training, and rehabilitation therapy. Chest tubes were removed when the 24-hour drainage volume was <200 mL, with no significant radiological abnormalities or air leakage observed. All patients received standardized postoperative analgesia, which included the routine administration of analgesia pump, and intravenous or oral analgesics within 1 week after surgery.

Data collection and outcomes

The primary outcome was postoperative symptom burden, assessed by the Perioperative Symptom Assessment Lung (PSA-Lung) inventory, a lung-specific, validated instrument including fatigue, coughing, pain, distress, disturbed sleep, and shortness of breath (SOB) (24). Patients rated each symptom on a scale from 0–10 scale, with 0 representing absence and 10 indicating the most severe symptom. Symptom severity was defined as the proportion of patients with a score ≥4 points, which was considered a clinically meaningful threshold for intervention (25). During hospitalization, patients reported symptoms twice a day until discharge or 5 days after surgery, and higher scores were recorded. After discharge, patients reported symptoms once a day within 1 week, then twice a week until 1 month, and once a week until 3 months post-discharge. Patients completed the questionnaire on our electronic symptom monitoring platform via the WeChat application, either independently or with assistance from others. Before surgery, physician assistants educated all patients and their spouses or children (or family members providing continuous care after surgery) on how to report symptoms and use our platform. To improve data accuracy and reliability, follow-up was conducted via the WeChat application or phone calls to remind patients to complete the questionnaire on time and respond to abnormal symptom scores after discharge.

Secondary outcomes were conventional clinical outcomes such as LOS, complication rate, and chest tube duration. Clinical data were collected from medical records, including type of surgery, duration of surgery, blood loss, and complications. Pulmonary function assessments were conducted for all patients before surgery. Postoperative pathological staging was according to the 8^th edition of the tumor-node-metastasis (TNM) classification for lung cancer (26).

Statistical analysis

Continuous variables with a normal distribution were presented as mean (standard deviation); otherwise, as median (interquartile range, IQR). Categorical variables were reported as counts or percentages. The Student’s t-test or the Wilcoxon rank-sum test was used to compare continuous variables. The Chi-squared test or 2-tailed Fisher’s exact test was used for categoric variables. The proportion of patients with severe symptom burden over time between U-VATS and M-VATS was compared using generalized estimating equation models (GEE), with time as a continuous variable, using a logit link function and binomial distribution. Mean scores of symptoms over time were compared using GEE with a normal distribution and identity link function. Factors with potential effects on symptom burden were included as covariates in the GEE, including age, sex, body mass index (BMI), smoking history, surgeon’s preference, American Society of Anesthesiologists Physical Status (ASA) classification (27), Charlson Comorbidity Index (CCI) (28), pulmonary function, tumor location, resection type, type of lymphadenectomy, and chest tubes placement. All models were adjusted for potential confounders. Results of unadjusted models were also reported. Statistical significance was defined as a two-sided P value <0.05. All analyses were conducted using IBM SPSS Statistics 25 and R (version 4.3.2).

Results

Demographic and clinical characteristics

A total of 455 patients were included in the final analysis, with 307 patients in the U-VATS group and 148 in the M-VATS group. The U-VATS group had a significantly higher proportion of segmentectomy, lymph node sampling, and better pulmonary function before surgery than the M-VATS group. In the U-VATS group, pigtail catheters or a combination of one pigtail catheter and one silicone chest tube were used in 67.8% of patients, while 67.1% of patients in the M-VATS group had one silicone chest tube. No significant difference was found in other clinical factors such as tumor stage, CCI, smoking history, and preoperative symptom burden (Table 1).

PROs

The completion rate of inventory was 100% at baseline, 90% to 100% during the 5-day postoperative hospitalization, and 95% to 100% during the 3 months after discharge. Symptom burden at baseline was similar between the 2 groups (Table S1).

During the 5-day postoperative hospitalization, the proportion of patients with severe pain (P<0.001), SOB (P=0.003), disturbed sleep (P<0.001), and fatigue (P=0.02) was significantly higher in the M-VATS group than in the U-VATS group. After adjusting for confounders, the M-VATS group had a higher proportion of severe pain (P=0.001), SOB (P=0.03), and disturbed sleep (P=0.02) compared with the U-VATS group. However, no difference was found in fatigue (Table 2, Figure 1).

Figure 1 Proportion of patients with severe symptoms during hospitalization. M-VATS, multiportal VATS; SOB, shortness of breath; U-VATS, uniportal VATS; VATS, video-assisted thoracoscopic surgery.

Within 1 month after discharge, results indicated that the proportion of patients with severe pain (P=0.002), SOB (P<0.001), disturbed sleep (P=0.008), and distress (P=0.004) were significantly higher in the M-VATS group, while the proportion of severe coughing (P=0.08) was similar between groups. Results were similar after adjusting for confounders, pain (P=0.02), SOB (P=0.007), disturbed sleep (P=0.005), and distress (P=0.003) were significantly better in the U-VATS group (Table 2, Figure 2). From 1 month to 3 months post-discharge, both adjusted and unadjusted results showed that the proportion of patients with severe pain and distress was higher in the M-VATS group while SOB, coughing and disturbed sleep were similar (Table 2, Figure 3).

Figure 2 Proportion of patients with severe symptoms within 1 month after discharge. M-VATS, multiportal VATS; SOB, shortness of breath; U-VATS, uniportal VATS; VATS, video-assisted thoracoscopic surgery.

Figure 3 Proportion of patients with severe symptoms from 1 to 3 months after discharge. M-VATS, multiportal VATS; SOB, shortness of breath; U-VATS, uniportal VATS; VATS, video-assisted thoracoscopic surgery.

Results for mean symptom scores were similar. During the 5-day postoperative hospitalization, the M-VATS group reported significantly higher pain, SOB, disturbed sleep, and fatigue scores whether adjusted or not. During 3 months after discharge, both adjusted and unadjusted results found that the M-VATS group reported higher pain, SOB, and distress scores. The M-VATS group also reported higher disturbed sleep scores after adjustment. Although statistically meaningful, the differences in mean symptom scores were relatively small, typically within 2 points, suggesting limited clinical value. Therefore, we recommend prioritizing symptom severity over mean scores when choosing between U-VATS or M-VATS (Table 3, Figures S1-S3).

Traditional clinical outcomes

The M-VATS group had longer operative time (P<0.001) postoperative LOS (P=0.01) and more intraoperative blood loss (P<0.001) compared with the U-VATS group. No differences were found in chest tube duration between the two groups. Complications with Clavien-Dindo classification II or higher grade were included in the analysis (29). During postoperative hospitalization, active bleeding occurs in 4 (1.2%) patients, and pneumonia in 2 (0.6%) patients. Three (0.9%) patients received chest tube reinsertion and no patients required secondary surgery. During the 1-month post-discharge, 8 (3.3%) patients underwent chest tube reinsertion and 3 (1.2%) patients required rehospitalization. No significant difference in postoperative complication rate was found between the two groups (Table 4).

Discussion

Studies comparing differences between U-VATS and M-VATS sub-lobar resection are lacking (6,7). Our study demonstrated that the U-VATS could reduce symptom burden and provide better clinical outcomes compared with the M-VATS.

At baseline, a higher proportion of patients in the M-VATS group did not undergo lymphadenectomy. Unlike our results, previous studies reported a similar number of dissected lymph nodes between groups (15-17,30,31). This might be because all patients in our study were diagnosed with benign tumors or stage 0 to I lung cancer, and surgeons routinely performing M-VATS preferred to omit lymph node dissection in those patients. Also, the two surgeons performing U-VATS routinely insert two ultrafine chest tubes instead of 20–30 F silicone chest tubes, which may result in a difference in chest tube placement.

The U-VATS group had significantly reduced operative time, intraoperative blood loss, and postoperative LOS, which are consistent with previous studies (31-34). Magouliotis et al. reported lower chest tube duration and LOS in the U-VATS group, while no differences were found regarding the operative time and blood loss (16). Zhang et al. reported longer operative time in the M-VATS group, but the blood loss was similar (15). Two studies including over 800 patients indicated that U-VATS was associated with decreased operative time, blood loss, chest tube duration, and LOS (14,30). However, these studies only included lobectomy patients. Han et al. reviewed 45 patients who underwent VATS segmentectomy. The U-VATS group had shorter LOS, while no significant difference was found in terms of operation time, and intraoperative events (17). Our results found no difference in complication rate, which was supported by existing studies (8-10,16,32,33). However, some studies reported the U-VATS group had a lower complication rate than the M-VATS group (17,30,31,34).

Studies comparing postoperative symptoms were scarce, most of which only assessed pain scores (14-16,18). Although some studies found no difference in pain scores between groups, most of the results demonstrated a significantly lower pain score in U-VATS than in M-VATS group (10,14-16,18,32,33,35).

In this study, the U-VATS reported a lower proportion of patients with severe pain, disturbed sleep, and SOB during hospitalization, which could be attributed to the smaller trauma associated with U-VATS. The single-port group had a lower burden of pain, SOB, distress, coughing, and disturbed sleep within 1 month after discharge, while the U-VATS group had a lower proportion of severe pain, SOB, and distress from 1 to 3 months after discharge. Xu et al. (14) included 120 patients who underwent U-VATS or M-VATS lobectomy. The U-VATS group had significantly higher physical, role, emotional, and social functions and lower fatigue and pain scores compared with the M-VATS group. Dai et al. (6) analyzed symptom burden among 174 lobectomy patients through the U-VATS or M-VATS approach. The PSA-Lung questionnaire was used to measure PROs after surgery. After adjusting for confounders including ASA classification, type of lymphadenectomy, number of chest tubes, and tumor pathologic stage, the U-VATS group had reported less severe pain, fatigue, constipation, coughing, SOB, and disturbed sleep during the 6-day postoperative hospitalization that the M-VATS group (6). However, none of these studies included segmentectomy or wedge resection, which was widely utilized in clinical practice. Both our study and Dai et al. found significantly higher symptom scores in the M-VATS group, but the differences were very small and hardly to be considered clinically meaningful. Thus, we translated symptom scores into different grades, which could provide a more significant reference value. This may explain why the results of the score were inconsistent with symptom severity, as the latter required a larger score difference. Moreover, Dai et al. defined symptom severity as a proportion of patients with symptoms over 7 points (6). However, if patients reported symptoms over 4 points, additional bedside visits or inquiries through telephone and WeChat would be applied in real-world work at our hospital (25).

There are some limitations in this study. First, this was an observational study, and further large clinical trials are required. We only assessed the most prevalent symptoms after lung surgery, other potentially meaningful symptoms and functional statuses were not analyzed. Moreover, the observational design led to potential biases. Several surgeons perform U-VATS or M-VATS in our center, their skill levels may affect patients’ postoperative outcomes. The choice of different approaches was made by surgeons based on their preference, experience, and patient’s condition. All these could lead to data bias.

Conclusions

The uniportal approach significantly reduced symptom burden and brought better clinical outcomes in patients who underwent sub-lobar resection compared with the multiportal approach.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1816/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1816/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1816/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1816/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by ethics committee of Guangdong Province People’s Hospital (No. KY-Q-2021-170-03) and informed consent was obtained before operation via the electronic symptom monitoring platform.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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