Interactive CardioVascular and Thoracic Surgery Advance Access published January 28, 2015
Cite this article as: Akter F, Routledge T, Toufektzian L, Attia R. In minor and major thoracic procedures is uniport superior to multiport video-assisted thoracoscopic surgery? Interact CardioVasc Thorac Surg 2015; doi:10.1093/icvts/ivu375.
In minor and major thoracic procedures is uniport superior to multiport video-assisted thoracoscopic surgery? Farhana Akter, Tom Routledge, Levon Toufektzian and Rizwan Attia* Department of Cardiothoracic Surgery, Guy’s Hospital, London, UK * Corresponding author. Department of Cardiothoracic Surgery, 6th Floor Tower Wing, Guy’s Hospital, London SE1 9RT, UK. Tel: +44-20-71880214; fax: +44-20-71881006; e-mail: [email protected] (R. Attia). Received 10 April 2014; received in revised form 11 December 2014; accepted 12 December 2014
Abstract A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was: Are there differences in outcomes in uniport compared with multiport video-assisted thoracoscopic surgery? Altogether, 45 papers were found using the reported search, of which 8 papers represent the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type and level of evidence of publication, relevant outcomes and results of these papers are tabulated. Two studies (272 patients) compared outcomes for lobectomy. One study found pain control was significantly better in uniportal (P < 0.01) with earlier mobilization (P < 0.05), and decreased hospital stay by half a day (P < 0.05). The chest drain volume was less, and consequently the number of days the chest drain remained in situ decreased by 1 day (P < 0.05). The second study looking at lobectomies failed to find any differences between the two techniques. For minor thoracic procedures ( pneumothorax, peripheral lung nodules, thymic tumours, lung biopsies, sympathectomies and mediastinal cystectomies), 3 papers (117 patients) showed a statistically significant reduction in pain score during inpatient stay, and 1 paper showed a reduction in pain score day 0 postoperatively, however, no difference in pain score days 1 and 3 postoperatively. Two papers (n = 91) showed no difference in the reported pain scores; however, the patients in the uniportal group experienced less paraesthesia postoperatively. Patients in the uniportal group in this study also had reduced in-hospital stay (P = 0.03), and this led to a reduction in inpatient costs (P = 0.03). Four other studies, however, did not find any significant difference in duration of hospital stay. Pain scores are lower in uniportal VATS, most studies however do not demonstrate differences in other outcomes including analgesic use, duration of chest tube drainage, length of hospital stay or other thoracic complications. We conclude that, although uniport access may offer improved pain scores, the current evidence reveals no differences in most postoperative outcomes between uniport and multiport approaches to VATS in either minor or major thoracic procedures. Keywords: Video-assisted thoracoscopic surgery • Uniport • Multiport • Outcomes • Pain • Complications
INTRODUCTION A best evidence topic was constructed according to a structured protocol. This is fully described in ICVTS [1].
THREE-PART QUESTION In minor and major [lung resection] is [uniport] superior to [multiport] [Video-Assisted Thoracoscopic Surgery] (VATS) in [outcomes]?
CLINICAL SCENARIO You routinely perform three-/four-port VATS lobectomies and minor lung resections. There are however encouraging single
centre reports for uniport VATS. You decide to look at the evidence on the topic to assess if a change in practice is warranted.
SEARCH STRATEGY A Medline search from 1990 to November 2014 was performed using [single incision.mp OR Uniport.mp] AND (VATS.mp OR Thoracic Surgery, Video-Assisted.mp OR thoracoscopy.mp)
SEARCH OUTCOME Forty-five papers were found using the reported search. From these, eight papers were identified that provided the best evidence to answer the question. These are presented in Table 1. The recommendations are based on operative outcomes of 2 centres (272 patients) for lobectomy and 6 centres (228 patients)
© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
BEST EVIDENCE TOPIC
BEST EVIDENCE TOPIC – THORACIC
Interactive CardioVascular and Thoracic Surgery (2015) 1–6 doi:10.1093/icvts/ivu375
F. Akter et al. / Interactive CardioVascular and Thoracic Surgery
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Table 1: Summary of best evidence Author, date, journal and country Study type (level of evidence)
Patient population
Outcome(s)
Li et al. (2013), Chin J Lung Cancer, China [2]
Single centre retrospective review over 2 years
Operative time
Single centre retrospective review (level IIb)
Lobectomy n = 162 Uniport = 87 Multiport = 75
Single centre prospective series over 1 year
VATS lobectomies Single centre prospective n = 110 series Uniport = 15 (level IIa) Multiport = 95
Comments
No difference in: Demonstrate the safety and Operative time (151.03 ± 25.97 vs feasibility to undertake uniport 156.27 ± 26.49 min, P = 0.207) compared with multiport VATS lobectomy in selected patients Lymph node dissection LN dissection number number (13.06 ± 1.36 vs 12.61 ± 1.56, P = 0.057) Intraoperative blood loss
Blood loss (188.62 ± 47.0 vs 179.60 ± 28.96 ml, P = 0.138)
Serious complications
Postoperative complications (18/87 vs 21/75, P = 0.278)
Time to first activity
McElnay et al. (2014), Eur J Cardiothorac Surg, UK [3]
Key results
Statistical difference in: Time to first activity (11.17 ± 8.69 vs 13.76 ± 7.43 h, P < 0.05)
Pain score
Pain score Days 1 and 3 (2 and 1.2 for uniport vs 5 and 4.8 for multiport VATS, P < 0.01)
Chest tube drainage (days)
Chest tube drainage (3.85 ± 1.21 vs 4.43 ± 1.43 days, P < 0.05)
Chest-drain volume
Chest-drain volume (671.49 ± 178.31 vs 736.93 ± 170.39 ml, P < 0.05)
Hospital stay
Hospital stay is higher in multiport patients (7.92 ± 2.03 vs 7.18 ± 1.95 days in uniport, P < 0.05)
Pain score
There was no difference in the first 24 h visual analogue pain scores, P = 0.65
Analgesia use
The median morphine use in the first 24 postoperative hours was 19 mg in the uniportal group and 23 mg in the multiport group P = 0.84
Uniport VATS lobectomy was deemed safe without any differences in pain scores, analgesia use or procedural outcomes
No difference in the duration of patient-controlled analgesia P = 0.97 Chest-drain duration
No difference in chest-drain duration P = 0.67
Hospital stay
No difference in hospital length of stay P = 0.54
Postoperative ITU stay
There were no admissions to ITU in either group
Mortality
No inpatient mortality and no unplanned admission to critical care in either group
Tamura et al. (2013), J Cardiothorac Surg, Japan [4]
Single centre Retrospective review over 10 months
Operative time
Single centre retrospective review (level IIb)
(pneumothorax, peripheral lung nodules and thymic tumours) n = 37
Duration of chest-drainage
There is no statistical difference in: Operative time (60.5 ± 3.1 vs 58.8 ± 3.2 min, P = 0.692)
The use of uniportal VATS for minor lung resections leads to better pain relief immediately post-procedure
Chest tube drainage (1.11 ± 0.09 vs 1.22 ± 0.09 days, P = 0.349)
Continued
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Table 1: (Continued) Author, date, journal and country Study type (level of evidence)
Patient population
Outcome(s)
Key results
Uniport = 19 Multiport = 18
Duration of hospital stay
Hospital stay (3.85 ± 0.27 vs 4.33 ± 0.28 days, P = 0.271)
Inpatient pain scores
Pain score day 1 (2.74 ± 0.34 for uniport and 3.78 ± 0.35 for multiport, P = 0.039) Pain score day 3 (1.32 ± 0.20 for uniport and 1.94 ± 0.21 for multiport, P = 0.037)
Use of analgesics
Use of analgesics (dose of per rectal diclofenac) 0.89 ± 0.24 for uniportal and 1.44 ± 0.94 (P = 0.119)
Comments
There is statistical difference in: Pain score day 0 (4.95 ± 0.38 for uniport and 6.44 ± 0.39 for multiport, P = 0.012)
Salati et al. (2008), Interact CardioVasc Thorac Surg, Italy [5] Single centre retrospective review (level IIb)
Single centre retrospective review over 5 years (pneumothorax: bullectomy, pleurectomy, pleural abrasion) n = 51 Uniport = 28 Multiport = 23
Patient satisfaction scores
Satisfaction scores (8.95 ± 0.24 vs 8.33 ± 0.24, P = 0.078)
Wound infection
Wound infection (0 patients (0%) vs 1 patient (5.6%), P = 0.663)
Hospital stay
There is no statistical difference in: Operative time (72.3 ± 31.8 vs 68.7 ± 25.5 min, P = 0.67)
Pain score
Pain score (0.6 ± 1 vs 1.3 ± 1.7, P = 0.24)
Paraesthesia
Paraesthesia (9/26 (35%) vs 18/19 (94%), P < 0.0001)
Postoperative costs
Postoperative stay costs (€1407 ± 649.2 vs €1793 ± 893.5, P = 0.03)
Prolonged air leak
Prolonged air leak > 5 days (1/28 (3.5%) vs 4/23 (17%), P = 0.09)
Recurrence rate
Recurrence rate (2/28 (10%) vs 3/23 (13%), P = 0.62)
Mobilization (normal activity)
Normal activity after 6 months (25/26 (95%) vs 15/19 (79%), P = 0.069)
Uniportal VATS for spontaneous pneumothorax is superior to multiport VATS with regard to decreased hospital stay and consequently postoperative costs. These patients also have less chance of prolonged air leak, suffer less paraesthesia and more mobile on long-term follow-up
There is a statistical difference in: Postoperative stay (3.8 ± 1.8 vs 4.9 ± 2.4 days, P = 0.03) Jutley et al. (2005), Eur J Cardiothorac Surg, Spain [6]
Single centre retrospective review over 3 years
Single centre retrospective review (level IIb)
(pneumothorax: bullectomy, pleurectomy, pleural abrasion) n = 35
Chest tube drainage Hospital stay
No difference in: Chest tube drainage (4.6 ± 2 vs 3.9 ± 2.1, P = 0.30) Hospital stay (4.6 ± 3.1 vs 4.1 ± .0, P = 0.35)
Uniportal VATS for pneumothorax is a safe alternative to multiportal VATS, and leads to greater pain control and less neurological symptoms on long-term follow-up
Continued
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Table 1: (Continued) Author, date, journal and country Study type (level of evidence)
Patient population
Outcome(s)
Key results
Uniport = 16 Multiport = 19
Inpatient pain score
Statistical difference in: Inpatient pain score (1.4 ± 0.9 vs 2.6 ± 0.9, P ≤ 0.001)
Comments
Long-term symptoms— Long-term symptoms—pain pain (4/14 (28%), vs 5/12 (42%), P = 0.6) Long-term symptoms— Long-term symptoms— neurological neurological (2/14 (14%) vs 7/12 (58%), P < 0.05) Chen et al. (2009), Chin Med J, China [7] Single centre retrospective review (level IIb)
Single centre retrospective review over 2 years (VATS sympathectomies) n = 45 Uniport = 20 Multiport = 25
Hospital stay
No difference in: Hospital stay (2.4 ± 0.8 vs 2.5 ± 0.8 days, P = 0.599)
Pain scores
Pain scores (0.8 ± 0.5 vs 1.2 ± 0.6, P = 0.025) Residual pain (n, %) (4 (20%) vs 8 (32), P = 0.366)
Postoperative complications
No statistical difference in postoperative complications.
Patient satisfaction scores
Patient satisfaction (mean score— 2.7 vs 2.5, P = 0.537)
Operating time
Mier et al. (2013), Surg Endosc, Spain [8]
Single centre prospective review over 12 months
(11 lung biopsies, 6 Single centre prospective pneumothorax procedures, 2 review mediastinic cystectomies and (level IIb) 1 catamenial pneumothorax) n = 20 Uniport = 10 Multiport = 10 Yang et al. (2013), Surg Endosc, South Korea [9]
Single centre retrospective review
(pneumothorax: bullectomy, Single centre prospective pleurectomy, pleural review abrasion) (level IIb) n = 40 Uniport = 13 Multiport = 27
Statistical difference in: Operating time (39.5 ± 10.0 vs 49.7 ± 10.6 min, P = 0.02)
Pleural drain duration
No difference in: Pleural drain duration (38.8 ± 31.8 vs 34.2 ± 22 h, P = 0.971)
Hospital stay
Hospital stay (4 ± 31.8 vs 43.2 ± 22 h, P = 0.971)
Pain score
Statistical difference in: Pain score (4.4 ± 1.7 vs 6.2 ± 1.4, P = 0.035)
Operative time
Uniport VATS sympathectomies for palmar hyperhydrosis is a safe alternative to multiport VATS. It is superior to multiport approach with regard to pain control and decreased operating time
No difference in: Operative time (74.6 ± 22.8 vs 72.4 ± 20.2 min, P = 0.77)
Postoperative complications
Postoperative complications (chemical pleurodesis 1 vs 0; no cases of reoperation or wound infection in either, P = 0.68)
Hospital stay
Hospital stay (2.3 ± 0.7 vs 2.5 ± 0.8 days, P = 0.72)
Pain score
Pain score (on the day of surgery: 4.1 ± 1.7 vs 4.8 ± 2.2, P = 0.26; on Day 1: 3.2 ± 1.4 vs 2.8 ± 1.4, P = 0.33; on Day 2: 2.7 ± 1.0 vs 2.6 ± 1.1, P = 0.61)
Residual paraesthesia
Residual paraesthesia (33.3 vs 76.9%, P = 0.01)
Uniportal VATS for various minor lung resections leads to better pain control. There were no differences in hospital stay or chest-drain duration
Uniportal VATS is safe, feasible and can be undertaken without an increase in costs or operation time. It has better cosmesis with minimal neurological sequelae and higher patient satisfaction scores
Continued
F. Akter et al. / Interactive CardioVascular and Thoracic Surgery
Table 1: (Continued) Author, date, journal and country Study type (level of evidence)
Patient population
Outcome(s)
Key results
Surgical costs
Surgical costs (US$1810 ± $320 vs $1741 ± $329, P = 0.58)
Patient satisfaction
Patient satisfaction (70.4 vs 30.7%, P = 0.03)
Comments
VATS: video-assisted thoracoscopic surgery; LN: lymph node; ITU: intensive therapy unit.
for minor thoracic surgeries ( pneumothorax, peripheral lung nodules, thymic tumours, lung biopsies, sympathectomies and mediastinal cystectomies).
RESULTS Lobectomy Li et al. [2] operated on 162 patients; uniportal VATS lobectomy (87) versus multiport VATS lobectomy (75). There was quicker mobilization out of bed (uniportal 11 vs 13 h multiport, P = 0.045). Postoperative hospital stay was also decreased (7.18 days uniport vs 7.92 days multiport, P = 0.02). There were no differences in postoperative complications (atelactasis, persistent air leak and arrhythmias, P = 0.278). The uniport group had lower pain score (P < 0.01). McElnay et al. [3] operated on 110 patients; uniport (15) versus multiport (95). There were no differences in patient demographics, thoracoscore or American Society of Anesthesia (ASA) score. There were no differences in postoperative pain scores (P = 0.65), analgesia use (P = 0.84), duration of patient controlled analgesia used (P = 0.97), chest-drain duration (P = 0.67) or hospital stay (P = 0.54). There were no differences in operative complications, postoperative intensive therapy unit stay or in-patient mortality.
Minor thoracic surgery Tamura et al. [4] compared 37 operations ( primary spontaneous pneumothorax, peripheral lung nodules and thymic tumours), 19 uniport resected lesions versus 18 three-port VATS resected lesions. Duration of postoperative drainage was 1.11 day uniport vs 1.22 day multiport, P = 0.349, and hospital stay 3.85 days uniport vs 4.33 days multiport, P = 0.271. Mean pain scores were lower initially postoperatively (Days 0, 1, 3 post-uniportal VATS were 4.95, 2.74 and 1.32, respectively, versus 6.44, 3.78 and 1.94, for multiport VATS, P = 0.012, 0.039 and 0.037, respectively). There were no differences in patient satisfaction score and analgesia use (P = 0.078 and P = 0.119, respectively). Salati et al. [5] reported that 51 spontaneous pneumothorax patients had bullectomy and pleurectomy via uniport (23 patients) versus multiport (28 patients). The uniport group had a shorter inpatient stay 3.8 vs 4.9 days (P < 0.03), which reportedly decreased
postoperative stay costs by €400 (P = 0.03). There was no difference in the pain score reported by patients in both groups (P = 0.24). The uniport group, however, did report less paraesthesia postoperatively than the multiport group (P < 0.0001). Recurrence was 10% uniportal vs 13% multiportal (P = 0.62). Authors conclude that uniport is a safe and economical alternative to multiport VATS for spontaneous primary pneumothorax. Jutley et al. [6] had 35 spontaneous pneumothorax patients that underwent blebectomy/bullectomy and pleural abrasion. Postoperative pain was lower in uniport group (1.4 vs 2.6, P < 0.001). Neurological symptoms such as paraesthesia were also lower in the uniport group (14 vs 58%, P < 0.05). There were no serious complications in either group. Chen et al. [7] compared 20 uniport and 25 multiport (two-port) VATS sympathectomies for palmar hyperhydrosis. The pain scores were higher in the multiport (1.2 vs 0.8, P = 0.025). During the first 3 weeks postoperatively, there was a decreased incidence of residual pain in the uniport group (P = 0.366). There were no significant differences between the two groups in terms of the mean hospital stay, patient satisfaction, recurrence, compensatory sweating or Horner’s syndrome. Mier et al. [8] studied 20 cases (11 lung biopsies, 6 pneumothorax procedures, 2 mediastinic cystectomies and 1 catamenial pneumothorax): Uniport 10 vs 10 multiport VATS. There was no statistical difference between inpatient stay in the hospital (P = 0.971) or mean pleural drain duration (P = 0.971). The multiport group reported higher pain score by 1.8 (P = 0.035). Authors suggest that decreased postoperative pain is due to the protective effect of the port over the intercostal nerve and periosteum as there is less contact with surgical instruments. The uniportal group had one surgical site infection, one seroma and one recurrent pneumothorax. Authors suggest that this could be due to increased pressure on the skin by the port and that its multi-purpose use including for the use of chest-drain placement might increase the risk of complications. Yang et al. [9] analysed 40 patients (n = 13) three-port technique compared with (n = 27) single port for primary spontaneous pneumothorax. There were no differences in mean operation time (74.6 ± 2.8 vs 72.4 ± 20.2 min; P = 0.77), hospital stay (2.3 ± 0.7 vs 2.5 ± 0.8 days; P = 0.72), visual analogue pain scale or total surgical material cost (US$1810 ± $320 vs $1741 ± $329; P = 0.58). However, the uniport group had a lower incidence of paraesthesia (33.3 vs 76.9%; P = 0.01) and higher satisfaction rate regarding wound scarring (70.4 vs 30.7%; P = 0.03).
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F. Akter et al. / Interactive CardioVascular and Thoracic Surgery
CLINICAL BOTTOM LINE There are no differences in most postoperative outcomes between uniport and multiport approaches to VATS in either minor or major thoracic procedures. Uniport access may offer improved pain scores, particularly after major lung resection.
[4]
[5]
Conflict of interest: none declared.
[6]
REFERENCES
[7]
[1] Dunning J, Prendgast B, Mackway-Jones K. Towards evidence based medicine in cardiothoracic surgery: best BETS. Interact CardioVasc Thorac Surg 2003;2:405–9. [2] Li C, Ma H, He J, Ni B, Xu C, Zhao J. Clinical analysis of thoracoscopic lobectomy in the treatment of peripheral lung cancer with single utility port. Chin J Lung Cancer 2013;16:487–91. [3] McElnay PJ, Molyneux M, Krishnadas R, Batchelor TJ, West D, Casali G. Pain and recovery are comparable after either uniportal or multiport video-
[8]
[9]
assisted thoracoscopic lobectomy: an observation study. Eur J Cardiothorac Surg 2014; doi:10.1093/ejcts/ezu324. Tamura M, Shimizu Y, Hashizume Y. Pain following thoracoscopic surgery: retrospective analysis between single-incision and three-port videoassisted thoracoscopic surgery. J Cardiothorac Surg 2013;12:153. Salati M, Brunelli A, Xiumè F, Refai M, Sciarra V, Soccetti A et al. Uniportal video-assisted thoracic surgery for primary spontaneous pneumothorax: clinical and economic analysis in comparison to the traditional approach. Interact CardioVasc Thorac Surg 2008;7:63–6. Jutley RS, Khalil MW, Rocco G. Uniportal vs. standard three-port VATS technique for spontaneous pneumothorax: comparison of post-operative pain and residual paraesthesia. Eur J Cardiothorac Surg 2005;28:43–6. Chen YB, Ye W, Yang WT, Shi L, Guo XF, Xu ZH et al. Uniportal versus biportal video assisted thoracoscopic sympathectomy for palmar hyperhidrosis. Chin Med J 2009;122:1525–8. Mier JM, Chavarin A, Izquierdo-vidal C, Fibla JJ, Molins L. A prospective study comparing three-port video-assisted thoracoscopy with the singleincision laparoscopic surgery (SILS) port and instruments for the video thoracoscopic approach: a pilot study. Surg Endosc 2013;27:2557–60. Yang HC, Cho S, Jheon S. Single-incision thoracoscopic surgery for primary spontaneous pneumothorax using the SILS port compared with conventional three-port surgery. Surg Endosc 2013;27:139–45.
Cite this article as: Akter F, Routledge T, Toufektzian L, Attia R. In minor and major thoracic procedures is uniport superior to multiport video-assisted thoracoscopic surgery? Interact CardioVasc Thorac Surg 2015; doi:10.1093/icvts/ivu375.
In minor and major thoracic procedures is uniport superior to multiport video-assisted thoracoscopic surgery? Farhana Akter, Tom Routledge, Levon Toufektzian and Rizwan Attia* Department of Cardiothoracic Surgery, Guy’s Hospital, London, UK * Corresponding author. Department of Cardiothoracic Surgery, 6th Floor Tower Wing, Guy’s Hospital, London SE1 9RT, UK. Tel: +44-20-71880214; fax: +44-20-71881006; e-mail: [email protected] (R. Attia). Received 10 April 2014; received in revised form 11 December 2014; accepted 12 December 2014
Abstract A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was: Are there differences in outcomes in uniport compared with multiport video-assisted thoracoscopic surgery? Altogether, 45 papers were found using the reported search, of which 8 papers represent the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type and level of evidence of publication, relevant outcomes and results of these papers are tabulated. Two studies (272 patients) compared outcomes for lobectomy. One study found pain control was significantly better in uniportal (P < 0.01) with earlier mobilization (P < 0.05), and decreased hospital stay by half a day (P < 0.05). The chest drain volume was less, and consequently the number of days the chest drain remained in situ decreased by 1 day (P < 0.05). The second study looking at lobectomies failed to find any differences between the two techniques. For minor thoracic procedures ( pneumothorax, peripheral lung nodules, thymic tumours, lung biopsies, sympathectomies and mediastinal cystectomies), 3 papers (117 patients) showed a statistically significant reduction in pain score during inpatient stay, and 1 paper showed a reduction in pain score day 0 postoperatively, however, no difference in pain score days 1 and 3 postoperatively. Two papers (n = 91) showed no difference in the reported pain scores; however, the patients in the uniportal group experienced less paraesthesia postoperatively. Patients in the uniportal group in this study also had reduced in-hospital stay (P = 0.03), and this led to a reduction in inpatient costs (P = 0.03). Four other studies, however, did not find any significant difference in duration of hospital stay. Pain scores are lower in uniportal VATS, most studies however do not demonstrate differences in other outcomes including analgesic use, duration of chest tube drainage, length of hospital stay or other thoracic complications. We conclude that, although uniport access may offer improved pain scores, the current evidence reveals no differences in most postoperative outcomes between uniport and multiport approaches to VATS in either minor or major thoracic procedures. Keywords: Video-assisted thoracoscopic surgery • Uniport • Multiport • Outcomes • Pain • Complications
INTRODUCTION A best evidence topic was constructed according to a structured protocol. This is fully described in ICVTS [1].
THREE-PART QUESTION In minor and major [lung resection] is [uniport] superior to [multiport] [Video-Assisted Thoracoscopic Surgery] (VATS) in [outcomes]?
CLINICAL SCENARIO You routinely perform three-/four-port VATS lobectomies and minor lung resections. There are however encouraging single
centre reports for uniport VATS. You decide to look at the evidence on the topic to assess if a change in practice is warranted.
SEARCH STRATEGY A Medline search from 1990 to November 2014 was performed using [single incision.mp OR Uniport.mp] AND (VATS.mp OR Thoracic Surgery, Video-Assisted.mp OR thoracoscopy.mp)
SEARCH OUTCOME Forty-five papers were found using the reported search. From these, eight papers were identified that provided the best evidence to answer the question. These are presented in Table 1. The recommendations are based on operative outcomes of 2 centres (272 patients) for lobectomy and 6 centres (228 patients)
© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
BEST EVIDENCE TOPIC
BEST EVIDENCE TOPIC – THORACIC
Interactive CardioVascular and Thoracic Surgery (2015) 1–6 doi:10.1093/icvts/ivu375
F. Akter et al. / Interactive CardioVascular and Thoracic Surgery
2
Table 1: Summary of best evidence Author, date, journal and country Study type (level of evidence)
Patient population
Outcome(s)
Li et al. (2013), Chin J Lung Cancer, China [2]
Single centre retrospective review over 2 years
Operative time
Single centre retrospective review (level IIb)
Lobectomy n = 162 Uniport = 87 Multiport = 75
Single centre prospective series over 1 year
VATS lobectomies Single centre prospective n = 110 series Uniport = 15 (level IIa) Multiport = 95
Comments
No difference in: Demonstrate the safety and Operative time (151.03 ± 25.97 vs feasibility to undertake uniport 156.27 ± 26.49 min, P = 0.207) compared with multiport VATS lobectomy in selected patients Lymph node dissection LN dissection number number (13.06 ± 1.36 vs 12.61 ± 1.56, P = 0.057) Intraoperative blood loss
Blood loss (188.62 ± 47.0 vs 179.60 ± 28.96 ml, P = 0.138)
Serious complications
Postoperative complications (18/87 vs 21/75, P = 0.278)
Time to first activity
McElnay et al. (2014), Eur J Cardiothorac Surg, UK [3]
Key results
Statistical difference in: Time to first activity (11.17 ± 8.69 vs 13.76 ± 7.43 h, P < 0.05)
Pain score
Pain score Days 1 and 3 (2 and 1.2 for uniport vs 5 and 4.8 for multiport VATS, P < 0.01)
Chest tube drainage (days)
Chest tube drainage (3.85 ± 1.21 vs 4.43 ± 1.43 days, P < 0.05)
Chest-drain volume
Chest-drain volume (671.49 ± 178.31 vs 736.93 ± 170.39 ml, P < 0.05)
Hospital stay
Hospital stay is higher in multiport patients (7.92 ± 2.03 vs 7.18 ± 1.95 days in uniport, P < 0.05)
Pain score
There was no difference in the first 24 h visual analogue pain scores, P = 0.65
Analgesia use
The median morphine use in the first 24 postoperative hours was 19 mg in the uniportal group and 23 mg in the multiport group P = 0.84
Uniport VATS lobectomy was deemed safe without any differences in pain scores, analgesia use or procedural outcomes
No difference in the duration of patient-controlled analgesia P = 0.97 Chest-drain duration
No difference in chest-drain duration P = 0.67
Hospital stay
No difference in hospital length of stay P = 0.54
Postoperative ITU stay
There were no admissions to ITU in either group
Mortality
No inpatient mortality and no unplanned admission to critical care in either group
Tamura et al. (2013), J Cardiothorac Surg, Japan [4]
Single centre Retrospective review over 10 months
Operative time
Single centre retrospective review (level IIb)
(pneumothorax, peripheral lung nodules and thymic tumours) n = 37
Duration of chest-drainage
There is no statistical difference in: Operative time (60.5 ± 3.1 vs 58.8 ± 3.2 min, P = 0.692)
The use of uniportal VATS for minor lung resections leads to better pain relief immediately post-procedure
Chest tube drainage (1.11 ± 0.09 vs 1.22 ± 0.09 days, P = 0.349)
Continued
F. Akter et al. / Interactive CardioVascular and Thoracic Surgery
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Table 1: (Continued) Author, date, journal and country Study type (level of evidence)
Patient population
Outcome(s)
Key results
Uniport = 19 Multiport = 18
Duration of hospital stay
Hospital stay (3.85 ± 0.27 vs 4.33 ± 0.28 days, P = 0.271)
Inpatient pain scores
Pain score day 1 (2.74 ± 0.34 for uniport and 3.78 ± 0.35 for multiport, P = 0.039) Pain score day 3 (1.32 ± 0.20 for uniport and 1.94 ± 0.21 for multiport, P = 0.037)
Use of analgesics
Use of analgesics (dose of per rectal diclofenac) 0.89 ± 0.24 for uniportal and 1.44 ± 0.94 (P = 0.119)
Comments
There is statistical difference in: Pain score day 0 (4.95 ± 0.38 for uniport and 6.44 ± 0.39 for multiport, P = 0.012)
Salati et al. (2008), Interact CardioVasc Thorac Surg, Italy [5] Single centre retrospective review (level IIb)
Single centre retrospective review over 5 years (pneumothorax: bullectomy, pleurectomy, pleural abrasion) n = 51 Uniport = 28 Multiport = 23
Patient satisfaction scores
Satisfaction scores (8.95 ± 0.24 vs 8.33 ± 0.24, P = 0.078)
Wound infection
Wound infection (0 patients (0%) vs 1 patient (5.6%), P = 0.663)
Hospital stay
There is no statistical difference in: Operative time (72.3 ± 31.8 vs 68.7 ± 25.5 min, P = 0.67)
Pain score
Pain score (0.6 ± 1 vs 1.3 ± 1.7, P = 0.24)
Paraesthesia
Paraesthesia (9/26 (35%) vs 18/19 (94%), P < 0.0001)
Postoperative costs
Postoperative stay costs (€1407 ± 649.2 vs €1793 ± 893.5, P = 0.03)
Prolonged air leak
Prolonged air leak > 5 days (1/28 (3.5%) vs 4/23 (17%), P = 0.09)
Recurrence rate
Recurrence rate (2/28 (10%) vs 3/23 (13%), P = 0.62)
Mobilization (normal activity)
Normal activity after 6 months (25/26 (95%) vs 15/19 (79%), P = 0.069)
Uniportal VATS for spontaneous pneumothorax is superior to multiport VATS with regard to decreased hospital stay and consequently postoperative costs. These patients also have less chance of prolonged air leak, suffer less paraesthesia and more mobile on long-term follow-up
There is a statistical difference in: Postoperative stay (3.8 ± 1.8 vs 4.9 ± 2.4 days, P = 0.03) Jutley et al. (2005), Eur J Cardiothorac Surg, Spain [6]
Single centre retrospective review over 3 years
Single centre retrospective review (level IIb)
(pneumothorax: bullectomy, pleurectomy, pleural abrasion) n = 35
Chest tube drainage Hospital stay
No difference in: Chest tube drainage (4.6 ± 2 vs 3.9 ± 2.1, P = 0.30) Hospital stay (4.6 ± 3.1 vs 4.1 ± .0, P = 0.35)
Uniportal VATS for pneumothorax is a safe alternative to multiportal VATS, and leads to greater pain control and less neurological symptoms on long-term follow-up
Continued
F. Akter et al. / Interactive CardioVascular and Thoracic Surgery
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Table 1: (Continued) Author, date, journal and country Study type (level of evidence)
Patient population
Outcome(s)
Key results
Uniport = 16 Multiport = 19
Inpatient pain score
Statistical difference in: Inpatient pain score (1.4 ± 0.9 vs 2.6 ± 0.9, P ≤ 0.001)
Comments
Long-term symptoms— Long-term symptoms—pain pain (4/14 (28%), vs 5/12 (42%), P = 0.6) Long-term symptoms— Long-term symptoms— neurological neurological (2/14 (14%) vs 7/12 (58%), P < 0.05) Chen et al. (2009), Chin Med J, China [7] Single centre retrospective review (level IIb)
Single centre retrospective review over 2 years (VATS sympathectomies) n = 45 Uniport = 20 Multiport = 25
Hospital stay
No difference in: Hospital stay (2.4 ± 0.8 vs 2.5 ± 0.8 days, P = 0.599)
Pain scores
Pain scores (0.8 ± 0.5 vs 1.2 ± 0.6, P = 0.025) Residual pain (n, %) (4 (20%) vs 8 (32), P = 0.366)
Postoperative complications
No statistical difference in postoperative complications.
Patient satisfaction scores
Patient satisfaction (mean score— 2.7 vs 2.5, P = 0.537)
Operating time
Mier et al. (2013), Surg Endosc, Spain [8]
Single centre prospective review over 12 months
(11 lung biopsies, 6 Single centre prospective pneumothorax procedures, 2 review mediastinic cystectomies and (level IIb) 1 catamenial pneumothorax) n = 20 Uniport = 10 Multiport = 10 Yang et al. (2013), Surg Endosc, South Korea [9]
Single centre retrospective review
(pneumothorax: bullectomy, Single centre prospective pleurectomy, pleural review abrasion) (level IIb) n = 40 Uniport = 13 Multiport = 27
Statistical difference in: Operating time (39.5 ± 10.0 vs 49.7 ± 10.6 min, P = 0.02)
Pleural drain duration
No difference in: Pleural drain duration (38.8 ± 31.8 vs 34.2 ± 22 h, P = 0.971)
Hospital stay
Hospital stay (4 ± 31.8 vs 43.2 ± 22 h, P = 0.971)
Pain score
Statistical difference in: Pain score (4.4 ± 1.7 vs 6.2 ± 1.4, P = 0.035)
Operative time
Uniport VATS sympathectomies for palmar hyperhydrosis is a safe alternative to multiport VATS. It is superior to multiport approach with regard to pain control and decreased operating time
No difference in: Operative time (74.6 ± 22.8 vs 72.4 ± 20.2 min, P = 0.77)
Postoperative complications
Postoperative complications (chemical pleurodesis 1 vs 0; no cases of reoperation or wound infection in either, P = 0.68)
Hospital stay
Hospital stay (2.3 ± 0.7 vs 2.5 ± 0.8 days, P = 0.72)
Pain score
Pain score (on the day of surgery: 4.1 ± 1.7 vs 4.8 ± 2.2, P = 0.26; on Day 1: 3.2 ± 1.4 vs 2.8 ± 1.4, P = 0.33; on Day 2: 2.7 ± 1.0 vs 2.6 ± 1.1, P = 0.61)
Residual paraesthesia
Residual paraesthesia (33.3 vs 76.9%, P = 0.01)
Uniportal VATS for various minor lung resections leads to better pain control. There were no differences in hospital stay or chest-drain duration
Uniportal VATS is safe, feasible and can be undertaken without an increase in costs or operation time. It has better cosmesis with minimal neurological sequelae and higher patient satisfaction scores
Continued
F. Akter et al. / Interactive CardioVascular and Thoracic Surgery
Table 1: (Continued) Author, date, journal and country Study type (level of evidence)
Patient population
Outcome(s)
Key results
Surgical costs
Surgical costs (US$1810 ± $320 vs $1741 ± $329, P = 0.58)
Patient satisfaction
Patient satisfaction (70.4 vs 30.7%, P = 0.03)
Comments
VATS: video-assisted thoracoscopic surgery; LN: lymph node; ITU: intensive therapy unit.
for minor thoracic surgeries ( pneumothorax, peripheral lung nodules, thymic tumours, lung biopsies, sympathectomies and mediastinal cystectomies).
RESULTS Lobectomy Li et al. [2] operated on 162 patients; uniportal VATS lobectomy (87) versus multiport VATS lobectomy (75). There was quicker mobilization out of bed (uniportal 11 vs 13 h multiport, P = 0.045). Postoperative hospital stay was also decreased (7.18 days uniport vs 7.92 days multiport, P = 0.02). There were no differences in postoperative complications (atelactasis, persistent air leak and arrhythmias, P = 0.278). The uniport group had lower pain score (P < 0.01). McElnay et al. [3] operated on 110 patients; uniport (15) versus multiport (95). There were no differences in patient demographics, thoracoscore or American Society of Anesthesia (ASA) score. There were no differences in postoperative pain scores (P = 0.65), analgesia use (P = 0.84), duration of patient controlled analgesia used (P = 0.97), chest-drain duration (P = 0.67) or hospital stay (P = 0.54). There were no differences in operative complications, postoperative intensive therapy unit stay or in-patient mortality.
Minor thoracic surgery Tamura et al. [4] compared 37 operations ( primary spontaneous pneumothorax, peripheral lung nodules and thymic tumours), 19 uniport resected lesions versus 18 three-port VATS resected lesions. Duration of postoperative drainage was 1.11 day uniport vs 1.22 day multiport, P = 0.349, and hospital stay 3.85 days uniport vs 4.33 days multiport, P = 0.271. Mean pain scores were lower initially postoperatively (Days 0, 1, 3 post-uniportal VATS were 4.95, 2.74 and 1.32, respectively, versus 6.44, 3.78 and 1.94, for multiport VATS, P = 0.012, 0.039 and 0.037, respectively). There were no differences in patient satisfaction score and analgesia use (P = 0.078 and P = 0.119, respectively). Salati et al. [5] reported that 51 spontaneous pneumothorax patients had bullectomy and pleurectomy via uniport (23 patients) versus multiport (28 patients). The uniport group had a shorter inpatient stay 3.8 vs 4.9 days (P < 0.03), which reportedly decreased
postoperative stay costs by €400 (P = 0.03). There was no difference in the pain score reported by patients in both groups (P = 0.24). The uniport group, however, did report less paraesthesia postoperatively than the multiport group (P < 0.0001). Recurrence was 10% uniportal vs 13% multiportal (P = 0.62). Authors conclude that uniport is a safe and economical alternative to multiport VATS for spontaneous primary pneumothorax. Jutley et al. [6] had 35 spontaneous pneumothorax patients that underwent blebectomy/bullectomy and pleural abrasion. Postoperative pain was lower in uniport group (1.4 vs 2.6, P < 0.001). Neurological symptoms such as paraesthesia were also lower in the uniport group (14 vs 58%, P < 0.05). There were no serious complications in either group. Chen et al. [7] compared 20 uniport and 25 multiport (two-port) VATS sympathectomies for palmar hyperhydrosis. The pain scores were higher in the multiport (1.2 vs 0.8, P = 0.025). During the first 3 weeks postoperatively, there was a decreased incidence of residual pain in the uniport group (P = 0.366). There were no significant differences between the two groups in terms of the mean hospital stay, patient satisfaction, recurrence, compensatory sweating or Horner’s syndrome. Mier et al. [8] studied 20 cases (11 lung biopsies, 6 pneumothorax procedures, 2 mediastinic cystectomies and 1 catamenial pneumothorax): Uniport 10 vs 10 multiport VATS. There was no statistical difference between inpatient stay in the hospital (P = 0.971) or mean pleural drain duration (P = 0.971). The multiport group reported higher pain score by 1.8 (P = 0.035). Authors suggest that decreased postoperative pain is due to the protective effect of the port over the intercostal nerve and periosteum as there is less contact with surgical instruments. The uniportal group had one surgical site infection, one seroma and one recurrent pneumothorax. Authors suggest that this could be due to increased pressure on the skin by the port and that its multi-purpose use including for the use of chest-drain placement might increase the risk of complications. Yang et al. [9] analysed 40 patients (n = 13) three-port technique compared with (n = 27) single port for primary spontaneous pneumothorax. There were no differences in mean operation time (74.6 ± 2.8 vs 72.4 ± 20.2 min; P = 0.77), hospital stay (2.3 ± 0.7 vs 2.5 ± 0.8 days; P = 0.72), visual analogue pain scale or total surgical material cost (US$1810 ± $320 vs $1741 ± $329; P = 0.58). However, the uniport group had a lower incidence of paraesthesia (33.3 vs 76.9%; P = 0.01) and higher satisfaction rate regarding wound scarring (70.4 vs 30.7%; P = 0.03).
BEST EVIDENCE TOPIC
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F. Akter et al. / Interactive CardioVascular and Thoracic Surgery
CLINICAL BOTTOM LINE There are no differences in most postoperative outcomes between uniport and multiport approaches to VATS in either minor or major thoracic procedures. Uniport access may offer improved pain scores, particularly after major lung resection.
[4]
[5]
Conflict of interest: none declared.
[6]
REFERENCES
[7]
[1] Dunning J, Prendgast B, Mackway-Jones K. Towards evidence based medicine in cardiothoracic surgery: best BETS. Interact CardioVasc Thorac Surg 2003;2:405–9. [2] Li C, Ma H, He J, Ni B, Xu C, Zhao J. Clinical analysis of thoracoscopic lobectomy in the treatment of peripheral lung cancer with single utility port. Chin J Lung Cancer 2013;16:487–91. [3] McElnay PJ, Molyneux M, Krishnadas R, Batchelor TJ, West D, Casali G. Pain and recovery are comparable after either uniportal or multiport video-
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assisted thoracoscopic lobectomy: an observation study. Eur J Cardiothorac Surg 2014; doi:10.1093/ejcts/ezu324. Tamura M, Shimizu Y, Hashizume Y. Pain following thoracoscopic surgery: retrospective analysis between single-incision and three-port videoassisted thoracoscopic surgery. J Cardiothorac Surg 2013;12:153. Salati M, Brunelli A, Xiumè F, Refai M, Sciarra V, Soccetti A et al. Uniportal video-assisted thoracic surgery for primary spontaneous pneumothorax: clinical and economic analysis in comparison to the traditional approach. Interact CardioVasc Thorac Surg 2008;7:63–6. Jutley RS, Khalil MW, Rocco G. Uniportal vs. standard three-port VATS technique for spontaneous pneumothorax: comparison of post-operative pain and residual paraesthesia. Eur J Cardiothorac Surg 2005;28:43–6. Chen YB, Ye W, Yang WT, Shi L, Guo XF, Xu ZH et al. Uniportal versus biportal video assisted thoracoscopic sympathectomy for palmar hyperhidrosis. Chin Med J 2009;122:1525–8. Mier JM, Chavarin A, Izquierdo-vidal C, Fibla JJ, Molins L. A prospective study comparing three-port video-assisted thoracoscopy with the singleincision laparoscopic surgery (SILS) port and instruments for the video thoracoscopic approach: a pilot study. Surg Endosc 2013;27:2557–60. Yang HC, Cho S, Jheon S. Single-incision thoracoscopic surgery for primary spontaneous pneumothorax using the SILS port compared with conventional three-port surgery. Surg Endosc 2013;27:139–45.
