Quality of life during the implementation of a robot-assisted thoracic surgery program compared to video-assisted thoracic surgery—a retrospective evaluation of 138 patients

Introduction

Since its introduction in 2002, robot-assisted thoracic surgery (RATS) has become established worldwide for major thoracic surgery (1,2). Studies have demonstrated both its safety and efficiency for anatomic lung resections and the resection of mediastinal tumors (3,4). In contrast to thoracotomies, RATS spares rib spreading and creates less pressure on the anatomical structures of the chest wall (5). Potential benefits for patients undergoing RATS compared to thoracotomy or video-assisted thoracic surgery (VATS) are currently being evaluated. It has been demonstrated that the length of hospital stay and the length of stay of chest tubes are shortened for patients after RATS than after thoracotomy and VATS, respectively. Compared with VATS, RATS appears to be associated with a shorter operator learning curve and higher precision, especially in mediastinal lymphadenectomy (6,7). However, compared to thoracotomy and VATS, higher overall costs per case for RATS procedures have been reported (8,9).

The implementation of a RATS program at a surgical center is complex. During the implementation period, patient safety must be ensured and, accordingly, clinical outcomes need to be monitored. This includes, for example, postoperative quality of life (QoL) and pain. Pain is an important dimension of QoL because QoL is known to be impaired significantly in patients with pain (10). Furthermore, acute pain following thoracic surgery is frequent and chronic pain, defined as recurring or persisting pain more than 2 months postoperatively, affects 20% to 50% of patients (11,12). Although minimally invasive thoracic surgery techniques are presumed to minimize postoperative pain, it is observed similarly in patients after both VATS and RATS (13-15). Existing data on QoL and pain during the implementation period of a RATS program generally favor RATS over VATS but these results are rare, sometimes inconsistent, or difficult to compare.

In this cross-sectional study, we included 138 patients who underwent RATS or VATS for the resection of tumors of the lung or mediastinum during the RATS implementation period. The aim of this study was to compare (I) the postoperative QoL and (II) the incidence of post-surgery pain during the RATS implementation program at our center. We present this article in accordance with the STROBE reporting checklist (available at https://vats.amegroups.com/article/view/10.21037/vats-24-5/rc).

Methods

Ethical statement

This study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the institutional ethics committee of the Medical Faculty Heidelberg (approval ID: S-089/2018 and S-921/2019) and individual consent for this retrospective analysis was waived.

General study characteristics

The analysis included all patients who underwent a resection of tumors of the lung or mediastinum by VATS or RATS at Thoraxklinik of the Heidelberg University between April 2018 and September 2019. The first RATS in our clinic was performed in April 2018. We defined the first 18 months as the RATS implementation period which determined the sample size. We retrospectively identified suitable patients by searching for relevant surgical procedure codes. For further eligibility, patients had to complete postoperative evaluation (3–18 months post-surgery) in our outpatient clinic. The exclusion criteria were thoracic surgeries other than those of the lung or mediastinum, incomplete postoperative follow-ups, chronic pain syndromes not explained by the thoracic intervention, or postoperative wound healing disorders. As the primary endpoint of this study, postoperative QoL was analyzed. As the secondary endpoint, the individual pain experience was used. All outcomes were considered in relation to the thoracic surgery received (VATS or RATS).

Thoracic surgery and pain management

The VATS procedures were performed as uni-, bi-, or triportal approaches. For VATS lobectomies, a bi- or triportal technique involving a 4 cm utility incision was used. The RATS procedures were performed using a da Vinci X System (Intuitive Surgical Inc., Sunnyvale, CA, USA) by applying a 3-arm or 4-port technique and using a 12–15 mm assistant port. The diameter of the robotic trocars was 8 mm. The incisions were then used to insert one or two chest tubes at the end of the operation. All incisions were placed in similar positions according to our in-house standard. Furthermore, the team of surgeons (n=8) was constant over time.

The general anesthesia was performed highly standardized. All patients scheduled for anatomical resection via VATS or RATS were offered epidural anesthesia. In addition, they received nonopioid analgesics post-surgery. After the chest tubes were removed, the epidural anesthesia was replaced with oral opioids that were subsequently reduced.

Postoperative evaluation

Patients followed up in the outpatient clinic were routinely asked to complete a 31-item questionnaire developed in our clinic that addressed the individual pain experience [e.g., current pain intensity, pain quality, medication, and QoL using the 100-point visual analogue scale (VAS) and the EQ-5D-3L index (16)]. EuroQoL approved our application of the EQ-5D-3L survey form (registration ID: 35821). Furthermore, patient characteristics were collected [e.g., age, sex, body mass index, and physical status according to the American Society of Anesthesiologists’ physical status classification system (17)] and perioperative details (e.g., hospital stay, number of ports in the case of VATS, duration of epidural anesthesia, pain from days 1 to 7 post-surgery using an 11-point numeric rating scale (18), and morphine equivalent daily dose at the time of discharge).

Complications were recorded if the patient showed symptoms of postoperative infection (e.g., pneumonia) and required antibiotic treatment, had a persistent bronchopleural fistula, or required intensive care.

To reduce information bias, the questionnaire was pretested by interdisciplinary experts from our hospital. We also checked the data for impossible coding and unreliable outlier values to reduce misclassification.

Statistical analysis

The data were analyzed using SPSS Statistics 26 (IBM, Armonk, NY, USA). Missing data were excluded from the analysis. Categorical variables were tested for frequency distribution with a Chi-squared test. The ordinal variables of the two groups (VATS, RATS) were compared for ranking with the Mann-Whitney U-test. A t-test was applied to detect differences in the means of the interval variables with regard to the different surgical procedures. Linear contrasts helped to assess the QoL of the RATS patients compared to that of the VATS patients. If the F-test showed a significant difference in the means of the two groups, a post hoc test was performed to reveal details. To address type I errors, a Bonferroni correction was applied. Multiple linear regression was also used to analyze the impact of the patient characteristics on the EQ-5D-3L index. The data are reported as mean ± standard deviation. Differences between groups were considered significant if P<0.05.

Results

General characteristics

A total of 138 patients agreed to complete the questionnaire and were included in this study (VATS: 48%, RATS: 52%; Figure 1). All other patients did not meet the eligibility criteria, did not agree to complete the questionnaire, or did not fill out the questionnaire completely. Table 1 summarizes the general patient and treatment characteristics.

Figure 1 Patient selection. VATS, video-assisted thoracic surgery; RATS, robot-assisted thoracic surgery.

Thoracic surgery

Lung resections were more often performed as VATS procedures. RATS was more often used to resect mediastinal tumors (P<0.001). There were no significant differences between uni-, bi-, or triportal approaches for VATS procedures. Postoperative complications occurred in 14% of all patients. The complication rate was significantly lower in patients who received RATS compared to those who received VATS (P=0.01). The main complication was postoperative pneumonia, which required antibiotic treatment. The length of hospital stay for RATS patients was also significantly shorter (7±3 days, VATS: 12±4 days; P<0.001). No significant differences were detected between VATS and RATS regarding the further postoperative oncological treatment.

Perioperative pain management

The data did not indicate the superiority of epidural analgesia in preventing long-term pain. Also, patients’ pain scores in the first 5 days after surgery did not correlate significantly with their long-term pain scores. At discharge, RATS patients required significantly fewer opioid analgesics (45%) than VATS patients (55%; P=0.001).

The individual amount of morphine equivalent daily dose at discharge did not correlate with long-term pain level. Table 2 summarizes all the pain management results.

Pain management after discharge

After hospital discharge, 71% of all patients reported persistent pain. The persistence of pain after discharge was less common after RATS (mean: 3.0±2.5 months) than after VATS (3.9±2.2; P=0.07). In addition, pain was less severe in RATS patients (mean pain score: 3.7±2.5) compared to VATS patients (4.5±2.4; P=0.07). Six months after surgery, 18 patients (13%) reported persistent pain (VATS: n=10/15%, RATS: n=8/11%; P=0.07). In contrast, 77% of patients reported freedom from pain. After repeat thoracic surgery, patients were not significantly more likely to report pain than those who had undergone an initial surgery.

At the time of the survey, 23% of the patients were still taking pain medication (VATS: 32%, RATS: 15%). RATS patients required significantly less pain medication by dosage (P=0.03). The patients took their pain medication either daily (31%) or sporadically (69%). Pain relief from medication was very good or good in 53% of patients, satisfactory in 40%, and inadequate in 7%.

QoL

RATS patients reported a significantly higher 100-point VAS QoL (mean: 7.7±2.2) than VATS patients (6.9±2.0; P=0.04). Furthermore, there was a trend for a higher EQ-5D-3L QoL in RATS patients (0.8±0.26) compared to VATS patients (0.71±0.24; P=0.06; Figure 2). Freedom from pain after discharge was associated with a significantly higher VAS QoL (mean: 8.0±1.9) than ongoing postoperative pain (7.0±2.2; P=0.02). This result was similar to the EQ-5D-3L index findings but statistically nonsignificant (mean EQ-5D-3L index for freedom of pain after discharge: 0.82±0.24, ongoing pain: 0.74±0.26; P=0.12).

Figure 2 Postoperative quality of life. VAS, visual analogue scale; VATS, video-assisted thoracic surgery; RATS, robot-assisted thoracic surgery.

The detailed comparison of the five EQ-5D-3L dimensions confirmed that RATS patients reported being free of pain significantly more often than VATS patients (P=0.03). Furthermore, mobility was improved after RATS (P=0.01). Finally, 74% of all patients reported that pain medication improved their QoL. Multiple linear regression showed a significant impact of existing preoperative pain on the EQ-5D-3L index scores (P=0.001). Table 3 summarizes all QoL results.

Discussion

In the present study, the postoperative QoL of RATS patients was not affected during the implementation of the robotic surgical method compared with that of VATS patients. In fact, QoL measured using the 100-point VAS was higher for RATS patients. When the EQ-5D-3L index was used, there was a trend toward a higher QoL. The difference between the two methods may be explained by the higher percentage of missing values for the EQ-5D-3L group (20% versus 7% in the 100-point VAS group).

These results support other findings by Worrell et al. attesting to acceptable QoL during and after a RATS implementation period (19). Worrell et al. evaluated QoL outcomes by applying the European Organisation for Research and Treatment of Cancer (EORTC) QoL questionnaire. This questionnaire is more complex and, therefore, less patient-centered than the EQ-5D-3L index or the 100-point VAS. To our knowledge, this literature is the only relevant study comparable with the present one which focuses QoL in developing a RATS program.

However, the general data remain limited and sometimes controversial. Lacroix et al. observed satisfactory QoL after RATS lobectomy alone by analyzing 39 patients at a mean follow-up of 7 months (13). QoL correlated with pain status, and in the case of higher pain levels, participation in daily activities was impaired. Williams et al. studied 219 patients for 6 months after VATS (n=139) and RATS lobectomies (n=80) and found that VATS was superior to RATS in terms of QoL (14). Cerfolio et al. similarly compared 106 RATS patients with 318 thoracotomy patients up to 4 months after surgery and found that physical and psychological QoL improved in favor of RATS (20). Balduyck et al. compared 14 patients who underwent mediastinal mass resection using RATS with 22 patients who received a sternotomy. The researchers found no significant difference in QoL up to 12 months postoperatively (21). Finally, the latest literature seems to favor RATS over VATS for maintaining QoL post-surgery (22,23).

The 100-point QoL VAS and the QoL EQ-5D-3L index are well established in clinical practice for various diseases (24,25). The VAS can easily be completed by patients, though the EQ-5D-3L index is a multidimensional and multilevel approach and is thus more precise. However, it requires higher patient compliance, and the transfer of data into the index is more time consuming. Despite these differences, the VAS’s approximations of QoL generated values similar to the EQ-5D-3L index. In clinical practice, the VAS seems to be suitable for estimating overall QoL in post-lung surgery patients, while for multi-aspect analyses, the EQ-5D-3L index (243 possible health states) may be more applicable. Other QoL indices, such as the EQ-5D-5L (3,125 states) or the Short Form 36 health survey (1.8×10²⁰ states), may provide a more in-depth evaluation, though they have rarely been used to evaluate RATS patients (26,27).

In our study, postoperative pain was not increased in RATS patients compared with VATS patients. A more detailed data analysis to evaluate the pain reduction potential of RATS procedures compared with VATS was not possible due to the small group sizes.

Compared with open lung surgery, minimally invasive procedures such as VATS and RATS are known to be associated with shorter intensive care unit stay, shorter overall hospital stay, less postoperative pain, and faster recovery (28,29). In this study, the hospital stay of the RATS patients was shorter than that of the VATS patients. Furthermore, the RATS patients required fewer opioid analgesics at discharge. This may suggest that the RATS procedure causes less stress on the anatomic structures of the chest wall, despite the greater number of mini-thoracotomies (<1 cm) compared to VATS. One explanation could be that the fully articulating and opposable robotic instruments exert less torque and pressure displacement on the thoracic trocars and thus on the intercostal space and the costal nerves (30).

Limitations

The current study presents cross-sectional data of patients treated in one of Germany’s largest centers of thoracic surgery. The characteristics of 138 patients after thoracic surgery were retrospectively evaluated. Because of the heterogeneity of the group and the different subgroups, the analysis is prone to bias. In addition, we followed up RATS patients in our outpatient clinic more frequently than VATS patients. Accordingly, a prospective study design and a larger sample size are needed to minimize potential errors and ensure broader generalizability of study results.

Conclusions

In our center, the RATS program was implemented safely. QoL was not impaired in the RATS patients compared to the VATS patients. In fact, patients had a higher QoL measured using the 100-point VAS and lower pain scores after RATS than after VATS.

Acknowledgments

The authors would like to thank the team of the outpatient clinic at Thoraxklinik/Heidelberg University Hospital for the support of this study. Furthermore, the authors thank Tom Bruckner, PhD (Institute of Medical Biometry and Informatics/Heidelberg University Hospital) for the assistance by preparing the statistical analysis.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://vats.amegroups.com/article/view/10.21037/vats-24-5/rc

Data Sharing Statement: Available at https://vats.amegroups.com/article/view/10.21037/vats-24-5/dss

Peer Review File: Available at https://vats.amegroups.com/article/view/10.21037/vats-24-5/prf

Funding: This work was supported by Intuitive Surgical.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://vats.amegroups.com/article/view/10.21037/vats-24-5/coif). H.W. and M.E.E. received advisory fees and research fundings from Intuitive Surgical. In addition, both are proctors for Intuitive Surgical. The other 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. This study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the institutional ethics committee of the Medical Faculty Heidelberg (approval ID: S-089/2018 and S-921/2019) and individual consent for this retrospective analysis was waived.

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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