Twenty one relevant studies were identified (n=2,641 patients), including two randomised controlled trials (RCTs, n=161 patients, range 61 to 100) and 19 observational cohort studies (n=2,480 patients, range 22 to 292). The mean Downs and Black quality score was 14 out of a maximum of 33 (standard deviation 2.3).
Morbidity and mortality: There were no statistically significant differences between video-assisted thoracic surgery and open lobectomy for postoperative prolonged air leak (eight studies; I2=0%), arrhythmia (seven studies; I2=35.1%), pneumonia (five studies; I2=28.3%), or perioperative mortality (three studies; I2=29.8%). The pooled estimates for some outcomes were associated with severe heterogeneity (I2 over 90%): blood loss (14 studies), chest drain duration (11 studies), and length of hospital stay (13 studies). The median conversion rate for video-assisted thoracic surgery to open lobectomy was 8.1% (range 0 to 15.7%; 14 studies) due to technical difficulties, extent of tumour, hilar lymph node metastasis, uncontrollable bleeding, completely fused fissure or other reasons.
Recurrence and survival: There was no statistically significant difference between video-assisted thoracic surgery and open lobectomy in locoregional recurrence (six studies; I2=30.2%), but video-assisted thoracic surgery was associated with a significantly reduced systemic recurrence rate (RR 0.57, 95% CI 0.34 to 0.95; five studies; I2=0%) and a significantly reduced all-cause five-year mortality rate (RR 0.66, 95% CI 0.45 to 0.97; seven studies; I2=0%).
The subgroup analyses for studies not using a rib spreader found similar non-significant results for postoperative prolonged air leak, arrhythmia, pneumonia, and locoregional recurrence, but the results for both systemic recurrence rate (three studies; I2=0%) and all-cause five-year mortality rate (four studies; I2=0%) did not show a statistically significant benefit for video-assisted thoracic surgery.