National Medical Policy
Subject:
Video-Assisted Thoracoscopic Surgery (VATS)
Policy Number:
NMP430
Effective Date*: August 2008
Updated:
September 2015
This National Medical Policy is subject to the terms in the
IMPORTANT NOTICE
at the end of this document
For Medicaid Plans: Please refer to the appropriate Medicaid Manuals for, coverage
guidelines prior to applying Health Net Medical Policies
The Centers for Medicare & Medicaid Services (CMS)
For Medicare Advantage members please refer to the following for coverage
guidelines first:
Use
X
Source
National Coverage Determination
(NCD)
Reference/Website Link
Lung Volume Reduction Surgery (Reduction
Pneumoplasty) (240.1):
http://www.cms.gov/medicare-coveragedatabase/search/advanced-search.aspx
X
National Coverage Manual Citation
Local Coverage Determination (LCD)*
Article (Local)*
Other
None
CMS Manual System Department of Health &
Human Services (DHHS). Pub. 100-03 Medicare
National Coverage Determinations. Transmittal 3:
https://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/downloads/R3NCD.p
df
Use Health Net Policy
Instructions
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in ALL regions.
 Medicare LCDs and Articles apply to members in specific regions. To access your
specific region, select the link provided under “Reference/Website” and follow the
search instructions. Enter the topic and your specific state to find the coverage
determinations for your region. *Note: Health Net must follow local coverage
determinations (LCDs) of Medicare Administration Contractors (MACs) located outside their
service area when those MACs have exclusive coverage of an item or service. (CMS
Manual Chapter 4 Section 90.2)

If more than one source is checked, you need to access all sources as, on
occasion, an LCD or article contains additional coverage information than
contained in the NCD or National Coverage Manual.
Video Assisted Thoracoscopic Surgery (VATS) Sep 15
1

If there is no NCD, National Coverage Manual or region specific LCD/Article,
follow the Health Net Hierarchy of Medical Resources for guidance.
Current Policy Statement
Please refer to the Health Net policy, Lung Volume Reduction Surgery
(LVRS) and the Health Net policy on Hyperhidrosis Treatments
Health Net, Inc. considers video-assisted thoracoscopic surgery (VATS) medically
necessary for diagnostic and therapeutic pleural, lung, and mediastinal surgery.
Many procedures historically performed as an open thoracotomy are now performed
as VATS. Some examples of procedures that can be performed by a VATS approach
include, but not limited to the following:








Biopsy (e.g. , mediastinal nodes, wedge resection lung, lesions of the pleura,
diaphragm, lung, pericardium, esophagus, spine)
Resection (e.g., blebectomy, pneumonectomy, segmentectomy, esophagectomy,
thymectomy)
Drainage (e.g., pleural, mediastinal abscess, pericardial window)
Pulmonary decortication
Pleurodesis
Pericardial procedures (e.g., pericardial window)
Thoracic sympathectomy
As an alternative to thoracotomy in individuals who meet the criteria specified in
the Health Net policy, Lung Volume Reduction Surgery (LVRS).
Contraindications
Contraindications to VATS are related to pulmonary disease (pulmonary
insufficiency) or anatomic limitations, such as fusion of the visceral and parietal
pleura, and thick fibrotic adhesions that obscure exposure and risk injury to vessels
and structures. Individuals who cannot tolerate selective lung ventilation due to
pulmonary insufficiency are not ideal candidates for VATS. Other contraindications
include:



Inability to perform a complete (R0) resection with suitable residual
cardiopulmonary reserve
Lymph node metastasis beyond regional lymph nodes
Widely metastatic disease
Definitions
VATS
NSCLC
SIGN
LVRS
BLVRS
PFT
PH
PLH
CH
Video-Assisted Thoracoscopic Surgery
Non-small cell lung cancer
Scottish Intercollegiate Guidelines Network
Lung Volume Reduction Surgery
Bilateral Lung Volume Reduction Surgery
Pulmonary function test
Palmar hyperhidrosis
Plantar hyperhidrosis
Compensatory hyperhidrosis
Codes Related To This Policy
NOTE:
The codes listed in this policy are for reference purposes only. Listing of a code in
this policy does not imply that the service described by this code is a covered or noncovered health service. Coverage is determined by the benefit documents and
medical necessity criteria. This list of codes may not be all inclusive.
Video Assisted Thoracoscopic Surgery (VATS) Sep 15
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On October 1, 2015, the ICD-9 code sets used to report medical diagnoses and
inpatient procedures will be replaced by ICD-10 code sets. Health Net National
Medical Policies will now include the preliminary ICD-10 codes in preparation for this
transition. Please note that these may not be the final versions of the codes and
that will not be accepted for billing or payment purposes until the October 1, 2015
implementation date.
ICD-9 Codes (List is not all inclusive)
162.9
780.8
492.0
492.8
511.9
Primary neoplasm of Lung
Hyperhidrosis
Emphysematous bleb
Other emphysema
Unspecified pleural effusion
ICD-10 Codes (List is not all inclusive)
C34.90
J43-J43.9
J44-j44.9
R61
R91.0
Malignant neoplasm of unspecified part of unspecified bronchus or
Lung
Emphysema
Other chronic obstructive pulmonary disease
Generalized hyperhidrosis
Solitary pulmonary nodule
CPT Codes
32601-32665
32666
32667
32668
32669
32670
32671
32672
32673
32674
Thoracoscopy
Thoracoscopy, surgical with therapeutic wedge resection (e.g.
mass, nodule) initial, unilateral
Thoracoscopy, surgical with therapeutic wedge resection (e.g.
mass, nodule), each additional resection, ipsilateral
Thoracoscopy, surgical with diagnostic wedge followed by anatomic
lung resection
Thoracoscopy, surgical with removal of a single lung segment
Thoracoscopy, with removal of two lobes (lobectomy)
Thoracoscopy, with removal of lung (pneumonectomy)
Thoracoscopy, with resection-plication for emphysematous or nonbullous) for lung volume reduction (LVRS), unilateral includes any
pleural procedure, when performed
Thoracoscopy, with resection of thymus, unilateral or bilateral
Thoracoscopy, with mediastinal and regional lymphadenectomy
HCPCS Codes
N/A
Scientific Rationale – Update September 2015
NCCN guidelines on NSCLC (Version 7.2015) state that video-assisted thoracic
surgery (VATS), also known as thorascopic lobectomy, is currently being investigated
in all aspects of lung cancer. They note that published studies suggest that
thorascopic lobectomy has several advantages over the standard thoracotomy that
includes less pain, shorter length of hospitalization, lower postoperative morbidity
and mortality, minimal risk of intraoperative bleeding, or minimal locoregional
recurrence. They also note that thorascopic lobectomy is associated with less
morbidity, fewer complications, and more rapid return to function than lobectomy by
thoracotomy. Per the NCCN guidelines, “In patients with stage I NSCLC who had
thorascopic lobectomy with lymph node dissection, the 5-year survival rate, longVideo Assisted Thoracoscopic Surgery (VATS) Sep 15
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term survival and local recurrence were comparable to those achieved by routine
open lung resection. Thorascopic lobectomy has also been shown to improve
discharge independence in older populations and in patients at high risk. Data show
that thorascopic lobectomy improves the ability of patients to complete postoperative
chemotherapy regimens. Based on its favorable effects on postoperative recovery
and morbidity, thorascopic lobectomy (including robotic-assisted approaches) is
recommended in the NCCN algorithm as an acceptable approach for patients who are
surgically resectable (and have no anatomic or surgical contraindications) as long as
standard principles of thoracic surgery are not compromised.”
Wu et al (2015) reviewed and compared the perioperative outcomes of VATS with
open thoracotomy for chest trauma patients. The authors conducted a systematic
review and meta-analysis of randomized control trials and cohort studies comparing
the perioperative outcomes of VATS with open thoracotomy for chest trauma
patients. Clinical endpoints included postoperative complications, perioperative
mortality rate, chest tube drainage volume, duration of tube drainage, duration of
hospitalization, operation time, and amount of bleeding and transfusion volume in
operation. A subgroup analysis was performed to explore the potential source of
heterogeneity. Twenty-six studies were included. Pooled analyses showed significant
reductions in the incidence of postoperative complications (risk ratio [RR] [95%
confidence interval (CI)], 0.47 [0.35, 0.64]), chest tube drainage volume (mean
difference [MD] [95% CI], -146.88 ml [-196.04, -97.72]), duration of tube drainage
(MD, -1.71 days; 95% CI -2.16 to -1.26), duration of hospitalization (MD, -4.67
days; 95% CI -5.19 to-4.14), operation time (MD, -41.18 min; 95% CI -52.85 to 29.51), and amount of bleeding (MD, -119.10 ml; 95% CI -147.28 to -90.92) and
transfusion volume (MD, -379.51 ml; 95% CI -521.24 to-237.77) in chest trauma
patients treated with VATS compared with open thoracotomy. The perioperative
mortality rate was not significantly different between patients received VATS and
open thoracotomy (RR, 0.52; 95% CI 0.22-1.21). The authors concluded compared
to open thoracotomy, VATS is an effective and even better treatment for improving
perioperative outcomes of hemodynamically stable patients with chest trauma and
reduce the complications. However, caution should also be exercised in certain
clinical scenarios.
Tane et al (2015) examined the advantages of thoracoscopy over thoracotomy in
terms of perioperative outcomes and toleration of adjuvant chemotherapy. Between
April 2010 and March 2013, 657 patients with NSCLC who underwent lobectomy
were classified into thoracoscopy (308 patients) and thoracotomy (349 patients)
groups and compared. The thoracoscopy group had less blood loss compared to the
thoracotomy group (p<0.001). When limiting the analysis to pathological stage I
patients, the results were similar (p<0.001). In addition, the difference in blood loss
between the 2 groups was greater in patients with severe pleural adhesions. The
postoperative morbidity of the thoracoscopy group was significantly less than that of
the thoracotomy group (13.3% vs. 21.2%, p<0.001), and this result was similar
when analyzing the pathological stage I patients (12.6% vs. 20.6%, p=0.001). A
higher percentage of the thoracoscopy group received both the full planned course
and dose of adjuvant chemotherapy compared to the thoracotomy group (84.2% vs.
65.8%, p=0.032). The authors concluded the results indicate that totally
thoracoscopic lobectomy is the more beneficial surgical approach with regard to the
incidence of postoperative complications and toleration of adjuvant chemotherapy.
Laursen et al (2015) compared the 30-day morbidity and mortality for lung cancer
patients operated by VATS lobectomy or lobectomy by open thoracotomy (OT). Data
were obtained from prospective national and regional databases, including patients
who underwent lobectomy for lung cancer in the eastern part of Denmark from 1
January 2005 to 31 December 2011. All patients operated before 2009 were reVideo Assisted Thoracoscopic Surgery (VATS) Sep 15
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staged according to the latest International Association for the Study of Lung Cancer
lung cancer classification. Patient characteristics, comorbidities, pathology and
operative data were assessed using an independent samples t-test, Pearson's χ2,
Fisher's exact test and Mann-Whitney test. Morbidity was assessed using multinomial
logistic regression adjusted for gender, age, cancer stage, forced expiratory volume
in 1 s (FEV1), year of surgery and Charlson comorbidity score. In total, 1379
patients underwent lobectomy, 785 patients via VATS and 594 patients via
thoracotomy. The two groups were similar in gender and FEV1. The patients
operated by VATS were older (P < 0.001), and had a lower Charlson comorbidity
score (P = 0.034), higher frequency of adenocarcinomas (P < 0.001) and lower
cancer stage (P < 0.001). Among the VATS patients, 285 (36.3%) and among the
thoracotomy patients, 288 (48.5%) had minor complications (P < 0.001); and 157
(20.0%) VATS patients and 212 (35.7%) thoracotomy patients had major
complications (P < 0.001). The 30-day mortality rate was 1% in the VATS group and
1.5% in the thoracotomy group (P = 0.47). Multinomial logistic regression analysis
showed that the prevalence of both minor [odds ratio (OR) = 1.51; 95% confidence
interval (Cl) = 1.18-1.96] and major complications (OR = 1.91, 95% Cl = 1.44-2.53)
was significantly higher for patients who underwent lobectomy via thoracotomy
compared with VATS. The authors concluded patients undergoing lobectomy via
VATS were less likely to have at least one minor complication within the first 30
postoperative days and less likely to have at least one major complication, compared
with patients operated by thoracotomy. These findings remained after adjusting for
gender, age, FEV1, cancer stage, year of surgery and Charlson comorbidity score.
Scientific Rationale – Update September 2014
Video assisted thoracoscopic surgery (VATS) is a set of minimally invasive thoracic
surgical procedures principally employed in the management of pulmonary,
mediastinal, and pleural pathology. Its main benefit has been the avoidance of a
thoracotomy incision, which allows a shorter operative time, less postoperative
morbidity, and earlier return to normal activity than with thoracotomy. Many
procedures historically performed as an open thoracotomy are now performed as
VATS although VATS is a technically demanding procedure.
The advantage of VATS, when compared with open thoracotomy, include reduced
hospital length of stay, less blood loss, less pain, improvement in pulmonary function
when compared with open thoracotomy, early patient mobilization with early
recovery and rapid return to work and daily activities, and less inflammatory
reaction, as measured by cytokine response in patients undergoing VATS lobectomy
compared with open thoracotomy. VATS is the procedure of choice for the diagnosis
and management of diseases of the pleura, nondiagnosed peripheral pulmonary
nodules, and interstitial lung disease. Today it is a well-accepted and established
procedure and has become the first choice technique for lung biopsies,
pleurectomies, sympathectomies, and other various pulmonary disorders.
NCCN guidelines on NSCLC (Version 4.2014) state that VATS, also known as
thorascopic lobectomy, is recommended as an acceptable approach for patients who
are surgically resectable (and have no anatomic or surgical contraindications) as
long as standards principles of thoracic surgery are not compromised. They note the
surgical procedure used depends on the extent of the disease and on
cardiopulmonary reserve of the patient.
Ren et al (2014) compared the short-term effect of anatomic VATS segmentectomy
and VATS lobectomy. From January 2011 to December 2012, 21 patients underwent
VATS segmentectomy and 61 underwent VATS lobectomy. Intraoperative blood loss,
operating time, postoperative drainage time, length of hospital stay, postoperative
complications, local recurrence, and survival were compared between the two
Video Assisted Thoracoscopic Surgery (VATS) Sep 15
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groups. The intraoperative blood loss and average hospital stay were less in the
segmentectomy group than in the lobectomy group (P<0.05). There was no
significant difference in the operating time, number of lymph nodes dissected,
postoperative drainage time, or 1-year survival between the two groups (P>0.05).
Only one patient died because of heart disease. The two groups had a similar
incidence of postoperative complications (P>0.05). There was one (4.8%) local
recurrence after segmentectomy and two (3.3%) after lobectomy (P>0.05). The
authors concluded VATS segmentectomy could be performed safely and is a method
with favorable 1-year survival. It may be the ideal surgical procedure for patients
with solitary pulmonary nodules in early stage lung cancer, especially for those with
limited cardiopulmonary reserve or significant comorbidities.
Rizk et al (2014) performed a prospective cohort study to compare quality of life and
pain scores during the first 12 months after VATS or open anatomic resection.
Patients were prospectively enrolled from May 2009 to April 2012. Patients with
clinical stage I lung cancer who were scheduled to undergo anatomic lung resection
were eligible. The Brief Pain Index and Medical Outcomes Study 36-Item Short Form
Health Survey were conducted perioperatively and at four assessments during the
first 12 months after the operation. Intent-to-treat analyses using mixed-effects
models were used to longitudinally assess the effect of treatment on quality of life
components (physical component summary and mental component summary) and
pain. In total, 74 patients underwent thoracotomy, and 132 underwent VATS
(including 19 patients who were converted to thoracotomy); 40 and 80 patients,
respectively, completed the 12-month surveys. Baseline characteristics were similar
between the two groups. Physical component summary and Brief Pain Index scores
were similar between the two groups throughout the 12 months of follow-up. The
mental component summary score, however, was consistently worse in the VATS
group. Investigators concluded patient-reported physical component summary and
pain scores after VATS and thoracotomy were similar during the first 12 months after
surgical resection.
Zhang et al (2014) performed a systemic review to investigate whether VATS could
achieve equivalent lymph node (LN) evaluation efficacy to thoracotomy. A
comprehensive search of PubMed, EMBASE, and Cochrane was performed to identify
studies comparing VATS and thoracotomy in LNs and node stations. Mean difference
was calculated by Review Manager 5.0 software and Stata 12. Twenty-four studies
met the inclusion criteria of LN evaluation. 2,015 patients were involved in VATS
group in contrast to 3,250 patients in thoracotomy group. The same number of total
nodes stations (mean difference, 0.09; 95 % CI -0.25 to 0.42; P = 0.61) and
mediastinal node stations (mean difference, -0.11; 95 % CI -0.24 to 0.01; P = 0.08)
could be assessed by thoracotomy and VATS. The same number of N1 LNs (mean
difference, -0.33; 95 % CI -0.70 to 0.05; P = 0.09) could be assessed by both
groups. While more total (mean difference, -1.41; 95 % CI -1.99 to -0.83; P <
0.00001) and mediastinal LNs (mean difference, -1.03; 95 % CI -1.81 to -0.24; P =
0.01) could be harvested by thoracotomy. The authors concluded the outcomes
show that the same number of total and mediastinal LN stations could be harvested
by VATS and OT. The same number of N1 LNs could be harvested by VATS and OT,
while less total and mediastinal LNs could be harvested by VATS.
Yang et al (2014) sought to identify the risk factors for major adverse events of
VATS lobectomy for primary lung cancer. 1806 Patients (1032 males, 57.1%)
planned to undergo VATS lobectomy for stage IA-IIIA lung cancer from July 2007 to
June 2012. The Thoracic Morbidity and Mortality Classification TM&M system was
used to evaluate the presence and severity of complications. Postoperative
complications were observed during a 30-day follow up. Univariate and multivariate
analysis were used to analyze the independent risk factors for major adverse events.
Video Assisted Thoracoscopic Surgery (VATS) Sep 15
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Successful rate of VATS lobectomy was 97.6% (1763/1806). Major complications
occurred in 129 patients (7.3%), with a mortality of 0.3% (5/1763). Pulmonary
complications contribute up to 90.7% of the major complications and 80% of
mortality. Logistic regression indicated that comorbidities, elder age ≥70y, operative
time ≥240min and hybrid VATS were predictors for major adverse events (P<0.05).
Hybrid and converted VATS lobectomy result in higher major adverse events
compared with complete VATS, 15.1%, 20.9% and 7.4% respectively (P=0.013).
Investigators concluded the overall complication rate and mortality of VATS
lobectomy are low, while major complications sometimes occur. Pulmonary
complications are the most common major complications and cause of mortality. Age
≥70y, comorbidities, operative time ≥240min and Hybrid VATS are predictors of
major adverse events.
Higuchi et al (2014) retrospectively compared long-term outcomes after VATS
lobectomy versus lobectomy via open thoracotomy for clinical stage IA non-small cell
lung cancer (NSCLC). From July 2002 to June 2012, 160 patients were diagnosed
with clinical stage IA NSCLC and underwent lobectomy. Of these, 114 underwent
VATS lobectomy and 46 underwent lobectomy via open thoracotomy. The 5-year
disease-free survival (DFS) rate was 88.0% in the VATS group and 77.1% in the
thoracotomy group for clinical stage IA NSCLC and 91.5% in the VATS group and
93.8% in the thoracotomy group for pathological stage IA NSCLC. The 5-year overall
survival (OS) rate was 94.1% in the VATS group and 81.8% in the thoracotomy
group for clinical stage IA NSCLC and 94.8% in the VATS group and 96.2% in the
thoracotomy group for pathological stage IA NSCLC. The rate of accurate
preoperative staging was 71.9% in the VATS group and 56.5% in the thoracotomy
group. Inconsistencies between the clinical and pathological stages were mainly
related to tumor size, nodal status, and pleural invasion. Local recurrence occurred
for one lesion in the VATS group and six lesions (five patients) in the thoracotomy
group. The reviewers concluded the DFS and OS were not inferior after VATS
compared with thoracotomy. Local control was significantly better after VATS than
after thoracotomy. Preoperative staging lacked sufficient accuracy.
Gu et al (2014) evaluated the feasibility and safety of (VATS, and to compare the
surgical results of VATS with the standard median sternotomy (MS) approach.
Between April 2010 and April 2012, the data of 245 patients who underwent
thymectomy for thymic tumors were prospectively collected. Among them, 93
patients with clinical stage I-II disease were retrospectively reviewed. Resection was
planned for VATS in 49 cases, and for MS in 44 cases. During operation, there were
3 conversions to open surgery because of local invasion (conversion to thoracotomy
in 1 patient, and sternotomy in 2). No transfusion was required in any patient. There
was no significant difference in duration or amount of postoperative chest tube
drainage between the 2 groups (P>0.05). Operative time, blood loss during
operation, average length of the intensive care unit stay, and length of hospital stay
were significantly less in the VATS group than the MS group (P<0.05). There were no
major perioperative complications or mortality. No recurrence was detected during a
median follow-up of 27 months (range, 12 to 36 mo). Reviewers concluded VATS
thymectomy for early-stage thymic tumors is safe and feasible. In comparison with
standard MS, the VATS approach was associated with a shorter intensive care unit
stay and hospital stay. Prospective randomized multi-institutional trials with longterm follow-up are needed to compare the oncological outcomes.
Manoly et al (2014) compared short- and mid-term outcomes for patients
undergoing VATs or trans-sternal resection for thymoma in a feasibility study,
highlights weaknesses in current research and makes recommendations for longterm technological evaluations in this field. Consecutive thymoma cases between
2004 and 2010 were identified. Patients were divided into two groups according to
Video Assisted Thoracoscopic Surgery (VATS) Sep 15
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surgical approach (Group I trans-sternal; Group II VATS) and comparisons were
made between groups. The primary outcome was overall survival. Secondary
outcomes included operative morbidity and mortality, hospital stay, recurrence rate
and disease-free survival. Thirty-nine patients were included (Group I: n = 22 vs
Group II: n = 17). There were no differences between groups at baseline for all
measured covariates. No deaths occurred within 30 days of surgery. More patients in
Group I developed complications (Group I: n = 10 vs Group II: n = 3; P = 0.093),
while hospital stay was shorter in Group II (Group I: 6.4 ± 4.6 days vs Group II: 4.4
± 1.8 days; P = 0.030). Five-year overall survival (Group I: 93.8 ± 6.1% vs Group
II: 83.3 ± 11.2%; P = 0.425), 5-year disease-free survival (Group I: 71.0 ± 15.3%
vs Group II: 83.3 ± 11.2%; P = 0.827) and recurrence rates at final follow-up
(Group I: n = 2 vs Group II: n = 1; P = 0.363) were similar between the groups.
Investigators concluded VATS thymectomy for thymoma is feasible, safe and has
comparable mid-term oncological outcomes to trans-sternal thymectomy. Future
research is required to evaluate long-term oncological outcomes of VATS
thymectomy for thymoma in national registries and randomized, controlled trials.
Boffa et al (2014) evaluated complications following anatomic resection of clinical
stage I lung cancer by VATS and thoracotomy to clarify the effect of the minimally
invasive approach. The Society of Thoracic Surgeons database was queried for
lobectomies and segmentectomies performed between 2001 and 2010 for clinical
stage I primary cancer. A total of 11,531 (7137 open and 4394 VATS) patients with
clinical stage I primary lung cancers underwent resection. Propensity scoring was
used to match cases into 2745 well-balanced pairs. Overall complications were
significantly more likely in the thoracotomy group (36%) than in the VATS cohort
(30%; P < .001). Patients undergoing thoracotomy experienced significantly more
pulmonary complications (21% vs 18%), atrial arrhythmias (13% vs 10%), and were
more likely to undergo transfusion (6% vs 4%). Operative mortality was similar
(thoracotomy 1.8%, VATS 1.3%; P = .13). The authors concluded anatomic
resection of early stage lung cancer is performed with a low mortality rate, according
to data from the Society of Thoracic Surgeons database. Perioperative complications
are significantly less likely to occur when patients with stage I lung cancers undergo
resection using the VATS approach. Further study is warranted to determine longterm effects of these differences in perioperative outcomes
Lin et al (2013) evaluated the risk and efficacy of wedge resection under VATS on
elderly high-risk patients with severe cardiopulmonary and other system
dysfunctions who are unable to tolerate pulmonary lobectomy with stage I peripheral
non-small-cell lung cancer (PNSCLC). Elderly patients (≥70 years) with suspected
PNSCLC were divided into high-risk group and conventional risk group. The high-risk
patients confirmed in stage I by the examination of positron emission tomography
computed tomography (PET-CT) and the postoperative patients in stage I PNSCLC
with negative incisal margin were treated with VATS wedge resection. The
conventional risk patients were treated with VATS radical resection and systematic
lymphadenectomy. The clinical and pathological data were recorded. The total
survival, tumor-free survival, recurrence time and style of patients were followed up.
The operative time and blood loss of the VATS wedge resection group (69.4 ± 15.5
min, 52.1 ± 11.2 ml) were significantly less than those of the VATS radical resection
group (128 ± 35.5 min, 217.9 ± 87.1 ml). Neither groups had postoperative death.
The overall and tumor-free survival rate of the VATS wedge resection group within
three years were 66.7% and 60.0%, and those of the VATS radical resection group
were 93.8% and 94.1%, without significant difference (P > 0.05). The recurrence
rates of the VATS wedge resection group and VATS radical resection group were
14.3% and 3.0%, without significant difference (P > 0.05). The authors concluded it
is safe, minimally invasive and meaningful to perform VATS wedge resection on the
elderly high-risk patients with stage I PNSCLC.
Video Assisted Thoracoscopic Surgery (VATS) Sep 15
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Scientific Rationale Update – July 2014
The Version 4. 2014 National Comprehensive Cancer Network (NCCN) guidelines on
non-small cell lung cancer (NSCLC) notes the following:

For resection, VATS or minimally invasive surgery should be strongly considered
for patients with no anatomic or surgical contraindications, as long as there was
no compromise of standard oncologic and dissection principles of thoracic
surgery.

The choice of biopsy or surgical excision should be based on the clinical suspicion
of lung cancer, location of lesion (feasibility of surgical identification and
resection by minimally invasive video assisted thoracic surgery (VATS) and
patient preference.

In patients with suspected NSCLC, many techniques are available for tissue
diagnosis. Diagnostic tools that should be routinely available include: Video
assisted thoracic surgery (VATS) and open surgical biopsy.

In high volume centers with significant VATS experience, VATS lobectomy in
selected patients results in improved early outcomes (i.e., decreased pain,
reduced hospital length of stay, more rapid return to function, fewer
complications) without compromise of cancer outcomes.

Patients with occult positive N2 nodes discovered at the time of pulmonary
resection should continue with the planned resection along with formal
mediastinal lymph node dissection. If N2 disease is noted in patients undergoing
VATS the surgeon may consider stopping the procedure so that induction
therapy can be administered before surgery; however continuing the procedure
is also an option.

Video-assisted thoracic surgery (VATS) which is also known as Thoracoscopic
lobectomy, is a minimally invasive surgical treatment that is currently being
investigated in all aspects of lung cancer.

Robotic VATS seems to be more expensive with longer operating times than
conventional VATS.
Scientific Rationale Update - March 2011
Lung volume reduction surgery (LVRS) or reduction pneumoplasty, also referred to
as lung shaving or lung contouring, is performed on patients with severe emphysema
in order to allow the remaining compressed lung to expand, and thus, improve
respiratory function. The two main surgical procedures for lung volume reduction
surgery (LVRS), also known as reduction pneumoplasty include thoracotomy or
median sternotomy with bilateral pneumectomy using stapler resection, and
endoscopic surgery (thoracoscopy or video-assisted thoracoscopic surgery) with laser
ablation and/or stapler resection of diseased lung tissue. The decision about whether
to perform LVRS via thoracotomy or thoracoscopy depends in large part on the
surgical and institutional expertise. Medicare-covered LVRS approaches are limited
to bilateral excision of a damaged lung with stapling performed via median
sternotomy or video-assisted thoracoscopic surgery.
Mckenna et al (2004) compared lung volume reduction surgery with medical therapy
for severe emphysema, including randomized and nonrandomized comparisons of
the median sternotomy and video-assisted thoracoscopic approaches for lung volume
Video Assisted Thoracoscopic Surgery (VATS) Sep 15
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reduction surgery. Lung volume reduction surgery was performed by median
sternotomy only at 8 centers and video-assisted thoracoscopy only at 3 centers; 6
centers randomized the approach to lung volume reduction surgery. Mortality,
morbidity, and functional status were assessed. In the nonrandomized comparison,
359 patients received lung volume reduction surgery by median sternotomy, and 152
patients received lung volume reduction surgery by video-assisted thoracoscopy. The
90-day mortality was 5.9% for median sternotomy and 4.6% for video-assisted
thoracoscopy. Overall mortality was 0.08 deaths per person-year for median
sternotomy and 0.10 deaths per person-year for video-assisted thoracoscopy.
Complication rates were low and not statistically different for the 2 approaches. The
median hospital length of stay was longer for median sternotomy than for videoassisted thoracoscopy (10 vs 9 days). By 30 days after surgery, 70.5% of median
sternotomy patients and 80.9% of video-assisted thoracoscopy patients were living
independently. Functional outcomes were similar for median sternotomy and videoassisted thoracoscopy at 12 and 24 months. Similar results were noted for the
randomized comparison. The investigators concluded morbidity and mortality were
comparable after lung volume reduction surgery by video-assisted thoracoscopy or
median sternotomy, as were functional results. The video-assisted thoracoscopic
approach to lung volume reduction surgery allowed earlier recovery than median
sternotomy.
Roberts et al (1998) compared patients undergoing bilateral lung volume reduction
(BLVRS) via median sternotomy and thoracoscopic techniques with emphasis on
hospital course and complications. Patients were analyzed for mortality and
morbidity, using a combination of prospective data analysis and retrospective chart
review. Patients undergoing BLVRS via median sternotomy were older than those
undergoing video-assisted thoracoscopic surgery (VATS) procedures (63.9+/-6.89 vs
59.3+/-9.4 years). Operating time was longer for the VATS procedure (147 versus
129 minutes) while estimated blood less was greater for median sternotomy (209
versus 82 L). Significant differences were found in intensive care unit stay, days
intubated, life-threatening complications, respiratory complications, requirement for
tracheostomy, and death that favored VATS BLVRS. When only later cohorts of
patients were compared, more life-threatening complications and deaths were found
in patients undergoing BLVRS by median sternotomy. There were no differences
between early and late median sternotomy BLVRS patients. Twenty-six percent of
the lethal complications in median sternotomy BLVRS patients were bowel
perforations, equally divided between duodenal ulcers and colons. The investigators
concluded bilateral video-assisted volume reduction offers equivalent functional
outcome with potentially decreased morbidity and mortality. Gastrointestinal
perforations can complicate the management of these patients.
Stammberger et al (1997) investigated the functional results, complications and
survival of bilateral VATS lung volume reduction surgery in 42 of 143 candidates with
severe, nonbullous pulmonary emphysema. Patients were short of breath on
minimal exertion due to severe airflow obstruction and hyperinflation (FEV1 < 30%)
pred., TLC > 130% pred., RV > 200% pred.). LVRS was performed bilaterally by
VATS using endoscopic staplers without buttressing the staple lines. Pulmonary
function test (PFT), MRC dyspnea score and 12 min walking distance were assessed
preoperatively, at 3, 6 and 12 months. In addition lung function was measured at
hospital discharge. The patients reported a marked relief of dyspnea, which
persisted at all follow-up visits. FEV1 increased from 0.80 +/- 0.24 (L) to 1.14 +/0.41 (L) postoperatively, a 43% gain. A relevant increase of FEV1 persisted for at
least 1 year. The residual volume to total lung capacity ratio decreased from 0.64 to
0.56 at hospital discharge. The mean 12 min walking distance increased from 500
+/- 195 (m) to 770 +/- 222 (m) after 1 year. The mean hospital stay was 13 +/5.5 days (median 12.0), drainage time was 9 +/- 4.3 (median 8.0) days. There was
Video Assisted Thoracoscopic Surgery (VATS) Sep 15
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no 30 day mortality. Three patients died between 2 and 15 months postoperatively
by non surgery related reasons. One patient underwent lung transplantation 5
months after surgical lung volume reduction. The investigators concluded in a
selected group of patients with severe, nonbullous pulmonary emphysema, bilateral
LVR by VAT results in instantaneous postoperative improvement in pulmonary
function and dyspnea. These favorable effects, including an amelioriation in exercise
performance, lasted for at least 1 year.
Some individuals with severe intractable, disabling hyperhidrosis often remain
symptomatic despite conservative medical treatment and thus may require surgical
intervention. The goal of surgery for hyperhidrosis is to disrupt the sympathetic
supply to sweat glands by destroying relevant ganglions in the upper thoracic
sympathetic chain. Although sympathectomy is sometimes performed as an open
procedure, most current techniques involve a limited sympathectomy that is
performed endoscopically.
Wolosker et al (2007) prospectively investigated, how surgery affects patients with
palmar hyperhidrosis (PH) and plantar hyperhidrosis (PLH) over one-year period. 70
consecutive patients with combined PH and PLH underwent VATS at the T2, T3, or T4
ganglion level (47 women and 23 men, with mean age of 23 years). Immediately
after the operation, all the patients said they were free from PH episodes, except for
two patients (2.8%) who suffered from continued PH. Compensatory hyperhidrosis
(CH) of various degrees was observed in 58 (90.6%) patients after one year. Only
13 (20.3%) suffered from severe CH. There was a great initial improvement in PLH
in 50% of the cases, followed by progressive regression, such that only 23.4% still
presented that improvement after one year. The number of cases without overall
improvement increased progressively (from 17.1% to 37.5%) and the numbers with
slight improvement remained stable (32.9-39.1%). Of the 24 patients with no
improvement after one year, 6 patients graded plantar sweating worse. The
investigators concluded patients with PH and PLH who undergo VATS to treat their
PH present a good initial improvement in PLH that reduces to a lower level of
improvement after the one-year period.
Prasad et al (2010) performed a prospective study of endoscopic thoracic
sympathectomies for palmar hyperhidrosis based on case histories and a prospective
pre- and postoperative questionnaire survey. The sample comprised of 322 patients
with a mean age of 24 years at a single institution. Bilateral video-assisted
thoracoscopic T3 level sympathectomies were performed in all cases. All patients
had immediate cessation of palmar hyperhidrosis. The mean postoperative stay was
1.1 days. A questionnaire was completed based on their response to a telephone
conversation or e-mail. A paired t test and Wilcoxon test was performed on these
data and it showed significant improvement in quality of life. Compensatory sweating
was found to be the most troublesome side effect for all patients. It was seen in 63%
of the patients. This is similar to other reports of compensatory sweating; however,
the figure decreases to 29% if we disregard the percentage of patients who reported
only mild compensatory sweating.
Rieger et al (2008) performed a retrospective analysis on prospectively collected
data of 402 thoracic sympathectomies performed in 204 consecutive patients with
palmar-plantar (n=123), palmar-axillary (34), isolated axillary (35), and craniofacial
(12) hyperhidrosis. The standard procedure was video-assisted thoracoscopic
resection of the sympathetic chain from T2 to T4/5. All procedures were performed
thoracoscopically without serious perioperative complications. Postoperative
morbidity was 2.5% (10/402) including two cases of incomplete Horner's syndrome
(0.5%). One hundred forty-three patients were followed for a mean of 21 months (686). Palmar hyperhidrosis was eliminated in 100% of cases and axillary
Video Assisted Thoracoscopic Surgery (VATS) Sep 15
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hyperhidrosis in 98.5%. There were three axillary recurrences (1.5%). Of all
patients, 60% suffered from transient postsympathectomy neuralgia which was mild
in the majority of cases. Strong compensatory sweating occurred in 17% of patients
with palmar-plantar and palmar-axillary hyperhidrosis and in 53% of patients with
isolated axillary hyperhidrosis. In the palmar-plantar and palmar-axillary groups,
92% were very satisfied with the postoperative results, 90% reported increased
quality of life, and 93% would repeat the operation. The corresponding numbers in
patients with isolated axillary hyperhidrosis were 47%, 44%, and 66%, respectively.
The investigators concluded video-assisted thoracoscopic resection of the
sympathetic chain from T2 to T4-5 is safe and effective and leads in almost 100% of
cases to the elimination of palmar and axillary hyperhidrosis. In contrast to the
excellent results in patients with palmar-plantar and palmar-axillary hyperhidrosis,
outcome in patients with isolated axillary hyperhidrosis was impaired by a high rate
of disturbing compensatory sweating.
Scientific Rationale Update – March 2010
Video Assisted Thoracoscopic Surgery (VATS)
Video Assisted Thoracoscopic Surgery is also referred to as a thoracoscopic biopsy or
VATS. This type of thoracic surgery takes its roots from medical thoracoscopy or
pleuroscopy, and has now been technically developed to the point that it can replace
thoracotomy in many indications.
VATS is performed using a small video camera that is introduced into the patient's
chest via a scope. The surgeon is able to view the instruments that are being used
along with the anatomy that is being operated on. The camera and instruments are
inserted through separate holes in the chest wall also known as "ports". These small
ports are advantageous because of the chance for infection and dehiscence are
drastically reduced. This allows for a faster recovery by the patient and a greater
chance for the wound to heal.
Traditionally, thoracic surgery performed for diagnosis or treatment of chest
conditions has required access to the chest through thoracotomy or sternotomy
incisions. Sternotomy requires the use of a sternal saw to divide the sternum and
requires spreading of the divided portions of the sternum with a sternal retractor to
allow for visualization of the thoracic structures, passage of instruments into the
chest, and removal of specimens. Thoracotomy, as most commonly performed,
requires division of one or more major muscles of the chest wall including the
latissimus dorsi, pectoralis or serratus muscles, along with spreading of the ribs with
a rib spreader. Because the joints of the ribs with the vertebral bodies have only
limited flexibility, the use of a rib spreader usually results in rib fractures in the
process of rendering the interspace between the ribs wide enough to perform
diagnostic or therapeutic maneuvers. Because of this, thoracic surgeons generally
intentionally remove a section of one or more ribs in an effort to prevent splintered
rib fractures associated with the use of a rib spreader. Sternotomy and thoracotomy
have been proven over decades to provide highly effective means of access to
thoracic structures and in general are tolerated by patients. However, both incisions
have the potential for causing significant pain that may last for extended periods and
both result in bony fractures that require a minimum of six weeks to heal during
which time patients must refrain from heavy lifting or strenuous activity. The great
advantage of VATS over sternotomy or thoracotomy is avoidance of muscle division
and bone fractures that allows for diminished duration and intensity of pain and a
shorter time to return to full activity.
The instrumentation for VATS includes the use of a camera-linked 5mm or 10mm
fiberoptic scope, with or without a 30 degree angle of visualization, and either
conventional thoracic instruments or laparoscopic instruments. Unlike with
Video Assisted Thoracoscopic Surgery (VATS) Sep 15
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laparoscopy, carbon dioxide insufflation is not generally required with VATS due to
the inherent vault-like shape of the thoracic cavity. However, lung deflation on the
side of the chest where VATS is being performed is a must to be able to visualize and
pass instruments into the thorax; this is usually effected with a double-lumen
endotracheal tube that allows for single lung ventilation or a bronchial blocker
delivered via a standard single-lumen endotracheal tube.
A lung biopsy may be performed using either a closed or an open method. Closed
methods are performed through the skin or through the trachea and are also known
as transthoracic, or percutaneous biopsies. A transbronchial biopsy is performed
through a fiberoptic bronchoscope through the main airways of the lungs. VATS
would not be indicated in situations appropriate for closed lung biopsy (i.e.
transbronchial, or percutaneous biopsies).
Video-assisted thoracoscopic surgery (VATS) may be performed on selected patients
in place of open lung biopsy. The surgeon makes several small incisions in the chest
wall. A thorascope, a thin, hollow, lighted tube with a tiny video camera mounted on
it, is inserted through one of the small incisions. The other incisions allow the
surgeon to insert special instruments to retrieve tissue for biopsy.
Medical Thoracoscopy
Medical thoracoscopy or pleuroscopy refers to the percutaneous insertion of an
endoscope into the pleural space. This procedure is used mainly for diagnostic
purposes in pleural diseases. The most common indications for pleuroscopy are
diagnosis of pleural effusion with inspection of the pleural cavity, combined with
biopsies from the parietal and visceral pleura, as well as treatment of malignant or
other therapy-refractory effusions by talc pleurodesis. It is a relatively simple and
inexpensive technique because it can be performed in an endoscopy room, under
local anesthesia or conscious sedation, through a single entry site with nondisposable
instruments.
Medical pleuroscopy (MP) offers a safe and minimally invasive tool for interventional
pulmonologists. It allows diagnosis of unexplained effusion, while at the same time
allowing drainage and pleurodesis. It can also help in the diagnosis of diffuse
interstitial disease or associated peripheral lung abnormality in the presence of
effusion. It can have a therapeutic role in pneumothorax and hyperhidrosis or
chronic pancreatic pain.
Scientific Rationale Initial
Video-assisted thoracoscopic surgery (VATS) is a minimally invasive surgical
technique that has been used to replace a traditional thoracotomy. This procedure
has been associated with a reduction in surgical morbidity and is particularly useful
for those with significant medical comorbidity. Each patient is evaluated individually
to determine if VATS is appropriate. The best candidates are those who have never
had chest surgery before, because scar tissue from previous procedures can make
access into the chest cavity more challenging.
VATS generally involves at least three small incisions or access ports placed in any
intercostal space. One port is used for the video thoracoscope and two ports for
endoscopic instrumentation. Although the access ports are small, the rigid
instruments could cause trauma to the intercostal nerves and rib periosteum that
can result in regional postoperative discomfort.
The size of video-assisted surgical incisions depends on the goals of the procedure
and the anatomic findings at the time of exploration. In patients undergoing
Video Assisted Thoracoscopic Surgery (VATS) Sep 15
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anatomic resection, such as segmentectomy or lobectomy, at least one of the
incisions is extended to permit extraction of the resected lung from the hemithorax.
For most video-assisted thoracic procedures, the operation requires single-lung
ventilation. Many patients with chronic respiratory insufficiency and preserved
ventilation-perfusion matching, tolerate periods of selective lung ventilation. The
ability of many patients with severe emphysema to tolerate selective ventilation has
led to the application of thoracoscopy for lung volume reduction surgery.
The usefulness of VATS in both diagnostic and staging of lung cancer is widely
recognized. Its utilization as an analytical tool in pleural and pulmonary disease is
well established especially in evaluating solitary pulmonary nodules, and pulmonary
processes of unclear etiology. It allows a complete exploration of the pleural cavity,
biopsy of mediastinal node stations not accessible at mediastinoscopy, assessment of
extension of primary tumor, and biopsy of associated lung nodules.
Video-assisted thoracic surgery has become routine for the removal of solitary
pulmonary nodules, 3 cm or less in diameter, of unknown etiology. It is also useful
for diagnosing certain pneumonia infections, diagnosing infections, and treating
repeatedly collapsing lungs. Doctors are continuing to develop other uses for VATS.
(2008) Annals of Thoracic Surgery: Video-assisted thoracoscopic surgery (VATS)
lobectomy provides a minimally invasive approach for the management of earlystage lung cancer. Questions about the safety of VATS lobectomy and its adequacy
as a cancer operation compared with open thoracotomy have hindered its universal
acceptance among thoracic surgeons. Evidence suggests that VATS lobectomy can
be safely performed and is an adequate cancer operation for early-stage non-small
cell lung cancer. However, additional adequately powered well-balanced studies
comparing VATS with open thoracotomy for lobectomy are necessary.
Shaw et al. (2008) reviewed data on 180 video-assisted thoracoscopic surgery
(VATS) patients who underwent thoracoscopic lobectomy or sublobar anatomic
resection between January 2002 and December 2006. Similar variables were
evaluated for patients aged older than 80 years, those with a forced expiratory
volume in 1 second (FEV1) that was less than 50% predicted, those who had
undergone pre-op neoadjuvant therapy, and those who had undergone lung-sparing
anatomic resections. Thoracoscopic anatomic lung resection was performed
successfully in 166 patients. One of 180 patients (0.6%) died, and 14 patients
(9.2%) underwent conversions. Overall median length of stay was 4 days (range, 1
to 98; interquartile range [IQR], 3), and median duration of chest tube drainage was
3 days (range, 0 to 35 days; IQR, 2). The median length of hospital stay and median
chest tube duration for the group aged 80 years and older was 5 and 3 days; for the
segmental resection group, 4 and 3 days; for the chemotherapy or radiotherapy
induction group, 3.5 and 3 days; and for the FEV1 less than 50% group, 5.5 and 4
days, respectively. No patients died in any of these groups. Thoracoscopic lung
resection can be performed safely in selected patients aged 80 years and older, in
those with marginal pulmonary function, and in those with pathologic response to
neoadjuvant therapy.
Nicastri et al. (2008) collected data from 153 consecutive patients who underwent
(video-assisted thoracoscopic surgery) lobectomy and assessed the perioperative
outcomes, postoperative pain, and chemotherapy course. A total of 111 of 127
patients with lung cancer had stage I non-small cell lung cancer. There were 9 major
complications (6%), including 1 perioperative death (0.7%). Conversion to
thoracotomy occurred in 14 patients (9.2%). Blood transfusion was required in 11
patients (7%). The median chest tube time was 3 days, and the length of hospital
Video Assisted Thoracoscopic Surgery (VATS) Sep 15
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stay was 4 days; 94.4% of patients went home at the time of discharge, and 5.6%
of patients required a rehabilitation facility. At a median postsurgical follow-up time
of 2 weeks, the mean postoperative pain score was 0.6 (0-3), 73% of patients did
not use narcotics for pain control, and 47% of patients did not use any pain
medication. Of patients receiving chemotherapy (N = 26), 73% completed a full
course on schedule and 85% received all intended cycles. Thoracoscopic (videoassisted thoracic surgery) lobectomy can be performed safely. Discharge
independence and low pain estimates in the early postoperative period suggest that
this approach may be beneficial. Furthermore, there is a trend toward improved
tolerance of chemotherapy.
Jones et al. (2008) compared the outcomes of converted VATS patients with open
thoracotomy controls. Between May 1992 and April 2006, 30 of 286 VATS
lobectomies for lung cancer required intraoperative conversion to open thoracotomy.
Four patients were of advanced stage and excluded from the study. The remaining
patients were matched 2:1 with open thoracotomy controls by age, sex, cancer
stage, year, and type of operation. Postoperative complications and pathology were
determined from the hospital discharge summary and pathology report. Long-term
survival information was obtained from the family doctor or central registry. There
were no statistically significant differences in postoperative complications between
the two groups (p = 0.093). There were no in-hospital deaths in the converted VATS
group. Conversion during attempted VATS resection does not prejudice short-term or
long-term surgical outcomes. We therefore suggest that VATS lobectomy should be
the treatment strategy of choice for stage I and II non-small cell lung cancer in view
of the well-established short-term benefits and equivalent survival associated with
successful VATS resection.
Sawada et al. (2008) completed a study that identified 198 patients that had
undergone VATS lobectomy for lung cancer between 1998 and 2002. The 5-year
survival rate and frequency of recurrence were evaluated as the long-term
outcomes, and the frequency of perioperative complications were also evaluated as
the short-term outcomes. Median postoperative follow-up period was 72.1 months.
Of the 198 patients, 138 and 30 were diagnosed as having p-stage IA and IB
disease, respectively, while the remaining 30 patients had more advanced disease.
Perioperative complications were observed in 20 patients (10.1%), however, there
were no perioperative mortalities. Recurrence was observed in 26 patients (13.1%):
of these, 11 patients showed local recurrence, including malignant pleural effusion
and mediastinal lymph node recurrence, and 16 patients showed distant metastasis,
the lung being the commonest site of metastasis; six patients had both local
recurrence and distant metastasis. During the study period, there were 26 deaths
(13.1%), of which 17 were due to lung cancer and 9 were due to other causes. The
5-year overall survival rates of the patients with p-stage IA and IB disease were
93.5% and 81.6%, respectively. VATS lobectomy for the treatment of lung cancer is
as feasible and safe as open lobectomy in terms of both very long- and short-term
outcomes.
(2007) American College of Chest Physicians - In patients with stage I non-small cell
lung cancer (NSCLC), who are considered appropriate candidates, the use of videoassisted thoracic surgery (VATS) by surgeons experienced in these techniques is an
acceptable alternative to open thoracotomy. Grade of recommendation is 1B, which
refers to stong recommendation.
(2007) A Clinical Trial is currently recruiting patients. The purpose of this study is to
examine the feasibility of VATS lobectomy for clinical stage IB or II non-small cell
lung cancer. Success is defined as VATS lobectomy without conversion. If success
Video Assisted Thoracoscopic Surgery (VATS) Sep 15
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rate over 90%, VATS lobectomy is considered as feasible procedures for clinical
stage IB or II non-small cell lung cancer.
Cedar-Sinai Medical Center is the leader in minimally invasive surgery of the lung.
McKenna et al. (2006) performed a retrospective review between 1992 and 2004, on
1100 patients who underwent either VATS lobectomy or pneumonectomy for
bronchogenic carcinoma. This included 595 (54.1%) women and 505 men (45.9%),
with mean age of 71.2 years (range 39-85 years). There were 9 deaths (0.8%)none were intra-operative or due to bleeding. 932 patients had no postoperative
complications (84.7%). Blood transfusion was required in 45 of the 1100 patients
(4.1%). Length of hospital stay was median of 3 days, mean of 4.78 days. One
hundred and eighty (180) patients were discharged on post-operative day (POD) 1 or
2 (20%). Conversion to a thoracotomy occurred in 28 patients (2.5%). In summary,
the authors of this study feel that VATS lobectomy with anatomic dissection can be
performed with low morbidity and mortality rates. The risk of intraoperative bleeding
or recurrence in an incision seems minimal. However, this was not a randomized
study and careful monitoring of the surgeons initial VATS outcomes is necessary
before adopting this procedure into routine practice. Data from providers using this
model and long-term disease free and overall survival outcomes from this series are
needed to confirm the success of VATS lobectomy.
Shigemura et al. (2006) performed a multi-institutional, retrospective review in 145
patients. Patients with clinical stage IA disease, with tumor size less than or equal to
2 cm in diameter, from three institutions underwent a complete VATS (c-VATS, n =
56), an assisted VATS (a-VATS, n = 34), or a conventional open (open, n = 55)
approach for pulmonary lobectomy and lymph node dissection. Patients undergoing
lobectomy and lymph node dissection with c-VATS had less blood loss, faster
recovery, shorter hospitalization, and longer operating times than did patients
undergoing the lobectomy with the a-VATS and open approaches. At a mean followup of 38.8 months, Kaplan-Meier probabilities of survival at 5 years were as follows:
c-VATS, 96.7%; a-VATS, 95.2%; open, 97.2%. There was no significant difference in
the rate of recurrence among the 3 different procedures. VATS lobectomy, a safe
procedure with earlier return to normal activities, can be regarded as an acceptable
cancer operation for the patients with peripheral non–small cell lung cancer less than
or equal to 2 cm in diameter (clinical stage IA) with the same long-term survivals as
open surgery.
Petersen et al. (2006) conducted a retrospective study of 97 patients, from 1996 to
2005, with NSCLC who underwent lobectomy after induction therapy to determine
the feasibility of thoracoscopic lobectomy compared with conventional thoracotomy
lobectomy. Lobectomy was performed by thoracotomy in 85 patients and
thoracoscopically in 12 patients (1 conversion), with complete resection in all
patients. All patients received induction chemotherapy, and 74 (76%) received
induction radiotherapy as well: 66 of 85 (78%) in the thoracotomy group and 8 of 12
(67%) in the thoracoscopy group. The overall median survival was 2.3 years, with no
difference between the groups. Patients undergoing a thoracoscopic lobectomy had a
shorter median hospital stay (3.5 vs 5 days, p = 0.0024) and chest tube duration (2
vs 4 days, p < 0.001). There were no significant differences in 30-day mortality,
hemorrhage, pneumonia, or respiratory failure. Thoracoscopic lobectomy is a feasible
approach for selected patients undergoing resection after induction therapy, and is
associated with shorter hospital stay and chest tube duration. Long-term follow-up of
survival will determine the role of thoracoscopic lobectomy in the management of
patients after induction therapy.
Video Assisted Thoracoscopic Surgery (VATS) Sep 15
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(2005) Scottish Intercollegiate Guidelines Network (SIGN). Video-assisted
thoracoscopic surgery (VATS) resection, undertaken by an appropriately skilled
surgeon, may be offered to selected patients with clinical stage I lung cancer.
Ohtsuka et al. (2004) completed a study of 106 patients with lung cancer in whom
major pulmonary resection by VATS, between August 1999 and March 2003, was
attempted. Their clinical stage I disease was determined preoperatively. The number
of procedures that were converted to open thoracotomy and the reasons for
conversion, the intraoperative blood loss, interval between surgery and chest tube
removal, length of postoperative hospital stay, postoperative complications, mortality
rate, prognoses, and patterns of recurrence, were all evaluated. VATS was completed
in 95 patients, whereas in another 11 patients (10%) conversion to open
thoracotomy was required. The operative procedures were lobectomy in 86
patients, segmentectomy in 8 patients, and bilobectomy in 1 patient. In 95 patients
VATS, postoperative complications developed in 9 patients (9%), and 1 patient (1%)
died from pneumonia. In the 86 patients without complications, the mean
postoperative hospital stay was 7.6 days (range, 4 to 15 days). In a mean follow-up
period of 25 months (range, 6 to 48 months) in patients with non-small cell lung
cancer (NSCLC), including the one perioperative death, the 3-year survival rate was
93% in 82 patients with clinical stage I disease, and 97% in 68 patients with
pathologic stage I disease. The 3-year disease-free survival rate was 79% in patients
with clinical stage I disease, and 89% in patients with pathologic stage I disease.
Local recurrence was observed in six patients (6%): recurrence in mediastinal lymph
nodes in five patients, and in the bronchial stump in one patient. Major pulmonary
resection by VATS is acceptable in view of its low perioperative mortality and
morbidity, and is an adequate procedure for the achievement of local control and
good prognosis in patients with clinical stage I NSCLC, although long-term follow- up
and prospective studies are required.
The biggest concerns regarding VATS lobectomy center on risk and management of
intraoperative bleeding, tumor recurrence in the incision, and the adequacy of the
cancer operation. The controversies with VATS involve the following issues: anatomic
dissection versus mass ligation of hilar structures, the length of the utility incision,
the use of a rib spreader, the use of endoscopic instruments versus conventional
instruments, and visualization through the incision or only on the monitor. The least
controversial issue is how hilar structures are addressed during a VATS lobectomy.
Although a simultaneous individual stapling lobectomy with mass stapling of the
vessels and the fissure was reported, this technique should be discouraged.
Individual ligation of vessels and bronchus has been the standard for more than 50
years, and so it should remain. An operation should not be compromised to make it a
minimally invasive operation.
Although the public perceives video-assisted thoracoscopic (VATS) surgery as
advantageous because it is less invasive, the medical community has questioned the
adequacy and safety of VATS lobectomy. Clinical studies have not addressed these
issues because they had only short-term follow up.
Indications for open thoracotomy include chest wall invasion, complex procedures
(such as sleeve resections), and prior chemotherapy or radiation. Limited resections
should be avoided for tumors >3 cm in size whenever possible. Defining the role of
VATS will require randomized, prospective trials to demonstrate efficacy equivalent
to a traditional surgical approach.
As noted above, the gold standard in chest surgery continues to be the thoracotomy.
Only 5% of lobectomies in the U.S. are performed by VATS. Some of the thoracic
societies including the Annals of Thoracic Surgery, feel that well-balanced studies
Video Assisted Thoracoscopic Surgery (VATS) Sep 15
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comparing VATS with open thoracotomy for lobectomy are lacking in the literature.
Others, such as the American College of Chest Physicians and the Scottish
Intercollegiate Guidelines Network, feel that video-assisted thoracoscopic surgery
(VATS) resection, undertaken by an appropriately skilled surgeon, may be offered to
selected patients with clinical stage I non-small cell lung cancer.
Review History
August 2008
March 2010
March 2011
January 2012
January 2013
January 2014
July 2014
September 2014
September 2015
Medical Advisory Council Initial Approval.
Health Net, Inc. considers video-assisted thoracoscopic
surgery (VATS) medically necessary for the following
scenarios: to remove a solitary pulmonary nodule, 3 cm or
less in diameter; or lobectomy for stage I non-small cell lung
cancer.
Revised policy to include VATS as medically necessary as an
alternative to Open Lung Biopsy, where open lung biopsy is
clinically indicated. Revised title to Video-Assisted
Thoracoscopic Surgery (VATS).
Revised policy to included VATS as medically necessary for
the treatment of intractable hyperhidrosis and as an
alternative to thoracotomy for lung volume reduction surgery
when criteria is met. Medicare table added. Code Updates
Update – no revision
Update – no revision. Codes updated.
Update – no revision. Codes updated.
Update – no revision. Codes updated.
Update – revised policy to consider VATs medically
necessary for diagnostic and therapeutic pleural, lung, and
mediastinal surgery. Code updates
Update – no revisions
This policy is based on the following evidence-based guidelines:
1.
2.
3.
Scott WJ, Howington J, Feigenberg S, et al. American College of Chest
Physicians. Treatment of non-small cell lung cancer stage I and stage II: ACCP
evidence-based clinical practice guidelines (2nd edition). Chest 2007 Sep;132(3
Suppl):234S-42S.
Scottish Intercollegiate Guidelines Network (SIGN). Management of patients with
lung cancer. A national clinical guideline. Edinburgh (Scotland): Scottish
Intercollegiate Guidelines Network (SIGN); 2005 Feb. 63 p.
National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice
Guidelines in Oncology. Non-Small Cell Lung Cancer. Version 4.2014. Update
7.2015
References – Update September 2015
1.
2.
3.
4.
Cai HB, Li YX, Li Z. Short term curative effect of video assisted thoracoscopic
lobectomy for early-stage lung cancer. Indian J Cancer. 2015 Feb;51 Suppl
2:e37-41.
Gill RR, Zheng Y, Barlow JS et al. Image-guided video assisted thoracoscopic
surgery (iVATS) - phase I-II clinical trial. J Surg Oncol. 2015 Jul;112(1):18-25.
Falcoz PE, Puyraveau M, Thomas PA, et al. Video-assisted thoracoscopic surgery
versus open lobectomy for primary non-small-cell lung cancer: a propensitymatched analysis of outcome from the European Society of Thoracic Surgeon
database. Eur J Cardiothorac Surg. 2015 Apr 26.
Hamaji M, Chen F, Matsuo Y, et al. Video-assisted thoracoscopic lobectomy
versus stereotactic radiotherapy for stage I lung cancer. Ann Thorac Surg. 2015
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subject to the facts of the individual clinical case, terms and conditions of the member’s contract, and
requirements of applicable laws and regulations. The contract language contains specific terms and
conditions, including pre-existing conditions, limitations, exclusions, benefit maximums, eligibility, and
other relevant terms and conditions of coverage. In the event the Member’s contract (also known as the
benefit contract, coverage document, or evidence of coverage) conflicts with the Policies, the Member’s
contract shall govern. The Policies do not replace or amend the Member’s contract.
Policy Limitation: Legal and Regulatory Mandates and Requirements
The determinations of coverage for a particular procedure, drug, service or supply is subject to applicable
legal and regulatory mandates and requirements. If there is a discrepancy between the Policies and legal
mandates and regulatory requirements, the requirements of law and regulation shall govern.
Reconstructive Surgery
CA Health and Safety Code 1367.63 requires health care service plans to cover reconstructive surgery.
“Reconstructive surgery” means surgery performed to correct or repair abnormal structures of the body
caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do
either of the following:
(1) To improve function or
(2) To create a normal appearance, to the extent possible.
Reconstructive surgery does not mean “cosmetic surgery," which is surgery performed to alter or reshape
normal structures of the body in order to improve appearance.
Requests for reconstructive surgery may be denied, if the proposed procedure offers only a minimal
improvement in the appearance of the enrollee, in accordance with the standard of care as practiced by
physicians specializing in reconstructive surgery.
Reconstructive Surgery after Mastectomy
California Health and Safety Code 1367.6 requires treatment for breast cancer to cover prosthetic devices
or reconstructive surgery to restore and achieve symmetry for the patient incident to a mastectomy.
Coverage for prosthetic devices and reconstructive surgery shall be subject to the co-payment, or
deductible and coinsurance conditions, that are applicable to the mastectomy and all other terms and
conditions applicable to other benefits. "Mastectomy" means the removal of all or part of the breast for
medically necessary reasons, as determined by a licensed physician and surgeon.
Policy Limitations: Medicare and Medicaid
Policies specifically developed to assist Health Net in administering Medicare or Medicaid plan benefits and
determining coverage for a particular procedure, drug, service or supply for Medicare or Medicaid
members shall not be construed to apply to any other Health Net plans and members. The Policies shall
not be interpreted to limit the benefits afforded Medicare and Medicaid members by law and regulation.
Video Assisted Thoracoscopic Surgery (VATS) Sep 15
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