Is a thoracotomy rather than thoracoscopic resection associated with improved survival after pulmonary metastasectomy?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was 'in patients undergoing pulmonary metastasectomy, does a thoracotomy (rather than a thoracoscopic approach) affect survival?' Altogether >153 papers were found using the reported search, of which seven represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. No papers were greater than level-three evidence. Length of stay and length of chest drainage were found to be significantly shorter in the minimally invasive groups in one study, although this result is undermined by significant differences between the two cohorts. One paper demonstrated that, although there was a significantly closer resection margin in thoracoscopic resections, this had no effect on survival or recurrence rates. A prognostic analysis found no correlation between surgical approach and survival across a number of primary pathologies. However, by analysing the results by primary pathology, the sample groups were small. Despite no difference being found in outcome, more complications were seen with open resections in one study, and although there was a trend towards improved disease survival following resection of single resections by video-assisted thoracoscopic surgery (VATS), this did not reach significance. We conclude that there have been few high-quality studies to date, and further studies would be beneficial. From the published data, VATS metastasectomy has been associated with shorter hospital stays, chest drainage times and perioperative complications. We did not find evidence for a survival difference with either approach, and the lack of high-quality data makes it impossible to recommend any particular surgical approach in terms of long-term survival.