Thorac Surg Clin 18 (2008) 235–247      The Variability of Practice in Minimally Invasive        Thoracic Surgery for Pulm...
236                                              ROCCO   et alfor certain nonmalignant diseases (ie, tuberculo-           ...
VARIABILITY OF PRACTICE IN INVASIVE THORACIC SURGERY                         237     direct visualization most often manda...
238                                                ROCCO   et aldefinitions (five questions); (2) indications for           ...
VARIABILITY OF PRACTICE IN INVASIVE THORACIC SURGERY                                         239Table 1Which terminology d...
240                                                     ROCCO    et alTable 4How do you define video-assisted thoracic surg...
VARIABILITY OF PRACTICE IN INVASIVE THORACIC SURGERY                                               241Table 8For what do y...
242                                                    ROCCO     et alTable 12Over time, which factors have been influentia...
VARIABILITY OF PRACTICE IN INVASIVE THORACIC SURGERY                                      243Table 15What proportion of yo...
244                                                   ROCCO   et alTable 18How do you envisage the training pathway of a r...
VARIABILITY OF PRACTICE IN INVASIVE THORACIC SURGERY                         245Question 13. Why do you think video-assist...
246                                              ROCCO   et alof VATS major lung resections, in particular                ...
VARIABILITY OF PRACTICE IN INVASIVE THORACIC SURGERY                              247to expand the appropriate use of VATS...
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  1. 1. Thorac Surg Clin 18 (2008) 235–247 The Variability of Practice in Minimally Invasive Thoracic Surgery for Pulmonary ResectionsGaetano Rocco, MD, FRCS (Ed), FECTSa,*, Eveline Internullo, MDb, Stephen D. Cassivi, MD, MSc, FRCSCc, Dirk Van Raemdonck, MD, PhDd, Mark K. Ferguson, MDe a Division of Thoracic Surgery, National Cancer Institute, Pascale Foundation, Naples, Italy b Division of Thoracic Surgery, University of Parma, Parma, Italy c Division of General Thoracic Surgery, Mayo Clinic, Rochester, MN, USA d Department of Thoracic Surgery, Kathoelike Universiteit Leuven, University Hospitals, Leuven, Belgium e University of Chicago, Chicago, IL, USA Video-assisted thoracic surgery (VATS) has solution was needed, which Yim named ‘‘mini-been extensively used to diagnose pulmonary con- thoracotomy with videoassistance,’’ to summarizeditions, such as interstitial lung disease and solitary the fundamental principles of a transition opera-pulmonary nodules. The progression to minimally tion from conventionally open, muscle dividing,invasive techniques has been almost a natural rib retracting with or without shearing approachesevolution of the use of VATS in the investigation to an innovative, rigorous VATS technique whereof pleural effusions. More controversial are the all these elements were not included.indications of VATS for the treatment of pulmo- The reasons to resort to minimally invasivenary parenchymal conditions. Although minimally pulmonary resections are diverse and have beeninvasive thoracic surgery (MITS), under various well described in the recent literature [2].denominations, is currently the accepted approach Although the need for parenchymal-sparing oper-to the treatment of spontaneous pneumothorax, its ations had increasingly been advocated for pa-use for the treatment of lung cancer and infectious tients with borderline respiratory function andconditions of surgical interest is still debated both infectious conditions of surgical interest, thefrom a philosophic and technical point of view. emerging view of a different oncologic approach Yim [1], in 2002, published a review on VATS to early stage lung cancer has paralleled the focusmajor pulmonary resections aimed, after almost on rigorous VATS techniques for pulmonarya decade since its introduction in clinical practice, lobectomy and segmentectomy [3]. Indeed, atat defining unresolved matters, such as the length some point, the consensus on a reduced immuno-of the minithoracotomy, the use of rib retraction, logic impact of VATS lobectomy, along with thethe relevance of visualization by the VATS moni- suggestions of reduced postoperative pain andtor to accomplish procedure-related maneuvers, length of hospital stay, emerged in the literature.and whether the simultaneous stapled ligation Concurrently, equivalent survival rates to lobec-technique could replace individual ligation of the tomy were being reported after segmentectomyhilar bronchovascular structures. At that time, it for early manifestations of lung cancers, such ashad already emerged clearly that a compromise ground-glass opacities and small (!2 cm) sized nodular adenocarcinomas (ie, bronchoalveolar carcinoma [BAC]), especially if located in the * Corresponding author. outer third of the lung. E-mail address: gaetano.rocco@btopenworld.com In addition, certain proponents have favored(G. Rocco). segmentectomy to remove pulmonary metastases,1547-4127/08/$ - see front matter Ó 2008 Published by Elsevier Inc.doi:10.1016/j.thorsurg.2008.06.002 thoracic.theclinics.com
  2. 2. 236 ROCCO et alfor certain nonmalignant diseases (ie, tuberculo- 9. The overall mortality was not different whensis), and for patients aged over 75 years, when only RCTs were considered. If non-RCTsa pathologic margin greater than 1 cm (margin-to- were added in the analysis, however, the 1-tumor ratio O1) could be obtained. and 5-year mortality was significantly better The issue of the comparison between wedge in the VATS group. Conversely, no advan-resection and anatomic segmentectomy for non– tage was seen in the stage-specific analysis.small cell lung cancer dates back to the seminalLung Cancer Study Group study [4]. In this trial, It is clear, from the increasing use of thesewedge resection was found to yield a threefold in- approaches, that at some point in the recent pastcreased risk of recurrence compared with lobec- the thoracic surgical community accepted thattomy. In addition, segmentectomy had a lower there was a benefit to less invasive approaches forrecurrence risk when compared with wedge resec- patients with lung cancer. This was furthered bytion. These findings have been subsequently con- the determination that there was at least the initialfirmed by the independent work of Okada and el technology necessary to perform these operations.Sherif [5–7]. What surgeons still cannot agree on is the exact In 2007, a meta-analysis was conducted by the methodology of MITS. What thoracic surgeonsInternational Society of Minimally Invasive do not agree on is as follows.Cardiothoracic Surgery [8], based on a comprehen- 1. Video-assisted thoracic surgery is not neces-sive review of all randomized (RCT) and non- sarily a synonym of ‘‘minimally invasive’’randomized controlled trials. It was aimed at surgery because it specifically addresses onlycomparing VATS with the conventional open the issue of technique visualization or visuali-approach to parenchymal-sparing resections. zation enhancement. The term VATS doesThe following results were reported: not directly address the issues of incisions or 1. Baseline prognosis was more favorable for of approach in general. It does imply potential VATS compared with open in non-RCT, for improved visualization to thoracic surgi- but not in RCT. cal procedures by adding an ‘‘in field’’ light 2. Postoperative complications were signifi- source and magnification. The difficulty aris- cantly reduced in the VATS group compared ing from the use over many years of different with open surgery considering aggregate terminology to define MITS is apparent, espe- results from non-RCT and RCT. cially if applied to parenchymal-sparing 3. Overall blood loss was reduced with VATS resections. (but there was no difference found in the 2. The length of the use of thoracotomy, the role incidence of excessive blood loss or re- of this incision in the parenchymal-sparing exploration for bleeding). resection performed by MITS, and the num- 4. Postoperative pain was reduced at different ber of port sites needed to complete the oper- levels up to week 4 for VATS. As a conse- ation are all unresolved matters. There seems quence, there was a significantly decreased to be consensus on the fact that no chest wall use of pain medications. muscles above the intercostals should be 5. Postoperative vital capacity was significantly divided to qualify as a MITS procedure. improved in the VATS group. This beneficial 3. When it comes to the technical definition of effect was maintained and observed up to VATS lobectomy, rib spreading or retraction 1 year after surgery. (even rib shearing or cutting) becomes an- 6. The degree of impairment of normal activi- other subject of controversy. According to ties and the time to return to normal activity some proponents of a stringently defined were significantly reduced in the VATS group VATS lobectomy and segmentectomy, (although no difference in function was noted whereas the chest wall muscles and the over- after 3 years from surgery). lying skin can be retracted, no spreading is 7. Length of stay in the hospital was reduced in allowed in the costal plane to decrease post- the VATS group (although operative time operative pain. was longer in the VATS group). 4. Many advocates of stringently defined VATS 8. Time to adjuvant chemotherapy was reduced lobectomy claim that only the monitor in the VATS group, although no difference should be used for visualization while per- was noted as to cancer recurrence rates. forming the pulmonary resection because
  3. 3. VARIABILITY OF PRACTICE IN INVASIVE THORACIC SURGERY 237 direct visualization most often mandates the responses from ESTS members was 219, of which need for rib spreading. 196 were complete answers (89%). In addition, as 5. Intraoperatively, the degree of lung manipu- of December 2007, 98 responses were provided lation may play a role in the immunologic through the CTSnet; of these, 84 were complete disturbances and possibly on the oncologic answers (86%). Out of approximately 800 notifi- outcome of the procedure. For this reason cation emails sent to ESTS members in the mail- some surgeons decry the back and forth ing list at the time the survey was opened, about retraction and movement of the lung during 50 were undelivered because of an incorrect or the procedure and advocate for a so-called absent email address. Accordingly, the response ‘‘no-touch’’ technique. rate by ESTS members was 26.1% (196 out of 750). The response rate provided by the CTSnet Other issues also need to be addressed link cannot be estimated because one cannot cal-regarding the pattern of work distribution. In culate the potential responders who have accessthis regard, two crucial questions demand to this resource (denominator). The inability toanswers. Is a dedicated operating room schedule calculate an overall response rate is an acknowl-and personnel (including surgeons) required for edged limitation of the study. This was recognizedVATS lobectomies or for MITS procedures in and accepted as a method of increasing accrual ofgeneral? Does the expected steep phase of the completed surveys without affecting the overalllearning curve for a VATS lobectomy surgeon value of the survey because members of CTSnetwarrant a redistribution of the routine surgical are thoracic surgeons.workload and operating room time among his or Overall, the number of complete answers washer partners and colleagues? 280 (88%) out of 317. Of these, 220 (78.6%) were These and other questions have been the entered by established surgeons or full consul-matter of a survey project by the European tants; 31 (11.1%) by junior consultants (within theSociety of Thoracic Surgeons (ESTS). This survey first 5 years of practice); 18 (6.4%) by seniorproject represents an attempt, by the leadership of trainees (last 2 years of training); and 11 (3.9%)the ESTS, to establish a framework for the by junior trainees (first 3 years of training). Indefinition and interpretation of technical and summary, 251 thoracic surgeons working atorganizational characteristics related to the per- a consultant level and 29 trainees participated informance of MITS and, in particular, to VATS the survey by providing a completedpulmonary resections. The results of this survey questionnaire.are hereafter reported. Of the 251 consultants, 194 (77.3%) were ESTS members, whereas 57 (22.7%) were non- ESTS members. As to the age distribution of theThe results of the European Society of Thoracic participating consultants, four age groupings wereSurgeons Survey on the interpretation of proposed. Only 5% of the consultants wereminimally invasive thoracic surgery for major younger than 35 years. A total of 42% ofpulmonary resections respondents were age 35 to 45 years, whereas the Several issues were addressed by the MITS 45- to 50-year-old and the older than 50 yearssurvey, which was originally an ESTS project groups represented 22% and 31% of the totalinitially conducted on-line through the ESTS consultants’ answers, respectively. As to the yearsWeb site (www.ests.org) as of November 2007. of practice as a consultant, 77% of the partici-Afterward, the Survey was also made available pants had more than 5 years of practice experiencein the Thoracic Portal of the Cardio-Thoracic at the consultant level. Of these, 24% had betweenSurgical Network (CTSnet; www.ctsnet.org) until 11 and 20 years of clinical practice at a consultantApril 2008. The questionnaire included 23 ques- level, whereas another 21% had more than 20tions about MITS practice; an additional request years of experience at that level. As to the countryfor comments was also included as the twenty- of practice, the most represented were the Unitedfourth item on the survey. States (15.5%); Italy (10.4%); Spain (8.8%); After an on-line collecting period of 125 days, Germany (8%); United Kingdom (5.2%); and,the total number of responses was 317. The ESTS Turkey (4.4%). Eleven consultants (4.4%) skip-members were invited to participate in the Survey ped the question on the country of practice.through an email link connected to the Society’s The questionnaire was structured into fiveWeb site (www.ests.org). The overall number of sections focused on (1) the terminology and
  4. 4. 238 ROCCO et aldefinitions (five questions); (2) indications for factors in determining whether a minimallyMITS (eight questions); (3) robotic thoracic invasive or an open approach had been usedsurgery (three questions); (4) case volume and (Table 2).learning curve (two questions); and (5) demo-graphic data (five questions). For each question, Question 3. How do you define a video-assistedthe participant had to select one or more answers thoracic surgery lobectomy? Part Irelevant to the current controversies discussed The consensus was that VATS lobectomy ispreviously. performed through two or three port incisions with the addition of a minithoracotomy (access incision to remove the specimen) (Table 3).Results Question 4. How do you define video-assisted The answers given to the questionnaire were thoracic surgery lobectomy? Part IIstratified by years of experience in the consultantposition, with 10 years being the selected arbitrary There was a general agreement (nearly 60% ofcut point between the two groups. A second the responders) that no rib spreading was anstratification was done according to the socioeco- important component of a strictly defined VATSnomic status of the country of practice of the lobectomy (Table 4).responding surgeon, distinguishing between low-and middle-income and high-income countries as Question 5. How do you define video-assistedper the ESTS three-tier subscription fee format thoracic surgery lobectomy? Part IIIinspired by the criteria of the World Trade The opinions were generally split as to whetherOrganization (www.ests.org). direct visualization of the surgical field could also be acceptable in VATS lobectomy. The mostQuestion 1. Which terminology do you prefer and prevalent answer (range, 52%–59%), however,do you use to describe less invasive thoracic surgical supported the idea of the dissection being doneprocedures? by visualization through only the video monitor Overall, 45% of the responders use VATS as (Table 5).the standard definition to describe less invasive Question 6. What are the main indications forthoracic procedures; VATS, in this case, meant minimally invasive procedures in your thoracicvideo-assisted thoracic surgery. VATS intended as surgical practice?‘‘video-assisted thoracoscopic surgery,’’ ‘‘mini-mally invasive thoracic surgery,’’ and ‘‘minimal- Participants were asked to clarify the indica-access thoracic surgery’’ were the preferred tions for minimally invasive procedures in theirterminology for the remaining 32%, 18%, and practice. Apparently, minimally invasive proce-3%, respectively. About 1% of the responders did dures are used primarily for diagnostic and minornot express a definitive view. No major differences therapeutic purposes, especially by surgeons fromin the answer distribution were noted between the low- to middle-income countries. Whether thistwo categories of seniority. Similarly, when the finding reflects different resource availability isresponders were stratified by socioeconomic status possible but not confirmed by these dataof the country of origin, answers from middle to (Table 6).low income countries overlapped the ones fromhigh income countries. The most prevalent answer Question 7. Of cases requiring access to theto the question at hand was ‘‘video-assisted thoracic cavity, approximately how often do youthoracic surgery’’ (Table 1). currently use the standard posterolateral thoracotomy (dividing at least the latissimus dorsiQuestion 2. What is your current definition of or both the latissimus and the serratus anterior‘‘open’’ thoracic surgery? muscles) for lung surgery? The most prevalent answer to this question was This question addressed the use of standarddefined by whether rib spreading was used. posterolateral thoracotomy in the participants’Furthermore, roughly 30% of the responders practice. Overall, 39% of the responders reportalso indicated that, along with rib spreading, the still using the standard posterolateral thoracot-length of the skin and the intercostal incision, and omy in more than 50% of their cases. Surpris-the division of chest wall muscles, were important ingly, no difference was noted as to the seniority
  5. 5. VARIABILITY OF PRACTICE IN INVASIVE THORACIC SURGERY 239Table 1Which terminology do you prefer and do you use to describe less invasive thoracic surgical procedures? Overall Overall !10-y !10-y O10-y O10-y response response practice practice practice practice count % count % count %Video-assisted thoracic surgery 114 45.4 48 42.9 66 47.5Video-assisted thoracoscopic 81 32.3 34 30.4 47 33.8 surgeryMinimally invasive thoracic 45 17.9 24 21.4 21 15.1 surgeryMinimal-access thoracic surgery 8 3.2 3 2.7 5 3.6I do not know 3 1.2 3 2.7 0 0Answered question 251 100 112 100 139 100Skipped question 0 0 0 0 0 0Table 2What is your current definition of open thoracic surgery? Overall Overall !10-y !10-y O10-y O10-y response response practice practice practice practice count % count % count %It depends on the length of the thoracic skin 29 11.6 16 14.3 13 9.4 incisionIt depends on the length of the incision 10 4 5 4.5 5 3.6 at the level of the intercostal musclesIt depends on whether the chest wall muscles 19 7.6 8 7.1 11 7.9 (latissimus dorsi, serratus anterior) are dividedIt depends on whether the ribs are spread 113 45 46 41.1 67 48.2It depends on whether a rib is cut or sheared 1 0.4 0 0 1 0.7All of the above 79 31.5 37 33 42 30.2Answered question 251 100 112 100 139 100Skipped question 0 0 0 0 0 0Table 3How do you define a video-assisted thoracic surgery lobectomy? Part I Overall Overall !10-y !10-y O10-y O10-y response response practice practice practice practice count % count % count %One port-sized incision with an additional 18 7.2 7 6.3 11 7.9 minithoracotomy (access incision)Two port-sized incisions with an 109 43.4 57 50.9 52 3.4 additional minithoracotomyThree or more port-size incisions 120 47.8 47 42 73 52.5 with an additional minithoracotomyMuscle-sparing thoracotomy 4 1.6 1 0.9 3 2.2Answered question 251 100 112 100 139 100Skipped question 0 0 0 0 0 0
  6. 6. 240 ROCCO et alTable 4How do you define video-assisted thoracic surgery lobectomy? Part II Overall Overall !10-y !10-y O10-y O10-y response response practice practice practice practice count % count % count %No skin retraction or rib retraction 67 26.7 33 29.5 34 24.5 or cuttingNo rib spreading or cutting 141 56.2 62 55.4 79 56.8With rib spreading 42 16.7 17 15.2 25 18With rib cutting 1 0.4 0 0 1 0.7Answered question 251 100 112 100 139 100Skipped question 0 0 0 0 0 0Table 5How do you define video-assisted thoracic surgery lobectomy? Part III Overall Overall !10-y !10-y O10-y O10-y response response practice practice practice practice count % count % count %Dissection done using only the video monitor 139 55.4 66 58.9 73 52.5 for visualizationDissection can be done using both video monitor 112 44.6 46 41.1 66 47.5 images and direct visualizationAnswered question 251 100 112 100 139 100Skipped question 0 0 0 0 0 0Table 6What are the main indications for minimally invasive procedures in your thoracic surgical practice? Overall Overall !10-y !10-y O10-y O10-y response response practice practice practice practice count % count % count %Diagnostic only (ie, mediastinoscopy, video-assisted 7 2.8 1 0.9 6 4.3 thoracic surgery for pleural effusions)Diagnostic and minor therapeutic (ie, wedge 127 50.6 54 48.2 73 52.5 resections of the lung for solitary pulmonary nodules, pneumothorax)Diagnostic, minor and major therapeutic (typical 117 46.6 57 50.9 60 43.2 segmentectomy, lobectomy, thymectomy)Answered question 251 100 112 100 139 100Skipped question 0 0 0 0 0 0Table 7Of cases requiring access to the thoracic cavity, approximately how often do you currently use the standard posterolat-eral thoracotomy (dividing at least the latissimus dorsi or both the latissimus and the serratus anterior muscles) for lungsurgery? Overall Overall !10-y !10-y O10-y O10-y response count response % practice count practice % practice count practice %O50% of the cases 98 39 42 37.5 56 40.3!30% of the cases 51 20.3 19 17 32 23!10% of the cases 29 11.6 16 14.3 13 9.4!5% of the cases 73 29.1 35 31.3 38 27.3Answered question 251 100 112 100 139 100Skipped question 0 0 0 0 0 0
  7. 7. VARIABILITY OF PRACTICE IN INVASIVE THORACIC SURGERY 241Table 8For what do you use video-assisted thoracic surgery for lung surgery Overall Overall !10-y !10-y O10-y O10-y response response practice practice practice practice count % count % count %Never, I only use video-assisted thoracic surgery 6 2.4 1 0.9 5 3.6 to diagnose pleural conditionsDiagnosis of interstitial lung disease and peripheral 129 51.4 51 45.5 78 56.1 solitary pulmonary nodules and treatment of pneumothoraxThe above and for segmental or lobar lung resections 116 46.2 60 53.6 56 40.3Answered question 251 100 112 100 139 100Skipped question 0 0 0 0 0 0Table 9Among the following answers, what is the main reason that you perform video-assisted thoracic surgery lobectomy? Overall Overall !10-y !10-y O10-y O10-y response response practice practice practice practice count % count % count %Better ability to tolerate the procedure in cases 44 17.5 22 19.6 22 15.8 of borderline cardiopulmonary functionBetter oncologic operation 2 0.8 1 0.9 1 0.7Decreased postoperative pain 152 60.6 65 58 87 62.6Decreased length of hospitalization 53 21.1 24 21.4 29 20.9Answered question 251 100 112 100 139 100Skipped question 0 0 0 0 0 0Table 10What is the second most important reason that you perform video-assisted thoracic surgery lobectomy? Overall Overall !10-y !10-y O10-y O10-y response response practice practice practice practice count % count % count %Better ability to tolerate the procedure in cases 58 23.1 20 17.9 38 27.3 of borderline cardiopulmonary functionBetter oncologic operation 1 0.4 0 0 1 0.7Decreased postoperative pain 76 30.3 35 31.3 41 29.5Decreased length of hospitalization 116 46.2 57 50.9 59 42.4Answered question 251 100 112 100 139 100Skipped question 0 0 0 0 0 0Table 11Of the lobectomies you perform every year, what percentage are video-assisted thoracoscopic surgery lobectomies? Overall Overall !10-y !10-y O10-y O10-y response count response % practice count practice % practice count practice %O50% of the cases 37 14.7 23 20.5 14 10.1!30% of the cases 31 12.4 15 13.4 16 11.5!10% of the cases 36 14.3 16 14.3 20 14.4!5% of the cases 147 58.6 58 51.8 89 64Answered question 251 100 112 100 139 100Skipped question 0 0 0 0 0 0
  8. 8. 242 ROCCO et alTable 12Over time, which factors have been influential in increasing or decreasing your likelihood to offer minimally invasiveprocedures? Overall Overall !10-y !10-y O10-y O10-y response response practice practice practice practice count % count % count %Scientific evidence on safety and effectiveness 126 50.2 60 53.6 66 47.5Patient demand for less invasive options 26 10.4 13 11.6 13 9.4Referring physician demand for less invasive options 6 2.4 1 0.9 5 3.6Medicolegal litigation environment 1 0.4 1 0.9 0 0Changes in technology available to assist with these 58 23.1 20 17.9 38 27.3 proceduresOpinion and practice of peers and partners 34 13.5 17 15.2 17 12.2Answered question 251 100 112 100 139 100Skipped question 0 0 0 0 0 0Table 13Why do you think video-assisted thoracic surgery lobectomy has not yet gained widespread popularity? Overall Overall !10-y !10-y O10-y O10-y response response practice practice practice practice count % count % count %Not enough scientific evidence to establish 33 13.1 13 11.6 20 14.4 safety and effectivenessDifficult technique, steep learning curve 48 19.1 24 21.4 24 17.3Resistance by older surgeons 22 8.8 14 12.5 8 5.8Logistic and financial issues (ie, capital cost 12 4.8 5 4.5 7 5 of necessary equipment and technology)Lack of adequate training and retraining in 28 11.2 13 11.6 15 10.8 video-assisted thoracic surgery pulmonary resectionsAll of the above 108 43 43 38.4 65 48Answered question 251 100 112 100 139 100Skipped question 0 0 0 0 0 0Table 14Do you consider robotic thoracic surgery to be a component of minimally invasive thoracic surgery? Overall Overall !10-y !10-y O10-y O10-y response response practice practice practice practice count % count % count %Yes, it is an evolution of video-assisted thoracic 150 59.8 67 59.8 83 59.7 surgeryYes, simply because it avoids a traditional 19 7.6 13 11.6 6 4.3 sternotomy or thoracotomyYes, because it entails a lesser degree of lung 3 1.2 2 1.8 1 0.7 manipulation, hence less immunologic disturbancesNo, my criteria for minimally invasiveness are 79 31.5 30 26.8 49 35.3 not met by robotic surgeryAnswered question 251 100 112 100 139 100Skipped question 0 0 0 0 0 0
  9. 9. VARIABILITY OF PRACTICE IN INVASIVE THORACIC SURGERY 243Table 15What proportion of your procedures do you perform with the use of robotic assistance each year? Overall Overall !10-y !10-y O10-y O10-y response count response % practice count practice % practice count practice %None 230 91.6 101 90.2 129 92.8!3% 10 4 5 4.5 5 3.6!5% 5 2 3 2.7 2 1.4!10% 4 1.6 3 2.7 1 0.7O10% 2 0.8 0 0 2 1.4Answered question 251 100 112 100 139 100Skipped question 0 0 0 0 0 0Table 16Why do you think robotically guided thoracic surgery has not yet gained widespread popularity? Overall Overall !10-y !10-y O10-y O10-y response response practice practice practice practice count % count % count %Financial issue (ie, capital costs, nonreusable 69 27.5 31 27.7 38 27.3 equipment costs, and so forth)Lack of technologic refinement in current 10 4 4 3.6 6 4.3 generation of equipmentRobotic-assisted procedures are unlikely to gain 14 5.5 5 4.5 9 6.5 widespread popularity until there is more widespread acceptance and use of video- assisted thoracic surgery and other minimally invasive approachesLack of evidence demonstrating advantage for 30 12 17 15.2 13 9.4 the patients over video-assisted thoracic surgeryAll of the above 128 51 55 49.1 73 52.5Answered question 251 100 112 100 139 100Skipped question 0 0 0 0 0 0Table 17If you worked in a group of four surgeons, how many should be doing video-assisted thoracic surgery lobectomies? Overall Overall !10-y !10-y O10-y O10-y response count response % practice count practice % practice count practice %Depends on the workload 99 39.4 40 35.7 59 42.4 and the available resources but at least oneOnly one 20 8 14 12.5 6 4.3Only two 32 12.7 12 10.7 20 14.4Everybody 100 39.8 46 41.1 54 38.8Answered question 251 100 112 100 139 100Skipped question 0 0 0 0 0 0
  10. 10. 244 ROCCO et alTable 18How do you envisage the training pathway of a resident for video-assisted thoracic surgery lobectomy? Overall Overall !10-y !10-y O10-y O10-y response response practice practice practice practice count % count % count %Stepwise, from classic open to classic video- 202 80.5 95 84.8 107 77 assisted thoracic surgery to video-assisted thoracic surgery lobectomyWith separate video-assisted thoracic surgery 49 19.5 17 15.2 32 23 lobectomy fellowship after conventional trainingAnswered question 251 100 112 100 139 100Skipped question 0 0 0 0 0 0level, whereas fewer surgeons from high-income again with no difference between consultants’countries seemed to use this approach for most of subgroups (Table 10).their cases (Table 7). Question 11. Of the lobectomies you perform everyQuestion 8. For what do you use video-assisted year, what percentage are video-assisted thoracicthoracic surgery for lung surgery? surgery lobectomies? As expected, more than half of the participants Most (59%) declared that VATS lobectomiesclaimed to use VATS lung surgery for the account for less than 5% of their lobectomy cases.diagnosis of interstitial lung disease and pulmo- About 15% of the participants claimed to performnary nodules, in addition to the treatment of more than 50% of their lobectomies by the VATSpneumothorax. Nevertheless, 46% of respondents approach. In this subset of responders, there weredeclared using VATS lung surgery also for ana- twice as many younger consultants than consul-tomic sublobar and lobar resections. Of these, tants with more than 10 years of seniority. If onemost (54%) were surgeons within the first 10 years analyzes the answers according to the socioeco-of independent practice. Once again, worthy of nomic backgrounds, 69% of surgeons from low-note was the minor impact of VATS lung surgery to middle-income countries performed less thanfor major pulmonary resections among 5% of their lobectomies by VATS, as opposed toresponders from low- to middle-income countries 56% in the higher-income subset. Compared with(38%) compared with the ones from high-income surgeons from low- to middle-income countries,countries (49%) (Table 8). the prevalence of surgeons from high-income countries performing VATS lobectomies in overQuestion 9. Among the following answers, what is 50% of their lobectomy candidates was threefoldthe main reason that you perform video-assisted higher (18% versus 5%) (Table 11).thoracic surgery lobectomy? By far, the primary reason was the reduced Question 12. Over time, which factors have beenincidence of pain compared with standard thora- influential in increasing or decreasing yourcotomy (61%) with a substantial agreement likelihood to offer minimally invasive procedures?between consultants with different experience Overall, 50% thought that the availability ofand from countries of differing socioeconomic scientific evidence on safety and effectiveness ofstatus (Table 9). these procedures played a major role in their decision to adopt these new approaches in theirQuestion 10. What is the second most important clinical practice. This was a shared opinion amongreason that you perform video-assisted thoracic surgeons, irrespective of their seniority and theirsurgery lobectomy? socioeconomic background. Interestingly, the When the participants were asked for the most senior surgeons seemed to believe thatsecondary reason for performing VATS lobecto- additional technologic advancements were stillmies, 46% claimed a reduced length of hospital- needed to increase the impact of minimallyization compared with standard thoracotomy, invasive surgery on their practice (Table 12).
  11. 11. VARIABILITY OF PRACTICE IN INVASIVE THORACIC SURGERY 245Question 13. Why do you think video-assisted Question 16. Why do you think robotically guidedthoracic surgery lobectomy has not yet gained thoracic surgery has not yet gained widespreadwidespread popularity? popularity? Most (43%) were inclined to think that there Participants replied that many issues factoredwas an ensemble of factors preventing further into this situation but a particularly importantdiffusion of VATS lobectomy. Most (48%) of the consideration seemed to be the costs of the device.consultant surgeons in practice for more than Moreover, 15% of the younger surgeons (versus10 years supported this view. Worthy of note was 9% senior) and 13% of those from higher-incomethe fact that younger consultants hinted at the countries (versus 5% from middle- to low-incomeissue of a possible resistance to change by older countries) seemed to believe that no distinctsurgeons (12% versus 6%). Interestingly, advantage of robotic over VATS has been dem-although surgeons from high-income countries onstrated. A total of 9% of the consultants fromseemed to emphasize the difficult learning curve middle- to low-income countries (versus 4% fromfor this procedure, their counterparts from mid- high-income countries) thought that the evolutiondle- to low-income countries tended to relate the to robotic approaches will be limited until VATSlack of widespread popularity of VATS lobec- clearly defines its role in the thoracic surgicaltomy to logistic and financial issues (Table 13). armamentarium (Table 16). Question 17. If you worked in a group of fourQuestion 14. Do you consider robotic thoracic surgeons, how many should be doing video-assistedsurgery to be a component of minimally invasive thoracic surgery lobectomies?thoracic surgery? The opinions were split between the view that Overall, 60% replied that they considered everybody should be equally able with thisrobotic surgery a direct evolution of VATS. In procedure and that, given a definite workload, atthis setting, consultants with lower seniority and least one surgeon should be dedicated to VATSthe ones from middle- to low-income countries lobectomy. The latter argument, in particular,were more convinced than senior colleagues that seemed to be supported by surgeons with higherrobotic surgery could fully replace, at some point, seniority (12.5% versus 4.3%) (Table 17).the thoracotomy or the sternotomy approach.More than 30%, however, especially the consul- Question 18. How do you envisage the trainingtants with longer seniority, denied that robotic pathway of a resident for video-assisted thoracicsurgery met their criteria for minimal invasive- surgery lobectomy?ness. In addition, when the collected data were There was an overwhelming majority (80%)stratified by national income, surgeons from favoring a stepwise approach to this procedure,higher-income countries also tended to be more from open to VATS. Younger surgeons expressedskeptical about considering robotic surgery as this view slightly more consistently than oldera part of the minimally invasive armamentarium surgeons (85% versus 77%) who were morecompared with their counterparts from the mid- inclined to propose an extracurricular trainingdle- to low-income countries (34% versus 25%) time rather than including this into the traditional(Table 14). training programs (23% versus 15%). When the socioeconomic background was analyzed, surgeons from middle- to low-income countriesQuestion 15. What proportion of your procedures favored the learning of VATS lobectomy as partdo you perform with the use of robotic assistance of a classic stepwise approach, contrary to theireach year? colleagues from higher-income countries who seemed to prefer a separate, dedicated VATS Overall, 92% of the respondents did not lobectomy training period (Table 18).perform any robotic cases. When the resultswere stratified according to the socioeconomicbackground, this percentage increased to 98% Summaryand decreased to 89% for middle- to low-incomeand higher-income countries, respectively Thoracic surgeons participating in this survey(Table 15). seemed to have clearly indicated their perception
  12. 12. 246 ROCCO et alof VATS major lung resections, in particular equally important factors. Resistance toVATS lobectomy. change by more senior surgeons ranked highly among younger surgeons, however, 1. The acronym VATS as a short form of as an explanation for the slow adoption of ‘‘video-assisted thoracic surgery’’ was the this technique. Senior surgeons, however, preferred terminology. seemed to focus their attention on the steep 2. According to the respondents, the need or learning curve of VATS lobectomy. In addi- use of rib spreading served as the defining tion, surgeons from middle- to low-income characteristic of ‘‘open’’ thoracic surgery. countries recognized certain financial and lo- 3. It was most commonly suggested that VATS gistic difficulties as major determinants of the lobectomy is performed by means of two or lack of popularity of VATS lobectomy. three port incisions with the addition of 12. Most surgeons thought that robotic tho- a minithoracotomy or access incision. racic surgery represented an evolution of 4. Rib spreading (shearing) was not deemed VATS. Nevertheless, almost 30% did not acceptable as part of a strictly defined think current robotic methods meet the cri- VATS procedure. teria for minimally invasive surgery. More 5. Although there was no general consensus, than 90% of the participants stated that respondents suggested that the preferred they did not perform robotic thoracic sur- approach for visualization in a VATS proce- gery. This was reportedly because of costs, dure was only through the video monitor. but also because of the fact that robotic 6. Although minimally invasive procedures for approaches have not yet demonstrated lung resection are still mainly being used a distinct advantage over nonrobotic VATS for diagnostic and minor therapeutic pur- procedures. poses, young surgeons seemed to be more 13. It was suggested that in every unit or likely to recommend VATS lung surgery for department there should be at least one major pulmonary resections than their more surgeon with a specific interest and capability senior colleagues. in VATS lobectomy. The younger surgeons, 7. The survey confirmed that the use of the however, seemed to envisage more wide- standard posterolateral thoracotomy is still spread competency being optimal. widespread. Almost 40% of the surgeons 14. Most suggested that training in VATS lobec- claimed to use the standard posterolateral tomy be done in a stepwise fashion starting thoracotomy for more than 50% of their from the classical open technique. Older sur- cases and less than 30% use it for less than geons wanted to see this as an extracurricular 5% of cases. activity following completion of the current 8. The major reasons to perform VATS lobec- training curriculum rather than included in tomy were perceived to be reduced pain and the traditional training program. decreased hospitalization. 9. Approximately 60% of the surgeons claimed In the opinion of the thoracic surgeons taking to perform VATS lobectomy in less than 5% part in this survey, pulmonary resections not of their lobectomy cases. Younger consul- performed according to these standards could tants reported using VATS lobectomy in up not be called VATS procedures but should be to 50% of their lobectomy cases. There was included within the MITS category at large, along the suggestion that lack of resources could with other diagnostic and therapeutic interven- justify the minor impact of VATS lobectomy tions. In addition, the survey confirmed that the in the thoracic surgical practice in middle- to time-honored muscle-dividing thoracotomy is still low-income countries. widely used. The opportunity for a progressive10. The currently available scientific evidence on move toward the routine use of less invasive safety and effectiveness, and technologic ad- approaches for major pulmonary resections, how- vancements were emphasized as the two fac- ever, is already well within sight. Given the results tors having a major impact on the of the ESTS survey supporting a stepwise teaching development of minimally invasive thoracic process leading to VATS lobectomy, hybrid and surgical practice. minimally invasive open lung resections (discussed11. Any lack of popularity of VATS lobectomy elsewhere in this issue) collectively defined as was presumed to be caused by several MITS may serve as starting point in this process
  13. 13. VARIABILITY OF PRACTICE IN INVASIVE THORACIC SURGERY 247to expand the appropriate use of VATS lobec- [4] Ginsberg RJ, Rubinstein LV. Randomized trial oftomy in the modern thoracic surgical practice. lobectomy versus limited resection for T1 N0 non- small cell lung cancer. Lung Cancer Study Group. Ann Thorac Surg 1996;62:1249–50.Acknowledgments [5] Okada M, Nishio W, Sakamoto T, et al. Effect of tumor size on prognosis in patients with non-small The authors thank Carol Blasberg and Tom cell lung cancer: the role of segmentectomy as a typeFerguson, MD, for their support with this project. of lesser resection. J Thorac Cardiovasc Surg 2005; 129:87–93. [6] El-Sherif A, Fernando HC, Santos R, et al. MarginReferences and local recurrence after sublobar resection of non-[1] Yim AP. VATS major pulmonary resection revisited: small cell lung cancer. Ann Surg Oncol 2007;14: controversies, techniques, and results. Ann Thorac 2400–5. Surg 2002;74:615–23. [7] Schuchert MJ, Pettiford BL, Luketich JD, et al.[2] Shaw JP, Dembitzer FR, Wisnivesky JP, et al. Video- Parenchymal-sparing resections: why, when, and assisted thoracoscopic lobectomy: state of the art how. Thorac Surg Clin 2008;18:93–105. and future directions. Ann Thorac Surg 2008;85: [8] Cheng D, Downey R, Kempf K, et al. Videoassisted S705–9. thoracic surgery in lung cancer resection: a meta-[3] D’Amico TA. Thoracoscopic segmentectomy: techni- analysis and systematic review of controlled trials. cal considerations and outcomes. Ann Thorac Surg Innovations 2007;2:226–92. DOI:10.1097/IMI.0b013 2008;85:S716–8. e3181662c6a.

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