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LUNG CANCER TREATMENT: THE SURGEONS ROLE AND PERSPECTIVE
- 1. LUNG CANCER TREATMENT: THE SURGEONS ROLE AND PERSPECTIVE FLASCO 2016 LUIS J. HER R ER A M D SE CT I O N HE A D, T HO RA CI C SU RG E RY U F HE A LT H CA N CE R CE N T E R/O RL A N DO HE A LT H O RL A N DO F L O RI DA
- 2. Disclosures IntuitiveSurgical-‐ Thoracic Surgery Epicenter: case observation/proctor
- 3. The Surgeon: Role in Lung Cancer ØSurgical Resection-‐ Obvious, traditional role ØExpanding Role ØDiagnostic assistance (Tissue diagnosis, Navigation, Surveillance, Screening) ØStaging (EBUS, Med, Surgical) ØPalliation (Airway, pleural effusion) ØLocal therapy oligometastasis, large tissue acquisition, SABR Rescue
- 4. Shrinking Role? ØCompeting treatments, improving effectiveness (SABR, TARGETED THERAPY IMMUNOTHERAPY)
- 5. Is Surgery Underutilized?? Ø“Patient refused surgery” ØFear of complications, pain, recovery, ØControversy regarding stage IIIA disease, T4 disease ØLocal therapy for octogenarians
- 6. The Problem ØSurgery for lung cancer is a highly effective therapy but has the perception of being a morbid procedure ØTraditional open approaches via thoracotomy are effective and safe, but can result in a long recovery, pain and a risk of respiratory complications The image part with relationship ID rId4 was not found in the file.
- 7. The Evolution of Minimally Invasive Lung Cancer Surgery VATS Lobectomy 1992 VATS Lobectomy Complex Surgery 2000 Robotic Lobectomy 2002 Uniportal Lobectomy Complex Surgery 2009 Robotic Lobectomy Complex Surgery 2010
- 8. VATS Approaches Safe and Effective
- 9. Nationally in the USA, Only 32% of Lung Cancers Treated with VATS or MIS Approach!!! The surgical approach consisted of thoracotomy in 6087 patients (70%), video-assisted thoracic surgery (VATS) in 2429 (28%), and others in 230 (2%). Lobectomy was per- formed via VATS in 1040 patients or 20% of all lobectomies. Over the past 3 years the percentage of lobectomies performed by VATS has increased (21.6% in 2004, 28.6% in 2005, and 32% in 2006).
- 10. SEER Review Shows Increased use of Robotic Approach, Some Increase use of VATS (37%) Thoracotomy 61% (decreased to 56%) VATS 37.5 % Robotic 1.3% (increased to 3.6%)
- 12. VATS Summary Ø VATS has less complications, quicker recovery and more rapid transition into adjuvant therapy than open thoracotomy approaches Ø Many centers are proficient in VATS approaches and perform the vast majority of resections with this approach including complex tumors Ø VATS utilization in the US is still low (37%) reflecting the technical limitations and difficulty in adapting the technique
- 14. Minimally Invasive lobectomy-‐ Robotic RS 2 4 1 C AS 4 arms (Re-‐dock arm 2 to AS port post stapling)
- 15. Why Use Robotics in Thoracic Surgery? Potential for wider surgeon acceptance than VATS Bimanual dissection, instruments not fighting via one port Better exposure, plane visualization, CO2 portal technique With greater experience, more complex cases that are now done open may be done MIS
- 16. VATS to Robotics: Why Not? Already competent and confident in VATS Cost Learning curve Uncomfortable with distance from patient and assistant controlling stapler Longer operative times
- 17. Our Introduction to Robotics Performing robotic surgery since 2007 ◦ Benign esophageal surgery ◦ Mediastinal pathology Approach for lobectomy-‐ VATS 2006-‐2010 ◦ Concerned about inferior outcomes during learning curve Approach for lobectomy-‐ Robotic2011-‐2016 ◦ Able to perform more complex cases, less open surgeries
- 18. Transition to Robotics: Lobectomy 2010-‐2015 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0 10 20 30 40 50 60 70 80 90 2009 2010 2011 2012 2013 2014 2015 OPEN VS MINIMALLY INVASIVE LOBECTOMY OPEN MIS MIS% First Robotic Lobectomy
- 20. In which patients is robotic lobectomy a real advantage over VATS? My Opinion Obesity N1/N2 disease Complex cases normally done open
- 21. OUTCOMES OPEN (207) VATS (188) ROBOTIC (260) MORTALITY 30 DAY-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐ 4 (1.9%) 4 (2.1%) 1 (0.3%) READMISSION-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐ 11 (5%) 7 (3.7%) 2 (0.6%) RETURN OR-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐ 5 (2%) 2 (1%) 3 (1.2%) MEAN OR TIME-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐ 204 MIN 173 MIN 211 MIN EMERGENT CONVERSION-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐ N/A ? 2 (0.7%) ELECTIVE CONVERSION-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐ N/A ? 22 (8%) INTRAOP PRBC-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐ 22 (10.6%) 1 (0.5%) 2 (0.7%) COMPLICATION %-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐ 98 (47%) 47(24.8%) 48 (18.5%) A. FIB-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐ 38 (18%) 20 (10.6%) 28 (11%) PNEUMONIA-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐ 22 (10.6%) 10 (5.3%) 3 (1.2%) REINTUBATION-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐ 8 (3.8%) 3 (1.5%) 0 AIR LEAK >5DAYS-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐ 25 (12%) 12 (6.3%) 13 (5.1%) MEDIAN LOS-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐ 4 4 4 MEAN LOS-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐ 6.1 5.4 5.4 Data-‐ Orlando Health STS Database
- 22. OH Average Direct Supply Costs q OPEN= $1,715 q VATS= $2,587 q ROBOTIC= $3,442 OH Average Inpatient Contribution/Case q OPEN= $3,712 q VATS= $3,151 q ROBOTIC= $3,175
- 23. Complex Case RUL/RML Bilobectomy
- 24. The Future: Robotics is an Ideal Platform ØNavigation ØSingle Port ØCancer labeling
- 25. Key Points Robotic Surgery ØSafe and effective approach for lung cancer MIS ØWith more experience, more complex cases can be completed potentially avoid an open approach ØOR time, outcomes and patient experience similar to VATS approach but better than open ØLearning curve (20 cases) necessary but feasible. May be easier to adopt for the surgeon that has difficulty with VATS
- 26. ØCosts of implementation may are higher than VATS but instrumentation, visualization and surgeon comfort is improved in most cases ØNecessary? No, but for me it is preferable and I can do a better job Key Points Robotic Surgery
- 27. Summary ØSurgery plays a key role in the treatment of lung cancer, the surgeon can facilitate the diagnosis, staging and surgical treatment in an efficient matter. ØA complete oncologic operation is the goal, and a minimally invasive approach is preferable ØThe modality of MIS approach is less important than a good outcome and a complete recovery ØVATS=ROBOTIC=UNIPORTAL but ≠ open thoracotomy
- 28. THANK YOU! Luis Herrera Cell: 407-‐401-‐2703 luisherreramd@gmail.com You tube channel: “herrera lobectomy”