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Original Research: Cardiothoracic Surgery |

Cross-sectional Survey on Lobectomy Approach (X-SOLA)Cross-sectional Survey on Lobectomy Approach FREE TO VIEW

Christopher Cao, MBBS; David H. Tian, BMed; Kevin Wolak, BMed; Jonathan Oparka, MD; Jianxing He, MD, PhD; Joel Dunning, MD; William S. Walker, MD; Tristan D. Yan, PhD
Author and Funding Information

From the Collaborative Research (CORE) Group (Drs Cao, Oparka, Dunning, and Yan and Messrs Tian and Wolak), Sydney, NSW, Australia; Department of Cardiothoracic Surgery (Dr Cao), St. George Hospital, University of New South Wales, Sydney, NSW, Australia; Department of Cardiothoracic Surgery (Dr He), The First Affiliated Hospital of Guangzhou Medical College, Guangzhou, China; Department of Cardiothoracic Surgery (Dr Walker), Royal Infirmary of Edinburgh, Scotland; and Department of Cardiothoracic Surgery (Dr Yan), Royal Prince Alfred Hospital, The University of Sydney, Sydney, NSW, Australia.

CORRESPONDENCE TO: Jianxing He, MD, PhD, Department of Cardiothoracic Surgery, The First Affiliated Hospital of Guangzhou Medical College, No. 151 Yanjiang Rd, Guangzhou 510120, Guangdong Province, China; e-mail: drjianxing.he@gmail.com


FOR EDITORIAL COMMENT SEE PAGE 246

FUNDING/SUPPORT: The authors have reported to CHEST that no funding was received for this study.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details


Chest. 2014;146(2):292-298. doi:10.1378/chest.13-1075
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BACKGROUND:  Lobectomy for non-small cell lung cancer (NSCLC) can be performed either through open thoracotomy or video-assisted thoracoscopic surgery (VATS). To improve the understanding of current attitudes of the thoracic community toward VATS lobectomy, the Collaborative Research Group conducted the Cross-sectional Survey on Lobectomy Approach (X-SOLA) study. We surveyed a large cohort of lobectomy-performing thoracic surgeons to examine their adoption of VATS lobectomy and their opinions of this technique vs conventional open thoracotomy.

METHODS:  Participants included thoracic surgeons identified through an international index search from the Web of Science and the cardiothoracic surgery network. A confidential questionnaire was e-mailed in June 2012. Nonresponders were given two reminder e-mails at monthly intervals.

RESULTS:  The questionnaire, completed by 838 thoracic surgeons within a 3-month period, identified 416 surgeons who only performed lobectomy through open thoracotomy and 422 surgeons who performed VATS or robotic VATS. Of those who performed VATS, 95% agreed with the definition of “true” VATS lobectomy according to the Cancer and Leukemia Group B trial. Ninety-two percent of surgeons who did not perform VATS lobectomy responded that they were willing to learn this technique, but were hindered by limited resources, exposure, and mentoring. Both groups agreed there was a need for VATS lobectomy training in thoracic residency programs and in standardized workshops.

CONCLUSIONS:  X-SOLA represents the largest cross-sectional report within the thoracic community to date, demonstrating the penetration of VATS lobectomy for NSCLC internationally. From our study, we were able to identify a number of obstacles to broaden the adoption of this minimally invasive technique.

Figures in this Article

Minimally invasive surgery has made a major impact in many surgical specialties since the first laparoscopic procedures in the 1970s. However, adoption of minimally invasive techniques has varied among disciplines as a result of anatomic applicability, technologic evolution, and physician attitude. Video-assisted thoracoscopic surgery (VATS) lobectomy for early-stage non-small cell lung cancer (NSCLC) was first performed in the early 1990s.1,2 Despite evidence suggesting similar long-term survival and improved morbidity outcomes compared with standard open thoracotomy,35 widespread practice of VATS lobectomy has been limited. Reported advantages for VATS lobectomy include lower incidences of pneumonia, arrhythmia, air leak, and postoperative pain.6 However, to our knowledge, these findings have been reported only in retrospective observational studies.

Currently, VATS lobectomy accounts for approximately 45% of all lobectomies in the Society of Thoracic Surgeons General Thoracic Database.7 The use of this technique in community cancer centers in the United States and Europe is much lower.8,9 Proponents of VATS cite the superior perioperative outcomes reported by institutional studies, while critics of this technique highlight the paucity of robust clinical evidence demonstrating oncologic efficacy. The lack of clinical equipoise in the thoracic surgery community has so far prevented a randomized controlled trial from being conducted according to the Cancer and Leukemia Group B (CALGB) 39802 definition of VATS lobectomy.10 Indeed, the impact of such a randomized controlled trial on clinical practice is unclear.

To improve the understanding of the current attitudes of thoracic surgeons toward VATS lobectomy at this 20-year mark, the Collaborative Research (CORE) Group conducted the Cross-sectional Survey on Lobectomy Approach (X-SOLA) study by contacting thoracic surgeons worldwide. The aim of this study was threefold: to assess the current practice of lobectomy in the thoracic surgical community, to identify potential reasons that inhibit the broader adoption of this technique, and to hypothesize about potential strategies that can advance this field in the future.

Participants

To identify thoracic surgeons who perform lobectomy for NSCLC, we searched for potentially relevant articles in the Web of Science (Thomson Reuters Corp) by using the following keywords separately: “lung and lobectomy,” “pulmonary resection,” “minimally invasive pulmonary resection,” “VATS lobectomy,” “video-assisted thoracic surgery,” and “video-assisted thoracoscopic surgery.” In total, 8,335 e-mail addresses of the corresponding authors were obtained, of which 4,693 e-mail addresses were identified without repetition. In addition, we also extracted e-mail addresses from the Cardiothoracic Surgery Network through the category “General Thoracic Surgery” (http://www.ctsnet.org/members/adv_member_search.cfm?membertype=Surgeon), and 6,906 e-mail addresses were added. After further elimination of repeated e-mail addresses from these two sources, 10,704 thoracic surgeons formed the basis of the present cross-sectional survey. An electronic link to a standardized, confidential questionnaire was e-mailed with an invitation from the CORE Group on June 1, 2012. Nonresponders were sent two reminder e-mails at monthly intervals after the initial e-mail.

Questionnaires

The online anonymous survey was supported by the CORE Group and established on the DXY survey system, an online survey tool that has been previously used to conduct large scale questionnaires for health professionals.11 Each thoracic surgeon was initially asked if they only performed lobectomy through open thoracotomy or if they also performed minimally invasive approaches (VATS and/or robotic VATS). A standardized set of seven questions was then given to participants who only performed open lobectomy, while a separate set of 13 questions was given to surgeons who also performed VATS or robotic-VATS lobectomy. Each question had to be completed to progress to the next question. Incomplete questionnaires were automatically excluded from data collection and analysis. A summary of the questionnaires can be viewed as supplementary files online (e-Appendix 1).

Surgeon Characteristics

The standardized, anonymous questionnaire was completed by 838 thoracic surgeons within a 3-month period. Baseline characteristics of the respondent surgeons are summarized in Table 1, including location of clinical practice and clinical experience.

Table Graphic Jump Location
TABLE 1  ] Surgeon Demographics in the Cross-sectional Survey on Lobectomy Approach Study

Data given as No. VATS = video-assisted thoracoscopic surgery.

Surgeons Performing Lobectomy by Open Thoracotomy

In this cross-sectional survey, 416 surgeons (49.6%) only performed lobectomy through an open thoracotomy. However, the majority of this group did perform other VATS procedures, including biopsy and pleurodesis (87%), pleurectomy and decortication (70%), and sublobar and wedge resection (79%). Regarding the routine management of lymph nodes, 4% of surgeons in this group stated they did not perform any sampling. When asked if the surgeon was prepared to learn VATS lobectomy, 381 surgeons (92%) responded “yes” and 35 (8%) responded “no.” Of the surgeons who responded “yes,” the hindrances preventing them from performing VATS currently included limited resources (50%), limited exposure and/or mentoring (45%), and the belief of limited robust clinical evidence (20%). Respondents to this question were able to select more than one option. Of the 35 surgeons who were not prepared to try VATS lobectomy, the main reasons listed included concerns regarding the safety of performing the procedure by the responding surgeon (54%), time consumption (31%), and concerns regarding oncologic efficacy (20%). A summary of responses by surgeons who only performed open lobectomies is presented in Figure 1.

Figure Jump LinkFigure 1  Survey responses for surgeons who did not perform lobectomy through VATS (n = 416). LN = lymph node; VATS = video-assisted thoracoscopic surgery.Grahic Jump Location
Surgeons Performing VATS Lobectomy

Of the 838 respondents, 422 surgeons (50.4%) reported performing some of their lobectomies through the VATS or robotic-VATS approach. In this group, 98 surgeons (23%) performed ≤ 20% of lobectomies through VATS, 79 surgeons (20%) performed 21% to 40% of lobectomies through VATS, 70 surgeons (17%) performed 41% to 60% of lobectomies through VATS, 82 surgeons (20%) performed 61% to 80% of lobectomies through VATS, and 93 surgeons (22%) performed > 80% of lobectomies through VATS. When asked how many VATS lobectomy cases were deemed necessary before gaining proficiency, 38% of responding VATS surgeons answered ≤ 25 cases, while 40% responded that 26 to 50 cases were necessary.

Respondents were informed of the CALGB 39802 definition of “true” VATS lobectomy, which required a single access incision of 4 to 8 cm with up to three 0.5-cm port incisions, individual ligation of lobar vessels and bronchus, hilar lymph node sampling or dissection, and no retractor or rib spreading.10 When asked if the surgeon performing VATS lobectomy routinely adhered to this definition in their surgical practice, 95% of surgeons answered “yes” and 5% answered “no.” Of the 19 surgeons who answered “no,” reasons listed for not complying with the CALBG definition included the use of rib spreading (42%), direct visualization through the thoracotomy (32%), and making incisions > 8 cm (21%). A summary of these responses by surgeons performing VATS lobectomy is presented in Figure 2.

Figure Jump LinkFigure 2  Survey responses for surgeons who performed lobectomy through VATS (n = 422). CALGB = Cancer and Leukemia Group B. See Figure 1 legend for expansion of other abbreviation.Grahic Jump Location

Regarding the impact of performing VATS lobectomy on their referral base, 53% of surgeons performing VATS lobectomy believed there was no significant impact, while 38% believed there was an increase. Comparing VATS vs open thoracotomy, 81% of surgeons performing lobectomy by VATS believed VATS resulted in less postoperative pain, 72% believed it resulted in shorter hospitalization, and 80% believed it offered higher patient satisfaction. Regarding the long-term oncologic efficacy of VATS lobectomy, 78% of surgeons performing VATS lobectomy believed it was similar to lobectomy through open thoracotomy. Regarding the cost-effectiveness of VATS lobectomy compared with the open approach, 35% of respondents believed it was similar, 35% believed it was more cost-effective, and 15% believed it was less cost-effective. A summary of these responses by surgeons performing VATS lobectomy is presented in Figure 3.

Figure Jump LinkFigure 3  Survey responses of surgeons who performed VATS lobectomy (n = 422). See Figure 1 legend for expansion of abbreviation.Grahic Jump Location
Future Directions

Surgeons from both groups were asked identical questions concerning VATS lobectomy in the future. In the group of surgeons performing VATS lobectomy, 81% believed VATS lobectomy should be incorporated into thoracic surgical training, 52% believed there should be more mentoring courses and workshops, 44% valued the establishment of a standardized multi-institutional database, and 34% thought it was important to perform a randomized controlled trial comparing true VATS consistent with the CALGB definition vs open thoracotomy. Correspondingly, in the group of surgeons who perform lobectomy by open thoracotomy, 60% believed VATS lobectomy should be incorporated into thoracic surgical training, 53% believed there should be more mentoring courses and workshops, 38% valued the establishment of a standardized multiinstitutional database, and 54% thought it was important to perform a randomized controlled trial. Bar graphs summarizing the responses from the two groups regarding the future of VATS lobectomy are presented in Figure 4.

Figure Jump LinkFigure 4  Responses regarding important issues related to the future of VATS lobectomy according to surgeons who only performed open thoracotomy (n = 416, dark columns), and those who performed VATS or robotic VATS (n = 422, light columns). RCT = randomized controlled trial. See Figure 1 legend for expansion of other abbreviation.Grahic Jump Location

The inherent hesitation by members of the surgical community to adopt and embrace potentially significant technologic advancement was exemplified by the rejection of Semm’s seminal dissertation on the first laparoscopic appendectomy in 1981 on the basis of “unethical conduct.” Although there is now general acceptance of simpler VATS procedures, such as pleural and lung biopsy, pleurodesis and treatment of pneumothorax, VATS lobectomy has only been performed by a minority of thoracic surgeons globally, even 20 years after its introduction. Currently, more complicated VATS procedures have been demonstrated to be feasible, and there is growing evidence suggesting equal or superior oncologic efficacy and superior perioperative outcomes for patients who undergo VATS lobectomy.1214 To elucidate the precise reasons for this reluctance and to identify the important issues on the present and future practice of VATS lobectomy, the X-SOLA study was performed by the CORE Group.

Results of the present study appear to indicate a progression toward the acceptance of VATS procedures compared with the results of a questionnaire performed by Mack et al15 in 1995, which included 189 completed responses from members of the General Thoracic Surgery Club. At that time, > 60% of responding surgeons performed general thoracic surgical procedures through the VATS approach in < 20% of all their thoracic cases, and 38% believed it was already being overused. VATS lobectomy was considered to be “unacceptable” or “investigational” by 84% of surgeons. The rationale for this reluctance included oncologic concerns (78%), lack of instrumentation (51%), and increased operating time (46%).

In total, 838 thoracic surgeons responded with a complete set of responses in our international cross-sectional survey, representing the largest questionnaire, to our knowledge, within the thoracic surgical community to date. Among the surgeons who performed VATS lobectomy, their reasons for using this technique was based on their perceived improvement in the perioperative outcomes, as summarized in Figure 3. The initial learning curve to acquire proficiency in performing VATS lobectomy was reported as fewer than 50 cases by 78% of surgeons performing lobectomy by VATS. However, it should be recognized that this case volume may not be attainable in many nontertiary centers for the vast majority of surgical trainees and community thoracic surgeons. Regarding the future of VATS lobectomy, the responses between the two groups of surgeons were not remarkably different, with the majority of respondents recommending VATS lobectomy to be incorporated into thoracic surgical training and additional mentoring programs and workshops for surgeons being made available. To improve the level of evidence in the future, a higher proportion of surgeons performing VATS lobectomy recommended the establishment of a standardized multi-institutional database compared with thoracotomy surgeons (44% vs 38%), while the opposite was true for conducting a randomized controlled trial (34% vs 54%). These results may represent the underlying lack of equipoise among some surgeons performing VATS lobectomy who now consider allocating patients to the open thoracotomy arm of a randomized trial to be ethically unjustified.

The majority of surgeons who did not perform VATS lobectomy procedures in the present survey did perform less complicated procedures through the VATS approach, and 92% reported a willingness to try VATS lobectomy. The most important hindrances to performing VATS in the current clinical setting included a lack of training and exposure, as well as limited resources. Regarding oncologic concerns, the majority of surgeons performing VATS lobectomy (78%) in the present study believed there was a similar efficacy between the two surgical approaches. In contrast, 20% of surgeons performing lobectomy by open thoracotomy who were not prepared to try VATS lobectomy did indicate uncertainties regarding long-term oncologic efficacy. From a technical perspective, there has clearly been an evolution of surgeons increasingly adopting less invasive techniques over the last 15 years, with 95% reporting to adhere to the CALGB definition of true VATS lobectomy in the present survey, compared with 55% of responding surgeons who said they “always” or “occasionally” used rib spreaders in a survey conducted by Yim et al16 in 1998 involving 33 surgeons performing VATS lobectomy.

Overall, concerns regarding the safety and oncologic efficacy associated with VATS lobectomy appear to have waned over the past decade, but the relatively slow adoption of this procedure due to technical challenges still persists. In the United States, these challenges may be met with more enthusiasm by general thoracic surgeons than cardiac surgeons, general surgeons, and surgical oncologists. A study by Cooke and Wisner17 analyzed data from academic medical centers in the United States, using the University Health System Consortium and Association of American Medical Colleges Faculty Practice Solution Center database. They reported a significantly higher number of VATS lobectomies and segmentectomies being performed by dedicated general thoracic surgeons compared with cardiac surgeons and general surgeons (16.0 vs 0.9 vs 0.2 cases per surgeon per year; P < .001). Perhaps even more importantly, the increase in the proportion of lobectomies and segmentectomies being performed through the VATS approach over the 3-year study period was much higher among general thoracic surgeons than cardiac surgeons (47.1% vs 27.4%). Authors of this study postulated that subspecialization of general thoracic surgery as a separate entity may have a significant impact on the future of referral patterns, credentialing policies, and residency curriculum in the United States. With these changes, it is likely that VATS lobectomy will be performed more frequently by surgeons dedicated to noncardiac thoracic procedures. However, it must be appreciated that not all patients with NSCLC are suitable for VATS lobectomy, and the threshold for contraindications may vary according to the surgeon’s technical ability and experience.

A number of limitations to the present study should be acknowledged and results should be interpreted with caution. First, participating surgeons who completed our survey were likely to have an interest in noncardiac thoracic procedures and may not be representative of the entire cardiothoracic surgical community. It may be possible that cardiothoracic surgeons whose practices focus predominantly on cardiac operations had been excluded or underrepresented in our data. Second, subgroup analysis of surgeons who performed VATS lobectomy at different frequencies was not performed, and this may have obscured the responses of those surgeons who have more comprehensively adopted the VATS lobectomy technique. In addition, some questions included in the survey were based on the respondent’s subjective perceptions, and these results should not be considered as objectively derived data. Finally, our survey did not identify why some surgeons who performed VATS as a proportion of their lobectomy procedures did not adopt this technique more frequently. It would be of tremendous interest to understand the obstacles that prevent surgeons who perform VATS lobectomies infrequently from broader adoption of this surgical technique. To address some of these issues, a number of relative and absolute contraindications to VATS lobectomy have recently been proposed by the VATS Lobectomy Consensus Statement.18

In conclusion, the X-SOLA study is the largest cross-sectional study to date demonstrating the current state of clinical practice of lobectomy approach for NSCLC worldwide. At the 20-year landmark since VATS lobectomy was first performed, it identified potential reasons that may inhibit the adoption of this technique and, more importantly, highlighted potential strategies that may advance this field in the future based on improved patient outcomes. In view of data suggesting short-term benefits from minimally invasive pulmonary resection techniques, and the paucity of data demonstrating inferior oncologic outcomes, it is important to understand the limitations to the wider adoption of CALBG-defined VATS lobectomy in patients with NSCLC.

Author contributions: T. D. Y. had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. C. C. served as principal author. C. C., J. H., W. S. W., and T. D. Y. contributed to study design; C. C., D. H. T., and K. W. contributed to data analysis; D. H. T. and K. W. contributed to data collection; J. H., W. S. W., and T. D. Y. contributed to academic supervision; C. C., J. O., and J. D. contributed to the writing of the manuscript; J. D. contributed to the editing of the manuscript; and D. H. T., K. W., J. O., J. H., W. S. W., and T. D. Y. contributed to the revision of the manuscript.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Additional information: The e-Appendix can be found in the Supplemental Materials section of the online article.

CALGB

Cancer and Leukemia Group B

CORE

Collaborative Research

NSCLC

non-small cell lung cancer

VATS

video-assisted thoracoscopic surgery

X-SOLA

Cross-sectional Survey on Lobectomy Approach

Lewis RJ. The role of video-assisted thoracic surgery for carcinoma of the lung: wedge resection to lobectomy by simultaneous individual stapling. Ann Thorac Surg. 1993;56(3):762-768. [CrossRef] [PubMed]
 
Walker WS, Carnochan FM, Pugh GC. Thoracoscopic pulmonary lobectomy. Early operative experience and preliminary clinical results. J Thorac Cardiovasc Surg. 1993;106(6):1111-1117. [PubMed]
 
Cao C, Manganas C, Ang SC, Yan TD. A meta-analysis of unmatched and matched patients comparing video-assisted thoracoscopic lobectomy and conventional open lobectomy. Ann Cardiothorac Surg. 2012;1(1):16-23. [PubMed]
 
Yan TD, Black D, Bannon PG, McCaughan BC. Systematic review and meta-analysis of randomized and nonrandomized trials on safety and efficacy of video-assisted thoracic surgery lobectomy for early-stage non-small-cell lung cancer. J Clin Oncol. 2009;27(15):2553-2562. [CrossRef] [PubMed]
 
Dunning J, Walker WS. How to set up a VATS lobectomy program. Ann Cardiothorac Surg. 2012;1(1):43-46. [CrossRef] [PubMed]
 
Cao CQ, Munkholm-Larsen S, Yan TD. True video-assisted thoracic surgery for early-stage non-small cell lung cancer [in Chinese]. Zhongguo Fei Ai Za Zhi. 2010;13(3):242-246. [PubMed]
 
Ceppa DP, Kosinski AS, Berry MF, Tong BC, Harpole DH, Mitchell JD, et al. Thoracoscopic lobectomy has increasing benefit in patients with poor pulmonary function: a Society of Thoracic Surgeons Database analysis. Ann Surg. 2012;256(3):487-493. [CrossRef] [PubMed]
 
Petersen RH, Hansen HJ. Learning curve associated with VATS lobectomy. Ann Cardiothorac Surg. 2012;1(1):47-50. [PubMed]
 
Rashid OM, Takabe K. Are video-assisted thoracoscopic surgery (VATS) and robotic video-assisted thoracic surgery (RVATS) for pulmonary resection ready for prime time? J Thorac Dis. 2012;4(4):341-342. [PubMed]
 
Swanson SJ, Herndon JE II, D’Amico TA, et al. Video-assisted thoracic surgery lobectomy: report of CALGB 39802—a prospective, multi-institution feasibility study. J Clin Oncol. 2007;25(31):4993-4997. [CrossRef] [PubMed]
 
Yu D, Li T. Facing up to the threat in China. Lancet. 2010;376(9755):1823-1824. [CrossRef] [PubMed]
 
Demmy TL. Video-assisted thoracoscopic extrapleural pneumonectomy for malignant pleural mesothelioma. Ann Cardiothorac Surg. 2012;1(4):533. [PubMed]
 
Oparka J, Yan TD, Richards JMJ, Walker WS. Video-assisted thoracoscopic pneumonectomy: the Edinburgh posterior approach. Ann Cardiothorac Surg. 2012;1(1):105-108. [PubMed]
 
Cao C, Manganas C, Ang SC, Peeceeyen S, Yan TD. Video-assisted thoracic surgery versus open thoracotomy for non-small cell lung cancer: a meta-analysis of propensity score-matched patients. Interact CardioVasc Thorac Surg. 2013;16(3):244-249. [CrossRef] [PubMed]
 
Mack MJ, Scruggs GR, Kelly KM, Shennib H, Landreneau RJ. Video-assisted thoracic surgery: has technology found its place? Ann Thorac Surg. 1997;64(1):211-215. [CrossRef] [PubMed]
 
Yim AP, Landreneau RJ, Izzat MB, Fung AL, Wan S. Is video-assisted thoracoscopic lobectomy a unified approach? Ann Thorac Surg. 1998;66(4):1155-1158. [CrossRef] [PubMed]
 
Cooke DT, Wisner DH. Who performs complex noncardiac thoracic surgery in United States academic medical centers? Ann Thorac Surg. 2012;94(4):1060-1064. [CrossRef] [PubMed]
 
Yan TD, Cao C, D’Amico TA, et al; on behalf of the International VATS Lobectomy Consensus Group. Video-assisted thoracoscopic surgery lobectomy at 20 years: a consensus statement [published online ahead of print October 14, 2013]. Eur J Cardiothorac Surg. doi:10.1093/ejcts/ezt463.
 

Figures

Figure Jump LinkFigure 1  Survey responses for surgeons who did not perform lobectomy through VATS (n = 416). LN = lymph node; VATS = video-assisted thoracoscopic surgery.Grahic Jump Location
Figure Jump LinkFigure 2  Survey responses for surgeons who performed lobectomy through VATS (n = 422). CALGB = Cancer and Leukemia Group B. See Figure 1 legend for expansion of other abbreviation.Grahic Jump Location
Figure Jump LinkFigure 3  Survey responses of surgeons who performed VATS lobectomy (n = 422). See Figure 1 legend for expansion of abbreviation.Grahic Jump Location
Figure Jump LinkFigure 4  Responses regarding important issues related to the future of VATS lobectomy according to surgeons who only performed open thoracotomy (n = 416, dark columns), and those who performed VATS or robotic VATS (n = 422, light columns). RCT = randomized controlled trial. See Figure 1 legend for expansion of other abbreviation.Grahic Jump Location

Tables

Table Graphic Jump Location
TABLE 1  ] Surgeon Demographics in the Cross-sectional Survey on Lobectomy Approach Study

Data given as No. VATS = video-assisted thoracoscopic surgery.

References

Lewis RJ. The role of video-assisted thoracic surgery for carcinoma of the lung: wedge resection to lobectomy by simultaneous individual stapling. Ann Thorac Surg. 1993;56(3):762-768. [CrossRef] [PubMed]
 
Walker WS, Carnochan FM, Pugh GC. Thoracoscopic pulmonary lobectomy. Early operative experience and preliminary clinical results. J Thorac Cardiovasc Surg. 1993;106(6):1111-1117. [PubMed]
 
Cao C, Manganas C, Ang SC, Yan TD. A meta-analysis of unmatched and matched patients comparing video-assisted thoracoscopic lobectomy and conventional open lobectomy. Ann Cardiothorac Surg. 2012;1(1):16-23. [PubMed]
 
Yan TD, Black D, Bannon PG, McCaughan BC. Systematic review and meta-analysis of randomized and nonrandomized trials on safety and efficacy of video-assisted thoracic surgery lobectomy for early-stage non-small-cell lung cancer. J Clin Oncol. 2009;27(15):2553-2562. [CrossRef] [PubMed]
 
Dunning J, Walker WS. How to set up a VATS lobectomy program. Ann Cardiothorac Surg. 2012;1(1):43-46. [CrossRef] [PubMed]
 
Cao CQ, Munkholm-Larsen S, Yan TD. True video-assisted thoracic surgery for early-stage non-small cell lung cancer [in Chinese]. Zhongguo Fei Ai Za Zhi. 2010;13(3):242-246. [PubMed]
 
Ceppa DP, Kosinski AS, Berry MF, Tong BC, Harpole DH, Mitchell JD, et al. Thoracoscopic lobectomy has increasing benefit in patients with poor pulmonary function: a Society of Thoracic Surgeons Database analysis. Ann Surg. 2012;256(3):487-493. [CrossRef] [PubMed]
 
Petersen RH, Hansen HJ. Learning curve associated with VATS lobectomy. Ann Cardiothorac Surg. 2012;1(1):47-50. [PubMed]
 
Rashid OM, Takabe K. Are video-assisted thoracoscopic surgery (VATS) and robotic video-assisted thoracic surgery (RVATS) for pulmonary resection ready for prime time? J Thorac Dis. 2012;4(4):341-342. [PubMed]
 
Swanson SJ, Herndon JE II, D’Amico TA, et al. Video-assisted thoracic surgery lobectomy: report of CALGB 39802—a prospective, multi-institution feasibility study. J Clin Oncol. 2007;25(31):4993-4997. [CrossRef] [PubMed]
 
Yu D, Li T. Facing up to the threat in China. Lancet. 2010;376(9755):1823-1824. [CrossRef] [PubMed]
 
Demmy TL. Video-assisted thoracoscopic extrapleural pneumonectomy for malignant pleural mesothelioma. Ann Cardiothorac Surg. 2012;1(4):533. [PubMed]
 
Oparka J, Yan TD, Richards JMJ, Walker WS. Video-assisted thoracoscopic pneumonectomy: the Edinburgh posterior approach. Ann Cardiothorac Surg. 2012;1(1):105-108. [PubMed]
 
Cao C, Manganas C, Ang SC, Peeceeyen S, Yan TD. Video-assisted thoracic surgery versus open thoracotomy for non-small cell lung cancer: a meta-analysis of propensity score-matched patients. Interact CardioVasc Thorac Surg. 2013;16(3):244-249. [CrossRef] [PubMed]
 
Mack MJ, Scruggs GR, Kelly KM, Shennib H, Landreneau RJ. Video-assisted thoracic surgery: has technology found its place? Ann Thorac Surg. 1997;64(1):211-215. [CrossRef] [PubMed]
 
Yim AP, Landreneau RJ, Izzat MB, Fung AL, Wan S. Is video-assisted thoracoscopic lobectomy a unified approach? Ann Thorac Surg. 1998;66(4):1155-1158. [CrossRef] [PubMed]
 
Cooke DT, Wisner DH. Who performs complex noncardiac thoracic surgery in United States academic medical centers? Ann Thorac Surg. 2012;94(4):1060-1064. [CrossRef] [PubMed]
 
Yan TD, Cao C, D’Amico TA, et al; on behalf of the International VATS Lobectomy Consensus Group. Video-assisted thoracoscopic surgery lobectomy at 20 years: a consensus statement [published online ahead of print October 14, 2013]. Eur J Cardiothorac Surg. doi:10.1093/ejcts/ezt463.
 
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