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Lobectomy by VATSSurvey on Lobectomy Approach: Taking the Plunge FREE TO VIEW

Melanie A. Edwards, MD; Keith S. Naunheim, MD, FCCP
Author and Funding Information

From the Division of Cardiothoracic Surgery, School of Medicine, Saint Louis University.

CORRESPONDENCE TO: Melanie A. Edwards, MD, Division of Cardiothoracic Surgery, School of Medicine, Saint Louis University, 3635 Vista Ave at Grand Boulevard, Box 15250, St. Louis, MO 63110-0250; e-mail: medwar13@slu.edu


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.

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):246-248. doi:10.1378/chest.14-0349
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Published online

Surgeons, being human, have widely varying thresholds for the adoption of new technology and techniques. Although we all would like to be working “at the cutting edge,” it can be somewhat difficult to “take the plunge” when new procedures appear. What one surgeon considers an exciting new technique might be considered challenging or even daunting by another.

In this issue of CHEST (see page 292), Cao and colleagues1 report on an international survey of thoracic surgeons that provides a snapshot of the current status of video-assisted thoracoscopic surgery (VATS) lobectomy worldwide nearly two decades after its introduction. Previous surveys have been more limited in scope and size,2,3 making this an important contribution to our understanding of current attitudes toward how VATS lobectomy is being incorporated into practice. Because of its international reach, this report also raises several issues regarding the real differences in the adoption of new technology between developed and developing nations.

The survey clearly illustrates that the adoption of minimally invasive lobectomy procedures is lagging behind in less economically developed areas like Africa and South America. While there can be no certainty regarding why this is true, it is possible that such locales do not provide adequate technical or financial support to allow for VATS lobectomy to be performed widely. It is also possible that in lower socioeconomic areas, less medical care is available to the population resulting in the late presentation of patients with lung cancer who are then clinically inappropriate for a VATS approach.

In the United States, the utilization of VATS techniques for lobectomy has risen significantly, and the most recent data from The Society of Thoracic Surgeons database demonstrates that 44% of lobectomies are performed via thoracoscopy vs 8% in 2003.4 However, the penetrance of VATS lobectomy is far from what might be expected considering the broad success of other minimally invasive procedures such as laparoscopic cholecystectomy or endovascular stent placement. In this vein, it is enlightening to compare and contrast the adoption by surgeons of a minimally invasive approach to lobectomy vs paraesophageal hiatal hernia repair. Both procedures were routinely performed in an open fashion by surgeons in the early 1990s, and the minimally invasive approach for each was first reported about that time. Although the minimally invasive approach was highly controversial for both of these disease entities initially, their rates of adoption have differed widely. A review of a 5% sample of the 2012 Medicare claims database reveals markedly different levels of penetrance occurring over these last two decades. In 2012, 80% of paraesophageal hernia repairs were reported using laparoscopic Current Procedural Terminology (CPT) codes (43280/43281/43282) whereas only 38% of lobectomies were reported with the thoracoscopic CPT code (32663). While it is probably true that a greater proportion of paraesophageal hernia repairs can be accomplished in a minimally invasive fashion as compared with lobectomy, this twofold variance is stark and begs the question: why the difference?

When surgeons are confronted with new techniques, each of us falls somewhere on the innovation curve between the extremes of “wild-eyed enthusiast” on one side and “obstinate traditionalist” on the other. Depending upon exactly where along this innovation curve one resides, the rationale behind slow adoption can be described either as judicious reticence or pig-headed obstinacy. This survey helps us in some measure to determine why the adoption of VATS lobectomy has been occurring at a plodding pace.

There are several reasons proffered in this survey for not adopting VATS lobectomy:

  1. The safety of VATS has not been demonstrated outside of specialty centers

  2. Oncologic efficacy of the technique has not been well demonstrated

  3. A randomized controlled trial is required to demonstrate the superiority of VATS

  4. Training of thoracic residents requires learning the open technique

  5. It is unreasonable for my program to adopt VATS lobectomy because we lack the appropriate clinical volume/technology/skilled faculty/mentorship (pick all that are applicable) necessary to proceed toward that goal

Generally, these are expressed sequentially in the order above. As one issue becomes settled, it is psychologically easy to slip into the next “rational excuse” and wait for that issue to be addressed. This process of stepwise rationalization, in conjunction with the natural and intrinsic resistance to change present in most humans, has likely resulted in many centers adopting minimally invasive lobectomy late or not at all.

In fact, most of the above issues have been addressed. The overall safety and clinical advantages of VATS lobectomy (pain, length of stay, return to work) have been well demonstrated in both academic and community settings.4-8 Recent articles from several institutions chronicle the long-term efficacy of the technique.9,10 While teaching residents open techniques is desirable and necessary, the reality is that they also must learn VATS lobectomy if they are to be well trained. And with the widespread public acceptance of and desire for minimally invasive approaches, a randomized controlled trial is unlikely to be performed in North America, although such an effort is currently under way in The Netherlands. The final rationale, which deals with programmatic shortfalls of volume, technology, personnel, and mentoring, can indeed be an impediment to instituting a VATS lobectomy program and likely constitutes the last valid reason for lack of such adoption.

Ultimately, surgeons select the operation that they think will yield optimal results both in the short term and long term based on the best available data and their individual and institutional capabilities. As the debates shift from comparisons of VATS and open thoracotomy to VATS vs robotic lobectomy, similar issues of safety, cost-effectiveness, and oncologic validity are being revisited. Surgeons are inherently resourceful and resilient, routinely navigating through difficult cases with equanimity and frequently devising creative solutions to difficult problems. Yet, when faced with a major paradigm shift, many are resistant, staying well ensconced in surgical inertia because of the uncertainty and difficulties associated with change. There is no dispute that new technology needs to be critically assessed and rigorous analysis has to be performed before wide adoption, but when a clear benefit exists for patients, it is time to take the plunge.

References

Cao C, Tain DH, Wolak K, et al. Cross-sectional survey on lobectomy approach (X-SOLA). Chest. 2014;146(2):292-298.
 
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]
 
Ceppa DP, Kosinski AS, Berry MF, 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]
 
Paul S, Altorki NK, Sheng S, et al. Thoracoscopic lobectomy is associated with lower morbidity than open lobectomy: a propensity-matched analysis from the STS database. J Thorac Cardiovasc Surg. 2010;139(2):366-378. [CrossRef] [PubMed]
 
Scott WJ, Allen MS, Darling G, et al. Video-assisted thoracic surgery versus open lobectomy for lung cancer: a secondary analysis of data from the American College of Surgeons Oncology Group Z0030 randomized clinical trial. J Thorac Cardiovasc Surg. 2010;139(4):976-981. [CrossRef] [PubMed]
 
Paul S, Sedrakyan A, Chiu YL, et al. Outcomes after lobectomy using thoracoscopy vs thoracotomy: a comparative effectiveness analysis utilizing the Nationwide Inpatient Sample database. Eur J Cardiothorac Surg. 2013;43(4):813-817. [CrossRef] [PubMed]
 
Swanson SJ, Meyers BF, Gunnarsson CL, et al. Video-assisted thoracoscopic lobectomy is less costly and morbid than open lobectomy: a retrospective multiinstitutional database analysis. Ann Thorac Surg. 2012;93(4):1027-1032. [CrossRef] [PubMed]
 
Lee PC, Nasar A, Port JL, et al. Long-term survival after lobectomy for non-small cell lung cancer by video-assisted thoracic surgery versus thoracotomy. Ann Thorac Surg. 2013;96(3):951-960. [CrossRef] [PubMed]
 
Taioli E, Lee DS, Lesser M, Flores R. Long-term survival in video-assisted thoracoscopic lobectomy vs open lobectomy in lung-cancer patients: a meta-analysis. Eur J Cardiothorac Surg. 2013;44(4):591-597. [CrossRef] [PubMed]
 

Figures

Tables

References

Cao C, Tain DH, Wolak K, et al. Cross-sectional survey on lobectomy approach (X-SOLA). Chest. 2014;146(2):292-298.
 
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]
 
Ceppa DP, Kosinski AS, Berry MF, 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]
 
Paul S, Altorki NK, Sheng S, et al. Thoracoscopic lobectomy is associated with lower morbidity than open lobectomy: a propensity-matched analysis from the STS database. J Thorac Cardiovasc Surg. 2010;139(2):366-378. [CrossRef] [PubMed]
 
Scott WJ, Allen MS, Darling G, et al. Video-assisted thoracic surgery versus open lobectomy for lung cancer: a secondary analysis of data from the American College of Surgeons Oncology Group Z0030 randomized clinical trial. J Thorac Cardiovasc Surg. 2010;139(4):976-981. [CrossRef] [PubMed]
 
Paul S, Sedrakyan A, Chiu YL, et al. Outcomes after lobectomy using thoracoscopy vs thoracotomy: a comparative effectiveness analysis utilizing the Nationwide Inpatient Sample database. Eur J Cardiothorac Surg. 2013;43(4):813-817. [CrossRef] [PubMed]
 
Swanson SJ, Meyers BF, Gunnarsson CL, et al. Video-assisted thoracoscopic lobectomy is less costly and morbid than open lobectomy: a retrospective multiinstitutional database analysis. Ann Thorac Surg. 2012;93(4):1027-1032. [CrossRef] [PubMed]
 
Lee PC, Nasar A, Port JL, et al. Long-term survival after lobectomy for non-small cell lung cancer by video-assisted thoracic surgery versus thoracotomy. Ann Thorac Surg. 2013;96(3):951-960. [CrossRef] [PubMed]
 
Taioli E, Lee DS, Lesser M, Flores R. Long-term survival in video-assisted thoracoscopic lobectomy vs open lobectomy in lung-cancer patients: a meta-analysis. Eur J Cardiothorac Surg. 2013;44(4):591-597. [CrossRef] [PubMed]
 
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