International VATS 2018: Segmentectomies

Ospedale San Gerardo, site of International VATS 2018 is located in Monza, just an hour outside of Milan

Monza, Italy

Dr. Scarci has returned to his native Italy, and his first-born child, the International VATS Symposium has come with him.  Now the chief of thoracic surgery at the 1,000 bed Ospedale San Gerardo,  Dr. Scarci has again managed to assemble many of the world’s best and brightest in thoracic surgery.


Over 130 attendees participated in the live surgery, and lab event – with a multitude of other participants watching and commenting thru the Live Streaming feature.  While the majority of on-site attendees were from Italy, there were attendees and lecturers from around the world, including Myanmar, Panama and Pakistan.

Many of our favorites were there, Gonzalez- Rivas, Dunning, and Sihoe.  While the dynamic Dr. Lim wasn’t in attendance this year, David Jones and Gaetano Rocco more than picked up the slack.

Segmentectomy by any other name?

The overarching theme of this year’s conference was segmentectomies (sublobar resections) but there were standout presentations in all areas.

The segmentectomy series of lectures discussed the differences between a wedge resection and a more anatomical sublobar segmentectomy).  Piergiorgio Solli was not pleased to give his lecture on the anatomy and nomenclature of segmentectomies, and it showed.  The usually composed surgeon was visibly irritated during his presentation.

Dr. Gaetano Rocco

The modern-day inventor of uniportal thoracic surgery, Dr. Gaetano Rocco discussed the latest data on morbidity and survival with segmentectomy.  Formerly of Naples, but now representing Sloan Kettering in New York, made a point to discuss the difference between intentional segmentectomies (suitable for ground glass opacities and very small limited cancers) and “compromise” or forced segmentectomies, which are lung resections performed on patients with very marginal lung function.  These forced segmentectomies are concerning for adequate margins.

He reminded surgeons that the scientific data isn’t always supported by our practice – while segmentectomies are superior to wedge resection, surgeons are doing wedge resections much more often even though the decrease in lung function (FEV1) after segmentectomy is only transient and limited in nature.  He also reminded surgeons that no matter the operation, adequate lymph node sampling was essential and that to some extent survival is based not just on adequate staging (via proper node sampling), and good margins, but on the physical location of the primary tumor, (with subcarinal and basilar based tumors carrying the best survival.)

Alex Brunelli and Dr. Marco Scarci debated sublobar resection versus lobectomy on several different points – with Dr. Brunelli reminding the audience that segmentectomies are just 5% of all lung resections, and that 75% of all procedures performed in Europe continue to be open procedures – so that theoretical discussions on research findings as well as minimally invasive techniques (in general) aren’t being replicated in real world practice for the majority of surgeons.

Dr. Piergiorgio Solli discusses the anatomy and naming of pulmonary segments for resection

Sublobar resections in the “Compromise” patient

Dr. Scarci discussed the current literature and evidence regarding respiratory outcomes on patients undergoing sublobar resections versus lobectomy.  Surprisingly, in the majority of these studies, the difference in post-operative lung function is very small – and transitory.  He discussed several of the limitations in currently published research which may have skewed some of these results, but that [at present] there is a lack of clear evidence to support the use of sublobar resection for preservation of pulmonary function.  

Nodes, nodes and more nodes

Luca Bertolaccini gave an interesting lecture on lymphadenectomy in segmentectomies – which boiled down to: take more nodes.  Do a complete and thorough lymph node dissection – and take at least  TEN nodes.

Dr. Dunning:  Fantastic style but still leaves you hungry

As usual, Dr. Dunning’s dramatic and charismatic style meant that he could argue just about anything in thoracic surgery and successfully acquit himself.  But not without hurtling a live grenade into the audience – criticizing Gonzalez Rivas and his adherents multiple times for slavish devotion to uniportal techniques.

I guess without Dr. Lim there to make thoughtful and logical arguments during the conference, someone had to stir up a ruckus.  Who better than thoracic surgery’s own Pied Piper?    Part showman, and part infomercial salesman, Dr. Dunning did his best  to argue for open surgery using the “It’s not the size of your incision, but the quality of the post-operative care” argument.

Despite his whimsical delivery style, Dr. Dunning was able to deliver the data  – reams of it.   Unable to resist a dig at the absent but larger-than-life Robert Cerfolio, Dr. Dunning repeated last year’s technique and cited a mountain of Cerfolio’s work in his defense of the humble thoracotomy, all while assuring the audience that “it’s not your grandfather’s thoracotomy.”

Using that thread, he went on to remind attendees of the importance of ongoing work in the area of massive resections for advanced cancers.  He presented a myriad of published titles highlighting major chest wall resections and advanced techniques for metastatic disease.

His always enjoyable delivery style as also punctuated with praise for another one of the speakers, Dr. Joao Carlos Das Neves Pereira, and his “extreme rehabilitation” program.   He also made a point of highlighting the published works of surgeons outside of the traditional confines of Europe and the United State, focusing on contributions of our colleagues in Brazil and Asia.

While it was a great lecture, it left the audience feeling a little bit hungry for more substance, instead of a remote control like flashing thru channels.   It was the perfect set up for the end of the day lecture by Dr. Das Neves Periera.   Too bad there were something like 12 other presentations between the two.