Act differently or watch thoracic surgery die

Dr. Eric Lim challenges thoracic surgeons to remain relevant with a call to action at the 3rd VATS International conference in London, England

“Act different or watch thoracic surgery die”

With that dramatic shot across the bow, the dynamic and forthright Mr. (Dr.) Eric Lim of Royal Brompton Hospital opened the third VATS International conference.   In a lecture entitled,  “The Why of advancing minimally invasive surgery,”  Dr. Lim put out a call to action to thoracic surgeons around the world, in an effort to remain relevant.

In an increasingly competitive world of thoracic oncology,  nonsurgical options like stereotactic radiotherapy, and the developing MRI proton beam therapy  are gaining traction for the treatment of early stage lung cancers.   These nonsurgical treatments are gaining publicity and popularity due to the efforts of radiation oncologists.

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The PCI of Lung Cancer Treatment

Reminding thoracic surgeons of the plight of their cardiac counterparts, Dr. Lim taunted the audience that having superior long-term outcomes does not guarantee success in a consumer-driven market.   Public and medical perception is shaped not only by clinical research findings, but by the inherent bias introduced by the authors of these publications.  As he explained, this bias, along with a public desire for simplicity, has driven the overwhelming success of percutaneous angioplasty (PCI)  and declining rates of cardiac surgery despite well-documented research studies and clear evidence demonstrating the overwhelming superiority of coronary artery bypass grafting (CABG) for long term survival.  Thoracic surgeons must not fall into the trap of complacency and arrogant belief in surgical superiority  that has plagued cardiac surgery if we want the specialty to survive.

Dr. Lim has identified three behaviors of thoracic surgeons that are harming the specialty:

  1. Refusal to look at the evidence –  thoracic surgeons must be willing to continuously review, understand and accept new clinical evidence and publications.  Evolving and emerging treatments have changed many of the cornerstones of thoracic surgery, and core concepts of 1980’s thoracic oncology management need to give way to the increasingly body of knowledge favoring VATS resections,  neo-adjuvant treatments, and improved outcomes.

An important caveat to this – is the need for Surgeon led research, and clinical trials to help eliminate the medical bias that has crept into much of the existing literature.  Surgeons need to stop allowing other specialties to control the narrative.  This is what allowed cardiologists to introduce concepts such as “non-inferiority” when research studies failed to show the benefit of cardiology interventions.

These research trials need to compare surgical interventions with non-surgical treatments.  Our inter-specialty debates over which surgical technique need to take a backseat to studies designed to compare relevant outcomes like long-term survival and cancer recurrence if we want to demonstrate surgical superiority over medical treatments.  “We need to stop arguing about which surgical technique and favor surgery over other therapies,” Dr. Lim explains.

  1. Refusal to engage with industry – industry drives and funds innovation. If we want to continue to develop wireless technologies, robotics and other innovations for use in minimally invasive surgery, thoracic surgeons must be willing to engage and participate with industry.

3.  Refusal to evolve – this is a fundamental problem plaguing thoracic surgery and addressing this issue is the underlying theme of many of the presentations at this year’s course. Dr. Lim has also addressed this refusal to evolve previously.  Surgeons need to evolve, and be willing and able to change their surgical practices based on evidence and clinical guidelines.  The failure to adopt VATS as the primary surgical approach in thoracic surgery in North America, and Europe despite decades of evidence and  clear clinical guidelines favoring this approach is a symptom of this failure to evolve.

The future of thoracic surgical oncology

How will thoracic surgery survive?  We already know that surgical excision offers the best long-term outcomes for our patients.  But as we have seen, having ‘right’ on your side isn’t enough.

Make surgery the most attractive option

For surgery to succeed, thoracic surgeons need to focus on making surgery safer and more acceptable to our patients.  Many patients prefer surgical removal on a philosophical level, but this preference is being eroded by promises of “easy” with SABER and newer chemotherapy regimens.

One of the benefits of surgery versus many of the newer treatments is that surgery is a single treatment versus multiple episodes of care.  If we can make that single encounter better for our patients, with shorter hospital stays, less pain/ less trauma and less risk, then surgery will remain the first and preferred treatment option for lung cancer.

 

Conference Highlight: Uniportal lobectomy: Intubated and Non-intubated

Dr. Diego Gonzalez Rivas discusses intubated and nonintubated uniportal thoracic surgery for complex thoracic procedures

Orlando, Florida

Dr. Diego Gonzalez Rivas discusses non-intubated thoracic surgery
Dr. Diego Gonzalez Rivas discusses non-intubated thoracic surgery

One of the standout presentations on Day One of the Duke Masters of Minimally Invasive Thoracic Surgery was Dr. Diego Gonzalez Rivas’ presentation on performing uniportal surgery on non-intubated patients. Surprisingly, this presentation was greeted with significant skepticism in the form of comments by fellow presenters.

No trocars, no rib spreading, one incision (with no rigid port placement)

Single port VATS lobectomy presentation

The use of one small 2.5 cm incision with the camera placed above the instruments allows the surgeon to maintain the traditional perspective of open surgery using a minimally invasive approach.  “Eyes above hands” Dr. Gonzalez states, reminding surgeons how to keep their visual perspective unaltered.  He also discussed some of the findings from an upcoming 2016 paper [in-press] entitled, “Pushing the envelope” which reviews the developments in the areas of single port (uniportal) thoracic surgery in non-intubated patients. This along with his new textbook, have dominated the international thoracic surgery news in recent years.

As part of his discussion, he demonstrated the ease and feasibility of performing a complete and thorough lymph node dissection using the uniportal approach.

Complete paratracheal lymph node dissection in a non-intubated patient

He also presented several complex thoracic cases such as a bronchial sleeve resection for carcinoid tumor in a young, otherwise healthy female, as well as a double sleeve case, and a uniportal bronchovascular reconstruction.  He discussed distal tracheal resection using high frequency ventilation jet in a non-intubated patient after resecting the carina – tracheal anastamosis and several chest wall resection cases via the uniportal approach.  But the main portion of his talk was devoted to the specifics of non-intubated surgery – from anesthesia protocols to creating a anatomic (surgical) pneumothorax which eliminates problems of lung inflation during surgery.  He discussed that while totally awake nonintubated surgery can be performed (with patients awake and talking), that he prefers the use of conscious sedation for patient comfort.

Nonintubated patient – VATS lobectomy

He highlighted the benefits of these approaches – with non-intubated surgical techniques allowing surgeons to operate on frailer, sicker patients who might otherwise be ineligible for surgery.  He also talked about the benefits of uniportal surgery versus robotic surgery.  Uniportal surgery is faster, and cheaper than costly robotic techniques that require lengthy patient positioning as well as the use of robotic tools that have to be replaced after 10 to 20 cases.

He also reviewed the relative contraindications for nonintubated surgery:

obese patients (BMI greater than 35)

patients with Malpati scores of 3 or 4 (difficult to intubate patients – in case of the need for emergent intubation)

patients with pulmonary hypertension (who will not tolerate permissive hypercapnia)

Masses greater than 6 cm in size

But he also reminded attendees that relative contraindications often change in the face of more experience.