Invited Commentary

Abstract

The article by Park and colleagues [1Park H.S. Detterbeck F.C. Boffa D.J. Kim A.W. Impact of hospital volume of thoracoscopic lobectomy on primary lung cancer outcomes.Ann Thorac Surg. 2012; 93: 372-380Abstract Full Text Full Text PDF PubMed Scopus (89) Google Scholar] supplements an arguably overwhelming body of evidence on the salutary effects of thoracoscopic lobectomy; in addition, this article suggests that the uniformity of its application can affect our interpretation of its outcomes. Many surgeons adopted video-assisted thoracoscopic surgery (VATS) for lobectomy in patients with favorable anatomy who could tolerate technical adverse events, eg, those with thin bodies, good cardiopulmonary function, and complete fissures. Using the long-term perspective, this population also had plenty of potential quality life to lose given a catastrophic technical complication or lack of oncologic equivalence. Since fit patients go home quickly at high-volume centers with efficient care pathways, low-risk VATS adoption may have had little effect on length of stay unless it was extended by a learning curve complication. Alternatively, thoracoscopic lobectomy adopted first in the frail, high-risk population raises the stakes if emergent conversion is needed; yet this is the group for which its differential benefits are maximal. Evidence for this relative risk reduction is found in studies showing that pulmonary function tests that once precluded patients from resection are less predictive, adjuvant chemotherapy starts faster, and independence at discharge is greater for VATS. I propose that the uniformity of thoracoscopic lobectomy application or “VATS reliability” is a measure of program maturity. In established VATS centers, thoracoscopic resection rates for all isolated lobectomies approach 90%. The adoption approach may have influenced this because high reliability skills accrue faster (by necessity) in the more difficult, high-risk patient for whom conversion is a poor option. Like other endeavors, challenging exercises (or opponents, using a gaming analogy) build skills faster. Given the low acuity adoption philosophy, critics of VATS lobectomy might conclude that its salutary effects, especially in single-institution reports, are the result of its use on patients with better risk factors. Park and associates did a fine job controlling for inappropriate case selection that may have led to misinterpretation of large administrative data sets used to control for this single-center bias. We also need to consider another explanation. There may have been temporal bias caused by sampling during the early learning curve adoption years. Learning curve complications may offset the reduced benefits of VATS in a healthy population that tends to go home faster and avoids adverse events. Perhaps more importantly, care pathway changes to speed discharge (such as eliminating the routine use of epidural anesthesia and streamlining chest tube management) are unlikely to occur until there is a high VATS reliability rate. Using a similar methodology, my review of administrative data capturing all New York State hospitals (Statewide Planning and Research Cooperative System [SPARCS]) supports the finding of this report—ie, high volume and VATS reliability individually predict shorter length of stay (unpublished data). In 2009, 24 of 112 New York programs met the criterion of high volume in this report (more than 20 cases) and their VATS reliability rates ranged from 0% to 89% (median, 40%). Given such variability, consistent reporting guidelines including overall programmatic VATS resection rates for isolated lobectomy (“reliability”), institutional patient selection/exclusion criteria, and CONSORT-like allocation diagrams will help readers interpret such future research endeavors. Impact of Hospital Volume of Thoracoscopic Lobectomy on Primary Lung Cancer OutcomesThe Annals of Thoracic SurgeryVol. 93Issue 2PreviewThis study evaluated hospital operative volume of video-assisted thoracoscopic surgery (VATS) lobectomy in primary lung cancer as a predictor of short-term outcomes after pulmonary lobectomy on a national scale. Some previous analyses comparing VATS vs open lobectomy outcomes have been limited by inaccuracies in patient cohort identification. Full-Text PDF