Session 1: Thoracoscopic Lobectomy - Duke University · ©2014 MFMER | slide-4 Thoracoscopic...

©2014 MFMER | slide-1

Session 1: Thoracoscopic Lobectomy State of the Art

Shanda H. Blackmon, M.D., M.P.H., FACS

Duke Masters of Minimally Invasive Surgery Meeting 2014


Disclosure

• I have no Disclosures


Thoracoscopic Lobectomy: State of the Art What does that mean?

• The term "state of the art" refers to the highest level of general development, as of a device, technique, or scientific field achieved at a particular time.

• It also refers to the level of development reached at any particular time as a result of the common methodologies employed.

• State of the Art” is often used to convey that a product is made with the best possible technology…

Blackmon


Thoracoscopic Lobectomy: State of the Art

• The cornerstone of therapy for early-stage lung cancer is anatomic individual vessel ligation and division by surgical lobectomy with concomitant removal of the draining nodal basin.

• This includes:

• Camera visualization of the dissection

• No rib spreading

• No serratus or latissimus muscle cutting



• Surgeons have successfully performed thoracoscopic lobectomy for more than 2 decades, with such technology disseminating throughout the thoracic surgical community establishing it as a standard for the management of early-stage non-small cell lung cancer (NSCLC)


VATS R side

If there were a standardized approach, what would it be?


VATS RUL


VATS RML


VATS RLL


VATYS RLL


VATS RLL


VATS RLL alternative approach


VATS LUL


VATS LLL



• Thoracoscopic lung resection can be performed safely in selected patients aged 80 years and older, in those with marginal pulmonary function, and in those with pathologic response to neoadjuvant therapy.

Blackmon

Shaw JP, Dembitzer FR, Wisnivesky JP, et al. Video-assisted thoracoscopic lobectomy: state of the art and future

directions. Ann Thorac Surg 2008 Feb;85(2):S705-9.

1ST

Author

# Year Patient Group Procedure

Performed

Con-

version, %

LOS, Med/mean Peri-op

morbidity,

%

Peri-op

Mortality,

%

Survival, %

McKenna 1100 2006 Stage I-III NSCLC Lobectomy 2.5 4.8 15 0.8 5Y: 1A=84.5; 1B=70.5;

2A=13.5; 2B 14; 3A=27.5

Onaitis 500 2006 Benign + NSCLC Lobectomy 1.6 3 NR 1.0 2Y:80

Yim 214 1998 Benign + NSCLC Lobectomy + 0.9 6.8/NR 22 0.5 23 mo = 93

Kaseda 204 2000 Benign + NSCLC Lobectomy + 1.5 NR/NR 2.3 0.8 5Y stage I = 97

Roviaro 171 2003 cIA NSCLC Lobectomy + 5.3 NR/NR 8.7 0.6 3 y = 77; 5Y = 63.6

Walker 159 2003 Stage I, II NSCLC Lobectomy,

Lingulectomy

11.2 NR/6 NR

1.8 Stage I = 77.9;

stage II = 51

Iwasaki 140 2004 Stage IA NSCLC Lobectomy +

segment

2.1 NR NR

0 5y = 70

Swanson 128 2002 Benign + NSCLC Lobectomy 13 3 8.2 2.1 NR

Daniels 110 2002 Benign + NSCLC Lobectomy 1.8 NR/3 19 3.6 NR

Ohtsuka 106 2004 Stage I NSCLC Lobectomy + 10 7.6 NR 0.9 3y = 79

Solaini 105 2001 Benign + NSCLC Lobectomy + 5.7 6.2/NR 12 NR 3y = 85

Sugi 100 2000 Stage IA NSCLC Lobectomy 4.2 NR NR NR 5y = 90

Shiraishi 95 2006 T1 N0 Mo NSCLC Lobectomy 14/95 NR NR

0 5y = 89

Kirby 61 1995 Stage I NSCLC (6

excluded)

Lobectomy 10 7.1 6 0 NR

Whitson 59 2007 Stage I NSCLC Lobectomy 11/70 6.4/NR NR NR 4y = 72

Total 3,252 98-07 0.9-15% 3-6.8d 2.3-22% 0-3.6 5Y average =


Thoracoscopic Lobectomy: State of the Art The New Gold Standard

• Thoracoscopic lobectomy is performed with increasing frequency for early-stage lung cancer.

• Thoracoscopic lobectomy is now clearly supported by evidence-based treatment guidelines [4]

• 3 of the 4 published RCT of VATS lobectomy versus open lobectomy demonstrated an advantage in the VATS group [5-8].

Blackmon

4. Ettinger DS, Akerly W, Bepler G, et al. National Comprehensive Cancer Network (NCCN). Non-small cell lung cancer clinical practice

guidelines in oncology. J Natl Compr Canc Netw 2008:6:228–69.

5. Kirby TJ, Mack MJ, Landreneau RJ, Rice TW. Lobectomy—video-assisted thoracic surgery versus muscle-sparing thoracotomy- A randomized

trial. J Thorac Cardiovasc Surg.1995; 109: 997-1001

6.Sugi K, Kaneda Y, Esato K. Video-assisted thoracoscopic lobectomy achieves a satisfactory long-term prognosis in patients with clinical stage

IA lung cancer. World J Surg 2000;24:27-31.

7.Craig SR, Leaver HA, Yap PL, et al. Acute phase responses following minimal access and conventional thoracic surgery. Eur J Cardiothorac

Surg 2001;20:455-463.

8.Shigemura N, Akashi A, Nakagiri T, et al. Complete vs. assisted thoracoscopic approach: a prospective randomized trial comparing a variety of

video-assisted thoracoscopic lobectomy techniques. Surg Endosc 2004;18:1492-1497.



• Some of the advantages of VATS lobectomy compared to thoracotomy include:

• less postoperative pain [9-11]

• less blood loss [5, 8, 10, 12]

• improved inflammatory response [13]

• shorter chest tube duration [ 9, 10, 13-15 ]

• improved post-operative independence [14]

• better pulmonary function [16-19]

• comparable operative times [9, 13, 14, 20]

• shorter hospitalization [2, 3, 5, 13-15, 21-24]

• more cost-effective [16]

• improved delivery of adjuvant chemotherapy to eligible patients [15, 17]

Blackmon

*Please see references at end of talk for notation…



• A recent assessment of morbidity and mortality after thoracoscopic lobectomy demonstrated improved results for many additional outcomes [18, 20, 25-30].

Blackmon

18. Kaseda S, Aoki T, Hangai N, Shimizu K. Better pulmonary function and prognosis with video-assisted thoracic surgery than with thoracotomy.

Ann Thorac Surg 2000;70:1644–6.

20. Cattaneo SM, Park BJ, Wilton AS, et al. Use of video-assisted thoracic surgery for lobectomy in the elderly results in fewer complications. Ann

Thorac Surg 2008;85:231– 6.

25. Villamizar NR, Darrabie MD, Burfeind WR, et al. Thoracoscopic lobectomy is associated with lower morbidity compared to thoracotomy. J

Thorac Cardiovasc Surg 2009;138: 419–4.

26. 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;139:366 –78.

27. Berry MF, Hanna J, Tong BC, et al. Risk factors for morbidity after lobectomy for lung cancer in elderly patients. Ann Thorac Surg

2009;88:1093–9.

28. Muraoka M, Oka T, Akamine S, et al. Video-assisted thoracic surgery lobectomy reduces the morbidity after surgery for stage I non-small cell

lung cancer. Jpn J Thorac Cardiovasc Surg 2006;54:49 –55.

29. Whitson BA, Andrade RS, Boettcher A, et al. Video-assisted thoracoscopic surgery is more favorable than thoracotomy for resection of clinical

stage I non-small cell lung cancer. Ann Thorac Surg 2007;83:1965–70.

30. D’Amico TA. Long-term outcomes after thoracoscopic lobectomy. Thorac Surg Clin 2008;18:259–62.



• Despite the many published advantages, thoracoscopic lobectomy is underutilized.

• Analyzing the board-certified thoracic surgeons participating in the General Thoracic Surgery component of the Society of Thoracic Surgeons database from 1999 to 2006

• only 20% of all lobectomies for NSCLC were thoracoscopically performed [31].

Blackmon

31. Boffa DJ, Allen MS, Grab JD, et al. Data from the Society of Thoracic

Surgeons General Thoracic Surgery database: the surgical management of

primary lung tumors. J Thorac Cardiovasc Surg 2008;135:247–54.


• In light of these advantages and with evidence of oncologic equivalence, thoracoscopic lobectomy is considered a gold standard for the treatment of early-stage lung cancer


http://www.google.com/url?url=http://ecoopportunity.net/2013/11/great-example-of-canadian-led-collaboration-towards-a-gold-standard-benchmark-for-sustainable-business/&rct=j&frm=1&q=&esrc=s&sa=U&ei=zwAOVNurKc6ayATq0IEQ&ved=0CCIQ9QEwBg&usg=AFQjCNFNsEoG9rudgfiJwLGmCYXQ8Ztamg


VATS Lobectomy Instrumentation has improved

Blackmon

East

West

North


Thoracoscopic Lobectomy: State of the Art 3-D Imaging; is it better?

• Robotic proponents often advocated the 3-d visualization is what made robotic surgery better;

• Well, now it is available for VATS

• There are currently 2 systems available:

• Storz

• Olympus

Blackmon


Thoracoscopic Lobectomy: State of the Art Expanding the Horizon…

• Chest wall resection

• Pneumonectomy

• Bronchoplasty

• Segmentectomy

• Bronchiectasis

Blackmon


VATS Consensus Statement Worldwide Expert Opinion

Yan TD, Cao C, D’Amico TA (Int’l VATS Lobectomy Consensus Group) et al. Video-assisted thoracoscopic surgery lobectomy

at 20 years: a consensus statement. Eur J Cardiothoracic Surg. 2014 Apr;45(4):633-9

Indications for VATS lobectomy

≤7 cm (T1, T2a and T2b) Recommended

N0 or N1 status Recommended

Contraindications for VATS lobectomy

Chest wall involvement including rib(s) Recommended

Centrality of tumour if invading hilar structure(s) Recommended

Previous thoracic surgery or pleurisy is not a contraindication Highly Recommended

FEV1 <30% Recommended

DLCO <30% Recommended

Preoperative Investigations

PET/CT and sampling of positive mediastinal lymph nodes Highly recommended

Sampling of positive lymph nodes by EBUS/EUS Recommended

VATS assessment at the time of surgery Highly recommended

Total ipsilateral lymph node dissection in all patients Recommended





Future directions

Establishment of multi-institutional database Recommended

Increased exposure of VATS lobectomy to

trainees Highly recommended

Establishment of standardized VATS

lobectomy workshops Highly recommended





Indications for conversion to open thoracotomy

Major bleeding Highly recommended

Significant chest wall involvement Recommended

Vascular sleeve Highly recommended

Bronchial sleeve Highly recommended

Broncho-vascular sleeve Highly recommended

Training

Number of cases to overcome steep learning

curve: 50 Highly recommended

Resident case volume of a training centre:

>50/year Recommended

Minimum case volume to maintain VATS

skills: >20/year Recommended

Proctoring should be necessary in all new

VATS surgeons Highly recommended


Interesting Cases

• Subxiphoid Single-Incision Thoracoscopic Left Upper Lobectomy Available online 23 August 2014 Chia-Chuan Liu, Bing-Yen Wang, Chih-Shiun Shih, Yun-Hen Liu JTCVS

http://www.sciencedirect.com/science?_ob=GatewayURL&_method=citationSearch&_urlVersion=4&_origin=SDAIPALERTHTML&_version=1&_piikey=S0022-5223(14)01185-4&md5=e6c61d6c14ed4fa1f60be5b417dce2c2









Interesting Cases

Yao X, Williamson C, Adalsteinsson VA

et al. Tumor cells are dislodged into the

pulmonary vein during lobectomy.

JTCVS 20142014 Jul 23

Epub ahead of print

• # tumor cells in PV


Interesting Cases New Devices: energy

Liberman M, Khereba M, Goudie E, et al. Pilot study of pulmonary arterial branch

sealing using energy devices in an ex vivo model. JTCVS 2014 Jul 19; epub ahead

of print.

• Forty-nine PA branches were sealed in 14 patients.

• The mean PA branch diameter was 7.4 mm (1.8-14.5 mm).

• Ten patients had normal PA pressure and 3 had PA hypertension





of print.

• The mean bursting pressure in each was as follows:

Device Mean bursting pressures

Harmonic Ace group 415.5 mm Hg (137.1-1388.4 mm Hg),

Thunderbeat group 875 mm Hg (237.1-2871.3 mm Hg

LigaSure group 214.7 mm Hg (0-579.6 mm Hg

Enseal group 133.7 mm Hg (0-315.38 mm Hg





of print.

• There were 2 complete sealing failures:

• LigaSure (diameter 6.78 mm)

• Enseal (diameter 8.3 mm)



• Forty-nine PA branches were sealed in 14 patients.

• The mean PA branch diameter was 7.4 mm (1.8-14.5 mm).

• In this pilot study to examine energy sealing of PA branches in a simulated ex vivo model, vascular sealing using energy was effective and was able to sustain high intraluminal bursting pressures.

• Further research is needed to determine the in vivo and long-term safety of PA branch energy sealing.



of print.


VATS Lobectomy What about the robot?

• VATS is the least expensive surgical approach

• Robotic cases must be shorter in operative time or reduce supply costs, or both, to be competitive

• Lessening operating time, eradicating unnecessary laboratory work, and minimizing intensive care unit stays will help decrease direct hospital costs

Nakamura H. Systematic review of published studies on safety and efficacy of thoracoscopic and robot-

assisted lobectomy for lung cancer. Annals of Thoracic & Cardiovascular Surgery. 20(2):93-8, 2014.


Questions & Discussion


• Taioli E, Leea DS, Lesserc M, Floresa R. Long-term survival in video-assisted thoracoscopic lobectomy vs open lobectomy in lung-cancer patients: a meta-analysis. European Journal of Cardio-Thoracic Surgery. 2013;44(4):591-597.

VATS Lobectomy What about ROL?


VATS ROL References

• 1. Siegel R, Naishadham D, Jemal A. Cancer Statistics. 2012.CA Cancer J Clin. 2012 Jan-Feb;62(1):10-29. doi: 10.3322/caac.20138. Epub 2012 Jan 4.

• 2. McKenna RJ, Houck W, Fuller CB. Video-assisted thoracic surgery lobectomy: experience with 1,100 cases. Ann Thorac Surg 2006;81:421– 6.

• 3. Onaitis MW, Petersen PR, Balderson SS, et al. Thoracoscopic lobectomy is a safe and versatile procedure: experience with 500 consecutive patients. Ann Surg 2006;244:420 –5.

• 4. Ettinger DS, Akerly W, Bepler G, et al. National Comprehensive Cancer Network (NCCN). Non-small cell lung cancer clinical practice guidelines in oncology. J Natl Compr Canc Netw 2008:6:228–69.

• 5. Kirby TJ, Mack MJ, Landreneau RJ, Rice TW. Lobectomy—video-assisted thoracic surgery versus muscle-sparing thoracotomy- A randomized trial. J Thorac Cardiovasc Surg.1995; 109: 997-1001

• 6.Sugi K, Kaneda Y, Esato K. Video-assisted thoracoscopic lobectomy achieves a satisfactory long-term prognosis in patients with clinical stage IA lung cancer. World J Surg 2000;24:27-31.

• 7.Craig SR, Leaver HA, Yap PL, et al. Acute phase responses following minimal access and conventional thoracic surgery. Eur J Cardiothorac Surg 2001;20:455-463.

• 8.Shigemura N, Akashi A, Nakagiri T, et al. Complete vs. assisted thoracoscopic approach: a prospective randomized trial comparing a variety of video-assisted thoracoscopic lobectomy techniques. Surg Endosc 2004;18:1492-1497.


VATS ROL References

• 9. Demmy TL, Curtis JJ. Minimally invasive lobectomy directed toward frail and high-risk patients: a case control study. Ann Thorac Surg 1999;68:194 –200.

• 10. Tajiri M, et al. Decreased invasiveness via two methods of thoracoscopic lobectomy for lung cancer, compared with open thoracotomy. Respirology. 2007;12:207-211. (at 1 yr)

• 11. Nagahiro I, Andou A, Aoe M, et al. Pulmonary function, postoperative pain, and serum cytokine level after lobectomy: a comparison of VATS and conventional procedure. Ann Thorac Surg 2001;72:362–5.

• 12. Nomori H, Horio H, Naruke T, Suemasu K. What is the advantage of a thoracoscopic lobectomy over a limited thoracotomy procedure for lung cancer surgery? Ann Thorac Surg. 2001;72(3):879-884

• 13. Yim APC, et al. VATS lobectomy reduces cytokine responses compared with conventional surgery. Ann Thorac Surg. 2000;70:243-247.

• 14. Demmy TJ, et al. Discharge independence with minimally invasive lobectomy. Am J Surg. 2004;188:689-702.

• 15. Petersen RP, Pham D, Burfeind WR, et al. Thoracoscopic lobectomy facilitates the delivery of chemotherapy after resection for lung cancer. Ann Thorac Surg 2007;83:1245–9.

• 16. Burfeind W, Jaik N, Villamizar N, Toloza E, Harpole D, D’Amico TA. A cost-minimization analysis of lobectomy: thoracoscopic vs. posterolateral thoracotomy. Eur J Cardiothorac Surg 2010 (E-pub; doi: 10.1016/j.ejcts.2009.10.017).


VATS ROL References

• 17. Tschernko E, Hofer S, Beiglmayer C, Wisser W, Haider W. Video-assisted wedge resection/lobectomy versus conventional axillary thoracotomy. Chest 1996;109:1636–42.

• 18. Kaseda S, Aoki T, Hangai N, Shimizu K. Better pulmonary function and prognosis with video-assisted thoracic surgery than with thoracotomy. Ann Thorac Surg 2000;70:1644–6.

• 19. Nakata M, et al. Pulmonary function after lobectomy: video-assisted thoracic surgery versus thoracotomy. Ann Thorac Surg. 2000; 70: 938-941.

• 20. Cattaneo SM, Park BJ, Wilton AS, et al. Use of video-assisted thoracic surgery for lobectomy in the elderly results in fewer complications. Ann Thorac Surg 2008;85:231– 6.

• 21. Park BJ, Zhang H, Rusch VW, Amar D. Video-assisted thoracic surgery does not reduce the incidence of postoperative atrial fibrillation after pulmonary lobectomy. J Thorac Cardiovasc Surg 2007;133:775–9.

• 22. Nicastri DG, Wisnivesky JP, Litle VR, et al. Thoracoscopic lobectomy: report on safety, discharge independence, pain, and chemotherapy tolerance. J Thorac Cardiovasc Surg 2008;135:642–7.

• 23. Swanson SJ, Herndon JE, D’Amico TA, et al. Video-assisted thoracic surgery (VATS) lobectomy—report of CALGB 39802: a prospective, multi-institutional feasibility study. J Clin Oncol 2007;25:4993–7.

• 24. Cajipe MD, Chu D, Bakaeen FG, Casal RF, LeMaire SA, Coselli JS, Cornwell LD. Video-assisted thoracoscopic lobectomy is associated with better perioperative outcomes than open lobectomy in a veteran population. Am J Surg. 2012 Nov;204(5):607-12.


VATS ROL References

• 25. Villamizar NR, Darrabie MD, Burfeind WR, et al. Thoracoscopic lobectomy is associated with lower morbidity compared to thoracotomy. J Thorac Cardiovasc Surg 2009;138: 419–4.

• 26. 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;139:366 –78.

• 27. Berry MF, Hanna J, Tong BC, et al. Risk factors for morbidity after lobectomy for lung cancer in elderly patients. Ann Thorac Surg 2009;88:1093–9.

• 28. Muraoka M, Oka T, Akamine S, et al. Video-assisted thoracic surgery lobectomy reduces the morbidity after surgery for stage I non-small cell lung cancer. Jpn J Thorac Cardiovasc Surg 2006;54:49 –55.

• 29. Whitson BA, Andrade RS, Boettcher A, et al. Video-assisted thoracoscopic surgery is more favorable than thoracotomy for resection of clinical stage I non-small cell lung cancer. Ann Thorac Surg 2007;83:1965–70.

• 30. D’Amico TA. Long-term outcomes after thoracoscopic lobectomy. Thorac Surg Clin 2008;18:259–62.

• 31. Boffa DJ, Allen MS, Grab JD, et al. Data from the Society of Thoracic Surgeons General Thoracic Surgery database: the surgical management of primary lung tumors. J Thorac Cardiovasc Surg 2008;135:247–54.

• 32. Hartwig MG, D'Amico TA. Thoracoscopic lobectomy: the gold standard for early-stage lung cancer? Ann Thorac Surg. 2010 Jun;89(6):S2098-101.


VATS ROL References

• 33. Ceppa DP, Kosinski AS, Berry MF, Tong BC, Harpole DH, Mitchell JD, D'Amico TA, Onaitis MW. Thoracoscopic lobectomy has increasing benefit in patients with poor pulmonary function: a Society of Thoracic Surgeons Database analysis. Ann Surg. 2012 Sep;256(3):487-93.

• 34. Bonadonna G, Valagussa P, Moliterni A, et al. Adjuvant cyclophosphamide, methotrexate, and fluorouracil in nodepositive breast cancer: the results of 20 years of follow-up. N Engl J Med 1995;332:901–26.

• 35. Yan TD, Black D, Bannon PG, McCaughan BC. Systematic review and meta-analysis on safety and efficacy of VATS lobectomy for NSCLC. J Clin Oncol 2009;27:2553– 62.

• 36. Lohrisch, C, Paltiel, C, Gelmon, K, et al. Impact on survival of time from definitive surgery to initiation of adjuvant chemotherapy for early-stage breast cancer. J Clin Oncol 2006;24:4888 –94.

• 37. Strauss GM, Herndon J, Maddaus MA, et al. Randomized clinical trial of adjuvant chemotherapy with paclitaxel and carboplatin following resection in stage 1B non-small cell lung cancer (NSCLC): report of Cancer and Leukemia Group B (CALGB) Protocol 9633. J Clin Oncol 2004;22(suppl 14):621s [abstract].

• 38. Scagliotti GV, Fossati R, Torri V, et al. Randomized study of adjuvant chemotherapy for completely resected stage I, II, or IIIA non-small-cell lung cancer. J Natl Cancer Inst 2003;95: 1453–61.

• 39. Flores RM, Ihekweazu U, Dycoco J, et al. Video-assisted thoracoscopic surgery (VATS) lobectomy: catastrophic intraoperative complications. J Thorac Cardiovasc Surg 2011;142:1412-7.


VATS ROL References

• 40. Yang CF, D’Amico TA. Thoracoscopic segmentectomy for lung cancer. Ann Thorac Surg. 2012 Aug;94(2):668-81.

• 41. Nwogu CE, Yendamuri S, Demmy TL. Does thoracoscopic pneumonectomy for lung cancer affect survival? Ann Thorac Surg. 2010 Jun;89(6):S2102-6.

• 42. Kamiyoshihara M, Ibe T, Takeyoshi I. Video-assisted thoracoscopic lobectomy with bronchoplasty for lung cancer; tip regarding bronchial anastomosis. Gen Thorac Cardiovasc Surg. 2008 Sep;56(9):476-8.

• 43. Demmy, TL, Nwogu CE, Yendamuri S. Thoracoscopic chest wall resection: What is its role? Annals of Thoracic Surgery 2010;89(6):S2142-2145

• 44. Cerfolio RJ, Bryant AS, Minnich DJ. Minimally invasive chest wall resection: sparing the overlying, uninvolved musculature of the chest. Ann Thorac Surg. 2012 Nov;94(5):1744-7.

• 45. Boffa DJ, Kosinski AS, Paul S, Mitchell JD, Onaitis M. Lymph Node evaluation by open or video-assisted approaches in 11,500 anatomic lung cancer resections. Ann Thorac Surg. 2012 Aug;94(2):347-53; discussion 353.

• 46. Park BJ, Melfi F, Mussi A, et al. Robotic lobectomy for non-small cell lung cancer (NSCLC): long-term oncologic results. J Thorac Cardiovasc Surg. 2012 Feb;143(2):383-9.


VATS Consensus Statement Indications and contraindications for VATS lobectomy Number of respondents (%)

T status for tumour

≤5 cm (T1 and T2a) 16 (32)

≤7 cm (T1, T2a and T2b) 31 (64)

None of above 3 (6)

N status for tumour

N0 only 1 (2)

N0 + N1 28 (56)

N0 + N1 + N2 21 (42)

Chest wall involvement is

A contraindication if involving parietal pleura 3 (6)

A contraindication if involving rib(s) 31 (62)

Not a contraindication for VATS lobectomy 16 (32)




VATS Consensus Statement

Indications and contraindications for VATS lobectomy Number of respondents (%)

Centrality of tumour is

An absolute contraindication if invading hilar

structure(s) 12 (24)

A relative contraindication if invading hilar

structure(s) 32 (64)

Not a contraindication 6 (12)

Previous thoracic surgery/pleurisy is

An absolute contraindication 0

A relative contraindication 10 (20)

Not a contraindication 40 (80)




VATS Consensus Statement Indications and contraindications for VATS

lobectomy Number of respondents (%)

VATS lobectomy is contraindicated if FEV1 is

<80% predicted 0

<70% predicted 1 (2)

<60% predicted 0




VATS lobectomy is contraindicated if DLCO is

<80% predicted 0

<70% predicted 0

<60% predicted 0










Perioperative management of

VATS lobectomy Number of respondents (%)

Preoperative investigation for N-status should include

PET/CT and sampling of

positive mediastinal lymph nodes 40 (80)

PET/CT and routine sampling

of mediastinal lymph nodes 9 (18)

PET/CT only 1 (2)

Your preferred approach to sample mediastinal lymph nodes

EBUS/EUS 30 (60)

Mediastinoscopy 18 (36)

VAMLA 1 (2)

I do not sample lymph nodes

preoperatively 1 (2)

Would you undertake VATS assessment routinely at the time of

surgical resection?

Yes 38 (76)

No 12 (24)

The most appropriate management of mediastinal lymph nodes is:

Total ipsilateral lymph node

dissection 33 (66)

Lobe specific lymph node

dissection 6 (12)

Systematic lymph node

sampling 11 (22)

Lobe specific sampling 0

Random/no sampling 0

Which group(s) would you recommend to have total ipsilateral lymph

node dissection?a

All patients 33 (66)

Central tumour 13 (26)

Patients unfit for adjuvant

chemotherapy or radiotherapy 5 (10)

N1-positive disease 15 (30)

N2-positive disease 14 (28)

None of above 1 (2)

Under which of the following clinical situation(s), would you

recommend conversion to open thoracotomy?a

Pneumonectomy 17 (34)

Bronchial sleeve 27 (54)

Vascular sleeve 48 (96)

Broncho-vascular sleeve 48 (96)

Pleural adhesions 2 (4)

Absence of fissure 1 (2)

Poor lung deflation 12 (24)

Major bleeding 46 (92)

Broncho-pleural fistula 18 (36)

Chest wall involvement 30 (60)

Operating theatre time

pressure 2 (4)

None of above 0

Your preferred loco-regional postoperative pain management is

PCA only 6 (12)

Epidural 17 (34)

Paravertebral 10 (20)

Intercostal nerve block 17 (34)

Others 0





VATS lobectomy training Number of respondents (%)

How many cases are required to overcome the learning curve?

25 10 (20)

50 39 (78)

75 0

>100 1 (2)

What is the minimum resident case volume that defines a training centre?

>30 cases per year 24 (48)

>50 cases per year 26 (52)

How many cases should a surgeon perform to maintain his/her VATS

lobectomy operative skills?

20 cases per year 31 (62)

40 cases per year 19 (38)

≥60 cases per year 0

Should a surgeon be proctored prior to commencing a VATS lobectomy

program?

Yes 50 (100)

No 0

Regarding the future direction in this field, please choose from the

following options:a

I think that it is necessary to

perform a RCT comparing CALGB-

defined VATS lobectomy vs open

thoracotomy

14 (27)

I think that it is necessary to

establish multi-institutional

databases, containing complete

VATS lobectomy as a treatment

approach

35 (67)

I think that more standardized

surgical mentoring courses and/or

programmes should be made

available on a regular basis in

different regions of the world in

order to popularize VATS

lobectomy approach

40 (77)

I think that VATS lobectomy

should be incorporated into the

current training programmes for all

cardiothoracic trainees

23 (44)

I think that VATS lobectomy

should be incorporated into the

current training programmes for

trainees intending to specialize/

have a major interest in thoracic

surgery

43 (83)

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