Original Thoracic

Does Previous Surgical Training Impact the Learning Curve in Video-Assisted Thoracic Surgery Lobectomy for Trainees? Andrea Billè1

Lawrence Okiror2

Karen Harrison-Phipps2

1 Department of Thoracic Surgery, Fondazione IRCCS National

Institute of Cancer, Milan, Italy 2 Department of Thoracic Surgery, Guy’s and St Thomas Hospital, London, United Kingdom

Tom Routledge2

Address for correspondence Andrea Billè, MD, Department of Thoracic Surgery, Fondazione IRCCS, National Institute of Cancer, Via G Venezian 1, Milan, Italy (e-mail: [email protected]).

Abstract

Keywords

► VATS lobectomy ► learning curve ► training program

Background To analyze if the number of open lung resections performed by trainees before starting video-assisted thoracic surgery (VATS) lobectomy training program has any impact on intraoperative and postoperative outcomes. Materials and Methods Retrospective analysis of 46 consecutive patients who underwent VATS lobectomies between December 2011 and September 2012 by two trainees (A.B. and L.O.). The previous surgical experience of the two trainees was evaluated to assess for any difference in terms of learning curve. Group A comprised 25 VATS lobectomies performed by one trainee (A.B.) and group B comprised 21 VATS lobectomies performed by the other trainee (L.O.). Results There was no statistical difference in terms of operating time and intraoperative bleeding between the two groups (p ¼ 0.16 and p ¼ 0.6). The conversion rate was 8% (2 out of 25 cases) in group A and 23.8% (5 out of 21 cases) in group B (p ¼ 0.002). Evaluation of vascular injury showed no difference in the conversion rate (p ¼ 0.56). The median length of the drainage and of hospital stay were 4 days and 7 days in group A and 4 days and 8 days in group B, respectively (p ¼ 0.36 and p ¼ 0.24). The complication rate was 44% in group A and 47.6% in group B (p ¼ 0.52). A.B. had performed 139 and L.O. 70 operations as first operator before starting their VATS lobectomy training; the surgical experience had an impact only on the conversion rate. Conclusion Our study showed that a training program in VATS lobectomy is feasible, and previous surgical training has a minimal impact on intraoperative and postoperative outcomes.

Introduction Since its advent more than 20 years ago, video-assisted thoracoscopic (VATS) lobectomy for treatment of early-stage lung cancer has been widely adopted. VATS lobectomy shows various advantages over a traditional open approach through a standard posterolateral thoracotomy, which have been previously reported, including less morbidity,1–3 less inflam-

received September 28, 2014 accepted after revision October 7, 2014

matory response to surgery,4,5 similar oncologic outcomes,1,6,7 and more rapid resumption of normal daily activities.8,9 A recent study has also reported better longterm outcomes including survival in patients who have had VATS lobectomy compared with a classical open approach.10 However, concerns over difficulties in teaching the endoscopic skills, required to safely perform a VATS lobectomy and

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DOI http://dx.doi.org/ 10.1055/s-0034-1396094. ISSN 0171-6425.

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Billè et al.

risks associated with the surgeons’ learning curve, continue to hamper the adoption of VATS lobectomy.11 This is particularly so in an era of an increasingly aging patient population with multiple comorbidities and heightened patient safety with reduced working hours for trainee surgeons.11,12 We have previously reported on our experience, analyzing the results of VATS lobectomy performed by surgical trainees compared with established consultants. This study aims to compare the postoperative results of VATS lobectomies done by two trainees and evaluate if the previous experience of open anatomical resections performed has any impact on the learning curve.

was created. No rib spreaders were inserted. The third port was used to improve the exposure and facilitate the dissection. A 30° scope was placed in the 8th mid-axillary intercostal space. In case of extensive adhesions, unexpected extensive lymph node involvement, or pulmonary injury, the procedure was converted and the operation was performed through a posterolateral thoracotomy or through an axillary thoracotomy. All procedures were performed using an anterior approach. The lobar vein and artery were identified and stapled with Covidien stapler (Covidien, Dublin, Ireland), also the bronchus was stapled. Lymphadenectomy sampling of the hilar and mediastinal lymph nodes was routinely performed. In case of secondary lesion, a lymphadenectomy was not performed. Finally, the fissure was then completed and the lobe with the lesion was removed through an endobag 15 mm (Ethicon EndoSurgery, US LLC). A paravertebral catheter was placed under direct control of the camera. One chest drain 28 Fr was positioned and the lung reinflated at the end of the operation. All the patients were extubated in theater and transferred in recovery. The chest drain was kept on suction at 20 cm H2O for the first 12 hours and then on free drainage. If the lung completely expanded and no air leak was observed, the drain was removed on the postoperative day 2 (POD2). The patients were followed up and specifically examined for chronic pain and postoperative complications at 1 month. If there were no complications, the patients were discharged and followed up locally by the local oncology team. Prolonged air leak was defined as an air leak lasting longer than 5 days and chest infection was defined as radiographic evidence of new opacities accompanied by raised inflammatory markers (white cell counts and C-reactive protein) with or without a fever. All grades of complications (1–5) were reported.

Materials and Methods This is a retrospective series of 46 consecutive patients who underwent a VATS lobectomy between December 2011 and September 2012. Group A included patients operated by A.B. and group B by L.O. Data on operations performed by A.B. and L.O. were collected prospectively. Prior surgical experience with open anatomical lung resections (pneumonectomy, lobectomy, segmentectomy) and wedge resection for primary lung cancer and/or secondary disease were reviewed and considered relevant to providing important experience for VATS lobectomy training. We also included previous cases of VATS wedge resection for diagnostic purpose or curative intent. However, VATS procedures for treatment of pleural effusions or pneumothorax (pleural biopsies, talc pleurodesis, pleurectomy, or pleural abrasion) were excluded. The choice of minimally invasive approach was determined by clinical TNM stage, and patient’s preference. Tumors larger than 5 cm, chest wall involvement, and extensive N1 lymph node involvement or N2 single station involvement were considered contraindications to perform a minimally invasive procedure. Incomplete fissure was not a contraindication for VATS lobectomy. All patients had a chest CT scan to ascertain the extent of the lung lesion. In addition, they had a CT abdomen and pelvis, as well as PET/CT scan to screen for regional and distal metastases. All patients had a full preoperative evaluation, including a thorough history, physical examination, and routine hematological and biochemical blood tests. Individual patient consent was obtained for each of the cases. The operations were performed by the trainees always supervised by an experienced consultant trained in performing VATS lobectomy. Both training consultants performed VATS lobectomy using a similar technique by an anterior approach with dissection of hilar structures from anterior to posterior. This was the technique the trainers taught and supervised for the two trainees involved in this study.

Surgical Protocol for VATS Lobectomy All procedures were performed under general anesthesia with the patient in lateral decubitus on single lung ventilation, two or three ports were inserted in the posterior, middle, and anterior axillary line (7th and 8th interspace) and one utility incision of 3–4 cm in the 4th intercostal space Thoracic and Cardiovascular Surgeon

Statistical Analysis Operative mortality included all patients who died within 30 days of surgical intervention. Continuous data are reported with medians and ranges, while categorical data are reported with counts and percentages. All potential prognostic indices were measured and evaluated as categorical variables. All the characteristics were tested in the two groups, A and B, prognostic variables are then analyzed with chi square test and Student t test to assess the difference in terms of surgical results in groups A and B where appropriate. Probability values less than 0.05 were considered statistically significant. All analyses were conducted using SPSS 18 (SPSS Inc., Chicago, Illinois, United States) software package.

Results In the group A (A.B.) the trainee performed 25 VATS lobectomies and in the group B (L.O.) the trainee performed 21 VATS lobectomies. ►Table 1 compares the characteristics of the two groups. The characteristics of the patients in the two groups were similar.

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Impact of Previous Surgical Training on VATS Lobectomy

Table 1 Patient characteristics Characteristic

Group A (n ¼ 25) n (%)

Group B (n ¼ 21) n (%)

Male

11 (44.0)

12 (57.1)

Female

14 (56.0)

9 (42.9)

67 (32–85)

67 (55–85)

Sex

Age median (range)

0.27

Location of tumor 14 (56.0)

8 (38.1)

RML

2 (8.0)



RLL

1 (4.0)

5 (23.8)

LUL

6 (24.0)



LLL

2 (8.0)

8 (38.1)

Adenocarcinoma

12 (48.0)

12 (57.1)

Squamous ca

6 (24.0)

7 (33.3)

Adenosquamous

4 (16.0)



Othersa

3 (12.0)

2 (9.6)

Histology

0.21

a

0.46

T1a

8 (36.3)

T1b

3 (13.6)

1 (4.8)

T2a

10 (45.6)

10 (47.6)

T2b

1 (4.5)

2 (9.5)

6 (28.6)

T3



2 (9.5)

pNa N0

0.88 0.003

RUL

pT

p

0.41 19 (86.4)

17 (81.0)

N1

2 (9.1)

4 (19)

N2

1 (4.5)



Abbreviations: LLL, left lower lobe; LUL, left upper lobe; RLL, right lower lobe; RML, right middle lobe; RUL, right upper lobe. a Colorectal metastases n ¼ 3; large cell neuroendocrine tumor n ¼ 1; small cell lung cancer n ¼ 1.

We analyzed the differences between intraoperative and postoperative results of the groups. In group A the median operating time was 132 minutes (range, 85–209 minutes) and 125 minutes (range, 50–185 minutes) in group B (p ¼ 0.16). There was no statistical difference in terms of intraoperative bleeding between the two groups (p ¼ 0.6): 100 mL (range, 100–1,000 mL) and 200 mL (range, 50–500 mL) in groups A and B, respectively. The conversion rate was 8% (2 out of 25 cases) in group A and 23.8% (5 out of 21 cases) in group B (p ¼ 0.002). In group A, the two cases were converted for vascular (pulmonary artery) injury; in group B, there was only one case of vascular injury, two cases of extensive adhesions, one case of obese patient with severe COPD with difficult lung exclusion, and one case of tumor infiltrating the chest wall. Considering only the vascular injury, there was no statistical difference in the conversion rate: 8% in group A and 4.8% in group B (p ¼ 0.56). The median length of the drainage and the

Billè et al.

median length of hospital stay were 4 days (range, 2–25 days) and 7 days (range, 3–20 days) in group A and 4 days (range, 1–16 days) and 8 days (range, 3–13 days) in group B, respectively. There were no statistical differences in terms of both variables in the two groups (p ¼ 0.36 and p ¼ 0.24). The complication rate was 44% (11 out of 25) in group A and 47.6% (10 out of 21) in group B (p ¼ 0.52). In group A, there were prolonged air leak (n ¼ 4), atrial fibrillation (n ¼ 1), chest infection (n ¼ 5), and respiratory failure cases requiring intensive care admission (n ¼ 1); in group B, there were prolonged air leak (n ¼ 3), postoperative bleeding requiring surgical reexploration (n ¼ 1), chest infection (n ¼ 4), chylothorax (n ¼ 1), and respiratory failure cases requiring intensive care admission (n ¼ 1). All air leak and chest infection cases were managed conservatively with chest drain and medical treatment, respectively. There were no statistical differences stratifying the different complications between the groups. In terms of long-term complications during the postoperative follow-up, there were no statistical differences (p ¼ 0.63). The complication rate in group A was 24% (6 out of 25 cases) and in group B 23.8% (5 out of 21). Four (16%) patients in group A and two (9.5%) in group B still experienced difficulties in breathing during exercises after a month (p ¼ 0.19). No patients in group A complained of chronic pain, while three (14.3%) patients in group B complained of chronic pain requiring opioid medications (p ¼ 0.09). We then analyzed the previous surgical background of the two trainees to assess any correlation between previous surgical training and difference in terms of learning curve and postoperative results during their VATS lobectomy training. We collected data on anatomical lung resection, open metastasectomy, VATS lung biopsy, and VATS metastasectomy for A.B. and L.O. A.B. performed in total 139 operations and L.O. 70 operations as first operator before starting their VATS lobectomy training (►Table 2). There was no statistical difference in terms of operations performed by the two trainees. There were no differences in terms of sleeve resection (p ¼ 0.46) and of anatomical resections (p ¼ 0.14). Even if the surgical experience of the trainee A.B. was bigger, in terms of intraoperative and postoperative findings there were no statistical differences in the two groups.

Table 2 Previous training experience: trainee operations Operation

AB

LO

Segmentectomy

7

4

Lobectomy

63

38

Bilobectomy

5

2

Sleeve lobectomy

4

1

Pneumonectomy

5

1

Metastasectomy

14

11

VATS wedge resection

21

4

VATS lung biopsy

20

9

Abbreviation: VATS, video-assisted thoracic surgery. Thoracic and Cardiovascular Surgeon

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The number of open operations can have an impact on the learning curve of the single trainees. In group A there was a statistical difference in terms of operating time between the first 10 cases and the second 15 cases, 150 minutes versus 125 minutes (p ¼ 0.02), but there was no difference in terms of operating time in group B, 133 versus 111 minutes (p ¼ 0.13). No statistical differences in terms on intraoperative bleeding, length of the drainage, length of hospital stay, and complication rate subdividing the groups in the first 10 cases and in the remaining cases.

tomy VATS operations and open anatomical resections, he or she can be safely introduced to VATS lobectomy training without necessarily completing a predetermined number of thoracic surgical operations.16 We recommend a competence-based approach with careful case selection by consultants for VATS lobectomy training of residents. Thoracoscopic competency can of course be assessed using elaborate tools such as that proposed by Konge et al.17 While such a tool is a useful first step, it was derived using an even smaller number of operations per person assessed (median of 4) and has not been externally validated. Ours is only a preliminary report and demonstrates the need for further work to assess trainee competence in VATS lobectomy. There are various limitations to this study. First, because case selection for VATS lobectomy training is at the discretion of the training consultant, there is a selection bias that may affect results. Second, this is a small retrospective study involving two trainees. It is, therefore, not possible to generalize these findings. Third, the previous operative experience of the two trainees was varied in case mix as well as numbers, and competency was assessed by the training consultants based on their experience working with the resident. It was therefore not possible to define what parameters were used to assess this. These limitations notwithstanding, we believe that this study demonstrates that VATS lobectomy training can be safely introduced to resident thoracic surgical trainees with relatively small numbers of previous first-operator open anatomical resections. This is particularly relevant now that open anatomical resections are increasingly being performed for difficult cases with large tumors only which perhaps are not appropriate for trainees. Further studies with larger case numbers and trainees will need to be performed to validate these results. This study was presented as a poster at the 21st European Conference on General Thoracic Surgery May 26–29, 2013, in Birmingham, United Kingdom.16

Discussion Our results show that VATS lobectomy performed by trainee thoracic surgeons is safe and feasible. The number of previous thoracic surgical operations, either open or nonanatomical VATS wedge resection, does not appear to affect the ability to perform VATS lobectomy if the trainee is competent enough to perform anatomical lung resections. Konge et al reported on their experience of VATS lobectomy performed by a single trainee who had previously performed 14 lobectomies through a thoracotomy. The median operating time was 120 minutes and median operative blood loss was100 mL in 29 consecutive VATS lobectomies, both of which compare with our results.13 In their report on introduction of thoracoscopic lobectomy to trainee resident thoracic surgeons, Reed et al reported on a stepwise model of training. Residents were initially trained in open anatomical resection and nolobectomy VATS operations until they were competent enough to perform these procedures before embarking on VATS lobectomy training.12 Although they did not report on the number of operations required to achieve competency before introduction to VATS lobectomy, the authors of this report reported good postoperative outcomes with low morbidity for VATS lobectomy performed by trainee surgeons. We similarly adopted a competency-based introduction to VATS lobectomy for the two trainees in this report based on proficiency with open anatomical lung resection and nonlobectomy VATS operations. Wan et al reported on their experience of VATS lobectomy training for resident trainee surgeons with at least 2 years of general thoracic surgical training and competency in open lung resections as well as simple VATS procedures.14 They found no significant difference in postoperative complication rate, duration of pleural drainage, and length of hospital stay between trainee-led and consultant-led VATS lobectomies in over 50 cases. There was no hospital mortality. We recorded similar results with no deaths, and similar duration of pleural drainage and hospital stay. As noted by Boffa et al in their survey of VATS lobectomy proficiency from recent graduates of North American thoracic residencies, we believe that VATS lobectomy training can be safely introduced during specialist thoracic surgical training and does not necessarily have to be the preserve of established independent, consultant thoracic surgeons.15 Although the number of previous thoracic surgical operations can be used as a guide for competency, we believe that if a trainee shows proficiency in initial training with nonlobecThoracic and Cardiovascular Surgeon

Funding No funding was used for this research.

Conflict of Interest Dr. Andrea Billè, Dr. Lawrence Okiror, Mrs. Karen HarrisonPhipps, and Mr. Tom Routledge have no conflicts of interest or financial ties to disclose.

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thoracic surgery (VATS) versus thoracotomy for lung cancer. J Thorac Cardiovasc Surg 2009;138(1):11–18 2 Kirby TJ, Mack MJ, Landreneau RJ, Rice TW. Lobectomy—videoassisted thoracic surgery versus muscle-sparing thoracotomy. A randomized trial. J Thorac Cardiovasc Surg 1995;109(5): 997–1001, discussion 1001–1002 3 Whitson BA, Groth SS, Duval SJ, Swanson SJ, Maddaus MA. Surgery for early-stage non-small cell lung cancer: a systematic review of the video-assisted thoracoscopic surgery versus thoracotomy

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Impact of Previous Surgical Training on VATS Lobectomy

5

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scopic surgery (VATS) lobectomy using a standardized anterior approach. Surg Endosc 2011;25(4):1263–1269 Reed MF, Lucia MW, Starnes SL, Merrill WH, Howington JA. Thoracoscopic lobectomy: introduction of a new technique into a thoracic surgery training program. J Thorac Cardiovasc Surg 2008;136(2):376–381 Konge L, Petersen RH, Hansen HJ, Ringsted C. No extensive experience in open procedures is needed to learn lobectomy by video-assisted thoracic surgery. Interact Cardiovasc Thorac Surg 2012;15(6):961–965 Wan IY, Thung KH, Hsin MK, Underwood MJ, Yim AP. Videoassisted thoracic surgery major lung resection can be safely taught to trainees. Ann Thorac Surg 2008;85(2):416–419 Boffa DJ, Gangadharan S, Kent M, et al. Self-perceived videoassisted thoracic surgery lobectomy proficiency by recent graduates of North American thoracic residencies. Interact Cardiovasc Thorac Surg 2012;14(6):797–800 Bille A, Okiror L, Harrison-Phipps K, et al. Does previous surgical training impact the learning curve in Video-Assisted Thoracic Surgery lobectomy for trainees? Interact Cardiovasc Thorac Surg 2013;17(Suppl 1):S36 doi:10.1093/icvts/ivt288.1. Abstract P136 Konge L, Lehnert P, Hansen HJ, Petersen RH, Ringsted C. Reliable and valid assessment of performance in thoracoscopy. Surg Endosc 2012;26(6):1624–1628

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approaches to lobectomy. Ann Thorac Surg 2008;86(6): 2008–2016, discussion 2016–2018 Craig SR, Leaver HA, Yap PL, Pugh GC, Walker WS. Acute phase responses following minimal access and conventional thoracic surgery. Eur J Cardiothorac Surg 2001;20(3):455–463 Yim AP, Wan S, Lee TW, Arifi AA. VATS lobectomy reduces cytokine responses compared with conventional surgery. Ann Thorac Surg 2000;70(1):243–247 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(1):27–30, discussion 30–31 Farjah F, Wood DE, Mulligan MS, et al. Safety and efficacy of videoassisted versus conventional lung resection for lung cancer. J Thorac Cardiovasc Surg 2009;137(6):1415–1421 Yang X, Wang S, Qu J. Video-assisted thoracic surgery (VATS) compares favorably with thoracotomy for the treatment of lung cancer: a five-year outcome comparison. World J Surg 2009;33(9):1857–1861 Demmy TL, Plante AJ, Nwogu CE, Takita H, Anderson TM. Discharge independence with minimally invasive lobectomy. Am J Surg 2004;188(6):698–702 Taioli E, Lee DS, Lesser M, Flores R. Long-term survival in videoassisted thoracoscopic lobectomy vs open lobectomy in lungcancer patients: a meta-analysis. Eur J Cardiothorac Surg 2013; 44(4):591–597

Billè et al.

Does Previous Surgical Training Impact the Learning Curve in Video-Assisted Thoracic Surgery Lobectomy for Trainees?

Background To analyze if the number of open lung resections performed by trainees before starting video-assisted thoracic surgery (VATS) lobectomy tra...
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