Self-perceived video-assisted thoracic surgery lobectomy proficiency by recent graduates of North American thoracic residencies

The utilization of educational resources published by the Thoracic Surgery Residents Association

OBJECTIVE

The Thoracic Surgery Residents Association (TSRA) is a trainee-led cardiothoracic surgery organization in North America that has published a multitude of educational resources. However, the utilization of these resources remains unknown.

METHODS

Surveys were constructed, pilot-tested, and emailed to 527 current cardiothoracic trainees (12 questions) and 780 former trainees who graduated between 2012 and 2019 (16 questions). The surveys assessed the utilization of TSRA educational resources in preparing for clinical practice as well as in-training and American Board of Thoracic Surgery (ABTS) certification examinations.

RESULTS

A total of 143 (27%) current trainees and 180 (23%) recent graduates responded. A higher proportion of recent graduates compared with current trainees identified as male (84% vs 66%; P = .001) and graduated from 2- or 3-year traditional training programs (81% vs 41%; P < .001), compared with integrated 6-year (8% vs 49%; P < .001) or 4 + 3 (11% vs 10%; P = .82) pathways. Current trainees most commonly used TSRA resources to prepare for the in-training exam (75%) and operations (73%). Recent graduates most commonly used them to prepare for Oral and/or Written Board Exams (92%) and the in-training exam (89%). Among recent graduates who passed the ABTS Oral Board Exam on the first attempt, 82% (97/118) used TSRA resources to prepare, versus only 48% (25/52) of recent graduates who passed after multiple attempts, failed, have not taken the exam, or preferred not to answer (P < .001).

CONCLUSIONS

Current cardiothoracic trainees and recent graduates have utilized TSRA educational resources extensively, including to prepare for in-training and ABTS Board examinations.

The Thoracic Surgery Residents Association: Past contributions, current efforts, and future directions

OBJECTIVE

The Thoracic Surgery Residents Association (TSRA) is a resident-led organization established in 1997 under the guidance of the Thoracic Surgery Directors Association to represent the interests and educational needs of cardiothoracic surgery residents. We aim to describe the past contributions, current efforts, and future directions of the TSRA within a conceptual framework of the TSRA mission.

METHODS

Primary review of educational resources was performed to report goals and content of past contributions. TSRA Executive Committee input was used to describe current resources and activities, as well as the future goals of the TSRA. Podcast analytics were performed to report national and global usage.

RESULTS

Since 2011, the TSRA has published 3 review textbooks, 5 reference guides, 3 test-preparation textbooks, 1 supplementary publication, and 1 multiple-choice question bank and mobile application, all written and developed by cardiothoracic surgery trainees. In total 108 podcasts have been recorded by mentored trainees, with more than 175,000 unique listens. Most recently, the TSRA has begun facilitating trainee submissions to Young Surgeon's Notes, fostered a trainee mentorship program, developed the monthly TSRA Newsletter, and established a wide-reaching presence on Facebook, Twitter, and Instagram to help disseminate educational resources and opportunities for trainees.

CONCLUSIONS

The TSRA continues to be the leading cardiothoracic surgery resident organization in North America, providing educational resources and networking opportunities for all trainees. Future directions include development of an integrated disease-based resource and continued collaboration within and beyond our specialty to enhance the educational opportunities and career development of cardiothoracic trainees.

Cumulative Sum Analysis of the Learning Curve for Uniportal Video-Assisted Thoracoscopic Lobectomy and Lymphadenectomy

Purpose: The study was performed to analyze the learning curve of performing uniportal video-assisted thoracoscopic surgery (uVATS) for lobectomy and lymphadenectomy, and to evaluate the possible disadvantages in outcomes during the course of learning. Materials and Methods: This is a prospective study of 52 consecutive patients undergoing uVATS lobectomy by a single surgeon from January 2016 to December 2017. Operation time (OPT) and the number of harvested lymph nodes (LNs) were evaluated by means of cumulative sum control chart by assessing efficiency (refinement in procedure to reach decreasing OPT and increasing number of harvested LNs) and mastery (absence of outliers). Failure rate, blood loss, and complications were retrospectively compared with the last 52 patients undergoing "classical" VATS lobectomy in the period before this study from January 2014 to December 2015. Results: Efficiency in OPT for uVATS was reached after 27 cases and mastery after 39 procedures (M_1st = 172 ± 39 minutes; M_2nd = 138 ± 34 minutes; p_{1-2 =} 0.022; M_3rd = 120 ± 25 minutes; p_{1-3 =} 0.00; p_{2-3 =} 0.65). Efficacy in the number of harvested LNs was reached after 26 cases and mastery after the 42nd procedure (MED_1st = 17, IQR 12-19; M_2nd = 21, IQR 16.25-29.75; p_{1-2 =} 0.018; M_3rd = 18, IQR 16-22; p_{1-3 =} 0.004; p_{2-3 =} 0.8). There were no significant differences in the failure rate (uVATS = 7.7%, VATS = 5.8%; P = .7), blood loss (MED_uVATS = 250 mL, IQR 200-387.5; MED_VATS = 225 mL, IQR 200-300; P = .77), and complications between the groups (uVATS = 13; 25%; VATS = 11; 21.2%; P = .41). Finally no significant differences could be found in OPT (uVATS = 151.36 ± 41.55; VATS = 156.69 ± 40.08; P = .52) or LNs (uVATS = 18, IQR 16-22; VATS = 19, IQR 14.25-20; P = .71) between the groups. Conclusions: Assuming a surgeon is skilled in "classic" VATS lung resections, achieving efficiency and mastery in uVATS is possible after sufficient experience even without dedicated education in this procedure, without measurable disadvantages throughout the course of learning. This study created a benchmark for already experienced VATS surgeons who are novices in uVATS, elucidating the number of operations required to reach both efficiency and mastery.

Conducting high-quality research in cardiothoracic surgical education: Recommendations from the Thoracic Education Cooperative Group

OBJECTIVE

There is a clear need for improved quality of research publications in the area of cardiothoracic surgical education. With the goals of enhancing the power, rigor, and strength of educational investigations, the Thoracic Education Cooperative Group seeks to outline key concepts in successfully conducting such research.

METHODS

Literature and established guidelines for conduct of research in surgical education were reviewed, and recommendations were developed for investigators in thoracic surgical education.

RESULTS

Key steps in educational research are highlighted and discussed with regard to their application to cardiothoracic surgical education. Specifically, advice is provided in terms of developing a research question, educational methodology, ethical issues, and handling power and sample sizes. Additional caveats of educational research that are addressed include aspects of validity, survey conduct, and simulation research.

CONCLUSIONS

Educational research can serve to enhance the practices and careers of current trainees, our scientific community, and thoracic surgical educators. To optimize the quality of such educational research, it is imperative that teachers, innovators, and contributors to academic scholarship in our field familiarize themselves with key steps in conducting educational studies.

Self-Appraised Readiness of Senior and Graduating General Surgery Residents to Perform Thoracic Surgery

OBJECTIVE

General surgeons perform up to 50% of noncardiac thoracic surgery (TS). Although data show consistent TS case volume during general surgery (GS) residency it is unknown whether this operative trend will persist given potentially limited subspecialty exposure. We sought to determine if certain aspects of residency programs and resident characteristics were associated with trainees' perceived comfort in performing certain basic TS procedures.

DESIGN

An anonymous survey was distributed to GS residents regarding program characteristics, presence of a TS residency, and intent to pursue thoracic surgical training, and estimated case volumes of individual procedures. Comfort levels for performing video-assisted thoracoscopic surgical (VATS) procedures, open lobectomy, elective thoracotomy, and sternotomy were attained through a 5-point Likert-type scale.

SETTING

This survey was administered at 50 training programs with responses recorded via an online form.

PARTICIPANTS

Fourth- and fifth-year GS residents in the United States.

RESULTS

Of 272 respondents 58% were fourth-year residents, 62% of residents trained at university-affiliated programs, and 64% reported a TS residency program at their institution and 16% stated intent to pursue TS. Fifth-year residents performed significantly more cases than fourth-year residents despite no difference in median comfort levels. Residents intending to pursue TS performed significantly more cases and were more comfortable performing a thoracotomy, sternotomy, VATS wedge resection/biopsy, and VATS decortication/pleurodesis (p = 0.044, <0.001, 0.045, 0.025). No characteristics were associated with comfort performing a lobectomy via thoracoscopic or open (thoracotomy) approaches.

CONCLUSION

Most senior or graduating GS residents state they are comfortable performing certain thoracic procedures with those pursuing additional thoracic surgical training more comfortable overall. No characteristics were associated with comfort performing a lobectomy. These findings may advise residency curriculum design to ensure continued thoracic surgical exposure and recommend against non-fellowship trained surgeons performing a pulmonary lobectomy.

Decreased In-Hospital Mortality after Lobectomy Using Video-assisted Thoracoscopic Surgery Compared with Open Thoracotomy

RATIONALE

There is a paucity of data regarding the optimal surgical approach for lung lobectomy. Lobectomy performed by video-assisted thoracoscopic surgery (VATS) has been associated with lower morbidity as compared with lobectomy performed by thoracotomy. However, no multicenter studies have shown improved mortality with VATS lobectomy compared with open surgical lobectomy.

OBJECTIVES

We used data from the United States Healthcare Cost and Utilization Project Nationwide Inpatient Sample database from 2009 to 2012 to compare VATS with open lobectomy for in-hospital mortality and other short-term outcomes.

METHODS

We used International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes to identify the patients undergoing lobectomy. We used 1:1 ratio propensity matching with the nearest neighbor method without replacement to generate matched pairs.

MEASUREMENTS AND MAIN RESULTS

Over the 4-year period, 27,451 patients underwent lobectomy. The majority of these procedures were performed by thoracotomy (65%) as compared with VATS (35%). A total of 9,393 matched pairs were created. VATS lobectomy was associated with significantly lower in-hospital mortality when compared with thoracotomy (1.3% vs. 2.5%, P < 0.001). A shorter length of hospital stay was observed for those undergoing VATS lobectomy (6.21 vs. 8.75 d, P < 0.001). The overall rate of perioperative complications was low, with those undergoing VATS being less likely to have any perioperative morbidity.

CONCLUSIONS

In recent years, the use of VATS for lobectomy has increased relative to thoracotomy. This trend has coincided with increased survival and shorter length of stay for VATS lobectomy compared with thoracotomy. Further studies are needed to identify comorbidities that identify ideal candidates for VATS lobectomy.

Anatomic pulmonary resection by video-assisted thoracoscopy: the Brazilian experience (VATS Brazil study)

OBJECTIVE

The objective of this study was to describe the results of anatomic pulmonary resections performed by video-assisted thoracoscopy in Brazil.

METHODS

Thoracic surgeons (members of the Brazilian Society of Thoracic Surgery) were invited, via e-mail, to participate in the study. Eighteen surgeons participated in the project by providing us with retrospective databases containing information related to anatomic pulmonary resections performed by video-assisted thoracoscopy. Demographic, surgical, and postoperative data were collected with a standardized instrument, after which they were compiled and analyzed.

RESULTS

The surgeons provided data related to a collective total of 786 patients (mean number of resections per surgeon, 43.6). However, 137 patients were excluded because some data were missing. Therefore, the study sample comprised 649 patients. The mean age of the patients was 61.7 years. Of the 649 patients, 295 (45.5%) were male. The majority-521 (89.8%)-had undergone surgery for neoplasia, which was most often classified as stage IA. The median duration of pleural drainage was 3 days, and the median hospital stay was 4 days. Of the 649 procedures evaluated, 598 (91.2%) were lobectomies. Conversion to thoracotomy was necessary in 30 cases (4.6%). Postoperative complications occurred in 124 patients (19.1%), the most common complications being pneumonia, prolonged air leaks, and atelectasis. The 30-day mortality rate was 2.0%, advanced age and diabetes being found to be predictors of mortality.

CONCLUSIONS

Our analysis of this representative sample of patients undergoing pulmonary resection by video-assisted thoracoscopy in Brazil showed that the procedure is practicable and safe, as well as being comparable to those performed in other countries.

OBJETIVO

O objetivo deste estudo foi descrever os resultados de ressecções pulmonares anatômicas por videotoracoscopia no Brasil.

MÉTODOS

Cirurgiões torácicos (membros da Sociedade Brasileira de Cirurgia Torácica) foram convidados, por correio eletrônico, a participar do estudo. Dezoito cirurgiões participaram do projeto enviando seus bancos de dados retrospectivos referentes a ressecções anatômicas de pulmão por videotoracoscopia. Dados demográficos, cirúrgicos e pós-operatórios foram coletados em um instrumento padronizado e posteriormente compilados e analisados.

RESULTADOS

Dados referentes a 786 pacientes foram encaminhados (média de 43,6 ressecções por cirurgião), sendo 137 excluídos por informações incompletas. Logo, 649 pacientes constituíram nossa população estudada. A média de idade dos pacientes foi de 61,7 anos, 295 eram homens (45,5%), e a maioria - 521 (89,8%) - foi submetida à cirurgia por neoplasia, mais frequentemente classificada como estádio IA. A mediana do tempo de drenagem pleural foi de 3 dias, e a do tempo de internação, 4 dias. Dos 649 procedimentos realizados, 598 (91,2%) foram lobectomias. A taxa de conversão para toracotomia foi de 4,6% (30 casos). Complicações pós-operatórias ocorreram em 124 pacientes (19,1%), sendo pneumonia, escape aéreo prolongado e atelectasia as mais frequentes. A mortalidade em 30 dias foi de 2,0%, tendo como preditores idade avançada e diabetes.

CONCLUSÕES

A casuística brasileira mostra que as ressecções pulmonares por cirurgia torácica videoassistida são factíveis e seguras, além de comparáveis àquelas de registros internacionais.

Training Assistants Improves the Process of Adoption of Video-Assisted Thoracic Surgery Lobectomy

BACKGROUND

Despite overwhelming evidence of decreased pain, fewer complications, and shorter length of stay with equivalent oncologic outcomes, video-assisted thoracic surgery (VATS) lobectomy has been slow to be adopted in the community. This study evaluates the role of training surgical assistants to ease the transition to VATS lobectomy.

METHODS

A half-day training course for physician assistants in the specific skills needed to assist with VATS lobectomy was developed to be offered annually in conjunction with a national meeting. Each participant completed a needs assessment before the course and a course assessment afterward. One-year follow-up data were obtained from the first cohort to determine the effects of the course on their practice.

RESULTS

Forty-four physician assistants participated in the course in either 2013 or 2014. Participant-identified educational needs included enhanced camera navigation skills, use of specialized instruments, and knowledge of the steps of the operation to provide proactive assistance. After completing the course, 90% (n = 39) felt more confident in their ability to provide optimal visualization for the operating surgeon, and 93% (n = 40) felt more confident in their ability to recognize and anticipate the steps of a VATS lobectomy. These changes persisted at 1 year.

CONCLUSIONS

Specific training directed at surgical assistants may improve the adoption of new technology by mechanisms including improved visualization and better understanding of methods to facilitate the operation and avoid frustration. This type of training should be made available to assistants of surgeons learning new operations.

Lung volume reduction surgery since the National Emphysema Treatment Trial: study of Society of Thoracic Surgeons Database

OBJECTIVES

The National Emphysema Treatment Trial demonstrated that lung volume reduction surgery is an effective treatment for emphysema in select patients. With chronic lower respiratory disease being the third leading cause of death in the United States, this study sought to assess practice patterns and outcomes for lung volume reduction surgery on a national level since the National Emphysema Treatment Trial.

METHODS

Aggregate statistics on lung volume reduction surgery reported in the Society of Thoracic Surgeons Database from January 2003 to June 2011 were analyzed to assess procedure volume, preoperative and operative characteristics, and outcomes. Comparisons with published data from the National Emphysema Treatment Trial were made using chi-square and 2-sided t tests.

RESULTS

In 8.5 years, 538 patients underwent lung volume reduction surgery, with 20 to 118 cases reported in the Society of Thoracic Surgeons Database per year. When compared with subjects in the National Emphysema Treatment Trial, subjects in the Society of Thoracic Surgeons Database were younger (P < .001), a larger proportion underwent the procedure thoracoscopically (P < .001), and forced expiratory volume in 1 second was 31% versus 28% of predicted (P < .001). When mortality was compared between subjects in the Society of Thoracic Surgeons Database and all subjects in the National Emphysema Treatment Trial randomized to surgery, there were no significant differences. However, mortality was 3% higher in subjects in the Society of Thoracic Surgeons Database when compared with the non-high-risk National Emphysema Treatment Trial subset (P = .005).

CONCLUSIONS

This study demonstrates the importance of patient selection and the need to develop consensus on appropriate benchmarks for mortality rates after lung volume reduction surgery. It underscores the need for dedicated centers to increasingly address the heavy burden of chronic lower respiratory disease in the United States in a multidisciplinary fashion, particularly for preoperative evaluation and postoperative management of emphysema.

Teaching video-assisted thoracic surgery (VATS) lobectomy

Video-assisted thoracic surgery (VATS) lobectomy has become the standard of care for early stage lung cancer throughout the world. Teaching this complex procedure requires adequate case volume, adequate instrumentation, a committed operating room team and baseline experience with open lobectomy. We outline what key maneuvers and steps are required to teach and learn VATS lobectomy. This is most easily performed as part of a thoracic surgery training program, but with adequate commitment and proctoring, there is no reason experienced open surgeons cannot become proficient VATS surgeons. We provide videos showing the key portions of a subcarinal lymph node dissection, posterior hilar dissection of the right upper lobe, fissureless right middle lobectomy, and fissureless left lower lobectomy. These videos highlight what we feel are important principals in VATS lobectomy, i.e., N2 and N1 lymph node dissection, fissureless techniques, and progressive responsibility of the learner. Current literature in simulation of VATS lobectomy is also outlined as this will be the future of teaching in VATS lobectomy.

No extensive experience in open procedures is needed to learn lobectomy by video-assisted thoracic surgery

OBJECTIVES

Lobectomies done by video-assisted thoracic surgery (VATS) result in fewer complications and less pain and save total costs compared with the traditional approach. However, the majority of procedures are still performed via open thoracotomies, because VATS lobectomy is considered difficult to learn, requiring experience in open surgery, and causing complications in the initial phase of the learning curve. The aim of this study was to describe a training model appreciating patient safety during training and to explore the initial learning curve for a trainee rather inexperienced in open surgery.

METHODS

A trainee who had performed 14 lobectomies by thoracotomy was enrolled in a training programme at a high-volume VATS centre. The training model included courses and simulations followed by the selection of suitable patients operated on during close expert supervision. Data regarding time, a variety of quality indicators and complications were collected prospectively and compared with experts' performance.

RESULTS

Over 12 months, 29 of 214 VATS lobectomies were performed by the trainee. Twice, the supervisor had to finish the procedure due to technical difficulties. None of the operations were converted to open thoracotomy. Compared with experts, the trainee operated significantly slower [median 120 (range 74-160) vs 100 (range 42-255) min, P = 0.04]; had similar perioperative bleeding [median 100 (range 10-500) vs 50 (range 5-2500) ml, P = 0.79]; had earlier chest tube removal [median 1 (range 1-6) vs 2 (range 1-32) postoperative days, P < 0.001]; and reduced hospital stay [median 3 (range 1-10) vs 4 (range 1-41) days, P < 0.001]. Twenty-three (79%) patients had no complications, while 2 had atrial fibrillation. Pneumothorax after chest tube removal, incisional infection, prolonged pain and need for pleuracentesis were each seen once.

CONCLUSIONS

With thorough preparation of trainees and training on selected patients under close supervision, the learning curve can be overcome with good results even if the trainee has limited prior experience in open surgery.

Thoracoscopic lobectomy has increasing benefit in patients with poor pulmonary function: a Society of Thoracic Surgeons Database analysis

OBJECTIVE

Using a national database, we asked whether video-assisted thoracoscopic surgery (VATS) lobectomy is beneficial in high-risk pulmonary patients.

BACKGROUND

Single-institution series demonstrated benefit of VATS lobectomy over lobectomy via thoracotomy in poor pulmonary function patients [FEV1 (forced expiratory volume in 1 second) or DLCO (diffusion capacity of the lung to carbon monoxide) <60% predicted].

METHODS

The STS General Thoracic Database was queried for patients having undergone lobectomy by either thoracotomy or VATS between 2000 and 2010. Postoperative pulmonary complications included those defined by the STS database.

RESULTS

In the STS database, 12,970 patients underwent lobectomy (thoracotomy, n = 8439; VATS, n = 4531) and met inclusion criteria. The overall rate of pulmonary complications was 21.7% (1832/8439) and 17.8% (806/4531) in patients undergoing lobectomy with thoracotomy and VATS, respectively (P < 0.0001). In a multivariable model of pulmonary complications, thoracotomy approach (OR = 1.25, P < 0.001), decreasing FEV1% predicted (OR = 1.01 per unit, P < 0.001) and DLCO% predicted (OR = 1.01 per unit, P < 0.001), and increasing age (1.02 per year, P < 0.001) independently predicted pulmonary complications. When examining pulmonary complications in patients with FEV1 less than 60% predicted, thoracotomy patients have markedly increased pulmonary complications when compared with VATS patients (P = 0.023). No significant difference is noted with FEV1 more than 60% predicted.

CONCLUSIONS

Poor pulmonary function predicts respiratory complications regardless of approach. Respiratory complications increase at a significantly greater rate in lobectomy patients with poor pulmonary function after thoracotomy compared with VATS. Planned surgical approach should be considered while determining whether a high-risk patient is an appropriate resection candidate.

Lymph node evaluation by open or video-assisted approaches in 11,500 anatomic lung cancer resections

BACKGROUND

Unsuspected lymph node metastases are found in the surgical specimens of 10% to 25% clinical stage I lung cancers. Video-assisted thoracic surgery (VATS) is a minimally invasive alternative to thoracotomy. Because detection of clinically occult metastases is dependent on the completeness of surgical lymph node dissection, the influence of surgical approach on nodal evaluation is of interest. We determined the frequency of nodal metastases identified in clinically node-negative tumors by thoracotomy ("open") and VATS approaches to approximate the completeness of surgical nodal dissections.

METHODS

The Society of Thoracic Surgery database was queried for lobectomies and segmentectomies from 2001 to 2010.

RESULTS

A total of 11,531 (7,137 open and 4,394 VATS) clinical stage I primary lung cancers were resected. Nodal upstaging was seen in 14.3% (1,024) in the open group and 11.6% (508) in the VATS group (p<0.001). Upstaging from N0 to N1 was more common in the open group (9.3% versus 6.7%; p<0.001); however, upstaging from N0 to N2 was similar (5.0% open and 4.9% VATS; p=0.52). Among 2,745 propensity-matched pairs, N0 to N1 upstaging remained less common with VATS (6.8% versus 9%; p=0.002).

CONCLUSIONS

During lobectomy or segmentectomy for clinical N0 lung cancer, mediastinal nodal evaluation by VATS and thoracotomy results in equivalent upstaging. In contrast, lower rates of N1 upstaging in the VATS group may indicate variability in the completeness of the peribronchial and hilar lymph node evaluation. Systematic hilar dissection is encouraged, particularly as more surgeons adopt the VATS approach.