The influence of prior multiport experience on the learning curve for single-port thoracoscopic lobectomy: a multicentre comparative study

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1 European Journal of Cardio-Thoracic Surgery 51 (2017) doi: /ejcts/ezx003 Advance Access publication 15 February 2017 ORIGINAL ARTICLE Cite this article as: Martin-Ucar AE, Aragon J, Bolufer Nadal S, Galvez Munoz C, Luo Q, Perez Mendez I et al. The influence of prior multiport experience on the learning curve for single-port thoracoscopic lobectomy: a multicentre comparative study. Eur J Cardiothorac Surg 2017;51: a b c d e The influence of prior multiport experience on the learning curve for single-port thoracoscopic lobectomy: a multicentre comparative study Antonio E. Martin-Ucar a,javieraragon b, Sergio Bolufer Nadal c, Carlos Galvez Munoz c,qigangluo d, Itzel Perez Mendez b,aland.l.sihoe e and Laura Socci a, * Thoracic Surgery Units, Sheffield Teaching Hospital, Sheffield, UK Unidad de Cirugia Toracica, Hospital Universitario Asturias, Oviedo, Spain Unidad de Cirugia Toracica, Hospital Universitario Alicante, Alicante, Spain Department of Thoracic Surgery, The University of Hong Kong Shenzhen Hospital, Shenzhen, China Department of Thoracic Surgery, University Hong Kong, Hong Kong, China * Corresponding author. Northern General Hospital, Sheffield Teaching Hospitals, Herries Road, Sheffield S5 7AT, UK. Tel: ; laura.socci@sth.nhs.uk (L. Socci). Received 29 July 2016; received in revised form 20 November 2016; accepted 23 November 2016 Abstract OBJECTIVES: Competency in video-assisted thoracoscopic (VATS) lobectomy is estimated to be reached after the surgeon completes 50 cases. We wanted to explore the impact of competency in performing multiport VATS lobectomies on completing the needed number of single-port VATS. METHODS: In a retrospective multicentre study, 6 individual surgeons (3 with previous competency in multiport VATS lobectomy and 3 without) submitted their first 50 cases of single-port VATS lobectomies. Extended and sublobar resections were excluded. Pre-, peri- and postoperative data were compared between the groups of surgeons. Chi-square and Wilcoxon s rank tests were used. The less experienced surgeons had previously attended dedicated training courses and visited with experts. RESULTS: A total of 300 cases were included [150 in Group A (surgeons with previous experience performing multiport VATS) and 150 in Group B (surgeons without extensive experience performing multiport VATS)]. Surgeons in Group B performed significantly more elective open lobectomies during their learning curve period than surgeons of Group A (58 vs 1). Patients in Group B were older and had more risk factors. There were 3 in-hospital deaths (respiratory failure, sepsis and fatal stroke). There were no differences between the groups in operative time, intensive care unit admissions, hospital stay, total complications, tumour size or number of N2 stations explored. Only the duration of intercostal drainage (2 vs 3 days, 0.012), incidence of respiratory tract infections (1% vs 7%, P = 0.002) and conversion rates (4% vs 12%, P = 0.018) were better in Group A. Patients characteristics played a role in the development of respiratory infections and longer drainage times but not in the need for conversion. CONCLUSIONS: Overall, postoperative outcomes during the learning curve period for single-port VATS lobectomies are not noticeably affected by previous multiport VATS experience. Less experienced surgeons were more selective in order to achieve competency (more lower lobectomies and more open operations). Competency in single-port VATS lobectomy can be acquired safely with adequate training and good case selection but will be achieved faster with previous competency in multiport VATS lobectomy. Keywords: Training Surgical outcomes Thoracoscopy INTRODUCTION Any development in a surgical approach should be deemed safe, efficient, reproducible and easily learned by the surgeons. Singleport video-assisted thoracoscopy (VATS) was initially recommended for use in minor and intermediate procedures [1, 2]. Presented at the 24th European Conference on General Thoracic Surgery, Naples, Italy, 29 May 1 June With the advances in expertise in traditional multiport VATS and the development of purposely designed thoracoscopic instruments, single-port VATS was used for lobectomies [3]. Other more complex procedures have since been described [4 6], but it is in the area of VATS lobectomy where this approach has expanded around the world. Without engaging in a discussion of the merits of all VATS techniques, it seems clear that the singleport VATS approach can achieve outcomes as satisfactory as VC The Author Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

2 1184 A.E. Martin-Ucar et al. / European Journal of Cardio-Thoracic Surgery Figure 1: Single-port VATS lobectomy using instruments designed specifically for this procedure. The utility incision required to extract the specimen is used to perform the whole procedure. those of other approaches; therefore, its use has expanded rapidly [7 9]. Learning a new technique or approach requires careful attention to physician training and patient selection. The impact of the learning curve for any new procedure on patients and outcomes must be considered and dealt with in order to minimize its effects. It is estimated that competency in performing VATS lobectomy is achieved after 50 procedures. During the period when the surgeon is perfecting the procedure, outcomes should be monitored and patient safety ensured [10]. The single-port VATS lobectomy has been adopted directly from open surgery or after experience with the traditional multiport VATS [11 13]. METHODS The aim of this international multicentre study was to evaluate the effects of the learning curve on surgeons with previous multiport VATS lobectomy experience (at least 50 cases performed) and those who had not completed the 50 cases required for certification of competency in VATS lobectomy before undertaking single-port VATS lobectomy. To achieve this goal, we compared the practice and outcomes of the initial 50 lobectomies performed via the single-port VATS approach by 3 surgeons who had completed at least 50 cases of multiport VATS (Group A) with 3 surgeons who had not (Group B). All surgeons were fully qualified specialists in thoracic surgery with experience in open procedures and had undergone practical training in the procedure by attending courses and visiting experts. For the purpose of this study, complex procedures (segmentectomies, sleeve resections and pneumonectomies) were not included. The operations were performed in centres from different countries (Spain, China and the UK). All surgeons used a similar operative technique: an anterior axillary line incision over the 4th and 5th intercostal space 3 6 cm long as required by the expected size of the tumour/lobe [14]. A longer incision is required for large tumours and lobes of 4 5 segments whereas a 3-cm incision would be sufficient to complete a right upper or a middle lobectomy with a small tumour. A 30-degree optic was placed at the most lateral point of the incision allowing for instrumentation alongside the rest of the incision. Procedures were completed without spreading the ribs, and soft tissue retractors were used per each surgeon s preferences. A specimen bag was used for retrieval of the specimen (Fig. 1). Data were collected retrospectively from 300 patients from preoperative (age, gender, spirometry, comorbities, smoking history and previous malignant disease), intraoperative (side, lobe removed, operative time, conversions, additional ports inserted, number of lymph node stations explored, tumour size, final histological report and staging) and postoperative (postoperative in-hospital deaths, hospital stay, duration of intercostal drainage, admission to the intensive care unit and postoperative complications) periods. Chest or respiratory tract infection was defined as the need for a course of antibiotics in the presence of a positive sputum culture or radiological changes. Vascular complications were defined as the development of a pulmonary embolism, a cerebrovascular accident or a deep vein thrombosis. Renal replacement therapy and cardiac complications (myocardial infarction, atrial fibrillation) were recorded. Wound complications included partial dehiscence, infection and prescription of antibiotics by the general practitioners. The groups were compared using the Chi-square test (and the Fisher s exact test when required) for categorical variables and the Wilcoxon rank test for quantitative variables. Statistical significance was defined by P-values less than 0.05 throughout

3 A.E. Martin-Ucar et al. / European Journal of Cardio-Thoracic Surgery 1185 Table 1: Preoperative data using SPSS v11.5. Data are expressed as number (%) or median (range). RESULTS Age, years 63 (18 82) 68 (21 85) <0.001 FEV1, % 84 (51-137) 86 (32-157) 0.86 TLCO, % 79 (39-117) 71 (33-120) Cardiac comorbidities, n (%) 18 (12) 45 (30) <0.001 Respiratory comorbidities, n (%) 33 (22) 51 (34) Vascular comorbidities, n (%) 13 (9) 22 (15) 0.15 Diabetes, n (%) 32 (21) 18 (12) Previous malignancies, n (%) 38 (25) 54 (36) Open lobectomies, n 1 58 <0.001 Preoperative variables between the groups. Data are presented as number (%) or median (range). FEV1: forced expiratory volume in the first second; TLCO: transfer capacity of the lungs for carbon monoxide. Table 2: Perioperative data* Right: left 82:68 85: Lower lobectomies, n (%) 46 (32) 61 (41) 0.11 Complete excision, n (%) 147 (98) 148 (99) 0.60 Tumour size, cm 2.8 (0.4 12) 2.5 (0.9 10) 0.41 N2 stations, n 3 (1 6) 3 (0 5) 0.58 Operation time, min 195 (60 420) 180 (55 420) Conversion to open surgery, 6 (4) 18 (12) n (%) Insertion of an extra port, n (%) 8 (5) 6 (4) 0.78 Intraoperative variables between the groups. Data are presented as number (%) or median (range). Table 3: Postoperative data Duration of drain, days 2 (0 26) 3 (0 35) Hospital stay, days 4 (1 21) 4 (1 36) 0.68 ICU admission, n (%) 5 (3.3) 3 (2) 0.72 Hospital deaths, n (%) 1 (0.7) 2 (1.3) 0.62 Atrial fibrillation, n (%) 1 (0.7) 5 (3.3) 0.16 Re-insertion of drain, n (%) 8 (5) 8 (5) 0.99 Renal complications, n (%) 3 (2) Vascular complications, n (%) 0 2 (1.4) 0.36 Chest infection, n (%) 1 (0.7) 12 (8) Wound complications, n (%) 3 (2) 10 (7) Postoperative variables between the groups. Data are presented as number (%) or median (range). ICU: intensive care unit. All 6 surgeons contributed data from their initial 50 cases dating from 2011 to The preoperative data are shown in Table 1. Age was more advanced and measurements of the transfer capacity of the lungs for carbon monoxide were lower in Group B; the prevalence of comorbidities was higher (cardiac and respiratory). During this initial period, surgeons in Group B continued to perform elective lobectomies via thoracotomy in their practice (a total combined 58 cases vs 1 in Group A, P < 0.001). The lobectomies were performed for primary lung cancer (87%), secondary deposits (5%) and non-malignant disease (8%). The distribution was similar in the 2 groups. In this experience, only 10 cases had undergone neoadjuvant therapies prior to surgery (3%): 9 in Group A and 1 in Group B. The operative time, anatomical location and size of tumours, number of N2 stations explored and need for insertion of a second port were similar between the groups (Table 2). The conversion rate for surgeons in Group B was 12%, whereas that in Group A was 4% (P = 0.018). Indications for conversion were technical difficulties in 9 cases, bleeding in 13 and local invasion in 2. Conversion was typically performed by all surgeons by extending the incision into an anterior thoracotomy approach. We found no significant differences in postoperative inhospital deaths: 0.7% and 1.3% in Groups A and B, respectively (P = 0.62). Causes of death were respiratory failure, sepsis and a fatal stroke. The incidence of admission to the intensive care unit, overall postoperative complications and duration of stay in hospital were also similar. There was an increase in the incidence of postoperative respiratory tract infection (8% vs 0.7%, P = 0.002) in patients in Group B. Patients operated by surgeons in Group A had their drains removed at a median of 2 days vs 3 days in Group B (P = 0.012) (Table 3). We did not collect data on the duration of air leaks after surgery, but the data can be extrapolated from the duration of intercostal drainage. A total of 6% of patients operated in Group A had their intercostal drains removed after 7 days vs 18% in Group B (P = 0.002). The incidence of wound complications (infection, dehiscence or use of antibiotics) reported approached significance (P = 0.052). The difference between the groups was 2% in Group A vs 7% in Group B. The duration of intercostal drainage was also related to other risk factors: impaired forced expiratory volume in the first second (P = 0.013), impaired transfer capacity of the lungs for carbon monoxide (P = 0.001) and advanced age (P = 0.041). Postoperative pneumonia was also related to advanced age (P = 0.005). Conversion to thoracotomy was, however, only related to the surgeon s previous multiport VATS experience, with no other factors approaching a significant correlation. DISCUSSION Adoption of new techniques and approaches is an integral part of surgical advances. Although there is no set manner in which to learn and implement them, there are initiatives that can aid the progress: visiting experts, attending practical courses in experimental surgery, watching live operations and video libraries. We are fortunate that experts have already assessed the learning

4 1186 A.E. Martin-Ucar et al. / European Journal of Cardio-Thoracic Surgery curve for VATS lobectomy. The recommendations are that the physician should complete about 50 cases to achieve competency [10]. It was suggested that learning the single-port VATS lobectomy might be better achieved if one had previous expertise in the traditional multiport VATS. Other authors with open surgery experience have reported good outcomes from their initial experiences with single-port VATS [11, 12, 15]. Our experience suggests that one can achieve good outcomes like those achieved with previous experiences. The differences are related more to the selection of cases and awareness of one s own limitations than to patient outcomes. Surgeons without previous VATS lobectomy experience are more prone to convert to open surgery, normally because the operation is difficult and the surgeon fails to progress. Also, they are more likely to select patients for single-port VATS lobectomy and to continue performing open resections during the initial stages of their learning curve. Suggestions for the selection process can be found in our own experiences: concentrate initially on dissections that are technically easier, such as lower lobectomies, and select single-port VATS for patients at higher risk of complications from thoracotomy (the elderly, those with important comorbidities or with a restricted pulmonary reserve). Published reports suggest that the application of VATS lobectomy in these groups of patients reduces the operative risks compared to thoracotomy [16 18]. We selected the initial 50 cases performed by all of the surgeons that met the definition of the learning curve after VATS lobectomy. By that point, all of the participating surgeons felt they had achieved initial competency in the approach and were already performing more complex surgeries (e.g. segmentectomies, sleeves). However, more surgeons with previous VATS lobectomy competency performed these complex procedures. Our report also indicates that clinical outcomes (mortality, complications), use of resources (operative time, admission to the intensive care unit and hospital stay) and oncological outcomes (rate of complete R0 excisions, lymph node stations explored during surgery) were similar between the groups. The slight increase in respiratory tract infections in Group B probably reflects the differences in the risk factors of the cohorts of patients (increased age, lower respiratory reserve and more comorbidities). The incidence of infective thoracic complications, however, compares reasonably well with rates reported in the literature [19, 20]. The number of conversions to thoracotomy decreases with experience, as has been shown in multiport VATS [21]. Our rates of 4% and 12% fall within the limits described in the literature [22, 23]. Only three of the conversions (1%) were salvage after a massive haemorrhage, the majority due to failure to progress, minor or moderate vascular injuries or prevention of probable complications. Wound complications, another outcome that differed between the groups, probably represent a softer outcome both by the definition and partly because they depend on the intervention of non-surgical doctors and nurses. They do not, however, represent a significant clinical issue for patients because no re-interventions were required. Similar rates of wound complications after thoracic procedures have been described in the literature [24, 25]. It is important to realize that all of the surgeons involved had attended hands-on operating courses using live animal models, had visited experts and had attended courses where live operations were performed. In most cases, the surgeons made a second visit or attended another course after the initial adoption. All surgeons felt that this second initiative helped them learn tricks and pitfalls encountered during their daily practice. We acknowledge the limitations of our study. It involved a limited number of surgeons with different practices even geographically. These surgeons progressed to single-port VATS lobectomy in diverse environments. The retrospective nature of this work, although based on prospectively recorded databases, is another limitation, as are the differences in the demographics between units. All surgeons have gone on to universally adopt the approach in their practices, so they could be labelled as enthusiasts. These limitations do not, however, restrict the value of our initiative as an honest exploration of our learning curve. The total number of patients included is substantive, and we hope that will make our report of interest to readers. Based on our experience, we believe that competency in performing single-port VATS lobectomies can be enhanced if the surgeon has previous experience performing multiport VATS or open surgeries without compromising outcomes. The competency is, however, acquired faster and with fewer conversions to open surgery when the surgeon has previous experience with multiport VATS lobectomies. An acceptable increase in postoperative respiratory complications and longer drainage time were also identified in the non-vats experience group but were also linked to patient characteristics. Conflict of interest: none declared. REFERENCES [1] Rocco G, Martin-Ucar A, Passera E. Uniportal VATS wedge pulmonary resections. Ann Thorac Surg 2004;77: [2] Rocco G, Khalil M, Jutley R. Uniportal video-assisted thoracoscopic surgery wedge lung biopsy in the diagnosis of interstitial lung diseases. J Thorac Cardiovasc Surg 2005;129: [3] Gonzalez D, Paradela M, Garcia J, De la Torre M. Single-port videoassisted thoracoscopic lobectomy. Interact CardioVasc Thorac Surg 2011;12: [4] Gonzalez-Rivas D, Fieira E, Mendez L, Garcia J. Single-port video-assisted thoracoscopic anatomic segmentectomy and right upper lobectomy. Eur J Cardiothorac Surg 2012;42:e [5] Gonzalez-Rivas D, Fernandez R, Fieira E, Rellan L. Uniportal videoassisted thoracoscopic bronchial sleeve lobectomy: first report. J Thorac Cardiovasc Surg 2013;145: [6] Shih CS, Liu CC, Liu ZY, Pennarun N, Cheng CT. Comparing the postoperative outcomes of video-assisted thoracoscopic surgery (VATS) segmentectomy using a multi-port technique versus a single-port technique for primary lung cancer. J Thorac Dis 2016;8:S [7] Zhu Y, Liang M, Wu W, Zheng J, Zheng W, Guo Z et al. Preliminary results of single-port versus triple-port complete thoracoscopic lobectomy for non-small cell lung cancer. Ann Transl Med 2015;3:92. [8] Mu JW, Gao SG, Xue Q, Zhao J, Li N, Yang K et al. A matched comparison study of uniportal versus triportal thoracoscopic lobectomy and sublobectomy for early-stage nonsmall cell lung cancer. Chin Med J (Engl) 2015;128: [9] Tamura M, Shimizu Y, Hashizume Y. Pain following thoracoscopic surgery: retrospective analysis between single-incision and three-port video-assisted thoracoscopic surgery. J Cardiothorac Surg 2013;12:153. [10] Yan TD, Cao C, D Amico TA, Demmy TL, He J, Hansen H et al. Video-assisted thoracoscopic surgery lobectomy at 20 years: a consensus statement. Eur J Cardiothorac Surg 2014;45: [11] Anile M, Diso D, Mantovani S, Patella M, Russo E, Carillo C et al. Uniportal video assisted thoracoscopic lobectomy: going directly from open surgery to a single port approach. J Thorac Dis 2014;6:S [12] Aragon J, Pérez Méndez I. From open surgery to uniportal VATS: asturias experience. J Thorac Dis 2014;6:S644 9.

5 A.E. Martin-Ucar et al. / European Journal of Cardio-Thoracic Surgery 1187 [13] Liu C-C, Shih C-S, Pennarun N, Cheng C-T. Transition from a multiport technique to a single-port technique for lung cancer surgery: is lymph node dissection inferior using the single-port technique? Eur J Cardiothorac Surg 2016;49:i [14] Gonzalez-Rivas D, Fernandez R, de la Torre M, Martin-Ucar AE. Thoracoscopic lobectomy through a single incision. Multimed Man Cardiothorac Surg 2012; doi: /mmcts/mms007. [15] Ismail M, Helmig M, Swierzy M, Neudecker J, Badakhshi H, Gonzalez-Rivas D et al. Uniportal VATS: the first German experience. J Thorac Dis 2014;6:S [16] Lau KK, Martin-Ucar AE, Nakas A, Waller DA. Lung cancer surgery in the breathless patient the benefits of avoiding the gold standard. Eur J Cardiothorac Surg 2010;38:6 13. [17] Paul S, Altorki NK, Sheng S, Lee PC, Harpole DH, Onaitis MW 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: [18] Jeon JH, Kang CH, Kim HS, Seong YW, Park IK, Kim YT et al. Video-assisted thoracoscopic lobectomy in non-small-cell lung cancer patients with chronic obstructive pulmonary disease is associated with lower pulmonary complications than open lobectomy: a propensity scorematched analysis. Eur J Cardiothorac Surg 2014;45: [19] Falcoz PE, Puyraveau M, Thomas PA, Decaluwe H, Hürtgen M, Petersen RH et al. Video-assisted thoracoscopic surgery versus open lobectomy for primary non-small-cell lung cancer: a propensity-matched analysis of outcome from the European society of thoracic surgeon database. Eur J Cardiothorac Surg 2016;49: [20] Petersen RH, Hansen HJ. Learning thoracoscopic lobectomy. Eur J Cardiothorac Surg 2010;37: [21] Li X, Wang J, Ferguson MK. Competence versus mastery: the time course for developing proficiency in video-assisted thoracoscopic lobectomy. J Thorac Cardiovasc Surg 2014;147: [22] Decaluwe H, Petersen RH, Hansen H, Piwkowski C, Augustin F, Brunelli A et al. Major intraoperative complications during videoassisted thoracoscopic anatomical lung resections: an intention-totreat analysis. Eur J Cardiothorac Surg 2015;48:588 98; discussion 599. [23] Puri V, Patel A, Majumder K, Bell JM, Crabtree TD, Krupnick AS et al. Intraoperative conversion from video-assisted thoracoscopic surgery lobectomy to open thoracotomy: a study of causes and implications. J Thorac Cardiovasc Surg 2015;149: [24] Imperatori A, Rovera F, Rotolo N, Nardecchia E, Conti V, Dominioni L. Prospective study of infection risk factors in 988 lung resections. Surg Infect (Larchmt) 2006;7:S [25] Rovera F, Imperatori A, Militello P, Morri A, Antonini C, Dionigi G et al. Infections in 346 consecutive video-assisted thoracoscopic procedures. Surg Infect (Larchmt) 2003;4:45 51.