The Musician, Instrument, or Orchestra?

The article by Liu and colleagues should be applauded for adding to the body of evidence that minimally invasive approaches, especially complex ones, have oncologic equivalence to open.1 Like other reports, retrospective single institutional and cancer registry data suffice because high-quality, randomized studies of our approaches have been impractical to conduct.2 Research participants and investigators find equipoise difficult without clear signals of oncologic failures in anecdotal or retrospective research to justify going back to open approaches. Even a consortium of lobectomy centers in China that do thousands of cases each year took time to complete accrual of a randomized video-assisted thoracoscopic surgery (VATS) versus axillary thoracotomy study.3 This trial reported fewer perioperative VATS complications, like Liu and colleagues, and long-term survival data are pending.

One VATS lobectomy signal for oncologic concern occurred with nodal upstaging which was more likely in open patients, according to a report using the Society of Thoracic Surgeons’ database.4 Such concerns were addressed by subsequent studies, but perhaps most convincingly by a report that reanalyzed lobectomy data from a European thoracic database consortium.5 When VATS was deemed feasible originally, it was generally recommended for smaller peripheral tumors less likely to have upstaging.6 Over time, as surgeons became comfortable with performing more complex surgery like minimally invasive sleeve resections, they ventured toward node dense central or larger tumors having main airway and vascular invasions. When added as a variable, centrality became the overwhelming predictor of nodal upstaging and approach was no longer significant in multivariable analysis.5

While generally central, surgeons may not document the specific nuanced tumor imaging effects on hilar structures that prompt scheduling open sleeve resections rather than VATS. Validated tools to systematically classify central invasion are lacking. Until there are such mandatory descriptors, it will be difficult to propensity match cohorts in institutional or consortium databases to answer oncologic validity questions. One way to do this indirectly would be to find out the rate at which minimally invasive approaches are applied to all cases. Some centers of excellence have a 90% application of VATS for all their lobectomies, which generally means that they are also wading into bronchoplastic work, minimally invasive pneumonectomy, etc.7 It is difficult to compare their outcomes with centers plateauing at 50% VATS because of imponderable selection biases. For institutions that upload all their cases, this yearly reliability rate could be calculated as an index of program maturity and an expected metric for journal publications. This methodology could be used for other advanced minimally invasive extirpations like minimally invasive esophagectomy.

The major technical challenge to sleeve lobectomy is achieving the desired airway reconstruction. Open surgery allows a variety of standard instruments and running and interrupted bronchial closures. Wristed instrumentation allows greater dexterity and one might assume (incorrectly) that robotic sleeve lobectomy case series would exceed VATS. While there is more dexterity, suture control is challenging, so some surgeons have modified their techniques to running anastomoses using barbed sutures.8 At our center, we use a combination of open and VATS approaches for sleeve resections with a greater proportion each year being minimally invasive. To aid in this effort, we use minimally invasive cardiac needle holders and occasionally wristed non-robotic devices like Flex-Dex™ or Artisential™. It is possible to do interrupted approaches using suture organizers, multiple thin-shafted (5 mm) tools to retract sutures, and tying aids like the Ty-Knot™.

Whether to use robotics over VATS for such cases is another lively ongoing debate. Proponents argue that enhanced 3D vision and wristed instruments enhance the critical peribronchial nodal dissections needed. We analyzed the data from the National Cancer Database and found that while upstaging was higher for the open group, more nodes were counted for minimally invasive cases (but not different between VATS and robotic).9 Survivorship was better for minimally invasive cases, but for stage 1 cases robotic survival trended downward over time.

The mechanism behind these observations is unclear, but gets at the title of this editorial. We found that outcomes like nodal dissection are linked more with the surgeon and institutional normative practice. Academic or dedicated cancer centers do better with these oncologic metrics.9 Early in the days of VATS, it was a plausible that excellent surgeons were hampered by limitations of optics and instrumentation, and had to compromise results. This is not the case today. For instance, both VATS and robotic surgeons can use 3D options shown in randomized research to reduce lobectomy operative time.10 The choice of approach and instruments creates a medium that requires hundreds of hours for the surgeon (artist) to master, and therefore we naturally defend such choices in our literature.

Yet, we generally do not go to see musicians or athletes because of the brand of instrument or equipment, even though such things are essential to their performance. We are interested in how the surgeon uses those instruments and coordinates the “orchestra” of supporting team members to get superb results from complex systems. Arguably, capable lobectomy surgeons have a sufficient palette of optical and instrument options to realize their operative goals today. Sleeve resections or other central tumor operations should “stress-test” oncologic validity more than early stage neoplasms, and yet there has not been a worrisome signal like unexpected recurrences.

We and our patients share a desire for less invasive therapeutic options as a sign of progress. It is reasonable to move away from open until signals suggest minimally invasive failures in safety or survival that are verifiable mechanistically. We should de-emphasize approach, per se, from research communications. By focusing instead on collecting important data like centrality or margins we could compare our results better with competing treatment options from radiation medicine [stereotactic body radiotherapy (SBRT)] or others.

Furthermore, VATS and robotic approaches have dozens of permutations that could influence outcomes but would be impractical to subcategorize.11 Will we someday have to compare and validate each VATS approach to the Intuitive™, robot X Y & Z, uniportal, and subxiphoid lobectomies? It might be better as a specialty to set a goal of high (> 95%) minimally invasive reliability for certain tumors, see who gets there first safely and efficiently, and then emulate those systems. Unfortunately, retrospective databases don’t have the variables needed to adequately tease out the effects of approach from the dynamic, complex surgical systems that support them.

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Demmy, T.L. The Musician, Instrument, or Orchestra?. Ann Surg Oncol 27, 4088–4090 (2020). https://doi.org/10.1245/s10434-020-08811-0

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