What is most important in improving outcomes after pulmonary lobectomy: the surgeon or the approach?

The development and growth of video-assisted thoracic surgery (VATS) lobectomy have made a major impact on the delivery of major thoracic surgical procedures. With the advent of VATS procedures, simple techniques of pleural assessment, lung biopsy and surgical management of spontaneous pneumothorax were rapidly adopted by a majority of thoracic surgeons, with a clear benefit to patients. On the other hand, the evolution of more complex VATS surgery, such as lobectomy and mediastinal tumour resections, has been more slowly accepted and applied, due to a more complicated surgical learning curve, questions about perceived benefits and concerns about safety and efficacy. There are now a plethora of institutional case series, as well as larger analyses of clinical and administrative databases, that establish the safety and efficacy of VATS lobectomy and also suggest a clinical benefit of decreased complications and hospital length of stay (LOS). In this journal issue, Paul et al. [1] have published one of the broadest examinations comparing VATS with open lobectomy using the Nationwide Inpatient Sample Database in the USA. They examined outcomes of over 68 000 patients who underwent lobectomy over a 2-year period (2007– 08). Only 15% had their lobectomy performed by VATS, but those that did had a lower rate of cardiac complications, empyema and deep venous thrombosis/pulmonary embolus, and had a significantly shorter hospital LOS. Contrary to other series however, Paul et al. did not find a difference between VATS and open lobectomy in operative mortality, respiratory complications, mechanical ventilation or infectious complications. Many find these data compelling enough to argue that the VATS is now the preferred technique for pulmonary lobectomy, and that the continued provision of open lobectomy is inappropriate or unethical, while others criticize the absence of randomized data and the apparent systematic bias in the published comparisons. The development of VATS techniques has had many associated collateral benefits. There have been marked advances in technology, with instruments, staplers and video systems that have allowed more complex VATS procedures, but have also provided improved tools for open surgical procedures. Likewise, the adaptation of VATS techniques has resulted in surgeons learning new approaches to pulmonary dissection, which has strengthened the diversity and creativity of lung resection to the benefit of patients undergoing both VATS and open procedures. However, perhaps the most profound, and yet under-appreciated advances are those made in peri-operative care. Surgeons adapting VATS techniques have simultaneously challenged many of the conventions of patient management after pulmonary resection in an effort to take advantage of the potential benefits of VATS resections. This has occurred simultaneously with efforts to decrease hospital LOS by health plans, insurers and hospitals. Surgeons using VATS have challenged the customs related to the number of chest tubes, duration of chest tubes, indications for chest tube removal and were early adopters of organized care pathways to help standardize post-operative care, while making it more efficient and allowing earlier patient discharge. Just as importantly, patients are provided with very different preoperative instructions regarding timing of discharge, setting the stage for patient expectations and acceptance of a shorter hospital LOS. All of these changes and challenges to the status quo of post-operative management have been beneficial and have the desired effect of shortening hospitalizations. What is less clear is whether the shorter hospital stay reported after VATS lobectomy is due to the performance of the VATS procedure itself, as alleged in each of these published reports, or whether it is due to the parallel changes in patient management championed by VATS advocates. Or maybe it could be both. But it is naive, and unintentionally deceptive, to not recognize and acknowledge important simultaneous changes in management, utilized more aggressively by VATS surgeons, that may be the dominant or sole factor decreasing hospital LOS in series of VATS lobectomy. There are other unmeasured biases tarnishing the comparisons of VATS with open lobectomy in the absence of a randomized comparison. First, it is well understood, and widely acknowledged, that VATS lobectomies are more often performed in patients with smaller, lower-stage and more peripheral tumours, and that this variability even occurs within a given tumour stage. The paper by Paul et al. [1] does not include any staging or cancer outcomes (these data are not available within the National Inpatient Sample) and the authors rightly note this