Author
Database
Time period
Total patients
VATS patients
Paul [4]
STS
2002–2007
6,323
20 %
Paul [5]
SEER
2007–2009
6,008
22 %
Farivar [6]
STS
2010–2011
10,525
44 %
Mungo [7]
NSQIP
2005–2012
6,567
37 %
Harrison [8]
NIS
2008–2011
19,353
32 %
Kent [9]
SID
2008–2010
33,095
38 %
Assessment of the frequency of MIS resections performed in Europe is a little more difficult because of the fragmented nature of the data. A review of published results demonstrates surprising differences among countries in the use of VATS for lobectomy. The EPITHOR project in France demonstrated a fourfold increase in the use of VATS for lobectomy from 2005 to 2012, culminating in an incidence of nearly 11 % [10]. In Denmark from 2007 to 2011, clinical stage I lung cancer was treated by VATS lobectomy in 47 % of patients [11]. The European Society of Thoracic Surgeons (ESTS) Database, a large voluntary effort including nearly all European countries, demonstrates a very variable penetration of VATS techniques at present, with Denmark having the highest percentage and many countries lacking centers of excellence [12]. The overall rate is between 10 % and 15 % (Table 1.2) [10–14].
Table 1.2
Frequency of use of VATS for lobectomy in European databases
Author | Database | Time period | Total patients | VATS patients |
|---|---|---|---|---|
Thorsteinsson [13] | Iceland | 1994–2008 | 404 | 0 % |
Licht [11] | DLCR | 2007–2011 | 2,230 | 47 % |
Morgant [10] | Epithor | 2005–2012 | 34,006 | 3.2 % |
Begum [12] | ESTS | 2010–2012 | Not stated | 11.3 % |
Falcoz [14] | ESTS | 2007–2013 | 28,771 | 9.5 % |
The rates of VATS use for lobectomy in other developed countries are difficult to determine. From an analysis of the literature, no nationwide databases reporting such results were available from Japan, Taiwan, South Korea, or Australia.
1.4 Minimally Invasive Esophagectomy (MIE)
The very low relative frequency of esophageal cancer compared to lung cancer, especially in Western countries, makes identification of rates of MIE quite difficult. In a survey of esophageal surgeons reported in 2010, the frequency of minimally invasive approaches worldwide was about 30 %. This figure varied considerably according to surgeon specialty, being highest for general surgeons (57 %) and lowest for surgical oncologists and cardiothoracic surgeons (20 %) [15]. Data from the STS Database for 2001–2011 indicate that 14 % of patients underwent MIE [16]. In Japan in 2011, the frequency of hybrid or totally minimally invasive esophagectomy was 33 % [17]. From these limited data it appears that the acceptance of minimally invasive approaches in developed countries remains limited.
1.5 Growth of MIS Thoracic Surgery in Developing Countries
Penetration of minimally invasive techniques into developing countries is very uneven. Obstacles to growth include lack of resources (equipment for thoracoscopy or laparoscopy; trained support staff; non-specialist anesthesiologists) and lack of training for surgeons. Whereas in most developed countries trainee instruction in thoracic MIS is routine and usually required, such is not the case in many developing countries. In centers of excellence that have high volumes of practice, particularly in India and China, VATS lobectomy and MIE are routine. In such centers more than 80 % of lobectomies are performed using VATS, and more than 90 % of esophagectomies are done via MIE.
1.6 Status of MIS Thoracic Surgery
There can be little doubt that VATS lobectomy and MIE are accepted as standard approaches to surgery for lung and esophageal cancer. The chapters in this atlas clearly identify outcomes after MIS and demonstrate numerous advantages over open surgery. Short-term benefits have been conclusively demonstrated, oncologic equivalence in terms of nodal harvest is similar to open operations, and oncologic equivalence in terms of long-term survival is apparent. What remains to be fully elucidated is relative costs, or cost-effectiveness, particularly for robotic thoracic MIS.
1.7 Future Areas of Study
Complex minimally invasive thoracic surgery was introduced in the early 1990s, less than 25 years before the publication of this atlas. In that short span of time its growth and acceptance have been remarkable. We can anticipate continued growth of this application in the developing world, and will also see rapid advancement in a variety of elements of MIS, including education, technology, and outcomes (Table 1.3).
Table 1.3
Target areas for future study of thoracic minimally invasive surgery
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