Robotic-assisted thoracic surgery training in France: a nation-wide survey from young surgeons.

OBJECTIVES: Evaluate theoretical and practical training of thoracic surgeons-in-training in robotic-assisted thoracic surgery (RATS) in France. METHODS: A survey was distributed to thoracic surgeons-in-training in France from November 2022 to February 2023. RESULTS: We recruited 101 thoracic surgeons-in-training (77% response rate). Over half had access to a surgical robotics system at their current institution. Most (74%) considered robotic surgery training essential, 90% had attended a robotic procedure. Only 18% had performed a complete thoracic robotic procedure as the main operator. A complete RATS procedure was performed by 42% of fellows and 6% of residents. Of the remaining surgeons, 23% had performed part of a robotic procedure. Theoretical courses and simulation are well developed; 72% of residents and 91% of fellows had undergone simulation training in the operating room, at training facilities, or during congress amounting to <10 h (for 73% of the fellows and residents), 10-20 h (17%), 20-30 h (8%) or >30 h (3%). Access to RATS was ≥1 day/week in 71% of thoracic departments with robotic access. Fellows spent a median of 2 (IQR 1-3) semesters in departments performing robotic surgery. Compared with low-volume centres, trainees at high-volume centres performed significantly more complete robotic procedures (47% vs 13%; P = 0.001), as did fellows compared with residents. CONCLUSIONS: Few young surgeons perform complete thoracic robotic procedures during practical training, and access remains centre dependent. Opportunities increase with seniority and exposure; however, increasing availability of robotic devices, theoretical formation, and simulation courses will increase opportunities.

Impact of robotic access on outcomes after lung cancer surgery in France: Analysis from the Epithor database.

Introduction: We aimed to compare postoperative outcomes after pulmonary resection for lung cancer after open thoracotomy (OT), video-assisted (VATS), and robotic-assisted (RA) thoracic surgery using a propensity score analysis. Methods: From 2010 to 2020, 38,423 patients underwent resection for lung cancer. In total, 58.05% (n = 22,306) were operated by thoracotomy, 35.35% (n = 13,581) by VATS, and 6.6% (n = 2536) by RA. A propensity score was used to create balanced groups with weighting. End points were in-hospital mortality, postoperative complications, and length of hospital stay, reported by odds ratios (ORs) and 95% confidence intervals (CIs). Results: VATS decreased in-hospital mortality compared with OT (OR, 0.64; 95% CI, 0.58-0.79; P < .0001) but not compared with RA (OR, 1.09; 95% CI, 0.77-1.52; P = .61). VATS reduced major postoperative complications compared with OT (OR, 0.83; 95% CI, 0.76-0.92; P < .0001) but not RA (OR, 1.01; 95% CI, 0.84-1.21; P = .17). VATS reduced prolonged air leaks rate compared with OT (OR, 0.9; 95% CI, 0.84-0.98; P = .015) but not RA (OR, 1.02; 95% CI, 0.88-1.18; P = .77). As compared with OT, VATS and RA decreased the incidence of atelectasis (respectively: OR, 0.57; 95% CI, 0.50-0.65; P < .0001 and OR, 0.75; 95% CI, 0.60-0.95; P = .016); the incidence of pneumonia (OR, 0.75; 95% CI, 0.67-0.83; P < .0001 and OR, 0.62; 95% CI, 0.50-0.78; P < .0001); and the number of postoperative arrhythmias (OR, 0.69; 95% CI, 0.61-0.78; P < .0001 and OR, 0.75; 95% CI, 0.59-0.96; P = .024). Both VATS and RA resulted in shorter hospital stays (-1.91 days [-2.24; -1.58]; P < .0001 and -2.73 days [-3.1; -2.36]; P < .0001, respectively). Conclusions: RA appeared to decrease postoperative pulmonary complications as well as VATS compared with OT. VATS decreased postoperative mortality as compared with RA and OT.

Interest of anatomical segmentectomy over lobectomy for lung cancer: a nationwide study.

BACKGROUND: Anatomical segmentectomy is an alternative to lobectomy for early-stage lung cancer (LC) or in patients at high risk. The main objective of this study was to compare the morbidity and mortality associated with these two types of pulmonary resection using data from the French National Epithor database. METHODS: All patients who underwent lobectomy or segmentectomy for early-stage LC from January 1st 2014 to December 31st 2016 were identified in the Epithor database. The primary endpoint was morbidity; the secondary endpoint was postoperative mortality. Propensity score matching was implemented and used to balance groups. The results were reported as odds ratios (OR) and 95% confidence intervals (CI). RESULTS: During the study period, 1,604 segmentectomies (9.78%) and 14,786 lobectomies (90.22%) were performed. After matching, the segmentectomy group experienced significantly less atelectasis (OR 0.54; 95% CI: 0.4-0.75, P<0.0001), pneumonia (OR 0.72; 95% CI: 0.55-0.95, P=0.02), prolonged air leaks (OR 0.75; 95% CI: 0.64-0.89, P=0.001) or bronchopleural fistula (OR 0.35; 95% CI: 0.14-0.83, P=0.017), and fewer patients had at least one complication (OR 0.7; 95% CI: 0.62-0.78, P<0.0001). According to the Clavien-Dindo classification, postoperative complications were significantly less severe in the segmentectomy group (OR 0.52; 95% CI: 0.37-0.74, P<0.0001). There was no significant difference in postoperative mortality at 30 days (OR 0.67; 95% CI: 0.38-1.20, P=0.18), 60 days (OR 0.78; 95% CI: 0.42-1.47, P=0.4), or 90 days (OR 0.77; 95% CI: 0.45-1.34, P=0.36). CONCLUSIONS: Anatomical segmentectomy is an alternative surgical approach that could reduce postoperative morbidity, but it does not appear to affect mortality.

Impact of video-assisted thoracic surgery approach on postoperative mortality after lobectomy in octogenarians.

OBJECTIVE: The number of octogenarians who present with localized lung cancer eligible for surgical resection is increasing. Video-assisted thoracic surgery lobectomy has been widely accepted, but the potential benefit in octogenarians is not well established, especially for postoperative mortality. This study aimed to assess the impact of a video-assisted thoracic surgery approach on postoperative mortality after lobectomy for lung cancer in octogenarians. METHODS: From January 2005 to December 2016, all patients aged more than 80 years who received lobectomy treatment for lung cancer were retrieved from the French Administrative Database. The end point was 30-day postoperative death. A propensity score was generated with 16 pretreatment variables and used to create balanced groups with matching (578 matches 1:1). Results are reported as odds ratios and 95% confidence intervals. RESULTS: Of the 75,892 patients operated for lobectomy during this period, 3560 were octogenarians. Video-assisted thoracic surgery was performed in 16.7% (n = 597) of cases, and thoracotomy was performed in 83.23% (n = 2963) of cases. From 2005 to 2016, the number of patients aged more than 80 years who were operated for lung cancer increased from 160 to 456 patients per year, and the proportion of lobectomy performed by video-assisted thoracic surgery increased as well (from 3.13% to 37.28%). Unmatched postoperative mortality was 3.85% (n = 23) for video-assisted thoracic surgery versus 7.9% (n = 234) for thoracotomy (P < .0001). Matched postoperative mortality was significantly lower in the video-assisted thoracic surgery approach with an odds ratio of 0.51 (95% confidence interval, 0.27-0.96; P = .038). CONCLUSIONS: Video-assisted thoracic surgery was significantly associated with reduced postoperative mortality compared with open thoracotomy after lobectomy for lung cancer in octogenarians.

Does age over 80 years have to be a contraindication for lung cancer surgery-a nationwide database study.

BACKGROUND: Nowadays surgery remains the best treatment for localized lung cancer (LC). However, patients over 80 years old are often denied surgery because of the postoperative risk of death. This study aimed to estimate in-hospital mortality (IHM) and determine whether age over 80 is the most important predictor of IHM after LC surgery. METHODS: From January 2005 to December 2015, 97,440 patients, including 4,438 patients over 80 years old, were operated on for LC and recorded in the French Administrative Database. Characteristics of patients, hospitals and surgery were analysed. RESULTS: Crude IHM was 3.73% (n=3,639) and 7.77% (n=345) for the over 80s vs. 3.54% (n=3,294) for younger patients (P<0.0001). In multivariate analysis, predictive factors for IHM with the odds ratios (OR) were: 2.60 for age ≥80 (95% CI: 2.30-2.94; P=0.0001), 5.85 for a previous liver disease (95% CI: 4.79-7.16; P=0.0001) and 5 for previous lung disease (95% CI: 4.25-5.9; P=0.0001). IHM was also linked to hospital volume with an OR of 0.75 (95% CI: 0.69-0.81; P=0.0001) and a linear decrease for predicted IHM according to hospital volume for the over 80s. Adjusted ORs were 1.15 (95% CI: 0.96-1.4; P=0.0116) for lobectomy, 2.18 for bilobectomy (95% CI: 1.7-2.8; P=0.0001) and 3.83 (95% CI: 3.2-4.6; P=0.0001) for pneumonectomy. CONCLUSIONS: Concerning IHM, age ≥80 had a lower weight than did a previous pulmonary or liver disease and the type of pulmonary resection. Patients over 80s with localized LC and no significant comorbidities should be referred for surgery if lobectomy or sublobar resection could be performed.