Proficiency of Robotic Lobectomy Based on Prior Surgical Technique in The Society of Thoracic Surgeons General Thoracic Database

doi:10.1016/j.athoracsur.2019.04.046

The Annals of Thoracic Surgery

Volume 108, Issue 4, October 2019, Pages 1013-1020

Presented at the Sixty-fifth Annual Meeting of The Southern Thoracic Surgical Association, Amelia Island, FL, Nov 7-10, 2018.

https://doi.org/10.1016/j.athoracsur.2019.04.046 Get rights and content

Background

Robotic lobectomy represents a paradigm shift for many surgeons. It is unknown if a surgeon’s prior operative approach influences development of proficiency. We compared outcomes based on prior lobectomy experience and used cumulative sum analysis to assess proficiency.

Methods

Using The Society of Thoracic Surgeons General Thoracic Database we grouped surgeons as de novo, open-to-robotic, or video-assisted thoracoscopic surgery (VATS)-to-robotic. Operative time, blood transfusion, mortality, and major morbidity were primary outcomes. Unacceptable and acceptable thresholds were determined by review of the literature. Proficiency was defined as 20 consecutive cases without crossing an upper control line. Surgeons were assessed individually, and proficiency was assessed by transition group.

Results

From 2009 to 2016, 271 surgeons performed 5619 robotic lobectomies for clinical stage I/II non–small cell lung cancer. Of these, 65 surgeons (24%) performed ≥20 lobectomies (4483 cases). Initial proficiency for an operative time target of 250 minutes was 40% for de novo compared with 14% for open-to-robotic and 21% for VATS-to-robotic surgeons, with improvement to 47%, 29%, and 21%, respectively, after 20 cases. Initial and sustained proficiency related to major morbidity was similar for open-to-robotic and VATS-to-robotic but lower for de novo at 40%. After 20 cases most were proficient (de novo, 93%; open-to-robotic, 100%; and VATS-to-robotic, 86%). Proficiency for 30-day mortality and blood transfusion was high in all groups.

Conclusions

Outcomes among all transition groups improved with experience. Operating room duration proficiency was challenging for all groups. Cumulative sum may be useful to monitor proficiency in not only subsequent studies but in clinical practice.

Section snippets

Patients and Methods

The institutional review board of the Swedish Medical Center approved this study with a waiver of individual participant and patient consent because of the retrospective use of deidentified data.

Results

Over the study period robotic lobectomy increased as a proportion of lobectomies from <1% in 2009 to 18.1% in 2016 (Figure 3). Open lobectomy decreased from 53.3% to 28.0%, with the proportion of VATS lobectomies stabilizing between 2014 and 2016.

The 65 surgeons completing 4483 robotic lobectomies were divided into transition groups: 15 DNS (1119 lobectomies), 21 ORS (1511 lobectomies), and 29 VRS (1853 lobectomies). A higher proportion of patients in the DNS group were women; however body mass

Comment

The primary finding in this study is that a surgeon’s previous approach to lobectomy does not exert a uniform effect on development of proficiency during transition to robotic lobectomy. Initial and sustained proficiency varied for each outcome metric, but all transition groups improved with increasing experience, resulting in quality being maintained during the transition. For 30-day mortality and transfusion all groups demonstrated high early and consistent proficiency. Comparatively

References (21)

B.E. Louie et al.
Early experience with robotic lung resection results in similar operative outcomes and morbidity when compared with matched video- assisted thoracoscopic surgery cases
Ann Thorac Surg
(2012)
B.E. Lee et al.
Transitioning from video-assisted thoracic surgical lobectomy to robotics for lung cancer: are there outcomes advantages ?
J Thorac Cardiovasc Surg
(2014)
A. Pardolesi et al.
Robotic anatomic segmentectomy of the lung: technical aspects and initial results
Ann Thorac Surg
(2012)
B.E. Louie et al.
Comparison of video-assisted thoracoscopic surgery and robotic approaches for clinical stage I and stage II non-small cell lung cancer using The Society of Thoracic Surgeons Database
Ann Thorac Surg
(2016)
V. Puri et al.
Defining proficiency for The Society of Thoracic Surgeons participants performing thoracoscopic lobectomy
Ann Thorac Surg
(2019)
Y. Hu et al.
Cumulative sum: a proficiency metric for basic endoscopic training
J Surg Res
(2014)
H.M. Waller et al.
Cumulative sum (Cusum) analysis provides an objective measure of competency during training in endoscopic retrograde
HPB (Oxford)
(2009)
S.A. Deen et al.
Defining the cost of care for lobectomy and segmentectomy: a comparison of open, video-assisted thoracoscopic, and robotic approaches
Ann Thorac Surg
(2014)
D.S. Oh et al.
Thoracoscopic and open lobectomy : propensity-matched analysis of recent premier data
Ann Thorac Surg
(2018)
R. Rajaram et al.
Nationwide assessment of robotic
Ann Thorac Surg
(2018)

There are more references available in the full text version of this article.

Cited by (24)

Surgeon Experience Is Associated With Prolonged Air Leak After Robotic-assisted Pulmonary Lobectomy
2022, Annals of Thoracic Surgery
Citation Excerpt :
Although surgeon comfort and adaptability are important, we have shown objective data that an experience of 50 cases is an important benchmark and is related directly to surgeon proficiency. Interestingly, this finding is consistent with McKenna’s 2008 published guide for VATS lobectomy, in which the consensus learning curve was 50 cases,30 as well as data from Swedish Cancer Center showing proficiency for robotic thoracic operations occurring after 50 cases.15 On the basis of these data, it appears that 50 cases may represent an important benchmark for surgeon proficiency in adopting a novel surgical approach to anatomic pulmonary lobectomy.
Prolonged air leak (PAL) (>5 days) after robotic-assisted pulmonary lobectomy is a significant complication. This study aimed to determine patient- and surgeon-related factors that can predict PAL after robotic lobectomy for lung cancer.
This study was a retrospective review of a single-center experience of robotic-assisted lobectomy for lung cancer. Perioperative variables, including surgeon case experience, patient demographics, diffusion capacity of lung for carbon monoxide, forced expiratory volume in 1 second, body mass index, and smoking status were evaluated.
A total of 305 robotic-assisted lobectomies performed by 4 surgeons met inclusion criteria from June 2016 to February 2019. The 30-day postoperative mortality was 1.2%. PAL developed in 27 of 305 (8.8%) patients. Surgeons’ robotic experience was grouped by 10-case increments. When adjusted for age and sex, the odds for PAL decreased by 15% for every 10 robotic lobectomies the surgeons performed (odds ratio [OR], 0.85; 95% CI, 0.74-0.99; P = .0384). Logistic regression models showed a linear transition curve at the 50th case. Female sex (OR, 2.62; 95% CI, 1.03-6.69; P = .0314) and younger age (OR, 0.61; 95% CI, 0.41-0.91; P = .0184) were statistically significant risk factors for PAL. Cumulative sum analysis similarly showed a strong association between experience and PAL. Preoperative diffusing capacity of lung for carbon monoxide, forced expiratory volume in 1 second, body mass index, and smoking status were not statistically significant predictive factors.
These results show that surgeon robotic case experience is associated with the rate of postoperative PAL: as the number of robotic lobectomies increases, the rate of PAL significantly decreases. It is imperative to emphasize that a learning curve exists for this approach that directly affects patient outcomes.
The Society of Thoracic Surgeons General Thoracic Surgery Database: Research Applications and Results
2020, Journal of Cardiothoracic and Vascular Anesthesia
Robotic Thoracic Surgery
2020, Surgical Clinics of North America
Citation Excerpt :
Whether there are advantages with regard to hospital length of stay or postoperative pain control remains controversial and is institution dependent. Similar to VATS procedures, the proficiency of robotic lung resection is realized with increased surgeon experience.46,47 In addition, hospital volume is directly correlated with length of stay and mortality; therefore, incorporating robotic lung resection into one’s practice should be more structured than just an occasional attempt at using the system.48
United States Administrative Databases and Cancer Registries for Thoracic Surgery Health Services Research
2020, Annals of Thoracic Surgery
Citation Excerpt :
Of importance, these composite scores focus on outcome measures, rather than process measures, when classifying the quality of a program37 and can be used for voluntary public reporting.40 Because of its robust, high-quality data specifically focused on thoracic surgery, the STS-GTSD has been a rich data source for thoracic surgery health services research.41-45 The STS-GTSD includes comprehensive data on patient demographic characteristics (ie, age, race, sex, insurance status, and comorbidities), preoperative evaluation (ie, diagnostic testing and clinical staging), operative details (ie, length of surgery, approach, and need for conversion), pathologic data (including completeness of resection and number of lymph nodes evaluated), perioperative outcomes, and vital status at 30 days.
Data from administrative claims and cancer registries have an ever-expanding role in thoracic surgery health services and health policy research. However, their strengths, limitations, and appropriate applications are often poorly understood, leading to errors in study design and data interpretation. The intent of this review is to discuss relevant and crucial considerations when conducting research with some of the most common national thoracic surgery data sources.
Information on the National Cancer Database; National Inpatient Sample; American College of Surgeons National Surgical Quality Improvement Project; Surveillance, Epidemiology, and End Results (SEER) Database; SEER-linked databases; The Society of Thoracic Surgery General Thoracic Surgery Database; and state cancer registries were obtained from the official webpages for these databases and from a review of PubMed (1990 to July 1, 2019).
We provided a review of the above-mentioned commonly used administrative databases and cancer registries in thoracic surgery health services research, with particular attention toward their strengths and limitations.
An appreciation of the strengths, limitations, and differences between various sources of data from administrative, hospital-based, and population-based cancer registries is equally essential for investigators to improve the quality and accuracy of their research and for readers to properly interpret the results of such studies.
The Society of Thoracic Surgeons General Thoracic Surgery Database: 2019 Update on Research
2019, Annals of Thoracic Surgery
Citation Excerpt :
On the basis of the data analysis on tracheal resections, the newer version of the GTSD contains a tracheal surgery module that expands the data fields to include more perioperative and procedural details. Feczko and colleagues9 used the GTSD to evaluate how a surgeon’s prior lobectomy experience affected his or her transition to robotic lobectomy. Surgeons were categorized into 3 groups: de novo robotic surgeons (DNS), open-to-robotic (ORS), and VATS-to-robotic (VRS).
The Society of Thoracic Surgeons (STS) Workforce on Research Development and the STS Research Center currently offer 3 outcomes research platforms using the STS General Thoracic Surgery Database: (1) the traditional Access and Publications Program supports STS-sponsored projects with data analysis conducted at an STS-approved data analytic center, (2) the STS Task Force for Funded Research supports STS investigators pursuing extramural research funding for projects incorporating STS National Database data linked to other data sets such as Centers for Medicare and Medicaid Services, and (3) the Participant User File (PUF) program that provides deidentified patient-level data files from the STS General Thoracic Surgery Database to investigators with approved projects to be analyzed at their institution. This report includes an updated review of each program in addition to an outline of 2019-based articles published or accepted.
Elevated respiratory complications following robotic-assisted lobectomy: A national cohort analysis of 26,140 cases
2024, International Journal of Medical Robotics and Computer Assisted Surgery

View all citing articles on Scopus

View full text

Original articleGeneral thoracicProficiency of Robotic Lobectomy Based on Prior Surgical Technique in The Society of Thoracic Surgeons General Thoracic Database

Background

Methods

Results

Conclusions

Section snippets

Patients and Methods

Results

Comment

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

J Surg Res

HPB (Oxford)

Ann Thorac Surg

Thoracoscopic and open lobectomy : propensity-matched analysis of recent premier data

Ann Thorac Surg

Nationwide assessment of robotic

Ann Thorac Surg

Original article
General thoracic
Proficiency of Robotic Lobectomy Based on Prior Surgical Technique in The Society of Thoracic Surgeons General Thoracic Database

Thoracoscopic and open lobectomy : propensity-matched analysis of recent premier data