Crisis of confidence in cardiothoracic trainees: National trends in the use of minimally invasive esophagectomy

摘要

Central MessageAlthough minimally invasive esophagectomy is becoming pervasive, use varies geographically and is less common at teaching hospitals, contributing to a crisis of confidence for cardiothoracic trainees.See Commentary on page 195. Although minimally invasive esophagectomy is becoming pervasive, use varies geographically and is less common at teaching hospitals, contributing to a crisis of confidence for cardiothoracic trainees. See Commentary on page 195. Esophagectomy is highly morbid. Although overall survival has improved with centralization of care, postoperative morbidity has been quoted as approaching 60%.1Dimick J.B. Cattaneo S.M. Lipsett P.A. Pronovost P.J. Heitmiller R.F. Hospital volume is related to clinical and economic outcomes of esophageal resection in Maryland.Ann Thorac Surg. 2001; 72 (discussion 339-41): 334-339Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar,2Merritt R.E. Kneuretz P.J. D'Souza D.M. Abdel-Rasoul M. Perry K.A. An analysis of outcomes after transition from open to minimally invasive Ivor Lewis esophagectomy.Ann Thorac Surg. September 1, 2020; ([Epub ahead of print])Google Scholar However, a recent multicenter randomized controlled trial reported a 77% reduction in major complications with hybrid minimally invasive esophagectomy compared with an open approach.3Mariette C. Markar S.R. Dabakuyo-Yonli T.S. Meunier B. Pezet D. Collet D. et al.Hybrid minimally invasive esophagectomy for esophageal cancer.N Engl J Med. 2019; 380: 152-162Crossref PubMed Scopus (213) Google Scholar Furthermore, randomized data support lower pulmonary morbidity following minimally invasive esophagectomy.4Biere S.S. van Berge Henegouwen M.I. Maas K.W. Bonavina L. Rosman C. Garcia J.R. et al.Minimally invasive versus open oesaphectomy for patients with esophageal cancer: a multicentre, open-label, randomized control trial.Lancet. 2012; 379: 1887-1892Abstract Full Text Full Text PDF PubMed Scopus (932) Google Scholar Despite these convincing data, a survey of recent cardiothoracic graduates suggested a crisis of confidence in performing minimally invasive esophagectomy.5Rothenberg P.E. Hughes B.D. Amirkhosravi F. Onaiwu B.P. Okereke I.C. Factors during training which predict future use of minimally invasive thoracic surgery.Ann Med Surg (Lond). 2018; 35: 149-152Crossref PubMed Scopus (2) Google Scholar Trainees identified attributed poor operative exposure as a significant contributing factor. We sought to examine national trends in the use of minimally invasive esophagectomy, focusing on characteristics of the institutions at which these procedures are performed. We conducted a retrospective analysis using Medicare data on esophagectomies performed in the United States between 2016 and 2018. Data were organized by operative approach (open vs minimally invasive/hybrid and transhiatal vs Ivor Lewis). Descriptive statistics were used to assess operative technique based on hospital factors, including geographic region and classification as a teaching institution. We examined 26,455 esophagectomies performed during the study period, 13,667 (51%) of which were transhiatal. Overall, 58% of transhiatal esophagectomies and 63% of Ivor Lewis esophagectomies were performed minimally invasively. The use of minimally invasive surgery increased over time and was more common at nonteaching hospitals. In 2016, 1246 (58%) of the transhiatal procedures performed at nonteaching hospitals used a minimally invasive technique, compared with 50% of those performed at teaching hospitals. This finding persisted over time, with a minimally invasive approach representing 69% of transhiatal procedures performed at nonteaching hospitals and 59% of those performed at teaching hospitals in 2018. A similar trend was found for Ivor Lewis esophagectomy (Figure 1). Operative technique varied geographically, with minimally invasive Ivor Lewis more common in the northeast US (69%) compared with the western US (69% vs 59%). Our d