Is CT surgery dying out/worth going into?

[dienekes88]

But how many ECMO cases are there really? Not that many. Certainly not enough to support a large workforce of surgeons in the future

Also one of my nurses just took a rep job for some endovascular placed VAD the cardiologists are doing (which blows my mind), so even that isn't a safe harbor for CTVS apparently

Depends on how ECMO is utilized. There are people who do all lung transplants on ECMO, so that beefs the numbers up a bit.

Would be curious which device. As below, it sounds like an Impella. A lot of issues with hemolysis and device malposition.

Big centers can have well over 100 ECMO runs per year. As far as the endovascular VAD you’re referring to, it’s probably an Impella CP, which cards can place in the cath lab, but doesn’t provide the same degree of support as the surgically implanted Impella 5.5 or ECMO. They all operate along a spectrum of support provided, one doesn’t necessarily replace the other.

I think the important thing to note is not so much that surgeons are needed for the bigger devices but that Impella devices are only approved for short term support and for LV decompression in patients on ECMO. Its not like you can get an impella and walk home to go about your business. You're stuck to a device that sits at the bedside.

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[droliver]

Big centers can have well over 100 ECMO runs per year

Depends on how ECMO is utilized. There are people who do all lung transplants on ECMO, so that beefs the numbers up a bit.

It's not really "big centers" being discussed here though.
Tertiary referral centers will still need a stable workforce and capability to do ECMO and transplant and less common cardiac and thoracic procedures. ECMO is not a high volume procedure at most community programs.

It's the at large work force needs scattered around community hospitals where you see CV groups collapsing/contracting in my observations, training and working in 3 metro areas between 1-2M. The #'s of cases are collapsing for those guys with many hospitals maybe only having 1 or 2 full time surgeon where 20 years ago it was supporting a group of 4-5.

 

[ESU_MD]

I dont think there is anything wrong with a conventional open lobectomy. It is still an excellent operation and I think the robotic/VATS procedures have not significantly changed outcomes, pain scores, etc. Most cardiac surgeons can do a lobectomy through an incision the same size as a utility port for the robot not to mention in alot less time.

that being said, the forces to separate cardiac from thoracic will continue to exist. but in a community practice, alot of us have to still do both

 

[dienekes88]

It's not really "big centers" being discussed here though.
Tertiary referral centers will still need a stable workforce and capability to do ECMO and transplant and less common cardiac and thoracic procedures. ECMO is not a high volume procedure at most community programs.

It's the at large work force needs scattered around community hospitals where you see CV groups collapsing/contracting in my observations, training and working in 3 metro areas between 1-2M. The #'s of cases are collapsing for those guys with many hospitals maybe only having 1 or 2 full time surgeon where 20 years ago it was supporting a group of 4-5.

Probably a fair point. As I said earlier. The days of the cardiac surgeon doing chip shot CABGs and AVRs and clearing 7 figures are over.

There's also increasingly consolidation of programs with the medium sized programs getting bigger, and the bigger programs getting huge. Also gone are the days of a surgeon going out into the community and hanging up his own shingle and doing 100 cases per year.

I dont think there is anything wrong with a conventional open lobectomy. It is still an excellent operation and I think the robotic/VATS procedures have not significantly changed outcomes, pain scores, etc. Most cardiac surgeons can do a lobectomy through an incision the same size as a utility port for the robot not to mention in alot less time.

that being said, the forces to separate cardiac from thoracic will continue to exist. but in a community practice, alot of us have to still do both

I think the robot is largely unnecessary in thoracic surgery.

I will admit that the data would support what you say, but i seem to recall the average VATS lobe leaving the hospital on POD 2... the open lobe didn't even have the epidural out before then. I think there's just a large amount of variability with what people are doing when it comes to VATS (interestingly, the same argument people make about OPCAB), and this is what contaminates the data. Beyond that, with the right setup... I do think a VATS lobe can be faster than an open lobe just by virtue of having less incision to close.

 

[CTFellowMD]

I dont think there is anything wrong with a conventional open lobectomy. It is still an excellent operation and I think the robotic/VATS procedures have not significantly changed outcomes, pain scores, etc. Most cardiac surgeons can do a lobectomy through an incision the same size as a utility port for the robot not to mention in alot less time.

that being said, the forces to separate cardiac from thoracic will continue to exist. but in a community practice, alot of us have to still do both

I think the robot is largely unnecessary in thoracic surgery.

I will admit that the data would support what you say, but i seem to recall the average VATS lobe leaving the hospital on POD 2... the open lobe didn't even have the epidural out before then. I think there's just a large amount of variability with what people are doing when it comes to VATS (interestingly, the same argument people make about OPCAB), and this is what contaminates the data. Beyond that, with the right setup... I do think a VATS lobe can be faster than an open lobe just by virtue of having less incision to close.

All I can say is Ugh.

Want to argue that Vats is equivalent to Robot? Sure. That argument is still on going. Big difference is the ability to do more complex cases robotically compared to VATS - chest wall resections, sleeves, post-radiation, etc. Major outcome that is consistently shown in the literature that is different is a lower conversion rate to thoracotomy for robotic.

The thoracotomy vs robot/VATS argument on the other hand has long been settled. Oncologic outcomes are the same, but you get less, pain, shorter length of stay, less blood loss, and fewer postoperative complications with minimally invasive approach. So yes. There is very much something wrong with conventional open lobectomy for early stage lung cancer. Thats like saying there is nothing wrong with doing an open cholecystectomy for routine gallbladder issues in 2022.

As far as an incision the same size as a utility port for the robot? Are you serious? There is no "utility port" for robotics. Most use a 12mm air seal port, and that gets extended to approximately 2cm for specimen extraction.

If you want to treat both cardiac and general thoracic issues in the community - that's perfectly fine. If you are offering early stage lung cancers only thoracotomy and spreading this false info that results are equivalent to VATS/Robotic, then please, just stop.

 

[Surgeon D.O.]

What kinds of places / locations do you see CT surgeons doing the old school cardiac, thoracic and light vascular work?

 

[deleted50541]

What kinds of places / locations do you see CT surgeons doing the old school cardiac, thoracic and light vascular work?

In practice? In my experience, that model is relegated to mainly non-academic centers with older CT surgeons who mostly focus on cardiac and do thoracic/"light' vascular as it comes.

In training at teaching institutions, cardiac and thoracic have really become separate sub-specialties. Though I maintain that both are important to learn whichever path one should choose and I don't foresee that changing anytime soon.

A few traditional fellowship programs still incorporate vascular surgery into the training, but it's not the norm. I can't speak for what the I-6 programs are doing. Nonetheless, endovascular skills have become a training requirement in the cardiac path, though I don't know how common it is for CT trainees to be doing things like CEAs, fistulas, or vascular access. Nor would I expect that to be a job requirement with the proliferation of vascular surgery as its own specialty.

 

[dienekes88]

All I can say is Ugh.

Want to argue that Vats is equivalent to Robot? Sure. That argument is still on going. Big difference is the ability to do more complex cases robotically compared to VATS - chest wall resections, sleeves, post-radiation, etc. Major outcome that is consistently shown in the literature that is different is a lower conversion rate to thoracotomy for robotic.

The thoracotomy vs robot/VATS argument on the other hand has long been settled. Oncologic outcomes are the same, but you get less, pain, shorter length of stay, less blood loss, and fewer postoperative complications with minimally invasive approach. So yes. There is very much something wrong with conventional open lobectomy for early stage lung cancer. Thats like saying there is nothing wrong with doing an open cholecystectomy for routine gallbladder issues in 2022.

As far as an incision the same size as a utility port for the robot? Are you serious? There is no "utility port" for robotics. Most use a 12mm air seal port, and that gets extended to approximately 2cm for specimen extraction.

If you want to treat both cardiac and general thoracic issues in the community - that's perfectly fine. If you are offering early stage lung cancers only thoracotomy and spreading this false info that results are equivalent to VATS/Robotic, then please, just stop.

I'm a bit behind the times when it comes to thoracic, but I find this pretty interesting. As recently as 2019-2021 there were still randomized trials being run for open vs. vats (VIOLET) and big data studies being published on the topic, so I'd be interested to hear the current evidence. Back when I was doing those operations despite my personal experience being that VATS patients had LOS that was substantially shorter... the published data was only suggesting a LOS that was 1 day shorter. Pain scores were slightly less. But statistically different and perhaps not clinically important differences.

If the latest studies really do show that VATS and robot are substantially better than open then it just goes to support my point that cardiac surgeons who can't find work won't flood the general thoracic market.

 

[deleted50541]

I'm a bit behind the times when it comes to thoracic, but I find this pretty interesting. As recently as 2019-2021 there were still randomized trials being run for open vs. vats (VIOLET) and big data studies being published on the topic, so I'd be interested to hear the current evidence. Back when I was doing those operations despite my personal experience being that VATS patients had LOS that was substantially shorter... the published data was only suggesting a LOS that was 1 day shorter. Pain scores were slightly less. But statistically different and perhaps not clinically important differences.

If the latest studies really do show that VATS and robot are substantially better than open then it just goes to support my point that cardiac surgeons who can't find work won't flood the general thoracic market.

The debate over minimally invasive vs open lung resections is pretty much over in terms of outcomes. The latest data from the STS GTSD also reflects the change in practice over the last 10 years showing minimally invasive lung and esophageal resections have become the preferred approach among STS participating sites.

The Society of Thoracic Surgeons General Thoracic Surgery Database: 2021 Update on Outcomes and Research

As you note though, it is interesting to see fairly recent studies showing a good proportion of patients still getting open lung resections. My med onc colleagues reviewed with us a pending publication from their recent meeting in support for adjuvant immunotherapy after lung resection. In that study, almost 50% of patients received a thoracotomy. Granted, this study spanned from 2010 to present, which would be more consistent with practice a decade ago, but not now.

 

[texan2414]

If you're going to count every cath you review in front of your attendings as part of an argument to how trained we are in reading caths, my fellowship has two hours of conference time per week dedicated strictly to reading caths, and we go over at least that many per week. I don't really count those, though, because it's kind of ridiculous to claim that reading a study prepared by someone else is in any way analogous to doing the study yourself and making on-the-spot decisions on what to image, how to image it, how to identify anomalous structures, how to spot abnormalities that aren't obvious until you find just the right view, when to inject various intracoronary medications, etc ... not to mention the growing number of tools we use in the cath lab to augment our understanding of coronary pathology (things like IVUS, OCT, FFR/IFR). Again, the idea that a junior I6 resident is better at reading angios than a senior cardiology fellow is Dunning-Kruger on steroids.

Anyway, on the off chance that the I6 program here is an aberration, I looked up a couple other programs for comparison:

Stanford has a grand total of one month for echo/CT/MRI in their program: Rotations

Yale has no dedicated imaging months:

Integrated Six-Year Cardiothoracic Surgery Residency

The Yale School of Medicine offers an ACGME-accredited integrated six-year cardiothoracic surgery residency program. This program is designed to train future

medicine.yale.edu

My understanding was that the I6 programs were created because the field of cardiac surgery was dying and it was hard to convince med students to do 5 years of gen surg and a minimum of 3 years of CTS fellowship just so they could enter a field in decline, so by lowering the time commitment they hoped to attract more candidates - not because cardiac surgeons were clamoring to spend more time reading echos and caths with the cardiologists lol.

Post reeks of ignorance. Cardiac surgeons are just as much technically skilled in percutaneous procedures and diagnostic evaluation as cardiology fellows. This is in addition to their considerable surgical skills that has actual empirical value compared to placing 20 stents that will eventually get occluded requiring eventual surgical bailout.

 

[texan2414]

Ask a CT fellow to perform a TAVR they can easily access groin and deliver the device.
Ask a Cardiology fellow to throw in a purse string suture in aorta for cannulation, I'd love to see the look on their face.

 

[texan2414]

Cardiac surgery is alive and well.
CABG is not going anywhere
TAVR has it's role, but is not designed to be a lifelong solution.

Indeed, CMS recognizes that and reimbursement model for TAVR is built around Heart-Team approach.

In addition to robotic cardiac surgery on the horizon, CT fellows are gaining considerable experience with percutaneous valve procedures. I do see a future where cardiac surgeons will once again begin to take primary ownership of patients, from the initial consult to discharge.

 

[dienekes88]

The debate over minimally invasive vs open lung resections is pretty much over in terms of outcomes. The latest data from the STS GTSD also reflects the change in practice over the last 10 years showing minimally invasive lung and esophageal resections have become the preferred approach among STS participating sites.

The Society of Thoracic Surgeons General Thoracic Surgery Database: 2021 Update on Outcomes and Research

As you note though, it is interesting to see fairly recent studies showing a good proportion of patients still getting open lung resections. My med onc colleagues reviewed with us a pending publication from their recent meeting in support for adjuvant immunotherapy after lung resection. In that study, almost 50% of patients received a thoracotomy. Granted, this study spanned from 2010 to present, which would be more consistent with practice a decade ago, but not now.

Interesting. Well... Just because the technique is preferred by STS participating institutions doesn't mean that the debate is settled. It just means that it is the popular technique. Having said that. I do prefer doing lobes VATS, but most prominently because I used to be able to get them done in about half the time.

If those patients are getting adjuvant, I am guess they were stage 2? I would venture a guess that VATS for stage 2 is still a bit controversial. I think a board safe answer is still VATS or robot for clinical stage 1. Open lobe for clinical stage 2 after invasive mediastinal staging. Back then i feel like it was concerns about potentially challenging lymph nodes in the hilum and the overall belief that VATS was less effective for a complete LN clean out, though this is highly technique dependent and i seem to recall a study showing that MLND wasn't even routine when lobes were being done by surgeons who didn't have a thoracic oncology focus. What's the latest on this?

 

[dienekes88]

Indeed, CMS recognizes that and reimbursement model for TAVR is built around Heart-Team approach.

In addition to robotic cardiac surgery on the horizon, CT fellows are gaining considerable experience with percutaneous valve procedures. I do see a future where cardiac surgeons will once again begin to take primary ownership of patients, from the initial consult to discharge.

I actually don't see a significant value to the robot in cardiac surgery. I think there are people who like to do mitrals with the robot just like there are those who do it via right thoracotomy, but the applicability to cabg and aortic surgery appears limited.

I don't really see surgeons taking primary ownership of the patients in general, i.e. being referred patients directly from the internist and continuing to manage patients, just because it doesn't make sense from an economic standpoint for either the surgeons or the hospitals. As for being the primary person during the index hospitalization for surgery, this is the case in most places I've practiced, so I'm a bit curious about this comment.

 

[deleted50541]

If those patients are getting adjuvant, I am guess they were stage 2? I would venture a guess that VATS for stage 2 is still a bit controversial. I think a board safe answer is still VATS or robot for clinical stage 1. Open lobe for clinical stage 2 after invasive mediastinal staging. Back then i feel like it was concerns about potentially challenging lymph nodes in the hilum and the overall belief that VATS was less effective for a complete LN clean out, though this is highly technique dependent and i seem to recall a study showing that MLND wasn't even routine when lobes were being done by surgeons who didn't have a thoracic oncology focus. What's the latest on this?

When I took the boards a few years ago, whatever technique you were comfortable doing was considered ok. In my practice, I do robot and my partner does VATS (just what we learned in training). It's rare that we do open lung resections unless we're concerned about controlling the hilum. I did a T4N0 left upper lobe robotic last week for example. NCCN guidelines supports minimally invasive resection for stage I, but does not comment on higher stages.

You are correct. Prior studies showed that VATS led to fewer nodes removed compared to open or robot approaches. But this is now generally viewed as operator-dependent and an experienced VATS surgeon can just as easily do an appropriate lymph node sampling/dissection. The current ACS COC guidelines no longer require a set number of lymph nodes to be removed though. It's based on sampling/dissecting one N1 and three N2 stations now.

As for inadequate nodal staging by surgeons who aren't thoracic oncology focused, I do recall a relatively recent paper showing that practice is still prevalent. Those patients were less likely to get invasive mediastinal staging pre-op and more likely to be pathologically upstaged. Anecdotally, I collaborate with three other hospitals with several older CT surgeons who occasional do lung resections (my hospital is the main center and the only one with a dedicated thoracic service). They don't do EBUS, rarely do invasive staging in general, and will do wedges without adequate nodal staging. I recently reviewed with them the current guidelines for appropriate staging. Mostly what they do is stage I. Anything more complex comes to us.

 

[dienekes88]

When I took the boards a few years ago, whatever technique you were comfortable doing was considered ok. In my practice, I do robot and my partner does VATS (just what we learned in training). It's rare that we do open lung resections unless we're concerned about controlling the hilum. I did a T4N0 left upper lobe robotic last week for example. NCCN guidelines supports minimally invasive resection for stage I, but does not comment on higher stages.

You are correct. Prior studies showed that VATS led to fewer nodes removed compared to open or robot approaches. But this is now generally viewed as operator-dependent and an experienced VATS surgeon can just as easily do an appropriate lymph node sampling/dissection. The current ACS COC guidelines no longer require a set number of lymph nodes to be removed though. It's based on sampling/dissecting one N1 and three N2 stations now.

As for inadequate nodal staging by surgeons who aren't thoracic oncology focused, I do recall a relatively recent paper showing that practice is still prevalent. Those patients were less likely to get invasive mediastinal staging pre-op and more likely to be pathologically upstaged. Anecdotally, I collaborate with three other hospitals with several older CT surgeons who occasional do lung resections (my hospital is the main center and the only one with a dedicated thoracic service). They don't do EBUS, rarely do invasive staging in general, and will do wedges without adequate nodal staging. I recently reviewed with them the current guidelines for appropriate staging. Mostly what they do is stage I. Anything more complex comes to us.

EBUS is an interesting thing. I didn't do much EBUS in training.

I guess this brings up another question about the modern approach to invasive mediastinal staging, management of stage 3 disease, and the "surprise" positive n2 node.

If there was concern about n2 nodes but the patient otherwise looked ready for surgery, we would do a bronch/mediastinoscopy and then if it was positive do induction chemoXRT. Follow up PET/CT that assessed for progression. The argument was always that even if you had a negative EBUS for bulky hot mediastinal nodal disease, you had to do the mediastinoscopy anyway. And if you didn't think there was much disease you could just be definitive by getting the nodes and you'd have a single anesthetic for the entire process.

Is there any new thought on the surprise n2 node in an otherwise clinical stage 1 or 2? With a thoracotomy, the general thought was that as long as it wasn't bulky mediastinal disease and adequate invasive staging was done, then you were just supposed to proceed if you thought you could do the resection without residual disease if I recall correctly. Is this still the same now that most people are doing it VATS? I can imagine some people would consider closing up and doing induction chemoXRT as long as they haven't dissected the hilum.

 

[deleted50541]

Is there any new thought on the surprise n2 node in an otherwise clinical stage 1 or 2? With a thoracotomy, the general thought was that as long as it wasn't bulky mediastinal disease and adequate invasive staging was done, then you were just supposed to proceed if you thought you could do the resection without residual disease if I recall correctly. Is this still the same now that most people are doing it VATS? I can imagine some people would consider closing up and doing induction chemoXRT as long as they haven't dissected the hilum.

Similarly, I didn't have much EBUS training in fellowship as it was dominated by IP, so we probably did less pre-op invasive staging than is now recommended if the PET/CT was ok. But that was the general trend for many years until fairly recently. I've since learned how to do EBUS and unless its a peripheral IA or selective IB, these patients all get an EBUS. I save mediastinoscopy for the equivocal EBUS or after induction therapy for re-staging if they might be a surgical candidate. Re-do mediastinoscopy is something I try to avoid.

Yes, that's still the answer to proceed with resection if occult N2 disease is found at the time of surgery so long as a formal MLND is performed. You wouldn't be wrong though if doing it VATS to consider stopping for induction therapy per NCCN. It's rare that I've been in that scenario, but it's a probably a good board question along with managing synchronous primaries.

 

[dienekes88]

Similarly, I didn't have much EBUS training in fellowship as it was dominated by IP, so we probably did less pre-op invasive staging than is now recommended if the PET/CT was ok. But that was the general trend for many years until fairly recently. I've since learned how to do EBUS and unless its a peripheral IA or selective IB, these patients all get an EBUS. I save mediastinoscopy for the equivocal EBUS or after induction therapy for re-staging if they might be a surgical candidate. Re-do mediastinoscopy is something I try to avoid.

Yes, that's still the answer to proceed with resection if occult N2 disease is found at the time of surgery so long as a formal MLND is performed. You wouldn't be wrong though if doing it VATS to consider stopping for induction therapy per NCCN. It's rare that I've been in that scenario, but it's a probably a good board question along with managing synchronous primaries.

This is great.

While this discussion doesn't generate as many clicks as some debate about whether cardiac surgeons or cardiology fellows can read cath better, I think this is one of the missed opportunities on this forum. Here we have 2 board certified cardiothoracic surgeons talking about contemporary general thoracic surgery practice. This is an opportunity for general surgery residents or students who are interested in thoracic surgery to learn about the nuts and bolts.

In any event. Great responses. Thanks.

 

[deleted50541]

This is great.

While this discussion doesn't generate as many clicks as some debate about whether cardiac surgeons or cardiology fellows can read cath better, I think this is one of the missed opportunities on this forum. Here we have 2 board certified cardiothoracic surgeons talking about contemporary general thoracic surgery practice. This is an opportunity for general surgery residents or students who are interested in thoracic surgery to learn about the nuts and bolts.

In any event. Great responses. Thanks.

Happy to contribute. I can't believe I've been on this forum for almost 20 years from pre-med to surgeon. The surgery forum doesn't seem as active as it used to be, but I still enjoy browsing through the content here and offering whatever wisdom I can.

 

[Darrow O'Lykos]

Happy to contribute. I can't believe I've been on this forum for almost 20 years from pre-med to surgeon. The surgery forum doesn't seem as active as it used to be, but I still enjoy browsing through the content here and offering whatever wisdom I can.

As a non-trad first year medical student still figuring out what I want to do, I can say that I appreciate reading posts such as this by you and @dienekes88 as I extend my study-breaks between lectures and dive down rabbit holes exploring CT surgery. I came in thinking ortho, but then became enamored with cardiovascular stuff. Still not sure what I want to do, but learning more about the different fields prior to my clerkships, even rudimentarily and vicariously through reading and/or interacting with docs online, is quite helpful.

Cheers