European Journal of Cardio-Thoracic Surgery Advance Access published January 31, 2016
EDITORIAL
European Journal of Cardio-Thoracic Surgery (2016) 1–2 doi:10.1093/ejcts/ezw001
Two lives Gaetano Rocco* Division of Thoracic Surgery, Department of Thoracic Surgical and Medical Oncology, Istituto Nazionale Tumori, Fondazione Pascale, IRCCS, Naples, Italy * Corresponding author. Division of Thoracic Surgery, Department of Thoracic Surgical and Medical Oncology, Istituto Nazionale Tumori, Fondazione Pascale, IRCCS, Naples, Italy. Tel: +39-081-5903262; fax: +39-081-5903823; e-mail: [email protected] (G. Rocco).
Keywords: Professional affairs • Lung cancer • Video-assisted thoracoscopy • Lobectomy • Sealants • Thoracic surgery In an effort to define the features of good surgical practice, the Royal College of Surgeons of England (RCSE) has issued carefully worded statements on what surgeons ‘must’, ‘should’ or ‘ensure’ [rcseng.ac.uk/surgeons/surgical-standards/professionalism-surgery/ gsp/documents/good-surgical-practice-pdf]. As an example, we are reminded that we are responsible to develop and maintain our professional competence by attending educational activities that ‘must’ be relevant to our practice and support our current skills, knowledge and career development [rcseng.ac.uk/surgeons/surgicalstandards/professionalism-surgery/gsp/documents/good-surgicalpractice-pdf]. Moreover, we should carry out surgical procedures in a timely, safe and competent manner, and ensure that we follow current clinical guidelines in our field [rcseng.ac.uk/surgeons/ surgical-standards/professionalism-surgery/gsp/documents/goodsurgical-practice-pdf]. Under the pressure coming from patients, media and governments to have better results while altering the invasiveness of our surgical procedures, we often demonstrate that we actually live two lives. The life we live at meetings is the one where most of us are caught in a sort of collective amnesia and lost in a sort of vanity fair where the reliability of data are at times unclear or questionable and the results inapplicable in the reality of our practice. Indeed, during meetings, we become suddenly forgetful that our professional life is curtailed by restrictions of operative time, shortage of anaesthesiologists or staff personnel, the implementation of working time directives and, last but not least, current socioeconomic constraints that end up limiting our activities. During meetings, we soon switch the centre of attention from patients to numbers and series, and we talk the language of statistics. It is a sort of cathartic reunion of peers without defined rules and regulations. We seem not to remember that, in real life, grey zones dominate and a clear-cut separation of clinical behaviours as in textbook chapters rarely exists. The meeting becomes the realm of nuances because, at the end, Verba volant—words fly away. The other life is the one we know best. The one we spend with patients—talking to them, speaking the language of empathy and humanity. With patients, we need a truth—the truth built on knowledge and experience, often not the truth affirmed during meetings. Because each of us has his/her own truth—and, quite frankly, my evidence is as good as yours. Conversely, the evidence we obtain from books and journals is the evidence that stays forever in print because Scripta manent—what is written remains. It is not by chance that between 30 and 40% of the papers presented at major meetings will not be published
(Dr Alexander Patterson, personal communication). After the meeting, reviewers are usually back to their own reality and they critically appraise papers with a different mindset. Many examples exist in the literature of the two lives we all live. It is a phenomenon we are all aware of, that nobody emphasizes and that may impact our ability to exchange scientific information. In the past few years, thoracic surgeons have been entangled in everlasting discussions about the difference between thoracotomy and video-assisted thoracoscopic surgery (VATS) for major pulmonary resections. Different levels of evidence have been produced only to confirm the obvious. In fact, VATS can be associated with less postoperative morbidity and less pain within the first weeks of surgery [1, 2]. However, since the technique of hilar dissection, vessel ligation and mediastinal lymphadenectomy should be identical and lead to the same result whatever the approach the surgeon uses to facilitate a lobectomy, the removal of a lobe will intuitively bring about similar oncological results. The clinical equipoise between open and endoscopic approaches has indeed been unequivocally demonstrated in other specialties [3]. In a time when other lung cancer specialists claim to obtain the same, if not improved, results as surgery in terms of local control and morbidity [4], some are wondering whether it would not be advisable to focus rather than on the magnitude of the incision, on other prognostic determinants, such as early detection and emphasize the ability of surgeons to provide tissue for pathological staging and biomolecular studies while collecting the final evidence of unsurpassed long-term survival rates [5–7]. At meetings, an unforgivable mistake we make is to confound the inability to practise with the lack of surgical skills. We have to give the benefit of the doubt that minimally invasive surgery may not be not a divine gift bestowed on a few ‘chosen ones’ but entails considerable organizational and logistic efforts to be put into place. A few years back, a survey revealed that non-technical issues often generate a significant variability of the practice of minimally invasive surgery worldwide [8]. Today, despite the increasing percentages of VATS lobectomies performed throughout the world [http://scts.org/_userfiles/pages/ file/Audit%20and%20Outcomes/3_year_data_summary_2015%5B1% 5D.pdf ], the general feeling is that we have not significantly affected that variability yet. In other words, minimally invasive surgery needs to be afforded before being consistently practised. As another example, sealants have long been considered a valid adjunct to reduce postoperative air leaks after pulmonary surgery. In fact, prolonged air leaks may be associated with significant morbidity and extended hospital stay. In spite of several sessions about sealants
© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
EDITORIALS
Cite this article as: Rocco G. Two lives. Eur J Cardiothorac Surg 2016; doi:10.1093/ejcts/ezw001.
2
G. Rocco / European Journal of Cardio-Thoracic Surgery
organized during major meetings prompted by some encouraging preliminary results, the surgical literature is filled with non-conclusive evidence [9]. A publication bias exists and it is obviously due to the reluctance to publish negative studies. This reluctance is embodied by the customary image of a ‘limping’ funnel plot which relates to the ‘limping’ evidence obtained from the available randomized trials [10]. These two lives we live need to merge into only one. It is not by chance that one often considers the most valuable part of the meeting paper not so much the manuscript itself, but the discussion that follows. The real meaningfulness of attending a meeting resides in the scientific interaction where players put all cards on the table for a common benefit. It is a matter of responsibility for senior surgeons to guide the change towards transparency by introducing appropriate corrective measures. One correction would entail dedicating more time to discussions taking place during conferences to be recorded and transcripted with all manuscripts. Nevertheless, the ability to strike a balance between clarity, conciseness and in-depth analysis of surgical matters should become distinctive features of what we say during meetings and what we write afterwards. Lastly, a healthy relationship with the Industry is of paramount importance to dissipate the shadows of a conflict of interest altering objectiveness of data interpretation and to dissipate the shadows of a conflict of interest which may alter the objectiveness of data interpretation and force the way towards the alternative life we live at meetings [11, 12]. In conclusion, the more the two lives eventually merge at the end, the closer we will get to the environment where we want our trainees to grow both as professionals and as human beings. This is why, more than ever today, it is important to quit living two lives. Let us reconnect to what we really are, what we really do and to whom we really serve—our patients. Conflict of interest: none declared.
REFERENCES [1] Klapper J, D’Amico TA. VATS versus open surgery for lung cancer resection: moving toward a minimally invasive approach. J Natl Compr Canc Netw 2015;13:162–4. Review. [2] Rizk NP, Ghanie A, Hsu M, Bains MS, Downey RJ, Sarkaria IS et al. A prospective trial comparing pain and quality of life measures after anatomic lung resection using thoracoscopy or thoracotomy. Ann Thorac Surg 2014; 98:1160–6. [3] Bonjer HJ, Deijen CL, Abis GA, Cuesta MA, van der Pas MH, de Lange-de Klerk ES et al. A randomized trial of laparoscopic versus open surgery for rectal cancer. N Engl J Med 2015;372:1324–32. [4] Chang JY, Senan S, Paul MA, Mehran RJ, Louie AV, Balter P et al. Stereotactic ablative radiotherapy versus lobectomy for operable stage I non-small-cell lung cancer: a pooled analysis of two randomised trials. Lancet Oncol 2015;16:630–7. [5] Cheng AM, Wood DE. VATS versus open surgery for lung cancer resection: moving beyond the incision. J Natl Compr Canc Netw 2015;13:166–70. Review. [6] Rice D, Sepesi B, Heymach J, Swisher S, Vaporciyan A. SABR vs surgery for NSCLC in the media. Lancet Oncol 2015;16:e422. [7] Rocco G, Allen MS, Altorki NK, Asamura H, Blum MG, Detterbeck FC et al. Clinical statement on the role of the surgeon and surgical issues relating to computed tomography screening programs for lung cancer. Ann Thorac Surg 2013;96:357–60. [8] Rocco G, Internullo E, Cassivi SD, Van Raemdonck D, Ferguson MK. The variability of practice in minimally invasive thoracic surgery for pulmonary resections. Thorac Surg Clin 2008;18:235–47. [9] Belda-Sanchís J, Serra-Mitjans M, Iglesias Sentis M, Rami R. Surgical sealant for preventing air leaks after pulmonary resections in patients with lung cancer. Cochrane Database Syst Rev 2010;1:CD003051. [10] Malapert G, Hanna HA, Pages PB, Bernard A. Surgical sealant for the prevention of prolonged air leak after lung resection: meta-analysis. Ann Thorac Surg 2010;90:1779–85. [11] Iserson KV, Cerfolio RJ, Sade RM. Politely refuse the pen and note pad: gifts from industry to physicians harm patients. Ann Thorac Surg 2007;84: 1077–84. [12] Okike K, Kocher MS, Wei EX, Mehlman CT, Bhandari M. Accuracy of conflict-of-interest disclosures reported by physicians. N Engl J Med 2009; 361:1466–74.
EDITORIAL
European Journal of Cardio-Thoracic Surgery (2016) 1–2 doi:10.1093/ejcts/ezw001
Two lives Gaetano Rocco* Division of Thoracic Surgery, Department of Thoracic Surgical and Medical Oncology, Istituto Nazionale Tumori, Fondazione Pascale, IRCCS, Naples, Italy * Corresponding author. Division of Thoracic Surgery, Department of Thoracic Surgical and Medical Oncology, Istituto Nazionale Tumori, Fondazione Pascale, IRCCS, Naples, Italy. Tel: +39-081-5903262; fax: +39-081-5903823; e-mail: [email protected] (G. Rocco).
Keywords: Professional affairs • Lung cancer • Video-assisted thoracoscopy • Lobectomy • Sealants • Thoracic surgery In an effort to define the features of good surgical practice, the Royal College of Surgeons of England (RCSE) has issued carefully worded statements on what surgeons ‘must’, ‘should’ or ‘ensure’ [rcseng.ac.uk/surgeons/surgical-standards/professionalism-surgery/ gsp/documents/good-surgical-practice-pdf]. As an example, we are reminded that we are responsible to develop and maintain our professional competence by attending educational activities that ‘must’ be relevant to our practice and support our current skills, knowledge and career development [rcseng.ac.uk/surgeons/surgicalstandards/professionalism-surgery/gsp/documents/good-surgicalpractice-pdf]. Moreover, we should carry out surgical procedures in a timely, safe and competent manner, and ensure that we follow current clinical guidelines in our field [rcseng.ac.uk/surgeons/ surgical-standards/professionalism-surgery/gsp/documents/goodsurgical-practice-pdf]. Under the pressure coming from patients, media and governments to have better results while altering the invasiveness of our surgical procedures, we often demonstrate that we actually live two lives. The life we live at meetings is the one where most of us are caught in a sort of collective amnesia and lost in a sort of vanity fair where the reliability of data are at times unclear or questionable and the results inapplicable in the reality of our practice. Indeed, during meetings, we become suddenly forgetful that our professional life is curtailed by restrictions of operative time, shortage of anaesthesiologists or staff personnel, the implementation of working time directives and, last but not least, current socioeconomic constraints that end up limiting our activities. During meetings, we soon switch the centre of attention from patients to numbers and series, and we talk the language of statistics. It is a sort of cathartic reunion of peers without defined rules and regulations. We seem not to remember that, in real life, grey zones dominate and a clear-cut separation of clinical behaviours as in textbook chapters rarely exists. The meeting becomes the realm of nuances because, at the end, Verba volant—words fly away. The other life is the one we know best. The one we spend with patients—talking to them, speaking the language of empathy and humanity. With patients, we need a truth—the truth built on knowledge and experience, often not the truth affirmed during meetings. Because each of us has his/her own truth—and, quite frankly, my evidence is as good as yours. Conversely, the evidence we obtain from books and journals is the evidence that stays forever in print because Scripta manent—what is written remains. It is not by chance that between 30 and 40% of the papers presented at major meetings will not be published
(Dr Alexander Patterson, personal communication). After the meeting, reviewers are usually back to their own reality and they critically appraise papers with a different mindset. Many examples exist in the literature of the two lives we all live. It is a phenomenon we are all aware of, that nobody emphasizes and that may impact our ability to exchange scientific information. In the past few years, thoracic surgeons have been entangled in everlasting discussions about the difference between thoracotomy and video-assisted thoracoscopic surgery (VATS) for major pulmonary resections. Different levels of evidence have been produced only to confirm the obvious. In fact, VATS can be associated with less postoperative morbidity and less pain within the first weeks of surgery [1, 2]. However, since the technique of hilar dissection, vessel ligation and mediastinal lymphadenectomy should be identical and lead to the same result whatever the approach the surgeon uses to facilitate a lobectomy, the removal of a lobe will intuitively bring about similar oncological results. The clinical equipoise between open and endoscopic approaches has indeed been unequivocally demonstrated in other specialties [3]. In a time when other lung cancer specialists claim to obtain the same, if not improved, results as surgery in terms of local control and morbidity [4], some are wondering whether it would not be advisable to focus rather than on the magnitude of the incision, on other prognostic determinants, such as early detection and emphasize the ability of surgeons to provide tissue for pathological staging and biomolecular studies while collecting the final evidence of unsurpassed long-term survival rates [5–7]. At meetings, an unforgivable mistake we make is to confound the inability to practise with the lack of surgical skills. We have to give the benefit of the doubt that minimally invasive surgery may not be not a divine gift bestowed on a few ‘chosen ones’ but entails considerable organizational and logistic efforts to be put into place. A few years back, a survey revealed that non-technical issues often generate a significant variability of the practice of minimally invasive surgery worldwide [8]. Today, despite the increasing percentages of VATS lobectomies performed throughout the world [http://scts.org/_userfiles/pages/ file/Audit%20and%20Outcomes/3_year_data_summary_2015%5B1% 5D.pdf ], the general feeling is that we have not significantly affected that variability yet. In other words, minimally invasive surgery needs to be afforded before being consistently practised. As another example, sealants have long been considered a valid adjunct to reduce postoperative air leaks after pulmonary surgery. In fact, prolonged air leaks may be associated with significant morbidity and extended hospital stay. In spite of several sessions about sealants
© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
EDITORIALS
Cite this article as: Rocco G. Two lives. Eur J Cardiothorac Surg 2016; doi:10.1093/ejcts/ezw001.
2
G. Rocco / European Journal of Cardio-Thoracic Surgery
organized during major meetings prompted by some encouraging preliminary results, the surgical literature is filled with non-conclusive evidence [9]. A publication bias exists and it is obviously due to the reluctance to publish negative studies. This reluctance is embodied by the customary image of a ‘limping’ funnel plot which relates to the ‘limping’ evidence obtained from the available randomized trials [10]. These two lives we live need to merge into only one. It is not by chance that one often considers the most valuable part of the meeting paper not so much the manuscript itself, but the discussion that follows. The real meaningfulness of attending a meeting resides in the scientific interaction where players put all cards on the table for a common benefit. It is a matter of responsibility for senior surgeons to guide the change towards transparency by introducing appropriate corrective measures. One correction would entail dedicating more time to discussions taking place during conferences to be recorded and transcripted with all manuscripts. Nevertheless, the ability to strike a balance between clarity, conciseness and in-depth analysis of surgical matters should become distinctive features of what we say during meetings and what we write afterwards. Lastly, a healthy relationship with the Industry is of paramount importance to dissipate the shadows of a conflict of interest altering objectiveness of data interpretation and to dissipate the shadows of a conflict of interest which may alter the objectiveness of data interpretation and force the way towards the alternative life we live at meetings [11, 12]. In conclusion, the more the two lives eventually merge at the end, the closer we will get to the environment where we want our trainees to grow both as professionals and as human beings. This is why, more than ever today, it is important to quit living two lives. Let us reconnect to what we really are, what we really do and to whom we really serve—our patients. Conflict of interest: none declared.
REFERENCES [1] Klapper J, D’Amico TA. VATS versus open surgery for lung cancer resection: moving toward a minimally invasive approach. J Natl Compr Canc Netw 2015;13:162–4. Review. [2] Rizk NP, Ghanie A, Hsu M, Bains MS, Downey RJ, Sarkaria IS et al. A prospective trial comparing pain and quality of life measures after anatomic lung resection using thoracoscopy or thoracotomy. Ann Thorac Surg 2014; 98:1160–6. [3] Bonjer HJ, Deijen CL, Abis GA, Cuesta MA, van der Pas MH, de Lange-de Klerk ES et al. A randomized trial of laparoscopic versus open surgery for rectal cancer. N Engl J Med 2015;372:1324–32. [4] Chang JY, Senan S, Paul MA, Mehran RJ, Louie AV, Balter P et al. Stereotactic ablative radiotherapy versus lobectomy for operable stage I non-small-cell lung cancer: a pooled analysis of two randomised trials. Lancet Oncol 2015;16:630–7. [5] Cheng AM, Wood DE. VATS versus open surgery for lung cancer resection: moving beyond the incision. J Natl Compr Canc Netw 2015;13:166–70. Review. [6] Rice D, Sepesi B, Heymach J, Swisher S, Vaporciyan A. SABR vs surgery for NSCLC in the media. Lancet Oncol 2015;16:e422. [7] Rocco G, Allen MS, Altorki NK, Asamura H, Blum MG, Detterbeck FC et al. Clinical statement on the role of the surgeon and surgical issues relating to computed tomography screening programs for lung cancer. Ann Thorac Surg 2013;96:357–60. [8] Rocco G, Internullo E, Cassivi SD, Van Raemdonck D, Ferguson MK. The variability of practice in minimally invasive thoracic surgery for pulmonary resections. Thorac Surg Clin 2008;18:235–47. [9] Belda-Sanchís J, Serra-Mitjans M, Iglesias Sentis M, Rami R. Surgical sealant for preventing air leaks after pulmonary resections in patients with lung cancer. Cochrane Database Syst Rev 2010;1:CD003051. [10] Malapert G, Hanna HA, Pages PB, Bernard A. Surgical sealant for the prevention of prolonged air leak after lung resection: meta-analysis. Ann Thorac Surg 2010;90:1779–85. [11] Iserson KV, Cerfolio RJ, Sade RM. Politely refuse the pen and note pad: gifts from industry to physicians harm patients. Ann Thorac Surg 2007;84: 1077–84. [12] Okike K, Kocher MS, Wei EX, Mehlman CT, Bhandari M. Accuracy of conflict-of-interest disclosures reported by physicians. N Engl J Med 2009; 361:1466–74.
