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PAPERS: Artyom Sedrakyan, Jan van der Meulen, James Lewsey, and Tom Treasure Video assisted thoracic surgery for treatment of pneumothorax and lung resections: systematic review of randomised clinical trials BMJ 2004; 329: 1008 [Abstract] [Full text]

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VATS in the treatment of Empyema- why was this omitted from your review?

Harsh Grewal   (29 October 2004)

Re: VATS in the treatment of Empyema- why was this omitted from your review?

Tom Treasure   (30 October 2004)

Does video assisted thoracoscopic surgery have clear advantages over thoracotomy?

C S Pramesh, Rajesh C Mistry   (10 November 2004)

How strong is the evidence?

John P Duffy   (30 November 2004)

VATS in the treatment of Empyema- why was this omitted from your review? 29 October 2004
Harsh Grewal, Associate Professor of Surgery Temple University School of Medicine, Philadelphia, PA 19140, USA Send response to journal: Re: VATS in the treatment of Empyema- why was this omitted from your review?	I congratulate the authors on their study which adds evidence to the growing literature that video assisted thoracic surgery (VATS) is superior to other treatments for pneumothorax and minor lung resection. I am curious why they did not review the role of VATS in treating empyema. We have treated a number of children with empyema using VATS and find this disease an ideal candidate for the application of VATS (Knudtson J, Grewal H. Pediatric empyema- An algorithm for early thoracoscopic intervention. JSLS 2004; 8: 31-34;Grewal H, Jackson RJ, Wagner CW, Smith SD. Early video -assisted thoracic surgery in the management of empyema. Pediatrics 1999; 103: e63. Competing interests: None declared
Re: VATS in the treatment of Empyema- why was this omitted from your review? 30 October 2004
Tom Treasure, Professor of Cardiothoracic Surgery Guy's Hospital, London, SE1 9RT Send response to journal: Re: Re: VATS in the treatment of Empyema- why was this omitted from your review?	We appreciate Dr Grewal’s interest and the question: why did we not review VATS in treating empyema? In the paired papers in this week’s BMJ we deliberately chose three well characterised procedures that can be performed either by a minimally invasive operation (VATS) or by a full thoracotomy, in order to compare practice with evidence. In contrast, empyema is heterogeneous in its manifestations, presents a wide spectrum of severity, and its management may be stepwise and not usefully simplified into a choice between VATS or thoracotomy. This makes it more difficult to analyse but we have tried in a systematic review in The Evidence for Cardiothoracic Surgery [1]. 1. Anyanwu A, Jaiswal P, Treasure T. Surgical treatment of thoracic empyema. In Treasure T, Keogh B, Hunt I, Pagano D, eds. The Evidence for Cardiothoracic Surgery, pp 131-9. Shrewsbury, UK: tfm Publishing Limited, 2005. Competing interests: None declared
Does video assisted thoracoscopic surgery have clear advantages over thoracotomy? 10 November 2004
C S Pramesh, Assistant Professor Tata Memorial Hospital, Mumbai 400012, India, Rajesh C Mistry Send response to journal: Re: Does video assisted thoracoscopic surgery have clear advantages over thoracotomy?	Sedrakyan and coleagues’ twin articles1, 2 on video assisted thoracoscopic surgery (VATS) in a recent issue of the journal make interesting reading. The inherent difficulties in conducting a double blind surgical trial invariably raise doubts regarding the conclusions drawn. We find that most trials included in the systematic review have had an inordinately long hospital stay in patients treated with thoracotomy. It is probably natural for clinicians convinced about the ‘minimal invasiveness’ of VATS to subconsciously push VATS patients to an early discharge and delay that of open surgery. A similar phenomenon was seen with laparoscopic cholecystectomy before a blinded study3 refuted most of the advantages claimed by other trials. We perform VATS and open oesophageal resections regularly and find that most postoperative parameters (including pulmonary complications, ICU and hospital stay) are remarkably similar in the two groups. Though VATS is an exciting approach to both benign and malignant thoracic disease, we feel that present evidence does not clearly establish the superiority of VATS. More rigorously conducted trials, with stringent and objective criteria for assessment, are required before a definite recommendation can be made. References 1. Sedrakyan A, van der Meulen J, Lewsey J, Treasure T. Video assisted thoracic surgery for treatment of pneumothorax and lung resections: systematic review of randomised controlled trials. BMJ 2004; 329: 1008-11 2. Sedrakyan A, van der Meulen J, Lewsey J, Treasure T. Variation in use of video assisted thoracic surgery in the United Kingdom. BMJ 2004; 329: 1011-12 3. Majeed AW, Troy G, Nicholl JP, Smythe A, Reed MW, Stoddard CJ, et al. Randomised, prospective single-blind comparison of laparoscopic versus small-incision cholecystectomy. Lancet 1996; 347: 989-94 Competing interests: None declared
How strong is the evidence? 30 November 2004
John P Duffy, Consultant Thoracic Surgeon Nottingham City Hospital, ng5 1 PB Send response to journal: Re: How strong is the evidence?	Dear Sir, I read with interest the articles in the BMJ by Sedrakyan et al and the associated commentary from P McCullough (BMJ 2004; 329:1008-12) I am afraid that in an issue of the BMJ discussing the importance of evidence- based medicine these papers illustrate the dangers of drawing conclusions based on inadequate data. I am a consultant thoracic surgeon who as a routine performs pleurectomy via a thoracoscopic approach. Whilst length of hospital stay and immediate post-operative pain are important, it should not be forgotten that the aim of a pleurectomy is to reduce the risk of recurrence of pneumothorax. Thus any study of surgery for pneumothorax should look at the recurrence rate. In the 4 small randomised studies quoted in the first article only 2 of these papers looked at recurrence rate. In one the recurrence rate was 10% and in the other 20%. This cannot be dismissed by stating in the first paper ‘this outcome related to the learning curve’ when there is absolutely no evidence presented in the paper to support this statement. In the second paper in the summary box ‘What is already known on this topic’ it states that ‘Video assisted thoracic surgery is effective’ implying that a VATs pleurectomy has been shown to be as effective as a pleurectomy via a thoracotomy. No data was presented in this paper to support this. In the commentary paper (P McCullough) the question ‘why is practice so variable in specialties where the evidence seems clear?’ is posed. Unfortunately the evidence presented is not clear with regard to VATs pleurectomy. If anything the data you have presented suggests that the operation is less effective than the open approach with a significantly higher recurrence rate. Perhaps this helps explain the reason that practice is so variable in the UK. For many surgeons the evidence is simply not robust enough for them to abandon a tried and tested technique and change to a technique for which there is little objective data to support it. (Certainly if there are only currently four randomised controlled trials of the technique guidance can only come from case series or historical comparisons). In some respects it could be said that those surgeons in the UK who have not adopted VATs pleurectomy should be regarded as true advocates of evidence-based medicine rather than be pilloried by insinuation as failing to embrace new technologies. Is it likely that the higher recurrence rate with VATs is just secondary to a learning curve? It is my belief that the higher recurrence rate for the VATs approach is real and may be explained by technical differences in the two approaches. Not least of these is the difficulty of checking for air leaks at the end of the operation which cannot be achieved at full lung inflation at thoracoscopy (no view). Competing interests: None declared