Commentary: Because we can

Waël C. Hanna, MDCM, MBA, FRCSC

Central Message.

Thoracic surgeons have pushed the technical boundaries of our specialty with multiple success stories, but careful selection and long-term outcomes should still be our guiding principles.

See Article page 323.

In this issue of JTCVS Techniques, Galvaing and colleagues¹ present a challenging but gratifying case of triple-sleeve right upper lobectomy, where reconstruction of the bronchus, pulmonary artery, and vena cava was necessary for the success of resection. The patient, a 66-year-old woman, had refused chemotherapy and was not a surgical candidate for a pneumonectomy. Although the caval resection and reconstruction was not planned, it was rapidly executed due to the appearance of superior vena cava syndrome intraoperatively. The patient lived 4 years after the initial resection—a true feat without chemotherapy—and died from a cause not related to lung cancer.

The report is rich in technical lessons learned from this case, the likes of which only 4 others have been reported. One cannot help but wonder why that is. Certainly, it would not be because of the paucity of T4 lung tumors. Could it be because many of these patients are receiving a pneumonectomy? Or is it because such operations have been tried and were not successful? So how do we measure the success of such cases?

The most valuable lesson that I learned from this case is not technical. It is that the feasibility of these cases is measured by a large number of critical steps—patient selection, surgeon selection, investigations, execution, and postoperative care. However, the success of these cases is measured only by one critical metric—survival. The authors waited 4 years to publish this report and only did so after it was determined that this patient will never have lung cancer recurrence. In other words, the technical lessons from this case are only worth sharing if the operation was beneficial to the patient.

We continue to push the technical boundaries of our specialty with multiple success stories, but we should never lose focus of why we do what we do. We don't do it because we can. We do it because it saves a life, for more than 90 days. Sometimes, the difference is not clearly obvious.