¹Program of Minimally Invasive Thoracic Surgery and New Technology, University Hospital of Catania, Italy; Department of General Surgery and Medical Specialties, University of Catania, Catania, Italy. ²VATS Editorial Office, AME Publishing Company.

Correspondence to: Kenney Hong. VATS Editorial Office, AME Publishing Company. Email: vats@amegroups.com.

Editor’s Note

Video-Assisted Thoracic Surgery (VATS) aims to promote the development of video-assisted thoracic surgery around the world by providing a professional platform for the sharing of experiences in video-assisted thoracic surgery between peers so that all patients may benefit. It has published a number of special series reporting the cutting-edge findings and application of video-assisted thoracic surgery in recent years, and received overwhelming responses from academic readers around the world. Our success cannot be achieved without the contribution of our distinguished guest editors. Taking this opportunity, VATS launched a new series “Interviews with Guest Editors” this year to highlight our active contributors. We hope to express our heartfelt gratitude for their tremendous effort and to further uncover the stories behind the special series.

The special series “Non-intubated Thoracic Surgery” (1) led by Profs. Marcello Migliore (Figure 1) and Tommaso Claudio Mineo and “VATS in Lung Metastasectomy” (2) led by Profs. Marcello Migliore and Michel Gonzalez have attracted numerous readers since they were published.

The aim of the series on NITS was threefold. The first is to confirm that there is a safer way to operate patients who cannot receive general anesthesia; the second to inform readers of the published consistent data in favor of NITS, and the third to give at the next generation of surgeons a start point from where to build their knowledge and experience. The series on VATS in lung metastasectomy was initiated to discover the truthful indications for surgery, to demonstrate which is the best surgical approach to treat LM and finally to generate new ideas by breaking old thinking visions.

Hereby, we are honored to have an interview with Prof. Migliore to share his experience in thoracic surgery and his insights on this special series.

Expert Introduction

Dr. Migliore is Professor of Thoracic Surgery and Chief of the Program of Minimally-Invasive Thoracic Surgery and New Technology at the University Hospital of Catania, Italy. He is married with 1 Daughter and 3 Sons. He also holds a Secretary Chair of the Assembly 8 - Thoracic Surgery and Transplantation - at the European Respiratory Society (ERS). At the age of 23, he graduated with laude in Medicine and Surgery at the University of Catania. He trained General Surgery in Italy and in thoracic surgery including lung transplantation in UK (Bristol and Newcastle) and in Belgium (Leuven). While he was Research Associate at the University of Chicago and Cornell University in New York in the USA, he also spent few months in Toronto, Canada.

Dr. Migliore has been Consultant Thoracic Surgeon at different hospitals in UK such as the prestigious “Papworth” in Cambridge, Exeter and Cardiff. He is known to be an innovator in thoracic surgery with special interest in making oncologic patient’s life enhanced and prolonged. 

Throughout his career Dr. Migliore achieved a number of first ascents. At the beginning Dr. Migliore concentrated his clinical and scientific work on the esophagus (3). He first described the “crico-esophageal incoordination” as one of the physiologic irregularities of certain type of the Zenker diverticulum, and one of the causes of unexplained pharyngo-esophageal dysphagia secondary to failed antireflux surgery (4-8). He also gave a contribution on the modern role of Belsey Mark IV fundoplication (9), and he demonstrated that the maintenance of the surgeon volume is necessary to decrease mortality after esophagectomy (10,11).

What it seems more important in his career is the case that in 1998 while in Sicily he understood the possibility to perform thoracic surgery through a small incision and a port, and he performed for the first time the “Video Assisted Thoracic Surgery through a single port” (successively called uniportal) (12-17); at that time, he also started “the awake thoracic surgery project” in Catania (18). The uniportal surgery has been ignored for many years, and after more than 20 years with the advancement of technologic dedicated instrumentations and the efforts of outstanding surgeons the uniportal approach is becoming more known worldwide (19,20). Professor Keyvan Moghissi in 2020 in his book “Perspectives in Lung cancer” wrote that the feasibility of Uniportal VATS was first demonstrated by Migliore and colleagues in 2000 and Dr. Migliore is the “real unsung hero of the uniportal VATS” (21).

Moreover, some of his recent interests lay in the area of treating the most difficult oncologic thoracic patients such as those with pulmonary metastases, advanced lung cancer and pleural mesothelioma. He proposed a revolution in the lung metastases treatment with the introduction of the dedicated mTNM staging for lung metastases with the intention to clarify prognosis and treatment. His idea was shared and published with Dr. Michel Gonzalez from Lausanne (22-24).

Dr. Migliore strongly believes that the personalization of oncologic treatment (individualization) will be more and more used in the future, and therefore guidelines should probably need to be rewritten (25-27) as different patients with the same tumor and stage could undergo different treatments because of different genes and temper. After his 10-year solo practice at the University Hospital of Catania, he agrees with others that one surgeon, called “uni-surgeon”, with a specialized scrub nurse will be enough to perform most of the thoracic operations, and this will be more acknowledged with the wider use of FreeHand robotic camera assistant (28-30). It seems obvious that in the future if the surgical indications remain the same, the number of surgeons worldwide need to be reconsidered (31), and surgical training need to be reassessed. Milestones in the career of Prof. Migliore are summarized in Table 1.

Figure 1 Prof. Marcello Migliore.

Table 1 Milestones in the career of Prof. Marcello Migliore. EACTS European Association of Cardiothoracic Surgery. ESOT European Society Organ Transplantation. HITHOC. Hyperthermic Intrathoracic chemotherapy.

VATS: As a reputable expert in the field of thoracic surgery, what prompted you to focus on thoracic surgery?

Prof. Migliore: thank you Dr. Hong and Dr. Gao for this great honor. I am glad to have the opportunity to review my career since childhood, and to reflect on the two series that have been finished (1,2). I was born in the beautiful city of Syracuse in Sicily one of the most attractive islands in the world. Since childhood, my dream was to be a Surgeon, at 4 years old I recall that my friends were the patients, and I was the doctor. Interestingly none of my parents or relatives were doctors. My Mom was a teacher at high school and we talked a great deal about Archimedes of Syracuse, and certainly, his outstanding scientific work influenced me (32). During my General Surgical Residency at the University of Catania in Italy, I have been very fortunate. At that time my main interest was the esophagus, and everything changed when in 1986 at the Italian Chapter of the American College of Surgeons organized in Taormina by Prof. Attilo Basile I met a Leading Surgeon in Thoracic Surgery: Dr. David B. Skinner, past President of the American Association of Thoracic Surgery. After the meeting, Dr. Skinner sent to my Chief in Catania a letter inviting me to spend few months at the University of Chicago in the USA. The next year at the age of 25, I went to Chicago. There I met Dr. Nasser Altorki and Dr. Mark Ferguson who are now well-known Thoracic Surgeons and Professors in New York and Chicago respectively. Nevertheless, during my stay in Chicago, my surgical mentors were two Masters in Thoracic Surgery including the esophagus: Dr. David B Skinner and Mr. Ronald Belsey. The latter was famous for the Belsey Mark IV fundoplication (33), and he was the first to describe the anatomical segmentectomy (34). Dr. Skinner was known for the “en bloc resection” of the esophagus (35) and to be a strong defender of innovations and surgical education (36). I recall during Thanksgiving Day in 1987, Dr. Skinner invited all his Fellows including myself to his large house on the border of the Michigan Lake, and one of the humblest guests was Dr. Charles Huggins, Noble Prize for Medicine (37) for his discoveries concerning hormonal treatment of prostatic cancer. I have been blessed: that day I was in the middle of Giants of Medicine and Surgery. Clearly, it was the beginning of my deep never-ending interest in thoracic surgery and surgical education.

Before we go to the next question, let me express my personal thanks to Prof. TC Mineo who left this beautiful world few years ago (38), and to Michel Gonzalez. Both of them agreed with the invitation to help me with the two series. Moreover, it is impossible not to thank those colleagues who accepted to write papers for the two series; as it is evident that the success in terms of reading and citations is mainly due to the outstanding content of their manuscripts.

VATS: Many years have passed since the “Non-Intubated Thoracic Surgery” special series was published (1), what is the current status of non-intubated thoracic surgery compared to a few years ago?

Prof. Migliore: it is unbelievable how things are going fast in thoracic surgery, and worldwide more and more thoracic units are now using the NITS for VATS which is performed, most of the time, by the uniportal approach. In very recent years the advances in anaesthetic drugs (39) made it possible that more technical difficult operations have been performed using NITS (39).

The evidence says that we are facing the fact that in some Thoracic Centres the indications for NITS have been expanded dramatically. I am sure that many surgeons never expected that NITS could also be performed for example for very complex reconstructive thoracic surgeries such as Surgery for Tracheal/Airway Resection and Reconstruction. With the intention to open a discussion, I recently posed some doubts about the unselective use of NITS for complex reconstructive surgery (39). It appears evident to my eyes that the limits of NITS should be clearly stated in the surgical community. For this reason, a consensus or expert recommendation is becoming necessary. 

VATS: Since “non-intubated VATS” is a rational choice in patients with respiratory and hemodynamic instability or high comorbidity, what do you think are the future advantages and directions of non-intubated VATS?

Prof. Migliore: I wrote in 2001 that the risk of morbidity and mortality of general anaesthesia and the risk of laryngotracheal injuries from the use of the double-lumen tube should not be taken in fragile patients or in those who need simple procedures such as drainage of simple and simple and complex pleural effusion, pleural or mediastinal biopsy, and pleurodesis with talc (18). Although there is no doubt that this concept is still valid today, future indications for NITS should be made clear as currently indications and contraindications for complex NITS are still uncertain (40), and based only on the surgical experience of few surgeons but not on the basis of stronger data obtained by prospective trials. Having performed hundreds of these operations I can speculate that future advantages include less hospital stay (day surgery), less hospital costs and, more importantly, better quality of life in the immediate postoperative period, but confirmation is necessary.

New directions should follow the Hippocrates Oath in medicine “primum non-nocere” with the main goal to demonstrate the efficacy and safety of NITS for more complex cases. Caution in complex cases is mandatory. Such complex NITS operations should be performed within prospective trials and only by expert surgeons.

VATS: As you mentioned in the special series on “VATS in Lung Metastasectomy”(2), it remains controversial which approach (open or VATS) is better than the other. What do you think of the disadvantages and advantages of both approaches?

Prof. Migliore: I very much enjoy having such a question. One of the main weakness of surgery for lung metastases is that every surgeon has her/his own indications and preferred approach. There are no guidelines and no expert opinions. I agree with Treasure et al. that we live in an era that professional opinion is not enough and that we have to believe more in the results of large prospective randomized trials (41). Many surgeons around the world, including myself, suggest that uniportal VATS is the perfect way to perform metastasectomy as an opening of 4-5 cm (42,43) permits the simultaneous palpation of the lung nodule(s) and eventually it will be easier to perform a more extended operation. Moreover, in the case of a subpleural nodule, it will be also simpler to perform the operation by uniportal VATS and NITS (44).

VATS: What do you think should be set as a priority in future research on both approaches (open or VATS)? How to search for scientific evidence of VATS lung metastasectomy?

Prof. Migliore: actually, scientific evidence is very poor. Even the PulMiCC trial is giving more questions than answers (45). Dozens of recently published papers do not permit to give a definite answer, and the never-ending dilemma is still present: to operate or not? I strongly encourage my colleagues globally to use and discuss the proposed dedicated TNM staging system for lung metastases to stratify the patients, to establish the prognosis and to decide if operation could be really useful or not (22-24).

VATS: What kind of projects are you recently working on? How is the topic of these special series associated with some of them?

Prof. Migliore: I have been working on a number of clinical studies for the most difficult patients in thoracic surgery because of the very limited survival. These patients suffer from mesothelioma, advanced NSCLC (especially M1a – pleural effusion), and pulmonary metastases. Most of the time the survival in these patients is less than 12 months.

Explicit goals which we are investigating include the use of HITHOC and debulking surgery via VATS with mini-thoracotomy to treat mesothelioma and patients with NSCLC and pleural effusion or nodules (M1a) (46-48). Furthermore, the dedicated staging system for pulmonary metastases is promising and could serve to definitively clarify the role of surgery.

My uncluttered desire is that researches we are promoting will make a strong positive impact on patients with lung metastases, physicians and surgeons. The goal is to prolong the patient’s survival to put a smile on their face.

VATS: If there is a chance to update these two-special series, what would you like to moderate, add or emphasize more?

Prof. Migliore: I would like to emphasize more the necessity of staging system of lung metastases looking at the survival for each stage of the disease, for the different tumors such as colorectal, lung cancer, sarcoma, gastric cancer, etc… Furthermore, precision (individualized) treatment should become the standard practice in lung metastasectomy, and the dedicated TNM staging system could be the “trojan horse” to achieve better result personalizing the treatment. To achieve this, the multidisciplinary team approach is mandatory.

Until now, most of the efforts have been done to achieve early diagnosis in lung cancer patients with the goal to operate more thoracic oncologic patients to prolong survival. Nevertheless, as a surgeon, I acknowledge that most colleagues do not believe that there is the possibility to give our surgical contribution to prolong survival in patients with stage IV NSCLC, and this group of patients generate less interest among surgeons. My personal vision is that it is time to demonstrate the value of science, and therefore we need to increase our efforts towards those 70 % of patients with NSCLC who cannot be operated on because advanced cancer is discovered at diagnosis. If we increase survival in the largest group of patients with NSCLC which is inoperable, we will put a smile on the face of millions of people with lung cancer.

Finally, as most of our generation of surgeons gravitate the way to thinking that we have all the responses in our practice, it would be pleasing that our two series will serve to stimulate the new generation of surgeons to break old views. To do so the suggestion to the juniors of every part of the world is to be curious. The best way is to pose themselves questions, a lot of questions. Naturally, the initial reaction is that the junior think that the questions are probably stupid, but if he thinks more deeply and with good communication with the Tutor maybe the question isn’t all that stupid, and something very good could be born for the benefit of our patients.

We have the duty to listen to our juniors, inspire and guide them, giving them the freedom to pose questions and to arise doubts. The final goal is to spur them to embark on prospective trials not only at local but at global level. In such a way, more beautiful things will happen in medicine and surgery in all corners of the world.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Video-Assisted Thoracic Surgery for the series “Interviews with Outstanding Guest Editors”. The article did not undergo external peer review.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form. The series “Interviews with Outstanding Guest Editors” was commissioned by the editorial office without any funding or sponsorship. MM serves as an unpaid editorial board member of Video-Assisted Thoracic Surgery from August 2021 to July 2023. KH and LMG report that they are full-time employees of AME Publishing Company. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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