National Wealth and the Global Spread of Minimally Invasive Thoracic Surgery: Insights from the European Society of Thoracic Surgeons Database

Background: The global adoption of minimally invasive thoracic surgical techniques, including robotic-assisted thoracic surgery (RATS) and video-assisted thoracic surgery (VATS), has significantly reduced surgical trauma and enhanced recovery. However, adoption rates vary widely across countries, influenced by economic, clinical, and systemic factors. This study examines the influence of national wealth, as measured by the gross domestic product (GDP) per capita, on the adoption of these techniques using data from the European Society of Thoracic Surgeons Database. Methods: A retrospective analysis of 148 628 lung operations (2001-2023) was conducted, integrating clinical data with GDP per capita from the World Bank. Generalized linear mixed models were used to assess the relationships between GDP and adoption rates, while adjusting for patient- and institution-level factors. Results: Thoracotomy rates have declined significantly over time (P < .001), while the adoption of VATS (p < .001) and RATS (p = .0049) has increased. VATS adoption was negatively associated with GDP per capita (p = .00022), whereas RATS adoption showed no significant correlation (p = .68). More straightforward procedures, such as wedge resections, were correlated with increased adoption of VATS (p < .001), whereas neoadjuvant therapy was negatively associated (p < .001). Country-level variability was significant (p < .001), with higher adoption rates in France and Italy and slower uptake in middle-income countries such as Turkey. GDP exhibited a nonlinear correlation with country adoption (p = .0036), whereas hospital-level differences were minimal (p = .78). Conclusions: National wealth, as measured by GDP per capita, significantly influences the adoption of VATS but not RATS, indicating that, whereas economic factors facilitate the initial diffusion of technology, other systemic and institutional variables, such as health technology assessment, reimbursement, and procurement frameworks, govern the uptake of more advanced platforms. Addressing disparities in access to minimally invasive thoracic surgery requires coordinated efforts to strengthen infrastructure, training, and policy frameworks. Scientific societies could play a pivotal role in promoting the equitable dissemination and implementation of these innovations across diverse health-care systems.