Unexpected conversion to thoracotomy during thoracoscopic lobectomy: a single-center analysis

Outcomes after Conversion from Video-Assisted Thoracoscopic Lobectomy to Thoracotomy

BACKGROUND

 Lung cancer resections are increasingly being performed via video-assisted thoracoscopic surgery (VATS). Conversion to thoracotomy can occur for many reasons and may affect outcomes. The objective of this study was to investigate the impact of VATS conversion on short- and mid-term outcomes and identify reasons for conversion.

METHODS

 Consecutive patients undergoing lobectomy for primary non-small cell lung cancer between 2012 and 2019 in a single UK center were included. Primary outcomes were 90-day mortality, intraoperative conversion, and overall survival. Reasons for conversion were defined as bleeding or nonbleeding. Outcomes were compared between groups using univariable analysis. Multivariable logistic regression analysis was performed to identify risk factors for conversion.

RESULTS

 A total of 2,622 patients were included with 20.6% (n = 541) completing surgery via VATS and 79.4% (n = 2,081) via thoracotomy. The rate of completed VATS surgery increased significantly over time (2012: 6.9%, 2019: 55.1%, p < 0.001). Overall conversion rate was 14.3% (n = 90/631) and has reduced significantly over time (p < 0.001). The rate of conversion due to intraoperative bleeding was 31.1% (n = 28/90). Obesity, male sex, and stage III disease were independent risk factors for conversion. The 90-day mortality rate after conversion was not significantly different from the rate for planned thoracotomy (3.3 vs. 3.4%, p = 0.987). There was no significant difference in overall survival between patients experiencing intraoperative conversion and those undergoing planned thoracotomy (p = 0.135).

CONCLUSION

 This study demonstrates comparable outcomes for patients undergoing conversion from VATS to those undergoing planned surgery via thoracotomy. It remains unclear if reason for conversion is associated with outcomes.

The Prediction of Fissure Integrity by Quantitative Computed Tomography Analysis

BACKGROUND

Incomplete interlobar fissure may increase the difficulty of thoracoscopic lobectomy. Herein, we compared the accuracy of visual versus quantitative analysis to predict fissure integrity in lung cancer patients undergoing thoracoscopic lobectomy and evaluated the effects of fissure integrity on surgical outcome.

METHODS

This was a single-center retrospective study including consecutive patients undergoing VATS (video-assisted thoracoscopic surgery) lobectomy for lung cancer. The target interlobar fissures were classified as complete or incomplete by visual and quantitative analysis. Using the intraoperative finding as the reference method, the diagnostic accuracy of the two methods to define fissure completeness (dependent variable) was calculated and statistically compared. Yet, we evaluated differences in postoperative outcomes between patients with complete and incomplete fissure integrity.

RESULTS

A total of 93 patients were included in the study; 33/93 (36%) presented complete fissure. Visual and quantitative analyses correctly identified complete fissure in 19/33 (57%) and 29/33 (88%) patients, respectively, and incomplete fissure in 56/60 (93%) and 58/60 (96%) patients, respectively. Quantitative analysis had better diagnostic accuracy than visual analysis (81 vs. 93%; p = 0.01). Patients with incomplete fissure compared with those with complete fissure had a higher conversion rate (6 vs. 13%; p = 0.43), higher persistent air leak rate (0/33 vs. 14/60; p = 0.03), and longer hospitalization (12.6 ± 3.8 vs. 7.1 ± 2.4 days; p = 0.01).

CONCLUSION

Quantitative analysis accurately predicted the fissures' integrity; it may be useful for selecting suitable cases for thoracoscopic lobectomy especially for surgeons with limited minimally invasive experience.

Analysis of the unplanned reoperation following surgical treatment of pulmonary tumor

BACKGROUND

In this study, we aimed to summarize the extremely important lesson and experience in the whole process of surgical treatments of lung tumors for the benefit of steps taken to prevent against unplanned reoperation.

METHODS

Demographical and clinical information of 7732 patients were retrospectively retrieved and reviewed, who were diagnosed with pulmonary tumor and underwent surgical treatments from January 2016 to March 2021. Those patients who underwent unplanned reoperation for the treatment of severe complications were focused carefully and analyzed meticulously.

RESULTS

A total of forty-one patients (41/7732) received 44 unplanned reoperations. Among them, eight and thirty-three patients were diagnosed with benign and malignant tumor, respectively. The incidence of unplanned reoperations seemed to be similar on both sides (Left vs. Right: 12/3231 vs. 29/4501, p = 0.103). Lobectomy plus segmentectomy is prone to reoperation (2/16, 12.5%) as compared to the other types of surgery. The complications leading to reoperation was hemothorax, including active hemorrhage (23/44, 52.3%) and clotted hemothorax (6/44, 13.6%), chylothorax (8/44, 18.2%), and the others (7/44, 15.9%) including bronchopleural fistula, torsion, or injury of right middle bronchus and pulmonary bulla rupture. The morbidity and mortality after unplanned reoperation were 17.1% (7/41) and 12.2% (5/41), respectively.

CONCLUSIONS

Bronchi or vessel stumps, the surgical edges of the lung parenchyma, and pleural adhesions should be checked to avoid postoperative bleeding. Prophylactic ligation of the thoracic duct should be recommended in case of the suspected oily-like exudation in the lymph node bed. Smooth expansion of the middle lobe is important to avoid narrowing and torsion before transection of the bronchus.

Did conversion to thoracotomy during thoracoscopic lobectomy increase post-operative complications and prejudice survival? Results of best evidence topic analysis

The potential complications related to unplanned conversion to thoracotomy remains a major concern in thoracoscopic lobectomy and may limit the wide adoption of this strategy. We reviewed the literature from 1990 until February 2022, analyzing all papers comparing successful thoracoscopic lobectomy versus converted thoracoscopic lobectomy and/or upfront thoracotomy lobectomy to establish whether unplanned conversion negatively affected outcomes. Thirteen studies provided the most applicable evidence to evaluate this issue. Conversion to thoracotomy was reported to occur in up to 23% of cases (range, 5%-16%). Vascular injury, calcified lymph nodes, and dense adhesions were the most common reasons for conversion. Converted thoracoscopic lobectomy compared to successful thoracoscopic lobectomy was associated with longer operative time and hospital stay in all studies, with higher postoperative complication rates in seven studies, and with higher perioperative mortality rates in four studies. No significant differences were found between converted thoracoscopic lobectomy and upfront thoracotomy lobectomy. Five studies evaluated long-term survival, and in all papers conversion did not prejudice survival. Surgeons should not fear unplanned conversion during thoracoscopic lobectomy, but to avoid unexpected conversion that may negatively impact surgical outcome, a careful selection of patients is recommended-especially for frail patients.

Intraoperative conversion from video-assisted thoracoscopic lobectomy to thoracotomy for non-small-cell lung cancer: Does it have an impact on long-term survival?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether intraoperative conversions to thoracotomy have an impact on long-term survival for patients with non-small-cell lung cancer who underwent video-assisted thoracoscopic lobectomy initially. A total of 461 papers were found using the reported search, of which 6 retrospective cohort studies represented the best evidence to answer the clinical question. The authors, date of publication, journal, country of the authors, patient group, study type, relevant outcomes and results of these papers were tabulated. Five cohort studies clarified that conversion did not compromise long-term survival, whereas 1 cohort study reported worse long-term outcomes after conversion to thoracotomy. However, the limited samples, different characteristics between groups and selection bias due to inherent design made it difficult to make a conclusion. Based on the current evidence, we concluded that intraoperative conversion from video-assisted thoracoscopic surgery (VATS) to thoracotomy for non-small-cell lung cancer might not impact long-term survival compared to a successful VATS lobectomy. In-hospital mortality might not be prejudiced, whereas longer hospitalizations were observed. However, whether conversion would adversely affect postoperative complication rates remained unclear because of the conflicting results. Moreover, 3 studies reported no statistical differences in short- and long-term survival between emergency and non-emergency conversions. Therefore, we suggest that thoracic surgeons should not hesitate to convert VATS into thoracotomy in the case of blood vessel injury or difficult hilum.

Conversion to Thoracotomy in Non-Small Cell Lung Cancer: Risk Factors and Perioperative Outcomes

Objective: We aimed to identify predictors of conversion to thoracotomy and test the hypothesis that conversion is associated with inferior perioperative outcomes in non-small cell lung cancer (NSCLC). Methods: We queried the National Cancer Database for patients with stage I to III NSCLC undergoing minimally invasive surgery (MIS) during 2010 to 2016. We compared clinicopathologic factors between patients undergoing MIS with and without conversion. We fitted multivariable regression models to identify independent predictors of conversion and compare perioperative outcomes between the 2 groups. Results: A rising trend in the use of MIS was accompanied by a declining trend in the rate of conversion to thoracotomy. A total of 11.3% of the 83,219 cases were converted. Conversion was associated with a higher Charlson-Deyo score, squamous histology, nodal involvement, high tumor grade, tumor size ≥5 cm, and a higher T stage ( P < 0.05). Successful MIS without conversion was predicted by advanced age, sublobar resection, robotic approach, and treatment at an academic high-volume facility ( P < 0.05). Conversion was linked to longer hospital stays, higher 30-day and 90-day mortality, and unplanned readmission ( P < 0.05), irrespective of the type of MIS approach. Conclusions: Conversion rates for video-assisted and robot-assisted thoracoscopic surgery have seen a decline in recent years. Irrespective of the type of MIS approach, conversion was associated with inferior perioperative outcomes. The robotic approach and treatment at an academic high-volume facility were associated with a lower likelihood of conversion. Early recognition of the individual risk factors for conversion may help to counsel patients about the likelihood of, and detriments associated with, conversion and ultimately reduce conversion rates.

[Reasons for Conversion to Thoracotomy in 83 Cases during Video-assisted Thoracic Surgery Lobectomy: A Summary of 1,350 Consecutive Operations by A Single Surgical Team]

背景与目的

电视胸腔镜手术（video-assisted thoracic surgery, VATS）为肺癌治疗的主流术式，本研究旨在分析单手术组连续VATS肺叶切除术1, 350例中转开胸83例的中转原因，以期对常态下胸腔镜肺叶切除术中转开胸的规律有更深层次的认识，并更好地把握中转开胸的手术时机。

方法

回顾性分析2009年9月21日-2020年6月1日河北医科大学第四医院胸外科单手术组连续行胸腔镜肺叶切除术的1, 350例患者资料。其中男性773例，女性577例，年龄8岁-87岁，中位年龄61.3岁。全组良性疾病83例，肺转移瘤38例，原发性肺癌1, 229例，其中Ⅰ期: 676例，Ⅱ期: 323例，Ⅲa期: 230例。全组行左肺上叶切除术301例（22.30%），左肺下叶切除术231例（17.11%），右肺上叶切除术378例（28.00%），右肺中叶切除术119例（8.81%），右肺下叶切除术262例（19.41%），右肺中上叶切除术16例（1.19%），右肺中下叶切除术43例（3.19%）。

结果

单手术组连续1, 350例胸腔镜肺叶切除术患者中有83例（6.15%）因不同原因中转开胸。良性病变的中转开胸率高于恶性肿瘤（P < 0.05）；病理分期为Ⅲa期的中转开胸率明显高于Ⅰ期、Ⅱ期患者（P < 0.05）。联合肺叶切除术的中转开胸率明显高于单肺叶切除术（P=0.001）；左肺上叶切除术的中转开胸率显著高于其他单肺叶切除术（P < 0.001）；右肺中叶切除术的中转开胸率低于其他单肺叶切除术（P=0.049）。中转开胸主要原因为血管损伤（38.55%）、淋巴结干扰（26.51%）、胸腔致密粘连（16.87%）；中转开胸组总体手术时间为（236.99±66.50）min，总体失血量（395.85±306.38）mL。其中淋巴结干扰组患者手术时间（322.50±22.68）min，长于其他原因中转开胸组（P < 0.05）；血管损伤组术中出血量（560.94±361.84）mL，多于其他原因中转开胸组（P < 0.05）；随着时间的推移以及经验的积累，在手术前、中、后期血管损伤例数逐步下降（P < 0.05）。

结论

在胸腔镜手术中，肺部良性病变和较晚期恶性肿瘤有较高的手术难度和中转率。不同肺叶切除术中转开胸率不同，左肺上叶切除术中转率较高，而右肺中叶切除术中转率较低。血管损伤、淋巴结干扰、胸腔致密粘连仍是常态下胸腔镜肺叶切除术中转开胸的主要原因。中转开胸会导致手术时间延长和手术出血量增加。随着手术例数的增加，胸腔镜肺叶切除术中转开胸率有持续下降趋势，其主要原因是肺血管的处理更加成熟。

Intraoperative conversion during video-assisted thoracoscopy resection for lung cancer does not alter survival

 

OBJECTIVES

The aim of this study was to assess the long-term outcomes of patients treated by anatomical pulmonary resection with the video-assisted thoracoscopic surgery (VATS) approach, VATS requiring intraoperative conversion to thoracotomy or an upfront open thoracotomy for lung cancer surgery.

METHODS

We performed a retrospective single-centre study that included consecutive patients between January 2011 and December 2018 treated either by VATS (with or without intraoperative conversion) or open thoracotomy for non-small-cell lung cancer (NSCLC). Patients treated for a benign or metastatic condition, stage IV disease, multiple primary lung cancer or by resection, such as pneumonectomies or angioplastic/bronchoplastic/chest wall resections, were excluded.

RESULTS

Among 1431 patients, 846 were included: 439 who underwent full-VATS, 94 who underwent VATS-conversion (21 emergent, 73 non-emergent) and 313 treated with upfront open thoracotomy. The median follow-up was 37 months. There were no statistical differences in stage-specific overall survival between the full-VATS, VATS-conversion, and open thoracotomy groups, with 5-year OS for stage I NSCLC of 76%, 72.3% and 69.4%, respectively (P = 0.47). There was a difference in disease-free survival for stage I NSCLC, with 71%, 60.2% and 53%, respectively at 5 years (P = 0.013). Fewer complications occurred in the full-VATS group (pneumonia, arrhythmia, length of stay), but complication rates were similar between the VATS-conversion and thoracotomy groups.

CONCLUSIONS

VATS resection for NSCLC with intraoperative conversion does not appear to alter the long-term oncological outcome relative to full-VATS or open upfront thoracotomy. Postoperative complications were higher than for full-VATS and comparable to those for thoracotomy. VATS should be favoured when possible.

Estimating the risk of conversion from video-assisted thoracoscopic lung surgery to thoracotomy-a systematic review and meta-analysis

Background

Understanding the risk of conversion from video-assisted thoracic surgery (VATS) to thoracotomy is important when considering patient selection and preoperative surgical risk assessment. This review aims to estimate the rate of intraoperative conversions to thoracotomy, predictive factors, and associated outcomes for VATS anatomic lung resections.

Methods

PubMed/MEDLINE and EMBASE were searched systematically in May of 2020. Observational studies examining conversions of VATS anatomic resections to thoracotomy were included. Conversion rates, causes, risk factors, and post-operative outcomes were reviewed and analyzed in aggregate.

Results

Twenty retrospective studies were reviewed, with a total of 72,932 patients undergoing VATS anatomic lung resection. The median conversion rate was 9.6% (95% CI: 6.6–13.9%). Nine studies reported a total of 114 emergency conversions, with a median incidence rate of 1.3% (95% CI: 0.6–2.8%). The most common reasons for thoracotomy were vascular injury/bleeding, difficulty lymph node dissection, and adhesions, accounting for 27.9%, 26.2% and 19% of conversions, respectively. Risk factors for conversion varied, but frequently included nodal disease, large tumors, and induction therapy. The risk of complications (OR 2.06; 95% CI: 1.77–2.40) and mortality (OR 4.11; 95% CI: 1.59–10.61) were significantly increased following conversions. There was also a significant increase in chest tube duration and length of stay following conversion.

Conclusions

The risk of conversion to thoracotomy may be as high as one in ten patients undergoing VATS anatomic lung resections, but may vary significantly based on patient selection. Although emergent conversions are rare, the need for thoracotomy may significantly increase postoperative morbidity and mortality.

Risk factors of conversion in robotic- and video-assisted pulmonary surgery for non-small cell lung cancer

BACKGROUND

This study aimed to investigate risk factors of conversion to thoracotomy for patients with non-small cell lung cancer (NSCLC) underwent robotic- (RATS) or video-assisted thoracoscopic surgery (VATS).

METHODS

A retrospective review was conducted to included consecutive participants from January 2016 to December 2018. Three groups [mini-invasive, conversion, and up-front open thoracotomy (OT) groups] and two series of comparison (conversion versus mini-invasive, and conversion versus OT) were generated. Propensity score-matched analysis (1:1) was conducted to verify outcomes of complications and perioperative factors. Multivariate binary logistic regression analysis was used to identify potential risk factors of conversion.

RESULTS

1177 patients (912 in mini-invasive group, 180 in conversion group, and 85 in OT group) were included. The overall conversion rate was 16.5%. Robotic approach resulted in dramatically lower conversion rate compared to VATS (2.4% vs 25.1%, p < 0.001). After propensity adjustment, no significant difference of complication rates was identified when comparing conversion group with mini-invasive and OT groups. Multivariate regression analyses shown that robotic approach (odd ratio (OR) = 0.037, 95% confidential interval (CI) 0.016-0.087), tumor size < 5 cm (OR = 0.274, 95% CI 0.152-0.493), no chief symptom(OR = 0.311, 95% CI 0.178-0.545), body mass index < 25 kg/m² (OR = 0.537, 95% CI 0.343-0.842), and lobectomy (OR = 0.079, 95% CI 0.017-0.370) were independent protectors of conversion.

CONCLUSIONS

Seven demographic factors might be recognized as independent predictors of conversion. For patients with highly risk of conversion, robotic approach is recommended to perform mini-invasive pulmonary surgery over VATS.

Comparison of short-term quality of life in patients undergoing video-assisted thoracoscopic surgery versus thoracotomy

Background

This study aims to compare the short-term quality of life of patients undergoing video-assisted thoracoscopic surgery versus thoracotomy.

Methods

A total of 96 patients (58 males, 38 females; mean age 58.4±11.7 years; range, 18 to 80 years) who underwent video-assisted thoracoscopic surgery or thoracotomy in our hospital between March 2018 and March 2019 were retrospectively analyzed. Demographic and clinical characteristics and comorbidities of the patients were recorded. Quality of life of the patients was evaluated using the Short Form-36 health survey at the first postoperative month.

Results

Of the patients, 43 (44.8%) were treated by video-assisted thoracoscopic surgery and 53 (55.2%) by thoracotomy. Complications occurred in nine (20.9%) patients following video-assisted thoracoscopic surgery and in 12 (22.6%) patients following thoracotomy (p=0.840). At one month postoperatively, the patients in the video-assisted thoracoscopic surgery group had a better quality of life than those in the thoracotomy group (p<0.05).

Conclusion

Our study results suggest that both recovery and short-term quality of life seem to be better in patients undergoing video-assisted thoracoscopic surgery than in those treated by thoracotomy.