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

Abstract

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.

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

“…Of the remaining 37 studies, 24 studies were further excluded. Therefore, 13 papers were included in the analysis and summarized in Table 1 12–24 …”

“…Fourdrain et al 13 retrospectively compared the data of patients undergoing anatomic resections (segmentectomy, lobectomy, and bilobectomy) for lung cancer by successful VATS ( n = 439), by converted VATS ( n = 94) and by upfront thoracotomy ( n = 313). The conversion rate was 17.6% ( n = 94) and in 21 cases (22%) it was because of bleeding (emergent conversion).…”

“…In seven studies, 12–14,16,17,20,21 converted VATS compared to successful VATS was associated with higher rate of post‐operative complications, whereas six studies showed no significant differences 15,18,19,22–24 . Four of 13 studies found a higher rate of peri‐ and postoperative deaths after conversion because of cardio‐respiratory complications 12,16,19,21 .…”

“…Emergent conversions because of vascular injuries were life‐threatening conditions conversely to non‐emergent conversions performed for technical reasons (i.e., pleural adhesions, limited space, stapler malfunction, difficult to perform single lung ventilation, and calcified nodes). Despite all, only 4 of 13 studies compared emergent versus non‐emergent conversions 12–14,20 . In three studies, 13,14,20 no differences were found, but one study 12 found that emergent conversion was associated with an increased mortality.…”

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

“…Fourdrain et al enrolled 533 patients in the study cohort, including 439 in the full VATS group and 94 (17.6%) in the conversion group [ 7 ]. All consecutive patients were treated by anatomical lobar pulmonary resection (486 by lobectomy and 8 by bilobectomy, 92.7%) or anatomical sublobar pulmonary resection (39 segmentectomy) for NSCLC.…”