Analysis of unexpected conversion to thoracotomy during thoracoscopic lobectomy in resectable lung cancer

Abstract

Since anatomical lung resection by video-assisted thoracoscopic surgery (VATS) was first introduced, VATS has played a major role in resectable lung cancer. However, conversion to thoracotomy is a major concern, since unexpected thoracotomy increases the risk of potential adverse outcomes. Therefore, we compared patients converted to thoracotomy to non-converted controls and identified the risk factors for thoracotomy conversion. Between January 2005 and December 2013, 69 of 1110 VATS lobectomies for resectable lung cancer required unexpected conversion to thoracotomy. Each converted case was individually matched to three randomly-selected non-converted controls based on date of operation, type of operation and pathologic TNM stage. The most common cause of conversion was fibrocalcified lymph node, found in 28 patients (40.6%), followed by vascular injury in 20 (29.0%), tumor invasion or extension in 11 (15.9%), pleural adhesion in 5 (7.2%), incomplete inter-lobar fissure in 3 (4.3%) and failure of single lung ventilation in 2 (2.9%). There were no significant differences in the rate of postoperative complications and in-hospital deaths between the two groups. However, respiratory complications such as acute respiratory distress syndrome, pneumonia and atelectasis were significantly more common in the conversion group (p=0.012). Also, the conversion group had increased operating time, higher blood loss and prolonged intensive care unit (ICU) stay. The independent risk factors for thoracotomy conversion were age ≥65 years, FEV1 <1.8 L/sec, and the presence of fibrocalcified lymph node on preoperative chest computed tomography. Unexpected conversion to thoracotomy during VATS lobectomy in resectable lung cancer does not appear to increase surgical mortality and morbidity. However, with high risk patients, the surgeon requires careful selection for VATS candidate. Also, if needed, the decision to convert must be made promptly to reduce the operation time, blood loss, ICU stay and possible critical respiratory complications in VATS lobectomy.