Division of Thoracic Surgery, Orlando Health, Orlando, Fla.
Division of Thoracic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
J Thorac Cardiovasc Surg. 2023 Jul;166(1):251-262.e3. doi: 10.1016/j.jtcvs.2022.10.050. Epub 2022 Nov 15.
Conversion to thoracotomy continues to be a concern during minimally invasive lobectomy. The aim of this propensity-matched cohort study is to analyze the outcomes and risk factors of intraoperative conversion during video-assisted thoracoscopic surgery (VATS) and robotic lobectomy (RL).
Data from consecutive lobectomy cases performed for clinical stage IA to IIIA lung cancer was retrospectively collected from the Pulmonary Open, Robotic, and Thoracoscopic Lobectomy study consortium of 21 institutions from 2011 to 2019. The propensity-score method of inverse-probability of treatment weighting was used to balance the baseline characteristics across surgical approaches. Univariate logistic regression models were applied to test risk factors for conversion. Multivariable logistic regression analysis was conducted using a stepwise model selection method.
Seven thousand two hundred sixteen patients undergoing lobectomy were identified: RL (n = 2968), VATS (n = 2831), and open lobectomy (n = 1417). RL had lower conversion rate compared with VATS (3.6% vs 12.9%; P < .0001). In the multivariable regression model, tumor size and neoadjuvant therapy were the most significant risk factors for conversion, followed by prior cardiac surgery, congestive heart failure, chronic obstructive pulmonary disease, VATS approach, male gender, body mass index, and forced expiratory volume in 1 minute. Conversions for anatomical reasons were more common in VATS than RL (66.6% vs 45.6%; P = .0002); however, conversions for vascular reasons were more common in RL than VATS (24.8% vs 14%; P = .01). The rate of emergency conversions was comparable between RL and VATS (0.5% vs 0.7%; P = .25) with no intraoperative mortalities.
Converted minimally invasive lobectomies were not associated with worse perioperative mortality compared with open lobectomy. Compared with VATS lobectomy, RL is associated with a lower probability of conversion in this propensity-score matched cohort study.
微创肺叶切除术中的中转开胸仍然令人担忧。本倾向评分匹配队列研究的目的是分析电视辅助胸腔镜手术（VATS）和机器人肺叶切除术（RL）中转开胸的手术结果和危险因素。
从 2011 年至 2019 年，来自 21 个机构的肺开放、机器人和胸腔镜肺叶切除术研究联盟连续收集了用于临床分期 IA 至 IIIA 肺癌的肺叶切除术病例的数据。采用逆概率治疗加权的倾向评分方法平衡手术方式之间的基线特征。采用单因素逻辑回归模型检验中转的危险因素。采用逐步模型选择法进行多因素逻辑回归分析。
共确定了 7216 例行肺叶切除术的患者：RL（n=2968）、VATS（n=2831）和开胸肺叶切除术（n=1417）。RL 的中转率低于 VATS（3.6% vs 12.9%；P<.0001）。在多因素回归模型中，肿瘤大小和新辅助治疗是中转的最显著危险因素，其次是既往心脏手术、充血性心力衰竭、慢性阻塞性肺疾病、VATS 方法、男性、体重指数和 1 秒用力呼气量。解剖学原因导致的中转在 VATS 中比 RL 更常见（66.6% vs 45.6%；P=.0002）；然而，血管原因导致的中转在 RL 中比 VATS 更常见（24.8% vs 14%；P=.01）。RL 和 VATS 的急诊中转率相当（0.5% vs 0.7%；P=.25），且术中无死亡病例。
与开胸肺叶切除术相比，微创肺叶切除术中转并不增加围手术期死亡率。与 VATS 肺叶切除术相比，在本倾向评分匹配队列研究中，RL 与中转的可能性较低相关。
