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Intraoperative conversion from video-assisted thoracoscopic surgery lobectomy to open thoracotomy: a study of causes and implications.

ABSTRACT: To study causes and implications of intraoperative conversion to thoracotomy during video-assisted thoracoscopic surgery (VATS) lobectomy.We performed an institutional review of patients undergoing lobectomy for known or suspected lung cancer with root cause analysis of every conversion from VATS to open thoracotomy.Between 2004 and 2012, 1227 patients underwent lobectomy. Of these, 517 procedures (42%) were completed via VATS, 87 procedures (7%) were converted to open procedures, and 623 procedures (51%) were performed via planned thoracotomy. Patients undergoing thoracotomy were younger and had a higher incidence of prior lung cancers. Planned thoracotomy and conversion group patients had higher clinical T stage than patients in the VATS group, whereas the planned thoracotomy group had higher pathologic stage than patients in the other groups. Postoperative complications were more frequent in patients in the conversion group (46%) than in the VATS group (23%; P < .001), but similar to the open group (42%; P = .56). Validating a previous classification of causes for conversion, 22 out of 87 conversions (25%) were due to vascular causes, 56 conversions (64%) were for anatomy (eg, adhesions or tumor size), and 8 conversions (9%) were the result of lymph nodes. No specific imaging variables predicted conversion. Within the conversion groups, emergent (20 out of 87; 23%) and planned (67 out of 87; 77%) conversion groups were similar in patient and tumor characteristics and incidence of perioperative morbidity. The conversion rate for VATS lobectomy dropped from 21 out of 74 (28%), to 29 out of 194 (15%), to 37 out of 336 (11%) (P < .001) over 3-year intervals. Over the same periods, the proportion of operations started via VATS increased significantly.With increasing experience, a higher proportion of lobectomy operations can be completed thoracoscopically. VATS should be strongly considered as the initial approach for the majority of patients undergoing lobectomy.

SUBMITTER: Puri V

PROVIDER: S-EPMC4272658 | biostudies-literature | 2015 Jan

REPOSITORIES: biostudies-literature

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Intraoperative conversion from video-assisted thoracoscopic surgery lobectomy to open thoracotomy: a study of causes and implications.

Puri Varun V Patel Aalok A Majumder Kaustav K Bell Jennifer M JM Crabtree Traves D TD Krupnick A Sasha AS Kreisel Daniel D Broderick Stephen R SR Patterson G Alexander GA Meyers Bryan F BF

The Journal of thoracic and cardiovascular surgery 20140917 1

<h4>Objective</h4>To study causes and implications of intraoperative conversion to thoracotomy during video-assisted thoracoscopic surgery (VATS) lobectomy.<h4>Methods</h4>We performed an institutional review of patients undergoing lobectomy for known or suspected lung cancer with root cause analysis of every conversion from VATS to open thoracotomy.<h4>Results</h4>Between 2004 and 2012, 1227 patients underwent lobectomy. Of these, 517 procedures (42%) were completed via VATS, 87 procedures (7%) ...[more]

PMID: 25439768

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Project description:BackgroundPatients undergoing video-assisted thoracoscopic surgery (VATS) have a lower risk of thrombosis compared to those undergoing open thoracotomy (OT) which may be due to several post-operative factors such as early mobilisation, shorter hospital stays, lower transfusion rates and lower risk of infections. Whether the higher thrombotic risk after OT is also linked to a peri-operative hypercoagulable state is a matter of debate. We therefore conducted a case-control study to compare peri-operative coagulation profiles in patients with primary lung cancer undergoing VATS vs OT.Materials and methodsAll consecutive patients undergoing VATS or OT for primary lung cancer at the Department of Thoracic Surgery of Padua University Hospital, Italy, between February and June 2018 were enrolled. Each patient provided a venous blood sample at least 30 min prior to surgical incision (T0) and 4±1 days after surgery (T1). Peri-operative coagulation profiles were assessed via traditional, viscoelastic whole blood (ROTEM® [Instrumentation Laboratory-Werfen]) and impedance aggregometry (Multiplate® Analyser [Roche Diagnostics]) tests.ResultsWe enrolled 65 patients (males 43, females 22; mean age 65±13 years) of whom 35 (54%) underwent VATS and 30 (46%) underwent OT. Compared to healthy controls, the surgical group (VATS and OT patients) had a significantly shorter clot formation time and higher alpha angle and maximum clot firmness values, as well as increased mean platelet function. In the post-operative period, patients who underwent OT had a significantly shorter clot formation time, higher alpha angle and maximum clot firmness values and higher mean platelet function vs VATS patients.DiscussionWhole blood ROTEM® profiles and Multiplate® aggregometry identified a more hypercoagulable post-operative state in patients who underwent OT than in those who underwent VATS. Larger studies are warranted to confirm our results and ascertain whether the observed hypercoagulability might promote post-operative thrombosis.

Project description:BackgroundLung cancer is highly prevalent in Chinese population. The association of operative approach with economic burden in these patients remains unknown.ObjectivesThis institution-level cohort study aimed to compare the cost-related clinical outcomes and health care costs among patients undergoing video-assisted thoracoscopic surgery (VATS) and open lobectomy, and to investigate the factors associated with the costs.MethodsThis retrospective cohort study included patients who underwent VATS or open lobectomy in a provincial referral cancer center in China in 2018. Propensity score matching (PSM) method was applied to balance the baseline characteristics in VATS lobectomy and open lobectomy group. Clinical effectiveness measures included post-operative blood transfusion, lung infection, and length of stay (LOS). Hospitalization costs were extracted from hospital information system to assess economic burden. Multivariable generalized linear model (GLM) with gamma probability distribution and log-link was used to analyze the factors associated with total costs.ResultsAfter PSM, 376 patients were selected in the analytic sample. Compared to open lobectomy group, the VATS lobectomy group had a lower blood transfusion rate (2.13% vs. 3.19%, P = 0.75), lower lung infection rate (21.28% vs. 39.89%, P < 0.001) and shorter post-operative LOS (9.4 ± 3.22 days vs. 10.86 ± 4.69 days, P < 0.001). Total hospitalization costs of VATS lobectomy group and open lobectomy were similar: Renminbi (RMB) 84398.03 ± 13616.13, RMB 81,964.92 ± 16748.11, respectively (P = 0.12). Total non-surgery costs were significantly lower in the VATS lobectomy group than in the open lobectomy group: RMB 41948.40 ± 7747.54 vs. RMB 45752.36 ± 10346.42 (P < 0.001). VATS approach, lung infection, longer post-operative length of stay, health insurance coverage, and lung cancer diagnosis were associated with higher total hospitalization costs (P < 0.05).ConclusionsVATS lobectomy has a lower lung infection rate, and shorter post-operative LOS than open lobectomy. Future studies are needed to investigate other aspects of clinical effectiveness and the economic burden from a societal perspective.

Project description:RATIONALE:Video-assisted thoracoscopic surgery (VATS) and open lobectomy are both standard of care for the treatment of early-stage non-small cell lung cancer (NSCLC) because of equivalent long-term survival. OBJECTIVES:To evaluate whether the improved perioperative outcomes associated with VATS lobectomy are explained by surgeon characteristics, including case volume and specialty training. METHODS:We analyzed the Surveillance, Epidemiology, and End Results-Medicare-linked registry to identify stage I-II NSCLC in patients above 65 years of age. We used a propensity score model to adjust for differences in patient characteristics undergoing VATS versus open lobectomy. Perioperative complications, extended length of stay, and perioperative mortality among patients were compared after adjustment for surgeon's volume and specialty using linear mixed models. We compared survival using a Cox model with robust standard errors. RESULTS:We identified 9,508 patients in the registry who underwent lobectomy for early-stage NSCLC. VATS lobectomies were more commonly performed by high-volume surgeons (P?<?0.001) and thoracic surgeons (P?=?0.01). VATS lobectomy was associated with decreased adjusted odds of cardiovascular complications (odds ratio [OR]?=?0.65; 95% confidence interval [CI]?=?0.47-0.90), thromboembolic complications (OR?=?0.47; 95% CI?=?0.38-0.58), extrapulmonary infections (OR?=?0.75; 95% CI?=?0.61-0.94), extended length of stay (OR?=?0.47; 95% CI?=?0.40-0.56), and perioperative mortality (OR?=?0.33; 95% CI?=?0.23-0.48) even after controlling for differences in surgeon volume and specialty. Long-term survival was equivalent for VATS and open lobectomy (hazard ratio?=?0.95; 95% CI?=?0.85-1.08) after controlling for patient and tumor characteristics, surgeon volume, and specialization. CONCLUSIONS:VATS lobectomy for NSCLC is associated with better postoperative outcomes, but similar long-term survival, compared with open lobectomy among older adults, even after controlling for surgeon experience.

Dataset Information

Intraoperative conversion from video-assisted thoracoscopic surgery lobectomy to open thoracotomy: a study of causes and implications.

Publications

Intraoperative conversion from video-assisted thoracoscopic surgery lobectomy to open thoracotomy: a study of causes and implications.

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