S. Hernandez2, F. Velez-Cubian2, R. Gerard2, C. Moodie1, J. Garrett1, J. Fontaine1,2, E. Toloza1,2 1Moffitt Cancer Center,Thoracic Oncology,Tampa, FL, USA 2University Of South Florida Health Morsani College Of Medicine,Tampa, FL, USA
Introduction: We aimed to identify risk factors and outcomes for conversion to thoracotomy from robotic-assisted video-assisted thoracoscopic (R-VATS) pulmonary lobectomy.
Methods: We retrospectively analyzed all patients (pts) who underwent R-VATS lobectomy for primary lung cancer by one surgeon between September 2010 and August 2016. Patients were grouped to “conversion” versus “non-conversion” to open lobectomy. Patients’ demographics, co-morbidities, pulmonary function tests (PFTs), perioperative outcomes, hospital length of stay (LOS), tumor histology, and pathologic stage were compared between groups. Chi-square, analysis of variance, Student’s t-test, or Kruskal-Wallis test was used, with p≤0.05 as significant.
Results: Twenty pts (5.3%) required conversion to open lobectomy from a total of 380 R-VATS lobectomy pts. “Conversion” pts were similar in age, BMI, smoking history, co-morbidities, and PFTs to “non-conversion” pts. More “conversion” pts received neoadjuvant therapy than “non-conversion” pts (25.0% vs. 3.6%; p<0.001). Estimated blood loss (EBL) was higher in “conversion” pts (500 mL [interquartile range (IQR)=675] vs 150 mL [IQR=150]; p<0.001), and median operative time was longer for “conversion” pts (298 min [IQR=157] vs 171 min [IQR=71]; p<0.001), compared to “non-conversion” pts. Tumor laterality and having an extended resection or re-do surgery did not significantly differ between groups. Bleeding from a pulmonary vessel occurred in 50% of “conversion” pts versus 0.3% of “non-conversion” pts (p<0.001). Tumor size, histology, grade of differentiation, and lymphovascular invasion were not significant factors for conversion. Patients with pN2 disease had higher risk for conversion (45.0% vs 16.4%; p<0.001). Pulmonary complications were similar between groups, including prolonged air leak (15.0% vs 21.9%; p=0.46), pneumonia (5.0% vs 6.4%; p=0.80), and respiratory failure (0% vs 1.9%; p=0.53), as was in-hospital mortality (5.0% vs 1.1%; p=0.14). However, “conversion” pts were at higher risk for cardiopulmonary arrest (5% vs 0.6%; p=0.029), cerebrovascular accident (5% vs 0%; p<0.001), and multi-organ failure (10% vs 0.6%; p<0.001). Median chest tube duration (5.0 days [IQR=3.8]) for “conversion” pts was longer compared to “non-conversion” pts (4.0 days [IQR=4.0]; p=0.022). Median hospital LOS was also longer for “conversion” pts (6.0 days [IQR=5.5] vs 4.0 days [IQR=4.0]; p=0.026).
Conclusions: Pulmonary lobectomy via R-VATS approach is associated with low conversion rate to thoracotomy. However, pts with neoadjuvant therapy or clinical N2 disease should be counseled about higher risk of conversion to thoracotomy. Further, preoperative cardiovascular risk assessment and postoperative monitoring for cardiovascular events are important.