Conversion from video-assisted thoracic surgery (VATS) to thoracotomy during major lung resection: how does it affect perioperative outcomes?

Abstract

Objectives: Since video-assisted thoracic surgery (VATS) was first performed in the early 1990s, there have been many developments, and the conversion rate has decreased over the years. This article highlights the specific outcomes of patients undergoing conversion to thoracotomy despite initially scheduled VATS lung resection.

Methods: We retrospectively reviewed 501 patients who underwent thoracoscopic anatomic lung resection (i.e. lobectomy, segmentectomy or bilobectomy) between 1 January 2012 and 1 August 2017 at our institution. We explored the risk factors for surgical conversion and adverse events occurring in patients who underwent conversion to thoracotomy.

Results: A total of 44/501 patients underwent conversion during the procedure (global rate: 8.8%). The main reasons for conversion were (i) anatomical variation, adhesions or unexpected tumour extension (37%), followed by (ii) vascular causes (30%) and (iii) unexpected lymph node invasion (20%). The least common reason for conversion was technical failure (13%). We could not identify any specific risk factors for conversion. The global complication rate was significantly higher in converted patients (40.9%) than in complete VATS patients (16.8%) (P = 0.001). Postoperative atrial fibrillation was a major complication in converted patients (18.2%) [odds ratio (OR) 5.09, 95% confidence interval (CI) 1.80-13.27; P = 0.001]. Perioperative mortality was higher in the conversion group (6.8%) than in the VATS group (0.2%) (OR 33.3, 95% CI 3.4-328; P = 0.003).

Conclusions: Through the years, the global conversion rate has dramatically decreased to <10%. Nevertheless, patients who undergo conversion represent a high-risk population in terms of complications (40.9% vs 16.8%) and perioperative mortality (6.8% vs 0.2%).

Keywords: Conversion; Lung resection; Perioperative complications; Video-assisted thoracic surgery.

Figure 1:

Evolution of the conversion rate over the years. VATS: video-assisted thoracic surgery.

Figure 2:

Distribution of complications according to the Clavien–Dindo classification, according to conversion status. Grade 1: any deviation from the normal postoperative course, grade 2: normal course altered, grade 3: complication that required interventions of various degrees (a: under local anaesthesia, b: general or epidural anaesthesia), grade 4: complications threatening the life of the patients (a: single-organ dysfunction, b: multi-organ dysfunction), grade 5: death of a patient. VATS: video-assisted thoracic surgery.

Figure 3:

Conversion rate in VATS lung resection according to each operator's experience in 1 centre. The pink arrow is a logarithmic representation of the decrease in conversion rate. VATS: video-assisted thoracic surgery.