What counts more: the patient, the surgical technique, or the hospital? A multivariable analysis of factors affecting perioperative complications of pulmonary lobectomy by video-assisted thoracoscopic surgery from a large nationwide registry
Authors: Infante Maurizio V , Benato Cristiano , Silva Ronaldo , Rocco Gaetano , Bertani Alessandro , Bertolaccini Luca , Gonfiotti Alessandro , Giovannetti Riccardo , Bonadiman Cinzia , Lonardoni Alessandro , Canneto Barbara , Falezza Giovanni , Gandini Paola , Curcio Carlo , Crisci Roberto ,   Italian VATS group members, Alloisio Marco , Amore Dario , Ampollini Luca , Andreetti Claudio , Argnani Desideria , Baietto Guido , Bandiera Alessandro , Benato Cristiano , Benvenuti MauroRoberto , Bertani Alessandro , Bertolaccini Luca , Bortolotti Luigi , Bottoni Edoardo , Breda Cristiano , Camplese Pierpaolo , Carbognani Paolo , Cardillo Giuseppe , Casadio Caterina , Cavallesco Giorgio , Cherchi Roberto , Crisci Roberto , Curcio Carlo , Dell’Amore Andrea , Beffa VittorioDella , Dolci Giampiero , Droghetti Andrea , Ferrari Paolo A , Fontana Diego , Gargiulo Gaetano , Gasparri Roberto , Gavezzoli Diego , Ghisalberti Marco , Giovanardi Michele , Gonfiotti Alessandro , Guerrera Francesco , Imperatori Andrea , Infante Maurizio , Iurilli Luciano , Lausi Paolo , LoGiudice Fabio , Londero Francesco , Lopez Camillo , Luzzi Luca , Mancuso Maurizio , Maniscalco Pio , Margaritora Stefano , Meacci Elisa , Melloni Giulio , Morelli Angelo , Mucilli Felice , Natali Pamela , Negri Giampiero , Nicotra Samuele , Nosotti Mario , Pariscenti Gianluca , Perkmann Reinhold , Pernazza Fausto , Pirondini Emanuele , Poggi Camilla , Puma Francesco , Refai Majed , Rinaldo Alessandro , Rizzardi Giovanna , Rosso Lorenzo , Rotolo Nicola , Russo Emanuele , Sabbatini Armando , Scarci Marco , Spaggiari Lorenzo , Stefani Alessandro , Solli Piergiorgio , Surrente Corrado , Terzi Alberto , Torre Massimo , Vinci Damiano , Viti Andrea , Voltolini Luca , Zaccagna Gino , Zaraca Francesco 
Published: June 2019

OBJECTIVES

Inherent technical aspects of pulmonary lobectomy by video-assisted thoracoscopic surgery (VATS) may limit surgeons’ ability to deal with factors predisposing to complications. We analysed complication rates after VATS lobectomy in a prospectively maintained nationwide registry.

METHODS

The registry was queried for all consecutive VATS lobectomy procedures from 49 Italian Thoracic Units. Baseline condition, tumour features, surgical techniques, devices, postoperative care, complications, conversions and the reasons thereof were detailed. Univariable and multivariable regressions were used to assess factors potentially linked to complications.

RESULTS

Four thousand one hundred and ninety-one VATS lobectomies in 4156 patients (2480 men, 1676 women) were analysed. The median age-adjusted Charlson index of the patients was 4 (interquartile range 3–6). Grade 1 and 2 and Grade 3–5 complications were observed in 20.1% and in 5.8%, respectively. Ninety-day mortality was 0.55%. The overall conversion rate was 9.2% and significantly higher in low-volume centres (&lt;100 cases, P &lt; 0.001), but there was no significant difference between intermediate- and high-volume centres under this aspect. Low-volume centres were significantly more likely to convert due to issues with difficult local anatomy, but not significantly so for bleeding. Conversion, lower case-volume, comorbidity burden, male gender, adhesions, blood loss, operative time, sealants and epidural analgesia were significantly associated with increased postoperative morbidity.

CONCLUSIONS

VATS lobectomy is a safe procedure even in medically compromised patients. An improved classification system for conversions is proposed and prevention strategies are suggested to reduce conversion rates and possibly complications in less-experienced centres.