109MO Respect the middle lobe: Perioperative survival of bilobectomy compared to lobectomy and pneumonectomy

Abstract

In some cases of right-sided lung cancer, tumor extension, bronchial involvement, or pulmonary artery infiltration may necessitate bilobectomy. Although the middle lobe is thought to represent only a small fraction of the total right lung function, the morbidity and mortality associated with bilobectomy in comparison to other pulmonary resections is not well described. We retrospectively identified patients in the Society for Thoracic Surgeons General Thoracic Surgery Database who underwent elective lobectomy, bilobectomy, or pneumonectomy for lung cancer from 2009 to 2017, excluding reoperations. The primary outcome was 30-day perioperative mortality. Cox proportional hazards were calculated after adjusting for patient demographics, comorbidities, and perioperative variables. Secondary outcomes included 30-day morbidity, mortality of upper versus lower bilobectomy, and rate of nodal upstaging or downstaging. Within the study period, 2,911 bilobectomy, 65,506 lobectomy, and 3,024 pneumonectomy patients met inclusion criteria. Patients undergoing pneumonectomy and bilobectomy had fewer comorbidities than lobectomy patients. Both unadjusted and adjusted 30-day mortality of bilobectomy were comparable to a left pneumonectomy, which was worse than left or right lobectomy but better than right pneumonectomy (Table). Bilobectomy had consistently worse 30-day morbidity than lobectomy. Upper bilobectomy had a small but significant unadjusted 30-day survival advantage compared to lower bilobectomy (98.3% vs 97%, log-rank p=0.04). Nodal upstaging of bilobectomy (22.8%) fell between that of lobectomy and pneumonectomy.Table: 109MOAdjusted 30-day Cox proportional hazards and absolute mortalityCox proportional hazardHR95% CIpAbsolute mortalityBilobectomyref--2.6%Left lobectomy0.440.34-0.56<0.00011.0%Right lobectomy0.470.36-0.60<0.00011.1%Left pneumonectomy1.320.95-1.850.103.5%Right pneumonectomy2.762.01-3.81<0.00017.0% Open table in a new tab The morbidity and mortality of bilobectomy is significantly worse than lobectomy and is comparable to the outcomes of left pneumonectomy. The addition of middle lobectomy to a pulmonary resection is not without risk and should be carefully considered during pre-operative risk stratification.