Are bilobectomies acceptable procedures?

doi:10.1016/0003-4975(95)00470-6

The Annals of Thoracic Surgery

Volume 60, Issue 3, September 1995, Pages 640-645

https://doi.org/10.1016/0003-4975(95)00470-6 Get rights and content

Background.

Controversy about operative morbidity and oncologic value of bilobectomy has led to a review of our experience over the past 12 years.

Methods.

The charts of 112 patients (100 men and 12 women with a mean age of 63 years) were reviewed for operative mortality and morbidity and long-term survival. Survival of patients with stage I or stage II disease was compared with that of stage-matched and age-matched groups having right pneumonectomy.

Results.

Four patients (3.5%) died postoperatively. Nonfatal complications occurred in 55 patients (49%); the most frequent problem was pleural space disease (34%). Survival studies focused on the 96 patients with non-small cell bronchogenic cancer (44 in stage I, 32 in stage II, and 20 in stage IIIA). The overall 5-year survival rate was 40%; the 5-year survival rate was similar for stage I and stage II (41% for stage I, 50% for stage II, and 17% for stage IIIA). The incidence of local recurrence was significantly increased after bilobectomy for stage I cancer (χ² = 5,066; p < 0.05) compared with pneumonectomy but did not affect 5-year survival. Local recurrence and survival were similar after bilobectomy and pneumonectomy in stage II.

Conclusions.

These data demonstrate an increased morbidity after bilobectomy. Survival studies demonstrate an increased risk of local recurrence in patients with stage I disease, which might be partly explained by understaging.

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Cited by (19)

Respect the Middle Lobe: Perioperative Risk of Bilobectomy Compared With Lobectomy and Pneumonectomy
2024, Annals of Thoracic Surgery
In some cases of right-sided lung cancer, tumor extension, bronchial involvement, or pulmonary artery infiltration may necessitate bilobectomy. Although the middle lobe is believed to represent a fraction of total lung function, the morbidity and mortality associated with bilobectomy is not well described.
We retrospectively identified patients in The Society of Thoracic Surgeons Database who underwent lobectomy, bilobectomy, or pneumonectomy for lung cancer from 2009 to 2017. The primary outcome was 30-day perioperative mortality. We performed propensity matching by patient demographics, comorbidities, and perioperative variables for each surgical type against bilobectomy and ran Cox proportional hazard models. Secondary outcomes of 30-day morbidity and mortality of upper vs lower bilobectomy were also compared.
Within the study period 2911 bilobectomy, 65,506 lobectomy, and 3370 pneumonectomy patients met the inclusion criteria. Patients undergoing pneumonectomy and bilobectomy had fewer comorbidities than lobectomy patients. After propensity matching 30-day mortality of bilobectomy was comparable with left pneumonectomy (hazard ratio [HR], 1.35; 95% CI, 0.95-1.91; P = .09) and significantly worse than left (HR, 0.40; 95% CI, 0.29-0.56; P < .0001) or right (HR, 0.43; 95% CI, 0.31-0.59; P < .0001) lobectomy. Bilobectomy was associated with a survival advantage compared with right pneumonectomy (HR, 2.54; 95% CI, 1.72-3.74; P < .0001). Thirty-day morbidity was higher for bilobectomy compared with lobectomy, and upper bilobectomy had a significant unadjusted 30-day mortality advantage compared with lower bilobectomy (98.3% vs 97%, P = .04).
The morbidity and mortality of bilobectomy is significantly worse than lobectomy and is comparable with left pneumonectomy. The addition of middle lobectomy to a pulmonary resection is not without risk and should be carefully considered during preoperative risk stratification.
Place of bilobectomy in pulmonary oncology and prognostic factors in NSCLC
2014, Revue de Pneumologie Clinique
Les bilobectomies sont indiquées pour différentes tumeurs et différentes contraintes chirurgicales. Dans la littérature, leurs résultats sont souvent contradictoires. Nous avons revu les particularités de cette résection.
Les dossiers des opérés pour tumeur du poumon de 1980 à 2009 ont été analysés : données démographiques, indications, histologie, TNM, complications, résultats sur la survie des bilobectomies et comparés à ceux des lobectomies et pneumonectomies droites.
Les bilobectomies représentaient 7,2 % des résections droites pour tumeurs (235/3280), 82 % (192/235) étant réalisées pour cancer pulmonaire non à petites cellules (CBNPC). Les bilobectomies inférieures et moyennes (BIM) réalisées le plus souvent pour carcinoïdes et épidermoïdes représentaient 60 % des cas. Les complications étaient plus fréquentes après bilobectomie qu’après les autres résections, toutefois moins après bilobectomies supérieures et moyennes (BSM) qu’après BIM. En cas de CBNPC N0, les taux de survie à 5 ans des bilobectomies (46,1 %) étaient intermédiaires entre ceux des lobectomies (52,6 %) et des pneumonectomies (31,7 %), p < 10⁻⁶. La différence des taux de survie entre BSM et BIM n’était pas significative (p = 0,09). Il n’y avait pas de différence de survie entre les patients ayant reçu ou non un traitement néoadjuvant.
La bilobectomie permet des taux de survie à long terme satisfaisants, une mortalité postopératoire acceptable malgré un taux plus important de complications. La survie des BSM tend vers celle des pneumonectomies et celle des BIM vers celle des lobectomies, ce qui semble en rapport avec certains aspects anatomopathologiques différents des tumeurs qui en sont à l’origine.
Bilobectomy may be performed for different reasons and lung tumors. There are still controversies regarding the results of this procedure. We reviewed our experience of bilobectomy to evaluate the particularities of this resection.
The clinical files of patients operated on for lung tumors in two French centers between 1980 and 2009 were prospectively recorded and retrospectively analyzed. The characteristics, management, pathology, and survival after right-sided resections for non-small cell lung cancer (NSCLC) were then compared.
During the study period, 3280 right-sided resections were performed, including 235 bilobectomy (7%), for NSCLC in 192 cases (82%). Lower-middle lobectomy (LML) represented 60% of bilobectomy, with carcinoid tumors and squamous cell carcinoma being more frequent in this group. Upper-middle lobectomy (UML) represented 40% of bilobectomy, with less postoperative complications and mortality in this group. In N0-NSCLC, the rate of postoperative mortality and 5-year survival rates after bilobectomy (4.7% and 46.1%, respectively) were intermediate between lobectomy (2.7% and 52.6%) and pneumonectomy (9.6% and 31.7%, P < 10^–6 for both comparisons). There was no significant difference in 5-year survival rates according to the type of bilobectomy and the performance of any induction therapy.
Bilobectomy is associated with acceptable in-hospital mortality and encouraging 5-year survival rates despite an increased incidence of postoperative complications. Approximation in survival of UML and pneumonectomy and of LML and lobectomy may be due to differences in histologic features with different fissure extension and interlobar node involvement.
Does bilobectomy offer satisfactory long-term survival outcome for non-small cell lung cancer?
2013, Annals of Thoracic Surgery
Citation Excerpt :
Lower-middle bilobectomy was very probably associated with the highest morbidity due to the larger parenchymal resection performed (7 anatomic segments removed vs 5), and because, in our study, the group of patients included a higher proportion of males suffering from COPD and lower FEV1. Thus, modalities for reducing the residual space after this resection (such as insertion of a supplemental drain with a high suction level of 150 mm Hg [6], realization of a pneumoperitoneum [5, 6], or phrenic nerve scratch [8]) should be employed in particular to minimize the occurrence of pleural collections and prolonged air leak. Our preferred method is currently resection of the sixth rib (Fig 4).
Results of bilobectomy for non-small cell lung cancer have rarely been studied.
Retrospective analysis was conducted on patients with non-small cell lung cancer having undergone bilobectomy from January 1999 to June 2012 at our institution. Analysis aimed at determining perioperative mortality and morbidity, and at studying prognostic factors for long-term survival using the 7th TNM classification.
A total of 103 patients (85 males; mean age 62 years) underwent upper-middle bilobectomy (n = 54) or lower-middle bilobectomy (n = 49). Histologic examination revealed 51 adenocarcinomas, 43 squamous cell carcinomas and 9 other cell carcinomas. Perioperative mortality was 0.97%. The overall morbidity rate was 71%, whereas the rate of life-threatening complications was 9.6%. Complications were more frequent in men (p = 0.032), in patients with chronic pulmonary obstructive diseases (p = 0.030) and after lower-middle bilobectomy (p = 0.0016). The overall 5-year Kaplan-Meier survival rate was 57.8%. In univariate analysis, factors associated with increased survival were the following: pathologic stage (stage I 74.9%, stage II 64.1%, stage III 28.8%, p = 0.0018); nodal status (N0 vs N1, p = 0.011; N0 vs N2, p = 0.0015; N0 vs N+, p = 0.0008); R status (R0 vs R1, p = 0.0032), and smoking status (past smoker or nonsmoker vs active smoker, p = 0.00054). Multivariate analysis revealed that active smokers (RR = 3.87, CI 95% [1.83 to 8.21]; p = 0.00042) and increasing stage (stage 0: RR=1; stage I: RR = 1.98, CI 95% [1.38 to 2.83]; stage II: RR = 3.90, CI 95% [1.90 to 8.02]; stage III: RR=7.72, CI 95% [2.62 to 22.73]; stage IV: RR = 15.25, CI 95% [3.61 to 64.40]; p = 0.0042) were significantly associated with poorer survival.
Bilobectomy can be performed with low mortality, acceptable morbidity and long term survival in accordance with TNM staging.
Bilobectomy for lung cancer: Analysis of indications, postoperative results, and long-term outcomes
2012, Annals of Thoracic Surgery
Citation Excerpt :
In the series of Keller and colleagues, 108 (65%) of the 166 patients underwent UMB. On the contrary, in the other experiences, a higher number of MLB was reported: Deneuville and colleagues [10] reported that 127 (86%) of 148 patients underwent MLB; Massard and colleagues [11] reported 94 (84%) of the 112 patients received a MLB; Carbognani and colleagues [12], 38 (82.6%) of 46 patients; and finally Kim and colleagues [14], 57 (62%) of 92 patients. In our series, we reported a similar incidence of UMB (52.7%, n = 77) and LMB (47.3%, n = 69).
Bilobectomy for lung cancer is considered a high-risk procedure for the increased postoperative complication rate and the negative impact on survival. We analyzed the safety and the oncologic results of this procedure.
We retrospectively reviewed patients who underwent bilobectomy for lung cancer between October 1998 and August 2009. Age, gender, bilobectomy type and indication, complications, pathology, stage, and survival were analyzed.
Bilobectomy was performed on 146 patients (101 men; mean age, 62 years). There were 77 upper-middle and 69 middle-lower bilobectomies. Indications were tumor extending across the fissure in 27 (18.5%) patients, endobronchial tumor in 39 (26.7%), extrinsic tumor or nodal invasion of bronchus intermedius in 66 (45.2%), and vascular invasion in 14 (9.6%). An extended resection was performed in 24 patients (16.4%). Induction therapy was performed in 43 patients (29.4%). Thirty-day mortality was 1.4% (n = 2). Overall morbidity was 47.2%. Mean chest tube persistence was 7 days (range, 6 to 46 days). Overall 5-year survival was 58%. Significance differences in survival were observed among different stages (stage I, 70%; stage II, 55%; stage III, 40%; p = 0.0003) and the N status (N0, 69%; N1, 56%; N2, 40%; p = 0.0005). Extended procedure (p = 0.0003) and superior bilobectomy (p = 0.0008) adversely influenced survival. Multivariate analysis demonstrated that an extended resection (p = 0.01), an advanced N disease (p = 0.02), and an upper-mild lobectomy (p = 0.02) adversely affected prognosis.
Bilobectomy is associated with a low mortality and an increased morbidity. Survival relates to disease stage and N factor. Optimal prognosis is obtained in patients with lower-middle lobectomy without extension of the resection.
Bilobectomy for non-small cell lung cancer: A search for clinical factors that may affect perioperative morbidity and long-term survival
2010, Journal of Thoracic and Cardiovascular Surgery
The resection of two lobes for non–small cell lung cancer has the potential for significant morbidity and mortality as well as a negative impact on survival. The purpose of this study is to analyze our bilobectomy experience.
Age, gender, diagnosis, bilobectomy type, bilobectomy indication, operative technique, pathologic condition, major complications, stage, and survival were reviewed from 1984 through 2007. Major complications were compared by Fisher's exact testing. Kaplan–Meier survival curves were compared by log–rank and likelihood ratio analysis.
Bilobectomies were performed on 92 patients with non–small cell lung cancer. A total of 35 upper–middle and 57 middle–lower bilobectomies were performed. Indications for bilobectomy were bronchial involvement (n = 49), extension across the fissure (n = 36), or other reasons (n = 7). The 5-year survival for all patients was 42%. Significant differences in survival were observed among the different stages (stage I, 65%; stage II, 42%; stage III, 13%; P < .0001). Squamous cell carcinomas had a higher 5-year survival than adenocarcinomas (54% vs 32%), a difference that approached significance by log–rank test (P < .079) and reached significance by likelihood ratios (P < .048). When bilobectomy was performed for extension across the fissure, survival approached significance for squamous cell carcinomas (71%) over adenocarcinomas (42%) by log–rank test (P < .089) and was significant by likelihood ratio (P < .048) when comparing survival between adenocarcinoma and squamous cell carcinoma. Multivariate analysis demonstrated that increasing age (P = .0102) and upper&middle bilobectomy (P = .0285) adversely affected 5-year survival, whereas early-stage disease (P = .0245) beneficially affected 5-year survival.
Bilobectomy can be performed with acceptable morbidity and mortality. Survival relates to disease stage. Optimal survival benefit occurs when the indication for bilobectomy is squamous cell carcinoma extending across the fissure.
NSCLC of early stage the place of surgery
2008, Revue des Maladies Respiratoires
Les cancers bronchiques non à petites cellules (CBNPC) de petit stade (stades I et II) se présentent sous des formes extrêmement variées et nombreuses, tant en ce qui concerne le T et le N que leur histologie. Un point commun les caractérise cependant : ils sont accessibles à une chirurgie d’exérèse curative sous réserve que l’état du patient la permette et offrent de ce fait les meilleures chances de guérison. Une grande variété d’exérèses existe et la tendance actuelle est de privilégier celles permettant d’éviter les pneumonectomies dont la mortalité postopératoire est élevée, notamment à droite. La chirurgie a une place incontournable sur le plan thérapeutique, mais ne peut être curatrice que sous réserve d’être complète, éradiquant macroscopiquement toutes les lésions tumorales et comportant donc un curage ganglionnaire. La place de la chirurgie est en outre souvent diagnostique, et elle permet une meilleure classification histologique, le meilleur des stagings des CBNPC, et donc de mieux adapter les traitements médicaux. De ce fait, sa place est déterminante sur l’ensemble de la prise en charge thérapeutique.
Non-small cell lung cancer (NSCLC) of early stage (stage I and II) form a wide variety of numerous heterogeneous tumors in respect to the T, the N and the histology. However, they share the common characteristic of being resectable, so providing the best chances of cure in patients amenable to surgery. A wide range of resections is available and the tendency at the present time is to favour resections permitting to avoid performing pneumonectomy, an operation whose postoperative mortality may be considerable, particularily on the right side. The place of surgery is of paramount importance in view of cure on condition that the resection is complete, that is without any tumor left behind, and includes a radical mediastinal lymphadenectomy. The place of surgery is also often diagnostic as well as therapeutic, and surgery provides the best histologic classification, the most accurate staging, and thus the best adapted adjuvant therapy and global management.

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Are bilobectomies acceptable procedures?

Background.

Methods.

Results.

Conclusions.

Ann Thorac Surg

Chest

J Thorac Cardiovasc Surg

J Thorac Surg

Chest

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg