Complete video assisted thoracic surgery major lung resection for Lung Cancer: the impact of Tuberculosis and post-inflammatory adhesions on outcomes

Abstract

OBJECTIVE: Minimally invasive Video Assisted Thoracic Surgery (VATS) is becoming increasingly established as the surgical approach of choice for curative resection of lung cancer. However, the impact of tuberculosis (TB) and post inflammatory adhesions – which are common in Asia – on outcomes after VATS has rarely been quantified. METHODS: Clinical data for 139 patients receiving major lung resection for lung cancer by a single thoracic surgeon in Hong Kong – a region endemic for TB – were reviewed. Only patients receiving a strictly defined ‘complete’ VATS (cVATS) approach with 3 ports, no rib-spreading and monitor visualization only were included for study. RESULTS: This cohort included 91 patients (65.5%) with pre-operative clinical stage I disease and 39 (28.1%) with a history of TB. Post inflammatory adhesions were encountered in 94 patients (67.6%), including inter-pleural adhesions in 86 (61.9%), hilar adhesions in 23 (16.5%), and fused inter-lobar fissures in 15 (10.8%). There was no in-hospital mortality and no conversion to open surgery. Previous TB increased mean operation time (180 minutes versus 148 minutes, p = 0.02), chest drain duration (6.6 days versus 4.7 days, p = 0.04), length of stay (9.9 days versus 6.6 days, p = 0.02), and incidence of postoperative air leak (35.7% versus 14.4%, p < 0.01). Adhesions prolonged operation time (174 minutes versus 124 minutes, p < 0.01), and inter-pleural adhesions in particular prolonged length of stay (8.5 days versus 6.3 days, p = 0.04). Minor non-air leak complications occurred in six patients (4.3%), but were not associated with TB or any form of adhesions. Fused fissures were associated with higher rate of downstaging after surgery (40.0% versus 17.7%, p = 0.04), suggesting false positives were more likely in pre-operative investigations for these patients. Neither TB nor any form of adhesions affected 2-year recurrence-free survival rates amongst patients confirmed to have stage I disease postoperatively, suggesting that these factors did not impair the adequacy of staging or cancer treatment by cVATS. CONCLUSIONS: Pleural adhesions from inflammatory disease (including TB) can prolong operation times and delay recovery following cVATS for lung cancer. These factors should be considered when interpreting surgical outcomes in regions where TB is prevalent, such as Asia. However, they do not diminish the safety or oncologic efficacy of surgery, and should not be considered contra-indications for cVATS.