Perioperative survival after a bilobectomy: respect the middle lobe

Results of a large retrospective analysis shed more light on the perioperative mortality and morbidity following a bilobectomy. From this analysis, it seems that the perioperative survival after a bilobectomy is worse than what is seen after a lobectomy, comparable to the survival following a left pneumonectomy and superior to the survival outcomes following a right pneumonectomy

In some cases of right-sided lung cancer, tumor extension, bronchial involvement, or pulmonary artery infiltration antitumoral surgery may necessitate a bilobectomy. With this procedure, two lobes of the right lung are resected, including the middle lobe. Although the middle lobe is thought to represent only a small fraction of the total right lung function, the morbidity and mortality associated with a bilobectomy compared to other pulmonary resections is not well described.

Methods

To address this knowledge gap, Li et al. retrospectively analyzed the data from patients in the Society for Thoracic Surgeons General Thoracic Surgery Database who underwent an elective lobectomy, bilobectomy, or pneumonectomy for lung cancer in the period from 2009 to 2017. The primary outcome of the presented analysis consisted of the 30-day perioperative mortality, while secondary objectives included 30-day morbidity, mortality of upper vs. a lower bilobectomy, and the rate of nodal upstaging or downstaging. Reoperations, surgeries addressing metastatic disease and non-elective procedures were excluded from the study.

Results

During the period that was studied, a total of 2,911 bilobectomies, 65,506 lobectomies, and 3,024 pneumonectomies were performed that met the inclusion criteria. Both the unadjusted and adjusted 30-day mortality of a bilobectomy was comparable to what was achieved with a left pneumonectomy. This 30-day mortality was worse than what was observed among patients with a left or right lobectomy but better than the 30-day mortality obtained with a right pneumonectomy. Bilobectomy had consistently worse 30-day morbidity than lobectomy. Of note, an 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). This should not come as a big surprise as an upper bilobectomy includes the removal of 5 segments as compared to the removal of 7 segments with a lower bilobectomy. In fact, the 30-day survival of a lower bilobectomy closely mirrored that of a left pneumonectomy. The incidence of 30-day post-operative events was similar between bilobectomy and pneumonectomy patients at 48.9% and 48.0%, respectively. However, this rate was markedly lower in lobectomy patients at 38%. Nodal upstaging of bilobectomy (22.8%) fell between that of lobectomy and pneumonectomy

Conclusions

The perioperative survival after a bilobectomy is worse than what is seen after a lobectomy and comparable to the survival following a left pneumonectomy. Compared to a lobectomy, a bilobectomy also comes with a worse perioperative morbidity. However, the survival after a bilobectomy is superior to what is observed in patients who undergo a right pneumonectomy. As such, the addition of middle lobectomy to a pulmonary resection is not without risk and should be carefully considered during pre-operative risk stratification. 

Reference

Li A, et al. Respect the Middle Lobe: Perioperative Survival of Bilobectomy Compared to Lobectomy and Pneumonectomy. Presented at ELCC 2022; Abstract 109MO.