Risk factors for postoperative chylothorax after robot-assisted versus video-assisted thoracic surgery in radical lung cancer resection: A propensity score matching study_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

LIU Deyu ¹ , XU Shiguang ² , XU Wei ² , LIU Bo ² , LI Bo ² , WANG Xilong ² , HU Boxiao ² , WANG Shiqi ² , XIU Yuchi ² ,  WANG Shumin ²

1. Graduate Training Base of General Hospital of Northern Theater Command, China Medical Univercity, Shenyang, 110016, P. R. China;
2. Department of Thoracic Surgery, General Hospital of Northern Theater Command, Shenyang, 110016, P. R. China;

Corresponding author：

WANG Shumin, Email: sureman2003congo@163.com

Keywords：

Robot-assisted thoracic surgery; video-assisted thoracoscopic surgery; postoperative chylothorax; radical lung cancer resection; systematic lymph node dissection; propensity score matching study

DOI：

10.7507/1007-4848.202107014

Video：

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Objective To compare the postoperative chylothorax outcomes of robot-assisted thoracic surgery (RATS) and video-assisted thoracoscopic surgery (VATS), analyze the risk factors for postoperative chylothorax after minimally invasive radical lung cancer resection and explore possible prevention and control measures. Methods Between June 2012 and September 2020, 1083 patients underwent minimally invasive pulmonary lobectomy and systematic lymph node dissection in our hospital, including 578 males and 505 females with an average age of 60.6±9.4 years. Patients were divided into two groups according to the operation methods: a RATS group (499 patients) and a VATS group (584 patients). After propensity score matching, 434 patients were included in each group (868 patients in total). Chylothorax and other perioperative indicators were compared between the two groups. Univariate and multivariate logistic regression analyses were performed to identify risk factors for postoperative chylothorax. Results Overall, 24 patients were diagnosed with chylothorax after surgery. Compared with the VATS group, the rate of chylothorax was higher (3.9% vs. 1.6%, P=0.038), the groups and numbers of dissected lymph nodes were more (both P<0.001), and the intraoperative blood loss was significantly less (P<0.001) in the RATS group. There was no statistical difference in the postoperative hospital stay (P=0.256) or chest tube drainage time (P=0.504) between the two groups. Univariate analysis showed that gender (P=0.021), operation approach (P=0.045), smoking (P=0.001) and the groups of dissected lymph nodes (P<0.001) were significantly associated with the development of chylothorax. Multivariate analysis showed that smoking [OR=4.344, 95%CI (1.149, 16.417), P=0.030] and the groups of dissected lymph nodes [OR=1.680, 95%CI (1.221, 2.311), P=0.001] were the independent risk factors for postoperative chylothorax. Conclusion Compared with the VATS, the rate of chylothorax after RATS is higher with more dissected lymph nodes and less blood loss. The incidence of chylothorax after minimally invasive radical lung cancer resection is higher in the patients with increased dissected lymph node groups and smoking history.

Citation： LIU Deyu, XU Shiguang, XU Wei, LIU Bo, LI Bo, WANG Xilong, HU Boxiao, WANG Shiqi, XIU Yuchi, WANG Shumin. Risk factors for postoperative chylothorax after robot-assisted versus video-assisted thoracic surgery in radical lung cancer resection: A propensity score matching study. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2022, 29(4): 449-456. doi: 10.7507/1007-4848.202107014 Copy

1.	Sung H, Ferlay J, Siegel RL, et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin, 2021, 71(3): 209-249.
2.	Ettinger DS, Wood DE, Aisner DL, et al. NCCN guidelines insights: Non-small cell lung cancer, version 2. 2021. J Natl Compr Canc Netw, 2021, 19(3): 254-266.
3.	Bryant AS, Minnich DJ, Wei B, et al. The incidence and management of postoperative chylothorax after pulmonary resection and thoracic mediastinal lymph node dissection. Ann Thorac Surg, 2014, 98(1): 232-235.
4.	王述民, 许世广, 刘博, 等. 机器人肺叶切除术治疗非小细胞肺癌. 中国胸心血管外科临床杂志, 2013, 20(3): 308-311.
5.	Uchida S, Suzuki K, Hattori A, et al. Surgical intervention strategy for postoperative chylothorax after lung resection. Surg Today, 2016, 46(2): 197-202.
6.	Liu CY, Hsu PK, Huang CS, et al. Chylothorax complicating video-assisted thoracoscopic surgery for non-small cell lung cancer. World J Surg, 2014, 38(11): 2875-2881.
7.	Chalret du Rieu M, Baulieux J, Rode A, et al. Management of postoperative chylothorax. J Visc Surg, 2011, 148(5): e346-e352.
8.	徐宁, 汤磊, 陈浩, 等. 胸腔镜与开胸肺叶切除手术方式的比较. 临床肺科杂志, 2014, 19(4): 627-629.
9.	王述民. 达芬奇机器人在肺癌根治术中的应用现状及展望. 中国肿瘤, 2014, 23(9): 736-742.
10.	Kent M, Wang T, Whyte R, et al. Open, video-assisted thoracic surgery, and robotic lobectomy: Review of a national database. Ann Thorac Surg, 2014, 97(1): 236-242.
11.	Kutlu CA, Sayar A, Olgac G, et al. Chylothorax: A complication following lung resection in patients with NSCLC—Chylothorax following lung resection. Thorac Cardiovasc Surg, 2003, 51(6): 342-345.
12.	Akin H, Olcmen A, Isgorucu O, et al. Approach to patients with chylothorax complicating pulmonary resection. Thorac Cardiovasc Surg, 2012, 60(2): 135-139.
13.	Wu Yl, Huang ZF, Wang SY, et al. A randomized trial of systematic nodal dissection in resectable non-small cell lung cancer. Lung Cancer, 2002, 36(1): 1-6.
14.	Hughes MJ, Chowdhry MF, Woolley SM, et al. In patients undergoing lung resection for non-small cell lung cancer, is lymph node dissection or sampling superior? Interact Cardiovasc Thorac Surg, 2011, 13(3): 311-315.
15.	Sugi K, Nawata K, Fujita N, et al. Systematic lymph node dissection for clinically diagnosed peripheral non-small-cell lung cancer less than 2 cm in diameter. World J Surg, 1998, 22(3): 290-294.
16.	Okada M, Sakamoto T, Yuki T, et al. Selective mediastinal lymphadenectomy for clinico-surgical stage Ⅰ non-small cell lung cancer. Ann Thorac Surg, 2006, 81(3): 1028-1032.
17.	Hishida T, Miyaoka E, Yokoi K, et al. Lobe-specific nodal dissection for clinical stageⅠ and Ⅱ NSCLC: Japanese multi-institutional retrospective study using a propensity score analysis. J Thorac Oncol, 2016, 11(9): 1529-1537.
18.	Demoor T, Bracke KR, Vermaelen KY, et al. CCR7 modulates pulmonary and lymph node inflammatory responses in cigarette smoke-exposed mice. J Immunol, 2009, 183(12): 8186-8194.
19.	Robbins CS, Franco F, Mouded M, et al. Cigarette smoke exposure impairs dendritic cell maturation and T cell proliferation in thoracic lymph nodes of mice. J Immunol, 2008, 180(10): 6623-6628.
20.	Öztoprak S, Gärtner H, Schick B, et al. Influence of external and endogenous factors on cervical lymph nodes: Sonographic study of size and morphology. HNO, 2018, 66(5): 383-389.
21.	Cho HJ, Kim DK, Lee GD, et al. Chylothorax complicating pulmonary resection for lung cancer: Effective management and pleurodesis. Ann Thorac Surg, 2014, 97(2): 408-413.
22.	Takuwa T, Yoshida J, Ono S, et al. Low-fat diet management strategy for chylothorax after pulmonary resection and lymph node dissection for primary lung cancer. J Thorac Cardiovasc Surg, 2013, 146(3): 571-574.
23.	Rudrappa M, Paul M. Chylothorax. Treasure Island. Florida: StatPearls Publishing, 2018.
24.	Merrigan BA, Winter DC, O'Sullivan GC. Chylothorax. Br J Surg, 1997, 84(1): 15-20.
25.	Misthos P, Kanakis MA, Lioulias AG. Chylothorax complicating thoracic surgery: Conservative or early surgical management? Updates Surg, 2012, 64(1): 5-11.
26.	Zabeck H, Muley T, Dienemann H, et al. Management of chylothorax in adults: When is surgery indicated? Thorac Cardiovasc Surg, 2011, 59(4): 243-246.
27.	Chen C, Wang Z, Hao J, et al. Chylothorax after lung cancer surgery: A key factor influencing prognosis and quality of life. Ann Thorac Cardiovasc Surg, 2020, 26(6): 303-310.
28.	管添. 荧光成像技术在胸外科手术中的应用进展. 中国微创外科杂志, 2021, 21(8): 746-750.

1. Sung H, Ferlay J, Siegel RL, et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin, 2021, 71(3): 209-249.
2. Ettinger DS, Wood DE, Aisner DL, et al. NCCN guidelines insights: Non-small cell lung cancer, version 2. 2021. J Natl Compr Canc Netw, 2021, 19(3): 254-266.
3. Bryant AS, Minnich DJ, Wei B, et al. The incidence and management of postoperative chylothorax after pulmonary resection and thoracic mediastinal lymph node dissection. Ann Thorac Surg, 2014, 98(1): 232-235.
4. 王述民, 许世广, 刘博, 等. 机器人肺叶切除术治疗非小细胞肺癌. 中国胸心血管外科临床杂志, 2013, 20(3): 308-311.
5. Uchida S, Suzuki K, Hattori A, et al. Surgical intervention strategy for postoperative chylothorax after lung resection. Surg Today, 2016, 46(2): 197-202.
6. Liu CY, Hsu PK, Huang CS, et al. Chylothorax complicating video-assisted thoracoscopic surgery for non-small cell lung cancer. World J Surg, 2014, 38(11): 2875-2881.
7. Chalret du Rieu M, Baulieux J, Rode A, et al. Management of postoperative chylothorax. J Visc Surg, 2011, 148(5): e346-e352.
8. 徐宁, 汤磊, 陈浩, 等. 胸腔镜与开胸肺叶切除手术方式的比较. 临床肺科杂志, 2014, 19(4): 627-629.
9. 王述民. 达芬奇机器人在肺癌根治术中的应用现状及展望. 中国肿瘤, 2014, 23(9): 736-742.
10. Kent M, Wang T, Whyte R, et al. Open, video-assisted thoracic surgery, and robotic lobectomy: Review of a national database. Ann Thorac Surg, 2014, 97(1): 236-242.
11. Kutlu CA, Sayar A, Olgac G, et al. Chylothorax: A complication following lung resection in patients with NSCLC—Chylothorax following lung resection. Thorac Cardiovasc Surg, 2003, 51(6): 342-345.
12. Akin H, Olcmen A, Isgorucu O, et al. Approach to patients with chylothorax complicating pulmonary resection. Thorac Cardiovasc Surg, 2012, 60(2): 135-139.
13. Wu Yl, Huang ZF, Wang SY, et al. A randomized trial of systematic nodal dissection in resectable non-small cell lung cancer. Lung Cancer, 2002, 36(1): 1-6.
14. Hughes MJ, Chowdhry MF, Woolley SM, et al. In patients undergoing lung resection for non-small cell lung cancer, is lymph node dissection or sampling superior? Interact Cardiovasc Thorac Surg, 2011, 13(3): 311-315.
15. Sugi K, Nawata K, Fujita N, et al. Systematic lymph node dissection for clinically diagnosed peripheral non-small-cell lung cancer less than 2 cm in diameter. World J Surg, 1998, 22(3): 290-294.
16. Okada M, Sakamoto T, Yuki T, et al. Selective mediastinal lymphadenectomy for clinico-surgical stage Ⅰ non-small cell lung cancer. Ann Thorac Surg, 2006, 81(3): 1028-1032.
17. Hishida T, Miyaoka E, Yokoi K, et al. Lobe-specific nodal dissection for clinical stageⅠ and Ⅱ NSCLC: Japanese multi-institutional retrospective study using a propensity score analysis. J Thorac Oncol, 2016, 11(9): 1529-1537.
18. Demoor T, Bracke KR, Vermaelen KY, et al. CCR7 modulates pulmonary and lymph node inflammatory responses in cigarette smoke-exposed mice. J Immunol, 2009, 183(12): 8186-8194.
19. Robbins CS, Franco F, Mouded M, et al. Cigarette smoke exposure impairs dendritic cell maturation and T cell proliferation in thoracic lymph nodes of mice. J Immunol, 2008, 180(10): 6623-6628.
20. Öztoprak S, Gärtner H, Schick B, et al. Influence of external and endogenous factors on cervical lymph nodes: Sonographic study of size and morphology. HNO, 2018, 66(5): 383-389.
21. Cho HJ, Kim DK, Lee GD, et al. Chylothorax complicating pulmonary resection for lung cancer: Effective management and pleurodesis. Ann Thorac Surg, 2014, 97(2): 408-413.
22. Takuwa T, Yoshida J, Ono S, et al. Low-fat diet management strategy for chylothorax after pulmonary resection and lymph node dissection for primary lung cancer. J Thorac Cardiovasc Surg, 2013, 146(3): 571-574.
23. Rudrappa M, Paul M. Chylothorax. Treasure Island. Florida: StatPearls Publishing, 2018.
24. Merrigan BA, Winter DC, O'Sullivan GC. Chylothorax. Br J Surg, 1997, 84(1): 15-20.
25. Misthos P, Kanakis MA, Lioulias AG. Chylothorax complicating thoracic surgery: Conservative or early surgical management? Updates Surg, 2012, 64(1): 5-11.
26. Zabeck H, Muley T, Dienemann H, et al. Management of chylothorax in adults: When is surgery indicated? Thorac Cardiovasc Surg, 2011, 59(4): 243-246.
27. Chen C, Wang Z, Hao J, et al. Chylothorax after lung cancer surgery: A key factor influencing prognosis and quality of life. Ann Thorac Cardiovasc Surg, 2020, 26(6): 303-310.
28. 管添. 荧光成像技术在胸外科手术中的应用进展. 中国微创外科杂志, 2021, 21(8): 746-750.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Risk factors for postoperative chylothorax after robot-assisted versus video-assisted thoracic surgery in radical lung cancer resection: A propensity score matching study

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