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Thorac Cardiovasc Surg 2023; 71(04): 317-326
DOI: 10.1055/s-0042-1742362
Original Thoracic

Bleeding during Learning Curve of Thoracoscopic Lobectomy: CUSUM Analysis Results

Alfonso Fiorelli 
1   Thoracic Surgery Unit, University of Campania Luigi Vanvitelli, Naples, Italy
,
Roberto Cascone
1   Thoracic Surgery Unit, University of Campania Luigi Vanvitelli, Naples, Italy
,
Annalisa Carlucci
1   Thoracic Surgery Unit, University of Campania Luigi Vanvitelli, Naples, Italy
,
Giovanni Natale
1   Thoracic Surgery Unit, University of Campania Luigi Vanvitelli, Naples, Italy
,
Antonio Noro
1   Thoracic Surgery Unit, University of Campania Luigi Vanvitelli, Naples, Italy
,
Mary Bove
1   Thoracic Surgery Unit, University of Campania Luigi Vanvitelli, Naples, Italy
,
Mario Santini 
1   Thoracic Surgery Unit, University of Campania Luigi Vanvitelli, Naples, Italy
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Abstract

Background The management of intraoperative bleeding during thoracoscopic lobectomy is challenging, especially for non-experienced surgeons. We evaluated intraoperative bleeding in relation to learning curve of thoracoscopic lobectomy, the strategies to face it, the outcomes, and the target case number for gaining the technical proficiency.

Methods This was a retrospective single center study including consecutive patients undergoing thoracoscopic lobectomy for lung cancer. Based on cumulative sum analysis, patients were divided into early and late experience groups, and the differences on surgical outcomes, with particular focus on vascular injury, were statistically compared.

Results Eight-three patients were evaluated. Cumulative sum charts showed a decreasing of operative time, blood loss, and hospital stay after the 49th, the 43th, and the 39th case, respectively. Early (n = 49) compared with late experience group (n = 34) was associated with higher conversion rate (p = 0.08), longer operative time (p <0.0001), greater blood loss (p <0.0001), higher transfusion rate (p = 0.01), higher postoperative air leak rate (p = 0.02), longer chest tube stay (p <0.0001), and hospitalization (p <0.0001). Six patients (7%) had intraoperative bleeding during early phase of learning curve, successfully treated by thoracoscopy in four cases. Patients with vascular injury (n = 6) compared with control group (n = 77) presented a longer operative time (p = 0.003), greater blood loss (p = 0.0001), and higher transfusion rate (p = 0.001); no significant differences were found regarding postoperative morbidity (p = 0.57), length of chest tube stay (p = 0.07), and hospitalization (p = 0.07).

Conclusion Technical proficiency was achieved after 50 procedures. All vascular injuries occurred in the early phase of learning curve; they were safely managed, without affecting surgical outcomes.

Keywords

surgery - complications - thoracoscopy - VATS - pulmonary artery - left upper lobectomy


Publication History

Received: 09 March 2021

Accepted: 24 November 2021

Article published online:
08 February 2022

© 2022. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

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