Prediction of Pulmonary Artery-Adherent Lymph Nodes for Minimally Invasive Lung Resection

During minimally invasive surgery (MIS), pulmonary artery (PA)-adherent lymph nodes (LNs) may increase the risk of conversion to thoracotomy and/or PA injury. The aims of this study were to investigate (1) preoperative workups as predictors of PA-adherent LNs and (2) predictors of conversion/PA injury during MIS.

We investigated 1210 patients who underwent anatomical lung resection (MIS: 772, thoracotomy: 438) and determined the PA-adherent LN status by reviewing the operation video/record. The size and calcification of the hilar LNs on computed tomography, bilateral high metabolic activity on positron emission tomography, and mucosal dark pigmentation on bronchoscopy were evaluated as potential predictors for PA-adherent LNs.

Among patients who underwent all 3 workups (n = 594), both bronchoscopy and computed tomography were independent predictors for PA-adherent LNs; the combination of dark pigmentation and LN size ≥8 mm stratified patients according to the risk of PA-adherent LNs (lowest to highest risk, 3%-65%). Among the patients who underwent MIS (n = 772), conversion and PA injuries were observed in 32 (4%) and 25 (3%) patients, respectively. Multivariate analysis revealed that the presence of PA-adherent LNs was an independent predictor of both conversion and PA injury (both P < .001). The effect of PA-adherent LNs on conversion risk was significantly modified by the resected lobe (P = .008).

The presence of PA-adherent LNs is associated with a high risk of conversion/PA injury during MIS. Bronchial dark pigmentation, size of hilar LNs, and their combination are useful for predicting PA-adherent LNs; this finding may help in achieving safer MIS.