Perioperative Risk and Modifiable Targets in Sequential Pulmonary Resection Within One Year

Background: Sequential pulmonary resections are heterogeneous clinical scenarios that may increase perioperative risks for patients. This study uses within-patient paired comparisons to characterize the perioperative experience of sequential operations, including optimal timing to return, impact of operative sequence, and complication rates. Methods: A single-institution retrospective review was conducted of 231 patients who underwent sequential pulmonary resections within one year between 2017 and 2025. Paired analysis was conducted for perioperative outcomes at the first (S1) and second (S2) operations. The primary outcome was major morbidity (Clavien-Dindo ≥ IIIa) at S2. A multivariable logistic regression model was fit for major morbidity at S2 with pre-specified predictors. Firth penalized logistic regression was performed with sensitivity analysis. Results: Across the entire cohort, major morbidity was similar at S1 and S2 (5% to 7%, p = 0.503). Sequential lobectomy+ (OR 4.87, 95% CI 1.02-23.20, p = 0.047) and ipsilateral re-entry (OR 4.48, 95% CI 1.31-15.36, p = 0.017) were both associated with major morbidity. Both associations persisted under Firth penalization (OR 4.99, 95% CI 1.02-20.54 and OR 4.06, 95% CI 1.32-14.34). No specific time interval was associated with major morbidity, whether modeled categorically or continuously. Prolonged air leak was the only complication that rose significantly at S2 (4% to 10%, p = 0.011), and was associated with increased length of stay after S2. Conclusions: Major morbidity did not increase significantly at S2 for sequential pulmonary resections within one year, and no interval within the year was shown to be safer than another. As the magnitude of the surgery (sequential lobectomy) and ipsilateral re-entry were most strongly associated with risk independent of timing, those patients should be counseled appropriately. Prolonged air leak prevention is a potentially modifiable target for enhanced recovery pathways adapted to reoperative patients.