Perioperative safety and risk stratification of simultaneous resection for multiple pulmonary nodules via video-assisted thoracoscopic surgery: a retrospective cohort study

Background: The detection of multiple pulmonary nodules (MPNs) has increased significantly, yet evidence regarding the safety of simultaneous resection using video-assisted thoracoscopic surgery (VATS) remains limited. This study evaluated treatment-requiring postoperative pulmonary complications (PPCs) and procedure-specific risk factors after VATS-based simultaneous resection for MPNs, with particular attention to combined anatomical resections and segmentectomy-related anatomy.

Methods: Lung cancer patients with a dominant tumor ≤3 cm who underwent synchronous thoracoscopic resection between December 2008 and October 2020 were retrospectively reviewed. The primary endpoint was treatment-requiring PPCs, defined as Clavien-Dindo grade ≥II. Multivariable logistic regression was used to identify factors associated with treatment-requiring PPCs. Subgroup and supplementary analyses evaluated resection combinations, basal segment involvement, segmentectomy complexity, surgery period, and complication severity.

Results: Among 1,052 patients, treatment-requiring PPCs occurred in 14.0% of patients, with no perioperative mortality. Impaired pulmonary function [forced expiratory volume in 1 second (FEV₁%) less than 80%; adjusted odds ratio (aOR) =2.76, P=0.002], larger dominant tumor size (aOR =1.35, P=0.03), and the resection of more than two nodules (aOR =1.75, P=0.02) independently increased baseline risks. In the comprehensive analysis, advanced age (≥70 years) (aOR =1.72, P=0.046) and lobectomy involvement (aOR =1.84, P=0.02) were independently associated with treatment-requiring PPCs. For two-nodule cases, combining a lobectomy with a segmentectomy carried the highest risk of treatment-requiring PPCs (aOR =3.19, P=0.007). Basal segment involvement was associated with treatment-requiring PPCs in the segmentectomy cohort (aOR =2.14, P=0.02) and remained associated after additional adjustment for complex segmentectomy.

Conclusions: Video-assisted thoracoscopic simultaneous resection of MPNs appears feasible in selected patients, with a low severe PPC rate and no perioperative mortality. Preoperative pulmonary reserve, nodule burden, advanced age, lobectomy involvement, and basal segment involvement in segmentectomy-related procedures should be considered when planning individualized surgical strategies.