Predictors of prolonged hospital stay in patients with lung cancer undergoing sublobar resection

Introduction

With the growing demand for healthcare resources, improving the efficiency of medical services and reducing healthcare costs have become pressing priorities (1). In surgical care, the postoperative length of stay (LOS) is a critical metric for evaluating healthcare expenditure and surgical outcomes. Identifying and addressing the risk factors contributing to prolonged LOS after surgery are necessary for enhancing the effectiveness of surgical services (2). Moreover, reducing postoperative LOS improves bed utilization, optimizes medical resource allocation for healthcare administrators, lowers medical expenses for patients, and enables an earlier return to daily activities (3,4).

As the malignancy with the highest incidence and mortality, lung cancer imposes a significant burden on public health systems (5,6). Since 1995, lobectomy has been the standard treatment for early-stage non-small cell lung cancer (NSCLC) (7). In recent years, the increasing rate of detection of early-stage lung cancer and advancements in surgical techniques have prompted thoracic surgeons to critically re-evaluate the importance of sublobar resection (SLR) for patients with early-stage NSCLC. In the JCOG0802/WJOG4607L trial, the 5-year overall survival (OS) and 5-year relapse-free survival after segmentectomy were not inferior to those after lobectomy in patients with clinical stage IA NSCLC (8). In another landmark randomized phase III trial (CALGB/ALLIANCE 140503) that included patients with clinical stage T1aN0 NSCLC, SLR was noninferior to lobectomy for disease-free survival and OS (9). Indeed, SLR has emerged as key surgical option for patients with early-stage lung cancer (10-14).

Although SLR may yield long-term survival outcomes comparable to those of lobectomy, the perioperative outcomes of these approaches are not entirely similar. Due to variations in surgical procedures and patient demographics, the LOS after SLR is generally shorter than that after lobectomy (15-17). Several studies have investigated the risk factors for prolonged LOS after lobectomy (3,18-21); however, research with a specific focus on SLR remains scarce. We aimed to identify the predictors of prolonged LOS after SLR using retrospective analysis. We present this article in accordance with the STROBE reporting checklist (available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-2026-0724/rc).

Methods

Patient population

We retrospectively collected data from patients who underwent SLR at West China Hospital between 2011 and 2021. The indications for performing SLR (either wedge resection or segmentectomy) primarily included: (I) peripheral cT1a-b NSCLC with ground-glass opacity (GGO) components, wherein a GGO component ≥75% was specifically required for wedge resection; and (II) patients who could not tolerate lobectomy due to compromised pulmonary function, advanced age or other reasons. The inclusion criteria were as follows: (I) surgical records indicating SLR, including single-site wedge resection, multisite wedge resection, single-segment resection, segmentectomy combined with wedge resection, or multisegment resection; and (II) complete postoperative hospitalization records. Patients who died intraoperatively or postoperatively due to severe complications, such as massive postoperative bleeding or acute respiratory failure, and those with unclear surgical procedure types or benign pulmonary diseases were excluded. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The protocol was approved by the Ethics Committee of West China Hospital, Sichuan University (No. 2024-2558). Individual consent for this retrospective analysis was waived.

Study variables

Perioperative data were collected from electronic medical records and included patient age, sex, symptoms at presentation (including cough, chest pain, blood-tinged sputum, chest tightness, and hemoptysis), history of diabetes, family history, surgical history, pulmonary function test (PFT) results, smoking history, and smoking cessation status. Additionally, detailed surgical information was recorded, including LOS after surgery, size of the main lesion, surgical approach [thoracoscopy or video-assisted thoracoscopic surgery (VATS)], conversion to thoracotomy, operative time, extent of resection, and pathological diagnosis of the tumor.

Definition of prolonged LOS after SLR

Given the differences in surgical procedures between wedge resection and segmentectomy, patients were grouped based on whether segmentectomy was performed. Segmentectomy typically involves the dissection, division, and anastomosis of blood vessels and bronchi, resulting in longer operative times and potentially extended postoperative hospital stays compared wedge resection. Prolonged LOS after SLR was defined as hospital stay exceeding the median duration for each group. In the wedge resection group (including single and multisite wedge resections), the threshold for prolonged LOS after surgery was 3 days. In the segmentectomy groups (including single-segment resection, segmentectomy combined with wedge resection, and multisegment resection), the threshold was 4 days.

Statistical analysis

Missing data is unavoidable in retrospective data analysis. To mitigate information loss that could result from simply excluding samples with missing values, we employed the missForest imputation method to fill in the missing data. Additionally, z-score standardization was applied to continuous variables to eliminate differences in scale and magnitude across variables, thereby enhancing their comparability.

To determine the association between the examined variables and prolonged LOS after SLR, univariate logistic regression was used to identify the variables that were significantly associated with prolonged LOS. Because a few categorical variables were imbalanced and would have resulted in wide 95% confidence intervals (CIs) for odds ratios (ORs) and reduce the accuracy of the results, we excluded variables with an excessively wide CI (upper to lower limit ratio exceeding 3). Univariate logistic regression was used to analyze the association of individual variables with prolonged LOS but did not account for interactions among variables or their combined effects. Therefore, variables with statistical significance in the univariate logistic regression were included in the multivariate logistic regression model for further analysis. Model optimization was performed via the Akaike information criterion, and the most critical influencing factors were identified via stepwise regression.

For the continuous variables, restricted cubic spline (RCS) plots were generated to visualize the association of changes in key risk factors with prolonged LOS. The thresholds for significant variables were on an OR ≥1 and a P value <0.05.

All statistical analyses were conducted with R software, version 4.4.1 (The R Foundation for Statistical Computing, Vienna, Austria).

Results

Baseline characteristics

A total of 4,173 patients who underwent SLR were included in this study, with 1,287 (30.8%) undergoing wedge resection and 2,886 (69.2%) undergoing segmentectomy (Figure 1). The median LOS after SLR was 3 days in the wedge resection group and 4 days in the segmentectomy group. In both groups, VATS was performed for the vast majority of patients (96.5% and 98.4% in the wedge resection and segmentectomy groups, respectively). Postoperative pathological examinations revealed that most patients were diagnosed with lung adenocarcinoma (96.3% and 98.8% in the wedge resection and segmentectomy groups, respectively). Detailed demographic and clinical characteristics of the included patients are presented in Table 1.

Figure 1 Study workflow. Overview of patient selection, grouping by surgical type (wedge resection and segmentectomy), and process for identifying factors associated with prolonged hospital stay.

Univariate analysis of risk factors associated with prolonged LOS after SLR

Univariate logistic regression analysis was performed to determine the independent association between each variable and a prolonged LOS after SLR. In the wedge resection group, the risk factors for prolonged LOS after surgery were symptoms at presentation (OR =2.60; 95% CI: 1.96–3.44), smoking history (OR =2.58; 95% CI: 1.94–3.44), male sex (OR =2.32; 95% CI: 1.83–2.93), larger size of the main lesion (OR =2.26; 95% CI: 1.95–2.61), longer operative time (OR =2.03; 95% CI: 1.77–2.33), advanced age (OR =1.68; 95% CI: 1.51–1.88), diabetes (OR =1.64; 95% CI: 1.06–2.55), and higher body mass index (BMI) (OR =1.25; 95% CI: 1.12–1.40) (Figure 2A). Meanwhile, the protective factors were surgical history (OR =0.73; 95% CI: 0.58–0.92), higher forced expiratory volume in 1 second (FEV₁) (OR =0.74; 95% CI: 0.66–0.83), higher percent predicted FEV₁ (FEV₁% predicted) (OR =0.68; 95% CI: 0.61–0.77), higher diffusion capacity for carbon monoxide (DLCO) (OR =0.74; 95% CI: 0.66–0.83), and higher percent predicted DLCO (DLCO% predicted) (OR =0.82; 95% CI: 0.73–0.91) (Figure 2A). Additionally, a family history of cancer, extent of resection, and smoking cessation were not associated with prolonged LOS after wedge resection (Table 2).

Figure 2 Forest plots for the logistic regression analysis of predictors of prolonged hospital stay. Forest plots displaying the ORs and 95% confidence intervals for the logistic regression analysis of predictors of prolonged hospital stay in patients undergoing (A) wedge resection and (B) segmentectomy in the univariate analysis and those undergoing (C) wedge resection and (D) segmentectomy in the multivariate analysis. The red dashed line indicates OR =1. DLCO, diffusing capacity of the lung for carbon monoxide; FEV₁, forced expiratory volume in 1 second; OR, odds ratio.

Figure 2B illustrates a similar pattern of risk factors between the segmentectomy and wedge resection groups. The risk factors for prolonged LOS after surgery were male sex (OR =1.88; 95% CI: 1.59–2.23), longer operative time (OR =1.87; 95% CI: 1.72–2.03), smoking history (OR =1.79; 95% CI: 1.46–2.20), diabetes (OR =1.55; 95% CI: 1.12–2.16), symptoms at presentation (OR =1.42; 95% CI: 1.16–1.74), larger size of the main lesion (OR =1.33; 95% CI: 1.22–1.45), and advanced age (OR =1.32; 95% CI: 1.21–1.44). Meanwhile, the protective factors for prolonged LOS after segmentectomy were smoking cessation (OR =0.52; 95% CI: 0.27–0.99), higher FEV₁% predicted (OR =0.79; 95% CI: 0.73–0.86), higher DLCO (OR =0.91; 95% CI: 0.83–0.98), and higher DLCO% predicted (OR =0.89; 95% CI: 0.82–0.97). However, prolonged LOS after segmentectomy was not associated with surgical history (P=0.90), family history of cancer (P=0.62), BMI (P=0.40), or the extent of resection (P=0.16). Moreover, conversion to open thoracotomy and epithelial origin exhibited a significant imbalance. Therefore, these variables were excluded from the subsequent multivariate logistic regression analysis.

Multivariate analysis of prolonged LOS after SLR

The multivariate analysis indicated that the risk factors for prolonged LOS after SLR were advanced age (wedge resection: OR =1.38, 95% CI: 1.21–1.56; segmentectomy: OR =1.20, 95% CI: 1.09–1.33), male sex (wedge resection: OR =1.70, 95% CI: 1.28–2.25; segmentectomy: OR =1.81, 95% CI: 1.48–2.20), and symptoms at presentation (wedge resection: OR =1.89, 95% CI: 1.37–2.62; segmentectomy: OR =1.35, 95% CI: 1.09–1.67), larger sized main lesion (wedge resection: OR =1.55, 95% CI: 1.32–1.83; segmentectomy: OR =1.17, 95% CI: 1.05–1.29), and longer operative time (wedge resection: OR =1.66, 95% CI: 1.43–1.93; segmentectomy: OR =1.85, 95% CI: 1.70–2.02) (Figure 2C,2D). Among the PFT-related factors, higher FEV₁% predicted was a protective factor for prolonged LOS after SLR (wedge resection: OR =0.80, 95% CI: 0.69–0.92; segmentectomy: OR =0.89, 95% CI: 0.82–0.98), whereas higher DLCO% predicted was a protective factor for prolonged LOS after segmentectomy (OR =0.85; 95% CI: 0.78–0.94). Table 2 presents the ORs and 95% CI of each variable.

For continuous variables, the RCS method was used to visually depict the nonlinear relationships of age, main lesion size, operative time, and PFT with prolonged LOS after SLR. Age, main lesion size, and operative time exhibited J-shaped relationships with the risk of prolonged LOS after SLR (all P values for nonlinearity <0.05; Figure 3). An L-shaped relationship was observed between PFT and the risk of prolonged LOS after SLR (all P values for nonlinearity <0.05; Figure 3). In the wedge resection group, the OR for prolonged LOS was significantly higher among patients aged >56 years, those with lesions >1.2 cm, and those who underwent procedures lasting >65 minutes (Figure 3A-3C). In contrast, the OR declined sharply with increasing predicted FEV₁% up to 106% and then plateaued (Figure 3D). In the segmentectomy group, the OR of prolonged LOS was significantly higher among patients aged >62 years, those with lesions >1.0 cm in size, and those who underwent procedures lasting >95.32 minutes (Figure 3E-3G). Meanwhile, the OR of prolonged LOS after SLR declined sharply with increasing predicted FEV₁% up to 98% and DLCO% up to 85%, after which it plateaued (Figure 3H,3I).

Figure 3 Restricted cubic spline analysis of the continuous variables associated with prolonged hospital stay. Restricted cubic spline plots illustrating the nonlinear relationships between continuous variables and the odds of prolonged hospital stay in patients undergoing (A-D) wedge resection and (E-I) segmentectomy. Variables analyzed include age, size of the main lesion, operative time, and lung function metrics (FEV₁% predicted and DLCO% predicted). The blue line represents the odds ratio, and the shaded grey area represents the 95% confidence interval. DLCO, diffusing capacity of the lung for carbon monoxide; FEV₁, forced expiratory volume in 1 second.

Discussion

Given the influence of insurance policies, such as bundled payments, enhancing the efficiency of healthcare delivery has become a critical priority for healthcare providers (22). As LOS constitutes a major component of healthcare expenditure, shortening LOS after surgery can conserve medical resources and reduce the risk of nosocomial infections (23). Patel et al. reported that identifying high-risk groups for prolonged LOS after surgery and implementing interventions could significantly reduce the LOS in patients undergoing lobectomy (4). In this study, we identified male sex, advanced age, symptoms at presentation, larger main lesion size, longer operative time, and impaired lung function as factors significantly associated with prolonged LOS after SLR.

Sex and age are common factors that significantly influence LOS after lobectomy (3,18,24). Advanced age and male sex were also risk factors for a prolonged LOS after SLR in our study. Reduced physiological reserves and compromised postoperative recovery capacities in older patients are major factors leading to extended LOS. In contrast to traditional analyses that directly categorized age groups (18), we employed the RCS method and identified inflection points at 56 and 62 years of age in patients who underwent wedge resection and segmentectomy, respectively. The risk of prolonged LOS after surgery significantly increased beyond inflection points. Although the age inflection point may vary across centers, it remains an important consideration for thoracic surgeons. The mechanisms underlying the association between male patients and prolonged LOS remain incompletely understood. This association may be partly explained by comorbidities that are predominantly prevalent in male patients. These underlying conditions may impair functional reserve and postoperative resilience, thereby delaying postoperative recovery and extending hospital stay.

Respiratory symptoms are the chief complaint of patients with advanced NSCLC. Athey et al. found that patients with asymptomatic lung cancer tend to have a more favorable prognosis; however, it is unclear whether this is the case for patients with early-stage NSCLC (25). Sheel et al. found that symptoms were not prognostic factors in patients with early-stage NSCLC who underwent surgery (26). In our study, we observed that symptoms at presentation were risk factors for a prolonged LOS after SLR. Hu et al. reported that lung cancer symptoms were predominantly associated with smoking history, chronic obstructive pulmonary disease (COPD), and tumor size (27). Additionally, respiratory symptoms may be linked to lung infections or airway hyperresponsiveness, which are likely to be key factors influencing LOS after SLR. Moreover, even in the absence of overt postoperative complications, symptomatic patients may require additional evaluation or treatment before discharge, contributing to prolonged LOS. Although some studies have shown that COPD may be associated with prolonged LOS after lobectomy (3), this was not found in our study owing to class instability. Moreover, neither smoking nor smoking cessation was associated with a prolonged LOS after SLR. However, significant controversy remains regarding the impact of smoking history and smoking cessation on perioperative complications and postoperative hospital stay in patients with lung cancer (28,29). Clarifying this issue may require large-scale prospective randomized controlled trials.

In patients with early-stage lung cancer, tumor size is a pivotal factor that influences treatment strategies. Numerous studies have investigated the impact of tumor size on the long-term prognosis of SLR (8,30). The current consensus is that peripheral lung cancers sized <2 cm are particularly suitable for SLR, with resection margins exceeding 2 cm or the longest diameter of the lesion. Our study further revealed that a larger main lesion size was significantly associated with a prolonged LOS after SLR. Specifically, patients who underwent segmentectomy for lesions >1 cm and wedge resection for lesions exceeding 1.2 cm were at an increased risk of prolonged LOS after SLR. This heightened risk may be attributed to the larger resection content required for clinicians to adhere to oncological resection principles, as well as the potential for increased surgical complexity, prolonged air leak, or postoperative inflammatory response. Although different studies have examined various indicators and thresholds (24,28), impaired pulmonary function is generally recognized as a risk factor for a prolonged LOS after lobectomy. Our findings support this conclusion. Specifically, decreased FEV₁% predicted was identified as a risk factor for prolonged LOS after SLR, whereas impaired DLCO% predicted was a risk factor for prolonged LOS after segmentectomy. Given the overall favorable lung function of the patient cohort, the threshold for defining a prolonged LOS in this study was relatively high and should not be generalized without a careful interpretation of the data. Nevertheless, these findings underscore the critical importance of lung function in the perioperative management of patients undergoing SLR.

Postsurgery LOS is widely recognized as a critical metric for surgical quality control (24,31). Surgical techniques significantly influence the incidence of postoperative complications and course of patient recovery (32). De Angelis et al. found that prolonged operative time was associated with an increased risk of complications and an extended LOS after lobectomy (32). Similarly, we identified extended operative time as a risk factor for prolonged LOS after SLR. Specifically, segmentectomy and wedge resection procedures lasting >96 and >65 minutes, respectively, were associated with a higher risk of prolonged LOS after SLR. Multiple factors, including patient-specific disease characteristics and proficiency of the thoracic surgical team, influence operative time. Improving surgical expertise and fostering effective medical team collaboration can minimize unnecessary surgical trauma, shorten anesthesia duration, lower the risk of postoperative complications, and consequently shorten the LOS after surgery. With the rapid adoption of minimally invasive thoracic techniques, nearly all patients undergoing SLR undergo VATS, with an exceptionally low rate of conversion to thoracotomy. Consequently, we could not evaluate the impact of VATS or conversion to thoracotomy on the LOS after SLR.

Our study involved several limitations that should be addressed. First, we employed a single-institution, retrospective design, and variability in patient populations across different hospitals and differences in thoracic surgeons’ technical expertise may limit the generalizability of the findings. Second, the relatively younger age and high proportion of adenocarcinoma may restrict the generalizability of our conclusions. The limited number of elderly patients and other histological subtypes constrained our ability to conduct robust subgroup analyses to evaluate the applicability of our findings in these specific populations. Third, as the data in the database were incomplete, we were unable to analyze the social factors that could influence the LOS after SLR, such as domicile and transportation accessibility, which were not evaluated in our analysis. Moreover, lacking of detailed complication data prevented us from elucidating the underlying mechanisms by which the identified risk factors lead to prolonged LOS. Nevertheless, as the largest retrospective study to date to investigate predictors of prolonged LOS in patients with lung cancer undergoing SLR, our findings provide valuable insights for thoracic surgeons and hospital administrators aiming to optimize the efficiency of medical service delivery and enhance patient satisfaction.

Conclusions

In this study, male sex, advanced age, symptoms at presentation, larger main lesion size, extended operative time, and impaired lung function were risk factors for prolonged LOS after SLR. Candidates for SLR with these risk factors may benefit from prehabilitation and more comprehensive postoperative management.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-2026-0724/rc

Data Sharing Statement: Available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-2026-0724/dss

Peer Review File: Available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-2026-0724/prf

Funding: This work was supported by the Postdoctoral Research Fund of West China Hospital, Sichuan University (No. 2023HXBH045 to X.H.), and the Natural Science Foundation of Sichuan Province (No. 2024YFFK0213 to J.C.).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-2026-0724/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The protocol was approved by the Ethics Committee of West China Hospital, Sichuan University (No. 2024-2558). Individual consent for this retrospective analysis was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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(English Language Editor: J. Gray)