Abstract
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.
Keywords: Multiple pulmonary nodules (MPNs), video-assisted thoracoscopic surgery (VATS), simultaneous resection, postoperative complications, segmentectomy
Highlight box.
Key findings
• Among 1,052 patients undergoing video-assisted thoracoscopic surgery-based simultaneous resection, the incidence of treatment-requiring (Clavien-Dindo grade ≥II) and severe (grade ≥III) postoperative pulmonary complications was 14.0% and 3.3%, respectively, with zero perioperative mortality. Key risk factors associated with treatment-requiring PPCs included impaired pulmonary reserve, larger dominant tumor size, advanced age, a higher nodule burden (>2 nodules), lobectomy involvement, and basal segment involvement as a segmentectomy-related anatomical risk marker.
What is known and what is new?
• Simultaneous resection is increasingly used for patients with multiple pulmonary nodules (MPNs), but procedure-specific risk stratification remains limited.
• This study links perioperative risk not only to pulmonary reserve, advanced age, and nodule burden but also to resection pattern and segmentectomy-related anatomy, particularly lobectomy plus segmentectomy and basal segment involvement.
What is the implication, and what should change now?
• Simultaneous resection of MPNs should be planned through stepwise assessment of pulmonary reserve, dominant tumor size, nodule burden, planned resection burden, and segmentectomy-related anatomical factors. Lobectomy-based combinations and basal segment-involved procedures require careful patient selection and perioperative planning.
Introduction
With the widespread use of low-dose computed tomography (LDCT) for lung cancer screening, the overall detection rate of pulmonary nodules has increased significantly (1,2). Importantly, a substantial proportion of these findings are not solitary; clinical evidence reveals that up to 50% of individuals with incidentally detected nodules actually present with multiple pulmonary nodules (MPNs) (3).
The management of MPNs presents a complex dilemma, as these lesions may represent synchronous multiple primary lung cancers, intrapulmonary metastases, or a mixture of malignant and benign nodules (4-6); in contemporary surgical cohorts, the incidence of synchronous multiple primary lung cancers has been reported to be as high as 20% (7). For patients with resectable early-stage lesions located in different lobes or segments, simultaneous resection of MPNs (SRMPN) is increasingly considered to achieve R0 resection while avoiding the need for a second operation (8,9). However, the short-term pulmonary risk of SRMPN in selected surgical candidates remains controversial.
In particular, whether the cumulative loss of lung parenchyma and surgical stress during SRMPN increases the risk of postoperative pulmonary complications (PPCs), which prolong hospitalization and increase healthcare costs, remains unclear (10,11). Data specifically evaluating short-term pulmonary morbidity after SRMPN remain limited. Previous studies have primarily focused on the technical feasibility of simultaneous bilateral resection or long-term oncological outcomes rather than procedure-specific short-term pulmonary risk (12,13).
It also remains unclear how different combinations of resection types (e.g., lobectomy plus segmentectomy versus multiple wedge resections) independently influence the risk of PPCs (14). Furthermore, while segmentectomy is increasingly used as a parenchyma-sparing strategy, the technical difficulty of segmentectomy varies by segmental anatomy and the number of intersegmental planes. Basal segment-involved procedures are often considered anatomically demanding, but whether basal involvement contributes additional perioperative risk in the context of SRMPN remains unclear (15,16). Identifying these procedure-related factors is essential to support risk-adapted surgical decision-making.
Therefore, we conducted this retrospective cohort study involving 1,052 patients to evaluate the incidence and predictors of treatment-requiring PPCs after VATS-based SRMPN. We aimed to determine whether specific resection patterns and segmentectomy-related anatomical factors were associated with elevated perioperative risk. We present this article in accordance with the STROBE reporting checklist (available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-2026-0524/rc).
Methods
Study design and population
The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of West China Hospital, Sichuan University (No. 2022-155); and individual consent for this retrospective analysis was waived because the data were anonymized, and the privacy rights of human subjects were strictly observed throughout the study.
We reviewed the data of consecutive patients who underwent SRMPN between December 2008 and October 2020 in the Western China Lung Cancer Database, a prospectively maintained database at the Department of Thoracic Surgery. SRMPN was defined as the resection of two or more pulmonary nodules located in different segments or lobes during the same anesthetic episode.
Patients were eligible if they (I) had a confirmed primary lung malignancy with the maximum diameter of the dominant tumor ≤3 cm; (II) underwent one-stage SRMPN via video-assisted thoracoscopic surgery (VATS) with diagnostic or therapeutic intent; (III) had complete perioperative records and definitive postoperative pathological results for all resected lesions; and (IV) were considered suitable for synchronous surgery after routine preoperative assessment. It is important to note that while the primary lesion was strictly required to be a primary lung cancer, the concurrently resected secondary nodules could be malignant, intrapulmonary metastases, or benign.
At West China Hospital, SRMPN was generally considered when all target nodules were technically resectable through VATS, when the expected cumulative loss of lung parenchyma was acceptable, and when the patient had adequate cardiopulmonary reserve after routine preoperative assessment. Staged resection was generally considered when the anticipated resection volume was high and pulmonary reserve was limited, or when simultaneous surgery was expected to substantially increase perioperative risk. This decision process was consistent with guideline and consensus principles emphasizing individualized pulmonary nodule management, malignancy-risk assessment, the balance of benefits and harms, and patient fitness for surgical treatment (8,9).
Patients were excluded if they (I) had isolated benign disease across all resected lesions without a primary lung malignancy; (II) were diagnosed with primary small cell lung cancer (SCLC) or pulmonary metastases from extra-thoracic malignancies; (III) underwent staged or metachronous resections; (IV) underwent open thoracotomy or required conversion to thoracotomy; (V) underwent combined resection of other organs; or (VI) had incomplete baseline, operative, or postoperative outcome data. According to institutional practice, patients with unresectable advanced disease or those deemed unable to tolerate synchronous resection on preoperative evaluation were not considered candidates for this procedure.
Variables and definitions
Exposure variables
We systematically extracted clinical data from electronic medical records and categorized them into preoperative and perioperative/pathological variables to facilitate a tiered analysis. Preoperative variables included age, sex, body mass index (BMI), smoking history, preoperative pulmonary function [forced expiratory volume in 1 second (FEV1%) predicted], comorbidities [evaluated by the presence of chronic obstructive pulmonary disease (COPD) and the Charlson Comorbidity Index (CCI)], clinical tumor size, tumor location, reason for second resection, and total nodule count. Perioperative and pathological variables encompassed the extent of resection (involvement of lobectomy, segmentectomy, or wedge resection), systematic lymph node dissection (yes vs. no), histology, pathological tumor-node-metastasis (TNM) stage (8th edition), lymphovascular invasion, and spread through air spaces (STAS).
To accurately analyze the impact of surgical extent, we derived two key variables: (I) lobectomy involvement, defined as whether at least one lobectomy was performed during the SRMPN procedure; and (II) resection pattern. For the subgroup analysis of patients with two nodules, surgical procedures were strictly categorized into five mutually exclusive patterns based on the combination of resection extent: double wedge, double segmentectomy, segmentectomy + wedge, lobectomy + wedge, and lobectomy + segmentectomy. Basal segment involvement was defined among procedures that included segmentectomy. Basal segments were considered involved if the operative description specified resection of S7–S10. Procedures were classified as basal-involved if any basal segment was resected, regardless of whether non-basal segments were concurrently removed.
For the supplementary segmentectomy-complexity analysis, segmentectomies were further classified as simple or complex using a prespecified anatomical definition consistent with consensus-based segmentectomy classifications. Simple segmentectomy included right S6, left S6, left upper division, lingular, and whole/common basal segmentectomy. Other single-segment, combined, multisite, bilateral, or subsegmental segmentectomy patterns were classified as complex. Complex segmentectomy involvement was defined at the patient level as the presence of at least one complex segmentectomy component during SRMPN (16).
Outcome variables
The primary endpoint of this study was the occurrence of treatment-requiring PPCs, defined as PPCs of Clavien-Dindo grade ≥II. The Clavien-Dindo classification ranks complications based on the therapy required: Grade I (bedside management), Grade II (pharmacological treatment, blood transfusion, or total parenteral nutrition), Grade III (surgical, endoscopic, or radiological intervention), Grade IV (life-threatening organ dysfunction), and Grade V (death). While we recorded specific pulmonary morbidity events (e.g., prolonged air leak >5 days, pneumonia), the binary outcome for logistic regression analysis was strictly defined as the presence of any PPC of Clavien-Dindo grade ≥II. Grade II PPCs and severe PPCs (defined as Clavien-Dindo grade ≥III) were also summarized separately to improve clinical interpretability. To minimize information bias, PPCs were independently diagnosed by two attending physicians according to identical, predefined criteria on the basis of clinical, imaging, and laboratory findings. For each patient, the dominant lesion was defined as the lesion with the largest diameter of the solid component or the highest pathological T-stage, whereas all other concurrently resected nodules were categorized as secondary nodules.
Statistical analysis
All statistical analyses were performed using R software (version 4.3.1). Continuous variables were assessed for normality using the Shapiro-Wilk test and visual inspection; they were expressed as mean with standard deviation (SD) for normally distributed data or median with interquartile range (IQR) for non-normally distributed data. Comparisons between groups were performed using the Student’s t-test or Mann-Whitney U test, as appropriate. Categorical variables were presented as frequencies (percentages) and compared using the Chi-squared test or Fisher’s exact test.
To systematically evaluate predictors of treatment-requiring PPCs, we performed a two-tier multivariable logistic regression analysis. Variables demonstrating an association with treatment-requiring PPCs in the univariable analysis (P<0.10) were considered for inclusion in the multivariable models. Initially, we constructed a preoperative model incorporating exclusively preoperative variables to identify baseline risk factors and assist in initial patient selection. Subsequently, a comprehensive model was developed integrating both preoperative and perioperative/pathological factors to evaluate whether perioperative and pathological factors were associated with treatment-requiring PPCs after baseline factors were accounted for. During the comprehensive analysis, pathological TNM staging was not entered into the multivariable model because it represents a composite pathological classification and may overlap conceptually with tumor size, nodal status, and other pathological or surgical variables. Finally, multicollinearity among covariates in the multivariable models was strictly assessed using the variance inflation factor (VIF) and generalized VIF (GVIF), with a threshold of <5 indicating the absence of severe multicollinearity. Results were reported as adjusted odds ratios (aORs) with Wald 95% confidence intervals (CIs) and Wald P values.
Furthermore, to specifically evaluate the safety profile of different surgical strategies, a subgroup analysis was performed on patients undergoing synchronous resection of exactly two nodules. In this subgroup, the association between five distinct resection patterns (ranging from double wedge resection to combined lobectomy and segmentectomy) and treatment-requiring PPCs was analyzed using multivariable logistic regression models, adjusting for potential confounders including age, sex, smoking history, tumor location, preoperative FEV1% predicted, COPD, and CCI.
To evaluate segmentectomy-related anatomical factors, we constructed three targeted multivariable models for basal segment involvement. Model A evaluated patients who underwent at least one segmentectomy, Model B was restricted to pure segmentectomies without concurrent lobectomy or wedge resection, and Model C evaluated the full cohort using segmentectomy without basal involvement as the reference. Model-specific adjustment sets are provided in the corresponding table footnotes. To assess whether the basal association was accounted for by the broader simple-versus-complex segmentectomy classification, we performed a supplementary same-covariate comparison within the segmentectomy cohort. Basal segment involvement and complex segmentectomy involvement were evaluated separately and then jointly, using the same patients and the same adjustment set as Model A. A four-category basal-complex cross-classification was summarized descriptively; no adjusted four-category model or interaction test was performed because the basal plus simple-only category was sparse. Additional descriptive and sensitivity analyses were performed to address potential heterogeneity and temporal effects. Baseline and perioperative characteristics were compared according to treatment-requiring PPC status. Secondary nodule pathology was summarized and compared with the occurrence of treatment-requiring PPCs. To assess whether inclusion of benign secondary nodules influenced the main findings, we repeated the comprehensive multivariable model after excluding patients with benign secondary nodules. To assess potential temporal effects, PPC rates were compared between an early period [2008–2014] and a later period [2015–2020] in an exploratory sensitivity analysis. Surgery period was then added to the preoperative multivariable model. Finally, treatment-requiring PPCs (Clavien-Dindo grade ≥II) were summarized as the primary endpoint, and Grade II PPCs and severe PPCs (Clavien-Dindo grade ≥III) were reported separately to clarify complication severity. All statistical tests were two-sided, and a P<0.05 was considered statistically significant.
Results
Baseline characteristics
A total of 1,052 patients who underwent SRMPN were included in this study (Figure 1, Table 1). Treatment-requiring PPCs occurred in 147 patients, whereas 905 patients did not develop treatment-requiring PPCs. The cohort mainly consisted of females (72.3%) and non-smokers (81.6%), and most patients were younger than 70 years (89.8%). Comorbidities were infrequent; the vast majority (98.7%) had no COPD, and 79.9% had a CCI score of 0. The most common histology of the dominant lesion was lung adenocarcinoma (96.9%). Pathological staging (8th edition) for the dominant lesion revealed that 94.7% of patients were N0, while 3.4% had N2 disease. Missing data were negligible for the key covariates included in the multivariable analyses. Compared with patients without treatment-requiring PPCs, those with treatment-requiring PPCs were older and more often male, had a higher prevalence of smoking history, COPD, impaired pulmonary function, and larger dominant tumors (Table 1).
Figure 1.
Flowchart of patient selection. PPC, postoperative pulmonary complication; VATS, video-assisted thoracoscopic surgery.
Table 1. Baseline clinicopathological characteristics according to treatment-requiring PPC status.
| Variable | Overall (N=1,052) | No treatment-requiring PPCs (n=905) | Treatment-requiring PPCs (n=147) | P value |
|---|---|---|---|---|
| Age | 0.003 | |||
| ≥70 years | 107 (10.2) | 82 (9.1) | 25 (17.0) | |
| <70 years | 945 (89.8) | 823 (90.9) | 122 (83.0) | |
| Sex | <0.001 | |||
| Male | 291 (27.7) | 230 (25.4) | 61 (41.5) | |
| Female | 761 (72.3) | 675 (74.6) | 86 (58.5) | |
| BMI | 0.33 | |||
| ≥24 kg/m2 | 300 (28.5) | 263 (29.1) | 37 (25.2) | |
| <24 kg/m2 | 752 (71.5) | 642 (70.9) | 110 (74.8) | |
| Smoking history | <0.001 | |||
| Yes | 194 (18.4) | 149 (16.5) | 45 (30.6) | |
| No | 858 (81.6) | 756 (83.5) | 102 (69.4) | |
| FEV1% predicted | <0.001 | |||
| <80% | 56 (5.3) | 36 (4.0) | 20 (13.6) | |
| ≥80% | 996 (94.7) | 869 (96.0) | 127 (86.4) | |
| COPD | 0.001 | |||
| Yes | 14 (1.3) | 7 (0.8) | 7 (4.8) | |
| No | 1,038 (98.7) | 898 (99.2) | 140 (95.2) | |
| CCI | 0.009 | |||
| 0 | 841 (79.9) | 729 (80.6) | 112 (76.2) | |
| 1 | 96 (9.1) | 73 (8.1) | 23 (15.6) | |
| ≥2 | 115 (10.9) | 103 (11.4) | 12 (8.2) | |
| Dominant tumor size, cm | 1.43 [0.67] | 1.39 [0.65] | 1.65 [0.71] | <0.001 |
| Tumor location | 0.14 | |||
| Right | 736 (70.0) | 623 (68.8) | 113 (76.9) | |
| Left | 306 (29.1) | 273 (30.2) | 33 (22.4) | |
| Bilateral | 10 (1.0) | 9 (1.0) | 1 (0.7) | |
| Secondary nodule pathology | 0.75 | |||
| Benign† | 439 (41.7) | 380 (42.0) | 59 (40.1) | |
| MPL | 572 (54.4) | 491 (54.3) | 81 (55.1) | |
| Invasive malignant lesion | 38 (3.6) | 31 (3.4) | 7 (4.8) | |
| Intrapulmonary metastasis | 3 (0.3) | 3 (0.3) | 0 (0.0) | |
| Systematic lymph node dissection | 0.01 | |||
| Yes | 745 (70.8) | 628 (69.4) | 117 (79.6) | |
| No | 307 (29.2) | 277 (30.6) | 30 (20.4) | |
| Histology | 0.04 | |||
| Adenocarcinoma | 1,019 (96.9) | 881 (97.3) | 138 (93.9) | |
| Non-adenocarcinoma | 33 (3.1) | 24 (2.7) | 9 (6.1) | |
| Pathological T stage | <0.001 | |||
| Tis | 36 (3.4) | 31 (3.4) | 5 (3.4) | |
| T1a | 341 (32.4) | 307 (33.9) | 34 (23.1) | |
| T1b | 372 (35.4) | 327 (36.1) | 45 (30.6) | |
| T1c | 137 (13.0) | 109 (12.0) | 28 (19.0) | |
| T2a | 160 (15.2) | 127 (14.0) | 33 (22.4) | |
| T3 | 3 (0.3) | 1 (0.1) | 2 (1.4) | |
| T4 | 3 (0.3) | 3 (0.3) | 0 (0.0) | |
| Pathological N stage | 0.01 | |||
| N0 | 996 (94.7) | 862 (95.2) | 134 (91.2) | |
| N1 | 20 (1.9) | 18 (2.0) | 2 (1.4) | |
| N2 | 36 (3.4) | 25 (2.8) | 11 (7.5) | |
| Lymphovascular invasion | 0.68 | |||
| Yes | 12 (1.1) | 10 (1.1) | 2 (1.4) | |
| No | 1,040 (98.9) | 895 (98.9) | 145 (98.6) | |
| STAS | 0.78 | |||
| Yes | 26 (2.5) | 22 (2.4) | 4 (2.7) | |
| No | 1,026 (97.5) | 883 (97.6) | 143 (97.3) | |
| Total nodule count | 0.046 | |||
| 2 | 907 (86.2) | 788 (87.1) | 119 (81.0) | |
| >2 | 145 (13.8) | 117 (12.9) | 28 (19.0) |
Data are presented as n (%) or mean [SD]. †,benign secondary nodule pathologies are detailed in Table S1. Treatment-requiring PPCs were defined as PPCs of Clavien-Dindo grade ≥II. P values were calculated using Pearson Chi-squared test, Fisher exact test, Student’s t-test, or Wilcoxon rank-sum test, as appropriate. BMI, body mass index; CCI, Charlson Comorbidity Index; COPD, chronic obstructive pulmonary disease; FEV1, forced expiratory volume in 1 second; MPL, multiple primary lung cancer; N, node; PPC, postoperative pulmonary complication; SD, standard deviation; STAS, spread through air spaces; T, tumor.
Perioperative outcomes
Treatment-requiring PPCs were observed in 14.0% (147/1,052) of the cohort (Table 2). Specifically, Grade II PPCs were observed in 10.6% of the cohort, while severe PPCs (Clavien-Dindo grade ≥III) occurred in 3.3%. The most frequent specific PPCs were prolonged drainage >7 days (7.4%) and postoperative pneumonia (6.7%). Regarding postoperative recovery metrics, 27.9% of patients required prolonged antibiotic duration (≥3 days), and 3.4% experienced a prolonged postoperative hospital stay (≥14 days).
Table 2. Short-term postoperative outcomes after SRMPN in the full cohort.
| Variables | Value |
|---|---|
| Clavien-Dindo grade | |
| Any PPC (grade I–V) | 158 (15.0) |
| Treatment-requiring PPCs (grade ≥II) | 147 (14.0) |
| Severe PPCs (grade ≥III) | 35 (3.3) |
| Grade I | 11 (1.0) |
| Grade II | 112 (10.6) |
| Grade III | 32 (3.0) |
| Grade IV | 3 (0.3) |
| Grade V | 0 (0.0) |
| Specific PPC categories | |
| Prolonged drainage (>7 d) | 78 (7.4) |
| Postoperative pneumonia | 70 (6.7) |
| Prolonged air leak (>5 d) | 52 (4.9) |
| Chylothorax | 11 (1.0) |
| Bronchopleural fistula | 2 (0.2) |
| Pulmonary embolism | 1 (0.1) |
| Postoperative recovery metrics | |
| Postoperative hospital stay (≥14 d) | 36 (3.4) |
| Prolonged antibiotic duration (≥3 d) | 294 (27.9) |
Data are presented as n (%). Percentages were calculated using the full cohort as the denominator. Treatment-requiring PPCs were defined as PPCs of Clavien-Dindo grade ≥II. Severe PPCs were defined as PPCs of Clavien-Dindo grade ≥III. Specific PPC categories were not mutually exclusive. PPC, postoperative pulmonary complication; SRMPN, simultaneous resection of multiple pulmonary nodules.
Analysis of risk factors for treatment-requiring PPCs
In the univariable analysis of preoperative factors, age ≥70 years, male sex, smoking history, COPD, lower FEV1% predicted, and larger dominant tumor size were associated with treatment-requiring PPCs. Tumor location and CCI category were additionally considered for multivariable modeling according to the prespecified screening strategy. In the broader perioperative and pathological analysis, N2 lymph node status and lobectomy involvement were associated with treatment-requiring PPCs, whereas lymphovascular invasion (P=0.79) and STAS (P=0.83) were not.
In the multivariable analysis of preoperative factors (Table 3, Figure 2), impaired pulmonary function (FEV1% predicted <80%) remained associated with a higher risk of treatment-requiring PPCs (aOR =2.76; 95% CI: 1.46–5.23; P=0.002). Resection of more than two nodules (aOR =1.75; 95% CI: 1.09–2.82; P=0.02) was also associated with an increased risk. Left-sided tumor location was associated with a lower risk of treatment-requiring PPCs compared with right-sided location (aOR =0.63; 95% CI: 0.41–0.98; P=0.04). Additionally, larger dominant tumor size was associated with treatment-requiring PPCs (aOR =1.35; 95% CI: 1.02–1.78; P=0.03), whereas advanced age (OR=1.63; 95% CI: 0.96–2.77; P=0.07) did not reach statistical significance in the multivariable model. When further incorporating perioperative and pathological factors into the comprehensive multivariable model (Table S2) to reflect the complete clinical scenario, lobectomy involvement (defined as performing at least one lobectomy during the procedure) was associated with treatment-requiring PPCs (aOR =1.84; 95% CI: 1.10–3.09; P=0.02). FEV1% predicted <80% (aOR =2.74; 95% CI: 1.45–5.19; P=0.002) and a total nodule count >2 (aOR =1.77; 95% CI: 1.09–2.85; P=0.02) remained independently associated with an increased risk of treatment-requiring PPCs. Additionally, advanced age (≥70 years) was independently associated with treatment-requiring PPCs in this comprehensive model (aOR =1.72; 95% CI: 1.01–2.94; P=0.046), whereas dominant tumor size (aOR =1.14; 95% CI: 0.84–1.55; P=0.39) and left-sided location (aOR =0.71; 95% CI: 0.45–1.12; P=0.14) did not show clear independent associations.
Table 3. Univariable and multivariable analyses of preoperative factors associated with treatment-requiring PPCs.
| Variables | Univariable analysis | Multivariable analysis | |||
|---|---|---|---|---|---|
| OR (95% CI) | P value | Adjusted OR (95% CI) | P value | ||
| Age (≥70 vs. <70 years) | 2.06 (1.26–3.35) | 0.004 | 1.63 (0.96–2.77) | 0.07 | |
| Sex (male vs. female) | 2.08 (1.45–2.99) | <0.001 | 1.44 (0.83–2.49) | 0.20 | |
| BMI (≥24 vs. <24 kg/m2) | 0.82 (0.55–1.22) | 0.33 | – | – | |
| Smoking history (yes vs. no) | 2.24 (1.51–3.31) | <0.001 | 1.28 (0.70–2.35) | 0.42 | |
| FEV1% predicted (<80% vs. ≥80%) | 3.80 (2.13–6.77) | <0.001 | 2.76 (1.46–5.23) | 0.002 | |
| COPD (yes vs. no) | 6.41 (2.22–18.56) | <0.001 | 2.97 (0.86–10.30) | 0.09 | |
| CCI | |||||
| 0 | Ref. | – | Ref. | – | |
| 1 | 2.05 (1.23–3.41) | 0.006 | 1.15 (0.64–2.06) | 0.65 | |
| ≥2 | 0.76 (0.40–1.42) | 0.39 | 0.59 (0.30–1.16) | 0.12 | |
| Clinical indication for secondary nodule resection (non-benign vs. benign) | 1.08 (0.76–1.54) | 0.67 | – | – | |
| Tumor location | |||||
| Right | Ref. | – | – | – | |
| Left | 0.67 (0.44–1.01) | 0.054 | 0.63 (0.41–0.98) | 0.04 | |
| Bilateral | 0.61 (0.08–4.88) | 0.64 | 0.62 (0.07–5.09) | 0.66 | |
| Tumor size | 1.72 (1.34–2.21) | <0.001 | 1.35 (1.02–1.78) | 0.03 | |
| Total nodule count (>2 vs. 2) | 1.58 (1.01–2.50) | 0.047 | 1.75 (1.09–2.82) | 0.02 | |
Variables with P<0.10 in univariable analysis were considered for multivariable modeling. ORs for dominant tumor size are reported per 1 cm increase. BMI, body mass index; CCI, Charlson Comorbidity Index; CI, confidence interval; COPD, chronic obstructive pulmonary disease; FEV1, forced expiratory volume in 1 second; OR, odds ratio; PPC, postoperative pulmonary complication.
Figure 2.
Forest plot demonstrating the multivariable logistic regression analysis of preoperative predictors for treatment-requiring PPCs. CI, confidence interval; COPD, chronic obstructive pulmonary disease; FEV1, forced expiratory volume in 1 second; OR, odds ratio; PPC, postoperative pulmonary complication.
Multicollinearity diagnostics confirmed that all selected variables exhibited acceptable GVIF values (all <3), indicating no severe multicollinearity among the predictors (Table S3). Secondary nodule pathology was further summarized in Table S1. The rate of treatment-requiring PPCs was 13.4% for benign secondary nodules, 14.2% for multiple primary lung cancers, 18.4% for invasive malignant lesions, and none for intrapulmonary metastasis. Because several detailed pathology categories had sparse counts, these findings were interpreted descriptively.
Subgroup analysis of resection patterns
Among the subgroup of patients with exactly two nodules (n=907), resection patterns involving a lobectomy were associated with a higher risk of treatment-requiring PPCs compared with the double-wedge reference group (Table 4). The “lobectomy + segmentectomy” pattern carried the highest risk (aOR =3.19; 95% CI: 1.37–7.42; P=0.007). The “lobectomy + wedge” pattern was also significantly associated with an elevated treatment-requiring PPC rate (17.4%; aOR =2.00; 95% CI: 1.06–3.79; P=0.03). In contrast, sublobar combinations, including “double segmentectomy” and “segmentectomy + wedge”, did not show a clear increase in the risk of treatment-requiring PPCs compared with double-wedge resections (P=0.62 and P=0.81, respectively).
Table 4. Association between selected resection patterns and treatment-requiring PPCs among patients with exactly two nodules.
| Resection pattern | Total (n) | Events (n) | Rate (%) | Unadjusted analysis | Adjusted analysis | |||
|---|---|---|---|---|---|---|---|---|
| OR (95% CI) | P value | OR (95% CI)† | P value | |||||
| Wedge + wedge | 169 | 14 | 8.3 | Ref. | – | Ref. | – | |
| Segmentectomy + segmentectomy | 49 | 5 | 10.2 | 1.26 (0.43–3.68) | 0.68 | 1.32 (0.44–3.96) | 0.62 | |
| Segmentectomy + wedge | 224 | 15 | 6.7 | 0.79 (0.37–1.69) | 0.55 | 0.91 (0.42–1.98) | 0.81 | |
| Lobectomy + wedge | 407 | 71 | 17.4 | 2.34 (1.28–4.28) | 0.006 | 2.00 (1.06–3.79) | 0.03 | |
| Lobectomy + segmentectomy | 58 | 14 | 24.1 | 3.52 (1.56–7.94) | 0.002 | 3.19 (1.37–7.42) | 0.007 | |
†, the multivariable model was adjusted for age, sex, smoking history, tumor location, preoperative FEV1% predicted, COPD, and CCI. Double wedge resection was used as the reference category. CCI, Charlson Comorbidity Index; CI, confidence interval; COPD, chronic obstructive pulmonary disease; FEV1, forced expiratory volume in 1 second; OR, odds ratio; PPC, postoperative pulmonary complication.
Basal segment involvement, segmentectomy complexity, and treatment-requiring PPCs
We further evaluated segmentectomy-related anatomical factors among patients who underwent at least one segmentectomy (Table 5 and Tables S4-S6). In the segmentectomy cohort, basal-involved procedures had a higher treatment-requiring PPC rate than non-basal segmentectomies (15.3% vs. 10.7%) and were associated with treatment-requiring PPCs after adjustment (aOR =2.14; 95% CI: 1.14–4.00; P=0.02). In the pure segmentectomy cohort, basal-involved procedures had a numerically higher treatment-requiring PPC rate than non-basal procedures (11.7% vs. 4.8%), although the adjusted association did not reach statistical significance (aOR =2.63; 95% CI: 0.71–9.77; P=0.15). In the full cohort model, segmentectomy with basal involvement was also associated with treatment-requiring PPCs compared with segmentectomy without basal involvement (aOR =1.85; 95% CI: 1.02–3.37; P=0.04).
Table 5. Association between basal segment involvement and treatment-requiring PPCs in segmentectomy-related analyses†.
| Exposure | Total (n) | Events (n) | Rate (%) | Adjusted OR (95% CI)‡ | P value |
|---|---|---|---|---|---|
| Model A: segmentectomy cohort | |||||
| Non-basal segmentectomy | 393 | 42 | 10.7 | Ref. | |
| Basal-involved segmentectomy | 131 | 20 | 15.3 | 2.14 (1.14–4.00) | 0.02 |
| Model B: pure segmentectomy only | |||||
| Non-basal segmentectomy | 84 | 4 | 4.8 | Ref. | – |
| Basal-involved segmentectomy | 60 | 7 | 11.7 | 2.63 (0.71–9.77) | 0.15 |
| Model C: full cohort | |||||
| Segmentectomy without basal segment involvement | 393 | 42 | 10.7 | Ref. | – |
| No segmentectomy | 528 | 85 | 16.1 | 0.80 (0.42–1.51) | 0.49 |
| Segmentectomy with basal segment involvement | 131 | 20 | 15.3 | 1.85 (1.02–3.37) | 0.04 |
†, basal segment involvement was defined as any segmentectomy involving basal segments (S7–S10). ‡, Model A evaluated patients who underwent at least one segmentectomy. Model B was restricted to patients undergoing pure segmentectomies without concurrent lobectomy or wedge resection. Model C evaluated the full cohort using segmentectomy without basal segment involvement as the reference group. Model A and Model C were adjusted for age, sex, smoking history, FEV1% predicted, COPD, CCI, lobectomy involvement, wedge resection involvement, dominant tumor size, total nodule count, and systematic lymph node dissection. Model B was adjusted for age, sex, smoking history, FEV1% predicted, COPD and CCI. Lobectomy involvement and wedge resection involvement were not included in Model B because they were fixed by cohort definition. CCI, Charlson Comorbidity Index; CI, confidence interval; COPD, chronic obstructive pulmonary disease; FEV1, forced expiratory volume in 1 second; OR, odds ratio; PPC, postoperative pulmonary complication.
Basal segment involvement substantially overlapped with complex segmentectomy. In the segmentectomy cohort, 125 of 131 basal-involved procedures (95.4%) and 266 of 393 non-basal procedures (67.7%) were classified as complex (Table S4). In the four-category descriptive analysis, treatment-requiring PPCs occurred in 20 of 125 patients (16.0%) undergoing basal plus complex segmentectomy, whereas the basal plus simple-only category included only six patients and no treatment-requiring PPC events (Table S5). When simple-only and complex segmentectomies were compared irrespective of basal location, the crude event rates were similar (12.0% vs. 11.8%). Accordingly, in the same-covariate comparison, complex segmentectomy alone was not associated with treatment-requiring PPCs (aOR =1.15; 95% CI: 0.59–2.25; P=0.68). When basal segment involvement and complex segmentectomy were entered jointly, basal segment involvement remained associated with treatment-requiring PPCs (aOR =2.20; 95% CI: 1.13–4.27; P=0.02), whereas complex segmentectomy did not show a positive association with treatment-requiring PPCs (aOR =0.91; 95% CI: 0.45–1.85; P=0.79) (Table S6).
Sensitivity and descriptive analyses
In a sensitivity analysis restricted to patients with non-benign secondary nodules (n=613; events =88), FEV1% predicted <80% remained associated with treatment-requiring PPCs (aOR =2.83; 95% CI: 1.15–6.92; P=0.02), and total nodule count >2 also remained associated with treatment-requiring PPCs (aOR =2.21; 95% CI: 1.26–3.85; P=0.005). Lobectomy involvement remained directionally elevated but was less precise in the restricted cohort (aOR =1.64; 95% CI: 0.86–3.13; P=0.13) (Table S7).
Surgery period was associated with treatment-requiring PPCs in temporal sensitivity analysis (Table S8). The treatment-requiring PPC rate was 36.6% in 2008–2014 and 12.3% in 2015–2020. In the preoperative model with additional adjustment for surgery period, impaired pulmonary function and total nodule count >2 remained associated with treatment-requiring PPCs, whereas the association for dominant tumor size was attenuated.
The severity composition of treatment-requiring PPCs is presented in Table S9.
Discussion
In this large retrospective cohort of patients undergoing VATS-based SRMPN, treatment-requiring PPCs occurred in 14.0% of patients, severe PPCs were uncommon, and no perioperative death occurred. Treatment-requiring PPCs were mainly associated with impaired pulmonary function, advanced age, greater nodule burden, lobectomy involvement, and basal segment involvement among segmentectomy-related procedures. These findings suggest that SRMPN may be feasible in carefully selected patients, but resection extent and segmentectomy-related anatomy should be incorporated into preoperative surgical planning.
The observed 14.0% incidence of treatment-requiring PPCs suggests that VATS-based SRMPN can be performed with an acceptable PPC rate in carefully selected patients. This rate aligns with the 8–15% range reported for standard single-region anatomical resections (17) and is lower than the 22.2% complication rate reported by Al-Thani et al. for multi-segment multi-segmentectomies (18). This discrepancy likely reflects differences in the surgical approach; whereas their cohort included open thoracotomies, all procedures in our cohort were performed via VATS, supporting the hypothesis that a minimally invasive approach attenuates the additive trauma of SRMPN. Most treatment-requiring PPCs were Clavien-Dindo grade II events, accounting for 76.2% of the primary endpoint events, and were generally managed with medical treatment or other noninvasive measures. Severe PPCs, defined as Clavien-Dindo grade ≥III, occurred in only 3.3% of patients. We therefore interpreted Clavien-Dindo grade ≥II events as treatment-requiring rather than as uniformly severe morbidity. Grade II events were reported separately from grade ≥III events to avoid conflating complications requiring pharmacological treatment with complications requiring invasive intervention or intensive care. For external context, the Society of Thoracic Surgeons (STS) lobectomy composite-score study reported a 9.6% major complication rate after standard lobectomy for lung cancer (19). Although the STS endpoint and case mix differ from those of the present SRMPN cohort, this benchmark supports the interpretation that severe PPCs after VATS-based SRMPN were uncommon in carefully selected patients.
A methodological strength of this study is the two-tier multivariable analysis, which separated preoperative predictors from perioperative and pathological factors. This approach reflects the clinical sequence from initial risk assessment to operative strategy selection. In the preoperative model, impaired pulmonary function (FEV1% predicted <80%), larger dominant tumor size, and the presence of more than two nodules emerged as independent predictors of treatment-requiring PPCs. Advanced age (≥70 years) was a predictor in the univariable analysis and ultimately emerged as an independent predictor in the comprehensive multivariable model (P=0.046), suggesting that older patients possess a lower physiological tolerance for the cumulative trauma of simultaneous resections. Although larger dominant tumor size was independently associated with treatment-requiring PPCs in the preoperative model, this association was no longer significant in the comprehensive model (P=0.39), suggesting that this preoperative association may partly reflect its relationship with operative extent, pulmonary reserve, or other surgical planning factors. We also found that left-sided procedures had a lower risk of treatment-requiring PPCs compared to right-sided resections in the baseline preoperative model, although this effect was attenuated in the comprehensive analysis. This is anatomically plausible, as the right lung accounts for a larger proportion of total lung volume and features a more complex bronchial architecture, making multiple right-sided resections inherently more disruptive to pulmonary mechanics (20,21). In the descriptive supplementary analysis, treatment-requiring PPC rates did not vary markedly across the major secondary nodule categories, although several detailed categories were sparse. This finding, together with the non-benign secondary-nodule sensitivity analysis, suggests that short-term perioperative risk may be more closely related to the extent of functional tissue loss and the mechanical trauma of parenchymal division than to the biological behavior of the nodules (22). From a practical perspective, these findings support a stepwise assessment before SRMPN: first evaluating pulmonary reserve, age-related physiological tolerance, dominant tumor size, and nodule burden; then estimating the planned resection burden; and finally identifying procedures that combine lobectomy with anatomical segmentectomy or involve basal segments. This framework is intended to support surgical planning rather than to serve as a validated prediction score.
Among the surgical combinations, lobectomy combined with segmentectomy showed the strongest association with treatment-requiring PPCs, followed by lobectomy plus wedge resection. The elevated risk associated with combining a lobectomy and an anatomical segmentectomy aligns with recent findings by Nakazawa et al., who reported a higher incidence of postoperative complications and prolonged operative times for this specific complex pattern compared to lobectomy plus wedge resections (23). Furthermore, combining a lobectomy and a wedge resection was also associated with a higher risk compared with double wedge resection in this VATS cohort. In contrast, sublobar combinations, such as double segmentectomy and segmentectomy plus wedge resection, did not show a clear increase in risk compared with double wedge resection. This distinction further implies that for patients requiring extensive resection, lung-sparing sublobar combinations may provide a safer alternative when oncologically appropriate. When lobectomy is required for the dominant lesion, adding a wedge resection appeared to be associated with a lower adjusted risk than adding an anatomical segmentectomy. This distinction may help surgeons balance oncological clearance against perioperative morbidity when planning combined resections.
The association between basal segment involvement and treatment-requiring PPCs should be interpreted in the context of segmentectomy-related anatomy. Basal segment-involved procedures showed a higher PPC rate than non-basal segmentectomies and remained associated with treatment-requiring PPCs in both the segmentectomy cohort and the full-cohort model. This finding is clinically plausible because basal resections often involve deeper parenchymal dissection and more demanding intersegmental-plane management (15,24). However, basal segment involvement should not be interpreted as a purely anatomical or causal effect. In our cohort, 95.4% of basal-involved procedures were classified as complex segmentectomy, although complex segmentectomy was also common among non-basal procedures. In the same-covariate comparison, the broad simple-versus-complex classification did not explain the basal association: the broad simple-versus-complex segmentectomy classification itself was not associated with treatment-requiring PPCs, and the basal estimate was not attenuated after adjustment for complex segmentectomy. These results suggest that basal segment involvement may capture a relevant pattern of segmentectomy-related anatomical difficulty within SRMPN that is not fully represented by the broad simple-versus-complex classification. This distinction is important when planning combined resections, particularly in patients with limited pulmonary reserve or a greater nodule burden.
Although smoking history and COPD were associated with higher rates of treatment-requiring PPCs in univariable analysis, neither emerged as independent risk factors in our multivariable models, diverging from previous reports (25-27). This discrepancy is likely attributable to the specific demographic profile of our cohort, which featured a very low prevalence of COPD (1.3%) and a high proportion of non-smokers (81.6%). Additionally, collinearity between COPD status and FEV1% predicted may explain this finding, as the functional metric (FEV1% predicted) proved to be the stronger and more direct predictor in our models.
Our study has several limitations. First, the retrospective, single-center design inherently introduced selection bias; surgeons likely selected healthier patients with better pulmonary reserve, lower operative risk, and technically resectable nodules for simultaneous resection. The low prevalence of COPD and the high proportion of non-smokers further indicate that this cohort was healthier than many real-world lung cancer surgery populations. Therefore, the observed safety profile should be interpreted as applying to carefully selected VATS candidates rather than to all patients with MPNs. Second, the study covered a long period during which VATS technique, perioperative care, imaging, and staging practices evolved. The temporal sensitivity analysis showed a lower rate of treatment-requiring PPCs in the later period, suggesting that calendar time may have influenced perioperative outcomes. Although surgery period was examined in sensitivity analysis, residual temporal confounding cannot be excluded. Third, by strictly excluding open thoracotomies to ensure cohort homogeneity, our findings may not be fully generalizable to patients requiring open conversions. Furthermore, because the cohort did not include patients treated with staged resection or nonoperative management, this study cannot compare simultaneous and staged strategies directly. In addition, the segmentectomy-specific analyses should be interpreted cautiously. The pure segmentectomy cohort included only 144 patients and the basal plus simple-only category included only six patients. Therefore, although basal segment involvement retained a risk signal after adjustment for complex segmentectomy, the available data could not fully separate the contribution of basal anatomy from other aspects of technical complexity. Larger multicenter cohorts with detailed segment-level operative information are needed to clarify this relationship. Finally, the study spanned 12 years, during which perioperative protocols evolved; however, the surgical team and the dominance of the VATS approach remained relatively constant.
Conclusions
SRMPN appeared feasible with acceptable short-term safety for selected patients with synchronous pulmonary nodules when performed via VATS. Our findings suggest that impaired pulmonary function, advanced age, greater nodule burden, lobectomy involvement, and basal segment involvement were associated with an increased risk of treatment-requiring PPCs. Therefore, for patients with multiple nodules, clinical decision-making should follow a stepwise approach: thoroughly evaluating baseline pulmonary reserve, age-related physiological tolerance, dominant tumor size, and nodule burden at the preoperative stage, and subsequently prioritizing parenchyma-sparing strategies whenever oncologically feasible. Lobectomy-based combinations and basal segment-involved procedures should be considered with caution, particularly in patients with limited pulmonary reserve, older age, or a greater nodule burden.
Supplementary
The article’s supplementary files as
Acknowledgments
None.
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. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of West China Hospital, Sichuan University (No. 2022-155); and individual consent for this retrospective analysis was waived because the data were anonymized, and the privacy rights of human subjects were strictly observed throughout the study.
Footnotes
Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-2026-0524/rc
Funding: This work was supported by the 1·3·5 project for disciplines of excellence from West China Hospital of Sichuan University (No. ZYGD23010 to L.L.); “Qimingxing” Research Fund for Young Talents (No. HXQMX0183 to S.W.); and the Postdoctoral Fellowship Program of China Postdoctoral Science Foundation (No. GZB20240495 to Z.Y.).
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-2026-0524/coif). Z.Y., S.W., and L.L. report that this work was supported by the 1·3·5 project for disciplines of excellence from West China Hospital of Sichuan University (No. ZYGD23010 to L.L.), “Qimingxing” Research Fund for Young Talents (No. HXQMX0183 to S.W.), and the Postdoctoral Fellowship Program of China Postdoctoral Science Foundation (grant No. GZB20240495 to Z.Y.). The other authors have no conflicts of interest to declare.
Data Sharing Statement
Available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-2026-0524/dss
References
- 1.Zhao Y, de Bock GH, Vliegenthart R, et al. Performance of computer-aided detection of pulmonary nodules in low-dose CT: comparison with double reading by nodule volume. Eur Radiol 2012;22:2076-84. 10.1007/s00330-012-2437-y [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Guo LW, Lyu ZY, Liu Y, et al. The probability of lung cancer in patients with pulmonary nodules detected via low-dose computed tomography screening in China. BMC Cancer 2025;25:1058. 10.1186/s12885-025-14449-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Loverdos K, Fotiadis A, Kontogianni C, et al. Lung nodules: A comprehensive review on current approach and management. Ann Thorac Med 2019;14:226-38. 10.4103/atm.ATM_110_19 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Voltolini L, Rapicetta C, Luzzi L, et al. Surgical treatment of synchronous multiple lung cancer located in a different lobe or lung: high survival in node-negative subgroup. Eur J Cardiothorac Surg 2010;37:1198-204. 10.1016/j.ejcts.2009.11.025 [DOI] [PubMed] [Google Scholar]
- 5.Trousse D, Barlesi F, Loundou A, et al. Synchronous multiple primary lung cancer: an increasing clinical occurrence requiring multidisciplinary management. J Thorac Cardiovasc Surg 2007;133:1193-200. 10.1016/j.jtcvs.2007.01.012 [DOI] [PubMed] [Google Scholar]
- 6.Shen KR, Meyers BF, Larner JM, et al. Special treatment issues in lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition). Chest 2007;132:290S-305S. [DOI] [PubMed] [Google Scholar]
- 7.Qu R, Ye F, Tu D, et al. Clinical Features and Surgical Treatment of Synchronous Multiple Primary Lung Adenocarcinomas With Different EGFR Mutations. Front Oncol 2021;11:785777. 10.3389/fonc.2021.785777 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Detterbeck FC, Mazzone PJ, Naidich DP, et al. Screening for lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013;143:e78S-e92S. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Bai C, Choi CM, Chu CM, et al. Evaluation of Pulmonary Nodules: Clinical Practice Consensus Guidelines for Asia. Chest 2016;150:877-93. 10.1016/j.chest.2016.02.650 [DOI] [PubMed] [Google Scholar]
- 10.Sengupta S. Post-operative pulmonary complications after thoracotomy. Indian J Anaesth 2015;59:618-26. 10.4103/0019-5049.165852 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Yang R, Wu Y, Yao L, et al. Risk factors of postoperative pulmonary complications after minimally invasive anatomic resection for lung cancer. Ther Clin Risk Manag 2019;15:223-31. 10.2147/TCRM.S195010 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Tao X, Zhao J, Wei W, et al. The feasibility and safety of simultaneous bilateral video-assisted thoracic surgery for the treatment of bilateral pulmonary lesions. Front Oncol 2022;12:975259. 10.3389/fonc.2022.975259 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Rea F, Zuin A, Callegaro D, et al. Surgical results for multiple primary lung cancers. Eur J Cardiothorac Surg 2001;20:489-95. 10.1016/s1010-7940(01)00858-2 [DOI] [PubMed] [Google Scholar]
- 14.Prisciandaro E, Ceulemans LJ, Van Raemdonck DE, et al. Impact of the extent of lung resection on postoperative outcomes of pulmonary metastasectomy for colorectal cancer metastases: an exploratory systematic review. J Thorac Dis 2022;14:2677-88. 10.21037/jtd-22-239 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Handa Y, Tsutani Y, Mimae T, et al. Surgical Outcomes of Complex Versus Simple Segmentectomy for Stage I Non-Small Cell Lung Cancer. Ann Thorac Surg 2019;107:1032-9. 10.1016/j.athoracsur.2018.11.018 [DOI] [PubMed] [Google Scholar]
- 16.Liu L, Aokage K, Chen C, et al. Asia expert consensus on segmentectomy in non-small cell lung cancer: A modified Delphi study. JTCVS Open 2023;14:483-501. 10.1016/j.xjon.2023.03.013 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Łochowski MP, Kozak J. Video-assisted thoracic surgery complications. Wideochir Inne Tech Maloinwazyjne 2014;9:495-500. 10.5114/wiitm.2014.44250 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Al-Thani S, Nasar A, Villena-Vargas J, et al. All segments are created equal: locoregional recurrence and survival after single versus multi-segment resection in patients with clinical stage IA ≤2 cm non-small-cell lung cancer. Eur J Cardiothorac Surg 2025;67:ezaf082. 10.1093/ejcts/ezaf082 [DOI] [PubMed] [Google Scholar]
- 19.Kozower BD, O'Brien SM, Kosinski AS, et al. The Society of Thoracic Surgeons Composite Score for Rating Program Performance for Lobectomy for Lung Cancer. Ann Thorac Surg 2016;101:1379-86; discussion 1386-7. 10.1016/j.athoracsur.2015.10.081 [DOI] [PubMed] [Google Scholar]
- 20.Agostini PJ, Lugg ST, Adams K, et al. Risk factors and short-term outcomes of postoperative pulmonary complications after VATS lobectomy. J Cardiothorac Surg 2018;13:28. 10.1186/s13019-018-0717-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.van Meerbeeck JP, Damhuis RA, Vos de Wael ML. High postoperative risk after pneumonectomy in elderly patients with right-sided lung cancer. Eur Respir J 2002;19:141-5. 10.1183/09031936.02.00226202 [DOI] [PubMed] [Google Scholar]
- 22.Fuzhi Y, Dongfang T, Wentao F, et al. Rapid Recovery of Postoperative Pulmonary Function in Patients With Lung Cancer and Influencing Factors. Front Oncol 2022;12:927108. 10.3389/fonc.2022.927108 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Nakazawa S, Shimizu K, Yazawa T, et al. Clinicopathological features and surgical outcomes of lobectomy combined with segmentectomy: a cohort study. J Thorac Dis 2023;15:1075-85. 10.21037/jtd-22-696 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Suzuki K, Saji H, Aokage K, et al. Comparison of pulmonary segmentectomy and lobectomy: Safety results of a randomized trial. J Thorac Cardiovasc Surg 2019;158:895-907. 10.1016/j.jtcvs.2019.03.090 [DOI] [PubMed] [Google Scholar]
- 25.You J, Chen D, Liu X, et al. Postoperative pneumonia in patients with non-small cell lung cancer undergoing thoracoscopic surgery: What should we care about? Front Oncol 2025;15:1564042. 10.3389/fonc.2025.1564042 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Jeganathan V, Knight S, Bricknell M, et al. Impact of smoking status and chronic obstructive pulmonary disease on pulmonary complications post lung cancer surgery. PLoS One 2022;17:e0266052. 10.1371/journal.pone.0266052 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Gupta H, Ramanan B, Gupta PK, et al. Impact of COPD on postoperative outcomes: results from a national database. Chest 2013;143:1599-606. 10.1378/chest.12-1499 [DOI] [PubMed] [Google Scholar]