Pulmonary Metastasectomy in Pediatric Patients: A Comparison of Open and Thoracoscopic Approaches

Background: Although the use of video-assisted thoracoscopic surgery (VATS) for resection of lung metastases has increased, surgeons still advocate for open resection as it permits palpation of lesions that may be missed on imaging. This study aimed to compare the utilization of open thoracotomy versus VATS over time and determine if the use of VATS changes perioperative outcomes. Methods: Using the Kids' Inpatient Database (2006, 2009, 2012, 2016), we identified children (age ≤20) with a diagnosis of secondary lung cancer with either lobectomy or sublobar resection coded during the same admission. Utilization was compared across years for the overall cohort and for patients with primary bone and connective tissue (PBCT) cancers. We defined prolonged length of stay (LOS) as LOS ≥75th percentile (LOS ≥7 days). Univariable and multivariable analyses compared in-hospital complication rates and LOS for open and VATS approaches. Results: Of the 1316 children (539 female) undergoing pulmonary resection, VATS was utilized in 374 (28.4%). Utilization increased rapidly from 2006 to 2009 (P < .001 for trend), but stabilized thereafter (P = .622). Metastatic PBCT cancers were the most common indication for resection (n = 496, 38%), but open and VATS approaches were used nearly equally (P = .368). Overall, 352 (26%) patients had complications. On multivariable analysis, the open approach remained independently associated with increased complications (odds ratio [OR] 1.48, 95% confidence interval [CI] [1.04-2.11]). Median LOS increased for open cases (5 versus 3 days, P < .001). Furthermore, open metastasectomy was associated with prolonged LOS (OR 1.50, [1.07-2.10]) after controlling for age, sex, primary cancer, reporting year, resection extent, obesity, complications, and nonoperative intubation. Conclusion: VATS approach to pulmonary metastasectomy resulted in fewer complications and shorter LOS in a nationwide sample of children. Despite these advantages, the use of VATS has plateaued. While this study cannot comment on oncologic safety or long-term outcomes, future studies should evaluate whether indications for VATS pulmonary metastasectomy can be expanded.