Outcomes after pulmonary bilobectomy for NSCLC: The role of surgical type, indication, and pulmonary function

Introduction: Bilobectomy is an uncommon but sometimes necessary procedure in selected patients with non--small cell lung cancer (NSCLC). However, whether outcomes are influenced by resection type or underlying surgical indication remains unclear. Materials and methods: This single-center study included consecutive patients undergoing bilobectomy for NSCLC between 2010 and 2024. Upper and lower bilobectomies were analyzed separately and stratified by surgical indication (trans-fissural invasion, N1 disease, or endobronchial involvement). Endpoints included major postoperative complications, overall survival (OS), and disease-free survival (DFS). Multivariable analyses identified independent predictors of outcomes. Results: A total of 153 patients were included, of whom 27 (17.6%) underwent upper and 126 (82.4%) lower bilobectomy. The overall complication rate was 36.4%, higher after lower bilobectomy (p = 0.020), while no differences were observed according to surgical indication (p = 0.550). Five-year DFS and OS were 41.9% and 55.3%, with no significant differences by indication or resection type (all p > 0.05). At multivariable analysis, lower bilobectomy (OR 4.89, p = 0.011) and neoadjuvant therapy (OR 2.92, p = 0.010) were associated with postoperative complications. FEV1 independently predicted both DFS (HR 0.61, p = 0.018) and OS (HR 0.57, p = 0.015), whereas neither indication nor bilobectomy type influenced survival. Conclusion: Bilobectomy provides acceptable perioperative and oncologic outcomes in selected NSCLC patients. Long-term survival is primarily driven by tumor biology and functional status rather than surgical factors. While lower bilobectomy is associated with increased postoperative morbidity, resection type and indication do not independently affect survival.