Video-Assisted Thoracic Surgery Utilizing Local Anesthesia and Sedation: 384 Consecutive Cases

Dexmedetomidine Versus Midazolam for Sedation During Medical Thoracoscopy: A Pilot Randomized-Controlled Trial (RCT)

BACKGROUND

Studies comparing the utility of dexmedetomidine with other drugs for sedation during medical thoracoscopy are lacking. In this pilot study, we compared dexmedetomidine with midazolam for sedation in thoracoscopy.

METHODS

Consecutive subjects were randomized to receive either dexmedetomidine (n=30) (group D) or midazolam (n=30) (group M). All received fentanyl for procedural analgesia. The primary endpoint was pulmonologist-rated overall procedure satisfaction on the visual analog scale (satisfaction VAS). Key secondary outcomes were pulmonologist-rated cough on VAS (cough VAS), patient-rated faces pain scale scores, change in hemodynamic variables, total additional fentanyl dose, and adverse events during procedure.

RESULTS

The satisfaction VAS score (mean±SD) was significantly greater in group D versus group M (7.5±1.4 and 6.5±1.1, respectively) ( P =0.003). The cough VAS scores (mean±SD) were 2.1±1.5 (group D) and 3.1±1.3 (group M) ( P =0.014). The scores (mean±SD) for patient-rated faces pain scale were 2.9±1.8 and 4.2±2.3 ( P =0.019) in group D and group M, respectively. The additional dose of fentanyl administered in group M was significantly greater than in group D ( P =0.001). The responses at the local anesthesia infiltration, skin incision, thoracoscope insertion, and biopsy between both groups were similar. The hemodynamic parameters were comparable in both groups. Also, more patients were willing for repeat thoracoscopy if needed; in the dexmedetomidine group.

CONCLUSION

The findings of this pilot RCT indicate that dexmedetomidine may be more efficacious than midazolam for sedation in patients undergoing medical thoracoscopy. These observations need to be confirmed in an adequately powered RCT.

Evaluation of pain and opioid consumption in local preemptive anesthesia and the erector spine plane block in thoracoscopic surgery: A randomized clinical trial

OBJECTIVE

assess pain and opioid consumption in patients undergoing anesthetic techniques of spinal erector plane block and local anesthetic block in video-assisted thoracic surgery in the immediate postoperative period.

METHODS

ninety-two patients undergoing video assisted thoracic surgery were randomized to receive ESPB or BAL before starting the surgical procedure. Using the numerical verbal scale, the primary outcome assessed was the patient's pain in the immediate postoperative period (POI). The secondary outcome comprises the assessment of opioid consumption in the IPP by quantifying the medication used in an equianalgesic dose of morphine expressed in milligrams, in the immediate post-anesthetic recovery period, 6h, 12h, and 24h after surgery.

RESULTS

the EVN scores in the LBA and ESPB group in the POI had a mean of 0,8 (±1,89) vs 0,58 (±2,02) in the post-anesthesia care room (REPAI), 1,06 (±2,00) vs 1,30 (±2,30) in 6 hours of POI, 0,84 (±1,74) vs 1,19 (±2,01) within 12 hours of POI and 0,95 (±1,88) vs 1 ( ±1,66) within 24 hours of POI, all with p>0.05. Mean opioid consumption in the BAL and ESPB groups in the POI was 12.9 (± 10.4) mg vs 14.9 (±10.2) mg, respectively, with p = 0.416. Sixteen participants in the ESPB group and seventeen in the BAL group did not use opioids during the first 24 hours of the PO analyzed.

CONCLUSION

local anesthesic block and ESP block techniques showed similar results in terms of low pain scores and opioid consumption during the period evaluated.

Non-intubated Thoracoscopic Surgery-Tips and Tricks From Anesthesiological Aspects: A Mini Review

Background

In the last few decades, surgical techniques have been developed in thoracic surgery, and minimally invasive strategies such as multi-and uniportal video-assisted thoracic surgery (VATS) have become more favorable even for major pulmonary resections. With this surgical evolution, the aesthetic approach has also changed, and a paradigm shift has occurred. The traditional conception of general anesthesia, muscle relaxation, and intubation has been re-evaluated, and spontaneous breathing plays a central role in our practice by performing non-intubated thoracoscopic surgeries (NITS-VATS).

Methods

We performed a computerized search of the medical literature (PubMed, Google Scholar, Scopus) to identify relevant articles in non-intubated thoracoscopic surgery using the following terms [(non-intubated) OR (non-intubated) OR (awake) OR (tubeless) OR (regional anesthesia)] AND [(VATS) OR (NIVATS)], as well as their Medical Subject Headings (MeSH) terms.

Results

Based on the outcomes of the reviewed literature and our practice, it seems that pathophysiological concerns can be overcome by proper surgical and anesthetic management. All risks are compensated by the advantageous physiological changes that result in better patient outcomes. With the maintenance of spontaneous breathing, the incidence of potential adverse effects of mechanical ventilation, such as ventilator-induced lung injury and consequent postoperative pulmonary complications, can be reduced. The avoidance of muscle relaxants also results in the maintenance of contraction of the dependent hemidiaphragm and lower airway pressure levels, which may lead to better ventilation-perfusion matching. These techniques can be challenging for surgeons as well as for anesthetists; hence, a good knowledge of physiological and pathophysiological changes, clear inclusion and exclusion and intraoperative conversion criteria, and good communication between team members are essential.

Conclusion

NITS-VATS seems to be a feasible and safe method in selected patients with evolving importance as a part of the minimally invasive surgical and anesthetic conception and has a role in reducing perioperative complications, which is crucial in the thoracic surgical patient population.

Avaliação da dor e consumo de opioides em anestesia preemptiva local e do plano eretor da espinha em cirurgia torácica videotoracoscópica: Um ensaio clínico randomizado

RESUMO Objetivo: avaliar a dor e o consumo de opioides dos pacientes submetidos a técnicas anestésicas de bloqueio do plano eretor da espinha (ESPB) e bloqueio anestésico local (LBA) em cirurgia torácica vídeo assistida no período pós-operatório imediato (POI). Métodos: noventa e dois pacientes submetidos a cirurgia torácica videotoracoscópica foram randomizados aleatoriamente para receberem ESPB ou LBA antes do início do procedimento cirúrgico. O desfecho primário avaliado foi a dor do paciente no POI através da escala verbal numérica. O desfecho secundário avaliou o consumo de opioides através da quantificação da medicação usada em dose equianalgésica de morfina expressa em miligramas, no período de recuperação pós-anestésica imediata, 6h, 12h e 24h após a cirurgia. Resultados: os escores da Escala Verbal Numérica de dor (EVN) no grupo LBA e ESPB no POI, respectivamente, tiveram média de 0,8 (±1,89) vs 0,58 (±2,02) na sala de recuperação pós anestesia (REPAI), 1,06 (±2,00) vs 1,30 (±2,30) em 6 horas do POI, 0,84 (±1,74) vs 1,19 (±2,01) em 12 horas do POI e 0,95 (±1,88) vs 1 ( ±1,66) em 24 horas do POI, todos com p>0,05. O consumo médio de opioides no grupo LBA e ESPB foi de 12,9 (±10,4) mg vs 14,9 (±10.2) mg, respectivamente, com p=0.416. Dezesseis participantes do grupo ESPB e dezessete do grupo LBA não utilizaram opioides durante as primeiras 24 horas do PO. Conclusões: as técnicas de bloqueio LBA e ESPB apresentaram resultados semelhantes em termos de baixos escores de dor e consumo de opioides durante o período avaliado.

Thoracic surgery in the non-intubated spontaneously breathing patient

BACKGROUND

The interest in non-intubated video-assisted thoracic surgery (NIVATS) has risen over the last decade and numerous terms have been used to describe this technique. They all have in common, that the surgical procedure is performed in a spontaneously breathing patient under locoregional anaesthesia in combination with intravenous sedation but have also been performed on awake patients without sedation. Evidence has been generated favouring NIVATS compared to one-lung-ventilation under general anaesthesia.

MAIN BODY

We want to give an overview of how NIVATS is performed, and which different techniques are possible. We discuss advantages such as shorter length of hospital stay or (relative) contraindications like airway difficulties. Technical aspects, for instance intraoperative handling of the vagus nerve, are considered from a thoracic surgeon's point of view. Furthermore, special attention is paid to the cohort of patients with interstitial lung diseases, who seem to benefit from NIVATS due to the avoidance of positive pressure ventilation. Whenever a new technique is introduced, it must prove noninferiority to the state of the art. Under this aspect current literature on NIVATS for lung cancer surgery has been reviewed.

CONCLUSION

NIVATS technique may safely be applied to minor, moderate, and major thoracic procedures and is appropriate for a selected group of patients, especially in interstitial lung disease. However, prospective studies are urgently needed.

Risk Factors for the Development of Intraoperative Hypoxia in Patients Undergoing Nonintubated Video-Assisted Thoracic Surgery: A Retrospective Study from a Single Center

Background

Nonintubated video-assisted thoracic surgery (NIVATS) has been demonstrated to be safe and effective in patients. However, the risk factors for intraoperative hypoxia are unclear. This retrospective study aimed to identify the risk factors for the development of intraoperative hypoxia in patients undergoing NIVATS.

Material/Methods

The study included patients who underwent NIVATS between January 2011 and December 2018. Intraoperative hypoxia was defined as SpO₂ ≤93%. Risk factors for hypoxia were identified by binary logistic regression analysis, and the characteristic distribution of patients with and without hypoxia was elaborated.

Results

Of 2742 included patients, age, anesthesia method, the technical level of surgeons, stair-climbing ability, and type of thoracic procedure were associated with intraoperative hypoxia (P<0.05). The characteristics of patients with hypoxia were older age (P=0.011), higher body mass index and revised cardiac risk index level (P=0.033 and P=0.031), and lower composition of stair-climbing ≥22 m (P<0.001). These patients also had more anatomical lung surgery and mediastinal mass resection (P=0.033) and more epidural anesthesia (P=0.005). The surgeries were more likely to be performed by surgeons with less than 10 years of VATS training (P=0.009) and to have increased intraoperative maximum end-expiratory carbon dioxide partial pressure (P<0.001). These patients had a longer Intensive Care Unit stay (P<0.001), duration of chest-tube drainage (P=0.019), and postoperative hospitalization (P=0.003).

Conclusions

The current study suggests that old age and stair-climbing ability of patients, anesthesia method, thoracic procedures, and surgeon experience are risk factors for intraoperative hypoxia in patients undergoing NIVATS.

Retrospective outcomes analysis of 99 consecutive uniportal awake lung biopsies: a real standard of care?

Background

Surgical lung biopsy for interstitial lung disease (ILD) is traditionally performed through video-assisted thoracic surgery (VATS) and general anesthesia (GA). The mortality and morbidity rates associated with this procedure are not negligible, especially in patients with significant risk factors and respiratory impairment. Based on these considerations, our center evaluated a safe non-intubated VATS approach for lung biopsy performed in ILD subjects.

Methods

Ninety-nine patients affected by undetermined ILD were enrolled in a retrospective cohort study. In all instances, lung biopsies were performed using a non-intubated VATS technique, in spontaneously breathing patients, with or without intercostal nerve blockage. The primary end-point was the diagnostic yield, while surgical and global operating room times, post-operative length of stay (pLOS), numeric pain rating scale (NPRS) after surgery and early mortality were considered as secondary outcomes.

Results

All the procedures were carried out without conversion to GA. The pathological diagnosis was achieved in 97 patients with a diagnostic yield of 98%. The mean operating room length-of-stay and operating time were 73.7 and 42.5 min, respectively. Mean pLOS was 1.3 days with a low readmissions rate (3%). No mortality in the first 30 days due to acute exacerbation of ILD occurred. Both analgesia methods resulted in optimal feasibility with a mean NPRS score of 1.13.

Conclusions

In undetermined ILD patients, surgical lung biopsy with a non-intubated VATS approach and spontaneous ventilation anesthesia appears to be both a practical and safe technique with an excellent diagnostic yield and high level of patient satisfaction.

Nonintubated Uniportal Video-Assisted Thoracic Surgery for Chest Infections

Chest infection is a health care problem in many regions of the world, and pleural empyema is the most common type of surgical chest infection. In the past decennium, the introduction of nonintubated surgery and uniportal video-assisted thoracic surgery changed considerably surgical treatment of pleural empyema. Although the advantages seem evident, the need for randomized controlled trials is necessary to confirm the usefulness. Moreover, in the future, an education and training program for thoracic surgeons and anesthesiologists would allow increasing the number of awake surgical options in caring for patients with stages II to III empyema.

Pleural mesothelioma: is the surgeon still there?

Malignant pleural mesothelioma (MPM) is a rare malignancy with some unique characteristics. Tumor biology is aggressive and prognosis is poor. Despite more knowledge on histology, tumor biology and staging, there is still a relevant discrepancy between clinical and pathologic staging resulting in difficult prediction of prognosis and treatment outcome, making treatment allocation more challenging than in most other malignancies. After years of nihilism in the late 80s, a period of activism started evaluating different treatment protocols combined with research driven mainly by academic centers; at the time, selection was based on histology and stage only. This period was important to gain knowledge about the disease. However, the interpretation of data was difficult since selection criteria and definitions varied substantially. Not surprisingly, until now there is no common agreement on best treatment even among specialists. Hence, a review of our current concepts is indicated and personalized treatment should become applicable in the future. Surgery was and still is an issue of debate. In principle, surgery is an effective approach as it allows macroscopic complete elimination of a tumor, which is relatively resistant to medical treatment. It helps to set the clock back and other therapies that have also just a limited effect can be applied sequentially before or after surgery. Furthermore, to date best long-term outcome is reported from surgical series in combination with other modalities. However, part of the community considers surgery associated with too high morbidity and mortality when balanced to the limited life expectancy. This criticism is understandable, since poor results after surgery are reported. The present article will review the indication for surgery and discuss the different procedures available for macroscopic complete resection-such as lung-preserving (extended) pleurectomy/decortication as well as extrapleural pneumonectomy to illustrate that 'The surgeon is still there!'

Feasibility of non-intubated anesthesia and regional block for thoracoscopic surgery under spontaneous respiration: a prospective cohort study

Data about the feasibility and safety of thoracoscopic surgery under non-intubated anesthesia and regional block are limited. In this prospective study, 57 consecutive patients scheduled for thoracoscopic surgery were enrolled. Patients were sedated with dexmedetomidine and anesthetized with propofol and remifentanil. Ropivacaine was used for intercostal nerve and paravertebral block. Lidocaine was used for vagal block. The primary outcomes were mean arterial pressure (MAP), heart rate (HR), oxygen saturation, and end-tidal carbon dioxide partial pressure (ETCO₂) at T0 (pre-anesthesia), T1 (immediately after laryngeal mask/nasopharyngeal airway placement), T2 (immediately after skin incision), T3 (10 min after opening the chest), T4 (end of surgery), and T5 (immediately after laryngeal mask/nasopharyngeal airway removal). One patient required conversion to intubation, 15 developed intraoperative hypotension, and two had hypoxemia. MAP at T0 and T5 was higher than at T1–T4; MAP at T3 was lower (P<0.05 vs other time points). HR at T0 and T5 was higher (P<0.05 vs other time points). ETCO₂ at T2 and T3 was higher (P<0.05 vs other time points). Arterial pH, PCO₂, and lactic acid at T1 differed from values at T0 and T2 (P<0.05). The Quality of Recovery-15 (QoR-15) score at 24 h was lower (P<0.05). One patient experienced dysphoria during recovery. Thoracoscopic surgery with regional block under direct thoracoscopic vision is a feasible and safe alternative to conventional surgery under general anesthesia, intubation, and one-lung ventilation.

Comparison of Diagnostic Yield and Safety between Semirigid Pleuroscopic Cryobiopsy and Forceps Biopsy for Undiagnosed Pleural Effusion

For undiagnosed pleural effusion, diagnostic yields and safety were similar between pleuroscopic cryobiopsy and forceps biopsy, but cryobiopsy obtained a larger pleural tissue sample than forceps biopsy.

Technical Issues and Patient Safety in Nonintubated Thoracic Anesthesia

Nonintubated thoracic surgery (NITS) has a good safety record in experienced hands, but has pitfalls for beginners. The main aim of NITS is to keep the patient under spontaneous respiration, avoiding adverse effects, such as hypoxemia, hypercapnia, panic attacks, and finally conversion to general anesthesia. In this paper, the safety aspects of anesthesia for NITS is discussed based on data from the literature and personnel clinical experiences.

Comparison of awake and intubated video-assisted thoracoscopic surgery in the diagnosis of pleural diseases: A prospective multicenter randomized trial

Background

This study aims to compare the safety and diagnostic accuracy of awake and intubated video-assisted thoracoscopic surgery in the diagnosis of pleural diseases.

Methods

This prospective randomized study was conducted between October 2016 and April 2018 and included 293 patients (201 males, 92 females; mean age 53.59 years; range, 18 to 90 years) from five medical centers experienced in video-assisted thoracoscopic surgery. The patients were randomized into two groups as awake video-assisted thoracoscopic surgery with sedoanalgesia (non-intubated) and video-assisted thoracoscopic surgery with general anesthesia (intubated). Patients with undiagnosed pleural effusions and pleural pathologies such as nodules and masses were included. Conditions such as pain, agitation, and hypoxia were indications for intubation. The groups were compared in terms of demographic data, postoperative pain, operative time, complications, diagnostic accuracy of the procedures, and cost. All patients completed a follow-up period of at least 12 months for samples that were non-specific, suspicious for malignancy or inadequate.

Results

Awake video-assisted thoracoscopic surgery was performed in 145 and intubated video-assisted thoracoscopic surgery was performed in 148 patients. Pleural disease was unilateral in 83% (243/293) and bilateral in 17% (50/293) of the patients. There was no difference between the groups in terms of presence of comorbidity (p=0.149). One patient in the awake video-assisted thoracoscopic surgery group (0.6%) was converted to general anesthesia due to refractory pain and agitation. As postoperative complications, fluid drainage and pneumonia were observed in one patient in the awake video-assisted thoracoscopic surgery group (0.6%) and fluid drainage was detected in one patient in the video-assisted thoracoscopic surgery group (0.6%). There were no differences in pain intensity measured with visual analog scale at postoperative 4, 8, 12, or 24 hours (p>0.05). Distribution and rates of postoperative pathological diagnoses were also similar (p=0.171). Both operative cost and total hospital cost were lower in the awake video-assisted thoracoscopic surgery group (p<0.001, p=0.001).

Conclusion

Our study showed that awake video-assisted thoracoscopic surgery is safe, has similar reliability and diagnostic accuracy compared to video-assisted thoracoscopic surgery performed under general anesthesia, and is less costly. Awake video-assisted thoracoscopic surgery can be the first method of choice in all patients, not only in those with comorbidities.

Single-trocar thoracoscopic pericardio-pleural fenestration under local anesthesia for malignant pleural effusion: a case report

Background

Pericardio-pleural fenestration by video-assisted thoracoscopic surgery is an efficient procedure for malignant pericardial effusion, but requires general anesthesia with single-lung ventilation.

Case presentation

A 43-year-old woman was referred with complaints of deteriorating dyspnea and orthopnea. Chest computed tomography revealed right massive pleural effusion and pericardial effusion. Echocardiography demonstrated collapse of both the right atrium and right ventricle due to cardiac tamponade. Semi-rigid thoracoscopic pleural biopsy and pericardio-pleural fenestration were successfully performed under local anesthesia via a single trocar, because surgical procedures under general anesthesia with single-lung ventilation might have been intolerable for the patient. Adequate biopsy specimens of pleura and pericardium and immediate relief of serious symptoms were obtained without perioperative complications. No recurrence of pleural or pericardial effusion was observed for 3 months postoperatively.

Conclusion

Thoracoscopic pericardio-pleural fenestration under local anesthesia via a single trocar is feasible as an alternative approach in critically ill patients, allowing effective pericardial drainage, evaluation of the pleural cavity, and accurate biopsies of the pericardium and parietal pleura simultaneously.

A Multidisciplinary Proposal for a Diagnostic Algorithm in Idiopathic Pulmonary Fibrosis: The Role of Transbronchial Cryobiopsy

The diagnosis of idiopathic pulmonary fibrosis (IPF) is a complex process that requires the multidisciplinary integration of clinical, radiological, and histological variables. Due to its diagnostic yield, surgical lung biopsy has been the recommended procedure for obtaining samples of lung parenchyma, when required. However, given the morbidity and mortality of this technique, alternative techniques which carry a lower risk have been explored. The most important of these is transbronchial cryobiopsy -transbronchial biopsy with a cryoprobe- which is useful for obtaining lung tissue with less comorbidity. Yield may be lower than surgical biopsy, but it is higher than with transbronchial biopsy with standard forceps. This option has been discussed in the recent clinical guidelines for the diagnosis of IPF, but the authors do not go so far as recommend it. The aim of this article, the result of a multidisciplinary discussion forum, is to review current evidence and make proposals for the use of transbronchial cryobiopsy in the diagnosis of IPF.

Pleuroscopy or video-assisted thoracoscopic surgery for exudative pleural effusion: a comparative overview

Exudative pleural effusions, such as malignant and tuberculous pleural effusions, are associated with notable morbidity and mortality. Unfortunately, a significant number of these effusions will remain undiagnosed despite thoracentesis. Traditionally, closed pleural biopsies have been the next best diagnostic step, but the diagnostic yield of blind closed pleural biopsies for malignant pleural effusions is insufficient. When image-guided targeted biopsies are not possible, both pleuroscopy and video-assisted thoracoscopic surgery are reasonable options for obtaining pleural biopsies, but the decision to select one procedure over the other continues to raise much debate. Pleuroscopy (aka. medical thoracoscopy, local anaesthetic thoracoscopy) is a relatively common procedure performed by interventional pulmonologists in the bronchoscopy suite with local anesthesia, often as an outpatient procedure, on spontaneously breathing patients. Video-assisted thoracoscopic surgery, on the other hand, is performed by thoracic surgeons in the operating room, on mechanically ventilated patients under general anesthesia, though admittedly considerable overlap exists in practice. Both pleuroscopy and video-assisted thoracoscopic surgery have reported diagnostic yields of over 90%, although pleuroscopy more often leads to the unsatisfactory diagnosis of 'non-specific' pleuritis. These cases of 'non-specific' pleuritis need to be followed up for at least one year, as 10-15% of them will eventually lead to the diagnosis of cancer, typically malignant pleural mesothelioma. Both procedures have their pros and cons, and it is therefore of paramount importance that all cases be discussed as part of a multidisciplinary approach to diagnosis within a "pleural team" that should ideally include interventional pulmonologists and thoracic surgeons.

Clarification of the resection line non-intubated segmentectomy using indocyanine green

A reflection on the measure of fluorescence specificity of indocyanine green (ICG) in non-intubated pulmonary segmentectomy.

Anesthesia for nonintubated video-assisted thoracic surgery

PURPOSE OF REVIEW

This review focuses primarily on nonintubated video-assisted thoracic surgery (NIVATS), and discusses advantages, indications, anesthetic techniques, and approaches to intraoperative crisis management.

RECENT FINDINGS

Advancements in endoscopic, endovascular, and robotic techniques have expanded the range of surgical procedures that can be performed in a minimally invasive fashion. For thoracic operations in particular, video-assisted thoracic surgery (VATS) has largely replaced traditional thoracotomy, and continued technical development has made surgical access into the pleural space even less disruptive. As a consequence, the need for general anesthesia and endotracheal intubation has been re-examined, such that regional or epidural analgesia may be sufficient for cases where lung collapse can be accomplished with spontaneous ventilation and an open hemithorax. This concept of NIVATS has gained popularity, and in some centers has now expanded to include procedures involving placement of multiple ports. Although still relatively uncommon at present, a small number of randomized trials and meta-analyses have indicated some advantages, suggesting that NIVATS may be a desirable alternative to general anesthesia with endotracheal intubation for specific indications.

SUMMARY

Although anesthesia for NIVATS is associated with some of the same risks as general anesthesia with endotracheal intubation, NIVATS can be successfully performed in carefully selected patients.

Successful use of regional anesthesia in non-intubated video-assisted thoracic surgery in patients with cardiopulmonary failure: two case reports

BACKGROUND

One-lung ventilation under general anesthesia is necessary for thoracic surgery, but this procedure is often difficult in surgery for patients with cardiopulmonary failure. Non-intubated video-assisted thoracic surgery (VATS) is performed under local anesthesia for patients with respiratory failure, but has not been performed for patients with circulatory failure. Here, we report management of two patients with cardiopulmonary failure who underwent non-intubated VATS with paravertebral block and infiltration anesthesia.

CASE PRESENTATION

Case 1 was a 79-year-old male with dyspnea at rest due to left large pleural effusion and cardiac dysfunction who underwent thoracoscopic pleural biopsy with paravertebral block under spontaneous breathing. The patient was also receiving dialysis. Case 2 was a 53-year-old male who developed empyema due to large pleural effusion, resulting in a poor general condition and cardiac dysfunction, and underwent video-assisted empyema curettage only with infiltration anesthesia under spontaneous breathing. In both patients, intraoperative respiration and circulation remained stable with values similar to those present preoperatively, and there were no problems after surgery.

CONCLUSIONS

We safely anesthetized two patients with difficulty to general anesthesia by ensuring sufficient regional anesthesia during VATS under spontaneous breathing. These cases suggest that regional anesthesia for non-intubated VATS can contribute to maintain intra- and postoperative respiration and circulation in patients with cardiopulmonary failure.

Nonintubated-Awake Anesthesia for Uniportal Video-Assisted Thoracic Surgery Procedures

Nonintubated video-assisted thoracic surgery (VATS) strategies are gaining popularity. This review focuses on noninutbated VATS, and discusses advantages, indications, anesthetic techniques, and approaches to intraoperative crisis management. Advances in endoscopic, endovascular, and robotic techniques have expanded the range of surgical procedures that can be performed in a minimally invasive fashion. The nonintubated thoracoscopic approach has been adapted for use with major lung resections. The need for general anesthesia and endotracheal intubation has been reexamined, such that regional or epidural analgesia may be sufficient for cases where lung collapse can be accomplished with spontaneous ventilation and an open hemithorax.

Single-Port Thoracoscopic Pericardial Window Under Local Anesthesia

There are numerous surgical approaches for the treatment of pericardial effusions but no clear consensus of best management. We present a 44-year-old woman with metastatic breast cancer presenting with a new 2-cm pericardial effusion on ultrasound. In light of the patient's palliative condition and the urgent need for chemotherapy, careful consideration was made for her surgical drainage of the pericardial effusion. Because of the patient's medical comorbidities, a general anesthetic was deemed not to be in the patient's best interest. Furthermore, the invasive subxiphoid or thoracotomy approach for a pericardial window would have risked delaying her much needed chemotherapy. A single-port thoracoscopic pericardial window was performed under light sedation, ventilating spontaneously on supplementary oxygen through nasal cannula only. The patient was positioned in a supine position, and a single 8-mm port was inserted into the left hemithorax at the 5th intercostal space, midaxillary line under local anesthetic, and a pericardial window made. This minimally invasive approach, without the need for intubation or ventilation, allowed for rapid relief of symptoms and discharge for the patient to begin her chemotherapy in a timely manner. By undergoing the procedure awake and through a single port, the patient was discharged after a short inpatient stay. This novel approach can be advocated for patients where a general anesthetic or invasive surgical procedure is not suitable in the treatment of their pericardial effusion.

Evaluation of safety and efficacy of regional anesthesia compared with general anesthesia in thoracoscopic lung biopsy procedure on patient with idiopathic pulmonary fibrosis

Background

Interstitial lung diseases are diseases that need histology diagnosis or obtaining a lung biopsy to establish the diagnosis. Surgical biopsies are performed usually using the thoracoscopy technique under general anesthesia (GA) although this procedure is still associated with morbidity rate. The aim of this study is to determine the effectiveness and safety of regional anesthesia (RA) compared with GA in thoracoscopic lung biopsy procedures done on patients with idiopathic pulmonary fibrosis (IPF).

Subjects and Methods

This is a retrospective qualitative study based on adult cases of video-assisted thoracoscopy (VAT) lung biopsy on patients with IPF admitted in the division of Thoracic Surgery, Department of General Surgery, King Khalid University Hospital, Riyadh, KSA. We included 67 patients with IPF, 26 with RA, and 41 with GA, who underwent this procedure from January 2008 to December 2015. Procedures performed under RA were done using three different approaches, intercostal nerve blocks, extrapleural infusion, and paravertebral block while GA was performed using double-lumen endotracheal tube placement. For statistical analysis, SPSS program, version 21.0. Software used to analyze the obtained data. The statistical significance was defined as P < 0.05.

Results

Sixty-seven patients underwent the procedure of thoracoscopic lung biopsy. Twenty-six of them (38.8%) underwent the procedure under RA and 41 (61.2%) under GA. The cross tabulation of the intercostal chest tube duration showed that it was significantly longer in GA group (6.23 ± 5.1 days) compared to RA group (3.12 ± 1.5 days), P = 0.004. Furthermore, for the Intensive Care Unit (ICU) stay, it was significantly longer in GA group (3.38 ± 2.1 days) compared to RA group (1.09 ± 0.7 days), P = 0.019. Regarding the relation between the number of biopsies taken and type of anesthesia performed, the probability values for GA group as well as RA group come out to be >0.05 (statistically independent) and the results of risk estimate also show that there was no significant association found between them. The cross tabulation of the representation of biopsies taken by the two methods showed that all biopsies taken under both settings were representative of the disease. Of 41 procedures done under GA, 16 of the total showed a number of complications. Likewise, of 26 procedures under RA, five cases showed complications. The significant (two-sided) value was (P = 0.110), there was no statistical significance between the risks of complications and the two types of anesthesia.

Conclusion

There was a significant decrease in chest tube duration and ICU stay in RA group compared to the GA group. There was no statistical difference between both types of anesthesia in the number of biopsy, representation, and postoperative complications although the rate of these complications was much less in the RA group. Based on this outcome, we can conclude that VAT lung biopsy procedure on patients with IPF under RA is safe, representative, and effective operation. In addition, high-risk patients for GA can go through this procedure under RA as an alternative and safe option with no added complications.

Video assisted thoracoscopic and open chest surgery in diagnosis and treatment of malignant pleural diseases

Parenchymal cancers of lung, breast, gastrointestinal tract and ovaries as well as lymphomas and mesotheliomas are among the most common cancer types causing malignant effusions, though almost all tumour types have been reported to cause a malignant effusion. The prognosis heavily depends on patients' response to systemic therapy however, regardless of the causing pathology and histopathologic form, malignant pleural disease is normally associated with a poor prognosis. To date, there are not sufficient data to allow accurate predictions of survival that would facilitate decision making for managing patients with malignant pleural diseases. Interventions are directed towards drainage of the effusion and, when appropriate, concurrent or subsequent pleurodesis or establishing long-term drainage to prevent re-accumulation. The rate of re-accumulation of the pleural effusion, the patient's prognosis, and the severity of the patient's symptoms should guide the subsequent choice of therapy. In contemporary medicine, not many cancers have managed to generate as intense debates concerning treatment, as malignant pleural mesothelioma. The relative advantages of surgery, radiation, chemotherapy and any combination of the three are continuously reassessed and reconsidered, even though not always based on scientific evidence. The aim of surgery in mesothelioma may be prolongation of life, in addition to palliation of symptoms. Longer recovery periods from more extensive surgical procedures could be justified, in carefully selected patients. Surgical options include: Video assisted thoracoscopic (VATS) pleurodesis, VATS partial pleurectomy (VATS PP)-both parietal and visceral; open pleurectomy decortication (PD)-with an extended option (EPD) and extrapleural pneumonectomy (EPP). Current evidence implies that EPD can be performed reliably in specialised centres with good results, both in terms of mortality and survival; however, no operation has yet been shown to be beneficial in a prospective randomized controlled clinical trial.

1000 cases of tubeless video-assisted thoracic surgery at the Rome Tor Vergata University

In the early 2000s, the ‘Awake Thoracic Surgery Research Group’ at Tor Vergata University began a program of thoracic operations in awake nonintubated patients. To our knowledge this was the first program created with this specific purpose. Since then over 1000 tubeless operations have been carried out successfully, making this series one of the widest in the world. Both nononcologic and oncologic conditions were successively approached and major operations for lung cancer are now being performed. Uniportal access was progressively adopted with significant positive outcomes in postoperative recovery, patient acceptance and economical costs. Failure rates due to patient's intolerance and open surgery conversion are progressively reducing. Tubeless thoracic surgery can be accomplished in a safe manner with effective results.

Modified single-port non-intubated video-assisted thoracoscopic decortication in high-risk parapneumonic empyema patients

BACKGROUND

Parapneumonic empyema patients with coronary artery disease and reduced left ventricular ejection fraction are risky to receive surgical decortication under general anesthesia. Non-intubated video-assisted thoracoscopy surgery is successfully performed to avoid complications of general anesthesia. We performed single-port non-intubated video-assisted flexible thoracoscopy surgery in an endoscopic center. In this study, the possible role of our modified surgery to treat fibrinopurulent stage of parapneumonic empyema with high operative risks is investigated.

METHODS

We retrospectively reviewed fibrinopurulent stage of parapneumonic empyema patients between July 2011 and June 2014. Thirty-three patients with coronary artery disease and reduced left ventricular ejection fraction were included in this study. One group received tube thoracostomy, and the other group received single-port non-intubated video-assisted flexible thoracoscopy surgery decortication. Patient demographics, characteristics, laboratory findings, etiology, and treatment outcomes were compared.

RESULTS

Mean age of 33 patients (24 males, 9 females) was 76.2 ± 9.7 years. Twelve patients received single-port non-intubated video-assisted flexible thoracoscopy surgery decortication, and 21 patients received tube thoracostomy. Visual analog scale scores on postoperative first hour and first day were not significantly different in two groups (p value = 0.5505 and 0.2750, respectively). Chest tube drainage days, postoperative fever subsided days, postoperative hospital days, and total length of stay were significantly short in single-port non-intubated video-assisted flexible thoracoscopy surgery decortication (p value = 0.0027, 0.0001, 0.0009, and 0.0065, respectively). Morbidities were low, and mortality was significantly low (p value = 0.0319) in single-port non-intubated video-assisted flexible thoracoscopy surgery decortication.

CONCLUSIONS

Single-port non-intubated video-assisted flexible thoracoscopy surgery decortication may be suggested to be a method other than tube thoracostomy to deal with fibrinopurulent stage of parapneumonic empyema patients with coronary artery disease and reduced left ventricular ejection fraction.

[Application of Non-intubated Anesthesia in VATS]

气管插管全麻技术可提高手术安全性，因此在电视胸腔镜手术（video-assisted thoracic surgery, VATS）中得到广泛应用，但气管插管的并发症却无法避免。如何发展一种“整体微创”手术（包括麻醉微损伤），已经成为微创胸外科领域的一个研究热点。随着麻醉管理技术与对手术风险管理的进步，非气管插管技术成功应用于VATS，即采用局部麻醉以维持患者的术中自主通气，术中仅需轻微镇静或者完全清醒的状态下实施VATS，因而又称清醒状态下VATS。此麻醉方式不但减少气管插管的麻醉损伤，而且符合快速康复外科的理念。本文对非气管插管应用在胸外科VATS中的发展简史、麻醉选择、手术优势、手术风险及管理、面临的问题等方面作一综述。

Non-intubated video-assisted thoracic surgery: where does evidence stand?

In recent years, non-intubated video-assisted thoracic surgery (NIVATS) strategies are gaining popularity worldwide. The main goal of this surgical practice is to achieve an overall improvement of patients' management and outcome thanks to the avoidance of side-effects related to general anesthesia (GA) and one-lung ventilation. The spectrum of expected benefits is multifaceted and includes reduced postoperative morbidity, faster discharge, decreased hospital costs and a globally reduced perturbation of patients' well-being status. We have conducted a literature search to evaluate the available evidence on this topic. Meta-analysis of collected results was also done where appropriate. Despite some fragmentation of data and potential biases, the available data suggest that NIVATS operations can reduce operative morbidity and hospital stay when compared to equipollent procedures performed under GA. Larger, well designed prospective studies are thus warranted to assess the effectiveness of NIVATS as far as to investigate comprehensively the various outcomes. Multi-institutional and multidisciplinary cooperation will be welcome to establish uniform study protocols and to help address the questions that are to be answered yet.

Anaesthetic considerations for non-intubated thoracic surgery

General anaesthesia with intubation and single lung ventilation has always been considered essential for thoracic surgery. Over the last decade there has been a huge evolution in thoracic surgery with the development of multiport and uniportal minimally invasive techniques. The development of a non-intubated technique during which thoracic surgery is performed on patients who are spontaneously ventilating awake, under minimal sedation with the aid of local or regional anaesthesia or under general anaesthesia with a supraglottic airway device is winning acceptance as a valid alternative technique. The concept is to allow the creation of a spontaneous pneumothorax as the surgeon enters the chest. This can provide excellent lung isolation without the need for positive pressure ventilation on the dependant lung. Awake and minimal sedation techniques, which avoid the need for general anaesthesia, maintain a more physiological cardiopulmonary and neurological status and avoid postoperative nausea and vomiting. However, general anaesthesia with a supraglottic airway device is the technique that provides a more stable airway and facilitates oxygenation in cases where an unexpected conversion to open thoracotomy in needed. For non-intubated thoracic surgery a regional analgesic technique is essential; nonetheless a 'multimodal' approach to analgesia is recommended. Non-intubated anaesthetic techniques for thoracic surgery are innovative and exciting and drive to reduce the invasiveness of the procedures. We recommend that centres starting out with non-intubated techniques begin by performing minor video-assisted thoracic surgery (VATS) procedures in selected low risk patients. Early elective conversion should be employed in any unexpected surgical difficulty or cardiopulmonary problem during the learning curve to reduce the risk of emergency conversion and complications. Further research is needed to establish which patients benefit more from the technique and what is the real impact on perioperative mortality and morbidity.

Outpatient thoracoscopy: safety and practical considerations

PURPOSE OF REVIEW

Medical thoracoscopy, also known as pleuroscopy, has been utilized by chest physicians for more than a century. Despite this, it has only recently re-emerged as an important tool for interventional pulmonologists to diagnose and treat pleural diseases. The purpose of this review is to critically assess the recent literature related to medical thoracoscopy, specifically as it pertains to its safety and feasibility as an outpatient procedure.

RECENT FINDINGS

Recent data have reaffirmed the clinical utility of medical thoracoscopy and suggest that it can be safely performed in an outpatient setting. A single-center study of 51 patients published in the past year described both the feasibility and safety of outpatient medical thoracoscopy. This study highlights the notion that the majority of patients do not require hospital admission after a routine diagnostic thoracoscopy in the absence of talc poudrage. Another study this year described the successful use of chest physician-directed ultrasound-guided cutting needle biopsy when medical thoracoscopy was not technically possible.

SUMMARY

The contribution of medical thoracoscopy in the diagnosis and management of pleural diseases is increasingly recognized. Evidence supports the routine practice of medical thoracoscopy on an outpatient basis in experienced centers.

Thoracoscopy: medical versus surgical-in the management of pleural diseases

Diseases of the pleura continue to affect a large population of patients worldwide and in the United States. Pleural fluid analysis and accompanying imaging of the pleura including chest X-rays, chest computed tomography (CT) scan and chest ultrasonography are among the first steps in the management of pleural effusions. When further diagnostic or therapeutic work up is necessary, open thoracotomy and thoracoscopy come to mind. However, given the significant morbidity and mortality associated with open thoracotomy, and the advances in medicine and medical instruments, thoracoscopy has now become a routine procedure in the management of the disease of the chest including pleura. Debates about surgical vs. medical thoracoscopy (MT) are ongoing. In the following pages we review the literature and discuss the similarities and differences between the two procedures, as well as their indications, contraindications, complications and efficacy in the management of pleural diseases.

Anesthetic management of nonintubated video-assisted thoracoscopic surgery using epidural anesthesia and dexmedetomidine in three patients with severe respiratory dysfunction

Nonintubated video-assisted thoracoscopic surgery (VATS) has been reported to be safe and feasible for patients with various thoracic diseases, including those who have respiratory dysfunction. In nonintubated VATS, it is important to maintain spontaneous respiration and to obtain a satisfactory operating field through adequate collapse of the lung by surgical pneumothorax. Therefore, we need to minimize the patient's physical and psychological discomfort by using regional anesthesia and sedation. If analgesia and sedation are inadequate, conversion to intubated general anesthesia may be required. Dexmedetomidine (DEX) is a highly selective α2-adrenoceptor agonist that provides anxiolysis and cooperative sedation without respiratory depression. It seems to be a suitable sedative for nonintubated VATS, especially in high-risk patients for intubated general anesthesia, but there have been no report about its use combined with epidural anesthesia in nonintubated VATS for adult patients. Here, we report three patients with severe respiratory dysfunction who underwent nonintubated VATS for pneumothorax using epidural anesthesia and DEX. In all three patients, DEX infusion was started after placement of an epidural catheter and was titrated to achieve mild sedation, while maintaining communicability and cooperation. This seems to be a promising strategy for nonintubated VATS in patients with respiratory dysfunction, as well as patients with normal respiratory function.

Thoracoscopy in pleural effusion – two techniques: awake single-access video-assisted thoracic surgery versus 2-ports video-assisted thoracic surgery under general anesthesia

Awake single access video-assisted thoracic surgery with local anesthesia improves procedure tolerance, reduces postoperative stay and costs. Materials & methods: Local anesthesia was made with lidocaine and ropivacaine. We realize one 20 mm incision for the ‘single-access’, and two incisions for the ‘2-trocars technique’. Results: Mortality rate was 0% in both groups. Postoperative stay: 3dd ± 4 versus 4dd ± 5, mean operative time: 39 min versus 37 min (p < 0.05). Chest tube duration: 2dd ± 5 versus 3dd ± 6. Complications: 11/95 versus 10/79. Conclusion: Awake technique reduce postoperative hospital stay and chest drainage duration, similar complications and recurrence rate. The authors can say that ‘awake single-access VATS’ is an optimal diagnostic and therapeutic tool for the management of pleural effusions, but above extends surgical indication to high-risk patients.

VIDEO-ASSISTED THORACIC SURGERY USING LOCAL ANESTHESIA IN LUNG ABSCESSES AND PYOPNEUMOTHORAX

The article presents the results of 42 video-abscessoscopies (VAS) in acute and gangrenous lung abscess and 32 video-thoracoscopies (VTS) in pyopneumothorax, which were performed using local anesthesia and sedation. There were several indication to operation: sanation of cavities, removal of necrotic sequestration and fibrin, decollement, biopsy. Perioperative complications developed after 11 surgeries (13%): emphysema of soft tissues of pectoral cells (5), phlegmon of the thorax (3), bronchial hemorrhage (2), pneumothorax (1). One of the patients died, because of progressing of main disease. VAS and VTS were carried out in 5-8 days after cavity drainage of abscess or pleural cavity in 50 patients. In other 15 cases operations were performed directly before drainage. The bronchial hemorrhage and phlegmons of the thorax were noted in patients of second group. The patients had good tolerance of VAS and VTS operations fulfilled using local anesthesia and sedation. They are safe in case that operation follows drainage of abscess or pleural cavity after decrease of inflammatory processes.

Urgent awake thoracoscopic treatment of retained haemothorax associated with respiratory failure

A number of video-assisted thoracoscopic surgery (VATS) procedures are being increasingly performed by awake anesthesia in an attempt of minimizing the surgical- and anesthesia-related traumas. However, so far the usefulness of awake VATS for urgent management of retained haemothorax has been scarcely investigated. Herein we present two patients with retained haemothorax following previous thoracentesis and blunt chest trauma, respectively, who developed acute respiratory failure and underwent successful urgent awake VATS management under local anesthesia through a single trocar access.

Nonintubated anesthesia in thoracic surgery: general issues

Anesthetic management for awake thoracic surgery (ATS) is more difficult than under general anesthesia (GA), being technically extremely challenging for the anesthesiologist. Therefore, thorough preparation and vigilance are paramount for successful patient management. In this review, important considerations of nonintubated anesthesia for thoracic surgery are discussed in view of careful patient selection, anesthetic preparation, potential perioperative difficulties and the management of its complications.

Effects on respiration of nonintubated anesthesia in thoracoscopic surgery under spontaneous ventilation

Thoracoscopic surgery without tracheal intubation [nonintubated video-assisted thoracoscopic surgery (VATS)] is an emerging treatment modality for a wide variety of thoracic procedures. By surgically induced open pneumothorax, the operated lung collapse progressively while the dependent lung is responsible for sufficiency of respiratory function, including oxygenation and ventilation. Encouraging results showed that ventilatory changes and oxygenation could be adequately maintained in major lung resection surgery and in patients with impaired respiratory function. In spite of a relative hypoventilation, mild hypercapnia is inevitable but clinically well tolerated. An understanding the respiratory physiology during surgical pneumothorax, either in awake or sedative status, and an established protocol for conversion into tracheal intubation are essential for patient safety during nonintubated VATS.

Awake video-assisted thoracic surgery in acute infectious pulmonary destruction

BACKGROUND

Many of thoracic minimally invasive interventions have been proven to be possible without general anesthesia. This article presents results of video-assisted thoracic surgery (VATS) application under local anesthesia in patients with lung abscesses and discusses its indications in detail.

METHODS

The study involved prospective analysis of treatment outcomes for all acute infectious pulmonary destruction (AIPD) patients undergoing VATS under local anesthesia and sedation since January 1, 2010, till December 31, 2013. Patients with pulmonary destruction cavity at periphery of large size (>5 cm) underwent non-intubated video abscessoscopy (NIVAS). Patients with pyopneumothorax (lung abscess penetration into pleural cavity) underwent non-intubated video thoracoscopy (NIVTS). Indications for NIVAS and NIVTS were as follows: cavity debridement and washing, necrotic sequestra removal, adhesion split, biopsy. All interventions were done under local anesthesia and sedation without trachea intubation and epidural anesthesia.

RESULTS

Sixty-five enrolled patients had 42 NIVAS and 32 NIVTS interventions, nine patients underwent two surgeries. None of the patients required trachea intubation or epidural anesthesia. In none of our cases with conversion to thoracotomy was required. Post-surgical complications developed after 11 interventions (13%): subcutaneous emphysema (five cases), chest wall phlegmon (three cases), pulmonary bleeding (two cases), and pneumothorax (one case). One patient died due to the main disease progression. In 50 patients NIVAS and NIVTS were done within 5 to 8 days after abscess/pleural cavity draining, while in other 15 patients-immediately prior to draining; both pulmonary bleeding episodes and all cases of chest wall phlegmon took place in the latter group.

CONCLUSIONS

NIVAS and NIVTS under local anesthesia and sedation are well tolerated by patients, safe and should be used more often in AIPD cases. Timing of NIVAS and NIVTS procedures was found to be of paramount importance for ensuring complete therapeutic effectiveness.

Non-intubated video-assisted thoracic surgery as the modality of choice for treatment of recurrent pleural effusions

This review will establish that the best mode of treatment for recurrent pleural effusions is non-intubated video-assisted thoracic surgery (VATS) with chemical talc pleurodesis. The nature of recurrent pleural effusions mandates that any definitive and effective treatment of this condition should ideally provide direct visualization of the effusion, complete initial drainage, a low risk outpatient procedure, a high patient satisfaction rate, a high rate of pleurodesis and a high diagnostic yield for tissue diagnosis. There are various methods available for treatment of this condition including thoracostomy tube placement with bedside chemical pleurodesis, thoracentesis, placement of an indwelling pleural catheter, pleurectomy and VATS drainage with talc pleurodesis. Of these treatment options VATS drainage with the use of local anesthetic and intravenous sedation is the method that offers most of the desired outcomes, thus making it the best treatment modality.

Non-intubated anesthesia in thoracic surgery-technical issues

Performing awake thoracic surgery (ATS) is technically more challenging than thoracic surgery under general anesthesia (GA), but it can result in a greater benefit for the patient. Local wound infiltration and lidocaine administration in the pleural space can be considered for ATS. More invasive techniques are local wound infiltration with wound catheter insertion, thoracic wall blocks, selective intercostal nerve blockade, thoracic paravertebral blockade and thoracic epidural analgesia, offering the advantage of a catheter placement which can also be continued for postoperative analgesia.

Non-intubated video-assisted thoracic surgery in patients aged 80 years and older

BACKGROUND

Video-assisted thoracic surgery (VATS) is routinely performed with general anesthesia and double-lumen endotracheal intubation, but this technique may stress an elderly patient's functional reserve. We chose to study the safety and efficacy of non-intubated VATS, utilizing local anesthesia, sedation, and spontaneous ventilation in the elderly.

METHODS

The medical records of all patients aged 80 years and older who underwent VATS under local anesthesia and sedation during the time period 6/1/2002 to 6/1/2010 at Geisinger Health System (Pennsylvania, USA) and 10/1/2011 to 12/31/2014 at Sinai Hospital (Maryland, USA) were retrospectively reviewed. Unsuccessful attempts at this technique were eligible for inclusion but there were none. No patient was excluded based on comorbidity.

RESULTS

A total of 96 patients ranging in age from 80 to 104 years underwent 102 non-intubated VATS procedures: pleural biopsy/effusion drainage with or without talc 73, drainage of empyema 17, evacuate hemothorax 4, pericardial window 3, lung biopsy 2, treat chylothorax 2, treat pneumothorax 1. No patient required intubation or conversion to thoracotomy. No patient required a subsequent procedure or biopsy. Complications occurred in three patients (3.1% morbidity): cerebrovascular accident, pulmonary embolism, prolonged air leak. One 94-year-old patient died from overanticoagulation and two 84-year-old patients died of their advanced lung cancers (3.1% morbidity).

CONCLUSIONS

Non-intubated VATS utilizing local anesthesia and sedation in the elderly is well tolerated and safe for a number of indications.