Oncological advantage of nonintubated thoracic surgery: Better compliance of adjuvant treatment after lung lobectomy

The relationship between microRNA-155-5p and postoperative inflammatory markers in children with acute suppurative appendicitis and its role in predicting postoperative complications

BACKGROUND

The prevalence of acute suppurative appendicitis (ASA) is the highest among pediatric cases of acute abdominal conditions. This research examined the stress response linked to surgical techniques and identified potential biomarkers that could predict postoperative complications to enhance clinical treatment strategies.

METHODS

This study involved a selection of 166 ASA patients who underwent laparoscopic appendectomy (LA), and 150 patients who underwent open appendectomy (OA), based on data collected from 2020 to 2023. Comprehensive documentation of clinical and pathological characteristics, as well as postoperative complications, was conducted following patient enrollment. Quantitative polymerase chain reaction (qPCR), enzyme-linked immunosorbent assay (ELISA), and blood smear techniques were employed to assess the levels of microRNA (miR)-155-5p, C-reactive protein (CRP), interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), superoxide dismutase (SOD), and malondialdehyde (MDA), as well as changes in leukocytes, neutrophils, and lymphocytes at preoperative and postoperative 0 h, and 24 h. A logistic regression model was utilized to identify risk factors associated with the development of complications. Furthermore, receiver operating characteristic (ROC) curve analysis was performed to assess the predictive capacity of miR-155-5p for the occurrence of complications.

RESULTS

The study revealed that the levels of miR-155-5p postoperatively in patients undergoing OA was significantly greater than that observed in patients undergoing LA (P.

Awake thoracic surgery for lung cancer treatment: where we are and future perspectives-our experience and review of literature

BACKGROUND

Lung cancer is the first cause of cancer-related death. Awake lung resection is a new frontier of the concept of minimally invasive surgery. Our purpose is to demonstrate the feasibility of this technique for lobar and sublobar lung resection in NSCLC patients.

METHODS

We retrospective reviewed all the medical charts of patients who underwent awake lung resection in our center between March 2018 and March 2024, focusing on patients with NSCLC, and we compared our results with the ones found in literature.

RESULTS

Among 45 patients treated with awake lung resections, we selected 15 patients with NSCLC and finally analyzed the results of 12 patients who underwent VATS awake lung resection, 3 lobectomies and 9 wedge resections. The median Charlson comorbidity index (CCI) was 3 and we had 5 patients (41.67%) with a CCI ≥ 4 and a median FEV1 of 56%. We report only 2 conversions to general anesthesia (16.67%) and no conversion to open thoracotomy. We used a nebulizator for the atomization of lidocaine on the lung surface to reduce the cough reflex. Our post-operative results are in line with literature, with a low complication rate (2 patients, 16.67%) and a median length of stay of 5 days. We safely performed a proper lymph node dissection in all 3 lobectomies. Median Overall Survival and Disease-Free Survival were 11 months.

CONCLUSIONS

Awake lung resections are a feasible way to perform a minimally invasive surgical procedure in NSCLC patients, with low risk of conversion to open surgery.

[Non-Intubated Video-assisted Thoracoscopic Surgery (niVATS)]

Non-intubated minimally invasive lung surgery garnered renewed interest during the past decade and many centers across the country successfully implemented the technique for minor procedures like pleurodesis or wedge resection. Anatomical lung resection under spontaneous breathing still is considered as challenging, and as existing data to support it is conflicting and confusing, the approach remains limited to few dedicated outfits. We seek to present the historical perspective, critically report potential advantages and limitations of the technique and hand out a guideline that might prove to be helpful in building up a dedicated program.

Operation room nursing based on humanized nursing mode combined with nitric oxide on rehabilitation effect after lung surgery

BACKGROUND

With advancements in the diagnosis and treatment of lung diseases, lung segment surgery has become increasingly common. Postoperative rehabilitation is critical for patient recovery, yet challenges such as complications and adverse outcomes persist. Incorporating humanized nursing modes and novel treatments like nitric oxide inhalation may enhance recovery and reduce postoperative complications.

AIM

To evaluate the effects of a humanized nursing mode combined with nitric oxide inhalation on the rehabilitation outcomes of patients undergoing lung surgery, focusing on pulmonary function, recovery speed, and overall treatment costs.

METHODS

A total of 79 patients who underwent lung surgery at a tertiary hospital from March 2021 to December 2021 were divided into a control group (n = 39) receiving a routine nursing program and an experimental group (n = 40) receiving additional humanized nursing interventions and atomized inhalation of nitric oxide. Key indicators were compared between the two groups alongside an analysis of treatment costs.

RESULTS

The experimental group demonstrated significant improvements in pulmonary function, reduced average recovery time, and lower total treatment costs compared to the control group. Moreover, the quality of life in the experimental group was significantly better in the 3 months post-surgery, indicating a more effective rehabilitation process.

CONCLUSION

The combination of humanized nursing mode and nitric oxide inhalation in postoperative care for lung surgery patients significantly enhances pulmonary rehabilitation outcomes, accelerates recovery, and reduces economic burden. This approach offers a promising reference for improving patient care and rehabilitation efficiency following lung surgery.

The Impact of Laparoscopic Appendectomy and Open Appendectomy on B7-H3-Mediated Intrinsic Immune Response in Children with Acute Suppurative Appendicitis

Purpose

Surgery impairs immune function and increases postoperative complications. B7H3, a co-stimulatory molecule, plays a crucial role in immune regulation. The present study examined the impact of B7H3 on the postoperative immune response in children with acute suppurative appendicitis (ASA) by comparing preoperative and postoperative B7H3 levels in laparoscopic surgery (LA) and open appendectomy (OA).

Patients and Methods

198 pediatric ASA patients were enrolled. The researcher group performed LA, while the control group performed OA. Perioperative time, recovery time of gastrointestinal function, time to pass gas, length of incision, and length of hospitalization were compared in the perioperative period. Additionally, an ELISA assay was conducted to examine the levels of inflammatory factors and B7H3 and CD28. Short-term postoperative complications were also evaluated.

Results

Compared with the control group, the research group had a short operative time, gastrointestinal function recovery time, gas time, and hospitalization time. The short-term complication rate was significantly lower in the research group. More importantly, B7H3 and CD28 were insignificantly different preoperatively, but they were all reduced postoperatively. Moreover, the reduction was more pronounced in the research group. The same results were noted in inflammatory factors and immune markers, which were non-significant different preoperatively and were typically reduced postoperatively, particularly in the research group. Finally, postoperative B7H3 was positively correlated with both inflammatory factors and immune cell levels.

Conclusion

B7H3 was reduced in both postoperative periods, and the reduction was more pronounced in the LA group. B7H3 may be involved in postoperative recovery by modulating postoperative inflammation and immune responses.

Awake uniportal video-assisted thoracoscopic surgery for the management of pericardial effusion

Introduction

Pericardial drainage can be performed either with pericardiocentesis or pericardial "window" in cases with hemodynamic compromise for therapeutic and diagnostic purposes. Awake single-port video-assisted thoracoscopic surgery (VATS) is an alternative to pericardial window (PW) that has been described only in case reports in the literature. We aimed to analyse a series of patients with chronic, recurrent and/or large pericardial effusions who underwent single-port VATS-PW opening without intubation.

Patients and Methods

The PW was opened using awake single-port VATS in 20 of 23 patients referred to our clinic with recurrent, chronic and/or large pericardial effusion between December 2021 and July 2022. Demographic data, imaging modalities, treatment processes and pathological samples were analysed retrospectively.

Results

The median age of 20 patients was 68 years (52-81). The mean body mass index was 29.1 ± 6.0 kg/m2 and mean pericardial fluid measurements with pre-operative transthoracic echocardiography (TTE) was 2,8 ± 0,9 cm. The mean operation time was 44 ± 13.0 min and mean peri-operative drainage was 700 ± 307 cc. On the 1st post-operative day, control TTE revealed ≤0.5 cm effusion in 18 (90%) patients and ≥0.5 cm in 2 (10%) patients. The median day of discharge or referral to the clinic where they are followed up was 1 (1-2).

Conclusions

Awake single-port VATS could be used safely in all patient groups with pericardial effusion or tamponade as a diagnostic and therapeutic option. This technique has advantages, especially in patients with high surgical risk.

A surgical Decision-making scoring model for spontaneous ventilation- and mechanical ventilation-video-assisted thoracoscopic surgery in non-small-cell lung cancer patients

BACKGROUNDS

Spontaneous ventilation-video-assisted thoracoscopic surgery (SV-VATS) has been applied to non-small cell lung cancer (NSCLC) patients in many centers. Since it remains a new and challenging surgical technique, only selected patients can be performed SV-VATS. We aim to conduct a retrospective single-center study to develop a clinical decision-making model to make surgery decision between SV-VATS and MV (mechanical ventilation) -VATS in NSCLC patients more objectively and individually.

METHODS

Four thousand three hundred sixty-eight NSCLC patients undergoing SV-VATS or MV-VATS in the department of thoracic surgery between 2011 and 2018 were included. Univariate and multivariate regression analysis were used to identify potential factors influencing the surgical decisions. Factors with statistical significance were selected for constructing the Surgical Decision-making Scoring (SDS) model. The performance of the model was validated by area under the receiver operating characteristic curve (AUC), calibration curves and decision curve analysis (DCA).

RESULTS

The Surgical Decision-making Scoring (SDS) model was built guided by the clinical judgment and statistically significant results of univariate and multivariate regression analyses of potential predictors, including smoking status (p = 0.03), BMI (p < 0.001), ACCI (p = 0.04), T stage (p < 0.001), N stage (p < 0.001), ASA grade (p < 0.001) and surgical technique (p < 0.001). The AUC of the training group and the testing group were 0.72 and 0.70, respectively. The calibration curves and the DCA curve revealed that the SDS model has a desired performance in predicting the surgical decision.

CONCLUSIONS

This SDS model is the first clinical decision-making model developed for an individual NSCLC patient to make decision between SV-VATS and MV-VATS.

ANESTHESIA FOR NON-INTUBATED VIDEO-ASSISTED THORACOSCOPIC SURGERY

With the growing adoption of Enhanced Recovery After Surgery protocols across all surgical groups, including thoracic surgery, coupled with improved video-assisted thoracoscopic surgery (VATS) equipment and techniques, nonintubated thoracoscopic surgery has gained significant popularity in recent years. Avoiding tracheal intubation with an endotracheal or double-lumen tube and general anesthesia may reduce or eliminate the risks associated with traditional mechanical ventilation, one-lung ventilation, and general anesthesia. Studies have shown a trend toward better preservation of postoperative respiratory function and improved postoperative lengths of hospital stay, morbidity, and mortality; however, these have not been conclusively proven. This review article discusses the advantages of nonintubated VATS, the types of thoracic surgery in which this technique has been described, patient selection, appropriate anesthetic techniques, surgical concerns, potential complications relevant to the anesthesiologist during the conduct of nonintubated VATS surgery, and suggested management of these complications.

Perioperative Systemic Inflammation in Lung Cancer Surgery

Systemic inflammation (SI) is a response of the immune system to infectious or non-infectious injuries that defends the body homeostasis. Every surgical intervention triggers SI, the level of which depends on the extent of damage caused by the surgery. During the first few hours after the damage, the innate or natural immunity, involving neutrophils, macrophages, and natural killer cells, plays a main role in the defense mechanism, but thereafter the adaptive immune response ensues. The number of leukocytes is elevated, the levels of lymphocytes and natural killer cells are reduced, and the cytokines released after surgery correlate with surgical damage. Minimally invasive thoracic surgery procedures induce less inflammatory response and reduce the immune defense in patients to a more moderate level compared with the open surgery procedures; this immunosuppression can be further diminished in spontaneous ventilation cases. The normal functioning of the immune defense is important in controlling the perioperative circulatory tumor cells. Moreover, elevated levels of inflammatory cytokines before immune therapy have a negative impact on the response, and significantly shorten the progression-free survival. Clinically, the lower are the levels of cytokines released during lung surgery, the lesser is the postoperative morbidity, especially pneumonia and wound infection. The return to normal levels of lymphocytes and cytokines occurs faster after spontaneous ventilation surgery. The use of locoregional anesthesia can also reduce SI. Herein, we review the current knowledge on the effects of different operative factors on postoperative SI and defense mechanism in lung cancer surgery.

The Anesthesiologist's Perspective Regarding Non-intubated Thoracic Surgery: A Scoping Review

Non-intubated thoracic surgery (NITS) is a growing practice, alongside minimally invasive thoracic surgery. To date, only a consensus of experts provided opinions on NITS leaving a number of questions unresolved. We then conducted a scoping review to clarify the state of the art regarding NITS. The systematic review of all randomized and non-randomized clinical trials dealing with NITS, based on Pubmed, EMBASE, and Scopus, retrieved 665 articles. After the exclusion of ineligible studies, 53 were assessed examining: study type, Country of origin, surgical procedure, age, body mass index, American Society of Anesthesiologist's physical status, airway management device, conversion to orotracheal intubation and pulmonary complications rates and length of hospital stay. It emerged that NITS is a procedure performed predominantly in Asia, and certain European Countries. In China, NITS is more frequently performed for parenchymal resection surgery, whereas in Europe, it is mainly employed for pleural pathologies. The most commonly used device for airway management is the laryngeal mask. The conversion rate to orotracheal intubation is a~3%. The results of the scoping review seem to suggest that NITS procedures are becoming increasingly popular, but its role needs to be better defined. Further randomized clinical trials are needed to better define the role of the clinical variables possibly impacting on the technique effectiveness.

Systematic Review Registration

https://osf.io/mfvp3/, identifier: 10.17605/OSF.IO/MFVP3.

Pathophysiological Advantages of Spontaneous Ventilation

Surgical procedures cause stress, which can induce an inflammatory response and reduce immune function. Following video-assisted thoracoscopic surgery (VATS), non-intubated thoracic surgery (NITS) was developed to further reduce surgical stress in thoracic surgical procedures. This article reviews the pathophysiology of the NITS procedure and its potential for reducing the negative effects of mechanical one-lung ventilation (mOLV). In NITS with spontaneous ventilation, the negative side effects of mOLV are prevented or reduced, including volutrauma, biotrauma, systemic inflammatory immune responses, and compensatory anti-inflammatory immune responses. The pro-inflammatory and anti-inflammatory cytokines released from accumulated macrophages and neutrophils result in injury to the alveoli during mOLV. The inflammatory response is lower in NITS than in relaxed-surgery cases, causing a less-negative effect on immune function. The increase in leukocyte number and decrease in lymphocyte number are more moderate in NITS than in relaxed-surgery cases. The ventilation/perfusion match is better in spontaneous one-lung ventilation than in mOLV, resulting in better oxygenation and cardiac output. The direct effect of relaxant drugs on the acetylcholine receptors of macrophages can cause cytokine release, which is lower in NITS. The locoregional anesthesia in NITS is associated with a reduced cytokine release, contributing to a more physiological postoperative immune function.

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.

Better intraoperative cardiopulmonary stability and similar postoperative results of spontaneous ventilation combined with intubation than non-intubated thoracic surgery

OBJECTIVES

Non-intubated spontaneous ventilation video-assisted thoracic surgery lobectomy is a well-known procedure, but there are doubts regarding its safety. To solve this problem, we developed a safe procedure for spontaneous ventilation thoracic surgery (spontaneous ventilation with intubation). This study analyzed the intraoperative parameters and postoperative results of spontaneous ventilation with intubation.

METHODS

Between March 11, 2020 and March 26, 2021, 38 spontaneous ventilation with intubation video-assisted thoracic surgery lobectomies were performed. We chose the first 38 non-intubated spontaneous ventilation video-assisted thoracic surgery lobectomy cases with a laryngeal mask performed in 2017 for comparison.

RESULTS

There were no significant differences between the non-intubated spontaneous ventilation and spontaneous ventilation with intubation groups in postoperative surgical results (surgical time: 98,7 vs. 88,1 min (p = 0.067); drainage time: 3.5 vs. 2.7 days (p = 0.194); prolonged air leak 15.7% vs. 10.5% (p = 0.5); conversion rate to relaxation: 5.2% vs. 13.1% (p = 0.237); failure of the spontaneous ventilation rate: 10.5% vs. 13.1% (p = 0.724); and morbidity: 21% vs. 13.1% (p = 0.364)) and oncological outcomes. Significantly lower lowest systolic and diastolic blood pressure (systolic, 83.1 vs 132.3 mmHg, p = 0.001; diastolic 47.8 vs. 73.4 mmHg, p = 0.0001), lowest oxygen saturation (90.3% vs 94.9%, p = 0.026), and higher maximum pCO₂ level (62.5 vs 54.8 kPa, p = 0.009) were found in the non-intubated spontaneous ventilation group than in the spontaneous ventilation with intubation group.

CONCLUSIONS

Spontaneous ventilation with intubation is a more physiological procedure than non-intubated spontaneous ventilation in terms of intraoperative blood pressure stability and gas exchange. The surgical results were similar in the two groups.

Management of intrathoracic phosphaturic mesenchymal tumor by nonintubated uniportal video-assisted thoracic surgery in a fragile patient

Background

Phosphaturic mesenchymal tumors are rare neoplasms, frequently presenting with osteomalacia. These neoplasms usually grow at a slow rate and are associated with unspecific symptoms.

Case

In this study, we present the case of a 70‐year‐old woman who had been suffering from musculoskeletal pain, hypophosphatemia, and spontaneous fractures. Positron emission tomography with Gallium showed increase uptake in a subpleural lesion.

Conclusion

The patient underwent surgical excision of the subpleural lesion with a non‐intubated uniportal video‐assisted thoracoscopic surgery approach.