Non-intubated video-assisted thoracoscopic surgery vs. intubated video-assisted thoracoscopic surgery for thoracic disease: a systematic review and meta-analysis of 1,684 cases

Effect of remimazolam in non-intubated video-assisted thoracic surgery: a retrospective cohort study

BACKGROUND

Single-incision video-assisted thoracoscopic surgery (VATS) is safer, more efficient, and less invasive, with fewer complications and shorter hospital stays. When combined with non-intubated spontaneous breathing, it enhances recovery by reducing complications, operating time, and anesthesia duration. Remimazolam, an ultrashort-acting benzodiazepine, provides rapid onset and offset with minimal respiratory depression, making it promising for non-intubated VATS (NIVATS).

METHODS

This retrospective study was conducted at Taipei Veterans General Hospital, Taiwan, and included 62 patients who underwent single-port NIVATS. Of these, 41 patients received propofol with dexmedetomidine (August 2019-December 2021), and 21 patients received remimazolam with dexmedetomidine (January 2023-December 2023). The primary outcome was the change in arterial carbon dioxide pressure (ΔPaCO2), while secondary outcomes included anesthesia duration, surgery duration, and postoperative hospital stay. Propensity score matching controlled for confounders, and subgroup analyses compared thoracic epidural anesthesia (TEA) with paravertebral block (PVB).

RESULTS

The patients in the remimazolam group showed a smaller PaCO2 increase (6.84 ± 6.01 mmHg vs. 14.42 ± 11.55 mmHg; p = 0.0113), shorter surgery duration (50.19 ± 26.12 min vs. 83.54 ± 24.86 min; p < 0.0001), and shorter postoperative hospital stay compared with those in the propofol group. No significant between-group differences were found with regard to anesthesia duration. Subgroup analysis showed consistent outcomes between TEA and PVB groups, supporting the flexibility of remimazolam-based sedation. None of the patients required flumazenil reversal.

CONCLUSIONS

This study demonstrated effective sedation and superior respiratory stability with the use of remimazolam-dexmedetomidine combination in NIVATS, suggesting it to be a viable alternative. Further studies are needed to confirm these findings in diverse surgical settings.

Perioperative Outcomes of Non-Intubated Versus Intubated Anesthesia in Video-Assisted Thoracoscopic Surgery for Early-Stage Non-Small Cell Lung Cancer: A Propensity Score-Matched Analysis

Background: Previous studies have shown that ventilation strategies used in general anesthesia influence perioperative outcomes of video-assisted thoracoscopic surgery (VATS). This study investigated the perioperative effects of non-intubated anesthesia (NIA) versus intubated anesthesia (IA) in patients with early-stage non-small cell lung cancer (NSCLC) undergoing VATS. Methods: This retrospective cohort study analyzed patients who underwent elective VATS for early-stage NSCLC between January 2015 and December 2022. Patients were categorized into the NIA and IA groups based on the ventilation strategies during general anesthesia. Comprehensive outcome data, including intraoperative and postoperative variables, were compared between the two groups. Univariate and multivariate logistic regression models were used to assess the odds ratios for conversion from NIA to IA. Results: A total of 372 patients who received NIA and 1560 who received IA for VATS were eligible for analysis. After propensity score matching, 336 patients were included in each group. In the matched analysis, patients who received NIA demonstrated favorable perioperative outcomes, including reduced opioid consumption, lower postoperative complication rates, and shorter hospital stays, compared to those who received IA. Additionally, patients with a lower baseline oxygen saturation and those who experienced intraoperative pulmonary and cardiovascular adverse events had a higher risk of conversion from NIA to IA. Conclusions: NIA during VATS in patients with early-stage NSCLC was associated with superior perioperative outcomes. Prospective studies are warranted to further evaluate the impact of NIA on perioperative outcomes in this patient population.

Awake thoracoscopic non-anatomic pulmonary resections under thoracic paravertebral block: Results of a tertiary referral centre

INTRODUCTION

Awake video-assisted thoracoscopic surgery (VATS) helps to avoid the adverse effects of general anaesthesia (GA) with single-lung ventilation. Its usage in anatomic and non-anatomic pulmonary resections has spread worldwide, and it is mostly performed under thoracic epidural analgesia (TEA). We herein report our surgical experience with awake VATS non-anatomical resections under the thoracic paravertebral block (TPB).

PATIENTS AND METHODS

This retrospective, single-centred study reviewed patients undergoing awake VATS non-anatomical pulmonary resection under TPB, who voluntarily accepted awake VATS despite being suitable for GA and were found unsuitable for GA based on pre-operative assessment results. Demographic, pre-, per- and post-operative data were collected, analysed and compared with the literature data.

RESULTS

Twenty-four patients (16 patients with normal pre-operative assessment results and 8 patients having high risk for GA) were selected. Fourteen bullectomies for recurrent spontaneous pneumothorax and 10 wedge resections (nine for metastasectomy and one for lung biopsy) were performed. Global in-operating room time was 77 ± 31 min. The morbidity rate was 20.8% ( n = 5), including prolonged air leak in three and pneumonia in two patients. The mean duration of the chest tube was 1.9 ± 1.5 days and mean duration of hospital stay was 3.5 ± 2.1 days. There was no in-hospital mortality. Our results were mostly similar to the literature data.

CONCLUSION

Non-anatomical lung resections by VATS can be performed easily and safely under TPB in awake patients. Although the perioperative and post-operative outcomes are not superior to other anaesthesia approaches, preferring TPB may help to avoid the serious potential complications of TEA.

[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.

Nonintubated spontaneous ventilation versus intubated mechanical ventilation anesthesia for video-assisted thoracic surgery in terms of perioperative complications and practitioners' workload assessments: a pilot randomized control study

BACKGROUND

The use of nonintubated video-assisted thoracoscopic surgery (NI-VATS) has been increasingly reported to yield favourable outcomes. However, this technology has not been routinely used because its advantages and safety have not been fully confirmed. The aim of this study was to assess the safety and feasibility of nonintubated spontaneous ventilation (NI-SV) anesthesia compared to intubated mechanical ventilation (I-MV) anesthesia in VATS by evaluating of perioperative complications and practitioners' workloads.

METHODS

Patients who underwent uniportal VATS were randomly assigned at a 1:1 ratio to receive NI-SV or I-MV anesthesia. The primary outcome was the occurrence of intraoperative airway intervention events, including transient MV, conversion to intubation and repositioning of the double-lumen tube. The secondary outcomes included perioperative complications and modified National Aeronautics and Space Administration Task Load Index (NASA-TLX) scores from anesthesiologists and surgeons.

RESULTS

Thirty-five patients in each group were enrolled in the intention-to-treat analysis. The incidence of intraoperative airway intervention events was greater in the NI-SV group than in the I-MV group (12 [34.3%] vs. 3 [8.6%]; OR = 0.180; 95% CI = 0.045-0.710; p = 0.009). No significant difference was found in the postoperative pulmonary complications between the groups (p > 0.05). The median of the anesthesiologists' overall NASA-TLX score was 37.5 (29-52) when administering the NI-SV, which was greater than the 25 (19-34.5) when the I-MV was administered (p < 0.001). The surgeons' overall NASA-TLX score was comparable between the two ventilation strategies (28 [21-38.5] vs. 27 [20.5-38.5], p = 0.814).

CONCLUSION

The NI-SV anesthesia was feasible for VATS in the selected patients, with a greater incidence of intraoperative airway intervention events than I-MV anesthesia, and with more surgical effort required by anesthesiologists.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR2200055427. https://www.chictr.org.cn/showproj.html?proj=147872 was registered on January 09, 2022.

[Perioperative pain therapy in minimally invasive thoracic surgery]

Thoracic surgery is often associated with severe postoperative pain levels. Even though these are less pronounced in thoracoscopic approaches, mechanical irritation, compression or injury of intercostal nerves and placement of chest tubes can cause pain levels, which must be treated. An adequate pain therapy in thoracic surgery is essential as insufficient inspiration due to inadequate analgesia may result in postoperative complications. Epidural anesthesia was considered the gold standard in thoracotomy for a long time. For video-assisted thoracoscopy, however, it is sometimes no longer recommended due to its benefit-risk ratio. Alternative thoracic blocks are the paravertebral block, the erector spinae plane block and the serratus anterior block, for which research has found heterogeneous results.This article summarizes the current recommendations for perioperative management of thoracoscopic surgery and gives an overview of the PROSPECT recommendations as well as the current Association of the Scientific Medical Societies in Germany (AWMF) guidelines for perioperative and postoperative pain therapy. In particular, individual regional anesthesia techniques and their current evidence are reviewed.

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.

Nonintubated versus Intubated Lung Volume Reduction Surgery in Patients with End-Stage Lung Emphysema and Hypercapnia

Lung volume reduction surgery (LVRS) represents an important treatment option in carefully selected patients with end-stage lung emphysema. The aim of this study was to assess the efficacy and safety of nonintubated LVRS compared to intubated LVRS in patients with preoperative hypercapnia and lung emphysema. Between April 2019 and February 2021, n = 92 patients with end-stage lung emphysema and preoperative hypercapnia undergoing unilateral video-assisted thoracoscopic LVRS (VATS-LVRS) performed in epidural anesthesia and mild sedation (nonintubated, group 1) or conventional general anesthesia (intubated, control, group 2) were prospectively enrolled in this study. Data were retrospectively analyzed. In all patients, low-flow veno-venous extracorporeal lung support (low-flow VV ECLS) was applied as a bridge through LVRS. Ninety-day mortality was considered as the primary outcome. Secondary endpoints included: chest tube duration, hospital stay, intubation and conversion to general anesthesia. Intergroup analysis showed no significant difference between the baseline data and patients' demographics. N = 36 patients underwent nonintubated surgery. VATS-LVRS under general anesthesia was performed in n = 56 patients. The mean duration of postoperative VV ECLS support was 3 ± 1 day in group 1 compared to 4 ± 1 in group 2. The 90-day mortality rate was 3% in group 1 compared to 7% in group 2. In group 1, all chest tubes were removed 5 ± 1 day (range 4-32 days) and 8 ± 1 day (range 4-44 days) in the control group after the surgery (p < 0.02). Prolonged chest tube therapy (>8 days) was observed in n = 3 patients in group 1 and n = 11 patients in the control group. The mean ICU stay was 4 ± 1 days in group 1 compared to 8 ± 2 days in the control group (p = 0.04). The mean hospital stay was significantly shorter in the nonintubated group 1 (6 ± 2 days vs. 10 ± 4 days, p = 0.01). Conversion to general anesthesia was necessary in one patient due to severe pleural adhesions. Nonintubated VATS-LVRS in patients with end-stage lung emphysema and hypercapnia is effective and well tolerated. Compared to general anesthesia, a reduction in mortality, chest tube duration, ICU and hospital stay and lower rate of prolonged air leak was observed. VV ECLS increases intraoperative safety and mitigates postoperative complications in such "high-risk" patients.

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.

Awake Uniportal VATS for the Evacuation of an Extensive, Superinfected Hemothorax in a Patient with Advanced Mediastinal SMARCA4-Deficient Tumor

Background  The so-called nonintubated or awake video-assisted thoracoscopic surgery (NIVATS) is performed on spontaneously breathing patients, which was shown to reduce postoperative complications and shorten hospital stay. Case Description  Awake uniportal VATS was indicated for the evacuation of an extensive, superinfected hemothorax with symptomatic mediastinal shift in a patient with advanced mediastinal SMARCA4-deficient tumor and declined condition, who did not allow a general anesthetic procedure and was not a candidate for extensive surgery. Conclusion  This short microinvasive intervention was a prerequisite to stabilize the threat to the patient's life and thus potentially enable any further tumor-specific therapy.

Perioperative Inflammatory Response and Cancer Recurrence in Lung Cancer Surgery: A Narrative Review

While surgical resection is the gold standard treatment for solid tumors, cancer recurrence after surgery is common. Immunosurveillance of remnant tumor cells is an important protective mechanism. Therefore, maintenance of anti-tumor cell activity and proper levels of inflammatory mediators is crucial. An increasing body of evidence suggests that surgery itself and perioperative interventions could affect these pathophysiological responses. Various factors, such as the extent of tissue injury, perioperative medications such as anesthetics and analgesics, and perioperative management including transfusions and methods of mechanical ventilation, modulate the inflammatory response in lung cancer surgery. This narrative review summarizes the pathophysiological mechanisms involved in cancer recurrence after surgery and perioperative management related to cancer recurrence after lung cancer surgery.

Non-intubated video-assisted thoracoscopic surgery under combination of erector spinae plane block and thoracic paravertebral block

Background

The use of anesthetics and analgesic drugs and techniques in combination yields a multimodal effect with increased efficiency. In this case series, we aimed to evaluate the anesthetic effect of the thoracic paravertebral block (TPVB) and erector spinae plane block (ESPB) combination in patients, who underwent non-intubated video-assisted thoracoscopic surgery (NIVATS).

Methods

Medical records of 16 patients, who underwent NIVATS for wedge resection under the combination of ESPB and TPVB were reviewed retrospectively. Demographic data of patients, duration of the sensory block, amount of the anesthetic agent used for premedication and sedo-analgesia, any presence of perioperative cough, operative times, postoperative visual analog scale (VAS) scores in the postoperative follow-up period, the need for additional analgesia, and patient satisfaction were reviewed.

Results

Of the patients included in the study, 12 were men and 4 were women. The mean age was 48.6 years and the mean BMI was 24.7 kg/m². The mean time needed for the achievement of the sensorial block was 14 min and the mean skin-to-skin operative time was 21.4 min. During the procedure, patients received 81.5 ± 27.7 mg of propofol and 30 ± 13.6 micrograms of remifentanil infusions, respectively. The mean dose of ketamine administered in total was 58.1 ± 12.2 mg. Only 2 patients needed an extra dose of remifentanil because of recurrent cough. No patients developed postoperative nausea vomiting. During the first 24 h, the VAS static scores of the patients were 3 and below, while VAS dynamic scores were 4 and below. Morphine consumption in the first postoperative 24 h was 13.2 mg.

Conclusions

In conclusion, combined ESPB and TPVB with added intravenous sedo-analgesia in the presence of good cooperation between the surgical team and the anesthesiologist in the perioperative period can provide optimal surgical conditions including the prevention of cough in NIVATS. It is not sufficient to state that this combination is superior to alone ESPB or alone TPVB, as it is a preliminary study with a limited number of cases.

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.

Spontaneous Ventilation Video-Assisted Thoracoscopic Surgery for Non-small-cell Lung Cancer Patients With Poor Lung Function: Short- and Long-Term Outcomes

Objective

The goal of this study was to explore the feasibility and safety of spontaneous ventilation video-assisted thoracoscopic surgery (SV-VATS) for non-small-cell lung cancer (NSCLC) patients with poor lung function.

Methods

NSCLC patients with poor lung function who underwent SV-VATS or mechanical ventilation VATS (MV-VATS) from 2011 to 2018 were analyzed. 1:2 Propensity score matching (PSM) was applied, and the short- and long-term outcomes between the SV-VATS group and the MV-VATS group were compared.

Results

Anesthesia time (226.18 ± 64.89 min vs. 248.27 ± 76.07 min; P = 0.03), operative time (140.85 ± 76.07 min vs. 163.12 ± 69.37 min; P = 0.01), days of postoperative hospitalization (7.29 ± 3.35 days vs. 8.40 ± 7.89 days; P = 0.04), and days of chest tube use (4.15 ± 2.89 days vs. 5.15 ± 3.54 days; P = 0.01), the number of N1 station lymph node dissection (2.94 ± 3.24 vs. 4.34 ± 4.15; P = 0.005) and systemic immune-inflammation index (3855.43 ± 3618.61 vs. 2908.11 ± 2933.89; P = 0.04) were lower in SV-VATS group. Overall survival and disease-free survival were not significantly different between the two groups (OS: HR 0.66, 95% CI: 0.41–1.07, P = 0.09; DFS: HR 0.78, 95% CI: 0.42–1.45, P = 0.43).

Conclusions

Comparable short-term and long-term outcomes indicated that SV-VATS is a feasible and safe method and might be an alternative to MV-VATS when managing NSCLC patients with poor lung function.

Italian survey on non-intubated thoracic surgery: results from INFINITY group

Background

Non-Intubated Thoracic Surgery (NITS) is becoming increasingly adopted all over the world. Although it is mainly used for pleural operations,, non-intubated parenchymal lung surgery has been less frequently reported. Recently, NITS utilization seems to be increased also in Italy, albeit there are no multi-center studies confirming this finding. The objective of this survey is to assess quantitatively and qualitatively the performance of NITS in Italy.

Methods

In 2018 a web-based national survey on Non-Intubated management including both thoracic surgeons and anesthesiologists was carried out. Reference centers have been asked to answer 32 questions. Replies were collected from June 26 to November 31, 2019.

Results

We raised feedbacks from 95% (55/58) of Italian centers. Seventy-eight percent of the respondents perform NITS but only 38% of them used this strategy for parenchymal surgery. These procedures are more frequently carried out in patients with severe comorbidities and/or with poor lung function. Several issues as obesity, previous non-invasive ventilation and/or oxygen therapy are considered contraindications to NITS. The regional anesthesia technique most used to provide intra- and postoperative analgesia was the paravertebral block (37%). Conversion to general anesthesia is not anecdotal (31% of answerers). More than half of the centers believed that NITS may reduce postoperative intensive care unit admissions. Approximately a quarter of the centers are conducting trials on NITS and, three quarters of the respondent suppose that the number of these procedures will increase in the future.

Conclusions

There is a growing interest in Italy for NITS and this survey provides a clear view of the national management framework of these procedures.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-021-01514-3.

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.

Nonintubated versus intubated “one-stage” preoperative localization and thoracoscopic lung resection

Objective

Nonintubated anesthesia, electromagnetic navigation (EMN)-guided preoperative localization, and uniportal video-assisted thoracic surgery (VATS) are recent innovations in minimally invasive thoracic surgery. This study aimed to explore the feasibility of applying nonintubated anesthesia in a “one-stage” localization and resection workflow.

Methods

Patients who underwent EMN-guided preoperative percutaneous localization with indocyanine green (ICG) and uniportal VATS were included. Perioperative data were compared between patients receiving nonintubated anesthesia and those receiving general anesthesia with endotracheal intubation.

Results

Forty-six patients with a total of 50 nodules were included in the study. Overall, finger palpation could be avoided in 94% of the nodules, whereas fluorescent green signals with a clear border on the pleural surface were noted in 91.3% (21 of 23) of nodules in the nonintubated group and 88.9% (24 of 27) of nodules in the intubated group. Intraoperatively, the nonintubated group had a lower median pH (7.33 [interquartile range (IQR), 7.28-7.40] vs 7.41 [IQR, 7.38-7.44]; P = .003), higher median arterial CO₂ (45.5 [IQR, 41.1-58.7] mm Hg vs 38.4 [IQR, 35.3-40.6] mm Hg; P < .001), and lower arterial oxygen (322 [IQR, 211-433] mm Hg vs 426 [IQR, 355-471] mm Hg; P = .005) levels compared with the intubated group. The nonintubated group also had a shorter median registration time (2.0 [IQR, 1.0-3.0] minutes vs 3.0 [IQR, 2.0-8.0] minutes; P = .008) and total time in the operating room (150 [IQR, 130-175] minutes vs 170 [IQR, 135-203] minutes; P = .035), whereas no between-group differences were seen in localization and operative time. The duration of chest drainage, postoperative complications, pathologic diagnosis, and margins were similar in the 2 groups.

Conclusions

Nonintubated “one-stage” EMN-guided percutaneous ICG localization and uniportal VATS can be an option for selected patients undergoing treatment for small peripheral nodules.

Clinical application of preserving spontaneous breathing non-intubation anesthesia in thoracoscopic surgery for lung cancer under ERAS concept

OBJECTIVE

To explore the safety and feasibility of thoracoscopic surgery in patients with lung cancer under non-intubation anesthesia, and to evaluate the advantages of the non-intubation anesthesia compared with intubation anesthesia on enhanced recovery after surgery (ERAS).

METHODS

A retrospective cohort study was conducted in which 100 patients who underwent thoracoscopic lung cancer surgery from January 2020 to February 2021 in the Department of Thoracic Surgery of the First Affiliated Hospital of Soochow University were included and divided into non-intubation group (n = 50) and intubation group (n = 50). The primary outcome was the comparison of intra- and postoperative parameters. Secondary outcomes included inflammatory response indicators and intra- and postoperative complications.

RESULTS

There was no significant difference between the two groups in anesthesia effect score, blood loss, lowest pulse oxygen saturation, operation time, postoperative chest tube indwelling time (P > 0.05). Non-intubation group had less intraoperative remifentanil dosage, less change of blood pressure and heart rate, lower postoperative pain numerical score(NRS), less medical costs, smaller incidence rate of throat discomfort (P < 0.05). The non-intubation group was also associated with less extubation time, postanesthesia care unit recovery time, ambulation time, food intake time, postoperative antibiotic use time, and hospital stay (P < 0.05). The increase of C-reactive protein in the non-intubation group was lower than that in the intubation group (P < 0.05).

CONCLUSION

Non-intubation anesthesia for thoracoscopic lung cancer surgery is safe and feasible. Compared with the intubation anesthesia, it has advantages in ERAS and reducing medical costs.

Spontaneous Ventilation Video-Assisted Thoracoscopic Surgery for Geriatric Patients With Non-Small-Cell Lung Cancer

OBJECTIVES

The aim of the present study was to compare the short-term outcomes between spontaneous ventilation video-assisted thoracic surgery (SV-VATS) and mechanical ventilation video-assisted thoracic surgery (MV-VATS) in the elderly. All patients included in the present study underwent lobectomy, segmentectomy, or wedge resection and lymph node dissection.

DESIGN

A retrospective cohor.

SETTING

The first affiliated hospital of Guangzhou Medical University, Guangzhou, China.

PARTICIPANTS

The present study included 799 elderly patients diagnosed with non-small-cell lung cancer undergoing SV-VATS or MV-VATS. After propensity score matching, 80 patients in the SV-VATS group and 80 patients in the MV-VATS group were analyzed.

INTERVENTIONS

Patients in the SV-VATS group received spontaneous-ventilation anesthesia, which was administered as follows: intravenous anesthesia + laryngeal mask airway + thoracic paravertebral block + visceral pleural surface anesthesia + thoracic vagus nerve block. Patients in the MV-VATS group received general endotracheal anesthesia. SV-VATS or MV-VATS was performed according to the preference of the patients.

MEASUREMENTS AND MAIN RESULTS

There were no significant differences in anesthesia time (226.3 ± 79.8 v 238.5 ± 66.2 min; p = 0.44), surgery time (166.2 ± 102.6 v 170.1 ± 83.4 min; p = 0.66), and number of dissected lymph nodes (5.3 ± 7.5 v 4.4 ± 7.4; p = 0.23) between the two groups. There were significant differences in intraoperative bleeding (61.5 ± 165.1 v 82.2 ± 116.9 mL; p < 0.001). After surgery, the two groups were statistically comparable in terms of hospitalization (17.6 ± 7.6 v 17.2 ± 6.9 days; p = 0.95) and incidence of complications (7.5% v 13.8%; p = 0.20), while there were significant differences in chest tube duration (6.1 ± 3.3 v 4.5 ± 1.2 days; p < 0.001).

CONCLUSIONS

SV-VATS is feasible and as safe as MV-VATS, and it could be considered as an alternative treatment for the elderly.

Comparison of early postoperative cytokine changes in patients undergoing intubated and non-intubated thoracic surgery: a randomized controlled trial

OBJECTIVES

The inflammatory response after surgery is associated with patient prognosis. Patients who undergo thoracic surgery exhibit a profound systemic inflammatory response due to the surgical procedures used and application of one-lung ventilation. The aim of this study was to compare perioperative inflammatory changes in patients after intubated and non-intubated thoracic surgery for primary lung cancer resection.

METHODS

This prospective randomized controlled study included forty patients who underwent surgical resection for stage I non-small-cell lung cancer. Blood samples for cytokine analysis were collected just before induction, at 1 and 24 h after surgery. Levels of the pro-inflammatory cytokine and anti-inflammatory cytokines were measured using quantitative sandwich enzyme immunoassay kits.

RESULTS

The basal values of cytokines were comparable between 2 groups. Within each group, the postoperative levels of interleukin (IL)-1, IL-6 and tumour necrosis factor-α increased, while those of IL-4 and IL-10 did not change significantly. The levels of IL-6 and tumour necrosis factor-α were significantly lower in group NI at 1 and 24 h postoperatively. Other cytokines did not differ in both groups during postoperative period. The IL-6/IL-10 ratio at 1 h after surgery was lower in non-intubated patients than in intubated patients, but there was no difference at 24 h after surgery.

CONCLUSIONS

Non-intubated thoracic surgery may attenuate the early inflammatory cytokine changes following major resection for primary lung cancer compared with intubated conventional surgery.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov registry number NCT04007354.

SV-VATS exhibits dual intraoperative and postoperative advantages

Background

The merits of spontaneous ventilation video-assisted thoracic surgery (SV-VATS) are still controversial. Our team retrospectively evaluated the intraoperative and postoperative advantages of this surgical approach, comparing with mechanical ventilation video-assisted thoracic surgery (MV-VATS).

Methods

We did a single center retrospective study at the First Affiliated Hospital of Yunnan Province. 244 patients were eventually assigned to the SV-group and MV-group, and their intraoperative indicators and thoracic surgery postoperative data were included in the comparison.

Results

The SV-group exhibited markedly less intraoperative bleeding and postoperative thoracic drainage, and the bleeding volume was correlated with the volume and duration of drainage. Further analysis showed that, patients undergoing SV-VATS had less activation of white blood cells and neutrophils after surgery, but they also had lower serum albumin concentrations. Risks of short-term postoperative complications, including inflammatory reactions, malignant arrhythmias, constipation, and moderate or more pleural effusions, were also significantly reduced in the SV-group. Additionally, hospitalization cost was lower in the SV-group than that in the MV-group.

Conclusions

SV-VATS is suitable for various types of thoracic surgery, and effectively reduce intraoperative bleeding and postoperative thoracic drainage. With less postoperative inflammatory response, it reduces the risk of short-term postoperative complications. It is also able to help to reduce the financial burden of patients.

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.

To tube or not to tube: a skeptic's guide to nonintubated thoracic surgery

PURPOSE OF REVIEW

The aim of this review is to provide an overview of the rationale and evidence for nonintubated thoracic surgery and guide clinicians, considering the implementation of nonintubated thoracic surgery, to find an anesthetic approach suitable for their department.

RECENT FINDINGS

Based on physiologic considerations alone, nonintubated thoracic surgery would be expected to be an advantageous concept in thoracic anesthesia, especially in patients at high risk for pulmonary complications. Currently existing evidence, however, does not support these claims. Although the feasibility and safety have been repeatedly demonstrated, high-quality evidence showing a significant benefit regarding clinically relevant patient-centered outcomes is not available.Anesthetic approaches to nonintubated thoracic surgery differ significantly; however, they usually concentrate on six main aspects: maintenance of airway patency, respiratory support, analgesia, patient comfort, cough suppression, and conversion techniques. Given the lack of high-quality studies comparing different techniques, evidence-based guidance of clinical decision-making is currently not possible. Until further evidence is available, anesthetic management will depend mostly on local availability and expertise.

SUMMARY

In select patients and with experienced teams, nonintubated thoracic surgery can be a suitable alternative to intubated thoracic surgery. Until more evidence is available, however, a general change in anesthetic management in thoracic surgery is not justified.

Anesthesiological considerations in emphysema surgery

In the last decades, developing thoracic surgery raised the demands for sophisticated anesthesiological management. Especially patients with end-stage thoracic emphysema challenge the anesthesiologist to make modern surgery possible and to provide a safe and effective perioperative management. The development and scientific work-up of single lung ventilation (SLV) laid the cornerstone for surgery of the non-ventilated lung and hemi-thorax. However, modern medicine extended surgical options to extensive tracheal surgery and to patients suffering from severely insufficient lung-capacity precluding single-lung ventilation or artificial ventilation in se. For those critically ill, different techniques were thus developed and evaluated in recent research, among others, non-intubated surgery and surgery under extracorporeal perfusion support that temporarily avoids pulmonary gas exchange and ventilation via the trachea in any way. To tackle postoperative pain with its successive problems of immobilization, insufficient respiration and airway-clearance, regional anesthesia offers great advantages. Thoracic epidural anesthesia (TEA) is considered as the gold standard; complementary, modern ultrasound techniques make regional anesthesia possible even when contraindications prohibit neuraxial blocks. Especially paravertebral block, musculus serratus anterior block, intercostal block and the musculus erector spinae block provide good postoperative pain relief and appear to influence chronic post-thoracotmy pain positively. Careful preoperative preparation, intraoperative monitoring and patient-tailored, individual perioperative management by a well-trained team ensure good results, a good survival and favorable quality of life. This article provides a brief overview over state-of-the-art techniques and future perspectives to provide anesthesia in emphysema surgery.

Spontaneous ventilation video-assisted thoracic surgery for mediastinal tumor resection in patients with pulmonary function deficiency

BACKGROUND

Whether non-intubated spontaneous ventilation video-assisted thoracoscopic surgery (SV-VATS) is a safe procedure remains controversial for mediastinal tumor patients with impaired lung function. Herein, we assessed feasibility of SV-VATS in lung function deficiency patients underwent mediastinal tumor resection.

METHODS

From December 2015 to February 2020, 32 mediastinal tumor patients with impaired lung function (preoperative forced expiratory volume in 1 second <70% of the predicted value) were retrospectively collected. Patients were divided into two groups: SV-VATS group and mechanical ventilation VATS (MV-VATS) group. Intraoperative and postoperative variables were compared between two cohorts.

RESULTS

Fifteen patients (46.88%) underwent SV-VATS and 17 patients (53.12%) were performed with MV-VATS. The most common causes of lung function deficiency were smoking (81.25%) and COPD (71.88%). Patients in the SV-VATS group had similar blood loss (20.63 vs. 18.76 mL, P=0.417) with MV-VATS group. The anesthesia time (217.51 vs. 197.76 min; P=0.343) and surgery time (141.23 vs. 132.36 min; P=0.209) were also similar between groups. Five people suffered postoperative complications in each group, in which 1 patient underwent MV-VATS was transferred to intensive care unit (ICU) because of prolonged extubation owing to hypoxia. There was no difference on chest tube removal time (2.6 vs. 2.3 days; P=0.172) or hospital duration (5.03 vs. 4.74 days; P=0.297) in patients underwent SV-VATS and MV-VATS.

CONCLUSIONS

SV-VATS is safe and provides similar short-term results to MV-VATS for mediastinal tumor resection in patients with limited pulmonary function.

Contralateral spontaneous rupture of the esophagus following severe emesis after non-intubated pulmonary wedge resection

Background

Non-intubated thoracoscopic lung surgery has been reported to be technically feasible and safe. Spontaneous rupture of the esophagus, also known as Boerhaave’s syndrome (BS), is rare after chest surgery.

Case presentation

A 60-year-old female non-smoker underwent non-intubated uniportal thoracoscopic wedge resection for a pulmonary nodule. Ultrasound-guided serratus anterior plane block was utilized for postoperative analgesia. However, the patient suffered from severe emesis, chest pain and dyspnea 6 h after the surgery. Emergency chest x-ray revealed right-sided hydropneumothorax. BS was diagnosed by chest tube drainage and computed tomography. Besides antibiotics and tube feeding, a naso-leakage drainage tube was inserted into the right thorax for pleural evacuation. Finally, the esophagus was healed 40d after the conservative treatment.

Conclusions

Perioperative antiemetic therapy is an indispensable item of fast-track surgery. Moreover, BS should be kept in mind when the patients complain of chest distress following emesis after thoracic surgery.

Nonintubated Versus Intubated Uniportal Thoracoscopic Segmentectomy for Lung Tumors

BACKGROUND

Although the use of the uniportal thoracoscopic technique has spread exponentially recently, a comparison of nonintubated and intubated uniportal thoracoscopic segmentectomies for lung tumors has not been reported. We aimed to compare the feasibility, safety, and short-term postoperative outcomes between the 2 methods.

METHODS

From January 2014 to June 2019 we retrospectively reviewed 185 consecutive patients with lung tumors who underwent uniportal thoracoscopic segmentectomy at our institute. A body mass index of ≥25 kg/m² was considered a contraindication for the nonintubated anesthetic approach. For the remaining cases the anesthetic approach was made at the discretion of each individual anesthesiologist. A propensity-matched analysis incorporating sex and body mass index was used to compare the clinical outcomes of the nonintubated and intubated groups.

RESULTS

Fifty patients (27.0%) underwent the procedure with the nonintubated anesthetic approach. The nonintubated group was more likely to be female (P < .001) and with a lower body mass index (P < .001). Other clinical features showed no significant difference. There was no significant difference between the 2 groups in the type of segmentectomy according to the difficulty classification system. After propensity matching 43 matched patients in each group were included. Anesthetic induction duration (12.0 vs 15.3 minutes, P = .014) was shorter in the nonintubated group. No other significant differences in perioperative, postoperative, and anesthetic results were noted between the 2 matched groups.

CONCLUSIONS

The nonintubated anesthetic approach can be a safe and feasible alternative to intubated uniportal thoracoscopic segmentectomy.

Standardized surgical technique for uniportal video-assisted thoracoscopic lobectomy

SUMMARY

Uniportal video-assisted thoracoscopic surgery may be the approach for any thoracic procedure, from minor resections to complex reconstructive surgery. However, anatomical lobectomy represents its most common and clinically proven usage. A wide variety of information about uniportal video-assisted thoracoscopic lobectomies can be found in the literature and multimedia sources. This article focuses on updating the surgical technique and includes important aspects such as the geometric approach, anaesthesia considerations, operating room set-up, tips about the incision, instrumentation management and the operative technique to perform the 5 lobectomies. The following issues are explained for each lobectomy: anatomical considerations, surgical steps and technical advice. Medical illustrations and videos are included to clarify the text with the goal of describing a standard surgical practice.

The Year in Thoracic Anesthesia: Selected Highlights from 2019

THIS special article is the 4th in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan; the associate editor-in-chief, Dr. Augoustides; and the editorial board for the opportunity to expand this series, the research highlights of the year that specifically pertain to the specialty of thoracic anesthesia. The major themes selected for 2019 are outlined in this introduction, and each highlight is reviewed in detail in the main body of the article. The literature highlights in this specialty for 2019 include updates in the preoperative assessment and optimization of patients undergoing lung resection and esophagectomy, updates in one lung ventilation (OLV) and protective ventilation during OLV, a review of recent meta-analyses comparing truncal blocks with paravertebral catheters and the introduction of a new truncal block, meta-analyses comparing nonintubated video-assisted thoracoscopic surgery (VATS) with those performed using endotracheal intubation, a review of the Society of Thoracic Surgeons (STS) recent composite score rating for pulmonary resection of lung cancer, and an update of the Enhanced Recovery After Surgery (ERAS) guidelines for both lung and esophageal surgery.

Non-intubated anesthesia in patients undergoing video-assisted thoracoscopic surgery: A systematic review and meta-analysis

INTRODUCTION

Non-intubated anesthesia (NIA) has been proposed for video-assisted thoracoscopic surgery (VATS), although how the benefit-to-risk of NIA compares to that of intubated general anesthesia (IGA) for certain types of patients remains unclear. Therefore, the aim of the present meta-analysis was to understand whether NIA or IGA may be more beneficial for patients undergoing VATS.

METHODS

A systematic search of Cochrane Library, Pubmed and Embase databases from 1968 to April 2019 was performed using predefined criteria. Studies comparing the effects of NIA or IGA for adult VATS patients were considered. The primary outcome measure was hospital stay. Pooled data were meta-analyzed using a random-effects model to determine the standard mean difference (SMD) with 95% confidence intervals (CI).

RESULTS AND DISCUSSION

Twenty-eight studies with 2929 patients were included. The median age of participants was 56.8 years (range 21.9-76.4) and 1802 (61.5%) were male. Compared to IGA, NIA was associated with shorter hospital stay (SMD -0.57 days, 95%CI -0.78 to -0.36), lower estimated cost for hospitalization (SMD -2.83 US, 95% CI -4.33 to -1.34), shorter chest tube duration (SMD -0.32 days, 95% CI -0.47 to -0.17), and shorter postoperative fasting time (SMD, -2.76 days; 95% CI -2.98 to -2.54). NIA patients showed higher levels of total lymphocytes and natural killer cells and higher T helper/T suppressor cell ratio, but lower levels of interleukin (IL)-6, IL-8 and C-reactive protein (CRP). Moreover, NIA patients showed lower levels of fibrinogen, cortisol, procalcitonin and epinephrine.

CONCLUSIONS

NIA enhances the recovery from VATS through attenuation of stress and inflammatory responses and stimulation of cellular immune function.

Nonintubated thoracoscopic surgery for early-stage non-small cell lung cancer

OBJECTIVES

Recent advances in the management of early-stage non-small cell lung cancer have focused on less invasive anesthetic and surgical techniques. Video-assisted thoracoscopic surgery without tracheal intubation is an evolving technique to provide a safe alternative with less short-term complication and faster postoperative recovery. The purpose of this review was to explore the latest developments and future prospects of nonintubated thoracoscopic surgery for early lung cancer.

METHODS

We examined various techniques and surgical procedures as well as the outcomes and benefits.

RESULTS

The results indicated a new era of video-assisted thoracoscopic surgery in which there is reduced procedure-related injury and enhanced postoperative recovery for lung cancer.

CONCLUSIONS

Nonintubated thoracoscopic surgery is a safe and feasible minimally invasive alternative surgery for early non-small cell lung cancer. Faster recovery and less short-term complication are potential benefits of this approach.