Nonintubated anesthesia in thoracic surgery: general issues

Chronic postoperative pain after non-intubated uniportal VATS lobectomy

Introduction

Patients undergoing thoracic surgery are at increased risk of developing, long-lasting pain. Beyond the non-surgical factors, the type of operation, including the number of incisions, and the anesthetic assessment seemed to be important factors, although some studies are controversial. The aim of our study was to examine the presence of chronic postoperative pain after non-intubated uniportal VATS lobectomy. We examined the difference between the intubated, relaxed and non-intubated spontaneous ventilation surgical approaches in patients who underwent video-assisted thoracoscopic (VATS) uniportal lobectomy.

Methods

Demographic and postoperative data were retrospectively collected and analyzed, focusing on the use of pain medications, in 67 patients of the 140 patients selected by propensity score matching who underwent intubated (iVATS) or non-intubated (NITS) uniportal VATS lobectomy. This study focused on the use of analgesic medications 3, 6, and 12 months after surgery.

Results

Thirty-five intubated and 32 non-intubated patients were compared. Although the analgesic consumption was nearly 2% higher among the iVATS patients during the follow-up period, there were no statistically significant differences at 3 months (15.6 vs. 17.1%) (p = 0.868), at 6 months (9.4 vs. 12.4%) (p = 0.785), and at 12 months (3.3 vs. 5.9%) (p = 0.633) between the NITS and iVATS groups, respectively. More female than male patients reported chronic pain, but the difference was not statistically significant (p = 0.616). Diabetes mellitus was a statistically significant cofactor associated with chronic pain (p = 0.03), while cardiac disease (p = 0.6), perioperative morbidity (p = 0.228), prolonged air leak (p = 0.057), and repeat drainage (p = 0.626) were not.

Conclusion

Our study suggests that after non-intubation VATS lobectomies, the postoperative pain was less at 3, 6, and 12 months in NITS patients compared to iVATS patients. The 2% difference was not significant, so it may not be appropriate to claim the advantages of NITS in terms of postoperative pain.

Awake uniportal VATS sublobar lung resections in high-comorbidity patients: Single-center early post-operative outcomes

Introduction

Awake minimally invasive Uniportal Video Assisted Thoracic Surgery (U-VATS) represents the last challenge in thoracic surgery that could change the future scenario for high comorbidity patients with early-stage non-small cell lung cancer (NSCLC). We report a single center preliminary experience of awake thoracoscopic uni-portal anatomic and non-anatomic sub-lobar resections in this setting.

Methods

We retrospectively analyzed data collected on a prospective database of patients undergoing U-VATS awake sub-lobar lung resections for NSCLC between September 2021 and September 2022. Inclusion criteria were clinical stage I disease; contraindication to standard lobectomy due to high respiratory function impairment; general anesthesia considered at high risk based on the American Society of Anesthesiologist score and on the Charlson Comorbidity Index. All patients underwent a standardized awake non-intubated anesthesia protocol approved by our institutional board.

Results

They were n = 10 patients: n = 8 wedge resections; n = 2 segmentectomies. We had n = 1 (10%) conversion to standard general anesthesia and n = 1 laryngeal mask support but maintaining spontaneous breathing. N = 5 patients (50%) needed an Intensive Care Unit recovery (mean time = 17.20 h). Mean chest tube duration and Hospital stay were 2.0 and 3.5 days respectively. We did not register 30- days postoperative mortality.

Conclusion

Awake thoracic surgery is a feasible technique, and it could be performed also in high comorbidities' patients without a high rate of complications and allows to operate patients that so far were considered borderline for surgery.

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.

Non-intubated Thoracic Surgery: Wedge Resections for Peripheral Pulmonary Nodules

The feasibility of performing pulmonary resections of peripheral lung nodules has been one of the main objectives of non-intubated thoracic surgery. The aim was to obtain histological characterization and extend a radical intended treatment to oncological patients unfit for general anesthesia or anatomic pulmonary resections. There is mounting evidence for the role of wedge resection in early-stage lung cancer treatment, especially for frail patients unfit for general anesthesia and anatomic resections with nodules, demonstrating a non-aggressive biological behavior. General anesthesia with single lung ventilation has been associated with a higher risk of ventilator-induced barotrauma and volotrauma as well as atelectasis in both the dependent and non-dependent lungs. Nonetheless, general anesthesia has been shown to impair the host immune system, eventually favoring both tumoral relapses and post-operative complications. Thus, non-intubated wedge resection seems to definitely balance tolerability with oncological radicality in highly selected patients. Nonetheless, differently from other non-surgical techniques, non-intubated wedge resection allows for histological characterization and possible oncological targeted treatment. For these reasons, non-intubated wedge resection is a fundamental skill in the core training of a thoracic surgeon. Main indications, surgical tips, and post-operative management strategies are hereafter presented. Non-intubated wedge resection is one of the new frontiers in minimal invasive management of patients with lung cancer and may become a standard in the armamentarium of a thoracic surgeon. Appropriate patient selection and VATS expertise are crucial to obtaining good results.

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.

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.

Non-intubated Thoracoscopic Surgery-Pros and Cons

Pulmonary resection by video-assisted thoracoscopic surgery with single-lung ventilation has become a standardized modality over the last decades. With the aim to reduce surgical stress during operation procedures, some have adopted a uniportal approach in pulmonary resection as an alternative to multiportal VATS. The ERAS program has been widely spread to achieve even better outcomes. In 2004, Pompeo reported the resection of pulmonary modules by conventional VATS under intravenous anesthesia without endotracheal intubation. Within less than a decade thereafter, complete VATS pulmonary resections under anesthesia without endotracheal intubation had been reported for a range of thoracoscopic procedures. Avoiding tracheal intubation under general anesthesia can reduce the incidence of complications such as intubation-related airway trauma, residual neuromuscular blockade, ventilation-induced lung injury, impaired cardiac performance, and postoperative nausea. Numerous studies can be found especially from Asian countries, focusing on comparison of intubated and non-intubated procedures showing that non-intubated VATS could reduce the rate of postoperative complications, shorten hospital stay and decrease the perioperative mortality rate, indicating that non-intubated VATS is a safe, effective and feasible technique for thoracic disease. However, if we look closely at all studies, it is obvious that there are no significant differences between intubated and non-intubated surgery in terms of the standard procedures and maneuvers. In non-intubated procedures it can be less comfortable for the surgeon to manipulate in the thoracic cavity, but the procedural steps remain the same. All the differences between the intubated and non-intubated operation procedure are found in perioperative management of the patient. The patient is still in deep anesthesia during the procedure and hypecapnia can occur. It is easier to manage this if the patient is intubated. In addition, if a complication occurs during the operation and intubation is required, this can cause an emergent situation, which means that not all patients are suitable for such a procedure, especially those with severe emphysema, obese patients and those with a problematic oropharyngeal configuration-Mallampati score. Moreover, studies on non-intubated thoracic surgery point to shortened hospitalization, faster recovery etc. But there are also studies on intubated uniportal VATS procedures in combination with ERAS protocol showing shortened hospitalization and better outcome for patients. Currently, especially with the use of optical intubation canylas, totally intravenous anesthesia (TIVA), BIS and relaxometer, anesthesia is safe for avoiding airway injury, hypercapnia, and there is minimal risk of residual curarization as well as one of the postoperative lung complications such as microaspiration and atelectasis. In addition, the patient recovers rapidly from anesthesia and can be verticalised and mobilized a couple of hours after the operation. It is desirable to take into consideration what type of patient and what lung disease is suitable for non-intubated technique and what is more convenient for intubation.

A comparison of non-intubated video-assisted thoracic surgery with spontaneous ventilation and intubated video-assisted thoracic surgery: a meta-analysis based on 14 randomized controlled trials

Background

Video-assisted thoracic surgery (VATS) generally involves endotracheal intubation under general anesthesia. However, inevitably, this may cause intubation-related complications and prolong the postoperative recovery process. Gradually, non-intubated video-assisted thoracic surgery (NIVATS) is increasingly being utilized. However, its safety and efficacy remain controversial.

Methods

Randomized controlled trials (RCTs) published up to August 2020 were selected from the Cochrane Library, Web of Science, PubMed, Embase, and ClinicalTrials.gov databases and included in this study according to the inclusion criteria. Two reviewers screened these RCTs and independently extracted the relevant data. After assessing the risk of bias in these RCTs, a meta-analysis was performed using Review Manager 5.3. Pooled data were meta-analyzed using a random-effects model.

Results

Meta-analysis data demonstrated that the mean difference (MD) in the length of hospital stay between non-intubated patients and intubated patients was −1.41 days, with a 95% confidence interval (CI) of −2.47 to −0.34 (P=0.01). The visual analogue scale (VAS) score between the two groups showed a MD of −0.34 (95% CI: −0.58 to −0.10; P=0.006). Patients who underwent NIVATS presented with lower rates of overall complications [odds ratio (OR) 0.41; 95% CI: 0.25 to 0.67; P=0.0004], air leak (OR 0.45; 95% CI: 0.24 to 0.87; P=0.02), pharyngeal discomfort (OR 0.08; 95% CI: 0.04 to 0.17; P<0.00001), hoarseness (OR 0.06; 95% CI: 0.02 to 0.21; P<0.00001), and gastrointestinal reactions (OR 0.23; 95% CI: 0.10 to 0.53; P=0.0005) compared to intubated patients. The anesthesia satisfaction scores in the NIVATS group were significantly higher than those of the VATS group (MD 0.50; 95% CI: 0.12 to 0.88; P=0.009). However, there were no statistically significant differences in the length of operation time (MD 0.90 hours; 95% CI: −0.23 to 2.03; P=0.12) and surgical field satisfaction (1 point) (OR 0.73; 95% CI: 0.34 to 1.59; P=0.43) between the two groups.

Conclusions

NIVATS is a safe and feasible form of intervention that can reduce the postoperative pain and complications of various systems and shorten hospital stay duration without prolonging the operation time.

Comparison of non-intubated versus intubated video-assisted thoracoscopic lobectomy for lung cancer

Background

Non-intubated, or awake, video-assisted thoracoscopic surgery has been implemented for non-anatomical lung resection and the results obtained were encouraging to consider the approach for anatomical pulmonary resection. This study was conducted to evaluate the perioperative outcomes of the non-intubated and intubated video-assisted thoracoscopic lobectomy in lung cancer in regards to feasibility and safety.

Methods

A retrospective analysis of 62 consecutive video-assisted thoracoscopic lobectomies (31 lobectomies as non-intubated, 31 lobectomies as intubated) performed in Seoul St. Mary's Hospital, The Catholic University of Korea between January and December 2016.

Results

Both groups share comparable clinical characteristics including the age, sex, BMI, FEV1, DLCO, smoking history, lung lobes procedure, histological type and pathological staging. There was no difference in the mean of postoperative hospitalization period (6.9 versus 7.6 days, P=0.578) and the total chest tube duration (5.6 versus 5.4 days, P=0.943) between non-intubated and intubated lobectomy respectively. Both groups had a comparable surgical outcome for the anesthesia duration, operative time, blood loss and postoperative complications. The operative time required for lobe-specific surgery was shorter in the non-intubated group except for the LLL (mean 121.7 minutes for non-intubated group versus 118.3 minutes for the intubated group). The only statistically significant surgical outcome was for the number of dissected lymph nodes between both groups (the mean number of nodes for the non-intubated group was 12.6 versus 18.0 nodes for the intubated group, P=0.003). One patient in the non-intubated group required conversion to single lung intubation and mini-thoracotomy because of bleeding with no conversion in the intubated group. No mortality encountered in either group.

Conclusions

The perioperative surgical outcomes for the non-intubated video-assisted thoracoscopic lobectomy are comparable to the intubated technique. Non-intubated video-assisted thoracoscopic lobectomy is safe and is technically feasible. However, further prospective randomized studies are needed for a better comparison between non-intubated and intubated VATS lobectomy.

A glance at the history of uniportal video-assisted thoracic surgery

In the history of thoracic surgery, the advent of video-assisted thoracic surgery (VATS) had on effect equivalent to that provoked by a true revolution. VATS successfully allowed minor, major and complex procedures for various lung and mediastinal pathologies with small incision instead of the traditional accesses. These small incisions abolished ugly scars, generated less acute and chronic pain, reduced hospital stay and costs, allowed faster return to normal day life activities. Conventional VATS was initially performed through 3-4 ports and rapidly evolved to uniportal or single portal access [uniportal video-assisted thoracic surgery (uniVATS)]. First uniportal procedures were published in 2000. In 2010, uniportal technique for lobectomy was described. Focused experimental courses, live surgery events, the internet media favored the rapid diffusion of this technique over the world. Major and complex uniVATS lung resections involving segmentectomy, pneumonectomy, bronchoplasty and vascular reconstruction, redo VATS, en bloc chest wall resections have been accomplished with satisfactory outcomes. Interestingly, different uniportal approaches and techniques are emerging from a number of VATS centers particularly experienced in the mini-invasive thoracic surgery. As confidence grew, in 2014, the first uniVATS left upper lobectomy via the subxiphoid approach was reported. This novel technique is quite challenging but appropriate patient selection as well as availability of dedicated instruments allowed to perform procedures safely. The diffusion of uniVATS paralleled with the development of nonintubated awake anesthesia technique. In 2007 the first nonintubated lobectomy was described. In 2014 the first single port VATS lobectomy in a nonintubated patient with lung cancer of the right middle lobe was accomplished. The nonintubated uniVATS represents an intriguing technique, so that very experienced thoracoscopic surgeons may enroll to surgery elderly and high risk patients. Decreased postoperative pain and hospitalization, faster access to the radio-chemotherapy and diminished inflammatory response are important benefits of the modern approach to the thoracic pathologies. The history of uniVATS documented a constant and irresistible progress. This technique may further provide unthinkable surprises in next future.

Nonintubated uniportal VATS pulmonary anatomical resections

Nonintubated procedures have widely developed during the last years, thus nowadays major anatomical resections are performed in spontaneously breathing patients in some centers. In an attempt for combining less invasive surgical approaches with less aggressive anesthesia, nonintubated uniportal video-assisted thoracic surgery (VATS) lobectomies and segmentectomies have been proved feasible and safe, but there are no comparative trials and the evidence is still poor. A program in nonintubated uniportal major surgery should be started in highly experienced units, overcoming first a learning period performing minor procedures and a training program for the management of potential crisis situations when operating on these patients. A multidisciplinary approach including all the professionals in the operating room (OR), emergency protocols and a comprehensive knowledge of the special physiology of nonintubated surgery are mandatory. Some concerns about regional analgesia, vagal block for cough reflex control and oxygenation techniques, combined with some specific surgical tips can make safer these procedures. Specialists must remember an essential global concept: all the efforts are aimed at decreasing the invasiveness of the whole procedure in order to benefit patients' intraoperative status and postoperative recovery.

Anaesthesiology for uniportal VATS: double lumen, single lumen and tubeless

The advent of one-lung ventilation (OLV) technique provides immobilized surgical field which is fundamental in minimally invasive thoracic surgery. Mainstem methods of achieving lung separation are either via a double-lumen endotracheal tube or placing a bronchial blocker (BB) through a single-lumen endotracheal tube. More recently, the use of non-intubated thoracic surgery (NITS) has been investigated intensively, attempting to minimise the complications that follow general anaesthesia. The aim of this review is to describe the mechanism of these techniques briefly and outlines the advantages and drawbacks of them with the comparison.

Non-intubated single-incision video-assisted thoracic surgery: a two-center cohort of 188 patients

BACKGROUND

Non-intubated single-incision procedures are slowly expanding because of high experience and skill required, and stricter selection criteria. The aim of this study is to present the first retrospective two-center series in Taiwan and Spain.

METHODS

We performed a retrospective analysis of 188 patients undergoing non-intubated single-incision video-assisted thoracic surgery (NI-SI-VATS) procedures between July 2013 to November 2015 in two centers in Taiwan (170 patients) and Spain (18 patients) with two different anesthetic methods. Demographic data, clinicopathological features, preoperative tests, and final outcomes were analyzed to compare the outcomes with the two different techniques.

RESULTS

Of the 188 patients, 147 (78%) were women, with a mean body mass index (BMI) of 22.7. Of the 196 specimens, 145 (74%) were malignancies with a mean size of 9.7 mm. Wedge resection was performed in 172 patients (91.4%), anatomical segmentectomy with lymphadenectomy in 8 (4.7%), and lobectomy with lymphadenectomy in 5 (2.6%). Three patients (1.6%) required conversion to orotracheal intubation, while 5 patients (2.7%) required additional ports. Complications appeared in 16 patients (8.5%) with air leak as the most frequent in 7 cases (3.7%). Median chest drainage was 1 day, and median postoperative stay was 3 days. There was neither perioperative death nor postoperative readmission.

CONCLUSIONS

Non-intubated single-incision procedures can be feasible and safe in expert hands and experienced teams, even for anatomical resections. Strict selection criteria, skill and experience are mandatory. Comparative cohorts and randomized trials are needed.

Non-intubated thoracoscopic surgery for decortication of empyema under thoracic epidural anesthesia: a case report

General anesthesia is the main strategy for almost all thoracic surgeries. However, a growing body of literature has reported successful cases of non-intubated thoracic surgery with regional anesthesia. This alternative strategy not only prevents complications related to general anesthesia, such as lung injury, incomplete re-expansion and intubation related problems, but also accords with trends of shorter hospital stay and lower overall costs. We experienced a successful case of non-intubated thoracoscopic decortication for a 68-year-old man who was diagnosed as empyema while the patient kept spontaneously breathing with moderate sedation under thoracic epidural anesthesia. The patient showed a fast recovery without concerns of general anesthesia related complications and effective postoperative analgesia through thoracic epidural patient-controlled analgesia device. This is the first report of non-intubated thoracoscopic surgery under thoracic epidural anesthesia in Korea, and we expect that various well designed prospective studies will warrant the improvement of outcomes in non-intubated thoracoscopic surgery.