Nonintubated Thoracoscopic Anatomical Segmentectomy for Lung Tumors

Anesthetic consideration for nonintubated VATS

In the recent decade, nonintubated-intubated video-assisted thoracoscopic surgery (VATS) has been extensively performed and evaluated. The indicated surgical procedures and suitable patient groups are steadily increasing. Perioperative anesthetic management presents itself as a fresh issue for the iatrogenic open pneumothorax, which is intended for unilateral lung collapse to create a steady surgical field, and the ensuing physiologic derangement involving ventilatory and hemodynamic perspectives. With appropriate monitoring, meticulous employment of regional anesthesia, sedation, vagal block, and ventilatory support, nonintubated VATS is proved to be a safe alternative to the conventional intubated general anesthesia.

Nonintubated thoracoscopic surgery: state of the art and future directions

Video-assisted thoracoscopic surgery (VATS) has become a common and globally accepted surgical approach for a variety of thoracic diseases. Conventionally, it is performed under tracheal intubation with double lumen tube or bronchial blocker to achieve single lung ventilation. Recently, VATS without tracheal intubation were reported to be feasible and safe in a series of VATS procedures, including management of pneumothorax, wedge resection of pulmonary tumors, excision of mediastinal tumors, lung volume reduction surgery, segmentectomy, and lobectomy. Patients undergoing nonintubated VATS are anesthetized using regional anesthesia in a spontaneously single lung breathing status after iatrogenic open pneumothorax. Conscious sedation is usually necessary for longer and intensively manipulating procedures and intraoperative cough reflex can be effectively inhibited with intrathoracic vagal blockade on the surgical side. The early outcomes of nonintubated VATS include a faster postoperative recovery and less complication rate comparing with its counterpart of intubated general anesthesia, by which may translate into a fast track VATS program. The future directions of nonintubated VATS should focus on its long-term outcomes, especially on oncological perspectives of survival in lung cancer patients. For now, it is still early to conclude the benefits of this technique, however, an educating and training program may be needed to enable both thoracic surgeons and anesthesiologists providing an alternative surgical option in their caring patients.

Analysis of feasibility and safety of complete video-assisted thoracoscopic resection of anatomic pulmonary segments under non-intubated anesthesia

OBJECTIVE

To explore the feasibility and safety of complete video-assisted thoracoscopic surgery (C-VATS) under non-intubated anesthesia for the resection of anatomic pulmonary segments in the treatment of early lung cancer (T1N0M0), benign lung diseases and lung metastases.

METHODS

The clinical data of patients undergoing resection of anatomic pulmonary segments using C-VATS under non-intubated anesthesia in the First Affiliated Hospital of Guangzhou Medical University from July 2011 to November 2013 were retrospectively analyzed to evaluate the feasibility and safety of this technique.

RESULTS

The procedures were successfully completed in 15 patients, including four men and eleven women. The average age was 47 [21-74] years. There were ten patients with adenocarcinoma, one with pulmonary metastases, and four with benign lung lesions. The resected sites included: right upper apical segment, two; right lower dorsal segment, one; right lower basal segment, two; left upper lingular segment, three; left upper apical segment, one; left upper anterior apical segment, two; left upper posterior segment, one; left lower basal segment, one; left upper posterior and apical segments, one; and left upper anterior and apical segments plus wedge resection of the posterior segment, one. One case had intraoperative bleeding, which was controlled with thoracoscopic operation and no blood transfusion was required. No thoracotomy or perioperative death was noted. Two patients had postoperative bleeding without the need for blood transfusions, and were cured and discharged. The pathologic stage for all patients with primary lung cancer was IA. After 4-19 months of follow-up, no tumor recurrence and metastasis was found. The overall mean operative length was 166 minutes (range 65-285 minutes), mean blood loss 75 mL (range 5-1,450 mL), mean postoperative chest drainage 294 mL (range 0-1,165 mL), mean chest drainage time 2 days (range 0-5 days), and mean postoperative hospital stay 5 days (range 3-8 days).

CONCLUSIONS

Complete video-assisted throacoscopic segmentectomy under anesthesia without endotracheal intubation is a safe and feasible technique that can be used to treat a selected group of IA patients with primary lung cancer, lung metastases and benign diseases.

Nonintubated thoracoscopic surgery using regional anesthesia and vagal block and targeted sedation

OBJECTIVE

Thoracoscopic surgery without endotracheal intubation is a novel technique for diagnosis and treatment of thoracic diseases. This study reported the experience of nonintubated thoracoscopic surgery in a tertiary medical center in Taiwan.

METHODS

From August 2009 through August 2013, 446 consecutive patients with lung or pleural diseases were treated by nonintubated thoracoscopic surgery. Regional anesthesia was achieved by thoracic epidural anesthesia or internal intercostal blockade. Targeted sedation was performed with propofol infusion to achieve a bispectral index value between 40 and 60. The demographic data and clinical outcomes were evaluated by retrospective chart review.

RESULTS

Thoracic epidural anesthesia was used in 290 patients (65.0%) while internal intercostal blockade was used in 156 patients (35.0%). The final diagnosis were primary lung cancer in 263 patients (59.0%), metastatic lung cancer in 38 (8.5%), benign lung tumor in 140 (31.4%), and pneumothorax in 5 (1.1%). The median anesthetic induction time was 30 minutes by thoracic epidural anesthesia and was 10 minutes by internal intercostal blockade. The operative procedures included lobectomy in 189 patients (42.4%), wedge resection in 229 (51.3%), and segmentectomy in 28 (6.3%). Sixteen patients (3.6%) required conversion to tracheal intubation because of significant mediastinal movement (seven patients), persistent hypoxemia (two patients), dense pleural adhesions (two patients), ineffective epidural anesthesia (two patients), bleeding (two patients), and tachypnea (one patient). One patient (0.4%) was converted to thoracotomy because of bleeding. No mortality was noted in our patients.

CONCLUSIONS

Nonintubated thoracoscopic surgery is technically feasible and safe and can be a less invasive alternative for diagnosis and treatment of thoracic diseases.