Nonintubated transareolar single-port thoracic sympathicotomy with a needle scope in a series of 85 male patients

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.

A prospective comparative study of thoracoscopic transareolar and uniportal approaches for young male patients with primary spontaneous pneumothorax

OBJECTIVE

In this study, we introduce a novel approach, thoracoscopic transareolar bullectomy, for treating young male patients with primary spontaneous pneumothorax (PSP). This approach might be less invasive and cosmetically superior to existing methods. We also prospectively compared transareolar and uniportal approaches.

METHODS

Between April 2018 and July 2019, 40 patients were prospectively assigned to transareolar (n = 21) and uniportal (n = 19) groups. We compared patient characteristics and perioperative results. Approximately 1 week or 1 year after the operation, postoperative pain was evaluated using a numerical rating scale (NRS), and cosmetic satisfaction was graded on a four-point scale.

RESULTS

We found no significant between-group differences in patient characteristics or perioperative results. NRS scores did not differ on postoperative day (POD) 7 (transareolar, 1.8 ± 0.9 vs. uniportal, 1.6 ± 0.9; p = 0.62) or in postoperative month (POM) 12 (transareolar, 1.3 ± 0.5 vs. uniportal, 1.1 ± 0.5; p = 0.18). In terms of cosmetic satisfaction, the transareolar group was more satisfied on POD 7 (transareolar, 3.5 ± 0.6 vs. uniportal, 2.9 ± 0.9; p = 0.02) and in POM 12 (transareolar, 3.8 ± 0.5 vs. uniportal, 3.3 ± 0.9; p = 0.0065).

CONCLUSION

Although the perioperative results of the transareolar and uniportal approaches were similar, the former approach afforded a little better cosmetic satisfaction and might be useful option for young males with PSP.

Transareolar single-port endoscopic thoracic sympathectomy with a flexible endoscope for primary palmar hyperhidrosis: a prospective randomized controlled trial

Background

Transareolar single-port endoscopic thoracic sympathectomy (ETS) with a flexible endoscope has rarely been reported. This study assessed the performance of this novel minimally invasive technique for primary palmar hyperhidrosis (PPH).

Methods

From January 2019 to September 2019, 118 males with severe PPH requiring single-port and bilateral ETS were randomly allocated to undergo transareolar ETS using a flexible endoscope (group A, n=58) or transaxillary ETS using a 5 mm thoracoscope (group B, n=60).

Results

Both groups had similar patient characteristics. All procedures were performed successfully, with no mortality or conversion to open surgery. All patients had dry and warm palms immediately after surgery. Compared with group B, group A had a significantly shorter median incision length [5.1 (5.0–5.2) vs. 10.9 (10.8–11.9) mm; P<0.001], and significantly lower median postoperative pain score [1 (1.0–2.0) vs. 3 (3.0–4.0); P<0.001]. There were no differences between the two groups in operative time, palmar temperature increase, and transient postoperative sweating. After complete follow-up, group A had a significantly higher median cosmetic score than group B [4.0 (3.0–4.0) vs. 3.0 (3.0–3.0); P<0.001]. There were no differences between the two groups regarding symptom resolution, compensatory hyperhidrosis, and satisfaction score. No patient reported residual pain or symptom recurrence.

Conclusions

Transareolar single-port ETS with a flexible endoscope is safe, effective, and minimally invasive with a small incision, minimal pain, and excellent cosmetic results. This novel procedure is suitable for routine treatment of PPH in males.

Feasibility of thoracoscopic pulmonary bullectomy using a transareolar approach for treatment of primary spontaneous pneumothorax

Background

Primary spontaneous pneumothorax (PSP) is a common disease among young patients, particularly men. While the most common thoracoscopic approach is triportal, the transareolar approach is rare. In this study, we prospectively investigated the feasibility of thoracoscopic pulmonary bullectomy using a transareolar approach for treatment of PSP.

Methods

Ten patients with PSP who underwent thoracoscopic transareolar pulmonary bullectomy were prospectively enrolled in this study between September 2017 and March 2018. For all 10 patients, we evaluated the perioperative outcomes, postoperative complications, recurrence, wound-related pain, and cosmetic satisfaction regarding the surgical wound.

Results

The mean patient age was 18.9±4.2 years; three patients were affected on the right side and seven patients were affected on the left side. Bullae and blebs were localized at the apex of the affected lung in all patients. All procedures were completed using a transareolar approach without additional ports or conversion to thoracotomy in any patient. The mean operative time was 39.8±8.6 min. The mean volume of blood lost during surgery was extremely small in all patients. The duration of postoperative drainage was 1 day, while the length of postoperative hospital stay was 2 days in all patients. No morbidities or recurrence of PSP occurred during the study period. The mean cosmetic satisfaction scores of the surgical wound were 3.3 and 3.2 on postoperative day (POD) 7 and at postoperative month (POM) 12. The mean NRS score was 1.5 on POD 7. All patients were pain-free at POM 12.

Conclusions

Transareolar thoracoscopic pulmonary bullectomy for treatment of PSP is feasible and safe, with a high degree of satisfaction for postoperative pain and cosmetics. This new approach could be a novel option for surgical treatment of PSP.

Endoscopic thoracic sympathicotomy for primary palmar hyperhidrosis: A retrospective multicenter study in China

BACKGROUND

This study aimed to evaluate the clinical efficacy and safety of endoscopic thoracic sympathicotomy and to explore strategies to decrease the incidence of transfer hyperhidrosis (TH).

METHODS

From January 2003 to July 2016, 10,275 patients with primary palmar hyperhidrosis underwent endoscopic thoracic sympathicotomy in 15 different institutions. We carried out a retrospective analysis of these patients who were grouped into group A, those with nonretained R2 (R2, R2-3, or R2-4 ablation), and group B, those with retained R2 (single R3 or R4 ablation).

RESULTS

All procedures were performed successfully. Both hands of all patients became warm and dry immediately after endoscopic thoracic sympathicotomy. Pneumothorax occurred in 146 patients, and 39 patients had intraoperative bleeding. Follow-up was carried out from 6 months to 13 years. A total of 531 patients (5.2%) were lost to follow-up. The effective rate for primary palmar hyperhidrosis was 100%. Palmar hyperhidrosis recurred in 73 patients (0.7%). Transfer hyperhidrosis appeared in 7,678 patients (78.8%). For groups A and B, the incidence of TH was 80.4% and 78.5%, respectively (P > .05), but the incidence of grade III+IV TH in group B (1.6%) was less than that in group A (4.8%; P < .001).

CONCLUSION

Endoscopic thoracic sympathicotomy is a minimally invasive, safe, and effective therapeutic method for primary palmar hyperhidrosis. Although the overall incidence of TH is high, the incidence of grade III to IV TH can be decreased by reserving R2, lowering the level of thoracic sympathicotomy, and single severing of R3 or R4.

Optimal targeting of sympathetic chain levels for treatment of palmar hyperhidrosis: an updated systematic review

BACKGROUND

Palmar hyperhidrosis involves excessive sweating of the palms, with no known etiology. Endoscopic thoracic sympathectomy (ETS) is a safe and effective treatment for palmar hyperhidrosis, but compensatory hyperhidrosis is a common complication after ETS, leading to reduced patient satisfaction and postoperative quality of life. However, the appropriate level of the sympathetic chain to target with ETS to achieve maximum efficacy and reduce the risk of compensatory hyperhidrosis (CH) is controversial. In this systemic review, we investigated the appropriate level of sympathectomy for palmar hyperhidrosis.

METHODS

PRISMA guidelines were implemented to complete a systematic review. We performed a computerized systematic literature search using PubMed and EMBASE from January 1990 to July 2016. We chose the Cochrane Collaboration's tool and the methodological index for non-randomized studies tool for examining study bias.

RESULTS

A total of 4075 citations were identified, of which 91 were eligible for inclusion, including 68 observational studies and 23 comparative trials. In observational studies, sympathectomies showed similar efficacies for curing PH at different levels. However, T2-free groups (i.e., at levels T3, T4, or T3-T4 combined) could render a lower risk of Horner's syndrome (0 vs. 1.21 ± 0.49%, p = 0.036) and CH (28.75 ± 7.25 vs. 57.46 ± 3.86, p = 0.002) compared with T2 involved. In comparative trials, there were 12 studies describing the comparison between T2-free ETS and T2 involved, and 9 of 12 (75%) showed T2-free ETS could reduce the incidence of CH. Overall, lowering the level and limiting the extent of sympathectomy could reduce the incidence of complications.

CONCLUSIONS

Cumulative data from more than 13,000 patients suggest that ETS is a safe, effective, and reproducible procedure with a high degree of patient satisfaction. Currently available evidence suggests that T2-free ETS may reduce the incidence of compensatory hyperhidrosis without compromising success rates and safety.