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Kong XG, Wang K, Wei YT, Sun B, Gao GD, Song CW, Li CW. 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. BMC Anesthesiol 2024; 24:99. [PMID: 38475699 DOI: 10.1186/s12871-024-02481-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 03/04/2024] [Indexed: 03/14/2024] Open
Abstract
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.
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Affiliation(s)
- Xian-Gang Kong
- Department of Anesthesiology, Jining No. 1 People's Hospital, No. 6 Jiankang Road, Rencheng District, Jining, 272011, China
| | - Kun Wang
- Department of Anesthesiology, Jining No. 1 People's Hospital, No. 6 Jiankang Road, Rencheng District, Jining, 272011, China
| | - Yu-Tao Wei
- Department of Thoracic Surgery, Jining No. 1 People's Hospital, No. 6 Jiankang Road, Rencheng District, Jining, 272011, China
| | - Bo Sun
- Department of Thoracic Surgery, Jining No. 1 People's Hospital, No. 6 Jiankang Road, Rencheng District, Jining, 272011, China
| | - Guo-Dong Gao
- Department of Thoracic Surgery, Jining No. 1 People's Hospital, No. 6 Jiankang Road, Rencheng District, Jining, 272011, China
| | - Cheng-Wei Song
- Department of Anesthesiology, Jining No. 1 People's Hospital, No. 6 Jiankang Road, Rencheng District, Jining, 272011, China
| | - Cheng-Wen Li
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, No. 95 Yongan Road, Xicheng District, Beijing, 100050, China.
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Szabo Z, Fabo C, Szarvas M, Matuz M, Oszlanyi A, Farkas A, Paroczai D, Lantos J, Furak J. Spontaneous Ventilation Combined with Double-Lumen Tube Intubation during Thoracic Surgery: A New Anesthesiologic Method Based on 141 Cases over Three Years. J Clin Med 2023; 12:6457. [PMID: 37892595 PMCID: PMC10607362 DOI: 10.3390/jcm12206457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 10/06/2023] [Accepted: 10/09/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Non-intubated thoracic surgery has not achieved widespread acceptance despite its potential to improve postoperative outcomes. To ensure airway safety, our institute has developed a technique combining spontaneous ventilation with double-lumen tube intubation (SVI). This study aimed to verify the feasibility and limitations of this SVI technique. METHODS For the SVI method, anesthesia induction involves fentanyl and propofol target-controlled infusion, with mivacurium administration. Bispectral index monitoring was used to ensure the optimal depth of anesthesia. Short-term muscle relaxation facilitated double-lumen tube intubation and early surgical steps. Chest opening preceded local infiltration, followed by a vagal nerve blockade to prevent the cough reflex and a paravertebral blockade for pain relief. Subsequently, the muscle relaxant was ceased. The patient underwent spontaneous breathing without coughing during surgical manipulation. RESULTS Between 10 March 2020 and 28 October 2022, 141 SVI surgeries were performed. Spontaneous respiration with positive end-expiratory pressure was sufficient in 65.96% (93/141) of cases, whereas 31.21% (44/141) required pressure support ventilation. Only 2.84% (4/141) of cases reversed to conventional anesthetic management, owing to technical or surgical difficulties. Results of the 141 cases: The mean maximal carbon dioxide pressure was 59.01 (34.4-92.9) mmHg, and the mean lowest oxygen saturation was 93.96% (81-100%). The mean one-lung, mechanical and spontaneous one-lung ventilation time was 74.88 (20-140), 17.55 (0-115) and 57.73 (0-130) min, respectively. CONCLUSIONS Spontaneous ventilation with double-lumen tube intubation is safe and feasible for thoracic surgery. The mechanical one-lung ventilation time was reduced by 76.5%, and the rate of anesthetic conversion to relaxation was low (2.8%).
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Affiliation(s)
- Zsolt Szabo
- Doctoral School of Multidisciplinary Medicine, University of Szeged, H-6720 Szeged, Hungary
| | - Csongor Fabo
- Department of Anesthesiology and Intensive Therapy, University of Szeged, H-6720 Szeged, Hungary
| | - Matyas Szarvas
- Department of Anesthesiology and Intensive Therapy, University of Szeged, H-6720 Szeged, Hungary
| | - Maria Matuz
- Institute of Clinical Pharmacy, Faculty of Pharmacy, University of Szeged, H-6720 Szeged, Hungary
| | - Adam Oszlanyi
- Department of Anesthesiology and Intensive Therapy, Bács-Kiskun County Teaching Hospital, H-6000 Kecskemét, Hungary
| | - Attila Farkas
- Department of Thoracic Surgery, Markusovszky University Teaching Hospital, H-9700 Szombathely, Hungary
| | - Dora Paroczai
- Department of Medical Microbiology, University of Szeged, H-6720 Szeged, Hungary
| | - Judit Lantos
- Department of Neurology, Bács-Kiskun County Teaching Hospital, H-6000 Kecskemét, Hungary
| | - Jozsef Furak
- Department of Surgery, University of Szeged, H-6720 Szeged, Hungary
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Lantos J, Németh T, Barta Z, Szabó Z, Paróczai D, Varga E, Hartmann P. Pathophysiological Advantages of Spontaneous Ventilation. Front Surg 2022; 9:822560. [PMID: 35360436 PMCID: PMC8963892 DOI: 10.3389/fsurg.2022.822560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 02/11/2022] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Judit Lantos
- Department of Neurology, Bács-Kiskun County Hospital, Kecskemet, Hungary
- *Correspondence: Judit Lantos
| | - Tibor Németh
- Department of Surgery, University of Szeged, Szeged, Hungary
| | - Zsanett Barta
- Department of Surgery, University of Szeged, Szeged, Hungary
| | - Zsolt Szabó
- Institute of Surgical Research, University of Szeged, Szeged, Hungary
| | - Dóra Paróczai
- Department of Medical Microbiology, University of Szeged, Szeged, Hungary
| | - Endre Varga
- Department of Traumatology, University of Szeged, Szeged, Hungary
| | - Petra Hartmann
- Department of Traumatology, University of Szeged, Szeged, Hungary
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Fabo C, Oszlanyi A, Lantos J, Rarosi F, Horvath T, Barta Z, Nemeth T, Szabo Z. Non-intubated Thoracoscopic Surgery-Tips and Tricks From Anesthesiological Aspects: A Mini Review. Front Surg 2022; 8:818456. [PMID: 35223971 PMCID: PMC8873170 DOI: 10.3389/fsurg.2021.818456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 12/30/2021] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Csongor Fabo
- Department of Anesthesiology and Intensive Care, University of Szeged, Szeged, Hungary
| | - Adam Oszlanyi
- Department of Cardiac Surgery, Zala County St. Raphael Hospital, Zalaegerszeg, Hungary
| | - Judit Lantos
- Department of Neurology, Bács- Kiskun County Hospital, Kecskemét, Hungary
| | - Ferenc Rarosi
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | | | - Zsanett Barta
- Department of Surgery, University of Szeged, Szeged, Hungary
| | - Tibor Nemeth
- Department of Surgery, University of Szeged, Szeged, Hungary
| | - Zsolt Szabo
- Ars Medica Laser Surgery Hospital, Budapest, Hungary
- *Correspondence: Zsolt Szabo
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Better intraoperative cardiopulmonary stability and similar postoperative results of spontaneous ventilation combined with intubation than non-intubated thoracic surgery. Gan To Kagaku Ryoho 2022; 70:559-565. [PMID: 34985733 DOI: 10.1007/s11748-021-01768-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 12/23/2021] [Indexed: 11/04/2022]
Abstract
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.
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Molnar TF, Drozgyik A. Narrative review of theoretical considerations regarding HITHOC between past and future. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:954. [PMID: 34350269 PMCID: PMC8263867 DOI: 10.21037/atm-20-5855] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 02/26/2021] [Indexed: 01/10/2023]
Abstract
Hyppocrates constructed the medicines-surgery-energy triangle which includes all therapeutical modalities. Hyperthermic intraoperative chemotherapy (HITHOC) is a synergy-based single stage multimodality treatment encompassing the locoregional manifestation of the systemic malignant process. Pleural space, thermal effect, lavage/irrigation and chemotherapy represent the basic science ports of the network hub: HITHOC. The malignant transformation and process of the pleural surface (and underlying lung) challenges space management and tissue control. Thermotherapy without local chemotherapy is insufficient, similar to the normothermic local irrigation aligned with anticancer agents. The local administration of combined heat-transfer fluid and chemotherapy with or without subsequent surgical removal offers reasonable outcome in extensive primary pleural neoplasms (malignant mesothelioma), advanced (> Stage IIIA) NSCLC, functionally inoperable lung cancer and pleural carcinosis from extrathoracic malignancies. Measured by symptom-free survival and the quality of life, HITHOC in its present form, offers a modest yet fully substantiated solution. HITHOC in combination with the local application of targeted therapy and/or immunotherapy administered in the pleural space are currently under investigation. Additional development including new acting substances, their solvents and the means regarding surgical delivery and anesthesiology techniques are sign posts up ahead. Level 2 evidence are required in order to stepping up the recommendation levels, rewriting protocols and guidelines, in which HITHOC earns its revered position in the decision making process it deserves.
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Affiliation(s)
- Tamas F Molnar
- Department of Operational Medicine, Faculty of Medicine, University of Pécs, Pécs, Hungary.,Chair of Surgery, Faculty of Medicine, University of Pécs/Dept Surgery, Aladar Petz University Teaching Hospital, Győr, Hungary
| | - Andras Drozgyik
- Chair of Surgery, Faculty of Medicine, University of Pécs/Dept Surgery, Aladar Petz University Teaching Hospital, Győr, Hungary
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