Video-Assisted Thoracoscopic Surgery Lobectomy for Lung Cancer in Nonintubated Anesthesia

Clinical application of intubation-free anesthesia in radical resection of lung cancer

Background

In recent years, video-assisted thoracic surgery (VATS) has become increasingly widespread. However, the implementation of VATS requires the assistance with lung isolation techniques. Spontaneous breathing with laryngeal masks is also increasingly used in VATS. However, evidence on the characteristics of intubated anesthesia is insufficient.

Objective

This study aimed to explore whether intubation-free anesthesia has more advantages than other intubation methods in the clinical setting.

Methods

Patients with lung tumors who underwent VATS in our hospital between June 2022 and October 2022 were included in the study. Perioperative data of patients, including basic information, intraoperative hemodynamic changes, postoperative inflammatory indicators, and adverse reactions were obtained through the electronic medical record system. According to the protocol of airway management during anesthesia, participants were divided into the following groups: laryngeal mask with spontaneous breathing group (LMSB group), laryngeal mask combined with bronchial blocker group (LM + BB group), double-lumen tube group (DLT group), and tracheal tube combined with bronchial blocker group (TT + BB group). All data were analyzed using SPSS 25.0 software.

Results

At baseline, patients in the LMSB and LM + BB groups had a lower body weight (P = 0.024). Systolic blood pressure (SBP), diastolic BP (DBP), and heart rate (HR) were significantly higher in the DLT group than in the non-intubated group during surgery (SBP: T1 P = 0.048, T4 P = 0.021, T5 P ≤ 0.001, T6 P ≤ 0.001, T7 P = 0.004; DBP: T5 P ≤ 0.001, T6 P ≤ 0.001, T7 P ≤ 0.001; HR: T1 P = 0.021, T6 P ≤ 0.001, T7 P = 0.007, T8 P ≤ 0.001). The input fluid (P = 0.009), urine output (P = 0.010), surgery duration (P = 0.035), and procalcitonin levels (P = 0.024) of the DLT group were also significantly higher than those of the other groups. The recovery duration of the LMSB group was significantly longer (P = 0.003) and the incidence of postoperative adverse reactions, mainly atelectasis, was higher (P = 0.012) than those of the other groups.

Conclusion

Although the intubation-free anesthesia has less stimulation during operation and less postoperative inflammatory response, it has obvious adverse reactions after operation, which may be not the best anesthesia scheme for radical resection of lung cancer in VATS.

Clinical trial registration

https://www.chictr.org.cn/showproj.html?proj=182767, identifier ChiCTR2200066180.

[The perioperative role of high-flow cannula oxygen (HFNO)]

High-flow nasal cannula oxygen (HFNO) is commonly used during the perioperative period. Its numerous physiological benefits, satisfactory tolerance and ease of use have led to its widespread application in intensive care and post-anesthesia care units. HFNO is also used in the operating theater in multiple indications: as oxygen supplementation (associated with pressurization) prior to orotracheal intubation; in digestive and bronchial endoscopies, especially in patients at risk of hypoxemia; and in intraoperative surgery requiring spontaneous ventilation (ENT, thoracic surgery…). During the postoperative period, HFNO can be used in a curative strategy for respiratory failure or in a prophylactic strategy to prevent reintubation. In a curative approach, HFNO seems of interest following cardiac or thoracic surgery but has not been evaluated in respiratory failure subsequent to abdominal surgery, in which case noninvasive ventilation remains the gold standard. The risk of respiratory complications depends on type of surgery and on patient comorbidities. As prophylaxis, HFNO is currently preferred to conventional oxygen therapy after cardiac or thoracic surgery, especially in patients at high risk of respiratory complications. For the clinician, it is important to acknowledge the limits of HFNO and to closely monitor patients receiving HFNO, the objective being to avoid delays in intubation that could lead to increased mortality.

General anaesthesia with double-lumen intubation compared to opioid-sparing strategies with laryngeal mask for thoracoscopic surgery: A randomised trial

BACKGROUND

General anaesthesia for thoracoscopic lung surgery can be performed with the opioid-sparing strategies without intubation and may reduce the risk of glottic injury and enhance recovery after surgery. We therefore tested the primary hypothesis that avoiding intubation reduces glottic injury.

METHODS

Adults having elective thoracoscopic lung resections were randomised to: (1) intubated group: routine general anaesthesia with a double-lumen tube intubation; or, (2) non-intubated group: a bundle of opioid-sparing strategies, which included paravertebral blocks and total intravenous anaesthesia with minimal remifentanil infusion from 0.05 to 1.0 ng/mL (avoid sufentanil unless the respiratory rate exceeds 25/min or the systolic blood pressure exceeds 30% of the baseline value), no muscle relaxation, and spontaneous ventilation through a laryngeal mask. The primary outcome was glottal injury as determined by transnasal bronchoscopy one hour after removal of the laryngeal mask or double-lumen tube.

RESULTS

Two hundred seventeen patients were assessed for the primary outcome. Sufentanil use was reduced 96% and remifentanil was reduced 40% in non-intubated opioid-sparing patients. The incidence of glottal injury was 9% (10/109) in the non-intubated vs. 37% (40/108) in the intubated patients (RR: 0.25; 95%CI: 0.13-0.47, P < 0.001). The non-intubated group also had less postoperative sore throat (8% vs. 39%; P < 0.001) and hoarseness (3% vs. 19%; P < 0.001). Postoperative pulmonary complications and lung injury biomarkers did not differ between the groups. Compared to the intubated group, the non-intubated group had less postoperative pain, faster recovery, and improved quality-of-life scores.

CONCLUSIONS

Non-intubated opioid-sparing strategies for video-assisted lung resections reduce airway injury and promote postoperative recovery.

CLINICAL TRIAL NUMBER AND REGISTRY URL

ChiCTR1800018198 https://www.chictr.org.cn/showproj.aspx?proj=30780.

Complete Video-Assisted Thoracoscopic Surgery and Traditional Open Surgery for Elderly Patients With NSCLC

Objective:

To observe the efficacy of complete video-assisted thoracoscopic surgery (CVATS) and traditional open surgery (TOS) in the treatment of elderly patients with non-small cell lung cancer (NSCLC) and their influence on cardiopulmonary function.

Methods

A total of 120 elderly patients with primary NSCLC who were treated surgically in our hospital from January 2018 to January 2021 were selected and divided into the study group and the control group according to the different surgical procedures, 60 patients in each group. CVATS was used in the observation group and TOS in the control group. The surgical indexes and cardiopulmonary function indexes were observed and compared between the two groups. The serum C-reactive protein (CRP) level and visual analog scale's (VAS) score of the patients at different time points were detected. The incidence of postoperative complications was compared between the two groups.

Results

The perioperative indexes such as operation time were significantly different between the two groups (p < 0.05), but the number of lymph node dissection was not significantly different (p > 0.05). The serum CRP level and VAS score of the observation group were significantly lower than those of the control group on the 1st, 3rd, and 7th postoperative days (p < 0.05). There were significant differences in cardiopulmonary function between the two groups on the 7th postoperative day (p < 0.05). The incidence of adverse reactions in the observation group was significantly lower than that in the control group (p > 0.05).

Conclusion

CVATS is effective in the treatment of NSCLC. Compared with TOS therapy, CVATS has less damage to cardiopulmonary function and fewer complications, which is conducive to the rehabilitation of elderly patients. It is a safe and reliable scheme for the treatment of elderly patients with NSCLC.

Ultrasound-guided paravertebral nerve block anesthesia on the stress response and hemodynamics among lung cancer patients

BACKGROUND

Thoracic surgery for radical resection of lung tumor requires deep anesthesia which can lead to an adverse inflammatory response, loss of hemodynamic stability, and decreased immune function. Herein, we evaluated the feasibility and benefits of ultrasound-guided paravertebral nerve block anesthesia, in combination with general anesthesia, for thoracic surgery for lung cancer. The block was performed by diffusion of anesthetic drugs along the paravertebral space to achieve unilateral multi-segment intercostal nerve and dorsal branch nerve block.

AIM

To evaluate the application of ultrasound-guided paravertebral nerve block anesthesia for lung cancer surgery to inform practice.

METHODS

The analysis was based on 140 patients who underwent thoracic surgery for lung cancer at our hospital between January 2018 and May 2020. Patients were randomly allocated to the peripheral + general anesthesia (observation) group (n = 74) or to the general anesthesia (control) group (n = 66). Patients in the observation group received ultrasound-guided paravertebral nerve block anesthesia combined with general anesthesia, with those in the control group receiving an epidural block combined with general anesthesia. Measured outcomes included the operative and anesthesia times, as well as the mean arterial pressure (MAP), heart rate (HR), and blood oxygen saturation (SpO₂) measured before surgery, 15 min after anesthesia (T1), after intubation, 5 min after skin incision, and before extubation (T4).

RESULTS

The dose of intra-operative use of remifentanil and propofol and the postoperative use of sufentanil was lower in the observation group (1.48 ± 0.43 mg, 760.50 ± 92.28 mg, and 72.50 ± 16.62 mg, respectively) than control group (P < 0.05). At the four time points of measurement (T1 through T4), MAP and HR values were higher in the observation than control group (MAP, 90.20 ± 9.15 mmHg, 85.50 ± 7.22 mmHg, 88.59 ± 8.15 mmHg, and 90.02 ± 10.02 mmHg, respectively; and HR, 72.39 ± 8.22 beats/min, 69.03 ± 9.03 beats/min, 70.12 ± 8.11 beats/min, and 71.24 ± 9.01 beats/min, respectively; P < 0.05). There was no difference in SpO₂ between the two groups (P > 0.05). Postoperative levels of epinephrine, norepinephrine, and dopamine used were significantly lower in the observation than control group (210.20 ± 40.41 pg/mL, 230.30 ± 65.58 pg/mL, and 54.49 ± 13.32 pg/mL, respectively; P < 0.05). Similarly, the postoperative tumor necrosis factor-α and interleukin-6 levels were lower in the observation (2.43 ± 0.44 pg/mL and 170.03 ± 35.54 pg/mL, respectively) than control group (P < 0.05). There was no significant difference in the incidence of adverse reactions between the two groups (P > 0.05).

CONCLUSION

Ultrasound-guided paravertebral nerve block anesthesia improved the stress and hemodynamic response in patients undergoing thoracic surgery for lung cancer, with no increase in the rate of adverse events.

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.

Computerized Tomography Image Features under the Reconstruction Algorithm in the Evaluation of the Effect of Ropivacaine Combined with Dexamethasone and Dexmedetomidine on Assisted Thoracoscopic Lobectomy

This research was aimed to study CT image features based on the backprojection filtering reconstruction algorithm and evaluate the effect of ropivacaine combined with dexamethasone and dexmedetomidine on assisted thoracoscopic lobectomy to provide reference for clinical diagnosis. A total of 110 patients undergoing laparoscopic resection were selected as the study subjects. Anesthesia induction and nerve block were performed with ropivacaine combined with dexamethasone and dexmedetomidine before surgery, and chest CT scan was performed. The backprojection image reconstruction algorithm was constructed and applied to patient CT images for reconstruction processing. The results showed that when the overlapping step size was 16 and the block size was 32 × 32, the running time of the algorithm was the shortest. The resolution and sharpness of reconstructed images were better than the Fourier transform analytical method and iterative reconstruction algorithm. The detection rates of lung nodules smaller than 6 mm and 6–30 mm (92.35% and 95.44%) were significantly higher than those of the Fourier transform analytical method and iterative reconstruction algorithm (90.98% and 87.53%; 88.32% and 90.87%) (P < 0.05). After anesthesia induction and lobectomy with ropivacaine combined with dexamethasone and dexmedetomidine, the visual analogue scale (VAS) decreased with postoperative time. The VAS score decreased to a lower level (1.76 ± 0.54) after five days. In summary, ropivacaine combined with dexamethasone and dexmedetomidine had better sedation and analgesia effects in patients with thoracoscopic lobectomy. CT images based on backprojection reconstruction algorithm had a high recognition accuracy for lung lesions.

Undiagnosed solitary caseating granulomas: Is lung resection surgery a feasible method for diagnosis and treatment?

BACKGROUND

In many patients, low-dose computed tomography (CT) screening for lung cancer reveals asymptomatic pulmonary nodules. Lung resection surgery may be indicated in these patients; however, distinguishing malignancies from benign lesions preoperatively can be challenging.

METHODS

From 2013 to 2018, 4181 patients undergoing surgery for pulmonary nodules were reviewed at National Taiwan University Hospital, and 837 were diagnosed with benign pathologies. Only patients with pathological diagnosis as caseating granulomatous inflammation were included, sixty-nine patients were then analyzed for preoperative clinical and imaging characteristics, surgical methods and complications, pathogens, medical treatment and outcomes. Mycobacterial evidence was obtained from the culture of respiratory or surgical specimen.

RESULTS

Overall, 68% of the patients were asymptomatic before surgery. More than half of the nodules were in the upper lobes, and all patients underwent video-assisted thoracoscopic surgery (VATS). Some patients (14.5%) developed grade I complications, and the mean postoperative hospital stay was 4 days. The final pathology reports of 20% benign entities postoperatively, and caseating granulomatous inflammation accounted for a significant part. MTB and NTM were cultured from one-fourth of the patients respectively. All patients with confirmed MTB infection received antimycobacterial treatment, while the medical treatment in NTM-infected patients was decided by the infectious disease specialists. The mean follow-up period was 736 days, and no recurrence was found.

CONCLUSION

Lung resection surgery is an aggressive but safe and feasible method for diagnosing MTB- or NTM-associated pulmonary nodules, and, potentially, an effective therapeutic tool for patients with undiagnosed MTB- or NTM-associated pulmonary nodules.