Nonintubated uniportal VATS pulmonary anatomical resections

Regulation of early diagnosis and prognostic markers of lung adenocarcinoma in immunity and hypoxia

Lung adenocarcinoma is still cancer with the highest mortality. Hypoxia and immunity play an essential role in the occurrence and development of tumors. Therefore, this study is mainly to find new early diagnosis and prognosis markers and explore the relationship among the markers and immunity and hypoxia, to improve the prognosis of patients. Firstly, based on the clinical database in TCGA, we determined the most critical clinicopathological parameters affecting the prognosis of patients through a variety of analysis methods. According to pathological parameters, logistic most minor absolute contraction selection operator (lasso), univariate and multivariate regression analysis, the risk genes related to early prognosis were screened, and the risk model was established. Then, in different risk groups, GSEA and CIBERSORT algorithms were used to analyze the distribution and enrichment of the immune cells and hypoxia, to study the effects of early prognostic indicators on hypoxia and immunity. At the same time, we analyzed the different levels of risk genes in normal cells (BSEA-2B) and tumor cells (H1299, A549, PC9, and H1975). Finally, A549 and PC9 cells were induced by CoCl2 to establish a hypoxic environment, and the correlation between risk genes and HIF1A was analyzed. The risk model based on risk genes (CYP4B1, KRT6A, and FAM83A) was accurate and stable for the prognosis of patients. It is closely related to immunity and hypoxia. In BSEA-2B cells, the mRNA and protein expression of CYP4B1 was higher, while the expression of KRT6A and FAM83A was lower. Finally, we found that FAM83A and HIF1A showed a significant positive correlation when A549 and PC9 cells were exposed to hypoxia. The discovery of early diagnostic markers related to immunity, hypoxia, and prognosis, provides a new idea for early screening and prognostic treatment of lung adenocarcinoma.

An air-locking port and high-flow nasal cannula in non-intubated uniportal video-assisted thoracic surgery for pneumothorax with pulmonary dysfunction: a case report

Background

Non-intubated video-assisted thoracic surgery is a therapeutic option for intractable secondary spontaneous pneumothorax in patients who are poor candidates for surgery with endotracheal intubation under general anesthesia. However, intraoperative respiratory management in this surgery is often challenging because of hypoxia caused by surgical pneumothorax.

Case presentation

A 75-year-old man with idiopathic pulmonary fibrosis who had been on home oxygen therapy underwent non-intubated uniportal video-assisted thoracic surgery for intractable spontaneous pneumothorax. During the operation, oxygen was administered using a high-flow nasal cannula at a high flow rate. An air-locking port for single-incision surgery was used to minimize the inflow of air into the pleural cavity. The intrapleural air was continuously suctioned through the chest tube. The air-leak point was easily identified and closed using ligation. Oxygenation was satisfactory throughout the operation.

Conclusions

Non-intubated uniportal video-assisted thoracic surgery for secondary spontaneous pneumothorax with an air-locking port, continuous pleural suction, and high-flow nasal cannula may achieve satisfactory intraoperative oxygenation in patients with respiratory dysfunction. The intrapleural space can be feasible for surgical manipulation without surgical pneumothorax in non-intubated video-assisted thoracic surgery even when supplied with oxygen at a high flow rate using a high-flow nasal cannula.

First experiences in non-intubated, video-assisted thoracoscopic surgery: a single-centre study

Introduction

Video-assisted thoracoscopic surgery (VATS) with non-intubated technique is safely performed under spontaneous breathing and sedation. With this surgery, many complex thoracic surgical interventions can be successfully applied.

Aim

We shared the results of our patients who underwent mediastinal biopsy, pleural biopsy, lung wedge resection, pneumothorax surgery, and pleural delocculation with non-intubated VATS.

Material and methods

Patients who underwent surgery with non-intubated VATS between March 2015 and May 2020 in our clinic were included in the study. The patients were evaluated in terms of many factors such as age, gender, applied surgical intervention, diagnosis, side of surgery, duration of surgery, and time of hospital stay, and the results were recorded retrospectively.

Results

Twenty of the patients were male and 12 were female. Regarding comorbid diseases in our patient group, 13 had extra-thoracic malignancy, 7 had hypertension, 6 had heart disease, 5 had chronic obstructive pulmonary disease and asthma, and 4 had diabetes mellitus. Pleural drainage and biopsy were performed in 10 patients and wedge resection in 8 patients. Bullectomy and apical pleural abrasion were performed in 6 patients, mediastinal mass biopsy was performed in 4 patients, and delocculation was performed in 4 patients due to empyema.

Conclusions

The non-intubated VATS approach can be safely applied in procedures such as lung resections, pleural or mediastinal interventions, and pneumothorax surgery. With this technique, the absence of intubation and mechanical ventilation facilitates the return to normal respiratory physiology, and we think that the recovery time of the patient, the duration of hospital stay, and treatment costs are reduced.

Nonintubated Uniportal Video-Assisted Thoracoscopic Surgery for Intrathoracic Diseases: Initial Results in Vietnam

OBJECTIVE

Nonintubated uniportal video-assisted thoracoscopic surgery (VATS) is a recent controversial procedure in many countries. Hence, the authors would like to present the experience in performing this approach and evaluate its initial results in the treatment, particularly, of intrathoracic diseases in Vietnam.

METHODS

A prospective, descriptive study was conducted on 17 patients with intrathoracic diseases treated with nonintubated uniportal VATS from February to July 2019. Preoperative, intraoperative, and postoperative parameters were gathered and analyzed by SPSS Statistics, Version 18.0.

RESULTS

Patients had an average age of 49.2 ± 20.5 (range 6 to 71) years. Regarding operative indications and methods, there were 3 ground glass opacity (17.6%) and 1 bullous lung disease receiving wedge resection (5.9%); 8 mediastinal tumors (47.1%) having resection, and 5 non-small-cell lung cancers receiving lobectomy combined with node dissection (29.4%). The average operative time and pleural drainage time were 108.6 ± 28.17 min (range 60 to 160) and 3.7 ± 1.18 days (range 2 to 8), respectively. The average hospitalization time was 4.9 ± 1.76 (range 3 to 12) days. No mortalities or major complications were recorded postoperatively.

CONCLUSIONS

Nonintubated uniportal VATS is a safe and considerable surgical choice for appropriate intrathoracic conditions.

The Year in Thoracic Anesthesia: Selected Highlights from 2019

THIS special article is the 4th in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan; the associate editor-in-chief, Dr. Augoustides; and the editorial board for the opportunity to expand this series, the research highlights of the year that specifically pertain to the specialty of thoracic anesthesia. The major themes selected for 2019 are outlined in this introduction, and each highlight is reviewed in detail in the main body of the article. The literature highlights in this specialty for 2019 include updates in the preoperative assessment and optimization of patients undergoing lung resection and esophagectomy, updates in one lung ventilation (OLV) and protective ventilation during OLV, a review of recent meta-analyses comparing truncal blocks with paravertebral catheters and the introduction of a new truncal block, meta-analyses comparing nonintubated video-assisted thoracoscopic surgery (VATS) with those performed using endotracheal intubation, a review of the Society of Thoracic Surgeons (STS) recent composite score rating for pulmonary resection of lung cancer, and an update of the Enhanced Recovery After Surgery (ERAS) guidelines for both lung and esophageal surgery.

Molecular and immune characteristics for lung adenocarcinoma patients with CMTM6 overexpression

BACKGROUND

CMTM6 was identified as an important regulator of the PD-L1 protein. The role of CMTM6 in lung adenocarcinoma (LUAD) has so far remained unclear. We aimed at investigating the role of CMTM6 in LUAD at transcriptome and genomic levels and its relationship with tumor-infiltrating immune cells (TIICs).

METHODS

We downloaded the data sets of LUAD from TCGA. The genomic profiles containing somatic mutations were analyzed and the transcriptome level of CMTM6 was also obtained. Gene set variation analysis (GSVA) was used to predict the pathway change. In addition, we explored the association between CMTM6 and LUAD immune infiltrates by means of CIBERSORT. The association between CMTM6 and PD-L1 mRNA was analyzed using an integrated repository portal for tumor-immune system interactions (TISIDB) and was further validated in 80 LUAD patients. Kaplan-Meier survival curve and the log-rank test was used to analyze the survival significance of CMTM6.

RESULTS

We found that CMTM6 was downregulated in LUAD. Patients with low CMTM6 expression were more likely to be frequent with somatic mutations. Moreover, GSVA analysis exhibited that CMTM6 was associated with immune responses and inflammatory activities. Specifically, a positive correlation between increased CMTM6 expression and immune infiltrating level of Dendritic cells resting, Eosinophils, Macrophages M1, Macrophages M2, Neutrophils, T cells CD4 memory activated and T cells CD4 memory resting was established. The CMTM6 expression was positively correlated with PD-L1 in both mRNA and protein level. Clinically, patients with high expression of CMTM6 tended to have a better survival.

CONCLUSION

CMTM6 expression likely had an important effect on TIICs composition and prognosis in LUAD patients. The CMTM6 expression was positively correlated with PD-L1 in LUAD. These findings establish CMTM6 as a promising target for immunotherapeutic prospects.

Comparison of tracheal intubation with controlled ventilation and laryngeal mask airway with spontaneous ventilation for thoracoscopic bullectomy

General anesthesia with double-lumen endobronchial intubation is considered mandatory for thoracoscopic bullectomy. We assessed the safety and feasibility of thoracoscopic bullectomy for treatment of primary spontaneous pneumothorax (PSP) under intubating laryngeal mask airway (ILMA) with spontaneous breathing sevoflurane anesthesia combined with thoracic paravertebral block (TPB).From January 2018 to December 2018, some 34 consecutive patients with PSP were treated by thoracoscopic bullectomy under ILMA with spontaneous breathing sevoflurane anesthesia combined with TPB (study group). To evaluate the safety and feasibility of this new technique, these patients were compared with the control group consisting of 34 consecutive patients with PSP who underwent thoracoscopic bullectomy using tracheal intubation with controlled ventilation from January 2017 to December 2017. The demographic characteristics, intraoperative surgical and anesthetic results, and postoperative results were assessed.The 2 groups had comparable anesthetic time, operation time, chest drainage time, postoperative hospital stays, and hospitalization cost. Visual analogue score (VAS) scores at 3 hours at rest and at coughing were significantly lower in the study group than in the control group (mean, 0.9 vs 2.0 and 1.8 vs 4.0, P = .024 and P = .006, respectively). No differences were seen in PaO2 values between the 2 groups in the intraoperative stage and postoperative stage (P > .05, respectively). The pH value was significantly lower in the intraoperative stage (mean, 7.28 vs 7.40, P = .01) and higher in the postoperative stage (mean, 7.35 vs 7.33, P = .014) in the study group than in the control group. The PaCO2 value was significantly higher in the intraoperative stage in the study group than in the control group (mean, 57.0 mm Hg vs 42.0 mm Hg, P = .015). In the study group, no cough reflex was found, and the level of collapse of the operative lung was excellent in 31 cases and good in 3 cases.Our study demonstrated that thoracoscopic bullectomy for treatment of PSP can be safely and feasibly performed in highly selected patients under ILMA with spontaneous breathing sevoflurane anesthesia combined with TPB.

Nonintubated thoracoscopic surgery for early-stage non-small cell lung cancer

OBJECTIVES

Recent advances in the management of early-stage non-small cell lung cancer have focused on less invasive anesthetic and surgical techniques. Video-assisted thoracoscopic surgery without tracheal intubation is an evolving technique to provide a safe alternative with less short-term complication and faster postoperative recovery. The purpose of this review was to explore the latest developments and future prospects of nonintubated thoracoscopic surgery for early lung cancer.

METHODS

We examined various techniques and surgical procedures as well as the outcomes and benefits.

RESULTS

The results indicated a new era of video-assisted thoracoscopic surgery in which there is reduced procedure-related injury and enhanced postoperative recovery for lung cancer.

CONCLUSIONS

Nonintubated thoracoscopic surgery is a safe and feasible minimally invasive alternative surgery for early non-small cell lung cancer. Faster recovery and less short-term complication are potential benefits of this approach.

Sevoflurane is an effective adjuvant to propofol-based total intravenous anesthesia for attenuating cough reflex in nonintubated video-assisted thoracoscopic surgery

BACKGROUND

Nonintubated video-assisted thoracic surgery (VATS) has been widely developed during the recent years. Cough reflex is an inevitably encountered problem while approaching lung lesions, and it may induce major bleeding. Sevoflurane anesthesia may attenuate cough reflex by inhibiting the pulmonary irritant receptors. However, the incidence of postoperative nausea and vomiting (PONV) in inhalational anesthesia is higher than in the propofol-based total intravenous anesthesia (TIVA). We investigated the effect of sevoflurane combination with propofol-based TIVA on cough reflex and PONV in nonintubated VATS.

METHODS

Ninety patients undergoing nonintubated VATS with laryngeal mask airway (LMA) and spontaneous breathing were randomly assigned for TIVA or propofol/sevoflurane anesthesia. In the TIVA group (n = 45), anesthesia was induced and maintained with propofol and fentanyl; in the propofol/sevoflurane (P/S) group (n = 45), 1% sevoflurane anesthesia was added to propofol and fentanyl anesthesia. The primary outcome measurements were cough reflex. In addition, the incidence of PONV and extubation time were investigated.

RESULTS

Patients with cough reflex were significantly fewer in the P/S group than in the TIVA group (10/45 vs 34/45; P < .001). The cough severity (35/5/5/0 vs 11/17/17/0; P < .001) and limb movement (40/5/0/0 vs 28/17/0/0; P < .001) were lower in the P/S group than in the TIVA group. Besides, incremental fentanyl bolus for cough reflex was 5 (0 [0-1]) in the P/S group and 17 (0 [0-3]) in the TIVA group (P < .05). And there was no conversion to general anesthesia, postoperative hemorrhage, aspiration pneumonia, or PONV in the 2 groups. Besides, there was no significant difference in extubation time (TIVA: 5.04 ± 2.88 vs P/S: 4.44 ± 2.98 minutes; P = .33).

CONCLUSION

Sevoflurane attenuated cough reflex under propofol-based TIVA and did not increase the incidence of PONV and extubation time in nonintubated VATS.

Tubeless major pulmonary resections

From its inception, cutting edge minimally invasive thoracic surgery has pursued to barely produce patient perturbation. Although state of the art techniques such as uniportal approach have achieved a remarkable reduction in postoperative morbidity, there is still a way to go in patient comfort. A new 'tubeless' concept has surfaced as an alternative to double-lumen intubation with general anaesthesia combining non-intubated spontaneous breathing video-assisted thoracic surgery (VATS) surgery under loco-regional blockade with the avoidance of central line, epidural or urinary catheter and chest tube in selected patients. Those procedures combine the most evolved and less invasive techniques in anaesthesia, video-assisted surgery and perioperative care to cause the least trauma and allow for faster recovery. Non-intubated thoracic surgery used to rise some concerns regarding spontaneous breathing collapse, oxygenation, cough reflex triggering and mediastinal shift. Today, experienced teams in high-volume centers have proven non-intubated major lung resections are feasible and safe once those drawbacks have been overcome with the proper techniques and extensive previous expertise in VATS. Tubeless thoracic surgery is currently evolving, challenging former exclusion criteria and expanding indications to major lung resections or even tracheal and carinal resections to provide better intraoperative status and promote minimal need for recovery.