Nonintubated uniportal thoracoscopic wedge resection for early lung cancer

Non-intubated Thoracic Surgery: Wedge Resections for Peripheral Pulmonary Nodules

The feasibility of performing pulmonary resections of peripheral lung nodules has been one of the main objectives of non-intubated thoracic surgery. The aim was to obtain histological characterization and extend a radical intended treatment to oncological patients unfit for general anesthesia or anatomic pulmonary resections. There is mounting evidence for the role of wedge resection in early-stage lung cancer treatment, especially for frail patients unfit for general anesthesia and anatomic resections with nodules, demonstrating a non-aggressive biological behavior. General anesthesia with single lung ventilation has been associated with a higher risk of ventilator-induced barotrauma and volotrauma as well as atelectasis in both the dependent and non-dependent lungs. Nonetheless, general anesthesia has been shown to impair the host immune system, eventually favoring both tumoral relapses and post-operative complications. Thus, non-intubated wedge resection seems to definitely balance tolerability with oncological radicality in highly selected patients. Nonetheless, differently from other non-surgical techniques, non-intubated wedge resection allows for histological characterization and possible oncological targeted treatment. For these reasons, non-intubated wedge resection is a fundamental skill in the core training of a thoracic surgeon. Main indications, surgical tips, and post-operative management strategies are hereafter presented. Non-intubated wedge resection is one of the new frontiers in minimal invasive management of patients with lung cancer and may become a standard in the armamentarium of a thoracic surgeon. Appropriate patient selection and VATS expertise are crucial to obtaining good results.

A comparison of non-intubated video-assisted thoracic surgery with spontaneous ventilation and intubated video-assisted thoracic surgery: a meta-analysis based on 14 randomized controlled trials

Background

Video-assisted thoracic surgery (VATS) generally involves endotracheal intubation under general anesthesia. However, inevitably, this may cause intubation-related complications and prolong the postoperative recovery process. Gradually, non-intubated video-assisted thoracic surgery (NIVATS) is increasingly being utilized. However, its safety and efficacy remain controversial.

Methods

Randomized controlled trials (RCTs) published up to August 2020 were selected from the Cochrane Library, Web of Science, PubMed, Embase, and ClinicalTrials.gov databases and included in this study according to the inclusion criteria. Two reviewers screened these RCTs and independently extracted the relevant data. After assessing the risk of bias in these RCTs, a meta-analysis was performed using Review Manager 5.3. Pooled data were meta-analyzed using a random-effects model.

Results

Meta-analysis data demonstrated that the mean difference (MD) in the length of hospital stay between non-intubated patients and intubated patients was −1.41 days, with a 95% confidence interval (CI) of −2.47 to −0.34 (P=0.01). The visual analogue scale (VAS) score between the two groups showed a MD of −0.34 (95% CI: −0.58 to −0.10; P=0.006). Patients who underwent NIVATS presented with lower rates of overall complications [odds ratio (OR) 0.41; 95% CI: 0.25 to 0.67; P=0.0004], air leak (OR 0.45; 95% CI: 0.24 to 0.87; P=0.02), pharyngeal discomfort (OR 0.08; 95% CI: 0.04 to 0.17; P<0.00001), hoarseness (OR 0.06; 95% CI: 0.02 to 0.21; P<0.00001), and gastrointestinal reactions (OR 0.23; 95% CI: 0.10 to 0.53; P=0.0005) compared to intubated patients. The anesthesia satisfaction scores in the NIVATS group were significantly higher than those of the VATS group (MD 0.50; 95% CI: 0.12 to 0.88; P=0.009). However, there were no statistically significant differences in the length of operation time (MD 0.90 hours; 95% CI: −0.23 to 2.03; P=0.12) and surgical field satisfaction (1 point) (OR 0.73; 95% CI: 0.34 to 1.59; P=0.43) between the two groups.

Conclusions

NIVATS is a safe and feasible form of intervention that can reduce the postoperative pain and complications of various systems and shorten hospital stay duration without prolonging the operation time.

Spontaneous breathing anesthesia for cervical tracheal resection and reconstruction

Background

Spontaneous breathing anesthesia (SBA) may have advantages over general anesthesia for cervical tracheal resection and reconstruction (TRR), avoiding the difficulties and complication caused by endotracheal intubation and surgical cross-field intubation. This prospective study evaluates SBA for cervical TRR.

Methods

Date was obtained from 35 patients who had cervical TRR under SBA from May 2015 to March 2019. Intravenous sedation and ultrasound-guided bilateral superficial cervical plexus block (CPB) were applied to maintain effective analgesia and sedation.

Results

Thirty-two patients with tracheal tumors and 3 patients with post-intubation tracheal stenosis underwent TRR. After the airway was opened, 29 patients resumed stable spontaneous breathing, 1 patient needed high-frequency jet ventilation, and 1 patient needed anesthesia conversion for surgical reasons.

Conclusions

Spontaneous breathing anesthesia is feasible for the cervical TRR. It can be an alternative anesthetic technique for certain patients.

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.

Computed tomography-guided dye localization for deeply situated pulmonary nodules in thoracoscopic surgery

Background

Increased lung cancer screening of asymptomatic adults using low-dose computed tomography (CT) with high-resolution imaging modalities has increased the identification of small and deeply situated pulmonary nodules. This study aimed to evaluate the role of preoperative patient blue vital (PBV) dye localization for an undiagnosed nodule deeply situated in the lung parenchyma followed by minimally invasive lung resection.

Methods

From July 2013 to December 2016, 27 consecutive patients (16 women, median age: 62 years) with small undiagnosed pulmonary nodules at a depth of more than 30 mm underwent preoperative CT-guided PBV dye localization followed by thoracoscopic diagnostic resection of the nodule at National Taiwan University Hospital. The clinical characteristics were collected retrospectively to evaluate the efficacy and safety of the procedure.

Results

The median size of pulmonary nodule in preoperative CT images was 11 mm with a median depth of 31.6 mm (range, 30.0-48.6 mm). Of the 27 nodules, 8 were pure ground-glass nodules, 3 were pure solid nodules, and 16 were partially solid nodules. The diagnostic yield of CT-guided dye localization following diagnostic wedge resection was 100%. The final pathological diagnoses were: primary adenocarcinoma of the lung (n=20), adenocarcinoma in situ (n=1), and benign nodules (n=6). Only asymptomatic complications were noted after localization, and the median hospital stay was 3 days [interquartile range (IQR), 3-4 days]. All of 21 patients were cancer-free after a median follow-up of 39.0 months (IQR, 29.5-50.0 months).

Conclusions

This study indicated that preoperative, percutaneous CT-guided PBV dye localization for undiagnosed nodules at a depth of more than 30 mm could be a safe and feasible procedure. Furthermore, it was considerably advantageous for preserving the lung parenchyma, especially for benign nodules.

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.