Non-intubated uniportal video-assisted thoracoscopic surgery

Nonintubated versus Intubated Lung Volume Reduction Surgery in Patients with End-Stage Lung Emphysema and Hypercapnia

Lung volume reduction surgery (LVRS) represents an important treatment option in carefully selected patients with end-stage lung emphysema. The aim of this study was to assess the efficacy and safety of nonintubated LVRS compared to intubated LVRS in patients with preoperative hypercapnia and lung emphysema. Between April 2019 and February 2021, n = 92 patients with end-stage lung emphysema and preoperative hypercapnia undergoing unilateral video-assisted thoracoscopic LVRS (VATS-LVRS) performed in epidural anesthesia and mild sedation (nonintubated, group 1) or conventional general anesthesia (intubated, control, group 2) were prospectively enrolled in this study. Data were retrospectively analyzed. In all patients, low-flow veno-venous extracorporeal lung support (low-flow VV ECLS) was applied as a bridge through LVRS. Ninety-day mortality was considered as the primary outcome. Secondary endpoints included: chest tube duration, hospital stay, intubation and conversion to general anesthesia. Intergroup analysis showed no significant difference between the baseline data and patients' demographics. N = 36 patients underwent nonintubated surgery. VATS-LVRS under general anesthesia was performed in n = 56 patients. The mean duration of postoperative VV ECLS support was 3 ± 1 day in group 1 compared to 4 ± 1 in group 2. The 90-day mortality rate was 3% in group 1 compared to 7% in group 2. In group 1, all chest tubes were removed 5 ± 1 day (range 4-32 days) and 8 ± 1 day (range 4-44 days) in the control group after the surgery (p < 0.02). Prolonged chest tube therapy (>8 days) was observed in n = 3 patients in group 1 and n = 11 patients in the control group. The mean ICU stay was 4 ± 1 days in group 1 compared to 8 ± 2 days in the control group (p = 0.04). The mean hospital stay was significantly shorter in the nonintubated group 1 (6 ± 2 days vs. 10 ± 4 days, p = 0.01). Conversion to general anesthesia was necessary in one patient due to severe pleural adhesions. Nonintubated VATS-LVRS in patients with end-stage lung emphysema and hypercapnia is effective and well tolerated. Compared to general anesthesia, a reduction in mortality, chest tube duration, ICU and hospital stay and lower rate of prolonged air leak was observed. VV ECLS increases intraoperative safety and mitigates postoperative complications in such "high-risk" patients.

Would the width of a metal rib spreader affect postoperative pain in patients who undergo video-assisted mini-thoracotomy (VAMT)?

Background

Hitherto, no study has evaluated postoperative pain in patients with non-small cell lung cancer (NSCLC) treated with video-assisted mini-thoracotomy (VAMT). In this study, we aimed to assess postoperative pain related to the width of the metal rib spreader in patients who underwent lobectomy using VAMT.

Methods

We retrospectively analysed the data of 94 consecutive patients with NSCLC who underwent lobectomy using VAMT at our institution between March 2019 and May 2022. We divided the patients into groups according to the width ratio of the rib spreader to that of a single intercostal space. Patients with width ratios ≤ 2.5 times were assigned to group A, and those with width ratios > 2.5 times were assigned to group B. Pre-, intra-, and postoperative data were collected and reviewed.

Results

We successfully performed VAMT in 94 patients with NSCLC. Forty-five patients were in group A, and 49 were in group B. There were no intraoperative mortalities, although one patient, due to respiratory failure, experienced 30-day mortality. There were no significant differences between the two groups in terms of the blood loss volume, operative time, drainage time, postoperative complications, length of hospital stay, or number of lymph node stations explored and retrieved. The drainage volumes (Day 1–Day 3) were higher in group B than in group A (P < 0.05). The postoperative visual analogue scale (VAS) pain scores were significantly lower in Group A than in Group B at 12, 24, and 48 h (P < 0.05), although there was no significant difference in the VAS scores between the two groups at 72 h and 1 week postoperatively (P > 0.05).

Conclusion

The smaller the width of the metal rib spreader used in surgery, the less pain experienced by the patient and the faster the recovery. Multicentre, randomised, controlled trials should be conducted in the future.

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.

Oncological advantage of nonintubated thoracic surgery: Better compliance of adjuvant treatment after lung lobectomy

BACKGROUND

Video-assisted thoracoscopic (VATS) surgery contributes to improved survival, adjuvant chemotherapy delivery and less postoperative complications. Nonintubated thoracic surgery (NITS) VATS procedures improves immunological responses in lung cancer patients; however, there is no data regarding adjuvant chemotherapy delivery effectiveness following NITS lobectomies. In this study, we aimed to compare protocol compliance and toxic complications during adjuvant chemotherapy after intubated and nonintubated VATS lobectomies in non-small cell lung cancer (NSCLC).

METHODS

We retrospectively reviewed the medical records of 66, stage IB-IIIB NSCLC patients who underwent intubated or nonintubated VATS lobectomy and received adjuvant chemotherapy.

RESULTS

A total of 38 patients (17 males, mean age 64 years) underwent conventional VATS and 28 (7 males; mean age 63 years) uniportal VATS NITS. Both groups had comparable demographic data, preoperative pulmonary function, and Eastern Cooperative Oncology Group (ECOG) status. Among the intubated and nonintubated patients, 82% and 75% were diagnosed with adenocarcinoma, respectively. The incidence of adenocarcinoma and squamous cell carcinoma cases were similar in both groups; however, the pathological staging showed significant differences, as 5 (18%) nonintubated patients had stage IB lung cancer, compared with the intubated group (P = 0.01). Further distribution of stages was similar between the groups. We observed significant differences in chest tube duration and operation time in the nonintubated group (P < 0.01). Among nonintubated patients, 92% completed the planned chemotherapy protocol, compared to 71% of the intubated group (P = 0.035). Grade 1/2 toxicity occurred significantly more often in the intubated group (16% vs. 0%, P = 0.03) and there was a lower incidence of grade 4 neutropenia in the nonintubated group (0% vs. 16%, P = 0.03).

CONCLUSIONS

Our results showed that the nonintubated procedure resulted in improved adjuvant chemotherapy compliance and lower toxicity rates after lobectomy.

KEY POINTS

SIGNIFICANT FINDINGS OF THE STUDY: Oncological advantage of the non-intubated thoracic surgery: better compliance with therapy protocol. What this study adds NITS lobectomies contribute to better administration of adjuvant chemotherapy with the planned cycle number and dosage.

Nonintubated Anesthesia for Tracheal/Carinal Resection and Reconstruction

Nonintubated anesthesia is feasible and might be associated with shorter surgery time and shorter hospitalization for tracheal/carinal resection and reconstruction. Only case reports and a few small retrospective series study were conducted to evaluate nonintubated anesthesia for tracheal/carinal resection and reconstruction; no randomized control trials exist. Further exploration should focus on selection of optimal candidates and prospective validation.