Expert consensus on tubeless video-assisted thoracoscopic surgery (Guangzhou)

[Non-Intubated Video-assisted Thoracoscopic Surgery (niVATS)]

Non-intubated minimally invasive lung surgery garnered renewed interest during the past decade and many centers across the country successfully implemented the technique for minor procedures like pleurodesis or wedge resection. Anatomical lung resection under spontaneous breathing still is considered as challenging, and as existing data to support it is conflicting and confusing, the approach remains limited to few dedicated outfits. We seek to present the historical perspective, critically report potential advantages and limitations of the technique and hand out a guideline that might prove to be helpful in building up a dedicated program.

Are chest drains routinely required after thoracic surgery? A drainology study of on-table chest-drain removals

Objectives

Advances in perioperative management for thoracic surgery have accelerated the postoperative recovery of patients by decreasing postoperative pain and the incidence of complications. We aimed to study whether it's safe to remove chest drains on table in selected cases.

Methods

This was a 5-year retrospective analysis of protocolized chest-drain removal on the operating table. The chest drain was removed in patients undergoing sublobar/wedge lung resection and other minor thoracic procedure (pleural biopsy, mediastinal mass biopsy/resection) via a thoracoscopic approach (video-assisted thoracoscopic surgery). Chest drains were removed at the end of the operation if air leak as documented by the digital drain was less than 20 mL/min. Outcome data on postdrain removal pneumothorax, effusion, and need for further intervention were obtained by reviewing the postoperative chest films, all reported by a radiologist.

Results

Between 2016 and 2021, 107 patients underwent drain removal in theater. Mean age (standard deviation) was 58 (17) years and 54 (50.5%) were male. Postdrain removal pneumothorax occurred in 22 patients (21%), pleural effusion in 6 (5.6%), and 21 of 22 postoperative pneumothoraces were managed conservatively without reinsertion of chest drain. As it is our standard policy to leave no pneumothorax in patients undergoing surgical management of primary spontaneous pneumothorax, only 1 such patient (0.9%) had a drain reinserted as a result. The median (interquartile) length of hospital stay was 1 day (1-2), and 14 patients (13%) were discharged on surgery day.

Conclusions

Our results demonstrate that on table chest-drain removal in selected cases is safe and repeatable using a digital drain, challenging the practice of routine drain insertion after thoracic surgery.

A surgical Decision-making scoring model for spontaneous ventilation- and mechanical ventilation-video-assisted thoracoscopic surgery in non-small-cell lung cancer patients

BACKGROUNDS

Spontaneous ventilation-video-assisted thoracoscopic surgery (SV-VATS) has been applied to non-small cell lung cancer (NSCLC) patients in many centers. Since it remains a new and challenging surgical technique, only selected patients can be performed SV-VATS. We aim to conduct a retrospective single-center study to develop a clinical decision-making model to make surgery decision between SV-VATS and MV (mechanical ventilation) -VATS in NSCLC patients more objectively and individually.

METHODS

Four thousand three hundred sixty-eight NSCLC patients undergoing SV-VATS or MV-VATS in the department of thoracic surgery between 2011 and 2018 were included. Univariate and multivariate regression analysis were used to identify potential factors influencing the surgical decisions. Factors with statistical significance were selected for constructing the Surgical Decision-making Scoring (SDS) model. The performance of the model was validated by area under the receiver operating characteristic curve (AUC), calibration curves and decision curve analysis (DCA).

RESULTS

The Surgical Decision-making Scoring (SDS) model was built guided by the clinical judgment and statistically significant results of univariate and multivariate regression analyses of potential predictors, including smoking status (p = 0.03), BMI (p < 0.001), ACCI (p = 0.04), T stage (p < 0.001), N stage (p < 0.001), ASA grade (p < 0.001) and surgical technique (p < 0.001). The AUC of the training group and the testing group were 0.72 and 0.70, respectively. The calibration curves and the DCA curve revealed that the SDS model has a desired performance in predicting the surgical decision.

CONCLUSIONS

This SDS model is the first clinical decision-making model developed for an individual NSCLC patient to make decision between SV-VATS and MV-VATS.

Opioid-sparing anesthesia with dexmedetomidine provides stable hemodynamic and short hospital stay in non-intubated video-assisted thoracoscopic surgery: a propensity score matching cohort study

OBJECTIVES

Dexmedetomidine is an alpha-2 agonist with anti-anxiety, sedative, and analgesic effects and causes a lesser degree of respiratory depression. We hypothesized that the use of dexmedetomidine in non-intubated video-assisted thoracic surgery (VATS) may reduce opioid-related complications such as postoperative nausea and vomiting (PONV), dyspnea, constipation, dizziness, skin itching, and cause minimal respiratory depression, and stable hemodynamic status.

METHODS

Patients who underwent non-intubated VATS lung wedge resection with propofol combined with dexmedetomidine (group D) or alfentanil (group O) between December 2016 and May 2022 were enrolled in this retrospective propensity score matching cohort study. Intraoperative vital signs, arterial blood gas data, perioperative results and treatment outcomes were analyzed. Of 100 patients included in the study (group D, 50 and group O, 50 patients), group D had a significantly lower degree of decrement in the heart rate and the blood pressure than group O. Intraoperative one-lung arterial blood gas revealed lower pH and significant ETCO₂. The common opioid-related side effects, including PONV, dyspnea, constipation, dizziness, and skin itching, all of which occurred more frequently in group O than in group D. Patients in group O had significantly longer postoperative hospital stay and total hospital stay than group D, which might be due to opioid-related side effects postoperatively.

CONCLUSIONS

The application of dexmedetomidine in non-intubated VATS resulted in a significant reduction in perioperative opioid-related complications and maintenance with acceptable hemodynamic performance. These clinical outcomes found in our retrospective study may enhance patient satisfaction and shorten the hospital stay.

Clinical guide to perioperative management for videothoracoscopy lung resection (Section of Cardiac, Vascular and Thoracic Anesthesia, SEDAR; Spanish Society of Thoracic Surgery, SECT; Spanish Society of Physiotherapy)

The introduction of video-assisted thoracoscopic (VATS) techniques has led to a new approach in thoracic surgery. VATS is performed by inserting a thoracoscope through a small incisions in the chest wall, thus maximizing the preservation of muscle and tissue. Because of its low rate of morbidity and mortality, VATS is currently the technique of choice in most thoracic procedures. Lung resection by VATS reduces prolonged air leaks, arrhythmia, pneumonia, postoperative pain and inflammatory markers. This reduction in postoperative complications shortens hospital length of stay, and is particularly beneficial in high-risk patients with low tolerance to thoracotomy. Compared with conventional thoracotomy, the oncological results of VATS surgery are similar or even superior to those of open surgery. This aim of this multidisciplinary position statement produced by the thoracic surgery working group of the Spanish Society of Anesthesiology and Reanimation (SEDAR), the Spanish Society of Thoracic Surgery (SECT), and the Spanish Association of Physiotherapy (AEF) is to standardize and disseminate a series of perioperative anaesthesia management guidelines for patients undergoing VATS lung resection surgery. Each recommendation is based on an in-depth review of the available literature by the authors. In this document, the care of patients undergoing VATS surgery is organized in sections, starting with the surgical approach, and followed by the three pillars of anaesthesia management: preoperative, intraoperative, and postoperative anaesthesia.

The Anesthesiologist's Perspective Regarding Non-intubated Thoracic Surgery: A Scoping Review

Non-intubated thoracic surgery (NITS) is a growing practice, alongside minimally invasive thoracic surgery. To date, only a consensus of experts provided opinions on NITS leaving a number of questions unresolved. We then conducted a scoping review to clarify the state of the art regarding NITS. The systematic review of all randomized and non-randomized clinical trials dealing with NITS, based on Pubmed, EMBASE, and Scopus, retrieved 665 articles. After the exclusion of ineligible studies, 53 were assessed examining: study type, Country of origin, surgical procedure, age, body mass index, American Society of Anesthesiologist's physical status, airway management device, conversion to orotracheal intubation and pulmonary complications rates and length of hospital stay. It emerged that NITS is a procedure performed predominantly in Asia, and certain European Countries. In China, NITS is more frequently performed for parenchymal resection surgery, whereas in Europe, it is mainly employed for pleural pathologies. The most commonly used device for airway management is the laryngeal mask. The conversion rate to orotracheal intubation is a~3%. The results of the scoping review seem to suggest that NITS procedures are becoming increasingly popular, but its role needs to be better defined. Further randomized clinical trials are needed to better define the role of the clinical variables possibly impacting on the technique effectiveness.

Systematic Review Registration

https://osf.io/mfvp3/, identifier: 10.17605/OSF.IO/MFVP3.

Ultrasound Evaluation of the Diaphragm in Clinical Anesthesia

When the human body is anesthetized, the human nerve tissue will be greatly affected, which also affects the breathing of the human body. The respiration during anesthesia is a lack of initiative, and the energy efficiency of the diaphragm in the lungs is very important to the safety of anesthesia. In this paper, the application of the ultrasound evaluation of the diaphragm in clinical anesthesia was studied. In this paper, 24 patients who underwent lung examination under medical anesthesia at our hospital were evaluated by the ultrasound vertical mixed echo method. Through patient voluntary selection and consent, 16 patients were examined with B-mode ultrasound and the other 8 patients with M-mode ultrasound to compare the effects of different ultrasounds on diaphragm image quality. In addition, this paper also analyzes the differences between different ultrasounds and the strengths and weaknesses of diaphragmatic ultrasound evaluation in clinical anesthesia. The suggestions of using different ultrasounds in ultrasonic evaluation are given. The study showed that 16 cases of B-mode ultrasound evaluation of the diaphragm obtained ultrasound images which showed a large field of vision, acoustic frequency between 7 and 18 MHz, and thickness difference between 0.35 and 0.52 cm. In 8 patients with the diaphragm evaluated by M-mode ultrasound, the local features of M-mode ultrasound images were clearer than those of B-mode ultrasound images, but the visual field area was smaller, the acoustic frequency was between 10 and 15 MHz, and the thickness difference was between 0.12 and 0.18 cm. Based on the above data, this paper suggests that, in the ultrasonic evaluation of the diaphragm, B-mode ultrasound should be used to check the patients first, and then M-mode ultrasound should be used to check the parts with poor quality so that the accurate diaphragm quality of patients can be obtained in the vast majority of patients.

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.

Perioperative and long-term outcomes of spontaneous ventilation video-assisted thoracoscopic surgery for non-small cell lung cancer

Background

Spontaneous ventilation video-assisted thoracoscopic surgery (SV-VATS) exhibits dual intraoperative and postoperative advantages for patients with non-small cell lung cancer (NSCLC). However, there is a lack of data regarding its long-term survival superiority over the double-lumen intubated mechanical ventilation video-assisted thoracoscopic surgery (MV-VATS) or thoracotomy.

Methods

A retrospective study was conducted from 2011 to 2018 in the First Affiliated Hospital of Guangzhou Medical University among patients with NSCLC who underwent the SV-VATS or the MV-VATS. Patients receiving the SV-VATS were the study group, and patients receiving the MV-VATS were the control group. Propensity score matching (PSM) was performed to establish 1:1 SV-VATS versus MV-VATS group matching to balance potential baseline confounding factors. Primary endpoints were overall survival (OS) and disease-free survival (DFS). Secondary endpoints were perioperative outcomes. The baseline information of these patients was recorded. The perioperative data and survival data were collected using a combination of electronic data record system and telephone interview. A 1:1:1 SPM was also used to compare the OS in the SV-VATS, the MV-VATS and thoracotomy group by using another database, including patients undergoing thoracotomy and the MV-VATS.

Results

For the two-group comparison, after 1:1 PSM, a matched cohort with 400 (200:200) patients was generated. The median follow-up time in this cohort was 4.78 years (IQR, 3.78–6.62 years). The OS (HR =0.567, 95% CI, 0.330 to 0.974, P=0.0498) and the DFS (HR =0.546, 95% CI, 0.346 to 0.863, P=0.013) of the SV-VATS group were significantly better than the MV-VATS group. There were no statistically differences between the SV-VATS and the MV-VATS group on the operative time (158.56±40.09 vs. 172.06±61.75, P=0.200) anesthesia time (247.4±62.49 vs. 256.7±58.52, P=0.528), and intraoperative bleeding volume (78.88±80.25 vs. 109.932±180.86, P=0.092). For the three-group comparison, after 1:1:1 PSM, 582 (194:194:194) patients were included for the comparison of SV-VATS, MV-VATS and thoracotomy. The OS of the SV-VATS group was significantly better than the thoracotomy group (HR =0.379, 95% CI, 0.233 to 0.617, P<0.001).

Conclusions

Invasive NSCLC patients undergoing SV-VATS lobectomy demonstrated better long-term outcomes compared with MV-VATS.

Radical resection of solitary tracheal extramedullary plasmacytoma under non-intubated anesthesia: a case report

Extramedullary plasmacytoma (EMP) is an uncommon monoclonal plasma cell malignancy that arises outside of the bone marrow. Rarely, EMPs can occur in the trachea, resulting in severe respiratory distress. Due to a small number of cases, the optimal management of tracheal EMP remains a topic of debate. Here, we report a rare case of solitary tracheal EMP causing symptoms of cough, sputum, paroxysmal nocturnal dyspnea, and progressive exertional dyspnea in a 65-year-old male patient. Computerized tomography and fibro bronchoscopy indicated a pedicled nodular mass on the anterior tracheal wall obstructing over 95% of the lumen. The patient was soon successfully managed with partial tracheal resection and reconstruction surgery under non-intubated anesthesia and was diagnosed as EMP by histopathology of the resected mass. Additional laboratory tests excluded the diagnosis of multiple myeloma (MM). There are no signs of recurrence after 6 months of follow-up. Although traditional intubated anesthesia with single-lung mechanical ventilation has been widely applied to radical surgery for tracheal tumors, it is associated with a higher incidence of intubation-related complications and thus prolongs the surgical procedure and postoperative recovery. In this article, we reported the application of tracheal resection and reconstruction under non-intubated anesthesia for the treatment of tracheal EMP, which was proved to be feasible and safe. Non-intubated anesthesia for tracheal resection and reconstruction is likely to be an alternative minimally invasive option for patients with tracheal EMP involving central airways.

Extended Pulmonary Resection by Sleeve Lobectomy and Carinal Pneumonectomy: Selection and Technique

Minimally invasive surgical approaches for extended pulmonary resections are becoming increasingly common as more surgeons gain experience in thoracoscopic and robotic technique. Outcome studies demonstrate improved decreased morbidity as compared with an open surgery.

Spontaneous Ventilation Video-Assisted Thoracoscopic Surgery for Geriatric Patients With Non-Small-Cell Lung Cancer

OBJECTIVES

The aim of the present study was to compare the short-term outcomes between spontaneous ventilation video-assisted thoracic surgery (SV-VATS) and mechanical ventilation video-assisted thoracic surgery (MV-VATS) in the elderly. All patients included in the present study underwent lobectomy, segmentectomy, or wedge resection and lymph node dissection.

DESIGN

A retrospective cohor.

SETTING

The first affiliated hospital of Guangzhou Medical University, Guangzhou, China.

PARTICIPANTS

The present study included 799 elderly patients diagnosed with non-small-cell lung cancer undergoing SV-VATS or MV-VATS. After propensity score matching, 80 patients in the SV-VATS group and 80 patients in the MV-VATS group were analyzed.

INTERVENTIONS

Patients in the SV-VATS group received spontaneous-ventilation anesthesia, which was administered as follows: intravenous anesthesia + laryngeal mask airway + thoracic paravertebral block + visceral pleural surface anesthesia + thoracic vagus nerve block. Patients in the MV-VATS group received general endotracheal anesthesia. SV-VATS or MV-VATS was performed according to the preference of the patients.

MEASUREMENTS AND MAIN RESULTS

There were no significant differences in anesthesia time (226.3 ± 79.8 v 238.5 ± 66.2 min; p = 0.44), surgery time (166.2 ± 102.6 v 170.1 ± 83.4 min; p = 0.66), and number of dissected lymph nodes (5.3 ± 7.5 v 4.4 ± 7.4; p = 0.23) between the two groups. There were significant differences in intraoperative bleeding (61.5 ± 165.1 v 82.2 ± 116.9 mL; p < 0.001). After surgery, the two groups were statistically comparable in terms of hospitalization (17.6 ± 7.6 v 17.2 ± 6.9 days; p = 0.95) and incidence of complications (7.5% v 13.8%; p = 0.20), while there were significant differences in chest tube duration (6.1 ± 3.3 v 4.5 ± 1.2 days; p < 0.001).

CONCLUSIONS

SV-VATS is feasible and as safe as MV-VATS, and it could be considered as an alternative treatment for the elderly.

Clinical guide to perioperative management for videothoracoscopy lung resection (Section of Cardiac, Vascular and Thoracic Anesthesia, SEDAR; Spanish Society of Thoracic Surgery, SECT; Spanish Society of Physiotherapy)

The introduction of video-assisted thoracoscopic (VATS) techniques has led to a new approach in thoracic surgery. VATS is performed by inserting a thoracoscope through a small incisions in the chest wall, thus maximizing the preservation of muscle and tissue. Because of its low rate of morbidity and mortality, VATS is currently the technique of choice in most thoracic procedures. Lung resection by VATS reduces prolonged air leaks, arrhythmia, pneumonia, postoperative pain and inflammatory markers. This reduction in postoperative complications shortens hospital length of stay, and is particularly beneficial in high-risk patients with low tolerance to thoracotomy. Compared with conventional thoracotomy, the oncological results of VATS surgery are similar or even superior to those of open surgery. This aim of this multidisciplinary position statement produced by the thoracic surgery working group of the Spanish Society of Anesthesiology and Reanimation (SEDAR), the Spanish Society of Thoracic Surgery (SECT), and the Spanish Association of Physiotherapy (AEF) is to standardize and disseminate a series of perioperative anaesthesia management guidelines for patients undergoing VATS lung resection surgery. Each recommendation is based on an in-depth review of the available literature by the authors. In this document, the care of patients undergoing VATS surgery is organized in sections, starting with the surgical approach, and followed by the three pillars of anaesthesia management: preoperative, intraoperative, and postoperative anaesthesia.

Tubeless video-assisted thoracoscopic surgery in mediastinal tumor resection

Background

It has been reported that tubeless video-assisted thoracoscopic surgery (tubeless-VATS) is feasible and safe for thoracic diseases. Herein, we compared the early outcomes of mediastinal lesion resection between the tubeless and traditional VATS.

Methods

Clinical data of all patients who underwent thoracoscopic mediastinal tumor resection were retrospectively collected. The study involved two groups: tubeless and traditional VATS group. Propensity score matching (PSM) was applied to eliminate the population bias. Intraoperative and postoperative variables were compared among matched cohorts.

Results

In total, 43 patients in the tubeless group and 231 patients in the traditional VATS group were included. After 1:1 PSM, baseline characteristics were comparable. Anesthesia time (177.63 vs. 202.53 min; P=0.004) was shorter in tubeless group, while operation time (90.95 vs. 101.47 min; P=0.109) was similar. Overall, the total postoperative morbidity rate was similar in the two groups (15% vs. 12.5%; P=0.556). Specially, 4/43 patients in tubeless VATS group need to be re-put chest tubes postoperatively. A significant lower similar level of visual analogue scale score was observed in tubeless VATS group (1.73±0.48 vs. 3.41±0.87, P<0.001) in postoperative day 1. Meanwhile, the number of patients using postoperative opioid analgesia was also lower in tubeless VATS group (22.88% vs. 48.38%, P=0.016). Furthermore, hospital duration after surgery (2.58 vs. 5.47 days; P=0.002) was shorter in tubeless group.

Conclusions

Compared with traditional VATS, tubeless VATS for mediastinal tumor may shorten the anesthesia time, decrease postoperative pain and fasten postoperative recovery in carefully selected patients.

To tube or not to tube: a skeptic's guide to nonintubated thoracic surgery

PURPOSE OF REVIEW

The aim of this review is to provide an overview of the rationale and evidence for nonintubated thoracic surgery and guide clinicians, considering the implementation of nonintubated thoracic surgery, to find an anesthetic approach suitable for their department.

RECENT FINDINGS

Based on physiologic considerations alone, nonintubated thoracic surgery would be expected to be an advantageous concept in thoracic anesthesia, especially in patients at high risk for pulmonary complications. Currently existing evidence, however, does not support these claims. Although the feasibility and safety have been repeatedly demonstrated, high-quality evidence showing a significant benefit regarding clinically relevant patient-centered outcomes is not available.Anesthetic approaches to nonintubated thoracic surgery differ significantly; however, they usually concentrate on six main aspects: maintenance of airway patency, respiratory support, analgesia, patient comfort, cough suppression, and conversion techniques. Given the lack of high-quality studies comparing different techniques, evidence-based guidance of clinical decision-making is currently not possible. Until further evidence is available, anesthetic management will depend mostly on local availability and expertise.

SUMMARY

In select patients and with experienced teams, nonintubated thoracic surgery can be a suitable alternative to intubated thoracic surgery. Until more evidence is available, however, a general change in anesthetic management in thoracic surgery is not justified.

Tubeless uniportal thoracoscopic wedge resection with modified air leak test and chest tube drainage

Background

To investigate whether tubeless uniportal thoracoscopic wedge resection with modified air leak test and chest tube drainage has better short-term outcomes than non-intubated approach with chest tube drainage.

Methods

Data were collected retrospectively from January 2017 and December 2019. Tubeless group included 55 patients with pulmonary nodules underwent tubeless uniportal thoracoscopic wedge resection, 211 patients underwent non-intubated uniportal thoracoscopic wedge resection with chest tube drainage were included in drainage group. Peri-operative outcomes between two groups were compared.

Results

After 1:1 matching, 110 patients remained for analysis, baseline demographic and clinical variables were comparable between the two groups. Mean incision size was 3 cm in both group. Mean operative time was 59.3 min in tubeless group and 52.8 min in drainage group. The detectable mean lowest SpO₂ and mean peak EtCO₂ during operation was acceptable in both groups. Conversion to intubated ventilation or thoracotomy was not required. No patient failed the air leak test and did not undergo a tubeless procedure. Mean postoperative hospital stay was 1.5 days in tubeless group and 2.5 days in drainage group. Residual pneumothorax or subcutaneous emphysema was not frequent and mild in tubeless group. Side effects were rare and mild, including cough and hemoptysis. No re-intervention or readmission occurred. The postoperative VAS score was significantly lower in tubeless group.

Conclusions

Tubeless uniportal thoracoscopic wedge resection with modified air leak test and chest tube drainage is feasible and safe for selected patients with peripheral pulmonary nodules, it might reduce post-operation pain and lead to faster recovery.

Spontaneous ventilation video-assisted thoracic surgery for mediastinal tumor resection in patients with pulmonary function deficiency

BACKGROUND

Whether non-intubated spontaneous ventilation video-assisted thoracoscopic surgery (SV-VATS) is a safe procedure remains controversial for mediastinal tumor patients with impaired lung function. Herein, we assessed feasibility of SV-VATS in lung function deficiency patients underwent mediastinal tumor resection.

METHODS

From December 2015 to February 2020, 32 mediastinal tumor patients with impaired lung function (preoperative forced expiratory volume in 1 second <70% of the predicted value) were retrospectively collected. Patients were divided into two groups: SV-VATS group and mechanical ventilation VATS (MV-VATS) group. Intraoperative and postoperative variables were compared between two cohorts.

RESULTS

Fifteen patients (46.88%) underwent SV-VATS and 17 patients (53.12%) were performed with MV-VATS. The most common causes of lung function deficiency were smoking (81.25%) and COPD (71.88%). Patients in the SV-VATS group had similar blood loss (20.63 vs. 18.76 mL, P=0.417) with MV-VATS group. The anesthesia time (217.51 vs. 197.76 min; P=0.343) and surgery time (141.23 vs. 132.36 min; P=0.209) were also similar between groups. Five people suffered postoperative complications in each group, in which 1 patient underwent MV-VATS was transferred to intensive care unit (ICU) because of prolonged extubation owing to hypoxia. There was no difference on chest tube removal time (2.6 vs. 2.3 days; P=0.172) or hospital duration (5.03 vs. 4.74 days; P=0.297) in patients underwent SV-VATS and MV-VATS.

CONCLUSIONS

SV-VATS is safe and provides similar short-term results to MV-VATS for mediastinal tumor resection in patients with limited pulmonary function.

Contralateral spontaneous rupture of the esophagus following severe emesis after non-intubated pulmonary wedge resection

Background

Non-intubated thoracoscopic lung surgery has been reported to be technically feasible and safe. Spontaneous rupture of the esophagus, also known as Boerhaave’s syndrome (BS), is rare after chest surgery.

Case presentation

A 60-year-old female non-smoker underwent non-intubated uniportal thoracoscopic wedge resection for a pulmonary nodule. Ultrasound-guided serratus anterior plane block was utilized for postoperative analgesia. However, the patient suffered from severe emesis, chest pain and dyspnea 6 h after the surgery. Emergency chest x-ray revealed right-sided hydropneumothorax. BS was diagnosed by chest tube drainage and computed tomography. Besides antibiotics and tube feeding, a naso-leakage drainage tube was inserted into the right thorax for pleural evacuation. Finally, the esophagus was healed 40d after the conservative treatment.

Conclusions

Perioperative antiemetic therapy is an indispensable item of fast-track surgery. Moreover, BS should be kept in mind when the patients complain of chest distress following emesis after thoracic surgery.

Factors influencing the length of stay after mediastinal tumor resection in the setting of an enhanced recovery after surgery (ERAS)-TUBELESS protocol

Background

Prolonged length of stay after surgery is considered to increase cost and hospital-acquired complications. Therefore, we aimed to identify the risk factors that were associated with an increased length of stay after mediastinal tumor resection in the setting of an enhanced recovery after surgery (ERAS)-TUBELESS protocol.

Methods

This prospective cohort study collected data on consecutive patients undergoing video-assisted thoracoscopic surgery (VATS) resection for mediastinal tumor between December 2015 and November 2018 at a single center in China. All patients followed the ERAS-TUBELESS protocol. A length of stay after VATS tumor resection (LOS) greater than 3 days was considered an increased LOS. Univariable and multivariable logistic regression models were used to identify potential factors associated with increased LOS. Factors were divided into patient-related risk factors and procedure-related risk factors.

Results

A total of 204 patients were included, of which 85 (41.67%) patients had a LOS of more than 3 days. The median LOS for the entire cohort was 3 days. All the patient-related risk factors had no significantly associated with a prolonged LOS. Procedure-related risk factors that were significantly associated with a prolonged LOS were surgeon, operation time, intraoperative blood loss, drainage tube, analgesic drugs, and complications. Anesthesia with spontaneous ventilation was correlated with early discharge (LOS ≤1 day).

Conclusions

In the setting of an ERAS-TUBELESS protocol, the main drivers of LOS were procedure-related factors. Anesthesia with spontaneous ventilation was associated with early discharge (LOS ≤1 day) and thus promoted thoracic day surgery.

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.