Non-intubated video-assisted thoracoscopic surgery anatomical resections: a new perspective for treatment of lung cancer

Persistent cough after pulmonary resection: Minor issue, major hurdle

Background

Persistent cough is one of the most common complications following pulmonary resection, that impairs patients' quality of life and prolongs recovery time. However, a comprehensive review of persistent cough after pulmonary resection (CAP) has not been performed.

Methods

A literature search of PubMed/MEDLINE, Web of Science, and Embase database was conducted for persistent-CAP up to June 2023. Subsequent qualitative systematic review focused on definition, risk factors, prevention, and treatment of persistent-CAP.

Results

Persistent-CAP stands as a prevalent postoperative complication subsequent to pulmonary resection procedures. with an incidence of 24.4-55.0 %. Although persistent-CAP has a minor impact on survival, this condition is of critical importance because it presents a major hurdle in recovery after surgery. In this review, we proposed a systemic definition for persistent-CAP based on available evidence and our own data. Several assessment tools used to assess severity of persistent-CAP are also introduced. Risk factors associated with persistent-CAP are explored, including surgical approaches, resection extent, surgical site, lymph node dissection, postoperative gastroesophageal acid reflux, tracheal intubation anesthesia, preoperative comorbidity, and sex among others. Surgical and anesthesia preventions targeting risk factors to prevent persistent-CAP are elaborated. A number of studies have shown that a multidisciplinary approach can effectively relieve persistent-CAP.

Conclusions

Although the mechanisms underlying persistent-CAP are still unclear, existing studies demonstrated that persistent-CAP is related to surgical and anesthesia factors. Therefore, in the future, prevention and treatment should be developed based on risk factors to overcome the hurdle of persistent-CAP.

The Anesthetic Management of Patients Undergoing Nonintubated Video-Assisted Thoracic Surgery

Purpose of Review

This review focuses on describing the procedural and anesthetic management of patients undergoing nonintubated video-assisted thoracoscopy surgery.

Recent Findings

Most thoracic surgery is performed under general endotracheal anesthesia with either a double lumen endotracheal tube or a bronchial blocker. In an attempt to lessen the incidence and severity of postoperative complications, the nonintubated video-assisted thoracoscopic technique was developed, where the surgical procedure is performed under regional anesthesia with sedation. Currently, this technique is recommended for the elderly and in patients with severe cardiopulmonary disease who are at increased risk of complications after general anesthesia. It is the role of the anesthesia team to assist in the decisions whether the patient is a candidate and which block should be performed and to carefully monitor these patients in the operating room.

Summary

Nonintubated video-assisted thoracic surgery is an emerging technique with the goal of reducing postoperative complications. The anesthetic technique is highly variable and ranges from general anesthesia with a laryngeal mask airway with a truncal block to thoracic epidural anesthesia with minimal to no block. It is important to have excellent communication with the surgical team and the patient to ensure a safe, successful procedure.

A Propensity Score-Matched Analysis for Non-Intubated Thoracic Surgery

BACKGROUND Most observations of non-intubated anesthesia under spontaneous breathing are small-cohort, non-homogeneous surgery types and lack an intubation control. We therefore retrospectively compared the perioperative conditions and postoperative recovery of non-intubated video-assisted thoracoscopic surgery (NIVATS group) and intubated VATS (IVATS group) with a propensity score-matching analysis. MATERIAL AND METHODS We case-matched 119 patients in the NIVATS group with patients in the IVATS group by a propensity score-matched analysis. All of them underwent lobectomy. RESULTS In the NIVATS group, operative and anesthesia times were significantly shorter (P<0.01). NIVATS showed a faster and more stable recovery in the PACU, postoperative awaking and post-anesthesia care unit (PACU) stay times was shorter (P<0.01), and use of sedatives and analgesics was lower (P<0.05). The incidence of pulmonary exudation, atelectasis, and pleural effusion were higher (P<0.05). Although intraoperative SpO2 was lower and PETCO2 was higher in the NIVATS group (P<0.01), postoperative PaCO2 and SaO2 in both groups were similar (P>0.05). Postoperative counts of leukocytes and neutrophils and hemoglobin levels also had no difference between the 2 groups (P>0.05). CONCLUSIONS NIVATS has a more rapid and stable recovery in the PACU, and has no significant influence on oxygenation, but is more likely to cause postoperative radiologic complications.

Comparison of non-intubated versus intubated video-assisted thoracoscopic lobectomy for lung cancer

Background

Non-intubated, or awake, video-assisted thoracoscopic surgery has been implemented for non-anatomical lung resection and the results obtained were encouraging to consider the approach for anatomical pulmonary resection. This study was conducted to evaluate the perioperative outcomes of the non-intubated and intubated video-assisted thoracoscopic lobectomy in lung cancer in regards to feasibility and safety.

Methods

A retrospective analysis of 62 consecutive video-assisted thoracoscopic lobectomies (31 lobectomies as non-intubated, 31 lobectomies as intubated) performed in Seoul St. Mary's Hospital, The Catholic University of Korea between January and December 2016.

Results

Both groups share comparable clinical characteristics including the age, sex, BMI, FEV1, DLCO, smoking history, lung lobes procedure, histological type and pathological staging. There was no difference in the mean of postoperative hospitalization period (6.9 versus 7.6 days, P=0.578) and the total chest tube duration (5.6 versus 5.4 days, P=0.943) between non-intubated and intubated lobectomy respectively. Both groups had a comparable surgical outcome for the anesthesia duration, operative time, blood loss and postoperative complications. The operative time required for lobe-specific surgery was shorter in the non-intubated group except for the LLL (mean 121.7 minutes for non-intubated group versus 118.3 minutes for the intubated group). The only statistically significant surgical outcome was for the number of dissected lymph nodes between both groups (the mean number of nodes for the non-intubated group was 12.6 versus 18.0 nodes for the intubated group, P=0.003). One patient in the non-intubated group required conversion to single lung intubation and mini-thoracotomy because of bleeding with no conversion in the intubated group. No mortality encountered in either group.

Conclusions

The perioperative surgical outcomes for the non-intubated video-assisted thoracoscopic lobectomy are comparable to the intubated technique. Non-intubated video-assisted thoracoscopic lobectomy is safe and is technically feasible. However, further prospective randomized studies are needed for a better comparison between non-intubated and intubated VATS lobectomy.

Minimally invasive thoracic surgery: beyond surgical access

Thoracic surgery has evolved throughout the decades. The difficulty of accessing the intrathoracic organs through the bony rib-cage has been a challenge for thoracic surgeons. In the past, large incisions stretching across the chest, such as posterolateral thoracotomies with rib spreading was the standard approach to access the lungs. These methods cause large amounts of trauma to the patient, with high rates of mortality and morbidity. However, with the advances in technology and the improvements in surgical technique, thoracic surgery has progressed to minimise trauma to the patient while still maintaining oncological and surgical principles. State-of-the-art technology, combined with wide variety of old and new surgical techniques give the thoracic surgeon a formidable armamentarium. Although there has been a focus on reducing the number and size of surgical wounds, considerations other than surgical approach can reduce the trauma suffered by the patient. Preservation of pulmonary function via organ preservation and anaesthetic techniques to further minimise the systemic inflammation such as non-intubated anaesthesia have also been shown to improve patient outcomes. This article aims to review the recent advances in minimally invasive thoracic surgery.

Non-intubated uniportal left-lower lobe upper segmentectomy (S6)

Worldwide accepted indications of anatomical segmentectomies are mainly early stage primary adenocarcinomas, pulmonary metastasis and benign conditions. Their performance through uniportal VATS has become more and more popular due to the less invasiveness of the whole procedure under this approach. Recently, many efforts have focused on non-intubated spontaneously breathing management of lobectomies and anatomical segmentectomies, although specific selection criteria and main advantages are not completely standardized. In a 62-year-old thin man with two pulmonary residual metastasis from sigma adenocarcinoma, after chemotherapy plus antiangiogenic treatment, we indicated a single-incision video-assisted left-lower lobe (LLL) upper segmentectomy (S6) under spontaneous breathing and intercostal blockade. Total operation time was 240 minutes. Chest tube was removed at 24 hours and the patient was discharge on postoperative day 2 without any complication. Non-intubated uniportal VATS is a safe and reasonable approach for lung-sparing resections in selected patients, although more evidence is required for selecting which patients can benefit more over standard intubated procedures.

Resection of pulmonary nodule in a patient with subglottic stenosis under modified spontaneous ventilation anesthesia

Subglottic stenosis is an uncommon structural abnormality that can pose as a difficulty for patients undergoing surgery, and treatment is complex due to the special anatomical location. Pulmonary nodule resection in patients with subglottic stenosis is challenging and has not yet been reported. Here we present a case of pulmonary nodule resection in a patient with subglottic stenosis using uniportal thoracoscopy under spontaneous ventilation anesthesia (SVA). Compared with traditional double lumen endotracheal intubation, we believe this modified technique can significantly reduce airway trauma, and accelerate patient recovery.

[Application of Non-intubated Anesthesia in VATS]

气管插管全麻技术可提高手术安全性，因此在电视胸腔镜手术（video-assisted thoracic surgery, VATS）中得到广泛应用，但气管插管的并发症却无法避免。如何发展一种“整体微创”手术（包括麻醉微损伤），已经成为微创胸外科领域的一个研究热点。随着麻醉管理技术与对手术风险管理的进步，非气管插管技术成功应用于VATS，即采用局部麻醉以维持患者的术中自主通气，术中仅需轻微镇静或者完全清醒的状态下实施VATS，因而又称清醒状态下VATS。此麻醉方式不但减少气管插管的麻醉损伤，而且符合快速康复外科的理念。本文对非气管插管应用在胸外科VATS中的发展简史、麻醉选择、手术优势、手术风险及管理、面临的问题等方面作一综述。