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Conversion method to manage surgical difficulties in non-intubated uniportal video-assisted thoracic surgery for major lung resection: simple thoracotomy without intubation.

ABSTRACT: BackgroundThe major limitations of widespread use of non-intubated thoracic surgery (NITS) is the fear of managing complications. Here we present our practice of converting from uniportal video-assisted thoracic surgery (VATS) NITS to open NITS in cases of surgical complications.MethodsThe study period was from January 26, 2017, to November 30, 2018. Total intravenous anesthesia was provided with propofol guided by bispectral index, and the airway was maintained with a laryngeal mask with spontaneous breathing. Local anesthesia with 2% lidocaine at the skin incision, and intercostal and vagus nerve blockades were induced using 0.5% bupivacaine. For conversion with surgical indications, a thoracotomy was performed at the incision without additional local or general anesthetics.ResultsIn 160 complete NITS procedures, there were 145 VATS NITS and 15 open NITS (9 conversions to open NITS and 6 intended NITS thoracotomies). In the 15 open NITS cases (2 pneumonectomies, 1 bilobectomy, 1 sleeve lobectomy, 7 lobectomies, 3 sublobar resections, 1 exploration), the mean operative time was 146.7 (105–225) and 110 (75–190) minutes in the converted and intended open NITS groups, respectively. There were no significant differences between systolic blood pressure (P=0.316; 95% CI, ?10.469 to 3.742), sat O2% (P=0.27; 95% CI, ?1.902 to 0.593), or propofol concentration in the effect site (P=0.053; 95% CI, ?0.307 to 0.002) but significant differences in pulse (P=0.007; 95% CI, ?10.001 to ?2.72), diastolic blood pressure (P=0.013; 95% CI, ?9.489 to ?1.420) and in end-tidal CO2 (P=0.016; 95% CI, ?7.484 to ?0.952) before versus after thoracotomy, but there was no clinical relevance of the differences.ConclusionsFor conversion with surgical indications during the VATS-NITS procedure, NITS thoracotomy can be performed safely at the site of the utility incision without the need for additional drugs, and the major lung resections can be performed through this approach.

SUBMITTER: Furak J

PROVIDER: S-EPMC7330381 | biostudies-literature | 2020 May

REPOSITORIES: biostudies-literature

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Project description:BackgroundNon-intubated uniportal video-assisted thoracoscopic surgery (niVATS) is a novel approach to major and minor lung resection. It benefits from a holistic anesthesiological concept with adequate pain relief and sedation in a minimal-invasive setup allowing thoracic procedures under spontaneous breathing. At present no anesthesiological gold standard for niVATS exists. The primary aim of our retrospective observational study was to evaluate feasibility and safety of minimally invasive niVATS for both minor and major pulmonary resections at our institution.MethodsAll 88 consecutive patients scheduled for niVATS minor or major thoracic procedures were included into the study. Anaesthesia was performed according to a departmental niVATS algorithm including both regional anaesthesia and sedation. Patient characteristics and early outcome data including intraoperative and postoperative findings were compared between groups. Prediction scores for postoperative complications (LAS VEGAS, ARISCAT, ThRCRI) were calculated and compared.ResultsNo early mortality and a low overall morbidity rate of 28.4% were encountered. Conversion to orotracheal intubation was required in 6.8% of all cases. Postoperative pulmonary complications occurred in 15.9% of total cases and were lower than predicted by both LAS VEGAS and ARISCAT respectively. Cardiac complications were found in 1.1% and lower than predicted by ThRCRI. A persistent air leak occurred in 11.4% of total cases and was significantly higher in major resection. Postoperative chest tube duration and hospital length of stay in the major resection group exceeded times reported by other groups.ConclusionsniVATS appears to be safe in both minor and major thoracic procedures. A minimally invasive anaesthesiological approach foregoing central iv lines, arterial blood pressure measurement and urinary catheterization is feasible. Our niVATS protocol appears to be a viable alternative for both minor and major thoracic procedures in selected patients.

Project description:BackgroundVideo-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.MethodsRandomized 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.ResultsMeta-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.ConclusionsNIVATS 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.

Project description:BackgroundCough is one of the shared complications after lung surgery. In this study, a prospective analysis was conducted for exploring the risk factors of persistent cough after uniportal video-assisted thoracoscopic pulmonary resection.MethodsOne hundred thirty-five patients with pulmonary nodules who underwent surgical treatment in the same surgical group from November 2019 to January 2020 were enrolled in this prospective study. The severity of cough and its impact on patients' quality of life before and after surgery were assessed by the Mandarin Chinese version of the Leicester cough questionnaire (LCQ-MC), and postoperative cough was tested by the cough visual analog scale (VAS) and cough symptom score (CSS). Risk factors of cough after pulmonary resection (CAP) were determined by univariate and multivariate logistic regression analysis.ResultsThe incidence of postoperative cough was 24.4% (33 of 135 patients). Univariate analysis showed that gender (female), the surgical site (upper right), the resection (lobectomy), subcarinal lymph node dissection, postoperative acid reflux, length of hospitalization contributed to the development of CAP resection. Multivariate logistic regression analysis showed that the resection (lobectomy) (OR 3.590, 95% CI: 0.637-20.300, P=0.017), subcarinal lymph node dissection (OR 4.420, 95% CI: 1.342-14.554, P=0.001), postoperative acid reflux (OR 13.55, 95% CI: 3.186-57.633, P<0.001) and duration of anesthesia (over 153 minutes, OR 0.987, 95% CI: 0.978-0.997, P=0.011) were independent risk factors for postoperative cough.ConclusionsThe application of uniportal video-assisted thoracoscopic techniques to several types of lung surgery are conducive to enhanced recovery after surgery (ERAS). Postoperative cough is related to an ocean of factors, the resection (lobectomy), subcarinal lymph node dissection, postoperative acid reflux, and duration of anesthesia (over 153 minutes) are independent high-risk factors for CAP resection.Trial registrationThis study was registered on ClinicalTrials.gov (NCT04204148).

Project description:BackgroundThe development of thoracic surgical techniques has provided a new avenue for treating thoracic tuberculosis. Moreover, microscopic treatment of spinal tuberculosis has attracted increasing attention, as it affords good visual access and reduces trauma. Traditional thoracoscopic treatment of spinal tuberculosis usually requires 2-3 passages, accompanied by a corresponding number of incisions. With a large number of conventional thoracoscopic surgeries performed, improved resolution of the microscopic field of view, effective hemostasis of the peripheral vessels using the ultrasonic knife, and many reports in the literature, thoracic tuberculosis can now be treated microscopically by creating a single channel. The aim of this study was to explore the feasibility and surgical technique for thoracic tuberculous spondylitis treatment via debridement and bone graft fusion surgery employing pure uniportal video-assisted thoracic surgery (VATS), combined with posterior internal fixation.MethodsSeven patients with relatively complete documentation were included in this study. All patients underwent lesion removal and bone graft reconstruction via uniportal VATS with posterior internal fixation. The mean patient age was 39.6 years. Surgical duration, blood loss volume, postoperative recovery time, and thoracic kyphosis angle were recorded.ResultsThe surgeries were successful with no severe postoperative complications. All patients were followed-up, and no recurrence of tuberculosis was observed. Imaging data, including computed tomography scans, confirmed the complete removal of the lesions. Additionally, bone fusion at the graft site was successful, no loss of the thoracic kyphosis angle was noted postoperatively, and the thoracic kyphosis angle improved.ConclusionsPure uniportal VATS yields satisfactory results and inflicts less trauma than previous surgical techniques. This technique also offers a reference value for treating thoracic tuberculous spondylitis.

Project description:BackgroundUniportal video-assisted thoracoscopic surgery (U-VATS) has recently emerged as an alternative procedure for non-small cell lung cancer (NSCLC); however, whether U-VATS has advantages over multiportal VATS (M-VATS) remains unknown.MethodsWe performed a systematic review of two databases (Pubmed and Web of Science) to search comparative studies of U-VATS and M-VATS anatomical pulmonary resection for NSCLC. Operative time, blood loss, number of resected lymph nodes, drainage duration, length of postoperative stay, pain in postoperative day 1(POD1) and conversion rates were retrieved to estimate the comparison of outcomes. A subgroup analysis stratified by study type (propensity-matched analysis and randomized-controlled trial versus non-propensity matched analysis) was performed.ResultA total of 20 studies with 4142 patients were included in this meta-analysis. U-VATS was performed on 1869 patients, whereas the other 2173 patients underwent M-VATS. This meta-analysis showed that there was no significant difference in operative time (U-VATS: 146.48 ± 55.07 min versus M-VATS: 171.70 ± 79.40 min, P = 0.81), blood loss (74.49 ± 109.03 mL versus 95.48 ± 133.67 mL, P = 0.18), resected lymph nodes (17.28 ± 9.46 versus 18.31 ± 10.17, P = 0.62), conversion rate (6.18% versus 4.34%, P = 0.14), drainage duration (3.90 ± 2.94 days versus 4.44 ± 3.12 days, p = 0.09), length of postoperative stay (6.16 ± 4.40 days versus 6.45 ± 4.80 days, P = 0.22), and pain in POD1 (3.94 ± 1.68 versus 3.59 ± 2.76, p = 0.07). Subgroup analysis showed the value of PSM and RCT group consistency with overall value.ConclusionThis up-to-date meta-analysis shows that the perioperative outcomes of U-VATS and M-VATS anatomical pulmonary resection are equivalent. In addition, the differences in long-term outcomes of these two approaches are still unclear. Thoracic surgeons should pay more emphasize on providing high-quality and personalized surgical care for patients, to improve the survival ultimately.

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Conversion method to manage surgical difficulties in non-intubated uniportal video-assisted thoracic surgery for major lung resection: simple thoracotomy without intubation.

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