In our study, awake video-assisted thoracoscopic bullectomy with pleural abrasion proved easily feasible and resulted in shorter hospital stays and reduced procedure-related costs while providing equivalent outcome to procedures performed under general anesthesia.

In this randomized study, awake nonresectional lung volume reduction surgery resulted in significantly shorter hospital stay than the nonawake procedure. There were no differences between study groups in physiologic improvements, freedom from contralateral treatment, and survival. We speculate that compared with the nonawake procedure, awake lung volume reduction surgery can offer similar clinical benefit but a faster postoperative recovery.

Background. Surgical stress and general anesthesia can have detrimental effects on postoperative immune function. We sought to comparatively evaluate postoperative lymphocytes response in patients undergoing videoassisted thoracoscopic surgery (VATS) under thoracic epidural or general anesthesia.Methods. Between October 2008 and June 2009, 50 patients with nonmalignant pulmonary conditions were randomized to undergo VATS through either sole epidural anesthesia and spontaneous ventilation (awake group, n ‫؍‬ 25) or general anesthesia with one-lung ventilation (control group, n ‫؍‬ 25). In both groups, assessment of total lymphocytes count and changes in proportion of lymphocyte subsets including CD19؉, CD3؉, CD4؉, CD8؉, CD4؉:CD8؉ ratio, and CD16؉CD56؉ (natural-killer cell) were evaluated by two-way analysis of variance test for repeated measures at baseline and postoperative days 1, 2, and 3. The Mann-Whitney test was performed at each time point only for significant parameters at between-group analysis of variance.

This study was undertaken to assess stress hormones response after awake videoassisted thoracoscopic surgery (VATS). Plasma levels of adrenal-corticotropic hormone (ACTH), cortisol, epinephrine, norepinephrine, and glucose were assessed at baseline, 3 h postoperatively (T1), and on postoperative mornings 2 (T2) and 3 (T3) in 21 patients undergoing awake VATS with epidural anesthesia for non-malignant conditions (n=11) or equivalent procedures performed with general anesthesia. Epinephrine level peaked in both groups at T1, although significant change from baseline values occurred in the control group only [median-Delta: 6 ng/l (IQR: 4-6), P=0.005]. Cortisol level was lower in the study group at T1 (15.5 microg/dl vs. 23.0 microg/dl, P=0.001) and T2 (15.2 microg/dl vs. 19.2 microg/dl, P=0.002). In the control group, peak cortisol level proved not to be related to changes in ACTH (R=0.23, P=0.46). At T2, glucose (137 mg/dl vs. 98 mg/dl, P=0.01) and C-reactive protein (P=0.04) were higher in the control group. No other clinically relevant between-groups differences were found in aspecific acute-response factors. Overall, these preliminary findings suggest attenuated stress response after awake VATS in comparison with equivalent procedure performed under general anesthesia and one-lung ventilation.

In our study, awake video-assisted pleural decortication proved feasible and resulted in satisfactory lung re-expansion in 95% of the patients. We hypothesise that spontaneous ventilation facilitated both identification of the correct plane and dissection, thus resulting in lesser surgical injury on the underlying lung.

Although general anesthesia still represents the standard when performing thoracic surgery, the interest toward alternative methods is increasing. These have evolved from the employ of just local or regional analgesia techniques in completely alert patients (awake thoracic surgery), to more complex protocols entailing conscious sedation and spontaneous ventilation. The main rationale of these methods is to prevent serious complications related to general anesthesia and selective ventilation, such as tracheobronchial injury, acute lung injury, and cardiovascular events. Trends toward shorter hospitalization and reduced overall costs have also been indicated in preliminary reports. Monitored anesthesia care in thoracic surgery can be successfully employed to manage diverse oncologic conditions, such as malignant pleural effusion, peripheral lung nodules, and mediastinal tumors. Main non-oncologic indications include pneumothorax, emphysema, pleural infections, and interstitial lung disease. Furthermore, as the familiarity with this surgical practice has increased, major operations are now being performed this way. Despite the absence of randomized controlled trials, there is preliminary evidence that monitored anesthesia care protocols in thoracic surgery may be beneficial in high-risk patients, with noninferior efficacy when compared to standard operations under general anesthesia. Monitored anesthesia care in thoracic surgery should enter the armamentarium of modern thoracic surgeons, and adequate training should be scheduled in accredited residency programs.

Nonintubated VATS talc pleurodesis can achieve similar results in pleural effusion to the same operation performed under general anesthesia but with earlier improvement of some quality-of-life domains as well as better mortality, morbidity, hospital stay, and costs.

In recent years, non-intubated video-assisted thoracic surgery (NIVATS) strategies are gaining popularity worldwide. The main goal of this surgical practice is to achieve an overall improvement of patients' management and outcome thanks to the avoidance of side-effects related to general anesthesia (GA) and one-lung ventilation. The spectrum of expected benefits is multifaceted and includes reduced postoperative morbidity, faster discharge, decreased hospital costs and a globally reduced perturbation of patients' well-being status. We have conducted a literature search to evaluate the available evidence on this topic. Meta-analysis of collected results was also done where appropriate. Despite some fragmentation of data and potential biases, the available data suggest that NIVATS operations can reduce operative morbidity and hospital stay when compared to equipollent procedures performed under GA. Larger, well designed prospective studies are thus warranted to assess the effectiveness of NIVATS as far as to investigate comprehensively the various outcomes. Multi-institutional and multidisciplinary cooperation will be welcome to establish uniform study protocols and to help address the questions that are to be answered yet.Keywords: Non-intubated thoracic surgery; video-assisted thoracic surgery (VATS); awake VATS; regional more dangerous in patients with pre-existing pulmonary disease. Other well-known side-effects of GA and one-lung ventilation include-but are not limited to-induction of cardiac arrhythmias (16), transient hypoxemia, injury to liver and kidney, cognitive deterioration, and impairment in perioperative immunosurveillance (17). Mechanical airway injury secondary to double-lumen tube insertion should be also taken into account, even though the estimated incidence of airway laceration is extremely low (18).The rationale of NIVATS is that avoidance of one-lung ventilation may help achieve a reduction in perioperative morbidity, particularly in subjects with poor cardiorespiratory performance. Accordingly, it is not surprising that most of the earliest NIVATS experiences consisted of small caseseries dealing with management of patients with chronic respiratory failure or other comorbidity.A paradigm shift is-however-being observed more recently and in some centers, adoption of NIVATS is being progressively extended to patients without any substantial risk factor for GA and one-lung ventilation.Indeed, in a recent survey from the European Society of Thoracic Surgeons, 70% of responders believed that ideal candidates for NIVATS are patients with multiple comorbidities although it is worth noting that 20% of them affirmed to be also favorable to the use of NIVATS regardless of patients ' comorbidity profile (19). This strategy appears to be justified when taking into account benefits other than protection from postoperative complications, which include reduced hospital stay, better quality of recovery and lower procedure-related costs. Furthermore, a lesser perturbation of immune and endocrine s...