Objectives Non-intubated spontaneous ventilation video-assisted thoracic surgery lobectomy is a well-known procedure, but there are doubts regarding its safety. To solve this problem, we developed a safe procedure for spontaneous ventilation thoracic surgery (spontaneous ventilation with intubation). This study analyzed the intraoperative parameters and postoperative results of spontaneous ventilation with intubation. Methods Between March 11, 2020 and March 26, 2021, 38 spontaneous ventilation with intubation video-assisted thoracic surgery lobectomies were performed. We chose the first 38 non-intubated spontaneous ventilation video-assisted thoracic surgery lobectomy cases with a laryngeal mask performed in 2017 for comparison. Results There were no significant differences between the non-intubated spontaneous ventilation and spontaneous ventilation with intubation groups in postoperative surgical results (surgical time: 98,7 vs. 88,1 min (p = 0.067); drainage time: 3.5 vs. 2.7 days (p = 0.194); prolonged air leak 15.7% vs. 10.5% (p = 0.5); conversion rate to relaxation: 5.2% vs. 13.1% (p = 0.237); failure of the spontaneous ventilation rate: 10.5% vs. 13.1% (p = 0.724); and morbidity: 21% vs. 13.1% (p = 0.364)) and oncological outcomes. Significantly lower lowest systolic and diastolic blood pressure (systolic, 83.1 vs 132.3 mmHg, p = 0.001; diastolic 47.8 vs. 73.4 mmHg, p = 0.0001), lowest oxygen saturation (90.3% vs 94.9%, p = 0.026), and higher maximum pCO 2 level (62.5 vs 54.8 kPa, p = 0.009) were found in the non-intubated spontaneous ventilation group than in the spontaneous ventilation with intubation group. Conclusions Spontaneous ventilation with intubation is a more physiological procedure than non-intubated spontaneous ventilation in terms of intraoperative blood pressure stability and gas exchange. The surgical results were similar in the two groups.

BackgroundIn the last few decades, surgical techniques have been developed in thoracic surgery, and minimally invasive strategies such as multi-and uniportal video-assisted thoracic surgery (VATS) have become more favorable even for major pulmonary resections. With this surgical evolution, the aesthetic approach has also changed, and a paradigm shift has occurred. The traditional conception of general anesthesia, muscle relaxation, and intubation has been re-evaluated, and spontaneous breathing plays a central role in our practice by performing non-intubated thoracoscopic surgeries (NITS-VATS).MethodsWe performed a computerized search of the medical literature (PubMed, Google Scholar, Scopus) to identify relevant articles in non-intubated thoracoscopic surgery using the following terms [(non-intubated) OR (non-intubated) OR (awake) OR (tubeless) OR (regional anesthesia)] AND [(VATS) OR (NIVATS)], as well as their Medical Subject Headings (MeSH) terms.ResultsBased on the outcomes of the reviewed literature and our practice, it seems that pathophysiological concerns can be overcome by proper surgical and anesthetic management. All risks are compensated by the advantageous physiological changes that result in better patient outcomes. With the maintenance of spontaneous breathing, the incidence of potential adverse effects of mechanical ventilation, such as ventilator-induced lung injury and consequent postoperative pulmonary complications, can be reduced. The avoidance of muscle relaxants also results in the maintenance of contraction of the dependent hemidiaphragm and lower airway pressure levels, which may lead to better ventilation-perfusion matching. These techniques can be challenging for surgeons as well as for anesthetists; hence, a good knowledge of physiological and pathophysiological changes, clear inclusion and exclusion and intraoperative conversion criteria, and good communication between team members are essential.ConclusionNITS-VATS seems to be a feasible and safe method in selected patients with evolving importance as a part of the minimally invasive surgical and anesthetic conception and has a role in reducing perioperative complications, which is crucial in the thoracic surgical patient population.

Objective: To reveal and review the main effects of mechanical ventilation, anaesthesia, thoracotomy and thoracoscopy on immune responses and clinical outcomes.Background: Several trials reported that intubated video-assisted thoracic surgery (VATS) is associated with favourable recovery time, hospital stay, fewer postoperative complications, better delivery and tolerability of adjuvant chemotherapy in patients with non-small cell lung cancer (NSCLC) as compared to traditional thoracotomy. Recent studies introduced a new approach in thoracic surgery focusing on the immunological outcomes and detrimental effects of thoracotomy and VATS along with patients' clinical benefits.Methods: We reviewed main laboratory and human research based on PubMed database to reveal the immune effects of intubated and non-intubated VATS, mechanical one-lung ventilation (mOLV) and anaesthesia on inflammatory cytokine production, cell responses and clinical outcomes.Conclusions: Although, there are still inconsistencies regarding whether VATS can improve long-term survival and immune responses. VATS results in better preserved immune functions: the postoperative number of natural killer (NK) cells, lymphocytes were less suppressed and the release of immunomodulatory interleukin (IL)-6 and IL-10 were reduced, compared to thoracotomy. Both thoracotomy and VATS are known to induce immune responses, however, these effects can be observed to a different extent as it depends on the modes of surgical technique, mOLV and even general anaesthesia. Thus, non-intubated thoracic surgery (NITS) was developed to avoid harmful immune effects, prevent acute lung injury (ALI) and increase patients' long-term survival. NITS could be also associated with less prominent pro-inflammatory cytokine responses and a preserved lymphocyte cell count postoperatively.

Surgical procedures cause stress, which can induce an inflammatory response and reduce immune function. Following video-assisted thoracoscopic surgery (VATS), non-intubated thoracic surgery (NITS) was developed to further reduce surgical stress in thoracic surgical procedures. This article reviews the pathophysiology of the NITS procedure and its potential for reducing the negative effects of mechanical one-lung ventilation (mOLV). In NITS with spontaneous ventilation, the negative side effects of mOLV are prevented or reduced, including volutrauma, biotrauma, systemic inflammatory immune responses, and compensatory anti-inflammatory immune responses. The pro-inflammatory and anti-inflammatory cytokines released from accumulated macrophages and neutrophils result in injury to the alveoli during mOLV. The inflammatory response is lower in NITS than in relaxed-surgery cases, causing a less-negative effect on immune function. The increase in leukocyte number and decrease in lymphocyte number are more moderate in NITS than in relaxed-surgery cases. The ventilation/perfusion match is better in spontaneous one-lung ventilation than in mOLV, resulting in better oxygenation and cardiac output. The direct effect of relaxant drugs on the acetylcholine receptors of macrophages can cause cytokine release, which is lower in NITS. The locoregional anesthesia in NITS is associated with a reduced cytokine release, contributing to a more physiological postoperative immune function.

Bevezetés A nem intubált spontán légző (NITS) minimál invazív (video-assisted thoracic surgery VATS) eljárás széles körben elterjedt, de felmerülnek kétségek az eljárás biztonságosságával kapcsolatosan. Ennek megoldására fejlesztettünk ki egy új, alacsonyabb kockázatú spontán légző mellkassebészeti módszert (intubált spontán ventilláció – SVI). Vizsgálatunkban az SVI sublobaris reszekciók korai posztoperatív eredményeit mutatjuk be. Anyag és módszer 2020. május 25. és 2021. március 26. között 20 SVI VATS sublobaris reszekciót végeztünk kétlumenű intratrachealis tubus használatával. Eredmények A műtétre került betegek közül 9 nő és 11 férfi, az átlagos életkor 66,1 év, az átlag BMI 27,8, FEV1 89,1%, Carlson Comorbidity Index pedig 6,2 volt. A műtéti idő 61,5 perc volt, a behelyezett mellkasi drain átlagosan 1,85 nap után került eltávolításra. A kórházi ápolási napok száma 3,35 volt. A morbiditásra 5%-os értéket kaptunk. 9 esetben primer tüdődaganat került eltávolításra, 6 metastasectomiát végeztünk, 5 esetben pedig benignus elváltozás miatt történt a műtét. Következtetés A kétlumenű intratrachealis tubus melletti spontán ventillációs VATS sublobaris reszekciók a posztoperatív eredményeik alapján biztonságos mellkassebészeti eljárásnak tarthatók.

Absztrakt: Bevezetés: Retrospektív munkánkban az elmúlt 12 év alatti két, 5 éves időszakban vizsgáltuk a tüdőmetastasisok szövettan szerinti megoszlásában és a metastasectomiák típusában végbement változásokat. Célkitűzés és módszer: Az első csoportban (2006–2010) 55 beteg volt: férfi 54,5% (n = 30), nő 45,5% (n = 25), átlagos életkor 57,9 év (24–80); a második csoportban (2014–2018) 115 beteg volt: férfi 60% (n = 69), nő 40% (n = 46), átlagos életkor 62,2 év (26–82). Eredmények: Az első időszakban a rectumban 19,3%-ban (n = 11), a colonban 17,5%-ban (n = 10), a vesében 14%-ban (n = 8) volt a primer tumor, a második periódusban a colonban 23,1%-ban (n = 31), a rectumban 15,7%-ban (n = 21), a vesében 9%-ban (n = 12). A műtétek megoszlása: atípusos reszekció: 38,6% (n = 22) és 46,3% (n = 62); lobectomia 31,6% (n = 18) és 26,9% (n = 36); pulmonectomia 10,5% (n = 6) és 1,5% (n = 2); segmentectomia 7% (n = 4) és 9,7% (n = 13); bilobectomia 1,8% (n = 1) és 0,7% (n = 1) az első és a második csoportban, egyenként. Az első periódusban végzett ’video-assisted thoracic surgery’ (VATS) műtétek aránya 5,3%-ról (n = 3) a második periódusban 64,9%-ra (n = 87) növekedett. A primer tumor műtéte és a tüdőáttét eltávolítása közötti betegségmentes időszak az első csoportban átlagosan 45,2 hónap (0–144), a másodikban átlagosan 33,8 hónap (0–180) volt. Az első periódusban észlelt 39 hónapos medián túlélés a második csoportban 59 hónapra emelkedett. Az átlagos 5 éves túlélés mindkét csoportunkban 41% volt. Következtetés: Az elmúlt 12 év alatt a tüdőáttétek eltávolításán átesett betegek száma a kétszeresnél is jobban megemelkedett, és jelentősen nőtt a VATS-metastasectomia aránya (5,3% vs. 64,9%). A primer tumoros megoszlásban nem találtunk jelentős eltérést. A medián túlélés a második csoportban némileg jobbnak bizonyult. Orv Hetil. 2020; 161(29): 1215–1220.

Thanks to the growing experience and the improvement of video-assisted thoracoscopic surgery (VATS) technique most pulmonary resections can now be performed by minimally invasive techniques.The present and the future of the thoracic surgery should be associated with a combination of surgical and anaesthetic advancement and improvements to reduce the perioperative surgical stress to the patient.Background: Traditionally intubated, ventilated general anaesthesia with one-lung ventilation was considered necessary for thoracoscopic major pulmonary resections for all patients. An adequate analgesia technique (regional or epidural) allows VATS to be performed in anesthetized patients and the potential adverse effects related to general anaesthesia and mechanical one lung ventilation (mOLV) can be avoided. Methods:A search was carried out on the databases PubMed, Web of Science and The Cochrane Library by means of the (MeSH)terms 'non intubated thoracic surgery', 'spontaneous breathing', 'regional blockade', 'cough reflex', 'mechanical ventilation' and 'pulmonary complications' screened according following inclusion criteria: availability as full text in English, categorization as original research, reviews or metaanalyses. Conclusions:The minimally invasive, non-intubated procedures try to minimize the adverse effects of general anesthesia, tracheal intubation, and mechanical ventilation. Furthermore, patients may have also benefit by preserved hypoxic pulmonary vasoconstriction from the efficient contraction of the dependent hemidiaphragm during surgically induced pneumothorax. The non-intubated anaesthesia combined with the uniportal surgical approach represents one step forward in the minimally invasive strategies of treatment and can be reliable offer to an increasing number of patients. Therefore, educating and training programs in minimally invasive techniques with spontaneous breathing (SB) patients may be needed and the continuous evolution and findings of the better and better anesthetical and surgical methods are vital in reduction of the perioperative complications.

Acute oropharyngeal palsy is a rare variant of Guillain-Barré syndrome. In our study we present the case of a 63-year-old man with general symptoms who was diagnosed with diabetic ketoacidosis and prescribed insulin therapy. Two weeks later, the patient complained of paraesthesia of the perioral region and the tip of the tongue, dysphagia, and dysarthria. These symptoms were initially thought to be complications of the patient’s type-1 diabetes. Due to rapidly developing paraparesis, the patient became bedridden. Clinical symptoms, cerebrospinal fluid analysis and a nerve conduction study resulted in a diagnosis of acute oropharyngeal palsy, a variant of Guillain-Barré syndrome. After five consecutive days of intravenous immunoglobulin treatment, neurological symptoms improved and the need for insulin ceased. One year later, the patient’s only remaining neurological symptom was loss of tendon reflexes in the lower extremities. Furthermore, the patient’s blood glucose level was normal without the use of medications or a special diet. Here, we report that oropharyngeal palsy can co-occur with diabetic ketoacidosis, and that immuntherapy is effective in treating both oropharyngeal palsy and type-1 diabetes. To our knowledge, this is the first description of a patient presenting with acut oropharyngeal palsy concomitant with diabetic ketoacidosis.