Uniportal video-assisted thoracic surgery colorectal lung metastasectomy in non-intubated anesthesia

Abstract

Background: More than ten years ago we started a program of video-assisted thoracic surgery (VATS) lung metastasectomy in non-intubated local anesthesia. In this study we investigated the effectiveness and long term results of this combined surgical-anesthesiological technique. Methods: Between 2005 and 2014, 48 patients (25 men and 23 women) with pulmonary oligometastases from colorectal cancer, at the first episode, underwent VATS metastasectomy under non-intubated local anesthesia. Three patients required intubation for intolerance. In the same period 13 patients scheduled for non-intubated metastasectomy refused awake surgery and were used as a control group. Results: The two groups were homogeneous for both demographic and pathological features. Mean number of lesions resected per patient were 1.51 (non-intubated) vs. 1.77 (control), respectively (P=0.1). The oxygenation was significantly lower in the non-intubated group especially at the end of the procedure, but the values inverted from the first postoperative hour. There was no mortality in any groups. The non-intubated group demonstrated a significant shorter overall operating time (P=0.04), better quality of recovery after both 24 (P=0.04) and 48 hours (P=0.04), shorter median hospital stay (P=0.03) and lower estimated costs (P=0.03), even excluding the hospital stay. Major morbidity rate was lower (6% vs. 23%) yet not significant (P=0.1). Both disease free survival and overall survival were similar between groups. Conclusions: VATS lung metastasectomy in non-intubated local anesthesia was safely performed in selected patients with oligometastases with significant advantages in overall operative time, hospital stay and economical costs. Morbidity rate was lower yet not significant. Long term results were similar.

A glance at the history of uniportal video-assisted thoracic surgery

“…Our recent studies showed that the same effects of lower immunological suppression and reduced inflammatory response can be detected when comparing uniVATS and multiport VATS (68). As a consequence, given the lower trauma of uniVATS, it is hypothesizable that this technique could favor an improved long-term survival and impact on tumor recurrence in patients with primary or secondary lung cancers (69).…”

“…It is, to our knowledge, the first dedicated to nonintubated thoracic surgery in the literature. During more than a decade this program achieved a consistent amount of knowledge about the surgery in awake patients and produced a great number of scientific publications (68,69,81,84,(95)(96)(97)(98)(99)(100)(101)(102)(103)(104)(105). In our program we initially privileged anesthesia delivered through an epidural catheter with a fully awake and collaborative patient (96)(97)(98)(99).…”

“…In this way we achieved the neurological surveillance that we consider a physiological pattern of monitoring. In our more recent nonintubated experiences we used an intercostal selective block that is simpler and quicker but equally effective in achieving thoracic analgesia (69,102).…”

Uniportal non-intubated lung metastasectomy

“…The reduction of the surgical accesses now possible through the development of high definition camera, energy devices, multi-articulated endoscopic stapler, represents an indubitable advantage in patients under non-intubated anesthesia. We have recently published the results of this mixed surgical/anesthesiologic approach demonstrating better early and similar long-term outcomes when compared with traditional intubated multiport-VATS metastasectomy (33).…”

Immunological and Inflammatory Impact of Non-Intubated Lung Metastasectomy

“…Surgery of lung metastases has been performed since the beginning of our experience [ 9 ]. Early operations were done under epidural anesthesia and three-port video-assisted thoracic surgery (VATS) [ 10 ] but starting from 2005, lung metastasectomies have been preferably accomplished through a unique thoracoscopic access under non-intubated anesthesia [ 11 ].…”