Thoracoscopy in Pleural Effusion – Two Techniques: Awake Single-Access Video-Assisted Thoracic Surgery Versus 2-Ports Video-Assisted Thoracic Surgery Under General Anesthesia

Abstract

Awake single access video-assisted thoracic surgery with local anesthesia improves procedure tolerance, reduces postoperative stay and costs. Materials & methods: Local anesthesia was made with lidocaine and ropivacaine. We realize one 20 mm incision for the 'single-access', and two incisions for the '2-trocars technique'. Results: Mortality rate was 0% in both groups. Postoperative stay: 3dd ± 4 versus 4dd ± 5, mean operative time: 39 min versus 37 min (p < 0.05). Chest tube duration: 2dd ± 5 versus 3dd ± 6. Complications: 11/95 versus 10/79. Conclusion: Awake technique reduce postoperative hospital stay and chest drainage duration, similar complications and recurrence rate. The authors can say that 'awake single-access VATS' is an optimal diagnostic and therapeutic tool for the management of pleural effusions, but above extends surgical indication to high-risk patients. KEYWORDS• awake VATS • pleural effusion • single port • VATSThe history of video-assisted thoracic surgery (VATS) utilizing the local anesthesia and sedation is almost one century old with Jacobeus and Bethune [1].The authors started an 'awake single port VATS' program because they hypothesized that the use of just one access associated with local anesthesia might be feasible and could result in a better procedure acceptance, in a more rapid recovery, in a reduced procedure-related cost and in a more less invasive procedure.A single access associated with local anesthesia aims to improve procedure tolerance, shorten recovery and reduce costs. Materials & methodsThe authors retrospectively analyzed 174 patients with pleural effusion treated by awake technique or general anaesthesia. At admission, patients underwent complete laboratory assay, blood gases, chest roentgenograms, ectrocardiogram and eventually chest computed tomography (CT) scan and cardiological evaluation. An informed consent was obtained from all patients, including possibility of endotracheal intubation and thoracotomy. Premedication consisted in atropine 0.01 mg/kg and ondansetron 8 mg. Pain control and sedation were obtained by remifentanile (0.05-0.1 μg/kg/min) and midazolam (0.02-0.04 mg/kg). In the operating room, the patient was turned to a full lateral decubitus position and the table was flexed to widen the rib spaces on the operation side. A small antidecubitus mattress was placed below the dependent hemitorax to obtain a slight splitting of intercostal spaces without patient's discomforts. The position of the lonely trocar was usually defined with the help of utrasound (US). The using of US to choose the site of access was a rapid and safe method that helped to visualize the pleural effusion and that guided the operator to define the site of access, keeping away from some 'hazardous areas.' A line which included the plan of incision was drawn and the standard antiseptic procedure was performed. Local anesthesia was obtained with For reprint orders, please contact: reprints@futuremedicine.com

Non-intubated video-assisted thoracic surgery: where does evidence stand?

“…The authors found a significant decrease in postoperative complications as well as in many other perioperative outcome measures including quality of life scores and hospital stay. Similar results came from Cajozzo et al (27). Finally in a controlled study from Tacconi et al (40), no substantial difference in morbidity rate was found with either NIVATS or GAVATS decortication for stage II pleural empyemas.…”

“…Other non-randomized studies reported significant differences in hospital stay in the settings of pleural effusion (27,40), pulmonary metastasectomy (42) and secondary PNX (36). On contrary, Wu et al (33) in their study on NIVATS lobectomy in a geriatric population failed to demonstrate any difference in hospital stay length (33).…”

Non-intubated video-assisted thoracoscopic surgery vs. intubated video-assisted thoracoscopic surgery for thoracic disease: a systematic review and meta-analysis of 1,684 cases

“…A flow diagram depicting the selection of eligible studies according to the PRISMA guidelines is shown in Figure 1 After the exclusion of 288 studies that did not meet our inclusion criteria, 15 eligible studies (12,15,(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34) were screened out for meta-analyses. One study was published in Chinese, and 14 studies were published in English.…”

“…Thirteen studies(12,15,22,(24)(25)(26)(27)(28)(29)(31)(32)(33)(34) with complete postoperative complication data were included in the analysis. As the heterogeneity between studies was acceptable (I 2 statistic =23%, P=0.20), the fixed-effect model was adopted for this meta-analysis.…”

Awake video-assisted thoracoscopic surgery

“…VATS daha az ağrı, daha az komplikasyon, daha kısa hastanede kalış süresi ve daha hızlı iyileşme süresi nedeniyle minimal invazif bir cerrahi girişimdir. Bununla birlikte, NI-VATS tekniğinin birçok göğüs cerrahi operasyonunda başarıyla uygulanabileceği mevcut literatürde iyi bilinmektedir (6)(7)(8).…”