From Open Operations to Nonintubated Uniportal Video-Assisted Thoracoscopic Lobectomy: Minimizing the Trauma to the Patient Diego Gonzalez-Rivas, MD, FECTS, Humberto Aymerich, MD, Cesar Bonome, MD, and Eva Fieira, MD Minimally Invasive Thoracic Surgery Unit (UCTMI), Coru~ na; Department of Thoracic Surgery, Coru~ na University Hospital, Coru~ na; Department of Anesthesia, Quir on Hospital, Coru~ na; and Department of Anesthesia, San Rafael Hospital, Coru~ na, Spain
V
ideo-assisted thoracic surgery (VATS) has become, in the last 2 decades, a revolution in the treatment of lung pathologies [1]. Because its approach is less invasive, the uniportal approach for VATS has emerged as a novel technique applicable to a large spectrum of thoracic diseases, from simply diagnostic procedures to the treatment of lung cancer [2–4]. As thoracic surgical techniques continue to evolve, we can see the emergence of new anesthetic and surgical approaches in the perioperative management of these patients [5]. Only a decade ago, there was no discussion regarding the optimal anesthetic management for thoracoscopic major pulmonary resections, and general anesthesia and thoracic epidural analgesia with single-lung ventilation using double-lumen endotracheal tube was the standard technique [6]. Surgical advances, such as VATS, allowed us to consider new possibilities: no epidural catheter, no invasive monitoring (central venous pressure, blood pressure, urinary catheter), and no general anesthesia [7–11]. The thoracoscopic operation in an awake patient provides a new approach, as different clinical cases of diverse pathologic entities are now performed under such circumstances. Nezu and colleagues [12] reported the first cases in 1997 using local anesthesia to perform minor pulmonary resections in the awake patient, and in 2007, the first nonintubated VATS lobectomy was reported [13]. Currently, the evolution of VATS to less invasive techniques, such as the uniportal VATS, may cause surgeons to reconsider the possibility of avoiding general intubated anesthesia for lobectomy. Although operations for pulmonary resection have become less invasive and more parenchymal sparing over time, anesthesia has evolved more slowly. Today, we have anesthetics with pharmacologic characteristics that allow us a high anesthetic depth with little influence on the time of awakening (propofol, desflurane, and remifentanil, among others). We also have devices for monitoring the depth of anesthesia, including bispectral index monitoring and entropy, that guide us in the administration of the right dose of anesthetics, preventing intraoperative Address correspondence to Dr Gonzalez-Rivas, Department of Thoracic Surgery, Coru~ na University Hospital, Xubias 84, 15006 Coru~ na, Spain; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
awareness without prolonging recovery times [14–16]. Other devices, such as the analgesia/nociception index, allow us to determine the analgesic efficacy of locoregional anesthetic techniques or whether more analgesics are needed for control of intraoperative surgical stimulation and to avoid postoperative pain [17, 18]. As with the development of any new technique, the key to success is the training and commitment of every member of the surgical team (surgeons, anesthesiologists, nurses, etc). It is important to make sure that everyone involved understands the technique and the reason for its development, considering the unavoidable effects (prolonged time in the theater, complications, etc) that arise during the learning curve as the surgical team is able to reduce the incidences of conversion to general anesthesia. In experienced groups, the rate of conversion to general anesthesia is less than 5%, and the most frequent causes are strong adhesions, mediastinal movement, bleeding, changes in the surgical plan, hypoxemia, suboptimal analgesia, and intractable cough. Our conversion rate to general anesthesia and intubation was 6.6% during the first 30 uniportal VATS lobectomies and nowadays is only 3%. Fatalities such as cardiac arrest are lower than 0.1% [11, 19]. In most operations, the volume effect of the hospital and the number of interventions performed by a particular surgeon are related to patient survival [20–22]. In VATS operations performed under general anesthesia and 1-lung ventilation, experience may not be a determinant variable in the postoperative course of patients [23]. Although the required minimum experience for VATS in nonintubated patients is not defined, the influence of mediastinal and diaphragmatic movement can interfere with hilar dissection, and surgeons with little experience in VATS may require conversion to general anesthesia [19]. Recent publications show a low rate of conversion to general anesthesia and a low incidence of complications in nonintubated major resections when performed by experienced VATS surgeons [19]. There is an important difference between the performance of minor procedures and anatomic resections in nonintubated patients. The risk of a surgical complication during a wedge resection is significantly lower than the risk posed by bleeding in the pulmonary hilum during Ann Thorac Surg 2015;100:2003–5 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.07.092
2004
EDITORIAL GONZALEZ-RIVAS ET AL NONINTUBATED UNIPORTAL: MINIMIZING PATIENT TRAUMA
a lobectomy in a patient under spontaneous ventilation. The fear of uncontrolled bleeding in nonintubated patients is one of the main obstacles to the worldwide adoption of this technique. Initially described to reduce trauma to the patient, improve outcomes, and reduce costs, only two groups really reported large series of patients undergoing nonintubated VATS for major pulmonary resections in lung cancer [24, 25]. The authors in both publications describe the use of several incisions, epidural blockade or infiltration of several intercostal spaces, and vagus block to avoid coughing. In recent years, however, VATS has evolved from a multiport to a single-incision approach, representing a less invasive way to operate on lung pathologies [4]. Uniportal or single-incision VATS has been shown to reduce postoperative pain, residual paresthesia, and hospital stay compared with conventional multiport VATS [3]. Our group described the uniportal technique for lobectomy in 2010 and published the first nonintubated uniportal VATS lobectomy in a patient with lung cancer in 2014 [4, 9, 10]. The choice of a single incision technique combined with the avoidance of general anesthesia could minimize even more the invasiveness of the procedure [9, 19, 24]. In our experience, the quality of the pulmonary collapse obtained by iatrogenic pneumothorax during VATS under spontaneous breathing is at least as good as in mechanical ventilation using a double-lumen endotracheal tube. The mechanism of performing this lung collapse is more physiologic through a small intercostal incision than by 1-lung mechanical ventilation, and that would result less lung inflammation and stress, with possibly better postoperative recovery and outcome [26]. Single-lung ventilation under spontaneous breathing also preserves a better match of perfusion/ventilation in surgical position and avoids intubation-related airway trauma, mechanical ventilation–induced lung injury, residual muscular blockade, and postoperative nausea and vomiting [24, 25]. In practice, we do not find that hypoxemia and hypercapnia are limiting factors during operations with a correct preoperative selection of the patients. Oxygen (6 to 9 L/min) is supplied through a facial mask or nasal cannula, which we prefer instead a laryngeal mask, because the less tight the airways, the better the lung collapse. Another advantage of the maintenance of negative intrathoracic pressure due to spontaneous breathing is a better hemodynamic control, with no decrease of venous return related with positive intrathoracic pressure during mechanical ventilation. Data from preliminary studies also suggest an attenuated stress response after awake VATS compared with equivalent procedure performed under general anesthesia and 1-lung mechanical ventilation [26, 27]. Our initial results suggest that single intercostal infiltration using direct thoracoscopic view, vagus blockade, and topical anesthesia on the surface of the lung and hilum is enough management for the uniportal approach. After testing different drugs, trying to find the lowest
Ann Thorac Surg 2015;100:2003–5
accurate concentration of local anesthetics to avoid toxic doses with the use of 30 to 50 mL during the entire surgical procedure, we use a mixture of lidocaine 1% and levobupivacaine 0.2%, which ensures at the same time fast onset of action and prolonged analgesia. The importance of avoiding epidural thoracic blockade is obvious. If we are able to control postoperative pain without opioids, the patient will be able to return faster to daily activities. Other advantages are the absence of epidural-related trauma and complications, the avoidance of unbalanced parasympathetic activity due to sympathetic block, which could trigger cough reflex and bronchial hyper-reactivity, and easier control of hemodynamic stability. Other important situations that contraindicate performing an epidural thoracic anesthesia relate to the frequent use of some medicines (b-blockers, anticoagulants, antiplatelets) and some concomitant diseases (first or second atrioventricular block, use of intercostal muscles for ventilating, etc) in our patients [28]. These nonintubated major pulmonary resections must only be performed by very experienced thoracoscopic surgeons, preferably skilled and experienced with complex or advanced cases and bleeding control through uniportal VATS. We consider it very important to reduce the surgical and anesthetic trauma in high-risk patients such as elderly patients or those with poor pulmonary function. Standard monitoring must include electrocardiogram, noninvasive blood pressure, pulse oximetry, and respiratory rate, with an approximation of the end-tidal carbon dioxide with a catheter placed in 1 nostril. Monitoring the adequacy of ventilation and the depth of sedation by using the bispectral index, entropy, or similar devices is also highly recommended. Pharmacologic management is based on a targetcontrolled infusion of remifentanil and propofol, with a premedication of midazolam (0.15 to 0.25 mg/kg) and atropine (0.01 mg/kg) 15 minutes before anesthesia, adjusting the real-time rate of infusion with the aggressiveness of each period during the operation. The use of a nebulization of 5 mL lidocaine 2% for 30 minutes helps to avoid coughing that could be troublesome when performing lung traction and intense hilar manipulation during the operation. The patients often receive nothing more than nonsteroid antiinflammatories in the postoperative period [9]. It is very important to perform a careful selection of the patients, especially during the learning curve, and to try to avoid all contraindications to monitored anesthesia care in thoracic operations [11]. Current reported studies support the contraindication of awake uniportal VATS for expected difficult airway management patients, obesity (body mass index >30 kg/m2), dense and extensive pleural adhesions, hemodynamically unstable patients, ASA>II (American Society of Anesthesiologists Physical Status Classification), and tumors larger than 6 cm [27]. When intraoperative conversion to intubated general anesthesia is needed, the surgical team must have a concise plan to minimize the risk to the patient.
Ann Thorac Surg 2015;100:2003–5
In case of complications such as major bleeding, significant mediastinal movement, or persistent hypoxemia and tachypnea, early conversion to intubated general anesthesia is suggested. We recommend the insertion of a double-lumen tube and maintaining the lateral decubitus position for expert and skilled anesthesiologists or, if that is not possible, intubation with single-lumen tube, followed by insertion of a bronchial blocker trying to maintain the patient’ position. Once a larger series of patients has undergone nonintubated VATS resections, a gold-standard technique will be defined, and patients will bypass intensive care units and be discharged home early with a lower incidence of surgical and anesthesia-related complications.
EDITORIAL GONZALEZ-RIVAS ET AL NONINTUBATED UNIPORTAL: MINIMIZING PATIENT TRAUMA
13.
14. 15. 16.
17. 18.
References 1. Ng CS, Lau KK, Gonzalez-Rivas D, Rocco G. Evolution in surgical approach and techniques for lung cancer. Thorax 2013;68:681. 2. Bertolaccini L, Rocco G, Viti A, Terzi A. Geometrical characteristics of uniportal VATS. J Thorac Dis 2013;5:214–6. 3. Jutley RS, Khalil MW, Rocco G. Uniportal vs standard threeport VATS technique for spontaneous pneumothorax: comparison of post-operative pain and residual paraesthesia. Eur J Cardiothorac Surg 2005;28:43–6. 4. Gonzalez-Rivas D, Paradela M, Fernandez R, et al. Uniportal video-assisted thoracoscopic lobectomy: two years of experience. Ann Thorac Surg 2013;95:426–32. 5. Katlic MR. Video-assisted thoracic surgery utilizing local anesthesia and sedation. Eur J Cardiothorac Surg 2006;30: 529–32. 6. Von Dossow V, Welte M, Zaune U, et al. Thoracic epidural anesthesia combined with general anesthesia: the preferred anesthetic technique for thoracic surgery. Anesth Analg 2001;92:848–54. 7. Yang JT, Hung MH, Chen JS, Cheng YJ. Anesthetic consideration for nonintubated vats. J Thorac Dis 2014;6:10–3. 8. Pompeo E. State of the art and perspectives in non-intubated thoracic surgery. Ann Transl Med 2014;2:106. 9. Gonzalez-Rivas D, Fernandez R, de la Torre M, Rodriguez JL, Fontan L, Molina F. Single-port thoracoscopic lobectomy in a nonintubated patient: the least invasive procedure for major lung resection? Interact Cardiovasc Thorac Surg 2014;19: 552–5. 10. Gonzalez-Rivas D, De la Torre M, Fernandez R, Bonome C. Uniportal video-assisted thoracoscopic left upper lobectomy under spontaneous ventilation. J Thorac Dis 2015;7:494–5. 11. Mineo TC, Tacconi F. From “awake” to “monitored anesthesia care” thoracic surgery: a 15 year evolution. Thorac Cancer 2014;5:1–13. 12. Nezu K, Kushibe K, Tojo T, et al. Thoracoscopic wedge resection of blebs under local anesthesia with sedation for
19.
20.
21.
22.
23. 24.
25. 26. 27.
28.
2005
treatment of a spontaneous pneumothorax. Chest 1997;111: 230–5. Al-Abdullatief M, Wahood A, Al-Shirawi N, et al. Awake anaesthesia for major thoracic surgical procedures: an observational study. Eur J Cardiothorac Surg 2007;32: 346–50. O’Connor MF, Daves SM, Tung A, Cook RI, Thisted R, Apfelbaum J. BIS monitoring to prevent awareness during general anesthesia. Anesthesiology 2001;94:520–2. Sear JW, Brown WE. Research into new drugs in anesthesia: then & now. Anesth Analg 2012;115:233–4. Shalbaf R, Behnam H, Sleigh JW, Steyn-Ross A, Voss LJ. Monitoring the depth of anesthesia using entropy features and an artificial neural network. J Neurosci Methods 2013;218:17–24. Ly-Liu D, Reinoso-Barbero F. Immediate postoperative pain can also be predicted by pupillary pain index in children. Br J Anaesth 2015;114:345–6. Boselli E, Bouvet L, Begou G, Torkmani S, Allaouchiche B. Prediction of hemodynamic reactivity during total intravenous anesthesia for suspension laryngoscopy using analgesia/nociception index (ANI): a prospective observational study. Minerva Anestesiol 2015;81:288–97. Gonzalez-Rivas D, Bonome C, Fieira E, et al. Non-intubated video-assisted thoracoscopic lung resections: the future of thoracic surgery? Eur J Cardiothorac Surg 2015; [Epub ahead of print], http://dx.doi.org/10.1093/ejcts/ezv136. Brusselaers N, Mattsson F, Lagergren J. Hospital and surgeon volume in relation to long-term survival after oesophagectomy: systematic review and meta-analysis. Gut 2014;63:1393–400. Rogers SO Jr, Wolf RE, Zaslavsky AM, Wright WE, Ayanian JZ. Relation of surgeon and hospital volume to processes and outcomes of colorectal cancer surgery. Ann Surg 2006;244:1003–11. Derogar M, Sadr-Azodi O, Johar A, Lagergren P, Lagergren J. Hospital and surgeon volume in relation to survival after esophageal cancer surgery in a population based study. J Clin Oncol 2013;31:551–7. Iwasaki A, Yamamoto S, Shiraishi T, Shirakusa T. How much skill should we need for a vats lobectomy in stage I lung cancer? An evaluation of surgeon groups. Int Surg 2008;93:169–74. Chen KC, Cheng YJ, Hung MH, Tseng YD, Chen JS. Nonintubated thoracoscopic surgery using regional anesthesia and vagal block and targeted sedation. J Thorac Dis 2014;6: 31–6. Dong Q, Liang L, Li Y, et al. Anesthesia with nontracheal intubation in thoracic surgery. J Thorac Dis 2012;4:126–30. Tacconi F, Pompeo E, Sellitri F, Mineo TC. Surgical stress hormones response is reduced after awake videothoracoscopy. Interact Cardiovasc Thorac Surg 2010;10:666–71. Chen KC, Cheng YJ, Hung MH, Tseng YD, Chen JS. Nonintubated thoracoscopic lung resection: a 3-year experience with 285 cases in a single institution. J Thorac Dis 2012;4: 347–51. Mineo TC. Epidural anesthesia in awake thoracic surgery. Eur J Cardiothorac Surg 2007;32:13–9.
V
ideo-assisted thoracic surgery (VATS) has become, in the last 2 decades, a revolution in the treatment of lung pathologies [1]. Because its approach is less invasive, the uniportal approach for VATS has emerged as a novel technique applicable to a large spectrum of thoracic diseases, from simply diagnostic procedures to the treatment of lung cancer [2–4]. As thoracic surgical techniques continue to evolve, we can see the emergence of new anesthetic and surgical approaches in the perioperative management of these patients [5]. Only a decade ago, there was no discussion regarding the optimal anesthetic management for thoracoscopic major pulmonary resections, and general anesthesia and thoracic epidural analgesia with single-lung ventilation using double-lumen endotracheal tube was the standard technique [6]. Surgical advances, such as VATS, allowed us to consider new possibilities: no epidural catheter, no invasive monitoring (central venous pressure, blood pressure, urinary catheter), and no general anesthesia [7–11]. The thoracoscopic operation in an awake patient provides a new approach, as different clinical cases of diverse pathologic entities are now performed under such circumstances. Nezu and colleagues [12] reported the first cases in 1997 using local anesthesia to perform minor pulmonary resections in the awake patient, and in 2007, the first nonintubated VATS lobectomy was reported [13]. Currently, the evolution of VATS to less invasive techniques, such as the uniportal VATS, may cause surgeons to reconsider the possibility of avoiding general intubated anesthesia for lobectomy. Although operations for pulmonary resection have become less invasive and more parenchymal sparing over time, anesthesia has evolved more slowly. Today, we have anesthetics with pharmacologic characteristics that allow us a high anesthetic depth with little influence on the time of awakening (propofol, desflurane, and remifentanil, among others). We also have devices for monitoring the depth of anesthesia, including bispectral index monitoring and entropy, that guide us in the administration of the right dose of anesthetics, preventing intraoperative Address correspondence to Dr Gonzalez-Rivas, Department of Thoracic Surgery, Coru~ na University Hospital, Xubias 84, 15006 Coru~ na, Spain; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
awareness without prolonging recovery times [14–16]. Other devices, such as the analgesia/nociception index, allow us to determine the analgesic efficacy of locoregional anesthetic techniques or whether more analgesics are needed for control of intraoperative surgical stimulation and to avoid postoperative pain [17, 18]. As with the development of any new technique, the key to success is the training and commitment of every member of the surgical team (surgeons, anesthesiologists, nurses, etc). It is important to make sure that everyone involved understands the technique and the reason for its development, considering the unavoidable effects (prolonged time in the theater, complications, etc) that arise during the learning curve as the surgical team is able to reduce the incidences of conversion to general anesthesia. In experienced groups, the rate of conversion to general anesthesia is less than 5%, and the most frequent causes are strong adhesions, mediastinal movement, bleeding, changes in the surgical plan, hypoxemia, suboptimal analgesia, and intractable cough. Our conversion rate to general anesthesia and intubation was 6.6% during the first 30 uniportal VATS lobectomies and nowadays is only 3%. Fatalities such as cardiac arrest are lower than 0.1% [11, 19]. In most operations, the volume effect of the hospital and the number of interventions performed by a particular surgeon are related to patient survival [20–22]. In VATS operations performed under general anesthesia and 1-lung ventilation, experience may not be a determinant variable in the postoperative course of patients [23]. Although the required minimum experience for VATS in nonintubated patients is not defined, the influence of mediastinal and diaphragmatic movement can interfere with hilar dissection, and surgeons with little experience in VATS may require conversion to general anesthesia [19]. Recent publications show a low rate of conversion to general anesthesia and a low incidence of complications in nonintubated major resections when performed by experienced VATS surgeons [19]. There is an important difference between the performance of minor procedures and anatomic resections in nonintubated patients. The risk of a surgical complication during a wedge resection is significantly lower than the risk posed by bleeding in the pulmonary hilum during Ann Thorac Surg 2015;100:2003–5 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.07.092
2004
EDITORIAL GONZALEZ-RIVAS ET AL NONINTUBATED UNIPORTAL: MINIMIZING PATIENT TRAUMA
a lobectomy in a patient under spontaneous ventilation. The fear of uncontrolled bleeding in nonintubated patients is one of the main obstacles to the worldwide adoption of this technique. Initially described to reduce trauma to the patient, improve outcomes, and reduce costs, only two groups really reported large series of patients undergoing nonintubated VATS for major pulmonary resections in lung cancer [24, 25]. The authors in both publications describe the use of several incisions, epidural blockade or infiltration of several intercostal spaces, and vagus block to avoid coughing. In recent years, however, VATS has evolved from a multiport to a single-incision approach, representing a less invasive way to operate on lung pathologies [4]. Uniportal or single-incision VATS has been shown to reduce postoperative pain, residual paresthesia, and hospital stay compared with conventional multiport VATS [3]. Our group described the uniportal technique for lobectomy in 2010 and published the first nonintubated uniportal VATS lobectomy in a patient with lung cancer in 2014 [4, 9, 10]. The choice of a single incision technique combined with the avoidance of general anesthesia could minimize even more the invasiveness of the procedure [9, 19, 24]. In our experience, the quality of the pulmonary collapse obtained by iatrogenic pneumothorax during VATS under spontaneous breathing is at least as good as in mechanical ventilation using a double-lumen endotracheal tube. The mechanism of performing this lung collapse is more physiologic through a small intercostal incision than by 1-lung mechanical ventilation, and that would result less lung inflammation and stress, with possibly better postoperative recovery and outcome [26]. Single-lung ventilation under spontaneous breathing also preserves a better match of perfusion/ventilation in surgical position and avoids intubation-related airway trauma, mechanical ventilation–induced lung injury, residual muscular blockade, and postoperative nausea and vomiting [24, 25]. In practice, we do not find that hypoxemia and hypercapnia are limiting factors during operations with a correct preoperative selection of the patients. Oxygen (6 to 9 L/min) is supplied through a facial mask or nasal cannula, which we prefer instead a laryngeal mask, because the less tight the airways, the better the lung collapse. Another advantage of the maintenance of negative intrathoracic pressure due to spontaneous breathing is a better hemodynamic control, with no decrease of venous return related with positive intrathoracic pressure during mechanical ventilation. Data from preliminary studies also suggest an attenuated stress response after awake VATS compared with equivalent procedure performed under general anesthesia and 1-lung mechanical ventilation [26, 27]. Our initial results suggest that single intercostal infiltration using direct thoracoscopic view, vagus blockade, and topical anesthesia on the surface of the lung and hilum is enough management for the uniportal approach. After testing different drugs, trying to find the lowest
Ann Thorac Surg 2015;100:2003–5
accurate concentration of local anesthetics to avoid toxic doses with the use of 30 to 50 mL during the entire surgical procedure, we use a mixture of lidocaine 1% and levobupivacaine 0.2%, which ensures at the same time fast onset of action and prolonged analgesia. The importance of avoiding epidural thoracic blockade is obvious. If we are able to control postoperative pain without opioids, the patient will be able to return faster to daily activities. Other advantages are the absence of epidural-related trauma and complications, the avoidance of unbalanced parasympathetic activity due to sympathetic block, which could trigger cough reflex and bronchial hyper-reactivity, and easier control of hemodynamic stability. Other important situations that contraindicate performing an epidural thoracic anesthesia relate to the frequent use of some medicines (b-blockers, anticoagulants, antiplatelets) and some concomitant diseases (first or second atrioventricular block, use of intercostal muscles for ventilating, etc) in our patients [28]. These nonintubated major pulmonary resections must only be performed by very experienced thoracoscopic surgeons, preferably skilled and experienced with complex or advanced cases and bleeding control through uniportal VATS. We consider it very important to reduce the surgical and anesthetic trauma in high-risk patients such as elderly patients or those with poor pulmonary function. Standard monitoring must include electrocardiogram, noninvasive blood pressure, pulse oximetry, and respiratory rate, with an approximation of the end-tidal carbon dioxide with a catheter placed in 1 nostril. Monitoring the adequacy of ventilation and the depth of sedation by using the bispectral index, entropy, or similar devices is also highly recommended. Pharmacologic management is based on a targetcontrolled infusion of remifentanil and propofol, with a premedication of midazolam (0.15 to 0.25 mg/kg) and atropine (0.01 mg/kg) 15 minutes before anesthesia, adjusting the real-time rate of infusion with the aggressiveness of each period during the operation. The use of a nebulization of 5 mL lidocaine 2% for 30 minutes helps to avoid coughing that could be troublesome when performing lung traction and intense hilar manipulation during the operation. The patients often receive nothing more than nonsteroid antiinflammatories in the postoperative period [9]. It is very important to perform a careful selection of the patients, especially during the learning curve, and to try to avoid all contraindications to monitored anesthesia care in thoracic operations [11]. Current reported studies support the contraindication of awake uniportal VATS for expected difficult airway management patients, obesity (body mass index >30 kg/m2), dense and extensive pleural adhesions, hemodynamically unstable patients, ASA>II (American Society of Anesthesiologists Physical Status Classification), and tumors larger than 6 cm [27]. When intraoperative conversion to intubated general anesthesia is needed, the surgical team must have a concise plan to minimize the risk to the patient.
Ann Thorac Surg 2015;100:2003–5
In case of complications such as major bleeding, significant mediastinal movement, or persistent hypoxemia and tachypnea, early conversion to intubated general anesthesia is suggested. We recommend the insertion of a double-lumen tube and maintaining the lateral decubitus position for expert and skilled anesthesiologists or, if that is not possible, intubation with single-lumen tube, followed by insertion of a bronchial blocker trying to maintain the patient’ position. Once a larger series of patients has undergone nonintubated VATS resections, a gold-standard technique will be defined, and patients will bypass intensive care units and be discharged home early with a lower incidence of surgical and anesthesia-related complications.
EDITORIAL GONZALEZ-RIVAS ET AL NONINTUBATED UNIPORTAL: MINIMIZING PATIENT TRAUMA
13.
14. 15. 16.
17. 18.
References 1. Ng CS, Lau KK, Gonzalez-Rivas D, Rocco G. Evolution in surgical approach and techniques for lung cancer. Thorax 2013;68:681. 2. Bertolaccini L, Rocco G, Viti A, Terzi A. Geometrical characteristics of uniportal VATS. J Thorac Dis 2013;5:214–6. 3. Jutley RS, Khalil MW, Rocco G. Uniportal vs standard threeport VATS technique for spontaneous pneumothorax: comparison of post-operative pain and residual paraesthesia. Eur J Cardiothorac Surg 2005;28:43–6. 4. Gonzalez-Rivas D, Paradela M, Fernandez R, et al. Uniportal video-assisted thoracoscopic lobectomy: two years of experience. Ann Thorac Surg 2013;95:426–32. 5. Katlic MR. Video-assisted thoracic surgery utilizing local anesthesia and sedation. Eur J Cardiothorac Surg 2006;30: 529–32. 6. Von Dossow V, Welte M, Zaune U, et al. Thoracic epidural anesthesia combined with general anesthesia: the preferred anesthetic technique for thoracic surgery. Anesth Analg 2001;92:848–54. 7. Yang JT, Hung MH, Chen JS, Cheng YJ. Anesthetic consideration for nonintubated vats. J Thorac Dis 2014;6:10–3. 8. Pompeo E. State of the art and perspectives in non-intubated thoracic surgery. Ann Transl Med 2014;2:106. 9. Gonzalez-Rivas D, Fernandez R, de la Torre M, Rodriguez JL, Fontan L, Molina F. Single-port thoracoscopic lobectomy in a nonintubated patient: the least invasive procedure for major lung resection? Interact Cardiovasc Thorac Surg 2014;19: 552–5. 10. Gonzalez-Rivas D, De la Torre M, Fernandez R, Bonome C. Uniportal video-assisted thoracoscopic left upper lobectomy under spontaneous ventilation. J Thorac Dis 2015;7:494–5. 11. Mineo TC, Tacconi F. From “awake” to “monitored anesthesia care” thoracic surgery: a 15 year evolution. Thorac Cancer 2014;5:1–13. 12. Nezu K, Kushibe K, Tojo T, et al. Thoracoscopic wedge resection of blebs under local anesthesia with sedation for
19.
20.
21.
22.
23. 24.
25. 26. 27.
28.
2005
treatment of a spontaneous pneumothorax. Chest 1997;111: 230–5. Al-Abdullatief M, Wahood A, Al-Shirawi N, et al. Awake anaesthesia for major thoracic surgical procedures: an observational study. Eur J Cardiothorac Surg 2007;32: 346–50. O’Connor MF, Daves SM, Tung A, Cook RI, Thisted R, Apfelbaum J. BIS monitoring to prevent awareness during general anesthesia. Anesthesiology 2001;94:520–2. Sear JW, Brown WE. Research into new drugs in anesthesia: then & now. Anesth Analg 2012;115:233–4. Shalbaf R, Behnam H, Sleigh JW, Steyn-Ross A, Voss LJ. Monitoring the depth of anesthesia using entropy features and an artificial neural network. J Neurosci Methods 2013;218:17–24. Ly-Liu D, Reinoso-Barbero F. Immediate postoperative pain can also be predicted by pupillary pain index in children. Br J Anaesth 2015;114:345–6. Boselli E, Bouvet L, Begou G, Torkmani S, Allaouchiche B. Prediction of hemodynamic reactivity during total intravenous anesthesia for suspension laryngoscopy using analgesia/nociception index (ANI): a prospective observational study. Minerva Anestesiol 2015;81:288–97. Gonzalez-Rivas D, Bonome C, Fieira E, et al. Non-intubated video-assisted thoracoscopic lung resections: the future of thoracic surgery? Eur J Cardiothorac Surg 2015; [Epub ahead of print], http://dx.doi.org/10.1093/ejcts/ezv136. Brusselaers N, Mattsson F, Lagergren J. Hospital and surgeon volume in relation to long-term survival after oesophagectomy: systematic review and meta-analysis. Gut 2014;63:1393–400. Rogers SO Jr, Wolf RE, Zaslavsky AM, Wright WE, Ayanian JZ. Relation of surgeon and hospital volume to processes and outcomes of colorectal cancer surgery. Ann Surg 2006;244:1003–11. Derogar M, Sadr-Azodi O, Johar A, Lagergren P, Lagergren J. Hospital and surgeon volume in relation to survival after esophageal cancer surgery in a population based study. J Clin Oncol 2013;31:551–7. Iwasaki A, Yamamoto S, Shiraishi T, Shirakusa T. How much skill should we need for a vats lobectomy in stage I lung cancer? An evaluation of surgeon groups. Int Surg 2008;93:169–74. Chen KC, Cheng YJ, Hung MH, Tseng YD, Chen JS. Nonintubated thoracoscopic surgery using regional anesthesia and vagal block and targeted sedation. J Thorac Dis 2014;6: 31–6. Dong Q, Liang L, Li Y, et al. Anesthesia with nontracheal intubation in thoracic surgery. J Thorac Dis 2012;4:126–30. Tacconi F, Pompeo E, Sellitri F, Mineo TC. Surgical stress hormones response is reduced after awake videothoracoscopy. Interact Cardiovasc Thorac Surg 2010;10:666–71. Chen KC, Cheng YJ, Hung MH, Tseng YD, Chen JS. Nonintubated thoracoscopic lung resection: a 3-year experience with 285 cases in a single institution. J Thorac Dis 2012;4: 347–51. Mineo TC. Epidural anesthesia in awake thoracic surgery. Eur J Cardiothorac Surg 2007;32:13–9.
