Title : Feasibility of non intubated thoracic surgery - Our experience
Abstract:
Uniportal video-assisted thoracoscopic surgery (uniVATS) is the most advanced evolution of minimally invasive surgery, which allows to reduce hospital costs, optimize the therapeutic pathway and to reduce the length of stay. Non-intubated uniVATS procedures allow the performance of surgeries with minimal sedation without general anesthesia, maintaining throughout the operation spontaneous breathing. The principle is to create an iatrogenic spontaneous pneumothorax without the need of a double lumen tube.
The aim of our study was to evaluate the feasibility of this surgical technique considering: postoperative pain control with NSAID or opioid, hospitalization time, incidence of side effects and chronic pain. A total of 37 patients underwent non-intubatated uniVATS minor pulmonary resection. 29 patients were classified as ASA III (78.4%), while the remnant as ASA II (21.6%). The indication to surgery were primary or secondary lung cancer associated with a symptomatic pleural effusion in 29 patients (78.4 %) and pulmonary nodules with no diagnosis in 8 patients (21.6%): in the former cases we performed a wedge resection, pleural biopsy and chemical pleurodesis, in the latter only a wedge resection. Performing the serratus plane block took a mean time of 5 minutes. We evalueted the acute pain level during the first 24 hours after surgery and chronic pain level at 1,3 and 6 months after surgery. We assessed the pain level with the Numeric Rating Scale (NRS) with a significant pain level of NRS>4. During the first 2 hours after surgery in the operation block, there was no basic antalgic therapy and 9 patients had a significant pain level (NRS>4): 5 patients required a single dose of opioid drugs, while 4 patients required a single dose of NSAID. In the conventional ward, all the patients were administrated with an antalgic therapy based on paracetamol with NSAID for breakthrough pain. At 6, 12 and 24 hours after surgery, there were: 2, 3 and 5 patients who respectively had a significant pain level; 1, 2 and 4 patients who respectively required additional drugs for breakthrough pain; 16, 13 and 12 patients who respectively did not need any antalgic therapy. All the patients referred satisfaction about the anesthesiological technique. At 1 month only one patient had significant pain level; at 3 and 6 months no patient had significant pain level among those who did not pass away. We observed an increased effectiveness in terms of postoperative pain control with reduced opioid and NSAID consumption. Reduction in length of stay in the thoracic surgery department due to causes not strictly related to the surgical procedure. Reduction in postoperative side effects. Reduction in the incidence of pain chronicization.
Non-intubated video-assisted thoracoscopic surgery under loco-regional anaesthesia for thoracic surgery proved to be feasible and safe. Future multicentre and well-designed randomized controlled trials with longer follow-up are needed.
