State of the art and perspectives in non-intubated thoracic surgery

Non-intubated thoracic surgery (NITS) entails procedures performed through regional anesthesia methods in awake or mildly sedated, spontaneously ventilating patients. The rationale is the avoidance of side-effects of intubated general anesthesia and maintenance of more physiologic muscular, neurologic, and cardiopulmonary status in order to reduce the procedure-related traumas, fasten recovery and optimize outcomes. Preliminary reports including some randomized studies have suggested optimal feasibility of several surgical procedures including management of pleural effusion, of spontaneous pneumothorax, wedge resection of undetermined pulmonary nodules, lung volume reduction surgery (LVRS) for severe emphysema and anatomical lung resection for lung cancer treatment. So far more widely accepted indications for NITS include easy-toperform procedures as well as surgical management of patients with significant risks for intubated general anesthesia. On the other hand, the adoption of NITS for major procedures such as anatomic lung resections and LVRS is still controversial. Further detailed investigation including further randomized trials is expected to help define indications, advantages and limitations of NITS, which might represent excellent ultra-minimally invasive strategies of treatment to be reliably offered in the near future to an increasing number of patients.