Clinical evaluation of the rapid recovery of patients who underwent video-assisted thoracoscopic lung surgery under non-intubated anesthesia
Introduction
Video assisted thoracic surgery (VATS) gradually be popularized in the past 3 decades, the way of minimally invasive surgery has become a thoracic surgery treatment of lung cancer is the most commonly choice (1). The traditional general anesthesia VATS achieved pulmonary surgery by endotracheal intubation with one-side lung ventilation, endotracheal intubation caused many adverse reactions for rehabilitation of postoperative patients as invasive device (2,3). Non-intubated VATS became the focus of many scholars. Non-intubated VATS, i.e., thoracoscopic surgery without endotracheal intubation by general anesthesia with spontaneous ventilation, is a new approach to this technique of minimally invasive surgery (4,5). Encouragingly, non-intubated anesthesia VATS optimized anesthesia and surgery, enhance recovery after surgery and early hospital discharge, reduce hospitalization cost, etc. (6,7), its clinical outcomes are also significant part of the rapid recovery strategy (8).
In recent years, with the popularization of the concept of enhanced recovery after surgery (ERAS), ERAS strategy, i.e., is a concept of perioperative management, promoting early discharge from hospital for reduce morbidity and costs of the patients ERAS can minimize complications and accelerate recovery by preoperative optimization and evidence-based clinical measures etc. (9,10). Non-intubated VATS have been achieved many clinical rehabilitation advantages, the clinical application of non-intubated anesthesia VATS is still controversial and has only been popularized in some research centers. The combination of non-intubated anesthesia VATS lung surgery with ERAS accelerates postoperative recovery less have reported, and its clinical feasibility still deserved to discuss. We performed non-intubated anesthesia VATS lung surgery, and better initial effects were obtained (11). We analyzed the clinical feasibility of rapid postoperative recovery in 192 patients underwent non-intubated anesthesia VATS lung surgery in our center. We present the following article in accordance with the STROBE reporting checklist (available at https://dx.doi.org/10.21037/atm-21-6434).
Methods
Study subjects
Inclusion indicators
The clinical data of thoracic surgery patients from September 2014 to December 2020 were retrospectively collected. One hundred ninety-two patients were identified who underwent thoracoscopic lung surgery. The patients were divided into an intubated anesthesia group (the control group) and a non-intubated anesthesia group (and experimental group). All procedures performed in this study involving human participants were in accordance with the Declaration of Helsinki (as revised in 2013). Ethical approval for the study was granted by the Ethics Committee of The First People’s Hospital of Yunnan Province (KHLL2021-KY091). In addition, written informed consent was obtained from all patients who participated in the study. To be eligible for inclusion in the study, patients had to meet the following inclusion criteria: baseline data (e.g., gender, age, past history and smoking history of patients).
Clinical indicators were observed that lists the intraoperative blood loss (mL), postoperative evaluation indexes {e.g., time to water intake/food intake [h], out-of-bed activity time [h], returning time of exhaust/defecation [d], laryngeal pain or discomfort, nausea or vomiting, postoperative complications, satisfaction degree), inflammatory indexes 24 h after surgery (routine blood), chest drainage changes 24 and 48 h after oral recovery, and the number of drainage days [d]}.
Exclusion indicators
Patients were excluded from the study if they met any of the following exclusion criteria: (I) had a contraindication to an anesthesia; (II) had a body mass index (BMI) >30 kg/m2; (III) had a difficult airway; (IV) had preoperative severe cardiopulmonary complications; (V) rejected the anesthesia plan, or had a surgical contraindication; and/or (VI) hypoxemia (PaO2 <60 mmHg) or hypercapnia (PaCO2 >50 mmHg) preoperatively; (VII) had underwent a previous pulmonary resection (12), see Table 1.
Table 1
| Exclusion criteria |
| BMI >30 kg/m2 |
| Difficult airway |
| Severe cardiopulmonary dysfunction |
| Patient rejection of anesthesia plan |
| Persistent cough or chronic cough with large amount of airway secretion |
| Hypoxemia (PaO2 <60 mmHg) or hypercapnia (PaCO2 >50 mmHg) preoperatively |
| Underwent a previous pulmonary resection |
BMI, body mass index.
Anesthesia and surgical methods
Non-intubation anesthesia groups: after the intravenous injection of etomidate, midazolam, sufentanil, and atropine, a laryngeal mask airway was inserted by manual-assisted ventilation or synchronous intermittent mechanical ventilation (SIMV). The parameters of the anesthetic ventilator (oxygen flow rate 3–5 mL/min and SpO2>90%) were evaluated and adjusted. Propofol and a remifentanil intravenous pump was used during the operation to maintain deep anesthesia, which was discontinued immediately after the operation. The chest wall incision was selected pleural cavity at the 4th or 5th intercostal space of the midaxillary line of the affected side that cut into pleural cavity, and promote the affected side lung tissue spontaneously collapse by cooperating of the anesthesiologist. The thoracic cavity was explored by dissecting and separating the surrounding tissues of focus. An endoscopic cutting and closing device were used to assist with the excision. The lung tissue was dissected, or the hilar lung and the mediastinal lymph nodes were dissected according to the intraoperative freezing pathology results. At the end of the operation, normal saline was injected into the thoracic cavity, and a lung expansion test was performed with the assistance of the anesthesiologist to confirm that there was no air leakage at the broken end of the bronchus. The thoracic drainage tube was left in the operation hole, and the chest was closed. After the patient recovered from the anesthesia, the patient was returned to the ward and the postoperative indicators were monitored.
Intubation anesthesia groups: anesthetic drugs, midazolam, etomidate, atropine and vecuronium bromide were injected into the peripheral vein. Double-lumen endotracheal intubation was performed after manual-assisted ventilation or SIMV. The intraoperative anesthesia management and operation methods were the same as those used in the non-intubation group (see above). Patients in both groups recovered well after surgery, and there were no cases of death or reoperation.
Statistical methods
SPSS23.0 software was used for the statistical analysis. The continuous data are expressed as means ± standard deviations. The χ2 test was used to examine the categorical data. The Mann-Whitney U-test was used to examine differences between the 2 groups. P value <0.05 was considered statistically significant.
Results
Patient characteristics and postoperative adverse events
The basic clinical data of 192 patients with pulmonary diseases who underwent VATS surgery between September 2014 and December 2020 were compared. Seventy-five patients received intubation under general anesthesia, and 117 patients received non-intubated anesthesia. There were no differences between the smoking histories and postoperative complications of the 2 groups. The degree of pharyngeal pain (or discomfort) and the degree of nausea or vomiting were lower in the non-intubated group than the intubated group. The differences in basic clinical data between the 2 groups are shown in Table 2.
Table 2
| Items | Intubation group, n=75 | Non-intubation group, n=117 | P |
|---|---|---|---|
| Gender | 0.019 | ||
| Male | 30 [40] | 69 [59] | |
| Female | 45 [60] | 48 [41] | |
| Age (mean ± SD, yr) | 53.99±10.38 | 52.80±11.40 | 0.465 |
| Smoking history, Y/N | 0.105 | ||
| Smoking | 28 (37.3) | 31 (26.5) | |
| No smoking | 47 (62.7) | 86 (73.5) | |
| Previous history | 0.000 | ||
| Previous history | 11 (14.7) | 47 (40.2) | |
| No previous history | 64 (85.3) | 70 (59.8) | |
| Postoperative complications | 0.688 | ||
| Complications | 7 (9.3) | 9 (7.7) | |
| No complications | 68 (90.7) | 108 (92.3) | |
| Postoperative throat discomfort (pain) | 0.004 | ||
| Throat discomfort (pain) | 7 (9.3) | 1 (0.85) | |
| No throat discomfort (pain) | 68 (90.7) | 116 (99.15) | |
| Postoperative nausea or vomiting | 0.029 | ||
| Nausea or vomiting | 3 [4] | 0 | |
| No nausea or vomiting | 72 [96] | 117 [1] |
Continuous data are shown as the mean ± standard deviation, and categorical variables as the number (%).
Analysis of intra- and post-operative indicators
The amount of intraoperative blood loss and the length of hospital stay were compared between the 2 groups (15.37 vs. 16.63 d, P=0.091; 86.87 vs. 84.8 mL, P<0.001). The postoperative recovery indicators were compared between the 2 groups, including the resumption of the oral intake of water and out-of-bed activity (3.52 vs. 1.12, 11.54 vs. 2.23, P<0.001). The postoperative satisfaction of non-intubated group compared to which intubated group was better and the exhaust time was shortened (96.18 vs. 99.8%, P<0.001; 1.11 vs. 1.01, P=0.004). In the 2 groups, the total thoracic drainage volume reduced more significantly in the non-intubation group than in the intubation group (667.24 vs. 440.65 mL, P=0.005), the postoperative thoracic tube drainage time was shorter (3.73 vs. 3.13 d, P<0.001; see Table 3).
Table 3
| Variable* | Intubation group, n=75 | Non-intubation group, n=117 | P |
|---|---|---|---|
| Hospital stay, day | 15.37±4.59 | 16.63±4.92 | 0.091 |
| Blood loss, mL | 86.87±90.51 | 84.8±41.88 | <0.001 |
| Total drainage volume (mL) | 667.24±716.81 | 440.65±479.75 | 0.005 |
| Thoracic drainage, day | 3.73±1.46 | 3.13±1.73 | <0.001 |
| Postoperative satisfied degree, % | 96.18±1.77 | 99.80±0.40 | <0.001 |
| Postoperative oral intake of food, hour | 3.98±0.60 | 1.658±0.51 | <0.001 |
| Postoperative oral intake of water, hour | 3.52±0.72 | 1.12±0.38 | <0.001 |
| Out-of-activity, hour | 11.54±2.44 | 2.23±0.47 | <0.001 |
| Postoperative exhaust, day | 1.11±0.35 | 1.01±0.14 | 0.004 |
| Postoperative defecation, day | 1.73±0.72 | 1.15±0.35 | <0.001 |
*, the continuous data are shown as the mean ± standard deviation.
Postoperative blood routine and pleural drainage indexes
Compared with intubation group, leukocyte (WBC), neutrophil (NEUT), and lymphocyte (LYMPH), hemoglobin (HB) counts decreased non-intubated group 24 h after surgery (9.25×109vs. 7.67×109, P=0.045; 7.06 vs. 5.53, P=0.039; 1.45 vs. 1.27, P=0.017). The changes inhemoglobin (HB) and platele (PLT) were not significant (126.93 vs. 120.45, P=0.213; 229.65 vs. 216.51, P=0.212). Notably, the pleural drainage fluid of non-intubated group progressively decreased 24 and 48 h after restoring oral intake (198.43 vs. 131.07 mL, 114.04 vs. 57.47 mL, P<0.001; see Table 4).
Table 4
| Variable* | Intubation group, n=75 | Non-intubation group, n=117 | P |
|---|---|---|---|
| Blood routine, 24 h | |||
| ⬥ WBC, ×109 | 9.25±4.40 | 7.67±2.15 | 0.045 |
| ⬥ NEUT, % | 7.06±4.02 | 5.53±1.84 | 0.039 |
| ⬥ LYMPH, % | 1.45±0.45 | 1.27±0.35 | 0.017 |
| ⬥ HB, g/L | 126.93±18.53 | 120.45±19.22 | 0.213 |
| ⬥ PLT, 109 | 229.65±69.95 | 216.51±57.49 | 0.212 |
| Oral intake chest drainage, hour | |||
| 24 h | 198.43±127.24 | 131.07±125.79 | <0.001 |
| 48 h | 114.04±109.48 | 57.47±87.06 | <0.001 |
*, postoperative indexes; the continuous data are shown as the mean ± standard deviation; w WBC ×109, w NEU%, w LYMPH%, w HB g/L, w PLT ×109 indicate the difference of white blood cell, neutrophilic granulocyte percentage, lymphocytes percentage, hemoglobin, platelet count for the 2 groups after surgery.
Discussion
At present, non-intubated anesthesia VATS is a new option for minimally invasive surgery of thoracic surgery. Lung surgery under spontaneous ventilation is closer to physiological characteristics, the reduction of anesthetic drugs and requires surgeons to achieve surgery more accurately and rapidly, optimizing anesthesia and surgical techniques, less invasive injuries, faster recovery, reduced postoperative complications, accelerated the rapid recovery and early discharge of postoperative patients (13). Comparing with intubation anesthesia VATS lung surgery, limitations of non-intubated anesthesia VTAS; including: (I) cough reflex, (II) mediastinal movement under spontaneous breathing, (III) persistent hypoxemia and hypercapnia during the operation, (IV) anesthesiologists and surgeons need tacit cooperation, etc. (14). These problems became the focus of discussion. We found that non-intubated anesthesia VATS lung surgery reduced postoperative complications and throat adverse reaction. Laryngeal mask ventilation and vagus nerve block advantageous to overcome these risk factors, our center achieved a 92-year-old patient who underwent non-intubation anesthesia VAST lung surgery and was successful rehabilitation. I deem that these risk factors of non-intubation anesthesia VAST lung surgery can be overcome to establish clinical advantage.
Enhanced postoperative recovery (ERAS) was initially known in many other surgeries (15,16). Non-intubated VATS lung surgery can optimize ERAS channel (8,17). Applications of non-intubated VATS may be better integrated with ERAS strategies, our outcomes show that non-intubated VAST lung surgery combined with ERAS strategies is beneficial for the quickly recovery of postoperative patients. we found that compared with the intubation group, the non-intubation group was significantly earlier for the recovery of postoperative oral intake water (food) [(3.52±0.72 vs. 1.12±0.38 h) and (3.98±0.60 vs. 1.658±0.51 h), P<0.001]. Liu et al. believe that non-intubated anesthesia VAST segmentectomy, the patient resumed oral-intake 6 hours of postoperation (18), but our outcomes shown patients were able to resume oral-intake less than 2 hours after surgery, postoperative rehabilitation outcome is better. The out of bed activity time of postoperative patients is earlier (11.54±2.44 vs. 2.23±0.47 h, P<0.001). In our view, pleural drainage was significantly reduced 24 and 48 h after recovery oral-intake, we consider that this is closely related to the early resumption of oral-intake and ambulation, pleural drainage fluid is rapidly absorbed. The time of the (exhaust) defecation and total pleural drainage were shorter than the intubation group (P<0.05). However, hospital stays not exist significant difference, we think that the outcome caused by longer data collection period.
When the stress and inflammatory responses subside, patients quickly recover. It has been reported that during VATS lung surgery with non-intubated anesthesia, the postoperative inflammatory cell responses of patients were significantly lower than those of patients in the general anesthesia intubated group, which may be the result of inflammatory regulation (19). Another report (20) showed that the postoperative stress reaction and inflammatory cell reaction of non-intubated VATS lung surgery patients were relatively mild, which was related to the inhibition of afferent and efferent sympathetic pathways. We found that the ♦WBC, ♦NEUT, and ♦LYMPH results of the non-intubated group after surgery were significantly lower than those of the intubated group.
Based on the comprehensive evaluation of this study, non-intubated anesthesia lung surgery accelerates the rapid postoperative recovery of patients. However, it should be noted that this retrospective study was conducted at a single-center and had a limited sample size, and thus some bias may exist. In addition, the mechanism underlying the rapid postoperative recovery of patients requires further study. We intend to examine this further in future studies at our center.
Conclusions
In summary, this study showed that non-intubated VATS lung surgery is a safe and beneficial option that encourages the rapid recovery of patients. Compared to intubation, the technique has a number of advantages in postoperative clinical rehabilitation. However, the correct administration and assessment for non-intubation anesthesia, multidisciplinary coordination and close cooperation during surgery are key factors related to its success. As this model promotes rapid patient recovery, it may represent an effective option for clinical surgeons in the future. As surgical teams gain experience, minimally invasive non-intubation anesthesia strategies can be extended to more challenging procedures.
Acknowledgments
Funding: The study was supported by Science and Technology Program of Kunming City (2020-1-H-003).
Footnote
Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://dx.doi.org/10.21037/atm-21-6434
Data Sharing Statement: Available at https://dx.doi.org/10.21037/atm-21-6434
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (Available at https://dx.doi.org/10.21037/atm-21-6434). The authors have no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Ethical approval for the study was granted by the Ethics Committee of The First People’s Hospital of Yunnan Province (KHLL2021-KY091). In addition, written informed consent was obtained from all patients who participated in the study. All procedures performed in this study involving human participants were in accordance with the Declaration of Helsinki (as revised in 2013).
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
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