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Nonintubated thoracoscopic surgery for pulmonary lesions in both lungs

2012; Elsevier BV; Volume: 144; Issue: 3 Linguagem: Inglês

10.1016/j.jtcvs.2012.06.025

1097-685X

Tung-Ming Tsai, Jin‐Shing Chen,

Medical Imaging and Pathology Studies

Thoracoscopic resections for pulmonary lesions in both lungs are usually performed under conditions of general anesthesia with double-lumen endotracheal intubation and sequential single-lung ventilation.1Chou S.H. Li H.P. Lee J.Y. Chang S.J. Lee Y.L. Chang Y.T. et al.Is prophylactic treatment of contralateral blebs in patients with primary spontaneous pneumothorax indicated?.J Thorac Cardiovasc Surg. 2010; 139: 1241-1245Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar A newly developed nonintubated technique that uses thoracic epidural anesthesia and sedation has been introduced for thoracoscopic resection of unilateral pulmonary lesions, with satisfactory results.2Pompeo E. Tacconi F. Mineo D. Mineo T.C. The role of awake video-assisted thoracoscopic surgery in spontaneous pneumothorax.J Thorac Cardiovasc Surg. 2007; 133: 786-790Abstract Full Text Full Text PDF PubMed Scopus (137) Google Scholar, 3Pompeo E. Mineo T.C. Awake pulmonary metastasectomy.J Thorac Cardiovasc Surg. 2007; 133: 960-966Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar, 4Chen J.S. Cheng Y.J. Hung M.H. Tseng Y.D. Chen K.C. Lee Y.C. Nonintubated thoracoscopic lobectomy for lung cancer.Ann Surg. 2011; 254: 1038-1043Crossref PubMed Scopus (146) Google Scholar, 5Tseng Y.D. Cheng Y.J. Hung M.H. Chen K.C. Chen J.S. Nonintubated needlescopic video-assisted thoracic surgery for management of peripheral lung nodules.Ann Thorac Surg. 2012; 93: 1049-1054Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar Nonintubated thoracoscopic surgery for lesions in both lungs, however, has not previously been reported. Here we report a case of successful resection with a nonintubated thoracoscopic technique for bilateral pulmonary lesions. Our results indicate that nonintubated thoracoscopic surgery can be used in a specific group of patients. A 57-year-old nonsmoking woman was referred to our hospital for undetermined bilateral pulmonary lesions. She had a medical history of Sjögren syndrome complicated with xerostomia for more than 10 years. Serial thoracic computed tomographic scans showed 2 ground-glass opacities: 1 corresponded to a 0.5-cm previously undetected lesion in the right lower lobe, and the other corresponded to a 0.7-cm stationary lesion in the left lower lobe (Figure 1). The patient had a family history of lung cancer, and computed tomographic findings suggested the presence of multiple early lung cancers. The preoperative forced expiratory volume in 1 second was 122% of the prediction value. After discussion with our surgical team, the patient opted for nonintubated anesthesia during thoracoscopic resection to avoid the airway mucosal injury caused by severe xerostomia after endotracheal intubation. In the operating room, the patient was medicated before surgery with an intravenous infusion of 50 μg fentanyl. Thoracic epidural anesthesia was administered in the T5-6 thoracic interspace by continuous infusion of 2% lidocaine. The patient was then sedated with an intravenous infusion of propofol (10 mg/mL), with a target-controlled infusion method used to maintain her in a mildly sedated, but communicative and cooperative, state (Ramsay sedation score III). During the procedure, the patient breathed oxygen through a ventilation mask. Subsequently, bilateral sequential thoracoscopic surgery was performed with the patient in the left decubitus position. The right pulmonary lesion was identified by preoperative computed tomographically guided hookwire localization. During right thoracoscopy, the right lung collapsed gradually under spontaneous breathing. To inhibit coughing during thoracoscopic manipulation, a vagal block was produced by infiltrating 2 mL of 2% lidocaine adjacent to the vagus nerve.4Chen J.S. Cheng Y.J. Hung M.H. Tseng Y.D. Chen K.C. Lee Y.C. Nonintubated thoracoscopic lobectomy for lung cancer.Ann Surg. 2011; 254: 1038-1043Crossref PubMed Scopus (146) Google Scholar Stapled-wedge resection was performed with the 3-port procedure. After the operation, a 28F chest tube was inserted, and the incisions were closed. The collapsed right lung was reexpanded with positive-pressure mask ventilation and negative-pressure suction through the chest tube. The patient was then turned to the right decubitus position, and the resection procedure was repeated for the left pulmonary lesion. The total operation duration was 185 minutes. Postoperatively, immediate arterial blood gas analysis showed normocapnia, and chest radiographic scan showed complete expansion of both lung fields. The pathologic report showed bronchioloalveolar carcinoma in the left lung and a pulmonary meningotheliallike tumor in the right lung (Figure 2). The patient was discharged uneventfully on the 5th postoperative day. The use of double-lumen endotracheal intubation with single-lung ventilation has been considered mandatory for thoracoscopic surgery. Many East Asian patients, however, especially women, have small bodies with a small tracheal caliber, and are susceptible to complications related to double-lumen endotracheal intubation or mechanical ventilation, such as hoarseness, subglottic stenosis, and pneumonia. With the combination of thoracic epidural anesthesia, sedation, and vagal blockade, we previously demonstrated that lobectomy and wedge resection can be performed without endotracheal intubation.4Chen J.S. Cheng Y.J. Hung M.H. Tseng Y.D. Chen K.C. Lee Y.C. Nonintubated thoracoscopic lobectomy for lung cancer.Ann Surg. 2011; 254: 1038-1043Crossref PubMed Scopus (146) Google Scholar, 5Tseng Y.D. Cheng Y.J. Hung M.H. Chen K.C. Chen J.S. Nonintubated needlescopic video-assisted thoracic surgery for management of peripheral lung nodules.Ann Thorac Surg. 2012; 93: 1049-1054Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar In this report, we have extended the application of nonintubated thoracoscopic surgery to a patient with bilateral pulmonary lesions. Some concerns might arise with the use of nonintubated anesthesia for bilateral pulmonary resections. First, manipulation and resection of the lung can induce a cough reflex. Second, prolonged sequential single-lung breathing can lead to hypoxia and hypercapnia, which may require conversion to general anesthesia with intubation. In this patient, we used lidocaine for intrathoracic vagal blockade, which effectively abolished the cough reflex during the operation.4Chen J.S. Cheng Y.J. Hung M.H. Tseng Y.D. Chen K.C. Lee Y.C. Nonintubated thoracoscopic lobectomy for lung cancer.Ann Surg. 2011; 254: 1038-1043Crossref PubMed Scopus (146) Google Scholar In addition, small stapled lung wedge resections in patients with good pulmonary function are simple and safe. They should not cause respiratory failure necessitating emergency intubation. The final pathologic description of the right lung nodule was pulmonary meningotheliallike tumor. The clinicopathologic characteristic of this benign tumor remain unclear, but it is usually very tiny (1-3 mm) and discovered incidentally after lung resection for other lesions. Presentation as a solitary nodule 5 mm in size, as in our patient, is not common. In conclusion, the successful treatment in this patient suggests that nonintubated thoracoscopic operation may be feasible and safe in the treatment of selected patients with bilateral small peripheral pulmonary lesions and good preoperative cardiopulmonary function.