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From Open Operations to Nonintubated Uniportal Video-Assisted Thoracoscopic Lobectomy: Minimizing the Trauma to the Patient

2015; Elsevier BV; Volume: 100; Issue: 6 Linguagem: Inglês

10.1016/j.athoracsur.2015.07.092

1552-6259

Diego González-Rivas, Humberto Aymerich, C Bonome, Eva Fieira,

Pleural and Pulmonary Diseases

Video-assisted thoracic surgery (VATS) has become, in the last 2 decades, a revolution in the treatment of lung pathologies [1Ng C.S. Lau K.K. Gonzalez-Rivas D. Rocco G. Evolution in surgical approach and techniques for lung cancer.Thorax. 2013; 68: 681Crossref PubMed Scopus (42) Google Scholar]. 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 [2Bertolaccini L. Rocco G. Viti A. Terzi A. Geometrical characteristics of uniportal VATS.J Thorac Dis. 2013; 5: 214-216PubMed Google Scholar, 3Jutley R.S. Khalil M.W. Rocco G. Uniportal vs standard three-port VATS technique for spontaneous pneumothorax: comparison of post-operative pain and residual paraesthesia.Eur J Cardiothorac Surg. 2005; 28: 43-46Crossref PubMed Scopus (195) Google Scholar, 4Gonzalez-Rivas D. Paradela M. Fernandez R. et al.Uniportal video-assisted thoracoscopic lobectomy: two years of experience.Ann Thorac Surg. 2013; 95: 426-432Abstract Full Text Full Text PDF PubMed Scopus (262) Google Scholar]. 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 [5Katlic M.R. Video-assisted thoracic surgery utilizing local anesthesia and sedation.Eur J Cardiothorac Surg. 2006; 30: 529-532Crossref PubMed Scopus (50) Google Scholar]. 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 [6Von 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: 848-854Crossref PubMed Scopus (106) Google Scholar]. 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 [7Yang J.T. Hung M.H. Chen J.S. Cheng Y.J. Anesthetic consideration for nonintubated vats.J Thorac Dis. 2014; 6: 10-13PubMed Google Scholar, 8Pompeo E. State of the art and perspectives in non-intubated thoracic surgery.Ann Transl Med. 2014; 2: 106Google Scholar, 9Gonzalez-Rivas D. Fernandez R. de la Torre M. Rodriguez J.L. 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: 552-555Crossref PubMed Scopus (59) Google Scholar, 10Gonzalez-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: 494-495PubMed Google Scholar, 11Mineo T.C. Tacconi F. From "awake" to "monitored anesthesia care" thoracic surgery: a 15 year evolution.Thorac Cancer. 2014; 5: 1-13Crossref Scopus (31) Google Scholar]. 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 [12Nezu K. Kushibe K. Tojo T. et al.Thoracoscopic wedge resection of blebs under local anesthesia with sedation for treatment of a spontaneous pneumothorax.Chest. 1997; 111: 230-235Crossref PubMed Scopus (83) Google Scholar] 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 [13Al-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: 346-350Crossref PubMed Scopus (90) Google Scholar]. 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 awareness without prolonging recovery times [14O'Connor M.F. Daves S.M. Tung A. Cook R.I. Thisted R. Apfelbaum J. BIS monitoring to prevent awareness during general anesthesia.Anesthesiology. 2001; 94: 520-522Crossref PubMed Scopus (104) Google Scholar, 15Sear J.W. Brown W.E. Research into new drugs in anesthesia: then & now.Anesth Analg. 2012; 115: 233-234Crossref PubMed Scopus (4) Google Scholar, 16Shalbaf R. Behnam H. Sleigh J.W. Steyn-Ross A. Voss L.J. Monitoring the depth of anesthesia using entropy features and an artificial neural network.J Neurosci Methods. 2013; 218: 17-24Crossref PubMed Scopus (61) Google Scholar]. 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 [17Ly-Liu D. Reinoso-Barbero F. Immediate postoperative pain can also be predicted by pupillary pain index in children.Br J Anaesth. 2015; 114: 345-346Crossref PubMed Scopus (16) Google Scholar, 18Boselli 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: 288-297PubMed Google Scholar]. 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% [11Mineo T.C. Tacconi F. From "awake" to "monitored anesthesia care" thoracic surgery: a 15 year evolution.Thorac Cancer. 2014; 5: 1-13Crossref Scopus (31) Google Scholar, 19Gonzalez-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/ezv136Google Scholar]. In most operations, the volume effect of the hospital and the number of interventions performed by a particular surgeon are related to patient survival [20Brusselaers 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: 1393-1400Crossref PubMed Scopus (120) Google Scholar, 21Rogers Jr., S.O. Wolf R.E. Zaslavsky A.M. Wright W.E. Ayanian J.Z. Relation of surgeon and hospital volume to processes and outcomes of colorectal cancer surgery.Ann Surg. 2006; 244: 1003-1011Crossref PubMed Scopus (145) Google Scholar, 22Derogar 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: 551-557Crossref PubMed Scopus (112) Google Scholar]. In VATS operations performed under general anesthesia and 1-lung ventilation, experience may not be a determinant variable in the postoperative course of patients [23Iwasaki 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: 169-174PubMed Google Scholar]. 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 [19Gonzalez-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/ezv136Google Scholar]. 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 [19Gonzalez-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/ezv136Google Scholar]. 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 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 [24Chen K.C. Cheng Y.J. Hung M.H. Tseng Y.D. Chen J.S. Nonintubated thoracoscopic surgery using regional anesthesia and vagal block and targeted sedation.J Thorac Dis. 2014; 6: 31-36PubMed Google Scholar, 25Dong Q. Liang L. Li Y. et al.Anesthesia with nontracheal intubation in thoracic surgery.J Thorac Dis. 2012; 4: 126-130PubMed Google Scholar]. 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 [4Gonzalez-Rivas D. Paradela M. Fernandez R. et al.Uniportal video-assisted thoracoscopic lobectomy: two years of experience.Ann Thorac Surg. 2013; 95: 426-432Abstract Full Text Full Text PDF PubMed Scopus (262) Google Scholar]. Uniportal or single-incision VATS has been shown to reduce postoperative pain, residual paresthesia, and hospital stay compared with conventional multiport VATS [3Jutley R.S. Khalil M.W. Rocco G. Uniportal vs standard three-port VATS technique for spontaneous pneumothorax: comparison of post-operative pain and residual paraesthesia.Eur J Cardiothorac Surg. 2005; 28: 43-46Crossref PubMed Scopus (195) Google Scholar]. 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 [4Gonzalez-Rivas D. Paradela M. Fernandez R. et al.Uniportal video-assisted thoracoscopic lobectomy: two years of experience.Ann Thorac Surg. 2013; 95: 426-432Abstract Full Text Full Text PDF PubMed Scopus (262) Google Scholar, 9Gonzalez-Rivas D. Fernandez R. de la Torre M. Rodriguez J.L. 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: 552-555Crossref PubMed Scopus (59) Google Scholar, 10Gonzalez-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: 494-495PubMed Google Scholar]. The choice of a single incision technique combined with the avoidance of general anesthesia could minimize even more the invasiveness of the procedure [9Gonzalez-Rivas D. Fernandez R. de la Torre M. Rodriguez J.L. 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: 552-555Crossref PubMed Scopus (59) Google Scholar, 19Gonzalez-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/ezv136Google Scholar, 24Chen K.C. Cheng Y.J. Hung M.H. Tseng Y.D. Chen J.S. Nonintubated thoracoscopic surgery using regional anesthesia and vagal block and targeted sedation.J Thorac Dis. 2014; 6: 31-36PubMed Google Scholar]. 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 [26Tacconi F. Pompeo E. Sellitri F. Mineo T.C. Surgical stress hormones response is reduced after awake videothoracoscopy.Interact Cardiovasc Thorac Surg. 2010; 10: 666-671Crossref PubMed Scopus (73) Google Scholar]. 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 [24Chen K.C. Cheng Y.J. Hung M.H. Tseng Y.D. Chen J.S. Nonintubated thoracoscopic surgery using regional anesthesia and vagal block and targeted sedation.J Thorac Dis. 2014; 6: 31-36PubMed Google Scholar, 25Dong Q. Liang L. Li Y. et al.Anesthesia with nontracheal intubation in thoracic surgery.J Thorac Dis. 2012; 4: 126-130PubMed Google Scholar]. 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 [26Tacconi F. Pompeo E. Sellitri F. Mineo T.C. Surgical stress hormones response is reduced after awake videothoracoscopy.Interact Cardiovasc Thorac Surg. 2010; 10: 666-671Crossref PubMed Scopus (73) Google Scholar, 27Chen K.C. Cheng Y.J. Hung M.H. Tseng Y.D. Chen J.S. Nonintubated thoracoscopic lung resection: a 3-year experience with 285 cases in a single institution.J Thorac Dis. 2012; 4: 347-351PubMed Google Scholar]. 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 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 (β-blockers, anticoagulants, antiplatelets) and some concomitant diseases (first or second atrioventricular block, use of intercostal muscles for ventilating, etc) in our patients [28Mineo T.C. Epidural anesthesia in awake thoracic surgery.Eur J Cardiothorac Surg. 2007; 32: 13-19Crossref PubMed Scopus (79) Google Scholar]. 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 target-controlled 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 [9Gonzalez-Rivas D. Fernandez R. de la Torre M. Rodriguez J.L. 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: 552-555Crossref PubMed Scopus (59) Google Scholar]. 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 [11Mineo T.C. Tacconi F. From "awake" to "monitored anesthesia care" thoracic surgery: a 15 year evolution.Thorac Cancer. 2014; 5: 1-13Crossref Scopus (31) Google Scholar]. 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 [27Chen K.C. Cheng Y.J. Hung M.H. Tseng Y.D. Chen J.S. Nonintubated thoracoscopic lung resection: a 3-year experience with 285 cases in a single institution.J Thorac Dis. 2012; 4: 347-351PubMed Google Scholar]. When intraoperative conversion to intubated general anesthesia is needed, the surgical team must have a concise plan to minimize the risk to the patient. 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.