Today’s recommended read is for all of the thoracic surgeons out there that are interested in establishing their own nonintubated uniportal programs. This is a interesting article if you’ve taken a masterclass on uniportal technique, reviewed the literature around nonintubated surgery, but haven’t yet taken the next step to start performing this procedure at your hospital.
Thoracics.org has reached out to the corresponding author, Sook Sung for more information about their experiences with nonintubated uniportal VATS including some updates, but let’s review the primary article while we await a reply.
In the article, Nonintubated uniportal video-assisted thoracoscopic surgery: a single center experience, Seha Ahn et al. discuss their experiences over a six month period after initiating this technique in January 2017.
During this period, 40 patients underwent this technique. Pre-operative patient selection was important with multiple exclusionary criteria.
Exclusionary criteria for initial cases: General
- Obesity (BMI greater than 30
- Anticipated/ expected difficult airway
- Persistant cough/ or high amount of secretions
- At increased risk of gastric reflux
Exclusionary criteria: Cardiopulmonary
- Expected/ anticipated to have extensive adhesions
- Prior pulmonary resection
- N2 stage lung cancer
- Severe cardiac dysfunction (exact definition not defined)
Anesthesia and Intra-operative Monitoring
Prior to the procedure, patients received dexmedtomidine. At the time of the procedure, patients were maintained with infusions of remifentanyl and propofol.
No patients were intubated. Patients did receive supplemental oxygen by mask at a rate of 6 to 9 liters/ min. Oxygenation was monitored with botha small single nostril end-tidal CO2 monitor and pulse oxymetry. Anesthesia monitoring including a BIS monitor. General hemodynamic monitoring consisted of continuous EKG/ telemetry and serial blood pressure cuff measurements.
As part of the surgical technique, the authors administered an intercostal nerve block for additional analgesia. In the majority of patients (35 of 40), intrathoracic vagal nerve blocks were also performed to reduce / prevent coughing during the procedure.
The procedure was carried out using a single 3 to 4 cm incision. The main surgical instruments used were a 10mm 30 degree scope, a harmonic scalpel and a curved suction tip catheter.
There were 40 total patients in this study, which spanned a period of six months. More than half of these patients (57.5%) were women. The mean age was 60.
The vast majority of these patients (72.5%) had lung cancer. Seven patients (17.5%) had surgery for pulmonary metastasis. The remainder of patients had surgery for either benign lung disease or pleural disease.
Over half of the patients underwent lobectomies (57.5%). 10 patients (25%) had wedge resections, with six patients having segmentectomies (15%) and a solo patient undergoing a pleural biopsy.
There were several intra-operative conversions. The majority of these conversions were related to anesthesia, with 3 patients requiring conversion to standard intubation. The authors are a little unclear with the reasons for this – with one sentence saying it was not related to hypoxia (with all patient sats greater than 90%). The authors then attribute the conversions to excessive respiratory movements, but then report that all three of the patients’ hypoxemia resolved with intubation. This is better explained in a later portion of the paper, but it is still a bit confusing as to whether excessive respiratory movement was a contributing cause for the reason to intubate mid-procedure.
There was only one conversion for surgical technique, which occurred after the dread pulmonary artery injury, with the authors converting to multi-port VATS. There were no conversions to open thoracotomy.
Seven total post-operative complications (17.5%)
- 3 patients with prolonged air leaks
- 2 chylothorax
- 1 delayed pleural effusion
- 1 pneumonia
Interestingly enough, outcomes based on traditional criteria, (chest tube days, and overall length of stay) were not significantly different that results published for more traditional types of thoracic procedures.
The average post-operative chest tube time was 3.2 days (range: 1-13 days)
The average hospital stay was 4.4 days (range 1 – 18 days).
There was one notable outlier listed, a patient with a prolonged airleak that resulted in a 20 day hospital stay.
This article is note worthy of several reasons, in that the authors both describe their techniques and the initial results of the initiation of a new surgical approach (nonintubated and uniportal) in their facility. The authors are to be commended for reporting research results that show a (17.5 %) high rate of complications, which is presumably related to the learning curve of adopting a new surgical protocol.
However, this article would have been much more informative if there had been more of an in-depth discussion of the challenges involved in initiating and managing a nonintubated uniportal program, instead of a general review of the literature. While the article notes that there was a solo surgeon involved in these 40 procedures, there is little discussion of the prior experience of that surgeon or the anesthesia team(s) involved. What the surgeon previously experienced in uniportal VATS? If so, what was the level of experience?
The same goes for the anesthesiologists involved in this study, since a large portion of the procedure (ie. the nonintubated portion) as well as the highest level of conversions (to standard intubation) occurred under their guidance. A short discussion about intra-operative intubation would have been a helpful addition for readers as well, such as a discussion of the difficulties (or lack thereof) of intubating a patient after they have been secured into a lateral decubitus position.
While the traditional outcomes measures appear fairly unchanged in comparison to standard VATS with general anesthesia and intubation, what was the difference in related outcomes?
Was there a difference in/ would they anticipate a difference in (with larger numbers of patients):
- Post-operative intubation? How man patients required urgent/ emergent intubation during the post-operative period?
- Post-operative pneumonias and other respiratory complications? While the authors cite one post-operative pneumonia, there appear to be few other respiratory complications cited in this study.
- Post-operative anesthetic complications such as hemodynamic compromise (requiring prolonged use of pressors, for example). What about post-operative nausea/ vomiting or gastric ileus?
Since nonintubated and uniportal techniques have been proposed as a alterative to standard surgery for high risk patients (patients with poor respiratory reserve/ cardiovascular disease), the presence or lack of these complications in patients (even specially selected patients) is important.
When reviewing the lack of clear-cut advantages such as shorter length of stay, were there other reasons for it, such as post-operative nursing care? Are there changes that need to be implemented/ have been implemented since this study was published that have resulted in fewer chest tube days, or a shorter overall length of stay?
In the time since this study was concluded, what have been this group’s continued experience? Have there been any unexpected outcomes or observations? What changes continue to need to be addressed?
Are there any other observations that the authors would like to share? While traditional journals have size and article length limitations, we don’t here at thoracics.org.
Seha Ahn, Youngkyu Moon, Zeead M. Alghamdi & Sook Whan Sung (2018). Nonintubated uniportal video-assisted thoracoscopic surgery: a single center experience. Korean Journal of Cardiovascular & Thoracic Surgery, 2018; 51:344 -349.