Elsevier

The Annals of Thoracic Surgery

Volume 78, Issue 5, November 2004, Pages 1761-1768
The Annals of Thoracic Surgery

Original article: general thoracic
Feasibility and Results of Awake Thoracoscopic Resection of Solitary Pulmonary Nodules

Presented at the Fortieth Annual Meeting of The Society of Thoracic Surgeons, San Antonio, TX, Jan 26–28, 2004.
https://doi.org/10.1016/j.athoracsur.2004.05.083Get rights and content

Background

General anesthesia with single-lung ventilation is considered mandatory for thoracoscopic pulmonary resection. We assessed in a randomized study the feasibility and results of awake thoracoscopic resection of solitary pulmonary nodules.

Methods

Between March 2001 and February 2003, 60 patients were randomized into two 30-patients arms: a general anesthesia arm entailing double-lumen intubation and thoracic epidural anesthesia (control group); and an awake arm entailing sole thoracic epidural anesthesia at T4-T5 (awake group). Anesthesia time; operative time; global operating room time; patient satisfaction with the anesthesia and technical feasibility scored into 4 grades (from 1 = poor to 4 = excellent); visual analog pain score (VAS), nursing care (number of patient calls per day), 24 hours changes in arterial oxygenation (ΔPaO2), and hospital stay were assessed.

Results

There was no mortality. There was no difference in technical feasibility between the groups although 2 patients in the awake group required conversion to thoracotomy due to severe adhesions. Other 2 patients in each group required conversion due to unexpected lung cancer requiring lobectomy. Comparisons of awake versus control group results showed that in the awake group, anesthesia satisfaction score was greater (4 vs 3, p = 0.04), whereas ΔPaO2 (-3 mm Hg vs –6.5 mm Hg, p = 0.002); nursing care (2.5 calls per day vs 4 calls per day, p = 0.0001), and hospital stay (2 days vs 3 days, p = 0.02) were significantly reduced.

Conclusions

In our study, awake thoracoscopic resection of solitary pulmonary nodules proved safely feasible. It resulted in better patient satisfaction, less nursing care and shorter in-hospital stay than procedures performed under general anesthesia.

Section snippets

Material and Methods

The study was started in March 2001 and was closed in February 2003. Written informed consent was obtained from all patients who took part and the study was approved by the institutional review board of the Tor Vergata University. Sixty patients with undetermined solitary pulmonary nodule, who met the entry criteria, were randomized by computer into two groups: 30 patients underwent VATS resection of the pulmonary nodule under conventional general anesthesia with one-lung ventilation. Thirty

Results

During the study period, 12 of 72 eligible patients refused to accept the randomization and were excluded from the analysis. Of these, 8 patients asked to undergo the awake procedure while 4 preferred general anesthesia. Table 1 shows that the two study groups were well matched in terms of base line characteristics and measures. Overall, the nodules were localized in the right upper, middle or right lower lobe in 22, 7, and 10 instances, respectively; in the left upper or lower lobe in 11 and

Comment

Selected controlled ventilation came with the introduction of the double-lumen endobronchial tube introduced by Zavod in 1940 [9] and refined by Carlens in 1949 [10]. It proved to be a revolutionary advance in thoracic surgery and is now the standard type of anesthesia for both open and VATS pulmonary resections. However, despite some indisputable and well-known advantages, several adverse effects can derive from this type of anesthesia including an increased risk of pneumonia, impaired cardiac

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