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 (⌬PaO 2 ), and hospital stay were assessed.Results. There was no mortality. There was no difference

In our study, awake video-assisted thoracoscopic bullectomy with pleural abrasion proved easily feasible and resulted in shorter hospital stays and reduced procedure-related costs while providing equivalent outcome to procedures performed under general anesthesia.

Objective: To assess the feasibility, safety, and early results of awake lung volume reduction surgery (LVRS) performed under thoracic epidural anesthesia by a new nonresectional technique. Summary Background Data: So far, resectional LVRS under general anesthesia and one-lung ventilation is the more frequently used technique, but procedure-related morbidity has been considerable. Methods: The study cohort included 12 patients undergoing unilateral awake LVRS. Evaluated parameters included technical feasibility and anesthesia satisfaction scored into 4 grades (from 1 ϭ poor to 4 ϭ excellent), global operating room time, and arterial carbon dioxide tension (PaCO 2 ). In addition, 6-month changes in outcome measures, including forced expiratory volume in 1 second (FEV1), residual volume (RV), 6-minute walking test (SMWT), and dyspnea index were recorded. Perioperative and 6-month results were comparable with those of a control group undergoing unilateral resectional LVRS. Results: Technical feasibility was excellent to satisfactory in 11 patients. One patient required conversion to one-lung ventilation. Differences between the awake and control group included global operating room time (90 Ϯ 17 minutes versus 145 Ϯ 19 minutes, P Ͻ 0.00001); PaCO 2 24 hours after surgery (45 Ϯ 6 mm Hg versus 49 Ϯ 6 mm Hg, P ϭ 0.02); and hospital stay (7.8 Ϯ 5 days versus 11.7 Ϯ 4 days, P ϭ 0.02). Significant (P Ͻ 0.002) improvements occurred at 6 months in FEV1 (0.31 Ϯ 0.17 L), RV (Ϫ1.41 Ϯ 0.7 L), SMWT (73 Ϯ 25 m), and dyspnea index (Ϫ1.3 Ϯ 0.5) and were comparable with those of the control group. Conclusions: In this study, awake nonresectional LVRS proved feasible and safe. This new modality was associated with a faster recovery and satisfactory 6-month outcome, which did not differ from that of resectional LVRS. (Ann Surg 2006;243: 131-136)

Background Progressive graft dysfunction (GDF) and loss of insulin independence (II) has been invariably observed in islet transplant recipients under the ‘Edmonton protocol’. To reestablish II we performed supplemental islet infusions (SI) in recipients of allogeneic islet transplant alone, displaying GDF. To improve the engraftment and long-term graft function of SI, exenatide (EXN) and etanercept treatment at islet infusion, and long-term EXN treatment were tested in a non-randomized pilot clinical trial. Methods Patients with GDF received SI under Edmonton-like immunosuppression with daclizumab induction, either without interventions (SI-control; n=5) or with EXN and etanercept treatment (SI-EXN; n=4). Clinical and metabolic profiles were assessed over 18–month follow-up. Results Long-term II (18 months) was observed in 100% of SI-EXN and in 20% of SI-Control (p=0.04). SI-EXN subjects demonstrated restoration of function better than that seen following initial islet infusions. Comparison of SI-EXN and SI-Control groups demonstrated better responses in SI-EXN subjects at three months post SI. Over the 18 months of follow-up, function was sustained in the SI-EXN subjects better than in SI-Controls. Acute effects of exenatide during MMTT and IVGTT results in improved first and second phase insulin release in response to intravenous glucose (IVGTT), and suppressed postprandial hyperglucagonemia after mixed meal tolerance test (MMTT). Conclusion These results suggest that the combination of exenatide and etanercept improve engraftment and long term islet survival and function in subjects undergoing SI. This data however must be interpreted with some caution due to small sample size, lack of randomization and sequential comparison with historical controls.