Nonintubated Thoracoscopic Lobectomy for Lung Cancer Using Epidural Anesthesia and Intercostal Blockade

Abstract

Intubated general anesthesia with single-lung ventilation has been considered mandatory for thoracoscopic lobectomy for nonsmall cell lung cancer. Few reports of thoracoscopic lobectomy without tracheal intubation are published, using either thoracic epidural anesthesia (TEA) or intercostal blockade. The comparisons of perioperative outcomes of nonintubated thoracoscopic lobectomy using epidural anesthesia and intercostal blockade are not reported previously.From September 2009 to August 2014, a total of 238 patients with lung cancer who underwent nonintubated thoracoscopic lobectomy were recruited from our prospectively maintained database of all patients undergoing nonintubated thoracoscopic surgery using TEA or intercostal blockade. A multiple regression analysis, adjusting for preoperative variables, was performed to compare the perioperative outcomes of the 2 anesthesia methods.Overall, 130 patients underwent nonintubated thoracoscopic lobectomy using epidural anesthesia whereas 108 had intercostal blockade. The 2 groups were similar in demographic data, except for sex, preoperative lung function, physical status classification, and history of smoking. After adjustment for the preoperative variables, nonintubated thoracoscopic lobectomy using intercostal blockade was associated with shorter durations of anesthetic induction and surgery (P < 0.001). Furthermore, hemodynamics were more stable with less use of vasoactive drugs (odds ratio: 0.53; 95% confidence interval [CI], 0.27 to 1.04; P = 0.064) and less blood loss (mean difference: −55.2 mL; 95% CI, −93 to −17.3; P = 0.004). Postoperatively, the 2 groups had comparable incidences of complications. Patients in the intercostal blockade group had a shorter average duration of chest tube drainage (P = 0.064) but a similar average length of hospital stay (P = 0.569). Conversion to tracheal intubation was required in 13 patients (5.5%), and no in-hospital mortality occurred in either group.Nonintubated thoracoscopic lobectomy using either epidural anesthesia or intercostal blockade is feasible and safe. Intercostal blockade is a simpler alternative to epidural anesthesia for nonintubated thoracoscopic lobectomy in selected patients with lung cancer.

Nonintubated uniportal thoracoscopic wedge resection for early lung cancer

“…Since 2014, we began utilizing intercostal nerve blocks instead of thoracic epidural anesthesia (14,19). Hung et al investigated 238 patients, revealing that those who received an intercostal nerve block (N=108) had a shorter duration of anesthetic induction and a more stable intraoperative hemodynamics (15). Thoracic intercostal nerve blocks provide a regional anesthetic component and exert an anesthetic-sparing effect (30).…”

“…Based on our experience and publications since August 2009 (6)(7)(8)(9)(10)(13)(14)(15), the appropriate selection criteria for nonintubated VATS comprise the following: (I) the primary tumor size should not exceeded 6 cm in diameter and (II) there should be no evidence of direct invasion into the chest wall, diaphragm or main bronchus. However, patients with an American Society of Anesthesiologists score ≥4, sleep apnea, unfavorable airway, or a spinal anatomy or chest wall deformity should be excluded.…”

“…We have described the protocol of nonintubated VATS surgery in full in our previous publications (6)(7)(8)(9)(10)(13)(14)(15). In brief, the patients were sedated with intravenous fentanyl (50-100 mg) and continuously monitored by electrocardiography, pulse oximetry, arterial blood pressure, and respiratory rate.…”

“…Using a 25-G top-winged infusion needle, 0.5% bupivacaine (1.5 mL for each intercostal space) was applied from the third to the eighth intercostal nerve, 2 cm lateral to the sympathetic chain (14,15). The intercostal nerve block contributes to analgesic control during the entire operation.…”

“…The intercostal nerve block contributes to analgesic control during the entire operation. In addition, the intrathoracic vagal block is routinely used to reduce the coughing reflex during lung manipulations (6,15). Three milliliters of bupivacaine was then injected via a long-needle instrument into the vagus nerve near the lower paratrachea (for right-sided procedures) and the aortopulmonary window (for left-sided procedures).…”