We hypothesized that video-assisted thoracic surgery (VATS) lung metastasectomy under non-intubated anesthesia may have a lesser immunological and inflammatory impact than the same procedure under ...general anesthesia.
Between December 2005 and October 2015, 55 patients with pulmonary oligometastases (at the first episode) successfully underwent VATS metastasectomy under non-intubated anesthesia. Lymphocytes subpopulation and interleukins 6 and 10 were measured at different intervals and matched with a control group composed of 13 patients with similar clinical features who refused non-intubated surgery.
The non-intubated group demonstrated a lesser reduction of natural killer lymphocytes at 7 days from the procedure (
= 0.04) compared to control. Furthermore, the group revealed a lesser spillage of interleukin 6 after 1 (
= 0.03), 7 (
= 0.04), and 14 (
= 0.05) days. There was no mortality in any groups. Major morbidity rate was significantly higher in the general anesthesia group 3 (5%) vs. 3 (23%) (
= 0.04). The median hospital stay was 3.0 vs. 3.7 (
= 0.033) days, the estimated costs with the non-intubated procedure was significantly lower, even excluding the hospital stay.
VATS lung metastasectomy in non-intubated anesthesia had significantly lesser impact on both immunological and inflammatory response compared to traditional procedure in intubated general anesthesia.
Objective The role of extended thymectomy in the treatment of class I myasthenia gravis is still controversial. This study compared the long-term outcomes of operated and nonoperated patients ...allocated according to their will. Methods We retrospectively reviewed 47 patients with class I nonthymomatous myasthenia gravis undergoing extended thymectomy between 1980 and 2007. These patients were matched with 62 class I patients who refused surgery and received only pharmacologic therapy. Outcomes were stable remission and clinical or pharmacologic improvement. Predictors of remission were analyzed by Kaplan–Meier and Cox regression. Results We observed low postoperative major morbidity (n = 2; 4.2%) and no perioperative mortality. Heterotopic thymus was found in 22 patients (46%). Twenty-one patients showed active germinal centers, in the heterotopic thymus in 12 patients (57.1%). Thirty operated patients (64%) versus 34 nonoperated patients (55%) achieved stable remission, and 8 patients (17%) versus 5 patients (9%) showed pharmacologic improvement. Nine patients who had no postoperative improvement showed active ectopic thymus. Surgery was a marginal prognosticator ( P = .053). Early treatment (≤6 months from symptoms onset) was the unique significant prognosticator ( P = .045), but this was due to the contribution of the operated patients ( P = .002). Other predictors of remission in the operated group were the absence of ectopic thymus ( P = .007) with no germinal centers ( P = .009). No significant predictor of remission was found in the nonoperated group. Conclusions Extended thymectomy achieved a more rapid remission than after nonsurgical treatment of class I myasthenia gravis. Significantly better outcomes resulted when thymectomy was performed within 6 months from the onset of symptoms.
Despite the indisputable and well-known advantages of general anesthesia in thoracic surgery, this can trigger some adverse effects including an increased risk of pneumonia, impaired cardiac ...performance, neuromuscular problems, mechanical ventilation-induced injuries, which include barotrauma, volotrauma, atelectrauma, and biotrauma. In order to reduce the adverse effects of general anesthesia, thoracic epidural anesthesia has been recently employed to perform awake thoracic surgery procedures including coronary artery bypass, management of pneumothorax, resection of pulmonary nodules and solitary metastases, lung volume reduction surgery, and even transsternal thymectomy. The results achieved in this early series have been encouraging, although indications and many pathophysiologic aspects remain to be elucidated. In this review we have tried to provide a first-step analysis of the anecdotal reports available in the literature on this topic. We also desired to provide insights into the main physiologic effects of awake thoracic surgery with epidural anesthesia, with particular attention to the several issues raised by its application in patients with chronic obstructive pulmonary disease, which can represent one of the most stimulating challenges in this setting.
Objective We assessed in a randomized study the feasibility and efficacy of awake video-assisted thoracoscopic bullectomy with pleural abrasion to treat spontaneous pneumothorax. Methods Between ...January 2001 and June 2005, a total of 43 patients with primary spontaneous pneumothorax were randomly assigned by computer to undergo video-assisted thoracoscopic bullectomy and pleural abrasion under sole thoracic epidural anesthesia or general anesthesia with single-lung ventilation (control group). Primary outcome measures included technical feasibility and patient satisfaction with anesthesia as scored into 4 grades (from 1, unsatisfactory, to 4, excellent). Secondary outcome measures included global operating room time, assessment of thoracic pain by visual analog pain scale, number of nursing care calls, hospital stay, and recurrences within 12 months. Results In the awake group, technical feasibility was scored as excellent, good, and satisfactory in 8, 7, and 6 patients, respectively. Intergroup comparisons (awake versus control) showed that global operating room time (78.0 ± 20.0 vs 105.0 ± 15.0 minutes, P < .0001), perioperative visual analog pain scale score (2.0 ± 3.0 vs 3.5 ± 2.0, P = .005), nursing care calls (2.0 ± 1 vs 3.0 ± 3.0, P = .017), hospital stay (2.0 ± 1.0 days vs 3.0 ± 1.0 days, P < .0001), and overall costs (€2540 ± €352 vs €3550 ± €435, P < .0001) were significantly better in the awake group. In the awake group, 5 patients (23.8%) could be discharged within the first 24 postoperative hours. One patient in the awake group and 2 patients in the control group had recurrences within 12 months (difference not significant). Conclusion 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 The study objective was to assess in a randomized controlled study (NCT00566839) the comparative results of awake nonresectional or nonawake resectional lung volume reduction surgery. ...Method Sixty-three patients were randomly assigned by computer to receive unilateral video-assisted thoracic surgery lung volume reduction surgery by a nonresectional technique performed through epidural anesthesia in 32 awake patients (awake group) or the standard resectional technique performed through general anesthesia in 31 patients (control group). Primary outcomes were hospital stay and changes in forced expiratory volume in 1 second. During follow-up, the need of contralateral treatment because of loss of postoperative benefit was considered a failure event as death. Results Intergroup comparisons (awake vs control) showed no difference in gender, age, and body mass index. Hospital stay was shorter in the awake group (6 vs 7.5 days, P = .04) with 21 versus 10 patients discharged within 6 days ( P = .01). At 6 months, forced expiratory volume in 1 second improved significantly in both study groups (0.28 vs 0.29 L) with no intergroup difference ( P = .79). In both groups, forced expiratory volume in 1 second improvements lasted more than 24 months. At 36 months, freedom from contralateral treatment was 55% versus 50% ( P = .5) and survival was 81% versus 87% ( P = .5). Conclusions In this randomized study, awake nonresectional lung volume reduction surgery resulted in significantly shorter hospital stay than the nonawake procedure. There were no differences between study groups in physiologic improvements, freedom from contralateral treatment, and survival. We speculate that compared with the nonawake procedure, awake lung volume reduction surgery can offer similar clinical benefit but a faster postoperative recovery.
In the early 2000s, the 'Awake Thoracic Surgery Research Group' at Tor Vergata University began a program of thoracic operations in awake nonintubated patients. To our knowledge this was the first ...program created with this specific purpose. Since then over 1000 tubeless operations have been carried out successfully, making this series one of the widest in the world. Both nononcologic and oncologic conditions were successively approached and major operations for lung cancer are now being performed. Uniportal access was progressively adopted with significant positive outcomes in postoperative recovery, patient acceptance and economical costs. Failure rates due to patient's intolerance and open surgery conversion are progressively reducing. Tubeless thoracic surgery can be accomplished in a safe manner with effective results.
Abstract
Objective: In a prospective non-randomized study, we compared results and costs of non-resectional lung volume reduction surgery (LVRS) performed through awake or non-awake anesthesia that ...was freely chosen by recruited patients. Method: Non-resectional LVRS was performed by epidural anesthesia in 41 patients (awake group) and by general anesthesia in 19 patients (non-awake group). Perioperative outcome included analysis of oxygenation (PaO2/FiO2) at fixed time points and global time spent in the operating room (anesthesia plus surgery plus weaning plus recovery times). Costs were evaluated at discharge. Forced expiratory volume in 1 s (FEV1), plethysmographic residual volume (RVplet) and maximal incremental treadmill test (MITT) score were assessed preoperatively and every 6 months, postoperatively. Results: Perioperative outcome was better in the awake group with better oxygenation 1 h after the operation (P = 0.004) and shorter global in-operating room stay (P ≪ 0.0001). There was no operative mortality. In the awake group, median hospital stay was shorter (6 days vs 7 days, P = 0.006), whereas median hospital charges were lower than in the non-awake group (7800 euros vs 8600 euros, P = 0.006). At 6 months, there was no difference (awake vs non-awake) in median ΔFEV (0.33 l vs 0.28 l, P = 0.09), ΔRV (−0.99 l vs −0.98 l, P = 0.95), and ΔMITT score (1.0 vs 0.75, P = 0.31). Conclusion: In our study, awake non-resectional LVRS was preferred by the majority of patients. It resulted in better perioperative outcome, shorter hospital stay, and lower costs than equivalent procedures performed by non-awake anesthesia. Six months' clinical results were comparable, showing that the awake approach had no impact on late clinical benefit.
The therapeutic effect of thymectomy on myasthenia gravis is not completely understood. Several types of thymectomy varying in approach and extent have been performed. None of these disclosed a neat ...superiority over others. Patients desire thymectomy through small, painless, and cosmetically favorable operations. Video-assisted thoracoscopic surgery (VATS) thymectomy fits all these requests as well as that of the surgeon. Indeed, this approach allows for ample operative space, easy maneuverability, and extended thymectomy. No mortality, low morbidity, faster recovery, short hospital stay, and small economical costs are undoubtedly advantages of VATS over transsternal and transcervical thymectomy. In the near future, the introduction of robotic devices will lead to a new era in the surgery of the thymus. Herein we analyzed our comprehensive experience.
Objective The presence of ectopic thymic tissue has been considered one of the most significant predictors of poor outcome after thymectomy for myasthenia gravis, but the role of active ectopic ...tissue is unknown. The current study analyzed the importance of this factor on post-thymectomy outcome of patients with class III myasthenia gravis. Methods We retrospectively reviewed 106 patients with class III, anti-acetylcholine receptor antibody-positive, nonthymomatous myasthenia gravis (70 female, 36 male; mean age, 41 ± 17 years) who underwent transsternal extended thymectomy between 1980 and 2005. Quality of life was assessed from 1996 with the Short Form 36 questionnaire. Prognosticators were investigated using complete stable remission and normalized component summaries as end points. Results Major morbidity rate was 5% with no perioperative mortality. Ectopic thymic tissue was detected in 51 patients (48%), 34 of whom (67%) presented germinal centers. Complete follow-up was available in 96 patients (mean 160 ± 91 months). Fifty-two patients (54%) achieved complete stable remission, and 20 patients (21%) presented clinical and pharmacologic improvement. Lack of postoperative improvement in physical and psychosocial domains was significantly correlated with active ectopic thymus. At Kaplan–Meier evaluation, duration of symptoms (>12 months) ( P = .04), oropharyngeal involvement ( P = .02), germinal centers ( P = .03), ectopic thymus ( P = .001), and active ectopic thymus ( P < .0001) were negative predictors of complete stable remission. The presence of active ectopic thymus was the most significant negative predictor of complete stable remission at Cox regression ( P = .03). Conclusions Extended thymectomy yields good outcome in patients with nonthymomatous class III myasthenia gravis. The presence of active ectopic thymus was the most significant predictor of poor outcome. These patients should be rigorously followed and undergo early aggressive therapy.
Abstract A retrospective review of a series of consecutive patients was carried out to evaluate the feasibility and the efficacy of a multimodal treatment in the management of stage IVA thymoma at ...first diagnosis. From 1998 to 2008, 18 patients affected by stage IVA thymoma underwent neoadjuvant chemotherapy, surgery and subsequent mediastinal radiation therapy. There were 10 males and 8 females, mean age 54.5 years (range 29–68). Not specific symptoms were present in 12 cases and thymus-related syndromes were reported in 4. Histological subtypes were 1 AB, 2 B1, 4 B2, 7 B3, 1 mixed B1–B2, 1 mixed B1–B3 and 2 mixed B2–B3 thymomas. Neoadjuvant chemotherapy (4 courses of cisplatin-based chemotherapy) was well tolerated in all cases. Those patients demonstrating clinical response at restaging (16/18) received surgical resection: “en-bloc” thymoma, residual thymic tissue and tumour involved organs resection was carried out together with the pleural implants removal. Complete macroscopic resection was achieved 10/16 patients (64%). Postoperative mortality and morbidity were null and 24%, respectively. Adjuvant radiation therapy consisted of 45–54 Gy administered by a 6 MV linear accelerator to the whole mediastinum and previous tumour bed. Mean follow-up was 82 ± 33 months (range 31–143); overall survival was 85% and 53% at 5- and 10-years. Disease-related survival of the entire cohort was 100% and 58% at 5- and 10-years, whereas freedom from relapse survival for patients submitted to complete resection was 58% and 42% at 5- and 10-years. Disease-related survival when complete and not complete resection were considered were 100% and 52% and 72% and 0% at 5- and 10-years respectively ( p = 0.048). Multimodal management based on induction chemotherapy, subsequent surgery and postoperative mediastinal radiation allows a good complete resection rate and it is demonstrated to be a safe and effective treatment to warrant a good long-term survival in stage IVA thymoma patients.
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