Szabo Zsolt, Fabo Csongor, Oszlanyi Adam, Hawchar Fatime, Géczi Tibor, Lantos Judit, Furák Jozsef
Tritonlife Szeged Hospital, Szeged, Hungary.
Department of Anesthesiology and Intensive Care, University of Szeged, Szeged, Hungary.
J Thorac Dis. 2022 Aug;14(8):3045-3060. doi: 10.21037/jtd-22-80.
Thanks to the growing experience with the non-intubated anesthetic and surgical techniques, most pulmonary resections can now be performed by using minimally invasive techniques. The conventional method, i.e., surgery on the intubated, ventilated patient under general anesthesia with one-lung ventilation (OLV) was considered necessary for the major thoracoscopic lung resections for all patients. An adequate analgesic approach (regional or epidural anesthesia) allows video-assisted thoracoscopy (VATS) to be performed in anesthetized patients and thus the potential adverse effects related to general anesthesia and mechanical OLV can be minimized.
Multiple medical literature databases (PubMed, Google Scholar, Scopus) were searched, using the terms [(non-intubated) OR (nonintubated) OR (tubeless) OR (awake)] AND [(thoracoscopic surgery)] from 2004 to December 2021. Thirty hundred and six scientific papers were collected. The editorials, commentaries, letters, and papers were excluded, that focus on other than the non-intubated (aka awake or tubeless) VATS technique, as well as the full text scientific papers available in languages other than English.
After reviewing the literature, we identified "schools" with different techniques but with very similar results. Most of the differences were in the anesthetic technique, oxygenation and analgesia, however, the immunological results, and the qualitative parameters (inpatient hospital care days, complication rate, mortality) of the perioperative period showed great similarity, in addition, all three schools identified the same risk factors (hypoxia, hypercapnia, airway safety). The combination of spontaneous ventilation with double lumen tube intubation, called VATS-spontaneous ventilation with intubation (SVI) method seems to be suitable for reducing these risk factors, which may serve as an alternative for patients not suitable for the non-intubated technique in the near future.
Based on the results, non-intubated thoracic surgery appears to be an increasingly widespread, safe procedure, that will be available to a wider range of patients as experience expands and by the implication of the constantly evolving new processes.
随着非插管麻醉和手术技术经验的不断积累，目前大多数肺切除术都可采用微创技术进行。传统方法，即在全身麻醉下单肺通气（OLV）的情况下对插管并通气的患者进行手术，曾被认为是所有患者进行主要胸腔镜肺切除术所必需的。适当的镇痛方法（区域麻醉或硬膜外麻醉）可使视频辅助胸腔镜手术（VATS）在麻醉患者中进行，从而将与全身麻醉和机械性OLV相关的潜在不良影响降至最低。
使用[(非插管)或(非插管的)或(无管的)或(清醒的)]与[(胸腔镜手术)]这些术语，在2004年至2021年12月期间对多个医学文献数据库（PubMed、谷歌学术、Scopus）进行检索。共收集到306篇科学论文。排除了关注非插管（即清醒或无管）VATS技术以外内容的社论、评论、信函和论文，以及非英文语言的全文科学论文。
在回顾文献后，我们确定了采用不同技术但结果非常相似的“流派”。大多数差异在于麻醉技术、氧合和镇痛，然而，围手术期的免疫学结果以及定性参数（住院天数、并发症发生率、死亡率）显示出高度相似性，此外，所有三个流派都确定了相同的风险因素（低氧、高碳酸血症、气道安全）。自发通气与双腔气管插管相结合的方法，即VATS - 自发通气伴插管（SVI）方法，似乎适合降低这些风险因素，在不久的将来可能成为不适合非插管技术患者的替代方法。
基于这些结果，非插管胸外科手术似乎是一种越来越广泛应用且安全的手术方式，随着经验的积累以及不断发展的新流程的应用，将有更多患者能够接受该手术。
