Akil Ali, Rehers Stephanie, Ziegeler Stephan, Ernst Erik, Haselmann Jan, Dickgreber Nicolas Johannes, Fischer Stefan
Department of Thoracic Surgery and Lung Support, Ibbenbueren General Hospital, 49477 Ibbenbueren, Germany.
Department of Anesthesiology, Intensive Care Medicine and Pain Management, Ibbenbueren General Hospital, 49477 Ibbenbueren, Germany.
J Clin Med. 2023 May 29;12(11):3750. doi: 10.3390/jcm12113750.
Lung volume reduction surgery (LVRS) represents an important treatment option in carefully selected patients with end-stage lung emphysema. The aim of this study was to assess the efficacy and safety of nonintubated LVRS compared to intubated LVRS in patients with preoperative hypercapnia and lung emphysema. Between April 2019 and February 2021, n = 92 patients with end-stage lung emphysema and preoperative hypercapnia undergoing unilateral video-assisted thoracoscopic LVRS (VATS-LVRS) performed in epidural anesthesia and mild sedation (nonintubated, group 1) or conventional general anesthesia (intubated, control, group 2) were prospectively enrolled in this study. Data were retrospectively analyzed. In all patients, low-flow veno-venous extracorporeal lung support (low-flow VV ECLS) was applied as a bridge through LVRS. Ninety-day mortality was considered as the primary outcome. Secondary endpoints included: chest tube duration, hospital stay, intubation and conversion to general anesthesia. Intergroup analysis showed no significant difference between the baseline data and patients' demographics. N = 36 patients underwent nonintubated surgery. VATS-LVRS under general anesthesia was performed in n = 56 patients. The mean duration of postoperative VV ECLS support was 3 ± 1 day in group 1 compared to 4 ± 1 in group 2. The 90-day mortality rate was 3% in group 1 compared to 7% in group 2. In group 1, all chest tubes were removed 5 ± 1 day (range 4-32 days) and 8 ± 1 day (range 4-44 days) in the control group after the surgery ( < 0.02). Prolonged chest tube therapy (>8 days) was observed in n = 3 patients in group 1 and n = 11 patients in the control group. The mean ICU stay was 4 ± 1 days in group 1 compared to 8 ± 2 days in the control group ( = 0.04). The mean hospital stay was significantly shorter in the nonintubated group 1 (6 ± 2 days vs. 10 ± 4 days, = 0.01). Conversion to general anesthesia was necessary in one patient due to severe pleural adhesions. Nonintubated VATS-LVRS in patients with end-stage lung emphysema and hypercapnia is effective and well tolerated. Compared to general anesthesia, a reduction in mortality, chest tube duration, ICU and hospital stay and lower rate of prolonged air leak was observed. VV ECLS increases intraoperative safety and mitigates postoperative complications in such "high-risk" patients.
肺减容手术（LVRS）是精心挑选的终末期肺气肿患者的一种重要治疗选择。本研究的目的是评估在术前存在高碳酸血症的肺气肿患者中，非插管LVRS与插管LVRS相比的疗效和安全性。在2019年4月至2021年2月期间，前瞻性纳入了n = 92例终末期肺气肿且术前存在高碳酸血症、接受单侧电视辅助胸腔镜LVRS（VATS-LVRS）的患者，这些患者在硬膜外麻醉和轻度镇静下进行手术（非插管，第1组）或接受传统全身麻醉（插管，对照组，第2组）。对数据进行回顾性分析。所有患者均应用低流量静脉-静脉体外肺支持（低流量VV ECLS）作为LVRS的过渡手段。90天死亡率被视为主要结局。次要终点包括：胸管留置时间、住院时间、插管情况以及转为全身麻醉的情况。组间分析显示基线数据和患者人口统计学特征之间无显著差异。n = 36例患者接受了非插管手术。n = 56例患者在全身麻醉下进行了VATS-LVRS。第1组术后VV ECLS支持的平均持续时间为3±1天，而第2组为4±1天。第1组的90天死亡率为3%，第2组为7%。在第1组，术后所有胸管在5±1天（范围4 - 32天）拔除，对照组为8±1天（范围4 - 44天）（P<0.02）。第1组有3例患者和对照组有11例患者观察到胸管治疗时间延长（>8天）。第1组的平均ICU住院时间为4±1天，对照组为8±2天（P = 0.04）。非插管的第1组平均住院时间显著更短（6±2天对10±4天，P = 0.01）。1例患者因严重胸膜粘连而有必要转为全身麻醉。终末期肺气肿和高碳酸血症患者的非插管VATS-LVRS有效且耐受性良好。与全身麻醉相比，观察到死亡率、胸管留置时间、ICU和住院时间降低，以及长时间漏气率降低。VV ECLS提高了此类“高危”患者的术中安全性并减轻了术后并发症。
