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Nonintubated thoracoscopic lobectomy for lung cancer using epidural anesthesia and intercostal blockade: a retrospective cohort study of 238 cases.

Hung MH, Chan KC, Liu YJ, Hsu HH, Chen KC, Cheng YJ, Chen JS - Medicine (Baltimore) (2015)

Bottom Line: 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.

View Article: PubMed Central - PubMed

Affiliation: From the Department of Anesthesiology (MHH, KCC, YJL, YJC); Graduate Institute of Clinical Medicine (MHH, KCC); Division of Thoracic Surgery (HHH, KCC, JSC), Department of Surgery; and Department of Traumatology (JSC), National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.

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.

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Related in: MedlinePlus

Local infiltration of bupivacaine to produce (A) intercostal blocks with a 25-gauge top-winged infusion needle and (B) intrathoracic vagal block with a long-needle instrument in a representative patient undergoing right-sided nonintubated thoracoscopic lobectomy. The right-sided vagus nerve (arrow) runs between the superior vena cava (SVC) and the lower trachea (T).
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Figure 1: Local infiltration of bupivacaine to produce (A) intercostal blocks with a 25-gauge top-winged infusion needle and (B) intrathoracic vagal block with a long-needle instrument in a representative patient undergoing right-sided nonintubated thoracoscopic lobectomy. The right-sided vagus nerve (arrow) runs between the superior vena cava (SVC) and the lower trachea (T).

Mentions: For patients undergoing INB, a thoracoscopy port in the midaxillary line and a working port in the auscultatory triangle were initially created after local infiltration with 2% lidocaine. After collapse of the lung undergoing lobectomy, INBs were then produced using direct thoracoscopic vision by infiltration of 0.5% bupivacaine (1.5 mL for each intercostal space) from the third to the eighth intercostal nerves by instillation with a 25-gauge, top-winged infusion needle under the parietal pleura, 2 cm lateral to the sympathetic chain (Figure 1A).17


Nonintubated thoracoscopic lobectomy for lung cancer using epidural anesthesia and intercostal blockade: a retrospective cohort study of 238 cases.

Hung MH, Chan KC, Liu YJ, Hsu HH, Chen KC, Cheng YJ, Chen JS - Medicine (Baltimore) (2015)

Local infiltration of bupivacaine to produce (A) intercostal blocks with a 25-gauge top-winged infusion needle and (B) intrathoracic vagal block with a long-needle instrument in a representative patient undergoing right-sided nonintubated thoracoscopic lobectomy. The right-sided vagus nerve (arrow) runs between the superior vena cava (SVC) and the lower trachea (T).
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4554018&req=5

Figure 1: Local infiltration of bupivacaine to produce (A) intercostal blocks with a 25-gauge top-winged infusion needle and (B) intrathoracic vagal block with a long-needle instrument in a representative patient undergoing right-sided nonintubated thoracoscopic lobectomy. The right-sided vagus nerve (arrow) runs between the superior vena cava (SVC) and the lower trachea (T).
Mentions: For patients undergoing INB, a thoracoscopy port in the midaxillary line and a working port in the auscultatory triangle were initially created after local infiltration with 2% lidocaine. After collapse of the lung undergoing lobectomy, INBs were then produced using direct thoracoscopic vision by infiltration of 0.5% bupivacaine (1.5 mL for each intercostal space) from the third to the eighth intercostal nerves by instillation with a 25-gauge, top-winged infusion needle under the parietal pleura, 2 cm lateral to the sympathetic chain (Figure 1A).17

Bottom Line: 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.

View Article: PubMed Central - PubMed

Affiliation: From the Department of Anesthesiology (MHH, KCC, YJL, YJC); Graduate Institute of Clinical Medicine (MHH, KCC); Division of Thoracic Surgery (HHH, KCC, JSC), Department of Surgery; and Department of Traumatology (JSC), National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.

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.

Show MeSH
Related in: MedlinePlus