Article Abstract

Awake non-intubated pulmonary metastasectomy

Authors: Vincenzo Ambrogi, Gianluca Perroni, Tommaso Claudio Mineo


Background: Pulmonary metastasectomy has been progressively considered a procedure feasible through a thoracoscopic approach under awake non-intubated anesthesia.
Methods: Since 2000 we established the program named “Awake Thoracic Surgery Research” under the guidance of Prof. Tommaso Claudio Mineo. To our knowledge, this program is the first in the world to be created for this specific purpose. From the beginning until 2005 procedures were carried out in an awake patient under thoracic epidural anesthesia and triportal approach. From 2005 onwards we shifted to an intercostal blockade and sedation controlled by bispectral index analysis through an uniportal approach.
Results: From 2000 to 2018 a total of 106 patients underwent lung metastasectomy: 14 with triportal and 92 with uniportal approach. Only 7 (6.6%) patients required the conversion to general anesthesia for intolerance of the procedure or technical difficulties. Median operative time was 31 [interquartile range, 23–53] minutes and a global in-operatory room stay was 51 [39–62] minutes per procedure. Multiportal video-assisted thoracic surgery (VATS) had a shorter operating time but compensated by the longer time for establishing effective thoracic epidural anesthesia. No mortality was documented. Major morbidity affected 6 patients (6.1%). Hospital stay was 3 [2–4] days. Not even in this case differences between group were evidenced. Overall survival at 3 years was 49%. No difference was correlated to the type of approach.
Conclusions: Selection for awake non-intubated lung metastasectomy should include patients with peripheral oligometastases easy to palpate and small enough to be safely resected with a limited number of staple firing.