Non-intubated minimally-invasive lung surgery in Germany—current status and outlook

Patrick Zardo, Norman Zinne, Alaa Selman, Hayan Merhej, Tobias Goecke,Henning Starke, Daniel Jaeger, Jan Karsten, Axel Haverich

【Abstract】 Lung surgery under spontaneous ventilation (non-intubated video-assisted thoracoscopic surgery, niVATS) picked up a lot of momentum during the past few years.Surgeons and anesthetists alike want to forgo known risks of orotracheal intubation and mechanical ventilation, ranging from local complications,like mucosal injury or even deleterious tracheal laceration and rupture, to increased release of proinflammatory cytokines and diaphragmatic dysfunction secondary to muscle relaxation.Despite initial adoption of VATS in Germany having been slow due to a general reticence towards it in smaller units, major thoracic centers nowadays have well-established minimally invasive programs and even perform minor non-intubated procedures on a regular basis.Experience with major niVATS cases still is sparse across Western Europe, and limited to specialized and highly trained centers, where exceptionally complex and often multimorbid patients can safely undergo lung surgery under spontaneous ventilation.Our group pioneered niVATS lobectomy in Germany back in 2018, and since then we tried to spread the technique by means of multidisciplinary Masterclass-courses held at our center, in which the participant’s initial reticence to perform niVATS often changed to enthusiasm for the procedure.This in turn led several visiting units to start with their own programs, and some of them even reported their initial experience.This article offers a short historic overview of VATS in general, gives an insight into how niVATS got pioneered in Germany and presents the current state of affairs.

【Key words】 Video-assisted thoracoscopic surgery (VATS); Non-intubated video-assisted thoracoscopic surgery (niVATS); Lung surgery in Germany; Major lung resection

Historical notes

Sir Francis Richard Cruise, an Irish urologist, first described a thoracoscopic chest cavity exploration under spontaneous breathing utilizing a cystoscope and a kerosene lamp back in 1866 (1).Some 40 years later, Swedish pneumologist Hans Christian Jacobaeus,considered by and large the father of thoracoscopy (2),propagated his technique of thoracocautery to induce therapeutic pneumothorax in treating tuberculosis.Some of his strategies and tools still live on to this day.Further essential technical innovations, like rodlense-endoscopes as first proposed by British physicist Harold Horace Hopkins back in the 1960s (3) and cold light lamps developed by German inventor Karl Storz (4), pushed technical boundaries and dramatically increased the quality of endoscopic procedures already more than half a century ago.Advent of modern video technology in the late 1970s finally empowered German gynecologist Kurt Karl Stephan Semm to become thefirst surgeon to perform a laparoscopic appendectomy on September 13th1980 in Kiel (5), and inaugurated the age of true minimally invasive surgery.Video-assisted thoracic surgery (VATS) gained momentum during the early 1990s after Italian surgeon Giancarlo Roviario performed the first minimally-invasive anatomical lung resection in Milan (6), and nowadays VATS-lobectomy is considered standard of care in early-stage lung cancer.

Since its humble beginnings more than 150 years ago (7), non-intubated lung surgery has come quite a long way.Following in the footsteps of Cruise and Jacobaeus, Russian surgeonAlexanderAlexandrovitch Wischnewsky published a large series of patients undergoing various thoracic procedures under local anesthesia by conventional thoracotomy as far back as the 1950s (8).Interest in non-intubated lung surgery continuously decreased, after Swedish physician Eric Carlens first introduced one lung ventilation (OLV)through a dedicated tube, initially developed for bronchospirometry, for resection of a tuberculous abscess of the right upper lobe in November 1949 (9).Following an almost 50-years-long hiatus, Tschopp and Nezu “rediscovered” the technique for minor thoracic procedures like treatment of spontaneous pneumothorax (10,11).Eight years later, Abdullatief and co-workers were the first to report successful non-intubated VATS (niVATS)major procedures (12), before Chenet al.published the to date largest series of patients undergoing niVATS-lobectomies with detailed description of their anesthesia and surgery protocols (13,14).Spanish surgeon Diego Gonzalez-Rivas reported the first uniportal niVATS-lobectomy in 2014 (15) and promoted his technique all across the globe ever since.

niVATS in Germany

Initial adoption of minimally invasive techniques for treating lung cancer in Germany has been tedious at best, and first anecdotal reports of successful major VATS resections are still fairly recent.Witteet al.were the first German group to report successful anatomical segmentectomy by VATS for early-stage non-small cell lung cancer (NSCLC) in a series of 20 consecutive patients in 2011, and mentioned a larger series of VATS lobectomies at their center as well (16).VATS lobectomy potentially becoming standard of care in early-stage NSCLC and replacing conventional thoracotomy was first discussed in a German publication in 2012 by Hendrik Dienemann,even though he based his assumption solely on reports from other (international)groups (17).Uniportal VATS, an evolutionary step in becoming ever less invasive, was first reported by Ismail and co-workers for major procedures in 2014 (18).His group based in Berlin demonstrated feasibility of a uniportal approach in performing major resections in 15 patients, although 3 of them had to be converted to conventional thoracotomy.Since then, VATS lobectomy in Germany gradually gained widespread acceptance, and nowadays is by and large considered standard of care in early-stage NSCLC.

Lung surgery under spontaneous ventilation picked up a lot of momentum during the past few years, and since then numerous publications lead to encouraging albeit heterogeneous results.Known risks in intubated procedures range from local complications, like mucosal injury or even deleterious tracheal laceration and rupture (19), increased release of pro-inflammatory cytokines (20) and diaphragmatic dysfunction secondary to muscle relaxation (21).As shown in a fairly recent and extensive meta-analysis, which included 27 publications with more than 2,500 patients, niVATS remains a multifaceted and complex procedure with numerous variables (22).Procedures performed by niVATS range from talk pleurodesis and wedge resection to anatomical lobectomy, and several different forms of analgesia and anesthesia were utilized.This notwithstanding,niVATS fared better than conventional VATS in regards to length of stay (SMD =-0.581, 95% CI: -0.792 to-0.371; P＜0.001; I2=71.7%), duration of procedure (SMD=-0.174, 95% CI: -0.340 to -0.007; P=0.041; I2=59.4%),chest tube duration (SMD =-1.122, 95% CI: -2.208 to -0.036; P=0.043; I2=97.0%; P for heterogeneity＜0.001), complications (OR =0.505, 95% CI: 0.384—0.665; P＜0.001; I2=0.0%) and mortality (OR =0.123,95% CI: 0.021—0.717; P=0.020; I2=0.0%).Despite likely being biased and suffering from a general lack of randomized studies, this meta-analysis is encouraging and suggests that 2 distinct forms of niVATS exist: Major and minor resections.A plethora of publications on minor niVATS surgery, mostly stemming from southern Europe, conclusively demonstrates its feasibility (23-25).Procedures like talc pleurodesis, pleurectomy or wedge resection aren’t technically challenging, and easily doable under spontaneous breathing as well.Anatomical lung resection in this setting is far more demanding, and published literature still is sparse.The largest series to date was first presented by Jin-Shing Chen and coworkers back in 2011 (13).Excellent short-term results were recently backed-up by just as good long-termdata (26), confirming feasibility of niVATS lobectomy in experienced hands.

In conjunction with Diego Gonzales-Rivas, ourgroup pioneered niVATS lobectomy in Germany back in 2018 (27).A more detailed breakdown of our technique stresses the need for dedicated multidisciplinary and multiprofessional teams of surgeons and anesthesiologists to successfully start a niVATS program (28).Only through close cooperation from initial regional pain management, to intraprocedural vagal nerve blockade and/or sedation and postoperative pain control, highly complex and often multimorbid patients can safely undergo lung surgery under spontaneous ventilation.

Recently, a survey among German thoracic surgeons confirmed that several national centers successfully started dedicated niVATS-programs (29), with 32 out of 157 Lung Cancer units regularly performing minor and 3 units even performing major niVATS procedures.Despite widespread skepticism in regards to technical feasibility and reasonability of niVATS in Germany (30), it’s adoption-rate continuously increases.A motor of this development certainly were multidisciplinary Masterclass-courses held at our center, in which the participant’s initial reticence to perform niVATS often changed to enthusiasm for the procedure.This in turn led several visiting units to start with their own programs, and some of them even reported their initial experience (31).As in most other Western European countries, minor niVATS procedures in Germany are slowly becoming standard of care in treating selected pathologies, but major resections remain restricted to dedicated centers.As only very limited data on major niVATS procedures in Western Europe is available, including Diego Rivas mention of 30 niVATS lobectomies performed in Spain back in 2014 (32),we decided to present our own initial experience (32).During the first 18 months of our niVATS program (33)we performed 25 lobectomies and 15 segmentectomies with no early mortality and a low overall morbidity rate of 28.4%.Conversion to orotracheal intubation was required in 6.8% of all cases, and postoperative pulmonary complications occurred in 15.9% of patients.Interestingly, our complication rate was lower than predicted by both LAS VEGAS (Local Assessment of Ventilatory Management During General Anaesthesia for Surgery) and ARISCAT (Assess Respiratory Risk in Surgical Patients in Catalonia) scores respectively.Additionally, cardiac complications were found in only 1.1% of patients, and thus lower than predicted by Thoracic Revised Cardiac Risk Index (ThRCRI).Despite postoperative chest tube duration and hospital length of stay exceeding times reported by other groups,we deemed niVATS major pulmonary resections to be feasible in a German tertiary care setting.

Bottom line

Even though initial adoption of niVATS in Germany has been slow, several centers nowadays routinely perform minor non-intubated lung surgery procedures in selected patients.Experience with major niVATS remains very limited all across Western Europe, and is often reserved to large Centers.

AcknowledgmentsFunding:None.

Footnote

Provenance and Peer Review:This article was commissioned by the editorial office,Chinese Journal of Thoracic Surgeryfor the “International Thoracic Surgery Column”.The article has undergone external peer review.

Conflicts of Interest:The authors have completed the ICMJE uniform disclosure form (available at https://dx.doi.org/10.3877/cma.j.issn.2095-8773.2021.04.01).The “International Thoracic Surgery Column” was commissioned by the editorial office without any funding or sponsorship.Dr.PZ serves as an unpaid editorial board member ofChinese Journal of Thoracic Surgeryfrom May 2021 to April 2023.The authors have no other conflicts of interest to declare.

Ethical Statement:The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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