Ya-Jung Cheng

Nonintubated thoracoscopic lobectomy for lung cancer.

Objective:To evaluate the feasibility and safety of thoracoscopic lobectomy without endotracheal intubation. Summary Background Data:General anesthesia with single-lung ventilation is considered mandatory for thoracoscopic lobectomy for non–small cell lung cancer (NSCLC). Nonintubated thoracoscopic lobectomy has not been reported previously. Methods:From August 2009 through June 2010, some 30 consecutive patients with clinical stage I or II NSCLC were treated by nonintubated thoracoscopic lobectomy using epidural anesthesia, intrathoracic vagal blockade, and sedation. To evaluate the feasibility and safety of this novel technique, they were compared with a control group consisting of 30 consecutive patients with clinical stage I or II NSCLC who underwent thoracoscopic lobectomy using intubated general anesthesia from August 2008 through July 2009. Results:Collapse of the operative lung and inhibition of coughing were satisfactory in the nonintubated patients, induced by spontaneous breathing, and vagal blockade. Three patients in the nonintubated group required conversion to intubated-single lung ventilation because of persistent hypoxemia, poor epidural anesthesia pain control, and bleeding. One patient in each group was converted to thoracotomy because of bleeding. The 2 groups had comparable anesthesia durations, surgical durations, blood loss, and numbers of dissected lymph nodes. Patients who underwent nonintubated surgery had lower rates of sore throat (6.7% vs 40.0%, P = 0.002) and earlier resumption of oral intake (mean, 4.7 hours vs 18.8 hours, P < 0.001). Patients undergoing nonintubated surgery also had a trend toward better noncomplication rates (90% vs 66.7%, P = 0.057) and shorter postoperative hospital stays (mean, 5.9 days vs 7.1 days, P = 0.078). Conclusions:Nonintubated thoracoscopic lobectomy is technically feasible and is as safe as lobectomy performed with intubation in highly selected patients. It can be a valid alternative of single-lung-ventilated thoracoscopic surgery in managing early-stage NSCLC.

Small-dose Propofol sedation attenuates the formation of reactive oxygen species in tourniquet-induced ischemia-reperfusion injury under spinal anesthesia

The release of a tourniquet produces reactive oxygen species (ROS), which can cause ischemia-reperfusion injury. We investigated the effects on ROS production in 22 adult ASA physical status I–II patients sedated with small-dose propofol infusion and IV midazolam undergoing elective total knee replacement under intrathecal anesthesia, allocated randomly to one of two groups. In the Propofol group, sedation was performed with propofol 0.2 mg/kg followed by infusion at a rate of 2 mg · kg−1 · h−1. In the Control group, IV midazolam 5 mg was given. ROS production was measured by lucigenin chemiluminescence analysis. Blood samples were obtained from the radial artery after spinal anesthesia, 1 min before release of the tourniquet and 5 and 20 min after reperfusion. The ischemic time was approximately 70 min. ROS production decreased nonsignificantly before reperfusion in both groups but increased significantly 5 and 20 min after reperfusion in the Midazolam group. In the Propofol group, no significant increase of ROS production was found. We conclude that small-dose propofol infusion attenuates ROS production in tourniquet-induced ischemia-reperfusion injury.

Low dose of intrathecal hyperbaric bupivacaine combined with epidural lidocaine for cesarean section--a balance block technique.

The present study was designed to develop a combined spinal/epidural anesthetic technique for cesarean section. We compared the effects of different doses of intrathecal hyperbaric bupivacaine (0.5%) combined with epidural lidocaine (2%). We attempted to interrupt somatosensory pathways with spinal anesthesia but to avoid acute high thoracic sympathetic block. The visceral afferent pathways were to be blocked relatively slowly with epidural lidocaine. Eighty term parturients were randomly divided into four groups. In Group A, 2.5 mg of bupivacaine intrathecally combined with 22.2 +/- 4.6 mL of lidocaine epidurally provided insufficient muscle relaxation. In Group B, 5 mg of bupivacaine with 10.1 +/- 2.0 mL of lidocaine resulted in satisfactory anesthesia with rapid onset and minimum side effects. Anesthesia in Group C (7.5 mg of bupivacaine) and Group D (10 mg of bupivacaine) was mostly due to spinal block. Complications included hypotension, nausea, and dyspnea. The combined spinal/epidural technique, using 5 mg of bupivacaine and with sufficient epidural lidocaine to reach a T4 level, had the advantages of both spinal and epidural anesthesia with few of the complications of either.

Nonintubated thoracoscopic lung resection: a 3-year experience with 285 cases in a single institution.

OBJECTIVE Tracheal intubation with one-lung ventilation is considered mandatory for thoracoscopic surgery. This study reported the experience of thoracoscopic lung resection without endotracheal intubation in a single institution. METHODS From August 2009 through July 2012, 285 consecutive patients were treated by nonintubated thoracoscopic surgery using epidural anesthesia, intrathoracic vagal blockade, and sedation for lobectomy, segmentectomy, or wedge resection in a tertiary medical center. The feasibility and safety of this technique were evaluated. RESULTS The final diagnosis for surgery were primary lung cancer in 159 patients (55.8%), metastatic lung cancer in 17 (6.0%), benign lung tumor in 104 (36.5%), and pneumothorax in 5 (1.8%). The operative methods consisted of conventional (83.2%) and needlescopic (16.8%) thoracoscopic surgery. The operative procedures included lobectomy in 137 patients (48.1%), wedge resection in 132 (46.3%), and segmentectomy in 16 (5.6%). Collapse of the operative lung and inhibition of coughing were satisfactory in most of the patients. Fourteen (4.9%) patients required conversion to tracheal intubation because of significant mediastinal movement [5], persistent hypoxemia [2], dense pleural adhesions [2], ineffective epidural anesthesia [2], bleeding [2], and tachypnea [1]. One patient (0.4%) was converted to thoracotomy because of bleeding. No mortality was noted in our patients. CONCLUSIONS Nonintubated thoracoscopic lung resection is technically feasible and safe in selected patients. It can be a valid alternative in managing patients with pulmonary lesions.

Feasibility and Safety of Nonintubated Thoracoscopic Lobectomy for Geriatric Lung Cancer Patients

BACKGROUND The feasibility and safety of thoracoscopic lobectomy using anesthesia without tracheal intubation for treatment of geriatric non-small cell lung cancer patients is unclear, although it has been used with success in younger populations. METHODS From 2009 through 2011, 84 consecutive patients aged 65 years or older with stage I or II non-small cell lung cancer underwent thoracoscopic lobectomy. Among them, 36 patients were treated without tracheal intubation using epidural anesthesia, intrathoracic vagal blockade, and sedation (nonintubated group). The other 48 patients were treated with single-lung ventilation under general anesthesia intubated with a double-lumen tube (intubated group). The perioperative profiles and short-term outcomes of the two groups were compared. RESULTS The 84 patients were a mean age of 73.0 years (range, 65-87 years). Both groups had comparable preoperative demographic and cancer staging profiles. The anesthetic duration of the nonintubated group was shorter. Both groups had comparable operation duration and blood loss. One patient in the nonintubated group was converted to tracheal intubation due to persistent hypoxemia. Postoperatively, the two groups had comparable hospital stays, complication rates, and dissected lymph nodes. Stridor was noted in 3 patients and delirium in 4 in the intubated group, but none occurred in the nonintubated group. CONCLUSIONS Nonintubated thoracoscopic lobectomy is technically feasible and was as safe as thoracoscopic lobectomy performed with tracheal intubation in the geriatric lung cancer patients. Thoracoscopic lobectomy without tracheal intubation during anesthesia is a valid alternative for managing selected geriatric patients with non-small cell lung cancer.

Nonintubated Needlescopic Video-Assisted Thoracic Surgery for Management of Peripheral Lung Nodules

BACKGROUND Video-assisted thoracic operations are usually performed with 5-mm or 10-mm instruments under general anesthesia with single-lung ventilation. Management of peripheral lung nodules by a needlescopic video-assisted thoracoscopic operation, without endotracheal intubation, has rarely been attempted. We evaluated the feasibility and safety of this minimally invasive technique in managing peripheral lung nodules. METHODS From August 2009 through March 2011, 46 patients with peripheral lung nodules were treated using 3-mm needlescopic video-assisted thoracoscopic operations for wedge resection with epidural anesthesia and sedation, without endotracheal intubation. RESULTS A definitive diagnosis was obtained in all 46. Extension of the 3-mm incisions was required in 8 patients because of primary lung cancer requiring a lobectomy in 3, pleural adhesions in 3, and difficulty in identifying or resecting the nodule in 2. Two patients required conversion to intubated single-lung ventilation because of dense adhesions between the lungs and the diaphragm. Operations lasted a mean of 69.2 ± 46.8 minutes. Postoperative side effects occurred in 4 patients, including sore throat, headache, and vomiting requiring medication. Operative complications developed in 1 patient who had air leaks for more than 3 days postoperatively. The mean postoperative chest tube drainage and hospital stay were 1.1 days and 2.7 days, respectively. Postoperative neuralgia was noted in 12 patients (26%). Most patients (74%) were very satisfied or satisfied with the resulting scars. CONCLUSIONS Nonintubated needlescopic video-assisted thoracoscopic operations are technically feasible and safe and may be a less invasive alternative in the management of selected patients with peripheral pulmonary nodules.

Epidemiological Characteristics of Twinning Rates in Taiwan

Delivery records of public hospitals and birth certificates of household registration offices were examined to study the epidemiological characteristics of twinning rate from 1955 to 1984 in Taiwan. The MZ twinning rate was consistently higher than the DZ rate during the study period. The DZ rate declined steadily from 2.7 per 1000 in 1955 to 1.3 per 1000 in 1975, and then gradually increased to 3.6 per 1000 in 1984. The MZ rate peaked periodically in 1956, 1966 and 1976, and gradually increased from 3.3 per 1000 in 1978 to 5.9 per 1000 in 1986. Both MZ and DZ rates were higher in urban than in rural areas and they were also higher in northern Taiwan than elsewhere in the island. While both MZ and DZ rates increased with maternal age and parity, the maternal age difference and the parity difference were more striking in DZ than in MZ rates. The international comparison also showed a greater racial difference in maternal age-specific DZ than MZ twinning rates; and the older the maternal age, the greater the international discrepancy in DZ rates.

The Effect of Carrier Intravenous Fluid Speed on the Injection Pain of Propofol

P ain is a common side effect during propofol injection (1). Pain intensity can be reduced by injecting the drug into a larger vein in the antecubital fossa (1,2) or by diluting it with Intralipid or 5% dextrose (3,4). Nevertheless, injection into a fastflowing intravenous infusion did not have the expected effect (5,6). Moreover, it is reported that increasing diluent flow increases the pain associated with injection. There is less pain when the carrier intravenous (IV) fluid is stopped completely and only undiluted propofol is infused (7). Since this finding has not been proved, we designed this randomized, double-blind study to investigate whether the speed of carrier IV fluid would influence the intensity of pain.

Graft failure caused by pulmonary venous obstruction diagnosed by intraoperative transesophageal echocardiography during lung transplantation

IMPLICATIONS Intraoperative transesophageal echocardiography can be useful to diagnose pulmonary venous anastomotic stenoses during lung transplantation.

Nonintubated thoracoscopic surgery using regional anesthesia and vagal block and targeted sedation

OBJECTIVE Thoracoscopic surgery without endotracheal intubation is a novel technique for diagnosis and treatment of thoracic diseases. This study reported the experience of nonintubated thoracoscopic surgery in a tertiary medical center in Taiwan. METHODS From August 2009 through August 2013, 446 consecutive patients with lung or pleural diseases were treated by nonintubated thoracoscopic surgery. Regional anesthesia was achieved by thoracic epidural anesthesia or internal intercostal blockade. Targeted sedation was performed with propofol infusion to achieve a bispectral index value between 40 and 60. The demographic data and clinical outcomes were evaluated by retrospective chart review. RESULTS Thoracic epidural anesthesia was used in 290 patients (65.0%) while internal intercostal blockade was used in 156 patients (35.0%). The final diagnosis were primary lung cancer in 263 patients (59.0%), metastatic lung cancer in 38 (8.5%), benign lung tumor in 140 (31.4%), and pneumothorax in 5 (1.1%). The median anesthetic induction time was 30 minutes by thoracic epidural anesthesia and was 10 minutes by internal intercostal blockade. The operative procedures included lobectomy in 189 patients (42.4%), wedge resection in 229 (51.3%), and segmentectomy in 28 (6.3%). Sixteen patients (3.6%) required conversion to tracheal intubation because of significant mediastinal movement (seven patients), persistent hypoxemia (two patients), dense pleural adhesions (two patients), ineffective epidural anesthesia (two patients), bleeding (two patients), and tachypnea (one patient). One patient (0.4%) was converted to thoracotomy because of bleeding. No mortality was noted in our patients. CONCLUSIONS Nonintubated thoracoscopic surgery is technically feasible and safe and can be a less invasive alternative for diagnosis and treatment of thoracic diseases.