For the present case, postoperative severe vomiting is presumed to be the reason for the onset of BS. BS mainly results from severe vomiting (forceful emesis) which is one of the most stressful complications of general anesthesia. The incidence of post-discharge vomiting after ambulatory surgery is approximately 30% [8]. Pain and vomiting always suggest the diagnosis of BS, but the patients don't always present with typical clinical features. A retrospective review showed that surgery should be considered regardless of the time after onset [9], especially for those who were admitted within 24 hours of perforation [10, 11]. Endoscopic management plays a vital role in the treatment of transmural defects [12], but evidence-based recommendation is still lacking to date. Moreover, naso-esophageal extraluminal drainage has been reported to be effective for the treatment of anastomotic leaks and subsequent mediastinal abscess [13].
Non-intubated VATS under minimal sedation with local or regional anaesthesia is useful to avoid postoperative nausea and vomiting [14]. However, the evidence supporting non-intubated VATS as the preferred approach for lung surgery is still limited. Previous meta-analyses reported that non-intubated procedure attenuated the inflammatory response and stress, followed by fewer postoperative complications as compared with the intubated VATS [15, 16]. Moreover, the indications for VATS could be extended by this less-invasive procedure. For example, patients with impaired lung function or chronic obstructive pulmonary disease are considered as high-risk for intubated general anesthesia; whereas the non-intubated VATS may be applied in these cases [17]. On the other hand, non-intubated VATS may be a better alternative to intubated surgery owing to its advantages [18]. However, given the potential emergencies including but not limited to the persistent hypoxemia, carbon dioxide retention, and extensive pleural adhesions, non-intubated anesthesia in lung resection surgery requires extra vigilance to ensure the safety of the patients [19]. Moreover, the other disadvantages of non-intubated thoracic surgery include cough and poor maneuverability due to the movements of the diaphragm and lung [20].
Although it is still premature to declare the superiority of non-intubated lung surgery versus the intubated procedure, there is an obvious trend for more and better studies to be introduced. The updated evidence in terms of the feasibility and safety of non-intubated thoracic surgery should be clarified. We searched PubMed, Web of Science, Scopus, Embase, Europe PMC, Cochrane Library and Google Scholar for randomized controlled trials (RCTs) up to June 2020 based on Population, Intervention, Comparator, and Outcomes framework according to the PRISMA Protocol. Key words and MeSH terms in title or abstract including “non-intubated” or “tubeless” or “awake” and “pulmonary” or “lung” and “surgery” were used. No restriction was made regarding the publication language. Finally a total of 13 reported RCTs were summarized in Table 1, which covered 627 patients who underwent non-intubated or tubeless VATS. Among them, 11 (1.8%) morbidities due to gastrointestinal reactions were recorded. Based on the findings from the literature review, non-intubated VATS is technically feasible with a satisfactory safe profile; however, the results should be interpreted with caution due to the potential bias and small samples. Further studies are warranted to elucidate the specific indications of conversion from sedation to intubated general anaesthesia as well as the reliable management of perioperative emergencies such as persistent hypoxemia, and carbon dioxide retention. The registered trials regarding non-intubated thoracic surgery were listed in Table 2.
Table 1
The reported randomized clinical trials regarding non-intubated thoracoscopic lung surgery
First author, year | Sample | Age, year | Anaesthesia method | Surgical procedure | Conversion to intubation | Postoperative analgesia | Morbidity due to gastrointestinal reactions |
Pompeo, 2004 [21] | 30 | 60 (45–68) | TEA at T4-T5 | Pulmonary nodule resection | 4 (13.3%) | TEA | NA |
Pompeo, 2007 [22] | 21 | 28 ± 14 | Locoregional anaesthesia | Bullectomy | 0 | TEA | 1 (4.8%) |
Vanni, 2010 [23] | 25 | 57 (51–62) | TEA | NA | 0 | PCIA | 0 |
Tacconi, 2010 [24] | 11 | 48 (43–55) | TEA | Lung nodule resection, bullectomy, pleura-lung biopsy | 0 | PCIA | 0 |
Pompeo, 2011 [25] | 32 | 64 ± 9 | TEA at T4-5 | Lung volume reduction | 2 (6.3%) | NA | 0 |
Pompeo, 2013 [26] | 20 | 67 ± 12 | TEA at T4 | Pleurodesis | 0 | NA | 0 |
Cai, 2013 [27] | 30 | 23.5 ± 10.6 | Laryngeal mask anesthesia | Bullectomy | 0 | PCIA | 3 (10.0%) |
Wang, 2014 [28] | 50 | 43.2 ± 14.7 | General anesthesia; laryngeal mask | Bullectomy, lobectomy, biopsy, mediastinal mass excision | 0 | NA | 0 |
Liu, 2015 [29] | 167 | NA | TEA | Wedge resection, lobectomy | 0 | NA | 4 (2.4%) |
Chen, 2016 [30] | 85 | 23.3 ± 6.8 | Intravenous anesthesia | Sympathectomy | 0 | NA | 0 |
Mao, 2018 [31] | 30 | 21 ± 3.2 | General anesthesia + laryngeal mask | NUSS procedure | 0 | PCIA | 3 (10.0%) |
Hwang, 2018 [32] | 21 | 17 (17–45) | Sedation anesthesia | Bullectomy | 0 | Local analgesia | 0 |
Mogahed, 2019 [33] | 35 | 42.9 ± 9.6 | General anaesthesia | Lung resections, excision/biopsy of mediastinal mass, foreign body extraction and pericardial window. | 0 | Intramuscular ketoprofen | NA |
35 | 43.5 ± 10.5 | General anaesthesia + TEA |
35 | 44.0 ± 9.3 | General anaesthesia + intercostal block infiltration |
Abbreviations: TEA, thoracic epidural anesthesia; PCIA, patient controlled intravenous analgesia; NA, not available. |
Table 2
The registered trials of non-intubated or tubeless thoracoscopic lung surgery
Registration identifier | Year | Disease | Anaesthesia method | Estimated enrollment | Major outcomes | Status | Country |
NCT00566839 | 2007 | Emphysema | TEA | 60 | Mortality, FEV1, dyspnea index | Completed | Italy |
NCT01469728 | 2011 | NA | TEA | 40 | Grade of medical care | Completed | Italy |
NCT01677442 | 2011 | NA | TEA at the T5/T6 | 500 | Recovery time | Unknown | China |
NCT01533233 | 2012 | Lung cancer | NA | 100 | Complication and morbidity | Unknown | China |
NCT02109510 | 2014 | Pneumothorax | Sedation anesthesia + intercostal nerve block | 40 | Postoperative discomforts | Completed | Korea |
NCT02123173 | 2014 | Lung neoplasms | NA (one lung ventilation) | 71 | Cardiac output | Completed | China |
NCT02393664 | 2015 | Lung neoplasms | General anesthesia + intercostal/vagal blocks | 300 | Quality of recovery | Unknown | China |
NCT02817048 | 2016 | Solitary lung nodule | NA (Tubeless) | 100 | Postoperative hospital stay | Not yet recruiting | China |
NCT03275428 | 2017 | Lung nodule | Intravenous sedation | 40 | Arterial oxygen pressure | Unknown | China |
NCT03083080 | 2017 | NA | Intercostal nerve plane block | 30 | Pain, time to lose skin sensation | Unknown | China |
NCT03086213 | 2017 | NA | Paravertebral/intercostal nerve block | 48 | The change of stress response markers | Unknown | China |
NCT03016858 | 2017 | Bulla | Intravenous anesthesia | 320 | Complications | Recruiting | China |
NCT03137576 | 2017 | Lung neoplasms | Erector spinae plane block/paravertebral block and sedation | 172 | Percentage of sedation escalation | Recruiting | Italy |
ChiCTR-INR-17012747 | 2017 | Thoracic diseases | General anesthesia | 30 | Length of hospital stay | Recruiting | China |
ChiCTR-IPR-17013325 | 2017 | Lung nodule | Intravenous anesthesia | 120 | CD3+, CD8+, CD4+, CD19+, NK cell concentration | Not yet recruiting | China |
NCT03711461 | 2018 | NA | NA | 32 | Impedance changes (swallowing) | Recruiting | China |
NCT03432637 | 2018 | Lung cancer | Spontaneous ventilating anesthesia | 450 | Hypoxemia or hypercapnia | Recruiting | China |
NCT03471884 | 2018 | Lung cancer | General anesthesia | 82 | Lung function | Recruiting | China |
NCT03469323 | 2018 | NA | NA (one-lung spontaneous breathing) | 30 | Quality of lung collapse | Recruiting | China |
ChiCTR1800018198 | 2018 | NA | Paravertebral nerve block + laryngeal mask | 110 | Glottal injury, sore throat | Recruiting | China |
NCT03653494 | 2018 | NA | General anesthesia + paravertebral block + surface spray anesthesia + vagus block with or without phrenic block | 80 | Anesthetic drugs needed | Enrolling by invitation | China |
ChiCTR1800018204 | 2018 | NA | Serratus anterior plane/erector spinae plane/paravertebral block | 90 | Nerve block time | Not yet recruiting | China |
ChiCTR1800017854 | 2018 | T1a (༜2 cm) peripheral lung adenocarcinoma | NA (Tubeless) | 200 | Complications | Not yet recruiting | China |
NCT03874403 | 2019 | NA | Intercostal nerve block | 60 | The density spectral array | Recruiting | China |
NCT04057586 | 2019 | NA | NA (one lung ventilation) | 240 | Intraoperative cerebral oxygenation | Recruiting | China |
ChiCTR1900027350 | 2019 | Lung cancer | Intercostal/paravertebral nerve block + general anesthesia using laryngeal mask | 80 | Hemodynamics, general anesthetic dose, recovery time | Recruiting | China |
ChiCTR1900022020 | 2019 | Thoracic disease | General anesthesia | 120 | Glottal injury incidence, lung collapse score | Recruiting | China |
NCT03958162 | 2019 | Interstitial lung disease | NA (tubeless) | 60 | Diagnostic yield after biopsy | Not yet recruiting | China |
NCT03902470 | 2019 | Lung cancer | TEA | 30 | Recovery time | Not yet recruiting | Egypt |
TEA, thoracic epidural anaesthesia; FEV1, Forced expiratory volume in one second; NA, not available. |
In summary, perioperative antiemetic should be considered as an indispensable item of fast-track thoracic surgery; meanwhile, a strict supervision is necessary in the ongoing trials. BS should be kept in mind when the patients report severe vomiting after non-intubated lung surgery.