We identified a patient with BS after severe emesis following minimally invasive lung surgery. Severe emesis is a stressful complication of anesthesia or analgesia. A retrospective study presented 10 patients with esophageal perforation after emesis associated with large volume of food and alcohol intake [8]. Moreover, every perforation was longitudinal tears (about 1-4 cm), locating in the left lower-third of the esophagus. Then the authors hypothesized that esophageal perforation probably resulted from emesis through a pathophysiological reaction within the upper digestive tract. Furthermore, they proposed that BS should be defined as post-emetic esophageal perforation. Therefore, we concluded that the present BS was probably secondary to the uncontrolled emesis rather than the surgical procedure itself.
The incidence of post-discharge emesis after ambulatory surgery is approximately 30% [9]. Chest pain and emesis always suggest the onset of BS, but the patients don't always present with typical clinical features. The major treatment options for BS were conservative, endoscopic and surgical approach; whereas the survival rate of the patients using these treatments was 75%, 100% and 81%, respectively [10]. Surgery should be considered especially for those who are admitted within 24 hours of perforation [11]. In addition, endoscopy also plays a role in the treatment of transmural defects [12], although an evidence-based recommendation is still lacking. Besides surgical and endoscopic interventions, naso-esophageal extraluminal drainage has been reported to be effective for the treatment of esophageal leaks and subsequent mediastinal abscess [13].
On the other hand, non-intubated thoracic surgery under minimal sedation with regional anaesthesia is useful to avoid nausea and emesis [14]. However, the evidence supporting non-intubated VATS as the preferred approach for lung surgery is still limited. Previous meta-analyses show that non-intubated procedures could attenuate surgery-related stress responses and decrease postoperative complications compared to intubated surgery [15, 16]. Moreover, for patients who are considered as high-risk under intubated general anesthesia due to their compromised lung function, non-intubated procedure could be considered [17]. A meta-analysis indicates that non-intubated VATS may be a better alternative to intubated surgery [18], although it requires extra vigilance to ensure the safety of the patients [19]. The disadvantages of non-intubated thoracic surgery include cough and poor maneuverability due to the movements of diaphragm and lung [20].
We searched PubMed, Web of Science, Scopus, Embase, Europe PMC, Cochrane Library and Google Scholar for randomized controlled trials (RCTs) up to June 2020 according to the PRISMA Protocol for updated evidence of nonintubated lung surgery. Key words in title or abstract include “non-intubated” or “tubeless” or “awake” and “pulmonary” or “lung” and “surgery”. Finally a total of 13 RCTs were obtained (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 these findings, non-intubated VATS is technically feasible and safe; however, the results should be interpreted with caution due to small samples in the trials and potential publication bias. Well-designed studies are warranted. The registered trials of non-intubated thoracic surgery were listed in Table 2, which might further elucidate the specific indications and contraindications of tubeless thoracic surgery.
In summary, perioperative antiemetic with strict supervision should be considered as an indispensable item of fast-track thoracic surgery. Moreover, the occurrence of BS and a timely intervention should be kept in mind when the patients report chest distress after severe emesis following lung surgery.