Non-intubated video-assisted thoracoscopic surgery under loco-regional anaesthesia for thoracic surgery: a meta-analysis

Abstract

Objectives: The short-term feasibility and safety of non-intubated video-assisted thoracoscopic surgery under loco-regional anaesthesia for thoracic surgery remains unknown. Therefore, we conducted a meta-analysis to provide evidence for the short-term efficacy and safety profile of non-intubated video-assisted thoracoscopic surgery under loco-regional anaesthesia for thoracic surgery.

Methods: We performed a systematic literature search in PubMed, Embase, Cochrane Library databases and Google Scholar, as well as American Society of Clinical Oncology to identify relevant studies comparing non-intubated video-assisted thoracoscopic surgery under loco-regional anaesthesia with conventionally intubated video-assisted thoracoscopic surgery under general anaesthesia, dated up to 31 August 2015. Data concerning global in-operating room time, hospital stays, rate of postoperative complications and perioperative mortality were extracted and analysed. We conducted a meta-analysis of the overall results and two subgroup analyses based on study design (a meta-analysis of randomized controlled trials and a second meta-analysis of observational studies).

Results: Four randomized controlled trials and six observational studies with a total of 1283 patients were included. We found that in the overall analysis, patients treated with non-intubated video-assisted thoracoscopic surgery under loco-regional anaesthesia achieved significantly shorter global in-operating room time [weighted mean difference = -41.96; 95% confidence interval (CI) = (-57.26, -26.67); P < 0.001] and hospital stays [weighted mean difference = -1.24; 95% CI = (-1.46, -1.02); P < 0.001] as well as a lower rate of postoperative complications [relative risk = 0.55; 95% CI = (0.40, 0.74); P < 0.001] than patients treated with intubated video-assisted thoracoscopic surgery under general anaesthesia. Subgroup meta-analyses based on study design achieved the same outcomes as overall analysis. In our meta-analysis, no perioperative mortality was observed in patients treated with non-intubated video-assisted thoracoscopic surgery under loco-regional anaesthesia.

Conclusions: Non-intubated video-assisted thoracoscopic surgery under loco-regional anaesthesia for thoracic surgery proved to be feasible and safe. Future multicentre and well-designed randomized controlled trials with longer follow-up are needed to confirm and update the findings of our study, as well as the long-term efficacy of non-intubated video-assisted thoracoscopic surgery under loco-regional anaesthesia.

Keywords: Anaesthesia; Meta-analysis; Non-intubated; Thoracic surgery; Video-assisted thoracoscopic surgery.

Figure 1:

Flow chart showing the progress of trials throughout the review. ASCO: American Society of Clinical Oncology.

Figure 2:

Risk of bias analysis for the RCTs: (A) risk of bias summary: a review of authors' judgements about each risk of bias item for each included study; (B) risk of bias graph: a review of authors' judgements about each risk of bias item presented as percentages across all included studies.

Figure 3:

Forest plot of: (A) global in-operating room time; (B) hospital stays; (C) postoperative complications in patients treated with non-intubated VATS under non-general anaesthesia. RCTs: randomized controlled trials; VATS: video-assisted thoracoscopic surgery; WMD: weighted mean difference; CI: confidence interval.

Figure 3:

Forest plot of: (A) global in-operating room time; (B) hospital stays; (C) postoperative complications in patients treated with non-intubated VATS under non-general anaesthesia. RCTs: randomized controlled trials; VATS: video-assisted thoracoscopic surgery; WMD: weighted mean difference; CI: confidence interval.

Figure 4:

Sensitivity analysis for (A) global in-operating room time, (B) hospital stays and (C) complications. CI: confidence interval.

Figure 4:

Sensitivity analysis for (A) global in-operating room time, (B) hospital stays and (C) complications. CI: confidence interval.

Figure 5:

Funnel plot of the included studies for overall analysis of postoperative complications (Begg's test: P = 0.446; Egger's test: P = 0.610).