Non-intubated anesthesia in patients undergoing video-assisted thoracoscopic surgery: A systematic review and meta-analysis

Abstract

Introduction: Non-intubated anesthesia (NIA) has been proposed for video-assisted thoracoscopic surgery (VATS), although how the benefit-to-risk of NIA compares to that of intubated general anesthesia (IGA) for certain types of patients remains unclear. Therefore, the aim of the present meta-analysis was to understand whether NIA or IGA may be more beneficial for patients undergoing VATS.

Methods: A systematic search of Cochrane Library, Pubmed and Embase databases from 1968 to April 2019 was performed using predefined criteria. Studies comparing the effects of NIA or IGA for adult VATS patients were considered. The primary outcome measure was hospital stay. Pooled data were meta-analyzed using a random-effects model to determine the standard mean difference (SMD) with 95% confidence intervals (CI).

Results and discussion: Twenty-eight studies with 2929 patients were included. The median age of participants was 56.8 years (range 21.9-76.4) and 1802 (61.5%) were male. Compared to IGA, NIA was associated with shorter hospital stay (SMD -0.57 days, 95%CI -0.78 to -0.36), lower estimated cost for hospitalization (SMD -2.83 US, 95% CI -4.33 to -1.34), shorter chest tube duration (SMD -0.32 days, 95% CI -0.47 to -0.17), and shorter postoperative fasting time (SMD, -2.76 days; 95% CI -2.98 to -2.54). NIA patients showed higher levels of total lymphocytes and natural killer cells and higher T helper/T suppressor cell ratio, but lower levels of interleukin (IL)-6, IL-8 and C-reactive protein (CRP). Moreover, NIA patients showed lower levels of fibrinogen, cortisol, procalcitonin and epinephrine.

Conclusions: NIA enhances the recovery from VATS through attenuation of stress and inflammatory responses and stimulation of cellular immune function.

Fig 1. Flowchart of study selection.

Fig 2. Risk of bias assessment in retrospective study or observational studies.

(A) Risk of bias summary. (B) Risk of bias graph.

Fig 3. Risk of bias assessment in randomized controlled trials (RCTs).

(A) Risk of bias summary. (B) Risk of bias graph.

Fig 4. Pooled risk for hospital stays with non-intubated anesthesia versus intubated anesthesia, stratified by study design.

Abbreviations: CI, confidence interval, SMD, standard mean difference.

Fig 5. Publication bias based on data for hospital stay.

(A) Funnel plot; (B) Data of Begg’s and Egger’s test; (C) Begg’s funnel plot; (D) Egger’s publication bias plot. Abbreviations: SMD, standard mean difference.

Fig 6. Pooled risk for estimated cost of non-intubated anesthesia versus intubated anesthesia, stratified by study design.

Abbreviations: CI, confidence interval, SMD, standard mean difference.

Fig 7. Pooled risk for chest tube duration of non-intubated anesthesia versus intubated anesthesia, stratified by study design.

Abbreviations: CI, confidence interval, SMD, standard mean difference.

Fig 8. Pooled risk for postoperative fasting time of non-intubated anesthesia versus intubated anesthesia, stratified by study design.

Abbreviations: CI, confidence interval, SMD, standard mean difference.

Fig 9. Graphic depiction of the linear correlation between moderate surgery (x axis) and the SMD of hospital stay (y axis).

The solid line represents the point estimates of association between moderate surgery and the SMD of hospital stay. Bubble size is inversely proportional to the SMD of the hospital stay reported by each study (slope = -0.56%, P = 0.036). Abbreviations: SMD, standard mean difference.