Comparison of short-term outcomes between non-intubated and intubated video-assisted thoracoscopic surgery: a propensity score matching analysis.

BACKGROUND: While video-assisted thoracoscopic surgery (VATS) has revolutionized thoracic interventions, the morbidity associated with general anesthesia and endotracheal intubation persists. In recent years, non-intubated VATS (NIVATS) has emerged as an alternative approach. However, large-scale, multi-center studies comparing NIVATS with intubated VATS (IVATS) remain lacking. Therefore, this study aims to systematically evaluate the feasibility, safety, and clinical advantages of NIVATS by comparing it to IVATS.

METHODS: This retrospective cohort study included 4,537 patients who underwent VATS at the Department of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, between January 2011 and December 2015. Surgical procedures were categorized as minor [pleural/pulmonary/mediastinal biopsies, peripheral wedge resections, thymectomies, and lung volume reduction surgery (LVRS)] or major (anatomical lung resections and airway reconstructions). Patients were stratified by anesthesia protocol: 960 NIVATS (pleural/pulmonary biopsies, peripheral wedge resections, thymectomies, LVRS) and 3,577 IVATS (anatomic resections, airway reconstructions). To minimize selection bias arising from non-randomized grouping, propensity score matching (PSM) was applied in a 1:1 ratio to match patients from both groups. Primary endpoints included operative metrics and recovery parameters.

RESULTS: A total of 4,537 VATS patients were included, with 960 in the NIVATS group and 3,577 in the IVATS group. After PSM, 686 matched pairs were analyzed (442 minor procedures: 221 NIVATS/221 IVATS; 244 major procedures: 122 NIVATS/122 IVATS). NIVATS was associated with shorter operative time (minor: 65.3±17.8 vs. 72.1±20.3 min, P=0.009; major: 138.5±28.4 vs. 147.9±32.1 min, P=0.03), less intraoperative blood loss (minor: 28.5±13.4 vs. 35.7±15.6 mL, P<0.008; major: 105.7±41.2 vs. 130.4±53.3 mL, P=0.02), and shorter postoperative hospital stay (minor: 4.1±1.3 vs. 4.8±1.6 days, P=0.009; major: 6.8±1.9 vs. 7.5±2.2 days, P=0.04). No significant differences were observed in oxygen saturation or end-tidal carbon dioxide (CO2) between groups.

CONCLUSIONS: This large-scale analysis establishes NIVATS as a safe and effective alternative to conventional IVATS across both minor and major thoracic procedures. The demonstrated advantages, such as reduced operative time, less intraoperative blood loss, and shorter hospital stay, position NIVATS as a transformative approach in minimally invasive thoracic surgery, warranting consideration in Enhanced Recovery After Surgery (ERAS) protocols.