Non-Intubated (Sedation) Versus Intubated General Anesthesia for VATS Pulmonary Spontaneous Ventilation Anesthesia: A Systematic Review and Meta-Analysis.

BACKGROUND

Non-intubated video-assisted thoracoscopic surgery (VATS) with sedation anesthesia (SA) has emerged as an alternative to general anesthesia (GA) with tracheal intubation for pulmonary spontaneous ventilation anesthesia. Its safety and perioperative efficacy remain incompletely defined. We also considered oncologic quality metrics, including margins and nodal evaluation, when spontaneous ventilation anesthesia was performed for suspected or confirmed malignancy.

METHODS

PubMed, Web of Science, and China National Knowledge Infrastructure (CNKI) were systematically searched through June 2025. Eligible studies compared SA (nonintubated, spontaneous ventilation) with GA using either double-lumen or single-lumen tubes with bronchial blockers (pooled as "intubated GA"). Primary outcomes were overall procedural time (induction + operation + emergence), postoperative length of stay (LOS), and perioperative complications. Secondary outcomes included operative duration. Random-effects models were applied.

RESULTS

Seventy-five studies were screened; five comparative studies (112 SA; 119 GA) met criteria. Overall procedural time favored SA (SMD -0.39, 95% CI -0.68 to -0.09), whereas induction time showed no significant difference (SMD -0.11, 95% CI -0.37 to 0.15). LOS was shorter with SA (SMD -1.41, 93% CI -2.65 to -0.16) but showed high heterogeneity across enhanced recovery adoption and discharge policies. Complication rates were comparable, and operative duration showed a nonsignificant trend favoring SA. Stratification by indication or GA technique was not feasible.

CONCLUSIONS

SA is a feasible alternative to intubated GA for VATS spontaneous ventilation anesthesia, potentially reducing procedural time and LOS without raising complication risk. Applicability to U.S. practice requires caution, given oncologic standards and lower adoption. Prospective randomized trials with standardized endpoints remain necessary.