Non-intubated video-assisted thoracic surgery with an integrated postoperative strategy for secondary spontaneous pneumothorax in high-risk patients.

BACKGROUND

Non-intubated video-assisted thoracic surgery (VATS) is an option for the treatment of secondary spontaneous pneumothorax (SSP) in high-risk patients. Although persistent air leakage remains a major postoperative challenge, the efficacy of subsequent treatment to arrest such leakage has not been fully clarified. This study aimed to describe the surgical procedures and postoperative management of non-intubated VATS and to evaluate treatment outcomes.

METHODS

A single-center retrospective study was conducted on patients who underwent non-intubated VATS for intractable SSP between 2011 and 2021. All patients were considered intolerant to surgery under general anesthesia with endotracheal intubation. The air-leak sites were managed with ligation or pleural coverage. Postoperative pleurodesis was performed to terminate air leakage or to prevent pneumothorax recurrence.

RESULTS

Twenty-one patients were included in the study. The mean age was 78.3±8.4 years. Air leakage was treated by ligation in 10 patients (48%). Postoperative air leakage occurred in 11 patients (52%). Twenty patients underwent pleurodesis. Air leakage was arrested by surgery alone or by surgery combined with pleurodesis in 16 patients (76%), and ultimately in 19 patients (90%), including three who required bronchial occlusion. Six patients (29%) died during hospitalization. Postoperative recurrence of pneumothorax was observed in two patients (11%). The 1- and 2-year overall survival rates were 47% and 35%, respectively.

CONCLUSIONS

Postoperative air leakage was common after non-intubated VATS for SSP. However, non-surgical interventions effectively controlled air leakage in most cases. The high in-hospital mortality rate likely reflected the patients' poor physical condition and the severity of their underlying diseases. Non-intubated VATS combined with postoperative pleurodesis or bronchial occlusion is an alternative for patients with persistent air leakage who are poor candidates for surgery under general anesthesia. Further studies are required to assess the validity of this procedure.