Awake Video-Assisted Surgery Option for 'Inoperable' Lungs

Ingrid Hein

May 24, 2018

Awake video-assisted thoracic surgery can be used successfully in patients with poor lung function who are not good candidates for surgery because of the risks associated with endotracheal intubation and general anesthesia, new research shows.

"Outcomes have been fantastic. I haven't had a single patient intubated," said Ara Klijian, MD, from the Sharp Grossmont Hospital in La Mesa, California and Scripps Mercy Hospital in San Diego.

Procedures such as wedge resection, segmentectomy, and lobectomy can be performed using local anesthesia and sedation, "with outcomes comparable or better than those done under general anesthesia," he told Medscape Medical News.

Klijian described his experience with more than 500 awake video-assisted thoracic surgeries at the American Thoracic Society 2018 International Conference in San Diego.

It's not for everybody. You have to carefully pick the right patients and do a lot of preplanning.

For patients who underwent awake lobectomy for cancer, the average hospital stay was 1.6 days, even in those with a forced expiratory volume in 1 second (FEV₁) of 0.6 and multiple comorbidities. In contrast, in a study of 22,647 patients who underwent standard lobectomy, the median hospital stay was 5 days (Eur J Cardiothorac Surg. 2016;49: e65-e71).

Of the 246 patients who underwent resection surgeries using the awake approach, 203 had a FEV₁ below 0.8, but outcomes were successful.

In most cases, the awake approach does not require central lines or arterial, urinal, or epidural catheters, which minimizes the chance of infection. In addition, it reduces the chance of postoperative morbidity, potentially decreases hospital costs, and offers a more comfortable recovery for patients.

These patients have multiple comorbidities, including diabetes, chronic obstructive pulmonary disease, atrial fibrillation, hypertension, and hepatic or renal dysfunction. However, "the mortality profile is actually better than with standard surgery, despite these being sicker patients," Klijian said.

The technique is relatively new and there is a learning curve. "It's not for everybody. You have to carefully pick the right patients and do a lot of preplanning," Klijian said.

More Preparation

You have to figure out where to go in because the lung is working while you're doing the surgery, kind of like open heart surgery, he explained.

"You don't have the luxury of having the lung deflated," he added. But "there are small surgical tricks you can use to move the lung around and get better visualization."

Initially, even the anesthesiologists were skeptical. "They said, 'are you serious? You really want to try this?'" But Klijian explained that there were no other options for these patients, who were eager. "Now they love doing it this way," he reported.

Several years and several hundred patients later, he said he is getting more adept at awake video-assisted thoracic surgery and is getting requests from other surgeons who want to learn the approach.

This presentation of a single surgeon's work suggests that the awake approach is "feasible and safe," said Charles Powell, MD, from the Mount Sinai–National Jewish Health Respiratory Institute in New York City.

The approach provides an option for patients with early-stage lung cancer and compromised lung function who could not otherwise undergo surgery.

It would be interesting to see how it compares, over the short and long term, with stereotactic body radiation therapy, "which has a longer track record," he pointed out.

But this is a good beginning. "Over time, as other institutions explore the options, they will get more comfortable with this approach, presuming it's demonstrated to be effective," Powell told Medscape Medical News.

Klijian and Powell have disclosed no relevant financial relationships.

American Thoracic Society (ATS) 2018 International Conference: Abstract A6416-105. Presented May 23, 2018.

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