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AimsThe detection of white-coat hypertension/white-coat uncontrolled hypertension (WCH/WUCH) with out-of-office blood pressure (BP) monitoring is time- and resource-consuming. We aim to develop a machine learning (ML)-derived prediction model based on the characteristics of patients from a single outpatient visit.Methods and resultsData from two cohorts in Taiwan were used. Cohort one (970 patients) was used for development and internal validation, and cohort two (464 patients) was used for external validation. WCH/WUCH was defined as an office BP of ≥140/90 mmHg and daytime ambulatory BP of ConclusionOur prediction models achieved good performance, underlining the feasibility of applying ML models to outpatient populations for the diagnosis of WCH and WUCH. Further validation with other prospective data sets should be considered in the future.

Background Nonintubated thoracoscopic lobectomy has been described as a feasible surgical treatment for early-stage lung cancer since 2011. Despite promising perioperative results, studies on tumor recurrence and long-term survival are very limited. This study was aimed to compare outcomes after thoracoscopic lobectomy with versus without intubation for stage I non-small cell lung cancer. Methods A retrospective data set including 115 and 155 patients who underwent nonintubated and intubated thoracoscopic lobectomy, respectively, between January 2011 and December 2013 was used to identify matched nonintubated and intubated cohorts (n = 97 per group) using a propensity score matching algorithm that accounted for confounding effects of preoperative patient variables. Primary outcome variables included freedom from recurrence and overall survival. Factors affecting survival were assessed using Cox regression analysis and Kaplan–Meier survival estimates. Results No perioperative mortality occurred in both groups. At an average follow-up of 74 months, comparing nonintubated thoracoscopic lobectomy with intubated procedure, no differences were observed in recurrence rates (14.4% vs. 25.8%, respectively; p = .057). Furthermore, no significant differences were noted in overall survival (97.9% vs. 93.8%, respectively; p = .144). Nonintubated thoracoscopic lobectomy was not found to be an independent predictor of recurrence (hazard ratio, .53; 95% confidence interval [CI], .28–1.02) or overall survival (hazard ratio, .33; 95% CI, .07–1.61). Conclusions In this propensity-matched comparison, nonintubated thoracoscopic lobectomy was not associated with an increased risk for recurrence and overall survival during the 5-year follow-up. However, more randomized trials should be conducted for further validation of these results.

BackgroundGeneral anesthesia and tracheal intubation potentially pose a high risk to health care workers (HCWs) managing surgical patients during the coronavirus disease 2019 (COVID-19) pandemic. Non-intubated anesthesia is a rational way of managing patients undergoing thoracoscopic surgery that avoids tracheal intubation and minimizes the aerosols generated during airway instrumentation. The purpose of this study was to determine whether non-intubated anesthesia in combination with a face mask is safe and feasible in patients undergoing thoracoscopic surgery.MethodsA total of 18 patients who underwent non-intubated thoracoscopic surgery with a face mask during the perioperative period between March 9, 2020 and April 6, 2020 were included. The main outcomes were anesthetic management and postoperative results.ResultsThe 18 patients had a mean age of 64 years and a body mass index of 22.9 kg/m2. All patients wore a mask during induction of anesthesia and throughout surgery. Three patients underwent lobectomy, four segmentectomy, ten wedge resection, and one underwent anterior mediastinal tumor resection. No patient developed cough or vomiting during the perioperative period. All patients were transferred to the postoperative recovery unit within 15 min of the end of surgery (average 7.2 min). No patient required conversion to tracheal intubation or conversion to thoracotomy.ConclusionNon-intubated anesthesia with a mask was safe and feasible in patients undergoing thoracoscopic surgery. Avoidance of intubated general anesthesia and use of a lung separation device may reduce the risk to HCWs of contamination by airway secretions, thereby conserving personal protective equipment, especially during the COVID-19 pandemic.

Background Nonintubated thoracoscopic surgery for lung tumor is not widely performed. This study assessed the safety, outcome, and risk factors for conversion to tracheal intubation of nonintubated thoracoscopic surgery for lung tumor resection. Methods We retrospectively reviewed the records of 1,025 patients who underwent lung tumor resection by nonintubated thoracoscopic surgery from August 2009 to December 2016 at our institution. Using univariable and multivariable analyses, we focused on the operative procedures, complications, conversion rate, surgical outcome, and risk factors for conversion to tracheal intubation. Results Most patients (73% [n = 748]) were women, and 14.3% (n = 147) of all patients were smokers. The average body mass index was 22.6 kg/m2. We performed 315 lobectomies, 111 segmentectomies, and 598 wedge resections. Postoperative complications included prolonged air leak for more than 5 days (20 patients [2%]), arrhythmia (2 [0.2%]), hemothorax (3 [0.3%]), pneumonia (4 [0.4%]), and chylothorax (2 [0.2%]). No surgical deaths occurred. During the operation 20 patients (2%) were converted to tracheal intubation. The main reason for conversion was considerable mediastinal movement. Multivariable analysis revealed that a body mass index of 25 kg/m2 or higher (p Conclusions Nonintubated thoracoscopic surgery was a safe and effective technique for lung tumor resection. Clinicians should be aware that patients with a body mass index of 25 kg/m2 or higher or who require pulmonary anatomical resection have a higher risk of conversion to tracheal intubation.

Background Hepatitis B virus (HBV) reactivation consequent to immunosuppressive therapy is an increasingly prevalent problem with serious clinical implications. Treatment with biologic agents conduces to the loss of protective antibody to HBV surface antigen (anti-HBs), which significantly increases the risk of HBV reactivation. Hence, we investigated the risk factors for losing anti-HBs in patients with rheumatic diseases and HBV surface antigen negative/anti-HBs positive (HBsAg−/anti-HBs+) serostatus during treatment with biologic disease-modifying anti-rheumatic drugs (DMARDs). Methods Using a nested case-control design, we prospectively enrolled patients with rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis/psoriasis, or juvenile idiopathic arthritis, who were treated with biologic DMARDs at Changhua Christian Hospital, Taiwan, from January 2013 to June 2019 and had HBsAg−/anti-HBs+ serostatus; the analytic sample excluded all patients with HBsAg+ or anti-HBs− serostatus. Anti-HBs titers were monitored 6-monthly and cases were defined as anti-HBs Results Among 294 eligible patients, 23 cases were matched with 311 controls. The incidence of anti-HBs loss was ~ 2.7%/person-year during biologic DMARDs treatment. Besides lower baseline anti-HBs titer (risk ratio 0.93, 95% CI 0.89–0.97), cases were significantly more likely than controls to have diabetes mellitus (risk ratio 4.76, 95% CI 1.48–15.30) and chronic kidney disease (risk ratio 14.00, 95% CI 2.22–88.23) in univariate analysis. Risk factors remaining significantly associated with anti-HBs loss in multivariate analysis were lower baseline anti-HBs titer (adjusted risk ratio 0.93, 95% CI 0.88–0.97) and chronic kidney disease (adjusted risk ratio 45.68, 95% CI 2.39–871.5). Conclusions Besides lower baseline anti-HBs titer, chronic kidney disease also strongly predicts future anti-HBs negativity in patients with HBsAg−/anti-HBs+ serostatus who receive biologic DMARDs to treat rheumatic diseases. Patients with low anti-HBs titer (≤ 100 mIU/ml) and/or chronic kidney disease should be monitored during biologic DMARDs therapy, to enable timely prophylaxis to preempt potential HBV reactivation.

Background/Purpose This study aimed to compare our experiences of nonintubated video-assisted thoracoscopic surgery (VATS) for pneumothorax and lung tumor resections with that of intubated VATS in pediatric patients. Methods In total, 17 nonintubated and 64 intubated pediatric VATS were performed between January 2012 and December 2018. Patient characteristics, operation period, comorbidities, precedent lung surgery, diagnosis, type of anesthesia, side and type of procedure, and perioperative outcomes were collected from medical records. Perioperative outcome data included induction time, operation time, postoperative chest tube drainage duration, and length of stay. Simple linear regression and multiple linear regression analyses were used to determine the influence of selected variables on perioperative outcomes. Results The mean age was 16.2 years in the intubated group and 15.2 years in the nonintubated group. Comorbidities including malignancy and asthma were noted in 9 intubated patients and 6 nonintubated patients. Nonintubated VATS was performed in 9 pneumothorax surgeries and 8 lung tumor resections. Five patients breathed oxygen through a face mask, 3 patients through a high-flow nasal cannula, and 9 patients through a laryngeal mask airway. No patient required tracheal intubation or thoracotomy. No major operative complications were noted in either group. After adjustments for statistically relevant confounders, the multiple regression analysis showed that the nonintubated technique influenced the length of stay, leading to a reduction of 0.75 days. Conclusion Nonintubated VATS is feasible and safe in selected children undergoing bullectomy or wedge resections for lung tumors. The nonintubated approach might enhance postoperative recovery.

Purpose of review The current review focuses on precise anesthesia for video-assisted thoracoscopic surgery (VATS) with the goal of enhanced recovery. Recent findings VATS has become an established and widely used minimally invasive approach with broad implementation on a variety of thoracic operations. In the current environment of enhanced recovery protocols and cost containment, minimally invasive VATS operations suggest adoption of individualized tailored, precise anesthesia. In addition to a perfect lung collapse for surgical interventions with adequate oxygenation during one lung ventilation, anesthesia goals include a rapid, complete recovery with adequate postoperative analgesia leading to early discharge and minimized costs related to postoperative inpatient services. The components and decisions related to precise anesthesia are reviewed and discussed including: letting patients remain awake versus general anesthesia, whether the patient should be intubated or not, operating with or without muscle relaxation, whether to use different separation devises, operating with different local and regional blocks and monitors. Conclusion The determining factors in designing a precise anesthesic for VATS operations involve consensus on patients' tolerance of the associated side effects, the best practice or techniques for surgery and anesthesia, the required postoperative support, and the care team's experience.

Although the use of the uniportal thoracoscopic technique has spread exponentially recently, a comparison of nonintubated and intubated uniportal thoracoscopic segmentectomies for lung tumors has not been reported. We aimed to compare the feasibility, safety, and short-term postoperative outcomes between the 2 methods.From January 2014 to June 2019 we retrospectively reviewed 185 consecutive patients with lung tumors who underwent uniportal thoracoscopic segmentectomy at our institute. A body mass index of ≥25 kg/mFifty patients (27.0%) underwent the procedure with the nonintubated anesthetic approach. The nonintubated group was more likely to be female (P .001) and with a lower body mass index (P.001). Other clinical features showed no significant difference. There was no significant difference between the 2 groups in the type of segmentectomy according to the difficulty classification system. After propensity matching 43 matched patients in each group were included. Anesthetic induction duration (12.0 vs 15.3 minutes, P = .014) was shorter in the nonintubated group. No other significant differences in perioperative, postoperative, and anesthetic results were noted between the 2 matched groups.The nonintubated anesthetic approach can be a safe and feasible alternative to intubated uniportal thoracoscopic segmentectomy.

OBJECTIVES To determine the success rate of blind insertion and the usefulness of fibre-optic bronchoscopy for directing rigid-angled endobronchial blockers (EBs) to the correct side and achieving satisfactory surgical fields. METHODS A randomized trial was designed to determine the extent to which the Coopdech Endobronchial Blocker Tube (Daiken Medical Co., Ltd) could successfully be placed through either auscultation (n = 57) or fibre-optic bronchoscopy (n = 55) in patients scheduled for thoracic surgery. The placement time was recorded and quality of the thoracoscopic operation field was determined by the thoracic surgeon. Anaesthesiologists with varying thoracic experience levels were enrolled. RESULTS The success rates of insertion through auscultation were 100% (32 of 32) for the right side and 88% (22 of 25) for the left side. Placement through auscultation was faster than that through bronchoscopy (mean 89.6 vs 141.1 s, P = 0.008) in the right-sided procedure but non-significant in the left-sided procedure (mean 138.5 vs 130 s, P = 0.795). Surgical grading of the operation field was not significantly different between both techniques (P = 0.502). Experienced anaesthesiologists took less time to position EBs (mean 91.0 vs 138.0 s, P = 0.015). Surgical grading was comparable between specialists and residents (P = 0.058). CONCLUSIONS Once an EB was correctly inserted and confirmed through auscultation, the corresponding surgical satisfaction was comparable to that through bronchoscopy. In the majority of cases, bronchoscopy is unnecessary for correct and efficient EB positioning. However, bronchoscopy is still mandatory in left-sided EB insertion and in patients with deviated tracheobronchial anatomy. Clinical registration number NCT02133235, registered at ClinicalTrials.gov [https://clinicaltrials.gov/ct2/show/NCT02133235 (8 July 2017, date last accessed)].

ObjectivesTo elucidate risk factors for loss of hepatitis B virus (HBV) surface antibody (anti-HBs) in patients with rheumatic diseases and HBV surface-antigen negative/anti-HBs positive (HBsAg−/anti-HBs+) serostatus during biologic disease-modifying anti-rheumatic drug (DMARD) treatment.MethodsThis nested case-control study prospectively enrolled patients with rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis/psoriasis, and juvenile idiopathic arthritis, who were treated with biologic DMARDs from January 2013 to September 2017. The analytic sample included patients with HBsAg−/anti-HBs+ serostatus. Anti-HBs titers were monitored, and cases defined as anti-HBs ResultsAmong 189 enrolled patients, 15 cases were matched with 211 controls. Risk factors associated with anti-HBs loss in multivariate analysis were low baseline anti-HBs titer (adjusted risk ratio = 0.96, 95% CI 0.93–0.99) and chronic kidney disease (adjusted risk ratio = 26.25, 95% CI 1.85–372.35). All cases had baseline anti-HBs titer ConclusionsIn addition to low baseline anti-HBs titer, chronic kidney disease is also an independent risk factors associated with loss of anti-HBs in patients with HBsAg−/anti-HBs+ serostatus who receive biologic DMARDs to treat rheumatic diseases.SignificanceGiven that loss of anti-HBs precedes HBV reactivation and that the use of biologic DMARDs is increasingly widespread nowadays, understanding those who are at risk of loss of anti-HBs is an important and practical clinical issue.InnovationIn addition to low baseline anti-HBs titer, chronic kidney disease is also an independent risk factors associated with loss of anti-HBs in patients with HBsAg−/anti-HBs+ serostatus who receive biologic DMARDs to treat rheumatic diseases.

Although drainage tube placement after thoracoscopic pulmonary resection is considered mandatory, the drainless approach after pulmonary resections may be feasible in selected patients. We aimed to determine whether a drainless approach is safe and associated with shorter hospital stay after thoracoscopic surgery for peripheral lung nodules.This single-center, open-label, parallel-group, prospective, randomized, controlled trial enrolled patients with peripheral lung nodules treated with uniportal thoracoscopic wedge resection. After confirming the absence of air leaks and before closing the wound, patients were allocated to receive or not receive drainage using a chest tube, according to a preestablished randomization sequence provided in sealed envelopes. The primary end point was the length of postoperative hospital stay.Of 107 patients who agreed to participate in the study between August 2016 and September 2017, 100 were randomized to the drainage group (n = 50) or drainless group (n = 50) for intention-to-treat analysis. Patients in the drainless group had shorter postoperative hospital stay (mean, 1.2 versus 2.6 days; P.001), shorter surgery duration (mean, 59.0 versus 73.7 minutes; P = .001), and lower pain on postoperative day 1 (mean, 0.9 versus 1.2 points; P = .011). In the drainless group, residual pneumothorax was noted in 31 patients at 6 hours (62%), in 18 patients at 1 day (36%), and in 1 patient at 10 to 14 days after surgery (2%). Medical costs were also substantially lower in the drainless group.Uniportal thoracoscopic wedge resection without drainage is feasible and safe for selected patients with peripheral lung nodules.

Less general anesthetic is required in patients with regional blocks than in those without, as assessed through commonly used anesthesia monitoring parameters such as blood pressure, heart rate, and bispectral index (BIS). Although intraoperative regional anesthesia has become more widely adopted, few studies have confirmed or monitored its anesthetic-sparing effects. Using recent reports of nonintubated video-assisted thoracoscopic surgery (VATS) by BIS-targeted propofol infusion and intraoperative multilevel thoracoscopic intercostal nerve blocks (TINBs), this retrospective study investigated whether the anesthetic-sparing effect can be realized by reducing the effect-site concentration (Ce) to the targeted BIS level or by reducing the blood pressure at the onset of regional blocks.A retrospective study of a prospectively collected case series of non-intubated VATS.Data on 56 adult patients who underwent nonintubated VATS were collected and analyzed. The mean operative time was 121 ± 32 minutes. BIS levels before and after one-lung ventilation/TINBs and surgery were 48% ± 11% and 47% ± 12%, respectively. The Ce of propofol infusion decreased significantly from 3.4 ± 0.8 μg/mL to 3.0 ± 0.7 μg/mL (p 0.01) after surgery with TINBs. Blood pressure did not change significantly, whereas the heart rate increased moderately but significantly (77 ± 14 beats/minute to 82 ± 15 beats/minute, p 0.01).With comparable BIS and blood pressure in the subsequent surgical procedure, the adequacy of anesthesia and the anesthetic component provided by intraoperative TINBs and vagal nerve could be monitored adequately. The anesthetic-sparing effect of intraoperative nerve blocks can be realized when the Ce of propofol infusion was reduced to the target BIS level.

This study compared the cardiac output (CO) obtained from PiCCO with that obtained from the noninvasive NICOM method.Twenty-one cirrhotic patients receiving liver transplantation were enrolled. During the operation, their CO was measured by the PiCCO system via the thermodilution method as the standard and by the NICOM method. Two parameters including cardiac index (CI) and stroke volume index (SVI) were collected simultaneously at three phases during the surgery including the dissection phase (T1), the anhepatic phase (T2), and the reperfusion phase (T3). Correlation, Bland and Altman methods, and linear mixed model were used to evaluate the monitoring ability of both systems.Poor correlation was noted between the data measured by NICOM and PiCCO; the correlation coefficients for CI and SVI measured between the two systems were 0.32 and 0.39, respectively. Bland and Altman analysis showed the percentage error of CI as 63.7%, and that of SVI as 66.6% for NICOM compared to PiCCO. Using the linear mixed model, the CI and SVI measured using NICOM were significantly higher than those using PiCCO (estimated regression coefficient 0.92 and 10.77, both p 0.001). Mixed model analysis showed no differences between the trends of CI and SVI measured by the two methods.NICOM provided a comparable CI and SVI trend when compared to the gold standard PiCCO, but it raises concerns as an effective CO monitor because of its tendency to overestimate CI and SVI especially during the state of high cardiac output.

BACKGROUND: Patients with impaired lung function or chronic obstructive pulmonary disease (COPD) are considered high-risk for intubated general anesthesia, which may preclude them from surgical treatment of their lung cancers. We evaluated the feasibility of non-intubated video-assisted thoracoscopic surgery (VATS) for the surgical management of lung cancer in patients with impaired pulmonary function. METHODS: From August 2009 to June 2015, 28 patients with impaired lung function (preoperative forced expiratory volume in 1 second

Background. Acute respiratory distress syndrome (ARDS) after living-donor liver transplantation (LDLT) is not uncommon, but it lacks the biomarkers for early detection. Club cell protein 16 (CC16), high-motility group box 1 protein (HMGB1), interleukin-1β (IL-1β), and IL-10 have been reported as relevant to the development of ARDS. However, they have not been investigated during LDLT. Methods. Seventy-three consecutive recipients undergoing LDLT were enrolled and received the same perioperative care plan. Perioperative serum CC16, HMGB1, IL-1β, and IL-10 levels were measured at the pretransplant state, 30 minutes after reperfusion, postoperative day 1 (POD1), and POD3. ARDS was diagnosed according to the 2012 Berlin definition. Results. Of the 73 recipients, 13 developed ARDS with significantly longer durations of mechanical ventilation and intensive care unit stay. Serum CC16 levels on POD1 increased significantly from the pretransplant state in the ARDS group but not in the non-ARDS group. Pretransplant serum CC16 levels were also higher in the ARDS group. The area under the receiver operating characteristic curves for POD1 serum CC16 levels used to discriminate ARDS was 0.803 (95% confidence interval: 0.679 to 0.895; p < 0.001). By comparison, HMGB1, IL-1β, and IL-10 were not associated with ARDS after LDLT. Conclusion. The higher pretransplant serum CC16 level and its increased level on POD1 were associated with the development of early ARDS after LDLT. This trial is registered with NCT01936545, 27 August 2013.

Background Myocardial injury after noncardiac surgery (MINS) is a major contributor to peri-operative morbidity and mortality with a reported incidence of about 8%. Tachycardia increases myocardial oxygen demand, and decreases oxygen supply, and is therefore a potential cause of MINS. Objective We tested the hypothesis that there is an association between intra-operative area above a heart rate (HR) of 90 bpm and a composite of MINS and in-hospital all-cause mortality. Design Retrospective analyses. Setting Major tertiary care hospital, Cleveland, USA. Patients Adults having elective or nonelective noncardiac surgery and scheduled troponin monitoring during the first 3 postoperative days between 2010 and 2015. Main outcome measures All-or-none composite of myocardial injury (MINS), defined by a peak postoperative generation 4 troponin T concentration at least 0.03 ng ml, and in-hospital all-cause mortality. Results Among 2652 eligible patients, 123 (4.6%) experienced MINS within 7 days after surgery and 6 (0.2%) died before discharge. Intra-operative area above HR more than 90 bpm was not associated with the all-or-none composite of MINS and in-hospital mortality, with an estimated odds ratio (95% confidence interval) of 0.99 (0.97 to 1.01) per 1 h bpm increase in area above HR more than 90 bpm. Secondary outcomes were also unrelated to the composite, with estimated odds ratios (98.3% confidence interval) of 0.99 (0.98 to 1.00) for area above HR more than 80, 0.98 (0.92 to 1.04) for area above HR more than 100 bpm, and 0.96 (0.88 to 1.05) for maximum HR. Conclusion There was no apparent association between various measures of tachycardia and a composite of MINS and death, a result that contradicts previously reported associations between other measures of intra-operative tachycardia and MINS/mortality.

Background: Non-intubated single-incision procedures are slowly expanding because of high experience and skill required, and stricter selection criteria. The aim of this study is to present the first retrospective two-center series in Taiwan and Spain. Methods: We performed a retrospective analysis of 188 patients undergoing non-intubated single-incision video-assisted thoracic surgery (NI-SI-VATS) procedures between July 2013 to November 2015 in two centers in Taiwan (170 patients) and Spain (18 patients) with two different anesthetic methods. Demographic data, clinicopathological features, preoperative tests, and final outcomes were analyzed to compare the outcomes with the two different techniques. Results: Of the 188 patients, 147 (78%) were women, with a mean body mass index (BMI) of 22.7. Of the 196 specimens, 145 (74%) were malignancies with a mean size of 9.7 mm. Wedge resection was performed in 172 patients (91.4%), anatomical segmentectomy with lymphadenectomy in 8 (4.7%), and lobectomy with lymphadenectomy in 5 (2.6%). Three patients (1.6%) required conversion to orotracheal intubation, while 5 patients (2.7%) required additional ports. Complications appeared in 16 patients (8.5%) with air leak as the most frequent in 7 cases (3.7%). Median chest drainage was 1 day, and median postoperative stay was 3 days. There was neither perioperative death nor postoperative readmission. Conclusions: Non-intubated single-incision procedures can be feasible and safe in expert hands and experienced teams, even for anatomical resections. Strict selection criteria, skill and experience are mandatory. Comparative cohorts and randomized trials are needed.

Background Uniportal video-assisted thoracoscopic surgery (VATS) has recently been introduced for various thoracic diseases. However, management of peripheral lung nodules by uniportal VATS without tracheal intubation has rarely been attempted. We evaluated the feasibility and safety of nonintubated uniportal VATS for peripheral lung nodules. Methods From January to March 2014, 32 patients with indeterminate peripheral lung nodules underwent uniportal VATS without tracheal intubation using a combination of intercostal nerve block, intrathoracic vagal block, and target-controlled sedation. Computed tomography-guided dye localization was sometimes used to identify small or ground-glass opacity lesions. Results A definite diagnosis was obtained in all 32 patients. A wedge resection was performed in 31 patients and a lobectomy in 1. Conversion to nonintubated multiport VATS was required in 4 patients (13%), in 3 because of primary lung cancer requiring further resection for adequacy of margins and in 1 because of difficulty in identifying a small nodule. Conversion to intubated 1-lung ventilation was required in 1 patient (3%) because of vigorous mediastinal movement. Operative complications developed in 2 patients who had air leaks for more than 3 days postoperatively. The median durations of postoperative chest tube drainage and hospital stay were 1 and 3 days, respectively. Postoperative neuralgia that required occasional use of analgesics occurred in only 1 patient (3%), and 97% of patients were very satisfied or satisfied with the resulting scars at 1 month. Conclusions Nonintubated uniportal VATS is technically feasible and safe for selected patients and is a less invasive alternative in managing indeterminate peripheral lung nodules.

Summary Video-assisted thoracoscopic surgery (VATS) has become a common and globally accepted mode of resection of pulmonary tumors. One-lung isolation using double-lumen endobronchial tubes or endobronchial blockers has been traditionally considered mandatory for VATS. However, recent reports showed that VATS pulmonary resections can also be performed safely using regional anesthesia without tracheal intubation. Mostly, nonintubated VATS pulmonary resections are performed using regional anesthesia, either a thoracic epidural anesthesia or intercostal blocks, in a spontaneously breathing state after an iatrogenic open pneumothorax. Conscious sedation is usually necessary for longer and intensively manipulating procedures. Intraoperative cough reflex can be effectively inhibited by ipsilateral intrathoracic vagal blockade to facilitate major pulmonary resections. The early outcomes of nonintubated VATS pulmonary resections include a faster postoperative recovery and a lower complication rate as compared with its counterpart of intubated general anesthesia, which may be translated into a fast track VATS program. The future directions of nonintubated VATS should focus on its long-term outcomes, especially on oncological perspectives and overall survival in lung cancer patients.

Video-assisted thoracoscopic surgery (VATS) has been widely used in recent decades. However, VATS, although different from an open thoracotomy, causes intense pain (1,2). In some individuals, it remains one of the most painful surgical procedures possible. Poor postoperative pain control after VATS may prolong hospitalization duration and result in the development of chronic persistent pain after surgery (3) However, for different pain sensations after VATS, multimodal analgesia, with or without conventional thoracic epidural or paravertebral analgesia, has become the mainstay for achieving adequate analgesia.

Background Intubated general anesthesia with one-lung ventilation is considered mandatory for anatomical pulmonary resections. Nonintubated thoracoscopic segmentectomy for management of lung tumors, which is technically challenging, has not been reported previously. The goal of this study was to evaluate the feasibility and safety of thoracoscopic anatomical segmentectomy without endotracheal intubation. Methods From August 2009 to December 2012, 21 patients with lung tumors were treated using thoracoscopic anatomical segmentectomy without endotracheal intubation using a combination of thoracic epidural anesthesia, intrathoracic vagal blockade, and target-controlled sedation. Results There were 16 patients with primary or metastatic lung cancers and 5 patients with nonmalignant tumors. Left upper lobe apical trisegmentectomy was most commonly performed (n = 6), followed by superior segmentectomy of the right lower lobe (n = 4) and left lower lobe (n = 4). One patient required conversion to intubated single-lung ventilation because of vigorous mediastinal and diaphragmatic movement. No patient required conversion to a thoracotomy or lobectomy. Operative complications developed in 1 patient who had an air leak for more than 3 days postoperatively. The mean duration of postoperative chest tube drainage and mean hospital stay were 2.5 days and 6.0 days, respectively. Anesthetic induction and the operation required a mean 26.5 minutes and 148.0 minutes, respectively. Conclusions Nonintubated thoracoscopic segmentectomy is technically feasible and safe. It can be an alternative to intubated single-lung ventilation for management of lung tumors in selected patients.

Background and objective Bile acid (BA) aspiration is associated with various lung diseases. It was hypothesized that BA may induce changes in alveolar epithelium permeability and contribute to the pathogenesis of lung injury. Methods Human alveolar epithelial cells were grown in monolayer and stimulated with a major component of BA, chenodeoxycholic acid (CDCA). Transepithelial electrical resistance (TER) and paracellular fluxes were measured to assess permeability alteration. Prostaglandin E2 (PGE2) production was measured, and its effect on TER and junctional proteins (JP) was also examined. Reverse transcription polymerase chain reaction and Western blots were used to investigate the expression of messenger RNA and JP. Results CDCA induced significant p38 and c-Jun N-terminal kinase (JNK) phosphorylation, cytosolic phospholipase A2 (cPLA2) and cyclooxygenase-2 (COX-2) messenger RNA expression, PGE2 production, TER reduction and decay of JP (including occludin, zonula occludens-1 (ZO-1) and E-cadherin, in which ZO-1 had maximal change). CDCA also increased paracellular fluxes, which was abolished by dexamethasone. Both CDCA and PGE2 contributed to TER reduction in an identical trend and a dose–response manner. PGE2 also reduced ZO-1 expression, which was similar to that observed by CDCA stimulation. Pretreatment with inhibitors of p38 (SB203580), JNK (SP600125), cPLA2 (mepacrine) and COX-2 (NS398) as well as dexamethasone reversed the CDCA-induced PGE2 production, TER reduction and decay of ZO-1. Conclusions The increase in alveolar permeability was associated with decay of JP. BA may induce permeability alteration through the upregulation of mitogen-activated protein kinase, cPLA2, COX-2, PGE2 and JP, which may contribute to the pathogenesis of BA-associated lung injury.

Background Endotracheal intubation and chest tube drainage are considered mandatory for thoracoscopic pulmonary resection. The management of peripheral lung nodules by tubeless uniportal thoracoscopic surgical repair has not been reported previously. Methods From October 2015 through January 2016, 30 consecutive patients with peripheral lung nodules underwent uniportal thoracoscopic wedge resection without endotracheal intubation and chest tube drainage (tubeless group). The clinical outcomes were compared with the outcomes in 30 consecutive patients with peripheral lung nodules who underwent uniportal thoracoscopic wedge resection with chest tube drainage from April through October 2015 (chest tube group). Results The demographic, anesthetic, and operative characteristics of the patients were comparable in both groups. No major adverse events occurred after operation. A small residual pneumothorax was noted in 12 (40.0%) patients at 6 hours and day 1 and in 2 (6.6%) patients on day 14 in the tubeless group. No patient required reintervention or readmission to the hospital. Patients in the tubeless group had lower pain scale scores on postoperative day 1 (mean, 1.0 vs 1.5, p = 0.012) and shorter postoperative hospital stays (mean, 3.1 days vs 4.4 days, p = 0.011) than did those in the chest tube group. Conclusions Tubeless uniportal thoracoscopic wedge resection is feasible and safe and may be a less invasive alternative for treating selected patients with peripheral lung nodules.

Background/PurposePostoperative acute lung injury (ALI) after liver transplantation is clinically relevant and common. The perioperative thoracic fluid indices changes as well as the association with ALI in liver transplantation have not been thoroughly investigated.MethodsA total of 52 consecutive adult recipients for elective living donor liver transplantation were enrolled. Each recipient received the same perioperative care plan. Thoracic fluid indices, including the cardiac index, intrathoracic blood volume index (ITBVI), extravascular lung water index (EVLWI), and pulmonary vascular permeability index (PVPI), were obtained at seven time points (pretransplantation, anhepatic phase, 30 minutes after reperfusion, 2 hours after reperfusion, and postoperative days 1–3) using the pulse contour cardiac output system. The indices of those who developed ALI (PaO2/FiO2