Fast-track video-assisted thoracoscopic surgery: future challenges

Abstract

Objectives To provide a short overview of fast-track video-assisted thoracoscopic surgery (VATS) and to identify areas requiring further research. Design A literature search was made using key words including: fast-track, enhanced recovery, video-assisted thoracoscopic surgery, robot-assisted thoracoscopic surgery (RATS), robotic, thoracotomy, single-incision, uniportal, natural orifice transluminal endoscopic surgery (NOTES), chest tube, air-leak, digital drainage, pain management, analgesia, perioperative management, anaesthesia and non-intubated. References from articles were screened for further articles. Using abstracts, areas of interest for developing a fast-track protocol were selected. Results The minimally invasive approach can be divided into several surgical methods that need further research to establish superiority. The role of intubation has to be further examined as well as the role of chest drains. Multimodal analgesic treatment including preoperative methylprednisolone seems promising and requires further research. Conclusions The fast-track data from other procedures may support future development and improvement of fast-track VATS.

Keywords:

• Analgesia
• comorbidity
• perioperative care
• postoperative complications
• robotic surgical procedures
• video-assisted thoracoscopic surgery

Introduction

The concept of “fast-track” or “enhanced recovery” surgical programmes has evolved over the past 15 years.[1] It was originally intended for abdominal procedures,[2] but soon spread across the majority of surgical fields.[3,4] The concept is based on multimodal interventions, including intensified preoperative patient information, minimally invasive surgical techniques, multimodal opioid-sparing procedure-specific analgesia, evidence-based fluid management, early mobilization and revision of traditions of surgical care (drains, restrictions, catheters, etc.).[1]

Overall, there is relatively limited high-quality data from thoracic surgery regarding fast-track surgery, with most data coming from open procedures.[5] Within the past decade video-assisted thoracoscopic surgery (VATS) has gained increased popularity, and it is therefore appropriate to update current knowledge on fast-track VATS and discuss future strategies for this minimally invasive technique with potential benefits on reducing postoperative morbidity and enhancing recovery.

Current status on fast-track VATS

Patient selection

VATS lobectomy is the standard treatment of early stage lung cancer, and VATS has been shown to improve morbidity, oncologic treatment and survival compared with open thoracotomy.[6–10] The indications for VATS lobectomy are constantly expanding to involve more difficult and morbid cases.[11] The consensus statement from 2013 identifies indications for VATS lobectomy as being tumour ≤7 cm and N0 or N1 disease.[12] Chest wall invasion involving rib(s), forced expiratory volume in 1 second (FEV1) < 30% of predicted and diffusing capacity of the lung for carbon monoxide (DLCO) <30% of predicted are identified as contraindications, and centrally placed tumour invading hilar structures is a relative contraindication. Regarding the VATS approach to N2 disease and tumour size >7 cm, controversy exist,[12] however indications for VATS seem to continually expand with experience and the development in technique and equipment. Correspondingly some cases previously considered unsuited for surgery have been performed thoracoscopically.[13,14]

Although no VATS-specific information is available, data from other studies have shown that preoperative co-morbidities and functional aspects should not exclude patients from a fast-track set-up.[15,16] In fast-track surgery the goal is to achieve a “pain and risk-free operation” with the potential of it being done as an outpatient procedure. With this goal in mind it is important to assess reasons for postoperative hospitalization and the patients’ recovery problems following VATS as done in other procedures.[17] Such an analysis forms the basis to identify focus areas to further enhance recovery.

Surgical technique

The current definition of VATS lobectomy derives from the CALGB 39802 report from 2007 where a 4–8 cm incision together with two or three additional ports are utilized for access without using a rib retractor.[18] Throughout Europe the anterior three-port Copenhagen approach has been adopted by many surgeons and seems to improve the rates of VATS procedures compared with open surgery.[19,20] The consensus statement recommends 50 cases of VATS lobectomies to overcome the learning curve, and subsequently 20 cases annually to maintain operative skills.[12]

A natural step to minimize the injury in VATS has been to progress into uniportal surgery, either directly or via a two-port method.[21] However, although the rationale of decreasing surgical stress by a single port seems intuitive, there is so far no firm evidence of an advantage over three-port VATS in short-term studies.[22] The technological advancement within minimally invasive thoracoscopic surgery is continually developing, and might bring novel techniques to the table to improve fast-track VATS.[23] In other surgical fields, however, SILS (single incision laparoscopic surgery) and NOTES (natural orifice transluminal endoscopic surgery) have been developed but without any widespread documentation of enhanced early recovery.[24–27]

Another minimally invasive technique is robot assisted thoracoscopic surgery (RATS) usually involving three or four ports.[28,29] Proponents of RATS technique have highlighted superior imaging, decreased compression of the intercostal nerves, and better manoeuvrability and stability of the instruments when compared with VATS. Opponents state that the current RATS setup is complicated with lack of tactile feedback, time consuming and expensive with no advance to an established VATS setup.[30–32] At present, RATS furthermore requires an assistant at the table performing the stapling, due to lack of robotic staplers. Some of these technical and cost-related issues are expected to diminish when new developers enter the market to avoid the current monopoly.[33] Experience with both VATS and RATS is limited to few centres, and often surgeons are performing either one technique or the other. Currently there is a need for well-designed comparative studies, ideally in a fast-track setting.

Anaesthesia

Non-intubated thoracoscopic surgery seems promising because avoidance of tracheal intubation, one-lung ventilation and general anaesthesia may lead to faster recovery.[34–36] However, the limited details on perioperative outcome, patient selection and safety issues do not allow any conclusions to be made, and calls for further studies. Nevertheless, the role of intubation per se may not be considered to have a major clinical impact on enhanced recovery after VATS.

Analgesic treatment

Acute pain after open thoracotomy poses a significant problem, but may be reduced by the VATS approach.[37] Traditionally, after open thoracotomy, continuous thoracic epidural analgesia has been a mainstay of analgesic treatment, although continuous paravertebral blockade may have similar efficacy with fewer side effects.[38]

The literature regarding regional analgesia for VATS is so far inconclusive.[37,39] However, preliminary data suggest that a combination of an intraoperative paravertebral block, an intercostal catheter at the drain site, and a multimodal oral analgesia regimen with paracetamol, a COX-2 inhibitor and gabapentin is a promising analgesic regimen.[40]. The risk of intraoperative nerve damage may occur at the port site, but the chest drain might also create pain.[41] Consequently, less use of chest drains in VATS surgery may facilitate future analgesic treatment.

Another promising treatment to enhance recovery is the multimodal analgesia supplemented with an additional preoperative high-dose glucocorticoid. This has been shown to be effective in other minimally invasive procedures[42] and requires further study.

Finally, the use of incisional slow-release, long-acting analgesic preparations may facilitate analgesia and recovery [43] but requires more procedure-specific VATS studies. A main step is the provision and development of effective multimodal opioid sparing techniques.[44] In summary, several possibilities exist to improve analgesic treatment and thereby enhance recovery after VATS.

Chest drain management

The single most important step to improve a fast-track course after pulmonary resections is early removal of chest drains, that are known to cause pain and impair mobilization.[45] Furthermore, it is a risk factor of infection that can eventually result in longer length of stay (LOS).[45–47] In patients with no co-morbidity, LOS is closely related to drain time and discharge usually occurs the day after drain removal.[47,48] However, a chest drain has to remain in place until an air leak is absent.

International consensus has been achieved on limiting the number of postoperative chest drains to one as opposed to two.[49] The size of chest drains has been extensively discussed in the literature for non-surgical patients; however, consensus following surgery has not been reached.[49] Commonly discussed disadvantages of large calibre chest drains are; the need for blunt dissection, pain during insertion and the need for a more invasive approach.[50] These factors are not issues in VATS where a port hole is used for drain access. Furthermore, studies on pain found no correlation favouring smaller drain size.[51] Evidence supporting small calibre postsurgical drains is lacking, and further studies might become relevant at a later stage when instrument size has diminished.

Prolonged air leak (PAL) is the most common complication following VATS lobectomy.[46] Important keys to avoiding PAL is ensuring an atraumatic handling of the lung parenchyma during mobilization,[19] using a fissureless technique by dividing the entire fissure with stapler,[52] and possibly applying a sealant.[53]

In traditional chest drainage systems, assessment of air leak relies on visual assessment of bubbling in the water-seal chamber. Development of digital drainage units provides a more precise assessment of air leak without the need for specialist observations during ward rounds, potentially allowing earlier drain removal. Most, but not all studies suggest that a digital drainage assessment may shorten drain time, LOS and overall cost.[54–56] However, more detailed studies in well-defined fast-track pathways are required.

Although the use of a chest drain has been mandatory to ensure early remission of pneumothorax and expansion of the lung,[49] a minor non-expanding pneumothorax is of little clinical relevance and requires no intervention.[57] Also, preliminary studies suggest that a chest drain may be omitted after some VATS procedures,[58,59] again calling for more detailed studies on recovery and safety.

Another reason for inserting a chest drain is drainage of pleural fluid. Criteria for fluid production before removal of a chest drain have been highly debated ranging from 200 mL/day to 500 mL/day, and it has been suggested that the rate of fluid drainage might not affect removal criteria.[48,60,61] A recent development with digital drain boxes (Thopaz⁺, Medela, Switzerland) provides the possibility of continuous monitoring of both air flow and fluid production, which potentially may provide objective data on the appropriate time for drain removal. Further research on this topic is urgently required.

Monitoring

In daily routine, VATS patients are monitored postoperatively in the intensive care unit or at an intermediate recovery ward for the first postoperative hours for haemodynamic, analgesic and respiratory problems. Depending on local policy, patients undergoing major lung resections may have a urinary bladder catheter. However, again this topic is debatable and specific studies on early removal or omission of a urinary catheter after VATS is required.[62] Although a chest x-ray is often taken within 2 h after surgery to control drain placement and lung expansion, preliminary data suggest that an x-ray may be taken on clinical indication only,[63–65] again calling for more safety studies.

Conclusion

The aim of this article was to discuss the current literature on fast-track VATS and to identify areas for further development. Despite much improvement within the past decade, data suggest the potential and need for further improvement in fast-track VATS research, as summarised in Table 1. Overall, the current data reviewed suggest that VATS procedures may require only 1–2 days admission in the future, and may become a “pain and risk-free operation”.

Table 1. Fast-track VATS – areas requiring further research.

Surgical technique	VATS 3-port versus uniportal
	VATS versus RATS
	Anaesthetic management	Intubated versus non-intubated
Analgesic treatment	Multimodal opioid-sparing analgesic regimen
	Preoperative high-dose glucocorticoid
	Chest drain	Possible omission of chest tube in selected patients
Consensus on removal criteria (regarding both air and fluid)
Postoperative monitoring		Possible avoidance of a postoperative urinary catheter
	Possible avoidance of a routine postoperative x-ray
	Possibility for early admission to standard ward
	Possible new areas	Identifying specific reasons for postoperative hospitalisation following VATS

Disclosure statement

Dr René Horsleben Petersen is speaker for Covidien, Medela, and Takeda. Dr Henrik Jessen Hansen is speaker for Covidien, Medela, and Bard. Professor Henrik Kehlet and Dr Bo Laksáfoss Holbek have no conflicts of interest to report.