Use of AVATS, Awake Video Assisted Thoracic Surgery, to Redefine Operability in Lung Cancer Patients With Extremely Poor Pulmonary Function

Abstract

<h3>Purpose/Objective(s)</h3> Surgery is the treatment for early NSC lung cancer in patients with normal pulmonary status but is excluded in poor pulmonary function. <i>AVATS</i>, Awake Video Assisted Thoracic Surgery, under local with sedation has been used in a variety of conditions. We wanted to see if patients with NSCCA and poor pulmonary reserve could benefit from <i>AVATS</i>. <h3>Materials/Methods</h3> Over 2300 AVATS have been performed, with a sub group of 502 resections with poor pulmonary status. Wedges, segments and even lobectomy has been performed without significant morbidity/ mortality. Pre-op PFT in these 502 patients showed FEV1 less than 0.8 (some under 0.5.) These patients would not tolerate general anesthesia and/or single lung ventilation. <i>AVATS</i> without affords surgical option. All had staging PET/CT scans. 83 Split function V/Q studies were used. Resections included 48 wedges, 123 segments, 21 bi-segments, 308 lobes, and 2 bi-lobectomies. No central venous, or epidural catheters were used. Only 15 arterial lines and only 8 urinary catheters were used. All had two year follow-up. Post-op PFT was available on 338. <h3>Results</h3> 502 patients with NSCCA with poor pulmonary reserve were offered <i>AVATS</i>. Comorbidities included: hypertension (390); CAD (262)-90 s/p CABG, 118 s/p stent; diabetes (108); COPD (382)-112 steroid dependent; smoking (438) with 12 active smokers; atrial fib (60)- 52 on anticoagulation; renal failure (79)-32 requiring dialysis; hepatic failure (28); thyroid disease (3); prior stroke (8). 502 patients with FEV1 less than 0.8 successfully had <i>AVATS</i> resection with 24-month follow-up. No deaths were seen. Avg. length of stay was 1.2 days. Thirty-eight had new onset atrial fib (all managed medically,) 1 had IV phlebitis. The use of dexmedetomidine allowed evaluation intra-op of the presence air leak significantly eliminating post-op air leak. Only 3 patients required >2 day chest tube for air leak. Five had readmission, all due to unrelated issues (2 for exacerbation of CHF, 2 for non-thoracic procedures, and 1 for diabetes.) AVATS, often via 1 small incisions, reduces pain minimizing narcotic usage. All received peri/post-operative IV acetaminophen, and if tolerated IV ketorolac minimizing nausea and alteration of sensorium, improving patient satisfaction. There was no stroke, UTI, DVT, PE, pneumothorax, pneumonia, hospital acquired infections, or prolonged (> 3 day) air leak. 338 patients had post-op PFT, the majority without reduction of FEV1 (39 had less than 10% reduction of FEV1 without clinical manifestation.) <h3>Conclusion</h3> <i>AVATS</i> is safe in select patients previously deemed inoperable often with improved outcomes compare with patients with good pulmonary status having VATS or robotic resection under general anesthesia. <i>AVATS</i> allows surgery in patients with poor pulmonary function with improved outcomes/patient satisfaction, shorter length of stay and presumably lower costs.