Tubeless minimally invasive treatment: taking a new step in enhanced recovery after surgery (ERAS)

Abstract

To the editor: We read with great interest the paper by Cui and colleagues1 where the authors compared the results of the application of two different chest tube management systems after video-assisted thoracoscopic (VATS) lobectomy. This proved that chest tube management plays a key role in enhanced recovery after lobectomy surgery (ERAS) and also showed a significant impact on patients treated with a minimally invasive surgical approach by using a drainage ball with negative pressure compared with the commonly used chest tube. Here, we summarize the new approaches used in ERAS with a perioperative regime optimization including the new suggested chest tube drainage. The concept of ERAS is well known by physicians and its implementation requires a combination of minimally invasive surgical techniques. Over the past three decades, the collaboration between the clinical practice of the ERAS concept and minimally invasive surgery has been greatly developed through collaboration with multidisciplinary teams. Tubeless minimally invasive treatment includes no intraoperative tracheal intubation during patient anesthesia, no urinary catheter placement during the operation and no chest tube after the operation. If these aspects of perioperative care regime optimization and all-in-one model in medical care were linked-up, minimally invasive treatment with ERAS could be realized. Thoracoscopic surgery was a milestone in thoracic surgery. The concept of ERAS in thoracoscopic surgery involves the foundation of pain and risk-free wards during the perioperative period and improving the patient's quality of life post discharge, including multimodal analgesia, minimizing the perioperative period to avoid the placement of excessive drainage tubes and patient transfusion, at the same time strengthening postoperative care and rehabilitation which is the goal of tubeless minimally invasive treatment. Intraoperative anesthesia for double-lumen intubation in patients with lung disease is considered by most anesthesiologists to be necessary, especially for VATS surgery. During long-term surgical anesthesia, it has been confirmed that double-lumen intubation can ensure a safe airway and adequate lung ventilation.2 The report by Pompeo et al. was one of the first to introduce nonintubated VATS.3 Several studies have subsequently shown the feasibility of this approach.4-8 which includes patients with small pulmonary nodules (SPN) less than 2 cm in diameter,6 patients with pulmonary tuberculoma4 and those with interstitial lung diseases.5 All the results showed that patients operated upon under spontaneous ventilation had a shorter postoperative recovery time when compared with the conventional VATS approach. The other two clinical trials also observed a more encouraging response in patients after using this method.9, 10 In patients where muscle relaxants were not used during surgery, the most obvious advantage of nonintubated anesthesia was that it could reduce postoperative respiratory complications, promote early postoperative activities and earlier oral feeding. However, all clinical thoracic surgeons should be aware that this type of operation requires an experienced and highly specialized anesthesiologist because it may be necessary to intubate the patient in the event of intraoperative complications2 (Table 1). Minimally invasive surgery represented by VATS has become the mainstream and consensus of lung cancer resection which has potential advantages, including less postoperative pain, faster recovery and a better cosmetic outcome.13 However, further improvisation of the precise treatment in VATS, reducing patient suffering and improving patient satisfaction remain a challenge for all thoracic surgeons. The first uniportal VATS of lung cancer resection was reported by Gonzalez et al. in 2011.14 The feasibility of this approach has been demonstrated in even very advanced pulmonary resections.15 With the clinical popularity and application of the E