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ORIGINAL ARTICLE
Year : 2015  |  Volume : 11  |  Issue : 8  |  Page : 265-270

The comparison of anesthesia effect of lung surgery through video-assisted thoracic surgery: A meta-analysis


Department of Anesthesiology, Friendship Hospital, Capital Medical University, Beijing 100050, China

Date of Web Publication26-Nov-2015

Correspondence Address:
Jing-Dong Ke
Department of Anesthesiology, Friendship Hospital, Capital Medical University, Beijing 100050
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.170534

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 > Abstract 

Objective: The epidural anesthesia and general anesthesia are the most commonly used in lung surgery through video-assisted thoracic surgery (VATS). Each of these methods has their advantages and disadvantages, so the aim of this meta-analysis is to identify which anesthesia is more conducive to lung surgery under VATS and rehabilitation of patients.
Materials and Methods: The Cochrane Library Database (Issue 12, 2013), PubMed (1966–2015), and China National Knowledge Infrastructure (1950–2015) were searched without language restrictions. Meta-analyses were conducted using Review Manager 5.2 software (The Cochrane Collaboration, Software Update, Oxford). We calculated odds ratio (OR) and its confidence interval (95% CI) to estimate the difference between epidural anesthesia and general anesthesia through finishing of the collected data.
Results: Due to our search results, 7 studies were included in our study. Studies among them show that different contents of these articles are not all the same about research direction. Our findings suggested that epidural anesthesia had more advantages than general anesthesia for operative time (mean difference = − 23.85, 95% CI: − 29.67–− 18.03, P = 0.0001). More than that, epidural anesthesia showed a good surgical outcome on postoperative hospital stay (mean difference = − 0.43, 95% CI: − 0.85–− 0.01, P = 0.04) than general anesthesia. But we found that there were no different on numbers of people with complications (OR = 0.45, 95% CI: 0.23–0.89, P = 0.97) and headache occurrence (OR = 2.69, 95% CI: 0.62–11.70, P = 0.91) between epidural anesthesia and general anesthesia.
Conclusion: These results indicated that epidural anesthesia can save operating time and postoperative hospital stay time. But epidural anesthesia and general anesthesia have the same effect on complications.

Keywords: Anesthesia, lung surgery, video-assisted thoracic surgery


How to cite this article:
Ke JD, Hou HJ, Wang M, Zhang YJ. The comparison of anesthesia effect of lung surgery through video-assisted thoracic surgery: A meta-analysis. J Can Res Ther 2015;11, Suppl S4:265-70

How to cite this URL:
Ke JD, Hou HJ, Wang M, Zhang YJ. The comparison of anesthesia effect of lung surgery through video-assisted thoracic surgery: A meta-analysis. J Can Res Ther [serial online] 2015 [cited 2020 Jan 18];11:265-70. Available from: http://www.cancerjournal.net/text.asp?2015/11/8/265/170534


 > Introduction Top


With the development of society, changes of the air have made the significant increase in the incidence of lung disease. And most of the disease still needs to treat with traditional surgery, such as lung cancer, pneumothorax, bronchiectasis, and so on. In order to increase the accuracy of the operation and reduce the trauma of the surgical incision to the patient, video-assisted thoracic surgery (VATS) has been widely used in clinical recent years. The introduction of VATS has allowed many procedures that previously required a thoracotomy to be performed by way of "minimally invasive approach."[1] Some studies showed that lung biopsy, wedge excision of pulmonary nodules, blebectomy and bullectomy and resection of mediastinal tumors have now all been successfully and safely accomplished by VATS approach.[2],[3],[4],[5] However, original VATS were performed through four-port, three-port, two-port in nearly all kinds of lung cancer resections, but recent clinical advances have shown that VATS could also undergo surgery through one-port.[6]

As we know, the selection of anesthetic method will have an impact on operational results. Anesthesia for VATS should not only achieve adequate depth but also control negative intrathoracic pressure and lung expansion during the surgery.[7] Among the anesthetic methods, epidural anesthesia and general anesthesia are commonly used in lung surgery. But we found that different anesthesia could relate to many factors in our operative, such as operative time. In order to evaluate the feasibility, safety and advantages of VATS, we conducted this study to compare the performance of epidural anesthesia and general anesthesia methods.


 > Materials and Methods Top


Literature search and selection criteria

Related articles were identified by searching Cochrane Library, PubMed and China National Knowledge Infrastructure databases, and the time from inception to September 01, 2015 without language restrictions. The searching keywords and MeSH terms were used in conjunction with a highly sensitive search strategy: ("video-assisted thoracic surgery" or "VATS") and ("lung surgery" or "pulmonary surgery" or "SR" or "lobectomy of lung") and anesthesia. At the same time, we also performed a manual search to find other potential articles on the basis of references identified in the returned articles.

Two investigators selected articles according to inclusion criteria independently. The following criteria were established for the eligibility of include studies: (1) the study design must be clinical cohort study or diagnostic; (2) during the course of treatment of two anaesthetic methods must be used alone; (3) contained a description of disease response or postoperative follow-up; (4) all included studies have made it clear that the use of anesthesia. The exclusion criteria were as follows: (1) animal studies, review articles, letters, editorials, communications, and case report; (2) studies that were not directly reporting anaesthetic methods; (3) studies with insufficient data for estimating or with no original data.

Data extraction and methodological assessment

After assessment for eligibility, two investigator used a standardized form to extract following data from previous included studies, and mainly figured out year, ethnicity, case number, gender, and the most important thing are operative time, postoperative hospital stay, people who turned up complications, and people who had headache. However, the type of complication also showed at our table even if part of the article did not mention that.

In the part of the article, there was no direct point to the average value of the operation time and the average in hospital time. So the data listed in this table are calculated by two researchers very objective according to the information provided in the article partially. And the data used in the article were represented by the mean of the number, and the variance will be used in the analysis.

Statistical analysis

The effect outcomes estimated by odds ratio (OR) for dichotomous data and reported with 95% confidence intervals (CIs). Our analysis was performed in RevMan version 5.3 software (Copenhagen: The Noric Cochrane Centre, the Cochrane Collaboration, 2014). The statistical heterogeneity between trials was evaluated by the Chi-squared Q-test based on the fixed-effect model. When the P value of the Q-test was <0.1, or when I2 was greater than 50%, it represented heterogeneous between epidural anesthesia and general anesthesia. Then, a random effect model was used to accommodate the heterogeneity. In a random effects model, it inassumed that there is variation between studies and thus the calculated OR has a more conservative value.


 > Results Top


Characteristics of included studies

A total of 425 articles relevant to the searched keywords were initially identified. And 365 articles were excluded after the titles and abstracts of all the articles were reviewed; another 27 articles were excluded due to fail to meet the inclusion criteria, and 4 studies were excluded according to data integrity [Figure 1]. Eventually, 6 clinical cohort studies which recruited a total of 820 patients were selected for statistical analysis.[1],[8],[9],[10],[11],[12] Eligible studies included in the current meta-analysis were published between 2008 and 2015. Overall, 3 studies were carried out among Chinese populations, 1 studies carried out among Italian populations, 2 among Japanese populations, and 1 among American. Finally, operative time, postoperative hospital stay time, a number of people with complications were taken into consideration to evaluate the difference of epidural anesthesia and general anesthesia in the statistics. Some studies also showed the type of complications at the end of the table, some of them described in great detail, but some articles did not specify. Baseline characteristics and methodological quality of eligible studies were recorded in [Table 1].
Figure 1: Flow chart of literature search and study selection and 7 studies was included in this meta-analysis

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Table 1: Baseline characteristics of included studies

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Quantitative data analysis

A meta-analysis could be conducted while there were at least two researchers have been done on the same topic and the same comparison. Many studies were presenting comparison of patients with epidural anesthesia or general anesthesia. Among them, six studies [1],[8],[9],[10],[11],[12] were included in the comparation of the two factors on operative time. The pooled estimates displayed a significant difference between epidural anesthesia and general anesthesia (P = 0.0001, I2 = 80%). The pooled mean difference was − 23.85 (95% CI = − 29.67–− 18.03) as showed in [Figure 2].
Figure 2: Forest plots for the comparison between epidural anesthesia and general anesthesia on operative time

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After surgery, there is a great relationship between the residence time in the hospital and the anesthesia method, so we analyze the 4 studies [1],[9],[10],[11] in this article. Data on postoperative hospital stay time were available involving 169 patients. The pooled estimates showed that the surgery treated with epidural anesthesia lead to less time in hospital than general anesthesia (mean different = − 0.43; 95% CI = − 0.85–− 0.01) with significant heterogeneity (P = 0.04; I2 = 65%) [Figure 3].
Figure 3: Forest plots for the comparison between epidural anesthesia and general anesthesia on postoperative hospital stay time

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Five studies presented the comparison between epidural anesthesia and general anesthesia on peoples who have complications.[8],[9],[11],[12],[13] And the pooled estimates suggested no significant difference between two anesthesia for surgical patients. The pooled OR was 0.45 (95% CI = 0.23–0.89) without significant heterogeneity (P = 0.97; I2 = 0%) [Figure 4].
Figure 4: Forest plots for the comparison between epidural anesthesia and general anesthesia on complications

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In the studies included or excluded in our analysis, we found that headache always happened to patients with anesthesia, such as epidural anesthesia and general anesthesia. So we took headache into consideration for our meta-analysis. But only three articles were available for the comparison.[8],[12],[13] The pooled analysis showed that patients with headache had no difference in two anesthesia methods (OR = 2.69; 95% CI = 0.62–11.70) with no obvious heterogeneity (P = 0.91; I2 = 0%) [Figure 5].
Figure 5: Forest plots for the comparison between epidural anesthesia and general anesthesia on complications of headache

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 > Discussion Top


Traditional open chest surgery has a large area of trauma, bleeding, and postoperative pain, it is possible to have potential complications, and the wound healing scar is obvious. From the perspective of human mechanics, it will destroy the stability of the body's chest, and may even cause a certain degree of the fracture of the chest, and a certain degree of physiological and psychological burden to the patients. The chest surgery will be all the defects have been solved, the biggest advantage is that the trauma is small, the patient recovered quickly.[14],[15] From the point of view of the technical level, VATS is in the TV image monitoring auxiliary, instead of the previously by traditional thoracotomy was performed and the operation, its essence is endoscopic surgery, and surgery operation principle is the same, but changed the traditional surgical approach and separation steps, ligation and suture and surgical procedure in the way of observation.[16],[17] All of the operations were achieved by endoscopic observation. So it is very important to ensure the stability of the patients in the operation process, so that the patients can be revived as soon as possible and reduce the negative effect of the operation on the patients.

Surgical intervention for respiratory management and complications after pneumonectomy and other lung surgery is quite challenging. Traditional surgical treatment consists of bullectomy and pleurectomy with intermittent apnea under epidural anesthesia or general anesthesia, which possesses the disadvantages of preoperative barotraumas and postoperative respiratory dysfunction associated with lung surgery under through VATS.[18],[19] However, patients who need to have a surgical always show a poor general condition, complicated with different disease, and patients' ability to withstand the surgery must be diminished, the risk of both surgery and anesthesia were increased. So the effectiveness and safety of anesthesia are very important to ensure the success of the surgery.[20]

Although the use of different anesthesia methods currently provides a good surgical visual field, the phenomenon of "a minor surgery under major anesthesia" is not uncommon. The key points in the selection of the anaesthetic method based on some issues as follows. Epidural anesthesia is mainly come about by injection of local anesthesia in the epidural space.[21] Because the spine and epidural space has been compressed by the disease for a long time, the dose of the anaesthetic should be reduced. Usually vast majority of the routine dose should be administered to ensure the safety of the anesthesia.[22] On the other way, general anaesthesia is a deep way, and the use of general ansesthesia combined with mechanical ventilation can better warrant the breathing and blood oxygen saturation. The use of a muscle relaxant in general anesthesia facilitates the surgical in vision.[23] In addition, we should take the comprehensive consideration of analgesic effect before selected anesthesic methods. According to the lung disease, such as lung tumor, general anesthesia could be better than epidural anesthesia. The choice of appropriate anesthesia method can also shorten the operation time.[24]

In our current review, we have demonstrated that epidural anesthesia showed a short operative time than general (P = 0.0001, I2 = 80%, 95% CI = − 29.67–− 18.03). Otherwise, we think that the operative time is related to the method of anesthesia, but it is also related to other factors, such as the methods of anesthesia on proficiency. At the same time, we also have a comparison of the observation time of the patients after operation. The result suggested that patients with epidural anesthesia had a shorter hospital stay time than general anesthesia (P = 0.04, I2 = 65%, 95% CI = − 0.85–− 0.01). Studies [25],[26],[27] have indicated that different anesthesia methods can also affect the postoperative complications. We compared patients with complications after epidural anesthesia or general anesthesia, and we found that there is no significant difference between anesthesia methods. However, the probability of a headache is higher in patients with epidural anesthesia. But there is no obvious difference between the two methods of our analysis. We think that this may be caused by less data related to headache.


 > Conclusion Top


It is important to summarize the available data that are driving clinical practice trends. And we acknowledge that the retrospective studies currently available in the literature limit our meta-analysis. Our findings and statistics showed the difference in some aspects. A count for lung surgery, epidural anesthesia may be better than general anesthesia for operative time, but in terms of lung tumor with large size may be general anesthesia more suitable. So our research is aimed at a general situation and in most cases which anesthesia method will be used. Furthermore, we still have to consider the use of a specific lung disease under the use of epidural anesthesia or general anesthesia. Some tomes may be the joint use of the two methods.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
 > References Top

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