Awake pulmonary metastasectomy

General anesthesia with single-lung ventilation and bimanual lung palpation is considered mandatory in pulmonary metastasectomy. We assessed the safety, feasibility, and early results of awake pulmonary metastasectomy under sole thoracic epidural anesthesia.

Between December 2003 and December 2005, 14 patients with radiologic evidence of peripheral solitary lung metastases underwent awake thoracoscopic metastasectomy under sole thoracic epidural anesthesia at T4 to T5. To achieve bimanual-like full lung palpation, a modified digital-instrumental palpation method was used. Anesthesia time, operative time, global operating room time, patient satisfaction with the anesthesia, and technical feasibility scored into 4 grades (from 1 = poor to 4 = excellent) were assessed. Preoperative and postoperative data were compared with those of a historical cohort undergoing video-assisted transxiphoid lung metastasectomy through general anesthesia and 1-lung ventilation.

There was neither mortality nor major morbidity. Technical feasibility was excellent in 10 instances and good or satisfactory in 2 instances, whereas anesthesia satisfaction score was excellent to good in 12 patients. Of 18 resected nodules, 15 proved to be metastases. At awake and control group comparisons, significant differences included median operative time (25.5 minutes vs 48.5 minutes, P < .00001), global in-operating room time (62.5 minutes vs 147.5 minutes, P < .00001), and hospital stay (2.5 days vs 4.0 days, P = .02). There was no difference in lung recurrence (2 vs 3, P = .66) 3-year actuarial survivals (40% vs 78%, P = .29).

Awake pulmonary metastasectomy proved safe and feasible. Global operating room time and hospital stay were significantly shorter than those of the control group who underwent operation with general anesthesia, whereas oncologic results were comparable.