Clinical evaluation of non-intubated spontaneous ventilation video-assisted thoracoscopic surgery in patients with non-small cell lung cancer and compromised pulmonary function: a propensity score-matched analysis.

BACKGROUND: Conventional video-assisted thoracoscopic surgery (VATS) under intubated general anesthesia poses significant risks in non-small cell lung cancer (NSCLC) patients with compromised pulmonary function, including postoperative pulmonary complications and respiratory failure. Non-intubated spontaneous ventilation video-assisted thoracoscopic surgery (NIVATS), which avoids one-lung ventilation (OLV) and airway instrumentation, may mitigate these risks and accelerate recovery. However, concerns remain regarding intraoperative hypoxemia, hypercapnia, and mediastinal flutter. This study aimed to evaluate the feasibility and safety of NIVATS as an alternative to intubated VATS in carefully selected NSCLC patients with impaired pulmonary function to facilitate enhanced recovery after surgery (ERAS) in this specific population. METHODS: A retrospective analysis was performed of 162 NSCLC patients with compromised pulmonary function who underwent either NIVATS (n=86) or intubated VATS (n=76) between January 2021 and May 2025. In the NIVATS group, 37 patients underwent lobectomy (48.7%) and 39 underwent segmentectomy or wedge resection (51.3%); in the VATS group, 46 underwent lobectomy (53.5%) and 30 underwent segmentectomy or wedge resection (46.5%). Propensity score matching (1:1) was performed to minimize confounding bias, yielding two balanced groups of 62 patients each. Short-term surgical outcomes were subsequently compared between the two groups. RESULTS: After propensity score matching, no significant differences were observed between the NIVATS and VATS groups in terms of operative time, anesthesia duration, procalcitonin (PCT) levels, or cardiovascular complications. Conversely, NIVATS was associated with significantly improved outcomes in chest tube duration (2.66±3.35 vs. 3.53±2.39 days; Standardized difference =0.001), anesthesia emergence time (7.98±2.55 vs. 15.69±3.68 min; Standardized difference <0.001), incidences of hypoxemia and gastrointestinal recovery (time to flatus/defecation), length of hospital stay, throat discomfort, postoperative pulmonary complications, and patient-reported satisfaction (all P<0.05). However, the NIVATS group had a higher incidence of hypercapnia compared with the VATS group. CONCLUSIONS: For carefully selected NSCLC patients with compromised pulmonary function, NIVATS represents a feasible and safe alternative to conventional intubated VATS. By mitigating anesthesia-related trauma, NIVATS facilitates ERAS and expands the boundaries of surgical treatment for high-risk patients.