Health care in our era is dominated by an increasing attention to patients’ quality of life and cost to benefit ratio of therapies. For these reasons, interest towards minimally invasive surgery procedures that are typically associated with minor postoperative pain and morbidity, short hospitalization and optimal cosmesis, continues to grow. Awake thoracic surgery is being developed according to the idea that making thoracic surgery procedures less and less aggressive can be a feasible task. Theoretically, the avoidance of well known adverse effects of general anesthesia and one-lung ventilation could translate into some advantages including a smoother postoperative course, a more rapid resumption of daily-life activities, and even an opportunity to offer surgical treatment to patients in whom this would be denied because of a high-risk for standard surgery.
The reader will have the opportunity to acknowledge that, though awake thoracic surgery is a totally explorable novel surgical field, many of the concepts we advocate today had already been hypothesized in the past by pioneer surgeons, whereas some of the fears of yesterday now prove either groundless, thanks to a better knowledge in cardiopulmonary physiology, or easily surmountable by our current technology. However, despite the enthusiasm and encouraging initial results, there is still a long way to go. Many pathophysiologic aspects as well as real advantages and cost-effectiveness of these novel options need to be better elucidated. Alternative non-surgical treatment procedures are being developed to cure a number of thoracic conditions and it is likely that many valid surgical procedures of today will become obsolete within a few years.
Awake thoracic surgery might represent one strong answer to this challenge and the aim of this e-Book is to provide a first overview on current advances matured in this exciting surgical field. Following some historical notes, the main pathophysiologic aspects of epidural anesthesia and the surgical pneumothorax in the awake patient, are focused to provide insights on intraoperative changes in oxygenation, ventilation and the main cardiopulmonary variables. In addition, the low impact of awake thoracic surgery on postoperative immunologic and stress hormone responses is also analyzed in detail. Chapters on surgical techniques include a description of the advantages, indications, technical details and results of several surgical procedures including the promising non-resectional awake lung volume reduction surgery technique for the treatment of end-stage emphysema, pulmonary resections and thymectomy.
This monograph is the result of a multi-mind effort and I want to thank all the authors for their excellent contributions. Some of them are talented young researchers from our own University, whereas others are well-known thoracic surgeons from other countries who are actively involved in awake thoracic surgery programs. I greatly thank my mentor, Prof. Mineo, who has given me the opportunity to be fully involved in advanced videothoracoscopic surgery, to apply my ideas and to develop our awake thoracic surgery clinical program. He constantly guided me in the art of surgery with his advice and constructive comments arising from an unexceptionable 40-year based full-time academic practice in thoracic surgery.
I am particularly grateful to Bentham Science Publishers that believed in this project and allowed its realization. The modern formula of an e-monograph has made it possible to include rich iconographic and multimedia material that will facilitate diffusion and understanding of the various topics.
Enjoy your reading.
Department of Thoracic Surgery
Policlinico Tor Vergata University