Non-intubated surgical lung biopsies in elderly and frail adults-one shot, two targets: a case report

Background: According to recent data, non-intubated thoracic surgery (NITS) appeared to be a safer and feasible alternative to conventional endobronchial intubation and one-lung positive pressure ventilation for diagnostic minor video-assisted thoracic surgery (VATS) procedures. NITS seems to provide a shorter anesthesiologic time, less postoperative pain, improved recovery, and shorter hospital length of stay, with less postoperative complications or morbidity. Nevertheless, these results in older and fragile adults are controversial. The peculiarity of the reported case is the concomitant presence of two possible pulmonary pathologies in a patient with more than one feature that could contraindicate surgery (age, obesity, restrictive pulmonary pathology, and other comorbidities).Case Description: An 86-year-old male obese patient [body mass index (BMI): 30.11 kg/m2] with multiple cardiac comorbidities, previous bladder cancer with multiple relapses, and scalp sarcoma presented with a diagnostic suspect of pulmonary interstitial disease and concomitant lung cancer nodule. The computed tomography scans showed lung parenchyma with widespread alterations in density due to the presence of multiple ground-glass opacities mainly arranged in the subpleural area interesting both lungs, associated with a consolidative lesion of the left lower lobe (17 mm x 35 mm). Following the diagnostic path, positron emission tomography scans showed increased 18F-fluorodeoxyglucose uptake in the apical segment of the left lower lobe. The respiratory function tests obtained the following values: forced vital capacity (FVC) 2.74 L (93%), forced expiratory volume in the first second (FED1) 2.35 L (113%), diffusion lung carbon monoxide (DLCO) 55%. According to the diagnostic suspect, considering the high operative patient risk and the patient's willingness, the safest surgical option appeared to perform a left thoracoscopy in awake surgery with a diagnostic purpose. The patient has been referred an excellent postoperative pain control with acetaminophen therapy and never experienced postoperative nausea and vomiting, allowing early mobilization and early pleural drainage removal. There was not any surgical or anesthetic adverse event. The hospital stay was of 6 days.Conclusions: Despite the age and the multiple comorbidities, the patient successfully underwent surgery with reduced operative time, low postoperative pain, and excellent aesthetic result with the diagnosis achievement and a complete surgical neoplasm resection with unaffected margins.