Is Less More? A Meta-Analysis of Non-Intubated Versus Intubated VATS for Anatomic Resections in Non-Small Cell Lung Cancer

Dimitrios E Magouliotis; Anna P Karamolegkou; Prokopis-Andreas Zotos; Fabrizio Minervini; Ugo Cioffi; Marco Scarci

doi:10.3390/jcm14196731

Is Less More? A Meta-Analysis of Non-Intubated Versus Intubated VATS for Anatomic Resections in Non-Small Cell Lung Cancer

J Clin Med. 2025 Sep 24;14(19):6731. doi: 10.3390/jcm14196731.

Authors

Dimitrios E Magouliotis¹, Anna P Karamolegkou², Prokopis-Andreas Zotos³, Fabrizio Minervini⁴, Ugo Cioffi⁵, Marco Scarci⁶

Affiliations

¹ Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Wynnewood, PA 19096, USA.
² Department of Anesthesiology, Hippocration General Hospital of Athens, 11527 Athens, Greece.
³ Department of Cardiothoracic Surgery, University of Thessaly, Biopolis, 41110 Larissa, Greece.
⁴ Luzern Kanton Hospital, 6003 Luzern, Switzerland.
⁵ Department of Surgery, University of Milan, 20122 Milan, Italy.
⁶ Department of Cardiothoracic Surgery, Hammersmith Hospital, Imperial College Healthcare, National Health Service (NHS) Trust, London W2 1NY, UK.

Abstract

Objective: Non-intubated video-assisted thoracoscopic surgery (NIVATS) has emerged as a less invasive alternative to conventional intubated VATS (IVATS) for patients undergoing lobectomy for non-small cell lung cancer (NSCLC). However, concerns regarding its safety, efficacy, and oncologic adequacy remain. This meta-analysis aimed to compare perioperative and short-term outcomes between NIVATS and IVATS. Methods: A systematic review and meta-analysis were conducted in accordance with PRISMA guidelines. PubMed, Scopus, and Cochrane CENTRAL were searched through 30 June 2025. Studies comparing NIVATS and IVATS for anatomical lung resections (lobectomy and/or segmentectomy) in NSCLC were included; wedge resections were excluded. Primary endpoints included postoperative complications, operative time, intraoperative blood loss, lymph node yield, and 30-day mortality. Secondary endpoints were chest tube duration, hospital length of stay, anesthetic time, and conversion to thoracotomy rates. Risk of bias was assessed primarily with ROBINS-I; the Newcastle-Ottawa Scale was applied for sensitivity. Results: A total of seven studies (six retrospective and one randomized controlled trial) encompassing 851 patients (374 NIVATS, 477 IVATS) were included. NIVATS was associated with a significantly lower rate of postoperative complications (OR 0.50; 95% CI: 0.30-0.86; p = 0.01; I² = 0%), shorter operative time (minutes) (WMD -21.85; 95% CI: -38.49, -5.21; p = 0.01), anesthetic time (minutes) (WMD -4.62; 95% CI: -6.60, -2.65; p < 0.01), and reduced intraoperative blood loss (mL) (WMD -24.36; 95% CI: -30.67, -18.05; p < 0.01). There were no significant differences in lymph node yield or conversion to thoracotomy rates. No 30-day mortality was reported in either group. The quality of included studies was moderate, and publication bias was not evident. Conclusions: NIVATS appears to be a safe and effective alternative to IVATS in selected patients undergoing lobectomy for NSCLC. It offers improved perioperative outcomes without compromising surgical or oncologic standards. Prospective trials are needed to confirm these findings and assess long-term survival.

Keywords: awake VATS; lobectomy; lung cancer; non-intubated VATS (NIVATS); non-small cell lung cancer (NSCLC); video-assisted thoracoscopic surgery (VATS).

Publication types

Review