The impact of American Society of Anesthesiologists physical status on the feasibility and safety of non-intubated video-assisted thoracoscopic surgery: a retrospective analysis

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Background: Non-intubated video-assisted thoracoscopic surgery (NIVATS) avoids the risks of general anesthesia, one-lung ventilation and tracheal intubation, and has traditionally been reserved for low-risk patients [American Society of Anesthesiologists (ASA) physical status I–II]. Its feasibility and safety in patients with higher ASA physical status remain insufficiently defined. We compared perioperative outcomes between low- and high-ASA patients undergoing NIVATS. Methods: This single-center retrospective cohort study included consecutive patients undergoing elective NIVATS for lung resection between September 2019 and December 2023. Patients were stratified into low-ASA (ASA I–II) and high-ASA (ASA III–IV) groups. Baseline characteristics and perioperative outcomes were compared using the Mann-Whitney U test, Chi-squared test or Fisher exact test. Multivariable Poisson regression adjusted for sex and operation type was used to estimate the independent association of high-ASA status with key outcomes, expressed as the incidence rate ratio (IRR). Results: A total of 663 patients were analyzed (low-ASA, n=517; high-ASA, n=146). High-ASA patients were older (median 66.9 vs. 42.1 years, P<0.001) and had a greater comorbidity burden. Conversion to intubated video-assisted thoracoscopic surgery (VATS) (2.1% vs. 1.4%, P=0.58), operative time (P=0.53) and overall perioperative complications (P=0.52) did not differ between groups. However, the high-ASA group had higher rates of reoperation (3.4% vs. 0.4%, P=0.007), longer hospital stay (P=0.003) and higher mortality (2.1% vs. 0.2%, P=0.03). After adjustment, high-ASA status independently predicted a prolonged hospital stay [IRR 2.18, 95% confidence interval (CI): 2.02–2.34, P<0.001] and markedly higher mortality (IRR 12.21, 95% CI: 1.27–117.51, P=0.03), but not conversion to intubated VATS, ICU admission or postoperative complications. Conclusions: NIVATS is technically feasible and intraoperatively well tolerated in high-ASA patients, with conversion and immediate complication rates comparable to those of low-ASA patients. However, high-ASA status independently predicts prolonged hospitalization and a substantially increased risk of mortality. These findings underscore the importance of careful patient selection and intensive, tailored postoperative care for high-risk patients undergoing NIVATS.