MCO Molecular and Clinical Oncology 2049-9450 2049-9469 D.A. Spandidos MCO-25-3-02967 10.3892/mco.2026.2967 Articles Short-term and long-term outcomes of non-tracheal intubation anesthesia in thoracoscopic lobectomy for lung cancer: A systematic review and meta-analysis HuangLizhi ZhangYangshun Department of Thoracic Surgery, Shenzhen Bao'an District People's Hospital, Shenzhen, Guangdong 518100, P.R. China Correspondence to: Dr Yangshun Zhang, Department of Thoracic Surgery, Shenzhen Bao'an District People's Hospital, Longjing 2nd Road, Xin'an, Bao'an, Shenzhen, Guangdong 518100, P.R. China yszhang0703@163.com

Abbreviations: IVATS, intubated video-assisted thoracic surgery; NIVATS, non-intubated video-assisted thoracic surgery; ERAS, enhanced recovery after surgery; ASA, American Society of Anesthesiologists; RCT, randomized controlled trials; NOS, Newcastle-Ottawa Scale; HRs, hazard ratios; CIs, confidence intervals; ORs, odds ratios; MDs, mean differences; PSM, propensity score matching; NSCLC, non-small cell lung cancer

 092026 28072026 25 3 58 11 11 2025 26 06 2026 Copyright: © 2026 Huang and Zhang. 2026 This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

The present study compared the efficacy and safety of non-intubated video-assisted thoracoscopic surgery (NIVATS) with intubated video-assisted thoracoscopic surgery (IVATS) for lobectomy in the treatment of lung cancer through a systematic review and meta-analysis. A total of six electronic databases were searched for studies comparing NIVATS and IVATS published up to October 2024. After rigorous screening and quality assessment, perioperative outcomes and postoperative complications were systematically analyzed from 18 studies, comprising three randomized controlled trials, six propensity score-matched studies and nine retrospective studies. A total of 2,313 patients with lung cancer underwent thoracoscopic lobectomy, of whom 1,082 underwent NIVATS and 1,231 underwent IVATS. The results revealed that NIVATS significantly reduced operative time [mean difference (MD)=11.02; 95% confidence interval (CI), -18.78 to -3.27], lymph nodes harvested (MD=-0.67; 95% CI, -1.24 to -0.11), anesthesia waking time (MD=-22.88; 95% CI, -33.13 to -12.64), feeding time (MD=-4.53; 95% CI, -5.74 to -3.32), chest tube indwelling time (MD=-0.68; 95% CI, -1.16 to -0.21) and hospital stay (MD=-1.16; 95% CI, -1.57 to -0.74) compared with the IVATS group. Total complications [odds ratio (OR)=0.53; 95% CI, 0.31 to 0.90], particularly sore throat (OR=0.18; 95% CI, 0.10 to 0.33) and pneumonia (OR=0.54; 95% CI=0.30 to 0.98) were significantly lower in the NIVATS group than in the IVATS group. Re-intubation occurred in 4.33% of NIVATS patients, while conversion to thoracotomy rates were similarly low in the NIVATS (0.69%) and IVATS (0.60%) groups. Importantly, NIVATS was associated with significantly improved overall survival [hazard ratio (HR)=0.63; 95% CI, 0.40 to 0.98] and recurrence-free survival (HR=0.62; 95% CI, 0.46 to 0.85). No significant differences were observed for anesthesia time, blood loss, hoarseness, air leakage or arrhythmia. Under the enhanced recovery after surgery framework, NIVATS appears to be a safe and technically feasible alternative to IVATS, with the potential to improve patient outcomes based on the available evidence. Its clinical adoption is supported by the evidence in the present study, offering a basis for informed decision-making.

 thoracoscopic lobectomy non-tracheal intubation anesthesia NIVATS lung cancer meta-analysis Funding: No funding was received. Introduction

Lung cancer remains one of the most common and lethal malignancies worldwide. According to the International Agency for Research on Cancer, in 2020, lung cancer accounted for 11.4% of newly diagnosed cancer cases and 18.0% of cancer-related mortalities worldwide, representing a notable public health burden (1,2). Current clinical management involves multidisciplinary approaches, including surgery, chemotherapy, radiotherapy and molecular targeted therapy, which have effectively reduced mortality and improved the quality of life of patients with lung cancer. Among these approaches, surgical resection remains the primary treatment strategy for treating lung cancer (3,4). Thoracic surgery has progressively shifted from conventional thoracotomy to minimally invasive thoracoscopic surgery over the past two decades (4). Particularly, intubated video-assisted thoracic surgery (IVATS) has traditionally been the standard anesthetic approach for thoracoscopic surgery. However, this method is associated with several complications, including airway injury, persistent dry cough, sore throat, nausea and vomiting, which may prolong postoperative recovery (5). Therefore, its safety and effectiveness need to be improved. With the increasing adoption of the enhanced recovery after surgery (ERAS) concept, a multimodal, multidisciplinary approach designed to reduce surgical stress and accelerate postoperative recovery (6), perioperative anesthesia management has received growing attention to minimize postoperative airway complications, shorten hospital stays and accelerate postoperative recovery, thereby improving overall patient outcomes.

In recent years, non-intubated VATS (NIVATS) with spontaneous breathing emerged as an alternative, initially applied in procedures such as pulmonary wedge resection, pulmonary bullae resection, sympathectomy and pleural mass resection (7). Evidence suggests that NIVATS is associated with reduced postoperative airway complications, shorter chest drainage duration and hospital stay, and faster recovery (8). However, compared with these procedures, thoracoscopic lobectomy requires more stringent anesthetic management due to its longer operative time and greater complexity. Few systematic reviews have specifically evaluated the safety and feasibility of NIVATS vs. IVATS in thoracoscopic lobectomy, and existing syntheses have largely focused on short-term perioperative endpoints. Therefore, the present study aimed to comprehensively and systematically evaluate the safety and feasibility of NIVATS in thoracoscopic lobectomy and its potential benefits in enhancing postoperative recovery and long-term outcomes.

 Materials and methods <sec> <title>Search strategy

The present study systematically searched major databases to evaluate the efficacy and safety of NIVATS in thoracoscopic lobectomy for lung cancer. The databases PubMed (https://pubmed.ncbi.nlm.nih.gov), Cochrane Library (https://www.cochranelibrary.com), Web of Science (https://www.webofscience.com), Embase (https://www.embase.com), CNKI (https://www.cnki.net) and Wanfang (https://www.wanfangdata.com.cn) were searched from inception to October 2024, without restrictions on language or geographic regions. Additionally, manual searches of relevant references were conducted. The search strategy combined MeSH and free text terms, including ‘non-intubation’, ‘non-tracheal intubation’, ‘non-intubated video-assisted thoracic surgery’, ‘NIVATS’, ‘thoracic surgery’, ‘thoracoscopic surgery’, ‘thoracoscopic lobectomy’, ‘video-assisted thoracic surgeries’ and ‘lobectomy’. The detailed search strategies for PubMed and Embase are shown in Tables SI and SII, respectively. The present systematic review was registered in PROSPERO (registration no. CRD420251065395; registered on 07 June 2025).

 Inclusion and exclusion criteria

Strict inclusion and exclusion criteria were applied to ensure the quality and relevance of the included literature. The inclusion criteria were as follows: i) Patients who signed informed consent for general anesthesia, scheduled for thoracoscopic lobectomy and with an American Society of Anesthesiologists (ASA) score of ≤3; ii) patients in the intervention group were subjected to non-tracheal intubation anesthesia, while those in the control group received conventional double-lumen endotracheal intubation anesthesia; iii) studies reporting at least one predefined outcome, including operative time, lymph nodes harvested, anesthesia time, blood loss, anesthesia waking time, feeding time, chest tube indwelling time, hospital stay, total complications, sore throat, pneumonia, hoarseness, air leakage, arrhythmia, re-intubation, conversion to thoracotomy, overall survival or recurrence-free survival; and iv) study designs were limited to randomized controlled trials (RCTs) and observational studies. Furthermore, the following exclusion criteria were applied: i) Studies without a control group; ii) studies with inconsistent or varied interventions; iii) studies without extractable data; iv) reviews, animal studies, letters, conference articles and case reports; and v) duplicate publications or studies with overlapping data, in which case the most recent or highest-quality study was included.

 Literature screening, data extraction and quality assessment

Following the study objectives, two authors independently conducted the literature search and screening according to the predefined inclusion and exclusion criteria. Duplicate publications were identified and removed using EndNote 20 software (Clarivate). Titles and abstracts were initially reviewed to identify those potentially meeting the inclusion criteria. Subsequently, the full-text articles were thoroughly screened to select eligible studies. Data extraction was performed by one reviewer and verified by another to ensure accuracy. The extracted data included: First author, publication year, country, study design, sample size, mean age, sex distribution, tumor stage and size, intervention details, ASA score, and reported outcomes. All data were directly extracted from the original text to ensure accuracy and completeness. Units for the outcome measures were defined as follows: Operative time (min), lymph nodes harvested (n), anesthesia time (min) blood loss (ml), anesthesia waking time (min), feeding time (h), chest tube indwelling time (days) and hospital stay (days). All data were directly extracted from the original text to ensure accuracy and completeness. When necessary, corresponding authors were contacted for additional information.

The quality of each study was independently assessed by two reviewers according to the specified criteria. For subject selection, comparability and outcomes, observational studies were evaluated using the Newcastle-Ottawa Scale (NOS) (9), with scores >6 indicating high quality. For RCTs, the modified Jadad scale (10) was used to evaluate methodological quality, including random sequence generation, allocation concealment, blinding and reporting of withdrawals. Scores ranged from 0 to 7, with 1-3 indicating low quality and 4-7 indicating high quality. Discrepancies in literature screening, data extraction and quality assessment were resolved through discussion or, when necessary, consultation with a third reviewer.

 Statistical analysis

All statistical analyses were performed using STATA version 15.1 (StataCorp LP) (11,12). For overall survival and recurrence-free survival, hazard ratios (HRs) with 95% confidence intervals (CIs) were used as effect measures and were extracted directly from the original studies. For binary and continuous variables, odds ratios (ORs) and mean differences (MDs) were calculated, respectively. Forest plots were generated to visualize the results of each study. All statistical tests were two-sided, with P<0.05 considered to indicate a statistically significant difference. Heterogeneity among studies was assessed using the χ2 (Q) test and the I2 statistic. A fixed-effects model was applied when heterogeneity was low (P>0.10 and I2≤50%), whereas a random-effects model was applied when P≤0.10 and I2>50% (significant heterogeneity). Sensitivity analyses were performed by excluding individual studies to evaluate the robustness and reliability of the results. Publication bias was assessed using Egger's linear regression test, with P<0.05 indicating potential publication bias (13). In addition, Duval and Tweedie's trim-and-fill method was used to evaluate the stability of the pooled results. A spliced and significantly varied pooled effect sizes indicated potential instability, warranting further analysis (14).

 Results <sec> <title>Study selection

A total of 1,179 potentially relevant studies were identified through the literature search. After screening titles and abstracts, 61 articles were selected for full-text review. Finally, 18 studies (15-32) met the inclusion criteria, including three RCTs, six propensity score matching (PSM) studies and nine retrospective studies. The detailed study selection process is illustrated in Fig. 1.

 Characteristics of the included studies and quality assessment

A total of 2,031 patients undergoing thoracoscopic lobectomy were included, with study sample sizes ranging from 40 to 400. Among them, 1,082 patients (46.78%) underwent NIVATS and 1,231 patients (53.22%) underwent IVATS. A total of nine studies employed laryngeal mask airway anesthesia, whereas nine used mask anesthesia. Seven studies included patients diagnosed with lung cancer, and nine studies included patients diagnosed with non-small cell lung cancer (NSCLC). Regarding tumor baseline characteristics, all patients had ASA scores of ≤3, indicating comparable preoperative health status. Six studies explicitly enrolled patients with stage I-II NSCLC, while four studies included patients with stage III/IIIb disease, accounting for <16% of the total sample. Tumor diameter was reported as <6 cm in nine studies, consistent with early-stage disease. Finally, four studies did not report tumor stage or tumor size. In terms of quality, all three RCTs were classified as high quality. Random sequence generation using computer-generated methods was reported in all RCTs. Appropriate allocation concealment using sealed envelopes was described in two studies. Blinding of outcome assessors was reported in two trials (one single-blind, one double-blind); complete blinding of patients and surgeons was not feasible due to the nature of the surgical intervention. Additionally, all six PSM studies and nine retrospective studies were judged to be of high methodological quality. Detailed characteristics and quality assessment of all the included studies are shown in Table I (15-32).

 Intraoperative parameters

Patients in the NIVATS group displayed a significantly shorter operative time (MD=-11.02; 95% CI, -18.78 to -3.27; I2=68.1%) and a slightly lower number of lymph nodes harvested (MD=-0.67; 95% CI, -1.24 to -0.11; I2=22.3%) compared with the IVATS group. No statistically significant differences were observed between groups for anesthesia time (MD=-9.35; 95% CI, -21.02 to 2.33; I2=86.9%) or intraoperative blood loss (MD=-9.38; 95% CI, -19.53 to 0.78; I2=51.8%) (Fig. 2).

 Postoperative recovery

The NIVATS group showed significantly shorter anesthesia waking time (MD=-22.88; 95% CI, -33.13 to -12.64; I2=98.4%), feeding time (MD=-4.53; 95% CI, -5.74 to -3.32; I2=95.0%), chest tube indwelling time (MD=-0.68; 95% CI, -1.16 to -0.21; I2=75.2%), and hospital stay (MD=-1.16; 95% CI, -1.57 to -0.74; I2=52.1%) compared with the IVATS group (Fig. 3).

 Safety and complications

The pooled incidence of overall complications was 15.79% in the NIVATS group and 23.13% in the IVATS group. The most common events included sore throat (6.20 vs. 26.03%), pneumonia (3.47 vs. 5.95%) and air leakage (8.50 vs. 10.17%). Re-intubation was required in 4.33% of NIVATS patients, while conversion to thoracotomy rates were similarly low in both groups (0.69 vs. 0.60%). The types and frequencies of individual complications are summarized in Table II. The pooled analysis demonstrated that the overall complication rate was significantly lower in the NIVATS group (OR=0.53; 95% CI, 0.31 to 0.90; I2=58.0%). Specifically, sore throat (OR=0.18; 95% CI, 0.10 to 0.33; I2=0%) and pneumonia (OR=0.54; 95% CI, 0.30 to 0.98; I2=0%) were significantly reduced in the NIVATS group. No statistically significant differences were observed for hoarseness (OR=0.39; 95% CI, 0.10 to 1.49; I2=0%), air leakage (OR=0.81; 95% CI, 0.42 to 1.57; I2=0%) or arrhythmia (OR=0.85; 95% CI, 0.38 to 1.90; I2=0%) (Fig. 4).

 Oncological outcomes

The pooled analysis revealed a significantly lower mortality risk in the NIVATS group compared with the IVATS group (HR=0.63; 95% CI, 0.40 to 0.98; I2=11.3%). Similarly, recurrence-free survival was significantly improved in the NIVATS group (HR=0.62; 95% CI, 0.46 to 0.85; I2=0%) (Fig. 5).

 Subgroup analysis

Subgroup analyses stratified by anesthesia modality (facemask vs. laryngeal mask) were performed for outcomes with substantial heterogeneity (I2>50%). The complete results are summarized in Table SIII. In general, the direction and significance of effects were consistent across both modalities for most outcomes, although heterogeneity remained elevated in several subgroup analyses (such as anesthesia waking time: Facemask, I2=94.5%; laryngeal mask, I2=99.1%).

 Publication bias and sensitivity analysis

Publication bias detection and sensitivity analysis were conducted for outcomes reported in ≥10 studies, including operative time, blood loss, chest tube indwelling time, hospital stay, total complications and pneumonia (Figs. S1, S2, S3, S4, S5 and S6). Sensitivity analysis indicated that pooled estimates remained stable after stepwise deletion of the included studies, suggesting robust results. Egger's regression test showed no significant publication bias for most outcomes; however, bias was detected for hospital stay (t=-1.850; P=0.009). Therefore, the trim-and-fill method was applied to evaluate the stability of the combined results. The analysis revealed no potentially missing studies were imputed, and the pooled effect size remained unchanged, confirming that the combined results were robust. The detailed results of the publication bias assessment and sensitivity analysis are shown in Table SIV.

 Discussion

The present study presents a systematic review and meta-analysis comparing the effectiveness of NIVATS and IVATS for thoracoscopic lobectomy. The results indicated that NIVATS significantly reduced operative time, anesthesia waking time, feeding time, chest tube indwelling time, hospital stay, and was associated with fewer overall complications, particularly sore throat and pneumonia. Re-intubation was required in 4.33% of NIVATS patients, while conversion to thoracotomy rates were similarly low in both groups (0.69 vs. 0.60%). Additionally, the NIVATS group showed significantly improved overall survival and recurrence-free survival compared with the IVATS group. No significant differences were observed between the two approaches for anesthesia time, blood loss, hoarseness, air leakage or arrhythmia.

With ongoing advances of medical science, the concept of ERAS has gained increasing popularity. VATS has become a standard approach in thoracic surgery due to its minimally invasive nature, thus protecting chest wall integrity, reducing surgical trauma and accelerating postoperative recovery (33,34). Conventional intubated anesthesia is commonly associated with adverse postoperative reactions and prolonged recovery time (35,36). By contrast, NIVATS enables spontaneous respiration, thereby avoiding tracheal intubation and reducing airway-related complications, stress and inflammatory reactions, while improving cellular immune function and promoting rapid recovery (37,38). Standard techniques include intercostal nerve block, paravertebral block, thoracic epidural anesthesia and laryngeal mask-assisted spontaneous respiration anesthesia (39). However, NIVATS exhibits technical challenges, particularly for anesthesiologists who need to balance its benefits against potential risks, including the management of iatrogenic open pneumothorax (40). NIVATS has evolved from the use of single epidural anesthesia to a range of combined anesthetic techniques and is now applied in various thoracic surgeries, including wedge resection, bullectomy, sympathectomy and pleural mass resection (5). Initially, its application in more complex surgeries, such as lobectomies, was limited due to the cough reflexes. During surgery, manipulation of the hilum can irritate the vagus nerve, thus resulting in mediastinal oscillation and diaphragmatic elevation. Sevoflurane anesthesia can suppress cough reflexes, thereby facilitating a stable surgical environment and enabling anatomical lobectomy. Non-intubated anesthesia can be individualized based on patient characteristics through a combination of intravenous, epidural or local anesthesia, nerve blocks, and pleural infiltration (41). This strategy ensures intraoperative stability and promotes postoperative recovery. However, the safety and efficacy of NIVATS in thoracoscopic lobectomy remain controversial due to its high anesthesia requirements and the need for careful patient selection.

The results of the present study revealed no significant difference in intraoperative blood loss between the two groups. This finding could be due to the employment of modern minimally invasive techniques, such as VATS, which ensures accurate dissection while minimizing tissue injury (42). In addition, patients in both groups could experience intraoperative complications, such as coughing and involuntary movements, including mediastinal displacement, thus contributing to procedural complexity (43).

Notably, patients in the NIVATS group showed a significant advantage in reducing postoperative airway complications. Particularly, NIVATS was markedly associated with a reduced incidence of postoperative adverse reactions such as sore throat and pneumonia. This could be due to the fact that patients in the NIVATS group were able to breathe spontaneously without the need for tracheal intubation or mechanical ventilation, thereby avoiding intubation-related complications and general anesthesia-related complications.

Previous studies have suggested that NIVATS performed under local or regional anesthesia can attenuate inflammatory responses, as evidenced by reduced levels of inflammatory cytokines, such as tumor necrosis factor-α and C-reactive protein, modulation of lymphocyte activity, and reduced stress hormone release (44). These effects could partially explain the improved postoperative recovery and lower complication rates observed in the NIVATS group.

In terms of long-term outcomes, the pooled analysis showed an association between NIVATS and improved survival compared with IVATS. This finding was consistent with the results of a retrospective study by Zheng et al (15), suggesting that patients who underwent self-ventilated VATS lobectomy had significantly improved overall survival and disease-free survival compared with those who underwent mechanically ventilated thoracoscopic surgery and open lobectomy. Greater reliance on regional anesthesia and reduced opioid use postoperatively have been proposed as potential contributing factors (45,46). However, recent studies have shown inconsistent findings. Two propensity score-matching studies by Wang et al (21) and Chen et al (30) reported that patients who underwent NIVATS achieved comparable local control, disease-free and overall survival to those who were treated with IVATS. These discrepancies could be attributed to differences in patient selection, tumor characteristics, surgical approaches and techniques, which could affect the balance of prognostic factors between groups. Overall, NIVATS was associated with improved survival in limited observational evidence; however, causality cannot be inferred.

Although NIVATS offers advantages in postoperative recovery, potential intraoperative safety risks warrant higher attention. A meta-analysis of 19 RCTs suggested that NIVATS could be associated with a higher incidence of intraoperative hypoxemia compared with IVATS. However, this risk could be mitigated through careful patient selection and intraoperative crisis resource management (47). Additionally, a PSM study reported a 7.7% conversion rate to intubation in the NIVATS group due to surgical difficulties, along with markedly elevated peak end-tidal CO2 levels (24). In addition to hypoxemia and hypercapnia, the present pooled descriptive data showed a re-intubation rate of 4.33% in NIVATS patients, highlighting the need for preparedness to convert to intubation during NIVATS procedures. To minimize these risks, careful patient selection is essential. Contraindications to NIVATS could include difficult airway, morbid obesity (BMI >30), extensive pleural adhesions, severe cardiopulmonary dysfunction and complex surgical procedures (40).

Several meta-analyses have compared NIVATS with IVATS for thoracic surgery (47-53). A previously published Chinese-language meta-analysis reported perioperative advantages of NIVATS for thoracoscopic lobectomy; however, the review focused on short-term endpoints, included mixed surgical types and did not assess long-term oncological outcomes or procedure-specific safety indicators such as re-intubation and conversion-to-thoracotomy rates (53). Although the present perioperative findings are broadly consistent with the previous report, the present study extends the evidence in several important respects. First, overall survival and recurrence-free survival were systematically evaluated, which were not assessed in previous meta-analyses. Second, NIVATS-specific safety indicators, including re-intubation and conversion-to-thoracotomy rates, were investigated which have not been quantitatively analyzed in previous reviews. Third, a detailed breakdown of postoperative complications, distinguishing intubation-related events from pulmonary and cardiovascular events, was performed rather than reporting a single aggregated ‘airway complications’ endpoint. Fourth, most previous analyses included mixed thoracic procedures (such as bullectomy, wedge resection or sympathectomy) rather than focusing specifically on lung cancer, and some were limited by small sample sizes from early studies. By contrast, the present study focused exclusively on lobectomy for lung cancer and incorporated 18 studies, offering more comprehensive and specific evidence for this common procedure. Fifth, detailed subgroup analyses by anesthesia technique (facemask vs. laryngeal mask) were performed, which were not extensively explored in prior reviews or meta-analyses.

NIVATS is a viable option for strictly selected patients undergoing thoracic surgery, with confirmed feasibility, safety and effectiveness under spontaneous ventilation. However, complete evaluation systems and practice guidelines are urgently needed. Future large-scale, multicenter, prospective studies are warranted to further confirm long-term outcomes. Since an increasing number of medical centers adopt NIVATS, its surgical indications can gradually expand, thus potentially benefiting a larger number of patients.

The present study has several limitations. First, the majority of the included studies were retrospective and the number of RCTs was limited, which could have introduced selection and information bias. Therefore, further high-quality RCTs are needed to validate these findings. Second, the overall sample size was relatively small, and most studies were carried out at single centers, potentially leading to publication bias and overestimated effect sizes. Third, differences in the anesthetic techniques used for NIVATS, in combination with differences in patient characteristics, likely contributed to heterogeneity in several outcomes. Fourth, survival analyses were based on only three studies, the majority of which were observational, limiting the ability to draw causal inferences regarding long-term outcomes. Due to the limited number of studies, more detailed subgroup and sensitivity analyses could not be performed. The small number of studies also precluded definitive conclusions, and future, large-scale RCTs are needed to confirm these findings. Fifth, substantial heterogeneity persisted in several outcomes, including anesthesia waking time and feeding time despite subgroup analyses by anesthesia technique and study design, thus suggesting that additional unmeasured factors could contribute to variability, such as differences in institutional ERAS protocols, variations in surgical expertise and learning curves, and heterogeneity in patient selection criteria across studies. Sixth, learning curve and center expertise bias may affect the outcomes, as experience with NIVATS varies across studies, and centers with greater expertise may overestimate its benefits. Additionally, patient selection constraints inherent in the primary studies, such as differences in inclusion and exclusion criteria may introduce heterogeneity, as selection criteria were not uniformly reported. These factors should be considered when interpreting the findings. Despite these limitations, the present study applied rigorous inclusion and exclusion criteria to comprehensively analyze the available evidence on non-intubated anesthesia thoracoscopic lobectomy, providing valuable insights to support clinical decision-making.

Overall, compared with IVATS, NIVATS in patients undergoing thoracoscopic lobectomy showed advantages in perioperative outcomes and fewer postoperative complications. Preliminary evidence also suggested improved overall survival and recurrence-free survival, although these findings require further confirmation. Within the ERAS framework, NIVATS appears to be a safe and technically feasible alternative for patients undergoing thoracoscopic lobectomy in appropriately selected cases. Large-scale, multicenter RCTs with long-term oncological follow-up are warranted to validate these findings and inform clinical decision-making.

 Supplementary Material Sensitivity analysis for operative time between the non-intubated video-assisted thoracoscopic surgery group and the intubated video-assisted thoracoscopic surgery group. MD, mean difference. Sensitivity analysis for blood loss between the non-intubated video-assisted thoracoscopic surgery group and the intubated video-assisted thoracoscopic surgery group. MD, mean difference. Sensitivity analysis for chest tube indwelling time between the non-intubated video-assisted thoracoscopic surgery group and the intubated video-assisted thoracoscopic surgery group. MD, mean difference. Sensitivity analysis for hospital stay between the non-intubated video-assisted thoracoscopic surgery group and the intubated video-assisted thoracoscopic surgery group. CI, confidence interval. MD, mean difference. Sensitivity analysis for postoperative airway complications between non-intubated video-assisted thoracoscopic surgery group and the intubated video-assisted thoracoscopic surgery group. OR, odds ratio; CI, confidence interval. Sensitivity analysis for pneumonia between the non-intubated video-assisted thoracoscopic surgery group and the intubated video-assisted thoracoscopic surgery group. CI, confidence interval; OR, odds ratio. Embase search strategy. PubMed search strategy. Subgroup analysis of different anesthesia methods. Evaluation of publication bias and sensitivity analysis. Acknowledgements

Not applicable.

 Availability of data and materials

The data generated in the present study may be requested from the corresponding author.

 Authors' contributions

LH performed data curation, methodology, visualization and wrote the original draft. YZ conceptualized the present study, performed the data curation, formal analysis, methodology and reviewed and edited the manuscript. LH and YZ confirm the authenticity of all the raw data. All authors read and approved the final version of the manuscript.

 Ethics approval and consent to participate

Not applicable.

 Patient consent for publication

Not applicable.

 Competing interests

The authors declare that they have no competing interests.

 References SungHFerlayJSiegelRLLaversanneMSoerjomataramIJemalABrayFGlobal cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countriesCA Cancer J Clin7120924920213353833810.3322/caac.21660 BadeBCDela CruzCSLung cancer 2020: Epidemiology, etiology, and preventionClin Chest Med4112420203200862310.1016/j.ccm.2019.10.001 HoyHLynchTBeckMSurgical treatment of lung cancerCrit Care Nurs Clin North Am3130331320193135155210.1016/j.cnc.2019.05.002 BendixenMJørgensenODKronborgCAndersenCLichtPBPostoperative pain and quality of life after lobectomy via video-assisted thoracoscopic surgery or anterolateral thoracotomy for early stage lung cancer: A randomised controlled trialLancet Oncol1783684420162716047310.1016/S1470-2045(16)00173-X MetelmannIBroschewitzJPietschUCHuschakGEichfeldUBerckerSKraemerSProcedural times in early non-intubated VATS program - a propensity score analysisBMC Anesthesiol214420213357360410.1186/s12871-021-01270-4 LjungqvistOScottMFearonKCEnhanced recovery after surgery: A reviewJAMA Surg15229229820172809730510.1001/jamasurg.2016.4952 Gonzalez-RivasDBonomeCFieiraEAymerichHFernandezRDelgadoMMendezLde la TorreMNon-intubated video-assisted thoracoscopic lung resections: The future of thoracic surgery?Eur J Cardiothorac Surg4972173120162589619610.1093/ejcts/ezv136 AnileMVannucciJFerranteFBrunoKDe PaoloDBassiMPuglieseFVenutaFNIVATS interest groupNon-intubated thoracic surgery: Standpoints and perspectivesFront Surg993763320223603439610.3389/fsurg.2022.937633 WellsGASheaBJO'ConnellJPetersonJWelchVLososMTugwellPThe Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Ottawa Health Research Institute, Ottawa, ON, 2014. JadadARMooreRACarrollDJenkinsonCReynoldsDJGavaghanDJMcQuayHJAssessing the quality of reports of randomized clinical trials: Is blinding necessary?Control Clin Trials171121996872179710.1016/0197-2456(95)00134-4 NyagaVNArbynMAertsMMetaprop: A stata command to perform meta-analysis of binomial dataArch Public Health723920142581090810.1186/2049-3258-72-39 HarrisRJDeeksJJAltmanDGBradburnMJHarbordRMSterneJACMetan: Fixed- and random-effects meta-analysisStata J83282008 EggerMDavey SmithGSchneiderMMinderCBias in meta-analysis detected by a simple, graphical testBMJ3156296341997931056310.1136/bmj.315.7109.629 DuvalSTweedieRTrim and fill: A simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysisBiometrics5645546320001087730410.1111/j.0006-341x.2000.00455.x ZhengJLiangHWangRZhongRJiangSWangWZhaoYChenZLiangWLiuJHeJPerioperative and long-term outcomes of spontaneous ventilation video-assisted thoracoscopic surgery for non-small cell lung cancerTransl Lung Cancer Res103875388720213485877810.21037/tlcr-21-629 ZhaoSClinical comparative study of general anesthesia with laryngeal mask airway and double lumen endotracheal intubation in thoracoscopic lobectomy. Journal 2021. https://d.wanfangdata.com.cn/thesis/Ch1UaGVzaXNOZXdTb2xyOVMyMDI2MDcxMDAxMjM1MRIJRDAyNTEyMTA0GggzMjZxamJuag%3D%3D. ZhangHPanWZhangLWenCComparison of laryngeal mask anesthesia and intubation anesthesia under spontaneous ventilation in uniportal video-assisted thoracoscopic surgeryJ Pract Med334554582017https://d.wanfangdata.com.cn/periodical/CihQZXJpb2RpY2FsQ0hJU29scjkyMDI2MDYxMDIwMjYwNjEw MTYxMjM4Eg9zeXl4enoyMDE3MDMwMzMaCDY1N2E4NXJ5. YuJKPTantraworasinALaohathaiSNon-intubated versus intubated video-assisted thoracoscopic lobectomy for lung cancer patientsAsian J Surg4740240620243777740710.1016/j.asjsur.2023.09.038 WuCYChenJSLinYSTsaiTMHungMHChanKCChengYJFeasibility and safety of nonintubated thoracoscopic lobectomy for geriatric lung cancer patientsAnn Thorac Surg9540541120132324544910.1016/j.athoracsur.2012.10.082 WangMLHowCHHungMHHuangHHHsuHHChengYJChenJSLong-term outcomes after nonintubated versus intubated thoracoscopic lobectomy for clinical stage I non-small cell lung cancer: A propensity-matched analysisJ Formos Med Assoc1201949195620213399423310.1016/j.jfma.2021.04.018 WangLWangDZhangYComparison of postoperative pulmonary complications and intraoperative safety in thoracoscopic surgery under non-intubated versus intubated anesthesia: A randomized, controlled, double-blind non-inferiority trialUpdates Surg762863287320243912653310.1007/s13304-024-01935-y UdelsmanBVJangAMuniappanAZhanPLBaoXChenTGaissertHAPerioperative morbidity and 3-year survival in non-intubated thoracoscopic surgery: A propensity matched analysisJ Thorac Dis161180119020243850504310.21037/jtd-23-591 QiLZChenKLuoBMaoGPanLHuangHLiJChenSClinical application of preserving spontaneous breathing non-intubation anesthesia in thoracoscopic surgery for lung cancer under ERAS conceptAsia Pac J Clin Oncol18e329e33720223481846710.1111/ajco.13726 PathonsamitCTantraworasinAPoopipatpabSLaohathaiSPerioperative outcomes of non-intubated versus intubated video-assisted thoracoscopic surgery in different thoracic procedures: A propensity score-matched analysisBMC Anesthesiol2215420223559023810.1186/s12871-022-01667-9 LiuZRenSLiuNLuoYClinical application of intubation-free anesthesia in radical resection of lung cancerFront Med (Lausanne)10117543720233725608910.3389/fmed.2023.1175437 LiuJCuiFPompeoEGonzalez-RivasDChenHYinWShaoWLiSPanHShenJThe impact of non-intubated versus intubated anaesthesia on early outcomes of video-assisted thoracoscopic anatomical resection in non-small-cell lung cancer: A propensity score matching analysisEur J Cardiothorac Surg5092092520162716577110.1093/ejcts/ezw160 LanLCenYZhangCQiuYOuyangBA propensity score-matched analysis for non-intubated thoracic surgeryMed Sci Monit248081808720183041526810.12659/MSM.910605 JeonJSungSMoonYKooJHyunKHanKHwangWComparison of early postoperative cytokine changes in patients undergoing intubated and non-intubated thoracic surgery: A randomized controlled trialInteract Cardiovasc Thorac Surg3234335020213383121610.1093/icvts/ivaa265 FangZWFangWQRuanLLFangFCLFUniportal video-assisted thoracoscopic surgery for non-small cell lung cancer under non-intubated anesthesia with spontaneous respirationJ Chin Pract Diagn Ther32101910212018https://d.wanfangdata.com.cn/periodical/ChlQZXJpb2RpY2FsQ0hJTmV3UzIwMjQw NzA0EhJzeXpkeXpsenoyMDE4MTE4MTAwMjQaCDl3bGZyNnBi. ChenPHChuangJHLuTPHungWTLiaoHCTsaiTMLinMWChenKCHsuHHChenJSNon-intubated versus intubated video-assisted thoracic surgery in patients aged 75 years and older: A propensity matching studyFront Surg988000720223558650110.3389/fsurg.2022.880007 ChenJSChengYJHungMHTsengYDChenKCLeeYCNonintubated thoracoscopic lobectomy for lung cancerAnn Surg2541038104320112186967610.1097/SLA.0b013e31822ed19b AlGhamdiZMLynhiavuLMoonYKMoonMHAhnSKimYSungSWComparison of non-intubated versus intubated video-assisted thoracoscopic lobectomy for lung cancerJ Thorac Dis104236424320183017486910.21037/jtd.2018.06.163 AndrewsWGPaulSTechniques of video-assisted thoracoscopic surgery lobectomy and critical review of published dataFuture Oncol12313320162773305510.2217/fon-2016-0340 Hernandez-VaqueroDVigil-EscaleraCPérez-MéndezIGutiérrezAAvanzasPWeiYDiazRSilvaJMorisCPascualISurvival after thoracoscopic surgery or open lobectomy: Systematic review and meta-analysisAnn Thorac Surg11130231320213273084010.1016/j.athoracsur.2020.05.144 WangYCChangCHWangYTHuangCHLinPLChengYJA survey of one-lung ventilation device in lung resection surgeries in Taiwan-A population-based nationwide cohort studyJ Formos Med Assoc11944945420203150621310.1016/j.jfma.2019.08.009 YuYLiuRSBoYYeJHuangYXuZZYangZYChenZMPengJComparison of two preoperative positioning techniques and unpositioning methods in non-intubated video-assisted thoracoscopic surgeryJ Thorac Dis1446447320223528048610.21037/jtd-22-114 AmbrogiVPatirelisATajèRNon-intubated thoracic surgery: Wedge resections for peripheral pulmonary nodulesFront Surg985364320223546543510.3389/fsurg.2022.853643 WangRJiangYHeJLinYWangZLiSElectromagnetic navigation bronchoscopy integrated non-intubated uniportal VATS in localization and resection of pulmonary nodulesFront Surg987249620223544955210.3389/fsurg.2022.872496 WangBGeSNonintubated anesthesia for thoracic surgeryJ Thorac Dis61868187420142558999410.3978/j.issn.2072-1439.2014.11.39 YangJTHungMHChenJSChengYJAnesthetic consideration for nonintubated VATSJ Thorac Dis6101320142445517010.3978/j.issn.2072-1439.2014.01.03 CaiLSHouBJinHBoYChenXLDaiJYangTLanBSYeJPengHPengJClinical evaluation of the rapid recovery of patients who underwent video-assisted thoracoscopic lung surgery under non-intubated anesthesiaAnn Transl Med9178320213507147710.21037/atm-21-6434 WhitsonBAAndradeRSBoettcherABardalesRKratzkeRADahlbergPSMaddausMAVideo-assisted thoracoscopic surgery is more favorable than thoracotomy for resection of clinical stage I non-small cell lung cancerAnn Thorac Surg831965197020071753237910.1016/j.athoracsur.2007.01.049 KasedaSAokiTHangaiNShimizuKBetter pulmonary function and prognosis with video-assisted thoracic surgery than with thoracotomyAnn Thorac Surg701644164620001109350210.1016/s0003-4975(00)01909-3 LiuJCuiFLiSChenHShaoWLiangLYinWLinYHeJNonintubated video-assisted thoracoscopic surgery under epidural anesthesia compared with conventional anesthetic option: A randomized control studySurg Innov2212313020152482125910.1177/1553350614531662 HeJLiuJZhuCDaiTCaiKZhangZChengCQiaoKLiuXWangGExpert consensus on tubeless video-assisted thoracoscopic surgery (Guangzhou)J Thorac Dis114101410820193173729210.21037/jtd.2019.10.04 HeJLiuJZhuCDaiTCaiKZhangZChengCQiaoKLiuXWangGExpert consensus on spontaneous ventilation video-assisted thoracoscopic surgery in primary spontaneous pneumothorax (Guangzhou)Ann Transl Med751820193180750010.21037/atm.2019.10.08 ZhangDWuJYangYPuRLiuZLiYDengWWangJHouBGeZComparison of non-intubated and intubated video-assisted thoracoscopic surgery for perioperative complications-a systematic review and meta-analysisBMC Anesthesiol2527220254044261610.1186/s12871-025-03154-3 ZhangKChenHGWuWBLiXJWuYHXuJNJiaYBZhangJNon-intubated video-assisted thoracoscopic surgery vs. intubated video-assisted thoracoscopic surgery for thoracic disease: A systematic review and meta-analysis of 1,684 casesJ Thorac Dis113556356820193155906210.21037/jtd.2019.07.48 YuMGJingRMoYJLinFDuXKGeWYDaiHJHuZKZhangSSPanLHNon-intubated anesthesia in patients undergoing video-assisted thoracoscopic surgery: A systematic review and meta-analysisPLoS One14e022473720193171490410.1371/journal.pone.0224737 LuoTZhangYXuBWZhangCCZhangLWRanXQFuMYNon-intubated vs. intubated video-assisted thoracoscopic surgery for the treatment of thoracic diseases: A systematic review and meta-analysis of propensity score-matched cohortsFront Surg12166146620254107929110.3389/fsurg.2025.1661466 MagouliotisDEKaramolegkouAPZotosPAMinerviniFCioffiUScarciMIs less more? A meta-analysis of non-intubated versus intubated VATS for anatomic resections in non-small cell lung cancerJ Clin Med14673120254109581010.3390/jcm14196731 PrisciandaroEBertolacciniLSeddaGSpaggiariLNon-intubated thoracoscopic lobectomies for lung cancer: An exploratory systematic review and meta-analysisInteract Cardiovasc Thorac Surg3149950620203291846410.1093/icvts/ivaa141 YangXF SQLiDSShort-term efficacy of non-tracheal intubation anesthesia in thoracoscopic lobectomy for lung cancer: A systematic review and meta-analysisChin J Clin Thorac Cardiovasc Surg32118111882025https://d.wanfangdata.com.cn/thesis/Ch1UaGVzaXNOZXdTb2xyOVMyMDI2MDcxMDAxMjM1MRIJRDAzNTUxODk2Ggg1aGM4Y3I1OA%3D%3D.

Flowchart of study selection.

Forest plots of intraoperative parameters for non-intubated video-assisted thoracoscopic surgery vs. control group. (A) Operative time, (B) lymph nodes harvested, (C) anesthesia time and (D) blood loss. WMD, weighted mean difference; CI, confidence interval.

Forest plots of intraoperative parameters for non-intubated video-assisted thoracoscopic surgery vs. control group. (A) Anesthesia waking time, (B) feeding time, (C) chest tube indwelling time and (D) hospital stay. WMD, weighted mean difference, CI, confidence interval.

Forest plots of safety and complication outcomes for non-intubated video-assisted thoracoscopic surgery vs. control group. (A) Total complications, (B) sore throat, (C), pneumonia, (D) hoarseness, (E) air leakage and (F) arrhythmia. CI, confidence interval; OR, odds ratio.

Forest plots of oncological outcomes for non-intubated video-assisted thoracoscopic surgery vs. control group. (A) Overall survival and (B) recurrence-free survival. HR, hazard ratio; CI, confidence interval.

Characteristics of the studies included in the present meta-analysis.

First author, year Country design No. of cases (NIVATS/IVATS) Sex, male (NIVATS/IVATS) Age, years (NIVATS/IVATS) Tumor stage Tumor size Intervention method ASA score Outcomesa Quality score (Refs.)
Wu et al, 2013 China Retrospective 36/48 21/27 72.9 (65-84)/73.0 (65-87) Stage I-II NSCLC <6 cm Epidural anesthesia, intrathoracic vagusblock + mask 1-3 1/2/3/4/8/9/10/11 NOS, 6 (19)
Liu et al, 2016 China PSM 116/116 66/62 56.0±10.3/57.3±10.5 Stage Ia NSCLC <6 cm Epidural anesthesia + mask 1-3 1/3/4/6/7/8/9/11 NOS, 6 (26)
Zhang et al, 2017 China Retrospective 20/20 10/11 58.6±8.1/61.7±7.8 Lung cancer <6 cm Intercostal nerve block+laryngeal mask 1-2 1/5/8/9 NOS, 6 (17)
Fang et al, 2018 China Retrospective 31/31 16/17 / Stage Ⅰ-Ⅲb NSCLC - Thoracic vagus block, 3-7 intercostal block + laryngeal mask 1-2 1/3/5/6/7/8/9 NOS, 6 (29)
AlGhamdi et al, 2018 Korea Retrospective 30/30 10/12 64.9±10.5/66.1±9.5 Stage I-II NSCLC <6 cm Intrathoracic vagusblock + mask 1-3 1/2/3/7/8/9/10/11 NOS, 7 (32)
Lan et al, 2018 China PSM 119/119 69/68 56.9±11.1/55.3±13.8 Lung cancer - Epidural anesthesia, intrathoracic vagus nerve block, intercostal nerve block + laryngeal mask 1-3 1/3/5 NOS, 6 (27)
Zhao et al, 2021 China RCT 30/30 13/15 58.7±4.9/58.8±6.5 Lung cancer <5 cm Intercostal nerve block + laryngeal mask 1-2 1/3/7/8/9 Jadad, 4 (16)
Jeon et al, 2021 Korea RCT 20/20 13/12 57.4±11.1/61.8±7.6 Stage I NSCLC - Intercostal nerve block + mask 1-2 1/2/3/4 Jadad, 7 (28)
Wang et al, 2021 China PSM 97/97 41/40 59.6±11.3/61.9±11.5 Stage I NSCLC <6 cm Epidural anesthesia + mask 1-2 12/13 NOS, 7 (20)
Zheng et al, 2021 China Retrospective 200/200 107/105 / Stage I-III NSCLC <10 cm Thoracic vagus nerve block, pleural surface block, intercostal nerve block + laryngeal mask 1-3 1/2/3/7/12/13 NOS, 7 (15)
Pathonsamit et al, 2022 Thailand PSM 52/52 22/24 55 (43.5-65.5) 59.5/(40.5-68) Lung cancer - Total intravenous anesthesia + mask 1-3 1/2/3/8/9/10 NOS, 6 (24)
Qi et al, 2022 China Retrospective 50/50 23/21 59.3±15.1/53.4±11.9 Lung cancer - Vagus block, intercostal block, thoracic paravertebral block + laryngeal mask 1-2 1/3/5/6/7/8/9 NOS, 6 (23)
Chen et al, 2022 China PSM 79/158 33/72 79.4±3.7/79.3±3.6 Stage I-III NSCLC - Epidural anesthesia, intercostal nerve block, vagus nerve block + mask 1-3 1/3/4/7/8/9/11/12/13 NOS, 6 (30)
Liu et al, 2023 China Retrospective 28/32 15/15 51.7±13.0/54.4±7.3 Lung cancer - Anterior serratus and intercostal nerve block + laryngeal mask 1-3 3/9 NOS, 7 (25)
Wang et al, 2024 China RCT 60/60 18/24 51.9±6.4/51.4±7.7 Lung cancer <5 cm Paracosternal nerve block, vagus nerve block + laryngeal mask 1-2 1/2/4/5/7/8/9/10 Jadad, 7 (21)
Chen et al, 2011 China Retrospective 30/30 7/13 57.9±10.4/56.5±9.5 Stage I-III NSCLC <5 cm Serratus anterior, intercostal nerves, parasternal, vagusnerve + laryngeal mask 1-3 1/2/3/4/7/8/10/11 NOS, 7 (31)
Udelsman et al, 2024 USA PSM 30/60 - - Stage I - Paravertebral or intercostal nerve block, vagus nerve infiltration + mask 1-3 12 NOS, 7 (22)
Yu et al, 2024 Thailand Retrospective 54/78 20/38 65 (55.5-72)/65 (59-73) T1-T4 <5 cm No regional block + mask 1-2 1/3/4/7/8/9 NOS, 7 (18)

aOutcomes: 1, operative time; 2, anesthesia time; 3, blood loss; 4, lymph nodes harvested; 5, anesthesia waking time; 6, feeding time; 7, chest time indwelling time; 8, hospital stay; 9, postoperative complications (including total complications, sore throat, pneumonia, hoarseness, air leakage and arrhythmia); 10, re-intubation; 11, conversion to thoracotomy; 12, overall survival; 13, recurrence-free survival. RCT, randomized controlled trials; PSM, propensity score matching; NIVATS, non-intubated video-assisted thoracic surgery; IVATS, intubated video-assisted thoracic surgery; NSCLC, non-small cell lung cancer; ASA, American Society of Anesthesiologists, NOS, Newcastle-Ottawa Scale.

Summary of complications.

Complication NIVATS, % IVATS, %
Re-intubation 4.33 -
Conversion to thoracotomy 0.69 0.60
Total complications 15.79 23.13
Sore throat 6.20 26.03
Hoarseness 1.22 3.72
Pneumonia 3.47 5.95
Air leakage 8.50 10.17
Arrhythmia 3.13 3.96

NIVATS, non-intubated video-assisted thoracic surgery; IVATS, intubated video-assisted thoracic surgery.