Lung cancer remains one of the most prevalent malignancies worldwide, imposing significant health and economic burdens (1). In recent years, advancements in imaging technologies and heightened public health awareness have led to increased early detection rates of lung cancer (2). Studies have demonstrated that, for patients with non-small cell lung cancer characterized by tumors ≤2 cm and a consolidation-to-tumor ratio between 0.5 and 1, segmentectomy offers comparable outcomes to lobectomy in terms of complications, mortality, and five-year overall survival rates (3). Moreover, segmentectomy preserves more lung parenchyma, making it a preferable option for many patients (4). Consequently, segmentectomy has become the treatment of choice for an increasing number of patients with early-stage NSCLC.

Traditionally, video-assisted thoracoscopic segmentectomy has been performed under IGA in major medical centers. This approach ensures satisfactory intraoperative ventilation and lung isolation, facilitating safe and efficient thoracic surgical procedures (5). However, endotracheal intubation can lead to adverse effects such as tracheal injury, laryngeal edema, and hoarseness (6–8). With advancements in anesthetic techniques and surgical proficiency, NIA has garnered attention. The spontaneous breathing NIA technique is increasingly applied in various thoracoscopic procedures (9–11). Existing literature suggests that NIA achieves clinical outcomes comparable to those of IGA (11–14). However, from the patient’s perspective, traditional clinical endpoints may not fully capture the postoperative experience and recovery quality associated with the two anesthetic approaches.

PROs are direct reports from patients regarding their health status, functional well-being, treatment experiences, and the impact on daily life. Numerous studies have shown that symptom monitoring based on PROs can alleviate symptom burden, enhance treatment responsiveness, improve prognosis, and facilitate better patient-provider communication (15–17). As a result, the FDA recommends PROs as novel clinical outcome indicators (18). PROs measurement tools are specialized instruments designed to assess PROs accurately, reflecting patients’ actual conditions, including symptom severity and functional status. They help identify perceived differences between seemingly similar surgical procedures, offering new insights into optimal surgical practices and providing scientific evidence for intervention optimization.

Currently, the symptom and functional burdens experienced by patients undergoing thoracoscopic segmentectomy under different anesthetic modalities remain unclear, particularly in the early postoperative period. This study aims to investigate early postoperative PROs and recovery quality following segmentectomy under different anesthesia methods through frequent, repeated assessments. The findings will provide a basis for anesthesiologists and surgeons to optimize perioperative management and inform clinical decision-making.

Traditional clinical metrics have often been employed to evaluate the advantages and disadvantages of different surgical approaches, frequently overlooking patient experiences and perceptions. Attentively considering patients’ viewpoints not only embodies fundamental medical ethics but also serves as a crucial means to enhance healthcare services and patient satisfaction. PROs have recently gained attention as valuable indicators for assessing postoperative recovery in lung cancer surgeries, offering deeper insights into patient-centered rehabilitation post-surgery (23–26). Concurrently, NIA is increasingly utilized worldwide, extending to complex procedures such as radical lung cancer surgeries and even lung transplants (10), its advantages over IGA from the perspective of PROs have yet to be definitively established. To our knowledge, this study is an earlier to evaluate PROs between NIA and IGA in patients undergoing segmentectomy. Our findings indicate comparable outcomes between the two groups, with NIA patients experiencing lower symptom burdens and better functional status postoperatively compared to those in the IGA group.

PROs following segmentectomy are influenced by multiple factors, including patient characteristics and surgical variables. In this study, preoperative characteristics were similar between groups. The early advantages of NIA in PROs may reflect reduced airway trauma and decreased use of anesthetic agents, leading to less physiological and functional disruption. Tracheal intubation and mechanical ventilation can directly irritate the pharyngeal and tracheal mucosa, resulting in postoperative throat pain and cough. Prolonged mechanical ventilation may cause alveolar overdistension and inflammatory responses (ventilator induced lung injury), exacerbating postoperative chest discomfort and pain. Additionally, IGA requires higher doses of sedatives and neuromuscular blockers, with delayed drug metabolism potentially prolonging postoperative sedation and indirectly intensifying pain perception. By preserving spontaneous breathing and incorporating local anesthesia, NIA significantly reduces postoperative pain perception. Pain in IGA patients may limit postoperative respiratory exercises, exacerbating symptoms of shortness of breath. The increased anesthetic requirements in IGA patients elevate the risk of postoperative complications such as restless sleep, fatigue, and drowsiness.​ Furthermore, reduced pain and dyspnea may, in turn, lessen impairment in walking and general activity functions.

Compared to patients undergoing IGA, those receiving NIA exhibit better postoperative mobility and general functional status. Early ambulation is fundamental to rapid recovery after thoracic surgery. Numerous studies have demonstrated the efficacy of early mobilization in reducing postoperative complications and accelerating functional recovery, including the clearance of airway secretions, decreasing the risks of atelectasis and pneumonia, and venous thrombosis (27–29). Early activity can expedite respiratory function recovery, stimulate deep breathing and coughing, enhance forced vital capacity, and reduce dependence on oxygen. Additionally, early mobilization offers psychological benefits, such as reduced perception of pain.

Notably, during follow-up after discharge, we observed no significant differences between the NIA and IGA groups in symptom severity and functional interference, except for cough and anxiety. This suggests that the impact of NIA on PROs tends to diminish over time. Persistent postoperative cough is a common complication following lung cancer surgery. Although less life-threatening than complications like progressive hemothorax, pneumothorax, and chylothorax, persistent cough can increase psychological burden, leading patients to question the efficacy of surgery and potentially causing anxiety and depression (30, 31). This may explain the more severe postoperative anxiety observed in IGA patients. Further characterization of persistent postoperative cough and early intervention in high-risk populations will be focal points of our subsequent research.

Several studies have demonstrated that NIA significantly shortens postoperative recovery room stays, time to ambulation, hospital length of stay, and overall hospitalization costs, indicating a positive impact on postoperative recovery for VATS patients (32, 33). In our study, the NIA group exhibited comparable intraoperative blood loss, number of lymph node stations dissected, postoperative drainage volume, and complication rates to the IGA group. Compared with the complete collapse of the affected lung in the IGA group, the affected lung in the NIA group had a certain degree of mobility and the surgical field was not good. To avoid lung traction injury, the respiratory circuit needs to be frequently disconnected to cooperate with thoracoscopic operations. However, tracheal intubation for one-lung ventilation can directly achieve lung collapse and reduce intraoperative pauses. Meanwhile, during tube-free anesthesia, the face mask is prone to displacement due to changes in body position (such as lateral position) or fluctuations in airway pressure. All the above reasons may increase the operation time. The NIA procedure minimizes the adverse effects of tracheal intubation and general anesthesia to the greatest extent, such as airway trauma related to intubation, lung injury caused by ventilation, residual neuromuscular block, and postoperative nausea and vomiting (34, 35). After the operation, patients under NIA have a significantly reduced risk of postoperative respiratory muscle paralysis due to a lower dosage of muscle relaxants during the operation, retention of diaphragm movement (36), better respiratory and expectoration functions, accelerated postoperative recovery, and shortened hospital stay. Furthermore, during one-lung ventilation with IGA, positive pressure ventilation may lead to excessive alveolar expansion and barotrauma, increasing the risk of exudation and air leakage in the surgical side of the lung (37, 38). The systemic inflammatory response caused by tracheal intubation may aggravate pleural exudation (27). NIA reduces the shear force of the lung parenchyma and the postoperative thoracic drainage volume by preserving spontaneous breathing or low tidal volume strategies, which is similar to the conclusions of previous studies (39). Although NIA significantly increased operative time, it resulted in better short-term recovery outcomes and shorter hospital stays, enhancing the overall patient experience.

Compared to previous studies comparing NIA and IGA, our research offers new insights. Firstly, NIA demonstrates good safety and reliability in moderately complex lung surgeries such as segmentectomy. Secondly, beyond traditional short-term surgical outcomes, this study employs PROs as indicators of short-term prognosis following segmentectomy, revealing lower symptom and functional burdens in NIA patients postoperatively. Thirdly, unlike earlier studies focusing primarily on pain, this research includes nine postoperative symptoms and functional items, providing a more comprehensive assessment of the postoperative experience, which is vital for delivering patient-centered care. Fourthly, we collected PROs at multiple postoperative time points, highlighting the severity and variability of early postoperative experiences following segmentectomy. Collecting PROs data offers clinicians more robust evidence for patient condition assessment, contributing to improved quality of life, enhanced recovery, strengthened doctor-patient communication, and reduced emergency department utilization (40). While some studies suggest that NIA offers long-term benefits over IGA (41, 42), this conclusion requires further investigation through large-scale randomized controlled trials to develop safer, more effective, and less invasive surgical strategies for patient optimization.

This study has certain limitations. Firstly, collecting PRO data weekly after discharge may not fully capture the dynamic changes in postoperative symptoms and functional status, particularly in the early postoperative period. Secondly, as a single-center study conducted in China, the generalizability of our findings is limited. We are seeking to conduct randomized controlled trials to validate our conclusions. Thirdly, only patients with ASA ≤ 2 were included in this study, which limited the universality of the study. Subsequently, we will gradually attempt to conduct research in a broader patient population. Fourthly, the retrospective nature of this study may introduce potential biases. For instance, surgeons may prefer IGA for patients undergoing complex segmentectomies due to perceived safety. Although baseline characteristics were balanced before analysis, large-scale randomized controlled trials are needed in the future to draw definitive conclusions. Fifthly, at present, the guidelines recommend reducing the oxygen concentration during the ventilation maintenance period to reduce the occurrence of complications such as postoperative oxygenation dysfunction. Due to the certain era limitations of the research design and certain conflicts with the current guidelines, this is one of the limitations of the article.

In conclusion, segmentectomy under NIA yields comparable short-term clinical outcomes to IGA, with faster recovery and lighter early postoperative symptom burdens, as well as better functional status. Future research is needed to elucidate the potential long-term effects of NIA on postoperative recovery and tumor recurrence in segmentectomy patients.