Sugammadex vs Neostigmine for Reversal of Neuromuscular Blockade and Association with Postoperative Atelectasis After Video-Assisted Thoracoscopic Surgery: A Propensity Score-Matched Cohort Study.

Purpose: Postoperative atelectasis remains a significant concern after video-assisted thoracoscopic surgery (VATS). This study aimed to evaluate the association between sugammadex use and postoperative atelectasis in patients who underwent VATS. Patients and methods: From the TriNetX Global Collaborative Network (2016-2024), adults undergoing elective VATS who received rocuronium reversed with either sugammadex or neostigmine were identified. The primary outcome was atelectasis within 30 days, identified using the administrative ICD diagnostic codes recorded in the TriNetX database. The secondary outcomes included pneumonia, acute respiratory failure, pneumothorax, sepsis, and major adverse cardiovascular events (MACEs). Outcomes were additionally assessed at 7-day and 90-day intervals. Results: After propensity score matching (1:1), 7345 patients were analyzed per group. Sugammadex exposure was associated with lower odds of atelectasis at 30 days (odds ratio [OR], 0.79; 95% confidence interval [CI], 0.72-0.86; P < 0.001), corresponding to an absolute risk reduction of 3.3% (15.3% vs 18.6%). The association remained consistent at 7-day (OR, 0.75) and 90-day (OR, 0.81) follow-ups. Time-to-event analysis demonstrated a lower hazard of atelectasis (hazard ratio, 0.82; 95% CI, 0.76-0.88). Sugammadex was also associated with reduced pneumothorax (OR, 0.90) and MACEs (OR, 0.75), but not with pneumonia, respiratory failure, or sepsis. Subgroup analyses revealed significant interactions between sex (P = 0.003) and obesity status (P = 0.047), with more pronounced associations in males and non-obese patients. Conclusion: Sugammadex use was associated with a reduced postoperative atelectasis risk in patients undergoing VATS. Prospective randomized trials are warranted to confirm these findings and establish causality.