Tracheal Resection With Patient Under Local Anesthesia and Conscious Sedation

Anaesthesia for tracheal resection and anastomosis

Tracheal resection anastomosis is one of the most challenging surgeries. Notable advances in this field have made possible a variety of surgical, anesthetic, and airway management options. There are reports of newer approaches ranging from use of supraglottic airway devices, regional anesthesia, and extracorporeal support. Endotracheal intubation with cross-field ventilation and jet ventilation are the standard techniques for airway management followed. These call for multidisciplinary preoperative planning and close communication during surgery and recovery. This review highlights the anesthetic challenges faced during tracheal resection and anastomosis with specific considerations to preoperative workup, classification of tracheal stenosis, airway management, ventilation strategies, and extubation. The newer advances proposed have been reviewed.

State of the art in tracheal surgery: a brief literature review

Background

Tracheal surgery requires a highly specialized team of anesthesiologists, thoracic surgeons, and operative support staff. It remain a formidable challenge for surgeons due to the criticality connected to anatomical considerations, intraoperative airway management, technical complexity of reconstruction, and the potential postoperative morbidity and mortality.

Main body

This article focuses on the main technical aspects and literature data regarding laryngotracheal and tracheal resection and reconstruction. Particular attention will be paied to anastomotic and non-anastomotic complications.

Short conclusion

Results from literature confirm that, when feasible, laryngotracheal and tracheal resection and reconstruction is the treatment of choice in cases of benign stricture and malign neoplasm. Careful patient selection, operative planning, and execution are required for optimal results.

Successful ventilation through a Rüsch intubation guide catheter in severe laryngotracheal stenosis

BACKGROUND

Providing adequate ventilation may remain complex in patients with severe proximal laryngotracheal stenosis, especially when the airway is shared with the surgeon during tracheal resection surgery. We describe an effective alternative to standard endotracheal intubation using a Rüsch flexible intubation guide catheter.

METHODS

In two patients undergoing tracheal repair surgery, we failed to insert a 5.0 inner diameter endotracheal tube (6.9 mm outer diameter) or a 6.0 mm outer diameter endoscope through the laryngotracheal stenosis. However, using indirect laryngoscopy, a 6.0 outer diameter Rüsch flexible intubation guide catheter was passed successfully through the vocal cords and then through the stenosis. Controlled ventilation was achieved by means of the Rüsch guide, provided with its two large Murphy's eyes. When the trachea was opened, the Rüsch guide was removed just enough for the surgeons to place a Montandon tracheal tube, at that point taking over ventilation. A 7.0 inner diameter endotracheal cuffed tube had been inserted onto the Rüsch guide and left pending upstream from the vocal cords. Once the posterior tracheal wall was sutured, this endotracheal cuffed tube was slid along the Rüsch guide through the vocal cords with the cuff placed beyond the tracheal sutures.

RESULTS

Controlled ventilation through the Rüsch flexible intubation guide catheter showed satisfying and stable ventilatory parameters in both patients. Inspiratory pressures of 25-30 mmHg were enough to reach adequate tidal volumes around 450 ml. End tidal CO₂ was kept between 35 and 40 mmHg (PaCO₂ showed similar values). Standard endotracheal intubation at the end of the tracheal resection was easy and safe thanks to the Rüsch guide still in place between the vocal cords.

CONCLUSIONS

We suggest an effective and reliable method using a Rüsch flexible intubation guide catheter for airway management in patients suffering from laryngotracheal stenosis in the setting of tracheal repair surgery.

Dexmedetomidine-based monitored conscious sedation combined local anesthesia for levator resection in a 10-year-old child with Marcus Gunn jaw-winking synkinesis: A case report

RATIONALE

Levator resection has become a routine procedure for patients with severe Marcus Gunn jaw-winking synkinesis (MGJWS). To optimize the surgical outcome, adult patients need to be kept awake, or easily aroused and responsive to verbal commands during the operation. However, levator resection is commonly performed under general anesthesia in pediatric patients. In the present case, we described a successful anesthetic protocol of conscious sedation with local anesthesia for levator resection in a child.

PATIENT CONCERNS

A 10-year-old boy with MGJWS was admitted to our hospital and scheduled for levator resection. The patient was born through a normal delivery and had no previous history of allergy, no comorbidity, and no history of receiving anesthesia or operation. The laboratory tests of the patient were unremarkable.

DIAGNOSES

The diagnosis of MGJWS was made by two experienced ophthalmologists.

INTERVENTIONS

A 10-year-old boy with MGJWS was admitted to our hospital and scheduled for levator resection. The levator resection was performed under monitored conscious sedation with dexmedetomidine and local anesthesia.

OUTCOMES

Patient with spontaneous breathing responded normally to verbal commands throughout the operation, and no adverse events occurred. The patient and ophthalmologist reported high satisfaction with anesthesia management.

LESSONS

Dexmedetomidine-based monitored conscious sedation with local anesthesia is a feasible alternative to general anesthesia for levator resection in collaborative patients.

New Approaches to Airway Management in Tracheal Resections-A Systematic Review and Meta-analysis

OBJECTIVES

Although endotracheal intubation, surgical crossfield intubation, and jet ventilation are standard techniques for airway management in tracheal resections, there are also reports of new approaches, ranging from regional anesthesia to extracorporeal support. The objective was to outline the entire spectrum of new airway techniques.

DESIGN

The literature databases PubMed/Medline and the Cochrane Library were searched systematically for prospective and retrospective trials as well as case reports on tracheal resections.

SETTING

No restrictions applied to hospital types or settings.

PARTICIPANTS

Adult patients undergoing surgical resections of noncongenital tracheal stenoses with end-to-end anastomoses.

INTERVENTIONS

Airway management techniques were divided into conventional and new approaches and analyzed regarding their potential risks and benefits.

MEASUREMENTS AND MAIN RESULTS

A total of 59 publications (n = 797 patients) were included. The majority of publications (71.2%) describe conventional airway techniques. Endotracheal tube placement after induction of general anesthesia and surgical crossfield intubation after incision of the trachea were used most frequently without major complications. A total of 7 new approaches were identified, including 4 different regional anesthetic techniques (25 cases), supraglottic airways (4 cases), and new forms of extracorporeal support (25 cases). Overall failure rates of new techniques were low (1.8%). Details on patient selection and procedural specifics are provided.

CONCLUSIONS

New approaches have several theoretical benefits, yet further research is required to establish criteria for patient selection and evaluate procedural safety. Given the low level of evidence, it currently is impossible to compare methods of airway management regarding outcome-related risks and benefits.

Surgical outcomes of post intubational or post tracheostomy tracheal stenosis: report of 18 cases in single institution

PURPOSE

Tracheal resection and end-to end anastomosis (TRE) is known as standard treatment of tracheal stenosis (TS) and there are various methods to keep ventilation during operation. We reviewed ventilation methods and postoperative outcomes in patients with postintubational (PI) or posttracheostomy (PT) TS.

PATIENTS AND METHODS

From May 2006 to May 2013, 18 patients with PI or PTTS underwent TRE in our hospital. All patients' records were retrospectively reviewed.

RESULTS

The mean duration of intubation and tracheostomy were 14.2 days (range: 2 to 27 days) and 114.9 days (range: 43 to 215 days). The location of stenosis was tube cuffs (n = 10), stoma (n = 6) and double stenosis involving cuff and stoma (n = 2). The mean diameter of stenotic lesion was 5.4 mm (range: 2 to 9 mm. ECMO (n = 4) was performed in critical stenosis. Of two cases with double stenosis, one underwent preoperative endotracheal balloon dilatation and the other underwent TRE with cricoplasty. The overall complication rate was 11.8%. The mean follow-up duration was 14.0 months (range: 0.9 to 56.3 months).

CONCLUSION

Comparing with the literatures, TS treated by TRE in our hospital has shown satisfactory outcomes. To maintain appropriate ventilation for critical stenosis, ECMO could be one of safe methods.