Insertion of intratracheal stents. Anaesthetic management using high frequency jet ventilation or cardiopulmonary bypass

Extracorporeal life support and cardiopulmonary bypass for central airway surgery: A systematic review

BACKGROUND

Major airway surgery can pose a complex problem to perioperative central airway management. Adjuncts to advanced ventilation strategies have included cardiopulmonary bypass, veno-arterial, or veno-venous extracorporeal life support. We performed a systematic review to assess the existing evidence utilizing these strategies.

METHODS

An electronic search was conducted to identify studies written in English reporting the use of extracorporeal life support (ECLS) during central airway surgery. Thirty-six articles consisting of 78 patients were selected and patient-level data were analyzed.

RESULTS

Median patient age was 47 [IQR: 34-53] and 59.0% (46/78) were male. Indications for surgery included central airway or mediastinal cancer in 57.7% (45/78), lesion or injury in 15.4% (12/78), and stenosis in 12.8% (10/78). Support was initiated pre-operatively in 9.9% (7/71) and at the time of induction in 55.3% (42/76). It was most commonly used at the time of tracheal resection/repair [93.2% (68/73)], intubation of the tracheal stump [94.4% (68/72)], and re-anastomosis [94.2% (65/69)]; 13.7% (10/73) patients were supported post-operatively. The most commonly performed surgery was tracheal repair or resection in 70.3% (52/74). Median hospital stay was 12 [8, 25] days and in-hospital mortality was 7.9% (6/76). There was no significant difference in survival between the three groups (p = .54).

CONCLUSIONS

Extracorporeal membrane oxygenation offers versatility in timing, surgical approach, and ECLS runtime that makes it a viable addition to the surgical armamentarium for treating complex central airway pathologies.

Cardiopulmonary bypass as an adjunct for the noncardiac surgeon

The use of cardiopulmonary bypass (CPB) in noncardiac surgical settings has been increasingly developed and has greatly benefited noncardiac surgeon. A few years after the advent of CPB as well as profound hypothermic circulatory arrest in the early years, it was employed by neurosurgeons in cerebrovascular surgery and by general thoracic surgeons in carinal tumor resection. Indications for CPB were extended and modified year after year. It has facilitated not only the surgical management by surgeons of lesions that cannot be managed safely and effectively by conventional techniques, or conventional techniques carry significant risks to the patient, but also the preservation of the viability of multiple organ procurement, the practice of isolated limb perfusion for the treatment of malignancies of the extremities, and emergent cardiopulmonary resuscitation. Owing to the complications arising from CPB and profound hypothermic circulatory arrest, such as postoperative bleeding, coagulopathy, and neurologic deficits, efforts have been made to avoid these common hazards. Thus, innovative techniques including extracorporeal membrane oxygenation, percutaneous cardiopulmonary support, venovenous bypass, normothermic CPB, and minimally invasive approaches have emerged and played an important role as alternatives of standard CPB in decreasing morbidity and mortality and improving survival.

Anaesthesia and tracheobronchial stenting for central airway obstruction in adults

In the last decade, stents suitable for the management of tracheobronchial stenoses and obstruction have evolved from bulky prostheses requiring tracheal resection to small devices that are self-expanding and can be inserted using fibreoptic techniques. The experience base for this review is more than 100 patients between 1989 and 2001 who have been anaesthetized for stent insertion. Early cases required rigid bronchoscopy for the routine of insertion. Anaesthetic techniques have evolved from those that were designed and developed for laser surgery in the central airways. The advent of modern devices now extends the variety of anaesthetic management techniques that can be used. But the original one, based on the requirement for use of a rigid bronchoscope, is best for dealing with complications and extracting problem stents. The most frequent complication of the processes of stent insertion has been respiratory failure because of carbon dioxide retention, consequent on obstruction with secretions in the area of the carina. The nature of central airway problems suggests that anaesthesia induction, management and teaching should not be founded on the conventional model-base of upper airway obstruction.

Intratracheal stent intubation under extracorporeal lung assist

An artificial stent was intubated using extracorporeal lung assist (ECLA) in two patients with inoperable tracheal stenosis. In a patient with an endotracheal tumor, an airway obstruction due to a partial stent collapse was overcome by an immediate ECLA perfusion. In another patient with chronic inflammatory tracheal stenosis, a repetitive balloon dilation of the trachea could be safely performed utilizing ECLA perfusion. Preventive femoral cannulation, employing the assistance of an ECLA circuit, is thus considered to be a safe and effective procedure for the treatment of inoperable tracheal stenosis.