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Nonintubated Spontaneous Respiration Anesthesia for Tracheal Glomus Tumor

2017; Elsevier BV; Volume: 104; Issue: 2 Linguagem: Inglês

10.1016/j.athoracsur.2017.02.028

1552-6259

Jun Huang, Yuan Qiu, Lei Chen, Hui Liu, Qinglong Dong, Lixia Liang, Jiaxi He, Jianxing He, Hanzhang Chen,

Salivary Gland Tumors Diagnosis and Treatment

Previous tracheal surgeries were performed under tracheal and cross-field intubation. However, the intubation would lead to bleeding if the tumors were large or hemorrhagic. Moreover, the tracheal intubation might interfere the surgical vision and anastomosis during the reconstruction process. Therefore, we performed a tracheal tumor resection and reconstruction via nonintubated spontaneous anesthesia. We describe the feasibility and safety of tracheal surgeries via such anesthesia. Previous tracheal surgeries were performed under tracheal and cross-field intubation. However, the intubation would lead to bleeding if the tumors were large or hemorrhagic. Moreover, the tracheal intubation might interfere the surgical vision and anastomosis during the reconstruction process. Therefore, we performed a tracheal tumor resection and reconstruction via nonintubated spontaneous anesthesia. We describe the feasibility and safety of tracheal surgeries via such anesthesia. The Video can be viewed in the online version of this article [http://dx.doi.org/10.1016/j.athoracsur.2017.02.028] on http://www.annalsthoracicsurgery.org.Tracheal tumor is one of rare tumors of upper respiratory system, consisting of only 2% upper respiratory neoplasms. It usually presents with airway irritating and obstructing symptoms including cough, sore throat, dyspnea, and shortness of breath. The diagnosis of such disease would be confirmed by fibrobronchoscopy or computed tomography (CT). Surgical resection is the predominant therapy either for radical or palliative purpose. The video-assisted transthoracic surgery (VATS) has been generally utilized in tracheal tumor patients with effectiveness and satisfaction [1Grillo H.C. Development of tracheal surgery: a historical review. Part 1: techniques of tracheal surgery.Ann Thorac Surg. 2003; 75: 610-619Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar]. The Video can be viewed in the online version of this article [http://dx.doi.org/10.1016/j.athoracsur.2017.02.028] on http://www.annalsthoracicsurgery.org. Recently, some articles reported the cases of VATS lung volume reduction surgery, segmentectomy, and lobectomy via nonintubated spontaneous respiration anesthesia [2Al-Abdullatief M. Wahood A. Al-Shirawi N. et al.Awake anaesthesia for major thoracic surgical procedures: an observational study.Eur J Cardiothorac Surg. 2007; 32: 346-350Crossref PubMed Scopus (90) Google Scholar, 3Hung M.H. Cheng Y.J. Chan K.C. et al.Nonintubated uniportal thoracoscopic surgery for peripheral lung nodules.Ann Thorac Surg. 2014; 98: 1998-2003Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar, 4Nakanishi K. Kuruma T. Video-assisted thoracic tracheoplasty for adenoid cystic carcinoma of the mediastinal trachea.Surgery. 2005; 137: 250-252Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar, 5Pompeo E. Mineo D. Rogliani P. Sabato A.F. Mineo T.C. Feasibility and results of awake thoracoscopic resection of solitary pulmonary nodules.Ann Thorac Surg. 2004; 78: 1761-1768Abstract Full Text Full Text PDF PubMed Scopus (198) Google Scholar]. It demonstrated that such method was feasible and safe. In our center we have accumulated a large amount of experiences in dealing with unexpected situations and complications of nonintubated spontaneous respiration anesthesia, with more than 250 cases [6Li S. Jiang L. Ang K.L. et al.New tubeless video-assisted thoracoscopic surgery for small pulmonary nodules.Eur J Cardiothorac Surg. 2016; ([e-pub ahead of print])Google Scholar, 7Liu J. Cui F. Li S. et al.Nonintubated video-assisted thoracoscopic surgery under epidural anesthesia compared with conventional anesthetic option: a randomized control study.Surg Innovation. 2015; 22: 123-130Crossref PubMed Scopus (119) Google Scholar, 8Liu J. Cui F. Pompeo E. et al.The 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 analysis.Eur J Cardiothorac Surg. 2016; 50: 920-925Crossref PubMed Scopus (63) Google Scholar]. Previous tracheal surgeries require tracheal intubation, chest intubation, and mechanical ventilation. However, tracheal intubation is a dilemmatic procedure in some particular cases of large and hemorrhagic tumors. To minimize the possibilities of injury, tumor displacement, or hemorrhage, which might be caused by intubation, we performed VATS tracheal tumor resection and reconstruction via nonintubated spontaneous respiration anesthesia. Moreover, we intend to demonstrate the feasibility and safety of such method by reporting the procedure and the postoperative results of the cases. The patient was a 38-year-old man who was presenting irritating cough and progressive hematemesis in the previous 20 days. The chest computed tomography scan showed a 2.4 × 2.2 × 2.7 cm neoplasm with heterogeneous vascular contrast enhancement involving the posterior tracheal wall at the level of second and third thoracic vertebras, 3 to 4 cm away from the carina (Fig 1). Bronchoscopy showed a lobulated hemorrhagic mass obstructing the airway, which was contact bleeding. Considering the possibility of hemorrhage during the tracheal intubation process and the suffocation causing by the tumor shedding, we therefore performed the tracheal tumor resection and reconstruction via nonintubated spontaneous respiration anesthesia after the discussion with the patient and the colleagues in departments of thoracic surgery and anesthesia. Intravenous anesthesia was used in this patient. The patient was sedated with propofol target-controlled infusion mode with concentration of 1.5 to 3.0 μg/mL and midazolam 0.05 to 0.1 mg/kg intravenously. Sufentanil (5 to 10 μg) was subsequently applied for analgesia in the induction of anesthesia. Anesthesia was maintained using propofol in target-controlled infusion mode (1.0 to 3.0 μg/mL), remifentanil (0.03 to 0.05 μg/kg/min), and dexmedetomidine (0.5 to 1.0 μg/kg/h). Also, 60% oxygen was delivered using a laryngeal mask at a rate of 3.5 mL/min. Spontaneous respiration was maintained throughout the surgery. The devices for tracheal intubation, VATS endobronchial intubation, and mechanical ventilation were prepared to prevent emergency situation (e.g., airway spasm or obstruction) and ensure the surgical safety. The patient was placed in left lateral decubitus position. A 1.2-cm observation port was made in the sixth intercostal space at middle axillary line. In addition, incisions (3.5 cm) were made in the third or fourth intercostal space at anterior axillary line (Fig 2A ). An extra incision (0.5 cm) would be made in sixth intercostal space at posterior axillary line if necessary. Vagal nerve blockage would be performed with a 4 to 6 mL mixture of 1% lidocaine and 0.375% ropivacaine via thoracoscopy before operation (Fig 2B) [4Nakanishi K. Kuruma T. Video-assisted thoracic tracheoplasty for adenoid cystic carcinoma of the mediastinal trachea.Surgery. 2005; 137: 250-252Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar]. We would spray 1% lidocaine on the surface of the lung, especially in the hilum area, which was also effective to prevent coughing. The tracheal mass was completely resected 0.5 to 1.0 cm away from the outer margin of the tumor. The reconstruction of the tracheal stump was performed by continuous suture using 3-0 Prolene sutures (Ethicon, Somerville, NJ), after the intraoperative frozen section analysis showed that the surgical margin was negative (Figs 2C, 2D). The medical imaging details and the surgical procedure of the cases are demonstrated in the Video. The total operation time was 130 min. It took 30 min to finish the reconstruction. No complication was observed during the 90-day postoperative follow-up. The chest tubes had been removed on the third day postoperatively. The pathology result turned out to be glomus tumor. No tumor recurrence was observed during the follow-up period. The tracheal endoscopy was performed within 3 months after surgery in each case. The results showed that the anastomosis had completely healed and no sign of inflammation or leakage was observed (Fig 3). Recently, nonintubated spontaneous respiration anesthesia has been reported and proved to be applicable in various pulmonary surgeries including lung volume reduction, segmentectomy, and lobectomy in different institutions [2Al-Abdullatief M. Wahood A. Al-Shirawi N. et al.Awake anaesthesia for major thoracic surgical procedures: an observational study.Eur J Cardiothorac Surg. 2007; 32: 346-350Crossref PubMed Scopus (90) Google Scholar, 5Pompeo E. Mineo D. Rogliani P. Sabato A.F. Mineo T.C. Feasibility and results of awake thoracoscopic resection of solitary pulmonary nodules.Ann Thorac Surg. 2004; 78: 1761-1768Abstract Full Text Full Text PDF PubMed Scopus (198) Google Scholar, 6Li S. Jiang L. Ang K.L. et al.New tubeless video-assisted thoracoscopic surgery for small pulmonary nodules.Eur J Cardiothorac Surg. 2016; ([e-pub ahead of print])Google Scholar, 7Liu J. Cui F. Li S. et al.Nonintubated video-assisted thoracoscopic surgery under epidural anesthesia compared with conventional anesthetic option: a randomized control study.Surg Innovation. 2015; 22: 123-130Crossref PubMed Scopus (119) Google Scholar, 8Liu J. Cui F. Pompeo E. et al.The 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 analysis.Eur J Cardiothorac Surg. 2016; 50: 920-925Crossref PubMed Scopus (63) Google Scholar]. A case of VATS thoracic tracheoplasty under general anesthesia with intubation has been reported by Kuruma and colleagues [4Nakanishi K. Kuruma T. Video-assisted thoracic tracheoplasty for adenoid cystic carcinoma of the mediastinal trachea.Surgery. 2005; 137: 250-252Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar]. During the surgical procedure, he had to intubate three times sequentially: (1) initial endotracheal tube before tumor resection, (2) chest (cross-field) intubation in the bronchi after tumor resection, and (3) another oral endotracheal tube in the bronchi after trachea membrane reconstruction [4Nakanishi K. Kuruma T. Video-assisted thoracic tracheoplasty for adenoid cystic carcinoma of the mediastinal trachea.Surgery. 2005; 137: 250-252Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar]. Compared with the intubation, the nonintubation anesthesia makes the tracheal reconstruction much simpler. In this case, the patient had no adverse cardiopulmonary function or other comorbidities. Besides, he had a body mass index less than 24 kg/m2. From our experience, the indications of such a technique are the following: (1) no operation or anesthesia contraindication, (2) no severe cardiopulmonary diseases, and (3) less airway secretion. Meanwhile, to ensure the safety and feasibility of the surgical process, some exclusion criteria should be applied: (1) obesity (body mass index greater than or equal to 25 kg/m2), (2) impaired cardiopulmonary function (American Society of Anesthesiologists class 3 or above), (3) respiratory infection, (4) long surgical duration (greater than 5 h), and (5) difficult airway (Mallampati classification greater than 3). Moreover, to ensure the safety during the procedure, an intubation, cross-field ventilation kit, and mechanical ventilation must be prepared in case of emergency. In summary, we reported a case of VATS tracheal glomus tumor resection and reconstruction via nonintubated spontaneous respiration anesthesia. We concluded that nonintubated VATS is a feasible and relatively safe method. Patients with large and hemorrhagic tumors are potential candidates of this technique. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI3MzdiNjllYTQ5ZTZkNDRiMDNiMjAxYmFhYzYxZmNlYyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4NzA1MjEwfQ.Y3eW-e5TX5YN68barMN9dt4wgH0EmxEiYc0DoGj-3e-Pd6d7kQ2ScfqJjXO4EqENSOA_Z4p5AVHCKZVvdBXf38ULviX_QrWp00lFF_4-9XNMxJ2_9zLC7UWzha70sF2nqD2g_UMSg-0PuLD0aVF_ahg8gFyBLf1TUeETnvP7b0FeTy5VIz4Zdps3806rwuoi0OIDGaizO47jZ7TJXtaJUFpnBv8YEw_Bc8aMF_q_a21WJi6IkyKoTWbn4UbUJZOFhBSRp6WGviMJlsQvxoHcB9KeyRhbghkST9zqzWSHPZbv9gaefYrk0rNy6N206HeMHrZ-3vfkcQJ4Maq7W_-V_w Download .mp4 (90.07 MB) Help with .mp4 files Video