Abstract
OBJECTIVES: Evaluation of complex, acquired, non-malignant tracheo/broncho-oesophageal fistulas (TEF) repaired by extrathoracic pedicled muscle flaps that were, in addition to their ...interposition between the airways and the gastro-intestinal tract, patched into gastro-intestinal or airway defects if primary closure seemed risky.
METHODS: A single institution experience of patients treated between 2003 and 2015. Twenty-two patients required TEF repair following oesophageal surgery (18), Boerhaave syndrome (1), chemotherapy for mediastinal lymphoma (1), carinal resection and irradiation (1) and laryngectomy (1); 64% of them underwent prior radio- or chemotherapy and 50% prior airway or oesophageal stenting.
RESULTS: Airway defects were closed by muscle flap patch (n = 12), lobectomy (n = 4), airway resection/anastomosis (n = 2), pneumonectomy (n = 1), segmentectomy (n = 2) or primary suture (n = 1). Gastro-intestinal defects were repaired by oesophageal diversion (n = 9), muscle flap patch (n = 8) or primary suture (n = 5). A muscle flap patch was used to close airway and gastro-intestinal defects in 55% and 36% of cases, respectively. The 90-day postoperative mortality and TEF recurrence rates were 18% and 4.5%. Airway healing and breathing without tracheal appliance was obtained in 95% of patients and gastro-intestinal healing in 77% of those without oesophageal diversion. Five of nine patients with oesophageal diversion underwent intestinal restoration by retrosternal colon transplants.
CONCLUSIONS: Complex TEF arising after oesophageal surgery, radio-chemotherapy or failed stenting can be successfully closed using extrathoracic muscle flaps that can, in addition to their interposition between the airway and the gastro-intestinal tract, also be patched into gastro-oesophageal or airway defects if primary closure seems hazardous.
During thoracic surgery, patients are usually positioned in lateral decubitus and only the dependent lung ventilated. The ventilated lung is thus exposed to the weight of the contralateral hemithorax ...and restriction of the dependent chest wall. We hypothesized that mechanical power would increase during one-lung ventilation in the lateral position.
We performed a prospective, observational, single-center study from December 2016 to May 2017. Thirty consecutive patients undergoing general anesthesia with mechanical ventilation (mean age, 68 ± 11 years; body mass index, 25 ± 5 kg·m) for thoracic surgery were enrolled. Total and partitioned mechanical power, lung and chest wall elastance, and esophageal pressure were compared in supine and lateral position with double- and one-lung ventilation and with closed and open chest both before and after surgery. Mixed factorial ANOVA for repeated measurements was performed, with both step and the period before or after surgery as 2 within-subject factors, and left or right body position during surgery as a fixed, between-subject factor. Appropriate interaction terms were included.
The mechanical power was higher in lateral one-lung ventilation compared to both supine and lateral position double-lung ventilation (11.1 ± 3.0 vs 8.2 ± 2.7 vs 8.7 ± 2.6; mean difference, 2.9 J·minute 95% CI, 1.4-4.4 J·minute and 2.4 J·minute 95% CI, 0.9-3.9 J·minute; P < .001 and P = .002, respectively). Lung elastance was higher during lateral position one-lung ventilation compared to both lateral and supine double-lung ventilation (24.3 ± 8.7 vs 9.5 ± 3.8 vs 10.0 ± 3.8; mean difference, 14.7 cm H2O·L 95% CI, 11.2-18.2 cm H2O·L and 14.2 cm H2O·L 95% CI, 10.8-17.7 cm H2O·L, respectively) and was higher compared to predicted values (20.1 ± 7.5 cm H2O·L). Chest wall elastance increased in lateral position double-lung ventilation compared to supine (11.1 ± 3.8 vs 6.6 ± 3.4; mean difference, 4.5 cm H2O·L 95% CI, 2.6-6.3 cm H2O·L) and was lower in lateral position one-lung ventilation with open chest than with a closed chest (3.5 ± 1.9 vs 7.1 ± 2.8; mean difference, 3.6 cm H2O·L 95% CI, 2.4-4.8 cm H2O·L). The end-expiratory esophageal pressure decreased moving from supine position to lateral position one-lung ventilation while increased with the opening of the chest wall.
Mechanical power and lung elastance are increased in the lateral position with one-lung ventilation. Esophageal pressure monitoring may be used to follow these changes.
The aim of this study was to assess the feasibility and safety issues concerning extraluminal use of the Uniblocker for one-lung ventilation (OLV) in the left thoracic surgery.
Forty patients ...undergoing elective left thoracic surgery were included in this study, and all patients were randomly allocated to extraluminal use of Uniblocker group (E group, n = 20) or intraluminal use of Uniblocker group (I group, n = 20). Time for intubation, time for verification of the correct position of Uniblocker, incidence of Uniblocker displacement, index of pulmonary collapse, mean arterial pressure, heart rate, peak airway pressure, oxygen saturation in two-lung ventilation, and 30 minutes after OLV, bronchial damage after OLV, sore throat, and hoarseness postoperative were recorded.
The time for positioning Uniblocker was 112.6 ± 31.2 seconds in intraluminal use group, whereas the time for positioning Uniblocker was significantly shorter in extraluminal use group (63.4 ± 15.8 seconds). The incidence of main bronchial injury, the time of intubation, the incidence of Uniblocker malposition after initial placement, the time of OLV, the degree of pulmonary collapse, mean arterial pressure, heart rate, peak airway pressure, oxygen saturation in two-lung ventilation, and 30 minutes after OLV, the incidence of sore throat and hoarseness postoperative have no statistical significance (P > .05).
Extraluminal use of the Uniblocker was proved to be a more rapid and more accurate method than conventional intraluminal use of the Uniblocker for OLV in left thoracic surgery.
Thoracic surgery milestones 2.0: Rationale and revision Mitzman, Brian; Beller, Jared P.; Edgar, Laura
The Journal of thoracic and cardiovascular surgery,
November 2020, 2020-Nov, 2020-11-00, 20201101, Volume:
160, Issue:
5
Journal Article
OBJECTIVES
Treatment of long-segment congenital tracheal stenosis (CTS) remains challenging. Recently, slide tracheoplasty has become the standard approach in many centres. The aim of this study was ...to evaluate the clinical outcomes of slide tracheoplasty.
METHODS
Between 2004 and 2011, 18 patients underwent slide tracheoplasty in our centre. The median patient age was 2.5 months (range, 18 days–4 years) and the median body weight was 4.2 (range, 2.2–17.7) kg at operation. Eleven (61%) patients were on a mechanical ventilator prior to surgery. The median stenotic segment estimated by a computed tomography scan was 52% of the length of total trachea (range, 18–84%). Five (28%) patients had proximal bronchial stenosis, 3 (17%) had tracheal bronchus, 2 (11%) had tracheobronchomalacia and 1 (6%) had agenesis of the right lung. Thirteen (72%) patients had a combined cardiac anomaly, including 8 patients with a pulmonary artery sling. Ten (56%) patients had associated extracardiac anomalies. Slide tracheoplasty was performed on cardiopulmonary bypass in all patients, and cardiac lesions were corrected.
RESULTS
There was no early death. The patient with agenesis of the right lung died of left bronchial stenosis 3 months after the surgery. Two (11%) patients were reoperated on for tracheal restenosis. In the other 15 patients, the median duration of ventilator support was 8 (range, 5–34) days and the median duration of hospitalization was 31 (range, 12–79) days. During the follow-up (median duration of 17 months; range, 2–77 months), 13 (72%) patients were symptom-free and 2 (11%) underwent tracheostomy for tracheomalacia.
CONCLUSIONS
Based on this study, slide tracheoplasty seems to be an effective technique for CTS. However, shortening of the trachea after reconstruction may give rise to recurrent obstruction.
Airway anomalies are common in children with cardiac disease but with an unquantified impact on outcomes. We sought to define the association between airway anomalies and tracheal surgery with ...cardiac surgery outcomes using the Society of Thoracic Surgery Congenital Heart Surgery Database.
Index cardiac operations in children aged less than 18 years (January 2010 to September 2018) were identified from the Society of Thoracic Surgery Congenital Heart Surgery Database. Patients were divided on the basis of reported diagnosis of an airway anomaly and subdivided on the basis of tracheal lesion and tracheal surgery. Multivariable analysis evaluated associations between airway disease and outcomes controlling for covariates from the Society of Thoracic Surgery Congenital Heart Surgery Database Mortality Risk Model.
Of 198,674 index cardiovascular operations, 6861 (3.4%) were performed in patients with airway anomalies, including 428 patients (0.2%) who also underwent tracheal operations during the same hospitalization. Patients with airway anomalies underwent more complex cardiac operations (45% vs 36% Society of Thoracic Surgeons/European Association for Cardiothoracic Surgery Congenital Heart Surgery Mortality category ≥3 procedures) and had a higher prevalence of preoperative risk factors (73% vs 39%; both P < .001). In multivariable analysis, patients with airway anomalies had increased odds of major morbidity and tracheostomy (P < .001). Operative mortality was also increased in patients with airway anomalies, except those with malacia. Tracheal surgery within the same hospitalization increased the odds of operative mortality (adjusted odds ratio, 3.9; P < .0001), major morbidity (adjusted odds ratio, 3.7; P < .0001), and tracheostomy (adjusted odds ratio, 16.7; P < .0001).
Patients undergoing cardiac surgery and tracheal surgery are at significantly higher risk of morbidity and mortality than patients receiving cardiac surgery alone. Most of those with unoperated airway anomalies have higher morbidity and mortality, which makes it an important preoperative consideration.
Airway anomalies and interventions are associated with increased morbidity and mortality. Display omitted
PDF
