The Montgomery T-tube: anaesthetic problems and solutions

The Montgomery T-tube is a device used as a combined trachealstent and an airway after laryngotracheal surgery. The deviceis used mostly in specialist centres for head and neck surgery,and therefore, many anaesthetists may be unfamiliar with itsuse. The Montgomery T-tube presents the anaesthetist with challengesboth during its surgical insertion when acute loss of the airwaymight occur and also during induction of anaesthesia in patientswho have such a tube in situ. Anaesthetists who are unfamiliarwith the tube may have to resort to ingenious ways of copingwith the problems of a shared airway with a T-tube, which doesnot have a suitable adaptor for a standard catheter mount, aswell as controlling and maintaining ventilation through thedevice. Safe management of such patients requires careful planning.We describe the anaesthetic management of two cases to illustratethe problems associated with Montgomery tubes. Br J Anaesth 2001; 87: 787–90     

Anaesthetic management for insertion of the Montgomery T-tube in a patient with subglottic stenosis

We report a patient with subglottic stenosis who required insertion of the Montgomery T-tube. During the operation, we could keep stable anaesthesia and adequate ventilation under general anaesthesia using continuous intravenous infusion of propofol with laryngeal mask airway (LMA).     

The anesthetic management of tracheal T-tube exchange using Patil-Syracuse mask]

We exchanged the tracheal T-tube inserted to a 17-year-old female, who wanted to be able to enunciate again, with relapsing polychondritis and difficulty in enunciation which the proximal end of tracheal T-tube above the false vocal cords was causing. The procedure was performed using Patil-Syracuse mask, without tracheal intubation, under-general anesthesia. This method will ensure precise length adjustment and correct placement of the T-tube under fiberoptic bronchoscope.     

Montgomery T-tube insertion using a rigid bronchoscope under direct observation

The Montgomery T-tube (T-tube) is an effective device for relieving tracheal stenosis when lesions are inappropriate for surgical reconstruction. Several techniques have been developed for the insertion of the T-tube in difficult conditions. The aim of this study was to present our experience using a rigid bronchoscope for T-tube insertion. A retrospective chart review of patients with tracheal stenosis who underwent T-tube insertion between April 2002 and July 2005 was conducted. Thirty-seven patients underwent 53 T-tube placements. Successful stent placement was achieved in all 37 patients. The T-tube was not tolerated in six patients because of granulation obstruction of the upper limb or sputum impaction. Thirty-one patients had good long-term results and enjoy adequate airway with the T-tube. There was no procedure-related mortality and there were no complications. Rigid bronchoscopic insertion of the T-tube for tracheal stenosis is a safe and an effective procedure. It ensures the correct placement of the T-tube when the technique described by Montgomery fails.     

Four-layer laryngotracheoplasty to repair an anterior tracheal wall defect induced by a Montgomery T-tube

A 37-year old patient was referred in 2000 for reconstruction of the anterior tracheal wall eroded by a Montgomery T-tube. A four-layer laryngotracheoplasty was proposed to the patient. The endotracheal plane was reconstructed by a bilateral random pattern quadrangular skin hinge flap raised from both sides of the defect. The chondral plane was realized with conchal cartilage. This cartilage graft was covered with an inferiorly based sternocleidomastoid flap. The fourth layer was a mesh split-thickness skin graft. Satisfactory and lasting results were observed during a three-year follow-up. Few articles deal specifically with tracheal reconstruction after anterior wall erosion induced by a Montgomery-T tube. We found no mention of the described four-layer flap in the literature.     

New approach to anaesthetizing a patient at risk of pulmonary aspiration with a Montgomery T-tube in situ

We describe our airway management in a patient requiring emergency laparotomy with a Montgomery T-tube in situ. This uncuffed silicone T-tube acts as both stent and tracheostomy after laryngotracheal surgery, and entails various difficulties for the anaesthetist. Several anaesthetic techniques have been described for T-tube insertion. The management of patients with a T-tube in situ, at risk of pulmonary aspiration, has not been addressed. Below, we present some possible approaches to this problem and describe how we successfully carried out an awake fibreoptic intubation via the tracheal limb of the T-tube. This technique might be considered for patients in similar circumstances, but knowledge of relevant internal and external tube diameters, and appropriate tracheal tube size selection, is crucial.     

Fechtner's syndrome: considerations of anesthetic management

Implications: Fechtner's syndrome is a rare form of macrothrombocytopenia (potentially associated with other hemostatic deficiencies, e.g., von Willebrand's disease and protein Z deficiency), which can exacerbate the risk of uncontrollable bleeding during surgery. We describe the management of a patient with Fechtner's syndrome involving desmopressin, prednisone, and platelets, which produced safe and effective results during cochlear implant surgery.     

Moyamoya disease: pathophysiology and anesthetic management

Moyamoya disease, an ischemic cerebrovascular disease, is characterized by a slowly increasing bilateral occlusion of the internal carotid circulation. Although collateral pathways are formed, therapy is aimed at further increasing blood flow by surgical anastomosis before ischemic events and fixed neurologic defects occur. This disease remains one of the few indications for performance of the operation of superficial temporal artery to middle cerebral artery anastomosis. Anesthetic considerations involve increasing substrate supply and decreasing demand for its use. Two cases of moyamoya disease are described, noteworthy not only because of the rarity of the disease but because of its occurrence in the Hispanic race rather than the traditional appearance in those only of Japanese descent. The anesthetic management is outlined and the literature reviewed.     

T-tube drainage of the common bile duct choleperitoneum: etiology and management

External drainage of the common bile duct by placement of a T-tube is a common practice after choledochotomy. This practice may result in the specific complication of bile peritonitis due to leakage after removal of the T-tube. This complication has multiple causes: some are patient-related (corticotherapy, chemotherapy, ascites), and others are due to technical factors (inappropriate suturing of the drain to the ductal wall, minimal inflammatory reaction related to some drain materials). The clinical presentation is quite variable depending on the amount and rapidity of intra-peritoneal spread of of bile leakage. Abdominal ultrasound (US), with US-guided needle aspiration and occasionally Technetium(99) scintigraphy are useful for diagnosis. Traditional therapy consists of surgical intervention including peritoneal lavage and re-intubation of the choledochal fistulous tract to allow for a further period of external drainage. When leakage is walled off and well-tolerated, a more nuanced and less invasive conservative therapy may combine percutaneous drainage with endoscopic placement of a trans-ampullary biliary drainage.     

Uterine leiomyoma with cardiac extension: anesthetic management

A 61-year-old woman complaining of dyspnea with moderate effort was diagnosed with intravenous leiomyomatosis arising in the inferior vena cava with right auricular extension. Surgery was performed in a one-stage procedure under extracorporeal circulation using atriotomy and venotomy of the inferior vena cava. Complete removal of the tumor was confirmed by transesophageal echocardiography during surgery. A femoral venous bypass graft to the root of the aorta allowed the effects of clamping the inferior vena cava to be attenuated and the use of blood products to be reduced. Intravenous leiomyomatosis is a rare benign tumor characterized by smooth muscle proliferation, sometimes involving the inferior vena cava and, very rarely, extending to the right heart chambers.