The anesthetic management of a case of tracheal necrosis

A 63-yr-old female patient developed a tracheal necrosis after esophageal resection with gastric interposition. We report the anesthetic management of this patient undergoing tracheal repair focusing on an original airway management and ventilation strategy.     

An unusual case of stridor after thyroidectomy

Twelve days after subtotal thyroidectomy, an air pocket developed in a patient's neck. The pressure in this pocket had gradually increased as small amounts of air, probably associated with coughing, came out of a tiny hole in the trachea to form a pneumocoele. This produced limited surgical emphysema, causing venous congestion and oedema of the soft tissues of the larynx, which in turn led to increasing airway obstruction. We believe that this is the first reported case of a pneumocoele that gradually increased in size, causing airway obstruction that was almost certainly due to secondary laryngeal oedema.     

Flexible lightwand-guided tracheal intubation with the intubating laryngeal mask Fastrach in adults after unpredicted failed laryngoscope-guided tracheal intubation

BACKGROUND: The authors determined the efficacy of using the intubating laryngeal mask airway Fastrach (ILM) as a ventilatory device and aid to flexible lightwand-guided tracheal intubation in patients with unpredicted failed laryngoscope-guided tracheal intubation when managed by experienced anesthetists. METHODS: During a 27-month period, 16 experienced anesthetists agreed to use the ILM as an airway device and airway intubator in patients (aged > 18 yr) with predicted normal airways who were subsequently found to be difficult to intubate (three failed attempts at laryngoscopy). Intubation via the ILM was performed with a flexible lightwand. The number of attempts at ILM placement, the number of adjusting maneuvers, the number of attempts at tracheal intubation via the ILM,and any episodes of hypoxia (oxygen saturation < 90%) were recorded. RESULTS: Forty-four of 11,621 patients (0.4%) met the inclusion criteria. ILM insertion and ventilation was successful at the first attempt in 40 of 44 patients (91%) and at the second attempt in 4 of 44 (9%). Flexible lightwand-guided tracheal intubation via the ILM was successful in 38 of 44 patients (86%) at the first attempt, 3 of 44 (7%) at the second attempt, 2 of 44 (5%) at the third to fifth attempts, and failed in 1 of 44 (2%). The median number of adjusting maneuvers before successful intubation was 1 (range, 0-4). Hypoxia occurred in 5 patients before ILM insertion (range, 52-82%), but none after ILM insertion. No patient developed hypoxia during or after intubation via the ILM. CONCLUSION: The ILM is an effective ventilatory device and aid to flexible lightwand-guided tracheal intubation in adult patients with predicted normal airways in whom laryngoscope-guided tracheal intubation subsequently fails when managed by experienced anesthetists.     

气管前入路手术路径在腹腔镜甲状腺手术中的应用

目的探讨腹腔镜甲状腺手术中的路径方法,以降低手术操作难度,减少并发症。方法对104例甲状腺疾病患者采用气管前入路手术方法施行腹腔镜甲状腺切除手术,先切断甲状腺峡部,继而切断管前筋膜、外侧韧带、悬韧带,甲状腺松动,再切断血管,根据病变决定甲状腺切除的多少。结果本组患者手术均获成功,手术平均时间105（85-195）min,平均出血量25（5-115）ml,平均住院时间4．5（3-6）d。2例二次患者术后出现轻微喉返神经麻痹症状,经观察分别于术后3、6个月后自行恢复,无永久．眭喉返神经损伤。结论气管前入路手术方法使腹腔镜甲状腺切除手术容易操作,同时减少手术并发症,是一种安全简捷的手术方法。     

A case of tracheal stenosis following surgery of esophageal cancer

A case of 54-year-old man with tracheal stenosis following surgery for thoracic esophageal cancer was reported. It was considered that the stenosis had occurred due to the tracheal ischemia after esophagectomy and lymph node dissection. Importance of preservation of tracheal blood supply was again noticed. On tracheal reconstruction, application of pedicled pleural flap was recognized to be useful in order to repair the leakage from membranous portion that could not be closed by suture.     

全甲状腺切除术后甲状旁腺的功能监测

目的 评估全甲状腺切除术后甲状旁腺功能减退症发生情况,探索早期预测术后低钙血症的方法.方法 对124例患者(甲状腺癌46例、结节性甲状腺肿78例)行全甲状腺切除术,恶性患者加行淋巴结清扫术,术前、术后1 h、1 d、2 d检测血钙和血PTH,观察术后甲状旁腺功能减退症发生情况,并用受试者工作特征曲线研究低钙血症早期预测指标.结果 58例发生术后暂时性甲状旁腺功能减退症(46.8%),甲状腺癌组22例(47.8%),结节性甲状腺肿组36例(46.2%),两组之间无明显差异(λ2=0.033,P=0.857);1例发生永久性甲状旁腺功能减退症(0.8%),发生在甲状腺癌组.术后90例(72.6%)出现血钙下降,58例(46.8%)出现血PTH下降,40例(32.3%)出现低钙症状.甲状腺癌组术后血钙(F=21.358,P=0.000)、血PTH(F=18.253,P=0.000)下降程度重于结节性甲状腺肿组,术后1 h血PTH下降百分比可很好的预测有临床症状的低钙血症(曲线下面积为0.933),以PTH下降76.6%作为分界点,此时预测有临床症状的低钙血症的敏感性为89.7%,特异性为87.9%. 结论全甲状腺切除术加行淋巴结清扫会加重术后血钙、血PTH下降程度但不会增加甲状旁腺功能减退症发生率;术后1 h血PTH下降百分比可预测低钙血症的发生.     

Hypothyroidism following partial thyroidectomy

OBJECTIVE: To compare rates of hypothyroidism following three types of partial thyroidectomy for multinodular goiter. STUDY DESIGN AND METHODS: All cases of partial thyroidectomies (hemi-, near-total, or subtotal) carried out at one Israeli and one Russian medical center (1990-2006) were retrospectively studied to determine the incidence of hypothyroidism after each procedure. RESULTS: There were 881 near-total, 1538 subtotal, and 1051 hemithyroidectomies (total 3470). Postoperative follow-up was 2 to 15 years. Twenty-eight percent of the hemithyroidectomy patients suffered permanent hypothyroidism compared to 100% of the near-total and 87% of the subtotal patients. Forty-six percent of the hemithyroidectomy patients suffered temporary hypothyroidism compared to 100% of the near-total and 93% of the subtotal patients. CONCLUSION: Subtotal and near-total thyroidectomies produced a rate of hypothyroidism close to that of total thyroidectomy compared to 28% after hemithyroidectomy. SIGNIFICANCE: Partial thyroidectomies provide no decisive advantage over total thyroidectomies in terms of subsequent requirements of supplemental hormone therapy.     

Endotracheal intubation following thyroidectomy

Thirty-five patients requiring tracheostomy or endotracheal intubation, following thyroidectomy are reviewed. Conditions included 30 patients with multinodular goitre, three patients with Graves's disease and two patients with carcinoma of the thyroid. Early in the series, emergency tracheostomy was performed in three patients with airway obstruction following thyroidectomy. Ten patients were deemed at extremely high risk of developing airway obstruction and underwent prophylactic tracheostomy. Endotracheal intubation has been used in preference to tracheostomy in the latter part of the series. Emergency endoctracheal intubation was performed on one patient and prophylactic intubation was carried out in 20 patients. The morbidity and length of hospital stay in this latter group was considerably less than those requiring tracheostomy. It is concluded that patients with potential airway obstruction following thyroidectomy should have prophylactic endotracheal intubation, in preference to tracheostomy.     

甲状腺术后的甲状腺功能维护

甲状腺功能减退是甲状腺手术最常见的并发症.左甲状腺素钠（L-T4）是治疗甲状腺功能减退的首选药物,甲状腺功能维护可于术后早期进行,L-T4的需要量受多个因素及目标TSH的影响,实施过程中应考虑患者的特殊性（依从性差、妊娠、老年）,并定期（4～6周）复查甲状腺功能,根据目标TSH调整最佳用药剂量,避免治疗不足和治疗过度.T3分次给药或L-T4/T3联合治疗可作为L-T4治疗失败患者的选择.     

Lesser curve necrosis following selective proximal vagotomy--a case report

A case of the lesser curve necrosis following selective proximal vagotomy for a perforated duodenal ulcer is reported. Although little is known of this very rare complication, it is potentially a fatal complication after selective proximal vagotomy. Early recognition and immediate reoperation must be save the life of the patient when this complication is suspected.