Bougienage and balloon dilation using a conventional tracheal tube for tracheobronchial stenosis before stent placement

In order to achieve urgent restoration of the airways in tracheobronchial stenosis and to make stent placement simpler and safer, we developed a method that allows combined bougienage and balloon dilation via the use of a conventional tracheal tube. Fifteen patients with tracheobronchial stenosis underwent bougienage and balloon dilation using a tracheal tube with a cuff attached, inserted via a tracheostomy, before stent placement. The conventional tracheal tube was inserted via a tracheostomy, the cuff was expanded at the stenotic site, and the tube was fixed to the tracheostomy and left in place for a few days until sufficient dilation was achieved. This procedure was conducted on the trachea in 10 patients, the left main bronchus in three patients, and the right main bronchus in two patients. In all patients, the procedure immediately relieved the obstructive symptoms and dilated the stenosis sufficiently. Thereafter, Dumon stents were inserted in 10 patients, dynamic stents in four patients, and an expandable metallic stent in one patient. The stents were introduced easily with no other dilation procedure after a mean of 5 days from the start of the procedure. For tracheobronchial stenosis, bougienage and balloon dilation using a tracheal tube with an integral cuff via a tracheostomy is a simple and safe method for achieving both urgent relief of airway stenosis and dilation before stent placement. Received: 20 May 1999/Accepted: 17 December 1999/Online publication: 25 April 2000     

Anesthetic management in ten cases for tracheobronchial Dumon stent placement

BACKGROUND: To determine perioperative complications, we evaluate herein 10 cases of anesthetic management for placement of Dumon stent in patient with tracheal or bronchial stenosis due to invasion of esophageal or lung cancer. METHODS: After sufficient oxygenation, anesthesia was induced with propofol and fentanyl. Since muscle relaxant has been considered safe for central-type air way stenosis except for cases involving large anterior mediastinal masses, we administered vecuronium for all cases to facilitate insertion of rigid bronchoscope and for surgical procedures. Anesthesia was maintained with continuous infusion of propofol, and ventilation was performed via a side-port of a rigid bronchoscope with 100% oxygen. Extra corporeal circulation was instituted in 2 cases. RESULTS: In 5 of the 10 cases, stent placement was uneventful. However, in the other 5 cases, respiratory failure (SpO2 < 90% and/or PaCO2 > 80 mmHg: 4 cases) or severe hypotension (systolic blood pressure < 60 mmHg: 3 cases) developed. Severe hypotension was attributed to relatively higher dose of anesthetic agents for cachexic status, or reduction in venous return following over-inflation of the lungs. Acute reduction in blood carbon dioxide levels due to extracorporeal circulation (case 4), and loss of consciousness after administration of anesthetic agents (case 2) could also have been involved in 2 cases. CONCLUSIONS: Circulatory status must be closely monitored during anesthetic management for Dumon stent placement.     

Anesthetic management of two patients with insulinoma using propofol--in association with rapid radioimmunoassay for insulin

We experienced anesthetic management of two patients with insulinoma in whom frequent hypoglycemic episodes with blood glucose levels of 39-42 mg.dl-1 had been observed. Each patient received epidural analgesia with a catheter inserted at the T 9/10 intervertebral space. Anesthesia was induced with propofol 80-100 mg and fentanyl 200 micrograms. Tracheal intubation was facilitated with vecuronium 6 mg. Anesthesia was maintained with continuous infusion of propofol and epidural anesthesia. Rapid measurements of immunoreactive insulin (IRI) were useful for localization of insulinoma during surgery. Perioperative plasma glucose levels could be maintained within normal ranges by continuous infusion of glucose. Rebound hyperglycemic episodes were not observed, and IRI was reduced after removal of the insulinoma. General anesthesia using propofol and epidural block is a useful choice for the anesthetic management of patients undergoing an operation for removal of an insulinoma.     

Endobronchial stenting as a palliation for advanced esophageal cancer.

Three cases of airway invasion of esophageal cancer treated palliatively by endobronchial stenting are reported. In case 1 (a 60-year-old male) expandable metallic stents were inserted into the totally occluded left main bronchus. In case 2 (a 45-year-old male) a Dumon stent was inserted into the totally occluded left main bronchus. Both patients recovered from performance status 4 to performance status 1 or 0 and were in good condition before they died of cancer, 150 and 54 days after stenting in cases 1 and 2, respectively. In case 3, a Dumon stent was inserted into the left main bronchus before total occlusion. The patient recovered from performance status 3 or 2 to performance status 1 or 0 and survived 40 days after stenting with no signs of airway obstruction. Endobronchial stenting is a useful palliation for keeping the performance status at a good level in patients with esophageal cancer obstructing or narrowing the main airway.     

Endobronchial stenting as a palliation for advanced esophageal cancer

Three cases of airway invasion of esophageal cancer treated palliatively by endobronchial stenting are reported. In case 1 (a 60-year-old male) expandable metallic stents were inserted into the totally occluded left main bronchus. In case 2 (a 45-year-old male) a Dumon stent was inserted into the totally occluded left main bronchus. Both patients recovered from performance status 4 to performance status 1 or 0 and were in good condition before they died of cancer, 150 and 54 days after stenting in cases 1 and 2, respectively. In case 3, a Dumon stent was inserted into the left main bronchus before total occlusion. The patient recovered from performance status 3 or 2 to performance status 1 or 0 and survived 40 days after stenting with no signs of airway obstruction. Endobronchial stenting is a useful palliation for keeping the performance status at a good level in patients with esophageal cancer obstructing or narrowing the main airway.     

Sequential Stenting for Extensive Malignant Airway Stenosis

Purpose: Malignant airway stenosis extending from the bronchial bifurcation to the lower lobar orifice was treated with airway stenting. We herein examine the effectiveness of airway stenting for extensive malignant airway stenosis.Methods: Twelve patients with extensive malignant airway stenosis underwent placement of a silicone Dumon Y stent (Novatech, La Ciotat, France) at the tracheal bifurcation and a metallic Spiral Z-stent (Medico’s Hirata, Osaka, Japan) at either distal side of the Y stent. We retrospectively analyzed the therapeutic efficacy of the sequential placement of these silicone and metallic stents in these 12 patients.Results: The primary disease was lung cancer in eight patients, breast cancer in two patients, tracheal cancer in one patient, and thyroid cancer in one patient. The median survival period after airway stent placement was 46 days. The Hugh–Jones classification and performance status improved in nine patients after airway stenting. One patient had prolonged hemoptysis and died of respiratory tract hemorrhage 15 days after the treatment.Conclusion: Because the initial disease was advanced and aggressive, the prognosis after sequential airway stent placement was significantly poor. However, because respiratory distress decreased after the treatment in most patients, this treatment may be acceptable for selected patients with extensive malignant airway stenosis.     

Anesthetic management of tracheobronchial stent insertion in patients who underwent laser resection, balloon dilatation and tracheostomy in advance

BACKGROUND: We report successful management of tracheobronchial stent insertion under general anesthesia. METHODS: In thirty-two cases, tracheobronchial stent insertion was performed under general anesthesia. The technique for airway management was chosen depending on the type of stent or the constriction level of the airway portion. We employed tracheostomy in order to avoid repeated intubations during the insertion of Dumon or Dynamic stent. In case of severe airway stenosis, laser resection or balloon dilatation was performed before stent insertion. RESULTS: We had 32 successful cases in 36 trials. Four trials failed due to insufficient expansion in one, mismatches of stent angle in one and pneumomediastinum in one. There was no exacerbation of respiratory condition in failed cases. There was no case who needed percutaneous cardiopulmonary support system. CONCLUSIONS: We managed tracheobronchial stent insertion under general anesthesia. Both the airway expansion by laser resection or balloon dilatation before stent insertion and also the insertion of Dumon or Dynamic stent through a tracheostomy were helpful strategies. These techniques facilitated more definitive airway maintenance and stable anesthetic management.     

Dexmedetomidine is a useful concomitant anesthetic agent for perioperative management during tracheobronchial Dumon stent surgery

We treated 2 patients, 1 undergoing placement and 1 removal of a tracheobronchial Dumon stent, both of whom required preservation of spontaneous breathing during the perioperative period to avoid life-threatening hypoxemia, with dexmedetomidine (DEX) as an anesthetic adjunct. In both cases, anesthesia was induced with 6 microg x kg(-1) x hr(-1) of DEX for 10 minutes and then maintained at 0.4-0.8 microg x kg(-1) x hr(-1), along with a target controlled infusion of propofol combined with intermittent administrations of low-dose fentanyl. Muscle relaxants were avoided and spontaneous breathing was preserved throughout the surgical procedures. The airway was secured using a rigid bronchoscope specific for a Dumon stent procedure. No rescue device, such as high frequency jet ventilation or a percutaneous cardiopulmonary support system, was needed. The perioperative courses were uneventful without any pulmonary or cardiovascular complications. DEX has potent sedative, amnesic, and analgesic properties with a low respiratory depressant effect. Therefore, it is considered useful as a concomitant anesthetic agent for perioperative management of patients who require preservation of spontaneous breathing.     

Granulation stenosis caused by a Dumon stent placed for endobronchial tuberculous stenosis

Two patients with cicatric tracheobronchial stenosis caused by tuberculosis who suffered granulation stenosis after placement of a Dumon stent are reported. Dumon stents, which were long enough to cover the stenotic sites, were placed in the trachea and left main bronchus of each patient. Granulation tissue grew at both edges of the stent 3 or 4 months after stent placement, which caused restenosis and necessitated removal of the stents. The authors conclude that a Dumon stent for treatment of tracheobronchial stenosis caused by tuberculosis can cause granulation stenosis at the edges of the stent.     

Tracheobronchial amyloidosis treated with rigid bronchoscopy and stenting

Tracheobronchial amyloidosis (TBA) is an uncommon disease that can cause airway obstruction. We present a case of TBA in a 20-year-old man that was treated successfully with rigid bronchoscopy and stenting. The patient presented with progressive dyspnea despite having had a tracheostomy fashioned at another institution. Airway obstruction secondary to TBA was found distal to the tracheostomy. The amyloid protein subtype was AA, which is uncommon and is seldom of clinical significance in the respiratory tract. The patient underwent rigid bronchoscopy to remove the amyloid protein causing the airway obstruction. A Dumon silicone stent was then inserted to alleviate the obstruction. Thereafter, he recovered well and was discharged without a tracheostomy. This report shows that in patients with TBA causing airway obstruction, excellent results can be obtained with rigid bronchoscopy and stenting of the obstructing lesion.     

Cricoarytenoid arthritis diagnosed after tracheostomy in a rheumatoid arthritis patient

A 65-year-old woman was scheduled for total knee replacement. She had been suffering from rheumatoid arthritis for 22 years. She also had a history of occasional acute dyspnea, which had been diagnosed as asthmatic bronchitis. Preoperative examinations of the airway revealed limited neck flexion, a small jaw, and normal mouth opening. After epidural catheterization, anesthesia was induced with propofol, and a #3 laryngeal mask airway (LMA) was inserted. However, her lungs could not be ventilated through the LMA. Despite repeated attempts, proper placement of the LMA could not be achieved. Hence, a 7.0 mm ID armored endotracheal tube was inserted through an intubating LMA. Anesthesia was maintained with nitrous oxide and sevoflurane in oxygen. The surgery proceeded uneventfully. Five minutes after extubation, inspiratory dyspnea occurred. The patient's trachea was re-intubated nasally with a bronchofiberscope. Since the bronchofiberscopy revealed remarkable laryngeal edema, percutaneous tracheostomy was performed. On the 3 rd postoperative day, cricoarytenoid arthritis that had caused occasional airway obstruction was diagnosed, although her laryngeal edema disappeared. She went home with a permanent tracheostomy. Although cricoarytenoid arthritis is a common occurrence in patients with rheumatoid arthritis, the diagnosis can be difficult. A scrupulous preoperative evaluation and awareness of cricoarytenoid arthritis are necessary for optimal anesthetic management.     

Operative and non-operative treatment of benign subglottic laryngotracheal stenosis.

OBJECTIVE: Surgery is the first line of treatment for laryngotracheal stenosis; Montgomery tube or permanent tracheostomy have been so far the only alternatives. Nd-YAG laser resection and indwelling endotracheal stents have rarely been used in subglottic stenosis for anatomic and technical reasons. We have used the latter approach to optimize the timing of surgery or to achieve palliation without tracheostomy. METHODS: Between 1991 and 2001 we have treated 18 patients with subglottic stenosis (10 males, 8 females; age range 14-78, mean 34). The upper margin of the stricture was 2mm to 1cm below the vocal cords; the stenotic segment extended from 1.5 to 5 cm. Three patients had tracheostomy done elsewhere. Four patients (Group I) had laser and stenting by a Dumon prosthesis as the only treatment; six had laser and stenting (#4) followed after 1-6 months by laryngotracheal resection (Group II); eight had surgery alone (Group III). RESULTS: In Group I, one patient required repositioning of the stent and in two the stent was removed; two patients died of their underlying disease; at a follow-up of 2-9 years all living patients did well but required permanent aerosolized therapy and periodical bronchoscopy. In Group II, we had two wound infections due to airway colonization by staphylococcus aureus. In Group III, two patients developed anastomotic postoperative stenosis, treated by laser (#2) and stenting (#1), and one patient with previous tracheostomy had a wound infection. Overall, in the 14 surgical patients (Groups II and III) stenosis occurred in 14.2% and infection in 21.3%. After a follow up of 15 months to 12 years, all surgical patients breathe and speak well. CONCLUSIONS: Laser resection and endoluminal stenting can be a viable alternative to surgery or optimize the timing of operation in patients with subglottic stenosis.     

Anesthetic management of MIDCAB in a patient with Wolff-Parkinson-White syndrome

We experienced the anesthetic management of a minimally invasive direct coronary artery bypass (MIDCAB) in a patient with Wolff-Parkinson-White (WPW) syndrome. A 55-year-old male had chest pain on effort and was diagnosed as having stenosis of the left coronary artery (#6). He was scheduled to undergo MIDCAB. Anesthesia was induced with midazolam 5 mg, fentanyl 300 micrograms, and vecuronium 10 mg and maintained with air-oxygen, propofol, and fentanyl (27 micrograms.kg-1). Diltiazem was continuously infused at a rate of 0.5-1.5 micrograms.kg-1.min-1 throughout the surgery. The hemodynamic parameters were maintained stable and paroxysmal supraventricular tachycardia was not observed during the procedure. We conclude that the administration of propofol and a medium dose of fentanyl is useful for the anesthetic management of MIDCAB in patients with WPW syndrome and that intraoperative administration of diltiazem might be needed to avoid paroxysmal supraventricular tachycardia.     

Anesthesia for insertion of a Dumon stent in a patient with a large tra-cheo-esophageal fistula

PURPOSE: To present the anesthetic management for the insertion of a Dumon silicon stent to the trachea of a patient with a large tracheo-esophageal fistula. The aim of the stent insertion was to seal the fistula in order to prevent aspiration of esophageal content and subsequent pneumonitis. CLINICAL FEATURES: A 45-yr-old man with a large tracheo-esophageal fistula was scheduled for the insertion of the Dumon stent. Since placement of the stent necessitates the insertion of a rigid bronchoscope, under general anesthesia, with its tip just proximal to the fistula, controlled ventilation was expected to be difficult to achieve because of the diversion of oxygen through the large fistula to the esophagus. We successfully ventilated the lungs, after the fistula was sealed using a large balloon which was inserted in the esophagus, and the stent insertion was completed uneventfully. CONCLUSION: Anesthesia for procedures involving the central airway is challenging. This report describes a simple and practical method to facilitate ventilation by temporary seal of a tracheo-esophageal fistula using a modified esophageal balloon.     

Propofol anesthesia for a patient with congenital myotonic dystrophy]

We report the anesthetic management for a five year old boy with congenital myotonic dystrophy. The patient was scheduled for bilateral orchiopexy under general anesthesia. Anesthesia was induced with fentanyl 50 micrograms, vecuronium 0.6 mg and propofol 40 mg intravenously to facilitate tracheal intubation. During operation, we monitored train of four ratio (TOF) to confirm effect of muscle relaxation. Anesthesia was maintained with propofol (2 mg.kg-1.hr-1), nitrous oxide and caudal block. At the end of the operation, the patient recovered smoothly from anesthesia and post-operative course was uneventful. Congenital myotonic dystrophy presents many problems for the management of general anesthesia, because of respiratory or circulatory complications. In this case, we were careful not to use drugs which may cause respiratory or circulatory depression. We have demonstrated that anesthesia with propofol is a safe method for the anesthetic management of a patient with this disease.     

Anesthetic management of tracheobronchial stent insertion and extracorporeal lung assist (ECLA)

We experienced eight cases of general anesthesia for tracheobronchial stent insertion. All stents were Ultraflex stent (Boston Scientific, Tokyo), and they were inserted guided by bronchofiberscopy under general anesthesia. Anesthesia was induced with patients under spontaneous breathing, and we inserted a tracheal tube or a laryngeal mask airway. Anesthesia was maintained with propofol and sevoflurane. In four cases with severe tracheobronchial stenosis, we used venovenous extracorporeal lung assist (ECLA) before general anesthesia induction. Oxygenation during stent insertion was well-maintained in all patients. We must evaluate the severity of tracheobronchial stenosis preoperatively. In high risk cases anticipated of airway obstruction, ECLA should be used for safe anesthetic management.     

Urologic complications of laparoscopic radical hysterectomy and lymphadenectomy

Introduction and hypothesis

The purpose of this study was to evaluate the intra- and postoperative urologic complications and management in patients with cervical or endometrial cancer treated with laparoscopic radical hysterectomy and lymphadenectomy.

Methods

We retrospectively reviewed the medical records of 146 patients with cervical or endometrial cancer who underwent total laparoscopic radical hysterectomy with lymphadenectomy between August 2002 and April 2011. The intra- and postoperative urologic complications were analyzed.

Results

Double ureteral stents were inserted prophylactically in 13 patients (8.9?%), 2 of whom had postoperative urologic complications. Nine patients (6.2?%) had postoperative urologic complications. Of four patients with ureterovaginal fistulas, two were treated conservatively with cystoscopic placement of ureteral stents and two underwent ureteroneocystostomies. Vesicovaginal fistulas occurred in two patients, both of whom underwent vesicovaginal fistula repairs. One patient noted to have a bladder injury intraoperatively had a laparoscopic repair, and one patient noted to have a ureteral injury postoperatively was treated conservatively with cystoscopic placement of ureteral stents.

Conclusions

Iatrogenic lower urinary tract injuries during laparoscopic radical hysterectomy are relatively common complications. Intraoperative prophylactic ureteral stent insertion and the early detection of urologic complications postoperatively is advised for patients who undergo laparoscopic radical hysterectomies.     

Anesthetic management of a child with myotubular myopathy who underwent two operations under total intravenous anesthesia (TIVA)

We present a case of anesthetic management in a child with myotubular myopathy. A 3-month-old, 3.0 kg, male patient, who had been suspected of a congenital myopathy, was scheduled for the muscle biopsy. He was intubated at birth in NICU. Anesthesia was induced with propofol and remifentanil, and maintained with propofol and remifentanil. The results of biopsy and gene analysis led to the diagnosis of myotubular myopathy. Five months later, this 8-month-old, 4.0 kg, patient was scheduled for the tracheostomy. Anesthesia was induced with propofol, fentanyl and rocuronium bromide, and maintained with propofol and fentanyl. The child underwent two operations under total intravenous anesthesia (TIVA) with propofol and fentanyl or remifentanil. These anesthetic courses were uneventful without symptoms of malignant hyperthermia nor propofol infusion syndrome. We did not use sugammadex, because there is still no evidence to the safe use of sugammadex in infants (aged 28 days-23 months). Congenital myopathy is related to malignant hyperthermia, and total intravenous anesthesia (TIVA) is a preferable and safe method for children with this disease.     

Use of silicone stents in the management of airway problems

We report the use of a silicone rubber T tube for the management of complex airway problems in 47 patients during the past 15 years. The tube has been used for palliation in 11 patients with malignant obstruction of the airway, and as the sole treatment or as an adjunct to operation in 36 other patients. Based on the satisfactory results with the use of these tubes, we have utilized silicone stents in the bronchus and bifurcation prostheses at the carina. In the past, we have inserted the T tubes through a tracheostomy stoma. More recently, we have used a technique for endoscopic placement of the T tubes in which the horizontal limb is pulled out through the tracheostomy stoma. This technique facilitates introduction of the tube and maintains the airway during insertion. The use of silicone stents provides an important tool in the management of complicated airway problems, and we anticipate their increased use in the future.     

Anesthetic management of laser surgery with bronchial stenting for a tracheal tumor

Anesthetic management during surgery for a tracheal tumor is extremely difficult in terms of airway management. We managed a patient with a tracheal tumor who was successfully treated without complication. The trachea of a 66-year-old woman was narrowed by a tumor to one-third of its original diameter, for which Nd-YAG laser surgery with insertion of an intratracheal Dumon stent was performed. Anesthesia was maintained with neuroleptanalgesia using fentanyl and droperidol, supplemented with a TCI infusion of propofol under spontaneous breathing. High frequency jet ventilation (HFJV) was prepared for intraoperative poor oxygenation and/or ventilation. The patient was able to maintain a good respiratory condition throughout the operation without special respiratory support, including use of HFJV. We conclude that the maintenance of spontaneous breathing is essential for anesthetic management in the present case, while an intraoperative airway strategy based on the preoperative breathing condition of the patient is also important.