Anaesthesia and tracheobronchial stenting for central airway obstruction in adults

In the last decade, stents suitable for the management of tracheobronchialstenoses and obstruction have evolved from bulky prosthesesrequiring tracheal resection to small devices that are self-expandingand can be inserted using fibreoptic techniques. The experiencebase for this review is more than 100 patients between 1989and 2001 who have been anaesthetized for stent insertion. Earlycases required rigid bronchoscopy for the routine of insertion.Anaesthetic techniques have evolved from those that were designedand developed for laser surgery in the central airways. Theadvent of modern devices now extends the variety of anaestheticmanagement techniques that can be used. But the original one,based on the requirement for use of a rigid bronchoscope, isbest for dealing with complications and extracting problem stents.The most frequent complication of the processes of stent insertionhas been respiratory failure because of carbon dioxide retention,consequent on obstruction with secretions in the area of thecarina. The nature of central airway problems suggests thatanaesthesia induction, management and teaching should not befounded on the conventional model-base of upper airway obstruction. Br J Anaesth 2003; 90: 367–74     

电视激光硬质气管镜的应用体会

目的 探讨电视激光硬质气管镜治疗大气道内良、恶性肿瘤及外压性恶性狭窄的方法和特点。方法2002年9月至2004年11月，应用电视激光硬质气管镜为13例大气道肿瘤病人进行了15次手术治疗。窄蒂良性肿瘤完全镜下取出；宽蒂或延伸至管壁外者中转开胸手术切除；大气道恶性狭窄者采用放置支架，或用电刀、氩气刀或激光灼烧瘤体使之再通的姑息治疗；可切除的原发气管恶性肿瘤，硬质气管镜作为根治术前的准备。结果良性肿瘤5例次手术：4例镜下完整切除，1例中转开胸切除。恶性肿瘤8例10次手术：3例置入支架，2例姑息切除肿瘤恢复气道通畅，3例开胸完成根治切除吻合。无围术期死亡和严重并发症。结论硬质气管镜对大气道腔内窄蒂良性肿瘤的完整切除、恶性肿瘤所致大气道狭窄的姑息治疗及原发大气道肿瘤开胸治疗的术前准备有较高的临床价值，而且安全、可靠。     

Development of a new insertion technique and a new device for the placement of bifurcated airway stents

We developed a new insertion technique and designed a forceps device for the placement of bifurcated airway stents; 131 of 142 endoscopically placed tracheobronchial Y-stents were inserted with a forceps and a laryngoscope. For the last 52 stent implantations we used the new stent forceps. It was determined to be a simple and safe method without major complications. In 11 cases alternative techniques had to be used. Technique and device are described in detail.     

Management of congenital tracheal stenosis in infancy

Objective: Congenital tracheal stenosis (CTS) is a very infrequent malformation. Till recently, the outlook for these patients was dismal because medical management was the only way of treatment. Surgical and endoscopical techniques developed in the last years have improved the prognosis. We review the short- and long-term outcomes of a single institution experience in the management of children with CTS, comparing different treatment modalities. Methods: Between 1991 and 2004, 19 cases of CTS have been managed in our Unit. Respiratory symptoms varied from mild stridor on exertion to severe distress. Bronchoscopy was performed for diagnostic purposes in all cases; other imaging techniques (computed tomography (CT), magnetic resonance imaging (MRI), bronchography, angiography, doppler-ultrasound) were performed on an individual basis. According to clinical and endoscopical features, patients were classified into three groups. The following data have been studied in each case: sex, age at diagnosis and treatment, anatomical type, associated anomalies, treatment modality, complications, outcome and time of follow-up. Results: Ten boys and nine girls have been included in this study. Age at diagnosis ranged from 3 days to 7 years (median, 4 months) and 84% of cases showed associated anomalies. Five patients presented mild or no symptoms and have been managed expectantly. The other 14 cases were operated on because of persistent or severe clinical symptoms. The following procedures were performed: slide tracheoplasty (n = 7), costal cartilage tracheoplasty (n = 5), tracheal resection and reconstruction (n = 3), endoscopical dilatation (n = 3), stent placement (n = 1), and laser resection (n = 1). Three patients required two or more procedures and surgical survival rate is 78%. Overall mortality in the series is 21% and all survivors (15 patients) are asymptomatic or show mild symptoms with respiratory infections only. Follow-up is complete, ranging from 8 months to 12.3 years (mean, 5 years). Conclusions: Bronchoscopy is our preferred diagnostic tool. Selection of the type of treatment depends on the patient's clinical status and the anatomical pattern of the stenosis. In symptomatic cases with short-segment stenosis (<30% of total tracheal length), we prefer tracheal resection with end-to-end anastomosis; for long-segment stenosis (>30%), slide tracheoplasty is our procedure of choice.     

External fixation of airway stents for upper tracheal stenosis and tracheoesophageal fistula

 Open in a separate windowOBJECTIVESStent migration is a common complication of airway stent placement for upper tracheal stenosis and tracheoesophageal fistula. Although several researchers have reported that external fixation is effective in preventing stent migration, the usefulness and safety of external fixation have not been proved because their cohorts were small. We therefore investigated the efficacy and safety of external fixation during upper tracheal stenting.METHODSRecords of patients who underwent airway stent placement from May 2007 to August 2018 in a single centre were retrospectively reviewed. We included only patients whose stent had been placed in the upper trachea with external fixation to the tracheal wall. The primary endpoint of this study was the rate of stent migration.RESULTSAltogether, 51 procedures were performed in 45 patients (32 males, 13 females; median age 60 years, range 14–91 years). The median follow-up period was 9 months (range 0.3–90 months). Among the procedures, 15 were performed for benign disease and 36 for malignancy. Stents were composed of either silicone (n = 42) or metal (n = 9). Stent migration occurred in 3 (6%) patients. The stents with migration were all composed of silicone. Other sequelae were granulation tissue formation in 10 (20%) patients, sputum obstruction in 6 (12%), cellulitis in 3 (6%) and pneumonia in 1 (2%).CONCLUSIONSExternal fixation was an effective method for preventing migration of airway stents placed for upper tracheal stenosis and tracheoesophageal fistula. The complications were acceptable in terms of safety.     

Therapeutic experience from 1428 patients with pediatric tracheobronchial foreign body

Purpose

Tracheobronchial foreign body (TFB) aspiration is a life-threatening emergency for children. Knowing how to reduce the incidence of complications and mortality during the management of TFB is critically important.

Methods and Patients

Pediatric patients with TFB, who were treated in the Department of Otorhinolaryngology-Head and Neck Surgery, The Affiliated Hospital of Medical College Qingdao University, Qingdao, Shandong Province, China, were included in this analysis during 1985 to 2007. One thousand four hundred twenty-eight patient records with TFB were retrospectively reviewed. This study mainly reported location and type of foreign body, complications, anesthesia methods, and outcome.

Results

Among the 1428 patients, 1424 (99.72%) underwent successful removal of a foreign body by bronchoscopy. First-attempt removal was successful in 1347 whose bronchoscopy was done under general anesthesia combined with topical anesthesia and in 65 cases with inhaled anesthesia by ether combined with topical anesthesia, respectively. Second-attempt removal was successful in 12 patients whose bronchoscopy was done under inhaled anesthesia by ether combined with topical anesthesia. Foreign bodies were located in the trachea in 75 cases (5.25%), right bronchial tree in 780 patients (54.62%), left bronchial tree in 567 cases (39.71%), and bilateral bronchial tree in 6 cases (0.42%). Types of foreign body included peanuts (1244 cases, 87.12%), beans (93 cases, 6.51%), and others (91 cases, 6.37%). Tracheotomy was performed in 4 patients. Three patients (0.21%) died in this study. Four patients developed toxicity from tetracaine during topical anesthesia.

Conclusions

Bronchoscopy under general anesthesia augmented with topical anesthesia is a very safe and effective procedure for patient with TFB. Surgeons and anesthetists must be aware of the risk of tetracaine toxicity and other complications.     

气管支架置入术治疗气管恶性狭窄的并发症分析

目的探讨应用气管支架治疗气管恶性狭窄的并发症。方法回顾性分析1999年11月—2011年6月在局麻和数字减影血管造影机下应用气管支架治疗气管恶性狭窄的25例患者资料,其中6例置入Z型不锈钢支架,19例置入镍钛记忆合金支架,观察支架相关并发症。结果置入Z型不锈钢支架的6例患者中,所有支架置入后即刻完全扩张,2例出现支架移位,随访期中支架再狭窄3例,其中肿瘤增生性狭窄1例,黏稠痰液阻塞性狭窄1例,支架断裂伴肉芽增生性狭窄1例;置入镍钛记忆合金支架的19例患者中,术中无支架移位,2例即刻完全扩张,17例术后3天～3个月扩张完全,随访期内支架再狭窄2例,其中肿瘤增生性狭窄1例,肉芽增生性狭窄1例。所有患者术后呼吸困难即刻明显改善。结论应用气管支架治疗气管恶性狭窄有一定并发症,但仍是一种作用迅速、效果显著的治疗措施。     

血管内支架成形术治疗颅外颈动脉狭窄

目的　评价颅外颈动脉狭窄支架成形术的安全性及近期疗效。　方法　 2 0 0 0年 10月～ 2 0 0 2年 12月共收治颈动脉狭窄 16 4例 ,其中颅外分叉部颈内动脉狭窄 14 6例 ,单纯颅外段颈内动脉狭窄 13例 ,单纯颈总动脉狭窄 5例 ,采用自膨胀支架进行血管成形治疗。　结果　 16 4例支架植入均获得成功 ,血管狭窄程度从治疗前 (78 8± 13 6 ) %降低到 (10 2± 7 5 ) % ,围手术期无死亡及大卒中发生 ,1例出现短暂性脑缺血发作 (Transientischemicattack ,TIA) (0 6 % ) ,1例出现小卒中 (0 6 % )。14 5例获得随访 ,时间 3月～ 30月 (平均 8 9月 ) ,随访期间无TIA及卒中发生 ,无死亡。术后 6月数字减影脑血管造影随访 4 5例 ,再狭窄 1例 (2 2 % ) ,但无临床症状。　结论　血管内支架成形术是治疗颈动脉狭窄安全而有效的方法 ,短中期结果令人满意。     

肺移植术后气道吻合口狭窄的原因和治疗

目的探讨肺移植术后气道吻合口狭窄的原因及预防和治疗方法。方法2003年1月至2005年8月，对11例重度肺气肿患者成功地实施了同种异体单肺移植手术，9例存活良好，气道吻合均采用端端支气管吻合（膜部连续软骨部间断缝合）方法。术后有4例发现霉菌感染以及其中2例出现支气管吻合口狭窄。结果2例分别于术后1个月、7个月发现支气管吻合口狭窄，置人镍钛网状支架后症状改善。结论气道吻合口狭窄与支气管缺血、霉菌感染以及吻合技术等多方面因素有关。气道支架置人治疗吻合口狭窄效果显著。     

Novel tubeless supraglottic ventilation in a difficult paediatric airway

Introduction

Discussion and careful planning are essential between surgeon and anaesthesiologist before upper airway surgery, especially in paediatric patients with upper airway obstruction. Tubeless supraglottic ventilation is an accepted technique worldwide.

双气道喉管用于中心气道狭窄气管支架置入术的效果

目的 评价双气道喉管用于中心气道狭窄气管支架置入术的效果。
方法 选择择期行中心气道狭窄气管支架置入术患者42例,男28例,女14例,年龄18~64岁,ASA Ⅱ或Ⅲ级。采用随机数字表法分为两组：双气道喉管组（D组）和普通喉罩组（C组）,每组21例。麻醉诱导后,D组、C组分别置入双气道喉管和普通喉罩,行机械通气。记录麻醉诱导前（T1）、置入喉管/喉罩开始通气时（T2）、手术开始（T3）、支架置入时（T4）及术毕停止麻醉药后5 min（T5）的MAP、HR和SpO₂。分别于支架置入前和置入后抽取动脉血样行血气分析,记录pH值、PaO₂和PaCO₂。记录手术时间和支架置入调整例数。记录气管黏膜损伤、术后声嘶和术后咽痛的发生情况。
结果 T1—T5时两组MAP、HR和SpO₂差异无统计学意义。与C组比较,D组支架置入后pH值、PaO₂明显升高,PaCO₂明显降低,手术时间明显缩短,支架置入调整例数明显减少,气管黏膜损伤、术后声嘶和术后咽痛发生率明显降低（P<0.05）。
结论 双气道喉管用于中心气道狭窄气管支架置入术,可有效减少并发症的发生。     

喉罩应用于瑞芬太尼静脉麻醉下气管狭窄的介入手术

目的：观察瑞芬太尼维持麻醉下喉罩在支气管镜下气管狭窄介入手术的应用情况。方法选择限期或急诊行气管狭窄介入手术患者29例,瑞芬太尼和异丙酚麻醉下置入喉罩,观察整个麻醉和手术过程中的平均动脉压（MAP）、心率（HR）、气道压变化、清醒时间和拔管时间,以及是否存在通气不良、缺氧、呛咳、体动及咽痛等其他不良反应。结果插管前后平均动脉压明显降低,分别为（85．8±21．6）mmHg 和（78．0±20．3）mmHg,P ＜0．05;心率无明显变化,分别为（89．9±25．4）次／min和（92．1±21．7）次／min。拔管期间均未见平均动脉压和心率明显变化,治疗前后气道压明显降低,分别为（22．5±03．81）cmH2 O 和（19．90±3．00）cmH2 O,清醒时间和拔管时间平均在（13．40±4．39）min。1例因患者气道压过高,超过喉罩的漏气压发生漏气,12人拔管后感觉咽痛。结论瑞芬太尼维持麻醉下喉罩应用于气管狭窄介入手术心血管刺激小、通气效果良好,适合高风险的患者,但仍有漏气的风险及咽痛的不适。     

全身麻醉下气管支架植入术治疗恶性气管狭窄

目的评价全身麻醉下气管支架植入术治疗恶性气管狭窄的疗效。方法选择因恶性肿瘤致气管狭窄、中、重度呼吸困难患者17例,行全身麻醉及气管插管,于DSA监视下经气管套管植入镍钛记忆合金支架。结果全部病例均成功植入支架,呼吸困难症状立即得到改善。随访3～24个月,支架无移位,气管通畅,患者无明显疼痛及异物感。结论全身麻醉下气管支架植入术治疗恶性气管狭窄安全、快捷、有效,患者痛苦小,可为后续治疗提供条件。     

Acute colonic obstruction: endoscopic stenting and laparoscopic resection

Introduction Acute colonic obstruction is a frequent emergency condition in a general surgical setting. The use of an endoscopic self-expanding stent can relieve obstruction and eventually prepare the patient for elective laparoscopic or open surgery. Materials and Methods From September 2001 to March 2006 we treated 25 patients with acute left or transverse colonic obstruction. In 23 patients stents were positioned planning an elective procedure to be performed. In two patients with multiple liver metastases and malignant ascites only a palliation was intended (2 of 25 patients). Results Mean age was 66.6 years. The 23 patients who underwent resection, 14 females and nine males, had a mean age of 65.5 years. Obstructions were located in the rectum (five), in the sigmoid (16) and in the transverse colon (two). In one patient stricture was due to radiotherapy, in twenty four cases it was due to primary cancer. Stents were successfully placed in 24 patients. In one of them two stents had to be placed due to the slippage of the first one beyond the stricture. Excellent resumption of colonic transit was achieved in all the patients. No complications were observed. In 23 patients resection was performed (19 laparoscopy; four open). Complications occurred in one patient in open group (pancreatic fistula after splenectomy) and was treated conservatively. Mean postoperative stay was 18.5 (range 9–35) days for the open group and 12 (range 9–20) for the laparoscopic group. Mean follow-up was 36 months. Conclusions use of self expanding endoscopic colonic stents can provide excellent palliation in acute obstruction, aiming both to prepare the colon to elective surgery after adequate preparation or to palliate the stricture in case of unresectable advanced tumors.     

先天性气管狭窄介入治疗后再狭窄的外科手术治疗9例临床分析

目的探讨对曾接受反复球囊扩张或金属支架置入的先天性气管严重狭窄患儿行手术治疗的经验。方法回顾性分析9例曾接受反复球囊扩张(>3次)或气管内置入金属支架治疗, 后因狭窄症状明显于2017年2月至2021年7月在山东大学齐鲁儿童医院心脏外科接受手术治疗的先天性气管狭窄患儿的临床资料。男7例, 女2例。中位手术年龄72.4个月(范围:13.3～98.9个月), 中位体重19.0 kg(范围:9.0～33.0 kg)。9例患儿均有完全性气管软骨环及长段狭窄。2例患儿分别在本次手术17.8、51.8个月前开始接受反复球囊扩张(均>3次);7例患儿曾接受金属支架置入, 距首次置入金属支架时间1例患儿为4 d, 另6例患儿中位时间为56.8个月(范围:21.6～74.2个月)。9例患儿均行Slide气管成形术。结果 Slide气管成形术均顺利完成。2例反复球囊扩张患儿, 术中见气管壁厚薄不一、局部瘢痕增生、管腔不规则, 其中1例气管壁局部明显钙化, 缝合难度较大。7例支架置入患儿, 1例因支架置入时间短, 完整取出支架, 其余6例因支架置入时间长仅能取出部分金属支架。本组患儿无手术死亡,...