Non-intubated combined with video-assisted thoracoscopic in carinal reconstruction

Carinal reconstruction is a difficult technique combined with video-assisted thoracoscopic surgery (VATS). It has a high requirement on the operator''s skills in operating thoracoscope and meanwhile requires the close cooperation from anesthesiologists. Tracheal intubation and ventilator-assisted ventilation are key steps to ensure the success of surgery. However, tracheal intubation itself may influence the exposure of surgical field and increase the difficulty of anastomosis. In close cooperation of anesthesiologists, we did not perform tracheal intubation; rather, we carried out non-intubated complete VATS carinal reconstruction in a patient with adenoid cystic carcinoma (ACC) of the lower trachea. The awake complete VATS carinal reconstruction was successfully performed. The anastomosis lasted about 36 hours, and the whole surgical procedure lasted 230 min. The intraoperative blood loss was about 80 mL. The patient recovered well 100 min after surgery. A semi-solid diet began 6 hours following the surgery. This non-intubated anesthesia method makes the surgery easier, especially during the anastomosis of stumps. It is feasible and safe to apply this anesthesia technique in carinal reconstruction.     

Video-assisted thoracoscopic surgery resection and reconstruction of thoracic trachea in the management of a tracheal neoplasm

Intratracheal tumor is a rare tumor, accounting for only 2% of upper respiratory tract neoplasms. Its symptoms are similar to those of head and neck cancers, including coughing up blood, sore throat, and airway obstruction. The diagnosis of this disease is often based on the findings of fibrobronchoscopy or computed tomography (CT). Surgery remains the treatment of choice for tracheal tumor. In patients with benign neoplasms or if the tumors have limited involvement, fibrobronchoscopic resection of the tumor can be performed. For malignant tumors, however, radical resection is required. In the past, open incision is used during the surgery for tumors located in thoracic trachea. Along with advances in video-assisted thoracoscopic surgery (VATS) minimally invasive techniques and devices, VATS resection and reconstruction of the trachea can achieve the radical resection of the tumor and meanwhile dramatically reduce the injury to the patients. In this article we describe the application of VATS resection and reconstruction of trachea in the management of a tracheal neoplasm.     

Video-assisted transthoracic surgery resection of a tracheal mass and reconstruction of trachea under non-intubated anesthesia with spontaneous breathing

Radical surgery for tracheal tumors is typically completed under basal anesthesia. Thus, endotracheal intubation and mechanical ventilation are required. However, these procedures may influence the surgical operation and meanwhile prolong the surgical duration and postoperative recovery. In this article we describe the application of video-assisted transthoracic surgery (VATS) resection of a tracheal mass and reconstruction of trachea a non-intubated patient with spontaneous breathing.     

A new surgical technique for adenoid cystic carcinoma involving tracheal carina

Reported is the successful treatment of a 24-year-old male with adenocystic carcinoma involving the tracheal carina, in which the tumor extended along the right main bronchus across the orifice of the right upper lobe. The patient underwent a carinal resection plus right upper lobectomy and reconstruction of the carina, resulting in neither anastomotic complication nor recurrence of disease during 28 months of follow-up.     

原发性气管、隆突肿瘤外科治疗48例临床分析

目的总结原发性气管、隆突肿瘤外科治疗经验。方法回顾分析我科2001-2010年手术治疗48例气管、隆突肿瘤的临床资料,气管环形切除＋对端吻合35例,气管＋隆突切除重建12例,气管楔形切除1例;5例术中辅助体外循环。结果无围手术期死亡,临床治愈41例（85.4%）;术后随访7个月-7年,死亡5例（10.4%）,生存至今43例（89.6%）,其中生存5年及以上者9例（18.8%）;5例术中辅助体外循环28~46 min,平均36 min,麻醉满意。结论气管、隆突肿瘤外科手术疗效确切,合理选择手术方式,适当应用体外循环技术可提高手术安全性。     

Video-assisted thoracoscopic right upper lobe sleeve lobectomy combined with carinal resection and reconstruction

We report a case of right upper lobe sleeve lobectomy in combination with carinal resection and reconstruction via video-assisted thoracoscopy surgery (VATS). A squamous cell carcinoma of stage T4N1M0 was identified on pathological examination. The bronchial anastomosis and carinal reconstruction were performed using a running suture with 3-0 prolene and an interrupted suture. The postoperative course was uneventful.     

外科治疗原发性气管肿瘤13例临床分析

目的总结外科手术治疗原发性气管肿瘤的临床经验。方法回顾分析我院1996～2006年13例手术治疗气管肿瘤的临床资料,采用颈领式切口1例,后外侧切口12例;3例患者在体外循环（Cardiopulmonarybypass,CPB）辅助下手术。结果切除长度1～5cm,平均切除气管长度为3．7cm;体外循环时间38～135min,平均76min;术后呼吸困难均有明显好转,围手术期无死亡。讨论气管节段切除手术是治疗气管恶性肿瘤的最有效方法。安全平稳的麻醉至关重要,对于严重梗阻的原发性气管肿瘤患者,应用体外循环（CPB）技术可降低麻醉手术风险,提供清晰术野和手术空间等有利条件,是解决气管切除及气道重建的有效方式。     

Flexible bronchoscopic excision of a tracheal mass under extracorporeal membrane oxygenation

Tracheal tumor is a rare but life-threatening condition that can cause obstruction of the airway. Management of tracheal tumors is very challenging and includes surgical resection, radiotherapy, and therapeutic bronchoscopy. Herein, we present a very rare case of an 88-year-old female patient with a tracheal mass due to direct invasion of a mediastinal teratoma. We devised a new method for resection of the tracheal mass because management of her airway and the tracheal mass by conventional methods was impossible. We successfully resected the tracheal mass with flexible bronchoscopic electrocautery under extracorporeal membrane oxygenation (ECMO) without any complications. When management of a patient’s airway and tracheal mass are impossible by conventional methods, this technique may be very useful.     

Potentially disseminated solitary fibrous tumor of the pleura: a case report

We report a case involving a female patient with frequent relapse, pleural dissemination, and port site recurrence (PSR) of a pleural solitary fibrous tumor (SFT). At the age of 55 years, she underwent tumor resection via video-assisted thoracoscopic surgery (VATS). The tumor arose from the mediastinal pleura; it was 7 cm in diameter and well demarcated. Histological examination showed neither hemorrhage nor necrosis, but moderate cellularity was present, and the Ki-67 labeling index was 15%. Despite complete resection, the tumor relapsed in the ipsilateral thoracic cavity 3 years postoperatively, and thoracoscopic complete tumor resection was performed; however, pleural lavage cytology (PLC) showed the presence of tumor cells. Multiple pleural dissemination and PSR developed 7 years after the initial surgery. The port site recurrent tumor was resected with the intercostal muscle via VATS. This case illustrates that a SFT may disseminate despite the fact that histological examination shows no evidence of malignancy.     

Venovenous extracorporeal membrane oxygenation-assisted tracheobronchial surgery: a retrospective analysis and literature review

BackgroundAirway management in tracheobronchial surgeries, especially carinal resection and reconstruction, remains one of the greatest challenges to thoracic surgeons. This study investigated the safety and effectiveness of venovenous extracorporeal membrane oxygenation (VV-ECMO) for respiratory support during tracheobronchial surgeries.MethodsThe data of patients who underwent VV-ECMO-assisted tracheobronchial surgeries at the Shanghai Chest Hospital from August 2006 to August 2021 were retrospectively reviewed. The clinicopathological, perioperative, and follow-up outcomes were analyzed.ResultsA total of 7 patients (4 males and 3 females) with a median age of 56 years (range, 11–70 years) were included in the study. The following tracheobronchial surgeries were conducted: carinal resection and reconstruction with complete pulmonary parenchyma preservation (n=4), left main bronchus and hemi-carinal sleeve resection (n=1), right upper sleeve lobectomy and hemi-carinal resection (n=1), and tracheal resection and reconstruction (n=1). The mean time on VV-ECMO was 167.7±65.8 min, and the mean operative time was 192.4±55.0 min. The average estimated blood loss was 271.4±125.4 mL. No perioperative death or reimplantation of VV-ECMO occurred. Postoperative complications were observed in 2 patients, including 1 case of respiratory failure due to preoperative severe chronic obstructive pulmonary disease (COPD) and 1 case of chylothorax. The median hospital stay was 11 days (range, 7–46 days). The median follow-up time was 30 months (range, 21–33 months). All the patients remained alive, and no postoperative readmission occurred during the follow-up period.ConclusionsVV-ECMO is a safe and feasible ventilation mode when intraoperative oxygen saturation cannot be well maintained during tracheobronchial surgery.     

Single-port thoracoscopic right main bronchial tumor sleeve resection and secondary carinal reconstruction

We describe herein a case of single-port thoracoscopic right main bronchial tumor sleeve resection and secondary carinal reconstruction. A 66-year-old male patient had a right main bronchial tumor longer than 12 months, who had been received endobronchial cryosurgery twice before. However, the tumor relapsed quickly. Then the patient transferred to our department. He was underwent a single-port complete thoracoscopic right main bronchial tumor sleeve resection and secondary carinal reconstruction. He recovered smoothly, without any perioperative complications. On the 5th postoperative day (POD), he was discharged in good condition.     

Tracheal and laryngotracheal resections and reconstructions—a single-centre experience

BackgroundSurgical resection has proven to be the most effective long-term treatment in managing airway stenoses and has shown to decrease the risk of tumor recurrence and mortality in patients with tumor infiltration to the airways. However, there are only a few Nordic reports on the results of a tracheal resection (TR) and cricotracheal resection (CTR). This study aimed to evaluate the volume and short-term outcome of TR and CTR at our institution.MethodsRetrospective review of patients who underwent TR or CTR between 2004 and 2019 at the Helsinki University Hospital (Helsinki, Finland).ResultsForty-four patients were included, of which 21 (47.7%) underwent surgery for a tumor, whereas 23 (52.3%) were operated for a benign stenosis. The most common tumor type was thyroid carcinoma with tracheal invasion (15.9%). The distance between the upper margin of the stenosis or tumor infiltration and the vocal cords was in median 3 [interquartile range (IQR), 2–5] cm and the median length of resection 2.5 (IQR, 2–3.5) cm. Overall success rate was 75% (no need for reoperation or postoperative intervention). Complications occurred in 20 (45.5%) patients, of which 10 patients were operated for a tumor, and 10 for a benign stenosis.ConclusionsTracheal and CTRs were effective in treating tracheal and subglottic stenoses with variable etiology. However, complications were common especially following cricotracheal tumor resections. These procedures show a clear need for further centralization due to their complex nature and should therefore be performed primarily at institutes with highly experienced multi-professional teams.     

Carinal leiomyoma: report of a case treated by carinal resection and reconstruction

Here, we present a case report on a young female patient with a carinal leiomyoma. The patient complained of progressive dyspnea and paroxysmal cough. The laminagram and bronchoscopy revealed a lobulated carinal tumor, and carinal resection and reconstruction were performed. In this report, we will emphasize the appropriate surgical treatment for this condition.     

Significance of the evaluation of tracheal length using a three-dimensional imaging workstation

BackgroundLimited information is available on the total tracheal length and its other characteristics for tracheal surgery. This study aimed to investigate the reference value of tracheal length and assess its relationship with physiological variables.MethodsWe measured the tracheal length of 215 patients (107 men and 108 women) who underwent contrast-enhanced computed tomography before thoracic surgery using a three-dimensional imaging workstation. Pearson correlation analysis and multiple linear regression analysis were performed to investigate the relationship between the total tracheal length (cervical and thoracic) and common physiological parameters.ResultsThe mean total tracheal length was 11.5±1 cm (range, 8.8–14.4 cm); 8% of the patients had a total tracheal length <10 cm. The cervical trachea was significantly shorter in men than in women (2.9±1.3 vs. 3.8±1.3 cm, P<0.001), whereas the thoracic trachea was significantly longer in men than in women (8.9±1.1 vs. 7.4±1.1 cm, P<0.001). Correlation analysis showed that the total tracheal length was positively associated with height in both sexes, while the height was positively associated with only cervical tracheal length. In the multiple linear regression analysis, the total tracheal length was influenced most by height, while cervical and thoracic tracheal lengths were influenced most by sex. Older age was also an independent contributor to a shorter cervical trachea and longer thoracic trachea in both sexes.ConclusionsThe total tracheal length ranged from short to long in individuals, and characteristics of tracheal length varied with height, age, sex, and part of the trachea. We should thus be aware of the tracheal length of each patient for appropriate tracheal management.     

体外循环辅助下原发性气管肿瘤切除3例临床分析

目的总结体外循环（CPB）下气管肿瘤外科手术治疗的临床经验。方法回顾性分析我院2002～2006年3例经体外循环辅助下切除气管肿瘤的临床资料，其中良性肿瘤1例，恶性肿瘤2例；2例患者经右股动、静脉插管建立体外循环，1例患者开胸经右心房和升主动脉插管；2例患者行气管环形切除、气管断端行端端吻合，1例患者行气管环形切除加肿瘤剔除。结果体外循环时间38-135min，平均76min，术后呼吸困难均有明显好转，平均切除气管长度为3．6cm，围手术期无死亡。结论对于气管严重梗阻的原发性气管肿瘤患者，应用体外循环（CPB）技术可降低麻醉手术风险，提供清晰术野和手术空间等有利条件，是解决气管切除及气道重建的有效方式。     

Resection of the tracheal carina in an eight-year-old child: a case report

An 8-year-old girl, who had been mechanically ventilated for 2 days, was referred to our clinic with total atelectasis of the right lung. Bronchoscopic examination showed an endobronchial mass lesion which was located on the right side of the carina. Carinal resection was performed and the patient was discharged on postoperative day 7. We presented this case report because of the rarity of tracheal tumors in childhood and to discuss the recommended surgical technique for pediatric carinal resection.     

Successful diagnosis and treatment of congenital tracheal web using a fiberoptic bronchoscope

Congenital tracheal web is a very rare abnormality that often manifests as wheezing, dyspnea, and respiratory failure. Misdiagnosis is common. Here we describe the case of a 47‐day‐old female infant who presented after severe, extended coughing. The diagnosis of congenital tracheal web was made following coronal computer tomography (CT) reconstruction and bronchoscopy. The bronchoscope was used to facilitate tracheal expansion. This is the youngest case reported to date to highlight the diagnosis and treatment of a 47 days infant with congenital tracheal web. An infant with tracheal web, a very rare congenital anomaly can be clearly diagnosed by coronal CT reconstruction combined with bronchoscopy. If diagnosed early, the bronchoscope may be used to facilitate tracheal expansion. Pediatr. Pulmonol. 2010; 45:945–947. © 2010 Wiley‐Liss, Inc.     

The treatment of low retrosternal tracheal stenosis in the neonate and small children

In the years 1979 to 1983, 8 infants or small children under 2 years of age were treated for severe low retrosternal (carinal) tracheal stenosis. The etiology was iatrogenic (postintubation) in 7 cases and congenital in one. Low tracheal stenosis was seen in 0.4% of all intubated (1607 patients) neonates during the same time period. In 6 cases of acute obstruction, diagnostic bronchoscopy was used to relieve the stenosis by forcefully dilating the trachea. One patient died and all had severe complications, but 3 children are living and doing well without further treatment. Only short granular retrosternal stenoses appeared to be suitable for violent dilatation, which is indicated if the patient is otherwise facing death due to suffocation. All other operative facilities must be at hand. Resection of low retrosternal trachea under cardiopulmonary bypass was performed in 4 patients - 2 of them had had earlier unsuccessful dilatations. One patient, aged 1.5 months, died. In this case the obstruction extended into both bronchi. Another patient was re-resected with success. The follow-up time of the 3 living patients with resection is already 2.4, 4.5 and 4.7 years respectively. The patients are living a normal life and the anastomoses are growing normally.     

The efficacy of high-frequency jet ventilation on intraoperative oxygen saturation compared to cross-field ventilation in patients undergoing carinal resection and reconstruction

BackgroundCross-field ventilation is used as a conventional choice during carinal resection and anastomosis, but may interfere with surgical procedures. High-frequency jet ventilation (HFJV) allows for control of oxygenation in the open airways; nevertheless, there is a paucity of data to support its benefits versus cross-field ventilation. Herein, we aimed to investigate the efficacy of HFJV on intraoperative oxygen saturation compared with cross-field ventilation in patients undergoing carinal surgeries.MethodsWe conducted a retrospective analysis of 82 adults who underwent carinal resection and reconstruction (CRR) for benign or malignant diseases and received cross-field ventilation or HFJV at Shanghai Chest Hospital between January 2018 and September 2021. Patients were excluded when they had emergency surgeries or critical airway stenosis requiring extracorporeal life support, or limited resection without the need for cross-field ventilation or HFJV. Patients were classified into two groups based on the airway approach: cross-field ventilation group and HFJV group. The primary outcome was the area under the curve (AUC) of intraoperative hypoxemia defined as peripheral oxygen saturation (SpO₂) below 90% lasting at least 1 minute. The secondary outcomes included cumulative time of SpO₂ below 90%, AUC and cumulative time of severe intraoperative hypoxemia (defined as SpO₂ below 80% lasting at least 1 minute), and AUC and cumulative time of suboptimal SpO₂ (defined as SpO₂ below 95% lasting at least 1 minute).ResultsThirty-two patients were included in the final analysis, with 22 patients in cross-field ventilation group and 10 patients in HFJV group. The two groups did not differ in the severity and duration of intraoperative hypoxemia (P=0.366). The median (IQR) AUC of SpO₂ below 90% was 21.92 (4.28, 54.48) min in cross-field ventilation group and 28.93 (10.78, 199.89) min in HFJV group. The cumulative time of SpO₂ <90% was 16.67 (4.46, 37.11) min in cross-field ventilation group and 19.32 (7.50, 121.24) min in HFJV group, without statistical difference between groups (P>0.05). Severe intraoperative hypoxemia did not occur in either group.ConclusionsThis retrospective case series demonstrates that HFJV can be adopted to maintain oxygenation in CRR, without the interruption of surgical procedure.     

Non-intubated resection and reconstruction of trachea for the treatment of a mass in the upper trachea

Tumors of the upper trachea are typically treated by tracheal resection and reconstruction via neck incision under general anesthesia. In recent years, non-intubated thoracic surgery has been widely applied for the treatment of lung diseases due to its advantages including quick postoperative recovery. In this article, we describe the application of non-intubated tracheal resection and reconstruction in one patient for the treatment of a mass in upper trachea.