This study was approved by the First Hospital of Guangzhou Medical University Research Ethics Committee, and written informed consent was waivered. This article adheres to the applicable Consolidated Standards of Reporting Trials (CONSORT) guidelines. We retrospectively collected and reviewed medical records of all patients treated at our hospital from 2018 to 2020, who were diagnosed with tracheal stenosis, who underwent TRR and for whom the initial strategy was spontaneous ventilation, without main bronchial sleeve and carina resections.
When a patient came to our hospital and was suspected of having tracheal stenosis, a high-resolution computerized tomography (CT) scan of the neck and upper thorax were performed. Tracheal lesions were evaluated in computed tomography images. Examination with a fiber optic bronchoscope (FOB), biopsies and histological diagnosis were carried out in all patients except those with iatrogenic subglottic tracheal stenosis. If there was more than 70–80% obstruction of the trachea along with aggravation of exertion dyspnea, intervention dilation or laser coagulation through FOB was used preoperatively.
After stricter patient selection, intraoperative management of the patients was provided by an experienced anesthesiologist. Routine cardiac and pulmonary functions were evaluated carefully, and a multidisciplinary consultation was held to assess risks and benefits, coexisting medical conditions and the preoperative situation. Careful choreographing of each step and efficient teamwork between anesthesiologists, operating room (OR) staff and surgeons are absolutely necessary.
For selected patients the standard monitors were placed, bispectral index (BIS) was used to monitor anesthetic depth to maintain adequate sedation levels, a central venous line (in cases in which the need for potent vasoactive drugs is anticipated, the subclavian or internal jugular approach was optional and should be away from the surgical field) and an intra-arterial catheter (preferably in the left radial artery, for hemodynamic changes and arterial blood gas monitoring) also needed to be made available for this operation.
Epidural anesthesia, thoracic paravertebral block or intercostal nerve blocks were performed. After thoracic epidural catheterization, anesthesia was induced with target-controlled infusion (TCI) of propofol. A laryngeal mask airway (LMA) or well-lubricated endotracheal tube was placed according to standard technique. The choice of airway device was reviewed.
A vagal block was performed adjacent to the vagus nerve at the level of the lower trachea for right-sided operations and at the level of the aortopulmonary window for left-sided operations. Topical lidocaine was applied to the surface of the lung before surgery under direct thoracoscopic vision.
All those patients we focused on were treated by tracheal resection with end-to-end anastomoses, which was mainly divided into three distinct phases: the dissection phase, the resection phase (incision/ resection and reanastomosis of the airway) and the closure phase. Normally, spontaneous respiration was maintained before completion of the anastomosis. To surgeons, “tubeless” means tubeless in the resection phase under stable spontaneous ventilation. During the resection and reconstruction phases, supplemental oxygen was provided via the airway device to maintain an adequate oxygenation supply. If spontaneous respiration failed to provide adequate ventilation, airway management would be changed to conventional airway management approaches and traditional ventilation models, and crossfield intubation or high frequency ventilation (HFV) would be used. We reviewed the device failure rate.
Patient demographics, etiology, location and morphology of the stenotic area, preoperative treatment, airway device and device failure, functional status, anesthetic management, medical therapy, hemodynamic measurements, clinical course and outcomes, blood chemistry, and capillary blood gas analysis were reviewed.
Normally-distributed data were expressed as mean ± standard deviation. Non-normally distributed data were expressed as median and interquartile range. Data analysis was performed using SPSS version 22.0 (SPSS, Inc, IBM Inc., Armonk, NY, USA).
Anesthetic agents were almost the same for intravenous analgesia and sedation. Anesthesia was maintained with propofol (target plasma concentration of 1.5–2.5 µg/mL), dexmedetomidine 0.5–1 µg/kg/h, and remifentanil 0.01–0.05 µg/kg/min. In these procedures, anesthetists try to reduce neuromuscular blockade, but not stop it completely. A small dose of muscle relaxant was chosen in several patients with diaphragmatic contraction and pendelluft. We tested the ability to ventilate spontaneously after each administration until the ventilation and surgical field was balanced. The patient was ventilated with 100% oxygen via the airway device under spontaneous breathing, the dosage is presented in Table 2. Furthermore, dopamine, or norepinephrine was used to maintain cardiac output and systemic blood pressure perioperatively. Unfortunately, we did not record the rate of cough reflex and that will be our focus in the future.
Thoracic epidural anesthesia (TEA) or other local anesthesia was administered in the operation room before anesthesia induction. The choice of local anesthetic is presented in Table 2. Epidural anesthesia, thoracic paravertebral block or intercostal nerve blocks were performed, and vagal block was performed adjacent to the vagus nerve at the level of the lower trachea for right-sided operations and at the level of the aortopulmonary window for left-sided operations. Topical lidocaine was applied to the surface of the lung before surgery under direct thoracoscopic vision.