Recent Advances in Video-Assisted Transthoracic Tracheal Resection Followed by Reconstruction Under Non-Intubated Anesthesia with Spontaneous Breathing

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Editorial

Recent advances in video-assisted transthoracic tracheal resection followed by reconstruction under non-intubated anesthesia with spontaneous breathing

Katsuhiro Okuda, Satoru Moriyama, Hiroshi Haneda, Osamu Kawano, Tadashi Sakane, Risa Oda, Takuya Watanabe, Ryoichi Nakanishi

Department of Oncology, Immunology and Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya 467-8601, Japan Correspondence to: Katsuhiro Okuda, MD, PhD. Department of Oncology, Immunology and Surgery, Nagoya City University Graduate School of Medical Science, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601, Japan. Email: [email protected]. Provenance: This is an invited Editorial commissioned by Section Editor Jianfei Shen, MD (Department of Cardiothoracic Surgery, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, Taizhou, China). Comment on: Li S, Liu J, He J, et al. Video-assisted transthoracic surgery resection of a tracheal mass and reconstruction of trachea under non- intubated anesthesia with spontaneous breathing. J Thorac Dis 2016;8:575-85.

Submitted Jul 27, 2017. Accepted for publication Aug 02, 2017. doi: 10.21037/jtd.2017.08.58 View this article at: http://dx.doi.org/10.21037/jtd.2017.08.58

Tracheal resection followed by reconstruction is one of the associated with some problems that remain to be improved. most difficult procedures in the field of thoracic surgery. There is a possibility of tracheal injury due to endotracheal Right thoracotomy performed via a posterolateral incision intubation, and lung parenchymal injury (including is selected for middle and lower tracheal resection under pneumonia) can occur in the perioperative period as a general anesthesia. In order to develop a novel less invasive result of mechanical ventilation (5,6). Furthermore, airway surgical procedure, it is necessary to devise methods to management during cross-field endotracheal intubation keep the operating field clear and to use better methods is complex as addition of port to insert the tube disturbs of anesthesia. Thoracic surgeons have attempted to the operating field. To improve the above problem, Zhao improve surgical techniques, the approach, and methods of et al. (7) reported that the interruption of ventilation anesthesia in order to minimize the trauma to the patient with transoral endotracheal intubation in VATS tracheal and to reduce the incidence of postoperative complications, resection and reconstruction eliminated the stress of cross- including respiratory complications. field endotracheal intubation, eliminating the need for a The feasibility and efficacy of video-assisted transthoracic port for operating field ventilation. surgery (VATS) resection followed by reconstruction as a Airway resection followed by reconstruction is typically minimally invasive procedure for the treatment of tracheal performed under general anesthesia with single-lung disease has been reported (1-3). The number of reports ventilation because it is necessary to maintain a sufficient on tracheal resection by VATS followed by reconstruction working space and to adjust the airway pressure for a has been increasing since the publication of a report on the leak test. In recent years, non-intubated thoracic surgery, safety and feasibility of VATS tracheal resection (4). which is associated with a lower rate of postoperative With regard to the incision for the initial approach, complications, especially airway complications, shorter almost all surgeons selected three or four ports plus one hospital stays, and lower invasiveness in comparison to port for inserting a ventilation tube in the operation field. thoracic surgery with endotracheal intubation, has gradually Tracheal resection and reconstruction by VATS or open been developed (8-11). thoracotomy are used to be performed under general Li et al. (12) reported on tracheal procedures under non- anesthesia and cross-field endotracheal intubation is needed intubated anesthesia with spontaneous breathing as a less during end-to-end anastomosis. Traditional procedures are invasive method of tracheal resection and reconstruction.

Furthermore, to decrease the patient’s stress and VATS tracheal resection and reconstruction under non- invasiveness, Guo et al. (13) reported the performance of intubated anesthesia should be strict to ensure the safety uniportal VATS for a tracheal tumor under non-intubated of the operation. Basically, non-intubated thoracoscopic anesthesia with spontaneous ventilation as a less invasive surgery under local and regional anesthesia is an alternative procedure in comparison to tracheal procedures by 3- or method for extending the surgical indications to include 4-port VATS. Now, this procedure will be the least invasive surgical treatment for pneumothorax and partial pulmonary approach for tracheal surgery. resection for the diagnosis of solitary pulmonary nodules in Peng et al. (14) reported the outcome of non-intubated patients in whom general anesthesia is contraindicated due thoracoscopic surgery for carinal reconstruction in a patient to cardiopulmonary dysfunction (16). Thus, the criteria for with an adenoid cystic carcinoma of the trachea. The selecting non-intubated anesthesia for patients undergoing pre-anesthesia preparation included the administration VATS tracheal resection and reconstruction differ from the of midazolam and atropine 30 minutes before surgery, criteria for patients undergoing minor thoracic surgery. At a thoracic epidural anesthesia (TEA) was performed at the minimum, it is necessary to establish the optimum selection T6-7 level, and intravenous anesthesia was performed criteria for patients and the best method of preparing for using remifentanil, dexmedetomidine and propofol, to surgical tracheal resection followed by reconstruction. When achieve sedation while maintaining spontaneous breathing. selecting patients who should undergo this procedure, we A laryngeal mask airway was inserted, and local anesthesia must also check the cardio-pulmonary function, tumor (lidocaine), an intercostal nerve block and a vagus nerve location, tumor size (the length of the trachea and carina block were also used. They concluded that carinal resection), and the predicted operation time. reconstruction under non-intubated anesthesia was safe and The previous studies on VATS lobectomy for lung feasible for selected patient and that it provided an ideal cancer patients under non-intubated anesthesia investigated surgical field without any intraoperative tubing systems. the feasibility and safety of non-intubated thoracoscopic Furthermore, the maintenance of spontaneous breathing lobectomy using TEA, intrathoracic vagal blockade, and makes airway reconstruction more anatomical. However, sedation (17,18). Although Chen et al. (17) reported that the method of anesthesia was complex; thus, the processes 3 of 30 patients in the non-intubated group required of preparation and surgery should be thoroughly discussed conversion to intubated single-lung ventilation due to by the surgical team before the procedure. persistent hypoxemia, poor pain-control and bleeding. Non-intubated thoracic surgery is more technically We previously reported the problems associated with challenging than thoracic surgery under general anesthesia. non-intubated airway surgery (19). Briefly, the management However, the developments of anesthetic agents, anesthesia of hypoxia while cutting open the airway, the management techniques and systems for monitoring the depth of of hypercapnia, an adequate method for performing an anesthesia using the bispectral index (BIS), pulse oximetry, air-leak test after reconstruction, the dropping of blood and end-tidal carbon dioxide have improved the safety and secretions into the airway during reconstruction, the of non-intubated thoracic surgery. There are several prevention of coughing during airway construction, and combination methods for achieving local and regional the limited experience in tracheal resection followed by anesthesia. Local wound infiltration, serratus anterior plane reconstruction under non-intubated anesthesia are problems blockade, selective intercostal nerve blockade, thoracic that remain to be solved. paravertebral blockade, TEA and the administration of To perform the tracheal resection followed by lidocaine in the pleural space can be considered (15). reconstruction under non-intubated anesthesia, the entire VATS tracheal resection and reconstruction under non- surgical team must be aware of the complications that intubated anesthesia with spontaneous breathing is a superior can occur during awake thoracic surgery; the potential procedure from the viewpoint of the patient’s postoperative risks including hypoxemia, uncontrolled cough and severe recovery and the reduction in airway complications. However, bleeding. To prevent severe complications, the common cases in which tracheal resection and reconstruction are criteria for conversion to thoracotomy or intubated required by patients for whom tracheal intubation is anesthesia during surgery should be decided by the unsuitable are very rare; thus, these methods of anesthesia surgical team. Navarro-Martínez et al. (20) emphasized and surgical techniques are not recognized worldwide. that responses to surgical and medical emergencies during Li et al. (12) noted that the selection of patients for non-intubated thoracoscopic surgery must follow the crisis

© Journal of Thoracic Disease. All rights reserved. jtd.amegroups.com J Thorac Dis 2017;9(9):2891-2894 Journal of Thoracic Disease, Vol 9, No 9 September 2017 2893 resource management guidelines. Footnote Li et al. (12) reported that VATS tracheal resection Conflicts of Interest: The authors have no conflicts of interest and reconstruction under non-intubated anesthesia with to declare. spontaneous breathing is a less invasive technique for tracheal surgery. The operating field is well maintained during tracheal suturing in the non-intubated, References spontaneously breathing patient, which makes tracheal 1. Nakanishi K, Kuruma T. Video-assisted thoracic suturing easier, and which reduces the time required for tracheoplasty for adenoid cystic carcinoma of the tracheal suturing in comparison to cases requiring operative mediastinal trachea. Surgery 2005;137:250-2. field intubation. In this point, this procedure may be ideal 2. Nakanishi R, Yamashita T, Muranaka K, et al. for both the patient and surgeon. The surgical team should Thoracoscopic carinal resection and reconstruction in have sufficient experience in tracheal surgery by VATS a patient with mucoepidermoid carcinoma. J Thorac and non-intubated anesthesia with spontaneous breathing Cardiovasc Surg 2013;145:1134-5. to be able to respond properly to surgical and anesthetic complications. Before beginning the tracheal procedure 3. Jiao W, Zhu D, Cheng Z, et al. Thoracoscopic tracheal under non-intubated anesthesia, they should confirm the resection and reconstruction for adenoid cystic carcinoma. process of the procedure and the criteria for conversion to Ann Thorac Surg 2015;99:e15-7. general anesthesia and not hesitate with such conversion. 4. Li J, Wang W, Jiang L, et al. Video-Assisted Thoracic The anesthesiologist must be trained to intubate in the Surgery Resection and Reconstruction of Carina and lateral decubitus position in case of an emergency during Trachea for Malignant or Benign Disease in 12 Patients: non-intubated thoracic surgery. The surgeons should Three Centers' Experience in China. Ann Thorac Surg recognize the limitations of non-intubated anesthesia, 2016;102:295-303. which are caused by the operation time and complications 5. Whitehead T, Slutsky AS. The pulmonary physician in during the operation. critical care * 7: ventilator induced lung injury. Thorax It is difficult to plan a randomized controlled trial to 2002;57:635-42. compare the postoperative mortality and complications 6. Kiss G, Castillo M. Non-intubated anesthesia in thoracic (including respiratory complications) between non- surgery-technical issues. Ann Transl Med 2015;3:109. intubated patients and intubated patients undergoing 7. Zhao K, Mei J, Hai Y, et al. Thoracoscopic tracheal tracheal resection, because tracheal procedures are relatively reconstruction without surgical field intubation. Thorac uncommon. Because the reports on tracheal resection Cancer 2016;7:495-7. and reconstruction under non-intubated anesthesia with 8. Katlic MR, Facktor MA. Video-assisted thoracic surgery spontaneous breathing are limited to case reports, the utilizing local anesthesia and sedation: 384 consecutive feasibility and safety of this technique should be confirmed cases. Ann Thorac Surg 2010;90:240-5. in a study after the accumulation of a suitable number of 9. Chen KC, Cheng YJ, Hung MH, et al. Nonintubated patients; furthermore, the institutions should be limited to thoracoscopic lung resection: a 3-year experience with 285 those with sufficient experience in VATS tracheal surgery cases in a single institution. J Thorac Dis 2012;4:347-51. and VATS under non-intubated anesthesia with spontaneous 10. Liu J, Cui F, Li S, et al. Nonintubated video-assisted breathing. The appropriate criteria for identifying thoracoscopic surgery under epidural anesthesia compared candidates for this procedure should be established. If the with conventional anesthetic option: a randomized control results of such a study show that the procedure is safe, and study. Surg Innov 2015;22:123-30. that it is associated with fewer operative complications, and 11. Hung MH, Chan KC, Liu YJ, et al. Nonintubated a better long-term prognosis, this procedure may spread thoracoscopic lobectomy for lung cancer using epidural throughout the world to become a standard procedure for anesthesia and intercostal blockade:a retrospective cohort tracheal resection followed by reconstruction. study of 238 cases. Medicine (Baltimore) 2015;94:e727. 12. Li S, Liu J, He J, et al. Video-assisted transthoracic surgery resection of a tracheal mass and reconstruction of Acknowledgements trachea under non-intubated anesthesia with spontaneous None. breathing. J Thorac Dis 2016;8:575-85.

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Cite this article as: Okuda K, Moriyama S, Haneda H, Kawano O, Sakane T, Oda R, Watanabe T, Nakanishi R. Recent advances in video-assisted transthoracic tracheal resection followed by reconstruction under non-intubated anesthesia with spontaneous breathing. J Thorac Dis 2017;9(9):2891-2894. doi: 10.21037/jtd.2017.08.58