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J Thorac Cardiovasc Surg 1998;116:177-179
© 1998 Mosby, Inc.

Brief Communication

Electrosurgery with a fiberoptic bronchoscope and a snare for endotracheal/endobronchial tumors

Sendai, Japan

From the Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan.

Received for publication Jan. 2, 1998. Accepted for publication Feb. 13, 1998. Address for reprints: Motoyasu Sagawa, MD, Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, 4-1 Seiryo-machi, Aoba-ku, Sendai 980-77, Japan.

Endobronchial tumors sometimes cause stenosis of the major bronchi, which requires prompt palliation. A number of techniques for palliation have been reported, such as the neodymium–yttrium-aluminum-garnet (Nd-YAG) laser, ¹ endoscopic cryosurgery, ^1,2 and electrosurgery with a rigid bronchoscope. ^1,3 However, electrosurgery with a fiberoptic bronchoscope and a snare is not a widely known technique in the surgery of the respiratory tract. ^4,5 In this study, we evaluate the effectiveness and complications of the technique in nine cases of tracheobronchial tumors resected by this technique. The indications and limitations of the technique are also discussed.

Technique

Endobronchial electrosurgery was performed under local anesthesia with an electrosurgical unit (UES/UES-10, Olympus, Tokyo, Japan), a flexible fiberoptic bronchoscope (BF-1TR/BF-P30/BF-P240, Olympus), and a snare (SD-11L-1/SD-18C-1, Olympus). Oxygen was given with nasal prongs. Patients received pentazocine, hydroxyzine hydrochloride, and atropine sulfate before the operation. Arterial oxygen saturation, blood pressure, and the electrocardiogram were monitored during the electrosurgery. An endotracheal tube was placed unless the stenosis was located in the upper part of the trachea. Careful manipulation with a snare was required to lasso the polypoid tumor. Energy at 40 W was applied, and the snare was pulled very slowly to avoid causing a mechanical cut by the snare that would produce bleeding. After the polypectomy, the resected specimen was removed with a grasping forceps.

Patients

Patient characteristics and results are summarized in Table I. The patients included five men and four women, having six malignant and three benign tumors. The tracheobronchial stenosis was severe in all the patients except one who had a squamous papilloma. The aims of the electrosurgery were dilation of the tracheobronchial stenosis in seven patients, curative resection of a benign tumor in three patients, and evaluation of carcinoma invasion in one patient.

The stenotic area was successfully dilated in six (patients 1, 5, 6, 7, 8, and 9) of the seven patients in whom this was the aim. In the remaining patient (patient 3), an emergency tracheostomy was performed for increased dyspnea.

In two (patients 2 and 5) of three patients with a benign tumor, curative resection of the tumor was successful and an additional thoracotomy was not required. In the remaining patient (patient 7), most of the tumor was removed by electrosurgery and the atelectasis of the right middle and lower lobes was relieved. However, a part of the tumor could not be removed and the atelectasis of the right S⁶ segment (the superior segment of the lower lobe) remained. A sleeve S⁶ segmentectomy was performed later.

Carcinoma invasion was successfully evaluated in one patient (patient 4). The protruding part of the tumor was resected without bleeding.

Intraoperative condition of the patients and complications

In eight of nine patients, electrosurgery was performed within 10 minutes, taking only a few minutes in most of them. This technique caused little smoke, and the arterial oxygen saturation, blood pressure, and electrocardiogram were not changed during the operation. Patients' symptoms, such as dyspnea, coughing, and stridor, were relieved promptly. No additional complications were observed.

Lassoing the tumor with a snare was very difficult in patient 3, and the patient's dyspnea was worsened. An emergency tracheostomy was required.

Discussion

A number of techniques have been reported for the palliation of bronchial obstruction or stenosis. The Nd-YAG laser is one of the most useful devices for dilatation of the stenotic bronchial tree. ¹ However, Nd-YAG laser therapy causes smoke, which sometimes decreases the arterial oxygen saturation of the patient and takes a relatively long time. Electrosurgery with a rigid bronchoscope is also a useful technique, ^1,3 but it requires general anesthesia and only limited tumor sites can be reached. Endoscopic cryosurgery is a safe technique because the bronchial cartilage cannot be damaged, ^1,2 but effective dilation with this technique requires a long time. Brachytherapy ¹ needs much time, too. These two techniques cannot be applied to patients who need prompt relief of dyspnea.

Electrosurgery with a fiberoptic bronchoscope and a snare caused little smoke, required only local anesthesia, and took only a few minutes to resect the tumor. This technique can be applied to polypoid tumors located anywhere within the sight of the bronchoscope. Patients' symptoms, including dyspnea, coughing, and stridor, were relieved promptly. A large specimen obtained by the technique made histologic examination easier. In some benign tumors, additional thoracotomy was not required.

This technique had some limitations. In patient 7, dilation of the intermediate trunk was successful, but dilation of the B⁶ segmental bronchus was not. The tumor at the intermediate trunk was polypoid, but the remaining tumor at the B⁶ segmental bronchus was not. This technique can be applied only to polypoid tumors. In patient 3, resection of the tracheal tumor was unsuccessful. The tumor was located so close to the vocal cord that handling a fiberoptic bronchoscope and a snare was difficult. This case was our first attempt with this technique and that may have influenced the result. Recently, a new snare for the respiratory tract has become available, and a similar operation was successfully done more easily in similar a case (patient 1).

Although electrosurgery with a fiberoptic bronchoscope and a snare has some limitations, it is very useful and may be the first choice for the resection of polypoid tumors in the bronchial tree.

Acknowledgments

We are grateful to Ms. Chieko Yoshida, Mr. Toshihiko Kanno, Ms. Mieko Kosuga, and Ms. Mutsuko Izumi for their technical assistance.

References

1. Jacobson MJ, LoCicero J. Endobronchial treatment of lung carcinoma. Chest 1991;100:837-41.
   
2. Marasso A, Gallo E, Massaglia GM, Onoscuri M, Bernardi V. Cryosurgery in bronchoscopic treatment of tracheobronchial stenosis. Chest 1993;103:472-4.[Abstract/Free Full Text]
   
3. Petrou M, Goldstraw P. The management of tracheobronchial obstruction: a review of endoscopic technique. Eur J Cardiothorac Surg 1994;8:436-41.[Abstract]
   
4. Themelin D, Duchatelet P, Boudaka W, Lamy V. Endoscopic resection of an endobronchial hypernephroma metastasis using polypectomy snare. Eur Respir J 1990;3:732-3.[Abstract]
   
5. Gerasin VA, Shafirovsky BB. Endoscopic electrosurgery. Chest 1988;93:270-4.[Abstract/Free Full Text]
   

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This Article Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Shigefumi Fujimura Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Sagawa, M. Articles by Fujimura, S. Search for Related Content PubMed PubMed Citation Articles by Sagawa, M. Articles by Fujimura, S.