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J Thorac Cardiovasc Surg 2002;124:1032-1034
© 2002 The American Association for Thoracic Surgery
Brief Communications |
From the Department of Thoracic Surgery and Medicine, Kamaishi Municipal Hospital, Iwate, Japan.
Received for publication April 15, 2002. Accepted for publication June 5, 2002. Address for reprints: Shinichiro Okada, MD, Department of Thoracic Surgery and Medicine, Kamaishi Municipal Hospital, 3-15-26, Ohwatari-cho, Kamaishi, Iwate, 026-0025 Japan (E-mail: shin575{at}opal.famille.ne.jp).
Self-expandable metallic stents have been used in the management of malignant or benign tumors causing airway stenosis or obstruction by means of a rigid bronchoscope or fluoroscopic control.
1 However, fully trained personnel are needed to manage the rigid bronchoscope, and the sites to be reached with it are limited. Additionally, mandibular arthrosis, or limited mouth opening, or spinal deformities might present technical problems with the rigid bronchoscope. On the other hand, it might often be difficult to achieve the exact fitting of the stent under fluoroscopic control.
The laryngeal mask is a reusable device with a larger internal diameter, allowing easier passage of a fiberoptic flexible bronchoscope or instruments (Figure 1, A), and does not require the usual endotracheal intubation or mask ventilation. 2-5 In this report we describe a procedure of inserting a self-expandable metallic stent under direct visual control with the use of the new laryngeal mask and a fiberoptic flexible bronchoscope in the management of tracheobronchial obstructive lesions.
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Stenting with a laryngeal mask and a flexible bronchoscope was performed after achievement of general anesthesia with a laryngeal mask placement (Figure 1
, B). Placement of the laryngeal mask has been described elsewhere. 5 Anesthesia was induced with propofol (2.5-3.0 mg/kg) and maintained with sevoflurane in 67% to 75% air. A muscle relaxant, such as vecuronium bromide, was used when necessary. Before stenting, bronchoscopic surgery, such as argon plasma coagulation or electrocautery, for airway lesions was performed when necessary. For stent insertion, we used a self-expandable metallic stent (Spiral Z stent; Medico's Hirata, Osaka, Japan). The flexible bronchoscope (BF P40; Olympus, Tokyo, Japan) was passed through the slit of the cap of the swivel connector (Portex Catheter Mount; SIMS Portex Inc, Kent, United Kingdom), which connected the laryngeal mask and the anesthesia machine. A guide wire through the working channel of the flexible bronchoscope was introduced beyond the stenotic site. After the bronchoscope was removed, a thin, fiberoptic flexible bronchoscope (BF3C30; Olympus) was passed through the cap of the slit of the swivel connector. The stent loader was also passed through the slit of the laryngeal mask, and it was introduced into the laryngeal mask tube and trachea. Then the expandable metallic stent that was passed through the stent loader was pushed out to sit across the stenosis under bronchoscopic vision. When subsequent fiberoptic bronchoscopy indicated the need to move the stent, it was precisely moved into the correct location with the use of a biopsy forceps. The entire procedure was performed without interruption of ventilation during the procedure. Percutaneous oxygen saturation with a pulse oximeter, blood pressure measurement, and electrocardiographic results were monitored during the procedure. Results were considered satisfactory when airway dilation at the stenotic site or improved clinical symptoms or both were achieved. Any outcome that did not accomplish the aims was judged unsatisfactory.
Results and discussion
Patients' characteristics and results are summarized in Table 1. Between April 1996 and December 2001, 12 patients aged 48 to 87 years (mean, 71 years) received tracheobronchial stent treatment. The patients included 5 men and 7 women, having 1 benign tumor, 3 thyroid cancers, and 8 primary lung cancers.
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The operating time ranged from 14 to 30 minutes (mean, 21 minutes). No complications, either related or unrelated to the procedure, occurred in any of the patients. No deaths have occurred from stent failure or related complications. Percutaneous oxygen saturation, blood pressure, and electrocardiographic results were not changed during the procedure. The delivery of the self-expandable metallic stent within the airway by using the laryngeal mask was easy and quick, without interrupting ventilation in all patients. Also, positioning of the stent under the direct bronchoscopic vision was easy and exact, without need of fluoroscopy. Satisfactory results were achieved in all patients.
Our preliminary results showed that self-expandable metallic stents can be inserted safely, quickly, and exactly with a laryngeal mask and a fiberoptic flexible bronchoscope without the use of fluoroscopy in the treatment of selected tracheobronchial tumors. This new procedure will, however, require careful evaluation in larger series.
The procedure, under general anesthesia, might be considered a disadvantage, but the use of general anesthesia allowed no motion of the patient and steady visualization of the airway during the procedure reduced risky complications and reduced the operating time.
References
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