- Email: [email protected]
Thoracoscopic surgery for tracheal and carinal resection and reconstruction under spontaneous ventilation
Accepted Manuscript Thoracoscopic Surgery for Tracheal and Carinal Resection and Reconstruction under Spontaneous Ventilation Long Jiang, MD, PhD, Jun Liu, MD, PhD, Diego Gonzalez-Rivas, MD, Yaron Shargall, MD, Martin Kolb, MD, PhD, Wenlong Shao, MD, PhD, Qinglong Dong, MD, Lixia Liang, MD, Jianxing He, MD, PhD PII:
S0022-5223(18)30405-7
DOI:
10.1016/j.jtcvs.2017.12.153
Reference:
YMTC 12621
To appear in:
The Journal of Thoracic and Cardiovascular Surgery
Received Date: 20 May 2017 Revised Date:
2 November 2017
Accepted Date: 26 December 2017
Please cite this article as: Jiang L, Liu J, Gonzalez-Rivas D, Shargall Y, Kolb M, Shao W, Dong Q, Liang L, He J, Thoracoscopic Surgery for Tracheal and Carinal Resection and Reconstruction under Spontaneous Ventilation, The Journal of Thoracic and Cardiovascular Surgery (2018), doi: 10.1016/ j.jtcvs.2017.12.153. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Thoracoscopic Surgery for Tracheal and Carinal Resection and Reconstruction
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under Spontaneous Ventilation
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Long Jiang, MD, PhD1; Jun Liu, MD, PhD1; Diego Gonzalez-Rivas, MD2; Yaron
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Shargall, MD3; Martin Kolb, MD, PhD4; Wenlong Shao, MD, PhD1; Qinglong Dong,
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MD5; Lixia Liang, MD5; Jianxing He, MD, PhD1
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Department of Thoracic Surgery, the First Affiliated Hospital of Guangzhou Medical
University; Guangzhou Institute of Respiratory Disease & China State Key
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Laboratory of Respiratory Disease & National Clinical Research Center for
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Respiratory Disease, Guangzhou, China.
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Coruña, Spain.
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Department of Thoracic Surgery, Coruña University Hospital, Xubias 84, 15006.
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Joseph’s Healthcare Hamilton, Hamilton, Ontario, Canada.
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Department of Surgery, Division of Thoracic Surgery, McMaster University/St.
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Firestone Institute for Respiratory Health, Hamilton, Ontario, Canada.
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Department of Medicine, Pathology and Molecular Medicine, McMaster University,
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University.
Department of Anesthesiology, the First Affiliated Hospital of Guangzhou Medical
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LJ and JL contributed equally to this work.
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Written on behalf of AME Thoracic Surgery Collaborative Group.
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Conflict of interest statement and source of funding: None.
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Correspondence to: Jianxing He, MD, PhD, FACS. Department of Thoracic
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Surgery/Oncology, the First Affiliated Hospital of Guangzhou Medical University;
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Guangzhou Institute of Respiratory Disease & China State Key Laboratory of
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Respiratory Disease & National Clinical Research Center for Respiratory Disease, No.
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151, Yanjiang Rd, Guangzhou 510120, China. Email: [email protected]
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Glossary of Abbreviations:
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VATS=video
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CT=computed tomography; PET=positron emission tomography; ASA=American
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Society of Anesthesiologists; BMI=body mass index; BIS=bispectral index; VAS=
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Visual Analogue Scale.
thorocoscopic
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SV=spontaneous
ventilation;
Central Picture Legend: Specific lesions and details of tracheal resection.
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surgery;
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assisted
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Central Message: SV-VATS is a feasible procedure in airway surgery in highly
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selected patients. It can be a valid alternative to conventional intubated VATS for
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airway surgery.
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Perspective statement: During conventional intubated tracheal and carinal surgery,
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airway management includes several challenges related to tube management without
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interfering with the surgical field and maintaining ventilation with favorable
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oxygenation. SV-VATS technique is a feasible procedure in airway surgery.
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ACCEPTED MANUSCRIPT Structured Abstract
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Objectives: The aim of this study was to describe and assess the techniques of
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spontaneous ventilation video-assisted thoracoscopic surgery (SV-VATS) for
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tracheal/carinal resections and compare the outcomes with the conventional
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thoracoscopic intubated method.
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Methods: From May 2015 to November 2016, some 18 consecutive patients with
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malignant or benign diseases invading distal trachea and carina who met the criteria
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for SV were treated by SV-VATS resection. To evaluate the feasibility of this novel
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technique, they were compared with a control group consisting of 14 consecutive
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patients with the same diseases who underwent VATS resection using intubated
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general anesthesia from October 2014 to April 2015. Data were collected with a
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median follow-up of 10.2 months 75 (range:1-27).
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Results: The SV-VATS group consisted of 4 carinal resections and 14 tracheal
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resections. In the control group, 2 patients underwent carinal resection and 12
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underwent tracheal resection. Median operative time was shorter in the SV-VATS
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group compared with the intubated group (162.5 min vs. 260 min), as was the median
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time for tracheal end-to-end anastomosis (22.5 min vs. 45 min) and carinal
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reconstruction (40 min vs. 86 min). The lowest oxygen saturation during the
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procedure was 94.2±4.9% in SV-VATS group and 93.9±4.5% in the control group.
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The peak CO2 level at the end of expiration was higher in the SV-VATS group
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ACCEPTED MANUSCRIPT (47.7±4.2mmHg vs. 39.1±5.7mmHg). No conversion to tracheal intubation was
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needed in the SV-VATS group. Postoperative complications occurred in six patients in
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the SV-VATS group and nine in the control group. Patients who undergoing SV-VATS
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had a trend toward shorter postoperative hospital stays (11.5±4.3d vs. 13.2±6.3d). One
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recurrence (SV-VATS group) and two deaths (one in each group) were observed
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during follow-up.
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Conclusions: SV-VATS is a feasible procedure in tracheal and carinal resection and
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reconstruction in highly selected patients. It can be a valid alternative to conventional
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intubated VATS for airway surgery.
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Key Words: spontaneous ventilation; video-assisted thoracoscopic surgery; trachea;
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carina; resection and reconstruction.
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ACCEPTED MANUSCRIPT Introduction
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Video-assisted thoracoscopic surgery (VATS) has been reported as feasible and safe in
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technically demanding complex tracheal and carinal surgery[1-3]. However,
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morbidity is not completely eliminated, with potential risks posed by conventional
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intubation and general anesthesia. Deep anesthesia and intravenous analgesics
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(primarily opioids) have deleterious
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postoperative complications[4,5]. Mechanical ventilation may cause airway
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pressure-induced injury by lung over-distension[6,7]. Endotracheal intubation can
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also result in sore throat, mucosal ulceration and airway injury[8].
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associated
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systemic side-effects
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Spontaneous ventilation VATS(SV-VATS) has recently been extensively investigated
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and has been reported to reduce the adverse effects of tracheal intubation and general
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anesthesia.[9-15] It has been advocated as an alternative to conventional intubated
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anesthesia for a variety of VATS procedures.[12,16,17] Our experience mirrored that
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of previous studies, demonstrating that patients operated under SV-VATS had a
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shorter post-operative recovery time, and were able to eat and mobilize earlier
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compared with the conventional endotracheal ventilation VATS approach[18,19].
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However, whether the SV-VATS technique can offer benefits for tracheal surgery is
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unknown. In the present study, we have expanded the SV-VATS application to include
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tracheal and carinal resections and reconstructions, and compared its outcomes with
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conventional intubated methods.
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Material and methods
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Between October 2014 and November 2016, clinical data for all consecutive patients
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undergoing VATS tracheal or carinal resection and reconstruction were analyzed. The
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patients in the control group received combined intravenous anesthesia using a
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single-lumen 6.5mm endotracheal tube (Well Lead, Inc, Guangzhou, Guangdong,
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China) for one-lung ventilation at the start of the procedures. Cross-field ventilation
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was used during the tracheal and carinal procedures. During the operation, the
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cross-field endobronchial tube can be introduced through either the operating port or
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an additional port[1]. Patients undergoing tracheal or carinal resection using
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conventional intubation were compared to those undergoing SV-VATS. The study was
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approved by the First Affiliated Hospital of Guangzhou Medical University Research
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Ethics Committee.
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Preoperative evaluation
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Cardiac and pulmonary functions were evaluated preoperatively using cardiac 2D
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echo, electrocardiogram and pulmonary function tests. Routine preoperative
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evaluation to exclude distant metastases included thoracic and abdominal contrast
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computed tomography (CT) or positron emission tomography (PET-CT) scan,
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magnetic resonance imaging (MRI) of the brain, and bone scintigraphy. Any
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ambiguities on the results were resolved by holding a multidisciplinary consultation to
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decide whether an operation was necessary. During patient evaluation, if
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bronchoscopic evaluation revealed more than 70%-80% obstruction of the trachea, a
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wire loop electrocautery was used to resect the majority of the tumor before tracheal
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resection as described in a previous report[20].
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Indications for SV-VATS anesthesia
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Patients eligible for SV-VATS fulfilled the following criteria: ASA grade of I-II, and a
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body mass index (BMI) <25. Patients with a bleeding disorder, sleep apnea, evidence
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of pleural adhesions, unfavorable airway features (such as congenital pulmonary
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airway malformation) or spinal anatomical characteristics were not eligible for this
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procedure. In addition, preoperative bronchoscopic examination was performed in
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each case to confirm pathology, as well as the extent of tumor involvement evaluated
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via multiple biopsies. In our center, we consider patients eligible for resection if they
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have a resectable airway lesion involving no more than 4cm of the trachea. Whether
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the SV-VATS or conventional technique was used was determined by surgeon’s
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preference.
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Anesthetic and surgical management in SV-VATS procedures
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Anesthetic Considerations
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Details of the anesthetic procedure were described in our previous report[21]. In short,
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anesthesia was induced with the target-controlled infusion (TCI) of propofol (target
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plasma concentration of 2-3ug/ml) and sufentanil 0.1-0.2 ug/kg. Muscle relaxants
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were not used. Bispectral index (BIS) monitoring was maintained at 40 to 60 during
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ACCEPTED MANUSCRIPT the operation. The spontaneous respiration rate was 12 to 20/min. During spontaneous
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ventilation, a gradual and natural collapse of the operative lung occurred allowing
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maximal visualization of the lungs after making the incisions. To reduce cough
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induced by thoracoscopic manipulations, under direct thoracoscopic vision vagus
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nerve block was performed and 2% lidocaine was sprayed on the surface of the
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lung[22].
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Anesthesia was maintained with TCI of propofol (target plasma concentration of 1-2
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ug/ml), dexmedetomidine 0.5-1 ug/kg/h and remifentanil 0.05 ug/kg/min. Incisions
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were performed after local application of 1% lidocaine. Optimally, the intercostal
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muscle and pleura were infiltrated under direct vision or palpation through the skin
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incision. The patients’ electrocardiogram (ECG), heart rate (HR), blood pressure (BP),
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pulse oxygen saturation (SpO2), end-tidal carbon dioxide (EtCO2), respiratory rate
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(RR) and BIS were continuously monitored. During the procedure, a laryngeal mask
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was used for oxygen inhalation, with an oxygen flow of 4-5 L/min, keeping oxygen
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saturation above 95%. Endotracheal ventilation and cross-field ventilation were also
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prepared as backup in case of an emergency situation, such as hypoxemia, requiring
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peri-operative conversion of the intubation method.
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Surgical techniques
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Surgical preparation for all patients was identical. All patients were positioned in a
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left lateral decubitus position. Three incisions were made: a 10-mm camera port, at
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operative port, located at the fourth intercostal space on the right anterolateral chest
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wall; and a 10-mm port, at the seventh intercostal space along the right posterior
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axillary line. We used a flexible bronchoscope through the laryngeal mask to identify
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the proximal and distal extent of the lesion. If lung resection was needed, it was
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performed followed by lymph node dissection.
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The azygous vein was dissected and divided, if needed, using a 35-mm Endo cutter
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(Ethicon, Inc, Somerville, NJ). The parietal pleura was then opened from this point
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extending toward the apex, along the lateral side of the superior vena cava. This
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maneuver allowed the trachea and proximal bronchus to be mobilized with a
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combination of blunt dissection and Harmonic Scalpel (Ethicon, Inc, Somerville, NJ).
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Right paratracheal lymph nodes were also removed to aid with exposure and
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mobilization of the airway if necessary. Extra attention was taken during this
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dissection to protect the bronchial arteries and vagus nerve. The right vagus nerve was
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identified and carefully moved to one side. We sometimes suspended it to the
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posterior chest wall with 3-0 polypropylene (Prolene, Ethicon, Inc, Somerville, NJ). A
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silicon sling was then placed around the trachea and each of the bronchi. Extra 3-0
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Prolene retraction sutures were also placed in each of the airways. This technique
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allowed retraction and exposure of the airway for further resection and reconstruction.
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Preoperative bronchoscopic examination was performed to confirm pathology, as well
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ACCEPTED MANUSCRIPT as the extent of tumor involvement evaluated via multiple biopsies. According to the
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biopsies, the resection was performed 5 to 10mm above and below the tumor margins.
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If the lesion was malignant, we resected the trachea on the near position of tumor
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cell-free. Two types of surgical procedures were performed in our study: tracheal
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resection with end-to-end anastomosis and carinal resection and reconstruction with
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two sets of anastomosis(Fig.2/3). Cervical extension was sometimes changed to a
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lower degree to allow the trachea to move into the mediastinum before the initiation
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of anastomosis. Anastomosis was carried out using a continuous 3-0 Prolene suture,
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starting from the posterior cartilaginous tissue followed by the membranous section.
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For carina reconstruction, we performed the resection of the carina first, followed by a
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total end-to-end anastomosis between the left main bronchus and the trachea, and
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finally anastomosis of the right main bronchus to the lateral, cartilaginous wall of the
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trachea. After end-to-end suture of the trachea, we used additional 3-0 Prolene
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tension-reduction suture to strengthen and protect the anastomosis. We did not use
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muscle flaps or other tissues to protect the anastomosis. And we do not perform hilar
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release.
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Following completion of the anastomosis, we used a saline solution to test for
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evidence of air leaks. If any air leak was observed, additional stitches were used to
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reinforce the suture until intraoperative air leak test was confirmed negative. Only one
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chest tube is placed at the end of the operation.(Video 1)
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anastomosis and, if there were concerns with sputum retention, any airway secretion
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was cleared. Upon completion of the operation, stitches between the chin and chest or
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philadelphia cervical collars were placed to avoid excessive tension in the early
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postoperative stage.
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Postoperative care in both groups
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Patients were transferred to the intensive care unit (ICU) if necessary according to the
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intraoperative and anesthesia situations in the operating room and during recovery.
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Chest X-ray and bedside ultrasound were performed for evaluation on the same day.
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The voice was accessed by otolaryngologists using a professional speech and voice
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analysis
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anti-inflammatory drugs or a fentanyl patch were used if necessary. Formal pain
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assessment for the study was carried out on the morning of post-operative day 1 using
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the Visual analogue scales (VAS: 0 is completely pain-free and 10 is hard to tolerate).
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system(Voice
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Statistical Analysis
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Continuous data are presented as mean ± standard deviation, median and interquartile
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range (IQR) depend on the distribution. The 95% confidence intervals are also
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reported. Categorical variables are given as a count and percentage of patients. Some
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variables were not-normally distributed (surgical duration, time of tracheal end-to-end
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anastomosis, time of carinal reconstruction, intraoperative blood loss), so median(IQR)
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was summarized. All statistical tests were performed using SPSS 13.0 for Windows
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(SPSS, Inc., Chicago, IL).
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Results
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Between October 2014 and November 2016, a total of eighteen patients underwent
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SV-VATS tracheal/carinal resection and reconstruction for benign or malignant
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diseases in our center (trachea:14; carina: 4) (Group 1- SV-VATS). This group was
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compared to a group of patients consisting of fourteen patients that underwent
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conventionally intubated VATS procedures(trachea: 12; carina: 2) during the same
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period of time (Group 2- control group). Age, sex, body mass index(BMI),
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comorbidities, pulmonary and cardiac functions, lesion size, distance from vocal
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cords, bronchoscopic biopsy patch and pathological diagnosis did not differ between
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the two groups. However, the ASA status was different between both groups as there
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were no grade III patients in the SV-VATS group whereas 4 patients with an ASA
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grade III were included in the control group. (Table.1)
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Operative and Anesthetic Data
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The same surgical team performed on all these airway surgery. Patients in the
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SV-VATS group had shorter median durations of operative time (162.5 min vs. 260
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min), tracheal end-to-end anastomosis time (22.5 min vs. 45 min) and carinal
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reconstruction time (40 min vs. 86 min) compared with the intubated group. The two
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tracheal excision. Final pathologic results showed positive surgical margins in 4
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patients, all were confirmed adenoid cystic carcinoma (SV-VATS:1 vs. control
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group:3). (Table.2)
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During the procedures, the mean lowest oxygen saturation was 94.2±4.9% in
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SV-VATS group and 93.9±4.5% in the control group. The mean peak EtCO2 in the
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SV-VATS group was higher than that in the intubated group (47.7±4.2 vs. 39.1±5.7)
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due to mild hypercapnia under spontaneous ventilation anesthesia. No conversion to
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tracheal intubation was needed in the SV-VATS group.
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Postoperative Recovery
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The post-operative VAS scores of both groups were similar(SV-VATS: 2.7±0.8 vs.
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control: 2.6±0.8). The median ICU stay was one day in the SV-VATS group and 2
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days in the intubated group. Additionally, patients who underwent SV-VATS had a
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trend toward shorter postoperative hospital stay (11.5±4.3d vs. 13.2±6.3d).
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Postoperative complications occurred in six patients in the SV-VATS group and nine
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in the control group (Table.3). In the SV-VATS group, anastomotic stenosis occurred
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in one patient which was successfully managed with placement of stents. In the
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intubated group, anastomotic fistula occurred in one patient and was repaired by
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reoperation. There were no cases of perioperative mortality.
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Survival and follow-up
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During a median follow-up time of 10.2 months, the minimal diameter of tracheal
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anastomotic position on Chest CT six months postoperatively was comparable in both
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groups (1.8±0.2cm vs. 1.6±0.4cm).
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For patients with malignant disease, the final results of tumor stage are shown in
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Table 4. Six patients in the SV-VATS group and three in the intubated group received
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adjuvant chemo- or radiotherapy (Table.3). One recurrence and two deaths were
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observed during the follow-up time. Mortality was 6.2% during follow-up.
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Discussion
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During conventional intubated tracheal and carinal surgery, airway management may
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present several challenges. Most significantly is the challenge of maintaining
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ventilation with favorable oxygenation using an endotracheal tube which can
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sometimes interfere with the surgical field[23]. Cross-field ventilation is a universally
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accepted strategy for conventional intubated VATS for airway surgery. However, this
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endobronchial tube may obstruct the view of the anastomosis site and may require
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periodical retraction during anastomosis to improve exposure. High-frequency jet
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ventilation (HFJV) via the lumen of the blocker tube was reported to help achieve
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one-lung ventilation without causing injury to the tumor. However, there have been
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syndrome[24]. While the SV technique is likely not possible to be performed during
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thoracotomy, it is a valid option for VATS cases, as demonstrated both in our own
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experience and recent literature. Since most of our practice, including airways
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resection and reconstruction, is performed thoracoscopically, it allowed us to
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carry-out this comparative study of conventional VATS intubation airways
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reconstruction with SV-VATS. Our study suggests that the SV-VATS technique
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facilitates the anesthetic and surgical procedures.
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Without the endotracheal tube the trachea is more flexible with a wider range of
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motion during resection and anastomosis. During the spontaneous ventilation
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anesthetic procedure, we use a laryngeal mask to protect the airway and aid the
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intubation procedure in the event emergency intubation is required. Avoiding the use
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of the endotracheal tube gives surgeons the advantage of an unobstructed view of the
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surgical field. Because of this, the anastomosis and reconstruction were much faster
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when compared with the intubated procedures, which resulted in an overall reduction
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of the operative time.
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We demonstrated that SV-VATS was feasible without a need for conversion. Though
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some hypercapnia was noted compared to the control group, especially during the
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anastomosis phase; in this case, we have found that temporary suspension of operative
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maneuvers and measures to maintain adequate hemostasis around the trachea will
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be well tolerated without affecting the hemodynamics or surgical procedures. Of note,
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it has previously been suggested that permissive hypercapnia may, in fact, improve
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hemodynamics and ventilation/perfusion match and provide protective effects on
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inflammatory responses[25].
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During the course of this study, we also developed some tips and tricks regarding the
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technique. Fire within the chest cavity is a well-documented event during airway
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surgery[26] that poses dangers to the patient as well as to the operating theatre
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personnel. The improved management of airway fire during airway surgery is based
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on prevention. We reinforce coordination and communication between the anesthetic
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and surgical teams, and systematically use suction to decrease the amount of oxygen
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near the electrocautery. During these procedures, we used a harmonic endocutter to
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reduce the risk of airway fire after resection of the trachea. Also at this point the
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resulting smoke if using electrocautery could affect the oxygen supply and/or increase
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the patients’ airway sensitivity. For patients who inhale too deeply or who have a
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longer remaining membranous portion after initial resection of the trachea that is
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likely to result in obstruction of the airway during inhalation, a small fine tube such as
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nasal oxygen catheter can be placed in the distal portion of the trachea. This tube is
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used to prevent complete closure of the distal trachea and to protect the spontaneous
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breathing of the patient after the resection and during the beginning of anastomosis.
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In our study, the mortality was 6.2% during the follow-up time of 10.2 months, which
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is consistent with mortality rates of previous reports ranging from 4% to
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12.7%[27,28]. There were four positive margins(SV-VATS:1, IVATS:3), all of which
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were adenoid cystic carcinoma,
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frozen section intraoperatively. This might be due to the intrinsic property of adenoid
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cystic carcinoma, which spread most commonly by direct extension, submucosal or
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perineural invasion, in transverse and longitudinal planes. Patients who underwent
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SV-VATS had a trend toward shorter postoperative hospital stays. This consideration
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is particularly important in China, where primary care at a patient´s home town is not
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widely available. We believe our SV-VATS technique allows early discharge without
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undue worries about patient safety after discharge home.
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The promising outcomes of the SV-VATS may partially be the result of careful patient
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selection, as outlined earlier in the discussion of our methods. Physical condition
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should also be taken into consideration. None of the patients in our study received
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neo-adjuvant radio-chemotherapy because no metastatic disease was found by
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preoperative evaluation. At the current time, we do not consider neo-adjuvant
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radio-chemotherapy in newly diagnosed N2 patients requiring carinal reconstruction
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mainly because of its association with anastomosis-related complications and
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operative mortality[29]. We assume that strict preoperative patient selection, good
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preoperative preparation, and improved postoperative care might have contributed to
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these encouraging results.
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To ensure patient safety, some clearly defined protocol for elective or urgent
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intubation must be determined prior to the operation. We have listed some reasons for
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conversion to general anesthesia in table 5. In addition, intubation in the lateral
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decubitus position is a technical challenge for anesthesiologists. The anesthesiologist
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must be skilled in placing a double-lumen tube, laryngeal mask, fibrotic
403
bronchoscopic intubation, video-assisted system management and endobronchial
404
blocker in order to securely choose the most appropriate device depending on the
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patient’s airway, the position of the patient, time of completion of the procedure and
406
the causes that have led to conversion to general anesthesia[30]. We think continuous
407
and effective communication between surgeons and anesthesiologists is paramount.
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As this is a preliminary feasibility study some limitations should be acknowledged.
410
First, it is retrospective in nature and bias between the study arms cannot be
411
completely excluded. Second, due to the relative infrequency of such complex surgery,
412
the cohort size is small, limiting the power of analysis and conclusions. Third, the
413
selection criteria itself, specifically in regards to BMI, were designed for a Chinese
414
population. We cannot be certain that our findings are necessarily applicable for
415
populations outside China. For Western populations, for example, the BMI inclusion
416
criteria can perhaps be raised to a BMI of <30[31].
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In conclusion, in our experience, SV-VATS for tracheal and carinal resections was
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feasible. The SV-VATS technique offered shorter operative times and potentially
420
faster recovery than the conventional intubated method. Further prospective research
421
is needed to confirm the validity of these results.
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Reference
425 426 427 428 429 430 431 432 433 434 435 436 437 438 439 440 441 442 443 444 445 446 447 448 449 450 451 452 453 454 455 456
1. Li J, Wang W, Jiang L, Yin W, Liu J, et al. (2016) Video-Assisted Thoracic Surgery Resection and
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Reconstruction of Carina and Trachea for Malignant or Benign Disease in 12 Patients: Three Centers' Experience in China. Ann Thorac Surg 102: 295-303.
2. Zhao G, Dong C, Yang M, Du X, Hu X (2014) Totally thoracoscopic tracheoplasty for a squamous cell
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carcinoma of the mediastinal trachea. Ann Thorac Surg 98: 1109-1111.
3. Jiao W, Zhu D, Cheng Z, Zhao Y (2015) Thoracoscopic tracheal resection and reconstruction for adenoid cystic carcinoma. Ann Thorac Surg 99: e15-17.
4. Sessler DI, Sigl JC, Kelley SD, Chamoun NG, Manberg PJ, et al. (2012) Hospital stay and mortality are increased in patients having a "triple low" of low blood pressure, low bispectral index, and low minimum alveolar concentration of volatile anesthesia. Anesthesiology 116: 1195-1203. 5. Hausman MS, Jr., Jewell ES, Engoren M (2015) Regional versus general anesthesia in surgical
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patients with chronic obstructive pulmonary disease: does avoiding general anesthesia reduce the risk of postoperative complications? Anesth Analg 120: 1405-1412. 6. Gothard J (2006) Lung injury after thoracic surgery and one-lung ventilation. Curr Opin Anaesthesiol 19: 5-10.
7. Della Rocca G, Coccia C (2013) Acute lung injury in thoracic surgery. Curr Opin Anaesthesiol 26:
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40-46.
8. Fitzmaurice BG, Brodsky JB (1999) Airway rupture from double-lumen tubes. J Cardiothorac Vasc Anesth 13: 322-329.
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9. Chen JS, Cheng YJ, Hung MH, Tseng YD, Chen KC, et al. (2011) Nonintubated thoracoscopic lobectomy for lung cancer. Ann Surg 254: 1038-1043.
10. Hung MH, Hsu HH, Chen KC, Chan KC, Cheng YJ, et al. (2013) Nonintubated thoracoscopic anatomical segmentectomy for lung tumors. Ann Thorac Surg 96: 1209-1215.
11. Wu CY, Chen JS, Lin YS, Tsai TM, Hung MH, et al. (2013) Feasibility and safety of nonintubated thoracoscopic lobectomy for geriatric lung cancer patients. Ann Thorac Surg 95: 405-411.
12. Mineo TC, Pompeo E, Mineo D, Tacconi F, Marino M, et al. (2006) Awake nonresectional lung volume reduction surgery. Ann Surg 243: 131-136. 13. Pompeo E, Mineo D, Rogliani P, Sabato AF, Mineo TC (2004) Feasibility and results of awake thoracoscopic resection of solitary pulmonary nodules. Ann Thorac Surg 78: 1761-1768. 14. Tacconi F, Pompeo E, Fabbi E, Mineo TC (2010) Awake video-assisted pleural decortication for empyema thoracis. Eur J Cardiothorac Surg 37: 594-601. 15. Pompeo E, Tacconi F, Mineo D, Mineo TC (2007) The role of awake video-assisted thoracoscopic
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surgery in spontaneous pneumothorax. J Thorac Cardiovasc Surg 133: 786-790. 16. Chen KC, Cheng YJ, Hung MH, Tseng YD, Chen JS (2012) Nonintubated thoracoscopic lung resection: a 3-year experience with 285 cases in a single institution. J Thorac Dis 4: 347-351. 17. Chen JF, Lin JB, Tu YR, Lin M, Li X, et al. (2016) Nonintubated transareolar single-port thoracic sympathicotomy with a needle scope in a series of 85 male patients. Surg Endosc 30: 3447-3453. 18. Liu J, Cui F, Li S, Chen H, Shao W, et al. (2015) Nonintubated video-assisted thoracoscopic surgery
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under epidural anesthesia compared with conventional anesthetic option: a randomized control study. Surg Innov 22: 123-130.
19. Liu J, Cui F, Pompeo E, Gonzalez-Rivas D, Chen H, et al. (2016) The impact of non-intubated versus intubated anaesthesia on early outcomes of video-assisted thoracoscopic anatomical resection in non-small-cell lung cancer: a propensity score matching analysis. Eur J Cardiothorac Surg 50: 920-925.
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20. Shao W, Shen J, Ying W, He J (2016) Mediastinoscopic tracheal resection and reconstruction under spontaneous-breathing anesthesia. J Thorac Cardiovasc Surg 151: e105-107. 21. Guo Z, Yin W, Wang W, Zhang J, Zhang X, et al. (2016) Spontaneous ventilation anaesthesia: total
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intravenous anaesthesia with local anaesthesia or thoracic epidural anaesthesia for thoracoscopic bullectomy. Eur J Cardiothorac Surg 50: 927-932.
22. Li S, Jiang L, Ang KL, Chen H, Dong Q, et al. (2016) New tubeless video-assisted thoracoscopic surgery for small pulmonary nodules. Eur J Cardiothorac Surg.
23. Nakanishi R, Yamashita T, Muranaka K, Shinohara K (2013) Thoracoscopic carinal resection and reconstruction in a patient with mucoepidermoid carcinoma. J Thorac Cardiovasc Surg 145: 1134-1135.
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24. Porhanov VA, Poliakov IS, Selvaschuk AP, Grechishkin AI, Sitnik SD, et al. (2002) Indications and results of sleeve carinal resection. Eur J Cardiothorac Surg 22: 685-694. 25. Sinclair SE, Kregenow DA, Lamm WJ, Starr IR, Chi EY, et al. (2002) Hypercapnic acidosis is protective in an in vivo model of ventilator-induced lung injury. Am J Respir Crit Care Med 166: 403-408. 26. Bowdle TA, Glenn M, Colston H, Eisele D (1987) Fire following use of electrocautery during
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emergency percutaneous transtracheal ventilation. Anesthesiology 66: 697-698. 27. Lanuti M, Mathisen DJ (2004) Carinal resection. Thorac Surg Clin 14: 199-209. 28. Block MI, Khitin LM, Sade RM (2006) Ethical process in human research published in thoracic surgery journals. Ann Thorac Surg 82: 6-11; discussion 11-12.
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29. de Perrot M, Fadel E, Mercier O, Mussot S, Chapelier A, et al. (2006) Long-term results after carinal resection for carcinoma: does the benefit warrant the risk? J Thorac Cardiovasc Surg 131: 81-89.
30. Gonzalez-Rivas D, Bonome C, Fieira E, Aymerich H, Fernandez R, et al. (2016) Non-intubated video-assisted thoracoscopic lung resections: the future of thoracic surgery? Eur J Cardiothorac Surg 49: 721-731. 31. Gonzalez-Rivas D, Aymerich H, Bonome C, Fieira E (2015) From Open Operations to Nonintubated Uniportal Video-Assisted Thoracoscopic Lobectomy: Minimizing the Trauma to the Patient. Ann Thorac Surg 100: 2003-2005.
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ACCEPTED MANUSCRIPT Figure legends
501
Figure 1. Specific lesions and details of tracheal and carinal resection and
502
reconstruction. a,c. chest reconstructed computed tomography. b,d. surgical resection
503
plan.
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Figure 2. Key techniques in tracheal resection and reconstruction. a. determine the
506
tumor margins under bronchoscopic view; b. mobilize the trachea and resect the
507
tumor; c. end-to-end anastomosis of the trachea starting from the distal corner of the
508
posterior tracheal wall; d. End-to-end anastomosis being completed.
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Figure 3. Key techniques in carinal resection and reconstruction. a. mobilize the
511
trachea and bronchus, and resect the tumor; b. end-to-end anastomosis of the distal
512
trachea and the left main bronchus starting from the posterior tracheal wall; c. right
513
main bronchus being implanted into the aperture; d. carinal reconstruction being
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completed.
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Video legend: The surgical procedure of SV-VATS carina resection and
517
reconstruction.
518 519 520 521
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Control events
n=18
n=14
Age, y(median, range)
49(16-59)
36(16-74)
(95% CI)
[36-51]
[30-52]
Male
10(56)
10(71)
Female
8(44)
4(29)
mass
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Body
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Sex(%)
index, 21.7±2.1
kg/m2(mean± ±SD)
[20.6-22.8]
(95% CI)
[18-27.2]
2(14)
1(6)
2(14)
Nonalcoholic fatty liver 2(11) disease
22.6±7.7
2(11)
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Diabetes mellitus
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Comorbidity(%) Hypertension
2(14)
Cardiovascular disease
0
0
Others
4(22)
1(7)
Pulmonary function texts, %(mean± ±SD) (95% CI) Forced vital capacity
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Variable
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91.7±10.4
91±14.4
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expiratory 67.7±27.8
Forced
[53.5-82]
volume in 1 second
ejection 73.4±4.6
Ventricular
fraction,%(mean± ±SD)
[70.0-75.4]
[80.2-101.8] 68.5±33.4 [43.4-93.7] 70.5±4.5
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[86.4-97]
[67.4-72.9]
(95% CI)
[1.5-2.3]
(95% CI) Distance
vocal 7.4±0.8(6-8.5)
from
cords, cm(mean ± SD, [7.0-7.8]
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range) (95% CI) ASA* status(%)
12(67)
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I II
Bronchoscopic
[1.6-2.5]
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cm(mean± ±SD, range)
2.1±0.8(1.1-3.8)
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Max length of lesion, 1.9±0.7(0.7-3.2)
7.9±1.5(6-10) [7.0-8.8]
3(21)
6(33)
7(50)
-
4(29)
biopsy, 8±2
7±3
times(mean± ±SD) Pathological diagnosis(%) Adenoid
cystic 5(28)
3(21)
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2(14)
2(11)
1(7)
Glomangioma
2(11)
1(7)
Others
4(22)
7(50)
Squamous-cell
Mucoepidermoid
*ASA: American Society of Anesthesiologists.
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CI: confidence intervals.
525 526
530 531 532 533 534 535 536 537
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carcinoma
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carcinoma
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ACCEPTED MANUSCRIPT Table 2. Operative details. SV-VATS group
Control group
(18)
(14)
Surgical duration, min, 162.5(75) median(IQR),
(95% [141.0-204.3]
260(126) [193.4-305.7]
CI)
(n=14)
end-to-end
median(IQR) (95% CI) Time
(n=12)
min, [19.3-38.4]
anastomosis,
of
[37.2-65.1]
carinal 40(14.3)
86(-)
min, (n=4)
(n=2)
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reconstruction,
45(28.3)
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tracheal 22.5(20.4)
of
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Time
median(IQR) (95% CI)
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Variable
[28.3-53.2]
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Lowest SpO2 during 94.2±4.9(83-100) operation, %(mean ± [91.7-96.7]
[22.5-149.5] 93.9±4.5(85-100) [91.2-96.5]
SD, range) (95% CI)
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Peak
EtCO2
during 47.7±4.2(41-55)
operation, mmHg(mean [45.5-49.8]
39.1±5.7(30-47) [35.6-42.5]
±SD, range) (95% CI) Conversion to tracheal 0
-
intubation Intraoperative
blood 25(30)
35(82.5)
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[23.3-94.6]
(95% CI) node
sample 11(2-35)
number, median(range)
(n=11)
(n=11)
node 2
Lymph
14(2-23)
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Lymph
2
involvement (N2) of
excision, 2.5±1(1.2-4)
(95% CI) Positive
surgical 1
margins
542 543 544 545 546 547 548 549
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541
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IQR: interquartile range
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[1.8-3.5]
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cm(mean ± SD, range) [2.0-3.0]
2.6±1.5(1-4)
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Length
3
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ACCEPTED MANUSCRIPT Table 3. Treatment outcomes Variable
SV-VATS
group Control
(18)
(14)
VAS 2.7±0.8
2.6±0.8
[2.4-3.2]
[2.2-3.1]
Anastomotic stenosis
1(6)
-
Anastomotic fistula
-
1(7)
Hemothorax
1(6)
Pulmonary atelectasis
-
Pneumonia
3(17)
Vocal cord paralysis
1(6)
Postoperative score* (95% CI)
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Postoperative ICU stay, 1(0-12)
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Postoperative
hospital 12±4 [9-14]
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stay, day (95% CI) Minimal
diameter
anastomotic
of 1.8±0.2
position [1.7-1.9]
postoperatively,
-
1(7)
5(36)
2(14)
2(1-7)
13±6 [10-17] 1.6±0.4 [1.4-1.9]
cm
(95% CI) Adjuvant therapy 551
VAS: visual analogue scale.
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Complications(%)
day, (median, range)
group
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550
3
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T4N0M0
Histology
Cases SV-VATS group
Control group
Squamous carcinoma
3
2
Adenocarcinoma
1
Adenoid
cystic 5
carcinoma
carcinoma Carcinoid
555 556 557 558 559 560 561 562
Squamous carcinoma
2
1
Small cell carcinoma
-
1
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554
1
1
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553
3
-
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T4N2M0
2
-
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Mucoepidermoid
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Pathologic stage
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552
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Table 5. Reasons for conversion to general anesthesia 1. Major bleeding, severe pleural adhesions, large tumors; 2. Severe hypoxemia, hypercapnia and acidosis;
arrhythmias and right ventricular failure;
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3. Haemodynamic instability: hypotension, cardiac index decreased, intractable
4. Persistent cough that creates difficulty or prevents performing surgery;
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5. Excessive movement of the diaphragm or mediastinum, causing unsafe surgery;
7. Intraoperative airways injury…
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6. Inability to collapse the lung;
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S0022-5223(18)30405-7
DOI:
10.1016/j.jtcvs.2017.12.153
Reference:
YMTC 12621
To appear in:
The Journal of Thoracic and Cardiovascular Surgery
Received Date: 20 May 2017 Revised Date:
2 November 2017
Accepted Date: 26 December 2017
Please cite this article as: Jiang L, Liu J, Gonzalez-Rivas D, Shargall Y, Kolb M, Shao W, Dong Q, Liang L, He J, Thoracoscopic Surgery for Tracheal and Carinal Resection and Reconstruction under Spontaneous Ventilation, The Journal of Thoracic and Cardiovascular Surgery (2018), doi: 10.1016/ j.jtcvs.2017.12.153. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Thoracoscopic Surgery for Tracheal and Carinal Resection and Reconstruction
2
under Spontaneous Ventilation
3
Long Jiang, MD, PhD1; Jun Liu, MD, PhD1; Diego Gonzalez-Rivas, MD2; Yaron
5
Shargall, MD3; Martin Kolb, MD, PhD4; Wenlong Shao, MD, PhD1; Qinglong Dong,
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MD5; Lixia Liang, MD5; Jianxing He, MD, PhD1
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1
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Department of Thoracic Surgery, the First Affiliated Hospital of Guangzhou Medical
University; Guangzhou Institute of Respiratory Disease & China State Key
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Laboratory of Respiratory Disease & National Clinical Research Center for
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Respiratory Disease, Guangzhou, China.
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13 14
2
15
Coruña, Spain.
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Department of Thoracic Surgery, Coruña University Hospital, Xubias 84, 15006.
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3
18
Joseph’s Healthcare Hamilton, Hamilton, Ontario, Canada.
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Department of Surgery, Division of Thoracic Surgery, McMaster University/St.
20
4
21
Firestone Institute for Respiratory Health, Hamilton, Ontario, Canada.
22
Department of Medicine, Pathology and Molecular Medicine, McMaster University,
2
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5
24
University.
Department of Anesthesiology, the First Affiliated Hospital of Guangzhou Medical
25
LJ and JL contributed equally to this work.
27
Written on behalf of AME Thoracic Surgery Collaborative Group.
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Conflict of interest statement and source of funding: None.
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Correspondence to: Jianxing He, MD, PhD, FACS. Department of Thoracic
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Surgery/Oncology, the First Affiliated Hospital of Guangzhou Medical University;
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Guangzhou Institute of Respiratory Disease & China State Key Laboratory of
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Respiratory Disease & National Clinical Research Center for Respiratory Disease, No.
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151, Yanjiang Rd, Guangzhou 510120, China. Email: [email protected]
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Word count: 3047
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Glossary of Abbreviations:
46
VATS=video
47
CT=computed tomography; PET=positron emission tomography; ASA=American
48
Society of Anesthesiologists; BMI=body mass index; BIS=bispectral index; VAS=
49
Visual Analogue Scale.
thorocoscopic
50
SV=spontaneous
ventilation;
Central Picture Legend: Specific lesions and details of tracheal resection.
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surgery;
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assisted
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Central Message: SV-VATS is a feasible procedure in airway surgery in highly
54
selected patients. It can be a valid alternative to conventional intubated VATS for
55
airway surgery.
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Perspective statement: During conventional intubated tracheal and carinal surgery,
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airway management includes several challenges related to tube management without
59
interfering with the surgical field and maintaining ventilation with favorable
60
oxygenation. SV-VATS technique is a feasible procedure in airway surgery.
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Objectives: The aim of this study was to describe and assess the techniques of
69
spontaneous ventilation video-assisted thoracoscopic surgery (SV-VATS) for
70
tracheal/carinal resections and compare the outcomes with the conventional
71
thoracoscopic intubated method.
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Methods: From May 2015 to November 2016, some 18 consecutive patients with
74
malignant or benign diseases invading distal trachea and carina who met the criteria
75
for SV were treated by SV-VATS resection. To evaluate the feasibility of this novel
76
technique, they were compared with a control group consisting of 14 consecutive
77
patients with the same diseases who underwent VATS resection using intubated
78
general anesthesia from October 2014 to April 2015. Data were collected with a
79
median follow-up of 10.2 months 75 (range:1-27).
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Results: The SV-VATS group consisted of 4 carinal resections and 14 tracheal
82
resections. In the control group, 2 patients underwent carinal resection and 12
83
underwent tracheal resection. Median operative time was shorter in the SV-VATS
84
group compared with the intubated group (162.5 min vs. 260 min), as was the median
85
time for tracheal end-to-end anastomosis (22.5 min vs. 45 min) and carinal
86
reconstruction (40 min vs. 86 min). The lowest oxygen saturation during the
87
procedure was 94.2±4.9% in SV-VATS group and 93.9±4.5% in the control group.
88
The peak CO2 level at the end of expiration was higher in the SV-VATS group
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90
needed in the SV-VATS group. Postoperative complications occurred in six patients in
91
the SV-VATS group and nine in the control group. Patients who undergoing SV-VATS
92
had a trend toward shorter postoperative hospital stays (11.5±4.3d vs. 13.2±6.3d). One
93
recurrence (SV-VATS group) and two deaths (one in each group) were observed
94
during follow-up.
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Conclusions: SV-VATS is a feasible procedure in tracheal and carinal resection and
97
reconstruction in highly selected patients. It can be a valid alternative to conventional
98
intubated VATS for airway surgery.
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Key Words: spontaneous ventilation; video-assisted thoracoscopic surgery; trachea;
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carina; resection and reconstruction.
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112
Video-assisted thoracoscopic surgery (VATS) has been reported as feasible and safe in
113
technically demanding complex tracheal and carinal surgery[1-3]. However,
114
morbidity is not completely eliminated, with potential risks posed by conventional
115
intubation and general anesthesia. Deep anesthesia and intravenous analgesics
116
(primarily opioids) have deleterious
117
postoperative complications[4,5]. Mechanical ventilation may cause airway
118
pressure-induced injury by lung over-distension[6,7]. Endotracheal intubation can
119
also result in sore throat, mucosal ulceration and airway injury[8].
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associated
with
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systemic side-effects
120
Spontaneous ventilation VATS(SV-VATS) has recently been extensively investigated
122
and has been reported to reduce the adverse effects of tracheal intubation and general
123
anesthesia.[9-15] It has been advocated as an alternative to conventional intubated
124
anesthesia for a variety of VATS procedures.[12,16,17] Our experience mirrored that
125
of previous studies, demonstrating that patients operated under SV-VATS had a
126
shorter post-operative recovery time, and were able to eat and mobilize earlier
127
compared with the conventional endotracheal ventilation VATS approach[18,19].
128
However, whether the SV-VATS technique can offer benefits for tracheal surgery is
129
unknown. In the present study, we have expanded the SV-VATS application to include
130
tracheal and carinal resections and reconstructions, and compared its outcomes with
131
conventional intubated methods.
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Material and methods
135
Between October 2014 and November 2016, clinical data for all consecutive patients
136
undergoing VATS tracheal or carinal resection and reconstruction were analyzed. The
137
patients in the control group received combined intravenous anesthesia using a
138
single-lumen 6.5mm endotracheal tube (Well Lead, Inc, Guangzhou, Guangdong,
139
China) for one-lung ventilation at the start of the procedures. Cross-field ventilation
140
was used during the tracheal and carinal procedures. During the operation, the
141
cross-field endobronchial tube can be introduced through either the operating port or
142
an additional port[1]. Patients undergoing tracheal or carinal resection using
143
conventional intubation were compared to those undergoing SV-VATS. The study was
144
approved by the First Affiliated Hospital of Guangzhou Medical University Research
145
Ethics Committee.
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Preoperative evaluation
148
Cardiac and pulmonary functions were evaluated preoperatively using cardiac 2D
149
echo, electrocardiogram and pulmonary function tests. Routine preoperative
150
evaluation to exclude distant metastases included thoracic and abdominal contrast
151
computed tomography (CT) or positron emission tomography (PET-CT) scan,
152
magnetic resonance imaging (MRI) of the brain, and bone scintigraphy. Any
153
ambiguities on the results were resolved by holding a multidisciplinary consultation to
154
decide whether an operation was necessary. During patient evaluation, if
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bronchoscopic evaluation revealed more than 70%-80% obstruction of the trachea, a
156
wire loop electrocautery was used to resect the majority of the tumor before tracheal
157
resection as described in a previous report[20].
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Indications for SV-VATS anesthesia
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Patients eligible for SV-VATS fulfilled the following criteria: ASA grade of I-II, and a
161
body mass index (BMI) <25. Patients with a bleeding disorder, sleep apnea, evidence
162
of pleural adhesions, unfavorable airway features (such as congenital pulmonary
163
airway malformation) or spinal anatomical characteristics were not eligible for this
164
procedure. In addition, preoperative bronchoscopic examination was performed in
165
each case to confirm pathology, as well as the extent of tumor involvement evaluated
166
via multiple biopsies. In our center, we consider patients eligible for resection if they
167
have a resectable airway lesion involving no more than 4cm of the trachea. Whether
168
the SV-VATS or conventional technique was used was determined by surgeon’s
169
preference.
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Anesthetic and surgical management in SV-VATS procedures
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Anesthetic Considerations
173
Details of the anesthetic procedure were described in our previous report[21]. In short,
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anesthesia was induced with the target-controlled infusion (TCI) of propofol (target
175
plasma concentration of 2-3ug/ml) and sufentanil 0.1-0.2 ug/kg. Muscle relaxants
176
were not used. Bispectral index (BIS) monitoring was maintained at 40 to 60 during
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178
ventilation, a gradual and natural collapse of the operative lung occurred allowing
179
maximal visualization of the lungs after making the incisions. To reduce cough
180
induced by thoracoscopic manipulations, under direct thoracoscopic vision vagus
181
nerve block was performed and 2% lidocaine was sprayed on the surface of the
182
lung[22].
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Anesthesia was maintained with TCI of propofol (target plasma concentration of 1-2
185
ug/ml), dexmedetomidine 0.5-1 ug/kg/h and remifentanil 0.05 ug/kg/min. Incisions
186
were performed after local application of 1% lidocaine. Optimally, the intercostal
187
muscle and pleura were infiltrated under direct vision or palpation through the skin
188
incision. The patients’ electrocardiogram (ECG), heart rate (HR), blood pressure (BP),
189
pulse oxygen saturation (SpO2), end-tidal carbon dioxide (EtCO2), respiratory rate
190
(RR) and BIS were continuously monitored. During the procedure, a laryngeal mask
191
was used for oxygen inhalation, with an oxygen flow of 4-5 L/min, keeping oxygen
192
saturation above 95%. Endotracheal ventilation and cross-field ventilation were also
193
prepared as backup in case of an emergency situation, such as hypoxemia, requiring
194
peri-operative conversion of the intubation method.
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Surgical techniques
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Surgical preparation for all patients was identical. All patients were positioned in a
198
left lateral decubitus position. Three incisions were made: a 10-mm camera port, at
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ACCEPTED MANUSCRIPT the seventh intercostal space along the right anterior axillary line; a 4-cm main
200
operative port, located at the fourth intercostal space on the right anterolateral chest
201
wall; and a 10-mm port, at the seventh intercostal space along the right posterior
202
axillary line. We used a flexible bronchoscope through the laryngeal mask to identify
203
the proximal and distal extent of the lesion. If lung resection was needed, it was
204
performed followed by lymph node dissection.
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The azygous vein was dissected and divided, if needed, using a 35-mm Endo cutter
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(Ethicon, Inc, Somerville, NJ). The parietal pleura was then opened from this point
208
extending toward the apex, along the lateral side of the superior vena cava. This
209
maneuver allowed the trachea and proximal bronchus to be mobilized with a
210
combination of blunt dissection and Harmonic Scalpel (Ethicon, Inc, Somerville, NJ).
211
Right paratracheal lymph nodes were also removed to aid with exposure and
212
mobilization of the airway if necessary. Extra attention was taken during this
213
dissection to protect the bronchial arteries and vagus nerve. The right vagus nerve was
214
identified and carefully moved to one side. We sometimes suspended it to the
215
posterior chest wall with 3-0 polypropylene (Prolene, Ethicon, Inc, Somerville, NJ). A
216
silicon sling was then placed around the trachea and each of the bronchi. Extra 3-0
217
Prolene retraction sutures were also placed in each of the airways. This technique
218
allowed retraction and exposure of the airway for further resection and reconstruction.
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219 220
Preoperative bronchoscopic examination was performed to confirm pathology, as well
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ACCEPTED MANUSCRIPT as the extent of tumor involvement evaluated via multiple biopsies. According to the
222
biopsies, the resection was performed 5 to 10mm above and below the tumor margins.
223
If the lesion was malignant, we resected the trachea on the near position of tumor
224
cell-free. Two types of surgical procedures were performed in our study: tracheal
225
resection with end-to-end anastomosis and carinal resection and reconstruction with
226
two sets of anastomosis(Fig.2/3). Cervical extension was sometimes changed to a
227
lower degree to allow the trachea to move into the mediastinum before the initiation
228
of anastomosis. Anastomosis was carried out using a continuous 3-0 Prolene suture,
229
starting from the posterior cartilaginous tissue followed by the membranous section.
230
For carina reconstruction, we performed the resection of the carina first, followed by a
231
total end-to-end anastomosis between the left main bronchus and the trachea, and
232
finally anastomosis of the right main bronchus to the lateral, cartilaginous wall of the
233
trachea. After end-to-end suture of the trachea, we used additional 3-0 Prolene
234
tension-reduction suture to strengthen and protect the anastomosis. We did not use
235
muscle flaps or other tissues to protect the anastomosis. And we do not perform hilar
236
release.
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Following completion of the anastomosis, we used a saline solution to test for
239
evidence of air leaks. If any air leak was observed, additional stitches were used to
240
reinforce the suture until intraoperative air leak test was confirmed negative. Only one
241
chest tube is placed at the end of the operation.(Video 1)
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ACCEPTED MANUSCRIPT At the end of the surgery, a bronchoscopy was used to check the integrity of the
244
anastomosis and, if there were concerns with sputum retention, any airway secretion
245
was cleared. Upon completion of the operation, stitches between the chin and chest or
246
philadelphia cervical collars were placed to avoid excessive tension in the early
247
postoperative stage.
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Postoperative care in both groups
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Patients were transferred to the intensive care unit (ICU) if necessary according to the
251
intraoperative and anesthesia situations in the operating room and during recovery.
252
Chest X-ray and bedside ultrasound were performed for evaluation on the same day.
253
The voice was accessed by otolaryngologists using a professional speech and voice
254
analysis
255
anti-inflammatory drugs or a fentanyl patch were used if necessary. Formal pain
256
assessment for the study was carried out on the morning of post-operative day 1 using
257
the Visual analogue scales (VAS: 0 is completely pain-free and 10 is hard to tolerate).
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Painkillers,
such
as
non-steroidal
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Disorder
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system(Voice
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Statistical Analysis
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Continuous data are presented as mean ± standard deviation, median and interquartile
261
range (IQR) depend on the distribution. The 95% confidence intervals are also
262
reported. Categorical variables are given as a count and percentage of patients. Some
263
variables were not-normally distributed (surgical duration, time of tracheal end-to-end
264
anastomosis, time of carinal reconstruction, intraoperative blood loss), so median(IQR)
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was summarized. All statistical tests were performed using SPSS 13.0 for Windows
266
(SPSS, Inc., Chicago, IL).
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Results
270
Between October 2014 and November 2016, a total of eighteen patients underwent
271
SV-VATS tracheal/carinal resection and reconstruction for benign or malignant
272
diseases in our center (trachea:14; carina: 4) (Group 1- SV-VATS). This group was
273
compared to a group of patients consisting of fourteen patients that underwent
274
conventionally intubated VATS procedures(trachea: 12; carina: 2) during the same
275
period of time (Group 2- control group). Age, sex, body mass index(BMI),
276
comorbidities, pulmonary and cardiac functions, lesion size, distance from vocal
277
cords, bronchoscopic biopsy patch and pathological diagnosis did not differ between
278
the two groups. However, the ASA status was different between both groups as there
279
were no grade III patients in the SV-VATS group whereas 4 patients with an ASA
280
grade III were included in the control group. (Table.1)
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Operative and Anesthetic Data
283
The same surgical team performed on all these airway surgery. Patients in the
284
SV-VATS group had shorter median durations of operative time (162.5 min vs. 260
285
min), tracheal end-to-end anastomosis time (22.5 min vs. 45 min) and carinal
286
reconstruction time (40 min vs. 86 min) compared with the intubated group. The two
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ACCEPTED MANUSCRIPT groups had comparable blood loss, numbers of dissected lymph nodes and length of
288
tracheal excision. Final pathologic results showed positive surgical margins in 4
289
patients, all were confirmed adenoid cystic carcinoma (SV-VATS:1 vs. control
290
group:3). (Table.2)
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During the procedures, the mean lowest oxygen saturation was 94.2±4.9% in
293
SV-VATS group and 93.9±4.5% in the control group. The mean peak EtCO2 in the
294
SV-VATS group was higher than that in the intubated group (47.7±4.2 vs. 39.1±5.7)
295
due to mild hypercapnia under spontaneous ventilation anesthesia. No conversion to
296
tracheal intubation was needed in the SV-VATS group.
297
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Postoperative Recovery
299
The post-operative VAS scores of both groups were similar(SV-VATS: 2.7±0.8 vs.
300
control: 2.6±0.8). The median ICU stay was one day in the SV-VATS group and 2
301
days in the intubated group. Additionally, patients who underwent SV-VATS had a
302
trend toward shorter postoperative hospital stay (11.5±4.3d vs. 13.2±6.3d).
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Postoperative complications occurred in six patients in the SV-VATS group and nine
305
in the control group (Table.3). In the SV-VATS group, anastomotic stenosis occurred
306
in one patient which was successfully managed with placement of stents. In the
307
intubated group, anastomotic fistula occurred in one patient and was repaired by
308
reoperation. There were no cases of perioperative mortality.
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Survival and follow-up
311
During a median follow-up time of 10.2 months, the minimal diameter of tracheal
312
anastomotic position on Chest CT six months postoperatively was comparable in both
313
groups (1.8±0.2cm vs. 1.6±0.4cm).
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For patients with malignant disease, the final results of tumor stage are shown in
316
Table 4. Six patients in the SV-VATS group and three in the intubated group received
317
adjuvant chemo- or radiotherapy (Table.3). One recurrence and two deaths were
318
observed during the follow-up time. Mortality was 6.2% during follow-up.
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Discussion
322
During conventional intubated tracheal and carinal surgery, airway management may
323
present several challenges. Most significantly is the challenge of maintaining
324
ventilation with favorable oxygenation using an endotracheal tube which can
325
sometimes interfere with the surgical field[23]. Cross-field ventilation is a universally
326
accepted strategy for conventional intubated VATS for airway surgery. However, this
327
endobronchial tube may obstruct the view of the anastomosis site and may require
328
periodical retraction during anastomosis to improve exposure. High-frequency jet
329
ventilation (HFJV) via the lumen of the blocker tube was reported to help achieve
330
one-lung ventilation without causing injury to the tumor. However, there have been
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ACCEPTED MANUSCRIPT concerns that the use of HFJV could contribute to acute respiratory distress
332
syndrome[24]. While the SV technique is likely not possible to be performed during
333
thoracotomy, it is a valid option for VATS cases, as demonstrated both in our own
334
experience and recent literature. Since most of our practice, including airways
335
resection and reconstruction, is performed thoracoscopically, it allowed us to
336
carry-out this comparative study of conventional VATS intubation airways
337
reconstruction with SV-VATS. Our study suggests that the SV-VATS technique
338
facilitates the anesthetic and surgical procedures.
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339
Without the endotracheal tube the trachea is more flexible with a wider range of
341
motion during resection and anastomosis. During the spontaneous ventilation
342
anesthetic procedure, we use a laryngeal mask to protect the airway and aid the
343
intubation procedure in the event emergency intubation is required. Avoiding the use
344
of the endotracheal tube gives surgeons the advantage of an unobstructed view of the
345
surgical field. Because of this, the anastomosis and reconstruction were much faster
346
when compared with the intubated procedures, which resulted in an overall reduction
347
of the operative time.
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We demonstrated that SV-VATS was feasible without a need for conversion. Though
350
some hypercapnia was noted compared to the control group, especially during the
351
anastomosis phase; in this case, we have found that temporary suspension of operative
352
maneuvers and measures to maintain adequate hemostasis around the trachea will
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ACCEPTED MANUSCRIPT result in the decrease of EtCO2. Our experience has also shown such hypercapnia to
354
be well tolerated without affecting the hemodynamics or surgical procedures. Of note,
355
it has previously been suggested that permissive hypercapnia may, in fact, improve
356
hemodynamics and ventilation/perfusion match and provide protective effects on
357
inflammatory responses[25].
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During the course of this study, we also developed some tips and tricks regarding the
360
technique. Fire within the chest cavity is a well-documented event during airway
361
surgery[26] that poses dangers to the patient as well as to the operating theatre
362
personnel. The improved management of airway fire during airway surgery is based
363
on prevention. We reinforce coordination and communication between the anesthetic
364
and surgical teams, and systematically use suction to decrease the amount of oxygen
365
near the electrocautery. During these procedures, we used a harmonic endocutter to
366
reduce the risk of airway fire after resection of the trachea. Also at this point the
367
resulting smoke if using electrocautery could affect the oxygen supply and/or increase
368
the patients’ airway sensitivity. For patients who inhale too deeply or who have a
369
longer remaining membranous portion after initial resection of the trachea that is
370
likely to result in obstruction of the airway during inhalation, a small fine tube such as
371
nasal oxygen catheter can be placed in the distal portion of the trachea. This tube is
372
used to prevent complete closure of the distal trachea and to protect the spontaneous
373
breathing of the patient after the resection and during the beginning of anastomosis.
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In our study, the mortality was 6.2% during the follow-up time of 10.2 months, which
376
is consistent with mortality rates of previous reports ranging from 4% to
377
12.7%[27,28]. There were four positive margins(SV-VATS:1, IVATS:3), all of which
378
were adenoid cystic carcinoma,
379
frozen section intraoperatively. This might be due to the intrinsic property of adenoid
380
cystic carcinoma, which spread most commonly by direct extension, submucosal or
381
perineural invasion, in transverse and longitudinal planes. Patients who underwent
382
SV-VATS had a trend toward shorter postoperative hospital stays. This consideration
383
is particularly important in China, where primary care at a patient´s home town is not
384
widely available. We believe our SV-VATS technique allows early discharge without
385
undue worries about patient safety after discharge home.
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though margins were confirmed tumor-free by
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The promising outcomes of the SV-VATS may partially be the result of careful patient
388
selection, as outlined earlier in the discussion of our methods. Physical condition
389
should also be taken into consideration. None of the patients in our study received
390
neo-adjuvant radio-chemotherapy because no metastatic disease was found by
391
preoperative evaluation. At the current time, we do not consider neo-adjuvant
392
radio-chemotherapy in newly diagnosed N2 patients requiring carinal reconstruction
393
mainly because of its association with anastomosis-related complications and
394
operative mortality[29]. We assume that strict preoperative patient selection, good
395
preoperative preparation, and improved postoperative care might have contributed to
396
these encouraging results.
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To ensure patient safety, some clearly defined protocol for elective or urgent
399
intubation must be determined prior to the operation. We have listed some reasons for
400
conversion to general anesthesia in table 5. In addition, intubation in the lateral
401
decubitus position is a technical challenge for anesthesiologists. The anesthesiologist
402
must be skilled in placing a double-lumen tube, laryngeal mask, fibrotic
403
bronchoscopic intubation, video-assisted system management and endobronchial
404
blocker in order to securely choose the most appropriate device depending on the
405
patient’s airway, the position of the patient, time of completion of the procedure and
406
the causes that have led to conversion to general anesthesia[30]. We think continuous
407
and effective communication between surgeons and anesthesiologists is paramount.
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As this is a preliminary feasibility study some limitations should be acknowledged.
410
First, it is retrospective in nature and bias between the study arms cannot be
411
completely excluded. Second, due to the relative infrequency of such complex surgery,
412
the cohort size is small, limiting the power of analysis and conclusions. Third, the
413
selection criteria itself, specifically in regards to BMI, were designed for a Chinese
414
population. We cannot be certain that our findings are necessarily applicable for
415
populations outside China. For Western populations, for example, the BMI inclusion
416
criteria can perhaps be raised to a BMI of <30[31].
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In conclusion, in our experience, SV-VATS for tracheal and carinal resections was
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feasible. The SV-VATS technique offered shorter operative times and potentially
420
faster recovery than the conventional intubated method. Further prospective research
421
is needed to confirm the validity of these results.
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2. Zhao G, Dong C, Yang M, Du X, Hu X (2014) Totally thoracoscopic tracheoplasty for a squamous cell
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3. Jiao W, Zhu D, Cheng Z, Zhao Y (2015) Thoracoscopic tracheal resection and reconstruction for adenoid cystic carcinoma. Ann Thorac Surg 99: e15-17.
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11. Wu CY, Chen JS, Lin YS, Tsai TM, Hung MH, et al. (2013) Feasibility and safety of nonintubated thoracoscopic lobectomy for geriatric lung cancer patients. Ann Thorac Surg 95: 405-411.
12. Mineo TC, Pompeo E, Mineo D, Tacconi F, Marino M, et al. (2006) Awake nonresectional lung volume reduction surgery. Ann Surg 243: 131-136. 13. Pompeo E, Mineo D, Rogliani P, Sabato AF, Mineo TC (2004) Feasibility and results of awake thoracoscopic resection of solitary pulmonary nodules. Ann Thorac Surg 78: 1761-1768. 14. Tacconi F, Pompeo E, Fabbi E, Mineo TC (2010) Awake video-assisted pleural decortication for empyema thoracis. Eur J Cardiothorac Surg 37: 594-601. 15. Pompeo E, Tacconi F, Mineo D, Mineo TC (2007) The role of awake video-assisted thoracoscopic
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surgery in spontaneous pneumothorax. J Thorac Cardiovasc Surg 133: 786-790. 16. Chen KC, Cheng YJ, Hung MH, Tseng YD, Chen JS (2012) Nonintubated thoracoscopic lung resection: a 3-year experience with 285 cases in a single institution. J Thorac Dis 4: 347-351. 17. Chen JF, Lin JB, Tu YR, Lin M, Li X, et al. (2016) Nonintubated transareolar single-port thoracic sympathicotomy with a needle scope in a series of 85 male patients. Surg Endosc 30: 3447-3453. 18. Liu J, Cui F, Li S, Chen H, Shao W, et al. (2015) Nonintubated video-assisted thoracoscopic surgery
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20. Shao W, Shen J, Ying W, He J (2016) Mediastinoscopic tracheal resection and reconstruction under spontaneous-breathing anesthesia. J Thorac Cardiovasc Surg 151: e105-107. 21. Guo Z, Yin W, Wang W, Zhang J, Zhang X, et al. (2016) Spontaneous ventilation anaesthesia: total
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24. Porhanov VA, Poliakov IS, Selvaschuk AP, Grechishkin AI, Sitnik SD, et al. (2002) Indications and results of sleeve carinal resection. Eur J Cardiothorac Surg 22: 685-694. 25. Sinclair SE, Kregenow DA, Lamm WJ, Starr IR, Chi EY, et al. (2002) Hypercapnic acidosis is protective in an in vivo model of ventilator-induced lung injury. Am J Respir Crit Care Med 166: 403-408. 26. Bowdle TA, Glenn M, Colston H, Eisele D (1987) Fire following use of electrocautery during
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emergency percutaneous transtracheal ventilation. Anesthesiology 66: 697-698. 27. Lanuti M, Mathisen DJ (2004) Carinal resection. Thorac Surg Clin 14: 199-209. 28. Block MI, Khitin LM, Sade RM (2006) Ethical process in human research published in thoracic surgery journals. Ann Thorac Surg 82: 6-11; discussion 11-12.
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29. de Perrot M, Fadel E, Mercier O, Mussot S, Chapelier A, et al. (2006) Long-term results after carinal resection for carcinoma: does the benefit warrant the risk? J Thorac Cardiovasc Surg 131: 81-89.
30. Gonzalez-Rivas D, Bonome C, Fieira E, Aymerich H, Fernandez R, et al. (2016) Non-intubated video-assisted thoracoscopic lung resections: the future of thoracic surgery? Eur J Cardiothorac Surg 49: 721-731. 31. Gonzalez-Rivas D, Aymerich H, Bonome C, Fieira E (2015) From Open Operations to Nonintubated Uniportal Video-Assisted Thoracoscopic Lobectomy: Minimizing the Trauma to the Patient. Ann Thorac Surg 100: 2003-2005.
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ACCEPTED MANUSCRIPT Figure legends
501
Figure 1. Specific lesions and details of tracheal and carinal resection and
502
reconstruction. a,c. chest reconstructed computed tomography. b,d. surgical resection
503
plan.
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Figure 2. Key techniques in tracheal resection and reconstruction. a. determine the
506
tumor margins under bronchoscopic view; b. mobilize the trachea and resect the
507
tumor; c. end-to-end anastomosis of the trachea starting from the distal corner of the
508
posterior tracheal wall; d. End-to-end anastomosis being completed.
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509
Figure 3. Key techniques in carinal resection and reconstruction. a. mobilize the
511
trachea and bronchus, and resect the tumor; b. end-to-end anastomosis of the distal
512
trachea and the left main bronchus starting from the posterior tracheal wall; c. right
513
main bronchus being implanted into the aperture; d. carinal reconstruction being
514
completed.
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Video legend: The surgical procedure of SV-VATS carina resection and
517
reconstruction.
518 519 520 521
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ACCEPTED MANUSCRIPT Table 1. Clinical characteristics of the patients. SV-VATS events
Control events
n=18
n=14
Age, y(median, range)
49(16-59)
36(16-74)
(95% CI)
[36-51]
[30-52]
Male
10(56)
10(71)
Female
8(44)
4(29)
mass
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Body
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Sex(%)
index, 21.7±2.1
kg/m2(mean± ±SD)
[20.6-22.8]
(95% CI)
[18-27.2]
2(14)
1(6)
2(14)
Nonalcoholic fatty liver 2(11) disease
22.6±7.7
2(11)
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Diabetes mellitus
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Comorbidity(%) Hypertension
2(14)
Cardiovascular disease
0
0
Others
4(22)
1(7)
Pulmonary function texts, %(mean± ±SD) (95% CI) Forced vital capacity
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Variable
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91.7±10.4
91±14.4
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expiratory 67.7±27.8
Forced
[53.5-82]
volume in 1 second
ejection 73.4±4.6
Ventricular
fraction,%(mean± ±SD)
[70.0-75.4]
[80.2-101.8] 68.5±33.4 [43.4-93.7] 70.5±4.5
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[86.4-97]
[67.4-72.9]
(95% CI)
[1.5-2.3]
(95% CI) Distance
vocal 7.4±0.8(6-8.5)
from
cords, cm(mean ± SD, [7.0-7.8]
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range) (95% CI) ASA* status(%)
12(67)
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III
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Bronchoscopic
[1.6-2.5]
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cm(mean± ±SD, range)
2.1±0.8(1.1-3.8)
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Max length of lesion, 1.9±0.7(0.7-3.2)
7.9±1.5(6-10) [7.0-8.8]
3(21)
6(33)
7(50)
-
4(29)
biopsy, 8±2
7±3
times(mean± ±SD) Pathological diagnosis(%) Adenoid
cystic 5(28)
3(21)
25
ACCEPTED MANUSCRIPT carcinoma 5(28)
2(14)
2(11)
1(7)
Glomangioma
2(11)
1(7)
Others
4(22)
7(50)
Squamous-cell
Mucoepidermoid
*ASA: American Society of Anesthesiologists.
524
CI: confidence intervals.
525 526
530 531 532 533 534 535 536 537
EP
529
AC C
528
TE D
527
M AN U
523
SC
carcinoma
RI PT
carcinoma
26
ACCEPTED MANUSCRIPT Table 2. Operative details. SV-VATS group
Control group
(18)
(14)
Surgical duration, min, 162.5(75) median(IQR),
(95% [141.0-204.3]
260(126) [193.4-305.7]
CI)
(n=14)
end-to-end
median(IQR) (95% CI) Time
(n=12)
min, [19.3-38.4]
anastomosis,
of
[37.2-65.1]
carinal 40(14.3)
86(-)
min, (n=4)
(n=2)
TE D
reconstruction,
45(28.3)
SC
tracheal 22.5(20.4)
of
M AN U
Time
median(IQR) (95% CI)
RI PT
Variable
[28.3-53.2]
EP
Lowest SpO2 during 94.2±4.9(83-100) operation, %(mean ± [91.7-96.7]
[22.5-149.5] 93.9±4.5(85-100) [91.2-96.5]
SD, range) (95% CI)
AC C
538
Peak
EtCO2
during 47.7±4.2(41-55)
operation, mmHg(mean [45.5-49.8]
39.1±5.7(30-47) [35.6-42.5]
±SD, range) (95% CI) Conversion to tracheal 0
-
intubation Intraoperative
blood 25(30)
35(82.5)
27
ACCEPTED MANUSCRIPT loss, ml, median(IQR) [24.1-48.2]
[23.3-94.6]
(95% CI) node
sample 11(2-35)
number, median(range)
(n=11)
(n=11)
node 2
Lymph
14(2-23)
RI PT
Lymph
2
involvement (N2) of
excision, 2.5±1(1.2-4)
(95% CI) Positive
surgical 1
margins
542 543 544 545 546 547 548 549
TE D
541
EP
540
IQR: interquartile range
AC C
539
[1.8-3.5]
M AN U
cm(mean ± SD, range) [2.0-3.0]
2.6±1.5(1-4)
SC
Length
3
28
ACCEPTED MANUSCRIPT Table 3. Treatment outcomes Variable
SV-VATS
group Control
(18)
(14)
VAS 2.7±0.8
2.6±0.8
[2.4-3.2]
[2.2-3.1]
Anastomotic stenosis
1(6)
-
Anastomotic fistula
-
1(7)
Hemothorax
1(6)
Pulmonary atelectasis
-
Pneumonia
3(17)
Vocal cord paralysis
1(6)
Postoperative score* (95% CI)
M AN U
TE D
Postoperative ICU stay, 1(0-12)
EP
Postoperative
hospital 12±4 [9-14]
AC C
stay, day (95% CI) Minimal
diameter
anastomotic
of 1.8±0.2
position [1.7-1.9]
postoperatively,
-
1(7)
5(36)
2(14)
2(1-7)
13±6 [10-17] 1.6±0.4 [1.4-1.9]
cm
(95% CI) Adjuvant therapy 551
VAS: visual analogue scale.
6
SC
Complications(%)
day, (median, range)
group
RI PT
550
3
29
ACCEPTED MANUSCRIPT Table 4 . Histology and stage of the tumor (N=17)
T4N0M0
Histology
Cases SV-VATS group
Control group
Squamous carcinoma
3
2
Adenocarcinoma
1
Adenoid
cystic 5
carcinoma
carcinoma Carcinoid
555 556 557 558 559 560 561 562
Squamous carcinoma
2
1
Small cell carcinoma
-
1
EP
554
1
1
AC C
553
3
-
TE D
T4N2M0
2
-
M AN U
Mucoepidermoid
RI PT
Pathologic stage
SC
552
30
ACCEPTED MANUSCRIPT 563
Table 5. Reasons for conversion to general anesthesia 1. Major bleeding, severe pleural adhesions, large tumors; 2. Severe hypoxemia, hypercapnia and acidosis;
arrhythmias and right ventricular failure;
RI PT
3. Haemodynamic instability: hypotension, cardiac index decreased, intractable
4. Persistent cough that creates difficulty or prevents performing surgery;
SC
5. Excessive movement of the diaphragm or mediastinum, causing unsafe surgery;
7. Intraoperative airways injury…
AC C
EP
TE D
564
M AN U
6. Inability to collapse the lung;
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT