Use of jet ventilation in thoracoscopic tracheo-esophageal fistula repair-can both surgeons and anesthesiologists be happy?

Safety of High-Frequency Jet Ventilation During Image-Guided Thermal Ablation Procedures

RATIONALE AND OBJECTIVE

Percutaneous thermal ablative technique is a common radiological procedure for malignant lesions treatment. Controlled assisted ventilation during general anesthesia is the usual mode of ventilation, but high-frequency jet ventilation (HFJV) can be a helpful alternative for the operator. The objective was to evaluate the safety of HFJV during thermal ablation procedures.

MATERIALS AND METHODS

This monocentric prospective analysis included adult patients undergoing percutaneous thermal ablation procedures for abdominal tumor performed under HFJV. Procedures with a transpulmonary path were excluded. The primary outcome was the incidence of respiratory complications. Secondary outcomes included gas exchange modifications (hypercapnia, hypoxemia, pulmonary atelectasis) and the incidence of barotrauma.

RESULTS

Sixty patients were included during the study period. The mean duration time was 88 min. All procedures went according to the protocol and there was no respiratory complication. There was no barotrauma event. Three patients had an exhaled capnia above 45 mmHg at the end of the procedure which normalized within 10 min of conventional ventilation.

CONCLUSION

HFJV during thermal ablation procedures is safe regarding gas exchange and barotrauma. This technique could be an interesting alternative to conventional ventilation during image-guided thermal ablation procedures. Clinical Trials database This study was registered in Clinical Trials database (NCT04209608).

Anesthesia for thoracic surgery in infants and children

The management of infants and children presenting for thoracic surgery poses a variety of challenges for anesthesiologists. A thorough understanding of the implications of developmental changes in cardiopulmonary anatomy and physiology, associated comorbid conditions, and the proposed surgical intervention is essential in order to provide safe and effective clinical care. This narrative review discusses the perioperative anesthetic management of pediatric patients undergoing noncardiac thoracic surgery, beginning with the preoperative assessment. The considerations for the implementation and management of one-lung ventilation (OLV) will be reviewed, and as will the anesthetic implications of different surgical procedures including bronchoscopy, mediastinoscopy, thoracotomy, and thoracoscopy. We will also discuss pediatric-specific disease processes presenting in neonates, infants, and children, with an emphasis on those with unique impact on anesthetic management.

Anesthesia management in neonatal congenital bronchobiliary fistula: case report and literature review

Background

There is very little published literature and none that discussed care in a neonate regarding anesthetic risk and management of neonate with congenital bronchobiliary fistula during thoracoscopy and thoracotomy. This article analyzes related risk factors and literature review from perioperative ventilation, circulation and other aspects of management.

Case presentation

A neonate diagnosed as congenital bronchobiliary fistula combined with severe chemical pneumonia, consolidation of the lungs, and infection was facing the risk of anaesthesia under thoracoscopy exploration surgery, who experiened more than 20 days diagnostic period before operation. Many risk factors have led to conversion from minimally invasive surgery to thoracotomy, including persistent hypoxemia, hypercapnia, difficult surgical exposure and extremly difficulty of intraoperative ventilation management. Anesthesia maintenance after conversion to open access remained problematic. Fortunately the patient showed no sign of any adverse CNS effects after 4 months of follow-up.

Conclusions

The most prominent anesthesia challenges are hypoxemia, increased airway resistance, impaired ventilation, and the risk of metabolic acidosis. Close cooperation among the entire neonatal medical team is the key factors in successful management of this rare case.

Thoracoscopy vs. thoracotomy for the repair of esophageal atresia and tracheoesophageal fistula: a systematic review and meta-analysis

Esophageal atresia (EA) and tracheoesophageal fistula (TEF) require emergency surgery in the neonatal period to prevent aspiration and respiratory compromise. Surgery was once exclusively performed via thoracotomy; however, there has been a push to correct this anomaly thoracoscopically. In this study, we compare intra- and post-operative outcomes of both techniques. A systematic review and meta-analyses was performed. A search strategy was developed in consultation with a librarian which was executed in CENTRAL, MEDLINE, and EMBASE from inception until January 2017. Two independent researchers screened eligible articles at title and abstract level. Full texts of potentially relevant articles were then screened again. Relevant data were extracted and analyzed. 48 articles were included. A meta-analysis found no statistically significant difference between thoracoscopy and thoracotomy in our primary outcome of total complication rate (OR 0.98, [0.29, 3.24], p = 0.97). Likewise, there were no statistically significant differences in anastomotic leak rates (OR 1.55, [0.72, 3.34], p = 0.26), formation of esophageal strictures following anastomoses that required one or more dilations (OR 1.92, [0.93, 3.98], p = 0.08), need for fundoplication following EA repair (OR 1.22, [0.39, 3.75], p = 0.73)-with the exception of operative time (MD 30.68, [4.35, 57.01], p = 0.02). Considering results from thoracoscopy alone, overall mortality in patients was low at 3.2% and in most cases was due to an associated anomaly rather than EA repair. Repair of EA/TEF is safe, with no statistically significant differences in morbidity when compared with an open approach.Level of evidence 3a systematic review of case-control studies.

Thoracoscopy in pediatrics: Surgical perspectives

Thoracoscopic surgery and other minimally invasive approaches in children achieved marked advancement and expanded to include several disciplines in the last decade. The new armamentarium of the minimally invasive surgery including the smaller instruments and better magnification led to the application of this technology in the small infants and neonates. Currently, thoracoscopy is considered the preferred surgical approach for various conditions in neonates and infants over the standard thoracotomy, and thoracoscopic training is included in the surgical training curriculum for the residents in many institutes worldwide. Children are different from adults, and technique modifications are required when using thoracoscopy in children. Thoracoscopy showed satisfactory results in several operations including pulmonary resections, mediastinal tumors biopsies or resections, repair of the diaphragmatic hernias, decortication, and tracheoesophageal fistula. This review aims to address the unique aspects of thoracoscopic surgery in children, identify its potential technical and anatomical challenges, and the proposed solutions. A literature search for latest and relevant publications was done using the keywords (thoracoscopy; pediatric; lung biopsy; decortication; lobectomy; mediastinum; esophagus; and diaphragmatic hernia).