Left Pulmonary Artery Sling: Postoperative Outcomes for Patients at a Single Center

Background Left pulmonary artery (LPA) sling is a rare anomaly characterized by the origin of the LPA from the right pulmonary artery with a course between the trachea and esophagus. It is often associated with airway and cardiac anomalies. Methods This is a retrospective case series of consecutive patients who underwent LPA sling repair (LPASR) at a tertiary care center over a 35-year period with a focus on tracheal and/or LPA reinterventions and survival. Results Between June 1983 and July 2018, 42 patients were identified: isolated LPASR was performed in 16 (38%), LPASR/intracardiac repair in 10 (24%), and LPASR/tracheal repair in 16 (38%). There were 5 (12%) in-hospital and 4 (10%) late deaths. Survival rates (15 years) were as follows: 100% (isolated LPASR), 65% (concomitant intracardiac repair), and 52% (concomitant tracheal surgery). Preoperative intensive care unit (ICU) hospitalization was associated with future intervention on the LPA/trachea (61%, 11/18). The median distribution of blood flow to the left lung post-index surgery was 38%. Freedom from isolated LPA intervention was 100% after isolated LPASR, 93% after LPASR/tracheal surgery, and 69% after LPASR/intracardiac repair. Freedom from isolated tracheal intervention was 92% after isolated LPASR, 73% after LPASR/tracheal surgery, and 78% after LPASR/intracardiac repair. Conclusions ICU hospitalization prior to index surgery may indicate the severity of associated cardiac/tracheal abnormalities as this is associated with increased morbidity and mortality. Patients who underwent LPASR/intracardiac surgery were more likely to undergo isolated LPA intervention and those who underwent LPASR/tracheal surgery were more likely to undergo isolated tracheal intervention.

Risk of Pediatric Cardiac Surgery Increased in Patients Undergoing Tracheal Surgery During the Same Hospitalization

Background The impact of complex tracheal surgery (TS) on outcomes of children undergoing cardiac surgery has rarely been investigated in large national databases and could impact anticipated outcomes in those patients. Methods The Pediatric Health Information System database was reviewed from January 1, 2005 to December 31, 2014, for pediatric (<18 years) patients undergoing select cardiac surgical procedures using International Classification of Disease-9 procedural coding. Patients were divided based upon having TS (excluding tracheostomy) during the same hospitalization. Patients with tracheal and cardiac surgeries (CHS + TS) were propensity matched in a 1 : 2 fashion to patients undergoing isolated cardiac surgeries without TS (CHS) based upon cardiac procedure(s), age at surgery, gender, and discharge year. Hospital mortality and other outcomes were compared between the 2 matched groups. Results The 283 CHS + TS patients were similar to the 566 CHS patients in gender, race, age, cardiac procedures, and presence of chromosomal abnormalities, all P > .05. Hospital mortality was 13.8% ( n = 39) for CHS + TS and 5.8% ( n = 33) for CHS patients with an unadjusted 2.58 hazard ratio of death (95% confidence interval: 1.59-4.20; P < .001). CHS + TS was also associated with a greater length of stay (63 days vs 12 days), a higher cost per hospitalization ($322 402 vs $80 273), and more readmissions (64.3% [ n = 182] vs 41.8% [ n = 243]), all P < .001. Conclusions Patients undergoing cardiac and TS in the same hospitalization are at greater risk of in-hospital mortality than patients undergoing similar cardiac surgeries alone and incur higher resource utilization thereafter. The increased risk of mortality is currently underappreciated, but it is important to recognize when discussing expectations with families and providers.

Expert Technique: Pediatric Tracheal Surgery

Substantial improvements in techniques of tracheal surgery for children have occurred in the past 20 years. Precise preoperative imaging with computed tomography clearly defines the anatomy for surgical planning and is assisted by on-the-table needle localization. The use of cardiopulmonary bypass greatly facilitates creation of an airtight, widely patent trachea. The use of Ciprodex as a postoperative nebulizer has significantly decreased granulation tissue along the suture line. Most important has been the adoption of slide tracheoplasty as the procedure of choice.

INTRAVENOUS INFUSIONS OF LIDOCAINE IN SURGERY OF THE TRACHEA

Objective. To evaluate the possibility of using intravenous infusion of lidocaine in tracheal surgery. Methods. The analysis of case histories of patients (n=19) operated on for tracheal stenosis was carried out. Depending on the perioperative analgesia, the patients were divided into two groups: the 1^st group (n=9) - intravenous infusion of lidocaine; the 2^nd - (n = 10) - narcotic analgesics. Tracheal resection was carried out using the cervical access. Before tracheal transection and after tracheal anastomosis was applied, protective mechanical ventilation of the lungs was performed. The stage of tracheal resection and formation of anastomosis is high-frequency jet ventilation (HFJV). Anesthesia was maintained with sevoflurane, and after opening the tracheal lumen - with propofol 6-8 mg/kg/h. In the first group, an intravenous bolus of lidocaine 1.5 mg / kg was added to the induction, followed by a continuous infusion of 1.5 mg / kg / h during surgery. The concentration of lidocaine was determined 15 minutes after the bolus and 24 h after surgery. Hemodynamics, acid-base state, glycemia, response to the endotracheal tube, time of extubation, occurrence of postoperative nausea and vomiting were assessed. Pain syndrome was assessed using a visual analogue scale every 15 minutes for an hour, and then every 4 hours until the end of the first day, the consumption of opioids was recorded. Results. Group 1 patients were extubated without agitation; the pressor response to extubation was less pronounced. Mean arterial pressure, blood gas composition and glycemia did not differ between these groups. There were no signs of systemic toxicity of lidocaine. Group 1 patients did not need promedol and tramadol, and the median and percentiles in group 2 patients, both for promedol and tramadol, were 60 [30; 60] and 400 [200; 400] mg, respectively. Four patients in group 2 had postoperative nausea and vomiting. Conclusion. Intravenous infusion of lidocaineis considered to be an alternative to perioperative opioid analgesia in tracheal surgery performed from the cervical approach. What this paper adds For the first time, in the case of the impossibility and absence of the need for a thoracic epidural block the intravenous application of lidocaine for analgesic purposes in tracheal surgery was studied. It was found that the use of intravenous infusion of lidocaine reduces the incidence of postoperative nausea and vomiting (PONV) caused by the use of opioids, and also showed a trend toward adecreased pressor responseto the endotracheal tube upon awakening of patients.

Various Uses of Laryngeal Mask Airway during Tracheal Surgery

Background The use of laryngeal mask airway (LMA) ventilation in surgeries to be performed in upper tracheal stenosis has been reported in the case series. However, there is no generally accepted standardized approach for the use of LMA. In this study, LMA usage areas and advantages of trachea surgery were examined. Methods The records of 21 patients who underwent tracheal surgery using LMA ventilation between March 2016 and May 2020 were evaluated retrospectively. The patient data were analyzed according to age, gender, mean follow-up time, surgical indication, mean tracheal resection length, anastomosis duration, mean oxygen saturation, mean end-tidal CO2 levels, and postoperative complications. Results Four patients were female and 17 were male, their median age was 43 (11–72 range) and the mean follow-up time was 17.6 months. The most common surgical indication was postintubation tracheal stenosis. The mean tracheal resection length was 26.6 mm and the mean anastomosis duration was 11.3 minutes. The mean pulse oximetry and mean end-tidal CO2 during laryngeal mask ventilation was 97.6% ± 2.1 and 38.1 ± 2.8 mm Hg, respectively. Postoperative complications were higher in patients with comorbidities. Conclusion LMA-assisted tracheal surgery is a method that can be used safely as a standard technique in the surgery of benign and malignant diseases of both the upper and lower airway performed on pediatric patients, patients with tracheostomy, and suitable patients with tracheoesophageal fistula.

Anomalous innominate artery complicating tracheal surgical procedures

Objective To highlight the importance of imaging in reducing an accidental injury to the anomalous brachiocephalic trunk and its branches during tracheal surgery. Case report This paper reports two cases of accidental injury to the great vessels in the neck during tracheal surgery. The first incident occurred during a repeat tracheostomy, when the right common carotid artery was injured. On reviewing the computed tomography images, the bifurcation of the brachiocephalic artery was seen to the left of the midline, and the right common carotid artery was adherent just below the tracheostomy site. The second incident happened during surgery for tracheal stenosis, when there was an inadvertent injury to the main brachiocephalic trunk, which was adherent to the trachea in the lower neck region. Conclusion For airway surgeons, radiological assessment of vascular structures in relation to the trachea prior to surgery is as important as the endoluminal airway assessment for the best outcome.