Nonintubated Tracheal Resection

The authors present the care provided to a 40-year-old man, a smoker, with a nonrelevant past history, experiencing chronic irritative cough and bloody sputum since one month before consultation. During the medical examination, stridor was noticed. Flexible bronchoscopy was performed and found an exophytic lesion in the upper trachea. Biopsy demonstrated an adenoid cystic carcinoma.

The treatment plan was discussed in a multidisciplinary meeting, and the patient was referred for surgical resection of the lesion. The patient refused to receive general anesthesia, so together with the anesthetist and after contraindications were ruled out, the nonintubated approach was considered.

Traditionally, tracheal resection and reconstruction surgery requires a total control of the airway, with the implementation of methods such as cross-field ventilation, nasotracheal intubation and jet ventilation, among others, with a full cooperation and coordination with the anesthesia team.
Despite this, after Macchiarini and colleagues’ experience in 2010 (1), more series of cases have been reported demonstrating the feasibility of this procedure under spontaneous ventilation in fully awake or sedated patients. Recently, the topic gained new interest after other authors published new series and evidence, extending the approach even to carinal resections (2, 3).

The nonintubated strategy for tracheal resections stands on the avoidance of general anesthesia and its possible complications; the faster recovery and potentially fewer complications avoiding the use of opioid and muscle relaxant drugs; faster end-to-end anastomosis procedure, decreasing the tracheal edema; and the better assessment of the tracheal range of moving during spontaneous breathing potentially achieving a better anatomical reconstruction, among others.

The surgery was uneventful. Surgical and anesthetic details are described in the video. The margins of the surgical piece were free of disease. The patient was discharged on postoperative day three, and one month follow-up showed no complications.

More evidence is needed in order to assess the outcomes, benefits, limitations, and possible advantages over the traditional technique.

References

1. Loizzi D, Sollitto F, De Palma A, Pagliarulo V, Di Giglio I, Loizzi M. Tracheal resection with patient under local anesthesia and conscious sedation. Ann Thorac Surg. 2013 Mar;95(3):e63-e65.
2. Liu J, Li S, Shen J, et al. Non-intubated resection and reconstruction of trachea for the treatment of a mass in the upper trachea. J Thorac Dis. 2016 Mar;8(3):594-599.
3. Li S, Liu J, He J, et al. Video-assisted transthoracic surgery resection of a tracheal mass and reconstruction of trachea under non-intubated anesthesia with spontaneous breathing. J Thorac Dis. 2016 Mar;8(3):575-585.