Department of General Thoracic Surgery, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain.
Ann Thorac Surg. 2010 Feb;89(2):387-90; discussion 390-1. doi: 10.1016/j.athoracsur.2009.10.044.
The need to compromise between surgical and anesthetic access in airway surgery is an important clinical problem. We wanted to determine the feasibility of performing upper airway surgery under awake anesthesia and spontaneous respiration.
This was a prospective, clinical feasibility study. Patients with upper tracheal stenosis were managed through cervical epidural anesthesia and conscious sedation, and atomized local anesthetic. No intraoperative intubation or jet ventilation was required. Outcome measures were ease of surgery, observer-rated functional result, early (less than 30 days) complications, and patient-reported satisfaction.
Twenty consecutive patients with idiopathic (n = 4) or postintubation (n = 16) complete (n = 3) or severe (>80%, n = 17) subglottic (n = 12) or upper trachea (n = 8) stenosis were enrolled. Operations included 12 subglottic and 8 segmental resections with primary anastomosis. Permissive hypercapnia was well tolerated. Median length of resection was 4.5 cm (range, 2 to 6 cm), and 12 releases (8 thyrohyoid, 4 suprahyoid) were required. One patient required a nasotracheal tube for 36 hours. All but 1 were able to cough and talk immediately, and to swallow fluids and solids, and were fully mobilized at 6 hours. There were no early complications. Median hospitalization was 3.1 days (range, 2 to 15). Patients had excellent (n = 16) or good (n = 4) functional (n = 20) outcomes, with no early relapse of stenosis. Median self-reported satisfaction at median 12 months was 9.5 +/- 1.0 (scale, 0 to 10). All patients indicated that they would be happy to repeat the procedure.
Awake and tubeless upper airway surgery is feasible and safe, and has a high level of patient satisfaction. If supported by randomized controlled trial, this method will change the way airway stenosis surgery is approached by both surgeons and anesthesiologist.
在气道手术中，需要在手术入路和麻醉之间进行权衡，这是一个重要的临床问题。我们希望确定在清醒麻醉和自主呼吸下进行上气道手术的可行性。
这是一项前瞻性临床可行性研究。对患有上气道狭窄的患者进行颈椎硬膜外麻醉和清醒镇静，并使用雾化局部麻醉。手术过程中无需进行气管插管或射流通气。观察指标为手术的难易程度、观察者评估的功能结果、早期（<30 天）并发症以及患者满意度。
20 例特发性（n=4）或气管插管后（n=16）完全性（n=3）或重度（>80%，n=17）声门下（n=12）或上气管（n=8）狭窄患者纳入研究。手术包括 12 例声门下和 8 例节段性切除术，行一期吻合。允许性高碳酸血症耐受良好。中位切除长度为 4.5cm（范围 26cm），需要 12 次松解术（8 例甲状舌骨，4 例舌骨上）。1 例患者需要经鼻气管插管 36 小时。除 1 例外，所有患者均能立即咳嗽、说话，立即吞咽液体和固体，并于 6 小时内完全活动。无早期并发症。中位住院时间为 3.1 天（范围 215 天）。20 例患者的功能结果均为优（n=16）或良（n=4），无一例早期出现狭窄复发。中位 12 个月的自我报告满意度为 9.5±1.0（范围 0~10）。所有患者均表示愿意再次接受该手术。
清醒、无管上气道手术是可行和安全的，患者满意度高。如果得到随机对照试验的支持，这种方法将改变外科医生和麻醉医生处理气道狭窄手术的方式。
