Abstract: We report the case of a terminally ill cancer patient with recurrent pericardial and bilateral pleural effusions who was scheduled for video-assisted thoracoscopic surgery. The operation was performed with the patient awake under epidural anaesthesia. The patient’s cough reflex in response to lung manipulation was successfully minimised by the inhalation of aerosolised lidocaine. Video-assisted thoracic surgery requires the exclusion of a lung from ventilation. In order to support one-lung spontaneous ventilation in this high-risk patient, we successfully used non-invasive bilevel positive airway pressure ventilation via a facemask. Based on this preliminary experience, we think that critically ill patients scheduled for palliative surgery can be successfully managed with the combination of minimally invasive surgical techniques and neuraxial block with non-invasive lung ventilation.

Authors
Schmid RA. Stammberger U. Hillinger S. Vogt PR. Amman FW. Russi EW. Weder W.
Institution
Department of Surgery, University Hospital, Zurich, Switzerland.
Title
Lung volume reduction surgery combined with cardiac interventions.
Source
European Journal of Cardio-Thoracic Surgery. 15(5):585-91, 1999 May.
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Abstract
OBJECTIVE: Postoperative course and functional outcome were evaluated in patients who underwent lung volume reduction surgery (LVRS) or in combination with valve replacement (VR), percutaneous transluminal coronary angioplasty (PTCA), placement of a stent, or coronary artery bypass grafting (CABG). METHODS: Patients with severe bronchial obstruction and hyperinflation due to pulmonary emphysema were evaluated for lung volume reduction surgery. Cardiac disorders were screened by history and physical examination and assessed by coronary angiography. Nine patients were accepted for LVRS in combination with an intervention for coronary artery disease (CAD). In addition, three patients with valve disease and severe emphysema were accepted for valve replacement (two aortic-, one mitral valve) only in combination with LVRS. Functional results over the first 6 months were analysed. RESULTS: Pulmonary function testing demonstrates a significant improvement in postoperative FEV1 in pa!
tients who underwent LVRS combined with an intervention for CAD. This was reflected in reduction of overinflation (residual volume/total lung capacity (RV/TLC)), and improvement in the 12-min walking distance and dyspnea. Median hospital stay was 15 days (10-33). One patient in the CAD group died due to pulmonary edema on day 2 postoperatively. One of the three patients who underwent valve replacement and LVRS died on day 14 postoperatively following intestinal infarction. Both survivors improved in pulmonary function, dyspnea score and exercise capacity. Complications in all 12 patients included pneumothorax (n = 2), hematothorax (n = 1) and urosepsis (n = 1). CONCLUSION: Functional improvement after LVRS in patients with CAD is equal to patients without CAD. Mortality in patients who underwent LVRS after PTCA or CABG was comparable to patients without CAD. LVRS enables valve replacement in selected patients with severe emphysema otherwise inoperable.

Title:Coronary artery bypass grafting in the conscious patient without endotracheal general anesthesia
Authors:Karagoz,H.Y.; Sonmez,B.; Bakkaloglu,B.
Journal : Annals of Thoracic Surgery 70: 91-6, 2000
BACKGROUND: Over the past several years, considerable experience has accumulated in performing coronary anastomoses on the beating heart, and various aspects of minimally invasive approaches have been simplified. In an attempt to further simplify and decrease the “invasiveness” of this procedure, performing this operation without endotracheal general anesthesia was deemed feasible in certain subsets of patients. METHODS: Between October 1998 and June 1999, 5 patients underwent coronary artery bypass grafting without endotracheal general anesthesia, using high thoracic epidural block to construct extension grafts with a short segment of radial artery, between the in situ left or right internal thoracic arteries and the left anterior descending (n = 4) or right coronary arteries (n = 1). There were 2 female and 3 male patients, with a mean age of 67.4 +/- 8.3 years. RESULTS: The perioperative course of the patients was uneventful. There was no perioperative morbidity or mortality. No patient was converted to general anesthesia or to conventional operation. Control angiograms revealed patent anastomoses in all patients. In 1 patient, spasm of the radial artery graft was observed that was relieved 3 weeks later spontaneously. Mean length of hospital stay was 2.2 +/- 0.4 days. All patients were symptom free and returned to normal daily life at the first postoperative month. CONCLUSIONS: Our initial experience confirms the feasibility of performing coronary bypass grafting in the conscious patient without endotracheal general anesthesia

Title:Efficacy and tolerance of a new silicone stent for the treatment of benign tracheal stenosis: preliminary results
Authors:Vergnon,J.M.; Costes,F.; Polio,J.C.
Journal: Chest 118: 422-6, 2000
Abstract:In inoperable patients with tracheal stenosis who are treated using silicone stents, stent migration occurs in 18.6% of cases. To decrease the migration rate, a new silicone stent with narrow central and larger distal parts is desribed. This study analyzes the stability and tolerance of this new stent. DESIGN: Preliminary prospective study conducted in two French university hospitals. PATIENTS: Thirteen inoperable patients with benign complex tracheal stenosis due to intubation or tracheotomy. INTERVENTIONS: Tracheal stent insertion was performed under general anesthesia with a rigid bronchoscope. The patients were followed up clinically up to stent removal, which was planned at 18 months. RESULTS: Stent insertion or removal was very simple and did not differ from other silicone stents. No migration occurred after a mean follow-up of 22.8 months. Minimal granuloma formation occurred in only one patient (7.7%). Sputum retention remained similar to that with other silicone stents and could be improved by a smoother internal wall. Stents have been removed in seven patients after a mean duration of 19.6 months, with a complete stenosis cure in four cases. CONCLUSION: This new stent combines the stability of the metallic stents and the tolerance and easy removal of straight silicone stents. This allows a prolonged use in order to obtain curative action

Author
Leonard IE. Myles PS
Institution
Department of Anaesthesia and Pain Management, Alfred Hospital, Melbourne, Victoria.
Title
Target-controlled intravenous anaesthesia with bispectral index monitoring for thoracotomy in a patient with severely impaired left ventricular function.
Source
Anaesthesia & Intensive Care, 28(3):318-321, 2000 June.
Abstract
The anaesthetic management of an elderly patient with severely impaired left ventricular function undergoing thoracotomy and lobectomy is described. Total intravenous anaesthesia (TIVA) with remifentanil and target-controlled infusion of propofol titrated according to the bispectral index (BIS) was used, with thoracic epidural anaesthesia commenced at the end of surgery providing postoperative analgesia. Avoidance of intraoperative epidural local anaesthetics and careful titration and dose reduction of propofol using the BIS was associated with excellent haemodynamic stability. The rapid offset of action of remifentanil and low-dose propofol facilitated early recovery and tracheal extubation. The BIS was a valuable monitor in optimal titration of TIVA.

Author
Karagoz HY. Sonmez B. Bakkaloglu B. Kurtoglu M. Erdinc M. Turkeli A. Bayazit K
Institution
Department of Cardiovascular Surgery, Guven Hospital, Ankara, Turkey. karagoz@tr-net.net.tr
Title
Coronary artery bypass grafting in the conscious patient without endotracheal general anesthesia.
Source
Annals of Thoracic Surgery, 70(1)1-96, 2000 July.
Abstract
BACKGROUND: Over the past several years, considerable experience has accumulated in performing coronary anastomoses on the beating heart, and various aspects of minimally invasive approaches have been simplified. Continue Reading »

Several recent articles in the British Anesthesia literature detail the high risk of perioperative complications associated with esophagectomy. Some of the interest in this area is due to the British Report of the National Confidential Enquiry into Perioperative Deaths 1996/1997 . (London NCEPOD,1998) which pointed out the high rates of mortality associated with this operation. Continue Reading »