ForgotPassword?
Sign Up
Search this Topic:
Forum Jump
Posts: 1443
Dec 11 08 5:58 PM
addition to these deaths, two patients have suffered severe disabling cerebral ischaemia. Although these five adverse outcomes were all associated with the use of double- lumen endobronchial intubation, there is no evidence to suggest that this technique is inherently dangerous. Double-lumen tube anaesthesia is still employed in many centres, particularly in the UK. The collapse of the lung allows excellent visualization of the chest cavity, without interference from a moving, ventilated lung. It is therefore ideal when learning or teaching ETS. However, accurate placement of the double-lumen tube is not easy and may require checking by bronchoscopy. The necessary skills may be lacking in units in which thoracic surgery is not performed regularly. In such circumstances there may be an argument for operating on the two sides on separate occasions 5 . It is worthy of note that in a worldwide context double-lumen intubation has gradually given way to standard two-lung anaesthesia. For example, a survey of 1556 procedures from 12 centres in Taiwan reported that single-lumen endotracheal intubation was the usual method, although surgeons occasionally requested the double-lumen approach 6 . With increasing experience there is a move to simpler anaesthetics. In a recent report of 734 bilateral cases from Brazil, the authors initially used Robertshaw tubes placed under bronchoscopic control but the use of double-lumen catheters was slowly discontinued during the course of the study in favour of simple orotracheal catheters 7 . The last of the nine deaths remains unexplained. A patient collapsed several hours after an uneventful ETS. Although post-mortem examination showed thrombosis in the cerebral circulation, the exact cause of the death could not be established. Short-term morbidity The most common perioperative complication is pneu- mothorax; up to 75 per cent of patients have some residual gas in the thorax at the end of the procedure. Although this mostly resolves spontaneously, temporary tube drainage is required in 0 ·4-2·3 per cent of patients 8,9 . Of 44 patients having thoracoscopic splanchnicectomy for pain, two needed a drain, but this was an extensive operation involving resection from T5 to T12 10 . The incidence of tension pneumothorax after surgery is unknown, but fortu- nately this problem seems rare. The cause of postoperative pneumothorax is usually either direct trauma to the lung at the time of trocar insertion or tearing of an apical adhesion as the lung is depressed. Occasionally apical bullae are seen; it is possible that rupture of a bulla may occur as a conse- quence of anaesthesia, especially if high inflation pressures are used at the end of the procedure. Prevention involves adequate reinflation of the lungs at the end of the operation and chest radiography approximately 4 h later to rule out significant pneumothorax. If present, chest intubation and underwater seal drainage for 24 h should suffice. Surgical emphysema is another fairly common periop- erative complication. It occurs in up to 2 ·7 per cent of patients, with or without a pneumothorax 11 . It is usually noted around the site of trocar insertion and is confined to the chest wall, but rarely it involves the mediastinum and tracks retroperitoneally, even as far as the scrotum in men. Emphysema is usually obvious clinically, but chest radio- graphy is required to rule out associated pneumothorax. If absent, management is conservative. Segmental collapse or atelectasis occurs occasionally. Lin and Fang 12 reported four such problems in a series of 1360 patients. Recov- ery was rapid with chest physiotherapy. Pleural effusion is also encountered occasionally. Reports vary from 0 to Copyright 2004 British Journal of Surgery Society Ltd www.bjs.co.uk British Journal of Surgery 2004; 91: 264-269 Published by John Wiley & Sons Ltd 266 T. A. Ojimba and A. E. P. Cameron 1 per cent but, as patients tend to be discharged quickly, the incidence may be much higher. Apart from the deaths mentioned above, reports of serious intraoperative bleeding are rare. Gossot et al. 8 described one laceration of the subclavian artery in 940 sympathectomies. It was managed by immediate thoracotomy and suture. In the same series there was a 5 ·3 per cent incidence of significant bleeding (blood loss of 300-600 ml) that was controlled thoracoscopically. No patient needed transfusion. In a collected series of 7017 cases from 50 Japanese institutions, Ueyama et al. 13 reported a 0 ·3 per cent incidence of intraoperative bleeding (amount not defined), with six patients (0 ·1 per cent)
addition to these deaths, two patients have suffered severe disabling cerebral ischaemia. Although these five adverse outcomes were all associated with the use of double- lumen endobronchial intubation, there is no evidence to suggest that this technique is inherently dangerous. Double-lumen tube anaesthesia is still employed in many centres, particularly in the UK. The collapse of the lung allows excellent visualization of the chest cavity, without interference from a moving, ventilated lung. It is therefore ideal when learning or teaching ETS. However, accurate placement of the double-lumen tube is not easy and may require checking by bronchoscopy. The necessary skills may be lacking in units in which thoracic surgery is not performed regularly. In such circumstances there may be an argument for operating on the two sides on separate occasions
5
.
It is worthy of note that in a worldwide context
double-lumen intubation has gradually given way to standard two-lung anaesthesia. For example, a survey of 1556 procedures from 12 centres in Taiwan reported
that single-lumen endotracheal intubation was the usual method, although surgeons occasionally requested the double-lumen approach
6
. With increasing experience
there is a move to simpler anaesthetics. In a recent report of 734 bilateral cases from Brazil, the authors initially used Robertshaw tubes placed under bronchoscopic control but the use of double-lumen catheters was slowly discontinued during the course of the study in favour of simple orotracheal catheters
7
The last of the nine deaths remains unexplained. A
patient collapsed several hours after an uneventful ETS. Although post-mortem examination showed thrombosis in the cerebral circulation, the exact cause of the death could not be established.
Short-term morbidity
The most common perioperative complication is pneu- mothorax; up to 75 per cent of patients have some residual gas in the thorax at the end of the procedure. Although this mostly resolves spontaneously, temporary tube drainage is required in 0
·4-2·3 per cent of patients
8,9
. Of 44
patients having thoracoscopic splanchnicectomy for pain, two needed a drain, but this was an extensive operation involving resection from T5 to T12
10
. The incidence of
tension pneumothorax after surgery is unknown, but fortu- nately this problem seems rare. The cause of postoperative pneumothorax is usually either direct trauma to the lung at the time of trocar insertion or tearing of an apical adhesion as the lung is depressed. Occasionally apical bullae are seen; it is possible that rupture of a bulla may occur as a conse- quence of anaesthesia, especially if high inflation pressures are used at the end of the procedure. Prevention involves adequate reinflation of the lungs at the end of the operation and chest radiography approximately 4 h later to rule out significant pneumothorax. If present, chest intubation and underwater seal drainage for 24 h should suffice.
Surgical emphysema is another fairly common periop-
erative complication. It occurs in up to 2
·7 per cent of
patients, with or without a pneumothorax
11
. It is usually
noted around the site of trocar insertion and is confined to the chest wall, but rarely it involves the mediastinum and tracks retroperitoneally, even as far as the scrotum in men. Emphysema is usually obvious clinically, but chest radio- graphy is required to rule out associated pneumothorax. If absent, management is conservative. Segmental collapse or atelectasis occurs occasionally. Lin and Fang
12
reported
four such problems in a series of 1360 patients. Recov- ery was rapid with chest physiotherapy. Pleural effusion is also encountered occasionally. Reports vary from 0 to
Copyright
2004 British Journal of Surgery Society Ltd
www.bjs.co.uk
British Journal of Surgery 2004; 91: 264-269
Published by John Wiley & Sons Ltd
266
T. A. Ojimba and A. E. P. Cameron
1 per cent but, as patients tend to be discharged quickly, the incidence may be much higher.
Apart from the deaths mentioned above, reports of
serious intraoperative bleeding are rare. Gossot et al.
8
described one laceration of the subclavian artery in 940 sympathectomies. It was managed by immediate thoracotomy and suture. In the same series there was a 5
·3 per cent incidence of significant bleeding (blood
loss of 300-600 ml) that was controlled thoracoscopically. No patient needed transfusion. In a collected series of 7017 cases from 50 Japanese institutions, Ueyama et al.
13
reported a 0
·3 per cent incidence of intraoperative bleeding
(amount not defined), with six patients (0
·1 per cent)
Interact
Share This