Extracorporeal Membrane Oxygenation-Assisted Esophagectomy Fulvio Pinelli, MD,* Stefano Romagnoli, MD,* Sergio Bevilacqua, MD,* and Paolo Macchiarini, MD, PhD†
A
THORACIC, abdominal, or cervical esophagectomy traditionally requires right thoracotomy and one-lung ventilation. Low-flow extracorporeal lung-assist devices have been used during thoracic surgery involving the upper airways.1 Alternatively, high-flow venovenous extracorporeal membrane oxygenation (VV-ECMO) usually is used to support lung function in cases of refractory respiratory failure2 or in refractory heart dysfunction in a venous-arterial configuration (VA-ECMO).3 The present case report presents the application of VV-ECMO for respiratory assistance during a complex transthoracic esophagectomy and reconstruction. CASE REPORT A 41-year-old man required an esophagectomy due to multiple areas of stenoses. His past surgical history included multiple esophageal surgeries and dilation procedures in his childhood due to esophageal atresia and, later, tracheobronchial reconstruction for an iatrogenic trachea-esophageal fistula. His medical history was otherwise noncontributory. To allow right lung collapse and to enable surgical access to the esophagus via a right thoracotomy, one-lung ventilation (OLV) traditionally is required. However, OLV obtained via conventional measures (double-lumen endobronchial tube or bronchial blocker) was not feasible given the past surgical modification of his tracheobronchial bifurcation. Moreover, the complex anatomic relationship between the airway and digestive tract required the availability of total extracorporeal ventilatory support if needed (ie, if surgical circumstances would not allow for mechanical ventilation). Ultra-low tidal volume ventilation and VV- ECMO assistance via the right internal jugular vein was then planned, and a written informed consent to perform the surgery in this manner was obtained from the patient. Anesthesia was induced with 3 mg/kg of propofol and 1 μg/kg of sufentanil. After the administration of 0.9 mg/kg of rocuronium, the trachea was intubated under fiberoptic guidance with a 6.5-mm (internal diameter) oral-tracheal tube, with the tip positioned just below the vocal cords. Anesthesia was maintained with 4-to-6 mg/kg/h of propofol and 0.1-to-0.2 μg/kg/min of remifentanil; 0.1-0.3 mg/kg/hr of rocuronium was administered according to the train-of-four monitoring. The American Society of Anesthesiologists standard monitoring was implemented with MostCare (Vygon, Vytech, Padova, Italy), a pulse contour-based system for cardiac output estimation that received its arterial waveform via the left radial artery with a standard pressure transducer. The MostCare system provides hemodynamic data by analyzing the arterial waveform at high sampling rate (1000 Hz) and, therefore, is not influenced by the VV-ECMO. In fact, the VV-ECMO drains and injects blood into the right side of the cardiovascular system without modifying, at steady state, right and left ventricular preload. A 27-Fr double-lumen
From the *Department of Anesthesiology and Intensive Care, Azienda Ospedaliera Universitaria Careggi, Firenze, Italy; and †Advanced Center for Translational Regenerative Medicine (ACTREM), Karolinska Institutet, Stockholm, Sweden. Address reprint requests to Fulvio Pinelli, MD, Department of Anesthesiology and Intensive Care, Azienda Ospedaliera Universitaria Careggi, Largo Brambilla 3, 50134, Firenze, Italy. E-mail: fulvio. [email protected] © 2015 Elsevier Inc. All rights reserved. 1053-0770/2602-0033$36.00/0 http://dx.doi.org/10.1053/j.jvca.2014.07.006 Key Words: extracorporeal membrane oxygenation, ECMO, esophagectomy 436
Avalon (Avalon Labs, Rancho Dominguez, CA) ECMO cannula was inserted into the right internal jugular vein under transthoracic echography guidance using the subcostal approach. After the administration of 5,000 IU of unfractionated heparin and radiologic confirmation of proper placement, the cannula was connected to an heparin-coated ECMO circuit (Rotaflow System, Maquet Cardiopulmonary AG; GmbH & Co. KG; Rastatt, Germany) and primed with lactated Ringer’s solution. Activated partial thromboplastin time was targeted to 50 to 70 seconds, and no further heparin administration was necessary throughout the case. During the thoracic portion of the surgery, the mean pump flow was 2.06 L/min (SD 0.1; range 1.96-2.24). Mean inspired oxygen fraction (FIO2) of the artificial lung was 0.5 (SD 0.05; range 0.4-0.6), and the mean sweep gas flow was 2.57 L/min (SD 0.36; range 2-3). The ventilator was set in pressure-control mode targeting a tidal volume of 3 mL/kg, with a respiratory rate of 10 breaths per minute. FiO2 o0.4, SpO2494%, and PaCO2 between 35 and 45 mmHg were maintained during the entire thoracic portion of the procedure. Mean cardiac output was 4.3 L/min (SD 0.1), mean blood pressure was 68 mmHg (SD 12), and heart rate was 76 beats/min (SD 13). Serum lactate concentration stayed within a normal range. At the end of the thoracic portion of the procedure, a right paravertebral catheter for postoperative analgesia was inserted by the surgeon. After 227 minutes, the patient was successfully weaned from ECMO, and the ECMO cannula was removed without heparin reversal. The patient was moved from a left lateral position to a supine position for the abdominal and cervical portions of the procedure. A standard gastric pull-up technique was used and anastomosed to the residual cervical esophagus. Post-thoracotomy pain control was achieved with the use of a continuous infusion of 0.2% ropivacaine via the right paravertebral catheter. Abdominal and neck pain were controlled by the use of systemic opiate infusion and acetaminophen. The postoperative period in the ICU was uneventful, and the patient was extubated 2 hours after surgery. He was discharged from the hospital on postoperative day 21. The patient gave his written consent to publish this case report. DISCUSSION
Since its first use more than 40 years ago,4 ECMO machines have undergone dramatic improvements in biocompatibility, performance, safety, and endurance, leading to reductions in the degree of blood trauma, hemolysis, and activation of the clotting cascade, along with the need for less heparin and anticoagulation.5 The widespread use of ECMO during the 2009 to 2010 H1N1 influenza pandemic provoked further evolution in materials to make this technology safer.6 VVECMO support was used during the present procedure because its feasibility already has been reported.7–10 To date, simpler extracorporeal pump-less systems such as the iLA-membrane Novalung (Novalung; Novalung GmbH, Hechingen, Germany) have been used for respiratory support during upper airway surgery.11 The advantage of these systems is the use of the arteriovenous pressure gradient, rather than an active pump system.12 However, the principal limitation of these devices is the need for a large-bore arterial cannula, which increases the risks for ischemic-embolic complications and the frequent need of inotropic support to maintain an adequate pressure gradient.1 Above all, the Novalung iLA, as well as other respiratory systems, allow for near-total carbon dioxide removal but only a minimal amount of oxygenation, with the consequent inability to completely support oxygen
Journal of Cardiothoracic and Vascular Anesthesia, Vol 29, No 2 (April), 2015: pp 436–438
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requirements. For these reasons, iLA was considered inadequate in the present case. During the planning of the surgical procedure, other alternatives to VV-ECMO support were evaluated, such as traditional cardiopulmonary bypass and VA-ECMO. Cardiopulmonary bypass was considered an undue risk, because it requires full anticoagulation. Its known and significant bleeding risk and hemodilution due to the large pump priming volume, and the activation of more intense inflammatory and coagulation cascades, made this option less favorable. VA-ECMO would not have been helpful in this case, because the patient had normal cardiac function and, therefore, no need for cardiac support. Moreover, VA-ECMO might have put the patient at risk for “Harlequin syndrome” (flow competition into the aorta)13 and limb ischemia.14 The Bi-Caval Dual-Lumen Avalon Catheter was used, allowing VV-ECMO via a single cannulation site in the right internal jugular vein, thus minimizing the risk of injury and infection. The design of the cannula consists of proximal superior vena cava and distal inferior vena cava (IVC) drainage ports and a right atrium infusion port. The tip of the catheter is placed in the IVC via a modified Seldinger technique. Typically, the appropriate cannula positioning is verified by fluoroscopic guidance or transesophageal echocardiography (TEE). In this case, TEE was not feasible due to multiple stenoses of the patient’s esophagus, and fluoroscopy was not available. Nevertheless, visualization of the IVC and right atrium was accomplished via subcostal transthoracic echocardiography, which allowed visualization of the wire and cannula. Radiologic confirmation was obtained before initiation of ECMO flow. The combination of partial ECMO support and low-volume mechanical ventilation during the thoracic portion of the procedure allowed for optimal surgical access to the esophagus, with blood-gas concentrations maintained within normal limits. Indeed, ECMO pump flow guaranteed optimal ventilation, while partial mechanical ventilation performed with 0.4-0.5 FIO2 allowed SpO2 to be maintained greater than 94%. Anticoagulation management based on an initial bolus of 5,000 IU of heparin did not lead to hemorrhagic or thrombotic complications. At the conclusion of the thoracic portion of the surgery, a standard ventilation technique was used; pump flow was weaned off and the cannula removed without complications.
To date, the only other case of VV-ECMO assistance for esophagectomy was described recently by Schiff et al, who used extracorporeal oxygenation assistance for right lung collapse because the patient previously had undergone a left pneumonectomy.15 Substantial differences should be noted between the Schiff et al application of VV-ECMO and this case. First, Schiff and his team used two cannulae: A 38-cm long 19-Fr armored catheter into the right internal jugular vein, as an “arterial” return cannula, and a 55-cm long 23-Fr “venous” cannula in the right femoral vein. In the present case, the aforementioned bicaval double-lumen cannula was chosen as a minimally invasive single venipuncture to lower the risk of cannula displacement.16 It also was more suitable for the patient, who had to be in the left lateral position. Furthermore, the combined system of admission and ejection should reduce the risk of recirculation of blood into the circuit.17 Secondly, the patient in the Schiff et al study required ECMO support for 3 days after surgery due to limited respiratory function. Conversely, because the present patient had normal respiratory function, ECMO support was removed intraoperatively after the thoracic phase of surgical repair. Finally, unlike Schiff et al, TEE was not used to confirm the correct position of the guidewire and the cannula; rather, the transthoracic subcostal echocardiograpic approach was used, which previously has been described in patients with acute respiratory distress syndrome.18 The use of VV-ECMO also has been described for other elective thoracic surgical procedures, as well as in emergency situations and for postoperative support in the ICU.7–10 However, the use of ECMO to facilitate surgery and for postoperative use is not covered by either of the two published guidelines describing the indications and practice of ECMO.19,20 Nevertheless, descriptions of feasibility and demonstrated advances in technology may lead to a more extended use of ECMO as support therapy during surgery in selected complex cases.21 In summary, although the use of ECMO support in noncardiac surgery remains anecdotal, the present experience with a single VV-ECMO cannula was a safe and feasible option in a case of transthoracic esophagectomy and reconstruction for which OLV could not be achieved by traditional means.
REFERENCES 1. Roman PE, Battafarano RJ, Grigore AM: Anesthesia for tracheal reconstruction and transplantation. Curr Opin Anaesthesiol 26: 1-5, 2013 2. Meyer A, Strüber M, Fischer S: Advances in extracorporeal ventilation. Anesthesiol Clin 26:381-391, 2008 3. Massetti M, Bruno P: Mechanical circulatory support for acute heart failure in 2013: An update on available devices, indications and results. Minerva Anestesiol 80:373-381, 2014 4. Hill JD, De Leval MR, Fallat RJ, et al: Acute respiratory insufficiency. Treatment with prolonged extracorporeal oxygenation. J Thorac Cardiovasc Surg 64:551-562, 1972 5. Braune SA, Kluge S: Extracorporeal lung support in patients with chronic obstructive pulmonary disease. Minerva Anestesiol 79: 934-943, 2013 6. Dalton HJ: Extracorporeal life support: Moving at the speed of light. Respir Care 56:1445-1453, 2011
7. Shao Y, Shen M, Ding Z, et al: Extracorporeal membrane oxygenation-assisted resection of goiter causing severe extrinsic airway compression. Ann Thorac Surg 88:659-661, 2009 8. Smith IJ, Sidebotham DA, McGeorge AD, et al: Use of extracorporeal membrane oxygenation during resection of tracheal papillomatosis. Anesthesiology 110:427-429, 2009 9. George TJ, Knudsen KP, Sodha NR, et al: Respiratory support with venovenous extracorporeal membrane oxygenation during stenting of tracheobronchomalacia. Ann Thorac Surg 94:1736-1737, 2012 10. Incagnoli P, Blaise H, Mathey C, et al: Pulmonary resection and ECMO: A salvage therapy for penetrating lung trauma [article in French]. Ann Fr Anesth Reanim 31:641-643, 2012 11. Sanchez-Lorente D, Iglesias M, Rodríguez A, et al: The pumpless extracorporeal lung membrane provides complete respiratory support during complex airway reconstructions without inducing cellular trauma or a coagulatory and inflammatory response. J Thorac Cardiovasc Surg 144:425-430, 2012
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12. Moerer O, Quintel M: Protective and ultra-protective ventilation: Using pumpless interventional lung assist (iLA). Minerva Anestesiol 77:537-544, 2011 13. Zangrillo A, Biondi-Zoccai G, Landoni G, et al: Extracorporeal membrane oxygenation (ECMO) in patients with H1N1 influenza infection: A systematic review and meta-analysis including 8 studies and 266 patients receiving ECMO. Crit Care 17:R30, 2013 14. Deschka H, Machner M, El Dsoki S, et al: Central closed chest implantation of extracorporeal membrane oxygenation to prevent limb ischemia. Int J Artif Organs 36:687-692, 2013 15. Schiff JH, Köninger J, Teschner J, et al: Veno-venous extracorporeal membrane oxygenation (ECMO) support during anaesthesia for oesophagectomy. Anaesthesia 68:527-530, 2013 16. Garcia JP, Iacono A, Kon ZN, et al: Ambulatory extracorporeal membrane oxygenation: A new approach for bridge-to-lung transplantation. J Thorac Cardiovasc Surg 139:e137-e139, 2010
PINELLI ET AL
17. Wang D, Zhou X, Liu X, et al: Wang-Zwische double lumen cannula—Toward a percutaneous and ambulatory paracorporeal artificial lung. ASAIO J 54:606-611, 2008 18. Chimot L, Marqué S, Gros A, et al: Avalon © bicaval duallumen cannula for venovenous extracorporeal membrane oxygenation: Survey of cannula use in France. ASAIO J 59: Avalon; : 157-161, 2013 19. Extracorporeal Life Support Organization: ELSO Guidelines for Cardiopulmonary Extracorporeal Life Support, Version 1.3, November 2013, Ann Arbor, MI. Available at www.elsonet.org 20. National Institute for Health and Clinical Excellence: Extracorporeal membrane oxygenation for severe acute respiratory failure in adults. April 2011. Available at http://www.nice.org.uk/ IPG391. 21. Klein A, Bailey CR: Who should undertake extracorporeal membrane oxygenation? Anaesthesia 68:445-452, 2013
A
THORACIC, abdominal, or cervical esophagectomy traditionally requires right thoracotomy and one-lung ventilation. Low-flow extracorporeal lung-assist devices have been used during thoracic surgery involving the upper airways.1 Alternatively, high-flow venovenous extracorporeal membrane oxygenation (VV-ECMO) usually is used to support lung function in cases of refractory respiratory failure2 or in refractory heart dysfunction in a venous-arterial configuration (VA-ECMO).3 The present case report presents the application of VV-ECMO for respiratory assistance during a complex transthoracic esophagectomy and reconstruction. CASE REPORT A 41-year-old man required an esophagectomy due to multiple areas of stenoses. His past surgical history included multiple esophageal surgeries and dilation procedures in his childhood due to esophageal atresia and, later, tracheobronchial reconstruction for an iatrogenic trachea-esophageal fistula. His medical history was otherwise noncontributory. To allow right lung collapse and to enable surgical access to the esophagus via a right thoracotomy, one-lung ventilation (OLV) traditionally is required. However, OLV obtained via conventional measures (double-lumen endobronchial tube or bronchial blocker) was not feasible given the past surgical modification of his tracheobronchial bifurcation. Moreover, the complex anatomic relationship between the airway and digestive tract required the availability of total extracorporeal ventilatory support if needed (ie, if surgical circumstances would not allow for mechanical ventilation). Ultra-low tidal volume ventilation and VV- ECMO assistance via the right internal jugular vein was then planned, and a written informed consent to perform the surgery in this manner was obtained from the patient. Anesthesia was induced with 3 mg/kg of propofol and 1 μg/kg of sufentanil. After the administration of 0.9 mg/kg of rocuronium, the trachea was intubated under fiberoptic guidance with a 6.5-mm (internal diameter) oral-tracheal tube, with the tip positioned just below the vocal cords. Anesthesia was maintained with 4-to-6 mg/kg/h of propofol and 0.1-to-0.2 μg/kg/min of remifentanil; 0.1-0.3 mg/kg/hr of rocuronium was administered according to the train-of-four monitoring. The American Society of Anesthesiologists standard monitoring was implemented with MostCare (Vygon, Vytech, Padova, Italy), a pulse contour-based system for cardiac output estimation that received its arterial waveform via the left radial artery with a standard pressure transducer. The MostCare system provides hemodynamic data by analyzing the arterial waveform at high sampling rate (1000 Hz) and, therefore, is not influenced by the VV-ECMO. In fact, the VV-ECMO drains and injects blood into the right side of the cardiovascular system without modifying, at steady state, right and left ventricular preload. A 27-Fr double-lumen
From the *Department of Anesthesiology and Intensive Care, Azienda Ospedaliera Universitaria Careggi, Firenze, Italy; and †Advanced Center for Translational Regenerative Medicine (ACTREM), Karolinska Institutet, Stockholm, Sweden. Address reprint requests to Fulvio Pinelli, MD, Department of Anesthesiology and Intensive Care, Azienda Ospedaliera Universitaria Careggi, Largo Brambilla 3, 50134, Firenze, Italy. E-mail: fulvio. [email protected] © 2015 Elsevier Inc. All rights reserved. 1053-0770/2602-0033$36.00/0 http://dx.doi.org/10.1053/j.jvca.2014.07.006 Key Words: extracorporeal membrane oxygenation, ECMO, esophagectomy 436
Avalon (Avalon Labs, Rancho Dominguez, CA) ECMO cannula was inserted into the right internal jugular vein under transthoracic echography guidance using the subcostal approach. After the administration of 5,000 IU of unfractionated heparin and radiologic confirmation of proper placement, the cannula was connected to an heparin-coated ECMO circuit (Rotaflow System, Maquet Cardiopulmonary AG; GmbH & Co. KG; Rastatt, Germany) and primed with lactated Ringer’s solution. Activated partial thromboplastin time was targeted to 50 to 70 seconds, and no further heparin administration was necessary throughout the case. During the thoracic portion of the surgery, the mean pump flow was 2.06 L/min (SD 0.1; range 1.96-2.24). Mean inspired oxygen fraction (FIO2) of the artificial lung was 0.5 (SD 0.05; range 0.4-0.6), and the mean sweep gas flow was 2.57 L/min (SD 0.36; range 2-3). The ventilator was set in pressure-control mode targeting a tidal volume of 3 mL/kg, with a respiratory rate of 10 breaths per minute. FiO2 o0.4, SpO2494%, and PaCO2 between 35 and 45 mmHg were maintained during the entire thoracic portion of the procedure. Mean cardiac output was 4.3 L/min (SD 0.1), mean blood pressure was 68 mmHg (SD 12), and heart rate was 76 beats/min (SD 13). Serum lactate concentration stayed within a normal range. At the end of the thoracic portion of the procedure, a right paravertebral catheter for postoperative analgesia was inserted by the surgeon. After 227 minutes, the patient was successfully weaned from ECMO, and the ECMO cannula was removed without heparin reversal. The patient was moved from a left lateral position to a supine position for the abdominal and cervical portions of the procedure. A standard gastric pull-up technique was used and anastomosed to the residual cervical esophagus. Post-thoracotomy pain control was achieved with the use of a continuous infusion of 0.2% ropivacaine via the right paravertebral catheter. Abdominal and neck pain were controlled by the use of systemic opiate infusion and acetaminophen. The postoperative period in the ICU was uneventful, and the patient was extubated 2 hours after surgery. He was discharged from the hospital on postoperative day 21. The patient gave his written consent to publish this case report. DISCUSSION
Since its first use more than 40 years ago,4 ECMO machines have undergone dramatic improvements in biocompatibility, performance, safety, and endurance, leading to reductions in the degree of blood trauma, hemolysis, and activation of the clotting cascade, along with the need for less heparin and anticoagulation.5 The widespread use of ECMO during the 2009 to 2010 H1N1 influenza pandemic provoked further evolution in materials to make this technology safer.6 VVECMO support was used during the present procedure because its feasibility already has been reported.7–10 To date, simpler extracorporeal pump-less systems such as the iLA-membrane Novalung (Novalung; Novalung GmbH, Hechingen, Germany) have been used for respiratory support during upper airway surgery.11 The advantage of these systems is the use of the arteriovenous pressure gradient, rather than an active pump system.12 However, the principal limitation of these devices is the need for a large-bore arterial cannula, which increases the risks for ischemic-embolic complications and the frequent need of inotropic support to maintain an adequate pressure gradient.1 Above all, the Novalung iLA, as well as other respiratory systems, allow for near-total carbon dioxide removal but only a minimal amount of oxygenation, with the consequent inability to completely support oxygen
Journal of Cardiothoracic and Vascular Anesthesia, Vol 29, No 2 (April), 2015: pp 436–438
437
ECMO-ASSISTED ESOPHAGECTOMY
requirements. For these reasons, iLA was considered inadequate in the present case. During the planning of the surgical procedure, other alternatives to VV-ECMO support were evaluated, such as traditional cardiopulmonary bypass and VA-ECMO. Cardiopulmonary bypass was considered an undue risk, because it requires full anticoagulation. Its known and significant bleeding risk and hemodilution due to the large pump priming volume, and the activation of more intense inflammatory and coagulation cascades, made this option less favorable. VA-ECMO would not have been helpful in this case, because the patient had normal cardiac function and, therefore, no need for cardiac support. Moreover, VA-ECMO might have put the patient at risk for “Harlequin syndrome” (flow competition into the aorta)13 and limb ischemia.14 The Bi-Caval Dual-Lumen Avalon Catheter was used, allowing VV-ECMO via a single cannulation site in the right internal jugular vein, thus minimizing the risk of injury and infection. The design of the cannula consists of proximal superior vena cava and distal inferior vena cava (IVC) drainage ports and a right atrium infusion port. The tip of the catheter is placed in the IVC via a modified Seldinger technique. Typically, the appropriate cannula positioning is verified by fluoroscopic guidance or transesophageal echocardiography (TEE). In this case, TEE was not feasible due to multiple stenoses of the patient’s esophagus, and fluoroscopy was not available. Nevertheless, visualization of the IVC and right atrium was accomplished via subcostal transthoracic echocardiography, which allowed visualization of the wire and cannula. Radiologic confirmation was obtained before initiation of ECMO flow. The combination of partial ECMO support and low-volume mechanical ventilation during the thoracic portion of the procedure allowed for optimal surgical access to the esophagus, with blood-gas concentrations maintained within normal limits. Indeed, ECMO pump flow guaranteed optimal ventilation, while partial mechanical ventilation performed with 0.4-0.5 FIO2 allowed SpO2 to be maintained greater than 94%. Anticoagulation management based on an initial bolus of 5,000 IU of heparin did not lead to hemorrhagic or thrombotic complications. At the conclusion of the thoracic portion of the surgery, a standard ventilation technique was used; pump flow was weaned off and the cannula removed without complications.
To date, the only other case of VV-ECMO assistance for esophagectomy was described recently by Schiff et al, who used extracorporeal oxygenation assistance for right lung collapse because the patient previously had undergone a left pneumonectomy.15 Substantial differences should be noted between the Schiff et al application of VV-ECMO and this case. First, Schiff and his team used two cannulae: A 38-cm long 19-Fr armored catheter into the right internal jugular vein, as an “arterial” return cannula, and a 55-cm long 23-Fr “venous” cannula in the right femoral vein. In the present case, the aforementioned bicaval double-lumen cannula was chosen as a minimally invasive single venipuncture to lower the risk of cannula displacement.16 It also was more suitable for the patient, who had to be in the left lateral position. Furthermore, the combined system of admission and ejection should reduce the risk of recirculation of blood into the circuit.17 Secondly, the patient in the Schiff et al study required ECMO support for 3 days after surgery due to limited respiratory function. Conversely, because the present patient had normal respiratory function, ECMO support was removed intraoperatively after the thoracic phase of surgical repair. Finally, unlike Schiff et al, TEE was not used to confirm the correct position of the guidewire and the cannula; rather, the transthoracic subcostal echocardiograpic approach was used, which previously has been described in patients with acute respiratory distress syndrome.18 The use of VV-ECMO also has been described for other elective thoracic surgical procedures, as well as in emergency situations and for postoperative support in the ICU.7–10 However, the use of ECMO to facilitate surgery and for postoperative use is not covered by either of the two published guidelines describing the indications and practice of ECMO.19,20 Nevertheless, descriptions of feasibility and demonstrated advances in technology may lead to a more extended use of ECMO as support therapy during surgery in selected complex cases.21 In summary, although the use of ECMO support in noncardiac surgery remains anecdotal, the present experience with a single VV-ECMO cannula was a safe and feasible option in a case of transthoracic esophagectomy and reconstruction for which OLV could not be achieved by traditional means.
REFERENCES 1. Roman PE, Battafarano RJ, Grigore AM: Anesthesia for tracheal reconstruction and transplantation. Curr Opin Anaesthesiol 26: 1-5, 2013 2. Meyer A, Strüber M, Fischer S: Advances in extracorporeal ventilation. Anesthesiol Clin 26:381-391, 2008 3. Massetti M, Bruno P: Mechanical circulatory support for acute heart failure in 2013: An update on available devices, indications and results. Minerva Anestesiol 80:373-381, 2014 4. Hill JD, De Leval MR, Fallat RJ, et al: Acute respiratory insufficiency. Treatment with prolonged extracorporeal oxygenation. J Thorac Cardiovasc Surg 64:551-562, 1972 5. Braune SA, Kluge S: Extracorporeal lung support in patients with chronic obstructive pulmonary disease. Minerva Anestesiol 79: 934-943, 2013 6. Dalton HJ: Extracorporeal life support: Moving at the speed of light. Respir Care 56:1445-1453, 2011
7. Shao Y, Shen M, Ding Z, et al: Extracorporeal membrane oxygenation-assisted resection of goiter causing severe extrinsic airway compression. Ann Thorac Surg 88:659-661, 2009 8. Smith IJ, Sidebotham DA, McGeorge AD, et al: Use of extracorporeal membrane oxygenation during resection of tracheal papillomatosis. Anesthesiology 110:427-429, 2009 9. George TJ, Knudsen KP, Sodha NR, et al: Respiratory support with venovenous extracorporeal membrane oxygenation during stenting of tracheobronchomalacia. Ann Thorac Surg 94:1736-1737, 2012 10. Incagnoli P, Blaise H, Mathey C, et al: Pulmonary resection and ECMO: A salvage therapy for penetrating lung trauma [article in French]. Ann Fr Anesth Reanim 31:641-643, 2012 11. Sanchez-Lorente D, Iglesias M, Rodríguez A, et al: The pumpless extracorporeal lung membrane provides complete respiratory support during complex airway reconstructions without inducing cellular trauma or a coagulatory and inflammatory response. J Thorac Cardiovasc Surg 144:425-430, 2012
438
12. Moerer O, Quintel M: Protective and ultra-protective ventilation: Using pumpless interventional lung assist (iLA). Minerva Anestesiol 77:537-544, 2011 13. Zangrillo A, Biondi-Zoccai G, Landoni G, et al: Extracorporeal membrane oxygenation (ECMO) in patients with H1N1 influenza infection: A systematic review and meta-analysis including 8 studies and 266 patients receiving ECMO. Crit Care 17:R30, 2013 14. Deschka H, Machner M, El Dsoki S, et al: Central closed chest implantation of extracorporeal membrane oxygenation to prevent limb ischemia. Int J Artif Organs 36:687-692, 2013 15. Schiff JH, Köninger J, Teschner J, et al: Veno-venous extracorporeal membrane oxygenation (ECMO) support during anaesthesia for oesophagectomy. Anaesthesia 68:527-530, 2013 16. Garcia JP, Iacono A, Kon ZN, et al: Ambulatory extracorporeal membrane oxygenation: A new approach for bridge-to-lung transplantation. J Thorac Cardiovasc Surg 139:e137-e139, 2010
PINELLI ET AL
17. Wang D, Zhou X, Liu X, et al: Wang-Zwische double lumen cannula—Toward a percutaneous and ambulatory paracorporeal artificial lung. ASAIO J 54:606-611, 2008 18. Chimot L, Marqué S, Gros A, et al: Avalon © bicaval duallumen cannula for venovenous extracorporeal membrane oxygenation: Survey of cannula use in France. ASAIO J 59: Avalon; : 157-161, 2013 19. Extracorporeal Life Support Organization: ELSO Guidelines for Cardiopulmonary Extracorporeal Life Support, Version 1.3, November 2013, Ann Arbor, MI. Available at www.elsonet.org 20. National Institute for Health and Clinical Excellence: Extracorporeal membrane oxygenation for severe acute respiratory failure in adults. April 2011. Available at http://www.nice.org.uk/ IPG391. 21. Klein A, Bailey CR: Who should undertake extracorporeal membrane oxygenation? Anaesthesia 68:445-452, 2013
