Bougie Insertion Research Articles

Implementation of Artificial Intelligence-Based Computer Vision Model for Sleeve Gastrectomy: Experience in One Tertiary Center.

Sleeve gastrectomy (SG) is the most common metabolic and bariatric procedure performed. Leveraging artificial intelligence (AI) for automated real-time data structuring and annotations of surgical videos has immense potential of clinical applications. This study presents initial real-world implementation of AI-based computer vision model in sleeve gastrectomy (SG) and external validation of accuracy of safety milestone annotations. A retrospective single-center study of 49 consecutive SG videos was captured and analyzed by the AI platform (December 2020-August 2023). A bariatric surgeon viewed all videos and assessed safety milestones adherence, compared to the AI annotations. Patients' data were retrieved from the bariatric unit registry. SG total duration was 47.5min (interquartile range 36-64). Main steps included preparation (12.2%), dissection of the greater curvature (30.8%), gastric transection (28.5%), specimen extraction (7.2%), and final inspection (14.4%). Out of body time comprised 6.9% of the total video. Safety milestones components and AI-surgeon agreements included the following: bougie insertion (100%), distance from pylorus ≥ 2cm (100%), parallel to lesser curvature (98%), fundus mobilization (100%), and distance from esophagus ≥ 1cm (true-100%, false-13.6%; kappa coefficient 0.2, p = 0.006). Intraoperative complications included notable hemorrhage (n = 4) and parenchymal injury (n = 1). The AI model provides a fully automated SG video analysis. Outcomes suggest its accuracy in four of five safety milestone annotations. This data is valuable, as it reflects objective performance measures which can help us improve the surgical quality and efficiency of SG. Larger cohorts will enable SG standardization and clinical correlations with outcomes, aiming to improve patients' safety.

Rhino- laryngoscope assisted bougie insertion through I-gel for endotracheal intubation in a child with an anticipated difficult airway.

Rhino- laryngoscope assisted bougie insertion through I-gel for endotracheal intubation in a child with an anticipated difficult airway.

403 Feasibility of Training for Ultrasound-Guided Cricothyrotomy Using a Novel 3-D Printed Training Model Simulating a Difficult Cricothyrotomy With Thick Pre-Tracheal Neck Tissue

403 Feasibility of Training for Ultrasound-Guided Cricothyrotomy Using a Novel 3-D Printed Training Model Simulating a Difficult Cricothyrotomy With Thick Pre-Tracheal Neck Tissue

Preoperative Dexamethasone for Airway-Related "Calibration Tube" Complications After Sleeve Gastrectomy: a Randomised Clinical Trial.

Bariatric surgeries utilise Bougie device to guide stomach resection. The device implementation is associated with many underreported complications. This study aims to compare nebulised vs. intravenous preoperative dexamethasone in mitigating airway-related Bougie complications after sleeve gastrectomy. This is a prospective double-blinded interventional study conducted by a tertiary hospital. The study involved 105 patients allocated to 3 groups: Group (I) received 8 mg dexamethasone intravenously (IV) preoperatively, group (N) received 8 mg dexamethasone from a nebulizer mask preoperatively, and Group (S) received nebulised normal saline. Outcomes evaluated were postoperative sore throat, odynophagia, change of voice, and nausea and vomiting. Nebulized dexamethasone was found to be significantly superior to IV dexamethasone in terms of postoperative sore throat at zero-hour (p = 0.001) and 1-h intervals (p = 0.011). No significant difference was found at 6- and 24-h intervals. For odynophagia, post hoc analysis showed there was no significant difference between (I), (N), and (S) groups. Incidence of change of voice was significantly lower in (N) and (I) groups compared to (S) group, with p values of 0.0067 and 0.00014, respectively. The incidence of post-operative sore-throat (PONV) in (I) group was significantly lower than incidences in (S) group (p = 0.00002) and (N) group (p = 0.0004). Preoperative nebulized and IV dexamethasone are effective strategies in mitigating complications related to mechanical effects of Bougie insertion. IV dexamethasone was as effective as nebulized dexamethasone in terms of late postoperative sore throat, and was superior in postoperative nausea and vomiting.

Role of Preoperative Dexamethasone Nebulization in Reducing Bougie Complications Encountered After Sleeve Gastrectomy: a Prospective Double-Blind Control Interventional Study.

The usage of bougie devices in guiding the extent of sleeve gastrectomies has been associated with several laryngeal and pharyngeal complications. Despite these being distressing for patients, they draw little attention in current literature. To study the role of preoperative nebulized dexamethasone in relieving the symptoms related to bougie insertion during laparoscopic sleeve gastrectomy postoperatively. A prospective interventional study that included 80 patients. The patients were assigned to two groups, 40 patients in each group: the dexamethasone group (D) which received nebulized dexamethasone 8 mg 1 h before surgery and the control group (S) which received saline nebulizer instead. Assessment of postoperative sore throat, nausea and vomiting, odynophagia, and change of voice was used as an outcome comparative tool. The patient's age ranged from 17 to 61 years, and the mean age of patients was 34.51 (± 9.5) years. Patients were composed of 13 (16.3%) males and 67 (83.8%) females. The study found a significant preference of outcome values in the dexamethasone group. Sore throat mean and medians were less at all-time intervals: 0 h (p < 0.001), 1 h (p < 0.001), 6 h (p < 0.004), and 24 h (p < 0.001). Nineteen patients of the saline group suffered from a change of voice (p < 0.001), compared to only 4 patients in the dexamethasone group. On the contrary, no significant differences are noted in the incidences of PONV and odynophagia. Preoperative nebulized dexamethasone was found to be an effective measure in reducing bougie insertion complications in laparoscopic sleeve gastrectomy.

Pediatric Lung isolation in a limited resource setup: a case report

Rationale: Pediatric lung isolation is a great challenge to an anesthesiologist. Despite various advances in techniques and equipment in lung isolation, most of the sophisticated devices are unavailable in remote setups. Blind techniques have been used, but they have a low success rate. Patient concerns: Here we report a case of a five year old male child who had cough and fever for one month. CT scan of chest revealed right sided empyema thoracis for which decortication was planned under general anaesthesia with one lung ventilation. Double lumen tube for this patient was not commercially available and we did not have a paediatric fiberoptic bronchoscope, which would fit inside the endotracheal tube necessary for the patient. Interventions: After anesthesia induction, an adult fiberoptic bronchoscope was used as an aid for insertion of bougie into the left mainstem bronchus followed by rail roading the endotracheal tube over the bougie for lung isolation. Outcomes: Surgery then proceeded in left lateral position with a right thoracotomy under a quiet surgical field. Conclusion: In case of unavailability of paediatric fiberoptic bronchoscope, an adult fiberoptic bronchoscope and a bougie can aid in successful lung isolation in paediatric patients.

Time to oxygenation for cannula‐ and scalpel‐based techniques for emergency front‐of‐neck access: a wet lab simulation using an ovine model

Emergency front-of-neck access to achieve a percutaneous airway can be a life-saving intervention, but there is debate about the preferred technique. This prospective, observational study was designed to compare the two most common emergency surgical airway techniques in a wet lab simulation using an ovine model. Forty-three doctors participated. After providing standardised reading, a lecture and dry lab benchtop training, participants progressed to a high-fidelity wet lab simulation. Participants entered an operating theatre where a 'cannot intubate, cannot oxygenate' situation had been declared and were directed to perform emergency front-of-neck access: first with a cannula technique (14-gauge cannula insertion with ventilation using a Rapid-O2® cricothyroidotomy insufflation device); and subsequently, a scalpel-bougie technique (surgical incision, bougie insertion into trachea and then tracheal tube passed over bougie, with ventilation using a self-inflating bag). The primary end-point was time from declaration of 'cannot intubate, cannot oxygenate' to delivery of oxygen via a correctly placed percutaneous device. If a cannula or tracheal tube was not placed within 240s, the attempt was marked as a failure. There was one failure for the cannula approach and 15 for the scalpel-bougie technique (OR 0.07 (95%CI 0.00-0.43); p <0.001). Median (IQR [range]) time to oxygenation, if successful, was 65 (57-78 [28-160]) s for the cannula approach and 90 (74-115 [40-265]) s for the scalpel-bougie technique (p=0.005). In this ovine model, emergency front-of-neck access using a cannula had a lower chance of failure and (when successful) shorter time to first oxygen delivery compared with a scalpel-bougie technique.

Tascope – Innovative Intubation Aid

First of all thanks to Dr. Pallavi Lande and Dr. Shiv Kumar Singh Sir for inviting me to write this article. The Anaesthetist Society (TAS) is the major contributor and driving force behind successful development of TASCOPE. Well, TASCOPE is a video intubation aid to help passage of tube in difficult airways. It involves the use of endoscope or borescope camera (5.5 mm diameter HD camera) which is either connected to laptop/or even compatible mobiles or tablet, and the camera is attached on our customized TASCOPE blades. Thus, the laptop or mobile becomes screen for our intubation. Now with the help to WiFi box, even iPhone, iPad, and other noncompatible devices can also be used as screen. We have also customized channel for insertion of bougie. Then, endotracheal tube is railroaded over bougie under vision. Tascope history Having been working in neurotrauma center and facing difficult intubation, cervical spine injuries, and faciomaxillary trauma, we felt the definite need of a device which is affordable, easy to use, and lightweight for difficult intubation. Thus, initially fixing larger endoscope camera to extended tongue retractor, we gradually developed design with much anatomical curve and hyperacute angle for vision for difficult intubation and also found insertion of bougie initially easier than guiding styletted tube into larynx. Now, we also have design to enter even in one finger mouth opening in cases with restricted mouth opening and have developed TASCOPE PEDIA for pediatric intubation. Intubation technique Intubation technique remains much similar as other intubation devices such as midline insertion, pushing blade over base tongue further to visualize epiglottis, reaching up to glossoepiglottic fold, then little lift up and visualization of larynx, insertion of bougie into larynx, and then railroad tube into larynx under vision. Sometimes difficulty faced in inserting bougie, as sometime bougie might be coming out of its channel in ABS (plastic) adult blade, in which case giving proper shape (curve) to bougie and inserting it in 11 o’clock position gently will solve the issue, some friends also find the use of cut suction catheter attached over edge of blade useful. Furthermore, there can be impingement of tube bevel between arytenoids, in which tube is not getting pushed inside larynx, in these cases counterclockwise rotation of tube from 90 to 180 degrees will solve the problem. Journey so far I, myself, have intubated &gt;600 difficult intubation cases with TASCOPE in the past 5 years, with 99% success, which include patient with ankylosis, fixed neck, with Philadelphia collar, and with faciomaxillary injury and fractured mandible, obese, short neck, in anticipated difficult intubation. Friends across India and abroad are using our device and find it useful in difficult intubation. At present, we have two types of adult blade (metal and ABS plastic) and three sizes pediatric blades available.

Oral gastroscope-guided bougie insertion and endotracheal intubation.

Oral gastroscope-guided bougie insertion and endotracheal intubation.

I-Gel versus laryngeal mask airway (LMA) classic as a conduit for tracheal intubation using ventilating bougie.

Background and Aims:Supraglottic airways (SGAs) are generally used for airway management; but can also be used as a conduit for tracheal intubation. Our primary aim was to evaluate i-Gel and laryngeal mask airway (LMA) classic as conduits for tracheal intubation using ventilating bougie by assessing number of attempts and time for insertion of SGAs, ventilating bougie and endotracheal tube (ETT), and total intubation time.Material and Methods:A randomized clinical trial was carried out in 58 patients requiring general anesthesia and endotracheal intubation for planned surgery. They were randomly divided into Group I and Group C. After induction of anesthesia, i-Gel was inserted in Group I and LMA Classic in Group C; ventilating bougie was passed through SGA followed by the removal of SGA and railroading of ETT over ventilating bougie. Parameters observed were number of attempts and time taken for device insertion, total intubation time, and hemodynamic variables.Results:Twenty-nine patients were included in each group. First attempt success rate for SGA insertion (86.2% in Group I and 75.9% in Group C (P = 0.5)), ventilating bougie insertion (79.32% in Group I and 82.8% in Group C (P = 0.99)) and ETT insertion (100% in Group I and 96.5% in Group C) was not different in the two groups. Total intubation time was 93.3 ± 9.0 s in Group I and 108. 96 ± 16.5 s in Group C (P < 0.0001).Conclusions:i-Gel and LMA Classic both can be used as a conduit for tracheal intubation using ventilating bougie with stable hemodynamic parameters.

Bougie Effects on Endotracheal Cuff Pressure and Sore Throat in Bariatric Surgery

Purpose: The purpose of this study was to evaluate the effects of a bougie insertion on the endotracheal cuff pressure and incidence of sore throat in sleeve gastrectomies. Materials and Methods: In this study, 40 patients scheduled for sleeve gastrectomies were enrolled and randomly allocated into two groups. The endotracheal tube (ETT) cuff pressures were set to 25 mmHg after intubation and the pressures were continuously monitored. In Group 1, the ETT cuff pressure was adjusted to 25 mmHg after the insertion of the bougie device, whereas in Group 2, the cuff pressure was not manipulated after the insertion of the bougie. The peak airway pressures and cuff pressures were recorded every 5 min in both groups, and the bougie insertion time, bougie duration, laryngoscopic and bougie complications, and surgery durations were noted. The incidence of postoperative sore throat was assessed and classified as none, mild, moderate, and severe. Results: There were no differences between the groups in the demographic variables, duration of surgery, peak airway pressure, or duration of bougie use. The bougie insertion time was at 28 ± 9 and 30 ± 10 min into the surgery in Groups 1 and 2, respectively. The cuff pressures were significantly higher in Group 2 at 20, 25, 30, and 35 min (p < 0.05), and the endotracheal cuff pressures exceeded 30 mmH2O in nine patients in Group 2. The postoperative sore throat scores were significantly higher in Group 2 at the 30th minute and at the 2nd and 24th hours. Conclusion: The insertion of a bougie may increase the cuff pressure and exacerbate a postoperative sore throat. Continuous cuff pressure monitoring and readjusting the cuff pressure after the bougie insertion procedure may alleviate a postoperative sore throat in bariatric surgery.

The traffic light bougie: a study of a novel safety modification

Use of a bougie is not without risk, and insertion too far may cause airway injury. We designed a new bougie with a 'traffic light' system to indicate depth of insertion. Forty anaesthetists were randomly assigned to insert either a conventional single-coloured bougie or a novel traffic light bougie. Depth of insertion was measured before and after railroading a tracheal tube. Participants were not informed as to the purpose of the colouring system. The median (IQR [range]) insertion depth of the traffic light bougie was 22 (21-24 [19-27])cm and for the conventional bougie was 28 (21-32 [20-35])cm (p=0.011). Median (IQR [range]) insertion depth after railroading for the traffic light bougie was 25 (25-28 [21-34])cm and for the conventional bougie was 30.5 (27-35 [23-40])cm (p=0.003). This simple colouring system appears to allow intuitive use and significantly reduced the depth of bougie insertion. This system could be also used with other airway exchange devices to improve safety.

Use of intubation introducers through a supraglottic airway to facilitate tracheal intubation: a brief review

This article is a narrative review regarding the usage and effectiveness of introducers or catheters to facilitate tracheal intubation through a supraglottic airway (SGA) as an alternative intubation technique in normal and difficult airway management. Relevant articles were obtained through Medline (1948-July 2011). The articles were subsequently cross-referenced for additional literature, and only articles published in English were included. In this review, we consider 32 reports using the LMA Classic™, LMA Unique™, LMA ProSeal™, LMA Supreme™, AuraOnce™, and i-gel™ as SGA conduits for intubation. In 13 articles, the use of an Aintree Intubation Catheter was described as an intubation introducer and resulted in high success rates in both elective and emergent situations. Eight studies used a guidewire exchange catheter technique. Although blind intubation using a guidewire resulted in a high failure rate, these studies found that using a bronchoscope improved successful intubation. Ten studies showed that insertion of a gum elastic bougie with a bronchoscope as an intubation introducer has high success rates compared with blind bougie insertion. One article described the use of a small endotracheal tube as an intermediary for tracheal intubation. In failed intubation scenarios, supraglottic airways, such as the LMA Classic™ or LMA ProSeal™ can serve as a conduit for tracheal intubation. A number of techniques using introducers or catheters can facilitate the insertion of an adequately sized endotracheal tube, particularly guided by a bronchoscope. Usage of introducers or catheters through a supraglottic airway may be a useful alternative intubation technique in difficult airway management.

Bougie insertion: A common practice with underestimated dangers

IntroductionEsophageal perforation after bariatric operations is rare. We report two cases of esophageal perforation after bariatric operations indicating the dangers of a common practice – like insertion of esophageal tubes – and we describe our management of that complication. Presentation of caseA 56 year old woman who underwent laparoscopic sleeve gastrectomy and a 41 year old woman who underwent laparoscopic adjustable gastric banding respectively. In both operations a bougie has been used and led to esophageal perforation. DiscussionThe insertion of bougie and especially of inflated bougie is a common practice. It is an invasive procedure that in most cases is performed by the anesthesiologist team. ConclusionBougie insertion is an invasive procedure with risks and should always be attempted under direct supervision of surgical team or should be inserted by a surgeon.

When Duzitol Does Not Do It All

When Duzitol Does Not Do It All

Airway Scope and gum elastic bougie with Macintosh laryngoscope for tracheal intubation in patients with simulated restricted neck mobility

BackgroundAirway Scope is a new videolaryngoscope which requires less cervical movement during intubation than direct laryngoscopy. Thus, in patients wearing a rigid cervical collar, we compared the efficacy of the Airway Scope and the gum elastic bougie with Macintosh laryngoscope during tracheal intubation. MethodsAnaesthesia was induced with propofol, fentanyl, and rocuronium. A rigid cervical collar was applied, and patients were randomly assigned to tracheal intubation with an Airway Scope (n=48) or multiple-use gum elastic bougie with Macintosh laryngoscope (n=48). Measurements included intubation time, gum elastic bougie insertion time, intubation success rate, and insertion and intubation attempts. Airway complications were also recorded. ResultsThe time required for successful intubation was significantly shorter with the Airway Scope compared with the gum elastic bougie with Macintosh laryngoscope [mean (sd) 34 (13) vs 49 (27) s, P=0.001], although the overall success rate of the Airway Scope (100%) compared with the gum elastic bougie with Macintosh laryngoscope (90%) did not reach the statistical significance (P=0.056). Oesophageal intubation (n=8) occurred only with the gum elastic bougie with Macintosh laryngoscope. Incidence of mucosal trauma and lip injury was similar with each device. No dental injury or hypoxia occurred with either device. ConclusionsThe Airway Scope shortens intubation time, is less likely to result in oesophageal intubation, and may offer a marginally higher intubation success rate in patients with simulated restricted neck mobility.

Cannot ventilate, difficult to intubate

Editor: A 57-yr-old (90 kg) male was scheduled to undergo a left orbit osseointegration procedure for attachment of a facial prosthesis. He had previously undergone a craniofacial resection for squamous cell carcinoma of the left ethmoid sinus with exenteration of the left orbit followed by a course of radiotherapy. The pre-anaesthetic evaluation of this patient was unremarkable apart from some limitation of mouth opening. He had a grommet insertion under general anaesthesia 3 months before but no records were available. Since his previous surgeries were apparently uneventful, it was decided to anaesthetize this patient using total intravenous anaesthesia with muscle relaxant. Because of the anticipated duration of surgery (>3 h) endotracheal intubation was planned. The patient was routinely asked to give consent for the use of his photographs for teaching and research purposes as well as for publications. In the theatre after monitoring was instituted, the patient was pre-oxygenated, given 3 mg of midazolam as a premedicant and target-controlled infusions of propofol and remifentanil infusions were commenced. It became apparent that we were unable to ventilate this patient with a face mask because of the facial defect and the removal of the orbital floor. A size-5 laryngeal mask was inserted through which ventilation was easy. Atracurium 45 mg was then given. On direct laryngoscopy we could not visualize the epiglottis. Attempts with a McCoy blade and blind bougie insertion also failed, although oxygenation and ventilation with the laryngeal mask was well maintained when reinserted. The patient's airway was secured by asleep fibre-optic nasal intubation with a 7.0 reinforced tracheal tube that was clearly visible through the orbital defect (Fig. 1). The surgery proceeded smoothly and the patient was extubated uneventfully.Figure 1.: Tracheal tube seen through the open orbit.Discussion Anaesthetists may find it difficult or impossible to face-mask ventilate such patients where the orbital floor has been removed. Endotracheal intubation may also be difficult because of altered anatomy as a result of previous surgery and the effects of radiotherapy. Awake trans-orbital intubation, fibre-optic trans-orbital intubation [1,2], the use of lighted stylets and tracheotomy have all been reported in the airway management of similar cases, especially in patients with scarring of the face and limited mouth opening. However, in our case a trans-orbital tube would have made the surgery difficult. In this case, awake fibre-optic intubation would have been the safest method of airway management.

乳頭損傷と乳房炎を合併した乳牛に乳頭管栓塞と搾乳休止による治療が奏効した1例

A six-year-old Holstein cow with anorexia and fever was diagnosed with teat-canal injury complicated by acute mastitis caused by Streptococcus uberis. The cow was treated by parenteral and intramammary administration of antibiotics and a wax-teat bougie (NIT) inserted into the teat canal of the affected quarter to halt milking. To rest the teat, the quarter was not milked for 25 days. Intramammary antibiotics infusions and bougie inser-tion were performed at five-day intervals. On day 26, a negative CMT and culture showed that the teat injury and the mastitis had been fully cured. On day 31, milk yield had recovered to pretreatment level.

Mechanisms and avoidance of esophageal perforation by anesthesia personnel during laparoscopic foregut surgery.

This study retrospectively assesses the mechanisms of 13 esophageal or gastric injuries resulting from dilator or nasogastric tube placement during laparoscopic foregut surgery and is intended to assist in determining methods of prevention. Information regarding esophageal or gastric injury during laparoscopic foregut surgery was obtained from six experienced laparoscopic surgeons. The specific mechanisms of injury were determined by discussion with the operating surgeon and review of the operative reports. Eleven cases of esophageal or gastric perforation occurred during bougie insertion and two perforations occurred secondary to nasogastric tube placement during Nissen fundoplication or Heller myotomy. Five perforations required conversion to open operation for repair including two delayed thoracotomies. The 13 injuries occurred during the performance of 1,620 laparoscopic foregut operations for an overall incidence of 0.8%. Foregut injury resulting from esophagogastric intubation during laparoscopic surgery is more common than expected. Risk factors include esophageal anatomy, intrinsic pathologic changes of the esophagus, and inexperience. Prevention must focus on close communication between the surgeon and anesthesiologist and safe techniques of dilator insertion.