Total tracheal resection for long-segment benign tracheal stenosis

Tracheal resection for long benign tracheal stenosis is challenging because of the lack of a suitable replacement to facilitate tension-free anastomosis. We describe a patient with a 6-cm post-tuberculous tracheal stricture, severely debilitated post-recurrent bronchoscopic intervention. Staged resection facilitated near-total tracheal resection with primary anastomosis and complete symptom resolution.     

Results of transverse tracheal resection in post-intubation tracheal stenoses

Tracheal problems in form of stenosis and malacia are a calculated risk of long-term tracheal intubation. Results with conservative treatment of such problems by bougienage, laser therapy, biopsy, cryotherapy, local steroids, tracheal stenting, and tracheostomy are not satisfactory in a higher percentage of cases. Resectional therapy of benign tracheal lesions has become an established technique, which combines excellent functional results with a low complication incidence. We have treated 40 patients of 17 to 76 years of age with postintubation tracheal lesions by cross resection of the affected segment. Of these patients 40% had received conservative therapeutical steps preoperatively. The mean resection length was 3.0 cm (1.5 to 6.5 cm). The perioperative morbidity was 7.8%, mortality was 2.5%. 85% of the patients operated between 1970 and 1989 were reached for a follow-up examination with x-ray, pulmonary function test and endoscopy. The patients subjective satisfaction with the operative result was good in 85%, minor in 12% and less in 3%. The objective investigations proved very good results in 90%. Our experience confirm the good results of other authors and recommend the resection treatment for cases of postintubation tracheal lesions.     

Experience with tracheal resection for traumatic tracheal stenosis

Ten patients with traumatic tracheal stenosis--unresponsive to conservative therapy--underwent tracheal resection. Two of the stenoses resulted from gunshot injuries, three were due to prolonged intubation, and five developed after tracheotomy. Eight of the operations were completely successful. There was one death, and one patient has had recurrent granulation tissue at the anastomotic site. The pathogenesis of tracheal stenosis, as well as its treatment--including the technical details of tracheal resection--are discussed.     

Post-intubation tracheal rupture: poor healing of the tracheal wall

Purpose

To describe tracheal rupture after orotracheal intubation assisted by a tracheal tube introducer.

Clinical features

A 73-yr-old morbidly obese female patient with a history of hypertension underwent a total knee replacement. There were no anticipated signs of difficult intubation. Orotracheal intubation was attempted twice by direct laryngoscopy, and a Boussignac bougie was used as a tube exchanger for the second attempt. Seven hours after tracheal extubation, the patient became dyspneic and showed a large subcutaneous emphysema. A chest x-ray and computerized tomography scan revealed rupture of the posterior tracheal wall. The distal part of the injury was 26.5 cm from the patient’s teeth and 0.5 cm from the carina (i.e., beyond the normal location of the tracheal tube tip) and extended to the origin of the right main bronchus, where the tip of the Boussignac bougie was probably pushed. Formation of an endotracheal sac occurred during the first two weeks after intubation, accompanied by dyspnea and alveolar hypoventilation, but symptoms resolved favourably with conservative management.

Conclusion

The tracheal rupture was attributed to airway manipulations, and the distal location of the lesion suggests that the cause was the Boussignac bougie rather than the tracheal tube. Long-term healing of the injury was satisfactory, although the patient continued to complain of dyspnea one year after the rupture.     

Difficult tracheal extubation

We describe a case of nasotracheal tube fixation with a screw. A second case is described in which a broken drill bit was found to impinge on the wall but not penetrate into the lumen of a nasotracheal tube. Possible sequelae of this complication include airway leak, aspiration, tube obstruction, and trauma from attempts at forceful extubation. We recommend the routine intraoperative testing for tracheal tube movement and routine fibreoptic bronchoscopy through the tube when blind surgical procedures occur in the vicinity of a tracheal tube.     

Reoperative tracheal surgery

Tracheal resection and reconstruction for postintubation stenosis is successful in more than 95% of initial repair attempts. The most likely causes of anastomotic failure are anastomotic tension, local devascularization, and granulomatous foreign body reaction. Incomplete resection of areas of stenosis or malacia might also lead to postoperative airway compromise. A variety of systemic factors might contribute to poor anastomotic healing. Postoperative respiratory difficulty requires immediate evaluation. In a patient with recurrent tracheal stenosis, the airway can be managed with dilation, or a tracheostomy or T-tube can be inserted through the failed anastomosis. Patients who are candidates for reoperative tracheal resection and reconstruction can expect good or satisfactory results in 91.9% of cases. Preoperatively addressing the patient's risk factors for failing, and liberally employing release procedures to reduce tension on the anastomosis contribute to the success of a reoperative procedure.     

Postintubation tracheal stenosis

Postintubation tracheal stenosis is a clinical problem caused by regional ischemic necrosis of the airway. The incidence of postintubation tracheal stenosis has decreased with recognition of its etiology and modifications in the design and management endotracheal and tracheostomy tubes; however, it remains the most common indication for tracheal resection and reconstruction. Single-stage resection and reconstruction by a competent tracheal surgeon results in good or satisfactory results in 93.7% of patients, with a failure rate of 3.9% and a mortality rate of 2.4%. The intellect and skill of Dr. Grillo has made the etiology and management of postintubation stenosis obvious to us all.     

Blunt tracheal transection

Blunt tracheobronchial injuries are rare, but can be life-threatening. A precise preoperative diagnosis and well recognized plan of surgical treatment, which may be unique for each patient are needed to restore the continuity of tracheobronchial tree in a one-stage intervention. We encountered 2 patients with complete tracheal transection of neck and 1 patient with complete tracheal transection in mediastinum and 15 cm tear in the posterior membranous trachea, whose tracheal injury was difficult to repair using direct intubation of distal airway by bronchoscopy. We achieved a good result of repair using a percutaneous cardiopulmonary support system (PCPS).     

Oxygen-jet ventilation during tracheal reconstruction in patients with tracheal stenosis

Intermittent jets of O2 at 60 psi via a small bore (5 mm), cuffed tracheal tube have been used relaxants to ventilate adult patients with tracheal stenosis undergoing surgical resection and reconstruction. Before resection, the tube was maintained proximal to the stenosis. During resection and reconstruction, the tube bypassed the resected gap into the distal tracheal segment. The technic allows the surgeon to mobilize, resect, and reconstruct the trachea around the small tube in an unhurried manner, and provides adequate ventilation and oxygenation throughout the procedure.     

Bilateral tracheal bronchi

A case of bilateral tracheal bronchi, first diagnosed at 14 months, is reported in a child who is currently alive and well at more than two years of age. This is only the second such case to be described in the world literature and is the only case to survive the first year of life. A tracheal accessory lung was also present. The varieties of tracheal bronchi are described. The importance of considering this uncommon abnormality in a number of clinical situations is emphasized.     

Retrograde tracheal intubation

Successful management of difficult tracheal intubation by retrograde intubation has been reported for almost 50 years and can be used whether or not it is anticipated. There are numerous reports of variations to the basic technique to enhance reproducibility of this guided blind procedure. A review and analysis of the equipment and techniques provides a better understanding of this effective technique.     

Pediatric tracheal surgery

BACKGROUND: Pediatric tracheal procedures are uncommon. We reviewed our experience to clarify management and results. METHODS: Retrospective single-institution review of pediatric tracheal operations, 1978 to 2001. RESULTS: One hundred sixteen children were evaluated, mean age 10.4 years (10 days to 18 years). Tracheal pathology was postintubation stenosis (n = 72; 62%), congenital stenosis (n = 23; 20%), neoplasm (n = 8; 7%), tracheomalacia (n = 7; 6%), and trauma (n = 6; 5%). Twenty-nine patients had previous tracheal operations. Thirty-six patients received only a minor procedure. Eighty patients had major operations: tracheal resection (n = 46; 58%), laryngotracheal resection (n = 22; 28%), slide tracheoplasty (n = 7; 9%), and carinal resection (n = 5; 6%). The mean length of airway resected was 3.3 cm (1.5 to 6 cm), which represented 30% of the entire trachea. Twenty-eight patients (35%) had complications. These included tracheomalacia (n = 3), recurrent nerve injury (n = 3), laryngeal edema requiring intubation (n = 2), stroke (n = 1), esophageal leak (n = 1), and lobar collapse (n = 1). Nineteen patients had anastomotic failure: severe restenosis (n = 6), mild restenosis (n = 9), dehiscence (n = 2), dehiscence with tracheoesophageal fistula (n = 1), and tracheoinnominate fistula (n = 1). Two children died (2.5%). Complications were more frequent in children less than 7 years of age (p = 0.05) and after previous operations (p = 0.02). Longer fractions of tracheal resection (> 30%) were more likely to result in anastomotic failure (p = 0.0005). Sixty-four (80%) patients achieved a stable airway free of any airway appliance. All patients with neoplasms are alive. CONCLUSIONS: The principles of adult tracheal operations are directly applicable to children and usually lead to a stable, satisfactory airway. Children tolerate anastomotic tension less well than adults; resections more than 30% have a substantial failure rate.     

Primary tracheal tumors

Primary tracheal tumors often present with locally advanced tumors. A majority of patients can safely undergo tracheal, laryngotracheal, or carinal resection with low perioperative risk. Airway interventions at the time of diagnosis should be selected carefully to avoid a compromise of curative treatment. Precise judgment is required to determine resectability. The proximity of intrathoracic organs creates anatomical limits to en bloc resection and necessitates adjuvant radiotherapy in malignant tumors. Early referral for consideration of surgical resection might offer the best opportunity for improving the overall prognosis of tracheal tumors.     

Acquired tracheal stricture

A 17-year-old boy developed tracheal stricture following tracheostomy with a cuffed tube leading to recurrent acute respiratory obstruction. The patient was initially managed with frequent dilatations of the stricture so as to tide over the crisis of respiratory obstruction, pulmonary infection and healing of the tracheostomy stoma. Subsequently he was taken up for surgical excision of strictured segment of the trachea and an end-to-end anastomosis was successfully performed. Postoperative recovery was uneventful.     

Primary tracheal schwannoma

We report a case of a primary tracheal schwannoma causing symptoms of airway obstruction in a 33-year-old man. Bronchoscopy and computerized tomography demonstrated a polypoid intratracheal mass obstructing 90% of the lumen. Tracheal resection with primary anastomosis was performed. Histologic analysis revealed a benign neurogenic tumor of Schwann cell origin.     

Aortopexy with tracheal reconstruction for postoperative tracheomalacia in congenital tracheal stenosis

PurposeCongenital tracheal stenosis is a rare condition and can be difficult to manage. One source of difficulty is postoperative tracheomalacia requiring long-term tracheal stenting. To prevent symptomatic postoperative tracheomalacia, we have been adding aortopexy to tracheal reconstruction since 2008. The aim of this study was to evaluate efficacy of aortopexy for preventing postoperative tracheomalacia after reconstruction of congenital tracheal stenosis.MethodsRetrospective chart review was conducted. From October 2003 to March 2011, 24 had tracheal reconstruction without aortopexy (group A) and 8 with aortopexy (group B). Statistical analysis was performed using Fisher's Exact test.ResultsOne had anastomotic leakage in group A, and 1, in group B (P = .44). Eleven patients required tracheostomy because of postoperative tracheomalacia confirmed by postoperative bronchoscopy in group A vs none in group B (P = .029).ConclusionsWe found that aortopexy with tracheal reconstruction reduced the need for postoperative tracheostomy in this patient group. Although there is a potential risk of anastomotic leakage because of the suspension suture on the anterior tracheal wall to aorta, we did not detect an increased incidence after aortopexy. Thus, aortic suspension may be a useful adjunct to prevent symptoms of tracheomalacia in these patients.     

Effect of catheter design on tracheal pressures during tracheal gas insufflation

BACKGROUND AND OBJECTIVE: This study investigated the distribution of pressures within a model trachea, produced by five different tracheal gas insufflation devices. The aim was to suggest a suitable design of a tracheal gas insufflation device for clinical use. METHODS: Each device was tested using insufflation flow rates of 5 and 10 L min(-1). For each flow rate, the pressure within the tracheal model was measured at 33 fixed points. RESULTS: The Boussignac tracheal tube produced the most even pressure distribution, while a reverse-flow catheter produced pressure changes of the smallest magnitude. CONCLUSIONS: We suggest that catheters producing the lowest pressure changes are likely to be safer for clinical use.     

Distal tracheal compression

The consultants concur that distal tracheal stenosis is a challenging problem in the pediatric patient but don't all agree on the presentation or management. Drs. Cotton and Crysdale agree that these children are usually seen with biphasic stridor. Dr. Parsons believes that biphasic stridor is not particularly common but inspiratory stridor is. The experts divide the differential diagnosis into intrinsic and extrinsic categories. Dr. Cotton lists tracheomalacia, complete tracheal rings and masses, such as an isolated hemangioma or granuloma. The usual extrinsic lesion is a vascular anomaly, the most common being an innominate artery. Dr. Crysdale's differential diagnosis includes tracheal stenosis, either congenital or acquired, and tracheomalacia. Vascular compression is most common as an extrinsic cause. Dr. Parsons includes tracheomalacia, complete tracheal rings, segmental tracheal stenosis, isolated masses, and vascular anomalies, such as an aberrant innominate artery. He also states that a tracheoesophageal fistula must be considered. Dr. Cotton prefers MRI and possibly a barium swallow for assessing vascular architecture. Even finding an air bronchogram on a chest x-ray can pinpoint an area of stenosis. The best test is direct laryngoscopy with video-photography. While Drs. Parsons and Crysdale agree that direct laryngoscopy is the best, Dr. Crysdale also suggests MRI or CT and adds that a contrast bronchogram is a most useful test.(ABSTRACT TRUNCATED AT 250 WORDS)     

Prevention of tracheal aspiration using the pressure-limited tracheal tube cuff

A new design of tracheal tube cuff, the pressure-limited cuff, used with a constant-pressure inflation system, was compared with a high-volume low-pressure cuffed tracheal tube for leakage of dye placed in the subglottic space into the trachea. Patients requiring ventilation on the intensive care unit were randomly allocated into two groups, one for each type of cuff, and blue food dye was instilled daily via a fine catheter above the cuff into the subglottic space. There were eight patients in the high-volume low-pressure group and seven in the pressure-limited cuff group. Dye leaked into the trachea in seven (87%) of the high-volume low-pressure group compared with none (0%) of the pressure-limited cuff group (p < 0.01). This study demonstrates that the pressure-limited cuffed tracheal tube, in combination with a constant-pressure inflation device, prevents leakage of fluid into the lungs that occurs with high-volume low-pressure cuffs in the critically ill, intubated patient.